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Background In the pivotal authorisation trial of carfilzomib, patients with severe cardiovascular abnormalities (NYHA III or IV), clinically significant and uncontrolled, were not included. Purpose The aim of this study was to analyse the cardiovascular events (CVAE) associated with carfilzomib in patients in whom an electrocardiogram was performed prior to starting treatment and compare these data with those of the pivotal trial. Material and methods Retrospective observational study in which all patients treated with carfilzomib were included. The data obtained from the electronic medical record were: age and comorbidities at diagnosis, schemes used prior to carfilzomib, dose of carfilzomib and development of CVAE after the use of carfilzomib. Results Thirty-six patients (19 males) with a median age 59 years (RIQ 53–67) were included. Seventy-eight per cent had comorbidities at the time of diagnosis, the most frequent being arterial hypertension (HTA) (16), followed by diabetes mellitus and dyslipaemia (seven in both). The average of previous regimens was one (30), with VCD (bortezomib, cyclophosphamide and dexamethasone) in 28 patients. In 34 patients the scheme used was KRD (carfilzomib, lenalidomide and dexamethasone) at a dose of 27 mg/m2. In two patients the dose was reduced due to adverse effects (hepatotoxicity and nonspecific toxicity). The incidence of all grades CVAE was 19.4% (three congestive heart failure, two paroxysmal atrial fibrillation, and one transient ischaemia and new onset HTA). Of all of them, 71% presented as comorbidity to the diagnosis of hypertension. Median age of patients was 65 years (RIQ 65–76). Two patients discontinued the treatment, three patients required modification of the diuretic treatment and in one patient the infusion time of carfilzomib was modified. Conclusion As in the ASPIRE study, patients are referred to the cardiology service prior to starting treatment and the expected results are similar (19.4% vs 22.3% in ASPIRE). The most vulnerable patients of developing CVE were those over 65 years of age, since they present more comorbidities pre-treatment. However, it should be mentioned that myeloma itself, or the corticosteroids, can also contribute to cardiovascular deterioration. References and/or acknowledgements Stewart AK, Rajkumar SV, Kimopoulos MA, et al; ASPIRE Investigators. Carfilzomib, lenalidomide, and dexamethasone for relapsed multiple myeloma. N Engl J Med 2015;372:142–52. No conflict of interest.

Background Vancomycin is a glucopeptide antibiotic widely used to treat Gram positive related infections. It is well known for its nefrotoxic and ototoxic profile, but neutropaenia and thrombocytopaenia are not so well described. Purpose The aim of this study was to describe the prevalence of some relevant vancomycin-related adverse events (AE): neutropaenia, thrombocytopaenia and acute kidney injury (AKI). Material and methods This retrospective observational study was conducted in all patients admitted to Donostia University Hospital that received vancomycin during 2016 and 2017 and were monitored by the pharmacy department (PD). Exclusion criteria: patients with neutropaenia, thrombocytopaenia or AKI prior to vancomycin therapy. Collected data: diagnosis, absolute neutrophil count (ANC), absolute platelet count (APT) and creatinine clearance (CrCl, calculated with Cockcroft–Gault formula) prior and during vancomycin therapy. Neutropaenia was defined as ANC Results A total of 177 patients were reviewed, with a mean age of 63.4±16.4 and 32.8% were women. Almost half of the patients 48.6% (n=86) had an ostearticular infection: bacteriemia accounted for 36.2% (n=64). The rest of the infections were related to the central nervous system 3.4% (n=6), endovascular system 3.4% (n=6) and others 8.4% (n=15). Patients excluded: eight due to neutropaenia (n=169), 15 due to thrombocytopaenia (n=162) and 14 due to AKI (n=163) prior to vancomycin therapy. Neutropaenia was developed in seven patients (=1:24), thrombocytopaenia in 12 patients (=1:14) and AKI in 26 patients (=1:6). The prevalence of nephrotoxicity is described as common (1:100–1:10) in the summary product characteristics (SPC). However, neutropaenia and thrombocytopaenia are classified as rare undesirable effects (1:10.000–1:1.000). Conclusion The prevalence of AE related to vancomycin therapy is higher than reported in SPC. In our study neutropaenia was reported in 7:169 patients, thrombocytopaenia in 12:162 and AKI in 26:163. The difference between SPC and our clinical practice is considerable. However, it should be noticed that only patients monitored by PD were reviewed, and therefore the number of patients included is low. It is of high importance to continue reporting any AE related to vancomycin therapy to the appropriate pharmacovigilance institution in order to better understand the toxic profile of the drug. References and/or acknowledgements No acknowledgements. No conflict of interest.

