colon cancer case with answer for therapeutics

1. Colon cancer
(Case answers)
Faculity of Clinical pharmacy
2018

6. ?
1a
Identify the patient’s drug therapy
problems

7. 1. Ineffective drug therapy.
CapeOx , bevacizumab, and capecitabine seems to
be ineffective.
2. Adverse drug reaction.
Acral erythema due to Capecitabine.
3. Needs additional drug therapy.
Elevated BP 164/93.
1a. Identify the patient’s drug therapy problems.

8. ?
1b
What clinical , laboratory , and
another information is consistent
with colon cancer

9.  Clinical presentation:
1 ) In general : In Our patient
1 ) Rectal bleeding 1) Abdominal pain ( 5-6) /10
2) blood mixed with stool 2) numbness
3) Dark red blood 3) tingling
4) Change in bowel habit 4) cramping and burning (6/10)
5) Constipation 5) Redness and swelling on palms
6) Diarrhea 6) Fewer bowel movement
7) Abdominal pain 7) barium enema revealed
8) weight loss 8) fatigue
9) weakness and fatigue

10.  Laboratory identification:
1) LDH is high
2) Hgb 9.6 g/dl ( low indicating anemia )
3) Hct 29% (low)
4) CEA ( Carcenoembergonic antigen ) 7.9/dl (high)
5) ALT and AST ( high)

11. ?
2
What are the pharmacotherapy
goals of this patient

12. • Since the patient suffers from stage IV of colon
cancer, the aim is to :
1. Palliative treatment to reduce symptoms.
2. Avoid disease-related complications.
3. Prolong survival.

13. ?
3a
What chemotherapeutic options are
appropriate in this patient

14. • Chemotherapy is the primary treatment
modality for unresectable MCRC.
• Epidermal growth factor receptor (EGFR)
inhibitors should be considered only in
patients with tumors with wild-type KRAS.

15. Accepted initial chemotherapy regimens:
• oxaliplatin-containing regimens (FOLFOX,
CapOx),
• irinotecan-containing regimens (FOLFIRI),
• oxaliplatin plus irinotecan plus fluorouracil plus
leucovorin
• (FOLFOXIRI),
• infusional fluorouracil plus leucovorin alone, and
• capecitabine alone

16. • FOLFOX (folinic acid=leucovorine , fluorouracil
and oxaliplatin)
• Leucovorin enhances cytotoxic activity of
fluorouracil.

17. EGFR inhibitors
• Panitumumab: can be combined with either
FOLFOX or FOLFIRI in patients with wild-type
KRAS tumors.
• Cetuximab : indicated for use in patients with
wild-type KRAS tumors in combination with
FOLFIRI
SE: acne-like skin rash, asthenia, lethargy,

21. ?
3b
What treatment modification are
appropriate to address escalating
oxaliplatin-induced neuropathy

22. • The current recommendations for the
management of the acute and cumulative
neurotoxicity from oxaliplatin include education
about exposure to cold, dose modification, “stop
and go”, and use of neuromodulatory agents, in
particular, intravenous calcium and magnesium
infusion.
• variety of nutritional supplements, including
vitamin E, B vitamins, alpha lipoic acid, acetyl-L-
carnitine

23. ?
4awhat drugs, dosage forms, treatment
schedule, and duration of therapy are the
best for treating this patient’s colon cancer

24. European Society for Medical Oncology
Our patient:
• KRAS gene wild type
• He is homozygous for the
UGT1A1 *28 allele:
reduced level of hepatic bilirubin
UDP-glucuronosyltransferase 1A1
Which increased risk of irinotecan
toxicity.

25. FOLFOX plus panitumumab
• Oxaliplatin 85 mg/m2 IV on day 1
• Leucovorin 400 mg/m2 IV on day 1
• Fluorouracil 400 mg/m2 IV bolus, after leucovorin on day 1, then 1200
mg/m2/day × 2 days CIV (total 2,400 mg/m2 over 46–48 hours)
• Repeat every 14 days
• Panitumumab 6 mg/kg IV day 1 before mFOLFOX6
• Repeat cycle every 2 weeks
• the optimal duration of chemotherapy for mCRC remains controversial but
options are a fixed treatment period (3–6 months)

26. ?
4bwhat drugs, dosage forms, treatment
schedule, and duration of therapy are the
best for treating this patient’s colon cancer

27.  For foot-hand syndrome: urea cream
 For possible emesis: Day1,2 and 3 odansetron
 For anemia: 324 mg iron flumate PO TID

28. ?
5aHow is the response to the treatment
regiment for the colon cancer assessed

34. ?
5bWhat acute adverse effects are anticipated
with the chemotherapy regimen , what
parameters should be monitored

35. -Monitoring :
o CBC
o CMP
o CEA
o CT

36. ?
5cwhat pharmacologic measures can be
instituted to prevent or manage the acute
toxicities associated with the chemotherapy
regimen

40. ?
5dWhat are the potential late-onset toxicities of
the chemotherapy regimen, and how can
they be detected and prevented

41. Heart problems:
Congestive heart failure (CHF)—weakening of the heart
muscle. People with CHF may experience shortness of
breath, dizziness, and swollen hands or feet.
Coronary artery disease—heart disease. People who have
heart disease may experience chest pain or shortness of
breath.
Arrhythmia—irregular heartbeat. People who have an
arrhythmia may experience lightheadedness, chest pain,
and shortness of breath.
Other heart tests may include a physical
examination, an electrocardiogram (EKG or ECG), and
a multigated acquisition scan (MUGA) scan.
High blood pressure:
testing blood pressure, losing weight, eating less salt, taking
medicine, and being active.

