7/17/2017

1

FSHP 2017 ANNUAL MEETING

Inpatient Management of Oncology Specialty DrugsInpatient Management of Oncology Specialty DrugsNew Agents, Opportunities, and ChallengesJennifer Swank, PharmD, BCOP

2017 ANNUAL MEETING

#FSHP2017DisclosureDisclosureDo not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation

2017 ANNUAL MEETING

#FSHP2017Pharmacist ObjectivesPharmacist Objectives• Identify common toxicities of oral oncology therapies in

the internal medicine patient• Describe management of oral oncology therapy toxicity

balanced with internal medicine complications• Discuss the identification and treatment of immune

related adverse events in the internal medicine patient

2017 ANNUAL MEETING

#FSHP2017Technician ObjectivesTechnician Objectives• Recognize oncology therapies by brand/generic name• Identify storage and dispensing issues with these

medications• Apply proper disposal techniques for these medications

in daily practice

2017 ANNUAL MEETING

#FSHP2017Vascular Endothelial Growth Factor (VEGF)Vascular Endothelial Growth Factor (VEGF)• Glycoprotein that activates intracellular signaling by

binding to VEGF receptor• Key role in the maintenance of vascular homeostasis

• Mediation of the production of vasodilator nitric oxide• Decreased vascular resistance trough the generation of new

blood vessels• VEGF inhibition

• Prevention of angiogenesis • Promotion of apoptosis• Causes endothelial dysfunction and increased endogenous

sFlt1 and endothelin-1 production

References: Brinda BJ, et al. Curr Treat Options Cardio Med 2016; 18(33): 1-16. 2017 ANNUAL MEETING

#FSHP2017Inhibiting Tyrosine Kinase SignalingInhibiting Tyrosine Kinase Signaling

References: Chen, MH, etal. Circulation 2008; 118: 84-95.

7/17/2017

2

Agent Indication Incidence of all grade HTN Other Cardiotoxicity

Bevacizumab (Avastin®) Cervical, ovarian, colorectal, NSCLC, RCC, GBM 22-24% Thrombosis

Sunitinib (Sutent®) GIST, PNET, RCC 15-34% HF

Sorafenib (Sorafenib®) HCC, RCC, Thyroid 17-29% ACS, HF

Axitinib (Inlyta®) RCC 40% Thombosis

Pazopanib (Votrient®) RCC, Soft tissue sarcoma 36-46% ACS, HF

Levantinib (Lenvima®) RCC, Thyroid cancer 73% QTC changes, thrombosis, CHF

Ziv-afibercept (Zaltrap®) Colorectal cancer 41% Thrombosis

Regorafenib (Stivarga®) Colorectal cancer, GIST 28-48.5% ACS

Ramucirumab (Cyramza®) Colorectal cancer, Gastric, NSCLC 16% Thrombosis

Vandetanib (Caprelsa®) Medullary thyroid cancer 33% QTC changes

Cabozantinib (Cometriq®) Thyroid cancer 32-37% ThrombosisReferences: Brinda BJ, et al. Curr Treat Options Cardio Med 2016; 18(33): 1-16. Key: Non Small Cell Lung Cancer (NSCLC), Renal Cell Carcinoma (RCC), Gleoblastoma multeforme (GBM), Gastrointestinal Stromal tumor (GIST), Pancreatic neuroendocrine tumor (PNET), Acute lymphoblastic leukemia (ALL), Chronic myelogenous leukemia (CML), Myelodysplastic syndrome (MDS)

VEGF Induced HTN

Set BP goal & implement lifestyle interventions

Initiate ACEs, ARB, or dihydrophyridine CCB

-Reinforce medication & lifestyle adherence

- Titrate doses of initial medications to max - Add & titrate second agent- If BP not controlled consider adding medication of other class (thiazide, b-blocker)

At BP Goal

Consider therapy with long acting NO donors

At BP Goal

Consider dose reduction or cessation of VEGF therapy

Initiate ACE or ARB

At BP Goal

Yes

Continue current treatment & monioring

Diabetes, Proteinuria or CKDGeneral Population

No

No

No

Yes

Yes

2017 ANNUAL MEETING

#FSHP2017VEGF Toxicity Management VEGF Toxicity Management • Rash: severe dermatologic toxicity rare• Diarrhea: maintain appropriate hydration and treat

symptomatically• Myocardial infarction: use with caution in patients with significant

cardiac history• Thrombosis: monitor for symptoms of clots and treat if identified• Heart Failure: monitor for symptoms of HF or EF reduction, if

symptoms obtain ECHO and discontinue therapy if EF <50% or 10% in baseline EF

• QTC prolongation: baseline EKG, maintain appropriate electrolyte levels, hold therapy if QTC >500msec

