Skin disorder management in oral anticancer drugs by collaboration of hospital pharmacists and community pharmacists

Background

In Japan, the multidisciplinary team approach in cancer chemotherapy has become quite widespread. However, patients treated with oral anticancer drugs in outpatient clinics usually receive short medical examinations from doctors without any intervention of pharmacists. To improve this medical circumstance, we made a skin disorder manual for community pharmacists and evaluated its feasibility.

Methods

Patients who underwent oral skin toxic chemotherapy from May 1, 2017, to October 31, 2017, were enrolled. The severity of skin toxicities was evaluated based on NCI-CTCAE ver4.0. Skin care and skin disorders were assessed by community pharmacists based on the assessment document arranged by the investigator. Numbers of patients who replied to the assessment, numbers of replies, numbers of assessments and instructions for skin care, and numbers of prescription proposals were evaluated to assess the value of intervention of community pharmacists.

Results

Sixty-two patients were enrolled in this study. Community pharmacy responded to 55 patients (88.7%), for a total of 335 replies. The data described in the replies were as follows: 317 assessments of skin disorders (94.6%), 307 assessments of skin care (91.6%), 248 instructions for skin care (74%), and 19 prescription proposals (5.7%).

Conclusions

Community pharmacists have high motivation for prevention and early detection of skin disorders. Although the number of prescription proposals is small, some proposals have contributed to improving side effects. Collaboration of hospital pharmacists and community pharmacists is important for prevention, early detection, and treatment of skin disorders caused by oral anticancer drugs.

The Adequateness of Methadone for Japanese Terminal Cancer Patients Can Be Determined Earlier than 7 Days: A Preliminary Retrospective Study

Introduction:

The Japanese packaging instructions for methadone prohibit dose escalation within 7 days of administration initiation as this may result in overdose and subsequent adverse events. However, for terminal cancer patients, evaluation of the effects of methadone may be desirable within 7 days because they have limited prognoses. We aimed to determine the possibility of estimating the adequateness of methadone earlier than the 7th day by investigating the onset timing of analgesic effects and adverse events of methadone in Japanese terminal cancer patients.

Methods:

Japanese terminal cancer patients who started taking methadone in Ashiya Municipal Hospital were enrolled from January 1, 2013 to February 28, 2019. Verbal rating scale (VRS) scores on pain and adverse events before and after methadone administration (on days 3, 5, and 7) were retrospectively investigated from medical records.

Results:

We enrolled 25 patients, of which 20 (80.0%) received methadone until day 7. The VRS score (mean ± standard deviation) on pain was significantly reduced to 0.90 ± 0.55 on day 3, compared with 1.65 ± 0.67 before the administration of methadone (p < 0.05). The mean VRS scores did not differ significantly on days 3, 5, and 7. Additionally, of the 23 patients who received methadone until day 3, 20 (87.0%) showed an analgesic effect on day 3 and 17 (85.0%) received methadone without experiencing serious adverse events until day 7.

Conclusions:

The adequateness of methadone in Japanese terminal cancer patients could be determined before day 7, considering the high analgesia incidence and few adverse events 3 days after the methadone administration under careful observation by a physician experienced in methadone administration. However, as this is a preliminary study, the relationship between pharmacokinetic parameters and analgesic effects was not evaluated. Further studies involving pharmacokinetics and multicenter prospective studies are required to support these findings.

[Global Standards for Pharmaceutical Education]

The environment surrounding clinical pharmacy practices has changed greatly in the past thirty-some years, basically since the end of the 1980s. During this period, the separation ratio between pharmacists' dispensing and prescribing functions has increased, from 12% to 74%. The three big events in this timeline include the beginning of pharmaceutical care for inpatients by hospital pharmacists in 1988; the transition of pharmacy schools to a six-year educational program in 2006; and the revision of Pharmaceutical Affairs Law, as well as its name change, in 2014. In concert with these events, the central role of the pharmacist has changed from being dispensing-centric to an active participation in patient treatment via medication as a member of the medical care team. As a key participant in these changes, the author helped to improve the operations of hospital pharmacists, strengthened their role with advanced information and communication technology (ICT) support, and established a baseline for clinical pharmacy research and education. Accordingly, in this paper, the history of this development will be reviewed, and the future of a global standard for pharmaceutical education will be discussed.

