Use of Biosimilar Granulocyte Colony-Stimulating Factor for Mobilization in Autologous and Allogeneic Hematopoietic Stem Cell Transplantation.

The biologic medication filgrastim is approved by the Food and Drug Administration (FDA) to mobilize hematopoietic progenitor cells (HPCs) for collection by leukapheresis for autologous hematopoietic stem cell transplant (HSCT). The FDA-approved biologic tbo-filgrastim is currently used off-label for this indication in both autologous and allogeneic HSCT at the Tennessee Valley Healthcare System. The purpose of this review is to compare the efficacy of filgrastim and tbo-filgrastim for this indication. The primary outcomes were the proportion of autologous patients and allogeneic donors with a CD34+ count ≥15 × 103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization. The secondary outcome was the use of plerixafor in the autologous population. A total of 469 subjects were identified for inclusion; 367 underwent mobilization for autologous HSCT and 102 for allogeneic HSCT donation. The primary outcome was achieved in 47.5% of patients who received filgrastim compared to 50.2% who received tbo-filgrastim in the autologous population (p = 0.67). Among donors for allogeneic HSCT, there was no difference between those eligible for collection on day 4 of filgrastim or tbo-filgrastim administration (97.6% vs. 100%, p = 0.41). No significant difference was identified in the number of patients requiring plerixafor use in the autologous HSCT population. The use of the biosimilar tbo-filgrastim for mobilization in either autologous HSCT patients or allogeneic HSCT donors has comparable outcomes to that of the biotherapeutic reference product filgrastim at a reduced cost to the healthcare system.

Exercising with Veterans: How Social Interaction with a Pharmacy Student Improves Patient Care.

With the baby boomer population anticipated to explode between 2010 and 2030, it is essential that student pharmacists learn how to properly care for older patients. One way for pharmacy students to prepare for providing health care to the elderly is to partake in an Advanced Pharmacy Practice Experience (APPE) elective course in geriatrics. Pharmacy students, and health care professionals in general, have an immense amount of information available to them that is not found in a patient's chart or textbook, but can be uncovered through increased social interaction with patients, promoting the best possible care. Although these are not novel ideas, this article describes a unique experience I recently had with the veterans at the Alvin C. York Campus of the Veterans Affairs (VA) Tennessee Valley Healthcare System. While completing an APPE elective in geriatrics, I was given the opportunity to attend twice-weekly exercise classes with the veterans. When my preceptor first told me about this project, I was both excited and intrigued because I thought it would be an interesting way to interact with my patients, but I never imagined how much the relationships I formed would positively impact my ability to care for my patients.

Monitoring of Urate-Lowering Therapy Among US Veterans Following the 2012 American College of Rheumatology Guidelines for Management of Gout.

BACKGROUND: With the prevalence of and hospitalizations for gout increasing, optimizing care for patients with gout is imperative. The 2012 American College of Rheumatology gout guidelines emphasize that timely monitoring is key to achieving serum urate (SUA) goals. Few studies have examined this metric following the 2012 update, and to our knowledge, none have examined a veteran population. OBJECTIVE: To evaluate adherence to urate-lowering therapy (ULT) monitoring guidelines in a veteran population. METHODS: This is a single-center, multisite, retrospective chart review of US veterans receiving ULT for gout within the VA (Veterans Affairs) Tennessee Valley Healthcare System from January 1, 2013, to June 30, 2015. The primary end point was percentage of patients with a SUA within 6 months of initial xanthine oxidase inhibitor prescription. Secondary end points included percentage of patients with SUA <6 mg/dL and percentage of patients with uptitration following SUA above goal. RESULTS: A total of 601 patients met inclusion criteria for the study; after application of exclusion criteria, 505 were analyzed. Of these, 295 patients (58%) did not have a SUA drawn within 6 months, and 162 patients (32%) reached the end of the study period without SUA measured. Of 226 patients with SUA above goal on initial check, 64 (28%) had timely dose adjustment, whereas 143 patients (63%) had no adjustment. A total of 161 patients (32%) had a SUA at goal within the study period. CONCLUSIONS: Rates of ULT monitoring at a major VA medical center were suboptimal, and improved adherence to guideline recommendations is needed.

Pharmacist Screening for Risk of Osteoporosis in Elderly Veterans.

