Antineoplastic agents
comprise one aspect of chemotherapy. These drugs act on and kill altered human
cells. While their action is intended to target abnormal cells, normal cells
are also affected. These drugs can work by affecting cell survival or by
boosting the immune system in its efforts to combat the abnormal cells.
Table of Common Drugs and Generic Names
Here is a table of
commonly encountered antineoplastics, their generic names, and brand names:
Classification
|
Generic Name
|
Brand Name
|
Alkylating Agents
|
altretamine
|
Hexalen
|
bendamustine
|
Treanda
|
|
busulfan
|
Busulfan, Myleran
|
|
carboplatin
|
Paraplatin
|
|
carmustine
|
BiCNU, Gliadel
|
|
chlorambucil
|
Leukeran
|
|
cisplatin
|
Platinol-AQ
|
|
cyclophosphamide
|
Cytoxan, Neostar
|
|
dacarbazine
|
DTIC-Dome
|
|
ifosfamide
|
Ifex
|
|
lomustine
|
CeeNu
|
|
mechlorethamine
|
Mustargen
|
|
melphalan
|
Alkeran
|
|
oxaliplatin
|
Eloxatin
|
|
procarbazine
|
Matulane
|
|
streptozocin
|
Zanosar
|
|
temozolomide
|
Temodar
|
|
thiotepa
|
Thioplex
|
|
Antimetabolites
|
capecitabine
|
Xeloda
|
cladribine
|
Leustatin
|
|
clofarabine
|
Clolar
|
|
cytarabine
|
DepoCyt, Tarabine
PFS
|
|
floxuridine
|
FUDR
|
|
fludarabine
|
Fludara
|
|
fluorouracil
|
Adrucil, Carac,
Efudex, Fluoroplex
|
|
gemcitabine
|
Gemzar
|
|
mercaptopurine
|
Purinethol
|
|
methotrexate
|
Rheumatrex, Trexall
|
|
pemetrexed
|
Alimta
|
|
pentostatin
|
Nipent
|
|
pralatrexate
|
Folotyn
|
|
thioguanine
|
Tabloid
|
|
Antineoplastic
Antibiotics
|
bleomycin
|
Blenoxane
|
dactinomycin
|
Cosmegen
|
|
daunorubicin
|
DaunoXome
|
|
doxorubicin
|
Adriamycin, Doxil
|
|
epirubicin
|
Ellence
|
|
idarubicin
|
Idamycin
|
|
mitomycin
|
Mutamycin
|
|
mitoxantrone
|
Novantrone
|
|
valrubicin
|
Valstar
|
|
Mitotic Inhibitors
|
cabazitaxel
|
Jevtana
|
docetaxel
|
Taxotere
|
|
etoposide
|
Toposar, VePesid
|
|
ixabepilone
|
Ixempra
|
|
paclitaxel
|
Abraxane, Onxol
Taxol
|
|
teniposide
|
Vumon
|
|
vincristine
|
Oncovin, Vincasar
|
|
vinorelbine
|
Navelbine
|
|
Hormones and Hormone
Modulators
|
anastrozole
|
Arimidex
|
bicalutamide
|
Casodex
|
|
degarelix
|
Degarelix for
Injection
|
|
estramustine
|
Emcyt
|
|
exemestane
|
Aromasin
|
|
flutamide
|
(generic)
|
|
fulvestrant
|
Faslodex
|
|
goserelin
|
Zoladex
|
|
histrelin
|
Vantas
|
|
letrozole
|
Femara
|
|
leuprolide
|
Lupron, Eligard
|
|
megestrol
|
Megace
|
|
mitotane
|
Lysodren
|
|
nilutamide
|
Nilandron
|
|
tamoxifen
|
Soltamox
|
|
toremifene
|
Fareston
|
|
triptorelin pamoate
|
Trelstar Depot
|
|
Cancer Cell-Specific
Agents
|
||
§ Protein Tyrosine Kinase Inhibitors
|
everolimus
|
Afinitor
|
gefitinib
|
Iressa
|
|
imatinib
|
Gleevec
|
|
lapatinib
|
Tykerb
|
|
nilotinib
|
Tasigna
|
|
pazopanib
|
Votrient
|
|
sorafenib
|
Nexavar
|
|
sunitinib
|
Sutent
|
|
temsirolimus
|
Torisel
|
|
§ Epidermal Growth Factor Inhibitor
|
erlotinib
|
Tarceva
|
§ Proteasome Inhibitor
|
bortezomib
|
Velcade
|
Other
antineoplastics
|
arsenic trioxide
|
Trisenox
|
asparaginase
|
Elspar
|
|
azacitidine
|
Vidaza
|
|
bexarotene
|
Targretin
|
|
decitabine
|
Dacogen
|
|
hydroxyurea
|
Hydrea
|
|
irinotecan
|
Camptosar
|
|
nelarabine
|
Arranon
|
|
pegaspargase
|
Oncaspar
|
|
porfimer
|
Photofrin
|
|
sipuleucel-T
|
Provenge
|
|
talc powder
|
Sclerosol
|
|
topotecan
|
Hycamtin
|
|
tretinoin
|
Vesanoid
|
|
vorinostat
|
Zolinza
|
Disease Spotlight: Cancer
