antineoplastic agents

methotrexate (generic) folate antagonist

- Trexall: brand name - Indications: treatment of acute lymphocytic leukemia; gestational choriocarcinoma; breast, head and neck, and many other cancers - immunosuppressive activity inhibits lymphocyte multiplication; useful in the treatment of rheumatoid arthritis

mechanism of action of antimetabolites

- cell cycle-specific - inhibit cellular growth by interfering with the synthesis or actions of compounds critical to cellular reproduction: the vitamin folic acid, purines, and pyrimidines. Purines and pyrimidines make up the bases contained in nucleic acid molecules (DNA and RNA).

cisplatin adverse effects

- parathesias - sore throat - flank pain - tinnitus - low WBC count Nephrotoxicity, peripheral neuropathy, ototoxicity

cladribine (Leustatin)

- purine antagonist - hair cell leukemia

fludarabine (Fludara)

- purine antagonist - indicated for various acute and chronic leukemias, NHL

cytarabine (Cystosar-U)

- pyrimidine antagonist - indicated for leukemias (several varieties) Non-Hodgkin Lymphoma - It is available only in injectable form and may be given IV, subcutaneously, or intrathecally. It is also now available in a special encapsulated liposomal form for intrathecal use only in treating meningeal leukemia.

capecitabine (generic) --> trade name: Xeloda

- pyrimidine antagonist - indicated for metastatic colorectal and breast cancer - A dose of capectiabine must be adjusted for renal dysfunction. It is contraindicated in patients with known hypersensitivity to it or to fluorouracil and in patients with severe renal impairment.

Neupogen (filgrastim)

- treats leukopenia - promotes the proliferation, differentiation, and activation of the cells that make granulocytes - patient has low neutrophil count

Antimetabolite indications

- used for the treatment of a variety of solid tumors and one hematologic cancers - overall enhance cytotoxic effect when used in combination chemotherapy regimes - because some of these drugs are available in both oral and topical preparations, they are sometimes used for low-dose maintenance and palliative cancer therapy

indications of an oncologic emergency

-Fever and/or chills with a temperature higher than 100.5°F (38.1°C) - New sores or white patches in the mouth or throat - Swollen tongue with or without cracks and bleeding - Bleeding gums - Dry, burning, "scratchy," or "swollen" throat - A cough that is new and persistent - Changes in bladder function or patterns - Blood in the urine - Changes in GI or bowel patterns, including "heartburn" or nausea, vomiting, constipation, or diarrhea lasting longer than 2 or 3 days - Blood in the stools

busulfan (mechanism, use, toxicity)

-Mechanism: cross-links DNA. -Use: CML. Also used to ablate patient's bone marrow before bone marrow transplantation. -Toxicicty: severe myelosuppression (in almost all cases), pulmonary fibrosis, hyperpigmentation

antimetabolites work via two mechanisms

(1) by falsely substituting for purines, pyrimidines, or folic acid; and (2) by inhibiting critical enzymes involved in the synthesis or function of these compounds. *they inhibit the synthesis of DNA, RNA, and proteins, all of which are necessary for cell survival

Alkylating agents

A chemical reaction in which an alkyl group is transferred from one molecule to another. In chemotherapy, alkylation leads to damage of the cancer cell DNA and cell death.

adverse effects of alkylating agents

Alkylating drugs are capable of causing all of the dose-limiting adverse effects gastrointestinal [GI] toxicity and bone marrow suppression

alkylating indications

Alkylating drugs are effective against a wide spectrum of malignancies, including both solid and hematologic tumors

musculoskeletal toxicity of antimetabolites

Backpain,limbpain,bonepain,myalgia,jointstiffness,arthralgia,muscleweakness,fibromyositis

alkylating agents MOA

The alkylating drugs work by preventing cancer cells from reproducing. Specifically, they alter the chemical structure of the cells' DNA. Alkyl groups that are part of the alkylating drugs structure that attach to DNA molecules by forming covalent bonds. As a result, abnormal chemical bonds form between the adjacent DNA strands, which leads to the formation of defective nucleic acids that are then unable to perform the normal cellular reproductive functions, which leads to cell death.

cytotoxic antibiotic anti-neoplastic drugs

The cytotoxic antibiotic antineoplastic drugs consist of natural substances produced by the mold Streptomyces, as well as semisynthetic substances in which chemical changes are made in the natural molecule. Cytotoxic antibiotics have bone marrow suppression as a common toxicity.

