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PACL(W)+RAMU

Cancer Type: Gastrointestinal, Esophagus, Gastric / Stomach  Intent: Palliative
Regimen Category: Evidence-Informed
Funding:
New Drug Funding Program
    Ramucirumab - Advanced or Metastatic Gastric Cancer or Gastroesophageal Junction Adenocarcinoma
A - Regimen Name

PACL(W)+RAMU Regimen
Paclitaxel (weekly)-Ramucirumab


Disease Site
Gastrointestinal - Esophagus
Gastrointestinal - Gastric / Stomach

Intent
Palliative

Regimen Category
Evidence-Informed :

Regimen is considered appropriate as part of the standard care of patients; meaningfully improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR).  Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.


Rationale and Uses

For the treatment of patients with advanced or metastatic gastric cancer or gastro-esophageal junction adenocarcinoma, with an ECOG performance status of 0 or 1 and with disease progression following first-line chemotherapy (see NDFP eligibility form for detailed funding criteria).


Supplementary Public Funding

ramucirumab
New Drug Funding Program (Ramucirumab - Advanced or Metastatic Gastric Cancer or Gastroesophageal Junction Adenocarcinoma) (NDFP Website)

 
B - Drug Regimen

ramucirumab
8 mg /kg IV Days 1 and 15 ONLY

 

THEN

PACLitaxel
80 mg /m² IV Days 1, 8 and 15
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C - Cycle Frequency

REPEAT EVERY 28 DAYS

Until disease progression or unacceptable toxicity occurs

If paclitaxel is later discontinued due to toxicity or intolerance, may continue with single agent ramucirumab until disease progression

 
D - Premedication and Supportive Measures

Antiemetic Regimen:

Low

Other Supportive Care:

On days 1 and 15:

  • diphenhydramine 50mg IV (or equivalent)
  • dexamethasone 20 mg IV
  • ranitidine 50 mg IV (or other IV H2 antagonist)
  • acetaminophen 500 mg PO (If prior grade 1 or 2 infusion reaction to ramucirumab)

On day 8 (paclitaxel only):

  • diphenhydramine 50 mg IV (or equivalent)
  • dexamethasone 20 mg IV 
  • ranitidine 50 mg IV (or other IV H2 antagonist)
 
E - Dose Modifications

Doses should be modified according to the protocol by which the patient is being treated. The following recommendations have been adapted from clinical trials or product monographs. 

Do not treat until the following have been met (see table below). If paclitaxel cannot be given on day 1, delay for up to 28 days and then restart; if it cannot be given on day 8 or 15, the dose should be skipped.  If ramucirumab cannot be given, the dose should be skipped. 

 

Ramucirumab

Paclitaxel

 

Day 1

Day 15

Day 1

Day 8 or 15

Neutrophils

 

 

≥ 1.5 x 109/L

 

Platelets

 

 

≥ 100 x 109/L

 

Bilirubin & Creatinine

 

 

≤ 1.5 x ULN

≤ 1.5 x ULN

AST/ALT*

 

 

≤ 3 x ULN

≤ 3 x ULN

Drug related toxicity

≤ grade 1 or baseline (except hypertension, VTE and other toxicity in this table and below)

Proteinuria

< 2 + or < 2g/24 hours

 

 

* ≤ 5 x ULN with known liver metastases

Dosage with toxicity

Dose level Paclitaxel (mg/m2) Ramucirumab (mg/kg)
0 80 8
-1 70 6
-2 60 5
 

Toxicity

Severity

Ramucirumab dose

Paclitaxel dose*** (reductions for Day 1 ONLY)

Febrile neutropenia (Grade 3 or Grade 4) or Neutropenia ≥ 5-7 days or Thrombocytopenia

Grade 4

Consider hold* until recovery. Restart at the same dose.

Hold* until recovery. Restart at ↓ 1 dose level.

Neurotoxicity or other paclitaxel-related non-hematologic toxicity (except alopecia)

Grade 3

Continue

Hold* until recovery. Restart at ↓ 1 dose level.

Neurotoxicity

Grade 4

Discontinue

Discontinue

Infusion-related reactions

Grade 1 or 2

If related to ramucirumab, reduce infusion rate by 50%, and for all subsequent infusions

If related to paclitaxel, hold and treat as required. Once resolved, resume infusion at 10% of original rate x 15 min, then 25% of original rate x 15 min. If no further symptoms, continue at original rate.

