Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (153 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
HIGH ALERTepirubicin (Rx)
(ep-ih-roo′bi-sin)
Ellence, Pharmorubicin
Func. class.:
Antineoplastic, antibiotic
Chem. class.:
Anthracycline
Do not confuse:
DOXOrubicin
DAUNOrubicin, eribulin, IDArubicin
epirubicin
/eribulin
Inhibits DNA synthesis primarily; replication is decreased by binding to DNA, which causes strand splitting; maximum cytotoxic effects at S and for G
2
phases; a vesicant
Adjuvant therapy for breast cancer with axillary node involvement after resection
Unlabeled uses:
Used in combination for treatment of advanced forms of cancer: bladder, gastric, head and neck, hepatocellular, lung, ovarian, multiple myeloma, soft-tissue sarcoma
Pregnancy (D), breastfeeding, hypersensitivity to product, anthracyclines, anthracenediones, baseline neutrophil count <1500 cell/mm
3
, severe myocardial insufficiency, recent MI
Black Box Warning:
Severe hepatic disease, IM/SUBCUT use
Precautions:
Children, geriatric patients, cardiac/renal/hepatic disease, accidental exposure, angina, dental disease, herpes, hyperkalemia, hyperphosphatemia, hypertension, hyperuricemia, hypocalcemia, infection, infertility, tumor lysis syndrome, ventricular dysfunction, previous anthracycline use
Black Box Warning:
Bone marrow depression (severe), heart failure, extravasation, secondary malignancy, requires an experienced clinician
Calculator
• Adult:
IV
100 mg/m
2
on day 1 with fluorouracil and cyclophosphamide (FEC regimen) every 21 days × 6 cycles or 60 mg/m
2
on days 1 and 8 with oral cyclophosphamide and fluorouracil every 28 days × 6 cycles.
• Adult:
IV
60 mg/m
2
day 1 with cyclophosphamide (500 mg/m
2
IV day 1), repeated every 21 days × 8 cycles or a higher-dose regimen of epirubicin 100 mg/m
2
IV day 1 with cyclophosphamide (830 mg/m
2
IV day 1), every 21 days × 8 cycles
• Nadir platelet counts <50,000/mm
3
, absolute neutrophil counts (anc) <250/mm
3
, neutropenic fever, or grades 3/4 non-hematologic toxicities:
Day 1 dose in subsequent cycles should be reduced by 25% of the previous dose
• For patients receiving divided-dose epirubicin (i.e., day 1 and 8):
Day 8 dose should be reduced by 25% of the day 1 dose if the platelet counts are 75,000–100,000/mm
3
and the ANC is 1000–1499/mm
3
; if day 8 platelet counts are <75,000/mm
3
, ANC <1000/mm
3
, or Grade 3/4 non-hematologic toxicity has occurred, omit the day 8 dose
• Adult:
IV
Bilirubin 1.2-3 mg/dl or AST 2-4× normal upper limit, 50% of starting dose; bilirubin >3-5 mg/dl or AST >4 × normal upper limit, 25% of starting dose
Available forms:
Inj (2 mg/ml) 10 mg/5 ml, 50 mg/25 ml, 150 mg/75 ml, 200 mg/100 ml
•
Antiemetic 30-60 min before product to prevent vomiting
•
Allopurinol or sodium bicarbonate to maintain uric acid levels, alkalinization of urine, monitor electrolytes
Black Box Warning:
To be used by a clinician experienced in giving cytotoxic products
Black Box Warning:
Do not use IM/SUBCUT because of severe tissue necrosis
•
Give IV, do not give IM, subcut; a vesicant; if extravasation occurs stop and complete via another vein, preferably in another limb; avoid infusion into veins over joints or in extremities with compromised venous or lymphatic drainage
•
Rapid injection can cause facial flushing or erythema along the vein; avoid administration time of <3 min
•
Product should be given to those with neutrophils ≥1500/mm
3
, platelet count ≥100,000/mm
3
, and non-hematologic toxicities recovered to ≤grade 1
•
When refrigerated, the preservative-free, ready-to-use solution can form a gelled product and will return to solution after 2–4 hr at room temperature
•
Visually inspect for particulate matter and discoloration before use
•
Use cytotoxic handling procedures; pregnant women must not handle product
•
Reconstitute 50 mg and 200 mg powder for injection vials with 25 ml and 100 ml, respectively, of Sterile Water for Injection (2 mg/ml), shake vigorously for up to 4 min; reconstituted sols are stable for 24 hr when stored refrigerated and protected from light or at room temperature in normal light
•
Solution can be further diluted with Sterile Water for Injection
•
Give doses of 100–120 mg/m
2
into tubing of a freely flowing 0.9% sodium chloride (NS) or D
5
W IV inf over 15–20 min; the infusion time may be decreased, proportionally, in those who require lower doses; infusion times <3 min are not recommended
•
Direct injection into the vein is not recommended because of the risk of extravasation; avoid use with any solution of alkaline pH because hydrolysis will occur
•
Dilute dose in 0.9% sodium chloride (NS) or D
5
W, infuse over 30–60 min, avoid use with any solution of alkaline pH because hydrolysis will occur
Y-site compatibilities:
Alemtuzumab, alfentanil, amifostine, amikacin, aminocaproic acid, anidulafungin, atracurium, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride/gluconate, CARBOplatin, caspofungin, ceFAZolin, cefotaxime, ceftizoxime, chlorproMAZINE, cimetidine, ciprofloxacin, cisatracurium, CISplatin, clindamycin, cyclophosphamide, cycloSPORINE, DAPTOmycin, dexrazoxane, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, dolasetron, DOPamine, doxacurium, doxycycline, droperidol, enalaprilat, ePHEDrine, EPINEPHrine, ertapenem, erythromycin, etoposide, famotidine, fenoldopam, fentaNYL, fluconazole, gatifloxacin, gemcitabine, gentamicin, granisetron, haloperidol, hydrocortisone, HYDROmorphone, hydrOXYzine, ifosfamide, imipenem-cilastatin, inamrinone, insulin (regular), isoproterenol, labetalol, levofloxacin, levorphanol, lidocaine, linezolid, LORazepam, mannitol,
meperidine, mesna, methotrexate, metoclopramide, metoprolol, metroNIDAZOLE, midazolam, milrinone, minocycline, mitoMYcin, mivacurium, morphine, nalbuphine, naloxone, nesiritide, niCARdipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ofloxacin, ondansetron, oxaliplatin, PACLitaxel, palonosetron, pamidronate, pancuronium, pentamidine, pentazocine, phenylephrine, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, quinupristin-dalfopristin, ranitidine, remifentanil, rocuronium, sodium acetate, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tirofiban, tobramycin, trimethobenzamide, vancomycin, vasopressin, vecuronium, verapamil, vinBLAStine, vinCRIStine, vinorelbine, voriconazole, zidovudine, zoledronic acid
CV:
Increased B/P,
sinus tachycardia, PVCs,
chest pain,
bradycardia, extrasystoles,
cardiomyopathy
GI:
Nausea, vomiting, anorexia, mucositis, diarrhea
GU:
Amenorrhea, hot flashes, hyperuricemia
HEMA:
Thrombocytopenia, leukopenia, anemia, neutropenia, secondary AML
INTEG:
Rash
,
necrosis,
pain at inj site, reversible alopecia
MISC:
Infection, febrile neutropenia, lethargy, fever, conjunctivitis
,
tumor lysis syndrome
Triphasic pattern of elimination; half-life 3 min, 2.5 hr, 33 hr; metabolized by liver; crosses placenta; excreted in urine, bile, breast milk
•
Give epirubicin before PACLitaxel if both are given
Increase:
toxicity—other antineoplastics or radiation, cimetidine
Increase:
ventricular dysfunction, CHF—trastuzumab
Increased:
heart failure—calcium channel blockers
Decrease:
antibody response—live virus vaccine
Black Box Warning:
Bone marrow depression (severe):
CBC, differential, platelet count weekly; withhold product if baseline neutrophil ≤1500/mm
3
; leukocyte nadir occurs 10-14 days after administration, recovery by day 21; notify prescriber of results
•
Infection:
treat before receiving this product if regimens >120 mg/m
2
, prophylactic antibiotics should be given (trimethaprin-sulfamethoxazole or a quinolone)
•
Blood, urine uric acid levels; swelling, joint pain primarily in extremities; patient should be well hydrated to prevent urate deposits
•
Renal disease: BUN, serum uric acid, urine CCr, electrolytes before, during therapy; I&O ratio; report fall in urine output to <30 ml/hr; dosage adjustment needed if serum creatinine >5 mg/dl
•
Increased fluid intake to 2-3 L/day to prevent urate, calculi formation
Black Box Warning:
Hepatic studies before, during therapy: bilirubin, AST, ALT, alk phos as needed or monthly
Black Box Warning:
Heart failure:
B/P, pulse, character, rhythm, rate, ABGs, ECG, LVEF, MUGA scan, or ECHO; watch for ST-T wave changes, low QRS and T, possible dysrhythmias (sinus tachycardia, heart block, PVCs); identify cumulative amount of anthracycline received (lifetime)
•
Bleeding: hematuria, guaiac, bruising, or petechiae, mucosa or orifices q8hr
•
Effects of alopecia on body image; discuss feelings about body changes
Black Box Warning:
Extravasation (vesicant):
local irritation, pain, burning, necrosis at inj site, discontinue and start at another site
•
GI symptoms: frequency of stools, cramping
•
Therapeutic response: decreased tumor size, spread of malignancy
•
That hair may be lost during treatment; that wig or hairpiece may make patient feel better; that new hair may be different in color, texture; new hair growth occurs in ≤3 mo after treatment
•
To avoid crowds, persons with infections when granulocyte count is low
•
That contraceptive measures recommended during therapy and for 4 mo thereafter for men and women; pregnancy (D)
•
To avoid vaccinations because reactions may occur; to avoid cimetidine during therapy
•
That urine may appear red for 2 days
•
To avoid OTC medications, supplements unless approved by prescriber
Black Box Warning:
That irreversible myocardial damage, leukopenia, menopause may occur
•
To report rapid heart beat, trouble breathing, fever, nausea, vomiting, oral sores