Antineoplastic Drugs

In the 1940s, antineoplastic (chemotherapeutic) drugs were developed to

treat cancer.
Today, many of these drugs have lower toxicity levels so they aren’t as
devastating to the patient.

Alkalating drugs

- effectively act against various malignant neoplasms.

Category
1. Nitrogen Mustards
2. Alkyl sulfonates
3. Nitrosoureas
4. Triazenes
5. Ethylenimines
6. Alkylating-like drugs

Nitrogen Mustards
- represent the largest group of alkylating drugs. (Chlorambucil,
cyclophosphamide, estramustine, ifosfamide, mechlorethamine HCL[the first
nitrogen mustard introduced and is the most rapid acting], melphalan)
- Its absorption varies widely. Metabolized in the liver and excreted by the kidneys.
- Mechlorethamine has rapid metabolism after a few minutes no active drug
remains.
- They form covalent bond with DNA molecules in a chemical reaction known as
alkylation. Alkylated DNA cannot replicate properly, thereby resulting in cell
death. Resistance is also possible.
- Used to treat neoplasms, Hodgkins disease- cancer causing painless
enlargement of the lymph nodes, spleen, and lymphoid tissues) and leukemia
(cancer of the blood forming tissues) that is associated with elevated WBC count.
The drug causes Leukopenia (low WBC)
- Effective against malignant lymphoma (cancer of the lymphoid tissue), multiple
myeloma (cancer of the narrow plasma cells), melanoma (malignancy that arises
from melanocytes), and cancer of the breast, ovaries, uterus, lung, brain, testes,
bladder, prostate, and stomach.
- DI: Calcium-containing drugs (antacid, dairy products) reduce absorption of
estramustine.
- Cyclophosphamide can reduce digoxin levels.
- Corticosteroids reduce the effects of ifosfamide.
- AR: FATIGUE. Others: bone marrow suppression (severe luekopenia and
thrombocytopenia)
- N/V from CNS irritation
- Stomatitis
- Reversible hair loss
- Powerful local vesicants (blistering drugs), direct contact with these drugs or their
vapors can cause severe reactions, especially to the eyes, skin and respiratory
tract.
- Nsg. Dx: Ineffective health maintenance related to the presence of neoplastic
disease.
- Ineffective protection related to drug-induced hematologic adverse
reactions
- Interventions: follow established procedures for safe and proper handling,
administration, and disposal of chemotherapeutic drugs.
- Keep epinephrene, corticosteroids and antihistamines available
during
administration.
- Administer the medication as ordered and monitor for effects.
- Administer adequate hydration and monitor intake and output.
- Administer an antiemetic for N/V
- Follow facility policy for infection control in
immunocompromised patients whose WBC counts fall below
2,000/mm3 or granulocyte counts fall below 1000/mm3.

