Pembrolizumab (Keytruda) Mechanism of Action |Nursing Considerations |Side effects |Patient Teachings

Introduction

In this article, you’ll learn about the Pembrolizumab (Keytruda) mechanism of action (MOA), nursing considerations, and side effects. Also, its dosage, indication, contraindications, interactions, nursing assessment, nursing interventions, and patient teachings.

Generic Name: Pembrolizumab

Brand Names: Keytruda

Pembrolizumab (Keytruda) Class and Category

Pharmacologic class: Anti-programmed death (PD)-1 monoclonal antibody

Therapeutic class: Antineoplastic, biologic response modifiers

Pregnancy category: not specified

Pembrolizumab (Keytruda) Dosage

  • Adults: IV: 200 mg, every 3 weeks (Q3W).
  • Children: IV: 2 mg/kg; maximum dose: 200 mg.

Note that Keytruda’s dosage is modified by the prescriber based on the severity of the unfavorable response.

Pembrolizumab (Keytruda) Pharmacokinetics and Pharmacodynamics

RouteOnsetPeakDuration
IVIn 3 monthsunknownmay last longer than 8 months
Pembrolizumab (Keytruda) Pharmacokinetics and Pharmacodynamics

Absorption: Bioavailability is 100% after IV injection.

Distribution: Unknown

Metabolism: Unknown.

Half-life: 26 days

Excretion: Unknown

Pembrolizumab (Keytruda) Mechanism of Action

Pembrolizumab is a monoclonal antibody that binds to the PD-1 receptor and inhibits its interaction with its ligands (PD-L1 and PD-L2). Thereby, inhibiting PD-1 pathway-mediated immunological response, including the anti-tumor immune response.

Keytruda is a high-affinity anti-PD-1 antibody that reactivates tumor-specific cytotoxic T cells in the tumor microenvironment and anti-tumor immunity by blocking the PD-1 receptor from binding to its ligands.

Therapeutic effect: inhibits cancer metastasis.

What are the indications of Pembrolizumab (Keytruda)?

Pembrolizumab (Keytruda) indications include:

  • To treat unresectable or metastatic melanoma in adults.
  • To treat melanoma with lymph node involvement that has been completely resected.
  • To treat non-small cell lung cancer (NSCLC).
  • To treat head and neck squamous cell cancer (HNSCC).
  • To treat classical Hodgkin lymphoma (cHL).
  • To treat primary mediastinal B-cell lymphoma (PMBCL).
  • To treat urothelial carcinoma.
  • To treat microsatellite instability-high cancers (such as colorectal and non-colorectal cancer).
  • To treat endometrial carcinoma.

What are the contraindications of Pembrolizumab (Keytruda)?

The contraindications of Pembrolizumab (Keytruda) are:

  • Hypersensitivity to pembrolizumab and its components.
  • Pregnancy and lactation.

Caution: Thyroid disease; hepatic impairment; renal failure; interstitial lung disease; electrolyte imbalance; hypertriglyceridemia.

Pembrolizumab (Keytruda) Interactions

  • Pembrolizumab’s interaction with other drugs are unknown.
  • Pembrolizumab can increase AST, blood glucose, and triglycerides.
  • Pembrolizumab can decrease serum albumin, serum calcium, and serum sodium levels.

Herbal/food interactions

  • Pembrolizumab has no known interaction with food or herbs.

What are the side-effects of Pembrolizumab (Keytruda)?

Pembrolizumab (Keytruda) side effects / adverse reactions include:

  • Fatigue
  • Nausea
  • Cough
  • Pruritus and rashes
  • Decreased appetite
  • Constipation/diarrhea
  • Arthralgia
  • Dyspnea
  • Paint in the extremities
  • Peripheral edema
  • Vomiting
  • Headache
  • Chills and fever
  • Insomnia
  • Myalgia
  • Abdominal pain
  • Vitiligo
  • Dizziness
  • Upper respiratory tract infection (URTI)
  • Life-threatening adverse effects: Immune-mediated pneumonitis; Immune-mediated colitis; Immune-mediated hepatitis; Immune-mediated hypophysitis; Immune-mediated nephritis or renal failure; Immune-mediated rhabdomyolysis; Sepsis; Infusion-related reactions.

Pembrolizumab (Keytruda) Nursing Considerations

Pembrolizumab (Keytruda) nursing considerations are divided into nursing assessment, nursing diagnosis, nursing interventions, and evaluation. 

Pembrolizumab (Keytruda) nursing assessment

  • Obtain detailed clinical history including hypersensitivity, pregnancy, and lactation.
  • Assess and document baseline vital signs and weight.
  • Perform a comprehensive dermatologic exam and a visual acuity test.
  • Obtain baseline CBC, BMP, ionized calcium, LFTs, TFTs, and urine pregnancy.

Pembrolizumab (Keytruda) nursing diagnosis

  • Fatigue (side effect).
  • Diarrhea (side effect).
  • Constipation (side effect).
  • Anxiety related life-threatening health status and progression of condition; treatment regimen.
  • Deficient knowledge related to drug’s adverse effects; disease process.

