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Agent Cyclophosphamide (Cytoxan) Mechanism Cross-link DNA Genetic Issues None Side Effects Alkylating Agents Myelosuppression; Hemorrhagic cystitis; Frequently causes alopecia; Pulmonary toxicity (not dose related); Cardiotoxic at high doses; Delayed nausea and vomiting; SIADH with doses over 50 mg/kg Myelosuppression; Alopecia; Pulmonary toxicity (after at least 6 mo. of treatment with a total cumulative dose >2 g) Renal/Hepatic Dosage Adjustment CrCl <10 mL/min: decrease dose by 25%; Bilirubin 3.15 mg/dL or transaminases >3xULN: decrease dose 25% CrCl 10-50 mL/min: decrease dose by 25%; CrCl <10 mL/min: decrease dose by 50%; Dosage adjustment may be necessary with hepatic dysfunction Dosage adjustment may be needed with hepatic dysfunction Comments With doses over 1200 mg/m2 hydration and mesna (Mesnex) at 60-80% of the Cytoxan dose to protect against hemorrhagic cystitis; Consider mesna with doses over 750 mg/m2
Chlorambucil (Leukeran)
Cross-link DNA
None
Cross-link DNA
Ifosfamide (Ifex)
Cross-link DNA
Cross-link DNA
None
Lomustine (CeeNU)
Cross-link DNA
None
Prolonged myelosuppression; Hyperpigmentation; Pulmonary toxicity; Severe nausea and vomiting, seizures, and sinusoidal obstruction syndrome with high doses Myelosuppression; Hemorrhagic cystitis; Frequently causes alopecia; Encephalopathy (confusion, lethargy, psychosis); Cranial nerve toxicity (lid lag, facial palsy, trigeminal neuralgia) Delayed myelosuppression; Severe nausea and vomiting; Hepatotoxic and nephrotoxic at high doses; High doses can cause encephalopathy (confusion, seizures); Pulmonary toxicity (doses >1,400 mg/m2) Delayed myelosuppression; Pulmonary toxicity; Nephrotoxic at high doses
Guidelines recommend mesna (Mesnex) at 60% of the ifosfamide dose at zero, 4, and 8 hours after ifosfamide to avoid cystitis other regimens include an equal mg dose Gliadel Wafer for brain tumors; Placed in tumor cavity after tumor removal and allowed to dissolve over 3 weeks
CrCl 46-60 mL/min: decrease dose by 20%; CrCl 31-45 mL/min: decrease dose by 25%; CrCl <30 mL/min: avoid use CrCl 10-50 mL/min: decrease dose by 25%; CrCl <10 mL/min: decrease dose by 50-75%
Administration at bedtime with an antiemetic lowers the risk and severity of nausea; Usually single oral dose per cycle
Temozolomide (Temodar)
Crosses the blood-brain barrier well; Minimize nausea by giving the dose at bedtime Monoamine oxidase inhibitor tyramine-rich foods must be avoided; Disulfiram-like reaction with alcohol May be used intrathecally Barbiturates increases metabolism; Cimetidine inhibits metabolism
Procarbazine (Matulane)
None None
Melphalan (Alkeran)
Cross-link DNA
None
CrCl 10-50 mL/: decrease dose 25%; CrCl <10 mL/min: decrease dose by 50% Vesicant; Can cause patients to become sterile; Can be prepared into an ointment; Unused vials should be neutralized with 5% sodium thiosulfate and 5% sodium bicarbonate
Mechlorethamine (Mustargen)
Cross-link DNA
None
None
Epirubicin (Ellence)
Myelosuppression; Cardiotoxicity; Frequently causes alopecia; Hyperpigmentation; Red urine; Nausea and vomiting
Idarubicin (Idamycin)
Myelosuppression; Cardiotoxicity; Mucositis; Red urine; Mild to moderate nausea and vomiting
Bilirubin >1.2-3 mg/dL or AST 2-4xULN: decrease dose by 50% Bilirubin >3 mg/dL or AST >4xULN: decrease dose by 75%; SCr >5 mg/dL: consider dose decrease or avoid Bilirubin >5 mg/dL: avoid use; Consider dose reductions for bilirubins lower than this (no published guidelines)
