DDI

June 1, 2023

Small Cell Lung Cancer: Pharmacologic Management

Small cell lung cancer (SCLC) accounts for approximately 14% of lung and bronchus cancers,1 with approximately 30,000 to 35,000
new cases diagnosed in the United States each year.2 In 2023, the National Cancer Institute (NCI) estimates that there will be
238,340 new cases of lung and bronchus cancer, which includes both SCLC and non-small cell lung cancer (NSCLC), and
approximately 127,070 deaths.3,4 In recent years, the incidence of SCLC has been decreasing; however, the COVID-19 pandemic has
likely affected recent estimates as many patients may not have been properly diagnosed and treated during this time.1

The largest risk factor for developing SCLC is a history of cigarette smoking or exposure to secondhand smoke.1 Occupational
exposure to other chemicals and substances such as asbestos, chromium, nickel, arsenic, and beryllium by those working in
construction, refineries, and metallurgy is also associated with an increased risk of SCLC. Patients who have been previously treated
with radiation therapy to the chest or breast or who have been exposed to radon for an extended period of time are also at increased
risk of developing SCLC.4

Table of Contents [ See Less ]

Small Cell Lung Cancer Staging
Small Cell Lung Cancer Treatment Recommendations
Primary and Adjuvant Treatment in Limited-Stage SCLC
Extensive-Stage SCLC
Preferred First-Line Treatments for Extensive-Stage SCLC
Other Recommended Therapies for Extensive-Stage SCLC
Subsequent Pharmacologic Treatment Recommendations for SCLC
Treating Older Adults With SCLC
Monitoring Side Effects, Adverse Events, and Drug-Drug Interactions for Small Cell Lung Cancer Treatments

Small Cell Lung Cancer Staging

Although the American Joint Committee on Cancer (AJCC) has developed a cancer staging and grading system to assist in treating
SCLC, physicians often opt to use the older Veterans Administration (VA) guidance for SCLC that uses 2 stages — limited stage and
extensive stage.5 The National Comprehensive Cancer Network (NCCN) recognizes this and has applied a combined approach when
outlining its treatment guidelines for SCLC.1

SCLC is an aggressive disease characterized by the early occurrence of metastases, which is likely due to the accelerated doubling
time and high growth fraction of SCLC cells.1 According to the NCCN and NCI, approximately 30% of patients present with limited-
stage disease at the time of diagnosis.1,4 In those cases, the cancer is limited to the mediastinum, supraclavicular lymph nodes, and
the side of the chest where it originated. The NCCN categorizes limited-stage disease as stages I to III. The remaining 70% of patients
have extensive-stage disease that has spread outside of the supraclavicular area at the time of diagnosis. The NCCN categorizes
extensive-stage disease as stage IV.

Small Cell Lung Cancer Treatment Recommendations

Few pharmacologic treatment options currently exist for SCLC, and systemic therapy is currently the mainstay of SCLC treatment.
Only 5% of patients with SCLC qualify for surgery as most patients present with spread of disease to lymph nodes and other organs
at diagnosis.5 Approximately 25% of patients who present with limited-stage NCLC and undergo prompt treatment can be cured of
the disease.2 Patients with extensive-stage SCLC may experience an initial response to chemotherapy and radiation therapy.
However, the disease often recurs in a resistant and more aggressive manner. Considering the paucity of treatments available, the
NCCN recognizes that clinical trials may offer the best option to patients, and their participation should be strongly encouraged.1

Primary and Adjuvant Treatment in Limited-Stage SCLC

All patients who have undergone surgery or stereotactic ablative radiotherapy (SABR) for SCLC should receive adjuvant
chemotherapy. Those who were ineligible for surgery should receive a combination of chemotherapy and thoracic radiation therapy.
The 2 most commonly used treatment combinations are etoposide + cisplatin and etoposide + carboplatin.

