Grunwald, V., Kalanovic, D., & Merseburger, A.S. (2010). Management of sunitinib-related adverse events: An evidence- and expert-based consensus approach. World Journal of Urology, 28, 343–351.

To provide advice for patient care in daily practice regarding the management of side effects of sunitinib.

Information was compiled and clinical experts were asked to identify the degree to which they agreed or disagreed with the information. Those measures agreed on by 70% of respondents were included in this summary. Clinicians had to have cared for at least 30 patients receiving sunitinib. Twelve German clinical experts provided analysis.

Databases searched were PubMed, Embase, Current Contents, and recommendations of oncology societies.

Key topics were sunitinib and tyrosine kinase inhibitor therapy management recommendations.

Arterial Hypertension:

• Mandatory blood pressure monitoring is recommended as often as daily. No clear recommendations exist for monitoring or optimal treatment with antihypertensives. The exact mechanism of effect is unclear, and hypertension may resolve during regular two-week pauses in treatment and reappear with continuation of therapy.
• Agreement was reached on routine exercise, weight control, a sodium-restricted diet, and decreased alcohol consumption.

Fatigue:

• Maintain normal social and physical activity.
• Balance work and sleep schedules.
• Get moderate exercise.
• Measure body weight routinely.
• Use distraction (e.g., reading).
• Offer medical treatment for secondary causes such as hypothyroidism, depression, anemia, or pain.
• Consider reduction of sunitinib in cases with reduced quality of life.

Mucositis/Oral Disorders:

• Avoid irritating food or drinks, such as spicy, acidic, very hot or cold, and dry or hard foods.
• Use lip protection.
• Oral hygiene is important.
• Use of dexpanthenol lozenges and ointment is appropriate for mucosal protection.  
• Oral symptoms should be treated with topical anesthetics, steroids, or anti-infectives.
• In case of pronounced symptoms, consider interruptions of sunitinib.

Diarrhea:

• Advise patients to split food and drinks into small amounts.
• Avoid spicy or fried food and large amounts of fruits and vegetables.
• Maintain sufficient fluid intake.
• Avoid use of laxatives.
• In cases of severe diarrhea, provide IV fluid and electrolytes.  
• Early treatment with agents such as loperamide is advised.
• Interruption or dose reduction of sunitinib was considered appropriate for grade 3 or 4 diarrhea only.

Nausea and Vomiting:

• Eat a bland diet with small servings.
• Use antiemetic drugs such as dopamine agonists and proton-pump inhibitors.
• Sunitinib dosage may be reduced 12.5 mg in cases of grade 3 or 4 symptoms, or if symptom interventions are not successful.

Skin Reactions

Hand-Foot Syndrome:

• Protect the hands and feet from heat and hot water.
• Use cold packs for pain relief.
• Apply moisturizers daily.
• Use systemic anti-inflammatory medication in some cases.
• Use topical antifungals for localized superinfection.
• Use oral ibuprofen or paracetamol for pain control.
• For grade 2 symptoms, consider break-in sunitinib.
• For grade 3 symptoms, interrupt treatment temporarily and use lower doses after symptoms have resolved to lower than grade 1.

Erythema, Dry Skin, and Dermatitis:

• Prevent sun exposure and use ultraviolet (UV) protective lotions with 15 to 30 sun protective factor (SPF).
• Avoid irritating care products.
• Use fatty creams or ointments after showering daily.
• Limit sunitinib dose alterations as much as possible. Only 66% agreement was reached that a treatment break should be considered with grade 2 to 4 skin toxicity.

• Experts were from a single setting, and one author was employed by Pfizer.
• Recommendations were based on the opinion of a few experts, who had limited patient experience with sunitinib. The association with varied levels of evidence to support these recommendations is not evident.
• Advice for patients and physicians was built mainly from the opinions of experts, rather than supporting data from controlled trials.

A significant need exists for more scientific evidence on the prevention and management of side effects caused by these agents for cancer treatment.