Pharm Chemotherapy and Immune System Drugs

Used to treat RA MOA: inhibits T-cell activation Caution if the patient has a history of recurrent infections or COPD Patients must be up to date on immunizations before starting therapy May increase risk of infections associated with live vaccines May decrease response to vaccines Cannot give with echinacea, which has immunostimulant properties

Abatacept (Orencia) Indication MOA Caution Nursing Considerations

Diphtheria, tetanus toxoids, acellular pertussis (DTaP) Haemophilus influenzae type B conjugate vaccine (Hib) Hepatitis B virus vaccines Influenza Measles, Mumps, Rubella (MMR) Meningococcal Pneumococcal vaccine, polyvalent, and 13-valent Poliovirus Rabies HPV vaccine (Gardasil, Gardasil 9) Herpes zoster Varicella virus vaccine

Active Immunizing Drug Examples

Indications: severe cases of RA that have failed to respond to other medications such as MTX Pts w/ Crohn's disease, UC, plaque psoriasis & psoriatic arthritis MOA: Prevents tumor necrosis factor (TNF) molecules from binding to TNF cell surface receptors Adverse effects: localized inflammatory rxn at injection site, URI and UTI infections, risk for various malignancies Contraindications: Active infection Injection only

Adalimumab (Humira) Indications MOA Adverse effects Contraindications

Alopecia N/V/D Myelosuppression Paresthesia (AKA hand-foot syndrome or Stevens-Johnson syndrome) Neurologic, cardiovascular, pulmonary, hepatobiliary, GI, GU, dermatologic, ocular, otic, and metabolic toxicity TUMOR LYSE SYNDROME- EMERGENCY

Adverse Effects of Antimetabolite Drugs

Impaired pancreatic function which can lead to: Hyperglycemia Pancreatitis Other: Dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and cardiovascular effects

Adverse Effects of Antineoplastic Enzymes

Chemotherapy can't differentiate between healthy and cancer cells. All rapidly dividing cells: - Hair Follicles: lose hair - GI tract cells (mouth to anus): sores throughout the GI tract - Bone marrow: low WBC, low platelet, low hemoglobin Dose-limiting adverse effects- Pt cannot tolerate an increase of the dosage of the drug that may be necessary to adequately treat the cancer & achieve a good response. Myelosuppression/BM Suppression leads to leukopenia/neutropenia (WBCs), anemia (RBCs), and thrombocytopenia (Plts)

Adverse Effects of Chemotherapy AKA Toxicities

Usually mild Most common include: - Fever - Muscle aches - Bone pain - Flushing

Adverse Effects of Hematopoietic Drugs

Increased risk for opportunistic infections May increase the risk of certain cancers (skin & lymphoma) Some drugs may cause: - Nephrotoxicity - Post transplant DM - Progressive multifocal leukoencephalopathy

Adverse Effects of immunosuppressants

Capillary leak syndrome- severe toxicity Capillaries lose ability to retain vital colloids in the blood; these substances are "leaked" into the surrounding tissues. - Sharp drop in BP, Sudden weight gain, Swelling in the extremities (feet, lower legs), Lightheadedness, Headaches - Results: massive fluid retention -> Respiratory distress Heart failure Myocardial infarction Dysrhythmias Reversible after IL therapy is DC'd

Adverse effects of Aldesleukin S/S

Dose Limiting (Some can be prevented or minimized by prophylactic measures) N/V (can give ondansetron [Zofran] ATC and then other anti-emetics PRN) Nephrotoxicity (can be prevented with IV hydration prior to chemo) Peripheral neuropathy Ototoxicity Bone marrow suppression Alopecia Extravasation

Adverse effects of Alkylating Drugs

Minor rxns can be treated w/acetaminophen (Tylenol) and rest - Soreness at injection site More severe rxns such as fever </= 1030F can be treated with acetaminophen and sponge baths Serum sickness sometimes occurs after repeated injections of equine (horse) derived immunizing drugs S/s: angioedema, rash, urticaria, arthritis, adenopathy, fever, flushing, itching, coughing, dyspnea, cyanosis, vomiting & cardiovascular collapse Tx: analgesics, antihistamines, epinephrine, and/or corticosteroids. Hospitalization may be required.

Adverse effects of Immunizing Drugs What can they be treated with?

Topotecan: BMS, mild to moderate nausea, vomiting, and diarrhea, headache, rash, muscle weakness, and cough Irinotecan: causes more severe adverse effects cholinergic diarrhea, moderate risk of nausea and vomiting

Adverse effects of Topoisomerase 1 Inhibitors

Most widely used of the interleukin drugs Recombinant form of the natural human IL-2 derivative manufactured using recombinant DNA technology Stimulates or restores immune response Binds to receptor sites on T cells, which stimulates the T cells to multiply Lymphokine-activated killer cells: recognize and destroy only cancer cells and ignore normal cells Indicated ONLY for the treatment of renal cell carcinoma and metastatic melanoma. Off labeled use: HIV, AIDS, NHL

Aldesleukin (Proleukin) are used for what?

Used to treat small-cell lung cancer and testicular cancer Not used as much now because of significant toxicities without therapeutic benefit Etoposide is a drug used in small quantities from this class

Alkaloid Topoisomerase II Inhibitors include...

