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Name /bks_53161_deglins_md_disk/fluorouracil
02/19/2014 08:36AM
1
High Alert
fluorouracil (flure-oh-yoor-a-sill)
Carac, Efudex, Fluoroplex, 5-FU
Classification
Therapeutic: antineoplastics
Pharmacologic: antimetabolites
Pregnancy Category D
Plate # 0-Composite
Adverse Reactions/Side Effects
More likely to occur with systemic use than with topical use CNS: acute cerebellar
dysfunction. GI: diarrhea, nausea, stomatitis, vomiting. Derm: alopecia, maculopapular rash, local inflammatory reactions (topical only), melanosis of nails, nail
loss, palmar-plantar erythrodysesthesia, phototoxicity. Endo: sterility. Hemat:
anemia, leukopenia, thrombocytopenia. Local: thrombophlebitis. Misc: fever.
Interactions
Drug-Drug: Combination chemotherapy with irinotecan may produce unaccept-
Indications
IV: Used alone and in combination with other modalities (surgery, radiation therapy,
other antineoplastics) in the treatment of: Colon cancer, Breast cancer, Rectal cancer, Gastric cancer, Pancreatic carcinoma. Topical Management of multiple actinic
(solar) keratoses and superficial basal cell carcinomas.
Action
able toxicity (dehydration, neutropenia, sepsis). Additive bone marrow depression
with other bone marrow depressants, including other antineoplastics and radiation therapy. Maypantibody response to live-virus vaccines andqrisk of adverse reactions.
Route/Dosage
Doses may vary greatly, depending on tumor, patient condition, and protocol used.
Inhibits DNA and RNA synthesis by preventing thymidine production (cell-cycle Sphase– specific). Therapeutic Effects: Death of rapidly replicating cells, particularly malignant ones.
Advanced Colorectal Cancer
Pharmacokinetics
Absorption: Minimal absorption (5– 10%) after topical application.
Distribution: Widely distributed; concentrates and persists in tumors.
Metabolism and Excretion: Metabolized by dihydropyrimidine dehydrogenase
Other Tumors
to a less toxic compound; inactive metabolites are excreted primarily in urine.
Half-life: 20 hr.
TIME/ACTION PROFILE (IV ⫽ effects on blood counts, Top ⫽ dermatologic effects)
ROUTE
IV
Top
ONSET
1–9 days
2–3 days
pg 1 # 1
PEAK
9–21 days (nadir)
2–6 wk
DURATION
30 days
1–2 mo
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Dihydropyrimidine dehydrogenase deficiency (patients atqrisk of 5– FU toxicity); OB, Lactation: Pregnancy or lactation.
IV (Adults): 370 mg/m2 preceded by leucovorin or 425 mg/m2 preceded by leucovorin daily for 5 days. May be repeated q 4– 5 wk.
IV (Adults): Initial dose— 12 mg/kg/day for 4 days, then 1 day of rest, then 6 mg/
kg every other day for 4– 5 doses or 7– 12 mg/kg/day for 4 days followed by 3-day
rest, then 7– 10 mg/kg q 3– 4 days for 3 doses. Maintenance— 7– 12 mg/kg q 7–
10 days or 300– 500 mg/m2/day for 4– 5 days, repeated monthly (no single daily
dose should exceed 800 mg). Poor-Risk Patients: 3– 6 mg/kg/day on days 1– 3, 3
mg/kg/day on days 5, 7, 9 (not to exceed 400 mg/dose). Doses of 370– 425 mg/m2/
day for 5 days have been used in combination with leucovorin.
Actinic (Solar) Keratoses
Topical (Adults): Carac— Apply 0.5% cream to lesions once daily for up to 4 wk;
Efudex— Apply 2% or 5% solution or cream to lesions twice daily for 2– 4 wk; Fluoroplex— Apply 1% cream to lesions twice daily for 2– 6 wk.
Use Cautiously in: Infections; Depressed bone marrow reserve; Other chronic
Superficial Basal Cell Carcinomas
debilitating illnesses; Obese patients, patients with edema or ascites (dose should be
based on ideal body weight).
Topical (Adults): Efudex— Apply 5% solution or cream to lesions twice daily for
3– 6 wk (up to 12 wk).
⫽ Canadian drug name.
