Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Adriamycin
(Doxorubicin)
IV Chemotherapy
Inhibits DNA transcription and
formation of cytotoxic free radicals
● Excreted in feces and kidneys
● Half Life = 20-48h
● Does not cross BBB
● Patients may notice darker urine for
1-2 days after
● Patients cardiac function should be
monitored
● Increased toxicity of: cytoxan,
herceptin, and 6-mercaptopurine
● Decreases efficacy of: Phenobarbital,
digoxin
● Avoid glutathione, NAC, curcumin
which may contribute to resistance
(CTCA)
● Glucosamine might induce resistance
to doxorubicin (Adriamycin) by reducing
the drugs' inhibition of topoisomerase II,
an enzyme required for DNA replication
in tumor cells
● Myelosuppression
● N/V (50%)
● Diarrhea, mucositis
● Cardiotoxic
●Alopecia (100%)
● Red-orange urine
● Skin discoloration
Increasing Efficacy:
● Gingko: 4caps 1hour prior to
infusion (J.Belanger, ND)
● Arginine: 4g q4h 5d prior/3d
post chemo (J.Belanger,ND)
● L-Theanine - increases
effectiveness
1. Myelosupression
● Esberitox 3 tablets tid
● Astragalus with Ligustrum
● Maitake
● Goji berries
● Panax ginseng
2. Nausea and vomiting
● Ginger tea, ginger capsules
● NAC 1800mg/d (Lamson)
3. Mucositis and diarrhea
● L-glutamine 10 g tid
● DGL ¼ tsp tid
● slippery elm,
● Glycgel, oral paste
● L-lysine 1g bid-tid
4. Cardiotoxicity
● CoQ-10 100-300 mg TID
● L-carnitine 4g/d
● Vit E (800IU), Vit C (1g)
● NAC (1800mg)
● Panax ginseng
Aldesleukin (see IL-2)
IV Immunotherapy
Alimta (Pemetrexed)
IV Chemotherapy
Anti-folate analog
● Half-Life = 3 hours
● 90% Renal Excretion
● NSAIDs may inhibit renal
excretion
● All patients should receive vitamin
supplementation with 350ug/day oral
folic acid and 1mg/day SC vitamin
B12 to reduce toxicity
● Myelosuppression
● Skin Rash
● N/V/D/Mucositis
● Fatigue
1
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Amiofostine (see Ethyol)
IV Chemoprotective Drug
Anastrozole
(see Arimadex)
Hormonal Therapy
Aranesp
(Darbopoetin alfa)
Growth Factor
IV, SC drug. Stimulates division and
differentiation of RBC in bone marrow
● ½ Life = 40-49h
● Contraindicated in uncontrolled
HTN,
● Remote risk of Creutzfeldt-Jacob
Syndrome transmission
● HTN
● N/V/D occasionally
● Fatigue, Arthralgia
Arimadex (Anastrozole)
Hormonal Therapy
Nonsteroidal sromatase inhibitor
Oral, Inhibits synthesis of estrogens
by inhibiting the conversion of
adrenal androgens to estrogens
● Liver Metabolism
● Fecal Excretion
● Half Life= 50h
Serum Estradiol levels are 90%
suppressed after 14 days, and near
100% after 6 weeks
●No interactions
● Absorption is not affected by food
● Hot Flashes (10%)
● Arthralgia (10-15%)
● Edema (7%)
Aromasin (Exemestane)
Hormonal Therapy
Steroidal aromatase inhibitor
● No interactions
● Absorption is not affected by food
● Hot Flashes
● Fatigue
● Nausea
2
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Permanently binds and inactivates
aromatase to inhibit estrogen
synthesis
● Liver P450 Metabolism
● Fecal Excretion
● Half-Life= 24h
Avastin (Bevacizumab)
Monoclonal Antibody
Binds to VEGF (which is
pro-angiogenic) to inhibit tumor blood
vessel permeability
● Cleared by liver, kidneys
● Half-Life= 17-21 days
● No interactions ●Bleeding Complications (GI
perforations, epistaxis,
hemoptysis)
● Thrombo-embolic events
● HTN (20-30%)
● Flu-like symptoms
BCG (Bacillus
Calmette-Guerin)
Immunotherapy
Intra-vesical, Attenuated strain of
M.bovis provides a local inflammation
in the bladder.
