doxorubicin hydrochloride

ROUTE	ONSET	PEAK	DURATION
IV	10 days	14 days	21–24 days

Drug-drug:

CYP2D6 inhibitors, CYP3A4 inhibitors, and P-glycoprotein inhibitors may ↑ levels and risk of toxicity; avoid concurrent use.
CYP2D6 inducers, CYP3A4 inducers, and P-glycoprotein inducers may ↓ levels and effectiveness; avoid concurrent use.
↑risk of bone marrow depression with other antineoplastics or radiation therapy.
Pediatric patients who have received concurrent doxorubicin and dactinomycin have an ↑ risk of recall pneumonitis at variable times following local radiation therapy.
May ↑ skin reactions at previous radiation therapy sites.
If paclitaxel is administered first, clearance of doxorubicin is ↓ and the incidence and severity of neutropenia and stomatitis are ↑ (problem is diminished if doxorubicin is administered 1st).
Hematologic toxicity is ↑ and prolonged by concurrent use of cyclosporine; risk of coma and seizures is also ↑.
Incidence and severity of neutropenia and thrombocytopenia are ↑ by concurrent progesterone.
May ↑ levels and risk of toxicity of phenytoin.
May ↑ risk of hemorrhagic cystitis from cyclophosphamide.
May ↑ risk of hepatotoxicity from mercaptopurine.
Cardiac toxicity may be ↑ by radiation therapy or cyclophosphamide.
↑risk of cardiac toxicity with trastuzumab; avoid use of doxorubicin for up to 7 mo after discontinuing trastuzumab.
If dexrazoxane is administered at initiation of doxorubicin-containing regimens, may ↑ risk of therapeutic failure and tumor progression.
May ↓ antibody response to live-virus vaccines and ↑ risk of adverse reactions.

Route/Dosage ⬆ ⬇

IV (Adults ): 60–75 mg/m² daily, repeat every 21 days; or 25–30 mg/m² daily for 2–3 days, repeat every 3–4 wk or 20 mg/m²/wk. Total cumulative dose should not exceed 550 mg/m² without monitoring of cardiac function or 400 mg/m² in patients with previous chest radiation or other cardiotoxic chemotherapy.
IV (Children ): 30 mg/m²/day for 3 days every 4 wk.

Hepatic Impairment

IV (Adults ): Serum bilirubin 1.2–3 mg/dL:↓ dose by 50%; Serum bilirubin 3.1–5 mg/dL:↓ dose by 75%.

Availability ⬆ ⬇

(Generic available)

Powder for injection: 10 mg/vial; 50 mg/vial; 150 mg/vial
Solution for injection: 2 mg/mL

Assessment ⬆ ⬇

Monitor BP, HR, respiratory rate, and temperature frequently during administration.
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 ↑ fatigue, dyspnea, and orthostatic hypotension.
Monitor intake and output. Encourage fluid intake of 2000–3000 mL/day. Allopurinol and alkalinization of the urine may be used to ↓ 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 before therapy and routinely around the clock for the next 24 hr as indicated. Monitor amount of emesis and notify health care provider 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, 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, ECG, and radionuclide angiography may be ordered before and periodically during therapy. Cardiotoxicity is more prevalent in children <2 yr and older adults and when cumulative dose >300 mg/m². Dexrazoxane may be used to prevent cardiotoxicity in patients receiving cumulative doses of >300 mg/m².
Assess oral mucosa frequently for development of stomatitis. ↑ dosing interval and/or ↓ dose is recommended if lesions are painful or interfere with nutrition.

Lab Test Considerations:

Verify negative pregnancy test before starting therapy.
- Monitor CBC with differential before 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. ↑ dosing interval and/or ↓ 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 before and periodically during therapy. Dose ↓ is required for bilirubin >1.2 mg/dL or serum creatinine >3 mg/dL.
- May ↑ serum and urine uric acid concentrations.

Implementation ⬆ ⬇

High Alert: Fatalities have occurred with incorrect administration of chemotherapeutic agents. Before administering, clarify all ambiguous orders; double-check single, daily, and course-of-therapy dose limits; have 2nd practitioner independently double-check original order, calculations, and infusion pump settings.
High Alert: Do not confuse doxorubicin hydrochloride with doxorubicin liposomal, daunorubicin hydrochloride, or idarubicin. Clarify orders that do not include both generic and brand names.
High Alert: Administer under supervision of a physician experienced in use of cancer chemotherapeutic agents.
Monitor cumulative dose of doxorubicin and other anthracyclines received; risk for cardiomyopathy ↑ as the cumulative dose ↑ (>250 mg/m² in pediatric patients <18 yr and 550 mg/m² in patients >18 yr).
Wear gloves, gown, and mask while handling medication. Discard IV equipment in specially designated containers.
- Aluminum needles may be used to administer doxorubicin but should not be used during storage, because prolonged contact results in discoloration of solution and formation of a dark precipitate. Solution is red.

