Worldwide Network for Blood and Marrow Transplantation (WBMT) Recommendations Regarding Essential Medications Required To Establish An Early Stage Hematopoietic Cell Transplantation Program.

Establishing a hematopoietic cell transplantation (HCT) program is complex. Planning is essential while establishing such a program to overcome the expected challenges. Authorities involved in HCT program establishment will need to coordinate the efforts between the different departments required to start up the program. One essential department is pharmacy and the medications required. To help facilitate this, the Worldwide Network for Blood and Marrow Transplantation organized a structured survey to address the essential medications required to start up an HCT program. A group of senior physicians and pharmacists prepared a list of the medications used at the different phases of transplantation. These drugs were then rated by a questionnaire using a scale of necessity based on the stage of development of the transplant program. The questionnaire was sent to 30 physicians, in different parts of the world, who have between 5 and 40 years of experience in autologous and/or allogeneic transplantation. This group of experts scored each medication on a 7-point scale, ranging from an absolute requirement (score of 1) to not required (score of 7). The results are presented here to help guide the prioritization of required medications.

Cardiovascular Toxicity Associated With Tyrosine Kinase Inhibitor Therapy In Chronic Myeloid Leukemia.

Treatment of Chronic myeloid leukemia (CML) typically entails a long-term course of tyrosine kinase inhibitors (TKI) therapy. This review provides a summary on the cardiotoxic effects of TKIs. Five small molecular TKIs were evaluated in our review. The cardiotoxic effects of TKIs can range from superficial edema to potentially fatal conditions such as congestive heart failure (HF) and acute coronary syndrome (ACS). With the constant introduction of newer generations of TKIs, it has been demonstrated that different TKIs have distinct cardiovascular safety profiles. Amongst which, the first-generation TKI - imatinib appears to have the safest profile, mainly causing edema along with nausea, rash and muscle cramps. Other TKIs, like the second-generation dasatinib, bosutinib,and nilotinib, have shown an increased incidence of pleural effusion and QT prolongation. Ponatinib, a third generation TKI, has shown a relatively high incidence of serious adverse effects including thrombotic vascular occlusion and heart failure, particularly in patients with a prior history of cardiovascular impairment. Therefore, it is advisable that at-risk patients taking TKIs be screened with an Electrocardiogram (ECG) and have a careful cardiovascular risk assessment before starting TKI therapy to avoid potential cardiotoxic effects such as arrhythmias, acute coronary syndrome (ACS), congestive heart failure, and pleural effusion. Keywords: tyrosine kinase inhibitor, TKI, chronic myelogenous leukemia, CML, cardiotoxicity, side effects, imatinib, dasatinib, bosutinib, nilotinib, ponatinib.

Comparison of closed system transfer devices for turnaround time and ease of use.

OBJECTIVE/PURPOSE: The primary purpose of this study was to compare three closed-system transfer devices with differing mechanical interfaces for their suitability for adoption into our daily practice. The secondary purpose was to use the results of this study to support the selection of one of the closed-system transfer devices, which would suit both the pharmacy and nursing staff at our institution, furthermore promoting the enculturation of international recommendations into our clinical practice. STUDY DESIGN/METHODS: The hazardous drug preparation process was observed and timed continuously from the moment the technician started compounding until the finished product was handed to the designated checker by raising hands. A self-administered, structured questionnaire was used for data collection looking at ease of use of each of the devices from the perspective of pharmacy technicians and nurses. The questionnaire contained an open-ended 10-point Likert-type scale of eight domains. RESULTS/KEY FINDINGS: An improvement in the compounding efficiency of hazardous drugs using PhaSeal™ ( n = 46), ChemoLock™ ( n = 45), and EquaShield® II ( n = 45), when compared respectively against the historical control ( n = 86), was statistically significant ( p < 0.001). However, no statistically significant difference among the different closed-system transfer devices for preparation of hazardous drugs was observed in our study ( p = 0.1). In terms of ease of use, there was no difference in preference for ChemoLock™ and Equashield®II among the pharmacy technicians with both scoring a mean score of 10 with regard to implementation. While PhaSeal™ scored a mean score of 7.2. Among the nursing staff there was a slight preference for ChemoLock™ over Equashield®II with a mean score of 9.2 and 9, respectively with regard to the recommended product, while PhaSeal™ scored a mean score of 7.4. Both nursing staff and pharmacy technicians had a preference ChemoLock™, with a mean score of 10 and 9.6, respectively in terms of on how easy was each device/system to use and overall impression for pharmacy technicians. This was followed by Equashield®II with a mean score of 9.8 and 8.6, respectively and then PhaSeal™ with a mean score of 7.2 and 6.6, respectively. Pharmacy technicians felt there were more steps, packaging and clutter when using PhaSeal® in comparison to the other devices. With Equashield® II, the estimation of clutter was higher than that of ChemoLock™ despite the number of packages being within a similar range. CONCLUSION/RECOMMENDATIONS: Our study found that with experienced staff, compounding of hazardous drugs with closed-system transfer devices can be as efficient as or even more so than with the traditional needle and syringe method. With the lack of statistically significant difference among the different closed-system transfer devices studied, in addition to the cost, ease of use was one of the factors that decided the products applicability in our institution.

Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia.

Objectives Febrile neutropenia management guidelines recommend the use of vancomycin as part of an empiric antimicrobial regimen when specific criteria are met. Often, vancomycin use among patients with febrile neutropenia is not indicated and may be over utilized for this indication. We sought to evaluate the impact of implementing a febrile neutropenia clinical pathway on empiric vancomycin use for febrile neutropenia and to identify predictors of vancomycin use when not indicated. Methods Adult febrile neutropenia patients who received initial therapy with an anti-pseudomonal beta-lactam with or without vancomycin were identified before (June 2008 to November 2010) and after (June 2012 to June 2013) pathway implementation. Patients were assessed for appropriateness of therapy based on whether the patient received vancomycin consistent with guideline recommendations. Using a comorbidity index used for risk assessment in high risk hematology/oncology patients, we evaluated whether specific comorbidities are associated with inappropriate vancomycin use in the setting of febrile neutropenia. Results A total of 206 patients were included in the pre-pathway time period with 35.9% of patients receiving vancomycin therapy that was inconsistent with the pathway. A total of 131 patients were included in the post-pathway time period with 11.4% of patients receiving vancomycin inconsistent with the pathway ( p = 0.001). None of the comorbidities assessed, nor the comorbidity index score were found to be predictors of vancomycin use inconsistent with guideline recommendations. Conclusion Our study has demonstrated that implementation of a febrile neutropenia pathway can significantly improve adherence to national guideline recommendations with respect to empiric vancomycin utilization for febrile neutropenia.