Search

Introduction: Oral targeted anticancer drugs (OTADs) have become a key component of therapy for multiple malignancies, and their use continues to expand. While several studies have identified numerous drug interactions (DIs) associated with these oral therapies, very few have described the role of an oncology pharmacist in DI management. Objectives: The purpose of this study was to quantify moderate/severe DIs with OTADs at initiation and describe the role of the pharmacist in interaction detection and management. Methods: This retrospective analysis was completed utilizing an electronic health record review of adult patients initiated on an OTAD with pharmacist documentation of medication review between July 2020 and July 2022. The outcomes of this study included the incidence of moderate/severe DIs, the distribution of pharmacokinetic/pharmacodynamic DIs, the incidence of pharmacist documentation of moderate/severe DIs, prescriber acceptance of documented pharmacist‐recommended interventions, the evaluation of severe DIs, and presence of DI related adverse effects within 60 days of OTAD initiation. Results: Two hundred sixty‐six patients were included. Forty‐six percent (122/266) of patients had at least one moderate/severe DI identified by investigators with a total of 220 moderate/severe DIs detected. Fifty‐eight percent (127/220) of the identified DIs were pharmacokinetic and 42% (93/220) were pharmacodynamic in nature. Pharmacist documentation was present for 36% (75/207) of the moderate DIs and 92% (12/13) of the severe DIs identified at OTAD initiation, and prescribers accepted 94% (82/87) of the pharmacists' recommended interventions. Lastly, 12.5% (26/208) of the incidence of adverse effects was potentially related to moderate/severe DIs within 60 days of OTAD initiation. Conclusion: Clinically significant (moderate/severe) DIs are common in patients receiving OTADs and may impact patient outcomes. Pharmacists can help to identify, prevent, and create a plan of action for the management of DIs and we advocate for their involvement in the management of OTAD therapies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Proteinuria is a common adverse event of vascular endothelial growth factor (VEGF) inhibitors. It is unclear, however, whether proteinuria has an adverse effect on treatment course and increases treatment discontinuation in a real-world setting. OBJECTIVES: To describe our experience with proteinuria in patients receiving VEGF inhibitor therapy in a real-world community setting and provide a review of literature related to VEGF inhibition--induced proteinuria. METHODS: A retrospective analysis was conducted of 139 adults receiving treatment with a VEGF inhibitor (bevacizumab or an oral tyrosine kinase inhibitor). Patients were assessed to describe new or worsening proteinuria and its impact on the course of therapy (rates of withholding therapy, treatment discontinuation) and adverse events. RESULTS: Proteinuria occurred or worsened in 78 (56%) patients, and nonsteroidal anti-inflammatory drug (NSAID) use was more common in this group than in patients without proteinuria (42% vs 23%, respectively; P=.017). The patients with proteinuria had a longer duration of therapy (8.2 months vs 3.9 months for patients without proteinuria; P=.005) and had similar discontinuation rates as a result of documented adverse events (12% vs 23%; P=.072). The effects on serum creatinine and blood pressure were comparable between groups. The patients who had proteinuria ≥2+ were more likely than those with no or less severe proteinuria to have treatment withheld (59% vs 36%, respectively; P=.02), but treatment discontinuation as a result of documented adverse events remained similar between the patients with and without ≥2+ proteinuria (9% vs 19%, respectively; P=.163). CONCLUSION: Proteinuria resulting from VEGF pathway inhibitor therapy does not have an adverse impact on treatment course and does not increase treatment discontinuation as a result of adverse events. The study data support previous evidence that advocates for a possible decrease in the frequency of urine protein monitoring with bevacizumab treatment. Further exploration of the potential impact of NSAIDs on having proteinuria is necessary to help inform therapy. [ABSTRACT FROM AUTHOR]

Explores the relationship between pupil attainments on British National Curriculum Tests at the end of Key Stage 2, teacher assessments, and several pupil characteristics, such as gender and age) using representative samples drawn from schools in England from 1996-1998. Finds levels of agreement between teacher assessments and test results remarkably consistent. (BT)

Purpose: A case of embolia cutis medicamentosa (Nicolau syndrome) in a patient receiving monthly intramuscular fulvestrant injections is presented. Summary: An 85-year-old woman receiving monthly fulvestrant injections in the outpatient setting developed a necrotic lesion at the fulvestrant injection site on her right buttock. Her medical history is notable for metastatic breast cancer with bone metastases. Prior to developing the necrotic lesion, the patient was receiving monthly fulvestrant injections for 6 years. Other potential causes such as infection and pressure necrosis were ruled out clinically. After 185 days of wound care involving multiple surgical debridements, topical therapy, and frequent follow-up appointments, the patient's wound resolved with 100% epithelialization. Nicolau syndrome has been reported with other non-vesicant, injectable medications such as antibiotics and corticosteroids; however, it has not been previously reported with fulvestrant. Conclusion: Nicolau syndrome developed in the right buttock of a patient with metastatic breast cancer following an intramuscular fulvestrant injection. Healthcare practitioners need to be cognizant of this adverse effect with intramuscular injections in order to recognize and refer patients for wound care evaluation early in the evolution of this syndrome. Proper injection technique is recommended to reduce the risk of this idiopathic adverse effect. [ABSTRACT FROM AUTHOR]

