worried [1,500/mm:<75,000/mm 3 ): Delay treatment until ANC 1,500/mm 3 and platelets 75,000/mm 3 ; resume treatment at previous dose. Grade 3 (ANC 500 to 999/mm 3 or platelets 25,000 to> <50,000/mm 3 ): Delay treatment until ANC 1,500/mm 3 and platelets 75,000/mm 3 ; resume treatment at previous dose. Grade 4 (ANC> <500/mm 3 or platelets> <25,000/mm 3 ): Delay treatment until ANC 1,500/mm 3 and platelets 75,000/mm 3 ; then resume at 25% dose reduction or continue at previous dose with granulocyte growth factor support. Multiple myeloma (in combination with Bortezomib) (see Bortezomib monograph for bortezomib dosage reduction with toxicity guidelines): Fever 38 C and ANC> <1,000/mm 3 : If prior to doxorubicin liposomal treatment (day 4), do not administer (withhold); if after doxorubicin liposomal administered, reduce dose by 25% in next cycle. ANC> <500/mm 3 , platelets> <25,000/mm 3 , hemoglobin> <8 g/dL: If prior to doxorubicin liposomal treatment (day 4); do not administer (withhold); if after doxorubicin liposomal administered and if bortezomib dose reduction occurred for hematologic toxicity, reduce dose by 25% in next cycle Nonhematologic toxicity: Hand-foot syndrome (HFS): Grade 1 (mild erythema, swelling, or desquamation not interfering with daily activities): If no prior grade 3 or 4 HFS toxicity, no dosage adjustment is necessary. If prior grade 3 or 4 HFS toxicity, delay dose up to 2 weeks and decrease dose by 25%. Grade 2 (erythema, desquamation, or swelling interfering with, but not precluding, normal physical activities; small blisters or ulcerations> <2 cm in diameter): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. If resolved to grade 0 or 1 within 2 weeks and no prior grade 3 or 4 HFS, continue treatment at previous dose. If a prior grade 3 or 4 HFS has occurred, decrease dose by 25%. Grade 3 (blistering, ulceration, or swelling interfering with walking or normal daily activities; cannot wear regular clothing): Delay dosing up to 2 weeks or until resolved to grade 0 or 1, then decrease dose by 25%. If no resolution after 2 weeks, discontinue liposomal doxorubicin. Grade 4 (diffuse or local process causing infectious complications, or a bedridden state or hospitalization): Delay dosing up to 2 weeks or until resolved to grade 0 or 1, then decrease dose by 25%. If no resolution after 2 weeks, discontinue liposomal doxorubicin. Infusion reaction: Temporarily stop infusion until resolution and then resume at a reduced rate. For serious or life threatening reaction, discontinue infusion. Stomatitis: Grade 1 (painless ulcers, erythema, or mild soreness): If no prior grade 3 or 4 toxicity, no dosage adjustment is necessary. If prior grade 3 or 4 toxicity, delay dose up to 2 weeks and decrease dose by 25%. Grade 2 (painful erythema, edema, or ulcers, but can eat): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. If resolved to grade 0 or 1 within 2 weeks and no prior grade 3 or 4 stomatitis, continue treatment at previous dose. If prior grade 3 or 4 stomatitis, decrease dose by 25%. Grade 3 (painful erythema, edema, or ulcers, and cannot eat): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. Decrease dose by 25% and return to original dosing interval. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. Grade 4 (requires parenteral or enteral support): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. Decrease dose by 25% and return to original dosing interval. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. Multiple myeloma (in combination with Bortezomib) (see Bortezomib monograph for bortezomib dosage reduction with toxicity guidelines): Grade 3 or 4 nonhematologic toxicity: Delay dose until resolved to grade> <2 and then reduce dose by 25% Neuropathic pain or peripheral neuropathy: No dose reductions needed for doxorubicin liposomal, refer to Bortezomib monograph for bortezomib dosing adjustment. Canadian labeling: Hematologic toxicity: Breast cancer, ovarian cancer: Refer to US dosage adjustment for hematologic toxicity section. AIDS-related Kaposi sarcoma: Grade 1 or grade 2 (ANC 1,500 to 1,900/mm 3 or platelets 75,000 to 150,000/mm 3 or ANC 1,000 to> <1,500/mm 3 or platelets 50,000 to> <75,000/mm 3 ): No dosage adjustment necessary. Grade 3 (ANC 500 to 999/mm 3 and platelets 25,000 to> <50,000/mm 3 ): Delay treatment until ANC 1,000/mm 3 and/or platelets 50,000/mm 3 and then resume with a 25% dose reduction. Grade 4 (ANC> <500/mm 3 and platelets> <25,000/mm 3 ): Delay treatment until