CARMUSTINE (kar-mus'teen) BCNU, BiCNU, Gliadel Classifications: antineoplastic; alkylating agent Prototype: Cyclophosphamide Pregnancy Category: D
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100 mg injection; 7.7 mg wafer
Highly lipid-soluble nitrosourea derivative with cell-cycle-nonspecific activity against rapidly proliferating cell populations.
Produces cross-linkage of DNA strands, thereby blocking DNA, RNA, and protein synthesis. Major toxic effect is bone marrow
suppression.
Drug metabolites thought to be responsible for antineoplastic activities. Full or partial activity against a variety of cancers
resulting in reduction or stabilization of tumor size and increased survival rates.
As single agent or in combination with other antineoplastics in treatment of Hodgkin's disease and other lymphomas, melanoma,
primary and metastatic tumors of brain, and GI tract malignancies.
Treatment of carcinomas of breast and lungs, Ewing's sarcoma, Burkitt's tumor, malignant melanoma, and topically for mycosis
fungoides.
History of pulmonary function impairment; recent illness with or exposure to chickenpox or herpes zoster; infection, decreased
circulating platelets, leukocytes, or erythrocytes; pregnancy (category D), lactation.
Hepatic and renal insufficiency; patient with previous cytotoxic medication, or radiation therapy.
Previously Untreated PatientsCarcinoma Adult: IV 150200 mg/m2 q6wk in one dose or given over 2 d Child: IV 200250 mg/m2 q46wk as single dose. Doses adjusted based on hematologic parameters.
Mycosis Fungoides Adult: Topical 0.050.4% solution in 30% alcohol to paint entire body (60 mLs) or ointment 12 times/d for 68 wk
(10 mg/d) (must be specially compounded)
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Note: When administering IV to infants and children, verify correct IV concentration and rate of infusion with physician.
Intravenous PREPARE: IV Infusion: Wear disposable gloves; contact of drug with skin can cause burning, dermatitis, and hyperpigmentation. Add supplied diluent
to the 100 mg vial. Further dilute with 27 mL of sterile water for injection to yield a concentration of 3.3 mg/mL. Each dose
is then added to 100500 mL of D5W or NS. If possible avoid using PVC IV tubing and bags.
ADMINISTER: IV Infusion: Infuse a single dose over at least 1 h. Slow infusion over 12 h and adequate dilution will reduce pain of administration.
Avoid starting infusion into dorsum of hand, wrist, or the antecubital veins; extravasation in these areas can damage underlying
tendons and nerves leading to loss of mobility of entire limb.
INCOMPATIBILITIES Solution/additive:
Sodium bicarbonate.
Y-site:
Allopurinol.
- Frequently check rate of flow and blood return; palpate injection site for extravasation. If there is any question about patency,
line should be restarted.
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- Reconstituted solutions of carmustine are clear and colorless and may be stored at 2°8° C (36°46°
F) for 24 h protected from light.
- Store unopened vials at 2°8° C (36°46° F), protected from light, unless otherwise directed
by manufacturer.
- Signs of decomposition of carmustine in unopened vial: liquefaction and appearance of oil film at bottom of vial. Discard
drug in this condition.
Hematologic: Delayed myelosuppression (dose-related); thrombocytopenia. CNS: Dizziness, ataxia. Respiratory:
Pulmonary infiltration or fibrosis. Skin: Skin flushing and burning pain at injection site, hyperpigmentation of skin (from contact). Special Senses: (with high doses) Eye infarctions, retinal hemorrhage, suffusion of conjunctiva. GI: Stomatitis, nausea, vomiting.
Drug:
Cimetidine may potentiate neutropenia and thrombocytopenia.
Distribution: Readily crosses bloodbrain barrier; CSF concentrations 1570% of plasma concentrations. Metabolism: Rapidly metabolized; metabolic fate not completely known. Elimination: 6070% excreted in urine in 96 h; 6% excreted through lungs, 1% in feces; excreted in breast milk.
Assessment & Drug Effects
- Monitor for nausea and vomiting (dose related), which may occur within 2 h after drug administration and persist for up to
6 h. Prior administration of an antiemetic may help to decrease or prevent these adverse effects.
- Lab tests: Baseline CBC with differential and platelet count, repeat blood studies following infusion at weekly intervals
for at least 6 wk. Baseline and periodic tests of hepatic and renal function.
- Platelet nadir usually occurs within 45 wk, and leukocyte nadir within 56 wk after therapy is terminated. Thrombocytopenia
may be more severe than leukopenia; anemia is less severe.
- Check temperature daily. Avoid use of rectal thermometer to prevent injury to mucosa. An elevation of 0.6° F or more
above usual temperature warrants reporting.
- Report symptoms of lung toxicity (cough, shortness of breath, fever) to the physician immediately.
- Be alert to signs of hepatic toxicity (jaundice, dark urine, pruritus, light-colored stools) and renal insufficiency (dysuria,
oliguria, hematuria, swelling of lower legs and feet).
Patient & Family Education
- Report burning sensation immediately, as carmustine can cause burning discomfort even in the absence of extravasation. Infusion
will be discontinued and restarted in another site. Ice application over the area may decrease the discomfort.
- Intense flushing of skin may occur during IV infusion. This usually disappears in 24 h.
- You will be highly susceptible to infection and to hemorrhagic disorders. Be alert to hazardous periods that occur 46
wk after a dose of carmustine. If possible, avoid invasive procedures (e.g., IM injections, enemas, rectal temperatures) during
this period.
- Report promptly the onset of sore throat, weakness, fever, chills, infection of any kind, or abnormal bleeding (ecchymosis,
petechiae, epistaxis, bleeding gums, hematemesis, melena).
- Do not breast feed while taking this drug.