1. Make a drug study on the individual drugs discussed in this course unit.

TYPE THEM IN WORD

and compile them.

CHEMOTHERAPEUTIC AGENTS
ALKYLATING AGENTS
DRUG ALTRETAMINE
DOSAGE
Ovarian Cancer
Adult: PO 260 mg/m2/d for 14 or 21 consecutive d in a 28-d cycle

THERAPEUTIC ACTION
Altretamine, formally hexamethyl melamine, is a synthetic cytotoxic antineoplastic drug. The mechanism of
action is not clearly underst ood. Altretamine probably requires the liver enzyme system for activation of its
cytotoxic properties.

ADVERSE EFFECTS
CNS: Paresthesias, hyporeflexia, muscle weakness, peripheral numbness, ataxia, Parkinson-like
tremors. GI: Nausea, vomiting. Hematologic: Leukopenia, thrombocytopenia. Urogenital: Slight increase in
serum creatinine. Skin: Alopecia and eczema.

CONTRAINDICATION
Hypersensitivity to altretamine, severe bone marrow depression, neurologic toxicity, pregnancy (category D),
lactation.

NURSING CONSIDERATIONS
Assessment & Drug Effects
 Lab tests: Monitor blood counts at least monthly and prior to each course of therapy.
 Perform a neurologic examination regularly; question patient about the presence of: paresthesias,
hypoesthesias, muscle weakness, peripheral numbness, ataxia, decreased sensations, and alterations in
mood or consciousness.
 Withhold medication if neurologic symptoms fail to resolve with dose reduction. Notify physician.
 Monitor for nausea and vomiting, which are related to the cumulative dose of altretamine. After several
weeks some patients develop tolerance to the GI effects. Antiemetics may be required to control GI
distress.
Patient & Family Education
 Taking altretamine after meals or with food or milk may decrease nausea.
 Report symptoms indicative of neurotoxicity to physician (paresthesias, hypoesthesias, muscle weakness,
peripheral numbness, ataxia, decreased sensations, and alterations in mood or consciousness).
 Note: GI, hematologic, and neurologic adverse effects may be severe.
 Do not breast feed while taking this drug.

DRUG BENDAMUSTINE
DOSAGE
Chronic Lymphocytic Leukemia
IV Infusion: ADULTS/ELDERLY: 100 mg/ m2 given over 30 min daily on days 1 and 2 of a 28-day cycle, up to
6 cycles.
Non-Hodgkin’s Lymphoma
IV Infusion: ADULTS/ELDERLY: 120 mg/ m2 on days 1 and 2 of a 21-day cycle, up to 8 cycles.
Dose Modification
Hematologic Toxicity: Grade 4 or greater: Withhold until ANC 1,000/ mm3 or greater, platelet 75,000/mm3 or
greater. CLL: Toxicity Grade 3 or greater: Reduce dose to 50 mg/m2 on days 1 and 2 of each treatment cycle.
Recurrence: Reduce dose to 25 mg/2 on days 1 and 2 of each cycle. NHL: Hematologic toxicity Grade 4 or
nonhematologic toxicity Grade 3 or greater: Reduce dose to 90 mg/m2 on days 1 and 2 of each cycle.
Recurrence: Reduce dose to 60 mg/ m2 on days 1 and 2 of each treatment cycle.
Dosage in Renal Impairment
Not recommended in pts with CrCl less than 40 mL/min.
Dosage in Hepatic Impairment
Mild: Use caution. Moderate to Severe: Not recommended.

THERAPEUTIC ACTION
Alkylates and cross-links macromolecules, resulting in DNA, RNA, and protein synthesis inhibition.
Therapeutic Effect: Inhibits tumor cell growth, causes cell death.

ADVERSE EFFECTS
Myelosuppression characterized as neutropenia (75% of pts), thrombocytopenia (77% of pts), anemia (89% of
pts), leukopenia (61% of pts) is an expected response to therapy. Infection, including pneumonia, sepsis may
occur. Tumor
lysis syndrome may lead to acute renal failure. Worsening of hypertension occurs rarely.

CONTRAINDICATION
Hypersensitivity to bendamustine. (Bendeka only): polyethylene glycol 400, or propylene glycol mono-
thioglycerol.

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain baseline CBC, BMP, LFT before treatment begins and routinely thereafter. Question for possibility of
pregnancy. Offer emotional support.
INTERVENTION/EVALUATION
Offer antiemetics to control nausea, vomiting. Monitor daily pattern of bowel activity, stool consistency. Assess
skin for evidence of rash. Monitor for signs of infection (fever, chills, cough, flu-like symptoms). Monitor for
hypertension. Hematologic nadirs occur in 3rd week of therapy and may require dose delays if recovery to
recommended values has not occurred by day 28.
PATIENT/FAMILY TEACHING
• Avoid crowds, those with known infection.
• Avoid contact with anyone who recently received live virus vaccine.]
• Do not have immunizations without physician’s approval (drug lowers body resistance).
• Promptly report fever, chills, flu-like symptoms, sore throat, unusual bruising/bleeding from any site.
• Male pts should be warned of potential risk to their reproductive capacities.
DRUG CARBOPLATIN

DOSAGE
Ovarian Carcinoma
IV: ADULTS: 360 mg/m2 on day 1, every 4 wks (as single agent), or 300 mg/m2 q4 wks (in combination with
cyclophosphamide) or target AUC 4–6 (single agent; in previously treated pts). Do not repeat dose until neutrophil
and platelet counts are within acceptable levels.
Dose Modification
Platelets less than 50,000 cells/ mm3 or ANC less than 500 cells/ mm3: Give 75% of dose.
Dosage in Renal Impairment
Initial dosage is based on creatinine clear acne; subsequent dosages are based on pt.’s tolerance, degree of
myelosuppression.

