| Oral Chemotherapy Monitoring & Counseling Medication Dose/FDA Indication Monitoring Parameters Key Counseling Points Afinitor® (everolimus) HR+, HER2- breast cancer BBW: None Administration: Swallow tablet whole, don’t crush or chew (with exemestane); pNET; • Take consistently with regards to food 2.5, 5, 7.5, 10mg Blister pack: RCC: 10mg PO daily Baseline & periodically: CBC w/ differentials, SCr, fasting serum • Avoid grapefruit/juice 28 tablets glucose/lipids • Missed dose should be taken if <6 hrs (4 x 7 tabs each) Disperz 2, 3, 5mg SEGA: Initial 4.5mg/m2, • Liver dysfxn: dose adj. based on Child Pugh score • Hazardous agent, use precautions when handling Blister pack: tablets for titrate at week 2 to attain • Dose adj. based on ADE (see PI) oral suspension trough conc. of 5-15ng/mL • S/sx of infection or new or worsening respiratory symptoms ADE: Stomatitis, N/V/D, cough, dyspnea, peripheral edema, rash, (4 x 7 tabs each) fatigue, decreased appetite, HTN DDI: CYP3A4 substrate (major) MOA: mTOR inhibitor • dose to 2.5mg daily with CYP3A4 inhibitor • risk of angioedema with ACE-inhibitor Alecensa® (alectinib) Anaplastic lymphoma BBW: None Administration: kinase (ALK)-positive, • Take with food 150mg metastatic non-small cell Baseline & periodically: LFT, heart rate, BP, CPK • Do not open or dissolve the contents of the capsule Bottle: 240 capsules lung cancer (NSCLC) who * Embryo-fetal toxicity, use contraception during tx & 1 week after • If a dose is missed or vomiting occurs after taking a dose, take the final dose MOA: TKI of ALK & RET have progressed on or are next dose at the scheduled time intolerant to crizotinib: DDI: No pharmacokinetic interactions with alectinib requiring • Store in the original container to protect from light & moisture 600mg PO BID dosage adjustment have been identified ADE: Fatigue, constipation, edema, myalgia, rash, cough, N/V/D, dyspnea, anemia Alkeran® (melphalan) Ovarian, MM: Various BBW: Antineoplastic experienced doctor Administration: regimens exist • Store refrigerated 2mg Baseline & periodically: CBC with differentials • Take on empty stomach, food bioavailability Bottle: 50 tablets Typical: 0.2mg/kg to 10mg • Bone marrow suppression: Infection, bleeding or anemia • Perform good oral hygiene PO daily for up to 7 days MOA: Alkylating agent • Hazardous agent, use precautions when handling ADE: Bone marrow suppression, nausea, mouth sores, pulmonary toxicity Arimidex® (anastrozole)* Breast Ca: 1mg PO daily generic available 1mg tablet MOA: nonsteroidal inhibitor** BBW: None Aromasin® (exemestane) Breast Ca: 25mg PO daily Administration (Exemestane): Take after a meal generic available Baseline & periodically: (Anastrozole): LFTs & Bili q3-6 months ADE: Hot flashes, peripheral edema, N/V/D, arthralgia & weakness 25mg tablet ( frequency with hepatic metastases) • Thrombosis & hot flashes less common than with Tamoxifen DDI: w/ Tamoxifen effectiveness • Does not affect cortisol or aldosterone MOA: nonsteroidal inhibitor** • Not indicated for premenopausal women or women w/ ER- tumors • Long-term effects: Osteoporosis & hypercholesterolemia Femara® (letrozole) Breast Ca: 2.5mg PO daily generic available 2.5mg tablet MOA: nonsteroidal inhibitor** * Anastrozole is a nonsteroidal inhibitor that interferes with estradiol production in peripheral tissues by inhibiting conversion of adrenally-generated androstenedione to estrone by aromatase. ** Arimidex, Aromasin & Femara are Aromatase Inhibitors (available as daily dose) MARCH 2018 | 1 Medication Dose/FDA Indication Monitoring Parameters Key Counseling Points Bosulif® (bositinib) Chronic, accelerated or BBW: None Administration: Swallow tablets whole, don’t crush or chew blast phase Ph+CML 100mg • Take with food resistant or intolerant to Baseline & periodically: CBC with differential & platelets, SCr, LFT • Avoid grapefruit/juice Bottle: 120 tablets prior therapy: 500mg PO • dose to 200mg daily (If LFTs rise >5x ULN, hold until <2.5x ULN & • Missed dose should be taken if <12 hrs resume at 400mg) 500mg once daily (if no CHR by • Hazardous agent, use precautions when handling week 8 or CCyR by week 12 • CrCl 30-50ml/min: 400mg, <30ml/min:300mg Bottle: 30 tablets dose to 600mg daily) • Grade 3+ diarrhea or myelosuppression, hold until ≤Grade 1 & dose by ADE: Myelosuppression, N/V/D, abdominal pain, edema, fatigue, 100mg MOA: TKI of BCR-ABL headache, rash DDI: CYP3A4 substrate (major) Cabometyx™ Indicated for the BBW: Administration: 60mg orally once daily, do not eat for at least 2 hours (cabozantinib) treatment of patients None before and at least 1 hour after taking Cabometyx. Do not ingest foods 60mg Bottle: 30 tablets with advanced renal or nutritional supplements known to inhibit cytochrome P450 during cell carcinoma (RCC): Baseline & periodically: Clinical and radiologic evidence of tumor response may Cabometyx therapy. Swallow whole with a full glass of water; do not 40mg Bottle: 30 tablets Recommended dose is 60mg indicate efficacy, blood pressure, before drug initiation and regularly during therapy, crush tablet. 