• Monitor BP, pulse, respiratory rate, and temperature frequently during administration. Report significant changes.
• 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 increased fatigue, dyspnea, and orthostatic hypotension.
• Monitor intake and output ratios, and report occurrence of significant discrepancies. Encourage fluid intake of 2000–3000 mL/day. Allopurinol and alkalinization of the urine may be used to decrease serum uric acid levels and to help prevent urate stone formation.
• Severe and protracted nausea and vomiting may occur as early as 1 hr after therapy and may last 24 hr. Administer parenteral antiemetics 30–45 min prior to therapy and routinely around the clock for the next 24 hr as indicated. Monitor amount of emesis and notify health care professional if emesis exceeds guidelines to prevent dehydration.
• Monitor for development of signs of cardiac toxicity, which may be either acute and transient (ST segment depression, flattened T wave, sinus tachycardia, and extrasystoles) or late onset (usually occurs 1–6 mo after initiation of therapy) and characterized by intractable HF (peripheral edema, dyspnea, rales/crackles, weight gain). Chest x ray, echocardiography, ECGs, and radionuclide angiography may be ordered prior to and periodically during therapy. Cardiotoxicity is more prevalent in children younger than 2 yr and geriatric patients. Dexrazoxane may be used to prevent cardiotoxicity in patients receiving cumulative doses of >300 mg/m².
• Assess injection site frequently for redness, irritation, or inflammation during and for up to 2 hr after completion of infusion. Doxorubicin is a vesicant but may infiltrate painlessly even if blood returns on aspiration of infusion needle. Severe tissue damage may occur if doxorubicin extravasates. If extravasation occurs, stop infusion immediately, restart, and complete dose in another vein. Local infiltration of antidote is not recommended. If extravasation is suspected, intermittent application of ice to site for 15 min. 4 times daily for 3 days may be useful. Because of the progressive nature of extravasation reactions, close observation and plastic surgery consultation are recommended. Blistering, ulceration, and/or persistent pain are indications for wide excision surgery, followed by split-thickness skin grafting. May use dexrazoxane to treat extravasation. Administer first infusion of dexrazoxane as soon as possible within 6 hr of extravasation. Remove ice packs for at least 15 min prior to and during dexrazoxane administration. Recommended dose of dexrazoxane for day 1 is 1000 mg/m² (up to 2000 mg); the dose for day 2 is 1000 mg/m² (up to 2000 mg); the dose for day 3 is 500 mg/m² (up to 1000 mg). Dexrazoxane is administered as an IV infusion over 1–2 hr. If swelling, redness, and/or pain persists beyond 48 hr, immediate consultation for possible debridement is indicated.
• Assess oral mucosa frequently for development of stomatitis. Increased dosing interval and/or decreasing dose is recommended if lesions are painful or interfere with nutrition.

Lab Test Considerations:

• Verify negative pregnancy test before starting therapy.Monitor CBC and differential prior to and periodically during therapy. WBC nadir occurs 10–14 days after administration, and recovery usually occurs by the 21st day. Thrombocytopenia and anemia may also occur. Increased dosing interval and/or decreased dose is recommended if ANC is <1000 cells/mm³ and/or platelet count is <50,000 cells/mm³.
  • Monitor renal (BUN and serum creatinine) and hepatic (AST, ALT, LDH, and serum bilirubin) function prior to and periodically during therapy. Dose reduction is required for bilirubin >1.2 mg/dL or serum creatinine >3 mg/dL.
  • May cause ↑ serum and urine uric acid concentrations.