CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Name of the regimen and anti-cancer drugs o Oral Treatment Generic name (pronunciation): trifluridine-tipiracil (try-FLOOR-ih-deen and ty-PEER-uh-sil) Brand name: Lonsurf® o Infusion Treatment Generic name (pronunciation): bevacizumab (beh-vuh-SIH-zoo-mab): Brand name: Avastin® Alymsys®, Mvasi™, Zirabev®, Vegzelma® Trifluridine-tipiracil plus bevacizumab consists of 2 different anti-cancer therapies. o Trifluridine-tipiracil o Bevacizumab Common uses This regimen is most commonly used for colorectal cancer but may be used for other cancers. Treatment dose and schedule The first part of your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line, is a long, f lexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. The second part of your treatment will be given orally. This medication will be ordered by your provider to take by mouth at home. Each trifluridine-tipiracil + bevacizumab treatment is repeated every 14 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Your bevacizumab is given through your vein (IV) on day 1 of each treatment cycle. o Your trifluridine-tipiracil should be taken by mouth twice daily on days 1-5 of each treatment cycle. Taking trifluridine-tipiracil as instructed is important to allow your treatment to be as effective as possible, so here are some key points to remember. o Your dose is based on many factors, including your height and weight, overall health and diagnosis. o Trifluridine-tipiracil should be taken within one hour after completion of the morning and evening meals, at the same time each day. o Trifluridine-tipiracil should be taken whole and not crushed, cut, or dissolved. If you are unable to swallow trifluridine tipiracil, talk to your care provider or pharmacist for possible options. o If you miss a dose of trifluridine-tipiracil or vomit afterwards, do not retake dose. Simply take your next dose at the regularly scheduled time. Be sure to write down if you miss a dose and let your care provider know about any missed doses. Page 1 Page 2 TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB CANCER TREATMENT EDUCATION Trifluridine-tipiracil dose, schedule, and administration Obtaining medication Talk with your care provider about the process for obtaining your capecitabine. Rare but serious side effects o If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Cycle 2 Day 1 IV Medication Given at Infusion Center Bevacizumab X X Oral Medication Taken at Home Trifluridine-tipiracil AM X X X X X X PM X X X X X X Instructions Anti-nausea medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: Possible drug interactions o Trifluridine-tipiracil + bevacizumab may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Common Side Effects of trifluridine-tipiracil plus bevacizumab Common side effects that have been known to happen in patients receiving trifluridine-tipiracil plus bevacizumab are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Decreased white blood cells (WBCs) and increased risk for infection Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Management Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection: • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal Check with your care team before taking any medicine for a fever or chills. Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night. • Avoid operating heavy machinery if you feel too tired. • Find a balance between “work” and “rest.” • Stay as active as possible, but know that it is okay to rest as needed, too. • You might notice that you are more pale than usual. Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 3 CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Possible Side Effect Decreased platelet count and increased risk of bleeding Management Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose. • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene. • When shaving use an electric razor instead of razor blades. • Use a nail file instead of a nail clippers. Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting. • Eat and drink slowly. • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland foods; avoid spicy, fried, and greasy foods. Nausea or vomiting • Avoid intense exercise immediately after eating. • Don’t lay down right away after eating. • Wear loose fitting clothing for comfort. • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Continued on the next page Page 4 CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Possible Side Effect Fatigue Management • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends. • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery. • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. Diarrhea (loose and/ or urgent bowel movements) Increased blood pressure • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more. • You feel dizzy or lightheaded. Your care team may recommend an over-the-counter medication or prescribe something to help manage your symptoms. Take your blood pressure often. Record your blood pressure in a diary and report these to your care team. Contact your care team for high blood pressure or if the following symptoms occur: • Headache • Dizziness • Chest pain • Shortness of breath • Fluid retention, weight gain, or swelling Continued on the next page Page 5 CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Possible Side Effect Decreased appetite or weight loss Management Talk to your care team if you notice a weight loss while taking this medication. When you do not feel like eating, try: • Small frequent meals instead of 3 large meals each day. • Keep snacks nearby so you can eat when you feel hungry. • Liquid nutritional supplements. • Drink 8-10 glasses of water or fluid each day, especially if you are not eating, unless your care team has instructed you to limit your fluid intake. Changes in liver function Your liver function will be checked regularly by a simple blood test. Contact your care team if you notice any of the following: • Yellowing of the skin or whites of your eyes • Dark or brown urine • Bleeding or bruising o Myelosuppression: bone marrow suppression is a decrease in the number of white blood cells, red blood cells and platelets that can be severe with trifluridine-tipiracil plus bevacizumab. Speak to your care team to know when you need to have laboratory tests done to monitor your blood cell counts. You also may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. o Infusion reaction: Bevacizumab can rarely cause an infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. o Gastrointestinal perforation or fistula (holes in the gastrointestinal tract or connections in the gastrointestinal tract