RESUME FARMAKOLOGI

ANTI CANCER

Oleh:
Nama : Ephysia Ratriningtyas
NIM : 115070201131022
K3LN 2011

UNIVERSITAS BRAWIJAYA FAKULTAS KEDOKTERAN

JURUSAN KEPERAWATAN
2013
 ANTICANCER

1. ANTINEOPLASTIC AGENTS
Terdapat 2 agen group utama yaitu:
a. CELL CYCLE - NONSPECIFIC (CCNS) ALKYLATING AGENTS
Cytotoxix pada fase sel efektif dalam memperlambat pertumbuhan tumor.
b. CELL CYCLE - SPECIFIC (CCS) 3 TYPES
1. ANTIMETABOLITES - cytotoxic is S phase
2. MITOTIC INHIBITORS - cytotoxic in M phase
3. CYTOTOXIC ANTIBIOTICS (some are CCNS)
Efktif dalam menghambat pertumbuhan tumor yang cepat.

Efek samping:

- Membunuh semua sel yang tumbuh cepat

- folikel rambut
- mukosa Saluran pencernaan
- Penekanan sumsum tulang (BMS) menyebabkan anemia, trombositopenia dan leukopenia
- Nephro-hepato-cardio-neoro dan ototoxic
- Ekstravasasi IV dapat menyebabkan kerusakan jaringan
- memiliki indeks emetik
- memiliki interaksi yang luas dengan obat lain.

2. ALKYLATING AGENTS (paling sering digunakan)

NITROGEN MUSTARDS
CNS killing ability
mechlorethamine is the prototypical agent
USES: Hodgkin’s disease & lymphomas. leukemias,
CANCERS OF
 lung,
 breast,
 ovary,
 testes,
 brain,
 bladder,

SELECTED AGENTS:
1. Mechlorethamine (Mustine, Mustargen): diberikan secara IV, dan hanya digunakan pada
orang dewasa saja.
2. Cyclophosphamide (Cytoxan, Neosar): diberikan secara IV dan ada yang PO. Dapat
diberikan pada usia dewasa dan pediatrik.
3. Carmustine (BiCNU) diberikan secara IV, pada usia dewasa saja. Dapat melewati blood-
brain barrier sehingga digunakan untuk mengobati lesi otak.
4. OTHER AGENTS: Chlorambucil, Streptozotocin
3. ANTIMETABOLITES
ACTIONS:
 Antagonis dari folat.
 Purin dan pirimidin diperlukan untuk sintesis asam nukleat.
 Menghentikan replikasi sel.

Penggunaan pada:

 Solid tumors
 (breast, lung, liver, brain, colon. Stomach, pancreas)
 Lymphomas, leukemias.
 Some agents also immunosuppressive,
 Useful in treating immune-mediated diseases

a. SELECTED AGENTS:
1. FOLIC ACID ANALOG
METHOTREXATE (Folex, Rheumatrex, MTx)
 Folic acid antagonist
 PO & IM, adult and pediatric use
 Also used to treat immune-mediated diseases,
 Used incombination with misoprostol for therapeutic abortion
 Causes profound anemia (folate depletion)
 Therefore leucovorin “rescue” often used to counteract
2. PURINE ANALOG
MERCAPTOPURINE (6-MP, Purinethol)
- Purine antagonist
- PO only, adult and pediatric use
3. PYRIMIDINE ANALOG
CYTARABINE (Ara-C, Cytosar-U)
- Pyrimidine antagonist
- IV and intrathecal (within spinal canal)

4. MITOTIC INHIBITORS
ACTIONS:
Plant alkaloids (periwinkle, yew tree, mandrake plant, etc.) Bind to and disrupt mitotic
spindles
USES:
- Lymphomas (Hodgkin’s and non-Hodgkin’s),
- Neuroblastoma
- Kaposi’s sarcoma,
- Solid tumors (breast, testicular, etc.)

