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McCullough KB. Do You See Me? J Clin Oncol 2023; 41:5473-5474. [PMID: 37874954 DOI: 10.1200/jco.23.01484] [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: 07/12/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 10/26/2023] Open
Abstract
Processing grief from the outside. How a pharmacist experiences patient loss.
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Mangaonkar AA, Langer KJ, Lasho TL, Finke C, Litzow MR, Hogan WJ, Shah MV, Go RS, Bartoo G, Kutzke J, McCullough KB, Koster M, Samec M, Warrington KJ, Reichard KK, Olteanu H, Riwes M, Patnaik MM, Alkhateeb HB. Reduced intensity conditioning allogeneic hematopoietic stem cell transplantation in VEXAS syndrome: Data from a prospective series of patients. Am J Hematol 2023; 98:E28-E31. [PMID: 36403135 DOI: 10.1002/ajh.26786] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Abhishek A Mangaonkar
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kimberly J Langer
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Terra L Lasho
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christy Finke
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Litzow
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William J Hogan
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mithun V Shah
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald S Go
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel Bartoo
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jade Kutzke
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristen B McCullough
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Koster
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Samec
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Horatiu Olteanu
- Dvision of Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary Riwes
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mrinal M Patnaik
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan B Alkhateeb
- Dvision of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Tefferi A, Begna KH, McCullough KB. Tyrosine kinase inhibitors dosing for chronic phase chronic myeloid leukemia: The case for starting low with dasatinib (50 mg/day) and ponatinib (15 mg/day). Am J Hematol 2022; 97:1394-1397. [PMID: 35996356 DOI: 10.1002/ajh.26695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kebede H Begna
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Farrukh F, Chetram D, Al‐Kali A, Foran J, Patnaik M, Badar T, Begna K, Hook C, Hogan W, McCullough KB, Mangaonkar A, He R, Gangat N, Tefferi A. Real-world experience with luspatercept and predictors of response in myelodysplastic syndromes with ring sideroblasts. Am J Hematol 2022; 97:E210-E214. [PMID: 35293000 DOI: 10.1002/ajh.26533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Faiqa Farrukh
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | | | - Aref Al‐Kali
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | - James Foran
- Division of Hematolog Mayo Clinic Jacksonville Florida USA
| | - Mrinal Patnaik
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | - Talha Badar
- Division of Hematolog Mayo Clinic Jacksonville Florida USA
| | - Kebede Begna
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | | | - William Hogan
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | | | | | - Rong He
- Division of Hematopathology Mayo Clinic Rochester Minnesota USA
| | - Naseema Gangat
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematolog Mayo Clinic Rochester Minnesota USA
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Herrmann J, McCullough KB, Habermann TM. How I treat cardiovascular complications in patients with lymphoid malignancies. Blood 2022; 139:1501-1516. [PMID: 34752600 PMCID: PMC8914183 DOI: 10.1182/blood.2019003893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
The prognosis of several lymphoid malignancies has improved through development of novel therapies, combination with traditional chemotherapies, and delineation of appropriate therapeutic sequencing. Toxicities that are arising because of prolonged or multiple sequential therapeutic interventions are becoming increasingly impactful. Among the broad spectrum of complications that patients with lymphoid malignancies may experience, cardiovascular toxicities are significant in terms of morbidity and mortality. The entire cardiovascular system can be affected, but cardiomyopathy, heart failure, and arrhythmias remain of greatest concerns with the use of anthracyclines, hematopoietic stem cell transplantation, and radiation therapy in patients with lymphoid malignancies. These aspects will be covered in this article within the framework of case-based discussions. Key to the management of cardiovascular complications in patients with lymphoid malignancies is awareness and preparedness across the cancer continuum. Baseline risk stratification helps to direct surveillance and early intervention efforts before, during, and after cancer therapy, which are paramount for the best possible outcomes. Along these lines, the overall goal is to enable the best possible therapies for lymphoid malignancies without the complications of clinically significant cardiovascular events.
