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DOXOrubicin (Liposomal)

Medically reviewed by Drugs.com. Last updated on Sep 19, 2020.

Pronunciation

(doks oh ROO bi sin lye po SO mal)

Index Terms

  • DOXOrubicin HCl Liposome
  • DOXOrubicin HCl Peg-Liposomal
  • DOXOrubicin Hydrochloride (Liposomal)
  • DOXOrubicin Hydrochloride Liposome
  • Lipodox
  • Liposomal DOXOrubicin
  • Pegylated DOXOrubicin Liposomal
  • Pegylated Liposomal DOXOrubicin
  • Pegylated Liposomal DOXOrubicin Hydrochloride (Doxil, Caelyx)

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Injectable, Intravenous, as hydrochloride:

Doxil: 2 mg/mL (10 mL, 25 mL)

Lipodox 50: 2 mg/mL (25 mL [DSC])

Generic: 2 mg/mL (10 mL, 25 mL)

Injectable, Intravenous, as hydrochloride [preservative free]:

Generic: 2 mg/mL (10 mL, 25 mL)

Brand Names: U.S.

  • Doxil
  • Lipodox 50 [DSC]

Pharmacologic Category

  • Antineoplastic Agent, Anthracycline
  • Antineoplastic Agent, Topoisomerase II Inhibitor

Pharmacology

Doxorubicin inhibits DNA and RNA synthesis by intercalating between DNA base pairs causing steric obstruction and inhibits topoisomerase-II at the point of DNA cleavage. Doxorubicin is also a powerful iron chelator. The iron-doxorubicin complex can bind DNA and cell membranes, producing free hydroxyl (OH) radicals that cleave DNA and cell membranes. Doxorubicin (liposomal) is a pegylated formulation which protects the liposomes, and thereby increases blood circulation time.

Distribution

Vdss: ~2.7 to 2.8 L/m2; largely confined to vascular fluid

Metabolism

Hepatic and in plasma to doxorubicinol and the sulfate and glucuronide conjugates of 4-demethyl,7-deoxyaglycones

Half-Life Elimination

Terminal: Distribution: ~4.7 to 5.2 hours, Elimination: ~52 to 55 hours

Protein Binding

Unknown; nonliposomal (conventional) doxorubicin: ~70%

Use: Labeled Indications

AIDS-related Kaposi sarcoma: Treatment of AIDS-related Kaposi sarcoma (after failure of or intolerance to prior systemic therapy).

Multiple myeloma: Treatment of multiple myeloma (in combination with bortezomib) in patients who have not previously received bortezomib and have received at least 1 prior therapy.

Ovarian cancer, advanced: Treatment of progressive or recurrent ovarian cancer (after platinum-based chemotherapy).

Off Label Uses

Breast cancer, metastatic

Data from a large, randomized trial comparing doxorubicin (liposomal) with commonly used salvage regimens support the use of doxorubicin (liposomal) in the treatment of taxane-refractory metastatic breast cancer [Keller 2004].

Castleman disease, multicentric (human herpesvirus-8-associated)

Data from a small study in HIV positive patients with human herpesvirus-8 [HHV-8]-associated multicentric Castleman disease (MCD) (also known as Kaposi sarcoma-associated herpesvirus) suggest that doxorubicin (liposomal) in combination with rituximab may be of benefit for the management of HHV-8 positive MCD [Uldrick 2014].

Cutaneous T-cell lymphomas (mycosis fungoides and Sézary syndrome), recurrent or refractory

Data from a multicenter phase 2 study support the use of doxorubicin (liposomal) in the treatment of recurrent or refractory advanced mycosis fungoides [Dummer 2012]. In addition, a small retrospective analysis also suggests that doxorubicin (liposomal) may be of benefit in the treatment of recurrent cutaneous T-cell lymphomas [Wollina 2003].

Diffuse large B-cell lymphoma

Data from a small phase 2 trial suggest that doxorubicin (liposomal) in combination with cyclophosphamide, vincristine, and prednisone may be of benefit in patients who may be poor candidates for doxorubicin (conventional) therapy due to advanced age, comorbidities, or clinical status [Martino 2002].

Hodgkin lymphoma (salvage treatment)

Data from a phase 1/2 trial support the use of doxorubicin (liposomal) in combination with gemcitabine and vinorelbine in the treatment of relapsed or refractory Hodgkin lymphoma [Bartlett 2007].

Soft tissue sarcomas, advanced or metastatic

Data from a randomized phase 2 study comparing doxorubicin (liposomal) to conventional doxorubicin support the use of doxorubicin (liposomal) in the treatment of advanced or metastatic soft tissue sarcomas [Judson 2001].

