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Notes for: Cytotoxic Drugs
Last edited [27/06/2012 08:42:11]

The chemotherapy of cancer is complex and should be confined to specialists in oncology, hence this chapter provides general information and is not a detailed listing of all medicines used in chemotherapy. The National Patient Safety Agency has issued an alert (January 2008) to all healthcare staff involved in the use of oral anti-cancer medicines of potentially fatal outcomes if incorrect doses of these medicines are used. These oral anti-cancer medicines are used in hospitals and in the community. Risks are increased if non-specialist practitioners prescribe, dispense or administer these oral medicines and bypass the normal safeguards used for injectable anti-cancer medicine.

NPSA recommendations include:

  • Treatment should be initiated by a cancer specialist.
  • All oral anti-cancer medicines should be prescribed only in the context of a written protocol and treatment plan.
  • Non-specialists who prescribe or administer on-going oral anti-cancer medication should have ready access to appropriate written protocols and treatment plans including guidance on monitoring and treatment of toxicity.
  • Staff dispensing oral anti-cancer medicines should be able to confirm that the prescribed dose is appropriate for the patient, and that the patient is aware of the required monitoring arrangements, by having access to information in the written protocol and treatment plan from the hospital where treatment is initiated and advice from a pharmacist with experience in cancer treatment in that hospital.

However it is inevitable that patients actively undergoing chemotherapy will contact other doctors regarding their symptoms. Should you require any additional information regarding management please contact the following at Royal Cornwall Hospitals NHS Trust:

Ward: 01872-252050

Oncology clinic: 01872-258300

Haematology clinic: 01872-252501


Last edited [27/06/2012 08:43:21]

Adverse effects: 

The following are common side effects that may affect patients taking cytotoxic drugs; any other specific effects are noted together with the drug information.

Neutropenia: Can be life threatening and requires urgent investigation and treatment. Patients undergoing chemotherapy presenting with signs of infection (eg temp > 38 oC, rigors, unexplained diarrhoea, systemic infection) require immediate hospital admission for an urgent full blood count/blood cultures, and empirical treatment with antibiotics as necessary. See RCHT policy Management of suspected infection in neutropaenic patients.

Thrombocytopenia: Patients undergoing chemotherapy, presenting with bruising, epistaxis, or bleeding, require an urgent full blood count. Patients with bleeding/bruising or those with platelets less than 10 x 109 / L, require urgent hospital admission for platelet support. Repeat blood counts at 24 - 48 hour intervals until the platelet count begins to rise.

Anaemia: Patients with symptomatic anaemia and haemoglobin of less than 8 - 10 g / dL require transfusion. This can often be arranged at their next routine attendance. Patients with anaemia related to bone marrow suppression should not receive oral iron. If the cause of the anaemia is unclear, B12, folate, iron and transferrin saturation are useful distinguishing investigations.

Nausea and vomiting: Adult oncology patients receiving highly emetogenic chemotherapy are routinely given the following oral anti-emetics on discharge: -

Ondansetron 8 mg BD for 1 day.

+ Dexamethasone 2 mg TDS for 3 days.

+ Metoclopramide 10 mg TDS for 3 - 7 days or, Domperidone 10 - 20 mg TDSfor 7 days

Ondansetron (and often dexamethasone) may be omitted for low emetogenic regimes. Domperidone suppositories 60 mg PR BD are useful if the patient is unable to tolerate tablets, and is not neutropenic. Granisetron and Ondansetron are extremely effective in the management of acute emesis (ie within 24 hours of chemotherapy) but are much less active in delayed emesis.

Patients on a less emetogenic chemotherapy regime may not require the full dose of anti-emetic therapy.

Haematology patients may be given similar regimes thought may have the steroid omitted.

See RCHT policy Anti Emetic Guidelines for the Prevention and Treatment of Chemotherapy induced Emesis.