Methotrexate (MTX)
None
CrCl 61 to 80 mL/min: decrease dose 25%; CrCl 51 to 60 mL/min: decrease dose 30%; CrCl 10 to 50 mL/min: decrease dose 50% to 70%; CrCl <10 mL/min: avoid use
Pemetrexed (Alimta)
Prevents DNA synthesis but uses more routes than MTX so resistance is less of a problem
None
CrCl >80 mL/min: 600 mg/m2; CrCl 40-79 mL/min: 500 mg/m2; Grade 4 transaminase elevation (>20 times ULN): reduce dose by 75% Effects of hepatic or renal dysfunction isnt known, but may need to hold or discontinue if liver function tests >3xULN
Therapeutic monitoring to ensure clearance and help determine leucovorin doses; Leucovorin rescue administered for doses >1000 mg/m2 until levels fall below 5 x 10-8 M; Urinary alkalinization required for high doses; Acetazolamide may be used with high dose therapy to keep urine pH >7 and avoid nephrotoxicity; Avoid NSAIDs and penicillins (increased risk of toxicity); May be administered intrathecally; Check for pleural effusions prior to administration Use with B12 and folate to lower cystathionine and homocysteine levels and lower risk of death due to neutropenic sepsis; Dexamethasone 4 mg BID the day before, day of, and day after administration helps the rash; Avoid NSAIDs Treat differentiation syndrome with dexamethasone 10 mg every 12 hours
Works through retinoid X and retinoic acid receptors to affect the growth and differentiation of cells
Biologic and Immune Therapies PML/RAR (alpha) Retinoic acid syndrome - fever, fusion gene absence respiratory distress, and predicts poor response hypotension; Skin dryness cracking of lips; Edema; Headache; Fever; Malaise; Hyperlipidemia; Nausea and vomiting; Pulmonary toxicity
Denileukin (Ontak)
Recombinant fusion protein combining active portions of IL-2 and diphtheria toxin that inhibits protein synthesis and causes cell death
None
Cetuximab (Erbitux)
Panitumumab (Vectibix)
Recombinant chimeric MoAb that binds to endothelial growth factor receptor (EGFR) causing inhibition of cell growth and vascular endothelial growth factor (VEGF) production and increased programmed cellular death (apoptosis) Recombinant human IgG2 MoAb that binds to the epidermal growth factor receptor inhibiting cell survival, growth, and proliferation
Acute hypersensitivity reactions hypotension, vasodilation, rash, chest tightness; Flu-like symptoms; Diarrhea; Vascularleak syndrome (delayed onset and usually self-limited); Nausea and vomiting; Asthenia; Hepatotoxicity Inhibitors of EGFR Receptors EGFR mutation may Severe infusion reactions predict benefit; KRAS airway obstruction and mutation predicts lack hypotension; Acne-like rash on of benefit; Consider face upper chest, and back BRAF testing if within the first 2 weeks of BRAF mutation is therapy; Fatigue; GI effects present may predict nausea, vomiting, diarrhea, lack of response constipation, abdominal pain; Hypomagnesemia; Hypersensitivity reactions; Fever EGFR mutation may Dermatologic toxicities common predict benefit; Not (acne-like lesions, itching, recommended to use redness, rash, skin exfoliation, with KRAS mutation; etc); Diarrhea Consider BRAF testing if BRAF mutation is present may predict lack of response
Thalidomide (Thalomid)
None
Miscellaneous Agents Somnolence; Constipation; Dizziness; Orthostatic hypotension; Rash; Peripheral neuropathy; Thrombosis
Lenalidomide (Revlimid)
Analog of thalidomide
Bleomycin (Blenoxane)
