1. Introduction to Clinical Pharmacology Chapter 50- Antineoplastic Drugs

2. Cell Cycle
Strategy of antineoplastic drug therapy is to affect cells that rapidly divide and reproduce-delays spread of cancer to other sites

3. How Does Chemotherapy Work?
There are 5 phases in the cell cycle, designated by letters and numbers:
G0 = Resting stage G1 = RNA and protein synthesis S = DNA synthesis G2 = Construction of mitotic apparatus M = Mitosis

4. The Cell Cycle
G0 phase (resting stage): Cells have not yet started to divide. Cells spend much of their lives in this phase. Depending on the type of cell, it can last for a few hours to a few years. When the cell is signaled to reproduce, it moves into the G1 phase.
G1 phase: During this phase, the cell starts making more proteins to get ready to divide. This phase lasts about 18 to 30 hours.
S phase: In the S phase, the chromosomes containing the genetic code (DNA) are copied so that both of the new cells formed will have the right amount of DNA. This phase lasts about 18 to 20 hours.
G2 phase: The G2 phase is just before the cell starts splitting into two cells. It lasts from 2 to 10 hours.

6. The Cell Cycle
M phase (mitosis): In this phase, which lasts only 30 to 60 minutes, the cell actually splits into 2 new cells.
This cell cycle is important to cancer doctors (oncologists) because many chemotherapy drugs work only on actively reproducing cells (not on cells in the resting phase, G0). Some of these drugs specifically attack cells in a particular phase of the cell cycle (the M or S phases, for example). Understanding how these drugs function helps oncologists predict which drugs are likely to work well together. Doctors can also effectively plan how often doses of each drug should be given based on the timing of the cell phases.
American Cancer Society-2006

7. Herbal Alert Green tea Antioxidant
Patients with insomnia and ulcers should use green tea with caution

8. Cell Cycle Specific Drugs: Actions and Uses
Plant Alkaloids:
Vinca alkaloids: Interfere with amino acid production in S phase and formation of microtubules in M phase
Taxanes: Interfere in M-phase with microtubules

9. Cell Cycle Specific Drugs: Actions and Uses (cont’d)
Antimetabolites:
Interfere with synthesis of RNA and DNA, make it impossible for cancerous cell to divide into two daughter cells
Drugs are used to treat:
Leukemia, lymphoma, solid tumors, autoimmune diseases

10. Cell Cycle Nonspecific Drugs: Actions and Uses
Alkylating agents:
Change cell to more alkaline environment, which in turn damages the cell
Nitrosureas are unique in that they can cross the blood-brain barrier and therefore used to tx brain tumors
EX: Busulfex-CML; Cytoxan-Hodgkin’s, leukemia, multiple myleoma; Mustargen-Hodgkin’s disease, leukemia
Antineoplastic antibiotics:
Interfere with DNA and RNA synthesis, delaying or inhibiting cell division ; Adriamycin-acute leukemia, Wilm’s tumor; Idamycin-leukemia; Mutamycin-adenocarcinoma of stomach, pancreas; Mithracin-malignant testicular tumors

11. Cell Cycle Nonspecific Drugs: Actions and Uses
Miscellaneous antineoplastic drugs:
Number of drugs are used for antineoplastic actions, do not belong to any one category EX:Oncaspar- ALL;Platinol/cisplatin-metastatic testicular tumors, bladder cancer, ovarian tumors
Antimetabolites-EX:Leustatin-hairy cell leukemia; Adrucil-carcinoma of breast, stomach, pancreas, colon; Fludara-CLL
Hormones-EX: Teslac-breast cancer;Depo-Provera- endometrial or renal cancer;Megace—breast or endometrial cancer;Nolvadex/tamoxifen**-breast cancer;Zoladex, Lupron (Gonadotropin-Releasing Hormones)
Mitotic Inhibitors-EX:Taxol-ovarian cancer;Velban;Oncovin, Vincasar**-acute leukemia

12. Cell Cycle Nonspecific Drugs: Adverse Reactions
Nausea and vomiting from highly emetic drugs or potential of IV extravasation of irritating solutions
Adverse reactions common to antineoplastic drugs:
Bone marrow suppression;-anemia, leukopenia, thrombocytopenia , Stomatitis; Diarrhea; Hair loss
Leukopenia and thrombocytopenia may cause cycles of chemotherapy to be delayed until blood cell counts can be raised
Damage gonads causing fertility problems

13. Adverse Reactions Intensity increases with higher doses
Bone marrow suppression, n/v, stomatitis, diarrhea, alopecia
Toxic
Hyperuricemia (increase fluids)

