Plasma pharmacokinetics and cerebrospinal fluid concentrations of erlotinib in high-grade gliomas: A novel, phase I, dose escalation study

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Background: Erlotinib (ERL) is an inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase. EGFR is overexpressed in glioblastoma multiforme (GBM). The primary objectives of this study were to determine the maximum tolerated dose (MTD), dose limiting toxicity (DLT) and to evaluate plasma and cerebrospinal fluid (CSF) ERL concentrations using a novel every 72 hour ERL dosing schedule. Methods: Patients = 18 years of age with GBM or high grade glioma with evidence of disease progression following first line therapy (surgery/XRT/chemotherapy) and Karnofsky performance status = 60 % were included. Patients were stratified based on use of enzyme-inducing antiepileptic drugs (EIAED). Patients not on EIAED were initiated on ERL 450 mg PO every 72h, while those on EIAED were initiated on 900 mg PO every 72 h. Results: Six patients have been enrolled and assessed for safety, 5 for plasma PK and 3 for CSF concentrations. For ERL, the area under the plasma concentration versus time curve (AUC) was greater and the half-life longer in patients not receiving EIAED. However, the AUC of OSI-420, the major metabolite of ERL, was lower in patients not receiving EIAED. The OSI-420 AUC: ERL AUC ratio was increased 3 fold among patients receiving EIAED, indicative of increased hepatic metabolism and increased clearance. CSF concentrations were detectable and ranged from 1 to 3% of peak plasma concentrations. Neither group has experienced a DLT or reached the MTD. The most common side effects (grade 1/2) have been diarrhea (83%), rash (100%) and fatigue (33%). To date, there has been 1 partial response, 1 patient with stable disease and 4 patients with disease progression. The partial response and stable disease have occurred in patients with GBM. Conclusions: ERL is a well tolerated therapy. Patient enrollment and subsequent dose escalation is ongoing and updated results will be presented at the ASCO 2007 meeting.

[Table: see text]

No significant financial relationships to disclose.

Phase I study of a novel recombinant human soluble thrombomodulin, ART-123

BACKGROUND

Anticoagulants are often given for extended periods of time to patients at high risk for venous thromboembolism, such as after orthopedic surgery. Daily subcutaneous (sc) injections can be inconvenient to the patient. A long-acting anticoagulant requiring less frequent dosing could make treatment more acceptable. Thrombomodulin is a natural anticoagulant that activates protein C, which leads to inactivation of factor (F)Va and FVIIIa and decreased thrombin formation. Recombinant human thrombomodulin is a novel anticoagulant with a long half-life in animal models.

METHODS AND RESULTS

This phase I study examined pharmacokinetics, pharmacodynamics, and safety of recombinant human soluble thrombomodulin (ART-123) after administration of doses between 0.02 and 0.06 mg kg(-1) body weight intravenously (iv), and between 0.02 and 0.45 mg kg(-1) sc in 55 healthy volunteers. The plasma half-life was 2-3 days after sc injection of various single doses. Plasma ART-123 levels estimated to be needed for prevention of thrombus formation in humans were maintained for at least 6 days after single sc injection of 0.30 and 0.45 mg kg(-1) ART-123. Antithrombotic activity with these doses was demonstrated by achieving prothrombinase inhibition of more than 80% for more than 6 days after administration. No major bleeding occurred. Pharmacodynamic modeling revealed that adequate antithrombotic ART-123 levels can be achieved for 6 days with one dose of 0.45 mg kg(-1) ART-123, and for 12 days with 2 doses of 0.30 mg kg(-1), given 5 days apart.

CONCLUSIONS

Recombinant human soluble thrombomodulin (ART-123) has a long half-life after sc injection and is well tolerated, making it a suitable agent to be tested in clinical thromboprophylaxis trials.

Assessing the impact of chemotherapy-induced nausea and vomiting on patients' daily lives: a modified version of the Functional Living Index-Emesis (FLIE) with 5-day recall

BACKGROUND

The Functional Living Index-Emesis (FLIE), a patient-reported outcome measure, was originally developed to assess the impact of chemotherapy-induced nausea and vomiting (CINV) on patients' daily lives over the 3 days following chemotherapy. More recent studies of CINV include assessments covering the 5 days following chemotherapy in an effort to capture information during both the acute (within 24 h) and delayed (up to 5-7 days) phases of CINV.

GOALS

To assess the measurement characteristics of a modified version of the FLIE with 5-day recall. Instrument reliability, validity, and missing data were assessed.

PATIENTS AND METHODS

Data were collected from 183 patients receiving cisplatin >or=70 mg/m(2) as part of a phase IIb antiemetic trial of an NK-1 receptor antagonist (MK-0869). Patients recorded the number of vomiting episodes and nausea ratings in a 5-day daily diary.

RESULTS

The 5-day FLIE had: (1) excellent internal consistency within FLIE Nausea and Vomiting domains (Cronbach's alpha 0.77-0.78), (2) acceptable construct validity shown by FLIE item-total correlations stronger within domains ( r=0.74-0.97) than across domains ( r=0.52-0.76), and (3) acceptable convergent validity as shown by moderate to strong correlations between FLIE domain scores and independent endpoints of emetic episodes, nausea ratings, and use of rescue medications. The extent of missing data was within acceptable limits with less than 2% of patients missing data.

CONCLUSION

The 5-day FLIE had adequate measurement characteristics for studying the impact of CINV on patients' daily lives during the period covering both the acute and delayed phases.

