Drugs for Cancer Patients

Mona Shrestha
MN (Adult Nursing)
 Cell cycle
Cell cycle can be divided into:
G0: This may be a temporary resting
period or more permanent. An
example of the latter is a cell that has
reached an end stage of development
and will no longer divide (e.g.
neuron).
G1: Cells increase in size in G0,
produce enzymes needed for DNA
synthesis
S Phase: To produce two similar
daughter cells, the complete DNA
instructions in the cell must be Mitosis or M Phase: Cell growth
duplicated. DNA replication occurs and protein production stop at
during this S (synthesis) phase. this stage in the cell cycle. All
Gap 2 (G2): It is the gap between DNA of the cell's energy is focused
synthesis and mitosis, the cell will on the complex and orderly
continue to grow and produce new
proteins & RNA. division into two similar
daughter cells.
 Cell cycle specificity of Anti-Neoplastic Agents

Vincristine, G0 = resting phase

Vinblastine G1 = pre-replicative phase
Cyclophosphamide Paclitaxel, Docetaxel G2 = post-replicative phase
Bleomycin S = DNA synthesis
Actinomycin D M = mitosis or cell division

M G0
resting

G2 G1 Hydrocortisone

Purine antagonists Actinomycin D

Methotrexate 5-Fluorouracil
Cyclophosphamide Cytosine arabinoside
5-Fluorouracil Methotrexate
Cytosine arabinoside 6-Mercaptopurine 14
Daunomycin 6-Thioguanine
 Cancer chemotherapeutic agents
They are classified into:
• Cell-cycle non specific agents(CCNS): are cytotoxic in any
phase of the cycle even on G0 phase and so are more effective
against large slowly growing tumors. E.g. Bleomycin.

• Cell-cycle specific (CCS): are cytotoxic on all phases but not on

cells out of the cycle(at G0 ) and so are more effective against
rapidly growing tumors. Work better in combination than alone
E.G. Mitomycin, doxorubicin,….etc.

• Phase specific: act on specific phase of the cycle

E.g. Vinca alkaloids act more in M-phase
,antimetabolites
(mainly act on S-phase.)
 Classification of Chemotherapy Drugs
• Alkylating agents: Cisplatin, Carboplatin, Cyclophosphamide
• Antimetabolites: Methotrexate, 5-Fluorouracil, Gemcitabine
• Anti-tumor antibiotics: Doxorubicin, Bleomycin, Mitomycin
C
• Vinca- alkaloids (Plant alkaloids): Vincristine, Viblastine,
Etoposide
• Miscellaneous: Interferon, Mesna, Calcium Folinate
• Hormonal: Dexamethasone, Tamoxifen and Prednisolone
• Targeted therapy: Imatinib, Sunitib, Bevacizumab
Commonly Used Chemotherapy Agents

