1. Antineoplastic Agents Pharmacology II NUR 312

2. Principles of Chemotherapy  The goal is to eliminate all malignant cells without excessive destruction of normal cells  Antineoplastic agents do not directly kill tumor cells; they act by interfering with cell reproduction or replication at some point in the cell cycle

3. Principles, con’t  Because chemo drugs are non-selective and affect all cells in the body ass they replicate, there is always some degree of injury to normal cells  Particularly susceptible to chemo are those with a high rate of growth (bone marrow, GI track, epithelium, hair folicles)

4. Principles, con’t  For cells to proliferate, the genetic material DNA must be replicated once every cell cycle

5. Chemotherapy may be used for:  Cure  Control of tumor growth  Palliation  Adjuvant therapy

6. Use of Combination Chemotherapy  The effectiveness of chemo will be more successful if “combination chemo” is given  Different chemo agents, each of which works best at a different point in the cell division cycle, will be used  This provides a better chance of cure, or gives longer remissions if cure not possible

7. MOPP Regimen  For Hodgkins Lymphoma, the MOPP regimen may be used:  M = nitrogen Mustard  O = Oncovin  P = Procarbazine  P = Prednisone

8. Alkylating Agents  Cisplatin (Platinol), Mechlorethamine (Mustargen) and Cytoxan are commonly used agents in this category  Action: substitutes an alkyl chemical structure for a hydrogen atom in the DNA  This results in a cross-linking of each strand of DNA, thus preventing cell division

9. Alkylating Agents, con’t  Effective against lymphomas, leukemias, myelomas, ovarian, testicular, breast, and pancreatic cancers  Cause bone marrow suppression, alteration in mucous membranes, severe N&V, alopecia  Cytoxan can cause hemorrhagic cystitis (give MESNA to protect the bladder)

10. Alkylating Agents, con’t  Can also cause ototoxicity and nephrotoxicity. Be sure the patient is well hydrated before receiving these agents

11. Antimetabolites  These drugs have a structure similar to a necessary building block for the formation of DNA.  These drugs are accepted by the cell as the necessary ingredient for cell growth, but because it is an imposter, it interferes with the production of DNA.

12. Antimetabolites, con’t  Actually interferes with the synthesis of DNA and RNA  Examples: Fluorouracil (5-FU), Methotrexate, and ARA-C  Side effects include bone marrow depression, alteration in mucous membranes, N&V, diarrhea, thrombocytopenia, alopecia.

13. Antimetabolites  Be sure the patient has at least 3 liters/day of fluids to minimize nephrotoxicity  After Methotrexate administration, Leukovorin will be given. This is a form of folic acid that will prevent severe anemia from developing

14. Antibiotic Antineoplastic Agents  These agents actually bind DNA, thus inhibiting DNA and RNA synthesis and therefore inhibiting cell growth.  Sadly, these drugs have great potential to cause irreversible cardiomyopathies.  Doxorubicin (Adriamycin) is used for acute leukemias, soft tissue/bone cancers, lymphomas, and breast cancer

15. Antibiotic Agents, con’t  Adriamycin is also a potent vessicant (will cause tissue necrosis if it infiltrates)  Most dangerous side effect is decreased ejection fraction (normal is 70%). Must do baseline CV assessment prior to beginning Adriamycin (EKG, echo, angiography).  Must reduce the dose of chemo at the first sign of heart failure

16. Antibiotic agents, con’t  Other side effects include stomatitis, alopecia, bone marrow suppression, hepatic impairment.

17. Mitotic Inhibitors  These drugs are also called Vinca-Alkaloids  Work by inhibiting mitosis during cell division  Vinblastine (Velban) and Vincristine (Oncovin) are commonly used agents for ALL, lymphomas, rhabdomyosarcoma)

18. Mitotic Inhibitors, con’t  Neurotoxicity is a specific side effect for this classification of drugs. Peripheral neuropathy, alteration in bowel and bladder tone (including paralytic ileus), headache, tingling of fingers/hands/toes, ataxia.  Constipation is common due to effects on the autonomic nervous system

19. Other Drugs Used to Treat Cancer

20. Hormonal Agents  Used to treat neoplasms that are sensitive to hormonal growth controls of the body.  They interfere with growth-stimulating receptors on target tissues.  Corticosteroids are considered hormonal agents. They retard lymphocytic proliferation, so they help with lymphocytic leukemias and lymphomas.

21. Hormonal Agents, con’t  Corticosteroids also decrease edema associated with tumor growth, especially in or around the brain, spinal cord, and mediastinum. Will decrease cerebral edema.  Androgens (testosterone) may be used to treat advanced breast cancer

22. Hormonal Agents, con’t  Anti-Estrogen drugs (Tamoxifen) block the uptake of estrogen and therefore are good for tumors that contain high concentrations of estrogen receptors  Estrogen may be used to treat androgen- sensitive cancers, such as prostate cancer  Progestins (Depo-Provera and Megace) are used to treat endometrial cancer

23. Administration of Chemo  IV is the most common route (peripheral administration is risky because many drugs are vesicants. Ports/central lines preferred)  Oral  Topical (some skin cancers)  Intrathecal (through Omaya reservoir into ventricle of brain)

24. Administration, con’t  Intracavity (directly into the bladder)  Intra-arterial (for hepatic lesions)

25. Allergic Reactions to Chemo  Be prepared to totally STOP the infusion if any sign of allergic reaction develops. Give NS wide open, monitor rhythm, assure airway  Dyspnea, wheezing, chest tightness, pain, pruritis, urticaria, tachycardia, dizziness, sudden anxiety, inability to speak, hypotension, decreased LOC, flushed skin

26. Safety Issues with Chemo  Nurses must be chemotherapy certified prior to administration of any chemotherapy agents  Double checking the chemo with another nurse is required  Wear special protective gloves, aprons  Special “spill precautions” are taken

27. Safety, con’t  Chemo bags, tubing, any chemo-soiled linens are discarded in special red “hazardous material” bags  Chemo is excreted through urine, stool, and vomitus, so special precautions must be taken to avoid contact exposure  Pregnant health care workers should not administer chemo

28. Special Nursing Care  Patient teaching is a priority  Anticipatory guidance concerning body changes and the expected treatment regimen  Assure hydration to avoid nephrotoxic effects of chemo

29. Nursing Care, con’t  Teach about all side effects and how they can be managed (loss of appetite, mouth sores, fatigue and malaise, bleeding tendencies, constipation and diarrhea, susceptibility to infection)

30. Management of Nausea and Vomiting  Antineoplastic drugs directly stimulate the chemo-receptor trigger zone in the medulla of the brain. This is what causes the nausea and vomiting  Cell death releases many toxins into the system which also stimulates the chemo- receptor trigger zone

31. N&V, con’t  Because patients expect and often experience N&V with the administration of chemo, the higher cortical centers of the brain can stimulate the CTZ to induce vomiting just at the thought of chemo!

32. Drugs that are Helpful for Chemo- Induced N&V  Marinol is a synthetic derivative of marijuana  Zofran and Kytril block serotonin receptors in the CTZ and are among the most effective antiemetics, especially if combined with a corticosteroid  Xanax and Ativan (Benzodiazepines) directly block the CTZ

33. N&V Drugs, con’t  Reglan calms activity of the GI track and is especially helpful if combined with a corticosteroid, an antihistamine, or a centrally acting drug like Ativan or Haldol  Compazine is a phenothiazine that has a strong antiemetic effect in the CNS  Treat for N&V BEFORE it occurs!