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Chemotherapy Chemotherapy and Biotherapy and Biotherapy AgentsAgents
ObjectivesObjectivesAt the completion of this session the participant will be able to:◦Identify common side effects for
individual medications◦Describe nursing interventions for
chemotherapy and biotherapy medications
◦Discuss the principles of chemotherapy administration
Chemotherapy Agents 2
Chemotherapy Agents 3
Chemotherapy Agents
Agent: Agent: Cyclophosphamide Cyclophosphamide ((Cytoxan®; Neosar®)Cytoxan®; Neosar®)
Indications Autoimmune Diseases PTLD Renal Disease
Side Effects: Common
◦ Anorexia◦ Nausea, vomiting◦ Myelosuppression◦ Alopecia◦ Gonadal dysfunction/sterility
Occasional◦ Hemorrhagic cystitis◦ SIADH
Route: IV Special Considerations
◦ Administration of high doses of cyclophosphamide should be preceded & followed by high volume IV hydration and mesna
◦ WBC nadir between 9-15 days (recovery by 21 days)
Chemotherapy Agents 4
Agent: Agent: Cyclophosphamide Cyclophosphamide ((Cytoxan®; Neosar®)Cytoxan®; Neosar®)Nursing Considerations:
◦ Maintain adequate hydration, urinary output◦ Check urine for blood and specific gravity◦ Administer early in the day when possible ◦ Encourage urination q 2 hours and before going to
bed for the night◦ Administer over 15-60 minutes to avoid unpleasant
side effects such as lightheadedness, tearing, nausea, perioral numbness, itchy nose
◦ Can be mixed with Mesna◦ Mesna should be given exactly as ordered, and on
time◦ Nausea/vomiting delayed for 4-8 hours, therefore
administer antiemetics prior to cyclophosphamide, at appropriate intervals, and the following morning after administration
Chemotherapy Agents 5
MESNAMESNA (Mesnex®)(Mesnex®)
Maybe used with cytoxan ◦ Cytoxan is a Pro-drugs: requires biotransformation by hepatic microsomal enzymes before expressing alkylating activity◦ Hepatic biotransformation creates active & inactive metabolites, mainly excreted in urine:
main metabolite = acrolein◦ Hemorrhagic cystitis is a unique toxicity from this group of drugs caused by acrolein.
How Does Mesna Work?◦ Binds with the metabolite in urine◦ Does not bind on a cellular level, therefore, does not counteract cytotoxic effects of cytoxan◦ MUST GIVE DRUG ON SCHEDULE!
Chemotherapy Agents 6
Agent: VincristineAgent: Vincristine SulfateSulfate ((Oncovin®Oncovin®))
Indications: ITPSide EffectsCommon
◦ Local ulceration if extravasated
◦ Hair loss◦ Loss of deep tendon
reflexesOccasional
◦ Constipation◦ Jaw pain
Route: IVSpecial Considerations
◦ Refrigerate and protect from light for continuous infusions
◦ Liver dysfunction or concomitant radiation therapy to the liver may enhance toxicity
◦ Should have special overwrap label that bears the statement, “Fatal if given intrathecally. For intravenous injection only.”
◦ Infants may have difficulty sucking because of jaw pain
◦ Maximum single dose: 2 mg regardless of body surface area (BSA). A few disease protocols do not cap the dose at 2 mg. Always check.
