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Supportive Care
Routine HBV Screening in Cancer Immunosuppressive Recipients Find Evidence of Virus in Some By Wayne Kuznar
CHICAGO—Routine screening for hepatitis B virus (HBV) in all patients being started on immunosuppressive therapy uncovers a significant percentage with HBV surface antigen (HBsAg) and HBV core antibody (HBcAb), said Emmy Ludwig, MD, at the 2010 annual meeting of the American Society of Clinical Oncology (ASCO). As such, she recommends a universal screening program for HBV at all cancer centers. Chemotherapy and immunosuppressive drugs can cause reactivation of HBV in persons who have the virus, with morbid and potentially fatal consequences. The recommendation for universal screening in this population is at odds with ASCO, which recently issued a provisional clinical opinion stating that the net benefits and harms of routine screening for HBV are not known for cancer patients who are about to receive cytotoxic or immunosuppressive therapy as part of their cancer therapy. The official stance of ASCO, therefore, is that HBV screening in cancer patients requires clinical judgment. The opinion was published online on June 1 in the Journal of Clinical Oncology. All patients at Memorial SloanKettering Cancer Center who were started on immunosuppressive therapy (chemotherapy and/or corticosteroids) were screened for HBV from June to December 2009, consisting of serologies for HBsAg and HBcAb and subsequent measurement of HBV polymerase chain reaction (PCR) if either test was positive. The screening program was begun after Ludwig and her colleagues identified cases in their center in which HBV was reactivated after immunosuppressive therapy, four of whom died (three who had solid tumors) and 19 of whom were hospitalized (one who required liver transplant). Two of the patients were being treated with steroids. In all, 1720 patients were screened prior to immunosuppressive therapy. During those 6 months, 1.1% were positive for HBsAg and 9.2% were positive for HBcAb. Less than half with HBsAg were born in Asia, where HBV is pandemic. More than nine (91%) of 10 positive tests were in patients with a solid tumor.
Four of the 155 patients in whom HBcAb was positive but HBsAg was negative had a positive HBV PCR, meaning that new HBV was being made despite the negative HBsAg test.
If screening was positive, patients were treated with prophylactic antiviral therapy with entecavir, 0.5 mg/day, which has proved 100% effective in preventing reactivation, said Ludwig, a
gastroenterologist at Memorial-Sloan Kettering. Entecavir prophylaxis is given for the entire duration of cancer therapy and continued for an additional 6 months. ●
In the treatment of patients with documented iron deficiency in whom oral administration is unsatisfactory or impossible
Making the Case for INFeD ®
Broad usage1 • Allows FDA-approved treatment of a wide range of patients with documented iron deficiency anemia
Proven safety profile of iron dextran • In a retrospective analysis of 841,252 doses, dyspnea, hypotension, and neurological symptoms were the most common major adverse drug events (ADEs)2 — The most common minor ADEs were nausea, vomiting, flushing, and pruritus2 • Serious adverse events are rare — In a nonuremic population, 3 serious adverse events occurred in 481 patients (0.6%) receiving 2099 iron dextran injections (0.1%), with no fatalities reported3 — In a retrospective analysis of 61,950 hemodialysis patients, the incidence of reactions requiring resuscitative medications was 0.0016% (7 episodes in 440,406 exposures)4 • Iron dextran products are not clinically interchangeable1 — Differ in chemical characteristics and may differ in clinical effects Important Safety Information1 Anaphylactic-type reactions, including fatalities, have followed the parenteral administration of iron dextran injection. A test dose should be administered prior to the first therapeutic dose, followed by the full therapeutic dose if no signs or symptoms of anaphylactic-type reactions are seen. Resuscitation equipment and personnel trained in the detection and treatment of anaphylactic-type reactions must be readily available during all INFeD® administrations. Patients should be observed for signs or symptoms of anaphylactic-type reactions during all INFeD® administrations. Fatal reactions have followed the test dose and have also occurred in situations where the test dose was tolerated. Use INFeD® only in patients in whom clinical and laboratory investigations have established an iron deficient state not amenable to oral iron therapy. Patients with a history of drug allergy or multiple drug allergies may be at increased risk of anaphylactictype reactions. INFeD® should be used with caution in individuals with histories of significant allergies and/or asthma, and is contraindicated in patients with hypersensitivity to the product and patients with all anemias not associated with iron deficiency. INFeD® should be used with extreme care in patients with serious impairment of liver function, and should not be used during the acute phase of infectious kidney disease. Unwarranted therapy with parenteral iron will cause excess storage of iron with the consequent possibility of exogenous hemosiderosis, which is particularly apt to occur in patients with hemoglobinopathies and other refractory anemias. Please see next page for references and brief summary of full Prescribing Information.
www.infed.com
Did You Know? Of the 1.63 billion prescriptions written in the United States in 2009, 12% (190 million) were written electronically, ac cording to a Surescripts audit.
www.TheOncologyPharmacist.com
© 2009, Watson Pharma, Inc., Morristown, NJ 07960. All rights reserved. 06107 11/09
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