Making moves: Transitioning R-EPOCH to the ambulatory setting.

PURPOSE: Ambulatory administration of chemotherapy provides benefit to patients and institutions alike. We hypothesized that transitioning rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (R-EPOCH) from an inpatient to ambulatory setting would reduce inpatient bed days and overall healthcare costs. The purpose of this effort was to create a guideline that would transition R-EPOCH to the ambulatory setting. To assess institutional benefit, we assessed inpatient bed days saved and financial impact. METHODS: A single center, retrospective analysis of inpatient R-EPOCH administration from January 2013 to December 2015 defined the need for medication use guidelines for ambulatory R-EPOCH administration. While this guideline targeted a reduction in inpatient bed days, it also created desired staff-and-patient education on R-EPOCH. Multidisciplinary collaboration enabled this comprehensive approach to outpatient chemotherapy administration. RESULTS: The 42 patients included received 147 cycles of R-EPOCH. Administration was primarily inpatient, amounting to 107 cycles and 799 inpatient days. Concurrently, 40 cycles of R-EPOCH were administered to 11 patients in the ambulatory setting. Only two patients received all cycles as outpatient; the other nine patients received chemotherapy in both settings. Financial analysis showed a 53% reduction in drug acquisition cost and 30% reduction in direct costs with ambulatory R-EPOCH administration. Based on our projection, after guideline implementation, 12 patients will be eligible for ambulatory R-EPOCH annually, resulting in a savings of 360 bed days and approximately $650,000 per year. CONCLUSION: Transitioning R-EPOCH is a viable option to significantly decrease inpatient bed days and overall healthcare costs. Multidisciplinary collaboration is vital to successfully transitioning regimens to the ambulatory setting and to establishing consistent support for ambulatory administration.

Evaluation of the Pharmacokinetics and Efficacy of a Busulfan Test Dose in Adult Patients Undergoing Myeloablative Hematopoietic Cell Transplantation.

Owing to interpatient variability in busulfan exposure, therapeutic monitoring of busulfan is often used in myeloablative allogeneic transplantation to ensure that patients are near the optimal steady-state goal of 900 ng/mL. One challenge in therapeutic monitoring of busulfan is the brief course of busulfan treatment, requiring prompt analysis and dose adjustments as needed. Pharmacokinetic evaluation of a busulfan test dose before the start of the conditioning regimen would allow for all conditioning regimen doses to be given at the calculated optimized dose. An observational study was completed to evaluate the effects of a busulfan test dose of 0.9 mg/kg administered before the start of a myeloablative intravenous busulfan-based conditioning regimen. Sixty adult patients who received a busulfan conditioning regimen were reviewed, including 30 patients prior to the implementation of the busulfan test dose (pretest dose group) and 30 patients who received the busulfan test dose (posttest dose group). The primary objective was a pharmacokinetic evaluation of the percentage of patients who achieved the desired steady-state goal using the test dose strategy. The safety and efficacy of the busulfan test dose were evaluated as well. The average busulfan steady-state level after the first dose of the conditioning regimen was significantly lower in the pre-test dose group compared with the post-test dose group (660 ng/mL versus 879.9 ng/mL; P < 0.001). Compared with the post-test dose group, significantly fewer patients in the pre-test dose group were within 10% of the busulfan steady-state goal (10% versus 73.3%; P < 0.001) or within 5% of the goal (0% versus 53%; P < 0.001). Requirements for parenteral nutrition and/or patient-controlled analgesia owing to mucositis and rates of veno-occlusive disease were not significantly different between the pre-test dose group and the post-test dose group. The rates of disease relapse, mortality, and acute graft-versus-host disease were similar in the two groups. A pretransplantation busulfan test dose of 0.9 mg/kg improved the patients' ability to reach therapeutic busulfan target levels after the first conditioning dose and resulted in fewer adjustments during conditioning. The use of a busulfan test dose did not significantly increase patients' risk of mucositis or other safety outcomes.