⫽ Genetic Implication.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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Name /bks_53161_deglins_md_disk/fluorouracil
02/19/2014 08:36AM
NURSING IMPLICATIONS
Assessment
● Monitor vital signs before and frequently during therapy.
● Assess mucous membranes, number and consistency of stools, and frequency of
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pg 2 # 2
Potential Nursing Diagnoses
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Plate # 0-Composite
vomiting. Assess for signs of infection (fever, chills, sore throat, cough, hoarseness, pain in lower back or side, difficult or painful urination). Assess for bleeding
(bleeding gums; bruising; petechiae; and guaiac test stools, urine, and emesis).
Avoid IM injections and taking rectal temperatures. Apply pressure to venipuncture sites for 10 min. Notify health care professional if symptoms of toxicity (stomatitis or esophagopharyngitis, uncontrollable vomiting, diarrhea, GI bleeding,
myocardial ischemia, leukocyte count ⬍3500/mm3, platelet count ⬍100,000/
mm3, or hemorrhage from any site) occur; drug will need to be discontinued. May
be reinitiated at a lower dose when side effects have subsided.
Assess IV site frequently for inflammation or infiltration. Patient should notify
nurse if pain or irritation at injection site occurs. May cause thrombophlebitis. If
extravasation occurs, infusion must be stopped and restarted in another vein to
avoid damage to subcut tissue. Report immediately. Standard treatment includes
application of ice compresses.
Assess skin for palmar-plantar erythrodysesthesia (tingling of hands and feet followed by pain, erythema, and swelling) throughout therapy.
Monitor intake and output, appetite, and nutritional intake. GI effects usually occur on 4th day of therapy. Adjusting diet as tolerated may help maintain fluid and
electrolyte balance and nutritional status.
Monitor patient for cerebellar dysfunction (weakness, ataxia, dizziness). This may
persist after discontinuation of therapy.
Topical: Inspect involved skin before and throughout therapy.
Lab Test Considerations: May causepin plasma albumin.
Monitor hepatic (AST, ALT, LDH, and serum bilirubin), renal, and hematologic
(hematocrit, hemoglobin, leukocyte, platelet count) functions before and periodically during therapy. Monitor CBC daily during IV therapy. Report WBC of ⬍3500/
mm3 or platelets ⬍100,000/mm3 immediately; they are criteria for discontinuation. Nadir of leukopenia usually occurs in 9– 14 days, with recovery by day 30.
May also cause thrombocytopenia.
May causeqin urine excretion of 5-hydroxyindoleacetic acid (5-HIAA).
Risk for infection (Side Effects)
Imbalanced nutrition: less than body requirements (Side Effects)
Implementation
● High Alert: Fatalities have occurred with incorrect administration of chemother-
apeutic agents. Before administering, clarify all ambiguous orders; double check
single, daily, and course-of-therapy dose limits; have second practitioner independently double check original order, calculations and infusion pump settings.
The number 5 in 5-fluorouracil is part of the drug name and does not refer to the
dose.
● Prepare solution in a biologic cabinet. Wear gloves, gown, and mask while handling IV medication. Discard IV equipment in specially designated containers.
IV Administration
● pH: 8.6– 9.2.
● Direct IV: Diluent: May be administered undiluted. Concentration: 50 mg/
mL. Rate: Rapid IV push administration (over 1– 2 min) is most effective, but
there is a more rapid onset of toxicity.
● Intermittent Infusion: Diluent: May be diluted with D5W or 0.9% NaCl.
● Use plastic IV tubing and IV bags to maintain greater stability of medication. Solution is stable for 24 hr at room temperature; do not refrigerate. Solution is colorless to faint yellow. Discard highly discolored or cloudy solution. If crystals
form, dissolve by warming solution to 140⬚F, shaking vigorously, and cooling to
body temperature. Concentration: Up to 50 mg/mL. Rate: Onset of toxicity is
greatly delayed by administering an infusion over 2– 8 hr.
