Classification: Multikinase Inhibitor
About Sunitinib (Sutent®)
Sunitinib is a type of targeted therapy. This means it targets something specific to the cancer cells, therefore decreasing side effects caused by damage to the healthy cells. Sutinib works by blocking 2 processes that allow cancer cells to grow. First it interferes with a protein that promotes cell division. It also works by blocking the VEGF receptor, which is responsible for angiogenesis, or the development of a blood supply to the tumor. This removes the tumor's source of nutrients.
How to Take Sunitinib
Sunitinib comes as a capsule to take by mouth with or without food. The dose and schedule is determined by your healthcare provider and is based on the type of cancer you have. Take sunitinib at around the same time every day. If you forget to take your sunitinib take it as soon as possible. However, if it is almost time for your next dose skip the missed dose and resume your regular schedule. Do not double up your dose.
The blood levels of this medication can be affected by certain foods and medications, so they should be avoided. These include: grapefruit, grapefruit juice, dexamethasone, carbamazepine, rifampin, phenytoin, St. John's wort, and phenobarbital. Be sure to tell your healthcare provider about all medications (prescription and over the counter) and supplements you take.
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.
Where do I get this medication?
Sunitinib is available through select specialty pharmacies. Your oncology team will work with your prescription drug plan to identify an in-network specialty pharmacy for distribution of this medication and shipment directly to your home.
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 Sunitinib
There are a number of things you can do to manage the side effects of sunitinib. Talk to your doctor or nurse about these recommendations. They can help you decide what will work best for you. These are some of the most common side effects:
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.
Nausea and/or Vomiting
Talk to your doctor or nurse 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 antacids, (e.g. milk of magnesia, calcium tablets such as Tums), saltines, or ginger ale to lessen symptoms.
Call your doctor or nurse if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.
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 breads, 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 on non-alcoholic, un-caffeinated fluid a day to prevent dehydration.
There are several things you can do to prevent or relieve constipation. Include fiber in your diet (fruits and vegetables), drink 8-10 glasses of non-alcoholic fluids a day, and keep active. A stool softener once or twice a day may prevent constipation. If you do not have a bowel movement for 2-3 days, you should contact your healthcare team for suggestions to relieve the constipation.
Decrease in Appetite
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 nurse 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.
Mouth Ulcers (Sores)
Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Notify your doctor or nurse if your mouth, tongue, inside of your cheek or throat becomes white, ulcerated or painful. Performing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your doctor or nurse can recommend a pain reliever.
- Brush with a soft-bristle toothbrush or cotton swab twice a day.
- Avoid mouthwashes that contain alcohol. A baking soda and/or salt warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon salt in an eight ounce glass of warm water) is recommended 4 times daily.
- If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on sugarless hard candy.
Avoid smoking and chewing tobacco, drinking alcoholic beverages and citrus juices.
Hand Foot Syndrome
Hand and foot syndrome (HFS) is a skin reaction that appears on the palms of the hands and/or the soles of the feet as a result of certain chemotherapy agents being absorbed by the skin cells. HFS can begin as a mild tingling, numbness, pins-and-needles feeling, or pain or swelling of the hands and/or feet. This can then progress to painful swelling, blistering or peeling skin that can interfere with your ability to do normal activities. Be sure to let your oncology team know right away if you notice these symptoms, as they may need to adjust the chemotherapy dose or take a break to allow the skin to heal. Some tips to help prevent HFS include:
- Avoid tight shoes or socks.
- Avoid activities that put pressure on the palms or soles for 1 week after treatment.
- Apply moisturizer liberally and often.
- Avoid hot water for baths and showers.
Skin, Hair & Nail Changes
You may develop a yellow discoloration of the skin and/or hair. This is thought to be related to the yellow color of the medication. However, yellowing of the skin or eyes can be a sign of liver problems and should be reported to your healthcare team. Some patients may develop a rash, very dry, or itchy skin. Use an alcohol free moisturizer on your skin and lips; avoid moisturizers with perfumes or scents. Your doctor or nurse can recommend a topical medication if itching is bothersome. Your nails may become dark, brittle or fall off. If your skin does crack or bleed or you lose a nail, be sure to keep the area clean to avoid infection. While receiving this medication, the hair on your head may become curly, fine or brittle. You may experience patchy hair loss or thinning. This tends to resolve once treatment is stopped.
Be sure to notify your healthcare provider of any rash that develops, as this can be a reaction and can become very severe. This includes blistering and peeling of your skin or the inside of your mouth. They can give you more tips on caring for your skin, hair and nails.
Your blood counts can be affected by this treatment, though the affect is usually mild. This can cause lower numbers of the following cells:
- White blood cells (WBC): important for fighting infection. You should let your doctor or nurse know right away if you have a fever (temperature greater than 100.4), sore throat or cold, shortness of breath, cough, burning with urination, or a sore that doesn't heal.
