Journal of Oncology Pharmacy Practice (J Oncol Pharm Pract)

Publications in this journal

• Article: Initial therapy in multiple myeloma: investigating the new treatment paradigm.

  Jacob K Kettle, Karen L Finkbiner, Susan E Klenke, Ronald D Baker, Dave W Henry, Casey B Williams
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  ABSTRACT: The development of three novel chemotherapeutic agents - thalidomide, lenalidomide, and bortezomib - has resulted in a fundamental shift in the management of multiple myeloma. Despite this tremendous advancement, the selection of initial treatment must still be made with a degree of uncertainty as a true standard therapy has yet to be established. Although challenging, the relative abundance of therapeutic options, when taken into consideration with unique patient characteristics, creates the potential for individualization of care.For patients eligible for autologous stem cell transplantation, various combinations of novel agents with dexamethasone or traditional chemotherapy have supplanted the previous standard regimen consisting of vincristine, doxorubicin, and dexamethasone. In elderly patients or others that are deemed ineligible for the transplant procedure, the addition of a novel agent to melphalan-prednisone has demonstrated significant improvements in response rates. Due to the immaturity of the available data, it is perhaps best to regard the era of novel agents with a degree of rational enthusiasm, as the ultimate impact on patient care remains undetermined. Although further research is clearly implicated, recent advancements have resulted in significant progress toward obtaining optimum outcomes in a historically challenging disease.
  Journal of Oncology Pharmacy Practice 04/2009; 15(3):131-41.
• Article: Immediate cross-hypersensitivity between micafungin and caspofungin: a case report.

  Shruti Patel, George J Alangaden, Larry G Lum, Simon M Cronin, Muneer H Abidi, Natalie Dieterle, Rami B Ibrahim
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  ABSTRACT: A hematopoietic stem cell transplant patient with a history of immediate drug hypersensitivity reaction to micafungin was considered for a caspofungin trial. A caspofungin intradermal skin test was performed. The result was positive, suggesting the presence of cross-reactivity and that the cyclic peptide nucleus chemical structure shared between echinocandins is the site of IgE recognition. It is recommended to avoid challenging patients with history of immediate hypersensitivity to one echinocandin with another.
  Journal of Oncology Pharmacy Practice 04/2009; 15(3):187-9.
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  Article: Modification of vincristine dosing during concomitant azole therapy in adult acute lymphoblastic leukemia patients.

  Stephen Harnicar, Nelly Adel, Joseph Jurcic
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  ABSTRACT: Vincristine is an important component in the treatment of acute lymphoblastic leukemia (ALL) and is now the backbone of therapy in the induction and consolidation phases of this disease. Proper dosing of vincristine is required to maximize disease control while avoiding toxicity. The gastrointestinal toxicity of vincristine such as decreased peristalsis can potentially be increased if the CYP 3A4 enzyme is inhibited. This interaction may become more prevalent with increasing use of CYP 3A4 inhibitors such as the azole antifungals. Since azoles are increasingly being used for prophylaxis and treatment of fungal infections in this patient population, an assessment of vincristine dosing and toxicity is the first step to constructing guidelines for the coadministration of these agents. ALL patients !18 years of age receiving vincristine-based therapy from August 2003 through December 2007 with or without azole therapy were included. Data was collected using electronic patient medical records and the pharmacy system (RxTFC). Information was entered into a database for this retrospective study. Patients were separated into two arms; vincristine with azoles and vincristine only. Patient demographic information, chemotherapy regimen, vincristine-induced symptoms, and concurrent strong CYP 3A4 inhibitors and inducers were collected. A total of 50 patients received vincristine of which 29 (58%) had concurrent azole therapy. No patients received concurrent major CYP 3A4 inhibitors and the baseline characteristics were similar between groups. Vincristine dosing modifications were more common in the azole group (58.6 vs. 23.8%; p = 0.02). The mean dose reduction of vincristine when combined with an azole was 46.5%. Symptoms of decreased peristalsis were more common in patients receiving azoles (65.5 vs. 28.6%; p = 0.019) and on average occurred after the second vincristine dose. Symptoms occurred in 50, 75, and 66.6% of patients receiving fluconazole, voriconazole, and posaconazole, respectively. Patients were more likely to have an incomplete course of vincristine when receiving azole therapy (48.3 vs. 9.5%; p = 0.004). Caution should be used with the coadministration of vincristine and azoles. It is recommended that institutional guidelines be developed to standardize care for patients receiving vincristine with azole therapy. Potential measures to avoid this interaction include revisiting azole prophylaxis in this patient group and being judicious in azole selection.
  Journal of Oncology Pharmacy Practice 03/2009; 15(3):175-82.
• Article: Oncocytic, focally anaplastic, thyroid cancer responding to erlotinib.

  Thomas Hogan, Jing Jie Yu, H James Williams, Ramin Altaha, Xiaobing Liang, Qi He
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  ABSTRACT: OBJECTIVE: To highlight the molecular findings and clinical response of a patient with rapidly progressing, focally anaplastic, oncocytic thyroid carcinoma (OTC) treated with erlotinib.Case Summary. A 69-year-old woman with recurrent, focally anaplastic OTC was given a therapeutic trial of erlotinib, a small molecule inhibitor of epidermal growth factor receptor (EGFR). Formalin-fixed, paraffin-embedded portions of the tumor were analyzed for EGFR expression, and tumor genomic DNA was amplified by polymerase chain reaction (PCR) and subjected to EGFR mutation analysis.Discussion. An early and dramatic response was achieved with erlotinib. The tumor was focally positive for EGFR by immunostaining and two point mutations were identified, one on exon 18 and one on exon 20 in the tyrosine kinase (TK) domain. CONCLUSION: Erlotinib or other novel protein kinase pathway inhibitors should be evaluated further in patients with aggressive thyroid cancer variants, who may exhibit these and perhaps other tyrosine kinase mutations.
  Journal of Oncology Pharmacy Practice 03/2009; 15(2):111-7.
• Article: Retrospective review of hemoglobin and/or hematocrit levels with occurrence of thrombosis in cancer patients treated with erythropoiesis stimulating agents.

  Amber C Fullmer, Rickey Miller
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  ABSTRACT: No data exists that directly compares hemoglobin and hematocrit levels between cancer patients with and without occurrence of thrombosis during treatment with erythropoiesis stimulating agents (ESAs). To determine the association of hemoglobin and hematocrit levels with the occurrence of thrombosis in cancer patients treated with ESAs. A retrospective case-control study approved by the Institutional Review Board was conducted on cancer patients billed for epoetin or darbepoetin between 1 July 2002 and 30 June 2007. Cases were defined as patients billed for thrombosis while controls were defined as patients not billed for thrombosis. Sixteen patients had an occurrence of thrombosis (cases) and were matched to 16 patients that did not have an occurrence of thrombosis (controls) based on age, sex, and cancer type. The mean peak hemoglobin levels for cases and controls were 12.6 +/- 1.2 g/dL versus 12.6 +/- 1.4 g/dL (p = 0.9). The mean peak hematocrit levels for cases and controls were 37.3 +/- 3.8% versus 37.9 +/- 4.3% (p = 0.8). For the 16/586 (2.7%) patients with thrombosis, the mean hemoglobin and hematocrit at time of thrombosis were 9.6 +/- 1.0 g/dL and 28.9 +/- 3.1%. A significant identifiable risk factor for thrombosis between the cases and controls was history of thrombosis 31.3% versus 0% (p = 0.04). There was no statistical difference in peak hemoglobin and hematocrit levels between patients with thrombosis and those without thrombosis. Further study is warranted to determine if these levels are true risk factors for thrombosis.
  Journal of Oncology Pharmacy Practice 03/2009; 15(3):167-73.
• Article: Nail toxicity induced by cancer chemotherapy.

