Exploring Pharmacy at Seoul National Uni Hospital

Rationale section has been omitted on this post for the purpose of keeping it a reasonable length. (See post 9/6/13 tag: tae for more explanation)

Case Study:

Acute Myeloid Leukemia (AML)

n Chief Complaint (CC)

•       Continuing cough, sputum, dyspnea, poor oral intake, general weakness at Day 12 since admission

•       General weakness, poor oral intake

n History of Present Illness (HPI)

•       Mr. JMJ is a 71 yo Male. 164 cm,, 43.9 kg (BMI 16.69)

•       Mr. JMJ was otherwise healthy individual until a recent diagnosis of myelodysplastic syndrome (MDS), with poor prognosis, 3 MA. He refused chemotherapy at this time and has been managed with intermittent transfusions on an outpatient basis. He has continued to experience general weakness and poor oral intake.

•       About 2 weeks ago, he experienced cough, sputum, dyspnea, for which he was admitted to another hospital. He was treated with empiric antibiotic therapy for pneumonia, but sx’s did not improve.

•       A week ago, he was referred to the ER during his outpatient appointment. The ER w/u showed elevated CRP, rt. lung haziness, crackle and fever. He was admitted for empiric antibiotic therapy for pneumonia and supportive care.

•       Further w/u revealed leukemic transformation of MDS.

n Past Medical History (PMH)

•       AML, MDS-related (dx 8/28/2013)

–       Evolved from MDS, RAEB-2 (dx 3 MA, May 2013)

–       Poor prognosis, high risk

–       on intermittent transfusions

•       Pneumonia (8/9/2013-  )

–       s/p ceftriaxone + clindamycin (8/9~about 1 wk)

–       Day 12, Tazoperan (piperacillin/tazobactam) Inj. 4.5 g MIV q6h + levofloxacin Inj. 750 mg IV q24h (8/23-  )

–       s/p O₂ nasal prong 1-2 L/min (8/23-8/27)

•       h/o PSVT on med (8/23/2013)

–       s/p adenosine x1 (8/23/13)

•       Rash on med (8/31-  )

n Family History (FH)/Social History (SH)

•       Family history:

–       3 younger sisters

•       Social history:

–       Alcohol hx: ex-heavy drinker (1-2 bottles, almost every day), quit 1 YA

–       Smoking hx: ex-smoker (30 PY), quit 4 MA

n Allergies and Adverse Drug Reactions

•       NKDA

n Compliance History

•       Practical impediment: none

•       Attitudinal barrier: wants to go home, doesn’t like the hospital; pt and family feel negative about chemotherapy

•       Knowledge deficit: lack of insight on AML, pt education with the attending occurred (9/1)

n Medication Profile (on 9/3/2013)

Pneumonia:

•       Tazoperan (piperacillin/tazobactam) Inj. 4.5 g MIV q6h (Day 12, 8/23-  )

•       Levofloxacin 750 mg IV q24h (Day 12, 8/23-  )

•       Anycough (theobromine) 300 mg 1 cap PO bid pc (8/23-  )

•       Roisol (ambroxol HCl) 30 mg 1 tab PO q8h (9/2-  )

Nutrition:

•       Folic acid (folate) 1 mg 1 tab PO daily pc (since May 2013)

•       Vitamin C (ascorbic acid) 1000 mg 1 tab PO daily pc (since May 2013)

•       Mecobalamin (cyanocobalamin) 0.5 mg 1 tab PO daily pc (since May 2013)

•       Beecom (vitamin B and C) 1 tab PO daily pc (8/23-  )

•       Megace (megesterol) 40 mg/ml susp 20 ml PO daily pc (8/23-  )

•       Combiflex (TPN) 1100 ml 1 bag IV q24h (8-23-  )

h/o PSVT:

•       Isoptin (verapamil) 40 mg 1 tab PO q12h (8/23-  )

Rash:

•       Adipam (hydroxyzine) 10 mg 1 tab PO qhs (8/31-  )

