VePesid
VePesid
[ve´pe-sid]etoposide (VP-16-213)
etoposide phosphate
Pharmacologic class: Podophyllotoxin derivative
Therapeutic class: Antineoplastic
Pregnancy risk category D
Action
Damages DNA before mitosis by inhibiting topoisomerase II enzyme. This action impairs DNA synthesis and inhibits selected cancer cell growth. Cell-cycle-phase specific.
Availability
Capsules: 50 mg
Injection: 20 mg/ml
Powder for injection (phosphate): 100 mg in single-dose vials
Indications and dosages
➣ Testicular cancer
Adults: 50 to 100 mg/m2 I.V. daily for 5 days. Or 100 mg/m2 I.V. on days 1,3, and 5, with course repeated q 3 to 4 weeks.
➣ Small-cell carcinoma of lung
Adults: 70 mg/m2 (rounded up or down to nearest 50 mg) P.O. daily for 4 days, then a maximum of 100 mg/m2 (rounded up or down to nearest 50 mg) P.O. daily for 5 days every 3 to 4 weeks. Alternatively, 35 mg/m2 I.V. daily for 4 days, then a maximum of 50 mg/m2 I.V. daily for 5 days q 3 to 4 weeks.
Dosage adjustment
• Renal impairment
Off-label uses
• AIDS-related Kaposi's sarcoma
• Wilms' tumor
• Neuroblastoma
• Malignant lymphoma
• Hodgkin's disease
• Ovarian neoplasms
Contraindications
• Hypersensitivity to drug or its components
Precautions
Use cautiously in:
• active infections, decreased bone marrow reserve, renal or hepatic impairment
• pregnant patients and patients with childbearing potential
• breastfeeding patients
• children (safety and efficacy not established).
Administration
• For I.V. concentrations above 0.4 mg/ml, mix each 100 mg with 250 to 500 ml of dextrose 5% in water or normal saline solution, to help prevent crystallization.
• Give I.V. infusion over 30 to 60 minutes. Don't use in-line filter.
See Avoid rapid infusion, which may cause severe hypotension and bronchospasm.
• Administer with antiemetics, as prescribed.
• Wear disposable gloves when handling. If drug comes into contact with skin, wash thoroughly with soap and water.
• Be aware that drug is given with other chemotherapeutic agents.
Adverse reactions
CNS: drowsiness, fatigue, headache, vertigo, peripheral neuropathy
CV: hypotension (with I.V. use), heart failure, myocardial infarction
GI: nausea, vomiting, stomatitis
GU: sterility
Hematologic: anemia, leukopenia, thrombocytopenia, bone marrow depression
Hepatic: hepatotoxicity
Metabolic: hyperuricemia
Musculoskeletal: muscle cramps
Respiratory: pulmonary edema, bronchospasm
Other: alopecia, fever, phlebitis at I.V. site, allergic reactions including anaphylaxis
Interactions
Drug-drug. Live-virus vaccines: increased risk of adverse reactions
Other antineoplastics: additive bone marrow depression
Drug-diagnostic tests. Hemoglobin, neutrophils, platelets, red blood cells, white blood cells: decreased values
Uric acid: increased level
Patient monitoring
See Monitor blood pressure during and after infusion. Stop infusion if severe hypotension occurs.
• With I.V. use, monitor infusion rate closely to prevent infusion reactions.
• Throughout infusion, check I.V. site for extravasation, which may cause thrombophlebitis.
See Keep diphenhydramine, hydrocortisone, epinephrine, and artificial airway at hand in case anaphylaxis occurs.
• Assess for CNS adverse effects. Assist patient during ambulation as needed.
See Monitor for signs and symptoms of bone marrow depression.
• Monitor CBC, liver function tests, and blood urea nitrogen and creatinine levels. Report platelet count below 50,000/mm3 or neutrophil count below 500/mm3.
Patient teaching
• Instruct patient to inspect mouth daily for ulcers and bleeding gums.
See Tell patient to immediately report difficulty breathing or signs and symptoms of allergic reaction.
See Caution female of childbearing age to avoid pregnancy and breastfeeding during drug therapy.
• Instruct patient to move slowly when sitting up or standing, to avoid lightheadedness or dizziness from sudden blood pressure decrease.
• Tell patient drug may cause hair loss.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
etoposide
(e-toe-poe-side) etoposide,VePesid
(trade name),VP-16
(trade name)Classification
Therapeutic: antineoplasticsPharmacologic: podophyllotoxin derivatives
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (noted as effects on blood counts)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | unknown | 7–14 days (granulocytes) 9–16 days (platelets) | 20 days |
| IV | unknown | 7–14 days (granulocytes) 9–16 days (platelets) | 20 days |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- drowsiness
- fatigue
Cardiovascular
- hypotension (IV)
Gastrointestinal
- anorexia (most frequent)
- diarrhea (most frequent)
- nausea (most frequent)
- vomiting (most frequent)
- abdominal pain
- stomatitis
Dermatologic
- alopecia (most frequent)
- pruritis
- rash
- urticaria
Endocrinologic
- sterility
Hematologic
- anemia (most frequent)
- leukopenia (most frequent)
- thrombocytopenia (most frequent)
Local
- phlebitis at IV site
Neurologic
- peripheral neuropathy
Miscellaneous
- allergic reactions including anaphylaxis (life-threatening)
- fever
Interactions
Drug-Drug interaction
↑ bone marrow depression with other antineoplastics or radiation therapy.May alter immune response to live-virus vaccines and ↑ risk of adverse reactions.Route/Dosage
Other regimens are usedTesticular NeoplasmsAvailability (generic available)
Nursing implications
Nursing assessment
- Monitor BP before and every 15 min during infusion. If hypotension occurs, stop infusion and notify physician or other health care professional. After stabilizing BP with IV fluids and supportive measures, infusion may be resumed at slower rate.