1
Alkyl Sulfonates
- historically been used to treat chronic myelogenous leukemia, polycythemia vera
(increased red blood cell and increase number of WBC and platelets, and other
myeloproliferative (pertaining to overactive bone marrow) disorders. Busulfan is
used at high doses to treat leukemia during bone marrow transplantation.
- Busulfan is absorbed rapidly and well from the GIT. Little is known about its
distribution. Metabolized extensively in the liver before urinary excretion. Its half-
life is 2 to 3 hours.
- Busulfan forms covalent bonds with the DNA molecules in alkylation.
- Primarily affects granulocytes (s type of WBC) and, to a lesser degree, platelets.
Because of its action on granulocytes, it has been used for treating chronic
myelogenous leukemia and in conditioning regimens for bone marrow
transplantation.
- Also used in the treatment of polycythemia vera. It can cause sever
myelosuppression (halting of bone marrow function)
- DI: If taken with anticoagulants / aspirin causes increased bleeding. Concurrent
use of Busulfan and thioguanine may cause liver toxicity, esophageal varices,
portal hypertention (increase pressure in the portal vein of the liver.
- AR: Major AR is bone marrow suppression, producing severe leukopenia, anemia,
and thrombocytopenia (reduced WBC, RBC, and platelets respectively which is
dose related and reversible. Pulmonary fibrosis may occur as late as 4 to 6
months after treatment. Seizures are also a concern (IV infusion – given with
phenytoin)
- Assessment: - Perform a complete assessment before therapy.
- Monitor WBC count and platelet counts weekly during therapy.
It will fall 10 days
after the start of therapy and continues to fall for 2 weeks after stopping the drug.
- Nsg. Dx: Ineffective health maintenance related to the presence of neoplastic
disease
Risk for infection related to drug-induced immunosuppression.
Interventions: follow established procedures for safe and proper handling,
administration, and disposal of chemotherapeutic drugs.
- Give drug same time each day/
- Treat extravasation promptly.
- Administer as ordered and monitor for effects.
- Hydrate and monitor I&O
- Dosage is adjusted based on weekly WBC counts and prescriber
may stop the drug if
severe leukopenia develops. Therapeutic effects are commonly accompanied by
toxicity.
- Usually given allopurinol to prevent hyperurecemia with resulting uric
acid
nephropathy.
- Can cause infant toxicity,
Nitrosoureas
- halt cancer cell reproduction (ex: carmustine, lomustine, streptozocine)
- Carmustine when given IV achieves a steady-state volume of distribution. Orally,
lomustine is absorbed adequately, although incompletely.
- Streptozocin given IV not orally (poor absorption)
- They are lipophilic drugs, and are distributed to fatty tissues and CSF. Theyre
metabolized extensively before urine excretion.
- During a process called bifunctional alkylation, they interfere with amino acid,
purines, and DNA needed for cancer cells to divide, thus halting their
reproduction.
- Used to treat brain tumors and meningeal leukemias (highly lipid fat soluble
crosses Blood Brain Barrier)
- DI: Cimetidine may increase carmustines bone marrow toxicity.
- Lomustine used with anticoagulants or aspirin increases the risk of
bleeding.
- Streptozocin can prolong the elimination half-life of doxorobicin,
prolonging leukopenia and thrombocytopenia.
- AD: severe N/V
- Carmustine and lomustine produce bone marrow suppression that
begins 4 to 6 weeks after treatment and last 1 to 2 weeks.
- Kidney Toxicity and Kidney failure.

2
 - High dose carmustine may produce reversible liver toxicity. It may
also cause lung toxicity characterized by lung infiltrates and scarring.
- Assessment: Obtain baseline pulmonary function tests before therapy. Be
sure to evaluate the results of liver, renal, and pulmonary function tests periodically
thereafter.
- Nsg Dx: Ineffective health maintenance related to the presence of neoplastic
disease.
Risk for injury related to drug-induced adverse reactions.
- Intervention: follow established procedures for safe and proper handling,
administration, and disposal of chemotherapeutic drugs.
Give antiemetic before giving the drug.
Administer the drug per facility policy for reconstitution, mixing,
storage, and admiistration. Monitor for effects.
Use carmustine only in glass containers. The solution is unstable in
plastic containers. Avoid contact with skin because it will cause brown discoloration.
If it happens wash it thoroughly.
Use double gloves when handling carmustine wafer in the operating
room.
Hydrate and monitor I&O
Allopurinol may be used to prevent hyperurecemia and uric acid
neuropathy.
May cause infant toxicity
Institute infection control and bleeding precautions.

Triazenes

- The triazenes, dacarbazine, functions as alkylating drug only after it has been
activated by the liver.
- After IV it is distributed throughout the body and metabolized throughout the
body and metabolized by the liver. Within 6 hours half is excreted unchanged the
other half is excreted os one of the metabolites.
- Its half-life may increase to 7 hours in pt. with kidney or liver dysfunction.
- Dacarbazine seems to inhibit RNA and protein synthesis. The drug is cell cycle-
nonspecific.
- For patients with malignant melanoma.
- No significant drug interactions.
- AR: leukopenia, thrombocytopenia, N/V (begins 1-3 hours and last for 12 hours),
phototoxicity, flulike syndrome, hair loss
- Nsg. Dx: Ineffective health maintenance related to the presence of neoplastic
disease.
Risk for injury related to drug induced adverse reaction.
- Nsg responsibilities: Administer antiemetic
Discard the drug if the solution turns pink – a sign of
decomposition
If the IV sites infiltrates, discontinue immediately and
apply ice to the area 24 – 28 hours and notify prescriber.
Advise patient to avoid sunlight and sun lamps for the
first 2 days after treatment.
Reassure patient that the flulike symptommmay be
treated with mild antipyretics (acetaminophen)

Ethylenimines

-Thiotepa, is a multifunctional alkylating drug.