• Thyroid abnormalities: order labs if symptoms of hypothyroidism• Many drugs with CYP drug interaction be aware

2017 ANNUAL MEETING

#FSHP2017Bevacizumab (Avastin®)Bevacizumab (Avastin®)• Impaired wound healing

• Discontinue therapy at least 28 days prior to surgery and continue to hold for 28 days post surgery and until wound is healed

• Thromboembolism• Risk factors include h/o of thrombosis, diabetes, >65 years of age

• GI perforation• Higher incidence with tumors involving the bowel

• Hemorrhage• Avoid use in patients with recent hemorrhage or hemoptysis

• Proteinuria/nephrotic syndrome• Withhold treatment for ≥2g proteinuria/24 hours, discontinue if nephrotic

syndrome

2017 ANNUAL MEETING

#FSHP2017Toxicity Monitoring and ManagementToxicity Monitoring and Management• Thromboembolic events• Myocardial infarction• Left ventricular dysfunction• Heart failure (HF)• QT interval prolongation

•BTK: Bruton’s tyrosine kinase, CML: Chronic Myelogenous Leukemia, CLL: Chronic lymphocytic lymphoma , FNHL: Follicular Non-Hodgkin’s Lymphoma, GIST: Gastrointestinal Stromal Tumors, HES: Hypereosinophilic Syndrome MCL: Mantle cell lymphoma, MDS: Myelodysplastic Syndrome PDGFR: Platelet Derived Growth Factor Receptor, SLL: Small Lymphocytic Lymphoma

Drug Indication Toxicity Monitoring

Bosutinib (Bosulif®) CML N/V

Dasatinib (Sprycel®) CML, ALL Pleural effusion, pulmonary arterial HTN CXray

Ibrutinib (Imbruvica®) CLL, MCL, WaldenstromsMacroglobulinemia

lymphocytosis, Afib, bleeding

Idelaisib (Zydelig®) CLL, SLL, FNHL Lymphocytosis, hepatotoxicity Monitor for infections

Imatinib (Gleevac®) ALL, CML, GIST, HES, MDS N/V

Nilotinib (Tasigna®) CML QTC prolongation ECG baseline & electrolytes

Panobinostat (Farydak®) MM Diarrhea, EKG changes EKG baseline

Ponatinib (Iclusig®) MM MI/Stroke Prevention with ACE I & ASA

Ruxolitinib (Jakafi®) Myelofibrosis, PCV QTC prolongation, blood counts EKG baseline & labs

Venetoclax (Venclexta®) CLL Tumor lysis syndrome CMP uric acid and LDH

Vorinostat (Zolinza®) Cutaneous T cell lymphoma Reduced blood counts

2017 ANNUAL MEETING

#FSHP2017Mammalian Target of Rapamycin (mTOR) InhibitorsMammalian Target of Rapamycin (mTOR) Inhibitors• mTOR pathway plays a central role in the control of the

growth of cells• When activated it induces mRNA transcription and

translation of numerous proteins stimulating cell cycle progression, division, and inhibiting apoptosis

• mTOR inhibitors halt cell cycle at G1 phase and blocking downstream phosphorylation of ribosomal proteins; exhibits anti-angiogenesis activity by reducing levels of hypoxia inducible factors (HIF) and VEGF

References:.

7/17/2017

3

2017 ANNUAL MEETING

#FSHP2017Mammalian Target of Rapamycin (mTOR) InhibitorsMammalian Target of Rapamycin (mTOR) Inhibitors

References: Everolimus prescribing informaton 2017 ANNUAL MEETING

#FSHP2017mTOR Inhibitor ToxicitymTOR Inhibitor Toxicity• Drugs• Temsirolimus (Torisel®)• Everolimus (Afinitor ®)• Electrolyte abnormalities

• Hypokalemia, hypomagnesemia, hypophosphatemia

• Hyperglycemia• Hypercholesterolemia• Mucositis• Interstitial pneumonitis

• Monitor for respiratory symptoms and start inhaled corticosteroids• Treatment Prednisone 40mg daily and taper by 10mg every 2 weeks• Perminately discontinue mTOR therapy

References: Martins F, et al. Oral Oncology 2013;49:293-98. Annelieke EC, et al. Int J Cancer 2016; 138: 2312-21.

