tositumomab

tositumomab (I 131 tositumomab)

Bexxar

Indications

Action

Pharmacokinetics

Time/action profile (depletion of lymphocytes)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• dizziness
• drowsiness
• headache
• weakness

Cardiovascular

• edema
• hypotension

Gastrointestinal

• abdominal pain (most frequent)
• diarrhea (most frequent)
• nausea (most frequent)
• vomiting (most frequent)

Endocrinologic

• hypothyroidism

Hematologic

• neutropenia
• thrombocytopenia
• anemia (most frequent)

Metabolic

• weight loss

Musculoskeletal

• arthralgia
• back pain
• myalgia
• neck pain

Miscellaneous

• hypersensitivity reactions including anaphylaxis (life-threatening)
• infusional toxicity (most frequent)
• fever
• pain
• secondary malignancies

Interactions

Drug-Drug interaction

Route/Dosage

Availability

Nursing implications

Nursing assessment

• Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.
• Monitor for infusional toxicity (fever, rigors, chills, sweating, hypotension, dyspnea, bronchospasm, nausea) during or within 48 hr of infusion; may also occur within 14 days of dosimetric dose. May pretreat with acetaminophen 650 mg and diphenhydramine 50 mg PO 30 min prior to dosimetric and therapeutic steps. If infusional toxicity occurs, slow and/or temporarily interrupt infusion.
• Monitor for signs of hypothyroidism (bradycardia, weight gain, lethargy) periodically during therapy.
• Lab Test Considerations: Monitor CBC prior to and at least weekly for at least 10–12 wks or until severe cytopenias have resolved. May cause thrombocytopenia, neutropenia, and anemia lasting 30–90 days with a nadir in 4–7 wks. If lymphoma marrow involvement is ≥25%, platelet count is <100,000cells/mm³ or neutrophil count is <1,500 cells/mm³, re-evaluate use of tositumomab.
  • May cause hypothyroidism. Monitor serum TSH levels before treatment and annually thereafter.
  • Monitor serum creatinine levels immediately prior to administration.

Potential Nursing Diagnoses

Implementation

• Tositumomab should be used only by health care professionals qualified by training in the safe use of therapeutic radionuclides.
  • All patients must receive thyroid blocking agents; patients unable to tolerate thyroid blocking agents should not receive tositumomab.
  • Reduce infusion rate by 50% for mild to moderate infusional toxicity; interrupt infusion for severe infusional toxicity. When symptoms have resolved, resume rate at 50%.

• Intravenous Administration

• Intermittent Infusion: Diluent: Dilute tositumomab 450 mg in 50 mL of 0.9% NaCl. Concentration: Concentration will be 9 mg/mL. Solution should be clear to opalescent and colorless to slightly yellow. Administer via IV tubing set with a 0.22 micron filter. Same IV tubing set and filter must be used throughout entire dosimetric or therapeutic step. Change in filter can result in loss of drug.
• Rate: Administer over 60 min.
  • Dilute iodine I 131 tositumomab in 30 mL of 0.9% NaCl.
• Rate: Administer over 20 min.

Patient/Family Teaching

• Inform patient that they will have a radioactive material in their body for several days upon discharge from hospital. Provide patient with verbal and written instructions for minimizing exposure to family, friends, and general public.
• Advise patient to use effective contraception for 12 mo following administration. Advise patient not to breastfeed during this time.
• Instruct patient to notify health care professional promptly if fever; chills; cough; hoarseness; sore throat; signs of infection; lower back or side pain; painful or difficult urination; bleeding gums; bruising; petechiae; blood in stools, urine, or emesis; increased fatigue; dyspnea; or orthostatic hypotension occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor and to avoid falls. Caution patient not to drink alcoholic beverages or take medication containing aspirin or NSAIDs; may precipitate gastric bleeding. Explain the need for frequent monitoring.
• May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
• Emphasize the importance of adherence with thyroid blocking agents and need for long-term monitoring.

Evaluation/Desired Outcomes

• Sustained depletion of CD20 lymphocytes, with decreased progression of lymphoma.