• Monitor for bone marrow depression. Assess for bleeding (bleeding gums; bruising; petechiae; guaiac stools, urine, and emesis) and avoid IM injections and 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 ↑ fatigue, dyspnea, and orthostatic hypotension.
• Assess for nausea and vomiting; usually begin within 3 hr of administration and persist for 24 hr. Prophylactic antiemetics may be used. Monitor intake and output, daily weight, and appetite. Adjust diet as tolerated for anorexia.
• Assess pulmonary function tests prior to initiation of therapy and periodically during therapy. Pulmonary toxicity may occur with cumulative doses of 600–1100 mg or with ≥6 mo of therapy.

Lab Test Considerations:

• Monitor CBC and differential prior to and weekly during therapy. If leukocytes ≥3,000/mm³ or platelets ≥75,000/mm³, do not adjust dose. If leukocytes 2,000–2,999/mm³ or platelets 25,000–74,999/mm³,↓ dose by 30%. If leukocytes <2000/mm³ or platelets <25,000/mm³,↓ dose by 50%. Hold dose for >6 wk if necessary until platelet count recovers to ≥100,000/mm³ and leukocytes recover to ≥4,000/mm³. The nadir of leukopenia occurs in 4–6 wk. The nadir of thrombocytopenia occurs in 4 wk. Notify provider if leukocyte count <4,000/mm³ or platelet count <100,000/mm³. Recovery from leukopenia and thrombocytopenia occurs in 1–2 wk. Myelosuppression is cumulative; subsequent courses of therapy should be delayed until recovery occurs.
  • Monitor liver function tests (AST, ALT, LDH, bilirubin) and renal function (BUN, serum creatinine) prior to and periodically during therapy.
  • May cause ↑ uric acid. Monitor periodically during therapy.
  • Obtain hepatitis B virus screening and management before starting therapy. Past infection may require antiviral prophylaxis and monitoring.