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Treatment Name: Bevacizumab (Avastin®) + Temozolomide (Temodar®)

Bevacizumab (Avastin®) + Temozolomide (Temodar®) is a Chemotherapy Regimen for Brain Cancer

What is High-Grade Glioma Brain Cancer?

High-grade gliomas consist of glioblastoma multiforme, a disease of the glial cells, and anaplastic astrocytoma, a disease of astrocytes, which are found in the brain. High grade gliomas are a rare condition. In most cases, the cause of high-grade glioma brain cancer is not known; however, they can arise from other low-grade brain cancers. Gliomas are classified into four grades (I, II, III, and IV), of which grades III and IV are considered to be high-grade.

How does bevacizumab + temozolomide work?

Bevacizumab stops the growth of blood vessels that supply nutrition to tumor cells. Temozolomide is designed to kill and slow growth of cancer cells in the brain.

Goals of therapy:

Bevacizumab + temozolomide is given to shrink tumors and decrease symptoms of high grade glioma brain cancer. Bevacizumab + temozolomide is not commonly given with the goal of cure but can potentially improve symptoms and prolong life.

Schedule

Create your own Treatment Tracker

How is bevacizumab + temozolomide therapy for high-grade glioma given?

  • Bevacizumab I.V. over 90 minutes on Day 1 of Cycle 1
    • then over 60 minutes for Cycle 2, if no infusion reactions occur
    • then over 30 minutes for Cycles 3 and on, if no infusion reactions occur
  • Temozolomide one or more capsules by mouth once daily on Days 1 through 21

Estimated total infusion time for this treatment:

  • Up to 1.5 hours for Cycle 1, Day 1; Up to 1 hour for Cycle 2, Day 1; as short as 30 minutes for the first day of Cycle 3 and beyond if well tolerated
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time

Bevacizumab is usually given in an outpatient infusion center, allowing the person to go home afterwards. Temozolomide is usually taken at home.

Bevacizumab + temozolomide is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated until treatment no longer works or until unacceptable side effects occur.

Click here for the common starting doses.

Side Effects

What are the most common side effects from Bevacizumab +Temozolomide for High-Grade Glioma?

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects of bevacizumab + temozolomide are shown here.

Although not reported in the original Bevacizumab + Temozolomide clinical trial, other possible side effects include, but are not limited to, nausea and vomiting, constipation, diarrhea, and mild hair loss.

On average, 8% of patients discontinue treatment due to unacceptable side effects.

Importantly, not all people who experience a side effect from bevacizumab + temozolomide will experience it in the same way. It may be mild in some or severe in others, depending upon the individual. Everybody is different. Additionally, side effects may vary over time. For some, side effects may be a reason to delay or switch treatment, reduce the dose, or avoid treatment with a certain medication altogether.

Side effects may be treatable when they occur or preventable by taking certain medications before they happen. When medications are taken to prevent a problem, this is known as prophylaxis, or "prophy" for short.

After starting treatment with bevacizumab + temozolomide, be sure to come back and watch all of the side effect videos shown below. Each of these videos contain valuable information about side effect management that will hopefully help you to both feel better and stay out of the hospital.

Watch videos on common Bevacizumab + Temozolomide therapy side effects below

Side effect videos Side Effect Videos
Fatigue Fatigue AnemiaAnemiaBlood ClotsBlood ClotsBleedingBleedingNausea and VomitingNausea and VomitingConstipationConstipationDiarrheaDiarrheaHair LossHair Loss

Monitoring

How often is monitoring needed?

Labs (blood tests) are usually checked before each treatment cycle. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), blood pressure, and urine protein level, plus any others your doctor may order.

How often is imaging needed?

Imaging of the site of disease is checked before treatment and is repeated as determined by your doctor. Imaging may include: magnetic resonance imaging (MRI) or computerized tomography (CT) scans.

How might blood test results/imaging affect treatment?

Depending upon the results, your doctor may advise to continue bevacizumab + temozolomide as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

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Questions to ask your DoctorNursePharmacist

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        Questions to ask your NurseDoctorPharmacist

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              Questions to ask your PharmacistDoctorNurse

                    ChemoExperts Tips

                    What are the most important things to know about bevacizumab + temozolomide while receiving therapy?

                    • Bevacizumab can impair your body’s ability to heal wounds. Talk to your oncologist about any planned surgeries and let your surgeon know you are taking this drug. Your schedule for surgery or chemotherapy may need to be altered
                    • Bevacizumab can commonly cause high blood pressure. Consider keeping a blood pressure monitor at home. Your doctor may prescribe a medication to help lower your blood pressure if needed
                    • Try taking your dose of temozolomide before bedtime on an empty stomach to avoid experiencing nausea and/or vomiting. Make sure you always have medications to help treat nausea with you
                    • Temozolomide can cause constipation. Drinking water, eating sufficient fiber, and remaining active will help prevent constipation. Over-the-counter medications may also be needed to prevent and/or treat constipation
                    • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
                    • Clinical trials may exist for high-grade glioma brain cancer. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

                    Patient Assistance & Co-payment Coverage

                    Patients under the age of 65 years, or those with private insurance plans:
                    If you have insurance and are looking for patient assistance or copay assistance for Bevacizumab (Avastin®) + Temozolomide (Temodar®), we have provided links that may help.