Background The therapeutic strategy for chronic hepatitis C (CHC) in our health system established that in mono- or co-infected HCV/HIV patients in whom prioritised therapy with glecaprevir/pibrentasvir is contraindicated, their chronic medication (CM) will be changed and/or an alternative therapy for HCV will be used: sofosbubir/velpatasvir (+7% cost per patient) or elbasvir/grazoprevir (+64% cost per patient). Purpose To analyse the influence of pharmacological interactions in the selection of HCV treatment in opiate-dependent patients. Material and methods All treatments started in a Mental Health Network (which opiate-dependent patients attend) from 1 January 2018 to 31 August 2018 were analysed. Prior to the approval of hepatitis C treatment by the CHC committee, the pharmacist reviewed the treatment and looked for possible pharmacological interactions of the HCV prioritised therapy with the CM. If there was a significant interaction, the pharmacist recommended either to change/stop the CM or to choose an alternative HCV treatment. Results Approved treatments by the CHC committee: 96. Completed treatments: 73, 98% monoinfected. HCV genotype: 1a: 31 (42%), 3: 22 (30%), 4: 11 (15%), 1b: seven (10%) and 2: two (3%). Forty-seven (64%) patients were ≤F3, 21 (29%) F4 and five (7%) were unknown. 64/73 (88%) patients were treated with glecaprevir/pibrentasvir. A CM change was needed in 14/64 (22%) patients: to avoid metamizole, delay proton-pump inhibitor administration time, to switch to another statin and stop oxcarbazepine. Only 9/73 patients (12%) received a non-prioritised treatment with sofosbuvir/velpatasvir. In eight of them due to interactions with their CM: antipsychotics (five), HIV protease inhibitor (one), anti-platelet (one) and ethinylestradiol (one). In another patient the reason was that he was Child-Pugh B. The sustained viral response is available only in 20% of patients, so the effectiveness has been measured as viral response at the end of treatment (VRE), being 96% (70/73) up to date. Three patients are pending to be determined. Conclusion The review of pharmacological interactions has allowed the treating of 88% of patients with the prioritised therapy, with an effectiveness in VRE of 96%, according to the results of the clinical trials. The pharmacological interactions evaluation and pharmaceutical interventions optimize the risk benefit ratio and contribute to the efficient use of HCV therapies. References and/or acknowledgements No acknowledgements. No conflict of interest.

Background Following a request by the Central Management Organisation of our Health System (HS), a decision was made to change from a patented drug of three active principals, emtricitabine/tenofovir-disopropilo/rilpivirine (FTC/TDF/RPV) to two drugs, one patented (RPV) and one generic drug (FTC/TDF). Both were administered once-daily, providing the same therapeutic efficacy and treatment compliance but in a more cost-effective way. Purpose To describe the procedure to implement this strategy and patient’s acceptance of it. Material and methods After several meetings between the Pharmacy (PD) and the Infectious Diseases Department (IDD) it was decided to make the change at the following patient’s visit to the HS, either in the PD when the patient attended to pick up the medication or in the IDD in the patient’s scheduled consultations. Inclusion criteria: HIV patients treated with FTC/TDF/RPV up to June 2018 using e-prescribing records. Patients that did not contact our HS were excluded. A retrospective review from July to October 2018 was conducted. Patients that would not accept the PD’s change were referred to the IDD. Collected data were: age, gender, treatment after the change and acceptance. Results Out of 133 patients, seven were excluded. Mean age 47.6 years, 20% women. PD was responsible for 86% of the changes. Out of 126 patients included, 16 (13%) did not accept the change. Of these 16 patients, five ended up accepting it (three after visiting the IDD and two on their second visit to the PD) and 11 declined to switch therapy for the following reasons: swallowing problems (one) (actual treatment: elvitegravir/cobicistat/emtricitabine/tenofovir-alafenamide); adverse events (actual treatment: dolutegravir ±TDF/FTC (one); abacavir/lamivudine (two) or lamivudine (one); and six patients continued with FTC/TDF/RPV (four waiting for IDD next consultation and two due to medical decisions). Conclusion By the time this abstract was written, the change was made in 115/126 patients (91%). It is very important to highlight the efficient teamwork between the PD and the IDD in order to implement the new strategy in a short period of time. Although initially 13% disagreed, finally only 9% of patients did not accept the proposed change. On the other hand, this strategy has reduced the economic impact of HIV treatment in 51% of patients. References and/or acknowledgements Infectious Diseases Department. No conflict of interest.