A. Alkylating agents
– Cell cycle non-specific
– Mechanism of action: interferes with RNA
transcription and DNA replication.
– Myelosuppression tend to be intermediate. Nadir
between 1 to 3 weeks, and recovery between 3
to 6 weeks.
Name and Route of Indications Adverse Effects Special
Medication * Usual liniting Considerstions
toxicities
a. Cyclophosphamid -Leukemias -Nausea and - If facial
e - Lymphoma vomiting discomfort , nasal
Cytoxan - Breast -Anorexia stuffiness and pain
Route: IV, PO cancer - Alopecia with rapid infusion
- Ovarian - SIADH syndrome occurs, slow down
cancer - Pulmonary the infusion rate.
- Many solid fibrosis - Ensure patient has
tumors - Infertility adequate
- Cardiac toxicity hydration and
- Hyperpigmentati empty their
on( when used bladder frequently.
with - Assess for
radiotherapy) hemorrhagic
cystitis incase of
*Myelosuppression pelvic irradiation.
-Hemorrhagic - Mesna required for
cystitis high dose
(>1gm/m2) to
protect from
cystitis.
Name and Route Indications Adverse Effects Special Considerations
of Drug * Usual limiting
toxicities
b. Ifosfamide -Cancer of testis • Hemorrhagic • Always administer
Ifos/ Ipamide -Cervix cancer cystitis Mesna with
Route: IV -Sarcoma • Myelosuppression Ifosfamide (IV) to
• Nausea and reduce the
vomiting incidence of
• Anorexia hemorrhagic cystitis.
• Alopecia • Ensure that the
• Nephrotoxicity patient has
• Lethargy adequate hydration.
• Confusion • Urine dispstick for
• Seizures blood is required.
• Keep urine output
more than> 150
ml/hr.
 Alkylating –like agents
Name and Indications Adverse Effects Special Considerations
Route of Drug * Usual limiting
toxicities
c. Cisplatin - Testicular • Nephrotoxicity - Assess for extravasation: it
Chemoplat cancer and can be due to irritants.
Route: IV, - Gynaecological myelosuppression - Always monitor creatinine ,
intraperitoneal cancer • Anorexia magnesium and electrolytes
- Head and neck • Tinnitus level prior to administering
cancer • Ototoxicity the drug.
- Lung cancer • Nausea and - Ensure rigorous hydration
- Bladder cancer vomiting and administer mannitol for
• Peripheral cisplatin, dose greater than
neuropathy 50mg/m2.
• Hyperuricemia - Notify physician if creatinine
• Hypokalemia level is elevated.
• Hypomagnesia - Keep urine output
• Hypocalcemia >150ml/hr and advise to
• Infertility drink plenty to keep high
urine output at least for a
week.
- Provide good prophylaxis for
highly emotogenic.
Name and Route of Indications Adverse Effects Special
Drug * Usual limiting Considerations
toxicities
d. Dacarbazine - Malignant *Myelosuppression • Assess for
Route: IV melanoma • Severe nausea and extravasation
- Sarcoma vomiting hazard.
- Hodgkins • Anorexia • Increase
disease • Alopecia dilution, reduce
• Metallic taste infusion rate and
• Local irritation apply cold
• Facial paresthesias compress to IV
• Flu-like syndrome site.
(can last upto 7 days • Protect solution
post-treatment) from light.
• Hypotension • Warn patient to
• Photosensitivity avoid exposure
to sun especially
right after
treatment.
 B. Antimetabolites
• Cell cycle specific
• Inhibit enzyme production necessary for DNA
synthesis to strand break.
• A purine nucleoside antimetabolite that inhibits DNA
repair.
• Disrupt folate dependent metabolic processes essential
for cell replication.
• Cause hypomethylaration of DNA causing cell death,
and cytotoxic effect on the normal hematopoetic cells
in bone marrow.
Name and Route Indications Adverse Effects Special Considerations
of Drug * Usual limiting
toxicities
a. Methotrexate -Lymphoma *Myelosuppression, • Administer
Route: IV, PO, IT, -Sarcoma stomatitis prophylactic
IM - Breast cancer • Nausea and antibiotics for most
