 Yeah, so of course, thanks so much for having me. I know we're running a little behind schedule So I'll try not to take up too much of your time Today, I'll be talking about tyrosine kinase inhibitors. I'm sure many of you are familiar with these drugs So several that come to mind are sootent, pozopinib, seraphinib, and lighta. Just to name a few of the drugs that are out there, not only used for kidney cancers So you may have heard other cancer patients talk about these drugs as well The main side effects we really think about with these drugs are hand-foot syndrome or sores, sore calluses on the hands and feet Sometimes mouth, I see some nods Sometimes mouth sores, rashes, high blood pressure Hypothyroidism, so not a well-functioning thyroid gland So these are just a few, and lighta is not on here, so I have to add that to my slides You know in this era where we're using all of these oral therapies for cancer treatment We're finding that medicine compliance is actually a bigger and bigger issue So a lot of health care providers are now You know having conferences and focusing a lot on compliance Sometimes that's over-compliance or under-compliance. So at home patients will sometimes say like well You know, I don't know if this is working or not So I'm gonna take an extra one or you know, I think this is too strong So I'm gonna cut the dose in half and it's really important to have a conversation with your oncologist before making any changes It's also really easy to forget sometimes to take your pills, you know, you're busy with your other activities Sometimes you're working while you're taking these treatments So I've actually found some some really cool apps. So I see a lot of people with iPhones today So sometimes helping to record or having an alarm that's set every day to take your pills Especially if they're twice a day medications It sounds really simple, but things like that can be really helpful to make sure that you're on track and using these drugs appropriately We talked about some of the common side effects And the most important thing I want to focus a lot on what you can do at home to help yourself with the side effects But you know picking up the phone and reporting them To your oncologist or the nurse practitioners or nurses who work in the clinic are really helpful The first thing we'll focus on is nausea and vomiting. Did anyone have nausea with some of these medications? couple of nods Yeah, so it's I also want this to be a dialogue. So if you have any helpful tips along the way, please just raise your hand So a few drugs that can be used at home I have a few different drug classes, but a couple of the first things you think about our drugs like at a van Sometimes this is used as an anti-anxiety drug, but can be really helpful For nausea. The only problem is if you're someone who's out and about it can cause sometimes drowsiness dizziness Cannabinoids like marinal can also be helpful not only for nausea and vomiting but also to help stimulate appetite if that is a problem for you But once again, we can have issues if you're someone who's out and about and trying to function It can be a difficult drug to take Things like composing you may have heard of that can also be a problem with drowsiness at times Probably the most friendly drug for people to take if you're you know, someone who's active or if you're still working is something like Undancetron or Zofran you can take it every every eight hours. The main complications are constipation and headache So you want to take other things to combat the constipation. You may want to take a stool softener every time you take one of these drugs With medicines or there are always side effects. So, you know, always something to consider But the things, you know, most patients find most helpful are things that are not Pharmacotherapy or not taking a drug to help a side effect. So you're not on you know, 10 pulls a day So things like eating small frequent meals rather than three large meals a day can be very helpful Less overwhelming. It's a little bit easier to digest Sort of pre-medicating sometimes so taking an anti-nausea pill 30 minutes to an hour before you're planning to have a meal Avoiding fatty and spicy foods. So even though Chipotle is delicious. It's probably not the best thing to you know, eat when you're feeling nauseous And cold and room temperature foods are actually the best tolerated a lot of patients when we see patients in the hospital can't stand the smell of the Trey coming because they sort of open the lid and that steamed smell makes them sick. So things that you know, like cold fruit Cold sandwiches things like that can be really helpful Ginger has not really been proven to help with nausea and vomiting but people swear by it So there are different things like ginger choose you can find them at Whole Foods Trader Joe's places like that And then there are alternative therapies. I actually think these help probably more for distraction than anything else Like music therapy aerobic exercise. I heard a lot of people saying they were using yoga yoga Reiki things like that and those a lot of patients report less nausea and vomiting when they're active Unfortunately diarrhea can also be a side effect of some of these therapies Emodium can be something to take over the counter. I see a few nods that can be a lifesaver at times And the modal which is also a prescription medication Um probiotics are everywhere now. I actually talked with a few of our pharmacists about probiotics and I was learning more We see them actually in