Hand Foot Syndrome Has the Strongest Impact on QOL in Skin Toxicities of Chemotherapy

Background: Chemotherapy often results in dermatologic toxicities, which decrease quality of life (QOL) of cancer patients. These adverse skin reactions sometimes happen simultaneously. Though previous reports have demonstrated that skin reactions influence QOL, those reports were focused on only one kind of skin toxicity or on the most serious skin toxicity. The aim of this study is to demonstrate the contribution of each skin toxicity to QOL.

Methods: This is a cross-sectional study at Kinki Central Hospital. Patients were enrolled who underwent skin toxic chemotherapy from April 1 to June 30, 2017. DLQI and Skindex29 were used to grade the QOL of patients. Also, the severity of skin toxicities was evaluated based on National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 (NCI-CTCAE ver4.0). We investigated how QOL changed with patient demographic and clinical characteristics, the worst skin toxicity grade, and each skin toxicity using statistical analyses.

Results: No significant differences were detected between QOL scores (total score of DLQI, emotions domain, symptoms domain, functioning domain and total score of Skindex29) and patient demographic and clinical characteristics (P values were 0.155, 0.086, 0.052, 0.312 and 0.114, respectively). There were statistically significant QOL differences among the grades of the worst skin toxicity (P values were <0.001). Xerosis, paronycia, pigmentation, and hand foot syndrome showed statistically significant associations with some QOL domains analyzed by multiple logistic regression analyses adjusted by demographic characteristics. When adjusted by both demographic characteristics and other skin toxicities, three of xerosis, paronycia, and pigmentation showed no statistically significant associations, but hand foot syndrome showed statistically significant associations in all subdomains and total score of Skindex29 (P values were <0.05).

Conclusions: Hand foot syndrome was a stronger factor in decreasing QOL than xerosis, paronychia, pigmentation, or rash. Therefore, especially in hand foot syndrome, prevention, early detection, and daily medical care are necessary to maintain QOL.

Validation of a Short-Term, Objective, Prognostic Predictive Method for Terminal Cancer Patients in a Palliative Care Unit Using a Combination of Six Laboratory Test Items

Background: There is no established method to objectively predict short-term prognosis. Recently, we proposed objective, short-term, prognostic predictive methods that are combinations of laboratory test items: WPCBAL score, derived from six values (white blood cell, platelet, C-reactive protein, blood urea nitrogen, aspartate aminotransferase, and lactate dehydrogenase). However, that study was conducted in an acute-phase hospital to identify the test items useful for prognostic prediction; thus, whether WPCBAL score could be applied to terminal cancer patients in a palliative care unit was unverified. Objective: To verify the usefulness of WPCBAL score for terminal cancer patients. Design: A retrospective study. Setting/Subjects: Patients admitted to the palliative care unit of Ashiya Municipal Hospital (N = 128) in Japan in 2016. Measurements: The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve (AUROC) were compared between WPCBAL score and the Glasgow prognostic score (GPS). Results: For predicting three-week prognosis, WPCBAL score showed higher AUROC compared with GPS (0.7540 and 0.6573, respectively). WPCBAL score predicting two-week prognosis showed greater AUROC than GPS predicting three-week prognosis (0.7491 and 0.6573, respectively). Conclusion: WPCBAL score was verified to objectively predict the two- or three-week prognosis for terminal cancer patients in a palliative care unit. WPCBAL score may be a new option for prognostic prediction for terminal cancer patients.