Carboplatin and cisplatin both belong to the class of chemotherapy drugs known as alkylating agents. They interact with electron-
rich molecules such as amino nitrogens and thiol sulfurs to covalently link to nucleic acids and proteins in cells. This linking disrupts
mitosis and basal cellular functions, forcing cells to undergo programmed cell death (apoptosis).6

Clinical trials have shown that carboplatin and cisplatin are equally effective for SCLC and can be interchangeable. One meta-
analysis of 4 studies comparing carboplatin-based and cisplatin-based regimens found that there was no significant difference in
progression-free survival, overall survival, or response.7 Physicians may choose to substitute carboplatin for cisplatin to reduce the
risk of unwanted side effects, including nephropathy, emesis, and neuropathy.

Recommended doses and scheduling for the preferred primary and adjuvant treatment of SCLC are as follows:

Cisplatin 75 mg/m2 on day 1 and etoposide 100 mg/m2 on days 1, 2, and 3

Cisplatin 60 mg/m2 on day 1 and etoposide 120 mg/m2 on days 1, 2, and 3

Four cycles of therapy are recommended with a planned cycle length of 21 to 28 days. In patients who are receiving both
chemotherapy and radiation therapy, cisplatin + etoposide is the preferred treatment regimen. It is important to note that the NCCN
recommends avoiding the use of myeloid growth factors (granulocyte-macrophage colony-stimulating factor [GM-CSF]) during
concurrent treatment with chemotherapy and radiation therapy.

The NCCN also recommends a lower-dose regimen of cisplatin and etoposide (cisplatin 25 mg/m2 and etoposide 100 mg/m2 both
administered on days 1, 2, and 3) as another treatment option. Carboplatin at area under the curve (AUC) 5 to 6 on day 1 and
etoposide 100 mg/m2 on days 1, 2, and 3 may also be used.

Extensive-Stage SCLC
Patients with extensive-stage SCLC have both localized disease and distant metastases.1 The programmed death-1/programmed
death ligand-1 (PD-1/PD-L1) axis is responsible for shielding cancer cells from the immune system, allowing them to evade
destruction and continue to spread. Monoclonal antibody agents designed to target both PD-1 on immune cells and PD-L1 on
immune cells and tumor cells have proven invaluable in treating lung cancer.8
Studies demonstrate that immune checkpoint inhibitors targeting the PD-1/PD-L1 axis are an effective first-line treatment strategy
for patients with extensive-stage SCLC. Specifically, the PD-L1 inhibitors atezolizumab and durvalumab have been found to improve
progression-free survival and overall survival when administered with platinum-based chemotherapy and etoposide.9,10

Figure. Axial computed tomographic imaging of the brain demonstrating masses suggestive of metastatic disease in a patient with lung cancer. Credit: Getty Images.

Preferred First-Line Treatments for Extensive-Stage SCLC

The preferred first-line treatment regimens with atezolizumab for extensive-stage SCLC include:

Carboplatin AUC 5 on day 1; etoposide 100 mg/m2 on days 1, 2, and 3; and atezolizumab 1200 mg on day 1 cycled every 21
days for 4 cycles total, followed by atezolizumab 1200 mg maintenance on day 1 cycled every 21 days
Carboplatin AUC 5 on day 1; etoposide 100 mg/m2 on days 1, 2, and 3; and atezolizumab 1200 mg on day 1 cycled every 21
days for 4 cycles total followed by atezolizumab 1680 mg maintenance on day 1 cycled every 28 days

The preferred first-line treatment regimens with durvalumab for extensive-stage SCLC include:

Cisplatin 75 to 80 mg/m2 on day 1; etoposide 80 to 100 mg/m2 on days 1, 2, and 3; and durvalumab 1500 mg on day 1 cycled
every 21 days for 4 cycles total, followed by durvalumab 1500 mg maintenance on day 1 cycled every 28 days
Carboplatin AUC 5 to 6 on day 1; etoposide 100 mg/m2 on days 1, 2, and 3; and durvalumab 1500 mg on day 1 cycled every 21
days for 4 cycles total, followed by durvalumab 1500 mg maintenance on day 1 cycled every 28 days

It should be noted that contraindications to immunotherapy regimens including PD-1/PD-L1 inhibitors include active or previously
diagnosed autoimmune disease and/or concurrent use of immunosuppressant agents.

