Safe prescription verification of Systemic Anti-cancer Therapies (SACT) by pharmacists

Transcription

1 Safe prescription verification of Systemic Anti-cancer Therapies (SACT) by pharmacists May 2015 Version 5.0

2 Name of Pharmacist:... GPhC no.:. Job Title: Hospital Start : Department Start : Level of Practitioner (e.g.fs2/band 6)... 2

3 LCA safe prescription verification by pharmacists: Accreditation Checklist... 4 LCA SACT dose calculation examples and competency... 5 SACT mock prescription verification examples and competency SACT prescription verification Multiple Choice Question (MCQ) Test SACT Supervised Prescription Verification Log LCA SACT pharmacist competency framework Clinical Verification Standards

4 The checklist below details the requirements for both local and LCA accreditation/sign-off. A Pharmacist can be assessed as competent to verify SACT by designated assessors. Each Trust will have a local list of accredited assessors. MOCK PRESCRIPTIONS AND WORKED EXAMPLES Completed examples in the LCA Trainee Workbook: Assessor s details: : Correctly completed mock prescriptions in workbook Correctly completed calculations in workbook (Pass mark 100%) Completed MCQ test (Pass mark 80%) Name: Signature: Job Title: Name: Signature: Job Title: Name: Signature: Job Title: SCREENING LOG Log of supervised SACT prescriptions completed to LCA criteria (refer to Passport accreditation programme guidance): Solid tumour Haemato-oncology Oral First cycles Clinical Trials Paediatrics Assessor s details: Name: Signature: Job Title: LOCAL REGISTER Pharmacist s name added to the local register for clinical verification of SACT Assessor s details: Name: Signature: Job Title: If the above has been successfully completed, please ensure the LCA-assessor for your Trust is given the paperwork to review and assess for LCA Passport competency. 4

5 Pharmacists are required to achieve 100% accuracy in the calculations section in order to continue with the accreditation programme. In clinical practice if in any doubt with calculations please seek advice from a senior colleague. You should attempt all questions and seek support where needed. 1. A 50 year old woman, diagnosed with metastatic breast cancer (bone and liver) presents for chemotherapy treatment. She has been assessed as fit for treatment and you are happy her FBC is acceptable. Doxorubicin 60mg/m 2 and Cyclophosphamide 600mg/m 2 have been prescribed. Calculate the dose of both drugs to be given if the patient s Body Surface Area (BSA) is 1.6m 2 a) Doxorubicin dose: b) Cyclophosphamide dose: 2. You are in clinic verifying prescriptions and need to check the correct dose has been calculated by the prescriber: a) For a drug that is usually prescribed at 75mg per kg; if the patient weighs 60kg, what should the dose of the drug be in grams? b) For a drug that is usually prescribed at 0.05g/kg; if the patient weighs 72kg, what should the dose of the drug be in milligrams? 3. A patient is due to receive Rituximab, for the treatment of lymphoma, as part of R-CHOP 21 regimen at a dose of 375mg/m 2 three-weekly. This drug is a monoclonal antibody and the risk of a hypersensitivity reaction is high, it is therefore given with paracetamol, chlorphenamine and prednisolone premedications. To reduce the risk of a reaction the drip rate for the infusion is slowly titrated upwards. The following instruction for the first dose at cycle 1 is given: Infuse at a rate of 50mg/hour for 30 minutes and if tolerated increase by 50mg/hour every 30 minutes, to a maximum dose of 400mg/hour. a) What is the dose of Rituximab the patient should be receiving (BSA 1.71m 2 )? Use the dose banding table below: BSA (m2) Dose (mg) Rituximab dose: 5

6 b) What does your local Intravenous (IV) guide or chemotherapy guide suggest is an adequate diluent volume for Rituximab for most patients? c) Based on your answers from above, what rate should be entered on the infusion pump in ml/hour for a bag of Rituximab? Please complete this without reference to a local standardised table. Please show your workings and round answers to the nearest whole number. Vial concentration =10mg/mL Extra volume added to bag = 65mL Total bag volume= 565 ml Final bag concentration = 1.15mg/mL 4. Looking at the dose banding table below what would the dose of Rituximab be for a patient with a BSA of 1.63m 2? BSA (m2) Dose (mg) Rituximab dose: 6

7 5. You need to mix a drug which is prescribed at a dose of 675mg and the instruction indicates to dilute to a concentration of 2mg/mL with either Sodium Chloride 0.9% or Glucose 5%. a) What volume of diluent should be used? b) What would be the volume of diluent if the final concentration was to be 4mg/mL? 6. A patient develops haematological toxicities and requires a dose reduction of 25%. If the starting dose was 175mg what will the new dose be? 7. A patient has been dose reduced by 75% and the dose is now 187.5mg. What was the original dose? 8. You are asked to commence a drug for a patient who is participating in a clinical trial. The drug needs to be administered at a rate of 2mg per minute for 15 minutes and then increase if tolerated to 4mg per minute. Calculate the rate to be administered in ml/hr. The drug dose is 150mg and the bag contains 75mL. (NB: you will need to sit with the patient and press stop on the pump at the end of 15 minutes) 9. You are asked to commence a drug for a patient who is participating in a clinical trial. The drug needs to be administered at a rate of 1mg per minute for 15 minutes and then increased if tolerated to 3mg per minute. Calculate the rate to be administered in ml/hr. The drug dose is 145mg and the bag contains 58mL. (NB: you will need to sit with the patient and press stop on the pump at the end of 15 minutes) 10. You need to give atropine as a part of the pre-medication for Irinotecan. The drug comes in 600 micrograms in 1mL. The dose prescribed is 0.25mg, how many mls need to be administered so the patient receives the correct dose? 11. What volume of diluent [Water For Injections (WFI)] needs to be added to reconstitute a 150mg powder vial to achieve a concentration of 21mg/mL considering the displacement value of 0.14 per vial: 7