- After IV, Thiopeta is 100% bioavailable. Significant systemic absorption may occur
when its administered into pleural or peritoneal spaces to treat malignant
effusions or instilled into bladder. It crosses the blood brain barrier and is
metabolized extensively in the liver. Excreted in the urine.

- Exerts it cytotoxic activity by interfering with DNA replication and RNA

transcription. It disrupts nucleic acid function and causes cell death.

- Used to treat bladder cancer. Palliative treatment for lymphomas and ovarian or
breast carcinomas.

3
- Used to treat intracavitary effusions. Also for Lung cancer.

- DI: Concurrent use of Thiopeta, anticoagulants, and aspirin may increase the risk
of bleeding. Concurrent use of Thiopeta and other alkylating agents and
radiotaion therapy may intensify toxicity. If taken with succinylcholine it will take
your breath away (prolonged respirations and apnea)

- AR: Leukopenia, anemia, thrombocytopenia, and pancytopenia (deficiency of all

cellular elements of the blood), N/V, stomatitis and ulceration of the intestinal
mucosa, hives, rash and pruritus.

- Nsg. Dx: Ineffective health maintenance related to the presence of neoplastic

disease.
Risk for injury related to drug induced adverse reaction.

- Nsg considerations: The drug may be given IV in doses of 0.3 to 0.4 mg/kg at
intervals of 1 to 4 weeks.
If pain occurs in the IV site use local anesthetic or dilute
the solution further.
Discard IV solution that appears grossly opaque or
contains
precipitate. The solution should be clear to slightly opaque.
Refrigerate and protect dry powder from direct sunlight.
Report a WBC count below 3,000/mm3 or a platelet count
3
below 150,000/mm and stop the drug.
Can be use with Allopurinol.
Can cause Infant toxicity.

Alkylating-Like Drugs

- Carboplatin, oxaplatin, and cisplatin are heavy metal complexes that contain
paltinum.
- Distribution and metabolism are not clearly defined. Eliminated primarily by the
kidneys.
- Highly protein bound, cisplatin reaches high concentrations in the kidneys, liver,
intestines, and testes, but has poor CNS penetration.
- They are cell cycle-nonspecific and inhibit DNA synthesis. They act by binding
functional alkylating drugs by cross-linking strands of DNA and inhibiting DNA
synthesis.
- Carboplatin – treat ovarian and lung cancer.
Cisplatin – bladder and metastatic ovarian and testicular cancers. Also for head,
neck, and lung cancer(unlabelled uses)
Oxaliptatin – used with other drugs in colorectal cancer.
- DI: Increase kidney toxicity when taken with aminoglycoside.
Cisplatin reduces serum phenytoin levels.
- AR: Carboplatin: produce bone marrow suppression
Longterm Cisplatin use may cause neurotoxicity (Tinnitus, hearing loss and
N/V).
- Nsg considerations: Don’t use needles or IV administration sets that contain
aluminum because it will displace platinum, causing a loss of potency and
formation of black precipitate.
Immediately give epinephrine, corticosteroids, or antihistamines
for anaphylactoid reactions.

