Chemotherapy & Medical Agents Used to Treat Cancer

Chemotherapy & Medical Agents Used to Treat Cancer

DRUG Interactions &

Patient Instruction

Adverse Effects Naturopathic

Interventions

Adriamycin

(Doxorubicin)

IV Chemotherapy

Inhibits DNA transcription and

formation of cytotoxic free radicals

● Excreted in feces and kidneys

● Half Life = 20-48h

● Does not cross BBB

● Patients may notice darker urine for

1-2 days after

● Patients cardiac function should be

monitored

● Increased toxicity of: cytoxan,

herceptin, and 6-mercaptopurine

● Decreases efficacy of: Phenobarbital,

digoxin

● Avoid glutathione, NAC, curcumin

which may contribute to resistance

(CTCA)

● Glucosamine might induce resistance

to doxorubicin (Adriamycin) by reducing

the drugs' inhibition of topoisomerase II,

an enzyme required for DNA replication

in tumor cells

● Myelosuppression

● N/V (50%)

● Diarrhea, mucositis

● Cardiotoxic

●Alopecia (100%)

● Red-orange urine

● Skin discoloration

Increasing Efficacy:

● Gingko: 4caps 1hour prior to

infusion (J.Belanger, ND)

● Arginine: 4g q4h 5d prior/3d

post chemo (J.Belanger,ND)

● L-Theanine - increases

effectiveness

1. Myelosupression

● Esberitox 3 tablets tid

● Astragalus with Ligustrum

● Maitake

● Goji berries

● Panax ginseng

2. Nausea and vomiting

● Ginger tea, ginger capsules

● NAC 1800mg/d (Lamson)

3. Mucositis and diarrhea

● L-glutamine 10 g tid

● DGL ¼ tsp tid

● slippery elm,

● Glycgel, oral paste

● L-lysine 1g bid-tid

4. Cardiotoxicity

● CoQ-10 100-300 mg TID

● L-carnitine 4g/d

● Vit E (800IU), Vit C (1g)

● NAC (1800mg)

● Panax ginseng

Aldesleukin (see IL-2)

IV Immunotherapy

Alimta (Pemetrexed)

IV Chemotherapy

Anti-folate analog

● Half-Life = 3 hours

● 90% Renal Excretion

● NSAIDs may inhibit renal

excretion

● All patients should receive vitamin

supplementation with 350ug/day oral

folic acid and 1mg/day SC vitamin

B12 to reduce toxicity


● Skin Rash

● N/V/D/Mucositis

● Fatigue

1


DRUG Interactions &

Patient Instruction


Interventions

Amiofostine (see Ethyol)

IV Chemoprotective Drug

Anastrozole

(see Arimadex)

Hormonal Therapy

Aranesp

(Darbopoetin alfa)

Growth Factor

IV, SC drug. Stimulates division and

differentiation of RBC in bone marrow

● ½ Life = 40-49h

● Contraindicated in uncontrolled

HTN,

● Remote risk of Creutzfeldt-Jacob

Syndrome transmission

● HTN

● N/V/D occasionally

● Fatigue, Arthralgia

Arimadex (Anastrozole)

Hormonal Therapy

Nonsteroidal sromatase inhibitor

Oral, Inhibits synthesis of estrogens

by inhibiting the conversion of

adrenal androgens to estrogens

● Liver Metabolism

● Fecal Excretion

● Half Life= 50h

Serum Estradiol levels are 90%

suppressed after 14 days, and near

100% after 6 weeks

●No interactions

● Absorption is not affected by food

● Hot Flashes (10%)

● Arthralgia (10-15%)

● Edema (7%)

Aromasin (Exemestane)

Hormonal Therapy

Steroidal aromatase inhibitor

● No interactions

● Absorption is not affected by food

● Hot Flashes

● Fatigue

● Nausea

2


DRUG Interactions &

Patient Instruction


Interventions

Permanently binds and inactivates

aromatase to inhibit estrogen

synthesis

● Liver P450 Metabolism

● Fecal Excretion

● Half-Life= 24h

Avastin (Bevacizumab)

Monoclonal Antibody

Binds to VEGF (which is

pro-angiogenic) to inhibit tumor blood

vessel permeability

● Cleared by liver, kidneys

● Half-Life= 17-21 days

● No interactions ●Bleeding Complications (GI

perforations, epistaxis,

hemoptysis)

● Thrombo-embolic events

● HTN (20-30%)

● Flu-like symptoms

BCG (Bacillus

Calmette-Guerin)

Immunotherapy

Intra-vesical, Attenuated strain of

M.bovis provides a local inflammation

in the bladder.

