carmustine

kar-MUS-teen

Therapeutic Classification: antineoplastics

Pharmacologic Classification: alkylating agents

High Alert

Brain tumors.
Multiple myeloma (in combination with prednisone).
Relapsed or refractory Hodgkin's lymphoma (in combination with other agents).
Relapsed or refractory non-Hodgkin's lymphoma (in combination with other agents).

Inhibits DNA and RNA synthesis (cell-cycle phase-nonspecific).

Therapeutic effects:

Death of rapidly replicating cells, especially malignant ones.

Absorption: IV administration results in complete bioavailability; following implantation, action is primarily local.

Distribution: Highly lipid soluble; readily penetrates CSF.

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

Half-Life: 15–75 min.

(effect on platelet counts)

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

Contraindicated in:

Hypersensitivity;
OB: Pregnancy;
Lactation: Lactation.

Use Cautiously in:

Infection;
Depressed bone marrow reserve;
Lung disease (↑ risk of pulmonary fibrosis);
Renal impairment;
Hepatic impairment;
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.

Derm: alopecia

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

GU: ↓fertility , renal failure

Hemat: anemia, LEUKOPENIA, THROMBOCYTOPENIA

Local: pain (at IV site)

Resp: PULMONARY FIBROSIS

Drug-drug:

↑bone marrow depression with other antineoplastics or radiation therapy.
May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions.

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.

(Generic available)

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

Monitor vital signs before and frequently during therapy.
Monitor for myelosuppression. 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. Patients receiving a cumulative dose >1400 mg/m² are at ↑ risk of pulmonary toxicity. Notify health care provider promptly if symptoms occur.
Monitor for signs/symptoms of meningitis, intracranial hypertension, or obstructive hydrocephalus (fever, headache, nuchal rigidity, photophobia, papilledema, vomiting, bulging fontanelle in infants) in patients receiving implant.
Monitor for new or worsening seizures in patients receiving implant; optimize antiseizure therapy prior to surgery and monitor postoperatively. Institute seizure precautions.
Monitor intake and output, appetite, and nutritional intake. Assess for nausea and vomiting, which may 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:

Verify a negative pregnancy test before starting therapy.
- Monitor CBC with differential and platelet count before and weekly for ≥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 <100,000/mm³ or leukocyte count <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, creatinine, and uric acid before and periodically during therapy.

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.

IV Administration:

When preparing IV, wear double chemotherapy gloves, protective gown, respiratory (N95) protection, and hair and shoe covers; optimally prepare in a ventilated control device. When administering, add eye/face protection if there is a potential that the substance could splash. Single chemotherapy gloves can be worn when administering. Discard IV equipment in specially designated containers. Contact with skin may cause transient hyperpigmentation; Immediately wash with soap and water thoroughly.
- Wear double gloves when handling wafers for intracranial implant; Immediately wash with soap and water thoroughly if contact with skin or mucous membranes occurs.
Carmustine is an irritant. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution, then remove needle/cannula. Elevate patient's extremity and apply dry cold compresses for 20 minutes 4 times day for 1–2 days.
Intermittent Infusion: Reconstitution: Reconstitute each 100-mg vial with 3 mL of absolute ethyl alcohol provided as a diluent, followed by addition of 27 mL of sterile water for injection. 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. Concentration: 3.3 mg/mL. Diluent: May be further diluted with 500 mL of D5W or 0.9% NaCl in a glass container or a PVC and DEHP free polypropylene container.
Rate: Infuse dose over ≥2 hr, not to exceed 1.66 mg/m²/min. Rapid infusion rate may cause local pain, burning at site, and flushing. Facial flushing occurs within 2 hr and may persist for 4 hr. 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.
Y-Site Compatibility:
- acyclovir
- amifostine
- amikacin
- aminocaproic acid
- aminophylline
- amiodarone
- amphotericin B deoxycholate
- amphotericin B lipid complex
- amphotericin B liposomal
- ampicillin
- ampicillin/sulbactam
- anidulafungin
- argatroban
- atracurium
- azithromycin
- aztreonam
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- caspofungin
- cefazolin
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- clindamycin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- daptomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- docetaxel
- dopamine
- doxorubicin hydrochloride
- doxycycline
- droperidol
- enalaprilat
- ephedrine
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- fluorouracil
- foscarnet
- fosphenytoin
- furosemide
- ganciclovir
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- haloperidol
- heparin
- hetastarch
- hydralazine
- hydrocortisone
- hydromorphone
- imipenem/cilastatin
- insulin, regular
- isoproterenol
- ketorolac
- labetalol
- leucovorin
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- melphalan
- meperidine
- meropenem
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoprolol
- metronidazole
- midazolam
- milrinone
- minocycline
- mitoxantrone
- morphine
- moxifloxacin
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- paclitaxel
- palonosetron
- pamidronate
- pantoprazole
- pemetrexed
- pentamidine
- pentobarbital
- phenylephrine
- piperacillin/tazobactam
- potassium acetate
- potassium chloride
- potassium phosphates
- prochlorperazine
- propranolol
- remifentanil
- rituximab
- rocuronium
- sargramostim
- sodium acetate
- sodium bicarbonate
- sodium phosphates
- succinylcholine
- sufentanil
- tacrolimus
- theophylline
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- trastuzumab
- trimethoprim/sulfamethoxazole
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zidovudine
- zoledronic acid
Y-Site Incompatibility:
- allopurinol
- dantrolene
- diazepam
- dobutamine
- epinephrine
- metoclopramide
- phenobarbital
- phentolamine
- phenytoin
- procainamide
- promethazine

Explain the purpose and side effects of carmustine. Do not stop receiving drug without consulting health care provider. If an appointment is missed, reschedule as soon as possible.
Instruct patient to notify health care provider 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 provider if shortness of breath or ↑ cough occurs.
Emphasize need for periodic lab tests to monitor for side effects.
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 provider.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
Rep: May cause fetal harm. Advise women of reproductive potential of the need for highly effective contraception during and for ≥6 mo after completion of therapy or implantation of wafer and to avoid breastfeeding during and for ≥7 days therapy or wafer implantation. Advise men with female partners of reproductive potential to use highly effective contraception during and for ≥3 mo after final dose of therapy or wafer implantation . May impair fertility in men.

Decrease in size and spread of tumor.
- Improvement in hematologic parameters in nonsolid cancers.

~~, BiCNU,~~ Gliadel

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US Brand Names ⬆