Managing Adverse Events of Ibrutinib in Patients With MCL
Insights From: Bijal D. Shah, MD, H. Lee Moffitt Cancer Center & Research Institute; Lauren C. Pinter-Brown, MD, UCI Health; Eduardo Sotomayor, MD, GW Cancer Center
Lauren C. Pinter-Brown, MD: I think what we see in the long term with ibrutinib is that many of the toxicities that are seen abate after the first year, that most patients can stay on drug because the toxicities are manageable. And as we get more and more experience with managing those toxicities, that’s just going to be more and more the case. So I feel that for the vast majority of my patients, they can stay on drug for a very long time and expect both a good quality of life and a long duration of response.
How do I manage the adverse effects? There are adverse effects that happen more as you initiate the drug and some that occur later. So when I initiate the drug, I tell the patients some of the adverse effects that they may experience that may dissipate with time, so that I can set their expectations, such as diarrhea or a mild rash. Then when the patient experiences that, they’re not upset. The longer-term complications, of course, have to be mentioned as well. And I think also the patients understand that, for instance, if they get hypertension, it will be something that has to be dealt with along with the benefits of having a good response. Patients tolerate the drug and accept the toxicities. But I think that their expectations need to be managed, as in all treatments.
Eduardo Sotomayor, MD: In terms of adverse effects of ibrutinib, first of all, you need to be aware of the mechanism of action—what it’s doing—and interactions with other potential medications. Like grapefruit juice has interactions with ibrutinib. So if you are not aware of those, your patient is going to be more prone to having more adverse effects or less efficacy. You need to be aware if the patient had taken CYP3A [cytochrome P450 3A] inhibitors or agonists or those types of drugs. So understand how to take that medication. Which medications are going to interact with ibrutinib are going to preemptively tell you what to do and what not to do. So that’s number 1.
And number 2 is, become familiar with the adverse effects. Most of these drugs are going to induce hematologic toxicity in different degrees: neutropenia, anemia, and thrombocytopenia. Most of these drugs in this class are going to have an episode of hemorrhage, bleeding. Although that last majority is going to be petechiae. There is incidence of severe bleeding in patients taking ibrutinib. So we need to be aware of that. So if you start to see a drop in hemoglobin, you can say, “Oh, it’s my drug.” But also in the back of your mind, you need to think, “Oh, maybe the patient is bleeding somewhere.” So it’s important.
In oncology, I don’t want to be chasing problems; I want to be ahead of the problem. And I think that’s the reason behind education about the adverse effects, understanding the adverse effects, understanding how to prevent them. So if you see an early sign, don’t wait for the late sign because when you have the late sign, it’s going to be severe hypertension. So that’s my message.