Investigation and management of common treatment-related toxicities3,4,18
| Anti-cancer therapies most commonly causing particular complication | Initial investigations | Differential diagnoses | Grading | Management |
|---|---|---|---|---|
| Nausea and vomiting | ||||
Cranial radiotherapy Abdominal radiotherapy Chemotherapies: Carboplatin Clofarabine Cisplatin Cyclophosphamide Docetaxel Epirubicin Ifosfamide Irinotecan Melphalan Methotrexate Oxaliplatin Streptozocin | Bloods including FBC, U/E, bone profile, blood cultures if clinically indicated Consider: AXR CT scan of head | Hypercalcaemia Raised intracranial pressure Bowel obstruction Gastrointestinal infection | Grade 1: Loss of appetite without alteration in eating habits; intervention not indicated Grade 2: Oral intake decreased without significant weight loss, dehydration or malnutrition; outpatient IV hydration; medical intervention indicated Grade 3: Inadequate oral caloric or fluid intake; tube feeding, TPN, or hospitalisation indicated Grade 4: Life-threatening consequences | Grade 1, 2 Assess for clinical or biochemical dehydration Do not assume that nausea and vomiting are always treatment related; consider other differential diagnoses Prescribe appropriate anti-emetic for diagnosis, in line with local guidelines Avoid using cyclizine with metoclopramide or domperidone (antagonistic effects) Prescribe only one of antiemetics with similar actions (eg domperidone/metoclopramide, levomepromazine/olanzapine) Grade 3, 4 Intravenous fluids, additional and parenteral antiemetics in line with local guidelines Consider syringe driver |
| Diarrhoea | ||||
Abdominal/pelvic radiotherapy 5-Fluorouracil Capecitabine | Bloods, including FBC, U/E, bone profile and magnesium Stool cultures for microscopy, sensitivity and culture, viral PCR and ova, cysts and parasites Clostridium difficile testing and abdominal X-ray should be performed if clinically indicated If grade 3 or above, consider sigmoidoscopy if no improvement after 24–48 h | Gastrointestinal infection Constipation with overflow diarrhoea Hyperthyroidism Inflammatory bowel disease Celiac disease Ischaemic colitis | Grade 1: increase of <4 stools per day over baseline; mild increase in ostomy output compared with baseline Grade 2: increase of 4–6 stools per day over baseline; moderate increase in ostomy output compared with baseline; limiting instrumental activity of daily living Grade 3: increase of ≥7 stools per day over baseline; hospitalisation indicated; severe increase in ostomy output compared with baseline; limiting self-care activity of daily living Grade 4: life-threatening consequences; urgent intervention indicated | Grade 1, 2 Loperamide 4 mg then 2 mg after every stool, max 16 mg/24 h Grade 3, 4 Consider admission, intravenous fluids, start stool chart, hold loperamide until stool cultures results if recent hospitalisation or antibiotics (consider C. difficile) In refractory cases, oral codeine, budesonide or subcutaneous octreotide may be required Seek gastroenterology advice |
| Pneumonitis | ||||
Thoracic radiotherapy Bleomycin Irinotecan Paclitaxel | Chest X-ray CTPA to exclude cancer progression or pulmonary embolism Arterial blood gas For grades 3 and above, consider bronchoscopy if not improving | Pneumonia PE Progressive disease Lymphangitis carcinomatosis | Grade 1: Asymptomatic or clinical or diagnostic observations only; intervention not indicated Grade 2: Symptomatic; medical intervention indicated; limiting instrumental activities of daily living Grade 3: Severe symptoms, limiting self-care activities of daily living; oxygen indicated Grade 4: Life-threatening respiratory compromise urgent intervention indicated (eg tracheotomy or intubation) | Grade 1 Monitor as outpatient Grade 2 High-dose prednisolone with PPI cover Grade 3, 4 Consider alternative diagnoses IV methylprednisolone 1–2 mg/kg OD with PPI cover Avoid high-flow O2 in bleomycin lung toxicity |
CTPA = computed tomography scan of pulmonary arteries; FBC = full blood count; IV = intravenous; OD = once daily; PE = pulmonary embolism; PO = per oral; PPI = protein pump inhibitor; QDS = four times daily; SC = subcutaneous; U/E = urea/electrolytes.