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Truong HL, Barreto JN, Mara KC, Hampel PJ, Micallef IN, Nowakowski GS, Thanarajasingam G, Thompson CA, Wang Y, Witzig TE, Herrmann SM, Leung N. Rechallenge With High-Dose Methotrexate After Treatment With Glucarpidase in Adult Patients With Lymphoma. JCO Oncol Pract 2024:OP2300628. [PMID: 38408299 DOI: 10.1200/op.23.00628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Limited evidence exists regarding methotrexate (MTX) resumption after patients with lymphoma receive glucarpidase for toxic MTX levels and acute kidney injury (AKI). METHODS This retrospective review included adults with lymphoma treated with glucarpidase after MTX at Mayo Clinic between January 31, 2020, and October 10, 2022. Descriptive statistics summarize patient characteristics and clinical outcomes. RESULTS Of 11 patients treated with glucarpidase after MTX, seven (64%) were rechallenged with MTX. Indications for MTX rechallenge included confirmed CNS disease (n = 6, 86%) and intravascular lymphoma (n = 1, 14%). Compared with the nonrechallenged subgroup, before receiving MTX that required glucarpidase rescue, the rechallenged patients had lower median pretreatment serum creatinine (Scr; 0.7 v 1.2 mg/dL), and none had AKI with previous MTX doses, n = 0 (0%) versus n = 2 (50%). During the MTX dose requiring glucarpidase rescue, the rechallenged group had lower median peak Scr (1.26 v 3.32 mg/dL) and lower incidence of AKI stage III (n = 1 [14%] v n = 3 [75%]), and none of the rechallenged patients required renal replacement therapy (RRT; n = 0 [0%] v n = 1 [25%]). At the first rechallenge after glucarpidase administration, the median MTX dose reduction was 56% (range, 46%-75%), and the lowest used dose when prescribed according to each treatment protocol schedule was 1.5 g/m2. Two (29%) patients experienced AKI (n = 1 stage I, n = 1 stage II) after MTX rechallenge. Zero patients required RRT, and zero required another glucarpidase administration. Six (86%) patients completed all recommended MTX doses. CONCLUSION In selected adults with lymphoma who required glucarpidase for toxic MTX levels after administration of high-dose MTX, resumption of MTX therapy at lower doses is safe. Patients selected for MTX resumption had experienced less severe AKI during the previous cycle compared with those not selected for MTX resumption.
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Affiliation(s)
- Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Loxo@Lilly, Lilly Corporate Center, Indianapolis, IN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Paul J Hampel
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ivana N Micallef
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Gita Thanarajasingam
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yucai Wang
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Sandra M Herrmann
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Rice ML, Barreto EF, Rule AD, Martin CE, Truong HL, Mara KC, Kashani KB, Thompson CA, Witzig TE, Barreto JN. Development and validation of a model to predict acute kidney injury following high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2024; 44:4-12. [PMID: 37926860 DOI: 10.1002/phar.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To develop and validate a model for predicting acute kidney injury (AKI) after high-dose methotrexate (HDMTX) exposure. DESIGN Retrospective analysis. SETTING Multisite integrated health system throughout Minnesota and Wisconsin. PATIENTS Adult patients with lymphoma who received HDMTX as a 4-h infusion. MEASUREMENTS AND MAIN RESULTS LASSO methodology was used to identify factors available at the outset of therapy that predicted incident AKI within 7 days following HDMTX. The model was then validated in an independent cohort. The incidence of AKI within 7 days following HDMTX was 21.6% (95% confidence interval (CI) 18.4%-24.8%) in the derivation cohort (435 unique patients who received a total of 1642 doses of HDMTX) and 15.6% (95% CI 5.3%-24.8%) in the validation cohort (55 unique patients who received a total of 247 doses of HDMTX). Factors significantly associated with AKI after HDMTX in the multivariable model included age ≥ 55 years, male sex, and lower HDMTX dose number. Other factors that were not found to be significantly associated with AKI on multivariable analysis, but were included in the final model, were body surface area, Charlson Comorbidity Index, and estimated glomerular filtration rate. The c-statistic of the model was 0.72 (95% CI 0.69-0.75) in the derivation cohort and 0.72 (95% CI 0.60-0.84) in the validation cohort. CONCLUSION This model utilizing identified sociodemographic and clinical factors is predictive of AKI following HDMTX administration in adult patients with lymphoma.
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Affiliation(s)
- Mikhaila L Rice
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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Barreto JN, Barreto EF, Mara KC, Rule AD, Lieske JC, Giesen CD, Thompson CA, Leung N, Witzig TE, Kashani KB. Tissue Inhibitor Metalloproteinase-2 and Insulin-Like Growth Factor Binding Protein-7 Kinetics Following Exposure to High-Dose Methotrexate. Kidney360 2023; 4:673-679. [PMID: 36888987 PMCID: PMC10278852 DOI: 10.34067/kid.0000000000000099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/14/2023] [Indexed: 03/10/2023]
Abstract
Urinary TIMP2×IGFBP7 (uTIMP2×IGFBP7) concentrations experienced a rapid and sustained decline after high-dose methotrexate (MTX) exposure. uTIMP2×IGFBP7 kinetics and concentrations after high-dose MTX exposure demonstrated no utility in predicting AKI.
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Affiliation(s)
| | | | - Kristin C. Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - John C. Lieske
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Callen D. Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Carrie A. Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas E. Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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4
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Powell MZ, Mara KC, Bansal R, Hathcock MA, Khurana A, Bennani NN, Wang Y, Paludo J, Bisneto JV, Ansell SM, Johnston PB, Lin Y, Barreto JN. Procalcitonin as a biomarker for predicting bacterial infection in chimeric antigen receptor T-cell therapy recipients. Cancer Med 2023; 12:9228-9235. [PMID: 36752185 PMCID: PMC10166938 DOI: 10.1002/cam4.5665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND It is unknown whether serum procalcitonin (PCT) concentration monitoring can differentiate between bacterial infection or cytokine release syndrome (CRS) when chimeric antigen receptor T-cell (CAR-T) recipients present with a constellation of signs and symptoms that may represent both complications. OBJECTIVE The objective of the study was to assess the utility of serum PCT concentrations as a biomarker of bacterial infection in CAR-T recipients. STUDY DESIGN This single-center, retrospective, medical record review evaluated patients prescribed CAR-T therapy until death or 30 days after infusion. Logistic regression modeling determined the association between elevated serum PCT concentrations within 48 h of fever onset and microbiologically confirmed infection. Secondary outcomes included clinically suspected infection, CAR-T toxicity rates, and broad-spectrum antibiotic usage. Predictive performance of PCT was assessed by area under the receiver operating characteristic curve (AUC). RESULTS The 98 included patients were a median age of 63 (IQR: 55-69) years old, 47 (48%) were male, and 87 (89%) were Caucasian. Baseline demographics and clinical characteristics were similar between patients with and without a bacterial infection. Serum PCT >0.4 ng/mL within 48 h of fever was significantly associated with a microbiologically confirmed bacterial infection (OR: 2.75 [95% CI: 1.02-7.39], p = 0.045). Median PCT values in patients with and without confirmed infections were 0.40 ng/mL (IQR: 0.26, 0.74) and 0.26 ng/mL (IQR: 0.13, 0.47), respectively. The AUC for PCT to predict bacterial infection was 0.62 (95% CI 0.48-0.76). All patients experienced CRS of some grade, with no difference in CRS severity based on elevated PCT. Broad-spectrum antibiotics were used for a median of 45% and 23% of days in those with and without confirmed infection, respectively (p = 0.075). CONCLUSION Elevated serum PCT concentrations above 0.4 ng/mL at time of first fever after CAR-T infusion was significantly associated with confirmed bacterial infection. Furthermore, rigorous, prospective studies should validate our findings and evaluate serial PCT measurements to optimize antimicrobial use after CAR-T therapy.
