Chemotherapy Toxicity Table With Boxed Warnings

Chemotherapy Toxicity Table With Boxed Warnings

Chemotherapeutic agents are used to control cancer cell proliferation, but they often come with toxicities to the host as well. It is important to monitor patients closely for the development of toxicities during therapy. Some of the potential toxicities of common chemotherapeutics are outlined below in our Chemotherapy Toxicity Table. 

Myelosuppression is a common adverse effect that can occur with most chemotherapeutic agents, with the exception being asparaginase, bleomycin, vincristine, and many monoclonal antibodies or tyrosine kinase inhibitors. Myelosuppression can be monitored by getting a CBC with differential, checking temperature, and looking for symptoms such as bleeding, fatigue, or shortness of breath. Management of myelosuppression includes colony-stimulating factors for neutropenia, red blood cell transfusions for anemia, and platelet transfusions for thrombocytopenia. 

Nausea and vomiting is most common with cisplatin, cyclophosphamide, and ifosfamide. It can be treated with a variety of agents including neurokinin-1 receptor antagonists, serotonin-3 receptor antagonists, dexamethasone, prochlorperazine, and metoclopramide. Diarrhea is also common with irinotecan, capecitabine, fluorouracil, and methotrexate. Hydration and antimotility medications like loperamide can be used. Atropine can be effective for early diarrhea due to irinotecan. Conversely, constipation can occur commonly with vincristine and can be treated with polyethylene glycol. 

Cardiotoxicity can occur with fluorouracil, anthracyclines (i.e. doxorubicin), and HER2 inhibitors. Due to the cardiomyopathy that can occur, doxorubicin has a maximum lifetime cumulative dose of 450-550 mg/m^2. Pulmonary toxicity can occur with bleomycin, resulting in bleomycin having a lifetime maximum cumulative dose of 400 units. 

Nephrotoxicity can occur with cisplatin and high doses of methotrexate. It is important to monitor kidney function including BUN, urinalysis, and SCr. For cisplatin, amifostine can be given as prophylaxis to reduce the chance of nephrotoxicity. Adequate hydration is important. Additionally, hemorrhagic cystitis can occur with ifosfamide as well as high doses of cyclophosphamide. Due to this risk, Mesna must always be given with ifosfamide, and may also be given with cyclophosphamide if indicated. 

Neuropathy is a potential toxicity that can occur with vincristine, cisplatin, oxaliplatin, and paclitaxel. It is important to monitor patients for signs of neuropathy such as numbness or tingling in the extremities. Due to neuropathy risk, vincristine should be limited to 2mg weekly or less. Oxaliplatin can cause neuropathy that is triggered by cold temperatures. 

Finally, tamoxifen can bring an increased thromboembolic risk. Monitor patients for signs of clots such as DVT, PE, or stroke. If risk factors are present, patients may be indicated for thromboprophylaxis. While we recognize that the table below is limited, it highlights some really important things that may show up on board exams 🙂 Here’s our chemotherapy toxicity table.

