MANAGING SIDE EFFECTS OF TKIS

Ming YAO M.D.Division of HematologyDepartment of Internal MedicineNational Taiwan University Hospital

GOALS OF MANAGING SIDE EFFECTS OF TKIS IN CML

Optimize patient’s adherence to TKI Maximize safety and efficacy of TKIs Case of a non-compliant CML patient

A 38-year-old man, took imatinib 400 mg per day from Jul, 2009 as initial treatment of CML, MMR achieved one year post Imatinib tx. He took imatinib irregularly since Jul-2009 due to GI upset. Loss of CCyR was noted then regained MMR after resuming imatinib.

GENERAL CONCEPTS IN MANAGING SIDE EFFECTS OF TKIS

Side effects vary from person to person.

Individuals may tolerate one drug much better than

another.

Side effects generally increase as dose increases.

Management of side effects essential to encourage

compliance or adherence.

GENERAL PRINCIPLES IN MANAGING SIDE EFFECTS OF TKIS Generally, grade 3/4 AEs are addressed via dose

interruption followed by resumption of treatment at a reduced dose after resolution of toxicity;

Dose reduction and temporary discontinuation of TKIs have been used effectively to treat events of neutropenia and thrombocytopenia in the clinical trial setting.

The time frame of recovery of individual patients guides dosing decisions.

Common mild or moderate AEs are addressed via specific treatments or supportive care.

Common Adverse Reactions Reported in Newly Diagnosed CML Clinical Trials of

Imatinib 400 mg Once Daily ( >10% of Patients)

Probably Hematlogic AEs Related

ALL GRADES (%) GRADES 3/4 (%)　 (N 551) (N 551)Fatigue 39 1.8Headache 37 0.5Dizziness 19 0.9Cough 20 0.2Nasopharyngitis 31 0URI 21 0.2Pyrexia 18 0.9Sore throat 18 0.2Influenza 14 0.2Sinusitis 11 0.2Hemorrhage 29 1.8GI hemorrhage 2 0.5CNS hemorrhage <1 0

IMATINIBManagement of Select Side Effects Associated with Imatinib Treatment of CML-CP

Hematologic● Grade 3/4 neutropenia (ANC<1,000/uL): Dose interruption until ANC > 1,500/Ul

Growth factors can be used in combination with imatinib for patients with resistant neutropenia.

● Grade 3/4 thrombocytopenia (PLT<50K/uL): Keep Imatinib with PLT transfusion or Dose interruption until PLT > 75K/uL

46-year-old man, CML, ever treated w INF, PCyR Start imatinib 400mg /d in late CP 3 months post imatinib, Gr 4 thrombocytopenia but

achieved CCyR and MMR He received regular PLT conc. transfusion and kept on

imatinib 400mg /d Resolution of thrombocytopenia at one year post imatinib He remained MMR and continued imatinib for 10 years

IMATINIB-INDUCED THROMBOCYTOPENIA

Common Adverse Reactions Reported in Newly Diagnosed CML Clinical Trials of

Imatinib 400 mg Once Daily ( >10% of Patients)

ALL GRADES (%) GRADES 3/4 (%)

　 (N=551) (N=551)Fluid retention 62 2.5Superficial edema 60 1.5Other fluid retention 7 1.3Weight increased 16 2

Nonhematologic—Specific interventions (Grade 2 or 3 severity)● Edema: Diuretics, supportive care● Fluid retention (pleural effusion, pericardial effusion, edema, and ascites): Weighed and monitored closely; salt restriction Diuretics, supportive care, dose reduction, interruption, or discontinuation. Consider echocardiogram to check left ventricular ejection fraction.

Periorbital Edema

Common Adverse Reactions Reported in Newly Diagnosed CML Clinical Trials of

Imatinib 400 mg Once Daily ( >10% of Patients)

ALL GRADES (%) GRADES 3/4 (%)　 (N=551) (N=551)Nausea 50 1.3Diarrhea 45 3.3Abdominal pain 37 4.2Vomiting 23 2Dyspepsia 19 0Constipation 11 0.7

● GI upset: Take medication with a meal and large glass of water split dosing, eg 200mg bid taking the imatinib prior to going to bed. antiemetic● Diarrhea: Supportive care

Common Adverse Reactions Reported in Newly Diagnosed CML Clinical Trials of

Imatinib 400 mg Once Daily ( >10% of Patients)

ALL GRADES (%) GRADES 3/4 (%)　 (N=551) (N=551)Muscle cramps 49 2.2Musculoskeletal pain 47 5.4Joint pain 31 2.5Myalgia 24 1.5Bone pain 11 1.6

● Muscle cramps and musculoskeletal pain : increased fluid intake calcium and potassium supplements tonic water (quinine content) NSAID

Common Adverse Reactions Reported in Newly Diagnosed CML Clinical Trials of

Imatinib 400 mg Once Daily ( >10% of Patients)

ALL GRADES (%) GRADES 3/4 (%)　 (N=551) (N=551)Skin rashes 40 2.9Insomnia 15 0Depression 15 0.5

● Rash: Most cases of skin toxicity are mild to moderate in severity and appear soon after treatment begins. Topical or systemic steroids Dose reduction, interruption, or discontinuation for severe case (rare)

If any of the grade 2 or 3 toxicities are not responsive to symptomatic measures, treat as grade 4.

