C.S. is a 61 yo male who was hospitalized a few days ago and it was found the patient has B Cell Non-Hodgkin’s Lymphoma. The patient is going to be put on R-CHOP therapy consisting of rituximab, doxorubicin, vincristine, cyclophosphamide, and prednisone. This patient has a past medical history of hyperlipidemia and hypertension. C.S. requires counseling of his new chemotherapy regimen prior to administration. 

Allergies: Codeine

Na: 138 meq/L     BP: 115/75 mm Hg

K: 4.3 meq/L      HR: 80 beats per minute

SCr: 0.9 mg/dL

Corrected Ca: 8.9 mg/dL

Mg: 1.9 meq/L

Medications:

Tylenol 650 mg PO prior to chemotherapy

Diphenhydramine 50 mg PO prior to chemotherapy

Zofran 24mg PO X 1 prior to chemotherapy

Compazine 10 mg PO q6h PRN nausea

Ativan 1 mg PO q6h PRN nausea/anxiety 

Which of the following statements are correct counseling points for CS's chemotherapy? Select all that apply.

A. Doxorubicin has the potential to turn bodily excretions such as urine, sweat, and tears a red color. 

B. Cyclophosphamide may cause hemorrhagic cystitis which can be exhibited as painful urination and bloody urine. 

C. Vincristine may cause heart failure in cumulative doses. Therefore an echocardiogram will be done at baseline and periodically to monitor function.  

D. Rituximab can often cause extravasation reactions  which can be exhibited as swelling, pain, and burning at the sight of injection.

E. The first rituximab infusion is typically given over a longer period of time to decrease the risk of a serious infusion reaction.

Brand/Generics Covered: Doxorubicin (Adriamycin), Vincristine (Oncovin), Cyclophosphamide (Cytoxan), Rituximab (Rituxan), Acetaminophen (Tylenol), Ondansetron (Zofran), Prochlorperazine (Compazine), Lorazepam (Ativan), 

Rationale:

While not all pharmacists will get to counsel on inpatient chemotherapy regimens, it is important to understand the basics of chemotherapy counseling, especially adverse effects and supportive care.  It is important for patients to have appropriate knowledge and expectations of their regimen, including efficacy and adverse effects. Pharmacists often help plan and/or manage supportive care regimens, such as pre-medicating patients for infusions or treating for chemo-induced nausea and vomiting. This question primarily focused on recognizing important side effects for doxorubicin, rituximab, cyclophosphamide, and vincristine. 

Answer A is correct because doxorubicin does cause bodily secretions to turn a red color and it is important for patients to know this prior to receiving therapy. Many drugs cause discoloration of body fluids such as rifampin and pyridium so counseling could help alleviate anxiety/fear when these effects occur. 

Answer B is correct because cyclophosphamide does potentially cause hemorrhagic cystitis and it is important for patients to recognize this as a side effect. Prevention of this adverse effect through the administration of Mesna, a compound that binds to acrolein which is the active metabolite of cyclophosphamide causing the hemorrhagic cystitis, is often done. Ifosfamide, a similar compound to cyclophosphamide, can also cause this adverse effect. Patients should receive adequate fluid intake as well to help prevent this side effect.  

Answer C is incorrect because vincristine does not cause cardiomyopathy with cumulative doses. Doxorubicin does however cause cardiomyopathy and can do so with cumulative doses (550mg/m² and greater is highest risk) so an echocardiogram is often performed at baseline. Vincristine can cause neuromuscular side effects with the most common being peripheral neuropathy. Vincristine should NEVER be given intrathecally as this can be fatal or at a minimum cause painful ascending paralysis. 

Answer D is incorrect because rituximab is actually not likely to cause extravasation. However, doxorubicin and vincristine do have a risk of causing extravasation as these are both vesicants. 

Answer E is correct because rituximab does have risk of serious and fatal infusion reactions, most associated with the first infusion. The acetaminophen and diphenhydramine listed above are often given prior to rituximab therapy to lessen infusion reactions. 

Correct Answers: A, B, E

NAPLEX Core Competencies covered:

2.2 (Brand/generic), 3.5 (Drug route of administration, dosage forms, or delivery systems), 3.6 (Drug Precautions), 3.7 (Adverse drug effects, toxicology, or overdose

Sources: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/050467s078,050629s030lbl.pdf - doxorubicin Package insert

https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103705s5311lbl.pdf - rituximab package insert

https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/071484s042lbl.pdf - vincristine package insert