Cytotoxics

Some therapies and treatments have originated from their use for malignant disease. The term chemotherapy is generally associated with cytotoxic drug therapy; essentially this means treatment with cell killing (cytotoxic) drugs, either used singularly or in a combination.

These therapies are potent immunosuppressive agents and are only used on specialist advice.

• The patient and family need appropriate counselling and support.
• Pre- treatment assessment includes:
• Blood tests - Full Blood Count, liver transaminase levels, serum creatinines.
• Varicella immunity status (consider also checking measles status). Consider immunisation before treatment starts if child is non-immune.
• Consider testing for tuberculosis in high risk individuals.
• Live vaccines are all contraindicated; inactivated vaccines are safe, but may have reduced efficacy. Annual flu vaccine and 5 yearly pneumovax advised.
• Advise adequate contraception in sexually-active females of child-bearing age.
• Regular monitoring is needed; disease status and blood tests (to check for bone marrow suppression, renal and liver function) .

Cyclophosphamide

• Cytotoxic drugs such as cyclophosphamide act predominantly on rapidly dividing cells, such as T and B lymphocytes. It is immunosuppressive and anti-inflammatory as well as having anti-cancer properties.
• Pulse IV cyclophosphamide may be used for the treatment of vasculitis disorders, systemic lupus erythematous (JSLE), and juvenile dermatomyositis (JDM).
• Protocols for use of cyclophosphamide involve cycles of infusions over several months. Pulses may be given with IV methylprednisolone.
• Possible side effects include bone marrow suppression, nausea and vomiting, haemorrhagic cystitis, and hair loss. Infertility is a risk and counselling is necessary. Infections are a serious complication.
• Treatment is usually given as a day case and before each dose it is important to check that the child is well with no evidence of infection. Blood tests are done (Full blood count, urea & electrolytes, liver function tests, and creatinine). The dose will be reduced or delayed if there is evidence of bone marrow suppression. Bone marrow suppression is most likely to occur 7–10 days after the infusion so the full blood count should be checked at this time. Urine should be monitored for haematuria and proteinuria throughout the treatment period.
• Personal protective equipment is necessary when preparing, handling, and administering cytotoxic drugs, to minimize the risk of accidental contamination.