  Peter Gilbar, Alice Hain, Veta-Marie Peereboom
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  ABSTRACT: To provide a comprehensive literature review of chemotherapy-induced nail toxicity, including clinical presentation, implicated drugs and approaches for prevention and management. A search of MEDLINE and EMBASE (1966-2008) databases was conducted using the terms (and variations of the terms) antineoplastic agents, nails, nail toxicity, onycholysis, and paronychia. Bibliographies from selected articles were reviewed for appropriate references. The retrieved literature was reviewed to include all articles relevant to the clinical presentation, diagnosis, incidence, prevention, and treatment of chemotherapy-induced nail toxicity. Nail toxicity is a relatively uncommon adverse effect linked to a number of chemotherapeutic agents. Clinical presentation varies, depending on which nail structure is affected and the severity of the insult. Nail changes may involve all or some nails. Toxicity may be asymptomatic and limited to cosmetic concerns, however, more severe effects, involving pain and discomfort can occur. Taxanes and anthracyclines are the antineoplastic drug groups most commonly implicated. It is suggested that the administration schedule may influence the incidence of nail abnormalities, for example reported cases linked to the weekly administration of paclitaxel.Before instituting chemotherapy, patients should be educated regarding potential nail toxicities and strategies for prevention implemented. Management includes appropriate nail cutting, avoiding potential irritants, topical, or oral antimicrobials, and possibly cessation or dose reduction of the offending agent. Cryotherapy, through the application of frozen gloves or socks, has been beneficial in reducing docetaxel-induced nail toxicity and may be effective for other drugs.
  Journal of Oncology Pharmacy Practice 02/2009; 15(3):143-55.
• Article: Antineoplastic agent workplace contamination study: the Alberta Cancer Board Pharmacy perspective Phase III.

  Susan Bigelow, Heidi Schulz, Roxanne Dobish, Carole R Chambers
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  ABSTRACT: To continue with workplace contamination monitoring in the Alberta Cancer Board (ACB) pharmacy practice environment. The ACB in the Canadian province of Alberta which includes two public tertiary centers and 19 associated community satellite sites based around the province in existing hospitals. After the completion of a Phase 1 and Phase 11 study,(1) which investigated the feasibility of routine monitoring of antineoplastic agent contamination in the pharmacy practice environment, it was decided to launch a Phase III study. The Phase III study would be done at the Cross Cancer Institute in the main pharmacy department as well as at a brand new satellite pharmacy within the CCI hospital. Samples would be taken in these areas as well as on the outer exterior of latex gloves worn to prepare cyclophosphamide and other antineoplastics. The result determined that the area in front of the biological safety cabinet in the main CCI pharmacy department as well as the exterior of the latex gloves showed evidence of cyclophosphamide contamination. The results from the sample taken in the new satellite pharmacy showed no evidence of cyclophosphamide contamination. results from this study prompted a decision to launch a Phase IV study to determine the feasibility within our network, for routine monitoring as well as sampling throughout the clean room beyond the BSC.
  Journal of Oncology Pharmacy Practice 02/2009; 15(3):157-60.
• Article: Patients' perspectives and safe handling of oral anticancer drugs at an Asian cancer center.