that are not supposed to be present): Gastrointestinal perforations and fistulas have been reported in patients treated with bevacizumab. Tell your doctor right away if you experience severe abdominal pain, chills, or fever. o Wound healing problems: Bevacizumab may affect how well your wounds heal. If you need to have a surgical or dental procedure, tell your doctor right away that you are taking bevacizumab. Your treatment may need to be stopped several days prior to surgery and held until your wound heals. o Hemorrhage (bleeding): You may be at a higher risk of bleeding while taking bevacizumab. Seek medical attention right away if you have any severe bleeding, such as vomiting or coughing up blood, or bloody diarrhea. Also report bleeding episodes such as nosebleeds, gums bleeding, or tarry stools. o Venous thromboembolism (blood clot): Contact your care team right away if you notice swelling, redness, or pain in your arms or legs or new shortness of breath or chest pain. Rare but serious side effects (continued) Page 6 CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB o Encephalitis: Bevacizumab may cause inflammation of the brain. This can be fatal and you should contact your doctor if you are experiencing any symptoms such as: headache, seizure, fever, fatigue, memory issues, sleepiness, hallucinations, or stiff neck. o Renal failure/proteinuria: Bevacizumab may be harmful to your kidneys. Speak to your care team to know when you need to have laboratory tests done to monitor your kidneys. o Heart failure: Bevacizumab can cause heart failure. Report symptoms related to swelling and shortness of breath to your care team. Storage and handling of trifluridine-tipiracil Handle trifluridine-tipiracil with care. Just like when chemotherapy is given into the vein, this drug can be toxic, and exposure of others to the drug should be limited. o Store trifluridine-tipiracil at room temperature (68 to 77 F) in a dry location away from light. o Keep trifluridine-tipiracil out of reach of children and pets. o Leave trifluridine-tipiracil in the provided packaging until it is ready to be taken. o Whenever possible, you should give trifluridine-tipiracil to yourself and follow the steps below. If a family member, friend, or caregiver needs to give the capecitabine to you, they also need to follow these steps. • Wash hands with soap and water. • Put on gloves to avoid touching the medication. (Gloves are not necessary if you give the drug to yourself.) • Gently transfer the trifluridine-tipiracil from its package to a small medicine or other disposable cup. • Administer the medicine immediately by mouth with water. • Remove gloves and do not use them for anything else. • Throw gloves and medicine cup in household trash. • Wash hands with soap and water. o If a daily pill box or pill reminder will be used, contact your care team before using: • Use a separate pill box for your trifluridine-tipiracil. Do not mix in a box with other medications. • The person filling the box or reminder should wear gloves (gloves are not necessary if you are filling the box or reminder yourself). • When empty, the box or reminder should be washed with soap and water before refilling. Be sure to wash hands with soap and water after the task is complete, whether or not gloves are worn. o If you have any unused trifluridine-tipiracil, do not throw it in the trash and do not flush it down the sink or toilet. Talk to your care provider or pharmacist about proper disposal of trifluridine-tipiracil. o If you are traveling, put your trifluridine-tipiracil’s packaging in a separate sealed plastic bag. Ask your pharmacist if any additional travel precautions are needed. Handling body fluids and waste Page 7 CANCER TREATMENT EDUCATION TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started trifluridine-tipiracil plus bevacizumab, follow the instructions below during your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with your body fluids. o Toilet and septic systems: • You may use the same toilet, septic tank, and/or sewer that you usually use. Close the lid and flush to ensure all waste has been discarded. If you have a low-flow toilet, close the lid and flush twice. o If the toilet or toilet seat is soiled with urine, stool, or vomit, clean the surface after every use before other people use the toilet. o Wash hands with soap and water for at least 20 seconds after using the toilet. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Pregnancy, sexual activity, and contraception o Patients of reproductive ability should not become pregnant or get their partners pregnant while recieving trifluridine-tipiracil plus bevacizumab. Patients of childbearing age and potential should use effective contraception during therapy and for a minimum of 6 months after the last dose of trifluridine-tipiracil or bevacizumab. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g., condoms), hormone methods (e.g., birth control pills), or surgery. o Do not breastfeed while taking trifluridine-tipiracil plus bevacizumab and for 6 months after the last dose of bevacizumab. o Please inform your care provider if you become pregnant. o Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. o It is safe to hug and kiss. Special precautions may be needed for sexual activity while on oral chemotherapy and you are encouraged to ask your care team for assistance. o Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Page 8 Page 9 TRIFLURIDINE-TIPIRACIL + BEVACIZUMAB CANCER TREATMENT EDUCATION Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the medication derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this medication and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this medication by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual consuming the medication. All decisions related to taking this medication should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Oral Chemotherapy Education (OCE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about oral cancer drugs. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2023 by Hematology/Oncology Pharmacy Association. All rights reserved. Additional resources Product website: Avastin®: https://www.avastin.com/patient/mcrc.html Lonsurf®: https://www.lonsurf.com/ Prescribing information links: Avastin®: https://www.gene.com/download/pdf/avastin_prescribing.pdf Lonsurf®: https://taihocorp-media-release.s3.us-west-2.amazonaws.com/documents/prescribing-information. pdf Product resources: Avastin®: https://www.avastin.com/patient/patient-resources.html Lonsurf®: https://www.lonsurf.com/financial-support/taiho-patient-support Updated – February 2, 2024 Additional instructions