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    Doxorubicin

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    Jul.13.2024

    DOXOrubicin

    Indications/Dosage

    Labeled

    • acute lymphocytic leukemia (ALL)
    • acute myelogenous leukemia (AML)
    • bladder cancer
    • breast cancer
    • Ewing's sarcoma
    • gastric cancer
    • Hodgkin lymphoma
    • neuroblastoma
    • non-Hodgkin's lymphoma (NHL)
    • osteogenic sarcoma
    • ovarian cancer
    • small cell lung cancer (SCLC)
    • soft-tissue sarcoma
    • thyroid cancer
    • Wilms' tumor

    Off-Label

    • biliary tract cancer
    • endometrial cancer
    • hepatocellular cancer
    • Kaposi's sarcoma
    • malignant melanoma
    • multiple myeloma
    • peripheral T-cell lymphoma (PTCL)
    • rhabdomyosarcoma
    • systemic anaplastic large-cell lymphoma
    • thymoma
    † Off-label indication

    For the treatment of acute lymphocytic leukemia (ALL)

    Intravenous dosage

    Adults, Adolescents, Children, and Infants

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of acute myelogenous leukemia (AML)

    Intravenous dosage

    Adults, Adolescents, Children, and Infants

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of bladder cancer

    for the treatment of metastatic transitional cell bladder cancer

    Intravenous dosage

    Adults

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628] Doxorubicin 30 mg/m2 slow IV push on day 2 in combination with vinblastine (3 mg/m2 IV on days 2, 15, and 22), methotrexate (30 mg/m2 slow IV push on days 1, 15, and 22), and cisplatin (70 mg/m2 IV on day 2) repeated every 28 days for up to a maximum of 6 cycles (MVAC regimen) has been evaluated in clinical trials.[18793] [36131]

    for the first-line treatment of advanced or metastatic bladder cancer in combination with vinblastine, cisplatin, and methotrexate

    Intravenous dosage

    Adults

    30 mg/m2 IV on day 2 in combination with methotrexate (30 mg/m2 IV on days 1, 15, and 22), cisplatin 70 mg/m2 IV on day 2, and vinblastine (3 mg/m2 IV on days 2, 15, and 22) repeated every 28 days (MVAC regimen) for up to 6 cycles has been evaluated in patients with advanced or metastatic transitional cell carcinoma of the bladder in a long-term analysis of a multicenter, randomized, phase III trial.[44748] Doxorubicin 30 mg/m2 IV on day 1 plus methotrexate (30 mg/m2 IV on days 1, 15, and 22), cisplatin (70 mg/m2 IV on day 1), and vinblastine (3 mg/m2 IV on days 1, 15, and 22) repeated every 4 weeks was studied in another randomized, phase III trial. All patients in this study received granulocyte colony-stimulating factor (G-CSF) following chemotherapy.[44750] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of rapidly recurrent (stage Ta or T1) or in situ transitional cell bladder cancer

    Intravesical dosage†

    Adults

    50 to 150 mg in 150 mL of normal saline instilled into the bladder. The solution is then retained for at least 30 minutes. Responses of up to 90% have been seen with doses of 50 to 150 mg; however, the duration of response is short. In a comparison trial of intravesical doxorubicin and BCG, the disease-free survival of BCG was significantly longer at 5 years than that of doxorubicin.[25969] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the neoadjuvant treatment of bladder cancer

    Intravenous dosage

    Adults

    30 mg/m2 slow IV push on day 2 in combination with vinblastine (3 mg/m2 IV on days 2, 15, and 22), methotrexate (30 mg/m2 slow IV push on days 1, 15, and 22), and cisplatin (70 mg/m2 IV on day 2); give every 28 days for 3 cycles (MVAC regimen).[18788] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of breast cancer

    for the neoadjuvant treatment of hormone receptor (HR)-negative, HER2-negative (triple-negative) breast cancer, in combination with cyclophosphamide (dose-dense AC) and atezolizumab, after completion of neoadjuvant nab-paclitaxel and atezolizumab

    Intravenous dosage

    Adults

    60 mg/m2 IV in combination with cyclophosphamide (600 mg/m2 IV) every 2 weeks (dose-dense AC) and atezolizumab (840 mg IV every 2 weeks) for 8 weeks, followed by surgery. Begin dose-dense AC plus atezolizumab after completion of neoadjuvant nab-paclitaxel (125 mg/m2 once weekly) plus atezolizumab (840 mg IV every 2 weeks) for 12 weeks. After surgery, continue atezolizumab 1,200 mg IV every 3 weeks for 11 cycles to complete approximately 12 months of atezolizumab therapy. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. In a randomized, phase 3 clinical trial (IMpassion031), neoadjuvant treatment with atezolizumab plus sequential nab-paclitaxel and AC chemotherapy significantly improved pCR compared with neoadjuvant placebo plus sequential nab-paclitaxel and AC chemotherapy in patients with early TNBC, regardless of PD-L1 status.[66038]

    for the neoadjuvant treatment of high-risk, early-stage hormone receptor (HR)-negative, HER2-negative (triple-negative) breast cancer, in combination with cyclophosphamide and pembrolizumab, after completion of neoadjuvant paclitaxel/carboplatin/pembrolizumab

    Intravenous dosage

    Adults

    60 mg/m2 IV every 3 weeks in combination with cyclophosphamide (600 mg/m2 IV every 3 weeks) [AC] for 4 cycles, followed by surgery; administer AC in combination with pembrolizumab (200 mg IV every 3 weeks OR 400 mg IV every 6 weeks). Begin AC plus pembrolizumab after the completion of 12 weeks of neoadjuvant carboplatin (AUC 5 IV on day 1 every 3 weeks), paclitaxel (80 mg/m2 IV once weekly), and pembrolizumab (200 mg IV every 3 weeks OR 400 mg IV every 6 weeks); alternatively, carboplatin may be dosed once weekly at an AUC of 1.5 IV for 12 weeks. Administer pembrolizumab prior to chemotherapy when given on the same day. After surgery, administer pembrolizumab 200 mg IV every 3 weeks for up to 9 doses OR 400 mg IV repeated every 6 weeks for up to 5 doses or until disease progression or unacceptable toxicity. Do not administer adjuvant pembrolizumab monotherapy to patients with disease progression or unacceptable toxicity related to neoadjuvant treatment with pembrolizumab plus chemotherapy. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Patients with high-risk (tumor size more than 1 cm but up to and including 2 cm in diameter with nodal involvement; or tumor size more than 2 cm in diameter regardless of nodal involvement), early stage triple-negative breast cancer were randomized to neoadjuvant treatment with pembrolizumab or placebo in combination with carboplatin and paclitaxel, followed by anthracycline and cyclophosphamide in a phase 3 clinical trial (KEYNOTE-522); after definitive surgery, patients received adjuvant pembrolizumab or placebo. Treatment with pembrolizumab plus chemotherapy significantly improved the rate of pathologic complete response (pCR) (63% vs. 55.6%) compared with placebo plus chemotherapy. The median event-free survival (EFS) was not reached in either arm, although EFS at 18 months was 91.3% in patients who received pembrolizumab compared with 85.3% in those who received placebo (HR 0.63; 95% CI, 0.43 to 0.93); overall survival results are immature.[66036] [57889]

    as adjuvant therapy in women with axillary lymph node involvement following resection of primary breast cancer in combination with cyclophosphamide

    Intravenous dosage

    Adults

    60 mg/m2 as an IV bolus on day 1 repeated every 21 days for 4 cycles of therapy, in combination with cyclophosphamide. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Disease-free survival and overall survival were not significantly different in women with axillary lymph node-positive early breast cancer who received adjuvant doxorubicin hydrochloride-containing regimens (n = 2,157) compared with cyclophosphamide, methotrexate, and fluorouracil (CMF) (n = 1,353) in a meta-analysis of 6 trials conducted by the Early Breast Cancer Trialists Collaborative Group (EBCTCG).[61628] Additionally, a dose-dense regimen of doxorubicin 60 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV on day 1 repeated every 14 days with growth-factor support has been studied.[33122]

    for the treatment of metastatic breast cancer

    Intravenous dosage

    Adults

    60 mg/m2 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 mg/m2 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[61628]

    For the treatment of metastatic gastric cancer

    Intravenous dosage

    Adults

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of Hodgkin lymphoma

    for the treatment of Hodgkin lymphoma as part of the ABVD or MOPP/ABV regimens

    Intravenous dosage

    Adults, Adolescents, and Children

    25 mg/m2 IV on days 1 and 15 repeated every 28 days in combination with vinblastine, bleomycin, and dacarbazine (ABVD regimen).[40473] A variation of this regimen includes doxorubicin 35 mg/m2 IV on day 8 in combination with mechlorethamine, vincristine, procarbazine, prednisone, bleomycin, and vinblastine (MOPP/ABV hybrid regimen).[40471] [40472] [40473] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Interruption of therapy and/or a dosage reduction may be necessary in patients who develop toxicity or intolerable side effects. Cumulative doxorubicin doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of Hodgkin lymphoma as part of the Stanford V regimen

    Intravenous dosage

    Adults and Adolescents 15 years and older

    25 mg/m2 IV on weeks 1, 3, 5, 7, 9, and 11 in combination with mechlorethamine (6 mg/m2 IV on weeks 1, 5, and 9), vinblastine (6 mg/m2 IV on weeks 1, 3, 5, 7, 9, and 11), vincristine (1.4 mg/m2 [Max of 2 mg] IV on weeks 2, 4, 6, 8, 10, and 12), bleomycin (5 units/m2 IV on weeks 2, 4, 6, 8, 10, and 12), etoposide (60 mg/m2 per day IV on 2 consecutive days in weeks 3, 7, and 11), and prednisone (40 mg/m2 PO every other day for 10 weeks then tapered by 10 mg PO every other day between weeks 10 and 12). Total duration of Stanford V regimen is 12 weeks (three 4-week cycles).[40464] [40465] [36931] [40466] [40469] Doses of mechlorethamine, doxorubicin, vinblastine, and etoposide have been reduced to 65% if the absolute neutrophil count (ANC) is less than 1,000 cells/mm3 (treatment delayed if ANC is less than 500 cells/mm3). Prophylactic sulfamethoxazole-trimethoprim, acyclovir, and a H2-blocker were given throughout the treatment period.[40464] G-CSF has also been used to maintain dose intensity as needed after the first dose reduction.[40465] [40469] Alternative prophylactic medications have also been used.[36931] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Interruption of therapy and/or a dosage reduction may be necessary in patients who develop toxicity or intolerable side effects. Cumulative doxorubicin doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of Hodgkin lymphoma as part of the BEACOPP regimen

    Intravenous dosage

    Adults and Adolescents 15 years and older

    25 mg/m2 IV on day 1 in combination with bleomycin (10 units/m2 IV on day 8), etoposide (100 mg/m2/day IV on days 1, 2, and 3), cyclophosphamide (650 mg/m2 IV on day 1), vincristine (1.4 mg/m2 [Max of 2 mg] IV on day 8), procarbazine (100 mg/m2 per day PO on days 1 to 7), and prednisone (40 mg/m2 PO on days 1 to 14). Cycles are repeated every 21 days for up to 8 cycles. Filgrastim was administered beginning on day 8 of each cycle and continued until the leukocyte count returned to normal in some clinical trials.[12501] [40572] The escalated dose BEACOPP regimen includes doxorubicin 35 mg/m2 IV on day 1 in combination with bleomycin (10 units/m2 IV on day 8), etoposide (200 mg/m2 per day IV on days 1, 2, and 3), cyclophosphamide (1,200 mg/m2 IV on day 1), vincristine (1.4 mg/m2 [Max of 2 mg] IV on day 8), procarbazine (100 mg/m2 per day PO on days 1 to 7), and prednisone (40 mg/m2 PO on days 1 to 14). Cycles are repeated every 21 days for up to 8 cycles. Filgrastim was administered beginning on day 8 of each cycle and continued until the leukocyte count returned to normal in some clinical trials.[12501] [40572] The standard dose BEACOPP and escalated dose BEACOPP regimens have shown benefit for the treatment of advanced Hodgkin lymphoma in clinical trials.[12501] [40572] [40568] Escalated dose BEACOPP has shown a significantly better freedom from treatment failure at 10 years (82% vs. 70%, p < 0.0001) and overall survival at 10 years (86% vs. 80%, p = 0.0053) compared to standard dose BEACOPP.[49830] A regimen of 4 cycles of escalated dose BEACOPP followed by 4 cycles of standard dose BEACOPP has also been used in patients who achieve a complete response after the initial 4 cycles of escalated dose BEACOPP.[40568] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Interruption of therapy and/or a dosage reduction may be necessary in patients who develop toxicity or intolerable side effects. Cumulative doxorubicin doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of previously untreated advanced classical Hodgkin lymphoma, in combination with brentuximab vedotin, vinblastine, and dacarbazine

    Intravenous dosage

    Adults

    25 mg/m2 IV in combination with brentuximab vedotin 1.2 mg/kg IV (not to exceed 120 mg/dose), vinblastine 6 mg/m2 IV, and dacarbazine 375 mg/m2 IV each given on days 1 and 15 repeated every 28 days for up to 6 cycles was evaluated in a randomized, phase III trial. Patients should receive primary prophylaxis with a granulocyte colony-stimulating factor due to the high incidence of febrile neutropenia.[62863] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Interruption of therapy and/or a dosage reduction may be necessary in patients who develop toxicity or intolerable side effects. Cumulative doxorubicin doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of previously untreated, high-risk classical Hodgkin lymphoma, in combination with brentuximab vedotin, vincristine, etoposide, prednisone, and cyclophosphamide

    Intravenous dosage

    Children 2 years and older and Adolescents

    25 mg/m2 IV on days 1 and 2 in combination with brentuximab vedotin 1.8 mg/kg (not to exceed 180 mg/dose) IV on day 1; vincristine 1.4 mg/m2 IV on day 8; etoposide 125 mg/m2 IV on days 1, 2, and 3; prednisone 20 mg/m2 PO twice daily on days 1 to 7; and cyclophosphamide 600 mg/m2 IV on days 1 and 2 repeated every 3 weeks for up to 5 cycles. Administer primary prophylaxis with a granulocyte colony-stimulating factor starting in cycle 1 due to the high incidence of febrile neutropenia.[45378] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. Interruption of therapy and/or a dosage reduction may be necessary in patients who develop toxicity or intolerable side effects. Cumulative doxorubicin doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628] At a median follow-up time of 42.1 (range, 0.1 to 80.9) months, the 3-year event-free survival rate was significantly improved in patients (median age, 15.6 years; range, 3.4 to 21.99 years) with newly diagnosed, stage IIB with bulk tumor or stage IIIB, IVA, or IVB classic Hodgkin lymphoma who received brentuximab vedotin plus AVEPC compared with doxorubicin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide (ABVE-PC) (92.1% vs. 82.5%; hazard ratio = 0.41; 95% CI, 0.25 to 0.67) in a multicenter, randomized, phase 3 trial (n = 587). The 3-year overall survival rates were 99.3% and 98.5% in the brentuximab vedotin plus AVEPC and ABVE-PC arms, respectively.[68172]

    For the treatment of metastatic ovarian cancer

    Intravenous dosage

    Adults

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of small cell lung cancer (SCLC)

    for the treatment of newly-diagnosed SCLC in combination with cyclophosphamide and vincristine

    Intravenous dosage

    Adults

    Multiple dosage regimens have been studied. Doxorubicin 40 mg/m2 IV on day 1 in combination with cyclophosphamide 750 mg/m2 IV on day 1 and vincristine 1.2 mg/m2 (Max of 2 mg) IV on day 1, every 4 weeks for 4 cycles.[51164] Doxorubicin 50 mg/m2 IV on day 1 in combination with cyclophosphamide 800 mg/m2 IV on day 1 and vincristine 1.4 mg/m2 (Max of 2 mg) IV on day 1, every 3 to 4 weeks for 4 cycles.[51165] Doxorubicin 40 mg/m2 IV on day 1 in combination with cyclophosphamide 1,000 mg/m2 IV on day 1 and vincristine 1 mg/m2 (Max of 2mg) IV on day 1, every 3 weeks for 6 cycles.[51166] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of newly-diagnosed SCLC in combination with cyclophosphamide and etoposide

    Intravenous dosage

    Adults

    45 mg/m2 IV on day 1 in combination with cyclophosphamide 1,000 mg/m2 IV on day 1 and etoposide 100 mg/m2 per day IV on days 1, 2, and 3 repeated every 3 weeks for 5 cycles.[51057] [50310] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of advanced or recurrent endometrial cancer† in combination with cisplatin and paclitaxel

    Intravenous dosage

    Adults

    45 mg/m2 IV on day 1, given immediately before cisplatin (50 mg/m2) on day 1, then give paclitaxel (160 mg/m2) on day 2; repeated every 21 days. In clinical trials, treatment was continued for up to 7 cycles or until disease progression, and filgrastim (5 mcg/kg) was administered on days 3 to 12. A phase III trial showed an increase in response rate, progression-free survival, and overall survival in patients receiving paclitaxel, doxorubicin, and cisplatin (TAP) compared with cisplatin and doxorubicin alone. Thrombocytopenia and neuropathy were higher in the TAP arm.[33938] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For induction therapy prior to autologous stem-cell transplantation in patients with newly diagnosed multiple myeloma†, in combination with vincristine and dexamethasone

    Intravenous dosage

    Adults 18 to 65 years

    9 mg/m2 per day IV and vincristine 0.4 mg per day IV on days 1, 2, 3, and 4 plus dexamethasone (VAD regimen) repeated every 4 weeks for 3 to 4 cycles as induction therapy prior to autologous stem-cell transplantation has been studied in previously untreated multiple myeloma patients.[49477] [49478] Doxorubicin and vincristine were administered as a continuous IV infusion over 24 hours per day or as a daily IV infusion.[49477] [49478] Dexamethasone was given as 40 mg PO daily on days 1, 2, 3, and 4; 9, 10, 11, and 12; and 17, 18, 19, and 20 or as 40 mg PO daily days 1, 2, 3, and 4 on all cycles and days 9, 10, 11, and 12 and 17, 18, 19, and 20 on cycles 1 and 2 only.[49478] [49477] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of non-Hodgkin's lymphoma (NHL)

    for the treatment of geriatric patients with NHL in combination with cyclophosphamide, vincristine, and prednisone

    Intravenous dosage

    Adults 65 years and older

    50 mg/m2 IV on day 1 in combination with cyclophosphamide 750 mg/m2 IV on day 1, vincristine 1.4 mg/m2 IV on day 1 (Max dose of 2 mg), and prednisone 50 mg/m2 PO once daily on days 1, 2, 3, 4, and 5, repeated every 21 days. After 3 cycles, patients with a complete response received 3 additional cycles, patients with a partial response received 5 additional cycles, and patients with progressive disease discontinued treatment.[52334] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of follicular NHL, in combination with rituximab, cyclophosphamide, vincristine, and prednisone (R-CHOP)

    Intravenous dosage

    Adults

    50 mg/m2 IV on day 1 in combination with rituximab 375 mg/m2 IV given on day 1 (or day 0), cyclophosphamide 750 mg/m2 IV on day 1, vincristine 1.4 mg/m2 IV (Max dose of 2 mg) on day 1, and prednisone 100 mg/m2 PO on days 1, 2, 3, 4, and 5 (R-CHOP regimen) repeated every 3 weeks for 6 to 8 cycles has been studied in previously untreated and previously treated patients with follicular lymphoma (FL) in randomized, phase III trials.[47202][47203][47204] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the first-line treatment of diffuse large B-cell, CD20-positive NHL, in combination with rituximab, cyclophosphamide, vincristine, and prednisone (R-CHOP)

    Intravenous dosage

    Adults 60 years and older

    50 mg/m2 IV on day 1 in combination with rituximab 375 mg/m2 IV on day 1, cyclophosphamide 750 mg/m2 IV on day 1, vincristine 1.4 mg/m2 (Max dose of 2 mg) IV on day 1, and prednisone 40 or 100 mg/m2 per day PO on days 1, 2, 3, 4, and 5 (R-CHOP) repeated every 21 days for up to 8 cycles has been evaluated in patients 60 years of age and older with previously untreated diffuse large B-cell lymphoma in randomized, clinical trials.[34649][31968] In a randomized, phase III study in 632 patients aged 60 years or older (range, 60 to 92 years), the 3-year failure-free survival rate was significantly higher with R-CHOP compared with CHOP (53% vs. 46%; hazard ratio (HR) = 0.78; 95% CI, 0.61 to 0.99; p = 0.04) at a median follow-up of 3.5 years. However, overall survival (OS) was not significantly improved in the R-CHOP arm (HR = 0.83; 95% CI, 0.63 to 1.09).[34649] In another randomized trial, the median progression-free survival (PFS) (4.8 vs. 1.2 years; p < 0.0001) and OS (8.4 vs. 3.5 years; p < 0.0001) times were significantly improved with R-CHOP compared with CHOP in 399 patients aged 60 to 75 years. The 10-year PFS rates were 36.5% and 20.1% in the R-CHOP and CHOP arms, respectively, and the 10-year OS rates were 43.5% and 27.6%, respectively.[47312] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of previously untreated diffuse large B-cell lymphoma (DLBCL), in combination with polatuzumab vedotin, rituximab, cyclophosphamide, and prednisone†

