Written By: Chris Sellers, RPh Area Manager, Texas Oncology
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The purpose is to provide management of common adverse events, follow-up with patients and dose modifications. Dose adjustments are common and greatly reduced frequency and severity of adverse reactions. In Lux-Lung 3, 43% maintained the 40mg starting dose, 38% reduced to 30mg and 19% further reduced to 20mg. Progression free survival remained consistent in patients with or without dose adjustments.
Background Afatinib is indicated for the first-line treatment of EGFR positive (exon 19 or exon 21) metastatic non-small cell lung cancer (NSCLC). In addition, it is also indicated for the treatment of patients with metastatic squamous NSCLC progressing after platinum-based chemotherapy. Proper follow up including patient assessment is essential when new patients start on therapy. An increase number of patient touches are needed to ensure patients are being managed properly and are dose reduced appropriately. Weekly follow ups are ideal to assess adverse events.
PQI Process
Day 1 – Initial Patient Counseling
- Educate patients that adverse events, especially diarrhea and rash/acne are expected and reassure patients that dose modifications are common
- Provide patients with loperamide. Advise patients to take loperamide and call the office at the onset of diarrhea and instruct patients to continue anti-diarrheal until loose stools cease for 12 hours
- Advise patients to call office at the onset and to minimize sun exposure with protective clothing and use of sunscreen due to cutaneous reactions ( rash, erythema, acneiform rash and palmar-plantar erythrodysesthesia syndrome)
- Advise patients to immediately report any new or worsening lung symptoms, or any combination of the following symptoms: trouble breathing or shortness of breath, cough, fever
- Advise patients to immediately report any symptoms of a liver problem [e.g., skin or the whites of eyes turn yellow, urine turns dark or brown (tea colored), pain on the right side of stomach, bleeds or bruises more easily than normal, lethargy
- Other: Keratitis, Left Ventricular Dysfunction, Embryo-Fetal Toxicity, Infertility, and do not breastfeed
Days 7, 14, 21, 28– Patient Follow-up
- Assess each of the side effects below and discuss each bullet point below
- Assess diarrhea and rash/acne
- These reactions cause the most dose reductions and typically occur within 14
- How many bouts of diarrhea have you had since we last spoke? Include any treatment you have taken for diarrhea and describe how it
- Describe any rashes or acne that may have developed since we last
- Discuss and manage the other common reactions – Stomatitis and Paronychia
- Describe changes, if any, you have noticed with any part of your mouth including your
- Describe changes, if any, you have noticed to your
- Discuss and manage less common reactions – Dry skin, Pruritus, Keratitis, Interstitial Lung Disease,
Hepatic toxicity
- Describe any other skin dryness or itching that has
- Describe any eye pain or visual changes you have experienced since starting
- Describe any new cough or difficulty breathing even at resting that may have
- Describe any changes to the whites of your eyes or any other skin
Afatinib Management
Hold therapy:
- ≥ grade 3 adverse reactions
- ≥ grade 2 diarrhea (persisting for 2 or more consecutive days while taking anti-diarrheal)
- cutaneous reactions (prolonged, lasting more than 7 days, or intolerable)
- renal impairment
Resume treatment at 10 mg less per day when adverse reaction fully resolves, returns to baseline, or improves to grade 1
Permanently Discontinue
- Life-threatening bullous, blistering, or exfoliative skin lesions
- Confirmed interstitial lung disease (ILD)
- Severe drug-induced hepatic impairment
- Persistent ulcerative keratitis
- Symptomatic left ventricular dysfunction
- Severe or intolerable adverse reaction occurring at a dose of 20 mg per day
Patient Centered Activities
- Provide Oncology Chemotherapy Education (OCE) sheet
- Supply of Anti Diarrheals
- Moisturizing cream
- Sun Screen
Supplemental Adverse Effect Information
| Diarrhea Management | Grade 1 | Grade 2 | Grade 3 | Grade 4 |
| < 4 stools | 4-6 stools | 7 or more stools | Life-Threatening | |
