Pharm Exam 3 - BRM

Nursing Process: Assessment

- herb (interactions) & drug history - physical status: head-to-toe, labs, VS, I&O, ADL, cardiopulmonary & skin assessment, nutrition status, presence or absence of underlying symptoms of disease, & use of current or past medication and treatment - Filgastrim, Pegfilgastrim, Sargramostim, & Oprelvekin: assess CBC before therapy & biweekly, rationale: avoid leukocytosis & thrombocytosis

Oprelvekin (Neumega) Uses?

- high risk non myeloid malignancy clients - prevents severe thrombocytopenia - reduces need for platelet transfusion following myelosuppressive chemo - platelet count increases in 5-9 days - efficacy: following chemo cycle

principles of drug therapy

- inpatient: can give concurrently with chemo - outpatient: upon follow-up appointments, must get blood levels tested

interferons (IFN)

- naturally occurring proteins Type I: alpha and beta, bind selectively to effector cells Type II: gamma, binds to a different cell surface receptor

IFN Alpha: S/E and adverse reactions: - hematologic (reversible) - dermatologic

- neutropenia & thrombocytopenia - maculopapular rash, pruritus, injection site irritation, & alopecia

colony-stimulating factors: tx?

- neutropenia secondary to disease or tx - subQ or IV - FDA approved: erythropoietic stimulating agents, granulocyte colony stimulating factor, granulocyte macrophage colony stimulating factor & thrombopoietic growth factor

IL-2: side effects/ adverse reactions?

- only used in clients with normal cardiac & pulmonary functioning - capillary leak syndrome (s/e: lose vascular tone, hypotension, low blood circulating to vital organs) - infection: sepsis & bacterial endocarditis (infection of heart) - hypotension, sinus tach, arrhythmias, NVD, GI bleed, ALOC, stomatitis, anorexia, & oliguria/anuria, anemia, thrombocytopenia, fever, chills, dyspnea, pain at injection site, fatigue, weakness, malaise, & elevated LFT

interferon alpha

- produced by B cells, T cells, macrophages, and null cells - antiviral, anti proliferative, & immunomodulatory effects - inhibits intracellular replication of viral DNA - interferes with tumor cell growth - enhances natural killer (NK) cell activity

colony-stimulating factors (CSF)

- proteins that stimulate or regulate the growth, maturation, & differentiation of bone marrow stem cells - not directly tumoricidal (don't kill tumor) - used in CA tx

Nursing Process: Assessment

- psychosocial status: preferred learning, support system, coping strategies, self-care abilities & emotional difficulties - signs and symptoms of BRMs: fatigue, edema, cardiac conditions, capillary leak syndrome, and respiratory distress - family: subQ injection & understanding of treatment

Epoetin Alfa (Procrit): - reduce dose ___% if Hgb is? - hold if >__ g/dl, resume once < __ g/dl

- reduce dose 25% if Hgb is 12 g/dl or increases > than 1 g/dl in any 2 weeks - hold if > 12 g/dl, resume once < 11 g/dl

Nursing Process: Assessment

- renal & hepatic dysfunction: LFT's, BUN &serum Cr - Eryhtropoietin Stimulating Agents: - Hct & Hgb, serum ferritin (>100), & serum iron transferring saturation (>20%) - most pt's will require iron supplements - assess BP before start of and especially early in therapy

Client Teaching?

- report difficulty in concentration, confusion, or somnolence - report weight loss - report dyspnea, palpitations, s/s of infection or bleeding - demonstrates subQ techniques - provide written or video instructions

Pelgastrim (Neulasta): Nursing Implications?