● Immunosuppressive Drugs

(Impaired efficacy)

● Antimicrobials/Quinolones

(impaired efficacy)

Patients must disinfect toilet with

bleachx15min after urination for 6h

after instillation

● Chemical cystitis

● Flu-like symptoms (35%)

Bevacizumab

(see Avastin)

Monoclonal Antibody

Bicalutamide

(see Casodex)

Antiandrogen Hormonal Drug

3


DRUG Interactions &

Patient Instruction


Interventions

Bortezomib

(see Velcade)

IV Chemotherapy

Drink Plenty of Fluids to decrease

hypotensive episodes

● Peripheral Neuropathy

● Hypotension

● CHF

● N/V

● Diarrhea or Constipation

● Thrombocytopenia

● Hepatic Events

1. CHF:● CoQ10

● L-carnitine

● Hawthorn

2. N/V: ginger, cinnamon

3. Diarrhea or constipation:● fiber

● L-glutamine for diarrhea

4. Asthenic conditions:● Licorice d/t corticosteroid

promoting effects

● Ginsengs

Capecitabine

(see Xeloda)

Oral Chemotherapy

● Decreased levels of

methylenetetrahdrofolate

● B6+B12+folic acid to increase

effectiveness, since drug resistance may

occur with decreased levels of MTH-folate

● PSK (from Coriolus

versicolor ) 3 g/d with tegafur/uracil

(UFT) {oral equivalent to 5-fu} in stage II

and III colorectal ca increased survival

and decreased recurrence or mets

● Take supplements 2 hours after

taking Xeloda. (by CTCA), especially

those that contain folic acid.

● Take AWAY from meals!

● Take AWAY from antacids

● Interacts with CYP450

● Monitor INR!

● Blepharitis, tear-duct

stenosis, acute and chronic

conjunctivitis

● Cardiotoxicity

● Nausea

● Hand-Foot Syndrome

● Mouth Sores

● Diarrhea

1.Hand-Foot Syndrome:

● Vit B6 50 mg BID up to 300 mg

QD for prevention

● All purpose salve topically for

hand-foot syndrome.

● Avoid exposure to heat

● Deodorant topically to palms

and bottom of feet

2.GI Toxicity (mouth sores,

diarrhea):

● L-glutamine to prevent GI

toxicity, mouth sores and diarrhea.

● DGL

● Glycgel, oral paste and

Slippery Elm, Vit E

● L-lysine 1g bid-tid for mouth

sores and heartburn.

3.Nausea: Ginger tea or capsules.

Carboplatin

IV Chemotherapy

Platinum analog binds DNA with

cytotoxic effects

● Avoid Glutathione

● Vitamin B6: no more than 200 mg

(one capsule of B complex #6), as

higher doses have been shown to

decrease efficacy of Cisplatin (ECOG

Enhancing Efficacy:

● Quercitin: 4caps q5h day

before and day of chemo

(J.Belanger,ND)

1. Myelosuppression


● Esberitox

2.Thrombocytopenia (by day 21)

● PA-Free Comfrey (Wise Woman)

● Sesame oil

4


DRUG Interactions &

Patient Instruction


Interventions

● Excreted by Kidneys

● half-life= 2-6hours

● Pre-treat with antiemetics

● Maintain oral hydration

● Alopecia not likely

Clinical trial using 300 mg/m2

(Cancer Invest. 1992;10(1):1-9), as

well as in vitro data. Please note: the

study concluded that pyridoxine

should not be used at all with

Cisplatin.

● Avoid Gingko; the only platinum

drug gingko is safe with is cisplatin

(J.Belanger,ND)

.

● Arginine: 4g q4h

5dprior/3dpost chemo

(J.Belanger,ND)

● Silymarin, PSK (CTCA)

● Red root

● Maitake-D-Fraction

3.N/V: Ginger , Cinnamon

4.Renal toxicity

● Minerals: Se, Ca, Mg, K, Na

● Glutamine

6. Peripheral neuropathy (<10%)

● Vit E, a-lipoic acid, Se,

Acetyl-L-carnitine, Mg

Casodex (Bicalutamide)

Antiandrogen Hormonal Drug

Oral, nonsteroidal antiandrogen

inhibiting androgen uptake.