THERAPEUTIC ACTION
Inhibits DNA synthesis by cross-linking with DNA strands, preventing cell division. Therapeutic Effect:
Interferes with DNA function.

ADVERSE EFFECTS
Myelosuppression may be severe, resulting in anemia, infection (sepsis, pneumonia), major bleeding. Prolonged
treatment may result in peripheral neurotoxicity
Myelosuppression may be severe, resulting in anemia, infection (sepsis, pneumonia), major bleeding. Prolonged
treatment may result in peripheral neurotoxicity

CONTRAINDICATION
Hypersensitivity to Carboplatin. History of severe allergic reaction to Cisplatin, platinum compounds, mannitol;
severe bleeding, severe myelosuppression. Cautions: Moderate bone marrow depression, renal impairment, elderly

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain EKG, CBC, serum chemistries, renal function test. Offer emotional support. Do not repeat treatment until
WBC recovers from previous therapy. Transfusions may be needed in pts receiving prolonged therapy
(myelosuppression increased in those with previous therapy, renal impairment).
INTERVENTION/EVALUATION
Monitor pulmonary function studies, hepatic/renal function tests, CBC, serum electrolytes. Monitor for fever, sore
throat, signs of local infection, unusual bruising/bleeding from any site, symptoms of anemia (excessive fatigue,
weakness).
PATIENT/FAMILY TEACHING
• Nausea, vomiting generally abate within 24 hrs. • Do not have immunizations without physician’s approval (drug
lowers body’s resistance). • Avoid contact with those who have recently received live virus vaccine.

DRUG CARMUSTINE
DOSAGE
Usual Dosage (Refer to Individual Protocols)
IV (BiCNU): ADULTS, ELDERLY: 150–200 mg/m2 as a single dose q6wks or 75–100
ALERT: Next dosage is based on clinical and hematologic response to previous dose (platelets greater than
100,000/mm3 and leukocytes greater than 4,000/mm3). Implantation (Gliadel Wafer): ADULTS, ELDERLY,
CHILDREN: Up to 8 wafers (62.6 mg) may be placed in resection cavity.
Dosage Modification
Leukocytes 2,000–2,999 cells/mm3 or platelets 25,000–74,999 cells/ mm3: Give 70% of dose. Leukocytes less than
2,000 cells/mm3 or platelets less than 25,000 cells/mm3: Give 50% of dose.

THERAPEUTIC ACTION
Inhibits DNA, RNA synthesis by crosslinking with DNA, RNA strands, preventing cell division. Cell cycle–phase
nonspecific. Therapeutic Effect: Interferes with DNA, RNA function.

ADVERSE EFFECTS
Hematologic toxicity due to myelosuppression occurs frequently. Thrombocytopenia occurs approximately 4 wks
after treatment begins and lasts 1–2 wks. Leukopenia is evident 5–6 wks after treatment begins and lasts 1–2 wks.
Anemia occurs less frequently. Mild, reversible hepatotoxicity occurs frequently. Prolonged, high-dose therapy
may produce impaired renal function, pulmonary toxicity (pulmonary infiltrate/ fibrosis).
CONTRAINDICATION
Hypersensitivity to carmustine. Cautions: Thrombocytopenia, leukopenia, anemia, renal/hepatic impairment.

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain CBC, renal/hepatic function studies before initiation and periodically thereafter. Offer emotional support.
INTERVENTION/EVALUATION
Monitor renal/hepatic function tests. Obtain CBC wkly during and for at least 6 wks after therapy ends. Monitor for
hematologic toxicity (fever, sore throat, signs of local infection, unusual bruising/bleeding from any site),
symptoms of anemia (excessive fatigue, weakness). Monitor for pulmonary toxicity; observe for dyspnea,
adventitious breath sounds.
PATIENT/FAMILY TEACHING
• Maintain adequate hydration (may protect against renal impairment). • Do not have immunizations without
physician’s approval (drug lowers body’s resistance). • Avoid contact with those who have recently received live
virus vaccine. • Report nausea, vomiting, fever, sore throat, chills, unusual bleeding/bruising

DRUG CHLORAMBUCIL

DOSAGE
Chronic Lymphocytic Leukemia (CLL)
PO: ADULTS, ELDERLY: 0.1 mg/kg/day for 3–6 wks or 0.4 mg/kg pulsed doses administered intermittently,
biweekly or monthly (increased by 0.1 mg/kg/dose until response/toxicity observed).
Hodgkin’s Lymphoma (HL)
PO: ADULTS, ELDERLY: 0.2 mg/kg/day for 3–6 wks.
Non-Hodgkin’s Lymphoma (NHL)
PO: ADULTS, ELDERLY: 0.1 mg/kg/day for 3–6 wks.
Dosage in Renal Impairment
CrCl 10–50 mL/min: 75% of dose. CrCl less than 10 mL/min: 50% of dose.
Dosage in Hepatic Impairment
Use caution.
THERAPEUTIC ACTION
Inhibits DNA, RNA synthesis by crosslinking with DNA, RNA strands. Therapeutic Effect: Interferes with DNA
replication and RNA transcription.
ADVERSE EFFECTS
Hematologic toxicity due to severe myelosuppression occurs frequently, manifested as neutropenia, anemia,
thrombocytopenia. After discontinuation of therapy, thrombocytopenia, neutropenia usually last for 1–2 wks, but
may persist for 3–4 wks. Neutrophil count may continue to decrease for up to 10 days after last dose. Toxicity
appears to be less severe with intermittent drug administration. Overdosage may produce seizures in children.
Excessive serum uric acid level, hepatotoxicity occur rarely.

