Aseptic Dispensing

Understand the difference between enteral and parenteral nutrition Important point: Use the gut if you can, or as soon as possible. If the gut is partially working, use it as much as possible. This is to prevent loss of function in the gut. Plus it's really expensive (to produce and administer because it's sterile AND needs to be given with a needle) It's annoying to the patient (invasive) Can even lead to intangible costs, like psychological changes And complications can arise, like phlebitis (inflammation of veins) or infections etc. Terminology (might want to skip this and read this as a summary) Parenteral nutrition is nutrients given from a route outside the gut (see below) Total Parenteral nutrition (TPN) is where the patient gets 100% of their nutrients, needs to be a large volume and is completely water soluble. We will prepare these quite frequently Peripheral nutrition is smaller volumes delivered via a peripheral vein Nutritional support is delivering a constant stream of nutrients to the blood (can be either enteral or parenteral) for special cases like cystic fibrosis (can't get enough nutrients quickly due to thick mucus layer) Basic differences Basically, enteral means through the gut (GI system), while parenteral is anywhere but the gut Enteral could be given: Orally Different tubes (e.g. nasogastric tubes) Stoma (piece of gut is exposed to the environment) Parenteral is generally giving via IV (can also be IM or IC) which can be at two different sites Central line- Jugular or subclavian vein, but it's inserted via the arm Generally more suitable for larger volumes which are not isoosmolaric Therefore, can be used for long-term Total Peripheral Nutrition (TPN, where all their nutrients are delivered this way) Patients may have protracted diarrhoea, chronic obstructions (or pseudo obstructions) of the GI system, or short bowel syndrome (too much GI system cut out due to surgery, think about inflammatory bowel conditions like Crohn's disease or ulcerative colitis) Peripheral line- out in the arm Generally suitable for smaller volumes, but must be iso-osmolaric Therefore, used for short terms (like after surgery) OVERALL: the goal is to get nutrients into the bloodstream of the patient. The gut processes larger molecules into smaller ones, while parenteral nutrition focuses on getting these nutrients directly into the bloodstream to bypass the gut

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 Arnold Lee

Contents of nutrition liquids Both types of liquid will contain all the components of the food we normally eat, such as carbohydrates, fats and amino acids, trace nutrients etc. Enteral formulations are quite simple, being made from more complex molecules like proteins and long chain carbohydrates Parenteral formulations need to have these complex molecules to be broken down to simple molecules, BECAUSE the gut is being bypassed (remember: the gut is normally responsible for the important function) In addition, because it's being added centrally, we need to make sure it's compatible with the blood Which means the fats need to be suitably water solubilised (as a suspension) and the osmolarity may need to be adjusted. Understand the importance of adequate nutrition in debilitated patients whether in hospital or in the community. You need to eat, it's kinda important. Effects of malnutrition Malnutrition is where a proper balance of nutrients isn't achieved So obese people are technically malnorished due to a lack of balance There are two types of malnutrition we can look at Patients can be in a catabolic state, where their body is breaking down proteins because the person isn't getting enough nutrients Leads to breakdown of various proteins and organ failure Patients could be in a normal metabolic state, but might not be getting enough energy Leads to tiredness, exhaustion and death Costs of malnutrition Tangible Slower healing times (longer visits are more expensive) Increased chance of infection Other complications, like muscle wasting (catabolic state) Costs of product and production (aseptic production is costly) Non-tangible Psychological Refeeding syndrome

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 After a long time of starvation, the body will adapt slowly to changes, such as reducing the insulin secretion Insulin secretion is tied to several electrolytes, such as potassium intake into cells and phosphate Leads to a reduction of electrolytes inside cells If a person is suddenly fed a lot of food after this state, insulin secretion will kick in and cause electrolyte imbalance (especially blood phosphate decreases due to absorption into cells) Causes death due to a multitude of problems Appreciate the role of the pharmacist in an Aseptic Production Unit (APU) with regard to parenteral nutrition

Aseptic versus Sterile

VERY important difference Sterile is an absolute, a black or white state where the product contains no contaminants whatsoever. Usually achieved with autoclaving or high temperatures etc. Aseptic production is where a product is prepared from sterile products in a very clean (aseptic) workplace. Does not guarantee sterility, but it's hoped it's sterile i.e. this definition isn't as black and white when it comes to contaminants Contaminants come in viable and non-viable flavours Viable contaminants are able to grow and give someone an infection (can lead to death by sepsis) Examples are bacteria, viruses or even fungi Non-viable contaminants can't grow, but still cause problems, such as occlusion of blood vessels or may be pyrogens Examples are bits of glass or dust FILTERS ARE IMPORTANT, they keep them out to prevent this issue TPN bags TPN bags contain a liquid for TPN May be divided into three compartments (glucose, amino acids and fat compartment) for enhanced stability. Must be combined before use Note: after combination, inspect bags for creaming of the lipid suspension (this is where the suspended lipids gather together to form larger particles, might kill your patient if given) TPN bags can generally be purchased and given in that state But they can be individualised within an aseptic production unit (APU) Gives a lot more flexibility, tailoring it to specific patient requirements, but this is very costly due to running the APU and hiring a pharmacist to make it. Understand the principles behind aseptic preparation AND Be familiar with basic aseptic manipulation We are the number one source of contamination Skin particles carry stuff We could cough or sneeze stuff out Therefore, we need to wear appropriate protective equipment Within the APU is a clean room Regularly checked to see if it's clean (taking swabs to see if anything will grow) Air is filtered
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Air is filtered Everything is flush against the wall (no overhangs or anything) A laminar air flow cabinet is in these clean rooms Horizontal cabinets blow air towards you, protects the product only (which means it can blow nasty chemicals like cytotoxics in your face) Vertical flow cabinets will blow air downwards, protecting both the product and the operator. Make sure you don't touch critical points Generally speaking, these points are where the liquid is going to touch the equipment This includes needle/syringe/filter tips, the inner ribs of the syringe etc. Make sure the paperwork gets done Reconciliation is where the products taken into the clean room are matched with what's leaving the clean room. This is in addition to other standard operating procedures, error reports, GMP requirements etc. NOTE: the person in the clean room might be a technician. Therefore, we are responsible for anything they do There's a window which allows you to observe and check on the tech.

Why is safety important?

Protect staff These cytotoxics are carcinogenic/toxic so we need to protect the people handling these compounds Protect patients Prevent complications
Administration TPN or cytotoxics are usually not delivered by the pharmacist, but they need to tell these people how to. Short infusions for cytotoxics (or peripherial nutrition) need to be controlled specifically by a pump Longer infusions (such as for TPN) can also be controlled by a pump, or they may use an elastomeric pump, which uses rubber to push liquids at a slow rate. Advantage is this allows for greater mobility, can let them go home instead, saves the hospital money. Because we need to tell how these medicines are used, we need to be very clear when writing labels Be as specific as possible "Not for intrathecal (spinal)" use is NOT acceptable. Use "For IV use only" Potentially fatal mistake with vesicants (blistering agents) Be careful to check it's the right patient, dose etc. Be wary of extravasation This is where the IV fluid leaks out into the surrounding tissues (so it's called being 'tissued' by nurses) In the case of vesicants (blistering agents) this can cause massive necrosis. Patients need to be told to report discomfort or pain ASAP Note: For intrathecal drugs Intrathecal drugs tend not to be given very often, so the pharmacist in charge will personally deliver it to prevent mistakes Also, you can only give a few millilitres via the intrathecal route (larger volumes are used for IV route), so the size difference should tip off the nurses as well

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Patient Information Need to tell the patient what to do Such as for extravasation Or if the elastomeric pump breaks at home How to counter side effects (like anti-emetics for vomiting) Check for: Doses Can vary greatly between patients and within patients e.g. changing organ function, reduced effect or tolerance etc. Stability Biological (contamination) Chemical (reactions occurring) Physical (precipitation or light sensitivity) Contraindications Allergies Pregnancy (debatable, risks to foetus need to be considered) Important information is the side effects which will affect the patients We need to know what can happen, and may have to advise on how to counter them Adverse reactions Note: REMEMBER, the cytotoxics will usually affect growing cells. These side effects are usually caused by affecting dividing cells like the bone marrow or mucosal surfaces etc. Mucositus Oral and GI mucosal damage due to cytotoxics affecting their regeneration and repair Oral hygiene becomes much more important Patients need to report abdominal pain or bleeding Myelosuppression/immunosuppression White blood cells and platelets are reduced by cytotoxics Must report bleeding due to reduced platelets Can also cause neutropenic sepsis (means low neutrophils plus infection) where temperature is high, chills, sore throat, pain on urination etc. Tumour lysis Lysis of tumour cells releases calcium, uric acid and potassium This can lead to gout, need to treat with allopurinol and keep hydrated Alopecia Hair grows back wavy Usually temporary and not harmful, but don't let the patient be surprised Be competent at calculations

Sometimes we might be adding extra nutrients or electrolytes to the TPN bags for specific requirements for the patient. So we need to be able to make calculations.
Generally, we already have these electrolytes in a solution, so we need to know what volume of these liquids we're adding. General tips: Try to understand why the calculations/formula works. Saves you from having to rote learn AND helps to pick up on any mistakes Watch out for other sources of electrolytes! Potassium ions can be supplied by potassium dihydrogen phosphate or potassium chloride
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potassium chloride So when you're adding phosphate, you have to add potassium The TPN bag might come with some electrolytes, make sure you take away these electrolytes from your calculations Premade TPN bags can generally hold 20% more fluid /)^3^(\ Important consideration: Calcium phosphate WILL form if calcium ions are in contact with phosphate ions In other words, adding calcium gluconate just after potassium dihydrogen phosphate (or vice versa) will lead to calcium phosphate formation This is VERY BAD, because calcium phosphate is insoluble, it will block your filter or piss off your patient with phlebitis if you don't kill them first To avoid this problem, just use another solution first (like sodium chloride if you have to add it) OR just rinse with water for injection Don't replace filters, they can cost $5US per filter Example calculation A patient needs 68mmol potassium ions and 40mmol phosphate ions in the TPN bag. The TPN bag already contains 48mmol potassium and 20mmol phosphate. You have the following solutions available: Potassium chloride 2mmol/mL (contains 2mmol/mL of potassium) Potassium dihydrogen phosphate 1mmol/mL (contains 1mmol/mL of potassium and phosphate) What must you do to fulfil the prescription? Start off by calculating how much of each electrolyte you need. In this case, the TPN bag already contains some of the electrolytes, so we need to subtract them:

Potassium: 68mmol - 48mmol = 20mmol Phosphate: 40mmol - 20mmol = 20mmol

We can see both are short by 20mmol, but we have two solutions we can use. We can't use potassium chloride, otherwise we'd have an excess once we try to add the phosphate because the phosphate solution also has potassium in it. Lucky for us, the shortage is a 1:1 ratio, so we can just use the potassium dihydrogen solution only to make up the 20mmol shortage. Now, we know each 1ml of the solution contains 1mmol of both potassium and phosphate, but we need 20 mmol of both, so we divide 20mmol by 1mmol/mL 20mmol / 1mmol/mL = 20mL Notice how the units will fit (mmol will cancel each other out, and since the ml is on the bottom, it gets flipped up after division), showing you did the right type of calculation So the answer is we need to add 20mL of potassium dihydrogen phosphate to the TPN bag to fill the prescription.

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Oncogenesis
Objective: Understand the biological basis of cancer Summary Cell division occurs through the cell cycle Tightly regulated with several checkpoints Cancer occurs because cell growth becomes unregulated The process is called oncogenesis Associated with two families of genes Suppressor genes Proto-oncogenes/ Activator genes Several factors are known to damage cells to cause them to have their growth unregulated Inherited Chemical Physical Infectious

The cell cycle

G0- "Growth 0" phase. The cell is at rest, no division is occurring (lots of cells are like this in the body, as they are terminally differentiated) G1- "Growth 1" phase. The cell prepares to divide, BECAUSE it's received an instruction to divide. As a result, it will now synthesise proteins and enzymes required for division The instruction can be from a hormone, growth factor, a change in local conditions etc. S- "Synthesis" phase. The cell will now replicate DNA. This is the longest stage clocking in at 6-8 hours. Antimetabolites, such as methotrexate will work here G2- "Growth 2" phase. The cell has two copies of DNA, and it will now produce proteins required for mitosis to occur. Takes 2-3 hours.

