TAS-102 and Bevacizumab: Key Insights on Later-Line Dosing in CRC

Collaboration with pharmacists supports safe dosing and adherence in CRC care.

Later-line treatment of colorectal cancer (CRC) requires careful consideration of patient comorbidities, dosing complexities, and supportive care needs.

In a recent interview with Oncology Nursing News, Kelley A. Rone, APRN, DNP, shared her perspective on how nurses and advanced practice providers (APPs) can navigate these challenges. The interview with Rone, a nurse practitioner at the Mayo Clinic Gastrointestinal Oncology Division of Hematology and Oncology in Phoenix, Arizona, followed a Case-Based Roundtable discussion moderated by Rone and hosted by Oncology Nursing News.

Rone highlighted that the combination of TAS-102 (trifluridine/tipiracil) with bevacizumab (Avastin) offers clinical benefit but comes with unique dosing schedules and monitoring demands. She emphasized the importance of considering factors such as hypertension, kidney function, and patients’ ability to adhere to oral therapy regimens. She also noted that collaboration with clinical pharmacists plays a key role in optimizing therapy, ensuring safe dosing, and providing patient education.

For oncology nurses and APPs, understanding when TAS-102/bevacizumab may or may not be appropriate is essential in improving quality of care. In this Q&A, Rone provides practical insights on managing later-line CRC therapy and overcoming dosing challenges.

Oncology Nursing News: What comorbidities should be considered when selecting later-line therapy in colorectal cancer?

Rone: If you have a patient who already has had to manage hypertension because they’ve been on [bevacizumab] for 2 or 3 years, that is something that you would take into consideration in regards to using fruquintinib [Fruzaqla]. If their kidney function is questionable because they’ve been on chemotherapy for so long, they’re older, or they’ve had ongoing hypertension issues, then it might be a little bit more difficult for you to use TAS-102 and bevacizumab.

If they already have questionable blood pressure and their kidney function is not stellar, then using bevacizumab along with the TAS-102 might be more challenging. You have the same problems with regorafenib [Stivarga], too. Hypertension is not as severe.

What makes TAS-102 challenging for some patients?

One of the issues with TAS-102, though it’s easier to manage given in combination with bevacizumab, is that the dosing is a little odd. You take it 5 days on, 2 days off, 5 days on, 2 weeks off. If you have patients who maybe aren’t that great at managing a schedule, sometimes it’s challenging for them to get that medication taken in the right way… Sometimes to get the right combination of medication or the right dose, you have to use 2 doses. That complicates things.

If you have a patient who you’re worried isn’t going to be able to manage their medications well (maybe because they have cognitive decline) you wouldn’t necessarily want to give them a drug where they have to take 2 different strengths in an odd way, so regorafenib would be better in that regard. You have to take that into consideration.

The other thing is that many of these patients are aware that they’re on the last couple of lines of therapy and that their time may be limited: if they don’t want to come to the infusion center every 2 weeks, then it would be better for them to have regorafenib or fruquintinib, because then they have to be seen less frequently.

What role do clinical pharmacists play in managing TAS-102/bevacizumab treatment?

We work closely with our clinical pharmacist. We have a clinical pharmacist who has an oral oncolytic program where she calls people. She also does the bulk of the education for the patients. She’ll call them, or, if she can, she’ll meet with them in the clinic the day they are told they’re going to start on one of these regimens… I always ask her to check my dosing. I’m say, “I’m sending a prescription for this TAS-102. Can you check, check it and make sure I’ve done it right?”

[Mistakes don’t] happen a lot, but it happens often enough where I’m a little nervous about it, and so I always have her make sure I did the right calculation, because the dosing on that is a little odd as well.

How do pharmacists support dose adjustments and patient adherence?

There’s a range: it’s based on body surface area, and sometimes, if their body surface area is near the edge of the range, sometimes we’ll dose down… if we don’t think they’ll tolerate the higher dose, or if their kidney function is not great. [Our clinical pharmacist] always says, “We should probably reduce this dose by so much because their kidney function isn’t great.” She’s really good about sending the patient a calendar that tells them the dates that they’re supposed to be on the medication. She’s really good about that.

The problem is that she doesn’t follow them more than 3 months, so hopefully by the time they get to the fourth month, they’ve figured it out, but we are still seeing them regularly. That’s one of the things that I think helps a lot, that that our clinical pharmacists’ shepherds people through that at the beginning.

This transcript has been edited for clarity and conciseness.