Supportive Care

True or False: All 5-HT3 receptor antagonists are equivalent for the prevention of acute emesis from highly emetogenic chemotherapy

• A. True (39%)
• B. False (61%)

Answer: B. False.

Reasoning: While 5-HT3 receptor antagonists generally demonstrate similar efficacy and safety when administered at equipotent doses, they are not considered equivalent in the context of highly emetogenic chemotherapy (HEC).

• Palonosetron Superiority: Meta-analyses have concluded that palonosetron is more effective than first-generation 5-HT3 antagonists (such as ondansetron or granisetron) in preventing both acute and delayed nausea and vomiting for patients receiving HEC.
• Mechanism: This superior efficacy is attributed to palonosetron’s unique allosteric and facilitative binding to the 5-HT3 receptor.
• Guideline Nuance: Although the NCCN does not preferentially recommend palonosetron for HEC on Day 1, it does maintain a preference for palonosetron in specific moderately emetogenic (MEC) settings where a neurokinin-1 receptor antagonist is not used.

Which one of the following antiemetics is NOT known to cause extrapyramidal symptoms?

• A. Metoclopramide (5%)
• B. Dexamethasone (83%)
• C. Droperidol (6%)
• D. Promethazine (80%)

The correct answer is B. Dexamethasone.

Reasoning: Extrapyramidal symptoms (EPS)—such as tremor, restlessness, and dystonia—are primarily associated with medications that block dopamine receptors.

• Dexamethasone: As a corticosteroid, its common side effects include hyperglycemia, insomnia, and dyspepsia. It is not a dopamine antagonist and is not associated with EPS.
• Metoclopramide: This benzamide derivative blocks dopamine at the chemoreceptor trigger zone (CTZ). EPS is a known risk, particularly at higher doses, often requiring an anticholinergic like diphenhydramine for prevention.
• Droperidol: A butyrophenone that blocks dopamine receptors. Clinical guidelines explicitly list EPS as a risk for this class of medication.
• Promethazine: A phenothiazine derivative that blocks dopamine receptors. Its common adverse effects include dystonia and akathisia, which are types of EPS.

JJ is a 66-year-old woman with breast cancer receiving her first cycle of paclitaxel chemotherapy. Sixty minutes before her chemotherapy, she
receives a hypersensitivity prevention regimen of dexamethasone, ranitidine, and diphenhydramine.

What antiemetic regimen do you recommend for her to receive before paclitaxel?

• A. Ondansetron 8 mg IV (42%)
• B. Fosaprepitant 150 mg IV (6%)
• C. Ondansetron 8 mg IV plus fosaprepitant 150 mg IV (18)
• D. No additional premedications needed (34)

The correct answer is D. No additional premedications needed.

Reasoning

• Emetic Risk Assessment: Paclitaxel is classified as having a low emetogenic risk, meaning the frequency of emesis is between 10% and 30%.
• Guideline Recommendations: For chemotherapy with low emetic risk, clinical guidelines recommend prophylaxis with a single agent, such as a 5-HT3 receptor antagonist or a corticosteroid like dexamethasone.
• Existing Coverage: JJ has already received dexamethasone as part of her hypersensitivity prevention regimen. Because this medication also serves as the recommended single-agent prophylaxis for low-emetogenic chemotherapy, she is already appropriately covered for CINV.
• Avoiding Over-treatment: Adding higher-potency agents like ondansetron (Option A) or fosaprepitant (Options B and C) is unnecessary for the low-risk level of paclitaxel and is not recommended.

ST is a 48-year-old male with colorectal cancer who is about to start FOLFOX (fluorouracil, leucovorin and oxaliplatin). He has no history of nausea/vomiting and also drinks 2 cans of beer daily.

Which of the following antiemetic regimens is most appropriate?

• A. Ondansetron 16 mg IV x 1 and dexamethasone 12 mg IV x1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (34%)
• B. Olanzapine 10 mg PO x1 and dexamethasone 12 mg IV x 1 on Day 1 followed by olanzapine 10 mg PO daily on Days 2-3 (3%)
• C. Palonosetron 0.25 mg IV x 1 and dexamethasone 12 mg IV x1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (52%)
• D. Fosaprepitant 150 mg IV x 1 and dexamethasone 12 mg IVX1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (12%)

The correct answer is C. Palonosetron 0.25 mg IV x 1 and dexamethasone 12 mg IV x 1 on Day 1, followed by dexamethasone 8 mg PO daily on Days 2-3.

Reasoning

• Emetic Risk: ST is receiving FOLFOX, which includes Oxaliplatin. Clinical guidelines classify Oxaliplatin as Moderately Emetogenic Chemotherapy (MEC).
• Preferred 5-HT3 Antagonist: For MEC regimens, NCCN and other guidelines preferentially recommend Palonosetron over other first-generation 5-HT3 receptor antagonists (like ondansetron) when an NK1 receptor antagonist is not used. This is because palonosetron has a longer half-life and has demonstrated superior efficacy in preventing both acute and delayed CINV.
• Steroid Dosing: The standard acute dose of dexamethasone for MEC is 12 mg. Adding dexamethasone on Days 2 and 3 provides necessary coverage for the delayed phase often associated with oxaliplatin.

Why the other options are incorrect

• A. Ondansetron: While acceptable, it is not the preferred 5-HT3 antagonist for MEC without an NK1 receptor antagonist.
• B and D. Olanzapine/Fosaprepitant: These higher-potency agents (NK1 antagonists or olanzapine-based triplets) are typically reserved for Highly Emetogenic Chemotherapy (HEC) or specific MEC cases with high-risk factors, such as carboplatin-based therapy. ST's risk is lower because of his history of alcohol consumption.

Which one of the following agents is a neurokinin-1 receptor antagonist?

• A. Dronabinol (7%)
• B. Fosaprepitant (85)
• C. Olanzapine (3%)
• D. Palonosetron (5%)

The correct answer is B. Fosaprepitant.

Reasoning and Drug Classification

• Fosaprepitant (NK-1 Receptor Antagonist): Fosaprepitant is an intravenous prodrug that is rapidly converted to aprepitant after administration. It belongs to the neurokinin-1 (NK-1) receptor antagonist class, which works through a primarily central mechanism by blocking Substance P from binding to NK-1 receptors in the brain regions implicated in the emetic reflex. These agents are highly effective at preventing both acute and delayed nausea and vomiting and are typically used as part of a multi-drug regimen with a 5-HT3 antagonist and dexamethasone.
• Dronabinol (Cannabinoid): Dronabinol is a cannabinoid that targets cannabinoid receptor CB1 in both the central and peripheral nervous systems. While used for breakthrough nausea, it is not an NK-1 antagonist.
• Olanzapine (Mixed Antagonist): Olanzapine is an atypical antipsychotic that potently blocks multiple receptor subtypes, including dopaminergic (D2), serotonergic (5-HT2 and 5-HT3), histaminergic, and muscarinic receptors. Its multi-receptor blockade makes it effective for both prophylaxis and breakthrough treatment, but it is not classified as an NK-1 antagonist.
• Palonosetron (5-HT3 Receptor Antagonist): Palonosetron is a second-generation serotonin subtype 3 (5-HT3) receptor antagonist. It works by blocking serotonin release from enterochromaffin cells in the GI tract and central receptors in the medulla. Unlike first-generation 5-HT3 antagonists, palonosetron has unique allosteric binding that provides efficacy in both acute and delayed CINV phases.

SS is a 55-year-old breast cancer patient receiving her fourth cycle of cyclophosphamide 600 mg/m², doxorubicin 60 mg/m^2. Before the chemotherapy begins, she rushes to the bathroom to experience a vomiting episode. Afterward, she states that she is ready to begin chemotherapy.

Why did she have this vomiting episode?

• A. SS is exhibiting anticipatory nausea and vomiting from her motion sickness history (10%)
• B. SS is constipated from anthracycline-induced neurotoxicity (10%)
• C. SS is experiencing delayed emesis from her last cycle of doxorubicin and cyclophosphamide, administered three weeks ago (6%)
• D. SS developed anticipatory vomiting from poor antiemetic control with previous cycles (83%)

The correct answer is D. SS developed anticipatory vomiting from poor antiemetic control with previous cycles.

Reasoning

• Definition of Anticipatory Emesis: This is a conditioned reflex that occurs before the administration of chemotherapy. It is triggered by sensory cues such as the sights, smells, or sounds of the treatment environment.
• Primary Cause: The strongest predictor of anticipatory nausea and vomiting is poor control of symptoms during previous chemotherapy cycles. Because SS is now in her fourth cycle of a highly emetogenic "AC" (Adriamycin/Cyclophosphamide) regimen, her body has developed a learned response to the upcoming treatment due to inadequate prevention in cycles 1 through 3.
• Patient Risk Factors: SS also possesses several intrinsic risk factors that predispose her to anticipatory symptoms, including being female and being under the age of 50.

Why the other options are incorrect

• A. Motion Sickness: While a history of motion sickness is a general risk factor for increased CINV, the specific trigger for vomiting before the drug is administered is the conditioned response (anticipatory) rather than the motion sickness history itself.
• B. Constipation/Neurotoxicity: Anthracyclines like doxorubicin are primarily associated with cardiotoxicity, not the neurotoxicity-driven constipation typically seen with agents like vincristine.
• C. Delayed Emesis: Delayed nausea and vomiting occur between 24 hours and 5 days after chemotherapy; a three-week gap is far outside the window for delayed emesis.

When dexamethasone is added to a 5-HT3 receptor antagonist. How much additional antiemetic protection is gained in the context of chemotherapy-related nausea and vomiting?

• A. None (40%)
• B. 5% (40%)
• C. 20% (76%)
• D. 80% (16%)

The correct answer is C. 20%.

Reasoning: Adding dexamethasone (a corticosteroid) to a 5-HT3 receptor antagonist (such as ondansetron, granisetron, or palonosetron) is a fundamental practice in oncology to enhance the prevention of chemotherapy-induced nausea and vomiting (CINV). Clinical data and meta-analyses consistently show that this combination increases antiemetic protection for acute emesis by approximately 20% compared to using a 5-HT3 antagonist as a single agent.

Synergistic Mechanism and Clinical Importance

• Complementary Pathways: 5-HT3 receptor antagonists work primarily via peripheral antagonism by blocking serotonin release from enterochromaffin cells in the GI tract and central antagonism in the medulla. While they are highly effective for acute symptoms, they have variable efficacy for delayed events.
• The Additive Role of Dexamethasone: Dexamethasone is specifically used to prevent delayed CINV and is known to significantly improve the efficacy of 5-HT3 inhibitors during the acute phase (the first 24 hours). Although its exact mechanism is not fully defined, it is believed to involve prostaglandin inhibition and anti-inflammatory effects in the brain.
• Standard of Care: Because of this significant ~20% boost in protection, all major clinical guidelines (ASCO, NCCN, and MASCC) mandate the use of dexamethasone as a core component of multi-drug prophylactic regimens for both Highly Emetogenic Chemotherapy (HEC) and Moderately Emetogenic Chemotherapy (MEC).

Why the Other Options are Incorrect

• A and B: Clinical evidence identifies a substantial, not negligible, benefit when adding a steroid. Meta-analyses confirm that the contribution of dexamethasone is a statistically and clinically significant improvement over 5-HT3 monotherapy.
• D: While the total control rate of a combination regimen may reach high levels, the additional (marginal) protection specifically gained by adding dexamethasone to an existing 5-HT3 regimen is approximately 20%, not 80%.

If a patient develops anticipatory nausea and vomiting from poor antiemetic control, which agent should be started?

• A. Dronabinol (3)
• B. Lorazepam (81%)
• C. Ondansetron (12%)
• D. Promethazine (4%)

The correct answer is B. Lorazepam (81%).

Reasoning

1. Definition and Cause of Anticipatory CINV Anticipatory nausea and vomiting (ANV) is a conditioned reflex that occurs before the administration of chemotherapy. It is typically triggered by sensory cues such as the sights, smells, or sounds of the treatment environment (e.g., the smell of the clinic or the sight of the infusion pump). The primary cause and strongest predictor for developing this condition is poor emetic control during previous chemotherapy cycles.

2. Why Lorazepam is the Preferred Agent Benzodiazepines, specifically lorazepam, are considered the most effective pharmacological class for managing anticipatory symptoms. Its efficacy is derived from several actions:

• Anterograde Amnesia: Lorazepam helps the patient "forget" the negative stimuli of the treatment environment, which is critical for breaking the conditioned reflex.
• Anxiolytic Effect: It decreases the baseline anxiety and distress that often contribute to and exacerbate the emetic response.
• CNS Depression: It causes global CNS depression, which reduces the signaling pathways that lead to vomiting.

3. Clinical Application and Guidelines Clinical guidelines (ASCO, NCCN, MASCC) recommend the following for patients who have developed anticipatory symptoms:

• Dosing Schedule: Lorazepam 0.5 mg to 2 mg PO (or alprazolam 0.5 mg to 1 mg PO) should be initiated the night before treatment and again 1–2 hours before the chemotherapy session begins.
• Behavioral Interventions: Because ANV is a psychologically conditioned response, behavioral therapies such as progressive muscle relaxation, systematic desensitization, hypnosis, and music therapy are also highly effective and recommended as adjuncts.

Why the other options are incorrect

• A. Dronabinol: This is a cannabinoid primarily used for breakthrough CINV and has limited evidence for efficacy in the anticipatory phase.
• C. Ondansetron: While 5-HT3 receptor antagonists are the backbone of acute CINV prevention, they target peripheral and central serotonin receptors and do not address the psychological conditioned reflex of anticipatory emesis.
• D. Promethazine: This is considered a weak antiemetic and is generally not preferred for use in adult cancer patients due to its lower efficacy and side effect profile.

IK is a 55-year-old male receiving cisplatin 75 mg/m² on Day 1 and etoposide 100 mg/m² on Days 1-3 for his small cell lung cancer. His antiemetic regimen included ondansetron, aprepitant, and dexamethasone. After his first cycle of chemotherapy, he complained of vomiting x 3 episodes starting 48 hours after chemotherapy

What change to his antiemetic regimen would you make for cycle 2?

• A. No change is necessary (7%)
• B. Change ondansetron to palonosetron (67%)
• C. Add granisetron to the current regimen (5%)
• D. Increase the dose of dexamethasone from 12 to 20 mg IV (21%)

The correct answer is B. Change ondansetron to palonosetron.

Reasoning: IK is receiving cisplatin, the prototypic Highly Emetogenic Chemotherapy (HEC) agent, which is well-characterized by a biphasic pattern of emesis (acute and delayed). His vomiting started 48 hours after chemotherapy, which is defined as delayed CINV (occurring >24 hours post-treatment).

• Palonosetron Efficacy: Unlike first-generation 5-HT3 receptor antagonists (like ondansetron or granisetron) which have variable efficacy for delayed events, palonosetron is a second-generation antagonist with a longer half-life and unique allosteric binding. Clinical evidence and meta-analyses show that palonosetron is more effective than first-generation agents in preventing both acute and delayed CINV in patients receiving HEC.
• Guideline Context: While his initial 3-drug regimen is a standard option, the failure to control delayed symptoms suggests a need for a more potent long-acting serotonin antagonist or the addition of a fourth drug like olanzapine.

Why the other options are incorrect

• A. No change: Inappropriate because IK experienced multiple vomiting episodes, indicating his current prophylaxis is inadequate.
• C. Add granisetron: Incorrect because granisetron is in the same pharmacological class as ondansetron (first-generation 5-HT3 RA) and would not provide superior delayed protection.
• D. Increase dexamethasone: The standard acute dose of dexamethasone is 12 mg when used with an NK1 receptor antagonist like aprepitant. Aprepitant inhibits CYP3A4, which increases the concentration of dexamethasone; therefore, increasing the dose to 20 mg could lead to excessive steroid toxicity without necessarily solving the delayed emesis issue.

Which of the following statements is true?

