Oncology handbook

CHEMOTHERAPY
I. Agents Generally Requiring Hospitalization for Administration

The vast majority of chemotherapy is given in the out-patient Heme-Onc Clinic.

Chemotherapy requiring hospitalization include:
1. Continuous infusion Doxorubicin (Adriamycin) or Daunorubicin in patients with internal reservoirs (extravasation causes severe tissue necrosis).
2. High-dose Methotrexate (3-12 g/m²) with hydration, alkalinization, and Leucovorin (folinic acid) rescue and antiemetics. MTX levels and urine PH and output need to be monitored closely to prevent toxicity.
3. Ifosfamide with hydration, repeated doses of Mesna (sulfhydryl uroprotector), and antiemetics.
4. Very high-dose Cyclophosphamide (Cytoxan) with hydration, repeated doses of Mesna and antiemetics.
5. Cis-Platin with hydration; forced Mannitol diuresis; magnesium, calcium, potassium IV supplementation, antiemetics.
6. High-dose Cytarabine (Ara-C), with frequent ophthalmic drops to prevent conjunctivitis and antiemetics.

A) Doxorubicin (Adriamycin)

An antibiotic which inhibits DNA replication. Severe tissue necrosis occurs if skin or subcutaneous extravasation occurs, thus requiring hospitalization for prolonged infusions. Cumulative doses can lead to irreversible cardiomyopathy. Echocardiograms are performed periodically to assess left ventricular function and changes in ejection and shortening fractions. Causes mucositis, nausea, vomiting, diarrhea, myelosuppression, and radiation recall (should not be administered concomitant with XRT.) Urine is often reddish-orange following administration. Dose reduction is required if bilirubin is elevated.
B) Methotrexate (MTX)

Folic acid analog: suicide substrate for dihydrofolate reductase. Dose limiting toxicities include myelosuppression and mucositis. Other side effects include nausea, vomiting, alopecia, hepatic injury (usually reversible), skin photosensitivity, glomerular damage. Methotrexate can accumulate in ascites, edema, and effusions which can result in prolonged toxicity, and should never be given if such fluids are present. Administration of high-dose Methotrexate (3 to 33 gm/M²) requires good renal function (determined by calculated creatinine clearance). Hydration with NaHCO₃ to promote alkalinization is required during and following Methotrexate administration. Leucovorin (folinic acid) rescue and serial serum Methotrexate levels are also required (see MTX excretion curve and leucovorn requirements below). Prophylactic Septra should be held during Methotrexate/Leucovorin administration.

Note: 1 x 10^–4 = 100 molar; 1 x 10^–5 molar = 10.0 molar; 1 x 10^–6 molar = 1.0 molar;