CONTRAINDICATION
Hypersensitivity to chlorambucil. Previous allergic reaction to other alkylating agents, prior resistance to
chlorambucil, pregnancy.

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain CBC before therapy and wkly during therapy, WBC count 3–4 days following each wkly, CBC during first
3–6 wks of therapy (4–6 wks if pt on intermittent dosing schedule).
INTERVENTION/EVALUATION
Monitor CBC, serum uric acid, LFT. Monitor for hematologic toxicity (fever, sore throat, signs of local infection,
unusual bruising/ bleeding from any site), symptoms of anemia (excessive fatigue, weakness). Assess skin for
rash, pruritus, urticaria.
PATIENT/FAMILY TEACHING
• Increase fluid intake (may protect against hyperuricemia). • Avoid acidic or spicy foods; may delay absorption of
medication. • Do not have immunizations without physician’s approval (drug lowers resistance). • Avoid contact
with those who have recently received live virus vaccine. • Promptly report fever, sore throat, signs of local
infection, unusual bruising/bleeding from any site, nausea, vomiting, rash.

ANTIMETABOLITES
DRUG FLUOROURACIL (5-FU)
DOSAGE
Usual Range
IV Bolus: ADULTS, ELDERLY: 200–1000 mg/m2/day for 1–21 days or 500–600 mg/m2/dose q3–4wks. IV
Infusion: ADULTS, ELDERLY: 15 mg/kg/ day or 500 mg/m2/day over 4 hrs for 5 days or 800–1200 mg/m2
over 24–120 hrs.
Multiple Actinic or Solar Keratoses
Topical (Carac): ADULTS, ELDERLY: Apply once daily for up to 4 wks. Topical (Efudex): ADULTS,
ELDERLY: Apply twice daily for 2–4 wks. Topical (Fluoroplex): Apply twice daily for 2–6 wks. Topical
(Tolak): Apply once daily for 4 wks.
Basal Cell Carcinoma
Topical (Efudex 5%): ADULTS, ELDERLY: Apply twice daily for 3–6 wks up to 10–12 wks.
Dosage in Renal Impairment
No dose adjustment.
Dosage in Hepatic Impairment
Use extreme caution.

THERAPEUTIC ACTION
Blocks formation of thymidylic acid. Cell cycle–specific for S phase of cell division. Therapeutic Effect:
Inhibits DNA, RNA synthesis. Topical: Destroys rapidly proliferating cells.
ADVERSE EFFECTS
Earliest sign of toxicity (4–8 days after beginning therapy) is stomatitis (dry mouth, burning sensation, mucosal
erythema, ulceration at inner margin of lips). Most common dermatologic toxicity is pruritic rash (generally on
extremities, less frequently on trunk). Leukopenia (WBC less than 3500 cells/mm3) generally occurs within 9–14
days after drug administration but may occur as late as 25th day. Thrombocytopenia (platelets less than 100,000
cells/mm3) occasionally occurs within 7–17 days after administration. Pancytopenia, agranulocytosis occurs
rarely.

CONTRAINDICATION
Hypersensitivity to fluorouracil. Myelosuppression, poor nutritional status, potentially serious infections.
Cautions: History of high-dose pelvic irradiation, hepatic/renal impairment, palmar-plantar erythrodysesthesia
syndrome (hand and foot syndrome), previous use of alkylating agents. Pts with widespread metastatic marrow
involvement

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain baseline CBC with differential, serum renal function, LFT and monitor during therapy. Question history
of hypersensitivity reaction, hepatic/renal impairment.
INTERVENTION/EVALUATION
Monitor for rapidly falling WBC, platelet count; intractable diarrhea, GI bleeding (bright red or tarry stool).
Assess oral mucosa for stomatitis. Drug should be discontinued if intractable diarrhea, stomatitis, GI bleeding
occurs. Assess skin for rash.
PATIENT/FAMILY TEACHING
• Maintain strict oral hygiene. • Report signs/symptoms of infection, unusual bruising/bleeding, visual changes,
nausea, vomiting, diarrhea, chest pain, palpitations. • Avoid sunlight, artificial light sources; wear protective
clothing, sunglasses, sunscreen. • Topical: Apply only to affected

DRUG CAPECITABINE (XELODA)

DOSAGE
Dosage in Renal Impairment
CrCl 51–80 mL/min: No adjustment. CrCl 30–50 mL/min: 75% of normal dose. CrCl less than 30 mL/min:
Contraindicated.
Dosage in Hepatic Impairment
No dose adjustment at start of therapy; interrupt therapy for grade 3 or 4 hyperbilirubinemia until bilirubin is 3
times ULN or less.

THERAPEUTIC ACTION
Enzymatically converted to 5-fluorouracil (5-FU). Inhibits enzymes necessary for synthesis of essential cellular
components. Therapeutic Effect: Interferes with DNA synthesis, RNA processing, protein synthesis.

ADVERSE EFFECTS
Serious reactions include myelosuppression (neutropenia, thrombocytopenia, anemia), cardiovascular toxicity
(angina, cardiomyopathy, DVT), respiratory toxicity (dyspnea, epistaxis, pneumonia), lymphedema. Palmar-
plantar erythrodysesthesia syndrome (PPES), presenting as redness, swelling, numbness, skin sloughing of hands
and feet, may occur.
CONTRAINDICATION
Severe renal impairment (CrCl less than 30 mL/min), dihydropyridine dehydrogenase (DPD) deficiency,
hypersensitivity to capecitabine, 5-fluorouracil (5-FU).