Lack of gender differences and large intrasubject variability in cytochrome P450 activity measured by phenotyping with dextromethorphan

Gender-based differences in cytochrome P450 (CYP) activity may occur due to endogenous hormonal fluctuations with the menstrual cycle, which are altered by oral contraceptives. This study assessed the average activity and within-subject variability in CYP3A4 and CYP2D6 in men, women taking Triphasil, and regularly menstruating women not receiving oral contraceptives. Thirty-three healthy volunteers participated in this 28-day pilot study (12 women receiving Triphasil) (OCs), 11 regularly menstruating women not on exogenous progesterone or estrogen (no OCs), and 10 men. CYP3A4 and CYP2D6 activities were phenotyped with dextromethorphan (DM) on study days 7, 14, 21, and 28 using urinary ratios of DM:3-methoxymorphinan (3MM) and DM:dextrorphan (DX), respectively. Serial blood concentrations of estrogen and progesterone and menstrual diaries were used to determine menstrual phase in both groups of women. Average urinary DM:3MM and DM:DX in the 28 extensive metabolizers of CYP2D6 did not differ between the three study populations (p = 0.86 and 0.93, respectively). Post hoc power analysis indicated that more than 1000 subjects would be needed for 80% power (alpha = 0.05) to detect a +/- 15% difference from the population mean in the urinary ratios of dextromethorphan and its metabolites 3MM and DX. Variability in CYP3A4 and CYP2D6 activity, characterized by intrasubject standard deviation, also did not differ. The varying doses of levonorgesterol and ethinyl estradiol in Triphasil, fluctuations in estrogen and progesterone, and menstrual phase did not influence CYP3A4 or CYP2D6 activity. It was concluded that CYP3A4 and CYP2D6 activity and intrasubject variability were not different in the three study populations, and thus a clinically important difference between men, women on Triphasil, and women not receiving oral contraceptives is unlikely. High inter- and intrasubject variability in DM:3MM and DM:DX were clearly demonstrated and limit the use of dextromethorphan to phenotype endogenous CYP3A4 and CYP2D6 activity.

Documentation of pain assessment and treatment: how are we doing?

The purpose of this analysis was to evaluate documentation of practice provided by a multidisciplinary team of nurses, physicians, and pharmacists who participated in an educational program on postoperative pain management. Chart audit of 787 patient charts at 6 sites revealed documentation of pain histories in approximately 75% of the charts, most often in the surgeon's history and physical examination. Examination of multiple assessment items indicated that the experimental group, relative to the control group, experienced an increase of more than 10% in the documentation of pain intensity, pain quality, pain duration, numeric rating scale used, pain behavior, factors that increase pain, vital signs, sedation level, cognitive status, social interaction, and mood from before the program to 6 months after the program. Across all sites, documentation of assessment, treatment, and treatment outcome data was infrequent and inconsistent. Calculation of documentation of 4 items that constituted a focused assessment of postoperative pain on the surgical floor revealed a significant program effect for assessment of pain quality and pain intensity. A postprogram survey of participants in the educational program revealed an increase in discussion of postoperative pain management with other practitioners and an increase in use of a 0 to 10 scale to rate pain. More documentation of patient pain history, clinical problems, treatment, and follow-up action is needed to improve practice and research.

Measured versus estimated glomerular filtration rate in the Calvert equation: influence on carboplatin dosing

PURPOSE

Carboplatin is frequently dosed to achieve a desired area under the plasma concentration-time curve (AUC) by using the Calvert or Chatelut equations to estimate carboplatin clearance. Accurate determination of glomerular filtration rate (GFR) is necessary to correctly calculate carboplatin clearance using the Calvert equation. In clinical practice, the Cockcroft-Gault formula is frequently used to estimate GFR, but this practice has been reported to under- and overestimate carboplatin clearance. The purpose of this trial was to compare determinations of carboplatin clearance using the Chatelut equation and four separate GFR determinations, including 99mTc-DTPA, the Cockcroft-Gault formula, a 24-h urine collection and a 2-h urine collection.

METHODS

Carboplatin clearance was estimated in 21 previously untreated extensive-stage small-cell lung cancer patients. GFR was determined using 99mTc-DTPA, the Cockcroft-Gault formula, 24-h urine collection and 2-h urine collection. Serum and urine creatinine concentrations were measured using enzymatic assays. The carboplatin clearance was then calculated by individually adding 25 to the four GFR determinations based on the Calvert equation, which states that carboplatin clearance equals GFR + 25 (nonrenal clearance). The carboplatin clearance was also estimated using the Chatelut equation. The five determinations of carboplatin clearance were compared using Friedman's test and post-hoc Wilcoxon signed rank tests. Precision and bias for each carboplatin clearance determination were calculated assuming that 99mTc-DTPA provided the most accurate measure of GFR.

RESULTS

A statistically significant difference was found between the five methods of estimating carboplatin clearance (P < 0.001). No difference was found between carboplatin clearance calculated using 99mTc-DTPA and the Chatelut equation, the Cockcroft-Gault formula or the 2-h urine collection. The Chatelut equation provided more precision and less bias than the 2-h urine collection (median precision 20% and 30%, median bias -1% and -18%, respectively).