cytotoxic interactions

The cytotoxic antibiotics that are used in chemotherapy interact with many drugs. They all tend to produce increased toxicities when used in combination with other chemotherapeutic drugs or with radiation therapy. Some drugs, most notably bleomycin and doxorubicin, have been known to cause serum digoxin levels to increase. Observe patients receiving one of these drugs along with digoxin for signs of digoxin toxicity. Dosage reduction or elimination of digoxin therapy may be indicated

Miscellaneous Antineoplastics

The miscellaneous antineoplastic drugs are those that, because of their unique structure and mechanism of action, cannot be classified into the previously described categories. However, some drugs that are originally classified as miscellaneous drugs are later reclassified as more is learned about their mechanisms of action and other characteristics. Drugs in the miscellaneous category include bevacizumab, everolimus, hydroxyurea (which is actually cell cycle specific), ipilimumab, imatinib, mitotane, ofatumumab, pazopanib, romidepsin, sorafenib, sunitinib, hormonal drugs, and radioactive and related antineoplastic drugs. Selected miscellaneous drugs are profiled in the following sections.

alkylating agents interactions

The most important rule for preventing such drug interactions is to avoid administering an alkylating drug with any other drug capable of causing similar toxicities. For example, a major adverse effect of cisplatin is nephrotoxicity. Therefore, if possible, do not administer it with a drug such as an aminoglycoside antibiotic (gentamicin, tobramycin, or amikacin) because of the resulting additive nephrotoxic effects and hence the increased likelihood of renal failure. Mechlorethamine and cyclophosphamide, both of which have significant bone marrow-suppressing effects, are not to be administered with radiation therapy or with other drugs that suppress the bone marrow.

ANC

The normal ANC range is 1.5 to 8.0, or 1500 to 8000 cells/mm3, with severe neutropenia being less than 500 cells/mm3. Assess for signs and symptoms of thrombocytopenia (decrease in thrombocytes [usually less than 100,000] and platelet clotting factors), including indications of unusual bleeding such as petechiae, purpura, ecchymosis, gingival (gum) bleeding, excessive or prolonged bleeding from puncture sites (e.g., intramuscular or IV administration sites or blood draw sites), unusual joint pain, blood in the stool, urine, or vomitus, loss of function in extremities, and a decrease in blood pressure with elevated pulse rate

cisplatin

Cisplatin (Platinol) is an antineoplastic drug that contains platinum in its chemical structure. It is classified as a probable alkylating drug because it is believed to destroy cancer cells in the same way as the classic alkylating drugs—by forming cross-links with DNA and thereby preventing its replication. It is also considered a bifunctional alkylating drug.

fluorouracil (Adrucil) Pyrimidine antagonist

Class: Anti-metabolite, antineoplastic, dermatologic Treats: palliative treatment for cancer; colon, rectal, breast, esophageal, head and neck, cervical, and renal cancer Admin: IV, Topical Adverse Reaction: alopecia, maculopapular rash, anemia, luekopenia, thrombocytopenia, stomatitis, diarrhea, jaundice, acute cerebellar dysfunction

gi toxicity: clinical manifestations of antimetabolites

Dyspepsia (heartburn), hiccups, gingivitis (inflamed gums), glossitis (inflamed tongue), abdominal pain, nausea, vomiting, diarrhea, constipation, gastroenteritis, stomatitis (painful mouth sores), oral candidiasis (thrush), ulcers, proctalgia (rectal pain), hematemesis, gastrointestinal hemorrhage, melena (blood in stool), toxic intestinal dilation, ileus (bowel paralysis), ascites, necrotizing enterocolitis

ocular toxicity of antimetabolites

Eye irritation, increased lacrimation, nystagmus, photophobia, visual changes, conjunctivitis, keratitis, dacryostenosis (narrowing of lacrimal duct)

neurologic toxicity of antimetabolites (manifestations)

Fatigue, weakness, depression, agitation, euphoria, insomnia, sedation, headache, reduced libido, confusion, amnesia, hallucinations (visual and auditory), dizziness, loss of taste or altered taste sensations, dysarthria (joint pain), polyneuropathy (e.g., numbness in extremities), neuritis, paresthesia (abnormal touch sensations), facial paralysis, migraine, tremor, hemiplegia, loss of consciousness, seizures, ataxia, stroke, encephalopathy

assessment for alkylating agents

For patients receiving alkylating drugs, bone marrow suppression (carboplatin), pulmonary fibrosis (busulfan), nephrotoxicity and/or neurotoxicity (more with cisplatin than carboplatin), and hemorrhagic cystitis (cyclophosphamide) may occur; thus perform an appropriate and thorough nursing assessment (see Assessment in Chapter 45). Be specific, and assess/document deep tendon reflexes and baseline hearing level. Assess results of any baseline pulmonary function testing, and perform a thorough respiratory assessment. High-dose cyclophosphamide may lead to hemorrhagic cystitis; therefore document baseline urinary patterns and any abnormal symptoms. Note hydration status before administering cyclophosphamide, to avoid hemorrhagic cystitis.