Other Recommended Therapies for Extensive-Stage SCLC

Other recommended treatment options from the NCCN for extensive-stage SCLC include:

Cisplatin 25 mg/m2 on days 1, 2, and 3 and etoposide 100 mg/m2 on days 1, 2, and 3
Cisplatin 75 mg/m2 on day 1 and etoposide 100 mg/m2 on days 1, 2, and 3
Cisplatin 80 mg/m2 on day 1 and etoposide 80 mg/m2 on days 1, 2, and 3
 Carboplatin AUC 5 to 6 on day 1 and etoposide 100 mg/m2 on days 1, 2, and 3

In certain circumstances, patients may be treated with a combination of carboplatin and irinotecan. The following dosing regimens
are recommended by the NCCN:

Cisplatin 30 mg/m2 and irinotecan 65 mg/m2 both on days 1 and 8

Cisplatin 60 mg/m2 on day 1 and irinotecan 60 mg/m2 on days 1, 8, and 15
Carboplatin AUC 5 on day 1 and irinotecan 50 mg/m2 on days 1, 8, and 15

Like those with limited-stage disease, patients with extensive-stage disease are also recommended to receive 4 cycles of systemic
therapy, but some patients may be eligible to receive 6 cycles if they responded well to treatment and have continued to tolerate it.
Clinical trials demonstrate that maintenance or consolidation chemotherapy following initial treatment provides only minor benefits
in extending the duration of response.11,12 However, there is little to no impact on survival and there is an increased risk of toxicity
that brings such treatment out of favor with the NCCN.

Subsequent Pharmacologic Treatment Recommendations for SCLC

Although nearly all patients with SCLC initially respond to treatment, most eventually relapse with resistant disease.1,2 Patients
should be monitored every 2 to 6 months for relapse, particularly within the first 1 to 2 years following diagnosis of SCLC. Magnetic
resonance imaging (MRI) or computed tomography (CT) imaging of the brain should be performed every 3 to 4 months in the first
year following diagnosis of SCLC.

The NCCN provides treatment recommendations regarding subsequent systemic therapy following relapse of SCLC. Many patients
receive subsequent treatment as palliative care, and it can offer relief from the symptoms of SCLC. Fewer than 10% of patients who
experience relapse within 6 months of beginning initial treatment will respond to subsequent treatment. If the time to relapse is
greater than 6 months, the expected response rate is approximately 25%.13,14

During treatment with subsequent systemic therapies, patients should be monitored after every 2 to 3 cycles are completed. Studies
have not yet identified an optimal duration for subsequent systemic therapy for SCLC. The NCCN recommends treating patients until
unacceptable toxicity develops — which is a common strategy when using cytotoxic chemotherapy — or until disease progression.

The preferred first-line subsequent systemic therapy for SCLC is platinum-based doublet chemotherapy. Physicians may rechallenge
with the original regimen of cisplatin + etoposide or carboplatin + etoposide used in an adjuvant setting or for limited-stage SCLC.

Other recommended second-line treatments and regimens provided by the NCCN for relapsed SCLC include several other
chemotherapies and monoclonal antibody agents.

