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Chemotherapy and Biotherapy Agents

Chemotherapy and Biotherapy Agents. Objectives. At 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

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Chemotherapy and Biotherapy Agents

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  1. Chemotherapy and Biotherapy Agents

  2. Objectives • At 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

  3. Chemotherapy Agents Chemotherapy Agents

  4. Agent: Cyclophosphamide(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

  5. Agent: Cyclophosphamide(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

  6. 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 • MUST GIVE DRUG ON SCHEDULE! Chemotherapy Agents

  7. Agent: VincristineSulfate(Oncovin®) Indications: • ITP Side Effects • Common • Local ulceration if extravasated • Hair loss • Loss of deep tendon reflexes • Occasional • Constipation • Jaw pain Route: IV Special 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

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

  9. Agents: Daunorubicin(Daunomycin, Cerubidine®)& Doxorubicin (Adriamycin PFS®; Adriamycin RDF®; Rubex®) Indications: • PTLD Route: IV Side 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

  10. Agents: 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

  11. Agent: Mitoxantrone Hydrochloride(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

  12. Agent: Mitoxantrone Hydrochloride(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

  13. Agent: Methotrexate(Rheumatrex®; Trexall™ ) Indications: • Chron’s Disease • JRA • Autoimmune Diseases Routes: • IV, IM, SQ, PO Side Effects (All Dose Related): • Nausea, vomiting • Transaminase and bilirubin elevations • Rash/photosensitivity • Myelosuppression • Mucositis/GI ulceration Chemotherapy Agents

  14. 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

  15. 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 methotrexate Chemotherapy Agents

  16. LEUCOVORIN & NaHC03 • 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

  17. Agent: Mercaptopurine(6-MP) (Purinethol®) Indications: • ITP • Autoimmune Hemolytic Anemia • Inflammatory Bowel Disease Route: PO Common 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

  18. Agent: Mercaptopurine(6-MP)(Purinethol®) • 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

  19. Agent: Pentostatin(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 • Special Considerations: • Combined use with Fludarabine may lead to severe, even fatal, pulmonary toxicity Chemotherapy Agents

  20. Agent: Pentostatin(Nipent®) • Nursing Considerations: • Monitor CBC and LFTs • Anti-emetics • Monitor respiratory and cardiac status Chemotherapy Agents

  21. Agent: Hydroxyurea(Droxia™; Hydrea®) • Indications: • Sickle Cell Disease • Route: PO • Common Side Effects • Myelosuppression with rapid drop in WBC Chemotherapy Agents

  22. 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

  23. Hormones • Corticosteroids Chemotherapy Agents

  24. Agent: Corticosteroids(Prednisone, Dexamethasone, Hydrocortisone, Methyl-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 IV Special Considerations • May mask fever or infection Chemotherapy Agents

  25. 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

  26. Biotherapy • Definition: • The term biotherapy includes agents derived from biological sources and/or use of agents that affect biological responses Biotherapy Agents

  27. 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 transformation) Biotherapy Agents

  28. Biotherapy Agents Biotherapy Agents

  29. Cytokines: Interferons • Indications • HLH • PTLD • Side Effects • Arrhythmia • Flu-like syndrome • Desquamation • Side Effects • Pruritus • Hepatoxicity • Myalgia • Arthralgia Biotherapy Agents

  30. Cytokines: Interferons • Nursing 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

  31. Intravenous Immunoglobulin(Gammagard, Sandoglobulin, Gamimmune) • Indications • ITP • JRA • Autoimmune Diseases • Nephrotic syndrome • Side Effects • Headache • Flushing • Chills • Myalgia • Tachycardia • Nausea • Hypotension Biotherapy Agents

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

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

  34. Anti Thymocyte Globulin (ATG) • 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

  35. 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

  36. Hybridoma Technology Biotherapy Agents

  37. Monoclonal Antibodies • Side 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

  38. Monoclonal Antibodies Biotherapy Agents

  39. Rituximab(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

  40. Tumor Necrosis Factor (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

  41. Infliximab(Remicade®) • Side Effects • Hypersensitivity reaction • Fever • Increased risk of infection • Myalgia and arthralgia • Headache • Titrate infusion • Monitor for hypersensitivity • Have emergency medications available Biotherapy Agents

  42. Adlimumab(Humira®) • Side Effects • Injection site reactions • Rash • Infection • Flu like syndrome • Administered as a sub-q injection Biotherapy Agents

  43. Etanercept(Enbrel®) Indications • JRA • Psoriasis Side Effects • Infection • Injection site reaction • Administered as a sub-q injection Biotherapy Agents

  44. Abatacept(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

  45. Daclizumab(Zenepax®) Indications • Organ rejection • MS Side Effects • Hypertension • Hypersensitivity reaction • Diarrhea • Vomiting • Administer within 4 hours of preparation • Infuse over 15 minutes Biotherapy Agents

  46. Natalizumab(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

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

  48. Immunosuppressive Agents • Immunosuppressive 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

  49. Cyclosporine(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

  50. Tacrolimus(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

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