Cisplatin (Platinol) - Solid Tumors Cyclophosphamide (Cytoxan) - Bone, blood, & solid tumors Mechlorethamine (Mustargen, nitrogen mustard) - Hodgkins, Hodgkin's Lymphoma Others include: Ifosfamide (Ifex), chlorambucil, melphalan Works by preventing cancer cells from reproducing. Alters the chemical structure of the cells' DNA

Alkylating Drugs include.... MOA

Measure of how many antibodies to a given antigen are present in the blood and is used to assess whether enough antibodies are present to protect the body effectively against the particular pathogen Booster shot: another dose of the vaccine is given to restore the antibody titers to a level that can protect the person against the infection

Antibody Titer

Interferes w/ the use of folic acid. As a result, DNA is not produced, and the cell dies methotrexate (MTX)* pemetrexed pralatrexate High does of MTX is always given with Leucovorin (rescue drug). MTX can also be used to treat psoriasis and RA. Given 24 hours after MTX** Leucovorin educes the bone marrow suppression caused by the methotrexate

Antimetabolites Folate Antagonist drugs MOA Special Considerations

Cell-specific analogues that work by antagonizing the actions of key cellular metabolites. Antagonists: Folate, Purine, Pyrimidine

Antimetabolites MOA

Interrupts metabolic pathways of purine nucleotides. Results in interruption of DNA & RNA synthesis. Tumor lyse syndrome cladribine fludarabine (F-AMP) mercaptopurine (6-PM) pentostatin thioguanine (6-TG)

Antimetabolites Purine Antagonist drugs MOA

Interrupts metabolic pathways of pyrimidine bases. Results in interruption of DNA & RNA synthesis. Capecitabine Cytarabine (ara-C) Fluorouracil (5-FU) Gemcitabine (Gemzar)

Antimetabolites Pyrimidine Antagonist drugs MOA

Synthesized using cultures of bacteria and recombinant DNA technology As a result, an enzyme is produced This enzyme is isolated and purified for clinical use Asparaginase (Elspar): used to treat acute lymphocytic leukemia (ALL) Pegaspargase (Oncaspar): ALL (usually in patients who have developed an allergy to asparaginase) Erwinia asparaginase: available only by special request from the National Cancer Institute for patients who have developed allergic reactions to Escherichia coli-based asparaginase

Antineoplastic Enzymes include...

Snake and spider antivenins (antivenom): anti-serum containing antibodies against a venom (poison) secreted by an animal Most antivenins are obtained from animals (usually horses) that have been injected with the particular venom Recombinant technology Serum contains immunoglobins that can neutralize the toxic effects of the venom

Antivenins (Antivenom) Indications/MOA

AKA vaccines body is clinically exposed to a relatively harmless form of an antigen that does not cause an actual infection (e.g. varicella [chickenpox] vaccine)

Artificial active immunization

Administration of serum or concentrated immunoglobulin The inoculated person is given the substance needed to fight off the invading microorganism This type of immunization bypasses the host's immune system Antitoxins, antivenins, immunoglobulins Minimizes effects of poisoning by the venoms of spiders and certain snakes

Artificial passive immunization

Prophylaxis of organ rejection concurrently with other immunosuppressant drugs such as cyclosporine and corticosteroids MOA: blocks T-cell proliferation Black box warning regarding bone marrow suppression, development of lymphoma and other malignancies Also associated with hepatosplenic T-cell lymphoma, a rare white blood cell cancer that is fatal

Azathioprine (Imuran) Indication MOA Adverse effects

Used to prevent rejection of transplanted kidneys (grafts) and is generally part of multidrug immunosuppressive regimen that includes cyclosporine and corticosteroids MOA: works by inhibiting the binding of the cytokine mediator IL-2 to the high affinity IL-2 receptor Cytokine release syndrome: can be severe and even involve anaphylaxis. Pts are often premedicated w/ corticosteroids (e.g. methylprednisolone IV) in an effort to avoid or alleviate this problem Black box warning- potential for lymphoproliferative disorders, opportunistic infections and severe hypersensitivity rxns including anaphylaxis. In addition, Pts are at a higher risk for developing new-onset DM when used w/ other immunosuppressants

Basiliximab (Simulect) Indication MOA Adverse effects

Assess baseline blood counts CBC w/ diff CMP Renal fxn (BUN, Creatinine, serum uric acid) Hepatic fxn (AST, ALT, LDH, bilirubin) Others: cardiac enzymes, INR, PT (for bleeding and clotting) Some chemotherapy may require a baseline then routine cardiac function tests such as an echocardiogram (ECHO) and a multigated acquisition (MUGA) scan. ANC should be 500-1500: Below 500 is neutropenic, pt cannot get chemo Obtain a current height and weight for BSA calculation & drug dosing Follow specific administration guidelines for each chemotherapy drug Pain assessment Mucous membranes (mouth to anus): N/V/D, mucositis, stomatitis (oral mucositis) Use baking soda, "magic mouthwash" of lidocaine and benadryl for pain in the mouth Hair follicles: alopecia Bone marrow suppression Reduce Fear & Anxiety Establish a therapeutic relationship beginning with trust and empathy Provide individualized explanations and teachings that the patient can understand Encourage patients to consider relaxation techniques (music, meditation, guided imagery) You may need to call on ancillary services depending on patient needs Inpatient: spiritual guidance/chaplain, social worker(s), counseling services Outpatient: community meal programs, social services, counseling services, financial assistance services

Before administering chemotherapy, the nurse should assess...

Adalimumab Tofacitinib Anakinra Certolizumab Etanercept (Enbrel) Golimumab Infliximab Adalimumab Abatacept (Orencia) Rituximab (Rituxan) Tocilizumab

Biologic DMARDs include...

