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      Interference of Herbal Medicine with Axitinib in Metastatic Renal Cell Cancer Treatment: A Case Study

      case-report

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          Abstract

          Introduction

          The awareness and the clinical relevance of the potential interactions between standard and complementary medicine are increasing in medical oncology. Nonetheless, the research and experience of the efficacy, safety, and toxicity of herbal substances are poorly documented.

          Case Presentation

          Here, we report the case of a 68-year-old female patient who had been diagnosed with advanced renal cell cancer with metastasis in the liver and pancreas and had undergone surgical resection with hemi-hepatectomy and resection of metastasis in the pancreas in November 2021. Thereafter, chemotherapy was immediately initiated with three-weekly infusions of pembrolizumab and daily intake of the tyrosine kinase inhibitor axitinib. Surprisingly, 3 months after initiation of systemic treatment, the patient developed early progression and metastasis in the liver, which was then treated with selective internal radiotherapy. Despite continued axitinib and pembrolizumab treatment, a short-term follow-up in November 2022 revealed another metastatic lesion in her pancreas. Due to the presumed lack of response to treatment, the plasma concentration of axitinib was measured and found to demonstrate subtherapeutic levels of exposure. Upon extended anamnesis, the patient reported regular intake of herbal substances prescribed by her oncology acupuncturist for gastrointestinal complaints associated with the primary operation.

          Conclusion

          Further clinical-pharmacological workup strikingly demonstrated a reduction of the therapeutic concentration of axitinib of about 90%, likely caused by herbal drugs such as Dang gui and Bai zhu.

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          Most cited references20

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          Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma

          Nivolumab plus ipilimumab produced objective responses in patients with advanced renal-cell carcinoma in a pilot study. This phase 3 trial compared nivolumab plus ipilimumab with sunitinib for previously untreated clear-cell advanced renal-cell carcinoma.
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            The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety

            The use of herbal medicinal products and supplements has increased tremendously over the past three decades with not less than 80% of people worldwide relying on them for some part of primary healthcare. Although therapies involving these agents have shown promising potential with the efficacy of a good number of herbal products clearly established, many of them remain untested and their use are either poorly monitored or not even monitored at all. The consequence of this is an inadequate knowledge of their mode of action, potential adverse reactions, contraindications, and interactions with existing orthodox pharmaceuticals and functional foods to promote both safe and rational use of these agents. Since safety continues to be a major issue with the use of herbal remedies, it becomes imperative, therefore, that relevant regulatory authorities put in place appropriate measures to protect public health by ensuring that all herbal medicines are safe and of suitable quality. This review discusses toxicity-related issues and major safety concerns arising from the use of herbal medicinal products and also highlights some important challenges associated with effective monitoring of their safety.
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              Use of complementary and alternative medicine in cancer patients: a European survey.

              The aim of this study was to explore the use of complementary and alternative medicine (CAM) in cancer patients across a number of European countries. A descriptive survey design was developed. Fourteen countries participated in the study and data was collected through a descriptive questionnaire from 956 patients. Data suggest that CAM is popular among cancer patients with 35.9% using some form of CAM (range among countries 14.8% to 73.1%). A heterogeneous group of 58 therapies were identified as being used. Herbal medicines and remedies were the most commonly used CAM therapies, together with homeopathy, vitamins/minerals, medicinal teas, spiritual therapies and relaxation techniques. Herbal medicine use tripled from use before diagnosis to use since diagnosis with cancer. Multivariate analysis suggested that the profile of the CAM user was that of younger people, female and with higher educational level. The source of information was mainly from friends/family and the media, while physicians and nurses played a small part in providing CAM-related information. The majority used CAM to increase the body's ability to fight cancer or improve physical and emotional well-being, and many seemed to have benefited from using CAM (even though the benefits were not necessarily related to the initial reason for using CAM). Some 4.4% of patients, however, reported side-effects, mostly transient. It is imperative that health professionals explore the use of CAM with their cancer patients, educate them about potentially beneficial therapies in light of the limited available evidence of effectiveness, and work towards an integrated model of health-care provision.
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                Author and article information

                Journal
                Case Rep Oncol
                Case Rep Oncol
                CRO
                CRO
                Case Reports in Oncology
                S. Karger AG (Basel, Switzerland )
                1662-6575
                9 November 2023
                Jan-Dec 2023
                9 November 2023
                : 16
                : 1
                : 1362-1369
                Affiliations
                [a ]Medical Faculty, University of Zurich, Zurich, Switzerland
                [b ]Tox Info Suisse, National Poison Centre, Associated Institute of the University of Zurich, Zurich, Switzerland
                [c ]Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
                [d ]Oncology, Seespital Horgen, Zurich, Switzerland
                [e ]Mobile Health AG, Zurich, Switzerland
                Author notes
                Correspondence to: Andreas Trojan, andreas.trojan@ 123456mobilehealth.ch
                Article
                534595
                10.1159/000534595
                10635677
                37954127
                20c006ff-bb4f-4b19-94c0-fa2bb8091a27
                © 2023 The Author(s). Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC) ( http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes requires written permission.

                History
                : 24 September 2023
                : 11 October 2023
                : 2023
                Page count
                Figures: 2, Tables: 2, References: 20, Pages: 8
                Funding
                The Foundation Swiss Tumor Institute has supported the master’s thesis with a restricted grant.
                Categories
                Article

                Oncology & Radiotherapy
                advanced metastatic renal cell cancer,axitinib,checkpoint inhibitors,herbal medicine,electronic patient-reported outcome,pharmaco-oncology

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