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Alert 🎙Pharmacy Grand Rounds Thread Ahead! 🚨
Last week I had one of my final presentations of the year! With a catchy title😉
Urine for an Update! Updates in the management of metastatic urothelial cancer
Hold your bladders, this is an extensive update! 😂
#oncopharm
Last week I had one of my final presentations of the year! With a catchy title😉
Urine for an Update! Updates in the management of metastatic urothelial cancer
Hold your bladders, this is an extensive update! 😂
#oncopharm
Bladder cancer can be divided into two ✌️subtypes:
1) Non-muscle invasive: encompasses in-situ and localized disease➡️5-yr OS >70%
2) Muscle invasive: encompasses regional or metastatic disease➡️5-yr OS dismal especially for metastatic disease 😔
1) Non-muscle invasive: encompasses in-situ and localized disease➡️5-yr OS >70%
2) Muscle invasive: encompasses regional or metastatic disease➡️5-yr OS dismal especially for metastatic disease 😔
Cisplatin=SOC
50% of pts w are ineligible due to older age👵🏻, poor PS, ⬇️ renal function, ⬇️hearing, neuropathy, heart failure 🫀& other comorbities that ⬆️ risk of ⚠️
Carboplatin yields inferior responses➡️NOT 🙅🏻♀️ an equal alternative due to ⬇️ OS😢➡️pt left w/minimal tx options
50% of pts w are ineligible due to older age👵🏻, poor PS, ⬇️ renal function, ⬇️hearing, neuropathy, heart failure 🫀& other comorbities that ⬆️ risk of ⚠️
Carboplatin yields inferior responses➡️NOT 🙅🏻♀️ an equal alternative due to ⬇️ OS😢➡️pt left w/minimal tx options
(1/10) 71 yo F with HTN and ESRD on HD presents to the ED w/ fever 🌡 + back pain, 🧫 BCx + Clostridium septicum. Which test should be considered? 🧐
(2/10) Clostridium septicum [motile, gram +, anaerobic, spore-forming rod] is rare in the GI tract. In colorectal tumor: anaerobic glycolysis = acidic and hypoxic environment ↑ C. septicum spore germination + tumors break down mucosal barrier and ↑ C. septicum blood entry
(3/10) Infxn mortality rates are high (60-79%)
Early diagnosis🩸and aggressive treatment💊of C. septicum are essential.
Colonoscopy is recommended to evaluate for malignancy. What is another gram + organism associated with colon CA?
pubmed.ncbi.nlm.nih.gov/11736823/
Early diagnosis🩸and aggressive treatment💊of C. septicum are essential.
Colonoscopy is recommended to evaluate for malignancy. What is another gram + organism associated with colon CA?
pubmed.ncbi.nlm.nih.gov/11736823/
Urine Trouble: A review of Immune checkpoint inhibitor associated nephritis
See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm
See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm
Immune checkpoint inhibitors (ICI) ➡️revolutionized tx 💊 of various malignancies
✅Treatment that offers some pts🙋🏻♀️a chance of cure🤯
Also see a range of unique toxicities⚠️➡️autoimmune in nature
An emerging one of which is nephritis! (Insert a needed kidney emoji)
✅Treatment that offers some pts🙋🏻♀️a chance of cure🤯
Also see a range of unique toxicities⚠️➡️autoimmune in nature
An emerging one of which is nephritis! (Insert a needed kidney emoji)
Pathogenesis of ICI-nephritis is unknown
Some hypothesis exist 🧐
✅stopping the breaks on the immune system results in excessive immune activation➡️ATIN
✅Previous renal insult or concurrent medications that lead to ATIN can accelerate the emergence of renal injury ☢️
Some hypothesis exist 🧐
✅stopping the breaks on the immune system results in excessive immune activation➡️ATIN
✅Previous renal insult or concurrent medications that lead to ATIN can accelerate the emergence of renal injury ☢️
In honor of Black History Month, I want to take some time and research black pioneers in pharmacy/pharmaceutical sciences. Follow this 🧵to see what I learn. #TwitteRx #PharmacyBHM #BlackPharmacists #BlackinPharmacy #BHM
Day 1/28: Anna Louise James was born January 19, 1886, to Anna Houston and Willis Samuel James. Her father was enslaved on a Virginia plantation until he escaped at age 16 and headed north to Connecticut on the Underground Railroad. #TwitteRx #PharmacyBHM #BlackPharmacists #BHM
Day 1/28: Anna was a diligent student that sought higher education after graduating high school. This drive led her to attend Brooklyn College of Pharmacy where she was the only woman in her class. #TwitteRx #PharmacyBHM #BlackPharmacists #BlackinPharmacy #BHM
Tip for new pharmacists; learn as MUCH as you can about diagnostic procedures as some play an important role in pharmacotherapy💊