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Assess sensitivity to capecitabine or 5-fluorouracil. Obtain baseline Hgb, Hct, serum chemistries, renal function.
INTERVENTION/EVALUATION
Monitor for severe diarrhea, nausea, vomiting; if dehydration occurs, fluid and electrolyte replacement therapy
should be initiated. Assess hands/feet for PPES. Monitor CBC for evidence of bone marrow depression. Monitor
renal/hepatic function. Monitor for blood dyscrasias (fever, sore throat, signs of local infection, unusual
bruising/bleeding from any site), symptoms of anemia (excessive fatigue, weakness).
PATIENT/FAMILY TEACHING
• Report nausea, vomiting, diarrhea, hand-and-foot syndrome, stomatitis. • Do not have immunizations without
physician’s approval (drug lowers body’s resistance). • Avoid contact with those who have recently received live
virus vaccine. •Promptly report fever higher than 100.5°F, sore throat, signs of local infection, unusual
bruising/bleeding from any site.

DRUG CLOFARABINE
DOSAGE
Acute Lymphoblastic Leukemia (ALL)
IV: CHILDREN 1–21 YRS: 52 mg/m2 over 2 hrs once daily for 5 consecutive days; repeat q2–6wks following
recovery or return to baseline organ function. (Subsequent cycles should begin no sooner than 14 days from day 1
of previous cycle and when ANC is 750 cells/mm3 or greater.)
Dosage in Renal Impairment
Dosage is modified based on creatinine clearance.

THERAPEUTIC ACTION
Metabolized intracellularly to ribonucleotide reductase. Alters mitochondrial membrane necessary in DNA
synthesis. Therapeutic Effect: Decreases cell replication, inhibits cell repair. Produces cell death.

ADVERSE EFFECTS
Neutropenia occurred in 57% of pts; pericardial effusion in 35%; left ventricular systolic dysfunction in 27%;
hepatomegaly, jaundice in 15%; pleural effusion, pneumonia, bacteremia in 10%; capillary leak syndrome in less
than 10%.

CONTRAINDICATION
Hypersensitivity to clofarabine.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Question possibility of pregnancy. Obtain CBC, BMP, LFT, CrCl prior to therapy
INTERVENTION/EVALUATION
Monitor CBC, renal function test, LFT, serum uric acid. Monitor respiratory status, cardiac function. Monitor daily
pattern of bowel activity, stool consistency. Assess for GI disturbances. Assess skin for pruritus, dermatitis,
petechiae, erythema on palms of hands and soles of feet. Assess for fever, sore throat; obtain blood cultures to
detect evidence of infection. Ensure adequate hydration.
PATIENT/FAMILY TEACHING
• Do not have immunizations without physician’s approval (drug lowers resistance). • Avoid contact with anyone
who recently received a live virus vaccine. • Avoid crowds, those with infection. • Avoid pregnancy; pts of
childbearing potential should use effective contraception. • Maintain strict oral hygiene and frequent handwashing.
• Report fever, respiratory distress, prolonged nausea, vomiting, diarrhea, easy bruising

TOPOISOMERASE INHIBITORS I (also called camptothecins)

DRUG IRINOTECAN
DOSAGE
Carcinoma of the Colon, Rectum (Camptosar)
IV (Single-Agent Therapy): ADULTS, ELDERLY: (WEEKLY REGIMEN): Initially, 125 mg/m2 once wkly for 4
wks, followed by a rest period of 2 wks. Additional courses may be repeated q6wks. Dosage may be adjusted in
25–50 mg/m2 increments/
decrements to as high as 150 mg/m2 or as low as 50 mg/m2. (THREE-WEEK REGIMEN): 350 mg/m2 q3wks.
Dosage may be adjusted to as low as 200 mg/m2 in decrements of 25–50 mg/m2.
(In Combination with Leucovorin and 5-Fluorouracil):
REGIMEN ONE: 125 mg/m2 on days 1, 8, 15, 22. Dose may be adjusted to 100 mg/m2, then 75 mg/m2, then
decrements of approximately 20%. REGIMEN TWO: 180 mg/m2 on days 1, 15, 29. Dose may be adjusted to 150
mg/m2, then 120 mg/m2, then decrements of approximately 20%. Pancreatic Cancer (Onivyde) IV Infusion:
ADULTS, ELDERLY: 70 mg/ m2 once q2wks (in combination with leucovorin and 5-fluorouracil).
Dosage in Renal Impairment
No dose adjustment.

THERAPEUTIC ACTION
Interacts with topoisomerase I, an enzyme that relieves torsional strain in DNA by inducing reversible single-strand
breaks. Prevents religation of these single-stranded breaks, resulting in damage to double-strand DNA, cell death.
Therapeutic Effect: Produces cytotoxic effect on cancer cells.

ADVERSE EFFECTS
Hematologic toxicity characterized by anemia, leukopenia, thrombocytopenia, and neutropenia; sepsis occurs
frequently. Camptosar may cause severe/fatal interstitial lung disease.

CONTRAINDICATION
Hypersensitivity to irinotecan. Cautions: Pt previously receiving pelvic, abdominal irradiation (increased risk of
myelosuppression), pts older than 65 yrs., hepatic dysfunction, hyperbilirubinemia, renal impairment, preexisting
pulmonary disease.

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Offer emotional support. Assess hydration status, electrolytes, CBC before each dose. Premedicate with
antiemetics on day of treatment, starting at least 30 min before administration. Inform pt of possibility of alopecia.
INTERVENTION/EVALUATION
Monitor daily pattern of bowel activity, stool consistency. Monitor hydration status, I&O, electrolytes, CBC, renal
function, LFT. Monitor infusion site for signs of inflammation. Assess skin for rash.
PATIENT/ FAMILY TEACHING
• Report diarrhea, vomiting, fever, lightheadedness, dizziness. • Do not have immunizations without physician’s
approval (drug lowers resistance). • Avoid contact with those who have recently received live virus vaccine. •
Avoid crowds, those with infections.

