pharm final Flashcards
Alopecia
Hair cells divide rapidly; common effect. Effects self esteem.
Emetic potential
May require pre-medication with anti emetic
Small frequent bland meals; nutritional supplementation
(Reglan, ondansetron, Thorazine)
Myelosuppression
Neutropenia may be a dose limiting factor (monitor CBC)
Withhold drug until blood counts normalize
Nadir
Lowest white blood cell count related to dosing
Extravasation
Drugs leak into surrounding tissue
Stop infusion, leave catheter in place (might be needed to administer antidote
methotrexate (MTX)
Folic acid antagonist, also used for rheumatoid arthritis Interferes with folic acid, which is used in DNA synthesis so the cells die
NO NSAIDs. Neutropenic precautions. Assess for bleeding and bruising. Hydrate, no spice, no acid, soft food.
High doses associated with severe bone marrow suppression
Purine antagonists
fludarabine (F-AMP)
mercaptopurine (6-MP)
allopurionol, others.
Results in interruption in between DNA and RNA synthesis and induces cell lysing
fluorouracil (5-FU)
typically used for breast, esophageal and stomach cancer
Pyrimidine antagonist
Pyrimidine antagonists
fluorouracil (5-FU)
cytarabine (ARA-C), others
Interrupts DNA and RNA synthesis
Antimetabolites: Indications
In combination with other drugs to treat various types of cancer, such as solid tumors and some hematologic cancers
Leukemias (acute & chronic)
Colon, rectal, breast, stomach, lung, pancreatic cancers
Antimetabolites: Adverse Effects
Alopecia, N & V, myelosuppression common
Antimetabolites Reacts With
Ibuprofen (NSAIDS) including ASA (aspirin) are contraindicated with methotrexate; ↑toxicity
leucovorin rescue
for severe bone marrow suppression
administered with high dose methotrexate
Gives ↑antitumor action with ↓ toxicity – can be used to kill the maximum amount of cells without killing the patient.
methotrexate special considerations
neutropenia (precautions, low microbe diet, NO nsaids)
pancytopenia - assess for bleeding and bruising (soft bristle toothbrush, electric shaver)
mucositis - soft diet, non-spicy, non-acidic and hydrate
Vinca alkaloids (vincristine)
IV ONLY - NEVER IN A CATHETER
Mitotic Inhibitors
Natural products obtained from the periwinkle plant, European and western yew trees
potentially neurotoxic: Peripheral neuropathy, parethesias, foot drop
Used as a part of a cocktail – combo with other drugs
cause hairloss, approved for leukemia
vincristine has excavated, what do you do
Stop infusion, leave catheter in place (might be needed to administer antidote
Several specific antidotes can be used
For vincristine mix hyaluronidase 150u/ml + 1 mL Nacl
Inject into extravasated site with multiple SQ injections
Repeat in several hours
Warm compress
Alkylating Drugs: Adverse Effects
Nausea and vomiting, myelosuppresion (can be dose-limiting)
Alopecia
Nephrotoxicity (can be prevented with hydration), peripheral neuropathy, ototoxicity
Extravasation causes tissue damage and necrosis
Alkylating Drugs: how to reduce nephrotoxicity?
hydration
cisplatin (Platinol-AQ)
Alkylating Drugs
especially nephrotoxic- don’t give with other nephrotoxic drugs
hydration can prevent nephrotoxicity – pre hydrate
Alkylating Drugs: Examples
cisplatin (Platinol-AQ)*
mechlorethamine (Mustargen)*
cyclophosphamide (Cytoxan)*
altretamine (Hexalen)
carmustine (BiCNU)
temozolomide (Temodar)
thiotepa (Thioplex)
Cytotoxic Antibiotics
while they’re antibiotics, they’re too toxic for normal infections. They’re for cancer treatment
Cytotoxic Antibiotics Side Effects
Hair loss, N&V, myelosuppression common
bone marrow suppression except (bleomycin)
Cytotoxic Antibodies Special Consideration
“Rubacins”-many look alike-sound alikes but dosing/protocols differ widely!
Doxorubicin (adriamycin)
Cytotoxic Antibiotic
for breast, bone, ovarian, leukemias, Kaposi sarcoma
!! Cardiotoxic !!
heart failure, cardiomyopathy, decreased CO
Need for routine heart scan for early detection with these agents!