Uterine leiomyosarcoma, advanced or recurrent

Data from a small phase 2 trial suggest that doxorubicin (liposomal) may be of benefit in the management of advanced, persistent, or recurrent uterine leiomyosarcoma [Sutton 2005].

Contraindications

Severe hypersensitivity (including anaphylaxis) to doxorubicin (liposomal), conventional doxorubicin, or any component of the formulation.

Canadian labeling: Additional contraindications (not in the US labeling): Breastfeeding.

Documentation of allergenic cross-reactivity for anthracyclines is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Liposomal formulations of doxorubicin should NOT be substituted for conventional doxorubicin hydrochloride on a mg-per-mg basis.

AIDS-related Kaposi sarcoma: IV: 20 mg/m2 once every 21 days until disease progression or unacceptable toxicity.

Breast cancer, metastatic (off-label use): IV: 50 mg/m2 every 4 weeks (Keller 2004).

Castleman disease, multicentric (human herpesvirus-8-associated (HHV-8 MCD) (off-label use): IV: 20 mg/m2 once every 3 weeks (in combination with rituximab and antiretroviral therapy); patients received up to 2 cycles beyond HHV-8 MCD symptom resolution and improvement in biochemical abnormalities and then received consolidation therapy (Uldrick 2014).

Cutaneous T-cell lymphomas (mycosis fungoides and Sézary syndrome), recurrent or refractory (off-label use): IV: 20 mg/m2 days 1 and 15 every 4 weeks for 6 cycles (Dummer 2012) or 20 mg/m2 every 4 weeks (Wollina 2003).

Diffuse large B-cell lymphoma (off-label use): IV: 30 mg/m2 on day 1 every 3 weeks (in combination with cyclophosphamide, vincristine, and prednisone) for 6 to 8 cycles (Martino 2002).

Hodgkin lymphoma, salvage treatment (off-label use): IV: GVD regimen: 10 mg/m2 (post-transplant patients) or 15 mg/m2 (transplant-naive patients) days 1 and 8 every 3 weeks (in combination with gemcitabine and vinorelbine) for 2 to 6 cycles (Bartlett 2007).

Multiple myeloma: IV: 30 mg/m2 on day 4 every 21 days (in combination with bortezomib) for 8 cycles or until disease progression or unacceptable toxicity (Orlowski 2007).

Ovarian cancer, advanced: IV: 50 mg/m2 once every 28 days until disease progression or unacceptable toxicity.

Off-label dosing: IV: 30 mg/m2 on day 1 every 28 days (in combination with bevacizumab and carboplatin) for up to 6 cycles, followed by bevacizumab maintenance; refer to protocol for further information (Pfisterer 2020) or 40 mg/m2 once every 28 days (as a single agent) until disease progression or unacceptable toxicity (Ferrandina 2008; Rose 2001) or 30 mg/m2 once every 28 days (in combination with carboplatin) for at least 6 cycles (Pujade-Lauraine 2010) or 40 mg/m2 once every 28 days (in combination with bevacizumab) until disease progression or unacceptable toxicity (Pujade-Lauraine 2014).

Soft tissue sarcoma, advanced or metastatic (off-label use): IV: 50 mg/m2 every 4 weeks for 6 cycles (Judson 2001).

Uterine leiomyosarcoma, advanced or recurrent (off-label use): IV: 50 mg/m2 every 4 weeks until disease progression or unacceptable toxicity (Sutton 2005).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Adjustment for Toxicity

US labeling: Note: Once a dosage reduction due to toxicity has been implemented, the dose should not be increased at a later time.

Hematologic toxicity:

AIDS-related Kaposi sarcoma and ovarian cancer:

Grade 1 (ANC 1,500 to 1,900/mm3or platelets 75,000 to 150,000/mm3): No dosage adjustment necessary.

Grade 2 (ANC 1,000 to <1,500/mm3 or platelets 50,000 to <75,000/mm3): Delay treatment until ANC ≥1,500/mm3 and platelets ≥75,000/mm3; resume treatment at previous dose.

Grade 3 (ANC 500 to 999/mm3 or platelets 25,000 to <50,000/mm3): Delay treatment until ANC ≥1,500/mm3 and platelets ≥75,000/mm3; resume treatment at previous dose.

Grade 4 (ANC <500/mm3 or platelets <25,000/mm3): Delay treatment until ANC ≥1,500/mm3 and platelets ≥75,000/mm3; then resume with a 25% dose reduction or continue at previous dose with granulocyte growth factor support.

Multiple myeloma (in combination with bortezomib) (see Bortezomib monograph for bortezomib dosage reduction with toxicity guidelines):

Fever ≥38°C and ANC <1,000/mm3: If prior to liposomal doxorubicin treatment (day 4), do not administer (withhold); if after liposomal doxorubicin administered, reduce dose by 25% in next cycle.