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Affiliation(s)
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Radhika Bansal
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew A Hathcock
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Arushi Khurana
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - N Nora Bennani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yucai Wang
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Villasboas Bisneto
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen M Ansell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick B Johnston
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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Ibarra M, Combs R, Taylor ZL, Ramsey LB, Mikkelsen T, Buddington RK, Heldrup J, Barreto JN, Guscott M, Lowe J, Hurmiz C, Marada S, Howard SC, Schaiquevich P. Insights from a pharmacometric analysis of HDMTX in adults with cancer: Clinically relevant covariates for application in precision dosing. Br J Clin Pharmacol 2023; 89:660-671. [PMID: 35998099 DOI: 10.1111/bcp.15506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS High-dose methotrexate (HDMTX) is an essential part of the treatment of several adult and paediatric malignancies. Despite meticulous supportive care during HDMTX administration, severe toxicities, including acute kidney injury (AKI), may occur contributing to patient morbidity. Population pharmacokinetics provide a powerful tool to predict time to clear HDMTX and adjust subsequent doses. We sought to develop and validate pharmacokinetic models for HDMTX in adults with diverse malignancies and to relate systemic exposure with the occurrence of severe toxicity. METHODS Anonymized, de-identified data were provided from 101 US oncology practices that participate in the Guardian Research Network, a non-profit clinical research consortium. Modelled variables included clinical, laboratory, demographic and pharmacological data. Population pharmacokinetic analysis was performed by means of nonlinear mixed effects modelling using MonolixSuite. RESULTS A total of 693 HDMTX courses from 243 adults were analysed, of which 62 courses (8.8%) were associated with stage 2/3 acute kidney injury (43 stage 2, 19 stage 3). A three-compartment model adequately fitted the data. Time-dependent serum creatinine, baseline serum albumin and allometrically scaled bodyweight were clinically significant covariates related to methotrexate clearance. External evaluation confirmed a satisfactory predictive performance of the model in adults receiving HDMTX. Dose-normalized methotrexate concentration at 24 and 48 hours correlated with AKI incidence. CONCLUSION We developed a population pharmacometric model that considers weight, albumin and time-dependent creatinine that can be used to guide supportive care in adult patients with delayed HDMTX elimination.
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Affiliation(s)
- Manuel Ibarra
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República, Montevideo, Uruguay
| | | | - Zachary L Taylor
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Laura B Ramsey
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Torben Mikkelsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Randal K Buddington
- Department of Molecular and Cellular Physiology, LSU Health Sciences, Shreveport, LA, USA
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
| | | | | | | | | | | | - Scott C Howard
- Resonance, Inc., Arlington, TN, USA.,College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paula Schaiquevich
- Unit of Innovative Treatments, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET, Buenos Aires, Argentina
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Barreto JN, Kashani KB, Mara KC, Rule AD, Lieske JC, Giesen CD, Thompson CA, Leung N, Witzig TE, Barreto EF. A Prospective Evaluation of Novel Renal Biomarkers in Patients with Lymphoma Receiving High-Dose Methotrexate. Kidney Int Rep 2022; 7:1690-1693. [PMID: 35812294 PMCID: PMC9263243 DOI: 10.1016/j.ekir.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
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7
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Barreto JN, Aitken SL, Krantz EM, Nagel JL, Dadwal SS, Seo SK, Liu C. Variation in Clinical Practice and Attitudes on Antibacterial Management of Fever and Neutropenia in Patients With Hematologic Malignancy: A Survey of Cancer Centers Across the United States. Open Forum Infect Dis 2022; 9:ofac005. [PMID: 35155714 PMCID: PMC8830528 DOI: 10.1093/ofid/ofac005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
Background Contemporary information regarding fever and neutropenia (FN) management, including approaches to antibacterial prophylaxis, empiric therapy, and de-escalation across US cancer centers, is lacking. Methods This was a self-administered, electronic, cross-sectional survey of antimicrobial stewardship physicians and pharmacists at US cancer centers. The survey ascertained institutional practices and individual attitudes on FN management in high-risk cancer patients. A 5-point Likert scale assessed individual attitudes. Results Providers from 31 of 86 hospitals (36%) responded, and FN management guidelines existed in most (29/31, 94%) hospitals. Antibacterial prophylaxis was recommended in 27/31 (87%) hospitals, with levofloxacin as the preferred agent (23/27, 85%). Cefepime was the most recommended agent for empiric FN treatment (26/29, 90%). Most institutional guidelines (26/29, 90%) recommended against routine addition of empiric gram-positive agents except for specific scenarios. Eighteen of 29 (62%) hospitals explicitly provided guidance on de-escalation of empiric, systemic antibacterial therapy; however, timing of de-escalation was variable according to clinical scenario. Among 34 individual respondents, a majority agreed with use of antibiotic prophylaxis in high-risk patients (25, 74%). Interestingly, only 10 (29%) respondents indicated agreement with the statement that benefits of antibiotic prophylaxis outweigh potential harms. Conclusion Most US cancer centers surveyed had institutional FN management guidelines. Antibiotic de-escalation guidance was lacking in nearly 40% of centers, with heterogeneity in approaches when recommendations existed. Further research is needed to inform FN guidelines on antibacterial prophylaxis and therapy de-escalation.
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Affiliation(s)
- Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sanjeet S Dadwal
- Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California, USA
| | - Susan K Seo
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
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8
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Barreto JN, Reid JM, Thompson CA, Mara KC, Rule AD, Kashani KB, Leung N, Larson T, McGovern RM, Witzig TE, Barreto EF. Prospective evaluation of high-dose methotrexate pharmacokinetics in adult patients with lymphoma using novel determinants of kidney function. Clin Transl Sci 2022; 15:105-117. [PMID: 34378331 PMCID: PMC8742646 DOI: 10.1111/cts.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022] Open
Abstract
High-dose methotrexate (HDMTX) pharmacokinetics (PKs), including the best estimated glomerular filtration rate (eGFR) equation that reflects methotrexate (MTX) clearance, requires investigation. This prospective, observational, single-center study evaluated adult patients with lymphoma treated with HDMTX. Samples were collected at predefined time points up to 96 h postinfusion. MTX and 7-hydroxy-MTX PKs were estimated by standard noncompartmental analysis. Linear regression determined which serum creatinine- or cystatin C-based eGFR equation best predicted MTX clearance. The 80 included patients had a median (interquartile range [IQR]) age of 68.6 years (IQR 59.2-75.6), 54 (67.5%) were men, and 74 (92.5%) were White. The median (IQR) dose of MTX was 7.6 (IQR 4.8-11.3) grams. Median clearance was similar across three dosing levels at 4.5-5.6 L/h and was consistent with linear PKs. Liver function, weight, age, sex, concomitant chemotherapy, and number of previous MTX doses did not impact clearance. MTX area under the curve (AUC) values varied over a fourfold range and appeared to increase in proportion to the dose. The eGFRcys (ml/min) equation most closely correlated with MTX clearance in both the entire cohort and after excluding outlier MTX clearance values (r = 0.31 and 0.51, respectively). HDMTX as a 4-h infusion displays high interpatient pharmacokinetic variability. Population PK modeling to optimize MTX AUC attainment requires further evaluation. The cystatin C-based eGFR equation most closely estimated MTX clearance and should be investigated for dosing and monitoring in adults requiring MTX as part of lymphoma management.
