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Download Table 1: Treatment algorithms for common RAF and MEK inhibitor
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Table 1: Treatment algorithms for common RAF and MEK inhibitor cutaneous toxicities Xerosis and Hand/Foot Skin Reaction to RAF Inhibitors Severity (CTCAE v.4) Intervention Grade 0 Gentle skin care instructions with use of fragrance-free soaps and detergents Avoid friction to the hands and feet, use thick gloves and socks during activity Continue drug at current dose and monitor for change in severity Grade 1 Moisturizing cream to the body and topical keratolytic (salicylic acid 6%, urea 20-40%, ammonium lactate 12%) to hands and feet bid Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Continue drug at current dose and monitor for change in severity Grade 2 Topical high-potency steroid (i.e., clobetasol) bid AND pain control with NSAIDs/GABA agonists/narcotics or topical lidocaine cream or patches Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Interrupt treatment until severity decreases to grade 0-1, and continue treatment of skin reaction with the following: Grade ≥ 3 Topical high potency steroid bid (i.e., clobetasol) AND pain control with NSAIDs/GABA agonists/narcotics or topical lidocaine cream or patches Dose interruption or decrease as per package insert Acneiform (papulopustular) Rash to MEK Inhibitors Severity (CTCAE v.4) Intervention Prophylactic treatment during weeks 1-6 and 8 Grade 0 Oral antibiotics for 6 weeks at start of therapy (doxycycline 100 mg bid OR minocycline 100 mg bid) AND alcohol-free over-the-counter moisturizing creams or ointment bid Sunscreen SPF ≥ 15 applied to exposed areas of body and every 2 hours when outside Topical low/moderate potency steroid to face and chest bid Continue drug at current dose and monitor for change in severity Grade 1 Topical low/moderate strength steroid daily AND topical antibiotic bid OR combined topical steroid and antibiotic Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Continue drug at current dose and monitor for change in severity Grade 2 Stop topical antibiotic if being used Oral antibiotic for 6 weeks (doxycycline 100 mg bid OR minocycline 100 mg bid ) AND topical low/moderate potency steroid Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Grade ≥ 3 Or Intolerable grade 2 Dose-modify; obtain bacterial/viral/fungal cultures if infection is suspected; continue treatment of skin reaction with the following: Oral antibiotic for 6 weeks (doxycycline 100 mg bid OR minocycline 100 mg bid OR oxytetracycline 500 mg bid) AND topical low/moderate potency steroid Dose interruption or decrease as per package insert Maculopapular Rash to RAF Inhibitor Severity (CTCAE v.4) Intervention Grade 0 Gentle skin care instructions given; over-the-counter moisturizing creams Continue drug at current dose and monitor for change in severity Grade 1 Topical steroid bid AND oral antihistamines Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Continue drug at current dose and monitor for change in severity Grade 2 Topical steroid bid AND oral antihistamines OR oral steroids (0.5 mg/kg or equivalent) Reassess after 2 weeks (either by healthcare professional or patient self-report); if reactions worsen or do not improve, proceed to next step Grade ≥ 3 Or Intolerable grade 2 Dose-modify; obtain bacterial/viral/fungal cultures if infection is suspected; continue treatment of skin reaction with the following: Oral antihistamines AND oral steroids (0.5 mg/kg or equivalent) Dose interruption or decrease as per package insert Adapted from: Dermatologic Principles and Practice in Oncology: Conditions of the Skin, Hair, and Nails in Cancer Patients, First Edition. Edited by Mario E. Lacouture. © 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc., Hoboken, NJ.
