PGY2 Oncology Pharmacy Residency

Cardio-Oncologic Interventions for Cardiotoxicity Associated with Oral Chemotherapy

Karen Abboud, PharmD, BCPS; Godsfavour Umoru, PharmD; Barry Trachtenberg, MD; Veronica Ajewole, PharmD, BCOP

PURPOSE

Chemotherapy-induced cardiotoxicity has a wide variety of presentations including arrhythmia, cardiomyopathy, and myocardial infarction. The true prevalence and incidence of cardiotoxicity with oral chemotherapy medications is underreported, and data related to the management of patients who develop cardiotoxicity on these agents is limited. As oral targeted cancer treatments are expected to exponentially increase, continued investigations to determine the best monitoring and treatment strategies are crucial. The purpose of this study was to characterize the cardiooncologic interventions performed in a cohort of patients who experienced cardiotoxicity on oral chemotherapy.

METHODS

This was a retrospective, cohort study of patients admitted to the hospital system between June 2016 and July 31, 2021, who had at least one medical record order of oral chemotherapy agents considered to have cardiotoxic potential based on supporting literature or reported cases in the FDA Event Reporting System (FAERS) Pharmacovigilance Database, and had an ICD10 code for arrythmias, heart failure, cardiomyopathy, myocardial infarction, pericardial disease, and venous and/or arterial thrombosis after starting oral chemotherapy. The primary endpoint was to describe cardio-oncologic and medication-related interventions (reducing the dose, holding treatment, discontinuing treatment, or initiating cardioprotective medications). Secondary endpoints included the correlation between cardiovascular risk factors and observed incidence of cardiotoxicity and the relationship between onset of cardiotoxicity and treatment duration.

RESULTS A total of 67 patients were included. The majority (97%) had pre-existing cardiovascular disease (CVD) or a risk factor for CVD. The three most common classes of oral chemotherapy were aromatase inhibitors (36%), BCR-ABL inhibitors (16%), and VEGFR inhibitors (13%). New-onset or worsening heart failure (n=31), which occurred after a median of 148 days (IQR 43-476 days) and arrhythmias (n=30), which occurred after a median of 95.5 days (IQR 20.75-361 days), were the most common cardiotoxic events. Pharmacological treatment of the cardiotoxicity (n=44) and treatment interruption (n=18) were the most frequent interventions.

CONCLUSION

Pre-existing CVD or CV risk factors appear to predispose patients to cardiotoxicity. Real-world practice reveals that treatment is continued in most cases with temporary interruption and initiation of pharmacologic treatment. A multidisciplinary, patient-centered approach to treatment that includes temporary interruption of treatment during workup of the cardiotoxicity, discussion of risks/benefits of treatment continuation, and initiation of guideline-directed treatment is recommended until high-quality, drug-specific data for monitoring and treatment is available.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Karen Abboud, PharmD, BCPS

Karen earned her PharmD from the Lebanese American University in 2019. She completed her PGY1 residency at Houston Methodist Hospital in 2020. Following completion of her PGY2, Karen will be staying on as a pharmacy clinical specialist in oncology at Houston Methodist Hospital. Primary project preceptor: Veronica Ajewole, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and HOPA’s 18th Annual Conference 2022.

Evaluation of Extended Duration Letermovir in Hematopoietic Stem Cell Transplant Recipients

James Cox, PharmD, BCOP; Godsfavour Umoru, PharmD; Will Musick, PharmD, BCIDP; Rammurti Kamble, MD

PURPOSE

Recipients of allogeneic hematopoietic cell transplants (HSCT) are highly susceptible to post‐transplant viral infections due to delayed immune reconstitution and long-term immunosuppression. Despite the use of prophylactic therapy, cytomegalovirus (CMV) remains the most common clinically significant infection in this patient population. It is not known if the patients that receive extended duration CMV prophylaxis with letermovir have less CMV reactivation and infection compared to those who do not. This study aimed to evaluate the efficacy of letermovir prophylaxis when continued for greater than 100 days post allogeneic stem cell transplant in CMV seropositive patients.

METHODS

A single-center retrospective chart review was conducted on all allogeneic HSCT recipients from November 2017 to July 2021. Patients were eligible for inclusion if they were at least 18 years of age, received an allogeneic HSCT, CMV seropositive, and initiated letermovir between days 0-28 post-transplant. The primary endpoint of this study is to compare rates of CMV reactivation in patients that stopped letermovir prophylaxis at day 100 days post-transplant versus those who continued letermovir prophylaxis.

RESULTS

A total of 87 patients met eligibility criteria for inclusion. The median duration of letermovir was 78 days and 132 days in the standard and extended duration groups respectively. There were more CMV reactivations in the standard duration group versus the extended duration group, 28% versus 19% respectively. CMV pneumonitis was observed in one of the patients in the standard duration group. All-cause mortality at day 200 posttransplant was similar between the two groups.

CONCLUSION

Extended duration letermovir prophylaxis was associated with less CMV reactivation compared to the standard duration group.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Breanna Hinman, PharmD

Breanna earned her PharmD from the University of Houston College of Pharmacy in 2020. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital in June 2021. Following completion of her oncology PGY2, Breanna has accepted a position as a Bone Marrow Transplant pharmacist at Houston Methodist Hospital. Primary project preceptor: James Cox, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and Hematology/Oncology Pharmacy Association (HOPA) Annual Conference.