Cumulative dose limitations
Cytoprotective drugs (dexrazoxane) to ↓ incidence
Daunorubicin
cytotoxic antibiotic
heart failure, liver toxicity
Bleomycin
cytotoxic antibiotic
pulmonary toxicity/fibrosis
bevacizumab (Avastin)
inhibits angiogenesis – blocks the blood supply to the tumor.
hydroxyurea (Hydrea)
antimetabolite – squamous cell carcinoma and some leukemias.
Lots of adverse effects. Nephrotoxicity, edema, pulmonary fibrosis.
imatinib (Gleevec)
chronic myeloid leukemia.
Not a monoclonal antibody.
Can cause many severe reactions as well. Be careful when combining with other drugs metabolized by the liver.
mitotane (Lysodren)
adrenal cancer. Cytotoxic. Given orally. CNS depression
Hormonal antineoplastic drugs
opposing hormones block tumor growth
Tamoxifen (nolvadex)
for breast cancer
is used to starve estrogen dependent tumors
induces menopause symptoms
Tamoxifen (nolvadex) treatment
FDA approved to prevent CA in BRCA + (broca? Gene)
Also used post breast CA treatment with surgery, radiation and chemo
Tamoxifen (Nolvadex) therapy notes
Acts as an agonist to endometrial tissue
Report abnormal uterine bleeding; annual GYN
Generally use limited to 5 yrs .or <
Contraindicated with DVT, PE, coumadin
Glucocorticoids High Therapy Side Effects
Fluid retention
Cushing’s symptoms
Osteoporosis
Mood Swings
Masks infections, raises BG
Glucocorticoids Examples
Prednisone, Dexamethasone
Special Precautions for Antineoplastic Drugs
Double flushing of bodily fluids in the commode
Special hampers for disposal of all objects that contact the patient’s body fluids
Personal protective equipment (mask, gown, booties, gloves)
Special concerns if chemotherapy liquid spills (spill kit)
Pregnant nurses handling & exposure
IV amifostine
Cytoprotective drug that is used to reduce renal toxicity associated with cisplatin
IV or PO allopurinol
is used to reduce hyperuricemia
Contraindicated if patient on cyclosporine (an immunosuppressant); increases toxicity
oncologic emergencies
Infections - fever
Pulmonary toxicity
Allergic reactions – rash, hives, fever, etc
Mucositis/Stomatitis with severe ulcerations
Bleeding
Metabolic aberrations
Bowel irritability with diarrhea
Renal, liver - (labs), cardiac toxicity – edema, EKG changes, HR changes, poor cardiac output. Monitor EKGs and Echos
nursing interventions for Mucositis, stomatitis
good oral hygiene, assess for gingivitis, pain, ulcers
Salicylates Examples
Aspirin
Diflunisal (Dolobid)
Salsalate (Salistab)
Choline salicylate (Arthropan)
Salicylic acid (aspirin)
Inhibits platelet aggregation
Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders
Aspercreme
topical salicylate
Enteric-coated aspirin (Ecotrin)
good for patients who take daily aspirin as it is coated and will protect their GI
Aspirin for Acute MI Administration Notes
Shown to reduce cardiac death after myocardial infarction (MI)
Should be administered at the first sign of MI
If not given before arriving in the emergency department, aspirin is one of the first drugs given if there are no contraindications.
~~chew it~~
Aspirin Dosage Notes
for daily aspirin it is best to go with the lower dose of 81 mg over the 325 mg, however it is not unheard of
Reye’s Syndrome
Acute and potentially life-threatening condition involving progressive neurologic deficits that can lead to coma and may also involve liver damage.
Triggered by viral illnesses such as influenza as well as by salicylate therapy itself in the presence of a viral illness.
Survivors of this condition may or may not have permanent neurologic damage.
