EpistemisIntegrated Summary of Pharmacological Adjustment and Safety
Quick reference tool to verify monitoring requirements, dose adjustments in renal and hepatic failure, emetogenic potential and safety category in pregnancy of fundamental oncological drugs.
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| Drug | Renal Adjustment (eGFR cutoff) | Liver Adjustment | Emetogenic Potential | Critical Toxicity / Key Monitoring |
|---|---|---|---|---|
| Cyclophosphamide | Reduce 25% if eGFR < 30 mL/min | Does not require mild; caution | Moderate to High (dose-dependent) | Acrolein hemorrhagic cystitis. Force hydration and MESNA. |
| Cisplatin | Contraindicated if eGFR < 50 mL/min | No dosage adjustment required | High (>90% risk of emesis) | Tubular nephrotoxicity, profound hypomagnesemia. Pre and post saline hydration. |
| Carboplatin | Dosage by Calvert (by GFR) | No dosage adjustment required | Moderate (30-90% risk) | Late nadir thrombocytopenia. Check blood count. |
| Oxaliplatin | Reduce 20% if eGFR < 30 mL/min | Not required in mild-moderate | Moderate (30-90% risk) | Acute cold neuropathy, cumulative peripheral paresthesias. |
| 5-Fluorouracil | No dosage adjustment required | Caution if bilirubin > 3 mg/dL | Low to Moderate | Fatal DPD deficiency. Mucositis, hand-foot syndrome, vasospasm. |
| Capecitabine | Reduce 25% if eGFR 30-50; avoid <30 | Caution if bilirubin > 3 mg/dL | Low to Moderate | Dose-limiting palmo-plantar erythrodissection. Avoid with PPI. |
| Methotrexate | Contraindicated if eGFR < 45 mL/min | Avoid if bilirubin > 5 mg/dL | Moderate to High (at high doses) | Acid tubular precipitation. Requires urinary pH > 7.5 and Leucovorin. |
| Cytarabine | Reduce 30% if eGFR < 30 (high doses) | Not required in standard doses | Low (High at high doses) | Cerebellar ataxia, chemical keratoconjunctivitis. Prophylaxis with dexamethasone eye drops. |
| Gemcitabine | Does not require mild; monitor | Adjust if increased transaminases | Low (<10% risk) | Flu-like syndrome. Dose-dependent neutropenia. |
| Doxorubicin | No dosage adjustment required | Reduce 50% if bilirubin 1.2-3 mg/dL | Moderate to High | Chronic accumulation cardiotoxicity. Limit of 450-550 mg/m². Vesicant. |
| Irinotecan | No dosage adjustment required | Reduce 25% if bilirubin 1.5-3 mg/dL | Moderate | Acute cholinergic (Atropine) and delayed secretory (Loperamide) diarrhea. |
| Paclitaxel | No dosage adjustment required | Reduce 30% if transaminases > 2.5x ULN | Low to Moderate | Glove and sock neuropathy. Hypersensitivity due to Cremophor. |
| Vincristine | Not required directly | Reduce 50% if bilirubin 1.5-3 mg/dL | Minimal (<10% risk) | Peripheral motor and autonomic neuropathy (ileus). Intrathecal route prohibited. |
| Trastuzumab | No dosage adjustment required | No dosage adjustment required | Minimum | Reversible cardiotoxicity type II. Quarterly monitoring with FEVI. |
| Cetuximab | Not required directly | No dosage adjustment required | Low to Moderate | Progressive acneiform eruption, profound hypomagnesemia. Wild-type KRAS only. |
| Bevacizumab | No dosage adjustment required | No dosage adjustment required | Minimum | Intestinal perforation, delayed healing, hypertension. Surgical hold. |
| Pembrolizumab | No dosage adjustment required | No dosage adjustment required | Minimum | irAEs (Colitis, pneumonitis, endocrinopathies). Management with methylprednisolone. |
| Tamoxifen | Not required directly | Does not require mild; monitor | Minimum | Venous thromboembolism, endometrial hyperplasia. Avoid with paroxetine/fluoxetine. |
| Letrozole | Not required if eGFR > 10 mL/min | Reduce in severe insufficiency | Minimum | Severe arthralgias, accelerated loss of bone density, osteoporosis. |
| Palbociclib | Does not require mild; caution | Reduce if Child-Pugh C | Minimum | Reversible cyclic deep neutropenia without high fever. Take with food. |
| Olaparib | Reduce 25% if eGFR 30-50 mL/min | Not required in mild-moderate | Moderate | Deep macrocytic anemia, extreme asthenia. Exclusive with BRCA mutation. |
Epistemis is educational review material. It is not a medical device, does not diagnose or prescribe treatment, and does not replace formal medical training, current clinical guidelines, or professional clinical judgment.
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- Oncology
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- Comparative Table of Clinical Settings and Safety