- Leukemia vomiting of the
- Head and neck • Diarrhea myelosuppressive
cancer • Dermatitis agents.
- Prophylaxis for • Photosensitivity • Tell patient that
graft vs host • Renal/ hepatic urine appears bright
disease dysfunction yellow to greenish.
• CNS toxicity with • Ensure vigorous
high doses hydration and
administer
Leucovorin at
scheduled intervals.
• Advise patient to
take vitamins that
contain folic acid in
it.
• Teach patient and
family members
about importance of
mouth cares and
precaution of
photosensitivity.
Name and Indications Adverse Effects Special Considerations
Route of * Usual limiting
Drug toxicities
b. Cytarabine - Acute *Myelosuppression • Assess for localized
Cytosar, leukemia • Nausea and thrombophlebitis and pain at
Arac-C - Lymphoma vomiting IV site.
Route: IV, IM, • Anorexia • For IT 15-80mg, dilute with
IT, SC • Stomatitis RL.
• Malaise • Administer hydrocortisone
• Fever eye drops to treat
• Rash photophobia.
• Pruritis • Perform neurological
• Hepatic assessment prior to
dysfunction administration of high dose
• Hyperuricemia Arac-C.
• Conjunctivitis • Administer Allopurinol and
• Photophobia ensure rigorous hydration for
• CNS toxicity newly diagnosed AML.
• Diarrhea • Check for cerebellar ataxia
• Keratitis before and after Cytarabine
adminstration.
Name and Indications Adverse Effects Special Considerations
Route of Drug * Usual limiting
toxicities
c. Fluorouracil - Breast * Myelosuppression • Assess for darkening of
5-FU cancer • Stomatitis the vein if given
Route: IV, - GI , • Diarrhea peripherally.
topical esophageal • Nail changes • Encourage patient to
cancer • Dermatitis suck an ice chips,
- Head/ neck • Rash before, during and post
cancer • Hyperpigmentation 5- FU bolus to reduce
• Photosensitivity stomatitis.
• Hand-foot • Monitor area around IV
syndrome with site closely for skin
continuous infusion irritation, rash, skin
• Alopecia breakdown when
• Eye irritation patient is on
• Excessive continuous 5FU
lacrimation infusion.
• Manage constipation
as it is common in long-
term admitted
patients.
 C. Anti-tumor Antibiotics
• Cell- cycle non-specific phase.
• Binds with DNA.
• Inhibits RNA and DNA synthesis.
Name and Indications Adverse Effects Special Considerations
Route of Drug * Usual limiting
toxicities
a. Doxorubicin - Lymphomas *Myelosuppression • Assess for
Adrim - Breast Cancer and cardiotoxicity extravasation hazard:
Route: IV - Lung Cancer • Nausea and vesicant- flare reaction
- Sarcoma vomiting during chemo
- Myeloma • Alopecia administration.
- Solid tumors • Stomatitis • Instruct the patient and
• Diarrhea family members that
• Radiation recall urine may turn pinkish
reaction or reddish in color for
• Transient ECG 24-48hours post
abnormalities chemo.
(arrythmias) • Perform
during injection. echocardiography to
rule out cardiac
abnormalities.
Name and Indications Adverse Effects Special Considerations
Route of * Usual limiting
Drug toxicities
b. - Acute leukemia *Myelosuppression • Assess for extravasation
Mitroxantron - Non-Hodgkin and cardiotoxicity hazard.
e Lymphoma • Nausea and • Tell the patient and
Route: IV - Breast cancer vomiting family members that
- Prostate cancer • Alopecia urine may turn greenish
• Stomatitis in color for 24-48 hours
post chemo.
Name and Indications Adverse Effects Special Considerations
Route of Drug * Usual limiting
toxicities
c. Bleomycin - Lymphoma *Pulmonary toxicity • Administer with caution
Route: IV - Head/ neck • Skin toxicity for 1st bleomycin dose.
cancer • Stomatitis • Educate patient the
- Testicular • Ridging of nails importance of informing
cancer • Fever and chills anaesthesiologist prior
to surgery about the
bleomycin.
• Perform PFT prior to