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Affiliation(s)
| | - Joel M. Reid
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA,Department of OncologyMayo ClinicRochesterMinnesotaUSA
| | - Carrie A. Thompson
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kristin C. Mara
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - Andrew D. Rule
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kianoush B. Kashani
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Nelson Leung
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Thomas R. Larson
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | | | - Thomas E. Witzig
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Erin F. Barreto
- Department of PharmacyMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
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Barreto JN, Bansal R, Hathcock MA, Doleski CJ, Hayne JR, Truong TA, Nedved AN, Ansell SM, Bennani NN, Paludo J, Villasboas JC, Lin Y, Johnston PB. The impact of granulocyte colony stimulating factor on patients receiving chimeric antigen receptor T-cell therapy. Am J Hematol 2021; 96:E399-E402. [PMID: 34350612 DOI: 10.1002/ajh.26313] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 01/08/2023]
Affiliation(s)
| | - Radhika Bansal
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Matthew A. Hathcock
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | | | - Justin R. Hayne
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Tuan A. Truong
- Department of Nursing Mayo Clinic Rochester Minnesota USA
| | | | - Stephen M. Ansell
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - N. Nora Bennani
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Jose C. Villasboas
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Patrick B. Johnston
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
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10
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Rice ML, Barreto JN, Thompson CA, Mara KC, Tosh PK, Limper AH. Incidence of Pneumocystis jirovecii pneumonia utilizing a polymerase chain reaction-based diagnosis in patients receiving bendamustine. Cancer Med 2021; 10:5120-5130. [PMID: 34155819 PMCID: PMC8335812 DOI: 10.1002/cam4.4067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/04/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening infection occurring in patients receiving bendamustine. The poorly defined incidence, particularly when utilizing polymerase chain reaction (PCR)-based diagnostic techniques, precipitates unclear prophylaxis recommendations. Our objective was to determine the cumulative incidence of PJP diagnosed by single copy target, non-nested PCR in patients receiving bendamustine. METHODS Patients were evaluated for PJP from initiation of bendamustine through 9 months after the last administration. The cumulative incidence of PJP was estimated using the Aalen-Johansen method. Cox proportional hazard models were used to demonstrate the strength of association between the independent variables and PJP risk. RESULTS This single-center, retrospective cohort included 486 adult patients receiving bendamustine from 1 January 2006 through 1 August 2019. Most patients received bendamustine-based combination therapy (n = 461, 94.9%), and 225 (46.3%) patients completed six cycles. Rituximab was the most common concurrent agent (n = 431, 88.7%). The cumulative incidence of PJP was 1.7% (95% CI 0.8%-3.3%, at maximum follow-up of 2.5 years), after the start of bendamustine (n = 8 PJP events overall). Prior stem cell transplant, prior chemotherapy within 1 year of bendamustine, and lack of concurrent chemotherapy were associated with the development of PJP in univariate analyses. Anti-Pneumocystis prophylaxis was not significantly associated with a reduction in PJP compared to no prophylaxis (HR 0.37, 95% CI (0.05, 3.04), p = 0.36). CONCLUSIONS Our incidence of PJP below 3.5%, the conventional threshold for prophylaxis implementation, indicates routine anti-Pneumocystis prophylaxis may not be necessary in this population. Factors indicating a high-risk population for targeted prophylaxis require further investigation.
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Affiliation(s)
| | | | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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11
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DeFino CE, Barreto JN, Pawlenty AG, Ruff MW, Carabenciov ID, Mara KC, Thompson CA. Lack of drug interaction between levetiracetam and high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2021; 41:430-439. [PMID: 33655525 DOI: 10.1002/phar.2516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/24/2021] [Accepted: 02/02/2021] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine whether there is a drug-drug interaction precluding the concomitant use of levetiracetam and high-dose methotrexate (HDMTX). DESIGN Retrospective analysis. SETTING Large academic tertiary care medical center. PATIENTS Adult lymphoma patients who received HDMTX as a 4-h infusion with or without concomitant levetiracetam. MEASUREMENTS AND MAIN RESULTS Generalized estimating equations clustered on patient were used to assess each outcome. The primary outcome was the incidence of delayed MTX elimination (MTX level >1 µmol/L at 48 h). Secondary outcomes included incidence of acute kidney injury (AKI) and hospital length of stay (LOS). The 430 included patients receiving 1993 doses of HDMTX had a median (IQR) age of 66 (57.5, 72.6) years, 88 (20.5%) received concomitant levetiracetam with at least one dose of MTX, 267 (62.1%) were male, and 397 (92.3%) were Caucasian. HDMTX doses ranged from 1 to 8 g/m2 . The most common lymphoma diagnoses were systemic diffuse large B-cell lymphoma (DLBCL; 58.5%) and systemic DLBCL with central nervous system (CNS) involvement (32.8%). Rates of delayed elimination with and without levetiracetam were 13.4% and 16.3%, respectively (OR = 0.80, 95% CI 0.47-1.34, p = 0.39). AKI occurred in 15.6% and 17.0% of patients with and without concomitant levetiracetam, respectively (OR = 0.83, 95% CI 0.52-1.33, p = 0.28). The median LOS with and without levetiracetam was 4.2 and 4.1 days, respectively (p = 0.039). On multivariable analyses, only age, body surface area, diagnosis of systemic DLBCL with CNS involvement, serum creatinine, hemoglobin, total bilirubin, and dose of HDMTX were associated with delayed elimination. CONCLUSIONS High-dose methotrexate administered with concomitant levetiracetam was not associated with increased risk for delayed MTX elimination or AKI. These results support that levetiracetam and HDMTX are safe for coadministration.
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Affiliation(s)
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Michael W Ruff
- Division of Neuro-Oncology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivan D Carabenciov
- Division of Neurocritical Care, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Barreto JN, Peterson KT, Barreto EF, Mara KC, Dierkhising RA, Leung N, Witzig TE, Thompson CA. Early, empiric high-dose leucovorin rescue in lymphoma patients treated with sequential doses of high-dose methotrexate. Support Care Cancer 2021; 29:5293-5301. [PMID: 33661366 DOI: 10.1007/s00520-021-06106-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 02/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND In patients exposed to high-dose methotrexate (HDMTX; >1g/m2) with a history of elevated methotrexate (MTX) concentrations during previous doses, it is unclear whether prescribing high-dose leucovorin (HDLV) rescue limits future high levels or reduces the likelihood of acute kidney injury (AKI). METHODS This retrospective, single-center study longitudinally followed adult lymphoma patients treated with HDMTX between 1/1/2011 and 10/31/2017 from diagnosis until 30 days after the last HDMTX dose. Endpoints included elevated MTX concentrations at 48 h (>1.0 μmol/L) and incident AKI after each HDMTX dose. RESULTS The 321 included patients had a median (IQR) age of 65 (57, 72) years, 190 (59%) were male, and 293 (91%) were Caucasian. There were 1558 HDMTX doses [median (IQR) 3 (2, 6) doses per patient] prescribed with 265 (83%) patients receiving more than one MTX dose. Those receiving HDLV rescue were more likely to have an elevated MTX concentration after that dose (OR = 2.69, 95% CI: 1.75-4.11, p < 0.001). Receiving HDLV rescue was associated with a greater likelihood of AKI after MTX (OR = 2.18, 95% CI: 1.38-3.43, p < 0.001). Hospital LOS was longer in those prescribed empiric HDLV rescue after MTX than those prescribed standard leucovorin with an estimated difference of 1.1 days, (95% CI: 0.5-1.7, p < 0.001). CONCLUSION Sequential HDMTX doses are associated with a significant incidence of elevated MTX levels and AKI during lymphoma management. HDLV rescue prescribed during subsequent MTX doses in patients with a previously elevated level was not associated with improved safety outcomes. The optimal supportive care strategy following HDMTX administration requires further investigation.
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Affiliation(s)
- Jason N Barreto
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Kristen T Peterson
- Department of Pharmacy, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Erin F Barreto
- Department of Pharmacy, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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13
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Barreto JN, Bansal R, Hathcock M, Doleski C, Hayne J, Truong T, Ansell S, Bennani NN, Paludo J, Villasboas Bisneto JC, Lin Y, Johnston PB. The Utility of Granulocyte Colony Stimulating Factor in Patients Receiving Chimeric Antigen Receptor T-Cell Therapy with Axicabtagene Ciloleucel. Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Aitken SL, Aitken SL, Barreto JN, Nagel J, Seo SK, Seo SK, Liu C. 208. Variation in Clinical Practice and Attitudes in the Management of Fever and Neutropenia in Patients With Hematologic Malignancy: A Survey of Cancer Centers Across the United States. Open Forum Infect Dis 2020. [PMCID: PMC7778280 DOI: 10.1093/ofid/ofaa439.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Fever and neutropenia (FN) is common in cancer patients after chemotherapy, and there are national guideline recommendations for FN prevention and treatment. We conducted a survey of practices across multiple US cancer centers to determine the extent to which these guidelines have been adapted.
Methods
US cancer centers performing 20 allogeneic hematopoietic stem cell transplantations annually were identified from the National Marrow Donor Program’s “Be the Match” directory. Antimicrobial stewardship physicians and pharmacists at each institution were identified using institutional websites, residency or fellowship program directories, and personal contacts. A survey assessing institutional practices and individual attitudes on FN management in high-risk patients was distributed via email. Duplicate responses at the hospital level were removed. Complete surveys regarding individual attitudes were assessed using a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.”
