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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.

Objectives To identify and analyze the phosphate concentration in glaucoma eye drops available in Spain. Material and methods Glaucoma medications containing phosphates were identified according to the 2013 Vademecum and the website of the Spanish Agency for Medicines and Medical Devices. Phosphate concentration was determined in these eye drops using ultraviolet molecular absorption spectrophotometry, and pH was determined using scan image analysis algorithms of pH strips. Results A total of 37 phosphate containing glaucoma eye drops were identified. The mean phosphate concentration was 97.72 ± 75.52 mM. The group with higher concentration of active substance was timolol (204.85 ± 42.38 mM) followed by brimonidine/timolol (200.9 mM). No statistically significant difference was found between brand name (95.65 ± 71.11 mM) and generic eye drops (99.14 ± 80 mM, p = 0.892). Although no statistically significant difference was found between products containing preservatives (99.24 ± 76.78 mM) and those without preservatives (85.17 ± 72.86 mM) (p = 0.730), a lower phosphate concentration was observed in the preservative-free Timolol and Latanoprost. Single dose samples showed a lower phosphate concentration than multi-dose ones (102.04 ± 75.39 vs. 22.24 ± 2.98 mM, p Conclusion The phosphate concentration in glaucoma eye drops exceeded the tear film physiological level (1.45 mM). No difference was observed between brand names and generic eye drops. Lower phosphate concentration was observed in preservative-free single dose eye drops.

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 Respiratory syncytial virus (RSV) infections can be prevented by good hygiene and prophylactic palivizumab, a monoclonal antibody against the fusion protein of VRS. The criteria for selecting patients for palivizumab prescription in our hospital are: Purpose To describe the use of palivizumab in the vaccination campaign in our hospital, evaluating the appropriateness of its use by the established criteria and its effectiveness. Material and methods We performed a retrospective observational study. All patients who received palivizumab between 01/10/2013 and 31/03/2014 were included. The data collected using the clinical records were: sex, gestational age, selection criteria, and number of hospitalizations due to acute bronchiolitis between 01/10/2013 and 30/09/2014. RSV was analysed in these patients by Polymerase Chain Reaction (PCR). Results Palivizumab was administered to 68 patients (48.5% female) with a median gestational age of 209 days (176–287). 24 patients (35.3%) fulfilled criterion 2, 14 (20.6%) criterion 1, 10 (14.7%) criterion 4, 5 (7.3%) criteria 1 and 3, 4 (5.9%) criteria 2 and 4, 3 (4.4%) criterion 3, 2 (2.9%) criteria 3 and 4. 4 patients did not meet any criteria and 2 had no data. Only 6 patients who received palivizumab were hospitalised with a diagnosis of acute bronchiolitis and their RSV PCRs were negative. Conclusion Palivizumab is used under the established criteria in our hospital. The study data show that immunising these at-risk patients with the palivizumab vaccine was an effective strategy for at least one year. Although the study period was 1 year, it would be desirable to measure effectiveness over a longer period. References and/or Acknowledgements No conflict of interest.

