PowerPoint Template

Non-small Cell Lung cancer Case

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Question #12The CaseMr AP, a 56-year-old former coal miner, presents to your hospital pharmacy from the oncology outpatients department with a prescription for the following medications:

Ondansetron 4 mg p.o. b.d. for 5 days Dexamethasone 2 mg p.o. b.d. for 5 days. Ranitidine 150 mg p.o. b.d. for 2 weeks.Sahal M. ShuaibThe CaseOn questioning the patient, you discover that he suffers from the more common type of lung cancer and is undergoing irradiation treatment currently.

At this point you also notice that his right index and middle fingers as well as his teeth are stained yellow.Sahal M. ShuaibQuestion #1What are the main types of lung cancer?Sahal M. ShuaibAnswerSmall cell lung cancer (SCLC).

. Sahal M. Shuaib

AnswerSmall cell lung cancer (SCLC).

SCLC accounts for about 20% of all lung cancers.

Although the cells are small, they multiply quickly and form large tumors that can spread throughout the body.

Smoking is almost always the cause of SCLC. Sahal M. ShuaibAnswerNon-Small cell lung cancer (NSCLC).

Is by far the most common type, accounting for approximately 80% of all lung 184 Pharmacy Case Studies cancersSahal M. ShuaibAnswerNon-Small cell lung cancer (NSCLC).

Within NSCLC, there are three main tumour subdivisions:Adenocarcinoma, Squamous cell carcinoma Large cell carcinoma.Sahal M. ShuaibAnswerAdenocarcinoma:This cancer is found in the glands of the lungs that produce mucus. This is the most common type of lung cancer in women and also among people who have not smoked.Sahal M. ShuaibAnswerAdenocarcinoma:Sahal M. Shuaib

AnswerB. Squamous cell carcinoma:

This is the most common type of NSCLC.

It forms in the lining of the bronchial tubes

The most common type of lung cancer in men.

Sahal M. ShuaibAnswerB. Squamous cell carcinoma:

Sahal M. Shuaib

AnswerC. Large cell carcinoma:

This cancer forms near the surface, or outer edges, of the lungs.

It can grow rapidly.Sahal M. ShuaibAnswerC. Large cell carcinoma:

Sahal M. Shuaib

Question #2a16Question #2a2a What are the risk factors associated with the development of lung cancer?

Asim S. AL.MoanaAnswerSmokinTadon GasesIndustrial exposureAir PollutionFamily HistoryDiet, supplemetnts and alcohol

Asim S. AL.MoanaOther Factors and Lung Cancer RiskPeople with HIV and AIDS even after accounting for smoking,although one study showed an association in men only.

Pneumonia.

The risk increase persisted for more than 20 years after TB diagnosis.Asim S. AL.Moana

Question #2b20Question #2bIs it possible that Mr AP has any of the risk factors for developing lung cancer?Saud A. Otaibi AnswerFrom the observation that Mr APs fingers and teeth are stained yellow, it appears likely that he is either a smoker or an ex-smoker. Also as a former coal miner, he may have been exposed to other occupational hazards; it has been suggested that up to 15% of lung cancer cases in men may be attributable to occupational factors in conjunction with smoking (Cancer Research UK,2004).Saud A. Otaibi

Question #323Question #3Q3/ Briefly describe the class of drugs that ondansetron, dexamethasone and ranitidine belong to :

Khalid A. HaddadiAnswerOndansetron is 5HT3-receptor antagonists.

Dexamethasone is a corticosteroid.

Ranitidine is (H2)-receptor antagonist.

Khalid A. HaddadiQuestion #3Q3/ Briefly describe the class of drugs that ondansetron, dexamethasone and ranitidine belong to and:(a) how ondansetron and dexamethasone work in the management of nausea and vomiting;(b) how ranitidine works in the management of dyspepsia; and(c) the rationale for co-prescribing ranitidine and dexamethasone.

Khalid A. HaddadiAnswerA) Ondansetron acts by blocking 5HT3 (serotonin) receptor in the chemoreceptor trigger zone (CTZ), vomiting centre and gastrointestinal tract. Dexamethasone is thought to act synergistically with Ondansetron by decrease serotonin release and antagonize serotonin receptors to potentiate the antiemetic effect.