Salicism
Salicylate toxicity
can be from short term high doses, or long term low doses
Increased heart rate
Tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, drowsiness
Nausea, vomiting, diarrhea
Sweating, thirst, hyperventilation, hypoglycemia or hyperglycemia
associated with methyl salicylate - oil of wintergreen
Acetic acid derivatives
diclofenac sodium (Voltaren)
indomethacin (Indocin)
sulindac (Clinoril)
tolmetin (Tolectin)
etodolac (Lodine)
** ketorolac (Toradol) **
meclofenamate (generic only)
mefenamic acid (Ponstel)
Indomethacin (Indocin)
acetic acid derivative
Analgesic, antiinflammatory, antirheumatic, and antipyretic properties
Uses: RA, OA, acute bursitis or tendonitis, ankylosing spondylitis, acute gouty arthritis, pericarditis, PDA (patent ductus arteriosus), and treatment of preterm labor
Oral, rectal, intravenous use
May cause nausea, vomiting
Ketorolac (Toradol)
acetic acid derivative
Some antiinflammatory activity
Used primarily for analgesic effects
Indication: short-term use (up to 5 days) to manage moderate to severe acute pain
post op pain
Ketorolac Adverse Effects
Adverse effects: renal impairment, edema, GI pain, GI bleed, dyspepsia, and nausea
Celecoxib (Celebrex)
COX-2 Inhibitor (1st and last one standing)
Indicated for OA, RA, acute pain symptoms, ankylosing spondylitis, and primary dysmenorrhea
Little effect on platelet function
Celecoxib (Celebrex) Adverse Reactions
Adverse effects include headache, sinus irritation, diarrhea, fatigue, dizziness, lower extremity edema, and hypertension
Theoretically less rick for GI upset than NSAIDs but the risk is still there
** not for patients with known sulfa allergy**
Propionic acid derivatives examples
fenoprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil, others)
ketoprofen (Orudis KT)
naproxen (Naprosyn, Aleve)
oxaprozin (Daypro)
Ibuprofen (Motrin, Advil)
Propionic Acid Derivative
Most commonly used NSAID
Uses: analgesic effects in the management of RA, OA, primary dysmenorrhea, gout, dental pain, musculoskeletal disorders, antipyretic actions
Naproxen
Second most commonly used NSAID
Somewhat better adverse effect profile than ibuprofen
Fewer drug interactions with ACE inhibitors given for hypertension
COX Enzymes
COX-1: has a role in maintaining the gastrointestinal (GI) mucosa
COX-2: going to have the beneficial effects on inflammation with little effects on GI
Aspirin
Irreversible inhibitor of COX-1 receptors within the platelets themselves
Reduced formation of thromboxane A2, a substance that normally promotes platelet aggregation other NSAIDs lack these antiplatelet effects
NSAID contraindications
aspirin allergy must not receive any other NSAIDs
(because of bleeding risk:)
Vitamin K deficiency
Peptic ulcer disease
Renal disease. NSAIDs can cause renal problems and damage
NSAID Adverse Effects
GI: heartburn to severe GI bleeding
Acute renal failure
Noncardiogenic pulmonary edema
Increased risk of MI and stroke – not aspirin though
Altered hemostasis
Hepatotoxicity
Skin eruption, sensitivity reaction
Tinnitus, hearing loss
Misoprostol (Cytotec)
prevents GI bleed
Synthetic prostaglandin E1 analogue: inhibits gastric acid secretion and has a cytoprotective component
Mechanism of action: unclear
Prophylactic use - not a treatment.
IN OB: to ripen the cervix
NSAIDs and Renal Function
Use of NSAIDs can compromise existing renal function.
Renal toxicity can occur in patients with dehydration, heart failure, liver dysfunction, or use of diuretics or angiotensin-converting enzyme (ACE) inhibitors.
NSAID Black Box Warning
All NSAIDs (except aspirin) share a black box warning regarding an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke.
NSAIDs may counteract the cardioprotective effects of aspirin.
NSAID GI Adverse Effects
Dyspepsia, heartburn, epigastric distress, nausea
GI bleeding* (tell pt to stop drinking)
Mucosal lesions* (erosions or ulcerations)
*Misoprostol (Cytotec) can be used to reduce these dangerous effects.