8 12. a) What volume of diluent (WFI) needs to be added to reconstitute a 500mg powder vial to achieve a concentration of 50mg/mL b) For the above question how many ml are needed if the displacement value of 0.3mL is taken to achieve the 50mg/mL concentration c) The above drug needs further dilution to achieve a maximum concentration of 5mg/ml. What volume should this dose be made up to if the dose to be given is 750mg? d) If the 750mg was put into a 250 ml bag what is the rate in mls/hour that this drug can be administered over if the minimum infusion rate is 10 mg/minute? 13. Mrs KA is to receive Cisplatin at a dose of 80mg/m 2. She is 72 years old, weighs 52kg Height 165cm and her Serum creatinine is 68 micromol/l (The recommended dose reductions in renal impairment are (GFR > 60ml/min give 100% dose; GFR 45-59ml/min >give 75% dose; <45ml/min consider carboplatin) For the purposes of this question please round your answer to the nearest mg. What is an appropriate dose of Cisplatin for Mrs KA? Please round your answer to the nearest whole number. Use the Cockcroft and Gault equation for renal function and Dubois method for BSA 14. Mrs KA returns 3 weeks later for cycle 2 of her cisplatin and her renal function has deteriorated; her serum creatinine is now 90micromol/L a) Calculate her new GFR b) The doctor decides to change her drug to carboplatin AUC6. What dose should she be having (Use Calvert equation) (NB: carboplatin doses are usually rounded to the nearest 50mg) 8

9 15. Mr LM is prescribed a Xelox regimen (oxaliplatin 130mg/m 2 IV day1 and Capecitabine 1000mg/m 2 twice a day days His BSA is 1.81m 2. a) How many tablets of capecitabine should he be dispensed in total? (Round dose to the nearest whole tablet combination) On his next visit, the doctors decide to add 8mmols of magnesium into his fluid bag. The Nurse only has 50% Magnesium Sulphate Injections b) How many mls of this preparation are needed? 16. Drug X is stable for 72 hours in 5% Glucose at a concentration of 0.35mg/mL to 1.5mg/mL. The drug is available in 100mg vials each of which has to be reconstituted with 4.7mL of WFI; each vial has a displacement value of 0.3mL. How many mls of this reconstituted solution would you need and what volume range of 5% Glucose would be suitable to dilute 245mg of Drug X in? 17. A patient is to receive the IVE regimen; please work out the chemotherapy bags that would need to be made up with reference to the drugs and diluents for a patient whose BSA is 1.6m 2. IVE Protocol: Epirubicin 50mg/m2 Day 1 only, Etoposide 200mg/m2 Day 1 3 in 1000ml Sodium Chloride 0.9% over 2 hours Mesna 1.8g/m2 Day 1 in 100ml Sodium Chloride 0.9% over 30min (pre Ifosfamide) Ifosfamide 3g/m2/day Day 1 3 with Mesna 3g/m2/day D 1-3 prophylaxis (administered as two bags of 1.5g/m2 Ifosfamide mixed with 1.5g/m2 Mesna each over 11 hours in 1000ml Sodium Chloride 0.9%) Mesna 5.4g/m2 Day 3 in 1000ml Sodium Chloride 0.9% over 12 hours (post Ifosfamide) 9

10 The following mock prescriptions should be screened in conjunction with the SPC, local protocols, local guidelines and LCA protocols (available on the LCA website). Consideration should be given to NICE and CDF funding. Please refer to the clinical summaries and any other references to screen the chemotherapy prescriptions and indicate any prescribing errors identified and/or interventions in the boxes below. Useful links Case Regimen Clinical verification criteria 1 FEC-T 2 R-CHOP 10

11 3 Docetaxel 4 Carboplatin + Pemetrexed 5 Capecitabine 11

12 6 FOLFIRI + Bevacizumab 7 EC 8 Ipilimumab 12

13 9 Ifosfamide + doxorubicin 10 FOLFOX + Cetuximab 13

14 CASE 1: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Belinda Pocket Hospital number 0001 NHS number DOB 26/4/63 Disease Information Primary disease Breast cancer Stage Disease status Histology HER 2+ Treatment Information Aim Line Regimen No. of cycles Response assessment after Concurrent radiotherapy Funding Adjuvant 1 st line FEC-T + Trastuzumab SC 6 cycles chemo + 18 cycles trastuzumab Blood results Hb WBC Plt N 29/9/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 29/9/ Hickman line/picc line LVEF (MUGA/ECHO) 65% 18/7/14 ECG Lung function Completed by A Doctor 14/7/14 14

15 CASE 1 (continued) The NHS Trust. Administration Breast Unit Ward: MDU Patient Name: <Belinda Pocket > Patient Number: <0001 > of Birth: <26/4/1963 > NHS No: FEC-T (FOR ADJUVANT BREAST CANCER) Cycle 4 (repeat every 3 weeks) for 3 cycles followed by 3 cycles Docetaxel 100mg/m 2 Height Weight BSA (cm) (kg) (m 2 ) 29/9/ <version number 1.0> Allergy Status Confirmation for Day 1 Critical tests Signatures Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 / Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min LVEF FUNDING Clinical Confirmation A Doctor Confirmation comments: Pharmacy Confirmation Day/ Admin Time Drug Dose Route DAY 1 1/10/14-20min T=0 Infusion Duration Dexamethasone 8 mg IV bolus Ondansetron 8 mg PO stat EPIRUBICIN 100 mg/m² 180 mg IV bolus CYCLOPHOSPHAMIDE 500 mg/m² 900 mg IV bolus FLUOROURACIL 500 mg/m² 900 mg IV bolus Administration Details Via fast-running sodium chloride 0.9% infusion Via fast-running sodium chloride 0.9% infusion First check Start time Sign. nurse Stop time Version 1.0 Sign. nurse Prescribed by: Prescriber signature A 1/10/14 Doctor Screened by: Pharmacist signature Cordless 15

16 CASE 1 (continued) The NHS Trust. TTO Patient Name: <Belinda Pocket Patient Number: <0001 of Birth: <26/4/1963 NHS No: /9/14 Height (cm) Weight (kg) BSA (m2) > > > Breast Unit FEC-T (FOR ADJUVANT BREAST CANCER) Cycle 4 Ward: MDU Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 (repeat every 3 weeks) for 3 cycles followed by 3 cycles Docetaxel 100mg/m2 Check (Initials) <version number 1.0> Allergy Status Day/ DAY 1 1/10/14 Drug Dose Route Directions Dexamethasone 4 mg PO TDS for 3 days Ondansetron 8 mg PO BD for 3 days Domperidone 10 mg PO TDS for 3 days, then PRN I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes Counselled by (signature) Designation Pharmacy Disp / Check Pharmacy Release Check / Location / / : / / : Given by (signature) Designation e TTO given to patient or carer by: Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Time Tim Pharmacist signature Cordless 16