● Fecal/Urine Excretion

● Half-Life= several days

● Warfarin (additive anticoagulant

effect)

● Altered sexual function

● Hot flashes (50%)

● Constipation (10%)

Cetuximab (see Erbitux)

IV Monoclonal Antibody

Cisplatin (Platinol)

IV Chemotherapy

Platinum analog binds DNA for

cytotoxic effect

● Excreted in urine

● Half-life = 20-30 min

● Patient should drink 1L water before

and 1L water after infusion

● Pretreat with antiemetics

● Avoid Glutathione, NAC which

may promote resistance (CTCA)

● Vitamin B6: no more than 300 mg

(one capsule of B complex #6), as higher

doses have been shown to decrease

efficacy of Cisplatin (ECOG Clinical trial

using 300 mg/m2 (Cancer Invest.

1992;10(1):1-9), as well as in vitro data.

Please note: the study concluded that

pyridoxine should not be used at all with

Cisplatin

Enhancing Efficacy:

●Folic acid and B12 may increase

chemosensitivity in patients with stage

IV non-small-cell lung cancer who are

also carriers of the MTHFR 677T

allele. (Clin Lung Cancer. 2004

May;5(6):360-5.)

● L-Theanine 200 mg daily may

increase tumor concentrations of

chemo, but not normal tissue. Do not

take at same time as glutamine

(competitive absorption).

1. Neurotoxicity

● Vitamin E (600mg) during and 1

month after prevented neuropathy

(PubMed)

● Vit E, a-lipoic acid, selenium,

L- carnitine, Mg, acetyl-L-carnitine

● Melatonin: 20mg for ototoxicity

2.Nephrotoxicity

● Magnesium, Ca, K depletion

by Cisplatin due to impaired

intestinal absorption

● Cysteine, Vit E, Crocus sativa (J

Pharm Belg 1998, 53(2))

5


DRUG Interactions &

Patient Instruction


Interventions

● Does cause alopecia

● Mg and Ca : Cisplatin nephrotoxicity

leads to magnesium and calcium wasting

and may affect may affect magnesium and

calcium metabolism, both of which

contribute to bone integrity. (see Pubmed)

● Gingko: 4caps 1hour prior to

infusion (J.Belanger, ND)



● Taurine restored kidney GSH

(Chemo 2002, 48(1))

● Vit C dose-dependent protection

(Pharmacol Res 2000, 41(4)).

● Glycine: Cisplatin -inducednephrotoxicity has been minimized (Ernst,2014)3.Fatigue

● L-carnitine 4g/d (PubMed)

4.Immunosuppression

● Melatonin (natural database)

● PSK with Cisplatin + 5-FU has

immunostimulatory effect (RCT

PubMed)

Cyclophosphamide

(see Cytoxan)

IV or Oral Chemotherapy

Cytoxan

(Cyclophosphamide)

IV or Oral Chemotherapy


● Excreted in Urine

● ½ Life = 4-6h

Inhibits DNA synthesis in all phases

of the cell cycle

● Patients should drink 2-3L water

per day to reduce hemorrhagic cystitis

● Encourage patient to empty

bladder every 2 hours

● Check INR, and Rx meds

● Avoid Gingko, Curcumin,

Glutathione, NAC; may promote

resistance (CTCA, JBElangerND)


● Folic acid, Vitamin A, Aloe,

and Ashwaganda (CTCA,

JBelangerND)



1. Immunosupression

● Astragalus might reduce

immunosuppression caused by

cyclophosphamide (see natural

database Astragalus)

● Ashwaganda (Cancer Letters

2000, CTCA)

● Astragalus promotes myelopoiesis,may protect WBC counts during cyclophosphamide therapy thereby reducing leukopenia [1].

● Echinacea may enhance low dose cyclophosphamide and myelosuppression may be reduced in high dose cyclophosphamide [1]

● Eleuthero extracts reduce adverse effects of cyclophosphamide by protecting against and reversing

6

http://www.uptodate.com/contents/cisplatin-drug-information?source=see_link


DRUG Interactions &

Patient Instruction


Interventions

● Used with Adriamycin in breast

cancer

leukopenia and enhancement of general stress resistance [1]

2. Survival

● PSK 3 g/d – breast ca in

combination with cytoxan and 5-fu

increased survival (RCT PubMed)

● Licorice in combination with cyclophosphamide (single mice study) showed a reduction in tumorigenesis and metastasis. [1]

3. Toxicity

● Alpha Lipoic Acid reduced

toxicity (UMM)

● Selenium in combination with antioxidants (beta carotene, B2, B3, Vit C, Vit E) shown to reduce hair loss, flatulence, abdom pain, weakness, malaise, and lack of appetite [1]

