Hi ,

Welcome back to the Oncology Insights Newsletter which helps you learn oncology, and other nuggets, as you progress in your oncology career. 

Last week you learned about the mental toughness needed in oncology, eating charcuterie boards on procarbazine, and basket trials

This week, you'll learn about crushing oral chemo and dosing of pegfilgrastim and chemo in children

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

To crush or not to crush, that is (often) the question 🤔

Pharmacists get a lot of questions about crushing oral chemotherapy, especially in pediatrics since children often can’t swallow pills (I couldn’t until I was in my 20s 😳)

Besides using normal drug information resources and package inserts to answer this question, in pediatrics we also have the Children’s Oncology Group (COG) administration guidelines as a resource

COG recommendations can differ from the package insert (PI)

For example, the ruxolitinib PI has recommendations for suspending one tablet in 40 mL of water

However, COG has additional guidance that tablets can be crushed and given with applesauce, apple juice, or orange juice

This resource can be helpful for all patients who may have trouble taking their oral medications

Unfortunately, COG resources are only available to organizations treating children with cancer - most of their resources are not available to the general public

So make friends with some peds onc pharmacists 😉

If you enjoyed this, please show some love on this Twitter/X post 🙏

Pearl

Pegfilgrastim prefilled syringes are super handy for everyone….except pediatric patients 🥴

Our kiddos need a white blood cell boost too!

The prefilled syringes are set for an adult dose (6 mg) and are not designed for doses less than that because the syringe doesn’t have graduation marks

Pediatric patients are dosed on weight. If they are >45 kg, easy peasy, they get the adult dose

Otherwise, they get doses between 1.5 and 4 mg (and even less if <10 kg)

So how are we supposed to dose them correctly with no volume marks on the syringe?

Either we dose in the clinic and the pharmacy draws it up in another syringe or….we train the caregiver to do it at home (because everyone wants to save clinic visits)

Caregivers can be taught to inject the prefilled syringe contents into an empty vial and use a TB syringe to draw up the correct amount

This is obviously a challenging situation that is prone to dosing errors so careful consideration should be made about which patients should administer at home

And then they have to get the shot into the child 😳

Sundry

Dosing chemotherapy (or really any drugs) in pediatric patients can be challenging, especially those younger than 3 - pediatric patients are not tiny adults

COG put together a task force to simplify drug doses and schedules used in COG protocols. They created a unified dosing method for chemotherapy in children with a BSA less than 0.6 (or 3 years of age and younger).

They looked at all the cancer drugs in COG protocols and found variability in dose modifications used in infants.

They created a single dosing method to address the increased toxicity they saw in infants that were treated with doses that were well tolerated in older kids, despite being adjusted for differences in weight.

For example: a patient with a BSA of 0.25-0.29 receiving a protocol with vincristine 1.5 mg/m2 would receive vincristine 0.24 mg (there is a table in the publication that lists these and more in the supplementary index).

💡 Have a topic you want to see discussed in the newsletter? Hit reply and share it! 💡

When you're ready, here are ways to get help

Learn with others in the ELO program

The ELO Collaborative is my signature oncology pharmacy membership community that was created for pharmacists working in oncology and trying to learn on the job. It combines a curated curriculum with access to expert oncology pharmacists to walk through case studies and answer questions.

Learn on your own with digital products

Prepare for BCOP with 400+ questions in the Question Bank

Learn about specific cancers with individual or bundled disease courses