Nurses Play a Key Role in Helping Patients Control Symptoms While on Ibrutinib

A clinically meaningful overall response rate was experienced by people with chronic graft versus host disease.

Ibrutinib (Imbruvica) is effective in reducing symptom burden in patients who have failed 1 to 3 prior treatments for chronic graft versus host disease (GVHD), according to study findings presented during a poster session at the Oncology Nursing Society Annual Congress.

“Ibrutinib is now considered as a viable option for GVHD treatment due to the recent FDA approval,” Melissa Logue ANP-BC, Vanderbilt University Medical Center in Nashville, said in an interview with Oncology Nursing News. “Our field has been longing for this for quite some time—a drug that will serve as a steroid-sparing agent, or for those who are steroid refractory.”

In the multicenter, phase Ib/II open-label study, researchers from Vanderbilt University Medical Center and Dana Farber Cancer Institute in Boston evaluated nursing practice patterns in managing symptom burden, treatment-emergent adverse effects (TEAEs), and concomitant medications in patients receiving ibrutinib.

Oncology nurses managed adverse events and concomitant medications through an online messaging system and study visit forms, and TEAEs based on institutional guidelines. Nurses were made aware of 13 concomitant medications being taken by patients, such as prednisone (100%), Bactrim (79%), acyclovir (71%), and oxycodone (45%). Moderate or strong cytochrome P450 3A inhibitors were being taken by 71% of patients.

Ibrutinib was given at a dose of 420 mg/day to 42 patients (median age, 56 years) until progressive disease or intolerable toxicity. They had all received ≤ 3 prior regimens for chronic GVHD following allogeneic stem cell transplantation. Most patients had cGVHD with multiple organs, including the mouth (86%), skin (81%), gastrointestinal system (33%), and liver (17%).

The Bruton’s tyrosine kinase inhibitor had clinically meaningful responses, including an overall response rate of 67%, and the rate of sustained response for ≥20 weeks was 71%.

“If using ibrutinib for the indication of GVHD, then it’s helpful to know expectations of response,” she said. “Most patients take several months to respond. Also, stabilization is considered a response.”

Nurses assessed patients using the Lee chronic GVHD Symptom Scale, which ranks skin, eyes and mouth; breathing, eating, and digestion; muscles and joints; energy; and mental and emotional health on a scale of 0 to 4-0 meaning not bothered at all and 4 extremely bothered. At 6 months, scores improved in 43% of patients. Overall, 61% saw improved scores.

Ibrutinib appeared well tolerated among the group. Fatigue was the most common TEAE, which was experienced by 57% of patients. Other common TEAEs included diarrhea, muscle spasms, and nausea. In addition, pneumonia was experienced by 17% of patients.

Using institution-specific recommendations, nurses effectively managed the TEAEs. For instance, patients were instructed to increase their exercise routine and take ibrutinib at bedtime to cope with fatigue. Antidiarrheals were used to mitigate drug-related diarrhea and physical therapy, stretching, and increased electrolyte intake were encouraged to alleviate muscle spasms. To prevent pneumonia, nurses recommended activity, pulmonary exercise, and continuation of prophylactic medications.

“Staying active and stretching while taking ibrutinib is extremely helpful,” Logue said. “It can help reduce the incidence of pneumonia (while also taking prophylactic drugs), and decrease or lessen muscle cramping.”

For concomitant medications, nurses recommended educating patients to communicate with their pharmacists and/or nurses; follow medication instructions; be aware of drug interactions, such as with certain foods; and remind patients to let their healthcare team know of any medications.

“Patient education regarding concomitant medications is vital due to potential drug-drug interactions,” Logue said. “Education regarding infection risk and when to call is also important since the risk for infection is greater with ibrutinib, as with any other drug that is immunosuppressant in nature.”

______________________________________________________________________________

Logue M, Stephenson S, Styles L, et al. Nursing management of patients receiving ibrutinib for steroid-dependent/refractory chronic graft versus host disease. Presented at: ONS 43rd Annual Congress; May 17-20, 2018; Washington, DC. Poster IS-17. https://ons.confex.com/ons/2018/meetingapp.cgi/Paper/2751.