Oncology, immunology and supportive care

23 Gulf Prometric Pharmacist (DHA, DOH, MOH, SCFHS, QCHP) practice questions on Oncology, immunology and supportive care, part of Clinical Pharmacy and Therapeutics. The first 23 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A patient develops severe mucositis, diarrhoea and neutropenia after the first cycle of fluorouracil. Which deficiency is the most likely explanation?

   1. APseudocholinesterase deficiency
   2. BThiopurine methyltransferase deficiency
   3. CG6PD deficiency
   4. DDihydropyrimidine dehydrogenase deficiency

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   Answer: D · Dihydropyrimidine dehydrogenase deficiency

   Dihydropyrimidine dehydrogenase breaks down most of a fluorouracil dose. Without it, drug levels stay high and cause severe early toxicity, and the dose is reduced or the drug avoided after testing. Uridine triacetate is the antidote.

   • A: Pseudocholinesterase deficiency prolongs suxamethonium.
   • B: Thiopurine methyltransferase deficiency affects mercaptopurine.
   • C: G6PD deficiency causes haemolysis with oxidant drugs.

   Remember this

   Severe early fluorouracil or capecitabine toxicity suggests DPD deficiency.

2. Question 2 · Medium

   On day 2 of chemotherapy for a high-grade lymphoma, which blood test pattern points to tumour lysis syndrome?

   1. AHigh potassium and calcium with low phosphate
   2. BLow sodium and high glucose with high calcium
   3. CLow potassium, phosphate and urate; high calcium
   4. DHigh potassium, phosphate and urate; low calcium

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   Answer: D · High potassium, phosphate and urate; low calcium

   Rapid lysis of tumour cells releases potassium, phosphate and nucleic acids, which are converted to uric acid. Phosphate binds calcium, causing hypocalcaemia. Hydration, urate-lowering drugs and monitoring are used for prevention.

   • A: Calcium is low, not high, in tumour lysis.
   • B: Sodium and glucose are not the defining changes.
   • C: The pattern is the reverse of what lysis causes.

   Remember this

   Tumour lysis syndrome shows high potassium, phosphate and urate with low calcium.

3. Question 3 · Medium

   A hospital pharmacist receives a vincristine syringe for a child. Which labelling and handling rule is critical?

   1. ADispense as an oral suspension for easier use by children
   2. BLabel for intrathecal use only, after dilution in normal saline solution
   3. CLabel for intravenous use only, fatal if given by other routes, and dispense in a minibag
   4. DLabel as safe by any parenteral route and dispense in a syringe

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   Answer: C · Label for intravenous use only, fatal if given by other routes, and dispense in a minibag

   Vincristine given into the cerebrospinal fluid is almost always fatal, causing ascending paralysis. Safeguards include the label with a clear fatal-if-given-other-routes warning and supplying doses in a minibag rather than a syringe. Its dose-limiting toxicity is peripheral neuropathy, and extravasation causes tissue damage.

   • A: No oral form exists, and it is poorly absorbed.
   • B: Intrathecal vincristine is fatal.
   • D: Vincristine is not safe by every parenteral route.

   Remember this

   Vincristine is for intravenous use only; intrathecal administration is fatal.

4. Question 4 · Hard

   A patient with rheumatoid arthritis was prescribed methotrexate 10 mg once weekly but has been taking it daily for 6 days, and now has mouth ulcers and a low neutrophil count. What is the best immediate management?

   1. AGive vitamin K to correct the low neutrophil count
   2. BStop methotrexate, check counts and renal function, give leucovorin
   3. CReduce to 5 mg daily and review in 4 weeks
   4. DContinue methotrexate and add folic acid on all the days between doses

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   Answer: B · Stop methotrexate, check counts and renal function, give leucovorin

   Daily methotrexate instead of weekly dosing is a well-known and often fatal error, causing mucositis and bone marrow suppression. The drug is stopped, blood counts and renal function are checked, and leucovorin rescue is given, with filgrastim if neutropenia is severe. The patient is then counselled on the weekly schedule.

   • A: Vitamin K does not treat marrow suppression.
   • C: Reducing to a daily low dose repeats the error.
   • D: Continuing the drug prolongs the toxicity.

   Remember this

   Accidental daily methotrexate needs immediate withdrawal and leucovorin rescue.

5. Question 5 · Medium

   A patient on chemotherapy attends the emergency department with a temperature of 38.6 C and a neutrophil count of 0.2 x 10^9/L. What is the right action?

   1. AGive paracetamol and review again in 24 hours
   2. BWait for the blood culture results before starting any treatment
   3. CStart oral amoxicillin and send him home
   4. DStart empirical broad-spectrum antipseudomonal antibiotics within an hour

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   Answer: D · Start empirical broad-spectrum antipseudomonal antibiotics within an hour

   Febrile neutropenia is an emergency with a high risk of fatal sepsis. After cultures are taken, an antipseudomonal beta-lactam such as piperacillin-tazobactam is started within an hour, without waiting for results.

   • A: An antipyretic alone does not treat sepsis.
   • B: Waiting for results delays life-saving treatment.
   • C: Oral amoxicillin has inadequate cover.

   Remember this

   Febrile neutropenia needs empirical antipseudomonal antibiotics within one hour.

6. Question 6 · Medium

   What is the most important counselling point for a woman of childbearing age starting mycophenolate mofetil after a transplant?

   1. AStop it once she feels well to avoid toxicity
   2. BTake it with grapefruit juice to raise the absorption of the drug
   3. CIt is safe in pregnancy if the dose is halved
   4. DTeratogenic: avoid pregnancy and use effective contraception

   Answer and explanation in LearnFree account

7. Question 7 · Hard

   A patient receiving high-dose methotrexate still has a plasma level of 10 micromol/L at 48 hours with rising creatinine. What is the best management?