Pulmonary toxicity; Frequently causes alopecia; Hyperpigmentation; Raynauds syndrome; Anemia; Hypersensitivity reactions; Nausea and vomiting Myelosuppression; Nausea and vomiting; Diarrhea; Constipation; Palmar-plantar dysesthesias or hand-foot syndrome (redness, tenderness, blistering of palms and soles of the feet); Mucositis
Hydroxyurea (Hydrea)
None
None
Cross-link DNA
None
Inhibits microtubule assembly and weak estrogenic activity Inhibits proteasomes (enzyme complex that degrades proteins responsible for cancer growth)
None
None
Temsirolimus (Torisel)
Binds to FKBP-12 and inhibits the activity of mammalian target of rapamycin (mTOR) resulting in inhibition of protein synthesis and angiogenesis
None
Prolongation of QT interval; Peripheral neuropathy; Musculoskeletal pain; Dry skin; Hyperglycemia; APL differentiation syndrome: pulmonary dysfunction, pleural or pericardial effusion Delayed myelosuppression; Pulmonary toxicity; Hemolytic uremic syndrome; Cardiac toxicity; Pulmonary toxicity Edema; Nausea and vomiting; Diarrhea; Thromboembolism; Gynecomastia Miscellaneous Targeting Agents Usually mild to moderate; Asthenia (fatigue, malaise, weakness); Nausea and diarrhea; Decreased appetite; Constipation; Thrombocytopenia; Anemia; Neutropenia; Peripheral neuropathy; Fever Rash; Fatigue; Mucositis; Nausea; Edema; Loss of appetite; Increases in creatinine and liver function tests; Thrombocytopenia; Neutropenia; Hyperglycemia; Hyperlipidemia; Rash; Shingles
Use with caution in renal dysfunction, but effects in renal or hepatic dysfunction are unknown
Take at least 1 hour before or 2 hours after eating Bilirubin >1.5x ULN: decrease dose to 0.7 mg/m2
Monitor blood glucose and lipids; Affected by CYP3A4 inhibitors and inducers
Ibritumomab (Zevalin)
Tositumomab (Bexxar)
Murine anti-CD20 MoAb that can be linked to I-131 to cause radiation induced cell death
Similar to ibritumomab
Cisplatin (Platinol)
Cross-link DNA
None
Carboplatin (Paraplatin-AQ)
Cross-link DNA
None
Oxaliplatin (Eloxatin)
Cross-link DNA
None
Moderate nausea and vomiting; Anemia; Causes glove and stocking and cold-induced neuropathy; Hypersensitivity reactions
Mild hypersensitivity reactions may respond to pretreatment with steroids and antihistamines
6-thioguanine (Tabloid)
Inhibit purine ring synthesis and nucleotide interconversions Inhibit purine ring synthesis and nucleotide interconversions Interferes with DNA polymerase and inhibits RNA transcription
Azathioprine (Imuran)
CrCl 10-50 mL/min: decrease dose by 25%; CrCl <10 mL/min: decrease dose by 50% CrCl 30-70 mL/min: decrease dose by 50%; CrCl <30 mL/min: avoid use (oral: give 50% of dose)
Metabolized to 6-MP; Allopurinol significantly decreases metabolism and results in serious toxicity Antibiotic prophylaxis against PCP and antivirals may be used until CD4 count normalizes
Inhibition of DNA synthesis effects both rapidly dividing and resting cancer cells Inhibits adenosine deaminase
None
Myelosuppression is often dose limiting; Immunosuppressant effects (decreases CD4 counts) can result in opportunistic infections; Severe neurotoxicity (altered mental status, temporary blindness, seizures, paralysis) with doses >90 mg/m2 for 5 to 7 days; Pulmonary toxicity Immunosuppressant effects (decreases CD4 counts) can result in opportunistic infections Immunosuppressant effects (decreases CD4 counts) can result in opportunistic infections
None
CrCl 10-50 mL/min: decrease dose 25%; CrCl <10 mL/min: decrease dose by 50% CrCl <60 mL/min: administer 70% of dose; CrCl <45 mL/min: administer 60% of dose; CrCl <30 mL/min: consider withholding