Antimetabolite Drugs

- Because antimetabolite drugs structurally resemble DNA base pairs, they can
become involved in processess associated with DNA base pairs – that is, the
synthesis of nucleic acids and proteins. Antimetabolite differ significantly from the
DNA base pairs in how they interfere with this synthesis. Because the
antimetabolites are cell-cycle specific and primarily affect cells that actively
synthesize DNA, theyre referred to as S phase – specific. Normal cells that are
reproducing actively as well as the cancer cells are affected by the metabolites.
- Classification

4
 - Folic Acid Analogues (Methotrexate) acute lymphoblastic leukemia,
lymphocytic leukemia, CNS diseases, choriocarcinoma, osteogenic carcinoma
(bone cancer), malignant lymphomas, carcinomas of the head, neck, bladder,
testis, and breast.
- Pyramidine analogues (capecitabine, cytarabine, floxuridine,
fluorouracil,
gemcitabine) Acute leukemias, GIT adenocarcinomas, carcinomas of the breast and
ovaries and malignant lymphomas
- Purine Analogues – (cladribine, fludarabine phosphate,
mercaptopurine, pemtostatin, thioguanine.) acute and chronic luekemias and
maybe useful in the treatment of lymphomas.

Antimetabolite drug: Methotrexate

Actions:
- Prevents the reduction of folic acid to tetrahydrofolate by binding to dihydrofolate
reductase.
- Kills certain cancer cells and reduces inflammation

Indication:
- Trophoblastic Tumors (choriocarcinoma, H-mole)
- Acute lymphoblastic and lymphatic leukemia, meningeal leukemia
- Burkitts lymphoma (stage I or II)
- Lymphosarcoma (stage III)
- Osteaocarcinoma

Nursing Considerations
- Monitor for adverse reactions, such as stomatitis, diarrhea, intestinal perforation,
N/V, renal failure, anemia, leukopenia, thrombocytopenia, acute hepatic toxicity,
pulmonary fibrosis, urticaria, and sudden death.
- Assess the underlying neoplastic disease before therapy and reassess regularly
throughout therapy.
- Follow facility policy for reconstitution and administration.

Teaching about antimetabolite drugs

Use proper oral hygiene. Chemotherapy can cause the risk of microbial
infection, delayed healing and bleeding gums.
Be aware that you may bruise easily because of the effect of the drug on
platelets. Avoid close contact with persons who have taken oral poliovirus vaccine
and with bacterial or viral infection.
Report redness and swelling in the injection site.
If AR occur stop the drug and tell doctor.
If you miss a dose don’t take the missed dose and don’t double the next one.
Continue with your regular schedule and check with your prescriber.

Antibiotic antineoplastic Drugs

- are antimicrobial products that produce tumoricidal effects by binding with DNA.
These drug inhibit cellular process of normal and malignant cells.
- Ex: anthracyclines, bleomycin, dactinomycin, mitomycin, mitoxantrone.
- Considered 100% bioavailable. Given IV, no absorption occurs.
- Except mitomycin, antibiotic antineoplastic drugs intercalate, or insert
themselves, between adjacent base pairs of a DNA molecule, physically
separating them. Causing cell death.
- Mitomycin is activated inside the cell to a bifunctional or trifunctional alkylating
drug. It produces single strand breakage of DNA, cross-links DNA, and inhibits
DNA synthesis.
- For treatment of: Hodgkins disease and malignant lymphomas, testicular
carcinoma, squamous cell carcinoma of the head, neck, and cervix, Wilms tumor
(a malignant neoplasm of the kidney, occurring in young children) Osteogenic
sarcoma and rhabdomyosarcoma (malignant neoplasm composed of striated
muscle cells), Ewings sarcoma (a malignant tumor that originates in the bone
marrow, typically in long bones or the pelvis) and other soft-tissue sarcomas,

5
 breast, ovarian, bladder, and lung cancer, melanoma, carcinomas of GIT,
choriocarcinoma and acute leukemia.
- DI: Concurrent therapy with fludarabine and idarubicin isnt recommended
because of the risk of fatal lung toxicity. Bleomycin may decrease serum digoxin
and serum phenytoin levels. Doxorubicin may reduce serum digoxin levels.
- AR: Bone Marrow Suppression, irreversible cardiomyopathy and acute ECG
changes, N/V.
- An antihistamine and antipyretic should be given before bleomycin to prevent
fever and chills. Doxorubicin may color urine red, mitoxantrone may color it blue
green.
- Nsg Dx: Ineffective health maintenance related to the presence of neoplastic
disease.
Risk for infection related to immunosuppression.
- Nsg. Responsibilities: Try to ease anxiety in the patient and his family before
treatment.
Keep epinephrine, corticosteroids, and antihistamines
available during therapy. Anaphylactoid reacttions may occur.