Lurbinectedin
Lurbinectedin is a chemotherapy that inhibits oncogenic transcription by inducing double-strand DNA breaks and blocking
polymerase activity. As a result, tumor cells are forced to undergo apoptosis.15 In clinical trials, the response rate to lurbinectedin
treatment was 45% in patients who had not received chemotherapy for at least 90 days and 22% in those who had received
chemotherapy within the same time interval.16

Topotecan
Topotecan is a topoisomerase inhibitor that blocks DNA replication by creating covalent bonds and inducing double-strand breaks.17
Topotecan is as effective as a single agent as it is in combination with chemotherapy treatment and is associated with fewer side
effects.18

PD-1 Inhibitors
Nivolumab and pembrolizumab are PD-1 inhibitors that activate a patient’s immune system against their tumor cells.8 In clinical
trials, treatment with nivolumab improved overall survival rates when compared with treatment with topotecan or amrubicin.19 The
KEYNOTE-028 (ClinicalTrials.gov Identifier: NCT02054806) and KEYNOTE-158 (ClinicalTrials.gov Identifier: NCT02628067)
studies evaluated pembrolizumab in patients with relapsed SCLC after 2 or more prior lines of therapy. The response rate to
pembrolizumab was 19.3% and median overall survival was 7.7 months.20

The US Food and Drug Administration (FDA) no longer indicates nivolumab or pembrolizumab as subsequent therapy for relapsed
SCLC, as the clinical trials did not show significant improvements in overall survival.1 However, the NCCN SCLC Panel still advises
that these treatments may be effective in subsets of patients. For example, patients who do not receive atezolizumab or durvalumab
and experience relapse after treatment for limited-stage disease are candidates for PD-1-inhibitor therapy. The NCCN SCLC Panel
also notes that patients who have experienced disease progression while on maintenance atezolizumab or durvalumab are not
recommended to receive nivolumab.

Other Chemotherapy Agents

The NCCN treatment guidelines provide evidence to support the use of paclitaxel, oral etoposide, gemcitabine temozolomide,
vinorelbine, and bendamustine as single agents to treat relapsed SCLC. However, the guidelines note that clinical trials are a
preferred option before any of these treatments are recommended. Clinical trials allow patients to gain access to experimental
therapies and a higher level of care under the supervision of study staff. For cancer with poor outcomes, including SCLC, clinical trials
offer patients another option to extend their lifespan and alleviate some of their disease burden.

Table 1. Management Guidelines for Subsequent Systemic Therapies for Small Cell Lung Cancer

Drugs Dosage Administration

Bendamustine 120 mg/m2 on days 1 and 2 of a 21-d cycle for up to 6 cycles IV infusion with ESAs and G-
total CSF as needed

Cyclophosphamide + doxorubicin Cyclophosphamide 1000 mg/m2, doxorubicin 45 mg/m2, IV infusion

+ vincristine (CAV) and vincristine 2 mg on day 1 of a 21-d cycle

Docetaxel 120 mg/m2 on day 1 of a 21-d cycle IV infusion over 1 h

Etoposide 50 mg/m2/d for 21 consecutive days Orally as a capsule

Gemcitabine 1000 mg/m2 on days 1, 8, and 15 of a 28-d cycle IV infusion over 30 min

Irinotecan 100 mg/m2 on days 1 and 8 of a 21-d cycle until disease IV infusion
progresses

Lurbinectedin 3.2 mg/m2 every 3 wk until unacceptable toxicity occurs or IV infusion over 1 h
disease progresses

Nivolumab 3 mg/kg every 2 wk until unacceptable toxicity occurs or IV infusion

disease progresses

Paclitaxel 175 mg/m2 every 3 wk IV infusion over 3 h

Pembrolizumab 10 mg/kg every 2 wk or 200 mg every 3 wk for up to 2 y IV infusion

Temozolomide 75 mg/m2/d for 21 or 28 days or 200 mg/m2/d for 5 Orally as a capsule

consecutive days of a 28-d cycle

Topotecan (a) 2.3 mg/m2/d or (b) 1.5 mg/m2/d on days 1-5 of a 21-d (a) Orally as a capsule or (b)
cycle IV infusion
 Vinorelbine 30 mg/m2 weekly IV infusion

ESA = erythropoiesis-stimulating agent; G-CSF = granulocyte colony-stimulating factor; IV = intravenous.