Nonhematologic—Grade 4

Hold drug until grade 1 or better, then consider resuming dose at 25%–33% dose reduction (not less than 300mg). Consider change to dasatinib, nilotinib, or clinical trial.

Nonhematologic — Liver

● Grade 2: Hold drug until grade <1. Resume at 25%–33% dose reduction (not less than 300 mg). Evaluate forother hepatotoxic drugs that may be contributing to toxicity, including acetaminophen. Consider change to DASA, NILO, or clinical trial.

● Grade 3/4: Consider change to DASA, NILO, or clinical trial.

IMATINIB

IMATINIB INTOLERANCE• 68-year-old woman CML-CP began imatinib (IM)400 mg/d• Quickly developed gr. 1 periorbital edema, loose stools, and

a slight elevation in bilirubin; reassurance !• CCyR in 3M post IM • After 6 Ms of therapy, she had a gr. 3 skin rash covering

30%-60% of her body. IM was suspended, treated with topical and oral steroids until the rash completely resolved

• Resume IM at 300 mg/d, rashes recurred, stop IM again • After several attempts to restart IM, which rapidly resulted

in a recurrent rash, the patient was considered to be intolerant to IM.

• Shift to to nilotinib, 400 mg twice daily. Six years after diagnosis, she is maintaining an MMR and is tolerating the nilotinib well.

DASATINIB COMMON SIDE EFFECTS (ALL PATIENTS, ALL GRADES)

Fluid retention (edema) 37%Diarrhea 31%Headache 24%Nausea 22%Pleural effusion 22%

Bleeding and thrombocytopenia (platelet dysfunction in vitro), platelets can drop very quickly, hemorrhage possible, monitor carefully.

Fluid retention can be severe, including pleural or pericardial effusion. If develop dyspnea (shortness of breath), do chest x-ray. May occur months into therapy.

Side effects less severe at 140 mg once a day dose vs. 70 mg twice a day.

Possible prolongation of QTc interval

Rash 22%Fatigue 21%Hemorrhage 21%Dyspnea 20%Musculoskeletal pain 14%

DASATINIB-INDUCED PLEURAL EFFUSIONS Dasatinib-induced pleural effusions are potentially serious

and require prompt diagnosis and treatment. For patients with grade 2-3 pleural effusion, dasatinib

therapy should be discontinued; a short course of diuretics or use of an oral steroid, such as prednisone 20 mg/day three times daily, should be administered.

Patients should be educated to report symptoms of chest pain, dyspnea, and dry cough as soon as they occur.

A lower dasatinib dose should be used when treatment is resumed.

Comorbid conditions (autoimmune disease, hypertension, cardiovascular disease) may play a role in the development of pleural effusions. Patients with these conditions, therefore, may need closer monitoring.

DASATINIB-INDUCED PLEURAL EFFUSIONS &THROMBOCYTOPENIA 42-year-old man, CML AP CHR but only PCyR after IM 600mg/d for one year Shift to dasatinib (DA)140 mg/d Gr 4 thrombocytopenia w Gr 3 pleural effusion Hold DA then he was back to Gr 1 AEs Resume DA at 100 mg/d, CCyR achieved (6M post DA) Gr 4 AEs again, PLT transfusion w diuretics Loss of CCyR (18M post DA) Allogeneic HSCT w unrelated donor Remained CMR 7 years post-allo-HSCT

NILOTINIBCOMMON SIDE EFFECTS (ALL PATIENTS, ALL GRADES)Rash 33%

Pruritis (itching) 29%Nausea 31%Headache 31%Fatigue 28%

Diarrhea 22%Constipation 21%Vomiting 21%Arthralgias 18%Cough 17%

•Special considerations in using nilotinib are related to QT interval prolongation. •Patients with hypokalemia, hypomagnesemia, or long QT syndrome should be avoided or employed with caution. •Nilotinib should not be used with strong CYP3A4 inhibitors. •ECG should be conducted before starting nilotinib, 7 days after initiation of therapy, with any dose changes, and regularly during treatment.

NILOTINIB: HEPATOTOXICITY Use with caution in patients with known hepatic impairment. Liver enzyme and bilirubin elevations are often transient,

resolve with short treatment break. Elevated lipase and amylase may occur.

Pancreatitis has also occurred.

● Elevated serum levels of lipase, amylase, bilirubin, and/or

hepatic transaminases (grade >3 ) serum levels return to

grade < 1. Resume nilotinib at 400 mg once daily.

NILOTINIB INDUCED HYPERBILIRUBINEMIA

42-year-old man, CML CP Nilotinib 300 mg bid as 1st line treatment CCyR with CMR achieved 3M post NI Gr 3 Hyperbilirubinemia & Gr 2 ALT elevation Adjust NI to 400 mg/d Gr 2 Hyperbilirubinemia without malaise, so hold NI resumed NI at 400 mg/d when AE returned to Gr 1 Resolution of Hyperbilirubinemia 6M after resuming NI Now on NI 400 mg/d, CML remains CMR

SUMMARY All 3 TKI’s well-tolerated compared to traditional

chemotherapy and interferon. With aggressive adverse effects management,

most patients have good quality of life. Adverse effects generally decrease over time. Management of side effects is essential to

encourage compliance or adherence.