Chemotherapy and
Biotherapy Agents
Objectives
 At
the completion of this session the
participant will be able to:
◦ Identify common side effects for individual
medications
◦ Describe nursing interventions for
chemotherapy and biotherapy medications
◦ Discuss the principles of chemotherapy
administration
Chemotherapy Agents
2
Chemotherapy
Agents
Chemotherapy Agents
3
Agent: Cyclophosphamide
(Cytoxan®; Neosar®)
Indications
 Autoimmune Diseases
 PTLD
 Renal Disease
Side Effects:
 Common
◦
◦
◦
◦
◦

Anorexia
Nausea, vomiting
Myelosuppression
Alopecia
Gonadal dysfunction/sterility


Route: IV
Special Considerations
◦ Administration of high
doses of cyclophosphamide
should be preceded &
followed by high volume IV
hydration and mesna
◦ WBC nadir between 9-15
days (recovery by 21 days)
Occasional
◦ Hemorrhagic cystitis
◦ SIADH
Chemotherapy Agents
4
Agent: Cyclophosphamide
(Cytoxan®; Neosar®)

Nursing Considerations:
◦
◦
◦
◦
◦
◦
◦
◦
Maintain adequate hydration, urinary output
Check urine for blood and specific gravity
Administer early in the day when possible
Encourage urination q 2 hours and before going to bed for the
night
Administer over 15-60 minutes to avoid unpleasant side effects
such as lightheadedness, tearing, nausea, perioral numbness, itchy
nose
Can be mixed with Mesna
Mesna should be given exactly as ordered, and on time
Nausea/vomiting delayed for 4-8 hours, therefore administer
antiemetics prior to cyclophosphamide, at appropriate intervals,
and the following morning after administration
Chemotherapy Agents
5
MESNA (Mesnex®)

Maybe used with cytoxan
◦ Cytoxan is a Pro-drugs: requires
biotransformation by hepatic microsomal enzymes before
expressing alkylating activity
◦ Hepatic biotransformation creates active & inactive
metabolites, mainly excreted in urine:
 main metabolite = acrolein

◦ Hemorrhagic cystitis is a unique toxicity from this group of
drugs caused by acrolein.
How Does Mesna Work?
◦ Binds with the metabolite in urine
◦ Does not bind on a cellular level, therefore, does not
counteract cytotoxic effects of cytoxan
◦ MUST GIVE DRUG ON SCHEDULE!
Chemotherapy Agents
6
Agent:Vincristine Sulfate
(Oncovin®)
Indications:
 ITP
Side Effects
 Common
◦ Local ulceration if extravasated
◦ Hair loss
◦ Loss of deep tendon reflexes

Occasional
◦ Constipation
◦ Jaw pain
Route: IV
Special Considerations
◦ Refrigerate and protect from light
for continuous infusions
◦ Liver dysfunction or concomitant
radiation therapy to the liver may
enhance toxicity
◦ Should have special overwrap label
that bears the statement, “Fatal if
given intrathecally. For intravenous
injection only.”
◦ Infants may have difficulty sucking
because of jaw pain
◦ Maximum single dose: 2 mg
regardless of body surface area
(BSA). A few disease protocols do
not cap the dose at 2 mg. Always
check.
Chemotherapy Agents
7
Agent:Vincristine (Oncovin®)

Nursing Considerations:
◦ Vesicant – severe tissue damage if extravasation
occurs
◦ Stool softeners may be given prophylactically, or
for constipation
Chemotherapy Agents
8
Agents:
Daunorubicin (Daunomycin, Cerubidine®)
& Doxorubicin
(Adriamycin PFS®; Adriamycin RDF®; Rubex®)
Indications:
◦ PTLD
Route: IV
Side Effects