Efficacy of pegfilgrastim administration in patients with esophageal cancer treated with docetaxel, cisplatin, and 5-fluorouracil

Chemotherapy is among the standard treatments for esophageal cancer. The docetaxel, 5-fluorouracil, and cisplatin (DCF) protocol yields a better response rate than 5-fluorouracil plus cisplatin. However, the incidence of side effects, such as febrile neutropenia and hematologic toxicity, is also significantly high with the DCF protocol. The granulocyte colony-stimulating factor and pegfilgrastim are prophylactically administered to prevent febrile neutropenia. This retrospective study evaluated the efficacy and safety of pegfilgrastim in patients receiving DCF therapy. Of the 65 patients who were administered DCF therapy in our hospital from 2011 through 2016, 21 received pegfilgrastim 24 hours or more after the end of chemotherapy. The protocol comprised 70 mg/m2 each of docetaxel and cisplatin on day 1 and 700 mg/m2 5-fluorouracil on days 1 to 5 via intravenous injection in a 3-week cycle. The primary endpoint was the rate of grade 3-4 neutropenia and febrile neutropenia. The mean patient age was 66.4 years. The incidence of grade 3 and 4 neutropenia was 14.2 % and 11.4 %, respectively, in the pegfilgrastim group and 31.9 % and 37.8 %, respectively, in the non-pegfilgrastim group. The incidence of febrile neutropenia in the pegfilgrastim group and non-pegfilgrastim group was 11.4 % and 40.3 %, respectively. Statistical analysis showed that the incidence of neutropenia and febrile neutropenia was significantly different (p<0.05) between the two groups. Pegfilgrastim prevents severe neutropenia and febrile neutropenia in patients with esophageal cancer who are treated according to the DCF protocol.

The analgesic effect of rescue administration of intravenous acetaminophen in cancer patients may be associated with sex and opioid dose, and the effect would appear to patients administered under 45 mg/day opioid (oral morphine equivalents)

There have been no investigations examining the analgesic effect of rescue administration of intravenous acetaminophen (IV APAP) for pain in cancer patients. Fifty cancer patients who received IV APAP for pain at Ashiya Municipal Hospital (Hyogo, Japan) between January 2014 and July 2016 were retrospectively evaluated. The degree of pain was evaluated using a 4-point verbal rating scale. Pain intensity differences ≥ 1 defined the IV APAP effective group, and the patient' characteristics were compared by a medical chart review. Variables were extracted from medical records for logistic regression analyses of factors associated with analgesic effect. The cut-off value of opioid dose (oral morphine equivalent) was determined using receiver operator characteristic (ROC) curve analysis. Thirty eight (76%) patients experienced an analgesic effect of rescue administration of IV APAP. Sex (odds ratio [OR] 5.4014; p = 0.0397) and opioid dose used for pain control (OR 0.9901; p = 0.0147) were found to be associated with the efficacy of rescue administration of IV APAP. The cut-off value of opioid dose (oral morphine equivalent), which may be difficult to match the analgesic effect of IV APAP, was calculated to be more than 45 mg/day. This study demonstrated the efficacy of a rescue administration of IV APAP for pain in cancer patients, and revealed that sex and opioid dose may be associated with the analgesic effect. Furthermore, this study also proposes a criterion for the analgesic effect.

[The Present Implementation Status and Problems of Vital-signs Measurement by Community Pharmacists in Home Medical Care in Osaka]

　While the community-based integrated care systems are in the process of being structured currently, more and more community pharmacists want to learn physical assessment skills. However, no large-scale survey focusing on present implementation status and problems of physical assessment by community pharmacists has been conducted yet. Osaka has the 2nd highest number of community pharmacies in Japan now, and the population aged ≥65 years will be expected to become the 3rd highest in 2025. Thus, Osaka can become a national leading model case for community pharmacists' activity in future home medical care. Therefore, this study aimed to reveal the present implementation status and problems of physical assessment by community pharmacists in Osaka, especially focusing on vital-signs. The questionnaires were sent to all the 3571 insurance pharmacies belonging to the Osaka Pharmaceutical Association and 871 pharmacies responded. Many pharmacists recognized the necessity for vital-signs measurement by pharmacists in home medical care (81.5% of pharmacies that offered home medical care and 75.4% of pharmacies that did not offer one). However, the proportion of pharmacies that conduct vital-signs measurement in home medical care was 18.7%, therefore, it was suggested that the present problem is "many pharmacists cannot conduct vital-signs measurement, although they think it should be conducted". Moreover, the most common reason for not measuring vital-signs was the lack of instruments, such as stethoscopes and sphygmomanometer (43.2%). This is the latest report with a large-scale sample, thus, it can serve as valuable knowledge in considering what pharmacists do for the future.