2017 ANNUAL MEETING

#FSHP2017

Immuno-Oncology: The Pharmacist Perspective

Immuno-Oncology: The Pharmacist Perspective

2017 ANNUAL MEETING

#FSHP2017T Cell Antitumor ResponseT Cell Antitumor Response

References: Andersen MH, et al. J Invest Dermatol 2006; 126(1):32-41; Pardoll DM. Nat Rev Cancer 2012; 12(4):252-64; Mellman I, et al. Nature 2011; 480(7378):480-9; Heemskerk B, et al. EMBO J 2013; 32(2):194-203; Boudreau JE, et al. Mol Ther 2011; 19(5):841-53

Tumor antigens released bytumor cells

Tumor antigens presented to T cells T cells are

activated and proliferate

T cells recognize tumor antigens

T cells kill tumor cells

1

4

23

5

2017 ANNUAL MEETING

#FSHP2017Tumor Mechanism to Evade Immune SystemTumor Mechanism to Evade Immune System

References: Drake CG, et al. Adv Immunol 2006; 90:51-81; Vesely MD, et al. Annu Rev Immunol 2011; 29:235-71.

(e.g., T-reg)

(e.g., TGF-B)

(e.g., down-regulation of MHC I)

(e.g., disruption of T cell checkpoint pathways)

Inhibition of tumor antigen presentation

1

Secretion of immunosuppressive factors

2

Inhibition of attack by immune cells

3

Recruitment of immunosuppressive

cell types

4

APCTumor Cell

T-regActivated

T cell

2017 ANNUAL MEETING

#FSHP2017T-Cell Checkpoint RegulationT-Cell Checkpoint Regulation• T-cell responses are regulated

through a complex balance of inhibitory (“checkpoint”) and activating signals

• Tumors can dysregulate checkpoint and activating pathways, and consequentlythe immune response

• Targeting checkpoint and activating pathways is an evolving approach to cancer therapy, designed to promote an immune response

References: Mellman I, et al. Nature 2011; 480(7378):480-9; Pardoll DM. Nat Rev Cancer 2012; 12(4):252-64

PD-1

CTLA-4

Inhibitory receptors

Activating receptors

TIM-3

LAG-3

Antagonistic (blocking) antibodies

Agonistic antibodies

T-cell stimulation

CD28

OX40

CD137

7/17/2017

4

2017 ANNUAL MEETING

#FSHP2017Mechanism of Action of Checkpoint InhibitorsMechanism of Action of Checkpoint Inhibitors• Anti-PD-1 therapies are designed to bind to PD-1 on activated T

cells in tumor microenvironment, Anti-CTLA-4 agents are designed to act by binding to CTLA-4 on activated T cells in the lymph nodes.

References: Wolchok J, et al. J Clin Oncol 31, 2013 (suppl; abstr 9012^); Wolchok JD, et al. New Engl J Med 2013; 369(2):122-33

2017 ANNUAL MEETING

#FSHP2017Available AgentsAvailable Agents• Cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibitor

• Ipilimumab (Yervoy®)• Programmed cell death-1 (PD-1) inhibitors

• Nivolumab (Opdivo®)• Pembrolizumab (Keytruda®)

• Programmed cell death ligand-1 (PDL-1) inhibitors• Atezolizumab (Tecentriq®)• Avelumab (Bavencio®)• Durvalumab (Imfinzi®)

References:.

