1. Pharmacology NURS 1950 1

2.  Objective 1: Describe the general factors utilized to select the therapy used to treat cancer ◦ Surgery ◦ Radiation ◦ Chemotherapy  Most effective against rapidly growing cells 2

3.  Objective 2: Describe the general uses of chemotherapy in the treatment of cancer ◦ Through blood ◦ Into body cavities ◦ As adjuvant therapy 3

4.  Cure:  Palliation  prophylaxis 4

5.  Objective 3: Identify the basic types of antineoplastic drugs 5

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8. ◦ G0 Phase: resting stage ◦ G1 Phase: synthesizes material needed to duplicate DNA ◦ S Phase: duplicates DNA ◦ G2 Phase: premitotic phase ◦ M Phase: mitosis occurs ◦ Cell returns to G0 phase 8

9.  Alkylating agents  Antimetabolites  Natural products  Antineoplastic antibiotics  Hormones  Biologic response modifiers & Misc. 9

10.  Bond with DNA so it can’t separate = no replication  Cell-cycle nonspecific ◦ Resistance can be a problem  Creates cross resistance with other alkylating agents 10

11.  Alkylating agents: non cell cycle specific drugs ◦ Activity occurs when the cell tries to replicate and the DNA can not separate ◦ Blood cells are very sensitive/responsive to this activity 11

12.  Busulfan (Myleran)  Carboplatin (Paraplatin)  Carmustine (BCNU)  Chloramubil (Leukeran)  Cisplatin (Platinol)  Cyclophosphamide (Cytoxan) ◦ prototype 12

13.  Fudarabine (Fludara)  Lomustine (CCNU, CeeNU)  Mechlorethamine (Nitrogen mustard, Mustargen)  Melphalan (Alkeran)  Streptozocin (Zanosar)  Thiotepa 13

14.  In general, toxicities include ◦ N/V, anorexia ◦ Bone marrow depression ◦ Anemia ◦ Nephrotoxicity ◦ Hepatic and renal toxicity ◦ Alopecia ◦ Cystitis ◦ infertility 14

15.  Discontinue if RBC, WBC and platelet counts fall  Caution use: hepatic or renal impairment  Hydrate before chemo—IV or oral  Advise to avoid crowds  Monitor nutritional intake  Assess for N/V—admin meds as needed  Offer non meds to relieve mouth pain 15

16.  Assess skin integrity  Monitor for hearing loss  Inform regarding impact of infertility  Maintain strict medical asepsis 16

17.  Each drug may have specific toxicities ◦ Example: Zanosar causes hypoglycemia 17

18.  Drugs included ◦ Capecitabine (Xeloda) ◦ Cytarabine hydrochloride (Cytosar) ◦ Fludarabine (Fludara) ◦ Flurouracil (5-FU, FU) ◦ Gemcitabine (Gemzar) 18

19.  Mercaptopurine (6-MP, Purinethol)  Methotrexate (MTX) prototype ◦ Overdosed: Leucovorin as rescue drug  Thioguanine (Lanvis) 19

20.  Antimetabolites are subclassed as folic acid, purine, and pyrimidine antagonists ◦ Inhibit key enzymes in biosynthetic pathways of DNA and RNA synthesis  Many are cell-cycle specific (S phase)  Uses: choriocarcinoma, breast, head and neck and lung ca, leukemia 20

21.  In general, toxicities include ◦ N/V, diarrhea, constipation, fatigue ◦ Bone marrow depression, dermatitis ◦ Oral and GI ulceration 21

22.  Contraindicated in pregnancy, hepatic and renal insufficiency, cardiac conditions  Avoid pregnancy for 6 months with category X drug  Monitor for photosensitivity and idiosyncratic pneumonitis  Teach good oral hygiene, mouth rinses  Monitor IV site for extravasation 22

23.  Come from periwinkle plant, specific yews  Cell-cycle specific: block mitotic spindle during mitosis  Use: Hodgkins, non hodgkins, Karposi, Wilm’s tumor, bladder and breast CA 23

24.  Drugs include ◦ Etoposide (VePesid) ◦ Docetaxel (Taxotere) ◦ Paclitaxel ◦ Vinblastine sulfate (Velban, Velbe) ◦ Vincristine sulfate (Oncovin) Prototype ◦ Vinorelbine (Navelbine) 24

25.  Assess for allergies to plants, foods  Vincristine may produce acute broncho spasm and rash  Ask about pregnancy/breast feeding  Emphasize nutritional plan to combat constipation  Monitor BP; watch for syncope, HA, dizziness  May produce mental depression; assess for suicidal ideation 25

26.  General toxicities ◦ N/V, stomatitis ◦ Leukopenia with VePesid: nadir in 10-14 days, recovery 3 weeks ◦ Bone marrow suppression, alopecia, peripheral neuritis, hepatotoxicity, bronchospasm 26