    Intravenous dosage

    Adults

    50 mg/m2 IV on day 1 in combination with polatuzumab vedotin 1.8 mg/kg IV, rituximab 375 mg/m2 IV, and cyclophosphamide 750 mg/m2 IV on day 1 plus prednisone 100 mg orally daily on days 1, 2, 3, 4, and 5 repeated every 21 days for 6 cycles has been evaluated in a randomized, double-blind, placebo-controlled, phase 3 trial (n = 879; the POLARIX trial). Rituximab 375 mg/m2 IV was continued for 2 additional cycles of therapy (cycles 7 and 8).[67350]

    For the treatment of metastatic osteogenic sarcoma

    Intravenous dosage

    Adults

    Multiple regimens have been studied. Doxorubicin 30 to 45 mg/m2 per day IV for 2 to 3 days monthly as a single agent (may be given daily in divided doses over 2 to 3 days) or 30 to 75 mg/m2 IV in combination with cisplatin or bleomycin, cyclophosphamide, methotrexate, and dactinomycin. Doxorubicin 25 mg/m2 per day IV on days 1, 2, and 3 or 37.5 mg/m2 per day IV on days 1 and 2 in combination with cisplatin, has been incorporated into multiple treatment protocols for osteogenic sarcoma. In the POG-8651 protocol, 106 patients (aged less than 30 years old) with previously untreated nonmetastatic high-grade osteogenic sarcoma were randomized to receive doxorubicin (37.5 mg/m2 per day IV on days 1 and 2) and cisplatin each cycle as part of a multiagent chemotherapy regimen in sequence with BCD (bleomycin, cyclophosphamide, and dactinomycin) and high-dose methotrexate, either before or after surgical resection. Patients also received single-agent doxorubicin (30 mg/m2 per day IV for 3 days) in week 20 of this regimen. Event-free survival (EFS), the primary endpoint, was not significantly different between the treatment arms, and reached 69% at 5 years in the post-operative group.[34600] In a comparison of the Memorial Sloan-Kettering Cancer Center T-10 and T-12 protocols, 73 patients (aged 4.6 to 36.4 years) with previously untreated, high-grade osteogenic sarcoma received doxorubicin (25 mg/m2 per day IV on days 1, 2, and 3) and cisplatin each cycle as part of a multiagent chemotherapy regimen in sequence with BCD, high-dose methotrexate, and surgical resection. The 5-year EFS was 78% and 73% in the T-12 and T-10 protocols, respectively.[34668] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    Adolescents and Children

    25 mg/m2 per day IV on days 1, 2, and 3 or 37.5 mg/m2 per day IV on days 1 and 2 in combination with cisplatin has been incorporated into multiple treatment protocols for osteogenic sarcoma. In the POG-8651 protocol, 106 patients (aged less than 30 years old) with previously untreated nonmetastatic high-grade osteogenic sarcoma were randomized to receive doxorubicin (37.5 mg/m2 per day IV on days 1 and 2) and cisplatin each cycle as part of a multiagent chemotherapy regimen in sequence with BCD (bleomycin, cyclophosphamide, and dactinomycin) and high-dose methotrexate, either before or after surgical resection. Patients also received single-agent doxorubicin (30 mg/m2 per day IV for 3 days) in week 20 of this regimen. Event-free survival (EFS), the primary endpoint, was not significantly different between the treatment arms, and reached 69% at 5 years in the post-operative group.[34600] In a comparison of the Memorial Sloan-Kettering Cancer Center T-10 and T-12 protocols, 73 patients (aged 4.6 to 36.4 years) with previously untreated, high-grade osteogenic sarcoma received doxorubicin (25 mg/m2 per day IV on days 1, 2, and 3) and cisplatin each cycle as part of a multiagent chemotherapy regimen in sequence with BCD, high-dose methotrexate, and surgical resection. The 5-year EFS was 78% and 73% in the T-12 and T-10 protocols, respectively.[34668] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of metastatic Ewing's sarcoma

    Intravenous dosage

    Adults, Adolescents, and Children

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of soft-tissue sarcoma

    for the treatment of metastatic soft-tissue sarcoma

    Intravenous dosage

    Adults

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628] Single-agent doxorubicin (given as 75 mg/m2 IV over 20 minutes on day 1 OR 25 mg/m2 per day as a continuous 24-hour IV infusion on days 1, 2, and 3) was compared with doxorubicin (25 mg/m2 per day as a IV bolus on days 1, 2, and 3) plus ifosfamide (2.5 grams/m2 per day IV over 4 hour on days 1, 2, 3, and 4) as first-line treatment of locally advanced, unresectable, or metastatic intermediate- or high-grade soft-tissue sarcoma in adult patients (age range, 18 to 63 years) in a multinational, randomized, open-label, phase III trial (n = 445; the EORTC 62012 trial). Patients in the doxorubicin/ifosfamide arm also received mesna (0.5 gram/m2 IV bolus prior to each ifosfamide dose, 1.5 grams/m2 IV over 4 hours given concurrently with each ifosfamide dose, and 1 gram/m2 orally at 2 and 6 hours after each ifosfamide infusion) and pegfilgrastim (6 mg subcutaneously given 24 hours after combination chemotherapy on day 5 of each cycle). Treatment was repeated every 3 weeks until disease progression or unacceptable toxicity, up to a maximum of 6 cycles. The median overall survival time (primary endpoint) was not significantly different with single-agent doxorubicin compared with doxorubicin/ifosfamide therapy (12.8 months vs. 14.3 months; hazard ratio (HR) = 0.83; 95.5% CI, 0.67 to 1.03; p = 0.076) at median follow-up times of 56 and 59 months, respectively. However, the median progression-free survival was significantly higher with doxorubicin/ifosfamide therapy (4.6 months vs. 7.4 months; HR = 0.74; 95.5% CI, 0.6 to 0.9; p = 0.003).[59636]

    Adolescents and Children

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    for the first-line treatment of unresectable or metastatic soft-tissue sarcoma in combination with dacarbazine, ifosfamide, and mesna

    Intravenous dosage

    Adults

    15 mg/m2 per day as a continuous IV infusion over 24 hours (CIV) for 4 days in combination with dacarbazine 250 mg/m2 per day CIV for 4 days, ifosfamide 2,000 mg/m2 per day CIV for 3 days, and mesna 2,500 mg/m2 per day CIV for 4 days repeated every 21 days (median of 3 cycles) (MAID regimen) was evaluated in patients with soft-tissue and bone sarcomas in a randomized, phase III trial.[46189] Five cycles of an intensified MAID regimen was compared with 6 cycles of a more standard MAID regimen (dacarbazine 300 mg/m2 per day IV over 1 hour on days 1, 2, and 3 plus doxorubicin 20 mg/m2 per day as an IV bolus or CIV on days 1, 2, and 3; ifosfamide 2.5 grams/m2 per day IV over 3 hours on days 1, 2 and 3; and mesna 2.5 grams/m2 per day CIV on days 1, 2, and 3) in patients with inoperable locally advanced or metastatic soft-tissue sarcoma in another randomized, phase III study.[44784] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of metastatic neuroblastoma

    Intravenous dosage

    Adults, Adolescents, Children, and Infants

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    for the treatment of intermediate-risk neuroblastoma in combination with etoposide, cyclophosphamide, and carboplatin

    Intravenous dosage

    Children and Infants

    Doxorubicin has been given in combination with carboplatin, cyclophosphamide, and etoposide. In Cycles 1 and 7: Carboplatin 560 mg/m2 IV on day 1 (18 mg/kg per day in children less than 12 kg) plus etoposide 120 mg/m2 per day IV on days 1, 2, and 3 (4 mg/kg per day in children less than 12 kg). Cycles 2 and 6: Carboplatin 560 mg/m2 IV on day 1 (18 mg/kg per day in children less than 12 kg) plus cyclophosphamide 1,000 mg/m2 IV on day 1 (33 mg/kg per day in children less than 12 kg), and doxorubicin 30 mg/m2 IV on day 1 (1 mg/kg per day in children less than 12 kg). Cycles 3 and 5: Cyclophosphamide 1,000 mg/m2 IV on day 1 (33 mg/kg per day in children less than 12 kg) plus etoposide 120 mg/m2 per day IV on days 1, 2, and 3 (4 mg/kg/day in children less than 12 kg). Cycle 4: Carboplatin 560 mg/m2 IV on day 1 (18 mg/kg per day in children less than 12 kg) plus etoposide 120 mg/m2 per day IV on days 1, 2, and 3 (4 mg/kg per day in children less than 12 kg), and doxorubicin 30 mg/m2 IV on day 1 (1 mg/kg per day in children less than 12 kg). Cycle 8: Cyclophosphamide 1,000 mg/m2 IV on day 1 (33 mg/kg per day in children less than 12 kg) plus doxorubicin 30 mg/m2 IV on day 1 (1 mg/kg per day in children less than 12 kg). All cycles given at 3 week intervals. Patients with favorable biologic features received 4 cycles; if incomplete response after 4 cycles, patients were given an additional 4 cycles. Patients with unfavorable biologic features received 8 cycles. Infants aged less than 60 days of age received granulocyte colony-stimulating factor after each cycle.[49848] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of metastatic thyroid cancer

    Intravenous dosage

    Adults

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of metastatic Wilms' tumor

    Intravenous dosage

    Adults, Adolescents, Children, and Infants

    60 to 75 mg/m2 IV repeated every 21 days as a single agent; 40 to 75 mg/m2 IV repeated every 21 to 28 days in combination with other chemotherapy agents. Cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy. Avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers.[61628]

    For the treatment of advanced stage hepatocellular cancer† in combination with cisplatin

    Intra-arterial dosage†

    Adults

    30 mg/m2 in combination with cisplatin 100 mg/m2, has been administered via intra-arterial administration as a solution or emulsified with the use of Lipiodol. Treatment was repeated every 2 months for at least 3 cycles.[50657] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of thymoma†

    for the treatment of unresectable, advanced thymoma in combination with cyclophosphamide and cisplatin†

    Intravenous dosage

    Adults

    50 mg/m2 IV on day 1 plus cisplatin 50 mg/m2 IV on day 1 and cyclophosphamide 500 mg/m2 IV on day 1 (with 1 liter of hydration before and after chemotherapy) repeated every 21 days (PAC regimen) for up to 8 cycles (median of 7 cycles) in patients with previously untreated, unresectable, extensive-stage thymoma or for 2 or 4 cycles (median of 4 cycles; range, 1 to 7 cycles) followed by radiotherapy in patients with previously untreated, unresectable, limited-stage thymoma who had stable disease or better was evaluated in a nonrandomized study.[41507] [47366] Additionally, multimodality treatment with 3 cycles of doxorubicin 30 mg/m2 per day continuous IV infusion over 24 hours on days 1, 2, and 3; cisplatin 30 mg/m2 per day IV on days 1, 2, and 3; cyclophosphamide 500 mg/m2 IV on day 1; and prednisone 100 mg PO on days 1 to 5 repeated every 3 to 4 weeks followed by surgery and radiation therapy and then consolidation chemotherapy with doxorubicin, cisplatin, and cyclophosphamide given at 80% of the original doses and prednisone (given at 100%) repeated every 3 to 4 weeks for 3 cycles was evaluated in another nonrandomized study.[41508] In these studies, overall response rates and overall survival rates were favorable.[41507] [47366] [41508] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    for the treatment of unresectable, advanced thymoma in combination with cisplatin, cyclophosphamide, and vincristine†

    Intravenous dosage

    Adults

    40 mg/m2 IV on day 1 plus cisplatin 50 mg/m2 IV on day 1, vincristine 0.6 mg/m2 IV on day 3, and cyclophosphamide 700 mg/m2 IV on day 4 repeated every 3 weeks (median of 5 cycles; range, 3 to 7 cycles) resulted in a favorable overall response rate in a nonrandomized study of 37 patients.[41511] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    Intravenous dosage

    Adults

    10 mg/m2 IV on day 1 in combination with bleomycin (15 units IV on day 1) and vincristine (1 mg IV on day 1), repeated every 2 weeks.[34595] Alternately, doxorubicin 20 mg/m2 IV on day 1 has been given in combination with bleomycin (10 mg/m2 IV on day 1) and vincristine (1 mg IV on day 1), repeated every 2 weeks for 6 cycles.[21306] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the first-line treatment of rhabdomyosarcoma† in combination with vincristine, dactinomycin, and ifosfamide

    Intravenous dosage

    Adolescents and Children

    40 mg/m2 per day IV on days 29 and 30 in combination with ifosfamide 6,000 mg/m2 continuous IV (CIV) over 48 hours on days 1, 29, and 50; mesna 6,000 mg/m2 CIV over 48 hours on days 1, 29, and 50; dactinomycin 0.5 mg/m2 per day IV on days 1, 2, and 3 and 50, 51, and 52; and vincristine 1.5 mg/m2 IV on days 1, 8, 15, and 22. The duration of therapy was dependent on stage at diagnosis (stage I: 16 weeks; II: 26 weeks; III: 40 weeks; IV: 48 weeks).[50231] FDA approved labeling for doxorubicin states to avoid concomitant use with CYP3A4, CYP2D6, and P-glycoprotein inhibitors and inducers and that cumulative doses above 550 mg/m2 are associated with an increased risk of cardiomyopathy.[61628]

    For the treatment of metastatic liver lesions from malignant melanoma†

    Intra-arterial dosage†

    Adults

    Doxorubicin 150 mg of 100 to 300 micron beads (given as 2 vials, each 2 mL in volume and containing 75 mg of doxorubicin) via intra-arterial chemoembolization. The maximum dose of doxorubicin was 150 mg/procedure. The beads were mixed with contrast before the procedure and injected slowly in 1 mL aliquots using a "sandwich technique" (i.e., beads then contrast) to identify and minimize reflux.[51160]

    For the treatment of biliary tract cancer† (unresectable intrahepatic cholangiocarcinoma) in combination with cisplatin, mitomycin, ethiodol, and polyvinyl alcohol

    Intra-arterial dosage†

    Adults

    Chemoembolization material consisted of mitomycin 10 mg, doxorubicin 50 mg, and cisplatin 100 mg dissolved in sterile contrast (8.5 mL) and diluted with 1.5 mL of sterile water. This was emulsified in a 1:1 ratio with ethiodol. Added to the final aliquot of the emulsion or separately following administration of the emulsion was 0.2 mL of 150- to 250-l polyvinyl alcohol particles. Normal saline at 200 to 300 mL per hour until the completion of the procedure, followed by normal saline at 150 mL per hour for a total of 3 liters. No diuretics were given. Prophylactic antiemetics (ondansetron 24 mg and dexamethasone 10 mg intravenously) and antibiotics (cefazolin 1 g and metronidazole 500 mg) were given.[50654]

    for the treatment of systemic anaplastic large-cell lymphoma (sALCL)†

    for the treatment of previously untreated sALCL, in combination with brentuximab vedotin, cyclophosphamide, and prednisone†

    Intravenous dosage

    Adults

    50 mg/m2 IV on day 1 in combination with brentuximab vedoin 1.8 mg/kg (not to exceed 180 mg/dose) IV on day 1, cyclophosphamide 750 mg/m2 IV on day 1, and prednisone 100 mg orally daily on days 1, 2, 3, 4, and 5 given every 21 days for 6 to 8 cycles of therapy. The progression-free survival (PFS) time (evaluated via an independent review facility) was significantly improved in patients with CD30-expressing sALCL or peripheral T-cell lymphoma who received brentuximab vedotin plus cyclophosphamide, doxorubicin, and prednisone (CHP) compared with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (48.2 months vs. 20.8 months; hazard ratio (HR) = 0.71; 95% CI, 0.54 to 0.93) in a multicenter, randomized, double-blind, phase 3 trial (the ECHELON-2 trial; n = 452). Overall survival was also significantly improved in the brentuximab vedotin-containing arm (HR = 0.66; 95% CI, 0.46 to 0.95). In patients with sALCL (n = 314; anaplastic lymphoma kinase (ALK)-negative sALCL, 48%; ALK-positive sALCL, 22%), the PFS times were 55.7 months and 54.2 months in patients who received brentuximab vedotin plus CHP and CHOP, respectively (HR = 0.59; 95% CI, 0.42 to 0.84).[45378]

    For the treatment of peripheral T-cell lymphoma (PTCL)†

    for the treatment of previously untreated CD30-expressing PTCL, in combination with brentuximab vedotin, cyclophosphamide, and prednisone†

    Intravenous dosage

    Adults

    50 mg/m2 IV on day 1 in combination with brentuximab vedotin 1.8 mg/kg (not to exceed 180 mg/dose) IV on day 1, cyclophosphamide 750 mg/m2 IV on day 1, and prednisone 100 mg orally daily on days 1, 2, 3, 4, and 5 given every 21 days for 6 to 8 cycles of therapy. The progression-free survival time (evaluated via an independent review facility) was significantly improved in patients with CD30-expressing systemic anaplastic large-cell lymphoma (sALCL) or PTCL who received brentuximab vedotin plus cyclophosphamide, doxorubicin, and prednisone (CHP) compared with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (48.2 months vs. 20.8 months; hazard ratio (HR) = 0.71; 95% CI, 0.54 to 0.93) in a multicenter, randomized, double-blind, phase 3 trial (the ECHELON-2 trial; n = 452). Overall survival was also significantly improved in the brentuximab vedotin-containing arm (HR = 0.66; 95% CI, 0.46 to 0.95). In this trial, 70% of patients had sALCL and 30% of patients had PTCL (e.g., including PTCL not otherwise specified (16%), angioimmunoblastic T-cell lymphoma (12%), adult T-cell leukemia/lymphoma (2%), and enteropathy-associated T-cell lymphoma (less than 1%))[45378]

    Therapeutic Drug Monitoring

    Maximum Dosage Limits

    • Adults

      Maximum lifetime cumulative dosage of doxorubicin is 550 mg/m2 IV; 450 mg/m2 IV in patients who have received previous mediastinal radiation.

    • Geriatric

      Maximum lifetime cumulative dosage of doxorubicin is 550 mg/m2 IV; 450 mg/m2 IV in patients who have received previous mediastinal radiation.

    • Adolescents

      Maximum lifetime cumulative dosage of doxorubicin is 550 mg/m2 IV; 450 mg/m2 IV in patients who have received previous mediastinal radiation.

    • Children

      Maximum lifetime cumulative dosage of doxorubicin is 550 mg/m2 IV; 450 mg/m2 IV in patients who have received previous mediastinal radiation. The dose should be based on body weight for children with a BSA < 0.5 m2. Children are more susceptible to cardiotoxicity and require long term follow-up.

    Patients with Hepatic Impairment Dosing

    Consult individual protocols for hepatic dosage recommendations.

