Management of cancer treatment-related diarrhea. Issues and therapeutic strategies

Effects of Probiotics on Chemotherapy-induced Diarrhea

Chemotherapy-induced diarrhea (CID) is a common adverse event in cancer patients, which, unless treated, may lead to drug discontinuation and treatment failure. Some probiotics such as Lactobacillus, Bifidobacterium, and Saccharomyces species have been gaining clinical attention in alleviating chemotherapy-induced adverse events including diarrhea. This comprehensive review provides an overview and discusses preventive approaches of probiotics with respect to CID in several types of cancers. The potential mechanisms of probiotics may comprise regulation of intestinal microbiota, modulation of immune functions, or reduction of proinflammatory cytokines. The efficacy and safety precautions of probiotics in immunocompromised cancer patients are discussed. The non-pharmacological strategy using probiotics could reduce the use of anti-diarrheal or antibiotic agents. Some individuals experienced shorter length of hospital stay, better gastrointestinal function, and reduced incidence of chemotherapy dose reduction after probiotic administration. Nonetheless, some studies failed to report the benefits of probiotics in certain patients. This review also highlights preventive protocols and therapeutic implications by considering the potential influencing factors, particularly types of probiotic strains, dosages of probiotics, duration of their administration, patients' tolerability, and variations in probiotic effects over the cancer stages.

Cancer management from a chronic gastrointestinal function perspective

Bowel dysfunction in cancer is a significant and challenging issue for both clinicians and patients. As cancer survival improves, the impact of gastrointestinal symptoms on quality of life is of ever-increasing relevance. This review aims to provide an overview of the common gastrointestinal complaints seen in cancer sufferers and discuss the principles of management and up to date treatment options available.

Plasma Cytokeratin 18 and fecal Alpha-1 Antitrypsin concentrations in dogs with osteosarcoma receiving carboplatin chemotherapy

Gastrointestinal (GI) toxicosis is a common side effect of cytotoxic chemotherapy treatment in humans and dogs. Measurement of cytokeratin 18 (CK18), an intracellular structural protein released during epithelial apoptosis, and Alpha1‐Antitrypsin (A1AT) in faeces provides a mechanism for evaluating damage to the intestinal mucosa secondary to cytotoxic chemotherapy. Our goal was to evaluate the clinical utility of plasma CK18 and faecal A1‐AT levels as non‐invasive biomarkers of cytotoxic chemotherapy induced GI toxicity. We conducted a prospective cohort study in dogs (N = 10) with osteosarcoma undergoing amputation followed by carboplatin chemotherapy. We hypothesized that plasma CK18 and faecal A1‐AT levels would increase following carboplatin administration due to drug‐induced GI epithelial damage/apoptosis, and that plasma CK18 and faecal A1‐AT levels would correlate with severity of GI toxicity. Mean baseline plasma CK18 concentration was variable amongst patients; however, CK18 concentration prior to carboplatin chemotherapy treatment was not significantly different from CK18 levels after treatment. There was significant intra and inter‐patient variability in mean faecal A1‐AT levels at baseline. Mean A1‐AT concentration did not change significantly from day 0 to day 21. Gastrointestinal toxicity was minimal; therefore, we were unable to determine the association of plasma CK18 and faecal A1‐AT concentrations with development of GI toxicosis. In this study population, plasma CK18 and faecal A1‐AT concentration were not clinically useful biomarkers for the detection of GI toxicosis secondary to carboplatin administration. Further prospective evaluation of CK18 and A1‐AT as biomarkers of drug‐induced GI toxicity is warranted in a larger cohort of dogs receiving cytotoxic chemotherapy.

AVMA clinical trial registration number: AAHSD004827.

Human ileal organoid model recapitulates clinical incidence of diarrhea associated with small molecule drugs

Drug-induced gastrointestinal toxicity (GIT) is a common treatment-emergent adverse event that can negatively impact dosing, thereby limiting efficacy and treatment options for patients. An in vitro assay of GIT is needed to address patient variability, mimic the microphysiology of the gut, and accurately predict drug-induced GIT. Primary human ileal organoids (termed 'enteroids') have proven useful for stimulating intestinal stem cell proliferation and differentiation to multiple cell types present in the gut epithelium. Enteroids have enabled characterization of gut biology and the signaling involved in the pathogenesis of disease. Here, enteroids were differentiated from four healthy human donors and assessed for culture duration-dependent differentiation status by immunostaining for gut epithelial markers lysozyme, chromogranin A, mucin, and sucrase isomaltase. Differentiated enteroids were evaluated with a reference set of 31 drugs exhibiting varying degrees of clinical incidence of diarrhea, a common manifestation of GIT that can be caused by drug-induced thinning of the gut epithelium. An assay examining enteroid viability in response to drug treatment demonstrated 90% accuracy for recapitulating the incidence of drug-induced diarrhea. The human enteroid viability assay developed here presents a promising in vitro model for evaluating drug-induced diarrhea.

The calcium-sensing receptor: A novel target for treatment and prophylaxis of neratinib-induced diarrhea

Diarrhea is one of the most commonly reported adverse effect of hemotherapy and targeted cancer therapies, such as tyrosine kinase inhibitors (TKI), which often significantly impact patient quality of life, morbidity, and mortality. Neratinib is an oral, irreversible pan-HER tyrosine kinase inhibitor, which is clinically active in HER2-positive breast cancer. Diarrhea is the most common side effect of this potent anticancer drug and the reasons for this adverse effect are still largely unclear. We have recently shown that activation of the calcium-sensing Receptor (CaSR) can inhibit secretagogue-induced diarrhea in the colon, therefore we hypothesized that CaSR activation may also mitigate neratinib-induced diarrhea. Using an established ex vivo model of isolated intestinal segments, we investigated neratinib-induced fluid secretion and the ability of CaSR activation to abate the secretion. In our study, individual segments of the rat intestine (proximal, middle, distal small intestine, and colon) were procured and perfused intraluminally with various concentrations of neratinib (10, 50, 100 nmol L-1). In a second set of comparison experiments, intraluminal calcium concentration was modulated (from 1.0 to 5.0 or 7.0 mmol L-1), both pre- and during neratinib exposure. In a separate series of experiments R-568, a known calcimimetic was used CaSR activation and effect was compared to elevated Ca2+ concentration (5.0 and 7.0 mmol L-1). As a result, CaSR activation with elevated Ca2+ concentration (5.0 and 7.0 mmol L-1) or R-568 markedly reduced neratinib-induced fluid secretion in a dose-dependent manner. Pre-exposure to elevated luminal calcium solutions (5.0 and 7.0 mmol L-1) also prevented neratinib-induced fluid secretion. In conclusion, exposure to luminal neratinib resulted in a pronounced elevation in fluid secretion in the rat intestine. Increasing luminal calcium inhibits the neratinib-associated fluid secretion in a dose-dependent manner. These results suggest that CaSR activation may be a potent therapeutic target to reduce chemotherapy-associated diarrhea.

