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Ado-Trastuzumab Emtansine

Pronunciation

(a do tras TU zoo mab em TAN seen)

Index Terms

  • Ado Trastuzumab
  • Adotrastuzumab
  • T-DM1
  • Trastuzumab Emtansine
  • Trastuzumab-DM1
  • Trastuzumab-MCC-DM1

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous [preservative free]:

Kadcyla: 100 mg (1 ea); 160 mg (1 ea) [contains mouse (murine) and/or hamster protein]

Brand Names: U.S.

  • Kadcyla

Pharmacologic Category

  • Antineoplastic Agent, Anti-HER2
  • Antineoplastic Agent, Antibody Drug Conjugate
  • Antineoplastic Agent, Antimicrotubular
  • Antineoplastic Agent, Monoclonal Antibody

Pharmacology

Ado-trastuzumab emtansine is a HER2-antibody drug conjugate which incorporates the HER2 targeted actions of trastuzumab with the microtubule inhibitor DM1 (a maytansine derivative). The conjugate, which is linked via a stable thioether linker, allows for selective delivery into HER2 overexpressing cells, resulting in cell cycle arrest and apoptosis.

Distribution

Vd: 3.13 L

Metabolism

DM1 undergoes hepatic metabolism via CYP3A4/5

Time to Peak

Near the end of the infusion

Half-Life Elimination

~4 days

Protein Binding

DM1: 93%

Special Populations: Hepatic Function Impairment

Systemic exposure (AUC) was ~38% and ~67% lower in patients with mild (Child-Pugh class A) and moderate (Child-Pugh class B) impairment, respectively, compared to patients with normal hepatic function during cycles 1 and 2 of a 3.6 mg/kg ado-trastuzumab dose.

Use: Labeled Indications

Breast cancer, metastatic: Treatment (single-agent) of HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and a taxane, separately or in combination, and have either received prior therapy for metastatic disease or developed disease recurrence during or within 6 months of completing adjuvant therapy.

Contraindications

US labeling: There are no contraindications in the manufacturer’s labeling.

Canadian labeling: Hypersensitivity to trastuzumab emtansine or any component of the formulation.

Dosing: Adult

Note: Do not substitute ado-trastuzumab emtansine (US) or trastuzumab emtansine (Canada) for or with conventional trastuzumab; products are different and are NOT interchangeable.

Breast cancer, metastatic, HER2+: IV: 3.6 mg/kg every 3 weeks until disease progression or unacceptable toxicity; Maximum dose: 3.6 mg/kg

Missed or delayed doses: If a planned dose is missed or delayed, administer as soon as possible (at the dose and rate most recently tolerated), do not wait until the next planned cycle. Then adjust schedule to maintain a 3-week interval between doses.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment

CrCl ≥30 mL/minute: No dosage adjustment necessary.

CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

Dosing: Hepatic Impairment

Hepatic impairment prior to treatment initiation:

Mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary; use with caution.

Severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Hepatotoxicity during treatment: Refer to dosage adjustment for toxicity for dose level reductions:

Grade 2 ALT, AST elevations (>2.5 to ≤5 times ULN): Continue at same dose level.

Grade 3 ALT, AST elevations (>5 to ≤20 times ULN): Withhold until ALT, AST recover to ≤grade 2, then resume with one dose level reduction.

Grade 4 ALT, AST elevations (>20 times ULN): Permanently discontinue treatment.

Grade 2 hyperbilirubinemia (>1.5 to ≤3 times ULN): Withhold until bilirubin recovers to ≤grade 1 (≤1.5 times ULN), then resume at the same dose level.

Grade 3 hyperbilirubinemia (>3 to ≤10 times ULN): Withhold until bilirubin recovers to ≤grade 1, then resume with one dose level reduction.

Grade 4 hyperbilirubinemia (>10 times ULN): Permanently discontinue treatment.

Concomitant ALT, AST >3 times ULN and total bilirubin >2 times ULN: Permanently discontinue treatment.

Nodular regenerative hyperplasia: Permanently discontinue treatment.

Dosing: Adjustment for Toxicity

Note: After a dose reduction is implemented, do not re-escalate dose.

Infusion-related reaction: Slow infusion rate or interrupt infusion. Permanently discontinue if life-threatening infusion reactions occur.

