Chemotherapeutic Agents

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Cancer is a disease characterized by

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a shift in the control mechanisms that govern cell survival, proliferation, and differentiation.

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Cells that have undergone neoplastic transformation usually express

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cell surface antigens that may be of normal fetal type or may display other signs of apparent immaturity

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Describe chromosomal and gene sequence changes

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qualitative or quantitative chromosomal abnormalities, including various translocations and the appearance of amplified gene sequences

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describe tumor formation

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Such cells proliferate excessively and form local tumors that can compress or invade adjacent normal structures

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A small subpopulation of cells within the tumor can be described as

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tumor stem cells.

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in the process called metastasis,

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cells retain the ability to undergo repeated cycles of proliferation as well as to migrate to distant sites in the body to colonize various organs

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Tumor cells are derived from

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normal cells in which proliferation is poorly controlled.

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Most anticancer agents inhibit act by

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inhibiting cell proliferation.

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how is cell proliferation inhibited?

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damaging DNA or preventing DNA repair

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Newer agents selectively target cancer cells by using what kind of technology?

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monoclonal antibody technology.

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Neoplastic and normal cells differ primarily with regard to

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the number of cells undergoing cell division,

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The drugs kill dividing cells by these two specific mechanisms

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interfering with DNA, RNA, or protein synthesis or by inhibiting the formation of microtubules in mitosis.

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cell specific agents

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exert their actions during distinct phases of the cell cycle.

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Agents that interfere with DNA synthesis are specific to what phase?

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S-phase

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Agents that interfere with microtubules disrupt what process?

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mitosis

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Agents that interfere with microtubules are specific to what phase?

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M-phase

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DNA alkylating agents do what?

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damage tumor cells regardless of whether the cell is actively dividing

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DNA alkylating agents are also called

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“cell cycle-nonspecific” drugs

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Alkylating agents (3)

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NITROGEN MUSTARDS, ALKL SULFONATES, NITROSOUREAS

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Alkylating agents mechanism of action

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Miscode DNA information or open purine ring with damage to the DNA molecule, depending on cell division not cycle specific.

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what type of resistance do alkylating agents cause?

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Acquired resistance

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general side effects of alkylating agents

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Bone marrow suppression, N/V, alopecia,pneuminitis, pulmonary fibrosis,seizures,

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important side effect of alkylating agents related to anesthesia

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decrease plasma cholinesterase (prolong succinylcholine)

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describe the duration of the G1 phase of the cell cycle

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varies markedly

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G1 phase

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synthesis of cellular components needed for DNA synthesis

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S phase

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replication of DNA genome

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G2 phase

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synthesis of cellular components needed for mitosis

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M phase

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mitosis

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CCS drugs kill what type of cells?

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actively dividing

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CCNS drugs kill what type of cells?

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non-dividing and actively dividing

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Antimetabolite Agents (analogues)

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FOLIC ACID ANALOGUES, PYRIMIDINE ANALOGUES, AND PURINE ANALOGUES

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Describe Antimetabolite Agents

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structural analogues of normal metabolites required for cell function and replication

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Antimetabolite Agents react with

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specific enzymes

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Antimetabolite Agents reaction with enzymes leads to

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inhibition of that enzyme and subsequent synthesis of an aberrant molecule that can not function normally.

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what type of resistance do Antimetabolite agents cause?

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acquired resistance

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METHOTREXATE type of analogue

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folic acid

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Side effects of Methotrexate

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ulcerative stomatitis, diarrhea, bone marrow depression, hemorrhagic enteritis, and death from perforation, pulmonary toxicity, renal and hepatic toxicity.

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florouracil type of analogue

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Pyrimidine

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Florouracil can cause what life-threatening event?

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can cause myocardial ischemia up to 1 week after treatment. The incidence is low in patients without pre-exisisting heart disease but increases to 4.5% in patients CAD.

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Plant Alkaloids examples (3)

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VINBLASTINE, VINCHRISTINE (periwinkle plant), PACLITAXEL (bark of the pacific yew)

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Vinblastine and Vincristine mechanisms of action

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block mitosis in rapidly dividing cells

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Most of the chemotherapeutic activity of Vinblastine and Vincristine is due to

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their ability to bind to microtubules which arrest cell division during metaphase.

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side effects of Vinblastine and Vincristine

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Leukopenia, thrombocytopenia, anemia, neuropathy, parathesia of hands and feet, hyponatremia, tachycardia, autonomic NS involvement).

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side effects of Paclitaxel

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Bradycardia, MI, Atrial dysrhythmias, VTachy

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Antibiotics are usually natural products of

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soil fungi

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Daunorubicin and Doxorubicin class

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antibiotics

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Doxorubicin used for treating

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metasatic adenocarcinoma of breast, carcinoma of bladder, bronchogenic carcinoma, metasatic carcinoma of thyroid, oat cell, and osteogenic carcinoma.

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side effects of Daunorubicin and Doxorubicin

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Causes Cardiomyopathy wide range of cardiac problems from nonspecific ST-T changes to PVC, SVT, decreased QRS voltage.

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describe onset of Daunorubicin and Doxorubicin induced cardiomyopathy

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Onset is insidious with dry cough to heart failure that is unresponsive to inotropic drugs or mechanical ventricular devices.

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acute left ventricular failure has been reported how long after cessation of treatment with doxorubiicin during general anesthesia

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2 months

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While receiving bleomycin, patients with lymphomas may develop

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hyperthermia, hypotension, and hypoventilation.

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Serious side effect of bleomycin

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pulmonary toxicity and Interstitial fibrosis develops and may progress to the entire lung.

