Supportive Care for Patients with Cancer

Transcription

1 3:15pm - 4:15pm: Breakout 4 - Oncology Option A: Supportive Care for Patients with Cancer ACPE UAN L01-P 0.1 CEU/1.0 Hr. Activity Type: Application-Based Program Objectives for Pharmacists: Upon completion of this program, participants should be able to: 1. Describe the common complications of cancer therapy and their treatments. 2. Evaluate the treatment options for nausea and vomiting by individual patient needs. 3. Evaluate the treatment options for anemia by individual patient needs. 4. Discuss various side effects from supportive drug therapy and the necessary drug therapy to combat negative patient outcomes. 5. Develop a plan for the role of the pharmacist with oncology patients in regard to pain management. Speaker: Michele Woods, PharmD, BCOP, is the Oncology Pharmacy Clinical Specialist with Oncology Hematology Associates of Central Illinois in Peoria, Illinois. Having earned a Masters degree in Biological Sciences from Northern Illinois University in 1990, she went back to college in the late 90s to earn first a Bachelors degree in 1998 then a Doctorate of Pharmacy in 1999 from Midwestern University s Chicago College of Pharmacy in Downer s Grove, Illinois. Dr. Woods began working with cancer patients in the outpatient oncology setting in 2000 and became Board Certified in Oncology Pharmacy in Dr. Woods has participated in many cancer screenings and health fairs, and has spoken to various community and support groups on topics such as herbal medications, hormone therapy for breast cancer, and supportive care in oncology. Since moving to Peoria in 2005, Dr. Woods continues to be active in community oncology, including becoming more involved in clinical trials and patient advocacy and participating in the HOPA Best Practices in Neutropenia Roundtable, presented at the Orlando 2006 annual meeting. Speaker Disclosure: Michele Woods reports she is a Speaker s Bureau member for Amgen, Novartis, and Eisai. The speakers have indicated that off-label use of medications will not be discussed during this presentation.

2 Supportive Care for Patients with Cancer Faculty Disclosure Michele Woods, PharmD, BCOP reports she is a speaker s bureau member for Amgen, BMS, Eisai, and Novartis. Michele Woods, PharmD, BCOP Director of Pharmacy Illinois CancerCare Learning Objectives Pre-Assessment Questions Upon completion of this program pharmacists will be able to: Describe the common complications of cancer therapy and their treatments. Evaluate the treatment options for nausea and vomiting by individual patient needs. Evaluate the treatment options for anemia, neutropenia, and thrombocytopenia by individual patient needs. Discuss various side effects from supportive drug therapy and the necessary drug therapy to combat negative patient outcomes. Develop a plan for the role of the pharmacist with oncology patients in regard to pain management. 1) Which of the following is NOT a common complication experienced by cancer patients? a) Mucositis b) Venous thromboembolism c) Superior vena cava syndrome d) Nausea e) Pain Pre-Assessment Questions 2) Choose the best answer about N/V a) Chemotherapy causes nausea/vomiting and there is not much you can do to avoid it. b) The best clinical pathway for N/V is one that gives every one a level one antiemetic agent and upgrades to more costly agents or adds agents if the patient has a poor response. c) All serotonin antagonists have been shown to have equivalent efficacy, except palonosetron, which has a longer duration of action and some activity against delayed nausea and vomiting. Pre-Assessment Questions 3) In early stage breast cancer, dose reductions and delays resulting in a dose intensity less than 85% of planned treatment can cause the chance of disease recurrence to approach that of a person who did not undergo any prophylactic chemotherapy. a) True b) False