                    Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Bevacizumab (Avastin®) + Temozolomide (Temodar®). Depending upon your income, they may be able to help cover the cost of:

                    • Bevacizumab
                    • Temozolomide

                    For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

                    • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

                    Medicare and Medicaid patients (Patients 65 years or older):
                    The clinic providing treatment will likely pre-authorize medications and immune therapies such as Bevacizumab (Avastin®) + Temozolomide (Temodar®) and are the best source to help you understand drug cost.

                    • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

                    Emotional Wellness

                    What is Emotional Wellness?
                    Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

                    Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

                    Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

                    Learn more about pursuing emotional wellness while receiving treatment with Bevacizumab (Avastin®) + Temozolomide (Temodar®)

                    Individual Drug Label Information

                    Bevacizumab (Avastin®, Mvasi®, Zirabev®, Alymsys®)

                    • Bevacizumab is an intravenous (I.V.) drug
                    • Use extreme caution in patients with a history of stomach and intestine perforations or disorders
                    • Do not use 28 days before or after any surgery
                    • Bleeding is more likely in patients taking this drug
                    • Bevacizumab treatment may be delayed or stopped for: surgery, high blood pressure, protein in urine, severe infusion reactions
                    General Bevacizumab Side Effects
                    • Infusion reactions: usually does not happen after first successful dose
                    • Bleeding
                    • Blood clots
                    • Stomach and intestinal problems
                    • Poor wound healing
                    • High blood pressure
                    • Protein leaking from kidneys into urine
                    • Avoid during pregnancy, Bevacizumab is known to cause fetal harm
                    • Ovarian failure
                    • Click on the bevacizumab package insert below for reported side effects and possible drug interactions

                    Temozolomide (Temodar®)

                    • Temozolomide is an oral capsule that comes in 5 mg (green capsule), 20 mg (yellow capsule), 100 mg (pink capsule), 140 mg (white/blue capsule), 180 mg (white/orange capsule) and 250 mg (white capsule)
                    • Take consistently with food or consistently without food with a large glass of water. Do not alternate between taking it with and without food
                    • Best to take at night to help avoid nausea
                    • Dose may be changed if certain blood counts get too low
                    • Capsules should not be opened or chewed; always swallow whole
                    • If you miss a dose or if you vomit up a dose do not make up missed dose, wait until next scheduled dose
                    • Store at room temperature in a dry place
                    • Interacts with an anti-seizure medication called valproic acid (Depakene®, Stavzor®). Talk to your doctor before taking temozolomide if you take these medications
                    • Can cause fetal harm; use during pregnancy should be avoided
                    General Temozolomide (Temodar) Side Effects
                    • May cause low red blood cells, white blood cells, and platelets. Your blood counts will be checked frequently during treatment
                    • Nausea and vomiting
                    • Temozolomide increases your risk of developing a lung infection called pneumocystis pneumonia also known as PCP or PJP. You may have to take antibiotics such as sulfamethoxazole/trimethoprim (Bactrim®), atovaquone (Mepron®), or dapsone to prevent this from ocurring 
                    • Liver injury; liver function tests are regularly checked throughout therapy
                    • Hair loss
                    • Both diarrhea and constipation have been reported
                    • Although rare, temozolomide can increase your risk or developing other cancers such as acute leukemia later in life
                    • Click on the temozolomide (Temodar) package insert below for reported side effects and possible drug interactions

                    References

                    1) Verhoeff JJ, Lavini C, van Linde ME, et al. Bevacizumab and dose-intense temozolomide in recurrent high-grade glioma. Ann Oncol 2010;21:1723-1727

                     

                    Created: June 15, 2021 Updated: June 16, 2021

                    What is Brain Cancer?

                    Also known as Central Nervous System Cancer, can be grouped into two main types: benign tumors or malignant (cancerous) tumors. Tumors can be of primary type which start in brain tissue, or secondary meaning that they have spread from somewhere else in the body. Symptoms depend upon what part of the brain the tumor is in and may include headache, vision problems, seizures, nausea & vomiting, or mental status changes. Diagnosis is made using imaging with a CT scan (computed tomography) or MRI (magnetic resonance imaging), then often followed by a surgical biopsy.

                    There is no standard staging system for primary type brain tumors. Brain tumors are assigned a "Grade" based upon the way the cancer cells look under a microscope. Grades include: I, II, III, and IV. Brain cancer is treated with surgery, chemotherapy, radiation therapy, or a combination of all these. Grading systems are used by doctors to determine which treatments to offer. The effectiveness of the treatment may depend upon the Grade at diagnosis.

                    NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

                    What does Cure mean?

                    The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

                    Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

                    Common Starting Doses

                    • Bevacizumab 10 mg/kg intravenous infusion over 30 to 90 minutes on Day 1
                    • Temozolomide 50 mg/m2 by mouth once daily on Days 1 through 21

                    Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability.

                    What is a CBC?

                    A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

                    Common uses:
                    1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

                    2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

                    3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

                    What is a CMP?

                    A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status, 2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

                    Electrolytes & Acid/Base status:
                    1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

                    Kidney Function:
                    5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

                    Liver Function:
                    7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

                    Blood sugar:
                    13) Serum glucose

                    Calcium:
                    14) Serum calcium