Implementation and outcomes of a pharmacist-led collaborative drug therapy management program for oncology symptom management.

INTRODUCTION: Nausea, vomiting, constipation, and diarrhea are common cancer and cancer therapy adverse effects. Pharmacists are uniquely positioned to optimize patient symptom control and minimize excess use of hospital resources, such as emergency department visits. METHODS: Michigan Medicine oncology clinical pharmacists have been independently providing patient symptom management through a collaborative drug therapy management (CDTM) program which established guidelines for management of gastrointestinal toxicities (nausea, vomiting, diarrhea, and/or constipation) secondary to a patient's cancer diagnosis or treatment of the cancer. Patients were referred to the pharmacist by the treating oncologist or hematologist. RESULTS: From June 2019 to May 2020, there were a total of 62 patient referrals. Ten of the 62 referrals did not meet the CDTM inclusion criteria, resulting in 52 patients who were managed by the pharmacists. The total number of individual pharmacist visits was 136, with a median of 2.2 (range, 0-11) visits per patient referred. A total of 169 categorized pharmacist interventions were captured. Most interventions (100/169, 59.2%) were related to nausea/vomiting. Diarrhea-related and constipation-related interventions accounted for 10 (5.9%) and 13 (7.7%) of the total interventions, respectively. Most patients (36/52, 69.2%) had a reduction in the severity of their referral diagnosis symptom(s) based on Common Terminology Criteria for Adverse Events grading. CONCLUSION: The Michigan Medicine Pharmacist CDTM program allowed pharmacists to independently manage gastrointestinal toxicities of patients with cancer and improved patient symptom severity. The CDTM program has the opportunity to improve quality of care.

Chemotherapy Remote Care Monitoring Program: Integration of SMS Text Patient-Reported Outcomes in the Electronic Health Record and Pharmacist Intervention for Chemotherapy-Induced Nausea and Vomiting.

PURPOSE: Chemotherapy-induced nausea and vomiting (CINV) is a common cause of unplanned healthcare utilization. The University of Michigan Rogel Cancer Center initiated the chemotherapy remote care monitoring program (CRCMP) to proactively identify patients experiencing CINV and intervene before the need for urgent evaluation. METHODS: High-risk patients for CINV are identified by neurokinin-1 (NK-1) antagonist administration, enrolled in the CRCMP, and received a daily text message survey for 7 days after chemotherapy administration to report symptoms. Responses above a set threshold trigger a message to the team pharmacist for intervention. The primary outcome of 14-day unplanned healthcare use was evaluated before and after CRCMP implementation. RESULTS: In 8 months, 652 patients received an NK-1 antagonist (2,244 cycles) and 387 patients were enrolled in the CRCMP (59%). Text message response rate was 94%. Clinical pharmacists provided 248 interventions in 121 patient episodes meeting threshold criteria. Fourteen-day unplanned healthcare use was decreased in the CRCMP-enrolled NK-1 episodes (6.68% v 4.53%, P = .02). Admissions were numerically lower for those enrolling in CRCMP when only admissions for nausea were considered (0.63% v 0.35%, P = .33). CONCLUSION: The CRCMP allowed for real-time management of patient-reported CINV symptom burden based on patient-reported outcomes (PROs) and an electronic medical record-integrated SMS text questionnaire. Clinical pharmacists were key team members to manage patient symptoms. Enrollment in CRCMP significantly reduced overall unplanned healthcare utilization. Although these changes were numerically small, any reduction in unnecessary care utilizing PROs can contribute to high-value care for patients with cancer.

New strategies in controlling drug resistance.