  Alexandre Chan, Yumei Cynthia Leow, Mui Hian Sim
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  ABSTRACT: Background. In view of the increased usage of oral anticancer drugs in the contemporary treatment of cancer, we aimed to examine cancer patients' perspectives of oral anticancer drugs, through a survey at an Asian cancer centre. This study also intended to describe patients' behavior regarding storage, handling, and administration of oral anticancer drugs. This cross sectional survey was conducted at a single site. The interviewer-administered survey was undertaken at the outpatient pharmacy of National Cancer Centre Singapore (NCCS), the largest ambulatory cancer center in Singapore, between January and March 2008. Eligible patients had received at least one cycle of oral anticancer agent treatment or had been taking oral anticancer agents continuously for 3 months. A total of 126 patients were surveyed. Median age of surveyed patients was 58 years (range 31-85 years). The drugs involved were capecitabine (39.7% of patients), tamoxifen (23.1%), aromatase inhibitors (18.2%), gefitinib (9.1%), and imatinib (3.3%). Over 90% patients self-administered their oral anticancer drugs. The majority of the patients (94.2%) reported no difficulties in adherence to their oral anticancer treatment regimens. Forty per cent of patients reported habitually washing their hands after administering their anticancer drugs. None of the patients, except two patients receiving capecitabine, indicated that they habitually used gloves to handle their oral anticancer medications. The majority of patients receiving oral anticancer agents reported no difficulty in adhering to their oral anticancer treatment regimens as prescribed. However, this survey demonstrated the need to improve patients' understanding of the requirements for storage, handling and safe administration of oral anticancer drugs.
  Journal of Oncology Pharmacy Practice 02/2009; 15(3):161-5.
• Article: The optimal therapeutic use of ixabepilone in patients with locally advanced or metastatic breast cancer.

  Laura Boehnke Michaud
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  ABSTRACT: The epothilones are a new class of microtubule-stabilizing drugs that exert potent antitumor activity against taxane-resistant and multidrug resistant cell lines. The most clinically advanced member of this class is the semisynthetic epothilone B derivative ixabepilone. This article reviews the preclinical and clinical data on ixabepilone in patients with locally advanced and metastatic breast cancer (MBC) and provides guidance for pharmacists on its optimal use. PubMed and conference proceedings through August 2008. In preclinical studies, ixabepilone has demonstrated potent antitumor activity and low susceptibility to mechanisms that confer tumor resistance. Clinically meaningful benefits have been achieved with ixabepilone monotherapy in phase 2 trials of patients with MBC who have failed previous chemotherapies (anthracyclines, taxanes, or capecitabine). In a randomized, phase 3 trial, the combination of ixabepilone and capecitabine proved more effective than capecitabine alone after the failure of taxane and anthracycline regimens. At the recommended dose and schedule, the therapeutic ratio of ixabepilone is generally favorable, and its adverse effects (notably neutropenia and peripheral neuropathy) are generally manageable and reversible. Ixabepilone represents an advance in the treatment of anthracycline - and taxane-pretreated MBC. Future studies will define its efficacy in combination with other drugs used in the treatment of MBC, as well as in other types of cancer.
  Journal of Oncology Pharmacy Practice 02/2009; 15(2):95-106.
• Article: The use of sodium hyaluronate for the treatment of radiation recall dermatitis.

  Shannon M Bauer, Carole Bauer
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  ABSTRACT: Hyaluronic acid (HA) is a high-molecular weight polysaccharide, a glycosaminoglycan that enhances fibroblast movement and metabolism during wound healing, increasing collagen fibers forming granulation tissue. We describe a 42-year-old female, who developed radiation recall dermatitis following an allogeneic stem cell transplant from an unrelated donor (MUD-PBSCT). Her skin was treated with a topical sodium hyaluronate gel twice daily (RadiaplexRX, MPM Medical). There was marked improvement after 5 days of therapy without discontinuation of any of her therapeutic agents. At a time when the health care providers were faced with considerable treatment dilemmas, this patient demonstrated improvement in the symptoms of radiation recall dermatitis with the topical application of sodium hyaluronate and no change in her medication profile. This agent could successfully allow practitioners to treat radiation recall dermatitis without discontinuation of the recall trigger drug and thus jeopardizing the outcome of the treatment regimen.
  Journal of Oncology Pharmacy Practice 12/2008; 15(2):123-6.
• Article: A medication error prevention survey: five years of results.