Background: Vascular endothelial growth factor (VEGF) inhibitors are known to cause hypertension. The purpose of this study was to assess the impact of blood pressure (BP) elevations on outcomes in patients receiving VEGF inhibitors. Methods: This retrospective chart review analyzed patients receiving treatment with VEGF inhibitors. The primary endpoint was time to progression (TTP) in those with or without significant increase in BP (increase in systolic BP greater than 20 mm Hg or greater than 10 mm Hg increase in diastolic BP). Secondary endpoints included treatment interruption, therapy discontinuation due to documented adverse effect, and time to BP elevation. Subgroup analyses were completed in those receiving bevacizumab and oral tyrosine kinase inhibitors. Results: A total of 155 patients were included and 93 patients (60%) experienced a significant increase in BP. Median time to development of an elevated BP was 47 days. Patients with significant increases in BP had a longer median TTP compared to patients without (8.1 months vs 4.4 months, p = 0.002). No differences were present between groups in treatment interruption or discontinuation due to a documented adverse effect and outcomes were similar in those receiving bevacizumab and oral tyrosine kinase inhibitors. In the analysis of the impact of severity of BP elevations, those with severe BP elevations were more likely to have treatment interrupted but discontinuation rates were similar across groups. Conclusion: Development of significant BP elevations may be a marker of therapeutic response to VEGF inhibitors and does not limit treatment duration, even in those with severe elevations. [ABSTRACT FROM AUTHOR]

Background: Few studies have been conducted investigating the use of bisphosphonates in hypercalcemia of malignancy (HCM) in the setting of renal dysfunction. Objective: The primary objective was to compare the incidence of acute kidney injury (AKI) within 7 days of receiving pamidronate for the treatment of HCM with pre-existing renal dysfunction versus normal renal function at the time of pamidronate administration. The secondary objectives explored the effects of pamidronate doses and infusion rates on the safety and efficacy in those with pre-existing renal dysfunction for the treatment of HCM. Methods: A retrospective chart review was conducted on patients who received pamidronate for the treatment of HCM at a community teaching hospital in Indianapolis, Indiana, from January 1, 2013, to May 31, 2017. Results: A total of 141 pamidronate administrations were included (116 patients had normal baseline renal function, and 25 patients had pre-existing renal dysfunction before pamidronate administration for the treatment of HCM). Two (8%) patients developed AKI in the pre-existing renal dysfunction group, compared with 4 (3.4%) patients in those without pre-existing renal dysfunction (P =.288). For those with pre-existing renal dysfunction, the incidence of AKI did not differ based on the dosage of pamidronate given (P =.762) or infusion rates (P =.373). Conclusion: Pamidronate appears to have limited impact on renal function at doses up to 90 mg in the setting of pre-existing renal dysfunction for the treatment of HCM. [ABSTRACT FROM AUTHOR]