Dose levels for dosage reductions and/or discontinuation:

Starting dose: 3.6 mg/kg

First dose reduction: Reduce dose to 3 mg/kg

Second dose reduction: Reduce dose to 2.4 mg/kg

Further reductions necessary: Discontinue treatment.

Hematologic toxicity:

Grade 3 thrombocytopenia (platelets 25,000/mm3 to <50,000/mm3): Withhold treatment until platelet count recovers to ≤ grade 1 (platelets ≥75,000/mm3), then resume treatment at the same dose level.

Grade 4 thrombocytopenia (platelets <25,000/mm3): Withhold treatment until platelet count recovers to ≤ grade 1 (platelets ≥75,000/mm3), then resume treatment with one dose level reduction.

Cardiotoxicity:

LVEF >45%: Continue treatment.

LVEF 40% to ≤45% and decrease is <10% points from baseline: Continue treatment and repeat LVEF assessment within 3 weeks.

LVEF 40% to ≤45% and decrease is ≥10% points from baseline: Withhold treatment and repeat LVEF assessment within 3 weeks; if repeat LVEF has not recovered to within 10% points from baseline, discontinue treatment.

LVEF <40%: Withhold treatment and repeat LVEF assessment within 3 weeks; if repeat LVEF is confirmed <40%, discontinue treatment.

HF (symptomatic): Discontinue treatment.

Peripheral neuropathy, grade 3 or 4: Temporarily discontinue until resolves to ≤ grade 2.

Pulmonary toxicity: Interstitial lung disease or pneumonitis: Permanently discontinue.

Reconstitution

Hazardous agent; use appropriate precautions for handling and disposal (NIOSH 2014 [group 1]). Check vial labels to assure appropriate product is being reconstituted (ado-trastuzumab emtansine and conventional trastuzumab are different products and are NOT interchangeable).

Slowly inject sterile water for injection into the vial (5 mL for 100 mg vial or 8 mL for 160 mg vial) to a reconstituted concentration of 20 mg/mL. Gently swirl vial until completely dissolved. Reconstituted solution will be clear or slightly opalescent (there should be no visible particles) and colorless to pale brown. Dilute for infusion by adding to 250 mL sodium chloride 0.9%; gently invert bag to mix (do not shake).

Administration

Check label to ensure appropriate product is being administered (ado-trastuzumab emtansine [US] or trastuzumab emtansine [Canada] and conventional trastuzumab are different products and are NOT interchangeable).

Infuse over 90 minutes (first infusion) or over 30 minutes (subsequent infusions if prior infusions were well tolerated) through a 0.2 or 0.22 micron inline nonprotein adsorptive polyethersulfone filter. Do not administer IV push or bolus. Do not administer with other medications.

Closely monitor infusion site during administration. Monitor patient during infusion for signs of infusion-related reactions (eg, fever, chills); monitor for at least 90 minutes following initial infusion and (if tolerated) for at least 30 minutes following subsequent infusions.

Hazardous agent; use appropriate precautions for handling and disposal (NIOSH 2014 [group 1]).

Compatibility

Stable in NS; incompatible in D5W

Storage

Store intact vials at 2°C to 8°C (36°F to 46°F). Do not freeze or shake intact vials, reconstituted solution, or solutions diluted for infusion. Reconstituted vials do not contain preservative and should be used immediately, although may be stored for up to 24 hours at 2°C to 8°C (36°F to 46°F). Solutions diluted for infusion in NS should be used immediately, although may be stored at 2°C to 8°C (36°F to 46°F) for up to 24 hours prior to use. This storage time is additional to the time allowed for the reconstituted vials.

