Antineoplastic Therapy



Antineoplastic Therapy


Kerry A. Twite

Jayme L. Cotter

Sol A. Yoder





KEY TERMS

Adjuvant

Alkylating Agents

Alopecia

Anticancer

Antimetabolite

Antineoplastic

Biotherapy

Bolus

Cell Cycle

Cytotoxic

Extravasation

Interferons

Interleukins

Investigational Protocol

Monoclonal Antibodies

Nadir

Neoadjuvant

Plant Alkaloids

Targeted Therapy

Toxicity

Vesicant


ROLE OF THE INTRAVENOUS NURSE IN CHEMOTHERAPY/BIOTHERAPY EDUCATION

Antineoplastics, which include both chemotherapeutic and biologic agents used in cancer treatment, present a challenge to nurses responsible for their administration. Many nurses point to the reputation of antineoplastics as intimidating and express anxiety about administering them. Success with these drugs usually is ensured, however, for nurses with refined intravenous (IV) skills, sensitive patient preparation practices, and keen awareness of how
and why chemotherapy and biotherapy work. The Infusion Nursing Standards of Practice echo that the nurse who administers antineoplastic agents is competent and has the knowledge of protocols for prescribed therapies (INS, 2011).

Approximately 85% of all patients with cancer will receive antineoplastic therapy that may include either chemotherapy or biotherapy or a combination of both in the course of treatment. Successful administration of an IV cancer treatment regimen depends on adequate patient preparation and education, the competence and skill of the nurse, mutual understanding of the patient and nurse on the current goal of therapy (cure, control, or palliation), and finally, the nurse’s broad knowledge of indications, administration, and side effects of the cancer treatment. The nurse is critical to the experience and outcomes of the patient when receiving chemotherapy/biotherapy. Nurses who are committed to the care of patients undergoing cancer treatment can make a difference in the lives of these patients.


Education for Nurses Administering Antineoplastic Drugs

The privilege of administering antineoplastic agents is preceded by extensive exposure to standardized educational preparation and practical experience. To provide consistently safe, appropriate, and high-quality patient care, many centers mandate comprehensive training programs leading to credentialing in chemotherapy administration.

To ensure consistency in practice, the Oncology Nursing Society (ONS) has developed a chemotherapy/biotherapy course that is presented nationwide. ONS members who become trainers for the course are selected based on criteria that include experience in administering chemotherapy and presenting educational content. The book, Chemotherapy and Biotherapy: Guidelines and Recommendations for Practice (Polovich, Whitford, & Olsen, 2009), provides a standardized framework for the didactic education to handle cytotoxic (cell-killing) agents and for the care of the patient undergoing cancer treatment. The instructional component is comprehensive and includes content covering the disease, drug treatment and administration, and side effects. An outline of the ONS chemotherapy/biotherapy major subject areas needed to prepare for chemotherapy administration is included in Box 19-1 (ONS, 2011).

The participant in the course must also achieve a passing score on a test in order to demonstrate requisite knowledge and receive a Chemotherapy/Biotherapy Provider card. Individual employers determine clinical competence. Course information is applied during a practicum phase at an institutional level where clinical skills are exercised and evaluated. Within the ONS Guidelines, the clinical practicum is described and an evaluation tool is included. The clinical practicum emphasizes clinical skills and allows the nurse to demonstrate competence in the safe administration of chemotherapy and biotherapy (Polovich et al., 2009).

Safe delivery of IV antineoplastic agents is only one part of caring for patients receiving chemotherapy/biotherapy. A nurse who specializes in oncology needs a solid foundation of specialized knowledge. See Box 19-2 for a list of areas of emphasis in a basic oncology online education program for nurses (ONS, 2013a, 2013b). With specialty knowledge plus clinical experience, the oncology nurse can prepare for professional certification through the Oncology Nursing Certification Corporation (ONCC). Certification is a formal recognition of the nurse who possesses specialized knowledge, skills, and experience required to provide quality patient care (INS/INCC, 2009; ONS, 2013a, 2013b).




BOX 19-1 PREPARATION OF THE PROFESSIONAL NURSE TO CARE FOR PATIENTS RECEIVING CHEMOTHERAPY/BIOTHERAPY

Major subject areas to be mastered by nurses who administer chemotherapy/biotherapy are based on Oncology Nursing Society Position on the Education of the Nurse Who Administers Chemotherapy and Biotherapy (1/2011)


I. Didactic Component



  • Cancer review covering tumor cell kinetics and angiogenesis


  • The drug development process, legal, and ethical issues related to cancer therapy


  • Indications, pharmacology, molecular biomarkers, and protectants related to chemotherapy and biotherapy


  • Principles of cancer chemotherapy and biotherapy


  • Types, classifications, and routes of administration of chemotherapy and biotherapy agents


  • Specific drug administration, as well as administration schedules, dose determinations, drug response, and drug delivery systems


  • Administration procedures, including administration schedule, dose, and route; patient consent; and appropriate medical record documentation


  • Safe handling practices: use and disposal of personal protective equipment (PPE) drugs


  • Safe mixing, storage, and labeling, transportation, and disposal of chemotherapeutic and biologic agents


  • Side effects (acute, late, and long term), as well as principles of management into survivorship, and patient/family education


II. Clinical Practicum (Completed under the auspices of the nurses’ institution)



  • Drug calculation and dose verification


  • Drug preparation, handling, and spill management


  • Drug storage, transport, and disposal of drugs and equipment


  • Prechemotherapy patient physical and laboratory assessment


  • Drug administration techniques, including peripheral IV access, central vascular access device (CVAD).


  • Extravasation and hypersensitivity management


  • Acute drug side effect management


  • Appropriate medical record documentation


  • Patient and family teaching and follow-up

Adapted from Oncology Nursing Society (ONS). (2011). Education of the RN who administers and cares for the individual receiving chemotherapy and biotherapy. Pittsburgh, PA: Author.




BOX 19-2 BASIC EDUCATION FOR ONCOLOGY NURSES BASED ON THE CANCER BASIC ONLINE COURSE (ONS, 2013A, 2013B)


Comprehensive Understanding of Cancer



  • Disease statistics


  • Carcinogenesis, including cell structure and cell cycle


  • Primary and secondary prevention of cancer


  • Seven warning signs of cancer


Current Treatment of Cancer



  • Diagnostic evaluation and staging of cancer


  • Treatment goals: cure, control, and palliation


  • Treatment modalities: indications and side effects



    • Radiation therapy


    • Chemotherapy


    • Biotherapy


    • Molecular-targeted therapy


    • Antiangiogenesis therapy


Patient Care Management and Treatment-Related Symptoms



  • Patient assessment and evaluation


  • Performance status


  • Nutritional status


  • Pain assessment and control


  • Hematologic assessment


  • Psychosocial assessment (coping skills and support systems)


  • Systems review (cardiac, renal, hepatic, pulmonary, GI), comorbidities


Complications and Toxicities



  • Short-term side effects: alopecia, GI reactions, bone marrow suppression, dermatologic and cutaneous disturbances, allergic reactions, phlebitis and extravasation, psychosocial changes


  • Long-term side effects: genetic, oncogenetic, immunosuppression, reproductive alterations, psychosocial changes


  • Specific organ toxicities: cardiac, renal, pulmonary, hepatic, GI, neurologic, dermatologic, reproductive


Nursing Care



  • Early detection and prevention of complications


  • Delivery of expert care


  • Patient and family education


  • Psychosocial support throughout the continuum of care (new diagnoses remission, recurrence, end of life, survivorship)


  • Follow-up support needs: complete remission, disease control, survivorship, hospice

Adapted from Oncology Nursing Society (ONS). (2013). Cancer basics online course. Pittsburgh, PA: Author. http://www.ons.org/CourseDetail.aspx?course_id=20



CLINICAL CHALLENGES

The remarkable progress of antineoplastic agents as a major treatment modality poses a growing series of challenges to infusion nurses. Ongoing and vigorous clinical investigations from cooperative groups are dedicated to drug development and discovering new therapeutic methods of delivering cytotoxic drugs. The use of the oral route has expanded. Nurses who specialize in oncology have a responsibility to maintain up-todate expertise through study of current professional literature along with continuing education programs.

Certification is an excellent demonstration of one’s knowledge in antineoplastic therapy. The Infusion Nurses Society (INS) supports certification in infusion nursing through the Infusion Nurses Certification Corporation (INCC). One of the nine major content areas on the infusion nurse’s examination is antineoplastic therapy. Nurses successful in the test receive the designation of CRNI (Certified Registered Nurse Infusion). The CRNI who possesses an RN license and has 1,000 hours of clinical practice in infusion nursing may renew every 3 years through testing or recertification units. The ONS Chemotherapy/Biotherapy Provider card is renewed every 2 years through completion of online self-study and testing. The ONCC offers one general oncology nursing certification. The CPOHN designation is awarded to the Certified Pediatric Hematology Oncology Nurse. Additionally, two national certifications for advanced practice oncology nurses are offered: one for Advanced Oncology Clinical Nurse Specialists and the other for Advanced Oncology Nurse Practitioners. Oncology Certification is renewed every 4 years by practice hours and exam, practice hours, or exam along with professional development points [known as ONC-PRO] (ONCC, 2013).


Patient Education

The nurse caring for an oncology patient can make all the difference in the patient’s experience with treatment. The nurse acts as the coordinator of care, collaborating with all providers to ensure the highest quality of care. It is critical that patients are actively involved and informed of all aspects of their care to ensure patient satisfaction and a sense of control during treatment. The nurse’s role is to advocate for and empower patients and family members to seek information and to ensure informed consent and understanding of their treatment plans. The nurse needs to evaluate whether the patient and significant other have a clear understanding of the treatment goals. Is the goal of treatment to cure, control, or offer palliative relief of symptoms? The patient and significant other should be educated in all aspects of the disease process and treatment methods. When administering antineoplastic agents, the nurse should establish open communication with the patient in all phases of care, even to the extent of actively soliciting patient assistance in clinical functions such as assessing vein status. The astute nurse listens to, and is guided by, patient statements like, “The nurse tried that vein two times last week, and it didn’t work.” In addition to providing a sense of patient involvement and control, the nurse can capitalize on a patient’s intimate knowledge of his or her own body.

It is important to inform a patient that, as IV solutions are infused, it is normal to detect a sense of coolness along the venous pathway. Likewise, it is prudent to alert a patient to early signs of extravasation (pain, burning, stinging, a feeling of tightness, tingling, numbness,
and any other unusual sensations) when vesicant (tissue-damaging) agents are infused because patients can usually detect them before they are apparent to the nurse.

Some antineoplastic and biotherapy drugs are associated with localized and generalized anaphylactic reactions. When signs and symptoms are reported early and treated properly, their course can be reversed or minimized. Particularly with these agents, patients should be encouraged to report unusual symptoms of generalized tingling, chest pains or sensations, shortness of breath, or light-headedness. Education must be tailored to the individual patient based on the patient’s learning needs. It is important that the patient understands some side effects can occur once treatment is completed or anytime during the course of their specific treatment, such as alopecia, bone marrow suppression, diarrhea, fatigue, mucositis, nausea and vomiting, depression, reproductive and sexual side effects, and changes in taste sensations. It is critical that patients are educated on side effects before treatment begins. This not only allows the patient to make an informed decision on the treatment plan but also reduces fear and anxiety when delayed reactions occur. Education needs to be ongoing with each interaction with your patient and to be multifaceted in delivery.

Patients with a cancer diagnosis experience dramatic life changes and loss of control. It is important for the nurse to partner with the patient to give the patient a sense of control. Once a relationship is established, the nurse usually finds that patients implicitly trust in the skill and judgment of the nurse with whom he or she is most familiar. During the active treatment phase, the staff and nurses offer security, hope, and stability to the patient and his or her extended family. It is important to connect with your patients and guide the patient and family through these uncertain times in their lives. Nurses administering chemotherapy and biotherapy have a tremendous opportunity to minimize treatment-related morbidity (and thus to enhance their patients’ quality of life) through competent patient education. Patient, family, and caregiver education is integral to the cancer treatment; teaching identification of signs and symptoms, appropriate self-care activities, and when to report sign and symptoms to the provider are critical.

Safe and competent delivery of antineoplastics is only half the job of contemporary IV therapy nursing professionals. The more sensitive (and sometimes more influential) part of the art revolves around the relationship with the patient, and then their education, individualized to address a patient’s situation. Nurses need to adhere to the scope of practice and standards of care established by the ONS. Key components to be included in patient/family education include the following:



  • The patient is able to describe his or her understanding of extent of disease and current treatment at a level consistent with cultural and educational background and emotional state.


  • The nurse and patient (and family) agree on learning outcomes based on the patient’s needs.


