Patient information - Recurrent or metastatic - Lenvatinib and pembrolizumab

• You may get:
  • chest pain or tightness
  • shortness of breath 
  • swelling of your ankles 
  •  an abnormal heartbeat.
• Heart problems are uncommon but potentially fatal. If heart problems were to occur, symptoms usually start within the first 3 months of treatment, but can happen at any time even after the treatment has finished.
• Tell your doctor if you have a history of heart problems or high blood pressure.
• Before or during treatment, you may be asked to have a test to see how well your heart is working.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the symptoms listed above.

• You may get:
  • bowel motions (stools, poo) that are more frequent or more liquid (diarrhoea)
  • blood or mucous in your stool 
  • dark, tarry, or sticky bowel motions
  • bloating, cramping, pain or tenderness in your stomach area. 
• Inform your doctor or nurse immediately if you get diarrhoea
• Take your anti-diarrhoeal or steroid medication as directed by your doctor.
• Drink plenty of fluids (unless you are on a fluid restriction).
• Eat and drink small amounts more often.
• Avoid spicy foods, dairy products, high fibre foods, and coffee.
• Tell your doctor or nurse immediately, or go to your nearest hospital Emergency Department if your diarrhoea is not controlled despite taking anti-diarrhoea medicine, severe stomach pains and bloating, and/or if you feel dizzy or light-headed.

• Blood problems are infrequent but can be serious.
• You may feel dizzy, light-headed, tired, weak and appear more pale than usual.
• You may get:
• dark, tarry bowel motions (stools, poo)
• blood in your urine or not urinating as often
• dark-coloured urine
• yellowing of the whites of your eyes, and/or your skin
• pinpoint red spots on your skin
• unexplained bleeding
• major bruising
• a fever
• shortness of breath
• a severe headache
• confusion
• faster heartbeat than normal
• Tell your doctor or nurse immediately or go to the nearest hospital Emergency Department if it has been longer than 12 hours since you have emptied your bladder or if you get any of the symptoms listed above.

• You may get: 
  • fatigue
  • severe nausea and vomiting
  • weight loss
  • bruising or bleeding more easily
  • pain or tenderness on the right side of your stomach area
  • dark coloured urine
  • yellowing of the whites of your eyes and/or your skin 
     
  • itchy skin 
  • drowsiness
• You will have regular blood tests to check how well your liver is working.
• Take your steroid medication as directed by your doctor.
• Tell your doctor or nurse as soon as possible if you notice that your urine is a dark colour, the whites of your eyes or skin look yellow, if you have unexplained bruising or bleeding or if you have severe stomach pain.

• You may get:
• muscle or joint stiffness, especially after a period of rest
• muscle weakness
• pain in your muscles or joints
• joint swelling
• tiredness
• headaches
• Take your pain relief or steroid medication as directed by your doctor.
• Tell your doctor or nurse as soon as possible if you get any of the symptoms listed above.

• Nervous system changes are rare, but can be serious.
• You may get: 
  • headaches
  • fever
  • stiff neck
  • confusion or difficulty concentrating
  • dizziness or drowsiness
  • loss of consciousness
  • muscle weakness or pain
  • numbness or tingling in your hands or feet
  • jerky movements.
• Take your steroid medication as directed by your doctor.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the symptoms listed above.

• You may get:
  • eye pain
  • itchy eyes
  • red or swollen eyes
  • blurred or change in vision
  • change in colour vision
  • watery or gritty eyes
  • dry eyes
  • sensitivity to light.
• Protect your eyes from the weather (sun and wind) by wearing sunglasses.
• Use your eye drops or take your steroid medication as directed by your doctor.
• Tell your doctor or nurse as soon as possible if you get any of the symptoms listed above.