• A. Both palonosetron and rolapitant have long half-lives and are thus more effective at preventing delayed nausea/vomiting (43%)
• B. ronabinol capsules have higher bioavailability than dronabinol oral solution (50%)
• C. All the NK1 antagonists (fosaprepitant, aprepitant, netupitant, fosnetupitant, and rolapitant) inhibit the metabolism of dexamethasone, leading to higher levels of dexamethasone when given concomitantly (28%)
• D. Aprepitant inhibits warfarin metabolism via CYP2C9 and can lead to supratherapeutic INRS for patients on concomitant aprepitant and warfarin (25%)

The correct answer is A. Both palonosetron and rolapitant have long half-lives and are thus more effective at preventing delayed nausea/vomiting.

Reasoning

• Palonosetron (5-HT3 Antagonist): Unlike first-generation serotonin antagonists like ondansetron, palonosetron is uniquely effective for delayed CINV. This is attributed to its long half-life and unique allosteric and facilitative binding to the 5-HT3 receptor.
• Rolapitant (NK-1 Antagonist): Rolapitant has a significantly long half-life of approximately 180 hours, whereas aprepitant's half-life is only 9–13 hours. This allows rolapitant to be administered as a single dose prior to chemotherapy while remaining effective through the delayed emetic phase.

Why the other options are incorrect

• B is incorrect: Clinical dosing for the dronabinol oral solution (2.1 mg) is lower than for the capsules (5–10 mg), but the capsules do not have higher bioavailability than the solution.
• C is incorrect: Rolapitant is an exception among NK-1 antagonists; it is neither an inhibitor nor an inducer of CYP3A4. Consequently, unlike aprepitant or netupitant, rolapitant has no drug-drug interaction with dexamethasone and does not require a steroid dose reduction.
• D is incorrect: Aprepitant induces CYP2C9, which increases the metabolism of warfarin. This results in a clinically significant decrease in INR (subtherapeutic) approximately 7–10 days after treatment, rather than a supratherapeutic increase.

TJ is a 72-year-old male who presents to the clinic with stage IV non-small cell lung cancer (NSCLC) with bone metastases. He has a 45 pack-year history of smoking and drinks 4-5 beer bottles a day. Your oncology team has decided to treat TJ's cancer with chemotherapy.

Which of the factors below are associated with a reduced risk of emetogenic potential for TJ?

• A.  Age, gender, alcohol history (63%)
• B.  Gender, alcohol history, smoking history (17%)
• C.  Alcohol history, smoking history, age (11)
• D.  Smoking history, age, gender (9%)

Answer (A)

The first answer option is correct as there are patient-specific factors that put TJ at a lower risk of having emesis. Older patients are at lower risk of emesis compared to younger patients. Males are also at lower risk of emesis compared to females. Alcohol use also reduces the risk of emesis
Smoking has not been identified to have a significant impact on the patient's risk of emesis.
The risk of emesis is reduced in patients who are older males and with alcohol use.
Other risk factors for nausea/vomiting include a history of motion sickness, a history of morning sickness, a history of nausea/vomiting, an environment in which chemotherapy is administered, a dosage of the emetogenic agent, and efficacy of the antiemetic regimen.

JS is a 55-year-old woman who was recently diagnosed with early-stage (stage II) NSCLC. She is a social drinker who stopped smoking 15 years ago. Her past medical history is significant for depression, morning sickness with her 2 pregnancies, and motion sickness. Following surgical resection, her oncologist wishes to use cisplatin 75 mg/m² IV and pemetrexed 500 mg/m² IV on day 1 every 21 days as her chemotherapy regimen.

JS is a 60-year-old woman who was recently diagnosed with early stage (stage II) NSCLC. She is a social drinker who stopped smoking 15 years ago. Her past medical history is significant for morning sickness with her 2 pregnancies, and motion sickness. JS has been treated for early stage breast cancer at age 29 with dose-dense AC and reports significant nausea with this regimen. Following surgical resection, her oncologist wishes to use cisplatin 75 mg/m2 IV and pemetrexed 500 mg/m2 IV on day 1 every 21 days as her chemotherapy regimen in the neoadjuvant setting prior to surgery.

True or False:

Oral 5-HT3 receptor antagonists are as effective as intravenous 5-HT3 receptor antagonists for the prevention of chemotherapy-induced nausea and vomiting:

• A True (73%)
• B False (27%)

Answer(A)

All oral 5-HT3 receptor antagonists show equivalent response rates compared to their intravenous formulations. Since a large percentage of the body's serotonin receptors are found in the GI tract, administering these agents orally makes intuitive sense. 
Examples of 5-HT3 receptor antagonists include: alosetron, dolasetron, granisetron, ondansetron, and palonosetron.

A 62-year-old male patient receives cisplatin and etoposide chemotherapy for small-cell lung cancer. He receives palonosetron 0.25 mg IVP. fosaprepitant 150 mg IV, dexamethasone 12 mg IV before cisplatin. He is sent home with a prescription for dexamethasone for the prevention of delayed emesis. He calls you the following day, complaining of one episode of vomiting and moderate nausea.

What therapy would you suggest?

• A. Ondansetron (28%)
• B. Aprepitant (7%)
• C. Prochlorperazine (47%)
• D. No intervention is needed at this time (18%)

The correct answer is C. Prochlorperazine.

Reasoning

• Breakthrough CINV Management: The patient is experiencing breakthrough emesis, which is nausea or vomiting occurring despite appropriate prophylactic treatment. For breakthrough symptoms, clinical guidelines recommend adding one agent from a different drug class than the initial prophylactic regimen.
• Initial Regimen: The patient’s Day 1 prophylaxis included an NK1 receptor antagonist (fosaprepitant), a 5-HT3 receptor antagonist (palonosetron), and a corticosteroid (dexamethasone).
• Class Selection: Prochlorperazine is a dopamine receptor antagonist (phenothiazine class), which provides a different mechanism of action to help control symptoms when the primary classes have already been utilized.

Why are the other options wrong

• A. Ondansetron: This is a 5-HT3 receptor antagonist, the same class as the palonosetron he already received. Guidelines generally suggest switching classes for breakthrough rescue.
• B. Aprepitant: He received fosaprepitant on Day 1, which provides enough NK1 coverage for the entire cycle; additional NK1 antagonists are not indicated for breakthrough management.
• D. No intervention: Breakthrough emesis is an active clinical issue that requires rescue therapy to prevent complications like dehydration or refusal of further treatment.

Which antiemetic regimen is recommended before CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy?

• A Prochlorperazine 10 mg PO (8%)
• B Ondansetron 24 mg PO (63%)
• C Dexamethasone 20 mg PO (26%)
• D Metoclopramide 30 mg PO (3%)

The correct answer is B. Ondansetron 24 mg PO.

Reasoning

• Emetic Risk: The CHOP regimen includes the combination of an anthracycline (Doxorubicin) and Cyclophosphamide. Clinical guidelines classify this "AC combination" as Highly Emetogenic Chemotherapy (HEC), meaning it has a >90% risk of causing emesis without prophylaxis.
• 5-HT3 Receptor Antagonist Dosing: For HEC regimens, a 5-HT3 receptor antagonist is a mandatory component of acute prevention. The recommended oral dose for ondansetron in this setting is 24 mg (or a range of 16–24 mg).
• Corticosteroid Consideration: Although dexamethasone is standard for HEC, CHOP already includes prednisone as part of the treatment. Clinical guidelines specifically state that clinicians should not reduce the dose or change the schedule of corticosteroids that are already part of the chemotherapy regimen. Therefore, the prednisone in CHOP provides the necessary corticosteroid coverage, making the 5-HT3 antagonist the primary additional prophylactic needed.

Why the other options are incorrect

• A and D: Prochlorperazine and metoclopramide (at standard doses) are low-potency antiemetics generally reserved for low or minimal emetic risk or as breakthrough rescue therapy.
• C: While 20 mg of dexamethasone is used in some HEC protocols, it is not the preferred addition here because the patient is already receiving a high-dose corticosteroid (prednisone) as part of the CHOP chemotherapy.

ZK is a 62-year-old man who is diagnosed with adenocarcinoma of the tung. He also had hemoptysis at the presentation. He is to receive his first cycle of cisplatin and paclitaxel

Which of the following antiemetic regimens would be most appropriate for ZK to receive before his first day of chemotherapy?

• A. Aprepitant 125 mg PO Ondansetron 16 mg PO-Dexamethasone 12 mg PO (87%)
• B. Aprepitant 125 mg PO Metoclopramide 20 mg PO Dexamethasone 12 mg PO (6%)
• C. Ondansetron 16 mg PO Metoclopramide 20 mg PO (4%)
• D. Ondansetron 16 mg PO Prochlorperazine 10 mg PO (3%)

The correct answer is A. Aprepitant 125 mg PO, Ondansetron 16 mg PO, and Dexamethasone 12 mg PO.

Reasoning

• Emetic Risk: ZK is receiving Cisplatin, which is the prototypic Highly Emetogenic Chemotherapy (HEC) agent, causing emesis in more than 90% of patients without prophylaxis.
• Triplet Regimen: For HEC, standard clinical guidelines (ASCO, NCCN, MASCC) require a multi-drug prophylactic triplet consisting of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone.
• Dosing Accuracy:
  • Aprepitant: The standard oral dose for Day 1 is 125 mg.
  • Ondansetron: 16 mg PO is an appropriate dose for acute prevention in HEC regimens.
  • Dexamethasone Adjustment: When used with an NK1 antagonist like aprepitant, the dexamethasone dose must be reduced to 12 mg because aprepitant inhibits the CYP3A4 pathway, which increases the concentration of the steroid in the blood.

Why other options are wrong

• Options B, C, and D are incorrect because they either substitute high-potency agents for low-potency ones like metoclopramide or prochlorperazine, which are insufficient for HEC acute prevention, or they fail to include all three necessary drug classes for the triplet regimen.

DM is a 32-year-old female with breast cancer who is started on AC (doxorubicin/cyclophosphamide). For her first cycle, she received aprepitant 125 mg PO x 1. palonosetron 0.25 mg IV x 1. and dexamethasone 12 mg IV x1 on Day 1 before chemotherapy followed by aprepitant 80 mg PO daily on Days 2-3. and dexamethasone 8 mg PO daily for Days 2-4. However, she is still experiencing severe nausea/vomiting one week after receiving chemotherapy.

Which of the following treatments is most appropriate for DM at this time?

• A. Prochlorperazine 25 mg PO q6h (40%)
• B. Haloperidol 5 mg PO q6h (16%)
• C. Ondansetron 8 mg PO q8h (24%)
• D. Dronabinol capsules 5 mg PO 4 times daily (20%)

The correct answer is D. Dronabinol capsules 5 mg PO 4 times daily.

Reasoning: DM is experiencing breakthrough CINV, which is defined as nausea or vomiting that occurs despite appropriate prophylactic treatment. For breakthrough symptoms, clinical principles recommend adding one agent from a different drug class than those used in the patient's initial prophylactic regimen.

• Class Selection: DM's initial prophylaxis included an NK1 receptor antagonist (aprepitant), a 5-HT3 receptor antagonist (palonosetron), and a corticosteroid (dexamethasone). Dronabinol is a cannabinoid, providing a different mechanism of action to help control her refractory symptoms.
• Dosing Accuracy: According to NCCN guidelines, dronabinol is an appropriate rescue agent at a dose of 5–10 mg every 4 to 6 hours. Administering 5 mg four times daily (every 6 hours) falls within these standard parameters.

Why the other options are wrong

• A. Prochlorperazine 25 mg PO: While prochlorperazine is a standard rescue agent, the oral dose provided here is incorrect. Guidelines specify a breakthrough dose of 10 mg every 6 hours; 25 mg is typically reserved for rectal administration every 12 hours.
• B. Haloperidol 5 mg PO: This dose is too high for breakthrough management. Clinical guidelines recommend a haloperidol dose of 0.5 to 2 mg every 4 to 6 hours for rescue therapy.
• C. Ondansetron 8 mg PO: DM already received a 5-HT3 receptor antagonist (palonosetron) on Day 1. Guidelines generally advise against repeating the same class for breakthrough rescue if that class was already utilized for prophylaxis.

Which of the following drugs is matched appropriately to its side effects?

• A. Granisetron headache, constipation (72%)
• B. Olanzapine diarrhea, drowsiness (18%)
• C. Lorazepam hyperglycemia. dyspepsia (30)
• D. Dexamethasone drowsiness. QTC prolongation (70)

The correct answer is A. Granisetron: headache, constipation.

Reasoning

• A is Correct: 5-HT3 receptor antagonists like granisetron are explicitly associated with headache and constipation as common adverse effects. They may also cause transient increases in liver function tests.
• B is Incorrect: While olanzapine causes drowsiness (somnolence), it is typically associated with constipation rather than diarrhea. Other side effects include weight gain, akathisia, and QTc prolongation.
• C is Incorrect: Hyperglycemia and dyspepsia are side effects of corticosteroids (like dexamethasone), not lorazepam. Lorazepam is associated with sedation, amnesia, and hypotension.
• D is Incorrect: Dexamethasone is associated with insomnia (not drowsiness) and hyperglycemia. QTc prolongation is a risk associated with agents like olanzapine and haloperidol.

JH is receiving high dose cisplatin 100 mg/m² in the ambulatory clinic. His antiemetic regimen included palonosetron, aprepitant, and dexamethasone administered 30-60 minutes before cisplatin.

Which antiemetic prescription should JH receive before going home?

• A. Aprepitant 80 mg PO daily for 2 days Dexamethasone 20 mg PO daily for 2 days (10%)
• B. Aprepitant 80 mg PO daily for 2 days Dexamethasone 8 mg PO daily for 3 days (57%)
• C. Prochlorperazine 10 mg PO four times a day PRN (17)
• D. Ondansetron 8 mg PO TID for 3 days (16%)

The correct answer is B. Aprepitant 80 mg PO daily for 2 days and Dexamethasone 8 mg PO daily for 3 days.

Reasoning: JH is receiving high-dose cisplatin, which is classified as Highly Emetogenic Chemotherapy (HEC). For HEC regimens, delayed nausea and vomiting prevention (Days 2–4) is determined by the specific agents administered on Day 1:

• NK1 Receptor Antagonist: Since JH received oral aprepitant on Day 1, clinical guidelines (ASCO, MASCC, NCCN) recommend continuing oral aprepitant at 80 mg once daily on Days 2 and 3. This is distinct from IV fosaprepitant, which does not require subsequent dosing.
• Corticosteroid: For cisplatin-based delayed prophylaxis, dexamethasone 8 mg PO daily should be administered on Days 2, 3, and 4 (a 3-day course). The dose remains at 8 mg because aprepitant’s inhibition of CYP3A4 continues to increase the steroid's concentration.
• 5-HT3 Antagonists: Guidelines do not recommend using agents like ondansetron for the prevention of delayed emesis in HEC protocols.

Why the other options are incorrect

• A is incorrect because 20 mg of dexamethasone is the unadjusted acute dose; for the delayed phase with an NK1 antagonist, the dose is 8 mg.
• C is incorrect because prochlorperazine is reserved for breakthrough nausea and is not part of a standard HEC delayed prophylaxis regimen.
• D is incorrect because 5-HT3 antagonists (like ondansetron) have limited efficacy for the delayed phase of cisplatin-induced emesis and are not recommended for this purpose.

AY is a 69-year-old female starting IV paclitaxel/carboplatin for non-small cell lung cancer. For her first cycle, she received ondansetron 8 mg IV x1 and dexamethasone 20 mg IV x 1 on Day 1 before chemotherapy, followed by dexamethasone 8 mg PO daily for Days 2-4. However, she is still experiencing severe nausea/vomiting on Day 5.

Which of the following treatments is most appropriate for AY at this time?

• A. Aprepitant 80 mg PO daily (25%)
• B. Ondansetron 8 mg PO q8h (21%)
• C. Promethazine 10 mg PO q6h (20%)
• D. Olanzapine 5 mg PO daily (33%)

The correct answer is D. Olanzapine 5 mg PO daily.