Chemotherapy Agents 7
Agent: Vincristine Agent: Vincristine ((Oncovin®Oncovin®))
Nursing Considerations:◦Vesicant – severe tissue damage if
extravasation occurs ◦Stool softeners may be given
prophylactically, or for constipation
Chemotherapy Agents 8
Agents: Agents: Daunorubicin Daunorubicin (Daunomycin, Cerubidine(Daunomycin, Cerubidine®®))
& Doxorubicin & Doxorubicin ((Adriamycin PFS®; Adriamycin RDF®; Rubex®) Adriamycin PFS®; Adriamycin RDF®; Rubex®) Indications:
◦ PTLDRoute: IVSide Effects Common
◦ Subclinical cardiac arrhythmias
◦ Nausea, vomiting◦ Local ulceration if
extravasated◦ Pink or red color to urine◦ Myelosuppression◦ Alopecia
Occasional◦ Cardiomyopathy
Special Considerations◦ Cardiac studies with
echocardiogram or multiple-gated arteriography (MUGA) scan should be done periodically to monitor cardiac function – must have acceptable cardiac ejection fraction
◦ Monitor cumulative dose◦ Dose adjustments for
renal/hepatic abnormalities◦ Radiation recall◦ Leukocyte and platelet
nadirs occur in 5-10 days; recover within 3 weeks
Chemotherapy Agents 9
Agents: Agents: Daunorubicin Daunorubicin (Daunomycin, (Daunomycin, CerubidineCerubidine®®)) & Doxorubicin & Doxorubicin ((Adriamycin PFS®; Adriamycin RDF®; Rubex®) Adriamycin PFS®; Adriamycin RDF®; Rubex®) Nursing Considerations:
◦ Vesicant – severe tissue damage if extravasation occurs
◦ Continuous infusions-protect from light◦ Educate that there may be pink or red color to
urine ◦ Inspect oral cavity; encourage good oral hygiene◦ Research suggests that sucking on ice cubes or
popsicles during infusion may decrease incidence of mucositis
◦ Change diapers frequently to prevent skin breakdown
Chemotherapy Agents 10
Agent: Agent: Mitoxantrone Mitoxantrone HydrochlorideHydrochloride((Novantrone®)Novantrone®) Indications: MS Route: IV Common Side Effects
◦ Bone marrow suppression. Nadir in 9-10 days.
◦ Cardiac toxicity including CHF and decreased left ventricular EF. Toxicity increased if pt. has cardiac history or mediastinal XRT.
◦ Hepatoxicity with some reports of jaundice.
Chemotherapy Agents 11
Agent: Agent: Mitoxantrone Mitoxantrone HydrochlorideHydrochloride((Novantrone®)Novantrone®)
Nursing Considerations:◦ Monitor blood counts closely
CBC Liver function
◦ Baseline cardiac function with ECHO and EKG◦ Continuous cardiac monitoring during
administration◦ Know cumulative dose◦ Watch for phlebitis; potential to cause tissue
necrosis with extravasation ◦ Blue in color
will turn urine green Potentially will turn skin a blue/green color
Chemotherapy Agents 12
Agent: MethotrexateAgent: Methotrexate (Rheumatrex®; Trexall™ )(Rheumatrex®; Trexall™ )
Indications:Chron’s DiseaseJRAAutoimmune
DiseasesRoutes: IV, IM, SQ, PO
Chemotherapy Agents 13
Side Effects (All Dose Related): Nausea, vomiting Transaminase and
bilirubin elevations Rash/
photosensitivity Myelosuppression Mucositis/GI
ulceration
Agent: MethotrexateAgent: Methotrexate(Rheumatrex®; Trexall™ )(Rheumatrex®; Trexall™ )
Special Considerations◦ Methotrexate enters body fluids easily,
patients with effusions may have delayed clearance
◦ Renal impairment enhances toxicity◦ Intermediate or high-dose, leucovorin is
administered as a rescue agent
Chemotherapy Agents 14
Agent: Methotrexate Agent: Methotrexate (Rheumatrex®; Trexall™ )(Rheumatrex®; Trexall™ )
Nursing Considerations:◦ Advise patients to use sunscreen; severe
sunburn can occur even with low weekly doses◦ Leucovorin must be administered exactly on
time◦ Avoid vitamins containing folic acid to avoid
the metabolic block caused by methotrexate◦ Discontinue Bactrim prophylaxis during high-
dose methotrexate