Hematopoietic drugs PURPOSE: to promote the synthesis of various types of major blood components by promoting the growth, differentiation, and function of their corresponding precursor cells in the bone marrow. Produced by recombinant DNA technology. HDs work by binding to receptors on the surfaces of specialized progenitor cells Immunomodulating drugs PURPOSE: to therapeutically alter a patient's immune response

Biologic response modifiers (BMRs) alter the body's response to disease such as cancer, autoimmune, inflammatory, and infectious disease They can be divided into broad 2 classes: What are their purposes?

R-EPOCH 1. Rituximab, Rituxan - stimulates body's natural immune defense 2. Etoposide Phosphate, Etopophos 3. Prednisone - reduces inflammation and lowers the body's immune response; to reduce side effects 4. Vincristine Sulfate, Oncovin 5. Cyclophosphamide, Cytoxan 6. Doxorubicin Hydrochloride, Hydroxydaunorubicin

Cancer Drug Nomenclature Protocol: ___________ Combination of chemo used to tx DLBCI Drugs include....

Known drug allergy Renal or hepatic failure HTN Concurrent radiation therapy Pregnant women (should ONLY be used in urgent situations)

Contraindications of immunosuppressants

Prevention of organ rejection May be used for other autoimmune disorders (various forms of arthritis, psoriasis, and IBS) MOA- inhibits production of and release of IL-2 Several black box warnings: - Renal impairment (structural kidney damage) - Increased risk of serious and fatal infections - Seizures - Encephalopathy - Skin cancer (teach Pt to avoid excessive UV light and sun exposure) Mix PO cyclosporine solution in a glass container - DO NOT use Styrofoam containers because they drug adheres to the inside of the wall of the container

Cyclosporine (Sandimmune) Indication MOA Adverse effects Nursing Implication

Anthracyclines: Daunorubicin Doxorubicin Epirubicin Idarubicin Valrubicin Others: Bleomycin Dactinomycin Mitomycin Mitoxantrone Plicamycin Used in combination chemotherapy regimens (remember R-EPOCH??) Used to treat a variety of solid tumors and some hematologic malignancies Natural substances produced by the mold Streptomyces as well as semisynthetic substances CCNS drugs are active in ALL phases of the cell cycle.

Cytotoxic Antibiotic Antineoplastic Drugs include...

All can produce bone marrow suppression (except bleomycin) Alopecia & N/V Heart failure (daunorubicin) EF below 40% Acute left ventricular heart failure (doxorubicin) Pulmonary fibrosis & pneumonitis (bleomycin) Liver, kidney, and cardiovascular toxicities Bleomycin & doxorubicin have been known to cause serum digoxin levels to increase. Dosage reduction or elimination of digoxin therapy may be indicated

Cytotoxic Antibiotic Antineoplastic: Adverse Effects

active bacterial infection active herpes zoster active or latent TB acute or chronic hepatitis B or C

DMARDs are NOT used in patients with:

- Modify the disease of RA - Exhibit anti-inflammatory, anti-arthritic, and immunomodulating effects - Inhibit the movement of various cells into an inflamed, damaged area, such as a joint - Slooooow onset of action (several weeks) versus minutes to hours for NSAIDs - 1st line therapy for many patients - 2 classes: Nonbiologic and Biologic

Disease-Modifying Antirheumatic Drugs (DMARDs) do what? Effects?

Cardiomyopathy is associated with large amounts of doxorubicin Routine monitoring of cardiac ejection fraction (EF) with ECHOs and MUGA scans Cumulative dose limitations; life-time cumulative dose of <550 mg/m2 Cytoprotective drugs such as dexrazoxane can decrease the incidence of cardiotoxicity - Give 10-30 min before doxorubicin

Doxorubin nursing considerations

Used to treat RA (including juvenile RA) and moderate to severe plaque psoriasis MOA: binds to TNF and blocks its interaction w/ cell surface receptors Patients MUST be screened for a latex allergy (some dosage forms may contain latex) Onset of action is 1-2 weeks Patients must avoid live vaccines Contraindicated in presence of active infections Reactivating of hepatitis and TB have been reported

Etanercept (Enbrel) Indication MOA Caution/Contraindication Nursing Considerations

↑ age Some cancers are more common in certain genders Familial clustering & chromosomal aberrations Oncogenic pathogens: HPV, Herpes virus, Epstein-Barr virus Occupational & environmental carcinogens: - Industrial chemicals (e.g., formaldehyde) - Tobacco (smokeless and secondhand included) Radiation (X-rays, UV light, tanning beds) Obesity & Dietary factors (preservatives, nitrates, alcohol) Immunologic factors: HIV

Etiology of Cancer

Only drug for relapsing forms of MS MOA: blocks T-cell autoimmune activity against myeline protein, which reduced the frequency of the neuromuscular exacerbations associated with MS Significant adverse effects: HA, hepatotoxicity, flu-like symptoms, back pain, AV block, bradycardia, hypotension, and macular edema

Fingolimod (Gilenya) Indication MOA Adverse effects

Decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia: - Enable higher doses of chemotherapy to be given - Decrease the duration of low neutrophil counts, thus reducing the incidence and duration of infections - Enhance RBC platelet counts in patients with bone marrow suppression resulting from chemotherapy - Decrease bone marrow recovery time after bone marrow transplantation or irradiation - Stimulate other cells in the immune system to destroy or inhibit the growth of cancer cells as well as virus or fungus infected cells

Hematopoietic Drugs are used to...

