She does not need to be on lifelong anticoagulation . She can certainly go back on HRT , but will need to be on anticoagulation for a minimum of six months based on how long it takes to normalize D-dimers and clear DVT by doppler ultrasound .
Muthalagu Ramanathan , MD UMass Memorial Health Care
Worcester , MA
I would do six months of anticoagulation and remove IVC filter once the patient is stable . Avoid HRT if feasible . If the patient wants to continue on HRT then probably do lifelong anticoagulation , knowing that the patient will always be at a higher risk of venous thromboembolism ( VTE ).
Bijoy P . Telivala , MD , MBBS Jacksonville , FL
Yes , I would allow her to resume HRT as long as she is apprised of and agrees to the potential increased risk of another thrombotic event . I would also recommend continued anticoagulation for at least six to 12 months and reassess at that time .
David H . Gordon , MD Cancer Care Centers of South Texas
San Antonio , TX
Table 3 : Hematologic Adverse Reactions Reported * in ≥ 20 % of Patients with MCL in Trial LY-004
Hematologic Adverse Reactions
CALQUENCE ® ( acalabrutinib ) capsules , for oral use
CALQUENCE 100 mg twice daily N = 124
All Grades (%) Grade ≥ 3 (%)
Hemoglobin decreased |
46 |
10 |
Platelets decreased |
44 |
12 |
Neutrophils decreased |
36 |
15 |
* Per National Cancer Institute Common Terminology Criteria for Adverse Events ( NCI CTCAE ) version 4.03 ; |
based on laboratory measurements and adverse reactions . |
Increases in creatinine 1.5 to 3 times the upper limit of normal occurred in 4.8 % of patients . |
DRUG INTERACTIONS |
Strong CYP3A Inhibitors |
Clinical Impact
Prevention or Management
Moderate CYP3A Inhibitors
Clinical Impact
Prevention or Management
Strong CYP3A Inducers
Clinical Impact
Prevention or Management
Gastric Acid Reducing Agents
Clinical Impact
Prevention or Management
• Co-administration of CALQUENCE with a strong CYP3A inhibitor ( itraconazole ) increased acalabrutinib plasma concentrations [ see Clinical Pharmacology ( 12.3 ) in the full Prescribing Information ].
• Increased acalabrutinib concentrations may result in increased toxicity .
• Avoid co-administration of strong CYP3A inhibitors with CALQUENCE .
• Alternatively , if the inhibitor will be used short-term , interrupt CALQUENCE [ see Dosage and Administration ( 2.2 ) in the full Prescribing Information ].
• Co-administration of CALQUENCE with a moderate CYP3A inhibitor may increase acalabrutinib plasma concentrations [ see Clinical Pharmacology ( 12.3 ) in the full Prescribing Information ].
• Increased acalabrutinib concentrations may result in increased toxicity .
• When CALQUENCE is co-administered with moderate CYP3A inhibitors , reduce acalabrutinib dose to 100 mg once daily .
• Co-administration of CALQUENCE with a strong CYP3A inducer ( rifampin ) decreased acalabrutinib plasma concentrations [ see Clinical Pharmacology ( 12.3 ) in the full Prescribing Information ].
• Decreased acalabrutinib concentrations may reduce CALQUENCE activity .
• Avoid co-administration of strong CYP3A inducers with CALQUENCE .
• If a strong CYP3A inducer cannot be avoided , increase the acalabrutinib dose to 200 mg twice daily .
• Co-administration of CALQUENCE with a proton pump inhibitor , H2-receptor antagonist , or antacid may decrease acalabrutinib plasma concentrations [ see Clinical Pharmacology ( 12.3 ) in the full Prescribing Information ].
• Decreased acalabrutinib concentrations may reduce CALQUENCE activity .
• If treatment with a gastric acid reducing agent is required , consider using a H2-receptor antagonist ( e . g ., ranitidine or famotidine ) or an antacid ( e . g ., calcium carbonate ).
Separate dosing by at least 2 hours [ see Dosage and Antacids
Administration ( 2.2 ) in the full Prescribing Information ].
H2-receptor antagonists
Proton pump inhibitors
Take CALQUENCE 2 hours before taking the H2-receptor antagonist [ see Dosage and Administration ( 2.2 ) in the full Prescribing Information ].
Avoid co-administration . Due to the long-lasting effect of proton pump inhibitors , separation of doses may not eliminate the interaction with CALQUENCE .
USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary
Based on findings in animals , CALQUENCE may cause fetal harm when administered to a pregnant woman . There are no available data in pregnant women to inform the drugassociated risk . In animal reproduction studies , administration of acalabrutinib to pregnant rabbits during organogenesis resulted in reduced fetal growth at maternal exposures ( AUC ) approximately 4 times exposures in patients at the recommended dose of 100 mg twice daily ( see Data ). Advise pregnant women of the potential risk to a fetus .
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown . All pregnancies have a background risk of birth defect , loss , or other adverse outcomes . In the U . S . general population , the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4 % and 15-20 %, respectively .
