Wednesday, April 4, 2012

Antineoplastic drugs


ALKYLATING AGENTS

·         Alters DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross-linking DNA strands
·         Indication:
o    Target malignancies: Hodgkin’s disease, Lymphosarcoma, Lung cancer, Adenocarcinoma of lung and breast, Leukemias, Multiple Myeloma
·         Contraindication:
o    Radiotherapy and chemotherapy within 1 month, thrombocytopenia, recent smallpox vaccination

Example:
busulfan (Myleran®)
carboplatin (Paraplatin®)
chlorambucil (Leukeran®)
cisplatin (Platinol®)
cyclophosphamide (Cytoxan®)
dacarbazine (DTIC-Dome®)
ifosfamide (Ifex®)
melphalan (Alkeran®)
thiotepa (Thioplex®)
mechlorethamine (Mustargen®)

Side Effects:

·         Anorexia
·         Nausea and vomiting
·         Stomatitis
·         Skin rash
·         Chlorambucil (Leukeran) and Mechlorathamine (Mustargen): hyperuricemia and gonadal suppression
·         Busulfan (Myleran): renal failure and pulmonary fibrosis
·         Cyclophosphamide (Cytoxan) and Ifosfamide (Ifex): renal failure, hemorrhagic cystitis, liver dysfunction
§  *administer Mesna (Mesnex) with ifosfamide to reduce potential of cystitis
·         Cisplatin (Platinol): renal toxicity and gonadal suppression
§   *administer amifostine (Ethyol) before cisplatin to reduce renal side effects

Nursing Considerations:

ü  Maintain good hydration.
ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.
ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.
ü  Monitor WBC, BUN, liver enzymes.
ü  Assess for infection.
ü  Encourage daily fluid intake of 2 to 3 L during treatment and monitor for signs of hemorrhagic cystitis (during cyclophosphamide and ifosfamide therapy).
ü  Assess lungs for fibrotic (coarse, loud) rales (during busulfan therapy).
ü  Assess for dizziness, tinnitus, hearing loss, incoordination, and numbing or tingling of extremities (during cisplatin therapy)
ü  Monitor IV site for inflammation and phlebitis.
Instruct patient about good oral hygiene



NITROSOUREAS

·         Similar to alkylating- agents; cross the blood-brain barrier
·         Indication:
o    Target malignancies: colorectal cancer, gastric cancer, skin cancer, pancreatic cancer
·         Contraindication:
o    Hypersensitivity

Example:
carmustine (BiCNU®, Gliadel®)
lomustine (CeeNU®)
semustine (methyl CCNU®)
streptozocin (Zanosar®)

Side Effects:

·         Nausea and vomiting
·         Delayed cumulative myelosuppression, especially thrombocytopenia

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.
ü  Monitor CBC, uric acid and electrolyte levels.
ü  Maintain good hydration.
ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.
ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.
ü  Instruct client to report signs of infection and bleeding.

TOPOISOMERASE I INHIBITORS

·         Introduces breaks in the DNA strand by binding to enzyme topoisomerase I, preventing cells from dividing
·         Indication:
o    Target malignancies: Colon cancer, lung cancer, ovarian cancer
·         Contraindication:
o    Hypersensitivity, concurrent administration of irinotecan with irradiation, chronic inflammatory bowel disease and bowel obstruction

Example:
irinotecan (Camptosar®)
topotecan (Hycamtin®)

Side Effects:

·         Bone marrow suppression
·         Nausea and vomiting
·         Irinotecan (Camptosar): diarrhea
·         Hepatotoxicity

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.
ü  Maintain good hydration.
ü  Monitor CBC.
ü  Assess results of liver function studies.
ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.
ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.
ü  Instruct patient to report signs of infection and bleeding.



ANTIMETABOLITES

·         Interferes with the biosynthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis
·         Indication:
o    Target malignancies: leukemia, osteosarcoma, colorectal cancer, breast cancer, gastric cancer, pancreatic cancer
·         Contraindication:
o    Marked bone marrow depression, anemia, psoriasis patients with severe hepatic disorders, alcoholism or alcoholic liver disease, severe renal impairment, diarrhea and ulcerative colitis

Example:
cytarabine (ara-C, Cytosar®)
capecitabine (Xeloda®)
5- fluorouracil (Adrucil, 5-FU®)
fluxoridine (FUDR®)
edatrexate fludarabine (Fludara®)
hydroxyurea (Hydrea®)
cladribine (Leustatin®)
6-Mercaptopurine (Purinethol®)
methotrexate (Folex®)
6-thioguanine
pentostatin (Nipent®)

Side Effects:

·         Nausea and vomiting
·         Diarrhea
·         Bone marrow suppression
·         Alopecia
·         Stomatitis
·         Cytarabine (Cytosar): hyperuricemia, hepatotoxicity
·         5-fluorouracil (Adrucil): phototoxicity reaction and cerebellar dysfunction
·         Methotrexate (Folex): hyperuricemia, photosensitivity, hepatotoxicity, hematological, gastrointestinal and skin toxicity
§  *Administer leucovorin as prescribed to prevent toxicity
·         6-Mercaptopurine (Purinethol): hyperuricemia and hepatotoxicity

Nursing Considerations:

ü  Monitor vital signs and temperature for signs of infection.
ü  Monitor CBC, WBC differential count, BUN, uric acid and  creatinine.
ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.
ü  Maintain good hydration.
ü  Monitor renal function studies (especially during methotrexate therapy).
ü  Assess for photosensitivity and monitor for cerebellar dysfunction (during 5-Fluorouracil therapy).
ü  Assess oral mucus membranes and treat ulcers prn.
ü  Instruct patient to use sunscreen and protective clothing.
ü  Teach care for hair loss.