  • The patient participates in decision making regarding plan of care and life activities if desired or possible.


  • The nurse selects educational methods and materials consistent with the patient’s and family’s learning needs and abilities.


  • The nurse considers how, when, and by whom teaching will be done.


  • The nurse continuously evaluates the patient’s and family’s comprehension, with reference to original learning outcomes.



  • The nurse conscientiously documents all components of the education process. An organized and systematic form in the medical record is an efficient and effective way to ensure that this phase of therapy is up to date and critical components are not missed.

Multiple psychosocial, emotional, cultural, and physiologic barriers come into play because of the nature of the disease and public perceptions of cancer and cancer therapy. A nurse’s primary concern is that the patient not only has adequate information but has absorbed sufficient information to provide legitimate informed consent. When assessing your patients, it is important to address their psychosocial status. How are they and their family members coping? Do they feel they have an adequate support system in place? Patients should be encouraged to communicate their feelings on coping with a cancer diagnosis and referred to appropriate community resources.

Some barriers to the patient learning (Table 19-1) can be overcome by methods as simple as teaching in a physical environment that reduces anxiety, including the family in the educational process, and providing patient-appropriate materials. Often it is wise to allow a span of time between a scheduled teaching session and treatment itself so that the patient has time to assimilate important information and form questions concerning areas that are unclear. Certainly, the patient education is an ongoing process, from the outset and for the duration of therapy. The process may sort itself into a natural division of three phases, with the common outcome of all phases an increased patient understanding of antineoplastic therapy. Table 19-2 summarizes the essential components of the education process. The following guidelines are for nurses involved in the patient education. They can be used to

evaluate teaching content and technique by assessing the degree to which expected patient outcomes are achieved:








TABLE 19-1 POTENTIAL BARRIERS TO SUCCESSFUL PATIENT LEARNING





















Type of Barrier

Examples


Emotional

Anxiety related to cancer diagnosis, anticipation of cancer therapy, concern over insurance coverage, family concerns


Depression related to disease process and treatment


Denial, used as a coping mechanism


External locus of control—learned helplessness and powerlessness


Physical

Pain, nausea and vomiting, fatigue, restlessness, irritability, impaired hearing or vision


Psychosocial

Altered consciousness caused by disease process or medications


Cultural attitudes, beliefs, roles, or values contributing to unwillingness to learn (“My wife/husband takes care of this kind of thing.”)


Refusal to claim ownership of self-care


Lack of inquisitiveness in effort to be perceived as a “good patient”


Functional

Compromised literacy level or language differences


Being overwhelmed by new information, names of drugs, disease jargon, personnel names, schedules, sequence, and so forth


Age, undeveloped or decreased data retention or memory


Environmental

Busy, rushed, and distracting


Unusual or foreign, high-tech, frightening, or threatening surroundings


Restrictive and depersonalized surroundings in close proximity to personnel and other patients









TABLE 19-2 EDUCATIONAL ESSENTIALS FOR PATIENTS RECEIVING CHEMOTHERAPY





















Outcomes

Nursing Interventions


Pretreatment Phase




  • Presentation of sufficient information for the patient to give valid informed consent



  • Provision of a nonthreatening environment conducive to learning and to accepting chemotherapy confidently


  • Provide written, patient-appropriate educational materials explaining specific chemotherapeutic agents and their effects before the treatment begins. Allow for extended learning period, if necessary



  • Thoroughly discuss expectations of the therapy



  • Discuss anticipated procedures and administration technique, including the need for central venous access, potential side effects, and planned interventions for symptom management



  • Encourage the patient’s involvement in decision making regarding care and treatment plan. Have the patient bring pretreatment question list to clinic or office



  • Conduct patient teaching in a quiet, comfortable, and private environment



  • Offer opportunity for the patient and family to tour the treatment area



  • If possible, introduce the patient to the IV nurse assigned to the patient



  • Provide nutritional counseling



  • Encourage the patient to express fears, concerns, and comprehension of situation



  • Emphasize variability and reversibility of side effects such as alopecia and offer patient assistance and alternatives



  • Be absolutely honest with the patient



  • Review drug and food allergy history (document this before first treatment)


Treatment Phase




  • Provision of sufficient and enabling information, allowing the patient to cope effectively with immediate effects of chemotherapy



  • Enhancement of the patient’s sense of participation in and control over care


  • Explain how chemotherapy works (e.g., cytotoxic effect of drugs)



  • Instruct the patient to report immediately any discomfort, pain, or burning during the administration of chemotherapy



  • Review the antiemetic schedule, foods to avoid, and hydration requirements



  • Identify known side effects of each drug in use



  • Discuss precautions to take against potential adverse effects



  • Assess potential for multiple drug therapy complications/incompatibilities, and caution the patient to take only medications ordered by a physician/LIP



  • Instruct the patient to maintain oral hygiene and to use non-alcoholbased mouth rinses



  • Provide a calendar with schedule of treatments, appointments with physicians/LIPs, laboratory tests, and expected time line for neutropenia or thrombocytopenia



  • Assist the patient in energy conservation program and in setting realistic goals for work and social activities



  • As appropriate, discuss contraceptive measures, potential for infertility, and sperm banking


Posttreatment or Ongoing Treatment Phase




  • Provision of sufficient information to allow the patient to demonstrate self-management strategies to control side effects and to promote functioning at maximum realistic potential


  • Explain self-care measures to use in managing side effects of each drug treatment



  • Explain reasons for follow-up studies to evaluate disease response



  • Remind the patient not to travel alone immediately after treatment in most cases



  • Instruct the patient to report temperature >100.4°F (38°C) and other signs and symptoms of complications, such as increased bruising, blood in urine or stool, bleeding gums, rashes, fatigue, shortness of breath, sore throat, oral lesions, change in bowel habits, numbness or tingling in the fingers or toes



  • Stress the importance of good personal hygiene and hand washing, and avoidance of rectal thermometers, enemas, anal sex, and people with known communicable diseases



  • Encourage the patient to call for assistance with any new or unusual signs or symptoms



  • Provide information on how to reach appropriate health care personnel 24 h a day



  • Confirm return appointments and assist with patient transport services, if needed or possible



  • Phone the patient after the first and subsequent treatments when there is a potential for problems



  • Solicit questions from the patient and caregivers



  • Review and reinforce previous information related to diagnosis, disease, and treatment




  • The patient demonstrates knowledge related to diagnosis and disease process:



    • States diagnosis and explains disease process


    • Describes previous experience with cancer and treatments


    • Acknowledges the need for treatment


    • States alternatives to prescribed treatment


  • The patient demonstrates knowledge related to rationale for chemotherapy and/or biotherapy:



    • Verbalizes the need for chemotherapy/biotherapy


    • Expresses attitude toward and expectations about cancer treatment


    • States understanding of use of chemotherapy or biotherapy alone or with other treatment modalities, if applicable


    • Identifies treatment protocol


  • The patient demonstrates knowledge related to potential therapeutic side effects of chemotherapy/biotherapy:



    • States diagnosis and expected response to treatment


    • Identifies specific effect of treatment with antineoplastic agents



  • The patient demonstrates knowledge of treatment plan and schedule:



    • Identifies drugs to be given


    • States frequency and duration of treatment


    • Identifies studies, tests, and procedures required before treatment


    • Identifies follow-up tests, studies, and procedures needed to evaluate treatment results


  • The patient demonstrates knowledge of potential drug side effects:



    • States mechanism of drug action


    • Defines reason for side effects


    • Identifies specific side effects that may occur with each drug


    • States self-management interventions to control side effects


    • Verbalizes signs and symptoms reportable to health care professionals


    • Identifies procedures for reporting signs and symptoms


  • The patient demonstrates knowledge of techniques to manage antineoplastic treatment:



    • Maintains nutritional status to best of ability


    • Follows oral, body, and environmental hygiene measures


    • Maintains optimal rest and activity pattern


    • Uses safety precautions to prevent injury


    • Seeks and uses resources as necessary


    • Verbalizes reduced anxiety related to treatment


    • States intention to comply with treatment plan


  • The patient demonstrates knowledge relative to various access devices, if applicable.

Oncology nurses are encouraged to refer to and follow the ONS Statement on the Scope and Standards of Oncology Nursing Practice (Brant & Wickham, 2004). Additionally, adhering to the ONS Standards of Oncology Education: Patient/Significant Other and Public (Blecher, 2004) will ensure thorough patient and family education in the disease process, treatment, toxicities, and symptom management.


Legal Considerations Related to Education

A thorough understanding of legal responsibilities and implications is an essential element of professional education for the nurse administering antineoplastic agents. Nurses need to know the specific regulations related to chemotherapy administration in their own state’s Nurse Practice Act.

It is in a nurse’s best interest to request a written definition of the institution’s scope of practice and to explore details of medical liability insurance covering the practice. Many employers provide adequate coverage for care administered when the nurse is on duty. All nurses—especially LIPs, instructors, or those working in a physician/LIP’s offices—may opt for personal malpractice coverage. Nurses who assume greater responsibility in administering cancer chemotherapy are at greater risk for litigation.

Meticulous adherence to the details of defined statutes and standards of care may minimize that risk. The ANA, individual departments of professional regulation for the state’s Nurse Practice Act, INS, and ONS can provide more details on legal statutes that govern nursing practice pertaining to administration of chemotherapeutic agents.




LEGAL ISSUES


Legal Considerations Pertinent to Cancer Chemotherapy



  • Clinical education: Before treating any patient, the nurse’s successful education and competency assessment in IV therapy and drug administration, specifically chemotherapy and biotherapy should be documented and available in personnel files.


  • Lines of supervision: The nurse should have a clear, written statement of the lines of supervision.


  • Standards of care: The nurse should have a clear, written statement of the employing facility’s standards of care, including a definition of reasonable care in each pertinent area of practice. Facility-specific policies and procedures and job descriptions should be based on nationally established standards from professional organizations, including but not limited to the Infusion Nurses Society (INS, 2011), ONS, and American Nurses Association (ANA).


  • Patient and family education: The nurse should initiate and complete patient and family education regarding treatment goals, all medications in the treatment regimen, side effects, length of therapy, and follow-up restaging. Evaluation of the patient’s understanding and response to teaching should be documented.


  • Informed consent: Patients who are participating in clinical drug trials must sign an informed consent form before administration of the investigational (experimental) protocol. Specific regulations regarding written informed consent for noninvestigational protocols vary from state to state. Although obtaining informed consent is a physician/licensed independent practitioner’s (LIP) responsibility in most states, a nurse should make sure that consent has been granted before administering chemotherapy. The hospital or institution may be held liable if treatment is administered without the informed consent of the patient or responsible parties. Failure to obtain a patient’s consent may constitute battery, defined as any physical contact of a patient without his or her permission.

Because a patient’s clinical record is a legal document that can be used as evidence in a lawsuit, it is a fundamental legal nursing responsibility to ensure that documentation is accurate, comprehensive, and current and reflects the care given to the patient. The essentials of adequate documentation include time of a significant incident, a thorough and objective description of the care provided, the patient’s status, and the exact nature of physician/LIP involvement.

The expert oncology nurse frequently practices more autonomously than nursing colleagues in other specialties, which implies increased legal vulnerability. For example, because extensive telephone contact is common with patients with cancer, the nurse should therefore be mindful of the accepted scope of practice when responding to patient needs. Telephone protocols related to symptom management may serve as guidelines for the nurse in responding to calls from patients. Telephone conversation, especially if
the nurse provides advice or instructions, should be documented in the medical record (Polovich, 2009).

The nurse commonly is a key clinician involved in clinical trials that call for take-home investigational drugs. By law, only a pharmacist or physician/LIP may dispense medication. Therefore, packaging and delivering investigational drugs are not usually legal functions for nurses. Finally, knowledge of common dosing and scheduling of each common chemotherapeutic agent is the best protection (for the patient and nurse) from delivering an incorrect and possibly lethal drug dose.


SAFE PREPARATION, HANDLING, AND DISPOSAL OF CHEMOTHERAPEUTIC AND BIOLOGIC AGENTS

In 2004, the U.S. National Institute for Occupational Safety and Health (NIOSH) issued an alert entitled “Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings.” Drugs are classified as hazardous if animal or human studies indicate that exposure to them has the potential for causing cancer, developmental or reproductive toxicity, or harm to organs (NIOSH, 2004). Antineoplastic drugs are among the agents considered hazardous. Personnel, who prepare, handle, administer, and dispose of chemotherapy and biotherapy drugs risk exposure to hazardous agents. Although the therapeutic benefits outweigh the risks of side effects for ill patients, health care workers who are exposed to hazardous drugs risk these same side effects without the therapeutic benefit. Guidelines have been established since 1986 for handling antineoplastics safely (Occupational Safety and Health Administration [OSHA], 1986). The 2004 NIOSH alert summarized the health effects associated with hazardous drugs and provided recommendations for safe handling. Subsequent NIOSH alerts expanded the list of hazardous drugs so health care workers had an up-to-date reference (NIOSH, 2012).

