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Managing treatment effects

Encourage your patients to communicate with you regularly regarding any side effects they may experience during treatment. In addition, your patients should call someone on the healthcare team if they experience any side effects that:

• Continue for an unreasonable amount of time
• Interfere with their daily life
• They consider to be serious

Diarrhea
Uncomplicated CTID can be managed conservatively
Management of uncomplicated CTID
Adapted from Kornblau et al, with permission from the US Cancer Pain Relief Committee.
Management

• Stop all lactose-containing products, alcohol, and high-osmolar dietary supplements
• Provide instruction for dietary management
• Drink 8-10 large glasses of clear liquids per day
• Eat frequent small meals
• Record number of stools and report life-threatening sequelae
• Grade 2: Hold cytotoxic chemotherapy until symptoms resolve; consider dose reduction

Treatment:

• Loperamide: Initial dose 4 mg followed by 2 mg q4h or after every unformed stool – maximum of 16 mg/24 h

Reassess in 12-24 hours
Diarrhea resolving

• Continue instructions for dietary management
• Gradually add solid foods
• Discontinue loperamide after 12-hour diarrhea-free interval

Persistent diarrhea (NCI grades 1-2)

• Loperamide 2 mg q2h
• Oral antibiotics (if needed)

Progression to severe diarrhea (NCI grades 3-4*)

• Treat as complicated diarrhea

Reassess persistent diarrhea after 12-24 hours
If diarrhea persists, reevaluate patient and consider the following:

• Check stool workup, CBC, and electrolytes
• Perform abdominal exam
• Replace fluids and electrolytes as appropriate
• Stop loperamide
• Begin octreotide (100-150 µg SC TID with dose escalation up to 500 µg TID)
• Or begin other second-line agent (eg, tincture of opium)

Progression to severe diarrhea (NCI grades 3-4*)

• Treat as complicated diarrhea

"NCI = National Cancer Institute; CBC = complete blood count; SC = subcutaneous; TID = 3 times per day.
*With or without fever, dehydration, neutropenia, and/or blood in stool.

Proper nutrition can be used to manage diarrhea
Dietary modifications to recommend:
Fluids
Drink liquids at room temperature slowly; drink at least 1 cup after each loose bowel movement or 8-12 cups/day

• Broth
• Soups
• Ginger ale (noncarbonated)
• Sports drinks
• Apple juice
• Water
• Weak tea

Foods to eat

• Low-fiber foods (eg, white bread, white rice, noodles, creamed cereals, ripe bananas, canned or cooked skinless fruits, cottage cheese,* yogurt,* eggs, mashed or baked skinless potatoes, pureed vegetables, skinless chicken or turkey, and fish)
• Potassium-rich foods (eg, bananas, oranges, potatoes, and peach or apricot nectars)^†

Foods to reintroduce

• Begin with BRAT (bananas, rice, applesauce, toast) diet and clear liquids
• When diarrhea begins to resolve, add easily digested foods (as tolerated)

*Limit to no more than 2 cups/day.
^†Unless instructed otherwise by clinician.

Foods to avoid

• Greasy, fried, spicy foods
• Hot or cold liquids
• High-fiber foods (eg, whole grain breads and cereals, raw vegetables, beans, broccoli, cauliflower, cabbage, nuts, seeds, popcorn, and fresh or dried fruits): Can irritate the bowel and increase motility
• Milk and milk products (if they make the diarrhea worse)
• Gas-forming foods and beverages (eg, peas, lentils, broccoli, cauliflower, cabbage, chewing gum, and soda) : Can increase abdominal cramping and bloating
• Sweets
• Caffeine and alcohol: Can irritate the bowel and increase motility

Prolonged diarrhea can lead to temporary lactose intolerance

Complicated CTID requires more aggressive management*

Management of complicated CTID
Admit to hospital^†

• Administer octreotide (100 to 150 µg SC TID or IV [25-50 µg/h] if dehydration is severe with dose escalation up to 500 µg TID)
• Start intravenous fluids and antibiotics as needed (eg, fluoroquinolone)
• Stool workup, CBC, and electrolyte profile
• Discontinue cytotoxic chemotherapy until all symptoms resolve; restart cytotoxic chemotherapy at reduced dose

Adapted with permission from Benson III et al.

