Transcript Managing side effects of CML treatments

Peig Carroll
CML Nurse Specialist
St. James’s Hospital
Dublin
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To review the common side effects of the
Tyrosine Kinase Inhibitors (TKI’s) that are
currently used in the treatment of CML
To increase awareness of some of the
different side effect profiles of each one
To offer practical advice on how to manage
the non- haematological side effects
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Most patients with Chronic Myeloid
Leukaemia will require life long treatment in
the form of a Tyrosine Kinase Inhibitor (TKI)
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Strict medication adherence is required to
achieve and maintain a good response to
treatment
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Reduction and management of side effects
from TKIs is essential for quality of life
Nilotinib (Tasigna)
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Imatinib (Glivec)
Diarrhoea
Constipation
Vomiting
Arthralgias (joint
aches/pains)
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Cough
Rash
Pruritis (itching)
Nausea
Headache
Fatigue
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Oedema (fluid
retention)
Nausea/
indigestion
Muscle cramps
Musculoskeletal
pain
Diarrhoea
Rash
Fatigue
Headache
Abdominal pain
Dasatinib (Sprycel)
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Diarrhoea
Headache
Cough
Skin rash
Fever
Nausea/Indigestion
Fatigue
Muscle pain
Infections
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Swelling of eyelids very common with Imatinib
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Mild diuretic, reduce salt intake, maintain
hydration
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Dry Eyes - Lacrilube (lubricating gel) apply at
night, Artificial tears, apply anytime
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Subconjunctival Haemorrhage (Blood shot eye)
Unsightly but not dangerous. Clear-eye drops
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More common in the first few weeks of taking TKIs
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Reduced by taking Imatinib (Glivec) after a meal,
may help to divide dose to twice a day
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Nilotinib (Tasigna) on an empty stomach, 2 hours
after and 1 hour before food
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Dasatinib can be taken with or without food, dose
should not be divided
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Anti-nausea drugs available if necessary,
Metoclopramide, (Maxolon) all 3 TKIs
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Take 1 hour before dose
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If history of indigestion or heartburn - breath test to
check for presence of Helicobacter Pylori infection
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If present treat with antibiotics and proton pump
inhibitor
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Imatinib and Nilotinib, Omeprazole (Losec) or
Lansoprazole (Zoton)
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Dasatinib - H2 blockers or proton pump inhibitors
not recommended. If required should be taken 12
hours apart
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Can occur with all 3 TKIs
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Topical hydrocortisone creams
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Antihistamines particularly if itchy
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If rash is severe drug should be held and oral
Prednisone given. TKI should be restarted at
lower dose and increased on weekly basis to full
dose if tolerated
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Mild red pimply type rash, low dose antibiotic
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Dry Skin - use daily moisturiser
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Maintain adequate daily fluid intake
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Increased Photo Sensitivity (burn from sun more
easily)
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Avoid direct sunlight – always wear high factor
sun screen and a hat
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Leg Cramps – Calcium and Magnesium supplement
(CAL-MAG) taken daily
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Musculoskeletal pain – Paracetamol in small
amounts - no more than 2 grams per day
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Ibuprofen non-steroidal anti inflammatory (NSAI)
can cause stomach upset/pain
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Heat packs -Topical anti-inflammatory gels/creams
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Gentle non-weight bearing exercise
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Interferes with the person’s ability to carry out
ordinary daily activities and it is not relieved by
rest or sleep
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Reduced activity and exercise causes aches and
pains, weakened muscles and fitness
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Fatigue can result in avoiding activity
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This in turn can cause emotions of Frustration,
Anxiety, Sadness, leading to further fatigue
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Regular exercise improves energy and mood
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Set realistic goals, begin slowly and increase
workouts gradually
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Get plenty of sleep and try to reduce stress
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Cognitive behavioural therapy, Yoga and meditation
increase feelings of wellbeing
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Eat foods high in energy, keep hydrated
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Diarrhoea common with high dose Imatinib
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Less common with Nilotinib or Dasatinib
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Eat foods like pasta, rice or bread, which are high
in carbohydrates
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Keep hydrated, maintain fluid intake - 2 liters per
day
Anti-diarrhoeal medicine, Loperamide
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More common with Nilotinib and Dasatinib
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Increase fibre intake, eat more fruit, wholegrain
bread and cereal, vegetables
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Increase fluid intake
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20 – 30 minutes gentle exercise per day
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If required stool softners, lactulose and mild
laxative, senokot
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Pleural effusions [fluid on the lung] appear to be a unique
side effect of Dasatinib
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Symptoms suggestive of pleural effusion include
shortness of breath, dry cough, chest pain
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Chest x-rays should be undertaken to confirm diagnosis
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To relieve symptoms a low dose diuretic (fluid tablet)
should be used.
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More severe cases may need fluid drained or
prednisolone
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All TKIs are metabolised (broken down) in the liver and
kidneys
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Nilotinib (Tasigna) is associated with elevated lipase and
bilirubin (pancreatic enzyme used for breaking down fats);
hyperglycaemia (increased blood sugar level);
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Imatinib (Glivec) is associated with hypophosphataemia,
(low phosphate); hypokalemia (low calcium) in a
proportion of patients – Calcium supplements sometimes
advised
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Blood Glucose and Renal Liver Bone tests should be
carried out regularly to monitor any changes
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Side effects can vary from patient to patient and
can be mild to severe regardless of age
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Careful consideration should be given to each
patient’s medical history when choosing a TKI
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Choice of second-line treatment should involve
consideration of patients previous side-effect profile
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Do not always assume that symptoms are related
to side effect of medication. Seek medical advice if
symptoms arise suddenly or become severe