Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (143 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
(dox-oh-roo′bi-sin)
Doxil, Lipodex
Func. class.:
Antineoplastic, antibiotic
Chem. class.:
Anthracycline glycoside
Do not confuse:
DOXOrubicin
/DOXOrubicin liposomal/DAUNOrubicin
Inhibits DNA synthesis primarily; replication is decreased by binding to DNA, which causes strand splitting; active throughout entire cell cycle; a vesicant
AIDS-related Kaposi’s sarcoma, multiple myeloma, metastatic ovarian carcinoma
Pregnancy (D), breastfeeding, hypersensitivity, systemic infections, cardiac disorders
Black Box Warning:
Cardiotoxicity, infusion reactions, myelosuppression, hepatic disease
Precautions:
Children, infection, leukopenia, stomatitis, thrombo-cytopenia
Calculator
Max lifetime cumulative dose 550 mg/m
2
; 400 mg/m
2
for those that have received other cardiotoxics or mediastinal radiation
•
Adult: IV
20 mg/m
2
every 3 wk
•
Adult: IV
30 mg/m
2
IV infusion on day 4 every 3 wk plus bortezomib 1.3 mg/m
2
/dose IV bolus on days 1, 4, 8, 11 of each cycle; give DOXOrubicin liposomal after bortezomib receipt on day 4. Administer up to 8 treatment cycles or until disease progression or unacceptable toxicity occurs
•
Adult: IV
50 mg/m
2
every 4 wk. Continue treatment for as long as the patient shows benefit and does not progress. A minimum of 4 courses is recommended
Available forms:
Liposomal dispersion for inj: 2 mg/ml
•
Prepared liposomal DOXOrubicin is a translucent, red liposomal dispersion. Visually inspect for particulate matter and discoloration before use
•
Pegylated liposomal DOXOrubicin (Doxil) is for IV INF use only and should not be given IM/subcut, give under the supervision of a physician who is experienced in cancer chemotherapy
Black Box Warning:
Care should be taken to avoid extravasation because the drug is irritating to extravascular tissue
•
Premedication with antiemetics is recommended
•
Reconstitution (Doxil):
Dilute the appropriate dose, not to exceed 90 mg/250 ml D
5
W. Do not mix with any other diluent, drugs, or bacteriostatic agent, use aseptic technique; product contains no preservative or bacteriostatic agent; diluted solution must be refrigerated and used within 24 hr
•
IV INF (Doxil):
Do not administer as a bolus injection or an undiluted solution. Rapid injection can increase the risk of an infusion-related reaction
Black Box Warning:
Care should be taken to avoid extravasation because the drug is irritating to extravascular tissue
•
An acute infusion reaction can occur during the first infusion and is usually resolved by slowing the rate of infusion. Most patients can tolerate subsequent infusions
•
Rate:
Infuse at an initial rate of 1 mg/min. If no infusion-related action, the rate can be increased to complete the infusion over 1 hr; do not filter
•
For hematologic toxicity in patients with ovarian cancer or HIV-related Kaposi’s sarcoma: Grade 1 (ANC of 1500-1900/mm
3
, platelets ≥75,000/mm
3
):
No dose reduction.
Grade 2 (ANC of 1000-1499/mm
3
, platelets ≥50,000/mm
3
and < 75,000/mm
3
:
Wait until ANC ≥1500 cells/mm
3
and platelets ≥75,000 cells/mm
3
; redose with no dose reduction.
Grade 3 (ANC of 500-999/mm
3
, platelets ≥25,000/mm
3
and <50,000/mm
3
):
Wait until ANC ≥1500 cells/mm
3
and platelets ≥75,000 cells/mm
3
; redose with no dose reduction.