•       Lacticare-HC (hydrocortisone) 1% App AA bid (8/31-  )

Mucositis ppx:

•       Hexamedine (chlorhexidine gluconate) gargle throat/mouth once daily (9/1-  )

•       Nystatin 1:5000 soln gargle throat/mouth tid (9/1-  )

•       Klenzo (irrigation NS) ut dict daily (9/1-  )

Supportive care:

•       Leukocyte depleted RBC, intermittent transfusions (since May 2013)

•       Plateletpheresis, intermittent transfusions (since May 2013)

AML, MDS-related: on order to be started today 9/3:

•       LD Ara-C: Cytarabine (cytosine arabinoside) 15 mg continuous IV q12h x 14 days

•       Kytril (granisetron) 3 mg Inj. IVS x 1

n Physical Examination (PE)

•       Height                        164 cm

•       Weight                       43.9 kg (usual 50 kg, lost 6 kg in last 3 mo, 74% IBW)

•       Gen               not so ill-looking, alert and oriented

•       VS                 BP 98/60 mmHg, PR 110, RR 24, BT 37.4℃, SpO₂ 98%

•       Skin               warm & dry, mild skin rash (whole body)

•       HEENT                       L/R(++/++), isocoric, prompt

                      anemic, not anicteric, dehydrated tongue(-) LNE(-) PI(-) PTH(-/-)

•       Neck              LNE(-/-) JVE(-/-) 

•       Chest             Sym exp without retraction 
                      crackle, wheezing 
                      RHB without murmur 

•       Cor or CV       RRR, normal S1, S2, no m/r/g

•       Abd                Soft, flat, NABS

                      T/RT(-/-), L/S/K(-/-/-) shifting dullness(-/-) 

B&Ext                        CVAT(-/-) P/C/C(-/-/-)

•       Neuro             A&Ox3

•       GU/Rect         deferred

n Review of Systems (ROS)

•       General weakness(+) Easy fatigue(+) Headache/Dizziness(-/-)

•       Wt loss/gain(+/-) Fever/Chills(-/-)

•       Cough/Sputum/Rhinorrhea(+/+/-) Sore throat (-)

•       Chest pain/Discomfort/Palpitation(-/-/-) Dyspnea(+)

•       Abd pain(-) Anorexia/Nausea/Vomiting/Diarrhea/Constipation(-/-/-/-/-)

•       Urinary sx(-)

n Labs (on 9/3/2013)

Na 131 mEq/L                  K 4.1 mEq/L                Cl 95 mEq/L
Ca 8.7 mg/dL                                P 3.8 mg/dL                 Mg 2.1 mEq/L
Alb 3.6 mg/dL                           BUN 24 mg/dL                 Scr 1 mg/dL
TCO₂ 24 mEq/L                 Uric acid 5.9 mg/dL     RBC 2.54 x10⁶/ul
WBC 4.7 x10³/ul                Platelet 16 x10³/ul       Hgb 8 g/dL      
Hct 22.9%                                     ANC 1222/ul                Blast 15%
hsCRP 0.86 mg/dL                       T. bili 1.1 mg/dL                      AST 16 IU/L
ALT 36 IU/L                                  Alk phos 48 IU/L                      Random Glu 148 mg/dL
Tot chol 77 mg/dL                       
hsCRP 11.75à 7.81 à 4.16à 2.58à 0.86 (9/3 today)
CBC          (9/3) 4700-8.0-16K, ANC 1222
             (8/28) 3400-8.3-41K, ANC 1156
             (8/23) 4200-7.9-26K, ANC 1050

8/31/2013 Iron Study
Iron 46 ug/dL                                Ferritin 47.7 ng/mL      TIBC 355 (Tsat 13%)

•       Microbiology:

–       8/23, 9/2: No identified microorganism in urine, blood, sputum

–       9/2 Aspergillus Ag (-), Legio Ur Ag (-), Pneumo Ur Ag (-), 8/30 C. difficile

n Identification of Real or Potential Drug Therapy Problems:

n Finding of Drug Related Problem #1 AML, MDS-related

•       Subjective info

–       General weakness

–       Poor oral intake

•       Objective info

–       Hgb: 8 g/dL

–       Hct: 22.9%

–       Platelet: 16 x103/ul

–       WBC: 4.7 x103/ul

–       RBC: 2.54 x103/ul

–       Blast: 15% (9/3) ß 37.2% (8/28) ß 12.8% (5/6)

–       ANC: 1222/ul (9/3) ß 1156 (8/28) ß 789 (5/6)

•        Current drug therapy

–       Not on medication

–       On order for today 9/3:

Cytarabine (cytosine arabinoside) 15 mg continuous MIV (in D5W 500 ml) q12h x 14 days

n Assessment of Drug Related Problem

•       Etiology/Risk Factors

–       Age

–       Male gender

–       Genetic mutations

–       Chemical exposures: benzene (smoking)

–       h/o MDS, RAEB-2

•       Severity of disease

–       Severe: poor prognosis (advanced age (>60 yo), poor-risk AML, secondary to MDS)

•       Evaluate need for therapy and/or evaluate current therapy

–       Progression from MDS to AML. Treatment induction is needed to prolong survival. Consider functional status and options for pt >60 yo.

n Patient Specific Recommendation

•       Goals of drug therapy¹

–       Bone marrow < 5% blasts

–       CRi (complete remission w/ incomplete recovery): for >60 yo or previous MDS

•       CRi: independent of transfusions, either ANC >1000/uL or Platelet >100K/uL, but with persistence of cytopenia (especially thrombocypenia)

•       CR: independent of transfusions, ANC >1000/uL, Platelet >100K/uL, No residual evidence of extrameduallary disease

–       Prevention of progression of disease

–       Prolong survival

–       Relieve symptoms

–       Prevention of complications (including infection)

–       Maintain/improve quality of life

–       Balance efficacy and toxicity and minimize drug related side effects

•       Drug therapy interventions

–       Chemotherapy: Low dose Ara-C

Cytarabine (cytosine arabinoside) 15 mg continuous MIV (in D5W 500 ml) q12h x 14 days

–       Supportive care

–       Antiemetics for CINV (see problem #2)

–       Transfusions:

•       Leukocyte-depleted RBC, if Hgb<8 g/dL or hospital guideline or anemia sx

•       Platelets, if <10K/ul or with signs of bleeding

–       Tumor lysis ppx:

•       Hydration with diuresis

•       Urine alkalization (C/I with increased phosphate)

•       Allopurinol or rasburicase (use as initial if rapidly increasing blast counts, high uric acid, or impaired renal function)

–       Abx ppx:

•       Neutropenia during induction chemotherapy

•       Non-drug therapy interventions¹

–       None

•       Drug Preparation, Formulation, and Administration²

–       Cytarabine: given in an injection (IV or SQ or IT), store intact vials of powder at room temperature 20°C to 25°C, store intact vials of solution at room temperature 15°C to 30°C. Reconstituted solutions should be stored at room temperature and used within 48 hours. Solutions for IV infusion diluted in D5W or NS are stable for 7 days at room temperature. If storage is necessary, store in isolated location or container clearly labeled.

•       Alternative Drug Therapy (unlabeled use) (Lexicomp)

–       Low dose cytarabine SQ (may cause hematoma if low platelet)

–       5-azacytidine 75 mg/m2/day SQ x 7 days, repeat q4wks (hypomethylating agent: response may not be event before 3-4 cycles)

–       Decitabine 20 mg/m2 IV over 1 hour daily x 5 days, q28days (hypomethylating agent)

–       Supportive care (hydroxyurea, transfusion support)

