8.2: Chemotherapeutic Drugs
By the end of this section, you should be able to:
- 8.2.1 Identify principles of proper handling of chemotherapeutic agents.
- 8.2.2 Discuss different administration methods, phases, routes of administration, and types of chemotherapy.
- 8.2.3 Describe major side effects of chemotherapeutic agents.
- 8.2.4 Identify characteristics of different classes of chemotherapeutic agents used in cancer treatment.
- 8.2.5 Explain the indications, actions, adverse reactions, and interactions of chemotherapeutic agents used in cancer treatment.
- 8.2.6 Describe the nursing implications of chemotherapeutic agents.
- 8.2.7 Explain the client education related to chemotherapeutic agents.
Handling of Chemotherapeutic Agents
The complexity of administering chemotherapy and caring for clients that have been treated with cancer therapies requires advanced knowledge. Special training and certifications to administer chemotherapy are required. Chemotherapy agents may cause cytotoxic exposure to those who compound and administer these drugs as well as to clients, families, and other caretakers who might be exposed through spills, improper handling and disposal, and other means. Proper training in compounding, administering, and managing exposure emergencies is a requirement of all personnel who work with chemotherapy. Principles of appropriate handling include, but are not limited to, storage of cytotoxic substances in impervious containers, double gloving (chemotherapy-rated gloves), compounding in a negative-pressure hood, and disposing of cytotoxic substances based on national standards and institutional policies.
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Chemotherapy Administration Safety Standards
The Oncology Nursing Society , a leader in developing oncology standards, developed chemotherapy administration guidelines and safety standards to assist nurses in safely administering chemotherapy and other cancer treatments. Advances in technology, cancer treatment, and nursing training prompted the need for a periodic review and revision of the standards for general oncology practices. The latest standards include pediatric oncology practices and new standards affecting chemotherapy prescription, preparation, and administration (Oncology Nursing Society, 2023).
Cancer Treatments
Chemotherapy may be given for many different reasons. Often, it is given as a curative measure to eradicate all malignant cells. However, cure is not always realistic. When cure is not attainable, chemotherapy can be used to decrease tumor size and prevent metastasis, and sometimes it may be used for palliation and symptom control. Differing regimens of chemotherapy are used for varying client needs (see Table 8.1).
| Type of Therapy | Description |
|---|---|
| Adjuvant therapy | Given after initial treatment with surgery to destroy leftover cells |
| Neoadjuvant therapy | Initial treatment given to shrink the cancer before surgery |
| Salvage therapy | Second-line therapy given when first-line therapy is unsuccessful |
| Targeted therapy | Given to selectively kill cancer cells without harming normal cells |
| Biologic therapy | Used to enable the immune system to better kill cancer cells |
Link to Learning
This video describes the typical day and process of the treatment of a client receiving chemotherapy.
Phases of Chemotherapy
There are three phases of chemotherapy, beginning with induction. This phase is also known as first-line, front-line, or primary therapy. During this phase, the goal is to induce a remission. For most tumors, this may be the only phase required. For hematological cancers, clients may undergo a second phase, called consolidation, intensification, or post-remission therapy. This phase is used after a remission has been achieved, with a goal of eradicating any remaining cancer cells. The third phase, the maintenance phase, may be used either after induction or after consolidation. In this phase, a maintenance dose of chemotherapy is given to prevent reoccurrence of cancer. This phase is the longest phase and may last for several years.
Routes of Chemotherapy Administration
Chemotherapy may be administered by different routes depending on the purpose and toxicities of each individual drug. These different routes include oral, intravenous, subcutaneous, intramuscular, intracavitary, topically, and intrathecally. Intracavitary administration involves the infusion of a chemotherapeutic agent into a body cavity such as the bladder or abdomen. Intrathecal administration involves instilling chemotherapy into the spinal column or intracranially to treat cancers in the central nervous system. For drugs that are vesicant s , which have the ability to cause necrosis if they extravasate , the intravenous route must be used. When a vesicant drug is being administered, slow administration in a rate/minute modality and vigilant assessment of the intravenous infusion site must be performed. Maintaining patency of the administration site is paramount to preventing tissue injury (see Figure 8.3).
