Table 3.
Antineoplastic treatment side effects, their pharmacological management and clinical considerations
| Cancer Treatment-Related Symptoms | Commonly Prescribed Medication | Medication Side Effects | Interaction Considerations |
|---|---|---|---|
| Nausea/Vomiting | Serotonin Receptor Antagonists • Ondansetron (Zofran) • Granisetron (Kytril) |
Blurred vision GI dysfunction Bradycardia Respiratory depression with risk of distress Sedation |
Contraindicated with apomorphine, a dopamine agonist used in the treatment of Parkinson’s disease. Risk of prolonged QT interval and reduced heart rate, may exacerbate CHF. |
| Corticosteroids λ • Dexamethasone • Methylprednisolone (Medrol) |
Tachycardia Fluid retention Mood disturbances Osteoporosis Muscle weakness Risk for bleeding Electrolyte imbalance Immune suppression |
May interfere with HTN medications leading to elevation in blood pressure. May interfere with DM blood glucose management leading to high levels of blood glucose and difficulty controlling glucose levels. Risk of bleeds is elevated with the use of anticoagulant therapies. May worsen delirium in older adults. |
|
| Neurokinin-1 (NK-1) Receptor Antagonist (substance p) • Aprepitant (Emend) |
Infertility Dizziness Liver dysfunction Diarrhea |
May reduce the effectiveness of antipsychotic drugs. May disrupt liver function and interfere with liver metabolism of other medications. |
|
| NK1 Receptor Antagonist/Serotonin-3 Receptor Antagonist • Netupitant (Akynzeo) |
Dizziness Diarrhea Disruption of liver function with prolonged use Headache |
Contraindicated with apomorphine, a dopamine agonist used in the treatment of Parkinson’s disease, due to excessive lowering of blood pressure. | |
| Dopamine Receptor Antagonists • Metoclopramide λ* (Reglan) • Domperidone (Motilium) |
Depression Irritability Sexual dysfunction Sedation |
Contraindicated with the use of antipsychotics. Contraindicated in people with suspected bowel obstruction. May exacerbate symptoms in individuals with Parkinson’s disease. Corticosteroid use could enhance effect. |
|
| Benzodiazepines λ* • Clonazepam (Klonopin) • Alprazolam (Xanax) • Diazepam (Valium) • Lorazepam (Ativan) |
Sedation Difficulty concentrating Blurred vision Loss of coordination Altered liver function with prolonged use |
Opioid use can dangerously increase sedation and risk is high for suppressed respiration. Addiction risk. Increases the risk for elevated eye pressure in individuals with glaucoma. May cause cognitive impairment and increase fall risk in older adults. |
|
| Cannabinoids • Nabilone (Cesamet) • Dronabinol (Marinol) |
Euphoria Anxiety Drowsiness Fatigue |
Avoid driving or operating heavy machinery. May cause unpredictable changes in blood pressure and heart rate in individuals with existing heart disease. May exacerbate existing psychiatric disorders. May increase the risk for seizures in individuals with epilepsy. |
|
| Pain | NSAIDS* • Ibuprofen (Advil) • Naproxen (Aleve) |
Gastric irritation Risk for bleeding Decreased appetite Dizziness Drowsiness Edema |
May increase the risk of gastric bleeding in individuals on anticoagulant therapy. May reduce the effectiveness of diuretics. May reduce kidney function and decrease the elimination of drug compounds, keeping their concentration high in the blood. This is concerning for lithium, and methotrexate. May counteract the action of anti-hypertension drugs, leading to an increase in blood pressure. |
| Acetaminophen (Tylenol) | Anemia Thrombocytopenia Headache Nausea |
Metabolism may be disrupted by the liver’s need to metabolize other medications, such as Tegretol and Rifidin, reducing the effectiveness of Acetaminophen. Reduced effectiveness with the use of cholestyramine. May increase risk of bleeding with anticoagulant therapy. |