Adherence to recommendations for safe handling of these agents minimizes potential routes of exposure through skin or mucous membrane contact via absorption, inhalation, ingestion, or accidental needlestick (Polovich et al., 2009), as well as contact with body fluids of the patient who has received antineoplastic agents within the past 48 hours. Occupational exposures to hazardous drugs can result in skin rashes, skin and mucous membrane irritation, nasal sore, blurred vision, light-headedness, dizziness allergic reactions, headache, abdominal pain, nausea and vomiting, and alopecia (hair loss). Long-term exposure can result in liver dysfunction, chromosomal abnormalities, reproductive risks, and increased risk of cancer (Itano & Taoka, 2005). These manifestations appear in direct relationship to the time, amount, and method of exposure to specific classes of antineoplastics. Health care professionals can minimize their potential health risks by strict adherence to safe handling guidelines embedded in antineoplastic policies and procedures, along with cautions during drug preparation and administration. Employees who are pregnant, planning pregnancy, or breast-feeding should be allowed to refrain from preparation and administration of hazardous agents or from caring for the patient during treatment with them (NIOSH, 2004; Polovich et al., 2009).

OSHA recommends that workers handling hazardous drugs be monitored through a medical surveillance program that includes medical and exposure history, physical examination, and some laboratory tests (NIOSH, 2004). A list of all employees who are exposed to
hazardous drugs should be maintained with careful documentation of spills, spill cleanup, and accidental exposures. Initial training and periodic review of drug preparation and administration practices that include risks of exposure and strategies to minimize exposure can ensure that all staff members have the necessary education to handle hazardous agents in the workplace (Polovich et al., 2009). Successful administration of chemotherapy and biotherapy calls for expert judgment based on scientific evidence. Expert technical skills aside, the safe administration of these agents requires knowledge of preparation, administration, and disposal of hazardous drugs (Box 19-3). A basic understanding of the indications for use and mechanisms of action of antineoplastic drugs is pivotal to the quality of patient care an IV nurse provides. In 2008, the ONS and the American Society of Clinical Oncology partnered together to develop recommendations to improve the quality and safety of


chemotherapy administration. The published 2009 Chemotherapy Administration Safety Standards included 31 voluntary standards focused on the outpatient setting (Jacobson et al., 2009). The ONS/ASCO 2011 revisions expanded the scope of recommendations to include inpatient settings (Jacobson et al., 2012). The next area this collaborative group will look at is the safety of oral chemotherapy (Box 19-4).



BOX 19-3 ADMINISTRATION OF ANTINEOPLASTIC AGENTS: SAFE HANDLING, PREPARATION, ADMINISTRATION, AND DISPOSAL


Drug Preparation

All antineoplastic drugs should be prepared by specially trained personnel in a centralized area to minimize interruptions and risks of contamination.



  • Prepare drugs in a Class II type B or Class III vertical airflow biologic safety cabinet. Air is exhausted to the outside through HEPA (high-efficiency particulate absorption) filters. The fan remains on at all times. The hood is serviced and certified by a qualified technician at least every 6 months (Polovich, 2009) according to the manufacturer’s recommendations.


  • Cover the work surface with a plastic-backed absorbent pad to minimize contamination as long as it does not interfere with the airflow. Change the pad immediately in the event of contamination and at the completion of drug preparation each day or shift.


  • Use aseptic preparation technique and mix according to the order, other pharmaceutical resources, or both.


  • Use unpowdered, disposable, good-quality gloves made of latex, nitrile, polyurethane, neoprene, or other materials that have been tested with hazardous drugs. Inspect gloves for visible defects. Use double gloves when preparing hazardous drugs. Tuck the inner glove under the gown sleeve; the cuff of the outer glove extends over the gown sleeve. Change gloves after each use, immediately if torn, punctured, or contaminated with drug or after 30 minutes of wear (ASHP, 2006; NIOSH, 2004; Polovich, 2009).


  • Wear a disposable long-sleeved gown made of lint-free fabric with knitted cuffs and a solid front during drug preparation. Laboratory coats and other cloth fabrics absorb fluids, so they are an inadequate barrier to hazardous drugs and are not recommended (Polovich, 2009). Discard gown after drug preparation, after handling cytotoxic drugs, and if visibly contaminated. Gowns should not be reused (NIOSH, 2004).


  • Wear a plastic face shield (protect eye, mouth, and nasal opening) or goggles (only protect eyes) when the possibility of splashing is evident. Use a powered air-purifying respirator or NIOSH-approved face mask when cleaning up cytotoxic spills. Surgical masks do not provide respiratory protection from aerosolized powders or liquids (Polovich, 2009).


  • Use needles, syringes, tubing, and connectors with Luer-lock connections (Polovich, 2009).


  • Guard against potential chemical contamination by priming all IV tubing under the protection of the laminar airflow hood with a compatible, nondrug solution before adding hazardous drugs (Polovich, 2009). This prevents potential exposure when connecting IV tubing.


  • Guard against drug leakage during drug preparation; use special care when reconstituting agents packaged in the following:



    • Ampules: Clear drug from neck of ampule; break top of the ampule away from the body using a gauze or alcohol pad as protection; withdraw the drug through a filter needle with ampule upright on a flat surface; change the needle before administration (ASHP, 2006).


    • Vials: Avoid the buildup of pressure within the vial. Use of a closed system (such as PhaSeal [Baxa Corp., Englewood, CO]) limits aerosolization of the drug and worker exposure to sharps when withdrawing hazardous drugs from vials (NIOSH, 2004).


  • Avoid overfilling syringes (Polovich, 2009).


  • After reconstituting the drug, label it according to institutional policies and procedures. Include the drug’s vesicant properties and hazardous drug warning on the label.


  • Transport antineoplastic drugs in an impervious packing material, such as a zippered bag, and mark the bag with a distinctive warning label stating “Cytotoxic Drug” or similar warning (Polovich, 2009).


  • Dispose of gowns, gloves, and preparation equipment in appropriately labeled puncture-proof containers.


  • Be informed on procedures to follow in the event of drug spillage.


Drug Administration

Chemotherapeutic agents are administered by registered professional nurses who have been specially trained and designated as qualified according to specific institutional policies and procedures.



  • Ensure that informed consent has been completed before administering any chemotherapeutic agent; also clarify any misconceptions the patient may have regarding the drugs and their side effects, and assure that education has been completed.



    • Review laboratory test results (e.g., complete blood count, renal and liver function values) for acceptable levels. Drug dosages may need to be adjusted by the physician/LIP according to laboratory values. Cardiac (ECG or multiple-gated acquisition [MUGA] scan) and pulmonary function tests (PFTs) may need to be evaluated based on the drug’s side effect profile.


  • Determine the vesicant/irritant potential of drugs and implement measures to minimize acute side effects of the drugs before drug administration.


  • Assess orders for completeness, for example, hydration and premedications such as antiemetics, antianxiety, antihypersensitivity agents (Polovich, 2009).


  • Have available a chemotherapy spill kit, extravasation management information and antidotes and equipment, and emergency drugs and equipment in case of adverse reactions, such as anaphylaxis.


  • Review the order. Compare with the formal drug protocol or reference source; check for completeness (schedule, route, admixture solution, etc.; Itano & Taoka, 2005).


  • Determine drug dose. Verify actual height and weight. Calculate body surface area (BSA) or appropriate dose calculations (e.g., milligrams per kilogram or area under the curve [AUC]).


  • Perform independent double check on dosage calculations (pharmacist and chemotherapy-credentialed nurse and/or two chemotherapy-credentialed nurses) and verify dose against the physician/LIP’s order. Verify that the dose is appropriate for the patient, diagnosis, and treatment plan (Polovich, 2009).


  • Check the syringe, IV bag, or bottle against the original medication order to verify medication, dose, route, time, and patient identification, using two different patient identifiers. Perform double check with two chemotherapy-credentialed nurses.


  • Wear PPE, including nonpowdered surgical latex, nitrile, polyurethane, or neoprene disposable gloves and a disposable gown made of a lint-free, low-permeability fabric with a solid front, long sleeves, and elastic or knit closed cuffs. Double gloving is recommended (NIOSH, 2004). Change gloves after each use, tear, puncture, or contamination or after 30 minutes of wear. Use gloves when handling oral antineoplastic agents. Use face shield if there is a risk of splashing, for example, intravesical instillation (Polovich, 2009).


  • Gather all supplies needed for drug administration. Protect the work surface with a disposable absorbent pad. Perform all work below eye level. Don PPE and inspect drug container within delivery bag for leaks prior to removing the hazardous drug from the delivery bag. Do not prime or expel air of intravenous (IV), intramuscular (IM), or subcutaneous (SQ) injection syringes (Polovich, 2009).


  • Confirm patency of line.


  • Administer the drug or drugs according to established institutional policies and procedures and the physician/LIP’s order, using safe handling precautions.


  • When infusion has completed, flush IV with a compatible flush solution.


  • Document drug administration, including any adverse reaction, in the medical record.


  • Establish a mechanism for identifying the patient receiving antineoplastic agents for the 48-hour period after drug administration.


  • Implement chemotherapy precautions (gowns, double gloves) when handling body secretions such as urine, stool, blood, or emesis of patients who received hazardous drugs within the prior 48 hours. Dispose of PPE after each use or when it becomes contaminated (NIOSH, 2004).


  • In the event of accidental exposure, remove contaminated gloves or gown immediately and discard according to institutional procedures.


  • Wash the contaminated skin with soap and water. Refer to MSDS for agent-specific interventions (Polovich, 2009).


  • For accidental eye exposure, flood the eye immediately with water or isotonic eyewash for at least 15 minutes. Areas where hazardous drugs are routinely handled should be equipped with an eye wash station (Polovich, 2009).


  • Obtain a medical evaluation as soon as possible after exposure and document the incident according to institutional policies and procedures.


Drug Disposal

Regardless of the setting (hospital, ambulatory care, the physician’s/LIP’s office, or home), all equipment and unused drugs are treated as hazardous and disposed of according to the institution’s policies and procedures.



  • Hazardous drug waste containers should be available in all areas where hazardous drugs are prepared and administered. Any item that comes in contact with a hazardous drug during preparation or administration is considered potentially contaminated and must be disposed of as hazardous waste (Polovich, 2009).


  • Discard all contaminated equipment, including needles, intact to prevent aerosolization, leaks, and spills. Dispose of contaminated sharps in a puncture-proof hazardous waste container.


  • Place contaminated materials including PPE in a sealable 4-mm polyethylene or 2-mm polypropylene bag and dispose of in a leak-proof, puncture-proof container with a distinctive warning label identifying “Hazardous Waste” (NIOSH, 2004; Polovich, 2009).


  • Put linen contaminated with bodily secretions of patients who have received chemotherapy/biotherapy within the previous 48 hours in a specially marked laundry bag with a distinctive biohazard warning label.


  • Follow established institutional policies and procedures for management of spills. The size of the spill might dictate who is to conduct the cleanup and decontamination and how the cleanup is managed. A small spill is one that is <l5 mL. A large spill is >5 mL.

(Adapted from Polovich, M., Whiteford, J. M., Olsen, M. (Eds.). (2009). Chemotherapy and biotherapy: Guidelines and recommendations for practice (3rd ed.). Pittsburgh, PA: Oncology Nursing Society.)




BOX 19-4 ASCO/ONS CHEMOTHERAPY ADMINISTRATION SAFETY STANDARDS



Staffing Standards



  • Policies/procedures are in place for verification of training and continuing education.



    • Qualified physicians/LIPs write and sign orders for parenteral and oral chemotherapy.


    • Qualified pharmacists, pharmacy technicians, and nurses prepare chemotherapy drugs (oral and parenteral).


    • Chemotherapy is administered only by qualified physicians/LIPs or registered nurses.


    • A comprehensive educational program is in place for new staff administering chemotherapy; includes competency assessment. The education includes all routes of administration. The ONS Chemotherapy/Biotherapy course meets this criteria.


    • Annual competency reassessment is done for all staff who administer chemotherapy.


    • All clinical staff maintain current basic life support (BLS) certification.