Gut microbial modulation in the treatment of chemotherapy-induced diarrhea with Shenzhu Capsule

Background

Gut microbiota plays a crucial role in the treatment of gastrointestinal (GI) diseases such as chemotherapy-induced diarrhea (CID). Shenzhu Capsule (SZC) is a Chinese herbal formula, which is composed of Renshen (rhizomes of Panax ginseng C. A. Mey.) and Baizhu (rhizomes of Atractylodes macrocephala Koidz.). Many Chinese traditional anti-diarrheal formulae that contain Renshen and Baizhu are capable of effectively alleviating CID. However, the efficacy in vivo and potential mechanism of SZC (the form of compatibility of Renshen and Baizhu) in the treatment of CID had not been elucidated. Here, this study aimed to investigate whether SZC exhibited the anti-diarrheal activity, and whether gut microbiota was involved in the therapeutic effect of SZC on CID.

Methods

High performance liquid chromatography (HPLC), gas chromatography-mass spectrometer (GC-MS) and infrared spectroscopy (IR) analyses were used to characterize the extracted components in SZC. The mice were orally administrated with SZC in a preventive mode on the first 2 days of this experiment, and then intraperitoneally injected with 5-FU (40 mg/kg/d) for 6 days. SZC treatment lasted until the 3rd day after the end of 5-FU chemotherapy. We investigated the effects of SZC on body weights, diarrhea, thymus/spleen indexes, colonic tissues, and gut microbiota. Colonic histology was examined by hematoxylin-eosin (HE) staining. 16S rDNA Amplicon Sequencing was used to analyze the gut microbial structure from fecal samples.

Results

SZC significantly increased the body weights and thymus/spleen indexes, alleviated diarrhea, and reversed histopathological changes of colons. In addition, gut microbiota analysis revealed that the overall structure of gut microbiota in CID mice was disturbed, but reversed to the normal state after SZC treatment. At genus level, SZC significantly inhibited the growth of some potential pathogens associated with diarrhea, such as Clostridiumm, Bacteroides, Parabacteroides, Alloprevotella, Acinetobacter and Pseudomonas.

Conclusions

In our study, these data illustrated that SZC inhibited the growth of many potential pathogens during the alleviation of CID. Gut microbial modulation was associated with the anti-diarrheal activity of SZC.

Intestinal epithelial potassium channels and CFTR chloride channels activated in ErbB tyrosine kinase inhibitor diarrhea

Diarrhea is a major side effect of ErbB receptor tyrosine kinase inhibitors (TKIs) in cancer chemotherapy. Here, we show that the primary mechanism of ErbB TKI diarrhea is activation of basolateral membrane potassium (K+) channels and apical membrane chloride (Cl-) channels in intestinal epithelia and demonstrate the efficacy of channel blockers in a rat model of TKI diarrhea. Short-circuit current in colonic epithelial cells showed that the TKIs gefitinib, lapatinib, and afatinib do not affect basal secretion but amplify carbachol-stimulated secretion by 2- to 3-fold. Mechanistic studies with the second-generation TKI afatinib showed that the amplifying effect on Cl- secretion was Ca2+ and cAMP independent, was blocked by CF transmembrane conductance regulator (CFTR) and K+ channel inhibitors, and involved EGFR binding and ERK signaling. Afatinib-amplified activation of basolateral K+ and apical Cl- channels was demonstrated by selective membrane permeabilization, ion substitution, and channel inhibitors. Rats that were administered afatinib orally at 60 mg/kg/day developed diarrhea with increased stool water from approximately 60% to greater than 80%, which was reduced by up to 75% by the K+ channel inhibitors clotrimazole or senicapoc or the CFTR inhibitor (R)-BPO-27. These results indicate a mechanism for TKI diarrhea involving K+ and Cl- channel activation and support the therapeutic efficacy of channel inhibitors.

The characterization, management, and future considerations for ErbB-family TKI-associated diarrhea

Purpose

Diarrhea is recognized as a common adverse event associated with tyrosine kinase inhibitors (TKIs), with those targeting the ErbB family of receptors being associated with the highest rate of diarrhea.

Methods

This paper reviews data on the incidence, timing, and duration of diarrhea associated with US Food and Drug Administration-approved ErbB family-targeted TKIs from the published literature, and sets forth recommendations for management.

Results

In the absence of anti-diarrheal prophylaxis the incidence of any-grade diarrhea varies and typically occurs early during the course of treatment. Although it is difficult to determine if the incidence and severity of diarrhea is related to inhibition of a particular kinase target because of the multi-targeted and overlapping activity of many agents, evidence suggests that second-generation TKIs with broader target profiles (i.e., afatinib, lapatinib, neratinib) result in a higher incidence of diarrhea compared with highly specific first- (erlotinib, gefitinib) or third- (osimertinib) generation agents. The mechanisms responsible for TKI-associated diarrhea are not fully understood and are likely multi-factorial, involving dysregulated ion transport, inflammation, and mucosal injury. Management strategies have been developed—and continue to be refined—to prevent and reduce the severity and duration of TKI-associated diarrhea. For agents associated with more significant symptoms, anti-diarrheal prophylaxis reduces the incidence and severity of diarrhea, and ongoing studies are evaluating specific strategies to further reduce incidence and duration of TKI-associated diarrhea.