ANC 1,000/mm 3 and/or platelets 50,000/mm 3 and then resume with a 50% dose reduction. Nonhematologic toxicity: Breast cancer, ovarian cancer: Hand-foot syndrome (HFS; palmar-plantar erythrodysesthesia): Grade 1 (mild erythema, swelling, or desquamation not interfering with daily activities): If at weeks 4 and 5 following prior dose, resume unless patients has experienced prior grade 3 or 4 HFS toxicity (if so, wait an additional week). If at week 6, decrease dose by 25%; return to 4-week interval. Grade 2 (erythema, desquamation, or swelling interfering with, but not precluding, normal physical activities; small blisters or ulcerations> <2 cm in diameter): If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, decrease dose by 25%; return to 4-week interval. Grade 3 or grade 4 (blistering, ulceration, or swelling interfering with walking or normal daily activities; cannot wear regular clothing or diffuse or local process causing infectious complications, or a bedridden state or hospitalization): If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, discontinue therapy. Stomatitis: Grade 1 (painless ulcers, erythema, or mild soreness): If at weeks 4 and 5 following prior dose, resume unless patients has experienced prior grade 3 or 4 HFS toxicity (if so, wait an additional week). If at week 6, decrease dose by 25%; return to 4-week interval or discontinue therapy (based on physical assessment). Grade 2 (painful erythema, edema, or ulcers, but can eat): If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, decrease dose by 25%; return to 4-week interval or discontinue therapy (based on physical assessment). Grade 3 or grade 4 (painful erythema, edema, or ulcers, and cannot eat or requires parenteral or enteral support): If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, discontinue therapy. Aids-related Kaposi sarcoma: Hand-foot syndrome (HFS; palmar-plantar erythrodysesthesia): Grade 0 (no symptoms): If at week 3 or 4 following prior dose, redose at a 2-to 3-week interval. Grade 1 (mild erythema, swelling, or desquamation not interfering with daily activities): If at week 3 following prior dose, resume unless patients has experienced prior grade 3 or 4 HFS toxicity (if so, wait an additional week). If at week 4 following prior dose, decrease dose by 25% and return to 3-week interval. Grade 2 (erythema, desquamation, or swelling interfering with, but not precluding, normal physical activities; small blisters or ulcerations> <2 cm in diameter): If at week 3 following prior dose, wait an additional week. If at week 4 following prior dose, decrease dose by 50% and return to 3-week interval. Grade 3 or grade 4 (blistering, ulceration, or swelling interfering with walking or normal daily activities; cannot wear regular clothing, diffuse or local process causing infectious complications, or a bedridden state or hospitalization): If at week 3 following prior dose, wait an additional week. If at week 4, discontinue therapy. Stomatitis: Grade 1 (painless ulcers, erythema, or mild soreness): No dosage adjustment necessary. Grade 2 (painful erythema, edema, or ulcers, but can eat): Wait 1 week and if symptoms improve, resume at 100% dose. Grade 3 (painful erythema, edema, or ulcers, and cannot eat): Wait 1 week and if symptoms improve, resume with a 25% dose reduction. Grade 4 (requires parenteral or enteral support): Wait 1 week and if symptoms improve, resume with a 50% dose reduction. Dosing: Obesity ASCO Guidelines for appropriate chemotherapy dosing in obese adults with cancer: Utilize patient s actual body weight (full weight) for calculation of body surface area- or weight-based dosing, particularly when the intent of therapy is curative; manage regimen-related toxicities in the same manner as for nonobese patients; if a dose reduction is utilized due to toxicity, consider resumption of full weight-based dosing with subsequent cycles, especially if cause of toxicity (eg, hepatic or renal impairment) is resolved (Griggs 2012). Reconstitution Dilute doses 90 in D5W 250 mL prior to administration. Dilute doses> 90 mg in D5W 500 mL. Solution is not clear, but has a red, translucent appearance due to the liposomal dispersion. Dilute ONLY in D5W; do not use bacteriostatic agents; do not mix with other medications. Administration Monitor for infusion reaction. For IV infusion only; do not administer IV push. If contact with skin/mucosa occurs, wash immediately with soap and water. Administer IVPB over 60 minutes; the manufacturer