CONCLUSION

Compared to 99mTc-DTPA, the Chatelut equation more accurately estimates carboplatin clearance than the Cockcroft-Gault formula, the 2-h urine collection and the 24-h urine collection. The greater negative bias found for the latter three estimates of carboplatin clearance could result in underdosing of carboplatin.

Pharmacology and therapeutic use of trastuzumab in breast cancer

The development, pharmacology, safety, efficacy, and dosage and administration of trastuzumab are reviewed. The discovery of HER2 gene amplification in up to 30% of women with breast cancer led to the development of trastuzumab, a humanized recombinant monoclonal antibody directed against the HER2-receptor protein on breast cancer cells. In large, multicenter trials of trastuzumab as a single agent or in combination with chemotherapy as first-line or second-line therapy for metastatic breast cancer (MBC), response rates have ranged from 12% to 23% for single-agent trastuzumab and from 25% to 62% for trastuzumab plus chemotherapy. Trastuzumab increased time to disease progression and survival time when administered in combination with chemotherapy. The National Comprehensive Cancer Network guidelines for the treatment of breast cancer now include trastuzumab and paclitaxel as an option for patients with MBC or recurrent breast cancer in which the HER2-receptor protein is overexpressed. Trastuzumab is administered weekly, with an initial i.v. dose of 4 mg/kg followed by weekly doses of 2 mg/kg. Most clinical trials continued treatment until disease progression occurred. Adverse effects include infusion-related reactions manifested by fever and chills, exacerbation of chemotherapy-induced gastrointestinal toxicity and myelosuppression, and cardiotoxicity. Trastuzumab, either as a single agent or in combination with chemotherapy, can be an effective therapeutic option for MBC patients who overexpress the HER2-receptor protein and has changed the standard of care.

In vivo and in vitro induction of human cytochrome P4503A4 by dexamethasone

PURPOSE

The aims of these experiments were to determine the effect of a therapeutic regimen of dexamethasone on cytochrome P4503A4 (CYP3A4) activity in healthy volunteers; and the concentration-effect relationship between dexamethasone and CYP3A4 activity in primary human hepatocyte cultures.

METHODS

The effect of dexamethasone (8 mg administered by mouth two times a day for 5 days) on CYP3A4 activity in 12 healthy volunteers was assessed with the erythromycin breath test and urinary ratio of dextromethorphan to 3-methoxymorphinan. Concentration-effect of dexamethasone on CYP3A4-dependent testosterone 6-beta-hydroxylation was determined in human hepatocytes treated with 2 to 250 micromol/L dexamethasone.

RESULTS

The percent of erythromycin metabolized per hour increased from 2.20% +/- 0.60% (mean +/- SD) at baseline to 2.67% +/- 0.55% on day 5 of dexamethasone (mean increase in hepatic CYP3A4 activity 25.7% +/- 24.6%; P = .004). The mean urinary ratio of dextromethorphan to 3-methoxymorphinan was 28 (4.8 to 109) and 7 (1 to 23) at baseline and on day 5 of dexamethasone (mean decrease = 49%; P = .06). Substantial intersubject variability was observed in the extent of CYP3A4 induction. The extent of CYP3A4 induction was inversely correlated with baseline erythromycin breath test (r2 = 0.58). In hepatocytes, dexamethasone 2 to 250 micromol/L resulted in an average 1.7-fold to 6.9-fold increase in CYP3A4 activity, respectively. The extent of CYP3A4 induction with dexamethasone in hepatocyte preparations was inversely correlated with baseline activity (r2 = 0.59).

CONCLUSIONS

These data demonstrate that dexamethasone at doses used clinically increased CYP3A4 activity with extensive intersubject variability and that the extent of CYP3A4 induction was, in part, predicted by the baseline activity of CYP3A4 in both healthy volunteers and human hepatocyte cultures.

Oral serotonin type 3-receptor antagonists for prevention of chemotherapy-induced emesis

The theoretical basis for and clinical experience with using oral serotonin type 3 (5-HT3)-receptor antagonists for preventing chemotherapy-induced emesis are discussed. Evidence supports the idea that antineoplastic drugs and irradiation can initiate emesis by releasing serotonin from enterochromaffin cells in the gut mucosa, which activates peripheral vagal afferent nerves. In view of the GI site of serotonin release and vagal afferent activation, the proximity of neuronal 5-HT3 receptors, and the pharmacologic properties of 5-HT3-receptor antagonists, the oral use of these agents is rational. Oral granisetron 2 mg once daily or 1 mg twice daily has been evaluated in more than 4500 patients receiving highly or moderately emetogenic chemotherapy. Rates of total control of emesis ranged from 44% to 60%, and complete-response rates ranged from 70% to 94%. Oral ondansetron 8 mg three times daily has proven effective in patients receiving antineoplastics with moderate or moderately high emetogenic potential. Two double-blind studies demonstrated the efficacy of a single 24-mg oral dose of ondansetron administered approximately 30 minutes before cisplatin-based chemotherapy. Patients randomized to oral ondansetron had higher total-control and complete-response rates than patients receiving intravenous granisetron or ondansetron. Oral dolasetron 100 or 200 mg once daily also prevented emesis. Oral administration of 5-HT3-receptor antagonists for the prevention of acute emesis associated with chemotherapy is rational and appears to be effective.

