• 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.
• Severe nausea and vomiting may occur. Administer parenteral antiemetic agents 30–45 min prior to therapy and routinely around the clock for next 24 hr as indicated. Monitor amount of emesis and notify health care professional if emesis exceeds guidelines to prevent dehydration.
• Measure cardiac function, using ECG and a multigated radionuclide angiography (MUGA) scan or an ECHO, prior to therapy. Perform repeated evaluations of left ventricular ejection fraction during therapy. Monitor for development of signs of cardiac toxicity, which may occur early (ST-T wave changes, sinus tachycardia, and extrasystoles) or late (may occur mo to yr after termination of therapy). Delayed cardiac toxicity is characterized by cardiomyopathy, tachycardia, peripheral edema, dyspnea, rales/crackles, weight gain, hepatomegaly, ascites, pleural effusion. Toxicity is usually dependent on cumulative dose.
• Assess injection site frequently for redness, irritation, or inflammation. Burning or stinging during infusion may indicate infiltration and infusion should be discontinued and restarted in another vein. Epirubicin is a vesicant but may infiltrate painlessly even if blood returns on aspiration of infusion needle. Severe tissue damage may occur if epirubicin extravasates. If extravasation occurs, stop infusion immediately, restart, and complete dose in another vein.
• Assess oral mucosa frequently for development of stomatitis (pain, burning, erythema, ulcerations, bleeding, infection). Increased dosing interval and/or decreased dosing is recommended if lesions are painful or interfere with nutrition.

Lab Test Considerations:

• Obtain negative pregnancy test before starting therapy.Monitor CBC and differential before and during each cycle of therapy. Epirubicin should not be administered to patients with a baseline neutrophil count <1500 cells/mm³. The WBC nadir occurs 10–14 days after administration, and recovery usually occurs by the 21st day. Severe thrombocytopenia and anemia may also occur.
  • Monitor renal (BUN and creatinine) and hepatic (AST, ALT, LDH, and serum bilirubin) function prior to and periodically during therapy. Dose reduction is required for bilirubin >1.2 m g/dL, AST 2–4 times the upper limit of normal, or serum creatinine >5 m g/dL.