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IS drug-induced hemolytic anemia possible and does tamoxifen make it worse?

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Posted on Sat, 25 Jan 2014
Question: I am a 46 year old female. I have warm antibody autoimmune hemolytic anemia for the past 20 years, post-splenectomy (2003). August 2013 had stage 1 invasive ductal carcinoma removed, no lymph nodes but poorly differientiated tumor, estrogen-positive -- I did surgery, radiation and 1 round of chemo (Cytoxan, taxotere) which started up the hemolysis --- very severe, went from 11 to 6 RBC in 3 days, had two transfusions, started on 80 mg.prednisone daily. Now am down to 10 mg prednisone but LDH levels have risen. I am supposed to start tamoxifen but am EXTREMELY worried about combination of prednisone, tamoxifen especially because of weight gain, diabetes risks etc. plus possibilities of depression. I want to know if there are cases of drug-induced hemolytic anemia and could tamoxifen make this worse? Are there alternatives to tamixifen that would also allow me to take an anti-depressant?
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Follow up: Dr. Indranil Ghosh (4 minutes later)
Follow up questions: Is it possible (as a premenopausal woman) to take something other than tamoxifen? What is the relationship between taking ritoxin (ritoxib?) for the autoimmune hemoloytic anemia (as suggested by doctor) and my immune system? I have heard that ritoxin, like all other treatments for aiha have only a short-term benefit. Will the damage to my overall immune system make it that much harder to fight a recurrence of cancer(s) in the future? I do not want to dismantle my immune system for the aiha only to weaken my chances to fight cancer now and in the future?
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Follow up: Dr. Indranil Ghosh (4 minutes later)
Although the tumor removed from my breast was 1.9 cm and there was no lymph node involvement, the tumor was considered very aggressive and poorly-differentiated, which was the reasoning behind trying chemotherapy. Does that imply that the chances are much greater for a metastasis, either in the other breast or in a distant part of my body? In other words, is there a chance that I will have to try chemo again in the future, and if so, which drugs would be less likely to cause a hemolytic crisis, like happened with the taxotere/Cytoxan? I'm not sure which or if either of those caused the hemolytic event, but do you have any insight as to which chemo may have caused that, and which other chemo drugs might have a better result?
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Answered by Dr. Indranil Ghosh (6 hours later)
Brief Answer: Please refer below Detailed Answer: Hi Thanks for your query. My answers to your queries.... 1. I want to know if there are cases of drug-induced hemolytic anemia and could tamoxifen make this worse? Are there alternatives to tamoxifen that would also allow me to take an anti-depressant? A. Drug-induced hemolytic anemia is well-known but there is no suggestion that tamoxifen can cause or worsen it. Even with tamoxifen you can take certain antidepressants like venlafaxine. Alternative to tamoxifen (considering you are premenopausal) is ovarian ablation, either by surgery or monthly injections of GnRH analogs. With these you can take other antidepressants also. 2. What is the relationship between taking ritoxin (ritoxib?) for the autoimmune hemoloytic anemia (as suggested by doctor) and my immune system? A. Rituxan (rituximab) is an antibody against B cells of the body so it helps to reduce the autoimmune response and improve the autoimmune hemolytic anemia. But it also damps the normal immunity of the body (like steroids) and increase susceptibility to some infections. 3. Will the damage to my overall immune system make it that much harder to fight a recurrence of cancer(s) in the future? A. No, I don't think there is any evidence to suggest that at this point. 4. which chemo may have caused that, and which other chemo drugs might have a better result? A. I don't think the chemo itself caused it. What had possibly happened is that chemo had reduced the bone marrow production of red cells. As you already had excess destruction of red cells, this weakening of bone marrow tipped the balance towards fall of hemoglobin level. Any other chemo can also cause that. 5. Does that imply that the chances are much greater for a metastasis, either in the other breast or in a distant part of my body? A. No, I don't think chemo would have had a great impact in preventing recurrences as the overall risk was quite low in your case. 6. In other words, is there a chance that I will have to try chemo again in the future, and if so, which drugs would be less likely to cause a hemolytic crisis, like happened with the taxotere/Cytoxan? A. Hopefully you would not have to take chemo in the future. If at all it is required, then we need to take a call at that time. Hope I have answered your query. I will be available to answer further followup queries, if any.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Indranil Ghosh

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Practicing since :2004

Answered : 1716 Questions

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IS drug-induced hemolytic anemia possible and does tamoxifen make it worse?

Follow up questions: Is it possible (as a premenopausal woman) to take something other than tamoxifen? What is the relationship between taking ritoxin (ritoxib?) for the autoimmune hemoloytic anemia (as suggested by doctor) and my immune system? I have heard that ritoxin, like all other treatments for aiha have only a short-term benefit. Will the damage to my overall immune system make it that much harder to fight a recurrence of cancer(s) in the future? I do not want to dismantle my immune system for the aiha only to weaken my chances to fight cancer now and in the future?