ANTITUMOR ANTIBIOTICS

·         Interferes with DNA synthesis by binding DNA; prevents RNA synthesis
·         Indication:


o    Target malignancies: Leukemias, Neuroblastoma, Nephroblastoma, breast caner, ovarian cancer, thyroid cancer and lung cancer

·         Contraindication:
o    Lung disease, renal and hepatic disorders, ulcers, and gastrointestinal disease

Example:
bleomycin (Blenoxane®)
dactinomycin (Actinomycin D®, Cosmegan®)
daunorubicin (DaunoXome®, Cerubidine®)
doxorubicin (Adriamycin®)
idarubicin (Idamycin®)
mitomycin (Mutamycin®)
mitoxantrone (Novantorone®)
plicamycin (Mithracin®)
valrubicin (Valstar®)

Side Effects:

·         Bone marrow suppression
·         Nausea and vomiting
·         Alopecia
·         Anorexia
·         Vesication
·         Daunorubicin (DaunoXome), Idarubicin (Idamycin) and Doxorubicin (Adriamycin): cardiotoxicity
·         Bleomycin (Blenoxane): pulmonary toxicity
·         Plicamycin (Mithracin): affects bleeding time

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.
ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.
ü  Monitor ECG; assess for arrhythmias, gallops and CHF (during dactinomycin [Actinomycin D], daunorubicin [DaunoXome, Cerubidine], Doxorubicin [Adriamycin] therapy.
ü  Monitor CBC with differential, BUN and uric acid.
ü  Assess pulmonary function studies (during Bleomycin [Blenoxane] therapy).
ü  Assess for bleeding; check stool for occult blood. Avoid use of aspirin, anticoagulants and thrombolytic agents (during Plicamycin [Mithracin] therapy).
ü  May see delayed cardiotoxicity months to years after administration of doxorubicin.
ü  To prevent heart failure related to doxorubicin, do not administer more than 550 mg/min a lifetime
ü  Evaluate hydration and nutrition status.
ü  Monitor IV site for vesication.
ü  Instruct oral care for stomatitis.
ü  Teach care for hair loss.

MITOTIC SPINDLE POISONS (Mitotic Inhibitors, Vinca Alkaloids)

·         Arrests metaphase by inhibiting mitotic tubular formation (spindle); inhibit DNA and protein synthesis
·         Indication:
o    Target malignancies: Leukemias, Hodgkin’s and Non-Hodgkin’s lymphomas,lymphocytic and histocytic lymphoma, neuroblastoma, nephroblastoma, Kaposi’s sarcoma, advanced testicular cancer and unresponsive breast cancer 
·         Contraindication: Cardiovascular, hepatic, nerve, and muscle disease


Example:
Plant Alkaloids
o    etoposide (VePesid®)
o    teniposide (Vumon®)
o    vinblastine (Velban®)
o    vincristine (Oncovin®)
o    vinorelbine (Navelbine®)
Taxanes
o    paclitaxel (Nov-Onxol®, Taxol®, Paclitaxel Novaplus®)
o    docetaxel (Txotere®)

Side Effects:

·         Alopecia
·         Hoarseness
·         Ptosis
·         Anorexia, nausea and vomiting
·         Stomatitis
·         Hyperuricemia
·         Constipation, paralytic ileus
·         Vinblastine(Velban®): bone marrow suppression
·         Vincristine (Oncovin®): Neorotoxicity/ neuropathies
·         Taxanes: Bradycardia, hypersensitivity reactions and neuropathies
·         Areflexia

Nursing Considerations:

ü  Assess vital signs.
ü  Monitor CBC with differential.
ü  Assess neuromuscular function.
ü  Evaluate gastrointestinal function; manage constipation.
ü  Administer antiemetics prn as ordered.
ü  Monitor eyes for ptosis; monitor for hoarseness.
ü  Teach ways to manage hair loss.

HORMONAL AGENTS

·         Binds to hormone receptor sites that alter cellular growth; block binding of estrogens to receptor sites (antiestrogens); inhibit RNA synthesis
·         Indication:
o    Target malignancies: Advanced breast and prostate cancer
·         Contraindication:
o    Pregnancy, hepatic and renal disease, osteoporosis, hypertension, hypercholesterolemia

Example:
diethylstilbestrol (DES, Stilphostrol®)
letrozole (Femara®)
raloxifene (Evista®)
tamoxifen (Nolvadex®)
goserilin acetate (Zoladex®)
Testosterone
medroxyprogesterone (Depo- Provera®)
asparaginase (Elspar®)
mitotane (Lysodren®)
megestrol acetate (Megace®)

Side Effects:

·         Hypercalcemia
·         Hypertension




·         Jaundice
·         Increased appetite, weight gain
·         Masculinization
·         Feminization
·         Sodium and fluid retention
·         Hot flashes
·         Vaginal dryness
·         Nausea and vomiting
·         Asparaginase (Eslpar): impaired pancreatic function
·         Mitotane (Lysodren): Hemorrhagic cystitis, hyperuricemia and hypercholesterolemia
·         Tamoxifen (Nolvadex): Edema, hypercalcemia, elevated cholesterol and triglyceride levels, decreased effects of estrogen
·         Diethylstilbestrol (DES, Stilphostrol):
§  Female: Fluid retention, feminization and uterine bleeding
§  Male: impotence and masculinization

Nursing Considerations:

ü  Monitor vital signs.
ü  Administer diuretics prn as ordered.
ü  Monitor for bleeding.
ü  Monitor electrolytes, uric acid and cholesterol levels.
ü  Monitor pancreatic function.
ü  Explain reason for sex characteristic alterations.
Provide patient teachings for managing hot flashes





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