14. Cell Cycle Nonspecific Drugs: Contraindications and Precautions
Antineoplastic drugs are contraindicated in patients with:
Leukopenia; Thrombocytopenia; Anemia; Serious infections; Renal disease; Hypersensitivity to drug; During pregnancy or lactation
Used cautiously in patients with:
Renal or hepatic impairment; Active infection; Debilitating illnesses; Those who have completed treatment with other antineoplastic drugs or radiation therapy

15. Contraindications Leukopenia Thrombocytopenia Platelets <100,000
Anemia
Infections
Renal disease

16. Cell Cycle Nonspecific Drugs: Interactions
Interactant Drug
Effect of Interaction
Plant Alkaloids
Digoxin
Decrease serum level of digoxin
Phenytoin
Increased risk for seizures
Oral anticoagulants
Prolonged bleeding

17. Cell Cycle Nonspecific Drugs: Interactions (cont’d)
Interactant Drug
Effect of Interaction
Alkylating Drugs
Aminoglycosides
Increased risk for nephrotoxicity and ototoxicity
Loop diuretics
Increased risk for ototoxicity
NSAIDs
Methotrexate toxicity

18. Nursing Process: Assessment
Preadministration assessment:
Initial assessment:
The type and location of the neoplastic lesion
Obtain v/s, weight
CBC if drug causes bone marrow depression
Anxiety or fears the patient may have regarding chemotherapy treatments

19. Nursing Process: Assessment (cont’d)
Ongoing assessment:
The patient’s general condition
The patient’s individual response to the drug
Adverse reactions that may occur
Guidelines established by the primary health care provider or hospital
Results of periodic laboratory tests and radiographic scans

20. Nursing Process: Nursing Diagnoses
Imbalanced nutrition: Less than body requirements
Fatigue
Risk for injury
Risk for infection
Disturbed body image
Anxiety
Impaired tissue integrity

21. Nursing Process: Planning
Expected outcomes:
An optimal response to therapy
Support of patient needs related to the management of adverse reactions
Understanding of prescribed treatment modalities

22. Nursing Process: Implementation
Promoting an optimal response to therapy (
Protection of the provider:
The Occupational Safety and Health Administration (OSHA) guidelines
Nurses need to be protected during administration and cleanup from accidental ingestion, inhalation, or absorption of drugs
PPE’s!!!!!!!!

23. Nursing Process: Implementation
Promoting an optimal response to therapy (cont’d):
Parenteral administration:
Give injection into large muscles using Z-track method
Sites should be rotated, charted appropriately if the injections are given frequently

24. Nursing Process: Implementation
Monitoring and managing patient needs:
Imbalanced nutrition: Less than body requirements
Assess nutritional status of patient before and during treatment
Provide small, frequent meals to coincide with patient’s tolerance for food to stimulate appetite
Stress importance of eating meals high in nutritive value, particularly protein
Mouth care q 4 hours, rinse with NS, avoid lemon/glycerin swabs-make stomatitis worse

25. Nursing Process: Implementation
Monitoring and managing patient needs
Fatigue, infection and injury: Myelosuppression
Monitor patients with thrombocytopenia (platelet count <100,000) for bleeding tendencies and take precautions to prevent bleeding
ALERT-report bleeding gums, tarry stools, bloody urine to MD
Neutropenia-observe for signs of infection
ALERT-report temp >100.4, Sore throat

26. Nursing Process: Implementation
Monitoring and managing patient needs (cont’d):
Fatigue, infection and injury: Myelosuppression (cont’d):
Apply pressure to injection site for 3 to 5 minutes to prevent bleeding into tissue and formation of hematoma
Inform patient to avoid use of electric razors, nail trimmers, dental floss, firm toothbrushes, any sharp objects

27. Nursing Process: Implementation
Monitoring and managing patient needs (cont’d):
Disturbed body image: Inform patient that hair loss may occur if hair loss is associated with antineoplastic drug being given
Forewarn patient that hair loss may occur suddenly and in large amounts
Assist in making plans for purchase of wig or cap to disguise hair loss until hair grows back

28. Nursing Process: Implementation
Monitoring and managing patient needs
Impaired tissue integrity (cont’d):
Monitor IV site continuously and check for blood return frequently during IV push procedures
Keep extravasation kit containing all materials necessary to manage extravasation available, along with extravasation policy and procedure guidelines
Avoid the sun, wear protective, loose clothing, monitor for erythema

29. Nursing Process: Implementation
Educating the patient and family:
Do not take nonprescription drug unless approved by primary healthcare provider
Avoid drinking alcoholic beverages unless approved by PCP
Inform physicians, dentists, medical personnel of therapy with this drug
Keep all appointments for laboratory tests ordered by the primary health care provider

30. Nursing Process: Evaluation
The therapeutic effect is achieved
Adverse reactions are identified, reported and managed
Anxiety is reduced
The patient verbalizes:
An understanding of the dosage regimen; Understanding of treatment modalities; Importance of continued follow-up care; Complying with the prescribed therapeutic regimen