Chemotherapy and Biotherapy Agents.ppt

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					Chemotherapy and
Biotherapy Agents
 Atthe completion of this session the
 participant will be able to:
 ◦ Identify common side effects for individual
 ◦ Describe nursing interventions for
   chemotherapy and biotherapy medications
 ◦ Discuss the principles of chemotherapy

                             Chemotherapy Agents   2

       Chemotherapy Agents   3
    Agent: Cyclophosphamide
    (Cytoxan®; Neosar®)

Indications                                Route: IV
 Autoimmune Diseases
                                           Special Considerations
                                            ◦ Administration of high
 Renal Disease
                                              doses of cyclophosphamide
                                              should be preceded &
Side Effects:                                 followed by high volume IV
 Common                                      hydration and mesna
    ◦   Anorexia
                                            ◦ WBC nadir between 9-15
    ◦   Nausea, vomiting
                                              days (recovery by 21 days)
    ◦   Myelosuppression
    ◦   Alopecia
    ◦   Gonadal dysfunction/sterility
   Occasional
    ◦ Hemorrhagic cystitis
    ◦ SIADH

                                               Chemotherapy Agents         4
Cyclophosphamide (Cytoxan®;
   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
    ◦   Administer over 15-60 minutes to avoid unpleasant side effects
        such as lightheadedness, tearing, nausea, perioral numbness, itchy
    ◦   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
MESNA (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

                                          Chemotherapy Agents        6
    Agent: Vincristine Sulfate

Indications:                             Route: IV
 ITP                                    Special Considerations
                                           ◦ Refrigerate and protect from light
Side Effects                                 for continuous infusions
                                           ◦ Liver dysfunction or concomitant
 Common                                     radiation therapy to the liver may
    ◦ Local ulceration if extravasated       enhance toxicity
    ◦ Hair loss                            ◦ Should have special overwrap label
                                             that bears the statement, “Fatal if
    ◦ Loss of deep tendon reflexes           given intrathecally. For intravenous
   Occasional                               injection only.”
                                           ◦ Infants may have difficulty sucking
    ◦ Constipation                           because of jaw pain
    ◦ 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

                                               Chemotherapy Agents                  7
    Agent: Vincristine (Oncovin®)
   Nursing Considerations:
    ◦ Vesicant – severe tissue damage if extravasation
    ◦ Stool softeners may be given prophylactically,
      or for constipation

                                 Chemotherapy Agents     8
    Daunorubicin (Daunomycin, Cerubidine®)
    & Doxorubicin
    (Adriamycin PFS®; Adriamycin RDF®; Rubex®)
Indications:                                Special Considerations
     ◦ PTLD                                   ◦ Cardiac studies with
                                                echocardiogram or multiple-gated
Route: IV                                       arteriography (MUGA) scan should
Side Effects                                    be done periodically to monitor
                                                cardiac function – must have
    Common                                     acceptable cardiac ejection fraction
     ◦   Subclinical cardiac arrhythmias      ◦ Monitor cumulative dose
     ◦   Nausea, vomiting                     ◦ Dose adjustments for renal/hepatic
     ◦   Local ulceration if extravasated       abnormalities
     ◦   Pink or red color to urine           ◦ Radiation recall
     ◦   Myelosuppression                     ◦ Leukocyte and platelet nadirs occur
                                                in 5-10 days; recover within 3
     ◦   Alopecia                               weeks
    Occasional
     ◦ Cardiomyopathy

                                                 Chemotherapy Agents                   9
Daunorubicin (Daunomycin, Cerubidine®)
& Doxorubicin
(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
Mitoxantrone Hydrochloride
  Indications: MS
  Route: IV
  Common Side Effects
    ◦ Bone marrow suppression. Nadir in 9-10
    ◦ Cardiac toxicity including CHF and
      decreased left ventricular EF. Toxicity
      increased if pt. has cardiac history or
      mediastinal XRT.
    ◦ Hepatoxicity with some reports of

                                         Chemotherapy Agents   11
   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
    ◦ Blue in color
         will turn urine green
         Potentially will turn skin a blue/green color

                                                    Chemotherapy Agents   12
 Agent: Methotrexate
 (Rheumatrex®; Trexall™ )

