NMSHP Presentation UNMHResidents slides per page.pdf · 10/4/18 7 Low-dose vs High-dose steroids ¡ Low-dose corticosteroids for grade 2: § prednisone or methylprednisolone 0.5–1

10/4/18

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ClinicalPearlsUNMHPharmacyResidents

JessicaLewis-Gonzalez,PharmDValentinPacuraru,PharmDAmre Elmaoued,PharmDSienaMeador,PharmDNgoc-YenPham,PharmD

ManagementofAdverseEffectsofPD1/PDL1Inhibitors

JessicaLewis-Gonzalez,PharmDPGY-1PharmacyResidentUniversityofNewMexicoHospitals

10/4/18

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Objectives

¡ Pharmacist§ EvaluateandassessthemanagementofadverseeffectsofthePD1/PDL1inhibitors

¡ Technician§ Identify managementofadverseeffectsofthePD1/PDL1inhibitors

Wait…whichdrugsarethoseagain???

¡ PD1Inhibitors§ Pembrolizumab(Keytruda)

§ Nivolumab(Opdivo)

¡ PDL1Inhibitors§ Atezolizumab(Tecentriq)§ Avelumab(Bavencio)§ Durvalumab(Imfinzi)

• TheseareIVcancerchemotherapymedicationsthatareadministeredmostcommonlyintheoutpatientsettingatinfusioncenters.

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Whyisthisimportanttoyou?

AdverseEventstobeAwareof:

¡ Immunerelatedadverseevents§ Dermatologic§ GI§ Hepatic§ Endocrine§ Otherlesscommoninflammatoryevents

Postcow.JourClin Onc.2015.

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GradingofAdverseEvents¡ PerCommonTerminologyCriteriaforAdverseEvents(CTCAE):

NIH,NCI.CommonTerminologyCriteriaforAdverseEventsV.5.0.2017.

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TreatmentofAdverseEvents(InGeneral)

¡ Grade1:Mild,asymptomatic§ Management:Observation,interventionnotneeded

¡ Grade2:Moderate§ Management:Localornoninvasiveinterventionindicated§ Willlikelyneedlow-doseoralprednisone/methylprednisoloneandmaybe

abletocontinuetreatment¡ Grade3:Severalormedicallysignificantbutnotimmediatelylife-

threatening§ Management:Stopimmunotherapy,hospitalizationindicated,highdose

prednisone/methylprednisolone¡ Grade4:Life-threateningconsequences

§ Management:Urgentintervention,willpermanentlystopimmunotherapy¡ Grade5:DeathrelatedtoAE

NIH,NCI.CommonTerminologyCriteriaforAdverseEventsV.5.0.2017.

Derm AdverseEvent- MaculopapularRashGrade Hold

ImmunotherapySteroids Antihistamine Other

1 Moderate-potencytopical

Topicalemollient

2 Consider holding High-potency topicalAND/OR

low-dose prednisone/methylprednisolone

Topicalemollient

3/4 High-potency topical+low-dose prednisone/methylprednisolone(increasedoseifno

improvement)

UrgentDermConsult

NCCN.ManagementofImmunotherapy-RelatedToxicities(Version1.2018).

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GIAdverseEvent- Diarrhea/Colitis

Grade HoldImmunotherapy

Steroids Permanently DC Other

1 Considerholding Loperamide,hydration

2 IVmethylprednisolone

1mg/kg/day

3(considerresumingafterresolution)

IVmethylprednisolone

2mg/kg/day

ConsiderInpatientSupportiveCare

4 IVmethylprednisolone

2mg/kg/day

ConsiderInpatientSupportiveCare

(NCCN).ManagementofImmunotherapy-RelatedToxicities(Version1.2018).

HepaticAdverseEvent- AcutePancreatitis

Grade HoldImmunotherapy

Steroids Permanently DC Other

1 ConsiderGastroenterology

Referral

2 Low-doseprednisone/

methylprednisolone

3/4 High-doseprednisone/

methylprednisolone

(NCCN).ManagementofImmunotherapy-RelatedToxicities(Version1.2018).

