Review of Systems for Patients on Cabozantinib
Patients on cabozantinib require systematic monitoring for hypertension, hand-foot skin reaction (HFSR)/palmar-plantar erythrodysesthesia, gastrointestinal toxicity (diarrhea, nausea), fatigue, and hepatotoxicity, as these are the most common and clinically significant adverse events that impact treatment tolerability and require dose modifications. 1, 2
Critical Adverse Events Requiring Systematic Assessment
Cardiovascular System
- Blood pressure monitoring is essential, as grade 3-4 hypertension occurs in 16% of patients on cabozantinib versus 2% on placebo 1
- Assess for new-onset or worsening hypertension at each visit
- Interestingly, hypertension may be associated with improved clinical outcomes 3
Dermatologic System
- Hand-foot skin reaction (HFSR)/palmar-plantar erythrodysesthesia is a hallmark toxicity, occurring as grade 3-4 in 17% of cabozantinib patients versus 0% in controls 1
- Systematically examine palms and soles for erythema, tenderness, blistering, or desquamation
- Ask about pain with walking or gripping objects
- Mucositis/HFSR may correlate with improved outcomes 3
Gastrointestinal System
- Diarrhea occurs as grade 3-4 in 10% versus 2% with placebo 1
- Nausea and decreased appetite are among the most common adverse reactions (≥25%) 4
- Assess frequency, severity, and impact on hydration status
- Screen for weight loss, which is a common adverse reaction 4
Constitutional Symptoms
- Fatigue is highly prevalent (≥25% of patients) and occurs as grade 3-4 in 10% versus 4% with placebo 1, 4
- Quantify impact on daily activities and quality of life
Hepatic Function
- Elevated AST occurs as grade 3-4 in 12% versus 7% with placebo 1
- Monitor liver function tests regularly, particularly in hepatocellular carcinoma patients with baseline liver dysfunction 5
Context-Specific Considerations
For Hepatocellular Carcinoma Patients
- Preserved liver function (Child-Pugh A) is critical, as cabozantinib is recommended only for this population 1, 5
- Monitor for signs of hepatic decompensation
- Nearly all patients (99%) in efficacy trials had Child-Pugh A liver function 5
For Renal Cell Carcinoma Patients
- Assess for progression of metastatic disease, particularly bone metastases where cabozantinib shows significant benefit 1
- Monitor renal function, as mild/moderate renal impairment increases cabozantinib AUC by 7-30% 6
Adverse Event Management Impact
More than half of patients require dose reduction, but treatment discontinuation rates due to adverse events remain relatively low (16-21% versus 3-5% with placebo/comparator) 1, 5, 2
- Serious adverse events occur in approximately 50% of cabozantinib patients versus 21% with placebo 5
- Drug-related adverse events leading to dose modifications are common but manageable with supportive care 2
- Patients with ≥3 metastatic sites or ≥2 prior lines of therapy are more likely to require dose reductions 3
Additional Safety Monitoring
Drug Interactions
- Avoid strong CYP3A4 inducers (decrease cabozantinib AUC by 76-77%) and use caution with strong CYP3A4 inhibitors (increase AUC by 34-38%) 6
- High-fat meals increase cabozantinib AUC by 57% 6