20mg Bottle: 30 tablets Signs and symptoms of perforations or fistulas once daily, patients instructed ADE: Hypertension, hair color changes, hypocalcemia, not to eat for at least 2 hours Concomitant use of Cabometyx with a strong CYP3A4 inhibitor increased the MOA: Inhibits the tyrosine DDI: hypophosphatemia, weight decreased, abdominal pain, constipation, before and at least 1 hour kinase activity of MET, exposure of Cabometyx compared to the use of Cabometyx alone decreased appetite, dental pain, diarrhea, nausea, stomatitis, after taking VEGFR-1, -2 and -3, AXL, • Increased Cabometyx exposure may increase the risk of exposure-related toxicity. taste sense altered, vomiting, lymphocytopenia, neutropenia, RET, ROS1, TYRO3, MER, Reduce the dosage of Cabometyx if concomitant use with strong CYP3A4 inhibitors thrombocytopenia, fatigue, elevated ALT/AST KIT, TRKB, FLT-3, and TIE-2. cannot be avoided (refer to PI for dosing recommendations) These receptor tyrosine Concomitant use of Cabometyx with a strong CYP3A4 inducer decreased the kinases are involved in both exposure of Cabometyx compared to the use of Cabometyx alone normal cellular function and • Decreased Cabometyx exposure may lead to reduced efficacy. Increase the pathologic processes such dosage of Cabometyx if concomitant use with strong CYP3A4 inducers cannot as oncogenesis, metastasis, be avoided (refer to PI for dosing recommendations) tumor angiogenesis, drug resistance, and maintenance of the tumor microenvironment. Calquence® (acalabrutinib) Adult patients with BBW: None Administration: 100mg orally approximately every 12 hrs; 100mg mantle cell lymphoma Baseline & periodically: CBC with differential & platelets, monitor for atrial swallow whole with water & with or without food Bottle: 60 capsules (MCL) who have received fibrillation & atrial flutter, S/S of infection ADE: Myelosuppression, headache, N/V/D, abdominal pain, at least one prior constipation, vomiting, fatigue, bruising, myalgia MOA: Inhibit Bruton DDI: therapy: Recommended tyrosine kinase (BTK) dose is 100mg orally • CYP3A inhibitor & inducer by covalently bonding approximately every twelve • Strong CYP3A inhibitor= avoid concomitant use. Interrupt Calquence therapy to a cysteine residue at hrs; swallow whole with if acute use, e.g. anti-infectives the active BTK site. This water & with or without • Moderate CYP3A inhibitor= 100mg once daily prevents activation of the food • Strong CYP3A INDUCER= avoid concomitant use. If inducers cannot be signaling proteins CD86 & avoided, increase Calquence dose to 200mg twice daily CD69, as well as inhibits • PPI’s= avoid concomitant use proliferation & survival of • H2-receptor antagonists= take Calquence 2 hrs before taking an malignant B cells H2-receptor antagonist • Antacids= separate dosing by at least 2 hrs MARCH 2018 | 2 Medication Dose/FDA Indication Monitoring Parameters Key Counseling Points Caprelsa® (vandetanib) Medullary thyroid cancer, BBW: None Administration: Don’t crush tablets, can be dispersed in 2oz of metastatic or locally water & swallow immediately 100, 300mg Baseline & periodically: CBC, serum electrolytes, TSH, BP, ECG advanced: 300mg PO daily • May take with or without food Bottle: 30 tablets • Dose adj. based on Grade 3+ ADE (see PI) • Avoid grapefruit/juice MOA: DDI: CYP3A4 substrate (major) • Missed dose should be taken if <12 hrs TKI of EGFR • QT prolongation additive effect ADE: HTN, fatigue, rash, N/V/D *Casodex® (bicalutamide) Metastatic prostate BBW: None Administration: May take with or without food generic available in combo with LHRH • Usually in combination with LHRH agonist analogs Baseline & periodically: LFTs (d/c if ALT >2x ULN or patient develops jaundice) 50mg agonist: 50mg PO daily • Hazardous agent, use precautions when handling • PSA Bottle: 30 tablets ADE: Hot flashes, gynecomastia, breast tenderness,decreased DDI: CYP3A4 inhibitor MOA: Androgen receptor libido, edema, arthralgia & weakness • Monitor INR closely with warfarin inhibitor *CeeNu® (lomustine) HL, malignant glioma: BBW: Antineoplastic experienced doctor Administration: Take on empty stomach as a single dose at generic available 100-130mg/m2 PO once bedtime, about 30 minutes after an antiemetic Baseline & periodically: CBC w/ differentials (dose adjust for platelets<75,000) q6wks • Hazardous agent, use precautions when handling 10, 40, 100mg • CrCl 10-50ml/min= by 25% dose Bottle: 20 capsules ADE: Myelosuppression (dose-limiting & delayed),