Background Polypharmacy and drug-related problems (DRP) increase the likelihood of negative health outcomes such as adverse reactions, interactions or lack of adherence. Moreover, published studies report DRPs as a frequent cause of hospitalisation and visits to emergency departments (ED), which makes it a target scenario for investigation. Purpose The aim was to analyse DRP and to explore its contribution to visits to the ED. Material and methods Prospective study was carried out in the ED of a tertiary hospital on polymedicated patients (≥5 drugs). Period of intervention: April–September 2018. Pharmacists collected information from previous reports, current emergency reports and prescriptions from the electronic prescribing records. Afterwards, patients were interviewed in order to check the information. The detected DRP were communicated to physicians (primary care, hospital specialist, ED) according to Pharmaceutical Care Network Europe Foundation V6.01 classification which was adapted. The ED physician was asked: ‘Do you think that any drug related problem has been able to contribute to the emergency visit?’ ‘Which one?’ The study is supported by the Ethics Committee of Gipuzkoa Health Area. Results One-hundred and one of 138 patients (73%) presented some DRP. The pharmacists considered that in 65 of 116 patients (47%) the DRP contributed to the visit to the ED. Thirty-three (50%) were male, mean age 75 years and an average of 9.2 prescriptions. The main reasons to go to the ED were: 16 (24%) dyspnea, six (9%) melaena, six (9%) dizziness and five (7.5%) general discomfort. DRP considered related to the visit were: 31 (47.7%) adverse effect, 20 (30.8%) adequate therapy but ineffective, three (4.6%) high dose, three (4.6%) lack of adherence, three (4.6%) indication without drug and four (6.2%), other. The ED physician agreed with the pharmacist in 94% of the cases, Cohens kappa: 0.913. Conclusion The prevalence of DRP and its contribution to the ED visit is higher than in other studies. 1, 2 Maybe this is due to a different methodology and patients’ characteristics (age, polypharmacy). 3 There is a high degree of agreement between the pharmacist and the ED physician in assessing the cases of DRP and the ED visit. The integration of a pharmacist in the ED has facilitated the detection of DRP and helped to identify their link with ED visits. References and/or acknowledgements 1. https://www.ncbi.nlm.nih.gov/pubmed/12126224 2. https://www.ncbi.nlm.nih.gov/pubmed/24493969 3. https://www.ncbi.nlm.nih.gov/pubmed/25795686 No conflict of interest.

Background Percutaneous radiologic gastrostomy (PRG) consists of inserting a long-term catheter in the gastric cavity through the anterior abdominal wall. The catheter is replaced every 6 months (180 days). However, it can often require a replacement in advance due to obstruction or bad management of the catheter. Purpose To analyse the most common causes of PRG replacement and its frequency. Material and methods An observational retrospective study was conducted. All patients with PRG were included. Also analysed was PRG indication, number of replacements and its causes, the average duration of catheter placement and the reason of removing it. All the data havw been collected from electronic medical records and have been processed through the Stata statistics program. Results A total number of 63 patients that had a 16 Fr catheter in place were included; 42 were males and 21 females with a mean age of 65.5±11.8. The median follow-up was 113 days. PRG indications were: 46% (29) head and neck tumour, 17.5% (11) amyotrophic lateral sclerosis (ALS), 16% (10) cerebrovascular accident, 1.5% (one) dementia and 19% (12) others. Ninety-four catheters were replaced, from which 79% (74) were not programmed due to: 34% (32) catheter came out, 17% (16) broken catheter, 9.5% (nine) medicines obstruction, 5.5% (five) obstruction due to liquid diet, 3.5% (three) leak, 1% (one) infected stoma and 8.5% (eight) others. The average duration of PRG before being replaced was 205±190 days in those patients that were programmed, whereas 78±66 days in those non-programmed. The average duration for a gastrostomy was 170 days. Results vary depending on the pathology: 263±164 days for ALS, 173±179 days for head and neck tumour and 134±123 days for cerebrovascular accidents. In 52 patients the catheter was removed, due to recovery (32%) or death (68%). Conclusion Only one-fifth of the catheter replacements were programmed. The most common causes were because they came out or they were broken. In order to prevent these complications it is necessary to develop standard operational procedures and patient information leaflets on catheter management by a multidisciplinary team including nursing, medical and pharmacy staff.