- Monitor for hypersensitivity reaction (fever, chills, dyspnea, pruritus, urticaria, bronchospasm, tachycardia, hypotension). If these occur, stop infusion and notify physician. Keep epinephrine, an antihistamine, corticosteroids, volume expanders, and resuscitative equipment close by in the event of an anaphylactic reaction.
- Assess for signs of infection (fever, chills, cough, hoarseness, lower back or side pain, sore throat, difficult or painful urination). Notify physician if these symptoms occur.
- Assess for bleeding (bleeding gums, bruising, petechiae, guaiac test stools, urine, and emesis). Avoid IM injections and taking rectal temperatures. Apply pressure to venipuncture sites for 10 min.
- Monitor intake and output, appetite, and nutritional intake. Etoposide causes mild-to-moderate nausea and vomiting. Prophylactic antiemetics may decrease frequency and duration of nausea and vomiting.
- Adjust diet as tolerated to help maintain fluid and electrolyte balance and nutritional status.
- Lab Test Considerations: Monitor CBC and differential before and periodically during therapy. The nadir of leukopenia occurs in 7–14 days. Notify physician if absolute neutrophil count is <1000/mm3. The nadir of thrombocytopenia occurs in 9–16 days. Notify physician if the platelet count is <75,000/mm3. Recovery of leukopenia and thrombocytopenia occurs in 20 days.
- Monitor liver function studies (AST, ALT, LDH, bilirubin) and renal function studies (BUN, creatinine) before and periodically during therapy to detect hepatotoxicity and nephrotoxicity.
Potential Nursing Diagnoses
Risk for injury (Side Effects)Risk for infection (Side Effects)
Implementation
- high alert: Fatalities have occurred with incorrect administration of 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. Do not confuse VePesid (etoposide) with Versed (midazolam). Do not confuse etoposide (VePesid) with etoposide phosphate (Etopophos).
- Solution should be prepared in a biologic cabinet. Wear gloves, gown, and mask while handling medication. Discard equipment in designated containers.
- Avoid contact with skin. Use Luer-Lok tubing to prevent accidental leakage. If contact with skin occurs, immediately wash skin with soap and water.
- Oral: Capsules should be refrigerated. Capsules are stable for 24 mo when refrigerated.
- Intermittent Infusion: Dilute with D5W or 0.9% NaCl to achieve a final concentration of 0.2–0.4 mg/mL (concentrations > 0.4 mg/mL may result in precipitation occurring). The 0.2 mg/mL solution is stable for 96 hr. The 0.4 mg/mL solution is stable for 48 hr. Discard solution if precipitate forms.
- Rate: Infuse slowly over 30–60 min. Temporary hypotension may occur with infusion rates shorter than 30 min.
- Y-Site Compatibility: allopurinol, amifostine, aztreonam, cladribine, doxorubicin liposome, fludarabine, gemcitabine, granisetron, melphalan, ondansetron, paclitaxel, piperacillin/tazobactam, sargramostim, sodium bicarbonate, teniposide, thiotepa, topotecan, vinorelbine
- Y-Site Incompatibility: cefepime, filgrastim, idarubicin
- Additive Compatibility: carboplatin, cisplatin, cytarabine, floxuridine, fluorouracil, hydroxyzine, ifosfamide, ondansetron
Patient/Family Teaching
- Instruct patient to take etoposide exactly as directed, even if nausea or vomiting occurs. If vomiting occurs shortly after dose is taken, consult physician. If a dose is missed, do not take at all.
- Advise patient to notify health care professional if fever; chills; sore throat or other signs of infection; bleeding gums; bruising; petechiae; 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. Caution patient not to drink alcoholic beverages or take products containing aspirin or NSAIDs.
- Instruct patient to notify health care professional if rapid heartbeat, difficulty breathing, abdominal pain, yellow skin/eyes, weakness, paresthesia, or gait disturbances occur.
- Instruct patient to inspect oral mucosa for redness and ulceration. If mouth sores occur, advise patient to use sponge brush and rinse mouth with water after eating and drinking. Viscous lidocaine swishes may be used if pain interferes with eating. Stomatitis pain may require treatment with opioid analgesics.
- Discuss with patient the possibility of hair loss. Explore coping strategies.
- Advise patient to use contraception.
- Instruct patient not to receive any vaccinations without advice of physician.
- Emphasize the need for periodic lab tests to monitor for side effects.
Evaluation/Desired Outcomes
- Decrease in size or spread of malignancies in solid tumors.