Grade 4 (ANC <500/mm
3
, platelets <25,000/mm
3
):
Wait until ANC ≥1500 cells/mm
3
and platelets ≥75,000 cells/mm
3
; reduce dose by 25% or continue with full dose with colony-stimulating factor
•
Give antiemetic 30-60 min before product to prevent vomiting
•
Use allopurinol or sodium bicarbonate to maintain uric acid levels, alkalinization of urine
•
Avoid mixing with other products
CNS:
Paresthesias, headache, depression, insomnia, fatigue, fever
CV:
Chest pain, decreased B/P,
cardiomyopathy, heart failure, dysrhythmias, tachycardia
EENT:
Optic neuritis, rhinitis, pharyngitis, stomatitis
GI:
Nausea, vomiting
, anorexia,
mucositis
,
hepatotoxicity, constipation, oral candidiasis, abdominal pain
HEMA:
Thrombocytopenia, leukopenia, anemia, neutropenia
INTEG:
Rash
,
necrosis at inj site,
dermatitis, reversible
alopecia
,
exfoliative dermatitis, palmar-plantar erythrodysesthesia,
thrombophlebitis at inj site
RESP:
Dyspnea, cough, respiratory infections
Half-life 55 hr; metabolized by liver; crosses placenta; excreted in urine, bile, breast milk
Increase:
life-threatening dysrhythmias—posaconazole, fluconazole, do not use together
Increase:
QT prolongation—other drugs that increase QT prolongation
Increase:
neutropenia, thrombocytopenia—progesterone
Increase:
cardiomyopathy—calcium-channel blockers
Increase:
toxicity—other antineoplastics, cycloSPORINE, radiation, mercaptopurine
Increase:
hemorrhagic cystitis risk, cardiac toxicity—cyclophosphamide
Increase:
effect of—phenytoin, fosphenytoin
Increase:
DOXOrubicin effect—streptozocin
Decrease:
DOXOrubicin effect—PHENobarbital
Decrease:
antibody response—live virus vaccine
Decrease:
antineoplastic effect—hematopoietic progenitor cell; do not use 24 hr before or after treatment
Decrease:
clearance of DOXOrubicin—PACLitaxel
Increase:
uric acid
Black Box Warning:
Bone marrow depression:
CBC, differential, platelet count weekly; withhold product if WBC is <4000/mm
3
or platelet count is <75,000/mm
3
; notify prescriber of these results
•
Renal studies: BUN, serum uric acid, urine CCr, electrolytes before, during therapy
•
I&O ratio: report fall in urine output to <30 ml/hr
•
Monitor temp; fever can indicate beginning infection
Black Box Warning:
Hepatotoxicity:
Hepatic studies before, during therapy: bilirubin, AST, ALT, alk phos as needed or monthly; check for jaundice of skin and sclera, dark urine, clay-colored stools, itchy skin, abdominal pain, fever, diarrhea
Black Box Warning:
Dysrhythmias:
ECG: watch for ST-T wave changes, low QRS and T, possible dysrhythmias (sinus tachycardia, heart block, PVCs), ejection fraction before treatment, signs of irreversible cardiomyopathy, can occur up to 6 mo after treatment begins
•
Bleeding: hematuria, guaiac, bruising, petechiae of mucosa or orifices every 8 hr
•
Effects of alopecia on body image; discuss feelings about body changes; almost total alopecia is expected
•
Inflammation of mucosa, breaks in skin
•
Buccal cavity every 8 hr for dryness, sores, ulceration, white patches, oral pain, bleeding, dysphagia
•
Alkalosis if severe vomiting is present
Black Box Warning:
Extravasation:
Local irritation, pain, burning at inj site; a vesicant; if extravasation occurs, stop drug, restart at another site, apply ice, elevate extremity to reduce swelling; if resolution does not occur, surgical debridement may be required
•
GI symptoms: frequency of stools, cramping
•
Liquid diet: carbonated beverages, gelatin may be added if patient is not nauseated or vomiting
•
Increased fluid intake to 2-3 L/day to prevent urate, calculi formation
•
Rinsing of mouth tid-qid with water, club soda; brushing of teeth bid-tid with soft brush or cotton-tipped applicators for stomatitis; use unwaxed dental floss
•
Store refrigerated for 24 hr after reconstituting
•
Therapeutic response: decreased tumor size, spread of malignancy
•
To add 2-3 L of fluids unless contraindicated before and for 24-48 hr after to decrease possible
hemorrhagic cystitis
•
To report any complaints, side effects to nurse or prescriber
•
That hair may be lost during treatment; that wig or hairpiece might make patient feel better; that new hair may be different in color, texture
•
To avoid foods with citric acid, hot or rough texture
•
To report any bleeding, white spots, ulcerations in mouth to prescriber; to examine mouth daily
•
That urine, other body fluids may be red-orange for 48 hr
•
To avoid crowds and persons with infections when granulocyte count is low
•
That barrier contraceptive measures are recommended during therapy and for 4 mo after (pregnancy [D]); to avoid breastfeeding
•
To avoid vaccinations because reactions can occur; to avoid alcohol
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert