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Mitoxantrone

Availability – 10mg, 20mg, and 25mg vials at a concentration of 2mg/ml. This product does not require dilution.

Route – To be given intravenously with an over-the-needle 22g catheter. Administer into the injection port of a running saline infusion over no less than 3 minutes. Use Nacl, NO HEPARIN-may form a precipitate.

Dosage – Dogs:

  • For lymphoproliferative disorders: 5-6mg/M2 every 3 weeks (Gilson and Page 1994)
  • For lymphoma, Squamous cell carcinoma, transitional cell carcinoma, mammary gland tumors, etc. Effective dose of 6mg/M2 IV every 2-3 weeks. (Ogilvie 2003)
  • As a single rescue agent for lymphoma: 5.5-6mg/M2 IV every 3 weeks (Meleo 2003)

Cats:

  • For soft-tissue sarcomas: 6-6.5 mg/M2 IV given every 3-4 weeks for 4-6 treatments. (Keller and Helfand 1994)
  • Effective dose:6.5 mg/M2 IV every 2-3 weeks (Ogilvie 2003a)
  • As a single rescue agent lymphoma:6-6.5 mg/M2 IV every 3 weeks (Meleo 2003)

Storage – New unopened bottles are to be stored at room temperature in a chemotherapy only area. Once a bottle has been opened it should be placed in an individual Ziploc bag with the date and time it was opened written on the bag. It is to be stored in a chemotherapy ONLY refrigerator and is good for 14 days once it has been opened.

Interactions–

  • Do not infuse with other drugs.
  • Increase risk of bone marrow suppression may occur with trimethoprim sulfa drug.
  • Live virus vaccines should be used with extreme caution if at all.

Contraindications/Precautions -

  • Impaired cardiac function
  • Myelosuppression
  • Concurrent infection
  • Those who have received prior cytotoxic drugs or radiation exposure
  • Use caution in patients with liver disease, hyperuricemia and hyperuricuria.

Extravasation – May result in severe tissue damage and necrosis. If extravasation should occur, it is recommended that intermittent ice packs be placed over the area and the affected extremity be elevated.

Possible Side Effects –

  • Blue-green color in the urine may be noted, but no concern.
  • Bluish color to the sclera may be noted, but no concern.
  • Vomiting
  • Anorexia
  • Diarrhea
  • Lethargy
  • Conjunctivitis
  • Jaundice
  • Renal failure
  • Seizures
  • Allergic reaction
  • Thrombocytopenia
  • Injection site irritation

Supplies –

  • Patient chart with chemotherapy log sheet
  • M2 conversion chart
  • Calculator
  • Mitoxantrone
  • Universal Vial Spike w/Clave (one per bottle)
  • Spiros Closed Male adaptor
  • Luerlock syringe- appropriate size
  • Administration set – Clave Drip Chamber
  • 250 ml bag Nacl
  • Chemotherapy gloves – one pair per person
  • Chemotherapy gown – one per person
  • Protective eye wear – one per person
  • Chemotherapy mask – one per person
  • Chemotherapy medical waste bag
  • Chemotherapy sharps container

Catheter supplies – Hair clipper with 40 blade

  • Surgical scrub/alcohol
  • 22g over-the-needle catheter
  • 1”white tape
  • Gauze pads
  • Bandaging material
  • Scissors

Patient if treated in hospital –

  • The patient should be housed in an appropriate sized cage or run, if caged a lower cage is suggested to avoid urine running to lower cage.
  • Cage/run should be in a location where they can be observed at all times
  • Patient identification card
  • Cage marked with a very visible sign indicating “Chemotherapy Patient”
  • Fresh water at all times

Pre-treatment –

  • Physical by DVM
  • Physical by Oncology technician
  • Owner authorization papers signed
  • Chemistry panel
  • CBC – monitor neutrophil count, postpone treatment if less than 3,000/ul
  • Monitor WBC, postpone if low, possibly start antibiotics
  • Prepare all supplies
  • Calculate drug dosage, triple check

Treatment Procedure –

  • Have the patient walked prior to treatment
  • Procedure should be performed in Chemotherapy room or a low traffic area
  • Place 22g catheter in cephalic vein alternating between right and left leg, This MUST be a clean stick, if not place higher on same leg or place in other leg
  • Secure catheter in place with bandaging material
  • Start a slow Nacl drip; Mitoxantrone should be diluted in at least 30 ml of Nacl
  • Have assistant and yourself dress in appropriate clothing
  • Draw up Mitoxantrone in Luerlock syringe with Spiros closed male adaptor
  • Make sure patient and assistant are comfortable
  • The diluted solution should be introduced slowly into the tubing as a freely running intravenous infusion of Nacl over a period of not less than 3 minutes.
  • Monitor above catheter site for swelling during entire treatment, if swelling is noted STOP injecting immediately. Remove IV catheter and follow extravasation procedure.
  • Once treatment is finished remove catheter with injection site covered with several gauze pads, once catheter is removed hold steady pressure over IV site for 5 minutes
  • Place a firm bandage over IV site and leave in place for one hour
  • Wear gloves when removing bandage, send gloves home with owner if out patient treatment is being performed
  • Patient can be placed back into their cage/run, be sure “Chemotherapy Patient” sign is visible.
  • Place all waste material, syringes, catheter, IV line, etc. in appropriate waste containers
  • You can now safely remove chemotherapy clothing; gloves should go into medical waste bag.

Patient Clean Up –

  • Medical staff must wear gloves when cleaning cage, bedding and excrement of all chemotherapy patients
  • Urine, stool and vomit is considered contaminated for 48 hours
  • All solid waste must be double bagged before being placed in the trash
  • If possible collect urine in a pan and flush it down the drain
  • If you do not catch the urine thoroughly rinse the area with copious amounts of water, avoiding splashing at all times
  • Blankets and bedding should be washed asap with regular disinfectant
  • Cage/run can be cleaned with regular disinfectant. DO NOT use a spray bottle or hose, avoid aerosolization

Discharge –

  • Supply owner with written home care instruction. Go over the entire form at EVERY visit. Have owner sign two copies, one for them and one for the patient record. See our version of “Home Care Instruction” in our specialty folder
  • Supply owner with gloves
  • Schedule follow-up blood work, CBC 10 day post treatment
  • Schedule next tentative chemotherapy treatment

References:
Plumb’s Veterinary Drug Handbook
Mitoxantrone drug insert
Oncology for Veterinary Technicians and Nurses – Moore and Frimberger
Cancer In Dogs And Cats Medical and Surgical Management – Morrison
Managing The Canine Cancer Patient – Ogilvie and Moore