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Published in Renal Cell Carcinoma

Expert Opinion / Cases · July 28, 2015

Hypertensive Patient on Pazopanib

Written by
Heather R Greene MSN, FNP, AOCNP

 

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Heather Greene MSN, FNP, AOCNP

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  • Andrew Fintel

    Aug 03, 2015

    This is a good question as you would want to offer a MultiKinase inhibitors like Pazopanib to help control his disease from progressing. It is standard of care to offer a drug like Pazopanib in this setting of metastatic RCC as it has a response rate of roughly 30% and in the COMPARZ trial it had a median OS of roughly 28 months. In regards to side effects Pazopanib has been shown to be more favorable...COMPARZ showed less fatigue, hand-foot syndrome, and thrombocytopenia with Pazopanib vs sunitinib. 
Hypertension is a side effect common to all TKIs and especially the MultiKinase inhibitors, but Hypertension has been evaluated as a biomarker of efficacy in mRCC. A retrospective analysis done in 2010 by Rini et al. showed Sunitinib induced HTN vs HTN not associated with TKIs was associated with prolonged survival and improved ORR without causing clinically significant increases in HTN induced side effects. 
In this patient with worsening HTN caused by Pazopanib that is now controlled on anti-hypertensive agents, I would consider continuing him on Pazopanib hoping that his TKI induced HTN is a sign of improved response rate and survival, but also seeing him frequently after restarting Pazopanib to make sure his HTN is under control so as to not cause HTN related side effects.

  • George Yaghmour

    Aug 04, 2015

    Interesting questions and limited data available. However, HTN and use of ACEI is associated with better outcome with TKIs. limited date, just restospective analysis and that better BP control may enable more dosing that may be result in the better outcome (PFS,OS)
Hypertension is one of the well-known toxicities associated with VEGF-directed therapies. Izzedine and colleagues, reported treatment strategies for hypertension among patients receiving sunitinib for metastatic renal cell carcinoma. Reported that hypertensive patients have a longer overall survival and a longer progression-free survival compared with non-hypertensive patients. One of the novel findings in their study is that angiotensin system inhibitors may also work to promote overall survival in this cohort. 
Bianchi et al, also reported that the novel agents pazopanib and axitinib have also demonstrated efficacy in mRCC patients. Several recent retrospective and prospective trials have suggested that some of their adverse events, such as hypertension, hypothyroidism, and hand foot syndrome (HFS) may act as potential biomarkers of response and efficacy of treatment. Early management of adverse events using a multidisciplinary approach is paramount to the favorable outcome of treatment with pazopanib and other targeted agents.
In This patient I would consider continuing Pazopanib. All meta analysis and literatures review recommended to control BP and continue treatment with better outcome, though limited data, with no prospective. Would consider to continue ACEI according to the retrospective analysis has been reported. In Addition, the  HTN crisis reflecting efficacy, and may reflect better outcome. However, close monitoring and BP medications adjustment is required to prevent a disaster.

  • Camille Joyner

    Aug 28, 2015

    Getting a nephrologist on board to manage the BP meds from the onset when a kidney is lost to RCC is really important. This is the doctor who can help fine-tune the BP meds so that the chemo (TKI's, VEGF's) can be better and longer tolerated. Earlier this year, my husband's nephrologist said, "You know, I haven't treated your husband as I normally would a renal patient, because so many of the issues are driven by his chemos." I said, "yes, and you are preserving his remaining kidney and preventing complications." My husband has a cocktail of BP meds: Losartan, Bystalic, a Clonidine patch. For BP PRNs we have amlodipine10mg up to twice a day and and clonidine 0.1 mg. up to twice a day. We have never had to use them all in the same day or even in the same week. We monitor the BP at least twice daily and watch the salt.  The combination has been highly successful. And as an RN, I know what to watch for. The nephrologist keeps up on the chemo side effects and effects on labs (such as PTH). We are fortunate that he takes such a great interest.

  • Apr 23, 2024

    Pending Moderator approval.
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