DrugBox WarningsToxicitiesManagement/Notes
cyclophosphamideNoneMyelosuppression, hemorrhagic cystitis (high dose), N&VGive with mesna if high dose (>1g/m^2). Monitor: CBC, BUN, SCr, hemorrhagic cystitis, renal toxicity, pulmonary toxicity, cardiac toxicity, hepatic toxicity
doxorubicinCardiomyopathy, extravasation, secondary malignancy, myelosuppressionCardiomyopathy, myelosuppressionVesicant, MUGA/ECHO before starting therapy. Monitor CBC, LFT, Ca, K, SCr, cardiac function, and hydration status. 
fluorouracilNoneMucositis, diarrhea, cardiomyopathyMonitor CBC, LFT, INR, CNS toxicity, stomatitis, diarrhea, hyperammonemic encephalopathy, hand-foot syndrome
vincristineExperienced provider, extravasation, IV use onlyPeripheral neuropathies, constipationVesicant, Intrathecal dosing is fatal.Monitor: electrolytes, hepatic function, CBC, hepatic sinusoidal obstruction, constipation, neurologic exam, peripheral neuropathy 
capecitabineInteraction with warfarin Hand-foot syndrome, dermatitis, paresthesias, diarrheaInteracts with warfarin and phenytoin. Monitor: CBC, hepatic function, renal function, INR, diarrhea, dehydration, hand-foot syndrome, Stevens-Johnsons, toxic epidermal necrolysis, stomatitis, cardiotoxicity
methotrexateHypersensitivity, pregnancy, bone marrow suppression, renal impairment, hepatotoxicity, pneumonitis, GI toxicity, secondary malignancy, tumor lysis syndrome, dermatologic toxicity, opportunistic infections, radiotherapy, experienced physicianMyelosuppression, nephrotoxicity, mucositis, diarrhea, pneumonitisMonitor: CBC, BUN, LFT, methotrexate levels, SCr, urine pH, fluid/electrolytes, pulmonary function, renal function, hepatic function
irinotecanDiarrhea, bone marrow suppressionDiarrhea, myelosuppressionGive with atropine for early diarrhea, and loperamide for late diarrhea. Monitor: CBC, electrolytes, bowel movements, hydration, pulmonary toxicity
paclitaxelExperienced physician, hypersensitivity, bone marrow suppressionMyelosuppression, alopecia, cardiac toxicity, peripheral neuropathy, myalgiaRequires filter and non PVC tubing.Premedicate with diphenhydramine, H2 agonist, dexamethasone.Monitor: CBC, kidney function, hypersensitivity, infusion site
IfosfamideBone marrow suppression, CNS toxicity, hemorrhagic cystitis, nephrotoxicityNephrotoxicity, hemorrhagic cystitis, N&VNeed to give with Mesna to bind toxic metabolite. Monitor: CBC, urine output, urinalysis, liver function, renal function, neurotoxicity, pulmonary toxicity, hemorrhagic cystitis
cisplatinMyelosuppression, N&V, nephrotoxicity, peripheral neuropathyNephrotoxicity, N&V, neurotoxicity, ototoxicity, peripheral neuropathyVigorous pre and post-hydration to preserve kidney function. Monitor: SCr, electrolytes, neurological function, hypersensitivity, neuropathy, ocular toxicity, secondary malignancies
carboplatinExperienced physician, bone marrow suppression, vomiting, hypersensitivityAlopecia, myelosuppressionMonitor: CBC, LFTs, SCr, electrolytes, hypersensitivity
oxaliplatinhypersensitivity/anaphylaxisPeripheral neuropathy, myelosuppression, diarrheaCBC, SCr, LFTs, electrolytes, INR, ECG, neurologic function, hypersensitivity, pulmonary toxicity, posterior reversible encephalopathy syndrome, neuropathy, GI toxicity, bleeding
daunorubicinExperienced physician, extravasation, bone marrow suppression, cardiomyopathy, hepatic impairment, renal impairmentCardiotoxicity, myelosuppressionMonitor: CBC, LFTs, ECG, renal function, LVEF (ECHO or MUGA)  
bleomycinExperienced physician, pulmonary toxicity, idiosyncratic reactionPulmonary fibrosis, hepatotoxicityMonitor pulmonary function, renal function, liver function
tamoxifenUterine malignancies and thromboembobleolic eventsThromboembolic riskConsider thromboprophylaxis based on risk. Monitor CBC, INR, LFT, vaginal bleeding. Breast and pelvic exam. CYP2D6 inhibitors may impair effectiveness.
cytarabineExperienced physician, drug toxicity (bone marrow suppression, N&V, diarrhea, hepatic dysfunction)Myalgia, myelosuppression, N&V, diarrhea, oral ulceration, hepatic dysfunctionMonitor: LFT, CBC, BUN, signs of bleeding, infection, neutropenic fever, tumor lysis syndrome
Chemotherapy Toxicity Table With Boxed Warnings

The article was written by Melody Grafton in collaboration with Eric Christianson, PharmD, BCGP, BCPS

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1 Comment

  1. Vivian M RodrĂ­guez

    Excellent post, extremely helpful…..
    I wish I had it for my NAPLEX exam.
    A big thanks to Melody ad Eric


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Written By Eric Christianson


April 28, 2021

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