Chart Documentation



  • Available chart documentation prior to the first administration of a new chemotherapy regimen includes the following:



    • Pathology report confirming or verifying the initial diagnosis of cancer


    • Initial cancer stage and current status of the patient’s disease since diagnosis


    • Medical history and physical, which includes height, weight, and assessment of organ function specific to the planned antineoplastic regimen


    • Allergies and history of hypersensitivity reactions


    • The patient’s understanding of the disease and planned medication regimens and associated medications are documented in chart


    • Psychosocial assessment, identifying concerns, need for support, and interventions taken


    • Chemotherapy treatment plan (chemotherapy drugs, doses, anticipated durations, and goals of care)


    • Treatment plan for oral chemotherapy includes schedule of office visits and monitoring based on the antineoplastic drugs and the individual patient


General Chemotherapy Practice



  • Standard chemotherapy regimens are defined by diagnosis with available references. All chemotherapy regimens have identified sources, including research protocols.


  • Deviations from standard regimens are supported by a reference. Dose modification or exception orders include the reasons for alterations.


  • Regimen-specific laboratory tests are determined, and their intervals are determined by evidence-based national guidelines, site practitioners, or as part of the standard chemotherapy orders.


  • Informed consent for chemotherapy is obtained and documented.


  • Quality control is maintained for chemotherapy that is mixed off-site.



Chemotherapy Orders



  • New orders and changes in chemotherapy orders are made in writing. There are no verbal orders except to hold or stop chemotherapy administration.


  • Parenteral chemotherapy orders are a standardized, regimen based in either a preprinted format or as electronic forms in e-prescribing software.


  • Orders list all medications by generic names and avoid all Joint Commissions’ prohibited abbreviations. All chemotherapy drugs in the regimen with their dosing are listed in the orders.



    • Complete orders include the patient’s name/second identifier, date, diagnosis, regimen name and cycle number, treatments conditions (lab results and toxicities) to be met to treat, allergies, established standards for dose calculation, height, weight, dosage, route and rate of administration, length of infusion, premedications, hydration, growth factors, and hypersensitivity medications, sequence of drug administration, time limit to ensure evaluation at designated intervals.


Drug Preparation



  • A second chemotherapy-credentialed practitioner verifies each order prior to preparation, confirming two patient identifiers, drug names, doses, volumes, rate and route of administration, dose calculations, and cycle and day of cycle.


  • Chemotherapy drugs are labeled upon preparation with the patient’s full name and second identifier, generic drug name, route, total volume required to give dose, date of administration, and date/time of preparation and expiration.


  • A policy for administration of intrathecal medications includes separate preparation from other drugs, stored after preparation in an isolated area with a unique intrathecal medication label, and delivery of the medication to the patient only with other medications for the central nervous system (CNS).


The Patient Consent and Education



  • The patient consent information includes diagnoses, goals of treatment, drugs, schedule, and length of treatment, short- and long-term side effects, drug-specific symptoms that trigger contact with the provider, and how to contact the provider and plan for follow-up and monitoring.


  • Informed consent is documented prior to initiation of the chemotherapy administration.


  • Patients prescribed oral chemotherapy are taught preparation, administration, and disposal of oral chemotherapy. Written information is provided to the patient and family and caregivers who will be assisting the patient in managing the therapy.


Administration of Chemotherapy



  • Prior to chemotherapy administration, confirm with the patient planned therapy before each cycle.



  • Two chemotherapy-credentialed practitioners verify the accuracy of drug names, dose, volume, rate, route, expiration dates/times, appearance, and physical integrity of drugs. This verification is documented in the medical record.


  • In front of the patient, two individuals verify the identity of the patient using two identifiers.


  • Extravasation procedures are current and referenced. Orders and access to antidotes are ensured.


  • A physician/LIP is on-site and immediately available during all chemotherapy administration.



Assessment and Monitoring



  • Response protocols are established and reviewed annually to manage life-threatening emergencies that include BLS and transfer to location for higher acuity patient support.



    • At each clinical visit or day of treatment: Assess and document clinical status, performance status, vital signs, weight, allergies, previous reactions, toxicities (NCI or WHO toxicity criteria), current medication list including OTV meds, complimentary/alternative therapies. Review and document medication changes.


  • Assess psychosocial concerns, identify needs, and refer to appropriate psychosocial and other support services.


  • Follow-up with patients who miss appointments and/or scheduled chemotherapy treatments.


  • Policy/procedure is in place for 24/7 access to a provider/department for care of side effects. A process for hand-off communication allows for written/verbal communication of toxicities across settings to provide continuity of care.


  • Cumulative doses of specific drugs, for example, doxorubicin, are tracked to determine the risk of cumulative toxicity.


  • The patient response to treatment is monitored using evidence-based standard disease-specific criteria.

(Adapted from Jacobson, J. O. Pelvic, M., Gilmore, T. R., Schulmeister, L., Esper, P., LeFebvre, K. B., et al. (2012). Revisions to the 2009 American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards: Expanding the Scope to Include Inpatient Settings. Oncology Nursing Forum, 39(1), 31-38.)


OVERVIEW OF ANTINEOPLASTIC THERAPY

Before the discovery of chemical and biologic agents to treat cancer, surgery and radiation therapy were the primary cancer treatment techniques. Surgery and radiation therapy provide an important approach to the treatment of local or regional cancers. These modalities treat localized tumors that can be surgically removed or destroyed by radiating the genetic material in the cancer cells in a particular part of the body.


In many cases, cancer is a systemic disease that requires systemic therapy (drugs distributed through the body by the blood stream). By nature, cancer cells deviate from normal cells in structure, function, and production; therefore, a characteristic of cancer is the cell’s ability to invade surrounding tissue, blood, and lymphatic vessels and spread beyond the localized region of the primary disease site (DeVita, Lawrence, & Rosenberg, 2011). The ability of these aberrant cells to metastasize forms the basis for systemic antineoplastic therapy. Antineoplastic therapy includes chemotherapy, hormonal therapies, biotherapy, and targeted therapies. These systemic modalities are indicated for hematologic malignancies or for solid tumors that either have the potential to spread or have already metastasized.


Chemotherapy

Chemotherapy agents work by disrupting cellular events occurring within the cell cycle of both cancer cells and normal cells. Chemotherapy controls cancer with cytotoxic (cell killing) effects. Chemical agents are designed to kill rapidly dividing cancer cells with minimal impact on cells with normal, healthy mitotic characteristics. Because of the effect on normal cells as well as cancer cells, the side effects that are experienced are related to the rapidly proliferating normal cells. Chemotherapy is limited by the toxic effects on normal cells.

Chemotherapy drugs are grouped according to their specific effect on cancer cell chemistry and the cell cycle phase in which they interfere. The cell cycle refers to a series of phases in normal cell and cancer cell growth. Cell cycle time is the length of time needed for a cell to replicate.

Chemotherapy agents fall into two categories: cell cycle phase-specific agents are active only during a particular phase in the cell proliferation cycle; cell cycle phase-nonspecific agents are active at any point of the cell proliferation cycle. Regardless of whether the chemotherapy is cell cycle specific or cell cycle nonspecific, the basic mechanism of antineoplastic action is the same: to disrupt DNA synthesis. This disables cell reproduction, so the cancer cells die. Chemotherapy generally is most effective when the cell is actively dividing.

Chemotherapeutic agents are further categorized into major groups: alkylating agents; nitrosoureas; antimetabolites; antitumor antibiotics; plant alkaloids such as, camptothecins; epipodophyllotoxins; taxanes; Vinca alkaloids; and miscellaneous (Polovich et al., 2009). Within each of these categories is a spectrum of agents with various toxicities, all of which relate to their antineoplastic properties.

Chemotherapy drug toxicities can be appreciated by understanding that these agents are designed to destroy rapidly dividing cells; therefore, the toxicities that are seen occur in cells that divide rapidly, such as bone marrow, hair follicles, gastrointestinal mucosa, and reproductive tissues. Thus, the most frequent side effects of these drugs include cytopenias, alopecia, mucositis, nausea, vomiting, and infertility.

Table 19-3 provides a quick reference chemotherapy guide for drug handling, dosing, administration, side effects, and major toxicities. Comprehensive tables are available and should be used for more detailed information on indications for use, drug preparation, pharmacokinetics, and protocols.


Biotherapy

Biotherapy refers to systemic treatment with agents from biologic sources or those agents that affect biologic responses. As a class, these agents are known as biologic response modifiers because of their ability to influence and change the relationship of the tumor and the host, resulting in therapeutic effects. Biologic agents are classified by their action: agents























that augment, modulate, or restore the immune response of the host; agents that have direct anticancer activity (antiproliferation or cytotoxic effect on cancer cells); agents that increase the vulnerability of cancer cells to the body’s immune system; agents that change the pathway that transforms normal cells to cancer cells; those agents that enhance the repair of normal cells damaged by therapy; agents that prevent metastasis; and lastly, agents that change the behavior of cancer cells to normal cells (Polovich et al., 2009).








TABLE 19-3 QUICK REFERENCE TO COMMONLY ADMINISTERED PARENTERAL CHEMOTHERAPEUTIC AGENTS











































































































































































































































































































































































Drug

Usual Dose

Usual Administration Technique

Comments and Major Toxicities


Amifostine (Ethyol)


Chemoprotectant

910-740 mg/m2 (nephroprotectant)


200-340 mg/m2 (reduction of xerostomia)

IVPB over 15 min, 30 min prior to chemotherapy agents


IVP over 3 min, 15-30 min prior to radiation Subcutaneous

Nausea and vomiting (dose dependent)— antiemetic medication, including dexamethasone and a serotonin 5-HT3 receptor antagonist, is recommended prior to amifostine


Transient hypotension (dose dependent)— monitor blood pressure


Sneezing, flushing, hypocalcemia, hiccups, cutaneous reactions


Arsenic trioxide (Trisenox)


Novel arsenical differentiation agent

Induction: 0.15 mg/kg until bone marrow remission (up to 60 doses)


Consolidation: 0.15 mg/kg × 25 doses over a period up to 5 wk

IVP (D5W, NS) in 100-250 mL over 2 h

“Differentiation syndrome” characterized as leukocytosis, fever, dyspnea, chest pain, tachycardia, hypoxia, and sometimes death. Corticosteroids seem to benefit this syndrome (dose limiting)


QT prolongation (common)


Avoid other drugs that prolong the QT interval


Rash, pruritus, headache, arthralgias, anxiety, bleeding, nausea, vomiting (common)


Liver and renal toxicity (uncommon)


Asparaginase (Elspar, Erwinaze)


Antineoplastic enzyme

6,000-25,000


units/m2 as a single dose


200 units/kg/d for 28 d

IVPB (D5W, NS) over no <30 min


IM (if more than


2 mL, give in multiple injections)

Hypersensitivity (life threatening, requiring anaphylaxis precautions, and a 2-unit test dose)


IM reduces incidence of anaphylaxis


Coagulopathy is common and requires monitoring


Nausea, vomiting, abdominal cramps, anorexia, elevated liver function tests, transient renal insufficiency (common)


Depression, lethargy, drowsiness, fatigue, confusion


Fever, pancreatitis


Azacitidine (Vidaza)


DNA demethylation agent

Initial cycle:


75 mg/m2 daily for 7 d


Subsequent cycles:


75-100 mg/m2 daily for 7 d


Recommended minimum 4-6 cycles

IVPB (NS, lactated Ringer’s) over 10-40 min. Infusion must be completed within 1 h of vial reconstitution Subcutaneous. Gently roll the syringe between the palms to mix the medication immediately prior to administration. Divide the dose >4 mL into two syringes and inject into two sites. Rotate sites

Myelosuppression (dose limiting)


Prolonged leukopenia


Nausea, vomiting, diarrhea (common)


Mucositis (rare)


Liver enzymes elevated and liver function compromised (common)


Transient azotemia


Lethargy, confusion, coma have been reported


Bendamustine (Treanda)


Alkylating agent

100 mg/m2 on days


1 and 2 every


28 d × 6 cycles (chronic lymphocytic leukemia)


120 mg/m2 on days 1 and 2 every 21 d × 8 cycles (non-Hodgkin lymphoma)

IVPB (D5W, NS) over 30-60 min

Myelosuppression (dose limiting)


Nausea, vomiting, diarrhea


Rash, pruritus


Pyrexia, fatigue, asthenia


Hyperuricemia, infections


Infusion reactions (if reaction with the first dose, consider administering subsequent doses with acetaminophen, diphenhydramine, and corticosteroid)


Bleomycin (Blenoxane)


Antitumor antibiotic

10-20 units/m2 every week or twice weekly


Cumulative lifetime dose should not exceed 400 units

IVP


IM


Subcutaneous


IVPB (rare)

Reversible or irreversible pulmonary fibrosis (dose limiting)


Hypersensitivity (administer a test dose)


Fever and chills (premedicate with acetaminophen)


Pruritic erythema, hyperpigmentation, photosensitivity (common)


Alopecia, nausea, and vomiting


Renal or hepatic toxicity


Mucositis, myelosuppression (rare)


Bortezomib (Velcade)