*Severe cases of diarrhea associated with treatment with TYKERB may require administration of oral or intravenous electrolytes and fluids and interruption or discontinuation of therapy with TYKERB.
^†For radiation-induced cases and select patients with chemotherapy-induced diarrhea, consider intensive outpatient management unless the patient has sepsis, fever, or neutropenia.

Rash

Assessment of rash
NCI Common Terminology Criteria for rash
Adapted from the NCI Common Terminology Criteria for Adverse Events, version 3.

Grade 1

• Macular or papular eruption or erythema without associated symptoms

Grade 2

• Macular or papular eruption or erythema with pruritus or other associated symptoms
• Localized desquamation or other lesions covering <50% of BSA

Grade 3

• Severe, generalized erythroderma or macular, papular, or vesicular eruption
• Rash/desquamation covering ≥50% BSA

Grade 4

• Generalized exfoliative, ulcerative, or bullous dermatitis

Grade 5

• Death

BSA = body surface area.

Grading rash properly can help to determine appropriate management strategies. When assessing for rash, it is important to ask patients if they have symptoms associated with rash, such as edema, redness, burning, itchiness, and tenderness of the skin. Most adverse effects associated with TYKERB, including rash, are mild or moderate.

Grade 1 and grade 2 rash occurred in 26% of patients taking TYKERB plus capecitabine versus 13% taking capecitabine alone. Grade 3 rash occurred in 2% of patients taking TYKERB plus capecitabine versus 1% taking capecitabine alone. No grade 4 rash was reported.

Assessment of nail changes
Nail changes occurred in 5% of patients taking TYKERB plus capecitabine versus 2% taking capecitabine alone.

NCI Common Terminology Criteria for nail changes
Adapted from the NCI Common Terminology Criteria for Adverse Events, version 3.

Grade 1

• Discoloration
• Ridging (koilonychias)
• Pitting

Grade 2

• Partial or complete loss of nails
• Pain in nail beds

Grade 3

• Interfering with ADL

Supportive management of skin to recommend:

Intervention	Patient Instructions
Mild soap	Use mild soap as soon as therapy begins When bathing or showering, use emollients instead of gel or soap to ensure maximal hydration of skin (eg, Cetaphil®, Aveeno®, Neutrogena®)
Bath/shower	Use tepid (lukewarm) water when bathing or showering
Sunscreen	Use a broad-spectrum sunscreen (zinc oxide or titanium dioxide, SPF 30 or higher)

Cetaphil is a registered trademark of Galderma Laboratories, L.P.
Aveeno is a registered trademark of Johnson & Johnson Consumer Companies, Inc.
Neutrogena is a registered trademark of Neutrogena Corporation.

Hand-foot syndrome (Palmar-plantar erythrodysesthesia) management to recommend:
Hand-foot syndrome causes redness, skin peeling, and tingling or numbness in the palms of your patients’ hands and the soles of their feet. Talk with your patients about ways to manage hand-foot syndrome⁵:

• Avoid exposure of hands and feet to heat or friction
• Apply ice for temporary pain relief
• Use lotions to moisturize hands and feet⁵
  
  

Nausea management to recommend:
Nausea is another side effect that your patients may experience. Advise your patients about taking medicine to help control nausea and vomiting.¹ The following tips may help patients who experience nausea:

• Eat before you feel hungry
• Eat small meals throughout the day
• Eat foods at room temperature
• Sip liquids all day long
• Go into another room to eat if cooking odors make you feel sick
• Avoid foods that are greasy, very sweet, or spicy⁶

Vomiting management to recommend:
Instruct your patients to avoid triggers that may cause vomiting:

• Limit contact with food or odors that make you feel as though you might throw up. Avoid activities that may cause motion sickness (such as riding in a car)⁶
• Follow the tips for managing nausea. Controlling nausea may prevent vomiting

If your patients start to vomit, you may advise them to:

• Stop eating and drinking until the vomiting is under control
• Start with small amounts of water, broth, or other clear liquids when you are ready to eat again. If those stay down, then try soft foods like gelatin, plain cornstarch pudding, yogurt, strained soup, or strained cooked cereal. Slowly work up to eating solid food^6,7

See Resources and patient support for downloadable materials to help your patients manage treatment effects.