Implementation, utilization, and evaluation of a pharmacist-driven romiplostim dosing service for patients with immune thrombocytopenia at a multisite cancer centre.

INTRODUCTION: Romiplostim is a thrombopoietin receptor agonist approved for the treatment of patients with chronic immune thrombocytopenia who have had an insufficient response to corticosteroids, immune globulin, or splenectomy. Dose adjustments of romiplostim are based on platelet counts and follow a dosing schema that requires frequent monitoring. As a quality improvement initiative to increase clinical efficiency and promote clinical pharmacy services at our institution, we developed a collaborative practice agreement and implemented a novel pharmacist-driven romiplostim dosing protocol. METHODS: A retrospective chart review was conducted to evaluate the acceptance, utilization, and impact of the pharmacist-driven romiplostim dosing service. The primary outcome of our analysis was the adoption rate by providers of the romiplostim pharmacist dosing service. Secondary endpoints were focused on patients newly initiating romiplostim on the dosing service and included platelet responses and number of dose adjustments by a pharmacist. RESULTS: A total of 54 patients received romiplostim in our analysis: 25 patients who had already been receiving romiplostim and 29 patients who newly initiated romiplostim during the study period. Of the 29 patients newly initiating romiplostim, 27 (93%) had their dosing managed by a pharmacist Twenty-one patients (84%) and 18 patients (75%) achieved an initial and durable response with romiplostim, respectively. Pharmacists made a median of 3 dose adjustments to romiplostim per patient. CONCLUSION: The implementation of a pharmacist-driven romiplostim dosing service led to a significant adoption and utilization by physicians at our health system.

Neutropenia-Associated Outcomes in Patients With Breast Cancer Receiving Myelosuppressive Chemotherapy With Reduced Doses of Pegfilgrastim.

BACKGROUND: Pegfilgrastim can be utilized to prevent neutropenia-associated complications in patients receiving myelosuppressive chemotherapy for breast cancer. A common adverse event associated with pegfilgrastim is bone pain. Clinicians may opt to reduce the dose of pegfilgrastim when administering it to patients with previous severe or refractory bone pain. There is limited and conflicting evidence with regard to the safety and efficacy of this practice. The purpose of this study was to investigate the impact of administering reduced doses of pegfilgrastim on neutropenia-associated outcomes in patients with breast cancer receiving myelosuppressive chemotherapy. METHODS: A retrospective chart review was conducted at a large, multistate health system with several different medical oncology practice sites. The primary outcome was the incidence of febrile neutropenia. Secondary outcomes included the incidence and severity of neutropenia, hospitalization for febrile, use of intravenous antimicrobials for febrile, delays in chemotherapy or dose reductions in chemotherapy secondary to neutropenia or febrile, rationale for dose reduction of pegfilgrastim, and improvement in bone pain. RESULTS: A total of 80 patients received reduced dose pegfilgrastim. Most patients had their doses reduced secondary to bone pain (54%) or leukocytosis (14%). One (1.25%) patient experienced febrile neutropenia that did not require hospitalization or intravenous antimicrobials. Chemotherapy treatment delays and dose reductions secondary to neutropenia or febrile neutropenia occurred in 1 (1.25%) and 2 (2.5%) patients, respectively. CONCLUSION: Reduced doses of pegfilgrastim in patients receiving myelosuppressive chemotherapy for breast cancer resulted in a low incidence of neutropenia-associated events, including febrile neutropenia and grade 3/4 neutropenia.

Pegfilgrastim-Induced Bone Pain: A Review on Incidence, Risk Factors, and Evidence-Based Management.

OBJECTIVE: To review the incidence, risk factors, and management of pegfilgrastim-induced bone pain (PIBP). DATA SOURCES: PubMed was searched from 1980 to March 31, 2017, using the terms pegfilgrastim and bone pain. STUDY SELECTION AND DATA EXTRACTION: English-language, human studies and reviews assessing the incidence, risk factors, and management of PIBP were incorporated. DATA SYNTHESIS: A total of 3 randomized, prospective studies and 2 retrospective studies evaluated pharmacological management of PIBP. Naproxen compared with placebo demonstrated a reduction in the degree, incidence, and duration of bone pain secondary to pegfilgrastim. Loratadine was not effective in reducing the incidence of bone pain prophylactically, but a retrospective study evaluating dual antihistamine blockade with loratadine and famotidine demonstrated a decreased incidence in bone pain when administered before pegfilgrastim. CONCLUSION: Naproxen is effective at managing PIBP. Although commonly used, antihistamines have a paucity of data supporting their use. Dose reductions of pegfilgrastim and opioids may also be potential management options; however, data supporting these treatment modalities are scarce.