    A dosage adjustment is necessary in patients with hepatic impairment as follows:

    Serum bilirubin level of 1.2 to 3 mg/dL: decrease dose by 50%.
    Serum bilirubin level of 3.1 to 5 mg/dL: decrease dose by 75%.
    Severe hepatic impairment (Child-Pugh Class C) or serum bilirubin level greater than 5 mg/dL: use is contraindicated.[61628]

    Additional recommendations for hepatic dose adjustments have been described in the literature.[67274]

    Patients with Renal Impairment Dosing

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    † Off-label indication
    Revision Date: 07/13/2024, 02:30:00 AM

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Phase III study of cyclophosphamide, doxorubicin, and etoposide compared with carboplatin and paclitaxel in patients with extensive disease small-cell lung cancer. Eur J Cancer 2007;16:2345-2350.50654 - Kiefer MV, Albert M, McNally M et al. Chemoembolization of intrahepatic cholangiocarcinoma with cisplatinum, doxorubicin, mitomycin C, ethiodol, and polyvinyl alcohol: a 2-center study. Cancer 2011;117:1498-1505.50657 - Carr BI, Bron K, Swanson DP et al. Prospective randomized trial of hepatic artery chemotherapy with cisplatin and doxorubicin, with or without lipiodol in the treatment of advanced stage hepatocellular carcinoma. J Clin Gastroenterol 2011;45:87-91.51057 - Ardizzoni A, Tjan-Heijnen VCG, Postmus PE, Buchholz E, Biesma B, Karnicka-Mlodkowska H, et al. 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Randomized trial of cyclophosphamide, doxorubicin, and vincristine versus cisplatin and etoposide versus alternation of these regimens in small-cell lung cancer. J Natl Cancer Inst 1991; 83: 855 – 61.51166 - Roth BJ, Johnson DH, Einhorn LH, Schacter LP, Cherng NC, Cohen HJ, et al. Randomized study of cyclophosphamide, doxorubicin, and vincristine versus etoposide and cisplatin versus alternation of these two regimens in extensive small-cell lung cancer: a phase III trial of the Southeastern Cancer Study Group. J Clin Oncol 1992; 10: 282 – 9152334 - Doorduijn JK, van der Holt B, van Imhoff GK, et al. CHOP compared with CHOP plus granulocyte colony-stimulating factor in elderly patients with aggressive non-Hodkin's lymphoma. J Clin Oncol 2003;21:3041-3050.57889 - Keytruda (pembrolizumab) injection package insert. Whitehouse Station, NJ: Merck Sharp and Dohme Corp.; 2024 June.59636 - Judson I, Verweij J, Gelderblom H, et al. Doxorubicin alone versus intensified doxorubicin plus ifosfamide for first-line treatment of advanced or metastatic soft-tissue sarcoma: a randomised controlled phase 3 trial. Lancet Oncol 2014;15(4):415-423.61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.62863 - Connors JM, Jurczak W, Straus DJ, et al. Brentuximab vedotin with chemotherapy for stage III or IV Hodgkin's lymphoma. N Engl J Med 2018;378(4):331-344.66036 - Schmid P, Cortes J, Pusztai L, et al. Pembrolizumab for Early Triple-Negative Breast Cancer. NEJM. 2020;382(9):810-821.66038 - Mittendorf EA, Zhang H, Barrios CH, et al. Neoadjuvant atezolizumab in combination with sequential nab-paclitaxel and anthracycline-based chemotherapy versus placebo and chemotherapy in patients with early stage triple-negative breast cancer (IMpassion031): a randomised, double-blind, phase 3 trial. Lancet. 2020;396:1090-1100.67274 - Superfin D, Iannucci AA, Davies AM. Commentary: Oncologic drugs in patients with organ dysfunction: a summary. Oncologist. 2007 Sep;12(9):1070-83.67350 - Tilly H, Morschhauser F, Sehn LH, et al. Polatuzumab vedotin in previously untreated diffuse large B-cell lymphoma. N Engl J Med 2022;386(4):351-363.68172 - Castellino SM, Pei Q, Parsons SK, et al. Brentuximab vedotin with chemotherapy in pediatric high-risk Hodgkin's lymphoma. N Engl J Med 2022;387(18):1649-1660.

    How Supplied

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (00143-9092) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (00069-0170) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (67457-0478) (Mylan Institutional LLC ) null

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (00069-0170) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (00143-9093) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (00069-0171) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (67457-0436) (Mylan Institutional LLC ) null

    Doxorubicin Hydrochloride Lyophilisate for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (00069-0171) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin 10mg Powder for Injection (55390-0231) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin 10mg Powder for Injection (00143-9275) (Hikma Pharmaceuticals USA inc.) (off market)Adriamycin 10mg Powder for Injection package photo

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin RDF 10mg Powder for Injection (00013-1086) (Pfizer Inc.) (off market)Adriamycin RDF 10mg Powder for Injection package photo

    Doxorubicin Hydrochloride Powder for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (10019-0920) (Baxter Anesthesia/Critical Care Oncology) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Doxorubicin Hydrochloride 10mg Powder for Injection (NOVAPLUS) (55390-0241) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin 20mg Powder for Injection (55390-0232) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin RDF 20mg Powder for Injection (00013-1096) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Doxorubicin Hydrochloride 20mg Powder for Injection (55390-0242) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin 50mg Powder for Injection (55390-0233) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin 50mg Powder for Injection (00143-9277) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin RDF 50mg Powder for Injection (00013-1106) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (10019-0921) (Baxter Anesthesia/Critical Care Oncology) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Doxorubicin Hydrochloride 50mg Powder for Injection (NOVAPLUS) (55390-0243) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Rubex 50mg Powder for Injection (00015-3352) (Bristol Myers Squibb Oncology Products) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Rubex 100mg Powder for Injection (00015-3353) (Bristol Myers Squibb Oncology Products) (off market)

    Doxorubicin Hydrochloride Powder for solution for injection

    Adriamycin RDF 150mg Powder for Injection (00013-1116) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 10mg/5mL Solution for Injection (00143-9549) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 10mg/5mL Solution for Injection (NOVAPLUS) (00143-9369) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 200mg/100mL Solution for Injection (00143-9546) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 200mg/100mL Solution for Injection (NOVAPLUS) (00143-9372) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 20mg/10mL Solution for Injection (00143-9548) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 20mg/10mL Solution for Injection (00143-9548) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 20mg/10mL Solution for Injection (NOVAPLUS) (00143-9370) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 2mg/ml Solution for Injection (55390-0238) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 2mg/ml Solution for Injection (55390-0237) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 2mg/ml Solution for Injection (55390-0236) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 2mg/ml Solution for Injection (55390-0235) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 50mg/25mL Solution for Injection (00143-9547) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin 50mg/25mL Solution for Injection (NOVAPLUS) (00143-9371) (Hikma Pharmaceuticals USA inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1176) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1136) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1156) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1146) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1286) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Adriamycin PFS 2mg/ml Solution for Injection (00013-1266) (Pfizer Inc.) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (53150-0320) (Amneal-Agila, LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (00143-9084) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (53150-0320) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (67457-0393) (Mylan Institutional LLC ) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (00069-3030) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (25021-0207) (Sagent Pharmaceuticals) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5ml Solution for Injection (45963-0733) (Teva/Actavis US) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5mL Solution for Injection (00703-5043) (Teva Pharmaceuticals USA) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5mL Solution for Injection (NOVAPLUS) (00143-9088) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5mL Solution for Injection (NOVAPLUS) (00069-4030) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 10mg/5mL Solution for Injection (PREMIER ProRx) (00069-4004) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 150mg/75ml Solution for Injection (00069-3033) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 150mg/75mL Solution for Injection (NOVAPLUS) (00069-4033) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (53150-0317) (Amneal-Agila, LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (00143-9087) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (53150-0317) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (67457-0396) (Mylan Institutional LLC ) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (00069-3034) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (25021-0207) (Sagent Pharmaceuticals) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (62756-0827) (Sun Pharmaceutical Industries, Inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (00703-5040) (Teva Pharmaceuticals USA) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100ml Solution for Injection (45963-0733) (Teva/Actavis US) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100mL Solution for Injection (70860-0208) (Athenex Pharmaceutical Division LLC) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100mL Solution for Injection (16714-0001) (NorthStar Rx LLC) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100mL Solution for Injection (NOVAPLUS) (00143-9091) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100mL Solution for Injection (NOVAPLUS) (00069-4034) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 200mg/100mL Solution for Injection (PREMIER ProRx) (00069-4037) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (53150-0314) (Amneal-Agila, LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (00143-9085) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (53150-0314) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (67457-0394) (Mylan Institutional LLC ) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (00069-3031) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10ml Solution for Injection (45963-0733) (Teva/Actavis US) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10mL Solution for Injection (NOVAPLUS) (00143-9089) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10mL Solution for Injection (NOVAPLUS) (00069-4031) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 20mg/10mL Solution for Injection (PREMIER ProRx) (00069-4015) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (63323-0101) (Fresenius Kabi AG) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (63323-0883) (Fresenius Kabi AG) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (63323-0883) (Fresenius Kabi AG) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (63323-0101) (Fresenius Kabi AG) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (00074-5040) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (00074-5043) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (00074-5046) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (NOVAPLUS) (55390-0246) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (NOVAPLUS) (55390-0245) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (NOVAPLUS) (55390-0247) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 2mg/ml Solution for Injection (NOVAPLUS) (55390-0248) (Bedford Laboratories, a Hikma Company) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (53150-0315) (Amneal-Agila, LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (00143-9086) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (53150-0315) (Mylan Institutional LLC) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (67457-0395) (Mylan Institutional LLC ) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (00069-3032) (Pfizer Injectables) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (25021-0207) (Sagent Pharmaceuticals) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (62756-0826) (Sun Pharmaceutical Industries, Inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (00703-5046) (Teva Pharmaceuticals USA) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25ml Solution for Injection (45963-0733) (Teva/Actavis US) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25mL Solution for Injection (NOVAPLUS) (00143-9090) (Hikma Pharmaceuticals USA inc.) null

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25mL Solution for Injection (NOVAPLUS) (00069-4032) (Pfizer Injectables) (off market)

    Doxorubicin Hydrochloride Solution for injection

    Doxorubicin Hydrochloride 50mg/25mL Solution for Injection (PREMIER ProRx) (00069-4026) (Pfizer Injectables) null

    Description/Classification

    Description

    Doxorubicin is a cytotoxic anthracycline antibiotic that inhibits nucleotide replication by intercalation into DNA and RNA; it is also a topoisomerase II inhibitor. Doxorubicin is indicated for the treatment of acute lymphoblastic leukemia, acute myeloblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, metastatic breast cancer, metastatic Wilms' tumor, metastatic neuroblastoma, metastatic soft tissue sarcoma, metastatic bone sarcoma, metastatic ovarian cancer, metastatic transitional cell bladder cancer, metastatic thyroid cancer, metastatic gastric cancer, and metastatic lung cancer; it is also indicated for the adjuvant treatment of breast cancer.[61628]

    Classifications

    • Antineoplastic and Immunomodulating Agents
      • Antineoplastics
        • Cytotoxic Antibiotics and Related Substances
          • Anthracyclines
    Revision Date: 07/13/2024, 02:30:00 AM

    References

    61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.

    Administration Information

    General Administration Information

    For storage information, see the specific product information within the How Supplied section.

    Hazardous Drugs Classification

    • NIOSH 2016 List: Group 1 [63664]
    • NIOSH (Draft) 2020 List: Table 1
    • Observe and exercise appropriate precautions for handling, preparation, administration, and disposal of hazardous drugs.
    • Use double chemotherapy gloves and a protective gown. Prepare in a biological safety cabinet or compounding aseptic containment isolator with a closed system drug transfer device. Eye/face and respiratory protection may be needed during preparation and administration.[63664]
    • Treat accidental contact with the skin or eyes immediately. Wash with water, soap and water, or sodium bicarbonate solution. Do not use a scrub brush on skin. Promptly seek medical attention.[61628]

    Emetic Risk

    Pediatrics:

    • Doses of 30 mg/m2 or higher: High
    • Doses of 25 mg/m2: Moderate
    • Doses of 10 mg/m2: Minimal

    Adults:

    • Moderate

    Administer routine antiemetic prophylaxis prior to treatment.[67392][67389]

    Extravasation Risk

    • Vesicant
    • Administer drug through a central venous line.[67387][55200]

    Route-Specific Administration

    Injectable Administration

    • Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

    Intravenous Administration

    • Doxorubicin is available as a lyophilized powder vial or a 2 mg/mL injectable solution.
    • Do not mix doxorubicin with other drugs.
    • If extravasation occurs or is suspected (e.g., blood return is present on aspiration of the infusion needle), manage as follows: 1) immediately terminate the injection or infusion; 2) elevate the extremity (if applicable); 3) apply ice to the site for 15 minutes 4 times daily for 3 days; 4) consider dexrazoxane administration as soon as possible and within the first 6 hours; and 4) do NOT remove the needle (until attempts are made to aspirate extravasated fluid), flush the line, or apply pressure to the site.[61628][61629]

     

    Reconstitution of the Lyophilized Powder Vial:

    • Add 5 mL of 0.9% Sodium Chloride Injection to the 10-mg vial and 25 mL of 0.9% Sodium Chloride Injection to the 50-mg vial for a final concentration of 2 mg/mL.
    • Gently shake the vial until the powder is dissolved.
    • Protect from light.
    • Formation of a gelled product may occur if the vial is refrigerated; allow the gelled product to sit out at room temperature (15 to 30 degrees C; 59 to 86 degrees F) for 2 to 4 hours to return the product to a slightly viscous, liquid solution.
    • Storage of reconstituted vial: store up to 7 days at room temperature or up to 15 days in the refrigerator (2 to 8 degrees C).[61628]


    Intravenous (IV) Injection:

    • Administer doxorubicin IV over 3 to 10 minutes through a central IV line or a secure and free-flowing peripheral venous line containing 0.9% Sodium Chloride Injection, 0.45% Sodium Chloride Injection, or 5% Dextrose Injection.
    • Decrease the rate of injection if erythematous streaking along the vein proximal to the site of infusion or facial flushing occur.

     

    Continuous IV infusion:

    • Dilute doxorubicin in 0.9% Sodium Chloride Injection or 5% Dextrose Injection and administer IV over 24 hours through a central IV line.
    • Decrease the rate of infusion if erythematous streaking along the vein proximal to the site of infusion or facial flushing occur.
    • Protect from light until the infusion is complete.[61628][61629]

    Other Injectable Administration

    Intraarterial Administration

     

    NOTE: Doxorubicin is not approved by the FDA for intraarterial administration.

    Hepatic artery chemoembolization:

    • Withdraw the appropriate volume of doxorubicin from the reconstituted or solution vial; administer within 1 hour of preparation.
    • Place catheter in the hepatic artery by the femoral route and infuse doxorubicin over 30 minutes; remove catheter.
    • Administer hydration (e.g., 5% Dextrose and 0.45% Sodium Chloride Injection with 0.02 mEq/mL of potassium chloride) for 2 hours prior to catheter placement and for 6 hours after chemotherapy.
    • Furosemide 40 mg IV and mannitol 12.5 grams IV were given when hydration was started.[50657]