Prophylactic antibiotics and antivirals may be used until CD4 count normalizes Prophylactic antibiotics and antivirals may be used until CD4 count normalizes
Capecitabine (Xeloda)
Prodrug of 5-FU
CrCl 30-50 mL/min: decrease dose by 25%; CrCl <30 mL/min: contraindicated SCr = 1.5-1.9 mg/dL or increased 0.5-1.2 mg/dL: no more than 1 g/m2; If Cr >1.9 mg/dL or increased >1.2 mg/dL: decrease dose to 0.1 g/m2 per day; Bilirubin >2 mg/dL: administer 50% of the dose
Take within 30 minutes of a meal; Avoid in patients on warfarin (significantly increases INR); 2C9 inhibitor so may increase phenytoin levels Dosing range for cytarabine is highly variable; Be sure to know the dose and method of administration; Avoid high dose therapy when age >60y; May be administered intrathecally
Gemcitabine (Gemzar)
None
Bilirubin >1.6 mg/dL: decrease dose by 20%; Bilirubin >7.5 mg/dL: avoid use
Use acetaminophen for fevers; Specific dose adjustments are based on hematologic toxicities (absolute neutrophil count and platelets)
Decitabine (Dacogen)
None
None
Taxanes Myelosuppression; Neurotoxicity (glove and stocking numbness); Bradycardia; Hypersensitivity reactions (less of a problem with the albumin bound product) ; Frequently causes alopecia; Cardiac conduction disturbances; Nausea is infrequent
24-hour infusion: Transaminases <2xULN and bilirubin <1.5 mg/dL: 135 mg/m2; Transaminases 2 to <10xULN and bilirubin <1.5 mg/dL: 100 mg/m2; Transaminases <10xULN and bilirubin 1.6 to 7.5 mg/dL: 50 mg/m2; Transaminases >10xULN or bilirubin >7.5 mg/dL: avoid 3-hour infusion: Transaminases <10xULN and bilirubin <1.25xULN: 175 mg/m2; Transaminases <10xULN and bilirubin 1.26 to 2xULN: 135 mg/m2; Transaminases <10xULN and bilirubin 2.01 to 5xULN: 90 mg/m2; Transaminases >10xULN or bilirubin >5xULN: avoid
Premedicate with steroids, antihistamines, and H2 antagonists unless using albumin-bound product; Affected by CYP 2C9, 2C8, and 3A4 inhibitors and inducers; When given with doxorubicin separate doses by 24 hours to avoid enhanced doxorubicin exposure; Administer before cisplatin to avoid reduced clearance of paclitaxel; Lower dose of gemcitabine when administered concurrently; Lower warfarin dose and monitor INR when used concurrently
None
Topoisomerase Inhibitors Myelosuppression; Neurotoxicity (numbness) Hepatotoxicity with high dose; Alopecia; Nausea and vomiting; Hypotension-fever-asthmatic episode after infusion; Mucositis
Teniposide (Vumon)
None
Myelosuppression; Neurotoxicity (numbness) Hepatotoxicity with high dose; Alopecia; Nausea and vomiting; Hypotension-fever-asthmatic episode after infusion; Mucositis
CrCl 10-50 mL/min: decrease dose by 25%; CrCl <10 mL/min: decrease dose by 50%; Bilirubin 1.53 mg/dL or AST 60 to 180 units: decrease dose by 50%; Bilirubin 3 to 5 mg/dL or AST >180 units: decrease dose by 75%; Bilirubin >5 mg/mL: Dont administer Dose adjustment may be necessary for renal or hepatic dysfunction
Topotecan (Hycamtin)
None
Gefitinib (Iressa)
Orally active selective EGFR-tyrosine kinase inhibitors that block cell proliferation, survival, and metastases Orally active selective EGFR-tyrosine kinase inhibitors that block cell proliferation, survival, and metastases 4-anilinoquinazoline kinase inhibitor that inhibits both EGFR and HER2
Erlotinib (Tarceva)
Lapatinib (Tykerb)
