Cytosar-U
cytarabine
cytarabine injection, lipid complex
Pharmacologic class: Antimetabolite, pyrimidine analog
Therapeutic class: Antineoplastic
Pregnancy risk category D
FDA Box Warning
• Drug should be given only by physicians experienced in cancer chemotherapy. For induction therapy, patients should be in facility with adequate resources to monitor drug tolerance and treat drug toxicity. Main toxic effect is bone marrow suppression with leukopenia, thrombocytopenia, and anemia. Less serious toxicities include nausea, vomiting, diarrhea, abdominal pain, oral ulcers, and hepatic dysfunction.
• Prescriber must weigh possible benefit against known toxic effects and should be familiar with complete package insert information.
• Give DepoCyt (liposomal injection) only under supervision of physician experienced with intrathecal cancer chemotherapy, in facility with adequate diagnostic and treatment resources. In all clinical studies, chemical arachnoiditis (manifested mainly by nausea, vomiting, headache, and fever) was common adverse event; unless treated, it may be fatal. Patients receiving DepoCyt should receive dexamethasone concurrently to mitigate arachnoiditis symptoms.
Action
Unclear. Cytotoxic effect may stem from inhibition of DNA polymerase by drug's active metabolite.
Availability
Injection (conventional form): 20 mg Liposomal injection for intrathecal use (sustained-release): 50 mg/5-ml vial Powder for injection (conventional form): 100 mg, 500 mg, 1g, 2 g
Indications and dosages
➣ To induce remission of acute nonlymphocytic leukemia
Adults: Injection (conventional form)-100 mg/m2/day by continuous I.V. infusion on days 1 through 7, or 100 mg/m2 I.V. q 12 hours on days 1 through 7, given with other antineoplastics
➣ Meningeal leukemia
Adults: Injection (conventional form)-5 to 75 mg/m2/day intrathecally for 4 days, or once q 4 days. Most common dosage is 30 mg/m2 q 4 days until cerebrospinal fluid is normal.
➣ Lymphomatous meningitis
Adults: Liposomal injection-50 mg intrathecally q 14 days for two doses (at weeks 1 and 3); then q 14 days for three doses (at weeks 5, 7, and 9), with one additional dose at week 13; then q 28 days for four doses
Contraindications
• Hypersensitivity to drug
• Active meningeal infection (liposomal form)
Precautions
Use cautiously in:
• renal or hepatic disease, active infection, decreased bone marrow reserve, other chronic illnesses
• pregnant or breastfeeding patients.
Administration
• Follow facility procedures for safe handling, administration, and disposal of chemotherapeutic drugs.
• For I.V. injection, reconstitute each 100 mg with 5 ml of diluent (if necessary), and give each 100-mg dose over 1 to 3 minutes. For I.V. infusion, dilute further with 50 to 100 ml of dextrose 5% in water or normal saline solution, and infuse over 30 minutes to 24 hours (depending on dosage and concentration).
• Be aware that conventional and liposomal forms can be administered intrathecally.
See Don't use intrathecal route for formulations containing benzyl alcohol.
• When giving conventional form intrathecally, reconstitute with autologous spinal fluid or preservative-free normal saline solution for injection. Use immediately.
• Patients receiving intrathecal cytarabine should be treated concurrently with dexamethasone to mitigate symptoms of chemical arachnoiditis.