initial treatment and at
regular intervals after
that.
• Take extreme caution
while handling these
drugs.
• Counsel the patient as
there is significant risk of
infertility.
 D. Plant Alkaloid
• Cell- cycle specific phase.
• Act in late G2 blocking DNA production and M-
phase preventing cell division.
Name and Route of Indications Adverse Effects Special
Drug * Usual limiting Considerations
toxicities
a. Vinblastine - Lymphoma *Myelosuppression • Assess for
- Testicular cancer • Nausea and extravasation
vomiting hazard.
• Alopecia • Monitor for
• Constipation possible side-
• Photosensitivity effects.
• Don’t administer
intrathecally as it
it is fatal.
Name and Indications Adverse Effects Special
Route of Drug * Usual limiting Considerations
toxicities
b. Vincristine - Lymphoma *Neurotoxicity • Assess for
VCR, Oncovin - Acute • Constipation extravasation
Route: IV Lymphoblastic • Paralytic ileus hazard.
Leukemia • Ataxia • Notify physician
- Sarcoma • Nausea prior severe
- Lung cancer • Vomiting paresthesia,
- Multiple • Myelosuppression motor weakness
myeloma • Alopecia or other
• Photosensitivity abnormality.
• Never administer
more than 2.8gm
per dose.
• Reinforce bowel
movement.
Name and Indications Adverse Effects Special Considerations
Route of * Usual limiting
Drug toxicities
c. - Breast cancer *Myelosuppression • Assess for extravasation
Vinorelbine - Lung cancer • Peripheral hazard.
neuropathy • Ensure adequate
flushing (75 to 125ml
NS) before and after its
administration.
• Ensure patient takes
adequate rest.
• Elevate and provide
warm compression to
the affected arm after
its administration.
• Instruct the patient to
seek medicine attention
immediately if severe
pain exists in chemo
site.
Name and Indications Adverse Effects Special Considerations
Route of Drug * Usual limiting
toxicities
d. Topotecan • Ovarian cancer *Myelosuppression • Myelosuppression can
Route: IV • Nausea be severe and
• Vomiting protracted, may need
• Fever G-CSF (Granulocyte
• Fatigue colony stimulating
• Flu-like factors) and higher
symptoms antibiotics.
• Headache • Counsel and prepare
• Alopecia the patient for it.
Name and Route of Indications Adverse Effects Special
Drug * Usual limiting Considerations
toxicities
e. Etoposide • Lung cancer *Myelosuppression • Monitor for
Etosid, Vepesid, VP- • Testicular cancer • Nausea possible
16 • Acute leukemia • Vomiting hypersensitivity
Route: IV, PO • Lymphoma • Fever reaction during
• Alopecia infusion.
• Bronchospasm • Monitor blood
• Orthostatic pressure pre and
hypotension post-treatment
• Mucositis
• Anorexia
 E. Miscellaneous
Name and route of Indications Adverse Effect Special
medication *Usual limiting toxicities Considerations
a. Asparaginase ALL *Allergic reactions • High risk for
Route: IM, IV The Anorexia, nausea, anaphylaxis
usual asparaginase vomiting, fever , reaction during
is derived from E- pancreatitis, neurologic treatment
coli. It inhibits lethargy, malaise,
protein. headache, confusion, • Treat each dose
hepatic dysfunction as one that
causing abnormal blood cause serious
chemistry. reaction
(hypoalbuminemia,
hyperglycemia, altered • Stop if patient
blood clotting factors), develops
hyperuricemia jaundice/
abdomial pain
and rule out
pancreatitis
Name and IndicationAdverse Effect Special Considerations
route of s * Usual limiting
medication toxicities
b. -Chronic *Myelosuppression Acts in S-phase as
Hydroxyurea Myeloid Nausea, rash, facial antimetabolite
Hydrea Leukemia erythema, nail
Route:PO - Acute changes, Contraindicated for those with
Lymphobla hyperpigmentation, hypersensitivity to ARA-C, 5FU
stic renal and hepatic
Leukemia dysfunction, Instruct patient on strict mouth
hyperuricemia care