ANC <500/mm3, platelets <25,000/mm3, hemoglobin <8 g/dL: If prior to liposomal doxorubicin treatment (day 4); do not administer (withhold); if after liposomal doxorubicin administered and if bortezomib dose reduction occurred for hematologic toxicity, reduce dose by 25% in next cycle.

Nonhematologic toxicity:

Hand-foot syndrome (HFS):

Grade 1 (mild erythema, swelling, or desquamation not interfering with daily activities): If no prior grade 3 or 4 HFS toxicity, no dosage adjustment is necessary. If prior grade 3 or 4 HFS toxicity, delay dose up to 2 weeks and decrease dose by 25%.

Grade 2 (erythema, desquamation, or swelling interfering with, but not precluding, normal physical activities; small blisters or ulcerations <2 cm in diameter): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. If resolved to grade 0 or 1 within 2 weeks and no prior grade 3 or 4 HFS, continue treatment at previous dose. If a prior grade 3 or 4 HFS has occurred, decrease dose by 25%.

Grade 3 (blistering, ulceration, or swelling interfering with walking or normal daily activities; cannot wear regular clothing): Delay dosing up to 2 weeks or until resolved to grade 0 or 1, then decrease dose by 25%. If no resolution after 2 weeks, discontinue liposomal doxorubicin.

Grade 4 (diffuse or local process causing infectious complications, or a bedridden state or hospitalization): Delay dosing up to 2 weeks or until resolved to grade 0 or 1, then decrease dose by 25%. If no resolution after 2 weeks, discontinue liposomal doxorubicin.

Infusion reaction: Temporarily stop infusion until resolution and then resume at a reduced rate. For serious or life threatening reaction, discontinue infusion.

Stomatitis:

Grade 1 (painless ulcers, erythema, or mild soreness): If no prior grade 3 or 4 toxicity, no dosage adjustment is necessary. If prior grade 3 or 4 toxicity, delay dose up to 2 weeks and decrease dose by 25%.

Grade 2 (painful erythema, edema, or ulcers, but can eat): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin. If resolved to grade 0 or 1 within 2 weeks and no prior grade 3 or 4 stomatitis, continue treatment at previous dose. If prior grade 3 or 4 stomatitis, decrease dose by 25%.

Grade 3 (painful erythema, edema, or ulcers, and cannot eat): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. Decrease dose by 25% and return to original dosing interval. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin.

Grade 4 (requires parenteral or enteral support): Delay dosing up to 2 weeks or until resolved to grade 0 or 1. Decrease dose by 25% and return to original dosing interval. If after 2 weeks there is no resolution, discontinue liposomal doxorubicin.

Multiple myeloma (in combination with Bortezomib) (see Bortezomib monograph for bortezomib dosage reduction with toxicity guidelines):

Grade 3 or 4 nonhematologic toxicity: Delay dose until resolved to grade <2 and then reduce dose by 25%

Neuropathic pain or peripheral neuropathy: No dose reductions needed for liposomal doxorubicin, refer to Bortezomib monograph for bortezomib dosing adjustment.

Canadian labeling:

Hematologic toxicity:

Breast cancer, ovarian cancer: Refer to US dosage adjustment for hematologic toxicity for ovarian cancer section.

AIDS-related Kaposi sarcoma:

Grades 1 or 2: No dosage adjustment necessary.

Grade 3: Delay treatment until ANC ≥1,000/mm3 and/or platelets ≥50,000/mm3 and then resume with a 25% dose reduction.

Grade 4: Delay treatment until ANC ≥1,000/mm3 and/or platelets ≥50,000/mm3 and then resume with a 50% dose reduction.

Nonhematologic toxicity:

Breast cancer, ovarian cancer:

Hand-foot syndrome (HFS; palmar-plantar erythrodysesthesia):

Grade 1: If at weeks 4 and 5 following prior dose, resume unless patients has experienced prior grade 3 or 4 HFS toxicity (if so, wait an additional week). If at week 6, decrease dose by 25%; return to 4-week interval.

Grade 2: If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, decrease dose by 25%; return to 4-week interval.

Grades 3 or 4: If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, discontinue therapy.

Stomatitis:

Grade 1: If at weeks 4 and 5 following prior dose, resume unless patients has experienced prior grade 3 or 4 stomatitis (if so, wait an additional week). If at week 6, decrease dose by 25%; return to 4-week interval or discontinue therapy (based on physical assessment).

Grade 2: If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, decrease dose by 25%; return to 4-week interval or discontinue therapy (based on physical assessment).