Conclusions

Continued investigations into risk factors and pharmacogenomic markers for diarrhea may further improve management of this common toxicity.

Capecitabine Versus Continuous Infusion Fluorouracil for the Treatment of Advanced or Metastatic Colorectal Cancer: a Meta-analysis

OPINION STATEMENT

Nowadays, systemic chemotherapy with intravenous (IV) 5-fluorouracil (5-FU) remains the most commonly prescribed treatment for metastatic colorectal cancers (CRC), in combination with other cytotoxic drugs. 5-FU can be administered through a bolus injection or continuous infusion (cIV), with the latter becoming the preferred administration method and standard of care in recent years. Oral fluoropyrimidines were developed to overcome challenges associated with the IV administration of 5-FU, among which capecitabine has become the most widely used one. However, although capecitabine and other oral fluoropyrimidine-based regimens are more convenient to administer, their efficacy and safety in comparison with IV 5-FU are not well understood. Results from recent randomized controlled trials, observational studies, and meta-analyses have been inconsistent. Safety, in particular, remains controversial. Our review, a first comprehensive meta-analysis comparing the efficacy and safety of cIV 5-FU with capecitabine, the two most widely used fluorouracil modalities in CRC, showed that cIV 5-FU-based regimens are associated with greater response rates compared with capecitabine-based regimens, with no difference in progression-free survival, time to treatment failure, overall survival, or disease-free survival between the two. Furthermore, cIV 5-FU-based regimens showed an improved safety profile compared with capecitabine-based regimens. Our findings suggest that cIV 5-FU remains a more effective and safer modality of fluorouracil administration than capecitabine, thus providing supporting evidence to guide clinical practice in the management of colorectal cancer.

Diagnosis and management of gastrointestinal complications in adult cancer patients: 2017 updated evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently suffer from gastrointestinal complications. In this manuscript, we update our 2013 guideline on the diagnosis and management of gastrointestinal complications in adult cancer patients by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). An expert group was put together by the AGIHO to update the existing guideline. For each sub-topic, a literature search was performed in PubMed, Medline, and Cochrane databases, and strengths of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using the 2015 European Society for Clinical Microbiology and Infectious Diseases (ESCMID) criteria. Final recommendations were approved by the AGIHO plenary conference. Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. Strengths of recommendation and levels of evidence are presented. A multidisciplinary approach to the diagnosis and management of gastrointestinal complications in cancer patients is mandatory. Evidence-based recommendations are provided in this updated guideline.

Development and validation of a patient-reported questionnaire assessing systemic therapy induced diarrhea in oncology patients

BACKGROUND

Systemic therapy-induced diarrhea (STID) is a common side effect experienced by more than half of cancer patients. Despite STID-associated complications and poorer quality of life (QoL), no validated assessment tools exist to accurately assess STID occurrence and severity to guide clinical management. Therefore, we developed and validated a patient-reported questionnaire (STIDAT).

METHODS

The STIDAT was developed using the FDA iterative process for patient-reported outcomes. A literature search uncovered potential items and questions for questionnaire construction used by oncology clinicians to develop questions for the preliminary instrument. The instrument was evaluated on its face validity and content validity by patient interviews. Repetitive, similar and different themes uncovered from patient interviews were implemented to revise the instrument to the version used for validation. Patients starting high-risk STID treatments were monitored using the STIDAT, bowel diaries and EORTC QLQ-C30. The STIDAT was evaluated for construct validity using exploratory factor analysis (EFA) using minimal residual method with Promax rotation, reliability and consistency. A weighted scoring system was developed and a receiver-operating characteristic (ROC) curve evaluated the tool's ability to detect STID occurrence. Median scores and variability were analysed to determine how well it differentiates between diarrhea severities. A post-hoc analysis determined how diarrhea severity impacted QoL of cancer patients.

RESULTS

Patients defined diarrhea based on presence of watery stool. The STIDAT assessed patient's perception of having diarrhea, daily number of bowel movements, daily number of diarrhea episodes, antidiarrheal medication use, the presence of urgency, abdominal pain, abdominal spasms or fecal incontinence, patient's perception of diarrhea severity, and QoL. These dimensions were sorted into four clusters using EFA - patient's perception of diarrhea, frequency of diarrhea, fecal incontinence and abdominal symptoms. Cronbach's alpha was 0.78; kappa ranged from 0.934-0.952, except for abdominal spasms (κ = 0.0455). The positive predictive value was 96.4%, with the minimum score of 1.35 predicting a positive STID occurrence. Patients with moderate or severe diarrhea experience significant decreases in QoL compared to those with no diarrhea.

CONCLUSIONS

This is the first patient-reported questionnaire that accurately predicts the occurrence and severity of diarrhea in oncology patients via assessing several bowel habit dimensions.

US oncology-wide incidence, duration, costs and deaths from chemoradiation mucositis and antimucositis therapy benefits

Approximate oncology-wide incidence, duration, costs and deaths associated with mucositis and identify health economic benefits of antimucositis therapies. Review the literature relevant to the clinical experience of mucositis by pathophysiology, incidence, duration, costs and deaths. Use US insurance actuarial and epidemiology on cancer to generalize an oncology-wide impact of toxic mucositis. Toxic mucositis causes oropharyngoesophageal ulcerations, chemo-induced nausea, vomiting and diarrhea. Acutely, it lasts 102 days/six cycles of chemotherapy, 60 days in human stem-cell transplantation patients and 70-84 days in head and neck cancer patients at annual costs of US$13.23 billion/522,166 treated patients (US$20,892/erosive-type mucositis patient, US$25,337/physiologic mucositis patient) and 46,699 deaths. Using antimucositis therapies prior to 2013 provided fractional benefits at high costs. By completely preventing and rapidly reversing mucositis, high-potency polymerized cross-linked sucralfate promises superior health economic benefits.

Chemotherapy induced diarrhea

Purpose: To provide a current review of the literature related to chemotherapy induced diarrhea (CID), including clinical assessment, recommended management guidelines and investigational pharmacological approaches for the prevention and treatment of CID.