Cytarabine

IV Chemotherapy, isolated from a sea

sponge

Inhibits DNA synthesis in

S-phase

●Metabolized by cytidine deaminase

in all tissues

● ½ Life = 2-6h

● Decreases efficacy of gentamicin,

5FU, digoxin

● Increased toxicity of cisplatin,

methotrexate, fludara, radiation

therapy

● Patients should be pre-treated

with steroid eyedrops in high dose

therapy to avoid conjunctivitis

● Myelopsuppression

● N/V/D + mucositis (7-10d post

therapy)

● Neurotoxicity (10%) including

confusion, ataxia

● Conjunctivitis

● Pulmonary distress

Darbopoetin alfa

(see Aranesp)

Dasatinib (see Sprycel)

Docetaxol

7


DRUG Interactions &

Patient Instruction


Interventions

(see Taxotere)

IV Chemotherapy

Doxorubicin

(see Adriamycin)

IV Chemotherapy

Erbitux (Cetuximab)


Anti-EGFR to induce apoptosis

Weekly Injections

● Unknown Excretion

● Half-Life = 5-7 days

● Skin toxicity indicates efficacy in

most patients

● May worsen interstitial lung

disease

● Avoid CYP3A4 herbs

● Gingko inhibits

● Flu-like reaction (40-50%)

● Acneiform rash (improves with

continued tx)

● Malaise (50%)

● Fatigue, HA

● Allergic Reaction (dose limiting)

● Lung Disease (dose limiting)

1. Skin and Nail Problems: avoid sun

2. Diarrhea

● L-Glutamine: 10g TID

3. Abdominal pain, N/V : Ginger,

cinnamon

Erlotinib

(see Tarceva)

Oral Chemotherapy

HER1/EGFR tyrosine kinase inhibitor.

● Half-life = 36 hours●CYP3A4 and CYP1A2 metabolism● 93% protein bound to albumin and alpha-1acid glycoprotein (AAG).

MONITOR warfarin.

Avoid P450 acting products such as St. John’s wort, Milk thistle, Ginsengs, Ginkgo and others .

● Pulmonary Toxicity -- There have

been infrequent reports of serious

Interstitial Lung Disease (ILD),

including pneumonitis, interstitial

pneumonia, interstitial lung disease,

obliterative bronchiolitis, pulmonary

fibrosis, Acute Respiratory Distress

Syndrome and lung infiltration.

● Rash and diarrhea. The median

time to onset of rash was 8 days, and

the median time to onset of diarrhea

was 12 days.

● Grade 3 conjunctivitis and

keratitis have been reported

infrequently in patients receiving

TARCEVA therapy. Corneal

ulcerations may also occur.

1. Pulmonary Toxicity

● Bromelain ?

● NAC?

2. Rash and diarrhea: L-glutamine

10g TID.

Erythropoietin ● Decreases efficiency of Heparin if

given concurrently

● Hypertension

● D/N/V occasionally

8


DRUG Interactions &

Patient Instruction


Interventions

(Procrit, Epogen)

Colony-stimulating factor

● Metabolized in liver and bone

● 10% urine excretion

● Half-life = 4-13h

● Aluminum antacids decrease

efficacy

● May benefit with p.o. Ferrous

sulfate as well

● fever, fatigue

Ethyol (Amiofostine )

IV Chemoprotective Drug

Free thiol acts as an antioxidant to

reduce free radical damage from

Cisplatin and Radiation

● Urinary excretion

● Half Life = 8 minutes

● Carboplatin (decreased clearance

by the kidney)

● BP meds should be discontinued

24h prior to administration (additive)

●Nause/Vomiting common

● Hypotension (60%)

● Hypocalcemia (<1%)

Etoposide (VP-16)

IV, Oral Chemotherapy

Plant alkaloid (Podophyllum) inhibits

topoisomerase II in late s-and

G2-phase

● Metabolized by liver

● 50% urine excretion

● Half-Life = 3-10h

● May alter Warfarin effect

● Theoretically, glucosamine might

induce resistance to etoposide (VP16,

VePesid) by reducing the drugs'

inhibition of topoisomerase II

● MONITOR warfarin.

● N/V (30-40%)


● Alopecia (67%)

● Mucositis, Diarrhea rare

1. Nausea/ vomiting: Ginger, cinnamon

2. Mucositis/ diarrhea: L-Glutamine

10g TID

Exemestane

(see Aromasin)

Steroidal aromatase inhibitor

Femara ● Thrombolytic events 1. Hot flashes

● HMC Hesperidin 250-500 mg tid

9


DRUG Interactions &

Patient Instruction


Interventions

Aromatase Inhibitor

● Mild elevation in serum

transaminases and serum

bilirubin

● Arthralgia

● Myalgia

● Headache

● Fatigue

● Hotflashes

● Gamma Oryzanol 300mg tid.

