Cytoxan: Potent Chemotherapy for Advanced Cancer Management
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Synonyms | |||
Cytoxan (cyclophosphamide) is a highly effective alkylating chemotherapeutic agent widely utilized in the treatment of various malignancies and autoimmune conditions. As a prodrug requiring hepatic activation, it exerts its cytotoxic effects by cross-linking DNA strands, ultimately leading to apoptosis in rapidly dividing cells. Its broad spectrum of activity and well-documented efficacy profile make it a cornerstone in both curative and palliative treatment regimens. This agent is particularly valued for its versatility, being employed as monotherapy or in combination with other antineoplastic drugs across numerous clinical protocols.
Features
- Alkylating chemotherapeutic agent with prodrug activation
- Available in oral tablet and intravenous formulations
- Demonstrated activity against numerous hematologic and solid tumors
- Established role in conditioning regimens for hematopoietic stem cell transplantation
- Used in high-dose and metronomic dosing strategies
- Metabolism primarily hepatic via cytochrome P450 system
Benefits
- Provides significant tumor burden reduction in sensitive malignancies
- Enables combination therapy synergies with multiple antineoplastic classes
- Offers flexible administration routes for inpatient and outpatient settings
- Demonstrates efficacy in both pediatric and adult populations
- Supports immune modulation in autoimmune disorders
- Facilitates stem cell mobilization in transplant protocols
Common use
Cytoxan is extensively employed in the management of various oncological conditions including non-Hodgkin lymphoma, Hodgkin disease, multiple myeloma, leukemias (particularly acute lymphoblastic leukemia), and advanced solid tumors such as breast, ovarian, and small cell lung cancer. Beyond oncology, it finds application in severe autoimmune disorders including systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis when conventional therapies prove inadequate. The drug is also utilized in preparation for bone marrow transplantation due to its potent immunosuppressive properties.
Dosage and direction
Dosage varies significantly based on indication, patient status, and treatment protocol. For oncological use, intravenous doses typically range from 500-1500 mg/m² administered every 2-4 weeks, while oral maintenance therapy may involve 50-100 mg daily. Autoimmune conditions generally require lower doses, often 1-2 mg/kg/day orally. Administration should be supervised by oncology specialists with appropriate hydration protocols (minimum 2L fluids daily) to prevent hemorrhagic cystitis. Dose adjustments are mandatory for renal impairment (CrCl <25 mL/min requires 75% dose reduction) and hepatic dysfunction.
Precautions
Routine monitoring of complete blood counts is essential due to profound myelosuppression risks. Patients should maintain vigorous hydration (3-4L daily) during treatment periods to minimize bladder toxicity. Live vaccinations are contraindicated during therapy and until immune recovery occurs. Secondary malignancies, particularly bladder cancer and acute myeloid leukemia, have been reported with long-term use. Fertility preservation discussions should precede treatment initiation in patients of reproductive potential. Cardiac function assessment is recommended with high cumulative doses (>150 mg/kg).
Contraindications
Absolute contraindications include severe bone marrow suppression (neutrophils <500/μL, platelets <50,000/μL), demonstrated hypersensitivity to cyclophosphamide or other alkylating agents, and active urinary tract infections. Relative contraindications encompass severe renal impairment (CrCl <10 mL/min without dialysis), moderate to severe hepatic dysfunction (Child-Pugh B/C), and pre-existing hemorrhagic cystitis. Pregnancy constitutes an absolute contraindication due to proven teratogenicity (FDA Pregnancy Category D).
Possible side effect
- Hematologic: Severe neutropenia (nadir 7-14 days), thrombocytopenia, anemia
- Genitourinary: Hemorrhagic cystitis (5-40%), bladder fibrosis, renal tubular necrosis
- Gastrointestinal: Nausea/vomiting (dose-dependent), mucositis, diarrhea
- Dermatologic: Alopecia (reversible), nail discoloration, skin pigmentation
- Pulmonary: Interstitial pneumonitis, pulmonary fibrosis (with chronic use)
- Reproductive: Amenorrhea, azoospermia, infertility (dose-dependent)
- Other: Syndrome of inappropriate antidiuretic hormone, cardiotoxicity (with high doses)
Drug interaction
Significant interactions occur with allopurinol (increased myelotoxicity), succinylcholine (prolonged apnea), and CYP2B6 inducers/inhibitors. Concurrent use with cardiotoxic agents (anthracyclines) increases myocardial damage risk. Live vaccines demonstrate reduced efficacy and potential complications. CNS depressants may exhibit enhanced effects due to reduced metabolism. Nephrotoxic drugs (aminoglycosides, NSAIDs) compound renal injury potential.
Missed dose
For oral administration, take the missed dose as soon as remembered unless within 12 hours of next scheduled dose. Never double doses to compensate. For intravenous regimens, contact oncology team immediately for rescheduling guidance. Maintain hydration even during missed dose periods. Document all missed doses in medication records for toxicity assessment.
Overdose
Manifests as exaggerated therapeutic effects including severe myelosuppression, hemorrhagic cystitis, and cardiotoxicity. Management requires immediate hospitalization with supportive care including granulocyte colony-stimulating factors, platelet transfusions, and vigorous hydration with mesna administration. Hemodialysis removes approximately 30% of unmetabolized drug. Monitor cardiac function and provide appropriate antiemetic support.
Storage
Store tablets at controlled room temperature (20-25°C/68-77°F) in original container protected from moisture. Reconstituted solution remains stable for 24 hours at room temperature or 6 days refrigerated. Intravenous solutions in NS or D5W are stable for 24 hours at room temperature. Never freeze any formulation. Keep all forms away from children and pets using child-resistant containers.
Disclaimer
This information serves educational purposes and does not replace professional medical advice. Treatment decisions must be made by qualified healthcare providers considering individual patient circumstances. Off-label uses described reflect clinical practice but may not have FDA approval. Always consult prescribing information and current clinical guidelines before administration.
Reviews
“Cytoxan remains fundamental in our lymphoma protocols, providing reliable response rates even in refractory cases. The predictable myelosuppression requires careful management but offers consistent cytotoxic effect.” - Hematologic Oncology Specialist
“In autoimmune indications, cyclophosphamide provides disease modification when conventional agents fail. The dose-dependent toxicity profile necessitates meticulous monitoring but justifies use in severe manifestations.” - Rheumatology Department Director
“The drug’s versatility across pediatric and adult populations makes it invaluable in academic centers. The well-characterized side effect profile allows for proactive management rather than reactive measures.” - Pediatric Oncology Pharmacist