1/
Ex: Lumbar puncture➡️procedure to collect CSF➡️assess for CNS🧠diseases (i.e meningitis, CNS leukemia)
‼️imperative to ✅ for timing ⏰ of LP
1/
Ex: Lumbar puncture➡️procedure to collect CSF➡️assess for CNS🧠diseases (i.e meningitis, CNS leukemia)
‼️imperative to ✅ for timing ⏰ of LP
B/c anticoagulants/antiplatelets must be discontinued🛑prior to an LP or else there is a risk of spinal hematoma🤯or intracranial hemorrhages🩸
🛑Apixaban/Riva 24-48 hrs before
🛑LMWH PPX 12 hrs and Tx dose 24 hours before
🛑Dabigatran 48 hrs before
🛑Warfarin until INR<1.4
🛑Apixaban/Riva 24-48 hrs before
🛑LMWH PPX 12 hrs and Tx dose 24 hours before
🛑Dabigatran 48 hrs before
🛑Warfarin until INR<1.4
Recommendations and infographic from in this awesome article below 👇🏻👇🏻
#oncopharm #pharmICU #TwitteRx #meded #MedTwitter
pn.bmj.com/content/practn…
#oncopharm #pharmICU #TwitteRx #meded #MedTwitter
pn.bmj.com/content/practn…
Pro-tip for #oncopharm heme 🩸💉 rounds💡
How to easily remember🧠 mutations that lead to secondary heme🩸malignancies (primarily MDS) from chemo💊?🤔
Use the numbers 🔢 in the mutation abnormalities to inform you of the agent 💊and time ⏰to onset!
See 👀 below 👇🏻👇🏻
How to easily remember🧠 mutations that lead to secondary heme🩸malignancies (primarily MDS) from chemo💊?🤔
Use the numbers 🔢 in the mutation abnormalities to inform you of the agent 💊and time ⏰to onset!
See 👀 below 👇🏻👇🏻
Alkylating agents〽️ (ex: platinums, cyclophosphamide)lead to ➡️mutations in chromosomes 5 and 7➡️median ⏰ to onset is 5-7 (‼️) years after exposure💢
Topoisomerase inhibitors🚫 (ex: etoposide) lead to➡️mutations in chromosome 11q23➡️ occurs 2-3 years (‼️) post-exposure💢
Topoisomerase inhibitors🚫 (ex: etoposide) lead to➡️mutations in chromosome 11q23➡️ occurs 2-3 years (‼️) post-exposure💢
#OTILT #IDtwitter #oncopharm
What factors do you have to consider while treating a cancer pt with a malignant pleural effusion and concurrent infection? 🤔
1/
🚨Cancer pts are at risk for MPE➡️consequence of metastatic involvement of the primary tumor in the pleura💨
What factors do you have to consider while treating a cancer pt with a malignant pleural effusion and concurrent infection? 🤔
1/
🚨Cancer pts are at risk for MPE➡️consequence of metastatic involvement of the primary tumor in the pleura💨
💡Lung, breast, and lymphoma are the most common causes💡
Query of the pleural fluid with the use of the Lights criteria will help to determine the etiology (transudative or exudative)
Exudative=malignant OR infection
One of the criteria is a serum protein ratio >0.5
Query of the pleural fluid with the use of the Lights criteria will help to determine the etiology (transudative or exudative)
Exudative=malignant OR infection
One of the criteria is a serum protein ratio >0.5
Since both MPE & infectious effusions🦠contain↗️↗️protein
🛑Avoid highly protein bound abx (Ex: daptomycin, ceftriaxone, ertapenem)➡️can get sequestered in the pleural fluid& have↘️systemic distribution & ↘️the ability to treat a bacteremia if present 😳🤯
🛑Avoid highly protein bound abx (Ex: daptomycin, ceftriaxone, ertapenem)➡️can get sequestered in the pleural fluid& have↘️systemic distribution & ↘️the ability to treat a bacteremia if present 😳🤯
Abiraterone 💊 is an oral antiandrogen approved for metastatic hormone sensitive and castrate resistant prostate cancer
Why does abieraterone have to be coadministered with prednisone? 🤔 What if a patient wishes to avoid steroid therapy? 🤯
#oncopharm #pharmpearl
Why does abieraterone have to be coadministered with prednisone? 🤔 What if a patient wishes to avoid steroid therapy? 🤯
#oncopharm #pharmpearl
Abiraterone is a CYP17 inhibitor that suppresses downstream non-gonadal androgen synthesis
As a consequence➡️ reflex↗️↗️ ACTH production leads to excess in mineralocorticoids
Early trials WITHOUT pred▶️pts developed severe hypertension, hypokalemia and edema 2/2 ↗️ aldosterone
As a consequence➡️ reflex↗️↗️ ACTH production leads to excess in mineralocorticoids
Early trials WITHOUT pred▶️pts developed severe hypertension, hypokalemia and edema 2/2 ↗️ aldosterone
To suppress the reflex activation of the HPA axis & diminish symptoms of mineralocorticoid excess▶️coadministration with prednisone is required
If a pt is reluctant to taking long term pred▶️try Epleronone ✅ Mineralocorticoid receptor antagonist- blocks🛑 aldosterone!