● Immunosuppressive Drugs
(Impaired efficacy)
● Antimicrobials/Quinolones
(impaired efficacy)
Patients must disinfect toilet with
bleachx15min after urination for 6h
after instillation
● Chemical cystitis
● Flu-like symptoms (35%)
Bevacizumab
(see Avastin)
Monoclonal Antibody
Bicalutamide
(see Casodex)
Antiandrogen Hormonal Drug
3
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Bortezomib
(see Velcade)
IV Chemotherapy
Drink Plenty of Fluids to decrease
hypotensive episodes
● Peripheral Neuropathy
● Hypotension
● CHF
● N/V
● Diarrhea or Constipation
● Thrombocytopenia
● Hepatic Events
1. CHF:● CoQ10
● L-carnitine
● Hawthorn
2. N/V: ginger, cinnamon
3. Diarrhea or constipation:● fiber
● L-glutamine for diarrhea
4. Asthenic conditions:● Licorice d/t corticosteroid
promoting effects
● Ginsengs
Capecitabine
(see Xeloda)
Oral Chemotherapy
● Decreased levels of
methylenetetrahdrofolate
● B6+B12+folic acid to increase
effectiveness, since drug resistance may
occur with decreased levels of MTH-folate
● PSK (from Coriolus
versicolor ) 3 g/d with tegafur/uracil
(UFT) {oral equivalent to 5-fu} in stage II
and III colorectal ca increased survival
and decreased recurrence or mets
● Take supplements 2 hours after
taking Xeloda. (by CTCA), especially
those that contain folic acid.
● Take AWAY from meals!
● Take AWAY from antacids
● Interacts with CYP450
● Monitor INR!
● Blepharitis, tear-duct
stenosis, acute and chronic
conjunctivitis
● Cardiotoxicity
● Nausea
● Hand-Foot Syndrome
● Mouth Sores
● Diarrhea
1.Hand-Foot Syndrome:
● Vit B6 50 mg BID up to 300 mg
QD for prevention
● All purpose salve topically for
hand-foot syndrome.
● Avoid exposure to heat
● Deodorant topically to palms
and bottom of feet
2.GI Toxicity (mouth sores,
diarrhea):
● L-glutamine to prevent GI
toxicity, mouth sores and diarrhea.
● DGL
● Glycgel, oral paste and
Slippery Elm, Vit E
● L-lysine 1g bid-tid for mouth
sores and heartburn.
3.Nausea: Ginger tea or capsules.
Carboplatin
IV Chemotherapy
Platinum analog binds DNA with
cytotoxic effects
● Avoid Glutathione
● Vitamin B6: no more than 200 mg
(one capsule of B complex #6), as
higher doses have been shown to
decrease efficacy of Cisplatin (ECOG
Enhancing Efficacy:
● Quercitin: 4caps q5h day
before and day of chemo
(J.Belanger,ND)
1. Myelosuppression
● Astragalus with Ligustrum
● Esberitox
2.Thrombocytopenia (by day 21)
● PA-Free Comfrey (Wise Woman)
● Sesame oil
4
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Excreted by Kidneys
● half-life= 2-6hours
● Pre-treat with antiemetics
● Maintain oral hydration
● Alopecia not likely
Clinical trial using 300 mg/m2
(Cancer Invest. 1992;10(1):1-9), as
well as in vitro data. Please note: the
study concluded that pyridoxine
should not be used at all with
Cisplatin.
● Avoid Gingko; the only platinum
drug gingko is safe with is cisplatin
(J.Belanger,ND)
.
● Arginine: 4g q4h
5dprior/3dpost chemo
(J.Belanger,ND)
● Silymarin, PSK (CTCA)
● Red root
● Maitake-D-Fraction
3.N/V: Ginger , Cinnamon
4.Renal toxicity
● Minerals: Se, Ca, Mg, K, Na
● Glutamine
6. Peripheral neuropathy (<10%)
● Vit E, a-lipoic acid, Se,
Acetyl-L-carnitine, Mg
Casodex (Bicalutamide)
Antiandrogen Hormonal Drug
Oral, nonsteroidal antiandrogen
inhibiting androgen uptake.
● Liver P450 Metabolism
● Fecal/Urine Excretion
● Half-Life= several days
● Warfarin (additive anticoagulant
effect)
● Altered sexual function
● Hot flashes (50%)
● Constipation (10%)
Cetuximab (see Erbitux)
IV Monoclonal Antibody
Cisplatin (Platinol)
IV Chemotherapy
Platinum analog binds DNA for
cytotoxic effect
● Excreted in urine
● Half-life = 20-30 min
● Patient should drink 1L water before
and 1L water after infusion
● Pretreat with antiemetics
● Avoid Glutathione, NAC which
may promote resistance (CTCA)
● Vitamin B6: no more than 300 mg
(one capsule of B complex #6), as higher
doses have been shown to decrease
efficacy of Cisplatin (ECOG Clinical trial
using 300 mg/m2 (Cancer Invest.
