APHON Pediatric Chemotherapy-Biotherapy Renewal

! Change the needle after drawing the medication into the syringe and administer the medication through a fresh needle in order to decrease the chance of tissue irritation along the injection track. ! Use an abdominal site of administration. ! Use the air-bubble technique (adding a small air bubble to the syringe, 0.1 mL), to decrease the possibility of tracking medication along the injection track. When calculating doses and administering bortezomib, the nurse should also be aware that the concentrations for the subcutaneous dose and the IV preparation are different. Oral Most small molecule inhibitors are available as capsules or tablets. The advantage of these oral preparations is that patients are able to receive their cancer treatments at home. Oral administration does, however, present some challenges for pediatric patients. Prescribing information for most oral small molecule inhibitors advises that they be taken whole, with specific instructions to not chew, break, or crush the capsule or tablet. Manipulation of these capsules or tablets may significantly affect absorption and potency. For example, disruption of the nilotinib capsule may result in increased absorption, causing the potential for increased toxicity. Studies have shown that when dasatinib is crushed and dispersed in liquid, its bioavailability is decreased by 36% (Lexicomp). Some small molecule inhibitors (e.g., imatinib, everolimus) are available as coated tablets because they are mucosal irritants. Absorption and potency of these small molecule inhibitors may also be affected by acidic environments (e.g., the stomach). Nurses can use the “Do Not Crush” list published by the Institute for Safe Medication Practices (www.ismp.org/recommendations/do-not-crush) as a quick reference tool to verify which small molecule inhibitors, and other medications, should not be crushed or otherwise manipulated (see also Table 1 ). When it is not possible for the patient to swallow pills or capsules, nurses should check with their pharmacy colleagues regarding the possibility of alternative dosing formulations. A few small molecule inhibitors come in alternate forms for patients who cannot swallow tablets or capsules. For example, everolimus is commercially available as a dispersible tablet, and larotrectinib is commercially available as an oral solution. Some small molecule inhibitors are approved for extemporaneous solutions (see Table 1). These extemporaneous solutions should be prepared one dose at a time and administered as soon as possible after preparation to ensure maximum effectiveness. They also may develop a bitter taste if left standing for longer than recommended time. A study by Li and associates (2016) demonstrated that extemporaneous suspensions of erlotinib, lapatinib, and imatinib were stable for several days.