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 M- "Mitosis" phase. The cell will now split, taking one copy of the DNA, to produce two identical cells. This is the shortest phase, clocking in at 1 hour. The cell will now return to G0 phase, and can re-enter the cycle if stimulated. Antimotility agents, such as paclitaxel will work here Normally, we would expect the number of dying cells to equal the number of cells created to keep the number of cells in the body constant A homeostatic mechanism exists in the body to keep things under control Cells will be killed off due to apoptosis over time While other cells will be triggered to grow to replace these dying cells If the homeostatic mechanism fails, then we get cancer. So the cell cycle is tightly regulated to stop this from happening

Cell division checkpoints

DNA damage is harmful to cells, as it can cause a loss in function, which includes not making a correct protein, or it could even become cancerous. Therefore, cells have defence mechanisms against mutations from being passed down during mitosis Once that mutation passes down through the cell cycle, it becomes fixed into the DNA permanently, because the cell doesn't have an original copy of the DNA to check against. So the cell cycle has several 'checkpoints' where the integrity of the DNA is checked to stop mutations from occurring. If the cell fails to pass the checkpoint test, the cell cycle is immediately halted to allow for repairs to occur before continuing: G1 arrest- the cell cannot enter the cell cycle G2/M arrest- the cell cannot enter mitosis If the DNA cannot be repaired, the cell will undergo apoptosis p53 and the Rb (retinoblastoma) genes are important in cell cycle control, as they will regulate the cell cycle. p53 is especially important, as it is a part of the G1 checkpoint, can induce DNA repair and induce apoptosis if needed Therefore, many tumours will have p53 deactivated Another important mechanism is the use of telomeres Telomeres are straight pieces of DNA at the end of a chromosome The straight ends cannot be perfectly copied, so they shorten with each cell division Once the telomeres are short enough, the cells are triggered to undergo apoptosis The reason for this is to make sure cells have an automatic 'expiry date' to prevent them from accumulating too many mutations, and becoming cancerous. To counter this, a cancerous cell can activate telomerase, which increases the length of the telomeres to prevent apoptosis from being triggered Therefore, it's also another common mutation seen in cancers

Oncogenesis
An important fact is one mutation is not enough to cause cancer Remember: the cell cycle is tightly regulated, so the cell has quite a few barriers which it needs to overcome to become cancerous For example, to become cancerous, the cell would have to ignore apoptotic signals (p53), grow independent from growth factors, have factors to promote angiogenesis (production of blood vessels), avoid the immune system etc.
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system etc. Normally, these mutations will be prevented by the checkpoints put in place But if the checkpoints are non-functional (either inherited or mutated), then it's much easier for these mutations to occur, so it's easier for the cell to become cancerous REMEMBER: normally a person will carry two copies of the gene, both must be broken to get cancer ('dominant' gene, so hetrozygous people are still at higher risk of getting cancer as a result) Because the cell needs multiple mutations to become cancerous, cancer is a disease which is concentrated in the elderly If you live long enough, by chance you will accumulate enough mutations Also, there are two main groups where mutations will cause cancer, as they are important for regulation of cell growth: Suppressor genes Activator genes (proto-oncogenes) Suppressor genes will work to prevent cancer, so these should be kept ON p53 is again an important suppressor gene, as it contains apoptosis genes BRCA is an important suppressor gene as it is involved in double stranded DNA repair If BRCA is mutated, the incidence of breast cancer shoots through the roof Anything inhibiting growth, such as growth regulator genes are important Contact inhibition genes- normally these will stop cells from dividing if they are in contact with each other, as it indicates there's no space to grow. Activator genes are also called proto-oncogenes, as normally they are not cancerous, but if mutated, will cause cancer. Therefore, to prevent cancer, these should be kept 'INACTIVATED' (not completely off, normal body function might need them, like healing) Angiogenic genes are very important in tumours, as the tumour must be able to get a blood supply set up to grow properly. Otherwise the tumours will be small and most likely unsuccessful. Some genes will allow cells to escape immune surveillance, or be immunosuppressive Others will help them survive outside the tumour, which allows distant metastasis to occur (surviving outside the original tumour is quite difficult)

How do we get cancer?

Inherited As stated before, you need functional suppressor and non-activated activator genes to NOT have cancer. Sometimes, people will inherit a non-functional copy (or copies) or suppressor genes Or receive one (or two) copies of an activated activator gene Therefore, these people are at a higher risk of getting cancer Think about it as they've already accumulated mutations required for cancer. Chemical Carcinogens are chemicals which will cause damage to DNA (either directly or indirectly through metabolites/breakdown products) Again, these mutations need to hit a suppressor or activator/protooncogene. Physical Ionising radiation Direct damage to DNA Non-ionising radiation Damage via production of radicals
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 Damage via production of radicals Either will cause DNA damage, which might give you cancer if the wrong genes are turned on/off (see above) Infectious agents Can inhibit p53 Quite a range of viruses can do this Why? Because p53 can trigger apoptosis and ruin their plans Human Papillomavirus (HPV) and Epsein-Barr virus Cause increased division, which leads to more chances of being mutated and causing cancer This is probably why hepatitis B and C cause liver cancer Insertion into oncogenic gene Yeah this can only end badly Seen by retroviruses (can enter the host's DNA) like HTLV-1 or HIV

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The role of the immune system in cancer

The immune system has a role in cancer (surprise!) Can be thought of having a role before AND after cancer Chronic inflammation can cause cancer The immune system can kill cancerous cells

Chronic inflammation and oncogenesis

It appears chronic inflammation can cause cancer Inflammation produces some reactive oxygen species which may damage DNA, causing activation/inactivation of genes Inflammation also encourages division of some cells (especially immune cells) which can lead to cancer Therefore, anti-inflammatory cytokines or chemokines may be used to prevent cancer. NSAIDs have some effect for protecting against cancer

Immune response AGAINST cancer

How is the immune system protective against cancer? Destroys the infectious agent which can cause cancer Kills any cancerous cells before becoming a tumour Recap: innate immune response vs acquired immune response Innate immune response is the first-line protection mechanisms Neutrophils, macrophages and dendritic cells Detect foreign cells, and abnormal body cells (due to infection or cancer) to trigger an immune response (produce cytokines and stuff), especially trigger the acquired immune response Slow down the infection long enough for the acquired immune system to kick in Acquired immune response is the killing blow T Lymphocytes for a cellular immune response, B lymphocytes for a humoural (antibody) response Produces more effective killing cells (natural selection, where lymphocytes with the best receptor against the antigen is stimulated more) Produces memory cells to prevent long term recurrence Self-reactive cells are killed off during thymic selection to protect the body against auto-immune reactions The requirement of a danger signal will also prevent any self-reactive cells from being activated as well So How does that help against cancer? All nucleated cells are able to get cancerous But all nucleated cells must express MHC-I The MHC-I is continuously recycled from displaying an antigen and being drawn back into the cell to find a new antigen to display Normally, the immune cells will see all the MHC-I receptors displaying normal body antigens But if the cell becomes cancerous, it might start producing antigens the immune system can't recognise This will lead to an immune response, and destruction of the cancerous cells

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 What kind of immune response? Because it's MHC-I, it needs the CD-8 co-receptor to stimulate CD8 T cytotoxic cells Therefore, the immune response will be mainly carried out by CD8 T lymphocytes (cellular response) Don't we have to worry about auto-immune reactions? Well, it's not the same as the diseases we've seen in the past Tumours will make 'Tumour specific antigens' (TSA) which are the mutated proteins the immune system can't recognise In addition, they might also make 'Tumour associated antigens' (TAA) , which is where the tumour produces proteins which shouldn't belong in that part of the body Lastly, an infectious agent can be causing cancer, these cells will display viral antigens to become a target for the immune system as well.

If cells are kept in anergy, how do we activate them against cancer? Danger signals can come from infected cells at least Also, if a tumour does form, then the centre of the tumour may become necrotic due to reduced blood supply to the region. The immune system will respond to necrosis with inflammation.
So our immune system should work against cancer effectively right? Maybe but cancers can have immune defences Tumours will be subject to natural selection, because vulnerable cancerous cells will be killed off easily, leaving cells which are resistant to immune attack Plus they are more likely to be subject to mutations due to inactivated suppressor genes. They can look normal to the immune system by expressing normal antigens on MHC-I They can shut down antigen presentation (however, see below) They can produce an environment which can be immunosuppressive Or the person just can't mount a response Immunosuppressed due to drugs, infectious agents or radiation Plus as people get older, their immune system strength decreases Or the person produces the wrong response The immune system decides to induce tolerance against the tumour cells, preventing any immune cells from attacking it Or the tumour cell or supporting cells will produce immunosuppressive factors like cytokines So one important result of treatment (radiation, chemo or surgery) is to kill off these immunosuppressive cells and let the immune system clean up What if the cell stops producing MHC-I? It's one method to prevent the immune system from noticing But Natural Killer (NK) cells will be able to detect if a cell is missing MHC-I NK cells are always set to kill, so they need an inhibitory signal to prevent the cell from being killed MHC-I provides the inhibitor signal, so cells with MHC-I will survive Cells which do not produce display MHC-I cannot send the inhibitory signal, and so they will die.

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Pharmacology of cytotoxic drugs

Why is it difficult to treat cancer? The amount of cells we can kill is limited by toxicity Narrow therapeutic range due to targeting the same pathways used by our healthy cells We can counter this by combining several drugs at lower doses to prevent extreme toxicity Cells are rapidly dividing, and the genomes are prone to mutation due to damaged repair/error checking mechanisms Leads to increased drug resistance Use multiple drugs to help to prevent increased resistance They can escape to safe sites in the body, where it is hard to get drugs or immune involvement in Brain and testes By the time we're treating the cancer, it's already growing slowly, and is less receptive to chemotherapy Therefore, we need to apply chemotherapy as soon as possible Combination therapy Again, results in better response (synergy) and reduced side effects and a lowered chance in gaining resistance There are a few principles you should keep in mind: Each drug should work against the cancer Each drug should have a different mechanism of action Drugs should avoid overlapping toxicities Target different stages of the cell cycle AND include a few which are non-cycle specific Reason for this is because only a certain portion of the cancerous cells will be in the part of the cell cycle, combining the two leads to a better outcome The dosing of a cell cycle specific vs. a non specific agent is different: Cell cycle specific drugs need to achieve high concentrations over a long period of time, as different cells will enter that specific part of the cell cycle at different times. Infusion over time or frequent dosing Think of it like the time-dependant kill antibiotics, a long period of time is preferred While non-specific agents just need to be given in one single high dose One fast infusion Think of it like the concentration-dependant kill antibiotics, where the highest concentration needs to be achieved Cell cycle specific drugs should be coordinated with surgery Surgery causes injury which stimulates cells to come out of G0 Therefore, can hit more of the cancerous cells Drugs are given in treatment cycles Allows the body's normal tissues to recover from the chemotherapy But the waiting time between treatments is short enough to prevent the cancerous cells from Pathways for antimetabolite drugs to target:

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 Methotrexate (MTX) Inhibits dihydrofolate reductase (DHFR) Stops the conversion of dihydrofolate to tetrahydrofolate to stop the production of all nucleotides Countered by the cancerous cells by increased efflux or a mutation or upregulation in DHFR Hydroxyurea Inhibits Ribonucleotide reductase (RR) Stops the conversion into deoxyribonucleotides, as that's the form needed to be incorporated into DNA 6-Mercaptopurine (6-MP) Inhibits IMP dehydrogenase (IMPDH) Stops purines from being made (A as AMP and G as GMP) 5-Flurouracil (5-FU) Inhibits thymidylate synthase Prevents the conversion of dUMP to dTMP to cause a thymineless death (a pyrimidine) Cytarabine Not shown above Inhibits DNA polymerase Stops nucleotides from being added to DNA to stop production Azathioprine and 6-MP metabolism Azathioprine is metabolised to 6-MP 6-MP is metabolised by TPMT (Thiopurine methyltransferase) Highly polymorphic Fast metabolisers will produce too much toxic side products Slow metabolisers will accumulate 6-MP leading to toxicity 6-MP is also metabolised by xanthine oxidase This is the enzyme which is inhibited by allopurinol 6-MP tends to be given to patients who need allopurinol to combat tumour
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 6-MP tends to be given to patients who need allopurinol to combat tumour lysis syndrome Adjust dose of 6-MP down to compensate Folinic acid Not to be confused with folic acid Folinic acid can be converted by another enzyme to several different forms, like THF or MTHF, which can readily be used by the cells of the body If it is used with 5-FU, it enhances the cytotoxic effect, as MTHF, a cofactor for the thymidylate synthase enzyme is required for binding and inhibition BUT it could also be used with methotrexate. Methotrexate depletes useable folate reserves (as THF) as dyhydrofolate reductase has been inhibited i.e. stops DHF from being recycled into THF Folinic acid rescue after methotrexate use will allow healthy cells of the body to produce nucleotides to prevent side effects Cancerous cells are too damaged by this point to be saved by this folinic acid rescue Mitotoxicity hypothesis DNA damage in normal cells will lead to apoptosis Therefore, the point of using of agents is to try and stimulate the cancerous cells to undergo apoptosis Problem is, it depends on the function of certain genes/proteins like p53 p53 induces apoptosis, it is a part of the G1 checkpoint of the cell cycle Some cancers will keep a normally functioning copy of p53 (wild type) These cancers are responsive to treatment, as p53 induces apoptosis Leukemias and lymphomas Other caners will get a mutation in p53, apoptosis isn't easily induced Minimally responsive to treatments Lung, pancreatic and colon cancers Telomeres Caps at the end of chromosomes 2-30 kilobases which repeats 'TTAGGG' A 50-300 base single stranded section will loop back onto the DNA and form a stable loop (t-loop) DNA polymerase isn't able to copy this section perfectly, it shortens with each replication Once it reaches a critical length, p53 steps in and prevents the cell from passing the G1 checkpoint, forcing the cell into senescence (remain in G0 forever) Therefore, old cells which may have gained a lot of mutations won't be allowed to grow anymore But cancer cells can get around this: Inactivated version of p53 and Activation of telomerase, which is an enzyme which adds to the length of telomeres, making them grow again. These two mutations will cause a cell to become immortal Photodynamic therapy Experimental therapy which has drugs which produce reactive oxygen species when exposed to light Looks like iron contained within a polyphoryn ring When struck by light, the iron will catalyse the production of free radicals
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 When struck by light, the iron will catalyse the production of free radicals Allows for some targeting to specific sites of the body DNA repair systems Mismatch repair Caused by natural errors Mutations can lead to colorectal cancers Base excision repair Single strand breaks (caused by alkylating agents and irinotecan) PARP1 repairs these, but if it is inhibited, BRCA1 and 2 can take over BRCA1 and 2 are slower as they are made for double strand breaks Nucleotide excision repair Addition of substances (such as alkylating agents) Double strand break repair Double strand breakages (topoisomerase inhibitors and bleomycin induces this, along with cross-linked DNA due to alkylating agents) Homologous recombination repair assisted by BRCA is the best bet, which is where the sister chromatid (remember you carry two copies) lends its information to help join the two strands together Non-homologous end joins is less safe as there's nothing to check against Topoisomerase I inhibitor- irinotecan Topoisomerase I is involved in uncoiling the DNA prior to replication Relieves coiled tension within the DNA strand (double helix) Current model for inhibition is: The enzyme will separate the two strands of DNA Cuts one strand Unties the strand by passing it over the other strand Joins the two cut pieces together to complete the unwinding Irinotecan will stop the ends from being joined together, leading to a single strand breakage Actually is metabolised into SN-38 which is 1000x more active, but it's highly protein bound and has a very short half life It is cleared by UGTA1, which is lacking in Gilbert's syndrome. Stops the SN-38 from clearing, leading to severe myelosuppression Topoisomerase II inhibitors Relieves supercoiling of DNA Relieves coiled tension BETWEEN DNA strands (not within the strand) Similar action to above Cuts both sides of the DNA strand Passes the strand past another strand to relieve the supercoiling Joins the two ends back together Some drugs like anthracyclines will allow the double strand breakage, but won't allow it to come back together Anti-mitotic drugs Attaches to tubulin, which makes up microtubules Important during the M phase to pull apart and drag the chromosomes Also important for intracellular trafficking of chemicals with vesicles Both classes of drugs lead to peripheral neuropathy Vinca alkaloids bind to the positive end of beta tubulin to prevent polymerisation of the chain
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of the chain Taxanes on the other hand will bind to the side of beta tubulin. It allows polymerisation, but not depolymerisation (so it become stuck) HER2 and Imatinib (and other signalling pathway blockers)

Some cancers will have unregulated growth due to expressing growth receptors We can block these receptors to prevent growth HER2 is a receptor which can be expressed in breast cancer Use Herceptin (trastuzumab) Imatinib blocks a tyrosine kinase associated receptor to prevent growth in Chronic Myeloid Leukaemia

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Medchem of cytotoxic drugs

Intro We want to specifically kill cancer cells over normal cells (selective toxicity) Otherwise, the chemo can kill the patient before it kills the cancer Problem is, cancerous cells tend to use the same biochemical pathways as normal cells, which is why it's very toxic Compared to antibiotics, which exploit differences in biochemical pathways between us and them So we tend to target rapidly dividing cells to target the cancer Some normal cells are rapidly dividing (gut, bone marrow, liver) so they are affected by chemo But some cancerous cells won't divide rapidly, so chemo won't work well against them Rapidly dividing cells are bad for treatment, because they tend to accumulate more mutations Leads to more drug resistance and treatment failure We want to maximise kill count (hopefully on a log scale) But it's limited by the toxicity of the drugs Finally, we also want to have them in a form which is easy to administer Oral forms are desired Vesicant- a substance which is able to cause blistering. Quite a few chemo drugs tend to be vesicants. This is why patients need to be told to look out for redness, swelling, discomfort or pain around the infusion site. Alkylating agents Designed to interfere with DNA function Can't copy or transcribe information from DNA Trigger apoptosis due to damage Guanine is generally targeted due to its nucleophilic properties (see below) How does it work? (mode of action): Modification of DNA bases (mono-alkylation) Guanine is alkylated, so there's this massive group attached to it This can lead to the elimination of the group as well (the base comes off the DNA, see below) Either way, the DNA can't work this way, so excision repair enzymes are activated, to cut the DNA to replace these faulty bases Because repairs can be made, this isn't effective Cross-linking within and between DNA strands (di-alkylation) See below for the structure a sulphur mustard Notice it has two chlorines, so it can alkylate twice It can form covalent bonds either: Between chains Within chains (more common) This will prevent the DNA from coming apart normally for normal function Effective Nucleotide mispairing Normally, we'd except A goes with T and C goes with G in DNA But alkylated G can go with T, which is a mistake This will lead to mutations Which can lead to a malfunctioning cell, and apoptosis Exhibits a 'Janus' effect
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 Exhibits a 'Janus' effect Janus is the Roman god of doors. He has two heads, one pointing inside, and the other pointing out. Why is this important? Because alkylating agents will kill cancerous cells BUT because they interfere with DNA, they can also CAUSE cancer. People may have secondary tumours which are completely different to the original tumour after a few years of treatment The alkylating agents will always have a specific moiety Below is a sulphur mustard, where there's a two carbon bridge between the S and the chlorines. THIS IS IMPORTANT. RECOGNISE THIS. Sulphur mustards are gases, due to low intermolecular bond strength (they don't H-bond to each other) so they are too dangerous to work with So nitrogen mustards were investigated, because they can H-bond to each other, so it's not a gas anymore, so it's safer to handle

Why is guanine (N7 nitrogen) targeted specifically? The two nitrogens in the right side ring presents a electron rich region This makes it nucleophilic, attacking the alkylating agent (seen as R) This addition will lead to a positive charge on the nitrogen, which needs to be removed. Can lead to the ring opening which permanently binds the agent to the base Or can cause the entire group to come off as a leaving group from the DNA But remember: monoalkylation (shown below) can easily be repaired

The mechanism of action of alkylating agents is all the same (and we need to memorise it) The electronegative chlorine atoms will draw electrons towards itself, causing the adjacent carbons to become slightly positive The non-bonding electron pair (NBP electrons) on the nitrogen is attracted to the positive charges, leading to intramolecular nucleophilic attack (SNi) Chlorine is a good leaving group as it comes of neutral with respects to acid-base chemistry (i.e. even though it's negatively charged, it doesn't have acid base chemistry) The SNi leads to the formation of the aziridium ion, which is a highly reactive
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 The SNi leads to the formation of the aziridium ion, which is a highly reactive electrophile (i.e. susceptible to nucleophilic attack) Bond angles are strained (at 60 degrees instead of normal 108) Both carbons are positively charged After nucleophilic attack with the nucleophile (which is likely to be guianine), the base is now alkylated. Remember: the molecule is bifunctional as it has two carbons, so it can crosslink DNA (deals more damage)

If the nitrogen mustard shown above had an aliphatic R group, it is too toxic to use in people Forms the aziridium ion too easily then, which will just react with all the cells it comes into contact with So we need to tie up those NBP electrons to stop forming the aziridium ion as easily to reduce toxicity, to reduce side effects Alkylating agents- examples R Mephylan

The NBP electrons on the nitrogen are partially taken up into the aromatic ring The sterochemistry on the carbon is R It's actually L-phenylalanine (amino acid) attached to the mustard They thought the phenylalanine would allow the drug to be taken up into growing cells because it's an amino acid But it's still actively taken up by all cells, leading to side effects This drug has some activity, because the NBPs are somewhat available If the phenylalanine comes off, it's still active because the mustard is intact If the amino or carboxylate groups are metabolised, again, the mustard is still intact and it's still active Cyclophosphamide This is the really important one because we use it quite often It is a prodrug, it must be metabolised first:
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 It is a prodrug, it must be metabolised first:

The NBP electrons in Cyclophosphamide are completely taken up into resonance, so no aziridium ion formation can occur, so there is no alkylation. In fact, the structure shown on the right can be further broken down to form just a bare nitrogen mustard, which is thought to have most of the activity Problem with cyclophosphamide is acrolein is a side-product which is toxic Need to co-administer with Mesna and make sure to keep the patient very well hydrated with IV fluids and oral fluids Mesna (pictured top left below) has a sulfate group purely for solubility and salt formation, while the active area of the molecule is the thiol (SH) group, which acts as a nucleophile to bind with the acrolein to form a non-toxic compound

Thiol groups could also be a hindrance to treatment though Some cancer cells produce a great amount of glutathione (GSH) GSH has a thiol group, which can react with the alkylating agent before it reaches the DNA to deal damage Remember: thiol is a nucleophile, the active aziridium ion form is very attractive Therefore, these cells will be resistant to treatment Lastly, some forms are slightly selective An alkylating agent may be conjugated to a steroid to help it get into specific cells Cyclophosphamide is actually quite targeted if you think about it It is only effective in cells which have low ALDH (aldehyde dehydrogenase), which are the well-differentiated blood cells, while the stem cells of the blood are quite high in ALDH, so they tend to be protected Alkylating agents- Methansulfonates

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 Busulfan has two methanesulfonate groups (the two sulfur containing groups on the sides) The oxygens are strongly electronegative, causing a great positive charge on the sulfur and adjacent carbon The methanesulfonate group is a good leaving group, so the carbon with the positive charge is able to attack guanine as well But because it's got two groups, its able to cross link DNA Alkylating agents- nitrosoureas

These are the drugs which tend to end in 'mustine' Very useful for brain cancers, as they are lipophilic enough to pass through the BBB Although they look like normal alkylating agents, they don't have the same mechanism Because the non-bonding pairs of electrons on the nitrogen are completely taken up into resonance, so the aziridium ion can't be formed Instead, through a complicated mechanism, it breaks down to form two positively charged carbocations which are the active molecules

Platins (alkylating-like agents) These are not alkylating agents, but shows some similar action (crosslinking of DNA) The classical one is cisplatnin Cisplatnin is a square planar molecule, with 2 amine and 2 chloride groups in
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 Cisplatnin is a square planar molecule, with 2 amine and 2 chloride groups in a cis configuration:

Interestingly, cisplatnin is formulated in normal saline (0.9% NaCl) This is because of this equilibrium reaction:

If the concentration of chlorine is high (as it is in the blood and in normal saline), then the equilibrium lies to the left, which is the inactive form However, if cisplatnin moves into the cells, the chloride concentration is much lower, the equilibrium moves to the right, and the activated 'aquated' form is produced (pretty much water chucked on) Therefore, platnins are prodrugs The aquated form is active, because the platinum atom can now attach to the N7 atom of guanine (just like alkylating agents) The H2O ligand is a very good leaving group

Because there are two chloride groups, the same process will happen again, which causes DNA to become cross-linked However, this is a intra-strand (within strand) crosslink. This will cause the DNA to have a 90 degree kink due to the shape of cisplatnin (square planar) This irregular shape means the DNA is now useless Again, another huge problem is with glutathione GSH will also bind to platnins to make them useless We can try to shield the platnin with a bulky group, but this is ineffective Cisplatnin is too reactive, it is quite toxic Therefore, we have newer, second generation platnins which are less reactive/toxic but still just as effective

Pictured above is oxaliplatnin, a second generation platnin It has a bi-dentate ligand instead of the two chorines This slows down the aquation of the platinum, leading to reduced toxicity Antimetabolites Self directed learning Up to now, we've looked at compounds which deliberately damage DNA But antimetabolites will cause DNA damage by preventing the synthesis of DNA, either by producing false metabolites, or interfering with the enzymes responsible for production
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for production Therefore, this class of drugs are S phase specific for the cell cycle The primary target enzyme is thymidylate synthase Responsible for producing thymine from uracil, uses tetrahydrofolate (THF) as a co-factor Disruption will mean thymine synthesis cannot occur, and the cell will apoptose due to a thymineless death Antimetabolites- 5-fluorouracil 5-flurouracil has a strongly electronegative group on the 5 position, which makes it quite attractive to the enzyme

It is a prodrug (even though Schmerer disagrees), it must first be converted to its deoxyribonucleotide form (pretty much just attach some phosphates to it to make it look something like a nucleotide) Note: he doesn't think it's a prodrug, because prodrugs tend to be catabolised (broken down) to its active form. 5-FU is anabolised (built up) to its final form due to the addition of ribose and phosphate When it enters the thymidylate synthase enzyme, it causes the formation of a false complex with tetrahydrofolate (THF) and thymidylate synthase Normally the THF would react with the uracil to form thymine, but this can't happen due to electrical repulsion between the fluorine and the nitrogen 10 of THF This effectively prevents thymidylate synthase from being regenerated, which stops thymine production Additionally, these false nucleotides may also be incorporated into the DNA and RNA This causes the elongation of DNA to be stopped, leading to apoptosis Anti-metabolites- folate metabolism As stated above folate (as THF) is an important co-factor for thymidylate synthase After thymine is produced from uracil, the THF is oxidised to dihydrofolate (DHF) It needs to be reduced back to THF to be used again The enzyme folate reductase is responsible for this function It is able to be inhibited Also causes a thymineless death May be used as a synergistic drug with 5-FU, as they both target the same process Methotrexate will inhibit folate reductase Better substrate compared to the endogenous substrate, folic acid due to the amine group Increases the electron density on the nitrogen at the bottom of the ring, which is essential for binding Therefore it will be able to outcompete folic acid

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Bleomycin Massive molecule which is synthesised by bacteria This is a problem, as it is hard to scale up to get large yields The action of bleomycin is to bind to the DNA and cause DNA breakages Although a part of the molecule is cut off, DNA binding sites lie to the right of the molecule shown below. However, it is unable to intercalate with DNA due to too much 3D structure (need to be flat to intercalate) The important bit is the iron in a square planar structure Notice how the oxygen is bound to the iron, it displaces the carbamate group The oxygen is reduced to oxygen free radicals, which then damage the DNA The molecule is enzymatically cleaved by hydrolase, which reduces DNA binding and damage Normally, it comes as a blue copper complex (the copper sits where the iron is sitting below) The copper is removed to inactivate the molecule to reduce toxicity (it will find iron to chelate to in the body) It is amazing to see such a large molecule being able to enter the nucleus. The sugars may be used as a recognition site to gain access to the nucleus

Because it converts oxygen into free radicals, the compound is associated with oxygen toxicity, leading to pulmonary fibrosis. Need to monitor patients carefully Actinomycin Composed of three basic parts: Flat ring system which isn't fully aromatic. It is still able to intercalate to the DNA Two large lactones made of 5 amino acids, they may differ or be the same
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 Two large lactones made of 5 amino acids, they may differ or be the same

The entirety of the molecule will be able to bind to the DNA, causing it to bend out of shape completely Planar rings allow pi-stacking Lactones will bind via hydrogen bonding (contains amino and carboxyl groups) and Vander Waals' forces (because it's big) Bending it out of shape this badly prevents topoisomerase II from unwinding the DNA properly, so the cell can't replicate or transcribe DNA, leading to death

Anthracyclines There are a few anthracyclines in use e.g. Doxorubicin Epirubicin Although they have 4 rings, they are not tetracyclines They are red coloured compounds, and they are renally excreted, causing urine to go red Tip: rubor is redness, can't forget it's red now The 4 flat rings allow for intercalation into the DNA, while the daunosamine sugar (seen at the bottom of the image) will aid with binding to the DNA Note: formaldehyde naturally formed by the body will attack the sugar, which can cause covalent bonding of the anthracycline to the DNA That is a good thing After intercalating with the DNA, it stabilises the interaction of topoisomerase II with the DNA, preventing it from doing anything else Prevents transcription and duplication of DNA

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They are also a target for reductase enzymes, this is a major issue Causes free radical formation, which does have some effect against DNA, but the problem is it also occurs in the cytosol of cells This is why it might be causing cardiotoxicity, as the cells of the heart cannot divide to form new cells, so the cells will take gradual damage over use Therefore, there is a maximum cumulative lifetime dose for all the molecules in the anthracycline family

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Targeted Drug Delivery systems

Importance of targeted systems for chemotherapy Chemotherapy drugs are generally not targeted at specific against cancer cells as we don't have many biochemical differences between cancer cells and normal cells. Therefore, if we were able to produce a targeted form, it would be better due to: Reduced toxicity as the drugs won't affect normal cell function Remember: treatments tend to be dose-limiting due to toxicity Increasing dose due to better targeting leads to better outcomes Increased efficacy as more of the drugs will hit the cancerous cells Levels of drug targeting

First order targeting Broadest targeting Targeting to the capillary bed of the desired organ Better than nothing
Second order targeting Targets at a cellular level Hit specific cells within a region or in the body Third order targeting Targets a specific part of the cell In our case, we want to target the nucleus of the cancerous cells to deal the greatest amount of damage to DNA To get these levels of targeting, we can consider two types of systems: Passive targeting Physicochemical properties of the carrier/drug will help the drug reach its target In other words, the body won't active move the drug, it needs to be designed to get there on its own Analogous to passive diffusion Examples are modifying pH or particle size Active targeting Manipulate the body to actively take the drug to where it's needed Analogous to active transport Examples are antibody based systems Ideal properties of a carrier Non-toxic Cheap Specific targeting to the desired cells Doesn't leak the drug while moving to the site of action (might be a liposome) Drug must get to the site Drug must be released at the site (otherwise the carrier will prevent it from having its action) Drug must remain at the site for as long as possible Generally, there are two types of carriers: Nano-particulates- encapsulates the drug to carry it to the site of action Liposomes- small spheres of phospholipid membranes which has drugs
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 Liposomes- small spheres of phospholipid membranes which has drugs inside (inside is a hydrophilic solvent) Emulsions- small spheres of lipids which has the drugs in the lipid compartment (inside is a lipophobic environment) See case 1 Drug-conjugates- drug is attached to the carrier to be enzymatically released at the site Polymers Proteins (make sure it's human protein to prevent an immune reaction) Both of these have long half-lives to give it enough time to reach the site See case 2

Barriers to drug delivery

High interstitial pressure in tumours Tumours are able to cause angiogenesis (required for growth larger than 1-2mm), but they can't produce a drainage lymphatic system The blood vessels formed in tumours are very leaky due to increased gaps between the tight junctions of the cells of the endothelium, this allows liquids to move out Pressure tends to be highest at the middle of the tumour, pushing liquids from the core outwards Liquids tend to be kept in the center due to a thicker extracellular matrix in the core Our drug can be pushed outwards due to this pressure, so chemotherapy is most effective around the outside of tumours Non-uniform perfusion Perfusion is greatest on the outside of tumours where the growth is occuring, while it is lowest at the core of the tumour, which may be hypoxic and necrotic Our drugs are delivered by the blood, so again, the surface of the tumour is more affected than the core Cell membrane barriers The membrane tends to keep bulky or polar substances from entering the cell, so it's hard for our drug to get in To make matters worse, the membrane is studded with efflux transporters like P-gp which kicks out the drugs as soon as they enter Intracellular inactivation Glutathione- contains a thiol group (-SH) which is very attractive for alkylating agents as it is also a good nucleophile. So our alkylating agents will attack glutathione instead of attacking the DNA DNA repair enzymes- if the cell can repair the damage the drugs are causing, then it will be resistant to attack Enhanced permeability and retention effect Although the lack of a lymphatic system in tumours causes an increased pressure within tumours, this is also an advantage to us The enhanced permeability and retention effect means our drug is able to enter the tumour easier, because the gaps between the tight junctions are wider (remember, these carriers tend to be quite big) And since there's no lymphatic system, the drug can't be washed away due to lymphatic drainage, so it stays in the tumour for longer Overall, this effect counteracts the increased pressure from the tumour Case 1: doxorubicin in PEGylated liposomes Normal liposomes use phosphodialcholine to create the phospholipid bilayer
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 Normal liposomes use phosphodialcholine to create the phospholipid bilayer seen in liposomes PEGylated liposomes will use a phospholipid with PEG (polyethylene glycol) polymer attached to the polar end of the phospholipid What happens is the PEG will be on the outside of the liposome, surrounding it with this polymer Normal liposomes will generally be ineffective, due to their poor pharmacokinetic variables Low Cmax Low AUC High clearance Short half-life Large volume of distribution PEGylated liposomes have much better pharmacokinetic variables, as they are able to evade the reticuloenothelial system (macrophages and monocytes), which is what causes the poor performance of liposomal compounds PEG prevents the cells from detecting and phagocytising the liposomes PEG prevents opsonisation, so it can't be picked up as a foreign component Case 2: Doxorubicin-polymer conjugates (PK1) Doxorubicin is attached to a polymer through an amino acid spacer The polymer makes the particle size very large Too large to enter through normal tight junctions, but small enough to enter through the leaky tight junctions of the tumour Allows some targeting, as normal cells won't be able to take up this conjugate easily Once the conjugate has reached the tumour, a tumour cell will take it up via pinocytosis ('cell drinking') Once it is inside the cell, the endosome (the vesicle formed from pinocytosis) will be fused with a lysosome The enzymes in the lysosome, together with the acidic environment of the endosome will cause cleavage of the amino spacer between the doxorubicin and polymer to be cleaved, releasing the free drug The free drug is now free to move around the cell and cause damage as required

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Antiangiogenic treatments
Background Angiogenesis is the process where new blood vessels are formed FROM PREEXISTING vasculature In adults it's important for healing and endometrial growth in females In embryos, it's important to produce vessels from vasculogenesis (the production of blood vessels from nothing) Tumours cannot grow any larger than 1-2mm if angiogenesis cannot take place Tumours need a supply of oxygen and nutrients which are delivered by the blood Can't get too big if there aren't any blood vessels supporting it Therefore, antiangiogenic treatments are being researched