Proteasome inhibitor

1.3 mg/m2 twice weekly for 2 wk followed by a


10-day rest period

IVP over 3-5 s


Subcutaneous

Myelosuppression


Nausea, vomiting, diarrhea, constipation, anorexia


Peripheral neuropathy (dose limiting)


Hepatic and renal toxicity


Rash, flu-like symptoms, fever, fatigue


Orthostatic hypotension


Busulfan (Busulfex)


Alkylating agent

Induction: 4-8 mg/d


Maintenance:


Usually 1-3 mg/d but can range from 2 mg/wk to 4 mg/d

IVPB (D5W, NS) over 2 h


Diluent volume should be 10 times busulfan, volume to final concentration of approximately ≥0.5 mg/mL


Also available in oral tablets

Nadir: 11-30 d; recovery 24-57 d


Prolonged myelosuppression with slow recovery (dose limiting)


Severe thrombocytopenia, anemia, electrolyte imbalances


Nausea, vomiting, anorexia, mucositis, hyperpigmentation, elevated liver function tests (common)


Hypertension, tachycardia, thrombosis, vasodilatation


Interstitial lung disease


Cabazitaxel (Jevtana)


Antimicrotubule agent

20-25 mg/m2 every 3 wk


Premedication with antihistamine, corticosteroid, and


H2 antagonist

IVPB (D5W, NS) over 1 h

Myelosuppression, especially neutropenia (dose limiting)


Peripheral neuropathy, dizziness, dysgeusia, headache


Diarrhea, nausea, vomiting, constipation, abdominal pain, dyspepsia


Hematuria, dysuria


Fatigue, asthenia, pyrexia, anorexia, back pain, dyspnea, cough, alopecia


Hypersensitivity reactions. Do not give if the patient has a history of a severe hypersensitivity reaction to cabazitaxel or to other drugs formulated with polysorbate 80


Carboplatin (Paraplatin)


Alkylating agent

360-400 mg/m2 every 4 wk


The dose is commonly based on a desired area under the curve (AUC) using a specific formula (Calvert formula: Total dose (mg) = target


AUC × (GFR + 25))

IVPB (D5W, NS) over at least 15 min to 24 h


May dilute to as low as 0.5 mg/mL


Intraperitoneal (IP)


Intra-arterial

FDA recommendation to cap the GFR at a maximum of 125 mL/min; it is not necessary to cap the GFR value when it is actually measured


Nadir at day 21; recovery by days 28-30


Myelosuppression, especially thrombocytopenia (dose limiting)


Nausea, vomiting, anorexia


Ototoxicity, hypersensitivity reaction (later cycles)


Increase in creatinine and blood urea nitrogen


Do not use aluminum needles


Carfilzomib (Kyprolis)


Proteasome inhibitor

20 mg/m2/d on 2 consecutive days each week for 3 wk (days 1, 2, 8, 9, 15, and 16) followed by 12 d of rest (days 17-28) for cycle 1; if tolerated, escalate the dose to 27 mg/m2/d in cycle 2 and continue


The dose is calculated using the patient’s ACTUAL BSA at baseline. Maximum BSA > 2.2 m2

IVPB (D5W) in 50 mL over 10 min


IVP undiluted over 2 to 10 min


Premedicate with dexamethasone 4 mg prior to all doses during cycle 1 and prior to all doses during the first cycle of dose escalation to reduce the severity of infusion reactions


The manufacturer confirms that while medication cannot be admixed in 0.9% NS, flushing with either 0.9% NS or D5W prior to or following administration is safe

Death due to cardiac arrest within 1 day of administration; new-onset congestive heart failure (NYHA III/IV, myocardial infarction within 6 mo excluded from trial); pulmonary arterial hypertension Thrombocytopenia, leukopenia, anemia (dose limiting)


Tumor lysis syndrome, hypokalemia, hypomagnesemia, hypercalcemia, hyperglycemia, hypophosphatemia, hyponatremia Headache, back pain, insomnia, dizziness, peripheral neuropathy


Nausea, diarrhea, constipation


Dyspnea, infusion reactions (up to 24 h post-administration); hepatic toxicity, pneumonia; acute renal failure, pyrexia, upper respiratory infection; cough; arthralgia/spasms


If history of herpes zoster infection, consider antiviral prophylaxis


Carmustine (BCNU)


Alkylating agent


Nitrosourea


Irritant

150-200 mg/m2 every 6 wk as a single dose or divided over a period of 2 d

IVPB (D5W, NS)


Dilute to a concentration of 0.2 mg/mL Stable for 8 h at room temperature


Carmustine wafers implanted during surgery

Delayed nadir 4-5 wk after administration and may last 60 d


Myelosuppression (slow at onset, cumulative, dose limiting)


Severe nausea and vomiting


Alopecia, painful/burning venous irritation during administration Hypotension


Infiltrates and/or pulmonary fibrosis


Azotemia, decreased kidney size, renal failure


Impotence, testicular damage causing infertility, facial flushing


Cisplatin (Platinol)


Alkylating agent


Vesicant if concentrated

20-40 mg/m2/d × 3-5 d every 3-4 wk


20-120 mg/m2 given as a single dose every 3-4 wk


Closely monitor creatinine clearance (may require dose adjustments)


100-200 mg/m2 for IP ovarian cancer

IV infusion (D5W, NS) in 250-1,000 mL


Infuse over 30 min-8 h


Prehydrate 1-2 L NS with potassium chloride


20 mEq/L + magnesium sulfate 8 mEq/L (commonly given)


Posthydration 1-2 L is also common


IP


Intra-arterial

Hydration should be adequate to maintain an I/O of 100-150 mL/h before administration of the drug


Severe nausea and vomiting—lasting 24-96 h


Aggressive antiemetic treatment is required


Peripheral neuropathy (dose limiting for cumulative doses)


Nephrotoxicity (dose limiting for individual doses)


Ototoxicity


Nadir on days 18-23 and recovery by day 39 (mild)


Alopecia


Electrolyte imbalances, especially potassium or magnesium wasting


Do not use aluminum needles


Protect from light


Cladribine (Leustatin)


2-CdA antimetabolite

0.09 mg/kg/d × 7 d (hairy cell leukemia)


Other malignancies


5-9 mg/m2/d × 5 d

Unstable in D5W


IV 24-hour continuous infusion for 7 d


A second cycle of treatment has been given to some nonresponding patients.


Can be given as 2-h infusion


Subcutaneous

Thrombocytopenia, neutropenia with nadir at 7-14 d


Universal lymphopenia


Cellulitis at the catheter site, rash, asthenia, fever, chills, fatigue


Renal toxicity (dose limiting)


Clofarabine (Clolar)


Antimetabolite (purine analog)

52 mg/m2/d × 5 consecutive days every 2-6 wk, following recovery or return to baseline organ function

IVPB (D5W, NS) over


2 h

Tumor lysis syndrome, cytokine release (systemic inflammatory response), capillary leak syndrome.


Recommend continuous IV fluids, allopurinol, and prophylactic steroids (hydrocortisone 100 mg/m2/d) on days 1-3


Hypotension, tachycardia


Neutropenia, anemia, thrombocytopenia


Dizziness, headache, anxiety, light-headedness


Nausea, vomiting, diarrhea, anorexia, abdominal pain, constipation


Dermatitis, erythema, petechiae, pruritus


Hematuria, elevated creatinine


Arthralgia, myalgia, limb pain, cough, epistaxis, fatigue, pyrexia, elevated LFTs


Cyclophosphamide (Cytoxan)


Alkylating agent

May be given as a single dose or in several divided doses, common doses of 500-1,500 mg/m2 every 3 wk


50 to 200 mg/m2/d orally for 14 d of a


28-d cycle


400 mg/m2/d for 4 d every 4-6 wk

IVP over 5-10 min (doses <750 mg)


IVPB (D5W, NS) infuse in 100-150 mL over 15-30 min


Higher doses require hydration of 500 mL or more of NS

Leukocyte nadir 8-14 d and recovery in 18-25 d


Myelosuppression (dose limiting)


Nausea and vomiting 6-10 h after treatment


Alopecia, nail and skin hyperpigmentation


Nasal congestion and burning, metallic taste during infusion


Hypersensitivity reactions


Testicular atrophy and amenorrhea


Acute hemorrhagic cystitis (give the dose in morning)


Frequent voiding; hydrate to prevent cystitis


Mesna (uroprotectant) for high doses


Cardiac necrosis and/or acute myopericarditis with high doses (rare)


Secondary malignancies


Cytarabine (Ara-C)


Antimetabolite

60 to 200 mg/m2 IV for 5-10 d


100 mg/m2 IV or subcutaneously BID for 5 d every 28 d


High dose: 1-3 g/m2 every 12 h for 3-6 d


10 mg/m2 subcutaneously every 12 h for 15-21 d


10-30 mg/m2 intrathecally up to 3 times per week

IVP (low dose) over 1-2 min, or IV in 50 mL or more approximately over 30 min


For high dose, IV (D5W, NS) in 250-500 mL over 1-3 h

Nadir in 5-7 d, leukopenia, thrombocytopenia, anemia (dose limiting) Nausea, vomiting, anorexia, diarrhea (common)


Metallic taste, mucositis (common)


Rare syndrome of sudden respiratory distress, rapid progression to pulmonary edema Keratoconjunctivitis with high doses (use dexamethasone eyedrops for prevention)


Cerebellar toxicity with high doses (lethargy, confusion, slurred speech)


Most cases resolve, but in some cases, irreversible and/or even fatal


Flu-like symptoms, bone/muscle pain, skin rash, alopecia (common)


Concurrent treatment with dexamethasone is recommended for an IT or intraventricular route


Cytarabine liposome (Depocyt)


Antimetabolite

Induction: 50 mg intrathecally every 14 d × 2 doses


Consolidation: 50 mg intrathecally every 14 d × 3 doses


Maintenance: 50 mg intrathecally every 28 d × 4 doses


Liposomal cytarabine is different dosing than conventional


Cytarabine

Intrathecal over 1-5 min by lumbar puncture or into an intraventricular reservoir


Do not filter

Mild neutropenia and thrombocytopenia


Headache, confusion, somnolence


Nausea, vomiting, constipation


Arachnoiditis syndrome (neck pain, N/V, headache, fever, back pain). Give dexamethasone 4 mg BID PO or IV for 5 d beginning on the day of injection


Asthenia, peripheral edema


Dacarbazine (DTIC)


Alkylating agent


Irritant

375 mg/m2 on days 1 and 15 (as part of the ABVD regimen for Hodgkin lymphoma)


150-250 mg/m2/d × 5 d every 3-4 wk


650-1,450 mg/m2 every 3-4 wk


250 mg/m2/d continuous infusion × 4 d every 3 wk

IVPB (D5W, NS) in 100 mL or more Infuse over 30-60 min


IVP or rapid infusion over 15 min but may increase venous irritation

Nadir at 2-4 wk after treatment, leukopenia, thrombocytopenia, anemia (dose limiting)


Severe nausea and vomiting; prevent with aggressive antiemetic support


Fever, anorexia, metallic taste (common)


Flu-like symptoms with high doses


Facial flushing


Irritant: Avoid extravasation. Local pain at the injection site. Slow the rate of infusion to decrease the pain from venous spasm Protect from sunlight. Pink solution indicates decomposition


Dactinomycin (Cosmegen)


Antitumor antibiotic


Vesicant

500 mcg/d × 5 d (ovarian)


1,000 mcg/m2 × 1 day (testicular)


12-15 mcg/kg/d × 5 d (gestational trophoblastic neoplasia)

IVP slowly over 2-3 min


IVPB (D5W, NS) in 50 mL over 10-15 min


Do not administer IM or SC


Regional perfusion: 50 mcg/kg (lower extremity) and 35 mcg/kg (upper extremity)

Leukopenia, thrombocytopenia 1-2 wk after treatment. Nadir at 3 wk (dose limiting)


Severe nausea and vomiting (occur 1 h after dose and may last several hours)


Erythema, multiforme, hyperpigmentation, alopecia (common)


Mucositis, anorexia, diarrhea (uncommon) Skin irritation, erythema, or necrosis in previously irradiated areas (“radiation recall”)


Daunorubicin (Cerubidine)


Antitumor antibiotic Vesicant

30-90 mg/m2/d for 2-3 d every 3-4 wk


Pediatric doses will vary

Single IV injection or split into a 3- to 5-day schedule running IV over 2-5 min

Nadir between 1 and 2 wk, recovery in 2-3 wk


Grade 3-4 neutropenia with higher dosing (dose limiting)


Nausea and vomiting 1 h after dose and lasting for several hours (prevented by antiemetics)


Alopecia, mucositis (common)


Rash, diarrhea, elevated liver enzymes (uncommon)


Cumulative cardiotoxicity at maximum lifetime dose of 500-600 mg/m2 (aggravated by concurrent radiation)