cardiovascular toxicity of antimetabolites (manifestations)

Hot flushes, edema, thrombophlebitis and bleeding (e.g., near infusion site), chest pain, tachycardia, bradycardia, other dysrhythmias, angina, venous or arterial thrombosis, transient ischemic attacks, heart failure, myocardial ischemia, pericarditis, pericardial effusion, pulmonary embolism, aneurysm, cardiomyopathy, myocardial infarction, stroke, cardiac arrest, sudden cardiac death

dermatologic toxicity of antimetabolites

Rash, erythema, pruritus, ecchymosis, dryness, edema, photosensitivity, sweating, discoloration (pigmentation changes), freckling, petechiae, purpura, numbness, tingling, hypersensitivity, fissuring, scaling, seborrhea, acne, eczema, psoriasis, skin hypertrophy, subcutaneous nodules, alopecia, nail disorder including onycholysis (loss of nails), dermatitis, cellulitis, excoriation, maceration, ulceration, urticaria, abscesses, benign skin neoplasm, hemorrhage (at injection site), palmar-plantar dysesthesia- paresthesia, toxic epidermal necrolysis, Stevens-Johnson syndrome

toxicity and management of overdose

Severe cases of cardiomyopathy are associated with large cumulative doses of doxorubicin. Routine monitoring of cardiac function, cumulative dose limitations, and the use of cytoprotective drugs such as dexrazoxane can decrease the incidence of this devastating toxicity

Neumega (oprelvekin)

Thrombocytopenia prevention patient has low platelet

metabolic toxicity of antimetabolites

Weight loss or gain, anorexia, dehydration, hypokalemia, hypocalcemia, hypomagnesemia, hypertriglyceridemia, hyperglycemia, syndrome of inappropriate secretion of antidiuretic hormone, hypoadrenalism, protein-losing enteropathy, hyperuricemia, tumor lysis syndrome

implementation for alkylating agents

With alkylating drugs, always handle these and all other antineoplastics with caution because of their possible carcinogenic, mutagenic, and teratogenic properties (see Box 46.3). The patient receiving alkylating drugs will more than likely experience problems related to bone marrow suppression, such as anemia, leukopenia, and thrombocytopenia (see Chapter 45 for specific interventions). Most nursing interventions are focused on preventing infection, conserving energy, preventing bleeding and injury, and reducing nausea. Other nursing considerations for these drugs include taking vital signs every 1 to 2 hours or as needed during infusion; increasing fluids; monitoring intake and output; following orders for intravenous therapy for hydration; and monitoring any nausea/vomiting. Contact the prescriber if vomiting is uncontrolled, so that appropriate medications can be administered. Monitor the patient constantly for abnormal peripheral sensations, especially with cisplatin. Report to the prescriber any numbness or tingling of extremities and any ringing or roaring in the ears and/or hearing loss. Encourage the patient experiencing peripheral neuropathies to avoid extremely cold temperatures or the handling of cold objects. Cisplatin is particularly nephrotoxic, so closely monitor renal function throughout therapy. Intravenous hydration is often required at a rate of 100 to 200 mL/hr starting before cisplatin administration, with a total of 2000 to 3000 mL/day, depending on the dose of cisplatin and if not contraindicated. Do not use aluminum needles or administration sets with many of these drugs because aluminum can degrade their platinum compounds; ensure that the proper infusion equipment is being used. One of the adverse effects associated with cyclophosphamide is hemorrhagic cystitis or the sudden onset of hematuria with bladder pain and discomfort. Hydration must be maintained and/or increased to minimize this adverse effect. Pulmonary toxicity may occur with some of the alkylating drugs, particularly busulfan; therefore constantly monitor and be alert to cough, shortness of breath, and abnormal breath sounds. Immediately report these adverse effects to the prescriber. Other drugs in this group may be given by various routes, such as intrapericardial, intratumoral, and intravesical. Be sure you perform appropriate interventions per the manufacturer's guidelines or health care institutional policy. Reconstitute the parenteral formulations for any of these drugs according to the manufacturer's guidelines and suggestions. Not all diluents are compatible. With the parenteral administration of alkylating drugs, frequently and closely observe the IV site/infusion for signs and symptoms of infiltration. Infiltration could lead to extravasation of the medication into the surrounding tissue. To briefly review, IV infiltration is the leakage of fluids or blood from a dislodged catheter or needle cannula from the intima of the vein and into the surrounding tissue. Signs and symptoms of infiltration include redness at or near the insertion site with swollen, taut skin with pain, blanching, and coolness of skin around the IV site; slowed or stopped IV infusion; and/or no blood return obtained. The reason infiltration is of concern with these drugs is that some of them are irritants and others are vesicants with the potential of severe tissue damage. Therefore, if extravasation occurs with some of these drugs, antidotes are required to try to prevent damage from leakage of the drug into the tissue. Specific antidotes for alkylating drugs are presented in Table 46.3. Always follow facility/institutional policy when treating any extravasation. There are many guidelines/policies outlining the standard of care, such as hourly assessment with documentation. It is important to note that the vast majority of chemotherapeutic drugs are administered via a central line indwelling catheter device (e.g., Port-A-Cath or MediPort) to minimize the risk for extravasation. Check the device and its patency prior to the drug's administration.

