Version July 2025
Note: The manufacturer recommends rounding each dose to the nearest 5 mg increment. Obtain blood counts prior to starting each cycle and on day 15 of each cycle. Do not initiate a cycle until ANC ≥1,500/mm3 or febrile neutropenia is resolved, platelets are ≥75,000/mm3, and/or grade 3 or 4 nonhematologic reactions are ≤ grade 1. Trifluridine/tipiracil is associated with a moderate or high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
Colorectal cancer, metastatic:
Colorectal cancer, metastatic (single-agent therapy): Oral: 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity (Ref).
Colorectal cancer, metastatic (combination therapy): Oral: 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (in combination with bevacizumab; maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity (Ref).
Note: Refer to specific protocol or to bevacizumab monograph for bevacizumab dosing when used in combination with trifluridine/tipiracil.
|
BSA |
Dosea administered twice daily |
Total daily dosea |
|---|---|---|
|
35 mg/m2/dosea twice daily: | ||
|
a Total daily dose (in mg) and dose (in mg) based on the trifluridine component. | ||
|
<1.07 m2 |
35 mg |
70 mg |
|
1.07 to 1.22 m2 |
40 mg |
80 mg |
|
1.23 to 1.37 m2 |
45 mg |
90 mg |
|
1.38 to 1.52 m2 |
50 mg |
100 mg |
|
1.53 to 1.68 m2 |
55 mg |
110 mg |
|
1.69 to 1.83 m2 |
60 mg |
120 mg |
|
1.84 to 1.98 m2 |
65 mg |
130 mg |
|
1.99 to 2.14 m2 |
70 mg |
140 mg |
|
2.15 to 2.29 m2 |
75 mg |
150 mg |
|
≥2.3 m2 |
80 mg |
160 mg |
Off-label combination/dosing: Oral: 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 every 2 weeks (in combination with bevacizumab); continue until disease progression or unacceptable toxicity (Ref).
Gastric cancer, metastatic: Oral: 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity (Ref).
|
BSA |
Dosea administered twice daily |
Total daily dosea |
|---|---|---|
|
35 mg/m2/dosea twice daily: | ||
|
a Total daily dose (in mg) and dose (in mg) based on the trifluridine component. | ||
|
<1.07 m2 |
35 mg |
70 mg |
|
1.07 to 1.22 m2 |
40 mg |
80 mg |
|
1.23 to 1.37 m2 |
45 mg |
90 mg |
|
1.38 to 1.52 m2 |
50 mg |
100 mg |
|
1.53 to 1.68 m2 |
55 mg |
110 mg |
|
1.69 to 1.83 m2 |
60 mg |
120 mg |
|
1.84 to 1.98 m2 |
65 mg |
130 mg |
|
1.99 to 2.14 m2 |
70 mg |
140 mg |
|
2.15 to 2.29 m2 |
75 mg |
150 mg |
|
≥2.3 m2 |
80 mg |
160 mg |
Missed dose: Do not re-administer doses that are missed or vomited; continue with the next scheduled dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Kidney function may be estimated by the Cockcroft-Gault equation.
CrCl ≥30 mL/minute: No initial dosage adjustment is necessary.
CrCl 15 to 29 mL/minute: 20 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle.
If unable to tolerate 20 mg/m2/dose: Further reduce the dose to 15 mg/m2/dose(based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle.
If unable to tolerate 15 mg/m2/dose: Permanently discontinue trifluridine/tipiracil.
CrCl <15 mL/minute and end-stage kidney disease: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
|
BSA |
Dosea administered twice daily |
Total daily dosea |
|---|---|---|
|
a Total daily dose (in mg) and dose (mg) based on the trifluridine component. | ||
|
20 mg/m2/dosea twice daily: | ||
|
<1.14 m2 |
20 mg |
40 mg |
|
1.14 to 1.34 m2 |
25 mg |
50 mg |
|
1.35 to 1.59 m2 |
30 mg |
60 mg |
|
1.6 to 1.94 m2 |
35 mg |
70 mg |
|
1.95 to 2.09 m2 |
40 mg |
80 mg |
|
2.1 to 2.34 m2 |
45 mg |
90 mg |
|
≥2.35 m2 |
50 mg |
100 mg |
|
15 mg/m2/dosea twice daily: | ||
|
<1.15 m2 |
15 mg |
30 mg |
|
1.15 to 1.49 m2 |
20 mg |
40 mg |
|
1.5 to 1.84 m2 |
25 mg |
50 mg |
|
1.85 to 2.09 m2 |
30 mg |
60 mg |
|
2.1 to 2.34 m2 |
35 mg |
70 mg |
|
≥2.35 m2 |
40 mg |
80 mg |
Mild impairment (total bilirubin ≤ ULN and AST >ULN or total bilirubin <1 to 1.5 times ULN and any AST): No dosage adjustment necessary.
