Use of doxorubicin is not associated with hemolytic complications in severely G6PD deficient patients with lymphoma

G6PD-deficiency is prevalent in the Middle East, and is linked to oxidative hemolysis with doxorubicin. Physicians substitute etoposide for doxorubicin in chemotherapy for G6PD-deficient lymphoma patients. We studied severely G6PD-deficient Hodgkin (HL) and diffuse large B cell lymphoma (DLBCL) patients. The primary outcome was the occurrence of hemolysis after doxorubicin, and secondary outcome was survival where etoposide was substituted for doxorubicin. Of 177 patients, 16% were severely G6PD-deficient. Eleven deficient HL patients had received ABVD, and seven deficient DLBCL patients had received R-CHOP, none had documented hemolysis. DLBCL patients who received R-CEOP had inferior survival compared to R-CHOP, while HL patients who received EBVD had comparable survival to ABVD. In the second part of the study, we prospectively monitored 39 severely G6PD-deficient lymphoma patients receiving doxorubicin, none had hemolysis. We conclude that doxorubicin is safe in severely G6PD-deficient patients. Substituting etoposide for doxorubicin in DLBCL was associated with decreased survival.