SELECTED AGENTS:
- ETOPOSIDE (VP-16, VePesid) IV and PO, adult use only
 - PACLITAZEL (Taxol) IV only, adult use only. drug of choice for ovary and breast ca
- VINCRISTINE (LCR, VCR,Oncovin) IV only, adult and pediatric use drug of choice for acute
leukemia

5. CYTOTOXIC ANTIBIOTICS
ACTIONS:

• Source: Streptomyces mold - work by intercalation (insertion of drug molecule

between the 2 DNA strands causing it to (“unwind”)

• Kill some bacteria and viruses but are too toxic to use for infections

IV extravasation constant danger !

USES:

- wide variety of solid tumors,

- always used in combination with other agents

SELECTED AGENTS:

a. DOXORUBICIN (ADR, Rubex, Doxil): diberikan secara IV only, dan hanya boleh diberikan
pada usia dewasa.
b. BLEOMYCIN (BLM, Blenoxane) :IM, IV, SQ, adult use only

Perlu di waspadai karena agen ini sangat toxic.

6. MISCELLANEOUS ANTINEOPLASTICS
Various actions: Both CCNS and CCS
Used in combinations with other agents

SELECTED AGENTS:

• Cisplatin (Platinol): diberikan secara IV, penggunaan pada adult and pediatric.

• ALTRETAMINE (Hexalen): diberikan secara PO, hanya diberikan pada orang dewasa. primarily
used to treat ovarian cancer

• ASPARAGINASE (Elspar): diberikan secara IV, adult and pediatric use

• HYDROXYUREA (Hydrea): diberikan secara IV, adult use only

HORMONES AND ANTAGONISTS.

1. Adrenocortical Suppressant: Mitotane, Aminoglutethimide. (Adrenal Cortex)

2. Adrenocortical Steroids. Prednisone. (Lukemias, Lymphomas, Breast)
3. Progestins. Hydroxyprogestrone.(Endometrium, (Breast) Medroprogestrone,
Megesterol acetate.
4. Estrogens. DES, Ethinylesterdiol.(Breast, Prostate)
 5. Antiestrogens. Tamoxifen .(Breast)
6. Androgens. Testosterone (Breast)
7. Antiandrogens. Flutamide (Prostate).
8. Gonadotropin Releasing Hormone Analog. Leuprolide. (Prostate)

Manajemen Keperawatan

Sebelum program kemoterapi perlu dilakukan penilaian status fisik dan data dasar serta memantau
berbagai hasil uji laboratorium. Beberapa tes diperlukan tergantung dengan obat-obatannya ((bone
marrow suppression, cardiotxic, nephrotoxic, neurotoxic, ototoxic, hepatotoxic)

PLANNING

- Decrease anxiety,
- understand of the chemotherapy program,
- adaptation to changes in body appereance and function,
- absence of the variety of injury,
- absence of diarrhea/ constipation,
- maintanance of oral mucous membrane integrity,
- maintanance of optimal nutritional status,
- maintanance of fluid and electrolyte balance,
- achievement of maximal physical mobility,
- peformance of self care activities within physical limitations.

INTERVENTIONS

- Body image disturbance (alopecia

- High risk for infection ~ bone marrow supp.
- High risk for nephrotoxicity
- Altered oral mucous membrane
- Altered nutrition
- High risk for drug extravasation (tissue damage,loss of function, infection, necrosis)
Antidotum:10% sodium thiosulfate ~ mechloretamine, pyridoxine~ mitomycin,
hyaluronidase and warming ~ vinca alcaloids, dimethyl sulfoxide ~
daunorubicin/doxorubicin)

Local Reactions from Chemotherapy Administration

 Extravasation: kebocoran atau infiltrasi agen kemoterapi yg menyebabkan bengkak ke dalam

jaringan lokal

 Vesicant: agen yang memiliki potensi untuk menyebabkan blistering atau jaringan nekrosis

 Irritant: agen yang menyebabkan reaksi inflamasi lokal tetapi tidak menyebabkan nekrosis
jaringan

 Flare reaction: vena respon inflamasi dengan pelepasan histamin berikutnya yang dapat
mengakibatkan reaksi suar, kejadian biasanya sekitar 3% dan durasi biasanya kurang dari 45
menit
Ekstravasasi treatment

 AT FIRST SIGN, stop chemo

 Attempt to aspirate residual drug

 Remove IV

 Notify physician

 Administer antidote (if ordered)

 Heat/Cold as appropriate

 Elevate extremity

 Document extravasation and management

1. Neutropenia

 Decreased number of granulocytes

 Granulocytes - one of the white blood cells

 Absolute neutrophil count (ANC) = number of granulocytes in the blood.