cytarabine (Cystosar-U) adverse effects

cytarabine syndrome Cytarabine syndrome is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise. It usually occurs 6 to 12 hours following cytarabine administration. The syndrome may be treated or prevented by the use of corticosteroids.

inquire about any nausea and vomiting

determine whether symptoms are acute, delayed, or anticipatory (occurring in future); if vomiting occurs, assess/document the color, amount, consistency, frequency, and odor and if any blood is present (hematemesis). Presence of blood in the stool, vomitus, and/or sputum needs to be reported promptly to the health care provider. The severity of nausea and vomiting may be rated using a scale of 1 to 10 (where 10 is the worst symptoms) or reported as mild, moderate, and severe.

otic toxicity of antimetabolites

hearing loss

mechlorethamine (Mustargen)

indications: HL, NHL, leukemia, bronchogenic carcinoma, others

cyclophosphamide (Cytoxan)

indications: HL, NHL, leukemia; breast, ovarian, and testicular cancer; retinoblastoma; almost every solid tumor

cisplatin (Platinol)

indications: Metastatic testicular, ovarian, and bladder cancer; brain tumors; esophageal, head, neck, lung, and cervical cancer

mitoxantrone (Novantrone)

is indicated for the treatment of acute nonlymphocytic leukemia and prostate cancer, as well as the neurologic disorder multiple sclerosis. It is available only in injectable form.

Drug extravasation

occurs when an intravenous catheter punctures the vein or artery and medication leaks (infiltrates) into the surrounding tissues. With chemotherapeutic drugs, in particular doxorubicin (a cytotoxic antibiotic), extravasation can cause severe tissue damage and necrosis (tissue death).

antineoplastic effects: assess oral mucosa for any signs and symptoms of stomatitis

such as pain or burning in the mouth, difficulty swallowing, taste changes, viscous saliva, dryness, cracking, and/or fissures with or without bleeding of the mucosa.

cell cycle specific drugs

○ more effective against rapidly growing tumors → antineoplastic drugs that are cytotoxic during a specific phase of cellular growth cycle

genitourinary toxicity CM of antimetabolites

Oliguria, nocturia, dysuria, proteinuria, crystalluria, hematuria, urinary retention, abnormal renal function test results, hemorrhagic cystitis, renal failure

assessment for cytotoxic antibiotics

One of the major adverse effects associated with the use of cytotoxic antibiotics (e.g., bleomycin) is pulmonary fibrosis. Assess and monitor the results of radiographs (x-rays), computed tomographic (CT) scans, magnetic resonance imaging (MRI) scans, positron emission tomography (PET) scans, arterial blood gas levels, and partial pressures of CO2 and O2. Dactinomycin and daunorubicin are given intravenously via a central line indwelling catheter device (e.g., Port-A-Cath or MediPort). Infusion through a central line is necessary because an infiltrated peripheral intravenous line will lead to extravasation of the drug. Infiltration of this drug results in necrosis with tissue sloughing that may erode through the layers of skin and underlying supportive structures (e.g., muscles, ligaments). See the pharmacology discussion of extravasation, as well as Table 46.3 and Box 46.3. In addition, in patients with documented cardiac disease or a history of thoracic irradiation, administer dactinomycin, daunorubicin, and doxorubicin with extreme caution due to cardiovascular toxicity. CT scans and ultrasound studies may be needed before and during treatment, to assess cardiac ejection fraction because of the risk for cardiotoxicity which is often associated with cumulative doses.