Reasoning: AY is experiencing breakthrough CINV, which occurs when nausea or vomiting develops despite receiving appropriate preventative therapy.

• Class Selection: For breakthrough symptoms, clinical guidelines (NCCN, ASCO) recommend adding one agent from a different pharmacological class than the ones used in the initial prophylactic regimen.
• Olanzapine Efficacy: AY’s initial regimen included a 5-HT3 receptor antagonist (ondansetron) and a corticosteroid (dexamethasone). Olanzapine is a preferred rescue agent because it works through a different, multi-receptor mechanism, blocking dopaminergic, serotonergic, and histaminergic pathways.
• Guideline Dosing: NCCN guidelines specifically recommend olanzapine at a dose of 5–10 mg daily as needed for breakthrough management.

Why the other options are incorrect

• A. Aprepitant: There is no clinical data to support starting or extending an NK1 antagonist like aprepitant to treat breakthrough nausea once it has already begun.
• B. Ondansetron: AY already received a 5-HT3 receptor antagonist for prophylaxis; guidelines generally advise against repeating the same drug class for rescue therapy.
• C. Promethazine: While it belongs to a different class, promethazine is considered a weak antiemetic and is not preferred for use in adult cancer patients.

Which of the following are risk factors for chemotherapy-induced nausea and vomiting?

• A Female sex (18%)
• B Patients younger than 50 years of age (3)
• C Minimal or no alcohol consumption (2%)
• D All of the above (77%)

The correct answer is D. All of the above.

Based on clinical guidelines and the provided sources, several patient-specific factors increase the likelihood of experiencing chemotherapy-induced nausea and vomiting (CINV):

• Female Sex: Women are more predisposed to CINV than men,,.
• Younger Age: Patients younger than 50 years of age (some sources specifically cite age ≤ 40) are at a higher risk,,,.
• Minimal or No Alcohol Consumption: A history of high alcohol intake (often defined as five or more drinks per week) is considered a protective factor; therefore, those with limited or no alcohol use are at increased risk,,.

In our earlier discussion regarding JS, we also noted that her history of motion sickness and morning sickness during pregnancy are additional strong predictors of high emetic risk,,,.

LJ is a 44-year-old man scheduled to receive his first regimen of CHOP chemotherapy for non-Hodgkin's lymphoma. He mentions to you that he does not like taking pills and prefers liquids or forms.

Which 5-HT3 antiemetic regimen would be preferred?

• A. Ondansetron 8 mg oral disintegrating tablet before CHOP (23%)
• B. Granisetron transdermal patch to be applied the day before chemotherapy for up to 7 days (28)
• C. Ondansetron 8 mg IV as a single dose (47%)
• D. Dolasetron 100 mg oral tablet before CHOP (10%)

The correct answer is B. Granisetron transdermal patch to be applied the day before chemotherapy for up to 7 days.

Reasoning

1. Emetic Risk of CHOP The CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisone) contains an anthracycline (doxorubicin) and cyclophosphamide. This "AC combination" is classified as Highly Emetogenic Chemotherapy (HEC), which carries a >90% risk of emesis without prophylaxis.

2. Addressing Patient Preference LJ specifically requested to avoid oral pills.

• Granisetron Transdermal Patch: This is an ideal non-oral option. It is applied 24 to 48 hours prior to chemotherapy and releases 3.1 mg of medication every 24 hours for up to 7 days.
• Comprehensive Coverage: Unlike single-dose IV ondansetron, which primarily targets acute emesis, the granisetron patch is effective for both acute and delayed nausea and vomiting, which is crucial for HEC regimens like CHOP.

Why the other options are less ideal

• A. Ondansetron ODT: While this disintegrates in the mouth, the 8 mg dose is generally considered too low for HEC; oral ondansetron doses for highly emetogenic regimens are typically 16–24 mg.
• C. Ondansetron 8 mg IV: While this avoids pills and is a standard acute dose, 5-HT3 antagonists have variable efficacy for delayed events when given as a single acute dose. The patch provides more sustained protection over the 7-day risk period.
• D. Dolasetron 100 mg oral tablet: This is a pill, which LJ explicitly stated he wishes to avoid.

MJ is a 55-year-old male receiving cisplatin 75 mg/m² on Day 1 and etoposide 100 mg/m² on Days 1-3 for his small cell lung cancer. His antiemetic regimen included palonosetron, aprepitant, and dexamethasone He returns to the clinic the following day with complaints of nausea and vomiting

What do you recommend for his treatment of breakthrough nausea and vomiting?

• A. Ondansetron 8 mg IV (15%)
• B. One liter normal saline plus ondansetron 8 mg IV (16%)
• C. One liter of normal saline plus haloperidol 2 mg IV (30%)
• D. Promethazine 25 mg by mouth (39%)

The most appropriate recommendation for MJ is C. One liter normal saline plus haloperidol 2 mg IV.

Reasoning

1. Breakthrough CINV Management MJ is experiencing breakthrough emesis, which occurs despite receiving appropriate prophylactic treatment,. The core principle for managing breakthrough symptoms is to add an agent from a different pharmacological class than those used in the initial prophylactic regimen,.

2. MJ's Initial Regimen and Drug Classes MJ’s prophylaxis included:

• 5-HT3 Receptor Antagonist: Palonosetron,.
• NK1 Receptor Antagonist: Aprepitant,.
• Corticosteroid: Dexamethasone,.

3. Why Option C is Correct

• Different Class: Haloperidol is a butyrophenone (dopamine receptor antagonist), providing a different mechanism of action than the drugs MJ already received,.
• Guideline Dosing: NCCN breakthrough recommendations include haloperidol at a dose of 0.5–2 mg every 4 to 6 hours as needed.
• Hydration: Because MJ is actively vomiting, administering one liter of normal saline is critical to treat or prevent dehydration and metabolic disturbances associated with CINV.

Why the other options are incorrect

• A and B are incorrect because they use Ondansetron. Since MJ already received a 5-HT3 antagonist (palonosetron), guidelines generally recommend switching to a different class rather than repeating the same one for breakthrough rescue.
• D is incorrect because Promethazine is considered a weak antiemetic and is explicitly not preferred for use in adult cancer patients.

Which of the following best represents the mechanism of action of palonosetron?

• A. Dopamine receptor antagonist (5)
• B. Reduces cerebral edema (1)
• C. Serotonin subtype 3 receptor antagonist (88%)
• D. Serotonin subtype 1 receptor agonist (70)

The correct answer is C. Serotonin subtype 3 receptor antagonist.

• Palonosetron is a second-generation selective serotonin (5-HT3) receptor antagonist. It works through selective antagonism of the 5-HT3 receptor subtype by blocking serotonin in two ways: peripheral antagonism by blocking release from cells in the GI tract, and central antagonism of receptors in the medulla. While it shares this primary mechanism with first-generation agents like ondansetron and granisetron, palonosetron is unique because of its allosteric and facilitative binding, which provides efficacy for both acute and delayed phases of nausea and vomiting.
• Dexamethasone's mechanism of action in the context of nausea and vomiting is unknown but one theory suggests it reduces cerebral edema.
• Serotonin agonists are the triptans (eg, sumatriptan), which treat migraines
• The dopamine antagonists include such drugs as phenothiazines and haloperidol

TK is a 62-year-old male with multiple myeloma who had only a partial response following autologous HSCT 3 months ago. His previous autologous HSCT was complicated by difficulty swallowing and significant ulceration of mouth and throat. The decision has been made to have TK receive a second autologous HSCT with melphalan 140 mg/m² and total body irradiation.

Which of the following would be the best with regards to his second HSCT to reduce the risk of the previous complication?

• A. Pailfermin pre- and post-conditioning regimen (85%)
• B. Reduce melphalan dose by 50% (11%)
• C. Double the dose of filgrastim (1%)
• D. Start methotrexate for GVHD prophylaxis day +21 (4%)

Answer (a)

• Pailfermin is a recombinant human keratinocyte growth factor that stimulates and protects epithelial cells. It has shown an absolute risk reduction of 35% in severe mucositis in patients undergoing autologous HSCT with radiation as a part of the conditioning regimen (answer a).
• Also, pailfermin reduced the duration of mucositis from 9 to 3 days.
• Reduced melphalan dose may reduce the risk of mucositis, but it may adversely impact the efficacy of HSCT. Therefore, it may not be the best option (answer b).
• Filgrastim may primarily help reduce the risk of neutropenia and febrile neutropenia, but not mucositis (answer c).
• Since the patient is receiving autologous HSCT, TK is not at risk of GVHD (answer d).

PT is a 58-year-old male with squamous cell carcinoma of the tongue who presents to the clinic with symptomatic hypercalcemia. An ECG is done, which reveals a shortened QT interval with a widened T wave. At presentation, PT had potassium 3.3 mmol/L serum creatinine 1.5 mg/dL calcium 12.6 mg/dL AST/ALT 20/24 U/L and albumin 3.0 g/dL.

Which of the following is the most appropriate first-line treatment modality for hypercalcemia of malignancy?

• A Normal saline hydration + pamidronate 60 mg IV + gallium nitrate 200 mg/m² IV (8%)
• B Normal saline hydration + zoledronic acid 5 mg IV + calcitonin (12%)
• C Normal saline hydration + zoledronic acid 4 mg IV + calcitonin (76%)
• D Normal saline hydration + gallium nitrate 200 mg/m2 IV + calcitonin (4%)

• The third answer is correct as initial therapy of hypercalcemia should consist of IV hydration, a bisphosphonate, and calcitonin.
  • Patients with hypercalcemia are dehydrated. IV hydration will help dilute the calcium concentration in blood and increase renal excretion of calcium.
  • Bisphosphonates such as zoledronic acid or pamidronate should be initiated as soon as possible as the response requires two-four days, and the nadir in serum calcium may take up to four-seven days after treatment is initiated.
  • Calcitonin is needed as the patient has moderate hypercalcemia but is symptomatic evident by ECG finding. Calcitonin will result in a more rapid response within 12–24 hours.
  • However, tachyphylaxis may occur, and its effect is limited to the first 48 hours.
• Gallium nitrate (first and last answers) is useful in refractory hypercalcemia but can cause nephrotoxicity and hypophosphatemia.
• Zoledronic acid 5 mg (second answer) is not an FDA-approved dose for this indication. 5 mg is the approved dose for the prevention and treatment of osteoporosis.
• Initial therapy of hypercalcemia should consist of IV hydration, a bisphosphonate, and calcitonin.
• Studies have shown zoledronic acid to be more potent and effective than pamidronate with a similar toxicity profile in the treatment of hypercalcemia of malignancy.
• Intranasal calcitonin is not effective for the treatment of hypercalcemia.

Which of the following adverse events is not attributed to the 5-HT3 receptor antagonists?

• A. Constipation (15%)
• B. Headache (5%)
• C. Diarrhea (31%)
• D. Hypertension (50%)

Answer (D)

• Remember that serotonin receptors are laden within the GI tract and CNS.
• Because of this characteristic, patients may exhibit either constipation or diarrhea.
• It is also well known that patients may exhibit headaches from the administration of these agents.

True or False.
Oral 5-HT3 receptor antagonists are as effective as intravenous 5-HT3 receptor antagonists for the prevention of chemotherapy induced nausea and vomiting.

• A True (73%)
• B False  (27%)

Answer (A)

• All oral 5-HT₃ receptor antagonists show equivalent response rates compared to their intravenous formulations.
• Since a large percentage of the body’s serotonin receptors are found in the GI tract, administering these agents orally makes intuitive sense.
• Examples of 5-HT₃ receptor antagonists include: alosetron, dolasetron, granisetron, ondansetron, and palonosetron.

A 62-year-old male patient receives cisplatin and etoposide chemotherapy for small cell lung cancer. He receives palonosetron 0.25 mg IVP, fosaprepitant 150 mg IV, dexamethasone 12 mg IV before cisplatin. He is sent home with a prescription for dexamethasone for the prevention of delayed emesis. He calls you the following day complaining of one episode of vomiting and moderate nausea. What therapy would you suggest?

• A Ondansetron (28%)
• B Aprepitant (7%)
• C Prochlorperazine (47%)
• D No intervention is needed at this time (18%)

Answer (c)

• Since this patient received the long-acting palonosetron (Aloxi), rescuing this patient with ondansetron (Zofran) is not the most appropriate therapy.
• The patient received fosaprepitant (Emend) 150 mg single dose therapy, so giving additional oral aprepitant is not recommended.
• What is recommended for breakthrough emesis or nausea is choosing an agent that was not part of the prophylactic regimen?

HER-2 neu is amplified or over-expressed in approximately what percentage of newly diagnosed breast cancers?

• A) 5 - 10% (4%)
• B) 15 - 20% (80%)
• C) 30 - 50% (13%)
• D) Greater than 75% (3%) 

Answer (B)

• It is important to realize that not all breast cancers express HER-2 neu.
• Human epidermal growth factor receptor 2 (HER2) is a protein called which promotes the growth of cancer cells and is associated with more aggressive cancer.
• Knowing this is also for treatment as hormone therapy is effective. Two treatments for HER-2 neu positive breast cancer include Trastuzumab (Herceptin), a monoclonal antibody, and Lapatinib (Tykerb). A tyrosine kinase inhibitor.

How emetogenic is the single agent pemetrexed?

• A Minimal (12%)
• B Low (54%)
• C Moderate (26%)
• D High (8%)

Answer (B)

• Pemetrexed (Alimta) is considered to have low-risk emetogenicity.
• Prophylactic antiemetics are not routinely used before pemetrexed.
• Dexamethasone is administered before pemetrexed as a means to minimize the development of cutaneous reactions rather as an antiemetic.

Dexamethasone assists in the following chemotherapy-related situations EXCEPT:

• A. Prevention of acute nausea and emesis (7%)
• B. Prevention of delayed nausea and emesis (8%)
• C. Treatment of nausea and emesis (22%)
• D. Prevention of anticipatory nausea and emesis (63%)

Answer (D)

• Dexamethasone is well known to assist in preventing chemotherapy acute and delayed nausea and vomiting.
• In addition, dexamethasone can also be used to treat breakthrough nausea and vomiting.
• Benzodiazepines, rather than corticosteroids, are used for anticipatory nausea and vomiting.

A 68-year-old male returns to the clinic after a recent diagnosis of glioblastoma. He is scheduled tomorrow to receive radiation for a total of 6 weeks.
You start temozolomide 75 mg/m²/day to be used concomitantly with radiation. He is also receiving dexamethasone, insulin, amlodipine, and hydrocodone/acetaminophen as needed. What additional medication should be initiated?

• A. Aspirin for VTE prophylaxis (5%)
• B. DocuSate sodium for constipation prophylaxis (12%)
• C. Enoxaparin for VTE prophylaxis (15%)
• D. Sulfamethoxazole/trimethoprim for Pneumocystis prophylyxis (68%)

Answer (D)

• Since the combination of steroids, radiation, and temozolomide places a patient at risk for developing Pneumocystis pneumonia, all patients, while receiving this therapy, should receiving prophylaxis with sulfamethoxazole/trimethoprim or dapsone during the 42-day regimen of concomitant temozolomide and radiation.
• Once the radiation is completed, the prophylaxis may be stopped as long as the patient is not lymphopenic.

True or False: Allopurinol and rasburicase should not be used concomitantly.

• A True (45%)
• B False (55%)

Answer (B)

• Allopurinol and rasburicase may be used together since they lower uric acid by different mechanisms.
• Allopurinol inhibits uric acid formation by blocking xanthine oxidase. Unfortunately, allopurinol does not affect circulating uric acid.
• Rasburicase quickly lowers uric acid levels by converting uric acid to allantoin.
• By using these agents together, there is a potential to use a lower rasburicase dose and duration since the formation of new uric acid will be inhibited.
• The approved rasburicase dose is 0.15–0.2 mg/kg IV daily for five days. However, there are many small studies describing positive experiences with single 3 to 6 mg rasburicase doses.