Clinical economics: calculating the cost of acute postoperative pain medication

Few data are available that address the cost of postoperative pain management, although such knowledge would enhance our understanding of caregiver choices related to direct medical costs, such as type, frequency, and route of medication. This article describes the cost of postoperative pain medications before and after an educational program provided to nurses, pharmacists, and physicians in six community hospitals. Medication costs were calculated by averaging across all brands the average wholesale price of the most common dose administered in the sample for each medication. The median cost of postoperative pain medication across all days, all surgeries, was $9.46. Calculating the cost of acute postoperative pain medication suggested that cost over stay is highly influenced by the use of a few expensive medications. The relationship of medication cost to length of stay (LOS), function, and pain intensity is discussed.

Anagrelide: a novel agent for the treatment of myeloproliferative disorders

Anagrelide hydrochloride (Agrylin, Roberts Pharmaceutical Corp.) is an oral imidazoquinazoline agent that has been shown to reduce elevated platelet counts and the risk of thrombosis in patients with thrombocythaemia in various myeloproliferative disorders (MPD). It is currently approved by the FDA as oral treatment for essential thrombocythaemia (ET) and thrombocythaemia associated with polycythaemia vera (PV). Anagrelide selectively suppresses bone marrow megakaryocytes by interfering with the maturation process and decreasing platelet production without affecting the erythroid and myeloid progenitor cells. Other medications indicated for the treatment of thrombocythaemia, including interferon alpha (IFN-alpha), alkylating agents and hydroxyurea, suppress all cell lines. Anagrelide is known to inhibit platelet cyclic adenosine monophosphate (cAMP) phosphodiesterase at concentrations that exceed those achieved at doses used to treat ET. Anagrelide is extensively metabolised in the liver and its metabolites are primarily excreted in the urine. Adverse effects associated with the use of anagrelide are primarily caused by the drugs' direct vasodilating and positive inotropic effects. These include headache, hypotension and diarrhoea. It has also been known to cause fluid retention, tachycardia, nausea, abdominal pain and arrhythmias. The starting dose of anagrelide ranges from 0.5 mg q.i.d. to 1 mg b.i.d. with a maximum dose of 2.5 mg q.i.d. Adequate responses have been maintained with a median dose of 2-2.5 mg/day. Platelet counts begin to decrease in 7-10 days, however, they return to pre-treatment levels within 4-8 days if therapy is stopped. Anagrelide 2 mg/day for one year costs approximately US$6439, and treatment must continue indefinitely [1].

American Society of Clinical Oncology clinical practice guidelines for the use of chemotherapy and radiotherapy protectants

PURPOSE

Because toxicities associated with chemotherapy and radiotherapy can adversely affect short- and long-term patient quality of life, can limit the dose and duration of treatment, and may be life-threatening, specific agents designed to ameliorate or eliminate certain chemotherapy and radiotherapy toxicities have been developed. Variability in interpretation of the available data pertaining to the efficacy of the three United States Food and Drug Administration-approved agents that have potential chemotherapy- and radiotherapy-protectant activity-dexrazoxane, mesna, and amifostine-and questions about the role of these protectant agents in cancer care led to concern about the appropriate use of these agents. The American Society of Clinical Oncology sought to establish evidence-based, clinical practice guidelines for the use of dexrazoxane, mesna, and amifostine in patients who are not enrolled on clinical treatment trials.

METHODS

A multidisciplinary Expert Panel reviewed the clinical data regarding the activity of dexrazoxane, mesna, and amifostine. A computerized literature search was performed using MEDLINE. In addition to reports collected by individual Panel members, all articles published in the English-speaking literature from June 1997 through December 1998 were collected for review by the Panel chairpersons, and appropriate articles were distributed to the entire Panel for review. Guidelines for use, levels of evidence, and grades of recommendation were reviewed and approved by the Panel. Outcomes considered in evaluating the benefit of a chemotherapy- or radiotherapy-protectant agent included amelioration of short- and long-term chemotherapy- or radiotherapy-related toxicities, risk of tumor protection by the agent, toxicity of the protectant agent itself, quality of life, and economic impact. To the extent that these data were available, the Panel placed the greatest value on lesser toxicity that did not carry a concomitant risk of tumor protection.

RESULTS AND CONCLUSION

Mesna: (1) Mesna, dosed as detailed in these guidelines, is recommended to decrease the incidence of standard-dose ifosfamide-associated urothelial toxicity. (2) There is insufficient evidence on which to base a guideline for the use of mesna to prevent urothelial toxicity with ifosfamide doses that exceed 2.5 g/m(2)/d. (3) Either mesna or forced saline diuresis is recommended to decrease the incidence of urothelial toxicity associated with high-dose cyclophosphamide use in the stem-cell transplantation setting. Dexrazoxane: (1) The use of dexrazoxane is not routinely recommended for patients with metastatic breast cancer who receive initial doxorubicin-based chemotherapy. (2) The use of dexrazoxane may be considered for patients with metastatic breast cancer who have received a cumulative dosage of 300 mg/m(2) or greater of doxorubicin in the metastatic setting and who may benefit from continued doxorubicin-containing therapy. (3) The use of dexrazoxane in the adjuvant setting is not recommended outside of a clinical trial. (4) The use of dexrazoxane can be considered in adult patients who have received more than 300 mg/m(2) of doxorubicin-based therapy for tumors other than breast cancer, although caution should be used in settings in which doxorubicin-based therapy has been shown to improve survival because of concerns of tumor protection by dexrazoxane. (5) There is insufficient evidence to make a guideline for the use of dexrazoxane in the treatment of pediatric malignancies, with epirubicin-based regimens, or with high-dose anthracycline-containing regimens. Similarly, there is insufficient evidence on which to base a guideline for the use of dexrazoxane in patients with cardiac risk factors or underlying cardiac disease. (6) Patients receiving dexrazoxane should continue to be monitored for cardiac toxicity. Amifostine: (1) Amifostine may be considered for the reduction of nephrotoxicity in patients receiving cisplatin-based chemoth

Organization of hospital-based acute pain management programs

BACKGROUND

The management of acute pain is an aspect of hospital-based practice that has been neglected. Control of pain is important for ethical reasons, for compliance with new guidelines and standards, and for optimizing patient satisfaction and outcomes.

