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When You Have Decided to Prescribe Trifluridine/Tipiracil

Insights From:John L. Marshall, MD, Georgetown University Hospital;Mohamed E. Salem, MD, Georgetown University Hospital;Monica Chacha, RN, BSN, OCN, Georgetown University Hospital
Published: Tuesday, Aug 23, 2016


Transcript:

John L. Marshall, MD:
You’ve decided to give Lonsurf, or TAS-102, to your patient with refractory metastatic colon cancer. Let’s give you a quick refresher on what we do here at Lombardi Georgetown for these patients. Mohamed, take it away. A new patient, Lonsurf. How do you do it?

Mohamed E. Salem, MD: I have to admit that our experience with Lonsurf is still relatively new, so we’re still learning along the way. The approved dose, which I use in my clinic, is 35 mg/m2. Remember, this is a cytotoxic drug, so we use it by body surface area. But, also we have to make sure that the physician knows that there’s a cap on the dose. So, 80 mg/m2 is an excellent dose. You can do it twice a day.

John L. Marshall, MD: Do you go in, do you calculate the BSA (body surface area)? You get a dose. It’s a split dose, right? So, what do you do? How do you do this?

Mohamed E. Salem, MD: Usually, we’ll have a calendar for the patient and we’ll mark when you’re going to start. And, the way we do it, we’ll calculate the body surface area, 35 mg/m2 and it depends on how much comes. If it is 77 mg/m2, we round it to the nearest 5 mg/m2. And, then, we have to say, “Okay, here’s how many pills of 15 mg/m2 you get and how many pills of 20 mg/m2 you get.”

John L. Marshall, MD: So, I’ll tell you, I don’t ever send them off with two prescriptions. I always use the one that gets closest to the dose that I’m recommending, so there’s no confusion. Have you been doing that, or you’re doing two pills?

Mohamed E. Salem, MD: I think, eventually, I will do it. But, right now, I’m using the approved dose.

John L. Marshall, MD: What are the main things you’re telling that patient for toxicity, the top two or three things that you’ve got to tell them?

Mohamed E. Salem, MD: I actually warn them, first, you have to follow up, because we need to see them frequently. We need to check their blood count. Because, myelosuppression is a key in that drug, and I’ll watch them very carefully. Also, make sure if you have a fever, you need to call us right away, because of possible neutropenic fever.

John L. Marshall, MD: Some nausea in some patients. You put that on the list?

Mohamed E. Salem, MD: Yes, nausea, vomiting, and diarrhea. But, those are very mild.

John L. Marshall, MD: So, they feel pretty good. The toxicity is not too bad, but the myelosuppression, they have to take it seriously.

Mohamed E. Salem, MD: That’s true.

John L. Marshall, MD: We come out of the door. We give you sometimes two prescriptions, depending on pill size for this medicine, and a complicated schedule. How do you take it from there?

Monica Chacha, RN: Yes. With this one, it takes a lot of patient education, especially depending on the person. Because it is confusing. Sometimes they’re going to have two types of pills, and then the dosing is day 1 through 5, and then 8 through 12, and then 2 weeks off. So, I write it all down on a calendar for sure, because they’re going to have to remember that dosing; it’s confusing. And, then, I also go over specialty pharmacy type things, and copay assistance. Because they’re not going to take the drug if they can’t pay for it if their copay is ridiculous. I go over all that, and then I also reiterate side effects, because, especially like he said, this one is really important with the myelosuppression. I don’t want these people at home with low counts having fevers and not telling me, so I tell them communication is key.

Mohamed E. Salem, MD: There’s one thing I actually found works very well. We tell the patient, when you have the medicine in hand, come to the clinic and we’ll walk you through this. We sit with them in the room. We teach them this is how much you should take, how many, how often, so on and so forth. We reinforce those instructions.

John L. Marshall, MD: So, it’s not just a simple prescription that you send off.

Mohamed E. Salem, MD: No.

John L. Marshall, MD: You have to stop. You do a lot of patient education, calendars, calculate the dose, two pill sizes or one, depending on your strategy, monitor for myelosuppression importantly, and watch for nausea, vomiting. That’s how we do it at Lombardi Georgetown for Lonsurf, TAS-102.