17 CASE 2: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Jacob Marley Hospital number 0002 NHS number DOB 3/2/45 Disease Information Primary disease Stage Disease status Histology Non-hodgkin s lymphoma Treatment Information Aim Curative Line 1 st line Regimen R-CHOP No. of cycles 6 Response assessment after 3 Concurrent radiotherapy No Funding NICE Blood results Hb WBC Plt N 29/9/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 29/9/ Hickman line/picc line LVEF (MUGA/ECHO) 72% 25/9/14 ECG Lung function Completed by A Doctor 1/10/14 17

18 CASE 2 (continued) The NHS Trust. Administration Lymphoma Unit Ward: MDU Version 1.0 Patient Name: < Jacob Marley > Patient Number: < 0002 > of Birth: <03/02/1945 > NHS No: Heig ht (cm) Weight (kg) BSA (m 2 ) R-CHOP FOR NON-HODGKIN S LYMPHOMA Cycle 1 (repeat every 3 weeks) 29/9/ <version number 1.0> Allergy Status NKDA Confirmation for Day 1 Critical tests Signatures Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min FUNDING Clinical Confirmation Pharmacy Confirmation A Doctor Day/ Admin Time Drug Dose Route DAY 1 1/10/14-30mins T= 0 +1h 30mins +1h 50mins Paracetamol 1000 mg PO Chlorphenamine 4mg PO Infusion Duration Confirmation comments: Administration Details Prednisolone 100mg PO Days 1-5 use TTO supply (page 2) RITUXIMAB 375 mg/m² See 500ml sodium chloride 0.9% 750 mg IV (check funding approval) protocol Variable rate. See protocol *1 hours 30 minutes is the minimum time to start the Ondansetron if Rituximab is given by the fast infusion method. This time may be exceeded if the Rituximab infusion above takes longer than 1 hours 30 minutes. Ondansetron 8mg PO DOXORUBICIN 50mg/m² 100 mg IV bolus Via fast-running drip VINCRISTINE 1.4mg/m² (max 2mg) 2 mg IV 5-10 min in 50mL sodium chloride 0.9% CYCLOPHOSPHAMIDE 750mg/m² 1440 mg IV bolus Via fast-running drip First check Start time Sign. nurse Stop time Sign. nurse Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Pharmacist signature Cordless 18

19 CASE 2 (continued) The NHS Trust. TTO Lymphoma Unit Ward: MDU Patient Name: < Jacob Marley > Patient Number: < 0002 > of Birth: <03/02/1945 > NHS No: Height (cm) Weight (kg) BSA (m 2 ) R-CHOP FOR NON-HODGKIN S LYMPHOMA Cycle 1 (repeat every 3 weeks) 29/9/ <version number 1.0> Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 PREDNISOLONE 100 mg PO OD for days 1-5 Allopurinol 300mg PO OD for cycle 1 only (supply 3 weeks) Metoclopramide 10 mg PO TDS for 3 days then PRN for the relief of sickness (supply 1 op) Co-Trimoxazole 480 mg PO BD Mon Wed Fri (supply 3 weeks) Lansoprazole 30mg PO OD (supply 3 weeks) Filgrastim Weight < 80kg 30MU daily Weight > 80kg 48MU daily I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes Prescribed by: 30 MU SC OD Days TTO given to patient or carer by: Prescriber signature 1/10/14 A Doctor Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check Check (Initials Pharmacy Release Check / Location / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Screened by: Pharmacist signature Cordless 19

20 CASE 3: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Horatio Fizkin Hospital number 0003 NHS number DOB 6/11/52 Disease Information Primary disease Stage Disease status Histology Prostate cancer Metastatic Treatment Information Aim Palliative Line 1 st line Regimen Docetaxel + Prednisolone No. of cycles up to 10 Response assessment after 5 Concurrent radiotherapy Funding NHS Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/14 58 Hickman line/picc line MUGA/ECHO ECG Lung function Completed by A Doctor 1 /_10 /_14 20

21 CASE 3 (continued) The NHS Trust. Administration Breast Unit Ward: MDU Patient Name: <Horatio Fizkin > Patient Number: <0003 > of Birth: <06/11/1952 > NHS No: Heig ht (cm) Weight (kg) BSA (m 2 ) DOCETAXEL ADJUVANT/ NEOADJUVANT Cycle 1 (repeat every 3 weeks) 30/9/ <version number 1.0> Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Allergy Status Penicillin rash Confirmation for Day 1 Critical tests Signatures FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) ml/min Clinical Confirmation A Doctor Confirmation comments: Pharmacy Confirmation Day/ Admin Time Drug Dose Route Infusion Duration Administration Details First check Start time Sign. nurse Stop time Sign. nurse DAY 1 1/10/14-30 mins Dexamethasone 12 mg IV bolus T=0 DOCETAXEL 100mg/m mg IV 1 hour In 250ml or 500ml glucose 5% Prescribed by: Prescriber signature A Doctor 1/10/14 Screened by: Pharmacist signature Cordless 21

22 CASE 3 (continued) The NHS Trust. TTO Breast Unit Ward: MDU Patient Name: <Horatio Fizkin > Patient Number: <0003 > of Birth: <06/11/1952 > NHS No: DOCETAXEL ADJUVANT/ NEOADJUVANT Cycle 1 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 30/9/ <version number 1.0> Allergy Status Penicillin rash Day/ Drug Dose Route Directions DAY 1 1/10/14 Domperidone 10 mg PO TDS for 3 days, then PRN Dexamethasone 8 mg PO BD for 3 days starting the day before chemotherapy Filgrastim 300 micrograms SC I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes Inject 300micrograms by SUBCUTANOUS injection ONCE a day for 7 days starting on day 5 Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check / / : Counselled by (signature) Designation Time Check (Initials) Pharmacy Release Check / Location TTO given to patient or carer by: / / : Given by (signature) Designation Time Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Pharmacist signature Cordless 22

23 CASE 4: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Amy Dorrit Hospital number 0004 NHS number DOB 20/8/55 Disease Information Primary disease Squamous cell Lung cancer Stage 1 Disease status Loco-regional Histology Treatment Information Aim Curative Line 1 st line Regimen Carboplatin + Pemetrexed No. of cycles 4 Response assessment after Concurrent radiotherapy no Funding Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line MUGA/ECHO ECG Lung function Completed by A Doctor 1 /_10 /_14 23

