Can a Patient with a Hip Fracture Receive Kadcyla?
Yes, a patient with a hip fracture can receive Kadcyla (ado-trastuzumab emtansine) for HER2-positive breast cancer, as hip fracture is not a contraindication to this therapy. 1
Key Clinical Considerations
No Absolute Contraindications Related to Hip Fracture
- The FDA prescribing information for Kadcyla lists no contraindications whatsoever, meaning there are no absolute reasons to withhold this medication 1
- Hip fracture does not appear in any of the boxed warnings or precautions for Kadcyla, which focus on hepatotoxicity, cardiac toxicity, embryo-fetal toxicity, pulmonary toxicity, infusion reactions, hemorrhage, thrombocytopenia, and neurotoxicity 1
Specific Safety Monitoring Required
The critical safety concerns with Kadcyla that require monitoring regardless of hip fracture status include:
- Hepatotoxicity: Monitor hepatic function prior to initiation and before each dose, with dose modifications or permanent discontinuation as appropriate 1
- Cardiac toxicity: Assess left ventricular ejection fraction (LVEF) prior to initiation and monitor throughout treatment, withholding or discontinuing as appropriate 1
- Thrombocytopenia: Monitor platelet counts prior to each dose, which is particularly relevant given that hemorrhage (including fatal cases) has occurred in clinical trials 1
Hemorrhage Risk Considerations with Hip Fracture
- Fatal hemorrhage has occurred in Kadcyla-treated patients both with and without identified risk factors, including those with thrombocytopenia and those receiving anticoagulation or antiplatelet therapy 1
- If the hip fracture patient requires anticoagulation or antiplatelet therapy (common in orthopedic trauma), use caution and consider additional monitoring when concomitant use is medically necessary 1
- Hemorrhage and epistaxis are among the most common adverse reactions (≥25%) with Kadcyla 1
Treatment Timing Algorithm
When to Initiate or Continue Kadcyla
For metastatic disease:
- Kadcyla is indicated as a single agent at 3.6 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity 1
- The hip fracture itself does not necessitate treatment delay unless the patient's performance status is severely compromised or they require procedures/medications that create unacceptable risk 2
For adjuvant treatment:
- Kadcyla is given for a total of 14 cycles in the adjuvant setting for patients with residual invasive disease after neoadjuvant therapy 1
- Hip fracture management should be coordinated with oncology to minimize treatment interruptions that could compromise survival outcomes 2
Practical Management Approach
- Assess performance status: If the hip fracture significantly impairs performance status temporarily, brief treatment delays may be reasonable, but prolonged delays should be avoided as delaying HER2-targeted therapy may preclude survival benefits 2
- Coordinate with orthopedics: Ensure platelet counts are adequate (monitor prior to each dose) if surgical intervention is planned 1
- Manage anticoagulation carefully: If venous thromboembolism prophylaxis or treatment is required post-fracture, implement additional monitoring for bleeding given Kadcyla's hemorrhage risk 1
- Monitor for mobility-related complications: Peripheral neuropathy is a known adverse effect of Kadcyla that may compound mobility issues from hip fracture; withhold dosing temporarily for Grade 3 or 4 peripheral neuropathy 1
Common Pitfalls to Avoid
- Do not unnecessarily delay Kadcyla: The evidence indicates that HER2-targeted therapy is most beneficial when used initially, and delaying may preclude survival benefits observed in clinical trials 2
- Do not substitute or interchange: Kadcyla cannot be substituted for or with trastuzumab—these are distinct agents with different dosing and administration 1
- Do not exceed recommended dose: Never administer Kadcyla at doses greater than 3.6 mg/kg 1
- Do not use as IV push or bolus: Kadcyla must be given as an intravenous infusion only, and dextrose 5% solution should not be used 1