An Overview of Oncologic Supportive Care

An Overview of Oncologic Supportive Care

Chelsea Parry, Pharm.D.

PGY-1 Pharmacy Resident

Piedmont Atlanta Hospital

February 23, 2019

Disclosure Statement

• I have no relevant financial relationships with any ACCME defined commercial interests.

Objectives

• Define supportive care

• Discuss the various subsets of supportive care

• Identify medications used in oncologic supportive care

• Describe the role pharmacists can play in supportive care

• National Comprehensive Cancer Network (NCCN)

• Lexi-comp

Supportive Care

Brief Overview of Supportive Care

• Definition• Care provided to improve quality of life in patients with serious or life-

threatening disease

• Goal is to prevent • Symptoms of a disease

• ADR from treatment

• Psychological, social, & spiritual problems

• Alternative terms• Comfort care, palliative care, symptom management

2/13/2019

Adult Cancer Pain

Discussion Questions

• How many adult patients do you think are affected by cancer pain?

• How is cancer pain addressed at your facility?• Protocol?

• Type of medications utilized?

• Opioid crisis effect

Adult Cancer Pain Basics

• Why is Pain Management important?• Treat the whole patient• Increase quality of life

• Multidisciplinary team approach

• Continuous assessment

• Goal of pain management – 5 A’s• Analgesia, activities, adverse effects, aberrant drug taking, affect

• Treatment• Includes non-pharmacologic & pharmacologic• Charts within NCCN guideline

Managing Opioid ADR

• Constipation• Goal – one non-forced BM every 1-2 days

• Approach• Prophylaxis – stimulant laxative, polyethylene glycol

• Maintain adequate fluid intake

• Maintain adequate dietary fiber intake

• Docusate may not provide benefit

• Exercise

Managing Opioid ADR Continued

• Persistent constipation• Additional agents – magnesium hydroxide, bisacodyl, lactulose, sorbitol,

magnesium citrate, polyethylene glycol

• Enemas – use sparingly and maintain awareness for electrolyte abnormalities

• Rectal suppositories and/or enemas are contraindicated in neutropenia and thrombocytopenia

• If all else fails – consider methylnaltrexone or naloxegol


• Nausea• Prochlorperazine 10 mg PO Q6H PRN

• Metoclopramide 10-15 mg PO QID PRN

• Haloperidol 0.5-1 mg PO Q6-8H PRN

• Consider serotonin antagonists as an alternative & scopolamine, dronabinol, or olanzapine


• Pruritus• Small doses of mixed agonist-antagonist – nalbuphine 0.5-1 mg IV Q6H PRN

• Continuous infusion of naloxone 0.25 mcg/kg/h & titrate to 1 mcg/kg/h

• Consider ondansetron and/or antihistamines

• Delirium• Consider initial titration with haloperidol, olanzapine, or risperidone

Antiemesis


• How many patients undergoing treatment will be affected by CINV?

• How is CINV addressed at your facility?• Protocol?

• Pharmacist involvement in prescribing?

• How often are rescue antiemetics required? Are these medications appropriate?

Antiemesis Basics

• Chemotherapy (or radiation) induced nausea and vomiting (CINV) can significantly affect quality of life

• Incidence is dependent on the chemotherapeutic regimen & patient factors

• NCCN provides charts for chemotherapeutic emetic risk and CINV prophylaxis regimens

Anticipatory Emesis

• Prevention is Key• Optimal antiemetic regimen

• Avoidance of strong smells that may precipitate symptoms

• Behavioral Therapy• Relaxation/systematic desensitization, hypnosis, relaxation exercises,

cognitive distraction, yoga

• Acupuncture/acupressure

• Consider anxiolytic therapy• Lorazepam 0.5-2 mg PO night prior to treatment, repeat 1-2 hours prior to

chemo

Acute & Delayed Emesis PreventionHigh Emetic Risk

Day 1 Days 2, 3, 4

Option A • NK-1RA (choose one)

Aprepitant 125 mg PO once Aprepitant 130 mg IV once Fosaprepitant 150 mg IV once Netupitant 300 mg/Palonosetron 0.5 mg PO once Fosnetupitant 235 mg/Palonosetron 0.25 mg IV

once Rolapitant 180 mg PO once

• 5-HT3 RA (choose one) Dolasetron 100 mg PO once Granisetron 10 mg SQ once, or 2 mg PO once, or

0.01 mg/kg (max 1 mg) IV once, or 3.1 mg/24-hour transdermal patch

Ondansetron 16-24 mg PO once, or 8-16 mg IV once

Palonosetron 0.25 mg IV once

• Dexamethasone 12 mg PO/IV once

• Aprepitant 80 mg PO daily on days 2,

3 (ONLY if PO used on day 1)

• Dexamethasone 8 mg PO/IV daily on days 2, 3, 4


Day 1 Days 2, 3, 4

Option B • Olanzapine 10 mg PO once

• Palonosetron 0.25 mg IV once


• Olanzapine 10 mg PO daily on days 2, 3, 4


Day 1 Days 2, 3, 4

Option C • Olanzapine 10 mg PO once

• NK-1 RA (choose one) Aprepitant 125 mg PO once Aprepitant 130 mg IV once Fosaprepitant 150 mg IV once Netupitant 300 mg/Palonosetron 0.5 mg PO once Fosnetupitant 235 mg/Palonosetron 0.25 mg IV once Rolapitant 180 mg PO once