Filgrastin

(see Neupogen)

Floxuridine (FUDR)

IV Chemotherapy

Metabolized to 5-FU to inhibit DNA

synthesis and repair in the S phase

● 90% hepatic metabolism

● Half-Life = 20h

● Patients should be put on H2

blockers to prevent peptic ulcer

disease while on therapy

● Resistance: Decreased expression

of the activating enzyme,

deoxycytidine kinase, with

diminished formation of fludarabine

triphosphate. Decreased nucleoside

transport of drug.

● Pentostatin—Increased incidence

of fatal pulmonary toxicity when

fludarabine is used in combination

with pentostatin. Use of this

combination is absolutely

contraindicated.

● hepatotoxicity, gastritis,

duodenal ulcer

● N/V/D rare

● Hand Foot Syndrome


Fludarabine (Fludara)

IV Chemotherapy

Antimetabolits, against dividing and

resting cells

●Elimination via urine

● Half-Life = 10-20h

● Allopurinol often given to prevent

hyperuricemia

● Bactrim for immunosupression

● Cytarabine may enhance

antitumor activity

● May enhance activity of

Cyclophosphamide, Cisplatin, and

Mitoxantrone

● Immunosuppression

● Fever: pyrogens from tumor

lysis

● Tumor Lysis

● Myelosupression is dose

limiting: occurs in 10 – 13 days,

recovery by day 14 – 21.

● Autoimmune hemolytic anemia

1. Myelosuppression

● Esberitox

● Astragalus

2. Autoimmune hemolytic anemia

● Fish oil

● Quercetin

● Consider probiotics (EB)

3. Nausea and vomiting: Ginger

10


DRUG Interactions &

Patient Instruction


Interventions

● Nausea and Vomiting

● HSR

● Neurotoxicity

● Opportunistic infection of

Pneumocystitis carni

5-Fluorouracil (5-FU)

IV Chemotherapy

S-phase inhibition of DNA synthesis and

function

● 90% exreted urine, lungs

● Half-Life = 10-20 min

● Avoid B-carotene (Altern Med

Review 1999;4:304-29), One

questionable study about combining

5-FU and beta-carotene

● Avoid high dose folic acid

● Avoid glutathione

● Mucositis, Diarrhea

● Hand-Foot Syndrome



● Gingko may increase drug

delivery, effectiveness: 350 mg

(4caps ac) 30 minutes prior to

infusion (J.Belanger,ND)

● DHA/omega-3 may increase

efficacy, reduce toxicity

● Bromelain increases

effectiveness (see BCQ paper)

● Aloe Vera

● PSK -- improves survival when

used with postoperative adjuvant

chemotherapy for colorectal cancer

with CEA >3 and PPD < 19 mm

(RCT PubMed); PSK 3 g/d – breast

ca in combination with cytoxan

and 5-fu increased survival (RCT

PubMed)

1. Diarrhea/mucositis


● Ice chips in mouth 10min pre/post

● DGL ¼ tsp tid,

● slippery elm

● Glycgel

● oral paste


2. Hand-foot syndrome

● Vitamin B6 50 mg BID

● avoid exposure to heat/cold

● use lotion after washing

3.Neutropenia/thrombocytopenia

● Esberitox

● Astragalus with Legustrum,

4. CNS toxicity


acetyl-L-carnitine, Mg

6. Metallic taste

● Hp. Mercury (excessive salivation,

trembling of the tongue, stringy or

soapy saliva)

● Zn drink

Faslodex (Fulvestrant)

Estrogen Receptor Antagonist

● P450 metabolism

● 90% fecal elimination

● hot flashes 20%

● asthenia

● change in bowel habits

Gemcitabine (see Gemzar)

11


DRUG Interactions &

Patient Instruction


Interventions

Gemzar (Gemcitabine)

IV Chemotherapy

S-phase alterations in RNA processing

and translation

● Excreted in urine

● Half-Life = 30-90 minutes in

infusions <70min, and 4-10h in

infusions >70min

● Radiosensitizer

● Urine color may change

● Alopecia is rare

● Phytoestrogens and soy C/I in

pancreatic ca.

●Gemcitabine and Cisplatin:

Folic acid and B12 may increase

chemosensitivity in patients with

stage IV non-small-cell lung cancer

who are also carriers of the MTHFR

677T allele. (Clin Lung Cancer. 2004

May;5(6):360-5.)

● Diarrhea/ mucositis 15-20%

● N/V mild


● Pneumonitis

● Infusion reaction presents as

flushing, facial swelling, headache,

dyspnea, and/

● Mild proteinuria and

hematuria. In rare cases,

hemolytic-uremic syndrome (HSU)

has been reported.

