Kristina Popovic SPN Pharmacology II Antineoplastics Due: August 27, 2012

Antineoplastic medications are also known as chemotherapeutic agents. They are

used to treat cancerous or malignant diseases. Antineoplastic medications are split into five categories: alkylating agents, antibiotic preparations, antimetabolies, hormones and miotic inhibitors. They can be used together or individually to treat patients. Alkylating agents interfere with the normal process of cell division. The drugs attach to deoxyribonucleic acid (DNA) in the tumor cells and go trough a process called alkylation. Alkylation is when the drug changed the structure of the DNA in the cancer cells and prevent them from functioning, resulting in the stop of new cancer cells forming. The drug does not kill the cancerous cell until it tries to divide into daughter cancer cells. That is the most widely used drug for cancer. Antibiotic preparations delay or prevent cell division of malignant cells. This happens when the drug interferes with the DNA synthesis of the cancer cell. They are the most toxic of all antineoplastic drugs. Antimetabolies work by disrupting normal cell function by interfering with the different parts of the metabolic functions of the cancer cells. They also interrupt critical cell pathways in cells. Because cancer cells reproduce rapidly they require a lot of nutrients to build proteins and nucleic acids. Antimetabolies resemble the essential building blocks of the cells, and when the cancer cells consume them, the results are retarding growth and death. This action works best on rapidly diving cancer cells, as well on normal rapid developing cells like hair and skin cells. Male or female sex hormone therapy involves cancer cells that are effected by sex glands or tissues. These include cancers such as breast cancer and even prostate cancer treatment. Patients are administered high doses of specific hormones or hormone antagonists. What this does is, block the receptors in reproductive tissue hormones and slow tumor growth. The last category are mitotic inhibitors. They act on cancer cells by directly interfering with cell division or directly stopping cell division.

Antineoplastic agents are some of the most dangerous drugs that can be given to patients. The patients have to be educated on the various side effects on the drugs as well as the benefits, and decide on the drug whose benefits outweigh the risks most. Some of the most common effects are nausea, vomiting, loss of appetite, diarrhea, alopecia and bone marrow suppression. These medications must be administered carefully following the directions of dosage, frequency and route. They are very toxic and can pose a threat to the nurse as well, special precautions to avoid exposure to healthy tissue must be taken very seriously. Some preparations have to be given by either a physician or a trained chemotherapy nurse. Four medications of antineoplastics are chlorambucil, daunorubicin, bleomycin and tamoxifen. Chlorambucil is an antineoplastic alkylating agent. This drug is used for Hodgkin disease, chronic lympocytic leukemia, malignant lymphomas. The generic name is chlorambucil, and the brand name is Leukeran. Chlorambucil is given to patients with chronic lymphocytic leukemia, Hodgkins disease, and malignant lymphomas. The drug alkylates DNA and RNA by inhibiting with enzymes that allow synthesis of amino acids in proteins. The activity can happen in any step of the cell cycle. This drug only comes in the oral form. When administering to adults the dosage starts P.O 0.1-0.2 mg/kg/day for 3 to 6 weeks. Then the dose is changed to a maintenance dose of 4-10 mg a day. For the geriatric patient the dose is equal to or less than 2 to 4 mg a day. For the child the dose is either 0.10.2 mg/kg/day or 4.5 mg/m2.day. This dose is given in one dose or divided doses for three to six weeks. (Mosby, 281) The side effects on the central nervous system are: seizures, confusion, agitation, ataxia and hallucinations. The G.I is effected by nausea, vomiting, diarrhea, weight loss, hepatoxicity and jaundice. Genitourinary system is effected by,

hyperuremia. The hematologic system is effected by thrombocytopenia, leukpenia, pancytopenia from prolonged use, and permanent bone marrow depression. The inetgumentary system effects are alopecia, dermatitis, rash and Steven-Johnsons syndrome. The respiratory system effects are fibrosis and pneumonia. Chlorambucil interacts with a few drugs. Filreastim, sargrmostin is contridicted 24 hours prior to or after chemotherapy. This drug should not be used at the same time as nalidixic acid or live virus vaccines. Other antineoplastics and radiation can increase the risk for toxicity. Anticoagulants and salicylates increase the risk for bleeding. As a nurse there are assessments that need to be done such as assess for bleeding, hematuria, bruising, petechia and mucosa every eight hours. Also check for jaundice, slera, dark urine and stool, itchy skin, abdominal pain, fever and diarrhea. A respiratory check of dyspnea, crackles, unproductive cough, chest pain and tachypnea. If there is alopecia that nurse should talk to the patient and observe for any signs of decreased self esteem or disturbed body image. There should be a Complete Blood Count lab, weekly platelet count is the white blood cells are lower than 2000 or granulocyte is lower than 1000 per mm^3 notify physician. There should also be pulmonary tests, BUN, renal studies, x-rays, hepatic studies and I&O ratio. If there is an output of less than 30 mL it should be reported. And lastly asses for therapeutic effects by monitoring the tumor size, and spread of malignancy. The patient should be educated on the dosage, they should take it at bedtime with an antimetic to avoid nausea. The patient should drink two to three liters of water a day. Teach the patient and family to report any infections, increased body temperature, persistent cough and flu like symptoms. Report signs of anemia, fatigue, faintness, shortness of breath, seizures, jaundice and bruising. To prevent bleeding the patient should be taught to