Chemotherapy Agents 15
LEUCOVORIN & NaHC0LEUCOVORIN & NaHC033
Leucovorin Calcium (Wellcovorin®)◦Term ‘rescue’ may be misleading
as leucovorin rescues the normal cells
◦Scheduling is CRUCIAL!NaHC03
◦Hydration and urine alkalinization used with higher dose infusions to prevent crystallization in the kidneys
Chemotherapy Agents 16
Agent: Mercaptopurine Agent: Mercaptopurine (6-MP) (6-MP) ((PurinetholPurinethol®®))
Indications:◦ ITP◦ Autoimmune Hemolytic
Anemia◦ Inflammatory Bowel
DiseaseRoute: POCommon Side Effects
◦ Myelosuppression
Special Considerations◦ Reduce oral dose
by 75% if given with Allopurinol
◦ May need to hold or reduce dose for myelosuppression
◦ May need to monitor labs
Chemotherapy Agents 17
Agent: Mercaptopurine Agent: Mercaptopurine (6-MP)(6-MP)((PurinetholPurinethol®®))
Nursing Considerations:◦Take daily dose at one
time, preferably at bedtime on an empty stomach Do not take with milk
products◦Teach caregivers to
wear gloves when handling
Chemotherapy Agents 18
Agent: Pentostatin Agent: Pentostatin (Nipent®) (Nipent®)
Indications: GvHD Route: IV Common Side Effects
◦ Central nervous system: Fever, chills, headache
◦ Dermatologic: rashes ◦ Gastrointestinal:
Nausea/vomiting/diarrhea◦ Hepatotoxicity◦ Renal toxicity◦ Myelosuppression◦ Respiratory: pulmonary
edema
Chemotherapy Agents 19
Special Considerations: Combined use with
Fludarabine may lead to severe, even fatal, pulmonary toxicity
Agent: Pentostatin Agent: Pentostatin (Nipent®) (Nipent®)
Nursing Considerations:◦Monitor CBC and LFTs◦ Anti-emetics◦Monitor respiratory and cardiac
status
Chemotherapy Agents 20
Agent: HydroxyureaAgent: Hydroxyurea ((Droxia™; Hydrea®Droxia™; Hydrea®))
Indications:◦ Sickle Cell Disease
Route: PO
Common Side Effects◦ Myelosuppression with rapid drop in
WBC
Chemotherapy Agents 21
Agent: HydroxyureaAgent: Hydroxyurea ((Droxia™; Hydrea®Droxia™; Hydrea®))
Nursing Considerations:◦Do not add to solutions that are
acidic or carbonated; alkaline solutions preferred
◦Take on empty stomach (1 hour before, or 2 hours after meals)
Chemotherapy Agents 22
HormonesHormonesCorticosteroids
Chemotherapy Agents 23
Agent: Agent: CorticosteroidsCorticosteroids (Prednisone, Dexamethasone, Hydrocortisone, Methyl-(Prednisone, Dexamethasone, Hydrocortisone, Methyl-prednisolone)prednisolone)
Indications:◦ Autoimmune Diseases◦ Nausea/vomiting◦ GVHD treatment
Side Effects Common
◦ Hyperphagia◦ Immunosuppression◦ Personality changes◦ Cushing syndrome◦ Pituitary-adrenal axis
suppression◦ Acne
Occasional◦ hyperglycemia
Routes: PO or IVSpecial Considerations
◦ May mask fever or infection
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Agent: Agent: CorticosteroidsCorticosteroids (Prednisone, Dexamethasone, Hydrocortisone, Methyl-(Prednisone, Dexamethasone, Hydrocortisone, Methyl-prednisolone)prednisolone)
Nursing Considerations:◦ Decrease salt intake◦ Observe for hyperglycemia◦ To decrease or prevent GI upset, take
with meals or snacks; may need to take with histamine H2-receptor antagonist such as cimetidine, ranitidine
◦ If possible, do not crush Prednisone tablets because of bitter taste – hide in a small amount of food
Chemotherapy Agents 25
BiotherapyBiotherapyDefinition:
◦The term biotherapy includes agents derived from biological sources and/or use of agents that affect biological responses
Biotherapy Agents 26
Biotherapy Biotherapy Mechanism of Mechanism of ActionAction
Biotherapy can be classified by mechanism of action into three major divisions :◦ Agents that augment, modulate or
restore the host’s immune responses◦ Agents that have direct anti-tumor
activity◦ Agents that have other biological effects
