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Discontinuation of Allopurinol for Tumor Lysis Syndrome Report
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Pembrolizumab Dose Conversion Adoption and Immune-Mediated Adverse Events
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.