Pazopanib (Votrient®)

Pazopanib is a type of targeted therapy called a tyrosine kinase inhibitor. A kinase is an enzyme that promotes cell growth. There are many types of kinases, which control different phases of cell growth. By blocking a particular enzyme from working, this medication can slow the growth of cancer cells.

Pazopanib is a tyrosine kinase inhibitor that blocks a few targets including VEGF, PDFR, FGFR, cKIT, IL-2, LcK and c-Fms. This means it works by targeting receptors present on the cancer cells. By blocking these targets on cancer cells, tumor growth and angiogenesis (the development of a blood supply to the tumor) are blocked.

How to Take Pazopanib

Pazopanib comes as a tablet to take by mouth. It should be taken without food, on an empty stomach, at least 1 hour before or 2 hours after a meal. Take the tablets whole; do not crush, break or chew. Take pazopanib at around the same time every day. If you miss a dose and it has been less than 12 hours since your regular dose time, take it as soon as you remember. If it has been more than 12 hours, skip the dose. Do not take 2 doses at once to make up for a missed dose.

It is important to make sure you are taking the correct amount of medication every time. Before every dose, check that what you are taking matches what you have been prescribed.

The blood levels of this medication can be affected by certain foods and medications, so they should be avoided. These include: grapefruit, grapefruit juice, amiodarone, atorvastatin, azithromycin, carvedilol, carbamazepine, citalopram, fluoxetine, hydroxychlorquine, itraconazole, ketoconazole, phenobarbital, phenytoin, posaconazole, quetiapine, rifampin, sotalol, St. John’s wort, verapamil, and voriconazole.

You should not take pazopanib at the same time as "heartburn" medications (including proton pump inhibitors such as prilosec, nexium, protonix; and H2 blockers, such as tagamet, zantac), as these may affect how pazopanib is absorbed. If needed, take these medications 2 hours before or after pazopanib.

Storage and Handling

Store your medication in the original, labeled container at room temperature and in a dry location (unless otherwise directed by your healthcare provider or pharmacist). This medication should not be stored in a pillbox. Keep containers out of reach of children and pets.

If a caregiver prepares your dose for you, they should consider wearing gloves or pour the pills directly from their container into the cap, a small cup, or directly into your hand. They should avoid touching the pills. They should always wash their hands before and after giving you the medication. Pregnant or nursing women should not prepare the dose for you. Ask your oncology team where to return any unused medication for disposal. Do not flush down the toilet or throw it in the trash.

Where do I get this medication?

Pazopanib is available through select specialty pharmacies. Your oncology team will work with your prescription drug plan to identify an in-network specialty pharmacy for the distribution of this medication and shipment directly to your home.

Insurance Information

This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals without prescription drug coverage. Co-pay cards, which reduce the patient co-pay responsibility for eligible commercially (non-government sponsored) insured patients, may also be available. Your care team can help you find these resources if they are available.

Possible Side Effects of Pazopanib

There are a number of things you can do to manage the side effects of pazopanib. Talk to your care team about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:

Liver Toxicity

This medication can cause liver toxicity, which your oncology care team may monitor for using blood tests called liver function tests. Notify your healthcare provider if you notice yellowing of the skin or eyes, your urine appears dark or brown, or you have pain in your abdomen (belly), as these can be signs of liver toxicity.

Diarrhea

Your oncology team can recommend medications to relieve diarrhea. Also, try eating low-fiber, bland foods, such as white rice and boiled or baked chicken. Avoid raw fruits, vegetables, whole-grain bread, cereals and seeds. Soluble fiber is found in some foods and absorbs fluid, which can help relieve diarrhea. Foods high in soluble fiber include: applesauce, bananas (ripe), canned fruit, orange sections, boiled potatoes, white rice, products made with white flour, oatmeal, cream of rice, cream of wheat, and farina. Drink 8-10 glasses of non-alcoholic, un-caffeinated fluid a day to prevent dehydration.

High Blood Sugar

This medication can cause elevated blood sugar levels in patients with and without diabetes. Your oncology care team will monitor your blood sugar. If you develop increased thirst, urination or hunger, blurry vision, headaches or your breath smells like fruit, notify your healthcare team. Diabetics should monitor their blood sugar closely and report elevations to the healthcare team.