Background Triple therapy-based treatment with protease inhibitors in infected genotype 1 hepatitis C (HCV) patients improves efficacy measured as sustained virological response (SVR). Purpose To compare the effectiveness and safety of triple therapy-based treatment in mono-infected and co-infected HCV-HIV patients. Material and methods All treatments started between 2012/07/01 and 2013/12/31 were analysed. A retrospective evaluation was made of electronic medical records and outpatient pharmacy records. SVR was defined as undetectable viral load at week 60. Results 83 patients were included, 80 treated with telaprevir and 3 with boceprevir, 58 mono-infected and 25 co-infected patients. Baseline characteristics in mono-infected patients were: 83% male, mean age 54 years; 26 genotype 1a, 30 1b, 2 untypable; 64% F4; 40% were treatment-naive, 14% relapsers, 12% partial responders, 31% null responders and 3% no data. In co-infected patients: 84% male, mean age 50 years; 17 genotype 1a, 71b, 1 untypable; 92% F4; 40% were treatment-naive, 28% relapsers, 12% partial responders, 12% null responders and 8% no data. We were able to assess the effectiveness of treatment in 71 patients, who achieved 60 weeks of treatment: 51 mono-infected and 20 co-infected. In the mono-infected group: 21 (41%) achieved SVR (86% treatment-naive or relapsers), 20 (39%) had a detectable viral load (50% null responders) (3 boceprevir-treated) and 10 (20%) discontinued treatment due to toxicity or disease progression. This compared with 11 (55%) (73% treatment-naive or relapsers), 8 (40%) (38% null responders) and 1 (5%) in the co-infected group. Adverse events were: anaemia 58%, neutropenia 81% and thrombocytopenia 36% in mono-infected vs. 44%, 80% and 52% in co-infected patients. Conclusion The rate of SVR was about 50%, higher in co-infected than in mono-infected HCV patients. However, it may have been affected by a greater proportion of null responders in the mono-infected group (p > 0.05), because as in published trials, the rates of SVR differed among patients with different responses to previous treatments. References and/or Acknowledgements Zeuzem S, Andreone P, Pol S, et al . Telaprevir for retreatment of HCV infection. N Engl J Med 2011;364:2417–28 Jacobson IM, McHutchison JG, Dusheiko G, et al . Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med 2011;364:2405–16 No conflict of interest.

Background Our Hospital Pharmacy Service (HPS) participates in the process of authorising off-label indications (OLIs) of drugs. Immunosuppressants are often used in OLIs. Purpose To analyse prescriptions for oral immunosuppressants dispensed as OLI in our HPS Outpatient Unit (HPSOU) to identify points in the system that could be improved. Material and methods Retrospective study of oral immunosuppressants dispensed at our centre between March 2012 and March 2014. Variables collected were age, sex, drug, prescribing service and indication; obtained from the HPSOU database and the electronic medical history. Results 269 patients (median age 52 years (5–92), 135 women (50%) and 134 men (50%)) were evaluated. 6 drugs were dispensed in 8 different medicinal products: tacrolimus 94 patients (35%), mycophenolate mofetil 78 (29%), mycophenolic acid 56 (21%), ciclosporin 34 (17%), everolimus 6 (2%) and sirolimus 1 (0.3%). 11 services were involved: Haematology (89 patients: 33%), Rheumatology (61: 23%), Nephrology (56: 21%), Ophthalmology (15: 6%), Digestive (14: 5%), Pneumology (10: 4%), Paediatrics (9: 3%), Neurology (8: 3%), Internal Medicine (4: 1%), Dermatology (2: 0.7%) and Oncology (1: 0.3%). Immunosuppressants were dispensed for 35 different indications. Main indications and their treatments were: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) for 75 patients (28%), with tacrolimus (71%), mycophenolate mofetil (17%) and ciclosporin (12%); Systemic Lupus Erythematosus (SLE) for 46 (17%), with mycophenolate mofetil (62%), mycophenolic acid (30%) and tacrolimus (8%) and Membranous Glomerulonephritis (MGN) for 20 (7%), with mycophenolic acid (50%) and tacrolimus. Conclusion The use of oral immunosuppressants as OLI is an established treatment for various indications, specially, allo-HSCT, SLE and GMN. The creation of multidisciplinary groups to develop protocols for the management of these drugs is required. References and/or Acknowledgements Summaries of product characteristics of the evaluated medicinal products. No conflict of interest.