IK is a 55-year-old male receiving cisplatin 75 mg/m² on Day 1 and etoposide 100 mg/m2 on Days 1-3 for his small cell lung cancer. After his first chemotherapy cycle, he complained of vomiting x 3 episodes starting 48 hours after chemotherapy.

What type of emesis does this represent and which agent is responsible for this outcome?

• A. Acute emesis from etoposide (3%)
• B. Delayed emesis from etoposide (15%)
• C. Acute emesis from cisplatin (6%)
• D. Delayed emesis from cisplatin (76%)

Answer (D)

• Cisplatin is the classic agent known to produce delayed nausea and vomiting. Delayed emesis occurs 24 hours after receiving cisplatin.
• Etoposide is unlikely to produce acute nausea and vomiting since it is considered a low-risk agent when used alone.

When switching from one opioid to a methadone based opioid regimen, which of the following should be considered regarding the initial calculated equivalent dose of methadone?

• A. Do not adjust the calculated equivalent dose of methadone (11%)
• B. Increase the calculated equivalent dose of methadone by 25% (15%)
• C. Decrease the calculated equivalent dose of methadone by 75% (62%)
• D. Conversion to methadone cannot be safely done (12%)

Answer (C)

• Due to the potency and long duration of action, when converting one opioid to a methadone based regimen, the initial equivalent dose of methadone should be reduced by 75% to 90% and then adjusted based on the response. Given the long half-life, methadone can quickly start to accumulate and thus lead to an overdose if not careful.
• The answers are all wrong or inaccurate.
• When switching to methadone based treatment regimens, the initial reductions in the dose should be higher than other medications to error on the side of caution/safety.
• Methadone has a half-life that can be as long as 60 hours.

Which of the following opioid medications are more dependent on CYP3A4 for metabolism and thus are at greater risks for potential drug-drug interactions?

• A. Fentanyl (42%)
• B. Hydrocodone (20%)
• C. Talwin (20%)
• D. Morphine (18%)

Answer (A)

• Fentanyl (Duragesic), a pure opioid receptor agonist, is the most correct answer choice. Fentanyl is a major substrate of CYP3A4 and, therefore, at a greater risk for drug-drug interactions.
• The other opioid that is also a major substrate of CYP3A4 and at higher risk for drug-drug interactions is methadone (Dolophine).
• Hydrocodone and pentazocine (Talwin) are more dependent on CYP2D6.
• Morphine primarily undergoes phase II metabolism via glucuronidation to morphine-3-glucuronide (inactive as an analgesic) and morphine-6-glucuronide (some activity as an analgesic).
• It is important to recognize medications that are known substrates for CYP3A4 since it is one of the more common phase I metabolic pathways subject to drug interactions. Inhibiting the metabolism of fentanyl could increase its pharmacologic effect and thus compromise its safety profile in that patient.

A 55-year-old patient with Stage 2A HER2 positive breast cancer receives adjuvant trastuzumab therapy every three weeks. At her appointment, she complains of fatigue and the inability to do her normal daily activities. Her lab results show that she is anemic with a hemoglobin of 9.9 g/dL (hematocrit 29%).

Which of the following treatments would be best for this patient?

• A Start epoetin alfa 40,000 units SQ weekly (17%)
• B Begin darbepoetin alfa 500 mcg SQ every three weeks (9%)
• C Initiate iron sucrose 200 mg IV followed by darbepoetin 500 mcg SQ every 3 weeks (12%)
• D No erythropoiesis stimulating agent (ESA) is indicated (82%)

Answer (D)

• This patient does not qualify for erythropoiesis-stimulating agent (ESA) therapy for two main reasons that are stated in the package insert.
• First, she is an early-stage breast cancer patient. So ESA use is not indicated in curative patients.
• Second, she is not receiving myelosuppressive chemotherapy. The use of monoclonal antibodies, such as trastuzumab (Herceptin), are not considered myelosuppressive chemotherapy.
• Since ESAs have a small but significant risk of disease recurrence and death, ESA use in curative patients is not recommended.

A patient is beginning a regimen of dexamethasone for delayed emesis prevention. What should be discussed with the patient about the use of dexamethasone?

• A- You may experience high blood sugar (95%)
• B- You may experience low blood pressure (2%)
• C- Watch out for easy bruising (2%)
• D- Weight loss is a potential problem (1%)

Answer (A)

• Corticosteroids are well known to stimulate hepatic gluconeogenesis leading to hyperglycemia.
• Diabetic patients need close monitoring during and after corticosteroid usage.
• The other side effects listed may occur in a cancer patient but most likely will not be directly linked to the corticosteroid.

• A. Cisplatin is considered highly emetogenic. Thus, GS should receive fosaprepitant + olanzapine before chemotherapy with olanzapine continued on days 2-4. (6%)
• B. Cisplatin is considered low to moderately emetogenic. Thus, GS should receive fosaprepitant + ondansetron + dexamethasone before chemotherapy with dexamethasone continued on days 2-4. (8%)
• C. Cisplatin can cause delayed nausea/vomiting. Thus, GS should receive fosaprepitant + palonosetron + dexamethasone before chemotherapy with dexamethasone continued on days 2-4. (7%)
• D. Cisplatin does not cause delayed nausea/vomiting. Thus, GS should receive ondansetron + dexamethasone before chemotherapy with dexamethasone continued on days 2-4. (9%)

Answer (C)

• Cisplatin is considered highly emetogenic and is also the classic agent for causing delayed nausea/vomiting (occurs > 24 hrs after chemotherapy and peaks about 48-72 hours after administration). Per the NCCN guidelines, any of the following 3-drug antileptemic regimens (A, B, or C, which are not listed in order of preference) should be given before highly emetogenic chemotherapy. When given concomitantly with an NK1 antagonist, there is no preferred 5-HT₃ antagonist. Therefore, palonosetron and ondansetron are interchangeable when given in combination with fosaprepitant.
• Regimen A:

• • NK1 antagonist (choose one of the following): Aprepitant PO1/V x 1; fosaprepitant IV x 1; netupitant/palonosetron PO x 1, fosnetupitant/palonosetron IV x 1 or rolipant PO x 1 AND
  • 5-HT3 antagonist (choose one of the following): Dolasetron PO x 1, granisetron subO/PO/IV x 1 or transdermal, ondansetron PO/IV x 1, or palonosetron IV x 1 AND
  • Dexamethasone PO/IV x 1
• Regimen B:
  • Olanzapine PO x 1(d) + Palonosetron IV x 1 + Dexamethasone PO/IV x 1
• Regimen C:
  • Olanzapine 10 mg PO x 1 AND
  • NK1 antagonist (choose one of the following): Aprepitant PO1/V x 1, fosaprepitant IV x 1, netupitant/palonosetron PO x 1, fosnetupitant/palonosetron IV x 1, or rolipant PO x 1 AND
  • 5-HT3 antagonist (choose one of the following): Dolasetron PO x 1, granisetron subO/PO/IV x 1 or transdermal, ondansetron PO/IV x 1, palonosetron IV x 1

• If a prepratant 125 mg PO x 1 is used on Day 1, it should be followed by 80 mg PO daily on Days 2–3.
• If the combination product (netupitant/palonosetron or fosnetupitant/palonosetron) is used, no further 5-HT3 antagonist is needed.
• If dexamethasone 12 mg PO/IV x 1 is used on Day 1, it should be followed by 8 mg PO/IV daily on Days 2–4.
• If olanzapine 10 mg PO x 1 is used on Day 1, it should be followed by 10 mg PO daily on Days 2–4.
• Fosaprepitant · olanzapine or ondansetron · dexamethasone are not appropriate antimetabolic regimens for highly emetogenic chemotherapy regimens.
• For highly emetogenic chemotherapy such as cisplatin, the NCCN guidelines recommend a variety of 3-drug regimens that target different receptors to prevent nausea/vomiting.
• Granisetron is available in a transdermal patch that should be applied 24–48 hours before the first dose of chemotherapy. It should be removed at least 24 hours after chemotherapy is completed and can be worn for up to 7 days.

PI is a 52-year-old female with a history of recurrent glioblastoma multiforme (GBM) who is receiving temozolomide. Recently, she was hospitalized for an acute asthmatic exacerbation and was discharged from the hospital on high dose prednisone. Based on the information provided, it would be best that Pi was discharged home on which of the medication?

• A. Captopril and hydrochlorothiazide (6%)
• B. Simvastatin (3%)
• C. Diphenhydramine (12%)
• D. Sulfamethoxazole and trimethoprim (7%)

Answer (D)

• The last answer option is correct because temozolomide use results in significant lymphopenia. Patients on concomitant temozolomide and radiation or if receiving steroids should get PCP prophylaxis, such as sulfamethoxazole/trimethoprim.
• Steroids may acutely increase the risk for higher blood pressure, but anti-hypertensive prophylaxis first answer is not recommended.
• PI is not at increased risk for hyperlipidemia or allergic reactions, thus making the second and third answer choices wrong.
• Patients who are on concomitant temozolomide and radiation or if receiving steroids should get PCP prophylaxis.
• Since temozolomide can cause myelosuppression, the absolute neutrophil count (ANC) and platelet count should be monitored before dosing and throughout treatment.

A 55-year-old male is admitted for high dose melphalan chemotherapy followed by an autologous hematopoietic stem cell transplant for his multiple myeloma. This patient has a history of poor dentition, and the nurses are inquiring about different strategies to minimize stomatitis from the melphalan.

Which is the best option to prevent or minimize mucositis?

• A Keeping his mouth clean with multiple brushings and flossing throughout the day (1%)
• B Using the triple mix (diphenhydramine, nystatin, and lidocaine) before meals (2%)
• C Have him use sucralfate 1 gm mouth rinses four times a day (6%)
• D Have him suck on ice chips before, during melphalan infusion, and for 30 minutes after infusion ends (62%)

Answer (D)

• Using cryotherapy, such as ice chips, may significantly reduce the mucositis’ severity in patients receiving high dose mefllithian.
• Use of prepared concoctions such as triple mix and sucralfate are ineffective in the prevention of mucositis.
• Keeping the patient’s mouth clean is important, but brushing and flossing may damage the gums and lead to an infection or severe mucositis.
• Using the soft foam toothpaste style device is the best option to clean the mouth without damaging the gums.
• Avoiding alcohol-containing mouthwashes is also prudent since it may dry out the mucosal tissues leading to mucositis.
• Lastly, using a salt and baking soda mixture is ideal to use multiple times a day to keep the mouth clean.

Which of the following oral agents requires the patient to receive antiemetic prophylaxis?

• A. Capecitabine (40%)
• B. Letrozole (3%)
• C. Temozolomide (45%)
• D. Erlotinib (13%)

Answer (C)

• Temozolomide (> 75 mg/m^²/day) is an oral agent that is considered moderately to highly emetogenic. Therefore, any patient on this type of oral chemotherapy should be provided an antiemetic prophylaxis regimen.
• Common understanding is that only intravenous chemotherapy agents can increase the risk of emesis. However, that is no longer true with the availability of newer oral chemotherapy agents.
• Capecitabine and erlotinib have a minimal to low emetic risk, and letrozole is not associated with a significantly increased risk of emesis.
• Temozolomide (> 75 mg/m^²/day) is considered to be moderately to highly emetogenic and should be given with antimetic prophylaxis.
• Per NCCN guidelines, temozolomide (≥ 75 mg/m²/day) should be considered moderately emetogenic with concurrent radiation.

JZ is a 55-year-old male diagnosed with multiple myeloma and osteolytic bone lesions. The oncologist has decided to initiate a monthly zoledronic acid infusion.

Which of the following adverse events would you counsel JZ about?

• A. Acute renal failure. osteonecrosis of the jaw. hypocalcemia (52%)
• B. Atrial fibrillation. acute renal failure. congestive heart failure (5%)
• C. Osteonecrosis of the jaw. congestive heart failure. bone pain (17%)
• D. Congestive heart failure. osteonecrosis of the jaw. acute renal failure (26%)

Answer (A)

• The third answer is correct as patients starting zoledronic acid should be counseled on the risk of renal toxicity, osteonecrosis of the jaw, musculoskeletal pain, and hypocalcemia.
• Congestive heart failure is not typical of zoledronic acid.
• Acute renal failure. osteonecrosis of the jaw, musculoskeletal pain, and hypocalcemia are all adverse reactions associated with zoledronic acid.
• Zometa (zoledronic acid) is approved for the treatment of hypercalcemia of malignancy and for multiple myeloma patients and solid tumor patients with documented bone metastases from solid tumors. The dose is 4 mg IV once every 3–4 weeks.
• On the other hand, Reclast (zoledronic acid) is approved for the treatment and prevention of osteoporosis and the treatment of Paget’s disease. The dose is typically 5 mg IV once every 1–2 years, depending on the indication.

Which agent can be administered to reduce the extrapyramidal side effects of metoclopramide?

• A. Diphenhydramine (7%)
• B. Promethazine (10%)
• C. Dexamethasone (12%)
• D. Dronabinol (7%)

• Metoclopramide is known to antagonize dopamine, therefore, placing patients at risk for developing parkinsonian symptoms, which are exacerbated along with higher levels of acetylcholine.
• Typical extrapyramidal symptoms include pill-rolling, muscular spasms of the neck, oculogyric crisis, and motor restlessness.
• Treatment includes drug cessation and the beginning of an anticholinergic agent such as diphenhydramine or benztropine.

Which of the following agents possess minimal emetogenic potential?

• A Carboplatin (10%)
• B Ifosfamide (13%)
• C Temozolomide 150 mg/m²/dose (20%)
• D Vinorelbine (57%)

Answer (D)

• Carboplatin, ifosfamide, and higher dose temozolomide all tend to be moderately emetogenic. If temozolomide were dosed at 75 mg/m2 or lower, then it would be considered a low-risk medication.
• All vinca alkaloids (vincristine, vinblastine, and vinorelbine) are all considered minimal emesis risk.

JK is a 65-year-old male receiving cisplatin 75 mg/m2 on Day 1 and etoposide 100 mg/m² on Days 1-3 for his small cell lung cancer. After his second and third cycles, he returns to the clinic for treatment of breakthrough nausea and vomiting. A week after his third cycle, JK was at the grocery store, and he happens to see his chemotherapy nurse. After speaking with her, JK begins to vomit. What type of vomiting is JK experiencing?

• A. Acute emesis (2%)
• B. Delayed emesis (19%)
• C. Breakthrough emesis (4%)
• D. Anticipatory emesis (75%)

Answer (D)

• Anticipatory vomiting is a learned response from a history of poor emesis control.
• If a patient has repeated emesis episodes after repeated chemotherapy cycles, the patient may be at risk for anticipatory vomiting.
• The patient may see someone or something or experience a certain smell and have vomiting.
• So in the above case, he sees his nurse and immediately has vomiting because she is associated with his chemotherapy and then having emesis.

A 68 year old male with glioblastoma is currently on temozolomide 75 mg/m²/day along with radiation. He is also currently receiving dapsone for Pneumocystis pneumonia prophylaxis.

When should the dapsone be discontinued?

• A. Continue dapsone until the end of radiation/temozolomide concomitant therapy and the lymphocyte count recovers (78%)
• B. Continue dapsone until temozolomide maintenance phase is complete (13%)
• C. Discontinue dapsone since it’s only needed with temozolomide 150-200 mg/m2 dosage (3%)
• D. Discontinue dapsonate only when the steroids are discontinued (65%)

Answer (A)

• Since the combination of steroids, radiation, and temozolomide places a patient at risk for developing Pneumocystis pneumonia, all patients receiving this combination therapy should also be receiving prophylaxis with sulfamethoxazole/trimethoprim or dapsone.
• Once the radiation is completed the prophylaxis may be stopped as long as the patient is not lymphopenic.

What liver enzyme is in part responsible for the metabolism of tramadol and also inhibited by paroxetine and fluoxetine?

