Chapter 23: Administration of systemic anticancer therapies
Skip chapter table of contents and go to main content
Source: LCA ([140]). Reproduced with permission of the London Cancer Alliance.
Source: LCA (2015). Reproduced with permission of the London Cancer Alliance.
Pre‐procedural considerations
Specific patient considerations
Education
Lack of individual adherence to self‐administered medications is a common clinical problem and it is even more critical when the patient is taking oral chemotherapy. There are significant safety issues surrounding these medications and patient education is paramount. It is critical that patient education is thorough so the patient understands:
- why they are taking their tablets
- how many tablets to take, how often and for how long
- the potential side‐effects of the treatment
- how to recognize toxicity
- what to do if they feel unwell.
For home‐based therapy to be successful, it is vital that patients take an active part in their care.
The responsibility to recognize and report any side‐effects rests with the patient. Therefore, patient education must emphasize recognition of early signs and symptoms and when to report problems. The role of pharmacy and nursing staff in educating the patient is paramount to ensure the safe handling and concordance to get the maximum benefit for the patient from their oral chemotherapy treatment. The London Cancer Alliance oral SACT counselling checklist forms the basis of oral chemotherapy counselling and is completed for every patient starting oral chemotherapy prior to cycle 1 (Table 23.5). Patients should be advised about all the safety aspects of handling oral chemotherapy, see Procedure guideline 23.5.
Table 23.5 Counselling checklist
| Oral anticancer patient and carer education checklist | |
|---|---|
| Prior to first cycle | |
| This checklist must be completed with the patient/carer at the point of handing the medication to the patient either in conjunction with or following a pre‐treatment consultation | Tick if discussed with the patient/carer |
| Instructions for taking | |
| Explain how and when to take the medicine including any treatment breaks | |
| If the patient is unable to swallow tablets or capsules or has a feeding tube, please refer to local chemotherapy/SACT treatment policy for information on how to dissolve or open capsules (if appropriate for the oral anticancer medicine) | |
| Missed doses can be taken if near to the scheduled time. Otherwise, do not try and catch up or double the next dose. Wait until the next dose is due | |
| In case of vomiting after taking a dose, do not repeat the dose and take the next dose at the normal time. If this occurs again, contact the chemotherapy team/24‐hour advice line | |
| Check the patient is aware of side‐effects and has received written information. Any side‐effects should be reported to their chemotherapy nurse or doctor | |
| If the patient is taking any prescribed/over the counter medicine/supplement the patient should inform their medical team | |
| Return any unused oral anticancer medicine to the hospital pharmacy. Do not flush or throw them away (for high‐cost drugs see counselling handbook) | |
| Storage and handling | |
| The oral anticancer medicine should not be handled by anyone who is pregnant or planning a pregnancy (unless taking on the advice of the medical team) | |
| If the carer is giving the anticancer medicine they should not handle the medicine directly but wear gloves or push the medicine out of the blister pack (if applicable) directly into a medicine pot | |
| Store the tablets/capsules in the container provided | |
| Store the tablets/capsules in a secure place, away from and out of sight of children | |
| Wash hands thoroughly after taking/giving the oral anticancer medicine | |
| Check the patient understands how to take the treatment, by asking them to repeat back their instructions | |
| Written information provided | |
| Taking an oral anticancer medicine patient information sheet | |
| Diary for taking oral anticancer medicine (if applicable) | |
For swallowing difficulty only – give relevant factsheet if appropriate for the oral anticancer medicine and an oral anticancer pack with disposables (e.g. oral/enteral syringes)
Dissolving oral anticancer tablets safely
Opening oral anticancer capsules safely
Giving an oral anticancer medicine through a feeding tube
Giving an anticancer syringe by mouth | |
| Patient name | Counselled by |
| Hospital number | Pharmacist/Pharmacy technician/Nurse/Interpreter |
| Signature and date | Signature and date |
Before all subsequent cycles:
- Check that the patient understood the counselling checklist in Table 23.5 and repeat if necessary.
- Check that any side‐effects experienced with their previous cycle were discussed with the patient's medical team.
- If a dose adjustment has been made, check that the patient is aware of why their dose has been changed and how many tablets/capsules they should now take.
- Check that the patient had no problems taking their previous cycle.
- Check that the patient understands how to take the treatment, by asking them to repeat back their instructions.
Patients with swallowing difficulties
Before advising patients to dissolve/open capsules or prepare for administration via feeding tubes, the patient must be assessed for the suitability of self‐administering oral SACT. Swallowing difficulties or the inability to manipulate medicines may contribute to the decision whether to treat with SACT via the oral route. Alternatively, if the patient is unable to swallow solids or liquids, they may have a feeding tube. Examples of feeding tubes include:
- short‐term: nasogastric (NG), nasoduodenal (ND), nasojejunal (NJ)
- long‐term: gastrostomy and jejunostomy (surgically placed), and percutaneous endoscopic gastrostomy (PEG) – and percutaneous endoscopic jejunostomy (PEJ) (endoscopically placed) (see Chapter c09: Patient comfort and supporting personal hygiene).
