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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Index-Oncology Medications

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

Index

This index is meant to highlight oncology drugs that cause specific concerns to older adults. Many of the well known, general side effects are not included such as neutropenia, thrombocytopenia, and anemia, unless they particularly affect this population. Common side effects  such as anorexia or fatigue are also not included.

Aldesleukin

  • ALERT: can cause somnolence, confusion, irritability, dizziness
  • LABS: monitor for renal insufficiency, elevated bilirubin, hypo or hyperthyroid
  • COMORBID: Patients with a history of cardiac or pulmonary disease are at higher risk for serious reactions from this drug; can cause capillary leak syndrome, can cause a drop in mean arterial blood pressure within 2-12 hours
  • INTEG: skin rash, pruritus and diaphoresis potential
  • PAIN: causes myalgias, arthralgias, flu like symptoms
  • RESP: cough, dyspnea 
  • REVIEW: Steroids counteract the immunostimulant effects , steroids should not be given concurrently

Amifostine

  • COMORBID: use of antihypertensive meds increase hypotension reaction
  • INTEG: rare skin reactions-Stevens Johnson syndrome, erythema multiforme
  • NUT: hydration necessary-hypotension enhanced with dehydration
  • ALERT: dizziness and somnolence possible

Anastrozole

  • LABS: Mild elevations in liver function tests and cholesterol Constitutional symptoms such as asthenia, myalgias, arthralgias, headache, edema, and fatigue are commonly reported.
  • GAIT / INDEPENDENCE: increased incidence of osteopenia, osteoporosis and bone fractures, increased risk of  DVT

Bendamustine

  • LABS: dose reductions for renal and hepatic dysfunction, may cause hyperbilirubinemia
  • SKIN: rash rare but may be severe
  • TOILET: diarrhea

Bevacizumab

  • COMORBID: monitor blood pressure: hypertension is common , caution in patients with h/o stroke/MI
  • PAIN: investigate any c/o new abd pain- r/o GI perforation
  • RESP: caution with h/o hemoptysis

Bicalutamide

  • REVIEW: concomitant warfarin (coumadin) increases anti-coagulability
  • LABS: use with caution in liver dysfunction

Bleomycin

  • RESP: ↑risk pneumonitis (esp with h/o RT to thorax) -- dose related
  • INTEG: skin toxicities, erythema, hyperpigmentation
  • ALERT: rare severe rxn (1% of lymphoma pts) confusion, fever/chills
  • LABS: use with caution in renal dysfunction

Bortezomib

  • COMORBID: monitor hypertension
  • GAIT: risk peripheral neuropathy
  • INTEG: irritant to veins, localized skin reaction possible

Busulfan

  • RESP: increased risk over time--pulm fibrosis
  • LABS: can cause hyperuricemia/renal stones, severe myelosuppression
  • NUT: ensure adequate hydration

Capecitabine

  • TOILET: diarrhea potential, may be severe
  • INTEG: potential for hand-foot syndrome, nail changes

Carboplatin

  • LABS: nephrotoxicity, monitor renal function
  • EARS: monitor hearing
  • GAIT: peripheral neuropathy

Carmustine

  • INTEG: venous irritation/burning with administration
  • RESP: pulm fibrosis/infiltrate potential
  • LABS: delayed nadir (4 weeks after admin)
  • GAIT: may cause dizziness, ataxia

Cisplatin

  • EARS: ototoxicity
  • NUT: severe N/V
  • TOILET: severe nephrotoxicity potential
  • LABS: monitor renal function, potential hypo magnesium
  • GAIT: monitor for peripheral neuropathy

Cyclophosphamide

  • REVIEW: may decrease serum digoxin level necessitating increased digoxin dose
  • TOILET: bladder irritation, potential for hemorrhagic cystitis
  • INTEG: alopecia, nail changes
  • RESP: potential for pulm fibrosis
  • LABS: consider dose modification in patients with impaired renal and hepatic function
  • COMORBID: monitor cardiac status, especially if given with doxorubicin
  • NUT: N/V, anorexia, encourage hydration

