• Save
Focussing on cytotoxic treatment alone is not enough
Upcoming SlideShare
Loading in...5

Focussing on cytotoxic treatment alone is not enough



PharmaCon2007 Congress, Dubrovnik, Croatia "New Technologies and Trends in Pharmacy, Pharmaceutical Industry and Education" http://www.pharmacon2007.com ...

PharmaCon2007 Congress, Dubrovnik, Croatia "New Technologies and Trends in Pharmacy, Pharmaceutical Industry and Education" http://www.pharmacon2007.com
Abstract is available at http://www.pharmaconnectme.com



Total Views
Views on SlideShare
Embed Views



1 Embed 1

http://www.pharmaconnectme.com 1



Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
  • http://www.fioricetsupply.com is the place to resolve the price problem. Buy now and make a deal for you.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment

Focussing on cytotoxic treatment alone is not enough Focussing on cytotoxic treatment alone is not enough Presentation Transcript

  • FOCUSSING ON CYTOTOXIC TREAT-MENT ALONE IS NOT ENOUGH Per Hartvig, European Society of Oncology Pharmacy, ESOP and University hospital pharmacy, Uppsala, Sweden
  • European Society of Oncology pharmacy, ESOP
    • AIM of ESOP is To support optimal treatment of cancer patients
    • Objectives:
      • To develop oncology pharmacy by
      • Education and training
      • Safe handling and administration of drugs
      • Quality management
      • Research and development
      • Pharmaceutical care
  • MasterClass in Oncology Pharmacy, Ishöj, Dk, Nov 5th to 9th
    • Oncology Pharmacy Production service
    • Safe handling of cytotoxic drugs
    • Clinical oncology pharmacy
    • Cancer care needs and future developments
    • Pharmaceutical care needs in oncology
  • Adverse effects of cytotoxic drugs in patients
    • Acute toxicity Nausea, hair loss etc,
    • "Oversensitivity" Rash, airway
    • obstruction, edema
    • Teratogenic Misscarriage, still
    • birth, malformations
    • Mutagenenic DNA damage
    • Cancerogenic Secondary cancer
  • Handling of cytotoxic of drugs
    • "Safe handling and preparation of cytotoxic drugs using gloves, protective cuffs, special gowning, mouth mask and glasses in a special vertical air laminar flow box do not give enhanced mutagenic activity in urine of personnel"
            • B Kolmodin-Hedman, P Hartvig, M Sorsa, K Falck
            • Arch Toxicol 54: 25-33, 1983
  • Exposure to cytotoxic drugs
    • Biomarkers
      • Bacterial fluctuation test
      • Sister chromatid exchanges
      • Thioethers in urine
      • Chromosmal abberations in lymphocytes
      • Direct assay of drug: HPLC with TOF-MS
      • (MS/MS)
  • Health risk of cytotoxic drugs
    • Increased rate of spontaneous abortions was 1.33 in 897 per year
    • Epidemiological studies only establish relation between exposure and outcome not CAUSE
  • Health risk of cytotoxic drugs
    • Only increased risk for spontaneous abortions
    • Underestimation of risk may cause major health effects
    • Overestimation causes may redirect limited resources away from larger risks
    • Effective risk communication necessary:
      • "People are more afraid of low relative risks"
  • Supportive care
    • Pain
    • Nausea and vomiting
    • Fatigue
    • Diarrhoea
    • Constipation
    • Cachexia
    • Fewer
    • Infection
    • Mucositis
    • Alopecia
    • Neutropenia
    • Anxiety
    • Sleep problems
    • Social interferences
    • Phycological distress
    • Sleep disturbances
  • Role of the oncology pharmacist
    • A member of the cancer care team
    • Formulate a treatment plan for each patient
    • Optimise supportive treatment for every patient
    • Expert on cytotoxic drug preparation
    • Pharmacologic consultant
    • Information to patients and personnel
  • Treatment of nausea and vomiting
    • Nausea and vomiting due to cancer and cancer treatment most feared side effect
    • Nausea appear in different phase (acute, delayed and anticipatory)
    • New drug principles has improved treatment
    • Mechanism of cytotoxic induced nausea and vomiting still unclear
  • Treatment of Cytotoxic induced emesis Perugia document 2004
    • Phase ___ Cytotoxics _ Recommended drugs
    • 1. Acute phase
    • Low 5FU, methotrexate Dexamethason
    • High Cyclophosphamide Sertrone + examethason Doxorubicin,epirubicin +aprepitant (NK1 ant)
    • Cisplatinum
    • 2.Delayed emesis
    • Low Dexametason
    • High Dexamethason+aprepitant
    • 3. Anticipatory emesis Prevention of acute and
    • delayed emesis-lorazepam
  • Questions still to be answered:
      • Why so intense ?
      • Why so long, even after elimination of cytotoxic drugs ?
      • Why occur emesis even without cytotoxic drugs - e.g. anticipatory emesis ?
      • Mechanism of action
  • Triggers for emesis
    • GI tract - chromaffin cells in the fundus of ventricle
    • Nucleus vestibularis in the centre for balance
    • Chemoreceptor triggerzon outside 4th ventricule
    • Centre of emesis in the brain
  • Acute phase of cytotoxic emesis
    • Starts on day one and have a short duration
    • often compatiple with kinetics of cytotoxics
    • Sertrones, blocking 5HT3 receptors in the stomach and emesis centre are effective
