Clinical Pharmacy Practice

Thao K. Huynh, PharmD, BCOPAssistant Professor

Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of Pharmacy

Email: t.huynh@pitt.edu

Clinical Oncology Specialist Practice: Clinical• Clinical rounds with the medical team (~1-4 hours)

Clinical Oncology Specialist Practice: Clinical• Patient counseling on chemotherapy • Discharge counseling • Neutropenic precautions • Adverse effect management

Clinical Oncology Specialist Practice: Clinical• Supportive care for chemotherapy recommendations• Chemotherapy order review• Indication (ex. Metastatic breast cancer HER2/neu-positive, ER/PR-negative)• Lab values • Dosing • Premedications (hypersensitivity reactions, nausea and vomiting, other

indications)

Clinical Oncology Specialist Practice: Administration• Chemotherapy protocol

development

Clinical Oncology Specialist Practice: Administration• Medication error reporting • Chemotherapy hospital committees (Pegfilgrastim Use – Medication

Use Evaluation and Order Form)• Procedure development

Clinical Oncology Specialist Practice: Teaching• Formal• Pharmacy students at School of Pharmacy • Medical students at School of Medicine

• Informal • Pharmacy student precepting • Pharmacy resident precepting • Medication resident education• Oncology medical fellow education• Nursing education • Pharmacist education

Clinical Resources for Oncology Pharmacy

References• Organizations• Hematology/Oncology Pharmacy Association (www.hoparx.org)

• Reference handbooks• Drug information handbook for oncology

• Online references• ASCO guidelines (http://jco.ascopubs.org/site/misc/specialarticles.xhtml) • NCCN guidelines (www.nccn.org) • Global RPh (http://www.globalrph.com/oncology_dilution.htm)• Drug calculators (http://www.globalrph.com/medcalcs.htm)

• Pharmacy Meetings

Patient Case DiscussionChief complaint• RG is a 41 year old female who was found down upstairs in her home and brought to

the emergency department by her son.

History of present illness• The patient has a history of malaise for the past 2 weeks, 15 pound weight loss over 2

months, new onset shortness of breath for the past week. Patient also reported “tremor-like” activity.

• The decision was made to obtain a head and chest CT along with routine lab work.

While waiting for the results of the scans and labs, you are the student pharmacist who interviews RG.

Patient Case Discussion• Past medical history

• Lung cancer (previously treated with carboplatin and paclitaxel) 4 years ago• Diabetes type 2 since 2014• Deep vein thrombosis 1 month ago

• Social history• Lives at home with husband, 2 kids, mother in law• Works part time as a teacher

• Family history• Father: deceased, lung cancer• Mother: deceased, heart disease • Brother: high blood pressure

Patient Case Discussion• Home medications• Metformin 1,000 mg PO BID• Warfarin 5 mg PO daily• Docusate 100 mg PO daily

Patient Case Discussion• Vital Signs• Ht 163 cm• Wt 81 kg• BSA: 1.92 m2

• http://www.globalrph.com/medcalcs.htm• HR 71 | RR 16 | T 37.4°C• BP 114/68 mm Hg

Patient Case DiscussionBUN 14 (7-15 mEq/L)Cr 1.5 (0.5-1.17 mg/dL)Albumin 4.2 (3.4-5.0 g/dL)Total protein 6.8 (6.7-8.2 g/dL)Total bilirubin 0.7 (0.1-1.0 mg/dL)AST 18 (14-37 U/L)ALT 26 (12-67 U/L)ALK Phos 91 (39-119 U/L)

INR 2.4

WBC 7.3 (3.8-10.6 K/uL)RBC 3.98 (3.90-5.00 M/uL)Hgb 13.1 (12-14.8 g/dL)Hct 41.2 (35-43%)MCV 91.1 (80.0-94.0 fL)MCH 29.1 (27.0-33.0 pg)MCHC 35.1 (30.0-37.0 g/dL)RDW 13.7 (11.5-14.5%)MPV 8.6 (6.8-10.4 fL)Platelets 218 (156-369 K/uL)Bands 1 (%) Segs 45 (%)

Patient Case Discussion: CT HeadNumerous parenchymal lesions in the bilateral cerebral hemispheres measuring up to 2.1 cm likely represent metastatic disease.

Patient Case Discussion: CT Chest, Abdomen, Pelvis

CHEST:1. 4 cm right apical lung mass highly suspicious for primary bronchogenic carcinoma. 2. Enlarged right paratracheal, right hilar and subcarinal lymph nodes, suspicious for metastatic diseaseABDOMEN:1. 2.7 cm irregular right adrenal nodule is highly suspicious for metastatic disease.2. No definite liver metastases. PELVIS:1. No metastases in the pelvis.

Patient Case Discussion: Diagnosis•Relapsed non-small cell lung cancer with

adenocarcinoma • Since the patient had a good response to carboplatin

and paclitaxel 4 years ago, the oncologist would like to give carboplatin, paclitaxel, and bevacizumab

Patient Case Discussion: Medication Question• Which medication needs to be stopped at this time from the patient’s

home medications?A. Metformin 1,000 mg PO BIDB. Warfarin 5 mg PO dailyC. Docusate 100 mg PO daily

What dose should this patient receive?• www.nccn.org (for guidelines)• Carboplatin AUC 6 = 456 mg• http://www.globalrph.com/medcalcs.htm

• Paclitaxel 200 mg/m2 = 384 mg• Bevacizumab 15 mg/kg = 1,215 mg

Reminder:Wt 81 kg

BSA 1.92 m2

What antiemetic premedications should this patient receive?• www.nccn.org• Day 1• Ondansetron 16 mg PO• Dexamethasone 12mg po

• Day 2• Dexamethasone 8 mg

• Day 3 • Dexamethasone 8 mg

Patient Case Discussion: Day 7BUN 14 (7-15 mEq/L)Cr 1.7 (0.5-1.17 mg/dL)Glucose 198 g/dL (70-100 g/dL)Albumin 4.2 (3.4-5.0 g/dL)Total protein 6.8 (6.7-8.2 g/dL)Total bilirubin 0.7 (0.1-1.0 mg/dL)AST 18 (14-37 U/L)ALT 26 (12-67 U/L)ALK Phos 91 (39-119 U/L)

INR 2.4

BP: 178/110 mm Hg

HR 105 BPMWBC 7.3 (3.8-10.6 K/uL)RBC 3.98 (3.90-5.00 M/uL)Hgb 13.1 (12-14.8 g/dL)Hct 41.2 (35-43%)MCV 91.1 (80.0-94.0 fL)MCH 29.1 (27.0-33.0 pg)MCHC 35.1 (30.0-37.0 g/dL)RDW 13.7 (11.5-14.5%)MPV 8.6 (6.8-10.4 fL)Platelets 218 (156-369 K/uL)Bands 1 (%) Segs 45 (%)

Patient Case Discussion: Recommendations? Monitoring?• Recommendations• Insulin • Glimiperide • Amlodipine 10 mg po daily

• Monitoring• Glucose• Blood pressure• Nausea vomiting • Creatinine

Clinical Pharmacy Practice

Thao K. Huynh, PharmD, BCOPAssistant Professor

Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of Pharmacy

Email: t.huynh@pitt.edu