Results
Thirty-four (23%) responses from 148 individuals were received, representing 31 of 86 hospitals (36%). 29 (94%) hospitals reported having guidelines for the management of FN. Of these, cefepime was the most commonly recommended agent for empiric treatment (26, 90%) and 16 (55%) provide guidance based on presumed site of infection. Eighteen (62%) hospitals recommend de-escalation of Gram negative therapy in certain situations, most often after being afebrile 48 – 72 hours or after neutrophil recovery (7 each, 39%). Twenty-seven (93%) hospitals recommended antibiotic prophylaxis, most often with levofloxacin (21, 78%). Of 34 respondents, attitudes were split regarding the statement “The benefit of antibiotic prophylaxis outweighs the harms in high-risk patients” (10 strongly agree or agree, 10 strongly disagree or disagree; 29% each); most agreed with the statement “I would use antibiotic prophylaxis in high-risk patients” (25, 78%).
Conclusion
Most cancer centers across the US have guidelines for the management of FN. While most recommend antibacterial prophylaxis, there were differences in individual perceptions regarding the risk / benefit. Significant variation exists in the approach to antibiotic de-escalation.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- Samuel L Aitken
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Samuel L Aitken
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Susan K Seo
- Memorial Sloan Kettering, New York, New York
| | - Susan K Seo
- Memorial Sloan Kettering, New York, New York
| | - Catherine Liu
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
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15
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Barreto JN, Thompson CA, Wieruszewski PM, Pawlenty AG, Mara KC, Potter AL, Tosh PK, Limper AH. Incidence, clinical presentation, and outcomes of Pneumocystis pneumonia when utilizing Polymerase Chain Reaction-based diagnosis in patients with Hodgkin lymphoma. Leuk Lymphoma 2020; 61:2622-2629. [PMID: 32623928 DOI: 10.1080/10428194.2020.1786561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A Polymerase Chain Reaction-based diagnosis of Pneumocystis Pneumonia (PCP) and the need for anti-Pneumocystis prophylaxis in Hodgkin lymphoma patients receiving chemotherapy requires further investigation. This retrospective, single-center, study evaluated 506 consecutive adult patients diagnosed with Hodgkin lymphoma receiving chemotherapy between January 2006 and August 2018. The cumulative incidence of PCP 1 year after start of chemotherapy was 6.2% (95% CI 3.8-8.5%). Mortality 30 days from PCP diagnosis was 8% (n = 2) with one death attributable to PCP. Bleomycin-containing combination chemotherapy regimen was not significantly associated with a higher risk for PCP when compared to other regimens (HR = 1.59, 95% CI 0.55-4.62 p = 0.40). Anti-Pneumocystis prophylaxis was not significantly associated with a decreased incidence of PCP (HR = 0.51, 95% CI 0.15-1.71, p = 0.28). As the overall incidence is above the commonly accepted 3.5% threshold, clinicians should consider the potential value of prophylaxis. The utility of universal vs. targeted anti-Pneumocystis prophylaxis requires prospective, randomized investigation.
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Affiliation(s)
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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16
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Teaford HR, Barreto JN, Vollmer KJ, Rule AD, Barreto EF. Cystatin C: A Primer for Pharmacists. Pharmacy (Basel) 2020; 8:E35. [PMID: 32182861 PMCID: PMC7151673 DOI: 10.3390/pharmacy8010035] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/22/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pharmacists are at the forefront of dosing and monitoring medications eliminated by or toxic to the kidney. To evaluate the effectiveness and safety of these medications, accurate measurement of kidney function is paramount. The mainstay of kidney assessment for drug dosing and monitoring is serum creatinine (SCr)-based estimation equations. Yet, SCr has known limitations including its insensitivity to underlying changes in kidney function and the numerous non-kidney factors that are incompletely accounted for in equations to estimate glomerular filtration rate (eGFR). Serum cystatin C (cysC) is a biomarker that can serve as an adjunct or alternative to SCr to evaluate kidney function for drug dosing. Pharmacists must be educated about the strengths and limitations of cysC prior to applying it to medication management. Not all patient populations have been studied and some evaluations demonstrated large variations in the relationship between cysC and GFR. Use of eGFR equations incorporating cysC should be reserved for drug management in scenarios with demonstrated outcomes, including to improve pharmacodynamic target attainment for antibiotics or reduce drug toxicity. This article provides an overview of cysC, discusses evidence around its use in medication dosing and in special populations, and describes practical considerations for application and implementation.
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Affiliation(s)
- Hilary R. Teaford
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Jason N. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Kathryn J. Vollmer
- College of Pharmacy and Health Sciences, Drake University, Des Moines, IA 50311, USA;
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA;
- Division of Epidemiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
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17
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Barreto JN, Piche SL, Hogan BM, Barreto EF. Effect of a multimodal multidisciplinary training program on pharmacy residents' knowledge and confidence toward research and biostatistics. Curr Pharm Teach Learn 2020; 12:20-26. [PMID: 31843160 DOI: 10.1016/j.cptl.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/28/2019] [Accepted: 10/15/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The optimal method to increase pharmacy resident knowledge and confidence toward research remains unknown. OBJECTIVE This study evaluated the impact of a structured curriculum on pharmacy residents' knowledge, confidence and attitude toward biostatistics and research. METHODS This prospective, multicenter study included pharmacy residents from 2016 to 2017. Residents underwent research training with (1) 60-hours of online modules delivered by multidisciplinary senior faculty (MD, PhD), (2) a 2-day interactive workshop delivered by experienced pharmacy researchers and (3) a mentored longitudinal research experience. Fifteen residents were invited to complete a questionnaire at baseline and again before graduation to measure knowledge, confidence and attitudes about research. Residents were followed for one additional year to measure peer-reviewed publications. RESULTS Eleven (73%) residents provided complete responses to ≥1survey domain. At baseline, 27% of respondents reported being at least somewhat confident about their biostatistics and research skills (a favorable response for ≥5 of the 9 confidence items). At follow-up, 91% self-reported confidence. Self-reported familiarity with statistical terminology (a score of 4 or 5) increased from 19% at baseline to 82% at follow-up. The mean correct score on the knowledge items at baseline was 15 ± 2.5 (total possible 28) and increased to 20 ± 2.7 after training. By one year after graduation, 53% of residents published at least 1 peer-reviewed manuscript and 20 peer-reviewed publications as first or co-author with a median journal impact factor of 3.16 (IQR: 2.61-4.59). CONCLUSION This study provides a framework for sustainable, multidisciplinary, multimodal research education that increased confidence and knowledge among pharmacy residents and resulted in tangible contributions to the scientific literature. Future studies should explore long-term knowledge gained and publications.
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Affiliation(s)
- Jason N Barreto
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, United States.
| | - Shannon L Piche
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, United States
| | - Breann M Hogan
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, United States
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, United States; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, United States
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18
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Barreto JN, Cullen MW, Mara KC, Grove ME, Sierzchulski AG, Dahl NJ, Tosh PK, Dierkhising RA, Patnaik MM, Ackerman MJ. QT prolongation in patients with acute leukemia or high-risk myelodysplastic syndrome prescribed antifungal prophylaxis during chemotherapy-induced neutropenia. Leuk Lymphoma 2019; 60:3512-3520. [PMID: 31298598 DOI: 10.1080/10428194.2019.1639165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Benefits of serial electrocardiographic (ECG) monitoring to detect QT prolongation in patients with hematological malignancies remain unclear. This retrospective, single-center, study evaluated 316 adult acute leukemia and high-risk MDS patients who received 11,775 patient-days of voriconazole prophylaxis during induction chemotherapy. Of these, 37 patients (16.2%) experienced QTc prolongation. Medications associated with QTc prolongation included furosemide, haloperidol, metronidazole, mirtazapine, prochlorperazine, and venlafaxine. Hypokalemia and hypomagnesemia were also significantly associated with QTc prolongation (HR 3.15; p = .003 and HR 6.47, p = .007, respectively). Management modifications due to QTc prolongation included discontinuation of QT prolonging medications (n = 25), more aggressive electrolyte repletion (n = 5), and enhanced ECG monitoring (n = 3). One patient with multiple QT prolonging factors experienced possible Torsades de Pointes. Overall mortality was 15% with no cardiac-related deaths. Serial ECG monitoring during induction chemotherapy can be tailored proportionally to QT-prolonging risk factors. Management should include aggressive electrolyte repletion and avoidance of concurrent QT prolonging medications.