Cytarabine

  • GAIT: can cause cerebellar dysfunction
  • ALERT: potential for confusion, disorientation and somnolence
  • EYES: conjunctivitis potential

Decitabine

  • LABS: severe myelosuppression, monitor electrolytes for  hyperglycemia, hyperbilirubinemia, hypomagnesemia, hypoalbuminemia, hypokalemia
  • NUT: moderate nausea and dyspepsia are common
  • TOILET: diarrhea or constipation
  • INTEG: monitor for Petechiae and ecchymosis
  • COMORBID: caution in patients with hepatic or renal insufficiency
  • RESP: cough, pharyngitis, and pulmonary edema has been reported

Docetaxel

  • INTEG: nail changes, vesicant--potential tissue damage with extravasation
  • COMORBID: potential fluid retention--may exacerbate CHF or pulm conditions
  • LABS: may need to dose reduce with hepatic dysfunction
  • NUT: potential mucositis

Doxorubicin

  • COMORBID: cardiac: potential congestive failure, decreased left ventricular ejection fraction; monitor cumulative dosing; discuss use of dexrazoxane when cum dose >300mg/m2; lifetime max dose= 500 mg/m2 (including other anthracyclines) or less if patient is > 65 years old, has a history of hypertension, preexisting heart disease,  previous mediastinal radiation or high dose cyclophosphamide
  • TOILET: instruct patient that urine may be discolored red
  • INTEG: vesicant, administer with caution, may induce radiation recall
  • NUT: potential mucositis

Etoposide (VP-16)

  • COMORBID: monitor for hypotension
  • NUT: N/V /Anorexia, taste changes
  • LABS: consider dose reduction with hepatic and renal dysfunction
  • GAIT: peripheral neuropathy

Faslodex 

  • LABS: elevated hepatic enzymes: ALT, AST, ALP
  • INTEG: can cause injection site pain
  • RESP: monitor for cough, dyspnea
  • PAIN: can cause diffuse arthralgias, headache, extremity or bone pain

Fludarabine

  • LABS: hyperuricemia and tumor lysis syndrome may occur in patients with large tumor burdens (e.g., high WBC counts, extensive adenopathy); IV hydration and monitoring for tumor lysis syndrome (elevations in potassium, uric acid, and phosphorous levels) may be indicated
  • COMORBID: consider dose reduction in patients with renal dysfunction based on creatinine clearance
  • GAIT: peripheral neuropathy possible
  • NUT: potential for mucositis; promote good oral hygiene
  • RESP: May cause fatal pulmonary toxicity if given in combination with pentostatin

Fluorouracil

  • TOILET: diarrhea
  • INTEG: nail changes, irritating to veins--may cause brown streaking, hand foot syndrome with continuous infusion
  • EYES: increased tearing, watery eyes
  • ALERT: high doses may cause

Gemcitabine

  • LABS: monitor renal and hepatic function
  • INTEG: irritant; may cause discomfort during administration
  • RESP: radiation sensitizer, may be associated with pneumonitis when administered with thoracic radiation, SE include flu-like symptoms (fever, chills, myalgias, headache, cough)
  • NUT: radiation sensitizer, may be associated with esophagitis when administered with thoracic radiation; encourage mouth care

Idarubicin

  • COMORBID: Cardiac dysfunction: congestive failure, serious dysrhythmias, including atrial fibrillation, myocardial infarction, and decreased left ventricular ejection fraction; monitor cumulative dosing; discuss use of dexrazoxane  when cum dose >110mg/m2
  • INTEG: vesicant--administer with caution
  • NUT: potential mucositis: encourage proactive mouth care

Ifosfamide

  • ALERT: may cause somnolence, confusion, depression, psychosis, hallucinations
  • TOILET: bladder irritation potential for hemorrhagic cystitis: MESNA must be given, encourage adequate hydration; consider dosage reduction in patients with renal dysfunction
  • INTEG: alopecia; may cause ridging of the nail

