Patients at BCCA often require submissions to Special Authority and other mechanisms (such as drug company-sponsored coverage) because supportive medications are not covered by the Agency. I am involved with discharge prescription and medication calendar planning for the patients under my care, but I wanted to highlight a special case.
This is a 29 year old woman with Ewing’s sarcoma, undergoing (overall) her 25th cycle of chemotherapy (salvage therapy with possibly curative intent). As she has unfortunately suffered an episode of febrile neutropenia in the past, she qualifies for Special Authority for filgrastim for secondary prophylaxis. I submitted the request on behalf of the attending physician, and also provided the following:
– Submission of request to ANSWERS 3rd party program for any additional coverage in case the pt had not met her Pharmacare deductible
– Liaison with the community pharmacy to ensure adequate stock was available
– She also was interested in use of various NHPs with her chemotherapy: counselled that use of vitamin B12 had no concerns but the other supplement (a proprietary blend of mushroom extracts) would be ill-advised
– Counselling to call the BCCA immediately at any sign of fever or “feeling off”, as not all neutropenic patients can mount a fever.
Today there was a new admission to the ward. This was a good example of gathering information that was necessary for a MedRec but not necessarily having the complete info that would be gathered from, say, a workup. This patient was in for nausea and vomiting, and drainage of a pleural effusion. She received her most recent cycle of BRAVGEMP 4 days ago. There were a few things to reconcile from the information on Pharmanet:
– She was taking atenolol 50 mg daily, not 25 mg daily
– She was applying fentanyl 12 mcg/h, one patch q72h, not 1/2 patch day 1, then the other 1/2 patch 24 hrs later as it appeared on Pharmanet (this was a titrating regimen she had completed a while ago)
– She was no longer taking escitalopram and nifedipine, even though it did show it was filled 3 months ago for a 3 month supply.
– She was taking extended-release dimenhydrinate QHS (patient’s own medications) with good effect for nausea.
Overall this highlighted for me how important it is to not simply blindly trust Pharmanet as an accurate source of medication information. It also allowed me the opportunity to collaborate with the physician in reconciling the orders.
During my first week at BCCA I had the opportunity to help take care of a patient (65 yo female) who was in for treatment of double-hit diffuse large B-cell lymphoma. During her admission, there were a few changes to her medication, in addition to adherence concerns as she missed a week of her SMX/TMP for PCP prophylaxis as there was confusion regarding blister packing. I made the following changes to her medications in collaboration with the doctor:
– Discontinued her ASA 81 mg PO daily that she was taking for primary CV prevention. She had a Hx of mitral valve prolapse, but in the absence of HF, A-fib or previous MI/stroke, there was no compelling indication.
– Increased her valacyclovir to 500 mg PO BID from PO daily as she was seropositive for HSV and suffered from an especially bad bout of mucositis (that was HSV-positive on swab) last cycle. The BID dose is usually for HIV-positive patients or leukemia patients, but given her aggressive regimen (daEPOCH-R), the doctor and I felt it prudent to increase the dose, also considering valacyclovir’s favourable safety profile.
– Increased her gabapentin from 600 mg PO QHS, adding 100 mg PO with breakfast and lunch, titrating q week to a target of 600 mg PO TID for fibromyalgia. There was a patient teaching point as well as I explained to her that one would develop tolerance to sedation as gabapentin is slowly titrated.
I made a med calendar for her, had her medications blister packed, prepared her discharge prescriptions, and explained the changes we made in hospital. What I hope to improve upon and apply in future is becoming more efficient with coordinating with the community pharmacy such that medications are delivered in good time when the patient goes home.
I notice that quite a few of the patients I have encountered so far in Clinical Orientation and my 1st patient on my Oncology rotation are on SMX/TMP for PCP prophylaxis. It begged the question: when is it warranted? According to this meta-analysis, if the risk is >6%, you give prophylaxis. Which conditions warrant this type of risk? Should all cancer patients receive it?
– Cancer patients who SHOULD receive PCP prophylaxis: HL, NHL, brain tumours, myelodysplasia, ALL, lymphoproliferative dz, or myeloma, relapsed dz, “high-dose” corticosteroids, or R-CHOP-14 regimen
– Treatment with 20 or more mg prednisone equivalent for 1 month or more
– Alemtuzumab or temozolomide recipients
– Allogenic and select autologous (w/purine analogue conditioning Tx) HCT recipients
– Solid organ transplant recipients
There are a few SMX/TMP regimens… DS tab daily, DS tab qMWF, SS tab daily… there isn’t much direction to choose one. There was an RCT in HIV-infected patients that wasn’t statistically significant for daily SMX/TMP, but there was roughly 2x more discontinuation due to ADRs from the daily group.
I’ve personally seen DS tab qMWF most but it all depends on patient-specific factors such as adherence and recent lab work!
I’m anticipating a big jump from Clinical Orientation right into Oncology, and I hope that the previous very very basic knowledge I gained from the oncology elective in undergrad will be activated so I can build upon it and apply it in a meaningful way!
Goal #1: Develop a head to toe approach to assessing a patient for adverse drug events secondary to chemotherapy, or supportive agents for chemotherapy.
Objectives to meet this goal:
– Assess 3 patients per week, head to toe, for ADRs as practice.
– Develop a “hit list” for treating various ADRs from chemo, such as neuropathy, nausea and vomiting, and hand-foot syndrome
– Document in the chart my findings based on this assessment for at least 2 patients per week.
Goal #2: Be able to provide executable recommendations upon demand for proactive nausea and vomiting management based on the BCCA protocol the patient is on.
Objectives to meet this goal:
– Know 10 chemotherapy agents that automatically qualify a regimen to be “highly” emetogenic as per BCCA protocols and the Hesketh algorithm
– Be able to rationalize changes to nausea and vomiting prophylaxis and treatment based on patient response from previous cycle of chemotherapy
– Provide recommendations to the team for nausea and vomiting management for at least 2 patients per week
Goal #3: Develop a process for counselling oncology patients on either a new chemotherapy regimen or supportive care medications.
Objectives to meet this goal:
– Counsel at least 1 patient per week on supportive care medications that they will bring to a community pharmacy
– Counsel at least 2 patients per week on a new chemotherapy regimen as per BCCA protocols
– Ask for feedback on counselling skills in the oncology clinic setting from preceptor after each session.