2017 ANNUAL MEETING

#FSHP2017Toxicity of Checkpoint InhibitorsToxicity of Checkpoint Inhibitors• Therapies designed to enhance the patient’s immune

response against the tumor can result in novel spectrum of adverse events arising from the activation of the immune system

• Termed “immune related adverse events (IrAEs)• May be due to cytokine release by activated T cells• May be unfamiliar to clinicians• Can be serious and potentially fatal• Requires prompt recognition and treatment• Requires education of the patients and healthcare team

References:

Skin•Skin rash or pruritus

Hepatic•Abnormal LFTs (e.g., AST, ALT, total bilirubin)

Renal•Abnormal SCR

Gastrointestinal•Diarrhea•Stomach pain •Nausea/vomiting/pain

•Blood in stool •Constipation

Endocrine•Headache •Visual changes •Fever •Fatigue/weakness •Confusion

Pulmonary•SOB on excertion•Hypoxia•Cough

Neurologic•Sensory or motor neuropathy

•Muscle weakness •Fatigue •Difficulty waking up

2017 ANNUAL MEETING

#FSHP2017Role of PharmacistRole of Pharmacist• Understanding irAEs:

• Diarrhea is common with CTLA-4 inhibitors but less common with PD-1/PDL-1 therapies

• Rash is common, but severe dermatitis is not• Endocrinopathies, hepatitis, and nephritis are uncommon• Infusion reactions are very rare• Pneumonitis and neurologic toxicities are very rare

• Early recognition of irAEs• Familiarity with side effects of newer therapies• Awareness of timing/onset of irAEs to ensure quick diagnosis

and prompt initiation of treatment• irAEs are dose-dependent, schedule-related, and

cumulative• irAEs are correlated with response

Referenc es: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7; Tarhini A. Scientifica (Cairo) 2013; 2013:857519

2017 ANNUAL MEETING

#FSHP2017Kinetics of irAEsKinetics of irAEs

References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7.

Rash, pruritisLiver toxicityDiarrhea, colitisHypophysitis

Toxi

cit

y g

rad

e

0 2 4 6 8 10 12 14

Weeks

7/17/2017

5

2017 ANNUAL MEETING

#FSHP2017Early Diagnosis and ManagementEarly Diagnosis and Management

Immune-related adverse

reactions

Result from increased or

excessive immune activity

Patient education for early recognition

Systemic high-dose corticosteroids*

may be required for severe events

Unless an alternate etiology

has been identified,

consider all signs and symptoms

Can be severe or life-threatening;

may involve various organs

Early diagnosis and appropriate management is

essential to minimise

life-threatening complications

2017 ANNUAL MEETING

#FSHP2017Guidelines for irAE TreatmentGuidelines for irAE Treatment

FOLLOW-UPResolved or improved to

grade 1

• Continue immunotherapy if grade 1 or 2 toxicity once steroids tapered to ≤ 10mg/day Prednisone equivalent

Ongoing symptoms

• If symptoms persist, treat as per organ-specific irAE algorithm

• If no improvement or in severity, permanently discontinue immunotherapy

Assess symptoms and

grade appropriately via CTAE 4 guidelines

Gra

de

3 &

gra

de

4

Gra

de

2

Treatment

• Follow organ-specific irAE guidelines

irAE MANAGEMENT

Gra

de

1

Don’t forget:GI prophylaxis for long-term steroid useConsider PCP prophylaxis for long-term high-dose steroid use

2017 ANNUAL MEETING

#FSHP2017Cutaneous Toxicity ManagementCutaneous Toxicity Management• Symptoms: erythematous and/or maculopapular rash,

dry skin, pruritus, vitiligo, blisters, ulceration, bullae, necrotic or hemhorrhagic lesions

References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)<10% BSA

Moderate (Grade 2)10-30% BSA

Severe (Grade 3 /4)>30% BSA, blisters, ulceration, bullae, necrotic or hemhorragic

lesions, TEN

Treat symptomatically: topical moisturizers, topical/oral antihistamines, antipruritic agents

Consider hospitalization, dermatology consult and biopsyConcern for secondary infection start empiric antibioticsMethylprednisolone IV 1-2 mg/kg/dayConcern for TEN, DRES, or SJS need burn unit careIf symptoms improve then 4-6 week steroid taperDiscontinue immunotherapy

Treat symptomatically as above Topical steroids (hydrocortisone/triamcinolone)Persistent symptoms 1-2 weeks then start Prednisone 0.5 mg/kg/day 2-3 week steroid taper if responds to <grade 1Persists or worsens treat as Grade 3 /4