1992;10(1):1-9), as well as in vitro data.
Please note: the study concluded that
pyridoxine should not be used at all with
Cisplatin
Enhancing Efficacy:
●Folic acid and B12 may increase
chemosensitivity in patients with stage
IV non-small-cell lung cancer who are
also carriers of the MTHFR 677T
allele. (Clin Lung Cancer. 2004
May;5(6):360-5.)
● L-Theanine 200 mg daily may
increase tumor concentrations of
chemo, but not normal tissue. Do not
take at same time as glutamine
(competitive absorption).
1. Neurotoxicity
● Vitamin E (600mg) during and 1
month after prevented neuropathy
(PubMed)
● Vit E, a-lipoic acid, selenium,
L- carnitine, Mg, acetyl-L-carnitine
● Melatonin: 20mg for ototoxicity
2.Nephrotoxicity
● Magnesium, Ca, K depletion
by Cisplatin due to impaired
intestinal absorption
● Cysteine, Vit E, Crocus sativa (J
Pharm Belg 1998, 53(2))
5
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Does cause alopecia
● Mg and Ca : Cisplatin nephrotoxicity
leads to magnesium and calcium wasting
and may affect may affect magnesium and
calcium metabolism, both of which
contribute to bone integrity. (see Pubmed)
● Gingko: 4caps 1hour prior to
infusion (J.Belanger, ND)
● Arginine: 4g q4h 5d prior/3d
post chemo (J.Belanger,ND)
● Taurine restored kidney GSH
(Chemo 2002, 48(1))
● Vit C dose-dependent protection
(Pharmacol Res 2000, 41(4)).
● Glycine: Cisplatin -inducednephrotoxicity has been minimized (Ernst,2014)3.Fatigue
● L-carnitine 4g/d (PubMed)
4.Immunosuppression
● Melatonin (natural database)
● PSK with Cisplatin + 5-FU has
immunostimulatory effect (RCT
PubMed)
Cyclophosphamide
(see Cytoxan)
IV or Oral Chemotherapy
Cytoxan
(Cyclophosphamide)
IV or Oral Chemotherapy
● Liver P450 Metabolism
● Excreted in Urine
● ½ Life = 4-6h
Inhibits DNA synthesis in all phases
of the cell cycle
● Patients should drink 2-3L water
per day to reduce hemorrhagic cystitis
● Encourage patient to empty
bladder every 2 hours
● Check INR, and Rx meds
● Avoid Gingko, Curcumin,
Glutathione, NAC; may promote
resistance (CTCA, JBElangerND)
Increasing Efficacy:
● Folic acid, Vitamin A, Aloe,
and Ashwaganda (CTCA,
JBelangerND)
● Arginine: 4g q4h 5d prior/3d
post chemo (J.Belanger,ND)
1. Immunosupression
● Astragalus might reduce
immunosuppression caused by
cyclophosphamide (see natural
database Astragalus)
● Ashwaganda (Cancer Letters
2000, CTCA)
● Astragalus promotes myelopoiesis,may protect WBC counts during cyclophosphamide therapy thereby reducing leukopenia [1].
● Echinacea may enhance low dose cyclophosphamide and myelosuppression may be reduced in high dose cyclophosphamide [1]
● Eleuthero extracts reduce adverse effects of cyclophosphamide by protecting against and reversing
6
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Used with Adriamycin in breast
cancer
leukopenia and enhancement of general stress resistance [1]
2. Survival
● PSK 3 g/d – breast ca in
combination with cytoxan and 5-fu
increased survival (RCT PubMed)
● Licorice in combination with cyclophosphamide (single mice study) showed a reduction in tumorigenesis and metastasis. [1]
3. Toxicity
● Alpha Lipoic Acid reduced
toxicity (UMM)
● Selenium in combination with antioxidants (beta carotene, B2, B3, Vit C, Vit E) shown to reduce hair loss, flatulence, abdom pain, weakness, malaise, and lack of appetite [1]
Cytarabine
IV Chemotherapy, isolated from a sea
sponge
Inhibits DNA synthesis in
S-phase
●Metabolized by cytidine deaminase
in all tissues
● ½ Life = 2-6h
● Decreases efficacy of gentamicin,
5FU, digoxin
● Increased toxicity of cisplatin,
methotrexate, fludara, radiation
therapy
● Patients should be pre-treated
with steroid eyedrops in high dose
therapy to avoid conjunctivitis
● Myelopsuppression
● N/V/D + mucositis (7-10d post
therapy)
● Neurotoxicity (10%) including
confusion, ataxia
● Conjunctivitis
● Pulmonary distress
Darbopoetin alfa
(see Aranesp)
Dasatinib (see Sprycel)
Docetaxol
7
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
(see Taxotere)
IV Chemotherapy
Doxorubicin
(see Adriamycin)
IV Chemotherapy
Erbitux (Cetuximab)
IV Monoclonal Antibody
Anti-EGFR to induce apoptosis
Weekly Injections
● Unknown Excretion
● Half-Life = 5-7 days
● Skin toxicity indicates efficacy in
most patients
● May worsen interstitial lung
disease
● Avoid CYP3A4 herbs
● Gingko inhibits
● Flu-like reaction (40-50%)
● Acneiform rash (improves with
continued tx)
● Malaise (50%)
● Fatigue, HA
● Allergic Reaction (dose limiting)
● Lung Disease (dose limiting)
1. Skin and Nail Problems: avoid sun
2. Diarrhea
● L-Glutamine: 10g TID
3. Abdominal pain, N/V : Ginger,
cinnamon
Erlotinib
(see Tarceva)
Oral Chemotherapy
HER1/EGFR tyrosine kinase inhibitor.
