Question

The patient with a nasogastric tube is prescribed venetoclax. The nurse should:

Answer 1

NURSING CONSIDERATIONS-

• Before beginning venetoclax therapy, patients should be assessed for TLS risk, as indicated by tumor burden and comorbidities.
• To reduce TLS risk, patients should receive pro­phylactic hydration and antiuricemics before beginning treatment.
• For the first dose, patients should have bloodwork done to monitor for TLS before, six to eight hours after, and 24 hours after the dose. Repeat the lab tests with the first increased dose on the ramp-up schedule.

Tumor Burden	Prophylaxis	Blood Chemistry Monitoringc,d
Hydrationa	Anti- hyperuricemics	Setting and Frequency of Assessments
Low	All LN <5 cm AND ALC <25 x109/L	Oral (1.5-2 L)	Allopurinolb	Outpatient For first dose of 20 mg and 50 mg: Predose, 6 to 8 hours, 24 hours For subsequent ramp-up doses: Predose
Medium	Any LN 5 cm to <10 cm OR ALC ≥25 x109/L	Oral (1.5-2 L) and consider additional intravenous	Allopurinol	Outpatient For first dose of 20 mg and 50 mg: Predose, 6 to 8 hours, 24 hours For subsequent ramp-up doses: Predose For first dose of 20 mg and 50 mg: Consider hospitalization for patients with CLcr <80ml/min; see below for monitoring in hospital
High	Any LN ≥10 cm OR ALC ≥25 x109/L AND any LN ≥5 cm	Oral (1.5-2L) and intravenous (150-200 mL/hr as tolerated)	Allopurinol; consider rasburicase if baseline uric acid is elevated	In hospital For first dose of 20 mg and 50 mg: Predose, 4, 8, 12 and 24 hours Outpatient For subsequent ramp-up doses: Predose, 6 to 8 hours, 24 hours
ALC = absolute lymphocyte count; CLcr = creatinine clearance; LN = lymph node. aAdminister intravenous hydration for any patient who cannot tolerate oral hydration. bStart allopurinol or xanthine oxidase inhibitor 2 to 3 days prior to initiation of VENCLEXTA. cEvaluate blood chemistries (potassium, uric acid, phosphorus, calcium, and creatinine); review in real time. dFor patients at risk of TLS, monitor blood chemistries at 6 to 8 hours and at 24 hours at each subsequent ramp-up dose.

• Women of reproductive potential should have a pregnancy test before beginning treatment with venetoclax.
• Blood counts should be monitored throughout treatment for hematologic and nonhematologic toxicities.
• Concurrent treatment with P-gp inhibitors or strong or moderate CYP3A inhibitors can increase toxicity from venetoclax and should be avoided. Strong CYP3A inhibitors are contraindicated during treatment initiation and dose increases. After the full dose is reached, patients who must use P-gp or CYP3A inhibitors will likely need their venetoclax dose adjusted. Strong or moderate CYP3A inducers should be avoided throughout treatment.  
• Nurse should also Look for proper treatment Guidelines as per the patient's.

-Schedule for Patients with CLL/SLL

Weeks	VENTOCLEX Daily Dose
Week 1	20 mg
Week 2	50 mg
Week 3	100 mg
Week 4	200 mg
Week 5 and beyond	400 mg

-Patients with AML

Days	VENTOCLEX Daily Dose
Day 1	100 mg
Day 2	200 mg
Day 3	400 mg
Days 4 and beyond	400 mg when dosing in combination with a zacitidine or decitabine	600 mg when dosing in combination with low-dose cytarabine

• Nurse should also Monitor certain Side effects of drug and manage them regularly-
  • Low platelet counts
  • low red blood cell counts
  • diarrhea
  • nausea
  • upper respiratory tract infection
  • cough
  • muscle and joint pain
  • tiredness
  • swelling of your arms, legs, hands, and feet