BNF for Children 2011-2012

BNFC 2011–2012 8.1 Cytotoxic drugs 415Intrathecal chemotherapyA Health Service Circular (HSC 2008/001) providesguidance on the introduction of safe practice in NHSTrusts where intrathecal chemotherapy is administered;written local guidance covering all aspects ofnational guidance should be available. Support fortraining programmes is also available.Copies, and further information may be obtainedfrom:Department of HealthPO Box 777London SE1 6XHFax: 01623 724524www.dh.gov.ukSafe system requirements for cytotoxic medicines:. Cytotoxic drugs for the treatment of cancer shouldbe given as part of a wider pathway of care that isco-ordinated by a multi-disciplinary team;. Cytotoxic drugs should be prescribed, dispensedand administered only in the context of a writtenprotocol or treatment plan;. Injectable cytotoxic drugs should only be dispensedif they are prepared for administration;. Oral cytotoxic medicines should be dispensed withclear directions for use.Risks of incorrect dosing of oral anti-cancermedicinesThe National Patient Safety Agency has advised(January 2008) that the prescribing and use of oralcytotoxic medicines should be carried out to thesame standard as parenteral cytotoxic therapy. Standardsto be followed to achieve this include:. non-specialists who prescribe or administer oralcytotoxic medication should have access towritten protocols and treatment plans, includingguidance on the monitoring and treatment oftoxicity. staff dispensing oral cytotoxic medicines shouldconfirm that the prescribed dose is appropriatefor the patient. Patients and their carers shouldhave written information that includes details ofthe intended oral anti-cancer regimen, the treatmentplan, and arrangements for monitoring,taken from the original protocol from the initiatinghospital. Staff dispensing oral cytotoxicmedicines should also have access to this information,and to advice from an experiencedcancer pharmacist in the initiating hospitalDosesDoses of cytotoxic drugs are determined using avariety of different methods including age, bodysurfacearea, or body-weight. Alternatively, dosesmay be fixed. Doses may be further adjusted followingconsideration of a patient’s neutrophil count,renal and hepatic function, and history of previousadverse effects to the cytotoxic drug. Doses mayalso differ depending on whether a drug is usedalone or in combination.Because of the complexity of dosage regimens in thetreatment of malignant disease, dose statementshave been omitted from many of the drug entriesin this chapter.Side-effects of cytotoxic drugs andtheir managementSide-effects common to most cytotoxic drugs are discussedbelow whilst side-effects characteristic of a particulardrug or class of drugs (e.g. neurotoxicity withvinca alkaloids) are mentioned in the appropriate sections.Manufacturers’ product literature, hospital-trustprotocols, and treatment protocols should be consultedfor full details of side-effects of individual drugs.Side-effects of cytotoxic drugs often do not occur at thetime of administration, but days or weeks later. It istherefore important that children, their carers, andhealthcare professionals can identify symptoms thatcause concern and can contact an expert for advice.Toxicities should be accurately recorded using a recognisedscoring system such as the Common ToxicityCriteria for Adverse Events (CTCAE) developed by theNational Cancer institute.Extravasation of intravenous drugs A number ofcytotoxic drugs will cause severe local tissue irritationand necrosis if leakage into the extravascular compartmentoccurs. For information on the prevention andmanagement of extravasation injury, see section 10.3.Gastro-intestinal effects Management of gastrointestinaleffects of cytotoxic drugs includes the use ofantacids, H 2 -receptor antagonists, and proton pumpinhibitors to protect the gastric mucosa, laxatives totreat constipation, and enteral and parenteral nutritionalsupport.Oral mucositis Good oral hygiene keeps the mouthclean and moist and helps to prevent mucositis; preventionis more effective than treatment of the complication.Good oral hygiene measures for children over 6months include brushing teeth with a soft small brushwith fluoride toothpaste 2–3 times daily, and rinsing themouth frequently. Daily fluoride supplements (section9.5.3) can be used on the advice of the child’s dentalteam. For children under 6 months or when it is notpossible to brush teeth, carers should be instructed howto clean the mouth using an oral sponge moistened withwater or with an antimicrobial solution such as dilutedchlorhexidine. Mucositis related to chemotherapy canbe extremely painful and may, in some circumstances,require opioid analgesia (section 4.7.2). Secondaryinfection with candida is frequent; treatment with asystemically absorbed antifungal, such as fluconazole(section 5.2), is effective.Nausea and vomiting Nausea and vomiting causeconsiderable distress to many children who receivechemotherapy, and to a lesser extent abdominal radiotherapy,and may lead to refusal of further treatment;prophylaxis of nausea and vomiting is therefore extremelyimportant. Symptoms may be acute (occurringwithin 24 hours of treatment), delayed (first occurringmore than 24 hours after treatment), or anticipatory(occurring prior to subsequent doses). Delayed andanticipatory symptoms are more difficult to controlthan acute symptoms and require different management.Susceptibility to nausea and vomiting may increase withrepeated exposure to the cytotoxic drug.Drugs may be divided according to their emetogenicpotential and some examples are given below, but the8 Malignant disease and immunosuppression