24 CASE 4 (continued) The NHS Trust. Administration Lung Unit Ward: MDU Patient Name: <Amy Dorrit > Patient Number: <0004 > of Birth: <20/8/1955 > NHS No: CARBOPLATIN + PEMETREXED Cycle 1 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 29/9/ <version number 1.0> Allergy Status Confirmation for Day 1 Critical tests Signatures NKDA Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >45ml/min FUNDING Clinical Confirmation A. Doctor Confirmati on Pharmacy Confirmation comments : Day/ Admin Time Drug Dose Route DAY 1 1/10/14-30 min 0 min 30 min Hydroxocobalamin 1 mg IM Infusion Duration Dexamethasone * 8 mg IV bolus Administration Details Give week before dose 1, and once every 3 cycles thereafter (cycle 4) Cross off if not required First check *Only give if dexamethasone oral pre-med has not been taken. (Cycle 1 only). Prescribe additional required doses see TTO section Ondansetron 8 mg PO PEMETREXED 500 mg/m² 750 mg IV 10 min 100 ml Sodium Chloride 0.9% via 0.2 micron filter 30 minute break between end of pemetrexed infusion and start of carboplatin infusion. CARBOPLATIN AUC 5 Dose = (EDTA + 25) x AUC 360 mg IV 1 hour 500 ml Glucose 5% Start time Sign. nurse Stop time Version 1.0 Sign. nurse Prescribed by: Prescriber signature 1/10/14 A. Doctor Screened by: Pharmacist signature Cordless 24

25 CASE 4 (continued) The NHS Trust. TTO Lung Unit Ward: MDU Patient Name: <Amy Dorrit > Patient Number: <0004 > of Birth: <20/8/1955 > NHS No: Height Weight BSA (cm) (kg) (m 2 ) CARBOPLATIN + PEMETREXED Cycle 1 (repeat every 3 weeks) 29/9/ <version number> Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 Dexamethasone 4 mg PO BD for 5 days starting the day before chemotherapy Domperidone 10 mg PO TDS for 5 days Folic Acid 400 micrograms PO OD (supply 21 days) Hydroxocobalamin 1 mg IM I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: ` Cycle 1 chemotherapy Dose changes For dispensing purposes only. Please use administration section for giving dose to patient. Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check Check (Initials) Pharmacy Release Check / Location / / : Counselled by (signature) Designation Time TTO given to patient or carer by: / / : Given by (signature) Designation Time Prescribed by: Prescriber signature 1/10/14 A. Doctor Screened by: Pharmacist signature Cordless 25

26 CASE 5: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Clara Barley Hospital number 0005 NHS number DOB 13/9/41 Disease Information Primary disease Stage Disease status Histology Breast Cancer Treatment Information Aim Palliative Line 3 rd line Regimen Capecitabine No. of cycles Until progression Response assessment after 4 Concurrent radiotherapy No Funding n/a Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line MUGA/ECHO ECG Lung function Completed by A Doctor 1 /_9 /_14 26

27 CASE 5 (continued) The Royal Marsden NHS Trust. TTO Breast Unit Ward: OP Patient Name: <Clara Barley > Patient Number: <0005 > of Birth: <13/09/1941 > NHS No: Height Weight BSA (cm) (kg) (m 2 ) CAPECITABINE Cycle 2 (repeat every 3 weeks) 29/9/ <version number 1.0> Critical tests Allergy Status Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Check (Initials) FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.5x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min NKDA Confirmation for Day 1 Checked by AD (initials) 1/10/14 (date) 14:30 (time) Day/ Drug Dose Route Directions DAY 1 1/10/14 CAPECITABINE 1250mg/m² (i.e mg/m²/day) Available as 150mg and 500mg tablets AM PM 2150 mg 2150 mg PO Take for 14 days continuously, followed by a 7 day rest. Swallow whole within 30 minutes after a meal and approximately 12 hours apart. Metoclopramide 10 mg PO TDS, when required for the relief of sickness Loperamide 2 mg PO I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes TTO given to patient or carer by: Take TWO capsules after first loose stool, then ONE capsule after each loose stool when required for the relief of diarrhoea. Maximum 8 capsules per day. Pharmacy Disp / Check Pharmacy Release Check / Location / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Pharmacist signature Cordless 27

28 CASE 6: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Oliver Twist Hospital number 0006 NHS number DOB 06/06/73 Disease Information Primary disease Colorectal cancer Stage 4 Disease status Metastatic Histology RAS wild type Treatment Information Aim Palliative Line 2 nd line Regimen FOLFIRI + Bevacizumab No. of cycles 6 Response assessment after 3 Concurrent radiotherapy No Funding Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line LVEF (MUGA/ECHO) ECG Lung function Completed by A Doctor 1 /_10 /_14 28

29 CASE 6 (continued) The NHS Trust. Administration GI Unit Ward: MDU Patient Name: <Oliver Twist > Patient Number: <0006 > of Birth: <06/06/1973 > NHS No: FOLFIRI + BEVACIZUMAB Cycle 1 (repeat every 2 weeks) Height Weight BSA (cm) (kg) (m 2 ) 29/9/ <version number> Allergy Status Confirmation for Day 1 Critical tests Signatures NKDA Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.5x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min BP 150/100 mmhg Urine Dipstick Proteinuria ++ FUNDING Clinical Confirmation A Doctor Confirmation Pharmacy Confirmation Day/ Admin Time Drug Dose Route DAY 1 1/10/14 0 BEVACIZUMAB 5mg/kg Funding required Dose round see protocol 325 mg IV Infusion Duration 10 minutes comments: Administration Details BP 160/105 trace protein in 100ml sodium chloride 0.9%. If not tolerated administer subsequent infusions over minutes Ondansetron 8 mg PO stat + 30min Dexamethasone 8 mg IV bolus Atropine 0.25 mg SC bolus + 1 hr IRINOTECAN 180mg/m mg IV 1 hour in 500ml glucose 5% + 2 hr FOLINIC ACID 400mg/m mg IV 1 hour in 250ml glucose 5% + 3 hr FLUOROURACIL 400mg/m 2 mg IV bolus over 5 minutes +3 hr 30min FLUOROURACIL 1200mg/m 2 /day 2100 mg IV 24 hours continuous infusion DAY 2 +3 hr 30min FLUOROURACIL 1200mg/m 2 /day 2100 mg IV 24 hours continuous infusion First check Start time Sign. nurse Stop time Sign. nurse Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Pharmacist signature Cordless 29

