Intro to Admin, Safe handling & Disposal of Chemotherapy yang

Majority of chemotherapy is administered via which formulation

IV

Extravasation

leakage of blood, lymph or other fluid (such as an anticancer drug) from a blood vessel (or tube) into the the tissue around it

What does it mean when blood return is absent?

catheter was most likely not placed into the blood vessel

Vesicant

Drug which has corrosive properties that has potential to cause tissue destruction if extravasated

Irritant

Drug that has potential to cause pain, aching, tightness and phlebitis w/ or w/o inflammation (rarely progresses to tissue breakdown)

Dactinomycin is vesicant or irritant?

vesicant

Daunorubicin is vesicant or irritant?

vesicant

Doxorubicin is vesicant or irritant?

vesicant

Vinblastine is vesicant or irritant?

vesicant

Vincristine is vesicant or irritant?

vesicant

Paclitaxel is vesicant or irritant?

vesicant

Oxaliplatin is vesicant or irritant?

vesicant

Cisplatin is vesicant or irritant?

irritant

Cyclophosphamide is vesicant or irritant?

irritant

Etoposide is vesicant or irritant?

irritant

Immediate ADRs related to extravasation

local burning, itching and erythema

How is extravasation related to cancer?

may occur after cytotoxic chemotherapy

Explain how extravasation can occur in chemotherapy admin

when IV meds are accidentally admin into surrounding tissues (leakage or by needle puncturing the vein)

Variables the determine severity of extravasation

the agent, the amount and the concentration

Which drug class has the most severe damage (vesicant)

anthracyclines (binds to DNA)

Infiltration of a vesicant drug into tissue results in ___ sensation

burning

Timing of late onset of extravasation

days to weeks after infusion

• redness gradually dimishes OR

• can progress to ulceration or necrosis

Why does extravasatioin typically occur on hand or wrist?

Less SQ tissue

T/F: generalized vascular disease in elderly and debilitated patients is a risk factor for extravasation

true

T/F: pts who undergone frequent venipuncture and tx w/ irritating chemotherpy is a risk factor for extravasation

true

T/F: pts who had prior radiation therapy to the injection site is a risk factor for extravasation

true

T/F: pt who never had radiation therapy are at risk of extravasation

false

T/F: pt who had recent venipuncture in the same vein are at risk of extravasation

true

T/F: use of injection sites over joints increases risk of extravasation

true

T/F: high BP is a risk factor for extravasation

false

T/F: using a central venous catheter increases risk of extravasation

false

Methods to manage vesicant admin

1. Use central catheter in pts receiving vesicant chemotherapy (bigger blood vessels, more blood volume, reaches the heart sooner)

2. prevention methods: special training w/ IV drug admin, monitor sx closely, report immediately any sensation changes

What type of compress causes vasodilation?

heat compress

What type of compress causes vasoconstriction ?

cold compress

Which type of compress aids in drug dispersal by increase drug distribution ?

heat compress

Which type of compress aids in drug dispersal by minimizing the spread of the drug, allowing time for local vascular and lymphatic systems to do the dispersing?

cold compress

Sodium thiosulfate MOA

has direct inactivation fx on mechlorethamine (mustine)

Dimethyl sulfoxide (DMSO) MOA

• enhances skin permeability, thus facilitating the systemic absorption of the vesicant drug

• free radical scavenging properties

Only administration method that can be used for dimethyl sulfoxide (DMSO)

Topical

Directions of application of dimethyl sulfoxide (DMSO)

apply with a cotton bud and let it air dry to avoid blilsters. Avoid applying to undamaged tissue

Name the antidote specifically for extravasation induced by anthracyclines

Dexrazoxane (zinecard)

Dexrazoxane (zinecard) MOA

iron chelator (protects cardiac tissue from anthracycline-induced toxicities)

Duration of use for dexrazoxane (zinecard)

3 days

dexrazoxane (zinecard) formulation

IV

time window to use dexrazoxane (zinecard)

within 6 hours of extravasation

major ADR of dexrazoxane (zinecard)

secondary malignancy

Name the agent used for extravasation induced by vinca alkaloids

hyaluronidase (hylenex)

