Role of Pharmacist in Supportive care cancer

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1 Role of Pharmacist in Supportive care cancer Manit Sae-teaw B.Pharm, BCOP, BCP Grad. Dip. In Pharmacotherapy Faculty of Pharmaceutical Science Ubon Ratchathani University 1

2 Outline Cancer facts Supportive care/palliative care in cancer Role of pharmacist in supportive care in cancer Demonstrate ADRs treatment Conclusion 2

3 Cancer facts No (thousands) World Thailand Population Number of new cases Number of cancer death Most frequent Lung, Breast, CRC, Stomach, Prostate Lung, Breast, Liver, CRC, Cervix GLOBOCAN 2012 (IARC) Section of cancer information 3

4 Ref : National Cancer Institute

5 Cancer facts Cancer death rates Ref : Centers of disease control and prevention. eases/2012/p0328_cancer_de athrates.html 35

6 Supportive care/palliative care Treatment of cancer often experience adverse effects related to Disease related symptoms Therapeutic interventions Advances in care have results curing of cancer Treatment are effective if patients can tolerated therapeutic interventions Ref : American Cancer Society. 6

7 Supportive care/palliative care Defined as any intervention that makes therapy more tolerable or improve QOL Originally, period between during active cancer therapy and at the end of life Broadened definition include time from diagnosis to end of life Ref : American Cancer Society. 7

8 Parallel care Palliative care should start at diagnosis of a life-threatening illness Gradually increase while disease modifying care may decrease 8

9 Side effect of treatment Differential diagnostic with disease related symptoms Can be classified with onset Acute Delayed (weeks to months) Late (months to years) Extravasation, Hypersensitivity, N/V, Mucositis, Myelosuppression Organ toxicities : Cardiotoxicity, Pulmonary toxicity, Neuropathy Organ damage : encephalopathy, sterility Ref : Olver IN, et al. The MASCC textbook of cancer supportive care and survivalship

10 National Cancer Institute: CTCAE

11 The ten most common ADRs in oncology patients: Do they matter you? Review 167 patients (171 administrations) 454 ADRs have been identified Ref :: Lau PM, et et al. Support Care Cancer. 2004;12:

12 The ten most common ADRs in oncology patients: Do they matter you? Ref : Lau PM, et al. Support Care Cancer. 2004;12:626. 2

13 Roles of pharmacist in supportive care cancer Prevention Develop protocol for ADRs prevention Screen patient risk factors for ADRs Provide/consult pharmacotherapy/nonpharmacotherapy Assess ADRs after prevention 13

14 Roles of pharmacist in supportive care cancer Treatment Develop protocol for ADRs management Evaluate ADRs severity Provide/consult pharmacotherapy/nonpharmacotherapy Assess ADRs after treatment Develop plan for prevent ADRs in future Patient education Summary and report 14

15 Demonstration ADRs management 15

16 Febrile neutropenia Fever Oral temperature measurement of 38.3 C (101.0 F) single 38.0 C (100.4 F) sustained over 1-h period Use of axillary temperature is discouraged Not reflect core body temperature Rectal temperature is avoided Prevent gut organisms 16

17 Febrile neutropenia Absolute neutrophil count (ANC) Seg : Segmented neutrophil Band : Band form neutrophil 17

18 Febrile neutropenia Neutropenia ANC < 500 cells/mm3 Expected to decrease to < 500 cells/mm3 during next 48 h Profound neutropenia : ANC < 100 cells/mm3 Functional neutropenia : qualitative defects of circulating neutrophil 18

19 Febrile neutropenia Fever occurs frequently during neutropenia % Solid tumor >80% hematologic malignancy Infectious source can be indentified ~30% 2 Bacteria always identified 85-90% 80% identified pathogen are patients normal flora 3 Common sites of tissue-based infection Respiratory tract, urinary tract, skin, gastrointestinal tract 1 Klastersky J, et al. Clin Infect Dis. 2004;39:S Pizzo PA, et al. N Engl J Med. 1993;328: Schimpff SC, et al. Ann Interm Med 1972;77:

20 Risk assessment of febrile neutropenia To determine The type of empirical antibiotic therapy (IV or Oral) Venue of treatment (Inpatient vs Outpatient) Duration of antibiotic therapy Classification into High risk group and Low risk group MASCC criteria Clinical criteria MASCC : Multinational Association for Supportive Care in Cancer 20

21 Empiric antibiotic therapy High risk Require hospitalization for IV empirical antibiotic Monotherapy with anti-pseudomonal β-lactam agent Cefepime Carbapenem Piperacillin-tazobactam Other antimicrobials may be added to manage complication Hypotension, pneumonia 21