Moderate impairment (total bilirubin >1.5 to 3 times ULN and any AST) or severe impairment (total bilirubin >3 times ULN and any AST): Do not initiate therapy.
American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2 : Utilize patient's actual body weight for calculation of BSA- or weight-based dosing; manage regimen-related toxicities in the same manner as for patients with a BMI <30 kg/m2 (Ref). Note: According to the prescribing information, if a dose is reduced due to toxicity, do not re-escalate the dose.
A maximum of 3 dose reductions are allowed (to a minimum dose of 20 mg/m2/dose); permanently discontinue in patients unable to tolerate 20 mg/m2/dose. Do not re-escalate dose after it has been reduced. Other concomitant combination therapy medications may also require treatment interruption, dosage reduction, and/or discontinuation.
Hematologic toxicity:
ANC <500/mm3 (uncomplicated or resulting in >1 week delay in the start of the next cycle) or febrile neutropenia: Interrupt therapy; following recovery to ANC ≥1,500/mm3 or resolution of febrile neutropenia, may resume therapy with the dose reduced by 5 mg/m2/dose from the previous dose. May require WBC growth factor support.
Platelets <50,000/mm3 (or resulting in >1 week delay in the start of the next cycle): Interrupt therapy; following recovery to platelets ≥75,000/mm3, may resume therapy with the dose reduced by 5 mg/m2/dose from the previous dose.
Nonhematologic toxicity: Grade 3 or 4 toxicity: Interrupt therapy until recovery to ≤ grade 1; following recovery, may resume with the dose reduced by 5 mg/m2/dose from the previous dose (excludes dose reduction for grade 3 nausea and/or vomiting controlled by antiemetic therapy or grade 3 diarrhea responsive to antidiarrheal treatment).
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults administered monotherapy.
>10%:
Gastrointestinal: Abdominal pain (21%), decreased appetite (34% to 39%), diarrhea (23% to 32%; grades 3/4: 3%), nausea (37% to 48%; grades 3/4: 2%), vomiting (25% to 28%; grades 3/4: 2% to 4%)
Hematologic & oncologic: Anemia (63% to 77%; grades 3/4: 17% to 19%), neutropenia (66% to 67%; grades 3/4: 38%;), thrombocytopenia (34% to 42%; grades 3/4: 4% to 6%)
Infection: Infection (23% to 27%)
Nervous system: Asthenia (≤52%), fatigue (≤52%)
Miscellaneous: Fever (19%)
1% to 10%:
Cardiovascular: Pulmonary embolism (2% to 3%)
Dermatologic: Alopecia (7%)
Gastrointestinal: Dysgeusia (7%), stomatitis (8%; grades 3/4: <1%)
Hematologic & oncologic: Febrile neutropenia (grades 3/4: 3%)
<1%: Respiratory: Interstitial lung disease
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Additional contraindication (not in the US labeling): Hypersensitivity to trifluridine, tipiracil, or any component of the formulation.
Concerns related to adverse effects:
• Bone marrow suppression: Severe and life-threatening (grade 3 or 4) bone marrow suppression (anemia, neutropenia, thrombocytopenia) has occurred with single-agent therapy and in combination with bevacizumab, including fatalities (rare) related to neutropenic infection, sepsis, or septic shock. In clinical trials, slightly over 10% of patients and ~30% of patients with single-agent and combination treatment, respectively, received growth factor support.
• Gastrointestinal toxicity: Nausea, vomiting, diarrhea, and abdominal pain have been commonly reported. Stomatitis may also occur. Advise patients to report severe gastrointestinal toxicity to their health care provider.