Background In our hospital, prescription, assessment and complication management of patients with tube feeding by enteral nutrition (EN) is made by a hospital pharmacist, who systematically monitors patients with EN. Purpose To describe the role of a hospital pharmacist monitoring patients with EN via different types of enteral tubes and to analyse the interventions made. Material and methods All patients (except those from the intensive care unit) were evaluated from 1 January to 31 July 2015. Data were obtained from the pharmacist´s nutritional records. Results 49 patients, 65% men, median age 66 years (45–84), were evaluated. Diagnoses were: 11 laryngeal (22%), 7 oesophageal (14%), 7 oral (14%), 3 pharynx (6%), 2 jaw (4%) and 1 mediastinal cancer (2%), 4 swallowing disorders (8%), 3 amyotrophic lateral sclerosis (6%), 3 chylothorax (6%), 3 stroke (6%), 1 acute pancreatitis (2%), 1 pharyngocutaneous fistula (2%), 1 parapharyngeal abscess (2%), 1 intestinal (2%) and 1 oesophageal perforation (2%). Enteral access were: 20 gastrostomy (41%), 19 nasogastric tube (NGT) (39%), 3 nasojejunal tube (NYT) (6%), 3 oral (6%), 1 gastrojejunostomy (2%), 2 NGT followed by gastrostomy (4%) and 1 NGT followed by NYT (2%). The administration method used was: intermittent administration exclusively in 28 (57%); continuous tube feeding infusion exclusively in 8 (16%); in 9 (18%) intermittent was changed to continuous because of diarrhoea. 4 (8%) started continuous infusion because of tolerance problems and changed to intermittent after achieving good tolerance. Among patients with continuous infusion, EN was cyclically administered in 62%. Mean duration, volume and energy intake per day were: gastrostomy (10 days, 1462 mL, 1729 kcal); NGT (15, 1539, 1804); NYT (19, 2150, 2163); oral (7, 1583, 1583); and gastrojejunostomy (39, 750, 750). 3 (6%) required oligopeptidic EN because of diarrhoea. 25 (51%) had complications: diarrhoea 14 (29%), fullness 3 (6%), nausea 2 (4%), hyperglycaemia 2 (4%), tube output 2 (4%), aspiration 1 (2%) and obstruction 1 (2%). Conclusion Most patients were oncologic with gastrostomy. Diarrhoea was the most common complication. It was managed by changing the administration method and EN type. Knowledge of the pharmacist about nutrition, industry prepared EN composition and management of complications improved, especially for oncologic patients with gastrostomy. No conflict of interest.

Background Drug dosage modifications are a common clinical practise regarding Tumor Necrosis Factor (TNF) blockers, using posologies not specified on the authorised product information summary. This practise has a significant financial impact on the healthcare system. Purpose To revise and investigate actual drug dosages in our Hospital’s rheumatology service for conventional TNF blockers. Materials and Methods The Pharmacy Service analysed the internal data record for rheumatology patients treated during April 2012 and for at least one year with infliximab (IFX), etanercept (ETN) or adalimumab (ADA). Off-label indications were excluded. Therapeutic indication, initial and current posology were recorded. Results Number of patients by drug; Number of patients by indication: RA: Rheumatoid arthritis, AS Ankylosing spondylitis, PA psoriatic arthritis, JIA: Juvenile idiopathic arthritis Regarding posology, 261 patients (65%) were on a conventional dose (CD), 93 (23%) on a reduced dose (DR) and 47 (12%) on an increased dose (DI) Percentage of patients by drug on CD, DR or DI was; Percentage of patients by indication was; Conclusions Only 65% of patients using TNF blockers on rheumatology use a CD while a quarter of them have a reduced posology. Infliximab is the drug that requires more dosage modifications, on almost 2/3 of patients. AS and PA are the indications that allow more DR. Drug dosage revisions at the end of the first year of treatment allow an important number of patients to reduce their dose while controlling their disease and it is a relevant efficacy instrument. No conflict of interest.

