• Monitor vital signs frequently, especially during first hr of the infusion.
• Monitor cardiovascular status especially during first 3 hr of infusion. Hypotension and bradycardia are common but usually do not require treatment. Continuous ECG monitoring is recommended only for patients with serious underlying conduction abnormalities or those concurrently taking doxorubicin.
• Monitor for bone marrow depression. Assess for bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis) and avoid IM injections and taking rectal temperatures if platelet count is low. Apply pressure to venipuncture sites for 10 min. Assess for signs of infection during neutropenia. Anemia may occur. Monitor for dyspnea and orthostatic hypotension. Granulocyte-colony stimulating factor (G-CSF) may be used if necessary.
• Monitor intake and output, appetite, and nutritional intake. Paclitaxel causes nausea and vomiting in 50% of patients. Prophylactic antiemetics may be used. Adjust diet as tolerated to help maintain fluid and electrolyte balance and nutritional status.
• Assess patient for arthralgia and myalgia, which usually begin 2–3 days after therapy and resolve within 5 days. Pain is usually relieved by nonopioid analgesics but may be severe enough to require treatment with opioid analgesics.
• Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome and toxic epidermal necrolysis. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.
• Paclitaxel: Monitor for hypersensitivity reactions continuously during the first 30 min and frequently thereafter. These occur frequently (19%), usually during the first 10 min of paclitaxel infusion, after the 1st or 2nd dose. Pretreatment is recommended for all patients and should include dexamethasone 20 mg PO (10 mg for patients with advanced HIV disease) 12 hr and 6 hr prior to paclitaxel, diphenhydramine 50 mg IV 30–60 min prior to paclitaxel. Most common manifestations are dyspnea, flushing, tachycardia, rash, hypotension, and chest pain. If these occur, stop infusion and notify health care professional. Treatment may include bronchodilators, epinephrine, antihistamines, and corticosteroids. Keep these agents and resuscitative equipment close by in the event of an anaphylactic reaction. Other manifestations of hypersensitivity reactions include flushing and rash.
• Assess for development of peripheral neuropathy. If severe symptoms occur, subsequent dose should be reduced by 20%.
• Paclitaxel protein-bound (albumin-bound): Consider premedication in patients who have had prior hypersensitivity reactions to paclitaxel protein-bound (albumin-bound). Do not re-challenge patients who experience a severe hypersensitivity reaction.
• Sensory neuropathy is dose- and schedule-dependent. If ≥Grade 3 sensory neuropathy occurs, withhold paclitaxel protein-bound (albumin-bound) until resolution to Grade 1 or 2 for metastatic breast cancer or until resolution to ≤Grade 1 for NSCLC and pancreatic cancer followed by a dose reduction for all subsequent courses of therapy.

Lab Test Considerations:

• Verify negative pregnancy test before starting therapy.
• Paclitaxel: Monitor CBC and differential prior to and periodically during therapy. The nadir of leukopenia occurs in 11 days, with recovery by days 15–21. If neutrophil counts <500/mm³ for ≥1 wk, reduce dose by 20% for subsequent courses.
  • Paclitaxel Protein-Bound Particles (albumin-bound)Monitor CBC and differential frequently, including before starting therapy and prior to dosing on Day 1 (for breast cancer), 8, and 15 (for NSCLC and pancreatic cancer). For NSCLC:If neutropenic fever (ANC <500/mm³ with fever >38°C) OR delay of next cycle by more than 7 days for ANC <1500/mm³ OR ANC <500/mm³ for >7 days, reduce dose on 1st occurrence to 75 mg/m² and on 2nd occurrence, reduce dose to 50 mg/m². For 3rd occurrence, discontinue therapy. Do not administer if neutrophil count is <1500/mm³. If severe neutropenia (neutrophils <500 cells/mm³ for seven days or more), reduce dose in subsequent courses. If platelet count <50,000/mm³, for 1st occurrence, reduce dose to 75 mg/m². Discontinue therapy at 2nd occurrence. For Pancreatic Cancer: On Day 1, if ANC <1500 cells/mm³ OR platelet count <100,000 cells/mm³, hold next dose until recovery. On Day 8, if ANC 500 to <1000 cells/mm³ OR platelet count 50,000 to <75,000 cells/mm³, reduce dose one level; On Day 8, if ANC <500 cells/mm³ OR <50,000 cells/mm³, hold dose. On Day 15, if Day 8 doses were reduced or given without modification, and ANC 500 to <1000 cells/mm³ OR platelet count 50,000 to <75,000 cells/mm³, reduce dose 1 level from Day 8. On Day 15, if Day 8 doses were reduced or given without modification, and ANC <500 cells/mm³ OR platelet count <50,000 cells/mm³, hold doses. On Day 15, if Day 8 doses were held and ANC ≥1000 cells/mm³ OR platelet count ≥75,000 cells/mm³, reduce dose 1 level from Day 1. On Day 15, if Day 8 doses were held and ANC 500 to <1000 cells/mm³ OR platelet count 50,000 to <75,000 cells/mm³, reduce dose 2 levels from Day 1. On Day 15, if Day 8 doses were held and ANC <500 cells/mm³ OR platelet count <50,000 cells/mm³, hold doses.
  • Monitor liver function studies (AST, ALT, LDH, bilirubin) prior to and periodically during therapy to detect hepatotoxicity.