Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (82 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
HIGH ALERTcarmustine (Rx)
(kar-mus′teen)
BiCNU, Gliadel
Func. class.:
Antineoplastic alkylating agent
Chem. class.:
Nitrosourea
Alkylates DNA, RNA; able to inhibit enzymes that allow for the synthesis of amino acids in proteins; activity is not cell-cycle–phase specific
Brain tumors such as glioblastoma, medulloblastoma, brain stem glioma, astrocytoma, ependymoma, metastatic brain tumors; multiple myeloma (with predniSONE), non-Hodgkin’s disease, Hodgkin’s disease, other lymphomas; GI, breast, bronchogenic, renal carcinomas; wafer, as adjunct to surgery/radiation for patients newly diagnosed with high-grade malignant glioma
Unlabeled uses:
Ablation, mycosis fungoides, stem cell transplant preparation
Pregnancy (D), breastfeeding, hypersensitivity, leukopenia, thrombocytopenia
Precautions:
Dental disease, extravasation, females, infection, leukopenia, neutropenia, secondary malignancy, thrombocytopenia
Black Box Warning:
Bone marrow suppression, pulmonary fibrosis
Calculator
• Adult:
IV
75-100 mg/m
2
over 1-2 hr × 2 days or 150-200 mg/m
2
× 1 dose q6-8wk or 40 mg/m
2
/day × 5 days q6wk or 150-200 mg/m
2
q6wk;
INTRACAVITARY
up to 8 wafers inserted into resection cavity
• Child (unlabeled):
IV
200-250 mg/m
2
as a single dose q4-6wks
• Adult:
IV
450-600 mg/m
2
as a single dose or 2 divided doses q12hr at a rate of no more than 3 mg/m
2
/min
Available forms:
Powder for inj 100 mg; wafer 7.7 mg (intracavitary)
•
Storage of reconstituted sol in refrigerator for 24 hr or at room temp for 8 hr; protect from light
•
Blood transfusions, RBC colony-stimulating factors to counter anemia
•
Antiemetic, serotonin antagonists, dexamethasone, nausea, vomiting can begin 2 hr after a dose and last ≤6 hr and may be severe
•
All medications PO, if possible; avoid IM inj if platelets are <100,000/mm
3
Black Box Warning:
Carmustine should not be given until platelets >100,000/mm
3
and WBC >4000/mm
2
•
If wafers are broken into several pieces, they should not be used
•
Foil pouches may be kept at room temp for 6 hr if unopened
•
Use cytotoxic handling procedures; do not use if an oil film appears on vial (decomposition)
•
Do not use with PVC IV tubing, do not admix
•
After
diluting
100 mg product/3 ml ethyl alcohol (provided),
further dilute
with 27 ml sterile water for inj;
then dilute
with 100-500 ml 0.9% NaCl or D
5
W,
give
over 1 hr or more, reduce rate if discomfort is felt; use only glass containers, protect from light
•
Flush
IV line after carmustine with 10 ml 0.9% NaCl to prevent irritation at site
Y-site compatibilities:
Amifostine, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, aztreonam, bivalirudin, bleomycin, caspofungin, cefepime, codeine, DAPTOmycin, dexmedetomidine, DOCEtaxel, ertapenem, etoposide, fenoldopam, filgrastim, fludarabine, gemcitabine, granisetron, levofloxacin, melphalan, meperidine, mitoXANtrone, nesiritide, octreotide, ondansetron, PACLitaxel, palonosetron, pamidronate, pantoprazole, PEMEtrexed, piperacillin-tazobactam, riTUXimab, sargramostim, sodium acetate, tacrolimus, teniposide, thiotepa, tigecycline, tirofiban, trastuzumab, vinCRIStine, vinorelbine, voriconazole
GI:
Nausea, vomiting, anorexia, stomatitis
,
hepatotoxicity
GU:
Azotemia
,
renal failure
HEMA:
Thrombocytopenia, leukopenia, myelosuppression, anemia
INTEG:
Pain, burning, hyperpigmentation at inj site, alopecia
RESP:
Fibrosis, pulmonary infiltrate
SYST:
Secondary malignant neoplastic disease
Degraded within 15 min; crosses blood-brain barrier; 70% excreted in urine within 96 hr; 10% excreted as CO
2
, fate of 20% is unknown
Increase:
bleeding risk—aspirin, anticoagulants
Increase:
myelosuppression—myelosuppressive agents
Increase:
toxicity: other antineoplastics, radiation, cimetidine
Increase:
adverse reactions, decreased antibody reaction—live vaccines
Decrease:
effects of digoxin, phenytoins
Increase:
bilirubin, prolactin, uric acid, LFTs
Decrease:
platelets, WBC, neutrophils, HCT
Black Box Warning:
Bone marrow suppression:
CBC, differential, platelet count weekly; withhold product if WBC is <4000 or platelet count is <100,000; notify prescriber of results
•
Hepatic studies: AST, ALT, bilirubin, monitor regularly, hepatotoxicity occurs rarely
Black Box Warning:
Pulmonary fibrosis/infiltrate:
pulmonary function tests, chest x-ray films before, during therapy; chest film should be obtained q2wk during treatment; monitor for dyspnea, cough, pulmonary fibrosis; infiltrate occurs after high doses or several low-dose courses (>1400 mg/m
2
cumulative dose), may occur months or years after treatment