implementation for cytotoxic antibiotics

Patients receiving cytotoxic antibiotics such as bleomycin may require more frequent monitoring of pulmonary function. Baseline chest x-rays may be obtained for comparison with subsequent x-rays if pneumonitis occurs. Monitor results of liver and renal function tests throughout therapy with dactinomycin, daunorubicin, doxorubicin, and mitomycin. Heart sounds, daily weights, blood pressure, pulse rate, and monitoring for signs and symptoms of cardiovascular toxicities (e.g., alterations in vital signs, abnormal heart sounds, dyspnea, chest pain) are especially important with doxorubicin, idarubicin, and mitoxantrone. In addition, if the patient experiences a weight increase of 2 pounds or more in 24 hours or 5 pounds or more in 1 week, notify the prescriber because this may reflect fluid retention related to heart failure. Mitomycin is associated with liver, kidney, and lung toxicities. Close monitoring of these systems during treatment is vital to patient safety.

cyclophosphamide adverse effects

-myelosuppression (hemorrhagic cystitis) -derma/gastroentero/hepatotoxicity -alopecia (hair loss) -aldosterone hypersecretion

gemcitabine (Gemzar) (D)

-pyrimidine antimetabolite - indicated for pancreatic, non-small cell lung, and bladder cancer

Treatment of doxorubicin extravasation

1. Once detected, contact prescriber, assess, and document. Emergency management is to be started immediately. 2. Stop IV infusion promptly. Know that treatment protocols for severe extravasations may vary from conservative to aggressive management of the acute injury, with additional variations in the management of the wound. 3. If peripheral line infiltration, stop infusion, discontinue drip, leave cannula in place, mark extravasated area, and contact prescriber. Aspirate extravasated drug and attempt to draw blood back from the cannula; if protocol allows, injection of 0.9% sodium chloride may aid in this. Follow individual management protocols regarding heat and cold application. Rest the extremity and elevate as instructed by protocol or as prescribed. 4. If central line, stop infusion, aspirate drug from the line, leave line in place, and inform prescriber. Management from this point often depends on whether the extravasation is in the nontunneled or tunneled section of the central line. 5. Referral to plastic surgery may be indicated.

antimetabolites interactions

As is true for cancer drugs in general, the administration of one antimetabolite drug with another that causes similar toxicities may result in additive toxicities.

cytotoxic antibiotics adverse effects

As with all of the antineoplastic drugs, cytotoxic antibiotics have the undesirable effects of hair loss, nausea and vomiting, and myelosuppression.

for effects on the GI mucosa

Assess bowel sounds (hyperactive, hypoactive, or normoactive). Assess presence of diarrhea, such as frequent, loose stools (more than three stools per day), urgency, and abdominal cramping. Assess the stool for consistency, odor, amount, and color.

for bone marrow suppression

Assess for signs and symptoms of anemia (e.g., pallor of the skin, oral mucous membranes, and conjunctiva; fatigue; lethargy; loss of interest in activities; shortness of breath; inability to concentrate) or a decrease in RBCs, hemoglobin level, and hematocrit. Assess for signs and symptoms of leukopenia (decrease in WBCs), including fever; chills; tachycardia; abnormal breath sounds; productive cough with purulent, green, or rust-colored sputum; change in the color of urine; lethargy; fatigue; and acute confusion.

antineoplastic effects: for altered nutritional status and impaired oral mucosa

Assess signs and symptoms of altered nutrition, with a focus on weight loss, abnormal serum protein-albumin and BUN levels (a negative nitrogen status due to low protein levels would be indicated by a decreasing BUN level), weakness, fatigue, lethargy, poor skin turgor, and pale conjunctiva.

for alopecia

Assess the patient's views, concerns, and emotions about potential hair loss. Assess the patient's need to prepare for hair loss, either by leaving the hair as it is and allowing it to fall out on its own; having the hair cut short; or wearing a scarf, hat, bandana, or hair wrap and/or purchasing a wig before the hair is actually lost. Purchasing a wig prior to chemotherapy will allow for a closer match to a patient's prechemotherapy hairstyle and color.

pulmonary-respiratory toxicity of antimetabolites (manifestations)