  Frances L Cusano, Carole R Chambers, D Lee Summach
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  ABSTRACT: The Alberta Cancer Board is composed of 19 cancer centers in Alberta, Canada. In 1996, the Alberta Cancer Board's Medication Error Prevention Committee developed a medication error prevention survey based on the medication error prevention policies. Since 1996, this survey has been sent annually to the pharmacy departments of the 19 cancer centers. Each year, the results are presented to the Pharmacy and Therapeutics Committee of the Alberta Cancer Board. The purpose of the paper was to present and analyze five years of medication error prevention survey results, thus summarizing adherence to the Alberta Cancer Board's medication error prevention policies. Medication error prevention survey results from 2003 to 2007 were collected. For each of the five years, a medication error prevention survey was faxed to the pharmacy department at each of the 19 cancer centers of the Alberta Cancer Board. Results of the survey were tabulated by the pharmacist responsible for quality assurance. Analysis of the five years of medication error prevention survey results revealed that over 90% of the medication error prevention policies were followed within the 19 Alberta Cancer Board sites. Adherence to the policies was 490% in the tertiary sites and associate clinics. Adherence was also >90% in the community cancer centers. Results from the survey indicated that the medication error prevention policies are practiced within the Alberta Cancer Board. Potential areas of improvement have been identified and will be addressed by the Medication Error Prevention Team.
  Journal of Oncology Pharmacy Practice 12/2008; 15(2):87-93.
• Article: A feasibility study to assess the integration of a pharmacist into neurooncology clinic.

  Louise Delaney, Carole Chambers, Gloria Roldán, Paula De Robles, Greg Cairncross, Peter Forsyth, Jacob Easaw
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  ABSTRACT: A multidisciplinary approach is increasingly used in NeuroOncology clinics. Although this model has several advantages, patients report feeling overwhelmed by the complexity of their treatment protocol and staff feel rushed because each provider must evaluate the patient within the limited clinic hours. We hypothesized that the presence of a pharmacist in clinic could address these concerns by (1) reviewing all treatment protocols and side-effect management with patients, (2) being available to address questions outside of clinic and (3) answering staff related medication questions. The pharmacist met with consenting patients at the initial clinic visit and followed up by telephone two additional times. The pharmacist was available to answer questions outside of clinic hours. Surveys were developed and given to patient and staff to evaluate their experience. Over 4 months, 13 patients were enrolled. The pharmacist interacted with each patient an average of 9 times with 55% of interactions occurring outside scheduled visits and two-thirds of pharmacist interventions directly involving patient care. A total of 85% of patients and staff responded to the evaluation survey and 90% of respondents indicated that the pharmacist should remain part of the NeuroOncology team. Patients reported less stress related to their treatment and clinical staff experienced improved clinical efficiency directly as a result of the presence of the pharmacist. Based on these results, a clinical pharmacist should become a permanent member of the outpatient NeuroOncology clinic.
  Journal of Oncology Pharmacy Practice 12/2008; 15(2):79-85.
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  Article: Economic analysis of albumin-bound paclitaxel for the treatment of metastatic breast cancer.

  George Dranitsaris, Wayne Cottrell, Biljana Spirovski, Sean Hopkins
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  ABSTRACT: An albumin-bound formulation of paclitaxel (nab-paclitaxel) was developed to provide additional efficacy and to overcome the safety drawbacks of paclitaxel and docetaxel in patients with metastatic breast cancer. To provide health economic data for the Canadian setting, an economic analysis comparing each of nab-paclitaxel and docetaxel, both as alternatives to paclitaxel in metastatic breast cancer was conducted. The clinical and safety data were obtained from a meta-analysis of randomized trials comparing either nab-paclitaxel (260 mg/m(2) q3wk) or docetaxel (100 mg/m( 2) q3wk), to standard paclitaxel (175 mg/m(2) q3wk). Health care resource use for the delivery of chemotherapy and the management of grade III/IV toxicity was collected from the oncology literature. Treatment preferences and health state utilities were obtained from 24 female oncology nurses and pharmacists using the time trade-off technique. Nab-paclitaxel had the lowest incidence of grade III/IV toxicity. This translated to lower overall costs for managing the grade III/IV events relative to both docetaxel and paclitaxel ($597 vs. $2626 vs. $1227). Using the median number of cycles administered and the cost impact of grade III/ IV toxicity, the overall cost for nab-paclitaxel would be $15,105 compared to $15,268 for docetaxel and $3557 for paclitaxel. When treatment preferences were assessed, 20 of 24 (83.3%) respondents selected nab-paclitaxel as their preferred choice compared to only 4 who selected docetaxel. These corresponded to a gain of 0.203 and 0.016 QALYs for nab-paclitaxel and docetaxel, respectively. With these utility benefits, the incremental cost per QALY gained was more favorable for nab-paclitaxel than docetaxel ($56,800 vs. $739,600). Nab-paclitaxel would be an economically reasonable alternative to docetaxel in MBC patients. As an alternative to paclitaxel, formulary committees must decide if the $56,800 cost per QALY represents good value in their health care setting.
  Journal of Oncology Pharmacy Practice 12/2008; 15(2):67-78.
• Article: Oncology medication safety: a 3D status report 2008.