2017 ANNUAL MEETING

#FSHP2017Gastrointestinal Toxicity ManagementGastrointestinal Toxicity Management• Symptoms: changes in bowel habits, abdominal pain,

blood or mucus in stool, nausea • Rule out other causes (ie. Infection)

References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)Diarrhea <4 stools/dayColitis asymptomatic

Moderate (Grade 2)Diarrhea 4-6 stools/day

Colitis: abd pain, blood in stool

Severe (Grade 3 /4)Diarrhea ≥ 7 stools/day, need for IVF, interfering with ADL

Colitis: severe abd pain, ileus, or peritoneal signs

Treat symptomatically: Imodium 4mg at onset of loose stool & 2mg after each loose stool (max 16mg/day)Lomotil #2 tabs po every 6 hours as needed

Hospitalization, strict NPO, CT Abd/pelvis, consider GI Endoscopy consult or GI surgery consult if peritoneal signsMethylprednisolone IV 2 mg/kg/dayIf symptoms improve then 4-6 week steroid taperIf symptoms persist >3 days or relapse with steroid taperInfliximab 5mg/kg IV x 1 dose (may repeat in 1 week if symptoms persist)• Discontinue immunotherapy

Treat symptomatically as abovePersistent symptoms >3 days then start Prednisone or IV Methylprednisolone 0.5-1mg/kg/day 2-4 week steroid taper if responds to <grade 1Persists or worsens treat as Grade 3

2017 ANNUAL MEETING

#FSHP2017Pulmonary Toxicity ManagementPulmonary Toxicity Management• Symptoms: new/worsening cough, dyspnea, or chest pain• Rule out other causes (ie. Infection, COPD exacerbation, PE)• High resolution CT scan of chest or CT angiogram

Activities of daily living (ADL) References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)Asymptomatic radiographic

changes only

Moderate (Grade 2)Cough, shortness of breath but

does not interfere with ADL

Severe (Grade 3 /4)Severe shortness of breath

limiting ADL, hypoxia, oxygen needed

Delay treatment and monitor symptoms every 2-3 daysRe-image at least every 3 weeks

Hospitalization, infectious disease and pulmonary consultsInitiate empiric antibiotic therapyMethylprednisolone IV 2-4 mg/kg/dayIf symptoms improve then 4-6 week steroid taperIf symptoms persist >48 hours or relapse with steroid taperInfliximab 5mg/kg IV x 1 dose (may repeat in 1 week if symptoms persist)• Discontinue immunotherapy

Hold treatment and consider hospitalizationPrednisone po or Methylprednisolone 1mg/kg/dayInitiate empiric antibiotic therapyInfectious disease and pulmonary consults 4 week steroid taper if responds No improvement re-image and treat as Grade 3 /4

2017 ANNUAL MEETING

#FSHP2017Neurologic Toxicity ManagementNeurologic Toxicity Management• Symptoms: neuropathies, myopathy, severe refractory

constipation, aseptic meningitis, Guillain-Barre syndrome, motor neuropathy, myasthenia gravis

Activities of daily living (ADL) References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)Asymptomatic or neuropathy

Moderate (Grade 2)Moderate symptoms limiting ADL

Severe (Grade 3 /4)Limiting self-care ADL or life-

threatening

Monitor and continue therapyIf worsens treat as grade 2 or grade 3 /4

Hospitalization, neurology or neuro-oncology consultsMRI brain/spine, LP with cytology, infectious work-upMethylprednisolone IV 4 mg/kg/dayIf symptoms improve then 6 week steroid taperIf symptoms persist or atypical presentation IVIG 400mg/kg/day x 5 days, if responds to therapy then 6 week steroid taper; no improvement consider plasmapheresis• Discontinue immunotherapy

Hold treatment and consider hospitalizationPrednisone po or Methylprednisolone 1mg/kg/dayConsider neurology consultImproves < grade 1 2-4 week steroid taper and may restart therapyNo improvement or persistent symptoms treat as Grade 3 /4

7/17/2017

6

2017 ANNUAL MEETING

#FSHP2017Endocrine Toxicity ManagementEndocrine Toxicity ManagementAE management

• Taper HD steroid over a minimum of 4 weeks

• Continue HRT as needed• Monitor endocrine labs as appropriate• Repeat MRI as clinically indicated

• Rule out other etiologies• Repeat endocrine labs in 1-3 weeks• Initiate frequent patient follow-up

• Initiate short course (7 days) of HD corticosteroids to reverse inflammation, dexamethasone 4 mg every 6 hours or equivalent

• Initiate HRT to manage endocrinopathy• Consult endocrinologist

Long-term follow-up

Improvement

Determine causeand severity

No

Abnormalworkup?

