Learning Outcomes
By the end of this section, you should be able to:
- 8.4.1 Identify characteristics of biologic response modifier drugs used to treat cancer.
- 8.4.2 Explain the indications, actions, adverse reactions, and interactions of biologic response modifier drugs used to treat cancer.
- 8.4.3 Describe the nursing implications of biologic response modifier drugs used to treat cancer.
- 8.4.4 Explain the client education related to biologic response modifier drugs used to treat cancer.
Monoclonal Antibodies and PD-1 Inhibitors
Cancer therapy has experienced an explosion of new treatments with the development of biologics. Monoclonal antibodies are a type of biologic response modifier used to treat autoimmune diseases as well as various cancer types. Rituximab is a monoclonal antibody that enables the immune system to better recognize and destroy cancer cells. These drugs pose a high risk of sensitivity reactions that include chills, fever, and anaphylaxis. Clients must be premedicated with diphenhydramine and acetaminophen to prevent or decrease risks for hypersensitivity reactions.
The newest approved class of monoclonal antibodies is PD-1 inhibitors. These drugs inhibit PD-1 proteins on T lymphocytes. When these proteins are blocked, the T lymphocytes are able to identify cancer cells and kill them more easily. Because these drugs increase the activity of T lymphocytes, a side effect of these drugs is possible development of autoimmune syndromes. Clients receiving these drugs must be carefully monitored throughout intravenous infusions for possible hypersensitivity reactions.
Growth Factor and Tyrosine Kinase Inhibitors
Growth factor inhibitors and tyrosine kinase inhibitors are also types of biologic response modifiers. Erlotinib is a tyrosine kinase inhibitor that is used to treat non-small cell lung cancer and late-stage pancreatic cancer. This drug works to prevent the growth of tumors influenced by epidermal growth factor receptors (EGFR). Cell differentiation, proliferation, and angiogenesis cannot occur when EGFR is blocked. Ibrutinib is another tyrosine kinase inhibitor used to treat leukemias and lymphomas.
Table 8.17 lists common growth factors and tyrosine kinase I inhibitors and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| PD-1 Inhibitors | |
| Pembrolizumab (Keytruda) |
200–400 mg/dose IV every 3 weeks or every 6 weeks per protocol. |
| Nivolumab (Opdivo) |
240 mg IV every 2 weeks or 480 mg IV every 4 weeks per protocol. |
| Durvalumab (Imfinzi) |
Clients with a body weight ≥30 kg: 10 mg/kg IV every 2 weeks or 1500 mg every 4 weeks. Clients with a body weight <30 kg: 10 mg/kg IV every 2 weeks. |
| Atezolizumab (Tecentriq) |
840 mg IV every 2 weeks or 1200 mg every 3 weeks or 1680 mg every 4 weeks. |
| Biologic Response Modifiers | |
| Rituximab (Rituxan) |
375–500 mg/m2 IV; frequency varies by cancer type (premedicate per protocol). |
| Tyrosine Factor/Growth Factor Inhibitors | |
| Erlotinib (Tarceva) |
100–150 mg/day orally on empty stomach. |
| Ibrutinib (Imbruvica) |
420 mg/day orally. |
Adverse Effects and Contraindications
One of the most critical adverse reactions of biologic therapy is hypersensitivity reactions. These may occur suddenly, especially during the initial treatment, and may be severe and life-threatening. Any premedication must be given, and emergency drugs such as epinephrine should be available. Biologic therapies are also associated with skin reactions that may be severe. Erlotinib has been shown to cause renal dysfunction, arrhythmias, hepatotoxicity, and gastrointestinal perforation. Clients may also develop widespread, severe acneiform rashes. In addition to severe hypersensitivity reactions, rituximab is also associated with cardiotoxicity, nephrotoxicity, leukoencephalopathy, bowel obstruction or perforation, tumor lysis syndrome, neutropenia, and infection.
Table 8.18 is a drug prototype table for biologic response modifiers featuring pembrolizumab. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class Biologic response modifier, PD-1 inhibitor Mechanism of Action Inhibits PD-1 to increase T lymphocyte activity |
Drug Dosage 200–400 mg/dose IV every 3 weeks or every 6 weeks per protocol. |
|
Indications Melanoma Non-small cell lung cancer Head and neck cancer Classical Hodgkin lymphoma Primary mediastinal large B-cell lymphoma (PMBCL) Urothelial cancer Gastric cancer Cervical cancer Hepatocellular carcinoma Merkel cell carcinoma Renal cell cancer Cutaneous squamous cell carcinoma Small cell lung cancer Esophageal cancer Endometrial cancer Triple-negative breast cancer Therapeutic Effects Reduction/elimination in cancerous cell expressions of PD-1 |
Drug Interactions Thalidomide Food Interactions None reported |
|
Adverse Effects Infusion-related reactions Severe, possibly fatal immune-mediated reactions |
Contraindications No significant contraindications Caution: Severe, possibly fatal immune-mediated reactions may occur May have severe infusion-related reactions Embryo-fetal toxicity |
Nursing Implications
The nurse should do the following for clients who are taking biologic and biologic response modifying agents:
- Assess client overall well-being prior to chemotherapy administration including vital signs, hydration status, oral mucosa, skin, weight, cardiac function, bowel pain, level of consciousness changes, and signs of neuropathy.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering biologic therapies.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a biologic or biologic response modifying agent should:
- Know signs and symptoms to report to the health care provider: fever, chills, productive cough, urinary symptoms, skin reactions, chest pain, confusion, and level of consciousness changes.
- Report side effects including nausea and vomiting and skin reactions.
- Know how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Understand the need for regular follow-up for early identification of long-term effects and secondary malignancies.
The client taking a biologic or biologic response modifying agent should not:
- Be around large crowds or around others who are sick to decrease the risk of infection.
- Become dehydrated.
FDA Black Box Warning
Rituximab
Rituximab may cause fatal infusion-related reactions, most often with the initial treatment. Mucocutaneous reactions, reactivation of hepatitis B, and progressive multifocal leukoencephalopathy have also been associated with rituximab.