Most persons experience only a few of the listed side effects.  Higher dosages and longer usages will aggravate some side effects.  Many but not all side effects may disappear with discontinuance.

PLEASE BE AWARE THAT WHEN "SIDE EFFECTS" ARE DETERMINED FOR A DRUG, THE LIST OFTEN INCLUDES ALL POSSIBLE CONDITIONS THAT WERE EVER ENCOUNTERED IN CLINICAL TRIALS, PERHAPS EVEN INCLUDING SOME EFFECTS FROM CAUSES OTHER THAN THE DRUG.

The following information is not intended to be used to make medical decisions.   See your licensed medical person for information on these drugs, side effects, and any other medical problems or symptoms you have.

For more complete information on Prednisone and other glucocorticoids, see "Prednisone and other glucocorticoids" http://www.uspharmacist.com/NewLook/CE/glucocort/lesson.htm

A 2008 study recommended that phenothiazines administered in low to moderate doses, (50-200mg CPZ or equivalent daily) produced an excellent response in all the patients suffering psychotic symptoms in the 14 patients studied who suffered from steroid psychosis.  The study cautioned against the use of tricyclic antidepressants while patients remained on steroids as in all situations where this regimen was tried, the patient's clinical condition worsened.

The following table is a list of possible side effects of Prednisone and other steroidal medications, including inhalers.

Some steroidal medications are (List is not complete):

Deltasone, Medrol, Prednisone (in it's many versions), Aerobid, Azmacort, Beclovent, Becloforte, Bronalide, Flovent, Flovent Rotadisk, Pulmicort, Vanceril, Vanceril 84Mcg DS

                                        #  Indicates possibly more serious side effects with long-term usage

                                        @  Indicates possibly more common side effects.
 
 

Tips on how to handle some of the common side-effects of Prednisone (always
 inform your doctor of any side-effects you experience while taking this or any other
 prescription medication):

                    Avoid high-sodium foods and cut down on the amount of salt you add to your
                    meals/cooking.

                    Eat more protein and less carbohydrates/sweets. Prednisone interferes with
                    proper carbohydrate & sugar metabolism (if you are diabetic, you will need
                    to monitor your blood sugar levels carefully while taking this medication).

                    Eat foods high in potassium. Parsley is a good option because it is a natural
                    diuretic, and so will not have negative side-effects (unlike most prescription
                    "water pills"); make tea with 1 teaspoon parsley flakes to 1 cup boiling water
                    - pour boiling water over the flakes & let steep 2-4 minutes before drinking.
                    No need to strain out the leaves, unless you are trying to avoid fiber. Some
                    other food sources of potassium include potato (with skins left on), fish,
                    dairy, legumes (beans & peas), winter squash, yams, fruits, wheat bran,
                    garlic, nuts, black-strap molasses, and brewers yeast.

                    Exercise. Start slowly & keep the body moving gently, low impact to start if
                    you are deconditioned. This will help combat osteoporosis (especially if you
                    use resistance exercises like weight training, aerobics, rapid walking, etc.),
                    and will help to prevent the stagnation of fluids in the extremities (arms &
                    legs) which can lead to infections or other unpleasant side-effects.

                    Water. Drink lots of water (8-12 full-size glasses a day, minimum; more if you
                    are doing any exercise). Avoid caffeine, soda pop, and artificial fruit juice
                    drinks, and just stick to plain ol' water for best results. Purified water is best,
                    since it won't have the harmful additives/chemicals of tap water. Drinking
                    enough fluids each day will help prevent water retention, muscle cramping,
                    and headaches.

                    Avoid stimulants (like caffeine & sugar) because they can raise blood
                    pressure even more than what Prednisone already does, which contributes
                    to mood swings, heart rhythm problems, water retention, muscle cramps,
                    etc.

                    Eat smaller meals more often, so your body isn't in a feast/famine
                    reactionary metabolism state. The goal is to provide steady calories &
                    nutrition without the typical hills/valleys of the 3 meals/day tradition. This will
                    help maintain consistant blood sugar levels, which then helps combat the
                    cravings and hunger Prednisone can cause.

                    Oil. Rub some olive or sesame oil on your skin to help soften & moisturize it.
                    Aloe vera is also a good thing to rub on your skin. These will help combat the
                    overstretching & consequent skin damage that occurs when you gain water
                    weight that fast.

                    For insomnia, use chamomile tea, a relaxing bath and/or lavendar essential
                    oil (add a drop to your bathwater if you want, or just burn a scented candle or
                    put a drop on a lightbulb you are using in the room where you are
                    relaxing/resting).

                    Take vitamin & mineral supplements at least 2 hours apart from any
                    medications, as it is common for nutritional factors to interfere with
                    medications and/or the medications to interfere with the vitamins & minerals.

                    For osteoporosis prevention and to help control stomach acid problems,
                    take 1000-1500mg/day calcium & 500-800mg/day magnesium
                    supplements. Do not take these two minerals within 2 hours (before or after)
                    of taking Prednisone because they both will inhibit absorption of
                    Prednisone, and Prednisone inhibits absorption of calcium & magnesium.

