Key points
- Doxorubicin is a strong chemotherapy drug given by injection; it turns the urine red for 1 to 2 days, which is harmless [1].
- It is used for breast cancer, leukaemia, lymphoma, sarcoma and several other cancers [1].
- Its most important late side effect is heart damage, which becomes more likely as the total dose builds up; this is why the total dose is limited [1].
- Heart function (usually by echocardiogram) is checked before, during and after treatment [1, 2].
- If the drug leaks out of the vein it damages the skin; report any burning or pain at the injection site straight away [1].
What is this drug and how does it work?
For physicians
Doxorubicin, with the older brand name Adriamycin, is an anticancer antibiotic from the anthracycline group and a topoisomerase inhibitor [1]. It intercalates between DNA strands, disrupts the enzymes that make DNA and RNA, and forms complexes with topoisomerase II that lead to DNA breaks and cancer cell death [1].
It was first approved in the United States in 1974 [1]. Doxorubicin is usually part of combination regimens, such as AC (with cyclophosphamide) in breast cancer, R-CHOP in lymphoma and ABVD in Hodgkin lymphoma [1, 3, 4]. This page is about conventional (non-liposomal) doxorubicin.
Which cancers is it used for?
Your doctor may prescribe this drug for:
- Breast cancer [1]
- Early triple-negative breast cancer [6]
- Breast cancer that has spread [1]
- Non-Hodgkin lymphoma (diffuse large B-cell lymphoma) [3, 7]
- Hodgkin lymphoma [4]
- Acute leukaemia [1]
- Other solid tumours [1]
Whether it suits you depends on the type and stage of your cancer and your test results. Details of each use are in the section for doctors.
For physicians
| Cancer | Setting |
|---|---|
| Breast cancer | Adjuvant treatment after surgery in women with axillary node involvement, in multi-drug regimens (such as AC) [1] |
| Early triple-negative breast cancer | Before surgery (neoadjuvant): AC or EC after paclitaxel and carboplatin, with pembrolizumab [6] |
| Metastatic breast cancer | Treatment of metastatic disease [1] |
| Non-Hodgkin lymphoma (diffuse large B-cell lymphoma) | R-CHOP or Pola-R-CHP regimen [3, 7] |
| Hodgkin lymphoma | ABVD or A+AVD (with brentuximab vedotin) in advanced stage [4] |
| Acute leukaemia | Acute lymphoblastic leukaemia and acute myeloblastic leukaemia [1] |
| Other solid tumours | Metastatic: soft tissue and bone sarcoma, Wilms tumour, neuroblastoma, ovarian, bladder, thyroid, gastric and lung cancer [1] |
| Cancer | Key evidence |
|---|---|
| Breast cancer | Meta-analysis in the FDA label: doxorubicin-containing regimens vs CMF, hazard ratio for disease-free survival 0.91 [1]; EBCTCG: anthracycline regimens with higher cumulative doses (CAF or CEF) reduced breast cancer mortality compared with CMF (RR 0.78) [5] |
| Early triple-negative breast cancer | KEYNOTE-522: pathological complete response 64.8% vs 51.2% with added pembrolizumab [6] |
| Non-Hodgkin lymphoma (diffuse large B-cell lymphoma) | R-CHOP vs CHOP: complete response 76% vs 63% and hazard ratio for death 0.64 [3]; POLARIX: 2-year progression-free survival 76.7% with Pola-R-CHP vs 70.2% with R-CHOP [7] |
| Hodgkin lymphoma | ECHELON-1: hazard ratio for death 0.59 and 6-year overall survival 93.9% with A+AVD vs 89.4% with ABVD [4] |
RR = ratio of death rates; CMF = cyclophosphamide, methotrexate and fluorouracil.
How it is taken and dosing
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Treatment regimens and doses: index3 regimens
Doxorubicin is given at a treatment centre by a trained nurse, as an intravenous injection over a few minutes or an infusion through a central line [1]. Cycles are usually 3 to 4 weeks apart [1]. Blood tests and liver tests are done before each dose, and heart function is checked before starting, during treatment and after it ends [1].
If you feel burning, pain or swelling at the needle site during the injection, tell the nurse straight away [1]. The number of cycles depends on the cancer and the regimen (for example 4 cycles of AC in adjuvant breast cancer treatment), and you should not stop or delay treatment on your own [1].
- Before starting: assess LVEF (echocardiography or MUGA, using the same method each time), CBC and liver tests (ALT, AST, ALP, bilirubin). Include previous doses of other anthracyclines and anthracenediones in the cumulative dose [1].