Background A drug adjustment programme for patients with renal disease was started in 2013 in our hospital. In this system, information from the electronic prescription programme is linked (using an Access application) with information sent by the laboratory (creatinine) and with a list of drugs that may require renal adjustment. Afterwards, an adjustment warning for the physician is added to the electronic prescription programme. Purpose To assess the acceptance by the physicians of pharmaceutical interventions in drug dosing in renal disease. Material and methods This prospective descriptive study was conducted in a tertiary university hospital with 1,200 beds. The study period was 39 days (from January 21st to March 20th, 2014). The pharmaceutical interventions were recorded during daily practice. The following data were collected: date of pharmaceutical intervention, clinical chart number, medical service, age, sex, creatinine, glomerular filtration rate, adjusted drug, adjustment warning. Finally, the degree of acceptance of these interventions by the physicians was reviewed. Results During the study period, 153 patients (mean age 75.3 years, 78 male and 75 female) were included and 271 renal adjustment interventions were performed (mean: 7 interventions per day). The degree of acceptance of the interventions was: accepted 84 (31.0%), partially accepted 25 (9.2%), not assessable 49 (18.1%), not accepted 112 (41.3%) and other (not an appropriate intervention) 1 (0.4%). Excluding not assessable and inappropriate interventions (finally 221 interventions), the result was: accepted 84 (38.0%), partially accepted 25 (11.3%) and not accepted 112 (50.7%). Conclusion The acceptance of pharmaceutical interventions by the physicians is approximately 40%, which is relatively low. One of the reasons of this low acceptance could be the location of the adjustment warning. Finally, it is necessary to consider what could be done to improve the acceptance of this type of pharmaceutical interventions. References and/or Acknowledgements No conflict of interest.

Background New oral anticoagulants are an alternative to acenocoumarol in the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation. Purpose To assess the suitability of prescriptions for new oral anticoagulants for those diagnoses, in accordance with criteria established by the health organisation and to analyse pharmaceutical interventions. Material and methods A prospective, observational and cross-sectional study of all patients admitted to our hospital who were prescribed dabigatran, rivaroxaban or apixaban from 01/02/2014 to 31/08/2014. Electronic medical records and electronic medical prescriptions were used as data sources. Demographics (age, gender), reason for admission, indication for anticoagulation, risk factors for complications such as renal and hepatic failure, concomitant drugs that increase the risk of bleeding (NSAIDs, platelet inhibitors, low molecular weight heparins) and adverse events were collected. In addition, adverse drug-related events avoided were also recorded. Results 64 patients (36 men) with mean age of 76 years (range 35–95) were included. 24 patients were treated with dabigatran, 38 with rivaroxaban and 2 with apixaban. 4 of these treatments were used as off-label treatments. 8 patients had renal failure and 23 had a risk of major bleeding due to concomitant treatments, mainly NSAIDs. Pharmaceutical interventions were performed in the 8 cases of renal failure because the doses needed adjustment. 14 patients with concomitant drugs that could increase the risk of bleeding were also monitored. 100% of recommendations were accepted by physicians. 2 severe adverse events were recorded: 2 bleeding episodes. Conclusion 94% of new oral anticoagulant prescriptions met the criteria established by the healthcare organisation. Pharmacists were involved in the optimisation of a third of the treatments, with total acceptance. It would be desirable to extend this activity, individualization of anticoagulant treatment, into primary medical care. Reference Agencia Espanola de Medicamentos y Productos Sanitarios. Informe de posicionamiento Terapeutico UT/V4/23122013 No conflict of interest.

Background When an unrelated donor is used for an allogeneic hematopoietic stem cell transplant (AlloHSCT) highly immunosuppressive treatment is needed during the early post-transplant period as prophylaxis against acute graft versus host disease (aGVHD). Tacrolimus is one the drugs used with a target level of 5–15 ng/mL. Purpose To compare the accuracy of real plasma tacrolimus levels with target levels in the immediate post-transplant period. Materials and methods A retrospective review was made between 2008/01/01 and 2013/09/30 of all aGVHD prophylaxis that included tacrolimus. Data were obtained from the electronic medical history records and the Pharmacy Unit intravenous database. Results Tacrolimus was used in 46 patients (17 women) with a median of 51 years old (17–69). First dose of tacrolimus was administered on day -1 at 0.03 mg/kg/day by continuous intravenous infusion. Only half of patients, 23 (50%), were within the therapeutic range when the first measure was made. Supratherapeutic levels were found in 15 patients and infratherapeutic in 8 patients. This first tacrolimus plasma level was obtained between day + 2 and + 11. Conditioning was done with myeloablative regimens (fludarabine-busulfan: 13 patients; total body irradiation and cyclophosphamide: 5 patients) and non myeloablative regimens (fludarabine-melphalan: 7 patients; fludarabine-busulfan: 17 patients; fludarabine-cyclophosphamide: 4 patients). Antibiotic prophylaxis was administered in all cases with ciprofloxacin and antifungal prophylaxis was fluconazole, voriconazole and caspofungin for 42, 3 and 1 patient, respectively. A direct relationship has not been found between the day of measurement, conditioning regimen, antibiotic or antifungal prophylaxis and the tacrolimus plasma level obtained. Conclusions There is great discordance between theoretical tacrolimus plasma levels and real levels. Renal function doesn’t affect tacrolimus pharmacokinetics, although it is potentially nephrotoxic, which might require dose adjustment. After this review a pharmacokinetic drug interaction among drugs used during conditioning or antibiotic or antifungal prophylaxis was excluded. A thorough investigation of how tacrolimus samples are obtained and handled is mandatory. No conflict of interest.