● Maculopapular skin rash with

pruritis, generally involving the

trunk and extremities.

● Flu-like syndrome

1. Leukopenia

● Esberitox

● Astragalus with Legustrum

2. Nausea and vomiting: Ginger

Gleevac (Imatinib)

Oral Chemotherapy Drug

Tyrosine Kinase Inhibitor

● Half-Life = 18 hours

● CYP3A4 Metabolism

● Fecal Excretion

● Caution with CYP3A4

inhibitors/inducers

● Inhibits metabolism of warfarif so

monitor INR if relevant

● Should be taken with food and full

glass of water to avoid GI irritation

● N/V (40-50%)

● Edema (ankle, periorbital)

● Myalgias


Herceptin (trasuzumab)


Anti-HER-2-antibody

● Half Life = 5-6days

● Minimal Renal/hepatic clearance

● ● Cardiotoxicity (5-7%, increases

to 30% when used with

anthracycline agents)

● Myelosuppression (risk

increased when given with

chemotherapy)

● Myalgias

● Pulmonary Toxicity

12


DRUG Interactions &

Patient Instruction


Interventions

IL-2 (Aldesleukin)

IV Immunotherapy

Binds to IL-2 receptors to enhance

lymphocyte and NK cell activity

● Broken down by Kidneys

● Elimination ½ life: 85 min

● Corticosteroids (reduce effect)

● NSAIDs (capillary leak)

● BP meds (additive effect)

● Melatonin increased tumor

regression better than IL-2 alone

● Flu-like symptoms (fever, chills,

malaise, myalgia observed in all

patients

● Capillary Leak: hypotension,

edema, arrhythmia.

Dose-Limiting.

● Neurologic: delirium, confusion,

cognitive change

L-Carnitine is depleted (AANP notes

2006)

Ibritumomab

(see Zevalin)

Ifosfamide

IV Chemotherapy

Nonspecific cell cycle agent

Alkylating Agent

● Elimination ½ life = 3 – 10 hours, up

to 14 days high dose

● Metabolized by P450

● Cimetidine and allopurinol

increase toxicity, as does cisplatin.

● MONITOR patients on warfarin,

contraindicated in folks with clotting

history

● Fatigue

● Renal/ Bladder toxicity


● N/V- usually w/in 3-6h of txt, up

to 3 days

● Neurotoxicity

● Alopecia (>80%)

1. Fatigue

● L-carnitine 4g/d (PubMed)

2. Renal/ Bladder toxicity

● MUST DRINK 2L WATER DAILY!

3. N/V: ginger, cinnamon

4. Neurotoxicity

● vitamin E, selenium (in multi

preventive)

● alpha-lipoic acid, L-carnitine (if

symptoms)

6. Alopecia (>80%)

● calcitriol

● vitamin E

Iressa, gefitinib

Irinotecan (Camptosar,

CPT-11)

IV Chemotherapy

Alkaloid from Camptotheca acuminate

tree

Cell-cycle nonspecific

● Laxatives should be avoided while

on therapy due to the risk of early

and late diarrhea

● Diarrhea is dose-limiting, can

be within 24h of infusion, or ‘late

diarrhea’ which up to 90%

experience


● Diarrhea

13


DRUG Interactions &

Patient Instruction


Interventions

● Half Life = 8-14 hours

● Primary fecal excretion (10% renal)

Neupogen (Filgrastim)

Colony stimulating factor

● Metabolized in liver and kidney

● Half-Life = 3.5h

● Transient bone pain (25%)

prevented with pre-med

acetaminophen

Oncovin (see Vincristine)

Panitumumab (see Vectibix)

Pemetrexed (see Alimta)

Platinol (see Cisplatin)

Procrit

(see Erythropoietin)

Revlimid

(Lenalidomide)

Unclassified, Analog of Thalidomide

Anti-angiogenic Agent through

inhibition of VEGF, bFBG

Immunomodulatory, stimulates

T-cell, IL-2, and IFNγ proliferation

Elimination ½ Life = 3 hours

66% excreted unchanged by kidneys

● Oral absorption max 60-90min

after ingestion

● Take away from food (food may

reduce maximal plasma

concentration


● Thromboembolic Events

● Nausea, Diarrhea

● Neurotoxicity is rare

Prophylaxis with warfarin or

aspririn is recommended to avoid

thromboembolic events

14


DRUG Interactions &

Patient Instruction


Interventions

Rituxan (Rituximab)

