Case Study 10

For each question, choose the answer you think is correct. Answers are provided at the end of the page.
L.A. is a 77-year-old male diagnosed with stage IV non-small cell lung cancer.  Biopsy testing demonstrates an EGFR-mutation positive adenocarcinoma.  ALK and PD-L1 mutation testing are negative. His performance status is ECOG 1. He was deemed as an appropriate candidate for the LUAVAFAT​ protocol.

Lab results taken 24 hours prior to first treatment:
Lab value
 Patient's labs
 Normal range 
WBC
7.3
4 – 10 x 109/L
ANC
5.1
2 – 7.5 x 109/L
Hgb
126
115 – 155 g/L
Plt
331
150 – 400 x 109/L
SCr
59
45 – 90 µmol/L
eGFR
86
≥ 60 mL/min/1.73m2
Albumin
37
35 – 50 g/L
GGT
32
<49 U/L
AST
26
<36 U/L
ALT
17
<36 U/L
ALP
96
35 – 120 U/L
Total bilirubin
4
<17 µmol/L​​
LD
410
<225 U/L
CRP
56<4.8 mg/L

Weight = 65.2 kg, Height = 165 cm

1. Which of the following are acceptable patient identifiers to confirm that the prescription you received was written for L.A.?

  1. Patient's name
  2. Patient's name and date of birth
  3. Patient's name and PHN
  4. Options 2 and 3 are correct
  5. Any of the above

2. Which of the following best describes the BC Cancer benefit status of AFAtinib?

  1. It is a Class I drug and does not require special approval prior to treatment
  2. It is a Class I drug and special approval must be obtained prior to treatment
  3. It is a restricted drug but does not require special approval prior to treatment
  4. It is a restricted drug and case-by-case Compassionate Access Program (CAP) approval must be obtained prior to treatment

3. What type of drug therapy is AFAtinib classified as?

  1. Chemotherapy
  2. Targeted therapy using PD-1 immune checkpoint inhibition
  3. Targeted therapy using tyrosine kinase inhibition
  4. Targeted therapy using  CDK4/6 inhibition

4. What is the standard dosing regimen of AFAtinib? 

  1. one 40 mg tablet PO once daily on an empty stomach
  2. one 40 mg tablet PO once daily for 2 weeks, then 2 weeks off
  3. one 40 mg tablet PO once daily for 3 weeks, then 1 week off
  4. one 40 mg tablet PO once daily with a high-fat meal

5. L.A. is concerned about developing diarrhea and asks for your advice on management so he can best prepare himself.  All of the following recommendations would be appropriate EXCEPT:

  1. Keep an adequate supply of loperamide 2 mg tablets at home so diarrhea can be treated at the first sign of loose or more frequent stools than usual
  2. Follow the loperamide package instructions for treatment of diarrhea at the first sign of loose or more frequent stools than usual
  3. To help with diarrhea: drink plenty of fluids, eat and drink often in small amounts, and avoid high-fibre foods
  4. If you are lactose-intolerant, you may need to take LACTAID® tablets before each AFAtinib dose
  5. Call your doctor if diarrhea does not improve 24 hours after starting loperamide

6. After 3 weeks of continuous therapy, L.A. develops a mild acneiform rash on his face and upper chest and calls the physician for help.  Which of the following would NOT be an appropriate management option?

  1. Treat the affected area with a topical steroid cream. Counsel to avoid sun exposure and to wear appropriate sun protection
  2. Treat with oral diphenhydramine. Counsel to avoid sun exposure and to wear appropriate sun protection
  3. Treat with oral pantoprazole. Counsel to avoid sun exposure and to wear appropriate sun protection
  4. Treat with oral minocycline. Counsel to avoid sun exposure and to wear appropriate sun protection

7. Upon disease progression on AFAtinib, which of the following second-line treatment options would L.A. be eligible for?

  1. gefitinib 250 mg PO once daily
  2. erlotinib 150 mg PO once daily
  3. Immunotherapy with nivolumab 6 mg/kg every 4 weeks
  4. Platinum-based doublet with CISplatin/CARBOplatin and DOCEtaxel/PACLitaxel
  5. All of the above

 
The correct answer is 4.

Rationale: According to the BC Cancer Clinical Pharmacy Guide module 2, a minimum of two patient identifiers are required to confirm patient identity. These identifiers include two of the following: name, date of birth, identification number (BC Cancer/hospital/PHN).

 
The correct answer is 1.

Rationale: According to the BC Cancer Benefit Drug List, AFAtinib is a class I drug.  This means that as long as the patient meets the eligibility criteria specified in the protocol, they may receive AFAtinib at no charge from BC Cancer.

 
The correct answer is 3.

Rationale: As mentioned in the BC Cancer drug monograph for AFAtinib, it is a second generation tyrosine kinase inhibitor that irreversibly binds to the kinase domains of EGFR, HER2 and HER4.

 
The correct answer is 1.

Rationale: As mentioned in the LUAVAFAT protocol, AFAtinib is taken orally once daily on an empty stomach (at least 1 hour before or 3 hours after a meal).  The standard starting dose is 40 mg daily.

 
The correct answer is 2.

Rationale: Diarrhea is managed with a dose that is much higher than the package instructions for loperamide.  Patients are instructed to use 4mg immediately, followed by 2mg with every loose bowel movement, up to a maximum of 20mg daily.  Loperamide should be continued until 12 hours after the last loose bowel movement.

 
The correct answer is 3.

Rationale: According to the BC Cancer drug monograph for AFAtinib, dependent on severity, management of acneiform rash includes topical or systemic steroids, anti-infectives or antihistamines. 

 
The correct answer is 4.

Rationale: As mentioned in the LUAVAFAT eligibility criteria, use of first-line AFAtinib to progression precludes the use of both gefitinib and erlotinib as any subsequent line of therapy in the same patient. Therefore, consideration should be given to a standard platinum-based doublet as second-line therapy.  L.A. does not yet meet the eligibility criteria to receive immunotherapy.