Ondansetron 16-24 mg PO once, or 8-16 mg IV once Palonosetron 0.25 mg IV once


• Olanzapine 10 mg PO daily on

days 2, 3, 4

• Aprepitant 80 mg PO daily on days 2, 3 (ONLY if aprepitant PO used on day 1)

• Dexamethasone 8 mg PO/IV daily on days 2, 3, 4

Acute & Delayed Emesis PreventionModerate Emetic Risk

Day 1 Days 2 & 3

Option D • 5-HT3 RA (choose one)

Dolasetron 100 mg PO once Granisetron 10 mg SQ once, or 2 mg PO once, or 0.01

mg/kg (max 1 mg) IV once, or 3.1 mg/24-hour transdermal patch



• Dexamethasone 8 mg PO/IV daily on days 2, 3

• OR• 5-HT3 RA monotherapy

Granisetron 1-2 mg (total dose) PO daily or 0.01 mg/kg (max 1 mg) IV daily on days 2, 3

Ondansetron 8 mg PO BID or 16 mg PO daily or 8-16 mg IV daily on days 2, 3

Dolasetron 100 mg PO daily on days 2, 3


Day 1 Days 2 & 3

Option E • Olanzapine 10 mg PO once

• Palonosetron 0.25 mg IV once


• Olanzapine 10 mg PO daily on days 2, 3


Day 1 Days 2 & 3

Option F • NK-1 RA (choose one)

Aprepitant 125 mg PO once Aprepitant 130 mg IV once Fosaprepitant 150 mg IV once Netupitant 300 mg/Palonosetron 0.5 mg PO once Fosnetupitant 235 mg/Palonosetron 0.25 mg IV

once Rolapitant 180 mg PO once





• Aprepitant 80 mg PO daily on days

2, 3 (ONLY if aprepitant PO used on day 1)

• + Dexamethasone 8 mg PO/IV daily on days 2, 3

Acute & Delayed Emesis PreventionLow & Minimal Emetic Risk

• Low (choose one)• Dexamethasone 8-12 mg PO/IV once

• Metoclopramide 10-20 mg PO/IV once

• Prochlorperazine 10 mg PO/IV once

• 5-HT3 RA• Dolasetron 100 mg PO once

• Granisetron 1-2 mg (total dose) PO once

• Ondansetron 8-16 mg PO once

• Minimal• No routine prophylaxis

Breakthrough Treatment

• General Principle• Add an additional agent from a different class to the current regimen

• Several Options Available• Lorazepam, cannabinoids, haloperidol, scopolamine, promethazine

• Efficacy of breakthrough treatment

Cancer- and Chemotherapy-Induced Anemia


• Should anemia always be pharmacologically treated in this patient population?

• What are some factors that may confound this type of anemia?

• How is cancer or chemotherapy related anemia addressed at your facility?• Protocol?

• Pharmacist involvement?

Cancer- & Chemo-Induced Anemia Basics

• Occurs in 30-90% of patients with cancer

• Treatment• Underlying etiology – iron deficiency, hemolysis, hemorrhage

• Provide supportive care – blood transfusion or erythropoietin stimulating agents

ESAs

• Available options• Epoetin alfa or epoetin alfa-epbx

• Darbepoetin alfa

• ADR• Thrombosis

• HTN/Seizures

Risks and Goals of ESAs & Transfusion

ESA in the Cancer Setting Red Blood Cell Transfusion

Risks • Increase thrombotic events• Possible decreased survival• Time to tumor progression shortened

• Transfusion reactions• Transfusion-associated circulatory overload (TACO)• Virus transmission• Bacterial contamination• Iron overload• Increase thrombotic events• Possible decreased survival• Alloimmunization• Increased risk of poor response to future platelet transfusions

Goals • Transfusion avoidance• Gradual improvement in anemia-related symptoms

• Rapid increase of HB and hematocrit levels• Rapid improvement in anemia-related symptoms

Myeloid Growth Factors


• Do all patients receiving chemotherapy treatment require a myeloid growth factor?

• Is the implementation of myeloid growth factors a standard at your facility?• Protocols?

• Particular regimens?


• Inpatient versus outpatient application?

• Does your facility utilize biosimilars?

Myeloid Growth Factor Basics

• Primarily used to reduce the incidence of neutropenia

• Severe neutropenia or febrile neutropenia

• Risk of developing neutropenia

Prophylaxis of Febrile Neutropenia

• Filgrastim, tbo-filgrastim, filgrastim-sndz• 5 mcg/kg SQ daily until post-nadir ANC recovery to normal or near-normal

• Begin the day after chemotherapy regimen completion and continue for 3-4 days

• Pegfilgrastim• A single dose of 6 mg per cycle given the day after chemotherapy is complete

• Not recommended in concurrent chemotherapy and radiation

• SQ route is preferred

Indications for Therapeutic Use in Febrile Neutropenia

• Sepsis syndrome

• Age >65

• ANC <100/µL

• Neutropenia expected to be >10 days in duration

• Pneumonia or other clinically documented infections

• Invasive fungal infection

• Hospitalization at the time of fever

• Prior episode of febrile neutropenia

Cancer-Associated Venous Thromboembolic Disease


• When does VTE prophylaxis become a concern?• Should we provide prophylaxis to all patients with cancer?

