Chemo toxicity classics

◆Cardiotoxicity

• •Doxorubicin (anthracycline): dose-dependent cardiomyopathy; monitor with ECHO; dexrazoxane for prevention
• •Trastuzumab: reversible cardiomyopathy (often); avoid concurrent with anthracycline
• •5-FU / capecitabine: coronary vasospasm → angina/MI; hold and use diltiazem

◆Pulmonary toxicity

• •Bleomycin: pulmonary fibrosis (dose-related); monitor DLCO; AVOID supplemental O2 unless needed (potentiates damage)
• •Methotrexate: hypersensitivity pneumonitis (acute or chronic)

◆Nephrotoxicity

• •Cisplatin: nephrotoxic + ototoxic + peripheral neuropathy + nausea — hydrate aggressively, give amifostine
• •Methotrexate: AKI (crystal formation in acid urine) — give leucovorin + alkalinize urine
• •Ifosfamide: hemorrhagic cystitis — give MESNA (binds acrolein); also neurotoxic
• •Cyclophosphamide: hemorrhagic cystitis — MESNA

◆Neurotoxicity

• •Vincristine: peripheral neuropathy (axonal), constipation — never give intrathecally (fatal)
• •Cisplatin: peripheral neuropathy, ototoxicity
• •Methotrexate intrathecal: aseptic meningitis, leukoencephalopathy
• •Ifosfamide: encephalopathy — methylene blue or thiamine

◆Other classics

• •Tamoxifen: endometrial cancer risk, VTE; hot flashes; agonist effects on bone (protective)
• •Aromatase inhibitors (anastrozole): osteoporosis, no endometrial risk (postmenopausal only)
• •Imatinib (CML): GI, fluid retention, hepatotoxicity
• •Checkpoint inhibitors (nivolumab, pembrolizumab): immune-mediated colitis, pneumonitis, hepatitis, endocrine (hypophysitis, thyroid, T1DM) — treat with steroids
• •Rituximab: hepatitis B reactivation (screen first), PML, infusion reactions
• •G-CSF (filgrastim): bone pain (loratadine), Sweet syndrome, splenomegaly

Drug ↔ toxicity classics