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BMT Introduction to Pharmaceutical Care Julian Lindsay Blood and - PowerPoint PPT Presentation

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BMT Introduction to Pharmaceutical Care Julian Lindsay Blood and Marrow Transplant Pharmacist Royal North Shore Hospital Aims and Objectives Aim Provide an overview of the role of the BMT pharmacist Objectives Classes of drugs

  1. BMT Introduction to Pharmaceutical Care Julian Lindsay Blood and Marrow Transplant Pharmacist Royal North Shore Hospital

  2. Aims and Objectives  Aim – Provide an overview of the role of the BMT pharmacist  Objectives – Classes of drugs (and terminology) – Drug administration – Drug calculation – Therapeutic drug monitoring – Common side effects and interactions

  3. Role of the BMT Pharmacist  Pharmacists are key members of the multidisciplinary HCT team.  As medication experts, they are central to medication management and transitions of care.  They are also trained to provide education and perform policy, quality, and research endeavors.  Evidence supports the direct and indirect value HCT pharmacists provide. Clemmons, A. B., Alexander, M., DeGregory, K. & Kennedy, L. The Hematopoietic Cell Transplant Pharmacist: Roles, Responsibilities, and Recommendations from the ASBMT Pharmacy Special Interest Group. Biol. Blood Marrow Transplant. 24, 914 – 922 (2018).

  4. Classes of Drugs (and Terminology)  Mobilisation  Conditioning  GVHD prophylaxis  Infection prophylaxis  Other Supportive Care

  5. Classes of Drugs (and Terminology)  Mobilisation (PBSC Collection) – Auto and Donor – GCSF (Granulocyte Colony Stimulating Factor) – Filgrastim (Neupogen, Nivestim, Tevagrastim) – G-primed or Cyclo-G – Healthy Donor or Own – Filgrastim dose is always 10microg/kg/day – Round to nearest 300microg or 480microg

  6. Mobilisation (eviq)

  7. Classes of Drugs (and Terminology)  Conditioning – Auto and Allo – Conditions (ie. ablates old cells to “make room”) bone marrow to allow for new stem cells to grow – VERY high dose cytotoxic chemotherapy or TBI – Single agent of combination – Varying degrees of myelotoxicity – Differs depending on type of transplant and age of patient eg. Auto vs Allo, Myeloablative vs RIC

  8. Conditioning (eviq)

  9. Conditioning (eviq)

  10. Classes of Drugs (and Terminology)  GVHD prophylaxis - Allo only – Graft Versus Host Disease – Pre/Post Stem Cell infusion – Varying degrees based on: o Risk of GVHD vs benefit of GVL vs risk of infection

  11. GVHD prophylaxis (eviq – FluMel)

  12. GVHD prophylaxis (eviq - FluMel)

  13. Classes of Drugs (and Terminology)  Infection prophylaxis – Auto and Allo – Infection risk due to o Neutropenia o Recovery of Immune system o Immune suppression – Antiviral (HSV, VZV) – Anti-PJP – Antifungal (choice based on duration of risk) – Antibacterial (broad to only encapsulated)

  14. Infection prophylaxis  Auto – Valaciclovir 500mg D from D+1 (for 6 months) – Fluconazole 200mg D from D+1 (until neutrophil recovery) – Bactrim DS 1 BD Mon/Thurs from neutrophil recovery (for 6 months)  Allo – Valaciclovir 500mg D from D+1 (for 6 months) – Itraconazole (Lozanoc) 200mg BD from D+1 until immune suppression weaned – Bactrim DS 1 BD Mon/Thurs only from neutrophil recovery (for 6 months)

  15. Classes of Drugs (and Terminology)  Other Supportive Care – Anti-nausea o 5HT3 (Palonosetron, Ondansetron, Granisetron) o NK1 receptor antagonist (Netupitant, Aprepitant) o Steriod – minimal o D2 antagonist (Metoclopramide, Domperidone) o Others … Cyclizine, Lorazepam, Olanzapine, Levomepromazine, Prochlorperazine, etc. – Growth support o GCSF (Auto) – Pain relief (eg Mucositis)

