Transcript Medical Presentation Templates_Sidra

Clinical Pharmacist in Oncology care…
a practical outlook
Dr Sidrah Andleeb
Senior Clinical Pharmacist
(Pharm-D, M.Phil. Part-1)
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case # 1
A 53 yrs old male presented in the ER with complain of oliguria.
Click
edit was
Master
title
style case of bladder
Serumto
potassium
5.3. Patient
is a diagnosed
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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Now…
Click to edit Master title style
Lets do the clinical evaluation of the case….
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Cont… case#1
He was previously diagnosed with type II DM for which he was
Click
to Metformin
edit Master
style 30mg OD.
receiving
850mg tid title
and pioglitazone
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.
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Now

Who evaluates drop in CrCl and correlate with the prescription
Click
to edit Master title style
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???
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Click to edit Master title style
The Clinical Pharmacist…
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Oncology care…
A multi-disciplinary area of medicine
Involves:
Chemotherapy
Click
to edit Master title style


Pain management

Emesis control

Infection & paraneoplastic diseases

Palliative care

Patient counseling at its highest level

Continuing education

Research
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Chemotherapy
What chemotherapy to give
e.g:
Click
to edit Master title style
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…
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case#2
A patient “X” with colorectal cancer, given Folinic acid + 5-Fu 3
Click
edit doses
Master
styledoes not respond
cyclesto
in accurate
over thetitle
right duration
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…
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Cont..Case#2
Patient is being administered chemo in the sequence as follows:
Click
to over
edit
Master title style
1.
F-fu
20 minutes
2.
Folinic acid as bolus
Note:
Folinic acid: brings the cell in the proliferative phase.
5-Fu: cell cycle specific anti-metabolite.
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Pain management
Its not only
Click
edit
Master
title style
 Theto
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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Pain management
Its also about
Click
to edit
Master
title
style an opioid to a 5
 Making
a risk/benefit
analysis
for prescribing
yr old suffering pain associated with tumour progression
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case#3
A lymphoma patient “Y” received high dose (8g/m2) of
methotrexate 2 days ago. The current serum level of MTX is
Click
toinedit
style bicarbonate
2.8ng/ml
spite ofMaster
completion title
of the continuous
hydration. The patient’s current prescription is as follows:

Paracetamol tablet(500mg) 1000mf QID

Ibuprufen tablet 400mg BID

Metoclopramide tablet 10mg TID
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Cont..case#3
Click to edit Master title style
Who should be involved in evaluating the current problem??
Shaukat Khanum Memorial Cancer Hospital and Research Centre
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)
Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Emesis
Pro-actively:
Click
to edit
title style
 Which
one to Master
choose?

How to choose?
Reactively:
How to monitor
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case # 4
Patient “Z” has been admitted with severe vomitting and Irinotecan induced
diarrhoea. His current prescription is
Click
to
edit
Master
title
style
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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case # 4
Click to edit Master title style
Can you identify the problem?
Shaukat Khanum Memorial Cancer Hospital and Research Centre
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
Click
to edit Master title style
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.
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Case # 5
Infection
Can the clinical pharmacist be of any help here?
Click
to edit Master title style
?
?
?
YES
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Cont...Case # 5
The on duty pharmacist suspected the fever episode as drug
Click
to edit
Master
title
style
(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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Patient Counseling

E.g ALL maintenance therapy includes
Click
to
edit Master title style
 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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Palliative care
Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
What we have learnt at SKMCH&RC…
Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Remember…

You are important
Because your profession is important
Click to edit Master title style

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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
How?
You cannot cover all clinical needs of your area/ward etc,
so you will start on few e.g.
You will choose 10 patients on your ward whose
Click prescriptions
to edit Master
style
you evaluatetitle
for dosage,
frequency, route,
interactions and metabolic profile.
1.
2.
3.
Evaluate your own competency shortcomings while
evaluating those prescriptions and improve on them
Never negate the physician’s decision unless you have
authentic evidence
.
Do not expect the physicians to salute you every time you
make an intervention
.
Counseling is rewarding
4
5
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Train yourselves as:

Proactive health-care member
Click
to edit
Master
title style
 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
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Remember
ClickIfto
edit
title style
we can
makeMaster
it there,
Then we can make it here
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Since..
Click
tohave
edit
Master
You don’t
to wait
for the 4 th oftitle
Octoberstyle
to make a difference.
If you are young, and passionate and honest and competent,
You make a difference everyday!
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Thanks!
Click to edit Master title style
QUESTIONS &
SUGGESTIONS
ARE WELCOME!
Shaukat Khanum Memorial Cancer Hospital and Research Centre