Contains hepatitis B surface antigen (HBsAg) Made from viral particles of yeast using recombinant DNA technology Antigenic HBsAg is used to promote active immunity to hepatitis B infection in people considered high-risk (such as healthcare workers) Recommended that all children receive this vaccine Also recommended that all patients with DM receive the vaccine (exposure to blood) IM only Given as a series of 3 injections Contraindicated in people who are hypersensitive to yeast

Hepatitis B virus vaccine (Recombivax, Engerix B) Nursing Implcations Recommended in... Contraindications

Zostavax Shingrix

Herpes Zoster Vaccines include...

Can push younger women into early menopause Aromatase inhibitors: anastrozole, aminglutethimide Selective estrogen receptor modulators: tamoxifen, toremifene Progestins: megestrol, medroxyprogesterone Androgens: fluoxymesterone, testolactone Estrogen receptor antagonist: Fulvestrant **Tamoxifen is used to prevent and treat patients with breast cancer**

Hormonal Drugs for Female Specific Neoplasms What can these drugs do to young women? What drug prevents and treats cancer?

Antiandrogens: bicalutamide, flutamide, nilutamide Antineoplastic hormone: Estramustine

Hormonal Drugs for Male-Specific Neoplasms include...

Used to treat a variety of neoplasms in men and women Oppose the effects of hormones Block the body's sex hormone receptors Used most commonly as adjuvant and palliative therapy

Hormonal therapy is used to:

Leaking of an antineoplastic drug into surrounding tissues during intravenous (IV) administration Can result in permanent damage to nerves, tendons, muscles... can lead to loss of limb Skin grafting or amputation may be necessary Prevention is essential: - Continuous monitoring of the IV site and checking for blood return is a MUST

How can antineoplastic drugs lead to extravasation? What can it result in? How is it prevented?

Chemotherapy works by killing cells (mostly cancer cells) by interrupting their cell cycle Chemo is used in combination because different drugs affect different parts of the cycle *Chemo is MOST effective when used in a rapidly dividing or highly proliferative tumor. Chemotherapy dosage is frequently based on body surface area (BSA) - Nurse needs to measure patient's weight and height

How does chemotherapy work? When is it most effective? What is dosage based on?

HPV is a common cause of genital warts and cervical cancer Papillomavirus vaccine (Gardasil, Gardasil-9) are the ONLY vaccines known to prevent cancer Recommended for all girls and boys 11 and 12 years of age and can be given to adult men and women up to 45 years of age Gardasil protects against 4 types of HPV that cause cancer Gardasil-9 protects against 9 types of HPV that cause cancer Cervical cancer, vaginal, vulvar, anal, head and neck, throat cancer, penile cancer; prevent genital warts Given in 3 injections (first dose, then two more doses 2 months and 6 months later) Contraindicated in patients who show hypersensitivity to yeast or to their first injection of the vaccine Not enough studies to know if its safe to give to pregnant women

Human Papillomavirus Vaccine Indication Recommended for... Contraindications

If suspected, STOP the infusion immediately (leaving the IV catheter in place) Aspirate any residual drug or blood from the catheter Contact the ordering physician Consult guidelines or the pharmacists regarding antidotes, application of hot or cold packs or sterile occlusive dressings, and elevation and rest of the affected limb Thoroughly document the extravasation incident Consult facility protocol and guidelines

If extravasation is suspected, what should the nurse do?

Perform a thorough assessment - Renal, liver, and cardiovascular fxn studies - Baseline CNS function - Respiratory assessment - Baseline VS - CBC (WBC, H/H, Platelet) Assess for contraindications, drug allergies, and drug interactions Monitor WBC counts throughout therapy; if the count drops below normal range, contact the prescriber PO immunosuppressants should be taken with food to minimize GI upset PO forms are used when possible to decrease the risk of infection that may occur with parenteral injections Note that there are several possible drug interactions Grapefruit juice also interacts with some of these drugs PO antifungal drugs ("zoles" or oral nystatin) are usually given with these drugs to treat oral candidiasis (thrush) that may occur Assess the oral cavity often for white patches on the tongue, mucous membrane, and oral pharynx Clients taking immunosuppressants should be encouraged to take measures to reduce the risk of infection - Avoid crowds - Avoid people with cold or other infections Inform clients to immediately report fever, sore throat, chills, joint pain, fatigue, or other signs of a severe infection Monitor for therapeutic responses Monitor for adverse effects and signs of drug toxicity Mix PO cyclosporine solution in a glass container - DO NOT use Styrofoam containers because they drug adheres to the inside of the wall of the container

Immunosuppressants Nursing Implications

Cyclosporine (Sandimmune) Azathioprine (Imuran) Muromonab-CD3 (Orthoclone) Daclizumab (Zenapax) Sirolimus (Rapamune) Basiliximab (Simulect) Glatiramer acetate (Copaxone) Tacrolimus (Prograf) Mycophenolate mofetil (CellCept) Fingolimod (Gilenya) Muromonab-CD3, mycophenolate, and tacrolimus are indicated for both prevention of rejection and treatment of organ rejection

Immunosuppressants to Prevent Organ Rejection include... Which drugs are indicated for both prevention of rejection and treatment of organ rejection

Weakened Partial Yes, periodically Hepatitis A, Flu (shot only), Polio (shot only), Rabies

Inactivated/ Killed vaccine Type of Bacteria/Virus Type of Immunity Boosters needed? Examples:

Indication: Prevent illness caused by bacteria, toxins, or viruses Contraindications: Allergy to the immunization itself or any of its components (eggs or yeast) Some are best deferred until after recovery from a febrile illness or a temporary immunocompromised state (after chemo)

