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BACKGROUND: Treatment with rituximab and antithymocyte globulin (ATG) are associated with infusion-related rigors. Treatment for rigors associated with chemotherapy is not well studied, and the current treatments are extrapolated from research in postanesthetic shivering. Historically, meperidine was used to stop rigors, despite having several adverse events, such as anxiety, tremors, and seizures, resulting from the accumulation of meperidine’s active metabolite normeperidine. Morphine’s role in the treatment of rigors is not currently established, and there are no known studies that have evaluated the use of morphine in this setting. OBJECTIVES: To assess if the use of intravenous (IV) morphine stopped rigors associated with treatment with rituximab and ATG. The secondary objectives included determining the dose required to treat rigors and the time to resolution of rigors. METHODS: This pharmacist-led, observational, single-center, retrospective chart review included patients who were aged ≥18 years, received rituximab or ATG for a hematology or oncology indication, and received ≥1 doses of IV morphine for the treatment of rigors at Atrium Health Wake Forest Baptist between July 2016 and July 2019. The study’s exclusion criteria included receiving treatment with a medication other than morphine for the initial rigor event, having rigors after receiving a medication other than rituximab or ATG, already meeting the inclusion criteria for a previous episode of rigors, and receiving morphine for an indication other than rigors within the past 12 hours. RESULTS: Of the 620 patient charts reviewed, 574 patients received rituximab and 46 received ATG. In all, 57 patients met the study’s inclusion criteria, of whom 34 received rituximab and 23 received ATG. The incidence rates of rigors were 6% in the patients who received rituximab and 50% in those who received ATG. Most patients were aged between 60 years and 79 years and received rituximab for the treatment of diffuse large B-cell lymphoma or ATG for the prevention of graft-versus-host disease. The patients who received rituximab were more likely to have an episode of rigors during their first treatment cycle than in later treatment cycles, potentially as a result of B-cell lysis and the volume of proinflammatory cytokines released with initial cycles. Of the 57 study patients, 55 (96%) received IV morphine and their rigors stopped, of whom 16 patients required a second dose of morphine. A total of 2 patients were escalated to treatment with IV meperidine. CONCLUSION: Morphine is a safe and appropriate alternative to meperidine for the treatment of rituximab- or ATG-related rigors that can be easily accessed in an infusion suite or an inpatient unit. Future studies are needed to assess the benefit of using morphine for the treatment of rigors that are induced by the use of other oncology medications. [ABSTRACT FROM AUTHOR]

During autologous stem cell transplant, granulocyte colony-stimulating factors (G-CSF) serve the integral role of mobilizing hematopoietic cells into the peripheral blood for subsequent collection by leukapheresis. Filgrastim (Neupogen®) is a G-CSF and affects hematopoietic cells by stimulating growth and differentiation of neutrophils. Filgrastim-sndz (Zarxio®), a biosimilar of filgrastim, received landmark approval as the first biosimilar product approved by the FDA in the United States. As a result of the recent FDA approval, our medical center made the conversion in August 2016 from using filgrastim to filgrastim-sndz to provide patients the same benefits of the filgrastim injection at a reduced cost. This retrospective, observational cohort study evaluated the comparative efficacy of the filgrastim-sndz biosimilar in 147 patients who underwent mobilization prior to stem cell transplant with filgrastim between 1 August 2015 and 31 July 2016 or filgrastim-sndz between 1 September 2016 and 30 November 2017. The mean number of CD34 cells collected during apheresis was 7.38 × 106 in the filgrastim group and 8.86 × 106 in the filgrastim-sndz group. Filgrastim-sndz was significantly non-inferior, as the difference between filgrastim and filgrastim-sndz was −1.48 × 106 with an upper 95% confidence bound equal to −0.24 × 106 that did not include the non-inferiority margin of 1 × 106 (p = 0.0006). The median number of days of apheresis was 2 in both groups (p = 0.3273). In conclusion, the biosimilar product was non-inferior for mobilization and the conversion from filgrastim to filgrastim-sndz afforded patients similar efficacy for mobilization in stem cell transplant at a reduced cost. [ABSTRACT FROM AUTHOR]

Monitoring accuracy during choice RT allows subjects to maintain fast, safe RT bands and avoid overly fast, unsafe RT bands. 5 retarded adults received trial-by-trial feedback on accuracy over a number of sessions to train monitoring of accuracy and to improve RT performance. Training was introduced according to a multiple-baseline-across-subjects (with reversal) design. Training had no significant effect on subsequent RT performance, suggesting that inefficient monitoring of accuracy may be a structural characteristic of mental retardation.