Common
◦
◦
◦
◦
◦
◦

Subclinical cardiac arrhythmias
Nausea, vomiting
Local ulceration if extravasated
Pink or red color to urine
Myelosuppression
Alopecia
Special Considerations
◦ Cardiac studies with
echocardiogram or multiple-gated
arteriography (MUGA) scan should
be done periodically to monitor
cardiac function – must have
acceptable cardiac ejection fraction
◦ Monitor cumulative dose
◦ Dose adjustments for renal/hepatic
abnormalities
◦ Radiation recall
◦ Leukocyte and platelet nadirs occur
in 5-10 days; recover within 3 weeks
Occasional
◦ Cardiomyopathy
Chemotherapy Agents
9
Agents:
Daunorubicin (Daunomycin, Cerubidine®)
& Doxorubicin
(Adriamycin PFS®; Adriamycin RDF®; Rubex®)
 Nursing
Considerations:
Vesicant – severe tissue damage if extravasation occurs
Continuous infusions-protect from light
Educate that there may be pink or red color to urine
Inspect oral cavity; encourage good oral hygiene
Research suggests that sucking on ice cubes or popsicles
during infusion may decrease incidence of mucositis
◦ Change diapers frequently to prevent skin breakdown
◦
◦
◦
◦
◦
Chemotherapy Agents
10
Agent:
Mitoxantrone Hydrochloride
(Novantrone®)
Indications: MS
 Route: IV
 Common Side Effects
◦ Bone marrow suppression. Nadir in 9-10
days.
◦ Cardiac toxicity including CHF and
decreased left ventricular EF. Toxicity
increased if pt. has cardiac history or
mediastinal XRT.
◦ Hepatoxicity with some reports of
jaundice.

Chemotherapy Agents
11
Agent:
Mitoxantrone Hydrochloride
(Novantrone®)

Nursing Considerations:
◦ Monitor blood counts closely
 CBC
 Liver function
◦
◦
◦
◦
Baseline cardiac function with ECHO and EKG
Continuous cardiac monitoring during administration
Know cumulative dose
Watch for phlebitis; potential to cause tissue necrosis with
extravasation
◦ Blue in color
 will turn urine green
 Potentially will turn skin a blue/green color
Chemotherapy Agents
12
Agent: Methotrexate
(Rheumatrex®; Trexall™ )
Indications:
 Chron’s Disease
 JRA
 Autoimmune Diseases
Routes:
 IV, IM, SQ, PO
Side Effects (All Dose Related):





Nausea, vomiting
Transaminase and
bilirubin elevations
Rash/photosensitivi
ty
Myelosuppression
Mucositis/GI
ulceration
Chemotherapy Agents
13
Agent: Methotrexate
(Rheumatrex®; Trexall™ )

Special Considerations
◦ Methotrexate enters body fluids easily, patients with
effusions may have delayed clearance
◦ Renal impairment enhances toxicity
◦ Intermediate or high-dose, leucovorin is
administered as a rescue agent
Chemotherapy Agents
14
Agent: Methotrexate
(Rheumatrex®; Trexall™ )

Nursing Considerations:
◦ Advise patients to use sunscreen; severe sunburn can
occur even with low weekly doses
◦ Leucovorin must be administered exactly on time
◦ Avoid vitamins containing folic acid to avoid the metabolic
block caused by methotrexate
◦ Discontinue Bactrim prophylaxis during high-dose
methotrexate
Chemotherapy Agents
15
LEUCOVORIN & NaHC03

Leucovorin Calcium (Wellcovorin®)
◦ Term ‘rescue’ may be misleading as
leucovorin rescues the normal cells
◦ Scheduling is CRUCIAL!

NaHC03
◦ Hydration and urine alkalinization used
with higher dose infusions to prevent
crystallization in the kidneys
Chemotherapy Agents
16
Agent: Mercaptopurine (6-MP)
(Purinethol®)
Indications:
◦ ITP
◦ Autoimmune Hemolytic
Anemia
◦ Inflammatory Bowel Disease
Route: PO
Common Side Effects
◦ Myelosuppression
Special Considerations
◦ Reduce oral dose by
75% if given with
Allopurinol
◦ May need to hold or
reduce dose for
myelosuppression
◦ May need to monitor
labs
Chemotherapy Agents
17
Agent: Mercaptopurine (6-MP)
(Purinethol®)