• Hormone changes are infrequent, but can be serious.
• You may get:
  • headaches
  • tiredness, dizziness or fainting
  • abnormal heartbeat (faster than usual)
  • a feeling of being hot or cold more easily
  • excessive sweating
  • weight changes 
  • a deepened voice
  • irregular or absent periods
  • nausea and vomiting
  • thirsty and need to urinate more often than normal
  • high blood sugar levels and increased risk of diabetes (requiring insulin therapy)
  • pain in your stomach area
  • muscle pain or weakness
  • difficulty sleeping
  • agitated more easily
  • changes in your mood or behaviour, such as decreased sex drive or irritability.
• Take your hormone or steroid medication as directed by your doctor.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you feel confused, weak, dizzy, or faint, or get sudden pain in your lower back or legs.

• You may get:
  • shortness of breath
  • difficulty breathing
  • faster heartbeat than normal
  •  chest pain
  • new or worsening cough
  • fever.
• Your doctor will monitor how well your lungs are working during your treatment.
• Take your steroid medication as directed by your doctor.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you have chest pain or become short of breath.

• This treatment can cause changes to how your kidneys work.
• You may get: 
  • a feeling of needing to urinate less often than normal
  • blood in your urine
  • swollen hands and feet
  •  loss of appetite.
• You will have regular blood tests to check how well your kidneys are working.
• You may need to drink more fluids while you are having treatment. Your doctor or nurse will tell you if you need to do this.
• Take your steroid medication as directed by your doctor.
• Tell your doctor or nurse as soon as possible if you notice that your urine changes colour or you don't need to empty your bladder as often.

• You may get
  • a red rash
  • a bumpy rash 
  • dry and itchy skin 
  • skin peeling or blisters. 
  • if you have had previous radiation therapy to an area this effect may be worse 
• Moisturise your skin with a gentle non-perfumed moisturising cream like sorbolene or aqueous cream.
• Avoid scratching your skin.
• Avoid wearing tight fitting clothing
• Protect your skin from the sun by wearing sun-protective clothing, a wide-brimmed hat, sunglasses and sunscreen of SPF 50 or higher.
• Take your antihistamine medication or apply your steroid cream as directed by your doctor.
• Tell your doctor or nurse as soon as possible if you notice any changes to the rash like pain or pus forming.

Thyroid problems are common with this treatment. The most common problem is an underactive thyroid gland (hypothyroidism), occasionally you may get an overactive thyroid gland (hyperthyroidism).

• If you have an underactive thyroid, you may get:
  • fatigue and low energy levels
  • depression
  • slow heart rate
  • unexplained weight gain
  • intolerance to cold temperatures
  • fatigued and aching muscles
  • dry, coarse skin
  • puffy face
  • hair loss
  • constipation
  • problems with concentration
  • changes in your periods
• If you have an overactive thyroid, you may get
  • abnormal heartbeat (faster than usual)
  • a feeling of being hot or cold more easily
  • excessive sweating
  • difficulty sleeping
  • anxiety, nervousness or agitated more easily
  • diarrhoea
  • changes in your periods
• You will have regular blood tests to check how well your thyroid is working.
• Take your hormone or steroid medication as directed by your doctor.
• Tell your doctor or nurse if you get any of the symptoms listed above.

• You may feel sick (nausea) or be sick (vomit).
• Take your anti-sickness medication as directed even if you don’t feel sick.
• Drink plenty of fluids (unless you are fluid restricted).
• Eat small meals more frequently.
• Try food that does not require much preparation.
• Try bland foods like dry biscuits or toast.
• Gentle exercise may help with nausea.
• Ask your doctor or nurse for eviQ patient information - Nausea and vomiting during cancer treatment. 
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you have uncontrolled vomiting or feel dizzy or light-headed.

• You may get an acne-like skin rash.
• Your skin may become red and dry.
• Moisturise your skin with a gentle non-perfumed moisturising cream like sorbolene or aqueous cream.
• Do not scratch your skin.
• Do not use over-the-counter acne treatments as these can make the rash worse.
• Protect your skin from the sun by wearing sun-protective clothing, a wide-brimmed hat, sunglasses and sunscreen of SPF 50 or higher.
• You may be given medications to prevent the rash.
• Tell your doctor or nurse as soon as possible if you notice any changes to the rash like itching, pain or pus forming

• Tell your doctor or nurse if you have a wound that does not heal.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the following signs or symptoms:
  • unusual bleeding or bruising
  • bright red or black, tarry bowel motions (stools, poo)
  • stomach pain
  • slurred speech
  • shortness of breath
  • a fast heartbeat.

