Managed Care - December 2008 - (Page 47)

TOMORROW’S MEDICINE Transdermal Patch Tailors Antinausea Treatment Sancuso is at least as effective as the oral form of therapy, and careful attention to daily medication needs may provide a cost savings Thomas Morrow, MD lthough few symptoms are more unpleasant than nausea and vomiting, most of us have not thought much about this disagreeable activity. Thankfully, most of us only experience this symptom when a virus hits. But those undergoing treatment for cancer expect to have nausea and vomiting with each course of chemotherapy. Chemotherapy-induced nausea and vomiting (CINV) was virtually impossible to control before the development of the 5-HT3 receptor antagonists. In fact, many patients were admitted to the hospital for chemotherapy and dehydration control because of extreme nausea and vomiting. A Therapy Current pharmacotherapy consists of combinations 5-HT3 receptor antagonists, NK1 receptor antagonists, corticosteroids, and dopamine antagonists such as butyrophenones, benzamides, phenothiazines, antihistamines, benzodiazepines and cannabinoids. The mainstay of therapy typically includes a cocktail of 5-HT3 receptor antagonists and NK1 receptor antagonists. NK1 receptor antagonists include aprepitant and fosaprepitant, which selectively block the binding site for substance P at the NK1 receptor in the CNS. In addition, corticosteroids have long been known to assist in the control of CINE but their exact mechanism of action is unknown. There are several 5-HT3 medications approved by the FDA including dolasetron, granisetron, palonosetron, and ondansetron. Many studies have compared various 5-HT3 receptor antagonists. None of the national oncology guidelines picks a preferred agent, although palonosetron has a longer half life. All the 5-HT3 drugs are available in intravenous and oral formulations except for palonosetron, which is available only in an injectable form. That will change on the release of Sancuso (Granisetron Transdermal System), a new transdermal version of granisetron that received FDA approval in October. It is manufactured by Avena Drug Delivery Systems for ProStrakan. Sancuso is a 52 cm2 patch containing 34.3 mg of granisetron, which is released at a rate of 3.1 mg each 24 hours for up to seven days. It is indicated for the prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy regimens of up to five consecutive day’s duration. The rationale for using transdermal delivery is that patients benefit from the steady serum levels and Classification of CINV Several national organizations, including the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the Multinational Association of Supportive Care in Cancer (MASCC), have created classification systems to determine the risk of emesis along with the types of drugs in each level of risk. The classification system consists of four levels based upon the occurrence of emesis: minimal (less than 10 percent), low (10 percent to 30 percent), moderate, (30 percent to 90 percent) and high (greater than 90 percent). Typical drugs included in the moderate risk category are: carboplatin, cyclophosphamide (<1500 mg/m2), daunorubicin, doxorubicin, oxaliplatin and irinotecan. Carmustine, cisplatin, high dose cyclophosphamide, dacorbazine and streptozotocin are examples of drugs that have a high risk of emesis. Thomas Morrow, MD, is the immediate past president of the National Association of Managed Care Physicians. He has 23 years of managed care experience at the payer or health plan level. DECEMBER 2008 / MANAGED CARE 47

Table of Contents Feed for the Digital Edition of Managed Care - December 2008

Managed Care - December 2008 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor ICD-10 Offers Huge Opportunity, Challenge Part D at a Crossroads Plans Can Weather the Financial Crisis DM vs. Medical Home? Tackle Prediabetes Reasonable Approach to Morning Sickness Formulary Files Tomorrow's Medicine Outlook

Managed Care - December 2008

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