Considerations with Oral Oncology Meds

Listen in as our expert panel discusses critical aspects of managing patients on oral cancer therapies. Our experts review tips for optimizing patient care and share best practices for handling these specialized medications.

Special guests:

• Jill Cassaday, BPharm, PharmD, BCPS, BCOP
  • Clinical Pharmacist Specialist – Multiple Myeloma
  • Banner MD Anderson Cancer Center
• Samuel Snowaert, PharmD, BCOP, MBA
  • Clinical Oncology Pharmacist 
  • Pharmacists Optimizing Oncology Care Excellence in Michigan (POEM)
  • Covenant Cancer Care Center
• Lisa Thompson, PharmD, BCOP, CPPS
  • Clinical Pharmacy Specialist in Oncology 
  • Kaiser Permanente Colorado

You’ll also hear practical advice from TRC’s Editorial Advisory Board member:

• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in October 2025.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• FAQ: Specialty Meds
• Chart: Guide for Helping Patients Afford Their Medications
• Chart: Drug Interactions: Cytochrome P450 (CYP), P-glycoprotein, and More
• Toolbox: Medication Adherence Strategies
• Algorithm: Redosing Oral Medications After Vomiting

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Chapters

• 0:00 Introduction
• 2:20 CE Information
• 2:54 Interactions with Oral Oncology Meds
• 7:21 Strategies for Screening and Managing Interactions
• 10:27 Drug-Food Interactions & Patient Counseling
• 11:48 Discussing Supplements and Drug-Supplement Interactions
• 14:05 Common Side Effects
• 19:00 Managing Nausea, Vomiting, and Diarrhea
• 23:12 Serious Side Effects & When to Refer
• 24:37 Pharmacy Staff: Safe Handling & Dispensing
• 26:39 Patient & Caregiver: Safe Handling & Cleaning
• 29:04 Storage & Disposal Guidelines
• 32:32 Pharmacy Strategies to Prevent Errors
• 34:19 Conclusion

Transcript

This transcript is automatically generated. 

00:00:07 Samuel Snowaert

There are certain drug classes that we know have more interactions. Acid suppressants interact with a lot of our oral anti-cancer agents, especially the PPIs. The SSRIs, SNRIs do have some interactions with tamoxifen's ability to function. 

00:00:22 Samuel Snowaert

So just some general classes that I'll look out for, as well as the cardiac comorbidities and underlying organ dysfunction.

00:00:30 Lisa Thompson

I found that some patients might have a fear of reporting side effects. They're worried that they might, you know, need a dose reduction and that they might not get the optimal doses of their cancer treatment when in fact by waiting until their symptoms have worsened and cause other complications. That approach is actually the opposite and the counterintuitive way to go.

00:00:50 Lisa Thompson

I always try to really emphasize it's better to take action, you know, to take that antiemetic when your nausea is mild, to contact the officer early instead of waiting for things to become severe.

00:01:04 Narrator

Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources.

00:01:13 Narrator

Proud to be celebrating 40 years of unbiased evidence and recommendations.

00:01:18 Narrator

On this episode, our expert panel discusses critical aspects of managing patients on oral cancer therapies.

00:01:25 Narrator

You'll listen as our experts review tips for optimizing patient care and share best practices for handling these specialized medications.

00:01:33 Narrator

Our guests today are Dr. Jill Cassaday, a Clinical Pharmacy Specialist at Banner MD Anderson Cancer Center in Arizona.

00:01:42 Narrator

Dr. Samuel Snowaert, a Clinical Pharmacist in Oncology at Covenant Cancer Care Center in Michigan

00:01:49 Narrator

And Dr. Lisa Thompson, a Clinical Pharmacy Specialist in Oncology at Kaiser Permanente Colorado

00:01:56 Narrator

You'll also your practical advice from TRC Editorial Advisory Board member Doctor Craig Williams from the Oregon Health and Science University.

00:02:05 Narrator

This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:02:20 CE Narrator

And now the CE information.

00:02:23 Narrator

This podcast offers Continuing Education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast and the list of available CE courses.

00:02:40 Narrator

None of the speakers have anything to disclose.

00:02:45 Narrator

Now, let’s join TRC Editors, Drs Stephen Small and Sara Klockars, and start our discussion.

00:02:54 Sara Klockars

Let's hone in on how to keep our patients using these medications safe and start by reviewing interactions. So, Lisa, why are interactions common in patients with cancer?

00:03:09 Lisa Thompson

That's a great question. I mean that the 30 to 40% that you have listed here from a study, I would say that it's probably at least that many patients just because the longer patients are treated with cancer, the more therapies they go through for instance. 