METHODS

Be review the rationale for establishing priority to the control of acute pain, the importance of an institutional approach to improve pain management, and specific steps in the establishment and conduct of an acute pain program.

RESULTS

Improvement in pain control depends on an institutional approach to facilitate changes in attitude and prioritization. Pain management programs should provide for patient and staff education, adequate documentation of care, institutional standards for pain control, quality assurance/continuous quality improvement (CQI) activities, and periodic review of practice and policy.

CONCLUSIONS

Effective pain management can set the stage for a rehabilitational approach to postoperative care, which should lead to earlier recovery and improved outcomes.

Cyclic AMP can decrease expression of genes subject to catabolite repression in Saccharomyces cerevisiae

External cyclic AMP (cAMP) hindered the derepression of gluconeogenic enzymes in a pde2 mutant of Saccharomyces cerevisiae, but it did not prevent invertase derepression. cAMP reduced nearly 20-fold the transcription driven by upstream activation sequence (UAS1FBP1) from FBP1, encoding fructose-1,6-bisphosphatase; it decreased 2-fold the activation of transcription by UAS2FBP1. Nuclear extracts from cells derepressed in the presence of cAMP were impaired in the formation of specific UASFBP1-protein complexes in band shift experiments. cAMP does not appear to act through the repressing protein Mig1. Control of FBP1 transcription through cAMP is redundant with other regulatory mechanisms.

Changing acute pain management to improve patient outcomes: an educational approach

The United States Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines were written to provide a scientific basis for practice. Educational programs designed to promote use of the guidelines may change practice in community hospitals. This article describes the development and implementation of an education program for nurses, physicians, and pharmacists in six community hospitals. Program content addressing the use of continuous quality improvement (CQI) teams, detailed pain histories, application of algorithms and dose calculation is described; direct and indirect outcome measures are reviewed. Six months after the program, all three experimental sites reported use of the AHCPR Guidelines in practice. Nurses reported that assessment and documentation of patients' duration of pain were perceived to be the most important caregiver behaviors providing benefit to patients: Across all respondents' reports of regularly performed activities, the activity performed by the largest proportion was assessing and documenting pain using a 0-10 rating scale.

Perception of chemotherapy side effects cancer versus noncancer patients

PURPOSE

This study was conducted to identify and compare perceptions regarding the disruption in quality of life caused by chemotherapy side effects in patients with cancer receiving chemotherapy and in noncancer, chemotherapy-naive patients.

DESCRIPTION OF STUDY

One hundred forty-six patients with cancer and 224 patients without cancer completed two instruments to assess the perceived magnitude of 41 physical and psychosocial chemotherapy side effects. Instrument 1 used a 5-point Likert scale (1 = not at all; 2 = a little bit; 3 = somewhat; 4 = quite a bit; and 5 = very much) to summarize patient responses to the question, "How much did or would each of the following side effects of chemotherapy bother you?" Instrument 2 was a serial ranking questionnaire that asked patients to select the 10 most bothersome side effects to numerically rank the top five. An index of the relative magnitude of chemotherapy side effects was calculated for each instrument.

RESULTS

For patients with cancer, loss of hair 50%), changes in taste (46%), constantly being tired (42%), affects work duties (39%), changes in smell perception (35%) were most frequently perceived as bothering them "quite a bit" or "very much." Nausea and vomiting were ranked 11th and 22nd, respectively. With instrument 2, the five side effects perceived as most troublesome were, in decreasing order: nausea, loss of hair, constantly tired, vomiting, and changes in the way things taste. For noncancer patients, those factors potentially bothersome "quite a bit" or "very much" were: financial hardship (82%), hardship on family (78%), vomiting (73%), shortness of breath (70%), and ability to perform work duties (69%). Via instrument 2, the top five side effects, in decreasing order were: vomiting, hardship on family, loss of hair, financial hardship, nausea, having to move close to a treatment center.

CLINICAL IMPLICATIONS

Noncancer, chemotherapy-naive patients perceived most chemotherapy-associated side effects as having greater impact on the quality of life than did cancer patients who had received chemotherapy. These findings can be used to direct patient education, education of the public, specific materials concerning cancer chemotherapy. The expertise of various members of the healthcare team can maximize the patient's comprehension of the adverse effects of the treatment options. The physician's knowledge of the overall treatment plan can assist in patient understanding; oncology pharmacists nurses are in a unique position to educate patients their families regarding potential chemotherapy side effects.

Quality of life in patients surviving at least 12 months following high dose chemotherapy with autologous bone marrow support

BACKGROUND

Over the past decade, high dose chemotherapy with autologous bone marrow (HDC-ABMT) support has been used increasingly in the treatment of patients with breast cancer. In evaluating the results of HDC-ABMT in patients with breast cancer, an assessment of quality of life can add to the traditional endpoints (toxicity, and disease-free and overall survival) that are routinely assessed in clinical trials.