Arrhythmias, usually asymptomatic/transient, congestive cardiomyopathy


Red urine—advise the patient


Daunorubicin liposomal (DaunoXome)


Antitumor antibiotic

40 mg every 2 wk

IVPB (D5W) over 60 min


Do not filter

Infusion reaction (triad of symptoms: back pain, flushing, chest tightness), within first 5 min of infusion; subsides with interruption of infusion; generally does not recur if infusion is resumed at a slower rate


Myelosuppression


Nausea, vomiting, diarrhea, fatigue, abdominal pain, anorexia, headache


Fever, chills, hyperuricemia, cough, dyspnea


Cumulative cardiotoxicity at a maximum lifetime dose of 320 mg/m2


Decitabine (Dacogen)


Pyrimidine analogue

15 mg/m2 every


8 h × 3 d every 6 wk


20 mg/m2/d daily × 5 d every 4 wk

IVPB (D5W, NS) over 1-3 h

Myelosuppression


Headache, dizziness, insomnia, confusion, fatigue


Nausea, vomiting, diarrhea, constipation, stomatitis, dyspepsia, hyperglycemia, pyrexia


Rash, erythema, pruritus, petechiae


Fever, edema, rigors, arthralgia, electrolyte imbalance, limb pain, cough


Dexrazoxane (Zinecard)


Cardioprotectant (Totect)


Extravasation


Antidote

(For cardioprotectant) Dosage ratio of 10 mg/m2 of dexrazoxane for every


1 mg/m2 of doxorubicin (10:1 ratio)


(For antidote) 1,000 mg/m2 (max 2,000 mg) on days 1 and 2, and then 500 mg/m2 (max 1,000 mg) on day 3

(For cardioprotectant) Slow IVP or rapid IV infusion (NS, D5W) over 15-30 min


In final concentration of 1.3-5 mg/mL


(For antidote) IVPB (NS 1,000 mL) over 1-2 h

As a cardioprotectant, administer within 30 min before the administration of doxorubicin


As an extravasation antidote, should be started within 6 h of event


Dexrazoxane may add to myelosuppression


Mild nausea, vomiting, anorexia (common)


Fever, mucositis, fatigue, anorexia (uncommon)


Hypotension, deep vein thrombosis, liver toxicity


Docetaxel (Taxotere)


Antimicrotubule agent


Irritant


Potential vesicant

60-100 mg/m2 every 3 wk


40 mg/m2 every week × 6 wk followed by 2-wk rest


75 mg/m2 every 3 wk


*Other doses have been evaluated

IV (D5W or NS) over 1-3 h


Final concentration of 0.3-0.74 mg/mL


Avoid PVC tubing or bags

Severe neutropenia (dose limiting)


Total alopecia (universal)


Edema, fluid retention, ascites, pleural effusions are common (dose limiting)


Recommended premedication: dexamethasone 8 mg BID 1 d prior to docetaxel for a total of 3 d to reduce fluid accumulation and prevent hypersensitivity reactions


Capillary leak syndrome in patients after cumulative dose of 400 mg/m2


Hypersensitivity or anaphylaxis (uncommon when premedicated with steroids and antihistamines)


Peripheral neuropathy, mucositis, diarrhea (mild, common)


Rash, hand-foot syndrome, elevated liver functions (uncommon)


Doxorubicin (Adriamycin)


Antitumor antibiotic


Vesicant

Usual dose of 40-75 mg/m2

Bolus (extravasation precautions) over 2-5 min IVPB (D5W, NS) in 50-100 mL over 20-30 min via central line Intra-arterial to liver, Intravesicular


IP

Nadir at 10-14 d and recovery in 21 d


Myelosuppression (universal, dose limiting with individual dose)


Alopecia, hyperpigmentation of nail beds and dermal creases, facial swelling (common)


Nausea and vomiting, anorexia, mucositis—especially with daily schedule


Radiation recall (irritation of previously irradiated areas)


Cardiotoxicity: CHF, EKG changes, monitoring of LVEF (dose limiting)


Lifetime cumulative dose 550 mg/m2


May enhance cyclophosphamide cystitis


Red urine up to 24 h after administration


Erythematous streak up the vein (“Adria flare”)


Incompatible with heparin and fluorouracil


Doxorubicin (Doxil)


Liposomal doxorubicin


Anthracycline

20 mg/m2 every


3 wk (Kaposi sarcoma)


50 mg/m2 every 4 wk (ovarian cancer)

IVPB (D5W) in 250 mL.


Doses of 20 mg/m2 are given over 30 min, larger doses are given over 1 h

Same toxicities as doxorubicin


Mild nausea, mucositis (common)


Severe hand-foot syndrome (can be dose limiting)


Acute infusion reaction: rate related: flushing, shortness of breath, facial swelling, chest tightness, hypotension—decrease the rate or stop infusion


Alopecia (uncommon)


Lifetime cumulative dose


550 mg/m2


Epirubicin (Ellence)


Anthracycline


Antitumor antibiotic


Vesicant

100 mg/m2/d on day 1 every 21 d or 60 mg/m2/d on days 1 and 8 every 28 d

Bolus (extravasation precautions) free-flowing line over 2-5 min


Continuous infusion through a central line

Epirubicin of ≥90 mg/m2 produces a degree of myelosuppression equivalent to doxorubicin 60 mg/m2


Leukopenia, expected nadir 10-14 d (dose limiting)


Thrombocytopenia, anemia


Hyperpigmentation of nail beds and dermal creases, dermatitis, radiation recall


Alopecia (expected)


Nausea, vomiting, mucositis, fatigue (common)


CHF increased the risk with higher doses


Lifetime cumulative dose


900 mg/m2


Red urine, fevers, anaphylactic reactions, parenthesis, headache


*If extravasated, will cause local tissue damage, flush along the vein, facial flush, urticaria, phlebitis


Eribulin mesylate (Halaven)

1.4 mg/m2 on days


1 and 8 of a 21-day cycle

IVP or IVPB (NS 100 mL over 2-5 min


Do not administer with dextrose-containing solutions

Neutropenia, anemia (dose limiting)


Peripheral neuropathy, headache


Nausea, constipation, vomiting, diarrhea


QT prolongation (observed on day 8, not on day 1)


Alopecia, asthenia/fatigue, fever, arthralgia, anorexia, cough, dyspnea


Etoposide (VP-16)


Plant alkaloid

50-150 mg/m2/d × 3-5 d


100 mg/m2/d × 5 d every 3 wk (testicular cancer in combination with cisplatin)


Oral doses are generally twice the IV dose

IVPB (D5W or NS) over at least 30 min-1 h


Dilute to concentration of 0.2-0.4 mg/mL


Final concentrations above 0.4 mg/mL could result in precipitation

Leukopenia; nadir within 7-14 d and recovery within 20 d (dose limiting)


Thrombocytopenia/anemia uncommon


Mild alopecia


Nausea and vomiting: mild; anorexia (common)


Elevated bilirubin and transaminase levels


Peripheral neuropathy


Transient hypotension associated with rapid administration: Infuse over


30 min-1 h


Discontinue infusion if hypersensitivity/bronchospasm occurs


Etoposide phosphate (Etopophos)


Plant alkaloid (water-soluble ester of etoposide)

35 mg/m2/d × 4 d to 50 mg/m2/d × 5 d every 3-4 wk


50-100 mg/m2/d on days 1 to 5 or 100 mg/m2/d on days


1, 3, and 5 every 3-4 wk

IV push over 5 min into freely running IV


IVPB (D5W, NS) over up to 120 min


For high-dose HSCT regimens (off-label use), infuse over 4 h directly into a central venous line. If undiluted etoposide is used, solutions should be prepared in sterile glass containers and administered through non-ABS tubing (e.g., nitroglycerin tubing) to avoid cracking of plastic

Blood pressure changes


Alopecia, rash, urticaria, pruritus


Anorexia, nausea, vomiting, mucositis, constipation/diarrhea


Myelosuppression


Anaphylaxis, chills, fever, dyspnea


Asthenia, malaise


Floxuridine (FUDR)


Antimetabolite

Continuous infusion


Intra-arterial infusion via pump (0.1-0.6 mg/kg/d)


Hepatic artery infusion via pump (0.4-0.6 mg/kg/d)


IV: 0.075-0.275 mg/kg/d × 14 d


30 mg/kg/d × 5 d

Intra-arterial Hepatic arterial infusion


IV

Thrombocytopenia, leukopenia, anemia


Vomiting, diarrhea, nausea, stomatitis


Erythema, alopecia, dermatitis, rash


Fever, lethargy, weakness, malaise, anorexia


Fludarabine (Fludara)


Antimetabolite

25-30 mg/m2/d for


5 consecutive days every 4 wk

IVPB (NS, D5W)

Leukopenia; nadir 13 d, thrombocytopenia nadir 16 d (dose related, may be cumulative, and dose limiting)


Lymphopenia (common and clinically important)


CNS toxicity—delayed blindness, coma, death—can occur up to 21-60 d after the last dose (rare, occurs in extreme high doses, and is dose limiting)


Somnolence, confusion, weakness, fatigue


Nausea, vomiting (rare), diarrhea, anorexia


Tumor lysis syndrome associated with large tumor burdens


Cough, pneumonia, dyspnea chills, fever, malaise


Fluorouracil (5-FU)


Antimetabolite

Numerous regimens used, including:


300-450 mg/m2/d


IVP × 5 d every 28 d


600-750 mg/m2


IVP every week or every other week


1,000 mg/m2 infused over 24 h × 4-5 d


300 mg/m2/d infused indefinitely

IVP, IVPB, or continuous infusion (NS, D5W) Intraocular 1 mg/0.1 mL in preservative-free NS


Arterial infusion, intracavitary


IP


Topical


Oral when mixed in liquids

Nadir at 9-14 d, with recovery in 21-25 d; less common with continuous infusion


Dermatitis, nail hyperpigmentation, alopecia, and chemical phlebitis with long-term infusion


Nausea, vomiting, and anorexia


Severe diarrhea associated with prolonged infusions (dose limiting)


Mucositis (more common with 5-d infusion and bolus dosing)


Cerebellar ataxia and headache (rare, with higher doses)


*Toxicities are more common and more severe in patients with dihydropyrimidine dehydrogenase deficiency


Gemcitabine (Gemzar)


Antimetabolite

1,000 mg/m2 every week × 7 wk, and then 1-week rest


Combination with cisplatin: 1,000 mg/m2/d on days 1, 8, and 15 of a 28-d cycle


1,250 mg/m2/d on days 1 and 8 of a 21-d cycle

IV over 30 min or a fixed-dose rate of 10 mg/m2/min; prolonged infusion times increase the active metabolite accumulation, which may increase toxicity


Use with NS only

Mild to moderate neutropenia, myelosuppression with anemia, recovery within 1 wk (dose limiting)


Mild nausea and vomiting, diarrhea, mucositis, flu-like symptoms


Fever during administration


Rash with pruritus


Elevations of hepatic transaminase level, hyperbilirubinemia


Peripheral edema


Proteinuria, hematuria, elevated BUN (uncommon)


Glucarpidase (Voraxaze)


Antidote for methotrexate toxicity


Recombinant enzyme from E. coli

50 units/kg

IVP over 5 min.


Flush the IV line before and after administration


Do not administer leucovorin within 2 h before and after glucarpidase as leucovorin may be inactivated

Pain at the injection site, rash, flushing


Idarubicin (Idamycin)


Antitumor antibiotic


Vesicant

12 mg/m2/d for 3 d


8-15 mg/m2 as a single dose every 3 wk

IVP over 1-5 min (extravasation precautions)

Myelosuppression (dose limiting for each individual dose)


Nausea, vomiting, (common)


Diarrhea and mucositis (occasional)


Alopecia (partial), extravasation reactions, and rash


Transient arrhythmias, decreased left ventricular ejection fraction, and CHF increased the risk with higher doses (cumulative dose-limiting toxicity)


Ifosfamide (Ifex)


Alkylating agent

1,000-1,200 mg/m2 over 5 consecutive days every 3-4 wk


Higher doses (2,500-4,000 mg/m2/day) have been given over 2-3 d

IVPB only (D5W, NS) in 250-1,000 mL over 30 min or longer

Leukopenia, thrombocytopenia (dose limiting); anemia


Nausea, vomiting, anorexia, constipation and diarrhea, mucositis


Alopecia, rash, urticaria, nail ridging


Increased ALT, AST, and bilirubin


Hemorrhagic cystitis and hematuria (dose limiting)


Hydration of 2 L/d to maintain urinary output, frequent voiding. Mesna recommended


Mesna (Mesnex)


Uroprotectant

Mesna must be given with


Ifosfamide

IVPB over 15 min or continuous infusion (infuse until 12-24 h after ifosfamide completion)


Recommended aggressive hydration to reduce the risk of hemorrhagic cystitis


Oral

CNS toxicity: somnolence, lethargy, disorientation, confusion, dizziness, malaise, myoclonus, seizures: reversible (dose limiting)


Electrolyte imbalance


Irinotecan (Camptosar, CPT-11)


Topoisomerase I inhibitor


Irritant

125 mg/m2 every week × 4, then 2-week rest and repeat cycle


350 mg/m2 every 28 d


If combined with cisplatin: 80 mg/m2 on day 1 every 4 wk


60 mg/m2 every week × 3 wk

IV (D5W preferred) in 500 mL over 60-90 min or longer

Myelosuppression, especially neutropenia and diarrhea (common and dose limiting)


Consult the manufacturer’s recommendations for guidelines


Diarrhea, “acute cholinergic” along with cramping, nausea, vomiting during or immediately following drug administration, or for several days after drug administration; treated with anticholinergics and antidiarrheal agents


Moderate to severe nausea, anorexia


Alopecia, flushing, rash (common)


Elevated liver enzymes


Fatigue, fevers, salivation, lacrimation


Increased prothrombin times of patients taking warfarin


Advise the patients not to take St. John’s wort


Ixabepilone (Ixempra)


Mitotic inhibitor

40 mg/m2 every 3 wk


Premedicate with


H1 antagonist and


H2 antagonist.