From NCCN Treatment Guidelines and literature.1,18,21-32

Treating Older Adults With SCLC

SCLC tends to be a disease of older adults, with a median age at diagnosis of older than 70 years.1 Many geriatric patients have
comorbid conditions or take several medications that could interfere with their tolerance and response to SCLC therapies. Patients in
this age group are also more likely to experience fatigue, myelosuppression, and other complications compared with younger
patients.1,33

The NCCN notes that older patients tend to have the same prognosis as their younger counterparts with stage-matched SCLC.
However, extra care must be taken to avoid unnecessary toxicity and injury. Studies demonstrate that less-intensive, single-agent
chemotherapies are not as effective as combination regimens. Chemotherapy and radiation therapy together also improve survival
compared with chemotherapy alone.

Older patients may be treated with 4 cycles of carboplatin + etoposide. Carboplatin is dosed using the AUC, which takes into account
a patient’s renal function. Oftentimes, older adults have compromised renal function, which can interfere with drug dosing and result
in unwanted toxicity and adverse events.1

Monitoring Side Effects, Adverse Events, and Drug-Drug

Interactions for Small Cell Lung Cancer Treatments
When treating patients with cytotoxic chemotherapy agents or immune checkpoint inhibitors, it is imperative to monitor them
closely and adjust their medication dosages as needed. The ultimate goal of treatment is to strike a balance between a high enough
dose to be effective while also limiting toxicity and unwanted side effects.

Chemotherapy drugs often exhibit off-target effects due to their mechanisms of action. Many of them target rapidly dividing cells,
and although this characteristic is invaluable for targeting SCLC tumor cells with rapid doubling times, chemotherapies may also
harm the body’s healthy cells that also replicate quickly. Many patients experience gastrointestinal symptoms, low blood cell counts,
and alopecia as a result of chemotherapy treatment.34

Immune checkpoint inhibitors present unique immune-mediated side effects that are typically not caused by traditional cytotoxic
chemotherapy drugs.1 This class of drugs is associated with a greater risk of infusion-related reactions and, in rare cases, severe and
even fatal adverse reactions. It is important to monitor a patient’s liver enzymes, thyroid function, and creatinine levels throughout
treatment.

Table 2. Side Effect Profiles of Recommended Treatments for Small Cell Lung Cancer

Drug Most Common Adverse Events Drug-Drug Interactions Special Population

Considerations

Atezolizumab Alopecia, cough, decreased appetite, None indicated May be harmful to fetus; avoid
dyspnea, fatigue using in breastfeeding patients
Warnings: Immune-related
reactions, infusion-related reaction
Bendamustine Anorexia, constipation, cough, CYP1A2 inhibitors or inducers May be harmful to fetus; avoid
cytopenias, fatigue and weakness, using in breastfeeding patients
pyrexia, headache, nausea, rash,
shortness of breath, vomiting,
weight loss
Warnings: Infusion reaction or
anaphylaxis, myelosuppression,
serious infections, severe
dermatologic reactions, TLS

Carboplatin Abdominal pain, back pain, None indicated May be harmful to fetus; avoid
constipation, cough, decreased using in breastfeeding patients
appetite, diarrhea, fatigue and
weakness, pyrexia, headache, joint
pain, musculoskeletal pain, nausea,
rash, upper respiratory tract
infection, vomiting

Warnings: Infusion reaction

Cisplatin Infections, myelosuppression,
nausea, peripheral neuropathy,
pyrexia, vomiting
Warnings: Injection site reaction,
nephrotoxicity, ocular toxicity,
ototoxicity, secondary leukemia
Nephrotoxic and ototoxic drugs May be harmful to fetus; avoid
using in breastfeeding patients;
use with caution in patients
with renal impairment