|
| Narcotic Opioid Analgesics λ* • Oxycodone (Oxycontin) • Hydrocodone (Vicodin) • Morphine • Fentanyl |
Itching Constipation Sedation Hallucinations Vomiting Abdominal pain Dry mouth |
Significant risk of respiratory depression and sedation with Serotonin Receptor Antagonists. MAO Inhibitors are contraindicated. Significant risk of CNS depression, respiratory depression, low blood pressure, and sedation with benzodiazepines. |
|
| Antidepressant SSRI λ* • Citalopram (Celexa) |
Risk for bleeds Sedation Loss of appetite Blurred vision Nausea |
MAO Inhibitors are contraindicated. May increase the risk for sedation with antihistamines, opioids, or benzodiazepines. May increase risk for bleeding with NSAIDS and anticoagulant therapies. May interfere with medical or laboratory tests possibly causing false results. |
|
| Corticosteroids λ • Dexamethasone • Methylprednisolone (Medrol) |
Tachycardia Fluid retention Mood disturbances Osteoporosis Muscle weakness Risk for bleeding Electrolyte imbalance Immune suppression |
May interfere with HTN medications leading to elevation in blood pressure. May interfere with DM blood glucose management leading to high levels of blood glucose and difficulty controlling glucose levels. Risk of bleeds is elevated with the use of anticoagulant therapies. |
|
| Anticonvulsants • Gabapentin (Neurotin) |
Hallucinations Sedation Dizziness Loss of coordination Tremor |
When used with antihistamines, antidepressants, muscle relaxants, and narcotics may cause marked drowsiness and increased sedation. | |
| Bisphosphonates • Zoledronic acid (Zometa) • Ibandronic acid (Boniva) • Letrozole (Femara) |
Dizziness Headache Flu-like symptoms |
Risk for osteonecrosis of the jaw with long term use. Risk for renal dysfunction with certain classes of antibiotics. Oral bisphosphonates may cause esophageal irritation and increase the risk for bleeds in individuals on NSAIDS or anticoagulant therapies. Diuretics may decrease effectiveness. |
|
| Cannabinoids • Nabilone (Cesamet) • Dronabinol (Marinol) |
Euphoria Anxiety Drowsiness Fatigue |
Avoid driving or operating heavy machinery. May cause unpredictable changes in blood pressure and heart rate in individuals with existing heart disease. May exacerbate existing psychiatric disorders. May increase the risk for seizures in individuals with epilepsy. |
|
| Constipation | Stool Softeners • Docusate (Colace) |
Stomach cramping Diarrhea Intestinal obstruction |
No significant drug interactions are reported; however, caution is needed to avoid diarrhea which may magnify the risk of dehydration in chemotherapeutically altered individuals. |
| Bone Fragility | Bisphosphonates • Zoledronic acid (Zometa) • Ibandronic acid (Boniva) • Letrozole (Femara) |
Dizziness Headache Flu-like symptoms |
Risk for osteonecrosis of the jaw with long term use. Risk for renal dysfunction with certain classes of antibiotics. Oral bisphosphonates may cause esophageal irritation and increase the risk for bleeds in individuals on NSAIDS or anticoagulant therapies. Diuretics may decrease effectiveness. |
| Calcitonin (Miacalcin) | Nausea/Vomiting Hot flashes Bone pain Headaches Nose bleeds (with nasal spray) |
May reduce lithium concentrations and decrease its effectiveness. | |
| Anemia | Iron Supplements | Nausea Constipation |
Oral bisphosphonates and Calcium supplements may inhibit uptake. |
| Hematopoietics • Epoetin Alpha (Epogen/Procrit) |
Body aches Malaise Fatigue |
May increase blood pressure necessitating adjustments to HTN medications. | |
| Neutropenia | Benzodiazepines λ* • Clonazepam (Klonopin) • Alprazolam (Xanax) • Diazepam (Valium) • Lorazepam (Ativan) |
Sedation Difficulty concentrating Blurred vision Loss of coordination Altered liver function with prolonged use. |
