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Doxorubicin, an anthracycline antibiotic derived from Streptomyces peucetius, remains a cornerstone chemotherapeutic agent for a wide range of solid tumors and hematologic malignancies, including breast cancer, sarcomas, leukemias, and lymphomas. The clinical utility of doxorubicin is balanced by significant risks, notably dose-dependent cardiotoxicity, myelosuppression, extravasation injury, and secondary malignancies. This activity provides a comprehensive review of doxorubicin's indications, mechanisms of action, pharmacokinetics, contraindications, and Food and Drug Administration box warnings, with emphasis on toxicity recognition and mitigation strategies. Participants gain the knowledge required to optimize dosing, anticipate and manage adverse effects, and apply evidence-based monitoring practices. The activity also highlights the importance of interprofessional collaboration in oncology care, equipping clinicians with practical tools to individualize treatment, enhance patient safety, and improve therapeutic outcomes. Objectives: Identify the indications for using doxorubicin in a chemotherapeutic regimen. Evaluate clinical and laboratory findings to detect early signs of doxorubicin-related toxicities. Assess patient-specific risk factors for doxorubicin-induced cardiotoxicity and determine appropriate monitoring strategies. Communicate patient-specific risks, dosing parameters, and toxicity concerns effectively across the interprofessional team to support timely clinical decision-making. Access free multiple choice questions on this topic.

Signs and Symptoms of Overdose/Toxicity Acute doxorubicin overdosage can cause severe mucositis, leukopenia, and thrombocytopenia. Doxorubicin has significant potential for cardiotoxicity, as with other anthracycline drugs.[42] Nanoparticle-based formulations of doxorubicin, including liposomal doxorubicin, are associated with fewer toxicities than conventional formulations.[43] Immune checkpoint inhibitors and other potential cardiotoxic agents may increase the risk of cancer therapy–related cardiac dysfunction. Cancer therapy–related cardiac dysfunction should be monitored in patients treated with immune checkpoint inhibitors using cardiac biomarkers and echocardiography.[44] Management of Overdose/Toxicity In the event of overdose, priority should be given to securing the airway, breathing, and circulation. Management of acute overdose is primarily supportive. Efbemalenograstim alfa and pegfilgrastim may be considered for chemotherapy-induced neutropenia; however, additional research is needed.[45] Management of cardiotoxicity is outlined in the 2022 American College of Cardiology/American Heart Association heart failure guidelines. In patients who develop cancer therapy–related cardiomyopathy or heart failure, a multidisciplinary discussion regarding the risks and benefits of continuing, discontinuing, or interrupting cancer therapy is recommended. In asymptomatic patients with cancer therapy–related cardiomyopathy (ejection fraction <50%), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and beta-blockers are considered reasonable to prevent progression to heart failure and to improve cardiac function. For patients with cardiovascular risk factors or known cardiac disease who are candidates for cardiotoxic anticancer therapies, a pretreatment assessment of cardiac function is recommended to establish a baseline and inform treatment decisions. Monitoring cardiac function during treatment is also reasonable to detect drug-induced cardiomyopathy early. The benefit of initiating beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for primary prevention in at-risk patients remains uncertain. Serial measurement of cardiac troponin may also be reasonable for risk stratification in patients receiving potentially cardiotoxic therapies.[46]

Doxorubicin is a frequently used chemotherapeutic agent for the treatment of many solid tumors and requires an interprofessional healthcare team for optimal effectiveness. Although effective, doxorubicin is associated with a serious adverse effect. The interprofessional team includes primary care clinicians who refer patients to oncologists and who perform cardiac screening for patients with risk factors for heart disease. Oncology nurses assist in all aspects of care, support regimen adherence, and address patient questions. Pharmacists contribute to dosing, medication reconciliation, and patient counseling. Doxorubicin can cause irreversible cardiomyopathy, which may occur at any time after treatment. An interprofessional approach optimizes patient outcomes while minimizing potential adverse effects. Baseline (pretreatment) and periodic monitoring of cardiac function using echocardiography or multigated radionuclide angiography (MUGA) are recommended in patients receiving doxorubicin. A cardiologist should be consulted for severe doxorubicin-related cardiotoxicity. The prescribing clinician should include a board-certified oncology pharmacist to optimize the regimen and prevent potential drug interactions. Discontinue doxorubicin in patients who exhibit a decrease in LVEF during treatment. Oncology nurses play a key role in assessing treatment effectiveness and monitoring for adverse events. Because higher cumulative doxorubicin doses increase the risk of cardiomyopathy, dose limitation is recommended to reduce cardiotoxicity.[6][47][48] An interprofessional team approach and effective communication among clinicians, advanced practice providers, specialists, pharmacists, and nurses are essential for minimizing adverse effects and improving outcomes in patients receiving doxorubicin.