Pharm Final: Oncology and Immune System

Adverse effects of chemotherapy: BAD GOATS

• Bone marrow suppression (neutropenia, anemia, thrombocytopenia)

• Administration concerns (infiltration/extravasation)

• GI Tract concerns (N/V, ulceration)

• Other safety concerns:

  • Alopecia

  • Tumor lysis syndrome: build up of uric acid, AKI risk

  • Sexual/reproductive: use additional contraception

Nadir and action to address

• Low point (when most neutrophils die)

• when highest risk of infection occurs

• take temperature every 4 hours

Febrile Neutropenia

• when a patient develops a fever when experiencing neutropenia– emergency

• start antibiotics stat

Granulocyte- Colony Stimulating Factor prototype

Filgrastim

Filgrastim use

• Severe Chronic Neutropenia

• Chemotherapy induced Neutropenia

Filgrastim administration instructions

• give at least 24 hours after chemo

• monitor CBC twice weekly

• HOLD if WBC >10,000 or ANC > 1000

Filgrastim adverse effects

• bone pain

• leukocytosis

Erythropoietin Stimulating Agents (ESA) prototype

• Epoetin alfa

• Darbepoetin alfa

What are Epoetin alfa and Darbepoetin alfa used to treat?

• Anemia in CKD

• Chemotherapy induced Anemia

Epoetin alfa goal of treatment

• increase the Hemoglobin and Hematrocit (H/H)

• goal cut off is Hgb of 11 gm/dL

Epoetin alfa adverse effects and contra-indications

• HTN

• cancer: worsen prognosis

• CKD (over 11 gm/dL)

• cardiovascular complications– blood clots

• CI:

  • allergy

  • uncontrolled HTN

  • head/neck cancers

  • thrombosis risk

Thrombocytopenia monitoring/considerations

• when Platelets (<150k)

• take actions to reduce bleeding risks

Infiltration vs. Extravasation actions

• Infiltration: remove catheter

• Extravasation: keep catheter in place

How do we manage Mucositis/Stomatitis?

(chemo GI side effect)

• maintain oral hygiene

  • floss daily

  • avoid alcohol-based mouthwash

  • run toothbrush in dishwater weekly

• magic mouthwash

• bland diet

• report ulcers and blood in stool

Chemo drug classes

• Anthracyclines

• Vinca Alkaloids

• Nitrogen Mustards

• Platinum Compounds

• Miscellaneous Anti-neoplastic

• Selective Estrogen Receptor Modulator [SERM]

• DMARD

Anthracycline prototype

Doxorubicin

Vinca alkaloids prototype

Vincristine

Vincristine unique adverse effects

• Peripheral/Parasympathetic Neuropathy (NERVE DAMAGE)

  • ANS damage → PNS damage → constipation and urinary retention

Nitrogen Mustard prototype

Cyclophosphamide

Cyclophosphamide unique adverse effect and protective agent

• acute hemorrhagic cystitis

  • increase fluids

  • given with protective agent Mesna

Platinum Compound prototype

Cisplatin

Cisplatin unique adverse effects

• ototoxic

• renal toxicity

Miscellaneous Anti-neoplastic drug

Bleomycin

Selective Estrogen Receptor Modulator [SERM] prototypes

Tamoxifen and Raloxifene

Antimetabolites/DMARD prototype

Methotrexate

Methotrexate uses

• cancer (high dose)

• Rheumatoid Arthritis (low dose)

• terminate pregnancy

Methotrexate mechanism

stops cells from utilizing folic acid for DNA synthesis (take with folic acid supplement to decrease adverse effects)

Methotrexate unique adverse effects and interactions

• teratogenic

• liver toxicity

• SCAR (SJS/TEN)

• photosensitivity– protect from sunlight

• increased toxicity with NSAIDS and some antibiotics

Methotrexate rescue agent

Leucovorin (folic acid analog)

Methotrexate administration instructions

oral versions given once weekly

Traditional disease modifying anti-rheumatic drugs (DMARDs)

• Methotrexate

• Cyclosporine

• Hydroxychloroquine

• Sulfasalazine

• Minocycline (a tetracycline)

• Azathioprine

Biologic disease modifying anti-rheumatic drugs (DMARDs)

• Etanercept

• Adalimumab

• Infliximab

Treatment Goals of DMARDs

1) Relieve Symptoms

2) Maintain Joint Function + Range of Motion

3) Minimize Systemic Involvement

4) Delay Disease Progression

Etanercept adverse effects

• injection site reactions

• immunosuppressant: risk for serious infections

• can reactive latent TB and HBV

• malignancies

• Blood dyscrasias (aplastic anemia, pancytopenia)

• Liver injury (can lead to liver failure)

• HF

• Hypersensitivity Reactions (SJS/TEN)

• Demyelinating Disorders (avoid in MS)

What are Adalimumab and Infliximab used to treat?

• Rheumatoid Arthritis

• Crohn’s

• Ulcerative Colitis

Adalimumab and Infliximab mechanism

Monoclonal Antibody that targets TNF of the immune system

Adalimumab and Infliximab adverse effects

Similar to etanercept

• Liver + Heart Concerns

• TB + HBV Concerns

• Hematologic Disorders

• Neurologic

• Severe Allergic Reactions

Hydroxychloroquine adverse effects

• Retinal damage

• QT Prolongation

Sulfasalazine use

• Rheumatoid Arthritis

• Ulcerative Colitis

Cyclosporine use

• Rheumatoid Arthritis

• Transplants

• Ulcerative Colitis

Cyclosporine 4 boxed warnings

• provider must be experienced in immunosuppression and transplants

• immunosuppression/malignancy risk

• don’t switch brands– bioavailability

• HTN and nephrotoxicity

Cyclosporine additional adverse effects

• Hirsutism

• Gingival Hyperplasia

• Hepatotoxicity

• Nephrotoxicity

• HTN

• Infections

• Malignancies

Cyclosporine nursing considerations

• narrow therapeutic index drug

  • monitor trough levels

• lots of drug interactions– no grapefruit juice