Medically reviewed by Drugs.com. Last updated on Feb 19, 2019.
(hye droks ee yoor EE a)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Droxia: 200 mg, 300 mg [contains brilliant blue fcf (fd&c blue #1)]
Droxia: 400 mg [contains fd&c yellow #10 (quinoline yellow)]
Hydrea: 500 mg
Generic: 500 mg
Siklos: 100 mg, 1000 mg
Brand Names: U.S.
- Antineoplastic Agent, Miscellaneous
Hydroxyurea is an antimetabolite that selectively inhibits ribonucleoside diphosphate reductase, preventing the conversion of ribonucleotides to deoxyribonucleotides, halting the cell cycle at the G1/S phase and therefore has radiation sensitizing activity by maintaining cells in the G1 phase and interfering with DNA repair. In sickle cell anemia, hydroxyurea increases red blood cell (RBC) hemoglobin F levels, RBC water content, deformability of sickled cells, and alters adhesion of RBCs to endothelium.
Readily absorbed (≥80%); relatively rapid (Rodriguez 1998)
Distributes widely into tissues (including into the brain); estimated volume of distribution approximates total body water (Gwilt 1998); concentrates in leukocytes and erythrocytes
Vd: Children: ~12 L (range: 2.5 to 52) (Ware 2011); Adults: ~20 L/m2 (Rodriguez 1998)
Up to 60% via hepatic metabolism and urease found in intestinal bacteria
Urine (sickle cell anemia: ~40% of administered dose)
Clearance: Children: ~7 L/hour (range: 1.6 to 22) (Ware 2011); Adults: ~7.5 L/hour (Rodriguez 1998)
Onset of Action
Sickle cell anemia: Fetal hemoglobin increase: 4 to 12 weeks
Time to Peak
Children: "Fast" phenotype: 15 to 30 minutes; "Slow" phenotype: 60 to 120 minutes (Ware 2011)
Adults: 1 to 4 hours
1.9 to 3.9 hours (Gwilt 1998); Children: Sickle cell anemia: 1.7 hours (range: 0.7 to 3 hours) (Ware 2011)
75% to 80% bound to serum proteins (Gwilt 1998)
Special Populations: Renal Function Impairment
Exposure is higher in patients with CrCl <60 mL/minute or end-stage renal disease.
Use: Labeled Indications
Chronic myeloid leukemia, resistant (Hydrea): Treatment of resistant chronic myeloid leukemia (CML)
Head and neck cancer (Hydrea): Management (in combination with chemoradiation therapy) of locally advanced squamous cell head and neck cancer (excluding lip cancer)
Sickle cell anemia (Droxia, Siklos): Management of sickle cell anemia (to reduce the frequency of painful crises and to reduce the need for blood transfusions in patients with recurrent moderate to severe painful crises) in adults (Droxia) or in children ≥2 years, adolescents, and adults (Siklos)
Off Label Uses
Acute myeloid leukemia, cytoreduction
Data from a nonrandomized, open-label trial in adults with acute myeloid leukemia (AML) suggest that hydroxyurea may be beneficial for cytoreduction in patients with AML [Grund 1977]. Additional trials may be necessary to further define the role of hydroxyurea in the treatment of this condition.
Based on the European LeukemiaNET panel recommendations, hydroxyurea is effective and recommended for cytoreduction in AML [European LeukemiaNET [Dohner 2010]].
Essential thrombocythemia, high-risk
Data from a randomized trial in patients with essential thrombocythemia at high risk for vascular events supports the use of hydroxyurea (in combination with low-dose aspirin) for the management of this condition [Harrison 2005].
Data from a retrospective study evaluating multiple therapies in patients with hypereosinophilic syndrome supports the use of hydroxyurea in the treatment of patients with this condition [Parillo 1978]. Clinical experience also suggests the utility of hydroxyurea in the treatment of hypereosinophilic syndrome [Klion 2006]. Additional trials may be necessary to further define the role of hydroxyurea in the treatment of this condition.
Data from 2 open-label, nonrandomized trials in patients with recurrent or high risk meningioma or those with an unresectable or residual meningioma suggest that hydroxyurea may be beneficial for the treatment of this condition [Newton 2000], [Rosenthal 2002]. Additional data may be necessary to further define the role of hydroxyurea in this condition.