00:03:25 Lisa Thompson

And then a lot of these newer oral agents or even some of the older ones, undergo sit metabolism via the liver or via other hepatic enzymes, and that also makes them very prone to drug drug interactions.

00:03:39 Lisa Thompson

These might be an interaction with a medication that's used to treat an acute issue while the patient is receiving their chemotherapy, such as an infection. 

00:03:48 Lisa Thompson

It could be an interaction with the medication the patient is taken for years, for a chronic issue, for example, a seizure medication, or it could be medications that we're actually using to manage a side effect of the anti-cancer agent.

00:04:02 Lisa Thompson

Such as drugs causing QT interval prolongation, for instance. Depending on the nature of the interaction, these could increase the risk of toxicity from the chemotherapy. 

00:04:13 Lisa Thompson

It could reduce the efficacy of the chemotherapy or it can impact the safety and efficacy of the other medications the patient is taking. 

00:04:20 Lisa Thompson

These drugs can definitely cause their own share of drug-drug interactions as well.

00:04:26 Lisa Thompson

Supplements and other foods such as grapefruit can also impact the metabolism of these medications, and additionally, there are drug-disease interactions that might need to be considered as well. 

00:04:37 Lisa Thompson

For instance, some oral chemotherapy agents might worsen long standing medical issues such as dyslipidemia, which would then require management.

00:04:47 Sara Klockars

Thank you. And can you comment, Sam, are there certain patients that you see in your practice that are at a high risk of experiencing interactions?

00:04:57 Samuel Snowaert

Sure, several of the oral anti-cancer agents have cardiac side effects. So I think that's one of the biggest things we look out for is does the patient have any baseline cardiac comorbidities because that might require some increased monitoring. 

00:05:10 Samuel Snowaert

Also, you know when patients come in, we're checking obviously their renal functionalities just like any pharmacist would in any setting.

00:05:17 Samuel Snowaert

In our case sometimes it gets a little bit, muddy, I guess because LFTs if a patient has cancer that's metastasized to the liver, those LFT elevations could be due to the cancer rather than the patient having an underlying hepatic dysfunction.

00:05:31 Samuel Snowaert

So we have to decide, is this the cancer or or is this an underlying hepatic issue? And then if it is the cancer, do we start at a reduce dose?

00:05:40 Samuel Snowaert

Or do we start at the standard dose and and not sacrifice that, you know quote unquote cancer killing ability of of the chemo. So that's always the discussion that's always a case-by-case basis.

00:05:51 Samuel Snowaert

One more thing, I'll add real quick too… patients with cancer, they tend to have poor oral intakes, they tend to have low serum albumin and for drugs that are highly protein bound, that can lead to increased side effects in patients who have have let low albumin and poor oral intake. So I’ll see the older patients listed as well that can be sometimes something that we have to watch out for with them.

00:06:12 Craig Williams

I’ll also add briefly, Sara, that because we increasingly seen these patients command or inpatient service on these medications that may not be there for the medications. But as we do medication reconciliation, if you're on enough medications, you're almost bound to have interaction. 

00:06:26 Craig Williams

So I’ll highlight the last to the right there polypharmacy. So it's we're working on. If we have 2 pages of medications patients are taking, we're definitely on the look for there being interaction.

00:06:36 Craig Williams

But that's probably our biggest factor we see in the kind of general medicine setting and it often then comes with lower comorbidities on those patients who are on more medications. But number of medications is a big signal to us.

00:06:46 Samuel Snowaert

So I've always I'm watching closely when patients have several drugs listed, several oral supplements listed always do oral supplement, you know, review as well with patients. There are certain drug classes that we know have more interactions, acid suppressants interact with a lot of our oral anti-cancer agents.

00:07:02 Samuel Snowaert

Especially the PPIs, the SSRIs, SNRIs do have some interactions with Tamoxifen's ability to function, so just some general classes that I'll look out for as well as the cardiac comorbidities and and underlying organ dysfunction.

00:07:18 Sara Klockars

Excellent points. Lisa, what strategies do you use in your practice to screen for these and manage these drug interactions?

00:07:28 Lisa Thompson

And I think the biggest thing is that through medication history that the other presenters have mentioned. It's one of the first steps is being able to identify and have that accurate list.

00:07:39 Lisa Thompson

Again, not only other prescription or over the counter medications, but also those complementary and alternative medicine products and a lot of patients, especially those with advanced cancer might be trying multiple strategies. And so it's important to make sure we keep those on the table as well.