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Low-dosevsHigh-dosesteroids¡ Low-dosecorticosteroidsforgrade2:

§ prednisoneormethylprednisolone0.5–1 mg/kg/day¡ High-dosecorticosteroidsforgrade3and4:

§ prednisoneormethylprednisolone1–2 mg/kg/day¡ Taperingoffsystemiccorticosteroidsover4–6 weeksafter

symptomshaveresolvedtoGrade1or2

Rudzki,JD.MemoSpringer.2018.

Summary¡ Whenitcomestoimmune-relatedadverseeventswith

checkpointinhibitors– Steroidsareyourfriends!§ Topical§ Low-dose§ High-dose

¡ WhenpatientspresenttothehospitalonaPD-1/PDL-1inhibitorwithanacuteevent:§ Considerdrugasapotentialcause§ Gradethereaction(ifcausedbydrug)§ Treatbasedongrading

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ApproachtothePatientwithNausea&VomitingandQTcProlongation

ValentinPacuraru,PharmDPGY-1PharmacyResidentUniversityofNewMexicoHospitals

LearningObjectives

Pharmacists• DefinetheextentofQTcprolongingeffectofseveralN/Vmedications.

Technicians• IdentifythefivemostcommonlyuseddrugsforN/VthatimpactQTc.

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QTcProlongationandriskofTorsades dePointes

Torsades

https://pedemmorsels.com/prolonged-qtc/

DefiningQTcProlongationQTc ValuesbyAgeandSex(ms)1– 15y/o AdultMales AdultFemales

Normal <440ms <430ms <450msBorderline 440– 460ms 430– 450ms 450– 470msProlonged >460ms >450ms >470ms

• >500ms

ClinicallySignificantQTcProlongation

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TorsadesdePointesRiskFactors¡ FemaleSex¡ Hypokalemiaand/orHypomagnesemia¡ Bradycardia¡ RecentCardioversion¡ StructuralHeartDisease¡ DigoxinTherapy¡ BaselineQTProlongation¡ RapidIVinfusionofQTprolongingmedications¡ PharmacokineticInteractions

LiM.PT.2017LinYL.Pharmacoepidemiol DrugSaf.2009

RiskScoringOptionTisdale RiskScoreRiskFactor Points QTc Interval RiskStratificationAge>68 1 RiskCategory RiskScoreFemaleGender 1

Low <7LoopDiuretic 1Potassium<3.5mEq 2QTc >450onAdmit 2

Moderate 7– 10AcuteMI 22+QTc Prolonging Drugs 3Sepsis 3

High >11HeartFailure 3OneQTc ProlongingMed 3

Maximum RiskScore 21TisdaleJE.CanPharmJ2016

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ApproachingNauseaandVomiting

Gastroparesis

Infectious

MedicationInduced

ElectrolyteorFluidAbnormality

GIObstruction/Inflammation

GERD

DiabetesRelated

TreattheUnderlyingEtiologyFirst

CommonInpatientMedicationsforNauseaandVomiting

Ondansetron

Promethazine

Prochlorperazine

MetoclopramideHaloperidol

Trimetho-benzamide

Olanzapine

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AlternateAgentsforNausea&Vomiting

Dexamethasone• BestdataforPONVandCINV• SideeffectslimituseinsimpleN/V

InhaledIsopropylAlcohol• PromisingEDdataincludingsuperioritytoondansetron

Benzodiazepines•Mostappropriateforwithdrawal,anxiety,andanticipatoryrelatednausea

AprilMDetal.AnnEmerg Med2018BeadleKL.AnnEmerg Med.2016

Haloperidol

D2ReceptorAntagonist

PublishedevidenceofQTc prolongationrangingfrom8ms –

35ms

Multiplepublicationsof

torsadogenesis andcardiacdysrhythmia

IM,IV,Sol,andTab

Wenzel-seifert K.Dtsch Arztebl Int.2011Vannoord C.JClin Psychopharmacol.2009

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Ondansetron

Serotonin-3ReceptorAntagonist

PublishedevidenceofQTcprolongation

rangingfrom4ms –32ms

Fewpublishedcasesoftorsades or

dysrhythmia,butassociatedhighIVdoses(32mg)