Purpose The implementation, benefits, and challenges of clinical pharmacist services within a Precision Medicine Program for cancer patients are described. By relating the practice model that was developed, this report may further encourage pharmacists at cancer centers nationally to be involved and lead precision-based care in the oncology setting. Summary A clinical pharmacist was integrated into a Precision Medicine Program for oncology patients using somatic testing to identify actionable mutations and apply targeted therapy to malignancies. This pharmacist served as a drug resource for the program's molecular tumor board and oncologists seeking precision-based oncologic strategies. The pharmacist was a facilitator of drug assistance and dispensing in collaboration with the specialty pharmacy and provided care to 14 oncology patients receiving precision-based therapies. The clinical pharmacist was readily accepted as an addition to the team by both oncologists and patients and the experience served as an important learning opportunity. Conclusion The success of integrating this precision medicine pharmacist into a newly formed Precision Medicine Program and the model it can serve as may be considered for other cancer centers that may or may not have easily accessible pharmacogenomic experts and resources. This service highlights the importance of pharmacist care in such a program and the various opportunities for integration. Oncology clinical pharmacists should seek to integrate into Precision Medicine Programs and systems directing this care and develop their knowledge and understanding of genomics to continue providing the highest level of cancer care as a pivotal member of the cancer care team. [ABSTRACT FROM AUTHOR]

High-dose glucocorticoids such as prednisone are combined with cytotoxic chemotherapy in the R-CHOP or dose adjusted R-EPOCH regimens used for non-Hodgkin lymphoma (NHL). In this retrospective study, our primary objective was to evaluate the incidence of hyperglycemia during first-line R-CHOP or DA-EPOCH-R. The secondary objectives were to evaluate the incidence of chemotherapy alteration and overall survival in those with and without hyperglycemia. One hundred and sixty patients were eligible. We found that 47% of all patients had at least one hyperglycemic episode and hyperglycemia was associated with chemotherapy alteration (p = .028). Multivariate analysis revealed international prognostic index (IPI) ≥ 3 (p = .045) and chemotherapy alteration (p = .001) were associated with decreased overall survival. We conclude that hyperglycemia is common during first-line NHL treatment with R-CHOP or DA-EPOCH-R, even in the absence of known diabetes and is associated with alterations of chemotherapy. Baseline pre-PET scan fasting blood glucose of 100 mg/dL or higher may predict hyperglycemia during therapy. [ABSTRACT FROM AUTHOR]

Background Extended infusion (EI) dosing provides a longer time above the minimum inhibitory concentration, which is important for the clinical success of β-lactam antibiotics, especially for patients with impaired immunity. The aim of this study was to determine the feasibility and clinical impact of administering cefepime by EI as treatment of febrile neutropenia. Methods This was a prospective, randomized, comparative pilot study. All patients received cefepime 2 g IV every 8 h, with the first dose administered using a 30-min infusion. After the first dose, patients were randomized to receive cefepime over 30 min as a standard infusion (SI) or 3 h (EI). Patients were >18 years old with febrile neutropenia (neutrophil count <500 cells/mm3 and temperature >38.0ºC) and received chemotherapy or stem cell transplant as treatment for malignancy. Patients were excluded for the following: allergy to a cephalosporin, creatinine clearance (CrCl) < 50 mL/min, receipt of concurrent Gram-negative antimicrobial, sepsis, or solid tumor malignancy. The primary outcome was defervescence by 72 h. Secondary outcomes included time to defervescence, clinical success, in-hospital mortality, hospital length of stay, and need for additional antimicrobials. Main results Sixty-three patients were enrolled: 33 in the SI arm and 30 in the EI arm. The groups were similar with regard to age, gender, weight, estimated creatinine clearance, and duration of neutropenia. None of the patients in the EI arm withdrew due to practical complications of receiving EI cefepime. Twenty-three patients in the SI arm and 20 patients in the EI arm defervesced by 72 h (p = 0.99). There were no differences in secondary outcome measures; however, patients in the EI arm appeared to have defervesced more rapidly (median 19 vs. 41 h, p = 0.305). Conclusion Administration of cefepime by EI for the treatment of febrile neutropenia is feasible. Larger clinical trials are necessary to determine if EI cefepime imparts a clinical benefit in the treatment of febrile neutropenia. [ABSTRACT FROM AUTHOR]