Types of Chemotherapy
There are many different classifications of chemotherapy drugs, many of which fall into one of two broad categories—cell-cycle specific and cell-cycle nonspecific therapies. Each cell goes through five phases of mitosis before producing daughter cells (see Figure 8.4). Chemotherapy agents that cause cancer cell death in all phases of mitosis are referred to as cell-cycle nonspecific (CCNS) , whereas those that are effective only in one phase of mitosis are called cell-cycle specific agents (CCS) . In combination chemotherapy, both CCS and NCCS agents are used to eliminate cancer cells more completely.
Adverse Effects and Contraindications
Alkylating agents are some of the most toxic chemotherapies used in cancer treatment. One benefit of these toxicities is that drugs like busulfan can be used to eradicate bone-marrow production prior to stem-cell and bone-marrow transplants. This reduces recurrence of the primary disease after transplant. However, alkylating agents are known for the negative effects associated with administration of these drugs. Short-term side effects include myelosuppression, which usually occurs 6–10 days after administration, with recovery after 14–21 days. Myelosuppression resulting in neutropenia can result in severe infections and sepsis. Mucositis , nausea, and vomiting are side effects that affect the client’s overall nutritional status. Neurotoxicity and alopecia are also short-term side effects. Long-term (delayed) effects of alkylating agents include pulmonary fibrosis, infertility, and secondary malignancies (Amjad & Kasi, 2020). These long-term effects may occur months after treatment or may develop many years later.
Table 8.4 is a drug prototype table for alkylating agents featuring cyclophosphamide. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Alkylating agent–nitrogen mustard Cell cycle nonspecific Mechanism of Action Causes crosslinking of DNA during mitosis to cause nucleic acid chain breakage resulting in cell destruction |
Drug Dosage
Oral: 1–5 mg/kg once daily. Intravenous (IV) (monotherapy): 40–50 mg/kg given in divided doses over 2–3 days, or 10–15 mg/kg given every 7–10 days. IV (combination therapy): 3–5 mg/kg given twice weekly. Note: Doses may be reported in grams versus milligrams. |
|
Indications
Lymphomas Multiple myeloma Leukemia Ovarian and breast cancers Therapeutic Effects Reduction of cancer cells |
Drug Interactions
Protease inhibitors Angiotensin-converting enzyme (ACE) inhibitors Thiazide diuretics Zidovudine Amiodarone |
|
Adverse Effects
Myelosuppression Sepsis Nephrotoxicity Pulmonary toxicity Cardiotoxicity Infertility Hyponatremia |
Contraindications
Myelosuppression Urinary outflow obstruction Caution: Monitor for hemorrhagic cystitis Mesna may be used in high-dose therapy to prevent bladder irritation |
Nursing Implications
The nurse should do the following for clients who are taking alkylating agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Become familiar with the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an alkylating drug should:
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria (cyclophosphamide), changes in hearing (cisplatin).
- Remain well hydrated. Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous access at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Monitor for and report any long-term effects of the chemotherapy.
- Follow up with all recommended health screenings.
- Report any concerning signs and symptoms to their health care provider.
The client taking an alkylating drug should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect their hands from the risk of bacterial contamination.
- Clean feline litter boxes to decrease the risk of exposure to bacteria or parasites.
- Take vaccines without their health care provider’s approval.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Various Alkylating Agents
Busulfan injection causes severe and prolonged myelosuppression at the recommended dosage.
Carboplatin causes severe bone marrow suppression, resulting in bleeding, infection, and anemia. Anaphylactic-like reactions to carboplatin may occur within minutes of administration.
Carmustine causes bone marrow suppression, which may contribute to bleeding and overwhelming infection. In cumulative doses above 1400 mg/m 2 , pulmonary toxicity is a significant risk.
Chlorambucil causes severe bone marrow suppression and infertility and is carcinogenic, mutagenic, and teratogenic.
Cisplatin causes severe renal toxicity that is dose related and cumulative. Peripheral neuropathy occurs and is cumulative with repeat courses. Cisplatin causes severe nausea and vomiting. Bone marrow suppression may be severe, requiring interruption of therapy.
Lomustine causes severe, dose-related, delayed, and cumulative myelosuppression, occurring 4–6 weeks after administration. Overdose is fatal. Only 1 dose should be dispensed with each prescription.
Oxaliplatin may cause anaphylactic-like reactions that may occur within minutes of administration.
