FDA Box Warning
Give under supervision of physician experienced in cancer chemotherapy.
Hematopoietic depression is most common toxicity; hepatic necrosis has also occurred.
Drug is carcinogenic and teratogenic in animals.
Prescriber must weigh potential benefit against toxicity risk.
Unclear. Thought to inhibit DNA synthesis by acting as purine analog. Also causes alkylation and may interact with sulfhydryl groups.
Injection: 100-mg and 200-mg vials
⊘Indications and dosages
➣ Hodgkin's disease
Adults: 150 mg/m2 I.V. daily for 5 days in combination with other drugs, repeated q 4 weeks. Or 375 mg/m2 I.V. on first day of combination therapy, repeated q 15 days.
➣ Metastatic malignant melanoma
Adults: 2 to 4.5 mg/kg I.V. daily for 10 days, repeated q 4 weeks. Or 250 mg/m2 I.V. daily for 5 days, repeated q 3 weeks.
• Malignant pheochromocytoma
• Hypersensitivity to drug
Use cautiously in:
• hepatic dysfunction, impaired bone marrow function
• pregnant or breastfeeding patients
• Follow facility procedures for safe handling, administration, and disposal of chemotherapeutic drugs.
• Reconstitute with sterile water for injection according to manufacturer's directions.
• Further dilute reconstituted drug with 5% dextrose in water or normal saline solution.
Administer over 30 to 60 minutes by I.V. infusion only.
Take steps to prevent extravasation, which may cause tissue damage and severe pain.
CNS: malaise, paresthesia
GI: nausea, vomiting, dyspepsia, anorexia
Hematologic: anemia, leukopenia, thrombocytopenia, bone marrow depression
Skin: dermatitis, erythematous or urticarial rash, alopecia, flushing, photosensitivity
Others: flulike symptoms, fever, hypersensitivity reactions including anaphylaxis
Drug-diagnostic tests.Platelets, red blood cells, white blood cells: decreased counts
Drug-behaviors.Sun exposure: photosensitivity reaction
Frequently monitor CBC with white cell differential and platelet count. Know that hematopoietic depression is the most common toxicity and can be fatal.
• Assess infusion site closely for extravasation.
Instruct patient to immediately report pain, burning, or swelling at infusion site; numbness in arms or legs; gait changes; respiratory distress; difficulty breathing; rash; or easy bruising or bleeding.
• Advise patient to minimize GI distress by eating small, frequent servings of healthy food and drinking plenty of fluids.
• Tell patient he'll undergo regular blood testing during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the tests and behaviors mentioned above.
Pharmacologic class: Potassium channel blocker
Therapeutic class: Multiple sclerosis agent
Pregnancy risk category C
Unknown. May increase conduction of action potentials in demyelinated axons through inhibition of potassium channels.
Tablets (extended release): 10 mg
⊘Indications and dosages
➣ To improve walking in patients with multiple sclerosis
Adults: 10 mg P.O. q 12 hours
• Mild renal impairment
• History of seizures
• Moderate or severe renal impairment
Use cautiously in:
• mild renal impairment
• pregnant or breastfeeding patients
• children younger than age 18 (safety and efficacy not established).
• Check creatinine clearance before starting drug.
• Administer with or without food.
CNS: insomnia, dizziness, headache, asthenia, balance disorder, paresthesia, seizures
EENT: nasopharyngitis, pharyngolaryngeal pain
GI: nausea, constipation, dyspepsia
GU: urinary tract infection
Musculoskeletal: back pain
Other: multiple sclerosis relapse
Discontinue drug if seizure occurs.
• Monitor renal function tests regularly (especially creatinine clearance).
• Instruct patient to take drug with or without food.
• Instruct patient to swallow tablet whole and not to break, crush, chew, or dissolve it.
Advise patient to discontinue drug and immediately report to prescriber if seizures occur.
• Instruct patient to promptly report urinary tract problems.
• As appropriate, review all other significant and life-threatening adverse reactions.
