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similar or worse compared with patients with diabetes or arthritis(19). Patients report that the bruising and bleeding resulting from ITPhas a substantial negative effect on their quality of life, and fatigue(possibly due to the anaemia caused by bleeding) hinders theirability to perform their routine daily activities. (20). When presentedwith a patient with ITP, the nurse therefore has to help the patientadapt to the physical and psychosocial demands of the disease. Thechanges to body image associated with corticosteroid treatment,the implications of a potential splenectomy, rehabilitation, roles andresponsibilities, and the risk of sepsis are examples of some of thefears and concerns that nurses should be assessing and addressingwhen informing patients about, and explaining, different treatmentoptions to patients with ITP. Keeping up to date with the developingand future therapeutic options enables the nurse to educate andreassure the patient, thereby potentially alleviating fears of treatmentfailure or that eventual splenectomy is unavoidable.The long-term efficacy and safety of romiplostim are now beingconfirmed in an ongoing, open-label, extension study (15). TheEuropean Medicines Evaluation Agency is currently reviewing theMarketing Authorisation Application for romiplostim. Romiplostimwas recently approved for the treatment of adults with chronic ITP inthe US and Australia.EltrombopagEltrombopag is a small molecule TPO receptor agonist that isadministered orally once-daily. It activates the TPO receptor bybinding to the transmembrane region. Although eltrombopag bindsto the receptor differently than endogenous TPO or romiplostim, thefinal pathways seem to be identical (4). The results from a 6-weektreatment-period, placebo-controlled phase II trial where the primaryend point was a platelet count of ≥50 x 10 9 /L on day 43 of treatmentshowed that 28%, 70%, and 81% of patients receiving, respectively,30 mg, 50 mg or 75 mg of eltrombopag daily achieved this endpoint(versus 11% in the placebo group). (16)When considering the management of the patient, two importantMild to moderate headache was the most commonly reported issues during the treatment of ITP arise: firstly, the need for treatmentadverse event followed by aspartate aminotransferase elevation, concordance and secondly, regular platelet count monitoring. A onceweeklysubcutaneous therapy such as romiplostim may facilitateconstipation, fatigue, and rash. Cataracts have been noted in bothpreclinical and clinical studies of eltrombopag, and elevated alanine concordance; it also combines treatment with frequent platelettransaminase in conjunction with raised bilirubin levels have been count monitoring and reinforces regular contact with medical staffobserved in some patients treated with eltrombopag (17). Phase III which may be reassuring for the patient. This approach facilitatesstudies of eltrombopag are currently ongoing and the published data individually tailored and controlled dosing schedules and minimisesare awaited soon.the risk of thrombosis that might occur if platelet counts increase(e.g. due to irregular drug intake).DiscussionWith the development of the TPO receptor agonists, the treatment In adults, ITP is a chronic disease often associated with a remittingoptions for patients with ITP have been widened. Current treatments – relapsing course. Many patients do not require treatment and thecan have many side effects and the treatment of ITP may result decision to introduce therapeutic interventions will be based uponin increased morbidity from adverse effects and opportunistic the laboratory findings, clinical circumstances, and individual patientinfections, which often surpass the problems actually caused by ITP risk factors. The development of the upcoming TPO receptor agonists(18). The phase III trials investigating romiplostim and the phase II provides patients with a new perspective to living with this chronictrials on eltrombopag show that TPO receptor agonists appear to be medical condition.well-tolerated and effective in patients with ITP (14, 16). As the TPOreceptor agonists are not immunosuppressive agents, the problems Acknowledgementsassociated with immunosuppressive treatment can be avoided and This article was supported by Amgen Europe GmbH, Zug, Switzerland.the overall health of the patient better maintained.Author for Correspondence: 033 Bevan House, Birmingham CityBoth the symptoms of ITP and its treatment affect the quality of life University, Edgbaston , Birmingham, B15 3TN, UK E-mail: dion.of the patient; indeed the impact on quality of life is perceived as smyth@bcu.ac.uk26 - newsletter fall 2008