                    Acne can be minimized by swabing the face (or wherever the acne occurs)
                    twice daily with rubbing alcohol or hydrogen peroxide (3% solution, sold in
                    most drug stores) before you apply make-up or lotions (allow alcohol or
                    hydrogen peroxide to evaporate fully before you apply any lotions or
                    make-up), regular bathing and hair-washing, drinking enough fluids, and
                    avoiding foods high in fats and refined sugar (i.e., avoid "junk foods").

INDEX

1- ADMINISTRATION OF CYCLOPHOSPHAMIDE

2 - INFECTION

Thrush
Shingles
Pneumocystis Carnii Pneumonia

3 - BONE MARROW SUPPRESSION

4 - CANCER

Leukemia/lymphoma
Bladder cancer
Bladder Problems
Other Cancers

5 - INFERTILITY

6 - AVOIDANCE DURING PREGNANCY

To some degree, the side effects of cyclophosphamide differ according to the way the drug is administered.  Cyclophosphamide may be administered either intravenously (periodically, approximately once a month) or orally (once a day, typically in a smaller dose than periodically).

Nausea is not uncommon, so an anti-nausea medication may be required.

2 - INFECTION:
Cyclophosphamide increases the risk of "opportunistic" infections, i.e. infections that a person's intact immune system would normally be able to fight off easily.  Thus, although cyclophosphamide does not enhance a patient's susceptibility to the common cold, it does heighten the risk of more serious infections, including tuberculosis, fungal infections, and serious viral infections.  Several specific infections frequently associated with cyclophosphamide use (or the use of immunosuppressive drugs in general) are described below:
 

"THRUSH"
Thrush is a fungal infection of the mouth caused by Candida.  It generally appears as white spots on the inside of the mouth, and is easily treatable with the use of anti-fungal mouthwash or troches.  Sometimes Candida infections also involve the esophagus (the "food tube" leading from the mouth to the stomach).  This condition, called "Candida esophagitis", often results in pain on swallowing, and must be treated with potent anti-fungal medications such as fluconazole.

Oral thrush, a fungal infection of the mouth, is a common side effect for patients on    immunosuppressive medications, can be treated with Nystatin or Mycostatin or a systemic antifungal.

"SHINGLES" (or Herpes zoster):
"Shingles" results from reactivation of the virus that causes chicken pox (Varicella zoster).  Nearly everyone who is now older than five had chickenpox at one time, generally as a child.  Normally, even after the rash and other symptoms of chickenpox subside, the virus that caused the sickness continues to reside in the body in a dormant state, "hiding" in the root of one of the nerves somewhere along the spine.  Decades later, as the immune system wanes slightly with age (a normal part of the aging process) or when the immune system is suppressed (by medications like cyclophosphamide), the virus becomes active again.

When it reactivates, Varicella zoster usually causes a painful rash in the distribution of a single nerve, such as over one side of the face or down one arm.  The rash is characterized by groups of small vesicles (blisters) sitting on a base of reddened skin, and may be extremely painful.   "Shingles" is treatable with anti-viral medicines such as Acyclovir or Famcyclovir.  These should be instituted as soon as possible.  Narcotic pain medicines may also be necessary for several weeks.  In a small minority of cases, "shingles" results in pain that can last for months.  This condition is called "post-herpetic neuralgia".

Grouped vesicles on an erythematous base: the classic rash of  "shingles" (or Herpes zoster) is caused by a reactivation of the virus that causes chicken pox.   This occurs not infrequently in patients on cyclophosphamide or other immunosuppressive drugs.

PNEUMOCYSTIS CARNII PEUMONIA ("PCP"):
Pneumocystis carinii is a fungus that resides within the lungs of most people.  People with intact immune systems have no trouble keeping the organism at bay.  In patients who are immunosuppressed, the organism can cause a serious type of pneumonia: PCP.  A few years ago, PCP was the most common cause of serious lung infections in patients with AIDS.  Because of advances in the treatment and prevention of this condition, PCP is now a much rarer problem in AIDS.  Similarly, PCP may also be prevented in patients with vasculitis by having patients take certain types of antibiotics daily or every other day.  The antibiotics most commonly used for this purpose are trimethoprim-sulfamethoxazole (Bactrim, Septra) or, in patients who are allergic to sulfa medications, Dapsone.

Suppression of the bone marrow by cyclophosphamide is usually transient - i.e. responsive to a decrease in dose or discontinuation of the medicine - but dangerously low levels of any of these three cell lines (or even permanent bone marrow failure) may occur.

The white blood cells are the cell line that is usually most sensitive to the effects of cyclophosphamide.  When cyclophosphamide is given intravenously, the white blood cell count tends to reach its low point ("nadir") between 7 and 14 days after administration.  Therefore, blood cell counts should be measured approximately 10 days after the administration of cyclophosphamide, and repeated as often as needed to insure that the counts do not go too low.