all different forms, but unless they're actually refrigerated many of them are not effective So some of the tablets and things sort of on the shelf that are available are sometimes really expensive and usually are not as Effective as things that you find in the refrigerated section of the grocery store or pharmacy And then just to follow up again with things that are not Related to drugs Sort of changing your diet. So the brat diet is something we think of bananas rice applesauce toast that can get really boring So I would just use it as a guideline to eat bland foods Broth these soups are great You sort of think of ramen things like that. So a lot of noodles things that are sort of easier to digest Avoiding foods high in insoluble fiber like fruits Seeds skins things like that Once again small frequent meals And staying really well hydrated is important if you're having diarrhea frequently So that you're not coming into the clinic to get IV hydration and things like that trying to stay ahead of Of your fluid intake So sort of talking about dermatologic side effects or the side effects we see on your skin more Rashes are really common with a lot of these drugs. I remember Serafinib Being one that we saw a lot of rashes with So definitely using milder soaps avoiding anything with fragrances or anything that's alcohol based So you really want to Become a little bit more intimate with the products that you're using flip it over and look at the ingredient list first If you see alcohol as one of the first things I would just put it back on the shelf Sometimes actually not showering every day, but every other day and you know Can really help just to not dry your skin out as much and increasing the use of lotions once again, not alcohol based lotions Has anyone experienced hand-foot syndrome? Yeah Can you tell the rest of the crowd what it was like for you? What did it show up as for you were they calluses or did you have sores on your hands and feet and how about Yeah Yeah, and I think that's actually why I asked because I think Sort of each patient is so different and this is sort of representative of many patients dealing with these medications Sort of trying if one drug isn't working or if you're having too many side effects You sort of go to the next and the next and there's no way that you know you walking in the door your oncologist won't know What side effect you're going to get from these drugs? So some of it is trial and error and once again reporting the symptoms It's important for us to all hear about these symptoms so that we can try to help or try to make a dose adjustment Or medication adjustment if that's necessary I'll go through some of the things that I would recommend for helping with hand-foot syndrome But I'd also love to hear from you if there are different things that you used Using protective gloves like cotton gloves sometimes, especially at night can be really helpful Socks comfortable shoes Sometimes, you know shoes can be difficult because some people will feel that sandals are most comfortable However, if you have open sores, we you know would worry about the infection risk So kind of introducing dirt and bacteria into open sores So try to you know, maybe it's comfortable socks and Birkenstock sandals or something like that What's that a glaze footwear? I know it's not time for stilettos unfortunately Avoiding hot water and soaking baths. I remember seeing a lot of patients who would say they were soaking their feet Trying to use different things they'd seen at the pharmacy and that's probably one of the worst things that you could do You don't want to do anything that will dry your skin out So, you know not using really hot water and avoid soaking is the best thing Moisturizing creams are definitely your best friend Using fragrance-free soaps once again nothing that is Alcohol-based one at least one to two times a daily if you could do three depending on your schedule That's that's really helpful These are a few of the skincare products that have actually have some evidence behind them But they're not the only ones that work. I actually put the utter cream up there because I've heard from patients that it works The best and it's hard to forget that label. So it's a good thing to look for in your pharmacy But things that we think of That are sort of extra greasy like aqua for can be very helpful, but you may want to use Covering like gloves or socks for that Did you use anything else that was helpful for you any other products? I It's really gentle Yeah, that's another yeah another great product the set of all also has They have a soap that's available as well as moisturizing cream And it's actually something that they use on babies in the hospital quite a bit So it is really gentle so anything that's sort of more on the gentle side you want to stick with and I have some anti itch Creams available. I see a lot of people taking pictures with the iPhones. That's a great way to remember some of the information So mouth care is another Another issue that can be really important sometimes dry mouth dry cracked lips or even mucosidus or mouth sores can occur with these medications Probably not the first thing that That I think of when I think of TKI's but it can certainly happen. So using a water-based lip moisturizer is really helpful Just keeping it in your pocket your purse your wallet whatever works for you Brushing two times it brushing your teeth is really important But using soft toothbrushes or even sometimes they have sponges available at the pharmacy So any avoiding anything