Cyclophosphamide Abdominal pain, alopecia, anorexia,
cytopenias, diarrhea, nausea, skin
rash, vomiting
Warnings: Cardiotoxicity, renal and
urinary tract toxicity, hyponatremia,
immunosuppression, impaired
wound healing, infertility,
myelosuppression, pulmonary
toxicity, secondary malignancies,
veno-occlusive liver disease
ACE inhibitors; amiodarone; May be harmful to fetus; avoid
amphotericin; anthracyclines; using in breastfeeding patients;
azathioprine; busulfan; use with caution in geriatric
coumarins; cyclosporine; patients and those with severe
cytarabine; etanercept; G-CSF; renal or hepatic impairment
GM-CSF; indomethacin;
metronidazole; natalizumab;
paclitaxel; pentostatin; protease
inhibitors; tamoxifen; thiazide
diuretics; trastuzumab

Docetaxel Alopecia, anorexia, cytopenias,
neuropathy, dysgeusia, dyspnea,
infections, myalgia, nail disorders,
skin reactions
Warnings: Colitis, eye disorders,
hepatic impairment,
hypersensitivity, skin reactions,
neurologic reactions
CYP3A4 inhibitors or inducers
May be harmful to fetus; avoid
using in breastfeeding patients;
patients with severe hepatic
impairment should not be
treated with docetaxel

Doxorubicin Alopecia, asthenia, chills, nausea,
pyrexia, urticaria, vomiting
Warnings: Cardiotoxicity,
hepatotoxicity, immunosuppression
and increased risk of infection,
Concomitant use of 6- May be harmful to fetus; avoid
mercaptopurine, dexrazoxane, or using in breastfeeding patients;
trastuzumab; CYP3A4, CYP2D6, reduce dose in patients with
and P-gp inhibitors or inducers severe hepatic impairment
 injection site reaction, secondary
leukemia

Durvalumab Abdominal pain, cough, diarrhea, None indicated May be harmful to fetus; avoid
dyspnea, fatigue, infections, using in breastfeeding patients
pruritus, pyrexia, rash
Warnings: Immune-related
reactions, infusion-related reaction

Etoposide Abdominal pain, constipation, Warfarin May be harmful to fetus; avoid

dysphagia, nausea, pyrexia, using in breastfeeding patients
vomiting, neutropenia
Warnings: Anaphylaxis,
myelosuppression, optic neuritis,
secondary leukemias

Gemcitabine Cytopenias, dyspnea, elevated liver None indicated May be harmful to fetus; avoid
enzymes, nausea, proteinuria, skin using in breastfeeding patients
rashes, vomiting
Warnings: Hemolytic uremic
syndrome, myelosuppression,
pulmonary and hepatic toxicity

Irinotecan Abdominal pain, alopecia, anorexia, Leucovorin; strong CYP3A4 or May be harmful to fetus; avoid
asthenia, constipation, cytopenias, UGT1A1 inhibitors; strong using in breastfeeding patients;
diarrhea, nausea, pyrexia, vomiting, CYP3A4 inducers; 5-fluorouracil use with caution in geriatric
weight loss patients and monitor them
Warnings: Cholinergic reactions and closely; use with caution in
diarrhea, hypersensitivity, increased patients with hepatic
toxicity in patients with impairment
performance status 2, increased risk
of neutropenia in patients with
reduced UGT1A1 activity,
myelosuppression, pulmonary
toxicity, renal impairment/failure

Lurbinectedin Constipation, cough, cytopenias, Moderate or strong CYP3A May be harmful to fetus; avoid
decreased albumin, decreased inhibitors or inducers using in breastfeeding patients
appetite, decreased magnesium,
decreased sodium, diarrhea,
dyspnea, fatigue, increased
creatinine, increased glucose,
increased liver enzymes,
musculoskeletal pain, nausea,
vomiting
Warnings: Extravasation resulting in
tissue necrosis, hepatotoxicity,
myelosuppression, rhabdomyolysis