DRUG TOPOTECAN
DOSAGE
Ovarian Carcinoma, Small Cell Lung Cancer
IV: ADULTS, ELDERLY: 1.5 mg/m2/day over 30 min for 5 consecutive days, beginning on day 1 of 21-day
course. Minimum of 4 courses recommended. If severe neutropenia (neutrophil count less than 1,500 cells/mm3)
occurs during treatment, reduce dose for subsequent courses by 0.25 mg/m2 or administer filgrastim (G-CSF) no
sooner than 24 hrs after last dose of topotecan.
PO (Small Cell Lung Cancer):
ADULTS, ELDERLY: 2.3 mg/m2/day for 5 days; repeat q21days (dose rounded to nearest 0.25 mg). For severe
neutropenia or prolonged neutropenia, platelets less than 25,000 cells/mm3, recovery from grade 3 or 4 diarrhea:
Reduce dose by 0.4 mg/m2/day for subsequent cycles.
Cervical Cancer
IV: ADULTS, ELDERLY: 0.75 mg/m2/day for 3 days (followed by Cisplatin 50 mg/ m2 on day 1 only). Repeat
q21days (baseline neutrophil count greater than 1,500 cells/mm3 and platelet count greater than 100,000
cells/mm3). For severe febrile neutropenia (neutrophils less than 1,000 cells/mm3 with temperature of 38°C) or
platelet count less than 25,000 cells/mm3: Reduce dose to 0.6 mg/m2/day for subsequent cycles. If necessary,
further decrease dose to 0.45 mg/m2/day

THERAPEUTIC ACTION
Interacts with topoisomerase I, an enzyme that relieves torsional strain in DNA by inducing reversible single-strand
breaks. Prevents religation of DNA strand, resulting in damage to double strand DNA, cell death. Therapeutic
Effect: Produces cytotoxic effect.

ADVERSE EFFECTS
Severe neutropenia (absolute neutrophil count [ANC] less than 500 cells/mm3) occurs in 60% of pts (develops at
median of 11 days after day 1 of initial therapy). Thrombocytopenia occurs in 26% of pts. Severe anemia (RBC
count less than 8 g/ dL) occurs in 40% of pts (develops at median of 15 days after day 1 of initial therapy). Severe
diarrhea may occur.

CONTRAINDICATION
Hypersensitivity to topotecan. Baseline neutrophil count less than 1,500 cells/mm3 and platelet count less than
100,000 cells/mm3, severe myelosuppression. Cautions: Mild myelosuppression, renal impairment, breastfeeding,
pregnancy, elderly pts. Pts at risk for developing interstitial lung disease (e.g., lung cancer, pulmonary fibrosis).

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Offer emotional support. Assess CBC with differential before each dose. Myelosuppression may precipitate life-
threatening hemorrhage, infection, anemia. If platelet count drops, minimize trauma to pt (e.g., IM injections, pt
positioning). Premedicate with antiemetics on day of treatment, starting at least 30 min before administration.
INTERVENTION/EVALUATION
Assess for bleeding, signs of infection, anemia. Monitor hydration status, I&O, serum electrolytes (severe diarrhea,
vomiting are common side effects). Monitor CBC for evidence of myelosuppression. Monitor renal function, LFT.
Assess response to medication; provide interventions (e.g., small, frequent meals; antiemetics for nausea/vomiting).
Question for complaints of headache. Assess breathing pattern for evidence of dyspnea.
PATIENT/FAMILY TEACHING
• Hair loss is reversible but new hair may have different color, texture. • Diarrhea may cause dehydration,
electrolyte depletion. • Antiemetic and antidiarrheal medications may reduce side effects. • Notify physician if
diarrhea, vomiting, persistent fever, bruising/bleeding, yellowing of eyes/skin occur. • Do not have immunizations
without physician’s approval (drug lowers resistance). • Avoid contact with those who have recently received live
virus vaccine.

TOPOISOMERASE INHIBITORS II (also called epipodophyllotoxins)

DRUG ETOPOSIDE (VP-16)

DOSAGE
Refractory Testicular Tumors
IV: ADULTS: 50–100 mg/m2/day on days 1–5, or 100 mg/m2/day on days 1, 3, 5 (as combination therapy). Give
q3–4wks for 3–4 courses.
Small-Cell Lung Carcinoma
PO: ADULTS: Twice the IV dose rounded to nearest 50 mg. Give once daily for doses 200 mg or less, in divided
doses for dosages greater than 200 mg. IV: ADULTS: 35 mg/m2/day for 4 consecutive days up to 50 mg/m2/day for
5 consecutive days q3–4wks (as combination therapy).

THERAPEUTIC ACTION
Induces single- and double-stranded breaks in DNA. Cell cycle–dependent and phase-specific; most effective in S
and G2 phases of cell division. Therapeutic Effect: Inhibits, alters DNA synthesis.

ADVERSE EFFECTS
Myelosuppression manifested as hematologic toxicity, principally anemia, leukopenia (occurring 7–14 days after
drug administration), thrombocytopenia (occurring 9–16 days after administration), and, to lesser extent,
pancytopenia. Bone marrow recovery occurs by day 20. Hepatotoxicity occurs occasionally.

CONTRAINDICATION
Hypersensitivity to etoposide. Cautions: Hepatic/renal impairment, myelosuppression, elderly, pts with low serum
albumin.