Use with opioids can dangerously increase sedation and risk is high for suppressed respiration. Addiction risk. Risk for increase in eye pressure in individuals with glaucoma. May cause cognitive impairment and increase fall risk in older adults. |
| Hematopoietics • Filgrastim (Neupogen) • Pegfilgrastim (Neulasta) |
Joint pain Bone pain Malaise Fatigue |
Closely monitor individuals with sickle cell and maintain hydration. | |
| Insomnia | Hypnotics* • Eszopiclone (Lunesta) • Zolpidem (Ambien) |
Dizziness Grogginess |
Use with opioids could dangerously enhance sedative effect. Risk for worsening depression. |
| Melatonin δ | Nausea/Vomiting Dizziness Angioedema Fatigue |
Contraindicated in individuals with sleep apnea. May increase levels of sedation with SSRI’s May increase the risk of bleeding with anticoagulant therapies. |
|
| Progestin δ • Megestrol acetate (Megace) |
Nausea/Vomiting Weight gain Mood changes Hot flashes |
May increase the risk for blood clots. Not indicated with aromatase inhibitors, or other estrogen modifying agents. |
|
| Anorexia/Cachexia | Cannabinoids • Nabilone (Cesamet) • Dronabinol (Marinol) |
Euphoria Anxiety Drowsiness Fatigue |
Avoid driving or operating heavy machinery. May cause unpredictable changes in blood pressure and heart rate in individuals with existing heart disease. May exacerbate existing psychiatric disorders. May increase the risk for seizures in individuals with epilepsy. |
| Testosterone δ (Androgel, Depo-testosterone, Testim) |
Fatigue Insomnia Aggression Increased PSA (in men) Hypogonadism |
May interact with anticoagulation therapies causing an elevated risk for bleeding. May decrease blood glucose, in individuals with DM. Insulin requirements may become variable. |
|
| Progestin δ* • Megestrol acetate (Megace) |
Nausea/Vomiting Weight gain Mood changes Hot flashes |
May increase the risk for blood clots. Not indicated with aromatase inhibitors, or other estrogen modifying agents. |
|
| Benzodiazepines λ* • Clonazepam (Klonopin) • Alprazolam (Xanax) • Diazepam (Valium) • Lorazepam (Ativan) |
Sedation Difficulty concentrating Blurred vision Loss of coordination Altered liver function with prolonged use. |
Use with opioids can dangerously increase sedation and risk is high for suppressed respiration. Addiction risk. Risk for increase in eye pressure in individuals with glaucoma. May cause cognitive impairment and increase fall risk in older adults. |
|
| Antidepressant • Mirtazapine (Remeron) |
Dizziness Drowsiness Lightheadedness Increased appetite Constipation |
Contraindicated with MAO inhibitors. May increase the risk of serotonin syndrome if taken with other drugs that increase serotonin (SSRIs). May lead to marked drowsiness when taken with other sedative medications or narcotic medications. |
|
| Anxiety/Depression | Tricyclic Antidepressant • Amitriptyline (Elavil) • Desipramine (Norpramin) |
Weight gain Constipation Drowsiness Fatigue |
When used with opioid pain medication magnifies effects. Contraindicated in individuals on MAO Inhibitors and those on anticholinergics. |
| Aminoketone Antidepressant • Bupropion (Wellbutrin) |
Weight loss Sweating Tinnitus Dizziness Muscle pain Tachycardia Insomnia Constipation |
May counteract anti-convulsants and increase the risk for seizures. May increase risk for seizures with benzodiazepines. Contraindicated with MAO inhibitors due to risk of severe reactions including uncontrolled HTN, hallucinations and paranoid feelings. Use with protease inhibitors, such as Ritonavir for HIV-related infection, may significantly reduce the effectiveness of Wellbutrin. |
|
| MAO Inhibitors • Rasagiline (Azilect) • Phenelzine (Nardil) • Isocarboxazid (Marplan) |
