Pharmacology NURS 1950

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Objective 1: Describe the general factors utilized to select the therapy used to treat cancer◦ Surgery

◦ Radiation

◦ Chemotherapy Most effective against rapidly growing cells

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Objective 2: Describe the general uses of chemotherapy in the treatment of cancer

◦ Through blood

◦ Into body cavities

◦ As adjuvant therapy

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Cure:

Palliation

prophylaxis

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Objective 3: Identify the basic types of antineoplastic drugs

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◦ 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

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Alkylating agentsAntimetabolitesNatural productsAntineoplastic antibioticsHormones Biologic response modifiers & Misc.

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Bond with DNA so it can’t separate = no replication

Cell-cycle nonspecific◦Resistance can be a problemCreates cross resistance with other alkylating agents

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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

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Busulfan (Myleran)Carboplatin (Paraplatin)Carmustine (BCNU)Chloramubil (Leukeran)Cisplatin (Platinol)Cyclophosphamide (Cytoxan)

◦prototype

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Fudarabine (Fludara)Lomustine (CCNU, CeeNU)Mechlorethamine (Nitrogen mustard, Mustargen)

Melphalan (Alkeran)Streptozocin (Zanosar)Thiotepa

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

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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

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

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

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Drugs included◦Capecitabine (Xeloda)◦Cytarabine hydrochloride (Cytosar)

◦Fludarabine (Fludara)◦Flurouracil (5-FU, FU)◦Gemcitabine (Gemzar)

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Mercaptopurine (6-MP, Purinethol)

Methotrexate (MTX) prototype◦Overdosed: Leucovorin as rescue drug

Thioguanine (Lanvis)

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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

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In general, toxicities include◦N/V, diarrhea, constipation, fatigue

◦Bone marrow depression, dermatitis

◦Oral and GI ulceration

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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

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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

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

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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

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General toxicities◦ N/V, stomatitis ◦ Leukopenia with VePesid: nadir in 10-14 days,

recovery 3 weeks◦ Bone marrow suppression, alopecia, peripheral

neuritis, hepatotoxicity, bronchospasm

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Bind to DNA, inhibit DNA, RNA synthesis

Cell-cycle nonspecific Admin IV or via catheter to body cavity

Use: breast, bladder, lung, ovary

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Drugs include◦Bleomycin (Blenoxane)◦Dactinomycin (Actinomycin D, Cosmegen)

◦Daunorubicin (Cerubidine)◦Doxorubicin (Adriamycin)prototype

◦Epirubicin (Ellence)

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Idarubicin Mitomycin CMitoxantronePlicamycinValrubicin

◦ Bladder specific

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

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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

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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 unknown32

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

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Drugs included◦Anastrozole (Arimidex)◦Diethylstilbestrol (DES)◦Prednisone◦Tamoxifen (Nolvadex) prototype

◦Testolactone (Teslac)◦Testosterone

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General toxicities◦N/V, headache◦Fluid retention, feminization or masculinization

◦Hot flashes Some can cause thrombocytopenia, leukopenia, hypercalcemia, increased bone and tumor pain

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Assess for pregnancy/lactation Tamoxifen is only ‘curative’ drug

◦ Important that family knows and understands limitations of this category

Fertility affected

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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

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Toxicities in general◦N/V, hot flashes, bone marrow depression, arrhythmias

◦Flulike syndrome◦Anemia, leukopenia◦Less toxic than other CA drugs

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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

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Filgastim (Neupogen) stimulates the production of neutrophils (WBC)

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

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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

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Oprelvekin (Neumega) stimulates platelet production at stem cell level

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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.

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◦ Prevent new blood vessels

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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

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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

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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

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Objective 5: describe what “tumor resistance” means◦Tumor cells are not as susceptible to antineoplastic agents as they should beCells escape damage from the drugs

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

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Normal cells responding to chemotherapy◦Rapidly growing cellsGI tractHair follicles RBCs, WBCs, platelets

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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

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◦Diarrhea: skin care a must◦Avoid foods that stimulate bowel motility

◦Eat foods high in K+ (loose it with diarrhea)

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Alopecia ◦Hair will begin to fall out in clumpsDevastating—cut hair short; get wigs, caps, turbans

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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

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

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

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Thrombocytopenia: client needs to watch for bleeding◦Nurse: use smallest needle when MUST give parenteral medication

◦Neumega may be used◦Teach safety measures

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

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

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Care of the nurse◦Prevent inhalation of aerosols◦Prevent drug absorption through the skin

◦Safe disposal◦Prevent contamination of body fluids

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Objective 8: describe the types of anemias

Anemia is a condition in which the hemoglobin concentration or the number of circulating RBCs is decreased

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

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Objective 9: identify drugs used to treat iron deficiency anemia

Drugs include ferrous sulfate, ferrous gluconate, ferrous fumarate and iron dextran (Imferon); iron polysaccharide

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

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Ferrous sulfate◦Oral, usually tablet or capsule◦SE: usually GI—nausea, pyrosis, bloating, constipation or diarrhea

◦If liquid prep: stains teethDilute in water or juiceAdminister with a strawRinse mouth after administration

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

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Ascorbic acid promotes absorption

Tetracycline and antacids decrease absorption

Iron (Fe) used for iron deficiency anemia or to prevent (pregnancy)

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Ferrous gluconate and ferrous fumarate◦Same therapeutic effect as ferrous sulfate

◦If no response to one drug form, no response to the others

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Iron dextran: for parenteral administration◦Used when oral iron ineffective or intolerable

◦Given IM or IV

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Major adverse effect◦Anaphylactic shock◦Test doses given for IV before the doseHave emergency drugs available STAT

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IM iron◦Persistent pain and discoloration at site occur

◦Can cause anaphylactic reactions

◦Must use Z track method of administration

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

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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

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Vitamin B12 can be oral or parenteral administration

Cyanocobalamin can be given IM or deep subq

Oral form usually as dietary supplement

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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

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

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Anxiety Knowledge deficitDisturbed body imageAnticipatory grievingRisk for infectionRisk for injury

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Nutrition: less than body requirements (or a risk for)

Impaired tissue integrity (or risk for)

Chronic pain (or acute, depending upon the situation)

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Activity intolerance Impaired oral mucous membranes

Self-care deficitNutrition: less than body requirements

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