PURPOSE

This study evaluated the quality of life (QOL) of breast cancer patients who had survived 1 or more years following high dose chemotherapy with autologous bone marrow transplant (HDC-ABMT) support.

METHODS

Eighty-two patients who had undergone HDC-ABMT were surveyed by written questionnaire and follow-up telephone interview at least 1 year following HDC-ABMT. Patients were asked to complete the Functional Living Index-Cancer (FLIC), the Symptom Distress Scale (SDS), and a survey of sexual function developed as part of the study.

RESULTS

The mean FLIC score among all patients was 130 +/- 19.1 (possible range 22-154). FLIC scores were significantly lower in patients with evidence of recurrent disease than in patients who were free of disease. The most commonly reported symptoms after HDC-ABMT were insomnia, fatigue, and pain. Sexual interest and sexual activity were reported to be lower after participation in HDC-ABMT than prior to the procedure. The majority of patients who were employed outside the home prior to HDC-ABMT returned to work with a median time away from work of 48 weeks.

CONCLUSIONS

Patients with breast cancer who survive 1 or more years following HDC-ABMT rate their QOL at a relatively high level and frequently return to work. Less than one-third of patients who were interviewed reported moderate to severe symptoms. Problems with sexual functioning were common.

IMPLICATIONS

Future research is needed on long-term outcomes after HDC-ABMT and on specific areas of concern, such as sexual functioning.

Quality of life and preferences for treatment following systemic adjuvant therapy for early-stage breast cancer

PURPOSE

To evaluate the quality of life (QOL) of breast cancer patients who survived 2 to 5 years following initiation of adjuvant cytotoxic and/or hormonal therapy and to characterize relationships between QOL and patient physical symptoms, sexual function, and preferences regarding adjuvant treatment.

PATIENTS AND METHODS

Eighty-six patients who had completed systemic adjuvant therapy for early-stage breast cancer between 1988 and 1991 were surveyed by written questionnaire and telephone interview. Sociodemographic information was obtained for each patient, and patients were asked to complete the Functional Living Index-Cancer (FLIC), the Symptom Distress Scale (SDS), the Medical Outcomes Study (MOS) Short Form 36 (SF-36), a series of questions regarding sexual function, and a survey about preferences for adjuvant therapy in relation to possible benefit.

RESULTS

The mean FLIC score among all patients was 138.3 (+/- 12.2), which suggests a high level of QOL. The reported frequency of moderate to severe symptoms was generally low (ie, < 15%), with fatigue (31.4%), insomnia (23.3%), and local numbness at the site of surgery (22.1%) occurring with greatest frequency. Patients reported a wide range of sexual difficulties. Preference assessment showed that more than 65% of patients were willing to undergo 6 months of chemotherapy for a 5% increase in likelihood of cancer cure.

CONCLUSION

Self-rated QOL in breast cancer patients 2 to 5 years following adjuvant therapy was generally favorable. Less than one third of patients reported moderate to severe symptoms. Selected aspects of sexual function appeared to be compromised. The majority of patients indicated a willingness to accept 6 months of chemotherapy for small to modest potential benefit.

Precipitous fall in platelet count with anagrelide: case report and critique of dosing recommendations

Thrombotic and hemorrhagic events may result from high circulating concentrations of platelets (> 1,000,000/mm3), and measures to reduce the platelet count are indicated in symptomatic or extreme thrombocytosis. The platelet count can be decreased quickly by plasmapheresis, but the effect is transient. Patients with thrombocytosis secondary to a myeloproliferative disease, such as chronic myelogenous leukemia (CML), frequently require more sustained suppression of the platelet count. Hydroxyurea, busulfan, and interferon are used to maintain a lower platelet count but are occasionally ineffective or intolerable. An alternative to these therapies is anagrelide, a quinazolin derivative that was approved by the Food and Drug Administration in March 1997. Because current dosing guidelines for anagrelide are scarce, the dosing method of the Anagrelide Study Group that published the largest study to date on the drug's efficacy in thrombocytosis was followed. Two unexpected episodes of anagrelide-induced thrombocytopenia occurred despite following these dosing methods. This prompted a critical evaluation of the pharmacodynamic response and the appropriateness of anagrelide dosage recommendations. A case of thrombocytosis treated with anagrelide in a patient with CML is described.

Antiemetic therapy in managed care oncology: roundtable discussion

Few diagnoses are feared more by patients than cancer. In addition to the life-threatening nature of many cancers, the spectre of very difficult the treatment provides patients with little or no level of comfort. However, recent advances in the treatment of the side effects of cancer chemotherapy are helping to change these attitudes. On April 4, 1996, a panel of experts was convened to discuss these issues and how they affect MCOs.

