BRMs enhance the bodys natural immune response Administer at BEDTIME to decrease fatigue symptoms Administer anti-emetic ATC

with BRMs Encourage consumption of 2L/day to eliminate cell breakdown Report weight loss or S/S infection or bleeding Stop Ginseng, Golden Seal, and Echinacea before using BRMs Affect Lymphoid cells or Myeloid cells (2 types of stem cells) Filgrastim, Pegfilgrastim, Sargramosim & OprelvekinAssess CBC before tx & biweekly to avoid leukocytosis & thrombocytosis

INTERFERONS
Interferons usually produced in response to virus or tumors.

Type I:
IFN-Alphabind selectively to effector sites; slow down proliferation of cells (good for slowing down tumors and viruses) o Produced by immune cells: B-cells, T-cells, Macrophages & Null cells o They are antiviral, antiproliferative, & immunomodulatory in effect o Inhibit DNA replication in viruses o Interferes with tumor cell growth o Enhances Natural Killer (NK) cell activity o 80% absorbed by body o Metabolized and excreted by liver and kidney cells so hepatic/renal issues are considerations o IM, IV, Sub-Q (only given Sub-Q if platelet count is <50,000bleeding would be a concern) o Flu side effects: (they stimulate immune system so makes sense that its similar to flu symptoms) Dose limiting: FATIGUE (lower dose necessary); ANOREXIA is another dose limiting GI side effect 70% pts have Neuro S/Es D/C side effect: SUICIDAL IDEATION (cautiously restarted later) Cardiopulmonary: TACHYCARDIA, TACHYPNEA, PALLOR, EKG CHANGES, ORTHOSTATIC HYPOTENSION, MI Renal/Hepatic: BUN/Cr increased; PROTEINURIA & increased TRANSAMINASES Monitor CBCs and LFTs Hematologic (reversible) effects: NEUTROPENIA & THROMBOCYTOPENIA Hydration reduces S/Es Birth control effects are interfered with Minimun 6 months tx IFN-Betaopposite effect but similar sites as A Enhances activity of the SUPPRESSOR T-cells (not the NK cells) Reduces the antigen presentation (this is why its useful for auto-immune diseases, like MS) Inhibits movement of lymphycytes into the CNS

Type II:
IFN-Gammaattaches to different site on the cells Enhances oxidative metabolism of macrophages Enhances antibody-dependent cell toxicity Activates NK cells (T cells) Enhances complement reactions (Fc receptors & histocompatibility) Tx: severe malignant osteoPETrosistoo much calcium in the bone & sarcoid (chronic granulomatous diseasescarring tissue build up.)

COLONY STIMULATING FACTORS

Erythropoietin/Erythropoietin Stimulating Agents (ESA) Epoietin Alpha (Procrit) Darbepoetin Alpha Granulocyte CSF (G-CSF) Neupogen Neulasta Granulocyte Macrophage CSF (GM-CSF) Sargramostim (Leukine) Thrombopoietic Growth Factor Oprelvekin (Neumega) Keratinocyte Growth Factor Palifermin (Kepivance)

Decrease length of post-treatment neutropenia (CA tx) Chemomedications o Cancer cells are so similar to normal body cells that the drugs used to treat those cells often adversely affect our bodys normal cellsespecially the fast-growing cells of the mouth AND worse, the bone marrow cells. CSF drugs help to stimulate growth, maturation and differentiation of bone marrow stem cells Permits delivery of HIGHER doses of cancer drugs (must wait until after CA tx for new cells to grow) Reduces recovery of bone marrow transplant (for this surgery all the bone marrow cells are killed off, and then the CSF helps build them back up quickly after transplant) SubQ or IV

Erythropoietinhormone produced by kidneys when they do not get enough oxygen (hypoxia); they send a signal to the bone marrow to produce more RBCs Erythropoietin Stimulating Agents Epoietin-Alpha (Procrit) Indicated for: CRFchronic renal failurenot producing the hormone so its used supplementally Reduce 25% if Hgb is 12g/dL or increases > than 1g/dL in any 2 weeks (strokes can occur from high RBCs) Resume once Hgb is down to 11g/dL Darbepoetin Alpha (Aransep) Tx of Anemia secondary to: o CRF o Chemotx. For nonmyeloid malignancies Closely monito for target Hgb Iron supplements may be administered to enhance erythropoiesis S/E & Adverse: Risks of death, serious CV events & tumor progression (CAREFUL not to inc. tumor growth) S/E: HTN, HA S/E (contd): arthralgias (joint pains), NVD, fatigue, chest pain, asthenia (weakness), dizziness, seizures, & thrombosis Nursing implications (ESAs) o Single use vial o DO NOT SHAKE o Warm to room temp: SubQ o 1mL or less/injection o Ice injection site to reduce pain fom injection o Use new needle