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Affiliation(s)
| | | | - Thomas M Habermann
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Golbach AP, McCullough KB, Soefje SA, Mara KC, Shanafelt TD, Merten JA. Evaluation of Burnout in a National Sample of Hematology-Oncology Pharmacists. JCO Oncol Pract 2021; 18:e1278-e1288. [PMID: 34793242 DOI: 10.1200/op.21.00471] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To evaluate the prevalence of burnout among hematology-oncology pharmacists and factors associated with an increased risk of high burnout. METHODS Between October and November 2020, members of the Hematology/Oncology Pharmacy Association were invited to complete an anonymous survey. Questions included the Maslach Burnout Inventory (MBI), Well-Being Index, and sociodemographic and occupational factors linked with burnout. RESULTS Of 3,024 pharmacists contacted, 614 pharmacists (20.3%) responded to an online survey and 550 (18.2% of overall sample) completed the MBI and were included for analysis. Overall, high levels of burnout were observed in 61.8% of respondents based on the MBI, with 57.9% of respondents scoring high on the emotional exhaustion domain and 31.3% high in the depersonalization domain. Pharmacists with burnout worked on average 48.6 (±9.6) hours per week compared with 44.5 (±9.6) hours per week for those without high burnout and spent more time on administrative tasks per week (7.5 hours v 4.3 hours; all P < .001). Pharmacists reporting high burnout were more likely to report concern they had made a major medication error within the past 3 months (27.6% v 8.1%; P < .001) and greater intent to leave their current job within 2 years (60.3% v 19.0%; P < .001). CONCLUSION Burnout is prevalent among hematology-oncology pharmacists and may affect both patient safety and the adequacy of the workforce. Risk factors for burnout among hematology-oncology pharmacists in this study may be targets for burnout mitigation and prevention strategies to reduce the impact on pharmacists and improve cancer care for patients.
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McCullough KB, Kuhn AK, Patnaik MM. Treatment advances for pediatric and adult onset neoplasms with monocytosis. Curr Hematol Malig Rep 2021; 16:256-266. [PMID: 33728588 DOI: 10.1007/s11899-021-00622-8] [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] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW For decades, the management of chronic myelomonocytic leukemia (CMML) or juvenile myelomonocytic leukemia (JMML) has been largely inextricable from myelodysplastic syndromes (MDS), myeloproliferative neoplasms, and acute myeloid leukemia. Hallmarks of these diseases have been the emergence of unique genomic signatures and discouraging responses to available therapies. Here, we will critically examine the current options for management and review the rapidly developing opportunities based on advances in CMML and JMML disease biology. RECENT FINDINGS Few clinical trials have exclusively been done in CMML, and in JMML, the rarity of the disease limits wide scale participation. Recent case series in JMML suggest that hypomethylating agents (HMAs) are a viable option for bridging to curative intent with allogeneic hematopoietic stem cell transplant or as posttransplant maintenance. Emerging evidence has demonstrated targeting the RAS-pathway via MEK inhibition may also be considered. In CMML, treatment with HMAs is largely derived from data inclusive of MDS patients, including a small number of patients with dysplastic CMML variants. Based on CMML disease biology, additional therapeutic targets being investigated include inhibitors of splicing, CD123/dendritic cell axis, inherent GM-CSF progenitor cell hypersensitivity, and targeting the JAK/STAT pathway. Current evidence is also expanding for oral HMAs. The management of CMML and JMML is rapidly evolving and clinicians must be aware of the genetic landscape and expanding treatment options to ensure these rare populations are afforded therapeutic interventions best suited to their needs.
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Affiliation(s)
- Kristen B McCullough
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Alexis K Kuhn
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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May HP, Barreto EF, Mara KC, McCullough KB, Patnaik MS, Leung N, Habermann TM. Risk for Significant Kidney Function Decline After Acute Kidney Injury in Adults With Hematologic Malignancy. Kidney Int Rep 2021; 6:1050-1057. [PMID: 33912755 PMCID: PMC8071647 DOI: 10.1016/j.ekir.2020.12.039] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/29/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Acute kidney injury (AKI) affects 30% of adults hospitalized with hematologic malignancy. Little is known about the long-term impact on kidney outcomes in this population despite the close relationship between kidney function and malignancy treatment eligibility. The purpose of this population-based cohort study was to determine the effect of AKI on kidney function in the year following a new diagnosis of acute leukemia or lymphoma. Methods Participants were adults hospitalized within 3 weeks of malignancy diagnosis. Baseline kidney function was determined and AKI diagnosed using standardized criteria. Cox proportional hazard modeling examined the relationship between AKI and a ≥30% decline in estimated glomerular filtration rate (eGFR) from baseline in the 1 year following hospitalization as the primary endpoint. Results AKI occurred in 33% of 1064 participants, with 70% of episodes occurring within 48 hours of hospitalization, and significantly increased risk for a ≥ 30% decline in eGFR (hazard ratio [HR] 2.7, 95% confidence interval [CI] 2.2–3.5) and incident chronic kidney disease (HR 2.2, 95% CI 1.7–2.8). AKI remained a significant predictor of eGFR decline in subgroup and multivariable analyses (adjusted HR 1.9, 95% CI 1.4–2.7). A ≥ 30% decline in eGFR increased the risk for death within 1 year in participants with AKI (HR 2.1, 95% CI 1.3–3.3). Conclusion Results aid in identifying individuals at highest risk for poor outcomes and highlight the need for research involving interventions that preserve kidney function from the time of initial hospitalization with a hematologic malignancy into the postdischarge period.