Vinorelbine: a novel vinca alkaloid

The chemistry, pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage and administration of vinorelbine are reviewed. Vinorelbine is a semisynthetic vinca alkaloid with a broader spectrum of antitumor activity in vitro than naturally occurring vinca alkaloids have. Vinorelbine shows selective activity against mitotic microtubules. Higher concentrations of vinorelbine relative to vinblastine and vincristine are required to affect axonal microtubules; presumably this accounts for the decreased neurotoxicity of vinorelbine. Vinorelbine is lipophilic and is rapidly distributed into peripheral tissues. It is highly bound to blood components. Vinorelbine is excreted slowly by the fecal route and rapidly by the urinary route. Disposition is characterized by a three-compartment model, high systemic clearance, and a long terminal-phase elimination half-life. In clinical studies, vinorelbine has shown antitumor activity both as a single agent and in combination with cisplatin in patients with non-small-cell lung cancer (NSCLC). Vinorelbine plus cisplatin produces a higher response rate and longer survival than vindesine plus cisplatin, a combination previously found to be superior to best supportive care. Encouraging results for vinorelbine in the treatment of advanced breast cancer, advanced ovarian epithelial cancer, and other tumors have also been observed. The dose-limiting adverse effect of vinorelbine is myelosuppression. Vinorelbine has FDA-approved labeling for use alone or in combination with cisplatin for the first-line treatment of unresectable, advanced NSCLC. The recommended dosage is 30 mg/sq m i.v. weekly administered by either slow i.v. push or i.v. infusion. Vinorelbine alone or in combination with other antineoplastics has shown activity against NSCLC, advanced breast cancer, and other malignancies. More study is needed to determine whether vinorelbine is superior to best supportive care in patients with NSCLC.

Vinorelbine: a novel vinca alkaloid

The chemistry, pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage and administration of vinorelbine are reviewed. Vinorelbine is a semisynthetic vinca alkaloid with a broader spectrum of antitumor activity in vitro than naturally occurring vinca alkaloids have. Vinorelbine shows selective activity against mitotic microtubules. Higher concentrations of vinorelbine relative to vinblastine and vincristine are required to affect axonal microtubules; presumably this accounts for the decreased neurotoxicity of vinorelbine. Vinorelbine is lipophilic and is rapidly distributed into peripheral tissues. It is highly bound to blood components. Vinorelbine is excreted slowly by the fecal route and rapidly by the urinary route. Disposition is characterized by a three-compartment model, high systemic clearance, and a long terminal-phase elimination half-life. In clinical studies, vinorelbine has shown antitumor activity both as a single agent and in combination with cisplatin in patients with non-small-cell lung cancer (NSCLC). Vinorelbine plus cisplatin produces a higher response rate and longer survival than vindesine plus cisplatin, a combination previously found to be superior to best supportive care. Encouraging results for vinorelbine in the treatment of advanced breast cancer, advanced ovarian epithelial cancer, and other tumors have also been observed. The dose-limiting adverse effect of vinorelbine is myelosuppression. Vinorelbine has FDA-approved labeling for use alone or in combination with cisplatin for the first-line treatment of unresectable, advanced NSCLC. The recommended dosage is 30 mg/sq m i.v. weekly administered by either slow i.v. push or i.v. infusion. Vinorelbine alone or in combination with other antineoplastics has shown activity against NSCLC, advanced breast cancer, and other malignancies. More study is needed to determine whether vinorelbine is superior to best supportive care in patients with NSCLC.

Overview of current development in patient-controlled analgesia

Over the past two decades, numerous trials have assessed the safety and efficacy of patient-controlled analgesia (PCA). Advantages over conventional parenteral narcotics reported from these trials include equivalent to superior pain relief, superior patient satisfaction, decreased sedation and anxiety, faster return to normal functional status, and reduction in nursing time and hospitalization. The majority of these trials have been conducted in the postoperative patient population. In the mid to late 1980s, interest arose in applying PCA technology to the management of cancer pain. Factors that served as an impetus for the use of PCA in cancer pain included favorable reports from the postoperative setting and the often-cited statistics regarding the magnitude of the cancer pain problem. Advances in PCA technology coupled with advances in vascular access technology that allow the placement of long-term ports and catheters to facilitate intravenous, epidural, or intrathecal administration of opioid analgesics have made the applicability of PCA in ambulatory cancer patients an attractive option. The greatest breakthrough in PCA technology came with the introduction of devices making it possible to choose between intermittent (demand bolus) and continuous administration (continuous infusion) or both intermittent and continuous modes. A comparison of these types of PCA devices is described. The limitations of the literature involving PCA therapy in cancer patients make it difficult to identify optimal patient selection criteria, PCA administration schedules, drug selection and dosing, and optimal route of administration. The current status and pertinent issues related to these topics are addressed.

Comparison of PT, aPTT, and factor VII values obtained by concurrent sample collection by direct venipuncture and peripheral venous catheters

STUDY OBJECTIVE

To compare prothrombin time (PT), activated partial thromboplastin time (aPTT), and factor VII values in concurrent blood samples obtained by direct venipuncture and from a peripheral venous catheter.

DESIGN

Concurrent samples obtained from catheters and by direct venipuncture were studied. In a separate crossover bioequivalence assessment of DNA-derived factor VIIa (rFVIIa) from two different batches, sample results of each technique were compared.

SETTING

University hospital clinical research unit.

PATIENTS

Six patients with hemophilia A under nonbleeding conditions.

INTERVENTIONS

The patients received a single dose of rFVIIa 70 micrograms/kg administered by intravenous push over 2 minutes. Concurrent blood samples were collected at 2, 3, 4, 6, 8, 10, and 12 hours after rFVIIa administration. Catheter blood samples were drawn from a three-way stopcock attached to an 18-gauge peripheral venous catheter in the patient's forearm and connected to an intravenous solution of 5% dextrose with half normal saline maintained at a rate of 30 ml/hour. Venipuncture samples were drawn from the opposite arm.