    • New sertrones have longer duration due to higher receptor affinity and better kinetics
  • Delayed cytotoxic induced emesis
    • Neuropeptides increase the release of neuro-transmitters which may trigger emesis
    • Cytotoxic drugs interfere with DNA in cells producing enzymes responsible for degradation of the neuropeptides
    • Cytotoxics increase levels of neuropeptides not degraded by loss of catabolising
    • enzymes
    • Blockade of neuropeptide receptors NK1 (aprepitant) are effective
  • Late phase–anticipatory emesis
    • Occurs month to years after cytotoxic drugs
    • Occurs by rememberance of cytotoxics
    • No effective treatment available
    • Mechanism: Induction of wind-up weith formation of a protein for rememberance
    • Suggested methods
      • effective treatment of early cytotoxic amnesia effect of benzodiazepines (lorazepam)
      • induced emesis
  • Knowledge nessecary for better emesis control in cancer
    • Different mechanisms over time
      • Acute : Induce release of serotonin and dopamine
      • Delayed : Increased neuropeptide levels due to inhibition of catabolism
      • Late anticipatory: Sensitisation with formation of a ”memory protein”
    • Although improved treatment, emesis still a problem following cytotoxic drugs.
  • Cytotoxic drug induced fatigue -still a treatment challenge for the suffering cancer patient
    • Prevalence is very high > 80 %
    • There is no translation of ”fatigue”
    • The cancer patient perspective
      • ” I have been tired in the past but never so much as now”
      • ” I now become tired very suddenly, My energy used to run out gradually instead of all at once now”
      • ” I am physically worn out”
  • Treatment of fatigue
    • Virtually NONE
    • Multidimensional disorder requiring a combination of interventions
    • ”… the best way to treat fatigue may be be to take into consideration and treat all components that contribute”( Kalman 1997 )
    • (Drugs, Antidepressants ?)
  • Fatigue in cancer patients
    • Mechanisms in fatigue
      • Cytokines as IL-1  and IL-6 with activation of the HPA axis and CRH
      • Stressinduced lower release of corticotropin releasing factor, CRH
      • Central changes in serotonin and noradrenergic transmission
      • The role of Substance P
      • EXERCISE ?
  • Exercise to combat fatigue
    • One week after treatment
    • Next treatment
  • Fatigue and other side effects
  • The Oncology Pharmacist
    • The role of the oncology pharmacist
      • Patients must be informed about fatigue in cancer and cytotoxic drug treatment
      • Fatigue must be included in a treatment plan
      • Treatment of patient´s side effects essential
      • Exercise good alternative to combat fatigue
      • Early and repeated information necessary to introduce exercise in daily life in cancer
  • Patients need information
    • Information FROM patients (needs assessment, feedback for quality improvement, values and preferences)
    • Information TO patients (prevention, self-care, treatment decisions, policy options)
  • Feed back from patients
    • No one to talk to about anxieties and concerns
    • Tests/treatments not clearly explained
    • Not enough involvement in decisions
    • Insufficient information for family/friends
    • Insufficient information about recovery
  • Research finding from Germany
    • Most patients want more information
    • Many, but not all, patients want to participate in decisions about their care
    • Clinicians underestimate patients’ desire for information
    • Clinicians are often unaware of patients’ preferences
  • Patient Information Needs
    • Illness and symptoms
    • Tests and treatment options
    • Self-help and prevention
    • Services and sources of help
    • Quality of health care providers
  • Patients questions at diagnosis
    • What is wrong with me?
    • What is causing the problem?
    • What are the tests for?
    • How certain is the diagnosis?
    • How does my experience compare with others with this problem?
  • Patients questions on treatment
    • What are the options?
    • Benefits and harms?
    • Will treatment relieve the symptoms?
    • Is treatment essential?
    • Recovery time?
    • Impact on quality of life?
  • Quality Standards for Patient information
    • Use patients’ questions as starting point
    • Address patients’ concerns
    • Include all treatment options
    • Honest about benefits and harms
    • Quantify where possible
    • Questions to ask the doctor
  • Questions reflecting pharmaceutical care
    • Are you interested to learn about side-effects and interactions related to your oncology therapy?
    • Has your pharmacist informed you about these topics?
    • In which topics you are mostly interested to be informed by your pharmacist?
  • Role of Oncology pharmacist
    • 60% of all patients like to get informations from pharmacists.
    • 75% of all patient, who like to get good informations have got no satisfaction.
    • Information about cytotoxics drugs as well as supportive drugs shall be added with information of alternative medicine (30% of all patients).
    • ENOUGH………..
    • Thank You all