ANTILIPEMIC MEDICATIONS

BILE SEQUESTERING DRUGS

·         Combines with bile acids to form an insoluble compound excreted in the stool

·         Indication:

o    Patient s unable to lower their LDL level through diet alone or with statin therapy.

·         Contraindication:

o    Should not be used as the only therapy in patients with elevated triglycerides (may raise triglyceride levels)

Example:

cholestyramine (Questran®)

colesevelam (Welchol®)

colestipol (Colestid®)

Side Effects:

·         Constipation

·         Peptic ulcer

Nursing Considerations:

ü  Cholestyramine-mix thoroughly in juice or water before administration

ü  Monitor patient for side effects.

ü  Provide patient teaching. Medication should be followed by sufficient fluid intake.

ü  May bind with thiazides, digoxin, warfarin and some antibiotics.

FIBRIC ACID DERIVATIVES

·         Lower triglycerides and raise HDL (good cholesterol)

·         Indication:

o    To reduce the risk of heart attack in patients with coronary artery disease who have low LDL, low HDL, high triglycerides

·         Contraindication:

o    Severe hepatic and renal disease, gallbladder disease, primary biliary cirrhosis, hypersensitivity

Example:

fenofibrate (Tricor®)

gemfibrozil (Lopid®)

Side Effects:

Gemfibrozil:

·         Upset stomach, nausea and vomiting

·         Abdominal pain

·         Increased risk for gallstones

·         Can interact with anticoagulants causing bleeding

Fenofibrate:

·         Rash

·         Stomach upset

·         Risk for gallstones

·         Hepatitis

·         Myositis

Nursing Considerations:

ü  Monitor patients liver function tests and WBC counts.

ü  Check triglycerides and cholesterol levels to assess for drug effectiveness.

ü  Notify physician for biliary colic. Give analgesic if necessary.

ü  Provide patient teaching:

o    Inform the patient about prescribed drug and side effects.

o    Instruct the patient with DM to monitor blood glucose levels regularly when using gemfibrozil.

HYDROXYMETHYLGLUTARYL-COENZYME A (HMG-CoA) REDUCTASE INHIBITORS (Statins)

·         Lower lipid levels by interfering with cholesterol synthesis. (↓LDL,↑HDL)

·         Indication:

o    To treat hypercholesterolemia and prevent cardiovascular events

·         Contraindication:

o    Do not administer with anticoagulants and gemfibrozil

o    Administer with caution in patients taking immunosuppressive drugs

Example:

atorvastatin (Lipitor®)

lovastatin (Mevacor®)

pravastattin (Pravachol®)

rosuvastatin (Crestor®)

simvastatin (Zocor®)

fluvastatin (Lescol®)

Side Effects:

·         Abdominal pain	·         Constipation
·         Dyspepsia	·         Diarrhea
·         Flatulence	·         Nausea and vomiting
·         Alopecia	·         Pruritus
·         Hepatotoxicity	·         Rhabdomyolysis

Nursing Considerations:

ü  Advise patient to begin or continue lifestyle changes (dietary management, weight control, exercise)

ü  Monitor liver function test results.

ü  Monitor cholesterol levels.

ü  Administer lovastatin with evening meal to enhance absorption.

ü  Administer pravastatin at bedtime (for geriatric patient, one with primary hypercholesterolemia, renal or hepatic dysfunction).

ü  Instruct patient to notify immediately for any signs of inexplained muscles aches.

CHOLESTEROL ABSORPTION INHIBITORS

·         Inhibit absorption of cholesterol and phytosterols at the small intestines

·         Indication:

o    To treat primary cholesterolemia

·         Contraindications:

o    Patients with liver disease or liver enzyme elevations

o    Hypersensitivity to drug components

Example:

ezetimibe (Zetia®)

Side Effects:

·         Abdominal pain	·         Diarrhea
·         Arthralgia	·         Cough
·         Back pain, myalgia	·         Dizziness
·         Chest pain	·         Fatigue
·         Upper respiratory tract infection	·         Headache

Nursing Considerations:

ü  Place patient on a diet for lowering cholesterol before therapy starts and urge patient to continue it during therapy.

ü  Assess liver function tests before therapy starts and periodically thereafter if given with HMG-CoA reductase inhibitor.

NICOTINIC ACID

·         Water- soluble vitamin that decreases triglyceride and apolipoprotein B-100 levels and increases HDL levels

·         Indication:

o    Used as adjunct to lower triglyceride levels in patients with type IV or V hyperlipidemia who are at risk for pancreatitis

·         Contraindication:

o    Patients with liver dysfunction, active peptic ulcer disease, or arterial bleeding

Example:

nicotinic acid (Niacor®)

Side Effects:

·         Flushing	·         Hepatotoxicity
·         Vasodilation	·         Hyperuricemia
·         Gastrointestinal disturbances

Nursing Considerations:

ü  May tahe ASA 30 minutes before to decrease flushing

ü  Monitor patient’s liver function tests.

ü  Assess lipid, triglyceride, cholesterol level.

ü  Monitor for possible drug induced adverse reactions.

ü  Assess patient’s nutrition status periodically.

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/m²  in 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