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When You Have Decided to Prescribe Regorafenib

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: Friday, Aug 19, 2016


Transcript:

John L. Marshall, MD:
You’ve decided to recommend to your patient Stivarga or regorafenib in the refractory setting for metastatic colon cancer. How do you dose it? What are your secrets?

Mohamed E. Salem, MD: The approved dose for Stivarga is 160 mg, 21 days, 1 week off.

John L. Marshall, MD: Four pills, 21 days, okay.

Mohamed E. Salem, MD: However, we learned after the drug was available to everybody, that perhaps this dose is too high for most of the patients. So, in my own practice, what I actually like is to start at lower dose.

John L. Marshall, MD: What dose?

Mohamed E. Salem, MD: It depends on the performance status of the patient. Usually my average was 120 mg, but it’s also common to use 80 mg. And, then, I go from there if I need to go up or down.

John L. Marshall, MD: How do you make that decision to go up or down?

Mohamed E. Salem, MD: Usually I bring the patient in 1 week after they start the medicine. And I check on him and see how he’s doing, his functional status, any complaints. I also pay close attention to his labs, especially his liver function test and a few other things, to make sure there’s no red flag to get me to either reduce the dose or stop.

John L. Marshall, MD: What are the biggest side effects that you tell the patient about?

Mohamed E. Salem, MD: I always warn them about hand-foot syndrome or about diarrhea, perhaps some hypertension and fatigue.

John L. Marshall, MD: Yes, these are big important ones. So, we come out of the room. We said, “Okay, we’re going to give this patient Stivarga.” Now what do you do?

Monica Chacha, RN: There are a couple of things that I focus on. Number 1) a lot of patients are going to want to know, “Is my insurance going to pay for this? How am I going to pay for it? How am I going to get it?” I go in depth about specialty pharmacies. Most insurances, these days, dictate that you have to get it through a specialty pharmacy, so we go over that process with them. Number 2) what if their copay is too high? I talk to them about programs for copay assistance, how we’re going to figure that out. Usually the doctor gives them an overview of the side effects, and then I try to go in depth to see if they have any questions. Like Dr. Salem said, especially with the regorafenib, I’m going to talk to them about fatigue, diarrhea, side effects to look for in case their liver function is changing.

John L. Marshall, MD: Do you hand out those kits? Do we use those?

Monica Chacha, RN: Yes.

John L. Marshall, MD: Do you think they’re useful?

Monica Chacha, RN: It depends on the patient. There’s a cream in there, and socks, which is really good for the hand-foot side effects. And, then, I tell people you’re going to want to put this cream on in the morning, and probably at night, to ward that off.

John L. Marshall, MD: So, quick summary. Depending on the performance status, drop your dose, 80 mg or 120 mg typically. See them weekly, get labs, look at their hands, look at their labs, and adjust up if you can get away with it.

Mohamed E. Salem, MD: If I start at 120 mg, I try not to adjust up unless if I need to.

John L. Marshall, MD: Gotcha. It’s really the 80 mg that you’re adjusting up. Is there anybody you start at 160 mg?

Mohamed E. Salem, MD: In a clinical trial.

John L. Marshall, MD: In a clinical trial. Make sure they get it covered because they won’t comply unless they do.

Monica Chacha, RN: Right.

John L. Marshall, MD: Quick follow-up. Tips on how to manage the hand-foot. That’s how we do it at Lombardi.

Transcript Edited for Clarity
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Transcript:

John L. Marshall, MD:
You’ve decided to recommend to your patient Stivarga or regorafenib in the refractory setting for metastatic colon cancer. How do you dose it? What are your secrets?

Mohamed E. Salem, MD: The approved dose for Stivarga is 160 mg, 21 days, 1 week off.

John L. Marshall, MD: Four pills, 21 days, okay.

Mohamed E. Salem, MD: However, we learned after the drug was available to everybody, that perhaps this dose is too high for most of the patients. So, in my own practice, what I actually like is to start at lower dose.

John L. Marshall, MD: What dose?

Mohamed E. Salem, MD: It depends on the performance status of the patient. Usually my average was 120 mg, but it’s also common to use 80 mg. And, then, I go from there if I need to go up or down.

John L. Marshall, MD: How do you make that decision to go up or down?

Mohamed E. Salem, MD: Usually I bring the patient in 1 week after they start the medicine. And I check on him and see how he’s doing, his functional status, any complaints. I also pay close attention to his labs, especially his liver function test and a few other things, to make sure there’s no red flag to get me to either reduce the dose or stop.

John L. Marshall, MD: What are the biggest side effects that you tell the patient about?

Mohamed E. Salem, MD: I always warn them about hand-foot syndrome or about diarrhea, perhaps some hypertension and fatigue.

John L. Marshall, MD: Yes, these are big important ones. So, we come out of the room. We said, “Okay, we’re going to give this patient Stivarga.” Now what do you do?

Monica Chacha, RN: There are a couple of things that I focus on. Number 1) a lot of patients are going to want to know, “Is my insurance going to pay for this? How am I going to pay for it? How am I going to get it?” I go in depth about specialty pharmacies. Most insurances, these days, dictate that you have to get it through a specialty pharmacy, so we go over that process with them. Number 2) what if their copay is too high? I talk to them about programs for copay assistance, how we’re going to figure that out. Usually the doctor gives them an overview of the side effects, and then I try to go in depth to see if they have any questions. Like Dr. Salem said, especially with the regorafenib, I’m going to talk to them about fatigue, diarrhea, side effects to look for in case their liver function is changing.

John L. Marshall, MD: Do you hand out those kits? Do we use those?

Monica Chacha, RN: Yes.

John L. Marshall, MD: Do you think they’re useful?

Monica Chacha, RN: It depends on the patient. There’s a cream in there, and socks, which is really good for the hand-foot side effects. And, then, I tell people you’re going to want to put this cream on in the morning, and probably at night, to ward that off.

John L. Marshall, MD: So, quick summary. Depending on the performance status, drop your dose, 80 mg or 120 mg typically. See them weekly, get labs, look at their hands, look at their labs, and adjust up if you can get away with it.

Mohamed E. Salem, MD: If I start at 120 mg, I try not to adjust up unless if I need to.

John L. Marshall, MD: Gotcha. It’s really the 80 mg that you’re adjusting up. Is there anybody you start at 160 mg?

Mohamed E. Salem, MD: In a clinical trial.

John L. Marshall, MD: In a clinical trial. Make sure they get it covered because they won’t comply unless they do.

Monica Chacha, RN: Right.

John L. Marshall, MD: Quick follow-up. Tips on how to manage the hand-foot. That’s how we do it at Lombardi.

Transcript Edited for Clarity
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