Non-small Cell

Lung cancer
Case
Question #1
The Case
Mr AP, a 56-year-old former coal miner,
presents to your hospital pharmacy from the
oncology outpatients department with a
prescription for the following medications:

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

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

.
Sahal M. Shuaib
Answer
1. Small cell lung cancer (SCLC).

SCLC accounts for about 20% of all lung
cancers.

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

Smoking is almost always the cause of SCLC.
Sahal M. Shuaib
Answer
1. Non-Small cell lung cancer (NSCLC).

Is by far the most common type, accounting for
approximately 80% of all lung 184 Pharmacy
Case Studies cancers
Sahal M. Shuaib
Answer
1. Non-Small cell lung cancer (NSCLC).

Within NSCLC, there are three main tumour
subdivisions:
A. Adenocarcinoma,
B. Squamous cell carcinoma
C. Large cell carcinoma.
Sahal M. Shuaib
Answer
A. Adenocarcinoma:
This cancer is found in the glands of the
lungs that produce mucus.
This is the most common type of lung
cancer in women and also among people
who have .
Sahal M. Shuaib
Answer
A. Adenocarcinoma:
Sahal M. Shuaib
Answer
B. Squamous cell carcinoma:

This is the most common type of NSCLC.

It forms in the lining of the bronchial tubes

The most common type of lung cancer in men.


Sahal M. Shuaib
Answer
B. Squamous cell carcinoma:




Sahal M. Shuaib
Answer
C. Large cell carcinoma:

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

It can grow rapidly.
Sahal M. Shuaib
Answer
C. Large cell carcinoma:


Sahal M. Shuaib
Question #2a
Question #2a
2a What are the risk
factors associated with
the development of lung
cancer?

Asim S. AL.Moana
Answer
Smokin
Tadon Gases
Industrial exposure
Air Pollution
Family History
Diet, supplemetnts and alcohol

Asim S. AL.Moana
Other Factors and Lung Cancer Risk

1. People with HIV and AIDS even after
accounting for smoking, although one study
showed an association in men only.

2. Pneumonia.

3. The risk increase persisted for more than 20
years after TB diagnosis.
Asim S. AL.Moana
Question #2b
Question #2b
Is it possible that Mr AP has any of the risk
factors for developing lung cancer?
Saud A. Otaibi
Answer
From the observation that Mr APs fingers and
teeth are stained yellow, it appears likely that he
is either a smoker or an ex-smoker. Also as a
former coal miner, he may have been exposed
to other occupational hazards; it has been
suggested that up to 15% of lung cancer cases
in men may be attributable to occupational
factors in conjunction with smoking (Cancer
Research UK,2004).
Saud A. Otaibi
Question #3
Question #3
Q3/ Briefly describe the class of drugs that
ondansetron, dexamethasone and ranitidine
belong to :

Khalid A. Haddadi
Answer

Ondansetron is
5HT3-receptor antagonists.

Dexamethasone is
a corticosteroid.

Ranitidine is
(H2)-receptor antagonist.

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

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

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

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

Khalid A. Haddadi
Answer
C) Ranitidine prescribe with dexamethasone due
to the gastric irritant effect of corticosteroids
which can lead to dyspepsia.
Khalid A. Haddadi
Question #4a
Question #4a
Mr AP states that he readily
suffers from bouts of constipation
and is concerned that these new
tablets may worsen this. What
would you advise?
Abdullah Al-Malki
Answer

One of the most commonly reported unwanted
effects of 5HT3-receptor antagonists is
that can occur in up to
and is generally in
nature.
Abdullah Al-Malki
Answer
Constipation caused by 5HT3-receptor
antagonists may be exacerbated in those
patients on or other
constipating drugs.

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

Abdullah Al-Malki
It would be important to advise Mr AP:
to take ondansetron for any longer than
prescribed .

to take any spare ondansetron left over at
the end of his treatment period to empirically
treat any episodes of nausea or vomiting that
may be unrelated to chemotherapy or
radiotherapy
Abdullah Al-Malki
It would be important to advise Mr AP:
Healthy diet with plenty of fibre to contribute to a
regular bowel habit and maintaining mobility
and exercise .

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


Abdullah Al-Malki
Question #4b
Question #4b
What are the other typical
side-effects of the drugs
prescribed for Mr AP?
Raed M. Refai
Answer

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

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

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

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