Dose is usually adjusted

according to the blood counts.
However frequent dose changes
can result in delayed response.
Name and Indications Adverse Effect Special Considerations
route of * Usual limiting
medication toxicities

c.Tretinoine Acute Retinoid acid Advise patient to reduce

ATRA (All Trans promyelocytic
Retinoic Acid) leukemia
syndrome sun exposure, and to take
(fever, respiratory sun protective measure.
distress, hypotension,
hyperleucocytosis Monitor for sign and
leading to multiple symptoms of retinoid acid
organ failure) syndrome.
headache, fever,
malaise, rash, nausea, On first appearance of its
vomiting s/s, patient is usually given
high dose Dexamethasone
(10mg IV BD for 3 days)
 Nurses Responsibilities
Prior to administration
• Patient assessment, confirm allergies, and evaluate any preexisting symptoms.
• Verify signed consent for treatment was obtained and signed by provider and
patient.
• Monitor laboratory values and verify laboratory values within acceptable
range for dosing.
• Take measures to prevent medication errors.

– Perform independent double-check of original orders with a second chemotherapy-

certified RN.
– Double check for accuracy of treatment regimen, chemotherapy agent, dose,
calculations of body surface area, schedule, and route of administration.
• Recalculate chemotherapy doses independently for accuracy.
• Verify appropriate pre-medication and pre-hydration orders.
• Ensure patient education completed and address outstanding patient questions.
Administration
• Dual nurse verification and sign off at the bedside:
– Compare original order to dispensed drug label at the bedside with another
chemotherapy-certified RN and verify patient identity.
• Safe handling of hazardous medications; reduce exposure to self and
others.
• Intravenous line management: insertion, evaluation, and assessment.
– Check patency of IV site for brisk blood return immediately prior to
connecting hazardous agent to the patient and as indicated during infusion.
– Continuous monitoring for infiltration, phlebitis, extravasation, or infection.
• Continuous patient monitoring for acute/adverse drug effects and
allergic reactions.
• Prompt recognition and management of hypersensitivity reactions.
• Safe handling and management of chemotherapy spills.
After administration
• Flush IV line, ensure brisk blood return prior to removing
peripheral IV device, flush/maintain vascular access device
according to institution policy.
• Safe handling and disposal of hazardous waste according to
institution policy.
• Document in medical record the medications given, patient
education, and patient response, including any adverse events.
• Ensure patient has appropriate discharge instructions, anti-
nausea medications, and education, and emergency contact
information of physician’s office in event of emergency
 Steroids
• Steroids are naturally made by our bodies in small amounts.
They help to control many functions including the immune
system, reducing inflammation and blood pressure.
• The type of steroids you might have as part of your cancer
treatment are usually a type called corticosteroids. These are
man-made versions of the hormones produced by the adrenal
glands just above the kidneys.
• Steroids used in cancer treatment include:
– Beclomethasone
– prednisolone
– methylprednisolone
– dexamethasone
– hydrocortisone
 Mechanism of Action
• Steroids are divided into glucocorticoids and
mieralocorticoids.
• Glucocorticoids decrease inflammation by the
suppression of migration of polymorphonuclear
leukocytes, fibroblastic, increased capillary
permeability and lysosomal stabilization. They have
varied metabolic effects and modify the body’s
immune responses to many stimuli.
• Mineralocorticoids act by increasing resorption of
Sodium by increasing hydrogen and potassium
excretion in the distal tubule.
Indications
• Larger doses are required for anti inflammatory,
immunosuppressive or anti neoplastic activity.
– when the cancer is first diagnosed
– before and after surgery
– before and after radiotherapy
– before, during and after chemotherapy treatment
– for an advanced cancer
• Used in replacement doses systematically to
treat adreno-cortical insufficiency.
• Inhalant corticosteroids are used in the chronic management
of reversible airway disease
• Intranasal and opthalmic corticosteroids are used in the
management of chronic allergy and inflammatory conditions.
• Adrenal insufficiency
Forms and Routes
• The most common ways of taking steroids during cancer
treatment are as:
– tablets or liquid (take them after a meal or with milk as they can
irritate stomach)
– intravenous
 Side-effects
• Increased risk of infection
• Mood changes
• Changes in blood sugar levels
• Increased appetite and weight gain
• Ascites
• Insomnia
• Indigestion or heartburn
• Cushing's syndrome