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Affiliation(s)
| | - Michael W Cullen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | - Nathan J Dahl
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael J Ackerman
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
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19
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Aitken SL, Nagel JL, Abbo L, Alegria W, Barreto JN, Dadwal S, Freifeld AG, Jain R, Pergam SA, Tverdek FP, Seo SK, _ _. Antimicrobial Stewardship in Cancer Patients: The Time is Now. J Natl Compr Canc Netw 2019; 17:772-775. [DOI: 10.6004/jnccn.2019.7318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Wieruszewski PM, Barreto EF, Barreto JN, Yadav H, Tosh PK, Mara KC, Limper AH. Preadmission Corticosteroid Therapy and the Risk of Respiratory Failure in Adults Without HIV Presenting With Pneumocystis Pneumonia. J Intensive Care Med 2019; 35:1465-1470. [PMID: 30813829 DOI: 10.1177/0885066619834242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Corticosteroid therapy is a well-recognized risk factor for Pneumocystis pneumonia (PCP); however, it has also been proposed as an adjunct to decrease inflammation and respiratory failure. OBJECTIVE To determine the association between preadmission corticosteroid use and risk of moderate-to-severe respiratory failure at the time of PCP presentation. METHODS This retrospective cohort study evaluated HIV-negative immunosuppressed adults diagnosed with PCP at Mayo Clinic from 2006 to 2016. Multivariable regression models were used to evaluate the association between preadmission corticosteroid exposure and moderate-to-severe respiratory failure at presentation. RESULTS Of the 323 patients included, 174 (54%) used preadmission corticosteroids with a median daily dosage of 20 (interquartile range: 10-40) mg of prednisone or equivalent. After adjustment for baseline demographics, preadmission corticosteroid therapy did not decrease respiratory failure at the time of PCP presentation (odds ratio: 1.23, 95% confidence interval: 0.73-2.09, P = .38). Additionally, after adjusting for inpatient corticosteroid administration, preadmission corticosteroid use did not impact the need for intensive care unit admission (P = .98), mechanical ventilation (P = .92), or 30-day mortality (P = .11). CONCLUSIONS Corticosteroid exposure before PCP presentation in immunosuppressed HIV-negative adults was not associated with a reduced risk of moderate-to-severe respiratory failure.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, 4352Mayo Clinic, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), 4352Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Department of Pharmacy, 4352Mayo Clinic, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), 4352Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 4352Mayo Clinic, Rochester, MN, USA
| | | | - Hemang Yadav
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, 4352Mayo Clinic, Rochester, MN, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, 4352Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, 4352Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, 4352Mayo Clinic, Rochester, MN, USA.,Department of Biochemistry and Molecular Biology, 4352Mayo Clinic, Rochester, MN, USA.,Thoracic Diseases Research Unit, 4352Mayo Clinic, Rochester, MN, USA
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21
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Division of Epidemiology, Mayo Clinic, Rochester, MN
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22
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Affiliation(s)
- Jonathan G. Leung
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Mayo Clinic – Rochester, 1216 Second Street SW, Rochester MN 55902
| | - Jason N. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Mayo Clinic – Rochester, 1216 Second Street SW, Rochester MN 55902
| | - Carrie A. Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic – Rochester, 200 First Street SW, Rochester, MN 55905
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23
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Yemm KE, Barreto JN, Mara KC, Dierkhising RA, Gangat N, Tosh PK. A comparison of levofloxacin and oral third-generation cephalosporins as antibacterial prophylaxis in acute leukaemia patients during chemotherapy-induced neutropenia. J Antimicrob Chemother 2018; 73:204-211. [PMID: 29040595 DOI: 10.1093/jac/dkx338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/21/2017] [Indexed: 11/12/2022] Open
Abstract
Background There is demonstrated benefit with fluoroquinolones as infection prophylaxis in neutropenic patients; however, side effects, drug interactions and increasing resistance necessitate investigation of alternative therapies. Objectives To compare the incidence of febrile neutropenia in high-risk patients with haematological malignancy receiving a fluoroquinolone with those receiving an oral third-generation cephalosporin (OTGC) as antibacterial prophylaxis during chemotherapy-induced neutropenia. Methods A retrospective, matched, single-centre study comparing clinical and microbiological outcomes in acute leukaemia patients receiving fluoroquinolones versus OTGCs as antibacterial prophylaxis after chemotherapy. Results A total of 120 patients (levofloxacin n = 80, OTGC n = 40) were included and matched. The 30 day incidence of febrile neutropenia was 89.7% (95% CI = 82.4-93.9). The rates of febrile neutropenia were similar between antimicrobials (OTGC versus levofloxacin HR = 0.90, 95% CI = 0.54-1.52, P = 0.70). The most frequent site of infection was the bloodstream (line related) (n = 24, 62%) and the majority (n = 28, 72%) of infections were caused by Gram-positive organisms. Groups were similar in terms of site of infection (P = 0.91) and morphology of recovered microorganisms (P = 0.74). There were significantly more cultures positive for Enterobacter spp. in the OTGC group (P = 0.043). Three patients died during follow-up (from first dose up to 30 days after the last dose) (30 day survival = 99.2%, 95% CI = 97.5-100), with only two of the reported deaths attributable to infection. Conclusions These findings demonstrate comparable rates of febrile neutropenia and culture positivity with an increase in cultures positive for Enterobacter spp. when OTGCs are compared with levofloxacin for antibacterial prophylaxis during chemotherapy-induced neutropenia. Further prospective, randomized investigation is warranted.
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Affiliation(s)
- Kristyn E Yemm
- Department of Pharmacy, University of Washington Medical Center, Seattle, WA, USA
| | - Jason N Barreto
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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24
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Barreto JN, McCullough KB, Peskey CS, Dierkhising RA, Mara KC, Elliott MA, Gastineau DA, Al-Kali A, Gangat N, Letendre L, Hogan WJ, Litzow MR, Patnaik MM. Safety and feasibility of lower antithrombin replacement targets in adult patients with hematological malignancies receiving asparaginase therapy<sup/>. Leuk Lymphoma 2017; 58:2588-2597. [PMID: 28482728 DOI: 10.1080/10428194.2017.1312384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The optimal antithrombin(AT) activity parameters for replacement as thromboprophylaxis following asparaginase remains unclear. This single-center, retrospective study evaluated two sets of AT replacement thresholds and targets in adults receiving asparaginase-containing chemotherapy. AT supplementation adhered to institutional standards, which lowered the AT activity target from 100% to 80% in 6/2014. Ninety-two patients were evaluated. Cumulative thrombosis incidence was 16% at 6 months (95%CI:6.8-24.0, maximum follow-up 315 days) with similar incidence between the 80% and 100% target groups, 14% (2 of the 14) and 13% (10 of the 78), respectively, with a small non-Line-Related DVT incidence (3%). Most thrombotic events occurred during induction chemotherapy and demonstrated no associations with replacement target, cumulative days or cumulative area under AT activity target, number of asparaginase doses, or cumulative asparaginase dose. Median estimated AT replacement expenditure was $34,963USD (IQR $16,260USD to $79,319USD) per patient. Cost-effectiveness and optimization of AT replacement for thromboprophylaxis following asparaginase requires prospective evaluation.