IV,IM,Sol,Tab,ODT,andPOFilm

Brygger L.ExpertOpin DrugSaf.2014Poluzzi E.PLoS ONE10.2015

Promethazine

H1andD2ReceptorAntagonist

PublishedEvidenceofQTc prolongation

Lowtorsadogenicpotential

IM,IV,PR,Sol,andTabavailable

JoSH..Pharmacol Res.2009Owczuk R.Anaesthesia.2009

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Metoclopramide

D2ReceptorAntogonist

PublishedevidenceofQTcprolongation

Fewpublishedcasereportsof

cardiacdecompensation

IV,IM,Sol,Tab,andODT

SmithHS.AnnPalliat Med.2012SmithHS.AnnPalliat Med2012ChouCCChangGungMedJ2001Ellidokuz E.AlimentPharmacol Ther.2003

Prochlorperazine


PublishedevidenceofQTc

prolongation,particularlyinvitro

Fewcasereportsofprochlorperazinecontributingtoan

arrhythmia

IM,IV,PR,Sol,andTab

Aström-lilja C.Pharmacoepidemiol DrugSaf.2008

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Olanzapine


PublishedevidenceofQTc prolongation

Fewcasereportsoftorsades withIVformulation

PO,IM,andIVformsavailable

Czekalla J.JClin Psychiatry.2001SuzukiY.HumanPsychopharmacology.2011LamYWF.BrownUniversityPsychopharmacology.2015

Trimethobenzamide


NopublishedevidenceofQTcprolongation

Nopublishedevidenceof

torsadogenesis

POandIMformsavailable

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RankingTorsadogenicRisk

7)Trimethobenzamide

6)Prochlorperazine

5)Metoclopramide

4)Olanzapine

3)Promethazine

2)Ondansetron

1)Haloperidol

Isbister GK.BrJClin Pharmacol.2013

FinalThoughts

• Noonesizefitsallanswer

• QTc prolongation≠ torsadogenic risk

• Additionalriskfactorsareimportant

• Risk/Benefitisapatientspecificdecision

• Medicationchoiceshouldbebasedonrisk/benefit,patientspecificcharacteristics,androute

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AlternativeUsesofHaloperidol

Amre Elmaoued,PharmDPGY-1PharmacyResidentUniversityofNewMexicoHospitals

Objectives

¡ Pharmacists:§ Evaluatesomealternativeusesofhaloperidol

¡ Technicians:§ Identifysomeoff-labelusesofhaloperidol

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Haloperidol- D2Antagonist

¡ 1stgenerationAntipsychotic(a.k.a.TypicalAntipsychotic)

¡ FDAIndication:§ Psychosis§ Schizophrenia

¡ TypicalDosing:0.5-2mgtwo- threetimesdaily

MechanismofAction

PsychopharmacologyInstitute.(n.d.)

Haloperidol- Characteristics

PsychopharmacologyInstitute.(n.d.)

D2 Activity High

5HT2Activity Medium

MuscarinicActivity

Low

Alpha-1adrenergicActivity

Low

AntihistamineActivity

Low

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IMLactateforIVBriefPsychRatingScale

Baseline 4Hours 24Hours

Diazepam 28.5 11.4 6.3

Haloperidol 30.5 3.8 8

¡ Lerneret.al.(1978):§ Randomized40patientsto

haloperidolordiazepam§ BothreceivedviaIVroute

¡ FDAWarning(2007):§ IncreasedriskofQTc

prolongationhasbeenseen§ Studiesareshowinglower

dose,<2mg,noincreasedQTc

¡ Bothequallyeffectiveantipsychotics¡ Doses

§ Haloperidol=15mgstart. 10mgq1hr.Totalaverage~20-35mg§ Diazepam=10-15mgstart.5-10mgq1hr.Total~30-40mg

¡ MorewithdrawalassociatedwithhaloperidolDuprey M.S,Int CarMed.2016Lerner,Y.AmofPsy.1979Hatta,K. JClin Psy. 2001