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Affiliation(s)
- Heather P. May
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Heather P. May, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905-0001, USA.
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Kristin C. Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mrinal S. Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology and Hypertension and Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M. Habermann
- Division of Nephrology and Hypertension and Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Habermann TM, Khurana A, Lentz R, Schmitz JJ, von Bormann AG, Young JR, Hunt CH, Christofferson SN, Nowakowski GS, McCullough KB, Horna P, Wood AJ, Macon WR, Kurtin PJ, Lester SC, Stafford SL, Chamarthy U, Khan F, Ansell SM, King RL. Analysis and impact of a multidisciplinary lymphoma virtual tumor board. Leuk Lymphoma 2020; 61:3351-3359. [PMID: 32967496 DOI: 10.1080/10428194.2020.1817432] [Citation(s) in RCA: 3] [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: 12/23/2022]
Abstract
The aim is to prospectively evaluate the impact of a multidisciplinary lymphoma virtual tumor board. The utility of multi-site interactive lymphoma-specific tumor boards has not been reported. The Mayo Clinic Lymphoma Tumor Board is a component of the International Mayo Clinic Care Network (MCCN). The format includes the clinical case presentation, presentation of radiology and hematopathology findings by the appropriate subspecialist, proposed treatment options, review of the literature pertinent to the case, pharmacy contributions, and discussion followed by recommendations. Three hundred and nine consecutive highly selected real-time cases with a diagnosis of lymphoma were presented at the Mayo Clinic Lymphoma Tumor Board from January 2014 to June 2018 and decisions were prospectively tracked to assess its impact on the treatment decisions. A total of 309 cases were prospectively evaluated. One hundred and forty (45.3%) cases had some changes made or recommended. The total changes suggested were 179, as some cases had more than one recommendation. There were 93 (30%) clinical management recommendations, 45 (14.6%) additional testing recommendations, 29 (9.4%) pathology changes, and 6 (1.9%) radiology changes. In an electronic evaluation process, 93% of the responders reported an improvement in knowledge and competence, and 100% recommended no change in format of the board. A multidisciplinary lymphoma tumor board approach was found to have a meaningful impact on lymphoma patients while enhancing interdisciplinary interactions and education for multiple levels of the clinical care team.
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Affiliation(s)
- Thomas M Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arushi Khurana
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ruth Lentz
- Division of Hematology, Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - John J Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jason R Young
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Pedro Horna
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Adam J Wood
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - William R Macon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Scott L Stafford
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Ushrasree Chamarthy
- Department of Medical Oncology and Hematology, Sparrow Cancer Center, Lansing, MI, USA
| | - Faraz Khan
- Department of Hematology-Oncology, American Hospital Dubai, Dubai, United Arab Emirates
| | - Stephen M Ansell
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rebecca L King
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Ice LL, Bartoo GT, McCullough KB, Wolf RC, Dierkhising RA, Mara KC, Jowsey-Gregoire SG, Damlaj M, Litzow MR, Merten JA. A Prospective Survey of Outpatient Medication Adherence in Adult Allogeneic Hematopoietic Stem Cell Transplantation Patients. Biol Blood Marrow Transplant 2020; 26:1627-1634. [PMID: 32505809 DOI: 10.1016/j.bbmt.2020.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 03/19/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022]
Abstract
Limited data exist regarding the prevalence and outcome of medication nonadherence in the adult allogeneic hematopoietic stem cell transplantation (allo-HSCT) population. The objective of this cross-sectional survey study is to determine the prevalence of medication nonadherence to immunosuppressant and nonimmunosuppressant medications in adult recipients of allo-HSCT. An electronic survey using previously validated medication adherence scales was distributed between December 2014 and April 2015 to 200 adult patients with at least 3 months of follow-up after allo-HSCT. Immunosuppressant serum drug levels and prescription refill records were retrospectively collected to assess correlation with survey responses. In the entire cohort, 51% of subjects (n = 102) reported nonadherence to nonimmunosuppressant medications (95% confidence interval [CI], 44.07% to 57.93%) on the Morisky Medication Adherence Scale. Of the 153 patients taking oral immunosuppressant medications at the time of the survey, 58 (37.9%) reported nonadherence to immunosuppressant therapy (95% CI, 30.22% to 45.6%), as measured by the Immunosuppressant Therapy Adherence Scale. Younger age and distress were associated with medication nonadherence. Nonadherence to immunosuppressant therapy was associated with mild chronic graft-vs-host disease (cGVHD), and a similar trend was observed for moderate cGVHD. Medication nonadherence was found to be highly prevalent for both immunosuppressant and nonimmunosuppressant medications in adult allo-HSCT recipient, and further study to identify interventions to improve adherence in these patients is warranted.