Polycythemia vera, high-risk
Data from a randomized trial in patients with polycythemia vera supports the use of hydroxyurea in the treatment of patients with this condition [Najean 1997]. Clinical experience also suggests the utility of hydroxyurea in the treatment of patients with polycythemia vera [Finazzi 2007]. Additional trials may be necessary to further define the role of hydroxyurea in the treatment of this condition.
US labeling: Hypersensitivity to hydroxyurea or any component of the formulation
Canadian labeling: Additional contraindications (not in the US labeling): Severe bone marrow depression (eg, leukopenia [<2,500/mm3], thrombocytopenia [<100,000/mm3], or severe anemia)
Note: Doses should be based on ideal or actual body weight, whichever is less (per manufacturer). Prophylactic administration of folic acid is recommended.
Chronic myeloid leukemia (Hydrea): Oral: Initial: 40 mg/kg/day (reduce initial dose for thrombocytopenia); reduce dose to 20 mg/kg/day if WBC count <2,000/mm3. Further individualize dose based on WBC counts (Hehlmann 1993). Hydroxyurea may be used for short-term therapy of elevated WBC counts prior to initiating a TKI (Bacarrini 2013, Cortes 2012).
Head and neck cancer (Hydrea): Oral (individualize treatment/regimen based on tumor type, response, and current clinical practice standards): 1,000 mg every 12 hours for 11 doses per cycle, in combination with continuous infusion fluorouracil and radiation therapy (Garden 2004).
Sickle cell anemia: Oral:
Droxia: Initial: 15 mg/kg/day as a single daily dose. Monitor blood counts every 2 weeks; if blood counts are in an acceptable range, may increase by 5 mg/kg/day every 12 weeks until the maximum tolerated dose of 35 mg/kg/day is achieved or the dose that does not produce toxic effects over 24 consecutive weeks (do not increase dose if blood counts are between acceptable and toxic ranges). If toxicity occurs, withhold treatment until the bone marrow recovers, then restart with a dose reduction of 2.5 mg/kg/day; if no toxicity occurs over the next 12 weeks, then the subsequent dose may be increased by 2.5 mg/kg/day every 12 weeks to a maximum tolerated dose (dose that does not produce hematologic toxicity for 24 consecutive weeks). If hematologic toxicity recurs a second time at a specific dose, discontinue treatment.
Acceptable hematologic ranges: Neutrophils ≥2,500/mm3; platelets ≥95,000/mm3; hemoglobin >5.3 g/dL; and reticulocytes ≥95,000/mm3 if hemoglobin is <9 g/dL
Toxic hematologic ranges: Neutrophils <2,000/mm3; platelets <80,000/mm3; hemoglobin <4.5 g/dL; and reticulocytes <80,000/mm3 if hemoglobin is <9 g/dL
Siklos: Initial: 20 mg/kg/day as a single daily dose. Monitor blood counts every 2 weeks; if blood counts are in an acceptable range, may increase by 5 mg/kg/day every 8 weeks or if a painful crisis occurs until mild myelosuppression (ANC 2,000 to 4,000/mm3) is achieved, or up to a maximum dose of 35 mg/kg/day. If blood counts are in a toxic range, discontinue until hematologic recovery. Following hematologic recovery, restart with the dose reduced by 5 mg/kg/day; may titrate dose up or down every 8 weeks in 5 mg/kg/day increments, seeking a stable dose with no hematologic toxicity for 24 weeks. Discontinue permanently if hematologic toxicity develops twice.
Acceptable hematologic ranges: Neutrophils ≥2,000/mm3; platelets ≥80,000/mm3; hemoglobin >5.3 g/dL; and reticulocytes ≥80,000/mm3 if hemoglobin is <9 g/dL
Toxic hematologic ranges: Neutrophils <2,000/mm3 (neutrophil limit of 1,250/mm3 may be acceptable in younger patients with lower baseline counts); platelets <80,000/mm3; hemoglobin <4.5 g/dL; and reticulocytes <80,000/mm3 if hemoglobin is <9 g/dL
Calculate rounded doses to the nearest 50 or 100 mg strength.
