Liquid Formulation of Gemcitabine Increases Venous Pain in Patients With Cancer: A Retrospective Study

PURPOSE

Venous pain induced by peripheral intravenous infusion of gemcitabine has remained an unresolved issue in clinical practice. This study aimed to identify differences between gemcitabine formulations as well as risk factors associated with gemcitabine-induced venous pain in patients with cancer.

METHODS

We retrospectively analyzed data from consecutive patients with cancer who had received chemotherapy including a lyophilized or liquid formulation of gemcitabine diluted with 5% glucose solution via a peripheral vein. The study was conducted at Ehime University Hospital using electronic medical records dated between January 2015 and July 2017. The primary end point was the prevalence of venous pain at the administration site during gemcitabine infusion, classified as injection site reaction of grade ≥2 according to the Common Terminology Criteria for Adverse Events, version 4.0. A multivariate logistic regression analysis with generalized estimating equations for longitudinal data was used to identify risk factors for venous pain during all courses of gemcitabine treatment.

FINDINGS

A total of 1150 treatment courses in 141 Japanese patients were evaluated in this study. Venous pain occurred in 115 courses (10.0%) and in 49 patients (34.8%). The multivariate logistic regression analysis with generalized estimating equations revealed that a dose increase of gemcitabine and use of the liquid formulation of gemcitabine were significantly associated with an increased risk for venous pain (dose increase, adjusted odds ratio [OR] = 1.25; 95% CI, 1.11-1.40 [P < 0.001]; and liquid formulation, adjusted OR = 12.43, 95% CI, 5.61-27.51 [P < 0.001]), whereas age, course number of gemcitabine, and use of the soft-back product of 5% glucose solution were significantly associated with a reduced risk for venous pain (age, adjusted OR = 0.75; 95% CI, 0.57-0.98 [P = 0.037]; course number, adjusted OR = 0.96; 95% CI, 0.92-0.99 [P = 0.023]; and soft back, adjusted OR = 0.39; 95% CI, 0.21-0.74 [P = 0.004]).

IMPLICATIONS

The use of the liquid formulation of gemcitabine was associated with a significant increase in the frequency of gemcitabine-induced venous pain despite dilution with 5% glucose solution compared to that with the lyophilized formulation. The lyophilized formulation of gemcitabine should hence be used in peripheral intravenous infusion for the treatment of patients with cancer.

Effect of pH adjustment by mixing steroid for venous pain in colorectal cancer patients receiving oxaliplatin through peripheral vein: a multicenter randomized phase II study (APOLLO)

PURPOSE

The aim of this phase II clinical trial was to evaluate the preventive effect of dexamethasone mixing injection for venous pain in patients with colorectal cancer during chemotherapy.

MATERIALS AND METHODS

Patients were randomized to receive a 2-h intravenous infusion of oxaliplatin 130 mg/m(2) on day 1 followed by capecitabine 1000 mg/m(2) (or S-1 40-60 mg/m(2)) twice daily on days 1 through 14 of every 3 weeks with or without dexamethasone 1.65 mg at the infusion on day 1.

RESULTS

A total of 53 patients were enrolled. The analysis population consisted of 49 patients (arm A, with dexamethasone N = 24; arm B, without dexamethasone N = 25). The incidence of venous pain ≥grade 2 based on the CTCAE version 4.0 was 33.3 % in arm A and 56.0 % in arm B (relative risk 0.60; 95 % CI 0.31-1.16). The incidences based on the verbal rating scale for arms A and B were 50.0 and 64.0 %, respectively (relative risk 0.78; 95 % CI 0.48-1.28).

CONCLUSION

The primary endpoint was not met in this preliminary study.

[Pharmacological study and pharmaceutical intervention to reduce intravenous injection-induced vascular injury]

Intravenous injection often causes vascular injury such as venous irritation, vascular pain, and phlebitis. Vascular injury deteriorates the patient's QOL and sometimes limits the continuation of injection therapy. Pharmaceutical intervention and pharmacological mechanisms used to reduce vascular injury induced by vinorelbine and epirubicin were reviewed. A multivariate logistic regression analysis revealed that the dose of vinorelbine (≥40 mg) was a significant predictor for venous irritation. Alteration of the volume of normal saline for vinorelbine dissolution, from 50 to 100 mL, significantly decreased the grade of venous irritation. On the other hand, the phlebitis scores were significantly higher in patients treated with epirubicin ready-to-use solution compared with lyophilized powder. The change of formulation of epirubicin to lyophilized powder decreased the risk of venous irritation. The concentration inducing 50% cell viability inhibition was lower in the order of vesicant, irritant, and nonvesicant drugs on porcine aorta endothelial cells (PAECs), suggesting that the injuring effects of anticancer drugs on PAECs may be relevant as an indicator of the frequency of their vascular injury. The exposure to vinorelbine of PAECs rapidly depleted intracellular glutathione levels and increased intracellular reactive oxygen species production. Moreover, exposure to epirubicin increased intracellular lipid peroxide levels and enhanced the phosphorylation of p38 mitogen-activated protein kinase. These results demonstrate that oxidative stress plays an important role in vinorelbine- and epirubicin-induced endothelial cell injury, and may therefore increase the potential for vascular injury upon intravenous injection.

Fatores de risco para trauma vascular durante a quimioterapia antineoplásica: contribuições do emprego do risco relativo

OBJETIVO: identificar a relação entre os fatores de risco para trauma vascular e o surgimento de eventos adversos de infiltração ou flebite por quimioterapia antineoplásica. MÉTODOS: Estudo de abordagem quantitativa observacional com 30 mulheres com câncer de mama. RESULTADOS: O tipo de material do cateter apresentou associação que sugere risco (RR=2,76; IC=1,199; 6,369); o fator velocidade de infusão apresentou RR=2,22; entretanto, IC= 0,7672; 6,436; os fatores trajetória, número de punção e mobilidade da veia apresentaram RR<1 mas não podem ser considerados como fatores de proteção. Local de inserção e a visibilidade da veia apresentaram risco próximo a 1. CONCLUSÃO: O uso de cateter com metal para punção venosa foi considerado neste estudo como fator para Risco de Trauma Vascular. A análise da associação pelo RR mostrou-se concordante com os dados da literatura pesquisada.