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Affiliation(s)
- Lauren L Ice
- Department of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | - Gabriel T Bartoo
- Department of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital, Rochester, Minnesota
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Moussab Damlaj
- Division of Hematology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Mark R Litzow
- Division of Hematology, Division of Palliative Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | - Julianna A Merten
- Department of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota.
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McCullough KB, Patnaik MM. Myelodysplastic syndrome/myeloproliferative neoplasm overlap syndromes - Advances in treatment. Best Pract Res Clin Haematol 2020; 33:101130. [PMID: 32460984 DOI: 10.1016/j.beha.2019.101130] [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: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
Optimal treatment for myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) overlap syndromes remain to be defined and are currently extrapolated from MDS and MPN. The heterogeneity of these diseases and their rare occurrences add to this void. Supportive care therapies such as erythropoiesis stimulating agents, iron chelation and cytoreductive therapy do not have prospective evidence in these disorders and the only approved treatments, hypomethylating agents, are based on the inclusion of a small number of chronic myelomonocytic leukaemia patients in MDS predominant trials. While allogeneic stem cell transplant remains the only curative option, the median age at presentation (7th decade), comorbidities, risk of disease relapse, and transplant related morbidity and mortality, make this option accessible to < 10% of patients. The advent of next generation sequencing has better defined the genomic landscape and opened the doors for personalized medicine. Herein we focus on recent therapeutic advances and options in MDS/MPN overlap syndromes.
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Affiliation(s)
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Parikh SA, Achenbach SJ, Call TG, Rabe KG, Ding W, Leis JF, Kenderian SS, Chanan‐Khan AA, Koehler AB, Schwager SM, Muchtar E, Fonder AL, McCullough KB, Nedved AN, Smith MD, Slager SL, Kay NE, Finnes HD, Shanafelt TD. The impact of dose modification and temporary interruption of ibrutinib on outcomes of chronic lymphocytic leukemia patients in routine clinical practice. Cancer Med 2020; 9:3390-3399. [PMID: 32187452 PMCID: PMC7221301 DOI: 10.1002/cam4.2998] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 01/30/2020] [Accepted: 02/12/2020] [Indexed: 12/18/2022] Open
Abstract
To study the impact of dose modification and temporary interruption of ibrutinib in routine clinical practice, we conducted a retrospective study of consecutive CLL patients treated with ibrutinib outside the context of a clinical trial at Mayo Clinic, (Rochester, MN) from 11/2013 to 12/2017. Of 209 patients, 131 (74%) had unmutated IGHV, 38 (20%) had TP53 disruption, and 47 (22%) were previously untreated. A total of 87/209 (42%) patients started reduced dose ibrutinib (<420 mg daily; n = 43, physician preference; n = 33, concomitant medications; and n = 11, other). During 281 person-years of treatment, 91/209 patients had temporary dose interruption (54%, nonhematologic toxicity; 29%, surgical procedures; 10%, hematologic toxicity; and 7%, other). After a median follow-up of 24 months, the estimated median event-free survival (EFS) was 36 months, and median overall survival (OS) was not reached. On multivariable analyses, temporary ibrutinib interruption (hazard ratio [HR]: 2.37, P = .006) and TP53 disruption at ibrutinib initiation (HR: 1.81, P = .048) were associated with shorter EFS, whereas only TP53 disruption (HR: 2.38, P = .015) was associated with shorter OS. Initial ibrutinib dose and dose modification during therapy did not appear to impact EFS or OS. These findings illustrate the challenges associated with continuous oral therapy with ibrutinib in patients with CLL.
