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 • • • • • • Rash Diarrhea Cough Shortness of Breath Loss of Appetite Other skin changes (itchy dry skin; brittle nails, redness around nails) Serious Side Effects • • • • 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 • • • • • • • Acaria Health Accredo Advanced Care Script Aetna Specialty Amber Pharmacy Avella Specialty Axium • • • • • • • Biologics Bioplus Specialty Pharmacy Caremark Caremed Cigna Tel Drug Commerce Pharmacy Curascript Specialty • • • • • • 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 • • • • • ILD Severe Hepatic Toxicity GI Perforation Severe Skin Conditions Corneal Perforation • Withhold Therapy • • • • • • • 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 • • • • • • • 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 • • • • • • • 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 • • • • • US Bioservices Curascripts Walgreens Specialty Accredo Specialty Pharmacy CVS Caremark Specialty Pharmacy Drug Interactions • • • • • • • • • 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 • • • • • • Antifungal medications Barbiturates Ergot Medicines Heart Rhythm Medications Antivirals Seizure Medications Dose Modifications • • • • Hematologic Toxicities Nonhematologic Toxicities Pneumonitis Grade 3 QTc Prolongation • • • • 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 • • • • • • 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 • • • • • • 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 • • • • 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 • • • • • • • • Ritonavir Cyclosporine Ketoconozole Itraconazole Erythromycin Verapamil Quinidine tacrolimus • • • • • • • • 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 • • • • 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 • • • • • Associate with the Positive People Count Your Blessings Find the Silver Lining Relax and Enjoy Life More Fake It Comments
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