§ Cancer is the second leading cause of
death in the United States. Treatment is usually multidisciplinary, prolonged,
and often debilitating. It can develop at any age.
§ Proliferation of abnormally-dividing cells
starts the pathologic process. Genetic abnormalities are passed along daughter
cells, eventually producing a tumor or neoplasm that has
characteristics quite different from those of the original tissue.
§ Consequently, original cell characteristics
are lost. Anaplasia is the loss of cellular differentiation and
organization. Autonomy is the ability to grow without usual
homeostatic restrictions that regulate cell growth and control.
§ Uncontrolled growth of neoplastic cells will
lead to invasion of healthy tissues in the area and metastasis, or
traveling from the place of origin to develop new tumors in other areas of the
body.
§ Cancers can be divided into two groups: 1)
solid tumors; and 2) hematological malignancies. Solid tumors can further be
differentiated into carcinomas, or tumors that originate in epithelial
cells, and sarcomas, or tumors that originate in the mesenchyme and are
made up of embryonic connective tissue cells.
§ The goal of cancer chemotherapy is
to decrease the size of neoplasm so that the human immune system can deal with
it.
Alkylating Agents
Description
§ Alkylating agents are non-cell cycle
specific antineoplastics drugs. They can affect cells even in the resting
phase.
§ These are the agents of choice for
slow-growing cancers.
Therapeutic Action
The desired and
beneficial action of agents for alkylating agents is:
§ Reacting chemically with portions of RNA, DNA,
or other cellular proteins to produce their cytotoxic effects.
§ Alkylating agents are most potent when binding
with cellular DNA.
§ The oldest drugs in this class are nitrogen
mustards.
Indications
Alkylating agents are
indicated for the following medical conditions:
§ Treatment of slow-growing cancers, like
lymphomas, leukemias, myelomas, some ovarian, testicular, and breast cancers,
and pancreatic cancers.
Here are some
important aspects to remember for indication of antineoplastics in different
age groups:
Children
§ Treatment of pediatric cancers follow
developed antineoplastic protocols and combination therapy is stressed to
eliminate as many of the mutant cells as possible. Checking the dosage for
children is crucial because of possible drug toxicity. In addition, the
nutritional needs and hydration status of children should be included in the
considerations for formulating a care plan.
§ Even under therapy, children must be allowed
to explore and learn like any other children. They would need extra support and
comfort as body image problems, lack of energy, and risk for
infection can isolate them. Lastly, bone marrow activity should be
monitored carefully and dose should be adjusted carefully.
Adults
§ Adults are also challenged with changes in
body image and activities that come with chemotherapy. It is usual for this age
group to fear the diagnosis too. Therefore, establishing a good
support system is important.
§ Antineoplastic agents are contraindicated to
pregnant and nursing women. Education, support, and referrals to appropriate
specialists are important. Women of childbearing age should use barrier
contraceptives when these drugs are being taken.
