Liquid Formulations of Oncologic Agents Improves Dosing Consistency, Treatment Adherence in Patients With Dysphagia

Manufacturing liquid formulations of oncologic agents can offer benefits such as dosing consistency, safer inpatient delivery, and ease of at-home administration for pediatric patients or patients with dysphagia, according to Christopher Phillips, PharmD.

One such example of this is the advanced liquid formulation of imatinib (Imkeldi), which was FDA approved in 2024 for the treatment of patients with certain forms of leukemia and other types of cancer.1,2 The formulation is stable, flavored, and non-refrigerated, potentially boosting patient adherence to treatment and overall accessibility.

“The key to good outcomes is patients staying adherent to their regimens,” said Phillips, a resident in the Department of Pharmacy at the Children's Hospital of Philadelphia (CHOP) in Pennsylvania. “Therefore, having available dosage forms that are palatable and that patients can tolerate is incredibly important for the success and curing of these patients. Involving pharmacists is truly [vital for] patient success, and we are eager to be involved in [treatment] decisions [so we can do] what's best for the patient.”

In an interview with OncLive®, Phillips highlighted the lack of pediatric-friendly dosage forms of oral chemotherapy and the hazardous nature of some formulations; how manufacturing liquid formulations of agents can improve treatment adherence and palatability; and the key role of the pharmacist in collaboration with medical oncologists for toxicity management, drug interactions, and supportive care.

OncLive: What are some of the challenges associated with administering oral medications to pediatric patients and/or patients with difficulty swallowing?

Phillips: We treat a wide range of patients in pediatrics. [We see] infants who present with oncologic processes, and we also treat patients who are near adult size. With oral formulations of [different agents], we have many new, exciting treatments that are becoming available. However, what's available on the market is not necessarily in pediatric-friendly dosage forms. As you may suspect, many of our younger children are not able to swallow tablets, so we have to get creative in coming up with ways to make sure that they can take their medication.

For instance, we may have to take a tablet and cut it into even quarters. While working at a pharmacy, it may be easy enough for us to manipulate these tablets to come up with a dose that's appropriate for a younger patient, for example. However, when [patients go] home and a family [member has] to be able to measure these doses and make sure they are coming up with an accurate dose, that can be a challenging and daunting process for them.

Therefore, the big issue at hand is the lack of pediatric-friendly formulations. Additionally, many of these formulations may be hazardous. With the new implementation of USP 800 standards in hospitals, we are having to employ a lot more engineering and additional steps to ensure we are protecting our employees when manipulating these dosage forms. This takes a lot of extra time.

What are some of the benefits of liquid formulations for both inpatient use and at-home dosing?

Starting with inpatient [administration], a good example [of the challenges we experience with oral agents] is venetoclax [Venclexta]. [Venetoclax] is a great oral agent that is utilized in leukemia. [However], the only available formulation [of this agent] is a tablet. We found that when trying to dispense it [in inpatient settings], crushing the tablet for patients who cannot take it causes it to disintegrate and create many particles in the air. Therefore, we employed a process where we have to crush the tablet in a chemotherapy hood.

Nursing staff were concerned about its teratogenicity and protecting employees from exposure. [Consequently,] orders [now] state, ‘Please request this an hour in advance before giving this medication.’ We've seen that [this] sometimes causes issues and extra delays in trying to give the medication. Although it is a daily medication and [this is] not a huge deal, it presents a challenge in a very large health system. These are the issues from the inpatient side, where we are creating workflows to ensure safer delivery of these medications.

When it comes to manipulating tablets at home, for example, I counsel patients before they are discharged. This involves reviewing [how to] cut a medication and giving them pill splitters to make sure they feel comfortable with that, [telling them to] use gloves, and [generally informing them of] things to look out for or consequences of coming in contact with those medications.

With liquid formulations, when I meet with my patients, I always try to come up with doses that are easy for parents to administer. It's beneficial to meet with families because I can think about ways to make things easier for them.

How can manufactured liquid formulations aid with dosing consistency and reduce the need for compounding medications for cancer management?

For some medications, there may be an extemporaneous recipe that we are using [to manufacture liquid formulations], based on maybe another institution's study, [for example]. However, when it's coming from a manufacturer, we know there's going to be much greater consistency, and we don't have to have staff pulled away to compound these medications. Otherwise, we are adding more human factors, and thus human error, into making a custom recipe [when compounding tablets or capsules].

