Proleukin
aldesleukin (interleukin-2, IL-2)
Pharmacologic class: Interleukin-2 (IL-2), human recombinant (cytokine)
Therapeutic class: Antineoplastic (miscellaneous)
Pregnancy risk category C
FDA Box Warning
• Give only to patients with normal cardiac and pulmonary function, as shown by thallium stress testing and pulmonary function testing. Use extreme caution when giving to patients with normal thallium stress test and normal pulmonary function tests who have a history of cardiac or pulmonary disease.
• Give under supervision of physician experienced in cancer chemotherapy, in setting where intensive care facilities and cardiopulmonary or intensive care specialists are available.
• Drug is linked to capillary leak syndrome, which causes hypotension and reduced organ perfusion (possibly severe and resulting in death).
• Before starting drug, preexisting bacterial infections must be treated, because drug may impair neutrophil function and increase disseminated infection risk. Patients with indwelling central lines are at special risk for infection with gram-positive microorganisms. Prophylactic antibiotics can help prevent staphylococcal infections.
• Withhold drug in patients who develop moderate to severe lethargy or somnolence; continued administration may cause coma.
Action
Activates cellular immunity and inhibits tumor growth by increasing lymphocytes and cytokines, which lyse tumor cells
Availability
Injection: 22 million international units/vial
Indications and dosages
➣ Metastatic renal cell carcinoma and metastatic melanoma
Adults older than age 18: 600,000 international units/kg I.V. given over 15 minutes q 8 hours for a maximum of 14 doses, followed by 9 days of rest. Repeat for another 14 doses, for a maximum of 28 doses per course.
Off-label uses
• Colorectal cancer
• Kaposi's sarcoma
• Non-Hodgkin's lymphoma
Contraindications
• Hypersensitivity to drug
• Arrhythmias, cardiac tamponade, seizures, severe GI bleeding, coma or toxic psychosis lasting more than 48 hours
• Organ allograft
• Abnormal thallium stress test or pulmonary function test results
Precautions
Use cautiously in:
• anemia, bacterial infections, heart disease, CNS metastases, hepatic disease, pulmonary disease, renal disease, thrombocytopenia
• pregnant or breastfeeding patients
• children.
Administration
• Make sure patient's thallium stress test and pulmonary function test results are normal before giving.
See Don't give if patient is drowsy or severely lethargic; contact prescriber immediately.
• Reconstitute drug according to label directions with 1.2 ml of sterile water for injection by injecting diluent against side of vial (to prevent excessive foaming).
• Further dilute reconstituted dose with 50 ml of 5% dextrose injection.
• Administer I.V. infusion over 15 minutes.
• Don't use in-line filter.
Adverse reactions
CNS: dizziness, mental status changes, syncope, sensory or motor dysfunction, headache, fatigue, rigors, weakness, malaise, poor memory, depression, sleep disturbances, hallucinations
CV: bradycardia, sinus tachycardia, premature atrial complexes, premature ventricular contractions, arrhythmias, myocardial ischemia, cardiac arrest, capillary leak syndrome and severe hypotension, myocardial infarction EENT: reversible vision changes, conjunctivitis
GI: nausea, vomiting, diarrhea, constipation, dyspepsia, abdominal pain, stomatitis, anorexia, intestinal perforation, ileus, GI bleeding
GU: hematuria, proteinuria, dysuria, renal failure, oliguria or anuria Hematologic: anemia, purpura, eosinophilia, thrombocytopenia, coagulation disorders, leukopenia, leukocytosis
Hepatic: jaundice, ascites
Metabolic: hyperglycemia, hypoglycemia, acidosis, alkalosis
Musculoskeletal: joint and back pain, myalgia
Respiratory: cough, chest pain, tachypnea, wheezing, dyspnea, pulmonary congestion, pulmonary edema, respiratory failure, apnea, pleural effusion
Skin: erythema, pruritus, rash, dry skin, petechiae, urticaria, exfoliative dermatitis
Other: weight gain or loss, fever, chills, edema, infection, pain or reaction at injection site, hypersensitivity reaction
Interactions
Drug-drug. Aminoglycosides, asparaginase, cytotoxic chemotherapy agents, doxorubicin, indomethacin, methotrexate: increased toxicity
Antihypertensives: increased hypotensive effect
Glucocorticoids: reduced antitumor effects
Drug-diagnostic tests. Alkaline phosphatase, bilirubin, glucose, blood urea nitrogen, creatinine, potassium, transaminases: increased levels
Calcium, glucose, magnesium, phosphorus, potassium, protein sodium, uric acid: decreased levels
Patient monitoring
• Monitor heart rate and rhythm, vital signs, and fluid intake and output.
