Chemotherapy Agent

Precautions wearing for chemo

double flush toilet

double gloving

special linen hamper

Anemia

Reduction in the number of circulating RBCs

Decreased hemoglobin, hematocrit (know the normals)

Treatment:

• Iron, folic acid

• Erythropoietin stimulating agent

  • epogen

  • iron, folic acid, blood transfusions

• Transfusion

• leucovorin rescue (folinic acid)

• extra rest periods- fatigue most common complaint, caregiver assistance

• bone marrow transplant

Thrombocytopenia

Reduction in circulating platelets, which increase the risk of bleeding

Client care:

• oprelvekin to INCREASE platelets

• Bleeding precautions: Avoid IM injections/venipunctures; no Foleys; avoid straining at stool; use electric razor; 

• Gentle prolonged pressure after puncture

• Monitor platelets (if < 50,000 notify HCP), PTT, PT/INR

• No NSAIDs

• Be alert for signs of bleeding, bruising; assess for petechiae

Neutropenia

Decrease in circulating neutrophils; Incidence and severity of infection are increased

Nadir (lowest blood count after chemo), occurs between days 10 -28 days 

Client care:

• filgrastim leukopoietic growth factor (ATI 8^th ed. p. 206, 9^th  ed. p. 202)

• sargramostim (ATI 8^th ed.  p. 207, 9^th  ed. p. 203)

• Monitor absolute neutrophil count (ANC) 2500-6000

  • Mild neutropenia: 1,000 – 1,500 ANC

  • Moderate neutropenia: 500 – 1,000 ANC

  • Severe neutropenia: Less than 500 ANC

Neutropenic precautions

• Temp Q4h, notify if >100.3 F°

• Notify of sore throat, cough, s/s infection

• Protective (reverse) isolation

• No fresh flowers (minimize raw fruits, veggies)

• Dedicated equipment

• Avoid crowds and sick people

• No vaccines

• Monitor ANC

• Limit Tylenol- can mask fever

colony stimulating factors

Medication	Therapeutic Effect	Adverse Effect
Epoetin alfa; erythropoietin (Epogen)	Increase production of RED blood cells	Headache, HTN Increased risk of blood clots
Oprelvekin (Neumega) thrombopoietic growth fact	Increase the production of PLATELETS	Peripheral edema, cardiac dysrhythmias
Filgrastim (Neupogen) leukopoietic growth factor	Increase the production of WHITE blood cells	Bone pain, splenomegaly, leukocytosis

effects of chemo

Chemo causes: 

Bone marrow suppression results in

• Anemia (SOB, fatigue, pallor)

• Thrombocytopenia (risk of bleeding)

• Leukopenia/ neutropenia (risk of bleeding)

May also cause: 

Hepatotoxicity (Increased liver enzymes, RUQ pain, fatigue, abdominal pain, jaundice)

These are DOSE-LIMITING toxicities

Nausea, vomiting, diarrhea, stomatitis are not necessarily dose-limiting, unless severe

Treatment of mucositis

Treatment option may include oral solution containing: 

• lidocaine (2% viscous)-numbing agent

• antacid (Mylanta)- soothes

• antihistamine (diphenhydramine)

• antifungal (Nystatin)

• Prednisolone- decrease inflammation

Client considerations: 

• Use toothettes instead of toothbrush

• Avoid hot, spicy foods, roughage, citric acid foods

CI N/V

Consider emetogenic potential of chemo

• Acute Emesis: < 24 hours post-chemotherapy

• Delayed Emesis: > 24 hours post-chemotherapy

• Anticipatory Nausea and Vomiting: Before administration of chemotherapy

Premedication with antiemetics 30-60 minutes prior to chemo admin

Combinations of antiemetics are more effective than single-drug therapy

• 5-HT3 receptor blocker- ondansetron (Zofran)

• dexamethasone (Decadron)

• aprepitant (Emend)

treatment of CINV

Client care

• Continue medication 48 after treatment

• IV fluids if continues

• Ginger tea, flat ginger ale

• Small frequent bland foods/meals

• Monitor fluid & electrolyte status of client

• May have accompanying diarrhea

  • avoid irritating foods

  • low fiber diet

  • loperamide (Imodium)

  • diphenoxylate (Lomotil) -controlled substance (V)

Decreased appetite

At risk for impaired nutrition

• Offer high-protein, high-calorie foods

• easy-to-swallow foods

• custards

• milkshakes

• mashed potatoes

• gelatins

• Appetite stimulants:

  • megestrol (Megace)

  • dronabinol (Marinol)

Mesna (Mesnex)

to treat hemorrhagic cystitis (irritation of the lining of the bladder from chemo → hematuria)

Mesna to prevent this. Chemoprotectant

Hemorrhagic cystitis

Irritation of the lining of the bladder from chemo metabolites; results in sterile cystitis and hematuria

Client care: 

8-10 glasses of water per day

Frequent (q2 hr during day) voiding

Risk lasts for 24 to 48 hours 

Mesna (Mesnex)  

• preventative medication given prophylactically to prevent cystitis

  • ADR- Diarrhea, headache, nausea, fatigue (mild)

Extravasation?