- similar to neupogen - do not administer 14 days before and 24 hrs after cytotoxic chemo - dosing: ANC dependent - contraindicated with hypersensitivity to E. coli derivant proteins - single use vials (no preservatives) - do not freeze or shake vials/syringes - do not take with Lithium (high WBC's) , risk for MI or stroke

Kepivance: side effects/adverse reactions

- skin toxicities - oral toxicities - HTN - transient high in serum lipase & amylase - tumor stimulation - only use in hematologic malignancies treated with myelotoxic chemo with stem cell support (only for blood cancers)

IFN Alpha: S/E and adverse reactions: - cardiopulmonary - renal & hepatic

- tachycardia, tachypnea, pallor, EKG changes, orthostatic hypotension, & MI - increased BUN/Cr, proteinuria, elevated transaminases

Monoclonal Antibodies

- targets antigens & receptors on cancer cells "targeted therapy" - have demonstrated effectiveness in cancer therapy: - makes cancer cells more visible to the immune system (blocks CA cells) - blocks growth signals - EGFR1 & EGFR2: receptors that are "turned on" in cancer - Rituximab: most common monoclonal antibodies

ESA C/Is?

- uncontrolled HTN - hypersensitivity to: mammalian cell-derived products & human albumin or Polysorbate - evaluate iron stores: transferring sat. (min. 20%) & ferritin (100 ng/ml), iron supplements to enhance erythropoiesis

Sargramostim: Side effects/ adverse reactions?

- underlying pulmonary disease (reduce by 1/2 or DC if dyspnea) - supraventricular dysrhythmia - labs: serum Cr, bilirubin, & LFTs

Peginterferon alfa-2a (Pegasus)

- used in combo with ribavirin, with or without an antihepaciviral - active against all genotypes of chronic hepatitis C

what does PEGylation mean?

bigger so you can give less frequently

IFN Alpha: S/E and adverse reactions?

- flu-like syndrome: chills, fever, myalgias, and fatigue - GI: N/V/D, anorexia, & xxerostomia

Erythropoietin

- glycoprotein produced by the kidneys - stimulates RBC production in response to hypoxia - stimulates division & differentiation of committed RBC progenitors in the bone marrow CKD -> erythropoietin CA > RBC killed by dz or chemo drugs

Sargramostim: Side Effects/Adverse Reactions?

- fever, malaise, sepsis, NVD, asthenia, liver damage, dyspnea, renal dysfunction, CNS disorder - pleural or peridarcial effusions (common) - causes increased fluid retention, hx of renal/ cardiac issues???

IFN Alpha: S/E and adverse reactions: - Neuro

- 70% - somnolence, mild confusion, poor concentration, irritability, seizures, transient aphasia (temp. inability to speak), & hallucinations - depression, SI, suicide attempts - DC immediately - reversible after DC'd

IFN Alpha Pharmocokinetics

- 80% absorbed by body, metabolized & excreted by liver and kidneys - given subQ, IM & IV, only given subQ if platelet count < 50,000

Peginterferon alfa

- Acts longer, and given less often - Produce steady blood levels 1. Peginterferon alfa-2a (Pegasus) 2. Peginterferon alfa-2b (PEG-Intron)

Interleukin-2 (IL-2)

- Aldesleukin (Proleukin) - A group of proteins produced by lymphocytes - FDA approved for tx of: - metastatic renal cell carcinoma - metastatic melanoma

ESA side effects/adverse reactions?

- DO NOT administer if Hgb > 12 g/dl - Closely monitor for target Hgb - Risks of death, serious CV events, & tumor progression - HTN, HA, arthralgias, N/V/D, fatigue, chest pain, asthenia, dizziness, seizures, & thrombosis

Sargramostim: Nursing Implications?

- Do not administer: 1. 24 hrs before or after chemo 2. Within 12 hrs before or after radiation - Reconstitute for injection w/ NS - May be stored up to 20 days

vitamins and mineral: beneficial to cellular membranes & regenerates & oxygenates RBCs

- Iron: manufactures Hgb & transfers to tissues - Vitamin B12, B6, & Folic Acid: production of RBCs - Copper: enzyme function: blood formation, bone metabolism, & immune system - Vitamin C: wound healing

Filgastim (Neupogen): S/E?