• Assess for signs and symptoms of hypersensitivity reaction and infection.
• Monitor for adverse CNS effects. Report these immediately.
• Evaluate chest X-rays.
• Monitor CBC, electrolyte levels, and liver and kidney function test results.
Patient teaching
See Tell patient that drug lowers resistance to infections. Advise him to immediately report fever, cough, breathing problems, and other signs or symptoms of infection.
See Advise patient to immediately report chest pain, irregular or fast heart beats, easy bruising or bleeding, or abdominal pain.
• Instruct patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• Provide dietary counseling. Refer patient to dietitian if adverse GI effects significantly limit food intake.
• Notify patient that he'll undergo blood testing and have chest X-rays taken during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
aldesleukin
(al-dess-loo-kin) aldesleukin,interleukin-2
(trade name),IL-2
(trade name),Proleukin
(trade name)Classification
Therapeutic: antineoplasticsPharmacologic: interleukins
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (tumor regression after completion of first course)
| ROUTE | ONSET | PEAK | DURATION |
| IV | 4 wk | unknown | 12 mo |
Contraindications/Precautions
Adverse Reactions/Side Effects
Respiratory
- apnea (life-threatening)
- respiratory failure (life-threatening)
- dyspnea (most frequent)
- pulmonary congestion (most frequent)
- pulmonary edema (most frequent)
- hemoptysis
- pleural effusion
- pneumothorax
- tachypnea
- wheezing
Cardiovascular
- cardiac arrest (life-threatening)
- HF (life-threatening)
- MI (life-threatening)
- stroke (life-threatening)
- arrhythmias (most frequent)
- hypotension (most frequent)
- tachycardia (most frequent)
- myocardial ischemia
- pericardial effusion
- thrombosis
Gastrointestinal
- bowel perforation (life-threatening)
- diarrhea (most frequent)
- jaundice (most frequent)
- nausea (most frequent)
- stomatitis (most frequent)
- vomiting (most frequent)
- ascites
- hepatomegaly
Genitourinary
- oliguria/anuria (most frequent)
- proteinuria (most frequent)
- dysuria
- hematuria
- renal failure
Dermatologic
- exfoliatative dermatitis (life-threatening)
- pruritus (most frequent)
Fluid and Electrolyte
- acidosis (most frequent)
- hypocalcemia (most frequent)
- hypokalemia (most frequent)
- hypomagnesemia (most frequent)
- hypophosphatemia (most frequent)
- hyperkalemia
- hyperuricemia
- hyponatremia
- metabolic alkalosis
Hematologic
- anemia (most frequent)
- coagulation disorders (most frequent)
- leukopenia (most frequent)
- thrombocytopenia (most frequent)
- eosinophilia
- leukocytosis
Miscellaneous
- capillary leak syndrome (life-threatening)
- chills (most frequent)
- fever (most frequent)
- weight gain
- weight loss
Interactions
Drug-Drug interaction
Corticosteroids decrease antineoplastic effectiveness. Avoid concurrent use with aldesleukin.Additive hypotension may occur with antihypertensives.Concurrent cardiotoxic, hepatotoxic, myelotoxic, or nephrotoxic drug therapy ↑ the risk of toxicity in these organs.Route/Dosage
Availability
Nursing implications
Nursing assessment
- Monitor ECG continuously during infusion. Cardiac function, including thallium stress testing, should be determined prior to initiation of therapy. Supraventricular arrhythmias may respond to digoxin or verapamil and usually resolve after completion of therapy.
- Monitor vital signs at least daily throughout therapy. Fever, chills, rigors, and malaise usually occur within hours of administration. Acetaminophen and an NSAID, such as indomethacin, should be administered prior to initiation of aldesleukin therapy to reduce fever. Meperidine may be given to control rigors associated with fever.
- Assess patient for the development of capillary leak syndrome (hypotension, hypovolemia, edema, ascites, pleural effusions). This initially manifests as a drop in arterial BP beginning 2–12 hr from start of administration. If BP decreases to <90 mmHg, constant ECG monitoring, hourly vital signs, and CVP monitoring are recommended.