3 Pre-Assessment Questions 4) Which of the following describes appropriate anticoagulation for a cancer patient with a DVT? a) LMWH at therapeutic dose X 5 days + warfarin 5mg qday, check INR and adjust warfarin until INR between 2-3 b) LMWH at therapeutic dose X 6 months c) LMWH at therapeutic dose X 6 months, followed by LMWH at prophylactic dose indefinitely d) LMWH at therapeutic dose indefinitely Pre-Assessment Questions 5) When a cancer patient starts requesting pain medication more frequently, your instinct tells you to first: a) Suspect that the patient may have a substance abuse problem and may be drug seeking. b) Do or request a new patient assessment (patient condition may be worsening or may have more than one type of pain). c) Check out the patient s home situation (patient or a family member may be diverting drug). d) Ask for a psych consult, as the patient is clearly becoming difficult to get more attention. The Cancer Patient in Active Treatment What might be going on at any time that the pharmacist should be aware of? Community dispensing pharmacists Hospital inpatient pharmacists Active Treatment Types of Cancer (not one disease) Solid tumors Hematologic malignancies Types of Treatments Surgery Radiation Traditional cytotoxic chemotherapy Biologic targeted agents Common Complications Nausea/Vomiting Diarrhea Mucositis Bone marrow suppression Venous thromboembolism Pain Oncologic Emergencies Hypercalcemia of malignancy Spinal cord compression Tumor lysis syndrome Superior vena cava syndrome

4 Nausea/Vomiting Highly emetogenic chemotherapy Cisplatin/carboplatin Doxorubicin/idarubicin/daunorubicin/epirubicin Cyclophosphamide/ifosfamide Methotrexate (high dose) Chemo-Induced Nausea (CIN) Acute 0 24 hrs after chemotherapy dose Mechanism is chemoreceptor trigger zone Responds well to neurotransmitter antagonists Delayed 2-5 days after chemotherapy dose Mechanism unknown Responds well to dexamethasone Anticipatory Can occur anytime to any trigger associated with treatment Pavlovian response to poor control on prior cycles Responds well to lorazepam Drug Therapy for CIN Targets of drug action Neurotransmitters Serotonin Ondansetron, granisetron, dolasetron Palonosetron Dopamine Metoclopramide Histamine Diphenhydramine Prochlorperazine Substance P Aprepitant, fosaprepitant GABA Benzodiazepines Prevention of CIN TAKE HOME LESSON: Patients who do not experience nausea and vomiting on the first cycle of chemotherapy are much less likely to experience nausea and vomiting on future cycles. And vice versa. Cohen, L et al. Chemotherapy-induced nausea and vomiting incidence and impact on patient quality of life at community oncology settings. Support Care Cancer (2007) 15: Diarrhea Chemotherapy likely to cause diarrhea Irinotecan Fluorouracil/capecitabine Drug Therapy for Diarrhea Loperamide Diphenoxylate/atropine Octreotide Atropine

5 Counseling Points for Diarrhea Emphasize risk of dehydration That sure sounds like a lot of pills That s okay. It s even okay that it is more than the OTC box tells you to take. We have to say that out loud. Look alike/sound alike Some patients have scripts for loperamide & Lomotil (diphenoxylate HCl and atropine sulfate) Mucositis/Stomatitis Chemotherapy likely to cause stomatitis Methotrexate Fluorouracil Doxorubicin/idarubicin/daunorubicin/epirubicin Non-Pharmacologic Therapy for Mucositis Cryotherapy (ice chips) Mouthwashes Good oral care Avoid smoking Avoid spicy foods Bone Marrow Suppression Neutropenia Anemia Thrombocytopenia Keefe, DM, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer Mar 1;109(5): Neutropenia Absolute neutrophil count (ANC) < 500 Impact on outcomes Dose Intensity in breast cancer, lymphoma Prevention of Neutropenia G-CSF Stimulates neutrophil production in the bone marrow Pegfilgrastim 6mg SQ on day 2 (once per cycle) Filgrastim 480mcg SQ daily until ANC > 1000 GM-CSF Stimulates production of macrophages + neutrophils Sargramostim 500mcg SQ daily until ANC > 1000