avoid use of razors, commercial mouthwash, aspirin and ibuprophen products. Report and changes in breathing or coughing, increase fluids. And avoid use of contraceptives and breastfeeding. DAUNOrubicin is an antineoplastic that inhibits DNA synthesis. This drug is used for adult leukemias. The generic name is DAUNOrubicin and the band name is Cerubidine. This drug is administered IV, the adult dose is 45-60 mg/m^2/day for three days, then two days of subsequent courses in combination with doses of 400-600 mg/m^2. For children the IV dose is 30-40 mg/m^2/day, for children less than two years the dose is less than 0.5 m^2. It is also available in an intramuscular dose of 20 mg powder/vial. After being constituted the solution for injection is 2mg/mL. The side effects of DAUNOrubicin are fever and chills on the central nervous system. The cardiovascular system is affected by side effects such as dysrythmias, CHF, pericarditis, myocarditis and peripheral edema. The G.I. is has side effects such as nausea, vomiting, anorexia, mucositis and hepatoxicity. The genitourinary system may be effected by impotence, steritlity, amenorrhea and gynecomastia. The blood and skin may see effects such as throbocytopenia, leukopenia, anemia, rash, extravasation, dermatitis, alopecia, cellulitis, thrombophlembitis at the injection site. And a system reaction os anaphylaxis is another possible adverse effect. This drug is contradicted for patients who are pregnant or breastfeeding, have hypersensitivity, systemis infections, cardiac disease and bone marrow depression. Drug interactions are as follows; With the use of NSAISs and salicylates the risk for bleeding is increased. Toxicity is increased with the use of other antineoplastic, radiation and cyclophosphamide. The effects of this drug are decreased antibody reaction with th use of live virus vaccines. This drug will increase uric acid. Laboratory tests that need to done and monitored are CBC,

differential platelet count every week, renal studies, BUN, urine CCr, electrolytes baseline before administration of each dose, I7O ratio, report if the outcome is less than 30mL and hour. Temperature needs to monitored every four hours, hepatic studies need to be done for the following prior to each dose: bilirubin, AST, ALT, akaline phosphate for jaundice of skin, sclera, dark urine. The patient needs to be taught to report any signs of an infection, bruising or bleeding, shortness of breath, swelling and change in heart rate. If the patient experiences fever, abdominal pain, dark tarry stools or dark urine it needs to be reported. The urine and other body fluids may be discolored for 48 hours after treatment, a redorange color. The patients need to be taught the possibility of hair loss, the patient may need to be provided with therapy along with a wig. Patients should avoid pregnancy while going through this treatment. They should be taught to avoid: foods with citric acid, spicy foods, hot or rough texture. There may be bleeding and white spots in the mouth, patients should monitor their mouth daily and report any such findings. The patients have to avoid vaccines, alcohol, NSAIDs, salicylates, and crowds with possible infections. Bleomycin is the generic name and the brand name is Blenoxane. This drug is used for testicular carcinoma, lymphomas, and squamous cell carcinomas of the head and neck, it is an antitumor antibiotic. This drug can be administered subcutaneously, intravascular (IV) and intramuscular (IM)0.25-0.5 units/kg, one to two times a eek or 10-20 units/m^2, then 1 unit/day or 5 units/week, do not exceed dose of more then 400 units in lifetime. If the drug is being given for Hodgkins disease then it is a dose of less then 2 untis for first two doses by Subq, IM, IV and then monitoring for the next 24 hours, for both adult and child. The vial is available in 15 or 30 units per vile. Side effects that need to be monitored are pain at tumor site, headache, confusion, MI, stroke, nausea, vomiting, anorexia,

stomatitis, weight loss, and ulceration of mouth and lips. Side effects of genitourinary and integunmentary system are: Hemolytic-uremic syndrome with idiosyncratic reactions of hypotension, confusion, fever, chills, wheezing. Integumentary side effects are rash, hyperkeratosis, nail changes, alopecia, pruritis, acne, striae peeling, hyperpigmentation. Respiratory adverse reactions are fibrosis, pneumonitis, wheezing and pulmonary toxicity. Systemic adverse reactions are anaphylaxis, radiation recall an Raynauds phenomenon. These drugs are to be used with precaution for patients over 70 years old with renal and hepatic or respiratory disease. While using this drug patients are advised to avoid live virus vaccines. This drugs toxicity is increased with the use of other antineoplastics, radiation therapy, general anesthesia, filgrastim and sargramostim. Phenytoin and fosphenytion decrease the serum phrnytoin levels when used at the same time. Uric acid is increased with the use of bleomycin. Tests that should be done while on this drug are pulmonary tests such as chest xrays and pulmonary diffusion capacity for carbon monoxide. Labratory tests that should be done are renal studies and serum creatine. The nurse should teach the patient to report any adverse effects, changes in breathing, coughing fever or infection. The nurse should talk to the patient and possible provide therapy for hair loss, a wig or hair piece may be provided. The patient should report any bleeding or white spots in the mouth. The patient should be taught to avoid foods with citric acid, hot or rough texture and avoid any live virus vaccines. The patient should be encouraged to use contraceptives to avoid pregnancy and avoid breastfeeding. Tamoxifen is a hormone antagonist antineoplastic drug that inhibits cell division by binding to cytpolasmic estrogen receptors. Tamoxifen is the generic name and the brand name is Soltamox, it is used for the treatment of breast cancer in postmenopausal women. The dose

