Bone marrow suppression monitoring

MANAGING HONE MARROW SUPPRESSION. Bone marrow suppression is a potentially dangerous adverse reaction resulting in decreased production of blood cells. Bone marrow suppression is manifested by abnormal laboratory test results and clinical evidence of leukopenia, thrombocytopenia, or anemia For example, there is a decrease in the white blood cells or leukocytes (leukopenia), a decrease in the thrombocytes (thrombocytopenia), and a decrease in the red blood cells, resulting in anemia Fhtients with leukopenia have a decreased resistance to infection, and the nurse must monitor them closely for any signs of infection. 

Carbamazepine Manufacturer recommends CBC and platelets (and possibly reticulocyte counts and serum iron) at baseline, and that subsequent monitoring be individualized by the clinician (e.g., CBC, platelet counts, and liver function tests every 2 weeks during the first 2 months of treatment, then every 3 months if normal). Monitor more closely if patient exhibits hematologic or hepatic abnormalities or if the patient is receiving a myelotoxic drug discontinue if platelets are less than 100,000/mm3, if white blood cell (WBC) count is less than 3,000/mm3 or if there is evidence of bone marrow suppression or liver dysfunction. Serum electrolyte levels should be monitored in the elderly or those at risk for hyponatremia. Carbamazepine interferes with some pregnancy tests. 

Bone marrow suppression ZDV Onset Few weeks to months Symptoms Fatigue, risk of T bacterial infections due to neutropenia anemia, neutropenia 1. Advanced HIV 2. High dose ZDV 3. Preexisting anemia or neutropenia 4. Concomitant use of bone marrow suppressants Avoid in patients with high risk for bone marrow suppression avoid other suppressing agents monitor CBC with differential at least every 3 months Switch to another NRTI D/C concomitant bone marrow suppressant, if possible for anemia Identify and treat other causes consider erythropoietin treatment or blood transfusion, if indicated for neutropenia Identify and treat other causes consider filgrastim treatment, if indicated... 

Myelosuppression Myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been reported in patients receiving linezolid. Monitor complete blood counts weekly in patients who receive linezolid, particularly in those who receive linezolid for more than 2 weeks, those with preexisting myelosuppression, those receiving concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have received previous or concomitant antibiotic therapy. 

Concurrent leucovorin Trimetrexate must be used with concurrent leucovorin to avoid potentially serious or life-threatening complications, including bone marrow suppression, oral and Gl mucosal ulceration, and renal and hepatic dysfunction. Leucovorin therapy must extend for 72 hours past the last dose of trimetrexate. Inform patients that failure to take the recommended dose and duration of leucovorin can lead to fatal toxicity. Closely monitor patients for the development of serious hematologic adverse reactions. 

Except for the treatment of acute nonlymphocytic leukemia, mitoxantrone therapy generally should not be given to patients with baseline neutrophil counts less than 1500 cells/mm. In order to monitor the occurrence of bone marrow suppression, primarily neutropenia, which may be severe and result in infection, it is recommended that frequent peripheral blood cell counts be performed on all patients receiving mitoxantrone. 

Bone marrow suppression (requires baseline and close monitoring of blood counts) Dizziness, drowsiness, rashes, nausea Liver toxicity, especially under 10 years of age... 

Because the onset of bone marrow suppression may be insidious, it is prudent to instruct patients to monitor themselves for the appearance of fever, malaise, sore throat, petechiae, or other evidence of possible hematological dysfunction rather than simply relying on periodic laboratory surveillance. In... 

CALCIUM CHANNEL BLOCKERS EPIRUBICIN Cases of T bone marrow suppression when verapamil is added to epirubicin Uncertain at present Monitor FBC closely... 

CYCLOPHOSPHAMIDE ANTIGOUT DRUGS-ALLOPURINOL t risk of bone marrow suppression Uncertain but allopurinol seems to T cyclophosphamide levels Monitor FBC closely... 

DOCETAXEL DOXORUBICIN t plasma concentrations of docetaxel (t AUC by 50-70%) with t efficacy and also t risk of toxicity, particularly when docetaxel is administered after doxorubicin, compared with administration of docetaxel alone Uncertain possibly due to interference with hepatic microsomal enzymes Monitor closely for T incidence of bone marrow suppression, neurotoxicity, myalgia and fatigue... 

AZATHIOPRINE LEFLUNOMIDE T risk of serious infections (sepsis) and of opportunistic infections (Pneumocystis jiroveci pneumonia, tuberculosis, aspergillosis) Additive immunosuppression Monitor platelets, white bloods cell, haemoglobin and haematocrit at baseline and regularly - weekly, during concomitant therapy. With evidence of bone marrow suppression, discontinue leflunomide and administer colestyramine or charcoal to T elimination of leflunomide - For signs and symptoms of immunosuppression, see Qinical Features of Some Adverse Drug Interactions, Immunosuppression and blood dyscrasias... 

Bone marrow suppression is the single most important dose-limiting factor with cytotoxic agents. Repeated blood monitoring is essential and transfusion of any/all formed elements of the blood may be needed, e.g. platelet transfusion for thrombocytopenic bleeding or where the platelet count falls below 10 x 10 /1. Cell growth factors. 

Of the toxic side effects, a major concern among clinicians is for dose-dependent bone marrow suppression (myelotoxicity), which occurs in 2. 6% of patients and can be fatal if not addressed properly. Study data suggest that a high incidence of secondary acute myeloid leukemia or brain cancer is correlated with low TPMT activity and high 6-TGN levels in children under immunosuppressive therapy. TPMT activity is subject to wide interindividual and interethnic variability due to TPMT gene polymorphism. In the Caucasian population, 0.3% of all individuals have no TPMT activity and 11% have intermediate activity, leading some to advocate additional monitoring of this activity in patients to help prevent unnecessary bone marrow toxicity from azathioprine treatment. 

Monitor hematology results for bone marrow suppression. 

Drugs for which concentration assays are clearly unsuited include acute therapies (i.e. not used at steady state), those with extraordinarily short half-times (e.g. injected or intranasal polypeptides) and those for which either treatment is indicated regardless (late acetaminophen/parace-tamol overdoses, see above), or when adverse events are almost automatic and should be monitored in other ways, for example CNS toxicity with salicylates (see above) or liability to bone marrow suppression with cytotoxic agents. Furthermore, the efficacy and tolerability of some drugs are known to be unrelated to circulating concentrations (e.g. penicillin anaphylaxis),... 

Mechlorethamine hydrochloride (Mustargen) and carmustine (bischloronitrosourea, BCNU, BICNU) are used topically to treat cutaneous T-cell lymphoma. Both can be applied as a solution or in ointment form. It is important to monitor complete blood counts and liver function tests because systemic absorption can cause bone marrow suppression and hepatitis. Other side effects include allergic contact dermatitis, irritant dermatitis, secondary cutaneous malignancies, and pigmentary changes. Carmustine also can cause erythema and posttreatment telangiectasias. 

Methotrexate exerts significant antiproliferative effects on the bone marrow therefore, complete blood counts should be monitored. Folinic acid (leucovorin) can be used to rescue patients with hematologic crises caused by methotrexate-induced bone marrow suppression. Careful monitoring of liver function tests is necessary but may not be adequate to identify early hepatic fibrosis in patients receiving chronic methotrexate therapy. Liver biopsy is recommended when the cumulative dose reaches 1-1.5 g. A baseline hver biopsy also is recommended for patients with increased... 

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