1. Anthracycline Side Effects Myelosuppression, dose limiting toxicity leukopenia more common than thrombocytoenia OR anemia Nausea & vomiting Mucositis & diarrhea, common but not dose limitng Cardiotoxicity Extravasation Alopecia Nausea &vomiting: ↑↑↑↑Mitoxantrone↑↑↑↑Mitoxantrone (70% of the patients) ↑↑↑Doxorubicin↑↑↑Doxorubicin (50% of the patients) ↑↑Daunorubicin↑↑Daunorubicin, Idarubicin, EpirubicinIdarubicinEpirubicin ↑Doxil® (liposomal Doxorubicine) (20% of the patients)

2. Special side effects Doxorubicin Daunorubicin Idarubicin Epirubicin Doxil® Hyperpigmentation of nails, rarely skin rash & urticaria. Red orange discoloration of urine. Doxil® HAND FOOT SYNDROME Mitoxantrone Blue discolourationof fingernails,sclera & urine 1-2 days after treatment Valrubicin Blood in urine Incontinence painful or difficult urination Unusually frequent urination

3. Extravasation Extravasation injury usually refers to the damage caused by leakage of solutions from the vein to the surrounding tissue spaces during intravenous administration. Once an extravasation has occurred, damage can continue for months and involve nerves, tendons and joints. If treatment is delayed, surgical intervension, skin grafting, and even amputation may be the unfortunate consequences

6. Doxorubicin extravasation Necrosis & tissue ulceration may occur some time after the extravasation has occurred, e.g. Daunorubicin extravasation

8. Cold causes vasoconstriction, localizing the extravasation and allowing time for local vascular and lymphatic systems to disperse the agent. decreased cellular uptake of drug at lower temperatures Apply cold packs for 20 minutes QID (4 times)x 3 days. Cold These have been used to reduce inflammation As intradermal or subcutaneous injections and topically as steroid creams. As single treatments and in combination with other agents. Corticosteroids Dimethyl sulphoxide (an oxygen-free radical scavenger) for daunorubicin, mitomycin and doxorubicin. 50-70% solution 1.5ml. Apply topically (ie. "paint" on the skin) QID x 14 days. Leave uncovered. Antidotes surgical excision of the extravasated area Clear cut full-thickness skin necrosis with or without frank ulceration or intractable pain. Surgery

9. Extravasation control Doxorubicin Daunorubicin Mitozantrone Epirubicin  Apply topical DMSO, every 2 hours at the extravasation site  followed by topical hydrocortisone cream and a cold compress.  Avoid contact with good skin. If blistering occurs, stop the DMSO and seek further advice.  Sodium bicarbonate may have a role  Surgical excision is sometimes required to prevent serious damage Doxorubicin Liposomal Daunorubicin Liposomal Apply topical hydrocortisone and cover the area with an ice pack for up to 12 hours, then at 8-12 hours post incidence apply DMSO 2 hourly for the next 24 hours.

10. Some reports of prevention/decreased ulcer formation were obtained when DMSO was used in conjunction with Vitamin E. There is one series of patients reported in whom topical application of 99% DMSO was thought to have prevented ulceration. Some reports of prevention/decreased ulcer formation were obtained when DMSO was used in conjunction with Vitamin E. There is one series of patients reported in whom topical application of 99% DMSO was thought to have prevented ulceration.

11. Venipuncture and placement of the cannula (or other IV access) should be performed by experienced personnel, where available. Venipuncture (e.g. patients with hardly visible veins, very obese patients, very elderly patients, young children, etc.). In all other patients, avoid multiple venipunctures in the same area. Venipuncture and placement of the cannula (or other IV access) should be performed by experienced personnel, where available. Venipuncture (e.g. patients with hardly visible veins, very obese patients, very elderly patients, young children, etc.). In all other patients, avoid multiple venipunctures in the same area. Choose a large, intact vein with good blood flow for the venipuncture and placement of the cannula. Prevention of Extravasation in hospitals

12. The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (oedema), "get red" (erythema), "get hot" (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, stop infusion immediately!oedemaerythema The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (oedema), "get red" (erythema), "get hot" (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, stop infusion immediately!oedemaerythema The infusion should consist of a suitable carrier solution with an appropriately diluted medicinal/chemotherapy drug inside. After the IV infusion has finished, flush the vein "clean" with only the carrier solution.