Interferon 

  • ALERT: may cause or exacerbate depression, somnolence, confusion, dizziness possible
  • LABS: decreased serum calcium levels, elevated LFTs, serum phosphorous and uric acid levels
  • COMORBID: use with caution in patients with pulmonary disease, diabetes mellitus, coagulation disorders, cardiovascular disease, or severe myelosuppression.
  • RESP: dyspnea, cough possible

Irinotecan

  • TOILET: probable diarrhea; patients who are > 65 years old or who have a history of radiation to the abdomen or pelvic area are at increased risk for diarrhea; may have cholinergic reaction with flushing, diaphoresis, abdominal pain, cramping and diarrhea (small doses of atropine may be indicated) 
  • LABS: monitor fluid and electrolytes especially with diarrhea
  • COMORBID: use with caution in pts with hepatic dysfunction and reduced doses in patients with increased total bilirubin levels or Gilbert's syndrome

Ixabepilone

  • GAIT: peripheral neuropathy, weakness 
  • PAIN: headache, myalgias
  • REVIEW: pre-medication with diphenhydramine and ranitidine required due to risk of hypersensitivity reaction; Ixabepilone is a CYP3A4 substrate--strong CYP3A4 inducers may decrease ixabepilone concentrations while potent CYP3A4 inhibitors may increase ixabepilone concentrations
  • COMORBID: dose reduce with hepatic dysfunction

Leuprolide

  • PAIN: may cause bone pain, headache
  • ALERT: dizziness, lethargy, memory impairment
  • GAIT: peripheral edema, thrombophlebitis possible

Lenalidomide

  • RESP: increased risk clots--PE risk
  • GAIT: increased risk of DVT
  • INTEG: rash, Stevens-Johnsons Syndrome
  • LABS: hepatotoxicity
  • COMORBID: dose reduce with hepatotoxicity

Liposomal doxorubicin

  • LABS: may see elevations in AST, ALT and Alk. Phos
  • COMORBID: cardiac: potential congestive failure, decreased left ventricular ejection fraction; monitor cumulative dosing; consider dose reduction in patients with hepatic dysfunction
  • INTEG: drug is an irritant; may cause hand-foot syndrome (PPE)
  • TOILET: remind patient urine may be red tinged color
  • NUT: potential mucositis

Lomustine

  • RESP: pulm fibrosis
  • LABS: delayed myelosuppression
  • ALERT: may cause lethargy, confusion, ataxia, dysarthria

Megestrol Acetate

  • LABS: fluid retention
  • GAIT: increased risk  DVT
  • COMORBID: new-onset diabetes mellitus and exacerbation of pre-existing diabetes have been reported with long-term use; may cause hypertension
  • NUT: increased appetite
  • TOILET: females may have vaginal bleeding or discharge

Melphalan

  • INTEG: irritant with vesicant potential, monitor for extravasation/skin ulceration, skin rash
  • COMORBID: consider dose reduction in patients with renal dysfunction based on creatinine clearance
  • REVIEW: cimetidine decreases oral bioavailability
  • LABS: may cause hyperuricemia, syndrome of inappropriate antidiuretic hormone (SIADH) induced hyponatremia
  • RESP: interstitial pneumonitis and pulmonary fibrosis possible
  • NUT: should be taken on an empty stomach to ensure adequate bioavailability

Methotrexate

  • REVIEW: enhanced toxicity (delayed excretion) with protein bound drugs such as phenytoin (Dilantin), salicylates (ASA), NSAIDs, and sulfonamides; discuss use of multivitamins containing folic acid--may interfere with methotrexate; Leucovorin must be given with large MTX doses to avoid severe toxicity 
  • COMORB: increased hepatotoxicity with alcohol; MTX elimination is decreased in patients with impaired renal function, ascites, or pleural effusions; may need dose reduction
  • LABS: monitor methotrexate levels
  • NUT: N,V, mucositis
  • RESP: potential for pulm fibrosis
  • INTEG: may cause photosensitivity, radiation recall reaction, skin rash

Mitomycin C

  • LABS: cleared by the liver, monitor LFTs, may need dose modification
  • TOILET: hemolytic uremic syndrome
  • INTEG: vesicant
  • RESP: potential interstitial pneumonitis--possible resp. reaction when administered with vinorelbine
  • NUT: N/V, mouth sores, diarrhea