00:07:54 Lisa Thompson

Additionally, you want to be aware of any medications they might be receiving that are injected. There are quite a few regimens that involve some oral medications as to how some injected anti-cancer medications and so you want to make sure to have those as well.

00:08:06 Lisa Thompson

One other important thing to consider, these drugs, as have been mentioned, come with a very high financial toxicity for our patients. And while some patient assistance programs will permit filling at their typical pharmacy, others do not and they involve the pharmaceutical manufacturer directly shipping drug to the patient. 

00:08:25 Lisa Thompson

And so you want to make sure you have those medications included on your list as well.

00:08:29 Lisa Thompson

Medical information can also be really helpful in evaluating these. If it's a QT interaction, you'll need EKG results, potentially laboratory values, as the other presenters have mentioned, may also be required to adequately assess these.

00:08:44 Lisa Thompson

And also the monitor, sometimes we do say OK, we need to proceed and so you want, we want to make sure there's a good monitoring plan in place.

00:08:50 Lisa Thompson

For a non-integrated system that might involve the pharmacist contacting the Prescriber's office. You know by phone say hey, here's the interaction. Do you have a plan to manage this and in an integrated system that can look like a multidisciplinary approach where you know the entire care team is involved in monitoring for that interaction.

00:09:08 Lisa Thompson

So sometimes management strategies could be as simple as patient education, you know, look out for this. Sometimes you need to change the dose of either the anti-cancer therapy or the other medication. And then also those monitoring recommendations.

00:09:23 Sara Klockars

Excellent. Thank you. Craig, do you have anything to add from your hospital practice?

00:09:30 Craig Williams

I mean this add is kind of the generalist trying to keep up with all this. You have to get familiar with and comfortable with your favorite drug interaction checkers. 

00:09:38 Craig Williams

So I'm fortunate to work in academic Medical Center and we have access to up-to-date the micro medics, both of which have pretty good drug interaction systems where you plug in the two medications of interest and hit enter and and you get a pretty well-detailed, accurate report for kind of what you should do.

00:09:53 Craig Williams

So we hope on the inpatient side, this has often been worked out on the outpatient side, but sometimes we're the ones starting new medications to be aware of. And there's too many of these to keep track of, I think even if your practice area.

00:10:05 Jill Cassaday

Something else that's useful too is if the patients are starting treatments inpatient and then coming outpatient, that having a good transition of care from the inpatient setting to the outpatient setting also helps us make sure that we're we're seeing the medications patients coming out on. So that certainly is beneficial as well.

00:10:27 Sara Klockars

I wanted to transition now to the drug-food interactions. So, Sam, I was wondering in your practice what are some counseling tips that you've used for patients regarding some of these food interactions?

00:10:43 Samuel Snowaert

Sure. So the food interactions like you mentioned, the grapefruit is probably the most common one, something that comes up every now and then is pomegranate as well. 

00:10:51 Samuel Snowaert

Star fruit, which we don't really get a lot of in Michigan but and then Seville orange is which are found in Orange Marmalades and every now and then patients are bummed that we're taking away their orange marmalades. But those are interactions as well.

00:11:03 Samuel Snowaert

And sometimes the oral agents do have certain recommendations as far as whether or not take with food or without, if it leaves it up for the patient to decide with or without food, I tend to tell them take it with the snack.

00:11:13 Samuel Snowaert

It seems to help settle the stomach. It seems to cause less nausea and diarrhea when they take it with a little bit of food.

00:11:18 Samuel Snowaert

That's not 100% true, but it does seem to help for the most part. If it specifies how to take the medication, then I do tell the patient why it must be taken that way. So like for example, capecitabine should be taken with food, because if you take on an empty stomach it gets absorbed too rapidly and can lead to side effects. 

00:11:34 Samuel Snowaert

So I will share that with the patient. Abiraterone is kind of the opposite, where if you take it with food, depending on what you eat, that could cause erratic absorption.

00:11:42 Samuel Snowaert

So, patients should take them on an empty stomach and and I consider an empty stomach either one hour before or two hours after eating. I I will touch on the supplements as well. 

00:11:50 Samuel Snowaert

This comes up a lot in the ambulatory clinic. Whenever I'm starting up the supplement discussion with a patient. 

00:11:55 Samuel Snowaert

I always start those conversations in a very non-confrontational open-minded manner because these are becoming more and more popular, especially on social media. 

00:12:04 Samuel Snowaert

So patients are asking about them more often and patients who ask about them, they tend to do their own research. So I always start those conversations by saying, you know, I think it's great that you're doing your own research and taking ownership of your health and taking your health into your own hands.

00:12:17 Samuel Snowaert

Do you mind if I take some time to share what I know about these supplements, or if I don't know anything about them? I say do you mind if I take some time to look into them before you start taking them? 