• Hypertension
• Eye problems: cataract, glaucoma, eye infections
• problems with your vision, such as blurred vision
due to increased pressure on the eyesight nerve
• Skin changes might include: rashes, skin thinning,
bruising, wounds might take longer to heal than
usual.
• Osteoporosis
• Dizziness and loss of balance (vertigo)
• Leukocytosis
• Hair changes
• Heart problems: Steroids can cause severe heart problems if you
have had a recent heart attack.
• Muscle wasting
• Allergic reaction
• Headaches
• Growth problems in children
• Steroids might cause growth problems in babies, children and
teenagers
• Hypokalemia
 Contraindications
• History of hypersensitivity reaction to steroids
• Active systemic fungal infections or
amoebiasis
 Nurses Responsibilities
Assessment
• History: Infections; renal or liver disease,
hypothyroidism, ulcerative colitis with impending
perforation, diverticulitis, active or latent peptic ulcer,
inflammatory bowel disease, CHF, hypertension,
thromboembolic disorders, osteoporosis, seizure
disorders, diabetes mellitus; hepatic disease; lactation
• Physical: Weight, temperature, reflexes and grip strength,
affect and orientation, pulse, BP, peripheral perfusion,
prominence of superficial veins, respiratory rate,
adventitious sounds, serum electrolytes, blood glucose
level.
Nursing Diagnosis (problem identification)
• Disturbed body image
• Deficient knowledge
• Risk for infection
Interventions
• Administer once-a-day doses in the morning before 9AM
to mimic normal peak corticosteroid blood levels.
• If medicine is taken per oral, administer with the body’s
normal secretion of cortisol.
• Increase dosage when patient is subject to stress.
• WARNING: Taper doses when discontinuing high-dose
or long-term therapy to avoid adrenal insufficiency.
• Do not give live virus vaccines with immunosuppressive
doses of corticosteroids.
Patient/Family teaching
• Emphasize need to take medicine exactly as directed.
Do not stop taking the drug without consulting health
care provider; take once-daily doses at about 9 AM.
• Encourage patients on long-term therapy to eat a diet
high in protein, calcium, and potassium, low in
sodium and carbohydrates.
• Instruct to avoid exposure to infections.
• Advise the patient to avoid exposure to avoid people
with known contagious illnesses.
• Instruct them to report unusual weight gain, swelling of the
extremities, muscle weakness, black or tarry stools, fever,
prolonged sore throat, colds or other infections, worsening
of the disorder for which the drug is being taken.
• Advise patient to consult health care professional before
receiving any vaccinations.
• Discuss possible side-effects on body image.
• Explore patient’s coping mechanisms.
• Advise patient to carry identification in the event of an
emergency in which patient can’t replace medical history.
 Anti-emetics
• Anti-emetics are divided into 5-HT3 antagonists, promethazine
and miscellaneous.
• Most commonly used drugs are Promethazine, Ondansetron,
Metoclopramide, Prochlorperazine, etc.
• Serotonin Antagonists: Ondansetron, Granisetron, and
Palonosetron are highly selective 5-HT3 receptor antagonists. .
Mechanism of Action
Selective serotonin receptor (5-HT3) antagonists block serotonin
both peripherally, on gastrointestinal (GI) vagal nerve terminals,
and centrally in the chemoreceptor trigger zone. This results in
powerful antiemetic effects.
• Promethazine act by blocking the chemoreceptor trigger zone in
the brain..
• Miscellaneous products work by either decreasing motion
sickness or delaying gastric emptying. Eg:Corticosteroids such as
dexamethasone are potent anti-emetics and are used in
combination with other agents. Lorazepam and other
benzodiazepines are potent anxiolytic agents that can be useful
additions to antiemetic therapy. They should not be used as
single agents for chemotherapy-induced emesis.
• The anxiolytic properties of benzodiazepines may be particularly
useful in the treatment of anticipatory nausea and vomiting.
 Indications
• Used to prevent nausea and vomiting due to
chemotherapy, radiotherapy and surgery (5-
HT3 antagonists).
• Used to relieve motion sickness
 Side effects
• Headache
• Dizziness
• Fatigue
• mild transient elevation of hepatic enzyme levels
• constipation
• with some agents, prolongation of cardiac
conduction intervals (particularly QT intervals).
• Dystonic reactions and akathisia (restlessness),
 Contraindications
• Hypersensitivity to anti-emetics.
 Nursing Considerations
Assessment
• Assess nausea, vomiting, bowel sounds,
abdominal pain before and after
administration.
• Monitor hydration status and intake and
output.
Nursing diagnosis
• Deficient fluid volume
• Imbalanced nutritional status; less than body
requirement
• Deficient knowledge
• Risk for injury
Implementation
