Chapter 42: Chemotherapy Agents

Anc

% of neutrophils + % of bands x WBC

Nadir

Lowest level of wbc is BLANK 10-28 days after dosing

Assessments

Pain assessment Assess for fear and anxiety Cultural, social, spiritual financial concerns

Remember: ATI chapters

Ch. 26, 33, 42 for cancer drugs

alopecia

Assess concerns Preparation for hair loss wig

IV sites assessment

Assess every hour, prn or per protocol Look for following: Redness Heat Swelling pain

contraindications (Interferons)

Autoimmune disorders Hepatitis or liver failure Concurrent use of immunosuppressant drugs Kaposi's sarcoma

Patient teaching

Avoid aspirin, ibuprofen and products containing these drugs Encourage fluids up to 3000 mL/day if not contraindicated Educate about ways to manage constipation or diarrhea Refer pt/family to legitimate web sites

Implementation--diarrhea

Avoid irritating, spicy and gas-producing foods Avoid or limit caffeine, high-fiber foods, alcohol, lactose-containing foods/beverages Help with meal planning Administer opioids

A nurse is teaching a client who has breast cancer about tamoxifen (Nolvadex). Which of the following adverse effects of tamoxifen should the nurse discuss with the client? A. Irregular heart beat B. Abnormal uterine bleeding C. Yellow sclera or dark-colored urine D. Difficulty swallowing

B. Abnormal uterine bleeding

A nurse is caring for a client who is being treated with interferon alfa-2b for malignant melanoma. For which of the following adverse effects should the nurse monitor? (Select all that apply.) A. Tinnitus B. Muscle aches C. Peripheral neuropathy D. Bone loss E. Depression

B. Muscle aches C. Peripheral neuropathy E. Depression

A nurse is caring for a client who receives rituximab (Rituxan) to treat non-Hodgkin's leukemia and who asks the nurse how rituximab works. The appropriate reply by the nurse is that rituximab destroys cancer cells by A. blocking hormone receptors. B. increasing immune response. C. binding with specific antigens on tumor cells. D. stopping DNA replication during cell division.

C. binding with specific antigens on tumor cells.

interactions (cell-cycle nonspecific)

Can prevent by not administering another drug capable of causing similar toxicities Example: not giving two nephrotoxic drugs, or two drugs that have bone marrow-suppressing effects and radiation

Miscellaneous alkylators

Carboplatin Cisplatin

Nitrosoureas

Carmustine Streptozocin

A patient is experiencing stomatitis after a round of chemotherapy. Which intervention by the nurse is correct?

Clean the mouth with a soft-bristle toothbrush and warm saline solution

Interactions(Hematopoietics)

Not given within 24 hours of myelosuppressive antineoplastics Timing: given as soon as possible to prevent wbc nadir from dropping to dangerous levels (Will come in on weekends to get done)

Examples of Monoclonal Antibodies

Olara-t-u-mab—human monoclonal antibody acting against tumors Inf-li-xi-mab—chimeric monoclonal antibody acting on the immune system Ada-lim-u-mab—human monoclonal antibody acting on immune system Bevacizumab = beva-ci-zu-mab= ?

Cytotoxic antibodies: safety alert

One group is nicknamed the "rubicins"—sound-alike But, use and effect are different Daunorubicin Doxorubicin Epirubicin Idarubicin valrubicin

Cancer drug contraindications

Patient too weak Very low wbc Infection Decreased kidney/liver function (or any other organ) Severe compromise in nutritional and hydration Pregnancy, esp first trimester

Epoetin alfa

Used to treat anemia from chemo or other drugs, renal disease, surgery Ineffective without adequate body iron stores, b12, folic acid and bone marrow function Often given with oral iron preparation Given subq or IV bolus 1-3 x per week Effective if hgb > 10 g/dl Monitor h & h twice a week

Implementation--alopecia

Warn the patient and family about possibility of hair loss Tell when it will occur (usually 7-10 days after start of treatment) Is reversible—new hair growth may be different color and/or texture Provide information for getting a wig or hairpiece

Labs to Check?

Wbc w/diff Anc normal is ≥ 1500 cells/mm3, severe neutropenia is < 500 cells/mm3 Rbc Platelets—thrombocytopenia usually < 100,000/mm3 Uric acid Bun Lft Alkaline phosphatase H & H (Hemoglobin/Hematocrit)

Bone marrow suppression

s/s of anemia Fever Chills Tachycardia Abnormal breath sounds Productive cough Lethargy Fatigue Confusion Bleeding—excessive or prolonged

Adverse Effects

Hair loss Nausea Vomiting (see relative emetic potential Box 45-1) Diarrhea Myelosuppression—RBC, WBC, platelets Fever and malaise are common general symptoms

contraindications (Monoclon. Antibodies)

Known active infections (these drugs have immunosuppressive qualities) Other contraindications are drug-dependent Drug allergy

Emetic potential varies

Stimulate the cells of the chemoreceptor trigger zone Vomiting can be mild-moderate-severe, or rated 0-10

Tumor lysis syndrome Treatment?

treated with diuretics, calcium supplement, potassium exchange resin, oral aluminum hydroxide Allopurinol used to treat hyperuricemia from tumor lysis syndrome

Hormonal antineoplastics—adverse effects

vasodilation, hot flashes, hypertension, mood disorders, depression, weight gain, menstrual irregularities, virilization of females, gynecomastia of males, acne, body odor, edema, breast tenderness

Methoxypolyethyleneglycol-epoetinbeta—

very long-acting biosynthetic form of natural erythropoietin (ATI pg 341)

Oprelvekin

—platelets

Filgrastim Pegfilgrastim

—wbc —wbc: long-acting, so less shots needed

interactions

Additive Toxicities

Selected drug names: Alkylator

Cyclophosphamide (Cytoxan) Mechlorethamine

filgrastim

Stop this drug when absolute neutrophil count (anc) rises above 10,000 cells/mm 3 - alt: DC when ANC 1000-2000 cells/mm3

Cytotoxic antibodies

Natural substances from the mold Streptomyces Bone marrow suppression is common Pulmonary toxicity from some Other severe toxicities affect the heart Are cell-cycle nonspecific drugs

Adverse Effects (Hematopoietics)

Adverse Effects Mild: Fever Muscle aches Bone pain Flushing Itching Rash Injection site reaction

Adverse effects Cell-cycle nonspecific

Adverse effects are important because of their severity Pulmonary fibrosis Nephrotoxicity Neurotoxicity Bone marrow suppression Hemorrhagic cystitis extravasation

Implementation—nutritional needs

Advise mild-tasting foods Used chicken, turkey cheese or greek yogurt for protein Used plastic rather than metal utensils if c/o metallic taste Encourage foods easy to swallow Avoid sticky or dry foods Small, frequent meals Appetite stimulants such as dronabinol Conserve energy, frequent rest periods: Cluster care, allowing enough rest in btwn visits

contraindications (DMARDS)

Active bacterial infections Active herpes Active/latent tuberculosis Acute or chronic hepatitis b or c

Examples

Adalimumab (humira)—tnf, given for severe ra Infliximab (remicade)—used for ra and crohn's disease Half life is 8-9 days

Epoetin alfa—rbc

A biosynthetic form of natural erythropoietin

Darbepoetin—rbc

A long-acting biosynthetic form of natural erythropoietin

A nurse is caring for a client who has breast cancer and asks why she is receiving a combination therapy of cyclophosphamide, methotrexate, and fluorouracil. The appropriate response by the nurse is that combination chemotherapy is used to do which of the following? (Select all that apply.) A. Decrease medication resistance. B. Attack cancer cells at different stages of cell growth. C. Block chemotherapy agent from entering healthy cells. D. Stimulate immune system. E. Decrease injury to normal body cells.

A. Decrease medication resistance. B. Attack cancer cells at different stages of cell growth. E. Decrease injury to normal body cells.

A nurse is preparing to administer cyclophosphamide IV to a client who has Hodgkin's disease. Which of the following medications should the nurse expect to administer concurrently with the chemotherapy to prevent an adverse effect of cyclophosphamide? A. Uroprotectant agent, such as mensa (Mesnex) B. Opiod, such as morphine C. Loop diuretic, such as furosemide (Lasix) D. H1 receptor antagonist, such as diphenhydramine (Benadryl)

A. Uroprotectant agent, such as mensa (Mesnex)

Biologic response-modifying and antirheumatic drugs

Biologic response-modifying and antirheumatic drugs - Hematopoietic drugs - Interferons - Monoclonal antibodies - Dmards