27.  Bind to DNA, inhibit DNA, RNA synthesis  Cell-cycle nonspecific  Admin IV or via catheter to body cavity  Use: breast, bladder, lung, ovary 27

28.  Drugs include ◦ Bleomycin (Blenoxane) ◦ Dactinomycin (Actinomycin D, Cosmegen) ◦ Daunorubicin (Cerubidine) ◦ Doxorubicin (Adriamycin)  prototype ◦ Epirubicin (Ellence) 28

29.  Idarubicin  Mitomycin C  Mitoxantrone  Plicamycin  Valrubicin ◦ Bladder specific 29

30.  Generally, toxicities include ◦ N/V, red tinged urine with some ◦ Bone marrow depression ◦ Cardiotoxicity ◦ Pulmonary fibrosis (Bleomycin) ◦ GI bleeding, CNS effects with some 30

31.  Assess cardiac status—EKG  Ask about pregnancy/lactation  Risk of hypersensitivity as in other antibx  No rectal suppositories or temp due to rectal mucosal changes  Wear protective clothing when preparing drug  Monitor IV site  Give drug thru large bore, quickly running IV 31

32.  Corticosteroids: lymphoma and acute leukemia as suppress mitosis in lymphocytes ◦ Help restore sense of well being, decrease edema with radiation, increase appetite and strength  Action: mostly unknown 32

33.  Estrogens and androgens: malignancies of sexual organs ◦ Use estrogen for prostate cancer (suppress the amount of androgen available) ◦ Use androgens for breast cancer (suppress the amount of estrogen available) ◦ Normally given as palliation 33

34.  Drugs included ◦ Anastrozole (Arimidex) ◦ Diethylstilbestrol (DES) ◦ Prednisone ◦ Tamoxifen (Nolvadex)  prototype ◦ Testolactone (Teslac) ◦ Testosterone 34

35.  General toxicities ◦ N/V, headache ◦ Fluid retention, feminization or masculinization ◦ Hot flashes  Some can cause thrombocytopenia, leukopenia, hypercalcemia, increased bone and tumor pain 35

36.  Assess for pregnancy/lactation  Tamoxifen is only ‘curative’ drug ◦ Important that family knows and understands limitations of this category  Fertility affected 36

37.  Drugs included ◦ Altretamine (Hexalen) ◦ Dacarbazine (DTIC-dome) ◦ Hydroxyurea (Hydrea) ◦ Interferon alfa-2b (Intran)  prototype ◦ Leuprolide acetate (Lupron) Action: stimulate immune system to fight tumor cell growth 37

38.  Toxicities in general ◦ N/V, hot flashes, bone marrow depression, arrhythmias ◦ Flulike syndrome ◦ Anemia, leukopenia ◦ Less toxic than other CA drugs 38

39.  Drugs used as adjunct therapy ◦ Epoetin alfa (Procrit) stimulates production of red blood cells ◦ Used to treat anemia induced by chemotherapy ◦ Increased risk of thrombus formation 39

40.  Filgastim (Neupogen) stimulates the production of neutrophils (WBC) 40

41.  Rituximab (Rituxan) binds to the surface of B lymphocytes ◦ Used to treat relapsed B-cell non-Hodgkin’s lymphoma 41

42.  Sargramostim (Leukine) stimulates the production of granulocytes and macrophages ◦ Also helpful in aplastic anemia ◦ Side effects:  Resp distress with initial dosing  Follow protocol  Use: AML, bone marrow transplant 42

43.  Oprelvekin (Neumega) stimulates platelet production at stem cell level 43

44.  Trastuzumab (Herceptin) inhibits growth of tumor cells (especially useful in metastatic breast cancer) ◦ Binds to specific protein in breast ca cells that leads to death of cell. 44

45. ◦ Prevent new blood vessels 45

46.  Multiple drugs from different classes ◦ Affect different stages in cell cycle ◦ Use different mechanisms of action to increase cell kill  Combinations allow for lower doses ◦ Reduce toxicity ◦ Slow development of resistance 46

47.  Specific dosing protocols ◦ Depend on the type of tumor, stage of disease, overall condition of the client ◦ Given as single dose or several ◦ Over days or weeks  Allows normal cells to recover ◦ Sometimes doses needs to be delayed  Allow client to recover  ie bone marrow depression 47

48.  Objective 4: identify the 2 factors that play a major role in the response of the cancer cell to the antineoplastic drug ◦ Tumor size ◦ Rate of cell replication 48

49.  Objective 5: describe what “tumor resistance” means ◦ Tumor cells are not as susceptible to antineoplastic agents as they should be  Cells escape damage from the drugs 49

50.  Objective 6: specify which normal cells are frequently affected by antineoplastic therapy; and signs and symptoms that result most frequently 50

