Pazopanib is an oral ther­apy that is approved to treat advanced renal cell car­ci­noma. It also exhibits activ­ity against melanoma and breast, prostate, colon, and lung can­cers, although it has not yet been approved for use in those can­cers. The drug specif­i­cally tar­gets the tyro­sine kinase recep­tor but also works against vas­cu­lar endothe­lial growth fac­tor recep­tor, platelet-​​derived growth fac­tor recep­tor, and c-​​Kit.

In their arti­cle in the Octo­ber 2011 issue of the Clin­i­cal Jour­nal of Oncol­ogy Nurs­ing, Bour­deanu, Twar­dowski, and Pal addressed the nurs­ing con­sid­er­a­tions for patients receiv­ing oral pazopanib for renal cell car­ci­noma. Poten­tial side effects of ther­apy as well as man­age­ment of those side effects are discussed.

Nurs­ing Con­sid­er­sa­tions
Before treat­ment begins, oncol­ogy nurses should con­duct a thor­ough med­ica­tion review with patients, record­ing all pre­scrip­tion drugs, over-​​the-​​counter med­ica­tions, vit­a­mins, min­er­als, and herbal treat­ments. CYP3A4 inhibitors (e.g., keto­cona­zole, clar­ithromycin) and induc­ers (e.g., rifampin) can affect the phar­ma­co­ki­net­ics of pazopanib, so dose mod­i­fi­ca­tions may be necessary.

Because pazopanib is an oral agent that can be taken by the patient at home, proper admin­is­tra­tion is vital. Nurses should pro­vide patients with clear writ­ten instruc­tions to take the med­ica­tion at the same time each day, and patients should record the time and amount of each dose in a diary. Nurses should review the diaries to ensure the med­ica­tion is being taken properly.

One of the key fac­tors that can affect patient adher­ence is the devel­op­ment of intol­er­a­ble side effects. How­ever, early recog­ni­tion of side effects can help nurses inter­vene quickly so that side effects remain tol­er­a­ble and patients main­tain their treat­ment reg­i­mens for opti­mal clin­i­cal out­comes. Although no for­mal tox­i­c­ity eval­u­a­tion guide­lines exist, Bour­deanu et al. (2011) reported that most aca­d­e­mic insti­tu­tions eval­u­ate patients on a monthly basis.

Side Effects
Bour­deanu et al. (2011) reported on a phase III clin­i­cal trial of 435 patients receiv­ing pazopanib for metasta­tic renal cell car­ci­noma. In that trial, patients reported the fol­low­ing side effects most frequently.

Diar­rhea: Although 52% of the patients in the study reported diar­rhea, less than 4% had grade 3 or 4 symp­toms. Nurses can man­age this side effect by instruct­ing patients to use anti­motil­ity agents (e.g., lop­eramide). The fol­low­ing dietary changes can also be beneficial.

• Con­sume suf­fi­cient flu­ids (e.g., sports drinks, diluted juices, non­caf­feinated drinks).
• Eat small, fre­quent meals.
• Eat foods high in sol­u­ble fiber or pectin (e.g., rice, noo­dles, bananas, white toast, skinned turkey or chicken, fish, mashed potatoes).
• Avoid foods high in insol­u­ble fiber (e.g., raw fruits and veg­eta­bles, seeds, legumes).
• Avoid greasy or fried foods, lac­tose, caf­feine, alco­hol, and hyper­os­motic liquids.

Hyper­ten­sion: 40% of the patients in the study expe­ri­enced hyper­ten­sion, with grade 3 tox­i­c­ity in 4%. Bor­deanu et al. (2011) explained that no for­mal guide­lines exist for the man­age­ment of hyper­ten­sion in the con­text of can­cer ther­a­pies; how­ever, oncol­ogy nurses can work closely with patients’ car­di­ol­o­gists or internists to coman­age treatment-​​related hyper­ten­sion. Patient blood pres­sures should be mon­i­tored regularly.

Hair color changes: Anec­do­tally in the study, patients reported yel­low­ing of their orig­i­nal hair color when on treat­ment with pazopanib. Oncol­ogy nurses should pre­pare patients for this poten­tial side effect, giv­ing them the nec­es­sary infor­ma­tion and teach­ing self-​​care strate­gies to min­i­mize and cope with changes.

Nau­sea and vom­it­ing: Grade 3 and 4 nau­sea and vom­it­ing is rare, so antiemetic pre­med­ica­tion typ­i­cally is not war­ranted. The fol­low­ing patient-​​specific fac­tors may increase a patient’s risk for devel­op­ing nau­sea and vomiting.

• Younger age
• Female gen­der
• His­tory of low alco­hol use
• Anx­i­ety
• Lower social functioning
• His­tory of motion sickness
• Hyper­eme­sis dur­ing pregnancy
• Poor con­trol of nau­sea and vom­it­ing dur­ing other chemotherapies

Patients should be instructed to use 5-​​HT3 antag­o­nists (i.e., odansetron) and related treat­ments as needed for nausea.

Anorexia: Patients’ weights should be recorded at each visit; if weight loss is appar­ent, a detailed account of patient appetites and caloric intake should be recorded. Patients should be referred for indi­vid­ual dietary coun­sel­ing if nec­es­sary. Appetite stim­u­lants, such as dron­abi­nol, may be used as needed.

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Lab­o­ra­tory abnor­mal­i­ties: Because fatal hepa­tox­i­c­ity events have occurred in patients receiv­ing pazopanib, the drug has a black box warn­ing and requires reg­u­lar liver func­tion test (LFT) mon­i­tor­ing. In the phase III trial, 53% of patients expe­ri­enced ele­vated ala­nine amino­trans­ferase and aspar­tate amino­trans­ferase; 12% and 7% were grade 3 and 4, respec­tively. Total biliru­bin was also ele­vated for 36% of patients, with 4% at grade 3 or 4. See Table 1 for pazopanib dose mod­i­fi­ca­tions in the event of LFT abnor­mal­i­ties. Patients with base­line mod­er­ate hepatic impair­ment may receive a less­ened dose, but patients with severe impair­ment should not receive pazopanib.

For more infor­ma­tion on pazopanib and its clin­i­cal impli­ca­tions for oncol­ogy nurses, refer to the com­plete arti­cle by Bour­deanu et al. (2011).

• Bour­deanu, L., Twar­dowski, P., & Pal, S.K. (2011). Nurs­ing con­sid­er­a­tions with pazopanib ther­apy: Focus on metasta­tic renal cell car­ci­noma. Clin­i­cal Jour­nal of Oncol­ogy Nurs­ing, 15, 513–517. doi: 10.1188/11.CJON.513–517

Five-​​Minute In-​​Service is a monthly fea­ture that offers read­ers a con­cise recap of full-​​length arti­cles pub­lished in the Clin­i­cal Jour­nal of Oncol­ogy Nurs­ing (CJON) or Oncol­ogy Nurs­ing Forum. This edi­tion sum­ma­rizes “Nurs­ing Con­sid­er­a­tions With Pazopanib Ther­apy: Focus on Metasta­tic Renal Cell Car­ci­noma,” by Laura Bour­deanu, NP, PhD, Prze­mys­law Twar­dowski, MD, and Sumanta Kumar Pal, MD, which was fea­tured in the Octo­ber 2011 issue of CJON. Ques­tions regard­ing the infor­ma­tion pre­sented in this Five-​​Minute In-​​Service should be directed to the CJON edi­tor at CJONEditor@​ons.​org. Pho­to­copy­ing of this arti­cle for edu­ca­tional pur­poses and group dis­cus­sion is permitted.