- Contraindications: severe myocardial insufficiency, recent myocardial infarction (4 to 6 weeks), severe persistent drug-induced myelosuppression, severe hepatic impairment (Child-Pugh C or bilirubin above 5 mg/dL), severe hypersensitivity [1].
- Administration: diluted in 0.9% sodium chloride or 5% dextrose, protected from light, used within 1 hour; IV injection over 3 to 10 minutes into a central vein or a secure, free-flowing peripheral vein (10 minutes or less peripherally); continuous infusion only through a central vein. Do not mix with heparin or fluorouracil (precipitation) [1].
- Extravasation: stop immediately; do not remove the needle until aspiration has been attempted, no flushing or pressure; intermittent ice for 15 minutes, 4 times a day for 3 days; in adults consider dexrazoxane at the site as soon as possible and within 6 hours [1].
- Heart: cumulative doses above 550 mg/m² are associated with a higher risk of cardiomyopathy; assess LVEF more often after 300 mg/m²; stop with signs of cardiomyopathy. Consider dexrazoxane for patients who have reached a cumulative dose of 300 mg/m² and need further treatment. Do not give with trastuzumab [1].
- Hepatic impairment (total bilirubin): 1.2 to 3 mg/dL: reduce the dose by 50%; 3.1 to 5: reduce by 75%; above 5: do not start or discontinue [1].
- Bone marrow: CBC before each dose (neutrophil nadir on days 10 to 14); with severe myelosuppression that has not recovered, delay the next dose, and with prolonged myelosuppression consider a dose reduction [1].
- Tumour lysis syndrome: in rapidly growing tumours, check uric acid, potassium, calcium, phosphate and creatinine after the first treatment [1].
For physicians
Regimens and dosing (FDA label)
Adjuvant AC
Node-positive breast cancer after surgeryCycle length: Every 21 days
Node-positive breast cancer after surgery
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Doxorubicin | 60 mg/m² | IV (bolus, 3 to 10 minutes) | Day 1 |
| Cyclophosphamide | 600 mg/m² | IV | Day 1 |
Cyclophosphamide dose from the label's safety data for this regimen (1492 women) [1].
Single-agent doxorubicin
Other labelled cancers (acute leukaemias, lymphomas, metastatic breast cancer, sarcomas, metastatic solid tumours)Cycle length: Every 21 days
Other labelled cancers (acute leukaemias, lymphomas, metastatic breast cancer, sarcomas, metastatic solid tumours)
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Doxorubicin | 60 to 75 mg/m² | IV | Day 1 |
Doxorubicin in a combination regimen
With other chemotherapy drugsCycle length: Every 21 to 28 days
With other chemotherapy drugs
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Doxorubicin | 40 to 75 mg/m² | IV | Day 1 |
In heavily pretreated patients, older adults or obese patients, consider the lower end of the dose range or a longer interval [1].
Doses follow the trial protocol, guideline or official drug label (source given in the notes of each regimen). Before prescribing, check blood counts, renal and hepatic function, drug interactions and the patient’s condition, and adjust the dose according to the drug label.
Side effects
For physicians
Common adverse reactions
According to the FDA label, the most common adverse reactions (above 10%) are alopecia, nausea and vomiting [1]. The table below shows data from 1492 women with node-positive breast cancer who received AC (doxorubicin 60 and cyclophosphamide 600 mg/m² every 3 weeks for 4 cycles) [1].
| Adverse reaction | Frequency with AC |
|---|---|
| Alopecia | 92% |
| Vomiting within the first 12 hours | 34% |
| Vomiting beyond 12 hours | 37% |
| Intractable vomiting | 5% |
| Grade 3 leucopenia | 3.4% |
| Grade 4 leucopenia | 0.3% |
| Shock or sepsis | 2% |
| Systemic infection | 2% |
| Symptomatic cardiac dysfunction | 0.1% |
Source: Table 2 of the FDA label [1]. Other adverse reactions reported after marketing: stomatitis, hyperpigmentation of skin and nails, photosensitivity, diarrhoea and conjunctivitis [1].
Serious side effects
These are less common but serious; tell your team early if you notice any sign of them:
- Heart damage: can appear during treatment or years later and becomes more likely with the total dose; this is why heart function is checked before and during treatment. Report shortness of breath, swollen legs or palpitations [1, 2].
- Serious infection: a temperature of 38 °C or chills [1].
- The drug leaking out of the vein: report burning, pain or redness at the injection site straight away; it can damage the skin [1].
- A small rise in the risk of leukaemia, usually 1 to 3 years after treatment [1].
