TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of...

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TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional Medical Center

Transcript of TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of...

Page 1: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

TREATMENT INTERACTIONS &TODAY’S MYELOMA PATIENT

Timothy Tyler, Pharm.D., FCSHPDirector of Pharmacy Services

Comprehensive Cancer Center

Desert Regional Medical Center

Page 2: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Objectives

Understand at a basic level, the complexity of current treatments for Multiple Myeloma

Review major interactions and cautions with standard and complementary treatments

Review specific oral supplements of concern Focus on appropriate sources of information Have Fun (that’s okay – really!)

Page 3: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Comprehensive Cancer CenterDesert Regional Medical CenterComprehensive Cancer CenterDesert Regional Medical Center

Page 4: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Comprehensive Cancer Center Established in 1990 – 21st year of operation Part of 5 cancer center chain (CA / FL / NY / NJ) DRMC-CCC began a CAM team in 1999 Presented 6 month study at ISOPP VII (Prague) CAM team established weekly meetings 2000 Team is composed of a Physician, Physiologist,

Pharmacist, Dietician, Social Worker Patient satisfaction survey results demonstrate

ongoing satisfaction with service

CAM = Complementary & Alternative Medicine

Page 5: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

The Desert Experience 108 cancer patients from a single physician

surveyed from 1/99 through 6/99 Brief patient interview with a questionnaire Overall 85% prevalence rate in CAM usage About 50% of which was multivitamins or

multivitamin w/ mineral supplement Information not volunteered prior to survey

CAM = Complementary & Alternative Medicine

Page 6: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

The Desert Experience

85% used at least one form of CAM (includes multivitamin, +/- mineral combination)

52% of those using CAM take only a multi-vitamin, +/- mineral combination

29% used herbal preparations 13% used food derivatives/supplements 9% used (other) complementary therapies

CAM = Complementary & Alternative Medicine

Page 7: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Possibly Unrealistic Goals …According to the late Varro Tyler, Ph.D., Sc.D. and professor emeritus of pharmacognosy at the School of Pharmacy at Purdue University, people do set somewhat unrealistic treatment goals. If people do set unrealistic goals for themselves as it pertains to herbal products, many time they verge on “paraherbalisim – the belief in the superiority of anything natural and organic”. The most dangerous misconception that this concept brings is that natural substances cannot cause harm. Tyler warns that “some highly toxic substances are derived from plants.”

Foreman J. The Boston Globe 3/17/97

Page 8: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Traditional Oriental Medicine (TOM) “Traditional” medical in such places such as:

China, Japan, Cambodia, Korea, and Vietnam Basic principles:

Five elements of wood, fire, earth, metal, and water. Tao = “the way”, significance of change & process Yin & Yang = 2 opposing forces that drive change Ch’i = invisible universal energy force that is believed to flow

through all living organisms. Acupuncture = opens the meridians and/or directing the flow of

ch’i to promote health

Combines diet, acupuncture, meditation, physical exercise, healing exercise, herbal medicine, and massage to promote health.

Page 9: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Acupuncture NIH supports efficacy in the control of:

Chemotherapy-related nausea & vomiting Palliation of chronic pain

Studies suggest that it is reasonable to accept the use of acupuncture in conjunction with a standard antiemetic to control chemotherapy-related nausea and cancer-related pain.

NIH = National Institute of Health

Page 10: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Acupuncture Caution should be exercised in patients with:

A compromised immune system Affected limb of someone who has a lymph node

dissection (impaired lymphatic drainage)

Avoid insertion of needles in patients who are: Thrombocytopenic (low platelet counts) Using anticoagulant therapy (warfarin, aspirin, etc)

Page 11: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Manual Healing Methods Touch and manipulation, used for hundreds of

years in the medical profession Hippocrates discussed the benefits of therapeutic

touch with students Three types:

Massage Bodywork Chiropractic

Use with extreme caution with bone pain and bone disease – particularly with Multiple Multiple MyelomaMyeloma

Page 12: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Massage Involves manipulation of soft tissues Benefits may include:

stress aches & pain Improved circulation Lymph movement & motility Enhanced digestion & intestinal function General relaxation

Page 13: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Massage Studies Results … Inconclusive for relief from cancer-related pain Evidence does not indicate promotion of tumor

metastasis at this time 1 trial showed that massage reduced nausea in

patients undergoing autologous (self) BMT 2 trials found manual lymph drainage to be

effective with compression bandaging or sleeves in patients with arm lymphedema after surgery for breast cancer

BMT = Bone Marrow Transplant

Page 14: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Massage Studies have shown that massage can be helpful

in treating pain, anxiety, depression, and lethargy Concerns:

Patients who are prone to bleed, thrombocytopenic or receiving anticoagulation therapy

Deep abdominal massage has been associated with internal bleeding

Avoid over stents or other prosthetic devices Multiple Myeloma patients have greater fracture risk

Page 15: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Agents Used in Multiple Myeloma IV CHEMOTHERAPY Bortezomib (Velcade) Carmustine (BCNU) Cyclophosphamide (Cytoxan) Doxorubicin, Lipo. (Doxil) Melphalan (Alkeran) Vincristine (Oncovin)

ORAL CHEMOTHERAPY Dexamethasone (Decadron) Lenadiomide (Revlamid) Melphalan (Alkeran) Prednisone (Deltasone) Thalidomide (Thalamid)

SUPPORTIVE CARE Pamidronate (Aredia) Zolendronic Acid (Zometa)

NOTE = Agents Listed are FDA-Approved (excluding compendia) for the treatment of Multiple Myeloma

Page 16: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Antioxidants vs. Chemotherapy

To date, no definitive studies in humans have demonstrated long term effects of combining oral antioxidants and chemotherapy. There is sufficient cause for concern regarding potential interactions and it should be possible to predict obvious interactions and suggest where caution should be exercised. Improving short-term tolerance should not come at the expense of decreased effectiveness.

Oncology – July 1999

Page 17: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Bortezomib + Green Tea = Bust Green tea contains powerful polyphenols such as

epigallocatechin gallate (EGCG) Preliminary research in vitro and in vivo shows green

tea polyphenols interact with Bortezomib (Velcade) and other proteasome inhibitors.

The result is blocking the proteasome inhibitory effects such that cell death is not induced in multiple myeloma or glioblastoma cancer cell lines.

Patients taking boronic acid-based proteasome inhibitors like Bortezomib (Velcade) should not take green tea.

Source = Natural Medicines Database

Page 18: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

St. John’s Wort = No Way Jose St. John's Wort induces liver enzymes thus making it

problematic and somewhat patient variable Drugs that might be affected include Chemotherapy

agents Etoposide, Paclitaxel, Vinblastine, Vincristine. In addition, pain medications, steroids, antiemetics,

antidepressants, OTC acid blockers and numerous others are impacted

Interaction Rating = Major (Do not take) Severity = High Occurrence = Probable Level of Evidence = B

Source = Natural Medicines Database

Page 19: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Cyclophosphamide + Astragalus = ? Be cautious with taking Cyclophosphamide (Cytoxan) + Astragalus

in combination Some evidence suggests astragalus might reduce

immunosuppression caused by Cyclophosphamide Astragalus seems to stimulate immune function so theoretically,

taking Astragalus might decrease the effects of immunosuppressive therapy such as steroids and chemotherapy like Cyclophosphamide

The problem stems from when the treating clinician does not know the patient is taking an immunomodulator

In addition to Astragalus, Alfalfa, Ashwagandha, Cat’s Claw, Echinacea and about 38 other immunostimulants should be used only after gaining approval from your doctor

Source = Natural Medicines Database

Page 20: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Chemotherapy + Alpha Lipoic Acid

Theoretically, use of Alpha Lipoic Acid (ALA) might decrease the effectiveness of chemotherapy.

Preliminary evidence from an unpublished study suggests antioxidants may decrease the effectiveness of chemotherapy

Natural Medicines Database listed this for Bortezomib, Carmustine, Doxorubicin, Cyclophosphamide, Melphalan, Vincristine

Source = Natural Medicines Database

Page 21: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Chemotherapy + Enzyme CoQ10 Theoretically, taking Coenzyme Q-10 supplements

might prevent cardiotoxicity induced by Doxorubicin & Cyclophosphamide

But there is also concern that coenzyme Q-10 might lower effectiveness of doxorubicin by protecting tumor cells from chemotherapeutic agents that work by inducing oxidative stress

Similar concerns exists for the alkylating agents such as Cyclophosphamide and radiation therapy

Source = Natural Medicines Database

Page 22: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Vitamin C and The Big ‘C’ Dr. Linus Pauling

advocated in the 1970’s 3 trials to date using

10,000 mg daily No difference in patient

survival has been seen Therapy with mega doses

are not benign

Oncolink Website 3/17/2000

Page 23: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Vitamin C and The Big ‘C’ The use of antioxidants like Vitamin C during chemotherapy

remains controversial There's concern that antioxidants could reduce the activity of

chemotherapy drugs which generate free radicals Mechanisms other than the antioxidant effects of vitamin C might

be involved. This might include prevention of the damaging to the cell powerhouse (mitochondria) caused by many chemotherapy drugs, which is involved in regulating cell death

In contrast, some researchers theorize that antioxidants might make chemotherapy more effective by reducing oxidative stress that could interfere with apoptosis (cell death) of cancer cells

More evidence is needed to determine what effects vitamin C has on chemotherapy. Advise patients to consult their oncologist before using vitamin C supplements, especially in high doses.

