Classification: Immunomodulatory Agent
About Thalidomide (Thalomid®)
Thalidomide is a type of "immunomodulatory agent", meaning it works by affecting the immune system. It appears to work in several ways, including inhibiting the formation of blood vessels, which tumors use to get nutrients needed to survive and grow. This is known as anti-angiogenesis. It also interferes with chemicals necessary for the growth of tumors and can cause cell death.
How to Take Thalidomide
Thalidomide is given in a capsule form. Capsules should be swallowed whole with water; do not break, crush or chew the capsules. Thalidomide is best taken before bedtime because it can cause sleepiness. It also should be taken at least one hour after your last evening meal.
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.
Thalidomide REMS Program
In order to receive thalidomide, patients will need to participate in a program called REMS (Risk Evaluation and Mitigation Strategy). This program educates healthcare professionals and patients about the dangers of thalidomide exposure to a fetus. This exposure can cause serious birth defects and patients taking the medication will need to use two reliable forms of birth control. This includes men taking thalidomide because it is present in sperm. The REMS program limits who can prescribe and dispense the medication. Patients will also need to complete a survey and safety agreement before starting the drug and every month they are taking it. Important safety reminders:
- Women should not become pregnant for 4 weeks before therapy, during therapy or for 4 weeks after therapy is stopped.
- Women must agree to use 2 forms of reliable birth control during this time.
- Men should not father a child for 4 weeks before therapy, during therapy or for 4 weeks after therapy is stopped.
- Men must use a condom for any sexual contact during this time, even if they have had a vasectomy.
- Any pregnancy (in women taking the medication OR partners of men who take the medication) should be reported to your oncology team right away.
- Do not donate blood or sperm during therapy and for at least 1 month after stopping therapy.
Where do I get this medication?
Thalidomide is available only through providers and pharmacies certified by the thalidomide REMS program. 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. Co-pay assistance may be available to qualifying individuals with or without prescription drug coverage. Your care team can help you find these resources, if they are available.
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 in the trash.
Possible Side Effects of Thalidomide
There are a number of things you can do to manage the side effects of thalidomide. 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:
When thalidomide was first introduced in the 1950's, it was used to treat insomnia, because drowsiness is the most common side effect of the medication. This can include fatigue, weakness, sleepiness, confusion and mood changes. It is best to take the medication at bedtime to reduce the tiredness during the day. Avoid alcohol or other sedating medications while taking thalidomide.
Low White Blood Cell Count (Leukopenia or Neutropenia)
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), 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 bath daily and perform frequent mouth care.
- Do not cut cuticles or ingrown nails. You may wear nail polish, but not fake nails.
- Ask your doctor or nurse before scheduling dental appointments or procedures.
- Ask your doctor or nurse before you, or someone you live with, has any vaccinations.
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 doctor or nurse 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®, Aleve®, Advil®, etc. as these can all increase the risk of bleeding. Unless your healthcare team tells you otherwise, you may take acetaminophen (Tylenol).
- Do not floss or use toothpicks and use a soft-bristle toothbrush to brush your teeth.
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.
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.
Peripheral Neuropathy (Numbness or Tingling in the Hands and/or Feet)
Peripheral neuropathy is a toxicity that affects the nerves. It causes a numbness or tingling feeling in the hands and feet, often in the pattern of a stocking or glove. This can get progressively worse with additional doses of the medication. In some people, the symptoms slowly resolve after the medication is stopped, but for some it never goes away completely. You should let your healthcare provider know if you experience numbness or tingling in the hands and feet, as they may need to adjust the doses of your medication.
Some patients may develop a rash, very dry or itchy skin. Some rashes can be a very seru=ious reaction and all skin changes should be reported to your care team. 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. If your skin does crack or bleed, be sure to keep the area clean to avoid infection. Your care team can give you more tips on caring for your skin.
Blood Clots, Stroke and Heart Attack
Thalidomide can increase the risk of blood clots, stroke and heart attack. If you experience symptoms of these problems, you should contact your healthcare provider immediately or go to an emergency room. 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. Let your care team know if you have a history of previous blood clots, as you may require preventive medication.
Other Reported Side Effects
- Some people may experience dizziness when standing up from a sitting position and swelling. Sit for a minute before getting up from a lying position.
- Some people may develop a slow heartbeat (bradycardia). If you have dizziness, fainting or shortness of breath, notify your healthcare provider.
- Serious skin reactions can occur. If you develop a skin rash or peeling of your skin, notify your healthcare provider right away.
- Seizures have been reported while taking this medication. Notify your oncology provider if you have a seizure.
As discussed above, 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.
Women should not become pregnant for four weeks prior to starting treatment, during treatment or for four weeks after treatment is complete. A woman should use two forms of birth control during this time period. Men should not father a child during treatment or for four weeks after treatment is complete. A man should use a condom during sexual contact during this time period even if he has had a vasectomy. Report pregnancy any suspected to your provider immediately. Do not breastfeed while taking this medication.