00:12:25 Samuel Snowaert

And then when I'm looking for interactions, my main concerns are, is this going to increase your risk of side effects from your treatment or is this going to decrease the efficacy of the treatment?

00:12:34 Samuel Snowaert

And if there are interactions I share with the patient exactly what I find. If there's limited information, I share that with them as well. So if it's kind of a Gray area, I'll kind of frame it as. 

00:12:44 Samuel Snowaert

Listen, if you were my mom or if you were my brother or my grandma, this is what I would recommend for you to do. But I can't give you a solid. Yes or no. 

00:12:53 Samuel Snowaert

There's certainly some pharmacists that take the approach of just suggesting stopping all herbal supplements, and that's a reasonable approach.

00:12:59 Samuel Snowaert

Because there is a lot of gray area in oncology and we're kind of adding an unknown with this herbal supplement as well. However, lately it seems like there's a lot of distrust towards the medical community. 

00:13:07 Samuel Snowaert

So I think when we can find these opportunities to kind of find a common ground with patients and meet them where they're at, it kind of reminds them that you're on the same team as them.

00:13:17 Samuel Snowaert

The sites that I like to use the Memorial Sloan Kettering Cancer Center has a great herbal supplement database. Really good patient information and provide information as well. 

00:13:25 Samuel Snowaert

Also, Natural Medicines has a really good herbal supplement database and interaction checker as well. So I use both of those sites.

00:13:33 Craig Williams

I really like the NHL's NCCIH complimentary integrative health website for information. There's actually a section there on cancer and, and they're pretty blunt about these generally haven't been found to be very helpful, and that's a great site that I, for patients who are open to it. 

00:13:48 Craig Williams

I have sent them there. And I we always tell them I'm not here to take away your supplements and herbals, but we love to educate you a bit more about these and so we've used that NCMH website quite a bit in helping with that in that area.

00:14:02 Sara Klockars

Great discussion, but I do want to move us along. We do have a few audience questions about side effects. So Jill, can you comment what are some common side effects you see?

00:14:14 Jill Cassaday

Sure. So side effects are going to vary depending on the patient, the type of cancer and also the particular oral medication that's being taken. 

00:14:22 Jill Cassaday

Some of the common side effects that are kind of related to you know, a lot of these medications are going to be fatigue, nausea and vomiting, diarrhea, skin changes, especially at the hands and feet and mouth sores.

00:14:34 Jill Cassaday

And there could be some hair loss. Other frequent side effects include things like changes and taste. You have the option of constipation, a decreased appetite, low blood counts and an increased risk of bleeding or infection.

00:14:48 Jill Cassaday

It is going to be patient specific. There are certain drugs that we'll just use cave side of being tends to be the one that we're kind of talking about. So there are hand foot changes.

00:14:56 Jill Cassaday

It's something called hand foot syndrome. Basically, it affects the palms of the hands and the soles of the feet like it's red can peel.

00:15:04 Jill Cassaday

They can actually turn darker and the areas actually do become painful in some patients. And so kind of, you know, making patients aware of that some institutions will prescribe creams and lotions to help kind of ease that when we have these side effects, what can happen is that it can delay treatment, it can cause dose reductions, non adherents.

00:15:25 Jill Cassaday

Those types of things, and eventually could you know overall could affect that survival. And so we want to make sure that patients are taking the medications at their optimal levels if at all possible and try to minimize those side effects.

00:15:39 Sara Klockars

Thanks, Jill. And when it comes to these side effects, Sam, how do you best prepare your patients?

00:15:46 Samuel Snowaert

So when I do my patient education in the clinic, I use education sheets to kind of help guide us both through the process. So they formerly was oral chewed edgesheets.com. Now it's patient educationsheets.com you can search any oral chemotherapy and and there's a very patient friendly version on that website. So that's why I like to use patients like it, they kind of shows you.

00:16:07 Samuel Snowaert

And what the side effects are, what you can do to manage them at home and when it's time to, you know, call the clinic because it might be beyond managing at home.

00:16:15 Samuel Snowaert

Whenever I'm starting a conversation with patients about these side effects, I start with, you know, acknowledging, you know, there are many potential side effects from these treatments. 

00:16:24 Samuel Snowaert

So I acknowledge that and I say, you know, I'm going to review a lot of side effects with you today just because we're discussing them does not mean you're going to experience all of them. You know, we just want you to know how you can manage them at home. 