Transcript Edited for Clarity
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Transcript:

John L. Marshall, MD:
You’ve decided to give Lonsurf, or TAS-102, to your patient with refractory metastatic colon cancer. Let’s give you a quick refresher on what we do here at Lombardi Georgetown for these patients. Mohamed, take it away. A new patient, Lonsurf. How do you do it?

Mohamed E. Salem, MD: I have to admit that our experience with Lonsurf is still relatively new, so we’re still learning along the way. The approved dose, which I use in my clinic, is 35 mg/m2. Remember, this is a cytotoxic drug, so we use it by body surface area. But, also we have to make sure that the physician knows that there’s a cap on the dose. So, 80 mg/m2 is an excellent dose. You can do it twice a day.

John L. Marshall, MD: Do you go in, do you calculate the BSA (body surface area)? You get a dose. It’s a split dose, right? So, what do you do? How do you do this?

Mohamed E. Salem, MD: Usually, we’ll have a calendar for the patient and we’ll mark when you’re going to start. And, the way we do it, we’ll calculate the body surface area, 35 mg/m2 and it depends on how much comes. If it is 77 mg/m2, we round it to the nearest 5 mg/m2. And, then, we have to say, “Okay, here’s how many pills of 15 mg/m2 you get and how many pills of 20 mg/m2 you get.”

John L. Marshall, MD: So, I’ll tell you, I don’t ever send them off with two prescriptions. I always use the one that gets closest to the dose that I’m recommending, so there’s no confusion. Have you been doing that, or you’re doing two pills?

Mohamed E. Salem, MD: I think, eventually, I will do it. But, right now, I’m using the approved dose.

John L. Marshall, MD: What are the main things you’re telling that patient for toxicity, the top two or three things that you’ve got to tell them?

Mohamed E. Salem, MD: I actually warn them, first, you have to follow up, because we need to see them frequently. We need to check their blood count. Because, myelosuppression is a key in that drug, and I’ll watch them very carefully. Also, make sure if you have a fever, you need to call us right away, because of possible neutropenic fever.

John L. Marshall, MD: Some nausea in some patients. You put that on the list?

Mohamed E. Salem, MD: Yes, nausea, vomiting, and diarrhea. But, those are very mild.

John L. Marshall, MD: So, they feel pretty good. The toxicity is not too bad, but the myelosuppression, they have to take it seriously.

Mohamed E. Salem, MD: That’s true.

John L. Marshall, MD: We come out of the door. We give you sometimes two prescriptions, depending on pill size for this medicine, and a complicated schedule. How do you take it from there?

Monica Chacha, RN: Yes. With this one, it takes a lot of patient education, especially depending on the person. Because it is confusing. Sometimes they’re going to have two types of pills, and then the dosing is day 1 through 5, and then 8 through 12, and then 2 weeks off. So, I write it all down on a calendar for sure, because they’re going to have to remember that dosing; it’s confusing. And, then, I also go over specialty pharmacy type things, and copay assistance. Because they’re not going to take the drug if they can’t pay for it if their copay is ridiculous. I go over all that, and then I also reiterate side effects, because, especially like he said, this one is really important with the myelosuppression. I don’t want these people at home with low counts having fevers and not telling me, so I tell them communication is key.

Mohamed E. Salem, MD: There’s one thing I actually found works very well. We tell the patient, when you have the medicine in hand, come to the clinic and we’ll walk you through this. We sit with them in the room. We teach them this is how much you should take, how many, how often, so on and so forth. We reinforce those instructions.

John L. Marshall, MD: So, it’s not just a simple prescription that you send off.

Mohamed E. Salem, MD: No.

John L. Marshall, MD: You have to stop. You do a lot of patient education, calendars, calculate the dose, two pill sizes or one, depending on your strategy, monitor for myelosuppression importantly, and watch for nausea, vomiting. That’s how we do it at Lombardi Georgetown for Lonsurf, TAS-102.

Transcript Edited for Clarity
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