Indications & Contraindications for Immunizing Drugs

Indications: Ankylosing spondylitis, Crohn's Disease, UC, plaque psoriasis, and RA MOA: Anti-TNF Common side effects: Nausea, nasopharyngitis, URI, arthralgia, pyrexia, fatigue, HA, cough, & infusion-related rxns Adverse effects: HA, rash, GI discomfort, dyspnea, upper and lower respiratory infection Contraindication in severe heart failure; it will worsen this condition FDA black box warning reporting cases of TB and fungal infections Recommended that clients be tested for latent TB before starting this drug

Infliximab (Remicade) Indications MOA Adverse effects Contraindication Special Considerations

Given annually before the flu season begins FluMist is a LIVE vaccine and is given intranasally, the others are given IM Made from egg-grown viruses that have been rendered noninfectious (inactivated) Each year a new flu vaccine is develop by virology researchers; usually contains 3 different influenza viruses (chosen from >100) CDC recommends that ALL people older than 6 months of age receive the flu vaccine; there is a "high dose" vaccine for those 65+

Influenza virus vaccine (Fluzone, Fluvirin, FluMist) Type of vaccines Recommended for...

Alpha, beta, & gamma IFNs - Antiviral - Antitumor - Immunomodulating Recombinantly manufactured substances that are identical to the IFN cytokines that are naturally present in the human body - Protect human cells from virus attack - Prevent cancer cells from dividing and replicating - Increase the activity of other cells in the immune system, such as macrophages, neutrophils, and NK cells Effects on the Immune System - Restore the immune systems function if it is impaired - Augment the immune systems ability to function as the body's defense - Inhibit the immune system from working

Interferons include... Indication Effects

Flu-Like symptoms - Fever, chills, HA, myalgia Dose-limiting adverse effect is fatigue Others - Anorexia - Dizziness - N/V/D

Interferons: Adverse Effects

Known drug allergy Hepatitis (pharmacological rxn) Liver failure Concurrent use of immunosuppressants Severe liver disease

Interferons: Contraindications

Viral infection (Genital warts, hepatitis) - Protect human cells by enabling the cells to produce enzymes that STOP viral replication and prevent viruses from penetrating healthy cells Cancer - Chronic lymphocytic leukemia (CLL), follicular lymphoma, hairy-cell leukemia, Kaposi's sarcoma & malignant melanoma Autoimmune disorders - Multiple sclerosis

Interferons: Indications

Natural part of the immune system; lymphokines Beneficial antitumor action IL receptor agonist - Aldesleukin (IL-2) - Tocilizumab: Used for severe RA - Anakinra (Kineret): Used to control symptoms of RA - Secukinumab (Cosentyx): Used to control symptoms of ankylosing spondylitis, plaque psoriasis, psoriatic arthritis

Interleukins include...

Used to treat active RA Alters the responses of the immune system to RA Antiproliferative, anti-inflammatory, and immunosuppressive activity Adverse effects: diarrhea, respiratory tract infection, alopecia, elevated liver enzymes, rash Contraindicated in women who are or may become pregnant (Category X)

Leflunomide (Arava) Indication MOA Effects Adverse Effects Contraindication

Live Lifelong (except FluMist) No, except for the FluMist MMR, varicella, Zoster Rotavirus, FluMist, Zostavax

Live attenuated vaccine Type of Bacteria/Virus Type of Immunity Boosters needed? Examples:

Measles, Mumps, Rubella virus vaccine Live vaccine that is weakened Promotes active immunity to these diseases by inducing the production of virus-specific immunoglobulin M antibodies Contraindicated in: - History of anaphylactic reaction - Immediate reaction to egg ingestion - Allergy to neomycin (topically or systemically) - Pregnant women (or wanting to become pregnant within 3 months - potential fetal infection) - Severely immunocompromised patients

MMR vaccine Indication Contraindications

Anticancer drug commonly used to treat RA in much lower doses Weekly dosing*** Adverse effect: bone marrow suppression Advise to take folic acid supplement to lessen likelihood of adverse effects Takes 3-6 weeks for onset of antirheumatic action Oral tablet Category X drug

Methotrexate (MTX) Indication Nursing Considerations

Angiogenesis inhibitor Blocks blood supply to the growing tumor Used to treat metastatic colon cancer, rectal cancer in combination with 5-FU for non-small cell lung cancer and malignant glioblastoma Many adverse effects, including nephrotoxicity

Miscellaneous Antineoplastic Bevacizumab (Avastin) MOA Adverse Effects

Used to treat chronic myeloid leukemia (CML) Targeted therapy, but is NOT a monoclonal antibody Works by inhibiting an enzyme that causes CML Used with other hepatic-metabolized drugs Potential drug interactions and involve other drugs metabolized by the cytochrome P-450 hepatic enzymes (e.g. amiodarone, verapamil, warfarin, azole antifungals, antidepressants, & abx) PO only

Miscellaneous Antineoplastic Describe Imatinib (Gleevec) Indication, MOA, consideration

Action is similar to antimetabolites Used to treat squamous cell carcinoma and some leukemias, Sickle Cell Anemia (increase HgbF, makes RBCs bigger and rounder) Many adverse effects such as: edema, drowsiness, headache, rash, hyperuricemia, N/V, dysuria, myelosuppression, nephrotoxicity, pulmonary fibrosis

Miscellaneous Antineoplastic Hydroxyurea (Hydrea, Droxia) Used to treat.... Adverse effects

Adrenal cytotoxic drug used specifically for treatment of inoperable adrenal corticoid carcinoma PO only Adverse effects: CNS depression, rash, N/V, muscle weakness, and headache Cannot take w/ other CNS depressants (e.g. benzodiazepines) Reduces effects of warfarin and phenytoin (anti-convulsant)

Miscellaneous Antineoplastic Mitotane (Lysodren) Indications, Adverse effects, considerations Drug Interactions

Carcinoid crisis (causes a severe episode of flushing, low blood pressure, confusion and breathing difficulty) Diarrhea caused by vasoactive intestinal peptide-secreting tumors

Miscellaneous Antineoplastic Octreotide (Sandostatin) Used for the management of:

Vinca alkaloids: vinblastine, vincristine, and vinorelbine - Natural products obtained from the periwinkle plant Taxanes: paclitaxel, docetaxel, cabazitaxel (Jevtana), and eribulin (Halaven) Can work in various phases of the cell cycle All work shortly before or during mitosis and thus retard cell division. Each different subclass inhibits mitosis in a unique way.