Adverse reactions
CNS: malaise, dizziness, headache, neuritis, neurotoxicity, chemical arachnoiditis
CV: chest pain, thrombophlebitis
EENT: conjunctivitis, visual disturbances including permanent blindness (with liposomal form)
GI: nausea, vomiting, diarrhea, abdominal pain, anal ulcers, esophagitis, esophageal ulcers, oral ulcers (in 5 to 10 days), anorexia, bowel necrosis
GU: urinary retention, renal dysfunction
Hematologic: anemia, megaloblastosis, reticulocytopenia, leukopenia, thrombocytopenia
Hepatic: hepatic dysfunction
Metabolic: hyperuricemia
Musculoskeletal: muscle ache, bone pain
Respiratory: pneumonia, shortness of breath
Skin: rash, pruritus, freckling, skin ulcers, urticaria, alopecia
Other: flulike symptoms, edema, infection, fever, cellulitis at injection site, anaphylaxis, infection (mild to fatal)
Interactions
Drug-drug. Digoxin: decreased digoxin blood level
Fluorocytosine: decreased fluorocytosine blood level
Gentamicin: decreased gentamicin effects
Drug-diagnostic tests. Hemoglobin, platelets, red blood cells, reticulocytes, white blood cells: decreased values
Megaloblasts, uric acid: increased levels
Patient monitoring
• Observe for signs and symptoms of cytarabine syndrome (malaise, fever, muscle ache, bone pain, occasional chest pain, maculopapular rash, and conjunctivitis).
See When giving liposomal form, assess for signs and symptoms of chemical arachnoiditis, such as neck rigidity and pain, nausea, vomiting, headache, fever, and back pain.
• Monitor liver function test results, CBC with differential, platelet count, blood urea nitrogen, and serum creatinine and uric acid levels.
See Observe closely for signs and symptoms of infection, which could become severe and fatal.
Patient teaching
See Tell patient to contact prescriber immediately if he develops signs or symptoms of infection, cytarabine syndrome (malaise, fever, muscle ache, bone pain, chest pain, rash, eye infection), or chemical arachnoiditis (neck rigidity or pain, nausea, vomiting, headache, fever, or back pain).
See Tell patient that drug makes him more susceptible to infection. Advise him to avoid crowds and exposure to illness.
• Advise patient to increase fluid intake, to promote uric acid excretion.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
d
cytarabine
(sye-tare-a-been) cytarabine,cytosine arabinoside
(trade name),Cytosar
(trade name),Cytosar-U
(trade name),DepoCyt
(trade name)Classification
Therapeutic: antineoplasticsPharmacologic: antimetabolites
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (IV, subcut—effects on WBCs; IT—levels in CSF)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| Subcut, IV (1st phase) | 24 hr | 7–9 days | 12 days |
| Subcut, IV (2nd phase) | 15–24 days | 15–24 days | 25–34 days |
| IT | rapid | 5 hr | 14–28 days |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- CNS dysfunction (high dose)
- confusion
- drowsiness
- headache
Ear, Eye, Nose, Throat
- corneal toxicity (high dose)
- hemorrhagic conjunctivitis (high dose)
- visual disturbances (including blindness)
Respiratory
- pulmonary edema (high dose) (life-threatening)
Cardiovascular
- edema
Gastrointestinal
- nausea (most frequent)
- vomiting (most frequent)
- hepatotoxicity
- severe GI ulceration (high dose)
- stomatitis
Genitourinary
- urinary incontinence
Dermatologic
- alopecia
- rash
Endocrinologic
- sterility
Hematologic
- (less with IT use):
- anemia (most frequent)
- leukopenia (most frequent)
- thrombocytopenia (most frequent)
Metabolic
- hyperuricemia
Neurologic
- Intrathecal only:
- chemical arachnoiditis (life-threatening)
- abnormal gait
Miscellaneous
- cytarabine syndrome
- fever
Interactions
Drug-Drug interaction
↑ bone marrow depression with other antineoplastics or radiation therapy.↑ risk of cardiomyopathy when used in high-dose regimens with cyclophosphamide.May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions.May ↓ absorption of digoxin tablets.May ↓ the efficacy of gentamicin when used to treat Klebsiella pneumoniae infections.Recent treatment with asparaginase may ↑ risk of pancreatitis.↑ neurotoxicity with concurrently administered IT antineoplastics (IT only).Route/Dosage
Dose regimens vary widelyAvailability (generic available)
Nursing implications
Nursing assessment
- Monitor for bone marrow depression. Assess for bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis) and avoid IM injections and taking 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 intake and output ratios and daily weights. Report significant changes in totals.