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Affiliation(s)
- Sameer A. Parikh
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Sara J. Achenbach
- Division of Biomedical Statistics & InformaticsMayo ClinicRochesterMNUSA
| | - Timothy G. Call
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Kari G. Rabe
- Division of Biomedical Statistics & InformaticsMayo ClinicRochesterMNUSA
| | - Wei Ding
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Jose F. Leis
- Department of Hematology and OncologyMayo ClinicPhoenixAZUSA
| | - Saad S. Kenderian
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | | | - Amber B. Koehler
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Susan M. Schwager
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Eli Muchtar
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | - Amie L. Fonder
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | | | | | | | - Susan L. Slager
- Division of Biomedical Statistics & InformaticsMayo ClinicRochesterMNUSA
| | - Neil E. Kay
- Division of HematologyDepartment of MedicineMayo ClinicRochesterMNUSA
| | | | - Tait D. Shanafelt
- Division of HematologyStanford University School of MedicinePalo AltoCAUSA
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13
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Personett HA, Barreto EF, McCullough KB, Dierkhising R, Leung N, Habermann TM. Impact of early rasburicase on incidence of clinical tumor lysis syndrome in lymphoma. Leuk Lymphoma 2019; 60:2271-2277. [PMID: 31223041 DOI: 10.1080/10428194.2019.1574000] [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: 12/22/2022]
Abstract
Early administration of rasburicase to enhance uric acid (UA) elimination has been adopted without robust evidence in support of its impact on clinical outcomes in tumor lysis syndrome (TLS), specifically, the prevention of acute kidney injury (AKI). This was a retrospective cohort study of adult lymphoma patients at intermediate or high risk for TLS. Excluded patients had AKI or were on dialysis at hospital admission. The incidence of new AKI in the setting of TLS was described along with predictors of its development, including early rasburicase use. In 383 included patients, the incidence of new-onset AKI during hospitalization was 6%. Predictors included age, history of renal or cardiovascular disease, and UA >8 mg/dL. Rasburicase use did not significantly impact the risk of developing AKI (HR 2.3; p = .11). The UA level at the time of administration did not modify the effect of rasburicase on prevention of AKI (p = .36 for the interaction term).
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Affiliation(s)
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic , Rochester , MN , USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic , Rochester , MN , USA
| | - Nelson Leung
- Division of Nephrology and Hypertension and Division of Hematology, Mayo Clinic , Rochester , MN , USA.,Division of Hematology, Mayo Clinic , Rochester , MN , USA
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McCullough KB, Hobbs MA, Abeykoon JP, Kapoor P. Common Adverse Effects of Novel Therapies for Multiple Myeloma (MM) and Their Management Strategies. Curr Hematol Malig Rep 2018; 13:114-124. [PMID: 29450683 DOI: 10.1007/s11899-018-0443-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 12/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to evaluate management strategies for common adverse effects of novel therapies in multiple myeloma (MM), including immunomodulatory drugs, proteasome inhibitors, monoclonal antibodies, and a histone deacetylase inhibitor. RECENT FINDINGS There are several adverse effects that occur across multiple classes of antimyeloma drugs, including rash, peripheral neuropathy, infusion reactions, and cardiotoxicity, but most can be managed without complete discontinuation of the agent or abandonment of the class. Additionally, several agents have critically important drug-drug interactions or dose-modification implications in hepatic or renal insufficiency that can be easily overlooked, and exacerbate adverse effects. As treatment of MM moves from fixed-duration traditional chemotherapy to novel agent-based regimens, commonly administered continuously until disease progression or intolerable toxicities, providers must adopt their management strategies for both acute and long-term adverse effects. Early and frequent monitoring for therapy-related complications, dose adjustments when needed, and timely treatment for toxicities are all important steps toward ensuring longevity of treatment from a limited array of therapeutic options that currently exist for a disease with a relapsing and remitting course.