A New Approach for Determining Short-Term, Objective Prognostic Predictive Methods for Terminal Cancer Patients Based on the Change Point of Laboratory Test Values

BACKGROUND

In terminal phase cancer, predicting a prognosis precisely plays an important role for patients and their families to live meaningful lives. However, there are no established short-term, objective prognostic predictive methods.

OBJECTIVE

To develop simple, short-term, objective prognostic predictive methods through detecting a change point for laboratory test values.

DESIGN

A retrospective chart review.

SETTING/SUBJECTS

Subjects were cancer patients aged ≥16 years and discharged dead from Osaka University Hospital in 2008.

MEASUREMENTS

Using different laboratory test values, new prognostic predictive methods were determined based on either six laboratory test values (white blood cell [WBC], platelet [PLT], C-reactive protein, blood urea nitrogen [BUN], aspartate aminotransferase [AST], and lactase dehydrogenase [LDH]): the WPCBAL score, or five test values (WBC, PLT, BUN, AST, and LDH): the WPBAL score. Their utility, including sensitivity and specificity, was compared with that of Glasgow prognostic scores (GPSs).

RESULTS

In total, 121 cancer patients were enrolled. WPCBAL and WPBAL scores showed higher sensitivity (0.88 and 0.91 vs. 0.68), specificity (0.79 and 0.70 vs. 0.53), negative predictive value (0.98 and 0.97 vs. 0.76), and a much larger relative risk (16.5 and 14.2 vs. 1.78) as prognostic predictors within two weeks of death than GPS as a prognostic predictor within three weeks of death.

CONCLUSION

This is the first study that suggests that the objective prognostic predictive methods, through detecting the change point of laboratory test values, are useful for predicting short-term prognosis. The WPCBAL score and WPBAL score could objectively predict the remaining lifetime within two weeks of mortality.

Weight Loss Associated with Platinum-Based Chemotherapy in Patients with Advanced Lung Cancer

BACKGROUND

We examined whether the weight loss that occurs with platinum-based chemotherapy in lung cancer patients is associated with chemotherapy side effects, treatment completion rates and therapeutic effect.

METHODS

We retrospectively reviewed charts of advanced lung cancer patients treated with ≥2 cycles of platinum-based chemotherapy. Patients were divided into 2 groups based on ≥5 or <5% weight loss. Relationships between weight loss and other variables were investigated.

RESULTS

Among 114 patients, 18 (15.8%) experienced ≥5% weight loss. Significantly more patients with small-cell lung cancer (SCLC) than with non-SCLC were found to have ≥5% weight loss (30.8 vs. 11.4%, p = 0.023). Patients with ≥5% weight loss experienced higher incidences of grade 3-4 leukopenia (p = 0.008) and neutropenia (p = 0.005), and treatment completion rates were lower in this group (p = 0.035). Weight loss was not significantly associated with therapeutic effect.

CONCLUSION

The weight loss in patients with advanced lung cancer receiving platinum-based chemotherapy is associated with SCLC, grade 3-4 leukopenia, neutropenia and a decrease in treatment completion rate.

Desirable Information of Opioids for Families of Patients With Terminal Cancer

OBJECTIVE

The aims of this study are to clarify the state of information regarding opioids for families and what kinds of experiences they had with opioids while the patient was followed as an outpatient and inpatient.

PARTICIPANTS

This study was part of a cross-sectional nationwide survey of bereaved families of patients with cancer, namely, the Japan Hospice and Palliative Care Evaluation 2 study. The participants in this study comprised 572 bereaved families who had experienced the death of a family member during the period from January 2008 to December 2009 at 1 of 103 certificated palliative care units.

MAIN OUTCOME MEASURES

In response to the question of "how much improvement was needed for information regarding opioids," 41% answered "improvement is not necessary at all," 43% answered "improvement is slightly necessary," 14% answered "improvement is necessary," and 2% answered "improvement is extremely necessary." Regarding anxiety about the use of opioid, it was found that 14% of respondents indicated "opioids are very safe," 65% of respondents indicated "opioids are relatively safe," 19% of respondents indicated "opioids are not so safe," and 2% of respondents indicated "opioids are not so safe at all." from the information obtained for opioids. It was found that 90% of families agreed with the item, "I would like to be clearly explained that drugs for medical purposes are safe and that the patient will not develop a drug addiction and their life expectancy will not be reduced."