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Affiliation(s)
- Jason N Barreto
- a Department of Pharmacy Services , Mayo Clinic , Rochester , MN , USA
| | | | - Candy S Peskey
- a Department of Pharmacy Services , Mayo Clinic , Rochester , MN , USA
| | - Ross A Dierkhising
- b Division of Biomedical Statistics and Informatics, Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | - Kristin C Mara
- b Division of Biomedical Statistics and Informatics, Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | - Michelle A Elliott
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Dennis A Gastineau
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Aref Al-Kali
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Naseema Gangat
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Louis Letendre
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - William J Hogan
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Mark R Litzow
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Mrinal M Patnaik
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
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Frazee E, Rule AD, Lieske JC, Kashani KB, Barreto JN, Virk A, Kuper PJ, Dierkhising RA, Leung N. Cystatin C-Guided Vancomycin Dosing in Critically Ill Patients: A Quality Improvement Project. Am J Kidney Dis 2017; 69:658-666. [PMID: 28131530 DOI: 10.1053/j.ajkd.2016.11.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of the study was to determine whether a vancomycin dosing algorithm based on estimated glomerular filtration rate from creatinine and cystatin C levels (eGFRcr-cys) improves target trough concentration achievement compared to an algorithm based on estimated creatinine clearance (eCLcr) in critically ill patients. STUDY DESIGN This prospective quality improvement project evaluated intensive care unit (ICU) patients started on intravenous vancomycin using one of 2 different strategies. Dosing regimens were selected and implemented after an individualized goal trough range was established (10-15 or 15-20mg/L). Steady-state goal trough achievement was compared between treatment arms with and without adjustment for potential confounders. SETTING & PARTICIPANTS 3 medical and surgical ICUs at a single tertiary medical center. QUALITY IMPROVEMENT PLAN During January 2012 to October 2013, vancomycin was dosed according to eCLcr using the Cockcroft-Gault formula (control arm). During December 2013 to May 2015, a multidisciplinary quality improvement team implemented a novel vancomycin dosing algorithm according to eGFRcr-cys using the CKD-EPI equation (intervention arm). OUTCOME Steady-state initial goal vancomycin trough concentration achievement. MEASUREMENTS & RESULTS More patients in the intervention arm (67 of 135 [50%]) achieved therapeutic trough vancomycin levels than in the control arm (74 of 264 [28%]; OR, 2.53; 95% CI, 1.65-3.90; P<0.001). Improved trough achievement was maintained even after adjustment for age, sex, APACHE (Acute Physiology and Chronic Health Evaluation) III score, fluid balance, baseline CLcr, surgical admission diagnosis, presence of sepsis, and goal trough concentration range (adjusted OR, 2.79; 95% CI, 1.76-4.44; P<0.001). Clinical outcomes were similar between groups. LIMITATIONS Nonrandomized, incomplete algorithm compliance. CONCLUSIONS A vancomycin dosing nomogram based on eGFRcr-cys significantly improved goal trough achievement compared to eCLcr among ICU patients with stable kidney function. Further studies are warranted to characterize the relationship between use of cystatin C-guided dosing and clinical outcomes.
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Affiliation(s)
- Erin Frazee
- Department of Pharmacy, Mayo Clinic, Rochester, MN.
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Abinash Virk
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Leung JG, Hasassri ME, Barreto JN, Nelson S, Morgan RJ. Characterization of Admission Types in Medically Hospitalized Patients Prescribed Clozapine. Psychosomatics 2016; 58:164-172. [PMID: 28153339 DOI: 10.1016/j.psym.2016.11.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clozapine is the antipsychotic of choice for treatment-resistant schizophrenia; however, rigorous monitoring is required to prevent or detect adverse drug events that contribute to morbidity and mortality. In addition to the Food and Drug Administration (FDA) boxed safety warnings specific to clozapine (agranulocytosis, hypotension, seizures, and cardiomyopathy/myocarditis), other adverse events such as pneumonia and gastrointestinal hypomotility have been reported in the literature to result in hospitalization. OBJECTIVE To explore the reasons for medical hospitalization in patients prescribed clozapine, a retrospective chart review was completed. METHODS Adults with schizophrenia or schizoaffective disorder prescribed clozapine were identified if they had a nonpsychiatric medical admission between 1/1/2003 and 8/1/2015. Demographics, admitting diagnosis, admitting service type, psychiatric consult information, clozapine dosing, and drug interactions were collected. RESULTS Overall, 104 patients, representing 248 hospitalizations, were admitted to a medical unit during the study period. The predominant admission types were for the management of either pulmonary (32.2%) or gastrointestinal (19.8%) illnesses. The most common pulmonary diagnosis was pneumonia, accounting for 58% of pulmonary admissions. Further, 61.2% of the gastrointestinal admissions were related to hypomotility, ranging from constipation to death. Clozapine was discontinued owing to neutropenia in 2 patients; however, in both cases concomitant chemotherapy had been given. CONCLUSION In patients prescribed clozapine admitted to nonpsychiatric medical settings, gastrointestinal and pulmonary illnesses were common, but not illnesses related to boxed warnings. Additional research is needed to better assess the causality and true incidence of gastrointestinal or pulmonary events associated with clozapine. Furthermore, clinicians must be prepared to prevent, detect, and manage potentially life-threatening events associated with clozapine.
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Affiliation(s)
| | | | | | - Sarah Nelson
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Robert J Morgan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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Barreto JN, Ice LL, Thompson CA, Tosh PK, Osmon DR, Dierkhising RA, Plevak MF, Limper AH. Low incidence of pneumocystis pneumonia utilizing PCR-based diagnosis in patients with B-cell lymphoma receiving rituximab-containing combination chemotherapy. Am J Hematol 2016; 91:1113-1117. [PMID: 27472910 DOI: 10.1002/ajh.24499] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 12/25/2022]
Abstract
Recent literature has demonstrated concern over the risk of Pneumocystis jirovecii pneumonia (PJP) when administering rituximab with combination chemotherapy such as in R-CHOP; however, the exact risk and potential need for prophylaxis is unknown. We sought to determine the incidence of PJP infection following R-CHOP administration in patients with B-cell lymphoma. Consecutive patients diagnosed with B-cell lymphoma receiving R-CHOP were evaluated from chemotherapy initiation until 180 days after the last administration. The primary outcome was cumulative incidence of PJP infection. Secondary endpoints included the association of rituximab, prednisone and subsequent chemotherapy with PJP infection risk. A total of 689 patients (53% male, median age 66 years) were included. Seventy-three percent of patients completed at least 6 cycles of R-CHOP treatment. Median rituximab and prednisone cumulative doses were 3950 mg and 5325 mg, respectively. Median daily prednisone dose through end of treatment was 45 mg (range 7.6 mg to 119 mg). The cumulative incidence of PJP was 1.51% (95% CI 0.57-2.43, at maximum follow-up of 330 days), below 3.5%, the conventional threshold for prophylaxis. Univariate analysis did not detect a statistically significant association between PJP and rituximab, steroids, or receipt of additional chemotherapy in this patient population. Our results demonstrate a low occurrence of Pneumocystis pneumonia during R-CHOP treatment of B-cell lymphoma and argue against universal anti-Pneumocystis prophylaxis in this setting. Further investigations should focus on targeted anti-Pneumocystis prophylaxis for patients presenting with high-risk baseline characteristics or when receiving rituximab-inclusive intensive combination chemotherapy regimens as treatment for other aggressive lymphoma subtypes. Am. J. Hematol. 91:1113-1117, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jason N. Barreto
- Department of Pharmacy Services; Mayo Clinic; Rochester Minnesota
| | - Lauren L. Ice
- Department of Pharmacy; Spectrum Health; Grand Rapids Michigan
| | - Carrie A. Thompson
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Pritish K. Tosh
- Division of Infectious Diseases; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Douglas R. Osmon
- Division of Infectious Diseases; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Ross A. Dierkhising
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | - Matthew F. Plevak
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | - Andrew H. Limper
- Division of Pulmonary and Critical Care Medicine; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
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Abstract
While lymphopenia is a well-defined risk factor for severe influenza, the effect of neutropenia is unknown. This was a retrospective single centre study of adult patients with documented neutropenia and influenza between 2005 and 2013. Forty patients were included with a median follow-up of 2 years (IQR 0.8-4.0). Median ANC at influenza diagnosis was 0.3 × 109/L (IQR 0.1-0.4 × 109/L). Outcomes included hospitalization (N = 28, 70%), pneumonia (N = 9, 23%), ICU admission (N = 9, 23%) and mechanical ventilation (N = 7, 18%). Three deaths (7.5%) were attributed to influenza, all of whom had lower respiratory tract infection (LRTI). Patients with LRTI (N = 18, 45%) also had a higher 30-day mortality (37 versus 0%) and 90-day mortality (42 versus 0%) than those with upper respiratory tract infection. In summary, neutropenic patients have high rates of influenza complications. Our study highlights the need for early diagnosis and aggressive management of influenza in this population.