Grades 3 or 4: If at weeks 4 and 5 following prior dose, wait an additional week. If at week 6, discontinue therapy.

AIDS-related Kaposi sarcoma:

Hand-foot syndrome (HFS; palmar-plantar erythrodysesthesia):

Grade 1: If at week 3 following prior dose, resume unless patients has experienced prior grade 3 or 4 HFS toxicity (if so, wait an additional week). If at week 4 following prior dose, decrease dose by 25% and return to 3-week interval.

Grade 2: If at week 3 following prior dose, wait an additional week. If at week 4 following prior dose, decrease dose by 50% and return to 3-week interval.

Grades 3 or 4: If at week 3 following prior dose, wait an additional week. If at week 4, discontinue therapy.

Stomatitis:

Grade 1: No dosage adjustment necessary.

Grade 2: Wait 1 week and if symptoms improve, resume at 100% dose.

Grade 3: Wait 1 week and if symptoms improve, resume with a 25% dose reduction.

Grade 4: Wait 1 week and if symptoms improve, resume with a 50% dose reduction.

Dosing: Obesity

ASCO Guidelines for appropriate chemotherapy dosing in obese adults with cancer: Utilize patient's actual body weight (full weight) for calculation of body surface area- or weight-based dosing, particularly when the intent of therapy is curative; manage regimen-related toxicities in the same manner as for nonobese patients; if a dose reduction is utilized due to toxicity, consider resumption of full weight-based dosing with subsequent cycles, especially if cause of toxicity (eg, hepatic or renal impairment) is resolved (ASCO [Griggs 2012]).

Reconstitution

Dilute doses ≤90 mg in D5W 250 mL prior to administration. Dilute doses >90 mg in D5W 500 mL. Solution is not clear, but has a red, translucent appearance due to the liposomal dispersion. Do not mix with other medications.

Administration

IV: For IV infusion only; do not administer IV push. If contact with skin/mucosa occurs, wash immediately with soap and water. Monitor for infusion reaction.

Administer IVPB over 60 minutes; the manufacturer recommends infusing the first dose at initial rate of 1 mg/minute to minimize risk of infusion reactions; if no infusion-related reactions are observed, then increase the infusion rate for completion over 1 hour. Do NOT administer undiluted. Do NOT infuse with in-line filters. Do not mix with other medications. Monitor for local erythematous streaking along vein and/or facial flushing (may indicate rapid infusion rate).

For multiple myeloma, administer doxorubicin (liposomal) after bortezomib on day 4 of each cycle.

Irritant (Perez Fidalgo 2012); monitor infusion site; avoid extravasation. Assure proper needle or catheter position prior to administration.

Extravasation management: If extravasation, infiltration, or burning/stinging sensation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity (Perez Fidalgo 2012; Polovich 2009). Do not apply pressure to the site. Apply ice to the site for 15 minutes 4 times a day for 3 days.

Storage

Store intact vials at 2°C to 8°C (36°F to 46°F); do not freeze. Solutions diluted for infusion in D5W should be refrigerated at 2°C to 8°C (36°F to 46°F); administer within 24 hours.

Drug Interactions

5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Abametapir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Ado-Trastuzumab Emtansine: May enhance the cardiotoxic effect of Anthracyclines. Management: When possible, patients treated with ado-trastuzumab emtansine should avoid anthracycline-based therapy for up to 7 months after stopping ado-trastuzumab emtansine. Monitor closely for cardiac dysfunction in patients receiving this combination. Consider therapy modification

Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Baricitinib: Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted. Consider therapy modification

BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

Bevacizumab: May enhance the cardiotoxic effect of Anthracyclines. Avoid combination

Cardiac Glycosides: May diminish the cardiotoxic effect of Anthracyclines. Anthracyclines may decrease the serum concentration of Cardiac Glycosides. The effects of liposomal formulations may be unique from those of the free drug, as liposomal formulation have unique drug disposition and toxicity profiles, and liposomes themselves may alter digoxin absorption/distribution. Monitor therapy

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Monitor therapy

Cladribine: May enhance the immunosuppressive effect of Immunosuppressants. Avoid combination

Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Avoid combination

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Cyclophosphamide: May enhance the cardiotoxic effect of Anthracyclines. Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Management: Consider avoiding this combination. Some combinations are specifically contraindicated by manufacturers; others may have recommended dose adjustments. If combined, monitor for increased substrate effects. Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to concomitant therapy when possible. If concomitant therapy cannot be avoided, monitor for reduced clinical effects of the CYP3A4 substrate. Consider therapy modification

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Consider therapy modification

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

Duvelisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Echinacea: May diminish the therapeutic effect of Immunosuppressants. Management: Consider avoiding Echinacea in patients receiving therapeutic immunosuppressants. If coadministered, monitor for reduced efficacy of the immunosuppressant during concomitant use. Consider therapy modification