OBJECTIVE: To assess the effect of pharmacist screening for osteoporosis risk with increased bone mineral density (BMD) testing. DESIGN: Prospective, quasi-experiment. SETTING: Veterans Affairs medical center Community Living Centers (CLC), home-based primary care, and outpatient geriatric clinic. PARTICIPANTS: Patients with a routine pharmacist interaction were included. Exclusion criteria included hospice, dialysis, and respite care. INTERVENTIONS: Risk assessment with recommendations communicated by progress notes to consider BMD testing or interventions in the settings described. A second phase of the project was conducted in CLC patients to evaluate the effect of an interdisciplinary team with the inclusion of a physician to assess clinical appropriateness of interventions. MAIN OUTCOME MEASURE(S): Proportion of patients meeting guidelines for BMD testing and change in proportion of patients with BMD testing ordered after intervention. Secondary measures included response to recommendations and initiation of osteoporosis pharmacotherapies. RESULTS: A total of 219 patients were included in the first phase of the project, with 120 (54.8%) identified as candidates for BMD testing with recommendations documented. Of this population, 5 patients without previous dual-energy absorptiometry results had BMD testing ordered (P = 0.6). In the second phase, 22 high-risk patients in the CLC met criteria for BMD testing, with 14 determined to have reasons for not pursuing BMD testing. CONCLUSION: Most patients in the settings described met guidelines for BMD testing. Pharmacist recommendations to consider BMD testing did not increase the rate of testing. Including a physician on an interdisciplinary team appeared to help determine appropriateness and improve the rate of testing, though the increase in testing was not statistically significant.

Evaluation of osteoporosis risk assessment in veterans receiving androgen-deprivation therapy.

OBJECTIVE: To identify whether veterans receiving androgen-deprivation therapy (ADT) are screened at any time by bone mass measurement. DESIGN: Cross-sectional study. SETTING: Veterans Administration Tennessee Valley Healthcare System (VA-TVHS). PATIENTS: All male veterans who received at least one dose of goserelin or leuprolide within the fiscal years October 1, 2005, through September 30, 2009. INTERVENTIONS: Data from patients' charts were extracted for demographic information (race, age, and weight prior to the initial injection); date of initiation of therapy; the use of calcium, vitamin D, bisphosphonate, or calcitonin therapy; and documented bone-mineral density testing. MAIN OUTCOME MEASURE: To determine whether veterans receiving ADT with goserelin or leuprolide for prostate cancer were screened at any time for BMD more or less than rates as documented in previous literature. RESULTS: 22.8% of veterans were screened for BMD, which was statistically significant when compared with results found in previous literature. CONCLUSION: Although rates of BMD testing were higher at VA-TVHS compared with previous literature, this rate is still low given the well-known risk of accelerated osteoporosis associated with ADT.

Retrospective review of megestrol use for weight loss in an elderly veteran population.

OBJECTIVE: Evaluate the efficacy of megestrol acetate therapy for nonmalignancy and/or non-AIDS-related weight loss in the elderly. DESIGN: Retrospective chart review. SETTING: Inpatients or outpatients at the West Palm Beach Veterans Affairs Medical Center. PATIENTS: Two inclusion criteria were applied: patients older than 65 years and patients initiated on megestrol therapy from January 1 to December 31, 2002. All eligible patients meeting the above criteria were eligible for inclusion in the study. Patients who had a diagnosis of malignancy and/or AIDS, no baseline weight, no follow-up weights, no record of laboratory values, and/or were receiving enteral or parenteral nutrition available at the West Palm Beach Veterans Affairs Medical Center, were excluded. Patients who received megestrol therapy for less than one week also were excluded. MEASUREMENTS: Weight loss in the previous six months, baseline weight, follow-up weights at 3, 6, 9, and 12 months after megestrol initiation, baseline and follow-up albumin for 12 months after megestrol initiation, and any adverse effects from megestrol. RESULTS: Fifty-seven patients (males 56, females 1) were included. The average age was 78.5 years old. The average duration of therapy was 3.2 months, and the average starting dose of megestrol was 436 mg per day. At baseline, patients were, on average, 102% of their ideal body weight. Baseline measurement of albumin was obtained in 89% (N = 23) of patients. Six out of 23 (26%) patients had a baseline albumin less than 3 g/dL. The average baseline albumin was 3.6. Weight loss in the six months prior to megestrol initiation occurred in 63% of patients. Over the 12-month follow-up period, the percentage of patients who gained weight was 40%, lost weight was 49%, and had no change in weight was 11%. There were no differences in baseline characteristics between the patients who did or did not gain weight during the 12-month period after megestrol initiation. No documented adverse side effects were attributed to megestrol. CONCLUSION: Patients both gained and lost weight when receiving megestrol therapy. There was no difference between the patients who did or did not gain weight using objective measures of weight loss.