Chemotherapeutic Agents
5-Fluorouracil (Fluorouracil, 5-FU)
SIDE EFFECTS
DRUG INTERACTIONS
• When given with cimetidine, the pharmacological effects of 5-Fluorouracil are increased.
• When given with thiazide diuretics, there is an increased risk of myelosuppression.
• Leucovorin causes increased 5-Fluorouracil toxicity and efficacy, must administer leucovorin before fluorouracil for this effect.
SPECIAL CONSIDERATIONS
• Contraindicated in patients with bone marrow depression, poor nutritional status, infection, active ischemic heart disease, or history of myocardial infarction within 6 months
• Monitor patients closely for mucositis and gastrointestinal toxicity.
• Patients who have grade 3 or 4 myelosuppression, gastrointestinal toxicity, or neurological toxicities may have an underlying deficiency of dihydropyrimidine dehydrogenase.
• Vitamin B6 may help to prevent the recurrence of hand-foot syndrome.
Chu E., Mota A., Bromberg M., et al. Chemotherapeutic and biologic drugs. In: Chu E., DeVita V.T. Cancer chemotherapy drug manual 2005. Sudbury, MA: Jones & Bartlett; 2003:181–188.
Takimoto C.H., Calvo E. Principles of oncologic pharmacotherapy. In: Pazdur R., Coia L.R., Hoskins W.J., et al. Cancer management: multidisciplinary approach. Lawrence, KS: CMP Healthcare Media; 2005:11–22.
Trissel L.A. Handbook on injectable drugs, 13th ed., Bethesda, MD: American Society of Health-Systems Pharmacist; 2005:672–674.
Wilkes G.M., Barton-Burke M. 2005 Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2005;168–170.
Altretamine (Hexalen)
PRETREATMENT GUIDELINES
• Complete blood cell count with differential before therapy is initiated, at the beginning of each subsequent cycle, and at periodic intervals during therapy
• Liver function studies (LFTs) before therapy is initiated, at the beginning of each subsequent cycle, and at periodic intervals during therapy
DRUG INTERACTIONS
• Concomitant use with monoamine oxidase inhibitors listed below may cause severe orthostatic hypotension:
• Phenobarbital increases the metabolism of altretamine, with a potential for decreased effect of altretamine.
• Cimetidine inhibits drug metabolism, increasing the half-life and toxicity of altretamine.
• Concomitant use of tricyclic antidepressants may cause severe dizziness and syncopal episodes.
PATIENT EDUCATION
• After stopping treatment with altretamine, do not receive any immunizations without the approval of your oncologist.
• Immediately report any feelings of anxiety, clumsiness, confusion, dizziness, numbness, or weakness in arms or legs.
• Explore sexual issues with the patient and discuss the impact of chemotherapy.
Gullatte M.M. A cancer chemotherapy handbook. Pittsburgh, PA: Oncology Nursing Press, 2001;76–78.
Huntsman Online Patient Education Guide. Altretamine. Retrieved May 14, 2006, from http://www.hopeguide.org-altretamine, 2006.
Medline Plus. Altretamine. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202634.html, 1999.
Medline Plus. Altretamine. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601200.html, 2003.
Polovich M., White J.M., Kelleher L.O. Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Press, 2005;20.
Wilkes G.M., Barton-Burke M. Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2005;47–48.
Amifostine for Injection (Ethyol, WR-2721)
PRETREATMENT GUIDELINES
• Premedicate with a 5-HT3 antagonist and dexamethasone.
• Blood pressure monitoring before treatment (NOTE: Blood pressure must also be monitored at 5-minute intervals during treatment and after treatment.)
• Patient should be placed in a supine position during treatment.
• Serum calcium and magnesium levels before treatment and periodically during therapy
USE
• To reduce the cumulative renal toxicity associated with cisplatin in patients with advanced ovarian carcinoma and non–small cell lung carcinoma
• To reduce the incidence of xerostomia in patients with head and neck carcinoma undergoing radiation therapy
PHARMACOKINETICS
• Metabolized well by the IV route (NOTE: Recent studies demonstrate good absorption subcutaneously.)
• Rapidly metabolized in the tissues to an active free thiol metabolite
• Half-life of elimination is 9 minutes
• Small amounts of amifostine and the subsequent metabolites are excreted in the urine.
• Prodrug dephosphorylated by alkaline phosphatase in tissues to an active free thiol metabolite preferentially taken up in normal cells. Protectant effect mediated by scavenging of free radicals, competition with oxygen, promotion of damage repair, and a protectant effect of normal tissue
USUAL DOSE AND SCHEDULE
SIDE EFFECTS
DRUG INTERACTIONS
SPECIAL CONSIDERATIONS
PATIENT EDUCATION
• Move slowly when you sit or stand up if you feel dizzy or lightheaded.