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describe the pulmonary toxicity process of bleomycin

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produces pulmonary endothelial damage and necrosis of type 1 and proliferation of type 2 alveolar cells.

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Common cause of fibrosis-related postoperative respiratory failure in bleomycin-treated patients

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arterial hyperoxia or excessive crystalloid administration

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FiO2 for patients treated with bleomycin or mitomycin

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30% or below

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Patients on Bleomycin should receive this type of fluid administration

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Replace fluids with colloids instead of crystalloids

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Plicamycin (mithramycin) side effects

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Highly toxic To GI and bone marrow.

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Plicamycin (mithramycin) effect on calcium

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Lowers calcium for metastatic bone tumors, tumors that produce parathyroid hormone and Paget’s disease. (hypocalcemia)

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Plicamycin (mithramycin) effect on coagulation

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Hemorrhagic diathesis occurs in 1-5%, prolong PT and fibrinolytic activity

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Asparaginase effects on bone marrow, GI or hair follicles.

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minimal

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side effects of enzymes

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Severe toxicity-liver, kidneys, pancreas, CNS, and inhibits clotting, hypofibrinogenemia.

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side effects of Cisplatin

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renal toxicity, ototoxicity,neuropathy, hyperurecemia, seizures, cardiac dysrhythmias.

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side effect of Estrogen and Androgens

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hypercalcemia

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side effect of Flutamide (antiandrogen)

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methemoglobinemia

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Antiestrogens examples

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Tamoxifen,anastrozole

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anesthestic consideration of stomatitis

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makes placement of pharyngeal airways, LMAs, esophageal catheters questionable.

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anesthestic consideration of inhaled and injected drugs

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response may be altered by drug-induced cardiac, hepatic, or renal dysfunction (including nondeplorizing muscle relaxants).

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anesthestic consideration of nmb

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May have decreased plasma cholinesterase and succinylcholine may be prolonged

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Chemotherapeutic have high incidence of what for female personnel who handle the drugs.

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spontaneous abortion in first trimester

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anesthestic consideration of coagulation status

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Patients may be anticoagulated, check labs.

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CNS Stimulants

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-- Armodafinil
 – Caffeine
 – Dextroamphetamine
 – Dextroamphetamine and Amphetamine
 – Doxapram
 – Ergotamine and Caffeine
 – Lisdexamfetamine
 – Methamphetamine
 – Modafinil

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Doxapram

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centrally acting analeptic (CNS stimulant) that selectively increases minute ventilation by activating the carotid bodies.

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The stimulation produced by administration of doxapram, 1mg/kg IV, is similar to that produced by

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a Pa02 of 38mmHg acting on the carotid bodies.

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Doxapram has what type of margin of safety as reflected by?

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large margin of safety as reflected by a 20-40-fold difference in the dose that stimulates ventilation and the dose that produces seizures.

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Doxapram side effects

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CNS stimulation-hypertension, tachycardia, cardiac dysrhythmias, vomiting, increased body temperature.

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Doxapram use

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temporary measure to maintain ventilation during administration of O2 to patients with COPD who are dependent on the hypoxic drive.

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Arousal from the residual effects of inhaled anesthetics follows the administration of doxapram but the effects are

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transient, nonselective, and not recommended.

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Dantrolene produces skeletal muscle relaxation by

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decreasing the amount of calcium released from the sarcoplasmic reticulum.

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Dantrolene does or does not not work at the neuromuscular junction as do standard neuromuscular blocking drugs?

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does not

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describe dantrolene muscle relaxation

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Does not render the muscle totally flaccid and without tone, but it may cause significant muscle weakness and respiratory insufficiency.

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dantrolene pH; side effects of pH

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Alkaline (pH 9.5) and can cause phlebitis, extravasation can cause tissue necrosis.

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what drug is added to dantrolene to make it isotonic?

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mannitol

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describe dantrolene metabolism

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Metabolized in the liver

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dantrolene metabolite and activity

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hydoxydantrolene, which is 30-50% as effective in depressing the twitch response.

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dantrolene elimination half time

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5-8 hours

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Oral Dantrolene Prophylaxis for MH

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oral 5mg/kg in 3-4 divided doses every 6 hours, with the last dose 4 hours preoperatively

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IV Dantrolene Prophylaxis for MH

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2.4mg/kg IV, 10-30 mins preinduction and ½ dose in 6 hours.

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Dantrolene treating and max dose

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2.5MG/KG IV,UNTIL SYMPTOMS SUBSIDE OR A CUMULATIVE DOSE OF 10MG/KGIV IS REACHED.

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Dantrolene Side effects

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skeletal muscle weakness, nausea, vomiting, diarrhea, blurred vision, uterine atony. Short term is not associated with hepatotoxicity.

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Amphetamine and methamphetamine are powerful CNS

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stimulants.

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Amphetamines act as what type of agents and where?

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indirect sympathomimetics, peripherally (similar to ephedrine)

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amphetamines effect on opioids

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Can enhance the effects of opioids

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amphetamines mechanism of action and where

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they release dopamine and other biogenic amines in the brain

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amphetamines action on MAO

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inhibit

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amphetamines with

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amine transporters in the plasma membrane

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Methylphenanidate (Ritalin).

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Less motor effect than amphetamines, mainly used in attention deficit disorder.

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Caffeine

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Causes cortical arousal and delay of fatigue.

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caffeine use

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One of the principal uses in anesthesia is the treatment of PDPH

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caffeine in low doses can cause

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nervousness and insomnia

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caffeine in high doses it can cause

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adrenal medullary stimulation and seizures.