Khalid A. HaddadiQuestion #3Q3/ Briefly describe the class of drugs that ondansetron, dexamethasone and ranitidine belong to and:(a) how ondansetron and dexamethasone work in the management of nausea and vomiting;(b) how ranitidine works in the management of dyspepsia; and(c) the rationale for co-prescribing ranitidine and dexamethasone.

Khalid A. HaddadiAnswerB) Ranitidine acts by inhibiting the stimulation of H2 receptors, resulting in a reduction in acid secretion from the gastrointestinal mucosa and relief dyspeptic symptoms.Khalid A. HaddadiQuestion #3Q3/ Briefly describe the class of drugs that ondansetron, dexamethasone and ranitidine belong to and:(a) how ondansetron and dexamethasone work in the management of nausea and vomiting;(b) how ranitidine works in the management of dyspepsia; and(c) the rationale for co-prescribing ranitidine and dexamethasone.

Khalid A. HaddadiAnswerC) Ranitidine prescribe with dexamethasone due to the gastric irritant effect of corticosteroids which can lead to dyspepsia.Khalid A. Haddadi

Question #4a32Question #4aMr AP states that he readily suffers from bouts of constipation and is concerned that these new tablets may worsen this. What would you advise?Abdullah Al-MalkiAnswerOne of the most commonly reported unwanted effects of 5HT3-receptor antagonists is constipation that can occur in up to 10% of patients and is generally mild to moderate in nature.Abdullah Al-MalkiAnswerConstipation caused by 5HT3-receptor antagonists may be exacerbated in those cancer patients on opiate analgesics or other constipating drugs.

It can lead to serious problems for patients with cancer, for example,puts the patient at risk of intestinal obstruction.

Abdullah Al-MalkiIt would be important to advise Mr AP: Not to take ondansetron for any longer than prescribed .

Not to take any spare ondansetron left over at the end of his treatment period to empirically treat any episodes of nausea or vomiting that may be unrelated to chemotherapy or radiotherapyAbdullah Al-MalkiIt would be important to advise Mr AP:Healthy diet with plenty of fibre to contribute to a regular bowel habit and maintaining mobility and exercise .

If he does become constipated during the period of treatment with ondansetron, seek advice from his GP or pharmacist on medications to treat constipation, such as docusate or bisacodyl.

Abdullah Al-Malki

Question #4b38Question #4bWhat are the other typical side-effects of the drugs prescribed for Mr AP?Raed M. RefaiAnswerRaed M. Refai

Question #541Question #5Mr AP also states that due to the large tumour pressing on my food pipe, he is currently having difficulty swallowing tablets. What alternative formulations could you suggest in order to facilitate medication compliance in this case?Abdulaziz Asiry

AnswerTo ensure Mr AP benefits from the medication that has been prescribed to him it is imperative that he is able to efficiently take his oral medication.

Cancer patients often have mechanical obstructions caused by tumours, particularly of the head and neck, oesophagus or lung.Abdulaziz AsiryAnswerThese tumours can either grow into the oesophagus or compress it, thus making eating difficult and, as in Mr APs case,causing difficulty in swallowing tablets or capsules (known as dysphagia).

A successful outcome of Mr APs radiotherapy treatment will likely involve an improvement in his ability to swallow.Abdulaziz AsiryAnswerIt is therefore important for the pharmacist to advise on and provide alternative formulations of medications to facilitate patient compliance. Specifically:Abdulaziz AsiryAnswer Ondansetron is available in a liquid form (4 mg/5 mL syrup), oral lyophilisates (tablets which are placed on the tongue, allowed to disperse and then swallowed) or suppositories (although these can cause rectal irritation). Dexamethasone is available in a liquid form (2 mg/5 mL oral solution). Ranitidine is available either in a liquid form (75 mg/5 mL syrup) or as effervescent tablets that may be dissolved in water.Abdulaziz AsiryAnswerAgain it will be important to seek information from Mr AP about any other concurrent medications he may be taking and whether he is having difficultyswallowing them. Further advice on what to do if his dysphagia is preventinghim from fully complying with his concomitant medications may be necessary.Abdulaziz AsiryAnswerIt should also be emphasised to Mr AP that it is important to maintain a healthy diet during the period of dysphagia. A referral to a dietitian by his clinician may be advisable to enable an assessment of diet requirements to be made and advice to be given on alternative nutritional supplements (in liquid form) if required.Abdulaziz Asiry