Oral Oncolytics for Lung Cancer

Oral Oncolytics for Nonsmall Cell Lung
Cancer
Erlotinib
Crizotinib
Afatinib
3 types of Nonsmall Cell Lung Cancer
• Squamous Cell Carcinoma
• Large Cell Carcinoma
• Adenocarcinoma
Adenocarcinoma
• Most common type
• Represents 40% of all lung cancer cases
• Women and younger people
• Found in outer regions of the lung
Squamous Cell
• Occurs in cells that line the airways
• 25 to 30% of all lung cancer cases
• Found in middle of the lungs near a large airway
Large Cell Carcinoma
• Accounts for 10 to 15% of all lung cancer
cases
• Grows and spreads fast
• Appears anywhere in the lung
Treatment Options
• Surgery
• Radiation
• Chemotherapy
• Biomarker Driven Therapy
To Test or Not To Test?
EFGR
ALK Fusion Gene
Erlotinib
• First line treatment
• Maintenance treatment
• 2nd line treatment
• 3rd line treatment
Common Side Effects
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Rash
Diarrhea
Cough
Shortness of Breath
Loss of Appetite
Other skin changes (itchy dry skin; brittle nails, redness around nails)
Serious Side Effects
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Interstitial Lung Disease
Liver or Kidney Disease
GI Perforations
Blood or clotting issues
Erlotinib Access
Access Solutions
• Emails patients at key intervals
• 24 hour phone support 7 days per week
• Free brochures
Limited Distribution
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Acaria Health
Accredo
Advanced Care Script
Aetna Specialty
Amber Pharmacy
Avella Specialty
Axium
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Biologics
Bioplus Specialty Pharmacy
Caremark
Caremed
Cigna Tel Drug
Commerce Pharmacy
Curascript Specialty
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Diplomat Specialty Pharmacy
Exactus Pharmacy Solutions
Icore Healthcare, LLC
Mission Road Pharmacy
Oncology RX Care Advantage
Oncomed
• OncoSourceRx
• Optum Rx
• Prime Therapeutics Specialty
Pharmacy
• RightSoure Specialty Pharmacy
• TNH Specialty Pharmacy
Dose Adjustments
• Discontinue dose
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ILD
Severe Hepatic Toxicity
GI Perforation
Severe Skin Conditions
Corneal Perforation
• Withhold Therapy
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Diagnostic evaluation for ILD
Severe Renal Toxicity
Preexisting Hepatic Impairment
Persistent Diarrhea
Severe Rash
Keratitis of Grade 3 or 4
Worsening Ocular Disorders
• Reduce Dosage in 50 mg
increments
• Restarting following withholding
treatment due to toxicity
• Concomitant use of other meds that
are strong CYP450 3A4 Inhibitors
• Increase Dosage by 50mg
Increments
• Cigarette smoking
• Concomitant Use of other meds that
are strong CYP450 3A4 Inducers
Drug Interactions
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Rifampin
Hifalutin
Rifapentine
Phenytoin
Carbamazepine
Phenobarbital
St John’s Wort
Atazanavir
Clarithromycin
Indinavir
Itraconazole
Ketoconozole
Nefazodone
Nelfinavir
Ritonavir
Saquinavir
Telithromycin
Voriconazole
Crizotinib
• Treatment of Patients with Metastatic NonSmall Cell Lung Cancer whose tumors are
anaplastic Lymphoma Kinase-(ALK)-Positive
as detected by an FDA-approved test
Common Side Effects
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Vision Problems
Nausea
Diarrhea
Vomiting
Constipation
Swelling of hands and feet
Feeling tired
Serious Side Effects
• Liver Problems
• Lung Problems
• Heart Problems
Crizotinib Access
• Pfizer First Resource Program
• Copay assistance
• Uninsured or Underinsured Patient Support
Limited Distribution
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US Bioservices
Curascripts
Walgreens Specialty
Accredo Specialty Pharmacy
CVS Caremark Specialty Pharmacy
Drug Interactions
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Blood Thinners such as warfarin
Cyclosporine
Dexamethasone
• Antibiotics such as clarithromycin, erythromycin,
rifabutin, rifampin, rifapentine
• Antidepressants such as citalopram, desipramine,
doxepin, escitalopram, mirtazapine, nefazodone,
sertraline, trazodone, trimipramine or Venlafaxine
Digoxin
Isoniazid
Nicardipine
Pimozide
St John’s Worts
Theophylline
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Antifungal medications
Barbiturates
Ergot Medicines
Heart Rhythm Medications
Antivirals
Seizure Medications
Dose Modifications
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Hematologic Toxicities
Nonhematologic Toxicities
Pneumonitis
Grade 3 QTc Prolongation
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Grade 4 QTc Prolongation
Bradycardia
Renal Impairment
Hepatic Impairment
Afatinib
• Kinase Inhibitor indicated for first line treatment of patients with metastatic
non-small cell lung cancer whose tumors have epidermal growth factor
receptor exon 19 deletions or exon 21 (L858R) substitution mutations as
detected by an FDA-Approved test
• Studies proving 2nd and 3rd line treatment for patients with advanced
metastatic non-small cell lung cancer after failures of Tarceva, Iressa and one
or two lines of Chemotherapy
Common Side Effects
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Diarrhea
Rash/dermatitis
Stomatitis
Dry skin
Decreased appetite
Pruritus
Dose Modifications
Withhold Dose
• Toxicity of Grade 3 or higher
• Diarrhea Grade 2
• Cutaneous Reactions
• Renal Dysfunction
Permanently Discontinue
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Life Threatening Bullous or skin lesions
Confirmed ILD
Severe Drug Induced Hepatic Impairment
Persistent Ulcerative Keratitis
Symptomatic Left Ventricular Dysfunction
Severe or intolerable Adverse Reaction
occurring at a dose of 20mg/day
Dose Modifications
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Coadministration with P-gp Inhibitors-reduce dose by 10mg
Coadministration with P-gp Inducers- Increase dose by 10mg
Moderate to Severe Renal Impairment
Hepatic Impairment
Drug Interactions
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Ritonavir
Cyclosporine
Ketoconozole
Itraconazole
Erythromycin
Verapamil
Quinidine
tacrolimus
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Nelfinavir
Saquinavir
Amiodarone
Rifampin
Carbamazepine
Phenytoin
Phenobarbital
St John’s Wort
Afatinib Access
• Provide Quick and affordable
access
• Patient Education Support
• Single dedicated Specialty
Pharmacy, Accredo
• Copay Support
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Solutions Plus Nurse Support
Dose Exchange
Patient Care Advocate
Patient Support Kit
11 Tips to Help You Think More Positively
• Believe in Yourself
• Set Clear Goals
• Form a Mental Picture of Your
Success
• Take Ownership and Responsibility for
Your Life
• Talk to Yourself
• Eliminate the Negative
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Associate with the Positive People
Count Your Blessings
Find the Silver Lining
Relax and Enjoy Life More
Fake It
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