Drug Interactions

Antineoplastic Agents (Anthracycline, Systemic): Ado-Trastuzumab Emtansine may enhance the cardiotoxic effect of Antineoplastic Agents (Anthracycline, Systemic). Management: When possible, patients treated with ado-trastuzumab emtansine should avoid anthracycline-based therapy for up to 7 months after stopping ado-trastuzumab emtansine. Monitor closely for cardiac dysfunction in patients receiving this combination. Consider therapy modification

Aprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

Belimumab: Monoclonal Antibodies may enhance the adverse/toxic effect of Belimumab. Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inhibitors (Strong): May increase serum concentrations of the active metabolite(s) of Ado-Trastuzumab Emtansine. Specifically, strong CYP3A4 inhibitors may increase concentrations of the cytotoxic DM1 component. Avoid combination

Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

Echinacea: May diminish the therapeutic effect of Immunosuppressants. Consider therapy modification

Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Idelalisib: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Ivacaftor: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification

Luliconazole: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination

Netupitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification

Palbociclib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification

Simeprevir: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Monitor therapy

Stiripentol: May increase the serum concentration of CYP3A4 Substrates. Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification

Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Avoid combination

Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Avoid combination

Adverse Reactions

>10%:

Central nervous system: Fatigue (36%), headache (28%), peripheral neuropathy (21%; grades 3/4: 2%), insomnia (12%)

Dermatologic: Skin rash (12%)

Endocrine & metabolic: Decreased serum potassium (33%; grade 3: 3%)

Gastrointestinal: Nausea (40%), constipation (27%), diarrhea (24%), abdominal pain (19%), vomiting (19%), xerostomia (17%), stomatitis (14%)

Hematologic & oncologic: Decreased platelet count (83% [nadir by day 8]; grade 3: 14%; grade 4: 3%), decreased hemoglobin (60%; grade 3: 4%; grade 4: 1%), decreased neutrophils (39%; grade 3: 3%; grade 4: <1%), hemorrhage (32%; grades 3/4: 2%), thrombocytopenia (31%; grades 3/4: 15%; Asians grades 3/4: 45%), anemia (14%; grades 3/4: 4%)

Hepatic: Increased serum AST (98%; grades 3/4: <8%), increased serum ALT (82%; grades 3/4: <6%), increased serum transaminases (29%), increased serum bilirubin (17%)

Neuromuscular & skeletal: Musculoskeletal pain (36%), arthralgia (19%), weakness (18%), myalgia (14%)

Respiratory: Epistaxis (23%), cough (18%), dyspnea (12%)

Miscellaneous: Fever (19%)

1% to 10%:

Cardiovascular: Peripheral edema (7%), hypertension (5%; grades 3/4: 1%), left ventricular dysfunction (2%; grades 3/4: <1%)

Central nervous system: Dizziness (10%), chills (8%)

Dermatologic: Pruritus (6%)

Endocrine & metabolic: Hypokalemia (10%; grades 3/4: 3%)

Gastrointestinal: Dyspepsia (9%), dysgeusia (8%)

Genitourinary: Urinary tract infection (9%)

Hematologic & oncologic: Neutropenia (7%; grades 3/4: 2%)

Hepatic: Increased serum alkaline phosphatase (5%)

Hypersensitivity: Hypersensitivity (2%)

Immunologic: Antibody development (5%)

Ophthalmic: Blurred vision (5%), conjunctivitis (4%), dry eye syndrome (4%), increased lacrimation (3%)

Respiratory: Pneumonitis (≤1%)

Miscellaneous: Infusion related reaction (1%)

<1% (Limited to important or life-threatening): Anaphylactoid reaction, hepatic encephalopathy, hepatotoxicity, nodular regenerative hyperplasia, portal hypertension

ALERT: U.S. Boxed Warning

Do not interchange:

Do not substitute ado-trastuzumab emtansine (Kadcyla) for or with trastuzumab (Herceptin).

Hepatotoxicity:

Serious hepatotoxicity has been reported, including liver failure and death. Monitor serum transaminases and bilirubin prior to initiation of treatment and prior to each dose. Reduce the dose or discontinue ado-trastuzumab emtansine as appropriate in cases of increased serum transaminases or total bilirubin.

Cardiotoxicity:

Ado-trastuzumab emtansine administration may lead to reductions in left ventricular ejection fraction (LVEF). Evaluate left ventricular function in all patients prior to and during treatment. Withhold treatment for a clinically significant decrease in left ventricular function.

Pregnancy:

Exposure to ado-trastuzumab emtansine during pregnancy can result in embryo-fetal harm. Advise patients of these risks and the need for effective contraception.

