Names and pronunciation
(blee-oh-mye′sin)
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Drug reference
(blee-oh-mye′sin)
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Func. class.: Antineoplastic, antibiotic
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Chem. class.: Glycopeptide
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ACTION: Inhibits synthesis of DNA, RNA, protein; derived from Streptomyces verticillus; phase specific to the G2 and M phases; a nonvesicant, sclerosing agent
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USES: Squamous cell carcinoma of head, neck, penis, cervix, vulva; Hodgkin’s/non-Hodgkin’s disease; tes- ticular carcinoma; as a sclerosing agent for malignant pleural effusion
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CONTRAINDICATIONS: Preg- nancy, breastfeeding, hypersensitivity Precautions: Patients >70 yr old, renal/ hepatic disease, respiratory disease, max lifetime dose 400 units, fever
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Black Box Warning: Pulmonary fibrosis; requires specialized care setting, experi- enced clinician Black Box Warning: Pulmonary toxicity/ fibrosis: risk increases >70 yr; pulmonary function tests; chest x-ray before, during therapy, should be obtained q2wk during treatment; pulmonary diffusion capacity for carbon monoxide (DLCO) monthly, if <40% of pretreatment value, stop treat- ment; treat pulmonary infection before treatment; dyspnea, crackles, unproduc- tive cough, chest pain, tachypnea, fatigue, increased pulse, pallor, lethargy, more common in the elderly, radiation therapy, pulmonary disease; usually occurs with cumulative doses >400 units • Temperature; fever may indicate be- ginning infection • Renal status: serum creatinine/BUN; CBC • Effects of alopecia, skin color altera- tions on body image; discuss feelings about body changes • Buccal cavity q8hr for dryness, sores, ulceration, white patches, oral pain, bleeding, dysphagia • Local irritation, pain, burning, discol- oration at injection site • Anaphylaxis: rash, pruritus, urticaria, purpuric skin lesions, itching, flushing, wheezing, hypotension; have emergency equipment available Black Box Warning: Idiosyncratic re- action: severe reaction in those with lymphoma, hypotension, mental confu- sion, fever, chills, wheezing in lymphoma Black Box Warning: Requires a special- ized care setting and experienced clini- cian due to severe reactions • Rinsing of mouth tid-qid with water, club soda; brushing of teeth with soft brush or cotton-tipped applicators for stomatitis; use unwaxed dental floss • Pregnancy/breastfeeding: do not use in pregnancy/breastfeeding
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SIDE EFFECTS CNS: Pain at tumor site, headache, con- fusion, fever, chills, malaise CV: Hypotension, peripheral vasoconstriction GI: Nausea, vomiting, anorexia, stoma- titis, weight loss GU: Hemolytic-uremic syndrome INTEG: Rash, alopecia, hyperpigmentation RESP: Fibrosis, pneumonitis, wheezing, pulmonary toxicity SYST: Anaphylaxis
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INTERACTIONS • Avoid live virus vaccines concurrently; adverse reactions may occur Increase: bleomycin toxicity—cisplatin Increase: oxygen requirements—anesthesia Decrease: serum phenytoin levels— phenytoin, fosphenytoin; check drug level periodically Drug/Lab Test Increase: uric acid
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DOSAGE AND ROUTES Test dose • Adult/child (unlabeled): IM/IV/SUB- CUT ≤2 units for first 2 doses followed by 24 hr of observation Non-Hodgkin’s lymphoma, testicular cancer, squamous cell carcinoma • Adult/child: SUBCUT/IV/IM After test dose 0.25-0.5 unit/kg 1-2×/wk or 10-20 units/m2, then 1 unit/day or 5 units/wk; max total dose of 400 units during life- time Hodgkin’s lymphoma • Adult/adolescent ≥15 yr: SUBCUT/IV/ IM After test dose 5-20 units/m2 may be given in combination • Child (unlabeled): SUBCUT/IV/IM After test dose 5-10 units/m2 dose will vary Malignant pleural effusion • Adult: BOLUS INTRAPLEURAL 60 units as a single dose Renal dose • Adult/child: CCr 40-50 mL/min reduce dose by 30%; CCr 30-39 mL/min reduce dose by 40%; CCr 20-29 mL/min reduce dose by 45%; CCr 10-19 mL/min reduce dose by 55%; CCr 5-10 mL/min reduce dose by 60%
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Available forms: Powder for injection, 15, 30 units/vial