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification

Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Erdafitinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Fam-Trastuzumab Deruxtecan: May enhance the cardiotoxic effect of Anthracyclines. Management: When possible, patients treated with fam-trastuzumab deruxtecan should avoid anthracycline-based therapy for up to 7 months after stopping fam-trastuzumab deruxtecan. Monitor closely for cardiac dysfunction in patients receiving this combination. Consider therapy modification

Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Fosnetupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination

Inebilizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Larotrectinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification

Lenograstim: Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification

Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification

Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination

Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Management: Avoid use of immunosuppressants (including systemic corticosteroids) prior to initiation of nivolumab. Use of immunosuppressants after administration of nivolumab (eg, for immune-related toxicity) is unlikely to affect nivolumab efficacy. Consider therapy modification

Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy

Ozanimod: Immunosuppressants may enhance the immunosuppressive effect of Ozanimod. Monitor therapy

Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Palifermin: May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Consider therapy modification

Pegloticase: May diminish the therapeutic effect of PEGylated Drug Products. Monitor therapy

Pegvaliase: PEGylated Drug Products may enhance the adverse/toxic effect of Pegvaliase. Specifically, the risk of anaphylaxis or hypersensitivity reactions may be increased. Monitor therapy

Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy

Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Management: Consider avoiding concomitant use of roflumilast and immunosuppressants as recommended by the Canadian product monograph. Inhaled or short-term corticosteroids are unlikely to be problematic. Consider therapy modification

Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy

Siponimod: Immunosuppressants may enhance the immunosuppressive effect of Siponimod. Monitor therapy

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy. Consider therapy modification

Smallpox and Monkeypox Vaccine (Live): Immunosuppressants may diminish the therapeutic effect of Smallpox and Monkeypox Vaccine (Live). Monitor therapy

Stavudine: DOXOrubicin (Liposomal) may diminish the therapeutic effect of Stavudine. Monitor therapy

Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification

Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Talimogene Laherparepvec: Immunosuppressants may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk for disseminated herpetic infection may be increased. Avoid combination

Taxane Derivatives: May enhance the adverse/toxic effect of Anthracyclines. Taxane Derivatives may increase the serum concentration of Anthracyclines. Taxane Derivatives may also increase the formation of toxic anthracycline metabolites in heart tissue. Management: Consider separating doxorubicin and paclitaxel administration by as much time as possible, using liposomal doxorubicin or epirubicin instead of doxorubicin, or using docetaxel instead of paclitaxel. Monitor closely for cardiovascular and other toxicities. Consider therapy modification

Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification

Trastuzumab: May enhance the cardiotoxic effect of Anthracyclines. Management: When possible, patients treated with trastuzumab should avoid anthracycline-based therapy for up to 7 months after stopping trastuzumab. Monitor closely for cardiac dysfunction in patients receiving anthracyclines with trastuzumab. Consider therapy modification

Upadacitinib: Immunosuppressants may enhance the immunosuppressive effect of Upadacitinib. Management: Concomitant use of upadacitinib with potent immunosuppressants is not recommended. Avoid combination

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated less than 2 weeks before starting or during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Avoid combination

Vinflunine: DOXOrubicin (Liposomal) may enhance the adverse/toxic effect of Vinflunine. Specifically, the risk for hematologic toxicities may be increased. DOXOrubicin (Liposomal) may increase the serum concentration of Vinflunine. Vinflunine may decrease the serum concentration of DOXOrubicin (Liposomal). Monitor therapy

Zidovudine: DOXOrubicin (Liposomal) may enhance the adverse/toxic effect of Zidovudine. DOXOrubicin (Liposomal) may diminish the therapeutic effect of Zidovudine. Management: Avoid concomitant use of doxorubicin and zidovudine. Reduced efficacy of zidovudine is possible based on in vitro data. Also, increased myelosuppressive effects are possible with combined administration. Consider therapy modification

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Cardiovascular: Cardiomyopathy (≤11%)

Central nervous system: Fatigue (>20%), headache (1% to 11%)

Dermatologic: Palmar-plantar erythrodysesthesia (ovarian cancer: 51%), skin rash (ovarian cancer: 29%, Kaposi sarcoma: 1% to 5%), alopecia (ovarian cancer: 19%; Kaposi sarcoma: 9%)

Gastrointestinal: Nausea (ovarian cancer: 46%; Kaposi sarcoma: 17%), stomatitis (ovarian cancer: 41%; ovarian cancer, grades 3/4: 8%: Kaposi sarcoma: 7%), vomiting (ovarian cancer: 33%; Kaposi sarcoma: 8%), diarrhea (ovarian cancer: 21%; Kaposi sarcoma: 8%), constipation (>20%), anorexia (20%; Kaposi sarcoma: 1% to 5%), mucous membrane disease (ovarian cancer: 14%), dyspepsia (ovarian cancer: 12%)

