Chemotherapy Administration Sequencing Chart

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Oncology pharmacists receive numerous questions regarding the sequence of chemotherapy administration. Several chemotherapy agents (eg, doxorubicin, docetaxel, paclitaxel) are extensively metabolized through the cytochrome P450 pathway, and many chemotherapy agents (eg, taxanes, platinum agents) have high degrees of protein binding. In addition, many chemotherapy agents have cell cycle–specific mechanisms of action that may increase the cytotoxicity or antagonize the mechanism of the second agent. We conducted a literature search for data supporting same-day chemotherapy administration sequences. This was achieved by searching PubMed using keywords and any combination of the drug name with "administration," "sequencing," or "interactions."

Table
Chemotherapy Administration Sequencing Chart.
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The literature search yielded 110 articles for evaluation. The original 110 articles provided evidence for 62 potential chemotherapy combination sequences. Based on the types of studies examined, 27 potential sequences remained clinically undefined be cause of a lack of clinical relevance of the studies that supported them, 21 combinations were justified with a particular sequence, and 14 combinations had evidence that sequence was irrelevant to outcomes. From these data, a chemotherapy administration sequence chart was created as a reference for nurses and pharmacists. From this literature search, we produced a chemotherapy sequencing chart (Table) that helps define recommended sequences of administration based on available published data. The sequence, if not clearly defined in the literature, should follow the sequence of administration published in that regimen's original study.

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