Key Terms: Adjuvant therapy, Anthracycline, Antineoplastic, Cytotoxic, Doxorubicin, Free radicals.
Definition
Epirubicin is a semi-synthetic anthracycline-based anticancer (or antineoplastic) drug derived from doxorubicin. It is also known by its trade name Ellence.
Purpose
Epirubicin is used as the chemotherapy agent for adjuvant therapy in patients diagnosed with breast cancer, and, as determined by the attending oncologist, epirubicin may be used in the treatment of lung, gastric, and pancreatic cancers.
Description
Epirubicin has been used extensively since the mid-1980s for both early stage and metastatic breast cancer. Epirubicin received Federal Drug Administration approval in the fall of 1999 for adjuvant therapy in patients with node-positive breast cancer. Like other DNA-interactive antineoplastic family members, epirubicin binds to DNA to inhibit DNA, RNA, and protein synthesis resulting in cell death. It has been demonstrated that epirubicin also acts to block cell growth and to increase the production of cytotoxic free radicals. For breast cancer treatment, epirubicin has proven highly effective when administered as a single agent in a sequential regimen. Epirubicin may be given in combination with cyclophosphamide, and 5-fluorouracil; however, currently there is no clinical evidence to suggest that long-term survival is greater in the combination regimen than with epirubicin alone. The lower toxicity associated with epirubicin treatment promotes better quality of life for the patient.
Recent research has examined the role of epirubicin in treating prostate cancer. Study of its effects in helping to relieve pain, quality of life, and survival are preliminary, but it appears that eprirubicin is not effective alone in treating metastatic prostate cancer. A study in 2003 reported that epirubicin, used in combination with cancer drugs cisplatin and irinotecan, might have promising broad antitumor activity. In the future, epirubicin might be used in combination therapies to treat many types of tumors.
Recommended Dosage
Epirubicin is administered as a red fluid via intravenous injection (IV) into a cannula placed into the vein or through a central line inserted under the skin into a vein near the collarbone. The dose of epirubicin prescribed will vary among patients, correlated with patient body size, the purpose of the dose, whether the epirubicin will be used as a single agent or in combination, and the stage and aggressiveness of the cancer type. A starting dose of 50 mg/m2 of body surface per dose cycle of epirubicin is an appropriate regimen. Treatment cycles may be given weekly. With higher doses, cycles may be reduced to only two to three times per month. The maximum cumulative dose for anthracyclines is defined by cardiotoxicity. Studies on epirubicin have only been conducted on adult patients; therefore, with the associated risk of cardiotoxicity there are no recommendations for dosage on young children or the elderly.
Precautions
To maximize treatment effects, patients receiving epirubicin should observe certain guidelines. Along with any specific modifications given by the oncologist, these guidelines should include monitoring the area surrounding the injection site, and regular laboratory testing for white blood cell count, and kidney, liver, and bone marrow function. In order to reduce the possibility of immunosupression, immunizations not approved or prescribed by the oncologist should be avoided. Those receiving epirubicin should avoid contact with individuals taking, or that have recently taken, oral polio vaccine or individuals that have an active infection. When necessary, a protective facemask can be worn. Specific instructions on oral hygiene procedures to reduce the risk of gum abrasion should be received. Avoiding touching the eye and nasal areas unless hands have been properly washed immediately prior to contact is advised. To reduce bleeding and bruising complications, patients should exercise extreme caution when handling sharp instruments and decline participation in contact sports. The oncologist may suggest increased fluid intake to prevent kidney problems and to ensure proper kidney function.
Prior to treatment, the patient's medical history should be thoroughly reviewed to avoid complications that might arise from previous conditions such as bone marrow depression; viral, fungal, or bacterial infection; heart, kidney disease, or liver disease; or tumor cell infiltration of bone marrow. The oncologist should also be made aware if the patient is pregnant, if there is the possibility the patient might be pregnant, or if the patient is a breast-feeding mother. Only prescribed medications or over the counter (OTC) drugs approved by the oncologist should be taken by a patient receiving epirubicin
Side Effects
Along with the desired anticancer effects from epirubicin treatment, less desirable side effects are to be anticipated. All presenting side effects should be discussed with the oncologist. Some side effects may occur that do not require medical attention, but nonetheless concern the patient. These commonly include hair loss (alopecia), lack of menstrual periods, discolored urine, nausea and vomiting, occasional diarrhea, hot flashes, and temporary decrease of bone marrow function. Less frequently, the patient also may experience loss of appetite with accompanying weight loss, darkening of the soles of the feet, palms, or nails, and cardiotoxicity. Most of these side effects disappear with the end of treatment or may be eased during treatment with prescribed intervention from the oncologist.
Other side effects from epirubicin treatment require immediate attention from a healthcare professional. These indicators of potentially life-threatening conditions or medical overdose frequently include bleeding and bruising; the presence of ulcers, sores, or redness in the mouth, throat, or on the lips; a cough or hoarseness; pain or difficulty in urination; fever or chills; lower back or side pain; black tarry stools; redness or drainage from the eyes or eye area; pinpoint red spots on the skin; and red streaks around the injected vein. More rare, but no less critical side effects may include wheezing or shortness of breath; joint pain; fast or irregular heartbeat; skin rash or itching; discoloration, redness, or warmth at the site of the injection; swelling in feet, legs, and abdomen; and tenderness of the abdomen or lymph nodes.
Interactions
More than 70 regularly prescribed drugs are known to have interactive effects with epirubicin. A complete and exhaustive list should be documented in the patient's history prior to treatment. In particular, the patient should be made aware of specific drugs that, when given concurrently with epirubicin, produce increased problems and risks in the following areas:
- liver problems
- blood disorders
- risk of infection
- risk of heart damage and heart failure
- extended clearance time of epirubicin from the body
- risk of secondary leukemia
Resources
Periodicals
"Cisplatin, Irinotecan, and Epirubicin Have Promising Broad Antitumor Activity." Cancer Weekly October 14, 2003: 12.
"Epirubicin Alone Should Not be Used to Treat Hormone-Resistant Prostate Cancer." Drug Week October 31, 2003: 333.
—Jane Taylor-Jones, Research Associate, M.S.