• A. CYP1A2 (3%)
• B. CYP2C9 (14%)
• C. CYP2D6 (67%)
• D. CYP3A4 (16%)

Answer (C)

• Tramadol is normally metabolized by CYP2D6 and CYP3A4 enzymes to active and inactive metabolites. Therefore, inhibitors of either enzyme will potentiate the effects of tramadol, causing an increase in the amount of norepinephrine and serotonin in the synaptic cleft.
• Several of the SSRIs (fluoxetine and paroxetine, in particular) are potent inhibitors of CYP2D6 and are likely to cause increases in tramadol concentrations.
• As mentioned earlier, the risk of developing serotonin syndrome while taking tramadol alone is notable and increases with higher doses of the drug; this risk is compounded by coadministration of SSRIs (specifically fluoxetine and paroxetine). As such, the manufacturer of tramadol provides a bolded warning regarding this drug interaction.

Which antiemetic regimen is recommended before CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy?

• A. Prochlorperazine 10 mg PO (8%)
• B. Ondansetron 24 mg PO (63%)
• C. Dexamethasone 20 mg PO (26%)
• D. Metoclopramide 30 mg PO (3%)

Answer (B)

• Since this regimen contains prednisone, the addition of dexamethasone along with ondansetron is not necessary.
• If the patient did not take their prednisone before receiving the chemotherapy, then the administration of dexamethasone along with ondansetron should be given.
• Prochlorperazine, metoclopramide, and/or dexamethasone alone are not recommended as first-line agents for the prevention of chemotherapies-induced nausea and emesis.

IK is a 62-year-old man who is diagnosed with adenocarcinoma of the lung. He also had hemoptysis at the presentation. He is to receive his first cycle of cisplatin and paclitaxel.

Which of the following anti-emetic regimens would be most appropriate for ZIK to receive before his first day of chemotherapy?

• A. Aprepitant 125 mg PO + Ondansetron 16 mg PO + Dexamethasone 12 mg PO (87%)
• B. Aprepitant 125 mg PO + Metoclopramide 20 mg PO + Dexamethasone 12 mg PO (6%)
• C. Ondansetron 16 mg PO + Metoclopramide 20 mg PO (4%)
• D. Ondansetron 16 mg PO + Prochlorperazine 10 mg PO (3%)

Answer (A)

• The first answer is correct because, based on cisplatin-based chemotherapy, ZK is at high risk (> 90%) for emesis. Per the NCCN guidelines, any of the following 3-drug antiemetic regimens (A, B, or C, which are not listed in order of preference) should be given before highly emetogenic chemotherapy on Day 1.

A

• NK1 antagonist (choose one of the following):
  • Aprepitant PO/IV x 1, fosaprepitant IV x 1, netupitant/palonosetron PO x 1, fosnetupitant/palonosetron IV x 1; rolapitant PO x 1
• AND
• 5-HT3 antagonist (choose one of the following):
  • Dolasetron PO x 1, granisetron SubQ/PO/IV x 1 or transdemoral, ondansetron PO/IV x 1, palonosetron IV x 1
• AND
• Dexamethasone PO/IV x 1

• B
  • Olanzapine PO x 122
  • AND
  • Palonosetron IV x 1
  • AND
  • Dexamethasone PO/IV x 1
• C
  • Olanzapine 10 mg PO x 144
  • AND
  • NK3 antagonist (choose one of the following):
    • Aprepitant PO/IV x 1, fosaprepitant IV x 1, netupitant/palonosetron PO x 122, fosnetupitant/palonosetron IV x 122, rolapitant PO x 1
  • AND
  • 5-HT3 antagonist (choose one of the following):
    • Dolasetron PO x 1, granisetron SubO/PO/IV x 1 or transdermal, ondansetron PO/IV x 1, palonosetron IV x 1
  • AND
  • Dexamethasone PO/IV x 133
• If prepatent 125 mg PO x 1 is used on Day 1, it should be followed by 80 mg PO daily on Days 2-3.
• If the combination product (nefutopant/palonosetron or fosequinptan/palonosetron) is used, no further 5-HT3 antagonist is needed.
• If dexamethasone 12 mg PO/IV x 1 is used on Day 1, it should be followed by 8 mg PO/IV daily on Days 2-4.
• If olanzapine 10 mg PO x 1 is used on Day 1, it should be followed by 10 mg PO daily on Days 2-4.
• Metoclopramide has not been studied in combination with aprepitant (secod and answer).
• Dexamethasone is a key component of any anti-emetic regimen for prophylaxis of acute emesis (third and fourth answers).

For highly emetogenic chemotherapy such as cisplatin, the NCCN guidelines recommend a variety of 3-drug regimens that target different receptors to prevent nausea/vomiting. Concomitant administration of prochlorperazine, promethazine, metoclopramide, or haloperidol should be used with caution since excessive dopamine blockade can increase the risk of extrapyramidal symptoms (EPS).

DM is a 32-year-old female with breast cancer who is started on AC (doxorubicin/cyclophosphamide). For her first cycle, she received aprepitant 125 mg PO x 1, palonosetron 0.25 mg IV x 1, and dexamethasone 12 mg IV x 1 and Day 1 before chemotherapy followed by aprepitant 80 mg PO daily on Days 2-3, and dexamethasone 8 mg PO daily for Days 2-4. However, she still experiencing severe nausea/vomiting one week after receiving chemotherapy.

Which of the following treatments is most appropriate for DM at this time?

• A Prochlorperazine 25 mg PO q6h (40%)
• B Haloperidol 5 mg PO q6h (16%)
• C Ondansetron 8 mg PO q6h (24%)
• D Dronabinol capsules 5 mg PO 4 times daily (20%)

Answer (D)

• The general rule for treating breakthrough nausea/vomiting is to add an agent from a different drug class to the current regimen. Thus, promethazine, haloperidol, and dronabinol are all appropriate options. However, only the dronabinol dose is listed correctly here (capsules 5-10 mg or oral solution 2:1-4.2 mg/m² PO 3-4 times daily).
• The correct oral prochlorperazine dose should be 0.5 mg PO q6h.
• The correct oral haloperidol dose for the prevention of nausea/vomiting should be 0.5-2 mg PO q4-6h.
• Ondansetron would not be appropriate in this situation as DM has already received a 5-HT₃ antagonist (paliyosontron) before chemotherapy and is still experiencing breakthrough nausea/vomiting. Furthermore, while ondansetron is effective for preventing acute emesis, it has not shown to be effective for delayed emesis.
• The treatment for breakthrough nausea/vomiting is to add an agent from a different drug class to the current regimen.
• Concomitant administration of phenothiazines (prochlorperazine, promethazine, metoclopramide, or haloperidol) should be used with caution as it may lead to an increased risk of extrapyramidal symptoms (EPS). Olanzapine, given in combination with any phenothiazine, can also increase the risk of EPS.

Which agent is NOT used to mobilize CD34+ cells for autologous hematopoietic stem cell collection?

• A. Plerixafor (Mozobil) (7%)
• B. Filgrastim (Neupogen) (4%)
• C. Sargamostim (Leukine) (7%)
• D. Oprelvekin (Neumega) (8%)

Answer: (D)

• Plerixafor, filgrastim, and sargamostim are all FDA approved to mobilize peripheral blood progenitor cells.
• Plerixafor increases the progenitor cells by antagonizing the chemokine receptor 4 binding thereby releasing them into the peripheral blood.
• Filgrastim and sargamostim are both colony stimulating factors designed to increase the production, maturation, and activation of neutrophils.
• Oprelvekin stimulates only the production of platelets and therefore would not be ideal as a mobilizer for CD34+ progenitor cells required for transplant.

Which of the following drugs is matched appropriately to its side effects?

• A. Granisetron headache, constipation (72%)
• B. Olanzapine diarrhea, drowsiness (18%)
• C. Lorazepam: hyperglycemia, dyspepsia (3%)
• D. Dexamethasone drowsiness, OTc prolongation (7%)

Answer: (A)

• First-generation 5-HT₃ antagonists such as granisetron commonly cause headache, constipation, and QTc prolongation. The risk for increased QTc interval is not on the package insert for palonosetron.
• Olanzapine is not typically associated with diarrhea but may cause fatigue, drowsiness, weight gain, and extrapyramidal symptoms (EPS).
• Lorazepam is not typically associated with hyperglycemia and dyspepsia but may cause drowsiness, amnesia, and hypotension.
• As with any steroid, dexamethasone typically causes hyperglycemia and insomnia (consider AM dosing to minimize this). It is not associated with drowsiness or QTc prolongation.
• Each antiemetic agent has a unique toxicity profile, and these adverse effects should be considered when selecting an appropriate antiemetic regimen for patients.
• Lorazepam plays a crucial role in preventing anticipatory nausea/vomiting through its anxiolytic effect.

JH is receiving high dose cisplatin 100 mg/m² in the ambulatory clinic. His anthelmetic regimen included palonosetron, aprepitant, and dexamethasone administered 30-60 minutes before cisplatin. Which antiemetic prescription should JH receive before going home?

• A. Aprepitant 80 mg PO daily for 2 days Dexamethasone 20 mg PO daily for 2 days (10%)
• B. Aprepitant 80 mg PO daily for 2 days Dexamethasone 8 mg PO daily for 3 days (57%)
• C. Prochlorperazine 10 mg PO four times a day PRN (17%)
• D. Ondansetron 8 mg PO TID for 3 days (16%)

Answer (B)

• As part of the delayed emesis prevention regimen, when patients receive cisplatin, aprepitant (Emend) is continued for two days, and dexamethasone should be administered for three days. The dose of dexamethasone depends on whether they received aprepitant.
• Since aprepitant inhibits the dexamethasone’s metabolism, the delayed dexamethasone dose is reduced from 8 mg PO BID to 8 mg PO once daily.
• The use of prochlorperazine (Compazine) alone would not be appropriate.
• The use of ondansetron (Zofran) would not be appropriate either since the patient received palonosetron, a long-acting 5-HT₃ receptor antagonist.

AY is a 6g-year-old female starting IV paclitaxel/carboplatin for non-small cell lung cancer. For her first cycle, she received ondansetron 8 mg IV x 1 and dexamethasone 20 mg IV x 1 on Day 1 before chemotherapy followed by dexamethasone 8 mg PO daily for Days 2-4. However, she is still experiencing severe nausea/vomiting on Day 5.

Which of the following treatments is most appropriate for AY at this time?

• A. Appretiant 80 mg PO daily (25%)
• B. Ondansetron 8 mg PO q3h (21%)
• C. Promethazine 10 mg PO q3h (20%)
• D. Olanzapine 5 mg PO daily (33%)

Answer (D)

• The general rule for treating breakthrough nausea/vomiting is to add an agent from a different drug class to the current regimen. Thus, olanzapine and promethazine would both be viable options. Although these drugs should be used in caution in the elderly due to an increased risk of CNS depression. However, the promethazine dose here is not correct (should be 12.5–25 mg PO q4–6h).
• NK1 antagonists such as aprepitant should be used primarily for prevention, not treatment of nausea/vomiting. Thus, it is not recommended in this situation but can be added onto AY’s future cycles if given before chemotherapy in combination with ondansetron and dexamethasone to prevent acute and delayed nausea/vomiting.
• Ondansetron would not be appropriate in this situation as AY has already received ondansetron before chemotherapy and is still experiencing breakthrough nausea/vomiting. Furthermore, while ondansetron is effective for preventing acute emesis, it has not shown to be effective for delayed emesis.
• The treatment for breakthrough nausea/vomiting is to add an agent from a different drug class to the current regimen.
• Since the oral route may not be feasible at times due to persistent vomiting, other routes of administration (rectal, topical, subcutaneous or IV) may be required. Promethazine is available PO, IV, and PR (rectally).
• Promethazine has a stronger antihistamine effect than prochlorperazine and is, therefore, more sedating.

Which of the following are risk factors for chemotherapy-induced nausea and vomiting?

• A. Female sex (18%)
• B. Patients younger than 50 years of age (3%)
• C. Minimal or no alcohol consumption (2%)
• D. All of the above (77%)

Answer (D)

• All of the above are classic risk factors for chemotherapy-induced nausea and vomiting.
• It is well known that young women with minimal alcohol intake history substantially increase the risk.
• If a patient has chronic alcohol consumption (≥100 g/day for several days), the risk of vomiting diminishes.
• Other risk factors for chemotherapy induced nausea and vomiting includes a history of motion sickness, pregnancy-related emesis, prior chemotherapy-related emesis, and high anxiety levels.

LJ is a 44-year-old man scheduled to receive his first regimen of CHOP chemotherapy for non-Hodgkin’s lymphoma. He mentions to you that he does not like taking pills and prefers liquids or forms.

Which 5-HT3 antimetallic regimen would be preferred?

• A Ondansetron 8 mg oral disintegrating tablet before CHOP (23%)
• B Granisetron transdermal patch to be applied the day before chemotherapy for up to 7 days (28%)
• C Ondansetron 8 mg IV as a single dose (47%)
• D Dolasetron 100 mg oral tablet before CHOP (1%)

Answer (C)

• Ondansetron (Zofran) taken by mouth is recommended at a dose of 2 mg versus 8 mg IV.
• Dolasetron (Anzemet) would be appropriate, but the patient did not want to take a tablet.
• Granisetron (Sancuso) transdermal patch is an attractive option but is not appropriate in this case.
• The cost difference between the two agents favors generic ondansetron versus the branded granisetron patch. Even though the patch may last seven days, the data available for a patient benefiting from prolonged granisetron usage lacks those receiving chemotherapy on a single day. Data with single or daily oral granisetron clearly demonstrate a lack of efficacy in the delayed phase emesis prevention. This patch may have a role in the prevention of acute emesis in multi-day chemotherapy regimens. However, ondansetron single daily dose would be the most frugal way to approach this patient.

DS is a 41-year-old male recently diagnosed with diffuse large B-cell lymphoma. Before receiving his R-CHOP therapy (rituximab, cyclophosphamide, vincristine, doxorubicin, prednisone), the labs are checked and are as follows: BUN 22 mg/dL serum creatinine 1.3 mg/dL, uric acid 6.5 mg/dL phosphate 4.4 mg/dL, LDH 333 U/L and potassium 4.4 mEq/L. Which preventative therapy should be started immediately?

• A Mesna (25%)
• B Rasburicase (19%)
• C Calcium acetate (9%)
• D Allopurinol (48%)

Answer (D)

• Allopurinol is a xanthine oxidase inhibitor that prevents the formation of uric acid. This drug should be started immediately in those patients at risk for tumor lysis syndrome (TLS).
• Patients with rapidly dividing malignancies such as certain types of leukemias (e.g., AML and lymphomas e.g., Burkitt’s lymphoma and diffuse large B cell lymphoma) are at risk for TLS.
• The LDH is a good marker that depicts tumor burden and may provide a hint of a patient’s TLS risk. Since this patient’s LDH was elevated and he has a diffuse large B-cell lymphoma, he is at risk for TLS.
• If this patient’s uric acid was over 10 mg/dL along with renal dysfunction, then the use of preventative rituximab would be indicated.
• All patients at intermediate or high risk for TLS except those with renal failure or oliguria should be given adequate hydration for the prevention and treatment of TLS to maintain equal fluid intake and urinary output.
• Rasburicase quickly converts uric acid to allantoin, which is really cleared. Mesna is not given with the CHOP regimen. Calcium acetate, a phosphate binder, may be started if the patient’s phosphorus level was elevated.

When trying to switch a patient from morphine to another opioid analgesic, which of the following is most accurate?