Pharmacologic: alkylating agents
Time/action profile (effects on blood counts)
|IV (WBCs)||16–20 days||21–25 days||3–5 days|
|IV (platelets)||unknown||16 days||3–5 days|
Adverse Reactions/Side Effects
- hepatic necrosis (life-threatening)
- anorexia (most frequent)
- nausea (most frequent)
- vomiting (most frequent)
- hepatic vein thrombosis
- facial flushing
- gonadal suppression
- anemia (most frequent)
- leukopenia (most frequent)
- thrombocytopenia (most frequent)
- pain at IV site (most frequent)
- phlebitis at IV site
- tissue necrosis
- facial paresthesia
- anaphylaxis (life-threatening)
- flu-like syndrome
Drug-Drug interactionAdditive bone marrow depression with other antineoplastics.Carbamazepine, phenobarbital, and rifampin may ↑ metabolism and decrease effectiveness.Blood levels may be ↑ with amiodarone, ciprofloxacin, fluvoxamine, ketoconazole, norfloxacin, ofloxacin, isoniazid, or miconazole.May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions.
Route/DosageOther regimens are used
- Monitor vital signs prior to and frequently during therapy.
- Monitor for bone marrow depression. Assess for bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis) and avoid IM injections and rectal temperatures if platelet count is low. Apply pressure to venipuncture sites for 10 min. Assess for signs of infection during neutropenia. Anemia may occur. Monitor for increased fatigue, dyspnea, and orthostatic hypotension.
- Monitor IV site closely. Dacarbazine is an irritant. Instruct patient to notify health care professional immediately if discomfort at IV site occurs. Discontinue IV immediately if infiltration occurs. Applications of hot packs may relieve pain, burning sensation, and irritation at injection site.
- Monitor intake and output, appetite, and nutritional intake. Assess for nausea and vomiting, which may be severe and last 1–12 hr. Administration of an antiemetic prior to and periodically during therapy, restricting oral intake for 4–6 hr prior to administration, and adjusting diet as tolerated may help maintain fluid and electrolyte balance and nutritional status. Nausea usually decreases on subsequent doses.
- Lab Test Considerations: Monitor CBC and differential prior to and periodically throughout therapy. The nadir of thrombocytopenia occurs in 16 days. The nadir of leukopenia occurs in 3–4 wk. Recovery begins in 5 days. Withhold dose and notify physician if platelet count is <100,000/mm3 or leukocyte count is <4000/mm3.
- Monitor for increased AST, ALT, BUN, and serum creatinine. May cause hepatic necrosis.
Potential Nursing DiagnosesRisk for infection (Side Effects)
Risk for injury (Side Effects)
- high alert: Fatalities have occurred with chemotherapeutic 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.
- pH: 3.0–4.0.
- Prepare solution in a biologic cabinet. Wear gloves, gown, and mask while handling medication. Discard equipment in designated containers (see ).
- Reconstitute each 200-mg vial with 19.7 mL of sterile water for injection. Solution is colorless or clear yellow. Do not use solution that has turned pink. Concentration: 10 mg/mL. Solution is stable for 8 hr at room temperature and for 72 hr if refrigerated.
- Intermittent Infusion: Diluent: Further dilute with up to 250 mL of D5W or 0.9% NaCl. Stable for 24 hr if refrigerated or 8 hr at room temperature.
- Rate: Administer over 30–60 min.
- Y-Site Compatibility: amifostine, aztreonam, bivalirudin, caspofungin, daptomycin, dexmedetomidine, docetaxel, doxorubicin liposome, ertapenem, etoposide phosphate, fenoldopam, filgrastim, fludarabine, granisetron, hetastarch, levofloxacin, mechlorethamine, melphalan, nesiritide, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron, quinupristin/dalfopristin, sargramostim, teniposide, thiotepa, tigecycline, tirofiban, vinorelbine, voriconazole
- Y-Site Incompatibility: allopurinol, amphotericin B liposome, cefepime, pantoprazole, pemetrexed, piperacillin/tazobactam
- Instruct patient to notify health care professional if fever; chills; sore throat; signs of infection; bleeding gums; bruising; petechiae; abdominal pain; yellowing of eyes; or blood in urine, stool, or emesis occurs. Caution patient to avoid crowds and persons with known infections. 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; may increase GI irritation.
- May cause photosensitivity. Instruct patient to avoid sunlight or wear protective clothing and use sunscreen for 2 days after therapy.
- Instruct patient to inform health care professional if flu-like syndrome occurs. Symptoms include fever, myalgia, and general malaise. May occur after several courses of therapy. Usually occurs 1 wk after administration. May persist for 1–3 wk. Acetaminophen may be used for relief of symptoms.
- Discuss with patient the possibility of hair loss. Explore coping strategies.
- Advise patient of the need for a nonhormonal method of contraception.
- Instruct patient not to receive any vaccinations without advice of health care professional.
- Decrease in size and spread of malignant melanoma or Hodgkin’s lymphoma.