Nursing Considerations:
◦ Take daily dose at one
time, preferably at bedtime
on an empty stomach
 Do not take with milk
products
◦ Teach caregivers to wear
gloves when handling
Chemotherapy Agents
18
Agent: Pentostatin (Nipent®)



Indications: GvHD
Route: IV
Common Side Effects
◦ Central nervous system: Fever,
chills, headache
◦ Dermatologic: rashes
◦ Gastrointestinal:
Nausea/vomiting/diarrhea
◦ Hepatotoxicity
◦ Renal toxicity
◦ Myelosuppression
◦ Respiratory: pulmonary edema

Special Considerations:

Combined use with
Fludarabine may lead to
severe, even fatal,
pulmonary toxicity
Chemotherapy Agents
19
Agent: Pentostatin (Nipent®)

Nursing Considerations:
◦ Monitor CBC and LFTs
◦ Anti-emetics
◦ Monitor respiratory and cardiac status
Chemotherapy Agents
20
Agent: Hydroxyurea
(Droxia™; Hydrea®)

Indications:
◦ Sickle Cell Disease

Route: PO

Common Side Effects
◦ Myelosuppression with rapid drop in WBC
Chemotherapy Agents
21
Agent: Hydroxyurea
(Droxia™; Hydrea®)

Nursing Considerations:
◦ Do not add to solutions that are acidic or
carbonated; alkaline solutions preferred
◦ Take on empty stomach (1 hour before, or 2
hours after meals)
Chemotherapy Agents
22
Hormones
 Corticosteroids
Chemotherapy Agents
23
Agent: Corticosteroids
(Prednisone, Dexamethasone, Hydrocortisone, Methyl-prednisolone)
Indications:
◦ Autoimmune Diseases
◦ Nausea/vomiting
◦ GVHD treatment
Side Effects
Routes: PO or IV
Special Considerations
◦ May mask fever or
infection
Common
◦ Hyperphagia
◦ Immunosuppression
◦ Personality changes
◦ Cushing syndrome
◦ Pituitary-adrenal axis suppression
◦ Acne
 Occasional
◦ hyperglycemia

Chemotherapy Agents
24
Agent: Corticosteroids
(Prednisone, Dexamethasone, Hydrocortisone, Methyl-prednisolone)

Nursing Considerations:
◦ Decrease salt intake
◦ Observe for hyperglycemia
◦ To decrease or prevent GI upset, take with
meals or snacks; may need to take with
histamine H2-receptor antagonist such as
cimetidine, ranitidine
◦ If possible, do not crush Prednisone tablets
because of bitter taste – hide in a small amount
of food
Chemotherapy Agents
25
Biotherapy
 Definition:
◦ The term biotherapy includes
agents derived from biological
sources and/or use of agents
that affect biological responses
Biotherapy Agents
26
Biotherapy Mechanism
of Action

Biotherapy can be classified by mechanism of
action into three major divisions :
◦
◦
◦
Agents that augment, modulate or restore the
host’s immune responses
Agents that have direct anti-tumor activity
Agents that have other biological effects (e.g.,
differentiating agents, agents that affect the tumor’s
ability to metastasize, or agents affecting cell
transformation)
Biotherapy Agents
27
BIOTHERAPY
AGENTS
Biotherapy Agents
28
Cytokines: Interferons

Indications
◦ HLH
◦ PTLD

Side Effects
◦ Arrhythmia
◦ Flu-like syndrome
◦ Desquamation

Side Effects
◦Pruritus
◦Hepatoxicity
◦Myalgia
◦Arthralgia
Biotherapy Agents
29
Cytokines: Interferons

Nursing
Considerations
◦Premedicate with
Acetaminophen
◦Continuous cardiac
◦monitoring during the
◦infusion
◦Monitor vital signs
◦Assess for chest pain or
palpitations
◦Assess respiratory
◦status
◦Monitor daily weights
◦and intake and output,
◦assess skin and mental
◦status frequently
◦Have emergency drugs
◦available
Biotherapy Agents
30
Intravenous Immunoglobulin
(Gammagard, Sandoglobulin, Gamimmune)