High Blood Pressure

High blood pressure (hypertension). Your provider will monitor your blood pressure. Report any severe headache, dizziness, blurry vision, nausea/vomiting, or changes in mental status right away to your medical provider or go to an emergency room.

Changes in Hair Color

This medication has been shown to change the color or texture of your hair. If your hair changes color, it is called "depigmentation." This will not cause any pain, but talk with your provider if you have any concerns.

Infection and Low White Blood Cell Count (Leukopenia/Neutropenia)

This medication can cause life-threatening infections, with or without a decrease in white blood cell counts.

White blood cells (WBC) are important for fighting infection. While receiving treatment, your WBC count can drop, putting you at a higher risk of getting an infection. You should let your doctor or nurse know right away if you have a fever (temperature greater than 100.4 °F or 38°C), sore throat or cold, shortness of breath, cough, burning with urination, or a sore that doesn't heal.

Tips to preventing infection:

• Washing hands, both yours and your visitors, is the best way to prevent the spread of infection.
• Avoid large crowds and people who are sick (i.e.: those who have a cold, fever or cough or live with someone with these symptoms).
• When working in your yard, wear protective clothing including long pants and gloves.
• Do not handle pet waste.
• Keep all cuts or scratches clean.
• Shower or bathe daily and perform frequent mouth care.
• Do not cut cuticles or ingrown nails. You may wear nail polish, but not fake nails.
• Ask your oncology care team before scheduling dental appointments or procedures.
• Ask your oncology care team before you, or someone you live with has any vaccinations.

Electrolyte Abnormalities

This medication can affect the normal levels of electrolytes (potassium, magnesium, calcium, etc.) in your body. Your levels will be monitored using blood tests. If your levels become too low, your care team may prescribe specific electrolytes to be given by IV or taken by mouth. Do not take any supplements without first consulting with your care team.

Low Platelet Count (Thrombocytopenia)

Platelets help your blood clot, so when the count is low you are at a higher risk of bleeding. Let your oncology care team know if you have any excess bruising or bleeding, including nose bleeds, bleeding gums or blood in your urine or stool. If the platelet count becomes too low, you may receive a transfusion of platelets.

• Do not use a razor (an electric razor is fine).
• Avoid contact sports and activities that can result in injury or bleeding.
• Do not take aspirin (salicylic acid), non-steroidal, anti-inflammatory medications (NSAIDs) such as Motrin/Advil (ibuprofen), Aleve (naproxen), Celebrex (celecoxib) etc. as these can all increase the risk of bleeding. Please consult with your healthcare team regarding use of these agents and all over the counter medications/supplements while on therapy.
• Do not floss or use toothpicks and use a soft-bristle toothbrush to brush your teeth.

Nausea and/or Vomiting

Talk to your oncology care team so they can prescribe medications to help you manage nausea and vomiting. In addition, dietary changes may help. Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic foods (lemons, tomatoes, oranges). Try saltines, or ginger ale to lessen symptoms.

Call your oncology care team if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.

Fatigue

Fatigue is very common during cancer treatment and is an overwhelming feeling of exhaustion that is not usually relieved by rest. While on cancer treatment, and for a period after, you may need to adjust your schedule to manage fatigue. Plan times to rest during the day and conserve energy for more important activities. Exercise can help combat fatigue; a simple daily walk with a friend can help. Talk to your healthcare team for helpful tips on dealing with this side effect.

Decrease in Appetite and Taste Changes

Nutrition is an important part of your care. Cancer treatment can affect your appetite and, in some cases, the side effects of treatment can make eating difficult. Ask your oncology care team about nutritional counseling services at your treatment center to help with food choices.

• Try to eat five or six small meals or snacks throughout the day, instead of 3 larger meals.
• If you are not eating enough, nutritional supplements may help.
• You may experience a metallic taste or find that food has no taste at all. You may dislike foods or beverages that you liked before receiving cancer treatment. These symptoms can last for several months or longer after treatment ends.
• Avoid any food that you think smells or tastes bad. If red meat is a problem, eat chicken, turkey, eggs, dairy products, and fish without a strong smell. Sometimes cold food has less of an odor.
• Add extra flavor to meat or fish by marinating it in sweet juices, sweet and sour sauce, or dressings. Use seasonings like basil, oregano, or rosemary to add flavor. Bacon, ham, and onion can add flavor to vegetables.