•       Insurance/Cost issues²

–       Cytarabine: 5,356 \/100 mg/2 mL/vial

n Monitoring Plan

•       Effectiveness

Parameter                 frequency                     range     

BM blast                    7-10 days after end of tx          <5%

•       Toxicity

Parameter                 frequency                     range       

Hgb                                       daily                            decrease ≤ 8g/dL

Platelet                                 daily until Tf independent       decrease < 10K/uL

WBC                          daily                            not WNL (4-10K/uL)

ANC                          daily                            decrease < 500/uL

T                               daily                            increase ≥ 38°C

Na                             daily                            not WNL (135-145 mEq/L)

K                               daily                            not WNL (3.4-4.5 mEq/L)

Cl                              daily                            not WNL (98-106 mEq/L)

BUN                          daily                            maintain baseline

SCr                            daily                            increase > 1.4 mg/dL

P                               daily                            not WNL (2.6-4.9 mEq/L)

Uric acid                    daily                            increase

TCO₂                         daily                            not WNL (22-27 mEq/L)

AST/ALT                   weekly                         increase > 41/54 IU/L

LDH                                       daily                            increase > 90 IU/L

PT                             daily                            not WNL (12.3-15.6 sec)

aPTT                         daily                            not WNL (23.2-33.7 sec)

N/V/D/C                     daily                            (+/+/+/+)

Mucositis                   daily                            (+)

Hair loss                    daily                            (+)

Skin necrosis                        daily                            (+)

n Patient Education Point (Lexicomp)

n Finding of Drug Related Problem #2. Chemotherapy-induced Nausea and Vomiting (CNIV)

•       Subjective info

–       N/A

•       Objective info

–       Chemo regimen planned for pt (refer to problem #1: AML, MDS-related)

•       Current drug therapy

–       On order for today: granisetron 3 mg Inj. IV x 1

n Assessment of Drug Related Problem⁶

•       Etiology/Risk Factors

–       Pt is receiving a modified, low-dose cytarabine àminimal emesis risk

•       Severity of disease

–       N/A

•       Evaluate need for therapy and/or evaluate current therapy

–       No routine emesis ppx is needed for minimal emesis risk chemotherapy. Need to d/c granisetron.

–       Breakthrough antiemesis treatment may be needed.

n Patient Specific Recommendation

•       Goals of drug therapy

–       To minimize side effects.

–       To relieve patient suffering

–       To promote willingness to continue chemotherapy

–       Prevent complications of CINV (dehydration and electrolyte imbalance, malnutrition)

•       Drug therapy interventions

–       D/C granisetron

–       For breakthrough emesis: lorazepam 0.5 mg IV q6h prn

•       Non-drug therapy interventions

–       Nutrition: Eating small frequent meals. Choosing healthful foods. Controlling the amount of foods consumed. Eating food at room temperature. Eating bland food.

–       Nausea: Distractions, including TV or music, guided imagery, relaxation meditation, hypnosis

–       Vomiting: Maintain hydration

–       Take measures to reduce anxiety

•       Drug Preparation, Formulation, and Administration

–       Lorazepam IV: Store parenteral intact vials in the refrigerator, protected from light. Discard if discolored or contains precipitate. Parenteral mixtures are stable at room temperature of 25°C for 24 hours. Prepare for IV injection administration by diluting IV dose with an equal volume of diluent (NS, D5, SWEI). Can chose not to dilute if administering IV infusion.

•       Insurance/Cost issues

–       Lorazepam IV: 487\/2 mg/0.5 ml/1 amp

n Monitoring Plan

•       Effectiveness

Parameter                 frequency                     range     

Frequency of N/V      q hour                          (-)

•       Toxicity

Parameter                 frequency                     range       

RR                             daily                            Decrease (<12)

Dizziness/light-headed         daily                            (+)

Sedation                   daily                            (+)

BP                             daily                            Decrease (<90/60)

Appetite changes      daily                            (+)

n Patient Education Point (Lexicomp)

n Finding of Drug Related Problem #3. Pneumonia

•       Subjective info

–       Cough, sputum, dyspnea, wheezing

•       Objective info

–       Tachypnea: RR 24

–       Chest CT:

8/23/2013

•       Consolidation and GGO in BUL and RML

•       Severe emphysema in both lungs

•       No interval change of tiny nodule in the RUL

1.     Benign inflammatory lesion, likely

•       Small amount of bilateral pleural effusion

•       Mild prominent 2R, 4B and both peribronchial LNs, probably active

9/2/2013 (compared with 8/23)

•       Consolidation and GGO in both lungs: extent decreased

•       Underlying lung parenchyma –diffused emphysema and nodular lesions in RULs: no changes

•       Pleural effusion in both hemithorax: improved

•       Prominent LNs: no big change

–       hsCRP 11.75à 7.81 à 4.16à 2.58à 0.86 (9/3 today)

–       CBC  (8/23) 4200-7.9-26K, ANC 1050

(8/28) 3400-8.3-41K, ANC 1156

(9/3) 4700-8.0-16K, ANC 1222

•       Current abx drug therapy

–       Tazoperan (piperacillin/tazobactam) Inj. 4.5 g MIV q6h (Day 12, 8/23-  )

–       Levofloxacin 750 mg IV q24h (Day 12, 8/23-  )

n Assessment of Drug Related Problem⁶

•       Etiology/Risk Factors

–       Increased organism burden in lungs

•       Elderly: poor cough, microaspiration

•       Prone position: aspiration risk

•       Hospitalization: colonization of upper respiratory tract with virulent pathogens

•       Emphysema

•       h/o or smoking: reduced ciliary action

–       Reduced clearance of organism from lungs

•       Immunosuppression (cancer, increased age)

•       Lack of influenza vaccination

•       Lack of pneumococcal vaccination

•       Severity of disease

–       Mild

1.     Pt’s symptoms are improving per chest CT, labs

•       Evaluate need for therapy and/or evaluate current therapy

–       Maintain and finish current abx therapy.

n Patient Specific Recommendation

•       Goals of drug therapy

–       Resolve s/sx

–       Improve quality of life

–       Prevent morbidity and mortality

•       Drug therapy interventions

–       Tazoperan (piperacillin/tazobactam) Inj. 4.5 g MIV q6h (Day 12, 8/23-  )

–       Levofloxacin 750 mg IV q24h (Day 12, 8/23-  )

•       Non-drug therapy interventions

–       Avoid oversedation

•       Drug Preparation, Formulation, and Administration

–       Tazoperan (piperacillin/tazobactam) IV: powder for reconstitution in clear vial

–       Levofloxacin IV solution in IV bag

–       Store at room temperature of 25°C (77°F)

•       Insurance/Cost issues

–       Tazoperan (piperacillin/tazobactam) IV: 7,417 \/4.5 g/1 vial

–       Levofloxacin IV: 18,429 \/750 mg/150 ml/bag

n Monitoring Plan

•       Effectiveness

Parameter                 frequency                     range     

hsCRP                                   daily                            <0.63 mg/dL

Fever                         daily                            (-) <38C

Cough                                   daily                            (-)

Sputum                                 daily                            (-)

Wheezing                  daily                            (-)

RR                             daily                            WNL (12-20 bpm)

SpO₂ %                                 daily                            Decrease <94%

•       Toxicity

Parameter                 frequency                     range       

SCr                            baseline, weekly                      Increase

K                               daily                            Decrease <3.5 mmol/L

WBC                          daily                            Not WNL

Platelet                                 daily                            Decrease

n Patient Education Point (Lexicomp)

n References

1. Lexicomp
2. druginfo.co.kr
3. Uptodate.com
4. NCCN 2.2013 AML guideline

Each day starts with an hour of pre-rounding by the IMN pharmacy team. This involves the patient-monitoring sheet projected to a screen and the newly admitted patient information is shared. Then the IMN pharmacist of the day joins the medical team for rounding at 9am.