Indications
◦ ITP
◦ JRA
◦ Autoimmune
Diseases
◦ Nephrotic
syndrome

Side Effects
◦
◦
◦
◦
◦
◦
◦
Headache
Flushing
Chills
Myalgia
Tachycardia
Nausea
Hypotension
Biotherapy Agents
31
Intravenous Immunoglobulin

Nursing Considerations
◦ May premedication with
Acetaminophen and antihistamines
◦ Titrate rate slowly to prevent
infusion reaction
◦ Monitor vital signs during and after
infusion
Biotherapy Agents
32
RH (D) Immune Globulin
(Win Rho)

Indication
◦ ITP

Side Effects

Administration
◦ Usually IVP over 3 to
5 minutes
◦ Headache
◦ Fever
◦ Chills
Biotherapy Agents
33
Anti Thymocyte Globulin (ATG)

Indications
◦ Aplastic Anemia
◦ PNH

Side Effects
◦
◦
◦
◦
◦
◦
◦
◦
Fever
Chills
Flu-like syndrome
Nausea
Anaphylaxis
Serum Sickness
Hypotension
Flank or back pain

Nursing
Consideration
◦ May need
premedication with
acetaminophen,
antihistamine, and
hydrocortisone
◦ Monitor vital signs
during infusion
◦ Infuse over 4 to 8
hours, avoid rapid
administration
Biotherapy Agents
34
Monoclonal Antibodies
A laboratory made protein that is
directed against a single antigenic
determinant on the surface of a cell
 They can be used alone or can
carry drugs, toxins, or radioactive
material to the specific cells

Biotherapy Agents
35
Hybridoma Technology
Biotherapy Agents
36
Monoclonal Antibodies

Side Effects
◦arrhythmia
◦capillary leak syndrome
◦flu-like syndrome
◦hypotension
◦myelosuppression
◦myalgia
◦neuropathic pain
◦infusion related reactions

Nursing
Considerations
◦May premedicate with
Benadryl and Tylenol
30 minutes prior
to infusion
◦Monitor vital signs
◦Monitor for
hypersensitivity
Biotherapy Agents
37
Monoclonal Antibodies
Agents
Indication
Rituxin (Rituximab)
Aplastic Anemia, ITP, PTLD
Adalimumab (Humira)
RA, Chron’s Disease
Daclizumab (Zenapax)
Transplant rejection
Infliximab (Remicade)
Chron’s Disease, GVHD
Palivizumab (Synagis)
RSV
Omalizumab (Xolair)
Asthma
Muromomab (OKT3)
Transplant rejection
Abatacept (Orencia)
JRA, Diabetes
Natalizumab (Tysabri)
MS
Eculizumab (Solaris)
PNH
Biotherapy Agents
38
Rituximab
(Rituxan®)

Side Effects

◦ Infusion reaction (may
be fatal)
◦ Fever, chills
◦ Headache
◦ Nausea
◦ Arthralgia
◦ Mucositis
◦ Skin reactions


Titrate each infusion
Pre Medicate with an
antihistamine and
acetaminophen
Monitor for anaphylactic
reactions
Biotherapy Agents
39
Tumor Necrosis Factor (TNF)


TNF is a cytokine that is
involved in the
inflammatory process
This can exacerbate
autoimmune diseases
such as JRA and Chron’s
disease
TNF blockers target
the effects of TNF
 TNF blockers
include:

◦ Enbrel
◦ Remicade
◦ Humara
Biotherapy Agents
40
Infliximab
(Remicade®)

Side Effects
◦ Hypersensitivity
reaction
◦ Fever
◦ Increased risk of
infection
◦ Myalgia and arthralgia
◦ Headache
Titrate infusion
 Monitor for
hypersensitivity
 Have emergency
medications available

Biotherapy Agents
41
Adlimumab
(Humira®)

Side Effects
◦
◦
◦
◦
Injection site reactions
Rash
Infection
Flu like syndrome

Administered as a
sub-q injection
Biotherapy Agents
42
Etanercept
(Enbrel®)
Indications
◦ JRA
◦ Psoriasis