Hematologic & oncologic: Thrombocytopenia (Kaposi sarcoma: grade 3: 61%, grade 4: 4%; ovarian cancer: grade 3: 1%), anemia (Kaposi sarcoma: grade 3: 55%, grade 4: 18%; grade 3: 5%, grade 4: <1%), neutropenia (Kaposi sarcoma: grade 3: 49%, grade 4: 13%; ovarian cancer: grade 3: 8%, grade 4: 4%)

Infection: Infection (1% to 12%)

Neuromuscular & skeletal: Asthenia (ovarian cancer: 40%; Kaposi sarcoma: 10%), back pain (1% to 12%)

Respiratory: Pharyngitis (ovarian cancer: 16%; Kaposi sarcoma: <1%), dyspnea (ovarian cancer: 15%; Kaposi sarcoma: 1% to 5%)

Miscellaneous: Fever (ovarian cancer: 21%; Kaposi sarcoma: 9%), infusion related reaction (7% to 11%)

1% to 10%:

Cardiovascular: Deep vein thrombosis (ovarian cancer: 1% to 10%), hypotension (1% to 10%), tachycardia (1% to 10%), vasodilation (ovarian cancer: 1% to 10%), chest pain (1% to 5%), peripheral edema (ovarian cancer: 1% to 5%)

Central nervous system: Depression (ovarian cancer: 1% to 10%), dizziness (1% to 10%), drowsiness (1% to 10%), anxiety (ovarian cancer: 1% to 5%), chills (1% to 5%), emotional lability (Kaposi sarcoma: 1% to 5%), insomnia (ovarian cancer: 1% to 5%), malaise (ovarian cancer: 1% to 5%)

Dermatologic: Acne vulgaris (ovarian cancer: 1% to 10%), ecchymoses (ovarian cancer: 1% to 10%), exfoliative dermatitis (ovarian cancer: 1% to 10%), fungal dermatitis (ovarian cancer: 1% to 10%), furunculosis (ovarian cancer: 1% to 10%), herpes simplex dermatitis (1% to 10%), maculopapular rash (ovarian cancer: 1% to 10%; Kaposi sarcoma: <1%), pruritus (1% to 10%), skin discoloration (ovarian cancer: 1% to 10%), vesiculobullous dermatitis (ovarian cancer: 1% to 10%), xeroderma (ovarian cancer: 1% to 10%), diaphoresis (ovarian cancer: 1% to 5%)

Endocrine & metabolic: Dehydration (ovarian cancer: 1% to 10%; Kaposi sarcoma: <1%), hypercalcemia (ovarian cancer: 1% to 10%), hypokalemia (ovarian cancer: 1% to 10%), hyponatremia (ovarian cancer: 1% to 10%), weight loss (1% to 10%), albuminuria (Kaposi sarcoma: 1% to 5%), hyperglycemia (Kaposi sarcoma: 1% to 5%), hypocalcemia (Kaposi sarcoma: 1% to 5%)

Gastrointestinal: Dysgeusia (ovarian cancer: 1% to 10%; Kaposi sarcoma: <1%), dysphagia (1% to 10%), esophagitis (ovarian cancer: 1% to 10%), intestinal obstruction (ovarian cancer: 1% to 10%), oral candidiasis (1% to 10%), oral mucosa ulcer (1% to 10%), abdominal pain (Kaposi sarcoma: 1% to 5%), aphthous stomatitis (Kaposi sarcoma: 1% to 5%), enlargement of abdomen (ovarian cancer 1% to 5%), glossitis (Kaposi sarcoma: 1% to 5%)

Genitourinary: Hematuria (ovarian cancer: 1% to 10%), urinary tract infection (ovarian cancer: 1% to 10%), vulvovaginal candidiasis (ovarian cancer: 1% to 10%)

Hematologic & oncologic: Rectal hemorrhage (ovarian cancer: 1% to 10%), hypochromic anemia (Kaposi sarcoma: ≥5%), hemolysis (Kaposi sarcoma: 1% to 5%), prolonged prothrombin time (Kaposi sarcoma: 1% to 5%)

Hepatic: Hyperbilirubinemia (1% to 10%), increased serum alkaline phosphatase (Kaposi sarcoma: 8%), increased serum alanine aminotransferase (Kaposi sarcoma: 1% to 5%)

Hypersensitivity: Hypersensitivity reaction (1% to 5%)