• A. No adjustments in the new opioid are needed since the equivalent dosing is well established (4%)
• B. The new opioid equivalent dose of oxycodone should be initially reduced by 25 to 50% (84%)
• C. All opioids should be converted to fentanyl equivalent doses first (6%)
• D. Individual responses to opioids are fairly consistent and predictable allowing for easy conversions (7%)

Answer (B)

• Assuming methadone and fentanyl transdermal patches are not being considered for the new opioid, the other opioids should have dose reductions of at least 25% to 50% of the initial calculated equivalent dose to error on the side of safety. Doses can then be titrated up to the response.
• Most conversions to another opioid are usually done in morphine equivalent, not fentanyl equivalents.
• Individual responses to opioids are usually variable (not consistent or predictable) and there is usually an incomplete cross-tolerance between agents which why dose reductions are initially made to the new opioid equivalent doses.
• Assuming methadone and fentanyl transdermal patches are not being considered for the new opioid, the other opioids should have dose reductions of at least 25% to 50% of the initial calculated equivalent dose to error on the side of safety.
• Morphine 10 mg IM is equivalent to 30 mg of morphine by mouth.

WW is a 56-year-old male with metastatic colon cancer who is starting FOLFIRI (fluorouracil, irinotecan, leucovorin). On the first night of chemotherapy, he begins experiencing severe abdominal cramping and diarrhea. Which of the following treatments is most appropriate for WW at this time?

• A Octreotide (9%)
• B Tincture of opium (4%)
• C Loperamide (46%)
• D Atropine (41%)

Answer (D)

• Irinotecan can cause acute or delayed diarrhea. Acute diarrhea occurs immediately after irinotecan administration and is associated with cholinergic symptoms such as abdominal cramping, rhinitis, lacrimation, and salivation. The mean duration of symptoms is 30 minutes, and atropine is the drug of choice.
• In this situation, VVW has acute diarrhea (< 24 hours after irinotecan was given).
• On the other hand, delayed diarrhea occurs more than 24 hours after irinotecan administration. It is noncumulative, and occurs at all dose levels.
• Octreotide, a synthetic analogue of somatostatin, inhibits the release of vasoactive intestinal peptide (VIP) and decreases the secretion of pancreatic juice.
• Irinotecan may cause acute or delayed diarrhea. The immediate onset of diarrhea is associated with cholinergic symptoms, and atropine is the drug of choice.
• Risk factors for irinotecan-induced diarrhea include weekly administration, poor performance status, high serum creatinine levels, prior abdominal radiation therapy, low WBC, age over 70 years. Gilbert syndrome and Crigler-Najjar syndrome type 1.

MJ is a 55-year-old male receiving cisplatin 75 mg/m² on Day 1 and etoposide 100 mg/m2 on Days 1-3 for his small cell lung cancer. His antiemetic regimen included palonosetron, aprepitant, and dexamethasone. He returns to the clinic the following day with complaints of nausea and vomiting. What do you recommend for his treatment of breakthrough nausea and vomiting?

• A. Ondansetron 8 mg IV (15%)
• B. One liter normal saline plus ondansetron 8 mg IV (16%)
• C. One liter normal saline plus haloperidol 2 mg IV (30%)
• D. Promethazine 25 mg by mouth (39%)

Answer (C)

• Administration of intravenous fluids is an effective strategy in the management of chemotherapy-induced nausea and vomiting.
• The treatment of breakthrough emesis requires the use of an agent not found in the patient’s prophylactic regimen.
• Therefore, the use of a 5-HT₃ receptor antagonist is not recommended since the patient received palonosetron (Aloxi) before chemotherapy.
• Haloperidol or phenothiazines (prochlorperazine or promethazine) are options for the treatment of breakthrough nausea and vomiting.
• The use of the oral route is not the preferred route for the treatment of breakthrough vomiting.

BL is a 33-year-old with acute myelogenous leukemia admitted for induction chemotherapy. He is currently receiving prophylactic antimicrobials such as acyclovir, levofloxacin, and posaconazole. He is complaining of some gas and abdominal discomfort since finishing his chemotherapy regimen. His doctor diagnosed him with gastritis, most likely from his dexamethasone-pimethasone medications for emesis prevention. Which of the following choices should you avoid?

• A. Pantoprazole (Protonix) (40%)
• B. Sucralfate (Carafate) (14%)
• C. Aluminum hydroxide/magnesium hydroxide/simethicone (Mylanta) (40%)
• D. Famotidine (Pepcid) (7%)

Answer (A)

• The use of proton pump inhibitors (PPI) along with posaconazole or itraconazole capsules. will negatively impact absorption and could lead to therapeutic failure.
• Coadministration with esomeprazole resulted in a 30% decrease in the posaconazole area under the curve (AUC). It is recommended to take posaconazole with meals and to avoid all PPIs if possible.
• Coadministration with cimetidine (Tagamet) led to a decrease in posaconazole AUC by 39%. However other H2 receptor blockers (e.g., famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac)) or oral antacids did not significantly alter posaconazole concentrations.

Which agent is classified as a keratolytic growth factor?

• A Interferon alfa-2b (Intron A) (8%)
• B Oprelvekin (Neumega) (23%)
• C Pailfermin (Kepivance) (65%)
• D Romiplostim (Nplate) (13%)

Answer (C)

• Palifermin is a human keratinocyte growth factor (KGF), which binds to the KGF receptor and results in proliferation, differentiation, and migration of epithelial cells.
• Palifermin 60 mcg/kg/day for 3 days is considered prior to conditioning treatment and for 3 days post-transplant to prevent oral mucositis in patients with hematological malignancies receiving high-dose chemotherapy and total body irradiation followed by autologous stem cell transplant.
• In head and neck cancer, palifermin has also been shown to reduce oral mucositis pain severity scores and the duration of mucositis but has not been shown to reduce the use of opioids for pain nor improve progression free survival.

CC is a 44-year-old male recently diagnosed with Burkitt's like lymphoma. Three days into receiving Hyper-CVAD therapy (cyclophosphamide, vincristine, doxorubicin, dexamethasone), the nurses noted a decrease in urinary output plus the following labs were found: BUN 2 mg/dL, serum creatinine 1.6 mg/dL, uric acid 14.5 mg/dL, phosphorous 4.4 mg/dL and potassium 4.6 mEq/L.

Which agent should be started immediately to lower the uric acid level immediately?

• A Allopurinol (17%)
• B Probenecid (10%)
• C Rasburicase (68%)
• D IV fluids with sodium bicarbonate (6%)

Answer (C)

• Allopurinol prevents the formation of uric acid. So it does not have any influence on circulating uric acid. The only agent list that will have a significant impact on uric acid levels will be rasburicase.
• Rasburicase rapidly converts uric acid to allantoin, which is readily eliminated renally. It should be considered when patients have an elevated uric acid plus an altered renal clearance, most likely to uric acid nephropathy.
• Probenecid prevents the reabsorption of uric acid at the proximal convoluted tubule, which allows for renal elimination of excess uric acid; this drug is not used for elevated uric acid levels from tumor lysis syndrome.
• The use of sodium bicarbonate to alkalinize urine is currently not recommended for the prevention and treatment of TLS due to the complications of metabolic alkalosis and calcium phosphate precipitation, as well as the lack of evidence demonstrating benefit. Furthermore, all patients at intermediate or high risk for TLS, except those with renal failure or oliguria, should be given adequate hydration for the prevention and treatment of TLS.

JJ is experiencing pain from his metastatic colorectal cancer and has received morphine basal at 2 mg/hr and 4 mg PCA dose with lockout every 15 minutes over the past 72 hours. He is ready to convert to a route appropriate for home usage.

What additional information do you need to make an accurate conversion?

• A. His weight (4%)
• B. Sites of metastatic disease (1%)
• C. How long he has been receiving opioids before admission to the hospital? (8%)
• D. How much basal morphine and PCA morphine was used in the past 24 hours? (87%)

Answer (D)

• In order to calculate an alternative opioid route, the total morphine usage should be calculated. This includes scheduled and PRN (as needed) doses.
• Metastatic disease sites may be an issue if the patient has liver and/or renal involvement.
• This would alter whether or not morphine would be the best choice in someone who had significant liver or renal impairment. Morphine is metabolized in the liver by glucuronidation and the main metabolite is then cleared renally.
• Weight in the adult patient has little impact on the treatment of chronic pain.
• His usage before admission to the hospital would impact the initial dose, but not on the conversion to another route upon discharge.

Which of the following best represents the mechanism of action of palonosetron?

• A. Dopamine receptor antagonist (5%)
• B. Reduces cerebral edema (1%)
• C. Serotonin subtype 3 receptor antagonist (88%)
• D. Serotonin subtype 1 receptor agonist (7%)

Answer (C)

• Palonosetron (Aloxi), ondansetron (Zofran). dolasetron (Anzemet). granisetron (Kytril) are all 5-HT3 (serotonin) receptor antagonists.
• They work both in the periphery at the vagus nerve level and in the central nervous system at the level of the chemoreceptor trigger zone (CTZ).
• Dexamethasone’s mechanism of action in the context of nausea and vomiting is unknown, but one theory suggests it reduces cerebral edema.
• Serotonin agonists’ are the -triptans (e.g., sumatriptan) which treat migraines.
• The dopamine antagonists include such drugs as phenothiazines and haloperidol.

MJ is a 63-year-old white male placed on tamoxifen 20 mg daily for five years for adjuvant treatment of his male breast cancer.

Which of the following should be shared with MJ?

• A. Tamoxifen should be used cautiously in those with hyperlipidemia (3%)
• B. He may be at increased risk of prostate cancer after starting tamoxifen (7%)
• C. If he continues his international business flights, he needs to be wary of an increased risk of thrombosis from tamoxifen (69%)
• D. He should begin taking calcium and vitamin D supplements since tamoxifen may increase the risk of osteoporosis (21%)

Answer (C)

• Tamoxifen will increase M.J.’s risk of thrombosis.
• It is well known that tamoxifen possesses antiestrogen effects on certain tissues such as the breast and vaginal mucosa, and estrogenic effects on the bones, lipids, and endometrium.
• Tamoxifen has also been associated with a hypolipidemic effect.
• In addition, it also carries similar thrombotic risks as the other hormonal agents (e.g., estrogen, oral contraceptives), and patients should be made aware of this adverse effect.

Tramadol (Ultram; Ultram ER; Ultracet) is best described as what type of medication?

• A Antidepressant only (2%)
• B Opioid analgesic only (23%)
• C Opioid analgesic with some antidepressant properties (73%)
• D Muscle relaxant (2%)

Answer (C)

• Tramadol is a unique medication in that it is known to have two mechanisms of action.
• It is first and most commonly used as a weak opioid for the treatment of mild to moderate pain.
• Furthermore, it is also known to inhibit the reuptake of serotonin (5-HT) and norepinephrine from the synaptic cleft within the central nervous system.
• As such, it can be used to treat pain and mild symptoms of depression, which commonly co-exist in patients with chronic pain.

BK is a 56-year-old female with a history of breast cancer comes into your pharmacy complaining of diarrhea, nausea & vomiting, increased thirst, and fatigue. Which of the following symptoms are consistent with signs & symptoms of hypercalcemia?

• A. Nausea & vomiting, increased thirst, fatigue (53%)
• B. Fatigue, diarrhea, nausea & vomiting (21%)
• C. Increased thirst, fatigue, diarrhea (11%)
• D. Diarrhea, nausea & vomiting, increased thirst (15%)

Answer (A)

• The first answer is correct as patients with hypercalcemia may present with gastrointestinal, renal, neurologic, and cardiac symptoms. Common gastrointestinal symptoms include nausea, vomiting, anorexia, or constipation, but not diarrhea.
• High-Yield Core Concept:
• Patients with hypercalcemia may present with increased thirst, fatigue, nausea, vomiting, and constipation.
• High-Yield Fast Fact(s):
• Patients with older age or a rapid increase to moderate hypercalcemia may lead to increased levels of neurologic dysfunction compared to patients with younger age or chronic severe hypercalcemia.

Which of the following is true of patients receiving opioid medications for pain management?

• A They will develop tolerance to opioid induced constipation and thus only need stimulant therapy for the first 1-2 weeks of opioid therapy (5%)
• B In opioid overdose, the patient’s pupils would normally be small (i.e. have miosis) (58%)
• C Morphine commonly causes IgE mediated histamine release from the mast cells. thereby causing a type I allergic reaction (19%)
• D All opioids do not require metabolism to active metabolites in order to provide analgesia (18%)

Answer (B)

• Pinpoint pupils are a classic physical exam finding or manifestation in patients who have overdosed on opioids.
• The other answer choices are all the opposite of what is normally seen or expected with opioid use.

True or False: All 5-HT3 receptor antagonists are equivalent for the prevention of acute emesis from highly emetogenic chemotherapy.

• A True (39%)
• B False (61%)

Answer (B)

• The 5-HT₃ receptor antagonists. ondansetron (Zofran), granisetron (Kytril), and dolasetron (Anzemet) are all considered to be interchangeable. However, palonosetron (Aloxi) has data demonstrating significant differences between palonosetron and dolasetron in the prevention of acute and delayed vomiting.
• Similar data is also seen with palonosetron vs. ondansetron. Palonosetron is suspected to be more effective based on its receptor binding affinity and its longer half-life than other 5-HT₃ receptor antagonists.
• Note: The 5-HT₃ receptor blockers all work to antagonize or block serotonin (5-HT₃) in both the periphery at the level of the terminal of the vagus nerve as well as centrally at the chemoreceptor trigger zone (CTZ). 5-HT₃ is a serotonin receptor subtype.

Which one of the following antiemetics is NOT known to cause extrapyramidal symptoms?

• A. Metoclopramide (5%)
• B. Dexamethasone (83%)
• C. Droperidol (6%)
• D. Promethazine (8%)

Answer (B)

• All the above agents except dexamethasone are dopamine antagonists. By blocking dopamine, patients are at risk for developing parkinsonian symptoms from excessive acetylcholine.
• Typical extrapyramidal symptoms include pill-rolling, muscular spasms of neck, oculogyric crisis, and motor restlessness.
• Treatment includes drug cessation and the beginning of an anticholinergic agent such as diphenhydramine (Benadryl) or benztropine (Cogentin).

JG is a 41-year-old female who was diagnosed with early-stage breast cancer. She received a mastectomy and is about to complete her adjuvant chemotherapy regimen. She is inquiring about adjuvant hormonal therapy.

Which of the following statements is TRUE regarding adjuvant tamoxifen therapy for breast cancer?

• A. High-risk patients who have received 5 years of adjuvant tamoxifen may benefit from an additional five years of adjuvant endocrine treatment (62%)
• B. Considering her early stage breast cancer, 2-3 years of adjuvant endocrine treatment may be adequate for JG (14%)
• C. Premenopausal patients do not benefit from tamoxifen (13%)
• D. ER- patients may still benefit (11%)

Answer (A)

• New studies have shown that patients at higher risk of recurrence who have been treated with tamoxifen for five years should consider extended tamoxifen for an additional five years to complete ten years. Thus, the first answer is correct. Two to three years of adjuvant tamoxifen is inadequate (second answer). Aromatase inhibitors are preferred in postmenopausal women compared with tamoxifen, but tamoxifen remains the standard of care for premenopausal patients (third answer). Tamoxifen has not been shown to have utility in ER-negative or PR-negative breast cancer (last answer).
• Patients at higher risk of recurrence should receive extended endocrine therapy for up to 10 years of adjuvant endocrine therapy.
• Adjuvant chemotherapy and endocrine therapy should be given sequentially with endocrine therapy following chemotherapy.

JJ is a 66-year-old woman with breast cancer receiving her first cycle of paclitaxel chemotherapy. Sixty minutes before her chemotherapy she receives hypersensitivity prevention regimen of dexamethasone, ranitidine, and diphenylhydramine.

What antiemetic regimen do you recommend for her to receive before paclitaxel?