Administered as a
sub-q injection
Side Effects
◦ Infection
◦ Injection site reaction
Biotherapy Agents
43
Abatacept
(Orencia®)
Indications
◦
RA
Side Effects
◦ Upper Respiratory
Infection
◦ Urinary Tract Infection
◦ Hypertension
◦ Rash
Monitor for infusion
related reaction
 May cause false
elevation in blood
sugar

Biotherapy Agents
44
Daclizumab
(Zenepax®)
Indications
◦ Organ rejection
◦ MS
Side Effects
Administer within 4
hours of preparation
 Infuse over 15
minutes

◦ Hypertension
◦ Hypersensitivity
reaction
◦ Diarrhea
◦ Vomiting
Biotherapy Agents
45
Natalizumab
(Tysabri®)
Indications

◦ MS
◦ Crohn’s Disease
Side Effects
◦ Opportunistic Infections
◦ Progressive multifocal
leukoencephalopathy
(PML)
◦ Hepatotoxicty


All patients must be
enrolled in the Tysabri®
Outreach Unified
Commitment to Health
(TOUCH) Prescribing
Program
Monitor for
hypersensitivity
Administer over 1 hour
Biotherapy Agents
46
Hematopoietic Growth Factors
Colony stimulating factors
that and regulate different
levels of the hematopoietic
cascade
GSCF (Neupogen,
Filgrastrim)
GM-CSF
Erythropoetin (Procrit)
Thrombopoetin
Route of
Administration: IV or
SQ
 Side Effects

◦ Bone Pain
◦ Injection site pain
◦ First Dose
Phenomenon
Biotherapy Agents
47
Immunosuppressive Agents
 Immunosuppressive
agents are
a group of drugs that slow
down the immune response
◦ Prevent rejection of solid organ
transplants
◦ Prevent Graft versus Host disease
◦ Slow down immune response in the
case of autoimmune diseases
Immunosuppressive Agents
48
Cyclosporine
(Neoral, Sandimmune, Gengraf, Restasis)

Side Effects
◦
◦
◦
◦
◦
Hypertension
Renal toxicity
Tremors
Hyperglycemia
Allergic Reactions
May have drug-drug
interactions
 Do not eat grapefruit
or drink grapefruit
juice
 Need to monitor
levels
 May adhere to plastic
tubing

Immunosuppressive Agents
49
Tacrolimus
(Prograf, FK506)

Side Effects
◦
◦
◦
◦
◦
◦
Tremors
Headache
Hypertension
Nausea
Renal Toxicity
Hepatic Toxicity

Nursing
Considerations
◦ May need to monitor
blood levels
◦ Avoid Grapefruit and
grapefruit juice
◦ Monitor for
anaphylaxis
◦ Give oral dose on
empty stomach
Immunosuppressive Agents
50
Sirolimus
(Rapamune)

Side Effects
◦ Severe
immunosuppression
◦ Hypersensitivity
reactions
◦ Peripheral edema
◦ Hypertension
◦ Renal toxicity
◦ Interstitial lung disease
Avoid grapefruit and
grapefruit juice
 Oral solution should
be mixed in water or
orange juice
 Monitor levels

Immunosuppressive Agents
51
Imuran
(Azathioprine)

Side Effects
◦
◦
◦
◦
◦
◦
Fever, chills
Arthralgias
Nausea, vomiting
Anorexia, diarrhea
Alopecia
Bone marrow
suppression
Reduced dose may
be used with
Allopurinol
 Administer with food

Immunosuppressive Agents
52
Mycophenolate Mofetil
(Cellcept®)

Side Effects
◦
◦
◦
◦
Hypertension
Dizziness
Diarrhea
Associated with
Progressive Multifocal
Leukoencephalopathy
(PML)
Spontaneous
abortions have
occurred after
exposure to cellcept
during pregnancy
 Administer oral
doses on an empty
stomach

Biotherapy Agents
53
Questions?