  Philip E Johnson, Carole R Chambers, Allen J Vaida
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  ABSTRACT: The safe use of medications is a major concern in oncology practice. Three organizations collaborated on a survey to determine if practitioners had implemented current recommended safe practices for IV vincristine administration, general oncology safe practices, and safe practices for oral chemotherapy. A survey was distributed to members of the Hematology Oncology Pharmacy Association (HOPA) and the International Society of Pharmacy Practitioners (ISOPP) using Survey Monkey. The Institute of Safe Medication Practices (ISMP) also solicited readers of its Medication Safety Alert! to respond to the survey. A comparison to results from a survey conducted by ISMP in 2006 on safe practices for IV vincristine was also conducted. The majority of respondents were aware of the WHO recommendations for IV vincristine, although the rate of implementation of the guidelines ranged from 24.1 to 53.6%. When compared to the ISMP 2006 survey there was a 25.8-37.4% improvement in following many of the safe practice guidelines. Administering IV vincristine via a minibag showed the lowest rate of adoption (less than 40%). Of the 35 survey items on general chemotherapy safety strategies, 80% of respondents had implemented at least 21 items in the survey. Overall 32.4% of respondents did not consider oral chemotherapy as requiring the same safety concerns as parenteral therapy. The results of this survey will provide a new baseline for the adoption rate of safe medication practice recommendations related to oncology. Further work on addressing barriers in adopting identified safe practice recommendations needs to be conducted.
  Journal of Oncology Pharmacy Practice 10/2008; 14(4):169-80.
• Article: Evaluation of osmolality and pH of various concentrations of methotrexate, cytarabine, and thiotepa prepared in normal saline, sterile water for injection, and lactated Ringer's solution for intrathecal administration.