Cough, rhinorrhea (runny nose), sore throat, sinusitis, bronchitis, pharyngitis, laryngitis, epistaxis (nosebleed), abnormal breath sounds, asthma, bronchospasm, atelectasis, pleural effusion, hemoptysis, hypoxia, respiratory distress, pneumothorax, diffuse interstitial pneumonitis, fibrosis, hemorrhage, anaphylaxis and generalized allergic reactions

cyclophosphamide

Cyclophosphamide (Cytoxan) is a nitrogen mustard derivative that was discovered during the course of research to improve mechlorethamine. It is a polyfunctional alkylating drug and is a prodrug requiring in vivo activation. It is used in the treatment of cancers of the bone and lymph, as well as other solid tumors. Cyclophosphamide is also used in the treatment of leukemias and multiple myeloma, as well as for noncancer-related illnesses such as prophylaxis for rejection of kidney, heart, liver, and bone marrow transplants and severe rheumatoid disorders. It is available in both oral and injectable dosage forms.

cytotoxic antibiotics MOA

Cytotoxic antibiotic antineoplastic drugs are cell cycle-nonspecific drugs. They interact with DNA through a process called intercalation, in which the drug molecule is inserted between the two strands of a DNA molecule, ultimately blocking DNA synthesis. These drugs inhibit the enzyme topoisomerase II, which leads to DNA strand breaks. Many of these drugs are able to generate free radicals, which also leads to DNA strand breaks and programmed cell death.

cytotoxic antibiotics indications

Cytotoxic antibiotics are used to treat a variety of solid tumors and also some hematologic malignancies.

doxorubicin, Liposomal (Doxil)

In this dosage formulation, the drug is encapsulated in a lipid molecule bilayer called a liposome. The advantages of liposomal encapsulation are reduced systemic toxicity and increased duration of action. Liposomal encapsulation extends the biologic half-life of doxorubicin to 50 to 60 hours and increases its affinity for cancer cells. The liposomal dosage formulation is currently indicated for the treatment of ovarian cancer and in combination with bortezomib for the treatment of multiple myeloma.

hepatobiliary toxicity of antimetabolites CM

Increased bilirubin and liver enzyme levels, jaundice, cholestasis, acalculiccholecystitis (inflamed gallbladder without stones), hepatitis, sclerosis, fibrosis, fatty liver changes, venoocclusive hepatic disease, cirrhosis

doxorubicin (Adriamycin)

It is contraindicated in patients with a known hypersensitivity to it, patients with severe myelosuppression, and patients who are at risk for severe cardiotoxicity because they have already received a large cumulative dose of any of the anthracycline antineoplastics. It is available only in injectable form.

important

With cell cycle-specific drugs, document allergies, cautions, contraindications, and drug interactions. Most antimetabolite drugs do not produce severe emesis (i.e., in fewer than 10% of cases). Pentostatin and some of the pyrimidine analogues have emetic potential, so assess baseline GI functioning when giving these drugs. In addition, the folate antagonists are not as likely to cause emesis but may be associated with GI abnormalities, such as ulcers and stomatitis. Because these drugs are generally administered parenterally (IV), assessing peripheral access areas or central venous sites is critical to prevent the risk for infection and/or damage to surrounding tissue, joints, and tendons. Assess IV sites every hour for redness, swelling, heat, and pain, as needed, or as per facility protocol. One specific assessment consideration associated with the use of the antimetabolite, cytarabine, is monitoring for the occurrence of cytarabine syndrome. This syndrome usually occurs within 6 to 12 hours after drug administration and is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise. Assessment and quick identification of this syndrome may lead to its prevention and appropriate treatment.

mechlorethamine

a bifunctional alkylating drug capable of forming cross- links between two DNA nucleotides, which interferes with RNA transcription and prevents cell division and protein synthesis. It is available in parenteral form only, for administration intravenously or by an intracavitary route, such as intrapleurally or intraperitoneally. It can also be used topically for treatment of cutaneous T-cell lymphoma.

antimetabolites

a compound that is structurally similar to a normal cellular metabolite is known as an analogue of that metabolite. Analogues may have agonist or antagonist activity. An antagonist analogue is also known as an antimetabolite.

carboplatin (Paraplatin)

adverse effects: Nephrotoxicity, neurotoxicity, bone marrow suppression

adverse effects of antimetabolites

antimetabolites can cause hair loss,, nausea, vomiting, diarrhea, and myelosuppression - other major types of toxicity including neurologic, cardiovascular, pulmonary, hepatobiliary, GI, genitourinary, dermatologic, ocular, otic, and metabolic toxicity.