Implementation—anemia, thrombocytopenia

Blood transfusions Iron, folic acid, erythropoietic growth factors Plan care to conserve energy Avoid injections, use smallest gauge needle then apply pressure Bp cuff can cause bruising Monitor for unusual bleeding

Adverse effect (DMARDS)

Bone marrow suppression (methotrexate) infection Fatigue, loss of appetite, edema, bleeding Pregnancy is discouraged -may need contraception up to 2 years after therapy Some adverse effects go away within 72-96 hours of discontinuation

Effects on GI mucosa

Bowel sounds s/s of diarrhea Urgency Abdominal cramping Blood in stool n/v—frequency, color, amount Cholinergic diarrhea (with topoisomerase I inhibitors)—may appear 2-10 days after irnotecan infusion - May be life-threatening - Do not give laxatives or diuretics with this medication

Implementation—reproductive tract

Counsel that male sterility may be irreversible, sperm banking before chemo Females protect against pregnancy, contraception during chemo and for 2 months after (some meds can cause genetic abnormalities up to 2 years)

A nurse is preparing to administer leucovorin to a client who has cancer and is receiving chemotherapy with methotrexate (Trexall). Which of the following responses is appropriate when the client asks why leucovorin is being given? A. "Leucovorin reduces the risk of a transfusion reaction from methotrexate." B. "Leucovorin increases platelet production and prevents bleeding." C. "Leucovorin potentiates the cytotoxic effects of methotrexate." D. "Leucovorin protects healthy cells from methotrexate's toxic effects."

D. "Leucovorin protects healthy cells from methotrexate's toxic effects."

alkylators

Developed from mustard gas agents used for chemical warfare around world war I Further divided into 3 categories Classic alkylators (nitrogen mustards) Nitrosoureas Miscellaneous alkylators Work by preventing cancer cells from reproducing

DMARDS

Disease-modifying AntiRheumatic Arthritis Drugs These drugs used to treat rheumatoid arthritis Antiinflammatory Antiarthritic immunomodulating

contraindications (Hematopoietics)

Drug allergy—sensitivity to e coli protein Presence of more than 10% myeloid blasts (immature tumor cells) in the bone marrow Epoetin not given if uncontrolled hypertension Epoetin not given if hgb above 10 g/dL for cancer pts, 12 g/dl for renal pts If given when hgb > 12 g/dl, serious adverse effects include heart attack, stroke, death Physicians and hospitals must be registered in fda program (esa apprise oncology) to dispense epoetin for cancer pts Athletes have abused this drug to increase oxygen-carrying capacity and improve performance

Cancer (Malignant Neoplasms) drugs

Drugs to treat = antineoplastics (Kill cancer cells without harming normal cells) Toxic; High potency Drugs can be cell-cycle specific: Antimetabolites Mitotic inhibitors Alkaloid topoisomerase ii inhibitors Topoisomerase I inhibitors Antineoplastic enzymes

Myelosuppression

Especially precursors of: WBC----leukopenia RBC----anemia Platelets---thrombocytopenia

Big risk when administering cancer drugs?

Extravasation; vesicant potential Antidote example (pg. 735)

Cytarabine Syndrome

Fever Muscle and bone pain Maculopapular rash Conjunctivitis Malaise 6-12 hours after cytarabine administration Treated or prevented by corticosteroids

s/s of an Oncologic Emergency

Fever/chills with temp >100.5 °F New sores or white patches in mouth/throat Swollen tongue w/ or w/o cracks and bleeding Bleeding gums Dry, burning, scratchy or swollen throat New and persistent cough Changes in bladder function or patterns Blood in urine Changes in GI or bowel patterns (heartburn, n/v, constipation or diarrhea longer than 2-3 days) Blood in stools

Adverse effects (Interferons)

Flulike symptoms: fever, chills, ha, malaise, myalgia, fatigue Major adverse effect is fatigue

Altered nutritional status and impaired oral mucosa

Focus on weight loss Abnormal serum protein-albumin and bun levels Weakness Fatigue Lethargy Poor skin turgor Pale conjunctiva Stomatitis anorexia

Antimetabolites Names?

Folate: methotrexate Purine: Cladribine, Mercaptopurine Pyrimidine antagonist: Fluorouracil (5-FU), cytarabine

Filgrastin administration

Given iv or subq Do not agitate the vial Use each vial for one dose Do not combine with other medications Do not put the needle back into the vial when withdrawing medication Monitor cbc 2 x/week

Implementation—risk for infection

Good handwashing Oral or axillary temp q4h while at risk Report temp > 100.5 Low microbe diet Turn, cough and deep breathe

What are the rapidly dividing cells?