(e.g., differentiating agents, agents that affect the tumor’s ability to metastasize, or agents affecting cell transformation)
Biotherapy Agents 27
BIOTHERAPY BIOTHERAPY AGENTSAGENTS
Biotherapy Agents 28
Cytokines: InterferonsCytokines: InterferonsIndications
◦HLH◦PTLD
Side Effects◦Arrhythmia◦Flu-like
syndrome◦Desquamation
Side Effects◦Pruritus◦Hepatoxicity◦Myalgia◦Arthralgia
Biotherapy Agents 29
Cytokines: InterferonsCytokines: InterferonsNursing
Considerations◦Premedicate with Acetaminophen◦Continuous cardiac◦monitoring during the◦infusion◦Monitor vital signs◦Assess for chest pain or palpitations
◦Assess respiratory◦status◦Monitor daily weights◦and intake and output,◦assess skin and mental◦status frequently◦Have emergency drugs◦available
Biotherapy Agents 30
Intravenous Intravenous ImmunoglobulinImmunoglobulin(Gammagard, Sandoglobulin, Gamimmune)(Gammagard, Sandoglobulin, Gamimmune)
Indications◦ITP◦JRA◦Autoimmune
Diseases◦Nephrotic
syndrome
Side Effects◦Headache◦Flushing◦Chills◦Myalgia◦Tachycardia◦Nausea◦Hypotension
Biotherapy Agents 31
Intravenous Intravenous ImmunoglobulinImmunoglobulin
Nursing Considerations◦May premedication with
Acetaminophen and antihistamines
◦Titrate rate slowly to prevent infusion reaction
◦Monitor vital signs during and after infusion
Biotherapy Agents 32
Indication◦ ITP
Side Effects◦ Headache◦ Fever◦ Chills
Administration◦ Usually IVP over 3
to 5 minutes
Biotherapy Agents 33
RH (D) Immune Globulin RH (D) Immune Globulin (Win Rho)(Win Rho)
Indications◦ Aplastic Anemia◦ PNH
Side Effects◦ Fever◦ Chills◦ Flu-like syndrome◦ Nausea◦ Anaphylaxis◦ Serum Sickness◦ Hypotension◦ Flank or back pain
Nursing Consideration◦ May need
premedication with acetaminophen, antihistamine, and hydrocortisone
◦ Monitor vital signs during infusion
◦ Infuse over 4 to 8 hours, avoid rapid administration
Biotherapy Agents 34
Anti Thymocyte Globulin Anti Thymocyte Globulin (ATG)(ATG)
Monoclonal Monoclonal AntibodiesAntibodiesA laboratory made protein that is directed against a single
antigenic determinant on the surface of a cell
They can be used alone or can carry drugs, toxins, or radioactive material to the specific cells
Biotherapy Agents 35
Hybridoma Hybridoma TechnologyTechnology
Biotherapy Agents 36
Monoclonal Monoclonal AntibodiesAntibodiesSide Effects
◦arrhythmia ◦capillary leak syndrome◦flu-like syndrome◦hypotension◦myelosuppression◦myalgia◦neuropathic pain ◦infusion related reactions
Nursing Considerations◦May premedicate with Benadryl and Tylenol 30 minutes prior to infusion◦Monitor vital signs◦Monitor for hypersensitivity
Biotherapy Agents 37
Monoclonal Monoclonal AntibodiesAntibodies
Agents IndicationRituxin (Rituximab) Aplastic Anemia, ITP,
PTLDAdalimumab (Humira) RA, Chron’s DiseaseDaclizumab (Zenapax) Transplant rejectionInfliximab (Remicade) Chron’s Disease, GVHDPalivizumab (Synagis) RSVOmalizumab (Xolair) AsthmaMuromomab (OKT3) Transplant rejectionAbatacept (Orencia) JRA, DiabetesNatalizumab (Tysabri) MSEculizumab (Solaris) PNH
Biotherapy Agents 38
RituximabRituximab(Rituxan®)(Rituxan®)
Side Effects◦ Infusion reaction
(may be fatal)◦ Fever, chills◦ Headache◦ Nausea◦ Arthralgia◦ Mucositis◦ Skin reactions
Titrate each infusion
Pre Medicate with an antihistamine and acetaminophen
Monitor for anaphylactic reactions
Biotherapy Agents 39
Tumor Necrosis Factor Tumor Necrosis Factor (TNF)(TNF)TNF is a cytokine
that is involved in the inflammatory process
This can exacerbate autoimmune diseases such as JRA and Chron’s disease
TNF blockers target the effects of TNF
TNF blockers include:◦ Enbrel◦ Remicade◦ Humara
Biotherapy Agents 40
