What side effects should be monitored in a patient with diffuse large B cell lymphoma treated with R-CHOP (rituximab, doxorubicin, cyclophosphamide, vincristine, and prednisone)?

Key Side Effects to Monitor in R-CHOP Therapy for DLBCL

Patients with diffuse large B-cell lymphoma (DLBCL) treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) should be closely monitored for myelosuppression (particularly neutropenia), infusion-related reactions, cardiotoxicity, neurotoxicity, and infection as the most critical side effects that impact morbidity and mortality. 1, 2

Hematologic Toxicities

• Neutropenia: Occurs in 40-60% of patients, with febrile neutropenia in 5-11% 3, 4

  • Monitor complete blood counts before each cycle
  • Consider prophylactic growth factors (G-CSF) in patients >60 years or with high risk of febrile neutropenia 1
  • Avoid dose reductions due to hematological toxicity as this may compromise treatment efficacy 1

• Thrombocytopenia: More common with dose-dense regimens (R-CHOP-14) at 9% vs. 5% with standard R-CHOP-21 4

• Anemia: Requires monitoring throughout treatment 3

Infusion-Related Reactions

• Acute infusion reactions: Occur in up to 36% of patients receiving rituximab 3
  • Most common during first infusion
  • Symptoms include fever, chills, rigors, hypotension, urticaria, and bronchospasm
  • Monitor vital signs during infusions, especially first dose
  • Pre-medication with acetaminophen and antihistamines recommended

Cardiac Toxicities

• Doxorubicin-related cardiotoxicity:
  • Assess left ventricular ejection fraction before treatment 1
  • Monitor for signs of heart failure, especially in elderly patients
  • Supraventricular arrhythmias occur in 4.5% of R-CHOP patients vs. 1% with CHOP alone 3

Neurological Toxicities

• Vincristine-induced peripheral neuropathy:
  • Monitor for paresthesias, numbness, motor weakness
  • Assess deep tendon reflexes before each cycle
  • May require dose adjustment or discontinuation of vincristine if severe

Infectious Complications

• Increased infection risk: Occurs in 19-23% of patients 3
  • Bacterial, viral, and fungal infections
  • Screen for hepatitis B and C before treatment 1
  • Consider HBV prophylaxis in patients with prior HBV exposure 1
  • Monitor for signs of infection between cycles

Metabolic Complications

• Tumor lysis syndrome:

  • Risk increases with high tumor burden
  • Consider prophylactic measures (hydration, allopurinol) 1
  • Monitor electrolytes, uric acid, creatinine

• Hyperglycemia: Due to prednisone component 3

  • Monitor blood glucose, especially in diabetic patients

Gastrointestinal Side Effects

• Nausea/vomiting: Occurs in 23-29% of patients 3

  • Provide appropriate antiemetic prophylaxis

• Mucositis/stomatitis: More common in pediatric patients but can occur in adults 3

  • Maintain good oral hygiene

Long-term Complications

• Secondary malignancies: Monitor during follow-up 1

  • Regular follow-up examinations recommended every 3 months for 1 year, every 6 months for 2-3 more years, then annually 1

• Thyroid dysfunction: Particularly in patients receiving neck radiation 1

  • Check thyroid function at 1,2, and 5 years post-treatment

Monitoring Schedule

• Before each cycle: Complete blood count, liver and kidney function tests, clinical assessment for toxicities
• After 3-4 cycles: Interim response assessment with imaging 1
• End of treatment: Complete response assessment with PET/CT 1
• Follow-up: Regular monitoring as outlined in guidelines 1

Special Considerations

• Elderly patients (>80 years): Consider attenuated regimens (R-miniCHOP) 1
• Patients with cardiac dysfunction: Consider doxorubicin substitution with etoposide, gemcitabine, or liposomal doxorubicin 1
• CNS prophylaxis: Consider in high-risk patients with involvement of bone marrow, testis, spine, or skull base 1

Remember that early recognition and management of these side effects is crucial to maintain dose intensity and optimize treatment outcomes in DLBCL patients.