Anti-epidermal growth factor receptor targeted therapy-associated ulcerations

The well-studied role of epidermal growth factor receptor (EGFR) in metastatic colorectal cancer (mCRC) and non-small cell lung cancer (NSCLC) has enabled the development of drugs that target this molecule, including panitumumab for the former and osimertinib for the latter. Oral adverse events due to those agents are rarely described in the literature and their exact characterization is hampered by inadequate reporting and/or incorrect terminology used. We report two cases of panitumumab- and osimertinib-associated oral ulcerations with emphasis on their possible pathogenesis and optimal management.

Mechanisms, Management and Prevention of Pemetrexed-Related Toxicity

Pemetrexed is a cytostatic antifolate drug and a cornerstone in the treatment of lung cancer. Although generally well tolerated, a substantial part of the patient population experiences dose-limiting or even treatment-limiting toxicities. These include mucositis, skin problems, fatigue, renal toxicity, and neutropenia. Several studies confirmed that pemetrexed pharmacokinetics can serve as a prognostic factor for the development of toxicity, especially for neutropenia. Preventing and managing toxicity of pemetrexed can help to ensure durable treatment. Several evidence-based strategies are already implemented in clinical care. With the introduction of standard vitamin supplementation and dexamethasone, the incidence of hematological toxicity and skin reactions substantially decreased. In the case of high risk for toxicity, granulocyte colony-stimulating factor can be used to prevent severe hematological toxicity. Moreover, high-dose folinic acid can resolve severe pemetrexed-induced toxicity. There are several experimental options to prevent or manage pemetrexed-related toxicity, such as the use of standard folinic acid, hemodialysis, antidotes such as thymidine, hypoxanthine, and glucarpidase, and the use of therapeutic drug monitoring. These strategies still need clinical evaluation before implementation, but could enable treatment with pemetrexed for patients who are at risk for toxicity, such as in renal impairment.

Comparative study of oral and IV dexamethasone premedication in the prevention of docetaxel induced allergic reactions

BACKGROUND

The hypersensitivity reactions after docetaxel administration is a main concern in this study. The aim of this study is to check the incidence of hypersensitivity reactions (HSRs) after receiving a single dose of intravenous dexamethasone before docetaxel administration.

METHOD

In this retrospective study, 1 year data from Jan 1st 2018 to Dec 31st 2018 was retrieved from hospital information system (HIS). We examined 210 patients who visited hospital during the last 12 months during their cancer treatment and took dexamethasone orally 3 days prior to docetaxel administration or 20 mg intravenously before 15 minutes of docetaxel.

RESULTS

Out of 210 patients, only 50 patients were taking IV dexamethasone injection prior to docetaxel constitutes only 23.5% while patients who were taking oral dexamethasone were found to be 160 which constitutes 75%. There was no hypersensitivity reaction with oral and IV dexamethasone before docetaxel administration. Majority of the patients were without taking oral dexamethasone before docetaxel administration which not only saved time but also improve patient compliance.

CONCLUSION

No hypersensitivity reaction had been found either in oral or intravenous dexamethasone prior to docetaxel administration by using patient data from Hospital Information System (HIS). However, intravenous dexamethasone not only improve patient compliance but also reduce the risk of hypersensitivity reactions but the cost of intravenous dexamethasone is higher than the cost of oral dexamethasone. In conclusion, single dose of intravenous IV dexamethasone is preferred treatment option.

Comparison between two premedication regimens of dexamethasone before a pemetrexed-based chemotherapy: A single-center experience study

Pemetrexed, frequently used for the treatment of pulmonary adenocarcinoma, may cause cutaneous reactions that can be reduced with three oral doses of dexamethasone starting the day before treatment, and continuing after chemotherapy for a number of doses which varies according to the emetogenic potential of the protocol. Dexamethasone may induce side effects and no guideline suggests the conduct to favor when dexamethasone doses are omitted before treatment with pemetrexed. This study was performed to evaluate the efficacy of a simplified regimen of dexamethasone administered before a pemetrexed-based chemotherapy in preventing cutaneous toxicities. A prospective study was conducted with patients starting a pemetrexed-based treatment between February 2016 and August 2017 at the ambulatory oncology clinic of an academic hospital. Patients were divided into two groups, one receiving the usual oral premedication and the other receiving a 20-mg intravenous dose of dexamethasone prior to chemotherapy. Among the 70 patients included, 39 received the alternative regimen prior to a total of 114 chemotherapy cycles, while the other 31 patients received the usual premedication before a total of 154 cycles. The cutaneous toxicity incidence was of 10 events in the simplified treatment group compared to 9 events in the standard group (p = 0.35). These events occurred in nine patients within the experimental group and five patients within the control group (p = 0.56). A single intravenous dexamethasone regimen represents a valid alternative to the usual prophylaxis in preventing cutaneous reactions.

Dexamethasone differentially depletes tumour and peripheral blood lymphocytes and can impact the efficacy of chemotherapy/checkpoint blockade combination treatment

Dexamethasone is a synthetic glucocorticoid commonly used for the prevention and management of side effects in cancer patients undergoing chemotherapy. While it is effective as an anti-emetic and in preventing hypersensitivity reactions, dexamethasone depletes peripheral blood lymphocytes and impacts immune responses. The effect of dexamethasone on the number and quality of tumour-infiltrating leukocytes has not been reported. To address this, we calibrated the dose in two different strains of mice to achieve the same extent of peripheral blood lymphocyte depletion observed in patients with cancer. Doses that caused analogous depletion of T and B lymphocytes and NK cells from the peripheral blood, elicited no change in these populations within the tumour. The expression of immune checkpoint molecules PD-1, OX40, GITR and TIM3 on tumour-infiltrating lymphocytes was not altered. We found that dexamethasone had a small but significant deleterious impact on weakly efficacious chemoimmunotherapy but had no effect when the protocol was highly efficacious. Based on these results, we predict that dexamethasone will have a modest negative influence on the overall effectiveness of chemoimmunotherapy treatment.