Data sources: A search of MEDLINE, PubMed, EMBASE, Cochrane Library, International Pharmaceutical Abstracts, and Web of Science (1996—2006) databases was conducted using terms such as: chemotherapy, diarrhea, diarrhoea, and irinotecan. Appropriate references from selected articles were also used. The search engine, Google, provided further access to information.

Data extraction: The retrieved literature was reviewed to include all articles pertaining to the pathophysiology, assessment and management of CID.

Data synthesis: Diarrhea is a debilitating and potentially life-threatening side effect associated with many chemotherapeutic agents. Despite the high incidence and severity of CID, it is often under recognized and poorly managed. A multidisciplinary panel recently updated recommended practice guidelines for the assessment and management of CID. Prompt and aggressive intervention is important in order to minimize the negative consequences of CID, such as dehydration, which may cause interruptions in optimal clinical outcomes or may lead to life-threatening sequelae. Further investigation into the pathophysiology of CID may allow for more directed approaches in the prophylaxis and treatment of CID. J Oncol Pharm Practice (2007) 13: 181—198.

The role of octreotide in symptom management in oncology and palliative care

Objective. To provide an overview of the role of octreotide for managing symptoms in oncology and palliative care.

Data Sources. A search of MEDLINE and IDIS databases from 1985 to 1999 and CANCERLIT from 1993 to 1999 was conducted using the terms octreotide, cancer and palliative care. The reference lists from selected articles were also reviewed. Clinical trial databases on the Internet were searched. Oncology and palliative care textbooks were also used to obtain additional references.

Data Extraction. The retrieved literature was reviewed to discuss the pharmacology, pharmacokinetics, adverse effects, indications and principally, the clinical use of octreotide for controlling a number of symptoms encountered in the oncology and palliative care population.

Data Synthesis. The unique inhibitory activity of octreotide lends itself to many possible indications, including diarrhoea from a number of causes, bowel obstruction, nausea and vomiting, bleeding, death rattle, gastrointestinal fistulae, pain and hypercalcaemia. However, convincing pieces of evidence from large prospective clinical trials are required to realise its full potential in oncology and palliative care. Completed studies and clinical experience suggest that octreotide has a role in the treatment of a number of difficult-to-manage conditions, particularly bowel obstruction and diarrhoea due to disease or treatment-related causes. Proposed benefits of octreotide must be weighed against the possible adverse effects and cost effectiveness of treatment.

Overview and management of toxicities associated with systemic therapies for advanced renal cell carcinoma

The advent of novel targeted agents for metastatic renal cell carcinoma (RCC) has offered clinical benefits over traditional immunotherapy (e.g., interleukin-2 and interferon-α) in both efficacy and safety profiles. The major classes of these targeted therapies for metastatic RCC include the tyrosine-kinase inhibitors, monoclonal antibody against vascular endothelial growth factor, and inhibitors of the mammalian target of rapamycin. Most recently, the success of immune checkpoint inhibitors--notably antibodies directed against programmed death-1 and its ligand--has also been demonstrated in RCC. With such progress in therapy, early detection, and subsequent management of treatment-related adverse events allow for patients to remain on active therapy for as long as possible and also enhance the probability of patients tolerating subsequent second line options. However, despite such impressive gains in efficacy with these new agents, therapeutic progress are primarily palliative in nature--hence, the critical importance of minimizing discomfort and potential harm in this patient population cannot be understated.

Guidance on the management of diarrhoea during cancer chemotherapy

Diarrhoea induced by chemotherapy in cancer patients is common, causes notable morbidity and mortality, and is managed inconsistently. Previous management guidelines were based on poor evidence and neglect physiological causes of chemotherapy-induced diarrhoea. In the absence of level 1 evidence from randomised controlled trials, we developed practical guidance for clinicians based on a literature review by a multidisciplinary team of clinical oncologists, dietitians, gastroenterologists, medical oncologists, nurses, pharmacist, and a surgeon. Education of patients and their carers about the risks associated with, and management of, chemotherapy-induced diarrhoea is the foundation for optimum treatment of toxic effects. Adequate--and, if necessary, repeated--assessment, appropriate use of loperamide, and knowledge of fluid resuscitation requirements of affected patients is the second crucial step. Use of octreotide and seeking specialist advice early for patients who do not respond to treatment will reduce morbidity and mortality. In view of the burden of chemotherapy-induced diarrhoea, appropriate multidisciplinary research to assess meaningful endpoints is urgently required.

Can administrative data be used to measure chemotherapy side effects?

Many of the issues with using data from clinical trials and observational studies for economic evaluations are highlighted in the case of chemotherapy side effects. We present the results of an observational cohort study using linked administrative data. The chemotherapy side effects identified in the administrative data are compared with patient self-reports of such events. The results of these comparisons are then used to guide a discussion of the issues surrounding the use of administrative data to identify clinical events for the population of economic models. Although the advantages of easy access and generalizability of the results make administrative data an attractive option for populating economic models, this is not always possible because of the limitations of these data.

Graft-versus-host disease in oncology nursing practice

INTRODUCTION

Gastrointestinal graft-versus-host disease (GI-GvHD) is extremely debilitating and is multifactorial in its causative factors, management and treatment. It is an exaggeration of normal physiological mechanisms wherein the donor immune system attempts to rid itself of the host. The inflammatory process that follows has the benefit of providing an anti-tumour effect for many diseases, but unfortunately in patients undergoing human stem-cell transplantation, the nature of the inflammation can result in disability, wasting and death.

AIM

The aim of this article is to discuss the pathophysiology of this often misunderstood or misdiagnosed condition, as well as its signs and symptoms, management and considerations for nursing care. Considerations for nursing practice: While the medical management is aimed at minimising GvHD through the reduction of T-cell production and proliferation and gastrointestinal decolonisation, the nursing care is often focused on the signs and symptoms that can have the most prominent impact on patients.