  16. Other Supportive Care

  17. Drug Administration  Route?  Rate?  Administration device/line?  Order? Premeds?  Precautions? – Resources available – EviQ – AIDH – Pharmacist :)

  18. Drug Administration

  19. Drug Administration

  20. Drug Calculation  mg/kg, mg/m 2 (Protocol)  Dose adjustments – Renal function, Hepatic function (Eviq, UpToDate, Micromedex) – Obesity?

  21. Drug Calculation (UpToDate)

  22. Drug Calculation Bubalo, J. et al. Conditioning chemotherapy dose adjustment in obese patients: a review and position statement by the American Society for Blood and Marrow Transplantation practice guideline committee. Biol. Blood Marrow Transplant. 20, 600 – 616 (2014).

  23. Therapeutic Drug Monitoring (TDM)  Narrow therapeutic index – Immune Suppression (GVHD vs GVL vs Toxicity) o Ciclosporin/Tacrolimus o Mycophenolate – Some antifungals (Vori – Effectiveness vs Toxicity) – Busulfan  Minimal Inhibitory Concentration – Posaconazole – Itraconazole*

  24. Therapeutic Drug Monitoring (TDM)  ?Trough/?AUC – Time level taken? – Line or peripheral?

  25. Common Side Effects and Interactions  Effect – Immune suppression – GVHD  Side Effects – Nausea – Mucositis – HSOS/VOD

  26. Common Side Effects and Interactions  Interactions – CYP3A4 substrates (some) o Ciclosporin/Tacrolimus o Cyclophosphamide (metabolites) o Quetiapine o Itraconazole – CYP3A4 inhibitors o Azoles (Posa/Itra/Vori/Flu) o Ciclosporin

  27. Common Side Effects and Interactions  Interaction management – TDM? – Withholding – Substituting – Modifying o Resources – EviQ, Micromedex, UpToDate

  28. Summary – An Allogeneic Protocol for a RIC Sib HSCT 18/05/18 (FRI) Day – 6 Start Ondansetron BD + Maxalon TDS Fludarabine 40mg/m2 po Start Ursofalk 500mg BD po 19/05/18 (SAT) Day -5 Fludarabine 40mg/m2 po 20/05/18 (SUN) Day -4 Fludarabine 40mg/m2 po 21/05/18 (MON) Day -3 Fludarabine 40mg/m2 po 22/05/18 (TUE) Day -2 Fludarabine 40mg/m2 po (at home) Commence hydration 1L N/S 2/24 pre & post Melphalan Stop BD Ondansetron, Akynzyeo IV once only + Dex 8mg IV for 3/7. Maxalon 10mg po TDS Melphalan 140mg/m² IVI over 15 mins. 23/05/18 (WED) Day -1 Commence Cyclosporin 1.5mg/kg BD IVI 24/05/18 (THU) Day 0 DONOR PERIPHERAL BLOOD STEM CELLS Start Palonosetron 0.25mg IV- rpt every 48/24 25/05/18 (FRI) Day +1 Methotrexate 5mg/m2 Day +1, Day+3, +6 ,+11 (Administer > 24/24 post HPC infusion) Give Folinic Acid 15 mg IVI 24/24 after each dose of MTX Start Valtrex 500mg po dly and Itraconazole 200mg BD 14/06/18 (THU) Day +21 Commence Bactrim DS BD twice weekly

