Regimen: Sunitinib Malate
Raymond E et al. N Engl J Med 2011;364:501–513
Sunitinib malate 37.5 mg per day orally, continually (total dose/week = 262.5 mg)
Notes:
In patients without an objective tumor response who had grade ≤1 nonhematologic or grade ≤2 hematologic treatment-related adverse events during the first 8 weeks, the dose may be increased to 50 mg per day
Patients can receive somatostatin analogs as needed
Supportive Care
Antiemetic prophylaxis
Emetogenic potential is MINIMAL–LOW
See Chapter 39 for antiemetic recommendations
Hematopoietic growth factor (CSF) prophylaxis
Primary prophylaxis is NOT indicated
See Chapter 43 for more information
Antimicrobial prophylaxis
Risk of fever and neutropenia is LOW
Antimicrobial primary prophylaxis to be considered:
See Chapter 47 for more information
Diarrhea management
Latent or delayed onset diarrhea✫:
Loperamide 4 mg orally initially after the first loose or liquid stool, then
Loperamide 2 mg orally every 2 hours during waking hours, plus
Loperamide 4 mg orally every 4 hours during hours of sleep
Continue for at least 12 hours after diarrhea resolves
Recurrent diarrhea after a 12-hour diarrhea-free interval is treated as a new episode
Rehydrate orally with fluids and electrolytes during a diarrheal episode
If a patient develops blood or mucus in stool, dehydration, or hemodynamic instability, or if diarrhea persists >48 hours despite loperamide, stop loperamide and hospitalize the patient for IV hydration
Alternatively, a trial of Diphenoxylate hydrochloride 2.5 mg with Atropine sulfate 0.025 mg (eg, Lomotil)
Initial adult dose is 2 tablets 4 times daily until control has been achieved, after which the dose may be reduced to meet individual requirements. Control may often be maintained with as little as 2 tablets daily
Clinical improvement of acute diarrhea is usually observed within 48 hours. If improvement of chronic diarrhea after treatment with a maximum daily dose of 8 tablets is not observed within 10 days, control is unlikely with further administration
Persistent diarrhea:
Octreotide acetate (solution) 100–150 mcg; subcutaneously 3 times daily. Maximum total daily dose is 1500 mcg
Antibiotic therapy during latent or delayed onset diarrhea:
A fluoroquinolone (eg, Ciprofloxacin 500 mg orally every 12 hours) if absolute neutrophil count <500/mm3 with or without accompanying fever in association with diarrhea
Oral care
Prophylaxis and treatment for mucositis/stomatitis
General advice:
Encourage patients to maintain intake of nonalcoholic fluids
Evaluate patients for oral pain and provide analgesic medications
Consider histamine (H2-subtype) receptor antagonists (eg, ranitidine, famotidine), or a proton pump inhibitor for epigastric pain
Lactobacillus sp.-containing probiotics may be beneficial in preventing diarrhea
Patients with intact oral mucosa:
Clean the mouth, tongue, and gums by brushing after every meal and at bedtime with an ultrasoft toothbrush with fluoride toothpaste
Floss teeth gently every day unless contraindicated. If gums bleed and hurt, avoid bleeding or sore areas, but floss other teeth
Patients may use saline or commercial bland, nonalcoholic rinses
If mucositis or stomatitis is present:
Keep the mouth moist using water, ice chips, sugarless gum, sugar-free hard candies, or a saliva substitute
Rinse mouth several times a day to remove debris
Use a solution of ¼ teaspoon (1.25 g) each of baking soda and table salt (sodium chloride) in 1 quart (~950 mL) of warm water. Follow with a plain water rinse
Do not use mouthwashes that contain alcohols
Foam-tipped swabs (eg, Toothettes) are useful in moisturizing oral mucosa, but ineffective for cleansing teeth and removing plaque
Advise patients who develop mucositis to:
Choose foods that are easy to chew and swallow
Take small bites of food, chew slowly, and sip liquids with meals
Encourage soft, moist foods such as cooked cereals, mashed potatoes, and scrambled eggs
For trouble swallowing, soften food with gravies, sauces, broths, yogurt, or other bland liquids
Avoid sharp, crunchy foods; hot, spicy or highly acidic foods (eg, citrus fruits and juices); sugary foods; toothpicks; tobacco products; alcoholic drinks
Hand–foot reaction (palmar–plantar erythrodysesthesia, PPE)
For patients who develop a hand–foot reaction, use topical emollients (eg, Aquaphor), topical or orally administered steroids, antihistamine agents (H1-receptor antagonists), or pyridoxine
Pyridoxine may provide relief for discomfort/pain associated with PPE although the mechanism through which this occurs remains unclear
Patient Population Studied