Granuloycyte CSF (G-CSF) G-CSF indications: Glycoprotein produced by monocytes, fibroblasts & endothelial cells Regulates production of neutrophils in the bone marrow FDA approved: Filgrastim (Neupogen) & Pegfilgrastam (Neulasta) Dec. incidence of infections in clients (bone marrow transplant, myelopsuppressive chemo, induction/consolidation chemo AML, periph. Blod progenitor cell collection & tx, severe/chronic neutropenia Filgrastim (Neupogen) S/Es: o BONE PAIN (occurs with higher doses), alopecia, fatigue, anorexia, dyspnea, chest pain & stomatitis o Bone pain tx: nonopioid analgesia (Tylenol) o Splenic rupture can present as referred shoulder pain Nsg Implications: o Do NOT administer 24 hrs before/after chemo o Dosing is ANC dependent Pegfilgrastim (Neulasta) Similar to Neupogen o Do NOT administer days before or 24 hours after cytotoxic chemo o Dosing is ANC dependent ONCE per chemotherapy cycle injection Granulocyte-macrophage CSF (GM-CSF) Sargrasmostim (Leukine) Clonal expression: stimulates specialized line of WBCs to grow Differentiation (maturation) of hemapoietic progenitor cells (stem cells becoming myleoid or lymphoid cellsthis process is stimulated) S/Es: o LIVER DAMAGE, DYSPNEA, RENAL DYSFUNCTION, pleural/pericardial effusions, fever, malaise, sepsis, NVD, alopecia, perpheral edema, CNS disorder o Reduce dose if dyspnea present o Labs: Serum C, bilirrubin, and LFTs o Drug Interactions: lithium & steroids both potentiate GM-CSFs effects Thrombopoietic Growth Factor Oprelvekin (Neumega) Single use vial: unrefrigerated dose used WITHIN 3 HOURS Dont shake vial Platelet growth factorplatelet count increases in 5-9 days Prevents recurrent severe chemo-induced thrombocytopenia Stimulates megakaryocyte and thrombocyte production normal circulating platelets S/Es: o PERIPHERAL EDEMA, EXERTIONAL DYSPNEA (both reversible after D/Cd several days) o Cardiovascular events: A. Fib & A. Flutter o Ventricular arrhythmias10%!! o D/C for brronchospasms or anaphylaxis occurs

Drug Interactions: o Diuretics Increase risk of hypokalemia Decrease in Hgb & serum proteins Increase in plasma fibrinogen Keratinocyte Growth Factor Palifermin (Kepivance) Binds with HEPARIN: flush with NS Cannot be used for CA of skin cells because it increases CA growth for those types Decreases the incidence and duration of severe oral mucositisbig problem for CA pts Initiates proliferation, differentiation & migation of epithelial cells thicker buccal mucosa S/Es: o Skin toxicities, oral toxicities, HTN, Transient inc. in serum lipase/amylase o Tumor stimulation-only use in hematologic malignancies treated with myelotoxic chemo with stem cell support Contraindicated: o Hypersensitivity to E. coli-derived tx or Palifermin o Kepivance binds to Heparin o DO NOT administer 24 hours of myelotoxic chemo Monoclonal Antibodies (Human epidermal growth factor receptor [EGFR]) EGFR1 Targets antigens & receptors on CA cells (targeted therapy) EGFR1 & EGFR2: receptor sites that are turned on in CAalways working in CA cells Monoclonal bodies block RECEPTOR sites Interleukin-2 (IL-2) Aldesleukin (Proleukin) Group of proteins produced by lymphocytes SERIOUS S/Es require that it be administered IV Indications: o Metastic renal cell carcinoma o Metastic melanoma (capillary leak syndrome) S/Es: o ONLY used in pts with NORMAL CARDIAC & PULMONARY function o Infection o Hypotension, sinus tachycardia, arrhythmias, NVD, stomatitis, anorexia, GI bleed, ALOC o Many S/Es require stopping med and restarting slowly