6 Drug Therapy for Febrile Neutropenia Outpatient Treatment (Low-risk patients) Ciprofloxacin 750mg PO q12h + amoxicillin/clavulanate 500mg PO TID Inpatient Treatment (High-risk patients) Imipenem 500mg IV q6h Ceftazidime 1-2grams IV q8h May add vancomycin in certain situations Drug Therapy for Febrile Neutropenia Continue antibiotics until ANC > 0.5 X 109/L If not responding Persistent or intermittent fever Persistent positive blood cultures Consider : Changing antibiotics Adding WBC growth factor Adding antifungal agent Anemia Drug Therapy for Anemia Erythropoietin Stimulating Agents (ESAs) Erythropoietin alpha Darbepoetin alpha Controversy Hypoxia versus promotion of tumor growth Erythropoietin receptors Allowing third party payers to determine clinical guidelines Alternative: Transfusion Thrombocytopenia Drug Therapy for Thrombocytopenia Oprelvekin (interleukin-11) Secondary prophylaxis only Poor side effect profile makes it a poor choice for a supportive care drug Pipeline drugs the future? New Immune Thrombocytopenic Purpura (ITP) drugs being studied for potential future use in chemotherapy-induced thrombocytopenia

7 Venous Thromboembolism (VTE) Deep Venous Thrombosis (DVT) Venous Thromboembolism (PE) VTE Impact on Outcomes Significant cause of cancer mortality Drug Therapy for VTE Low molecular weight heparin Enoxaparin Dalteparin Tinzaparin Factor Xa inhibitor: Fondaparinux Vitamin K antagonist: Warfarin Not a preferred agent in cancer patients due to poor outcomes (Trousseau s syndrome, etc.) Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM, Weitz JI. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):141S-59S. VTE Prophylaxis Primary prophylaxis Secondary prophylaxis TAKE-HOME LESSON: Cancer increases hypercoaguability. Cancer patients who have experienced a DVT/PE should be maintained on therapeutic anticoagulation with LMWH as long as that hypercoaguable state exists. For many of those patients that will be for the rest of their lives. Pain Drug Therapy for Cancer Pain Opiates Adjuvant pain medications Neuropathic pain Local anesthetics

8 Pharmacist Role in Pain Management Calculate switches between opiates Longer-acting alternatives Short-acting for breakthrough Help choose alternate routes as needed For less frequent dosing as pill count increases Difficulty swallowing due to mucositis Suggest adjuvant medications for intractable pain Neuropathic pain Different mechanisms of action 1) Which of the following is NOT a common complication experienced by cancer patients? a) Mucositis b) Venous thromboembolism c) Superior vena cava syndrome d) Nausea e) Pain 2) Choose the best answer about N/V a) Chemotherapy causes nausea/vomiting and there is not much you can do to avoid it. b) The best clinical pathway for N/V is one that gives every one a level one antiemetic agent and upgrades to more costly agents or adds agents if the patient has a poor response. c) All serotonin antagonists have been shown to have equivalent efficacy, except palonosetron, which has a longer duration of action and some activity against delayed nausea and vomiting. 3) In early stage breast cancer, dose reductions and delays resulting in a dose intensity less than 85% of planned treatment can cause the chance of disease recurrence to approach that of a person who did not undergo any prophylactic chemotherapy. a) True b) False 4) Which of the following describes appropriate anticoagulation for a cancer patient with a DVT? a) LMWH at therapeutic dose X 5 days + warfarin 5mg qday, check INR and adjust warfarin until INR between 2-3 b) LMWH at therapeutic dose X 6 months c) LMWH at therapeutic dose X 6 months, followed by LMWH at prophylactic dose indefinitely d) LMWH at therapeutic dose indefinitely 5) When a cancer patient starts requesting pain medication more frequently, your instinct tells you to first: a) Suspect that the patient may have a substance abuse problem and may be drug seeking. b) Do or request a new patient assessment (patient condition may be worsening or may have more than one type of pain). c) Check out the patient s home situation (patient or a family member may be diverting drug). d) Ask for a psych consult, as the patient is clearly becoming difficult to get more attention.