• A Ondansetron 8 mg IV (42%)
• B Fosaprepitant 150 mg IV (6%)
• C Ondansetron 8 mg IV plus fosaprepitant 150 mg IV (18%)
• D No additional premedications needed (34%)

Answer (D)

• Paclitaxel is considered a low risk emetogenic therapy. Since the receiver dexamethasone before her treatment, the use of an emetemic would only be necessary if she had previous nausea or vomiting problems. She may be given a prescription for PRN antiemetics to be used at home.
• Fosaprepitant (Emend for injection) and aprepitant (Emend) when used alone are inferior to 5-HT₃ receptor antagonists for acute emesis prevention. However when used in combination with 5-HT₃ receptor antagonists they excel in the prevention of acute and delayed emesis.
• Paclitaxel is not known to produce delayed emesis.
• Note: 5-HT₃ receptor antagonists include dolasetron (Anzemet), granisetron (Granisol; Kytril; Sancuso); ondansetron (Zofran), palonosetron (Aloxi).

CC is a 44-year-old male recently diagnosed with diffuse large B-cell lymphoma. Two days after receiving R-CHOP therapy (rituximab, cyclophosphamide, vincristine, doxorubicin, prednisone), the nurses noted a decrease in urinary output plus the following labs were found: BUN 22 mg/dL serum creatinine 16 mg/dL, uric acid 8.2 mg/dL, phosphorus 7.4 mg/dL, calcium 8 mg/dL, and potassium 4.6 mEq/L.

Which agent should be started now?

• A Calcium acetate PO (31%)
• B Rasburicase IV (49%)
• C Probenecid PO (11%)
• D Calcium chloride IV (10%)

Answer (A)

• Since this patient is experiencing tumor lysis syndrome manifesting as hyperphosphatemia, initiation of calcium acetate orally will be preferred.
  Avoidance of intravenous calcium products is prudent because of the high risk of precipitation of calcium and phosphate products.
• The patient does not have a significant elevation in uric acid (see lab reference link in Q-Bank), so rasburicase and probenecid are not indicated.
• Rasburicase is an enzyme that rapidly converts uric acid into allantoin, which is ideal in someone who is suffering from uric acid nephropathy.
• Probenecid prevents the reabsorption of uric acid at the proximal convoluted tubule, which allows for renal elimination of excess uric acid; this drug is not used for elevated uric acid levels from tumor lysis syndrome.
• In this case, like many on board exams, you will need to discern which answer is MOST correct. Rasburicase could be given but since the patient does not have a significant uric acid elevation, the most likely reason for increased creatinine is the elevated phosphorus. This patient will need aggressive intravenous fluids and a phosphate binder such as calcium acetate. Intravenous calcium should be avoided since the risk of precipitation is great with concomitant elevated phosphorus.

Which of the following statements is true?

• A Apply the Sancuso (granisetron transdermal system) patch 2 hours before chemotherapy to prevent acute nausea/vomiting. (16%)
• B The Sancuso (granisetron transdermal system) patch should be only worn for 3 days after chemotherapy. (12%)
• C The dexamethasone dose when used concomitantly with aprepitant and ondansetron should be increased due to concern for decreased efficacy as a result of a potential CYP3A4 interaction. (8%)
• D Olanzapine, palonosetron plus dexamethasone or netupitant/palonosetron plus dexamethasone are both alternative regimens that can be used for the prevention of acute and delayed nausea/vomiting associated with highly emetogenic chemotherapy. (64%)

Answer (D)

• Sancuso (granisetron transdermal system) should be applied to the upper outer arm at a minimum of 24 hours and a maximum of 48 hours before chemotherapy. The patch releases 3.1 mg of granisetron per 24 hours for up to 7 days and may be worn up to 7 days.
• Aprepitant is a moderate CYP3A4 inhibitor, which inhibits the metabolism of dexamethasone. Thus, the dose of dexamethasone in the recommended three-drug regimen (aprepitant, dexamethasone, ondansetron) should be reduced to 12 mg on day 1 and 8 mg on days 2 to 4.
• Olanzapine, palonosetron plus dexamethasone or netupitant/palonosetron plus dexamethasone can be considered for the prevention of nausea/vomiting with highly emetogenic chemotherapy.

MN is a 69-year-old female who is recently diagnosed with stage IV squamous cell lung cancer. She is scheduled to receive her first cycle of cisplatin (Day 1) and gemcitabine (Day 1 and Day 8) every three weeks.

Which of the following types of emesis are of major concern?

• A Acute and anticipatory (17%)
• B Anticipatory and breakthrough (11%)
• C Breakthrough and delayed (13%)
• D Acute and delayed (59%)

Answer (D)

• There are multiple types of emesis. All chemotherapy has the potential to cause acute emesis, which occurs within 24 hours of receiving chemotherapy. Delayed emesis occurs > 24 hours after receiving chemotherapy. Chemotherapy agents such as cisplatin, carboplatin, cyclophosphamide, and/or anthracyclines are known to cause delayed emesis.
• Thus, the last answer is correct as the patient is receiving cisplatin.
• Breakthrough emesis can occur with any chemotherapy when prophylactic antiemetics do not work. It is possible with this chemotherapy regimen but is of secondary concern.
• Anticipatory emesis is not likely with the first cycle of chemotherapy, as it is caused by a previous significant incidence of emesis.
• Cisplatin is one of several agents known for causing acute and delayed nausea/vomiting.
• High-Yield Fast Fact:
• For cisplatin, emesis reaches its peak at 48-72 hours after administration and can last up to 6-7 days.

When a patient exhibits acute emesis from chemotherapy, which neurotransmitter is primarily involved in this pathway?

• A Dopamine (10%)
• B Acetylcholine (6%)
• C Serotonin (74%)
• D Substance P (10%)

Answer (C)

• During the acute emesis phase (within 24 hours after chemotherapy), the primary neurotransmitter serotonin is released from the enterochromaffin cells in the gastrointestinal site and also within the brain.
• Substance P is primarily released in the delayed phase (24 hours to 120 hours after chemotherapy).
• Dopamine is released throughout the different phases, however: the use of dopamine blockers such as prochlorperazine and haloperidol are less effective in preventing emesis than 5-HT3 receptor antagonists (e.g. ondansetron).
• Acetylcholine has a limited role in chemotherapy induced emesis.

XD is a 45-year-old female diagnosed with stage IV colon cancer. She received the 3rd cycle of chemotherapy yesterday. Today, she presents with complaints of nausea and vomiting. PK states that she has vomited eight times over the last 24 hours and has not been able to keep any food down.

What are the complications of emesis that PK is likely to have if emesis is not resolved immediately?

• A Congestive heart failure and gastro-esophageal reflux disease (2%)
• B Dehydration and acid-base imbalance (88%)
• C Acid-base imbalance and congestive heart failure (2%)
• D Gastro-esophageal reflux disease and dehydration (8%)

Answer (B)

• The second answer option is correct as excessive vomiting results in significant fluid loss. In addition, it results in the loss of electrolytes and bicarbonate. Both of these reasons can lead to dehydration and acid-base imbalance.
• Congestive heart failure and gastroesophageal reflux disease (GERD) are other co-morbidities or excessive use of specific medications.
• Severe nausea/vomiting can lead to dehydration and acid-base imbalances.
• Nausea/vomiting can result in dehydration, electrolyte imbalances, degeneration of self-care and functional ability, nutrient depletion, anorexia, a decline of the patient’s performance and mental status, wound dehiscence, esophageal tears, and withdrawal from potentially useful or curative anticancer treatment.

Autologous hematopoietic stem cell transplantation is the standard of care for patients not responding to standard dose chemotherapy for all of the following conditions except one.

Which of the following will not be routinely treated with a peripherally collected autologous hematopoietic stem cell transplant?

• A. Aplastic anemia (49%)
• B. Multiple myeloma (9%)
• C. Non-Hodgkin’s lymphoma (14%)
• D. Germ cell tumor (27%)

Answer (A)

• Autologous hematopoietic transplants require the use of the patient's own cells to be collected and then reinfused back into the patient after the high dose chemotherapy has been administered.
• Since aplastic anemia is a disease where the bone marrow has pancytopenia (anemia, neutropenia, and thrombocytopenia), obtaining an optimal autologous collection is problematic.
• There are case reports published stating successes with autologous transplants in aplastic anemia; however, the use of allogeneic transplant is currently the standard practice.
• Since the patient is receiving another person’s stem cells with allogeneic transplant, this will replace the diseased marrow and allow for the return of cell repopulation.

ST is a 48 year old male with colorectal cancer who is about to start FOLFOX (fluorouracil, leucovorin and oxaliplatin). He has no history of nausea/vomiting and also drinks 2 cans of beer daily.

Which of the following antiemetic regimens is most appropriate?

• A. Ondansetron 16 mg IV x 1 and dexamethasone 12 mg IV x 1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (34%)
• B. Olanzapine 10 mg PO x 1 and dexamethasone 12 mg IV x 1 on Day 1 followed by olanzapine 10 mg PO daily on Days 2-3 (3%)
• C. Palonosetron 25 mg IV x 1 and dexamethasone 12 mg IV x 1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (52%)
• D. Fosaprepitant 150 mg IV x 1 and dexamethasone 12 mg IV x 1 on Day 1 followed by dexamethasone 8 mg PO daily on Days 2-3 (12%)

Answer (C)

• ST is receiving FOLFOX which is a moderately emetogenic regimen. Per the NCCN guidelines, any of the following 3-drug antiemetic regimens (D, E or F) which are not listed in order of preference should be given prior to moderately emetogenic chemotherapy on Day 1:
  • D
    • 5-HT₃ antagonist (choose one of the following):
    • Dolasetron PO x 1, granisetron subQ (preferred)/PO/IV x 1 or transdermal ondansetron PO/IV x 1, palonosetron IV x 1 (preferred) AND
    • Dexamethasone PO/IV x 1

• E
  • Olanzapine PO x1 AND Palonosetron IV x1 AND Dexamethasone PO/IV x1
• F
  • NK1 antagonist (choose one of the following):
    • Aprepitant PO/IV x1, fosaprepitant IV x1, netupitant/palonosetron PO x1, fosnetupitant/palonosetron IV x1, rolapitant PO x1 AND 5-HT3 antagonist (choose one of the following):
    • Dolasetron PO x1, granisetron subPO/IV x1 or transdermal ondansetron PO/IV x1, palonosetron IV x1 AND Dexamethasone PO/IV x1
• Since ST has no history of nausea/vomiting and his chronic alcohol use would also put him at lower risk, he does not likely need a NK1 antagonist.Palonosetron and dexamethasone is a recommended antienetic regimen.
• When used with NK1 antagonists, there is no preferred 5-HT3 antagonist. However, without a NK1 antagonist, palonosetron or extended release granisetron is the preferred agent. Thus, ondansetron and dexamethasone is not the best regimen for ST.
• Olanzapine and dexamethasone alone is not correct. Per the NCCN guidelines, olanzapine and dexamethasone should be given with palonosetron.
• Fosaprepitant and dexamethasone alone is not correct. Per the NCCN guidelines, fosaprepitant and dexamethasone should be given with a 5-HT3 antagonist.
• For patients receiving moderately emetogenic chemotherapy, additional risk factors or previous treatment failure should be taken into consideration in determining the appropriate antiemetie regimen.
• Granisetron extended-release is a unique formulation using polymer-based drug delivery system and should only be given subcutaneously (not interchangeable with the IV formulation).

Which one of the following agents is a neurokinin-1 receptor antagonist?

• A. Dronabinol (7%)
• B. Fosaprepitant (85%)
• C. Olanzapine (3%)
• D. Palonosetron (5%)

Answer (B)

• Fosaprepitant (Emend for injection) is rapidly converted by phosphatase enzymes to the active form - aprepitant (Emend). a neurokinin-1 receptor antagonist.
• Dronabinol (Marinol) is a tetrahydrocannabinol (THC) derivative, while olanzapine (Zyprexa) is an atypical antipsychotic.
• Palonosetron (Aloxi) is a long-acting 5-HT3 receptor antagonist.

Which of the following is the approximate equivalent dose of morphine administered parenterally versus by mouth for the treatment of chronic pain?

• A. Morphine 1 mg IM + 10 mg by mouth (11%)
• B. Morphine 5 mg IM + 10 mg by mouth (12%)
• C. Morphine 10 mg IM + 30 mg by mouth (71%)
• D. Morphine 20 mg IM + 30 mg by mouth (6%)

Answer (C)

• While the equivalent doses of opioid is not an “exact” or precise science, there are generally accepted conversions when moving from one opioid to another.
• In general, approximately 10 mg of morphine given by IM injection is roughly equal to 30 mg of morphine administered by mouth for those with chronic pain. This changes to a 16 ratio for acute pain management.
• In general, approximately 10 mg of morphine given by IM injection is roughly equal to 30 mg of morphine administered by mouth for those with chronic pain.
• The rescue dose of opioid analgesics should be about 5% to 15% of the total daily dose of the long-acting opioid and then given in divided doses.

SS is a 55-year-old breast cancer patient receiving her fourth cycle of cyclophosphamide 600 mg/m², doxorubicin 60 mg/m². Before the chemotherapy begins, she rushes to the bathroom to experience a vomiting episode. Afterward, she states that she is ready to begin chemotherapy.

Why did she have this vomiting episode?

• A. SS is exhibiting anticipatory nausea and vomiting from her motion sickness history (10%)
• B. SS is constipated from anthracycline-induced neurotoxicity (1%)
• C. SS is experiencing delayed emesis from her last cycle of doxorubicin and cyclophosphamide administered three weeks ago (6%)
• D. SS developed anticipatory vomiting from poor antiemetic control with previous cycles (83%)

Answer (D)

• Anticipatory nausea and vomiting is a Pavlovian response from poor nausea and vomiting control.
• It classically occurs after several cycles of uncontrollable nausea and vomiting until the patient develops an unprovoked emetic response.
• Benzodiazepines are usually instituted to help decrease the anxiety related to this response.

When dexamethasone is added to a 5-HT3 receptor antagonist, how much additional antiemetic protection is gained in the context of chemotherapy-related nausea and vomiting?

• A. None (4%)
• B. 5% (4%)
• C. 20% (76%)
• D. 80% (16%)

Answer (C)

• Approximately 20% improvement in emetic response is seen when dexamethasone is added to a 5-HT₃ receptor antagonist monotherapy for chemotherapy-related emesis.
• In a trial using granisetron with or without dexamethasone, the complete protection from vomiting was 93% with the combination compared with 71% with dexamethasone alone or 72% with granisetron alone.
• When looking at nausea protection, the combination was effective in 72% compared with 55% dexamethasone and 48% granisetron alone.

This agent antagonizes chemokine receptor 4 binding to stromal derived factor-1 on bone marrow stromal cells allowing for an increase in the amount of peripheral progenitor cells.

Which agent possesses this mechanism of action?

• A. Plerixafor (Mozobil) (50%)
• B. Filgrastim (Neupogen) (28%)
• C. Sargramostim (Leukine) (14%)
• D. Ipilimumab (Yervoy) (8%)

Answer (A)

• Filgrastim and sargamostim are both colony-stimulating factors designed to primarily increase the production, maturation, and activation of neutrophils.
• Ipilimumab is a monoclonal antibody designed to bind to the cytotoxic T-lymphocyte associated antigen 4, allowing for T-cell activation.
• Plerixafor in combination product with filgrastim and is approved for the mobilization of progenitor stem cells.

Which of the following scenarios would be the most difficult to control their chemotherapy-induced nausea and vomiting?

• A. A patient receiving his first cycle of carboplatin and etoposide (44%)
• B. A patient receiving his fourth cycle of carboplatin and etoposide (44%)
• C. A patient receiving his third cycle of fluorouracil, leucovorin, and oxaliplatin (FOLFOX) (6%)
• D. A patient receiving high-dose chemotherapy, carmustine, etoposide, cytarabine, and melphalan. (BEAM) before hematopoietic stem cell transplant (66%)

Answer (D)

• Most preparative regimens for hematopoietic stem cell transplants are highly emetogenic.
• They can produce profound acute and delayed nausea and vomiting.
• Carboplatin and FOLFOX regimens are both considered moderately emetogenic.

If a patient with tumor lysis syndrome has elevated potassium, which of the following agents will NOT lower the serum potassium level?

