Should a patient on Stivarga (Regorafenib) hold off on taking their daily dose until after a Y90 procedure due to an NPO (Nil Per Os) order?

Management of Stivarga (Regorafenib) During NPO Status for Y90 Mapping Procedure

The patient should hold their daily dose of Stivarga (regorafenib) during the NPO period for the Y90 mapping procedure and resume it after the procedure when oral intake is permitted.

Rationale for Holding Oral Medications During NPO Status

When patients are placed on NPO status for procedures, oral medications should not be administered until a swallowing assessment has been completed or the NPO status has been lifted 1. This is a standard safety precaution that applies to all oral medications, including Stivarga.

The Canadian Stroke Best Practice Recommendations clearly state:

• "Patients should remain NPO (nil per os—no oral intake) until swallowing screen completed for patient safety" 1
• "Oral medications should not be administered until swallowing screen using a validated tool has been completed and found normal; alternate routes such as intravenous and rectal administration should be considered while a patient is NPO" 1

Considerations for Stivarga During Procedures

Stivarga (regorafenib) is an oral multi-kinase inhibitor that targets angiogenic, stromal, and oncogenic receptor tyrosine kinases 2. It is typically administered daily and is used in the treatment of:

• Metastatic colorectal cancer
• Gastrointestinal stromal tumors (GIST)
• Advanced hepatocellular carcinoma (HCC) 3

Key points about Stivarga management during procedures:

• No parenteral alternative: Unlike some medications, Stivarga does not have an intravenous formulation that could be substituted during NPO status.

• Short-term interruption is acceptable: A brief interruption of Stivarga for a procedure is unlikely to significantly impact its therapeutic efficacy, as the drug has a relatively long half-life.

• Safety concerns: Taking oral medications while NPO increases the risk of aspiration and complications.

Timing of Medication Resumption After Procedure

After the Y90 mapping procedure, Stivarga can be resumed once the patient is allowed to take oral medications again. The timing should follow these guidelines:

1. Confirm NPO status is lifted: Ensure the patient has been cleared to resume oral intake by the procedural team.

2. Resume at regular dosing: Once oral intake is permitted, the patient should resume their regular daily dose of Stivarga 1.

3. No need for dose adjustment: Unlike anticoagulants which may require special dosing considerations after procedures, Stivarga can typically be resumed at the pre-procedure dose without adjustment 4.

Important Considerations for Y90 Procedures

For patients undergoing Y90 mapping and potential subsequent Y90 radioembolization:

• Medication interactions: There are no specific contraindications to resuming Stivarga after a Y90 procedure, as both treatments can be used in the management of liver-dominant metastatic disease 5.

• Timing considerations: In patients with liver-dominant disease who may be candidates for both Y90 and other liver-directed therapies, treatment sequencing should be carefully planned 5.

Summary

1. Hold Stivarga during the NPO period for the Y90 mapping procedure
2. Resume the regular daily dose once oral intake is permitted after the procedure
3. No dose adjustment is necessary when resuming Stivarga
4. Monitor for any procedure-related complications before resuming medication

This approach ensures patient safety while minimizing disruption to the patient's cancer treatment regimen.