Older adults
§ Older patients are more susceptible to GI and
CNS adverse effects of antineoplastic therapy, particularly those with hepatic
and renal dysfunctions. Precautions are used accordingly. Protection
from infection and injury should be the focus of nurses.
Pharmacokinetics
Here are the
characteristic interactions of alkylating agents and the body in terms of
absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
Oral
|
Varies
|
1 h
|
15-20 h
|
T1/2: 60-90 min
Metabolism: liver Excretion: kidney (urine) |
Contraindications and Cautions
The following are
contraindications and cautions for the use of alkylating agents:
§ Pregnancy and lactation. Severe effects
to fetus and neonate.
§ Known allergy to drugs. Caution
is exercised to prevent hypersensitivity reactions.
§ Bone marrow suppression. The index for
redosing and dosing levels
§ Suppressed renal or hepatic function. Interfere
with drug metabolism and excretion.
Adverse Effects
Use of alkylating
agents may result to these adverse effects:
§ GI: nausea, vomiting, anorexia, diarrhea,
and mucous membrane deterioration, hepatic toxicity
§ GU: renal toxicity, potentially toxic increase
in uric acid levels
§ Hematological: bone marrow suppression
§ Alopecia or hair loss
Antimetabolites
Description
§ Antimetabolites are drugs that have chemical
structures similar to those of various natural metabolites that are necessary
for growth and division of rapidly growing neoplastic cells and normal cells.
Therapeutic Action
The desired and
beneficial action of antimetabolites is:
§ Inhibiting DNA production in cells that depend
on certain natural metabolites to produce their DNA. They replace these needed
metabolites and thereby prevent normal cellular function.
§ Inhibit thymidylate synthase, DNA polymerase,
or folic acid reductase, all of which are needed for DNA synthesis.
§ Considered to be S phase specific in the cell
cycle, they are most effective in rapidly dividing cells, preventing cell
replication, and leading to cell death.
Indications
Antimetabolites are
indicated for the following medical conditions:
§ Treatment of various leukemias and some GI and
basal cell cancers
§ Use has been somewhat limited because
neoplastic cells rapidly develop resistance to these agents. Therefore, they
are commonly administered as part of combination therapy.
Pharmacokinetics
Here are the
characteristic interactions of antimetabolites and the body in terms of
absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
Oral
|
Varies
|
1-4 h
|
–
|
IV
|
Rapid
|
0.5-2 h
|
–
|
T1/2: 2-4 h
Metabolism: none Excretion: kidney (urine); unchanged |
Contraindications and Cautions
The following are
contraindications and cautions for the use of antimetabolites:
§ Known allergy to drug. Prevent
hypersensitivity reactions
§ Pregnancy and lactation. Severe effects
on the fetus and neonate
§ Bone marrow suppression. Index of
redosing and dosing levels
§ Renal and hepatic dysfunction. Interfere
with drug metabolism and excretion
§ Known GI ulceration or ulcerative diseases. Can
be exacerbated by the effects of the drug
Adverse Effects
Use of antimetabolites
may result to these adverse effects:
§ CNS: headache, drowsiness,
aphasia, fatigue, malaise, dizziness
§ Respiratory: pulmonary toxicity, interstitial
pneumonitis
§ Hematological: bone marrow suppression
§ GI: nausea, vomiting, anorexia, diarrhea,
mucous membrane deterioration, hepatic toxicity
§ GU: renal toxicity
§ Leucovorin is an active form of folic
acid that is used to rescue normal cells from the adverse effects of
methotrexate therapy in the treatment of osteosarcoma.
Antineoplastic Antibiotics
Description
§ This group of drugs is selective for bacterial
cells. However, they are also toxic to human cells.
§ They are aimed towards rapidly-multiplying
cells.
Therapeutic Action
The desired and
beneficial action of antineoplastics antibiotic is:
§ Either breaking up DNA links or preventing DNA
synthesis
§ They interfere with cellular DNA synthesis by
inserting themselves between base pairs in the DNA chain. This causes a mutant
DNA molecule, leading to cell death.
Indications
Antineoplastic antibiotics are
indicated for the following medical conditions:
§ Treatment of various types of cancer,
particularly those with rapidly-dividing nature.