MEASUREMENTS AND MAIN RESULTS

The PT and aPTT values were determined by using a BBL Fibrometer (PT) and a Coagamate X-2 with automated aPTT reagent. Blood samples were analyzed for factor VII concentration using the Novo Clot assay. The mean venipuncture-obtained PT (8.9 +/- 1.0 sec) and aPTT (48.7 +/- 13.6 sec) values were numerically equivalent to mean catheter-derived PT (9.0 +/- 1.0 sec) and aPTT (48.3 +/- 12.5 sec) results, as were mean venipuncture and catheter-obtained FVII:C values.

CONCLUSIONS

The PT and aPTT values determined after venipuncture and through the peripheral catheter were not statistically different (p > 0.05) when compared by paired or unpaired analysis. Similarly, values of FVII:C measured after venipuncture were statistically equivalent to those after sampling through the peripheral catheter. All six patients preferred the catheter method of blood collection over venipuncture.

Hospital-based HMO: an outpatient study

With the increasing pressure from managed care companies and in cooperation with its medical staff's independent practice association, the Vista Hill Foundation formed its own specialty health maintenance organization. This is a report on an outpatient study of treatment satisfaction among 124 mental healthcare providers (50% of whom were psychiatrists) and their 218 patient experiences. Treatment outcome was rated as "very satisfactory" or "satisfactory" in 82% of the studied cases. Managed care was found to cause "mild" to "moderate" treatment interference in 26% of the cases and "significant" to "major" interference in 6%. There was no interference reported in 60% of the cases studied. Our study demonstrates that a hospital provider and its managed care system can provide satisfactory care, but it also reveals the need to constantly review treatment programs to reduce interference. The study and report are part of Vista Hill Foundation's ongoing quality review efforts.

Treatment of gastrointestinal and renal adenocarcinomas with interferon-alpha

Treatment of adenocarcinomas with interferon-alpha as a single agent has been disappointing. Recent efforts have focused on the combination of interferon with cytotoxic drugs such as 5-fluorouracil. A number of postulated mechanisms can explain synergistic interactions between 5-fluorouracil and interferon-alpha, including interaction with pyrimidine pathways, and alteration of drug metabolism. Previous studies in colorectal cancer, using 5-fluorouracil and interferon-alpha are reviewed, suggesting that the combination is more active than 5-fluorouracil alone. In renal cell carcinoma, the literature is reviewed, suggesting that daily interferon is the most efficacious schedule; preliminary data suggest that addition of 5-fluorouracil to interferon-alpha can double the expected response rate of 16% achieved by interferon-alpha alone.

The lymphomas: Hodgkin's disease and non-Hodgkin's lymphomas

This review presents an overview of a heterogeneous group of disorders that fall under the general heading of lymphomas. Many specific subtypes and presentations exist; their presentations, treatments, and prognoses vary greatly. Patients with lymphomas are generally treated with external beam radiation therapy, chemotherapy, or a combination of these two modalities. The community pharmacist may play an important role in management of patients by recognizing and alleviating the distressing side effects of treatment. Unfortunately, prevention and early detection play little role in the management of lymphomas. The improvement in survival rates of patients with all but indolent NHL is a direct result of advances in chemotherapy.

Outcome assessment: functional status measures and quality of life as therapeutic endpoints in oncology

There is now agreement among most authorities regarding the need for a global measure of outcome in cancer clinical trials and guarded enthusiasm for incorporation of these. The next step--selection of existing instruments or development of new ones--appears to represent the current state of affairs. There is an urgent need for additional research into the meaning of life and health that the diagnosis of cancer generates. There are obvious dangers in relying on scales that do not reflect the patient's perception of quality of life. A number of instruments are available, and some of these are adequate in selected contexts. Poor psychometric testing and absence of evidence of predictive validity of existing or newly developed instruments may be expected to lead to false negative findings, however, when the impact of treatments on quality of life are compared. Following instrument development will be the incorporation of questionnaires into study design, which will represent a large task for many individuals. And last, but probably most important, we will have to determine how the results of QOL trials will be interpreted. The first important step towards incorporation of QOL/functional status as outcome measures in cancer clinical trials has occurred. To reach this goal will undoubtedly require a positive commitment from both medical and research staffs.

Methods of inventory control

Various methods for controlling inventory are described, and the advantages and disadvantages of each are discussed. The open-to-buy (OTB) budget method limits purchases to a specific amount of funds available for purchasing pharmaceuticals during a specified period. The emphasis of the OTB method is financial control of the pharmacy inventory. Although it is useful in monitoring and adjusting the dollar value of the inventory, it should be combined with other methods for a total inventory control system. The primary emphasis of the short-list method is to provide accurate and timely inventory information to the person responsible for order placement. The short list identifies the items that are in short supply. It is the most common feedback and control mechanism in use, but it is best suited for settings where duplicate or reserve stock is maintained and monitored by more rigorous methods. The main objective of the minimum and maximum method is to determine when and how much to order of each item. It also provides limited dollar control. The major disadvantage of this method is the time it requires to establish the minimum and maximum levels and to update them regularly to reflect changes in demand. The stock record card method is used to record information on the movement of goods in and out of the storage area. Stock cards can also be used to monitor inventory levels and facilitate order initiation. It is probably the optimum method to be used alone. The most effective system of inventory control is one employing a combination of these methods tailored to meet the institution's needs and available resources.