Table 23.6 details medicines that can be dissolved or opened and liquids/foods that can be used to mask the taste. All patients with swallowing difficulties should be provided with the relevant patient information factsheet (if applicable for the medicine) and an oral anticancer pack only after the pharmacist, pharmacy technician or nurse has talked through the procedure with the patient. There is a space on the relevant patient information factsheet to specify the suitable liquid/flavouring or food. Factsheets can be found in the oral SACT counselling handbook available at rmpartners.cancervanguard.nhs.uk.
Table 23.6 Oral anticancer administration table for patients with swallowing difficulties
| Can be: | |||||
|---|---|---|---|---|---|
| Drug name Tablet (T) / capsule (C) | Dissolved | Opened | Mixed with: | PO/feeding tube | Comment |
| Afatinib (T) | Yes | Non‐carbonated water. No other liquids should be used | PO/enteral tube | Disperses in approximately 100 mL of non‐carbonated drinking water. The tablet should be dropped into the water without crushing it, and stirred occasionally for up to 15 minutes until it is broken up into very small particles. The dispersion should be consumed immediately. Rinse glass with approximately 100 mL of water which should also be consumed. The dispersion can also be administered through a gastric tube | |
| Axitinib (T) | Yes | Distilled/purified water | PO/enteral tube | Do not use tap/bottled water. 15 mL distilled/purified water should be used for enteral route. Use amber coloured syringe/container to disperse tablet – light sensitive. Ensure suspension is protected from light | |
| Bosutinib (T) | No | See comment | PO | Film coated, immediate release tablets. Do not crush. Pfizer have not evaluated crushing, splitting, dissolving or feeding tube administration | |
| Busulfan (T) | Yes | Water | PO/enteral tube | Disperses in 18 minutes. Liquid preparation available | |
| Cabozantinib (C) | No | See comment | PO | This class of drugs – TKIs – and Cometriq® in particular is associated with increased likelihood of gastrointestinal bleeding and fistula formation. For this reason, opening the capsules cannot be recommended | |
| Capecitabine (T) | Yes | Raspberry or blackcurrant juice (not citric juices) | PO/enteral tube | Disperses in 15 minutes in 200 mL lukewarm water (not hot) | |
| Chlorambucil (T) | Yes | Water | PO/enteral tube | Disperses in 18 minutes. Tablets should not be divided | |
| Crizotinib (T) | Yes | Water | PO/enteral tube | Allow capsule to disintegrate in 30 mL (2 tablespoons) boiling water, add 15 mL (1 tablespoon) room temperature water – consume immediately but ensure not boiling hot on drinking. A mint sweet before and after taking can help mask the taste | |
| Cyclophosphamide (T) | Yes | Water | PO/enteral tube | Disperses in ~25 minutes. Liquid preparation available | |
| Dabrafenib (C) | No | See comment | PO | Capsules should not be opened or crushed and should not be mixed with food or liquids due to chemical instability of dabrafenib | |
| Dasatinib (T) | Yes | 100% apple or 100% orange juice (not water) | PO/enteral tube | Disperses in 20 minutes in 30 mL volume and rinse with 15 mL. Resting of suspension increases bitterness – consume immediately after dispersion | |
| Erlotinib (T) | Yes | Water, sweetened fruit juice (not grapefruit juice), or a sweet | PO/enteral tube | Disperses in 5–8 minutes | |
| Etoposide (C) | No | No | Oral injection can be mixed with orange/apple juice/lemonade (not milk, grapefruit or cranberry juice) | PO/enteral tube | Use injection orally at 70% of oral dose. Prepared by aseptic unit (requires orange order form by pharmacist). Liquid preparation available |
| Everolimus (T) | Yes | Water (not milk or fruit juice) | PO/enteral tube | Disperses in 5–10 minutes in 30 mL | |
| Fludarabine (T) | No | See comment | PO | Alternative IV route, refer to pharmacist/clinician | |
| Gefitinib (T) | Yes | Water | PO/enteral tube | Disperses in 20 minutes | |
| Hydroxycarbamide (C) | Yes | Water | PO | Siklos® tablets disperse immediately in 5 mL or capsules can be opened. Liquid preparation available | |
| Ibrutinib (C) | No | See comment | PO | The capsules are hard and should not be opened, broken, or chewed | |
| Idarubicin (C) | No | No | See comment | PO | Contents of idarubicin capsules are extremely irritating to tissues. Alternative IV route |
| Imatinib (T) | Yes | Water, apple juice | PO | Nil info enteral feeding | |
| Isotretinoin (C) | Yes | Lukewarm milk or soft food, e.g. cottage cheese, yoghurt, chocolate mousse or oatmeal | PO/enteral tube | See patient information sheet. Enteral feeding – may need dose adjustment if given by this route (lower peak levels) | |
