Gemcitabine (Gemzar®)

Gemcitabine is a type of medication called an “antimetabolite.” Antimetabolites affect the DNA of cancer cells, leading to the slowing or stopping of cancer. Since cancer cells divide faster and with less error-correcting than healthy cells, cancer cells are more sensitive to this damage than normal cells.

How to Take Gemcitabine

Gemcitabine is given by intravenous (IV, into a vein) infusion. The dosage and scheduledepends on your size and type of cancer. It can be given alone or with other medications or therapies, such as radiation.

When given at the same time as radiation, there can be more side effects. At least one week should pass between the start or end of radiation therapy and a full gemcitabine dose. Please make sure all your healthcare providers are aware of your treatment history with gemcitabine and/or radiation.

Patients may have gemcitabine toxicity if the medication is infused for more than 60 minutes or if the medication is given more than once a week. Side effects of toxicity can include severe flu-like symptoms, fever, low blood pressure, and low blood counts. If you have any of these side effects, let your provider know. You may be told to take medication to manage these side effects and you will be closely monitored for toxicity.

Possible Side Effects of Gemcitabine

There are a number of things you can do to manage the side effects of gemcitabine. Talk to your care team about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:

Nausea and/or Vomiting

Talk to your oncology care team so they can prescribe medications to help you manage nausea and vomiting. In addition, dietary changes may help. Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic foods (lemons, tomatoes, oranges). Try saltines, or ginger ale to lessen symptoms.

Call your oncology care team if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.

Liver Toxicity

This medication can cause liver toxicity, which your provider will monitor for using blood tests called liver function tests. Tell your healthcare provider if you notice yellowing of the skin or eyes, if your urine appears dark or brown, or if you have pain in your abdomen (belly), as these can be signs of liver toxicity.

Low Red Blood Cell Count (Anemia)

Your red blood cells are responsible for carrying oxygen to the tissues in your body. When the red cell count is low, you may feel tired or weak. You should let your oncology care team know if you experience any shortness of breath, difficulty breathing, or pain in your chest. If the count gets too low, you may receive a blood transfusion.

Low White Blood Cell Count (Leukopenia or Neutropenia)

White blood cells (WBC) are important for fighting infection. While receiving treatment, your WBC count can drop, putting you at a higher risk of getting an infection. You should let your doctor or nurse know right away if you have a fever (temperature greater than 100.4°F/38°C), sore throat or cold, shortness of breath, cough, burning with urination, or a sore that doesn't heal.

Tips to preventing infection:

• Washing hands, both yours and your visitors, is the best way to prevent the spread of infection.
• Avoid large crowds and people who are sick (i.e.: those who have a cold, fever, or cough or live with someone with these symptoms).
• When working in your yard, wear protective clothing including long pants and gloves.
• Do not handle pet waste.
• Keep all cuts or scratches clean.
• Shower or bathe daily and perform frequent mouth care.
• Do not cut cuticles or ingrown nails. You may wear nail polish, but not fake nails.
• Ask your oncology care team before scheduling dental appointments or procedures.
• Ask your oncology care team before you, or someone you live with has any vaccinations.

Low Platelet Count (Thrombocytopenia)

Platelets help your blood clot, so when the count is low you are at a higher risk of bleeding. Let your oncology care team know if you have any excess bruising or bleeding, including nose bleeds, bleeding gums, or blood in your urine or stool. If the platelet count becomes too low, you may receive a transfusion of platelets.

• Do not use a razor (an electric razor is fine).
• Avoid contact sports and activities that can result in injury or bleeding.
• Do not take aspirin (salicylic acid), non-steroidal, anti-inflammatory medications (NSAIDs) such as Motrin/Advil (ibuprofen), Aleve (naproxen), Celebrex (celecoxib), etc. as these can all increase the risk of bleeding. Please consult with your healthcare team regarding the use of these agents and all over-the-counter medications/supplements while on therapy.
• Do not floss or use toothpicks and use a soft-bristle toothbrush to brush your teeth.

Rash

Some patients may develop a rash, dry skin, or itching. This rash can become severe, so be sure to let your care team know if you develop a rash. Use an alcohol-free moisturizer on your skin and lips; avoid moisturizers with perfumes or scents. Your doctor or nurse can recommend a topical medication if itching is bothersome. If your skin does crack or bleed, be sure to keep the area clean to avoid infection. Be sure to notify your healthcare provider of any rash that develops, as this can be a reaction. They can give you more tips on caring for your skin.

Fluid Retention / Swelling

Some patients may develop fluid retention, which can cause swelling in the feet and/or ankles or face or gain weight. Fluid can also build up in the lungs and cause you to feel short of breath. Notify your healthcare team if you have any swelling, unexpected weight gain, or shortness of breath.

Important but Less Common Side Effects

• Lung Problems: This medication may cause pulmonary fibrosis (a scarring and stiffening of the lung tissue), interstitial pneumonitis, pulmonary edema, or acute respiratory distress syndrome (ARDS). These problems can develop during treatment or up to two weeks after treatment is completed. Call your physician right away if you have shortness of breath, cough, wheezing, or difficulty breathing.
• Posterior Reversible Encephalopathy Syndrome (PRES): PRES is a rare, reversible neurological disorder that can occur with the use of gemcitabine. Symptoms of PRES include seizure, high blood pressure, headache, confusion, fatigue, confusion, any changes in your vision, or difficulty walking or thinking. If you experience any of these symptoms, contact your care team or go to the emergency room immediately.
• Hemolytic Uremic Syndrome (HUS): This medication can also cause a rare complication called hemolytic uremic syndrome (HUS). Your healthcare team will monitor you for symptoms of HUS throughout your treatment. Notify your healthcare team if you notice changes in the color or amount of your urine or if you develop bleeding or increased bruising.
• Capillary Leak Syndrome: Capillary leak syndrome is a condition in which blood and components of blood leak out of vessels and into body cavities and muscles. The movement of this fluid out of the vessels can cause hypotension (low blood pressure) and organ failure. Signs and symptoms of capillary leak syndrome include a sudden drop in blood pressure, weakness, fatigue, sudden swelling of the arms, legs, or other parts of the body, nausea, and lightheadedness. If you are having any of these symptoms notify your infusion nurse or provider immediately.
• Radiation Recall: Radiation recall is when the administration of a medication causes a skin reaction that looks like a sunburn (redness, swelling, soreness, peeling skin) in areas where radiation was previously given. Notify your oncology team if you notice this side effect. Treatment can include topical steroid ointments and a delay in your next chemotherapy dose.
• Severe cutaneous adverse reactions (SCARs), including Stevens Johnson Syndrome and toxic
  epidermal necrolysis (TEN): This medication can cause rare, but serious allergic reactions that affect the skin and mucous membranes. These skin reactions often start as a rash or painful blister and can progress (get worse) to serious damage to the skin and, in some cases, death. If you notice a new rash, have a fever and flu-like symptoms, lesions on mucuous membranes, or swollen lymph nodes, call your care team right away.

Reproductive Concerns

This medication may affect your reproductive system, resulting in the menstrual cycle or sperm production becoming irregular or stopping permanently. Women may experience menopausal effects including hot flashes and vaginal dryness. In addition, the desire for sex may decrease during treatment. You may want to consider sperm banking or egg harvesting if you may wish to have a child in the future. Discuss these options with your oncology team.

Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication. For women, effective birth control is necessary during treatment and for 6 months after your last dose. For men, effective birth control is necessary during treatment and for 3 months after your last dose.Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should not breastfeed while receiving this medication or for 1 week after your final dose.