Hemorrhagic cystitis is rare when<unk>  is given with mesna. A common and dose-limiting side effect is encephalopathy (brain dysfunction). It occurs in some form in up to 50% of people receiving the agent. The reaction is probably mediated by chloroacetaldehyde, one of the breakdown products of the<unk>  molecule, which has chemical properties similar to acetaldehyde and chloral hydrate. The symptoms of<unk>  encephalopathy can range from mild (difficulty concentrating, fatigue), to moderate (delirium, psychosis), to severe (nonconvulsive status epilepticus or coma). In children, this can interfere with neurological development. Apart from the brain,<unk>  can also affect peripheral nerves. The severity of the reaction can be classified according to either the National Cancer Institute or the Meanwell criteria (grade I–IV). Previous brain problems and low levels of albumin in the blood increase the likelihood of<unk>  encephalopathy. In most cases, the reaction resolves spontaneously within 72 hours. If it develops during an infusion of the drug, discontinuing the infusion is advised. The most effective treatment for severe (grade III–IV) encephalopathy is an intravenous solution of methylene blue, which appears to shorten the duration of encephalopathy; the exact mechanism of action of methylene blue is unclear. In some cases, methylene blue may be used as a prophylaxis before further doses of<unk>  are administered. Other treatments include albumin and thiamine, and dialysis as a rescue modality.<unk>  may also cause a normal anion gap acidosis, specifically renal tubular acidosis type 2.
Ifosfamide
Vincristine
Lomustine
Bendamustine
Mitoxantrone
Cladribine
Busulfan
Normustine