Off-LabelUses• Intractableheadaches• Agitation/RapidTranquilization• Nausea/Vomiting

• Intractablehiccups• ChoreaofHuntingtondisease• DeliriumintheICU• Obsessive-compulsivedisorder

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IntractableHeadaches

¡ Comparedhaloperidol5mgIVvs.metoclopramide10mgIV§ EmergencyDepartment,N=64

▪ 31haloperidol▪ 33metoclopramide

¡ Allpatientswerepretreatedwithdiphenhydramine25mg

¡ VASmeasured0,20,40,60,80min

Gaffigan,M.E.,JEmerg Med.2015

Agitation/RapidTranquilization

¡ Dose:haloperidollactate2.5mg-10mgIM

Ostinelli,E.G.etal.CochraneDatabaseSyst Rev.2017

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Nausea/Vomiting

¡ UsualDose:0.5mg- 2.5mgQDorBID¡ Studiedin:

§ Cancer§ PalliativeCare§ Post-OperativeNauseaandVomiting

Nausea/VomitingResponse Complete

ResponsePartial Response NoResponse Failure

Patient-ratedDay2(n = 33)

8 12 10 3

Patient-ratedDay5(n = 23)

7 10 2 4

Observer-ratedDay2(n = 29)

8 15 4 2

Observer-ratedDay5(n = 19)

6 9 3 1

AdaptedfromHardy,J.R.,etal.JPainSymptomManage.2010.

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Nausea/VomitingResponse Response

(CR + PR)n/N(%)Response

(AllPatients) n/N(%)Patient-ratedDay2(n = 33) 20/33(60) 20/42(47)

Patient-ratedDay5(n = 23) 17/23(74) 17/42(40)

Observer-ratedDay2(n = 29) 23/29(79) 23/42(54)

Observer-ratedDay5(n = 19) 15/19(78) 15/42(35)

AdaptedfromHardy,J.R.,etal.JPainSymptomManage.2010.

SideEffects

TRANSLATESTOExtrapyramidalSideEffects

VeryHigh

AnticholinergicEffects

VeryLow

HypotensiveEffects

VeryLow

SedatingEffects VeryLow

D2 Activity High

5HT2Activity Medium

MuscarinicActivity

Low

Alpha-1adrenergicActivity

Low

AntihistamineActivity

Low

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SideEffects- QTc Prolongation

RISKFACTORS CONSIDERATIONS

¡ BaselineECG¡ IfgivingIVhaloperidol,monitor

ECGclosely¡ Discontinuemultiplemedications

withQTcprolongation¡ QTc >500msà consideredrisk

forTdP§ >450msformalesà considered

prolonged§ >470msforfemales

Unmodifiableriskfactors Potentiallymodifiableriskfactors

FemaleGender Hypokalemiaorseverehypomagnesaemia

IncreasingageBradycardia

GeneticallylongQTsyndromeFamilyhistoryofsuddendeathHistoryofpreviousdrug-inducedQTprolongation

>1QTcprolongingmedication

Medsthatcauseelectrolyteabnormalitiesormaycauserenalorhepaticdysfunction

Structuralheartdisease/LVdysfunction

Starvationorobesity

Impairedeliminationduetorenalorhepaticdisease

HighdrugconcentrationsduetooverdoseorrapidIVadministration

RapidUpdate:RecentlyApprovedAntimicrobials

SienaMeador,PharmDPGY-1PharmacyResidentUniversityofNewMexicoHospitals

10/4/18

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Objectives

¡ Pharmacist:§ Discusstheroleofrecentlyapprovedantimicrobialtherapies

¡ Technician:§ Identifyrecentlyapprovedantimicrobialtherapies

Baxdela™delafloxacin

https://jamanetwork.com/journals/jama/article-abstract/2646700

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FDAApprovedIndications

¡ Fluoroquinoloneforthetreatmentofacutebacterialskinandskinstructureinfections(ABSSSI)inadults≥18yearsold

Baxdela™(delafloxacin)[packageinsert].2017.

K.pneumoniae

P.

aeruginosa E.coli

E.faecalis

CertainStaphylococcus

spp.