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Affiliation(s)
- Urshila Durani
- a Department of Internal Medicine , Mayo Clinic , Rochester MN , USA
| | - Maria V Dioverti Prono
- b Division of Infectious Diseases, Department of Internal Medicine , Mayo Clinic , Rochester MN , USA
| | - Pritish K Tosh
- b Division of Infectious Diseases, Department of Internal Medicine , Mayo Clinic , Rochester MN , USA
| | - Mrinal Patnaik
- c Division of Hematology, Department of Internal Medicine , Mayo Clinic , Rochester MN , USA
| | - Jason N Barreto
- d Hospital Pharmacy Services , Mayo Clinic , Rochester , MN , USA
| | - Aaron J Tande
- b Division of Infectious Diseases, Department of Internal Medicine , Mayo Clinic , Rochester MN , USA
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Daniels LM, Barreto JN, Kuth JC, Anderson JR, Zhang B, Majka AJ, Morgenthaler TI, Tosh PK. Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy. Am J Health Syst Pharm 2016; 72:1195-203. [PMID: 26150569 DOI: 10.2146/ajhp140632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE A failure mode and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to above-target International Normalized Ratios (INRs) in warfarin-treated patients receiving concurrent antimicrobial therapy. METHODS The INRs of patients on long-term warfarin therapy who received a course of trimethoprim-sulfamethoxazole, metronidazole, fluconazole, miconazole, or voriconazole (highly potentiating antimicrobials, or HPAs) between September 1 and December 31, 2011, were compared with patients on long-term warfarin therapy who did not receive any antimicrobial during the same period. A multidisciplinary team of physicians, pharmacists, and a systems analyst was then formed to complete a step-by-step outline of the processes involved in warfarin management and concomitant HPA therapy, followed by an FMEA. RESULTS Patients taking trimethoprim-sulfamethoxazole, metronidazole, or fluconazole demonstrated a significantly increased risk of having an INR of >4.5. The FMEA identified 134 failure modes. The most common failure modes were as follows: (1) electronic medical records did not identify all patients receiving warfarin, (2) HPA prescribers were unaware of recommended warfarin therapy when HPAs were prescribed, (3) HPA prescribers were unaware that a patient was taking warfarin and that the drug interaction is significant, and (4) warfarin managers were unaware that an HPA had been prescribed for a patient. CONCLUSION An FMEA determined that the risk of adverse events caused by concomitantly administering warfarin and HPAs can be decreased by preemptively identifying patients receiving warfarin, having a care process in place, alerting providers about the patient's risk status, and notifying providers at the anticoagulation clinic.
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Affiliation(s)
- Lisa M Daniels
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Jason N Barreto
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - John C Kuth
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Jeremy R Anderson
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Beilei Zhang
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Andrew J Majka
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Timothy I Morgenthaler
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Pritish K Tosh
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN.
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Barreto JN, Leung JG, Philbrick KL, Rasmussen KG, Thompson CA. Clozapine therapy throughout myelosuppressive chemotherapy: regulations without standardization. Psychooncology 2015; 24:1581-5. [DOI: 10.1002/pon.3779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/12/2015] [Accepted: 01/29/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Jason N. Barreto
- Department of Pharmacy Services; Mayo Clinic; 200 First Street SW Rochester MN 55905 USA
| | - Jonathan G. Leung
- Department of Pharmacy Services; Mayo Clinic; 200 First Street SW Rochester MN 55905 USA
| | - Kemuel L. Philbrick
- Department of Psychiatry and Psychology; Mayo Clinic; 200 First Street SW Rochester MN 55905 USA
| | - Keith G. Rasmussen
- Department of Psychiatry and Psychology; Mayo Clinic; 200 First Street SW Rochester MN 55905 USA
| | - Carrie A. Thompson
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; 200 First Street SW Rochester MN 55905 USA
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Vasoo S, Barreto JN, Tosh PK. Emerging issues in gram-negative bacterial resistance: an update for the practicing clinician. Mayo Clin Proc 2015; 90:395-403. [PMID: 25744116 DOI: 10.1016/j.mayocp.2014.12.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/02/2014] [Accepted: 12/02/2014] [Indexed: 10/23/2022]
Abstract
The rapid and global spread of antimicrobial-resistant organisms in recent years has been unprecedented. Although resistant gram-positive infections have been concerning to clinicians, the increasing incidence of antibiotic-resistant gram-negative infections has become the most pressing issue in bacterial resistance. Indiscriminate antimicrobial use in humans and animals coupled with increased global connectivity facilitated the transmission of gram-negative infections harboring extended-spectrum β-lactamases in the 1990s. Carbapenemase-producing Enterobacteriaceae, such as those containing Klebsiella pneumoniae carbapenemases and New Delhi metallo-β-lactamases, have been the latest scourge since the late 1990s to 2000s. Besides β-lactam resistance, these gram-negative infections are often resistant to multiple drug classes, including fluoroquinolones, which are commonly used to treat community-onset infections. In certain geographic locales, these pathogens, which have been typically associated with health care-associated infections, are disseminating into the community, posing a significant dilemma for clinicians treating community-onset infections. In this Concise Review, we summarize emerging trends in antimicrobial resistance. We also review the current knowledge on the detection, treatment, and prevention of infection with these organisms, with a focus on the carbapenemase-producing gram-negative bacilli. Finally, we discuss emerging therapies and areas that need further research and effort to stem the spread of antimicrobial resistance.
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Affiliation(s)
- Shawn Vasoo
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | | | - Pritish K Tosh
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
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Dao BD, Barreto JN, Wolf RC, Dierkhising RA, Plevak MF, Tosh PK. Serum peak sulfamethoxazole concentrations demonstrate difficulty in achieving a target range: a retrospective cohort study. Curr Ther Res Clin Exp 2014; 76:104-9. [PMID: 25408788 PMCID: PMC4229511 DOI: 10.1016/j.curtheres.2014.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Trimethoprim (TMP)/sulfamethoxazole (SMX) has consistently demonstrated great interindividual variability. Therapeutic drug monitoring may be used to optimize dosing. Optimal peak SMX concentration has been proposed as 100 to 150 μg/mL. The objective of our work was to determine the success rate of a TMP/SMX dosing guideline in achieving a targeted serum peak SMX concentration range. METHODS Our retrospective cohort study enrolled 305 adult hospitalized patients who received treatment with TMP/SMX and underwent serum peak SMX concentration monitoring from January 2003 to November 2011. Patients receiving low-dose TMP/SMX therapy (TMP <15 mg/kg/d) were compared with those receiving high-dose therapy (TMP >15 mg/kg/d). RESULTS Patients were classified into peak and modified peak SMX concentration cohorts based on time between TMP/SMX dose and SMX quantification. The association between dosing group and the outcome of the SMX level within the goal range was measured using logistic regression models. The primary outcome measured was serum peak SMX concentration 100 to 150 μg/mL. Serum peak SMX concentrations were attained within range for the peak and modified peak cohort 29% and 26% of the time, respectively. The median peak SMX concentration was 144 μg/mL (range 25-471 μg/mL). The low daily dose cohort demonstrated a trend toward improvement in the odds of target peak concentration range attainment. The results were similar regardless of the method used to adjust for baseline characteristics. The pure peak and modified peak cohorts had 44% and 46% of patients with above-target SMX peak concentrations, respectively. CONCLUSIONS Attainment of the intended target concentration range was low with no difference in attainment between the low-dose and high-dose cohorts. Higher proportions of patients had an above-target SMX peak, which may indicate that the dosing algorithm is overly aggressive in obtaining the therapeutic goal.
