Best Practices for the Management of Neuroendocrine Tumors - Episode 12
Practice Pearl 2: Management of Stomatitis When Using Everolimus for NETs
Cecilia Lau, RPh, BCOP, APh, and Daneng Li, MD, discuss the management of stomatitis caused by everolimus when used for NETs.
Cecilia Lau, RPh, BCOP, APh: The management of stomatitis or prevention of stomatitis was not studied in patients with neuroendocrine tumors, but there are data available from our breast cancer colleagues.
There was a phase 2 study called the SWISH trial where patients newly starting on everolimus plus exemestane were prescribed a dexamethasone mouth rinse for the first 8 weeks. There was no control arm on the study, so the investigators used the historical control from the BOLERO-2 study. By the end of 8 weeks, grade 2 or higher stomatitis in the SWISH study was only 2% vs the historical control of the BOLERO-2 study in which, at the end of 8 weeks, stomatitis occurred at 30%. In the SWISH study, the patients were allowed to continue for another 8 weeks of dexamethasone mouthwash if needed, and it is not clear whether patients might even continue beyond the total of 16 weeks because this drug is readily available, inexpensive, and covered by most insurance.
One thing that we as pharmacists should be aware of is that dexamethasone liquid is available as an oral solution and an oral elixir at the same concentration. When we dispense, we need to make sure that we are dispensing the alcohol-free oral solution formulation. The dose is 1 mg or 10 mL, and the patient should be instructed to swish the 10 mL in their mouth for 2 minutes, after which they will spit out the solution. They are to do this 4 times a day.
Daneng Li, MD: That is so important. For patients, when you are switching treatment, usually the role of everolimus gets added after someone has been on other treatments such as somatostatin analogue therapy, so that there might be a lot of anxiety in terms of understanding the efficacy as well as safety and adverse-effect profile. If you are able to have that communication sometimes, I value all our pharmacists and colleagues, who you are going to get a lot of questions from patients where the provider might be prescribing this medication. But if you are able to walk them through the adverse effects that they might encounter, that is going to be helpful to keep their mind at ease. It is 1 of the treatment options that we have for this disease, so we need to use every treatment that we can for these patients.