Mechanism
Wounded areas will produce angiogenic factors, like vascular endothelial growth factor (VEGF) These factors are peptides, not other hormones These factors will bind to receptors on the endothelial cells of the blood vessel Growth factors are then required to bind to other receptors to really kick off angiogenesis by activating the endothelial cells Activated cells will break down the basement membrane of the blood vessel to form holes for new blood vessels to poke out of The endothelial cells will then divide and poke out of the holes to travel towards the injury site using adhesion molecules to drag themselves forwards They then roll up to form a tube Smooth muscle cells will then support the newly made blood vessel for structural support How does this apply to secondary cancers? Tumours will produce an angiogenic factor to produce blood vessels But once they get big enough, they also secrete angiostatin, a natural inhibitor of angiogenesis, normally used to prevent unnecessary angiogenesis Luckily, this stops any secondary tumours from carrying out angiogenesis Once the initial large tumour is removed, this secretion of angiostatin is also stopped The concentration of angiostatin drops, which allows smaller tumours to grow, as they are able to form blood vessels now Thalidomide Has antiangiogenic effects Mechanism of action is unknown May be used in multiple myeloma as a last resort However, it is strongly teratogenic Need to have effective contraception, as it is present in semen Hormonal contraception/IUD or surgery PLUS condoms/diaphragm Make sure no one can get pregnant Therefore is contraindicated in: Pregnant women Women who are able to have children but are unwilling to use contraceptive methods Ditto for men
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 Ditto for men Monoclonal antibodies Cetuximab has a high affinity for the epidermal growth factor receptor, which is used in angiogenesis Because it binds so tightly, it stops normal factors from attaching to prevent angiogenesis Expected side effect: reduced healing, irregular periods

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Workshop 1- Solid tumours

Intro/Glossary Cure Removal of all cancerous cells from the body. Ideally, the patient will now have the same life expectancy as someone who doesn't have cancer. Remission Reducing the cancer, even to below detectable levels. However, the cancer is not completely removed, and may return at any time. Adjuvant chemotherapy Additional therapy given with the main method of treatment. For example, adjuvant chemotherapy is chemotherapy given in addition to surgery (the main treatment). Adjuvant therapy may also include radiation as well. All this is done to decrease the chances of reoccurrence of cancer Neo-adjuvant chemotherapy Chemotherapy given BEFORE the main treatment, for example, chemotherapy may be carried out to reduce the size of a tumour before surgery, which can reduce the amount of tissue to cut, reduce the vasculature (that's a good thing, means you'd lose less blood during surgery) and make it shrink away from healthy tissue to save that tissue. NOTE: Remember, chemo is more effective on the outer edge of solid tumours, which causes the shrinkage. Palliative chemotherapy By this point, we know the cancer can't be cured, so chemo is given to reduce the tumour sizes to relieve symptoms. PLUS it can be used to extend life. Just remember, we can't cure them by this point, make them more comfortable and live a bit longer. TMN staging system T= size of the initial tumour, higher the number, bigger it is N= number of lymph nodes or extent of spread along lymph nodes, higher the number, it's spread more throughout the lymphatic system M= indicates if it has metastasized, where 0 is no, 1 is yes. e.g. T2N1M0 means it's a medium sized tumour with little regional node infiltration and no distant metastasis. Metastasis Cancer cells are able to split off and travel around the body to for new tumours at different sites of the body. There are four main sites they will go to, leading to a common set of symptoms: Bone (leads to bone pain) Liver (leads to jaundice) Brain (leads to mental changes) Lungs (leads to difficulties in breathing)

Disease templates
Breast cancer The most common cancer in females. However, it does occur rarely in males. The disease is also more common in older people, which is common for cancers.

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Pathophysiology is common to most cancers, where the genetic material of cancerous cells is damaged, leading to unregulated growth. However, there are some specific risk factors: Age Family history Race BRCA1 and BRCA2 double strand DNA repair mechanism genes are faulty in a high number of cases. This mutation can be passed down, leading to some women developing breast cancer quite early in life Increased exposure to estrogen Early menarche (menstruating from a young age) Not having children

Signs and symptoms: 90% of the time, a small painless lump can be felt Solid, hard Irregular Non-tender Solitary 10% of the time, stabbing or aching pain can occur Sometimes, it can become tender, and a discharge can be seen Very, very curable if picked up early Regular screening is recommended Mammograms and ultrasounds are used to detect them
See above for symptoms if the cancer is advanced. See common treatment goals Non-pharmacological treatments: Mastectomy (removal of the breasts) Now days a partial removal (breast saving surgery) is recommended Radiation therapy (instead of surgery) Note: may be just as effective as mastectomy in some cases Pharmacological treatments (see 'Mechanisms of action' and 'side effects' below for details): Early stage- focus on cure Adjuvant therapy with FEC is common: 5-flurouracil Epirubicin Cyclophosphamide Notice how the above combo has two drugs which are not specific for any parts of the cell cycle, and 5-FU is specific for the S-phase. This makes them synergistic as the treatment will work regardless of what stage the cells are in. Late stage- focus on palliative care Taxanes Paclitaxel CAUTION: anthracyclines have cumulative cardiotoxicity. In other words, if you used Epirubicin during adjuvant therapy, you can't use it again or anything else in that family (like doxorubicin). Therefore, avoid use. Misc Endocrine therapy only if the cancer carries estrogen receptors Tamoxifen- a estrogen receptor antagonist. Normally, the estrogen
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 Endocrine therapy only if the cancer carries estrogen receptors Tamoxifen- a estrogen receptor antagonist. Normally, the estrogen stimulates the growth of the tumour. Trastuzumab AKA Herceptin is only good for HER-2 positive cancers only Non-cancer Pain Opioids like morphine are the gold standard Long acting formulation + short acting for breakthrough pain Also give laxatives to prevent constipation Paracetamol can work NSAIDs can be useful for bone pain Bisphosphonate for bone pain Nausea Ondansetron plus dexamethasone Lorazepam for anticipatory nausea due to anxiety

Prostate cancer
The most common cancer in males, again it is more common in older people. For obvious reasons, it cannot occur in females. It has been linked to: Age (old) Race (African Americans are more affected) Family history Symptoms are: Generally little to no symptoms if locallised Urgency and dribbling if it's starting to spread (the urethra passes through the prostate gland, so if it's starting to grow, it will block it, so you can't piss as easily) Can result in back pain plus other generalised symptoms if advanced Population wide screening is not implemented, but there are some ways to diagnose prostate cancer: PSA assay has a low diagnostic value, some people without cancer have increased PSA, while people with cancer can have a low PSA Only carry it out if symptoms are present, or if the person has a high risk Digital Rectal Examination (DRE) has good diagnostic value, but people aren't very keen on having them. Can confirm cases quite easily and quickly Transrectal ultrasound Imaging allows points of interest to be mapped out and biopsied (with a needle) to check for cancerous cells, helps to grade the cancer.

Gleason score should be taken, which is where the cancer cells are checked to see if they form glands (well differentiated cells) or not (undifferentiated cells). Undifferentiated cells will cause a worse prognosis.
Importantly, we need to know how hormones affect the tumour:

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Importantly, we need to know how hormones affect the tumour:

LH-RH (also known as GnRH or gonadotropin releasing hormone) will stimulate the pituitary gland to release LH (Lutenizing hormone) and FSH (follicular stimulating hormone) LH and FSH will stimulate the testes to release testosterones which will stimulate the prostate to grow, making the cancer worse We need to target this pathway for a specific treatment (see below) Non pharmacological treatments: Surgery to remove the prostate is well recommended for a complete cure at early stages (this is the main treatment, and what we're aiming for) However, radiation is just as effective (external beam therapy, where radiation is fired at the prostate) It depends on what side effects the patient prefers At later stages, surgery to remove the testes (orchidectomy) can be performed (not very popular though) Plus old people are not candidates for this treatment, need to use a pharmacological treatment Or for some patients, it's better for their life if they just waited and watched the tumour carefully. This is because these people tend to be old, so it might not be worth dragging them through treatment to make the rest of their lives miserable. Pharmacological treatments (advanced cancers): Goserelin injections- depot of goserelin injected monthly GnRH agonist, will attempt to over-stimulate the pituitary gland, and cause the receptors to desensitise to reduce the downstream production of testosterone Causes 'tumour flare', which causes an increase in symptoms arising from the tumour, plus hot flushes, decreased impotence and tender breasts Occurs because at the beginning of treatment, the GnRH receptors haven't desensitised, so there's a lot of testosterone being produced downstream Flutamide tablets- given daily for a short period of time Non-steroidal testosterone receptor antagonist Prevents testosterone from binding to the receptor, mainly to counteract the tumour flare effect Causes the same side effects as goserelin, but can also cause bone loss (osteoporosis) If non-responsive, need to focus on palliative care and maybe some other conventional chemotherapy drugs e.g. vincristine etc.
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conventional chemotherapy drugs e.g. vincristine etc. Surgery is not an option, because it's metastasized Make sure the chemotherapy agent is compatible with the patient

Colorectal cancer
Very common cancer overall in the population
Risk factors: Age is the main one (again) Low fibre-high fat diet Sedentary lifestyle Hereditary (family history) Inflammatory bowel conditions (especially Ulcerative colitus, Crohn's disease to a lesser extent) Signs and symptoms: Changes in bowel motions (chronic constipation) Weight loss Abdominal pain and cramps Malaena, tarry stools with blood Bloating Diagnosis: Most commonly, a barium enema can be used to check for growths A colonoscopy may also be used May be anemic, due to blood loss A DRE can be used to rule out haemorrhoids as the cause of symptoms Non-pharmacological treatments: Again, surgery is first line treatment for non-metastasized cancers, with adjuvant chemotherapy (FOLFOX) Remove the tumour and surrounding tissue to make sure to remove all the traces of cancer for a total cure Colostomy will be performed just after the surgery, which is where one part of the bowel will be open to the outside world to allow food in. Later on, after the ends have healed, the GI tract is put back together. Radiation is not as effective here Adjuvant therapy for local invasion of some tissues Radiation is more effective for rectal cancers Nutritional support to reverse weight loss Pharmacological treatments: FOLFOX (first line treatment): Folinic acid Not for 'rescue use' as for methotrexate Instead, it improves the action of 5-FU on thymidylate synthase 5-Flurouracil Oxaliplatin Capecitabine (prodrug of 5-FU) if not responsive or at late stage FOLFIRI 5-FU Folilic acid Irinotecan (instead of Oxaliplatnin) Topoisomerase inhibitor SEVERE diarrhoea Bevacizumab is an antibody which prevents the angiogenesis of metastatic
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 Bevacizumab is an antibody which prevents the angiogenesis of metastatic growths, preventing them from growing Good for late stage cancers

Common treatment goals

Generally speaking, at earlier stages of cancer, the tumour is small, encapsulated (i.e. cells are completely surrounded and cannot leave) and has not invaded any other tissues. Therefore, a complete cure is possible if the tumour is cut out, with some adjuvant chemotherapy to make sure there aren't any cancer cells left. However, in later stages, palliative care is more important, trying to reduce the sizes of the tumour and distant metastasis. A multitude of drugs can be given, and surgery is less important because it wouldnt achieve a cure. Also, we have to weigh up between treating the cancer and preserving the life quality of the patient. For example, if the person is old and has advanced cancer, then it might not be worth giving them chemotherapy because it would severely reduce their life quality without much of an impact on the life expectancy. See prostate cancer for more examples. Mechanisms of action Antimetabolites 5-flurouracil Specifically targets the S-phase of the cell cycle (because it stops DNA replication) Pyridine analogue which gets incorporated into the growing DNA strand. Because it has a fluorine on the 5 position, it stops any more nucleotides from being added to the molecule, stopping synthesis of DNA. Also blocks thymidylate synthase Anthracyclines Doxyrubicin, epirubicin G2 cell cycle specific Prevents DNA and RNA from being made Intercalates between bases in DNA to inhibit topoisomerase II and stabilise topoisomerase II once the DNA has been cut Can trigger apoptosis Also generates free radicals. However, this is not important to its action, but it results in some side effects Cumulative Cardiotoxicity WARNING: take care with people with ischemic heart disease Alkylating agents Cyclophosphamide Not cell cycle specific Binds to nucleophiles, the pyridine bases of DNA, causing alkylation, cross linking within or between strands of DNA Can also lead to apoptosis Side product, acrolein, is produced. It causes inflammation of the bladder Causes haemorrhagic cystitis (bleeding in bladder) Need to co-administer with Mesna and plenty if IV fluids to counter this Taxanes Paclitaxel
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 Paclitaxel Anti-mitotic agent, inhibits microtubule formation by attaching to the actin subunit Prevents the M phase (where they build microtubules to split the genetic material between nuclei) Strong peripheral neuropathy Constiaption is common as a result Vinca alkaloids Vincristine Also prevents mitosis by inhibiting microtubule formation by attaching to the actin subunit Attaches at a different site compared to taxanes Prevents the M phase Extreme peripheral neuropathy Monitor symptoms Can cause constipation due to reduced gastric motility Platins Oxaliplatin Binds to DNA (crosslinking between strands) DNA becomes unusable Causes extreme peripheral neuropathy (monitor symptoms) Causes sensitivity to cold, avoid cold drinks/ice May cause deafness and renal toxicity Consider amifostine administration to protect against nephrotoxicity, it contains thiol to prevent damage MONITOR: peripheral neuropathy Monitor renal as well Increase fluids to prevent renal toxicity Non-cancer agents Ondansetron Serotonin 5-HT3 receptor antagonist Antiemetic effect Dexamethasone Glucocorticoid Enhances the effect of Ondansetron