Pembrolizumab (Keytruda) nursing interventions/ actions

  • Monitor vital signs
  • Monitor the patient for signs and symptoms of immune-mediated adverse events. Such as:
    • Immune-mediated pneumonitis (eg; dyspnea, chest pain, new or worsening cough).
    • Immune-mediated colitis (eg; diarrhea, pain in the abdominal, blood in stool [Hematochezia] or mucus in stool, normo- or hyperthermia).
    • Immune-mediated hepatitis (eg; jaundice, unusual darkening of urine, unusual fatigue, abdominal pain in right upper quadrant).
    • Immune-mediated hypophysitis (eg; persistent or unusual headache, extreme fatigue, dizziness or fainting, vision changes)
  • Monitor for signs and symptoms of infusion-related complications (such as hypersensitivity, anaphylaxis, rigors, chills, fever, wheezing, pruritis, flushing, rash, hypotension, hypoxemia, fever).
  • Monitor intake and output and daily weight.
  • Monitor patient’s CBC, RFTs, LFTs, TFTs, blood glucose, and electrolytes.

Pembrolizumab (Keytruda) intravenous administration considerations

  • Reconstitute Keytruda by adding 2.3 mL of sterile water for injection along vial walls to avoid foaming. DO NOT shake the vial, slowly swirl to mix the contents.
  • Allow up to five minutes for the bubbles in the vial to settle.
  • Assess for discoloration and presence of any particles in the vial. Keytruda is a clear to slightly opalescent, colorless to slightly yellow solution. If discolored or visible particles are detected, DO NOT USE.
  • Add Pembrolizumab to either 0.9% sodium chloride or 5% glucose (dextrose). The final concentration should be between 1 and 10 mg/mL. Mix diluted solution by gentle inversion.
  • Administer the infusion solution IV over 30 minutes using a sterile, non-pyrogenic, low-protein binding 0.2 to 5 µm in-line or add-on filter.
  • Other medications should not be administered through the same infusion line.
  • Keytruda is intended for single usage in a single patient; any remaining medication should be discarded.

Storage & handling:

  • Store Keytruda vial containing lyophilized powder refrigerated at 2°C to 8°C (36°F to 46°F) in their original container to prevent light exposure.
  • Keytruda vial also can be stored at room temperature below 25°C for up to 24 hours before dilution.
  • Reconstituted medication should be used as soon as possible. Since Keytruda does not have any preservative. If not used immediately;
    • May keep total of 6 hours at room temperature below 25°C.
    • May also be refrigerated at 2°C to 8°C; however, the total period from Keytruda reconstitution to completion of infusion should not exceed 24 hours.
    • Allow the vials and/or IV bags to come to room temperature before using if refrigerated.
  • DO NOT freeze the vial containing lyophilized powder or diluted solution.
  • DO NOT shake

Evaluation

Evaluate the effectiveness of the Pembrolizumab (Keytruda): for decreased progression of carcinoma; no signs or symptoms of immune-mediated adverse effects.

Pregnancy/breastfeeding considerations for Pembrolizumab (Keytruda)

  • Pembrolizumab is an IgG4. And IgG4 is known to cross the placental barrier. Therefore, Pembrolizumab is not recommended to use during pregnancy. Because it can be fatal to the fetus.
  • Advise the patients of reproductive age to use an effective contraception during and for 4 months after the last dose.
  • It is unknown whether Keytruda is excreted in breastmilk. Consult with the prescriber whether you should continue or discontinue breastfeeding.

What is the nurse patient teachings for Pembrolizumab (Keytruda)?

The nursing patient teaching for pembrolizumab (Keytruda) should include the following points.

  • Teach the patient/caregiver about immune-mediated adverse effects of Pembrolizumab. For example:
    • Immune-mediated pneumonitis (eg; dyspnea, chest pain, new or worsening cough).
    • Immune-mediated colitis (eg; diarrhea, pain in the abdominal, blood in stool [Hematochezia] or mucus in stool, normo- or hyperthermia).
    • Immune-mediated hepatitis (eg; jaundice, unusual darkening of urine, unusual fatigue, abdominal pain in right upper quadrant).
    • Immune-mediated hypophysitis (eg; persistent or unusual headache, extreme fatigue, dizziness or fainting, vision changes)
  • Instruct the patient/caregiver to seek medical attention as soon as any immune-mediated adverse effect occurs.
  • Teach the patient about infusion-related reactions and advise to contact their healthcare provider immediately for signs or symptoms of infusion-related reactions.
  • Advise the patients of reproductive age to avoid pregnancy and use an effective contraception during and for 4 months after the last dose.
  • Explain to the patient about the importance of doing routine blood tests as scheduled.

Treatment for Pembrolizumab (Keytruda) Overdose

Pembrolizumab (Keytruda) overdosage does not have a specific treatment. Symptomatic treatment should be given to the patient.  Also, closely observe for adverse effects.

Conclusion

You’ve learned about the Pembrolizumab (Keytruda) mechanism of action (MOA), nursing considerations, and side effects in this article.

In addition, you’ve learned about pembrolizumab’s pharmacokinetics, dosage and administration, indications, contraindications, nursing assessment, nursing diagnoses, nursing interventions, and patient teaching.

Recommended Readings & Reference

Australian TGA Pembrolizumab (Keytruda) Information

FDA Pembrolizumab (Keytruda) Information

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Kizior, R., & Hodgson, K. (2021). SAUNDERS NURSING DRUG HANDBOOK 2021. Elsevier Inc.

Skidmore-Roth, L. (2021). MOSBY’S 2021 NURSING DRUG REFERENCE (34th ed.). Elsevier Inc.

Vallerand, A., Sanoski, C., & Quiring, C. (2019). Davis’s Drug Guide for Nurses (19th ed.). F.A. Davis Company.

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