00:16:34 Samuel Snowaert

If they were to come up and when to call us if it's not something that you should manage yourself so you know, for example, when we're talking about capacitor being, I'm talking Basile, LFT elevations, I'm talking about nausea, vomiting, diarrhea, the hand, foot syndrome, mucositis. 

00:16:47 Samuel Snowaert

There's a potential for cardiotoxicity with that one, there's the D PYD, pharmacogenomics. There. There's a lot of stuff to go over there, but then at the end, I kind of summarize it and say, OK, here's your grocery list of things to go, you know, go get some low pyramide, go get a urea based lotion, urea based lotion or typically any that are like for eczema. Urea helps with that hand foot syndrome a lot.

00:17:10 Samuel Snowaert

You know, have a salt soda rinse at home for mouth sores and then pick up your antiemetics from the pharmacy and I'll kind of summarize it up for the patient at the end. And I'll say these are the things that we most commonly see in the clinic. Yes, it's possible there could be these severe side effects, but these are the things that we see most commonly. And this is how we manage them.

00:17:29 Lisa Thompson

In addition to that, I always try to really emphasize it's better to take action, you know, to take that anti medic when your nausea is mild, you know to call the office or start that lotion when you're first starting to notice some redness on your palms and feet instead of waiting for things to become severe. 

00:17:45 Lisa Thompson

I found that some patients might have a fear of reporting side effects. They're worried that they might, you know, need a dose reduction and that they might not get the optimal doses of their cancer treatment.

00:17:57 Lisa Thompson

When in fact by waiting until their symptoms have worsened and cause other complications such as, you know, dehydration or acute kidney injury from uncontrolled nausea and vomiting, that approach is actually the opposite and the counterintuitive way to go.

00:18:12 Lisa Thompson

It's better to contact the office early to take that anti medic early on instead of waiting for things to become severe.

00:18:20 Craig Williams

Just going to answer that I love on the previous slide that kind of question-based approach for the patient and helping us meet the patient where they're at. 

00:18:28 Craig Williams

The thing we often come on the inpatient side. Sometimes we're meeting patients when they're hospitalized for an adverse effect from the therapy. 

00:18:33 Craig Williams

And one thing we're always working with with both outpatient inpatient oncology colleagues and the patients, how are you doing on this therapy?

00:18:41 Craig Williams

Because they understandably, if their cancer is responding well to this therapy, they can be very committed to staying on that and sometimes that can be difficult because of the adverse effects that they're having. But we always need to understand how their cancers respond to the therapy to kind of decide how we're going to respond to the adverse effects that they're having as well.

00:19:00 Sara Klockars

Excellent. I do want to take a few minutes to answer some of these questions we're getting about how to manage nausea and vomiting. So Jill, would you want to comment on them?

00:19:10 Jill Cassaday

You know, nausea and vomiting, obviously. We we will treat with antiemetics again depending on the risk of the emetic potential. And so NCCN has a very good chart that talks about the immunogenicity of these agents. It goes from high to low to minimal. And so each of those agents will be treated differently. 

00:19:29 Jill Cassaday

So it's important for us to know where those medications fall and what medications we can give those patients to help with that nausea and vomiting.

00:19:37 Sara Klockars

Lisa, would you want to comment on that?

00:19:40 Lisa Thompson

Yeah. I mean, I think the five HT-3 inhibitors, granisetron ondansetron, are probably the two most frequently take home antiemetics that our patients receive even for oral chemotherapy agents that have a relatively low risk of Ms. We do typically give them at least one agent to take on an as needed basis.

00:20:01 Lisa Thompson

For some of these regimens, a patient will be instructed, hey, this is a high risk. You need to take this one hour before every single dose. Whether you think you need it or not and other cases, it's something that we add as needed. If the patient experiences it. 

00:20:14 Lisa Thompson

There are so many different potential options to treat this. One important consideration whenever selecting one of these for an oral regimen, is this isn't something that they're going to get only once every three weeks or every two weeks.

00:20:27 Lisa Thompson

This is something that they're taking their oral chemotherapy most likely pretty frequently.

00:20:34 Lisa Thompson

And So what are the side effects of this drug when it's taken continuously, for instance, dexamethasone is an excellent antiemetic, but I wouldn't want to put someone on 8 or 12 milligrams of dexamethasone every single day, you know for 21 days out of every month. 

00:20:49 Lisa Thompson

And so it's important to kind of consider that and have that as part of the consideration.

00:20:53 Lisa Thompson

And I really think that's why you see so much of the five HT 3, umm, antagonist use in addition to their efficacy. Also some of the different side effect profiles compared to some of the others in this group.

