Overview of Chemotherapy Drugs

Side effects commonly associated with various chemotherapy classes

  • Antimetabolites:  myelosuppression, diarrhea
  • Taxanes:  peripheral neuropathy
  • Anthracyclines:  vesicants (need to apply ice), radiation recall (irritation in the area where the pt received the chemo before), red urine, cardiotoxicity (must get a baseline ejection fraction prior to treatment)
  • Alkylating agents:  increased risk of sterility/infertility
  • Corticosteroids:  insomnia, nausea, fluid retention, increased appetite, hyperglycemia, irritability
    • These drugs are lymphocytotoxic

Hallmark toxicities and dose-limiting toxicities

  • Fluorouracil  (aka 5-FU) is an antimetabolite
    • Dose limiting:  stomatitis, diarrhea
    • Hallmark:  stomatitis, diarrhea
  • Capecitabine (aka xeloda, prodrug of 5-FU) is an antimetabolite
    • Dose limiting and hallmark toxicities:  hand-foot syndrome  (desquamation, bleeding, ulceration, pain)
  • Cytarabine (aka cytosar-U) is a pyrimidine antimetabolite
    • Standard dose causes myelosuppression
    • Dose limiting and hallmark toxicities:  cerebellar symptoms (slurred speech, confusion, ataxia, nystagmus)
  • Azacitidine (aka vidaza) is a pyrimidine antimetabolite
    • SE:  myelosuppression, fever (51%), febrile neutropenia (16%)
  • Decitabine (aka Dacogen) is a pyrimidine antimetabolite
    • Hallmark symptom:  hyperglycemia
    • Other SE:  myelosuppression, edema, low K/Mg, pneumonia
  • Methotrexate is a folate antimetabolite
    • Low dose SE:  hepatotoxicity, pulmonary toxicity
    • Dose limiting and hallmark toxicities in high doses:  myelosuppression, mucositis, & diarrhea
      • Nephrotoxicity is also a high dose hallmark toxicity of methotrexate
      • Myelosuppression, mucositis, diarrhea & edema are also SE of pralatrexate (another folate antimetabolite)
  • Paclitaxel is a taxane
    • Hallmark:  complete hair loss
    • Dose limiting:  peripheral neuropathy
    • Other SE:  hypersensitivity, myalgias
  • Paclitaxel NAB is a taxane
    • Common SE:  Myelosuppression & peripheral neuropathy (but less so than paclitaxel)
    • No pre-meds are needed (as opposed to regular paclitaxel)
  • Docetaxel is a taxane
    • Hallmark toxicity:  Edema
    • Other SE:  peripheral neuropathy & complete hair loss
  • Cabazitaxel is a taxane
    • SE: myelosuppression, N/V, diarrhea, hypersensitivity
  • Ixabepilone is an epothilone
    • Dose limiting SE:  peripheral neuropathy
    • Other SE:  hypersensitivity, myalgias
  • Eribulin is a non-taxane microtubule inhibitor
    • Dose limiting SE:  peripheral neuropathy
    • Other SE:  myelosuppression, QT prolongation
    • No pre-meds needed though
  • Vincristine is a vinca alkaloid
    • Dose limiting and hallmark toxicities:  peripheral neuropathy
    • Other SE:  constipation
  • Vinorelbine is a vinca alkaloid
    • SE:  myelosuppression, peripheral neuropathy
  • Vinblastine is a vinca alkaloid
    • Dose limiting SE:  myelosuppression
    • Other SE:  muscle aching
  • Irinotecan is a topoisomerase I inhibitor
    • Dose limiting and hallmark toxicities:  delayed diarrhea (which may be life-threatening if it occurs for > 12 hours after dose)
      • Need to pretreat w/ loperamide
  • Etoposide is a topoisomerase II inhibitor
    • Rare SE:  orthostatic hypotension
    • Stability is concentration dependent (the more concentrated it is, the less stable)
  • Teniposde is a topoisomerase II inhibitor
    • SE:  Rate dependent hypotension
  • Doxorubicin, daunorubicin, idarubicin, epirubicin (Anthracyclines)
    • All have a dose-limiting & hallmark toxicities of cardiotoxicity
      • All require an ejection fraction prior to treatment
      • Doxo & daunorubicin:  don’t exceed 550 mg/m2
      • Idarubicin:  don’t exceed 150 mg/m2
      • Epirubicin:  don’t exceed 900 mg/m2
        • All of these anthracycline SE are a cumulative life time dose
  • Mitoxatone causes blue-green discoloration of the urine, sclera & skin
    • Less cardiotoxicity than anthracyclines; not a vesicant
  • Busulfan is an alkylating agent
    • Known for causing pulmonary fibrosis (“busulfan lung”)
  • Temozolomide is a non-classic alkylating agent  (Oral therapy)
    • Common SE:  constipation, N/V, HA, seizure
  • Cisplatin is a platinum agent
    • Hallmark toxicity:  N/V
    • Other SE:  peripheral neuropathy, ototoxicity, nephrotoxicity
  • Carboplatin is a platinum agent
    • Known for myelosuppression
    • Causes less ototoxicity, n/v, nephrotoxicity than cispatin (may be good choice for pts with hepatic dysfunction)
  • Oxaliplatin is a platinum agent
    • Hallmark/dose-limiting toxicity of peripheral neuropathy w/in 14 days
      • Exacerbated by cold weather
  • Cyclophosphamide & are ifosfamide an alkylating agent
    • Hallmark toxicity:  hemorrhagic cystitis
    • Ifosfamide also may cause CNS toxicity (confusion) so you always use mesna in combo with this product
  • Procarbazine is an oral MAOI
    • Need to have a tyramine-free diet, also has DDIs w/ SSRIs, TCA, alcohol (disulfiram like reaction)
  • Bendamustine is an antimetabolite/alkylating agent
    • Can cause skin reactions like Steven-Johnson’s syndrome (rash)
  • Bleomycin
    • Hallmark toxicities:  interstitial pneumonitis & pulmonary fibrosis (may present w/ dyspnea, low grade fever, non-productive cough, x-ray showing bilateral infiltrates)
  • Arsenic Trioxide helps differentiate cells
    • Hallmark toxicity:  retinoic acid syndrome (must treat promptly w/ corticosteroids)
      • Patient may be hypotensive, in respiratory distress & pulmonary infiltrates
  • Thalidomide is an anti-angiogenesis agent
    • Hallmark toxicity:  teratogenicity
    • Other SE:  peripheral neuropathy, fatigue, constipation
  • Lenalidomide is an anti-angiogenesis agent
    • SE:  fatigue, peripheral neuropathy, thought to be teratogenic as well
  • Peginterferon-alpha 2b has many different mechanisms of action
    • Dose limiting:  neurological toxicities (vertigo, decreased mental status, confusion, depression, etc)
    • Other SE:  flu-like syndrome, fatigue
  • Interleukin-2 has multiple mechanisms of action
    • SE:  hypotension, fluid retention, renal dysfunction, GI hemorrhage, stomatitis, in high doses: capillary leak syndrome (may cause weight gain–CHF, MI, respiratory distress, arrhythmias, etc)
  • Romidepsin is a histone deacetylase inhibitor
    • SE:  QT prolongation, electrolye abnormalities, hyperglycemia, arrhythmias
  • Vorinostat is a histone deacetylase inhibitor
    • SE:  DVT/PE, QT prolongation, hyperglycemia
  • Temsirolimus is a mTOR inhibitor
    • SE:  hyperglycemia, increased triglycerides, hypersensitivity, hypophosphatemia
  • Everolimus is a mTOR inhibitor
    • SE:  hyperglycemia, increased TGs, increased lipids, stomatitis