CONCLUSION

From this study, it is important for families of patients with cancer to be explained profound and careful information of opioid.

Microchamber device for detection of transporter activity of adherent cells

We present a method to detect the transporter activity of intact adherent cells using a microchamber device. When adherent cells are seeded onto the poly-di-methyl siloxane substrate having microchambers with openings smaller than the size of a cell, the cells form a confluent layer that covers the microchambers, creating minute, confined spaces. As substances exported across the cell membrane accumulate, transporter activity can be detected by observing the fluorescence intensity increase in the microchamber. We tested the microchamber device with HeLa cells over-expressing MDR1, an ATP-binding cassette transporter, and succeeded in detecting the transport of fluorescence-conjugated paclitaxel, the anti-cancer drug, at the single-cell level.

L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial

The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. The present study investigated whether L-glutamine (glutamine) decreases the severity of mucositis in the oral cavity, pharynx and larynx induced by CRT. This double-blind, randomized, placebo-controlled trial included 40 untreated patients with squamous cell carcinoma of the nasopharynx, oropharynx, hypopharynx or larynx. Patients received 66 or 70 Gy of total radiation at the rate of 2 Gy/fraction daily and 5 fractions/week. Cisplatin (20 mg/m²) and docetaxel (10 mg/m²) were intravenously co-administered once a week for 6 weeks. Patients were randomized to orally receive either glutamine (group G) or placebo (group P) at a dose of 10 g 3 times a day throughout the CRT course. Mucositis was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The primary end point was mucositis severity. Mucositis developed in all patients. A maximal mucositis grade of G4 was observed in 0 and 25% group G and P patients, respectively, while that of G2 was observed in 10 and 0% group G and P patients, respectively (p=0.023). Glutamine significantly decreased the maximal mucositis grade (group G, 2.9±0.3; group P, 3.3±0.4; p=0.005) and pain score at weeks 4, 5 and 6. Glutamine significantly decreased mucositis severity in the oral cavity, pharynx and larynx induced by CRT in patients with HNC.

[Effect of the administration of zoledronic acid on life expectancy in patients with multiple myeloma with or without renal impairment]

Zoledronic acid(ZA)is believed to exert anticancer effects in patients with multiple myeloma(MM). For patients with impaired renal function, its dosage should be determined according to creatinine clearance(Ccr). However, there is no reported difference in life expectancy improvement between those with and without renal impairment. Therefore, we conducted a retrospective study to investigate this clinical question. Seventy-eight MM patients receiving ZA injections were selected and divided into 2 groups: (1)normal group(n=39), baseline Ccr≥60mL/min, and(2)impaired group(n=39), baseline Ccr<60mL/min. Patients in the normal group received a significantly higher initial dose(p<0.001), were of a younger age(p<0.001), had lower b2-microglobulin(b2-M)levels(p<0.001), and had higher rates of prior hematopoietic stem cell transplantation(p<0.001)than those in the impaired group. We then compared the survival rate between 31 patients in the normal group and 27 patients in the impaired group whose treatment outcome data were available and found no significant difference(p=0.251). Therefore, our results suggest that the survival rate on ZA administration may not differ between MM patients with and without renal impairment.

Can Gradual Dose Titration of Ketamine for Management of Neuropathic Pain Prevent Psychotomimetic Effects in Patients With Advanced Cancer?

Background:

Ketamine is often used to manage neuropathic pain in patients with cancer. However, it occasionally causes psychotomimetic effects such as vivid dreams, nightmares, illusions, hallucinations, and altered body image. Objective: To examine whether gradual dose titration of ketamine for management of neuropathic pain prevents psychotomimetic effects in patients with advanced cancer.

Methods:

This was a retrospective chart review. We administered ketamine when neuropathic pain in patients with advanced cancer became refractory to opioids and oral adjuvant analgesics. The starting dose of ketamine was 10 mg/d by continuous intravenous infusion. The dose was gradually increased by 10 mg/d every 4 to 6 hours to 50 mg/d or until the pain was relieved. It was subsequently increased by 25 mg/d every 12 to 24 hours until the pain was relieved.

