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30.02 Alkylating Agents

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  1. Alkylating agents are a type of chemotherapy medication to treat cancer.
  2. This was the first classification of an anti-cancer drug to be developed.
  3. Chemotherapy precautions must be taken
    1. Administration considerations
    2. Chemo certified nurses
  4. Agents include:
    1. Busulfan
    2. Cyclophosphamide
    3. Melphalan

Nursing Points


  1. Alkylating agents work to destroy DNA and block replication of cells in any phase of the cell cycle → even cells that are not rapidly diving in G0→ this makes it a good option for slower-growing cancers
  2. Two sub-types exist
    1. Nitrosoureas → lipid-soluble → CAN cross the blood-brain barrier
      1. Carmustine is an example
    2. Platinum containing compounds → also cause mitochondrial damage
      1. Cisplatin is an example


  1. Side effects → rapidly dividing cells more susceptible to side effects even though all cells are vulnerable
    1. Bone marrow suppression
      1. Pancytopenia → low white blood cells, platelets, and low hemoglobin
      2. Risk of infection, bleeding, and anemia
      3. Risk of secondary malignancy- cancer later in life → usually leukemia
    2. GI toxicities
      1. Nausea and vomiting- can be severe and delayed
      2. Diarrhea
      3. Mucositis- severe mouth sores → we sometimes give ice chips with chemo to prevent
    3. Reproductive harm
    4. Organ-specific
      1. Renal → extra hydration and special infusions with a drug called mesna to protect kidneys

Therapeutic Management

  1. Used to treat MANY cancers and often as part of a combination of different therapies
    1. Some examples → Lymphomas, breast cancer, multiple myeloma, bladder cancer

Nursing Concepts

  1. Cellular regulation
    1. Disrupts cell duplication by damaging DNA
  2. Lab Values
    1. WBC normal 5-10 x10-3/mL
    2. HGB normal 12-17 g/dL (depending on gender)
    3. Platelets normal 150-400 x10-3/mL
  3. Patient Education

Patient Education

  1. Infection prevention
    1. Neutropenic precautions
    2. Hand hygiene
    3. Food preparation
    4. Avoid large crowds
  2. Bleeding precautions
    1. Shaving with an electric razor
    2. Fall prevention
    3. Oral care
  3. Managing side effects
    1. Nausea
    2. Diarrhea
  4. Fertility concerns
    1. Preservation specialists

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Video Transcript

All right. Hi guys. Today, we’re talking about alkylating agents, which is a type of chemotherapy or a classification of chemotherapy, several chemos fall within this category.
I did mention before it is a type of chemotherapy, so there’s certainly a lot of safety precautions that go with that. And I encourage you to check out the antineoplastic lecture to learn more about those chemo precautions, but specifically to alkylating agents. I just want to mention here they are the first anticancer medication, which is just pretty interesting, right? And they are cell-cycle nonspecific. So what that means is chemo is usually targeting cells that are within the cell cycle that are actively replicating. That’s what this cell cycle does, right? One cell goes in two cells come out, but this, this type of chemotherapy can even target cells that are not in the cell cycle yet. 

So that’s important because they can also be used to treat the slow growing tumors that aren’t within this cell cycle frequently. And some of these medications, some examples are busulfan, melphalan, cyclophosphamide, and cisplatin, You might hear those names. And then of course I did mention the importance of chemo precautions with these medications.
Okay. So how do they work? What they do is they cause DNA destruction and what that does with the DNA destruction, that blocks replication of cells. So I mentioned that cell cycle, right? This can even prevent cells from entering that cell cycle or within the cell cycle. It’s going to destroy the DNA. So it cannot replicate. Now, if the cell cannot replicate, eventually the tumor is gone. We’re going to have tumor death, right? Tumor destruction. These medications can also cause mitochondrial damage. If you remember within the cell, those are the powerhouses. So they can kill cells actually by destroying the mitochondrial. Also there are two subtypes of alkylating agents, nitrosureas. These ones are important because they are a lipid soluble. 
And that means they can cross the blood brain barrier. So that’s super important because it is hard to treat tumors of the CNS or in the brain because our body has this great safety mechanism to prevent these harmful substances from getting to the brain right by that blood brain barrier. But that makes it hard to treat things like brain cancer or brain tumors rather. So this is one of the chemotherapies that can be given, and it does cross that blood brain barrier and example is carmustine. And then another category in this one is platinum containing compounds. And these are the ones that cause those mitochondrial damage. And one in this category is called cisplatin. You’re going to hear this one. So this one pretty often it’s used for many types of cancers. Now side effects of these types of chemotherapies are bone marrow suppression, just like many, many chemotherapies. So that’s going to cause the pancytopenia. 