- Monitor for symptoms of gout (increased uric acid, joint pain, edema). Encourage patient to drink at least 2 L of fluid each day. Allopurinol may decrease uric acid levels. Alkalinization of urine may increase excretion of uric acid.
- Assess nutritional status. Nausea and vomiting may occur within 1 hr of administration, especially if IV dose is administered rapidly, less severe if medication is infused slowly. Administering an antiemetic prior to and periodically throughout therapy and adjusting diet as tolerated may help maintain fluid and electrolyte balance and nutritional status.
- Monitor patient for development of cytarabine or ara-C syndrome (fever, myalgia, bone pain, chest pain, maculopapular rash, conjunctivitis, malaise), which usually occurs 6–12 hr following administration. Corticosteroids may be used for treatment or prevention. If patient responds to corticosteroids, continue cytarabine and corticosteroids.
- Assess patient for respiratory distress and pulmonary edema. Occurs with high doses rarely; may be fatal.
- Monitor patient for signs of anaphylaxis (rash, dyspnea, swelling). Epinephrine, corticosteroids, and resuscitation equipment should be readily available.
- Intrathecal: CSF flow should be evaluated prior to IT therapy. Allow DepoCyt to warm to room temperature. Gently agitate or invert to re-suspend particles; do not shake. Administer directly into CSF via an intraventricular reservoir or by direct injection into the lumbar sac slowly over 1–5 min. Following administration by lumbar puncture, patient should lie flat for 1 hr. Chemical arachnoiditis (nausea, vomiting, headache, fever, back pain, CSF pleocytosis and neck rigidity, neck pain, or meningism) is an expected side effect of IT cytarabine. Incidence and severity of symptoms may be decreased with coadministration of dexamethasone. 4 mg bid, PO or IV, for 5 days beginning on day of injection.
- Monitor patients receiving IT therapy continuously for the development of neurotoxicity (myelopathy, personality changes, dysarthria, ataxia, confusion, somnolence, coma). If neurotoxicity develops, decrease amount of subsequent doses and discontinue if neurotoxicity persists. Risk may be increased if cytarabine is administered intrathecally and IV within a few days.
- Lab Test Considerations: Monitor CBC with differential and platelet count prior to and frequently during therapy. Leukocyte counts begin to drop within 24 hr of administration. The initial nadir occurs in 7–9 days. After a small ↑ in the count, the second, deeper nadir occurs 15–24 days after administration. Platelet counts begin to ↓ 5 days after a dose, with a nadir at 12–15 days. Leukocyte and thrombocyte counts usually begin to ↑ 10 days after the nadirs. Therapy is usually withdrawn if leukocyte count is <1000/mm3 or platelet count is <50,000/mm3. Bone marrow aspirations are recommended every 2 wk until remission occurs.
- Monitor renal (BUN and creatinine) and hepatic function (AST, ALT, bilirubin, alkaline phosphatase, and LDH) prior to and routinely during therapy.
- May cause ↑ uric acid concentrations.
Potential Nursing Diagnoses
Risk for infection (Adverse Reactions)Risk for injury (Side Effects)
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: Do not confuse high-dose and regular therapy. Fatalities have occurred with high-dose therapy.
- Solution should be prepared in a biologic cabinet. Wear gloves, gown, and mask while handling IV medication. Discard IV equipment in specially designated containers (see ).
- May be given subcut, direct IV, intermittent IV, continuous IV, or IT.
- Intravenous: Subcutaneous: Reconstitute 100-mg vials with 5 mL of bacteriostatic water for injection with benzyl alcohol 0.9% for a concentration of 20 mg/mL. Reconstitute 500-mg vials with 10 mL for a concentration of 50 mg/mL, 1-g vials with 10 mL, and 2-g vials with 20 mL for a concentration of 100 mg/mL. Reconstituted solution is stable for 48 hr. Do not administer a cloudy or hazy solution.