   1. AStop leucovorin because the level is already very high at 48 hours
   2. BRestrict fluids to avoid circulatory overload
   3. CGive glucarpidase and continue leucovorin, with hydration and urine alkalinisation
   4. DGive oral folic acid instead of leucovorin rescue

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8. Question 8 · Medium

   A patient taking warfarin is to receive a course of aprepitant. What is the correct pharmacist advice?

   1. AStop warfarin for the whole course of aprepitant
   2. BDouble the warfarin dose beforehand to cover induction
   3. CCheck the INR 7-10 days after starting because aprepitant can lower it
   4. DNo monitoring is needed because there is no interaction

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9. Question 9 · Hard

   A liver transplant patient stable on tacrolimus starts rifampicin for tuberculosis. Which outcome and plan is correct?

   1. ATacrolimus is inactivated in the gut wall, so it must be given by injection only
   2. BLevels fall sharply; raise the dose with frequent trough checks, or consider rifabutin instead
   3. CNo interaction; continue the same dose unchanged
   4. DTacrolimus levels rise; halve the dose and recheck

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10. Question 10 · Easy

    Which drug is used to reduce the cardiotoxicity of doxorubicin?

    1. ADexrazoxane
    2. BOndansetron
    3. CLeucovorin
    4. DAllopurinol

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11. Question 11 · Easy

    How does tacrolimus produce immunosuppression in a transplant patient?

    1. AIt inhibits dihydrofolate reductase in dividing cells
    2. BIt blocks purine synthesis in lymphocytes
    3. CIt binds CD20 on the surface of B cells
    4. DIt inhibits calcineurin, lowering IL-2 production

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12. Question 12 · Easy

    Which adverse effect is the main dose-limiting toxicity of cisplatin?

    1. ACumulative cardiomyopathy
    2. BNephrotoxicity
    3. CPulmonary fibrosis
    4. DHaemorrhagic cystitis

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13. Question 13 · Medium

    A man who received bleomycin for testicular cancer last year needs surgery. Which anaesthetic precaution is important?

    1. AAvoid all opioid analgesics during the operation
    2. BUse the lowest oxygen concentration that keeps saturation adequate
    3. CUse 100% oxygen throughout to prevent postoperative atelectasis and hypoxia
    4. DGive prophylactic cisplatin before the operation

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14. Question 14 · Medium

    When should filgrastim be started after a cycle of cytotoxic chemotherapy?

    1. ATogether with the chemotherapy infusion itself
    2. BOnly 2 weeks after the chemotherapy ends
    3. CAt least 24 hours after chemotherapy ends
    4. DBefore the chemotherapy on the same day

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15. Question 15 · Hard

    Using the Calvert formula (dose in mg = target AUC x (GFR + 25)), what carboplatin dose is needed for a target AUC of 5 mg/mL/min and a GFR of 75 mL/min?

    1. A500 mg
    2. B1,250 mg
    3. C375 mg
    4. D625 mg

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16. Question 16 · Medium

    A patient is about to start adalimumab for rheumatoid arthritis. Which pre-treatment screening is essential?

    1. AAudiometry and vestibular testing
    2. BCreatine kinase and thyroid function
    3. CLatent TB and hepatitis B screening
    4. DSerum lipid profile and fasting glucose

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17. Question 17 · Easy

    To which class of antiemetic does ondansetron belong?

    1. ADopamine D2 antagonist
    2. B5-HT3 receptor antagonist
    3. CNK1 receptor antagonist
    4. DAntimuscarinic

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18. Question 18 · Medium

    A patient who is HBsAg-negative but anti-HBc-positive is to start rituximab for lymphoma. What is the best step?

    1. AStart antiviral prophylaxis such as entecavir and monitor hepatitis B DNA
    2. BNo action is needed, because the HBsAg result is negative
    3. CGive hepatitis B vaccine only and review later
    4. DStart interferon throughout the rituximab course

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19. Question 19 · Hard

    A patient has already had doxorubicin 300 mg/m2. The institutional lifetime limit is 450 mg/m2 and each further cycle is 60 mg/m2. How many further full cycles can be given without exceeding the limit?

    1. A3 cycles
    2. B1 cycle
    3. C4 full cycles
    4. D2 cycles

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20. Question 20 · Easy

    Which drug is given with ifosfamide to prevent haemorrhagic cystitis?

    1. AMesna
    2. BPalifermin
    3. CFilgrastim
    4. DRasburicase

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21. Question 21 · Medium

    A patient is to receive cisplatin, a highly emetogenic chemotherapy. Which antiemetic plan is recommended?

    1. ALorazepam alone given before chemotherapy
    2. BMetoclopramide alone given as needed
    3. CA 5-HT3 antagonist, an NK1 antagonist and dexamethasone
    4. DOndansetron alone given before each dose of the chemotherapy

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22. Question 22 · Medium

    A patient receiving pembrolizumab for melanoma develops severe watery diarrhoea and abdominal pain after 8 weeks. What is the most likely cause and management?

    1. ALactose intolerance; advise a dairy-free diet for two weeks
    2. BImmune-related colitis; withhold the drug and start corticosteroids
    3. CClostridioides difficile infection alone; give loperamide and continue the drug
    4. DNeutropenic enterocolitis; give filgrastim and continue pembrolizumab

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23. Question 23 · Medium

    A kidney transplant patient stable on tacrolimus is prescribed fluconazole for oral candidiasis. What is the expected effect and plan?

    1. ATacrolimus is converted to ciclosporin in the liver
    2. BTacrolimus levels fall; increase the dose to compensate
    3. CLevels rise; reduce tacrolimus and monitor troughs
    4. DNo effect on levels; continue the same dose

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