Side effects
General side effects and how to avoid them: Extravasation (immediate effect) Fluid from infusion can seep out into surrounding tissues Incredibly dangerous as some drugs are vesicants (blistering agents) May be caused by poor circulation (due to incorrect line site, use a central line, which has good flow compared to a peripheral line) Patients must be told to report discomfort or pain at the infusion site so it can be stopped and an antidote can be administered. Nausea and vomiting (immediate effect) Caused when the drug is detected by the chemoreceptor zone in the brain, triggers nausea and vomiting Ondensetron and Dexamethasone are commonly used Mucositis and diarrhoea (delayed effect)
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 Mucositis and diarrhoea (delayed effect) Will also damage oral linings as well as the rest of the GI tract, leading to diarrhoea Occurs because the mucus membranes contain rapidly dividing cells, and they too are affected by treatment Good oral health and nystatin (anti-fungal drug) are given to prevent oral issues, while loperamide (anti-diarrhoeal) will be given for GI symptoms. Myelosuppression/neutropenia (delayed effect) Reduced white blood cells and platelets, leading to increased bleeding or susceptibility to infections Again, the bone marrow contains rapidly dividing cells, leading to a shortage in these cells Need to monitor blood cell counts weekly Worst suppression occurs 7-14 days after infusion If neutrophils are very low, they must be put into isolation gCSF (granulocyte Colony-Stimulating Factor) can be given to stimulate white blood cells to grow WARNING: must tell patients to look for symptoms of infection: Sore throat Pain on urination Feeling pretty shit Fever may be present Hair loss and alopecia (delayed effect) Again due to hair follicles containing rapidly dividing cells Use a government subsidised wig or just buy a scarf Specific side effects have been listed with the specific drug

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Workshop 4- Diffuse tumours

Intro The last clinical workshop dealt with solid tumours. This workshop deals with tumours which do not form solid masses (as they are in the blood). These tumours are diffuse tumours. Acute Lymphoblastic Leukaemia (ALL) Blast cells, which are immature cells of the circulatory system are present in large amounts in the blood There shouldn't be any detectable in the blood Due to the high volume of blast cells, normal haematopoiesis (production of blood cells) can't occur Therefore, most of the symptoms we encounter are from a lack of functioning blood cells (e.g. anaemia) In ALL, a large amount of lymphocytes are being produced B and T lymphocytes The most common age is 5 years old (best prognosis between 2-9) Signs and symptoms Anaemia Pale, tired Also shows reduced haemoglobin in the blood Easily bruised/ bleeds easily Due to thrombocytopenia (lack of platelets) Can also be seen as petechiae (purple spots on skin due to minor haemorrhage on the surface of the skin) Enlarged lymph nodes, liver and spleen Weight loss Highly susceptible to infections May have a cold as a result Even though number of white blood cells are increased in blood test results (because these cells are useless at fighting off infection) Blood tests will also show blast cells in the blood Shouldn't be present in the blood May have Philidelphia chromosome (see below), which indicates a worse prognosis Treatments Split into three phases: Induction Bulk of the cells will be killed off here Drugs are: Allopurinol Anti-gout medication Required to prevent tumour lysis syndrome, which is where cells release uric acid on death Generally required for diffuse cancers due to the sheer number of cells being killed Vincristine Vinca alkaloid Antimitotic drug Severe peripheral neuropathy (loss of feeling and constipation,
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Severe peripheral neuropathy (loss of feeling and constipation, consider docusate) L-asparginase Asparginine is an amino acid which can't be synthesized in lymphoblasts (but is produced everywhere else) This enzyme will reduce the amount of circulating asparginine to retard the growth of the cancerous cells Watch out for anaphylactic shock (reaction against enzymes) and hyperglycaemia Prednisone Glucocorticoid which causes immunosuppression Although it doesn't kill many cells, it's given to stop any further growth Can cause restlessness or increased aggression Methotrexate Administered intrathecally (into the spine) Anti-folate drug Used to destroy cancerous cells in the CNS, as the other drugs can't cross the BBB Caution: may cause seizures, monitor carefully Caution: do NOT get mixed up with vincristine, as intrathecal vincristine is fatal Mixups are avoided as the pharmacist personally delivers the dose The volume which can be delivered intrathcally is small (3-5ml) compared to 100s of ml for IV

Intensification Approximately 3 months after remission Aggressive chemotherapy to prevent relapse Can use the same drugs at a higher dose Any drug can be used , cycle them as required Vincristine Doxorubicin Etoposide Cytarabine Etc. Plus the usuals Intrathecal methotrexate Prednisone Maintenance May take up to 2-3 years to mop up any remaining cells 6-Mercaptopurine Daily by mouth Inhibits purine synthesis (required for DNA and RNA) Be aware of mutations of TPMT, as they can cause overdose (myelosuppression) or underdose (therapeutic failure) ALSO be aware of interaction with allopurinol, 6-MP is metabolised by xanathine oxidase, the same enzyme which is inhibited by allopurinol to prevent gout Methotrexate Weekly by mouth Check to see if prescription is for weekly dosage Folinic acid Rescue mechanism to reduce side effects from methotrexate Saves normal cells, while cancerous cells can't be salvaged as they are too damaged
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are too damaged Contrast with FOLFOX, where it's used to increase the effectiveness of 5-flurouracil Chronic Myeloid Leukaemia (CML)

To contrast with the above, CML has the non-lymphocyte cells going crazy Has three phases Chronic phase- little/no symptoms Accelerated phase- symptoms start appearing, and blood tests will reveal some blasts (10% of cells) Blast phase- late stage of the disease, a high number of cells are blast cells (30%). Low survival rates
Signs and symptoms Half of the people with this disease are asymptomatic (in the chronic phase) Fatigue Fever Weight loss Bleeding GI discomfort and cramps Blood tests Increased platelets Blasts Anaemia Hugely increased granulocytes (neurophils, basophils and eosinophils) A bone marrow biopsy will show cells with the Philadelphia chromosome 9-22 chromosomes swap around parts (translocation) Good for diagnosing Treatments Daily interferon injections Interferon alfa 2b Effective in control Hydroxyurea Thought to be an antimetabolite Ribonucleotide reductase inhibitor Imatinib Tyrosine kinase inhibitor (stops signalling for growth) Very effective for maintaining relapse May cause myelosuppression, as inhibiting tyrosine kinase prevent growth in other cells Metabolised by CYP3A4 Can cause flu-like symptoms, nephrotoxicity, hepatotoxicity and cardiovascular effects (hypertension) Bone marrow transplant Matched donor is required (hard to find) Used as a cure (chemo alone can't cure it) Non-Hodgkin's Lymphoma (NHL) A bunch of cancers of lymphocytes which isn't Hodgkin's lymphoma So there's a lot of diseases which can fall under this category Therefore, we can at least say what type of cells are being produced e.g. large B cells with CD20 Treatments
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Treatments Bone marrow transplant Need to find a suitable donor Host can't be too old or weak, otherwise would not survive the treatment rCHOP Cyclophosphamide Doxorubicin Vincristine Constipation, give docusate prophylactically Prednisone MONITOR: bone density in old women in case of osteoporosis MONITOR: blood glucose, as it may cause hyperglycaemia Rituximab Mouse monoclonal antibody against CD20+ cells Infusion reactions (fevers, chills, rash) on the first few times Give IV antihistamine and paracetamol Allopurinol Prevent tumour lysis syndrome As always, monitor blood counts for myelosuppression and see if blast cells and B cells decrease over time

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All about opioids

Overview Opioids are substances which acts at the opioid receptor to produce an effect (or in the case of antagonists, a lack of an effect) Mu receptors are responsible for analgesia, generally they are in the brain But also cause respiratory depression, constipation and addiction Fact: there are mu-opioid receptors in the gut... Kappa receptors work at the spinal cord to prevent pain transmission But cause psychotic effects (so they aren't very popular) The strength of an opioid (i.e. whether it is a strong or weak opioid) depends on two factors: Pharmacokinetics Can the drug easily reach the receptors in the brain? The BBB tends to be very good at keeping drugs out Pharmacodynamics How well the drug binds to the receptor Generally speaking, a mild analgesic will not directly bind to the mu-receptor (e.g. codeine) Instead they are metabolised into drugs which acts at the mu-receptor Basic ring structure For natural opioids, they have a 5-ring structure (morphine shown):

These rings don't have to be kept in all opioid drugs BUT rings A, B and D are important for antagonist activity The A ring (the aromatic ring) AND the phenol is essential Drugs which have kept all the rings are semi-synthetic morphine derivatives Only have had their peripheral groups modified But synthetic drugs have lost at least one of these rings Metabolism of morphine Morphine has two alcohol groups and one tertiary nitrogen Glucuronidation at the 6 alcohol leads to the active metabolite M-6-G Sulfation or glucuronidation at the 3 position leads to M-3-G or the sulfated version The glucurides can undergo enterohepatic recycling Leads to long half-life of these drugs The methyl group at the nitrogen can be removed to produce normorphine Reduced activity as the N won't be charged as much, as a tertiary amine is more basic as the methyl groups stabilise the positive charge

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Weak analgesics
Codeine Considered to be a mild analgesic, as it does not have any activity by itself It must be converted to morphine by CYP2D6 in the liver:

Notice how the methyl group has been removed to produce the phenol, it is now able to bind to the mu-opioid receptor Some people have a polymorphism in CYP2D6 expression. Underexpression leads to a lack of morphine being produced, so codeine doesn't work for these people Ring C modification- Hydrocodone Ring C can be modified, which causes pharmacokinetic changes, but has a little effect on pharmacodynamics Hydrocodone (shown on the left in the diagram below) is similar to codeine Notice how the phenol doesn't exist due to the methyl group. It must also be removed to form a phenol for activity Only difference is the lack of an alcohol group at the 6 position (replaced with =O) It also means the person needs to have CYP2D6 to convert the hydrocodone to the active hydromorphone It is more lipophilic, and it will enter the CNS easier, leading to greater effects

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 Fact: hydrocodone is found in Vicodin, a staple of bizzaro TV doctors worldwide Tramadol Considered to be similar to a phenylpiperidine (an opioid which only has two rings) It is not a phenylpiperidine, as it doesn't have the D ring (see how the nitrogen isn't in a ring?) It is also lacking a phenol Makes it a weak mu-agonist Therefore it is a weak analgesic However, it is also a dopamine reuptake inhibitor Has other CNS effects, avoid in epileptic patients Causes an emetic effect

Dextromethorphan No analgesic activity Unlikely to get past the BBB, doesn't have much lipophilic groups No free phenol, weak agonist at the receptor Moderate antitussive (anti-cough) Not as good as codeine

Strong analgesics
Heroin Same structure as morphine, except for the two alcohol groups which have been replaced with esters Although the ester removes the phenol, it hugely increases the lipophilicity of the molecule Heroin has little binding to the mu receptor due to a lack of the phenol But it is very easily converted into morphine in vivo within the CNS Therefore, it is an incredibly strong analgesic
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 Therefore, it is an incredibly strong analgesic

Oxycodone- 14 OH modification Considered to be just as potent as morphine when it comes to analgesia This is due to the OH group on the 14 position Important for antagonists later on An advantage of oxycodone is its good oral bioavailability Just a good as morphine, without the injections.