CONCLUSION

GI-GvHD has serious life-threatening complications, namely wasting syndrome, diarrhoea and dehydration. The basis of signs and symptomology is easily recognisable owing to the stages of progression through the human stem-cell transplantation process. Oncology nurses are in a prime position to identify these serious risks, initiate treatment immediately and collaborate effectively within the multidisciplinary team to minimise GvHD onset and provide expert support to patients, family and caregivers.

Management of common adverse events in patients treated with sorafenib: nurse and pharmacist perspective

Sorafenib, a tyrosine kinase inhibitor, is indicated for the treatment of patients with unresectable hepatocellular carcinoma (HCC) and advanced renal cell carcinoma (RCC). Sorafenib is currently being evaluated in phase II and III trials in various malignancies as a single agent (locally advanced/metastatic radioactive iodine-refractory differentiated thyroid cancer [DTC]), as part of multimodality care (HCC), and in combination with chemotherapies (metastatic breast cancer). Grade 1 and 2 adverse events (AEs) that commonly occur during treatment (ie, dermatologic manifestations, diarrhea, fatigue, and hypertension) should be proactively managed. The goal is to allow patients to remain on their full dose of sorafenib for as long as their treatment is indicated. A combination of early recognition of and intervention for AEs, patient education, and an open dialogue between patients and their multidisciplinary healthcare team, with timely reporting of AEs, will allow for effective management of AEs and minimize the need for sorafenib dose reduction or discontinuation.

Secondary prophylaxis of docetaxel induced diarrhea with loperamide: case report

Diarrhea is a common adverse event of docetaxel with 20%-40% of incidence and severe diarrhea occurs in 5%-6%. Several treatment guidelines for chemotherapy induced diarrhea (CID) exist, however the prophylaxis for that is not well known. We describe a new prophylactic approach for the CID with loperamide. A 72-yr-old male patient with stage IV non-small-cell lung cancer developed diarrhea repeatedly after docetaxel-cisplatin chemotherapy. His diarrhea persisted despite treatment including loperamide and fasting. However, the diarrhea was successfully prevented when loperamide was given before and after the chemotherapy. To our knowledge, this is the first report of prophylactic approach for the CID with loperamide.

Diagnosis and management of gastrointestinal complications in adult cancer patients: evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

BACKGROUND

Cancer patients frequently suffer from gastrointestinal complications. However, a comprehensive, practical and evidence-based guideline on this issue is not yet available.

PATIENTS AND METHODS

An expert group was put together by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) to develop a guideline on gastrointestinal complications in cancer patients. For each subtopic, a literature search was carried out in PubMed, Medline and Cochrane databases and the strength of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using a modification of the 'Infectious Diseases Society of America' criteria. Consensus discussions were held on each of the topics.

RESULTS

Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. For all recommendations, the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis and management of gastrointestinal complications in cancer patients.

Effect of genistein, a natural soy isoflavone, on the pharmacokinetics and intestinal toxicity of irinotecan hydrochloride in rats

Objectives

The effect of genistein, a natural soy isoflavone, on pharmacokinetics and intestinal toxicity, or late-onset diarrhoea, of irinotecan hydrochloride (CPT-11) was examined in rats.

Methods

Probenecid, a typical inhibitor of multidrug resistance-associated protein (MRP) 2, was also employed for comparison with genistein. Plasma concentration, biliary excretion and intestinal secretion of CPT-11, 7-ethyl-10-hydroxycamptothecin (SN-38) and SN-38 glucuronide (SN-38G) were determined in untreated, genistein-treated and probenecid-treated rats. CPT-11 was administered repeatedly by intravenous injection (60 mg/kg/day for 4 days), and the effects of genistein and probenecid on CPT-11-induced intestinal toxicity were evaluated by measuring body weight, induction of diarrhoea, and alkaline phosphatase (ALP) activity in the intestinal mucosal membranes.

Key findings

Genistein, as well as probenecid, significantly suppressed the MRP2-mediated biliary and intestinal secretion of CPT-11 and its metabolites and increased their plasma concentrations. Multiple administration of CPT-11 reduced body weight and ALP activity, and induced watery diarrhoea. Genistein, as well as probenecid, significantly suppressed the loss in body weight and the reduced mucosal ALP activity in the ileum, and ameliorated the symptoms of diarrhoea induced by CPT-11.

Conclusions

Intravenous genistein was effective in ameliorating CPT-11-induced late-onset diarrhoea, by suppressing MRP2-mediated biliary excretion of CPT-11 and its metabolites.

Antiangiogenic therapy for advanced renal cell carcinoma: management of treatment-related toxicities

Treatment of metastatic renal cell carcinoma (mRCC) has evolved rapidly over the last two decades as major pathways involved in pathogenesis have been elucidated. These include the vascular endothelial growth factor (VEGF) axis and mammalian target of rapamycin (mTOR). Therapies targeting the VEGF pathway include bevacizumab, sorafenib, sunitinib, pazopanib, and axitinib, whereas temsirolimus and everolimus inhibit the mTOR pathway. All of these novel therapies—VEGF and mTOR inhibitors—are associated with a variety of unique toxicities, some of which may necessitate expert medical management, treatment interruption, or dose reduction. Common adverse events with newer drugs include hypertension, skin reactions, gastrointestinal disturbances, thyroid dysfunction, and fatigue. Skilled management of these toxicities is vital to ensure optimal therapeutic dosing and maximize patient outcomes, including improved survival and quality of life. This review describes and compares the toxicity profiles of novel molecularly targeted agents used in the treatment of mRCC and presents guidance on how best to prevent and manage treatment-related toxicities. Particular attention is given to axitinib, the newest agent to enter the armamentarium. Axitinib is a second-generation receptor tyrosine kinase inhibitor with potent VEGF receptor inhibition that provides durable responses and superior progression-free survival in advanced RCC compared with sorafenib.

Clinical activity of patupilone in patients with pretreated advanced/metastatic colon cancer: results of a phase I dose escalation trial

Background:

New agents that are active in patients with metastatic colorectal cancer are needed. Patupilone (EPO906; epothilone B) is a novel microtubule-stabilising agent.