Mucositis and mouthcare: The patient’s mouth may become sore or dry during treatment, they may also experience taste changes. For patients undergoing chemotherapy, general mouth care is important and the use of a mouthwash is helpful. Patients requiring mouth care are prescribed prophylactic mouthwashes (chlorhexidine or benzydamine). Itraconazole 600 mg capsules daily or 5 mg / kg solution is routinely prescribed for patients at high risk of aspergillous infection (eg bone marrow transplant patients and those with acute leukaemia) BUT is contraindicated in patients on vinca alkaloids eg vincristine, vinorelbine, vinblastine, vindesine. If oral candidiasis is suspected in non-high risk patients fluconazole (50 - 100 mg PO OD for 7 days) is indicated.

Guidelines for mouthcare in patients undergoing radiotherapy to their head and neck: Treat with Gelclair, Adcortyl in Orabase®, and frequent mouth rinse with nystatin or fluconazole. Artificial saliva preparations may also be used.

Caution should be taken when prescribing benzydamine hydrochloride or chlorhexidine gluconate mouthwashes as these can burn and cause extra discomfort. Please seek advice for further guidance.

Extravasation injury: If a patient who has recently been given chemotherapy begins to experience pain, redness or swelling around the site of injection, please refer immediately to the department in which they were treated. There is RCHT guidance on on the management of extravasation of cytotoxic drugs in adults and in children.

Diarrhoea: Patients should drink plenty of fluid. Oral rehydration salts or loperamide may be used in recommended dosages. If diarrhoea is persistent antibiotics may be necessary according to clinical need or type of chemotherapy, seek further advice.

Alopecia: Reversible hair loss is a common complication, although it varies in degree between drugs and individual patients.

Fatigue: Patients should be advised that it is important to allow plenty of time for rest during treatment. Gentle exercise such as walking should be encouraged. Anaemia or depression should be excluded as a cause.

Skin changes: Skin hyperpigmentation may occur, also rashes and irritation, appropriate treatments should be prescribed.

Hand and foot syndrome: A symptom associated with specific chemotherapy. Patients will be advised about skin care and avoiding extremes of hot and cold. For acute/severe reactions seek further advice.

Other points to note:

Vaccination: Live vaccines should be avoided for patients having chemotherapy. These include polio, measles, rubella, MMR and yellow fever. Patients on chemotherapy can be given the following vaccines: influenza, whooping cough, diphtheria, tetanus, hepatitis B, rabies, cholera and anthrax. (Note an alternative inactivated polio vaccination is available).

Psychological support: Experience indicates that patients receiving chemotherapy need extra psychological support during their treatment.

Patients on chemotherapy at home: Patients may receive continuous infusions of chemotherapy via a portable infusion device (Graseby, Intermate, Multi-day Infusor and Surefuser) at home. Patients are instructed of the ‘do’s and don’ts’ with these devices. If a patient presents with a blocked line or leaking device, advice should be sought from the appropriate ward / outpatient department.


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Antibiotics Antibiotics

NameTariffBNF Sub Paragraph
2.5 mg tab Pack of 100
£4.80PCT FORMULARY STATUSSpecialist Initiated Drugs AntimetabolitesView BNF Article on 'Methotrexate'View SPC on 'Methotrexate'View PIL on 'Methotrexate'
Used as a weekly dose only
50 mg tablets Pack of 25
£8.45PCT FORMULARY STATUS: Specialist Initiated Drugs AntimetabolitesView BNF Article on 'Mercaptopurine 'View SPC on 'Mercaptopurine 'View PIL on 'Mercaptopurine '
Fluorouracil Cream (Efudix)
5 % cream (40g tube) Pack of 40
£32.90PCT FORMULARY STATUS: Specialist Initiated Drugs AntimetabolitesView BNF Article on 'Fluorouracil Cream'View SPC on 'Fluorouracil Cream'View PIL on 'Fluorouracil Cream'
Mercaptopurine Solution
100 mg / 5 mL Suspension (Special) Pack of 1
- PCT FORMULARY STATUS: Hospital Only Drugs AntimetabolitesView BNF Article on 'Mercaptopurine Solution'View SPC on 'Mercaptopurine Solution'View PIL on 'Mercaptopurine Solution'

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