Note: A clinical response to treatment may take 3 to 6 months; a 6-month trial of the maximum tolerated dose is recommended prior to considering discontinuation due to treatment failure. Effectiveness of hydroxyurea depends upon daily dosing adherence. For patients who have a clinical response, long-term hydroxyurea therapy is indicated (NHLBI 2014).
Acute myeloid leukemia (AML), cytoreduction (off-label use): Oral: 50 to 100 mg/kg/day until WBC <100,000/mm3 (Grund 1977) or 50 to 60 mg/kg/day until WBC <10,000 to 20,000/mm3 (Dohner 2010)
Essential thrombocythemia, high-risk (off-label use): Oral: 500 to 1000 mg daily; adjust dose to maintain platelets <400,000/mm3 (Harrison 2005)
Hypereosinophilic syndrome (off-label use): Oral: 1,000 to 3,000 mg/day (Klion 2006)
Meningioma (off-label use): Oral: 20 mg/kg once daily (Newton 2000; Rosenthal 2002)
Polycythemia vera, high-risk (off-label use): Oral: 15 to 20 mg/kg/day (Finazzi 2007)
Refer to adult dosing. May require lower doses.
Note: Doses should be based on ideal or actual body weight, whichever is less (per manufacturer); calculate rounded doses to the nearest 50 mg or 100 mg strengths.
Sickle cell anemia: Infants ≥6 months, Children, and Adolescents: Limited data available in infants and children <2 years: Initial: Oral: 20 mg/kg/dose once daily; monitor blood count every 2 weeks; may increase by 5 mg/kg/day every 8 weeks until mild myelosuppression (see the following Acceptable Hematologic Ranges) is achieved or if painful crises occur (as long as myelosuppression acceptable); maximum daily dose: 35 mg/kg/day (Hankins 2005; NHLBI 2014; Strouse 2012; Thornburg 2009; Wang 2001; Wang 2011). An initial starting dose of 15 mg/kg/dose once daily has also been studied (Kinney 1999; Zimmerman 2004). A clinical response to treatment may take 3 to 6 months; a 6-month trial of the maximum tolerated dose is recommended prior to considering discontinuation due to treatment failure; effectiveness of hydroxyurea depends upon daily dosing adherence. For patients who have a clinical response, long-term hydroxyurea therapy is indicated (NHLBI 2014).
Acceptable hematologic ranges: Neutrophils ≥2,000 to 4,000/mm3 (younger patients with lower baseline counts may safely tolerate ANC down to 1,250/mm3), platelets ≥80,000/mm3; hemoglobin >5.3 g/dL, and reticulocytes ≥80,000/mm3 if hemoglobin is <9 g/dL
Dosing adjustment for toxicity: Infants ≥6 months, Children, and Adolescents: Oral:
Hematologic: Sickle cell disease:
Toxic myelosuppression (Neutrophils <2,000/mm3 [ANC minimum limit of 1,250/mm3 may be acceptable in younger patients with lower baseline counts], platelets <80,000/mm3; Hgb <4.5 g/dL or reticulocyte <80,000/ mm3 with Hgb <9 g/dL): Hold therapy until counts recover (monitor weekly); reinitiate at a dose 5 mg/kg/day lower than the dose given prior to onset of toxic myelosuppression (NHLBI 2014); some have recommended reinitiating at a dose 2.5 mg/kg/day lower (Hankins 2005; Heeney 2008; Wang 2001; Wang 2011; Zimmerman 2004). Titrate dose up or down every 8 weeks in 5 mg/kg/day increments until the patient is at a stable dose that does not result in hematologic toxicity for 24 weeks. If hematologic toxicity develops again (ie, twice), permanently discontinue therapy.
Non-hematologic: The presented adjustments are based on experience in adult patients; specific recommendations for pediatric patients are limited. Refer to specific protocol for management in pediatric patients if available.
Cutaneous vasculitic ulcerations: Discontinue
Pancreatitis: Discontinue permanently
Dosing: Adjustment for Toxicity
Cutaneous vasculitic ulcerations: Discontinue
Pancreatitis: Discontinue permanently
Hematologic toxicity: CML, head and neck cancer: Do not initiate therapy if bone marrow function is markedly reduced.