                            Side Effects (All Dose Related):
                                l   Nausea, vomiting
 Chron’s Disease               l   Transaminase and
 JRA                               bilirubin elevations
                                l   Rash/photosensitivit
 Autoimmune Diseases               y
Routes:                         l   Myelosuppression
 IV, IM, SQ, PO                l   Mucositis/GI

                                    Chemotherapy Agents        13
Agent: Methotrexate
(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
(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

                                         Chemotherapy Agents        15
    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 (6-MP)

Indications:                     Special Considerations
  ◦ ITP                            ◦ Reduce oral dose by
  ◦ Autoimmune Hemolytic             75% if given with
  ◦ Inflammatory Bowel Disease
                                   ◦ May need to hold or
Route: PO
                                     reduce dose for
Common Side Effects                  myelosuppression
  ◦ Myelosuppression               ◦ May need to monitor

                                     Chemotherapy Agents   17
Agent: Mercaptopurine (6-MP)

    Nursing Considerations:
     ◦ Take daily dose at one
       time, preferably at
       bedtime on an empty
       Do not take with milk
     ◦ Teach caregivers to wear
       gloves when handling

                                Chemotherapy Agents   18
    Agent: Pentostatin (Nipent®)
   Indications: GvHD                  ¢   Special Considerations:
   Route: IV                              l    Combined use with
   Common Side Effects                         Fludarabine may lead to
    ◦ Central nervous system: Fever,            severe, even fatal,
      chills, headache                          pulmonary toxicity
    ◦ Dermatologic: rashes
    ◦ Gastrointestinal:
    ◦ Hepatotoxicity
    ◦ Renal toxicity
    ◦ Myelosuppression
    ◦ Respiratory: pulmonary edema

                                               Chemotherapy Agents        19
Agent: Pentostatin (Nipent®)

   Nursing Considerations:
    ◦ Monitor CBC and LFTs
    ◦ Anti-emetics
    ◦ Monitor respiratory and cardiac status

                              Chemotherapy Agents   20
Agent: Hydroxyurea
(Droxia™; Hydrea®)

    Indications:
     ◦ Sickle Cell Disease

    Route: PO

    Common Side Effects
     ◦ Myelosuppression with rapid drop in WBC

                                 Chemotherapy Agents   21
Agent: Hydroxyurea
(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
 Corticosteroids

                    Chemotherapy Agents   23
    Agent: Corticosteroids
    (Prednisone, Dexamethasone, Hydrocortisone, Methyl-prednisolone)

Indications:                             Routes: PO or IV
     ◦ Autoimmune Diseases
     ◦ Nausea/vomiting                   Special Considerations
     ◦ GVHD treatment                      ◦ May mask fever or
Side Effects                                 infection
 Common
  ◦ Hyperphagia
  ◦ Immunosuppression
  ◦ Personality changes
  ◦ Cushing syndrome
  ◦ Pituitary-adrenal axis suppression
  ◦ Acne
 Occasional
  ◦ hyperglycemia

                                              Chemotherapy Agents      24
Agent: Corticosteroids
(Prednisone, Dexamethasone, Hydrocortisone, Methyl-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
 Definition:
 ◦ The term biotherapy includes
   agents derived from biological
   sources and/or use of agents
   that affect biological responses

                       Biotherapy Agents   26
    Biotherapy Mechanism
    of Action
    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

                                      Biotherapy Agents          27

     Biotherapy Agents   28
Cytokines: Interferons

   Indications              Side Effects
    ◦ HLH                     ◦Pruritus
    ◦ PTLD                    ◦Hepatoxicity
   Side Effects              ◦Myalgia
    ◦ Arrhythmia
    ◦ Flu-like syndrome       ◦Arthralgia
    ◦ Desquamation

                                Biotherapy Agents   29
    Cytokines: Interferons

   Nursing                     ◦Assess respiratory
    Considerations              ◦status
    ◦Premedicate with           ◦Monitor daily weights
    Acetaminophen               ◦and intake and output,
    ◦Continuous cardiac         ◦assess skin and mental
    ◦monitoring during the      ◦status frequently
    ◦infusion                   ◦Have emergency drugs
    ◦Monitor vital signs        ◦available
    ◦Assess for chest pain or