If a pt is reluctant to taking long term pred▶️try Epleronone ✅ Mineralocorticoid receptor antagonist- blocks🛑 aldosterone!
Belantamab mafodotin approved!
#mmsm #oncopharm
@SagarLonialMD
PI @ bit.ly/39YwDI6.
Clin pharm: BCMA directed ADC with MMAF maytansinoid payload (less neurotox vs MMAE)
Dose=2.5 mg/kg over 30 mins Q3 wk with art. tears QID throughout rx (avoid contact lenses)
1/
#mmsm #oncopharm
@SagarLonialMD
PI @ bit.ly/39YwDI6.
Clin pharm: BCMA directed ADC with MMAF maytansinoid payload (less neurotox vs MMAE)
Dose=2.5 mg/kg over 30 mins Q3 wk with art. tears QID throughout rx (avoid contact lenses)
1/
REMS for ocular AEs (blurred vision - sx in 22%, Gr 3/4 in 4%, other exam findings).
No exposure-response relationship (thus dose = 2.5 rather than 3.4).
Positive exposure-tox relationship (e.g., corneal AEs)
2/
No exposure-response relationship (thus dose = 2.5 rather than 3.4).
Positive exposure-tox relationship (e.g., corneal AEs)
2/
PK: Accumulation = 70%
Slight reduction in CL over time
t1/2 @ SS = 14 days
No diff in PK on age (34-89), weight (42-130 kg), renal (30-89 mL/min).
Unknown re: < 30 mL/min - hard for me to see how CL of a MoAb and a hepatically cleared MMAF would be substantially diff
3/
Slight reduction in CL over time
t1/2 @ SS = 14 days
No diff in PK on age (34-89), weight (42-130 kg), renal (30-89 mL/min).
Unknown re: < 30 mL/min - hard for me to see how CL of a MoAb and a hepatically cleared MMAF would be substantially diff
3/
Ever wonder how the BCG (Bacillus Calmette–Guérin) vaccine works against bladder cancer?🤔
BCG vaccine➡️approved for the tx of bladder cancer in 1990⌛️
✅Main intravesical agent shown to⬇️risk of progression of non-muscle invasive to muscle-invasive disease (>platinum chemo!)🤯
BCG vaccine➡️approved for the tx of bladder cancer in 1990⌛️
✅Main intravesical agent shown to⬇️risk of progression of non-muscle invasive to muscle-invasive disease (>platinum chemo!)🤯
So, how does a vaccine for MYCOBACTERIUM work for bladder cancer!?🤨(dont worry, I was making the same confused face you are! Let me explain it to you!)
BCG=attenuated live strain of Mycobacterium🦠 bovis (which interestingly is related to the bacteria that causes tuberculosis)
BCG=attenuated live strain of Mycobacterium🦠 bovis (which interestingly is related to the bacteria that causes tuberculosis)
It is administered by DIRECT instillation into the bladder and the mycobacterium outer membrane binds to a substance (Fibronectin) that is ALSO found within the urothelium.
Why do some pts with renal cell carcinoma present w/ polycythemia🩸vs others w/anemia🤔?
1/ Erythropoietin (EPO)➡️glycoprotein that induces differentiation of erythrocytes in the bone marrow to promote RBC production➡️produced in the KIDNEY
1/ Erythropoietin (EPO)➡️glycoprotein that induces differentiation of erythrocytes in the bone marrow to promote RBC production➡️produced in the KIDNEY
In RCC➡️EPO is produced ectopically by RCC tumor cells causing abnormalities in RBC production
🧐In fact‼️ ectopic EPO occurs in 66% of RCC pts!
Despite high concentrations of EPO➡️Anemia (⬇️RBC) is common due to poor nutrition🍎, hematuria🩸 or ineffective erythropoiesis🛑
🧐In fact‼️ ectopic EPO occurs in 66% of RCC pts!