Results:

For this study, we enrolled 46 patients with advanced cancer. The mean age was 52.2 ± 16.9 years. The mean dose at onset of action and maximum dose of ketamine were 56 ± 58 and 272 ± 214 mg/d, respectively. The mean pain intensity (numerical rating scale) decreased significantly from 7.3 ± 2.0 to 3.5 ± 2.2 after the administration of ketamine ( P < .01). The effectiveness was 69.5%. No psychotomimetic effect of less than 300 mg/d was observed during the introduction phase even though psychotropic drugs were not prescribed. Mild sedation was observed in 3 patients (7%) as the only adverse effect during the introduction phase.

Conclusion:

Gradual dose titration of ketamine for management of neuropathic pain can prevent psychotomimetic effects in patients with advanced cancer.

[Development of evaluation methods for student performance in National Universities: formative assessment and portfolio]

Formative assessment which refers to frequent, interactive assessments of student progress and understanding is one of the most effective strategies for promoting high student performance and developing students' "learning to learn" skills. Portfolio (personal record of learning) is a useful tool for tracking individual student progress toward learning goals. We conducted the questionnaire survey in 14 National Universities on approach to the formative assessment methods and the use of portfolio in the long-term practice experience (pharmacy clerkship) at community pharmacy and hospital pharmacy which was undergone for the first time in 2010. The finding obtained from our questionnaires implicated that portfolio is useful for sharing information among student, tutorial pharmacist and faculty members. All universities have provided tools for visible assessment of student achievement. However, they are not used enough for feedback on student performance, and formative assessment is not practiced systematically. A reason seems to be differences in understanding of it. In addition to improvement of the tools to support formative assessment, promotion of effective assessment practice will need for systematic evaluation.

A retrospective chart review of opioid-induced nausea and somnolence on commencement for cancer pain treatment

Morphine, oxycodone, and fentanyl are major opioids available as controlled-release morphine (CRM), controlled-release oxycodone (CRO), and transdermal fentanyl (TDF), respectively, in Japan. The authors conducted a retrospective chart review to examine (1) nausea and somnolence on commencement of CRM, CRO, and TDF for cancer pain treatment, (2) the antiemetic effectiveness of prochlorperazine to prevent opioid-induced nausea, and (3) the side effect of prochlorperazine on somnolence in patients with cancer pain. Four hundred thirteen patients with cancer were prescribed with CRM (N = 66), CRO (N = 196), and TDF (N = 151). The incidence of nausea on commencement of the TDF group (6.8 percent) was significantly lower than that of both the CRM group (22.6 percent) and the CRO group (35.4 percent; p < 0.001). There was no significant difference in the incidence of nausea on commencement of all groups combined with prochlorperazine at dosage of 15 mg/d. The incidence of somnolence on commencement of the TDF group (9.0 percent) was significantly lower than that of both the CRM group (31.3 percent) and the CRO group (41.5 percent; p < 0.001). The incidence of somnolence on commencement of the CRO group combined with prochlorperazine was significantly higher than that of the CRO combined without prochlorperazine (p < 0.05). In conclusion, the incidence of nausea and somnolence on commencement of TDF are significantly lower than that of both CRM and CRO for cancer pain treatment. Prochlorperazine at a dosage of 15 mg/d may not be effective in preventing opioid-induced nausea and may cause somnolence in patients with cancer pain.