● Half-life = 36 hours●CYP3A4 and CYP1A2 metabolism● 93% protein bound to albumin and alpha-1acid glycoprotein (AAG).
MONITOR warfarin.
Avoid P450 acting products such as St. John’s wort, Milk thistle, Ginsengs, Ginkgo and others .
● Pulmonary Toxicity -- There have
been infrequent reports of serious
Interstitial Lung Disease (ILD),
including pneumonitis, interstitial
pneumonia, interstitial lung disease,
obliterative bronchiolitis, pulmonary
fibrosis, Acute Respiratory Distress
Syndrome and lung infiltration.
● Rash and diarrhea. The median
time to onset of rash was 8 days, and
the median time to onset of diarrhea
was 12 days.
● Grade 3 conjunctivitis and
keratitis have been reported
infrequently in patients receiving
TARCEVA therapy. Corneal
ulcerations may also occur.
1. Pulmonary Toxicity
● Bromelain ?
● NAC?
2. Rash and diarrhea: L-glutamine
10g TID.
Erythropoietin ● Decreases efficiency of Heparin if
given concurrently
● Hypertension
● D/N/V occasionally
8
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
(Procrit, Epogen)
Colony-stimulating factor
● Metabolized in liver and bone
● 10% urine excretion
● Half-life = 4-13h
● Aluminum antacids decrease
efficacy
● May benefit with p.o. Ferrous
sulfate as well
● fever, fatigue
Ethyol (Amiofostine )
IV Chemoprotective Drug
Free thiol acts as an antioxidant to
reduce free radical damage from
Cisplatin and Radiation
● Urinary excretion
● Half Life = 8 minutes
● Carboplatin (decreased clearance
by the kidney)
● BP meds should be discontinued
24h prior to administration (additive)
●Nause/Vomiting common
● Hypotension (60%)
● Hypocalcemia (<1%)
Etoposide (VP-16)
IV, Oral Chemotherapy
Plant alkaloid (Podophyllum) inhibits
topoisomerase II in late s-and
G2-phase
● Metabolized by liver
● 50% urine excretion
● Half-Life = 3-10h
● May alter Warfarin effect
● Theoretically, glucosamine might
induce resistance to etoposide (VP16,
VePesid) by reducing the drugs'
inhibition of topoisomerase II
● MONITOR warfarin.
● N/V (30-40%)
● Myelosuppression
● Alopecia (67%)
● Mucositis, Diarrhea rare
1. Nausea/ vomiting: Ginger, cinnamon
2. Mucositis/ diarrhea: L-Glutamine
10g TID
Exemestane
(see Aromasin)
Steroidal aromatase inhibitor
Femara ● Thrombolytic events 1. Hot flashes
● HMC Hesperidin 250-500 mg tid
9
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Aromatase Inhibitor
● Mild elevation in serum
transaminases and serum
bilirubin
● Arthralgia
● Myalgia
● Headache
● Fatigue
● Hotflashes
● Gamma Oryzanol 300mg tid.
Filgrastin
(see Neupogen)
Floxuridine (FUDR)
IV Chemotherapy
Metabolized to 5-FU to inhibit DNA
synthesis and repair in the S phase
● 90% hepatic metabolism
● Half-Life = 20h
● Patients should be put on H2
blockers to prevent peptic ulcer
disease while on therapy
● Resistance: Decreased expression
of the activating enzyme,
deoxycytidine kinase, with
diminished formation of fludarabine
triphosphate. Decreased nucleoside
transport of drug.
