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Other antineoplastics: Nursing Pharmacology

Notes

Notes

OTHER ANTINEOPLASTICS, PART 1/2
DRUG NAME
asparaginase (Elspar), pegaspargase (Oncaspar)
*High Alert Medications*

altretamine
*High Alert Medication*

azacitidine (Onureg, Vidaza)
*High Alert Medication*

CLASS
Other antineoplastic agents
MECHANISM of ACTION
Deplete circulating asparagine levels → cancer cells can’t synthesize their own asparagine → impaired protein synthesis, apoptosis
Crosslinking of DNA → stops cancer cell division → cancer cell death


Damage to double stranded DNA during cell division
INDICATIONS
  • Acute lymphoblastic leukemia
  • Ovarian cancer
  • Myelodysplastic syndrome
  • Acute myeloid leukemia
ROUTE(S) of ADMINISTRATION
  • IM
  • PO
  • PO
  • IV
  • SubQ
SIDE EFFECTS
  • GI toxicity: nausea, vomiting, diarrhea
  • Hypersensitivity reactions
  • Asparaginase: pancreatitis, fever, hepatotoxicity, hyperglycemia
  • Neurotoxicity (boxed warning)
  • Bone marrow suppression
  • Dermatological reactions (rash, eczema, pruritus, alopecia)
  • GI toxicity: nausea, vomiting, diarrhea
  • Hepatotoxicity
  • Nephrotoxicity
  • Bone marrow suppression
  • Dermatological reactions (rash, eczema, pruritus, alopecia)
  • GI toxicity: nausea, vomiting, diarrhea
  • Injection site reactions
  • Fever
  • Fatigue
  • Respiratory infections
  • Nephrotoxicity
  • Tumor lysis syndrome
CONTRA-INDICATIONS & CAUTIONS
  • Pregnancy and breastfeeding
  • History of pancreatitis, thrombosis or hemorrhagic events with previous asparaginase treatment
  • Caution when using alongside MAO inhibitors (risk of hypotension)

OTHER ANTINEOPLASTICS, PART 2/2
DRUG NAME
hydroxyurea (Droxia, Hydrea, Siklos)
*High Alert Medication*

irinotecan (Camptosar)
*High Alert Medication*

CLASS
Other antineoplastic agents
Irinotecan: topoisomerase I inhibitor
MECHANISM of ACTION
Inhibits enzymes involved in DNA synthesis → stops cancer cell division
Inhibits enzymes involved in DNA synthesis (topoisomerase I) → stops cancer cell division
INDICATIONS
Chronic myeloid leukemia; head and neck cancer
Metastatic colon cancer
ROUTE(S) of ADMINISTRATION
  • PO
  • IV
SIDE EFFECTS
  • Risk of secondary malignancy (boxed warning)
  • Bone marrow suppression
  • Dermatological reactions (rash, eczema, pruritus, alopecia)
  • GI toxicity: nausea, vomiting, diarrhea
  • Fever
  • Headache
  • Stomatitis
  • GI toxicity: diarrhea (boxed warning)
  • Bone marrow suppression
  • Dermatological reactions (rash, eczema, pruritus, alopecia)
  • Neurotoxicity
  • Hepatotoxicity
  • Pulmonary toxicity
  • Cholinergic syndrome (hypotension, miosis, diaphoresis, flushing, sialorrhea, rhinitis)
CONTRAINDICATIONS & CAUTIONS
  • Pregnancy and breastfeeding
  • Elderly population
  • Renal disease
  • Radiation therapy in the past
  • HIV medications
  • Elderly population
  • Hepatic disease
  • Renal disease
NURSING CONSIDERATIONS for
OTHER ANTINEOPLASTICS
ASSESSMENT & MONITORING
Assessment
  • Current symptoms: fatigue, dizziness, easily bruising or bleeding, bone pain, unexplained fevers, abdominal fullness
  • Weight and vital signs
  • Laboratory test results: CBC, coagulation studies, hepatic function, amylase and lipase, blood glucose 
  • Diagnostic tests: peripheral blood smear, bone marrow examination 

Administration
  • Emergency equipment and medications readily available
  • Patent large-bore IV or central line 
  • Adequately hydrated with IV fluids 
  • Premedication with antiemetic 
  • Confirm correct dosage and input into infusion pump
  • Wear gloves and other PPE when handling the medication 
  • Hypersensitivity reaction 
    • If occurs, stop infusion and administer emergency medications 