                                  Biotherapy Agents       30
Intravenous Immunoglobulin
(Gammagard, Sandoglobulin, Gamimmune)

   Indications                  Side Effects
    ◦ ITP                         ◦   Headache
    ◦ JRA                         ◦   Flushing
    ◦ Autoimmune                  ◦   Chills
      Diseases                    ◦   Myalgia
    ◦ Nephrotic                   ◦   Tachycardia
      syndrome                    ◦   Nausea
                                  ◦   Hypotension

                                      Biotherapy Agents   31
Intravenous Immunoglobulin
    Nursing Considerations
     ◦ May premedication with
       Acetaminophen and antihistamines
     ◦ Titrate rate slowly to prevent
       infusion reaction
     ◦ Monitor vital signs during and after

                              Biotherapy Agents   32
RH (D) Immune Globulin
(Win Rho)
   Indication        Administration
    ◦ ITP              ◦ Usually IVP over 3 to
   Side Effects         5 minutes
    ◦ Headache
    ◦ Fever
    ◦ Chills

                       Biotherapy Agents         33
Anti Thymocyte Globulin (ATG)
   Indications                 Nursing
    ◦ Aplastic Anemia            Consideration
    ◦ PNH
                                 ◦ May need
   Side Effects                   premedication with
    ◦   Fever                      acetaminophen,
    ◦   Chills                     antihistamine, and
    ◦   Flu-like syndrome          hydrocortisone
    ◦   Nausea                   ◦ Monitor vital signs
    ◦   Anaphylaxis                during infusion
    ◦   Serum Sickness           ◦ Infuse over 4 to 8
    ◦   Hypotension                hours, avoid rapid
    ◦   Flank or back pain         administration

                                    Biotherapy Agents    34
Monoclonal Antibodies
 A 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 Technology

      Biotherapy Agents   36
Monoclonal Antibodies
   Side Effects                     Nursing
    ◦arrhythmia                       Considerations
    ◦capillary leak syndrome          ◦May premedicate with
    ◦flu-like syndrome                 Benadryl and Tylenol
    ◦hypotension                       30 minutes prior
    ◦myelosuppression                  to infusion
    ◦myalgia                          ◦Monitor vital signs
    ◦neuropathic pain                 ◦Monitor for
    ◦infusion related reactions        hypersensitivity

                                       Biotherapy Agents      37
Monoclonal Antibodies
 Agents                  Indication
 Rituxin (Rituximab)     Aplastic Anemia, ITP, PTLD
 Adalimumab (Humira)     RA, Chron’s Disease
 Daclizumab (Zenapax)    Transplant rejection
 Infliximab (Remicade)   Chron’s Disease, GVHD
 Palivizumab (Synagis)   RSV
 Omalizumab (Xolair)     Asthma
 Muromomab (OKT3)        Transplant rejection
 Abatacept (Orencia)     JRA, Diabetes
 Natalizumab (Tysabri)   MS
 Eculizumab (Solaris)    PNH

                                  Biotherapy Agents   38

   Side Effects                  Titrate each infusion
    ◦ Infusion reaction (may      Pre Medicate with an
      be fatal)                    antihistamine and
    ◦ Fever, chills                acetaminophen
    ◦ Headache                    Monitor for anaphylactic
    ◦ Nausea
    ◦ Arthralgia
    ◦ Mucositis
    ◦ Skin reactions

                                   Biotherapy Agents          39
Tumor Necrosis Factor (TNF)
   TNF is a cytokine that is      TNF blockers target
    involved in the                 the effects of TNF
    inflammatory process
                                   TNF blockers
   This can exacerbate
    autoimmune diseases             include:
    such as JRA and Chron’s         ◦ Enbrel
    disease                         ◦ Remicade
                                    ◦ Humara

                                    Biotherapy Agents     40

   Side Effects                  Titrate infusion
    ◦ Hypersensitivity            Monitor for
      reaction                     hypersensitivity
    ◦ Fever
                                  Have emergency
    ◦ Increased risk of
                                   medications available
    ◦ Myalgia and arthralgia
    ◦ Headache