Methods:

Patients with advanced colon cancer who progressed after prior treatment regimens received intravenous patupilone (6.5–10.0 mg m^–2) once every 3 weeks by a 20-min infusion (20MI), 24-h continuous infusion (CI-1D) or 5-day intermittent 16-h infusion (16HI-5D). Adverse events (AEs), dose-limiting toxicities (DLTs), pharmacokinetics and anti-tumour activity were assessed.

Results:

Sixty patients were enrolled. The maximum tolerated dose (MTD) was not reached in the 20MI arm (n=31), as no DLTs were observed. Three patients in the CI-1D arm (n=26) experienced 1 DLT each at 7.5, 8.0 and 9.0 mg m^–2, but MTD was not reached. However, the prolonged 16HI-5D arm was terminated at 6.5 mg m^–2 after two of the three patients developed a DLT. Diarrhoea was the most common AE and DLT, with increased severity at the higher doses (9.0 and 10.0 mg m^–2). Grade 3 or 4 diarrhoea was observed in 11 (35%) of the patients in the 20MI arm, 4 (15%) of the patients in the CI-1D arm and 2 (67%) of the patients in the 16HI-5D arm. Patupilone activity was observed in the 20MI arm with a disease control rate of 58%, including four confirmed partial responses. The disease control rate in CI-1D arm was 39%.

Conclusion:

Patupilone given once every 3 weeks as a 20-min infusion had promising anti-tumour activity and manageable safety profile at doses that demonstrated therapeutic efficacy.

The significance of altered gastrointestinal permeability in cancer patients

PURPOSE OF REVIEW

The diagnosis and assessment of severity of intestinal mucosal damage in cancer patients treated by anticancer therapy still rely mostly on anamnestic data. We review here studies reporting on the use of intestinal permeability measurements in cancer patients before and during treatment.

RECENT FINDINGS

The concept of intestinal permeability is based on differential permeability of intestinal mucosa to molecular markers, including monosaccharides and disaccharides, along the crypt-villus axis. Cytotoxic drugs and/or radiation impair replacement of intestinal epithelia and induce flattening of the villi, leading to increased exposure of luminal contents to crypts and increased disaccharide absorption. Increased disaccharide/monosaccharide ratio and decreased xylose absorption have been described in patients treated by radiotherapy as well as different cytotoxic or targeted agents across a spectrum of malignant disorders. Intestinal permeability changes correlated with clinical manifestations, including diarrhea, mucositis, neutropenic enterocolitis and systemic infections. The measurement of intestinal permeability has also been used as a surrogate end-point in interventional studies.

SUMMARY

Intestinal permeability testing using nonmetabolized sugars may represent a tool for noninvasive objective assessment of intestinal toxicity of anticancer therapy.

Lapatinib side-effect management

Lapatinib is an oral dual tyrosine kinase inhibitor targeting epidermal growth factor receptor and HER2. Diarrhea and dermatologic adverse events are reported commonly by patients treated with lapatinib. Diarrhea can range from mild to severe based on the agents used in combination with lapatinib. The adverse events may diminish quality of life, reduce treatment adherence, and lead to discontinuation of therapy. Consequently, proactive management of diarrhea is crucial, especially in patients receiving lapatinib in combination with other agents that also cause diarrhea. As the utility of lapatinib expands, crucial proactive diarrhea-management and dose-reduction strategies are evolving to decrease the likelihood of grade 3 or 4 toxicity. With regard to dermatologic adverse events, most are mild to moderate in severity, are of limited duration, and frequently do not require treatment intervention. However, in some patients, management of dermatologic adverse events is of great importance. This article reviews data regarding diarrhea and dermatologic adverse events in patients treated with lapatinib and summarizes the key role that oncology nurses play in educating patients about the potential for adverse events and the importance of preventive measures, ongoing surveillance, appropriate treatment, and dose reductions.

Prevention and management of chemotherapy-induced diarrhea in patients with colorectal cancer: a consensus statement by the Canadian Working Group on Chemotherapy-Induced Diarrhea

Chemotherapy-induced diarrhea (cid) is a common side effect of cancer treatment and can cause significant morbidity and mortality. Diarrhea is frequently severe enough to require a dose reduction of, a delay in, or a discontinuation of chemotherapy. Diarrhea-associated mortality has been reported to be as high as 3.5% in clinical trials of irinotecan and bolus 5-fluorouracil in colorectal cancer. The frequency of cid and its impact on patient management are frequently under-recognized in clinical practice.A Canadian working group, consisting of medical oncologists and an oncology pharmacist, was formed in 2001 to review the optimal approach to managing cid and to identify and implement new areas of research. The recommendations that follow are the result of the group's work.Acute medical management of cid includes loperamide or diphenoxylate as first-line agents. Subcutaneous octreotide is recommended for intractable grade 2 diarrhea and may be considered for grade 1 cid that does not resolve with high-dose loperamide. Hospitalization is recommended for patients with grades 3 and 4 cid; in-hospital care includes rehydration, antibiotic therapy, and octreotide.A chemotherapy dose reduction is generally advised for patients who have experienced grade 3 or 4 diarrhea in a previous chemotherapy cycle. If a dose reduction is not desired, prophylaxis with intramuscular long-acting release octreotide may be considered.The foregoing recommendations are based on expert opinion and require validation in prospective clinical trials.

Chemotherapy-induced diarrhoea

PURPOSE OF REVIEW

Diarrhoea is a major manifestation of chemotherapy-induced mucositis that until recently has received very little attention. To date, there is no detailed understanding of the underlying mechanisms of the condition. The purpose of this review is to examine the plethora of recent studies, both in the laboratory and in the clinic, which have attempted to elucidate effective treatment options.

RECENT FINDINGS

Over recent years, there have been many new treatment options trialled for ameliorating chemotherapy-induced diarrhoea. Some of these have shown great promise in small clinical studies and now need to be investigated in larger trials. Furthermore, there have been developments in the understanding of the underlying mechanisms of chemotherapy-induced diarrhoea. These developments may also lead to effective treatment options.

SUMMARY

Here, we describe the current thinking behind the mechanisms of chemotherapy-induced diarrhoea and present current and new treatment options. This opinion article highlights the shift towards more effective research into diarrhoea caused by chemotherapy.