    Clinical Pharmaceutics Information

    From Trissel's 2‚Ñ¢ Clinical Pharmaceutics Database

    Doxorubicin hydrochloride

    pH Range
    pH 3.8 to 6.5 (reconstituted products) pH near 3.0 (solution products)
    ReferencesAnon. Manufacturer's information and labeling. (Package insert).
    ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
    Osmolality/Osmolarity
    Reconstituted doxorubicin hydrochloride 2 mg/mL in sterile water for injection is isotonic having an osmolality of 280 mOsm/kg.
    ReferencesTrissel LA. Drug information- osmolalities. Data on file.
    Stability
    Doxorubicin hydrochloride in intact vials stored as directed by the manufacturer is stable until the labeled expiration date. Martel et al. reported that the stability of lyophilized doxorubicin hydrochloride in intact vials stored at an elevated temperature of 33 degree C protected from exposure to light for 12 months exhibited little or no loss of drug when tested by stability-indicating HPLC analysis. The authors stated such temperatures might be reached during transportation of the vials during summer months. The manufacturer indicates that the reconstituted doxorubicin hydrochloride solutions are stable for 7 days at room temperature and 15 days refrigerated. Stiles et al. reported that doxorubicin hydrochloride 2 mg/mL in sodium chloride 0.9% was stable in Pharmacia-Deltec pump reservoirs at 23 degree C for 14 days followed by 30 degree C for an additional 30 days. At 37 degree C in a Medtronic DAD implantable pump doxorubicin hydrochloride 3 to 5 mg/mL in sodium chloride 0.9% sustained losses of 5 to 6% per week according to Vogelzang et al. Keusters et al. reported that heating doxorubicin hydrochloride 1 mg/mL to 100 degree C resulted in 26% drug loss in 1 hour. Most stability reports (Tavolini et al., Poochikian et al, Beijnen et al., Sautou-Miranda et al., Vogelzang et al.) have not indicated substantial concentration dependency for drug stability. However, Janssen et al. reported a greater loss at higher concentrations, as did Beijnen et al. who reported increasing the doxorubicin concentration from 1.4 mg/mL to 2.37 mg/mL resulted in an increased amount of decomposition from 10% to 16% in 14 days at 37 degree C. Infusion Solutions: The manufacturers recommend dilution in dextrose 5% and sodium chloride 0.9% to deliver doxorubicin hydrochloride. Wood et al. reported that doxorubicin hydrochloride 0.1 mg/mL in dextrose 5% and in sodium chloride 0.9% was stable for 43 days at room temperature with HPLC analysis finding about 8% loss and 10% loss in the two diluents, respectively. Under refrigeration, losses were found to be 4% and 8% for dextrose 5% and sodium chloride 0.9%, respectively. Packaging in Syringes: Walker et al. reported that doxorubicin 2 mg/mL and 1 mg/mL in sodium chloride 0.9% in Monoject and Terumo plastic syringes were physically stable and HPLC analysis found little or no loss of drug in 142 days at room temperature and refrigerated exposed to light. No extractable materials from the syringes were found as well. Wood et al. also reported little or no doxorubicin hydrochloride loss by HPLC analysis from a 2-mg/mL solution packaged in polypropylene syringes and stored refrigerated for 43 days.
    ReferencesAnon. Manufacturer's information and labeling. (Package insert).
    ReferencesBeijnen JH, Neef C, Menwissen OJAT, et al. Stability of intravenous admixtures of doxorubicin and vincristine. Am J Hosp Pharm. 1986; 43
    ReferencesBeijnen JH, van der Houwen OAGJ, Underberg WJM. Aspects of the degradation kinetics of doxorubicin in aqueous solution. Int J Pharm. 1986; 32
    ReferencesTavoloni N, Guarino AM, Berk PD. Photolytic degradation of adriamycin. J Pharm Pharmacol. 1980; 32
    ReferencesJanssen MJH, Crommelin DJA, Storm G, et al. Doxorubicin decomposition on storage. Effect of pH, type of buffer and liposome encapsulation. Int J Pharm. 1985; 23
    ReferencesKeusters L, Stolk LML, Umans R, et al. Stability of solutions of doxorubicin and epirubicin in plastic minibags for intravesical use after storage at -20 degree C and thawing by microwave radiation. Pharm Weekbl Sci Ed. 1986; 8
    ReferencesMartel P, Pinguet F, Petit I, et al. Stability of the principal cytostatic agents during storage at unusual temperatures. Int J Pharm. 1997; 149
    ReferencesPoochikian GK, Cradock JC, Flora KP. Stability of anthracycline antitumor agents in four infusion fluids. Am J Hosp Pharm. 1981; 38
    ReferencesSautou-Miranda V, Brigas F, Thibault M, et al. Compatibility of doxorubicin, daunorubicin, and epirubicin with low-density polyethylene and polyvinyl chloride, and stability in various conditions of storage. Eur Hosp Pharm. 2001; 7
    ReferencesStiles ML, Allen LV Jr. Stability of doxorubicin hydrochloride in portable pump reservoirs. Am J Hosp Pharm. 1991; 48
    ReferencesVogelzang NJ, Ruane M, DeMeester TR. Phase I trial of an implanted battery-powered, programmable drug delivery system for continuous doxorubicin administration. J Clin Oncol. 1985; 3
    ReferencesWood MJ, Irwin WJ, Scott DK. Stability of doxorubicin, daunorubicin and epirubicin in plastic syringes and minibags. J Clin Pharm Ther. 1990; 15
    pH Effects
    The solution stability of doxorubicin hydrochloride is pH dependent. The drug is unstable at pH values above 7 and below 3. The drug is more stable at acidic pH with the stability improving as the pH declines from 7.4 to 4.5. Maximum stability is reported to occur at about pH 3 to 5. At alkaline pH, cleavage of the amino sugar results in a color change from red to deep purple. At acidic pH, the glycosidic bond is split resulting in formation of an insoluble aglycone.
    ReferencesBeijnen JH, Rosing H, de Vries PA, et al. Stability of anthracycline antitumour agents in infusion fluids. J Parenter Sci Tech. 1985; 39
    ReferencesBeijnen JH, van der Houwen OAGJ, Underberg WJM. Aspects of the degradation kinetics of doxorubicin in aqueous solution. Int J Pharm. 1986; 32
    ReferencesBouma J, Beijnen JH, Bult A, et al. Anthracycline antitumor agents, a review of physicochemical, analytical and stability properties. Pharm Weekbl Sci Ed. 1986; 8
    ReferencesDorr RT. Incompatibilities with parenteral anticancer drugs. Am J IV Ther. 1979; 6
    ReferencesJanssen MJH, Crommelin DJA, Storm G, et al. Doxorubicin decomposition on storage. Effect of pH, type of buffer and liposome encapsulation. Int J Pharm. 1985; 23
    ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
    ReferencesPoochikian GK, Cradock JC, Flora KP. Stability of anthracycline antitumor agents in four infusion fluids. Am J Hosp Pharm. 1981; 38
    ReferencesTrissel LA, Kleinman LM, Davignon JP, et al. Investigational drug information - daunorubicin hydrochloride and streptozotocin. Drug Intell Clin Pharm. 1978; 12
    ReferencesWood MJ, Irwin WJ, Scott DK. Stability of doxorubicin, daunorubicin and epirubicin in plastic syringes and minibags. J Clin Pharm Ther. 1990; 15
    Light Exposure
    Doxorubicin hydrochloride solutions are light sensitive, especially at very low concentrations. However, this photolability has not been found at higher concentrations. Walker et al. reported a 10-fold difference in photolability half-life in comparing 0.1 mg/mL to 0.01 mg/mL solutions. Yuan et al. reported no doxorubicin hydrochloride loss after 124 hours of constant exposure to fluorescent light in a multi-drug admixture that included doxorubicin hydrochloride 0.4 mg/mL. Sautou-Miranda et al. reported that doxorubicin hydrochloride exhibited some photolability at a very low concentration of 20 mcg/mL in dextrose 5% and sodium chloride 0.9% in both polyvinyl chloride (PVC) and low-density polyethylene containers. Losses of up to 60% occurred in 8 days exposed to normal room light but not sunlight. At a doxorubicin hydrochloride concentration of 0.1 mg/mL no photolability was found. No unacceptable adverse effect on drug concentration due to normal fluorescent light exposure was observed in stability studies of doxorubicin hydrochloride in infusion solutions. The manufacturers recommend protecting doxorubicin hydrochloride from exposure to sunlight.
    ReferencesAnon. Manufacturer's information and labeling. (Package insert).
    ReferencesBenvenuto JA, Adams SC, Vyas HM, et al. Pharmaceutical issues in infusion chemotherapy stability and compatibility. in Lokich JJ (ed), Cancer chemotherapy by infusion. Chicago: Precept Press. 1987;
    ReferencesBosanquet AG. Stability of solutions of antineoplastic agents during preparation and storage for in vitro assays II. Assay methods, adriamycin, and the other antitumor antibiotics. Cancer Chemother Pharmacol. 1986; 17
    ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
    ReferencesPoochikian GK, Cradock JC, Flora KP. Stability of anthracycline antitumor agents in four infusion fluids. Am J Hosp Pharm. 1981; 38
    ReferencesSautou-Miranda V, Brigas F, Thibault M, et al. Compatibility of doxorubicin, daunorubicin, and epirubicin with low-density polyethylene and polyvinyl chloride, and stability in various conditions of storage. Eur Hosp Pharm. 2001; 7
    ReferencesTavoloni N, Guarino AM, Berk PD. Photolytic degradation of adriamycin. J Pharm Pharmacol. 1980; 32
    ReferencesWalker SE, Lau D, DeAngelis C, et al. Doxorubicin stability in syringes and glass vials and evaluation of chemical contamination. Can J Hosp Pharm. 1991; 44
    ReferencesWilliams BA, Tritton TR. Photoinactivation of anthracyclines. Photochem Photobiol. 1981; 34
    ReferencesYuan P, Grimes GJ, Shankman SE, et al. Compatibility and stability of vincristine sulfate, doxorubicin hydrochloride, and etoposide phosphate in 0.9% sodium chloride injection. Am J Health-Syst Pharm. 2001; 58
    Freezing
    The manufacturer does not recommend freezing doxorubicin hydrochloride solutions. However, if solutions are frozen anyway, room temperature thawing is recommended to avoid overheating to avoid the possibilities of drug decomposition and bag bursting from microwave oven thawing. Four studies have reported the frozen stability of doxorubicin hydrochloride at concentrations of 2 mg/mL in sterile water for injection, 1.4 mg/mL in sodium chloride 0.9%, 1 mg/mL in sodium chloride 0.9%, and 0.1 mg/mL in both dextrose 5% and sodium chloride 0.9%. Little or no doxorubicin hydrochloride loss occurred in the studies covering 30 to 43 day periods. Repetitious freeze-thaw cycles using microwave ovens resulted in less than 5% loss of drug.
    ReferencesHayakawa E, Sugiyama K, Furuya K, et al. Stability of mitomycin C and adriamycin in frozen state. Yakuzaigaku. 1989; 49
    ReferencesHoffman DM, Grossano DD, Damin L, et al. Stability of refrigerated and frozen solutions of doxorubicin hydrochloride. Am J Hosp Pharm. 1979; 36
    ReferencesKarlsen J, Thonnesen HH, Olsen IR, et al. Stability of cytotoxic intravenous solutions subjected to freeze-thaw treatment. Nor Pharm Acta. 1983; 45
    ReferencesKirschenbaum BE, Latiolais CJ. Injectable medications - a guide to stability and reconstitution. New York, NY: McMahon Group. Data on file. 1993;
    ReferencesKeusters L, Stolk LML, Umans R, et al. Stability of solutions of doxorubicin and epirubicin in plastic minibags for intravesical use after storage at -20 degree C and thawing by microwave radiation. Pharm Weekbl Sci Ed. 1986; 8
    ReferencesWilliamson M, Luce JK. Microwave thawing of doxorubicin hydrochloride admixtures not recommended. Am J Hosp Pharm. 1987; 44
    ReferencesWood MJ, Irwin WJ, Scott DK. Stability of doxorubicin, daunorubicin and epirubicin in plastic syringes and minibags. J Clin Pharm Ther. 1990; 15
    Filtration
    Studies of doxorubicin hydrochloride filtration are variable. Some have found loss due to binding to the filters while others have reported no loss due to binding to the filters. It appears that drug concentration may play a role, but differing binding capacities between filter materials may indeed exist. Bosanquet and Pavlik et al. have reported substantial losses of doxorubicin hydrochloride to cellulose nitrate/acetate ester (Millex-OR) filters and polytetrafluoroethylene filters. However, their test concentrations were in the microgram/mL concentration range. Ennis et al. reported that 92% of a doxorubicin hydrochloride 2-mg/mL solution was delivered through a 0.22-micron Ultipor nylon air eliminating filter even after a 10-mL saline flush. Francomb et al. also found about 20 to 25% loss from a 1-mg/mL solution in the first 15 to 60 minutes using an Ultipor nylon filter and a 35% loss using a Pall Posidyne ELD96 nylon filter. Delivered drug concentrations returned to full level after about 2 hours or so. Hoffman et al., Stevens et al., and Francomb et al. reported that doxorubicin hydrochloride at concentrations of 2 mg/mL, 1 mg/mL, and 50 mcg/mL little or no drug loss due to binding to the filter occurred when delivered through several filters including 0.22-micron Millex, 0.2-micron Pall nylon ELD96LL, Minisart 45 cellulose acetate, Acrodisc 45 polysulfone, and Nylaflo nylon filters. Pall reports that doxorubicin hydrochloride 1 mg/mL underwent no loss due to filtration through a Supor membrane filter.
    ReferencesAnon. Pall Medical Supor-membrane IV filter device drug-adsorption data. Data on file. 2004; 8
    ReferencesBosanquet AG. Stability of solutions of antineoplastic agents during preparation and storage for in vitro assays. General considerations, the nitrosoureas and alkylating agents. Cancer Chemother Pharmacol. 1985; 14
    ReferencesEnnis CE, Merritt RJ, Neff ON. In vitro study of inline filtration of medications commonly administered in pediatric cancer patients. J Parenter Enter Nutr. 1983; 7
    ReferencesFrancomb MM, Ford JL, Lee MG. Adsorption of vincristine, doxorubicin and mitoxantrone to in-line intravenous filters. Int J Pharm. 1994; 103
    ReferencesHoffman DM, Grossano DD, Damin L, et al. Stability of refrigerated and frozen solutions of doxorubicin hydrochloride. Am J Hosp Pharm. 1979; 36
    ReferencesPavlik EJ, van Nagell JR, Hanson MB, et al. Sensitivity to anticancer agents in vitro: standardizing the cytotoxic response and characterizing the sensitivities of a reference cell line. Gynecol Oncol. 1982; 14
    ReferencesPavlik EJ, Kenady DE, van Nagell JR, et al. Properties of anticancer agents relevant to in vitro determination of human tumor cell sensitivity. Cancer Chemother Pharmacol. 1983; 11
    ReferencesStevens RF, Wilkins KM. Use of cytotoxic drugs with an end-line filter - a study of four drugs commonly administered to pediatric patients. J Clin Pharm Ther. 1989; 14
    Sorption Leaching
    Sorption: Doxorubicin hydrochloride is subject to small amounts of sorption to polyvinyl chloride (PVC) materials at low concentrations. However, at clinical concentrations such sorption is unimportant. In addition, Xu et al. reported no sorption occurred to a polyurethane central catheter from Arrow International as well as no leaching of the chlorhexidine antimicrobial in it. Dine et al. reported that doxorubicin hydrochloride 0.016 mg/mL in both dextrose 5% and sodium chloride 0.9% did not exhibit major fluctuations in delivered drug concentrations delivered through PVC administration set tubing over 24 hours at room temperature. Wood et al. reported that about 7 to 8% loss occurred from a doxorubicin hydrochloride 0.1-mg/mL solution to PVC containers in 8 days at room temperature and refrigerated. Losses were somewhat higher when sodium chloride 0.9% was used as the diluent compared to dextrose 5%. Francomb et al. reported no loss of doxorubicin hydrochloride from a 1-mg/mL solution in sodium chloride 0.9% to PVC administration set tubing. Additionally, in several stability studies doxorubicin hydrochloride has not been found to undergo substantial sorption to glass containers, PVC containers, Freeflex (Fresenius Kabi) low-density polyethylene containers and other polyolefin containers, polypropylene (in syringes), ethylene vinyl acetate containers, or to elastomeric pump reservoirs. Leaching: Sautou-Miranda et al. did not find any leached DEHP plasticizer from Viaflex PVC containers into solutions of doxorubicin hydrochloride 20 mcg/mL and 0.1 mg/mL in dextrose 5% and sodium chloride 0.9% stored for 8 days at room temperature and under refrigeration.
    ReferencesAllen LV Jr, Stiles ML, Prince SJ, et al. Stability of 14 drugs in the latex reservoir of an elastomeric infusion device. Am J Health-Syst Pharm. 1996; 53
    ReferencesAnon. Guidelines for the administration of drugs using the Homepump Eclipse and C-Series disposable elastomeric infusion systems. Lake Forest, CA: I-Flow Corporation. 2004;
    ReferencesBenvenuto JA, Anderson RW, Kerkof K, et al. Stability and compatibility of antitumor agents in glass and plastic containers. Am J Hosp Pharm. 1981; 38
    ReferencesBenvenuto JA, Adams SC, Vyas HM, et al. Pharmaceutical issues in infusion chemotherapy stability and compatibility. in Lokich JJ (ed), Cancer chemotherapy by infusion. Chicago: Precept Press. 1987;
    ReferencesDine T, Cazin JC, Gressier B, et al. Stability and compatibility of four anthracyclines: doxorubicin, epirubicin, daunorubicin and pirarubicin with PVC infusion bags. Pharm Weekbl Sci Ed. 1992; 14
    ReferencesRochard EB, Barthes DMC, Courtouis PY. Stability of fluorouracil, cytarabine, or doxorubicin hydrochloride in ethylene vinylacetate portable infusion-pump reservoirs. Am J Hosp Pharm. 1992; 49
    ReferencesSautou-Miranda V, Brigas F, Thibault M, et al. Compatibility of doxorubicin, daunorubicin, and epirubicin with low-density polyethylene and polyvinyl chloride, and stability in various conditions of storage. Eur Hosp Pharm. 2001; 7
    ReferencesWood MJ, Irwin WJ, Scott DK. Stability of doxorubicin, daunorubicin and epirubicin in plastic syringes and minibags. J Clin Pharm Ther. 1990; 15
    ReferencesXu QA, Zhang Y, Trissel LA, et al. Adequacy of a new chlorhexidine-bearing polyurethane central catheter for administration of 82 selected parenteral drugs. Ann Pharmacother. 2000; 34
    Other Information
    Doxorubicin hydrochloride is cited by NIOSH as a drug that should be handled as hazardous. Aluminum: Ogawa et al. and Gardiner reported that doxorubicin hydrochloride reacts with metallic aluminum in administration equipment resulting in solution darkening, precipitation, and black patches forming on the aluminum; only needles and other equipment that contain no aluminum should be used. Williamson et al. reported that other metal equipment such as stainless steel needles with steel or plastic hubs do not react with doxorubicin hydrochloride in 24 hours. Microbial Growth Potential: Hamilton-Miller reported that doxorubicin exhibited little or no antimicrobial activity against 28 strains of microbes including Gram-positive aerobic bacterial, Gram-negative aerobic bacteria, anaerobic bacteria, and yeasts. Gaj et al. reported that doxorubicin hydrochloride 0.5 mg/mL in sodium chloride 0.9% supported the growth of four organisms associated with nosocomial infections. Similarly, Yuan et al. reported that a doxorubicin-containing admixture was unable to pass the USP test for antimicrobial growth effectiveness. The growth promotion capacity of doxorubicin hydrochloride should be included into decisions regarding beyond use dating. However, when Favier et al. evaluated the antimicrobial effects of doxorubicin 1.8 mg/mL in dextrose 5% against five microorganisms: Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, and Candida albicans. Test samples were packaged in Luer-lock syringes and were stored at room temperature and refrigerated at 4 to 8 degree C for up to 98 hours. The authors indicated a decrease in the growth rate for all of the microorganisms tested compared to the negative controls. The differing antimicrobial activity results might be related to differences in the test concentrations. Quality Control: Lelievre et al. described an approach to quality control and accuracy assessment for 22 cancer chemotherapy drugs, including doxorubicin hydrochloride, which is designed to reduce the risk of erroneously prepared doses reaching patients. The technique utilized an ultraviolet (UV)-visible and infrared (IR) scanning analysis (Multispec, Microdom) of the finished dosage forms to verify the right molecule, concentration, and solution. Of 3149 doses of the 22 drugs tested, 7.82% varied by more than 10% from the intended concentration.
    ReferencesAnon. Preventing occupational exposure to antineoplastic and other hazardous drugs in health care settings. NIOSH Publication No. 2004-165. 2004; 165
    ReferencesFavier B, Latour JF, Fuhrmann C. Viability of microorganisms in bags of cytotoxic drugs. J Oncol Pharm Pract. 2001; 6
    ReferencesGaj E, Sesin GP, Griffin RE. Evaluation of growth of five microorganisms in doxorubicin and floxuridine media. Pharm Manufacturing. 1984; 1
    ReferencesGardiner WA. Possible incompatibility of doxorubicin hydrochloride with aluminum. Am J Hosp Pharm. 1981; 38
    ReferencesHamilton-Miller JMY. Antimicrobial activity of 21 anti-neoplastic agents. Br J Cancer. 1984; 49
    ReferencesLelievre B, Devys C, Daouphars M, et al. Qualitative and quantitative analysis of chemotherapy preparations. Eur J Hosp Pharm Pract. 2010; 16
    ReferencesOgawa GS, Young R, Munar M. Dispensing-pin problems. Am J Hosp Pharm. 1985; 42
    ReferencesWilliamson MJ, Luce JK, Hausmann WK. Doxorubicin hydrochloride-aluminum interaction. Am J Hosp Pharm. 1983; 40
    ReferencesYuan P, Grimes GJ, Shankman SE, et al. Compatibility and stability of vincristine sulfate, doxorubicin hydrochloride, and etoposide phosphate in 0.9% sodium chloride injection. Am J Health-Syst Pharm. 2001; 58
    Stability Max
    Maximum reported stability periods: Reconstituted in NS: 142 days at room temperature and refrigerated protected from light. In D5W- 43 days at room temperature and refrigerated protected from light. In NS- 43 days at room temperature and refrigerated protected from light.
    ReferencesWalker SE, Lau D, DeAngelis C, et al. Doxorubicin stability in syringes and glass vials and evaluation of chemical contamination. Can J Hosp Pharm. 1991; 44
    ReferencesWood MJ, Irwin WJ, Scott DK. Stability of doxorubicin, daunorubicin and epirubicin in plastic syringes and minibags. J Clin Pharm Ther. 1990; 15
      Revision Date: 07/13/2024, 02:30:00 AMCopyright 2004-2024 by Lawrence A. Trissel. All Rights Reserved.

      References

      50657 - Carr BI, Bron K, Swanson DP et al. Prospective randomized trial of hepatic artery chemotherapy with cisplatin and doxorubicin, with or without lipiodol in the treatment of advanced stage hepatocellular carcinoma. J Clin Gastroenterol 2011;45:87-91.55200 - Schulmeister L. Extravasation management: clinical update. Semin Oncol Nurs 2011;27(1):82-90.61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.61629 - Adriamycin (doxorubicin) injection package insert. Eatontown, NJ: West-Ward Pharmaceuticals; 2015 Aug.63664 - CDC National Institute for Occupational Safety and Health (NIOSH). NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 2016. DHHS (NIOSH) Publication Number 2016-161, September 2016. Available on the World Wide Web at https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB201616167387 - Perez Fidalgo, JA, Garcia Fabregat L, Cervantes A, et al. Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol. 2012 Oct;23 Suppl; vii167-73.67389 - Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020 Aug 20;38(24):2782-2797.67392 - Paw Cho Sing E, Robinson P, Flank J, et al. Classification of the acute emetogenicity of chemotherapy in pediatric patients: A clinical practice guideline. Pediatr Blood Cancer. 2019 May;66(5):e27646. Doi: 10.1002/pbc.27646. Epub 2019 Feb 7.

      Adverse Reactions

      Mild

      • abdominal pain
      • alopecia
      • amenorrhea
      • anorexia
      • asthenia
      • azoospermia
      • chills
      • diarrhea
      • fever
      • gonadal suppression
      • infection
      • injection site reaction
      • lacrimation
      • malaise
      • nail discoloration
      • nausea
      • oligospermia
      • onycholysis
      • photosensitivity
      • pruritus
      • rash
      • skin hyperpigmentation
      • spermatogenesis inhibition
      • urine discoloration
      • urticaria
      • vomiting
      • weight gain

      Severe

      • anaphylactoid reactions
      • cardiomyopathy
      • cardiotoxicity
      • coma
      • GI bleeding
      • heart failure
      • keratitis
      • leukopenia
      • myocarditis
      • new primary malignancy
      • peptic ulcer
      • pericarditis
      • seizures
      • thrombocytopenia
      • tissue necrosis
      • tumor lysis syndrome (TLS)
      • typhlitis

      Moderate

      • bleeding
      • bone marrow suppression
      • colitis
      • conjunctivitis
      • dehydration
      • elevated hepatic enzymes
      • erythema
      • esophagitis
      • growth inhibition
      • leukopenia
      • neutropenia
      • oral ulceration
      • palmar-plantar erythrodysesthesia (hand and foot syndrome)
      • peripheral neuropathy
      • phlebitis
      • radiation recall reaction
      • skin ulcer
      • stomatitis
      • thrombocytopenia

      Bone marrow suppression including reversible, dose-dependent neutropenia has been reported with doxorubicin therapy; blood or platelet transfusions, hospitalization, and death may occur with doxorubicin use. Monitor complete blood counts (CBC) prior to starting doxorubicin; monitor CBC and for signs of clinical complications (e.g., infections, bleeding) during therapy. Septic shock (2%), systemic infection (2%), and severe leukopenia (grade 3, 3.4%; grade 4, 0.3%) and thrombocytopenia (grade 4, 0.1%) were reported in women who received 4 cycles of doxorubicin 60 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV (AC regimen) repeated every 3 weeks for the adjuvant treatment of axillary lymph-node positive breast cancer (n = 1,492). When doxorubicin is given every 3 weeks, the neutrophil count nadir is reached at 10 to 14 days following the dose.[61628]

      Cardiotoxicity, including cardiomyopathy, pericarditis, myocarditis, and left ventricular heart failure has been reported with doxorubicin therapy. Assess left ventricular function (e.g., MUGA or echocardiogram) before starting doxorubicin therapy and then regularly during and after therapy; use the same method of assessment at all time points. If the cumulative doxorubicin dose exceeds 300 mg/m2 in a patient that will continue to receive therapy, increase the frequency of cardiac assessment and consider starting dexrazoxane to reduce the incidence and severity of cardiomyopathy. The incidence of cardiotoxicity is highest in patients who exceed the maximum cumulative lifetime dose of 550 mg/m2. Cardiomyopathy may develop during treatment or up to several years after the completion of treatment. The estimated risk of developing cardiomyopathy (when doxorubicin is given every 3 weeks) is 1% to 2% at a cumulative dose of 300 mg/m2, 3% to 5% at a cumulative dose of 400 mg/m2, and 6% to 20% at a cumulative dose of 500 mg/m2. Asymptomatic cardiac dysfunction occurred in 0.2% of women who received 4 cycles of doxorubicin 60 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV (AC regimen) repeated every 3 weeks for the adjuvant treatment of axillary lymph-node positive breast cancer (n = 1,492); transient (0.1%) and symptomatic (0.1%) cardiac dysfunction were also reported. Cardiogenic shock was reported in postmarketing surveillance of doxorubicin.[61628]

      Fever and chills have been reported in postmarketing surveillance of doxorubicin.[61628]