§ These drugs have potentially adverse effects
which limit their usefulness in patients with pre-existing disease and those
who are debilitated.
Pharmacokinetics
Here are the
characteristic interactions of antineoplastic antibiotics and the body in terms
of absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
IV
|
Rapid
|
2 h
|
24-36 h
|
T1/2: 12 min, then
3.3 h, then 29.6 h
Metabolism: liver Excretion: kidney (urine), liver (bile), colon (feces) |
Contraindications and Cautions
The following are
contraindications and cautions for the use of antineoplastic antibiotics:
§ Known allergy to drug. Prevent
hypersensitivity reactions
§ Pregnancy and lactation. Severe effects
on the fetus and neonate
§ Bone marrow suppression. Index of
redosing and dosing levels
§ Renal and hepatic dysfunction. Interfere
with drug metabolism and excretion
§ Known GI ulceration or ulcerative diseases. Can
be exacerbated by the effects of the drug
§ Pulmonary problems. Exacerbated by
bleomycin or mitomycin
§ Cardiac problems. Exacerbated by
idarubicin or mitoxantrone
Adverse Effects
Use of antineoplastic
antibiotics may result to these adverse effects:
§ CNS: headache, drowsiness, aphasia, fatigue,
malaise, dizziness
§ Respiratory: pulmonary toxicity, interstitial
pneumonitis
§ Hematological: bone marrow suppression
§ GI: nausea, vomiting, anorexia, diarrhea,
mucous membrane deterioration, hepatic toxicity
§ GU: renal toxicity
§ Alopecia
Mitotic Inhibitors
Description
§ Drugs that kill cells as the process of
mitosis begins.
§ Mitotic inhibitors are cell
cycle-specific agents that inhibit DNA synthesis.
Therapeutic Action
The desired and
beneficial action of mitotic inhibitors is:
§ Interfering with the ability of the cell to
divide by blocking or altering the M phase of the cell cycle.
Indications
Mitotic inhibitors are
indicated for the following medical conditions:
§ Treatment of a variety of tumors and
leukemias.
Pharmacokinetics
Here are the
characteristic interactions of mitotic inhibitors and the body in terms of
absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
IV
|
Varies
|
15-30 min
|
–
|
T1/2: 5 min, then
2.3 hrs, then 85 hrs
Metabolism: liver Excretion: kidney (urine), colon (feces) |
Contraindications and Cautions
The following are
contraindications and cautions for the use of mitotic inhibitors:
§ Known allergy to drug. Prevent
hypersensitivity reactions
§ Pregnancy and lactation. Severe effects
on the fetus and neonate
§ Bone marrow suppression. Index of
redosing and dosing levels
§ Renal and hepatic dysfunction. Interfere
with drug metabolism and excretion
§ Known GI ulceration or ulcerative diseases. Can
be exacerbated by the effects of the drug
Adverse Effects
Use of mitotic
inhibitors may result to these adverse effects:
§ CNS: headache, drowsiness, aphasia, fatigue,
malaise, dizziness
§ Respiratory: pulmonary toxicity, interstitial
pneumonitis
§ Hematological: bone marrow suppression
§ GI: nausea, vomiting, anorexia, diarrhea,
mucous membrane deterioration, hepatic toxicity
§ GU: renal toxicity
§ Can cause necrosis and cellulitis if
extravasation occurs
Hormones and Hormone Modulators
Description
§ Some cancers are sensitive
to estrogen stimulation. Estrogen-receptor sites on the tumor react
with circulating estrogen, and this reaction stimulates the tumor cells to grow
and divide.
§ Hormones and hormone modulators block or
interfere with these receptor sites to prevent growth of the cancer and cause
cell death.
§ Some hormones are used to block the release of
gonadotropic hormones in breast or prostate cancer if the tumors are responsive
to gonadotropic hormones. Others may block androgen-receptor sites directly.
Therapeutic Action
The desired and
beneficial action of hormones and hormone modulators is:
§ Blocking the stimulation of growing cancer
cells that are sensitive to the presence of that hormone.