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain CBC before and at frequent intervals during therapy. Antiemetics readily control nausea, vomiting. Offer
emotional support.
INTERVENTION/EVALUATION
Monitor CBC, B/P, hepatic/renal function tests. Monitor daily pattern of bowel activity, stool consistency. Monitor
for hematologic toxicity (fever, sore throat, signs of local infection, unusual bruising/bleeding from any site),
symptoms of anemia (excessive fatigue, weakness). Assess for paresthesia (peripheral neuropathy). Monitor for
stomatitis.
PATIENT/FAMILY TEACHING
• Hair loss is reversible, but new hair growth may have different color, texture. • Do not have immunizations with
out physician’s approval (drug lowers resistance). • Avoid contact with those who have recently received live virus
vaccine. • Promptly report fever, sore throat, signs of local infection, unusual bruising or bleeding from any site,
burning or pain with urination, numbness in extremities, yellowing of skin or eyes.
DRUG MITOXANTRONE (also acts as an anti-tumor antibiotic)
DOSAGE
Combination Therapy for ANLL
Adult: IV Induction Therapy: 12 mg/m2/d on days 1–3, may need to repeat induction course. IV Consolidation
Therapy: 12 mg/m2 on days 1 and 2 (max: lifetime dose 80–120 mg/m2)
Child: IV 8–33 mg/m2 q3–4wk
Solid Tumors
Child: IV 5–8 mg/m2 once a week or 18–20 mg/m2 q3–4wk
Multiple Sclerosis
Adult: IV 12 mg/m2 over 5–15 min q3mo (max: lifetime dose 140 mg/m2)

THERAPEUTIC ACTION
Noncell-cycle specific antitumor agent with less cardiotoxicity than doxorubicin. Interferes with DNA synthesis by
intercalating with the DNA double helix, blocking effective DNA and RNA transcription.

ADVERSE EFFECTS
CV: Arrhythmias, decreased left ventricular function, CHF, tachycardia, ECG changes, MI (occurs with cumulative
doses of >80–100 mg/m2), edema, increased risk of cardiotoxicity. GI: Nausea, vomiting, diarrhea, hepatotoxicity.
Hematologic: Leukopenia, thrombocytopenia. Other: Discolors urine and sclera a blue-green color. Skin: Mild
phlebitis, blue skin discoloration, alopecia.

CONTRAINDICATION
Hypersensitivity to mitoxantrone; myelosuppression; pregnancy (category D), lactation.

NURSING CONSIDERATIONS
Assessment & Drug Effects
 Monitor IV insertion site. Transient blue skin discoloration may occur at site if extravasation has occurred.
 Monitor cardiac functioning throughout course of therapy; report signs and symptoms of CHF or cardiac
arrhythmias.
 Lab tests: Perform liver function tests prior to and during course of treatment. Monitor serum uric acid levels
and initiate hypouricemic therapy before antileukemic therapy. Monitor carefully CBC with differential prior
to and during therapy.
Patient & Family Education
 Understand potential adverse effects of mitoxantrone therapy.
 Expect urine to turn blue-green for 24 h after drug administration; sclera may also take on a bluish color.
 Be aware that stomatitis/mucositis may occur within 1 wk of therapy.
 Do not to risk exposure to those with known infections during the periods of myelosuppression.
 Do not breast feed while taking this drug.
ANTI-TUMOR ANTIBIOTICS
DRUG DAUNORUBICIN
DOSAGE
Acute Lymphoblastic Leukemia
IV: (Cerubidine): ADULTS, ELDERLY: 45 mg/m2 on days 1, 2, and 3 (in combination with vincristine,
prednisone, asparaginase). CHILDREN 2 YRS AND OLDER AND BODY SURFACE AREA 0.5 m2 OR
GREATER: 25 mg/m2 on day 1 of every wk for up to 4–6 cycles (in combination with vinCRIStine, prednisone).
CHILDREN YOUNGER THAN 2 YRS, OR BODY SURFACE AREA LESS THAN 0.5 m2: 1 mg/kg/dose on
day 1 of every wk for up to 4 to 6 cycles (in combination with vincristine, prednisone).
Acute Myeloid Leukemia
IV: (Cerubidine): ADULTS YOUNGER THAN 60 YRS:45 mg/m2 on days 1, 2, and 3 of induction course, then
on days 1 and 2 of subsequent courses (in combination with cytarabine). ADULTS 60 YRS AND OLDER: 30
mg/m2 on days 1, 2, and 3 of induction course, then on days 1 and 2 of subsequent courses (in combination with
cytarabine)
Kaposi’s Sarcoma
IV: (DaunoXome): ADULTS: 40 mg/m2 over 1 hr repeated q2wks until disease progression.
Dosage in Renal Impairment
Cerubidine: Serum creatinine greater than 3 mg/dL: 50% of normal dose.

THERAPEUTIC ACTION
Inhibits DNA and RNA synthesis by intercalation between DNA base pairs and by steric obstruction. Cell cycle–
phase nonspecific. Therapeutic Effect: Prevents cell division.

ADVERSE EFFECTS
Myelosuppression manifested as hematologic toxicity (severe leukopenia, anemia, thrombocytopenia). Decrease in
platelet count, WBC count occurs in 10–14 days, returns to normal level by third week. Cardiotoxicity noted as
either acute, transient, abnormal. EKG findings and/or cardiomyopathy manifested as HF (risk increases when
cumulative dose exceeds 550 mg/m2 in adults, 300 mg/m2 in children 2 yrs and older, or total dosage greater than
10 mg/kg in children younger than 2 yrs).