Infliximab Infliximab (Remicade®)(Remicade®)
Side Effects◦ Hypersensitivity
reaction◦ Fever◦ Increased risk of
infection◦ Myalgia and
arthralgia◦ Headache
Titrate infusionMonitor for
hypersensitivityHave emergency
medications available
Biotherapy Agents 41
AdlimumabAdlimumab(Humira®)(Humira®)
Side Effects◦ Injection site
reactions◦ Rash◦ Infection◦ Flu like syndrome
Administered as a sub-q injection
Biotherapy Agents 42
EtanerceptEtanercept(Enbrel®)(Enbrel®)
Indications◦ JRA◦ Psoriasis
Side Effects◦ Infection◦ Injection site
reaction
Administered as a sub-q injection
Biotherapy Agents 43
AbataceptAbatacept(Orencia®)(Orencia®)
Indications◦ RA
Side Effects◦ Upper Respiratory
Infection◦ Urinary Tract
Infection◦ Hypertension◦ Rash
Monitor for infusion related reaction
May cause false elevation in blood sugar
Biotherapy Agents 44
DaclizumabDaclizumab(Zenepax®)(Zenepax®)
Indications◦ Organ rejection◦ MS
Side Effects◦ Hypertension◦ Hypersensitivity
reaction◦ Diarrhea◦ Vomiting
Administer within 4 hours of preparation
Infuse over 15 minutes
Biotherapy Agents 45
NatalizumabNatalizumab(Tysabri®)(Tysabri®)
Indications◦ MS◦ Crohn’s Disease
Side Effects◦ Opportunistic
Infections◦ Progressive multifocal
leukoencephalopathy (PML)
◦ Hepatotoxicty
All patients must be enrolled in the Tysabri® Outreach Unified Commitment to Health (TOUCH) Prescribing Program
Monitor for hypersensitivity
Administer over 1 hour
Biotherapy Agents 46
Hematopoietic Growth Hematopoietic Growth FactorsFactors
Colony stimulating factors that and regulate different levels of the hematopoietic cascade GSCF (Neupogen, Filgrastrim)GM-CSFErythropoetin (Procrit)Thrombopoetin
Route of Administration: IV or SQ
Side Effects◦ Bone Pain◦ Injection site pain◦ First Dose
Phenomenon
Biotherapy Agents 47
Immunosuppressive Immunosuppressive AgentsAgentsImmunosuppressive agents are a group of drugs that slow down the immune response◦Prevent rejection of solid organ
transplants◦Prevent Graft versus Host disease◦Slow down immune response in
the case of autoimmune diseases
Immunosuppressive Agents 48
CyclosporineCyclosporine(Neoral, Sandimmune, Gengraf, Restasis)(Neoral, Sandimmune, Gengraf, Restasis)
Side Effects◦ Hypertension◦ Renal toxicity◦ Tremors◦ Hyperglycemia◦ Allergic Reactions
May have drug-drug interactions
Do not eat grapefruit or drink grapefruit juice
Need to monitor levels
May adhere to plastic tubing Immunosuppressive Agents 49
TacrolimusTacrolimus(Prograf, FK506)(Prograf, FK506)
Side Effects◦ Tremors◦ Headache◦ Hypertension◦ Nausea◦ Renal Toxicity◦ Hepatic Toxicity
Nursing Considerations◦ May need to
monitor blood levels
◦ Avoid Grapefruit and grapefruit juice
◦ Monitor for anaphylaxis
◦ Give oral dose on empty stomach
Immunosuppressive Agents 50
SirolimusSirolimus(Rapamune)(Rapamune)
Side Effects◦ Severe
immunosuppression◦ Hypersensitivity
reactions◦ Peripheral edema◦ Hypertension◦ Renal toxicity◦ Interstitial lung
disease
Avoid grapefruit and grapefruit juice
Oral solution should be mixed in water or orange juice
Monitor levels
Immunosuppressive Agents 51
ImuranImuran(Azathioprine)(Azathioprine)
Side Effects◦ Fever, chills◦ Arthralgias◦ Nausea, vomiting◦ Anorexia, diarrhea◦ Alopecia◦ Bone marrow
suppression
Reduced dose may be used with Allopurinol
Administer with food
Immunosuppressive Agents 52
Mycophenolate MofetilMycophenolate Mofetil(Cellcept®)(Cellcept®)
Side Effects◦ Hypertension◦ Dizziness◦ Diarrhea◦ Associated with
Progressive Multifocal Leukoencephalopathy (PML)
Spontaneous abortions have occurred after exposure to cellcept during pregnancy
Administer oral doses on an empty stomach
Biotherapy Agents 53
Questions?Questions?