Black Box Warning:
Only to be used by an experienced clinician in use of cancer, immune suppression
•
Renal studies: BUN, serum uric acid, urine CCr before, during therapy; I&O ratio; report fall in urine output of 30 ml/hr, may use allopurinol for hyperuricemia with increased fluids
•
Monitor for cold, cough, fever (may indicate beginning infection)
•
Bleeding:
hematuria, guaiac, bruising, petechiae, mucosa, orifices q8hr
•
Rinsing of mouth tid-qid with water or club soda; use of sponge brush for stomatitis
•
Warm compresses at inj site for inflammation; reduce flow rate if patient complains of burning at inf site
•
Therapeutic response: decreasing size of tumor, spread of malignancy
Black Box Warning:
To report any changes in breathing or coughing, to avoid smoking
•
To avoid foods with citric acid, hot or rough texture if stomatitis is present; to report any bleeding, white spots, ulceration in mouth to prescriber; to examine mouth daily
•
To avoid aspirin, ibuprofen, razors, commercial mouthwash
•
To report signs of anemia (fatigue, irritability, shortness of breath, faintness); to report signs of infection (sore throat, fever); pulmonary toxicity can occur up to 15 yr after treatment
•
To use contraception during treatment; to avoid breastfeeding, pregnancy (D)
•
Not to receive live vaccines during treatment
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(kar′tee-oh-lol)
Func. class.:
Antiglaucoma
Chem. class.:
Beta-blocker
May decrease aqueous humor and increase outflows
Treatment of chronic open-angle glaucoma and ocular hypertension
Hypersensitivity, AV block, heart failure, bradycardia, sick sinus syndrome
Precautions:
Abrupt discontinuation, children, pregnancy, breastfeeding, COPD, depression, diabetes mellitus, myasthenia gravis, hyperthyroidism, pulmonary disease, angle-closure glaucoma
Calculator
• Adult:
Instill 1 drop in the affected eye(s) bid.
Available forms:
Ophthalmic solution 1%
•
For ophthalmic use only. Shake the ophthalmic suspension well before use
•
Do not touch the tip of the dropper to the eye, fingertips, or other surface to prevent contamination
•
Wash hands before and after use. Tilt head back slightly and pull the lower eyelid down with the index finger to form a pouch. Squeeze the prescribed number of drops into the pouch. Close eyes to spread drops. To avoid excessive systemic absorption, apply finger pressure on the lacrimal sac for 1-2 min after use
•
If more than one topical ophthalmic drug product is being used, the drugs should be administered at least 5 min apart
•
To avoid contamination or the spread of infection, do not use dropper for more than one person, do not touch the eyelids or surrounding areas with the dropper tip of the bottle
•
Decreased intraocular pressure can take several weeks, monitor IOP after a month
CNS:
Insomnia, headache, dizziness
CV:
Palpitations
EENT:
Eye stinging/burning, tearing, photophobia
Onset 30 min, peak 2 hr, duration ≥12 hr
Increase:
beta blocking effect—oral beta blockers
Increased:
intraocular pressure reduction—topical miotics, dipivefrin, EPINEPHrine, carbonic anhydrase inhibitors, this may be beneficial
Increase:
B/P, severe—when abruptly stopping cloNIDine
Increase:
depression of AV nodal conduction, bradycardia, or hypotension—adenosine, cardiac glycosides, disopyramide, other antiarrhythmics, class 1C antiarrhythmic drugs (flecainide, propafenone, moricizine, encainide, quiNIDine or drugs that significantly depress AV nodal conduction)
Increase:
AV block nodal conduction, induce AV block—high doses of procainamide
Increase:
antihypertensive effect—other antihypertensives
•
Systemic absorption:
When used in the eye, systemic absorption is common with the same adverse reactions and interactions
•
Glaucoma: Monitor intraocular pressure
•
Decreasing intraocular pressure
•
For ophthalmic use only. Shake the ophthalmic suspension well before use
•
Not to touch the tip of the dropper to the eye, fingertips, or other surface to prevent contamination
•
Wash hands before and after use. Tilt the head back slightly and pull the lower eyelid down with the index finger to form a pouch. Squeeze the prescribed number of drops into the pouch. Close eyes to spread drops. To avoid excessive systemic absorption, apply finger pressure on the lacrimal sac for 1-2 min following use
•
If more than one topical ophthalmic drug product is being used, the drugs should be administered at least 5 min apart
•
To avoid contamination or the spread of infection, do not use dropper for more than one person, do not touch the eyelids or surrounding areas with the dropper tip of the bottle