Taxanes and Premedication

DR CARLSON: The experience in the clinical trials is that the use of premedications to avoid allergic reactions is not necessary with nab paclitaxel. The randomized trials used premedications with docetaxel and paclitaxel and specifically did not with nab paclitaxel. Despite that, they saw far fewer allergic reactions with nab paclitaxel.

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One of the advantages associated with nab paclitaxel is that patients don’t require premedications, and they don’t experience the toxicities associated with dexamethasone or the sedation associated with the antihistamines. Patients who receive dexamethasone for either antiemesis or the avoidance of allergic reactions complain about insomnia and the jitters. Dexamethasone makes disease management for the diabetic patient, especially the borderline diabetic patient, much more difficult. Avoiding steroids is a good goal.

I wouldn’t want to use premedications if everything else were equal, although the occasional patient does like the “upper” effect of the steroid.

Breast Cancer Update 2007 (4)

DR RUTH O’REGAN: I am using nab paclitaxel, and I’m surprised that it hasn’t been used more extensively, particularly in the first-line setting. The shorter infusion time and lack of premedication with nab paclitaxel are huge advantages. Patients complain about having to take the steroids with paclitaxel. In terms of the shorter infusion time, that is a huge benefit in a busy practice.

Breast Cancer Update 2007 (2)

DR HOLMES: I administer nab paclitaxel in preference to paclitaxel, period. It’s a huge advantage to be able to avoid premedication and to have shorter infusion times. Patients have a life. They have kids. They have day care. At its best, getting through the clinic is difficult. I have emergencies, so I’m backed up. There are all kinds of built-in delays.

We all think we know what it is to go through therapy from the patient’s standpoint, but it’s hard to remember all the delays, all the problems: “Oh gosh, counts aren’t up today. You have to come back later.”

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To begin with, these people have a life, and their time is valuable. In addition, not having to take the dexamethasone is a huge benefit. How many people are hyperactive? They can’t sleep that first night. They have to take the steroids and then take lorazepam or something else to relax them.

Finally, we all know that patients gain weight on adjuvant chemotherapy. Apparently, they do not eat more, and their energy intake isn’t increased, but their energy expenditure is decreased. Add this anabolic agent on top of that, and we know that some women are sensitized to this. Then there’s that minority of patients who develop acne from the dexamethasone. Really, less is more, and avoiding premedication is a tremendous advantage.

Breast Cancer Update 2007 (2)

DR SEIDMAN: I find with nab paclitaxel, not having to administer premedications or corticosteroids, being able to infuse the drug over half an hour instead of three hours and not worrying about potential allergic reactions, which are occasionally life threatening, make it a no-brainer in terms of which taxane
I use.

Steroids are like a double-edged sword in the sense that often, along with the prescription for steroids, I have to write a prescription for zolpidem because the patient can’t sleep well at night. Also, with weekly taxanes and weekly steroids, I do see steroid myopathy and occasionally diabetics who have trouble controlling their blood sugars. What I hear most that limits the use of nab paclitaxel is the pharmacoeconomics of the drug, and I don’t have a great response to that.

Breast Cancer Update 2006 (7)

DR TRIPATHY: The shorter infusion time and lack of need for premedication are advantages, but I believe the big advantage is that you don’t have to use steroids. Not only do they cause nuisance-type side effects, but in patients with diabetes, they also cause major problems. So that alone is a big advantage.

Breast Cancer Update 2006 (6)

DR OSBORNE: The attractive thing about nab paclitaxel is that you don’t have to administer premedication. For patients who are on this drug for a long period of time, that’s a big advantage. Dexamethasone premedication can cause its own side effects. I haven’t used nab paclitaxel all that often yet, but I like it and I’m anxious to see how it’s going to be incorporated earlier in the management of the disease.

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