Complications
Mesna binds to and deactivates acrolein, the urotoxic metabolite of cyclophosphamide and ifosfamide, in the urinary bladder. It may be given with cyclophosphamide in addition to copious fluids to prevent urotoxicity.[66]
Prophylactic treatment for osteoporosis should be given to patients on long-term corticosteroid treatment, based on individual risk factors.[55]
Screening and preventive measures against corticosteroid-induced osteoporosis should be instituted, along with monitoring and treatment for other complications of corticosteroid treatment (e.g., hypertension, diabetes mellitus, dyslipidemia).[55] See Osteoporosis (Management approach).
Sperm banking is suggested for men. Embryo storage is suggested for couples. Emerging processes include inducing chemical menopause in fertile women, as well as oocyte storage.
Long-term high-dose corticosteroid leads to adrenal suppression. Therefore, the corticosteroid dose needs to be slowly tapered, to allow for the patient’s own adrenal glands to slowly increase corticosteroid production.
Leukopenia is a common consequence of cytotoxic and antimetabolite therapies and may predispose toward infection.
Generally treatment with the drug is held and patients are monitored until the leukopenia resolves; the medication is then restarted at 75% of the initial dose.
Immunosuppressive therapy increases the risk of all infection (both conventional and opportunistic).
Immunization is recommended for patients at risk, ideally before starting immunosuppressive therapy, which may limit the vaccine response, particularly in the case of rituximab.
Bacterial infections should be treated aggressively with antibiotics and prophylaxis against Pneumocystis jirovecii.
EGPA may commonly involve the pericardium. It uncommonly involves the myocardium (leading to regional or global left ventricular systolic dysfunction) and, rarely, the coronary arteries.
Destructive cardiac valvular disease occurs in about 3% to 5% of patients with EGPA:[64][65] these patients may develop valvular disease severe enough to warrant valve replacement. The extent and duration of peripheral eosinophilia correlates with the risk of cardiac disease involvement.
Bladder cancer is a known complication of cyclophosphamide treatment. Risk depends on the cumulative dose of the drug. Hematuria in a patient who has been exposed to cyclophosphamide mandates cystoscopy. Screening cystoscopy is recommended every 3 years in patients who have received cyclophosphamide for more than 1 year in total.[40]
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