Sickle cell anemia:
Droxia: Neutrophils <2,000/mm3, platelets <80,000/mm3, hemoglobin <4.5 g/dL, or reticulocytes <80,000/mm3 with hemoglobin <9 g/dL: Interrupt treatment; following recovery, may resume with a dose reduction of 2.5 mg/kg/day. Hydroxyurea may then be titrated up or down every 12 weeks in 2.5 mg/kg/day increments until the patient is at a stable dosage that does not result in hematologic toxicity for 24 weeks. If hematologic toxicity recurs a second time at a specific dose, discontinue treatment.
Siklos: Neutrophils <2,000/mm3 (neutrophil limit of 1,250/mm3 may be acceptable in younger patients with lower baseline counts), platelets <80,000/mm3, hemoglobin <4.5 g/dL, and reticulocytes <80,000/mm3 with hemoglobin <9 g/dL: Interrupt treatment; following recovery, may resume with a dose reduction of 5 mg/kg/day. Hydroxyurea may then be titrated up or down every 8 weeks in 5 mg/kg/day increments until the patient is at a stable dosage that does not result in hematologic toxicity for 24 weeks. If hematologic toxicity recurs a second time at a specific dose, discontinue treatment.
ASCO Guidelines for appropriate chemotherapy dosing in obese adults with cancer (solid tumors): 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 (Griggs 2012). Note: The manufacturer recommends dosing based on ideal or actual body weight, whichever is less.
100 mg/mL Oral Solution (ASHP Standard Concentration) (ASHP 2017)
A 100 mg/mL oral solution may be prepared with capsules. Mix the contents of twenty 500 mg capsules with enough room temperature sterile water (~50 mL) to initially result in a 200 mg/mL concentration. Stir vigorously using a magnetic stirrer for several hours, then filter to remove insoluble contents. Add 50 mL Syrpalta (flavored syrup without color, HUMCO) to filtered solution, resulting in 100 mL of a 100 mg/mL hydroxyurea solution. Stable for 1 month at room temperature in amber plastic bottle (Heeney 2004).Heeney MM, Whorton MR, Howard TA, et al. Chemical and functional analysis of hydroxyurea oral solutions. J Pediatr Hematol Oncol. 2004;26(3):179-184.15125610
Oral: Administer at the same time each day. Swallow whole, do not open capsules.
Siklos: Administer with water. If unable to swallow tablets whole, may disperse immediately before use in a small amount of water in a teaspoon (add tablet to spoon, add water; tablet dissolves in ~1 minute; administer immediately); drink an additional glass of water after administering the dose. The 100 mg tablets are scored with 1 line to enable splitting into 2 parts and the 1 g tablets are scored with 3 lines to enable splitting into 4 parts; wear gloves and use a damp paper towel surface to break scored tablets (properly dispose of used gloves and paper towel).
Impervious gloves should be worn when handling bottles containing hydroxyurea or when handling/administering intact capsules/tablets. Wash hands with soap and water before and after contact with hydroxyurea. Avoid exposure to crushed capsules/tablets or open capsules. If skin contact occurs, immediately wash the affected area thoroughly with soap and water. If eye(s) contact occurs, the affected area should be flushed thoroughly with water or isotonic eyewash designated for that purpose for at least 15 minutes. If powder from the capsules or tablets is spilled, immediately wipe it up with a damp disposable towel and discard (along with the empty capsules) in a closed container, such as a plastic bag. The spill areas should then be cleaned using a detergent solution followed by clean water.
Supplemental administration of folic acid is recommended; hydroxyurea may mask development of folic acid deficiency.
Droxia, Hydrea: Store at 25°C (77°F); excursions permitted between 15°C and 30°C (59°F and 86°F). Keep bottle tightly closed.
Siklos: Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F). Keep bottle tightly closed; use split tablets within 3 months.
