||Antineoplastic agents may alter the anticoagulant effect of warfarin
||Monitor INR regularly and adjust warfarin dosage as appropriate; consider alternative anticoagulant (e.g. LMWH or unfractionated heparin)
|Direct oral anticoagulants (DOACs) e.g. apixaban, rivaroxaban, dabigatran
Interaction with both CYP3A4 and P-gp inhibitors /inducers.
DOAC and antineoplastic levels may both be altered, possibly leading to loss of efficacy or toxicity (i.e. increased bleeding).
Apixaban: avoid concurrent use with strong CYP3A4 and P‑gp inhibitors. If treating VTE, avoid use with strong CYP3A4 and P‑gp inducers.
Rivaroxaban: avoid concurrent use with strong CYP3A4 and P‑gp inhibitors.
Dabigatran: avoid combination with strong P‑gp inducers and inhibitors.
If concurrent use is unavoidable, monitor closely for efficacy/toxicity of both drugs.
||Antineoplastic agents can damage the lining of the intestine; affecting the absorption of digoxin
||Monitor digoxin serum levels; adjust digoxin dosage as appropriate
||Both altered antiepileptic and antineoplastic levels may occur, possibly leading to loss of efficacy or toxicity
||Where concurrent use of an enzyme-inducing antiepileptic cannot be avoided, monitor antiepileptic serum levels for toxicity, as well as seizure frequency for efficacy; adjust dosage as appropriate.
Also monitor closely for efficacy of the antineoplastic therapy
|Antiplatelet agents and NSAIDs
||Increased risk of bleeding due to treatment related thrombocytopenia
||Avoid or minimise combination.
If combination deemed essential, (e.g. low dose aspirin for ischaemic heart disease) monitor for signs of bleeding
|Serotonergic drugs, including selective serotonin reuptake inhibitors (SSRIs e.g. paroxetine) and serotonin noradrenaline reuptake inhibitors (SNRIs e.g. venlafaxine)
||Increased risk of serotonin syndrome with concurrent use of 5-HT3 receptor antagonists (e.g. palonosetron, ondansetron, granisetron, tropisetron, dolasetron, etc.)
If combination is clinically warranted, monitor for signs and symptoms of serotonin syndrome (e.g. confusion, agitation, tachycardia, hyperreflexia).
For more information link to TGA Medicines Safety Update
||Diminished response to vaccines and increased risk of infection with live vaccines
||Live vaccines (e.g. BCG, MMR, zoster and varicella) are contraindicated in patients on immunosuppressive therapy. Use with caution in patients on non-immunosuppressive therapy.
For more information; refer to the recommended schedule of vaccination for cancer patients, as outlined in the Australian Immunisation Handbook