ifosfamide

Ifex

Indications

Action

Pharmacokinetics

Time/action profile (effects on blood counts)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• CNS toxicity (somnolence, confusion, hallucinations, coma) (most frequent)
• cranial nerve dysfunction
• disorientation
• dizziness

Cardiovascular

• cardiotoxicity

Gastrointestinal

• nausea (most frequent)
• vomiting (most frequent)
• anorexia
• constipation
• diarrhea
• hepatotoxicity

Genitourinary

• hemorrhagic cystitis (most frequent)
• dysuria
• sterility
• renal toxicity

Dermatologic

• alopecia (most frequent)

Hematologic

• anemia
• leukopenia
• thrombocytopenia

Local

• phlebitis

Miscellaneous

• allergic reactions

Interactions

Drug-Drug interaction

Route/Dosage

Availability (generic available)

Nursing implications

Nursing assessment

• Monitor BP, pulse, respiratory rate, and temperature frequently during administration. Report significant changes.
• Monitor urinary output frequently during therapy. Notify health care professional if hematuria occurs. To reduce the risk of hemorrhagic cystitis, fluid intake should be at least 3000 mL/day for adults and 1000–2000 mL/day for children. Mesna is given concurrently to prevent hemorrhagic cystitis.
• Monitor neurologic status. Ifosfamide should be discontinued if severe CNS symptoms (agitation, confusion, hallucinations, unusual tiredness) occur. Symptoms usually abate within 3 days of discontinuation of ifosfamide but may persist for longer; fatalities have been reported.
• Assess nausea, vomiting, and appetite. Weigh weekly. Premedication with an antiemetic may be used to minimize GI effects. Adjust diet as tolerated.
• Monitor for bone marrow depression. Assess for bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis) and avoid IM injections and taking rectal temperatures if platelet count is low. Apply pressure to venipuncture sites for 10 min. Assess for signs of infection during neutropenia. Anemia may occur. Monitor for increased fatigue, dyspnea, and orthostatic hypotension.
• Lab Test Considerations: Monitor CBC, differential, and platelet count prior to and periodically during therapy. Withhold dose if WBC <2000/mm³ or platelet count is <50,000/mm³. Nadir of leukopenia and thrombocytopenia occurs within 7–14 days and usually recovers within 21 days of therapy.
  • Urinalysis should be evaluated before each dose. Withhold dose until recovery if urinalysis shows >10 RBCs per high-power field.
  • May cause ↑ in liver enzymes and serum bilirubin.
  • Monitor AST, ALT, serum alkaline phosphatase, bilirubin, and LDH prior to and periodically during therapy. Ifosfamide may cause ↑ in liver enzymes and serum bilirubin.
  • Monitor BUN, serum creatinine, phosphate, and potassium periodically during therapy. May cause hypokalemia.

Potential Nursing Diagnoses

Implementation

• Prepare solution in a biologic cabinet. Wear gloves, gown, and mask while handling IV medication. Discard IV equipment in specially designated containers.

• Intravenous Administration

• pH: 6.0.
• Intravenous: Prepare solution by diluting each 1-g vial with 20 mL of sterile water or bacteriostatic water for injection containing parabens. Use solution prepared without bacteriostatic water within 6 hr. Solution prepared with bacteriostatic water is stable for 1 wk at 30°C or 6 wk at 5°C.
• Intermittent Infusion: Diluent: May be further diluted in D5W, 0.9% NaCl, LR, or sterile water for injection.Concentration: 0.6 to 20 mg/mL (maximum 40 mg/mL). Dilute solution is stable for 7 days at room temperature or 6 wk if refrigerated.
• Rate: Administer over at least 30 min.
• Continuous Infusion: Has also been administered as a continuous infusion over 72 hr.
• Y-Site Compatibility: acyclovir, alfentanil, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amiodarone, amphotericin B cholesteryl, amphotericin B colloidal, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, atracurium, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, caspofungin, cafazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, cimetidine, ciprofloxacin, cisatracurium, cisplatin, clindamycin, codeine, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, diltiazem, dipehnhydramine, dobutamine, docetaxel, dolasetron, dopamine, doripenem, doxacurium, doxorubicin, doxorubicin liposome, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, ertapenem, erythroycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, foscarnet, fosphenytoin, furosemide, ganciclovir, gemcitabine, gentamicin, granisetron, haloperidol, heparin, hetastarch, hydrocortisone, hydromorphone, idarubicin, imipenem/cilastatin, insulin, isoproterenol, ketorolac, labetalol, leucovorin, levofloxacin, levorphanol, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, melphalan, meperidine, meropenem, mesna, methohexital, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron, pancuronium, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, topotecan, trastuzumab, trimethoprim/sulfamethoxazole, vancomycin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine
• Y-Site Incompatibility: cefepime, diazepam, methotrexate, pantoprazole, phenytoin, potassium phosphates
• Additive Compatibility: carboplatin, cisplatin, epirubicin, etoposide, fluorouracil, mesna

Patient/Family Teaching

• Emphasize need for adequate fluid intake throughout therapy. Patient should void frequently to decrease bladder irritation from metabolites excreted by the kidneys. Notify health care professional immediately if hematuria is noted.
• Instruct patient to drink at least 8 glasses of water/day during and for 3 days after completion of therapy.
• Instruct patient to notify health care professional promptly if fever; chills; cough; hoarseness; sore throat; signs of infection; lower back or side pain; painful or difficult urination; bleeding gums; bruising; petechiae; blood in urine, stool, or emesis; or confusion occurs.
• Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor and to avoid falls. Patients should also be cautioned not to drink alcoholic beverages or to take products containing aspirin or NSAIDs, as these may precipitate GI hemorrhage.
• Review with patient the need for contraception during therapy.
• Discuss with patient the possibility of hair loss. Explore methods of coping.
• Advise patient to consult health care professional before taking any Rx, OTC, or herbal products.
• Instruct patient not to receive any vaccinations without advice of health care professional; ifosfamide may decrease antibody response to and increase risk of adverse reactions from live-virus vaccines.

Evaluation/Desired Outcomes

• Decrease in size or spread of malignant germ cell testicular carcinoma.