Toxic effects and their management: daily clinical challenges in the treatment of colorectal cancer

Among the many chemotherapeutic options for metastatic colorectal cancer, none has shown clear superiority in efficacy. All pharmacologic agents in current use have been associated with adverse events. Frequently reported adverse events associated with the chemotherapeutic agents oxaliplatin, irinotecan, 5-fluorouracil, and capecitabine include acute and chronic neuropathy, hypersensitivity reactions, diarrhea, neutropenia, and hand-foot syndrome. Although biologic agents are seemingly less toxic, toxic effects can also arise with their use; antiangiogenic agents result in hypertension, and EGFR inhibitors can cause severe hypersensitivity, paronychial infections, and more commonly, dermatologic rash. Furthermore, a correlation has been reported for the efficacy of anti-EGFR agents and development of rash. Data indicate that elderly patients with colorectal cancer who have adequate function and performance status, who may previously have been dissuaded from pursuing active therapy solely on the basis of age, should receive the same treatment as younger patients. To enhance the survival of patients with metastatic colorectal cancer, many therapies are administered. Recognition of treatment-emergent toxic effects will, therefore, aid the design and implementation of management strategies that minimize treatment interruption and/or discontinuation, and enhance quality of life for patients.

Safety and efficacy of patupilone in patients with advanced ovarian, primary fallopian, or primary peritoneal cancer: a phase I, open-label, dose-escalation study

PURPOSE To evaluate the safety, maximum tolerated dose (MTD), and pharmacokinetics of patupilone administered once every 3 weeks with proactive standardized diarrhea management in patients with resistant or refractory ovarian, fallopian, or peritoneal cancer. PATIENTS AND METHODS Patients received patupilone (6.5 to 11.0 mg/m(2)) every 3 weeks via 20-minute infusion. Adverse events, dose-limiting toxicities (DLT), MTD, and tumor response were determined. The tumor response was measured by Response Evaluation Criteria in Solid Tumors (RECIST) and cancer antigen 125 levels. Results Forty-five patients were enrolled. Adverse events were mild to moderate in intensity, and grade 3 diarrhea (13%) was the most commonly reported serious adverse event. Grade 3 peripheral neuropathy was noted in two patients (4%). Diarrhea, peripheral neuropathy, and fatigue were the most common DLTs; however, these were uncommon in the first cycle and the MTD was therefore not reached in this study. Overall response (OR; complete and partial responses; median cycles, 8) per RECIST in patients with measurable disease (n = 36) was 19.5%. Median duration of disease stabilization (complete and partial responses and stable disease) was 15.8 months. These results appear improved from a previous study in a similar patient population using a weekly schedule (2.5 mg/m(2)/week; N = 53; OR, 5.7%). CONCLUSION Patupilone once every 3 weeks was well-tolerated at doses up to 11.0 mg/m(2). Patupilone demonstrated promising antitumor activity in patients with drug-resistant/refractory disease. An ongoing phase III study in this patient population is testing the 10.0 mg/m(2) dose.

Phase I Dose-Finding Study of Weekly Single-Agent Patupilone in Patients With Advanced Solid Tumors

Purpose

To evaluate the safety and maximum-tolerated dose (MTD) of weekly patupilone, a natural epothilone B, in patients with advanced solid tumors.

Patients and Methods

Patients were treated with patupilone (0.3 to 3.6 mg/m2) for 6 weeks on/3 weeks off or 3 weeks on/1 week off. Dose-limiting toxicities (DLTs), MTD, and pharmacokinetics were determined for each schedule of administration.

Results

Ninety-one patients were enrolled. The most common tumor types included ovarian, breast, and colon cancers. Doses of patupilone less than 2.5 mg/m2 using either the 6 weeks on/3 weeks off or the 3 weeks on/1 week off schedule were tolerated well. At higher doses, DLTs were observed using both dosing schedules, with diarrhea the most common DLT. The MTD for both treatment schedules was 2.5 mg/m2. After a short infusion, patupilone blood concentrations declined in a multiphasic manner with a terminal half-life of 4 days. Drug clearance was nonrenal and was not related to body-surface area. Over the dose range evaluated, systemic drug exposure was approximately dose proportional. Three patients achieved a partial response, and 31 patients had stable disease. Two patients experiencing a partial response had received prior taxane therapy.

Conclusion

Patupilone is well tolerated when administered at a dose of 2.5 mg/m2, using either a 6 weeks on/3 weeks off or a 3 weeks on/1 week off schedule. In contrast with murine studies, patupilone has a relatively prolonged terminal half-life in humans. The partial responses in patients previously treated with taxanes is consistent with promising preclinical results.

St. John's Wort modulates the toxicities and pharmacokinetics of CPT-11 (irinotecan) in rats

CPT-11 is a DNA topoisomerase I inhibitor for the therapy of colorectal cancer, whereas St. John's Wort (Hypericum perforatum, SJW) is a widely used herbal anti-depressant. This study aimed to investigate the effects of co-administered SJW on the toxicities and pharmacokinetics of CPT-11 and the underlying mechanisms. The body weight loss, gastrointestinal and hematological toxicities induced by CPT-11, and the pharmacokinetic parameters of CPT-11 were evaluated in rats pretreated with SJW or vehicle. Rats treated with CPT-11 alone experienced rapid decrease in body weight, whereas co-administration of SJW with CPT-11 resulted in lesser body weight loss. The gastrointestinal and hematological toxicities following CPT-11 injection were both alleviated in the presence of SJW. The rat pharmacokinetics of both CPT-11 and its metabolite SN-38 were significantly altered in presence of SJW. In conclusion, co-administered SJW significantly ameliorated the toxicities induced by CPT-11. The protective effect of SJW may be partially due to pharmacokinetic interaction between CPT-11 and SJW.