● Y-Site Compatibility: acyclovir, alfentanil, allopurinol, amifostine, amikacin,
aminophylline, amphotericin B lipid complex, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, azithromycin, aztreonam,
bivalirudin, bleomycin, bumetanide, butorphanol, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, cisatracurium, cisplatin, clindamycin,
cyclophosphamide, cyclosporine, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, docetaxel, dopamine, doripenem, doxorubicin liposome, enalaprilat, ephedrine, ertapenem, erythromycin, esmolol, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, foscarnet,
fosphenytoin, furosemide, ganciclovir, gemcitabine, gentamicin, granisetron,
䉷 2015 F.A. Davis Company
CONTINUED
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Name /bks_53161_deglins_md_disk/fluorouracil
02/19/2014 08:36AM
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CONTINUED
fluorouracil
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heparin, hetastarch, hydrocortisone, hydromorphone, ifosfamide, imipenem/cilastatin, isoproterenol, ketorolac, labetalol, leucovorin, levorphanol, lidocaine, linezolid, magnesium sulfate, mannitol, melphalan, meperidine, meropenem,
mesna, methohexital, methotrexate, methylprednisolone, metoprolol, metronidazole, milrinone, mitomycin, mitoxantrone, morphine, nalbuphine, naloxone,
nesiritide, nitroglycerin, nitroprusside, octreotide, paclitaxel, palonsetron, pamidronate, pancuronium, pantoprazole, pemetrexed, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium acetate, potassium chloride, potassium phosphates, procainamide, propofol, propranolol, ranitidine,
remifentanil, rituximab, sargramostim, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, teniposide, theophylline, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trastuzumab, vasopressin, vecuronium, vinblastine, vincristine, vitamin B complex with
C, voriconazole, zidovudine, zoledronic acid.
● Y-Site Incompatibility: aldesleukin, amiodarone, amphotericin B cholesteryl,
amphotericin B colloidal, buprenorphine, calcium chloride, caspofungin, chlorpromazine, ciprofloxacin, diazepam, diltiazem, diphenhydramine, dobutamine,
doxycycline, droperidol, epinephrine, epirubicin, filgrastim, haloperidol, hydroxyzine, idarubicin, irinotecan, levofloxacin, lorazepam, midazolam, nicardipine,
pentamidine, phenytoin, prochlorperazine, promethazine, quinapristin/dalfopristin, topotecan, vancomycin, verapamil, vinorelbine.
● Topical: Consult health care professional before administering topical preparations to determine which skin preparation regimen should be followed. Tight occlusive dressings are not advised because of irritation to surrounding healthy tissue. A loose gauze dressing for cosmetic purposes is usually preferred. Wear
gloves when applying medication. Do not use metallic applicator.
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Plate # 0-Composite
pg 3 # 3
Instruct patient to use soft toothbrush and electric razor. Patients should be cautioned not to drink alcoholic beverages or take products containing aspirin or
NSAIDs.
Advise patient to rinse mouth with clear water after eating and drinking and to
avoid flossing to minimize stomatitis. Viscous lidocaine may be used if mouth pain
interferes with eating. Stomatitis pain may require treatment with opioid analgesics.
Discuss with patient the possibility of hair loss. Explore methods of coping.
Review with patient the need for contraception during therapy.
Caution patient to use sunscreen and protective clothing to prevent phototoxicity
reactions.
Instruct patient not to receive any vaccinations without advice of health care professional.
Emphasize the importance of routine follow-up lab tests to monitor progress and
to check for side effects.
Topical: Instruct patient in correct application of solution or cream. Emphasize
importance of avoiding the eyes; caution should also be used when applying medication near mouth and nose. If patient uses clean finger to self-administer, emphasize importance of washing hands thoroughly after application. Explain that erythema, scaling, and blistering with pruritus and burning sensation are expected.
Advise patient to avoid sunlight or ultraviolet light (tanning booths) as much as
possible; may increase side effects. Therapy is discontinued when erosion, ulceration, and necrosis occur in 2– 6 wk (10– 12 wk for basal cell carcinomas). Skin
heals 4– 8 wk later.
Evaluation/Desired Outcomes
● Tumor regression.
● Removal of solar keratoses or superficial basal cell skin cancers.
Why was this drug prescribed for your patient?
Patient/Family Teaching
● Instruct patient to notify health care professional if fever; chills; sore throat; signs
of infection; yellowing of skin or eyes; abdominal pain; joint or flank pain; swelling
of feet or legs; bleeding gums; bruising; petechiae; or blood in urine, stool, or emesis occurs. Caution patient to avoid crowds and persons with known infections.
⫽ Canadian drug name.
⫽ Genetic Implication.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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