Background Oral chemotherapy against metastatic or advanced renal-cell carcinoma (mRCC) is currently benefiting from a wide range of possibilities. Purpose To analyse the effectiveness of the actual therapy for the treatment of the mRCC in real conditions based on survival at one and two years and modifications in dosage or drug. Materials and methods Retrospective evaluation of clinical history from November 2011 to September 2013. In our hospital tyrosine kinase inhibitors were the first line treatment and mTOR inhibitors were the second line. Results 68 patients were treated for mRCC. Male/Female: 73/27. Average age: 64.6 years. After 1 year of treatment 81.4% patients survived (22/27) and 42.8% after two years (3/7). 44/68 patients (65%), needed a drug change due to progression. Average time to change was 6.4 months (59% CL: 4.6–8.1) (median: 5.1). 8/68 (11.7%) required a treatment change towards a third line. Of these 8 patients; 3 restarted treatment with sunitinib as fourth line. Out of 41 patients who initiated therapy with sunitinib 50 mg once daily on schedule 4–2; 19 patients (46.3%) needed a descending adjustment of the dose. The average time to dose adjustment was 4.2 months (59% CL: 2.6–5.7) Conclusions Oral treatment of advanced renal cancer has several therapeutic possibilities; which must be treated with rigorous criterion in favour of the clinical benefit applying the maximum efficiency. Even limited by the small sample size, the results are similar to those previously reported in this setting. First year survival rate: 81.4% vs. 75% 1 Second year survival rate: 42.8% vs. 50% 1 Of the 68 patients studied, 65% required a drug change during their treatment mostly due to loss of efficacy. Sunitinib 50 mg 4–2 schedule dose adjustment: 46.3% vs. 46% 2 (33% + 13%) Time to dose adjustment: 4.2 months versus 7.5 months 2 References RJ Motzer, B Escudier, R Bukowski, et al . Prognostic factors for survival in 1059 patients treated with sunitinib for metastatic renal cell carcinoma. British Journal of Cancer 2013;108:2470-2477 Martin E Gore, Cezary Szczlik, Camillo Porta, et al . Safety and efficacy of sunitinib for metastatic renal-cell carcinoma: an expanded-access trial. Lancet Oncol 2009;10:757-63 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.

Background Vitamin D is essential for strong bones because it helps the body use calcium from the diet. Because most people have low levels of vitamin D, correcting to the recommended ranges will bring added value to patient healthcare in hospital. Purpose To detect patients with low vitamin D levels in an Orthopedic ward. To evaluate the degree of acceptance of the pharmacist9s recommendations to correct vitamin D levels by the physicians. To devise an educational session for patients and evaluate the efficacy of the intervention. Materials and methods From 7/03/2011 to 9/03/2011, total serum 25-hydroxycholecalciferol ((25OH)D 3 ) was measured in patients on the Orthopedic ward. A lack of vitamin D was defined as ((25OH)D 3 ) ≤30 ng/mL. The individual recommendation for vitamin D supplementation was written in each patient9s medical record by the pharmacist. Patients presenting low vitamin D levels were randomised to enrol in the educational programme, consisting of a 15-min session about vitamin D, nutritional habits, and supplementation with vitamin D. All patients were given an appointment 2 months later for a vitamin D test to evaluate the efficacy of the intervention. Conclusions There was a significant vitamin D deficiency in the population studied. Pharmaceutical intervention has been proved useful when adjusting vitamin D levels.