Light-induced deterioration test of carboplatin under clinical settings

Chemotherapeutic drug dosages are calculated precisely based on the patient's height, body weight, and renal function, etc. To ensure safe and favorable outcomes of treatment, dosing solutions are prepared by appropriate mixing of the drug solutions based on such calculations. The package inserts for many injectable preparations include a warning for storing the product "shielded from light." However, there are no reports of stability assessment of a mixed product against light exposure or the residual amount of active ingredient in the dosing solution during or at the end of treatment. We evaluated the stability of carboplatin from the time of mixing of the dosing solution until the end of drug infusion in a clinical-like setting. With 4-hour exposure to outdoor scattered light, the dosing solution began to show discoloration by 1 hour, becoming dark yellow by 4 hours, with reduction of the percent residual carboplatin to about 23%. To identify the optimal light-shielding shade, the dosing solution was shielded from outdoor scattered light with 1 of 3 protective covers: aluminum foil, yellow plastic shade, and brown plastic shade. The yellow plastic shade prevented any changes of the appearance of the dosing solution during the 4-hour exposure period. The percent residual carboplatin, determined by HPLC, in the dosing solution shielded with a yellow plastic shade was about 85.2% at 2 hours and 78.6% at 4 hours. Thus carboplatin dosing solution should be completely shielded from light until infusion is completed.

[Clinical features of paclitaxel-induced peripheral neuropathy and role of Gosya-jinki-gan]

Paclitaxel (PTX) is frequently used for a chemotherapy of breast cancer and gynecologic cancer. Besides a bone-marrow depression and hypersensitive reaction, the peripheral neuropathy is one of the serious adverse events of PTX. The mechanism of peripheral neuropathy has not been clarified, and few agents have been reported to be effective for the treatment and the prevention of that. Recently, it has been reported that Gosya-jinki-gan is useful for the PTX induced peripheral neuropathy, so we carried a retrospective study(n=82)to evaluate the effectiveness of Gosya-jinkigan with the medical records. It is suggested that peripheral neuropathy developed more rapidly in sequential administration of PTX every week than in administration in 4 weeks cycles consisting of 3 weeks on and 1 week off(5.4w vs. 9.4w). We have also found that Gosya-jinki-gan was possibly effective for the treatment and the prevention of peripheral neuropathy. Additionally Gosya-jinki-gan might be more effective for peripheral neuropathy when it is administered from the beginning of chemotherapy including PTX.

A retrospective chart review of the antiemetic effectiveness of risperidone in refractory opioid-induced nausea and vomiting in advanced cancer patients

Nausea and vomiting are distressing symptoms in advanced cancer patients. The causes of nausea and vomiting are multifactorial. Among the causes is opioid therapy, the mainstay of cancer pain management. When nausea or other opioid side effects occur, it may hamper pain management and undermine the quality of life of cancer patients. Risperidone exerts an antiemetic effect in animals, but there has been no clinical report on its antiemetic activity. We conducted a retrospective chart review to examine whether risperidone is useful for opioid-induced nausea and vomiting in advanced cancer patients (n=20). Risperidone was given as doses of 1mg once a day. Complete response was observed in 50% of patients (10/20) for nausea and 64% (7/11) for vomiting. Sedation (n=2) was documented as an adverse effect. This observation suggests that risperidone can be an effective antiemetic drug in the treatment of refractory opioid-induced nausea and vomiting in advanced cancer patients.

[Comparison of antiemetic efficacy of 5-HT3 receptor antagonists in orthopedics cancer patients receiving high-dose chemotherapy]

There are no reports comparing the efficacy of 3 selective 5-HT(3) receptor antagonists (Granisetron, Ondansetron, and Ramosetron). We designed a prospective study to compare the efficacy of Granisetron, Ondansetron, and Ramosetron. Thirteen patients gave informed consent to participate in the study. We assigned them to groups taking Granisetron, Ondansetron, or Ramosetron before the high-dose chemotherapy. They themselves reported the extent of their nausea and how many times they vomited per day from the first to the sixth day of chemotherapy. We evaluated their report with PLS (Partial Least Squares) and Welch's t-test. From the results of PLS, it was suggested that CDDP contributed the most and Ramosetron the least to the extent of nausea, while Doxorubicin (ADM)/CDDP contributed the most and Ramosetron the least to the frequency of vomiting. Then we compared the antiemetic effect of the agents regarding the types of chemotherapy. It was concluded that Ramosetron might have been the most effective of the three agents in reducing nausea and vomiting, but with no significant difference.

In vitro inhibitory effects of Kampo medicines on metabolic reactions catalyzed by human liver microsomes

BACKGROUND

Although it is well known that drug-drug interactions may lead to toxicity and therapeutic failure, little is known about the incidence and consequences of herb-drug interactions in patients receiving Kampo medicines.

