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Case Study 7

For each question, choose the answer you think is correct. See the end of this page for the answers.

​P.N. is a 76-year-old female, diagnosed with adenocarcinoma of the colon, metastatic to the liver. The oncologist has determined that infusional fluorouracil is not suitable for this patient. First line treatment will be given with GIAVCAP.

Weight: 87 kg Height: 160 cm

Lab results taken 24 hours prior to first treatment:

  • WBC 8.4
  • ANC 4.4
  • Hgb 105
  • Platelets 318
  • Bilirubin 7
  • LDH 225
  • AST 75
  • Alk Phos 263
  • Creatinine 111
1. What is the calculated dose of capecitabine and how would an oncologist order this dose, taking into consideration the strength of tablets available?
  1. The dose should be 1970 mg PO BID × 14 days, ordered as 2000 mg PO BID × 14 days 
  2. The dose should be 2463 mg PO BID × 14 days, ordered as 2450 mg PO BID × 14 days 
  3. The dose should be 1847 mg PO BID × 14 days, ordered as 2000 mg PO BID × 14 days 
  4. The dose should be 1478 mg PO BID × 14 days, ordered as 1500 mg PO BID × 14 days 
2. What statement best describes her LFTs?
  1. LFTs are within normal limits and P.N. can receive the dose as prescribed 
  2. LFTs are elevated due to liver metastases and the dose should be reduced by 75%, as capecitabine is extensively metabolized by the liver 
  3. LFTs are elevated, which is a common occurrence with liver metastases and capecitabine should be discontinued 
  4. LFTs are elevated due to liver metastases, but P.N. can receive the dose as prescribed 

After the fourth cycle of capecitabine, P.N. develops peeling, redness, and pain on both of her hands. She is diagnosed with Grade 3 palmar-plantar erythromatosis (hand-and-foot syndrome), and the physician decides to delay subsequent capecitabine doses until her pain resolves and then reduce the capecitabine dose for the next cycle. 30 days following the fourth cycle, the PPE symptoms have resolved and the oncologist prescribes capecitabine 1477 mg PO daily × 14 days.

Lab results 24 hours prior to treatment:

  • WBC 6.7
  • ANC 2.4
  • Platelets 318
3. Are the interval since the last treatment and the dose both correct for this patient?
  1. The interval is correct but the dose should be 1500 mg PO BID × 14 days 
  2. The interval is too long and the dose should be 1500 mg PO daily × 14 days 
  3. The interval is too long and the dose should be 975 mg PO daily × 14 days 
  4. The interval is correct but the dose should be 975 mg PO BID × 14 days 

The correct answer is 1.

 

Rationale:

BSA calculation

 

 

 

Creatinine Clearance =

 

N x (140-age) x weight (kg
Serum creatinine (micromol/L)  Where N = 1.04 for females

 

     = 1.04 x (140-76) x 87 
                    111

     = 52.2 mL/min


According to the GIAVCAP protocol, the lower dose of 1000 mg/m2 is used because the patient is elderly. Since creatinine clearance is greater than 50 mL/min, dose reduction is not required.


     1000 mg/m2 x 1.97 m2 = 1970 mg BID x 14 days


As only 150 mg and 500 mg tablets of capecitabine exist, the oncologist should order 2000 mg PO BID x 14 days, and 4 x 500 mg tablets would be used.

 

 

 

The correct answer is 4.


Rationale: Although ranges for liver function test vary from lab to lab, the values given in the example for LDH, AST and Alk Phos are definitely elevated. With the occurrence of liver metastases, liver function tests may be elevated. We know this patient has liver metastases, but the drug she is being prescribed is not primarily handled by the liver, therefore there are no dose reductions and PN can receive the drug as ordered.

The correct answer is 1.


Rationale: Based on GIAVCAP protocol, "Dose Modifications: 2. Hand-Foot Skin Reaction", the dose should be reduced to 75% of initial dose for Grade 3 hand-foot skin reaction. Since our patient received 2000 mg, a 75% reduction would bring this to 1500 mg.


The interval since the last treatment is correct, as treatment should be stopped and delayed until the reaction has resolved to a grade 0-1 level.

SOURCE: Case Study 7 ( )
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