Disease-related concerns:
• Hepatic impairment: Patients with severe hepatic impairment (total bilirubin >3 times ULN and any AST) were not included in studies. In a pharmacokinetic study in patients with hepatic impairment, several patients with moderate impairment (total bilirubin >1.5 to 3 times ULN and any AST) experienced grade 3 or 4 bilirubin elevations.
Special populations:
• Older age: Patients ≥65 years of age experienced a higher incidence of grade 3 and grade 4 neutropenia and thrombocytopenia with single-agent and combination therapy, as well as increased grade 3 anemia with single-agent therapy, compared to patients <65 years of age.
Dosage form specific issues:
• Tablet strength: Trifluridine/tipiracil is available in two tablet strengths (trifluridine 15 mg/tipiracil 6.14 mg and trifluridine 20 mg/tipiracil 8.19 mg); both tablet strengths may be necessary to provide the correct dose. Read labels carefully in order to ensure the appropriate dose is administered. Dosing is based on the trifluridine component. The manufacturer recommends rounding doses to the nearest 5 mg increment.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Lonsurf: Trifluridine 15 mg and tipiracil 6.14 mg, Trifluridine 20 mg and tipiracil 8.19 mg
No
Tablets (Lonsurf Oral)
15-6.14 mg (per each): $261.65
20-8.19 mg (per each): $348.86
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Lonsurf: Trifluridine 15 mg and tipiracil 6.14 mg, Trifluridine 20 mg and tipiracil 8.19 mg
Trifluridine/tipiracil is associated with a moderate or high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
Oral: Administer with food. Swallow tablets whole.
Hazardous agent (NIOSH 2024 [table 1]).
Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2023; NIOSH 2024; USP-NF 2020).
Colorectal cancer, metastatic: Treatment of metastatic colorectal cancer, as a single agent or in combination with bevacizumab, in adults previously treated with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy, an anti-VEGF biological therapy, and if RAS wild-type, an anti-EGFR therapy.
Gastric cancer, metastatic: Treatment of metastatic gastric or gastroesophageal junction adenocarcinoma in adults previously treated with at least two prior lines of chemotherapy which included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy.
Trifluridine may be confused with trifluoperazine.
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (chemotherapeutic agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
5-Aminosalicylic Acid Derivatives: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Abrocitinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Antithymocyte Globulin (Equine): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor
Antithyroid Agents: Myelosuppressive Agents may increase neutropenic effects of Antithyroid Agents. Risk C: Monitor
Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Baricitinib. Risk X: Avoid
BCG Products: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of BCG Products. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor
Brivudine: May increase adverse/toxic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Chikungunya Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid
Chloramphenicol (Ophthalmic): May increase adverse/toxic effects of Myelosuppressive Agents. Risk C: Monitor
Chloramphenicol (Systemic): Myelosuppressive Agents may increase myelosuppressive effects of Chloramphenicol (Systemic). Risk X: Avoid
Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Cladribine. Risk X: Avoid
CloZAPine: Myelosuppressive Agents may increase adverse/toxic effects of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor
Coccidioides immitis Skin Test: Coadministration of Immunosuppressants (Cytotoxic Chemotherapy) and Coccidioides immitis Skin Test may alter diagnostic results. Management: Consider discontinuing cytotoxic chemotherapy several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider Therapy Modification
COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor
COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider Therapy Modification
COVID-19 Vaccine (Subunit): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor
Deferiprone: Myelosuppressive Agents may increase neutropenic effects of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider Therapy Modification
Dengue Tetravalent Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Denosumab: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and cytotoxic chemotherapy. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider Therapy Modification
Deucravacitinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Etrasimod: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Fexinidazole: Myelosuppressive Agents may increase myelosuppressive effects of Fexinidazole. Risk X: Avoid
Filgotinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor
Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating chemotherapy if possible. If vaccination occurs less than 2 weeks prior to or during chemotherapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider Therapy Modification
Leflunomide: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as cytotoxic chemotherapy. Risk D: Consider Therapy Modification
Linezolid: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Nadofaragene Firadenovec: Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid
Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid
Ocrelizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor
Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor
Olaparib: Myelosuppressive Agents may increase myelosuppressive effects of Olaparib. Risk C: Monitor
Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pidotimod. Risk C: Monitor
Pimecrolimus: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor
Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may increase hypersensitivity effects of Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider Therapy Modification
Promazine: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider Therapy Modification
Ritlecitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid
Ropeginterferon Alfa-2b: Myelosuppressive Agents may increase myelosuppressive effects of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider Therapy Modification
Ruxolitinib (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid
Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants, such as cytotoxic chemotherapy, prior to initiating sipuleucel-T therapy. Risk D: Consider Therapy Modification
Sphingosine 1-Phosphate (S1P) Receptor Modulators: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor
Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid
Talimogene Laherparepvec: Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid
Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Tertomotide. Risk X: Avoid
Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tofacitinib. Risk X: Avoid
Typhoid Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Typhoid Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor
Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Upadacitinib. Risk X: Avoid
Vaccines (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may decrease therapeutic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Vaccines (Non-Live/Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Give non-live/inactivated/non-replicating vaccines at least 2 weeks prior to starting chemotherapy when possible. Patients vaccinated less than 14 days before or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider Therapy Modification
Yellow Fever Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Yellow Fever Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Zoster Vaccine (Live/Attenuated): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid
Verify pregnancy status prior to treatment initiation in patients who could become pregnant. Patients who could become pregnant should use effective contraception during therapy and for at least 6 months after the final trifluridine and tipiracil dose. Patients with partners who could become pregnant should use condoms during therapy and for at least 3 months following the final dose.
Based on the mechanism of action and data from animal reproduction studies, in utero exposure to trifluridine/tipiracil may cause fetal harm.
It is not known if trifluridine or tipiracil are present in breast milk. Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer during therapy and for one day following the last trifluridine/tipiracil dose.
CBCs prior to each cycle and on day 15 of each cycle (or more frequently if clinically necessary); liver and renal function tests. Verify pregnancy status prior to treatment in patients who could become pregnant. Monitor for signs/symptoms of GI toxicity. Monitor adherence.
The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.
Trifluridine, the active cytotoxic component of trifluridine/tipiracil, is a thymidine-based nucleic acid analogue; the triphosphate form of trifluridine is incorporated into DNA which interferes with DNA synthesis and inhibits cell proliferation. Tipiracil is a potent thymidine phosphorylase inhibitor which prevents the rapid degradation of trifluridine, allowing for increased trifluridine exposure (Mayer 2015).
Protein binding: Trifluridine: >96% (primarily to albumin); Tipiracil: <8%
Metabolism: Trifluridine and tipiracil are not metabolized by cytochrome P450 (CYP) enzymes. Trifluridine is mainly eliminated by metabolism via thymidine phosphorylase to form an inactive metabolite, 5-(trifluoromethyl) uracil (FTY)
Half-life elimination: Trifluridine: 2.1 hours (at steady state); Tipiracil: 2.4 hours (at steady state)
Time to peak, plasma: ~2 hours
Excretion:
Trifluridine: Urine (55% [as inactive metabolite FTY and trifluridine glucuronide isomers]; <3% [as unchanged drug]); feces (<3% [as unchanged drug]); expired air (<3%)
Tipiracil: Urine (27% [as tipiracil and 6-HMU]); feces (50% [as tipiracil and 6-HMU])
Altered kidney function: In a study of patients who received a trifluridine/tipiracil dose of 35 mg/m2/dose twice daily (except patients with CrCl 15 to 29 mL/minute who received a dose of 20 mg/m2/dose twice daily), the steady-state AUC0-last of trifluridine was 56% and 140% higher in patients with CrCl 30 to 59 mL/minute and CrCl 15 to 29 mL/minute, respectively, as compared to patients with normal kidney function. The steady-state AUC0-last of tipiracil was 139% and 614% higher in patients with CrCl 30 to 59 mL/minute and CrCl 15 to 29 mL/minute, respectively, as compared to patients with normal kidney function.
Hepatic function impairment: In a pharmacokinetic study of patients with hepatic impairment, grade 3 or 4 bilirubin elevations were seen in patients with moderate (total bilirubin >1.5 to 3 times ULN and any AST) impairment (compared to patients with normal hepatic function). No clinically important differences in mean exposures were noted.