is P.O 20-40 mg/day for 5 years; divide doses to two doses of 20 or less mg for the AM and Pm administration. The central nervous system adverse effects include; hot flashes, headaches, lightheadedness, depression and mood changes. Cardiovascular adverse effect are: chest pain, stroke, fluid retention and flushing. Adverse effects for the eyes, ears and nose include: occular lesions, retinopathy, cataracts, corneal opacity, and blurred vision with high doses. G.I and genitourinary adverse effects are: nausea, vomiting and altered taste that can lead to anorexia, vaginal bleeding, pruritis vulvae, uterine malignancies, altered menses and amenorrhea. Other adverse effects that can occur are thrombocytopenia, leukopenia, DVT, rash, alopecia, hypercalcemia and pulmonary embolism. This drug is contradicted for patients who are pregnant, breastfeeding or have hypersensitivity. There are a lot of drug interactions with the use of this medication. PARoxetine should not be used at the same time because it can increase the chance of death from breast cancer. Anticoagulant will increase the risk for bleeding, bromocriptine will increase the tamoxifen levels. While aminoglutethimide and rifamycin decrease tamoxifen levels. Cytotoxics will increase the thromboembolic events. The risk for toxicity is increase with the use of CYP3A4 inhibitors, and the effect of the tamoxifen will be reduced as well. Letrozole levels are decreased with the use of letrozole, and the effect of tamoxifen will be decreased with the use antidepressants or CYP2D6 inhibitors. The nurse should asses and follow up on labs such as CBC to monitor white blood cell count and platelet count. The nurse has to teach the patient to report any adverse effects to the medication. The patients should increase fluid to two liters a day, and protect their self from sun expose with sunscreens, sunglasses and other protective clothing. If there are any hot flashes or vaginal bleeds they can be reversed with the discontinuation of tamoxifen, however vaginal bleeds need to

reported immediately. Eye tests should be done regularly and any vision changed should be reported right away because they may not be reversible. If the patient does experience increase in the size of tumor or increased bone pain they may take analgesics, but the pain will eventually subside. There may be loss of hair, the nurse should talk to the patient and if preferred or necessary help provide a wig or therapy. If the patient is pre-menopausal they should use contraceptives to avoid pregnancy.

Nursing Diagnosis: Anxiety related to loss of psychological well-being A.E.B cancer. Outcome: Patient will be able to express 3 fears about death within the 7 to 14 days. Interventions: 1.) Listen to patient, provide empathy and provide non-judgmental care.

2.) Encourage the client to express feelings of anxiety, and any fears they have. 3.) Answer any questions the patient has relating to the disease. Rationales: 1.) Making the client feel safe and comfortable will make them feel safe. A client who feels safe and not judged will express fears and concerns. 2.) Acknowledging fears will help the client and nurse cope with them and move forward for the benefit of the patient. 3.) Answering questions will give the patient knowledge on the disease, and know what to expect to reduce fears of the unknown. Nursing Diagnosis: Knowledge deficit related to disease process. Outcome: Patient will be able to define cancer and three side effects of the disease process by the end of meeting. 1.) Teach the client about what cancer is, and what does the disease does to the body. 2.) Teach client and family side effects of cancer, and what to expect. 3.) Teach client and family what side effects to report. Rationales: 1.) Teaching the client about the disease will help the patient understand what is happening to their body. 2.) Teaching the patient common side effect of cancer will make the patient know what to expect. 3.) Teaching the client what to report will prevent toxicity and reduce any chances of harm to the body from chemotherapy or antineoplastic drugs.

Nursing Diagnosis: Chronic pain related to the disease process. Outcome: Patient will have minimal pain for the next 60 days. Intervention: 1.) Provide patient with assistive devices such as a wheel chair or walking assistive device. 2.) Provide patient assistance with ADLs. 3.) Teach patient importance of taking pain medication before the pain starts. Rationales: 1.) A wheel chair or a walking assistive device will allow the patient to move around without exerting their body. This will provide less pain. 2.) Having help with ADLs will prevent the patient from straining their self, and preventing possibilities for further injuries. 3.)Taking pain medications before they start will prevent severe pain.