Clinical pharmacy services-Thao's presentation

1. Clinical Pharmacy Practice
Thao K. Huynh, PharmD, BCOP
Assistant Professor
Department of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy
Email: t.huynh@pitt.edu

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

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

4. 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)

5. Clinical Oncology Specialist Practice:
Administration
• Chemotherapy protocol
development

6. Clinical Oncology Specialist Practice:
Administration
• Medication error reporting
• Chemotherapy hospital committees (Pegfilgrastim Use – Medication
Use Evaluation and Order Form)
• Procedure development

7. 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

8. Clinical Resources for
Oncology Pharmacy

9. 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

10. Patient Case Discussion
Chief 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.

11. 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

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

13. 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

14. Patient Case Discussion
BUN 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 (%)

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

16. 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 disease
ABDOMEN:
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.

17. 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

18. 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 BID
B. Warfarin 5 mg PO daily
C. Docusate 100 mg PO daily

19. 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

20. 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

21. Patient Case Discussion: Day 7
BUN 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 BPM
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 (%)

22. Patient Case Discussion: Recommendations?
Monitoring?
• Recommendations
• Insulin
• Glimiperide
• Amlodipine 10 mg po daily
• Monitoring
• Glucose
• Blood pressure
• Nausea vomiting
• Creatinine

23. Clinical Pharmacy Practice
Thao K. Huynh, PharmD, BCOP
Assistant Professor
Department of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy
Email: t.huynh@pitt.edu