IV Administration:

Doxorubicin hydrochloride is a vesicant. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient's extremity and apply dry cold compresses for 20 min 4 times day for 1–2 days. Initiate antidote (dexrazoxane or topical dimethyl sulfoxide) based on time frame of noting extravasation. If extravasation is noted ≤6 hr of doxorubicin hydrochloride infusion, administer dexrazoxane 1000 mg/m² over 1–2 hr on Days 1 and 2 (max dose = 2000 mg/day), followed by 500 mg/m² over 1–2 hr on Day 3 (max dose = 1000 mg/day). Hold cold compresses 15 min before initiating and after completing dexrazoxane infusion. Concurrent treatment with topical dimethyl sulfoxide should not be used with dexrazoxane because it may ↓ dexrazoxane's effectiveness.If extravasation is noted >6 hr after completion of doxorubicin hydrochloride infusion, apply dimethyl sulfoxide by saturating a gauze pad and painting on an area twice the size of the extravasation. Allow site to air-dry and repeat application every 8 hr for 7 days. Do not cover the area with dressing.
IV Push: Reconstitution: Reconstitute each 10 mg vial with 5 mL of 0.9% NaCl (nonbacteriostatic) for injection. Shake to dissolve completely. Do not add to IV solution. Reconstituted medication is stable for 24 hr at room temperature and 48 hr if refrigerated. Protect from sunlight. Concentration: 2 mg/mL.
Rate: Administer each dose over 3–10 min through Y-site of a free-flowing infusion of 0.9% NaCl or D5W. Facial flushing and erythema along involved vein frequently occur when administration is too rapid.
Intermittent Infusion: May be further diluted in 50–1000 mL of D5W or 0.9% NaCl.
Rate: Infuse over 30–60 min.
Y-Site Compatibility:
- alemtuzumab
- amikacin
- anidulafungin
- argatroban
- arsenic trioxide
- aztreonam
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- carboplatin
- carmustine
- caspofungin
- chlorpromazine
- ciprofloxacin
- cisplatin
- cladribine
- clindamycin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
- daptomycin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxycycline
- droperidol
- enalaprilat
- ephedrine
- epinephrine
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- gemcitabine
- gentamicin
- granisetron
- haloperidol
- hetastarch
- hydrocortisone
- hydromorphone
- ifosfamide
- imipenem/cilastatin
- irinotecan
- isoproterenol
- ketorolac
- labetalol
- leucovorin
- lidocaine
- linezolid
- lorazepam
- mannitol
- melphalan
- meperidine
- mesna
- methadone
- methotrexate
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- mitomycin
- morphine
- moxifloxacin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- 0.9% NaCl
- octreotide
- ondansetron
- oxaliplatin
- paclitaxel
- palonosetron
- pamidronate
- phenylephrine
- potassium acetate
- potassium chloride
- procainamide
- prochlorperazine
- promethazine
- propranolol
- sargramostim
- sodium acetate
- sufentanil
- tacrolimus
- theophylline
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- trastuzumab
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- zidovudine
- zoledronic acid
Y-Site Incompatibility:
- acyclovir
- allopurinol
- aminophylline
- amiodarone
- amphotericin B deoxycholate
- amphotericin B liposomal
- ampicillin
- ampicillin/sulbactam
- azithromycin
- cefazolin
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftriaxone
- cefuroxime
- diazepam
- digoxin
- ertapenem
- foscarnet
- fosphenytoin
- ganciclovir
- gemtuzumab ozogamicin
- magnesium sulfate
- meropenem
- methohexital
- minocycline
- pantoprazole
- pemetrexed
- pentamidine
- pentobarbital
- phenobarbital
- phenytoin
- piperacillin/tazobactam
- potassium phosphates
- propofol
- rituximab
- sodium phosphates
- trimethoprim/sulfamethoxazole
- voriconazole

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy.
Instruct patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other Rx, OTC, or herbal products.
Instruct patient to notify health care provider promptly if fever; sore throat; signs of infection; bleeding gums; bruising; petechiae; blood in stools, urine, or emesis; ↑ fatigue; dyspnea; or orthostatic hypotension occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor and to avoid falls. Caution patient not to drink alcoholic beverages or take medication containing aspirin or NSAIDs, because these may precipitate gastric bleeding.
Instruct patient to report pain at injection site immediately.
Instruct patient to inspect oral mucosa for erythema and ulceration. If ulceration occurs, advise patient to use sponge brush, rinse mouth with water after eating and drinking, and confer with health care provider if mouth pain interferes with eating. Pain may require treatment with opioid analgesics. The risk of developing stomatitis is greatest 5–10 days after a dose; usual duration is 3–7 days.
Instruct patient to notify health care provider immediately if irregular heartbeat, shortness of breath, swelling of lower extremities, or skin irritation (swelling, pain, or redness of feet or hands) occurs.
Discuss the possibility of hair loss with patient. Explore methods of coping. Regrowth usually occurs 2–3 mo after discontinuation of therapy.
Instruct patient not to receive any vaccinations without advice of health care provider.
Inform patient that medication may cause urine to appear red for 1–2 days.
Instruct patient to notify health care provider if skin irritation occurs at site of previous radiation therapy.
Advise family and/or caregivers to take precautions (i.e., latex gloves) in handling body fluids for >5 days post-treatment.
Inform patient that doxorubicin may ↑ risk of developing secondary cancers.
Emphasize the need for periodic lab tests to monitor for side effects.
Rep: May cause fetal harm. Advise women of reproductive potential to use effective contraception during therapy and for 6 mo after last dose and to avoid breastfeeding during therapy and for 10 days–6 wk after last dose. Advise men with female partners of reproductive potential to use effective contraception during therapy and for 3–6 mo after last dose of doxorubicin. A pregnancy registry is available for all cancers diagnosed during pregnancy at Cooper Health (877-635-4499). Inform patient before initiating therapy that this medication may cause irreversible gonadal suppression, irreversible amenorrhea, or early menopause.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