This normally means checking blood counts every 2-4 weeks.  When cyclophosphamide is given orally (i.e., every day, rather than once a month), blood counts should be checked about 7 days after starting treatment and then not less frequently than once every 3 weeks.  At some centers experienced in the care of patients with vasculitis and the use of cyclophosphamide, blood counts are checked every 2 weeks.

A temporary solution to cyclophosphamide-induced hair loss: a nice hat!  Eventually the patient's hair will return.  Complete hair loss is an unusual complication of cyclophosphamide in the doses typically used to treat vasculitis.  More commonly, mild to moderate thinning of the hair occurs.

4 - CANCER:
Many of the side effects of cyclophosphamide are most likely to occur while the patient is taking the medication.  With those side effects, the risk of their occurrence diminishes greatly after discontinuation of the drug.  In contrast, the risk of cancer associated with cyclophosphamide use may continue for many years, even after patients stop the medication.

The risk of cancer appears to be dependent upon the length of time patients have taken the medication and the cumulative dosage of the drug.  Patients who have taken cyclophosphamide have an increased risk for at least two primary types of malignancy: leukemia/lymphoma and bladder cancer.

Leukemia/lymphoma:  One of the long-term side effects of cyclophosphamide use is a significant increase in the risk of bone marrow and lymph node cancers (known as leukemia and lymphoma, respectively).  Physicians are currently unable to predict which patients will be at risk for these complications.  The best means of avoiding these types of cancer is to use cyclophosphamide judiciously: the lowest possible dose of the medicine for the shortest length of time necessary to control the disease.

Bladder Cancer:  Cyclophosphamide has a tendency to damage the bladder (see Bladder problems, below).  This damage predisposes patients to the development of bladder cancer.

The risk of bladder cancer (and of other bladder complications) is greater when cyclophosphamide is administered in the oral daily form.  Among patients with Wegener's granulomatosis treated with oral daily cyclophosphamide at the National Institutes of Health, the risk of bladder cancer was 6%.  Among patients followed for up to 15 years, the incidence of bladder cancer was as high as 16%.

A 2004 study showed the risk of bladder cancer doubled for every 10 g increment in cyclophosphamide [...]. Treatment duration longer than 1 year was associated with an eightfold increased risk [...]. The absolute risk for bladder cancer in the cohort reached 10% 16 years after diagnosis of Wegener’s granulomatosis, and a history of bladder cancer was (non-significantly) twice as common as expected at the time of diagnosis of Wegener’s granulomatosis.

Therefore, patients who have been treated with cyclophosphamide need to be followed indefinitely for the possibility of bladder complications of the treatment.  The best method of screening for this complication is to check for red blood cells in the urine by performing a urinalysis, followed by cystoscopy if red blood cells are present.

When cyclophosphamide is administered intravenously, a bladder-protective medicine called MESNA may be given at the same time.  MESNA appears to neutralize the toxic metabolite of cyclophosphamide (Acrolein) that is thought to be responsible for the bladder complications.

Additional strategies for decreasing the bladder toxicity of cyclophosphamide include: 1) giving intravenous hydration prior to cyclophosphamide; 2) taking all of the medicine in a single morning dose and washing it down with a large amount of fluid; and 3) drinking ample quantities of fluid throughout the day (eight 8-ounce glasses of water) to maintain a brisk urine output.

bladder Problems:  In addition to cancer, cyclophosphamide may cause a variable amount of bleeding from the bladder, a complication known as "hemorrhagic cystitis".  This bleeding may range from a few red blood cells in the urine (invisible to the naked eye; only detectable by examining the urine under the microscope) to life-threatening hemorrhage from the bladder.  If any bleeding from the bladder is discovered while a patient is taking cyclophosphamide, the medicine should be stopped until the bladder can be evaluated by cystoscopy.

Other cancers:A recent study shows an increased risk of cancers at other sites, including those affected by the granulomatosis, which points to the need to minimize cumulative cyclophosphamide exposure.

5 - INFERTILITY:
Cyclophosphamide may cause infertility in both men and women who are treated with the medication.  As with many of cyclophosphamide's side effects, the risk of infertility appears to be related to the length of time a patient receives the drug (and probably the cumulative dose, as well).   A woman's age may also affect her risk of infertility, with the occurrence of early menopause higher in women over the age of 30 at the time treatment is begun.

6 - AVOIDANCE DURING PREGNANCY:  It may be unsafe to use Cyclophosphamide or similar cytotoxic immunosuppressives during pregnancy.  Check with your physician regarding use of cytotoxic immunosuppressives during or before pregnancy.  It may be that other medications with less risk can be used instead of Cyclophosphamide.

7 - RARE SIDE EFFECTS:
Rarely, pulmonary fibrosis or interstitial fibrosis may be the result of using Cyclophosphamide.  Similarly, rare lung fibrosis has been reported for patients on Methotrexate.

8- RECOMMENDED CLINICAL RESPONSES TO CYCLOPHOSPHAMIDE EFFECTS