What is the recommended dosing for Epidermal Growth Factor Receptor (EGFR) inhibitors, such as erlotinib (erlotinib) or afatinib (afatinib), in an 80-year-old patient?

From the Guidelines

For an 80-year-old patient, the recommended dosing for Epidermal Growth Factor Receptor (EGFR) inhibitors, such as erlotinib or afatinib, should be carefully considered due to age-related factors, with a reduced starting dose often necessary to balance efficacy and tolerability. When considering the use of EGFR inhibitors in elderly patients, it's crucial to assess their overall health, including comorbidities and frailty, as these factors can significantly impact the tolerability of these medications 1. The standard starting dose of erlotinib is 150 mg once daily, but for elderly patients, a reduced starting dose of 100 mg daily may be more appropriate to minimize the risk of adverse effects such as rash, diarrhea, and mucositis 1. Similarly, for afatinib, the standard dose is 40 mg once daily, but a lower starting dose of 30 mg daily is often recommended for elderly patients to mitigate potential side effects 1. Dose adjustments should be made based on tolerability, and renal and hepatic function should be assessed before initiating therapy, as impairment may necessitate further dose reductions 1. Treatment should continue until disease progression or unacceptable toxicity occurs, with regular monitoring of liver function, electrolytes, and skin condition being essential 1. It's also important to note that the choice of EGFR inhibitor and the dosing strategy may depend on the specific type of EGFR mutation present, as well as other individual patient factors 1. In general, the goal is to find a balance between maximizing the efficacy of the treatment and minimizing its toxicity, particularly in elderly patients who may be more susceptible to adverse effects 1. By carefully considering these factors and adjusting the dosing regimen accordingly, healthcare providers can help optimize the use of EGFR inhibitors in elderly patients with non-small cell lung cancer. Key considerations include:

• Starting with a reduced dose to assess tolerability
• Monitoring for common side effects such as rash, diarrhea, and mucositis
• Adjusting the dose based on renal and hepatic function
• Continuously assessing the patient's overall health and adjusting the treatment plan as needed
• Considering the specific type of EGFR mutation and other individual patient factors when selecting an EGFR inhibitor and determining the dosing strategy.

From the Research

Recommended Dosing for EGFR Inhibitors in 80-Year-Old Patients

The recommended dosing for Epidermal Growth Factor Receptor (EGFR) inhibitors, such as erlotinib or afatinib, in an 80-year-old patient can vary depending on several factors, including the patient's overall health, performance status, and previous treatments.

• A study published in 2016 2 found that a low starting dosage of afatinib (20 or 30mg/day) might enable elderly or low performance status patients with advanced refractory non-small-cell lung cancer to receive this drug as salvage therapy.
• Another study published in 2017 3 evaluated the toxicity, pharmacokinetics, and efficacy of twice weekly pulse and daily low-dose erlotinib in patients with EGFR-mutant lung cancers.
• A meta-analysis published in 2017 4 compared the risk of treatment-related toxicities from EGFR tyrosine kinase inhibitors, including gefitinib, erlotinib, and afatinib, in advanced EGFR-mutated non-small cell lung cancer.

Dosing Considerations

When considering the dosing of EGFR inhibitors in elderly patients, the following factors should be taken into account:

• The patient's age and performance status
• The presence of any comorbidities or previous treatments
• The potential for adverse events, such as diarrhea, rash, and increased liver enzyme levels
• The need for dose adjustments or reductions based on the patient's response to treatment

Specific Dosing Recommendations

• A study published in 2020 5 found that low-dose erlotinib (50 mg/d) was safe and effective in elderly or frail patients with EGFR mutation-positive non-small cell lung cancer.
• The study suggested that low-dose erlotinib could be a valid treatment option for these patients, with a significant objective response rate and minimal adverse events.
• Another study published in 2011 6 compared the efficacy and tolerability of erlotinib versus standard chemotherapy in the first-line treatment of patients with advanced EGFR mutation-positive non-small cell lung cancer, but did not specifically address dosing in elderly patients.

Adverse Events and Dose Adjustments

• The most common adverse events associated with EGFR inhibitors include diarrhea, rash, and increased liver enzyme levels 4.
• Dose adjustments or reductions may be necessary based on the patient's response to treatment and the presence of any adverse events 2, 5.