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Thrombocytopenia may occur (nadir achieved by day 8; generally resolves to ≤ grade 1 by the next scheduled dose). The incidence of thrombocytopenia may be higher in patients of Asian ancestry. Monitor platelet count at baseline and prior to each dose. May require treatment interruption or dose reduction. Monitor closely if at bleeding risk due to thrombocytopenia and/or concomitant anticoagulant use. Has not been studied in patients with platelets <100,000/mm3 at treatment initiation. Neutropenia and anemia have also occurred.

• Cardiotoxicity: [US Boxed Warning]: May result in left ventricular ejection fraction (LVEF) reductions. Evaluate left ventricular function (in all patients) prior to and at least every 3 months during treatment; withhold for clinically significant left ventricular function decreases. Treatment interruption or dosage reductions are required inpatients who develop decreased LVEF. Use has not been studied in patients with LVEF <50% at baseline, with a history of symptomatic CHF, serious arrhythmia, or recent history (within 6 months) of MI, or unstable angina.

• Extravasation reactions: Local reactions (erythema, irritation, pain, swelling, or tenderness) secondary to extravasation have been noted. These were generally mild and typically occurred within 24 hours of infusion. Monitor infusion site during infusion for possible infiltration.

• Hemorrhage: Hemorrhagic events, including central nervous system, respiratory, and gastrointestinal hemorrhage, have been observed; some hemorrhages were fatal. Some events occurred in patients who were receiving anticoagulation or antiplatelet therapy, or in patients with thrombocytopenia, although bleeding also occurred in patients without additional risk factors. Use caution when administering with antiplatelet agents or anticoagulants; consider additional monitoring when indicated.

• Hepatotoxicity: [US Boxed Warning]: Serious hepatotoxicity, including liver failure and death, has been reported. Monitor transaminases and bilirubin at baseline and prior to each dose. Increases (transaminases or total bilirubin) may require dose reductions or discontinuation. Hepatotoxicity is typically manifested by asymptomatic and transient increases in transaminases, although fatal cases of drug induced liver injury and hepatic encephalopathy have occurred; may be confounded by comorbidities or concomitant hepatotoxic medications. Use with caution in patients with hepatic impairment (has not been studied in patients with baseline serum transaminases >2.5 times ULN or bilirubin >1.5 times ULN, or in patients with active hepatitis B or C virus). Cases of nodular regenerative hyperplasia (NRH), a rare liver disorder characterized by widespread benign transformation of hepatic parenchyma into small regenerative nodules, have been observed (by biopsy). NRH may develop into noncirrhotic portal hypertension. Consider NRH in patients with clinical symptoms of portal hypertension and/or cirrhosis-like pattern seen on liver CT scan, although without associated transaminase elevations or other manifestations of cirrhosis. Diagnosis of NRH is confirmed by histopathology; permanently discontinue if histopathology confirms NRH.

• Hypersensitivity/infusion-related reactions: Infusion reactions (flushing, chills, fever, bronchospasm, dyspnea, wheezing, hypotension, and/or tachycardia) have been reported. After termination of infusion, these reactions generally resolved within several hours to a day. Medications for the treatment of reactions should be available for immediate use. Monitor closely for infusion reactions, especially during initial infusion. If reaction occurs, decrease infusion rate; for severe infusion reactions, interrupt infusion; permanently discontinue for life-threatening reactions. Serious allergic/anaphylactic reaction was observed (rare). Use is not recommended in patients who had trastuzumab permanently discontinued due to infusion reaction or hypersensitivity (has not been evaluated).

• Peripheral neuropathy: Sensory peripheral neuropathy has been reported, usually grade 1, although grade 3 peripheral neuropathy was also described. Monitor for signs and symptoms of neuropathy. May require treatment interruption and/or dose reduction.

• Pulmonary toxicity: Interstitial lung disease (ILD), including pneumonitis has been reported; some cases resulted in acute respiratory distress syndrome and/or fatalities. Permanently discontinue with diagnosis of ILD or pneumonitis. Signs and symptoms of pneumonitis include dyspnea, cough, fatigue, and pulmonary infiltrates; may or may not occur in correlation with infusion reaction. Patients with dyspnea at rest (due to advance malignancy complications or comorbidity) may be at increased risk for pulmonary toxicity.

Concurrent drug therapy issues:

• Drug-drug/drug-food interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Asian ancestry: The incidence of thrombocytopenia may be higher in patients of Asian ancestry.