                                   Biotherapy Agents       41

   Side Effects                      Administered as a
    ◦   Injection site reactions       sub-q injection
    ◦   Rash
    ◦   Infection
    ◦   Flu like syndrome

                                       Biotherapy Agents   42

Indications                       Administered as a
   ◦ JRA                           sub-q injection
   ◦ Psoriasis
Side Effects
   ◦ Infection
   ◦ Injection site reaction

                                   Biotherapy Agents   43

Indications                 Monitor for infusion
   ◦   RA                    related reaction
Side Effects                May cause false
   ◦ Upper Respiratory       elevation in blood
     Infection               sugar
   ◦ Urinary Tract
   ◦ Hypertension
   ◦ Rash

                             Biotherapy Agents      44

Indications               Administer within 4
  ◦ Organ rejection        hours of preparation
  ◦ MS                    Infuse over 15
Side Effects               minutes
  ◦ Hypertension
  ◦ Hypersensitivity
  ◦ Diarrhea
  ◦ Vomiting

                           Biotherapy Agents      45

Indications                        All patients must be
   ◦ MS                             enrolled in the Tysabri®
                                    Outreach Unified
   ◦ Crohn’s Disease
                                    Commitment to Health
Side Effects                        (TOUCH) Prescribing
   ◦ Opportunistic Infections       Program
   ◦ Progressive multifocal        Monitor for
   ◦ Hepatotoxicty                 Administer over 1 hour

                                     Biotherapy Agents         46
 Hematopoietic Growth Factors
Colony stimulating factors       Route of
that and regulate different       Administration: IV or
levels of the hematopoietic
GSCF (Neupogen,
                                 Side Effects
Filgrastrim)                      ◦ Bone Pain
GM-CSF                           ◦ Injection site pain
Erythropoetin (Procrit)          ◦ First Dose

                                  Biotherapy Agents       47
Immunosuppressive Agents
 Immunosuppressive  agents are
 a group of drugs that slow
 down the immune response
 ◦ Prevent rejection of solid organ
 ◦ Prevent Graft versus Host disease
 ◦ Slow down immune response in the
   case of autoimmune diseases

                         Immunosuppressive Agents   48
(Neoral, Sandimmune, Gengraf, Restasis)

   Side Effects                       May have drug-drug
    ◦   Hypertension                    interactions
    ◦   Renal toxicity                 Do not eat grapefruit
    ◦   Tremors                         or drink grapefruit
    ◦   Hyperglycemia                   juice
    ◦   Allergic Reactions             Need to monitor
                                       May adhere to plastic

                                          Immunosuppressive Agents   49
(Prograf, FK506)

   Side Effects              Nursing
    ◦   Tremors                Considerations
    ◦   Headache               ◦ May need to monitor
    ◦   Hypertension             blood levels
    ◦   Nausea                 ◦ Avoid Grapefruit and
    ◦   Renal Toxicity           grapefruit juice
    ◦   Hepatic Toxicity       ◦ Monitor for
                               ◦ Give oral dose on
                                 empty stomach

                               Immunosuppressive Agents   50

   Side Effects                     Avoid grapefruit and
    ◦ Severe                          grapefruit juice
      immunosuppression              Oral solution should
    ◦ Hypersensitivity                be mixed in water or
                                      orange juice
    ◦ Peripheral edema
                                     Monitor levels
    ◦ Hypertension
    ◦ Renal toxicity
    ◦ Interstitial lung disease

                                       Immunosuppressive Agents   51

   Side Effects                Reduced dose may
    ◦   Fever, chills            be used with
    ◦   Arthralgias              Allopurinol
    ◦   Nausea, vomiting        Administer with food
    ◦   Anorexia, diarrhea
    ◦   Alopecia
    ◦   Bone marrow

                                 Immunosuppressive Agents   52
    Mycophenolate Mofetil

   Side Effects                    Spontaneous
    ◦   Hypertension                 abortions have
    ◦   Dizziness                    occurred after
    ◦   Diarrhea                     exposure to cellcept
    ◦   Associated with              during pregnancy
        Progressive Multifocal      Administer oral
        Leukoencephalopathy          doses on an empty

                                     Biotherapy Agents      53

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