Yes

Signs and symptomspresent

Suspectadrenal

crisis?

No

Yes

Performance workup

1. Imaging for evidence of disease progression

2. Check endocrine labs (i.e., TSH, free T4, ACTH)

3. MRI head with pituitary cuts plus visual field testing, if appropriate

4. Obtain endocrine consult and medical monitor consult

Treat adrenal crisis

Rule out sepsis

Signs and symptoms suggestive of underlying

endocrinopathy

Hypophysitis, headache, visual field defects, fatigue, weakness, asthenia, failure to thrive, anorexia, nausea

and vomiting, lethargy, impotence, amenorrhea,

fever, coma, new-onset atrial fibrillation,

hypotension, hypoglycemia,

hyponatremia, eosinophilia

2017 ANNUAL MEETING

#FSHP2017Hepatic Toxicity ManagementHepatic Toxicity Management• Symptoms: yellowing of skin or whites of eyes, severe nausea/

vomiting, pain in right side of abdomen, drowsiness, dark urine, bleeding or bruising more than normal, feeling less hungry

• Evaluate other causes: medications, infection, progression of disease

Activities of daily living (ADL) References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)AST/ALT <3 x ULN &/or Tbili <1.5 x ULN or <2 x baseline

Moderate (Grade 2)AST/ALT 3 to ≤5 x ULN &/or Tbili >1.5 to ≤3 x ULN or ≥2 x baseline

Severe (Grade 3 /4)AST/ALT >5 x ULN &/or Tbili >3

x ULN r >3 x baseline

Monitor liver function 1 to 2 times weeklyContinue therapyIf worsens treat as grade 2 or grade 3 /4

Hospitalization, CT abd/pelvis, autoimmune workup, daily liver function monitoring, hepatology and gastrointestinal endoscopy consults, consider liver biopsyMethylprednisolone IV 2-4 mg/kg/dayIf symptoms improve then prednisone 2mg/kg and 6 week steroid taperNo response in 3-5 days then mycophenolate mofetil 1gm po BID; no response in additional 3-5 days consider IVIG 400mg/kg IV daily x 5 days

Hold immunotherapy and monitor liver function every 3 daysConsider CT abd/pelvisNo improvement in 3 days consider hospitalization Prednisone 0.5mg/kg/day; twice weekly LFTReturn to grade 1 or baseline taper steroids over 4 weeksWorsen or no response treat as grade 3/ 4

2017 ANNUAL MEETING

#FSHP2017Renal Toxicity ManagementRenal Toxicity Management• Evaluate for other causes: recent IV contrast, medications,

fluid status, etc

Activities of daily living (ADL) References: Weber JS, et al. J Clin Oncol 2012; 30(21):2691-7., Eigentler TK, et al. Cancer Treatment Reviews 2016; 45:7-18.

Mild (Grade 1)SCr increase >0.3mg/dL; SCr

1.5-2 x above baseline

Moderate (Grade 2)SCr level 2-3 x above baseline

Severe (Grade 3 /4)SCr >3 x baseline or >4 mg/dL

OR dialysis indicated

Monitor SCr weekly and continue therapyIf worsens treat as grade 2 or grade 3 /4

Hospitalization, renal panel daily, nephrology consult, consider renal biopsyMethylprednisolone IV 1-2 mg/kg/dayIf symptoms improve then 6 week steroid taperIf elevations persist >5 days Infliximab 5mg/kg x 1 dose (may repeat in 1 week if elevations persist)

Hold treatment, monitor SCr every 3 days, nephrology consult, and consider renal biopsyPrednisone po 1mg/kg/dayImproves < grade 1 4 week steroid taper and may restart therapy once <10mg/day prednisone equivalentNo improvement in >7 days treat as Grade 3 /4

FSHP 2017 ANNUAL MEETING

Inpatient Management of Oncology Specialty DrugsInpatient Management of Oncology Specialty DrugsNew Agents, Opportunities, and ChallengesJennifer Swank, PharmD, BCOP