The current arrangement of both the IMN and Hem/Onc teams is that pharmacists rotate each day to follow-up on the patients. Therefore the sharing of the patient-monitoring sheet with everyone is crucial to ensure understanding and proper follow-up. The reason for this arrangement is to share the time devoted to clinical responsibilities fairly among the pharmacists, as part of their graduate program. The pharmacists agree that it is difficult to mange all the patients on this rotating basis. From the perspective of patient safety, there must be extra precautions taken for this type of arrangement to ensure thorough transitions. Therefore, all pharmacists engage in the pre-rounding very actively and work together.

Throughout the day, the IMN pharmacist of the day participates in rounding with the medical team, doing medication reconciliation for new patients, and discharging patients. The pharmacist also provides drug information services. Patient education is a big part of the pharmacists’ duty.

-Tae

There is a demand for clinical pharmacists in Korea.  Upon graduation, the majority of the pharmacists go into the community pharmacy workforce.  The remaining pharmacists who work in industry or in academia are heavily focused on clinical research.

Currently, the scope of clinical pharmacists in the hospital setting seems limited and the opportunities for clinical pharmacists seem scant.  But a big part of the reason is actually because there aren’t enough pharmacists to meet the demands. With a bigger workforce, the pharmacy departments at hospitals will be able to provide more of the valuable clinical services aside from the basic responsibility of dispensing products.

During my discussion with my preceptor, I learned that there are about thirty pharmacy schools and about 3,000 pharmacists in Korea now.  Just several years ago, there were only about twenty pharmacy schools.  With a growing demand for clinical pharmacists in hospitals and ambulatory care clinics, the country is in the process of expanding the number of pharmacy programs and improving pharmacy education (e.g. 2+4 pharmacy program mentioned in a previous post)

- Tae

While it is technically a research lab, our preceptors spend a lot of time working on patients. It’s amazing how hard working the preceptors are here! They are all involved in research, all the while taking care of their patients in their respective services.

Each service has four clinical pharmacy students. The “eldest” PhD students are the “leaders” of each service and are the main preceptors for their service. The four of us (Jason, Tae, Min Oh and I) are each assigned one student from each of the services to be our go-to preceptor while we are on service. The preceptors take turns taking care of the patients. On each service, one person would work up the old and new patients the night before, and be ready to present all the patients during the pre-rounds meeting. Then they would take care of the patient during rounds. That night, a different person would work up the patients in preparation for the next day. Basically, you took care of the entire service every 4 days, with the preceptors rotating. It was an interesting way of doing things – very different from the ways I’ve seen in done at UCSF, where preceptors would take care of a service for their assigned time length. For example, at gen med @ Mt Zn, we would have a preceptor assigned to the surgical floor and a preceptor assigned to the gen med floor for X weeks, and that preceptor would oversee the patients during those entire weeks (unless of course someone has vacation/sick days). I think I understand why SNUH is organized differently; because our preceptors are also graduate students, they need a lot of time to work on research, while still exercising their clinical pharmacy muscles.

Because we are students (with no pharmacy degree), we are not allowed to do anything but shadow on the actual hospital floor. In Korea, there are a lot of legal barriers preventing students from participating in a meaningful way. So while we will be using the EMR and following patients, we won’t be able to actually counsel or making recommendations directly to doctors. In Korea, BS pharmacy students do not get any clinical experience while in school. It’s a bit of a surprise to me: I never thought about what a privilege it was to be able to work and not just constantly shadow, thanks to our California intern licenses. I’m glad that we were able to get the experiences from our internships. I already feel a bit overwhelmed at the thought of being an official graduate and pharmacist in a few months’ time – I can only manage how much more anxious I would feel if I didn’t have my intern experience. Not only is it valuable work experience, I always found it interesting to talk to classmates and learn what they do and learn from their own internships, as there are a great variety of internship settings out there and one person can’t possible experience them all in the short time we are in school.

-Lena