Intravenous Administration
- pH: 7.0–9.0.
- Diluent: Administer undiluted.Concentration: 100 mg/mL.
- Rate: Administer each 100 mg over 1–3 min
- Intermittent Infusion: Diluent: May be further diluted in 0.9% NaCl, D5W, D10W, D5/0.9% NaCl, Ringer’s solution, LR, or D5/LR.Concentration: Dilute doses in 100 mL of diluent.
- Rate: Infuse over 15–30 min.
- Continuous Infusion: Rate and concentration for IV infusion are ordered individually.
- Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amifostine, amakacin, aminocaproic acid, aminophylline, amphotericin B cholesteryl, amphotericin B lipid complex, amphotericin B liposome, ampicillin, ampicillin/sulbactam, amsacrine, anidulafungin, argatroban, atracurium, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, cladribine, clindamycin, cyclophosphamide, cyclosporine, daunorubicin hydrochloride, dexamethasone phosphate, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doxacurium, doxorubicin hydrochloride, doxorubicin liposome, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenolsopam, fentanyl, filgrastim, fluconazole, fludarabine, foscarnet, fosphenytoin, furosemide, gemcitabine, gentamicin, granisetron, haloperidol, heparin, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, insulin, irinotecan, isoproterenol, ketorolac, labetalol, leucovorin, levofloxacin, levorphanol, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, melphalan, meperidine, meropenem, mesna, methohexital, methotrexate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium acetate, potassium chloride, potassium phosphates, procainamide, prochlorperazine, promethazine, propofol, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trastuzumab, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid
- Y-Site Incompatibility: allopurinol, amiodarone, amphotericin B colloidal, daptomycin, diazepam, ganciclovir, phenytoin
- Intrathecal: Patients receiving liposomal cytarabine should be started on dexamethasone 4 mg twice daily PO or IV for 5 days beginning on the day of liposomal cytarabine injection.
- Allow vial to warm to room temperature. Gently agitate or invert vial to resuspend particles immediately before withdrawal from vial. No further reconstitution or dilution is required with liposomal cytarabine. Reconstitute conventional cytarabine with preservative-free 0.9% NaCl or autologous spinal fluid. Use immediately to prevent bacterial contamination.
- Liposomal cytarabine must be used within 4 hr of withdrawal from the vial. Discard unused portions. Inject directly into CSF via intraventricular reservoir or by direct injection into lumbar sac. Do not use in-line filters.
- Instruct patient to lie flat for 1 hr following IT injection. Monitor for immediate toxic reactions.
Patient/Family Teaching
- Caution patient to avoid crowds and persons with known infections. Report symptoms of infection (fever, chills, cough, hoarseness, sore throat, lower back or side pain, painful or difficult urination) immediately.
- Instruct patient to report unusual bleeding. Advise patient of thrombocytopenia precautions (use soft toothbrush and electric razor, avoid falls, do not drink alcoholic beverages or take medication containing aspirin or NSAIDs; may precipitate gastric bleeding).
- 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. Stomatitis may require treatment with opioid analgesics.
- Instruct patient not to receive any vaccinations without advice of health care professional.
- Advise patient that this medication may have teratogenic effects. Contraception should be used during therapy and for at least 4 mo after therapy is concluded.
- Emphasize the need for periodic lab tests to monitor for side effects.
- Intrathecal: Inform patient about the expected side effects (headache, nausea, vomiting, fever) and about early signs of neurotoxicity. Instruct patient to notify health care professional if these signs occur.
- Emphasize the importance of taking dexamethasone with lyposomal cytarabine.
Evaluation/Desired Outcomes
- Improvement of hematopoietic values in leukemias.
- Decrease in size and spread of the tumor in non-Hodgkin’s lymphomas. Therapy is continued every 2 wk until patient is in complete remission or thrombocyte count or leukocyte count falls below acceptable levels.
- Treatment of lymphomatous meningitis.