| Lapatinib (T) | Yes | Water (not grapefruit juice) | PO/enteral tube | Disperses in 15 minutes | |
| Lenalidomide (C) | No | No | See comment | PO | No info available, refer to pharmacist/clinician |
| Lomustine (C) | Yes | Milk, yoghurt, fromage frais, ice cream, pureed food | PO | Nil info enteral feeding. Do not mix with water or juice as this can cause stomach irritation | |
| Melphalan (T) | Yes | Water | PO | Nil info enteral feeding. Best not to take with food due to reduction in bioavailability | |
| Mercaptopurine (T) | Yes | Water | PO/enteral tube | Disperse in a syringe (oral/enteral). Liquid preparation available | |
| Methotrexate (T) | Yes | Water | PO/enteral tube | Tablets disperse. Liquid preparation available | |
| Mitotane (T) | No | High‐fat food/dairy‐based products, e.g. yoghurt, mousse | PO/enteral tube | Dilute dairy‐based products containing crushed tablets in water for administration via enteral feeding tube. Liquid preparation available | |
| Nilotinib (C) | Yes | Apple sauce (pureed apple) | PO | Only use apple sauce. Content of one capsule in one teaspoon of apple sauce only. Nil info on enteral feeding | |
| Pazopanib (T) | No | See comment | PO | Crushing tablets significantly increases bioavailability and absorption (adverse events reported most frequently with crushed tablet administration included erythema, vomiting and fatigue). Refer to pharmacist/clinician | |
| Pomalidomide (C) | No | See comment | PO | Hard gelatine capsules should not be opened or crushed. If powder from pomalidomide makes contact with the skin, the skin should be washed immediately and thoroughly with soap and water. If pomalidomide makes contact with mucous membranes, they should be thoroughly flushed with water | |
| Ponatinib (T) | No | See comment | PO | Film‐coated tablets should not be dissolved or crushed. Nil info on the safety and efficacy of crushed or broken tablets, or nasogastric tube administration | |
| Procarbazine (C) | Yes | Water | PO/enteral tube | Powder is very irritant. Give immediately once dispersed as unstable. Liquid preparation available | |
| Ruxolitinib (T) | No | See comment | PO | Tablets are uncoated, immediate release and should not be crushed. In addition, risk of drug exposure from dust/powder/bits of tablet if crushed. Contact medicines information | |
| Sorafenib (T) | Yes | Water | PO | Disperses in 10 minutes. Nil info on enteral feeding | |
| Sunitinib (C) | Yes | Apple sauce, yoghurt (saline if used for enteral feeding) | PO/enteral tube | Mix contents in a teaspoonful of apple sauce/ yoghurt. For enteral feeding, disperse contents in 5 mL saline, and rinse with 5 mL. Some discolouration of the tube may remain, due to the strong orange colour of the sunitinib | |
| Temozolomide (C) | Yes | Fruit juice (not grapefruit), apple sauce | PO/enteral tube | 30 mL fruit juice for enteral route. Liquid preparation available | |
| Teysuno (C) | No | Water | PO/enteral tube | Try commercial jelly products obtainable over‐the‐counter to aid swallowing of tablets (e.g. Pill Glide). Capsules dissolve in 50°C water | |
| Thalidomide (C) | Yes | Semi‐solid foods, e.g. apple sauce, ice cream. (Water for nasogastric) | PO/enteral tube | Disperses in water but not very water‐soluble, therefore enteral tubes must be flushed well post dose to avoid blockage | |
| Tioguanine (T) | Yes | Water (simple syrup, wild cherry syrup as flavouring) | PO | Do not stir tablets or shake the container; allow tablets to disperse naturally. Liquid preparation available. Nil info on enteral feeding. Tablets can be halved using dedicated tablet cutter | |
| Topotecan (C) | No | No | See comment | PO | No information on opening capsules |
| Tretinoin (C) | Yes | Soya bean oil or lukewarm milk | PO/enteral tube | See patient information sheet | |
| Vandetanib (T) | Yes | Water (no other liquid) | PO/enteral tube | Stir tablet until dispersed (approx. 10 minutes) | |
| Vemurafenib (T) | No | See comment | PO | Tablets have low solubility and permeability. Due to hardness of tablets, crushing is difficult. Refer to pharmacist/clinician | |
| Vinorelbine (C) | No | See comment | PO | Vinorelbine capsules must not be opened as they are carcinogenic, and the liquid is irritant to oesophagus. Alternative IV route | |
| Vismodegib (C) | No | See comment | PO | The capsules must not be opened. Vismodegib has a low solubility in aqueous media | |
| IV, intravenous; PO, per os (by mouth); TKI, tyrosine kinase inhibitor. |
Procedure guideline 23.5