● Pentostatin—Increased incidence
of fatal pulmonary toxicity when
fludarabine is used in combination
with pentostatin. Use of this
combination is absolutely
contraindicated.
● hepatotoxicity, gastritis,
duodenal ulcer
● N/V/D rare
● Hand Foot Syndrome
● Myelosuppression
Fludarabine (Fludara)
IV Chemotherapy
Antimetabolits, against dividing and
resting cells
●Elimination via urine
● Half-Life = 10-20h
● Allopurinol often given to prevent
hyperuricemia
● Bactrim for immunosupression
● Cytarabine may enhance
antitumor activity
● May enhance activity of
Cyclophosphamide, Cisplatin, and
Mitoxantrone
● Immunosuppression
● Fever: pyrogens from tumor
lysis
● Tumor Lysis
● Myelosupression is dose
limiting: occurs in 10 – 13 days,
recovery by day 14 – 21.
● Autoimmune hemolytic anemia
1. Myelosuppression
● Esberitox
● Astragalus
2. Autoimmune hemolytic anemia
● Fish oil
● Quercetin
● Consider probiotics (EB)
3. Nausea and vomiting: Ginger
10
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Nausea and Vomiting
● HSR
● Neurotoxicity
● Opportunistic infection of
Pneumocystitis carni
5-Fluorouracil (5-FU)
IV Chemotherapy
S-phase inhibition of DNA synthesis and
function
● 90% exreted urine, lungs
● Half-Life = 10-20 min
● Avoid B-carotene (Altern Med
Review 1999;4:304-29), One
questionable study about combining
5-FU and beta-carotene
● Avoid high dose folic acid
● Avoid glutathione
● Mucositis, Diarrhea
● Hand-Foot Syndrome
● Myelosuppression
Increasing Efficacy:
● Gingko may increase drug
delivery, effectiveness: 350 mg
(4caps ac) 30 minutes prior to
infusion (J.Belanger,ND)
● DHA/omega-3 may increase
efficacy, reduce toxicity
● Bromelain increases
effectiveness (see BCQ paper)
● Aloe Vera
● PSK -- improves survival when
used with postoperative adjuvant
chemotherapy for colorectal cancer
with CEA >3 and PPD < 19 mm
(RCT PubMed); PSK 3 g/d – breast
ca in combination with cytoxan
and 5-fu increased survival (RCT
PubMed)
1. Diarrhea/mucositis
● L-glutamine 10 g tid
● Ice chips in mouth 10min pre/post
● DGL ¼ tsp tid,
● slippery elm
● Glycgel
● oral paste
● L-lysine 1g bid-tid
2. Hand-foot syndrome
● Vitamin B6 50 mg BID
● avoid exposure to heat/cold
● use lotion after washing
3.Neutropenia/thrombocytopenia
● Esberitox
● Astragalus with Legustrum,
4. CNS toxicity
● Vit E, a-lipoic acid, selenium,
acetyl-L-carnitine, Mg
6. Metallic taste
● Hp. Mercury (excessive salivation,
trembling of the tongue, stringy or
soapy saliva)
● Zn drink
Faslodex (Fulvestrant)
Estrogen Receptor Antagonist
● P450 metabolism
● 90% fecal elimination
● hot flashes 20%
● asthenia
● change in bowel habits
Gemcitabine (see Gemzar)
11
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Gemzar (Gemcitabine)
IV Chemotherapy
S-phase alterations in RNA processing
and translation
● Excreted in urine
● Half-Life = 30-90 minutes in
infusions <70min, and 4-10h in
infusions >70min
● Radiosensitizer
● Urine color may change
● Alopecia is rare
● Phytoestrogens and soy C/I in
pancreatic ca.
●Gemcitabine and Cisplatin:
Folic acid and B12 may increase
chemosensitivity in patients with
stage IV non-small-cell lung cancer
who are also carriers of the MTHFR
677T allele. (Clin Lung Cancer. 2004
May;5(6):360-5.)
● Diarrhea/ mucositis 15-20%
● N/V mild
● Myelosuppression
● Pneumonitis
● Infusion reaction presents as
flushing, facial swelling, headache,
dyspnea, and/
● Mild proteinuria and
hematuria. In rare cases,
hemolytic-uremic syndrome (HSU)
has been reported.
● Maculopapular skin rash with
pruritis, generally involving the
trunk and extremities.
