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Bleomycin (Bleomycin) - Side Effects and Adverse Reactions

 
 



ADVERSE REACTIONS

Pulmonary

The most serious side effects are pulmonary adverse reactions, occurring in approximately 10% of treated patients.  The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis.  Approximately 1% of patients treated have died of pulmonary fibrosis.  Pulmonary toxicity is both dose and age related, being more common in patients over 70 years of age and in those receiving over 400 units total dose.  This toxicity, however, is unpredictable and has been seen in young patients receiving low doses.  Some published reports have suggested that the risk of pulmonary toxicity may be increased when bleomycin is used in combination with G-CSF (filgrastim) or other cytokines.  However, randomized clinical studies completed to date have not demonstrated an increased risk of pulmonary complications in patients treated with bleomycin and G-CSF.

Because of lack of specificity of the clinical syndrome, the identification of patients with pulmonary toxicity due to bleomycin has been extremely difficult.  The earliest symptom associated with bleomycin pulmonary toxicity is dyspnea.  The earliest sign is fine rales.

Radiographically, bleomycin-induced pneumonitis produces nonspecific patchy opacities, usually of the lower lung fields.  The most common changes in pulmonary function tests are a decrease in total lung volume and a decrease in vital capacity. However, these changes are not predictive of the development of pulmonary fibrosis.

The microscopic tissue changes due to bleomycin toxicity include bronchiolar squamous metaplasia, reactive macrophages, atypical alveolar epithelial cells, fibrinous edema, and interstitial fibrosis.  The acute stage may involve capillary changes and subsequent fibrinous exudation into alveoli producing a change similar to hyaline membrane formation and progressing to a diffuse interstitial fibrosis resembling the Hamman-Rich syndrome.  These microscopic findings are nonspecific; e.g., similar changes are seen in radiation pneumonitis and pneumocystic pneumonitis.

To monitor the onset of pulmonary toxicity, roentgenograms of the chest should be taken every 1 to 2 weeks (see WARNINGS ).  If pulmonary changes are noted, treatment should be discontinued until it can be determined if they are drug related.  Recent studies have suggested that sequential measurement of the pulmonary diffusion capacity for carbon monoxide (DLco) during treatment with bleomycin may be an indicator of subclinical pulmonary toxicity.  It is recommended that the DLco be monitored monthly if it is to be employed to detect pulmonary toxicities, and thus the drug should be discontinued when the DLco falls below 30% to 35% of the pretreatment value.

Because of bleomycin’s sensitization of lung tissue, patients who have received bleomycin are at greater risk of developing pulmonary toxicity when oxygen is administered in surgery.  While long exposure to very high oxygen concentrations is a known cause of lung damage, after bleomycin administration, lung damage can occur at lower concentrations that are usually considered safe.  Suggested preventive measures are:

    1.  Maintain FlO2 at concentrations approximating that of room air (25%) during surgery and the postoperative period.

    2.  Monitor carefully fluid replacement, focusing more on colloid administration rather than crystalloid.

 

Sudden onset of an acute chest pain syndrome suggestive of pleuropericarditis has been reported during bleomycin infusions.  Although each patient must be individually evaluated, further courses of bleomycin do not appear to be contraindicated.

Pulmonary adverse events which may be related to the intrapleural administration of bleomycin have been reported.

Idiosyncratic Reactions

In approximately 1% of the lymphoma patients treated with bleomycin, an idiosyncratic reaction, similar to anaphylaxis clinically, has been reported.  The reaction may be immediate or delayed for several hours, and usually occurs after the first or second dose (see WARNINGS ).  It consists of hypotension, mental confusion, fever, chills, and wheezing.  Treatment is symptomatic including volume expansion, pressor agents, antihistamines, and corticosteroids.

Integument and Mucous Membranes

These adverse reactions have been reported in approximately 50% of treated patients.  They consist of erythema, rash, striae, vesiculation, hyperpigmentation, and tenderness of the skin.  Hyperkeratosis, nail changes, alopecia, pruritus, and stomatitis have also been reported.  It was necessary to discontinue bleomycin therapy in 2% of treated patients because of these toxicities.

Scleroderma-like skin changes have been reported.