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
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
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
Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination
Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy
Didanosine: May enhance the adverse/toxic effect of Hydroxyurea. An increased risk of pancreatitis, hepatotoxicity and/or neuropathy may exist. Hydroxyurea may enhance the adverse/toxic effect of Didanosine. An increased risk of pancreatitis, hepatotoxicity and/or neuropathy may exist. Avoid combination
Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination
Echinacea: May diminish the therapeutic effect of Immunosuppressants. 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
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
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination
Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification
Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. 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
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. Consider therapy modification
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
Stavudine: Hydroxyurea may enhance the adverse/toxic effect of Stavudine. An increased risk of pancreatitis, hepatotoxicity and/or neuropathy may exist. Stavudine may enhance the adverse/toxic effect of Hydroxyurea. An increased risk of pancreatitis, hepatotoxicity and/or neuropathy may exist. Avoid combination
Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination
Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. 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 neutropenic effect of Immunosuppressants. Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated 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
Hydroxyurea may interfere with lactic acid, urea, or uric acid assays, resulting in falsely elevated results.
Dermatologic: Eczema (infants and children: 13% [Thornburg 2012])
Hematologic & oncologic: Macrocytosis (MCV >97: 42% [Randi 2005])
1% to 10%:
Dermatologic: Leg ulcer (7% [Hernández-Boluda 2011]), dermal ulcer (3% [Antonioli 2012])
Gastrointestinal: Acute mucocutaneous toxicity (5% [Hernández-Boluda 2011])
Respiratory: Asthma (infants and children: 9% [Thornburg 2012])
Frequency not defined:
Dermatologic: Alopecia, nail discoloration (melanonychia)
Gastrointestinal: Gastric distress (infrequent [Antonioli 2012]), gastritis (potentiated with radiation therapy), mucositis (potentiated with radiation therapy), oral mucosa ulcer (infrequent [Hernández-Boluda 2011])
Hematologic & oncologic: Anemia, bone marrow depression (recovery: within 2 weeks), hemorrhage, leukemia, leukopenia, reticulocytopenia (Wang 2011), thrombocytopenia
Neuromuscular & skeletal: Panniculitis (Antonioli 2012)
<1%, postmarketing, and/or case reports: Actinic keratosis (Antonioli 2012), anorexia, asthenia, atrophy of nail, azoospermia, basal cell carcinoma (Antonioli 2012), chills, cholestasis, constipation, dermatomyositis-like skin changes, desquamation, diarrhea, disorientation, dizziness, drowsiness, dyspnea, dysuria, edema, facial erythema, fever (onset within 6 weeks of initiation; resolved on discontinuation; recurred within 24 hours after readministration), gangrene of skin and/or subcutaneous tissues (patients with myeloproliferative disorders), hallucination, headache, hepatitis, hyperkeratosis (Antonioli 2012), hyperpigmentation, hypersensitivity reaction, increased blood urea nitrogen, increased liver enzymes, increased serum creatinine, increased uric acid, lesion, localized erythema of the extremities, maculopapular rash, malaise, malignant neoplasm (Wong 2014), mucous membrane lesion (Antonioli 2012), nausea, oligospermia, papule, pneumonitis (Antonioli 2012), pulmonary fibrosis, pulmonary infiltrates, seizure, skin atrophy, skin carcinoma, squamous cell carcinoma (Antonioli 2012), stomatitis, tumor lysis syndrome, vasculitic ulcerations (patients with myeloproliferative disorders), vomiting
Concerns related to adverse effects:
• Bone marrow suppression: [US Boxed Warning]: Hydroxyurea may cause severe myelosuppression. Monitor blood counts at baseline and throughout treatment. Interrupt treatment and reduce dose as necessary. Leukopenia and neutropenia commonly occur (thrombocytopenia and anemia are less common); leukopenia/neutropenia occur first. Severe or life-threatening myelosuppression may occur at the recommended initial dose. Hematologic toxicity is reversible (rapid) with treatment interruption; after treatment interruption, resume therapy at a lower dose. Use with caution in patients with a history of prior chemotherapy or radiation therapy; myelosuppression is more common. Correct severe anemia prior to initiating treatment. Do not initiate therapy if bone marrow function is markedly reduced. Pediatric patients are at increased risk for myelosuppression at the time of dosage adjustments due to changes in body weight.
