Abstract
We describe the successful administration of ibrutinib via nasogastic (NG) tube & percutaneous endoscopic gastrostomy (PEG)tube. It was not previously known by the manufacturer if this route of administration was possible.
Our patient was a 71 year old man diagnosed with a leukaemic variant mantle cell lymphoma. He was commenced on R-CHOP (rituximab, cyclophospahmide, doxorubicin, vincristine, prednisolone) chemotherapy however after 3 cycles of chemotherapy there was no reduction in his lymphadenopathy or splenomegaly despite a reduction in the peripheral blood lymphocytosis.
During the R-CHOP chemotherapy, the patient suffered left-sided facial shingles causing Ramsay Hunt syndrome. He was left with a residual neurological swallowing deficit requiring nasogastric feeding. Due to the lack of response to R-CHOP chemotherapy, we felt that ibrutinib could be a useful second line treatment, however we were not sure if the capsule could be opened to allow administration via his nasogastric tube. We contacted the manufacturer who said that there was no data about this method of administration and therefore it was not recommended. Our own research identified one ongoing clinical trial comparing suspension and sprinkle formulations of ibrutinib to the capsule formulation (NCT02390609). This trial was unreported however we felt encouraged that this method of administration did seem feasible.
It was felt that ibrutinib represented the best chance of a useful disease response so full dose treatment was commenced via the nasogastric tube. This was later changed to a percutaneous endoscopic gastrostomy (PEG) tube. The patient opened the capsule and flushed the contents down the tube with water.
A follow up blood count 2 weeks later showed a marked lymphocytosis (baseline lymphocyte count 0.4 x109/L, risen to 40.8 x 109/L), as would be expected with ibrutinib therapy. This reduced to near normal values over the following 3 months, accompanied by an improvement in the haemoglobin and platelet counts. Imaging at 3 months confirmed compete resolution of all pre-existing lymphadenopathy and the previous 25.6 cm splenomegaly.
Our patients' dramatic response suggests that capsule formulation ibrutinib can be successfully administered by NG or PEG tubes.
Maddox:Janssen: Other: Funding to attend ASH 2016 (travel, accommodation, registration); Boehringer-Ingelheim: Other: Funding to attend ASH 2014 (travel, accommodation, registration).
Author notes
Asterisk with author names denotes non-ASH members.