Mitotic Inhibitors drugs include... MOA

Hair loss N/V Myelosuppression Liver, kidney, lung toxicities Convulsions Peripheral neuropathy Neurotoxicity with vincristine (peripheral neuropathy, constipation, paralytic ileus) Extravasation

Mitotic Inhibitors: Adverse Effects

Quickly becoming the standard of therapy for cancer, RA, MS, and organ transplants For cancer patients, they specifically target cancer cells and have minimal effect on healthy cells -> Reduced adverse effects Produce flulike symptoms Adalimumab (Humira) Bevacizumab (Avastin) Infliximab (Remicade) Rituximab (Rituxan) Trastuzumab (Herceptin

Monoclonal Antibodies (MABs) Indication Drugs include....

Reversal and prevention of graft rejection MAB MOA: specifically targets the binding sites of the T cell that recognize foreign invaders, such as a transplanted organ Contraindicated in patients' w/ hypersensitivity to murine (mouse) products who are experiencing fluid overload Can cause cytokine release syndrome; premedicate w/a corticosteroid

Murimonab-CD3 (Orthoclone OKT3) Indication MOA Contraindications Adverse effects

Indicated for the prevention of organ rejection as well as the treatment for organ rejection MOA: suppressed T cell proliferation Black box warning for increased risk of congenitial malformation and spontaneous abortions when used during pregnancy Common side effects: HTN, hypotension, peripheral edema, tachycardia, pain, HA, hyperglycemia, HLD, electrolyte disturbances, and other

Mycophenolate (CellCept) Indication MOA Adverse effects

person acquires immunity by surviving the disease itself and producing antibodies to the disease-causing organism

Natural active immunization

antibodies are transferred from the mother to her infant in breastmilk or through the bloodstream via the placenta during pregnancy

Natural passive immunization

Methotrexate Leflunomide (Arava) Hydroxychloroquine (Plaquenil) Sulfasalazine (Azulfidine) American College of Rheumatology guideline recommends starting w/ MTX or Leflunomide in most patients.

Nonbiologic DMARDs include... Start with _______ for treatment of RA

- Altered nutritional status & impaired oral mucosa - Effects on the GI mucosa - Alopecia - Possible teratogenesis and damage to the ovaries in women; sterility (in both) - Bone marrow suppression: S/S of anemia = Pale, fatigue, inability to concentrate; Infection; Bleeding

Nursing Assessment as related to chemotherapy

Past Medical History (PMH), Family History Current medications (and OTCs & herbal supplements) Vital Signs Physical assessment Cultural, emotional, spiritual, sexual, financial concerns and issues

Nursing Assessment for patients about to go on chemotherapy

Monitor dose expected effects of bone marrow suppression Expect N/V/D & stomatitis Hydration is important to prevent nephrotoxicity Report tinnitus or ringing in the ears- possible ototoxicity Report tingling, numbness, or pain in the extremities (peripheral neuropathies may occur)

Nursing Implications for Alkylating Drugs

Expect bone marrow suppression N/V/D & stomatitis Monitor pulmonary status because pulmonary fibrosis may occur (bleomycin) Monitor for nephrotoxicity & hepatotoxicity Monitor cardiovascular status (doxorubicin and daunorubicin) Doxorubicin and daunorubicin may turn the urine a reddish color

Nursing Implications for Cytotoxic Antibiotics

Assess the patient's health hx, medication hx, allergies, and pregnancy status Assess previous rxns and responses to immunizations Assess for contraindications, including immunosuppression administration Follow manufacturer's guidelines for drug storage, administration, route, and site of administration Encourage parents of young children to keep a journal of the child's immunization status with dates of immunizations and rxns, if any If discomfort occurs at the injection site, apply a cool compress and give acetaminophen and allow the child to rest DO NOT give aspirin to children Monitor for therapeutic responses and adverse reactions

Nursing Implications for Immunizing Drugs

Assess for allergies, specifically allergies to egg proteins or neomycin Assess for conditions that may be contraindications Assess baseline blood counts; perform cardiac, renal and liver studies Assess for presence of infection Follow specific guidelines for preparation and administration of drug ALWAYS know WHY the patient is taking the drug and assess your own knowledge about the medication Monitor the patient's response during therapy Teach patients to report signs of infection immediately: - Fever >/= 100.5oF (38.1oC) - Sore throat - Diarrhea - Vomiting Monitor for therapeutic responses: - Decrease in growth or lesion - Improved blood counts - Absence of infection, anemia and hemorrhage Monitor for adverse effects

Nursing Implications for Immunomodulating Drugs

Monitor closely for anaphylactic reactions Keep epinephrine, antihistamines, and anti-inflammatory drugs close by. Monitor closely for complications associated with bone marrow suppression: anemia, thrombocytopenia, & neutropenia Monitor for oncologic emergencies: Infections Pulmonary toxicity Allergic rxns Stomatitis w/ severe ulcerations Bleeding Metabolic aberrations Bowel irritability w/ diarrhea Renal, liver, cardiac toxicity

Nursing implications for chemotherapy in general (what to monitor for)

Hepatitis B immunoglobin Immunoglobin Rh0(D) immunoglobin Rabies immunoglobin Tetanus immunoglobin Varicella-zoster immunoglobin

Passive Immunizing Drugs include...