Orthostasis Weakness Dizziness Drowsiness Fatigue Agitation Changes in mood or behavior Weight gain Sexual dysfunction |
Contraindicated for use with other antidepressants, opioids, and other serotonin antagonists as there is high risk for confusion, high blood pressure, hyperactivity, coma and death. May interact with anti-convulsants. May cause acute hypertension when used with antihistamines. |
|
| Serotonin-norepinephrine reuptake inhibitor (SNRI) • Duloxetine (Cymbalta) |
Nausea Dry mouth Insomnia Fatigue Constipation Increased blood pressure |
Contraindicated with use of MAO Inhibitors and Tricyclic Antidepressants as it may lead to fatal reactions including high body temperature, muscle rigidity, rapid fluctuations of heart rate and blood pressure. Use with an SSRI may reduce liver metabolism of SNRI, increasing blood levels and risking adverse effects. May increase risk for bleeding with NSAIDs and anticoagulant therapies. May cause stomach and GI irritation reactions with Prilosec due to early dissolution. DM may increase the risk of stomach irritation due to slow gastric emptying. |
|
| Selective Serotonin Reuptake Inhibitors (SSRI) λ* • Citalopram (Celexa) • Fluoxetine (Prozac) • Praoxetine (Paxil) |
Dry mouth Vision changes Depression Bleeding risk Prolonged QT interval Seizures |
MAO Inhibitors are contraindicated. May have severe side effects with antipsychotics. NSAIDS may increase the risk for bleeding with anticoagulant therapies. |
|
| Dyspnea | Supplemental Oxygen | Dizziness Lightheadedness |
Risk for falls |
| Sensory Neuropathy (Diabetic and CIPN) | Anticonvulsants • Gabapentin (Neurontin) • Carbamazepine* (Tegretol) |
Hallucinations Sedation Dizziness Loss of coordination Tremor |
Use with antihistamines, antidepressants, muscle relaxants, and narcotics may cause marked drowsiness and increased sedation. May contribute to extremity swelling when used with diuretics. |
| Serotonin-norepinephrine reuptake inhibitor (SNRI) • Duloxetine (Cymbalta) |
Nausea Dry mouth Insomnia Fatigue Constipation Increased blood pressure |
Contraindicated with use of MAO Inhibitors and Tricyclic Antidepressants as it may lead to fatal reactions including high body temperature, muscle rigidity, rapid fluctuations of heart rate and blood pressure. Use with an SSRI may reduce liver metabolism of SNRI, increasing blood levels and risking adverse effects. May increase risk for bleeding with NSAIDs and anticoagulant therapies. May cause stomach and GI irritation reactions with Prilosec due to early dissolution. DM may increase the risk of stomach irritation due to slow gastric emptying. |
|
| Diarrhea | Octreotide (Sandostatin) | Stomach pain Nausea/Vomiting Gas Abnormal stool Constipation Fluctuating blood glucose Headache Gallbladder and pancreas problems |
Interferes with nutrient absorption and may decrease absorption of oral medications. May reduce the effectiveness of oral diabetic medications, beta blockers, calcium channel blockers, and may disrupt fluid and electrolyte balance. |
| Opium Tincture | Sedation Constipation Nausea/vomiting Itching |
Opium tincture contains morphine and is contraindicated with MAO inhibitors as it may cause high blood pressure, hyperactivity, and death. |
Abbreviations: GI – Gastrointestinal, QT – on EKG, the interval of time between start of the Q wave and end of the T wave associated with arrhythmias, CHF – Congestive Heart Failure, HTN – Hypertension, DM – Diabetes Mellitus, MAO – Monoamine Oxidase, CNS – Central Nervous System, NSAIDS – Non-steroidal Anti-inflammatory Drugs, SSRI – Selective Serotonin Reuptake Inhibitor, PSA – prostate specific antigen
*
Classified as Potentially Inappropriate Medication by Beer’s Criteria
λ
Identified by NCNN as a Medication of Concern for Older Adults
δ
Hormonal