 Measures the first line of defense against infection

 ANC = total WBC x (% polys + % bands) [example: 5000 x ( 40% + 10%) = 2,500]

Resiko infeksi pada neutropenia

 ANC of > 1000 = No risk of infection

 ANC 500 to 1000 = Mild to moderate risk

 ANC < 500 = Severe risk of infection

Semakin lama neutropenia yang parah berlangsung, semakin besar risiko infeksi yang
mengancam jiwa

Pemeriksaan

 Demam adalah monitor utama dalam infeksi

 Monitor ANC

 Perhatikan timbulnya rasa sakit, kemerahan di lokasi luka, daerah terbuka, sering
buang air kecil, perubahan status mentalPemeriksaan head to toe

 Teach patient to observe for signs of infection

 Lakukan pemeriksaan temperatur secara berkala selama 24jam

Manajemen Neutropenia

 Temperatures q 4 hours around the clock

 Limit Tylenol; can mask fever

 Cultures done with first fever (before abx)

 Antibiotik pertama diberikan sebagai STAT dosis ( ~ 1 jam)

 Memantau tanda-tanda vital- sepsis kills rapidly

 Jika demam berlanjut

- perlu mengubah antibiotik

- menambahkan agen anti-jamur

- Temp harus turun 1 derajat dalam 24 jam dan hilang setelah 48 jam jika abx bekerja

Pencegahan Neutropenic

 NOT reverse isolation

 Controversial whether infection risk is lowered

 Private room

 No fresh fruits or vegetables to eat

 No live plants/flowers/standing water

 No sick visitors or caregivers

 No small children (very controversial)

 No caregivers taking care of other infected pts

 Pt wears mask when out of room

2. Trombositopenia
 Decreased number of platelets
 Risk of bleeding increases below 50,000
 Risk of bleeding substantial under 20,000
 Transfusions may not be done until 10-15,000 (risk of auto-immunizing patient)

Manajemen:

 Assess head to toe for bleeding/petechiae

  Monitor platelet count

 Teach patient to report signs of bleeding or increased petechiae

 Transfuse as ordered (pre-medicate usually)

Tindakan pencegahan pendarahan

 NO ASA or NSAIDS

 Tidak memasukan sesuatu kedalam rectum atau vagina

 Tidak ada penggunaan kateter Foley jika mungkin

 Tidak ada suntikan IM

 Meminimalkan tindakan venipunctures dan prosedur invasif

 Penggunakan sikat gigi yang lembut-no flossing - electric razor

 No vigorous exercise

 Hindari mengejan

3. Anemia

 Decreased number of red blood cells

 Transfusions given when Hgb < 8, Hct < 24 or patient is symptomatic

 Elderly patients or those with history of cardiac problems may not tolerate anemia

 Epogen (Procrit) given to stimulate RBC production

- Helps combat fatigue

4. Fatigue
 Multiple causes
 Most common side effect from chemo
 Not relieved by sleep
 Prevention of anemia can reduce incidence
 Short periods of mild exercise can reduce severity
 Teach energy conservation and appropriate rest periods
- Need for caregiver assistance

5. Mual dan Muntah

 Stimulation of vomiting center (brain) by chemo-receptor trigger zone (CTZ), vagal
stimulation, seratonin, etc.
 Most distressing side effect of chemo
 Acute, delayed, anticipatory
  Not all chemo drugs have same emetic potential

Manajemen Mual dan Muntah

 Very sensitive to smells (may be abnormal)
 TAKE antiemetics as ordered
 Room temperature or cold foods smell less
 Frozen juice or popsicles are soothing
 Avoid fatty, greasy, spicy, sweet foods
 Eat small meals
 Avoid favorite foods at this time