If hypersensitivity reaction, add corticosteroid premedication

IVPB (lactated Ringer’s 250 mL or adjust to concentration between 0.2 and 0.6 mg/mL) over 3 h


Use non-PVC infusion containers and administration sets with a 0.2- to 1.2-µm filter

Use with caution in cardiac disease


Myelosuppression


Asthenia, peripheral neuropathy, dizziness


Abdominal pain, diarrhea, constipation, nausea, stomatitis, vomiting


Alopecia, hand-foot syndrome


Arthralgia, myalgia, fatigue, hypersensitivity reactions


Avoid concomitant administration with CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir). If coadministration is necessary, consider reducing ixabepilone dose to 20 mg/m2


Leucovorin, Calcium


Tetrahydrofolic acid derivative


Nonchemotherapeutic agent

Methotrexate rescue: 10-25 mg/m2 every 6 h × 6-8 doses starting up to 24 h after the start of methotrexate


To potentiate the cytotoxic effect of 5-FU: 20-500 mg/m2 dose

IVP at any convenient rate


IM


Oral


IVPB (D5W, NS)


50-250 mL over 15 min

Rare hypersensitivity reactions


Thrombocytosis, nausea, diarrhea, rash, headache


Dose adjustments are made based on methotrexate serum levels and serum creatinine levels


Mechlorethamine (Nitrogen Mustard)


Alkylating agent Vesicant

6 mg/m2 on days


1 and 8 (MOPP regimen for Hodgkin lymphoma)


Up to 0.4 mg/kg as a single agent monthly

IVP over 1-5 min (extravasation precautions) into the tubing of a rapidly running IV Intracavitary injection; usually painful—patients should be given appropriate analgesia


IP should be avoided

Leukopenia and thrombocytopenia within 24 h, with a nadir at 6-8 d to 3 wk (dose limiting)


Severe nausea and vomiting beginning


1-3 h after treatment (dose limiting); aggressive antiemetic premedication is mandatory


Discoloration of the infused vein and phlebitis


Alopecia and mucositis


Vesicant antidote is sodium thiosulfate if extravasation occurs


Metallic taste


Amenorrhea and impaired spermatogenesis, sterility (common)


Diarrhea, anorexia, jaundice, tinnitus, skin rash (topical application)


Secondary malignancy and hearing loss (rare)


Incompatible with other antineoplastic agents


Short stability


Melphalan (Alkeran)


Alkylating agent Vesicant

16 mg/m2


0.1 mg/kg/d for 2-3 wk or up to 6 mg/m2 for 5 d every 6 wk (multiple myeloma)

IVPB over 15-20 min 60 min stability


Oral tablets

Myelosuppression, prolonged recovery, effects cumulative (dose limiting)


Nausea, vomiting


Vein reactions, scarring


Diarrhea, mucositis (uncommon)


Pulmonary fibrosis, alopecia, vasculitis, infertility, secondary leukemia (uncommon)


Mesna


Uroprotective agent (nonchemotherapeutic)

20% of ifosfamide dose given just before and at 4 and 8 h after ifosfamide


Can be administered with high-dose cyclophosphamide

IVPB (D5W, NS) 50-100 mL


IVP (<100 mg) Oral tablets

Nausea, vomiting, diarrhea, abdominal pain, altered taste, flushing


Rash and urticaria


Lethargy, headache, joint or limb pain, fatigue


Methotrexate


Antimetabolite

30 mg/wk (psoriasis)


200-500 mg/m2 every 2-4 wk (leukemias and lymphomas)


Low dose: <100 mg/m2


Moderate dose: 100-1,000 mg/m2 High dose: >1,000 mg/m2


Intrathecal: usually 10-15 mg in preservative-free NS or lactated Ringer solution

IVPB (D5W, NS) in 50 mL (up to 500 mL) over 30 min to 1 h


Can also be given as 24-h continuous infusions


Intrathecally


IM

Myelosuppression expected (dose limiting)


Mucositis, sore throat, and pruritus with high dose


Hematemesis


Nausea and vomiting (uncommon)


Diarrhea (common)


Renal toxicity, dose related, and more likely to occur in patients with compromised renal function; reversible


Hepatotoxicity, pulmonary dysfunction (rare)


Encephalopathy with multiple intrathecal doses


Confusion, ataxia, tremors, irritability, seizures, and coma


Hypersensitivity reactions associated with fever, chills, and rash


Skin erythema, depigmentation or hyperpigmentation, alopecia, and photosensitivity


Doses >80 mg/wk should be accompanied by leucovorin rescue


Mitomycin (Mitomycin-C, Mutamycin)


Antitumor antibiotic


Vesicant

10-20 mg/m2 every 6-8 wk


It is recommended that total cumulative doses not exceed 50 mg/m2 to avoid excessive toxicity

IVP over 2-5 min


Use vesicant precautions


IVPB (D5W, NS in up to 250 mL) over 30 min


Intravesical


IP


Intraocular


Intra-arterial

Leukopenia and thrombocytopenia: delayed, cumulative, and dose limiting; anemia


Nadir at 4-5 wk, recovery


2-3 wk later


Alopecia (4%), dermatitis, and pruritus


Nausea, vomiting, anorexia, fatigue (common)


Diarrhea, mucositis, fever (uncommon)


Hepatotoxicity; venoocclusive disease (rare)


Parenthesis, lethargy, weakness, and blurred vision


Interstitial pneumonitis infrequent toxicity but can be severe


Bronchospasm, acute SOB when given with a Vinca alkaloid


Hemolytic uremic syndrome (rare)


Nephrotoxicity at doses >50 mg/m2


Mitoxantrone (Novantrone)


Antitumor antibiotic Irritant

12 mg/m2/d × 3 d (in combination with cytarabine) for induction therapy for AML


12 mg/m2 every 3-4 wk

IVP has been used (over ≥ 3 min, dilute in at least 50 mL), but IVPB the preferred route


IVPB (D5W, NS, in at least 50 mL) over 15-30 min or longer

Pain on injection and phlebitis


Leukopenia expected, nadir at 10-12 d, with recovery 21-28 d


Alopecia (mild), pruritus, and dry skin


Nausea, vomiting, diarrhea, and mucositis (mild)


Cumulative cardiomyopathy; maximum lifetime dose is 140-160 mg/m2


Hypersensitivity: hypotension, urticaria, and rash


Blue-green urine, stool, and sclera for 24-48 h after treatment; the vein may be discolored


Fever, conjunctivitis, phlebitis, and amenorrhea


Nelarabine (Arranon)


Antimetabolite (prodrug of Ara-G)

1,500 mg/m2 on days 1, 3, and 5 every 21 d

IV undiluted over 2 h (adults) or 1 h (pediatrics)

Anemia, thrombocytopenia, neutropenia


Altered mental status, severe somnolence,


Convulsions, peripheral neuropathy, demyelination, dizziness, headache, paresthesia, seizures


Nausea, diarrhea, vomiting, constipation


Petechiae, fatigue, pyrexia, asthenia, peripheral edema, infection


Anorexia, myalgia, cough, dyspnea, pleural effusion


Oxaliplatin (Eloxatin)


Alkylating agent

85 mg/m2 on day 1 every 2 wk in combination with fluorouracil


130 mg/m2 every 3 wk in combination with the 5-FU protocol


Numerous regimens refer to chemotherapy text for doses/schedules of protocols

IVPB (D5W in 250-500 mL) of over 2-6 h


Should be administered prior to fluorouracil

Myelosuppression mild, occasionally dose limiting; the risk of grade 3 and 4 neutropenia is significantly increased with combination of fluorouracil


Nausea, vomiting, diarrhea, dehydration, hypokalemia, metabolic acidosis


Hand-foot syndrome


Elevations of transaminase enzymes, hyperbilirubinemia


Tachycardia supraventricular arrhythmia, hypertension, phlebitis, thromboembolism


Acute/chronic neurologic symptoms, aggravated with exposure to cold (dose limiting)


Hypersensitivity reactions (later cycles)


Fatigue, back pain, arthralgia


Pharyngolaryngeal dysesthesias


Paclitaxel (Taxol)


Plant alkaloid


Taxane


Irritant


Potential vesicant

Variety of doses/schedules including:


Ovarian: 135-175 mg/m2 over 3 h every 3 wk or 135 mg/m2 over 24 h repeated every 3 wk


Breast: 175 mg/m2 over 3 h every 3 wk (doses up to 200-250 mg/m2 have been administered)


Non-small cell lung cancer: 135 mg/m2 as CI over 24 h (higher doses have been given in combination with carboplatin)

IV infusion (NS, D5W) Over 1, 3, or 24 h Concentration of 0.3-1.2 mg/mL in glass, polypropylene, or polyolefin containers


Avoid contact of the undiluted paclitaxel with plasticized PVC equipment


Use an in-line filter of 0.22 µm or less, and a non-PVC-containing infusion set

Pancytopenia (dose limiting), shorter infusions produce less neutropenia; mild anemia, infection


Premedicate to avoid hypersensitivity reaction, with dexamethasone, diphenhydramine, and ranitidine (or cimetidine)


Hypersensitivity: urticaria, wheezing, chest pain, dyspnea, and hypotension (common)


Cardiovascular: hypertension, hypotension, premature contractures, bradycardia—monitor vital signs during the first hour; EKG abnormalities (common)


Peripheral neuropathy (increases with cumulative doses)


Nausea, vomiting, diarrhea


Mucositis (with longer infusions)


Alopecia—complete, rash, flushing, nail changes, arthralgia/myalgia


Liver toxicity, interstitial pneumonitis (uncommon)


Paclitaxel proteinbound (Abraxane)


Taxane Vesicant

260 mg/m2 every 3 wk


100-250 mg/m2 on days 1, 8, and 15 of a 28-day cycle

IV over 30 min


Extravasation precautions


Do not use an in-line filter

Contains human albumin, which may be prohibited in certain religious/cultural beliefs


Myelosuppression, primarily neutropenia (dose limiting)


Thrombocytopenia (uncommon); anemia (common)


Sensory neuropathy (common)


Hypersensitivity reactions: dyspnea, flushing, hypotension, chest pain, arrhythmia (uncommon)


No premeds needed for hypersensitivity prevention


Hypotension and bradycardia during a 30-minute infusion (uncommon)


Nausea, vomiting, diarrhea, mucositis (common)


EKG abnormalities (common)


Dyspnea and cough


Ocular/visual disturbances (e.g., keratitis, blurred vision; severe, reversible)


Arthralgia/myalgia; transient, resolved within a few days


Interstitial pneumonia, lung fibrosis, and pulmonary embolism (rare)


Pegaspargase (Oncaspar)


Pegylated form of asparaginase

2,500 units/m2 every 14 d with other agents for induction and maintenance

IM

Acute liver dysfunction, hypercholesterolemia


Coagulopathy


Hypersensitivity and anaphylaxis can still occur (used when the patient is allergic to asparaginase)


Pancreatitis, hyperglycemia, fever, chills, anorexia, lethargy, confusion, headache, seizures, azotemia (same as asparaginase allergy)


Pemetrexed (Alimta)