Nivolumab Abdominal pain, back pain, None indicated May be harmful to fetus; avoid
decreased appetite, diarrhea, using in breastfeeding patients
nausea, fatigue and weakness,
pyrexia, headache, musculoskeletal
pain, nausea, skin itching and rash,
 upper respiratory tract infection,
urinary tract infection, vomiting
Warnings: Anaphylaxis, immune-
mediated reactions, infusion-related
reaction
Paclitaxel Arthralgia, cytopenias, diarrhea,
elevated liver enzyme levels,
infections, myalgia, nausea, vomiting
Warnings: Bradycardia,
hypersensitivity, hypotension
Pembrolizumab Abdominal pain, alopecia, arthralgia,
cough, decreased appetite, fatigue,
headache, insomnia, myalgia,
peripheral neuropathy, pyrexia, skin
rash, stomatitis
Warnings: Severe immune-related
reactions, infusion reactions
Temozolomide Alopecia, fatigue, nausea, vomiting
Warnings: Hepatotoxicty,
myelosuppression, pneumocystis
pneumonia, secondary MDS/AML
Topotecan Abdominal pain, asthenia,
cytopenias, dyspnea, fatigue,
nausea, pain, pneumonia, sepsis
Warnings: Extravasation and tissue
injury, ILD, myelosuppression
Vincristine Anemia, constipation, decreased
appetite, diarrhea, fatigue, febrile
neutropenia, insomnia, nausea,
peripheral neuropathy, pyrexia
Warnings: Extravasation tissue
injury, hepatic toxicity,
myelosuppression, neurotoxicity,
severe constipation and bowel
obstruction, TLS
Vinorelbine Cytopenias, elevated liver enzymes,
nausea, peripheral neuropathy,
vomiting, injection site reaction
Warnings: Bowel obstruction from
severe constipation; extravasation;
CYP2C8 and CPY3A4 inhibitors May be harmful to fetus; avoid
and inducers using in breastfeeding patients;
use with caution in geriatric
patients
None indicated May be harmful to fetus; avoid
using in breastfeeding patients
None indicated May be harmful to fetus; avoid
using in breastfeeding patients;
use with caution in geriatric
patients, as they may develop
serious thrombocytopenia or
neutropenia in the first
treatment cycle
None indicated May be harmful to fetus; avoid
using in breastfeeding patients;
reduce dosing in patients with
creatinine clearance of 20-39
mL/min; no dose adjustments
need to be made for patients
with creatinine clearance ≥40
mL/min
Strong CYP3A inhibitors or May be harmful to fetus; avoid
inducers; P-gp inhibitors or using in breastfeeding patients;
inducers use with caution in patients
with hepatic impairment
CYP3A inhibitors May be harmful to fetus; avoid
using in breastfeeding patients;
use with caution in patients
with hepatic impairment
 myelosuppression; neurologic,
hepatic, and pulmonary toxicity

ACE = angiotensin converting enzyme; AML = acute myeloid leukemia; G-CSF = granulocyte colony-stimulating factor; GM-CSF =
granulocyte-macrophage colony-stimulating factor; ILD = interstitial lung disease; MDS = myelodysplastic syndrome; P-gp = P-
glycoprotein; TLS = tumor lysis syndrome; uridine diphosphate-glucuronosyl transferase 1A1.

From FDA-approved prescribing information.35-55

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Author Bio

Emily Wagner, MS, earned a Bachelor of Science in biotechnology from the Rochester Institute of Technology in 2018 and a Master
of Science in biomedical sciences with a focus in pharmacology from the University of Colorado Anschutz Medical Campus in 2020.
During her thesis work, she studied non-small cell lung cancer and how the immune system plays a role in response to different
treatments. Emily currently lives in Colorado where she enjoys the mountains, spending time with her dog, baking, and reading a
good book.

TOPICS: DDI SMALL CELL LUNG CANCER TREATMENT REGIMENS

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