METHODS

We evaluated the frequency of the combined use of Kampo medicines and Western drugs at Osaka University Hospital, and investigated the effects of these formulae on the metabolic activity of different cytochrome P450 (CYP) isoforms using pooled microsomes obtained from human liver.

RESULTS

Twenty-two Kampo formulae were used together with 40 Western drugs catalyzed by the CYP isoforms CYP3A4, CYP2C9, CYP2D6 and CYP1A2. Among the Kampo medicines, HOCHUEKKI-TO, SHOSAIKO-TO, NINJINYOUEI-TO, SAIREI-TO and KAKKON-TO were most frequently used during the study period (1996-2000). These were co-administered with 11 categories of drugs, which are substrates for CYP3A4. HOCHUEKKI-TO and SAIREI-TO were competitive inhibitors of CYP3A4 with Ki values of 0.65 and 0.1 mg/mL, respectively. HOCHUEKKI-TO, SHOSAIKO-TO and SAIREI-TO inhibited the metabolic activities of CYP2C9, but had no effect on CYP2D6. HOCHUEKKI-TO and SAIREI-TO exhibited non-competitive inhibition of the metabolic activity of CYP2C9 with a similar Ki value (0.7-0.8 mg/mL). SAIRE-TO (0.25 mg/mL) was a potent inhibitor of CYP1A2 (inhibition > 68%).

CONCLUSIONS

Frequently used Kampo medicines may interact with Western drugs, which are substrates for CYP3A4, CYP2C9 and CYP1A2. Their co-administration should be undertaken with care.

Microsomal enzyme induction and clinical aggravation of porphyria: the evaluation of human urinary 6beta-hydroxycortisol/cortisol ratio as the index of hepatic CYP3A4 activity

The clinical aspect of porphyria has been investigated, and it is well known that porphyrinogens such as estrogens and alcohol or other inducers of P450 isoenzymes exacerbate the porphyric state. However, there can be a delay in diagnosing porphyria and a difficulty in selecting safe medicine for it even today. A 21-year-old woman developed epilepsy, disturbance of mental state, and spastic tetraparesis during the convalescent period after acute viral encephalitis. She was diagnosed with porphyria after the fifth hospitalization. In the course of modifying her anticonvulsant regimen, the authors examined the 6beta-hydroxycortisol/cortisol ratio (6beta-OHF/F) in her urine, which can be the index of hepatic CYP3A4 activity, with electrospray ionization/mass spectrometry/mass spectrometry (ESI/MS/MS). Generalized and partial complex seizures, other neurological signs and symptoms, and laboratory data were improved after modification of her anticonvulsant regimen. This is the first report of evaluating the urinary 6beta-hydroxycortisol/cortisol ratio in a case of porphyria.

[Drug compliance in the elderly]

In order to clarify the characteristics of elderly patients concerning their attitudes toward taking prescribed medicine, self-reported compliance with prescriptions was compared among different age groups. We performed a survey in 626 outpatients and their attending physicians in 4 of our affiliated hospitals, and analyzed self-reported compliance by the patients to the prescription and their answers to questions related to drug-taking along with the diagnoses and prescriptions reported by the physician. The number of prescribed medicine was 2.3 tablets on the average for patients younger than 40, while 5.1 tablets were prescribed for patients over 70. However, self-reported compliance was best in patients over 70 than in other age groups. Compliance was good in 76% of patients who answered that the amount of medicine was appropriate, while good compliance was lower in those who thought the prescription excessive (67%). Likewise, compliance of patients who had concerns with drug side effects or who were not feeling well under medication was lower than that of patients who felt well under medication. Prescriptions for after lunch were most liable to be forgotten than those for other times of the day. Moreover, a high percentage of elderly patients attended more than 2 departments or medical facilities, and one third of those patients did not inform the physician of the fact suggesting that they were at higher risks of overdosing and unexpected drug interaction. Furthermore, the percentage of patients who did not receive explanation from physicians was higher in the elderly thus demonstrating that elderly patients have quite different characteristics in attitude with regard to medicine from younger age group patients.(ABSTRACT TRUNCATED AT 250 WORDS)