And that means we’re going to have low white blood cells. So low immune system They will have low platelets. So risk of bleeding, right? And low red blood cells, which equate equates to low hemoglobin. Okay. And that’s because the bone marrow is fast growing, right. Even though these target cells that are not necessarily always fast growing, they, they do impact these fast growing cells also. So GI toxicities, nausea, and vomiting. Now this is again with most chemos, but with these particular alkylating agents, the nausea and vomiting can be severe some of the worst and also delayed. So that’s an important consideration. They might not have the nauseousness and vomiting while they’re getting their administration or even a day later, it might come a couple of days later and then diarrhea and mucositis is a big one. So those are mouth sores. So we have to do meticulous mouth care to prevent those from happening. And reproductive harm. So we refer these patients to a fertility specialist right before they start treatment. And then an organ specific is renal, especially with that cisplatin that I mentioned, we need to protect the kidneys. So we often give a medication with this one called mesna or  a lot of fluid, and that protects our kidneys.
Okay. And what types of cancer do these treat? So there’s  many, many cancers that these types of chemotherapy treat, some of them are lymphoma, bladder, breast, and multiple myeloma. But like I said, there is several, and we often do combination therapy. You’re going to hear me say this a lot in all of the oncology lectures or the antineoplastic lectures, because we give medications in combination to target different areas of that cell cycle for more tumor destruction and cancer destruction. Right. So that’s just important to mention, um, many times these are combined with other types of chemos, okay. 

Education for patients. We need to educate them about infection prevention. And why is that? Because they have the low white blood cells, so they can be neutropenia low neutrophils, right? So we’ll say neutropenic precautions. And then we need to talk about the hand hygiene, um, food preparation, avoiding large crowds, that sort of thing, bleeding precautions. And why is that? Because they have low platelets, right? They’re at risk of bleeding. So we need to talk to them about preventing falls about, using an electric razor, proper oral care, right? Don’t floss, managing side effects. So this is going to be specific to the exact chemo that they’re getting, but a big one is going to be that nausea and vomiting. Remember it can be severe and delayed with these alkylating agents and fertility concerns. These are some of the worst chemos for fertility concerns. So you want to refer them right to an oncofertility specialist prior to beginning treatment in case they can preserve their eggs or their sperm. 

Now nursing concepts. You’re going to hear this several times throughout the chemotherapy lectures. So we’re talking about cellular regulation, how this is impacting this cell cycle, right? And then lab value is because of the pancytopenia right, low white blood cells, low platelets, low red blood cells and patient education is huge, huge, huge with any chemotherapy.
Key points here with these alkylating agents, they are cell cycle nonspecific, so they can work even on the slow growing cancers. These are chemotherapies. So we need to talk about those chemo and safety precautions, side effects, bone marrow suppression. GI that nausea, vomiting, diarrhea, and then organ specific- We talked about the kidneys. These ones can be pretty damaging to the kidneys and chemos are often given as combo therapies. So that results in more cell, more cancer kill, right? More destruction of the cancer and less side effects. Okay. That’s all I have. So we love you guys, go out and be your best self today and as always happy nursing.



Module 0 – Pharmacology Course Introduction
Module 3 – Disease Specific Medications

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