Antimetabolites
Antimetabolite chemotherapies are a group of drugs that prevent cancer cell growth by imitating metabolites, which are substances necessary for tumor cell growth. Cancer cells use these substances, which, once inside the cell, prevent DNA replication. This results in cell death. Within this class, there are three types of metabolites that are inhibited: purines, pyrimidines, and folic acid. Each drug in this class specifically targets replacement of one of these substances. The most common drugs within this class are fluorouracil, fludarabine, gemcitabine, and methotrexate. Common side effects include nausea and vomiting, diarrhea, anorexia, stomatitis, alopecia, and myelosuppression. Antimetabolites are useful in treating leukemias, lymphomas, and cancers of the gastrointestinal and biliary tracts.
Table 8.5 lists common antimetabolite agents and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Folate Antimetabolites | |
|
Methotrexate
( Trexall ) |
Intrathecal:
6–15 mg/m
2
age-based dose; frequency depends on regimen.
IV: 10 mg/m 2 up to 12,000 mg/m 2 at varying frequencies depending on the diagnosis and treatment regimen. |
|
Pemetrexed
( Alimta ) |
500 mg/m 2 IV every 21 days. |
| Pyrimidine Antimetabolites | |
|
5-Fluorouracil
(5-FU) |
Colon/rectal adenocarcinoma:
400 mg/m
2
IV bolus followed by 2400–3000 mg/m
2
continuous infusion over 46 hours every 2 weeks.
Pancreatic adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400 mg/m 2 continuous infusion over 46 hours every 2 weeks. Breast adenocarcinoma: 500–600 mg/m 2 IV days 1 and 8 every 28 days for 6 cycles. Gastric adenocarcinoma: 200–1000 mg/m 2 IV over 24 hours at varying frequencies depending on regimen. |
|
Capecitabine
( Xeloda ) |
1250 mg/m 2 orally twice daily for 2 weeks followed by a 1-week rest period. |
|
Cytarabine
( Ara-C ) |
IV:
100 mg/m
2
daily as a single treatment over 7 days.
Intrathecal: 5–75 mg/m 2 once every 4 days. |
| Purine Antimetabolites | |
|
Mercaptopurine
( Purixan ) |
1.5–2.5 mg/kg orally once daily. |
|
Thioguanine
( Tabloid ) |
2–3 mg/kg orally daily. |
|
Gemcitabine
( Gemzar ) |
1000 mg/m 2 IV on days 1 and 8 of a 21-day cycle. |
|
Fludarabine
( Fludara ) |
25 mg/m 2 IV daily for 5 days, every 28 days. |
Adverse Effects and Contraindications
Antimetabolites are associated with many adverse effects. Folate antimetabolites are associated with myelosuppression, mucositis, hepatotoxicity, nephrotoxicity, and cutaneous reactions. Pyrimidine antimetabolites cause mucositis and myelosuppression as well but are also associated with dose-limiting hand-foot syndrome and diarrhea. Contraindications for fluorouracil include clients with dihydropyridine dehydrogenase (DPD) deficiency, which may result in toxic levels of fluorouracil. This can lead to cardiac dysfunction, colitis, neutropenia, and encephalopathy. Uridine triacetate is used to treat toxicity in these clients. Cytarabine is associated with inflammation of the conjunctiva. Corticosteroid eye drops are used prophylactically to prevent this. Purine antimetabolites, in addition to causing myelosuppression, also decrease the CD4 lymphocyte count, resulting in immunosuppression and risk of opportunistic infections (Amjad & Kasi, 2020).
Table 8.6 is a drug prototype table for antimetabolites featuring fluorouracil. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Antimetabolite (pyrimidine antagonist) Mechanism of Action Antagonizes metabolites necessary for cell growth, results in apoptosis (cell death) of cancerous cells |
Drug Dosage
Colon/rectal adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400–3000 mg/m 2 continuous infusion over 46 hours every 2 weeks. Pancreatic adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400 mg/m 2 continuous infusion over 46 hours every 2 weeks. Breast adenocarcinoma: 500–600 mg/m 2 IV days 1 and 8 every 28 days for 6 cycles. Gastric adenocarcinoma: 200–1000 mg/m 2 IV over 24 hours at varying frequencies depending on regimen. |
|
Indications
Breast, colon, pancreatic, and gastric cancers Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Warfarin |
|
Adverse Effects
Mucositis Diarrhea Hand-foot syndrome Myelosuppression Neurotoxicity Gastrointestinal ulcers |
Contraindications
Hypersensitivity Decreased dipyridine dehydrogenase Caution: Increases international normalized ratio (INR) when administered to clients receiving warfarin |
Nursing Implications
The nurse should do the following for clients who are taking antimetabolite agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, oral mucosa, skin, eyes (cytarabine), and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes. Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and spill protocols.
