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It seems that our experiences thus far have been variable with the 480mg q 4 wk dosing, and certainly seems that the low grade flu like sx can an education point that we can all cover with our patients whether they are just starting tx or transitioning from another dosing regminen. Fortunately, in our observations, they have been short lived (usually several days) and respond to no intervention or supportive care such as acetaminophen or ibuprofen.
We have transitioned about 8 patients from other braf / mek agents to the Braf-tovi & Mek-tovi & they are doing very well in regard to tolerablitliy and not having reoccurrences of the AE’s that were dlt’s & drug holds on prior therapies.
Have you transitioned any patients?
How are patients doing on BRAFtovi & Mektovi?
Thoughts on how you will proceed with starting BRAF/ Mek therapies as we move forward?we have had a couple of patients with hemolytic anemia all from combination ipi/nivo, 1 was hospitalized at an outside hospital & our team was in touch with the hosptial team, the pt made a full recovery. another was close to our center so we were able to avoid a hospitalization, through use of oral high dose steroids& close oversight & she is fully recovered.
We don’t routinely check our IIB pts or primary lesions, we will check the primary lesion if the tissue from nodes is QNS and there is no other source of sampling or if safety is an issue wtih a new issue in sampling.
Although primary tumors may possess BRAF mutations, they don’t always 100% of the time correlate to metastatic sites, so checking new advanced disease against a high risk primary result would be prudent. As Rajni mentioned a quick 24 hour turn around with tissue IHC for BRAF can be conducted while conducting a full genetic analysis, especially if the start of treatment is urgent. I agree Krista, we will be seeing more sampling in earlier high risk disease, thank you for sharing your routine practice.Great question, tough topic, we have a few patients who have had varient mutations and when they failed immunotherapies we have utilized either a braf or a mek inhibitor to try and slow or arrest their disease. The inhibition is not as robust as with a true BRAF V600 E, K or M variant but the pt may receive some term of benefit. Approval of inhibotors for variant mutations, can either go smoothly or a letter of medical necessity may be required with a peer reviewed journal article &/ or a peer to peer may also be necessary.
Such an important topic, as many supplements are OTC and unregulated. In our practice, we first explore if supplements being used were recommended by a HCP who has training and experience with supplements, herbals, homeopathy or essential oils or if a pt has added “supplements” themselves.
We investigate the intent of the “supplements” and evaluate which may safely remain in a patients’ regimen in relation to treatment. Sometimes, pts make choices of supplements based on what they think they need without real guidance or input as to how the supplements may interact with one another or prescribed medications. As Mollie pointed out some supplements especially poly supplements can interfere with oral targeted therapies or set up a renal or hepato –toxic situation in respect to immune checkpoint inhibitors. Additionally, the growing access to CBD (cannabidiol) oil and ingestion of CBD which is a powerful CYP450 3A 4&5 inhibitor can interfere with other oral agents causing toxicity with prescribed medications.Rumor mill update- hearing that early June is when the new combo therapy will be available. Behind the scenes sounds very ready for launch and immediate availability of meds for pts. That’s what I am hearing.
We do not routinely premedicate either unless with the first or a subsequent dose there have been adverse events experienced. When we do premed and manage post injection sx we typically use tylenol or ibuprofen and benadryl 25mg since the gmcsf component often creates a cytokine release which causes the elevated temps and chills / flu-like sx.
We will have a patient premed day of, then remedicate every 8 hours for up to 48 hours as needed, but definitely the first 24 hours. On a very rare occassion we have use low dose dex for a pt who atypically went up to 105, he was on concurrent pembro.Suzanne, great spotlight on ICI induced AI- thank you for that reminder!
I have had 1 patient in the past with sensitive skin ( no rash or itching) as you have described, steroids were not helpful however gabapentin was helpful, pt remained on it until the sx resolved, If I recall it was a couple of months.
Our institution has transitioned to utilizing a radiology authorization team. This is a team of non clinicians interpreting and providing clinical information can sometimes trigger a delay in a review or result in a peer to peer. Overall the team is pretty good and this service has been helpful to alleviate some work load from our secretaries. The only pitfall is when they have multiple auths to that require peer to peer and we as the clinicians are only provided with a short window of time to obtain this.
Most of the pvt payor companies we deal with have transitioned to a scheduled peer to peer appointment call. The negatives are that at times when an urgent auth is needed and no MD is available this can delay care rendered to the pt.
Positives: you can (most of the time) choose the time when you would like to conduct the call, you can plan and prepare for it rather than having a reactive call with a scheduler/ secty calling asking you to get on the phone with the doctor who is on the line at that moment. I find the docotor is prepared for the call and that has contributed to a quicker and more often pleasant call.
At times when I really need an auth before the next day, I have been successful with speaking to an MD within a short time frame or scheduled for later in the day/ just after clinic hours.Indeed though this is just one example of the numerous areas of a patients care that requires review and authorization.
So sorry to hear this outcome, Lisa, thank you for letting us know.
We have not seen this either,yes, please keep us apprised of how your patient is doing. Hoping that they’ve already improved.
I am hoping that OncoEndocrinology will become a specialty such as oncodermatology has in response to the oncology patient community needs. I suspect the development of a specialty will take some time, but the long term endocrine effects are across the cancer spectrum now.
Fertility preservation and long term planning as noted above can vary state to state and insurance plan to plan, sometimes at great personal cost. We will only find out more by doing research and following this population of patients.Thank you, Lisa for sharing the issue with medicare & the 480mg dosing of Opdivo. I will need to bring this to the attention of my financial folks as they have been clearing a bunch of our patients during the past week-mostly medicare pts.
Regarding the time extension, for the majority of our pateints, they were prepared & looking forward to the change in schedule. During trials we did not (are not seeing) any more appreciable side effects (anecdotal).
We really push alot of education up front with the empahasis on pts “calling at the onset of any changes”.
We empahsize that this is the most important job that they are responsible for and we are in the best position to help when we are aprised of any symptomatic changes.
I think this topical issue directly relates to health literacy (current hot topic), and our assessement of each individual patients understanding and potential needs. Our own health literacy proficiency as nurses comes into play with identifying the patient who may not be as adherent vs the one who may be very nervous and need more support have different needs and we as nurses are pretty great at identifying the pt who may need that interim follow up.Suzanne, you make a good point that infliximab should not be administered for immune hepatitis, in the literature, this is noted as a contraindication due to it’s own potential for hepatotoxicity.
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