Managing Adverse Events from Brentuximab Vedotin

Brentuximab vedotin (BV; Adcetris), a CD30-directed antibody conjugated to a microtubule-disrupting agent, monomethyl auristatin E (MMAE), is used to fight several hematological malignancies. Adverse events (AEs) associated with BV may be serious, and nurses need to understand what they are, monitor for them, and treat them promptly.

Applications of BV

BV is FDA-approved for the treatment of patients with relapsed classical Hodgkin lymphoma or relapsed systemic Anaplastic Large Cell Lymphomas (ALCLs).

It is also approved for consolidation in patients with classical HL at high risk of relapse or progression following autologous hematopoietic stem cell transplantation (auto-HSCT).

In addition, it is approved for patients with primary cutaneous ALCL, or CD30-expressing mycosis fungoides who have received prior systemic therapy and for patients with previously untreated stage III/IV classical Hodgkin HL in combination with chemotherapy.

Kathleen Clifford, RN, MSN, FNP-BC, AOCNP, from St. Luke’s Mountain States Tumor Institute in Boise, Idaho, and her colleagues published a detailed review in the August 2018 issue of the Clinical Journal of Oncology Nursing.

According to the article, the recommended dose and administration schedule for BV in patients with relapsed classical Hodgkin lymphoma or systemic ALCL, HL at high risk of progression after auto-HSCT, and patients with cutaneous ALCL or mycosis fungoides is 1.8 mg/kg administered as an IV infusion over 30 minutes every 3 weeks; and in previously untreated patients with classical Hodgkin lymphoma in combination with chemotherapy is 1.2 mg/kg up to a maximum of 120 mg BV is administered every 2 weeks for a maximum of 12 doses.

Monitoring and Treating AEs

Several AEs are associated with BV treatment. Peripheral neuropathy may be sensory or motor, and signs and symptoms can range from mild (tingling) to severe (burning, muscle aches). Peripheral neuropathy has patient safety considerations, so patients need to be assessed for risk of falling.

Peripheral neuropathy can be assessed through vibratory sensation, deep tendon reflexes, and touch. Early peripheral neuropathy may be noted by the patient, and include things such as difficulty buttoning a shirt or picking up a coin. Strategies for managing peripheral neuropathy include the use of gabapentin/pregabalin, duloxetine, tricyclic antidepressants, or a compounded topical gel containing baclofen, amitriptyline hydrochloride, and ketamine. Acupuncture and physical therapy also may be useful.

Neutropenia is a common AE related to BV treatment. Patients need to be informed about the possibility of developing neutropenia, the importance of temperature monitoring, and measures to protect themselves from infection. Neutropenia is managed through dose reduction and growth factor support.

Infusion-related reactions from BV treatment range from mild pruritus to anaphylaxis-like symptoms. These reactions generally occur within the first 2 BV treatment cycles. Patients need to be monitored during BV infusion, and if a reaction is suspected, the treatment should be stopped and appropriate medications for managing these reactions need to be given. Premedication is recommended for subsequent infusions.

Gastrointestinal AEs associated with BV treatment include nausea, diarrhea, vomiting, abdominal pain, and constipation. Management is dependent on the particular symptom. If diarrhea occurs, the patient should be tested for infection and assessed for colitis. Patients should be taught to report gastrointestinal symptoms, drink enough fluids, monitor weight (for gain or loss), and be referred to a dietician when needed for nutritional counseling.

Progressive multifocal leukoencephalopathy is a rare but fatal condition that occurs as a result of reactivation of John Cunningham virus. It has been reported in patients receiving BV and is included as a boxed warning. Symptoms can include progressive weakness, visual or speech impairment, headaches, seizures, and mental status or personality changes. Symptoms are evaluated by imaging, analysis of cerebrospinal fluid, and neurology consultations.

Other AEs that may occur include noninfectious pulmonary toxicities, hepatotoxicity, and pancreatitis. Since nurses are on the frontline of care, they need to be alert for various AEs associated with BV treatment and promptly initiate their management.

Reference

Clifford K, Copeland A, Knutzen G, Samuelson E, Grove L, Schiavo K. Brentuximab vedotin: A nursing perspective on best practices and management of associated adverse events. Clin J Oncol Nurs. 2018, 22(4), E103-E114 DOI: 10.1188/18.CJON.E103-E114.