Other oncology nurses have mentioned to me that they infuse rituximab (Rituxan) over 90 minutes. Are there references for this? — Ruth C. Gholz, RN, MS, AOCN, and colleagues at the Cincinnati VA Medical Center

The 5- to 6-hour infusion time utilized for rituximab has stimulated research into safely speeding up the infusion. One study involved 1,200 patients with only one Grade 3 reaction when rituximab was administered over 90 minutes (Blood. 2007;109:4171-4173). Another study reported successful administration in 60 minutes without significant reactions (Ann Oncol. 2006;17:1027-1028). Before attempting more rapid infusions of rituximab, strict safety monitoring algorithms should be established. Temperature, blood pressure, and heart and respiratory rates should be measured before the infusion and again at 15, 30, 60, and 90 minutes; and the patient questioned about adverse experiences. — Donald Fleming, MD

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Why do children with Down syndrome who are being treated for acute lymphocytic leukemia (ALL) sometimes require oral leucovorin after intrathecal methotrexate administration?

Children with Down syndrome have between a 10- and 20-fold higher increase in developing ALL compared to the general population. Incidence peaks first in the newborn period and again at ages 3 to 6 years. During the first four stages of treatment for ALL (induction, consolidation, interim maintenance, and delayed intensification), children with Down syndrome are at particular risk to develop systemic toxicities, especially from methotrexate. Leucovorin is a methotrexate antidote administered to decrease the potential for systemic toxicity (bone marrow suppression and liver impairment). — Karen MacDonald, RN, BSN, CPON

Why is trimethoprim/sulfamethoxazole (TMP-SMX) held during methotrexate administration?

Pediatric oncology patients are typically prescribed (TMP-SMX) at a dosage of 5 mg/kg/d divided into two doses for 2 to 3 consecutive days per week during treatment and for 6 months after therapy is complete to prevent the development of Pneumocytis carinii (now renamed Pneumocystis jiroveci) infection. (TMP-SMX) should not be administered with, or close to the administration of, high-dose methotrexate (doses of 3 g/m2 or higher). Both trimethoprim and sulfonamides have similar toxicities and can increase the risk of toxicity (such as hepatic and renal impairment) with high-dose methotrexate therapy. — Karen MacDonald, RN, BSN, CPON


What is the determining factor for preservation of fertility? Why can some women get pregnant after treatment and others cannot or do not? Is fertility preservation based on what chemotherapy one is receiving? — Tiffany Hunter, RN, York, PA.

Preservation of fertility in cancer patients depends on the patient’s age, disease, sex, type of chemotherapeutic agents used, radiation fields, dose, dose-intensity, methods of administration (oral versus intravenous), and pretreatment fertility (J Clin Oncol. 2006;24:2917-2931). Infertility should be discussed as early as possible with all patients as a potential risk of therapy. Fertility preservation options should be explained and patient interest ascertained before initiating treatment. Male and female infertility are highly associated with chemotherapy regimens involving alkylating agents and total body irradiation. — Jiajoyce R. Conway, DNP, FNP-BC, NP-C ONA