Indications
Hormones and hormone
modulators are indicated for the following medical conditions:
§ Treatment of breast cancer in
postmenopausal women or in other women without ovarian function.
§ Treatment of prostatic cancers that are
sensitive to hormone manipulation.
Pharmacokinetics
Here are the
characteristic interactions of hormones and hormone modulators and the body in
terms of absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
Oral
|
Varies
|
4-7 h
|
–
|
T1/2: 7-14 days
Metabolism: liver Excretion: colon (feces) |
Contraindications and Cautions
The following are
contraindications and cautions for the use of hormones and hormone modulators:
§ Known allergy to drug. Prevent
hypersensitivity reactions
§ Hypercalcemia. Contraindication to the
use of toremifene because the drug can increase serum calcium levels.
§ Pregnancy and lactation. Severe effects
on the fetus and neonate
§ Bone marrow suppression. Index of
redosing and dosing levels
§ Renal and hepatic dysfunction. Interfere
with drug metabolism and excretion
§ Known GI ulceration or ulcerative diseases. Can
be exacerbated by the effects of the drug
Adverse Effects
Use of hormones and
hormone modulators may result to these adverse effects:
§ Menopause-associated effects: hot flashes,
vaginal spotting, vaginal dryness, moodiness, and depression
§ Hematological: bone marrow suppression
§ GI: hepatic toxicity
§ GU: renal toxicity
§ Hypercalcemia is encountered as the
calcium is pulled out of the bones without estrogen activity to
promote calcium deposition.
Cancer Cell-Specific Agents
Description
§ These agents are only specific to cancer cells
and spare the healthy cells its devastating effects. Patients do not experience
the numerous adverse effects associated with antineoplastic chemotherapy.
§ Three groups of drugs are cancer
cell-specific: protein tyrosine kinase inhibitors, epidermal growth factor
inhibitor, and proteasome inhibitor.
Therapeutic Action
The desired and
beneficial action of cancer cell-specific agents is:
§ Protein tyrosine kinase inhibitors act on
specific enzymes that are needed for protein building by specific tumor cells.
Blocking of these enzymes inhibits tumor cell growth and division.
§ Epidermal growth factor inhibitors are
drugs that act on epidermal growth factor receptors which are found in both
normal and cancerous cells but are more abundant on the latter.
§ Proteasome inhibitors are drugs indicated
for inhibition of proteasome in human cells, a large protein complex that works
to maintain cell homeostasis and protein production.
Indications
Cancer cell-specific
agents are indicated for the following medical conditions:
§ Imatinib, the first drug approved protein
tyrosine kinase inhibitor, is given orally and is approved to treat chronic
myelocytic leukemia (CML). It selectively inhibits the Bcr-Abl
tyrosine kinase created by the Philadelphia chromosome abnormality in CML.
§ Bortezomib is used for the treatment of
multiple myeloma in patients whose disease had progressed after two standard
therapies.
Pharmacokinetics
Here are the
characteristic interactions of cancer cell-specific agents and the body in
terms of absorption, distribution, metabolism, and excretion:
Route
|
Onset
|
Peak
|
Duration
|
Oral
|
Slow
|
2-4 h
|
–
|
T1/2: 18-40 h
Metabolism: liver Excretion: colon (feces) |
Contraindications and Cautions
The following are
contraindications and cautions for the use of cancer cell-specific agents:
§ Pregnancy. All drugs in this class is
pregnancy category D.
§ Women of childbearing age. Must be
advised to use barrier contraceptives while taking these drugs.
§ Lactation. Can enter breastmilk and use
is only justified if benefits outweigh the risks.
§ Hepatic dysfunction. Increased risk of
toxicity with imatinib and pazopanib.
§ Risk for prolonged QT intervals (hypokalemia,
hypomagnesia, taking drugs that can prolong QT intervals). Contraindicated
with nilotinib.
§ Known allergy to the drug. Prevent
hypersensitivity reactions.
Adverse Effects
Use of cancer
cell-specific agents may result to these adverse effects:
§ Imatinib: GI
upset, muscle cramps, heart failure, fluid retention, skin rash.
