Accidental Overdose of Oral Cyclosporine in Haematopoietic Stem Cell Transplantation: A Case Report and Literature Review

A dynamic time-to-event model for prediction of acute graft-versus-host disease in patients after allogeneic hematopoietic stem cell transplantation

BACKGROUND

Acute graft-versus-host disease (aGvHD) is a major cause of death for patients following allogeneic hematopoietic stem cell transplantation (HSCT). Effective management of moderate to severe aGvHD remains challenging despite recent advances in HSCT, emphasizing the importance of prophylaxis and risk factor identification.

METHODS

In this study, we analyzed data from 1479 adults who underwent HSCT between 2005 and 2017 to investigate the effects of aGvHD prophylaxis and time-dependent risk factors on the development of grades II-IV aGvHD within 100 days post-HSCT.

RESULTS

Using a dynamic longitudinal time-to-event model, we observed a non-monotonic baseline hazard overtime with a low hazard during the first few days and a maximum hazard at day 17, described by Bateman function with a mean transit time of approximately 11 days. Multivariable analysis revealed significant time-dependent effects of white blood cell counts and cyclosporine A exposure as well as static effects of female donors for male recipients, patients with matched related donors, conditioning regimen consisting of fludarabine plus total body irradiation, and patient age in recipients of grafts from related donors on the risk to develop grades II-IV aGvHD. Additionally, we found that higher cumulative hazard on day 7 after allo-HSCT are associated with an increased incidence of grades II-IV aGvHD within 100 days indicating that an individual assessment of the cumulative hazard on day 7 could potentially serve as valuable predictor for later grades II-IV aGvHD development. Using the final model, stochastic simulations were performed to explore covariate effects on the cumulative incidence over time and to estimate risk ratios.

CONCLUSION

Overall, the presented model showed good descriptive and predictive performance and provides valuable insights into the interplay of multiple static and time-dependent risk factors for the prediction of aGvHD.

Unexpected overdose of oral cyclosporine in a kidney transplant patient: a case report

Cyclosporine is a widely used immunosuppressive agent to prevent rejection of solid organ transplant. Here, we describe the case of a 71-year-old man who received the prescribed dose of cyclosporine 10 times 6 days after a kidney transplantation because of a concentration miscalculation involving two galenic forms. The patient presented gastrointestinal and neurological disorders. Therapeutic drug monitoring revealed high cyclosporine blood concentrations (693 ng/mL, therapeutic range 100-300 ng/mL). Symptomatic management of digestive disorders was performed, and haemodialysis was started the day after the cyclosporine overdose in the face of acute renal failure. The patient's disorders were quickly resolved. The dosing regimen was adapted in order to administer the most appropriate galenic form and to avoid another administration error. Long-term follow-up showed no failure of renal transplantation. The purpose of this case report is to warn physicians and clinical pharmacists about the vigilance required on cyclosporine prescription, especially when two galenic forms are administered to obtain the prescribed dose.

Medication Errors in the Context of Hematopoietic Stem Cell Transplantation: A Systematic Review

BACKGROUND

There have been numerous efforts by health institutions and professionals to prevent and reduce medication errors.

OBJECTIVES

The aim of this study was to identify in the literature the incidence, related factors, consequences, and prevention mechanisms of medication errors in the context of hematopoietic stem cell transplantation.

METHODS

This is a systematic review carried out in the databases LILACS, PubMed, PMC, EMBASE, and CINAHL databases, from January 11 to 13, 2017.

RESULTS

Eleven studies were included in this review and presented in 4 categories of analysis. (1) occurrence-most of the medication errors were related to administration and prescription; (2) related factors-multicausal, highlighting issues including polypharmacy, lack of double checking, and similarity between the medications' names; (3) consequences-the main ones were associated with adverse reactions, with prolonged hospitalization time as outcome; (4) preventive measures-related to safe practices in pharmacotherapy, such as double check and application of the 10 rights of medication administration.

CONCLUSION

Medication administration is an activity of great responsibility for nursing; however, in order to achieve a decrease in medication errors, prevention strategies are necessary for the whole health team.

IMPLICATIONS FOR PRACTICE

Practice improvements are needed including establishing institutional drug administration protocols and keeping them updated, using a computerized prescription system, and promoting patient safety with staff.