Hormonal antineoplastic drugs and hormone modulators

- prescribed to alter the growth of malignant neoplasms or to manage and treat

their physiologic effects.
- Classification: Aromatase inhibitors, Antiestrogens, Androgens, Antiandrogens,
progestins, gonadotropin-releasing hormone analouges.
- Proved effective against hormone-dependent tumors, such as cancers of the
prostate and endometrium.

Aromatase Inhibitors

- prevent androgen from being converted into estrogen in postmenopausal women.

This blocks estrogens ability to activate cancer cells by limiting the amount of
estrogen reaching the cancer cells to promote growth.
- Type 1 – Steroidal inhibitors or Type 2 – nonsteroidal inhibitors.
- Taken orally in pill form and are well tolerated by most woemn. Inactive
metabolites are excreted in urine.
- Works by lowering the production of the female hormone estrogen.
- Indicated for postmenopausal women with metastatic breast cancer.
- DI: Tamoxifen and estrogen containing drugs reduce the effectiveness of
anastrazole.
- AR: RARE. Dizziness, mild nausea, mild muscle and joint aches, and ho flashes.
- Nursing Responsibilities: Don’t give the drug with estrogen-containing
drugs because
doing so could interfere with the drugs intended action.
Administer the drug after meals.

Antiestrogens

-bind to estrogen receptors and block estrogen action. Ex: Tamoxifen Citrate and
Toremifene citrate(NON STEROIDAL ESTROGEN), and fulvestrant. (PURE ESTROGEN
ANTAGONIST)

- After oral administration tamoxifen is absorbed well and undergoes extensive

metabolism in the liver before being excreted in feces.
- Pharmacodynamics is UNKNOWN. They act as estrogen antagonist. They bind to
estrogen receptor and inhibit estrogen mediated tumor growth in breast tissue.
- Tamoxifen is used as adjuvant treatment with radiation therapy and surgery in
women with negative axillary lymph nodes and in postmenopausal women. Used
to reduce the incidence of breast cancer in women at high risk.
- DI: No Known. Tamoxifen and Toremifene may increase the effects of warfarin Na,
increase PT and increase risk of bleeding. Bromocriptine increases the effects of
tamoxifen.
- AR: tamoxifen: relatively nontoxic drug, hot flashes, N/V, diarrhea, fluid
retention, leukopenia or thrombocytopenia, hypercalcemia.
- Toremifene: hot flashes, sweating, N/V, vaginal discharge or bleeding,
edema.

6
 Fulvestrant: hot flashes, N/V, diarrhea or constipation, abdominal pain,
H/A, back pain, pharyngitis.

Intervention: Make sure that the patient swallows enteric-coated tablets whole.
Monitor for AR and DI

Androgens

- Derivatives of naturally occuring testosterone.

- Example: Fluoxymesterone, testolactone, testosterone enanthate, testosterone
propionate.
- Oral androgens (Fluoxymesterone, testolactone) are absorbed well. The
parenteral ones (testosterone enanthate, testosterone propionate) are designed
for slow absorption after IM injection.
- They may reduce the number of prolactin receptors or may bind competitively to
those that are available.
- For palliative treatment of advanced breast cancer in postmenopausal women
with bone metastasis.
- DI: Alters dose requirement in patients taking insulin, OHA, or oral anticoagulants.
- AR: N/V, most common. Females: Acne, clitoral hypertrophy, deeper voice,
increased facial and body hair, increased sexual desire, menstrual irregularity.
Male: Gynecomastia, prostatic hypertrophy, testicular atrophy.
Children: premature epiphyseal closure, secondary sex characteristics.
Nsg consideration: Encourage to drink fluids to aid calcium excretion
Encourage to exercise to prevent hypercalcemia.
Inform patient that therapeutic response may not be
immediate, it may take up to 3 months for the benefit to be noted.