Background: Oral mucositis, a common complication of several different anticancer therapies, causes significant morbidity in cancer patients. It is characterized by the destruction of the mucosa throughout the gastrointestinal tract including the oral cavity. Limited data exist regarding the treatment of established oral mucositis with oral mucoadhesive hydrogel (MuGard) or supersaturated calcium phosphate oral rise (Caphosol) compared to standard topical therapies. Objectives: To evaluate the effects of MuGard and Caphosol compared to standard topical therapy in the treatment of established oral mucositis. Methods: A retrospective chart review was performed including adults receiving MuGard, Caphosol, and/or standard topical therapy for the treatment of established oral mucositis while admitted to a community teaching hospital. A post hoc propensity score was used to match patients receiving newer agents (Mugard/Caphosol) to those receiving standard topical therapy (ST). Results: One hundred and forty-seven patients were included for analysis (125 ST, 15 MuGard, 7 Caphosol). From this population, 14 patients in each group were matched. The primary endpoint of median change in average daily pain score at days 3 and 7, compared to baseline, demonstrated no difference between matched groups at day 3 (ST 0, MuGard/Caphosol 0.18, p = 0.830) or day 7 (ST 0, MuGard/Caphosol 0.8, p = 0.494). No differences were noted between groups in opioid usage, oral mucositis symptom duration or progression, or incidence of documented infection. Conclusion: MuGard and Caphosol did not demonstrate any benefits compared to standard topical therapy at reducing pain scores or increasing mucosal recovery in the treatment of oral mucositis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Febrile neutropenia is an oncologic emergency that requires quick intervention with antipseudomonal beta-lactam antibiotics, such as piperacillin-tazobactam. Previous studies suggest that extended infusions of beta-lactam antibiotics may improve clinical outcomes; to date, only 3 previous studies have investigated the use of extended infusions of beta-lactam antibiotics in this patient population. OBJECTIVE: To determine the effectiveness in reaching defervescence using extended infusions of piperacillin-tazobactam in oncologic patients with febrile neutropenia. METHODS: This retrospective chart review compared the benefits of using extended infusions versus intermittent infusions of piperacillin-tazobactam in patients with febrile neutropenia. Adults with cancer who were admitted to a community teaching hospital between January 2012 and March 2017 with febrile neutropenia were included if they received infusions with piperacillin-tazobactam. Patients were divided into 2 groups based on the type of piperacillin-tazobactam infusion they received: intermittent infusions were infused over 30 minutes, whereas the extended infusions were given over 4 hours. RESULTS: The study included 50 patients who were divided into 2 groups: 16 patients received extended infusions of piperacillin-tazobactam and 34 received intermittent infusions of the drug. The patients’ baseline characteristics between the 2 groups were homogeneous. No difference was found between the groups regarding patients achieving defervescence at 24 hours, defined as the first temperature of ≤100.4°F that was sustained for at least 24 hours (ie, 50% in the extended infusions group vs 53% in the intermittent infusions group; P = .85) or in the median time to defervescence (20.8 hours vs 22.8 hours, respectively; P = .84). Multivariate analyses indicated that receiving prophylactic antibiotics increased the odds of reaching defervescence at 24 hours by 7.66 (95% confidence interval, 1.07-54.72; P = .04). CONCLUSION: These findings demonstrate that extended infusions of piperacillin-tazobactam resulted in similar outcomes to intermittent infusions, including defervescence, duration of antibiotic use, inpatient mortality, mortality within 30 days, and antibiotic failure. Further prospective research is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients receiving intensive chemotherapy regimens are at high risk for infection-related complications caused by prolonged neutropenia and hospital stay. Currently, some providers attempt to prevent infection in this patient population by using probiotics in addition to prophylactic antibiotics, despite a lack of data supporting this approach. OBJECTIVES: To compare the incidence of febrile neutropenia in patients receiving or not receiving probiotics, and to compare the incidence of and time to Clostridium difficile infection, time to first fever, incidence of documented C difficile infection, and 30-day readmissions for infection-related issues. METHODS: Patients receiving induction or reinduction chemotherapy for acute myeloid leukemia and those undergoing hematopoietic stem-cell transplant were included in the study. Patients were divided into 2 groups based on the use of probiotics. RESULTS: A total of 175 patients were included in the study. No significant differences were found between patients taking probiotics (n = 29) and patients not taking probiotics (n = 146) in terms of the incidence of febrile neutropenia (79% vs 71%, respectively; P = .337), the incidence of C difficile infection (10% vs 6%, respectively; P = .422), time to first fever (10 days vs 9 days, respectively; P = .606), or 30-day readmission rate for an infection-related issue (0% vs 7% respectively; P = .147). However, we found an association between probiotic use and documented infection (48% vs 29%, respectively; P = .04). Bloodstream infections (45% vs 21%, respectively; P = .006) were most notably increased in patients taking probiotics. CONCLUSIONS: Our results suggest that probiotics lack benefit in preventing infections in individuals at risk for prolonged neutropenia and should not be recommended for use in patients without other indications for probiotic use. [ABSTRACT FROM AUTHOR]

Background: Cancer treatment costs are increasing; the global cost of antineoplastic medications rose to $83.7 billion in 2015. As a result, it is imperative for institutions to implement cost-saving strategies and to maximize reimbursement for costly medications such as antineoplastic drugs.Objectives: Evaluate the necessity and drug costs of administering antineoplastic medications in the inpatient setting and explore savings associated with the 2013 implementation of an institutional policy that defined criteria necessitating inpatient administration of antineoplastic medication.Methods: We conducted a retrospective chart review of patients receiving inpatient antineoplastic medications during January, April, July, and October of 2010, 2012, 2014, and 2015 at a community teaching hospital. Necessity of chemotherapy administration during the hospital admission was determined based on adherence to institutional policy.Results: Records of 648 patients admitted for chemotherapy were reviewed. The annualized numbers of chemotherapy regimens received during inpatient admission in 2010, 2012, 2014, and 2015 were 537, 618, 369, and 420, respectively. Of all regimens administered in the inpatient setting, 80% in 2010, 78% in 2012, 83% in 2014, and 91% in 2015 met institutional policy criteria for inpatient administration (P = 0.005). The annualized average wholesale price of antineoplastic medications administered to patients that did not meet criteria for inpatient drug administration decreased from $269,049 in 2010 to $105,447 in 2015. A trend in the chemotherapy regimens administered was apparent; only one regimen (carboplatin/paclitaxel), which is relatively inexpensive, was administered to more than 5% of patients in 2015, and all patients receiving monoclonal antibodies in 2015 met criteria for inpatient administration.Conclusions: Implementation of a policy defining the appropriate criteria necessitating inpatient administration of antineoplastic medications has the potential to decrease the number of inpatient administrations and associated drug costs. [ABSTRACT FROM AUTHOR]