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Understanding Nitrogen Mustards: Therapeutic Uses and Nursing Care

Written by Mariya Rizwan, PharmD

Nitrogen mustards were developed as a potential chemical warfare tool in the 1920s and 1930s. They are vesicants or blister agents, similar to sulfur mustards. Nitrogen mustards come in various smells, such as fruity, soapy, musty, or fishy. Moreover, they also exist in different forms, such as solid, oily textured liquids, or vapors. At room temperature, they are liquid. In solid or liquid form, they can be clear, pale amber, or yellow-colored.

The first introduced nitrogen mustard drug was mechlorethamine- a rapid-acting drug. With most alkylating drugs, their absorption and distribution vary widely. However, nitrogen mustards are metabolized in the liver and excreted through the kidneys. Often, they undergo metabolism quite rapidly. Mechlorethamine undergoes metabolism in a few minutes, leaving no active drug remaining.

Nitrogen mustard acts by forming covalent bonds with the deoxyribonucleic acid (DNA) molecule in a chemical reaction known as alkylation. Since alkylated DNA can not replicate properly, it results in cell death, hindering the growth of cancerous cells. However, sometimes those cells may develop drug resistance to the cytotoxic effects of nitrogen mustards, which makes them ineffective.

Nitrogen mustards are alkylating agents that produce antineoplastic effects by damaging DNA. Being the largest group of alkylating agents, they include:

  • Chlorambucil
  • Cyclophosphamide
  • Estramustine
  • Ifosfamide
  • Mechlorethamine hydrochloride
  • Melphalan

When Are Nitrogen Mustards Used?

Nitrogen mustards produce leukopenia – a decreased number of white blood cells (WBCs). Hence, they are beneficial in treating neoplasms, such as Hodgkin’s disease – cancer that causes painless enlargement of the lymph nodes, spleen, and lymphoid tissues and leukemia, a cancer of the blood-forming tissues that can have an associated elevated WBC count.

Nitrogen mustards are also useful in the treatment of malignant lymphoma – cancer of the lymphoid tissue; multiple myeloma – cancer of the marrow plasma cells; melanoma – malignancy that arises from melanocytes and cancer of the breast, ovaries, uterus, lung, brain, testes, bladder, prostate, and stomach.

What Are the Drug Interactions With Nitrogen Mustards?

Various drug interactions can occur with nitrogen mustards. Calcium-containing supplements like antacids or food such as dairy products can reduce the absorption of estramustine. Therefore, avoid their concomitant administration.

Cyclophosphamide, when given with other cardiotoxic drugs, can cause increased cardiac adverse effects. Moreover, cyclophosphamide can also reduce serum digoxin levels.

The risk of ifosfamide toxicity increases when given with other drugs, such as allopurinol, barbiturates, chloral hydrate, or phenytoin. Therefore, caution must be taken with their administration. Also, when ifosfamide is given with corticosteroids, it results in reduced ifosfamide effects.

The lung toxicity threshold of carmustine may be reduced when given with melphalan. Interferon alfa can reduce the serum concentration of melphalan.

What Are the Adverse Reactions of Nitrogen Mustards?

Nitrogen mustards can be hard to tolerate, causing immense fatigue to the patient. With that, they can cause other adverse drug reactions, such as bone marrow suppression that can lead to severe leukopenia and thrombocytopenia, nausea and vomiting due to central nervous system (CNS) irritation, stomatitis, and reversible hair loss- which can be emotionally overwhelming for the patient. Adequate mental health support is necessary.

Nitrogen mustards are powerful vesicants that cause blisters on the skin. Therefore, avoid skin contact with them or their vapors, as they can cause severe skin, eyes, and respiratory tract reactions.

Nursing Processes

With nitrogen mustard therapy, a specific nursing process should be followed.

Before starting the therapy, assess the patient’s underlying neoplastic disorder and continue assessment regularly throughout the therapy. Also, perform a complete assessment before the therapy begins. Throughout, monitor the patient for any adverse drug reactions. Moreover, monitor platelet and total and differential leukocyte counts as well as hematocrit, blood urea nitrogen (BUN), alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LD), serum bilirubin, serum creatinine, uric acid, and other levels as needed.

Throughout drug administration, monitor the patient’s vital signs and catheter or intravenous line patency and evaluate the patient’s and their caregiver’s knowledge of drug therapy.

Make sure to follow established guidelines for the proper handling, administration, and disposal of chemotherapeutic drugs. If extravasation occurs, treat it promptly. Anaphylactic reactions can occur during the administration of a chemotherapeutic drug. Therefore, keep epinephrine, antihistamines, and corticosteroids handy.

Administer the medicines as prescribed by the healthcare provider and monitor for effects. Hydrate the patient well and monitor fluid intake and output. Also, manage nausea and vomiting with antiemetics that occur due to chemotherapy. Follow facility policy for infection control in immunocompromised patients whose WBC counts fall below 2,000/μL or granulocyte counts fall below 1,000/μL.

The Bottom Line

Tolerating nitrogen mustard therapy can be challenging for the patient. Frequent monitoring is necessary. Be vigilant when they receive chemotherapy. Also, compel the patient to report to you as soon as they experience any adverse effects.

About the Author:

Mariya Rizwan is an experienced pharmacist who has been working as a medical writer for four years. Her passion lies in crafting articles on topics ranging from Pharmacology, General Medicine, Pathology to Pharmacognosy.

Mariya is an independent contributor to CEUfast’s Nursing Blog Program.

Please note that the views, thoughts, and opinions expressed in this blog post are solely of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

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