CertainStreptococcus

spp.

Dosing¡ Bymouth

§ 450mgtabletevery12hours§ Notrenallyadjusted§ Withoutregardtofood

¡ IntravenouseGFR Dose Interval≥30 300mg 12hours15-29 200mg 12hours

<15ordialysis Notrecommended,consider switchingtotablet


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Warnings/AdverseEffects

¡ BlackBoxWarnings§ Tendinitis/tendonrupture§ Peripheralneuropathy§ Centralnervoussystemeffects§ Exacerbationofmuscle

weaknessinmyastheniagravis¡ Contraindication

§ Hypersensitivity¡ Warnings

§ C.difficile-associateddiarrhea§ Drug-resistantbacteria

¡ AdverseReactions§ Nausea(8%)§ Diarrhea(8%)§ Headache(3%)§ Transaminaseelevations(3%)§ Vomiting(2%)

¡ Requiresamedicationguide


PlaceinTherapy

¡ Limitedbenefitoverotherfluoroquinolonesbutmore

expensive

¡ MostskinandskinstructureinfectionsarecausedbyGram

positivebacteria

¡ Gramnegativecoverageisnotusuallyindicated

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Vabomere™meropenem/vaborbactam

http://www.vabomere.com


¡ Carbapenem+β-lactamaseinhibitorforthetreatmentofcomplicatedUTI,includingpyelonephritis,inadults≥18yearsold

Vabomere™(meropenemandvaborbactam)[packageinsert]2017.

K.pneumoniae

Enterobactercloacaespp

E.coli

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Dosing¡ Intravenous

¡ Onlycompatiblewithnormalsaline¡ Alldosesareadministeredover3hours

eGFR Dose Interval Minimum diluent

≥50 4 gm 8 hours 250 mL30-49 2gm 8 hours 125mL15-29 2gm 12hours 125mL

<15 or dialysis 1gm 12hours 70 mL

Vabomere™(meropenemandvaborbactam)[packageinsert].2017.


¡ Contraindication§ Hypersensitivity(1.8%)

¡ Warnings§ Seizures§ OtherCNSexperiences§ Neuromotor impairment§ Reducedvalproic acidlevels§ Thrombocytopenia§ C.difficile-associateddiarrhea§ Drug-resistantbacteria

¡ Adverseeffects§ Headache(8.8%)§ Phlebitis/infusionreactions

(4.4%)§ Diarrhea(3.3%)§ Nausea(1.8%)§ Transaminaseelevations

(1.8%)§ Pyrexia(1.5%)§ Hypokalemia(1.1%)

Vabomere™(meropenemandvaborbactam)[packageinsert].2017.

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PlaceinTherapy

¡ Carbapenem-resistantenterobacteriaceae (CRE)

¡ DoesNOThaveimprovedefficacyagainstmultidrugresistant

Pseudomonasspp.orAcinetobacterspp.

¡ Limitedbydosingandadministrationrequirements

Solosec™secnidazole

https://www.solosec.com

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¡ Nitroimidazoleforthetreatmentofbacterialvaginosisinwomen≥18yearsold

Solosec™(secnidazole)[packageinsert].2017.

Bacteriodesspp.

Gardnerellavaginalis

Prevotella spp. Mobiluncusspp.

Megasphaera-liketypeI/II

Dosing

¡ Singledoseof2grams(1packet)¡ Sprinkleoverapplesauce,yogurt,orpudding¡ Consumewithin30minutes¡ Donotcheworcrunchthegranules¡ Maybefollowedwithaglassofwater¡ DoNOTdissolveinanyliquid


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¡ Contraindication§ Hypersensitivity

¡ Warnings§ Vulvo-vaginalcandidiasis(9.6%)

§ Riskforcarcinogenicity§ Drugresistance

¡ Adverseeffects§ Headache(3.6%)§ Nausea(3.6%)§ Dysgeusia(3.4)§ Vomiting(2.5%)§ Diarrhea(2%)§ Abdominalpain(2%)§ Vulvovaginalpruritus(2%)