  Mário L de Lemos, Shirin Monfared, Tetyana Denyssevych, Linda Hamata, Sarah Jennings, Brian Thiessen, Sharon Smith, Dawn Waterhouse
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  ABSTRACT: Neurotoxicity of intrathecal (IT) chemotherapy has been variously attributed to the preservatives, volume, osmolality, and pH of the preparations. There has been little evaluation of how different drug concentrations or diluents can affect the osmolality and pH of the final solution. We conducted a three-part study: survey of cancer centers regarding the drug concentrations and diluent used in preparing IT chemotherapy; review of the literature on common practice of preparing IT chemotherapy; evaluation of the pH and osmolality of commonly used chemotherapy preparations for IT. We surveyed selected cancer centers to provide information on their standard volume, drug concentrations, and choice of diluents. MEDLINE was searched for clinical reports using the MeSH terms of 'cytarabine,' 'methotrexate,' or 'thiotepa' with the subheading 'Cerebrospinal fluid' and combined with 'intrathecal' in all database fields. Data retrieved included the choice of diluent, volume, and/or drug concentration. We evaluated the pH and osmolality of methotrexate (1, 2, 5, and 10 mg/mL), cytarabine (2, 5, 10, and 25 mg/mL), and thiotepa (1, 2, and 5 mg/mL) in normal saline, sterile water for injection (SWFI), and lactated Ringer's solution. Nine centers were surveyed (seven in Canada, one in Australia, one in United Kingdom). Most centers used 5 mL of preservative-free normal saline, irrespective of the drug or drug concentration used. Forty-four reports in the literature were reviewed. Most reported 5 mL of preservative-free normal saline. Most information on drug concentrations was provided for methotrexate, with an average concentration of about 1-2.5 mg/ mL. Cytarabine 0.4-20 mg/mL and thiotepa 1 mg/mL were also reported. In our in vitro evaluation, there was a trend of increased pH associated with increasing concentration of methotrexate and cytarabine. There was no apparent impact of thiotepa concentration on the pH values of the final preparations, irrespective of the diluent used. Except for cytarabine 10 and 25 mg/mL, all the tested solutions have pH within 10% of the physiologic range of CSF. There was a concentration-dependent change in osmolality with methotrexate and cytarabine preparations. Osmolality was increased with increased concentrations in all except methotrexate mixed in SWFI and thiotepa mixed in normal saline and lactated Ringer's solution. Except for some thiotepa solutions, all the tested solutions have osmolality within 10% of the physiologic range of CSF. There is limited published literature on the potential impact of diluent and drug concentration on the pH and osmolality of IT chemotherapy preparation. Most cancer centers conventionally prepare IT chemotherapy with 5 mL of preservative diluent normal saline, irrespective of the specific drug or dose used. The conventional practice means that most methotrexate preparations are likely to have comparable pH and osmolality to CSF. In contrast, cytarabine preparations may show significantly higher pH than the CSF, while thiotepa preparations generally have lower osmolality than the CSF.
  Journal of Oncology Pharmacy Practice 10/2008; 15(1):45-52.
• Article: The management of prolonged, isolated hyperbilirubinemia following cytarabine-based chemotherapy for acute myeloid leukaemia.

  John Coutsouvelis, Carmela E Corallo
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  ABSTRACT: Patients diagnosed with Acute Myeloid Leukaemia (AML) often receive cytarabine-based chemotherapy as standard treatment. Cytarabine is usually given in combination with other agents such as idarubicin. Such treatments are known to cause hepatic dysfunction characterized by a combination of jaundice, hyperbilirubinemia and increases in liver enzymes. Isolated hyperbilirubinemia is rarely reported. It is often difficult to identify a causative agent for the hepatic dysfunction, as there are often complicating factors such as sepsis. To report a case of isolated hyperbilirubinemia in a patient treated with cytarabine-based chemotherapy for AML. CLINICAL DETAILS: After a diagnosis of AML the patient was admitted to hospital to receive induction chemotherapy consisting of high-dose cytarabine, idarubicin, and etoposide. All baseline laboratory results were normal, except the full blood evaluation that was consistent with AML. The chemotherapy was delivered over 7 days, and on the eighth day the patient had a bilirubin (BL) level of 27 micromol/L(normal range 522 micromol/L). All other liver function tests (LFT) were normal. This isolated hyperbilirubinemia remained for the rest of the patient's admission, peaking on day 26, with a level of 255 micromol/L. After a stay in the intensive care unit, the patient was discharged on day 45 with a bilirubin level of 33 micromol/L. All other LFT remained unremarkable. The isolated hyperbilirubinemia resolved slowly and on day 68, when the patient was re-admitted for further dose-reduced cytarabine, the BL level was 21 micromol/L. The patient was successfully retreated with this lower dose regimen. Isolated hyperbilirubinemia is an uncommon presentation of cytarabine induced liver dysfunction. Resolution does occur but over a prolonged period. A lower dose of cytarabine for future treatment should be considered.
  Journal of Oncology Pharmacy Practice 10/2008; 15(2):107-10.
• Article: Acute retinal pigment epithelial detachment secondary to pamidronate administration.