- Be aware of drugs’ boxed warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an antimetabolite agent should:
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, eye irritation (cytarabine), and mouth ulcers (fluorouracil).
- Remain well hydrated.
- Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Monitor and report any long-term effects.
- Follow up with recommended screenings for early identification of any secondary malignancies.
The client taking an antimetabolite should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to decrease the risk of exposure to mold and bacteria.
- Clean feline litter boxes to minimize bacteria or parasite exposure.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Antimetabolites
Methotrexate causes embryo-fetal toxicity, hypersensitivity reactions, benzyl alcohol toxicity, and other serious adverse reactions.
Capecitabine causes increased risk for bleeding when administered with coumarins such as warfarin.
Fludarabine causes severe central nervous system toxicity, including blindness, coma, seizures, and death. Autoimmune syndromes including hemolytic anemia, thrombocytopenia, and hemophilia may occur with fludarabine administration. Concomitant use of deoxycoformycin (pentostatin) may cause fatal pulmonary toxicity.
Anthracyclines/Antitumor Antibiotics
Anthracyclines are some of the most potent chemotherapies on the market today. These drugs are very strong vesicants that cause severe necrosis when extravasated. Three major drugs in this class are daunorubicin, doxorubicin, and epirubicin. These drugs cause cell death by preventing DNA replication. They do this by inhibiting topoisomerase, leaving DNA strands unable to unwind and replicate. The major side effects of anthracyclines are myelosuppression, nausea and vomiting, alopecia, skin and nail hyperpigmentation, and, most notably, cardiotoxicity. Many drugs in this class are red in color and can resultingly cause urine and other body fluids to turn red/orange. This is a benign side effect but is usually discussed with clients to avoid any panic. These drugs are assigned maximum lifetime dose limits to aid in preventing debilitating chemotherapy-induced heart failure. Additionally, clients must have a left ventricular ejection fraction of at least 55% to receive these drugs. Table 8.7 lists common anthracyclines/antitumor antibiotics and typical routes and dosing for adult clients.
| Drug | Drug Routes and Dosages |
|---|---|
| Anthracyclines/Antitumor Antibiotics | |
|
Daunorubicin
( Cerubidine ) |
25–45 mg/m 2 IV; frequency depends on cancer type and other agents administered in combination (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Doxorubicin
( Adriamycin , Doxil ) |
60–75 mg/m 2 IV every 21 days (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Epirubicin
( Ellence ) |
IV: 100–120 mg/m 2 frequency depends on prescribed regimen (720 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
| Other Anthracyclines | |
|
Bleomycin
( Blenoxane ) |
0.25–0.5 units/kg (10–20 units/m 2 ) given IV, intamuscularly, or subcutaneously weekly or twice weekly. (Drug may be discontinued if pulmonary toxicity occurs.) |
|
Dactinomycin
( Cosmegen ) |
12–1250 mcg/m 2 IV; frequency depends on cancer type. |
|
Mitomycin
( Mutamycin ) |
20 mg/m 2 IV at 6–8 week intervals. |
Adverse Effects and Contraindications
Anthracyclines and antitumor antibiotics are associated with very serious adverse effects. In general, the drugs cause significant myelosuppression, alopecia, and nausea and vomiting. Doxorubicin and daunorubicin are associated with both short- and long-term cardiotoxicity. These drugs are contraindicated in clients with preexisting cardiac disease when the left ventricular ejection fraction is less than 55%. Clients receiving doxorubicin are also limited to a lifetime cumulative dose of 550 mg/m 2 . Bleomycin administration requires vigilant monitoring for cumulative pulmonary toxicity and fibrosis . Doxorubicin and daunorubicin are vesicant drugs that cause severe necrosis if extravasation into tissues occurs.