- Monitor respiratory status and pulse oximetry frequently. Pulmonary function tests, including arterial blood gases, and chest x-ray should be monitored prior to and periodically throughout therapy. Pulmonary toxicity (respiratory failure, tachypnea, wheezing) and pulmonary infiltration may become apparent by the 4th day of therapy and usually resolve within a few weeks after therapy. Respiratory failure may require intubation.
- Monitor weight daily. Weight gain during therapy may be more than 10% of pretreatment weight. Reversal of weight gain, via diuresis of fluid, may take up to 1–2 wk after therapy.
- Monitor for changes in mental status. Hold administration if patient develops moderate-to-severe lethargy or somnolence. Low doses of haloperidol have been used for debilitating mental status changes.
- Assess frequently for signs of infection, particularly sepsis and bacterial endocarditis. Antibiotic prophylaxis directed against Staphylococcus aureus may be used for patients with central lines. Any intercurrent infections should be managed aggressively. Aldesleukin impairs the function of WBCs.
- Assess for signs of anemia (increased fatigue, dyspnea, orthostatic hypotension) and bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis). Ranitidine or cimetidine may be given for prophylaxis of GI irritation and bleeding. Transfusions of RBCs and/or platelets may be required.
- Assess nutrition and bowel status. Stomatitis may require a liquid diet or initiation of parenteral nutrition. Nausea, vomiting, and diarrhea occur in most patients and may lead to hypokalemia and acidosis. Antiemetics and antidiarrheals may be given as needed and are usually discontinued 12 hr after last dose.
- Assess skin daily for rash or blisters on skin. Notify health care professional if these occur; exfoliative dermatitis can be fatal.
- Lab Test Considerations: Monitor CBC, differential, platelet count, blood chemistries including electrolytes, and renal and hepatic function prior to and daily throughout therapy. May cause elevated bilirubin, BUN, serum creatinine, transaminase, and alkaline phosphatase levels. May cause anemia, thrombocytopenia, hypomagnesemia, acidosis, hypocalcemia, hypophosphatemia, hypokalemia, hyperuricemia, hypoalbuminemia, and hypoproteinemia.
- Monitor thyroid function periodically during therapy.
Potential Nursing Diagnoses
Risk for infection (Side Effects)Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Implementation
- 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.
- high alert: Aldesleukin should be administered only in a hospital setting with intensive care facilities.
Intravenous Administration
- Intermittent Infusion: Reconstitute each vial with 1.2 mL of sterile water for injection. Concentration: 18 million IU (1.1 mg)/mL. Direct the sterile water at the side of the vial during reconstitution and swirl contents gently to prevent excessive foaming. Do not shake. Solution should be clear and colorless to slightly yellow. Administer within 48 hr of reconstitution. Discard unused portion.
- Diluent: Dilute reconstituted dose in 50 mL of D5W. Do not reconstitute or dilute with bacteriostatic water for injection, 0.9% NaCl, or albumin.
- Do not use an in-line filter during administration of aldesleukin.
- Rate: Infuse each dose over 15 min.
- Y-Site Compatibility: amikacin, amphotericin B colloidal, calcium gluconate, diphenhydramine,. fluconazole, foscarnet, gentamicin, magnesium sulfate, metoclopramide, morphine, ondansetron, ranitidine, tobramycin, trimethoprim/sulfamethoxazole, vancomycin
- Y-Site Incompatibility: fluorouracil, ganciclovir, lorazepam, pentamidine, prochlorperazine, promethazine, rituximab, trastuzumab
- Additive Incompatibility: Do not mix with other drugs.
Patient/Family Teaching
- Instruct patient to notify health care professional if dyspnea, sore throat, fever, chills, yellow skin, unusual bleeding or bruising, or fatigue occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use a soft toothbrush and electric razor and to be especially careful to avoid falls. Patients should be cautioned not to drink alcohol or take medication containing aspirin or NSAIDs, because these may precipitate gastric bleeding.
- Inform patient that visual problems usually begin shortly after aldesleukin administration and may persist for several weeks but are reversible.
- Advise patient to use a nonhormonal method of contraception throughout therapy.
Evaluation/Desired Outcomes
- Decrease in size or spread of renal cell carcinoma.