● Flu-like syndrome
1. Leukopenia
● Esberitox
● Astragalus with Legustrum
2. Nausea and vomiting: Ginger
Gleevac (Imatinib)
Oral Chemotherapy Drug
Tyrosine Kinase Inhibitor
● Half-Life = 18 hours
● CYP3A4 Metabolism
● Fecal Excretion
● Caution with CYP3A4
inhibitors/inducers
● Inhibits metabolism of warfarif so
monitor INR if relevant
● Should be taken with food and full
glass of water to avoid GI irritation
● N/V (40-50%)
● Edema (ankle, periorbital)
● Myalgias
● Myelosuppression
Herceptin (trasuzumab)
IV Monoclonal Antibody
Anti-HER-2-antibody
● Half Life = 5-6days
● Minimal Renal/hepatic clearance
● ● Cardiotoxicity (5-7%, increases
to 30% when used with
anthracycline agents)
● Myelosuppression (risk
increased when given with
chemotherapy)
● Myalgias
● Pulmonary Toxicity
12
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
IL-2 (Aldesleukin)
IV Immunotherapy
Binds to IL-2 receptors to enhance
lymphocyte and NK cell activity
● Broken down by Kidneys
● Elimination ½ life: 85 min
● Corticosteroids (reduce effect)
● NSAIDs (capillary leak)
● BP meds (additive effect)
● Melatonin increased tumor
regression better than IL-2 alone
● Flu-like symptoms (fever, chills,
malaise, myalgia observed in all
patients
● Capillary Leak: hypotension,
edema, arrhythmia.
Dose-Limiting.
● Neurologic: delirium, confusion,
cognitive change
L-Carnitine is depleted (AANP notes
2006)
Ibritumomab
(see Zevalin)
Ifosfamide
IV Chemotherapy
Nonspecific cell cycle agent
Alkylating Agent
● Elimination ½ life = 3 – 10 hours, up
to 14 days high dose
● Metabolized by P450
● Cimetidine and allopurinol
increase toxicity, as does cisplatin.
● MONITOR patients on warfarin,
contraindicated in folks with clotting
history
● Fatigue
● Renal/ Bladder toxicity
● Myelosuppression
● N/V- usually w/in 3-6h of txt, up
to 3 days
● Neurotoxicity
● Alopecia (>80%)
1. Fatigue
● L-carnitine 4g/d (PubMed)
2. Renal/ Bladder toxicity
● MUST DRINK 2L WATER DAILY!
3. N/V: ginger, cinnamon
4. Neurotoxicity
● vitamin E, selenium (in multi
preventive)
● alpha-lipoic acid, L-carnitine (if
symptoms)
6. Alopecia (>80%)
● calcitriol
● vitamin E
Iressa, gefitinib
Irinotecan (Camptosar,
CPT-11)
IV Chemotherapy
Alkaloid from Camptotheca acuminate
tree
Cell-cycle nonspecific
● Laxatives should be avoided while
on therapy due to the risk of early
and late diarrhea
● Diarrhea is dose-limiting, can
be within 24h of infusion, or ‘late
diarrhea’ which up to 90%
experience
● Myelosuppression
● Diarrhea
13
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Half Life = 8-14 hours
● Primary fecal excretion (10% renal)
Neupogen (Filgrastim)
Colony stimulating factor
● Metabolized in liver and kidney
● Half-Life = 3.5h
● Transient bone pain (25%)
prevented with pre-med
acetaminophen
Oncovin (see Vincristine)
Panitumumab (see Vectibix)
Pemetrexed (see Alimta)
Platinol (see Cisplatin)
Procrit
(see Erythropoietin)
Revlimid
(Lenalidomide)
Unclassified, Analog of Thalidomide
Anti-angiogenic Agent through
inhibition of VEGF, bFBG
Immunomodulatory, stimulates
T-cell, IL-2, and IFNγ proliferation
Elimination ½ Life = 3 hours
66% excreted unchanged by kidneys
● Oral absorption max 60-90min
after ingestion
● Take away from food (food may
reduce maximal plasma
concentration
● Myelosuppression
● Thromboembolic Events
● Nausea, Diarrhea
● Neurotoxicity is rare
Prophylaxis with warfarin or
aspririn is recommended to avoid
thromboembolic events
14
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Rituxan (Rituximab)
Monocolonal antibody against CD20
Elimination ½ life: 76 hrs
Often combined with CHOP
● Myelosupression
● N/V
● Infusion reaction
● Myalgia, Arthralgia
Dose Limiting Rxns: tumor lysis
syndrome, hep B, HSR, cardiac
arrhythmia, acute renal failure,
mucocutaneous rxn
Sprycel (Dasatinib)
Oral Tyrosine Kinase Inhibitor
● CYP3A4 Metabolism
● Half Life = 3-5 hours
● Primary Fecal Excretion
● Antacids: Take 2 hours away from,
as pH is essential to absorption
● Caution with other CYP450 drugs
● Myelosuppression
● Fluid Retention
● N/V/D
● Bleeding Events
Sutent (sunitinib malate)
Oral Multi-Kinase Inhibitor
● CYP3A4 Metabolism
● Half Life = 40-60 hours
● Fecal/Renal Excretion
● 50 mg orally once daily, with or
without food, 4 weeks on treatment
followed by 2 weeks off.