PlaceinTherapy

¡ Onlysingle-dosetreatmentforbacterialvaginosis

¡ Beneficialforpatientswithadherenceconcerns

¡ Maybeusefulinhospital-ownedoutpatientclinics

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SHINGRIX™ZosterVaccineRecombinant,Adjuvanted

https://www.shingrix.com/index.html

FDAApprovedIndication/Dosing

¡ Forthepreventionofherpeszosterinadults≥50yearsold¡ Twovaccineseries,2to6monthsapart¡ 0.5mLinjectedintramuscularly¡ 2vialsperinjection¡ Keeprefrigerated,donotfreeze

Imagefromgsksource

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¡ Contraindication§ Severeallergicreactiontoanycomponentorafterapreviousdose

¡ Localreactions§ Pain(78%)§ Redness(38.1%)§ Swelling(25.9%)

¡ Generalreactions§ Myalgia(44.7%)§ Fatigue(44.5%)§ Headache(37.7%)§ Shivering(26.8%)§ Fever(20.5%)§ GIsymptoms(17.3%)

SHINGRIX™(ZosterVaccineRecombinant,Adjuvanted)[packageinsert].2017.

PlaceinTherapy

¡ AdvisoryCommitteeonImmunizationPractices(ACIP):

§ Vaccinateallimmunocompetentpatients≥50yearsold

§ Recombinantherpeszosterispreferredoverthelivezostervaccine

§ Adultspreviouslyvaccinatedwiththelivezostervaccineshouldbe

revaccinatedwithShingrix

Dooling KL,etal.RecommendationsoftheAdvisoryCommitteeonImmunizationPracticesforUseofHerpesZosterVaccines.

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PreventionofHepatitisBreactivationinpatientsreceivingRituxantherapy

Ngoc-YenPham,PharmD.PGY-1PharmacyResidentUniversityofNewMexicoHospitals

LearningObjectives

¡ Pharmacists:§ FormulateanappropriaterecommendationtomanagepatientswithHepatitisBwhorequireimmunotherapymanagementwithRituxan

¡ Technicians:§ IdentifythetherapiesusedtomanagepatientswithHepatitisBwhorequireimmunotherapymanagementwithRituxan

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Rituxan(rituximab)

IndicationsMonoclonalantibody

Boxedwarnings

Non-HodgkinLymphomaChronicLymphocytic

Leukemia(CLL)Rheumatoidarthritis

Vasculitis

Anti-CD20directedonB-lymphocytes

InfusionreactionMucocutaneousReactionsHepatitisBReactivationProgressiveMultifocalleukoencephalopathy

Rituxan(rituximab)[prescribinginformation].

HepatitisBVirus(HBV)Serology

§ IgMantibodytoHBVcoreantigen§ Indicatesrecent/acuteHBV

infectionin≤6months

§ HBVsurfaceantigen§ IndicatesapersonisinfectiousHBsAg § AntibodytoHBVsurfaceantigen

§ IndicatesimmunityAnti-HBs

§ IgGantibodytoHBVcoreantigen§ Markerofpastorcurrent

infectionwithHBV

IgMAnti-HBc

§ TotalantibodytoHBVcoreantigen

§ IndicatesexposuretoHBV

§ CorrelateswiththelevelsofHBVvirusparticles

§ MarkerofHBVreplicationandinfection

§ HBVeantigen§ MarkerofHBVreplication

andinfectionHBeAg

Anti-HBc

IgGAnti-HBc

HBVDNA

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RiskfactorsforHBVreactivation(HBVr)

¡ HBV-DNAlevel

¡ Anthracyclines/steroiduse

¡ Transplantation

¡ Presenceoflymphoma

§ Malegender

§ LackofHBsantibody

§ HBsAgpositive

§ Presenceofprecore mutant

Tsutsumi Y.WorldJHepatol.2013.

Prophylacticantiviraltherapy

ProphylacticantiviraltherapyOrmonitoring

Monitoring

High

Moderate

Low

ManagementofHBVreactivationScreenpatientsbefore

immunosuppressivetherapy

HBsAg+Anti-HBc +

HBsAg-Anti-HBc +

HBsAg-Anti-HBc-

CheckHBVDNA

AssessRisk

HwangJ,NatRevGastroenterolHepatol.2014.Perrillo R.Gastroenterology.2015.