Table 8.8 is a drug prototype table for anthracycline agents featuring doxorubicin. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Anthracycline/antitumor antibiotic Mechanism of Action Inhibits topoisomerase to prevent DNA replication |
Drug Dosage
60–75 mg/m 2 IV every 21 days (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Indications
Breast, bronchogenic, and thyroid cancers Leukemia Lymphoma Sarcoma Wilms tumor Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Paclitaxel Trastuzumab 6-mercaptopurine Dexrazoxane (may be used as a cardioprotective agent in certain populations or upon extravasation) |
|
Adverse Effects
Cardiotoxicity Myelosuppression Alopecia Hyperpigmentation of skin and nails Stomatitis |
Contraindications
Hypersensitivity Myelosuppression Decreased cardiac function Caution: 550 mg/m 2 maximum lifetime limit Client must have ejection fraction of at least 55% to receive doxorubicin Severe necrosis with extravasation |
Nursing Implications
The nurse should do the following for clients who are taking anthracyclines/antitumor antibiotic agents:
- Assess client overall well-being prior to chemotherapy administration including vital signs, hydration status, oral mucosa, skin, and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, liver enzymes, and left ventricular ejection fraction and pulmonary function tests (bleomycin).
- Carefully record cumulative doses when lifetime limits are necessary.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an anthracycline/antitumor antibiotic agent should:
- Know signs and symptoms to report to the health care provider, including fever, chills, productive cough, urinary symptoms, hematuria, palpitations, chest pain, shortness of breath (doxorubicin, daunorubicin, epirubicin), pulmonary pain, and breathing difficulties (bleomycin).
- Remain well-hydrated.
- Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Follow up with screenings for long-term effects and secondary malignancies.
The client taking an anthracycline and antitumor antibiotic agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect hands from direct contact with bacteria and mold present in the soil.
- Clean feline litter boxes to reduce risk of contact with bacteria and parasites.
- Take vaccines without prior approval of their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Doxorubicin and Epirubicin
Potentially fatal congestive heart failure can occur during or years after therapy. The probability is based on the total cumulative doses received.
Secondary acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS) has been reported in clients taking these medications.
Plant Alkaloids
Several chemotherapies are derived from plants and are considered plant alkaloids . Vinca alkaloids are the most common plant alkaloids. Vincristine, vinblastine, and etoposide (VP-16) are all plant alkaloids that cause misalignment of chromosomes in cancer cells, resulting in apoptosis, or cell death. These are useful in treating lymphomas, leukemias, Kaposi sarcoma, squamous cell carcinomas, lung cancer, and bladder cancer. Side effects include myelosuppression, mouth sores, nausea, vomiting, and fatigue. The most significant adverse effects involve the nervous system. Because plant alkaloids decrease nerve function, these substances can cause hearing loss, neuropathies, and severe constipation that may develop into a paralytic ileus. Neurologic symptoms may necessitate discontinuance of therapy. Vinca alkaloids are often part of regimens that also require intrathecal administration. However, close attention and safety measures (i.e., drug is always compounded in an IV bag for infusion) must be in place to ensure these are never administered via the intrathecal route. The drugs are fatal if administered intrathecally.
Table 8.9 lists common plant alkaloids and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Vincristine
( Oncovin ) |
1.4 mg/m 2 IV weekly. |
|
Vinblastine
( Velban ) |
3.7 mg/m 2 IV initial dose; subsequent doses up to 18.5 mg/m 2 administered weekly. |
|
Etoposide
( Vepesid , VP-16 ) |
35–100 mg/m 2 IV; frequency depends on cancer type and other agents administered. |
Adverse Effects and Contraindications
Peripheral neuropathy is a common but serious adverse effect of plant alkaloids. Both motor and sensory functions are affected, and neuropathy can be severe enough to result in paralytic ileus. Myelosuppression is another adverse effect caused by plant alkaloids. These drugs are classified as irritants, which may cause significant irritation to the skin should extravasation occur.
Table 8.10 is a drug prototype table for plant alkaloids featuring vincristine. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Plant alkaloid Mechanism of Action Causes chromosomal link errors, results in apoptosis of cancerous cells |
Drug Dosage
1.4 mg/m 2 IV weekly. |
|
Indications
Lymphoma Leukemia Kaposi sarcoma Squamous cell carcinoma Lung cancer Bladder cancer Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Anticonvulsants Amiodarone Carvedilol Erythromycin Fluconazole Rifampin Warfarin Food Interactions Grapefruit |
|
Adverse Effects
Neuropathy Severe constipation Paralytic ileus Urinary retention Hearing loss Alopecia |
Contraindications
Hypersensitivity Charcot-Marie-Tooth disease Caution: For intravenous administration only Fatal if administered intrathecally Causes severe irritation with extravasation |
Nursing Implications
The nurse should do the following for clients who are taking plant alkaloid agents:
- Assess client overall well-being prior to chemotherapy administration including vital signs, hydration status, oral mucosa, skin, weight, bowel function, and signs of neuropathy.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Inspect drug preparation to ensure that these drugs are properly mixed and prepared as intravenous infusions. Do not administer these medications directly to the client using a syringe. This will decrease the risk of having the medication erroneously administered intrathecally, which can be fatal. Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a plant alkaloid agent should :
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, decreased bowel elimination or constipation, hearing loss, and peripheral neuropathy.