that's harsh that will break down your gums is really nice Once again not using alcohol-based mouth rinses Nothing really harsh on your gums. So non irritating mouth rinses Sometimes just normal saline like salt water or you can use Baking soda as well. That's really helpful and gentle on the gums Floss daily if your platelets are actually high enough most most of the patients on this drug Have platelets which are high enough to tolerate that and avoiding irritating beverages when you have mouth sores I'm sure you wouldn't really Want to drink orange juice or anything like that, but certainly avoiding tobacco spicy foods and Here a few products if you're interested That are available like sense of dying sort of anything that is is soothing Cardiac side effects are the next topic. I want to talk about and as a patient There's not quite as much you can do about that. That's really more the job of your health care provider to be monitoring EKG's You know your blood pressure all of those things, but many patients on these drugs are keeping a log of their blood pressures now at home I also found some applications you could get for free on your phone to keep track of that It's I see a couple of nods And there are actually ways that you can depending on the blood pressure monitor You have you can plug it into a computer and load it directly so that when you go to your oncology appointment You've got all that information available So it's important for you as the patient to tell your health care providers about any pre-existing conditions You have before we start these drugs We usually ask pretty thoroughly have you ever had a history of high blood pressure congestive heart failure any abnormal rhythms heart attack strokes So those are definitely things you want to bring up before starting these drugs. We sometimes check serial EKG's To check the heart rhythm Looking at specific numbers just to make sure that these they're not having any effects on your heart We would want you to report any symptoms like swelling chest discomfort shortness of breath dizziness or heart palpitations Which I'm sure you would do Go ahead Actually, I have one of I can give you the blood pressure when I actually wrote it down in my phone So I can give that to you for the blood pressure one that I found And then lastly, I just wanted to talk about fatigue a little bit a lot of the side effects of not only TKI's but many of the other treatments that are out there for kidney cancer as Well as just having kidney cancer alone can cause fatigue So extra size is actually it sounds counterintuitive, but it is really important There've been a lot of studies done in cancer patients That show that exercise does help the fatigue level But certainly as tolerated like some of you are saying if you've got foot sourced that are so bad that you can't walk You're probably not exercising a whole lot So trying to do as much as you can even if you're sitting in a chair at least, you know doing some leg lifts or arm lifts during the day Sort of Balancing your day a little bit planning activities so that you're alternating rest with activity I heard Jordan saying this earlier except help from others when it's offered So if you're feeling exhausted and you know, you need help, you know, maybe picking up You know a parent that used to pick up and help with other things or you know walking your dog or making meals if other people Volunteer help say yes once in a while Organizing your house a little bit so that tasks are easy for you to get done And prioritizing activities, so if you know you get really tired in the afternoon Don't don't plan your appointments in the afternoon plan them all in the morning So there are a lot of causes of fatigue. It's it's sort of difficult to pinpoint in a 20 minute talk But certainly some of the medications that I've mentioned today can cause fatigue anemia which can occur with kidney cancer patients having low thigh low thyroidism levels which we can help with as well Pain depression sleep disturbances There are many reasons for this so sort of talking with your health care providers to pinpoint The cause can be most helpful I've listed some of the causes like anemia, of course occasionally we give blood transfusions or red blood cell boosters injections that we give Hypothyroidism we can give supplementation for that and that is actually pretty common with TKI's There are other drugs of course Sometimes if fatigue is so severe we use things like psychostimulants which can help like many of you have probably heard of Ritalin But these are what things that we would sort of avoid unless they're More severe Provigil multi vitamins can help just if it's a nutritional cause An antidepressants or therapy to help if that's if depression is really the cause of the fatigue And lastly I just want to say that dose reduction is Sometimes necessary to help with these side effects sometimes no matter what we do no matter what creams or lotions we use We really can't control the side effects So sometimes reducing the dose or the schedule like Sutent for example is usually given for four weeks on two weeks off Some patients find that two weeks on one week off that modified schedule will help enough that they can continue taking the drug To help treat their kidney cancer while tolerating the side effects of the drug so don't be discouraged if If you need a dose reduction or sometimes a change in therapy as we've As I heard you know someone say in the audience you've been through several of these different treatments because of side effects