Monocolonal antibody against CD20

Elimination ½ life: 76 hrs

Often combined with CHOP

● Myelosupression

● N/V

● Infusion reaction

● Myalgia, Arthralgia

Dose Limiting Rxns: tumor lysis

syndrome, hep B, HSR, cardiac

arrhythmia, acute renal failure,

mucocutaneous rxn

Sprycel (Dasatinib)

Oral Tyrosine Kinase Inhibitor



● Primary Fecal Excretion

● Antacids: Take 2 hours away from,

as pH is essential to absorption

● Caution with other CYP450 drugs


● Fluid Retention

● N/V/D

● Bleeding Events

Sutent (sunitinib malate)

Oral Multi-Kinase Inhibitor



● Fecal/Renal Excretion

● 50 mg orally once daily, with or

without food, 4 weeks on treatment

followed by 2 weeks off.

● May interact with CYP3A4

inhibitors and inducers

● Discoloration (yellow), and

dryness of the skin

● Diarrhea, Nausea, Dyspepsia

● Fatigue

● High Blood Pressure

Tarceva (Erlotinib)

Oral Chemotherapy

EGFR Tyrosine kinase inhibitor to

inhibit proliferation, angiogenesis


● Fecal, Renal Excretion

● ½ Life = 36h

● Oral availability increased with

food to 100%

● May inhibit P450 enzymes

(caution with warfarin, etc)

● Acneiform rash (treat with

Cleocin gel)

● Diarrhea

● Interstitial Lung disease

1. Rash and diarrhea

● L-glutamine 10g TID

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Interventions

Oral availability increased with food

to 100%

Taxol (Paclitaxel)

Inhibits M-Phase

Antioxidants: increases efficacy

Calcitriol 0.5 mcg/kg/week in

prostate ca and breast ca enhances

taxol effectiveness + prevents from

alopecia

GLA in breast ca enhances

effectiveness, where Omega –3 to

much less extent

Retinoic Acid and Vit D as pretx in

hormone positive breast CA, increase

effectiveness

● Neutropenia: dose limiting

● HSR

● Neurotoxicity

● Transient asymptomatic

bradycardia

● Mucositis and/or diarrhea

● Nausea and Vomiting

● Onycholysis

● Myalgia and Arthralgia

1. Neutropenia

● Esberitox,


2. Neurotoxicity


L-carnitine, L-glutamine

● Acetyl-L-Carnitine 1000mg/kg

analgesic (PubMed)

3. Alopecia: calcitriol

4. Mucositis and/or diarrhea


● DGL ¼ tsp tid

● Slippery elm

● Glycgel and oral paste


5. Nausea and vomiting: Ginger,

cinnamon

6. Myalgia & Arthralgia

● L-glutamine (PubMed)

Taxotere (Docetaxol)

IV Chemotherapy

Inhibits M-phase (Mitosis)

● P450 Metabolism

● Fecal Elimination

● ½ Life = 11h

Typically infused q3wk

● Caution with P450 Drugs , Avoid

CYP3A4 herbs (ginkgo, St. John’s

Wort, Milk Thistle, ginseng, and

others)

● Radiosensitizing

● Patients receive pre-medication

with steroids to reduce fluid retention

and hypersensitivity

● Monitor weight to assess fluid

retention

P450-acting agents.●Quercetin (BCQ) – most in vitro

studies show that quercetin inhibits

conversion of Taxol to its inactive


● Fluid Retention (50%)

● Dry, itchy skin, browning of the

fingernails (50%)

● Alopecia (80%)

● Diarrhea/mucositis (40%)

● Peripheral neuropathy less than

with paclitaxel

1. Myelosuppression :● Esberitox 3 tid

● Astragalus with Legustrum

2. Hand-foot syndrome

(palmar-plantar erythrodysesthesia)

● Vit B6 50 mg BID up to 300 mg QD

● Avoid heat exposure

3. Alopecia: calcitriol

4. Mucositis and/or diarrhea

● L-glutamine 10 g tid,

● DGL ¼ tsp tid

● Slippery Elm

● Glycgel, oral paste


5. Nausea and Vomiting - Ginger ,cinnamon

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Patient Instruction


Interventions

metabolites and also prevents drug

resistance by reducing elimination of

Taxol from CA cells, but 1 study

showed that quercetin inhibits Taxol

apoptosis signaling in breast CA

cells. (PubMed)

6. Peripheral neuropathy

● Vit E

● A-lipoic acid

● Selenium

● L-carnitine

● Mg

7. Generalized fatigue

● L-carnitine 4g/d.