- Remain well hydrated and use stool softeners and laxatives when needed.
- Report side effects including nausea and vomiting, mucositis, and constipation.
- Learn how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Understand the need for surveillance for long-term effects and secondary malignancies.
The client taking a plant alkaloid agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to avoid direct contact with potentially contaminated soil.
- Clean feline litter boxes to protect hands from contamination by bacteria or parasites.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
Taxanes
Taxanes are a group of chemotherapeutic agents that were developed from the bark of a yew tree. These are effective in the treatment of breast, ovarian, prostate, gastric, esophageal, pancreatic, and non-small cell lung cancers as well as Kaposi sarcoma. These agents are typically used in combination with other agents rather than as a monotherapy. Adverse reactions include, most notably, hypersensitivity reactions. For this reason, clients will be premedicated, usually with corticosteroids, but may also receive diphenhydramine and a histamine-2 receptor antagonist to prevent these reactions from occurring. Other adverse effects include hepatotoxicity, fluid retention, myelosuppression, alopecia, skin and nail changes, and nausea, vomiting, and diarrhea.
Table 8.11 lists common taxanes and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Docetaxel
( Taxotere ) |
60–100 mg/m 2 IV every 3 weeks. |
|
Paclitaxel
( Taxol ) |
100–175 mg/m 2 IV every 3 weeks. |
Adverse Effects and Contraindications
Taxanes are most known for the adverse effect of hypersensitivity reactions. A test dose and premedication with antihistamines and acetaminophen may be used prior administration. Myelosuppression may result in lowered levels of platelets and white blood cells. Taxanes are contraindicated in solid tumors with myelosuppression with neutrophil counts under 1500 cells/mm 3 . Peripheral neuropathy is also commonly associated with taxanes, resulting in pain and limited movement. Fatigue and arthralgias are also seen with these drugs. Cardiovascular changes including hypotension, bradycardia, hypertension, and electrocardiogram (ECG, EKG) changes may be noted (DailyMed, Paclitaxel , 2023).
Table 8.12 is a drug prototype table for taxanes featuring paclitaxel. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Taxane Mechanism of Action Binds to microtubules to block spindle formation during mitosis, blocking cell division during the M phase of mitosis |
Drug Dosage
100–175 mg/m 2 IV every 3 weeks. |
|
Indications
Breast, ovarian, and non-small cell lung cancers Kaposi sarcoma Therapeutic Effects Prevents tumor cell growth |
Drug Interactions
Midazolam Buspirone Statins Felodipine Protease inhibitors Repaglinide Rifampin |
|
Adverse Effects
Hypersensitivity reactions Myelosuppression ECG changes Peripheral neuropathy Arthralgia Nausea Vomiting Diarrhea Mucositis Alopecia Infusion site reactions |
Contraindications
Hypersensitivity Myelosuppression with neutrophil counts under 1500 µL Caution: May cause anaphylaxis due to the medication vehicle, not the drug itself Must premedicate |
Nursing Implications
The nurse should do the following for clients who are taking taxane agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, oral mucosa, skin, weight, cardiac function, and signs of neuropathy.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a taxane agent should:
- Recognize signs and symptoms to report to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, decreased bowel elimination or constipation, hearing loss, and peripheral neuropathy.
- Understand the importance of remaining well hydrated and use stool softeners and laxatives when needed.
- Learn how to manage side effects including nausea and vomiting, mucositis, and constipation.
- Understand how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Understand the need for surveillance and follow-up for management of long-term effects and early identification of secondary malignancies.
The client taking a taxane agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect hands from exposure to bacteria and mold.
- Clean feline litter boxes to protect hands from direct contact with bacteria.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting with their health care provider.