• Cutaneous vasculitic toxicities: Vasculitic ulcerations and gangrene have been reported in patients with myeloproliferative disorders during hydroxyurea treatment, most often in patients with a history of or receiving concurrent interferon therapy. Discontinue hydroxyurea (or reduce the dose) and consider alternate cytoreductive therapy if cutaneous vasculitic toxicity develops. Ulcers may rarely be caused by leukocytoclastic vasculitis. Avoid use in patients with leg ulcer wounds.
• Hypersensitivity: Drug-induced fever has been reported (with cardiovascular, dermatologic, GI, hepatic, musculoskeletal, or pulmonary manifestations); may require hospitalization. The onset is usually within 6 weeks of treatment initiation and resolves with discontinuation. Fever usually recurred within 24 hours with re-challenge.
• Macrocytosis: Self-limiting macrocytosis may be seen early in treatment (may resemble pernicious anemia, but is unrelated to vitamin B12 or folic acid deficiency). May mask diagnosis of pernicious anemia. Prophylactic folic acid supplementation is recommended.
• Secondary malignancy: [US Boxed Warning]: Hydroxyurea is carcinogenic. Advise sun protection and monitor patients for malignancies. Treatment of myeloproliferative disorders (eg, polycythemia vera, thrombocythemia) with long-term hydroxyurea is associated with secondary leukemia; it is unknown if this is drug-related or disease-related. Skin cancer has been reported with long-term hydroxyurea use. Monitor for signs/symptoms of secondary malignancies.
• Tumor lysis syndrome: Hyperuricemia may occur with antineoplastic treatment; adequate hydration and initiation or dosage adjustment of uricosuric agents (eg, allopurinol) may be necessary.
• HIV-infected patients: Pancreatitis, hepatotoxicity, and peripheral neuropathy have occurred when hydroxyurea was administered with antiretroviral medications, including didanosine and stavudine.
• Renal impairment: Use with caution in patients with renal impairment; may require dose reductions.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Elderly: May be more sensitive to the effects of hydroxyurea; may require lower doses.
• Radiation therapy recipients: Patients with a history of radiation therapy are at risk for exacerbation of post irradiation erythema and myelosuppression.
• Immunizations: Avoid use of live vaccines during hydroxyurea therapy. Concomitant use may potentiate viral replication and may possibly increase vaccine adverse reactions due to suppression of normal defense mechanisms by hydroxyurea and result in severe infections. The antibody response to vaccines may be decreased. Consider consultation with a specialist if immunization with a live vaccine is necessary.
CBC with differential and platelets (once weekly for antineoplastic indications; every 2 weeks initially for sickle cell anemia), renal function and liver function tests, serum uric acid; hemoglobin F levels (sickle cell disease; every 3 to 4 months); pregnancy status prior to therapy initiation in women of reproductive potential; monitor for cutaneous toxicities
Sickle cell disease: Monitor for toxicity every 2 weeks during dose escalation (neutrophils, platelets, hemoglobin, reticulocytes) (manufacturer's labeling) or at least every 4 weeks when adjusting the dose (CBC with WBC differential, reticulocytes) [NHLBI 2014]). Once on a stable dose, may monitor CBC with differential, reticulocyte count and platelets every 2 to 3 months (NHLBI 2014). Monitor RBC, MCV (mean corpuscular volume) and HbF (fetal hemoglobin) levels for evidence of consistent or progressive laboratory response (NHLBI 2014).
Adverse effects have been observed in animal reproduction studies. Based on its mechanism of action, hydroxyurea may cause fetal harm if administered during pregnancy. Women of reproductive potential should be advised to avoid becoming pregnant during treatment (verify pregnancy status prior to starting hydroxyurea therapy) and should use effective contraception during and for at least 6 months after completion of therapy. Hydroxyurea use may damage spermatozoa and testicular tissue; males with female partners of reproductive potential should use effective contraception during and for at least 6 months (Siklos) or 1 year (Droxia, Hydrea) after therapy. Azoospermia or oligospermia (sometimes reversible) has been observed in male patients; counsel males of reproductive potential about sperm banking prior to therapy initiation.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience hair loss, nausea, lack of appetite, constipation, diarrhea, weight gain, headache, or mouth sores. Have patient report immediately to prescriber signs of infection, signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; 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), mole changes, skin growths, severe loss of strength and energy, skin ulcers, skin changes, or nail changes (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
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