• You may get bowel motions (stools, poo) that are more frequent or more liquid.
• You may also get bloating, cramping or pain.
• Take your antidiarrhoeal medication as directed by your doctor.
• Drink plenty of fluids (unless you are fluid restricted).
• Eat and drink small amounts more often.
• Avoid spicy foods, dairy products, high fibre foods, and coffee.
• Ask your doctor or nurse for eviQ patient information - Diarrhoea during cancer treatment. 
• Tell your doctor or nurse immediately, or go to your nearest hospital Emergency Department if your diarrhoea is not controlled, you have 4 or more loose bowel motions per day, and if you feel dizzy or light-headed.

• You may not have any signs or symptoms if you have high blood pressure. 
• If it is severe you may get headaches, shortness of breath or feel dizzy. 
• Your blood pressure will be taken regularly during your treatment.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the signs or symptoms listed above. 

• You may get chest pain, shortness of breath, an abnormal heartbeat or swelling in your arms or legs.
• Before, during or after treatment you may be asked to have tests to see how well your heart is working.
• You will also have other blood tests to check your electrolyte levels.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department, if you get any of the symptoms listed above.

• You may get:
  • chest pain or tightness
  • shortness of breath 
  • swelling of your ankles 
  •  an abnormal heartbeat.
• Heart problems can occur months to years after treatment.
• Tell your doctor if you have a history of heart problems or high blood pressure.
• Before or during treatment, you may be asked to have a test to see how well your heart is working.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the symptoms listed above.

• This side effect is rare, but can be very serious.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of these signs or symptoms:
  • severe stomach pain 
  • swollen and hot skin around your stomach 
  • bleeding 
  • nausea or vomiting 
  • fever or chills 
  • a fast heartbeat
  • you feel short of breath.

• This treatment may cause changes to how your kidneys work. This may cause protein in your urine.
• This is not something that you will notice.
• You will have blood and urine tests to check that your kidneys are working properly.

• Blood clots can occur with this treatment. 
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you get any of the following signs or symptoms:
  • redness, heat or pain in your leg(s)
  • numbness or weakness in your face, arm or leg
  • chest pain
  • sudden shortness of breath
  • dizziness
  • trouble speaking
  • blurred vision
  • severe headache
  • unexplained falls or loss of balance.

• This treatment can have an effect on your brain, but this is rare.
• Tell your doctor or nurse immediately or go to the nearest hospital Emergency Department if you get any of the following signs or symptoms:
  • headaches or vision problems
  • nausea and vomiting
  • tiredness
  • confusion
  • fits (seizures)
  •  high blood pressure.

• You may get: 
  • yellowing of your skin or eyes
  • itchy skin 
  • pain or tenderness in your stomach
  • nausea and vomiting
  •  loss of appetite
• You will have regular blood tests to check how well your liver is working.
• Tell your doctor or nurse as soon as possible if you notice that your urine is a dark colour, the whites of your eyes look yellow, or if you have stomach pain.

• The palms of your hands and soles of your feet may become:
  • red and hot
  • swollen
  • painful and tender
  • blistered.
• The skin in the area may also peel.
• Moisturise your hands and feet daily with sorbolene or aqueous cream.
• Keep your hands and feet clean and dry.
• Avoid hot water, instead use lukewarm water to bathe.
• Avoid direct sunlight.
• Avoid unnecessary walking, jogging or exercise.
• Wear cotton socks and avoid tight-fitting shoes.
• Tell your doctor or nurse as soon as possible if you notice any skin changes on your hands or feet.

