Hospital Pharmacy - May 2017 - 343

343

Garrett et al.
treat breakthrough nausea. One of the following regimens is recommended:
1. Metoclopramide 0.5 to 2 mg/kg PO every 4 to 6
hours if needed, ±diphenhydramine 25 to 50 mg
PO every 6 hours if needed.
2. Prochlorperazine 10 mg PO every 4 to 6 hours
if needed, ±diphenhydramine 25 to 50 mg PO
every 6 hours if needed.
3. Prochlorperazine 25 mg rectally every 4 to 6
hours if needed, ±diphenhydramine 25 to 50 mg
PO every 4 to 6 hours if needed.
4. Promethazine 25 to 50 mg PO every 4 to 6 hours
if needed, ±diphenhydramine 25 to 50 mg PO
every 4 to 6 hours if needed.
C. Hypersensitivity Precautions: Oxaliplatin is
reported to cause hypersensitivity reactions in 8% to
13% of patients, with the incidence of moderate to
severe reactions ranging from <1% to 7%. The most
common symptoms are flushing and swelling of the
face and hands, itching, sweating, lacrimation, skin
rash, hives, rigors, dyspnea, and fever. Such reactions
usually occur during the second or subsequent cycles,
but one study suggests that the reactions most often
occur around cycle 9 or 10.23-25
For mild reactions, the oxaliplatin infusion is stopped and an
antihistamine and a corticosteroid may be administered.
Moderate to severe reactions usually require administration of
parenteral corticosteroids. One report suggests that lengthening
the oxaliplatin infusion time from 2 to 6 hours reduces the incidence of hypersensitivity reactions and may be appropriate for
some patients. Premedication with corticosteroids and antihistamines does not prevent subsequent hypersensitivity reactions.23
If the reaction to oxaliplatin is determined to be anaphylactic, a
desensitization regimen may be necessary for future doses.25
D. Hematopoietic Growth Factors: Accepted practice
guidelines and pharmacoeconomic analysis suggest
that an antineoplastic regimen have a greater than 20%
incidence of febrile neutropenia before prophylactic
use of colony-stimulating factors (CSFs) is warranted.
For regimens with an incidence of febrile neutropenia
between 10% and 20%, use of CSFs should be considered. For regimens with an incidence of febrile neutropenia less than 10%, routine prophylactic use of CSFs
is not recommended.26,27 Because febrile neutropenia
was reported in 1% to 2% of patients and grade 3 or 4
neutropenia was reported in 4% to 22% of patients in
the trials reviewed,1-4 primary prophylactic use of
CSFs is not recommended.1-4 CSFs should be considered if a patient experiences febrile neutropenia or
grade 4 neutropenia in a prior cycle of BCapOx.
E. Diarrhea: Diarrhea is a frequent consequence of
capecitabine administration.

Diarrhea is usually mild to moderate, responding to conventional therapy. Occasionally, the problem can be severe
or dose-limiting.
Patients should receive a prescription for an antidiarrheal
agent for use at the onset of diarrhea. The standard recommendation is loperamide 4 mg PO at the onset of diarrhea, followed by 2 mg PO every after each unformed stool, or as often
as every 2 hours for 24 hours.28 Patients should be counseled
to29:
1.
2.
3.

F.

Monitor bowel movements.
Treat grade 1 or 2 diarrhea (increase of <7 stools
per day or nocturnal stools) with loperamide and
oral rehydration.
Immediately seek advice from their physician, pharmacist, or nurse for persistent (>24
hours) grade 1 or 2 diarrhea, or grade 3 diarrhea
(increase of ≥7 stools per day or incontinence or
symptoms of dehydration).

Neurotoxicity: Neurotoxicity was reported in 1% to
83% of patients receiving BCapOx,1-5 with grade 3 or
4 neurotoxicity reported in 8% to 26% of patients.1-5

Oxaliplatin causes acute neurotoxicity consisting of coldinduced or cold-exacerbated paresthesias/dysesthesias and
muscle contractions. It also causes chronic neurotoxicity that
can impair quality of life. Preclinical data suggest the acute
neurotoxicity may be due to oxaliplatin's effects on voltagedependent sodium channels and/or chelation of intracellular
calcium by the oxaliplatin metabolite, oxalate.30
IV infusion of 1 g each of calcium gluconate and magnesium sulfate before and after the oxaliplatin infusion was
reported to significantly reduce the incidence of neurotoxicity.31-33 Recent data indicate that this is not effective. The use
of calcium gluconate and magnesium sulfate is no longer
recommended.34