recommends infusing the first dose at initial rate of 1 mg/minute to minimize risk of infusion reactions; if no infusion-related reactions are observed, then increase the infusion rate for completion over 1 hour. Do NOT administer undiluted. Do NOT infuse with in-line filters. Do not mix with other medications. Monitor for local erythematous streaking along vein and/or facial flushing (may indicate rapid infusion rate). For multiple myeloma, administer doxorubicin liposomal after bortezomib on day 4 of each cycle. Irritant (Perez Fidalgo 2012); monitor infusion site; avoid extravasation. Assure proper needle or catheter position prior to administration. Extravasation management: If extravasation, infiltration, or burning/stinging sensation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity (Perez Fidalgo 2012; Polovich 2009). Do not apply pressure to the site. Apply ice to the site for 15 minutes 4 times a day for 3 days. Storage Store intact vials refrigerated at 2 C to 8 C (36 F to 46 F); avoid freezing. Solutions diluted for infusion in D5W should be refrigerated at 2 C to 8 C (36 F to 46 F); administer within 24 hours. Drug Interactions Abiraterone Acetate: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity. Consider therapy modification Ado-Trastuzumab Emtansine: May enhance the cardiotoxic effect of Anthracyclines. Management: When possible, patients treated with ado-trastuzumab emtansine should avoid anthracycline-based therapy for up to 7 months after stopping ado-trastuzumab emtansine. Monitor closely for cardiac dysfunction in patients receiving this combination. Consider therapy modification Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Asunaprevir: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Consider therapy modification BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination Bevacizumab: May enhance the cardiotoxic effect of Anthracyclines. Monitor therapy Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy Cardiac Glycosides: May diminish the cardiotoxic effect of Anthracyclines. Anthracyclines may decrease the serum concentration of Cardiac Glycosides. The effects of liposomal formulations may be unique from those of the free drug, as liposomal formulation have unique drug disposition and toxicity profiles, and liposomes themselves may alter digoxin absorption/distribution. Monitor therapy CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination Cyclophosphamide: May enhance the cardiotoxic effect of Anthracyclines. Monitor therapy CYP2D6 Inhibitors (Moderate): May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy CYP2D6 Inhibitors (Strong): May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors). Consider therapy modification CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Consider therapy modification Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification Dasatinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination Echinacea: May diminish the therapeutic effect of Immunosuppressants. Consider therapy modification Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination Imatinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification Lenograstim: Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Palifermin: May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Consider therapy modification Panobinostat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of sensitive CYP2D6 substrates when possible, particularly those substrates with a narrow therapeutic index. Consider therapy modification Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Consider therapy modification Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy QuiNINE: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Monitor therapy Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Monitor therapy St John's Wort: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification Stavudine: DOXOrubicin (Liposomal) may diminish the therapeutic effect of Stavudine. Monitor therapy Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination Taxane Derivatives: May enhance the adverse/toxic effect of Anthracyclines. Taxane Derivatives may increase the serum concentration of Anthracyclines. Taxane Derivatives may also increase the formation of toxic anthracycline metabolites in heart tissue. Consider therapy modification Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification Trastuzumab: May enhance the cardiotoxic effect of Anthracyclines. Management: When possible, patients