Antimetabolite

500 mg/m2 every 21 d with cisplatin (75 mg/m2 over 2 h) to follow


30 min later

IV infusion over 10 min

Myelosuppression, especially neutropenia, thrombocytopenia


Fatigue, nausea, vomiting, dyspnea


Side effects reduced with vitamin supplementation: Administer folic acid 350-1,000 mcg daily starting 1-3 wk prior to the first cycle and daily for 1-3 wk after the final cycle. Vitamin B12 injection 1,000 mcg IM given 1-3 wk before the first cycle and repeat every 9 wk until the treatment is completed


Dexamethasone 4 mg BID for 3 d starting the day before treatment decreases the incidence of skin rash


Pentostatin (Nipent)


Antimetabolite

4 mg/m2 every 2 wk


Dose reduction may be necessary for renal dysfunction exhibited by creatinine clearance <60 mL/min

IV bolus over 5 min


IVPB (NS, D5W, in 25-50 mL) over 20 min or longer


Recommend hydration of 1-2 L before and after each treatment


IVPB (D5W, NS, in 100 mL) or more over 30-60 min

Severe leukopenia; lymphopenia common; can lead to serious infection (dose limiting)


Thrombocytopenia, anemia


Nausea, vomiting, fever fatigue (common)


Anorexia, diarrhea, mucositis, rashes, dry skin, headache (uncommon)


Elevated hepatic transaminase levels, nephrotoxicity (uncommon)


Keratoconjunctivitis, photophobia, arthralgia, cough


Neurotoxicities rare with standard dose, increased with higher dosing


Acute tubular necrosis, hepatitis (rare)


Cumulative myelosuppression, anemia, leukopenia, and thrombocytopenia


Pralatrexate (Folotyn)


Antimetabolite (folate analog inhibitor)

30 mg/m2 once weekly × 6 wk in a 7-week cycle


Supplement with vitamin B12 1 mg IM every 8-10 wk, starting no more than 10 wk prior to first dose, and folic acid 1-1.25 mg PO daily starting 10 d prior to treatment and ending 30 d after the last pralatrexate dose

IVP undiluted over 3-5 min

Thrombocytopenia, anemia, neutropenia


Mucositis, nausea, vomiting, constipation, diarrhea


Edema, cough, dyspnea, fever, fatigue, epistaxis hypokalemia, rash, severe dermatologic reactions


Tumor lysis syndrome, hepatic dysfunction


Romidepsin (Istodax)


HDAC (histone deacetylase) inhibitor

14 mg/m2 on days 1, 8, and 15 in 28-day cycles

IVPB (NS 500 mL) over 4 h


Due to the risk of QT prolongation, potassium and magnesium levels should be within normal range

Thrombocytopenia, neutropenia, anemia


EKG T-wave changes


Nausea, vomiting, diarrhea, anorexia, constipation


Fatigue, fever, infections, hypomagnesemia


Coadministration with strong inhibitors of CYP3A4 may increase romidepsin concentrations and coadministration of potent CYP3A4 inducers may decrease concentrations and should be avoided


Streptozocin (Zanosar)


Alkylating agent Irritant

500-1,000 × 5 d every 4-6 wk 1,000-1,500 mg/m2/wk


Doses >1,500 mg/m2/d should not be exceeded owing to an increased risk of nephrotoxicity.


Doses should be adjusted for creatinine clearance <50 mL/min

Continuous infusion × 5 d


Can be given IVP, recommended slow administration


IVPB (NS, D5W) over 30-60 min or over 6 h

Leukopenia; nadir 10-14 d (dose limiting)


Eosinophilia


Nausea and vomiting (severe), anorexia, diarrhea, abdominal cramps (potentially dose limiting)


Nephrotoxicity (renal tubular damage) with proteinuria (common and potentially dose limiting)


Vein irritation during administration; slow infusion to minimize pain


Transient increases in ALT, AST, alkaline phosphatase, and LDH


Glucose intolerance and glycosuria


Fever, delirium, depression (rare)


Temozolomide (Temodar)


Alkylating agent

75-200 mg/m2


Bioequivalence w/oral form only established when given over 90 min. Infusion over shorter or longer time may result in suboptimal dosing and/or increase in infusion-related reactions

IV (in an empty 250-mL bag without further dilution) over 90 min

Myelosuppression


Nausea, vomiting, constipation, diarrhea


Headache, dizziness, convulsions, confusion, somnolence, fatigue, anorexia


Dyspnea, coughing, rash, alopecia, fever


Temsirolimus (Torisel)


Kinase inhibitor

25 mg weekly until disease progression or unacceptable toxicity


Premedicate with diphenhydramine 25-50 mg IV

IV undiluted over 30-60 min.


A non-PVC infusion container should be used due to the polysorbate 80 vehicle.


Use an administration set with an in-line polyethersulfone filter not >5 µm

Myelosuppression, especially anemia


Insomnia, headache


Mucositis, anorexia, nausea, vomiting, diarrhea, constipation


Rash, pruritus, hypersensitivity reaction


Elevated serum creatinine, acute renal failure


Hyperglycemia, hyperlipemia, asthenia, edema, fever, arthralgia, myalgia, cough, dyspnea, elevated LFT’s, wound healing complications, interstitial lung disease


If patients must be coadministered a strong CYP3A4 inhibitor or CYP3A4 inducer, a dose modification may be warranted


Teniposide (VM-26)


Plant alkaloid

165 mg/m2 2 times/week for 8-9 doses (with cytarabine protocol)


Maintenance dose of 250 mg/m2 weekly for 4-8 wk

IVPB (D5W, NS) over at least 30-60 min


Maintain concentration of 0.1-0.4 mg/mL Administer via non-PVC containers or glass


IP

Anaphylaxis may occur


Mucositis, nausea, vomiting, diarrhea, anorexia (uncommon)


Alopecia (mild)


Hypotension (rapid IV infusion)


Fatigue, seizures, somnolence, fever, renal insufficiency, and secondary malignancies (rare)


Leukopenia: nadir at 14 d and recovery after 2-4 wk (dose limiting)


Thiotepa


Alkylating agent

Nontransplant: 12-16 mg/m2 every 1-4 wk


Transplant: 900 mg/m2


Intrathecal: 1-10 mg/m2 1-2 times weekly


Bladder instillation: 30-60 mg every week × 4 wk


Numerous routes of administration

IV over 30 min


Intravesically


Intrathecally

Anemia, thrombocytopenia


Alopecia


Hypersensitivity reactions: angioedema, hives, rash, and pruritus


Nausea, vomiting, anorexia, mucositis, diarrhea, fever (uncommon)


Headache, dizziness, and weakness of lower extremities


Paresthesias associated with intrathecal administration


Impaired fertility—azoospermia and amenorrhea


Dose-limiting neutropenia grade 4 with nadir on days 10-12


Topotecan (Hycamtin)


Topoisomerase 1 inhibitor

1.5 mg/m2/d × 5 consecutive days every 21 d for the first four courses of treatment


Subsequent treatment should be administered at a dose of 1.25 mg/m2/d × 5 d


Numerous other doses have been evaluated

IVPB (D5W 50 mL) over 60-90 min


IVP

Mild thrombocytopenia, anemia (common)


Total alopecia


Nausea, vomiting, diarrhea (common)


Headache, fever, fatigue, anorexia, malaise, elevated liver enzymes (common)


Hypertension, tachycardia, urticaria, renal insufficiency, hematuria, dizziness, peripheral neuropathy, mucositis (uncommon)


Dyspnea


Patients with moderate renal compromise require a dose adjustment


Trimetrexate (Neutrexin)


Antimetabolite

45 mg/m2 × 21 d with concomitant leucovorin


Leucovorin must also be given


3 d after cessation of treatment with trimetrexate


Has also been given 110 mg/m2 in combination with fluorouracil every week × 6 wk followed by 2 wk of rest

IVP over 1-5 min Extravasation precautions


IVPB not recommended

Patients with hypoalbuminemia are more likely to experience severe anemia, mucositis, thrombocytopenia


Myelosuppression dose related (leucovorin greatly reduces these toxicities)


Fever, shaking, chills, malaise


Transient elevations of liver enzymes


Dose-limiting leukopenia with early nadirs


Thrombocytopenia and anemia (uncommon)


Extravasation: treat with application of heat


Valrubicin (Valstar)


Antitumor antibiotic (semisynthetic analog of doxorubicin)

800 mg intravesicularly once weekly × 6 wk


Use non-PVC containers and tubing

Intravesical instillation via a urethral catheter.


The patient should retain the drug for 2 h before voiding


Warming may be required if precipitation occurs

Urinary frequency, urgency, incontinence, dysuria, spasm, pain, hematuria, cystitis


Nausea, abdominal pain, dizziness


Urinary tract infection, headache, malaise, rash


Vinblastine (Velban)


Plant alkaloid Vesicant

6-10 mg/m2 every 2-4 wk


Also given every week and as a continuous infusion in a dose of 1.7-2 mg/m2/d for 96 h through a central line

IVP over 1 min


Occasionally given as a continuous infusion (D5W, NS)

Rash and photosensitivity


Nausea, vomiting, and constipation; abdominal cramping, anorexia


Peripheral neuropathy, myalgias, headache, seizures, depression, dizziness, and malaise


Acute bronchospasm, dyspnea, chest pain, tumor pain, fever, especially when administered with mitomycin


Severe jaw pain, pain in pharynx, bones, back


Phlebitis and vein discoloration


SIADH and angina pectoris (rare)


Leukopenia (mild and rare); thrombocytopenia (rare)


Alopecia


Vincristine (Oncovin)


Plant alkaloid Vesicant

0.5-1.4 mg/m2 every 1-4 wk


Usually the maximum dose is 2 mg 0.5 mg/d to 0.5 mg/m2/d over 96 h via a central line

IV syringe (NS, D5W), IV bag (NS, D5W, lactated Ringer’s)

If extravasated, treat with application of heat


Nausea, vomiting (rare); constipation; abdominal pain, anorexia


Intrathecal administration is fatal


Peripheral neuropathy, paresthesias, paralytic ileus, and myalgias (cumulative, dose limiting)


Acute bronchospasm, dyspnea when administered with mitomycin


Diplopia, ptosis, photophobia, cortical blindness


Azoospermia and amenorrhea


Vincristine liposomal (Marqibo)


Vinca alkaloid

2.25 mg/m2 once every 7 d


Use actual BSA

IVPB (D5W, NS to total volume of 100 mL) over 1 h


Preparation requires water bath and thermometer

Febrile neutropenia, pyrexia


Anemia


Peripheral neuropathy, insomnia


Constipation, nausea, diarrhea


Fatigue, decreased appetite


Vindesine (Eldisine)


Vinca alkaloid


Vesicant

3-4 mg/m2/wk


1-2 mg/m2 on days


1-5 (continuous infusion) every 2-4 wk


0.2-2 mg/m2 × 5-21 consecutive days


Maximum tolerated dose is 4 mg/m2/wk

IVP over 2-3 min


IVPB 15-20 min or 24-h continuous infusion

Leukopenia, thrombocytopenia (dose limiting)


Pyrexia, malaise, myalgia, alopecia, paresthesia, loss of deep tendon reflexes (dose limiting)


Mild nausea and vomiting, constipation


Vinorelbine (Navelbine)


Vinca alkaloid


Vesicant

30 mg/m2/wk

Infuse over 6-10 min into a side port of a free-flowing IV, flush with 100-200 mL of solution to reduce the risk of phlebitis

Myelosuppression, mostly leukopenia (dose limiting)


Acute reversible dyspnea, chest pain, wheezing after IV administration; prevented by premedication with steroids


Injection site erythema, pain, phlebitis


Fatigue, tumor pain, jaw pain


Mild nausea, constipation, diarrhea, stomatitis


Hepatic: transient elevated LFTs


Chest pain with or without


EKG changes


Ziv-aflibercept (Zaltrap) (Aflibercept)


Vascular endothelial growth factor (VEGF) inhibitor

4 mg/kg every 2 wk

IVPB (D5W, NS) over 1 h


Final concentration between 0.6 and 8 mg/mL


Use a 0.2-µm filter

Hypertension


Dysphonia, epistaxis, dyspnea, oropharyngeal pain, rhinorrhea


Neutropenia, leukopenia, thrombocytopenia


Headache


Palmar-plantar erythrodysesthesia syndrome, skin hyperpigmentation


Diarrhea, stomatitis, abdominal pain, hemorrhoids, rectal hemorrhage, proctalgia


Proteinuria, increased serum creatinine


Urinary tract infections


Increased AST/ALT, fatigue, weight loss, decreased appetite, asthenia, dehydration

Only gold members can continue reading. Log In or Register to continue

Related posts:

History of Infusion Therapy Diagnostic Testing and Values Fluid and Electrolyte Balance Central Venous Access Infusion Therapy in an Older Adult Pediatric Infusion Therapy

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 17, 2016 | Posted by in ONCOLOGY | Comments Off on Antineoplastic Therapy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access