CONTRAINDICATION
Hypersensitivity to DAUNOrubicin. Cautions: Preexisting heart disease or bone marrow suppression,
hypertension, concurrent chemotherapeutic agents, elderly, infants, radiation therapy.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain WBC, platelet, erythrocyte counts before and at frequent intervals during therapy. EKG should be obtained
before therapy. Antiemetics may be effective in preventing, treating nausea. Obtain accurate height and weight for
dose calculation. Offer emotional support.
INTERVENTION/EVALUATION
Monitor for stomatitis. May lead to ulceration within 2–3 days. Assess skin, nailbeds for hyperpigmentation.
Monitor hematologic status, renal/hepatic function, serum uric acid. Monitor daily pattern of bowel activity, stool
consistency. Monitor for hematologic toxicity (fever, sore throat, signs of local infection, unusual
bruising/bleeding from any site), symptoms of anemia (excessive fatigue, weakness).
PATIENT/FAMILY TEACHING
• Urine may turn reddish color for 1–2 days after beginning therapy. • Hair loss is reversible, but new hair growth
may have different color, texture. • New hair growth resumes about 5 wks after last therapy dose. • Maintain strict
oral hygiene. • Do not have immunizations without physician’s approval (drug lowers resistance). • Avoid contact
with those who have recently received live virus vaccine. • Promptly report fever, sore throat, signs of local
infection, unusual bruising/bleeding from any site, yellowing of whites of eyes/skin, difficulty breathing. • Increase
fluid intake (may protect against hyperuricemia). • Report for persistent nausea, vomiting.

DRUG DOXORUBICIN (ADRIAMYCIN)

DOSAGE
Usual Dosage
IV: (Adriamycin): ADULTS: (Single agent Therapy): 60–75 mg/m2 as a single dose every 21 days, 20 mg/m2
once wkly. (Combination Therapy): 40–75 mg/m2 q21–28 days. Because of risk of cardiotoxicity, do not exceed
cumulative dose of 550 mg/m2 (400–450 mg/m2 for those previously treated with related compounds or irradiation
of cardiac region). CHILDREN: (Single-agent Therapy): 60–75 mg/m2 q3wks. (Combination Therapy): 40–75
mg/m2 q21–28 days.

THERAPEUTIC ACTION
Inhibits DNA, DNA-dependent RNA synthesis by binding with DNA strands. Liposomal encapsulation increases
uptake by tumors, prolongs drug action, may decrease toxicity. Therapeutic Effect: Prevents cell division.

ADVERSE EFFECTS
Myelosuppression manifested as hematologic toxicity (principally leukopenia and, to lesser extent, anemia,
thrombocytopenia) generally occurs within 10–15 days, returns to normal levels by third wk. Cardiotoxicity (either
acute, manifested as transient EKG abnormalities, or chronic, manifested as HF) may occur.

CONTRAINDICATION
Hypersensitivity to Doxorubicin. Adriamycin: Severe hepatic impairment, severe myocardial insufficiency, recent
MI (within 4–6 wks), severe arrhythmias. Previous or concomitant treatment with high accumulative doses of
Doxorubicin, DAUNOrubicin, Idarubicin, or other anthracyclines or anthracenediones; severe, persistent drug-
induced myelosuppression or baseline ANC count less than 1,500 cells/mm3. Doxil: Breastfeeding (Canada).
Cautions: Hepatic impairment. Cardiomyopathy, preexisting myelosuppression, severe HF. Pts who received
radiation therapy
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain ANC, CBC, erythrocyte counts before and at frequent intervals during therapy. Obtain EKG before therapy,
LFT before each dose. Antiemetics may be effective in preventing, treating nausea. Offer emotional support.
INTERVENTION/EVALUATION
Monitor for stomatitis (burning or erythema of oral mucosa at inner margin of lips, difficulty swallowing). Observe
IV injection site for infiltration, vein irritation. May lead to ulceration of mucous membranes within 2–3 days.
Assess dermal creases, nailbeds for hyperpigmentation. Monitor hematologic status, renal/ hepatic function studies,
serum uric acid levels. Monitor daily pattern of bowel activity, stool consistency. Monitor for hematologic toxicity
(fever, sore throat, signs of local infection, unusual bruising/bleeding from any site), symptoms of anemia
(excessive fatigue, weakness).
PATIENT/FAMILY TEACHING
• Hair loss is reversible, but new hair growth may have different color, texture. New hair growth resumes 2–3 mos
after last therapy dose. • Maintain strict oral hygiene. • Do not have immunizations without physician’s approval
(drug lowers resistance). • Avoid contact with those who have recently received live virus vaccine. • Promptly
report fever, sore throat, signs of local infection, unusual bruising/bleeding from any site. • Report persistent
nausea/vomiting. • Avoid alcohol (may cause GI irritation, a common side effect with liposomal Doxorubicin).
DRUG ERIBULIN
DOSAGE
Metastatic Breast Cancer, Liposarcoma
IV: ADULTS, ELDERLY: 1.4 mg/m2 over 2–5 min on days 1 and 8 of 21-day cycle.
Dosage in Renal Impairment
Mild: No dose adjustment. Moderate to severe impairment (CrCl 15–49 mL/min): 1.1 mg/m2/dose.
Dosage in Hepatic Impairment
Mild: 1.1 mg/m2/dose. Moderate impairment: 0.7 mg/m2/dose. Severe impairment: Use not recommended.
Recommended Dose Delays
Do not administer day 1 or day 8 of treatment for any of the following: ANC less
than 1,000 cells/mm3, platelets less than 75,000 cells/mm3, Grade 3 or 4 nonhematologic toxicities. Day 8 dose
may be delayed for maximum of 1 wk. If toxicities do not resolve or improve to Grade 2 severity by day 15, omit
dose. If toxicities resolve or improve to Grade 2 severity by day 15, continue treatment at reduced dose and
initiate next cycle no sooner than 2 wks later. Do not re-escalate dose after it has been reduced.

THERAPEUTIC ACTION
Binds directly on microtubules during active stage of G2 and M phases of cell cycle, preventing formation of
microtubules, an essential part of process of separation of chromosomes. Therapeutic Effect: Blocks cells in
mitotic phase of cell division, leading to cell death.