BACKGROUND: Chronic myeloid leukemia (CML) is most often caused by the translocation of chromosomes 9 and 22 to create the fusion protein, BCR-ABL. This constitutively active tyrosine kinase promotes cell division and blocks apoptosis, leading to unregulated growth of hematopoietic stem cells. Imatinib is a small molecule that binds to BCR-ABL at the site in which adenosine triphosphate (ATP) binds and blocks BCR-ABL function by blocking its ability to use ATP. As a front-line therapy, imatinib has been tremendously successful, with 80% to 90% of patients with chronic phase (CP) CML remaining progression free for more than 5 years. Increasingly, however, imatinib-resistant clones are appearing that allow the disease to progress. dealing with the rise of these resistant clones has presented an important challenge to health care providers. OBJECTIVE: To review the mechanisms by which CML becomes resistant to imatinib and to discuss the new therapeutic alternatives to imatinib and when they should be considered. SUMMARY: Managed care weighs advances and associated costs to determine the introduction of imatinib has indefinitely lengthened the survival time of patients with CML, transforming this into a chronic disease condition. However, care must be taken to avoid the appearance of imatinib- resistant clones. resistance can manifest through 1 of several mechanisms, including increased plasma protein binding, increased drug efflux, the appearance of BCR-ABL mutants that have low affinity for imatinib, the appearance of BCR-ABL independent proliferation signals, and the amplification of the BCR-ABL gene. Subtherapeutic dosing is highly likely to result in the selection of a resistant clone; thus, it is of paramount importance to ensure the imatinib dose is sufficient. Measurements of plasma levels of imatinib are proving to be predictive of outcomes, suggesting that the monitoring of imatinib levels will be an important and necessary aspect of monitoring disease. Several clinical trials have shown that high-dose imatinib provides greater and faster response rates. This also may lead to better long-term blockade of disease progression. waiting until disease progression begins appears to lead to greater resistance to high-dose imatinib and should be avoided. dasatinib is a next-generation kinase inhibitor that binds to both SrC and to multiple conformations of BCR-ABL. It is capable of blocking several BCR-ABL mutants that are resistant to imatinib. Clinical trials have shown dasatinib is effective in maintaining patients in CP and can return a percentage of patients with advanced CML to CP. economic analysis indicates that the cost-efficacy ratio for imatinib is approximately $40,000 per year and compares favorably with the costs of accepted procedures, such as dialysis. data have shown that tyrosine kinases also have better mortality rates than allogeneic bone marrow transplant for the first 8 years and appear to also be more cost-effective than transplantation for this time frame. CONCLUSION: New clinical data are beginning to supply us with effective dosing and monitoring parameters for imatinib and dasatinib treatment of CML. economic analysis indicates that these therapies are acceptable in cost and effective in providing good quality of life to patients.

Cost-effectiveness analysis of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting.

OBJECTIVE: To compare the cost-effectiveness of 2 antiemetic agents, ondansetron and prochlorperazine, for the prevention of postoperative nausea and vomiting (PONV) in patients undergoing total hip replacement or total knee replacement procedures. METHODS: The cost-effectiveness analysis model was applied to data derived from a previous clinical study conducted in 1995 and 1996. This study involved 78 adult patients (62.8% female and 37.2% male) undergoing total hip replacement or total knee replacement procedures. Patients were enrolled in a randomized, double-blind manner to receive either ondansetron 4 mg intrvenously (n=37) or prochlorperazine 10 mg intramuscularly (n=41) immediately upon completion of surgery and were monitored for occurrences of PONV during the subsequent 48 hours. In our analysis, we measured the cost-effectiveness ratio (C/E ratio), defined as the cost per successfully treated patient, for each antiemetic agent using the clinical data obtained from the previous study. RESULTS: The incidence of PONV and use of rescue antiemetics was significantly greater in the ondansetron group compared with the prochlorperazine group. The mean total costs of PONV management per patient in the prochlorperazine and ondansetron groups were dollar 13.99 and dollar 51.98, respectively (based on 2004 average wholesale prices [AWP]). The cost of successfully treating one patient with prochlorperazine and ondansetron was dollar 31.87 and dollar 275.01, respectively. One-way sensitivity analysis was performed adjusting the percent efficacy rate of each antiemetic and the drug cost of ondansetron (up to a 50% reduction in AWP). Prochlorperazine remained the dominant strategy across each scenario. CONCLUSION: The results indicate that prochlorperazine is a more cost-effective antiemetic compared with ondansetron for the prevention of PONV in a mixed gender, adult inpatient population undergoing total joint arthroplasty.