an overview of oncologic supportive care
TRANSCRIPT
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An Overview of Oncologic Supportive Care
Chelsea Parry, Pharm.D.
PGY-1 Pharmacy Resident
Piedmont Atlanta Hospital
February 23, 2019
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Disclosure Statement
• I have no relevant financial relationships with any ACCME defined commercial interests.
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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
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• National Comprehensive Cancer Network (NCCN)
• Lexi-comp
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Supportive Care
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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
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Adult Cancer Pain
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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
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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
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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
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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
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Managing Opioid ADR Continued
• 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
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Managing Opioid ADR Continued
• 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
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Antiemesis
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Discussion Questions
• 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?
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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
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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
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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
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Acute & Delayed Emesis PreventionHigh Emetic Risk
Day 1 Days 2, 3, 4
Option B • Olanzapine 10 mg PO once
• Palonosetron 0.25 mg IV once
• Dexamethasone 12 mg PO/IV once
• Olanzapine 10 mg PO daily on days 2, 3, 4
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Acute & Delayed Emesis PreventionHigh Emetic Risk
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
• 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
• 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
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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
Ondansetron 16-24 mg PO once, or 8-16 mg IV once Palonosetron 0.25 mg IV once
• Dexamethasone 12 mg PO/IV once
• 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
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Acute & Delayed Emesis PreventionModerate Emetic Risk
Day 1 Days 2 & 3
Option E • Olanzapine 10 mg PO once
• Palonosetron 0.25 mg IV once
• Dexamethasone 12 mg PO/IV once
• Olanzapine 10 mg PO daily on days 2, 3
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Acute & Delayed Emesis PreventionModerate Emetic Risk
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
• 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 aprepitant PO used on day 1)
• + Dexamethasone 8 mg PO/IV daily on days 2, 3
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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
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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
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Cancer- and Chemotherapy-Induced Anemia
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Discussion Questions
• 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?
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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
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ESAs
• Available options• Epoetin alfa or epoetin alfa-epbx
• Darbepoetin alfa
• ADR• Thrombosis
• HTN/Seizures
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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
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Myeloid Growth Factors
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Discussion Questions
• 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?
• Pharmacist involvement?
• Inpatient versus outpatient application?
• Does your facility utilize biosimilars?
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Myeloid Growth Factor Basics
• Primarily used to reduce the incidence of neutropenia
• Severe neutropenia or febrile neutropenia
• Risk of developing neutropenia
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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
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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
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Cancer-Associated Venous Thromboembolic Disease
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Discussion Questions
• 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?
• Pharmacist involvement?
• Medications utilized?
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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
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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
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Inpatient/Outpatient Prophylactic Anticoagulation
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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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
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Treatment Anticoagulation for VTEMonotherapy
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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Treatment Anticoagulation for VTECombination Therapy with Warfarin
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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Therapeutic Anticoagulation for VTECombination Therapy with Edoxaban
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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Therapeutic Anticoagulation for VTECombination Therapy with Dabigatran
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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Anticoagulation for VTE patient with Chemotherapy-Induced Thrombocytopenia
• Thrombocytopenia increases the risk of bleeding in the setting of therapeutic anticoagulation for VTE
National Comprehensive Cancer Network. "NCCN
Clinical Practice Guidelines–Cancer-Associated Venous
Thromboembolic Disease. V. 2.2018." (2018).
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Management of Immunotherapy-Related Toxicities
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Discussion Questions
• 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?
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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
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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
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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
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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
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Assessment Question 2
• All patients that have a history of cancer and are currently hospitalized require VTE treatment.• True
• False
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Assessment Question 3
• 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
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Assessment Question 4
• Immunotherapy-related toxicities can occur in all of the following organs EXCEPT:
a. Skin
b. Gallbladder
c. Liver
d. Kidneys
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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