Source = Natural Medicines Database

Page 24: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Chemotherapy + Vitamin E The use of antioxidants like vitamin E during chemotherapy remains

controversial. There's concern that antioxidants could reduce the activity of

chemotherapy drugs which generate free radicals, such as Cyclophosphamide, Carmustine, and Doxorubicin

However, some researchers theorize that antioxidants might make chemotherapy more effective by reducing oxidative stress that might interfere with apoptosis (cell death) of cancer cells

More evidence is needed to determine what effect, if any, antioxidants such as vitamin E have on chemotherapy

Natural Medicines Database advises patients to consult their oncologist before using vitamin E supplements, particularly when considering high doses especially with bleeding risks or surgery

Source = Natural Medicines Database

Page 25: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Acceptable CAM Treatments Nutrition – Fluid, Protein, Fat, MVI (RDA)

Variety of fish (Omega 3 FA) 2-3 servings/day Soy in form of food 1-2 tablespoonfuls daily ground Flaxseed

Certain herbal products – consulted & supervised Acupuncture for N/V and pain Massage for anxiety and pain (Physician willing) Moderate exercise (Physician willing) Psychological and mind-body therapies

Source = Comprehensive Cancer Center CAM Team

Page 26: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Top 12 Notes on Medicinal Herbs

Doctors should be asking you about your use of herbs/supplements If they don't – volunteer the information especially when on

treatment Natural does not mean safe (strychnine is natural) Lack of standardization: contents and efficacy may vary with brands Lack of quality control/regulation: contamination Do not use more than the recommended dose Herbals generally should not be used for more than several weeks Infants, children, and elderly should use with professional guidance Medicinal herbs should not be taken during pregnancy and lactation Avoid herbals that are known to have toxic/adverse side effects Accurate diagnosis and discussion of proven treatments are essential Stop all herbs at least 10 days prior to surgery

Page 27: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

CAM or SHAM? Many have adopted a

“whatever works”“whatever works” philosophy of medicine

There are products that have documented aid

There are products with documented harm

There are products we don’t know much about

Page 28: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Web Surfing: Watch Four Red Flags One study suggests to avoid sites with one or more

of the following red flags: 1. Online purchase of described product is available.

2. Treatment description includes patient testimonials.

3. The treatment is described as a “cancer cure.”

4. The treatment is described as “having no side effects.”

The authors also point out that the absence of red flags isn’t necessarily a guarantee of scientific accuracy.

Page 29: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

http://nccam.nih.gov

Created by congressional mandate in 1992 to “facilitate the evaluation of alternative medical treatment modalities”. Originally called the Office of Alternative Medicine, it was renamed the National Center for Complementary and Alternative Medicine in 1998. It is a division of the National Institute of Health, which is under the auspices of the Department of Health and Human Services.

  

Page 30: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Reasons People with Cancer Choose CAM Making Choices What is Complementary and Alternative Medicine Types of Complementary and Alternative Medicine Talk with Your Doctor Before You Use CAM Natural Does Not Mean Safe! Choose Practitioners with Care Getting Information from Trusted Sources Resources

Page 31: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Questions to ask about a Web site: Who runs and pays for the site? Does it list any credentials? Does it represent an organization that is well-known & respected? What is the purpose of the site, and who is it for? Is the site selling or promoting something? Where does the information come from? Is the information based on facts or only on someone's feelings / opinions? How is the information chosen? Is there a review board or is the content reviewed by experts? How current is the information? Does the site tell when it was last updated? How does the site choose which other sites to link you to?

Page 32: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Elements of good information:

Also Known As (AKA) Scientific Names (geekius herbifora) People Use This For (you’d be amazed) Safety Profile (MANDATORY):

Likely SafeLikely UnsafeDefinitely Unsafe

Page 33: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

More good Elements: Effectiveness:

Likely Effective for…Likely Ineffective for…Unknown efficacy ?

Mechanism of Action Adverse Reactions Dosage and Administration References

Page 34: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Nothing Exists in a Vacuum Interactions with Herbs & Supplements Interactions with Drugs Interactions with Foods Interactions with Lab Tests Interactions with Diseases or Conditions Interactions with pocketbook!!!pocketbook!!!

Page 35: TREATMENT INTERACTIONS & TODAY’S MYELOMA PATIENT Timothy Tyler, Pharm.D., FCSHP Director of Pharmacy Services Comprehensive Cancer Center Desert Regional.

Good CAM/Drug Information

Until there is a cure … There is the IMF