Improving Patient Safety Through Proper Ordering and Administration of Andexanet Alfa.

Objective: To evaluate prescribing practices for the anti-Xa reversal agent, andexanet alfa, to identify challenges in ordering and administering this medication, and to offer recommendations to improve patient safety. Patients and Methods: This retrospective study reviewed all adult patients treated with andexanet alfa (AA) at a single institution between January 1, 2018, and March 31, 2020. We identified ordering and administration benchmarks based on recommendations from previous clinical trials on AA. We then reviewed these medical records to determine compliance with these benchmarks. We also collected data related to thrombotic complications and mortality. Results: Twenty-two AA dosing sets (loading and infusion dose) were given to 20 patients. Eight (36%) dosing sets met our ordering benchmarks regarding appropriate dose, time since last direct oral anticoagulants, urgency of administration, and documentation. Three (14%) dosing sets met the administrative benchmarks of being started within 30 minutes of the initial order, and 13 (59%) dosing sets had timely infusion of the infusion dose after the loading dose. No dosing set met all our administration benchmarks. There was 1 thrombotic event within 24 hours of the correct AA dose and 1 potential death related to AA. Conclusion: This study highlights challenges in ordering and administering AA at our institution and brings awareness to potential similar concerns at other institutions. These challenges also identified the need for optimized order sets, a streamlined administration process, and frequent provider education to improve patient safety.

Acquired Factor VII Deficiency Associated With Chronic Myeloid Leukemia Blast Crisis.

Factor VII (FVII) is an important, vitamin K-dependent clotting factor. Acquired FVII deficiency is a rare entity that is associated with serious bleeding complications. We report a case of acquired FVII deficiency in a patient with recurrent chronic myeloid leukemia in blast crisis who developed bilateral retinal hemorrhages. The coagulopathy was corrected with the initiation of chemotherapy and subsequent reduction in peripheral blast count.

Deep vein thrombosis in the setting of Klippel-Trenaunay syndrome and sirolimus treatment.

Klippel-Trenaunay syndrome (KTS) is a congenital vascular disorder characterized by the triad of cutaneous capillary malformation, lymphatic and venous anomalies, and soft tissue and bone overgrowth. Sirolimus is a mechanistic target of rapamycin inhibitor used as an immunosuppressive drug. It has also been used to improve and treat vascular malformations that can predispose to intravascular coagulopathy. We have described the case of a patient with KTS receiving a therapeutic anticoagulation dose, for whom sirolimus was initiated, and who had presented with an extensive venous thromboembolism. Correlations between the use of sirolimus in patients with KTS are limited, and cautious use and monitoring could be necessary.

Radiotherapy in Early-stage Gastric MALT: Improved Survival Without Increased Cardiac Death.

PURPOSE: Radiotherapy (RT) is an effective treatment for localized gastric mucosa-associated lymphoid tissue (MALT) lymphomas unresponsive to antibiotic therapy; however, irradiating the stomach can result in significant radiation to the heart, a risk factor for cardiac disease. We analyzed the Surveillance, Epidemiology, and End Results database to evaluate outcomes related to cardiac disease among patients treated with RT for stage I gastric MALT. MATERIALS AND METHODS: We identified adult patients treated between 1993 and 2014. The relationship between treatment modality (RT, chemotherapy, combination, and no treatment) and overall survival (OS), mucosa-associated lymphoid tissue-specific survival (MSS), non-mucosa-associated lymphoid tissue-specific survival (non-MSS), and cardiac-specific survival (CSS) was assessed using the Kaplan-Meier estimator and Cox proportional hazards analyses. RESULTS: A total of 2996 patients (median follow-up, 5.6 y) were analyzed: 27.5% had received RT alone, 12.1% chemotherapy alone, 3.9% chemoradiotherapy, and 56.5% no/unknown treatment (including antibiotic therapy). Compared with RT alone, patients who received chemotherapy alone exhibited worse OS (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.32-2.10; P<0.001) and MSS (HR: 2.10; 95% CI: 1.36-3.23; P=0.001). Although CSS appeared worse in patients who received chemotherapy (HR: 1.56; 95% CI: 0.92-2.66; P=0.10), it was not statistically significant. When comparing orbital and gastric MALT patients, there was no significant difference in CSS (HR: 0.80; 95% CI: 0.49-1.31; P=0.38). CONCLUSIONS: RT improved survival among patients with stage I gastric MALT without increasing the risk of cardiac death. Those with gastric MALT exhibited similar CSS to those with orbital MALT. Although we cannot analyze nonfatal cardiac toxicity, these results suggest that, absent antibiotic therapy, RT should remain first-line treatment for early-stage gastric MALT.