Pattullo V.ClinMolHepatol.2016.

vaccinations

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RiskStratificationforHBVrRiskGroups HBVr drugestimatesHigh-riskgroups(>10%) B-celldepletingagents

- Rituximab- OfatumumabAnthracyclinederivatives- Doxorubicin- EpirubicinCorticosteroidstherapy≥ 4weeks(prednisone20mg)

Mediumriskgroup(1%- 10%) TNF–α inhibitorsCytokinesandintegrininhibitorsTyrosinekinaseinhibitors

Low-riskgroups(<1%) Azathioprine,6-mercaptopurineMethotrexateIntra-articularcorticosteroids

Perrillo R.Gastroenterology.2015.HwangJ,NatRevGastroenterolHepatol.2014.Pattullo V.ClinMolHepatol.2016.

ProphylacticAntiviraltherapyResistance

ClassBoxedwarning:lacticacidosisandseverehepatomegalywithsteatosis,acuteexacerbationofHBVupondiscontinuation

Lamivudine Lowbarriertoresistance

Mutationandresistance

Entecavir Higherbarrierofresistance

Renaldoseadjustments

Tenofovir Higherbarrierofresistance

Renaldoseadjustmentsnephrotoxicity

HanS.JAmBoardFamMed.2015.LamperticoP.JHepatol.2017.

Concerns

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ProphylaxisversusPre-emptivetherapyReference) Antiviralsvs

controls(n)Antiviraltiming Reactivationrates

Lauetal.(2003)

lamivudinevspre-emptivetreatment

1weekbeforechemotherapyordeferreduntilserologicalevidenceofHBV

0%verus53%(P=0.002)

Hsu etal.(2008)

lamivudinevspre-emptivetreatment

Onday1ofchemotherapyanduntil2monthsafterorstartedontreatmentifALTlevels>1.5xULN

11.5%versus56%(P=0.001)

Huang etal.(2013)

entecavirvspre-emptivetreatment

Beforechemotherapyto3monthsafteroratthetimeofHBVreactivation

Atmonths6,12,and180%,0%,and4.3%intheETVprophylacticgroupversus8%,11.2%,and25.9%(P=.019)

LauG.Gastroenterology.2003.HsuC.Hepatology.2008.HuangY.JClinOncol.2013. Prophylaxis>pre-emptivetherapy

Durationoftherapyandmonitoring

LoombaR.Gastroenterology.2017.HwangJ.JOncolPract.2015.Pattullo V.ClinMolHepatol.2016.

Guideline Duration MonitoringAGA 2-4weekspriortoinitiationand6-12

monthsafterlastdoseLFTsandHBsAglevels:every3monthsuntil6monthsafterlastdose

EASL ReceivingRituxan:atleast18monthsaftercessationoftherapyImmunosuppressivetherapy:atleast12months

Duringprophylaxis:LFTsandHBVDNAevery3to6months

Afterwithdrawal:LFTandHBVDNAatleast12monthsafter

ASCO Upto12monthsaftercessationoftherapy

HBVDNAandALTlevelsevery3monthsduringtherapy

AGA:AmericanGastroenterologicalAssociation,EASL:EuropeanAssociationfortheStudyoftheLiverisaEuropean,ASCO:AmericanSocietyofClinicalOncology

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Conclusions

¡ ProphylaxistreatmentwithnucleotideanalogsisrecommendedinpatientswithmoderateorhighriskofHBVr

¡ InstitutionscreeningtoolsshouldincludeHBsAg,anti-HBc,andHBVDNAtoassesstheriskofreactivationpriortotheinitiationofRituxan

ThankYou

Documents

NMSHP Presentation UNMHResidents slides per page.pdf · 10/4/18 7 Low-dose vs High-dose steroids ¡ Low-dose corticosteroids for grade 2: § prednisone or methylprednisolone 0.5–1