• Always commence antiemetics before chemotherapy.
• Give oral doses at least 30 minutes before chemotherapy is initiated.
• Antiemetics are best given regularly; not prn and ensure courses are completed.
• Optimal emetic control in the acute phase is essential to prevent nausea and
vomiting in the delayed phase
• Dexamethasone should be given prophylactically where indicated, and not as a
treatment for emesis.
• Dexamethasone should be given no later than 2pm to minimise wakefulness in the
night.
• Consider initiating domperidone on the evening of chemotherapy
• For prophylactic administration, follow directions for specific drugs so that peak
effect corresponds to time of anticipated nausea.
• Discontinue Phenothiazine 48 hours before and don’t resume for 24 hours
following myelography, as they lower seizure threshold.
Patient/Family Teaching
• Advise patient and family to use general measures to
decrease nausea (begins with sips of liquid and small,
non-greasy meals, provide oral hygiene and remove
noxious stimuli from environment.
• Advise patient to call for assistance when ambulating
and to avoid driving or other activities requiring
alertness until response to medication is known.
• Advise patient to make position changes slowly to
minimize orthostatic hypotension.
 Analgesics/ NSAIDS
• Most commonly used drugs are Diclofenac,
Ibuprofen, Indomethacin, Ketorolac, Ketoprofen, etc.
Mechanism of Action
• NSAIDs have analgesic, antipyretic and anti-
inflammatory properties.
• Analgesic and anti-inflammatory effects are due to
inhibition of prostaglandin synthesis.
• Antipyretic action is due to vasodilation and
inhibition of prostaglandin synthesis in the CNS.
 Indications
• Mild to moderate pain
• Fever
• Various inflammatory conditions
 Side- effects
The most common side effects are:
• Nausea
• Anorexia
• Drowsiness
• Abdominal pain
• Dizziness
The most common adverse reactions are:
• Nephrotoxicity
• Blood dyscrasias
• Hepatitis
 Contraindications
• Patients with hypersensitivity, asthma, severe
renal/hepatic disease should not use these products.
 Nursing Considerations
• Assess patients who have asthma, allergies and nasal
polyps for possible hypersensitivity reaction as they are
at an increased risk for developing hypersensitivity
reaction.
• Assess pain and limitation of movement; note type,
location and intensity prior to and following
administration.
• Assess fever and note associated signs (diaphoresis ,
tachycardia, malaise, chills).
• Monitor renal, hepatic, blood studies; BUN, creatinine,
AST, ALT before treatment, and periodically thereafter.
Nursing Diagnosis
• Acute pain
• Hyperthermia
• Deficient knowledge
Implementation
• Take history regarding hypersensitivity reaction to drugs.
• Administer NSAIDs after meals or with food or an antacid to minimize
gastric irritation.
Patient/Family Teaching
• Instruct patient to take NSAIDs with a full glass of water and to remain
in an upright position for 15-30 min after administration.
• Caution patient to avoid concurrent use of alcohol with this medication
to minimize possible gastric irritation; 3 or more glasses of alcohol per
day may increase the risk of GI bleeding with salicylates or NSAIDs.
• Advise patient on long term therapy to inform health care professional
of medication regimen prior to surgery.
 Laxatives
• Laxatives are drugs that change faecal consistency,
speed the passage of faeces through the colon and
aid in the elimination of stool from the rectum.
• They are used mainly to treat constipation and to
prepare the bowel before surgery or investigative
procedures.
• They may also be used in bowel training for
patients who have lost neurogenic control of the
bowel.
Laxatives are further divided into:
a. Bulk forming laxatives
Mechanism of Action
These work by absorbing water and expanding to increase
moisture content and bulk in the stool. Examples include:
– Methylcellulose: Route: PO
– Psyllium: Route: PO
b. Stimulant laxatives
• These act by increasing peristalsis by direct effect on the
intestine. Examples include:
– Bisacodyl: Route: PO, PR, Forms: Tablets, suppositories
– Senna: PO
c. Surfactant laxative (stool softener)
• These reduce surface tension of liquids of the bowel.
• Examples include:
– docusate sodium:Route: PO, Forms: tablets/capsules
– Docusate calcium: Route: PO, Forms: syrup, capsules
d. Osmotic laxatives
• These increase distension and promote peristalsis.
• Examples include:
– lactulose syrup: PO
– Sorbitol: PO, PR
– magnesium salts (Epsom salts, Cream of magnesia)
– phosphate enemas
– sodium citrate
e. Lubricants: These coat the stool with slippery
lipids and retard colonic absorption of water so
that the stool slides through the colon more
easily.
Lubricant laxatives also increase the weight of
stool and decrease intestinal transit time. Eg:
mineral oil
 Side effects