- NVD, bone pain, skeletal pain, alopecia, neutropenia, fever, mucositis, fatigue, anorexia, dyspnea, HA - Bone pain: tx: non-opioid analgesia - occurs in pt's receiving higher IV doses - Splenic rupture: LUQ abd./shoulder tip pan

Keratinocyte Growth Factor

- Palifermin (Kepivance) - initiates proliferation, differentiation, & migration of epithelial cells --> thicker buccal mucosa - decreases the incidence & duration of severe oral mucositis (drug go choice) - decreases opioid use for oral mucositis in transplant clients

granulocyte CSF (G-CSF) - regulates what? - FDA approved meds?

- a glycoprotein produced by: monocytes, fibroblasts, & endothelial cells - regulates the production of neutrophils in the bone marrow - FDA approved 1. Filgastrim (Neupogen) 2. Pegfilgrastam (Neulasta)

interferon nursing implications?

- administer cautiously in: severe cardiac, renal, & hepatic disease, seizures, and CNS dysfunction - 18 & older - use 2nd form of contraceptive - baseline and periodic CBC & LFTs minimum 6 months of tx - dose reductions

Epoetin Alfa (Procrit)

- anemia secondary to CRF - AZT-treated HIV infections - Cancer Chemotherapy - Anemic clients to undergo surgery

ESA: Darbepoetin Alfa (Aranesp)

- anemia secondary to CRF - chemotherapy tx for Nonmyeloid Malignancies - we don't give as much - require less blood transfusions

EGFR: Human epidermal growth factor receptor (EGFR)

- are a type of receptor tyrosine kinase (aka EGFR, ErbB1 and HER1) - involved in cell signaling pathways that control cell division and survival

Kepivance: Nursing Implications?

- contraindicated with hypersensitivity to E. coli-derived therapy or Palifermin - flush central line containing Heparin - Kepivance binds to Heparin (always flush first bc interacts with Heprarin) - do not administer within 24 hrs of myelotoxic chemo - reconstitute --> stable up to 24 hrs refrigerated --> administer at room temp - d/c after 1 hr in room temp

Filgastim (Neupogen): Nursing Implications?

- do not administer 24 hrs before or after chemo - dosing: ANC dependent (<1, might not give) - contraindicated with hypersensitivity to E. coli deviant proteins - single use vials (no preservatives) - do not freeze or shake vials/syringes

ESA Nursing Implications

- do not shake vial (denatures glycoproteins-inactivates) - single use vial - warm to room temp: subQ - 1 ml or less/injection - ice injection site - change needle for injection

Oprelvekin (Neumega): Nursing Implications?

- dose reduction in renal dysfunction - platelet count determines tx duration - single use reconstituted vial (SubQ) - do not rub injection site - d/c 2-3 ??? before chemo begins

s/s of anemia + late sign

- fatigue - SOB - weakness - dizzy - HA - ALOC - lightheaded late sign: cyanosis

granulocyte CSF: decreases the incidence of infections in clients who: (5)

1. receiving myelosupressive cancer chemo (very strong) 2. receiving induction or consolidation chemo for Acute Myeloid Leukemia 3. receiving bone marrow transplantation for cancer 4. undergoing peripheral blood progenitor cell collection & therapy 5. severe, chronic neutropenia

Normal absolute neutrophil count (ANC)

1.5 to 8.0

Normal platelet count

150-360

Nursing Process: planning/goals? (5)

1. Client & family will verbalize an understanding of reporting BRM- related side effects. 2. Client & family will demonstrate correct & safe BRM administration. 3. Client & family will identify strategies to deal with BRM-related side effects 4. Client will remain free of infection (Filgastrim & Sargramostim) 5. Client will remain free of hemorrhage

Erythropoietin Stimulating Agents (ESAs)? (2)

1. Epoetin Alfa (Procrit) 2. Darbepoetin Alfa (Aranesp)

Nursing Process: Nursing Interventions (8)