For physicians
The FDA label for doxorubicin has a boxed warning about four risks [1]:
- Cardiomyopathy: may develop during treatment or up to years afterwards. The risk is about 1 to 2% at a cumulative dose of 300, 3 to 5% at 400, 5 to 8% at 450 and 6 to 20% at 500 mg/m² (with dosing every 3 weeks). Chest radiotherapy and other cardiotoxic drugs such as cyclophosphamide and trastuzumab increase the risk. Arrhythmias, pericarditis and myocarditis have also been reported [1].
- Secondary malignancies: the risk of acute myeloid leukaemia and myelodysplastic syndrome is increased; the cumulative incidence in two adjuvant breast cancer trials ranged from 0.2% at 5 years to 1.5% at 10 years, usually occurring 1 to 3 years after treatment [1].
- Extravasation and tissue necrosis: leakage of the drug outside the vein can cause blistering, ulceration and tissue death, sometimes needing surgery and skin grafting [1].
- Severe myelosuppression: may lead to serious infection, septic shock, the need for transfusion and death; the neutrophil nadir is usually 10 to 14 days after the injection [1].
Other warnings: increased toxicity in hepatic impairment, tumour lysis syndrome, and enhanced radiation toxicity or radiation recall [1]. The 2022 European Society of Cardiology (ESC) guideline recommends cardiovascular risk assessment before starting an anthracycline and cardiac monitoring during treatment and for 12 months afterwards, and suggests dexrazoxane or liposomal doxorubicin as cardioprotective strategies in high-risk patients [2].
When should I call my doctor?
Contact your treatment team or go to the emergency department straight away if you have [1]:
- Fever, chills or any sign of infection
- New or worsening shortness of breath, swelling of the ankles or legs, palpitations or an irregular heartbeat, dizziness or fainting (during treatment or even years later)
- Burning, pain, redness or swelling at the injection site, during or after the injection
- Nausea, vomiting, diarrhoea or mouth sores so severe that you cannot eat or drink
- Unusual bruising or bleeding
- A possible or confirmed pregnancy
Interactions, pregnancy and precautions
- Red urine: red urine for 1 to 2 days after the injection is normal and comes from the colour of the drug [1].
- Other medicines: some medicines raise or lower the level of doxorubicin in the blood; give your doctor a list of all your medicines. If you also have paclitaxel, doxorubicin should be given before it; doxorubicin may increase the liver toxicity of mercaptopurine [1].
- Trastuzumab: using it at the same time as trastuzumab increases the risk of heart damage; anthracyclines should be avoided where possible for up to 7 months after stopping trastuzumab [1].
- Pregnancy: the drug can harm an unborn baby. Women should use effective contraception during treatment and for 6 months afterwards, and men with a partner who could become pregnant for 3 months afterwards; men whose partner is pregnant should use condoms for at least 10 days after the last dose [1].
- Breastfeeding: the drug passes into breast milk; do not breastfeed during treatment and for 10 days after the last dose [1].
- Fertility: it may stop periods, cause early menopause, or reduce or stop sperm production; talk about fertility preservation before treatment [1].
Frequently asked questions
Why has my urine turned red after the injection?
Doxorubicin is red, and the urine looks red for 1 to 2 days after the injection; this is not dangerous [1]. If the red colour lasts longer or comes with pain, tell your doctor.
Will doxorubicin damage my heart?
There is a risk of heart damage, and it grows with the total amount of drug received; this is why your doctor keeps the total amount limited and checks your heart [1]. Heart function is checked before starting, during and after treatment [1, 2]. Take symptoms such as shortness of breath or swollen legs seriously, even years after treatment.
Will my hair fall out?
Yes, hair loss is very common; almost all women who had this drug with cyclophosphamide lost their hair [1]. Hair usually grows back after chemotherapy ends.
How many sessions does treatment take?
Can I get pregnant after treatment?
Scientific evidence
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Key studies
5 itemsNivolumab+AVD in Advanced-Stage Classic Hodgkin's Lymphoma
Assessing the efficacy and tolerability of PET-guided BrECADD versus eBEACOPP in advanced-stage, classical Hodgkin lymphoma (HD21): a randomised, multicentre, parallel, open-label, phase 3 trial
Overall Survival with Brentuximab Vedotin in Stage III or IV Hodgkin's Lymphoma
Pembrolizumab for Early Triple-Negative Breast Cancer
Polatuzumab Vedotin in Previously Untreated Diffuse Large B-Cell Lymphoma
Clinical guidelines
3 itemsBreast Cancer, Version 4.2026, NCCN Clinical Practice Guidelines In Oncology
Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer
Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification
Related cancer types
Treatment regimens (physicians)
References
7 referencesShow all references, 6 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
- 1
- 2
- 3
- 4
- 5Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100 000 women in 123 randomised trials
- 6
- 7
This page is based on reputable scientific sources and was last updated on 27 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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