- Red blood cells: responsible for carrying oxygen to the tissues in your body. You should let your doctor or nurse know if you experience any shortness of breath, difficulty breathing or pain in your chest. If the count gets too low, you may receive a blood transfusion.
- Platelets: help your blood clot, so when the count is low you are at a higher risk of bleeding. Let your doctor or nurse know if you have any excess bruising or bleeding, including nose bleeds, bleeding gums or blood in your urine or stool.
This medication can cause liver toxicity, which your doctor 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 pain in your abdomen, as these can be signs of liver toxicity.
High Blood Pressure
High blood pressure (hypertension) occurred in clinical trials with sunitinib. Patients should have their blood pressure checked periodically during therapy. Any hypertension should be treated appropriately. In cases of severe hypertension, sunitinib should be stopped until blood pressure is controlled. Signs of hypertension to report to your team include: blurry vision, nosebleed, headache and fatigue.
Some patients may develop heart failure or weakening of the heart muscle while taking sunitinib. Patients with a history of cardiac problems should have their heart function tested prior to starting this therapy, as well as during therapy if any symptoms arise. Symptoms include: shortness of breath, weight gain or swelling, cough or weakness, and should be reported to your healthcare team.
This medication can cause heart rhythm abnormalities (arrhythmias) caused by a prolonged QT interval. If you are at risk for this, your healthcare provider will monitor you for heart problems through electrocardiograms. Notify your healthcare provider right away if you feel abnormal heartbeats or if you feel dizzy or faint.
This medication can affect the thyroid or adrenal glands, resulting in abnormal hormone levels, including hypothyroidism (under active thyroid) and hyperthyroidism (over active thyroid). Your doctor will perform blood tests to check the function of your thyroid and adrenal glands. Symptoms to report to your care provider include: tiredness, feeling hot or cold, change in your voice, weight gain or loss, hair loss, muscle cramps or weakness, lightheadedness, and excess urination.
Osteonecrosis of the Jaw
Osteonecrosis of the jaw (ONJ) is a rare side effect, however, it is important that you know about it and take steps to protect your dental health. It is most common in people who are also taking a bisphosphonate medication (for osteoporosis or bone metastases).
The maxilla (upper jaw bone) and mandible (lower jaw bone) are normally covered by gum tissue. In the case of ONJ, this tissue is gone and the bone is exposed. Typical symptoms associated with ONJ are: pain, swelling or infection of the gums, loosening of the teeth, exposed bone (often at the site of a previous tooth extraction). Some patients may report numbness or tingling in the jaw or a "heavy" feeling jaw. ONJ may have no symptoms for weeks or months and may only be recognized by the presence of exposed bone. ONJ most often occurs soon after a dental procedure, though not always. Stop treatment with this medication several weeks prior to any dental procedures.
- Prior to starting therapy, you should have a complete dental exam, cleaning, and removal of any teeth in poor health.
- Dentures should be checked for proper fit.
- Brush your teeth after meals and at bedtime with a soft brush. Floss gently once a day. If your gums bleed, talk with your healthcare team to see if you can continue to floss.
- Check your teeth and gums in a mirror daily for any sores, swelling, loose teeth, pain or numbness, or other changes and report these to your dentist or oncology team immediately.
This medication may interfere with wound healing. The manufacturer recommends stopping the drug before any surgical procedure and not restarting until there is adequate wound healing.
Bleeding & Stroke
Bleeding has occurred in patients taking this medication, including bleeding in the GI tract, lungs, urinary tract and brain (stroke). Let your healthcare provider know if you develop any bleeding, including nosebleeds, coughing up blood, vomiting blood or coffee ground appearing vomit, blood in the stool or black stools. If you experience changes in your speech or balance, confusion, difficulty walking, vision changes or numbness on one side of the body, call 911 right away.
Damage to Small Blood Vessels
This medication can cause damage to small blood vessels called thrombotic microangiopathy (TMA), which can result in blood clots. Symptoms of TMA include fever, fatigue, bruising, swelling, confusion, vision loss, and seizures. Report any of these symptoms to your provider right away.
Tumor Lysis Syndrome
If there is 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.
Other Side Effects
Other reported side effects include:
- Low blood sugar (hypoglycemia). Diabetic patients may need to monitor their glucose more often and/or change their diabetes medication.
- Excess protein in the urine. Your care team will monitor for this.
- Swelling in the arms, feet, ankles and legs. While swelling is a common reaction to this medication, it can be a sign of a serious heart problem and should be evaluated by your provider.
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 at least 6 months after treatment. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should consult with your healthcare team before breastfeeding while receiving this medication.