treated with trastuzumab should avoid anthracycline-based therapy for up to 7 months after stopping trastuzumab. Monitor closely for cardiac dysfunction in patients receiving anthracyclines with trastuzumab. Consider therapy modification Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Avoid combination Vinflunine: DOXOrubicin (Liposomal) may enhance the adverse/toxic effect of Vinflunine. Specifically, the risk for hematologic toxicities may be increased. DOXOrubicin (Liposomal) may increase the serum concentration of Vinflunine. Vinflunine may decrease the serum concentration of DOXOrubicin (Liposomal). Monitor therapy Zidovudine: DOXOrubicin (Liposomal) may enhance the adverse/toxic effect of Zidovudine. DOXOrubicin (Liposomal) may diminish the therapeutic effect of Zidovudine. Consider therapy modification Adverse Reactions Frequency not always defined. >10%: Cardiovascular: Cardiomyopathy (dose related: 11%; Kaposi sarcoma: <1%), cardiotoxicity (11%), chest tightness (11%), flushing (11%), hypotension (1% to 11%) Central nervous system: Fatigue (> 20%), headache ( 11%) Dermatologic: Palmar-plantar erythrodysesthesia (ovarian cancer: 51%), skin rash (29%, Kaposi sarcoma: 1% to 5%), alopecia (9% to 19%), facial swelling (11%) Gastrointestinal: Nausea (ovarian cancer: 46%; Kaposi sarcoma: 17% to 18%), stomatitis (41%, Kaposi sarcoma: 5% to 8%), vomiting (33%; Kaposi sarcoma: 8%), constipation (>20%), diarrhea (21%; Kaposi sarcoma: 3% to 8%), anorexia (20%; Kaposi sarcoma: 1% to 5%), mucous membrane disease (14%), dyspepsia 12% Hematologic & oncologic: Thrombocytopenia (dose related, Kaposi sarcoma: 1% to 61%), neutropenia (dose related: 4% to 49%), leukopenia (37%), anemia (16% to 58%; dose related <1% to 5%) Neuromuscular & skeletal: Weakness (40%; Kaposi sarcoma: 7% to 10%), back pain (12%; Kaposi sarcoma: 1% to 5%) Respiratory: Pharyngitis (16%; Kaposi sarcoma> <1%), dyspnea (1% to 15%) Miscellaneous: Fever (21%; Kaposi sarcoma: 8% to 9%), infusion related reaction (7% to 11%) 1% to 10%: Cardiovascular: Cardiac arrest ( 10%), chest pain (Kaposi sarcoma: 1% to 5%), deep thrombophlebitis (ovarian cancer: 1% to 10%), tachycardia (1% to 10%), vasodilation (ovarian cancer: 1% to 10%) Central nervous system: Depression (ovarian cancer: 1% to 10%), dizziness (1% to 10%), drowsiness (1% to 10%), chills (Kaposi sarcoma: 1% to 5%) Dermatologic: Acne vulgaris (ovarian cancer: 1% to 10%), ecchymoses (ovarian cancer: 1% to 10%), exfoliative dermatitis (ovarian cancer: 1% to 10%), fungal dermatitis (ovarian cancer: 1% to 10%), furunculosis (ovarian cancer: 1% to 10%), herpes simplex dermatitis (1% to 10%), pruritus (1% to 10%), skin discoloration (ovarian cancer: 1% to 10%), vesiculobullous dermatitis (ovarian cancer: 1% to 10%), xeroderma (ovarian cancer: 1% to 10%), maculopapular rash ( 10%) Endocrine & metabolic: Hypercalcemia (ovarian cancer: 1% to 10%), hypokalemia (ovarian cancer: 1% to 10%), hyponatremia (ovarian cancer: 1% to 10%), weight loss (1% to 10%), dehydration ( 10%), hyperglycemia (1% to 5%) Gastrointestinal: Dysphagia (1% to 10%), esophagitis (ovarian cancer: 1% to 10%), intestinal obstruction (ovarian cancer: 1% to 10%), oral candidiasis (1% to 10%), oral mucosa ulcer (1% to 10%), dysgeusia (1% to 10%), abdomen enlarged (ovarian cancer 1% to 5%), glossitis (1% to 5%), cachexia Genitourinary: Hematuria (ovarian cancer: 1% to 10%), hemorrhagic cystitis, urinary tract infection (ovarian cancer: 1% to 10%), vulvovaginal candidiasis (ovarian cancer 1% to 10%) Hematologic & oncologic: Rectal hemorrhage (ovarian cancer: 1% to 10%), hemolysis (1% to 5%), prolonged prothrombin time (1% to 5%), bone marrow depression (Kaposi sarcoma), progression of cancer (Kaposi sarcoma) Hepatic: Hyperbilirubinemia (1% to 10%), increased serum alkaline phosphatase (Kaposi sarcoma 1% to 8%), increased serum ALT (Kaposi sarcoma 1% to 5%) Hypersensitivity: Hypersensitivity reaction (Kaposi sarcoma 1% to 5%) Infection: Infection (1% to 12%), herpes zoster ( 10%), paresthesia (5%), myalgia (ovarian cancer: 1% to 5%), neuropathy (ovarian cancer 1% to 5%), toxoplasmosis (Kaposi sarcoma) Ophthalmic: Dry eye syndrome (ovarian cancer: 1% to 10%), conjunctivitis ( 10%), retinitis (Kaposi sarcoma 1% to 5%) optic neuritis (Kaposi sarcoma) Respiratory: Epistaxis (ovarian cancer: 1% to 10%), pneumonia (1% to 10%), rhinitis (ovarian cancer: 1% to 10%), sinusitis (ovarian cancer: 1% to 10%), increased cough ( 10%), cough (Kaposi sarcoma)> <1% (Limited