pharming_in_korea | Tae’s Case Presentation II: AML, MDS-related

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)

Objectives	1. Understand the epidemiology, etiology, pathophysiology, signs and symptoms, and the diagnosis of AML.
	2. Be able to apply appropriate treatment goals and approach for AML.
	3. Be able to assess appropriateness and make evidence-based pharmacologic recommendations for AML and provide appropriate patient counseling.
	4. Understand the monitoring parameters of pharmacologic interventions for 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 O₂nasal 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%)

n Other tests

5/6/2013 8/28/2013

• FISH Monosomy 7 (42%) Monosomy 7 (82.5%)

Complex karyotype Complex karyotype

• Bone Marrow Bx Blast 12.8% Blast 37.2%

MDS, RAEB-2 AML, MDS-related
(Refractory Anemia w/ Excess Blasts-2)

• 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 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

• 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:

Medical problems	Current Medication	Drug-related Problem
#1 AML, MDS-related	LD Ara-C: Cytarabine (cytosine arabinoside) 15 mg continuous IV q12h x 14 days (on order for today 9/3)	Maintain
#2 Chemotherapy -induced Nausea and Vomiting (CINV) ppx	Kytril (granisetron) 3 mg Inj. IVS x 1 (on order for today 9/3)	No indication for the current drug ordered
#3 Infection - Pneumonia	Antibiotics: - Tazoperan (piperacillin/tazobactam) Inj. 4.5 g MIV q6h (Day 12) - Levofloxacin 750 mg IV q24h (Day 12) Sx management: - Anycough (theobromine) 300 mg 1 cap PO bid pc - Roisol (ambroxol HCl) 30 mg 1 tab PO q8h	Maintain
#4 Infection - Mucositis ppx	- Hexamedine (chlorhexidine gluconate) gargle throat/mouth once daily - Nystatin 1:5000 soln gargle throat/mouth tid - Klenzo (irrigation NS) ut dict daily	Maintain
#5 Nutrition	- Folic acid (folate) 1 mg 1 tab PO daily pc - Vitamin C (ascorbic acid) 1000 mg 1 tab PO daily pc - Mecobalamin (cyanocobalamin) 0.5 mg 1 tab PO daily pc - RBC, platelet transfusions, PRN - Beecom (vitamin B and C) 1 tab PO daily pc - Megace (megesterol) 40 mg/ml susp 20 ml PO daily pc - Combiflex (TPN) 1100 ml 1 bag IV q24h	Maintain
#6 Skin rash	- Adipam (hydroxyzine) 10 mg 1 tab PO qhs - Lacticare-HC (hydrocortisone) 1% App AA bid	Maintain
#7 h/o PSVT	Isoptin (verapamil) 40 mg 1 tab PO q12h	Maintain

Patient Focused Approach of Pharmaceutical Care Plan Process

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)

Brand/ Generic	Cytarabine/cytosine arabinoside
MOA/ Use	A pyrimidine analog chemotherapy agent used to kill cancer cells.
Admin- istration	This drug is available in IV form. The dose to be received is 15mg by continuous IV every 12 hours for 14 days.
Storage	Administered at hospital.
Adverse effects	Report immediately any chills, pain, swelling, or redness at injection site, respiratory difficulty, or signs of an infection, including fever of 38°C or higher, chills, sore throat, ears or sinus pain, cough, more sputum than usual, change in color of sputum, pain with passing urine, mouth sores, wounds that will not heal or anal itching or pain.
DDI	Make sure to talk to your doctor or pharmacist before starting any new medication, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication.
Others	After administration of the drug, please be especially careful of infections. You may have an increased chance of getting an infection. Wash hands often. Stay away from people with infections, colds, or flu. Take all medications as prescribed, including antibiotics and oral solutions to decrease chance of infection.

Patient Focused Approach of Pharmaceutical Care Plan Process

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)

Brand/ Generic	Ativan/lorazepam
MOA/ Use	This drug is available IV form. The dose to be received is 0.5 mg IV q6h prn breakthrough emesis
Admin- istration	This drug can be administered via IV.
Storage	To be administered at the hospital. Store at room temperature.
Adverse effects	-Report immediately if you have any of the following signs and symptoms: signs of an allergic reaction, chest pain, very bad dizziness/light-headedness, heartbeat that does not feel normal, fever, chills, sore throat, trouble urinating, and trouble controlling body movements. -Other side effects may include headache, constipation, and sleepiness. Signs of an allergic reaction include rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest.
DDI	Make sure to talk to your doctor or pharmacist before starting any new medication, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication.
Others	Avoid alcohol and other medicines that cause respiratory depression

Patient Focused Approach of Pharmaceutical Care Plan Process

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)

Brand/ Generic	Tazoperan (piperacillin/tazobactam)
MOA/ Use	This medicine is used to treat bacterial infection (pneumonia).
Admin- istration	To be administered IV.
Storage	Store at room temperature. Store in a dry place.
Adverse effects	-Report any signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. -Diarrhea, high blood pressure, chest pain, rash, C/N/V, abdominal pain
DDI	Make sure to discuss with your doctor or pharmacist before starting any new medications or getting vaccines, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication.
Others	N/A

Brand/ Generic	Levofloxacin
MOA/ Use	This medicine is used to treat bacterial infection (pneumonia).
Admin- istration	To be administered IV.
Storage	Store at room temperature.
Adverse effects	-Report any signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. -This drug may raise the chance of tendons getting irritated and tearing. The chance is greater in people over the age of 60; heart, kidney, or lung transplant patients; or people taking steroid drugs. Call your doctor right away if you have pain in the back of the ankle or joint pain or swelling. -Chest pain, edema, insomnia, rash, N/D/C, abdominal pain, dyspnea
DDI	-Make sure to discuss with your doctor or pharmacist before starting any new medications or getting vaccines, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication. -Multivitamins/Minerals (with ADEK, Folate, Iron) may decrease the absorption of this medicine if taken by mouth.
Others	N/A