1. Which of the following tyrosine kinase inhibitors demonstrate survival benefits in the first-line setting for advanced hepatocellular carcinoma?
A. Axitinib and erlotinib
B. Ibrutinib and sorafenib
C. Lenvatinib and imatinib
D. Sorafenib and lenvatinib
2. Which of the following tyrosine kinase inhibitors demonstrate survival benefits in the second-line setting for advanced hepatocellular carcinoma?
A. Cabozantinib and ibrutinib
B. Regorafenib and cabozantinib
C. Regorafenib and ibrutinib
D. Sorafenib and erlotinib
3. Toxicities related to tyrosine kinase inhibitors (TKIs) can be associated with their targets. The mechanisms of current, effective TKIs used in hepatocellular carcinoma target which of the following pathways, proteins, or receptors?
A. Rapidly accelerated fibroblast (RAF), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF)
B. Fibroblast growth factor receptor (FGFR), Philadelphia chromosome (BCR-ABL), and PDGF
C. Human epidermal growth factor receptor (HER-2), RAF, and Janus associated kinases (JAK2)
D. Bruton's tyrosine kinase (BTK), HER-2, and RAF
4. TG is a patient with advanced hepatocellular carcinoma and you are the pharmacist on her multidisciplinary care team. At her last visit, you provided her with education for her regimen of sorafenib 400 mg orally twice daily. Today, she returns for a 2-week follow-up appointment. Which of the following monitoring parameters will you review?
A. Hepatitis C surface antigen, hepatitis C core antibody, hepatitis B surface antigen, and hepatitis B core antibody
B. Thyroid-stimulating hormone; hepatitis C quantitative polymerase chain reaction; complete blood count (CBC) with differential; and toxicity assessment focusing on diarrhea, fatigue, and skin reactions, including hand-foot skin reaction (HFSR)
C. Toxicity assessment only focusing on bleeding events, alopecia, abdominal pain, and fatigue
D. CBC with differential; liver function tests; electrolytes; blood pressure; compliance; and toxicity assessment focusing on diarrhea, fatigue, and skin reactions, including HFSR
5. BW is beginning therapy with regorafenib as second-line treatment for hepatocellular carcinoma. Which of the following is NOT something she needs to know about this agent?
A. Hand-foot skin reactions are common with this agent, and preventative measures include using a moisturizer; avoiding tight-fitting clothes, shoes, and socks to minimize friction; and removing calluses before starting regorafenib
B. Take this agent once daily with a low-fat meal, defined as fewer than 600 calories and less than 30% fat
C. Constipation is a common side effect with this agent, but it can be managed with over-the-counter medications such as senna or polyethylene glycol 3350; the goal should be 2 stools per day
D. Diarrhea can occur with this agent, but it can be managed with loperamide and avoidance/minimization of triggers such as caffeine, milk products, and greasy and spicy foods
6. Which of the following is TRUE regarding treatments for hepatocellular carcinoma (HCC)?
A. Sorafenib increased recurrence-free survival following surgical resection or local ablation of HCC
B. Hand-foot skin reactions from sorafenib or regorafenib are best treated with alcohol-based solutions, hot tub baths or saunas, and compression stockings
C. Tyrosine kinase inhibitors are frequently metabolized by cytochrome P450 isozyme 3A4, and this must be considered when choosing verapamil or diltiazem for the treatment of secondary hypertension
D. Cabozantinib is currently approved for first-line systemic therapy of HCC
7. HK takes an oral tyrosine kinase inhibitor (TKI) for hepatocellular carcinoma (HCC). At a routine follow-up visit with you (her pharmacist), she reports that she has not taken her drug for the past 2 weeks. On further discussion, you discover that she is having issues with diarrhea (6 or fewer stools per day) that impact her daily activities. Which of the following considerations would NOT be appropriate at this stage?
A. Have her define or describe how many stools or episodes she is having above her baseline to further define the grade of toxicity
B. Continue to hold her TKI
C. Discuss what potential aggravating factors might be affecting her, educate her to minimize or avoid offending food or drink, and recommend a symptom/food journal if further clarity is desired
D. Recommend a trial of loperamide, titrating to return HK to normal/tolerable stool frequency
8. What is the threshold blood pressure above which additional or increased drug therapy should be considered?
A. 130/80 mmHg or a diastolic blood pressure that increases more than 20 mmHg above baseline
B. 140/90 mmHg or a diastolic blood pressure that increases more than 30 mmHg above baseline
C. 120/60 mmHg or a systolic blood pressure that increases more than 10 mmHg above baseline
D. 150/80 mmHg or a systolic blood pressure that increases more than 20 mmHg above baseline
9. All-grade hand-foot skin reactions have been documented in more than 20% of studied patients for which of the following tyrosine kinase inhibitors used in hepatocellular carcinoma?
A. Sorafenib only
B. Sorafenib and lenvatinib
C. Sorafenib, lenvatinib, and regorafenib
D. Sorafenib, lenvatinib, regorafenib, and cabozantinib
10. Rare but serious toxicities can occur with tyrosine kinase inhibitors (TKIs). All of the following may warrant discontinuation of TKI therapy, except:
A. Cardiac ischemia or infarction
B. Grade 4 hepatotoxicity
C. Grade 2 diarrhea
D. Gastrointestinal perforation or intracranial bleed