00:21:05 Jill Cassaday

The same thing with things like diarrhea. We already know that certain drugs cause diarrhea, so preemptively giving them an anti-diarrheal to help with that certainly helps the patients in the long run.

00:21:16 Jill Cassaday

Things like mouth sores are the same thing. You know, a lot of our breast cancer treatments do have the risk of, you know and the hand foot syndrome, the nausea and vomiting, the diarrhea, the mouth sores.

00:21:26 Jill Cassaday

Those types of things and so being able to just kind of upfront give the patients those medications to help with these side effects. 

00:21:33 Sara Klockars

Thank you. We have a subscriber question about vomiting. So what should we recommend if a patient vomits shortly after taking their med?

00:21:48 Jill Cassaday

Sure. So a lot of that will be dependent on when the vomiting actually occurred.

00:21:54 Jill Cassaday

Kind of a rule of thumb. Generally, if they vomit within about 15 to 30 minutes after they've taken their dose, it's possible that the medication was not absorbed or minimally absorbed. 

00:22:05 Jill Cassaday

If it's greater than that of 30 to 60 minutes or more, some absorption is likely occurred and retaking the dose could be dangerous. 

00:22:13 Jill Cassaday

So ultimately the patient really should be reaching out to the provider or making sure that they are aware when they get the medications that if they happen to vomit, this is what they need to do in that case.

00:22:24 Jill Cassaday

I don't know, Lisa, if you guys or Sam, if you guys do the same thing with that 15 to 30 minute window or the 30 to 60 minute window in your institutions.

00:22:37 Samuel Snowaert

My personal preference is if a patient does vomit a dose, I tend to tell them we're done for the day.

00:22:41 Samuel Snowaert

Because, you know, if they vomited, you know this day and age in oncology, we really shouldn't be having patients vomits. 

00:22:48 Samuel Snowaert

Hopefully we would be controlling that with Antiemetics. So you know, I kind of use that as an opportunity to kind of refigure out their antiemetic regimen and get those under control. 

00:22:55 Samuel Snowaert

And I just get worried about there being potential for absorption if they take another dose and vomit that dose up too. Then we have two missed days. So that's my personal preference but I don't think there's one right or wrong answer for this question.

00:23:11 Sara Klockars

Thank you for that. Sam, could you comment on serious side effects or symptoms that require immediate referral to the Doctor or the ED.

00:23:22 Samuel Snowaert

Sure. One thing I touched on with a lot of these drugs we mentioned already is a lot of these have cardiac side effects, sometimes even MI's or nuance at Afib. 

00:23:30 Samuel Snowaert

So for sudden chest pain, chest tightness with severe shortness of breath, they should just go to the ER for that. Also, some of these meds can cause clots. 

00:23:39 Samuel Snowaert

So if they start getting the swelling, redness, pain, and their lower extremities. You know, they they can call us. We're probably gonna recommend they go to the ER.

00:23:48 Samuel Snowaert

Are also any fevers or any other signs of infection, like a newer worse than cough or even a UTI, patients should at minimum be evaluated at at an urgent care. If not go to an ER. 

00:23:59 Samuel Snowaert

Things that can be handled more in the outpatient setting. You know, obviously we've talked about the GI side effects also changes in breathing, abnormal bleeding, bruising, dizziness, light headedness.

00:24:10 Samuel Snowaert

Those are all things that I approached the physician about, if patients are reporting that to me or anything that's outside of my comfort zone.

00:24:15 Samuel Snowaert

And then especially if patients are reporting any altered mental status or headaches, you know this may be a side effect from the drug, but also unfortunately, you know, cancer does metastasize to the brain, especially breast and lungs. 

00:24:26 Samuel Snowaert

So patients are reporting changes in mental status or headache. That's something that should be reported to the physician they may need to do some brain imaging or something like that.

00:24:37 Sara Klockars

I still want to discuss a little bit about safe handling and disposal and then just some other pharmacy considerations. So Steve, I'm going to turn it over to you to discuss the handling considerations.

00:24:51 Steve Small

Thanks, Sarah. So, Lisa, what should we think about when handling oral anti-cancer meds? We've actually had several viewers asking about this, what general tips should we keep in mind?

00:25:02 Lisa Thompson

That's a great question and it's one that I don't think always comes to the forefront of your mind as a dispensing pharmacist.

00:25:11 Lisa Thompson

There's an international group of pharmacists that have published recommendations about the safe handling of these products within the pharmacies. 

00:25:19 Lisa Thompson

They include things like don't use your automated counting machine because of particulates that my aerosolize and then also contaminate the machine with every other medication in it. 

00:25:28 Lisa Thompson

If you need to handle the actual medication, it's recommended to wear gloves and wash your hands after doing that. 