30 CASE 6 (continued) The NHS Trust. TTO GI Unit Ward: MDU Patient Name: <Oliver Twist > Patient Number: <0006 > of Birth: <06/06/1973 > NHS No: Height (cm) Weight (kg) BSA (m 2 ) FOLFIRI + BEVACIZUMAB Cycle 1 (repeat every 2 weeks) 29/9/ <version number 1.0> Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 Dexamethasone 4 mg PO TDS for 3 days Metoclopramide 10 mg PO TDS for 3 days, then if required Loperamide 2 mg PO Ciprofloxacin 250 mg PO Lansoprazole 30mg PO CVAD flushing kit (PICCs, tunnelled catheters) Implanted Venous Port flushing kit (implanted ports) Please tick I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes Prescribed by: TTO given to patient or carer by: Prescriber signature 1/10/14 A Doctor Take TWO after first loose stool then ONE after each loose stool. Contact the doctor if diarrhoea is severe or persists for more than 24 hours. BD for 7 days. To take after seeking medical advice if diarrhoea persists longer than 24 hours OD Supply on odd numbered cycles Only for patients with central venous access devices Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check Check (Initials) Pharmacy Release Check / Location / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Screened by: Pharmacist signature Cordless 30

31 CASE 7: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Dora Spenlow Hospital number 0007 NHS number DOB 16/5/49 Disease Information Primary disease Breast cancer (ABVD 20 years ago for HL) Stage 1 Disease status Loco-regional Histology HER 2+ Treatment Information Aim Neo-adjuvant Line 1 st line Regimen EC T No. of cycles 4+4 Response assessment after 4 Concurrent radiotherapy Funding Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA Hickman line/picc line LVEF (MUGA/ECHO) ECG Lung function Completed by A Doctor 1 /_10 /_14 31

32 CASE 7 (continued) The NHS Trust. Administration Breast Unit Ward: MDU Patient Name: <Dora Spenlow > Patient Number: <0007 > of Birth: <16/5/1949 > NHS No: EC Cycle 1 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 1/10/ <version number 1.0> Allergy Status Confirmation for Day 1 Critical tests Signatures NKDA Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min Clinical Confirmation Pharmacy Confirmation A Doctor Confirmation comments: Pending biochemistry Day/ Admin Time Drug Dose Route Infusion Duration Administration Details First check Start time Sign. nurse Stop time Sign. nurse DAY 1 1/10/14-10mins Dexamethasone 8mg IV bolus Ondansetron 8mg PO stat T = 0 Epirubicin 90mg/m 2 170mg IV bolus + 30mins Cyclophosphamide 600mg/m 2 mg IV bolus via a fast running infusion of sodium chloride 0.9% via a fast running infusion of sodium chloride 0.9% Prescribed by: Prescriber signature 1/10/14 A Doctor Screened by: Pharmacist signature Cordless 32

33 CASE 7 (continued) The NHS Trust. TTO Breast Unit Ward: MDU Patient Name: <Dora Spenlow > Patient Number: <0007 > of Birth: <16/5/1949 > NHS No: Height (cm) Weight (kg) BSA (m 2 ) Cycle EC (repeat every 3 weeks) 29/9/ <version number> Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Check (Initials) Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 Dexamethasone 4mg PO TDS for 3 days Domperidone 10mg PO TDS for 3 days, then prn Ondansetron 8mg PO TDS for 3 days I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes TTO given to patient or carer by: Pharmacy Disp / Check Pharmacy Release Check / Location / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Prescribed by: Prescriber signature A Doctor 1/10/14 Screened by: Pharmacist signature Cordless 33

34 CASE 8: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Sydney Carton Hospital number 0008 NHS number DOB 23/11/67 Disease Information Primary disease Stage Disease status Histology Treatment Information Aim Line Regimen No. of cycles Response assessment after Concurrent radiotherapy Funding Melanoma Unresectable Advanced 1 st line Ipilimumab Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line LVEF (MUGA/ECHO) ECG Lung function Completed by A Doctor 1 /_11 /_14 34

35 CASE 8 (continued) The NHS Trust. Administration Skin & Melanoma Unit Ward: MDU Patient Name: <Sydney Carton > Patient Number: <0008 > of Birth: <23/11/67 > NHS No: IPILIMUMAB Cycle 5 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 29/9/14 80 <version number 1.0> Allergy Status Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Grade 1 skin rash Version 1.0 Confirmation for Day 1 Critical tests Signatures FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min FUNDING NICE Clinical Confirmation Pharmacy Confirmation A Doctor Confirmation comments: Day/ Admin Time Drug Dose Route Infusion Duration Administration Details First check Start time Sign. nurse Stop time Sign. nurse DAY 1 1/10/14 T=0 Ipilimumab 3mg/kg 240 mg IV 90 mins In 100ml sodium chloride 0.9% Prescribed by: Prescriber signature 1/11/14 A Doctor Screened by: Pharmacist signature Cordless 35

36 CASE 8 (continued) The NHS Trust. TTO Skin & Melanoma Unit Ward: MDU Patient Name: <Sydney Carton > Patient Number: <0008 > of Birth: <23/11/67 > NHS No: IPILIMUMAB Cycle 5 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 29/9/14 80 <version number 1.0> Allergy Status Day/ Drug Dose Route Directions DAY 1 Prednisolone 20mg PO OD for 3 weeks Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check Check (Initials) Pharmacy Release Check / Location I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes TTO given to patient or carer by: / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Prescribed by: Prescriber signature A Doctor 1/10/14 Screened by: Pharmacist signature Cordless 36

37 CASE 9: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name Lucy Manette Hospital number 0009 NHS number DOB 3/6/56 Disease Information Primary disease Stage Disease status Histology Treatment Information Aim Line Regimen No. of cycles Response assessment after Concurrent radiotherapy Funding Soft tissue Sarcoma Advanced 1 st line Ifosfamide + Doxorubicin Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line LVEF (MUGA/ECHO) ECG Lung function Completed by A Doctor 1 /_10 /_14 37