Infection: Herpes zoster infection (ovarian cancer: 1% to 10%; Kaposi sarcoma: <1%), paresthesia (5%), myalgia (ovarian cancer: 1% to 5%)

Ophthalmic: Conjunctivitis (ovarian cancer: 1% to 10%; Kaposi sarcoma: <1%), dry eye syndrome (ovarian cancer: 1% to 10%), retinitis (Kaposi sarcoma 1% to 5%)

Respiratory: Increased cough (ovarian cancer: 10%; Kaposi sarcoma: <1%), epistaxis (ovarian cancer: 1% to 10%), pneumonia (1% to 10%), rhinitis (ovarian cancer: 1% to 10%), sinusitis (ovarian cancer: 1% to 10%)

<1%: Bundle branch block, candidiasis, cardiac failure, cryptococcosis, hepatitis, palpitations, sepsis, thrombophlebitis, thrombosis, ventricular arrhythmia

Frequency not defined:

Hematologic & oncologic: Bone marrow depression, progression of cancer

Infection: Toxoplasmosis

Ophthalmic: Optic neuritis

Postmarketing: Erythema multiforme, lichenoid eruption (keratosis), muscle spasm, pulmonary embolism, secondary acute myelocytic leukemia, squamous cell carcinoma, Stevens-Johnson syndrome, toxic epidermal necrolysis

ALERT: U.S. Boxed Warning

Cardiomyopathy:

Doxorubicin (liposomal) can cause myocardial damage, including acute left ventricular failure. The risk of cardiomyopathy was 11% when the cumulative anthracycline dose was between 450 and 550 mg/m2. Assess left ventricular cardiac function prior to initiation of doxorubicin (liposomal) and during and after treatment.

Infusion-related reactions:

Serious, life-threatening, and fatal infusion-related reactions can occur with doxorubicin (liposomal). Acute infusion-related reactions occurred in 11% of patients with solid tumors. Withhold doxorubicin (liposomal) for infusion-related reactions and resume at a reduced rate. Discontinue doxorubicin (liposomal) for serious or life-threatening infusion-related reactions.

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Neutropenia, anemia, and thrombocytopenia may occur. Monitor blood counts. Treatment delay, dosage modification, or discontinuation may be required. Hematologic toxicity may occur at a higher frequency and severity with combination chemotherapy.

• Cardiomyopathy: [US Boxed Warning]: Doxorubicin (liposomal) can cause myocardial damage, including acute left ventricular failure. The risk of cardiomyopathy was 11% when the cumulative anthracycline dose was between 450 and 550 mg/m2. Assess left ventricular cardiac function prior to initiation of doxorubicin (liposomal) and during and after treatment. Cardiomyopathy is defined as a >20% decrease in resting left ventricular ejection fraction (LVEF) from baseline (if LVEF remained in the normal range) or a >10% decrease from baseline (where LVEF was less than the institutional lower limit of normal). Some patients developed signs/symptoms of heart failure without documented evidence of cardiomyopathy. The risk of cardiomyopathy with doxorubicin is generally proportional to the cumulative exposure; include prior use of other anthracyclines or anthracenediones in the calculations of the cumulative dose. The risk of cardiomyopathy may be increased at lower cumulative doses in patients with prior mediastinal irradiation. Assess left ventricular function with ECG or multigated acquisition scan prior to and during treatment to detect acute changes; monitor after treatment to detect delayed cardiotoxicity. Use in patients with a history of cardiovascular disease only if potential benefits outweigh cardiovascular risk.

• Hepatitis B virus screening: The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.

• Infusion-related reactions: [US Boxed Warning]: Serious, life-threatening, and fatal infusion-related reactions can occur with doxorubicin (liposomal). Acute infusion-related reactions occurred in 11% of patients with solid tumors. Withhold doxorubicin (liposomal) for infusion-related reactions and resume at a reduced rate. Discontinue doxorubicin (liposomal) for serious or life-threatening infusion-related reactions. Infusion reactions may include flushing, shortness of breath, facial swelling, headache, chills, back pain, tightness in the chest or throat, fever, hypotension, chest pain, pruritus, rash, cyanosis, syncope, tachycardia, bronchospasm, asthma, and apnea. Most reactions occurred during the first infusion. Some reactions have resulted in dose interruption; withhold doxorubicin (liposomal) for ≤ grade 3 infusion-related reactions and resume at a reduced infusion rate. Medication and equipment to manage infusion reactions should be immediately available during infusion. Initiate infusion at a rate of 1 mg/minute, with the rate increased (to complete infusion over 60 minutes) as tolerated.

• Palmar-plantar erythrodysesthesia (hand-foot syndrome): Hand-foot syndrome has been reported in patients receiving doxorubicin (liposomal), including grade 3 or 4 cases. It is usually seen after 2 to 3 treatment cycles, although may also occur earlier. Dosage modification may be required; in severe or debilitating cases, treatment discontinuation may be required.