8. Arthralgias and myalgias

● L-glutamine

Temodar (Temozolomide)

Oral Chemotherapy

Alkylating Agent, cell cycle

non-specific, inhibits DNA

●Crosses Blood-Brain Barrier

● Elimination ½ Life = 2 hours

● Renal Excretions

● No formal drug interactions

● Food reduces absorption

● Avoid sun exposure


(dise-limiting)

● N/V (max 1-12h post ingestion)

● HA, fatigue

● Photosensitivity

Vectibix (Panitumumab)


Binds to EGFR

● Elimination ½ Life = 7.5 days


● Limit sun exposure

● Skin/nail-related toxicities

(90%)

● N/V/D

● Fatigue

● Electrolyte Depletion

Velcade (bortezomib)

IV Chemotherapy

Inhibits 26S Proteosome to lead to cell

death


● Not for patients with boron,

mannitol , boron, or bortezomib

Hypersensitivity

●VELCADE is a substrate for

cytochrome P450 3A4, 2C19, and 1A2

● Fatigue, more pronounced

during first 2 cycles

● GI Toxicity (N/V/D)


● Peripheral Neuropathy (mostly

sensory)

● Orthostatic hypotension (12%)

1. Hypotension: Advise on adequate

fluid intake

3. CHF:● Co-q-10

● L-carnitine

● Hawthorn

4. N/V: Ginger, cinnamon

5. Diarrhea or constipation:

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● Half-Life= 9-15 hours

Metabolized by liver P450 system.

Avoid CYP3A4 herbs: gingko, St.

John’s wort, Milk thistle,

Ginsengs and others.

● fiber

● l-glutamine for diarrhea

● 1 whole papaya for constipation

6. Asthenic conditions: Licorice d/t

corticosteroid promoting effects, ginsengs

Vincristine (Oncovin)

M-phase inhibitor


● ½ life = 85 hours

●Avoid CYP3A4 herbs: gingko

inhibits, St. John’s wort, Milk thistle,

Ginsengs and others.

● Bromelain increases effectiveness

(see BCQ paper)

● Constipation

● Neurotoxicity: dose-limiting

toxicity

● Syndrome of inappropriate

secretion of antidiuretic hormone

(SIADH).

● Myelosuppression. Generally

mild and much less significant

than with vinblastine

● Alopecia, skin rash, and

fever.

1. Constipation

● stool softeners

● high-fiber

2. Neurotoxicity

● Vit E

● a-lipoic acid

● selenium

● L-carnitine

● L-glutamine

3. Myelosuppression.

● Esberitox


Xeloda (Capecitabine)

Oral Chemotherapy

Converted to 5FU in liver and tumor

tissues resulting in cell death

● Metabolized in liver

● Excreted by kidneys

● Half-Life= 45 minutes

● Warfarin – monitor PT/INR

● Antacids – aluminum/magnesium

hydroxides may increase

bioavailability of Xeloda by 35%

● Phenytoin – may require dose

adjustment

● Leucovorin – when given before

Xeloda, increases efficacy and toxicity

Take with water, 30 minutes after a

meal.

● B6+B12+folic acid to increaseeffectiveness, since drug resistance may occurwith decreased levels of MTH-folate● PSK 3 g/d with tegafur/uracil (UFT) {oralequivalent to 5-fu} in stage II and III colorectalca increased survival and decreased recurrenceor mets (many RCTs PubMed)

● Diarrhea (40%)

● Hand-Foot Syndrome (15-20%),

(often treated with B6 (50-100mg),

celecoxib, nicotine patch, and bag

balm)

● Myelosuppression, Elevated

bilirubin

1. Hand-Foot Syndrome:

● Vit B6 50 mg BID up to 300 mg QD

to prevent hand foot syndrome

● Hand soaks, lotions, All purpose

salve topically

● Avoid exposure to heat

2. GI Toxicity (mouth sores,

diarrhea):

● L-glutamine to prevent GI

toxicity, mouth sores and diarrhea.

● DGL

● Glycgel

● Oral paste

● Slippery Elm,

● Vit E

● L-lysine 1g bid-tid for mouth sores

and heartburn.

3. Nausea: Ginger tea or capsules.

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Patient Instruction


Interventions

Zevalin

(Ibritumomab)

Monoclonal Antibody

Linked to Yttrium-90

● Half-Life = 30h

● Premedication with

acetaminophen and benadryl

● Contraception should be used for

12mo after therapy

● Myelosupporession (30%

infection rate in 3 mo following)

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DRUG Interactions &

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Interventions

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Chemotherapy & Medical Agents Used to Treat Cancer

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Transcript of Chemotherapy & Medical Agents Used to Treat Cancer