38 CASE 9 (continued) The NHS Trust. Administration Sarcoma Unit Ward: Dickens Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Patient Name: <Lucy Manette > Patient Number: <0009 > of Birth: <3/6/56 > NHS No: Height Weight BSA (cm) (kg) (m 2 ) IFOSFAMIDE 9g/m 2 + DOXORUBICIN 60mg/m 2 over 3 days Cycle 1 (repeat every 3 weeks) 29/9/ <version number 1.0> Allergy Status Confirmation for Day 1 Critical tests Signatures NKDA Version 1.0 FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min Clinical Confirmation A Doctor Confirmation Pharmacy Confirmation comments: Day/ Admin Time Drug Dose Route DAY 1 1/10/14 Infusion Duration -1 hr Sodium Chloride 0.9% 500ml IV 1 hour -10 min Dexamethasone 8mg IV bolus Administration Details Ondansetron 8mg PO bolus 0 Via a fast running drip of sodium chloride DOXORUBICIN 20mg/m 2 36mg IV 0.9% +30 min Mesna 600mg/m mg IV 15 mins In 100ml sodium chloride 0.9% +45 min Mannitol 10% 200ml IV 30 mins +1 hr 15mins +5 hr 15mins IFOSFAMIDE 3000mg/m 2 MESNA 3000mg/m mg 5400mg IV 4 hours In 1000ml sodium chloride 0.9% Mesna 1800mg/m mg IV 12 hours In 100ml sodium chloride 0.9% First check Start time Sign. nurse Stop time Sign. nurse Prescribed by: Prescriber signature Screened by: Pharmacist signature Cordless 38

39 CASE 9 (continued) The NHS Trust. Administration Sarcoma Unit Ward: Dickens Patient Name: <Lucy Manette > Patient Number: <0009 > of Birth: <3/6/56 > NHS No: IFOSFAMIDE 9g/m 2 + DOXORUBICIN 60mg/m 2 over 3 days Cycle 1 (repeat every 3 weeks) Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) <version number 1.0> Day/ Admin Time Drug Dose Route Infusion Duration Administration Details DAY 2-1 hr Sodium Chloride 0.9% 500ml IV 1 hour -10 min Dexamethasone 8mg IV bolus Ondansetron 8mg PO bolus 0 DOXORUBICIN 20mg/m 2 36mg IV bolus Via a fast running drip of sodium chloride 0.9% +30 min Mesna 600mg/m mg IV 15 mins In 100ml sodium chloride 0.9% +45 min Mannitol 10% 200ml IV 30 mins +1 hr 15mins IFOSFAMIDE 3000mg/m mg MESNA 3000mg/m mg IV 4 hours In 1000ml sodium chloride 0.9% +5 hr 15mins Mesna 1800mg/m mg IV 12 hours In 100ml sodium chloride 0.9% DAY 3-1 hr Sodium Chloride 0.9% 500ml IV 1 hour -10 min Dexamethasone 8mg IV bolus Ondansetron 8mg PO bolus 0 DOXORUBICIN 20mg/m 2 36mg IV Via a fast running drip of sodium chloride 0.9% +30 min Mesna 600mg/m mg IV 15 mins In 100ml sodium chloride 0.9% +45 min Mannitol 10% 200ml IV 30 mins +1 hr 15mins IFOSFAMIDE 3000mg/m mg MESNA 3000mg/m mg IV 4 hours In 1000ml sodium chloride 0.9% +5 hr 15 mins Mesna 1800mg/m mg IV 12 hours In 100ml sodium chloride 0.9% First check Start time Sign. nurse Version 1.0 Stop time Sign. nurse Prescribed by: Prescriber signature Screened by: Pharmacist signature Cordless 39

40 CASE 9 (continued) The NHS Trust. TTO Sarcoma Unit Ward: Dickens Patient Name: <Lucy Manette > Patient Number: <0009 > of Birth: <3/6/56 > NHS No: IFOSFAMIDE 9g/m 2 + DOXORUBICIN 60mg/m 2 over 3 days Cycle 1 (repeat every 3 weeks) Height Weight BSA (cm) (kg) (m 2 ) 29/9/ <version number 1.0> Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 Metoclpramide 10mg PO TDS Dexamethasone 4mg PO TDS Corsodyl 5ml MW QDS Sodium Docusate 100mg PO TDS Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0 Pharmacy Disp / Check Check (Initials) Pharmacy Release Check / Location I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes TTO given to patient or carer by: / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Prescribed by: Prescriber signature Screened by: Pharmacist signature Cordless 40

41 CASE 10: Oncology & Haematology Directorate Systemic Therapies Referral Form Patient Details Patient name David Copperfield Hospital number 0010 NHS number DOB 16/9/57 Disease Information Primary disease Colorectal cancer Stage 4 Disease status Metastatic liver + lungs Histology RAS mutant Treatment Information Aim Advanced Line 1 st line Regimen FOLFOX + Cetuximab No. of cycles 12 Response assessment after 6 Concurrent radiotherapy No Funding Blood results Hb WBC Plt N 1/10/ Biochemistry ALT Bili Cr CrCl (C&G) EDTA 1/10/ Hickman line/picc line MUGA/ECHO ECG Lung function Completed by A Doctor 1 /_10 /_14 41