51.  Normal cells responding to chemotherapy ◦ Rapidly growing cells  GI tract  Hair follicles  RBCs, WBCs, platelets 51

52.  Side effects/toxicities to expect ◦ GI tract: N/V, diarrhea or constipation, stomatitis  Take PRN medications as needed  Will have pre-treatment drugs for N/V  Stomatitis requires good oral hygiene, mouth wash with local anesthetic  Weekly weights 52

53. ◦ Diarrhea: skin care a must ◦ Avoid foods that stimulate bowel motility ◦ Eat foods high in K+ (loose it with diarrhea) 53

54.  Alopecia ◦ Hair will begin to fall out in clumps  Devastating—cut hair short; get wigs, caps, turbans 54

55.  Skin care: lukewarm water, mild soap  Keep skin clean and dry  If drugs cause photosensitivity, avoid sun  Skin creams available from MD to heal, protect ◦ Especially important with radiation 55

56.  Decreased RBCs = decreased 02 transport ◦ May receive Procrit ◦ May have blood transfusion ◦ Need to rest often ◦ Avoid orthostatic hypotension 56

57.  Neutropenia: avoid crowds (infections) ◦ Neupogen may be used ◦ Meticulous care of central lines needed 57

58.  Thrombocytopenia: client needs to watch for bleeding ◦ Nurse: use smallest needle when MUST give parenteral medication ◦ Neumega may be used ◦ Teach safety measures 58

59.  Objective 7: discuss the nursing care for the client receiving antineoplastic therapy 59

60.  Clients with cancer require holistic nursing ◦ Medications ◦ Physical assessment ◦ Psychosocial support ◦ Emotional support ◦ Growth and development support, esp. for kids 60

61.  Care of the nurse ◦ Prevent inhalation of aerosols ◦ Prevent drug absorption through the skin ◦ Safe disposal ◦ Prevent contamination of body fluids 61

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63.  Objective 8: describe the types of anemias  Anemia is a condition in which the hemoglobin concentration or the number of circulating RBCs is decreased 63

64. ◦ Anemia occurs because of:  Blood loss  Hemolysis  Bone marrow dysfunction  Deficiencies of substances essential for hematopoiesis  Lack of iron, vitamin B12 or folic acid 64

65.  Objective 9: identify drugs used to treat iron deficiency anemia  Drugs include ferrous sulfate, ferrous gluconate, ferrous fumarate and iron dextran (Imferon); iron polysaccharide 65

66.  Objective 10: describe the nursing responsibilities associated with administering iron preparations 66

67.  Ferrous sulfate ◦ Oral, usually tablet or capsule ◦ SE: usually GI—nausea, pyrosis, bloating, constipation or diarrhea ◦ If liquid prep: stains teeth  Dilute in water or juice  Administer with a straw  Rinse mouth after administration 67

68.  High doses are toxic ◦ Usually accidental ◦ Children susceptible: >3 gms can be fatal 68

69.  Ascorbic acid promotes absorption  Tetracycline and antacids decrease absorption  Iron (Fe) used for iron deficiency anemia or to prevent (pregnancy) 69

70.  Ferrous gluconate and ferrous fumarate ◦ Same therapeutic effect as ferrous sulfate ◦ If no response to one drug form, no response to the others 70

71.  Iron dextran: for parenteral administration ◦ Used when oral iron ineffective or intolerable ◦ Given IM or IV 71

72.  Major adverse effect ◦ Anaphylactic shock ◦ Test doses given for IV before the dose  Have emergency drugs available STAT 72

73.  IM iron ◦ Persistent pain and discoloration at site occur ◦ Can cause anaphylactic reactions ◦ Must use Z track method of administration 73

74.  Objective 11: describe pernicious anemia and identify the drug used to treat it ◦ May see it called vitamin B12 deficiency anemia or megaloblastic anemia 74

75.  Vitamin B12 deficiency occurs because of ◦ Lack of B12 in diet ◦ Lack of intrinsic factor in stomach  Causes oversized erythroblasts; can be fatal  Have CNS effects, neurological damage 75

76.  Vitamin B12 can be oral or parenteral administration  Cyanocobalamin can be given IM or deep subq  Oral form usually as dietary supplement 76

77.  Folic acid deficiency  Folic acid available as tablet and for IM, IV, or subq administration  Leucovorin: active form of folic acid used as a rescue drug in cancer therapy; may also see in rheumatoid arthritis clients taking methotrexate 77

78.  Objective 12: apply the nursing process when caring for the client receiving antineoplastic and antianemic agents 78

79.  Anxiety  Knowledge deficit  Disturbed body image  Anticipatory grieving  Risk for infection  Risk for injury 79

80.  Nutrition: less than body requirements (or a risk for)  Impaired tissue integrity (or risk for)  Chronic pain (or acute, depending upon the situation) 80

81.  Activity intolerance  Impaired oral mucous membranes  Self-care deficit  Nutrition: less than body requirements 81