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Administer: B • Antiemetic 30-60 min prior to giving product to prevent vomiting • Topical or systemic analgesics for pain of stomatitis as ordered; antihistamines and antipyretics for fever, chills • May be given IM, SUBCUT, IV, intra- pleurally, intralesionally, intraarterially IM/SUBCUT route • After reconstituting 15 units/1-5 mL or 30 units/2-10 mL of 0.9% NaCl or bacterio- static water for injection, max concentra- tions 5 units/mL, rotate injection sites; do not use products that contain benzyl alco- hol when giving to neonates or that contain dextrose because of loss of potency IV route • Use cytotoxic handling procedures • After reconstituting 15- or 30-unit vial with 5 or 10 mL of NS, respectively, inject slowly over 10 min or, after further dilu- tion with 50-100 mL 0.9% NaCl, give at prescribed rate • For patients with lymphoma, give 2 test doses of 2-5 units before initial dose; monitor for anaphylaxis • Store for 2 wk after reconstituting if refrigerated or for 24 hr at room tem- perature; discard unused portions Y-site compatibilities: Acyclovir, alfen- tanil, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amio- darone, ampicillin, ampicillin-sulbactam, anidulafungin, atenolol, atracurium, azithromycin, aztreonam, bivalirudin, bu- metanide, buprenorphine, busulfan, bu- torphanol, calcium chloride/gluconate, CARBOplatin, carmustine, caspofungin, ceFAZolin, cefepime, cefotaxime, cefoTEtan, cefOXitin, cefTAZidime, ceftizoxime, cefTRIAXone, cefuroxime, chloramphenicol, chlorproMAZINE, ci- metidine, ciprofloxacin, cisatracurium, CISplatin, clindamycin, codeine, cyclo- phosphamide, cycloSPORINE, cytarabine, dacarbazine, DACTINomycin, DAPTOmy- cin, DAUNOrubicin, dexamethasone, dex- medetomidine, dexrazoxane, digoxin, diltiazem, diphenhydrAMINE, DOBUTa- mine, DOCEtaxel, DOPamine, doxacuri- um, DOXOrubicin, DOXOrubicin liposo- mal, doxycycline, droperidol, enalaprilat, ePHEDrine, EPINEPHrine, epirubicin, ertapenem, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fentaNYL, filgrastim, fluconazole, fludarabine, fluorouracil, foscarnet, fos- phenytoin, furosemide, ganciclovir, gati- floxacin, gemcitabine, gentamicin, glyco- pyrrolate, granisetron, haloperidol, heparin, hydrALAZINE, hydrocortisone sodium succinate, HYDROmorphone, hy- drOXYzine, IDArubicin, ifosfamide, imipenem-cilastatin, inamrinone, insulin (regular), irinotecan, isoproterenol, ketorolac, labetalol, leucovorin, levo- floxacin, levorphanol, lidocaine, linezol- id, LORazepam, magnesium sulfate, man- nitol, mechlorethamine, melphalan, meperidine, meropenem, mesna, meta- raminol, methohexital, methotrexate, methyldopate, methylPREDNISolone, metoclopramide, metoprolol, metroNI- DAZOLE, midazolam, milrinone, minocy- cline, mitoMYcin, mitoXANtrone, mivacu- rium, morphine, nafcillin, nalbuphine, naloxone, nesiritide, niCARdipine, nitro- glycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, palonosetron, pamidronate, pancuroni- um, pantoprazole, PEMEtrexed, pentami- dine, pentazocine, PENTobarbital, PHE- Nobarbital, phenylephrine, piperacillin, piperacillin-tazobactam, polymyxin B, potassium chloride, potassium phos- phates, procainamide, prochlorperazine, promethazine, propranolol, quiNIDine, ranitidine, remifentanil, riTUXimab, ro- curonium, sargramostim, sodium ace- tate, sodium bicarbonate, sodium phos- phates, succinylcholine, SUFentanil, sulfamethoxazole-trimethoprim, tacroli- mus, teniposide, theophylline, thiopental, thiotepa, ticarcillin, ticarcillin-clavula- nate, tirofiban, tobramycin, tolazoline, trastuzumab, trimethobenzamide, vanco- mycin, vasopressin, vecuronium, verap amil, vinBLAStine, vinCRIStine, vinorel- bine, voriconazole, zidovudine
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Assess: • IM test dose of 1-2 units in patients with lymphoma before first 2 doses • CBC, differential baseline and periodi- cally, thrombocytopenia, leukopenia may occur (nadir 12 days)
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Evaluate: • Therapeutic response: decrease in size of tumor
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • To report any changes in breathing, coughing, fever • That hair may be lost during treatment and that wig or hairpiece may make pa- tient feel better; that new hair may be different in color, texture • To report any bleeding, white spots, ulcerations in mouth; to examine mouth daily and report symptoms; to report decreased urination • That continuing exams and lab work will be needed • Skin toxicity: To report rash, color changes, sensitivity, irritation • Stomatitis: Teach patient that mouth ulcerations, redness may occur, use soft toothbrush • Pregnancy/breastfeeding: to use contraception during treatment; to avoid breastfeeding B • Not to receive vaccines during treatment HIGH ALERT
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PHARMACOKINETICS Half-life 2-4 hr; when CCr is >35 mL/ min, half-life is increased with lower clearance; metabolized in liver; 70% excreted in urine (unchanged) IV, IM, SUBCUT: Peak 30-60 min
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• Adult/adolescent ≥15 yr: SUBCUT/IV/ IM After test dose 5-20 units/m2 may be given in combination
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