Managing Side Effects and Dosage Adjustments for Nexavar in Liver Cancer Treatment

Issues related to the reduction of side effects and dosage adjustments for Nexavar in liver cancer treatment?

Dear Dr.
Lin,
My father is 65 years old and has been diagnosed with liver cancer.
He has been taking Nexavar at a dosage of 200 mg twice a day for nearly two years.
Earlier this year, he experienced diarrhea for over a week, but currently, he has no issues in that regard.
The only concern is that the skin on his hands and the soles of his feet is peeling, for which he has been applying a cream prescribed by his doctor.
Recently, my father has reported severe pain while walking, even when wearing cushioned shoes.
He feels that the skin on his soles is becoming thinner and is unsure how to alleviate the symptoms.

Due to financial constraints, we are very grateful for the lifesaving medications provided by the national health insurance.
If we had to pay out of pocket, we would likely incur significant debt.
My father previously consulted with his doctor about these symptoms, but it seemed the doctor was not pleased and insisted that his treatment was appropriate.
My father is afraid of upsetting the doctor and potentially facing a discontinuation of his medication, so he has been hesitant to ask further questions.
(I do not intend to blame the doctor; I understand that they work long hours and see many patients.
We are thankful for their assistance in obtaining such valuable medication.
It may also be that we simply do not understand the situation fully, which could have caused some inconvenience for the doctor.)
Given that my father's walking continues to be very painful, I would like to ask you: 1.
How can we alleviate the peeling skin on his feet and the pain while walking? 2.
Is it possible to adjust the dosage? I found information from Chi Mei Hospital online (http://www.chimei.org.tw/main/cmh_department/55500/Dinfo/data/20S020.pdf), specifically on page four, Table 3, which mentions that the dosage can be adjusted to 400 mg every other day due to skin toxicity.
However, I am unsure if it can be adjusted to 200 mg daily or if there are other adjustment options.
We do not want to make any changes to the medication or dosage on our own; we simply hope you can explain the feasible dosage adjustment options so that we can clearly communicate with my father's attending physician afterward.
Thank you for your assistance, and I appreciate your time in addressing our concerns.

Yiling, 20~29 year old female. Ask Date: 2023/04/06

Dr. Lin Minghui reply Gastroenterology and Hepatology

Lenvatinib is a multi-kinase inhibitor used as a targeted therapy for patients with advanced liver cancer.
It works by reducing blood supply and slowing the growth of cancer cells, thereby inhibiting tumor growth and spread.
The goal is to delay the progression of the tumor.
Prolonged use of Lenvatinib can extend survival time.
It is recommended by physicians to maintain an appropriate dosage for optimal therapeutic effect.
Maintaining a tolerable dosage is important, and if liver cancer progresses, there are subsequent medications available for use.
However, targeted therapies for liver cancer may cause side effects that can be very uncomfortable for patients.

Common skin issues, also known as hand-foot skin reactions, are clinically classified into three grades based on symptoms and severity:
- Grade 1: Abnormal sensations (tingling or burning), redness, but no pain.

- Grade 2: Redness, swelling, pain that affects daily life.

- Grade 3: Peeling, blistering, ulcers, severe pain, and potential impact on mobility.

The focus of care is to address issues at Grade 2 to prevent progression to Grade 3 skin lesions.
When Grade 2 reactions occur, it is necessary to reduce the medication dosage or pause treatment until the reaction returns to Grade 1, at which point the medication can be resumed; otherwise, symptoms may continue to worsen, potentially leading to discontinuation of the drug.
To alleviate foot peeling and walking pain, wearing cotton socks and placing soft pads in shoes can help.
Keeping the skin moisturized is recommended—using moisturizing creams, lotions, or topical urea-based ointments can hydrate the skin, prevent further hardening, and improve discomfort.
If a rash appears, applying a moisturizing lotion can relieve itching, and it is advisable to avoid direct sunlight or hot water baths.
Strenuous exercise should be avoided, and pain relief medications can be used if necessary.
How can the dosage be adjusted? According to the Lenvatinib prescribing information, for liver cancer patients with Grade 1 skin reactions, topical treatment is primarily recommended.
If Grade 2 skin reactions do not respond to topical treatment, the medication should be paused until the reaction returns to Grade 1 before resuming treatment—reducing the dosage to 400 mg once daily or 400 mg every other day is suggested for Grade 2 skin reactions.
Maintaining such a dosage may provide better therapeutic efficacy.