• STOP INFUSION OF DRUG

• Leave infiltrated access in place

• Aspirate any residual drug

• Notify the prescriber

• Instill antidote thru existing access

• Apply sterile occlusive dressing

• Warm/cold compresses as appropriate

• Elevate affected limb 

Other side effects

Photosensitivity

• Increased skin sensitivity to UV exposure

• Drugs causing: 5-FU, Methotrexate, Taxol, Adriamycin, Vincristine

• Sunburn with blisters and erythema; hyperpigmentation

• Avoid tanning booths, sunbathing even on cloudy days

Neurotoxicity

• Numbness and tingling of fingers and toes most common-peripheral

• Sensitivity to cold 

• Mental status changes may be seen-central 

• These are usually reversible when Rx stopped

Nephrotoxicity

• Initial chemotherapy treatment

• Most often hematologic cancers

• Vigorous IV Hydration done

• Occasionally with bicarbonate

• Electrolytes watched closely

• Amofostine = drug given to help prevent kidney damage 

Sexual side effects

• Related to drug, dose, length of treatment, age and sex of patient

• Men: impotence, decreased libido, hot flashes, decreased sperm count, gynecomastia

• Women: irregular or no menses, vaginal dryness, decreased ova production, painful intercourse, decreased libido, hot flashes

Amofostine

Help prevent kidney damage from chemo agent

chemoprotectant

Methotrexate

Chemoagent

Oral, IV, IM, Intrathecal

ADR: Mucositis, nausea, vomiting, alopecia, bone marrow suppression (esp. neutropenia), photosensitivity, renal toxicity, gastric ulcers

Pregnancy category X (for up to 6 mo after treatment)

Non-vesicant

5-Fluorouracil (5-FU)

Indications: colon, rectal, breast, stomach, pancreatic cancer, skin cancers

IV, topical 

ADR: mucositis, nausea, vomiting, diarrhea, bone marrow suppression, mild alopecia, photophobia, rash (with topical route)- may last for 2+ weeks after use, radiation recall

Non-vesicant

Doxorubicin

Indications: solid tumors (lung, bone, stomach, breast cancers); Hodgkin’s and non-Hodgkin’s  lymphomas; sarcomas of soft tissue and bone; carcinoma of ovaries, testes and thyroid

IV infusion               “red devil”

ADR: Bone marrow suppression, nausea, vomiting, alopecia, mucositis, cardiotoxicity, radiation recall, photosensitivity, red urine, sweat (not harmful, lasts 1-2 days)

VESICANT

MUGA^* / Echocardiogram before dosing

ADR all red stuff

CARDIOTOXIC <3

• need baseline cardiac exams

What is radiation recall

• Redness in a previously irradiated area (may be months or years prior) after systemic chemotherapy

• Pattern corresponds to radiation field

• May be painful

• Treat symptomatically

  • antihistamines

  • analgesics

Vincristine (Oncovin)

Used in combination with other chemotherapy agents; leukemia, Wilms tumor, rhabdomyosarcoma, bladder/breast cancers; Hodgkin’s and non-Hodgkin’s  lymphomas; Kaposi’s sarcoma

IV infusion

VESICANT

ADR: alopecia, nausea, vomiting, nerve injury (autonomic nerve injury results in constipation, urinary retention; peripheral nerve injury results in peripheral neuropathy- paresthesias, decreased reflexes, loss of sensation), bone marrow suppression (mild)

AUTONOMIC AND PERIPHERAL NERVE INJURY

Paclitaxel (Taxol)

Indications: ovarian, non-small cell lung tumors, Kaposi’s sarcoma, leukemias

IV infusion

VESICANT (usually an irritant, but can be considered vesicant)

ADR: bone marrow suppression, alopecia (severe), arthralgia/ myalgia, nausea, vomiting, diarrhea, peripheral neuropathy, hypersensitivity reactions, mucositis, renal toxicity, radiation recall

severe alopecia

Cyclophosphamide (Cytoxan)

Indications: cancer of the ovaries, breast, blood lymph system, neuroblastoma (mainly in children); retinoblastoma, multiple myeloma, nephrotic syndrome and immunosuppression in rheumatic disorders (ex. SLE, juvenile idiopathic vasculitis)

PO, IV

ADR: hemorrhagic cystitis, alopecia, nausea, vomiting, hemorrhagic colitis, mucositis, neutropenia

Cisplatin

Indications: bladder, testicular, ovarian cancers; off-label cervical, endometrial, prostate cancer; bone marrow transplants

IV infusion

VESICANT

ADR: nause, vomiting (highly emetogenic), nephrotoxicity, ototoxicity (esp. children), bone marrow suppression, alopecia, anaphylaxis

LOTS of VOMITING

Nephrotoxic, ototoxic

Bleomycin

Indications: testicular, lymphoma, squamous cell carcinomas, Hodgkin’s disease

IV infusion

Irritant

ADR: Pulmonary fibrosis and pneumonitis (fatal in 1% of clients), mucositis, stomatitis, acute febrile reaction, mucocutaneous toxicity (rash, erythema, hyperpigmentation, urticaria), alopecia

Pulmonary toxic!

• fobrisis, pneumonitis

Hormonal Chemo agents

hormone-blocking tumors (breast cancers, testicular cancers)

Tamoxifen

Indications: breast cancer (treatment and prevention in high-risk women*)

Estrogen receptor blocker; stops growth of breast cancer cells, which are estrogen-dependent cancers

ADR: hot flashes, vaginal discharge, menstrual changes, bone pain (increased calcium), endometrial cancer (<1%), thromboembolic event (DVT, PE, CVA) (<1%), n/v

Stops growth of breast cancer cells

hormonal side effects

Nursing interventions: 

• Monitor calcium levels

• Monitor for abnormal vaginal bleeding, discharge

• Administer fluids and antiemetics as needed

Client education: Have yearly gynecological exam (risk of endometrial cancer); report chest pain, shortness of breath, or leg pain/ edema (DVT/ PE); educate client about hot flashes

estrogen EQUALS

clots