| Increase of <4 stools per day over baseline, mild increase in ostomy output compared to baseline | Increase of 4-6 stools per day over baseline; not interfering with daily activities; IV fluids indicated,24 hrs; moderate increase in ostomy output compared to baseline | Increase of 7 or more stools per day over baseline; incontinence; interfering with daily activities; IV fluid fluids ≥ 24 hrs; hospitalization; severe increase in ostomy output compared to baseline | Life-Threatening consequences (eg. hemodynamic collapse) | |
| Maintain dose | Consider pausing | Pause | Pause | |
| Continue same dose of GILOTRIF. Stop laxatives and advise patient to drink 8-10 glasses of water or clear fluids per day. Prescribe 4 mg loperamide taken immediately; followed by 2 mg after each loose stool (max. 16 mg/day) until bowel movements cease for 12
hours |
Continue same dose of GILOTRIF unless grade 2 diarrhea continues for ≥ 48 hours, in which case GILOTRIF must be paused until reduced to grade 1 or below; follow with dose reduction; see grade 1; continue loperamide; assess for dehydration and electrolyte imbalance; consider IV fluid and electrolyte replacement | Pause GILOTRIF until recovered to grade 1 or below and follow with dose reduction. In addition to grade 2 interventions, an infection process should be ruled out with stool cultures; aggressive IV fluid replacement for ≥ 24 hours; hospitalization to monitor progress; consider prophylactic antibiotics if patient
is also neutropenic |
See Grade 3 | |
| Rash/ Acne
Management |
Grade 1 | Grade 2 | Grade 3 | Grade 4 |
| Macular or papular eruptions or erythema without associated symptoms | Macular or papular eruptions with pruritus or other associated symptoms; localized desquamation or other lesions covering <50% of BSA | Severe, generalized erythroderma or macular, papular, or vesicular eruption; desquamation covering
≥ 50% of BSA; associated with pain, disfigurement, ulceration,or desquamation |
Generalized exfoliative, ulcerative, or bullous dermatitis | |
| Maintain dose | Pause | Pause | Permanently
Discontinued |
|
| Topical Steroids or tacrolimus ointment alternative. Consider topical antibiotics twice daily.
Recommend cream for isolated scattered lesions, and lotion for multiple scattered areas. |
Topical steroid treatment as for grade 1 oral antibiotic (6 weeks)
e.g. doxycycline 100 mg b.i.d., minocycline hydrochloride 100 mg b.i.d., or, if available, oxytetracycline 500 mg b.i.d. Stop topical antibiotic if being used |
Topical and systemic treatment as for grade 2. If Infection suspected (yellow crusts, purulent discharge, painful skin/nares), switch oral antibiotic to broad spectrum/gram negative coverage and consider skin swab for bacterial culture | Permanently discontinue GILOTRIF for life- threatening bullous, blistering, or exfoliative skin lesions |
| Paronychia (Nails) Management | Grade 1 | Grade 2 | Grade 3 | Grade 4 |
| Nail fold edema or erythema; disruption of the cuticle | Localized intervention indicated; oral intervention indicated (e.g. antibiotic, antifungal, antiviral); nail fold edema or erythema with pain; associated with discharge or nail plate separation; limiting
instrumental ADL |
Surgical intervention or IV antibiotics indicted; limiting self-care activities of daily living (ADL) | N/A | |
| Maintain dose | Prolonged: Pause | Pause | N/A | |
| Topical antibiotics/antiseptics, vinegar soaks, and topical ultrapotent steroids | Topical antibiotics, vinegar soaks, silver nitrate application weekly, and topical ultrapotent steroids | Topical antibiotics, vinegar soaks, silver nitrate application weekly/ consider nail avulsion and systemic antibiotics | N/A | |
| Stomatitis
Management |
Grade 1 | Grade 2 | Grade 3 | Grade 4 |
| Erythema of the mucosa | Patchy ulcerations or pseudomembranes | Confluent ulcerations or pseudomembranes; bleeding with minor trauma | Tissue necrosis; significant spontaneous bleeding; life- threatening consequences |
|
| Maintain dose | Prolonged: pause | Pause | Pause | |
| Oral rinses with agents such as non-alcoholic mouthwash, normal saline, diluted salt and baking soda solution | Addition of topical analgesic mouth treatments, topical corticosteroids, antiviral therapy if herpetic infection confirmed, antifungal therapy preferably topical on a case by case basis | Same as for grade 2; institute additional symptomatic therapy (topical or systemic) as clinically indicated | Same as for grade 2; institute additional symptomatic therapy (topical or systemic) as clinically indicated |