Antiandrogens

- Used as an adjunct with gonadotropin releasing hormone analogues in treating

advance prostate cancer.
- Example: Flutamide, nilutamide, bicalutamide.
- Orally, they are absorbed rapidly. Metabolized rapidly and extensively and
excreted primarily in the urine.
- Flutamide, nilutamide. And bicalutamide exert their antiandrogenic action by
inhibiting androgen uptake or preventing androgen binding in cell nuclei intarget
tisseus.
- DI: Doesn’t significantly interact.
- AR: hot flashes, decreased sexual desire, impotence, diarrhea, N/V, breast
enlargement.
- Nsg Dx: Ineffective health maintenance related to the presence of prostate
cancer.
Risk for fluid volume deficit related to GI reactions.
- Nsg considerations: Drug may be given without regard to meals.
Monitor the patient for adverse effects and DI.

Progestines

- are hormones used to treat various forms of cancer: hydroxyprogesterone

caproate, medroxyprogesterone acetate, megestrol acetate
- Orally megestrol acetate is absorbed well. After IM injection in an aqueous or oil
suspension, hydroxyprogesterone caproate and medroxyprogesterone are
absorbed slowly from their deposit sites.
- Mechanism of action is unknown. Researchers believed that the drugs bind to a
specific receptor to act on hormonally sensitive cells. They are not cytotoxic but
cytostatic.
- Palliative treatment of advance endometrial, breast, and renal cancers. Megestrol
is used most often.
- DI: Megestrol have no DI. Barbiturates, carbamazepine, and rifampin reduce the
progestin effects of hydroxyprogesterone.
Dose adjustments in oral anticoagulants may be needed when theyre taken
with hydroxyprogesterone.
- AR: Mild fluid retention is probably the most common reaction to progestins.
Others: Thromboemboli, breakthrough bleeding, spotting and changes in

7
 menstrual flow, breast tenderness, liver function abnormalities. Hypersensitivity
to oil carriers.
- Nsg Consideration: Rotate injection sites to prevent muscle atrophy. Warn patient
that IM injection maybe painful.
Instruct the patient to avoid caffeine and smoking during drug
therapy.
Teach a female patient how to perform routine monthly breast
self-examinations.

Gonadotropin-releasing hormone analougues

- Goserilin Acetate
- Lueprolide Acetate
- Triptorelin Pamoate

- Goserelin is absorbed slowly for the first 8 days of therapy and rapidly and
continously thereafter. Lueprolide administered SC is absorbed well. The
distribution isnt clearly understood.

- Goserilin and leuprolide act on the males pituitary gland to increase LH

secretions, which stimulates testosrone production. The peak testosterone level is
reached about 72 hours after daily administration. After long-term continuous
administration, LH and FSH secretion steadily declines and testicular and ovarien
steridogenesis decreases.

- Goserelin, triptorelin and leuprolide are used for the palliative treatment of
metastatic prostate cancer. These drugs lower the testosterone level without the
adverese psychological effects of castration or the adverse cardiovascular effects
of diethylstilbestrol.

- DI: No KNOWN

- AR: Hot flashes, impotence and decreased sexual desire are commonly reported
reactions to geserelin and leuprolide. Others: peripheral edema, N/V, constipation
and anorexia.

- Nsg DX: Ineffective health maintenance related to underlying condition

Acute pain related to drug-induced adverse reactions.

- Intervention: Drug should be given under supervision of the prescriber.

To avoid the need for a new syringe and injection site, don’t
aspirate after inserting the needle.
Implant comes in a preloaded syringe for goserelin. If the
package is damaged, don’t use the syringe. Make sure that the drug is visible in the
transluscent chamber.
After implantation, withdraw the needle and apply bandage to
the area?
Be prepared to schedule the patient for an ultrasound to locate
goserilin implants if they require removal.
Notify the prescriber of adverse reactions and provide
supportive care, as indicated and ordered.
Advise the patient to report every 28 days for a new implant. A
delay of a few day is permissible.
Tell the patient to call her prescriber if menstruation persist or if
breakthrough bleeding occurs. Menstruation should stop during treatment. After
therapy ends, inform the patient that she may experience delayed return of menses.
Persistenmt amenorrhea is rare.
If the patient is to continue SC injection of leuprolide at home,
instruct him on proper techinique and advise him to use only syringes provided by
the manufacturer.