Ifosfamide-Containing Germ

Cell Tumor Regimens

Garrett Terhune, PharmD
PGY-1 Pharmacy Resident
August 25, 2022
Speaker Disclosures

 I have no actual or potential conflicts of interest in this presentation

2
Objectives

Discuss first-line treatment options

for germ cell cancers

Review administration sequence and

timing of medications

Evaluate treatment options for side

effects experienced during therapy

3
Ifosfamide Concerns

4
Major Adverse Effects

Encephalopathy

Hemorrhagic cystitis

Bone marrow suppression

Nephrotoxicity
5
IU Health Order Sets and Treatment Algorithms

6
VIP Overview
 Etoposide
 75 mg/m2/day over 60 minutes for 5 doses (days 1, 2, 3, 4, and 5)
 Ifosfamide
 1200 mg/m2/day over 60 minutes for 5 doses (days 1, 2, 3, 4, and 5)
 Cisplatin
 20 mg/m2/day over 60 minutes for 5 doses (days 1, 2, 3, 4, and 5)
 Mesna
 240 mg/m2 once over 15 minutes day 1
THEN
 400 mg/m in 1000 mL NS continuous infusion at 125 mL/hr (days 1, 2, 3, 4, and 5)
2

⎻May discontinue continuous Mesna infusion after the end of day 5 or upon discharge

7
VIP Administration Order

Cisplatin

Mesna

Ifosfamide

Etoposide
8
VeIP Overview
 Vinblastine
 0.11 mg/kg over 10 minutes infused to gravity for 2 doses (days 1 and 2)
 Ifosfamide
 1200 mg/m2/day over 60 minutes for 5 doses (days 1, 2, 3, 4, and 5)
 Cisplatin
 20 mg/m2/day over 60 minutes for 5 doses (days 1, 2, 3, 4, and 5)
 Mesna
 240 mg/m2 once over 15 minutes day 1
THEN
 400 mg/m in 1000 mL NS continuous infusion at 125 mL/hr (days 1, 2, 3, 4, and 5)
2

⎻May discontinue continuous Mesna infusion after the end of day 5 or upon discharge

9
VeIP Administration Order

Vinblastine

Cisplatin

Mesna

Ifosfamide
10
Question #1
 Which of the following is a major concern regarding therapy with regimens that contain ifosfamide?
A. Nephrotoxicity
B. Encephalopathy
C. Bone marrow suppression
D. Hemorrhagic cystitis
E. All of the above

11
Question #1
 Which of the following is a major concern regarding therapy with regimens that contain ifosfamide?
A. Nephrotoxicity
B. Encephalopathy
C. Bone marrow suppression
D. Hemorrhagic cystitis
E. All of the above

12
Additional IV Fluids for Administration
 For VIP regimen:
 1000 mL NS at 500 mL/hr over 2 hours prior to cisplatin then 100 mL/hr until Mesna infusion starts then
discontinue
 1000 mL NS at 1000 mL/hr over 1 hour day 5 after completion of final cisplatin dose then discontinue

 For VeIP regimen:

 1000 mL NS at 1000 mL/hr over 1 hour prior to cisplatin day 1 then discontinue
 1000 mL NS at 1000 mL/hr over 1 hour day 5 after completion of final cisplatin dose then discontinue

13
Side Effect Management

14
Antiemetics
 Fosaprepitant 150 mg IV 30 minutes prior to chemotherapy days 3 and 5
 Ondansetron 16 mg PO daily 30 minutes prior to chemotherapy on days 1, 2, 3, 4, and 5
 Dexamethasone 20 mg PO daily 30 minutes prior to chemotherapy on days 1 and 2
 Dexamethasone 4 mg PO twice daily on days 6, 7, and 8
 Olanzapine 10 mg PO at bedtime days 2, 3, and 4 (only for VIP order set)

 Rescue antiemetic: lorazepam 1 mg IV push every 6 hours PRN

15
Myelosuppression Prevention
 Neulasta Onpro® typically ordered for patients receiving VIP or VeIP to minimize neutropenia risk after inpatient
infusion
 Due to cost of medication when administered inpatient, patients are to receive as outpatient
 Appointment should be scheduled with outpatient infusion clinic to receive after discharge

16
Lab Orders and Monitoring/Assessment

17
Lab Orders
 Baseline lab orders:
 CMP
 CBC with diff
 LDH
 Beta-HCG
 Alpha-fetoprotein
 Urinalysis
 Daily lab orders:
 Urinalysis

18
Monitoring/Assessment
 VIP and VeIP:
 Assess for confusion or mental status changes every 8 hours
⎻Hold ifosfamide and call oncology attending if present
 Hold ifosfamide and notify physician if urinalysis has greater than 10 RBC present

19
Question #2
 Which of the following is a lab order that should be ordered as daily in ALL patients receiving VIP and VeIP?
A. CBC with diff
B. Urinalysis
C. CMP
D. LDH

20
Question #2
 Which of the following is a lab order that should be ordered as daily in ALL patients receiving VIP and VeIP?
A. CBC with diff
B. Urinalysis
C. CMP
D. LDH

21
What questions do you have?

22
Ifosfamide-Containing Germ
Cell Tumor Regimens
Garrett Terhune, PharmD
PGY-1 Pharmacy Resident
August 25, 2022