Fludarabine

INTRODUCTION

Indications

B-cell chronic lymphocytic leukemia unresponsive to standard therapy. Unlabeled Use: Non-Hodgkin's lymphoma.

Action

Converted intracellularly to an active phosphorylated metabolite that inhibits DNA synthesis. Therapeutic Effects: Death of rapidly replicating cells, particularly malignant ones.

Adverse Reactions/Side Effects

CNS: NEUROTOXICITY, fatigue, agitation, coma, confusion, headache, malaise, weakness. EENT: hearing loss, visual disturbances. Resp: PULMONARY HYPERSENSITIVITY, cough, pneumonia, dyspnea, sinusitis. CV: edema. GI: GI BLEEDING, diarrhea, nausea, anorexia, esophagitis, mucositis, stomatitis, vomiting. GU: dysuria, hematuria, urinary tract infection. Derm: rashes. Endo: gonadal suppression. Hemat: PANCYTOPENIA, anemia, leukopenia, thrombocytopenia, hemolytic anemia. MS: myalgia. Neuro: peripheral neuropathy. Misc: fever, tumor lysis syndrome.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of CNS toxicity, including confusion, agitation, severe headache, hearing loss, visual disturbances, and decreased consciousness. Notify physician, especially if patient becomes unresponsive or difficult to arouse.

• Assess pulmonary function periodically by measuring lung volumes, breath sounds, and respiratory rate (See Appendices I, J, K). Notify physician or nursing staff immediately if patient experiences signs of pulmonary hypersensitivity (dry cough, dyspnea, tightness in the throat and chest, shortness of breath, cyanosis).

• Monitor signs of GI bleeding, including abdominal pain, vomiting blood, blood in stools, or black, tarry stools. Report these signs to the physician or nursing staff immediately.

• Watch for signs of blood dyscrasias such as leukopenia (fever, sore throat, signs of infection), thrombocytopenia (bleeding gums, bruising, petechiae, hematuria), or unusual weakness and fatigue that might be due to aplastic anemia or other anemias. Report these signs to the physician or nursing staff immediately.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Assess numbness, tingling, or weakness that might indicate peripheral neuropathy. Establish baseline electroneuromyographic values using EMG and nerve conduction whenever possible. Periodically reexamine these values to document drug-induced changes in peripheral nerve function.

• Monitor neuromuscular signs of electrolyte imbalances that might indicate tumor lysis syndrome. Signs include severe muscle weakness or paralysis due to increased plasma potassium (hyperkalemia) or muscle hyperexcitability and tetany due to phosphate and calcium imbalances (hyperphosphatemia and hypocalcemia). Notify physician or nursing staff immediately if these signs occur.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic training to maintain muscle strength and aerobic capacity during cancer chemotherapy or to help restore function after chemotherapy.

• Because of the risk of pulmonary hypersensitivity, assess pulmonary function during exercise, and terminate exercise if patient exhibits untoward symptoms ...