Monitoring
  • Laboratory test results 
  • Side effects 
  • Evaluate the therapeutic response: decrease in symptoms of leukemia
CLIENT EDUCATION
  • Purpose of medication: to treat (remission / induction) of leukemia in combination with other medications
  • Administered IV daily for 28 days 
  • Side effects 
    • Nausea, vomiting
      • Small, frequent meals, increase fluid intake 
    • Notify healthcare provider 
      • Pancreatitis 
        • Nausea, abdominal pain that occurs after eating, pain in upper abdomen that radiates to the back 
      • Hepatotoxicity 
        • Fatigue, anorexia, abdominal pain, dark urine, yellowing of the eyes or skin 
      • Hyperglycemia 
        • Increased hunger or thirst, increased urination and frequency
    • Follow up regularly for laboratory test monitoring 
Transcript

Antineoplastic agents are medications used to treat cancer. Except for the usual antineoplastics, there are other medications that can be also used to treat various forms of cancer, particularly acute lymphoblastic leukemia or ALL, ovarian cancer, and cutaneous T-cell lymphoma.

Other antineoplastics that are commonly used include asparaginase, and pegaspargase, which are given intramuscularly or intravenously to treat acute lymphoblastic leukemia, as well as altretamine, which is taken orally to treat ovarian cancer. Then there’s azacitidine, a medication that can be administered orally, intravenously or subcutaneously to treat myelodysplastic syndrome or acute myeloid leukemia; hydroxyurea, which is administered orally in clients with chronic myeloid leukemia or head and neck cancer; and irinotecan, which is administered intravenously to clients with metastatic colorectal cancer.

Once administered, what asparaginase and Pegaspargase do is break down asparagine, which is a non-essential amino acid, into aspartic acid and ammonia. Cancer cells can’t synthesize asparagine themselves, so this impairs their protein synthesis, ultimately stopping cellular processes and causing apoptosis.

On the other hand, the way altretamine works is not perfectly clear, but it could damage cancer cells by crosslinking of DNA, which means the agent links two DNA bases together, forming cross-bridges. Cross-linking prevents DNA from being separated for essential cell processes, like replication or transcription, eventually resulting in cancer cell death and stopping the multiplication of cancer cells.

Next, azacitidine causes damage to double stranded DNA during cell replication, while hydroxyurea and irinotecan inhibit enzymes involved in DNA synthesis, ultimately stopping cancer cell division. Irinotecan in particular belongs to a group of medications called topoisomerase I inhibitors, so it inhibits this enzyme to eventually cause double stranded DNA breaks and halt cell replication.

Unfortunately, these medications can also damage healthy cells and cause side effects. All of them, with the exception of asparaginase and Pegaspargase can cause dermatological reactions, like skin rashes, eczema, pruritus and alopecia; and bone marrow toxicity, which is a boxed warning for altretamine, hydroxyurea and irinotecan. Bone marrow suppression can lead to anemia; leukopenia, increasing the risk of infections; and thrombocytopenia, increasing the risk of bleeding.

Gastrointestinal toxicity, which can manifest as nausea, vomiting or diarrhea, is also a common side effect, and irinotecan actually has a boxed warning for causing severe diarrhea. Other boxed warnings include neurotoxicity for altretamine, and the risk of developing a secondary malignancy after prolonged use for hydroxyurea.

And now for specifics. Azacitidine can cause injection site reactions, as well as fever, fatigue, respiratory infections, nephrotoxicity and tumor lysis syndrome. Asparaginase and Pegaspargase can both cause serious hypersensitivity reactions, and asparaginase can additionally cause fever, hepatotoxicity, nephrotoxicity, and hyperglycemia. Altretamine can also cause hepato- and nephrotoxicity, while hydroxyurea also comes with a risk of fever, headache and stomatitis.

Finally, treatment with irinotecan can lead to cholinergic syndrome, which encompasses a lot of parasympathetic reactions, including diaphoresis; or excessive sweating; flushing; increased peristalsis; miosis; sialorrhea, or excessive salivation; and rhinitis. Other side effects for irinotecan include fever, neurotoxicity, hepatotoxicity, and pulmonary toxicity.

Now, these other antineoplastics are generally contraindicated during breastfeeding, and they should also be used with caution during pregnancy. Asparaginase andPegaspargase should also be avoided in clients with a history of pancreatitis, thrombosis or hemorrhagic events with previous asparaginase treatment. Altretamine should be used with caution alongside monoamine oxidase inhibitors treatment, since using the two together can increase the risk of hypotension.

Hydroxyurea, on the other hand, should be used with caution in the elderly population, people with renal problems, or those who have received radiation therapy in the past; and when used together with some medications used to manage the HIV infection, that can increase the risk of hepatotoxicity, peripheral neuropathy and pancreatitis. Finally, irinotecan should be given with caution in the elderly population, people with renal disease, or people with hepatic impairment.