- Become pregnant.
FDA Black Box Warning
Docetaxel
Docetaxel has been associated with fatalities among clients with abnormal liver function, who are receiving higher doses, with non-small cell carcinoma, or with a history of receiving platinum-based chemotherapy including cisplatin, carboplatin, and oxaliplatin.
Common Drugs Used as Supportive Therapies for Clients Receiving Chemotherapy
Because chemotherapy regimens are so complex, supportive care with other pharmacologic agents is usually required. Management of adverse effects is critical to safe and successful chemotherapy treatment. Myelosuppression and nausea and vomiting are most commonly managed with supportive therapies. Corticosteroids and biologic colony stimulating factors are frontline supportive therapies. Table 8.13 encompasses the most common supportive therapies that may be necessary when administering chemotherapy.
| Classification/Drug | Routes and Dosages | Use |
|---|---|---|
| Corticosteroids | ||
|
Dexamethasone
( Decadron ) |
Oral:
0.75–9 mg/day.
IV/intramuscular: 0.5–9 mg/day. |
Decreases nausea and vomiting.
Used as premedication to reduce hypersensitivity reactions. |
| Antihistamines | ||
|
Diphenhydramine
( Benadryl ) |
Oral:
25–50 mg every 4–6 hours as needed.
IV/intramuscular : 10–50 mg up to 100 mg if required; 400 mg maximum daily dose. |
Treats/prevents hypersensitivity reactions. |
|
Loratadine
( Allegra ) |
Oral: 10 mg 1 hour prior to chemotherapy initiation. | Prevents hypersensitivity reactions. |
| Colony Stimulating Factors | ||
|
Filgrastim
( Neupogen ) |
5–10 mcg/kg/day administered as a single daily subcutaneous or IV injection or by continuous subcutaneous or IV infusion. |
Stimulates bone marrow stem cells to produce increased neutrophil production.
Prevents infection. |
|
Pegfilgrastim
( Neulasta ) |
6 mg/dose subcutaneously. |
Stimulates bone marrow stem cells to produce increased neutrophil production.
Prevents infection. |
|
Epoetin alfa
( Epogen ) |
150 units/kg subcutaneously 3 times weekly or 40,000 units/dose weekly; titrated based on hemoglobin response. |
Stimulates bone marrow stem cells to produce increased erythocyte production.
Prevents/treats anemia. |
These supportive therapies can increase the client’s quality of life as well as decrease risks associated with pancytopenia, such as sepsis and decreased oxygen-carrying capacity of the blood. The advent of biologic colony stimulating factors marked a significant decrease in sepsis-related deaths for clients receiving chemotherapy. Ondansetron, specifically, has greatly changed the way chemotherapy-related nausea and vomiting are treated. Traditional phenothiazines cause vein and tissue irritation as well as central nervous system depression, placing a client at risk for injury. Ondansetron does not affect central nervous system function, reducing the risk of falls and other injuries.
FDA Black Box Warning
Erythropoiesis-Stimulating Agents (ESAs)
Erythropoiesis-stimulating agents (ESAs) increase the risk of death, myocardial infarction, stroke, venous thromboembolism, and tumor progression or recurrence.
Unfolding Case Study
Part A
Read the following clinical scenario to answer the questions that follow. This case will evolve throughout the chapter.
Guadalupe Himenez is a 32-year-old female client who presents to the oncology clinic for her first visit after recently being diagnosed with breast cancer. She initially saw her gynecologist after detecting a lump in her left breast. Her provider ordered a mammogram and biopsy, which determined the mass was malignant, and a surgeon performed a lumpectomy to remove it. The surgeon has referred her to the oncologist to start chemotherapy. Prior to this, she has been in good health without any chronic medical conditions.
Social History
Tobacco use: None
Alcohol use: Occasionally drinks socially
Married with two children
Current Medications
None
| Vital Signs | Physical Examination | |
|---|---|---|
| Temperature: | 98.2°F |
|
| Blood pressure: | 122/76 mm Hg | |
| Heart rate: | 73 beats/min | |
| Height: | 5'7" | |
| Weight: | 174 lb |
While completing the initial assessment, which of the following is a priority to assess?
- Answer
-
Date of last menstrual period
After discussing all the treatment options, Guadalupe consents to starting chemotherapy. What type of treatment is this?
- Answer
-
Adjuvant therapy