      Gastrointestinal (GI) adverse events including nausea, mucositis/oral ulceration, stomatitis, necrotizing colitis, typhlitis, gastric erosion/peptic ulcer, GI bleeding, hematochezia, esophagitis, anorexia, abdominal pain, dehydration, diarrhea, hyperpigmentation of the oral mucosa have been reported with doxorubicin therapy. Vomiting for 12 hours or less (34%), vomiting for greater than 12 hours (37%), and intractable vomiting (5%) were reported in women who received 4 cycles of doxorubicin 60 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV (AC regimen) repeated every 3 weeks for the adjuvant treatment of axillary lymph-node positive breast cancer (n = 1,492).[61628]

      Alopecia was reported in 92% of women who received 4 cycles of doxorubicin 60 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV (AC regimen) repeated every 3 weeks for the adjuvant treatment of axillary lymph-node positive breast cancer (n = 1,492). Skin hyperpigmentation, nail discoloration/disorder, onycholysis, rash (unspecified), pruritus, photosensitivity, urticaria, acral erythema, and palmar-plantar erythrodysesthesia (hand and foot syndrome) have been reported in postmarketing surveillance of doxorubicin.[61628]

      Urine discoloration, specifically red coloration of urine for 1 to 2 days after administration, has been reported with IV doxorubicin use.[61628]

      Conjunctivitis, keratitis, and lacrimation have been reported in postmarketing surveillance of doxorubicin.[61628]

      Injection site reaction (e.g., extravasation, skin ulcer, severe local tissue necrosis) has been reported with doxorubicin therapy; wide excision of the affected area and skin grafting may be necessary if severe tissue injury occurs. Immediately stop the injection or infusion of doxorubicin if signs or symptoms of extravasation occur. If extravasation occurs or is suspected, apply ice at the site for 15 minutes 4 times daily for 3 days; administer dexrazoxane at the site as soon as possible and within the first 6 hours following extravasation. Extravasation may occur in the absence of typical symptoms (e.g., stinging or burning sensation) or when patients have adequate blood return on aspiration of the infusion needle. If doxorubicin is administered through a peripheral IV line, infuse doxorubicin over 10 minutes or less to minimize the risk of extravasation. Decrease the rate of doxorubicin infusion if erythematous streaking along the vein proximal to the site of infusion or facial flushing occur. Phlebosclerosis and phlebitis/thrombophlebitis have been reported in postmarketing surveillance of doxorubicin.[61628]

      Anaphylactoid reactions have been reported in postmarketing surveillance of doxorubicin.[61628]

      A radiation recall reaction that may include cutaneous or pulmonary toxicity has been reported in doxorubicin-treated patients who received prior radiation therapy.[61628]

      Tumor lysis syndrome (TLS) may occur in patients with rapidly growing tumors who received doxorubicin. Monitor serum electrolytes (e.g., potassium, calcium, phosphorus), uric acid levels, and serum creatinine prior to and during initial treatment. Administer hydration, urine alkalinization, and uric acid lowering therapy (e.g., allopurinol) as necessary to minimize the risk of complications associated with TLS.[61628]

      A new primary malignancy, including acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS), has been reported with doxorubicin therapy. In patients who received doxorubicin as adjuvant treatment for breast cancer, the cumulative incidence of secondary malignancy ranged from 0.2% at 5 years to 1.5% at 10 years in 2 separate trials; AML/MDS typically occurred within 1 to 3 years following treatment.[61628]

      Doxorubicin may cause gonadal suppression and infertility. Amenorrhea and premature menopause have been reported in females of reproductive potential who received doxorubicin. Ovulation and menstruation may return when therapy is discontinued. The recovery of menses is related to age at treatment. Oligospermia, azoospermia, and spermatogenesis inhibition resulting in permanent loss of fertility have occurred in males treated with doxorubicin. Sperm counts returned to normal levels in some men, sometimes several years after the end of treatment. Gonadal suppression/impairment has been reported in pediatric patients who received doxorubicin as part of intensive chemotherapy; most cases were reversible.[61628]

      Elevated hepatic enzymes (i.e., increased ALT and AST levels) have been reported in postmarketing surveillance of doxorubicin. Monitor liver function tests prior to starting doxorubicin and during therapy. A dose reduction is recommended in patients with mild or moderate hepatic disease/impairment (serum bilirubin levels of 1.2 to 5 mg/dL).[61628]

      Weight gain has been reported in postmarketing surveillance of doxorubicin.[61628]

      Malaise/asthenia has been reported in postmarketing surveillance of doxorubicin.[61628]

      Prepubertal growth inhibition/failure have been reported in pediatric patients who received doxorubicin as part of intensive chemotherapy; gonadal impairment was usually reversible.[61628]

      Peripheral neuropathy (sensory and motor), seizures, and coma have been reported in postmarketing surveillance of doxorubicin.[61628]

      Revision Date: 07/13/2024, 02:30:00 AM

      References

      61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.

      Contraindications/Precautions

      Absolute contraindications are italicized.

      • anthracycline hypersensitivity
      • hepatic disease
      • myocardial infarction
      • bone marrow suppression
      • breast-feeding
      • cardiomyopathy
      • cardiotoxicity
      • children
      • contraception requirements
      • extravasation
      • females
      • growth inhibition
      • heart failure
      • infants
      • infection
      • infertility
      • leukopenia
      • male-mediated teratogenicity
      • maximum cumulative lifetime dose
      • myocarditis
      • neutropenia
      • new primary malignancy
      • pericarditis
      • pregnancy
      • radiation therapy
      • reproductive risk
      • thrombocytopenia
      • tissue necrosis
      • tumor lysis syndrome (TLS)
      • vaccination

      Doxorubicin is contraindicated in patients who have had a severe hypersensitivity reaction (e.g., anaphylaxis) to doxorubicin.[61628] Use doxorubicin with caution in patients who have an anthracycline hypersensitivity (or anthracenedione hypersensitivity) to another agent in the class.

      Doxorubicin is contraindication in patients with severe hepatic impairment (defined as Child-Pugh class C or serum bilirubin levels greater than 5 mg/dL). Use doxorubicin with caution in patients with mild or moderate hepatic disease/impairment (serum bilirubin levels of 1.2 to 5 mg/dL); a dose reduction is recommended in these patients. Monitor liver function tests prior to starting doxorubicin and during therapy.[61628]

      Cardiotoxicity (e.g., cardiomyopathy, pericarditis, myocarditis, and left ventricular heart failure) has been reported with doxorubicin therapy. Doxorubicin use is contraindicated in patients with severe myocardial insufficiency or recent (occurring within the past 4 to 6 weeks) myocardial infarction. Assess left ventricular function (e.g., MUGA or echocardiogram) before starting doxorubicin therapy and then regularly during and after therapy; use the same method of assessment at all time points. If the cumulative doxorubicin dose exceeds 300 mg/m2 in a patient that will continue to receive therapy, increase the frequency of cardiac assessment and consider starting dexrazoxane to reduce the incidence and severity of cardiomyopathy. Increased cumulative anthracycline (or anthracenediones) doses, concomitant cardiotoxicity medication (e.g., cyclophosphamide, trastuzumab), and prior mediastinum radiotherapy increase the risk of cardiotoxicity. The incidence of cardiotoxicity is highest in patients who exceed the maximum cumulative lifetime dose of 550 mg/m2. Cardiomyopathy may develop during treatment or up to several years after the completion of treatment. The estimated risk of developing cardiomyopathy (when doxorubicin is given every 3 weeks) is 1% to 2% at a cumulative dose of 300 mg/m2, 3% to 5% at a cumulative dose of 400 mg/m2, and 6% to 20% at a cumulative dose of 500 mg/m2.[61628]

      Severe myelosuppression/bone marrow suppression (leukopenia, neutropenia, thrombocytopenia) has been reported with doxorubicin therapy; serious infection, septic shock, blood or platelet transfusions, hospitalization, and death may occur due to severe myelosuppression. Doxorubicin use is contraindicated in patients with severe persistent drug-induced bone marrow suppression. Monitor complete blood counts (CBC) prior to starting doxorubicin; monitor CBC and for signs of clinical complications (e.g., infection, bleeding) during therapy. A reversible, dose-dependent neutropenia is the most common doxorubicin-induced hematologic toxicity. When doxorubicin is given every 3 weeks, the neutrophil count nadir is typically reached 10 to 14 days following the dose.[61628]

      Extravasation and severe local tissue necrosis have been reported with doxorubicin therapy; wide excision of the affected area and skin grafting may be necessary if severe tissue injury occurs. Immediately stop the injection or infusion of doxorubicin if signs or symptoms of extravasation occur. If extravasation occurs or is suspected, apply ice at the site for 15 minutes 4 times daily for 3 days; administer dexrazoxane at the site as soon as possible and within the first 6 hours following extravasation. Extravasation may occur in the absence of typical symptoms (e.g., stinging or burning sensation) or when patients have adequate blood return on aspiration of the infusion needle. If doxorubicin is administered through a peripheral IV line, infuse doxorubicin over 10 minutes or less to minimize the risk of extravasation.[61628]

      A new primary malignancy, including acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS), has been reported with doxorubicin therapy. In patients who received doxorubicin as adjuvant treatment for breast cancer, the cumulative incidence of secondary malignancy ranged from 0.2% at 5 years to 1.5% at 10 years in 2 separate trials; AML/MDS typically occurred within 1 to 3 years following treatment.[61628]

      Increased toxicity to the myocardium, mucosa, skin, and liver may occur when doxorubicin is used concurrently with radiation therapy. Additionally, a radiation recall reaction that may include cutaneous or pulmonary toxicity has been reported in doxorubicin-treated patients who received prior radiation therapy.[61628]

      Tumor lysis syndrome (TLS) may occur in doxorubicin-treated patients with rapidly growing tumors. Monitor serum electrolytes (e.g., potassium, calcium, phosphorus), uric acid levels, and serum creatinine prior to and during initial treatment. Administer hydration, urine alkalinization, and uric acid lowering therapy (e.g., allopurinol) as appropriate to minimize the risk of complications associated with TLS.[61628]

      Females may have an increased risk of anthracycline-induced cardiotoxicity. Female patients had a significantly greater reduction in cardiac contractility compared with male patients based on echocardiogram evaluations in a study in 120 children and adults who had been treated with bolus doses of doxorubicin (cumulative doses of 244 to 550 mg/m2) in childhood.[24421]

      Pediatric patients including adolescents, children, and infants are at risk for developing late cardiovascular dysfunction with anthracycline therapy. Pediatric patients should receive long-term, periodic cardiac evaluations after receiving doxorubicin. Risk factors include young age at treatment (especially in children less than 5 years of age), high cumulative doses, and a history of receiving combined modality therapy. Prepubertal growth inhibition/failure and gonadal impairment have been reported in pediatric patients who received doxorubicin as part of intensive chemotherapy; gonadal impairment was usually reversible.[61628] In pediatric patients receiving greater than or equal to 250 mg/m2 of cumulative anthracycline (doxorubicin) exposure, primary prophylaxis with dexrazoxane should be considered.[68606]

      Doxorubicin is pregnancy category D. It may cause fetal harm when administered to a pregnant woman. Females of reproductive potential should avoid pregnancy during doxorubicin therapy. Apprise the patient of the potential hazard to a fetus if doxorubicin is used during pregnancy or if the patient becomes pregnant while taking doxorubicin. In animal studies in rats and rabbits, doxorubicin was teratogenic (e.g., esophageal and intestinal atresia, tracheo-esophageal fistula, hypoplasia of the urinary bladder, and cardiovascular anomalies) and embryotoxic at doses approximately 0.07-times (based on body surface area) the recommended human dose of 60 mg/m2.[61628]

      Counsel patients about the reproductive risk and contraception requirements during doxorubicin treatment. Females of reproductive potential should use effective contraception during and for 6 months after treatment with doxorubicin. Due to male-mediated teratogenicity, men with female partners of reproductive potential should use effective contraception during therapy and for 6 months following the final dose of doxorubicin. Doxorubicin may cause infertility; amenorrhea has been reported in females and oligospermia, azoospermia, and permanent loss of fertility have been reported in males. Sperm counts returned to normal levels in some men who received doxorubicin, sometimes several years after the end of treatment.[61628]

      Doxorubicin has been detected in breast milk and should not be administered in breast-feeding women. Peak milk concentrations in 1 patient were approximately 4.4-times greater than plasma concentrations 24 hours after treatment. Doxorubicin was detectable in breast milk up to 72 hours after therapy. Due to the potential for serious adverse reactions in nursing infants from doxorubicin, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.[61628]

      Vaccination with live vaccines should be avoided during treatment with doxorubicin due to the risk of serious or fatal infections. Killed or inactivated vaccines may be administered; however, patient response may be diminished due to immunosuppression.[43236] [61628]

      Revision Date: 07/13/2024, 02:30:00 AM

      References

      24421 - Lipshultz SE, Lipsitz SR, Mone SM, et al. Female sex and higher drug dose as risk factors for late cardiotoxic effects of doxorubicin therapy for childhood cancer. N Engl J Med 1995;332:1738-43.43236 - National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60(2):1-64.61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.68606 - Liesse K, Harris J, Chan M, et al. Dexrazoxane Significantly Reduces Anthracycline-induced Cardiotoxicity in Pediatric Solid Tumor Patients:A Systematic Review. J Pediatr Hematol Oncol 2018;40:417–425.

      Mechanism of Action

      Doxorubicin is a cytotoxic anthracycline antibiotic derived from Streptomyces peucetius. It prevents the replication of rapidly growing cells by intercalating between base pairs of the DNA/RNA strand and inhibiting DNA and RNA synthesis. Doxorubicin is also a topoisomerase II inhibitor that works by stabilizing the covalently bound form of the topoisomerase II enzyme with DNA causing increased topoisomerase II cross-linked DNA strand breaks.[61628] Several mechanisms of doxorubicin-induced cardiotoxicity have been proposed including iron-catalyzed induction of cardiac oxidative stress, altered calcium homeostasis, impaired gene expression of cardiac proteins, dysregulation of protein degradation by the ubiquitin–proteasome system, induction of mitochondrial DNA lesions, and interference with topoisomerase II. Doxorubicin undergoes one-electron reduction to form oxygen free radical intermediates. In the presence of oxygen and metal catalysts such as iron (Fe2+), doxorubicin undergoes reduction to the semiquone radical. In the presence of oxygen, the semiquone radical can form a superperoxide that in the presence of hydrogen peroxide forms hydroxyl radicals. Mitochondria appear to be an important target for anthracycline-induced cardiotoxicity; anthracyclines are found in high concentrations in the mitochondrial compartment. Doxorubicin binds with high-affinity to cardiolipin, a major phospholipid component of heart mitochondrial inner membranes.[61705]

      Revision Date: 07/13/2024, 02:30:00 AM

      References

      61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.61705 - Sterba M, Popelova O, Vavrova A, et al. Oxidative stress, redox signaling, and metal chelation in anthracycline cardiotoxicity and pharmacological cardioprotection. Antioxid Redox Signal 2013;18(8):899-929.

      Pharmacokinetics

      Doxorubicin is administered intravenously (IV). Doxorubicin and its major metabolite, doxorubicinol, are approximately 75% bound to plasma proteins; binding is independent of plasma concentration up to 1.1 mcg/mL. It does not cross the blood brain barrier. In pharmacokinetic analyses of doxorubicin, the steady-state volume of distribution was 809 to 1,214 L/m2, the plasma clearance was 324 to 809 mL/min/m2, and the terminal half-life was 20 to 48 hours. Doxorubicin is primarily excreted in the bile. Following a doxorubicin IV dose, about 40% of the dose is found in the bile and 5% to 12% of the parent drug and its metabolites appear in the urine within 5 days. Less than 3% of the dose is recovered as doxorubicinol in the urine within 7 days. The AUC ratio between doxorubicinol and doxorubicin is about 0.5.

       

      Affected cytochrome P450 (CYP450) isoenzymes and drug transporters: CYP2D6, CYP3A4, P-gp

      Doxorubicin is metabolized via CYP3A4 and CYP2D6; it is also a P-glycoprotein (P-gp) substrate. Avoid concomitant use with CYP3A4, CYP2D6, or P-gp inhibitors and inducers.[61628]

      Route-Specific Pharmacokinetics

      Intravenous Route

      In cancer patients, doxorubicin exhibits multiphasic disposition after an IV injection. It had dose independent pharmacokinetics in 4 patients receiving doxorubicin 30 to 70 mg/m2.[61628]

      Special Populations

      Hepatic Impairment

      The clearance of doxorubicin is reduced in patients with elevated serum bilirubin levels.[61628]

      Pediatrics

      In a pharmacokinetic analysis in pediatric patients (n = 60; age range, 2 months to 20 years), the clearance was 1,443 +/- 114 mL/min/m2) following doxorubicin 10 to 75 mg/m2 IV. The clearance was 1,540 mL/min/m2 in pediatric patients greater than 2 years of age which was increased compared with adult patients. The clearance was 813 mL/min/m2 in patients younger than 2 years of age.[61628]

      Gender Differences

      Gender did not significantly affect doxorubicin pharmacokinetics in a clinical study. A higher median clearance (1,088 vs. 433 mL/min/m2) and a longer half-life (54 vs. 35 hours) were reported in men (n = 6) compared to women (n = 21) who received doxorubicin.[61628]

      Obesity

      The systemic clearance of doxorubicin was significantly reduced in obese women with an ideal body weight (IBW) greater than 130% compared with patients with less than 115% of IBW. There was no change in volume of distribution.[61628]

      Revision Date: 07/13/2024, 02:30:00 AM

      References

      61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.

      Pregnancy/Breast-feeding

      pregnancy

      Doxorubicin is pregnancy category D. It may cause fetal harm when administered to a pregnant woman. Females of reproductive potential should avoid pregnancy during doxorubicin therapy. Apprise the patient of the potential hazard to a fetus if doxorubicin is used during pregnancy or if the patient becomes pregnant while taking doxorubicin. In animal studies in rats and rabbits, doxorubicin was teratogenic (e.g., esophageal and intestinal atresia, tracheo-esophageal fistula, hypoplasia of the urinary bladder, and cardiovascular anomalies) and embryotoxic at doses approximately 0.07-times (based on body surface area) the recommended human dose of 60 mg/m2.[61628]

      breast-feeding

      Doxorubicin has been detected in breast milk and should not be administered in breast-feeding women. Peak milk concentrations in 1 patient were approximately 4.4-times greater than plasma concentrations 24 hours after treatment. Doxorubicin was detectable in breast milk up to 72 hours after therapy. Due to the potential for serious adverse reactions in nursing infants from doxorubicin, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.[61628]

      Revision Date: 07/13/2024, 02:30:00 AM

      References

      61628 - Doxorubicin injection package insert. Rockford, IL: Mylan Institutional LLC; 2016 July.