Incidence of cutaneous reactions with pemetrexed: Comparison of patients who received three days of oral dexamethasone twice daily to patients who did not

Pemetrexed is a multitargeted antifolate indicated for locally advanced or metastatic non-squamous non-small-cell lung cancer and malignant pleural mesothelioma. Cutaneous reactions are associated with pemetrexed use. Pemetrexed prescribing information recommends oral dexamethasone 4 mg twice daily for three days starting the day before pemetrexed infusion to prevent cutaneous reactions. Patients receive intravenous dexamethasone before pemetrexed infusion at the University of New Mexico Comprehensive Cancer Center, but the oral dexamethasone recommendation is not always followed. The objective of this study was to determine if there is a difference between patients who received three days of oral dexamethasone starting the day before pemetrexed infusion and patients who did not by determining incidence of cutaneous reactions, delay in therapy, and therapy change due to adverse reactions. Eighty-five patients received at least one dose of pemetrexed between August 1, 2012 and August 31, 2017. Twenty-nine patients did not receive three days of oral dexamethasone 4 mg twice daily and 56 patients did (34.1% vs. 65.9%). There was no statistically significant difference in the incidence of cutaneous reactions between the intervention group and the control group (13.8% vs. 25.0%; p = 0.384), delay in pemetrexed therapy between groups (44.8% vs. 32.1%; p = 0.2), or therapy change due to adverse events (34.5% vs. 23.2%; p = 0.654). Results suggest three days of oral dexamethasone 4 mg twice daily did not significantly affect incidence rates of cutaneous reactions, delay in therapy, or therapy change in patients who received intravenous dexamethasone before pemetrexed infusion at University of New Mexico Comprehensive Cancer Center.

[Pemetrexed-induced eyelid edema]

BACKGROUND

Drug-induced eyelid edemas are rare. Herein, we describe a patient who developed this type of edema under chemotherapy.

PATIENTS AND METHODS

A 56-year-old male patient with a history of hypertension and adenocarcinoma of the lung with brain metastases consulted for incipient non-itchy eyelid edema with progressive worsening. The swelling occurred after 3 cycles of pemetrexed-carboplatin. There was no evidence of any other cause of edema. A diagnosis of pemetrexed-induced eyelid edema was made. Given the efficacy of this treatment and the patient's consent thereto, it was maintained.

DISCUSSION

Palpebral edemas secondary to pemetrexed are very rare, with only 22 published cases in the literature. Other differential diagnoses must be ruled out before considering this etiology. The pathogenesis of eyelid edema remains unknown. One hypothesis is capillary protein leakage inducing swelling in soft tissue and non-malignant effusion, as has been suggested for docetaxel. Other agents such as tyrosine kinase inhibitors (imatinib and nilotinib) and mTOR inhibitors (sirolimus) may also cause eyelid edema. Treatment of eyelid edema is difficult and one case of surgical treatment has been published with good results and no recurrence after 6 months.

Dexamethasone pretreatment impairs the thymidylate synthase inhibition mediated flare in thymidine salvage pathway activity in non-small cell lung cancer

INTRODUCTION

Successful inhibition of thymidylate synthase (TS) by pemetrexed, a TS inhibitor, results in a reproducible transient burst or "flare" in thymidine salvage pathway activity at 2 hrs. of therapy which can be measurable with FLT-PET ([18F]fluorothymidine-positron emission tomography) in non-small cell lung cancer (NSCLC). Routine administration of dexamethasone with pemetrexed-based therapy could potentially confound this imaging approach since dexamethasone is known to inhibit expression of thymidine kinase 1, a key enzyme in the thymidine salvage pathway. Here we examine the potential impact of dexamethasone on the TS inhibition-mediated thymidine salvage pathway "flare" in NSCLC.

MATERIALS AND METHODS

In order to determine NSCLC cell line sensitivity to dexamethasone and pemetrexed, IC50 studies were performed on NSCLC cell lines H23, H1975, H460, H1299. TS inhibition-mediated "flare" in thymidine salvage pathway activity was then measured at 2hrs. of exposure to pemetrexed and cisplatin in NSCLC cells lines following using 3H-thymidine incorporation assays under the following conditions: control (no chemotherapy or dexamethasone), or treated with pemetrexed and cisplatin without dexamethasone, with 24 hrs. pre-treatment of dexamethasone or with dexamethasone administered together with chemotherapy. These conditions were chosen to model the delivery of pemetrexed-based therapy in the clinic.

RESULTS

The IC50 of H23, H1975, H460, H1299 for dexamethasone and pemetrexed were 40, 5.9, 718, 362 μM and 0.22, 0.73, 0.14 and 0.66 μM respectively. Significant blunting of the thymidine salvage pathway "flare" is observed at 2hrs. of pemetrexed-based therapy when dexamethasone sensitive cell lines H23 and H1975 were pretreated with dexamethasone but not when dexamethasone was given together with pemetrexed therapy or in the setting of dexamethasone resistance (H460 and H1299).

CONCLUSION

24 hr. pretreatment with dexamethasone, but not same day co-administration of dexamethasone with therapy, impairs the TS inhibition-mediated "flare" in thymidine salvage pathway activity in NSCLC.