Mitoxantrone

  • TOILET: remind patient urine may be discolored blue-green for 24-48 hours
  • INTEG: alopecia; irritant; may cause temporary blue-green discoloration at skin
  • COMORBID: cardiac-risk increases with cumulative dose > 140 mg/m2 and with h/o previous mediastinal radiation or anthracycline therapy; monitor cardiac function (ejection fraction); consider dose reduction with hepatic dysfunction
  • LABS: may cause elevated bilirubin
  • NUT: mucositis

Oxaliplatin

  • TOILET: diarrhea
  • GAIT: peripheral neuropathy, ataxia possible
  • LABS: potential for hypomagnesium, hypocalcemia
  • NUT: pharyngeal paresthesias and lip numbness exacerbated by cold foods/fluids

Paclitaxel

  • GAIT: peripheral neuropathy
  • NUT: potential mucositis
  • REVIEW: premeds may cause confusion, drowsiness

Pentostatin

  • NUT: mucositis
  • TOILET: may need dose reduce with renal insufficiency
  • INTEG: rash
  • PULM: pulm edema and hypotension if given with high dose cyclophosphamide, carmustine and etoposide; can cause fatal toxicity if given with fludarabine
  • ALERT: can cause asthenia, fever, chills

Procarbazine

  • ALERT: mental status changes: confusion, lethargy, insomnia, nervousness
  • EYES: photophobia--encourage wearing sunglasses; may cause diplopia
  • NUT: special tyramine free diet--no alcohol, wine, beer, hard cheese, bananas, yogurt
  • COMORBID: interaction with SSRIs, MAOs
  • REVIEW: CNS depressants with procarbazine may potentiate sedative effects, especially with phenothiazines, barbiturates, narcotics, and antihistamines; concurrent use of procarbazine and antidiabetic agents, such as sulfonylureas and insulin, may potentiate hypoglycemic effect
  • INTEG: photosensitivity, educate pt to avoid prolonged exposure to sun

Streptozotocin

  • INTEG: irritant--may burn during admin; ice applied helpful
  • LABS: renal dysfunction--monitor for hypophosphatemia 
  • COMORBID: renal disease
  • REVIEW: monitor other drugs for additive nephrotoxic
  • NUT: N/V

Sunitinib

  • INTEG: yellowing of skin
  • TOLIET: diarrhea
  • NUT: GI upset
  • REVIEW: CYP 450 drug 2

Tamoxifen  

  • LABS: Fluid retention
  • REVIEW: interacts with anticoagulants; monitor PT; avoid antacids with admin
  • PAIN: a flare of bone pain

Temozolomide

  • TOILET: constipation 
  • NUT: N/V; take on empty stomach at bedtime, if possible; premedicated with 5HT3
  • REVIEW: consider PCP prophylaxis

Thalidomide

  • GAIT: peripheral neuropathy
  • TOILET: constipation

Topotecan

  • COMORBID: consider dose reduction in patients with renal dysfunction based on creatinine clearance
  • LABS: increased risk of myelosuppression if prior therapy with alkylating agents (e.g., Carboplatin, Cisplatin, Cyclophosphamide); radiation to more than 25% of marrow bearing bones, or history of renal impairment
  • REVIEW: increased drug toxicity with low protein and hepatic dysfunction; monitor LFT

Vinblastine

  • TOILET: drug causes autonomic neuropathy, which contributes to severe constipation; encourage laxative and monitor outcome 
  • GAIT: peripheral neuropathy
  • PAIN: tumor pain

Vincristine

  • TOILET: drug causes autonomic neuropathy, which contributes to severe constipation; encourage laxative and monitor outcome
  • GAIT: peripheral neuropathy

Vinorelbine 

  • TOILET: drug causes autonomic neuropathy, which contributes to severe constipation; encourage laxative and monitor outcome
  • INTEG: vesicant
  • GAIT: per neuropathy
  • RESP: potential reaction when given with mitomycin c; can cause bronchospasm, dyspnea

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