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Affiliation(s)
| | - Miriam A Hobbs
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Formea CM, Nicholson WT, Vitek CR, Wix KK, McCullough KB, Cunningham JL, Zeuli JD, Matey ET, Merten JA, Richardson DM, Billings AL, Schramm GE. Implementation of a pharmacogenomics education program for pharmacists. Am J Health Syst Pharm 2018; 75:1939-1946. [PMID: 30301720 DOI: 10.2146/ajhp170771] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development, implementation, and evaluation of a pharmacogenomics education program for pharmacists in a large, integrated multicampus health system are described. SUMMARY Pharmacogenomics has been described as tailoring medications to each patient's unique genetic sequence with the goals of minimizing harmful effects and optimizing therapeutic effects. Pharmacists are uniquely trained to lead the implementation of pharmacogenomics in clinical care. After assessment of pharmacists' comfort with pharmacogenomics, different approaches were explored to develop, pilot test, and disseminate pharmacogenomics education across a multicampus academic medical center. Limited success with large-audience, single-lecture didactic education led to development and delivery of targeted, competency-based online modules using the institution's academic virtual learning environment and course management system. Implementation steps included (1) collaboration with the Mayo Clinic Center for Individualized Medicine to create an interprofessional development team and project charter, (2) galvanizing pharmacy leadership support across multiple campuses, (3) development of competency-based interactive modules, and (4) assessment of the quality of and learner satisfaction with the modules. Significant improvements in competency scores were observed with each module and across the multiple campuses. Satisfaction with the education program was assessed at the end of a 4-module series. CONCLUSION A pharmacogenomics educational program targeting pharmacists was developed through interprofessional collaboration and provided a novel opportunity to construct an educational infrastructure to support enterprise health-system campuses with limited educational resources.
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Affiliation(s)
- Christine M Formea
- Department of Pharmacy, Mayo Clinic College of Medicine, Rochester, MN, and Mayo Clinic Hospital-Rochester, Rochester, MN
| | - Wayne T Nicholson
- Department of Anesthesiology, Mayo Clinic Hospital-Rochester, Rochester, MN
| | | | - Kelly K Wix
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | | | - John D Zeuli
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Eric T Matey
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | | | - Andrea L Billings
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN
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16
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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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17
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Finnes HD, Chaffee KG, Call TG, Ding W, Kenderian SS, Bowen DA, Conte M, McCullough KB, Merten JA, Bartoo GT, Smith MD, Leis J, Chanan-Khan A, Schwager SM, Slager SL, Kay NE, Shanafelt TD, Parikh SA. Pharmacovigilance during ibrutinib therapy for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) in routine clinical practice. Leuk Lymphoma 2016; 58:1376-1383. [PMID: 27820970 DOI: 10.1080/10428194.2016.1251592] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 12/31/2022]
Abstract
Due to Cytochrome P450 3A (CYP3A) metabolism, clinical trials of ibrutinib-treated chronic lymphocytic leukemia (CLL) patients prohibited concurrent medications metabolized by CYP3A. We evaluated concomitant medication use in 118 ibrutinib-treated CLL patients outside the context of clinical trials. Seventy-five (64%) patients were on medications that could increase ibrutinib toxicity and 4 (3%) were on drugs that could decrease ibrutinib efficacy. Nineteen (16%) patients were on concomitant CYP3A inhibitors (11 moderate, 8 strong), and 4 (3%) were on CYP3A inducers (two patients were on both CYP3A inhibitors and inducers). Although the ibrutinib starting dose was changed in 18 patients on CYP3A interacting medications, no difference in 18-month progression-free survival or rate of ibrutinib discontinuation was observed in patients who were not. In routine clinical practice, 2 of 3 CLL patients commencing ibrutinib are on a concomitant medication with potential to influence ibrutinib metabolism. Formal medication review by a pharmacist should be considered in all patients initiating ibrutinib.