Despite high concentrations of EPO➡️Anemia (⬇️RBC) is common due to poor nutrition🍎, hematuria🩸 or ineffective erythropoiesis🛑
Polycythemia➡️less common in 1-5% of pts, most common in clear cell RCC is due to paraneoplastic production of EPO results in excess RBC and reduction in inhibitory proteins that haunt RBC production!
pubmed.ncbi.nlm.nih.gov/2297568/
#oncopharm
#twitterx #OTILT #renalcellcarinoma #rcc
pubmed.ncbi.nlm.nih.gov/2297568/
#oncopharm
#twitterx #OTILT #renalcellcarinoma #rcc
Starting MICU with @HeavnerPharmD this month🥳! Month long series of #OLWLT (1 thing WE learned today😊)
Posterior Reversible Encephalopathy Syndrome(PRES)➡️serious🧠condition characterized by
🩺Hypertension 🤯headache ⚡️seizures & 👀 loss
TACROLIMOUS▶️immunosuppressant
1/
Posterior Reversible Encephalopathy Syndrome(PRES)➡️serious🧠condition characterized by
🩺Hypertension 🤯headache ⚡️seizures & 👀 loss
TACROLIMOUS▶️immunosuppressant
1/
used for GVHD prophylaxis in HSCT⤴️neurotoxicity&⤴️HTN perpetuating the risk of PRES🤯
During an episode of GVHD➡️ tac levels are often ⤴️ to prevent worsening GVHD BUT➡️⤴️inflammation⤴️tac🧠 penetration & risk of PRES😟
🛑Tac can lead to PRES even if levels are THERAPEUTIC🛑
During an episode of GVHD➡️ tac levels are often ⤴️ to prevent worsening GVHD BUT➡️⤴️inflammation⤴️tac🧠 penetration & risk of PRES😟
🛑Tac can lead to PRES even if levels are THERAPEUTIC🛑
Management is complex⚠️
🎯 is to balance risk of GVHD Vd worsening PRES
✅seizures➡️benzos
✅HTN▶️rapidly titratable anti-hypertensives
May PRES-ur luck by🔄 to cyclosporine➡️but risk for PRES still exists😬
Sirolimous/MMF➡️↘️risk of PRES, but efficacy 4️⃣ GVHD is questionable🧐
🎯 is to balance risk of GVHD Vd worsening PRES
✅seizures➡️benzos
✅HTN▶️rapidly titratable anti-hypertensives
May PRES-ur luck by🔄 to cyclosporine➡️but risk for PRES still exists😬
Sirolimous/MMF➡️↘️risk of PRES, but efficacy 4️⃣ GVHD is questionable🧐
🚨Alot of🗣about COVID-19🚨
Great commentary by @OncLive about⤴️risk in pts with cancer or immunodef.
⚠️Nationwide🌏analysis of 1590 pts w/laboratory-conf COVID-19
Pts w/cancer➡️⤴️ risk ICU admission requiring invasive ventilation,or death (39% vs 18% P = 0003)
👇🏻
Great commentary by @OncLive about⤴️risk in pts with cancer or immunodef.
⚠️Nationwide🌏analysis of 1590 pts w/laboratory-conf COVID-19
Pts w/cancer➡️⤴️ risk ICU admission requiring invasive ventilation,or death (39% vs 18% P = 0003)
👇🏻
Pts w/cancer “deteriorated more rapidly” ⛔️(HR, 3.56; 95% CI, 1.65-7.69; P < .0001)⛔️
Pts w. chemo or surgery with 𝟭 month📆⤴️ risk of severe events(75% vs 43%)
Even if a vaccine is made, pts w/immunodef do not produce enough antibodies 4 protection🤯
Pts w. chemo or surgery with 𝟭 month📆⤴️ risk of severe events(75% vs 43%)
Even if a vaccine is made, pts w/immunodef do not produce enough antibodies 4 protection🤯
So what do we do🧐
✅Encourage 🙌🏻 hygiene
✅Cover 🤧 and sneezes
✅Stay HOME 🏡 if not feeling well 🤒
✅Remain vigilant about monitoring for infection (may not mount same signs of symptoms due to low WBC!)
#oncopharm #COVID19
onclive.com/web-exclusives…
✅Encourage 🙌🏻 hygiene
✅Cover 🤧 and sneezes
✅Stay HOME 🏡 if not feeling well 🤒
✅Remain vigilant about monitoring for infection (may not mount same signs of symptoms due to low WBC!)
