Doxorubicin (Adriamycin®, Rubex®)

Anthracyclines work by interrupting the copying of DNA, which is necessary for cancer cell growth. This causes the cancer cells to die, slowing or stopping tumor growth. Doxorubicin interferes with the growth of cancer cells and slows their spread in the body by inhibiting DNA synthesis and causing the production of harmful free radicals.

How to Take Doxorubicin

Doxorubicin is given through an intravenous (IV, into a vein) infusion or injection. It can be given alone or with other drugs. The dosage and schedule are determined by your height and weight, type of cancer, and how the medication is given.

Even when carefully and correctly administered by trained personnel, this drug may cause a feeling of burning and pain. There is a risk that this medication may leak out of the vein at the injection site, leading to tissue damage that can be severe. If the area of injection becomes red, swollen, or painful at any time during or after the injection, tell your care team right away. Do not apply anything to the site unless told to do so by your care team.

This medication is red. Your urine may look orange or reddish in color for 1-2 days after the infusion. This is not blood. This is expected as the medication is cleared from your body. If the red urine lasts more than two days or if you have other urinary symptoms, such as frequency or painful urination, call your healthcare provider.

The blood levels and effectiveness of this medication can be affected by certain foods and medications, so they should be avoided. These include verapamil, phenytoin, fluconazole, voriconazole, St. John’s wort, phenobarbital, trastuzumab, dexrazoxane, and 6-mercaptopurine, among others. Be sure to tell your healthcare provider about all medications and supplements you take.

Possible Side Effects of Doxorubicin

There are a number of things you can do to manage the side effects of doxorubicin. 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:

Heart Problems

In rare cases, the heart muscle can be damaged by this medication, causing heart failure and cardiomyopathy. This heart damage can occur during therapy or many months to years after treatment. The risk is highest at higher doses, in patients who receive other cardio-toxic medications, radiation to the chest area, and in children. There is a maximum lifetime dose that you can receive of this medication. Your provider may order tests to check your heart function before you begin treatment or if any symptoms arise.

If you have shortness of breath, new or worsening cough, ankle swelling, chest pain, rapid or irregular heartbeats, call your provider right away, or call 911.

Secondary Cancers

A secondary cancer is one that develops as a result of cancer treatment for another cancer. This is quite rare, but you should be aware of the risk. In most cases, a secondary cancer related to chemotherapy is a blood cancer (leukemia, lymphoma). This can occur years after treatment. This is most often associated with repeated treatments or high doses. Your provider will monitor your labs closely. You may need a complete blood count with differential checked each year by your healthcare provider if you received high-risk therapies.

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 or 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 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 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.

Loss or Thinning of Scalp and Body Hair (Alopecia)

Your hair may become thin, brittle, or may fall out. This typically begins two to three weeks after treatment starts. This hair loss can be all body hair, including pubic, underarm, legs/arms, eyelashes, and nose hairs. The use of scarves, wigs, hats, and hairpieces may help. Hair generally starts to regrow soon after treatment is completed. Remember your hair helps keep you warm in cold weather, so a hat is particularly important in cold weather or to protect you from the sun.

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.

Diarrhea

Your oncology care team can recommend medications to relieve diarrhea. Also, try eating low-fiber, bland foods, such as white rice and boiled or baked chicken. Avoid raw fruits, vegetables, whole-grain breads, cereals, and seeds. Soluble fiber is found in some foods and absorbs fluid, which can help relieve diarrhea. Foods high in soluble fiber include applesauce, bananas (ripe), canned fruit, orange sections, boiled potatoes, white rice, products made with white flour, oatmeal, cream of rice, cream of wheat, and farina. Drink 8-10 glasses of non-alcoholic, un-caffeinated fluid a day to prevent dehydration.

Mouth Ulcers (Mucositis)

Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Notify your oncology care team if your mouth, tongue, inside of your cheek or throat becomes white, ulcerated or painful. Performing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your doctor or nurse can recommend a pain reliever.

• Brush with a soft-bristle toothbrush or cotton swab twice a day.
• Avoid mouthwashes that contain alcohol. A baking soda and/or salt with warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon of salt in an eight-ounce glass of warm water) is recommended 4 times daily.
• If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on sugarless hard candy.
• Avoid smoking and chewing tobacco, drinking alcoholic beverages, and citrus juices.

Nail and Skin Changes

Your fingernails/toenails may become dark, brittle, or fall off. You may notice dry skin or changes in the color or tone of your skin. Your skin will be more sensitive to the sun, which can result in severe sunburn or rash. Sun sensitivity can last even after chemotherapy is completed. Avoid the sun between 10-2 pm, when it is strongest. Wear sunscreen (at least SPF 15) every day, wear sunglasses and long sleeves/pants to protect your skin. Keep your fingernails and toenails clean and dry. You may use nail polish, but do not wear fake nails. If any nails fall off, clean the nail bed well with soap and water and cover with a bandaid.

Important but Less Common Side Effects

• 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.
• Tumor Lysis Syndrome: If there are a large amount of tumor cells in your body prior to treatment, you are at risk for tumor lysis syndrome. This happens when the tumor cells die too quickly and their waste overwhelms the body. You may be given a medication (allopurinol) and IV fluids to help prevent this. If you experience nausea, vomiting, diarrhea or become lethargic (drowsy, sluggish), notify your oncology team right away. TLS can affect your kidney function. Your provider will monitor your kidney function with blood work. Notify your provider if you have little or no urine output.

Sexual & Reproductive Concerns

This drug 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.

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. Women should use effective birth control during and for 6 months after treatment, even if your menstrual cycle stops. Men should use condoms during and for three months after treatment even if believe you are not producing sperm. If you have a pregnant partner, you should use condoms during and for 10 days after the last dose. 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. You should not breastfeed while receiving this medication.