Chemotherapy and Biotherapy Agents

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

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)


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


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!


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.


Agent: Vincristine Agent: Vincristine ((Oncovin®Oncovin®))

Nursing Considerations:◦Vesicant – severe tissue damage if

extravasation occurs ◦Stool softeners may be given

prophylactically, or for constipation


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


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


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.


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


Agent: MethotrexateAgent: Methotrexate (Rheumatrex®; Trexall™ )(Rheumatrex®; Trexall™ )

Indications:Chron’s DiseaseJRAAutoimmune

DiseasesRoutes: IV, IM, SQ, PO


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


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


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


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


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


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


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


Agent: HydroxyureaAgent: Hydroxyurea ((Droxia™; Hydrea®Droxia™; Hydrea®))

Indications:◦ Sickle Cell Disease

Route: PO

Common Side Effects◦ Myelosuppression with rapid drop in

WBC


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)


HormonesHormonesCorticosteroids


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


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


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 BIOTHERAPY AGENTSAGENTS


Cytokines: InterferonsCytokines: InterferonsIndications

◦HLH◦PTLD

Side Effects◦Arrhythmia◦Flu-like

syndrome◦Desquamation

Side Effects◦Pruritus◦Hepatoxicity◦Myalgia◦Arthralgia


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


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


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


Indication◦ ITP

Side Effects◦ Headache◦ Fever◦ Chills

Administration◦ Usually IVP over 3

to 5 minutes


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


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


Hybridoma Hybridoma TechnologyTechnology


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


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


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


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


Infliximab Infliximab (Remicade®)(Remicade®)

Side Effects◦ Hypersensitivity

reaction◦ Fever◦ Increased risk of

infection◦ Myalgia and

arthralgia◦ Headache

Titrate infusionMonitor for

hypersensitivityHave emergency

medications available


AdlimumabAdlimumab(Humira®)(Humira®)

Side Effects◦ Injection site

reactions◦ Rash◦ Infection◦ Flu like syndrome

Administered as a sub-q injection


EtanerceptEtanercept(Enbrel®)(Enbrel®)

Indications◦ JRA◦ Psoriasis

Side Effects◦ Infection◦ Injection site

reaction

Administered as a sub-q injection


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


DaclizumabDaclizumab(Zenepax®)(Zenepax®)

Indications◦ Organ rejection◦ MS

Side Effects◦ Hypertension◦ Hypersensitivity

reaction◦ Diarrhea◦ Vomiting

Administer within 4 hours of preparation

Infuse over 15 minutes


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


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


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


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


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


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


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Chemotherapy and Biotherapy Agents