• What about those with a history of cancer?

• How is cancer-related VTE addressed at your facility?• Protocol?


• Medications utilized?

Cancer-Associated VTE Basics

• VTE includes: deep venous thrombosis (DVT), pulmonary embolism (PE), superficial vein thrombosis (SVT), and thrombosis in other vascular territories

• Retrospective study resulted in approximately 3-12% of patients experiencing VTE

• VTE increases likelihood of death by 2- to 6-fold

Inpatient VTE Prophylaxis

• At-risk population• Adult medical or surgical patient

• Diagnosis of cancer or clinical suspicion of cancer

• Contraindication to anticoagulation• Mechanical prophylaxis should be implemented – intermittent pneumatic

compression (IPC)

• No contraindication to anticoagulation• Consider pre-op dosing with unfractionated heparin (UFH) or low-molecular-

weight heparin (LMWH) for high-risk surgery patients

• +IPCs

Inpatient/Outpatient Prophylactic Anticoagulation

National Comprehensive Cancer Network. "NCCN

Clinical Practice Guidelines–Cancer-Associated Venous

Thromboembolic Disease. V. 2.2018." (2018).

Treatment Anticoagulation for VTE

• Medication selection based on:• Renal failure, inpatient/outpatient status, FDA approval, cost, ease of

administration, monitoring, bleeding risk assessment, ability to reverse anticoagulation

• Recommended baseline labs include: CBC, renal and hepatic function panel, aPTT, PT/INR

• Recommend continued monitoring with the following labs: Hgb, Hct, platelet count at least every 2-3 days for the first 14 days and then every 2 weeks or as clinically indicated

• Duration• Minimum of 3 months• Continued discussions of risks and benefits

Treatment Anticoagulation for VTEMonotherapy




Treatment Anticoagulation for VTECombination Therapy with Warfarin




Therapeutic Anticoagulation for VTECombination Therapy with Edoxaban




Therapeutic Anticoagulation for VTECombination Therapy with Dabigatran




Anticoagulation for VTE patient with Chemotherapy-Induced Thrombocytopenia

• Thrombocytopenia increases the risk of bleeding in the setting of therapeutic anticoagulation for VTE




Management of Immunotherapy-Related Toxicities


• What are some toxicities related to immunotherapy?

• Is immunotherapy provided at your facility?• If so, do you have a protocol for how toxicities are managed?

• Is there pharmacist involvement?

Immunotherapy Basics

• Immunotherapy boosts the body’s natural ability to fight cancer

• Immune checkpoint inhibitors

• Vigilance in monitoring for drug interactions

• ADR presentation is graded – Grade 1-4

Immunotherapy ADR – General Information

• May affect one or several different organ systems

• Mobilization of T cells to attack immune-related adverse events (irAEs)• May occur at anytime during the course of treatment

• Severity of irAEs may vary• Combination therapy may increase severity

• Continuous monitoring and follow-up is key

• Rechallenge may be considered

Overview of Toxicity Management

• Mild to moderate adverse events• Symptomatic management

• May delay immunotherapy until resolution

• Corticosteroids may be required

• Severe adverse events• Discontinue immunotherapy

• Initiate corticosteroids – consider IV methylprednisolone

• Supportive care during immunosuppressant therapy

Assessment Question 1

• Which of the following are areas where pharmacists can aid in oncologic supportive care? Select all that apply.

a. Anemia

b. Immunotherapy toxicity

c. Alopecia

d. Antiemesis

e. Pain


• All patients that have a history of cancer and are currently hospitalized require VTE treatment.• True

• False


• Myeloid growth factors include the following:a. Filgrastim

b. Darbepoetin alfa

c. Epoetin alfa

d. Pegfilgrastim

e. A & B only

f. A & D only

g. All of the above


• Immunotherapy-related toxicities can occur in all of the following organs EXCEPT:

a. Skin

b. Gallbladder

c. Liver

d. Kidneys

References• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines–Adult Cancer

Pain. V. 1.2019." (2019).

• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines–Antiemesis. V. 3.2018." (2018).

• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines–Cancer- and Chemotherapy-Induced Anemia. V. 3.2018." (2018).

• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines–Cancer-Associated Venous Thromboembolic Disease. V. 2.2018." (2018).

• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines in partnership with the American Society of Clinical Oncology (ASCO)–Management of Immunotherapy-Related Toxicities. V. 1.2019." (2018).

• National Comprehensive Cancer Network. "NCCN Clinical Practice Guidelines–Myeloid Growth Factors. V. 2.2018." (2018).

• NCI Dictionary of Cancer Terms. (n.d.). Retrieved January 30, 2019, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/supportive-care

An Overview of Oncologic Supportive Care

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