42 CASE 10 (continued) The NHS Trust. Patient Name: <David Copperfield > Patient Number: <0010 > of Birth: < 16/9/57 > NHS No: Height Weight BSA (cm) (kg) (m 2 ) Administration FOLFOX + CETUXIMAB Cycle 1 (repeat every 2 weeks) 29/9/ <version number 1.0> Allergy Status Confirmation for Day 1 Critical tests Signatures NKDA GI Ward: MDU Unit Dosing Comments (e.g. 25% dose reduction due to G3 diarrhoea) Version 1.0. FBC: Hb >90 g/l WCC >3 x10 9 /L Plt >100 x10 9 /L Neut >1.0 x10 9 /L Biochem: Cr <60 µmol/l ALT <40 U/L Bil <17µmol/L CrCl (EDTA / C&G) >50ml/min FUNDING Clinical Confirmation Pharmacy Confirmation A Doctor Confirmation comments: Day/ Admin Time Drug Dose Route Infusion Duration Administration Details DAY 1 1/10/14 DAY 2 Prescribed by: -10 min Chlorphenamine 10 mg IV bolus Dexamethasone 8 mg IV bolus CETUXIMAB 500mg/m 2 Funding required 850 mg IV 1-2 hours Cycle 1: 2 hours Cycle 2+ : 1 hour 0 min (NICE TA176: Cycle of 8) Use separate infusion set for cetuximab Observe patient for 1 hour for hypersensitivity reaction on cycle 1 then on subsequent cycles if previous reaction. * 1hr is the minimum time to start the Ondansetron. This time may be exceeded if there is an observation time. +1 hr * Ondansetron 8 mg* IV bolus +3 hr +27 hr OXALIPLATIN 85mg/m mg hours IV FOLINIC ACID 400mg/m mg IV 2 hours in 250ml glucose 5% FLUOROURACIL 400mg/m mg IV bolus over 5 minutes FLUOROURACIL 1200mg/m 2 /day FLUOROURACIL 1200mg/m 2 /day 2100 mg IV 24 hours continuous infusion 2100 mg IV 24 hours continuous infusion Prescriber signature A Doctor 1/10/14 in 250 or 500ml glucose 5% via a y- connector concurrently with folinic acid. (over 6 hours for laryngopharyngeal spasm) Screened by: First check Start time Pharmacist signature Cordless Sign. nurse Stop time Sign. nurse 42

43 CASE 10 (continued) The NHS Trust. TTO GI Unit Ward: MDU Patient Name: <David Copperfield > Dosing Comments Patient Number: <0010 > (e.g. 25% dose reduction due to G3 diarrhoea) of Birth: < 16/9/57 > NHS No: Height (cm) Weight (kg) BSA (m 2 ) FOLFOX + CETUXIMAB Cycle 1 (repeat every 2 weeks) 29/9/ <version number 1.0> Allergy Status NKDA Day/ Drug Dose Route Directions DAY 1 1/10/14 Dexamethasone 4 mg PO TDS for 3 days Metoclopramide 10 mg PO TDS for 3 days, then if required Diprobase cream Hydrocortisone 1% cream topical topical Lymecycline 408mg PO CVAD flushing kit (PICCs, tunnelled catheters) Implanted Venous Port flushing kit (implanted ports) Please tick Apply to the face, hands, feet, neck, back and chest ONCE in the morning. (Supply at cycle 1, then prn) Apply thinly to face, hands, feet, neck, back and chest ONCE at bedtime. (Supply 4 x 30g at cycle 1) Take ONCE daily. (Supply 28 capsules on alternate cycles) Only for patients with central venous access devices Pharmacy Disp / Check Version. Check (Initials) Pharmacy Release Check / Location Advise patients to apply sunscreen (para-aminobenzoic acid [PABA] - free, sun protection factor (SPF) 15 or higher, UV-A, and UV-B protection) to exposed skin areas before going outdoors I have confirmed with the patient that they understand how and when to take the above medication(s) and the main side effects. Include the following counselling if appropriate: Cycle 1 chemotherapy Dose changes Prescribed by: TTO given to patient or carer by: Prescriber signature A Doctor 1/ 10/14 / / : Counselled by (signature) Designation Time / / : Given by (signature) Designation Time Screened by: Pharmacist signature Cordless 43

44 This is an open book test you can have access to all the necessary resources available in your department. This may include local trust intranet systems and policies, national and regional guidelines from bodies such as NHSE, NICE, NPSA, LCA etc. It must be completed independently. You will have a maximum of 1 hour to complete this test Please complete section A and Section B Section A Select one answer only from the following. 1. The NPSA RRR Risks of incorrect dosing of oral anti-cancer medicines (Jan 2008) makes the following recommendations for reducing the risk of dosing errors with oral anti-cancer medicines: a) Oral anti-cancer medicines should be prescribed in the context of written protocols and treatment plans b) Treatment should be initiated by a cancer specialist c) Patient should receive both written and verbal instructions and be fully informed about their oral anti-cancer therapy d) All of the above e) None of the above 2. Which one of the following formulae is commonly used to calculate the BSA for adult patients receiving chemotherapy? a) Calvert b) Cockroft c) Dubois d) Jelliffe e) Wright 3. Which of the following combination of tests should be routinely checked by an oncology pharmacist when verifying chemotherapy prescriptions? a) FBC, LFT, b) FBC, tumour markers, biomarkers c) FBC, LFT, Renal profile d) FBC, Bone profile, Coagulation screen e) LFT, Renal profile 44

45 4. Which of the following combination of results before chemotherapy would indicate that chemotherapy can be administered to a patient without further tests, dose reductions or delays? a) ANC 4.0x10 9 /L; platelets 65 x10 9 /L; Bilirubin 18µmol/L; AST 20iu/L; b) ANC 3.3 x x10 9 /L; platelets 300 x10 9 /L; Hb 6.5g/L; GFR 55mL/min; c) ANC 0.8 x x10 9 /L; platelets 100 x10 9 /L; Sr Creatinine 160µmol/L; Bilirubin 25µmol/L d) ANC 1.2 x x10 9 /L; platelets 225 x10 9 /L; GFR 80 ml/min; AST 25 iu/l; BIlirubin 12 µmol/l e) ANC 1.2 x x10 9 /L; platelets 260 x10 9 /L; GFR 25 ml/min; AST 55 iu/l; Bilirubin 52 µmol/l 5. Which of the following combinations of anti-emetics drugs is commonly prescribed for limiting nausea vomiting after a highly emetogenic regimen which includes high dose cisplatin? a) Domperidone prn b) Domperidone and Dexamethasone c) Aprepitant, dexamethasone, ondansetron and domperidone d) Aprepitant, ondansetron and domperidone e) Dexamethasone and aprepitant 6. Which of the following statements regarding the national Cancer Drug Fund (CDF) is false? a) The CDF is for additional drugs/indications that would not otherwise be funded by the NHS b) The CDF applies to patients who live in England only c) The CDF is used to fund medicines, interventional procedures, medical devices and radiotherapy used in the treatment of cancer d) NHS England is accountable for the management of the CDF e) Individual CDF requests will be considered by NHS England for rarer types of cancers 7. What does a colorectal patient being treated with Cetuximab need to be tested for before administration? a) EGFR & BRAF status b) HER 2 & CD20 status c) KRAS & NRAS status d) BRAF & NRAS status e) CD20 status 8. Which of the following statements about GCSF products is not true? a) GCSF may be given to patients before chemotherapy in some circumstances b) Daily GCSF is administered on all the days between cycles c) Pegfilgrastim is usually given to patients 24 hours after chemotherapy d) Biosimilar GCSF products are available for use in the UK e) GCSF can be prescribed for patients as secondary prophylaxis for some regimens 45

