Assessment

• Nausea and vomiting of gradual onset frequently occur. Tolerance may develop after several weeks of therapy. Treatment includes antiemetics or dosage reduction and, rarely, discontinuation. Monitor amount of emesis and notify physician if emesis exceeds guidelines to prevent dehydration

• Monitor for bone marrow depression throughout therapy. Although the patient is often asymptomatic, symptoms include anemia (unusual tiredness), leukopenia (fever, chills, sore throat, cough or hoarseness, lower back or side pain, painful or difficult urination), and thrombocytopenia (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis). Notify physician if these symptoms occur

• Avoid IM injections and taking rectal temperatures. Apply pressure to venipuncture sites for 10 min

• Assess patient for signs of neurotoxicity including CNS effects (anxiety, clumsiness, confusion, dizziness, mental depression, weakness, seizures) and peripheral neuropathy (numbness, tingling, paresthesia) prior to initiation of each course and routinely throughout therapy. Pyridoxine may minimize peripheral neuropathy; usually reversible on discontinuation of altretamine. If neurotoxicity continues after dosage reduction, discontinue therapy

• Monitor CBC and platelets prior to each course of therapy, monthly, and as clinically indicated. The nadir of leukopenia and thrombocytopenia occurs in 3–4 wk with 21-day therapy and recovers in 6 wk with intermittent dosing; with continuous dosing the nadir occurs in 6–8 wk. Dose should be held for 14 or more days and resumed at 50 mg/m²/day 4 times daily for any of the following: GI intolerance unresponsive to conventional therapy, WBC <2000 mm³, granulocytes <1000 mm³, platelet count <75,000 mm³, or progressive neurologic toxicity

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