Infusion-related reactions

Grade 3 or 4

If related to ramucirumab, discontinue

If related to paclitaxel, discontinue

Hypertension

Grade 3 or 4

Hold until controlled with antihypertensive therapy. Discontinue if cannot be controlled.

Continue

Proteinuria

1st occurrence urine protein ≥ 2 g/24 hours

Hold** and restart at ↓ 1 dose level once urine protein < 2 g/24 hours. 

Continue

 

2nd occurrence urine protein ≥ 2 g/24 hours

 

 

 

Hold** and restart at ↓ 2 dose levels once urine protein < 2 g/24 hours.
 

Continue

Toxicity Severity Ramucirumab dose Paclitaxel dose***  (reductions for Day 1 ONLY)

Proteinuria cont'd

3rd occurrence OR urine protein > 3 g/24 hours OR nephrotic syndrome

Discontinue

Continue

Delayed wound healing

n/a

Hold prior to scheduled surgery until the wound is fully healed. Discontinue if wound healing complications arise.

Continue

Arterial thromboembolism

Life-threatening VTE

Bleeding

Grade 3 or 4

Discontinue

Discontinue

GI perforation

PRES

Cystoid macular edema

Any

Discontinue

Discontinue

*Do not restart until ANC  ≥ 1.0 x 109/L, platelets  ≥ 75 x 109/L and non-hematologic toxicity < grade 2 or baseline.

**If urine protein does not return to < 2 g/24 hours, discontinue. ***If must be held on day 8 or 15, the dose should be skipped.



Hepatic Impairment

For paclitaxel, patients with hepatic impairment may be at risk of myelosuppression (see table for suggested dosage adjustment). For ramucirumab, no dosage adjustment is recommended for patients with hepatic impairment. New onset or worsening ascites, encephalopathy or hepatorenal syndrome can occur in patients with Child-Pugh B or C cirrhosis. Treat only if potential benefit outweighs risk in these patients.
 

Bilirubin and/or AST/ALT paclitaxel dose (mg/m2)
2-4 x ULN 60
>4 x ULN 40 or omit

Renal Impairment

For paclitaxel, no dosage adjustment required, but consider for patients with HIV-AIDS if creatinine ≥ 2 x ULN. For ramucirumab, no dosage adjustment is recommended in mild to moderate renal impairment. No data is available for CrCl < 30 ml//min.


Dosage in the Elderly

No dose adjustment required. No overall differences in safety or effectiveness were observed between patients ≥65 years compared with younger patients. Elderly patients on paclitaxel may be more at risk of toxicity.

Dosage based on ethnicity

Higher incidences of grade 3 proteinuria and nephrotic syndrome were reported in Asian patients living in East Asia compared to Caucasian patients.

 


 
F - Adverse Effects

Refer to ramucirumab drug monograph(s) for additional details of adverse effects


Very common 

  Common

Less common (10-24%)

Uncommon (< 10%),

but may be severe or life-threatening

  • Alopecia
  • Peripheral neuropathy (may be severe)
  • Fatigue
  • Musculoskeletal pain
  • Myelosuppression ± infection, bleeding(may be severe)
  • Nausea/vomiting
  • Infusion-related reactions
  • Abdominal pain
  • Diarrhea
  • Peripheral edema
  • Increased LFTs (may be severe)
  • Rash
  • Proteinuria (may be severe)
  • ECG changes
  • Hypertension (may be severe)
  • Mucositis
  • Injection site reaction
  • Arterial thromboembolism
  • Venous  thromboembolism
  • Cardiotoxicity
  • Arrhythmia
  • GI obstruction, perforation, fistula
  • Pancreatitis
  • Increased creatinine
  • Hypothyroidism (not usually severe)
  • PRES
  • Delayed wound healing
  • Cystoid macular edema / optic nerve disorder
  • Typhlitis
  • Secondary malignancy
  • Pneumonitis
  • Seizure
  • Nephrotic syndrome
 
G - Interactions

Refer to ramucirumab, PACLitaxel drug monograph(s) for additional details


  • Caution with the use of paclitaxel (or other CYP2C8 substrates) as metabolism of these substrates or paclitaxel may be altered.
  • Caution with the use of paclitaxel and CYP2C8 or CYP3A4 inducers/inhibitors.
  • Use of angiogenesis inhibitors and bisphosphates may increase the risk of osteonecrosis of the jaw.
 