Name the agent used for extravasation induced by epipodophyllotoxins

hyaluronidase (hylenex)

Name the agent used for extravasation induced by taxanes

hyaluronidase (hylenex)

hyaluronidase (hylenex) MOA

enzyme responsible for degrading hyaluronic acid → enhances systemic uptake of the infiltrated cytotoxic drugs

hyaluronidase (hylenex) ROA

SQ

Name the agent used for extravasation induced by alkyating agents

1/6 M solution of sodium thiosulfate

Name the agent used for extravasation induced by mitomycin-C

dimethyl sulfoxide

sodium thiosulfate ROA

SQ

All extravasation management requires cold compress except for extravasation caused by which agent?

Vinca alkaloids (uses warm compress)

Procedure for management of suspected extravasation

1. stop infusion immediately, aspirate as much of the solution as possible, then remove IV

   1. DO NOT REMOVE THE NEEDLE

2. contact physician or oncologist ASAP

3. if appropriate → instill an antidote in the infiltrated areas (via the extravasated needle if possible)

4. remove the needle

5. app ice to site (or warm compress if vinca alkaloids) and elevate extremity for first 24-48 h

6. administer pain relief if required

7. document drug, suspected volume extravasated and tx in pt’s medical record

8. check site frequently for 5-7 d

9. consult surgeon early

examples of infusion related reactions

hypersensitivity rxn and cytokine release syndrome

infusion reactions can occur with what types of therapy

cytotoxic or monoclonal antibody therapy

which type of infusion reaction are mediated by IgE?

anaphylactic reaction

which type of infusion reaction are NOT mediated by IgE?

anaphylactoid reacion

which type of infusion reaction are caused by cytokine release (and can be rechallenged) ?

anaphylactoid reaction

which type of infusion reaction can not be rechallenged?

anaphylactic reaction

cause of most infusion reactions related to mabs

cytokine release

what drug class causes an infusion reaction where sx appear to subside with each subsequent dose

monoclonal antibodies

management of infusion reactions caused by mabs

• short term cessation of mab infusion

• admin histamine blockers

• restart infusion at slower rate

• pre-medication (APAP + antihistamine)

• other strategies: alemtuzumab + blinatumomab

which agent causes an infusion reaction that occurs early ?

taxanes

which taxane has a higher risk of infusion reaction

paclitaxel

explain the cause of infusion reaction from paclitaxel

cremophor vehicle (castor oil and ethanol)

explain the cause of infusion reaction from docetaxel

polysorbate

are taxane infusion reactions anaphylaxis or anaphylactoid

anaphylactoid (rarely can be anaphylaxis)

pre medication for paclitaxel to avoid infusion reaction

H1/H2 blockers: diphenhydramine PO/IV AND famotidine IV

pre medication for docetaxel to avoid infusion reaction

dexamethasone PO day before, day of and day post infusion

acute management of taxane induced infusion reactions

turn off infusion + give additional antihistamines, corticosteroids, and other supportive care prn

in which condition can you rechallenge in taxane induced infusion reaction

if cremophor related

in taxan induced infusion reaction avoid ____ and only use non PVC set

PVC bag/tubing

Which formulation of taxanes does not require pre medication ?

abraxane

Which drug class causes an infusion reaction that is delayed

platinum agents

when does platnium agent induced infusion reaction occur

after 6-8 cycles

cause of infusion reaction d/t platnium agents

cumulative exposure

premedication for platinum agents to avoid infusion reaction

no pre medication

acute management for platnium agent induced infusion reaction

turn off infusion and admin antihistamines ± corticosteroids

management of platnium agent induced infusion reaction if > 7 course

desensitization protocol

cause of infusion reaction from etoposide

d/t polysorbate

management of etoposide induced infusion reaction

• switch to etopophos

• slow down infusion rate

pegaspargase (oncaspar) ROA

IV

erwinia asparaginase ROA

IM

management of pegasparaginase induced infusion reaction + downside

switch to erwinia asparaginase (erwinaze) ; downside is that 1 dose of pegaspargase = 6 doses of erwinia asparaginase