1. Monitor temp. @ onset of chills 2. Administer Meperidine 25-50 mg IVP to decrease rigors (relaxes pt) 3. Premeditate with Tylenol to decrease chills and fever; Benadryl to decrease nausea 4. Encourage > 2L/day to promote excretion of cell breakdown - hydrate! unless CHF 5. Administer antiemetic ATC after BRM administration to prevent N/V (zofran, reglan) 6. Administer BRM @ bedtime to decrease fatigue 7. Sargramostim: single use dose/vial, do not shake vial - use within 6 hrs once reconstituted 8. Filgrastrim: same as Sargramostim 9. Oprelvekin: single use vial - use refrigerated dose within 3 hours - don't shake vial 10. Palifermin binds with Heparin - central line: flush with NS prior to and after administration of Palifermin

Oprelvekin (Neumega): S/E & Adverse Reactions

1. Serious fluid retention - peripheral edema (may have to give diuretics), exertion dyspnea, worsening pleural effusions, ascites (fluid in abdomen) - reversible after dc'd, several days 2. Cardiovascular events - a fib & a flutter ~ 10 days - ventricular arrhythmias

actions of interferons?

1. aid immune system to resist invading microorganisms 2. decrease cell proliferation

Nursing Process: Evaluation? (5)

1. ask client & family about the potential effects of BRM on the quality of life 2. self-administration technique 3. client & family's management of BRM side effects (teach s/s to family) 4. there will be a low incidence of infection in clients after autologous bone marrow transplant 5. there will be a low incidence of thrombocytopenia in clients after chemo

colony-stimulating factors: uses? (5)

1. decreases length of post-treatment neutropenia (reduces incidence & duration of infection) 2. permits delivery of higher doses (minimizes myelosupression toxicity, bone marrow is so depressed that everything is so low) 3. reduces bone marrow recovery time after bone marrow transplantation 4. enhances macrophage or granulocyte tumor-, virus-, & fungus-destroying ability 5. prevents severe thrombocytopenia after myelosuppressive chemotherapy

what herbs cause prolonged bleeding?

1. echinacea 2. elderberry 3. ginseng 4. goldseal 5. green tea

biologic response modifier (immunomodulator): functions?

1. enhance client immunologic functions- immunomodulation 2. destroy or interfere with tumor activities - cytotoxic/cytostatic effects 3. promote differentiation of stem cells (ability of our cells to make new cells) - examples: interferons, interleukins, colony-stimulating factors, & monoclonal antibodies

Interferon Beta (1a and 1b) uses? (4)

1. enhances activity of suppressor T cells 2. reduces production of pro inflammatory "cytokines" -> "cell communication" 3. reduces antigen-presentation 4. inhibits movement of lymphocytes in the central nervous system (CNS) Tx: multiple sclerosis: autoimmune neuromuscular disorder S/E: flu-like symptoms

Sargramostim: contraindications?

1. excessive leukemia myeloid blast cells in the bone marrow or peripheral blood 2. known hypersensitivity to: GM-CSF or any component of the product, yeast-derived products

Client Teaching? (6)

1. explain rationale of BRM therapy 2. explain frequency & rationale for studies & procedures 3. teach that most BRM side effects disappear within 72-96 hrs after DC of tx 4. Instruct client to use contraceptives during tx until 2 yrs after completion 5. provide info on effects of BRM-related fatigue on ADLs & sexuality 6. explain that herbal products with BRM therapy is not recommended

Interferon alfa 2a (Roferon-A) uses? (3)

1. hairy cell leukemia (18 & older) 2. condylomata acuminata (anogenital warts) 3. AIDS-related Kaposi's sarcoma - no longer preferred as the initial tx, but may be used for childbearing women

Oprelvekin (Neumega): drug interactions: diuretics

1. high risk of hypokalemia 2. low in Hgb (plasma volume related) & serum proteins (albumin) 3. high in plasma fibrinogen

nursing process: analysis (7)

1. imbalanced nutrition, less than body requirements, r/t side effects of BRM therapy 2. Potential for infection r/t side effects of chemo & disease condition 3. Impaired oral mucous membrane, skin integrity r/t side effects of chemo & disease condition 4. Fatigue r/t side effects of BRM therapy 4. Anxiety r/t cancer diagnosis & the unknown outcomes of tx 5. Fear r/t the cancer diagnosis 6. Risk for caregiver role strain r/t the cancer dx, tx, & care responsibilities 7. Risk for deficient fluid volume r/t side effects of cancer therapy.

EGFR1 results in? (4)

1. increased cell proliferation 2. avoidance of programmed cell death or apoptosis 3. increased cell invasiveness leading to metastasis 4. release of vascular endothelial growth factor (VEGF)

Interferon alfa 2b (Intron-A) uses? (6)

1. malignant melanoma 2. hairy cell leukemia 3. follicular non-Hodgkin's lymphoma 4. AIDS-related Kaposi Sarcoma 5. Condylomata Acuminata (anogenital warts)

ANC determines the effectiveness of?

Epogen

Oprelvekin (Neumega): Side effects/Adverse Reactions

3. Opthalmologic events - papilledema (optic disc swelling) & transient visual blurring (1.5%) 4. hypersensitivity reactions: - including anaphylaxis (tongue welling, respiratory distress, hives) - DC if symptomatic bronchospasms or anaphylaxis occurs

ANC =

ANC = Total WBC x (% "Segs" + % "Bands") Equivalent to: WBC x percentage of mature & nearly mature neutrophil

Sociocultural & Religious Considerations: Erythropoietin

Jehova's Witness: - Induction of hematopoiesis - Cellular protection in hypoxic conditions - Leviticus: "as for any man who eats any sort of blood, I shall certainly set my face against the soul that is eating the blood, and I shall indeed cut him off from among his people"

The WBC consists of the following (differential):

Lymphocytes: 20-40% Neutrophils: 50-60% Basophils: 0.5-2% Eosinophils: 1-4% Monocytes: 2-9%

Thrombopoietic Growth Factor

Oprelvekin (Neumega) - very expensive, we give platelets transfusions instead of this drug bc of price - recombinant human interleukin-11 - a platelet growth factor - prevents recurrent severe chemo-induced thrombocytopenia - stimulates megakaryocyte & thrombocyte production --> normal circulating platelets

granulocyte-macrophage colony-stimulating factor (GM-CSF)

Sargramostim (Leukine) 1. support survival 2. clonal expression 3. differentiation (maturation) of hematopoietic progenitor cells - if successful, increase in WBC in 2 weeks

Interferon Gamma-1b (Actimmune)

Tx: -Severe Malignant Osteoporosis - Chronic Granulomatous disease - Chronic Myelogenous Leukemia - Renal Cell Carcinoma

what NSAID do you give for bone pain?

Tylenol

granulocytes

WBCs characterized with granules in their cytoplasm: neutrophils, eosinophils, and basophils

these herbs cause what?

act to stimulate the immune system, cause untoward effects, not recommended in combo with BRMs

hematinics

agents that increase the Hgb level & erythrocytes

Peginterferon alfa-2b (PEG-Intron)

also indicated for use in chronic hepatitis C, with ribavirin

bold letters = dose limiting toxicity

dr. thinks its too much for patient, will decrease dose or stop med

normal RBC count female/male

female: 11.5-16 male: 14-18

hematopoiesis

formation of blood cells in response to body demands

reticulocytes

immature red blood cells

leukopenia

low # of WBCs in the blood

neutropenia?

low # of neutrophils in the blood

thrombocytopenia

low platelet count

erythrocytes

mature red blood cells

hydration ______ side effects, but C/I in who?

minimizes, CHF

do any herbs interact with Intron-A?

no

normal, mild, moderate and severe neutropenia levels

normal: 1.5-8 mild: 1-1.5 moderate: 0.6-1 severe: 0-0.5

T/F: Epoetin Alfa (Procrit) prevents need for blood transfusions and reactions

true

T/F: ESAs should be administered at the lower possible dose

true