22 Empiric antibiotic therapy Vancomycin Indication for addition antibiotic against Gram positive organism Hemodynamic instability Pneumonia documented radiographically Positive blood culture for Gram positive infection Serious catheter related infection Skin and soft tissue infection Colonization with MRSA, PRSP Severe mucositis, if previous fluoroquinolone prophylaxis and ceftazidime use for empirical therapy 22

23 Empiric antibiotic therapy Low risk Medication therapy include Ciprofloxacin plus amoxicillin-clavulanate Levofloxacin or ciprofloxacin monotherapy Ciprofloxacin plus clindamycin Previous quinolone prophylaxis should not receive oral empirical quinolone 23

24 Modified antimicrobial Should be guided by clinical and microbiologic data Unexplained persistent fever Clinical stable : Not require antibiotic change Clinical unstable : Broadened antimicrobial Vancomycin may be stopped after 2 days (If no gram positive infection) Low risk patients require hospitalized if fever persist >48 hours Empirical antifungal should be considered after 4-7 days of antibacterial treatment IV-to-Oral switch may be made if Clinically stable Gastrointestinal absorption is adequate 24

25 Duration of antimicrobial treatment Clinical and microbiology documented Treatment until neutropenia resolved Clinically necessary Unexplained fever (No microbiological documented) Treatment until neutropenia resolved Alternatively if treatment course has been completed Patients who remain neutropenia may resume oral quinolone until marrow recovery 25

26 Hematopoietic growth factor Recommended guideline American society of clinical oncology (ASCO) European organisation for research and treatment of cancer (EORTC) National comprehensive cancer network 3 Indication Primary prophylaxis Secondary prophylaxis Treatment during febrile neutropenia 1 Smiths TJ, et al. J Clin Oncol. 2006;24: Aapro MS, et al. Eur J Cancer. 2011;47: Available at : 26

27 Hematopoietic growth factor Primary prophylaxis American Society of Clinical Oncology (ASCO) guideline updates 2006 Chemotherapy with febrile neutropenia risk 20% Intensive chemotherapy regimen Dose-dense (increased frequency) Dose-intense (increased dose) High risk patient Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

28 Hematopoietic growth factor Primary prophylaxis High risk patient Age > 65 years Poor performance status Previous episode of FN Extensive prior treatment including large radiation port Administration CCRT Cytopenia due to bone marrow involvement by tumor Poor nutritional status Presence of open wound or active infection More advanced cancer Other serious comorbidity Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

29 Hematopoietic growth factor Secondary prophylaxis Recommended for patients who experienced a neutropenic complication from a prior cycle of chemotherapy Especially in reduced dose may compromise therapeutic outcome Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

30 Hematopoietic growth factor Treatment Restrict use in high risk FN patients Expected prolonged (>10 days) and profound (ANC<100 cells/mm 3 ) neutropenia Age > 65 years Uncontrolled primary disease Pneumonia Sepsis syndrome (multiorgan dysfunction) Invasive fungal infection Hospitalized at a time of fever developed Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

31 Hematopoietic growth factor Acute leukemia and Myelodysplastic syndromes Acute myeloid leukemia (AML) Not recommended in induction phase prophylaxis Recommended in consolidation phase prophylaxis Myelodysplastic syndromes (MDS) Recommended treatment intermittent in severe neutropenia and recurrent infection Acute lymphocytic leukemia (ALL) Recommended in induction phase prophylaxis Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

32 Hematopoietic growth factor Compare colonystimulating factors Filgrastim Lenograstim Sargamostim Pegfilgrastim Source E.Coli - Yeast Yeast Dose 5 mcg/kg/d 5 mcg/kg/d 250 mcg/m2/d 6 mg single dose** Route SC, IV SC,IV SC,IV SC Half life 3.5 hr 3 hr 2 hr hr Eliminate Renal Renal - Neutrophil Adverse effect Bone pain, Bruising, diarrhea*, edema*, fatigue*, fever*, rash, injection site reaction Bone pain, injection site reaction, urticaria * Less frequent with filgrastim compare with sargamostim ** Do not used in infants and children and BW < 45 kg 32

33 Hematopoietic growth factor Colonystimulating factor regimen Colonystimulating factor Filgrastim : 5 mcg/kg/day Lenograstim : 5 mcg/kg/day GM-CSF : 250 mcg/m 2 /day Pegfilgrastim : 6 mg Duration Should started 24 to 72 hours after chemotherapy Continued up to 14 days or until reaching ANC 3,000 cells/mm 3 for 2 consecutive days Pegfilgrastim : single dose Ref : Smiths TJ, et al. J Clin Oncol. 2006;24:

34 Nausea and vomiting Emesis (vomiting) is measured by the number of vomiting or retching episode after treatement Nausea is the patient s perception that emesis may occur American Society of Clinical Oncology 2011

35 Classification of Emesis 1. Acute emesis Mainly 5-HT3 2. Delayed emesis Mainly Dopamine 3. Anticipatory emesis 4. Breakthrough emesis 5. Refractory emesis 35

36 Risk factor for CINV Previous chemotherapy that resulted in Moderate/severe/intolerable N/V Feeling warm all over/sweating Generalized weakness, dizziness History of motion sickness Pretreatment anxiety Age less than 50 years Gralla RJ, et al. J Clin Oncol 1999; Chin SB, et al. Am J Clin Oncol 1992;15: Morrow GR, et al. J Pain Symptom Manage 1991;6:

37 2011 ASCO Recommendations for Specific Emetic Risk Categories: Chemotherapy-Induced Acute Emesis High Moderate Low Minimal (>90%) (30% to 90%) (10% to 30%) (<10%) o Carmustine o Carboplatin o 5-Fluorouracil o2-chlorodeoxyadenosine o Cisplatin o Cyclophosphamide 1500 mg/m 2 o Dacarbazine o Dactinomycin o Mechlorethamine o Streptozotocin o Cyclophosphamide <1500 mg/m 2 o Cytarabine > 1 gm/m 2 o Daunorubicin o Doxorubicin o Epirubicin o Idarubicin o Ifosfamide o Irinotecan o Oxaliplatin o Bortezomib o Cetuzimab o Cytarabine 1000 mg/m 2 o Docetaxel o Etoposide o Gemcitabine o Methotrexate o Mitomycin o Mitoxantrone o Paclitaxel o Pemetrexed o Topotecan obevacizumab obleomycin obusulfan ofludarabine orituximab ovinblastine ovincristine ovinorelbine o Trastuzumab American Society of Clinical Oncology

38 Classes of Antiemetic Agents Serotonin Antagonists Corticosteroids NK 1 Receptor Antagonist (i.e. Aprepitant) Dopamine antagonists Metoclopramide Phenothiazines (i.e. Prochloroperazine) Butyrophenones (i.e. Haloperidol) Benzodiazepines Cannabinoids (i.e. Marinol ) 38

39 Emetic Risk Category American Society of Clinical Oncology

40 Emetic risk by site of radiation therapy Emetic risk High Moderate Low Minimal Site of radiation therapy Total body irradiation Total nodal irradiation Upper abdomen Upper body irradiation Half body irradiation Cranium, Craniospinal, Head and neck, lower thorax region, pelvis Extremities Breast American Society of Clinical Oncology

41 Emetic risk by site of radiation therapy Emetic risk High Moderate Low Minimal Recommendation 5HT3 antagonist : before each fraction and at least 24 hr after end of RT Dexamethasone : 4 mg IV/PO fraction 1-5 5HT3 antagonist : before each fraction Dexamethasone : 4 mg IV/PO fraction 1-5 5HT3 antagonist : for rescue and prophylaxis 5HT3 antagonist : for rescue and prophylaxis Prophylaxis : continue throughout radiation treatment if patients experiences RINV while receiving rescue therapy American Society of Clinical Oncology

42 Roles of pharmacist in supportive care cancer Prevention Develop protocol for ADRs prevention Screen patient risk factors for ADRs Provide/consult pharmacotherapy/nonpharmacotherapy Assess ADRs after prevention 13

43 Roles of pharmacist in supportive care cancer Treatment Develop protocol for ADRs management Evaluate ADRs severity Provide/consult pharmacotherapy/nonpharmacotherapy Assess ADRs after treatment Develop plan for prevent ADRs in future Patient education Summary and report 14

44 Conclusion More cancer are curable or can be halted in a chronic state that make supportive care is an important issue Most of drug related problems or ADRs are preventable and treatable Roles of pharmacist including prevention, treatment, patient education, summary and report 42

45 Thank you for your attention 43

Febrile neutropenia. Febrile neutropenia. Febrile neutropenia. Febrile neutropenia 1/30/2019. Infection in patients with cancer

Febrile neutropenia. Febrile neutropenia. Febrile neutropenia. Febrile neutropenia 1/30/2019. Infection in patients with cancer Manit Sae-teaw B.Pharm, BCP, BCOP Glad dip in pharmacotherapy Faculty of pharmaceutical sciences Ubon Ratchathani University Fever Oral temperature measurement of 38.3 C (101.0 F) single 38.0 C (100.4