NSAID Renal and Cardiovascular Adverse Effects
Renal
-Reductions in creatinine clearance
-Acute tubular necrosis with renal failure
Cardiovascular
-Noncardiogenic pulmonary edema
NSAID Interactions
Anticoagulants – can increase bleeding
Aspirin – increased risk of GI problems
Corticosteroids and other ulcerogenic drugs – increased ulcerogenic effects
Protein bound drugs – effects absorption
Diuretics and ACE inhibitors – decrease hypotensive effects and decrease diuretic effects
Salicylates Administration Notes
NOT FOR CHILDREN - Reyes Syndrome
take with food or milk to prevent GI upset
Therapeutic effect may take 3-4 weeks
Glucosamine and Chondroitin
Herbal Products used to treat the pain of OA
Adverse effects
-GI discomfort
-Drowsiness, headache, skin reactions (glucosamine)
Drug interactions
-Enhances effects of warfarin
-May increase insulin resistance (glucosamine)
Gout
condition that results from inappropriate uric acid metabolism (make too much or cant get rid of it)
Uric acid crystals are deposited in tissues and joints, resulting in pain
Hyperuricemia (elevated uric acid levels, a blood test, not a urine test)
- often in feet, you will see BIG toes -
Antigout Drugs
first line therapy is NSAIDs, these are secondary
allopurinol (Zyloprim)
febuxostat (Uloric)
colchicine (Colcyrs)
probenecid (Benemid)
sulfinpyrazone (Anturane)
Allopurinol (Zyloprim)
Used to prevent uric acid production and to prevent acute tumor lysis syndrome
Exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis
monitor uric acid levels
Probenecid (Benemid)
Inhibits the reabsorption of uric acid in the kidneys and thus increases the excretion of uric acid: less uric acid in the blood, more in the urine
Febuxostat (Uloric)
Nonpurine selective inhibitor of xanthine oxidase
More selective for xanthine oxidase than allopurinol
May pose a greater risk of cardiovascular events than allopurinol
Colchicine
Reduces inflammatory response to the deposits of urate crystals in joint tissue
Used for short-term management or prevention of gout
May cause short-term leukopenia and bleeding into the GI or urinary tracts
Have the patient report any blood in urine
Empty stomach
Increase fluid intake – important to stay hydrated
joint pain should decrease
to prevent organ transplant rejection
mycophenolate mofetil (CellCept)
daclizumab (Zenapax)* -BBW: lymphoproliferative (can initiate that word and hypersensitivity reactions)
basiliximab (Simulect)*
sirolimus (Rapamune)
*give prednisone to prevent anaphylactic response
Belatacept (nulojix)
only drug for long term IV maintenance
Why pre medicate with corticosteroids before immunosuppressants
Cytokine release syndrome can lead to anaphylaxis. Patients are often pre-medicated with corticosteroids to avoid or alleviate that problem.
solumedrol often used
azathioprine (Imuran)
Used as an adjunct medication to prevent rejection of kidney transplants
Also used in the treatment of rheumatoid arthritis
Expected reactions include leukopenia, thrombocytopenia, hepatotoxicity.
monitor CBC – can induce leukopenia. Also liver function tests.
cyclosporine (Cyclosporin A)
Primary drug used in the prevention of kidney, liver, heart, and bone marrow transplant rejection; other autoimmune disorders (refractory RA, plaque psoriasis)
cyclosporine (cyclosporin A) administration notes
Oral tabs: when possible to avoid skin penetration;* same time QD
Oral liquids; mix with juice, choc milk, etc. No Styrofoam cups
IV: no bolus dosing; use a pump; reactions in first 30 minutes; serum levels monitored
cyclosporine (cyclosporin A) does not intermingle with
Often combined with a corticosteroid; oral antifungal
Co administration of allopurinol ↑ action of cyclosporine, but also toxicity! *
Grapefruit juice will ↑serum levels, ↑ toxicities
Cyclosporine Adverse Reactions
CV: moderate hypertension in 50% of cases!*
CNS: neurotoxicity/tremors 20% of patients
Liver: hepatotoxicity with cholestasis, ↑bilirubin
Renal: toxic and often dose limiting – BBW
Other: hypersensitivity, gingival hyperplasia, hirsutism
Tacrolimus (Prograf)
Prevention of liver, kidney, heart transplant rejection
IV and PO formula’s available;
IV 1st 2-3 days post transplant
Switch to PO and maintain
may also be used for severe psoriasis, Crohn’s, nephritis, atopic dermatitis
Tacrolimus (Prograf) Adverse Reactions
Side effects: predominately renal (albuminuria, dysuria, ARF & CNS (agitation dconfusion, neuropathy)
Tacrolimus (prograf) does not intermingle with
cyclosporine
glatiramer acetate (Copaxome)
The only immunosuppressant drug used for the treatment of multiple sclerosis (MS)
Used to reduce the frequency of MS relapses (exacerbations) in relapsing-remitting multiple sclerosis (RRMS)
Nursing Implications for Immunosuppressants
watch for signs of infection
WATCH FOR MILD SYMPTOMS
Renal, liver, and cardiovascular function studies, CBC
Take with food
Oral given to avoid IV/IM related infections
oral cyclosporine administration notes
must be mixed in a glass container, Styrofoam fucks it up