Data
Animal Data In a combined fertility and embryo-fetal development study in female rats , acalabrutinib was administered orally at doses up to 200 mg / kg / day starting 14 days prior to mating through gestational day [ GD ] 17 . No effects on embryo-fetal development and survival were observed . The AUC at 200 mg / kg / day in pregnant rats was approximately 16-times the AUC in patients at the recommended dose of 100 mg twice daily . The presence of acalabrutinib and its active metabolite were confirmed in fetal rat plasma .
In an embryo-fetal development study in rabbits , pregnant animals were administered acalabrutinib orally at doses up to 200 mg / kg / day during the period of organogenesis ( from GD 6-18 ). Administration of acalabrutinib at doses ≥ 100 mg / kg / day produced maternal toxicity and 100 mg / kg / day resulted in decreased fetal body weights and delayed skeletal ossification . The AUC at 100 mg / kg / day in pregnant rabbits was approximately 4-times the AUC in patients at 100 mg twice daily .
Lactation Risk Summary
No data are available regarding the presence of acalabrutinib or its active metabolite in human milk , its effects on the breastfed child , or on milk production . Acalabrutinib and its active metabolite were present in the milk of lactating rats . Due to the potential for adverse reactions in a breastfed child from CALQUENCE , advise lactating women not to breastfeed while taking CALQUENCE and for at least 2 weeks after the final dose .
Pediatric Use The safety and efficacy of CALQUENCE in pediatric patients have not been established .
Geriatric Use Eighty ( 64.5 %) of the 124 MCL patients in clinical trials of CALQUENCE were 65 years of age or older , and 32 patients ( 25.8 %) were 75 years of age or older . No clinically relevant differences in safety or efficacy were observed between patients ≥ 65 years and younger .
PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling ( Patient Information ).
Hemorrhage
Inform patients to report signs or symptoms of severe bleeding . Inform patients that CALQUENCE may need to be interrupted for major surgeries [ see Warnings and Precautions ( 5.1 ) in the full Prescribing Information ].
Infections
Inform patients to report signs or symptoms suggestive of infection [ see Warnings and Precautions ( 5.2 ) in the full Prescribing Information ].
Cytopenias
Inform patients that they will need periodic blood tests to check blood counts during treatment with CALQUENCE [ see Warnings and Precautions ( 5.3 ) in the full Prescribing Information ].
Second Primary Malignancies
Inform patients that other malignancies have been reported in patients who have been treated with CALQUENCE , including skin cancer . Advise patients to use sun protection [ see Warnings and Precautions ( 5.4 ) in the full Prescribing Information ].
Atrial Fibrillation and Flutter
Counsel patients to report any signs of palpitations , lightheadedness , dizziness , fainting , shortness of breath , and chest discomfort [ see Warnings and Precautions ( 5.5 ) in the full Prescribing Information ].
Dosing Instructions
Instruct patients to take CALQUENCE orally twice daily , about 12 hours apart . CALQUENCE may be taken with or without food . Advise patients that CALQUENCE capsules should be swallowed whole with a glass of water , without being opened , broken , or chewed [ see Dosage and Administration ( 2.1 ) in the full Prescribing Information ].
Missed Dose
Advise patients that if they miss a dose of CALQUENCE , they may still take it up to 3 hours after the time they would normally take it . If more than 3 hours have elapsed , they should be instructed to skip that dose and take their next dose of CALQUENCE at the usual time . Warn patients they should not take extra capsules to make up for the dose that they missed [ see Dosage and Administration ( 2.1 ) in the full Prescribing Information ].
Drug Interactions
Advise patients to inform their healthcare providers of all concomitant medications , including over-the-counter medications , vitamins and herbal products [ see Drug Interactions ( 7 ) in the full Prescribing Information ].
Lactation
Advise women not to breastfeed during treatment with CALQUENCE and for at least 2 weeks after the final dose [ see Use in Specific Populations ( 8.2 ) in the full Prescribing Information ].
Distributed by : AstraZeneca Pharmaceuticals LP , Wilmington , DE 19850 Under license of Acerta Pharma B . V .
CALQUENCE is a registered trademark of the AstraZeneca group of companies . © AstraZeneca 2017
10 / 17 US-14202 11 / 17
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I assume that her VTE was pathogenetically related to the severe trauma , immobilization , and , possibly , HRT . This was clearly a VTE associated with mainly temporary risk factors , and her recurrence risk may not be very high . Still , I would continue anticoagulant therapy , ideally with a direct oral anticoagulant , for infinite time ( as long as she is on HRT ).
Bernhard Lämmle , MD Center for Thrombosis and Hemostasis , University Medical Center Mainz
Mainz , Germany
Reversible cause of thrombosis . I would give six months of anticoagulation and continue hormonal therapy . If possible , I would remove the IVC filter .
Jason Gonsky , MD , PhD SUNY Downstate Medical Center
New York , NY
Since she had not had a thrombotic episode prior to her trauma and multiple surgeries , I see no reason to withhold anticoagulation . Lifelong anticoagulation is an option given the HRT .
Geoffrey K . Sherwood , MD Brigham and Women ’ s Faulkner Hospital
Waban , MA
This is a provoked DVT . She can go back to hormone treatment after recovery and a period of treatment .
Robert G . Lerner , MD Westchester Medical Center
Valhalla , NY
See more reader responses at ashclinicalnews . org / you-make-the-call .
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