Some patients receiving sunitinib as monotherapy or in combination with bevacizumab experienced thrombotic microangiopathy (TMA). Sunitinib should be discontinued in patients who develop TMA. Discontinuing the drug has led to reversal of the effects of TMA.

Obtain baseline and periodic urinalysis during treatment to assess for developing or worsening proteinuria, with follow-up measurement of 24-hour urine protein as clinically indicated. If 24-hour urine protein is 3 g or higher, interrupt sunitinib treatment and reduce the dose. Repeat episodes or nephritic syndrome warrants discontinuing treatment with sunitinib.


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Assess patients for erythema multiforme, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). Discontinue treatment if the patient presents with signs or symptoms of these dermatologic toxicities, such as progressive skin rash often with blisters or mucosal lesions. Treatment should not be resumed if SJS or TEN is suspected and if the patient develops necrotizing fasciitis.

Obtaining baseline laboratory measurement of thyroid function is recommended, with close monitoring for signs and symptoms of thyroid dysfunction. Patients with suspected thyroid dysfunction, such as hypothyroidism, hyperthyroidism, or thyroiditis, should undergo laboratory tests for monitoring thyroid function; treat as needed per standard medical practice.

Sunitinib is associated with hypoglycemia in patients with GIST or renal cell carcinoma, and this effect may be worse in patients with diabetes. Regular blood glucose measurements should be performed during treatment and after discontinuing the drug. Patients with diabetes may need dose modifications of their antidiabetes medications.

Preventive dentistry to reduce the risk of osteonecrosis of the jaw should be considered prior to initiating treatment. Invasive dental procedures should be avoided, particularly if the patient is receiving intravenous bisphosphate therapy.

Sunitinib may impair wound healing; therefore, treatment should be temporarily interrupted in patients undergoing major surgical procedures. Because clinical experience in regard to resuming treatment is limited, the decision to do so should be on the basis of clinical judgment of recovery from surgery. Clinicians are also advised to monitor for adrenal insufficiency in patients undergoing major surgery, as well as those experiencing stress such as trauma or severe infection.2


Debra Hughes is a medical writer based in Lusby, Maryland.  


REFERENCES

1. Gleevec [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2015.

2. Sutent [package insert]. New York, NY: Pfizer, Inc; 2015.

3. Stivarga [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc; 2016.