• This treatment lowers the amount of platelets in your blood. Platelets help your blood to clot. When they are low, you are at an increased risk of bleeding and bruising.
• Try not to bruise or cut yourself.
• Avoid contact sport or vigorous exercise. 
• Clear your nose by blowing gently.
• Avoid constipation.
• Brush your teeth with a soft toothbrush.
• Don't take aspirin, ibuprofen or other similar anti-inflammatory medications unless your doctor tells you to.
• Tell your doctor or nurse if you have any bruising or bleeding. 
• Tell your doctor or nurse immediately, or go to your nearest hospital Emergency Department if you have any uncontrolled bleeding.

• You may not feel like eating.
• Try to avoid drinking fluids at meal times.
• Try to eat small meals or snacks regularly throughout the day.
• Try to eat food that is high in protein and calories.
• If you are worried about how much food you can eat, or if you are losing weight, ask to speak to a dietitian.

• You may have bowel motions (stools, poo) that are less frequent, harder, smaller, painful or difficult to pass.
• You may also get:
  • bloating, cramping or pain
  • a loss of appetite 
  •  nausea or vomiting.
• Drink plenty of fluids (unless you are fluid restricted).
• Eat plenty of fibre-containing foods such as fruit, vegetables and bran.
• Take laxatives as directed by your doctor.
• Try some gentle exercise daily.
• Tell your doctor or nurse if you have not opened your bowels for more than 3 days.

• You may get muscle, joint or general body pain and stiffness.
• Applying a heat pack to affected areas may help.
• Talk to your doctor or nurse about other ways to manage these symptoms. You may need medication to help with any pain.

• You may feel very tired, have no energy, sleep a lot, and not be able to do normal activities or things you enjoy.
• Do not drive or operate machinery if you are feeling tired.
• Nap for short periods (only 1 hour at a time)
• Prioritise your tasks to ensure the best use of your energy.
• Eat a well balanced diet and drink plenty of fluids (unless you are fluid restricted).
• Try some gentle exercise daily.
• Allow your friends and family to help.
• Tell your doctor or nurse if you get any of the symptoms listed above.

• You can get a urine infection whilst receiving lenvatinib. 
• You may get:
  • pain on passing urine
  • burning or difficulty in passing urine
  • the need to pass urine more often
• Drink plenty of water 
• Avoid alcohol and caffeine 
• Tell your doctor or nurse as soon as possible, if you get any of the symptoms listed above  

• You may:
  • fatigue and low energy levels
  • depression
  • slow heart rate
  • unexplained weight gain
  • intolerance to cold temperatures
  • fatigued and aching muscles
  • dry, coarse skin
  • puffy face
  • hair loss
  • constipation
  • problems with concentration
• You will have regular blood tests to check how well your thyroid is working
• Tell your doctor or nurse if you get any of the symptoms listed above.

• You may feel dizzy, light-headed, tired and appear more pale than usual.
• Tell your doctor or nurse if you have any of these signs or symptoms. You might need a blood transfusion.
• Tell your doctor or nurse immediately, or go to the nearest hospital Emergency Department if you have any chest pain, trouble breathing, or feel like your heart is racing.

• Your hair may become dry and may break easily.
• You may lose some of your hair.
• Use a gentle shampoo and a soft hairbrush.
• Take care with hair products like hairspray, hair dye, bleaches and perms.
• Protect your scalp from the cold with a hat or scarf.
• Protect your scalp from the sun with a hat and sunscreen of SPF 50 or higher.
• Ask your doctor or nurse about the Look Good Feel Better opens in a new tab or window program (www.lgfb.org.au)

• You may get the following signs or symptoms during treatment, or after you have stopped treatment:
  • pain, swelling or infection in the gums
  • loosening of teeth
  • numbness or heaviness in the jaw
  •  poor healing of gums and sockets, especially after dental treatment
• Do your mouth care regularly. 
• See a dentist before you begin treatment and then for 6 monthly check ups.
• Make sure you tell your dentist that you are starting this treatment.
• If you need a tooth removed, talk to your doctor first, as you will need to stop treatment before the dental work. Your doctor will advise you when to stop and restart your treatment.  
• Tell your doctor or dentist immediately if you get any of the symptoms listed above.