#oncopharm #COVID19
onclive.com/web-exclusives…
AMAZING blog on the important role ED providers play in recognizing the nuances that go into the managing AF in patients on ibrutinib! 👏🏻 Awesome job @iEMPharmD
One of my FAVORITE #cardioonc topics!
Summary of the 🔑 considerations 👇🏻
One of my FAVORITE #cardioonc topics!
Summary of the 🔑 considerations 👇🏻
Clinical conundrum: ibrutinib interferes with each pillar of AF management
Risk scoring tools (CHADS2VASC OR HASBLED) NOT validated in cancer patients‼️
Ibrutinib: Inhibitor 🆇 of PGP & substrate of CYP3A4➡️DDI💊
Ibrutinib ⤴️bleeding risk ALONE & only further in pts on AC
Risk scoring tools (CHADS2VASC OR HASBLED) NOT validated in cancer patients‼️
Ibrutinib: Inhibitor 🆇 of PGP & substrate of CYP3A4➡️DDI💊
Ibrutinib ⤴️bleeding risk ALONE & only further in pts on AC
Overall, difficult clinical conundrum, how do we maintain the therapeutic benefit of ibrutinib while ⤵️toxicities⚠️?
As Craig mentioned,🆕BTK inhibitors may ⬇️ risk, BUT data w/acalabrutinib still shows signals of AF risk&bleeding is on-target BTK effect so risk remains
As Craig mentioned,🆕BTK inhibitors may ⬇️ risk, BUT data w/acalabrutinib still shows signals of AF risk&bleeding is on-target BTK effect so risk remains
OTILT: Pain&Palliative Care
We talk a lot of opioid rotation, ever consider steroid rotation?🤔
Dexamethasone▶️widely used for bone pain, cerebral edema, & N/V
However➡️Dex⤴️hiccups➡️ anorexia,depression&insomnia
🛑D/Cing Dex works BUT subjects pts to⤴️N/V/pain 😕
Read on👇🏻
We talk a lot of opioid rotation, ever consider steroid rotation?🤔
Dexamethasone▶️widely used for bone pain, cerebral edema, & N/V
However➡️Dex⤴️hiccups➡️ anorexia,depression&insomnia
🛑D/Cing Dex works BUT subjects pts to⤴️N/V/pain 😕
Read on👇🏻
Switching to methylprednisolone has the potential to ⤵️ hiccup frequency & intensity WITHOUT compromising efficacy when used for N/V!
Just remember conversions!
Switch 🔁 Dex to methylprednisone the conversion;
🔑 0.75 mg dexamethasone=4 mg methylprednisolone✅
#oncopharm
Just remember conversions!
Switch 🔁 Dex to methylprednisone the conversion;
🔑 0.75 mg dexamethasone=4 mg methylprednisolone✅
#oncopharm
Here goes it! 🎙
Okay for all those non-oncology experts walking into this situation, let’s take a few steps back 🦶 and give a background on ibrutinib 👩🏫📜
Okay for all those non-oncology experts walking into this situation, let’s take a few steps back 🦶 and give a background on ibrutinib 👩🏫📜
Ibrutinib (Ibruvica®️) is a first in class ORAL 💊 Bruton tyrosine kinase (BTK) inhibitor,
Used for the treatment of a variety of B-cell lymphomas and Waldenstrom macroglobulinemia 🧬
Used for the treatment of a variety of B-cell lymphomas and Waldenstrom macroglobulinemia 🧬
Ibrutinub was a paradigm shift in the management of patients with CLL as initial or relapsed refractory cases
✅improved progression-free survival, ✅overall response rates, and ✅ overall survival
This was compared w/ ofatumumab (AKA rituximabs cousin) & ⚠️ chlorambucil ⚠️
✅improved progression-free survival, ✅overall response rates, and ✅ overall survival
This was compared w/ ofatumumab (AKA rituximabs cousin) & ⚠️ chlorambucil ⚠️
PART 3! If you’re not sold on moderately intensive chemo, outcomes with HMA +/- ven also rival outcomes with CPX-351 in sAML. One could argue the control group in the CPX-351 paper should have been hypomethylating agent-based regimens!
CR/CRi rates with 10-d decitabine are consistently >50%, irrespective of sAML, age, and cytogenetics. Median OS in Blum, PNAS 2010 ~13 months. pnas.org/content/107/16…
Whether venetoclax adds anything to this remains to be seen. In the phase I/II study of HMA+ven, CR/CRi in elderly sAML was 67%, median OS NR. Wait for the phase III before you make any conclusions #oncstewardship #anothertweetorial? ncbi.nlm.nih.gov/pubmed/30361262