• A. Sodium bicarbonate intravenous (25%)
• B. Insulin with dextrose 50% infusion (9%)
• C. Calcium gluconate infusion (47%)
• D. Sodium polystyrene sulfonate orally (19%)

Answer (C)

• The first and second answer choices will both drive potassium intracellularly and provide temporary lowering of potassium while the last choice will allow for a cationic exchange in the bowel and will produce lower potassium upon defecation.
• Calcium infusions are only indicated to reduce the risk of dysrhythmias through stabilization of the cardiac cell membrane but do not directly impact serum potassium levels.

When the erythropoiesis-stimulating agents (ESA) epoetin and darbepoetin are used for chemotherapy-induced anemia, at what hemoglobin may they be initiated?

• A. <10 g/dL (8g%)
• B. 10-11 g/dL (7%)
• C. 11-12 g/dL (3%)
• D. 12-14 g/dL (2%)

Answer (A)

• These agents should not be initiated until the hemoglobin level is less than 10 g/dL.
• Further restrictions include the chemotherapy duration needs to be two months or longer and that the patient is NOT of curative intent.
• The goal of therapy is to minimize the need for red blood cell transfusions with the smallest ESA dose.

If a patient develops anticipatory nausea and vomiting from poor antiemetic control, which agent should be started?

• A. Dronabinol (3%)
• B. Lorazepam (81%)
• C. Ondansetron (12%)
• D. Promethazine (4%)

Answer (B)

• Anticipatory nausea and vomiting is a Pavlovian response from poor nausea and vomiting control.
• It classically occurs after several cycles of uncontrollable nausea and vomiting until the patient develops an unprovoked emetic response.
• Benzodiazepines are usually instituted to help decrease the anxiety related to this response.

IK is a 55 year old male receiving cisplatin 75 mg/m2 on Day 1 and etoposide 100 mg/m2 on Days 1-3 for his small cell lung cancer. His antiemetic regimen included ondansetron, aprepitant, and dexamethasone. After his first cycle of chemotherapy, he complained of vomiting x 3 episodes starting 48 hours after chemotherapy. What change to his antiemetic regimen would you make for cycle 2?

• A No change is necessary (7%)
• B Change ondansetron to palonosetron (67%)
• C Add granisetron to the current regimen (5%)
• D Increase the dose of dexamethasone from 12 to 20 mg IV (21%)

Answer (B)

• Since he is already receiving the recommended triple therapy, the only appropriate option would be changing to palonosetron (Aloxi).
• Palonosetron is a longer acting 5-HT₃ receptor antagonist than ondansetron (Zofran) which displays better control of delayed emesis compared with ondansetron in patients receiving cisplatin. There are no reliable data using two different 5-HT₃ receptor antagonists together.
• The dose of dexamethasone in combination with aprepitant is recommended at 12 mg since aprepitant interferes with the metabolism of dexamethasone.

Which of the following statements is true?

• A. Both palonosetron and rolapitant have long half-lives and are thus more effective at preventing delayed nausea/vomiting (43%)
• B. Dronabinol capsules have higher bioavailability than dronabinol oral solution (5%)
• C. All the NK1 antagonists (fosaprepitant, aprepitant, netupitant, fosequinat, and rolapitant) inhibit the metabolism of dexamethasone leading to higher levels of dexamethasone when given concomitantly (28%)
• D. Aprepitant inhibits warfarin metabolism via CYP2C9 and can lead to supratherapeutic INRs for patients on concomitant aprepitant and warfarin (25%)

Answer (A)

• Both palonosetron (1-40 hours in adults) and rolapitant (~7 days for oral and 76 days of IV) have long half-lives and are recommended by the NCCN guidelines to prevent acute and delayed nausea/vomiting.
• On the contrary, dronabinol oral solution has a higher bioavailability than dronabinol capsules (2.1 mg oral solution + 2.5 mg capsules).
• All the NK1 antagonists (fosaprepitant, aprepitant, netupitant, fosnetupitant) EXCEPT for rolipastin inhibit the metabolism of dexamethasone, leading to higher levels of dexamethasone when given concomitantly.
• On the contrary, aprepitant induces warfarin metabolism via CYP2C9 and may significantly reduce INRs, especially for patients on therapeutic warfarin. The INR may initially increase during the first week before persistently decreasing for up to 2-3 weeks, warranting close monitoring.
• Each antiemetic agent has unique pharmacodynamic/kinetic properties that must be considered when selecting an appropriate antiemetic regimen for patients.
• Apprehension also decreases the AUC of oral contraceptives. Thus, patients should have alternative contraception methods during preantipat treatment and one month after the last dose of aprepitant.

TJ is a 72-year-old male who presents to the clinic with stage IV non-small cell lung cancer (NSCLC) with bone metastases. He has a 45 pack-year history of smoking and drinks 4-5 beer bottles a day. Your oncology team has decided to treat TJ’s cancer with chemotherapy. Which of the factors below are associated with a reduced risk of emetogenic potential for TJ?

• A. Age, gender, alcohol history (63%)
• B. Gender, alcohol history, smoking history (17%)
• C. Alcohol history, smoking history, age (11%)
• D. Smoking history, age, gender (9%)

Answer (A)

• The first answer option is correct as there are patient-specific factors that put TJ at a lower risk of having emesis. Older patients are at lower risk of emesis compared to younger patients. Males are also at lower risk of emesis compared to females. Alcohol use also reduces the risk of emesis.
• Smoking has not been identified to have a significant impact on the patient’s risk of emesis.
• The risk of emesis is reduced in patients who are older, male, and with alcohol use.
•  Other risk factors for nausea/vomiting include a history of motion sickness, history of morning sickness, history of nausea/vomiting, an environment in which chemotherapy is administered, a dosage of the metronomic agent, and efficacy of the antiemetic regimen.

DS is a 68-year-old with non-small lung cancer who presents to his oncologist with complaints of heartburn and stomach pains. He denies any black or bloody stools, and he does not have any nausea or vomiting. He is currently receiving erlotinib therapy. He has stable pain, which is controlled with nonsteroidal anti-inflammatory drugs (NSAIDs) along with morphine. Which agent would be the most appropriate therapy for his suspected NSAID induced gastritis?

• A. Stop NSAIDs and begin aluminum hydroxide/magnesium hydroxide (53%)
• B. Stop NSAIDs and begin cimetidine (9%)
• C. Continue NSAIDs and start ranitidine (11%)
• D. Continue NSAIDs and start omeprazole (27%)

Answer (A)

• Stopping non-steroidal anti-inflammatory drugs (NSAIDs) will be the most appropriate initial therapy for DS.
• Proton pump inhibitors (PPIs) or H2 receptor blockers will be more effective than antacids for gastritis but will potentially decrease the pH-dependent absorption of erlotinib. Oral antacids do not significantly alter gastric pH, so this interaction will be unlikely.
• There is some data that claims separating the H2 receptor blockers from the erlotinib dose will minimize this interaction.
• Cimetidine (Tagamet) could be administered in that fashion but is not desirable because of a drug interaction. Cimetidine is also an inhibitor of cytochrome P450 3A4 which is required for erlotinib metabolism.

QP is a 43-year-old male who is day +72 after an allogeneic HSCT. He is seropositive for varicella-zoster virus and herpes simplex virus. Which of the following is the best for QP to receive for prophylaxis?

• A No routine antibiotic or antiviral therapy (4%)
• B Moxifloxacin 400 mg daily (1%)
• C Acyclovir 400 mg twice daily (33%)
• D Acyclovir 800 mg twice daily (62%)

Answer (D)

• All patients with seropositive varicella zoster or herpes simplex virus are at risk for viral infection. Anti-viral prophylaxis does help reduce viral infection re-activation.
• Antibiotics will not be helpful as the goal is to reduce the risk of viral infection in OP.
• Acyclovir is the best choice in this setting. The 400 mg dose is appropriate in non-HSCT patients. Higher acyclovir dosing (800 mg) is required for high-risk patients. Like patients undergoing HSCT, Virus serology negative patients do not need acyclovir prophylaxis.

True or False:The erythropoiesis-stimulating agents (ESAs) should be avoided in cancer patients with curative intent receiving myelosuppressive chemotherapy.

• A True (81%)
• B False (19%)

Answer (A)

• According to the prescribing information, ESAs should be avoided in patients with curative intent especially in breast, cervical, head and neck, lymphoid, and non-small cell lung cancer patients.
• In some of these trials, an increased risk of time to tumor progression or recurrence and/or decreased survival.

You have used the Gail model and predicted a 4% risk of breast cancer in a 60-year-old postmenopausal woman with an intact uterus. Significant medical history includes diabetes, hypertension, hypothyroidism, and a history of venous thromboembolism.

Which agent would be most appropriate for breast cancer prevention?

• A. Raloxifene (13%)
• B. Anastrozole (48%)
• C. Tamoxifen (15%)
• D. None of the above (25%)

Answer (B)

• Per NCCN guidelines, postmenopausal patients desiring risk reduction therapy may receive either tamoxifen, raloxifene, or exemestane. Although aromatase inhibitors are not FDA-approved for this indication, and insurance may not cover the medication, they are listed as one of two category 1 recommendations for postmenopausal women: the other being tamoxifen. The two aromatase inhibitors that have been studied for risk reduction are anastrozole 1 mg PO daily and exemestane 24 mg PO daily. Unfortunately, there is no data comparing the benefits and risks of exemestane and anastrozole to those of tamoxifen and raloxifene. The side effects typically associated with aromatase inhibitors include hot flashes, musculoskeletal events, arthralgias, vaginal dryness, osteoporosis, arthritis, and NOT thromboembolic events, which makes anastrozole the best option for this patient based on her history of VTE.
• If aromatase inhibitors were not an option, then raloxifene would be preferred over tamoxifen since this patient has an intact uterus plus a history of VTE. Tamoxifen can increase the risk of endometrial cancer and thromboembolism. According to the Breast Cancer Prevention Trial, those patients with a hypercoagulable state (e.g., Factor V Leiden) were not at an increased risk of clots. Patients should still be counseled on the risk and symptoms of thromboembolism with tamoxifen. Raloxifene would not increase this patient’s risk of cancer or clot.

When the erythropoiesis-stimulating agents (ESA), epoetin and darbepoetin are used for chemotherapy-induced anemia, at what hemoglobin level may they be initiated?

• A. <10 g/dL (89%)
• B. 10-11 g/dL (7%)
• C. 11-12 g/dL (3%)
• D. 12-14 g/dL (2%)

The correct answer is A. < 10 g/dL 

Reasoning: Erythropoiesis-stimulating agents (ESAs), such as epoetin and darbepoetin, are used to manage chemotherapy-induced anemia by stimulating the bone marrow to produce red blood cells. According to standard clinical guidelines (ASCO/ASH and NCCN) and the principles of oncology supportive care:

• Initiation Threshold: ESAs should only be initiated when the hemoglobin (Hb) level falls below 10 g/dL.
• Goal of Therapy: The primary goal is to increase hemoglobin to a level that avoids the need for a red blood cell transfusion.
• Safety Limits: Therapy should be titrated to maintain the lowest hemoglobin level necessary to avoid transfusion; guidelines generally recommend not exceeding a hemoglobin level of 11–12 g/dL due to increased risks of thromboembolic events and potential tumor progression.

Connection to Chemotherapy: Anemia is a well-documented hematologic toxicity associated with many of the agents discussed in your previous cases, including:

• Paclitaxel: Specifically noted to cause anemia.
• Ixabepilone: Also associated with anemia and other myelosuppressive side effects.
• General Toxicity: Anemia is listed as one of the 13 major side effects of chemotherapy that oncology pharmacists must monitor and manage.

Which of the following is true of patients receiving opioid medications for pain management?

• A. They will develop tolerance to opioid induced constipation and thus only need stimulant therapy for the first 1-2 weeks of opioid therapy (53%)
• B. In opioid overdose, the patient's pupils would normally be small (ie. have miosis) (58%)
• C. Morphine commonly causes IgE-mediated histamine release from the mast cells, thereby causing a type 1 allergic reaction (19%)
• D. All opioids do not require metabolism to active metabolites in order to provide analgesia (18%)

The correct answer is B. In opioid overdose, the patient's pupils would normally be small (ie. have miosis).

Reasoning

• Miosis as a Clinical Sign: Miosis (pinpoint pupils) is a classic neurological sign associated with the presence of opioids in the system and is a hallmark of overdose.
• Constipation and Tolerance: Choice A is incorrect because, unlike side effects such as nausea or sedation, patients do not develop tolerance to opioid-induced constipation. Constipation is a persistent gastrointestinal effect that requires a consistent bowel regimen as long as the opioid is being used.
• Histamine Release Mechanism: While opioids like morphine trigger histamine release from mast cells, this is typically a non-IgE mediated (pseudoallergic) reaction rather than a true Type 1 IgE-mediated allergic reaction.
• Active Metabolites: Choice D is incorrect because many opioids require metabolism into active metabolites to provide their full analgesic effect (for example, codeine must be metabolized into morphine via the CYP2D6 pathway).

Which of the following is the approximate equivalent dose of morphine administered parenterally versus by mouth for the treatment of chronic pain?

• A. Morphine 1 mg IM-10 mg by mouth (11%)
• B. Morphine 5 mg IM- 5o mg by mouth (12%)
• C. Morphine 10 mg IM - 30 mg by mouth (71%)
• D. Morphine 20 mg IM-30 mg by mouth (6%)

The correct answer is C. Morphine 10 mg IM - 30 mg by mouth.

Reasoning: In clinical practice and standard pain management protocols, the dose of morphine administered orally is generally considered to be three times the parenteral (IM/IV) dose due to the first-pass metabolism effect. This results in an approximate conversion ratio of 1:3 for parenteral to oral administration.
While the provided excerpts focus primarily on chemotherapy-induced nausea and vomiting (CINV), they acknowledge the clinical importance of managing drug-related side effects from opioids, which are recognized as a non-antineoplastic cause of nausea and vomiting. Identifying correct dosages is a critical role for the oncology pharmacist to ensure both analgesic efficacy and the mitigation of side effects.

Why the other options are incorrect

• A and B: These suggest a 1:10 ratio, which significantly overestimates the oral dose needed and increases the risk of toxicities or severe side effects like respiratory depression or miosis.
• D: This suggests a 1.5:1 ratio, which would result in under-treating the patient's chronic pain.

Tumor Lysis Syndrome (TLS)

TLS is a high-yield supportive care topic:

• Classification: Laboratory TLS (LTLS) involves metabolic derangements, while Clinical TLS (CTLS) includes organ failure or seizures.
• Prevention: The foundation is aggressive IV hydration (2-3 L/m²/day).
• Urate Management: Allopurinol is for low-to-intermediate risk; Rasburicase is reserved for high-risk patients or those with existing hyperuricemia (contraindicated in G6PD deficiency)

V. Supportive Care and Monitoring (Crucial for BCOP)

• Bone Health: Bisphosphonates (Zoledronic acid or Pamidronate) or Denosumab are recommended for all patients receiving primary therapy to prevent skeletal-related events.
• Infection Prophylaxis: Antiviral prophylaxis (e.g., acyclovir) is mandatory for patients receiving proteasome inhibitors (bortezomib, carfilzomib, ixazomib), daratumumab, or elotuzumab to prevent herpes zoster reactivation.
• VTE Prophylaxis: Required for patients on IMiD-based regimens (lenalidomide, pomalidomide, thalidomide). Aspirin is used for low-risk patients, while anticoagulants (LMWH or DOACs) are used for those at high risk based on SAVED or IMPEDE scores.
• Hypercalcemia Management: Includes aggressive hydration, bisphosphonates, and subcutaneous/IM calcitonin for rapid initial reduction in symptomatic cases.
• REMS Programs: Pharmacists must manage compliance for several drugs, including IMiDs (due to teratogenicity) and newer agents like Teclistamab or CAR-T (due to Cytokine Release Syndrome and neurotoxicity)