H - Drug Administration and Special Precautions

Refer to ramucirumab, PACLitaxel drug monograph(s) for additional details


Paclitaxel administration:

  • Use non-PVC equipment, including 0.2 or 0.22 micron in-line filter, in order to minimize patients’ exposure to DEHP leaching from PVC bags or sets.
  • Dilute in 500-1000 mL Normal Saline or 5% Dextrose, in a final concentration of 0.3-1.2 mg/mL.
  • For weekly dosing, may be infused over 1 hour - mix in 250mL bag as above (not approved by manufacturer).

Ramucirumab administration:

  • Administer as IV infusion only. DO NOT administer as IV push or bolus.
  • Withdraw required volume and transfer to an empty IV container
  • Dilute with normal saline, as required to desired volume. DO NOT use dextrose as a diluent.
  • Gently invert container to mix. DO NOT shake.
  • Give ramucirumab before administering paclitaxel when used in combination.
  • Infuse IV over approximately 60 minutes (maximum rate 25 mg/min) using a separate infusion line, with a protein sparing 0.2 to 0.22 micron filter.
  • Flush the line with normal saline at the end of the infusion.

Special precautions:

  • Avoid in patients with a history of severe hypersensitivity reactions to paclitaxel, ramucirumab, other drugs formulated in Cremophor EL (polyethoxylated castor oil), or any of the components in the formulation
  • Avoid in patients with severe baseline neutropenia (ANC <1.5 x 109/L; < 1 x 109/L for patients with AIDS-related Kaposi’s)
  • Paclitaxel contains ethanol, and is administered with agents such as antihistamines which cause drowsiness. Patients should be cautioned regarding driving and the use of machinery.
  • Treat with ramucirumab only if potential benefit outweighs risk in patients with Child-Pugh Class B or C cirrhosis.
  • Use with caution in patients with known or increased risk of coronary artery disease and/or those receiving cardiotoxic chemotherapy.
  • Use with caution in patients at risk of bleeding, including those receiving concomitant antiplatelets and/or anticoagulants.
  • Ramucirumab has not been evaluated in patients with serious or non-healing wounds and may impair healing. Withhold prior to surgery.
  • Use with caution in patients with risk factors for GI perforation, including intra-abdominal metastases, inflammatory bowel disease, diverticulitis, ischemic bowel, peptic ulcers, obstruction and injury from endoscopy and surgery.

Pregnancy & lactation:

  • Paclitaxel and ramucirumab should not be used in pregnancy. Adequate contraception should be used by both sexes during treatment and at least for 6 months after the last dose.
  • Breastfeeding is not recommended. Fertility may be affected.
 
I - Recommended Clinical Monitoring

Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph.

Recommended Clinical Monitoring

  • Blood pressure; Baseline and every 2 weeks, or more frequently as clinically indicated
  • Cardiac monitoring with prior arrhythmia; Baseline and as clinically indicated
  • CBC; Baseline and before each dose
  • Liver function tests; Baseline and before each dose
  • Thyroid function tests; Baseline and every 2 to 3 cycles. Continue after treatment as indicated (thyroid dysfunction may persist)
  • Urinalysis (for protein); Baseline and before each cycle; if urine protein level is 2+ or higher, perform 24-hour urine collection (see dose modifications table under proteinuria)
  • Clinical toxicity assessment for infusion-related reactions, bleeding, infection, thromboembolism, cardiotoxicity, GI and neurologic effects, and impaired wound healing; At each visit
  • Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version

Suggested Clinical Monitoring

Renal function tests; Baseline and as clinically indicated


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J - Administrative Information

Approximate Patient Visit
Days 1 and 15: 4 hours; Day 8: 2 hours
Pharmacy Workload (average time per visit)
24.063 minutes
Nursing Workload (average time per visit)
46.5 minutes
 
K - References

Paclitaxel and ramucirumab drug monographs, Cancer Care Ontario.

Wilke H, Muro K, Van Cutsem E, et al; RAINBOW Study Group. Ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (RAINBOW): a double-blind, randomised phase 3 trial. Lancet Oncol. 2014 Oct;15(11):1224-35.

October 2017 updated adverse effects, precautions and monitoring sections


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M - Disclaimer

Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph.  Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
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