00:25:35 Lisa Thompson

Don't crush or split or otherwise manipulate the tablets, even if that's the service that your pharmacy might provide for some patients, it's not something that you would want to do outside of a biological safety cabinet.

00:25:47 Lisa Thompson

And then also when you are counting these out, make sure to use a designated counting tray that's cleaned after each use. 

00:25:54 Lisa Thompson

One other thing to consider with these as well. A lot of these are meant to be dispensed in the original container, which can help mitigate some of these risks in terms of the staff handling it. 

00:26:03 Lisa Thompson

But one other thing that I always like to note is that more and more of these agents are being supplied in dosing blister packs, so instead of the patient taking 2 tablets out of a pharmacy, dispensed vile, they're popping two out of the blister pack. 

00:26:17 Lisa Thompson

It's meant to improve patient convenience and adherence. However, I always recommend really, closely examining the dispensed quantity to make sure that you are giving the patient the correct quantity for their day supply

00:26:29 Lisa Thompson

And then also ensuring your label is placed in a way that does not make it difficult for the patient to read the labeling and achieve their intended dose.

00:26:39 Steve Small

And in a similar vein, what are handling recommendations for patients and caregivers? Sam, in my experience, you know patients in the hospital see us going head to toe in PPE and have questions. Am I supposed to do that at home when I'm handling these medications? What's your take on that?

00:26:58 Samuel Snowaert

Yeah, that's definitely a question that comes up frequently. And you know, the way I kind of frame that with patients is you know these nurses or pharmacists are handling maybe these medications multiple times a day and different kinds of those medications.

00:27:10 Samuel Snowaert

And we don't want them to be exposed to chemotherapy if they don't have to be and especially when it's an occupational hazard. So that's kind of how I'll frame it for patients.

00:27:17 Samuel Snowaert

When patients are at home they can handle their medications, but they should wash their hands before and after they touch their medication, because if they get the residue on their fingers, they could be touching countertops, door handles, etc.

00:27:28 Samuel Snowaert

If it's cytotoxic chemotherapy like capecitabine, you know, it maybe best to wear gloves, but it's just hard to tell a patient that they need to wear gloves for a drug that they're putting inside of their body. 

00:27:39 Samuel Snowaert

So as long as they wash their hands really good at before and after, you know, I'm OK with them touching it. Caregivers, however, should wear gloves for the same reason that the nurses who are handling the chemotherapy wear gloves and gowns.

00:27:50 Samuel Snowaert

You know to protect themselves from the chemotherapy. We don't want people to be exposed to chemotherapy if they don't need to be. And that's kind of the take home point.

00:27:59 Steve Small

Great. And similar to that, what are some other household special instructions for caregivers thinking things like laundry or cleaning that may come up? Any recommendations there?

00:28:11 Samuel Snowaert

Sure. The big thing is any soiled linens or clothes should be washed on their own and washed twice with patient, urinated themselves, or defecated themselves or any vomiting on their clothes or even drenching night sweats.

00:28:23 Samuel Snowaert

I'd say it's like someone dumping a bucket of water on you.

00:28:26 Samuel Snowaert

Those things should be washed in the washing machine on their own and washed twice. You can still share bathrooms with the people. You can still use public bathrooms. You can still hug, kiss, show affection to each other, but just take some of those extra precautions. 

00:28:39 Samuel Snowaert

Like if there are any drips or dribbles on the toilet seat, wipe those up.

00:28:42 Samuel Snowaert

If they were to have diarrhea and the toilet has a lid, close that lid of the toilet, flush it twice to make sure things washed down, and then any accidents around the house can be cleaned with regular household cleaners.

00:28:53 Samuel Snowaert

But if the caregivers clean it up, they should wear gloves and they should just do a thorough job of cleaning up. Treat it like there's chemotherapy in there and then just do a thorough job cleaning all that up.

00:29:03 Steve Small

Great. And then Jill, how should oral oncology meds be stored? I'm sure it can vary by product, but any general tips there to share?

00:29:13 Jill Cassaday

Sure, some general storage guidelines, they need to be kept in the original container. This is to help protect them and ensure proper labeling. They should be kept in a cool, dry place. 

00:29:22 Jill Cassaday

Example like a dresser drawer or a kitchen cabinet, but not in the bathroom. And that’s primarily because it can be hot and humid in the bathroom, which could affect the medication itself.

00:29:32 Jill Cassaday

If they're going to store it in a kitchen, it should be in a cabinet, away from the stove or sink, or even appliances. 