46 9. Which one of the following is not essential to check for when you are verifying a prescription for single agent Bevacizumab? a) any recent major surgery within the last 28 days b) the hypertension profile of the patient c) current renal function status d) a urine analysis test for proteinuria levels e) approval from the cancer drug fund 10. Which one of the following drugs does not have a pregnancy prevention program recommended by the manufacturers? a) Thalidomide Celgene b) Revlimid c) Erivedge d) Imnovid e) Iressa Section B Case study 1 A 58 year old male patient, Mr XC has been prescribed a XELOX regimen (also known as Cape/Ox, consisting of Oxaliplatin and Capecitabine) and you are going through his medication to go home with. He reveals the drugs which he is currently taking: Metoprolol 50mg bd; Ramipril 5mg od; Allopurinol 300mg daily; Maalox 10mls tds; Warfarin 3mgs daily; Simvastatin 20mg nocte. His height is 180cm and weight is 80kg; WBC= 5.6, ANC= 2.3, SrCr= 75µmol/L; Bilirubin= 12mmol/L. 11. What is the BSA of Mr XC using the Dubois method? a) 1.66m2 b) 1.75m2 c) 1.86m2 d) 1.97m2 e) 2.00m2 12. What is the correct dose and duration of his Capecitabine tablets? a) 1000mg twice a day for 14 days every 14 days b) 1300mg twice a day for 21 days every 21 days c) 1300mg twice a day for 14 days every 21 days d) 2000mg twice a day for 14 days every 21 days e) 2000mg twice a day for 21 days every 21 days 46

47 13. Which of the following combination of preparations that he is on may need reviewing as they may have a significant interaction with the capecitabine? a) Ramipril and allopurinol b) Metoprolol, Simvastatin and Maalox c) Allopurinol, Warfarin and Maaolx d) Ramipril, allopurinol, simvastatin and warfarin e) Warfarin only 14. Mr XC comments that the capecitabine tablets are too large to swallow, and asks you how to take them. Which of the following options would you recommend? a) Still have to swallow them whole, and take one hour before food b) May crush them up, transfer to a glass of water and swallow immediately, on an empty stomach c) Allow to disperse in half a glass of water and take half an hour before food d) Allow to disperse in half a glass of water and take 30 minutes after food e) Cut the tablets in half with a tablet cutter and take them 30minutes after food 15. Mr XC comes back on the ward for cycle 2 and his serum creatinine rises to 130µmol/L. What should his recommended doses be on cycle 2? a) reduce capecitabine and oxaliplatin by 25% b) leave capecitabine and oxaliplatin at 100% c) reduce capecitabine by 25% and leave oxaliplatin at 100% d) leave capecitabine at 100% and reduce oxaliplatin by 25% e) leave capecitabine at 100% and omit oxaliplatin Section B Case Study 2 Mr AM is a 75 year old male, and comes into the ward for his first cycle of neo adjuvant ECX (epirubicin, cisplatin, and capecitabine) for his newly diagnosed upper GI cancer. His blood results taken the day before are as follows: Ht= 170cm, Wt= 75kg; WBC= 8.2 x 10 9 /L; ANC 4.7x 10 9 /L; Platelets 300x10 9 /L SrCr= 85 µmol/l; Bilirubin 12 µmol/l; AST -25IU/L; ALT26 IU/L 16. What is the BSA for Mr AM using the Dubois method? a) 1.75 m2 b) 1.78m2 c) 1.82m2 d) 1.86m2 e) 1.90m2 47

48 17. What should the calculated doses be for his first cycle? (products may be dose banded) a) Epirubicin 110mg Cisplatin 95mg ; capecitabine 1150mg bd b) Epirubicin 90mg Cisplatin 110mg ; capecitabine 1250mg bd c) Epirubicin 95mg Cisplatin 110mg ; capecitabine 1150mg bd d) Epirubicin 95mg Cisplatin 120mg ; capecitabine 1150mg bd e) Epirubicin 90mg Cisplatin 100mg ; capecitabine 1150mg bd 18. Mr AM goes home after chemotherapy on Day 1. On Day 9 he phones the pharmacy at 4pm and asks you what to do because he has missed his morning dose of Capecitabine. As well as asking him to inform the doctor at the next visit, you advise him to a) Take the morning dose with the evening dose b) Take the morning dose immediately and the evening dose as normal c) Omit the evening dose today and continue as normal tomorrow d) Omit the morning dose and take the evening dose as normal e) Talk to the clinician who prescribed him the chemotherapy 19. On day 15, Mr AM phones you again at 9am to say that he has run out of tablets and is not sure about when to get more supply. What should you do next? a) Reassure him that he has completed his course and he will be given further supply on his next visit b) Confirm the dose he has been taking, look at pharmacy and prescription records, and then call him back to reassure him that there isn t a problem and he will get some more the next cycle c) Confirm the dose he has been taking, look at pharmacy and prescription records, and then call him back to reassure him that there isn t a problem and he get some more from his GP who can prescribe some more d) Confirm the dose he has been taking, look at pharmacy records, and then tell him to return to the pharmacy tomorrow as he may need further supply e) Confirm the dose he has been taking, look at pharmacy records, and then call him to return to the pharmacy immediately as he will need further supply. 20. On his visit to the hospital for cycle 2, his renal function has deteriorated (SrCr is now 110 µmol/l) and his doses need to be reduced. What should his new doses be according to the LCA protocols? a) Epirubicin 95mg Cisplatin 83mg ; capecitabine 1150mg bd b) Epirubicin 85mg Cisplatin 95mg ; capecitabine 1150mg bd c) Epirubicin 90mg Cisplatin 90 mg ;capecitabine 1250mg bd d) Epirubicin 95mg Cisplatin 55mg ; capecitabine 1150mg bd e) Epirubicin 70mg Cisplatin 110mg ; capecitabine 1150mg bd 48