• Pregnancy: [US Boxed Warning]: Exposure to ado-trastuzumab emtansine during pregnancy may cause embryo-fetal harm. Effective contraception must be used in women of reproductive potential. Pregnancy status should be verified prior to therapy. Effective contraception is recommended during therapy and for 7 months after the last dose for women of childbearing potential and for 4 months after the last dose in males with female partners of reproductive potential.

Dosage form specific issues:

• Do not interchange: [US Boxed Warning]: Ado-trastuzumab emtansine and conventional trastuzumab are NOT interchangeable. Do not substitute. In Canada, the generic name for Kadcyla is trastuzumab emtansine (ie, lacks Ado- prefix) and may be confused with conventional trastuzumab. Verify product label prior to reconstitution and administration to prevent medication errors.

Special handling:

• Hazardous agent: Use appropriate precautions for handling and disposal (NIOSH 2014 [group 1]).

Other warnings/precautions:

• HER2 expression: Establish HER2 overexpression or gene amplification status prior to treatment; has only been studied in patients with evidence of HER2 overexpression, either as 3+ IHC (Dako Herceptest) or FISH amplification ratio ≥2 (Dako HER2 FISH pharmDx test). There is only limited data on patients with breast cancer positive by FISH and 0 or 1+ by IHC.

Monitoring Parameters

Platelet count (at baseline and prior to each dose), transaminases and bilirubin (at baseline and prior to each dose); verify pregnancy status prior to treatment initiation; HER2 expression status. Evaluate left ventricular function (prior to and at least every 3 months during treatment; for LVEF <40% or 40% to 45% with ≥10% absolute decrease below baseline value, reassess within 3 weeks). Monitor infusion site during infusion for possible infiltration; monitor for infusion reactions (during infusion and for 90 minutes after initial infusion and for 30 minutes after subsequent infusions); signs and symptoms of bleeding, neuropathy, and/or pulmonary toxicity

Pregnancy Considerations

Animal reproduction studies have not been conducted. [US Boxed Warning]: Exposure to ado-trastuzumab emtansine during pregnancy may cause embryo-fetal harm. Effective contraception must be used in women of reproductive potential. Oligohydramnios and oligohydramnios sequence (manifested as pulmonary hypoplasia, skeletal malformations and neonatal death) were observed following trastuzumab exposure during pregnancy (trastuzumab is the antibody component of ado-trastuzumab emtansine). Monitor for oligohydramnios if trastuzumab exposure occurs during pregnancy or within 7 months prior to conception; conduct appropriate fetal testing if oligohydramnios occurs. Based on the mechanism of action, the DM1 component of the ado-trastuzumab emtansine formulation may also cause fetal harm if administered during pregnancy. Verify pregnancy status (in females of reproductive potential) prior to therapy. Effective contraception is recommended during therapy and for 7 months after the last dose for women of childbearing potential. Males with female partners of reproductive potential should use effective contraception during therapy and for 4 months after the last dose. Ado-trastuzumab emtansine may impair fertility in females and males.

If ado-trastuzumab emtansine exposure occurs during pregnancy or within 7 months prior to conception, healthcare providers should report the exposure to the Genentech Adverse Event Line (888-835-2555). Women exposed to ado-trastuzumab emtansine during pregnancy or within 7 months prior to conception are encouraged to enroll in MotHER Pregnancy Registry (1-800-690-6720).

European Society for Medical Oncology (ESMO) guidelines for cancer during pregnancy recommend delaying treatment with HER-2 targeted agents until after delivery in pregnant patients with HER-2 positive disease (Peccatori 2013).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience dry mouth, change in taste, abdominal pain, nausea, vomiting, diarrhea, constipation, muscle pain, joint pain, headache, nosebleed, dizziness, mouth irritation, insomnia, or rash. Have patient report immediately to prescriber signs of infusion reaction, signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), signs of heart problems (cough or shortness of breath that is new or worse, swelling of the ankles or legs, abnormal heartbeat, weight gain of more than five pounds in 24 hours, dizziness, or passing out), signs of infection, signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding), burning or numbness feeling, severe injection site pain, burning, edema, or irritation, severe loss of strength and energy, swelling of arms or legs, signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal headache), or signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse) (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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