Methadone Somehow is an agonist at the receptor (don't ask me, I have no idea) Considered to be a strong agonist at the receptor Its main method of inactivation is to be converted into normethadone (top path in the diagram below) Leads to non-bonding pair electrons being available, which allows intramolecular nucleophilic attack Produces an inactive compound Its long duration of action is actually attributed to the two active compounds alpha-normethadol and alpha-dinormethadol See the bottom pathway Now there are very long acting methadones available (LAAM) Based on alpha-methadol (middle of bottom row below) Replaces the OH group with a carboxyl group

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Opioid antagonists
Important features: All are semisynthetic (have all the rings present) All have a larger N substituent An alcohol group on the 14 position will produce a pure antagonist Naloxone Orally inactive Therefore, it can be compounded with opioid drugs to make them unsuitable for illicit injection Pure antagonist, OH group on the 14 position

Naltrexone Orally active Pure antagonist, OH group on the 14 position

Methylnaltrexone

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 Interesting drug, as it is able to prevent constipation without affecting analgesia Due to the quaternary ammonium ion, due to the extra methyl group attached It will be able to stop the side effects as they lie outside the BBB But it can't pass off into the BBB due to the positive charge, so it won't be an antagonist at the CNS, leading to no decreased analgesic effects

Buprenorphine Only partial agonist/antagonist available in NZ Causes partial agonism and antagonism at the mu and kappa receptor Leads to pain relief in nave patients Due to it's partial agonism: It causes withdrawal in addicts on high doses of opioids, as the partial activity means they don't get as much activation as before, leading to withdrawal Prevents withdrawal in addicts who have come off high doses of opioids as it produces some action to stave off symptoms

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Workshops 3 and 7- Morphine and palliative care

Opioids Works at the opioid receptors in the body Intention is to treat pain Pain is a big part of cancer and palliative care Formulations of morphine There are several formulations of morphine available, each with their advantages and disadvantages: Advantages Oral liquid Disadvantages Easy to titrate dose (any Tastes bitter amount of morphine can be Volumes may be excessive (can given) fix this) Easy to swallow Not very portable, difficult to Good for breakthrough pain measure while out. Lower compliance, q4-6h dosing

Immediate release tablets

Easy to carry and take, no Hard to adjust and titrate need to measure. doses due to fixed doses Good for breakthrough pain Lower compliance, q4-6h dosing
Good compliance due to q12h dosing Portable and no need to measure anything Good for low grade, consistent pain Fast absorption Provides alternative route from oral route Crushed tablets will lose their properties, not suitable for people with trouble swallowing. However, capsule granules can be dispersed Not suitable for palliative care, patients tend not to have much muscle to inject into Local reactions possible Specialist required Potentially painful Specialist nurses are required to maintain the pump Local reactions possible

Delayed release tablets/pellets in capsule

IM injection

SC infusion

Fast absorption Provides alternative route from oral route

Suppositories

Alternative route from the Some people aren't keen oral route No specialist care required, self-insertion is possible Recommended for people who aren't ready for a pump

Pharmacokinetics of morphine Metabolism Morphine will be glucuronidated to morphine-6-glucuronide (M-6-G) or M-3-G in the liver Initially, people thought these were inactive
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 Initially, people thought these were inactive But it turns out M-6-G is quite potent and it's slightly selective for the mu1 receptors (associated with analgesia) The way morphine is dosed, M-6-G accumulates over time, which tends to be associated with analgesia and some of the adverse effects (such as drowsiness) to appear if taken for long periods of time. Glucuronides tend to stay for long periods of time in the body This is due to enterohepatic recycling, where the bacteria will strip the glucose off (the glucuronide bit) which yields the original morphine, which can then be absorbed again Routes of administration We examined four different routes for M-6-G: Intravenous Fastest mean residence time (MRT) and half life Removed quickly Fastest absorption Highest Cmax Subcutaneous Very comparable to IV admin in terms of perimeters High bioavailability We prefer to use this route for morphine administration because the IV is usually in use Par orally Much slower compared to IV and SC But it will lead to enterohepatic recycling, as the liver will be able to metabolise the morphine before it reaches systemic circulation Nebulised Pretty much useless for systemic effects Might be good for local effects (chest pain)

Palliative care principles Firstly, palliative care is looking after people to relieve them of their suffering due to their disease (i.e. improve their quality of life) This means the treatments used in palliative care shouldn't affect the length of survival for the patient, just need to focus on making them feel better Palliative care focuses on more than just health, need to think about things like spirituality, especially because people start to think a lot more as they are going
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spirituality, especially because people start to think a lot more as they are going out. Who is involved in palliative care? Doctors Nurses (managing the pumps etc) Family members (part of the grieving process) Social workers (supports the family and the sick person) Ministers/Chaplains (for spirituality if required) And pharmacists Give advice on how to use the medications Tell them what adverse effects to expect and watch out for Can recommend different drugs which may have a reduced side effect profile Check for interactions between medications (important for morphine pumps)

Morphine and dosing

Initial dosing can be carried out using oral morphine liquid. Patients will be told to take the morphine as required for a week Note: liquid morphine elixir comes in many strengths, give them a strength which will be big enough to measure accurately, but small enough to be easily swallowed. About 5ml should be good. Note 2: Ask the doctor to give you a specific mitte, even though it's prn. Why? Because if we supplied the maximum prn amount, it tends to be very excessive. From the use over the week, the doctor can determine a suitable sustained morphine dose e.g. if they used 60mg daily on average, then that can be split into 2 doses of 30mg every 12 hours Then the doctor will write up a prescription for the slow release tablets/capsules while giving them the oral morphine for breakthrough pain They should also record how much of the extra oral morphine they are taking, just in case they need to make modifications to the dose. Major adverse effect: They will experience drowsiness, nausea and vomiting for the first few days. This will subside after a few days. If it doesn't contact the doctor. Constipation is the other major adverse effect Senna (stimulant laxative) and docusate (stool softener) tablets are very effective. They should be taken at night, and they tend to work overnight. Lastly, if the oral route is not available (either difficulty in swallowing or due to vomiting), then a subcutaneous pump can be used Handy for the patient, as the nurse just needs to keep it running for them Multiple medications can be given in 1 syringe (but we need to check for compatibility between the drugs)

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Workshop 7- Palliative care and chemotherapy

Chemotherapy As we all know, chemo has some seriously nasty side effects For palliative care, we need to try and reduce these side effects

Dry eyes Give lubricating eye drops (PVP or cellulose based) to use while the patient is awake Give ointment when asleep Longer lasting, but it occludes vision Perfect qualities to have overnight
Dry mouth Suck on ice chips or chew on gum to keep the mouth moist CAUTION: Some treatments (e.g. platnins and anti-mitotic agents) will cause cold extremities. Do not recommend ice chips. Artificial saliva can be given (but patients might not like it, tastes and feels bad) Pilocarpine mouthwash can be prescribed, which will stimulate saliva (it works on the parasympathetic system) Will lead to dental carries and ulcers if the mouth is kept dry (the saliva has a protective function) Visit dentist regularly Practice good oral health/hygiene Some chemotherapy drugs are secreted into the saliva, causing a higher concentration do to more damage Dilute with taking oral liquids or ice chips Cell cycle specific agents like methotrexate and 5-FU will cause the most damage to the mouth as the oral mucosa is growing rapidly all the time Remember: cell cycle agents are effective against dividing cells Follinic acid rescue for methotrexate will be effective in preventing oral side effects due to methotrexate treatment Remember: methotrexate depletes folate, follinic acid is a replacement Nausea and vomiting The following drugs are good for chemotherapy induced vomiting Drugs will hit the brain to trigger vomiting Metoclopramide Prokinetic antiemetic (gets stuff out of the stomach quickly to prevent vomiting) Not recommended for use with loperamide, because that slows down the GI tract Watch out for extrapyrimidal effects (Parkinson's like tremors) Cyclizine Antihistamine Ondansetron 5-HT receptor antagonist Dethamexasone Corticosteroid Take care in elderly women due to osteroporosis However, very effective, especially when given with ondensetron However, we also need to consider anticipatory vomiting (where the thought of getting chemo causes vomiting), nervousness makes it worse as well Talking to the person to calm them down is quite effective
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 Talking to the person to calm them down is quite effective But if that doesn't work (or is too young to talk) a benzodiazepine is good for anticipatory vomiting Diarrhoea Loperamide is the drug of choice 2statrun8 2 immediately, 1-2 capsules after each loose bowel motion and to a maximum of 8 daily Side effect: constipation Diphenoxylate and atropine (diastop) can also be used But associated with some side effects Especially bad with irinotecan Cholinergic activity which causes diarrhoea 5-FU and taxanes will also cause diarrhoea Notice these are all cell cycle specific agents Will cause diarrhoea 5-7 days after treatment as that's how long it takes for the lining to break down When the lining breaks down, fluids escape the gut and leak out, causing diarrhoea Use somatostatin to reduce this leakage of contents Alopecia Hair loss, and odd regrowth Grows back curly and thick, might even be a different colour But it becomes normal over time Wear a wig (funded) or a scarf Tends to be caused by anthracyclines and taxanes Constipation Especially bad with anti-mitotic agents due to peripheral neuropathy, causing a lack of gut movements leading to constipation Opioids given for pain can also cause constipation Refer to previous year for treatment

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HIV and Pharmacology of antiretroviral drugs

Introduction Antiretroviral drugs are used to counter the HIV virus, which in turn prevents AIDS from precipitating i.e. HIV will eventually give someone AIDS, we want to prolong the time this takes, or prevent the symptoms of AIDS by controlling the HIV virus There are four therapeutic classes: Entry inhibitors Co-receptor antagonists Fusion inhibitors Reverse transcriptase inhibitors Nucleoside reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Integrase inhibitors Protease inhibitors (PI) HIV virus The HIV virus belongs to the lentivirus genus (where lente means slow), which is within the family of retroviruses Split into HIV-1 (most common, this is the one we study) and HIV-2 (isolated to Africa) Retroviruses carry ssRNA which is transcribed into dsDNA through the action of Reverse transcriptase Transmission depends on several factors: Route of exposure Direct transmission of infected blood has a very high (95%) infection rate Surprisingly, sexual transmission is quite low (at best 10% chance) Viral factors Some are more virulent than others Also depends on the 'dose', the amount of viral secretion correlates to plasma viral titres. Therefore, highest transmission rates occur initially and people with full blown AIDS due to these phases having the highest viral titres. Host factors Concomitant STI increases chance of getting HIV infection, as some of the protective barriers of the skin will be breached due to open sores etc. Host immune function is also important Host HLA type, some are more susceptible

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 HIV viruses attack T cells of the body by attaching to either the CXCR4 or CCR5 coreceptors present on the surface of T cells gp120 is present on the surface of HIV to allow them to bind to these receptors Once bound to the co-receptor, the virus fuses with the membrane, allowing its genome to enter the cell Mediated by gp41 of HIV virus Once the genome has been converted to DNA, it may be incorporated into the host's genome through the action of intergrase The DNA can then be transcribed to form RNA for new viruses, along with a large protein, which is broken down into smaller proteins which are used to build new viruses Viral proteases will break down this large protein, it is also another drug target