• All types of laxatives can cause abdominal cramps, which may be
accompanied by nausea and vomiting.
• Allergic reactions, including pruritis, urticaria and rhinitis
• Fluid and electrolyte disturbances may occur with hyperosmolar
laxatives.
• Bulk-forming laxatives can cause abdominal obstruction or
impaction if they are taken without adequate fluids.
• Long-term use of lubricant laxatives may impair absorption of
nutrients and fat-soluble vitamins (A, D, E, K).
• Stimulant laxatives may produce muscle weakness and, if used
excessively, could cause irritable bowel syndrome. Prolonged
diarrhoea may lead to hyponatraemia (low concentrations of
sodium in the blood), hypokalaemia and dehydration.
 Contraindications
• Person with GI obstruction, perforation,
gastric retention.
• Toxic colitis
• Megacolon
• Abdominal pain
• Nausea, vomiting or fecal impaction
 Nursing Considerations
Assessment
• Assess patient for abdominal distension, presence of
bowel sounds, and usual pattern of bowel function.
• Assess color, consistency, and amount of stool
produced.
Nursing Diagnosis
• Constipation
• Deficient knowledge
Implementation
• Many laxatives may be administered at bed time for better results.
• Taking oral doses on an empty stomach will usually produce more
rapid results.
• Don’t crush or chew enteric-coated tablets. Take with a full glass
of water or juice.
• Stool softeners and bulk laxatives may take several days for
results. Laxatives should be seen as a short-term solution to
constipation.
• As a general rule, laxative should be started when an opioid is
first started.
• They are available over the counter and subject to overuse,
which can disrupt the body’s natural emptying rhythm.
• Abuse may lead to hypokalaemia and an atonic non-
functioning colon.
• Patients with chronic renal insufficiency should avoid
osmotic laxatives containing magnesium or potassium.
• Laxatives containing sodium are contraindicated in
pregnancy and in patients with cardiac conditions.
• Bulk-forming laxatives with a high sugar content are
contraindicated in patients with diabetes mellitus.
 Patient/ Family Teaching
• Advise patients, other than those with spinal cord injuries, that
laxatives should be only used for short term therapy.
• Advise patient to increase fluid intake to a minimum of 1500-
2000ml/day during therapy to prevent dehydration.
• Encourage patients to use other forms of bowel regulation;
increasing bulk in the diet, increasing fluid intake, and
increasing mobility.
• Instruct patients with cardiac disease to avoid straining during
bowel movements.
• Advise patient that laxatives should not be used when
constipation is accompanied by abdominal pain, fever, nausea
or vomiting.
 Others
i. Hormonal therapy: Progestin, estrogen,
androgen
ii. Biologic Response Modifiers: Interferon
iii. Anti-angiogenesis agents: Imatinib, Sunitib
iv. Monoclonal Antibodies: Trastuzumab,
Alemtuzumab
i. Hormonal therapy
Mechanism of Action
It works to add, block or remove hormones from the body to
slow or stop the growth of cancer cells. It is used to fight against
various forms of cancer alongside to combat side effects.
Indications
• Breast cancer
• Ovarian cancer
• Prostate cancer
• Kidney cancer
ii. Biologic response modifiers:
Mechanism of Action
Some biologic therapies for cancer use vaccines
or bacteria to stimulate the body’s immune
system to act against cancer cells.
Indications
• Treat cancer itself
• Treat side effects of other cancer treatment
iii. Anti- angiogenesis agents:
MOA
• These drugs bind to receptors on the surface of
endothelial cells or to other proteins in the
downstream signaling pathways, blocking their
activities.
iv. Monoclonal Antibodies
MOA
• These specifically target a certain antigen, such
as one found on cancer cells.
• Different types of monoclonal antibodies are
used in cancer treatment.
– Naked monoclonal antibodies
– Conjugated monoclonal antibodies
– Bispecific monoclonal antibodies
 Assessment
• Monitor for thromboembolic disease.
• Monitor for abnormal uterine bleeding.
• Monitor breast health and assess for vision
changes.
• Monitor blood glucose levels.
 Implementation
• Encourage patient not to smoke.
• Encourage patient to avoid caffeine.
• Monitor for seizure activity.
• Manage fatigue and depression.
• Encourage self care and participation in
decision making.
Patient/Family Teaching
• Report shortness of breath, feeling of heaviness, chest
pain, severe headache, warmth or swelling in affected part.
• Instruct patient to have regular breast examination.
• Take daily dose of hormones in the evening to decrease
occurrence of side effects.
• Incase of patients on immunotherapy, minimize symptoms
by managing fever and flu like symptoms: increase fluid
intake, take analgesic and anti pyretic medication and
maintain bed rest until symptom subside.