References1. Cines DB, McMillan R: Management of adult idiopathicthrombocytopenic purpura. Annu Rev Med 56:425-42, 2005.2. Kaye J, Schoonen M, Fryzek J: ITP incidence and mortality inUK general practice research database. Haematologica 92(Suppl.1):280 (Abstract 0751), 2007.3. Bussel J: Treatment of immune thrombocytopenic purpura inadults. Semin Hematol 43 (3 Suppl 5):S3-10; discussion S18-9,2006.4. Stasi R, Evangelista ML, Amadori S: Novel thrombopoietic agents:A review of their use in idiopathic thrombocytopenic purpura.Drugs 68 (7):901-12, 2008.5. Arnold J, Ouwehand WH, Smith GA, Cohen H. A young womanwith petechiae. Lancet 352:618, 1998.6. Azuno Y, Yaga K, Sasayama T, Kimoto K. Thrombocytopeniainduced by Jui,a traditional Chinese herbal medicine [Letter]. Lancet 354:304-5,1999.7. George J, et al.: Idiopathic thrombocytopenic purpura: a practiceguideline developed by explicit methods for the American Societyof Hematology [see comments]. Blood 88 (1):3-40, 1996.8. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. NEngl J Med 346: 995-1008, 20029. Provan D, et al.: Activity and safety profile of low-dose rituximabfor the treatment of autoimmune cytopenias in adults.Haematologica 92 (12):1695-8, 2007.10. Godeau B, et al.: Rituximab efficacy and safety in adultsplenectomy candidates with chronic immune thrombocytopenicpurpura - results of a prospective multicenter phase 2 study.Blood:Epub ahead of print, 2008.11. Arnold DM, Dentali F, Crowther MA, et al. Systematic Review:Efficacy and Safety of Rituximab for Adults with IdiopathicThrombocytopenic Purpura. Ann Intern Med. 2007;146(1):25-33.12. Stasi R, Pagano A, Stipa E, et al. Rituximab chimeric anti-CD20monoclonal a ntibody treatment for adults with chronicidiopathic thrombocytopenic purpura. Blood. 2001;98(4):952-957. Clinical trial.13. Stasi R, Stipa E, Forte V, et al. Variable patterns of responseto rituximab treatment in adults with chronic idiopathicthrombocytopenic purpura. Blood. 2002;99(10):3872-3873.14. Kuter DJ, et al.: Efficacy of romiplostim in patients with chronicimmune thrombocytopenic purpura: a double-blind randomisedcontrolled trial. Lancet 371 (9610):395-403, 2008.15. Newland C, et al.: Evaluating the long-term efficacy ofromiplostim (AMG 531) in patients with chronic immunethrombocytopenic purpura (ITP) during an open-label extensionstudy. Haematologica 93 (Suppl.1):377 (Abstract 0945), 2008.16. Bussel JB, et al.: Eltrombopag for the treatment of chronicidiopathic thrombocytopenic purpura. N Engl J Med 357(22):2237-47, 2007.17. FDA Oncologic Drug Advisory Committee Briefing Document.Promacta (Eltrombopag Tablets) http://www.fda.gov/ohrms/dockets/AC/08/briefing/2008-4366b1-02-GSK.pdf. AccessedJuly 21st 200818. Portielje JEA, et al.: Morbidity and mortality in adults withidiopathic thrombocytopenic purpura. Blood 97 (9):2549-2554,2001.19. McMillan R, et al.: Self-reported health-related quality of life inadults with chronic immune thrombocytopenic purpura. Am JHematol 83 (2):150-4, 2008.20. Mathias SD, et al.: Impact of chronic Immune ThrombocytopenicPurpura (ITP) on health-related quality of life: a conceptual modelstarting with the patient perspective. Health Qual Life OutcomesFeb 8;6:13, 2008Update accreditation• Diploma of Advanced Studies Berner Fachhochschule in Onkologiepflege, Lindenhof Schule, BernSwitzerland, educational programme of study. For more information: www.lindenhof-schule.ch• Chemotherapy course for oncology nurses, Estonian Oncology Nursing society, 14,15,16 April 2008,educational event• ESO “11 Internationales seminar: Onkologische pflege Fortgeschrittene Praxis”., September 2008,educational event. For more information: www.oncoconferences.chnewsletter fall 2008 -27
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