  29. Summary 18/05/18 (FRI) Day – 6 Start Ondansetron BD + Maxalon TDS Fludarabine 40mg/m2 po Start Ursofalk 500mg BD po 19/05/18 (SAT) Day -5 Fludarabine 40mg/m2 po 20/05/18 (SUN) Day -4 Fludarabine 40mg/m2 po 21/05/18 (MON) Day -3 Fludarabine 40mg/m2 po 22/05/18 (TUE) Day -2 Fludarabine 40mg/m2 po (at home) (from) Commence hydration 1L N/S 2/24 pre & post Melphalan Stop BD Ondansetron, Akynzyeo IV once only Mobilisation + Dex 8mg IV for 3/7. Maxalon 10mg po TDS Melphalan 140mg/m² IVI over 15 mins. 23/05/18 (WED) Day -1 Commence Cyclosporin 1.5mg/kg BD IVI 24/05/18 (THU) Day 0 DONOR PERIPHERAL BLOOD STEM CELLS Start Palonosetron 0.25mg IV- rpt every 48/24 25/05/18 (FRI) Day +1 Methotrexate 5mg/m2 Day +1, Day+3, +6 ,+11 (Administer > 24/24 post HPC infusion) Give Folinic Acid 15 mg IVI 24/24 after each dose of MTX Start Valtrex 500mg po dly and Itraconazole 200mg BD 14/06/18 (THU) Day +21 Commence Bactrim DS BD twice weekly

  30. Summary 18/05/18 (FRI) Day – 6 Start Ondansetron BD + Maxalon TDS Fludarabine 40mg/m2 po Start Ursofalk 500mg BD po 19/05/18 (SAT) Day -5 Fludarabine 40mg/m2 po 20/05/18 (SUN) Day -4 Fludarabine 40mg/m2 po 21/05/18 (MON) Day -3 Fludarabine 40mg/m2 po 22/05/18 (TUE) Day -2 Fludarabine 40mg/m2 po Conditioning Commence hydration 1L N/S 2/24 pre & post Melphalan Stop BD Ondansetron, Akynzyeo IV once only + Dex 8mg IV for 3/7. Maxalon 10mg po TDS Melphalan 140mg/m² IVI over 15 mins. 23/05/18 (WED) Day -1 Commence Cyclosporin 1.5mg/kg BD IVI 24/05/18 (THU) Day 0 DONOR PERIPHERAL BLOOD STEM CELLS Start Palonosetron 0.25mg IV- rpt every 48/24 25/05/18 (FRI) Day +1 Methotrexate 5mg/m2 Day +1, Day+3, +6 ,+11 (Administer > 24/24 post HPC infusion) Give Folinic Acid 15 mg IVI 24/24 after each dose of MTX Start Valtrex 500mg po dly and Itraconazole 200mg BD 14/06/18 (THU) Day +21 Commence Bactrim DS BD twice weekly

  31. Summary 18/05/18 (FRI) Day – 6 Start Ondansetron BD + Maxalon TDS Fludarabine 40mg/m2 po Start Ursofalk 500mg BD po 19/05/18 (SAT) Day -5 Fludarabine 40mg/m2 po 20/05/18 (SUN) Day -4 Fludarabine 40mg/m2 po 21/05/18 (MON) Day -3 Fludarabine 40mg/m2 po 22/05/18 (TUE) Day -2 Fludarabine 40mg/m2 po (at home) GVHD Commence hydration 1L N/S 2/24 pre & post Melphalan Stop BD Ondansetron, Akynzyeo IV once only Prophylaxis + Dex 8mg IV for 3/7. Maxalon 10mg po TDS Melphalan 140mg/m² IVI over 15 mins. 23/05/18 (WED) Day -1 Commence Cyclosporin 1.5mg/kg BD IVI 24/05/18 (THU) Day 0 DONOR PERIPHERAL BLOOD STEM CELLS Start Palonosetron 0.25mg IV- rpt every 48/24 25/05/18 (FRI) Day +1 Methotrexate 5mg/m2 Day +1, Day+3, +6 ,+11 (Administer > 24/24 post HPC infusion) Give Folinic Acid 15 mg IVI 24/24 after each dose of MTX Start Valtrex 500mg po dly and Itraconazole 200mg BD 14/06/18 (THU) Day +21 Commence Bactrim DS BD twice weekly

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