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  • Most antineoplastic agents have toxic side effects.

  • New antineoplastic agents are frequently being developed and not all side effects are known.

  • Diagnosis or organ dysfunction due to drug toxicity is largely a diagnosis of exclusion.

  • Maintaining a level of clinical suspicion is key to detection of drug toxicity.

  • Therapy for drug-induced toxicity is largely supportive.

  • Myelosuppression is a common toxic side effect from high-dose combination chemotherapy regimens used in leukemia and bone marrow transplant patients.

  • Pulmonary toxicity may manifest as acute respiratory distress syndrome, especially in patients undergoing treatment for hematologic malignancies (eg, cytarabine or gemcitabine) and pulmonary fibrosis (eg, bleomycin).

  • Cardiotoxic side effects of anthracyclines such as doxorubicin can lead to refractory heart failure if not identified and managed early, while treatment with 5-fluorouracil may precipitate symptoms of acute MI due to vasospasm in patients with underlying risk factors for heart disease.

  • Mucositis of the oropharynx and GI tract is painful and can lead to dehydration and malnutrition. Severe cases of oral mucositis may require intubation for airway protection.

  • Intractable nausea, vomiting, and diarrhea can lead to dehydration, hypovolemia, and electrolyte disturbances.

  • Nephrotoxicity is a dose-limiting side effect of cisplatin and causes renal salt-wasting syndrome.

  • During treatment with methotrexate, special attention must be paid to urinary pH to avoid precipitation in the renal tubules, resulting in ATN and renal obstruction.

  • Both peripheral and central nervous system toxicities, including posterior reversible encephalopathy syndrome, are reported after high-dose chemotherapy.

  • The spectrum of severity of hypersensitivity reactions ranges from flushing and rash to anaphylactic shock. Common causes of these reactions include paclitaxel, platinum compounds, and monoclonal antibodies.

  • Venous thromboembolic disease is a well-known complication of tamoxifen.

  • Thrombotic thrombocytopenic purpura or thrombotic microangiopathy has been associated with mitomycin, cisplatin, and gemcitabine.


Cancer patients are often admitted to intensive care units (ICUs) either due to complications of their illness or due to the complications from anticancer therapies. Some side effects of anticancer therapies are acute, while others may be due to prior exposure. These complications may occur at any point during treatment. Hence, it is important for the intensivist to be aware of these therapies and toxicities to manage patients under their care. Here we review mechanisms of commonly used anticancer therapies in brief and review complications to commonly affected organ systems.


Broadly speaking, there are three modalities for the treatment of cancers: surgery, radiation, and systemic therapies. Systemic therapies may be in the form of chemotherapy agents, targeted therapies, or immune system modulating therapies. Chemotherapies are often given as combination regimens. There is a dose-response, so adequate dosing is required. The kill hypothesis states that chemotherapeutic agents kill a constant fraction rather than number of rapidly growing cells. Hence, multiple cycles are needed for effective control of tumor.

Chemotherapeutic Agents

Cancer therapies may be ...

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