1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacology in Nursing Antineoplastic Drugs Part 2: Cell Cycle–Nonspecific Drugs and Miscellaneous Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cancer Drugs: Antineoplastic Medications  Cell cycle–nonspecific (CCNS) drugs  Alkylating drugs  Cytotoxic antibiotics

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Alkylating Drugs  Classic alkylators (nitrogen mustards)  Nitrosoureas  Probable alkylators

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Alkylating Drugs (cont’d)  CCNS antineoplastics  Effective at any stage in the growth cycle of cancer cells  Prevent cancer cells from reproducing with the process of alkylation

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

7. Alkylating Drugs: Indications  Used in combination with other drugs to treat various types of cancer, such as:  Recurrent ovarian cancer  Brain tumors  Lymphomas  Leukemias  Various forms of cancer (breast, ovarian, bladder)  Others

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Alkylating Drugs: Adverse Effects  Dose-limiting adverse effects  Nausea and vomiting, myelosuppresion  Alopecia  Nephrotoxicity, peripheral neuropathy, ototoxicity  Hydration can prevent nephrotoxicity  Extravasation causes tissue damage and necrosis

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Alkylating Drugs: Examples  cisplatin (Platinol-AQ)  cyclophosphamide (Cytoxan)  altretamine (Hexalen)  carmustine (BiCNU)  mechlorethamine (Mustargen)  temozolomide (Temodar)  thiotepa (Thioplex)

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics  Natural substances produced by the mold Streptomyces  Synthetic substances also used  Used to treat cancer–too toxic to treat infections

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics (cont’d)  All can produce BMS (except bleomycin)  Pulmonary toxicity (bleomycin)  Heart failure (daunorubicin)

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics (cont’d)  Anthracycline antibiotics  daunorubicin, doxorubicin, idarubicin, others  Anthracenedione antibiotics  Mitoxantrone  Other cytotoxic antibiotics  bleomycin, dactinomycin, mitomycin, plicamycin, others

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics (cont’d)  Most are CCNS drugs, and are active in all phases of the cell cycle  Most act by the process of alkylation and resulting in blocking DNA synthesis  Some act by intercalation, resulting in blockade of DNA, RNA, and protein synthesis

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics: Indications  Used in combination chemotherapy regimens  Used to treat a variety of solid tumors and some hematologic malignancies  Leukemia, ovarian, breast, bone, others  Squamous cell carcinomas  AIDS-related Kaposi’s sarcoma (when intolerant to other treatments)

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics: Adverse Effects  Hair loss, nausea and vomiting, myelosuppression  Pulmonary fibrosis (bleomycin)  Liver, kidney, and cardiovascular toxicities  Many others

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Cytotoxic Antibiotics: Adverse Effects (cont’d)  Cardiomyopathy is associated with large amounts of doxorubicin  Dexrazoxane can be used as a cytoprotective drug  Monitor cardiac ejection fractions

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics  bevacizumab (Avastin)  hydroxyurea (Hydrea)  imatinib (Gleevec)  mitotane (Lysodren)  Hormonal antineoplastic drugs  Radiopharmaceuticals

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics (cont’d)  bevacizumab (Avastin)  Angiogenesis inhibitor  Blocks the blood supply to the growing tumor  Many adverse effects, including nephrotoxicity

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics (cont’d)  hydroxyurea (Hydrea)  Action similar to antimetabolites  Used to treat squamous cell carcinoma and some leukemias  Oral form only  Many adverse effects

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics (cont’d)  imatinib (Gleevec)  Used to treat chronic myeloid leukemia (CML), especially in cases where interferon alfa therapy failed  It is NOT a monoclonal antibody  Works by inhibiting an enzyme that is active in the CML process  Use with other hepatic-metabolized drugs may cause severe interactions

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics (cont’d)  mitotane (Lysodren)  Adrenal cytotoxic drug  Used specifically for adrenal corticoid carcinoma  Oral form only