  Constantin A Dasanu, Doru T Alexandrescu
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  ABSTRACT: Bisphosphonates are associated with an important number of inflammatory ocular side-effects including but not limited to conjunctivitis, episcleritis, scleritis, uveitis, and optic neuritis. The intravenous bisphosphonates appear to be linked with more severe ocular inflammation than the orally administered ones. These eye complications tend to resolve with the bisphosphonate discontinuation and can re-occur with its re-challenge. We present here the first case of an acute retinal pigment epithelial detachment associated with pamidronate infusion in a 59-year-old patient with metastatic prostate cancer.
  Journal of Oncology Pharmacy Practice 10/2008; 15(2):119-21.
• Article: Use of prescription and nonprescription medications and supplements by cancer patients during chemotherapy: questionnaire validation.

  Marie H Hanigan, Brian L Dela Cruz, David M Thompson, Kevin C Farmer, Patrick J Medina
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  ABSTRACT: Cancer patients take medications for coexisting disease and self-medicate with over-the-counter drugs (OTCs). A complete analysis of the use of prescription drugs, OTCs, and supplements during cancer treatment has never been done. The study developed and validated a self-administered questionnaire on the use of concomitant medications by patients undergoing treatment with chemotherapy. The questionnaire listed 510 prescription medications, OTCs, and supplements (including vitamins, minerals, and herbs). Fifty-two subjects completed the questionnaire while visiting the infusion clinic to receive chemotherapy. On a subsequent visit the subjects brought their medications to the clinic and a pharmacist reviewed their completed questionnaire. Ninety-six percent of the subjects reported taking prescription medications within 3 days prior to chemotherapy, 71% reported taking OTCs and 69% reported use of supplements. The subjects took an average of 5.5 (range 0-13) prescription drugs, 2.2 (0-20) OTCs, and 1.9 (0-11) supplements. Twenty-one drugs were each taken by at least 10% of the subjects. Acetaminophen was taken by 59.6% of the subjects. One subject reported taking five acetaminophen-containing drugs. The questionnaire's sensitivity was 92.0%, specificity 99.9%. Within 3 days prior to chemotherapy, subjects took an average of 9.6 concomitant medications, many of which alter drug metabolism and or disposition. In clinical trials, multivariate analysis of all concomitant medications could add to clinically relevant data to identify drug interactions that negate or potentiate the efficacy of cancer treatment regimens. In some instances, apparent resistance of tumors to chemotherapy may be the result of drug interactions.
  Journal of Oncology Pharmacy Practice 10/2008; 14(3):123-30.
• Article: Managing reduced methotrexate clearance in a patient with a heterozygous methylenetetrahydrofolate reductase gene polymorphism.

  David C Gammon, Mansi S Bhatt, Bhavini Patel, Meghan Anderson, Alixis Van Horn, Michael J Glantz
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  ABSTRACT: High dose methotrexate has become one of the treatments of choice for patients with primary CNS lymphomas due to its ability to penetrate the blood-brain barrier. A potentially serious complication of this therapy is methotrexate-related nephrotoxicity. We report the case of a patient with a common genetic polymorphism that may have predisposed this patient experience clinically significant toxicity from systemic folate depletion. After the first cycle of chemotherapy that included high dose methotrexate, the patient's serum creatinine rose and the patient's methotrexate level remained above the toxic range for six days. On cycle two, the patient was treated with a 25% dose reduction in methotrexate and more aggressive hydration and alkalization. With this alteration in the regimen, the patient was able to receive six more cycles and had a complete radiographic tumor response in the brain and a disappearance of tumor cells in the CSF without any further renal complications. This case report illustrates the feasibility of administering high dose methotrexate with modifications as a treatment of choice in individuals with methylenetetrahydrofolate reductase gene mutations.
  Journal of Oncology Pharmacy Practice 10/2008; 14(3):153-6.