The Assessment and Management of Cancer Treatment–Related Diarrhea

Cancer treatment-induced diarrhea affects a high percentage of patients with cancer that receive chemotherapy or radiation treatment. Widely used criteria for measuring treatment-induced diarrhea, such as the National Cancer Institute Common Toxicity Criteria, do not account for important characteristics of treatment-induced diarrhea. These characteristics include the assessment of the duration of the diarrhea, coexisting symptoms, abdominal cramping, or the presence of nocturnal diarrhea. Until recently, there were no universally accepted guidelines for the management of diarrhea. An expert panel developed guidelines with recommendations regarding assessment of the patient and treatment. These guidelines stress the importance of a thorough assessment of the patient, and treatment based upon severity of symptoms. By employing these guidelines, the aggressive management of diarrhea may impact the overall morbidity of this symptom. Education regarding the importance of diarrhea is essential. Patients who are informed will better understand their role in managing this side effect and when to contact their health care provider with emergent symptoms. Early recognition and management of diarrhea will be essential to improve control of diarrhea, and in turn will positively impact patients' quality of life.

Recommended guidelines for the treatment of cancer treatment-induced diarrhea

PURPOSE

To update and expand on previously published clinical practice guidelines for the treatment of cancer treatment-induced diarrhea.

METHODS

An expert multidisciplinary panel was convened to review the recent literature and discuss recommendations for updating the practice guidelines previously published by this group in the Journal of Clinical Oncology in 1998. MEDLINE searches were performed and the relevant literature published since 1998 was reviewed by all panel members. The treatment recommendations and algorithm were revised by panel consensus.

RESULTS

A recent review of early toxic deaths occurring in two National Cancer Institute-sponsored cooperative group trials of irinotecan plus high-dose fluorouracil and leucovorin for advanced colorectal cancer has led to the recognition of a life-threatening gastrointestinal syndrome and highlighted the need for vigilant monitoring and aggressive therapy for this serious complication. Loperamide remains the standard therapy for uncomplicated cases. However, the revised guidelines reflect the need for recognition of the early warning signs of complicated cases of diarrhea and the need for early and aggressive management, including the addition of antibiotics. Management of radiation-induced diarrhea is similar but may not require hospitalization, and chronic low- to intermediate-grade symptoms can be managed with continued loperamide.

CONCLUSION

With vigilant monitoring and aggressive therapy for cancer treatment-induced diarrhea, particularly in patients with early warning signs of severe complications, morbidity and mortality may be reduced.

Resolution of refractory chemotherapy-induced diarrhea (CID) with octreotide long-acting formulation in cancer patients: 11 case studies

PURPOSE

Subcutaneous (SC) octreotide has been shown to effectively relieve chemotherapy-induced diarrhea (CID) refractory to conventional therapy but requires t.i.d. injections. A microencapsulated, long-acting formulation (LAR) of octreotide has been developed for once-monthly intramuscular (IM) dosing. Efficacy in resolving severe diarrhea and preventing further episodes of diarrhea in cancer patients was explored.

PATIENTS AND METHODS

Patients with advanced cancer who developed CID and failed conventional antidiarrheal therapy (loperamide + diphenoxylate-atropine) received octreotide LAR IM. The starting dose was either 20 or 30 mg with possible dose escalation from 20 to 30 mg and from 30 to 40 mg. Treatment was repeated every 28 days during chemotherapy.

RESULTS

Complete resolution of diarrhea within 1 to 4 weeks from injection time was seen in all cases with octreotide LAR 30 mg. With a subsequent prophylactic injection once every 28 days, CID was limited to NCI grade 1. This resulted in increased patient quality of life (QOL) and allowed better patient compliance with therapy. Therapy could then be completed at full dose and on schedule after resolution of often debilitating diarrhea.

CONCLUSION

The ability of octreotide LAR 30 mg to speed the resolution of CID and limit further episodes of diarrhea to infrequent NCI grade 1 controlled with loperamide (prn) suggests that long-acting somatostatin homologues have the potential to be useful in the secondary prevention of diarrhea in patients undergoing chemotherapy.

Overview of radiation- and chemoradiation-induced diarrhea

OBJECTIVES

To describe the pathophysiology, incidence, and impact of radiation-induced diarrhea (RID), and to highlight the radiation oncology nurse's role.

DATA SOURCES

Primary and tertiary literature, and clinical experience.

CONCLUSION

RID is a frequent complication of pelvic radiation, both when given alone and with chemotherapy. RID can significantly affect patient quality of life. Since diarrhea may be a difficult topic for patients to discuss, special care needs to be taken to avoid underdiagnosis of this problem.

IMPLICATIONS FOR NURSING PRACTICE

The oncology nurse is uniquely situated to monitor patients for the development of RID, assess its severity and provide guidance to the health care team on the patient's status.

Symptom Occurrence, Symptom Intensity, and Symptom Distress in Patients Undergoing High-dose Chemotherapy With Stem-cell Transplantation

The main aim of this study was to investigate the patients' self-reported symptom occurrence, symptom intensity (SI), and symptom distress (SD) from admission for stem-cell transplantation (SCT) until discharge from the ward. Forty-three patients participated and data were collected at 7 different time-points by using the self-administered Symptom Frequency, Intensity, and Distress questionnaire for SCT (SFID-SCT). The results showed that symptom occurrence followed a curve on which the highest frequencies of symptoms were reported from the day of the SCT (T2) until the end of the protective care period (T5). The mean SI and SD scores became higher when the number of reported symptoms increased. Between T2 and T5, 33% to 54% of the patients reported >10 simultaneous symptoms. Symptoms reported by more than 50% of the patients during T2-T5 were tiredness, loss of appetite, mouth dryness, nausea, sleeping disturbances, diarrhea, and changes of taste. Loss of appetite, tiredness, and mouth dryness were, in descending order, the 3 symptoms reported as most intense and distressing. A statistically significantly higher SD-score was found for the patients undergoing allogeneic SCT on the day before start of the conditioning regimen, as compared to the patients undergoing autologous SCT. Patients reporting no anxiety on admission were found to have higher, mean SD-scores at the end of the hospital stay than anxious patients. The SFID-SCT questionnaire was found to give useful information not only about symptom occurrence but also about SI and SD. To use an instrument that distinguishes between these aspects of the symptom experience may help health care professionals to support the patients through the SCT-process.