Major Toxicities
Most of the toxicities listed below are presented according to
their degree of severity. Higher grades represent more severe
toxicities. Although there are several grading systems for cancer chemotherapy toxicities, all are similar. One of the frequently used systems is the National Cancer Institute (NCI)
Common Terminology Criteria for Adverse Events (http://
ctep.info.nih.gov). Oncologists generally do not adjust doses
or change therapy for grade 1 or 2 toxicities but make, or consider making, dosage reductions or therapy changes for grade
3 or 4 toxicities. Incidence values are rounded to the nearest
whole percent unless incidence was less than or equal to 0.5%.
A. Cardiovascular: Angina (grade 3 or 4) 1%3; bleeding
from colostomy (grade 1 or 2) 1%3; bleeding gums
(grade 1 or 2) 1%3; bloody stool (grade 1 or 2) 1%3;
epistaxis (all grades) 1% to 12%3; gastrointestinal


https://ctep.cancer.gov/ https://ctep.cancer.gov/

Table of Contents for the Digital Edition of Hospital Pharmacy - May 2017

Editorial, For Sale: FDA Priority Review Vouchers
Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Pharmacists’ Knowledge of the Cost of Laboratory Testing
Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 317
Hospital Pharmacy - May 2017 - 318
Hospital Pharmacy - May 2017 - 319
Hospital Pharmacy - May 2017 - 320
Hospital Pharmacy - May 2017 - 321
Hospital Pharmacy - May 2017 - 322
Hospital Pharmacy - May 2017 - 323
Hospital Pharmacy - May 2017 - Editorial, For Sale: FDA Priority Review Vouchers
Hospital Pharmacy - May 2017 - 325
Hospital Pharmacy - May 2017 - Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Hospital Pharmacy - May 2017 - Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
Hospital Pharmacy - May 2017 - 328
Hospital Pharmacy - May 2017 - 329
Hospital Pharmacy - May 2017 - ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Hospital Pharmacy - May 2017 - 331
Hospital Pharmacy - May 2017 - 332
Hospital Pharmacy - May 2017 - 333
Hospital Pharmacy - May 2017 - Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Hospital Pharmacy - May 2017 - 335
Hospital Pharmacy - May 2017 - 336
Hospital Pharmacy - May 2017 - 337
Hospital Pharmacy - May 2017 - 338
Hospital Pharmacy - May 2017 - 339
Hospital Pharmacy - May 2017 - 340
Hospital Pharmacy - May 2017 - Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Hospital Pharmacy - May 2017 - 342
Hospital Pharmacy - May 2017 - 343
Hospital Pharmacy - May 2017 - 344
Hospital Pharmacy - May 2017 - 345
Hospital Pharmacy - May 2017 - 346
Hospital Pharmacy - May 2017 - 347
Hospital Pharmacy - May 2017 - Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Hospital Pharmacy - May 2017 - 349
Hospital Pharmacy - May 2017 - 350
Hospital Pharmacy - May 2017 - 351
Hospital Pharmacy - May 2017 - 352
Hospital Pharmacy - May 2017 - Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Hospital Pharmacy - May 2017 - 354
Hospital Pharmacy - May 2017 - 355
Hospital Pharmacy - May 2017 - 356
Hospital Pharmacy - May 2017 - Pharmacists’ Knowledge of the Cost of Laboratory Testing
Hospital Pharmacy - May 2017 - 358
Hospital Pharmacy - May 2017 - 359
Hospital Pharmacy - May 2017 - 360
Hospital Pharmacy - May 2017 - Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Hospital Pharmacy - May 2017 - 362
Hospital Pharmacy - May 2017 - 363
Hospital Pharmacy - May 2017 - 364
Hospital Pharmacy - May 2017 - 365
Hospital Pharmacy - May 2017 - 366
Hospital Pharmacy - May 2017 - Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Hospital Pharmacy - May 2017 - 368
Hospital Pharmacy - May 2017 - 369
Hospital Pharmacy - May 2017 - 370
Hospital Pharmacy - May 2017 - 371
Hospital Pharmacy - May 2017 - 372
Hospital Pharmacy - May 2017 - 373
Hospital Pharmacy - May 2017 - Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 375
Hospital Pharmacy - May 2017 - 376
Hospital Pharmacy - May 2017 - 377
Hospital Pharmacy - May 2017 - 378
Hospital Pharmacy - May 2017 - 379
Hospital Pharmacy - May 2017 - 380
Hospital Pharmacy - May 2017 - 381
Hospital Pharmacy - May 2017 - 382
Hospital Pharmacy - May 2017 - 383
Hospital Pharmacy - May 2017 - 384
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