• Drink extra fluids before you get amifostine so your blood pressure will not get too low.
• Do not take your blood pressure medicine for a day before you get amifostine.
• Ask your doctor before restarting your blood pressure medicine.
Gullatte M.M. A cancer chemotherapy handbook. Pittsburgh, PA: Oncology Nursing Press, 2001;79–81.
Huntsman Online Patient Education Guide. Amifostine. Retrieved May 14, 2006, from http://www.hopeguide.org-amifostine, 2006.
Medline Plus. Amifostine. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a696014.html, 2003.
Medline Plus. Amifostine. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/203557.html, 2005.
Polovich M., White J.M., Kelleher L.O. Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Press, 2005;190.
Wilkes G.M., Barton-Burke M. Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2005;386.
Arsenic Trioxide (Trisenox)
SIDE EFFECTS
• Hematological—leukocytosis, anemia, thrombocytopenia, neutropenia, and disseminated intravascular coagulation
• Gastrointestinal (GI) abnormalities—nausea, vomiting, diarrhea, constipation, anorexia, abdominal pain, dyspepsia, sore throat, GI hemorrhage, and fecal incontinence
• Musculoskeletal—arthralgias, myalgias, bone pain, neck and back pain
• Neurological—dizziness, headache, insomnia, tremor, anxiety, depression, agitation, paresthesias, somnolence, convulsions, and coma
• Dermatological—dermatitis, pruritus, petechiae, erythema, dry skin, hyperpigmentation, urticaria, pallor, flushing, eye irritation
• Respiratory events—cough, dyspnea, rales, wheezing
• APL differentiation syndrome characterized by fever, weight gain, dyspnea, and pulmonary or pleural infiltrates
• Cardiovascular—QT prolongation and other ECG abnormalities, tachycardia, palpitations, edema, and hypotension or hypertension
• Miscellaneous—fatigue and weakness, rigors, injection site pain, hypersensitivity, dry mouth, hypokalemia or hyperkalemia, hypomagnesemia, hypocalcemia, hyperglycemia, increased hepatic transaminases, infections, blurred vision, renal impairment/failure, and earache
DRUG INTERACTIONS
• Antiarrhythmics: adenosine, amiodarone, atenolol, digoxin, digitoxin, diltiazem, metoprolol, nadolol, propranolol, quinidine, verapamil
• Antifungals: fluconazole, ketoconazole
• Fluoroquinolones: ciprofloxacin, enoxacin, levofloxacin, lomefloxacin
• Diuretics: especially those that are potassium-depleting: bumetanide, furosemide, thiazide diuretics
• Tricyclic antidepressants: amitriptyline, desipramine, doxepin, imipramine, nortriptyline
SPECIAL CONSIDERATIONS
• Causes APL differentiation syndrome, which can be fatal.
• High-dose steroids (dexamethasone 10 mg IV twice daily) should be instituted for at least 3 days or until the symptoms abate.
• Causes QT interval prolongation and complete A-V block. Monitor patient for concomitant use of medications that prolong QT interval, previous history of torsades de pointes, preexisting QT prolongation, congestive heart failure, use of potassium-wasting diuretics, concurrent administration of amphotericin B.
Gullatte M.M. A Cancer chemotherapy handbook. Pittsburgh, PA: Oncology Nursing Press, 2001;81–83.
Medline Plus. Arsenic trioxide. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/500241.html, 2005.
Munshi N.C. Arsenic trioxide: an emerging therapy for multiple myeloma. The Oncologist. 2001;6(Suppl 2):17–21.
Polovich M., White J.M., Kelleher L.O. Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Press, 2005;30.
Wilkes G.M., Barton-Burke M. Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2005;57–64.
Asparaginase (Elspar)
PHARMACOKINETICS
• Asparaginase hydrolyzes serum asparagines into aspartate, depriving leukemia cells of the amino acid needed for protein synthesis.
• The drug is cell cycle specific in the G1 postmitotic phase.
• Metabolism is independent of renal and hepatic function. Only trace amounts are excreted in the urine.
SIDE EFFECTS
• Hypersensitivity/anaphylaxis including respiratory distress, hypotension, laryngeal constriction, diaphoresis, bronchospasms, loss of consciousness, or death can occur in 10%-40% of patients. Hypersensitivity is more common when asparaginase is given IV and when previous cumulative doses exceed 6000 – 12,000 international units/m2. Intradermal test dose is recommended. If hypersensitivity reaction occurs with aspariginase product, obtain Erwinia L-asparaginase (from E. coli) or pegaspargase and use with caution.
• Coagulation defects such as disseminated intravascular coagulation and prolongation of factors V, VII, VIII, and IX and prothrombin and fibrinogen.
• Pancreatitis is uncommon but may occur.
