Proactive Rash Management Vital for PI3K, AKT Inhibition in Breast Cancer

For patients with breast cancer receiving treatment with PI3K or AKT inhibitors such as capivasertib (Truqap) or alpelisib (Piqray), Hope S. Rugo, MD, FASCO, recommends pretreating patients for rash.

In an interview with Oncology Nursing News at the 24th Annual International Congress on the Future of Breast Cancer® East, hosted by Physicians’ Education Resource® (PER), LLC, Rugo explained that because little is known about which patients with breast cancer receiving a PI3K or AKT inhibitor are most likely to develop a rash during treatment, every patient should be receiving twice-daily antihistamines to prevent rash.

As Rugo emphasized, rashes are more likely to return if they have occurred once, unlike other adverse events (AEs) such as mouth sores, which can be treated immediately and are not typically recurrent or chronic.

Rugo, the division chief of breast medical oncology as well as director of the Women's Cancers Program at City of Hope in Duarte, California, also highlighted the importance of educating patients about this difference and why it is imperative for patients to adhere to premedication regimens.

Additionally, she explained that diarrhea is another common AE associated with PI3K and AKT inhibitors, and patients experiencing diarrhea should be similarly educated to be proactive in managing symptoms with loperamide (Imodium).

Transcript

We have no idea who gets a rash—and rash can be a big deal—so we want to be proactive [about it]. There’s no reason why [every patient with breast cancer receiving PI3K or AKT inhibitors] shouldn’t take twice daily nonsedating antihistamines for a premedication starting the day before and then continue it through.

If you get a rash, we treat it with topical steroids, and we treat a grade 3 rash with oral steroids, but it can be hard to manage if a patient gets a grade 3 rash, because they will keep getting a rash, sometimes even when you dose reduce.

That sort of preventive strategy is important. We did that commonly with alpelisib, and it seemed to markedly reduce the rash, just like we use the steroid mouthwash for everolimus [Afinitor] to reduce the mouth sores. It makes a big difference.

Mouth sores are different from rashes: You treat them if they occur. It works just as well as premedication if you treat them once they’ve occurred. You just don’t want a bad mouth sore. Rash is a different thing. You must do the preventive strategy. It’s very important. Tell patients why it’s more important to do prevention than treatment [with rashes].

The last thing is diarrhea, which is interesting. Diarrhea is [linked with] these agents. It seems to be a little bit more with capivasertib than with some of the other drugs, although we saw it as a late issue with alpelisib along with weight loss, and inavolisib [Itovebi] has the same feature. But diarrhea occurs with the AKT inhibitor. You’re taking [these agents on a] 4-days-on, 3-days-off schedule. You need to talk to people about diet and using a loperamide-type agent.

Something important that sometimes people don’t realize is that they can cut the pill in half. Just tell people, “OK, you’re going to go out and have a big salad at lunch. You’re going to go for a big hike in the woods where there’s no bathroom. Take a half of an Imodium before you go. If you get bad diarrhea, take a whole Imodium.” You can titrate it, and it really helps people’s quality of life a lot.

This transcript has been edited for clarity and conciseness.