● May interact with CYP3A4
inhibitors and inducers
● Discoloration (yellow), and
dryness of the skin
● Diarrhea, Nausea, Dyspepsia
● Fatigue
● High Blood Pressure
Tarceva (Erlotinib)
Oral Chemotherapy
EGFR Tyrosine kinase inhibitor to
inhibit proliferation, angiogenesis
● CYP3A4 Metabolism
● Fecal, Renal Excretion
● ½ Life = 36h
● Oral availability increased with
food to 100%
● May inhibit P450 enzymes
(caution with warfarin, etc)
● Acneiform rash (treat with
Cleocin gel)
● Diarrhea
● Interstitial Lung disease
1. Rash and diarrhea
● L-glutamine 10g TID
15
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Oral availability increased with food
to 100%
Taxol (Paclitaxel)
Inhibits M-Phase
Antioxidants: increases efficacy
Calcitriol 0.5 mcg/kg/week in
prostate ca and breast ca enhances
taxol effectiveness + prevents from
alopecia
GLA in breast ca enhances
effectiveness, where Omega –3 to
much less extent
Retinoic Acid and Vit D as pretx in
hormone positive breast CA, increase
effectiveness
● Neutropenia: dose limiting
● HSR
● Neurotoxicity
● Transient asymptomatic
bradycardia
● Mucositis and/or diarrhea
● Nausea and Vomiting
● Onycholysis
● Myalgia and Arthralgia
1. Neutropenia
● Esberitox,
● Astragalus with Ligustrum
2. Neurotoxicity
● Vit E, a-lipoic acid, selenium,
L-carnitine, L-glutamine
● Acetyl-L-Carnitine 1000mg/kg
analgesic (PubMed)
3. Alopecia: calcitriol
4. Mucositis and/or diarrhea
● L-glutamine 10 g tid
● DGL ¼ tsp tid
● Slippery elm
● Glycgel and oral paste
● L-lysine 1g bid-tid
5. Nausea and vomiting: Ginger,
cinnamon
6. Myalgia & Arthralgia
● L-glutamine (PubMed)
Taxotere (Docetaxol)
IV Chemotherapy
Inhibits M-phase (Mitosis)
● P450 Metabolism
● Fecal Elimination
● ½ Life = 11h
Typically infused q3wk
● Caution with P450 Drugs , Avoid
CYP3A4 herbs (ginkgo, St. John’s
Wort, Milk Thistle, ginseng, and
others)
● Radiosensitizing
● Patients receive pre-medication
with steroids to reduce fluid retention
and hypersensitivity
● Monitor weight to assess fluid
retention
P450-acting agents.●Quercetin (BCQ) – most in vitro
studies show that quercetin inhibits
conversion of Taxol to its inactive
● Myelosuppression
● Fluid Retention (50%)
● Dry, itchy skin, browning of the
fingernails (50%)
● Alopecia (80%)
● Diarrhea/mucositis (40%)
● Peripheral neuropathy less than
with paclitaxel
1. Myelosuppression :● Esberitox 3 tid
● Astragalus with Legustrum
2. Hand-foot syndrome
(palmar-plantar erythrodysesthesia)
● Vit B6 50 mg BID up to 300 mg QD
● Avoid heat exposure
3. Alopecia: calcitriol
4. Mucositis and/or diarrhea
● L-glutamine 10 g tid,
● DGL ¼ tsp tid
● Slippery Elm
● Glycgel, oral paste
● L-lysine 1g bid-tid
5. Nausea and Vomiting - Ginger ,cinnamon
16
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
metabolites and also prevents drug
resistance by reducing elimination of
Taxol from CA cells, but 1 study
showed that quercetin inhibits Taxol
apoptosis signaling in breast CA
cells. (PubMed)
6. Peripheral neuropathy
● Vit E
● A-lipoic acid
● Selenium
● L-carnitine
● Mg
7. Generalized fatigue
● L-carnitine 4g/d.