• Secondary malignancy: Cases of secondary oral cancers (primarily squamous cell carcinoma) have been reported with long-term (>1 year) doxorubicin (liposomal) exposure; these secondary oral malignancies have occurred during treatment and up to 6 years after treatment. The development of oral ulceration or discomfort should be monitored and further evaluated in patients with past or present use of doxorubicin (liposomal). Tissue distribution of the liposomal doxorubicin compared to free doxorubicin may play a role in the development of oral secondary malignancies associated with long-term use.

Disease-related concerns:

• Hepatic impairment: Pharmacokinetics in patients with hepatic impairment have not been adequately studied. Doxorubicin is predominantly eliminated hepatically; reduce doxorubicin (liposomal) dose in patients with serum bilirubin ≥1.2 mg/dL.

Dosage form specific issues:

• Liposomal vs conventional formulation dosing: Liposomal formulations of doxorubicin should NOT be substituted for conventional doxorubicin hydrochloride on a mg-per-mg basis.

Monitoring Parameters

CBC with differential and platelet count, liver function tests (ALT/AST, bilirubin, alkaline phosphatase). Hepatitis B virus screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning systemic anticancer therapy (ASCO [Hwang 2020]). Verify pregnancy status prior to treatment initiation (in females of reproductive potential). Monitor infusion site, monitor for infusion reactions, hand-foot syndrome, stomatitis, and oral ulceration/discomfort suggestive of secondary oral malignancy.

Cardiac function (left ventricular ejection fraction; baseline and periodic); ECG, or multigated acquisition scan may be used.

Reproductive Considerations

Evaluate pregnancy status prior to use in females of reproductive potential. Females of reproductive potential and males with female partners of reproductive potential should use effective contraception during therapy and for 6 months after treatment. Doxorubicin (liposomal) may impair fertility in males and females. In males, doxorubicin (liposomal) may damage spermatozoa and testicular tissue, resulting in possible genetic fetal abnormalities; may also result in oligospermia, azoospermia, and permanent loss of fertility (sperm counts have been reported to return to normal levels in some males, occurring several years after the end of therapy). In females of reproductive potential, doxorubicin may cause infertility and result in amenorrhea; premature menopause can occur.

Pregnancy Considerations

In placental perfusion studies, doxorubicin (liposomal) crossed the placenta similar to conventional doxorubicin (Soininen 2015). Based on the mechanism of action and data from animal reproduction studies, in utero exposure to doxorubicin (liposomal) may cause fetal harm. Use during the first trimester should be avoided.

The European Society for Medical Oncology has published guidelines for diagnosis, treatment, and follow-up of cancer during pregnancy; the guidelines recommend referral to a facility with expertise in cancer during pregnancy and encourage a multidisciplinary team (obstetrician, neonatologist, oncology team). In general, if chemotherapy is indicated, it should be avoided in the first trimester and there should be a 3-week time period between the last chemotherapy dose and anticipated delivery, and chemotherapy should not be administered beyond week 33 of gestation (ESMO [Peccatori 2013]).

A long-term observational research study is collecting information about the diagnosis and treatment of cancer during pregnancy. For additional information about the pregnancy and cancer registry, or to become a participant, contact Cooper Health (1-877-635-4499).

Patient Education

What is this drug used for?

• It is used to treat cancer.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Constipation

• Diarrhea

• Abdominal pain

• Nausea

• Vomiting

• Lack of appetite

• Back pain

• Headache

• Hair loss

• Sore throat

• Weight loss

• Urine or body fluid discoloration

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Infection

• Blood clots like numbness or weakness on one side of the body; pain, redness, tenderness, warmth, or swelling in the arms or legs; change in color of an arm or leg; chest pain; shortness of breath; fast heartbeat; or coughing up blood

• Heart problems like cough or shortness of breath that is new or worse, swelling of the ankles or legs, abnormal heartbeat, weight gain of more than five pounds in 24 hours, dizziness, or passing out

• Infusion reaction like flushing, shortness of breath, wheezing, swelling in your throat, headache, chills, chest pain, back pain, chest or throat tightness, fast heartbeat, severe dizziness, passing out, or blue/gray skin discoloration

• Bleeding like vomiting blood or vomit that looks like coffee grounds; coughing up blood; blood in the urine; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding

• Mouth sores

• Mouth pain

• Mouth ulcers

• Burning or numbness feeling

• Redness or irritation of palms or soles of feet

• Severe loss of strength and energy

• Severe injection site redness, burning, pain, swelling, or leaking of fluid

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.