Myelosuppression; Mucositis; Nausea and vomiting; Mild alopecia; Fatigue; Rash; Mild diarrhea Tyrosine Kinase Inhibitors EGFR mutation may Acne-like or erythematous predict benefit; KRAS rashes most commonly on the mutation predicts lack face that may respond to steroid of benefit creams, acne oral or topical antibiotics, or oral antihistamines; Diarrhea EGFR expression may Rash (similar to cetuximab); predict benefit with Interstitial lung disease; therapy; KRAS Diarrhea; Fatigue; Anorexia; mutation predicts lack Nausea and vomiting; of benefit Stomatitis; Hepatotoxicity; Conjunctivitis HER2/neu overMyelosuppression; Diarrhea; expression required for Hepatotoxicity; Rash; QT use interval prolongation; Hand-andfoot syndrome
CrCl 20-30 mL/min: decrease dose by 75; CrCl <20 mL/min: not established Effect of hepatic impairment unknown No survival benefit in inoperable non-small cell lung cancer (NSCLC) so only for patients who have failed other therapies and previously benefited from it Take on an empty stomach 1 hour before or 2 hours after a meal; Monitor warfarin for increasing INR; Affected by inhibitors or inducers of CYP3A4 Additive activity with some traditional chemotherapeutic agents; Affected by inhibitors or inducers of CYP3A4; Give on an empty stomach
Stop therapy if bilirubin increases to >3xULN or transaminases >5xULN; If baseline bilirubin >3xULN: Use caution, consider using 75 mg daily Severe hepatic impairment: consider using 750 mg daily
Dasatinib (Sprycel)
Similar to above
Nilotinib (Tasigna)
Myelosuppression; Rash; Pruritus; Nausea; Fatigue; Headache; Constipation; Diarrhea; Vomiting; QT prolongation Diarrhea; Rash; Fatigue; Hypertension; Congestive heart failure; Neutropenia; Hyperpigmentation; Hepatotoxicity; Palmar-plantar dysesthesias or hand-foot syndrome (redness, tenderness, blistering of palms and soles of the feet); Bleeding; Yellow skin with dryness and cracking; Hair may depigment with doses over 50 mg/day Diarrhea; Rash; Fatigue; Hypertension; Palmar-plantar dysesthesias or hand-foot syndrome (redness, tenderness, blistering of palms and soles of the feet)
Indicated for leukemia resistant to imatinib; Monitor for swelling of legs, feet, or shortness of breath; Affected by 3A4 inhibitors and inducers Indicated for leukemia resistant to imatinib; Inhibitor of CYP2C8, CYP2C9, and CYP2D6 Affected by 3A4 inhibitors and inducers
Sunitinib (Sutent)
Inhibitor of tyrosine kinase, VEGFR-2, platelet derived growth factor receptor, c-KIT (GI stromal tumors), and FLT3 (leukemia)
Sorafenib (Nexavar)
Similar to above, plus inhibits serine/threonine kinase Raf which is involved in cell proliferation
None
Vinblastine (Velban)
None
Vinorelbine (Navelbine)
None
Dose limiting myelosuppression; Neurotoxicity less than vincristine (paresthesias, depression of reflexes, stumbling, falling); Cranial nerve toxicity (lid lag, facial palsy, trigeminal neuralgia); Constipation; Pulmonary toxicity in combo with mitomycin; Rash; Stomatitis Dose limiting myelosuppression; Dyspnea/cough; Neurotoxicity (paresthesias, depression of reflexes, stumbling, falling); Cranial nerve toxicity (lid lag, facial palsy, trigeminal neuralgia)
Bilirubin 1.5-3.0 mg/dL or AST 60-180 units: decrease dose by 50%; Bilirubin 3-5 mg/dL: decrease dose by 75%; Bilirubin >5 mg/dL or AST >180 units: avoid use
Bilirubin >2.1-3.0 mg/dL: decrease dose by 50%; Bilirubin >3 mg/dL: decrease dose by 75%
APL = acute promyelocytic leukemia CrCl = creatinine clearance PCP = Pneumocystis pneumonia SCr = serum creatinine SIADH = syndrome of inappropriate antidiuretic hormone ULN = upper limit of normal