Skin toxicity is a relatively late manifestation usually developing in the second and third week of treatment after 150 to 200 units of bleomycin have been administered and appears to be related to the cumulative dose.

Intrapleural administration of bleomycin has been associated with local pain.  Hypotension possibly requiring symptomatic treatment has been reported.  Death has been reported in association with bleomycin pleurodesis in seriously ill patients.

Other

Vascular toxicities coincident with the use of bleomycin in combination with other antineoplastic agents have been reported.  The events are clinically heterogeneous and may include myocardial infarction, cerebrovascular accident, thrombotic microangiopathy (HUS), or cerebral arteritis.  Various mechanisms have been proposed for these vascular complications.  There are also reports of Raynaud’s phenomenon occurring in patients treated with bleomycin in combination with vinblastine with or without cisplatin or, in a few cases, with bleomycin as a single agent.  It is currently unknown if the cause of Raynaud’s phenomenon in these cases is the disease, underlying vascular compromise, bleomycin, vinblastine, hypomagnesemia, or a combination of any of these factors.

Fever, chills, and vomiting have been reported.  Anorexia and weight loss have been reported and may persist long after termination of this medication.  Pain at tumor site, phlebitis, and other local reactions have been reported.

Malaise has been reported.



REPORTS OF SUSPECTED BLEOMYCIN SIDE EFFECTS / ADVERSE REACTIONS

Below is a sample of reports where side effects / adverse reactions may be related to Bleomycin. The information is not vetted and should not be considered as verified clinical evidence.

Possible Bleomycin side effects / adverse reactions in 69 year old male

Reported by a health professional (non-physician/pharmacist) from United Kingdom on 2012-02-09

Patient: 69 year old male

Reactions: Gastrointestinal Haemorrhage, Blood Creatinine Increased

Suspect drug(s):
Bleomycin
    Dosage: 30000 iu, day 2
    Indication: Testicular Germ Cell Cancer

Carboplatin
    Indication: Testicular Germ Cell Cancer

Cisplatin
    Dosage: 100 mg/m2, cyclic
    Indication: Testicular Germ Cell Cancer

Etoposide
    Dosage: 500 mg/m2, cyclic
    Indication: Testicular Germ Cell Cancer



Possible Bleomycin side effects / adverse reactions in 27 year old male

Reported by a physician from Portugal on 2012-02-15

Patient: 27 year old male

Reactions: Bronchopulmonary Aspergillosis, Lymphopenia, Neutropenia

Adverse event resulted in: hospitalization

Suspect drug(s):
Bleomycin
    Indication: Testis Cancer

Cisplatin
    Dosage: 1st-line: cycles every 21d, 2nd-line: cycles every 28d
    Indication: Testis Cancer

Etoposide
    Indication: Testis Cancer

Ifosfamide
    Indication: Testis Cancer

Vinblastine Sulfate
    Indication: Testis Cancer



Possible Bleomycin side effects / adverse reactions in 18 year old male

Reported by a health professional (non-physician/pharmacist) from Germany on 2012-02-15

Patient: 18 year old male

Reactions: Arthralgia, C-Reactive Protein Increased, Bone Pain, Sepsis, C-Reactive Protein Decreased, Pyrexia, Device Related Infection

Adverse event resulted in: hospitalization

Suspect drug(s):
Adriamycin PFS
    Dosage: 35 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Bleomycin
    Dosage: 10 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Cyclophosphamide
    Dosage: 1250 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Etoposide
    Dosage: 200 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Filgrastim
    Dosage: unk unk, qd
    Indication: Hodgkin's Disease
    Start date: 2011-03-03
    End date: 2011-03-09

Prednisone TAB
    Dosage: 40 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Procarbazine Hydrochloride
    Dosage: 100 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Rituximab
    Dosage: 375 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-03-16

Vincristine
    Dosage: 1.4 mg/m2, unk
    Indication: Hodgkin's Disease
    Start date: 2011-02-24

Other drugs received by patient: Cotrim DS; Acyclovir; Ciprofloxacin; Pantoprazole



See index of all Bleomycin side effect reports >>

Drug label data at the top of this Page last updated: 2014-09-30

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