Regarding whether the dosage can be adjusted to 200 mg daily, this reduction may vary by cancer type, and the prescribing information provides guidance.
Ultimately, the adjustment should be based on patient tolerance and the physician's professional judgment regarding treatment efficacy.
It is advisable to discuss with a physician or pharmacist.
Wishing you safety!

Reply Date: 2023/04/06

More Info

Managing side effects and dosage adjustments for Nexavar (sorafenib) in liver cancer treatment can be quite challenging, especially considering the delicate balance between effective cancer management and the quality of life for the patient. Your father's situation is not uncommon among patients undergoing treatment with Nexavar, and it’s important to address both the side effects he is experiencing and the potential for dosage adjustments.

1. Managing Skin Peeling and Pain in the Feet
The skin peeling and pain in the feet that your father is experiencing are known side effects of Nexavar. These symptoms can be quite distressing and may significantly impact his mobility and overall quality of life. Here are some strategies that may help alleviate these symptoms:
- Moisturizing Creams: Regular application of emollient creams or ointments can help keep the skin hydrated and reduce peeling. Look for products that contain urea or lactic acid, as they can be particularly effective for dry skin.

- Foot Care: Encourage your father to keep his feet clean and dry. Soaking his feet in warm water followed by gentle exfoliation can help remove dead skin. Afterward, applying a thick moisturizer can provide relief.

- Pain Management: Over-the-counter pain relief medications, such as acetaminophen or ibuprofen, may help alleviate foot pain. However, it’s crucial to consult with his healthcare provider before starting any new medication.

- Footwear: Ensure that your father is wearing well-fitted shoes with adequate cushioning. If he is experiencing significant pain, he might benefit from custom orthotics or cushioned insoles.

- Consult a Dermatologist: If the skin issues persist or worsen, it may be beneficial to consult a dermatologist who can provide specialized care and possibly prescribe stronger topical treatments.

2. Dosage Adjustments for Nexavar
Regarding the dosage of Nexavar, it is essential to approach any adjustments with caution and under the guidance of a healthcare professional. The standard starting dose for Nexavar is typically 400 mg taken twice daily. However, if your father is experiencing significant side effects, such as skin toxicity, dose adjustments may be warranted.

- Dose Reduction: According to the guidelines you referenced, if a patient experiences severe skin toxicity, the dose may be reduced to 400 mg once daily or even temporarily held until the symptoms improve. It is crucial to have a discussion with your father's oncologist about the possibility of reducing the dose to 200 mg twice daily or any other adjustment that may be appropriate based on his current health status.

- Monitoring: Any changes in dosage should be closely monitored by the healthcare team. Regular follow-ups and assessments of side effects are essential to ensure that the treatment remains effective while minimizing discomfort.

- Communication with the Oncologist: It’s understandable that your father may feel hesitant to discuss his symptoms with his doctor, especially if he fears upsetting them. However, open communication is vital for effective treatment. Encourage him to express his concerns and symptoms clearly, as this will help the doctor make informed decisions regarding his care.

Conclusion
In summary, managing the side effects of Nexavar and considering dosage adjustments requires a collaborative approach between the patient, family, and healthcare providers. It’s essential to address any side effects promptly and to have open discussions about treatment options. Encourage your father to communicate his symptoms and concerns with his oncologist, as they can provide the best guidance tailored to his specific situation. Remember, the goal is to maintain the effectiveness of the cancer treatment while ensuring the patient’s comfort and quality of life.

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