Important but Less Common Side Effects

• Heart Problems: This medication can cause cardiac problems. Be sure your provider is aware if you have or have had any heart problems in the past.
  • This medication can cause abnormal heart rhythm called QT prolongation. Your provider will perform ECG testing and monitor electrolytes with blood tests. Notify your healthcare provider right away if you feel abnormal heartbeats or if you feel dizzy or faint.
  • This medication can cause new or worsening heart failure. Your provider may monitor your heart function before and during treatment. Report any swelling, rapid weight gain, or shortness of breath.
• Thyroid Problems: This medication can cause hypothyroidism (underactive thyroid). Your provider will perform blood tests to check the function of your thyroid and treat this side effect if it develops. Symptoms of thyroid problems include: tiredness, feeling hot or cold, change in your voice, weight gain or loss, hair loss, and muscle cramps.
• Proteinuria: Pazopanib can cause an increase in the amounts of protein in your urine. Your healthcare team will monitor your kidney function and protein in your urine throughout treatment with this medication.
• GI Bleed & Tear: This medication can cause bleeding or a tear in the intestinal wall or a fistula (whole connecting two parts of your GI tract). Signs of these problems include: unexpected bleeding, blood in the stool or black stools, coughing up blood, vomiting blood, vomit that looks like coffee grounds, fever, severe pain in the abdomen (belly), or new abdominal swelling. If you experience any of these, contact your healthcare provider immediately or go to the emergency room.
• Blood Clots, Heart Attack, and Stroke: This medication can increase the risk of blood clots, stroke, and heart attack. Symptoms can include: swelling, redness or pain in an extremity, chest pain or pressure, pain in your arm, back, neck, or jaw, shortness of breath, numbness or weakness on one side of the body, trouble talking, confusion, or mental status changes. If you experience any of these symptoms, you should contact your oncology care team immediately or go to an emergency room.
• Lung Changes: This medication may cause a collapsed lung (pneumothorax) or interstitial lung disease. Patients can also develop an inflammation of the lungs (called pneumonitis) while taking this medication. Notify your healthcare provider right away if you develop any new or worsening symptoms, including shortness of breath, trouble breathing, cough, or fever.
• Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TTP/HUS): This medication can also cause another rare syndrome called thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). Your healthcare team will monitor you for symptoms of TTP/HUS throughout your treatment. Notify your healthcare team if you have bruising or bleeding.
• Posterior Reversible Encephalopathy Syndrome (PRES): In rare cases, this medication has caused a neurological disorder called posterior reversible encephalopathy syndrome (PRES), also called reversible posterior leukoencephalopathy (RPLS). Symptoms of PRES/RPLS include headache, seizure, lethargy, confusion, blindness, and other visual and neurological disturbances. Report any of these symptoms to your healthcare team immediately.
• Wound Healing: This medication can lead to slower or incomplete wound healing, such as a surgical wound not healing or staying closed. Be sure to inform the team performing the surgical procedure that you are taking pazopanib. You should also inform your oncology team that a surgical procedure is planned It is recommended that this medication be discontinued prior to any surgery. In addition, any surgical incision should be fully healed prior to starting or restarting the medication. If you have a surgical wound that has not healed or begins to have signs of infection (redness, swelling, warmth), report this to your healthcare team.
• Tumor Lysis Syndrome: If there are a large amount of tumor cells in your body prior to treatment, you are at risk for tumor lysis syndrome. This happens when the tumor cells die too quickly and their waste overwhelms the body. You may be given a medication (allopurinol) and IV fluids to help prevent this. If you experience nausea, vomiting, diarrhea or become lethargic (drowsy, sluggish), notify your oncology team right away. TLS can affect your kidney function. Your provider will monitor your kidney function with blood work. Notify your provider if you have little or no urine output.

Reproductive Concerns

This medication may affect your ability to have children. You may want to consider sperm banking or egg harvesting if you may wish to have a child in the future. Talk about these options with your oncology team before starting treatment.

Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication. Effective birth control is necessary during treatment and for 2 weeks after treatment has stopped. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should not breastfeed while taking this medication or for 2 weeks after your last dose.