6. Anorexia
 Taste changes last ~ 1 week
 Smells become acute; lasts 1-3 weeks
 Mild exercise or wine may stimulate appetite
 Avoid too much liquid near mealtime
 Eat high calorie, nutritious foods
 Avoid junk food
 Use supplements as needed
 Megace can stimulate appetite (> 350 mg/day)

7. Diare
 Increase in liquidity and frequency of stool (> 3 stools above usual amount)
 Destruction of epithelium of GI tract
 Related to medication, dose and frequency
 Worse with RT to abdomen/gut area
 Drugs: Camptosar, Methotrexate, 5-FU
 May be dose-limiting toxicity of drug
 May be concommitant infection (C. diff)

Manajemen Diare

 Camptosar: treat early diarrhea with Atropine and late diarrhea with Immodium--
prophylactically

 BRAT diet -- low residue diet -- clear liquids

 Avoid milk products

 Scrupulous peri care; keep area dry

 Use moisture barrier cream (Desitin)

 Use anti-diarrheals: Lomotil, Immodium, Kaopectate, Pepto-bismol, Sandostatin (last

resort)

8. Konstipasi
  Infrequent hard, dry, bowel movements that may cause pain or bleeding
 Vinca Alkaloids - Vincristine worst
 Other reasons: dehydration, no activity, opioid use, low residue diet
 May cause bloating, pain, N&V, obstruction or ileus, rectal bleeding, hemorrhoids,
tears.

Manajemen Konstipasi

 Treat prophylactically
- Adequate fluid intake
- Increased fiber intake
- Increased activity
- Stool softeners taken routinely (Senekot)
 Laxative or Cathartic if no BM in 3 days
 Try to avoid enemas

9. Stomatiti/ mucotitis
 Inflammation or ulceration of mouth which can progress to entire GI tract
 Destruction of fast-growing epithelial cells
 Drugs: 5-FU, Methotrexate, Xeloda, Bleomycin, HD chemo
 Radiation fields that include mouth or throat
 Alcohol, tobacco use
 Poor oral hygiene, dental caries
 Causes pain, infection, dehydration, weight loss

Manajemen Mucositis
 Daily/Bid oral assessment
 Frequent (q 2 hr) mouth care
o NS rinse (avoid alcohol-containing mouthwash)
o Brush with soft toothbrush--also brush tongue
o Keep lips and mouth moist
 Soft diet with high caloric bland foods
 Topical anesthetic agents
 Treat infections quickly
 PREVENTION is best

10. Alopecia
 Temporary - begins in 2 to 3 weeks
 Hair regrows 4 to 6 weeks after chemo
- Texture and color may be different in new hair
 Degree of alopecia related to drug, dose, schedule, and amount of hair patient had
prior to chemo
 MOST distressing symptom
- May be equally distressing for men and women
 Manajemen Alopecia
 PATIENT TEACHING is very important
 May lose hair on entire body (taxanes, high dose chemo or total body radiation)
 Cut hair short to reduce irritation from shedding
 Wig or headcovering resources available-may be insurance benefit--can get script for
wig
 Wear headcovering to reduce temperature loss
 Protect scalp from sun (may be photosensitive)

11. Photosensitif
 Increased skin sensitivity to UV exposure
 Drugs causing: 5-FU, Methotrexate, Taxol, Adriamycin, Vincristine
 Sunburn with blisters and erythema; hyperpigmentation
 Avoid tanning booths, sunbathing even on cloudy days
 Wear sunscreen (> 15 spf) or protective clothing

12. Pengaruh terhadap seksual

 Related to drug, dose, length of treatment, age and sex of patient
 Men: impotence, decreased libido, hot flashes, decreased sperm count, gynecomastia,
body image changes
 Women: irregular or no menses, vaginal dryness, decreased ova production, painful
intercourse, decreased libido, hot flashes, body image changes

Manajemen

 Patient education

 Discuss concerns frankly

 Sperm banking

 Birth control

 Lubrications

 Position changes

 Counseling (time of high stress)