Severe adverse effects of traditional antineoplastic therapy (severe bone
marrow depression, alopecia, severe GI effects) do not occur.
§ Gefitinib: potentially severe interstitial
lung disease and various eye symptoms
§ Pazopanib: some bone marrow depression,
diarrhea, hypertension, and liver impairment, change in hair color
§ Lapatinib: diarrhea, liver impairment, altered
heart function
§ Erlotinib and bortezomib: cardiovascular
events, pulmonary toxicity
§ Bortezomib: peripheral neuropathy, liver and
kidney impairment
Interactions
The following are
drug-drug interactions involved in the use of antineoplastic agents:
§ Any drug that has potential for hepatic or
renal toxicity
§ Adversely affect drugs metabolized in the
liver (e.g. oral anticoagulants)
§ Antineoplastic antibiotics can increase
toxicity of drugs that are toxic to the heart and lungs.
§ Echinacea: increased risk of hepatotoxicity
with antineoplastics
§ Ginkgo: inhibits blood clotting,
which can cause problems after surgery or with bleedingneoplasms
§ Saw palmetto: increase the effects of
various estrogen hormones and hormone modulators; advise patients taking such
drugs to avoid this herb
§ St. John’s wort: can greatly increase
photosensitivity, which can cause problems in patient who have received
radiation therapy or are taking drugs that cause other dermatological effects.
In addition, it can decrease the effectiveness of some antineoplastic agents.
Nursing Considerations
Here are important
nursing considerations when administering antineoplastic agents:
Nursing Assessment
These are the
important things the nurse should include in conducting assessment, history
taking, and examination:
§ Assess for the mentioned cautions and
contraindications (e.g. drug allergies, hepatorenal impairment, bone marrow
suppression, pregnancy and lactation, etc.) to prevent any untoward
complications.
§ Perform a thorough physical assessment (other
medications taken, orientation and reflexes, vital signs, bowel sounds, etc.)
to establish baseline data before drug therapy begins, to determine effectiveness
of therapy, and to evaluate for occurrence of any adverse effects associated
with drug therapy.
§ Monitor result of laboratory tests such as CBC
with differential to identify possible bone marrow suppression and toxic drug
effects and establish appropriate dosing for the drug; and liver and renal
function tests to determine need for possible dose adjustment and identify
toxic drug effects.
Nursing Diagnoses
Here are some of
the nursing diagnoses that can be formulated in the use of these
drugs for therapy:
§ Acute pain related to GI, CNS, and skin
effects of the drug
§ Disturbed body image related to alopecia,
skin effects, and impaired fertility
§ Anxiety related to diagnosis
§ Risk for infection related to bone marrow
suppression
Implementation with Rationale
These are vital
nursing interventions done in patients who are taking alkylating agents:
§ Arrange for blood tests before, periodically
during, and for at least 3 weeks after therapy to monitor bone marrow function
to aid in determining the need for a change in dose or discontinuation of the
drug.
§ Administer medication according to scheduled
protocol and in combination with other drugs as indicated to improve
effectiveness.
§ Ensure that patient is well hydrated to
decrease risk of renal toxicity.
§ Protect the patient from infection; limit
invasive procedures when bone marrow suppression limits the patient’s
immune/inflammatory responses.
§ Provide small, frequent meals,
frequent mouth care, and dietary consultation as appropriate to
maintain nutrition when GI effects are severe.
§ Arrange for proper head covering at extremes
of temperature if alopecia occurs; a wig, scarf, or hat is important for
maintaining body temperature.
§ Plan for rest periods because fatigue and
weakness are common effects of the drug.
Evaluation
Here are aspects of
care that should be evaluated to determine effectiveness of drug therapy:
§ Monitor patient response to therapy
(alleviation of cancer being treated, palliation of signs and symptoms of
cancer).
§ Monitor for adverse effects (bone marrow
suppression, GI toxicity, neurotoxicity, and alopecia, renal or hepatic
dysfunction).
§ Evaluate patient understanding on drug therapy
by asking patient to name the drug, its indication, and adverse effects to
watch for.
§ Monitor patient compliance to drug therapy.
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