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Hormonal Drugs  Used to treat a variety of neoplasms in males and females  Hormonal therapy used  To oppose effects of hormones  To block the body’s sex hormone receptors  Used most commonly as adjuvant and palliative therapy

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Hormonal Drugs (cont’d)  Drugs for female-specific neoplasms  anastrozole (Arimidex)  tamoxifen (Nolvadex)  megestrol (Megace)  medroxyprogesterone (Provera)  fluoxymesterone (Halotestin)  fulvestrant (Faslodex)  Several others

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Hormonal Drugs (cont’d)  Drugs for male-specific neoplasms (prostate cancer)  bicalutamide (Casodex)  flutamide (Eulexin)  nilutamide (Nilandron)  leuprolide (Lupron)  goserelin (Zoladex)  estramustine (Emcyt)

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Miscellaneous Antineoplastics (cont’d)  Radiopharmaceuticals  Used to treat a variety of cancers, or symptoms caused by cancers Porfimer sodium Porfimer sodium Chromic phosphate P 32 Chromic phosphate P 32 Samarium SM 153 lexidronam Samarium SM 153 lexidronam Sodium iodide I 131 Sodium iodide I 131 Sodium phosphate P 32 Sodium phosphate P 32 Strontium Sr 89 Strontium Sr 89

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Extravasation  Leaking of an antineoplastic drug into surrounding tissues during IV administration  Can result in permanent damage to nerves, tendons, muscles, loss of limbs  Skin grafting or amputations may be necessary

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Extravasation (cont’d)  Prevention is essential  Continuous monitoring of the IV site is essential

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Extravasation (cont’d)  If suspected, stop the IV infusion immediately but do not remove the IV tube  If possible, aspirate remaining drug or blood from the tube  Follow instructions for giving the appropriate antidote through the existing IV tube, then remove the catheter  Some antidotes are not given through the IV catheter

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Extravasation (cont’d)  Cover area with sterile, occlusive dressing if ordered  Apply warm or cold compresses, depending on the extravasated drug  Rest and elevate the affected limb  PREVENTION is the best approach!

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

31. Handling Antineoplastic Drugs  Those preparing and administering these drugs may be exposed to negative consequences  Most facilities have these drugs mixed under special environments in the pharmacy

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Handling Antineoplastic Drugs (cont’d)  During care of a patient receiving these drugs, special precautions may be implemented, depending on facility policies  Double flushing of bodily fluids in the commode  Special hampers for disposal of all objects that contact the patient’s body fluids  Personal protective equipment  Special concerns if chemotherapy liquid spills

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Assess baseline blood counts before giving any antineoplastic drugs  Follow specific administration guidelines for each antineoplastic drug

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Alkylating drugs  Monitor for expected effects of bone marrow suppression  Expect nausea, vomiting, diarrhea, stomatitis  Hydration is important to prevent nephrotoxicity  Report ANY ringing/roaring in the ears—possible ototoxicity  Peripheral neuropathies may occur—report tingling, numbness, pain in extremities

35. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Cytotoxic antibiotics  Expect bone marrow suppression, nausea, vomiting, diarrhea, stomatitis  Monitor pulmonary status  Monitor for nephrotoxicity, liver toxicity  Monitor cardiovascular status  Daunorubicin may turn the urine to a reddish color

36. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  In general  Monitor closely for anaphylactic reactions  Keep epinephrine, antihistamines, antiinflammatory drugs on hand  Monitor closely for complications associated with bone marrow suppression Anemia, thrombocytopenia, neutropenia Anemia, thrombocytopenia, neutropenia

37. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Cytoprotective drugs may be used to reduce toxicities  IV amifostine (Ethyol) to reduce renal toxicity associated with cisplatin  IV or PO allopurinol (Zyloprim) to reduce hyperuricemia

38. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor for oncologic emergencies  Infections  Pulmonary toxicity  Allergic reactions  Stomatitis with severe ulcerations  Bleeding  Metabolic aberrations  Bowel irritability with diarrhea  Renal, liver, cardiac toxicity