Targeted Therapies: Symptom Management

 Kris at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Mary Pat Lynch, who will be talking with us about any and all questions you have regarding targeted therapies. Welcome Mary Pat!

 marypatlynch 

Hello everyone! Please send your questions on targeted therapy.

 marypatlynch 

What type of settings are you working in?

 marypatlynch 

Targeted therapies are general terms that refer to medications that target a specific pathway in the growth or development of a tumor.

 maryg 

I'm curious if Mylotarg typically causes nausea and vomiting.

 marypatlynch 

There are many types of targeted therapies. Tyrosine kinase inhibitors, angiogenesis inhibitors, proteasome inhibitors and immunotherapy, to name a few.

 tparks 

What is everyone doing for rash management - are you treating prophylactically or waiting until symptoms appear?

 marypatlynch 

Mylotarg - nausea is common affecting almost 70% of patients.

 marypatlynch 

Has that been your experience in treating patients with Mylotarg?

 maryg 

I have given it 5 or 6 times and it has only been the last patient that has experience this.

 maryg 

She sailed through ARA-C etc. with no N&V and now she is just miserable.

 maryg 

Nothing seems to help her nausea.

 marypatlynch 

Rash management is the hot topic! I'd like to hear what others are doing. In our practice, we treat prophylactically with hypoallergenic moisturizer that does not contain alcohol, sun avoidance or sun screen, then start topical hydrocortisone 1% if erythema develops.

 marypatlynch 

If they get pustules, we then use topical clindamycin lotion and add oral antibiotics such as doxycycline if it is severe.

 marypatlynch 

re nausea/Mylotarg: I wonder if it’s a cumulative effect as this is second line chemo. What have you tried?

 Kris at ONS 

Have you heard about using oatmeal for the rash?

 tparks 

How do you use oatmeal?

 marypatlynch 

I have heard that topical oatmeal can be helpful, especially in some of the online patient forums. It seems to provide comfort for some people. But the drug company recommends good prophylactic skin care and then use of steroid creams and antibiotics if needed. The rash can be very distressing for some people.

 marypatlynch 

The oatmeal is used as a topical agent, over the skin.

 tparks 

Do you mix it up as usual and put on the skin or bathe in it or what?

 marypatlynch 

Some of the over the counter lotions such as Aveeno contain oatmeal, others use regular oatmeal moistened into a paste an put on the skin. There are oatmeal baths as well.

 marypatlynch 

Has anyone used different products for the rash that have been successful?

 tparks 

Have you tried the new Sancuso patch for the nausea?

 lisa 

Remember that the rash is an inflammatory response and the skin needs to be kept moist. Being proactive by making sure the patient takes the medication on an empty stomach, uses an emollient cream and sun screen are helpful.

 marypatlynch 

RE: Sancuso: No, I haven't used it, have you had success with it?

 tparks 

RE: Sancuso:We haven't had much success in obtaining it for patients due to cost/insurance issues.

 marypatlynch 

Lisa, re:inflammatory nature of rash: good point, we have seen the best results with those patients who really follow the prophylactic management. There are studies that show that those patients who get a skin reaction have a better response to the drug, so it’s important to try to keep them on it. It’s believed to be a inflammatory response due to the EGFR inhibition in skin tissue.

 marypatlynch 

The Sancuso patch is a five day granisetron patch, just approved in Sept of 08 for CINV, a seratonin antagonist. My guess is that it is new and that’s why you’re having problems with insurance coverage.

 tparks 

Yes I'm sure you are right about that. It is for a select group of patients I think and quite expensive, but in a patient who has failed other therapies it would certainly be worth a try if one could obtain it. Just wondering if it might benefit the Myelotarg patient.

 marypatlynch 

Regarding the rash, it’s important that patients not use OTC acne preparations even though it can be an acniform rash, they can really dry out the skin.

 marypatlynch 

tparks, re: Sancuso for the N/V refractory pt: good point. it might be worth a call to the company to see if there are any patient assistance programs available. It is recommended for moderately and/or highly nausea –inducing chemo, so it might be helpful for the Mylotarg patient, if they have tried everything else. Thanks for the idea.

 marypatlynch 

Regarding skin rashes, there are two good references that I found to be useful, one in in the Forum, issue 1, 2008 by Karen Oishi and one in the April, 2008 issue of CJON by Beth Eaby et al.

 marypatlynch 

What type of practice settings are you in?

 marypatlynch 

Last night we had some questions on compliance and disposal of oral drugs. Is that an issue for anyone?

 ghrn2004 

Our safe handling includes disposing of chemo drugs in a chemo-approved bin.

 marypatlynch 

What do you recommend to patients who are on oral drugs at home? Do they bring the unused drugs into the office for disposal?

 ghrn2004 

Yes, in a plastic bag. we also supply nitrile gloves and instruct people to double glove.

 marypatlynch 

Great, that is what most people recommend. Compliance is also a real issue that many people are struggling with, how to document and ensure that patients are taking the drugs correctly.

 ghrn2004 

I'm inpatient, so most of our patients are compliant with

 ghrn2004 

IV

 ghrn2004 

LOL

 marypatlynch 

True, that's easier!

 marypatlynch 

There are new patient safety standards being developed by ONS and ASCO that will be available for outpatient settings, they are up for public comment right now, prior to final approval. You can access them off the ONS website main page right now.

 ghrn2004 

Any recommendations on disposing of waste from peritoneal chemo?

 marypatlynch 

I would think it is the same as disposal of any other chemo waste, according to the safe handling guidelines.

 ghrn2004 

We are just beginning to explore it, and we were concerned about the relatively huge amount of fluid.

 marypatlynch 

They recommend that you handle urinary /peritoneal drainage as contaminated body fluid, wearing a gown, glove and face shield. Dispose of all materials used as hazardous waste.

 ghrn2004 

thanks

 ghrn2004 

We were discussing Mylotarg earlier-does anyone else keep Mylotarg infusions separate from transfusions by at least 24 hours?

 marypatlynch 

What is the rationale? to minimize hypersensitivity reaction?

 ghrn2004 

yes-we had two patients die after receiving Mylotarg and platelets within the same 24 hour period. Our docs, pharmD, and RNs wrote a case study in a pharm journal, but I have been unable to find any larger studies.

 marypatlynch 

Wow, I haven't seen that and didn't see anything in my references about a combination of Mylotarg and transfusion risk. Were the patients seriously ill prior to the infusions?

 ghrn2004 

Not at all- both had received Mylotarg and platelets before, simply not within the same 24 hour period.

 marypatlynch 

Interesting. There is a high risk of hypersensitivity reaction and of tumor lysis syndrome with Mylotarg, I wonder if that played a part. Has anyone else seen this?

 Kris at ONS 

We have about 5 more minutes- please continue to ask your questions! Also, at the end of today’s chat, please take a moment to cut and paste this URL into your browser and take our very brief survey - we’d love to hear what you think of these chats! The URL is: http://research.zarca.com/k/RsTUTRsSPYsXYTSTsPsP THANK YOU!

 marypatlynch 

Thanks for coming! Have a good day!

 ghrn2004 

thank you