      Interactions

      Level 2 (Major)

      • Abacavir; Lamivudine, 3TC; Zidovudine, ZDV
      • Abiraterone
      • Abrocitinib
      • Acetaminophen; Chlorpheniramine
      • Acetaminophen; Chlorpheniramine; Dextromethorphan
      • Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine
      • Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine
      • Acetaminophen; Chlorpheniramine; Phenylephrine
      • Adagrasib
      • Amiodarone
      • Amlodipine; Celecoxib
      • Amobarbital
      • Amoxicillin; Clarithromycin; Omeprazole
      • Apalutamide
      • Aspirin, ASA; Butalbital; Caffeine
      • Atazanavir
      • Atazanavir; Cobicistat
      • Avacopan
      • Belumosudil
      • Berotralstat
      • Bexarotene
      • Bosentan
      • Bupropion
      • Bupropion; Naltrexone
      • Butalbital; Acetaminophen
      • Butalbital; Acetaminophen; Caffeine
      • Butalbital; Acetaminophen; Caffeine; Codeine
      • Butalbital; Aspirin; Caffeine; Codeine
      • Cannabidiol
      • Capivasertib
      • Capmatinib
      • Carbamazepine
      • Celecoxib
      • Celecoxib; Tramadol
      • Cenobamate
      • Ceritinib
      • Chloramphenicol
      • Chlorpheniramine
      • Chlorpheniramine; Codeine
      • Chlorpheniramine; Dextromethorphan
      • Chlorpheniramine; Dextromethorphan; Phenylephrine
      • Chlorpheniramine; Dextromethorphan; Pseudoephedrine
      • Chlorpheniramine; Hydrocodone
      • Chlorpheniramine; Ibuprofen; Pseudoephedrine
      • Chlorpheniramine; Phenylephrine
      • Chlorpheniramine; Pseudoephedrine
      • Chlorpromazine
      • Cimetidine
      • Cinacalcet
      • Ciprofloxacin
      • Clarithromycin
      • Clobazam
      • Cobicistat
      • Cocaine
      • Conivaptan
      • Crizotinib
      • Cyclosporine
      • Dabrafenib
      • Dacomitinib
      • Dalfopristin; Quinupristin
      • Danazol
      • Danicopan
      • Daridorexant
      • Darifenacin
      • Darunavir
      • Darunavir; Cobicistat
      • Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide
      • Delavirdine
      • Dextromethorphan; Bupropion
      • Dextromethorphan; Quinidine
      • Diltiazem
      • Dronedarone
      • Duloxetine
      • Duvelisib
      • Efavirenz
      • Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate
      • Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate
      • Elacestrant
      • Elexacaftor; tezacaftor; ivacaftor
      • Eliglustat
      • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide
      • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate
      • Enasidenib
      • Encorafenib
      • Enzalutamide
      • Erdafitinib
      • Erythromycin
      • Escitalopram
      • Eslicarbazepine
      • Ethotoin
      • Etravirine
      • Fedratinib
      • Fluconazole
      • Flutamide
      • Fluvoxamine
      • Fosamprenavir
      • Fosphenytoin
      • Fostamatinib
      • Futibatinib
      • Gilteritinib
      • grapefruit juice
      • Hydantoins
      • Idelalisib
      • Imatinib
      • Indinavir
      • Isoniazid, INH
      • Isoniazid, INH; Pyrazinamide, PZA; Rifampin
      • Isoniazid, INH; Rifampin
      • Istradefylline
      • Itraconazole
      • Ivacaftor
      • Ketoconazole
      • Lamivudine, 3TC; Zidovudine, ZDV
      • Lansoprazole; Amoxicillin; Clarithromycin
      • Lapatinib
      • Larotrectinib
      • Lasmiditan
      • Lefamulin
      • Lenacapavir
      • Letermovir
      • Levoketoconazole
      • Lonafarnib
      • Lopinavir; Ritonavir
      • Lorcaserin
      • Lorlatinib
      • Lumacaftor; Ivacaftor
      • Lumacaftor; Ivacaftor
      • Margetuximab
      • Maribavir
      • Mavacamten
      • Mavorixafor
      • Methohexital
      • Mirabegron
      • Mitapivat
      • Mitotane
      • Modafinil
      • Mycophenolate
      • Nafcillin
      • Nefazodone
      • Nelfinavir
      • Neratinib
      • Nicardipine
      • Nicotine
      • Nilotinib
      • Niraparib; Abiraterone
      • Nirmatrelvir; Ritonavir
      • Nirogacestat
      • Omeprazole; Amoxicillin; Rifabutin
      • Oritavancin
      • Osimertinib
      • Oxcarbazepine
      • Pacritinib
      • Palbociclib
      • Paroxetine
      • Pazopanib
      • Peginterferon Alfa-2b
      • Pentobarbital
      • Perampanel
      • Pertuzumab; Trastuzumab; Hyaluronidase
      • Pexidartinib
      • Phenobarbital
      • Phenobarbital; Hyoscyamine; Atropine; Scopolamine
      • Phentermine; Topiramate
      • Phenytoin
      • Pirtobrutinib
      • Posaconazole
      • Pretomanid
      • Primidone
      • Propafenone
      • Quinidine
      • Quinine
      • Ranolazine
      • Repotrectinib
      • Ribociclib
      • Ribociclib; Letrozole
      • Rifabutin
      • Rifampin
      • Rifapentine
      • Ritonavir
      • Rolapitant
      • Saquinavir
      • Sarecycline
      • Secobarbital
      • Selpercatinib
      • Sodium Phenylbutyrate; Taurursodiol
      • Sofosbuvir; Velpatasvir; Voxilaprevir
      • Sorafenib
      • Sotorasib
      • Sparsentan
      • St. John's Wort, Hypericum perforatum
      • Streptogramins
      • Temsirolimus
      • Tepotinib
      • Tezacaftor; Ivacaftor
      • Thioridazine
      • Thiothixene
      • Tipranavir
      • Topiramate
      • Trandolapril; Verapamil
      • Trastuzumab
      • Trastuzumab; Hyaluronidase
      • Tucatinib
      • Valproic Acid, Divalproex Sodium
      • Vemurafenib
      • Verapamil
      • Voclosporin
      • Vonoprazan; Amoxicillin; Clarithromycin
      • Voriconazole
      • Voxelotor
      • Zafirlukast
      • Zidovudine, ZDV

      Level 3 (Moderate)

      • Aprepitant, Fosaprepitant
      • Brigatinib
      • Carvedilol
      • Cholera Vaccine
      • Cyclophosphamide
      • Dengue Tetravalent Vaccine, Live
      • Desogestrel; Ethinyl Estradiol
      • Dexrazoxane
      • Drospirenone; Ethinyl Estradiol
      • Drospirenone; Ethinyl Estradiol; Levomefolate
      • Elbasvir; Grazoprevir
      • Ethinyl Estradiol; Norelgestromin
      • Ethinyl Estradiol; Norethindrone Acetate
      • Ethinyl Estradiol; Norgestrel
      • Ethynodiol Diacetate; Ethinyl Estradiol
      • Etonogestrel; Ethinyl Estradiol
      • Gadobenate Dimeglumine
      • Ganciclovir
      • Glecaprevir; Pibrentasvir
      • Isavuconazonium
      • Ledipasvir; Sofosbuvir
      • Levonorgestrel; Ethinyl Estradiol
      • Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate
      • Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate
      • Mercaptopurine, 6-MP
      • Mifepristone
      • Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate
      • Norethindrone; Ethinyl Estradiol
      • Norethindrone; Ethinyl Estradiol; Ferrous fumarate
      • Norgestimate; Ethinyl Estradiol
      • Paclitaxel
      • SARS-CoV-2 (COVID-19) vaccines
      • SARS-CoV-2 Virus (COVID-19) Adenovirus Vector Vaccine
      • SARS-CoV-2 Virus (COVID-19) mRNA Vaccine
      • SARS-CoV-2 Virus (COVID-19) Recombinant Spike Protein Nanoparticle Vaccine
      • Segesterone Acetate; Ethinyl Estradiol
      • Tuberculin Purified Protein Derivative, PPD
      • Valganciclovir

      Level 4 (Minor)