Advise the parent/caregiver to notify the prescriber if high or prolonged fever, rash, itching, or SOB occur after the vaccination Stress the importance that the parent/caregiver always keeps a double record (two copies in two separate places) of all if the medications being taken, especially all vaccinations received The CDC recommends that preteens and teens with chronic health conditions (DM, asthma, heart disease" do NOT get the intranasal flu vaccine Make sure that parents are aware of the need to inform whomever is administering the injectable flu vaccine, if there is a severe allergy to chicken eggs It may be helpful to have the patient lay down when getting the shot and up in 15 minutes to avoid fainting The Vaccines for Children program does vaccines for children </= 18 who are uninsured/underinsured, Medicaid-eligible, Native American, or Alaskan Native If a patient is not sure what vaccines have been received in the past, there are many ways to find vaccination records. Visit www.cdc.gov for more information

Patient-Centered Teaching for Immunizing Drugs

Protect against any illness that caused by Streptococcus pneumoniae Polyvalent type of vaccine (Pneumovax 23) is designed to be effective against the 23 strains of pneumococcus- used primarily in adults Also recommended for pediatric patients at high risk for pneumonia (serious chronic illness or immunocompromised) 13-valent vaccine (PVC13, or Prevnar 13) - routinely recommended for children; designed to be effective against the top 13 pneumococcal strains found in pediatric pneumonia cases. CDC recommends that all smokers 19-64 years of age receive the pneumococcal vaccine CDC also recommends that those 65+ receive Prevnar 13 in addition to Pneumovax if they have never received a pneumonia vaccine Contraindicated in known allergy, current significant febrile illness, or immunocompromised as a result of drug therapy

Pneumococcal vaccine, Polyvalent, & 13-valent Indication Recommended for... Contraindications

Risk factors: - High tumor burden (bulky disease) that proliferate at a high rate - Clients with renal insufficiency - Dehydration Prevention: - Identify any risk factors - Correction of any electrolyte abnormalities prior to the initiation of chemotherapy - Aggressive IVF hydration (2-3 L/day, maintaining urine output of greater than 100 mL/hour) - Allopurinol (reduce the incidence of acute renal failure by normalizing the serum uric acid levels) - Rasburicase (urate oxidase)

Risk factors of Tumor Lyse Syndrome Prevention

Indications: follicular low-grade NHL and RA MOA: binds to antigen CD20, a protein found on the membrane of both normal and malignant B-cells Adverse effects: Pyrexia, chills, HA, potentially fatal infusion-related events (including bronchospasm, dyspnea, hypoxia, pulmonary infiltrates, respiratory distress, hypotension, angioedema, TLS w/ acute renal failure) Special Considerations: pre-medicate w/ acetaminophen & diphenhydramine to prevent infusion-related adverse effects

Rituximab (Rituxan) Indications MOA Adverse effects Special Considerations

CSF; Used in children and adults specifically for idiopathic thrombocytopenia when other medications or a splenectomy haven't worked well enough.

Romiplostim (N-Plate) indication

Indicated for promoting bone marrow recovery after autologous or allogenic bone marrow transplantation in patients w/ various types of leukemia and lymphoma

Sargramostim (Leukine) indication

50+ New recombinant vaccine; given in 2 dose series (separated by 2 to 6 months) - Two doses of Shingrix is >90% effective - Protection stays >85% for at least the first four years after vaccination Provides greater protection (shingles AND postherpetic neuralgia) If you'd had shingles in the past and/or received Zostavax you can get the Shingrix vaccine Increased risk of mild side effects: pain at injection site, myalgia, fatigue, HA, fever

Shingrix Indication Recommended in... Contraindications

Macrycyclic immunosuppressive, antifungal, antitumor drug MOA: inhibiting T-lymphocyte activation in response to antigenic stimulation and inhibits antibody production, which suppresses cytokine-mediated T cell proliferation PO Cannot take w/ high fat meals (increased drug level)

Sirolimus (Rapamune) Indication MOA Nursing Implication

These patients MUST avoid live vaccines These patients will be immunosuppressants for a lifetime Often on combination therapy, put them at risk for drug interactions Grapefruit juice should be avoided (P-450 enzyme) Diet modifications depending on the medication (may need a low potassium or low-fat diet) May need to avoid herbal supplements such as St. John's wort, cat's claw, and echinacea

Special Considerations of immunosuppressants

Use a specific isolated protein of the antigen Most offer a strong and long-lasting immune response Yes, may need repeated doses initially and subsequent booster doses in subsequent year Hep B, HPV, meningococcal, pneumococcal, Shingrix

Subunit, recombinant conjugate Type of Bacteria/Virus Type of Immunity Boosters needed? Examples:

Calcineurin inhibitor Used to prevent rejection and to treat rejection once it occurs PO and Injectable

Tacrolimus (Prograf) Drug Class Indication Nursing Implication

Contains tetanus antitoxin antibodies that neutralize the bacterial exotoxin produced by Clostridium tetani, the bacterium that causes tetanus Prepared from plasma of adults who are hyperimmunized with the tetanus toxoid Given as prophylaxis to persons with tetanus prone wounds May also be used to treat active tetanus

Tetanus immunoglobulin (BayTet) Indications

Relatively NEW class of chemotherapy drugs Used primarily to treat ovarian and colorectal cancer, but also indicated for small-cell lung cancer Derived from camptothecin, a substance taken from a Chinese shrub Topotecan (Hycamtin) Irinotecan (CPT-11, Camptosar) MOA: Inhibit proper DNA function in the S phase; prevent DNA relegation

Topoisomerase 1 Inhibitors (Camptothecins) include... MOA?