8. Arthralgias and myalgias
● L-glutamine
Temodar (Temozolomide)
Oral Chemotherapy
Alkylating Agent, cell cycle
non-specific, inhibits DNA
●Crosses Blood-Brain Barrier
● Elimination ½ Life = 2 hours
● Renal Excretions
● No formal drug interactions
● Food reduces absorption
● Avoid sun exposure
● Myelosuppression
(dise-limiting)
● N/V (max 1-12h post ingestion)
● HA, fatigue
● Photosensitivity
Vectibix (Panitumumab)
IV Monoclonal Antibody
Binds to EGFR
● Elimination ½ Life = 7.5 days
● No formal drug interactions
● Limit sun exposure
● Skin/nail-related toxicities
(90%)
● N/V/D
● Fatigue
● Electrolyte Depletion
Velcade (bortezomib)
IV Chemotherapy
Inhibits 26S Proteosome to lead to cell
death
● No formal drug interactions
● Not for patients with boron,
mannitol , boron, or bortezomib
Hypersensitivity
●VELCADE is a substrate for
cytochrome P450 3A4, 2C19, and 1A2
● Fatigue, more pronounced
during first 2 cycles
● GI Toxicity (N/V/D)
● Myelosuppression
● Peripheral Neuropathy (mostly
sensory)
● Orthostatic hypotension (12%)
1. Hypotension: Advise on adequate
fluid intake
3. CHF:● Co-q-10
● L-carnitine
● Hawthorn
4. N/V: Ginger, cinnamon
5. Diarrhea or constipation:
17
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
● Liver P450 Metabolism
● Half-Life= 9-15 hours
Metabolized by liver P450 system.
Avoid CYP3A4 herbs: gingko, St.
John’s wort, Milk thistle,
Ginsengs and others.
● fiber
● l-glutamine for diarrhea
● 1 whole papaya for constipation
6. Asthenic conditions: Licorice d/t
corticosteroid promoting effects, ginsengs
Vincristine (Oncovin)
M-phase inhibitor
● Liver P450 Metabolism
● ½ life = 85 hours
●Avoid CYP3A4 herbs: gingko
inhibits, St. John’s wort, Milk thistle,
Ginsengs and others.
● Bromelain increases effectiveness
(see BCQ paper)
● Constipation
● Neurotoxicity: dose-limiting
toxicity
● Syndrome of inappropriate
secretion of antidiuretic hormone
(SIADH).
● Myelosuppression. Generally
mild and much less significant
than with vinblastine
● Alopecia, skin rash, and
fever.
1. Constipation
● stool softeners
● high-fiber
2. Neurotoxicity
● Vit E
● a-lipoic acid
● selenium
● L-carnitine
● L-glutamine
3. Myelosuppression.
● Esberitox
● Astragalus with Ligustrum
Xeloda (Capecitabine)
Oral Chemotherapy
Converted to 5FU in liver and tumor
tissues resulting in cell death
● Metabolized in liver
● Excreted by kidneys
● Half-Life= 45 minutes
● Warfarin – monitor PT/INR
● Antacids – aluminum/magnesium
hydroxides may increase
bioavailability of Xeloda by 35%
● Phenytoin – may require dose
adjustment
● Leucovorin – when given before
Xeloda, increases efficacy and toxicity
Take with water, 30 minutes after a
meal.
● B6+B12+folic acid to increaseeffectiveness, since drug resistance may occurwith decreased levels of MTH-folate● PSK 3 g/d with tegafur/uracil (UFT) {oralequivalent to 5-fu} in stage II and III colorectalca increased survival and decreased recurrenceor mets (many RCTs PubMed)
● Diarrhea (40%)
● Hand-Foot Syndrome (15-20%),
(often treated with B6 (50-100mg),
celecoxib, nicotine patch, and bag
balm)
● Myelosuppression, Elevated
bilirubin
1. Hand-Foot Syndrome:
● Vit B6 50 mg BID up to 300 mg QD
to prevent hand foot syndrome
● Hand soaks, lotions, All purpose
salve topically
● Avoid exposure to heat
2. GI Toxicity (mouth sores,
diarrhea):
● L-glutamine to prevent GI
toxicity, mouth sores and diarrhea.
● DGL
● Glycgel
● Oral paste
● Slippery Elm,
● Vit E
● L-lysine 1g bid-tid for mouth sores
and heartburn.
3. Nausea: Ginger tea or capsules.
18
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
Zevalin
(Ibritumomab)
Monoclonal Antibody
Linked to Yttrium-90
● Half-Life = 30h
● Premedication with
acetaminophen and benadryl
● Contraception should be used for
12mo after therapy
● Myelosupporession (30%
infection rate in 3 mo following)
19
Chemotherapy & Medical Agents Used to Treat Cancer
DRUG Interactions &
Patient Instruction
Adverse Effects Naturopathic
Interventions
20