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Affiliation(s)
- Heidi D Finnes
- a Department of Pharmacy , Mayo Clinic , Rochester , MN , USA
| | - Kari G Chaffee
- b Department of Biomedical Statistics and Informatics , Mayo Clinic , Rochester , MN , USA
| | - Timothy G Call
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Wei Ding
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Saad S Kenderian
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Deborah A Bowen
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Michael Conte
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | | | | | | | - Matthew D Smith
- a Department of Pharmacy , Mayo Clinic , Rochester , MN , USA
| | - Jose Leis
- d Division of Hematology Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Asher Chanan-Khan
- e Division of Hematology Oncology, Mayo Clinic , Jacksonville , FL , USA
| | - Susan M Schwager
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Susan L Slager
- f Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | - Neil E Kay
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Tait D Shanafelt
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Sameer A Parikh
- c Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
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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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Formea CM, Nicholson WT, McCullough KB, Berg KD, Berg ML, Cunningham JL, Merten JA, Ou NN, Stollings JL. Development and evaluation of a pharmacogenomics educational program for pharmacists. Am J Pharm Educ 2013; 77:10. [PMID: 23459098 PMCID: PMC3578323 DOI: 10.5688/ajpe77110] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [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: 02/08/2012] [Accepted: 09/21/2012] [Indexed: 05/09/2023]
Abstract
Objectives. To evaluate hospital and outpatient pharmacists' pharmacogenomics knowledge before and 2 months after participating in a targeted, case-based pharmacogenomics continuing education program.Design. As part of a continuing education program accredited by the Accreditation Council for Pharmacy Education (ACPE), pharmacists were provided with a fundamental pharmacogenomics education program.Evaluation. An 11-question, multiple-choice, electronic survey instrument was distributed to 272 eligible pharmacists at a single campus of a large, academic healthcare system. Pharmacists improved their pharmacogenomics test scores by 0.7 questions (pretest average 46%; posttest average 53%, p=0.0003).Conclusions. Although pharmacists demonstrated improvement, overall retention of educational goals and objectives was marginal. These results suggest that the complex topic of pharmacogenomics requires a large educational effort in order to increase pharmacists' knowledge and comfort level with this emerging therapeutic opportunity.
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McCullough KB, Formea CM, Berg KD, Burzynski JA, Cunningham JL, Ou NN, Rudis MI, Stollings JL, Nicholson WT. Assessment of the pharmacogenomics educational needs of pharmacists. Am J Pharm Educ 2011; 75:51. [PMID: 21655405 PMCID: PMC3109805 DOI: 10.5688/ajpe75351] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [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: 08/23/2010] [Accepted: 12/06/2010] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To evaluate the self-perceived knowledge and confidence of inpatient and outpatient pharmacists in applying pharmacogenomics information to clinical practice. METHODS A 19-question multiple-choice, electronic needs-assessment survey instrument was distributed to 480 inpatient and outpatient pharmacists in a large, academic, multi-campus healthcare system. RESULTS The survey response rate was 64% (303). Most respondents (85%) agreed that pharmacists should be required to be knowledgeable about pharmacogenomics, and 65% agreed that pharmacists should be capable of providing information on the appropriate use of pharmacogenomics testing. Sixty-three percent felt they could not accurately apply the results of pharmacogenomics tests to drug-therapy selection, dosing, or monitoring. CONCLUSION Pharmacists believe pharmacogenomics knowledge is important to the profession, but they lack the knowledge and self-confidence to act on the results of pharmacogenomics testing and may benefit from pharmacogenomics education.
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McCullough KB, Wolf RC. Cancer Pain: From Molecules to Suffering. Ann Pharmacother 2011. [DOI: 10.1345/aph.1p655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Thomas JB, Fall MJ, Cooper JB, Rothman RB, Mascarella SW, Xu H, Partilla JS, Dersch CM, McCullough KB, Cantrell BE, Zimmerman DM, Carroll FI. Identification of an opioid kappa receptor subtype-selective N-substituent for (+)-(3R,4R)-dimethyl-4-(3-hydroxyphenyl)piperidine. J Med Chem 1998; 41:5188-97. [PMID: 9857089 DOI: 10.1021/jm980511k] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A three-component library of compounds was prepared in parallel using multiple simultaneous solution-phase synthetic methodology. The compounds were biased toward opioid receptor antagonist activity by incorporating (+)-(3R,4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (a potent, nonselective opioid pure antagonist) as one of the monomers. The other two monomers, which included N-substituted or unsubstituted Boc-protected amino acids and a range of substituted aryl carboxylic acids, were selected to add chemical diversity. Screening of these compounds in competitive binding experiments with the kappa opioid receptor selective ligand [3H]U69,593 led to the discovery of a novel kappa opioid receptor selective ligand, N-¿(2'S)-[3-(4-hydroxyphenyl)propanamido]-3'-methylbutyl¿-(3R, 4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (8, RTI-5989-29). Additional structure-activity relationship studies suggested that 8 possesses lipophilic and hydrogen-bonding sites that are important to its opioid receptor potency and selectivity. These sites appear to exist predominantly within the kappa receptor since the selectivity arises from a 530-fold loss of affinity of 8 for the mu receptor and an 18-fold increase in affinity for the kappa receptor relative to the mu-selective ligand, (+)-N-[trans-4-phenyl-2-butenyl]-(3R, 4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (5a). The degree of selectivity observed in the radioligand binding experiments was not observed in the functional assay. According to its ability to inhibit agonist stimulated binding of [35S]GTPgammaS at all three opioid receptors, compound 8 behaves as a mu/kappa opioid receptor pure antagonist with negligible affinity for the delta receptor.