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Affiliation(s)
- Bao D Dao
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota ; Current affiliation: Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Jason N Barreto
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Matthew F Plevak
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Pritish K Tosh
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
Bone marrow is a complex organ responsible for the regulation of hematopoietic cell distribution throughout the human body. Patients receiving antineoplastic agents as a therapeutic intervention for hematologic malignancy often experience varying degrees of myelotoxicity. Antineoplastic agents cause hypocellularity in marrow resulting in a reduction in hematopoietic tissue activity and a corresponding decline in cell production. Quantifying the adverse effects on hematopoiesis is based on the properties of a single agent, the use of individual drugs within a combination chemotherapy regimen, and the course, or courses, of chemotherapy designed to treat cancer. The direct or indirect suppression of erythrocytes, granulocytes, and megakaryocytes has potential for multiple negative clinical consequences ranging from increased monitoring of blood counts to life-threatening infection and death. This review will provide an overview of the structure and function of competent adult bone marrow, describe the process of hematopoiesis, and characterize the myelotoxicities associated with common antineoplastic agents currently used in the treatment of cancer.
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Affiliation(s)
- Jason N. Barreto
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | | | - Lauren L. Ice
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Judith A. Smith
- Department of Gynecologic Oncology & Reproductive Medicine, Division of Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Daniels LM, Barreto JN, Tosh PK. Supratherapeutic international normalized ratios in warfarin-treated patients who receive a highly potentiating antimicrobial course. JAMA Intern Med 2014; 174:1200. [PMID: 25003887 DOI: 10.1001/jamainternmed.2014.1615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lisa M Daniels
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason N Barreto
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Pritish K Tosh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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Wojenski DJ, Barreto JN, Wolf RC, Tosh PK. Cefpodoxime for antimicrobial prophylaxis in neutropenia: a retrospective case series. Clin Ther 2014; 36:976-81. [PMID: 24832560 DOI: 10.1016/j.clinthera.2014.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/18/2014] [Accepted: 04/08/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial prophylaxis in select neutropenic patients has reduced fever, infection rates, hospital length of stay, and hospitalization rates. Guidelines from the Infectious Diseases Society of America recommend the consideration of prophylaxis with a fluoroquinolone in patients at high risk for infection after chemotherapy. The use of fluoroquinolones has been associated with many adverse events, and there is limited evidence on alternative antimicrobial prophylaxis in patients intolerant of fluoroquinolones. OBJECTIVES Our study describes a single-center experience of cefpodoxime as an alternative to fluoroquinolones for antibacterial prophylaxis during neutropenia after chemotherapy and represents a retrospective evaluation of an oral cephalosporin in adult patients for this purpose. METHODS This retrospective case series analyzed data from the electronic medical records of 41 patients having hematologic malignancies and given cefpodoxime for neutropenic prophylaxis. RESULTS The rate of febrile neutropenia was 85%, with 60% culture-positive infections. Gram-positive organisms were identified in 52% of positive cultures, and gram-negative organisms represented 40% of positive cultures. Antimicrobial resistance to guideline-recommended empiric treatment regimens was not seen in breakthrough infections. CONCLUSIONS Cefpodoxime can be utilized for prophylaxis, without adversely affecting resistance to broad-spectrum agents, and maintains a high level of appropriateness of guideline-recommended empiric regimens. This study of cefpodoxime prophylaxis in adult patients intolerant to fluoroquinolones adds to the literature of potential alternative agents for prophylaxis in neutropenic patients.
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Affiliation(s)
| | | | - Robert C Wolf
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Pritish K Tosh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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Puzniak LA, Morrow LE, Huang DB, Barreto JN. Impact of Weight on Treatment Efficacy and Safety in Complicated Skin and Skin Structure Infections and Nosocomial Pneumonia Caused by Methicillin-Resistant Staphylococcus aureus. Clin Ther 2013; 35:1557-70. [DOI: 10.1016/j.clinthera.2013.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 06/21/2013] [Accepted: 08/01/2013] [Indexed: 01/28/2023]
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Barreto JN, Beach CL, Wolf RC, Merten JA, Tosh PK, Wilson JW, Hogan WJ, Litzow MR. The incidence of invasive fungal infections in neutropenic patients with acute leukemia and myelodysplastic syndromes receiving primary antifungal prophylaxis with voriconazole. Am J Hematol 2013; 88:283-8. [PMID: 23460251 DOI: 10.1002/ajh.23388] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/02/2013] [Accepted: 01/04/2013] [Indexed: 01/23/2023]
Abstract
The objective of this study is to characterize the outcomes of primary antifungal prophylaxis with voriconazole in patients receiving intensive chemotherapy for acute myelogenous leukemia (AML) or myelodysplastic syndromes (MDS). We conducted a single center, retrospective, cohort study of consecutive adult patients with AML or MDS at Mayo Clinic between January 1, 2006 and July 1, 2010. The study included patients undergoing induction or first relapse combination chemotherapy who received voriconazole 200 mg orally twice daily as prophylaxis during the neutropenic phase. Patient records were evaluated until 30 days after neutrophil recovery for development of invasive fungal infection (IFI) as defined per EORTC/MSG 2008 criteria with computed tomography scans independently reviewed by a radiologist. Therapeutic drug monitoring and reasons for voriconazole discontinuation were documented. Twenty four episodes of IFI were detected among 165 consecutive patients for an overall incidence of 145 per 1000 patients. The incidence of IFI was 24, 42, and 78 per 1000 patients for proven, probable, and possible infection, respectively. Four patients developed proven IFI (n = 2 Aspergillus spp., n = 2 Rhizopus spp.). Serum voriconazole trough concentrations were available in 39 patients, and no statistically significant difference in voriconazole trough level was observed between those with versus without an IFI. Voriconazole prophylaxis was discontinued in 81 patients due to suspected IFI (n = 24), fever of unknown origin (n = 19), adverse events (n = 23), and other causes (n = 17). Voriconazole as primary IFI prophylaxis is safe and may be beneficial in AML/MDS patients receiving intensive chemotherapy.
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Affiliation(s)
| | - Cassidy L. Beach
- Department of Pharmacy; Duke University Medical Center; Durham North Carolina
| | - Robert C. Wolf
- Department of Pharmacy; Mayo Clinic; Rochester Minnesota
| | | | - Pritish K. Tosh
- Division of Infectious Diseases; Mayo Clinic; Rochester Minnesota
| | - John W. Wilson
- Division of Infectious Diseases; Mayo Clinic; Rochester Minnesota
| | | | - Mark R. Litzow
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Therriault BL, Wilson JW, Barreto JN, Estes LL. Characterization of bacterial infections in allogeneic hematopoietic stem cell transplant recipients who received prophylactic levofloxacin with either penicillin or doxycycline. Mayo Clin Proc 2010; 85:711-8. [PMID: 20675508 PMCID: PMC2912731 DOI: 10.4065/mcp.2010.0006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the effect of a combination prophylactic regimen of levofloxacin, a synthetic chemotherapeutic antibiotic of the fluoroquinolone drug class, with either penicillin or doxycycline on the changing epidemiology of bacterial infections and antimicrobial resistance patterns of isolated organisms in the allogeneic hematopoietic stem cell transplant (HSCT) patient population. PATIENTS AND METHODS We conducted a single-center, retrospective cohort study of all allogeneic HSCT recipients from January 1, 2003, through August 31, 2008, who received prophylactic levofloxacin in combination with penicillin (or with doxycycline in penicillin-allergic patients) from allogeneic stem cell infusion until neutrophil engraftment. RESULTS Of the 258 patients who underwent allogeneic HSCT during the study period, 231 received levofloxacin prophylaxis, 76 (33%) of whom developed an infection within 3 months after transplant. Over time, the ratio of gram-positive to gram-negative (GN) infections decreased from 2.11 in 2004, the first year that GN organisms were isolated, to 1.11 in 2008 (P=.20). Emergence of fluoroquinolone-resistant GN bacteria was observed (P=.02), whereas resistance to extended-spectrum beta-lactams did not change over time. Combined vancomycin-resistant enterococci colonization and infection rates increased during the study period (P=.04). Clostridium difficile colitis was uncommon. CONCLUSION Levofloxacin with penicillin or doxycycline prophylaxis may contribute to the emergence of resistant GN infections in allogeneic HSCT recipients over time. Our findings provide additional support for the current standard of practice of administering empiric monotherapy with an antipseudomonal beta-lactam if these patients develop fever or are suspected to have an infection.
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