42. Lung problems: The late effects may include the
following:
• A change in how well the lungs work
• Thickening of the lining of the lungs
• Inflammation of the lungs
• Difficulty breathing
Hormone problems for men.
receive treatments to raise their testosterone levels
Fertility
• Protecting the testes from radiation therapy
• Sperm banking
• Testicular sperm extraction and epididymal sperm
aspiration.
• Testicular-tissue freezing.

43. ?
6What information should you provide to the
patient to enhance compliance , ensure
successful therapy, and minimize adverse
effects

44. General points
 The treatments available:
 Surgery to remove the part of the colon or rectum that has cancer
 Chemotherapy, which is the medical term for medicines that kill cancer
cells or stop them from growing.
 Radiation therapy
 Lifestyle :
 Decrease the diet containing high in fat and meat.
 Avoid smoking
 Avoid alcohol intake
 Decrease the body weight and monitor for any increasing in the weight
 Tell your doctor and pharmacist about all of your drugs
(prescription or OTC, natural products, vitamins) and any other
health problems

45. Medications
Pantiumumab:
• If you are allergic to any drugs like this one, any other drugs,
foods, or other substances. Tell your doctor about the allergy
and what signs you had, like rash; hives; itching; shortness of
breath; wheezing; cough; swelling of face, lips, tongue, or
throat; or any other signs.
• If you have upset stomach, throwing up, loose stools
(diarrhea), or are not hungry, talk with your doctor.
• Have a blood and eye tests periodically.
• This drug may cause fertility problems.

46. WARNING/CAUTION:
 Signs of an allergic reaction, like rash; hives; itching; red, swollen,
blistered, or peeling skin with or without fever; wheezing; tightness
in the chest or throat; trouble breathing, swallowing, or talking;
unusual hoarseness; or swelling of the mouth, face, lips, tongue, or
throat.
 Signs of fluid and electrolyte problems like mood changes,
confusion, muscle pain or weakness, a heartbeat that does not feel
normal
 Change in eyesight, eye pain, or very bad eye irritation.
 Chest pain or pressure.
 Coughing up blood.

47. Fluorouracil +
leucovorin+oxaliptin :
 Risk of infection
Contact your doctor if you have :
 your temperature goes over 37.5°C (99.5°F) or over 38°C (100.4°F),
depending on the advice given by your chemotherapy team
 you suddenly feel unwell, even with a normal temperature
 you have symptoms of an infection – these can include feeling shaky, a
sore throat, a cough, diarrhea or needing to pass urine a lot

48. Tell your doctor if you have any bruising or bleeding you can’t explain.
This includes nosebleeds, bleeding gums, blood spots or rashes on the
skin. If the number of red blood cells is low, you may be tired and
breathless . Tell your doctor or nurse if you feel like this. If you are very
anemic, you may need a drip to give you extra red blood cells (blood
transfusion).
Diarrhea
 This may happen more than 24 hours after the treatment and can
sometimes be severe. If you get diarrhea, take the anti-diarrhoea
drugs you were given straight away. It’s important to take them
exactly as your nurse or pharmacist explained and follow any other
advice you were given. Make sure you drink at least two liters
(three and a half pints) of fluids every day if you have diarrhea.

49. Sore mouth
Your mouth may become sore and you may get ulcers. This can make you more likely
to get an infection in your mouth. Gently clean your teeth or dentures in the morning,
at night and after meals. Use a soft-bristled or children’s toothbrush. Your nurse might
ask you to rinse your mouth regularly or use mouthwashes
Hair loss
Your hair will thin or you may lose all the hair from your head. This usually starts after
your first or second cycle of chemotherapy. It is almost always temporary and your
hair will grow back after chemotherapy ends. It is important to cover your head to
protect your scalp when you are out in the sun
eye problems
Your eyes may become watery and feel sore. Your doctor can prescribe eye drops
to help with this. If your eyes get red and inflamed (conjunctivitis), tell your doctor

50. ?
7
What treatment options would be
consider at this time

51. Refractory for initial therapy
 The patient were not responding to the primary and secondary therapy
which abd CT scan shown worsening in liver metastasis (increase lesions
size & elevate liver enzymes)
 The chest CT scan revealed pulmonary metastasis (multiple bilateral
nodules)

52.  Based on this clinical trial that shown significant improvement in PFS and
OS, the disease control rate was significantly higher with regorafenib use
 Regorafenib as monotherapy 160 mg/d for first 3 weeks of each 4 week
cycle + supportive care
 Regorafenib 160 mg/d for first 3 weeks of each 4 week cycle + supportive
care + FOLFIRI regimen
 The adverse event profile of regorafenib were hand-foot skin reaction,
fatigue, hypertension, diarrhea, skin rash and Fatal hepatic failure

53. Refrences
Up to date
Handbook if pharmacotherapy 9th ed
Pubmed