to important or life-threatening): Abnormal vision, abscess, acute brain syndrome, albuminuria, alkaline phosphatase increased anaphylactic reaction, anxiety, arthralgia, asthma, balanitis, blindness, bone pain, bronchitis, bundle branch block, BUN increased, candidiasis, cardiomegaly, cardiomyopathy, cellulitis, CHF, colitis, confusion, congestive heart failure (Kaposi sarcoma), creatinine increased, cryptococcosis, cryptococcosis, diabetes mellitus, dysuria,edema, emotional lability, erythema multiforme, erythema nodosum, eosinophilia, fecal impaction, flatulence, flu-like syndrome, gastritis, hemorrhage, hepatic failure, hepatitis, hepatosplenomegaly, hyperkalemia, hyperlipidemia, hypernatremia, hyperuricemia, hyperventilation, hypoglycemia, hypomagnesemia, hypophosphatemia, hypoproteinemia, hypothermia, injection site hemorrhage, injection site pain, insomnia, jaundice, ketosis, lactic dehydrogenase increased, lymphadenopathy, lymphangitis, migraine, myositis, muscle spasm, optic neuritis, pain, pallor, palpitations, pancreatitis, pericardial effusion, petechia, pneumothorax, peripheral edema, pleural effusion, pulmonary embolism, radiation injury, sclerosing cholangitis, seizure, secondary acute myelocytic leukemia, sepsis, skin necrosis, skin ulcer, syncope, squamous cell carcinoma, Stevens-Johnson syndrome, tenesmus, thrombophlebitis, thromboplastin decreased, thrombosis, tinnitus, toxic epidermal necrolysis, urticaria, vertigo, ventricular arrhythmia ALERT: U.S. Boxed Warning Myocardial toxicity: Doxorubicin (liposomal) may cause myocardial damage (including congestive heart failure) as the total cumulative dose of doxorubicin approaches 550 mg/m 2 . In a clinical study of 250 patients with advanced cancer who were treated with doxorubicin (liposomal), the risk of cardiotoxicity was 11% when the cumulative anthracycline dose was between 450 and 550 mg/m 2 . Prior use of other anthracyclines or anthracenediones should be included in calculations of total cumulative dosage. The risk of cardiomyopathy may be increased at lower cumulative doses in patients with prior mediastinal irradiation Infusion reactions: Acute infusion-related reactions consisting of, but not limited to, flushing, shortness of breath, facial swelling, headache, chills, back pain, tightness in the chest or throat, and/or hypotension occurred in 11% of patients with solid tumors treated with doxorubicin (liposomal). Serious, life-threatening and fatal infusion reactions have been reported. Warnings/Precautions Concerns related to adverse effects: Bone marrow suppression: Neutropenia, anemia, and thrombocytopenia may occur. Monitor blood counts. Treatment delay, dosage modification, or discontinuation may be required. Hematologic toxicity may occur at a higher frequency and severity with combination chemotherapy. Infusion reactions: [US Boxed Warning]: Acute infusion-related reactions consisting of, but not limited to, flushing, shortness of breath, facial swelling, headache, chills, back pain, tightness in the chest or throat, and/or hypotension occurred in 11% of patients with solid tumors treated with doxorubicin (liposomal). Serious, life-threatening and fatal infusion reactions have been reported. Infusion reactions have also included chest pain, pruritus, rash, cyanosis, syncope, tachycardia, bronchospasm, asthma, and apnea. Most reactions occurred during the first infusion. Some reactions have resulted in dose interruption. Medication and equipment to manage infusion reactions should be immediately available during infusion. Initiate infusion at a rate of 1 mg/minute, with the rate increased (to complete infusion over 60 minutes) as tolerated. If an infusion reaction occurs, temporarily interrupt infusion until resolved and resume at a reduced rate. Discontinue for serious or life-threatening infusion reactions. Myocardial toxicity: [US Boxed Warning]: Doxorubicin liposomal may cause myocardial damage (including congestive heart failure) as the total cumulative dose of doxorubicin approaches 550 mg/m 2 . In a clinical study of 250 patients with advanced cancer who were treated with doxorubicin liposomal, the risk of cardiotoxicity was 11% when the cumulative anthracycline dose was between 450 to 550 mg/m 2 . Prior use of other anthracyclines or anthracenediones should be included in calculations of total cumulative dosage. The risk of cardiomyopathy may be increased searching for what you offer
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