Special dispensing or administration instructions for chemotherapy agents

  • Fluorouracil:  radiosensitizer, leucovorin enhances its activity & toxicity, has significant DDIs w/ warfarin
    • May also cause hand-foot syndrome
  • Cytarabine:  neuro checks before each dose for cerebellar symptoms
  • Azacitidine & decitabine:  no live vaccines, cardiac problems in < 5% of ppl (A fib, CHF)
  • Methotrexate & pralatrexate:  interact w/ Bactrim & NSAIDs
    • Methotrexate:  hydrate w/ Na Bicarb, keep urine pH > 7 to prevent renal toxicity, drug will accumulate in ascites, pleural effusions
      • Need to admin Leucovorin 24-36 hours after each dose
    • Pralatrexate:  need to admin folic acid 1 mg daily for 10 days before until 30 days after treatment & Vit B12 1000mcg IM before & every 8-10 weeks
  • Paclitaxel:  requires a pre-treatment with dexamethasone, benadryl & H2 antagonist to prevent reactions.  No PVC products
  • Docetaxel:  requires treatment w/ dexamethasone for 3 days to prevent edema.  No PVC products
  • Carbazitaxel:  3A4 metabolism, no PVC products, pretreat w/ dexamethasone, benadryl & H2 antagonist to prevent reactions
  • Ixabepilone:  no PVC products, 3A4 metabolism, requires a pre-treatment with  benadryl & H2 antagonist to prevent reactions (only use dexamethasone if the patient has a reaction).
  • Vincristine, vinorelbine & vinblastine are vinca alkaloids that are vesicants (NO INTRATHECAL ADMIN)
  • Teniposide:  don’t use PVC products, stability is concentration dependent
  • Busulfan:  has a SE of pulmonary fibrosis so it’s necessary to watch out for a non-productive cough, SOB, weight loss, abnormal chest x-ray
    • Risk of seizures, so admin prophylactic phenytoin (continue for 48-72 h after busulfan admin)
  • Cisplatin:  need to hydrate w/ NS b/c this is the most emetic of the platinum agents
  • Carboplatin:  dosing is based on AUC
  • Oxaliplatin is given over 2 hours to lessen toxicities
  • Cyclophosphamide:  hydrate the pt & have them urinate frequently to prevent signs & symptoms (painful urination, etc)
  • Ifosfamide:  always use mesna, hydrate & have them frequently urinate
    • Mesna can be admin’d as a IV infusion, IV liquid (it tastes bad though) or a tablet
  • Bendamustine:  may cause tumor lysis syndrome so pretreat w/ allopurinol.  Infection prophylaxis in CLL patients
  • Thalidomide:  need to do STEPS program.  Increased risk of DVT/PE with dexamethasone
  • Lenalidomide:  requires the RevAssist program, increased risk of DVT/PE when used with dexamethasone
  • Romidepsin:  significant CYP3A4 metabolism
  • Vorinostat:  interacts w/ warfarin
  • Temsirolimus (IV) & everolimus (PO) are both mTOR inhibitors metabolized by CYP3A4

Calculating a BSA and calculate chemotherapy doses

  • BSA = √ [{(height in cm) x (weight in kg)} / 3600]

Calculating a Carboplatin dose using the Calvert formula

  • CrCl = (140 – age) x weight (kg)   /   72 x SCr
    • Times by 0.85 for females
  • Dose = (CrCl + 25) x AUC

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