Some hospitals either cannot or do not have the bandwidth to be able to compound these medications, so the lack of liquid formulations is truly an issue. For patients, we can come up with the best plan and the regimen that we have for them, but then we may be setting them up for failure if they can't find a compounding pharmacy when they're discharged, or if the hospital they're admitted to doesn't have the means to compound that medication.

Alternatively, they may have to get it through a special pharmacy and then consider the logistics of getting it delivered, or they may have to drive out of their way to get this medication. In the beginning, we could have had a manufactured liquid formulation that was compounded under good manufacturing processes. With a manufactured liquid, we can ensure a consistent product that has the right concentration, and it's likely to be more palatable than something we could put together by crushing tablets, which may have a bitter aftertaste.

How important is palatability for treatment compliance, especially among pediatric patients?

We cannot force a child to take something if it's not going to be good, or if it makes them even more nauseous. We [often see] chemotherapy-induced nausea and vomiting. Sometimes we have to think about whether it is the actual flavor of the medication [causing issues], or a large volume of liquid. This is something I've seen even in adolescents. My role as a pharmacist involves considering—especially for older patients—whether we can get Child Life involved. At CHOP, we have many great Child Life team members.

They can start by practicing with small candies like Nerds, working up to Skittles or M&Ms, to help children learn to swallow tablets, because there's a significant psychological component to that [process]. Just the other day, when I was reviewing patient records, I saw patients who were on a mix of liquids and tablets. For those ready, we try to switch them from liquids to all tablets, if possible. This is another perspective to consider.

What is the role of pharmacists in toxicity management, medication review, and supportive care within oncology?

Our attending providers are experts in the field; they have extensive experience and are primarily driving treatment decisions. My role, however, heavily focuses on supportive care, including making things more palatable and managing toxicity, dose adjustments, and drug interactions.

A prime example involves a newer medication used in leukemia [called] revumenib [Revuforj] that has many drug interactions we must consider. [This] is crucial because [the drug] interacts with other medications that can cause cardiac toxicity by prolonging the QT interval. [As a pharmacist], I played a key role in identifying other medications that may also prolong the QT interval. This involves considering if a medication is absolutely necessary, exploring options for deprescribing other medications that could prolong the QT interval, and identifying those that do, as the primary medication may need to be stopped if the QT interval becomes too long. This [helps] ensure that a patient can continue on treatment, potentially extending their life.

Regarding chemotherapy-induced nausea and vomiting, we have excellent clinical pathways here [at CHOP]. I ensure that when orders come through, basic medications like ondansetron, for example, are appropriately ordered. I verify that we are following guidelines for highly emetogenic treatments. From a prophylaxis perspective, anti-infective prophylaxis is always a priority.

I also aim to cover all necessary aspects, such as confirming if [trimethoprim /sulfamethoxazole] is prescribed, or if not, exploring alternatives, and identifying any gaps given our busy services. [Essentially], I make sure that everything is ordered appropriately, and if not, I investigate the reasons why. Other things [I do include] double-checking medication reconciliation, looking for anything missing from home that we should consider ordering, and questioning whether the current regimen is effective for the patient.

Why is it important for medical oncologists to collaborate with pharmacists during and after the treatment decision-making process, particularly when considering an oral vs liquid formulation?

There is a varying degree to which providers are open to pharmacist involvement. I find that I work best with collaborative providers. Pharmacists' training differs significantly from medical school training, and our areas of focus are distinct.

I [often] work collaboratively with physicians who are on my teams. The overall direction in our field involves engaging multiple parties, bringing us all to the table for collaborative thinking, and developing good solutions by leveraging our different backgrounds to care for the patient.

In pediatric pharmacy, children grow, so doses often change. When I'm meeting with families, I try to explain to them that this is the dose currently, but we must monitor changing weights and adjust accordingly. I am always monitoring this.

I round with the teams, and my focus is on the medications that are ordered. My process involves reviewing each medication to ensure there's an indication, the correct dose, the right route, and to check for any drug interactions. Pharmacists can effectively scrutinize the medical record, reviewing all medications to ensure they align with the medical team's plan.

References

1. Shorla Oncology announces FDA approval of Imkeldi (imatinib) oral solution, an oral liquid for the treatment of certain forms of leukemia and other cancers. News release. Shorla Oncology. November 25, 2024. Accessed November 25, 2024. https://www.businesswire.com/news/home/20241125044117/en
2. Ryan, C. FDA Approves Oral Solution of Imatinib for Certain Leukemias, Other Cancers. OncLive. November 25, 2024. Accessed September 3, 2025. https://www.onclive.com/view/fda-approves-oral-solution-of-imatinib-for-certain-leukemias-others-cancers