      • Acetaminophen; Aspirin; Diphenhydramine
      • Acetaminophen; Diphenhydramine
      • Cabozantinib
      • Dextromethorphan; Diphenhydramine; Phenylephrine
      • Diphenhydramine
      • Diphenhydramine; Ibuprofen
      • Diphenhydramine; Naproxen
      • Diphenhydramine; Phenylephrine
      • Docetaxel
      • Estradiol; Progesterone
      • Progesterone
      • Zonisamide
      Abacavir; lamiVUDine, 3TC; Zidovudine, ZDV: (Major) Avoid concomitant administration of zidovudine, ZDV, and doxorubicin as an antagonistic relationship has been demonstrated in vitro. [28305] Abiraterone: (Major) Avoid coadministration of doxorubicin with abiraterone due to increased plasma concentrations of doxorubicin. Doxorubicin is a CYP2D6 substrate and abiraterone is a moderate CYP2D6 inhibitor. Clinically significant interactions have been reported with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. [44156] [56361] Abrocitinib: (Major) Avoid coadministration of abrocitinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and abrocitinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67277] Acetaminophen; Aspirin; diphenhydrAMINE: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] Acetaminophen; Chlorpheniramine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Acetaminophen; Chlorpheniramine; Dextromethorphan: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Acetaminophen; Chlorpheniramine; Phenylephrine : (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Acetaminophen; diphenhydrAMINE: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] Adagrasib: (Major) Avoid coadministration of doxorubicin with adagrasib due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a CYP3A, CYP2D6, and P-gp substrate; adagrasib is a strong CYP3A, moderate CYP2D6, and P-gp inhibitor. Concurrent use of CYP3A, CYP2D6, or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68325] Amiodarone: (Major) Avoid coadministration of amiodarone with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and amiodarone is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [56579] amLODIPine; Celecoxib: (Major) Avoid coadministration of celecoxib and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Celecoxib is a CYP2D6 inhibitor, and doxorubicin is a CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. [56268] [56361] Amobarbital: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [4752] [56361] Amoxicillin; Clarithromycin; Omeprazole: (Major) Avoid coadministration of clarithromycin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Clarithromycin is a strong CYP3A4 inhibitor and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 inhibitors or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28238] [34329] [56361] Apalutamide: (Major) Avoid coadministration of doxorubicin with apalutamide due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and apalutamide is a strong CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [62874] Aprepitant, Fosaprepitant: (Moderate) Aprepitant, fosaprepitant is indicated for the prophylaxis of chemotherapy-induced nausea/vomiting and is often used in combination with doxorubicin. However, use caution and monitor for a possible increase in non-emetogenic doxorubicin-related adverse effects for several days after administration of a multi-day aprepitant regimen. Of note, doxorubicin was included in treatment regimens used in four of the multicenter, randomized, double-blind, controlled clinical trials evaluating the efficacy of aprepitant in highly emetogenic (HEC) and moderately emetogenic chemotherapy (MEC). Doxorubicin is a CYP3A4 substrate. Aprepitant, when administered as a 3-day oral regimen (125 mg/80 mg/80 mg), is a moderate CYP3A4 inhibitor and inducer and theoretically could increase plasma concentrations of doxorubicin. For example, a 5-day oral aprepitant regimen increased the AUC of another CYP3A4 substrate, midazolam (single dose), by 2.3-fold on day 1 and by 3.3-fold on day 5. After a 3-day oral aprepitant regimen, the AUC of midazolam (given on days 1, 4, 8, and 15) increased by 25% on day 4, and then decreased by 19% and 4% on days 8 and 15, respectively. As a single 125 mg or 40 mg oral dose, the inhibitory effect of aprepitant on CYP3A4 is weak, with the AUC of midazolam increased by 1.5-fold and 1.2-fold, respectively. After administration, fosaprepitant is rapidly converted to aprepitant and shares many of the same drug interactions. However, as a single 150 mg intravenous dose, fosaprepitant only weakly inhibits CYP3A4 for a duration of 2 days; there is no evidence of CYP3A4 induction. Fosaprepitant 150 mg IV as a single dose increased the AUC of midazolam (given on days 1 and 4) by approximately 1.8-fold on day 1; there was no effect on day 4. Less than a 2-fold increase in the midazolam AUC is not considered clinically important. [30676] [34506] [40027] [56361] Aspirin, ASA; Butalbital; Caffeine: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Atazanavir: (Major) Atazanavir is a strong CYP3A4 inhibitor; doxorubicin is a major substrate of CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of atazanavir and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [50767] [56361] Atazanavir; Cobicistat: (Major) Atazanavir is a strong CYP3A4 inhibitor; doxorubicin is a major substrate of CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of atazanavir and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [50767] [56361] (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] Avacopan: (Major) Avoid coadministration of doxorubicin with avacopan due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP3A and avacopan is a moderate CYP3A inhibitor. Concurrent use of CYP3A inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67036] Belumosudil: (Major) Avoid coadministration of belumosudil with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and belumosudil is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [66808] Berotralstat: (Major) Avoid coadministration of doxorubicin with berotralstat due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP2D6 and CYP3A and berotralstat is a moderate CYP2D6 inhibitor and moderate CYP3A inhibitor. Concurrent use of CYP2D6 or CYP3A inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [66159] Bexarotene: (Major) Avoid coadministration of doxorubicin with bexarotene due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and bexarotene is a moderate CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [28068] [56361] Bosentan: (Major) Bosentan is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of bosentan and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28496] [56361] Brigatinib: (Moderate) Monitor for an increase in doxorubicin-related adverse reactions if coadministration with brigatinib is necessary. Doxorubicin is a substrate of P-glycoprotein (P-gp). Brigatinib inhibits P-gp in vitro and may have the potential to increase concentrations of P-gp substrates. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [61628] [61909] buPROPion: (Major) In vitro, bupropion is a mild CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of bupropion and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [41057] [56361] buPROPion; Naltrexone: (Major) In vitro, bupropion is a mild CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of bupropion and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [41057] [56361] Butalbital; Acetaminophen: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Butalbital; Acetaminophen; Caffeine: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Butalbital; Acetaminophen; Caffeine; Codeine: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Butalbital; Aspirin; Caffeine; Codeine: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Cabozantinib: (Minor) Monitor for an increase in doxorubicin-related adverse reactions if coadministration with cabozantinib is necessary. Doxorubicin is a P-glycoprotein (P-gp) substrate. Cabozantinib is a P-gp inhibitor and has the potential to increase plasma concentrations of P-gp substrates; however, the clinical relevance of this finding is unknown. [34506] [52506] [56361] [60738] Cannabidiol: (Major) Avoid coadministration of cannabidiol with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and cannabidiol is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63309] Capivasertib: (Major) Avoid coadministration of doxorubicin with capivasertib due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP2D6 and capivasertib is a moderate CYP2D6 inhibitor. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [69896] Capmatinib: (Major) Avoid coadministration of capmatinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Capmatinib is a P-gp inhibitor and doxorubicin is a P-gp substrate. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [34506] [56361] [65377] carBAMazepine: (Major) Avoid coadministration of doxorubicin with carbamazepine due to the risk for decreased doxorubicin plasma concentrations which may compromise the efficacy of chemotherapy. Doxorubicin is a CYP3A substrate and carbamazepine is a strong CYP3A inducer. [56361] [56579] Carvedilol: (Moderate) Increased concentrations of doxorubicin may occur if it is coadministered with carvedilol; exercise caution. Carvedilol is a P-glycoprotein (P-gp) inhibitor and doxorubicin is a P-gp substrate. [34506] [51834] [56361] [58220] Celecoxib: (Major) Avoid coadministration of celecoxib and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Celecoxib is a CYP2D6 inhibitor, and doxorubicin is a CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. [56268] [56361] Celecoxib; Tramadol: (Major) Avoid coadministration of celecoxib and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Celecoxib is a CYP2D6 inhibitor, and doxorubicin is a CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. [56268] [56361] Cenobamate: (Major) Avoid coadministration of doxorubicin with cenobamate due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and cenobamate is a moderate CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [64768] Ceritinib: (Major) Avoid coadministration of ceritinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ceritinib is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [57094] Chloramphenicol: (Major) Chloramphenicol is a CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chloramphenicol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Codeine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Dextromethorphan: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; HYDROcodone: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Phenylephrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] Chlorpheniramine; Pseudoephedrine: (Major) Chlorpheniramine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of chlorpheniramine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29624] [56361] chlorproMAZINE: (Major) Avoid coadministration of chlorpromazine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Chlorpromazine is a CYP2D6 inhibitor, and doxorubicin is a major substrate of CYP2D6. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [43065] [56361] Cholera Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the live cholera vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to cholera bacteria after receiving the vaccine. [60871] Cimetidine: (Major) Cimetidine is a mild inhibitor of CYP2D6 and CYP3A4; doxorubicin is a major CYP2D6 and CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of cimetidine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34364] [56361] [56579] [57012] Cinacalcet: (Major) Avoid coadministration of doxorubicin with cinacalcet due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP2D6 and cinacalcet is a moderate CYP2D6 inhibitor. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [28126] [56361] Ciprofloxacin: (Major) Avoid coadministration of ciprofloxacin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ciprofloxacin is a moderate CYP3A4 inhibitor, and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [43411] [56361] [56579] Clarithromycin: (Major) Avoid coadministration of clarithromycin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Clarithromycin is a strong CYP3A4 inhibitor and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 inhibitors or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28238] [34329] [56361] cloBAZam: (Major) Avoid coadministration of doxorubicin and clobazam due to the potential for altered doxorubicin exposure. Doxorubicin is a major substrate of CYP3A4 and CYP2D6. Clobazam is a weak inhibitor of CYP2D6 and a weak inducer of CYP3A4. Clinically significant interactions have been reported with inhibitors of CYP2D6 resulting in increased concentration and clinical effect of doxorubicin while inducers of CYP3A4 may decrease the concentration of doxorubicin. [46370] [56361] Cobicistat: (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] Cocaine: (Major) Cocaine is a potent CYP2D6 inhibitor and a mild inhibitor of CYP3A4; doxorubicin is a major CYP2D6 and CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Increased side effects of doxorubicin, including myelosuppression and cardiotoxicity, might occur. Avoid coadministration of cocaine and doxorubicin when possible. Local, limited topical use of cocaine in medical procedures is not expected to produce interactions. [56361] [57067] Conivaptan: (Major) Avoid coadministration of doxorubicin with conivaptan due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a substrate of CYP3A and P-gp and conivaptan is a moderate CYP3A and P-gp inhibitor. [31764] [56361] Crizotinib: (Major) Avoid coadministration of crizotinib with doxorubicin due to the risk of increased doxorubicin exposure resulting in increased treatment-related adverse reactions. Crizotinib is a moderate CYP3A inhibitor and doxorubicin is a major substrate of CYP3A4; clinically significant interactions have been reported with other CYP3A4 inhibitors, resulting in increased concentration and clinical effect of doxorubicin. [45458] [56361] cycloPHOSphamide: (Moderate) Monitor for signs and symptoms of cardiac dysfunction if coadministration of cyclophosphamide with anthracyclines is necessary as there is an additive or potentially synergistic increase in the risk of cardiomyopathy. [61628] [65780] [65781] [65782] cycloSPORINE: (Major) Concurrent use of doxorubicin with other agents which cause bone marrow or immune suppression such as other immunosuppressants may result in additive effects. In addition, high doses of cyclosporine (starting at 16 mg/kg/day IV) may increase exposure to anthracyclines (e.g., doxorubicin) in cancer patients. Cyclosporine is a substrate and inhibitor of P-glycoprotein, an energy-dependent drug efflux pump encoded for by the multidrug resistance gene-1 (MDR1). Overexpression of this protein has been described as a mechanism of resistance to naturally-occurring (non-synthetic) chemotherapy agents. Cyclosporine can block MDR1-mediated resistance when given at much higher doses than those used in transplantation and may also enhance the efficacy of doxorubicin by inhibiting this protein. Valspodar is a cyclosporine analog with less renal and immunosuppressive effects than cyclosporine while retaining effects on MDR. The addition of cyclosporine or valspodar to doxorubicin therapy may result in increases in AUC for both doxorubicin and doxorubicinol possibly due to a decrease in clearance of parent drug, a decrease in metabolism of doxorubicinol, or an increase in intracellular doxorubicin concentrations. Literature reports suggest that adding cyclosporine to doxorubicin results in more profound and prolonged hematologic toxicity than doxorubicin alone; coma and/or seizures have also been described. [4718] [5228] [54614] [5622] Dabrafenib: (Major) Dabrafenib is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of dabrafenib and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [54802] [56361] Dacomitinib: (Major) Avoid coadministration of dacomitinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a substrate of CYP2D6; dacomitinib is a strong CYP2D6 inhibitor. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effects of doxorubicin. [56361] [63584] Dalfopristin; Quinupristin: (Major) Avoid coadministration of dalfopristin; quinupristin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Dalfopristin; quinupristin is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [28491] [56361] Danazol: (Major) Danazol is a CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of danazol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34717] [56361] Danicopan: (Major) Avoid coadministration of danicopan with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and danicopan is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [70492] Daridorexant: (Major) Avoid coadministration of daridorexant with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and daridorexant is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67248] Darifenacin: (Major) Avoid coadministration of darifenacin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Darifenacin is a moderate CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [30711] [56361] Darunavir: (Major) Avoid coadministration of darunavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Darunavir is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [32432] [56361] Darunavir; Cobicistat: (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] (Major) Avoid coadministration of darunavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Darunavir is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [32432] [56361] Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] (Major) Avoid coadministration of darunavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Darunavir is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [32432] [56361] Delavirdine: (Major) Delavirdine is a potent CYP3A4 inhibitor as well as a CYP2D6 inhibitor; doxorubicin is a major CYP2D6 and CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of delavirdine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28476] [56361] Dengue Tetravalent Vaccine, Live: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the dengue virus vaccine. When feasible, administer indicated vaccines at least 2 weeks prior to initiating immunosuppressant medications. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [64100] [65107] Desogestrel; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Dexrazoxane: (Moderate) Dexrazoxane is a cardioprotectant administered prior to doxorubicin-containing chemotherapy regimens in women with metastatic breast cancer who have received a cumulative doxorubicin dose of 300 mg/m2 and who will continue to receive doxorubicin therapy. Monitor blood counts if these agents are used together; additive myelosuppression may occur. Do not use dexrazoxane as a cardioprotectant when doxorubicin therapy is first begun; significantly lower tumor response rates and a shorter time to disease progression were reported in women with metastatic breast cancer who received dexrazoxane at the start of doxorubicin therapy in a randomized trial. [60637] [61628] Dextromethorphan; buPROPion: (Major) In vitro, bupropion is a mild CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of bupropion and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [41057] [56361] Dextromethorphan; diphenhydrAMINE; Phenylephrine: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] Dextromethorphan; quiNIDine: (Major) Avoid coadministration of quinidine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Quinidine is a potent CYP2D6 inhibitor and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP2D6 and P-gp. Concurrent use of CYP2D6 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [47357] [56361] dilTIAZem: (Major) Avoid coadministration of diltiazem and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. Diltiazem is a moderate CYP3A4 inhibitor; doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. [28277] [56361] diphenhydrAMINE: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] diphenhydrAMINE; Ibuprofen: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] diphenhydrAMINE; Naproxen: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] diphenhydrAMINE; Phenylephrine: (Minor) Diphenhydramine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. However, these drugs are often used together in treatment. [34522] [34523] [56361] DOCEtaxel: (Minor) Docetaxel appears to cause sequence-related drug interactions with doxorubicin. Antagonism may occur if docetaxel and doxorubicin are administered simultaneously, and when doxorubicin was added prior to docetaxel. [5949] Dronedarone: (Major) Avoid coadministration of dronedarone with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Dronedarone is a CYP3A4, CYP2D6, and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4, CYP2D6, and P-gp. Concurrent use of CYP3A4, CYP2D6, or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [36101] [56361] Drospirenone; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Drospirenone; Ethinyl Estradiol; Levomefolate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] DULoxetine: (Major) Duloxetine is a CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of duloxetine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [29934] [56361] Duvelisib: (Major) Avoid coadministration of duvelisib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Duvelisib is a moderate CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63571] Efavirenz: (Major) Avoid coadministration of efavirenz with doxorubicin due to decreased doxorubicin plasma concentrations. Efavirenz is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [28442] [56361] Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Major) Avoid coadministration of efavirenz with doxorubicin due to decreased doxorubicin plasma concentrations. Efavirenz is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [28442] [56361] Efavirenz; lamiVUDine; Tenofovir Disoproxil Fumarate: (Major) Avoid coadministration of efavirenz with doxorubicin due to decreased doxorubicin plasma concentrations. Efavirenz is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [28442] [56361] Elacestrant: (Major) Avoid coadministration of elacestrant with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and elacestrant is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68530] Elbasvir; Grazoprevir: (Moderate) Administering doxorubicin with elbasvir; grazoprevir may result in elevated doxorubicin plasma concentrations. Doxorubicin is a substrate of CYP3A and the drug transporter breast cancer resistance protein (BCRP). Elbasvir and grazoprevir are inhibitors of BCRP, and grazoprevir is also a weak CYP3A inhibitor. If these drugs are used together, closely monitor for signs of adverse events. [34506] [56361] [60523] Elexacaftor; tezacaftor; ivacaftor: (Major) Ivacaftor is a mild inhibitor of CYP3A and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ivacaftor and doxorubicin if possible. If avoidance is not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [48524] [56361] Eliglustat: (Major) Avoid coadministration of eliglustat with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Eliglustat is a CYP2D6 and P-glycoprotein (P-gp) inhibitor, and doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [34506] [57803] [61628] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Major) Avoid coadministration of cobicistat and doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Cobicistat is a strong inhibitor of CYP3A4 and an inhibitor of CYP2D6 and P-glycoprotein (P-gp); doxorubicin is a major CYP2D6, CYP3A4, and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58000] Enasidenib: (Major) Avoid coadministration of enasidenib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Enasidenib is a P-gp inhibitor and doxorubicin is a P-gp substrate. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [62181] Encorafenib: (Major) Avoid coadministration of doxorubicin with encorafenib due to the risk for decreased doxorubicin plasma concentrations which may compromise the efficacy of chemotherapy. Doxorubicin is a CYP3A substrate and encorafenib is a strong CYP3A inducer. [56361] [63317] Enzalutamide: (Major) Avoid coadministration of doxorubicin with enzalutamide due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and enzalutamide is a strong CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [51727] [56361] Erdafitinib: (Major) Avoid coadministration of erdafitinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and erdafitinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64064] Erythromycin: (Major) Avoid coadministration of erythromycin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Erythromycin is a CYP3A4 and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28251] [34329] [34331] [34332] [61628] Escitalopram: (Major) Avoid coadministration of escitalopram with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Escitalopram is a moderate CYP2D6 inhibitor and doxorubicin is a major substrate of CYP3D6. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [28270] [56361] Eslicarbazepine: (Major) Avoid coadministration of doxorubicin with eslicarbazepine due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A substrate and eslicarbazepine is a moderate CYP3A inducer. Inducers of CYP3A may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [56436] Estradiol; Progesterone: (Minor) Enhanced doxorubicin-induced neutropenia and thrombocytopenia may occur if coadministered with progesterone. [1954] [5622] Ethinyl Estradiol; Norelgestromin: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Ethinyl Estradiol; Norethindrone Acetate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Ethinyl Estradiol; Norgestrel: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Ethotoin: (Major) Patients receiving antineoplastic agents concurrently with hydantoins may be at risk for toxicity or loss of clinical efficacy and seizures; anticonvulsant therapy should be monitored closely during and after administration of antineoplastic agents. Phenytoin concentrations may be decreased by doxorubicin. Fosphenytoin, a prodrug of phenytoin, may also be susceptible to this interaction with doxorubicin; as well as ethotoin, another anticonvulsant hydantoin. Additionally, phenytoin and fosphenytoin are potent inducers of CYP3A4; doxorubicin is a major CYP3A4 substrate. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenytoin or fosphenytoin if possible. If not possible, monitor doxorubicin closely for efficacy. [28022] [50763] [54190] [56361] Ethynodiol Diacetate; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Etonogestrel; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Etravirine: (Major) Etravirine is a CYP3A4 inducer/substrate and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a CYP3A4 and P-gp substrate. Inducers of CYP3A4 my decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of P-gp and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of etravirine and doxorubicin if possible. If not possible, closely monitor for doxorubicin efficacy, as well as increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [11364] [33718] [56361] Fedratinib: (Major) Avoid coadministration of fedratinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Fedratinib is a moderate CYP3A4 and CYP2D6 inhibitor and doxorubicin is a major substrate of CYP3A4 and CYP2D6. Concurrent use of CYP3A4/CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64568] Fluconazole: (Major) Avoid coadministration of fluconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Fluconazole is a moderate CYP3A4 inhibitor, and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [28674] [61628] Flutamide: (Major) In vitro, flutamide is a CYP3A4 inhibitor; doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of flutamide and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [48644] [56361] fluvoxaMINE: (Major) Avoid coadministration of fluvoxamine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Fluvoxamine is a CYP3A4 inhibitor, and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [50507] [54631] [54632] [56361] Fosamprenavir: (Major) Avoid coadministration of doxorubicin with fosamprenavir due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP3A and fosamprenavir is a moderate CYP3A inhibitor. Concurrent use of CYP3A inhibitors with doxorubicin has resulted in clinically significant interactions. [29012] [56361] Fosphenytoin: (Major) Patients receiving antineoplastic agents concurrently with hydantoins may be at risk for toxicity or loss of clinical efficacy and seizures; anticonvulsant therapy should be monitored closely during and after administration of antineoplastic agents. Phenytoin concentrations may be decreased by doxorubicin. Fosphenytoin, a prodrug of phenytoin, may also be susceptible to this interaction with doxorubicin; as well as ethotoin, another anticonvulsant hydantoin. Additionally, phenytoin and fosphenytoin are potent inducers of CYP3A4; doxorubicin is a major CYP3A4 substrate. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenytoin or fosphenytoin if possible. If not possible, monitor doxorubicin closely for efficacy. [28022] [50763] [54190] [56361] Fostamatinib: (Major) Avoid coadministration of fostamatinib and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. Fostamatinib is a P-gp inhibitor, and the active metabolite of fostamatinib, R406, is a CYP3A4 inhibitor; doxorubicin is a major substrate of both CYP3A4 and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. [56361] [63084] Futibatinib: (Major) Avoid coadministration of futibatinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and futibatinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68013] Gadobenate Dimeglumine: (Moderate) Gadobenate dimeglumine is a substrate for the canalicular multi-specific organic anion transporter (MOAT). Use with other MOAT substrates, such as anthracyclines, may result in prolonged systemic exposure of the coadministered drug. Caution is advised if these drugs are used together. [58462] Ganciclovir: (Moderate) Use ganciclovir and doxorubicin together only if the potential benefits outweigh the risks; bone marrow suppression, spermatogenesis inhibition, skin toxicity, and gastrointestinal toxicity may be additive as both drugs inhibit rapidly dividing cells. [32676] Gilteritinib: (Major) Avoid coadministration of gilteritinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and gilteritinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63787] Glecaprevir; Pibrentasvir: (Moderate) Caution is advised with the coadministration of glecaprevir and doxorubicin as coadministration may increase serum concentrations of doxorubicin and increase the risk of adverse effects. Doxorubicin is a substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP); glecaprevir is an inhibitor of P-gp and BCRP. [34506] [56361] [62201] (Moderate) Caution is advised with the coadministration of pibrentasvir and doxorubicin as coadministration may increase serum concentrations of doxorubicin and increase the risk of adverse effects. Doxorubicin is a substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP); pibrentasvir is an inhibitor of P-gp and BCRP. [34506] [56361] [62201] Grapefruit juice: (Major) Grapefruit juice is a potent CYP3A4 inhibitor, a moderate inhibitor of P-glycoprotein (P-gp), and an in vitro inhibitor of CYP2D6; doxorubicin is a major substrate of CYP2D6, CYP3A4, and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, CYP3A4, and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of grapefruit juice and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [56361] [58104] Hydantoins: (Major) Patients receiving antineoplastic agents concurrently with hydantoins may be at risk for toxicity or loss of clinical efficacy and seizures; anticonvulsant therapy should be monitored closely during and after administration of antineoplastic agents. Phenytoin concentrations may be decreased by doxorubicin. Fosphenytoin, a prodrug of phenytoin, may also be susceptible to this interaction with doxorubicin; as well as ethotoin, another anticonvulsant hydantoin. Additionally, phenytoin and fosphenytoin are potent inducers of CYP3A4; doxorubicin is a major CYP3A4 substrate. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenytoin or fosphenytoin if possible. If not possible, monitor doxorubicin closely for efficacy. [28022] [50763] [54190] [56361] Idelalisib: (Major) Avoid coadministration of doxorubicin with idelalisib due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Idelalisib is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [57675] Imatinib: (Major) Imatinib, STI-571 is an inhibitor of CYP2D6 and CYP3A4; doxorubicin is a major CYP2D6 and CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of imatinib and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28240] [56361] Indinavir: (Major) Indinavir is a potent inhibitor of CYP3A4 and in vitro, a mild CYP2D6 inhibitor; doxorubicin is a major CYP2D6 and CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and/or CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of indinavir and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28731] [56361] Isavuconazonium: (Moderate) Concomitant use of isavuconazonium with doxorubicin may result in increased serum concentrations of doxorubicin. Doxorubicin is a substrate of the hepatic isoenzyme CYP3A4 and drug transporter P-glycoprotein (P-gp); isavuconazole, the active moiety of isavuconazonium, is an inhibitor of CYP3A4 and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of isavuconazonium and doxorubicin if possible. If avoidance is not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [56361] [59042] Isoniazid, INH: (Major) Avoid coadministration of isoniazid with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Isoniazid is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63701] Isoniazid, INH; Pyrazinamide, PZA; rifAMPin: (Major) Avoid coadministration of isoniazid with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Isoniazid is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63701] (Major) Rifampin is a potent CYP3A4 inducer, a moderate inducer of P-glycoprotein (P-gp), and a mild inducer of CYP2D6. Doxorubicin is a major substrate of CYP3A4, P-gp, and CYP2D6. Inducers of CYP3A4, CYP2D6, and/or P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of rifampin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28818] [29812] [34450] [34549] [56361] Isoniazid, INH; rifAMPin: (Major) Avoid coadministration of isoniazid with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Isoniazid is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63701] (Major) Rifampin is a potent CYP3A4 inducer, a moderate inducer of P-glycoprotein (P-gp), and a mild inducer of CYP2D6. Doxorubicin is a major substrate of CYP3A4, P-gp, and CYP2D6. Inducers of CYP3A4, CYP2D6, and/or P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of rifampin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28818] [29812] [34450] [34549] [56361] Istradefylline: (Major) Avoid coadministration of istradefylline with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Istradefylline is a P-gp inhibitor and doxorubicin is a P-gp substrate. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64590] Itraconazole: (Major) Avoid coadministration of itraconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Itraconazole is a strong CYP3A4 inhibitor and an inhibitor of P-glycoprotein (P-gp). Doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [29036] [40233] [57486] [61628] Ivacaftor: (Major) Ivacaftor is a mild inhibitor of CYP3A and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ivacaftor and doxorubicin if possible. If avoidance is not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [48524] [56361] Ketoconazole: (Major) Avoid coadministration of ketoconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ketoconazole is a potent CYP3A4 inhibitor, and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [27982] [29036] [57486] [61628] lamiVUDine, 3TC; Zidovudine, ZDV: (Major) Avoid concomitant administration of zidovudine, ZDV, and doxorubicin as an antagonistic relationship has been demonstrated in vitro. [28305] Lansoprazole; Amoxicillin; Clarithromycin: (Major) Avoid coadministration of clarithromycin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Clarithromycin is a strong CYP3A4 inhibitor and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 inhibitors or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28238] [34329] [56361] Lapatinib: (Major) Avoid coadministration of lapatinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Lapatinib is a CYP3A4 and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [33192] [56361] Larotrectinib: (Major) Avoid coadministration of larotrectinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Larotrectinib is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [63780] Lasmiditan: (Major) Avoid coadministration of lasmiditan with doxorubicin due to the risk for increased systemic exposure of doxorubicin that may result in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and lasmiditan is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64685] Ledipasvir; Sofosbuvir: (Moderate) Ledipsavir is a P-glycoprotein (P-gp) inhibitor and doxorubicin is a major P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ledipsavir and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [56361] [58167] Lefamulin: (Major) Avoid coadministration of oral lefamulin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP3A4 and oral lefamulin is a moderate CYP3A4 inhibitor; an interaction is not expected with intravenous lefamulin. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64576] Lenacapavir: (Major) Avoid coadministration of doxorubicin with lenacapavir due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a CYP3A and P-gp substrate and lenacapavir is a moderate CYP3A and P-gp inhibitor. Concurrent use of CYP3A or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68383] Letermovir: (Major) Avoid use of letermovir with doxorubicin, as concurrent use may increase doxorubicin concentration and risk for adverse events. The magnitude of this interaction may be increased in patients who are also receiving cyclosporine. Doxorubicin is a substrate of CYP3A4. Letermovir is a moderate CYP3A4 inhibitor. The combined effect of letermovir and cyclosporine on CYP3A4 substrates may be similar to a strong CYP3A4 inhibitor. [56361] [62611] Levoketoconazole: (Major) Avoid coadministration of ketoconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ketoconazole is a potent CYP3A4 inhibitor, and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [27982] [29036] [57486] [61628] Levonorgestrel; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Lonafarnib: (Major) Avoid coadministration of doxorubicin with lonafarnib due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a CYP3A4 and P-gp substrate; lonafarnib is a P-gp and strong CYP3A4 inhibitor. Concurrent use of CYP3A4 and P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [66129] Lopinavir; Ritonavir: (Major) Avoid coadministration of ritonavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ritonavir is a strong CYP3A4 inhibitor and a P-gp inhibitor; doxorubicin is a CYP3A4 and P-gp substrate. Concurrent use of CYP3A4 and/or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [47165] [56361] Lorcaserin: (Major) Lorcaserin is a mild CYP2D6 inhibitor and doxorubicin is a major CYP2D6 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of locaserin and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [51065] [56361] Lorlatinib: (Major) Avoid coadministration of doxorubicin with lorlatinib due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and lorlatinib is a moderate CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [63732] Lumacaftor; Ivacaftor: (Major) Concomitant administration of doxorubicin and lumacaftor; ivacaftor may alter the exposure of doxorubicin; avoid concurrent use. Doxorubicin is a major substrate of CYP3A4 and P-glycoprotein (P-gp). Lumacaftor is a strong CYP3A inducer; in vitro data also suggest lumacaftor; ivacaftor may induce and/or inhibit P-gp. [34506] [56361] [59891] (Major) Ivacaftor is a mild inhibitor of CYP3A and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ivacaftor and doxorubicin if possible. If avoidance is not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [48524] [56361] Lumacaftor; Ivacaftor: (Major) Concomitant administration of doxorubicin and lumacaftor; ivacaftor may alter the exposure of doxorubicin; avoid concurrent use. Doxorubicin is a major substrate of CYP3A4 and P-glycoprotein (P-gp). Lumacaftor is a strong CYP3A inducer; in vitro data also suggest lumacaftor; ivacaftor may induce and/or inhibit P-gp. [34506] [56361] [59891] Margetuximab: (Major) Avoid administration of anthracyclines during margetuximab therapy and for up to 4 months after the last dose of margetuximab due to the risk of increased cardiac dysfunction. If concomitant use is unavoidable, closely monitor cardiac function. This interaction has not been studied with margetuximab; however, clinical data from other HER2-directed antibodies warrants consideration. [66181] Maribavir: (Major) Avoid coadministration of maribavir with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and maribavir is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67137] Mavacamten: (Major) Avoid coadministration of doxorubicin with mavacamten due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A substrate and mavacamten is a moderate CYP3A inducer. Inducers of CYP3A may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [67543] Mavorixafor: (Major) Avoid coadministration of doxorubicin with mavorixafor due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a CYP2D6 and P-gp substrate and mavorixafor is a strong CYP2D6 and P-gp inhibitor. Concurrent use of CYP2D6 and P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [70577] Mercaptopurine, 6-MP: (Moderate) Use mercaptopurine and doxorubicin together with caution; doxorubicin may potentiate mercaptopurine-induced hepatotoxicity. If these drugs are used together, monitor patients for signs and symptoms of hepatic dysfunction. Additionally, a mercaptopurine dosage reduction may be required when it is used in combination with other myelosuppressive agents such as doxorubicin. Hepatic dysfunction (i.e., hyperbilirubinemia, elevated AST and alkaline phosphatase levels) occurred in all 11 patients with refractory leukemia who received mercaptopurine (500 mg/m2 IV daily for 5 days) and doxorubicin (50 mg/m2 IV) repeated every 2 to 3 weeks; some patients also received vincristine and prednisone. Hepatotoxicity was observed in 19 of 20 patients who received mercaptopurine and doxorubicin as induction therapy for resistant leukemia in another report. [61628] Methohexital: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] miFEPRIStone: (Moderate) Avoid coadministration of mifepristone and doxorubicin if possible. Mifepristone is an inhibitor of CYP3A4 and may also inhibit P-glycoprotein (P-gp); doxorubicin is a major substrate of both P-gp and CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. When mifepristone is used chronically for hormonal conditions, as in the treatment of Cushing's disease, increased concentrations of CYP3A substrates are expected, and any drug interactions that do occur may be prolonged due to mifepristone's long duration of action. If not possible to avoid use of these drugs together, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [24580] [25387] [28003] [48697] [56361] Mirabegron: (Major) Mirabegron is a moderate CYP2D6 inhibitor; doxorubicin is a substrate of both CYP2D6 and CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of mirabegron and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [51111] [56361] Mitapivat: (Major) Avoid coadministration of mitapivat with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and mitapivat is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67403] Mitotane: (Major) Concomitant use of mitotane with doxorubicin should be undertaken with caution as it could result in decreased plasma concentrations of doxorubicin, leading to reduced efficacy. Mitotane is a strong CYP3A4 inducer and doxorubicin is a CYP3A4 substrate; coadministration may result in decreased plasma concentrations of doxorubicin. [34506] [41934] [56361] Modafinil: (Major) Modafinil is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of modafinil and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [41243] [56361] Mycophenolate: (Major) Concurrent use of doxorubicin with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5622] Nafcillin: (Major) In vitro, nafcillin is a CYP3A4 inducer; doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of nafcillin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [34455] [34456] [56361] Nefazodone: (Major) Nefazodone is a potent CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of nefazodone and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28683] [54634] [56361] Nelfinavir: (Major) Nelfinavir is a potent CYP3A4 inhibitor and a moderate inhibitor of P-glycoprotein (P-gp); doxorubicin is a major substrate of both CYP3A4 and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of nelfinavir and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28839] [56361] Neratinib: (Major) Avoid coadministration of neratinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Neratinib is a P-glycoprotein (P-gp) inhibitor and doxorubicin is a P-gp substrate. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [62127] NiCARdipine: (Major) Avoid coadministration of nicardipine and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. Nicardipine is a CYP2D6 and CYP3A4 inhibitor; doxorubicin is a major substrate of CYP2D6 and CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6 and CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. [50341] [56361] Nicotine: (Major) Nicotine is a mild CYP2D6 inducer and doxorubicin is a major substrate of CYP2D6. Inducers of CYP2D6 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of nicotine and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] [57040] Nilotinib: (Major) Avoid coadministration of nilotinib with doxorubicin due to the risk of increased doxorubicin exposure. Nilotinib is a moderate CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4; clinically significant interactions have been reported with other CYP3A4 inhibitors, resulting in increased concentration and clinical effect of doxorubicin. [56361] [58766] Niraparib; Abiraterone: (Major) Avoid coadministration of doxorubicin with abiraterone due to increased plasma concentrations of doxorubicin. Doxorubicin is a CYP2D6 substrate and abiraterone is a moderate CYP2D6 inhibitor. Clinically significant interactions have been reported with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. [44156] [56361] Nirmatrelvir; Ritonavir: (Major) Avoid coadministration of ritonavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ritonavir is a strong CYP3A4 inhibitor and a P-gp inhibitor; doxorubicin is a CYP3A4 and P-gp substrate. Concurrent use of CYP3A4 and/or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [47165] [56361] Nirogacestat: (Major) Avoid coadministration of doxorubicin with nirogacestat due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP3A and nirogacestat is a moderate CYP3A inhibitor. Concurrent use of CYP3A inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [69917] Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Norethindrone; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Norgestimate; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Omeprazole; Amoxicillin; Rifabutin: (Major) Rifabutin is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of rifabutin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [29210] [29812] [34450] [34549] [56361] Oritavancin: (Major) Doxorubicin is metabolized by CYP3A4 and CYP2D6; oritavancin is a weak CYP3A4 and CYP2D6 inducer. Inducers of CYP2D6 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of oritavancin and doxorubicin if possible. If not possible, monitor the patient for signs of lack of efficacy. [56361] [57741] Osimertinib: (Major) Avoid coadministration of osimertinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Osimertinib is a P-gp inhibitor and doxorubicin is a P-gp substrate. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [60297] OXcarbazepine: (Major) Oxcarbazepine is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of oxcarbazepine and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [29014] [56361] PACLitaxel: (Moderate) Use paclitaxel and doxorubicin together with caution. Administer doxorubicin prior to paclitaxel; the AUC values of doxorubicin and its metabolites may increase if paclitaxel is given first. Paclitaxel and doxorubicin are both CYP3A4 substrates. [58751] [61628] Pacritinib: (Major) Avoid coadministration of pacritinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and pacritinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [67427] Palbociclib: (Major) Avoid coadministration of palbociclib with doxorubicin due to the risk of increased doxorubicin exposure. Palbociclib is a weak time-dependent inhibitor of CYP3A. Doxorubicin is a major substrate of CYP3A4; clinically significant interactions have been reported with other CYP3A4 inhibitors, resulting in increased concentration and clinical effect of doxorubicin. [34506] [56361] [58768] [64721] PARoxetine: (Major) Avoid coadministration of paroxetine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Paroxetine is a strong CYP2D6 inhibitor and doxorubicin is a major substrate of CYP3D6. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interaction. [28260] [56361] PAZOPanib: (Major) Avoid coadministration of pazopanib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Pazopanib is a CYP2D6 and CYP3A4 inhibitor; doxorubicin is a major substrate of CYP2D6 and CYP3A4. Concurrent use of CYP2D6 or CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [37098] [61628] Peginterferon Alfa-2b: (Major) Monitor for adverse effects associated with increased exposure to doxorubicin if peginterferon alfa-2b is coadministered. Peginterferon alfa-2b is a CYP2D6 inhibitor, while doxorubicin is a CYP2D6 substrate. [29627] [34506] [43887] [56361] PENTobarbital: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Perampanel: (Major) In vitro, perampanel is a mild CYP3A4 inhibitor; doxorubicin is a major substrate of CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of perampanel and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [52140] [56361] Pertuzumab; Trastuzumab; Hyaluronidase: (Major) Avoid coadministration of anthracyclines and trastuzumab products due to the risk of increased cardiac dysfunction; if possible, continue to avoid for up to 7 months after the last dose of trastuzumab. If concomitant use is unavoidable, carefully monitor cardiac function. Anthracycline treatment after therapy with trastuzumab product may increase the risk of cardiac dysfunction due to the long washout period of trastuzumab. [28061] [61454] [61628] [62658] [63839] [64521] [64524] Pexidartinib: (Major) Avoid coadministration of doxorubicin with pexidartinib due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and pexidartinib is a moderate CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [64535] PHENobarbital: (Major) Phenobarbital is a potent inducer of CYP3A4 and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Primidone and mephobarbital, both metabolized to phenobartital, are also potent CYP3A4 inducers. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenobarbital, primidone, and mephobarbital if possible. If not possible, monitor doxorubicin closely for efficacy. [28021] [28597] [34452] [56361] [57104] [57105] PHENobarbital; Hyoscyamine; Atropine; Scopolamine: (Major) Phenobarbital is a potent inducer of CYP3A4 and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Primidone and mephobarbital, both metabolized to phenobartital, are also potent CYP3A4 inducers. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenobarbital, primidone, and mephobarbital if possible. If not possible, monitor doxorubicin closely for efficacy. [28021] [28597] [34452] [56361] [57104] [57105] Phentermine; Topiramate: (Major) Topiramate is a mild CYP3A4 inducer; doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of topiramate and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28378] [56361] [57036] Phenytoin: (Major) Patients receiving antineoplastic agents concurrently with hydantoins may be at risk for toxicity or loss of clinical efficacy and seizures; anticonvulsant therapy should be monitored closely during and after administration of antineoplastic agents. Phenytoin concentrations may be decreased by doxorubicin. Fosphenytoin, a prodrug of phenytoin, may also be susceptible to this interaction with doxorubicin; as well as ethotoin, another anticonvulsant hydantoin. Additionally, phenytoin and fosphenytoin are potent inducers of CYP3A4; doxorubicin is a major CYP3A4 substrate. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenytoin or fosphenytoin if possible. If not possible, monitor doxorubicin closely for efficacy. [28022] [50763] [54190] [56361] Pirtobrutinib: (Major) Avoid coadministration of pirtobrutinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and pirtobrutinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68520] Posaconazole: (Major) Avoid coadministration of posaconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Posaconazole is a strong CYP3A4 inhibitor and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYPsA4 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [32723] [61628] Pretomanid: (Major) Avoid coadministration of pretomanid with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and pretomanid is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64561] Primidone: (Major) Phenobarbital is a potent inducer of CYP3A4 and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Primidone and mephobarbital, both metabolized to phenobartital, are also potent CYP3A4 inducers. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of doxorubicin with phenobarbital, primidone, and mephobarbital if possible. If not possible, monitor doxorubicin closely for efficacy. [28021] [28597] [34452] [56361] [57104] [57105] Progesterone: (Minor) Enhanced doxorubicin-induced neutropenia and thrombocytopenia may occur if coadministered with progesterone. [1954] [5622] Propafenone: (Major) Avoid coadministration of propafenone with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Propafenone is a CYP2D6 and P-gp inhibitor and doxorubicin is a CYP2D6 and P-gp substrate. Concurrent use of CYP2D6 and/or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [34331] [61628] quiNIDine: (Major) Avoid coadministration of quinidine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Quinidine is a potent CYP2D6 inhibitor and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP2D6 and P-gp. Concurrent use of CYP2D6 or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [47357] [56361] quiNINE: (Major) Avoid coadministration of quinine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Quinine is a CYP3A4, CYP2D6, and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4, CYP2D6, and P-gp. Concurrent use of CYP3A4, CYP2D6, or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [31403] [34335] [56361] Ranolazine: (Major) Avoid coadministration of ranolazine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ranolazine is a CYP3A4, CYP2D6, and P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4, CYP2D6, and P-gp. Concurrent use of CYP3A4, CYP2D6, or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [31938] [56361] Repotrectinib: (Major) Avoid coadministration of doxorubicin with repotrectinib due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A substrate and repotrectinib is a moderate CYP3A inducer. Inducers of CYP3A may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [69884] Ribociclib: (Major) Avoid coadministration of ribociclib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ribociclib is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [61816] Ribociclib; Letrozole: (Major) Avoid coadministration of ribociclib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ribociclib is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [61816] Rifabutin: (Major) Rifabutin is a CYP3A4 inducer and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of rifabutin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [29210] [29812] [34450] [34549] [56361] rifAMPin: (Major) Rifampin is a potent CYP3A4 inducer, a moderate inducer of P-glycoprotein (P-gp), and a mild inducer of CYP2D6. Doxorubicin is a major substrate of CYP3A4, P-gp, and CYP2D6. Inducers of CYP3A4, CYP2D6, and/or P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of rifampin and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28818] [29812] [34450] [34549] [56361] Rifapentine: (Major) Avoid coadministration of doxorubicin with rifapentine due to decreased doxorubicin plasma concentrations. Doxorubicin is a CYP3A4 substrate and rifapentine is a strong CYP3A4 inducer. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [65685] Ritonavir: (Major) Avoid coadministration of ritonavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ritonavir is a strong CYP3A4 inhibitor and a P-gp inhibitor; doxorubicin is a CYP3A4 and P-gp substrate. Concurrent use of CYP3A4 and/or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [47165] [56361] Rolapitant: (Major) Avoid coadministration of doxorubicin and rolapitant because it can result in doxorubicin-related adverse effects, including cardiac effects. Doxorubicin is a major substrate of CYP2D6, and is also metabolized via P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP); rolapitant inhibits CYP2D6, P-gp, and BCRP. The inhibitory effect of rolapitant is expected to persist beyond 28 days for an unknown duration. Exposure to another CYP2D6 substrate, following a single dose of rolapitant increased about 3-fold on Days 8 and Day 22. The inhibition of CYP2D6 persisted on Day 28 with a 2.3-fold increase in the CYP2D6 substrate concentrations, the last time point measured. The Cmax and AUC of another BCRP substrate were increased by 140% and 130%, respectively, on day 1 and 17% and 32%, respectively, on day 8 after rolapitant administration. When rolapitant was administered with another P-gp substrate, the day 1 Cmax and AUC were increased by 70% and 30%, respectively; the Cmax and AUC on day 8 were not studied. Of note, in a multicenter, randomized, double-blind, placebo-controlled clinical trial showing efficacy of rolapitant in patients treated with moderately emetogenic chemotherapy (n = 1369), at least 50% of patients received a combination of anthracycline and cyclophosphamide. In a similarly designed study of patients receiving highly emetogenic chemotherapy (n = 532), 6% received doxorubicin. Non-gastrointestinal adverse effects are not reported by the manufacturer; however, an increased incidence of hematologic toxicity is possible, as well as an unknown impact on short- and long-term cardiotoxicity. [34506] [56361] [60142] Saquinavir: (Major) Avoid coadministration of saquinavir with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Saquinavir is a strong CYP3A4 inhibitor and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 inhibitors or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28995] [56361] Sarecycline: (Major) Avoid coadministration of sarecycline with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a substrate of P-glycoprotein (P-gp); sarecycline is a P-gp inhibitor. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of P-gp, resulting in increased concentration and clinical effects of doxorubicin. [34506] [56361] [63605] SARS-CoV-2 (COVID-19) vaccines: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the SARS-CoV-2 virus vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) Adenovirus Vector Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the SARS-CoV-2 virus vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) mRNA Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the SARS-CoV-2 virus vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) Recombinant Spike Protein Nanoparticle Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the SARS-CoV-2 virus vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] Secobarbital: (Major) Barbiturates induce CYP3A4 and doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of barbiturates and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] Segesterone Acetate; Ethinyl Estradiol: (Moderate) Ethinyl Estradiol is a mild CYP3A4 inhibitor and doxorubicin is a major CYP3A4 substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ethinyl estradiol and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [47343] [56361] [57085] Selpercatinib: (Major) Avoid coadministration of selpercatinib with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and selpercatinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [65387] Sodium Phenylbutyrate; Taurursodiol: (Major) Avoid coadministration of taurursodiol with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and taurursodiol is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68007] Sofosbuvir; Velpatasvir; Voxilaprevir: (Major) Avoid concurrent administration of voxilaprevir with doxorubicin. Taking these medications together may increase doxorubicin plasma concentrations, potentially increasing the risk for adverse events. Doxorubicin is a substrate for the drug transporters P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP). Voxilaprevir is a P-gp and BCRP inhibitor. [62131] SORAfenib: (Major) Avoid coadministration of sorafenib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Sorafenib is a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of P-gp. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [31832] [56361] Sotorasib: (Major) Avoid coadministration of doxorubicin with sotorasib due to altered doxorubicin plasma concentrations, which may lead to increased toxicity or decreased efficacy. Doxorubicin is a CYP3A4 and P-gp substrate; sotorasib is a moderate CYP3A4 inducer and P-gp inhibitor. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. [56361] [66700] Sparsentan: (Major) Avoid coadministration of sparsentan with doxorubicin due to the risk for increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and sparsentan is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [68641] St. John's Wort, Hypericum perforatum: (Major) St. John's Wort, Hypericum perforatum, is a potent inducer of CYP3A4 and a moderate P-glycoprotein (P-gp) inducer; doxorubicin is a major substrate of both CYP3A4 and P-gp. Inducers of CYP3A4 and/or P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of St. John's Wort and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [56361] [57202] [57852] Streptogramins: (Major) Avoid coadministration of dalfopristin; quinupristin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Dalfopristin; quinupristin is a weak CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [28491] [56361] Temsirolimus: (Major) Avoid coadministration of doxorubicin with temsirolimus due to the potential for increased doxorubicin exposure. Doxorubicin is a P-glycoprotein (P-gp) substrate and temsirolimus is a P-gp inhibitor. Clinically significant interactions have been reported with inhibitors of P-gp, resulting in increased concentration and clinical effect of doxorubicin. [34506] [50586] [56361] Tepotinib: (Major) Avoid coadministration of tepotinib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and tepotinib is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [66372] Tezacaftor; Ivacaftor: (Major) Ivacaftor is a mild inhibitor of CYP3A and P-glycoprotein (P-gp); doxorubicin is a major CYP3A4 and P-gp substrate. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or P-gp, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of ivacaftor and doxorubicin if possible. If avoidance is not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [34506] [48524] [56361] Thioridazine: (Major) Avoid coadministration of thioridazine with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Thioridazine is a CYP2D6 inhibitor and doxorubicin is a major substrate of CYP2D6. Concurrent use of CYP2D6 inhibitors with doxorubicin has resulted in clinically significant interactions. [35427] [43715] [56203] [61628] Thiothixene: (Major) In vitro, thiothixene is a mild CYP2D6 inhibitor; doxorubicin is a major substrate of CYP2D6. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of thiothixene and doxorubicin if possible. If not possible, closely monitor for increased side effects of doxorubicin including myelosuppression and cardiotoxicity. [28001] [56203] [56361] [56844] Tipranavir: (Major) Tipranavir is a potent CYP2D6 and CYP3A4 inhibitor; it is also a potent inducer of P-glycoprotein (P-gp). Doxorubicin is a major substrate of CYP2D6, CYP3A4 and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4 and/or CYP2D6, resulting in increased concentration and clinical effect of doxorubicin. Inducers of P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of tipranavir and doxorubicin if possible. If not possible, closely monitor for doxorubicin efficacy and increased side effects of doxorubicin, including myelosuppression and cardiotoxicity. [31320] [56361] Topiramate: (Major) Topiramate is a mild CYP3A4 inducer; doxorubicin is a major substrate of CYP3A4. Inducers of CYP3A4 may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of topiramate and doxorubicin if possible. If not possible, monitor doxorubicin closely for efficacy. [28378] [56361] [57036] Trandolapril; Verapamil: (Major) Avoid the concomitant use of doxorubicin and verapamil; use of these drugs together may increase doxorubicin concentrations and increase the risk of doxorubicin-induced toxicity. Doxorubicin is a substrate of CYP3A4 and P-glycoprotein (P-gp); verapamil is a substrate and inhibitor of CYP3A4 and P-gp. [25892] [40025] Trastuzumab: (Major) Avoid coadministration of anthracyclines and trastuzumab products due to the risk of increased cardiac dysfunction; if possible, continue to avoid for up to 7 months after the last dose of trastuzumab. If concomitant use is unavoidable, carefully monitor cardiac function. Anthracycline treatment after therapy with trastuzumab product may increase the risk of cardiac dysfunction due to the long washout period of trastuzumab. [28061] [61454] [61628] [62658] [63839] [64521] [64524] Trastuzumab; Hyaluronidase: (Major) Avoid coadministration of anthracyclines and trastuzumab products due to the risk of increased cardiac dysfunction; if possible, continue to avoid for up to 7 months after the last dose of trastuzumab. If concomitant use is unavoidable, carefully monitor cardiac function. Anthracycline treatment after therapy with trastuzumab product may increase the risk of cardiac dysfunction due to the long washout period of trastuzumab. [28061] [61454] [61628] [62658] [63839] [64521] [64524] Tuberculin Purified Protein Derivative, PPD: (Moderate) Immunosuppressives may decrease the immunological response to tuberculin purified protein derivative, PPD. This suppressed reactivity can persist for up to 6 weeks after treatment discontinuation. Consider deferring the skin test until completion of the immunosuppressive therapy. [43298] [43299] Tucatinib: (Major) Avoid coadministration of doxorubicin with tucatinib due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a CYP3A4 and P-glycoprotein (P-gp) substrate; tucatinib is a strong CYP3A4 inhibitor and P-gp inhibitor. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [65295] valGANciclovir: (Moderate) Use valganciclovir and doxorubicin together only if the potential benefits outweigh the risks; bone marrow suppression, spermatogenesis inhibition, skin toxicity, and gastrointestinal toxicity may be additive as both drugs inhibit rapidly dividing cells. [28463] Valproic Acid, Divalproex Sodium: (Major) In vitro, valproic acid, divalproex soidum is a mild CYP3A4 and P-glycoprotein (P-gp) inducer; it is also a mild CYP3A4 inhibitor. Doxorubicin is a major substrate of CYP2D6, CYP3A4 and P-gp. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Inducers of CYP3A4 and/or P-gp may decrease the concentration of doxorubicin and compromise the efficacy of chemotherapy. Avoid coadministration of valproic acid and doxorubicin if possible. If not possible, closely monitor for doxorubicin efficacy and increased side effects of doxorubicin, including myelosuppression and cardiotoxicity. [56361] [57048] [57080] Vemurafenib: (Major) Avoid coadministration of vemurafenib with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Vemurafenib is a P-glycoprotein (P-gp) inhibitor, and doxorubicin is a major substrate of P-gp. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [45335] [56361] Verapamil: (Major) Avoid the concomitant use of doxorubicin and verapamil; use of these drugs together may increase doxorubicin concentrations and increase the risk of doxorubicin-induced toxicity. Doxorubicin is a substrate of CYP3A4 and P-glycoprotein (P-gp); verapamil is a substrate and inhibitor of CYP3A4 and P-gp. [25892] [40025] Voclosporin: (Major) Avoid coadministration of voclosporin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a P-gp substrate and voclosporin is a P-gp inhibitor. Concurrent use of P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [66336] Vonoprazan; Amoxicillin; Clarithromycin: (Major) Avoid coadministration of clarithromycin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Clarithromycin is a strong CYP3A4 inhibitor and a P-glycoprotein (P-gp) inhibitor; doxorubicin is a major substrate of CYP3A4 and P-gp. Concurrent use of CYP3A4 inhibitors or P-gp inhibitors with doxorubicin has resulted in clinically significant interactions. [28238] [34329] [56361] Voriconazole: (Major) Avoid coadministration of voriconazole with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Voriconazole is a strong CYP3A4 inhibitor and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions. [24580] [25387] [28158] [61628] Voxelotor: (Major) Avoid coadministration of doxorubicin with voxelotor due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Doxorubicin is a major substrate of CYP3A and voxelotor is a moderate CYP3A inhibitor. Concurrent use of CYP3A inhibitors with doxorubicin has resulted in clinically significant interactions. [56361] [64778] Zafirlukast: (Major) In vitro, zafirlukast is a CYP3A4 inhibitor; doxorubicin is a major substrate of CYP3A4. Clinically significant interactions have been reported when doxorubicin was coadministered with inhibitors of CYP3A4, resulting in increased concentration and clinical effect of doxorubicin. Avoid coadministration of zafirlukast and doxorubicin if possible. If not possible, closely monitor increased side effects of doxorubicin, including myelosuppression and cardiotoxicity. [28222] [56361] Zidovudine, ZDV: (Major) Avoid concomitant administration of zidovudine, ZDV, and doxorubicin as an antagonistic relationship has been demonstrated in vitro. [28305] Zonisamide: (Minor) Zonisamide is a weak inhibitor of P-glycoprotein (P-gp), and doxorubicin is a substrate of P-gp. There is theoretical potential for zonisamide to affect the pharmacokinetics of drugs that are P-gp substrates. Use caution when starting or stopping zonisamide or changing the zonisamide dosage in patients also receiving drugs which are P-gp substrates. [28843] [34506] [56361]
      Revision Date: 07/13/2024, 02:30:00 AM

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      Monitoring Parameters

      • CBC with differential
      • echocardiogram
      • LFTs
      • multi-gated radionuclide angiography (MUGA)
      • serum bilirubin
      • serum creatinine/BUN
      • serum electrolytes
      • serum uric acid

      US Drug Names

      • Adriamycin
      • Adriamycin PFS
      • Adriamycin RDF
      • Rubex
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