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Affiliation(s)
- J B Thomas
- Chemistry and Life Sciences, Research Triangle Institute, Research Triangle Park, North Carolina 27709, USA
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Thomas JB, Mascarella SW, Burgess JP, Xu H, McCullough KB, Rothman RB, Flippen-Anderson JL, George CF, Cantrell BE, Zimmerman DM, Carroll FI. N-substituted octahydro-4a-(3-hydroxyphenyl)-10a-methyl-benzo[g]isoquinolines are opioid receptor pure antagonists. Bioorg Med Chem Lett 1998; 8:3149-52. [PMID: 9873693 DOI: 10.1016/s0960-894x(98)00576-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
N-Methyl- and N-phenylethyl-(+/-)-1,2,3,4,4a,5,10,10a- octahydro-4a-(3-hydroxyphenyl)-10a-methyl-benzo[g]isoquinolines (4 and 5, respectively) were found to be pure opioid antagonists. These compounds were shown to share many of the characteristics identified with the N-methyl- and N-phenylethyl trans-3,4-dimethyl-4-(3-hydroxyphenyl)piperidine (1 and 2, respectively) including N-substituent mediated potency and a lack of N-substituent mediated antagonism. These data suggest that compounds 4 and 5 and the N-substituted trans-3,4-dimethyl-4-(3-hydroxyphenyl)piperidines (1 and 2) may interact with opioid receptors similarly.
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Affiliation(s)
- J B Thomas
- Chemistry and Life Sciences, Research Triangle Institute, North Carolina 27709, USA
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Thomas JB, Mascarella SW, Rothman RB, Partilla JS, Xu H, McCullough KB, Dersch CM, Cantrell BE, Zimmerman DM, Carroll FI. Investigation of the N-substituent conformation governing potency and mu receptor subtype-selectivity in (+)-(3R, 4R)-dimethyl-4-(3-hydroxyphenyl)piperidine opioid antagonists. J Med Chem 1998; 41:1980-90. [PMID: 9599247 DOI: 10.1021/jm980063g] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A study of the binding site requirements associated with the N-substituent of (+)-(3R,4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (4) derivatives was undertaken using a set of rigid vs flexible N-substituents. The study showed that compounds 7-9 bearing the trans-cinnamyl N-substituent most closely reproduced the potency at the opioid receptor of the flexible N-propylphenyl or N-propylcyclohexyl analogues previously reported. Neither the N-substituted cis-cinnamyl nor the cis-phenylcyclopropylmethyl compounds 10 and 11, respectively, showed high affinity for the opioid receptor. However, the N-trans-phenylcyclopropylmethyl compound 12 closely approximated the affinity of compounds 7-9. Additionally, we found that free rotation of the phenyl ring is necessary for high affinity binding and mu receptor subtype selectivity as the planar N-substituted thianaphthylmethyl and benzofuranylmethyl compounds 13 and 14 had significantly lower binding affinities. Altogether, these findings suggest that the high binding affinity, selectivity, and antagonist potency of N-propylphenyl or N-propylcyclohexyl analogues of (+)-(3R, 4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (4) are achieved via a conformation wherein the connecting chain of the N-substituents is extended away from piperidine nitrogen with the appended ring system rotated out-of-plane relative to the connecting chain atoms. This conformation is quite similar to that observed in the solid state for 5, as determined by single crystal X-ray analysis. Additionally, it was found that, unlike naltrexone, N-substituents bearing secondary carbons attached directly to the piperidine nitrogen of 4 suffer dramatic losses of potency vs analogues not substituted in this manner. Using a functional assay which measured stimulation or inhibition of [35S]GTP-gamma-S binding, we show that the trans-cinnamyl analogues of (+)-(3R, 4R)-dimethyl-4-(3-hydroxyphenyl)piperidine (4) retain opioid pure antagonist activity and possess picomolar antagonist potency at the mu receptor.
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Affiliation(s)
- J B Thomas
- Chemistry and Life Sciences, Research Triangle Institute, Research Triangle Park, North Carolina 27709, USA
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