Toxins Partial Yes, periodically Tetanus, Diphtheria

Toxoid vaccine Type of Bacteria/Virus Type of Immunity Boosters needed? Examples:

Available as injection only; given IM Generally considered safe for use in pregnancy AFTER the 1st trimester Contraindicated in people who have have had prior systemic hypersensitivity reactions or neurologic reaction to one of the ingredients

Toxoids Nursing Implications Contraindications

Indications: HER2+ Breast cancer MOA: Inhibits proliferation of human tumor cells that overexpress the HER2 protein Adverse effects: Pyrexia, chills, HA, N/V/D, dizziness, HA, insomnia, GI discomfort, edema, dyspnea, rhinitis, asthenia, back pain, infection Special considerations: Black box warning reporting cases of ventricular dysfunction before & during treatment and HF Fatal hypersensitivity reactions, infusion reactions, and pulmonary events

Trastuzumab (Herceptin) Indications MOA Adverse effects Special Considerations

Erythropoietic drugs (RBCs): *keep hematocrit 30-33%, therapeutic for oncology patients* Epoetin alfa - synthetic derivative of erythropoietin Darbeopoetin alfa - longer acting version of epoetin alfa Colony-stimulating factors [CSFs] (WBCs): Filgrastim (Neupogen) - synthetic analogue of human granulocyte colony stimulating factor; promotes. proliferation, differentiation, and activation of the cells that make granulocytes Pegfilgrastim (Neulasta) - long acting, so it decreases the # of injection required Sargramostim (Leukine) - synthetic analogue of human granulocyte-macrophage colony stimulating factor; stimulates bone marrow precursor cells that make monocytes Platelet-promoting: Romiplostim

Types of HDs Drugs include....therapeutichematocrit

Interferons (IFNs) Monoclonal antibodies (MABs) Interleukin (IL) receptor agonists and antagonist

Types of Immunomodulating Drugs include...

Varivax Live attenuated vaccine is used to prevent varicella (chickenpox) Varicella primarily occurs in kids <8 or in individuals w/ compromised immune systems (older adults, HIV) Vaccine must be stored in a freezer Contraindicated in immunocompromised patients OR patients who have received high dose systemic steroids in the previous months It is recommended that salicylates be avoided for 6 weeks after getting the vaccine (Reye's syndrome) Should be given at 12 to 15 months of age then a second dose at 4-6 years of age

Varicella Virus Vaccine Indication Recommended Contraindications

Various group of symptoms that cannot be directly attributed to the spread of a cancerous tumor May be the 1st sign of malignancy Cachexia (most common) - Complex metabolic disorder - Irreversible Fatigue, fever, weight loss

What are Paraneoplastic Syndromes? S/S?

Drugs that decrease or prevent an immune response, thus suppressing the immune system Used to prevent or treat rejection of transplanted organs Immunosuppressive therapy Used for: RA, systemic lupus erythematosus, Crohn's disease, MS, myasthenia gravis, psoriasis, and others Generally- all suppress certain T-lymphocyte cell lines which prevents their involvement in the immune response Each drug differs in the exact way in which it suppresses certain cell lines involved in the immune response

What are immunosuppressants? What are they used for? MOA

Indicated to prevent or treat febrile neutropenia in patients receiving myelosuppressive chemotherapy for NON bone marrow malignancies. Must be give BEFORE a patient develops an infection, given after 24 hours after myelosuppressive chemotherapy Don't want patient to have low WBC

What is Filgrastim (Neupogen) used for? (indication, nursing consideration)

Autoimmune disorder causing inflammation and tissue damage in joints Diagnosis primarily symptomatic (pain, stiffness, decreased ROM, symmetrical swelling of multiple joints) - Usually appears between 25 and 50 yo - Women >Men - Smokers - Family history Treatment consists of NSAIDs and DMARDs Osteoarthritis (OA): - Another type of arthritis - Age-related degeneration of joint tissues - Pain and reduced function

What is Rheumatoid Arthritis (RA)? Most common in? Treatment? Osteoarthritis?

Occurs as a result of rapid tumor cell breakdown (lyse) and the consequent release of massive amounts of intercellular contents including potassium, phosphate, calcium, and uric acid into the systemic circulation. Can cause sudden death if not treated Hyperphosphatemia Hyperkalemia Hyperuricemia Hypocalcemia Labs every 4-6 hours**

What is Tumor Lyse Syndrome? Signs/Symptoms? Nursing considerations?

Any serious or unusual rxn to immunizing drugs need to be reported to the vaccine adverse event reporting system (VAERS)

What is VAERS

Myelosuppression/BM Suppression leads to leukopenia/neutropenia (WBCs), anemia (RBCs), and thrombocytopenia (Plts) Nadir: 10-28 days after treatment begins - When blood counts are the absolute lowest

What is nadir?

Used to prevent reactivation of the zoster virus that causes shingles One-time live attenuated vaccine 60+ Does not prevent postherpetic neuralgia It can be given to people who have already had shingles Must be stored in a freezer Contraindicated in patient that are immunosuppressed or receiving immunosuppressant therapy and pregnant woman

Zostavax Indication Recommended in... Contraindications