Hair Gi tract Bone marrow fetus

Monoclonal antibodies

Have -mab as a suffix Can specifically target cancer cells Minimal effect on healthy cells Price in the hundreds or thousands of $$ per single dose May remain in tissues for many weeks or months

Interferons

Have the word "interferon" somewhere in their name Are recombinant manufactured Identical to natural interferon cytokines produced in T cells to fight viral infections Used to treat some viral infections and cancers

assessments

If platelets < 100,000/mm3, or leukocytes < 2,000 cells/mm3, may need to temporarily halt therapy

methotrexate

Immunosuppressive and anti-inflammatory properties High-dose methotrexate assoc. with severe bone marrow suppression Always given with "rescue" drug leucovorin (Leucovorin is rapidly converted to active folic acid—prevents death of normal cells, in particular bone marrow).

Extravasation treatment

In case extravasation: Stop the infusion, leaving the IV catheter in place Usually aspirate any residual drug Hot or cold packs Rest affected limb >> Consult facility protocols

Implementation--stomatitis

Inflamed, sore mouth - Good oral hygiene - Avoid lemon, glycerin, peroxide or alcohol-containing mouth care products - Soft bristle toothbrush - Saliva substitutes, sugarless candy or sugarless gum to stimulate saliva - Avoid spicy, acidic, hot foods, alcohol and tobacco - Oral antifungal suspensions may be needed

Antimetabolites

Inhibits DNA/RNA Synthesis

Tumor lysis syndrome?

It often develops during chemotherapy for high-grade lymphoma, leukemias, and other tumors that have rapid cell turnover and high sensitivity to chemo. Hyperphosphatemia Hyperkalemia Hypocalcemia Hyperuricemia

Handling vesicant drugs

Laminar airflow hood and ppe needed for mixing—pharmacy does this Nurses administer and can be affected by these drugs Must be certified to administer chemotherapy Spill kits used for any spill Disposal of patient's bodily secretions Disposal of items that come into contact with the patient

Drug names

Methotrexate Etanercept (Enbrel) Abatacept (orencia) Some monoclonal antibodies

interventions

Prevent: - Infection - Conserve energy - Prevent bleeding and injury - Reduce nausea Take vs q1-2h or prn during infusion encourage fluids during infusion I & O Report numbness, tingling, ringing or roaring in ears or hearing loss

Adverse effects (Monoclon. Antibodies)

Range from flu-like symptoms to severe Severe inflammatory reactions call for premedication with APAp or diphenhydramine

Nursing implementation

Reduce fear and anxiety Encourage relaxation techniques Consider referrals for pastoral care, dietician, social worker, psychologist, Meals On Wheels, financial assistance, etc.—any or all forms of support

Implementation—n/v

Remove noxious odors or sights Restrict oral intake as ordered Oral hygiene Promote relaxation Small, frequent meals, eat slowly Clear liquids, bland diet Premedication with antiemetic 30-60 min before chemotherapy

Hormonal antineoplastics

Some tumor growth is accelerated by hormones, example: breast cancer and estrogen, or prostate cancer and androgens. Opposing effect of other hormones or blocking of sex hormone receptors is used to slow the growth of tumor cells

Indications

Used in treatment of solid tumors and some hematologic cancers (Combination therapy common). Methotrexate also used to treat psoriasis, rheumatoid arthritis and ectopic pregnancy

Cell-cycle nonspecific

The drugs in this chapter are generally more toxic than the drugs in the previous chapter Two broad categories Alkylating cytotoxic

Hematopoietic drugs

These drugs promote growth, differentiation and function of: - Erythrocytes (rbc) - Colony—leukocytes: basophils, eosinophils and neutrophils - Thrombocytes (platelets) Decrease duration of chemo-induced anemia, neutropenia and thrombocytopenia Enable higher doses of chemotherapy Decrease bone marrow recovery time after bone marrow transplant or irradiation Stimulate other cells in the immune system

extravasation (Cell-cycle nonspecific)

These meds often given via picc line or central catheters Can still extravasate Peripheral veins too small and not enough blood there to dilute the chemo med Aspirate blood prior to administration to check for patency