00:29:40 Jill Cassaday

If it gets too hot, it can affect the medication itself. It needs to be in a safe location to prevent accidental ingestion. So keep up and away from children and pets.

00:29:51 Jill Cassaday

Some medications do have to be kept in the refrigerator, so if that's the case, the recommendation is for the patient to put the medication in the container and a plastic bag or plastic container.

00:30:01 Jill Cassaday

That they can seal and then put it in a place away from food and other things within the refrigerator. So again, you know, making sure that it's not close to the temperature monitor. You know those types of things where it's going to stay at a stable temperature within the refrigerator.

00:30:20 Steve Small

Great. And let's say we've stored it perfectly. How should we then dispose of them safely when we're done with the product? Any recommendations there?

00:30:30 Jill Cassaday

Sure. The main thing is, is that they want to make sure that they're not flushing the meds down the toilet or dropping them in the sink.

00:30:37 Jill Cassaday

They should also not be put in the trash. I'll come back to this one in just a minute, but that's the general recommendation is to not put it in the trash.

00:30:45 Jill Cassaday

Ultimately, they should be doing what they call the take back program. There's different areas. So there's a lot of pharmacies, especially like the pharmacy that they fill it out will have a bin, if you will.

00:30:57 Jill Cassaday

Within the pharmacy that the patients can drop the medications into twice a year, typically like the police stations, fire stations, those types of things will have what they call a medication take back program.

00:31:09 Jill Cassaday

And people can bring unused, leftover whatever medications to those places to have those medications safely disposed of, kind of going back to the whole the trash thing again.

00:31:19 Jill Cassaday

We recommend not putting them in the trash, but if for some reason the patient cannot get to the pharmacy to return them or to one of those take back programs… 

00:31:28 Jill Cassaday

The recommendation is to put those tablets in with Kitty litter, dirt, those types of things. But again, in a container that's sealed and cannot be punctured. 

00:31:41 Jill Cassaday

If you will, you can put it in the trash and then as close to trash day and put it out. But again, that's the ultimately that's not the recommendation that the take back programs are surely what they should be doing.

00:31:53 Samuel Snowaert

And some cancer centers have cancer drug repositories where patients can donate their unused, unopened medication. They have to be in at their sealed manufacturer packaging, but it it's nice if there's a patient down the road who has insurance issues or cost coverage issues, then that could be an option for the patient down the road.

00:32:11 Steve Small

That's a good call out there. And those programs generally have stipulations, for example, that meds can't be expired.

00:32:18 Sara Klockars

Yes. And keep in mind that you can search for year-round, drop off locations online. The DEA now says every day is take back day. So don't hesitate to refer your patients to your pharmacy team for help.

00:32:33 Sara Klockars

And with that, let's talk about other pharmacy considerations for these risky meds. So Sam what are some strategies to prevent errors with these high risk meds?

00:32:46 Samuel Snowaert

Yeah. So I would say, you know from both the patient and the pharmacy perspective as well, I think what gets confusing is that these drugs aren't, you know, they're not always just something OK, take one tablet once a day. 

00:32:55 Samuel Snowaert

You know, sometimes there's a confusing schedule, they'll take it two weeks on, one week on, one week off, 3 weeks on, one week off. So there's some new drugs coming out where they just take two to four doses a week and then that's not continuous. They still have a week off.

00:33:07 Samuel Snowaert

So these schedules get quite confusing, like especially our myeloma regiments can get quite confusing, so making calendars for patients helps a lot.

00:33:16 Samuel Snowaert

Also you know in the pharmacy because we're trying to figure out these directions the the frequency. Sometimes it's easy to miss. You know our our easiest things which are you know renal and hepatic dose adjustments. 

00:33:27 Samuel Snowaert

So if you are at a pharmacy where you're verifying these medications, I would have a checklist check indication, directions, schedule, dose, renal impact, dose adjustments, allergy, drug interactions. 

00:33:39 Samuel Snowaert

And go through that checklist each time. I work in the field and I still do this where I have a checklist because it's easy to just miss things when when these schedules can get a little bit confused.

00:33:48 Craig Williams

I'm just going to add, Sara, in terms of taking medications safely, a touch point with the patient, if you have the time when they're not right in front of you can be very instructive. 

00:33:56 Craig Williams

So seeing them on the inpatient side when they're discharged, they all get a follow up appointment when they leave our service. But if that gets missed that appointment for some reason, they can suddenly be two or three weeks since they've been told how to maybe take a new medication or changing medication regimen.

00:34:08 Craig Williams

So a quick phone call to them and say, how are you doing and tell me how to take that medication can be important to see if they remember what you told them a week or two ago.

00:34:19 Narrator

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