ADVERSE EFFECTS
Neutropenia occurs in 82% of pts, with 57% developing grade 3 neutropenia. Severe neutropenia (ANC less than
500 cells/mm3) lasting more than 1 wk occurred in 12%. Anemia occurs in 58% of pts. Peripheral neuropathy
occurs in 8% of pts but is the most common adverse reaction requiring discontinuation of therapy. Prolonged QTc
may be noted on or after day 8 of treatment.

CONTRAINDICATION
Hypersensitivity to denibulin. Cautions: Prolonged QTc (congenital, other medications that prolong QT interval),
hypokalemia, hypomagnesemia, hepatic/renal impairment, moderate to severe neuropathy, HF

NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Question for possibility of pregnancy. Obtain baseline CBC, serum chemistries before treatment begins. Obtain
CBC prior to each dose. Offer emotional support.
INTERVENTION/EVALUATION
Diligently monitor for neutropenia, peripheral neuropathy (most frequent cause of drug discontinuation). Monitor
for symptoms of neuropathy (burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic
pain). Assess hands, feet for erythema. Monitor CBC for evidence of neutropenia, thrombocytopenia. Assess
mouth for stomatitis (erythema, ulceration, mucosal burning).
PATIENT/FAMILY TEACHING
• Avoid crowds, those with known infection. • Avoid contact with anyone who recently received live virus
vaccine. • Do not have immunizations without physician’s approval (drug lowers body resistance). • Promptly
report fever over 100.5°F, chills, cough, burning or pain urinating, numbness, tingling, burning sensation,
erythema of hands/feet. • Women of reproductive potential should use effective contraception during and for 2
wks following last dose of eribulin; males with female partners of reproductive potential should use effective
contraception during and for 3.5 mos. following last dose of eribulin.
DRUG IDARUBICIN
DOSAGE
Acute Myelogenous Leukemia (AML)
Adult: IV 8–12 mg/m2 daily for 3 d injected slowly over 10–15 min
Acute Nonlymphocytic Leukemia, Acute Lymphocytic Leukemia
Child: IV 10–12 mg/m2/d for 3 d

THERAPEUTIC ACTION
Cytotoxic anthracycline antibiotic and derivative of daunorubicin. Potency of idarubicin is greater than that of
daunorubicin or doxorubicin. It may be less cardiotoxic than other anthracyclines. Idarubicin exhibits inhibitory
effects on DNA and RNA polymerase and, therefore, on nucleic acid synthesis. Intensive maintenance with
idarubicin is not recommended due to its considerable toxicity, including deaths while patient was in remission of
acute myelogenous leukemia (AML).

ADVERSE EFFECTS
CV: CHF, atrial fibrillation, chest pain, MI. GI: Nausea, vomiting, diarrhea, abdominal
pain, mucositis. Hematologic: Anemia, leukopenia, thrombocytopenia. Other: Nephrotoxicity,
hepatotoxicity, alopecia, rash.

CONTRAINDICATION
Myelosuppression, hypersensitivity to idarubicin or doxorubicin, pregnancy (category D), lactation.

NURSING CONSIDERATIONS
Assessment & Drug Effects
 Monitor infusion site closely, as extravasation can cause severe local tissue necrosis. Notify physician if
pain, erythema, or edema develops at insertion site.
 Lab tests: Monitor hepatic and renal function, CBC with differential and coagulation studies periodically.
 Monitor cardiac status closely, especially in older adult patients or those with preexisting cardiac disease.
 Monitor hematologic status carefully; during the period of myelosuppression, patients are at high risk for
bleeding and infection.
 Monitor for development of hyperuricemia secondary to lysis of leukemic cells.
Patient & Family Education
 Learn all potential adverse reactions to idarubicin.
 Anticipate possible hair loss.
 Discuss interventions to minimize nausea, vomiting, diarrhea, and stomatitis with health care providers.
 Do not breast feed while taking this drug.

DRUG VALRUBICIN
DOSAGE
BCG-Refractory Bladder Carcinoma in situ
Adult: Intravesically 800 mg once per wk x 6 wk.

THERAPEUTIC ACTION
Semisynthetic analog of doxorubicin. It is a cytotoxic antibiotic agent that inhibits the incorporation of
nucleosides in DNA and RNA, which results in extensive chromosomal damage. Valrubicin interferes with DNA
topoisomerase II, which is responsible for the normal DNA separation of strands and the resealing of DNA
strands.
ADVERSE EFFECTS
Body as a Whole:  Abdominal pain, asthenia, back pain, fever, headache, malaise,
myalgia. CNS: Dizziness. CV: Vasodilation. GI: Diarrhea, flatulence, nausea, vomiting. Urogenital: Urinary
frequency, urgency, dysuria, bladder spasm, hematuria, bladder pain, incontinence, cystitis, UTI, nocturia, local
burning, urethral pain, pelvic pain, gross hematuria, urinary
retention. Respiratory: Pneumonia. Skin: Rash. Other: Anemia, hyperglycemia, peripheral edema.

CONTRAINDICATION
Hypersensitivity to valrubicin, doxirubicin; patients with a perforated bladder, concurrent UTI, active infection;
severe irritable bladder symptoms; severe myelosuppression; pregnancy (category C); lactation

NURSING CONSIDERATIONS
Assessment & Drug Effects
 Therapeutic effectiveness: Indicated by regression of the bladder tumor.
 Notify physician if bladder spasms with spontaneous discharge of valrubicin occur during/shortly after
instillation.
Patient & Family Education
 Expect red-tinged urine during the first 24 h after administration.
 Report prolonged passage of red-colored urine or prolonged bladder irritation.
 Drink plenty of fluids during 48 h period following administration.
 Use reliable contraception during therapy period (approximately 6 wk).
 Do not breast feed infants during therapy period (approximately 6 wk).