The initial infection will cause flu-like symptoms for about 3 weeks with no genital involvement Fever Malaise Headache Swollen lymph nodes Hard to pick up HIV infection due to no genital involvement During the initial infection, seroconversion will occur This is where the body starts to produce antibodies against the initial infection Huge viral titres around this time Once the initial infection has been fought off, the viral titres are brought back under control Generally lasts for a few months to a few years Eventually, the virus is able to beat the immune system, could be due to a range of reasons: CD4 cells drop off over time as the virus and CD8 cytotoxic cells will kill them, and the production can't keep up Eventually, the virus mutates to a form which the CD8 cells can't mount a response against, as the CD4 cells won't be able to produce that initial response Remember: the CD4 cells need to 'tell' the CD8 cells to attack a virus, if the CD4 cells aren't there, then CD8 cells won't work At this point, the CD4 count plummets, precipitating AIDS Usual cause of death is respiratory disease (pneumonia)
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 Usual cause of death is respiratory disease (pneumonia) Entry inhibitors There are two pathways available to prevent the entry of HIV viruses into cells: Prevent binding to the co-receptors Maraviroc is the first drug which has been approved Antagonist at the CCR5 receptor, stops gp120 interacting with CCR5 Used if the patient has treatment resistant HIV Prevent fusion A transmembrane glycoprotein (gp41) is involved in fusion between the viruses' membrane and the T cell membrane Once activated, they undergo a conformational change, which allows fusion A drug may be used to prevent the conformational change to prevent fusion T-20 is made of 36 amino acids which makes up gp41, it can enter into gp41 to prevent a conformational change Overall: this class isn't used much Reverse transcriptase inhibitors (RTIs) This is the main class of antiretroviral drugs used Reminder: reverse transcriptase is used to transcribe RNA into DNA This function isn't needed in humans Therefore, this protein is virus specific, which is a good drug target Broad therapeutic index (low toxicity against host) There are two classes Nucleoside RTIs (NRTIs) Because they resemble nucleosides, they will bind to the active site Therefore, they are competitive inhibitors Non-nucleoside RTIs (NNRTIs) They do not resemble nucleosides, they won't bind to the active site (i.e. allosteric binding) Therefore, they are non-competitive inhibitors NRTIs They are prodrugs The drugs are nucleosides, they must be built up into nucleotides Tenofivir is an exception, it already has one phosphate group, which makes it a nucleotide. It needs to be hydrolysed into the nucleoside form so it can be built back up into the nucleotide form Note: Schmerer would say these aren't prodrugs due to this anabolic process, but who's keeping count? Anyway, the nucleosides are built up into nucleotides via the addition of phosphate groups. There are three phosphate groups in nucleotides, but none on nucleosides Zidovudine is the first NRTI available The 3-OH present in thymidine was replaced in zidovudine This stopped the elongation of the DNA as it was being transcribed (this process is called chain termination) The 3-OH position is important as it allows binding to the next nucleotide to lengthen the DNA Otherwise, zidovudine is identical to thymidine (mimics the DNA base, which is the top ring, and the ribose sugar, which is the bottom ring)

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 As stated above, mimicking either the ribose ring or the DNA base is important for the activity of the drug NNRTIs Reminder: binds to an allosteric site to cause a conformational change, instead of binding directly to the active site These allosteric binding sites tend to develop resistance easier Might be due to the fact that changing the active site can lead to reduced activity, while changing an allosteric site might not have an effect on the activity of the enzyme. Therefore, there's reduced selection pressure against these mutations. The SAR is quite complicated H-bond acceptors in the middle Aromatic ring on the right Hydrophobic on the left

Integrase inhibitors Reminder: Integration is where RNA is transcribed into DNA and inserted into the host genome This integration process is vital to the replication of the virus The enzyme responsible is intergrase, and it has two functions: Strips a nucleotide from the viral DNA Covalently links these ends to cellular DNA Raltegravir is the first approved drug Prevents the DNA from being linked to the host DNA Thought to have worked by linking to a magnesium ion at the active site This is not true, but it still works Not a first-line drug, but is useful for people with resistance

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Protease inhibitors

Other major class used Reminder: cuts up a large immature protein into smaller ones which can be used to assemble the virus

Protease inhibitors work by mimicking the peptide link which needs to be hydrolysed By tricking the protease into accepting it as a substrate, the protease is unable to hydrolyse the normal substrate The inhibitor has a different group so it cannot be hydrolysed (see below) In fact, it doesn't have a peptide bond, so it can't be hydrolysed

Resistance is possible again, need to give it in combination with other drugs

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HIV vaccines

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Workshop 8- Infections in the immunocompromised

Introduction This workshop deals with HIV and infections in immunocompromised patients

HIV and AIDS

Definition and pathophysiology HIV infection involves HIV viruses infiltrating CD4+ cells (which includes T cells), and there are three stages of infection: Initial infection- Flu-like symptoms, with no symptoms at the genitalia Latent phase- Viral counts drop, CD4+ cell count is adequate AIDS- Eventually, T cells are depleted, preventing the host from mounting an effective response against any pathogens Diagnosis Patient will present with an atypical infection or an AIDS defining illness Pneumocystitis jervocii pneumonia (PJP), mycobacterium avians, candida in the oesophagus, recurring herpes ELISA Uses antibodies to form a specific essay to detect viral components One set of antibodies in the ELISA well will bind to any components in the plasma After washing out the wells, another set of antibodies will be added, which again binds to the components But these set of antibodies are special, they are bound to an enzyme which converts a colourless substance to a coloured substance to indicate the presence of a protein Western Blot Run viral components with gel electrophoresis and then use an antibody probe to detect specific viral components. Detection of at least two components are needed Antibodies Note: antibodies take some time to be produced, once seroconversion has occurred, it's too late to cure. PCR Not used for diagnosis, but good for determining viral levels in the blood Treatment Do not start treatment immediately if CD4+ counts are acceptable 'Acceptable counts' will vary, can be as high as 500counts/ml Starting too early will just expose the person to too many side effects However, start treatment immediately if counts are low (about 200-300/ml) or if the patient presents with an AIDS defining illness We use the new British guidelines, where we ideally pick one drug from each column (A, B and C): Regimen Preferred Alternative A Efavirenz (n), D B Tenofovir (N), B3 Abacavir (N), B3 C Lamivudine (N), B3 Emtricitabine (N), B1

Lopinavir/r (P) Didanosine (N), B2 Fosamprenavir/r (P) Zidovudine (N), B3 Atazanavir/r (P) Saquinavir/r (P)
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Saquinavir/r (P) Specific groups Nevirapine (n), B3 Atazanavir (P), B2 N = NRTI n= nNRTI P= PI Ritonavir (indicated as /r) is a booster. Although it is a PI, it's main action is to inhibit CYP3A4 enzymes to increase the concentration of the other agents It's classified as B3 If we follow these guidelines, the patient will get 2 NRTIs (B and C)and either a NNRTI or PI (which is similar to older treatments, shown in A) Atripla is a combination of Efavirenz, tenofovir and emtracitabine in one capsule. This is the recommended treatment in nave patients with no resistances Simple to take, good efficacy and high compliance. Note: for pregnancy, it appears Atazanavir (not boosted), Didanosine and Emtricitabine combination seems to be the safest, due to their B2 and above classifications. But remember: a healthcare team would have to weigh up the risks and benefits. None of these drugs are classified as X by the TGA Drugs NRTIs General effects: Lactic acidosis Anemia can be linked to lactic acidosis, monitor bloods Liver and pancreas toxicities Take LFTs at baseline and only take LFTs again if symptoms occur. There is no point of constant monitoring Nausea and vomiting Headaches MONITOR blood count every 3 weeks for 3 months, then monthly after that Don't forget LFTs Specific effect: Efavirenz- vivid dreams nNRTIs General effects: Rash May develop into Stevens-Johnson (SJ) syndrome, which is an autoimmune disease where the epidermis separates from the dermis Teratogenic Efavirenz is classified as D Protease inhibitors General effects: Strong inhibition of CYP3A4 (major source of interactions) Dyslipidemia (very bad for people with CVS disease) Not only does it worsen blood lipids, it also causes fat redistribution in the body, which is unslightly GI symptoms Atazanavir has special extras: Requires an acidic stomach for absorption, contraindicated with omeprazole and other anti-acid medications The unboosted form is the best choice for people with CV disease (and a PI is essential for them), as it causes the least effect on lipids Otherwise, if they don't need a PI, then switch them off PI and use
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 Otherwise, if they don't need a PI, then switch them off PI and use nNRTIs because that allows patients to use statins (CYP3A4 metabolised) Note: if statins are used with PIs, it's a very bad idea. The statins won't be metabolised properly, so they accumulate and cause rhabdomylosis. Nevirapine needs to be restricted to patients who have less than 250 (females) or 400 (males) CD4+ counts/ml due to a risk of jaundice. Non-pharmacological treatments: Very important to maintain compliance Low compliance leads to higher viral copies which strongly encourages resistance to form Compliance tends to drop off over time. If patients are starting to slip on compliance, they may go on a 'drug holiday' for a short time. It's much better to have a window of non-compliance compared to a long period of non-compliance. Nutrition is an important part of therapy Normally, weight loss is common, and low weight is attributed to poor outcomes However, for patients on PIs, they need to be careful with lipid intake due to dyslipidemia caused by the PI. Prevention of viral spread is important Needle sharing should be curbed via a national needle exchange program Explain the need for safe sex Infections

The following infections occur commonly in the immunocompromised (HIV/AIDS patients or chemotherapy patients)
CD4+/ml Low (but higher than above) 200 100 50 Infection Herpes simplex, cytomegalovirus, Karposis scarcoma, candidiasis PJP (PCP) toxoplasmosis Mycobacterium avian

Pneumocystis jiroveci pneumonia (PJP, formerly PCP)

Diagnosis Pneumocystis is a fungus! Has a distinct X-ray pattern of the lungs Diffuse nodes in the lungs Due to granuloma formation Thick and fluffy sputum produced Can be cultured to confirm diagnosis Symptoms Shortness of breath and cyanosis (looking blue around the lips) Lack of oxygen due to fungi in the lungs Thick and fluffy sputum leads to a dry cough Fever
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 Fever Feeling unwell Treatment High dose cotrimoxazole It works on fungi not just an antibacterial agent However, it has strong emetic properties. Consider giving metoclopramide or cyclizine or ondesantron for antiemesis Important: if the patient's CD4+ levels are below 200 counts/ml they are at risk of contracting PJP again. Need to commence prophylactic treatment at lower doses Second line: dapsone Another sulfa drug Also suitable for prophylactic treatment Corticosteroids are important Prednisone Inflammation in the lungs are also preventing normal air exchange, need to reduce inflammation Give treatment for 21 days Monitor treatment for symptomatic improvement Then repeat chest X-ray 3 weeks later to check Other possible infections: Cryptococcus neformans Likes to cause CNS infections Aspergillus Candida They tend to have a lot of diarrhoea, because their immune system can't fight off GI infections as easily Note: Kaposi's sarcoma is cancerous growths seen on the skin These growths are very aggressive Speculated to be due to: Reduced immunosurveilence, as the immune system would normally deal with these cancer cells Increased susceptibility to viruses which can cause cancers, like herpesvirus Will tend to disappear after antiretroviral therapy

Febrile neutropenia
Caused after about 5-6 days after a course of chemotherapy This is when the neutrophillic count is at the lowest point Symptoms and signs Fever (hence the 'febrile' bit) Note: not all cases of neutropenia have a fever, because the neutrophils are involved in releasing pyrogens. If they're gone, then there won't be as much pyrogens around to cause a fever CHECK the infusion sites, they may have become infected CHECK for mucositis (another common site of infection) Pharynx, mouth, chest and perianal area Fast pulse Fast respiratory rate Low blood pressure (shock) Low platelets Low haemoglobin

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Factors affecting prognosis Duration of neutropenia Extent/severity of neutropenia Age (older=worse off because of reduced immune function) Co-morbidities An important one is leukaemia (AML to be exact), as leukaemia will affect neutrophil production Treatment Empirical IV treatment STAT Tazocin pepericillin (broad spectrum penicillin) and tazobactin (beta lactamase inhibitor). If serious, also give Tobramycin It's an aminoglycoside, TDM (Therapeutic drug monitoring) is needed If allergic to beta lactams, use vancomycin or tobramycin Give IV antibiotics for 7-10 days or until stable Switch to oral antibiotics once stable Side effect to watch for: Red man syndrome- turns red if infusion is too fast Histamine release, give IV antihistamine and paracetamol MONITOR: Serum creatinine (nephrotoxicity) TDM as required If no improvement, it suggests fungal infection: IV or oral voriconazole Voriconazole is very bioavailable IV liposomal amphotericin B is second line Use liposomal forms, less nephrotoxic Causative agent is usually Candida or aspergillus For prevention: Granulocyte colony stimulating factor (GCSF) is funded for people who have been affected by febrile neutropenia Isolation is not necessary, as the infective organisms tend to be commensals (i.e. comes from the person instead of from someone or somewhere else) Ciprofloxacin prophylactic treatment can be considered due to its broad spectrum activity But the most important measure is hygiene, hand washing is important.

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