ICI VEGF combo- HCC, RCC, uterine ca MSI proficient
Lenvatinib induced HTN and ICI induced colitis were both markers of good outcomes.
1. For diarrhea, prophylaxis includes patients keeping a stool diary to share with HCPs and altering their diet to one less likely to upset their digestion. Antidiarrheal agents can be offered as supportive care, as can hydration and moisture-barrier ointment.
2. Prophylaxis for fatigue includes establishing the patient’s fatigue history, encouraging healthy diet and fluid intake, and activity. Supportive care for fatigue includes referrals to a nutritionist and physical therapist, as well as psychosocial interventions. If you have someone with grade ≥3 fatigue, you really should be thinking more about the ICI and the possibility of immune-mediated adrenal disorders or even myositis.
3. Stomatitis is an AE associated with cabozantinib. Regular dental examinations are recommended for patients, as is careful oral hygiene with frequent brushing and use of mouthwash. Supportive care includes sodium bicarbonate–containing oral rinses, swishing ice chips, and gum or candy to stimulate saliva production.
4. Avoiding hot water, friction, and pressure on the hands and feet may help patients avoid palmar–plantar erythrodysesthesia. If it develops, creams containing urea, salicylic acid, or ammonium lactate may be helpful. There are also topical numbing agents to help relieve symptoms, and oral analgesics can be considered if topical therapy is ineffective.
5.Evaluate blood pressure before starting treatment to check for preexisting hypertension. During treatment, patients should frequently monitor their blood pressure. Supportive care for hypertension includes antihypertensive agents and the avoidance of CYP3A4 inhibitors.
6. Monitor for proteinuria with lenvatinib
7. Monitor thyroid function routinely with all ICI. For grade 2 fatigue rule out pituitary and or thyroid dysfunction
8. Drop in EF could be due to VEGF TKI but also consider myocarditis due to ICI
9.AST ALT elevations with nivo cabozantinib. Grade 3 hepatitis, needs steroids. If steroid refractory--> MMF. Do NOT use infliximab or vedolizumab
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