Background Current guidelines (GESIDA/PNS-2012) for antiretroviral therapy (ART) in adults recommend the combination of 3 drugs for the treatment of chronic HIV infection. Purpose To analyse the ART in adult HIV- infected patients monitored in our hospital. Materials and Methods A retrospective and descriptive analysis was conducted at the Outpatient Hospital Pharmacy studying the types of ART in HIV adult patients treated on 1 January 2012. Dates were obtained from the electronic outpatient database. Results 1226 patients were receiving ART. The type of therapy was: monotherapy in 40 patients (3.3%), dual therapy in 37 (3%), triple in 1107 (90.3%), quadruple in 32 (2.6%), quintuple in 7 (0.5%), sixfold in 2 (0.2%) and sevenfold in 1 (0.08%). 156 different treatments were observed with 22 drugs. The most common ART combinations were 2 nucleoside reverse transcriptase inhibitors (NRTI) plus a non-nucleoside reverse transcriptase inhibitor (NNRTI) in 585 patients (47.7%), followed by 2 NRTIs plus a protease inhibitor (PI) in 345 (28.1%) and 3 NRTIs in 75 (6.1%). 43.2% (530) received PI therapy and, mainly, boosted. The combinations tenofovir-emtricitabine or lamivudine-efavirenz were the most frequently prescribed in 358 patients (29.2%), followed by abacavir-lamivudine-efavirenz in 89 (7.3%), tenofovir-emtricitabine-lopinavir-ritonavir in 80 (6.6%), tenofovir-emtricitabine-darunavir-ritonavir in 74 (6%) and abacavir-lamivudine-zidovudine in 72 (5.9%). All patients received oral treatment and 3 of them subcutaneous treatment with the T-20 fusion inhibitor. 621 patients (50.7%) received once-daily treatment (49.3%), 604 twice-daily and one patient three doses daily. Regarding the number of dosage forms, 337 (27.5%) patients were taking one, 273 (22.3%) five, 238 (19.4%) three, 77 (14.4%) were taking two. Conclusions On January 2012, 76% of our hospital HIV patients treated with ART were taking triple combinations of 2 NRTIs + 1 NNRTI or 1 PI. All patients except one received once or twice daily treatment and 42% took 1 or 2 dosage forms/day. No conflict of interest.

Background Multiple myeloma (MM) is a malignant monoclonal gammapathy that occurs mainly in patients over 65 years. Lenalidomide is indicated in combination with dexamethasone for the treatment of MM in patients who have received at least one prior treatment regimen. All this makes it likely the patient will require Pharmaceutical Care (PC). PC consists of collaboration with other health professionals and with the patient to design a safe and effective treatment plan, as well as to identify Drug Related Problems (DRPs) and to resolve and prevent negative outcomes associated with medication (RNMs). Purpose To evaluate the impact of pharmaceutical intervention in patients diagnosed with MM treated with lenalidomide in a pharmacists-led haematological consultation within the Pharmacy Service. Materials and Methods Quasi-experimental study of 4 months duration on patients diagnosed with MM treated with lenalidomide. Clinical practise follow-up procedures used the Dader method adapted to the study situation. Data were obtained from interviews with patients, electronic medical records and Outpatient Service Pharmacy records. Results During this period, 29 patients were diagnosed with MM and treated with lenalidomide, 21 joined the study (4 didn’t gave consent and 2 weren’t able to visit the pharmacy), 11 women and 10 men. Average age: 70.3 years (52–89). During study a total of 17 DRPs were detected: 4 related to the indication, 1 to the effectiveness and 8 to the safety, and a total of 35 RNMs: 4 related to the need, 5 to the effectiveness and 26 to the safety. Of these 35, 45.7% could have been avoided. A total of 25 pharmaceutical interventions were made: 10 related to the amount of drug, 9 to the pharmacological strategy and 6 to patient education. Conclusions A variety of goals were achieved through pharmaceutical interventions: medicines reconciliation, resolution of health problems by detecting RNMs and avoidance of RNMs by detecting DRPs. No conflict of interest.