• Hepatotoxicity with elevated aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin
• Hyperglycemia with glucosuria, polyuria, and diabetic ketoacidosis
• Neurotoxicity manifested as depression, fatigue, coma, confusion, agitation, hallucinations, or a parkinson-like syndrome
• Renal insufficiency, nausea and vomiting, myelosuppression, skin rash, urticaria, arthralgia, fever, and chills
DRUG INTERACTIONS
• Asparaginase used concomitantly with methotrexate can diminish the antineoplastic effects of the methotrexate.
• Increased likelihood of hyperglycemia if given concomitantly with prednisone.
• Neurotoxicities associated with vincristine can be increased if asparaginase is administered before the vincristine.
• Asparaginase has the potential for affecting liver function and can increase the toxicities of other drugs metabolized by the liver, such as probenecid (Benemid) or sulfinpyrazone (Anturane)
SPECIAL CONSIDERATIONS
Intradermal Test Dose
• Administer 2 International Units of asparaginase. Skin test should be observed for 1 hour for reaction. A negative skin test does not ensure that there will be no reaction when full-dose therapy is administered. Be prepared to treat anaphylaxis with each administration.
• Monitor fibrinogen: if the fibrinogen level is below 100 mg/dL, hold the dose and obtain order for fresh-frozen plasma.
PATIENT EDUCATION
• Instruct patient regarding potential for hypersensitivity reaction.
• Teach patient about the potential for excess bleeding and blood clotting and instruct patient to report any unusual symptoms.
• Educate patient about the potential for hyperglycemia and instruct them to report increased thirst, urination, and appetite.
• Instruct patient about potential central nervous system toxicities and to report any unusual symptoms.
• Explore sexual issues with the patient and discuss the impact of chemotherapy.
Gullatte M.M. A Cancer chemotherapy handbook. Pittsburgh, PA: Oncology Nursing Press, 2001;81–83.
Medline Plus. Arsenic trioxide. Retrieved April 29, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/500241.html, 2005.
Munshi N.C. Arsenic trioxide: an emerging therapy for multiple myeloma. The Oncologist. 2001;6(Suppl 2):17–21.
Polovich M., White J.M., Kelleher L.O. Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Press, 2005;30.
Wilkes G.M., Barton-Burke M. Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2005;57–64.
Azacitidine (Vidaza)
USUAL DOSE AND SCHEDULE
• Administer 75 mg/m2 IV or SQ daily for 7 days. Repeat cycle every 4 weeks.
• Dose may be increased to 100 mg/m2 if two treatment cycles fail to obtain desired response and no toxicities other than nausea and vomiting have developed.
• A minimum of four treatment cycles is recommended.
• Treatment may be continued as long as benefit is observed.
Pharmion. Vidaza prescribing information. Retrieved March 20, 2007, from http://www.vidaza.com/corporateweb/vidazaus/homeb.nsf/AttachmentsByTitle/FullPrescribingInformation/$FILE/FullPrescribingInformationforVidaza.pdf, 2007.
Wilkes G.M., Barton-Burke M. Oncology nursing drug handbook. Sudbury, MA: Jones & Bartlett, 2007;70–73.
Bacillus Calmette-Guérin (BCG, TheraCys, TICE BCG)
HOW TO ADMINISTER
• The solution is instilled into the bladder after the bladder has been emptied and allowed to remain in the bladder for 1-2 hours.
• The patient is to lie on each side and in the prone and supine positions for 15 minutes each; then the patient can get up while still retaining the solution for the second hour.
• After 2 hours the patient may empty their bladder, voiding in a seated position.
PHARMACOKINETICS
• Induces a granulomatous reaction at the local site of administration
• Induces a variety of cytokines into the urine of patients with transitional cell carcinoma of the bladder. Some of these cytokines have antiangiogenic activity.
• May induce a cytokine-mediated antiangiogenic environment in addition to a cellular immune response.
SIDE EFFECTS
• Dysuria, bladder irritability, burning, especially on first urination
• Urinary problems, such as continuing pain and burning
• Urinary urgency, urinary frequency, cramps/pain
• Blood or blood clots in the urine
• Flu-like symptoms including malaise, fever, chills, rigors, and joint pain
• Frequent or persistent coughing
MIXING INSTRUCTIONS
• Preparation should be performed by using aseptic technique. To avoid cross-contamination, parenteral drugs should not be prepared in the same area as bacillus Calmette-Guérin.
• Wear gloves and a mask when preparing bacillus Calmette-Guérin.
• Please check guidelines for specific brand. The mixing instructions will vary depending on which product is used. Usual instruction is to draw 1 mL of sterile preservative-free saline solution into a small syringe and add to one vial of bacillus Calmette-Guérin to resuspend. Swirl until a homogenous suspension is obtained. Add to the top end of a catheter-tipped syringe that contains 49 mL of saline solution to bring the total volume to 50 mL.
