carmustine

Absorption: Following IV administration, absorption is complete. Following implantation, action is primarily local.

Distribution: Highly lipid soluble; readily penetrates CSF. Enters breast milk.

Metabolism/Excretion: Rapidly metabolized. Some metabolites have antineoplastic activity.

Half-Life: Biologic: 15–30 min; chemical: 5 min.

Time/Action Profile ⬆ ⬇

(effect on platelet counts)

ROUTE	ONSET	PEAK	DURATION
IV	days	4–5 wk	6 wk

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity;
OB: Pregnancy (may cause fetal harm);
Lactation: Lactation.

Use Cautiously in:

Infections;
Depressed bone marrow reserve;
Impaired pulmonary, hepatic, or renal function;
Other chronic debilitating illnesses;
Rep: Women of reproductive potential or men with female partners of reproductive potential;
Geri: Consider age related in body mass, renal/hepatic/cardiovascular function, concurrent medications and chronic illnesses.

Adv. Reactions/Side Effects ⬆ ⬇

Derm: alopecia

GI: hepatotoxicity, nausea, vomiting, anorexia, diarrhea, esophagitis

GU: ↓fertility (males), renal failure

Hemat: anemia, LEUKOPENIA, THROMBOCYTOPENIA

Local: pain at IV site

Resp: PULMONARY FIBROSIS, pulmonary infiltrates

Interactions ⬆ ⬇

Drug-drug:

↑bone marrow depression with other antineoplastics or radiation therapy.
Smoking↑ risk of pulmonary toxicity.
May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions.
Myelosuppression may be ↑ by cimetidine.

Route/Dosage ⬆ ⬇

IV (Adults and Children ): 150–200 mg/m² every 6–8 wk or 75–100 mg/m²/day for 2 days every 6 wk or 40 mg/m²/day for 5 days every 6 wk.
Intracavitary
(Adults ): 61.6 mg (8 wafers) placed in cavity created during surgical resection of brain tumor.

Availability ⬆ ⬇

(Generic available)

Lyophilized powder for injection: 100 mg/vial
Intracavitary wafer: 7.7 mg

Assessment ⬆ ⬇

Monitor vital signs before and frequently during therapy.
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.
Assess respiratory status for dyspnea or cough. Obtain pulmonary function tests at baseline and frequently during therapy. Pulmonary toxicity usually occurs after high cumulative doses or several courses of therapy but may also occur following 1–2 courses of low doses. Symptoms may be rapid or gradual in onset; damage may be reversible or irreversible. Delayed pulmonary fibrosis may occur years after therapy. Notify health care professional promptly if symptoms occur.
Monitor IV site closely. Carmustine is an irritant. Instruct patient to notify nurse immediately if discomfort occurs at IV site. Discontinue IV immediately if infiltration occurs. Ice may be applied to site. May cause hyperpigmentation of skin along vein.
Monitor intake and output, appetite, and nutritional intake. Assess for nausea and vomiting, which occur within 2 hr of administration and persist for 4–6 hr. Administration of an antiemetic before and during therapy and adjusting diet as tolerated may help maintain fluid and electrolyte balance and nutritional status.

Lab Test Considerations:

Obtain a negative pregnancy test before starting therapy.Monitor CBC with differential and platelet count before and weekly for at least 6 wk following each dose. The nadir of thrombocytopenia occurs in 4–5 wk; the nadir of leukopenia in 5–6 wk. Recovery usually occurs in 6–7 wk but may take 10–12 wk after prolonged therapy. Withhold dose and notify physician if platelet count is <100,000/mm³ or leukocyte count is <4000/mm³. Anemia is usually mild.
- Monitor serum bilirubin, AST, ALT, and LDH before and periodically during therapy. May cause mild, reversible ↑ in AST, alkaline phosphatase, and bilirubin.
- Monitor BUN, serum creatinine, and uric acid before and periodically during therapy. Notify health care professional if BUN is elevated.

Implementation ⬆ ⬇

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.

IV Administration:

Solution should be prepared in a biologic cabinet. Wear gloves, gown, and mask while handling medication. Discard equipment in designated containers. Contact with skin may cause transient hyperpigmentation.
Intermittent Infusion: Dilute contents of each 100-mg vial with 3 mL of absolute ethyl alcohol provided as a diluent. Dilute this solution with 27 mL of sterile water for injection. Concentration: 3.3 mg/mL. Diluent: May be further diluted with 500 mL of D5W or 0.9% NaCl in a glass container.
- Solution is clear and colorless. Do not use vials that contain an oily film, which indicates decomposition. Reconstituted solution is stable for 24 hr when refrigerated and protected from light. Solution contains no preservatives; do not use as a multidose vial.
- IV lines may be flushed with 5–10 mL of 0.9% NaCl before and after carmustine infusion to minimize irritation at the injection site.
Rate: Infuse dose over at least 2 hr. Rapid infusion rate may cause local pain, burning at site, and flushing. Facial flushing occurs within 2 hr and may persist for 4 hr.

Patient/Family Teaching ⬆ ⬇

Instruct patient to notify health care professional if fever; chills; sore throat; signs of infection; lower back or side pain; difficult or painful urination; 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. Patients should be cautioned not to drink alcoholic beverages or to take products containing aspirin or NSAIDs.
Instruct patient to notify health care professional if shortness of breath or increased cough occurs. Encourage patient not to smoke; smokers are at greater risk for pulmonary toxicity.
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.
Discuss with patient the possibility of hair loss. Explore coping strategies.
Instruct patient not to receive any vaccinations without advice of health care professional.
Rep: May be teratogenic. Advise female patient of reproductive potential of the need for highly effective contraception during and for at least 6 mo after completion of therapy or implantation of wafer and to avoid breastfeeding during and for at least 7 days therapy or wafer implantation. Advise male patients with female partners of reproductive potential to use highly effective contraception during and for at least 3 mo after final dose of therapy or wafer implantation . Inform male patient that carmustine may impair fertility.
Emphasize need for periodic lab tests to monitor for side effects.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