Shaukat Khanum Memorial Cancer Hospital and Research Centre Dr Sidrah Andleeb Senior Clinical...

Shaukat Khanum Memorial Cancer Hospital and Research Centre

Dr Sidrah AndleebSenior Clinical Pharmacist

(Pharm-D, M.Phil. Part-1)

Clinical Pharmacist in Oncology care…a practical outlook

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Case # 1

A 53 yrs old male presented in the ER with complain of oliguria.

Serum potassium was 5.3. Patient is a diagnosed case of bladder

cancer and received Cycle 2 of Cisplatin 70mg/m2. Patient was admitted and was declared as Cisplat induced renal toxicity case.

FeNa was 6.3 which identified ATN, patient is being kept on

dialysis and his further chemotherapy is on hold



Now…

Lets do the clinical evaluation of the case….



Cont… case#1

He was previously diagnosed with type II DM for which he was

receiving Metformin 850mg tid and pioglitazone 30mg OD.

Before start of 1st cycle of cisplatin his CrCl was 123ml/min.

When he came for the next cycle his calculated Crcl was

65ml/min.Literature says you do not need to adjust cisplatin dose

at 65ml/min. The next time he reported to the ER with SCr of 7.3.



Now

Who evaluates drop in CrCl and correlate with the prescription

drug?

Who evaluates the prescription drugs of the patient for

possible interactions with Cisplatin?

Who identifies the patient as a high risk candidate for

development of renal adverse effects pro-actively rather than

reactively as happened in this case???



The Clinical Pharmacist…



Oncology care…

A multi-disciplinary area of medicine

Involves: Chemotherapy

Pain management

Emesis control

Infection & paraneoplastic diseases

Palliative care

Patient counseling at its highest level

Continuing education

Research



Chemotherapy

What chemotherapy to give

e.g:

Documented efficacy of chemo regimen and the type of cancer

Regimen toxicity VS age

Curative or palliative intent

Regimen doses according to the mode of anticancer therapy

Also

When to give…



Case#2

A patient “X” with colorectal cancer, given Folinic acid + 5-Fu 3

cycles in accurate doses over the right duration does not respond

to therapy as expected. The consultants, physicians, are at loss to

explain the reasons. The pharmacist looks at the nursing

administration chart and identifies the problem…



Cont..Case#2

Patient is being administered chemo in the sequence as follows:

1. F-fu over 20 minutes

2. Folinic acid as bolus

Note:

Folinic acid: brings the cell in the proliferative phase.

5-Fu: cell cycle specific anti-metabolite.



Pain management

Its not only

The WHO ladder of pain management

The obvious interactions between the prescribed analgesics

The choice of analgesic according to the type of pain (viceral,somatic or neuropathic)

The dose route and/or frequency of the analgesic



Its also about

Making a risk/benefit analysis for prescribing an opioid to a 5

yr old suffering pain associated with tumour progression

Pain management



Case#3

A lymphoma patient “Y” received high dose (8g/m2) of

methotrexate 2 days ago. The current serum level of MTX is

2.8ng/ml in spite of completion of the continuous bicarbonate

hydration. The patient’s current prescription is as follows:

Paracetamol tablet(500mg) 1000mf QID

Ibuprufen tablet 400mg BID

Metoclopramide tablet 10mg TID



Cont..case#3

Who should be involved in evaluating the current problem??



The one…

Who deals with the kinetics of drugs ( in this case MTX)

The one who is knowledgeable about the nature of drugs ( in this case, PCM & Ibuprufen)



Emesis

Pro-actively:

Which one to choose?

How to choose?

Reactively:

How to monitor



Case # 4

Patient “Z” has been admitted with severe vomitting and Irinotecan induced

diarrhoea. His current prescription is

Metocloprmide 20mg QID

Domperidone tablet 10mg TID

Attapulgite tablet 625mg QID

Patient’s diarrhea has not improved on the current prescription.

Cultures are negative,

CBC is not suggestive of any infection.

Physician asks you (clinical pharmacist), to intervene



Can you identify the problem?

Case # 4



Case # 5 Infection

Judicious use of antibiotics

A patient “A” admitted with severe febrile neutropenia following H-CVAD

chemotheray regimen. ANC has normalized, cultures are negative, continuous

fever has abated. Still patient suffers a fever episode once daily. His

prescription is :

Piptez inj 4500mg q6hrs Amphotericin injection 35mg OD Paracetamol 1000mg PO prn/tid Metocopramide tablet 10mg PRN/tid.

Even though labs suggest so, physician is hesitant on discontinuing the

antibiotics due to the fever of unknown origin.



Can the clinical pharmacist be of any help here?

?

?

?

YES

Case # 5 Infection



Cont...Case # 5

The on duty pharmacist suspected the fever episode as drug

(Amphotericin induced). Since the medicine was administered

daily at around 10 a.m.

Amphotericin was discontinued on the clinical pharmacist’s

suggestion, and the patient suffered no further fever episode



Patient Counseling

E.g ALL maintenance therapy includes

Oral 6-MP

Oral MTX

Oral Co-trimoxazole for PCP prophylaxis

An interaction you cannot avoid..

So what you do?

You monitor the patient and

You counsel the patient



Palliative care



What we have learnt at SKMCH&RC…



Remember…

You are important

Because your profession is important

You need to learn more

Because the drug related education of your health-care team and the patients depends on you

You need to be competent

Because an appropriate diagnosis is useless without an appropriate treatment



How?

You cannot cover all clinical needs of your area/ward etc,

so you will start on few e.g.

1. You will choose 10 patients on your ward whose prescriptions you evaluate for dosage, frequency, route, interactions and metabolic profile.

2. Evaluate your own competency shortcomings while evaluating those prescriptions and improve on them

3. Never negate the physician’s decision unless you have authentic evidence

4. Do not expect the physicians to salute you every time you make an intervention

5. Counseling is rewarding



Train yourselves as:

Proactive health-care member

Identifiers of drug therapy problem

Find rational solutions based on evidence based practice

First listen, then speak.

First learn then teach

First ponder, then speak

First command, then demand respect



Remember

If we can make it there,

Then we can make it here



Since..

You don’t have to wait for the 4th of October to make a difference.

If you are young, and passionate and honest and competent,

You make a difference everyday!



Thanks!Thanks!

QUESTIONS & QUESTIONS & SUGGESTIONS SUGGESTIONS ARE WELCOMEARE WELCOME!!

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