Thrombo-Embolism in Patients Receiving Erythropoeitic Stimulating Agents.

Abstract 4005 Poster Board III-941 Background There is an increased risk of thrombo-embolism in patients receiving erythropoeitic stimulating agents (ESAs) in the treatment of anemia due to cancer and chemotherapy as well as in patients with chronic renal failure. This fact coupled with evidence of the negative impact on survival in some patients with cancer has prompted a change in the FDA label and restricted the use of ESAs. The exact incidence of thrombo-embolism etiologically related to ESAs in community cancer practices is not known. In this retrospective study we examined the relationship between the administration of ESAs and thrombo-embolism in patients treated after initiating the more conservative use of such agents based on label change. Methods One-hundred fifty-eight cases of thrombo-embolism and central catheter occlusion observed between August 2007 and May 2009 were identified through the electronic medical records (EMR) database at Gabrail Cancer Center. Likewise, all patients who received ESAs during the same time period were identified through the EMR. Records of all patients were examined to verify diagnosis, confirm data, and validate timing of administration of the ESAs. Results A total of 496 patients received ESAs during the study period. Of these patients, 158 developed thrombo-embolism or central catheter occlusion. There were 128 patients with cancer and 34 had non-cancerous diagnoses with mean age of 62 and M:F of 4:1. Of the 128 patients with cancer 99 patients developed uncomplicated catheter occlusion and 39 developed DVT and/or pulmonary embolism. Seventy-four of the 99 patients who had catheter occlusion had received ESAs (74%). Of the 39 patients who developed DVT and pulmonary embolism 26 were treated with ESAs (67%). Of the 99 patients who developed catheter occlusion 51 (51%) received ESAs prior to catheter occlusion of the 39 patients who had DVT and PE 19 (48%) of the events happened after ESAs were initiated. The total number of patients who received ESAs during the same time period was 496. Only 32% of these patients developed thrombo-embolism and catheter occlusion. However, only 114 patients (23%) experienced a thrombotic episode after ESAs were initiated. This did not differ significantly from the incidence of thrombosis either in the form of catheter occlusion, deep vein thrombosis, or pulmonary embolism in this patient population. Conclusion Although some studies have shown an increased incidence of thromboembolism in cancer patients receiving ESAs, such studies were performed at a time when the use of these agents was more liberal in order to increase the Hb to normal or above normal levels. In this community-based practice study that included patients treated after the label change, the incidence was not greater than that seen in cancer patients not receiving ESAs. However, a prospective clinical trial is needed to confirm these findings especially after the label change that has restricted the use of ESAs. 3(Transmittal 80, Pub 100-03 Medicare National Coverage Decision, eff. 7/30/2007) Disclosures: No relevant conflicts of interest to declare.

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Prostate Cancer-Associated Trousseau´S Syndrome Versus Asymptomatic Isolated Muscular Calf Vein Thrombosis as the Origin of Acute Submassive Pulmonary Embolism: A Case Report and Review of the Literature

Clinical Oncology and Research ◽

10.31487/j.cor.2020.05.05 ◽

2020 ◽

pp. 1-6

Author(s):

Antonis Tsamaloukas ◽

Aristoteles Giagounidis ◽

Jan Roigas ◽

Stefan Glück

Keyword(s):

Prostate Cancer ◽

Pulmonary Embolism ◽

Case Report ◽

Cancer Patients ◽

Cancer Type ◽

Factor Xii ◽

Vein Thrombosis ◽

Patients With Cancer ◽

Increased Risk ◽

Calf Vein

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in cancer patients. Cancer patients have a four to sevenfold increased risk of VTE compared with non-cancer patients and approximately 20% -30% of all VTE occurs in patients with cancer. Incidence of VTE varies with cancer type and is the highest among patients with metastatic-stage disease. Assessing risk of VTE in the patients with cancer and risk stratification tools as the Khorana score may predict VTE. The highest risk is associated with cancers of the pancreas, stomach, brain, and lung and some hematologic malignancies, whereas lower risks are associated with breast and prostate cancer. The incidence rate ratio (IRR) for prostate cancer is 3.25(2,56 - 4,13) and for pancreas 15.56 (10.50-23.0). We give a case report with a quite perplexing undertaking, where a submassive acute pulmonary embolism (PE) originated from an asymptomatic calf vein thrombosis or intertwined with the Trousseau´s syndrome. Essential Section: One of the authors (A.T) was unexpected faced with the diagnosis of poorly differentiated prostate cancer. There were no signs of the disease, the PSA level was normal. As a retired medical oncologist, he had to care for many patients with prostate cancer and had now to cope with this cancer. To make the matter worse he suffered after the radical prostatectomy a submassive asymptomatic pulmonary embolism. Clinically there were no signs if a deep venous thrombosis. The coincidence of both events without clinical signs of a thrombosis could be caused by the Trousseau´s syndrome. Prostasomes extracellular vesicles synthesizes by prostate cancer cells and secreted into body fluids are prothrombotic by virtue of the expression of polyphosphate-activated coagulation factor XII.

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Staphylococcus Aureus colonization and bacteremia in children with cancer.

Blood ◽

10.1182/blood.v114.22.3666.3666 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3666-3666

Author(s):

Ashok Srinivasan ◽

Steven Seifried ◽

Liang Zhu ◽

Deo Kumar Srivastava ◽

Matthew Bankowski ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Conflicts Of Interest ◽

Methicillin Resistance ◽

Healthy Children ◽

Children With Cancer ◽

Spa Typing ◽

Patients With Cancer ◽

Number Of Patients ◽

Increased Risk ◽

Rectal Colonization

Abstract Abstract 3666 Poster Board III-602 Background Staphylococcus aureus is an important cause of blood stream infections in children and adults. In recent years, new strains of methicillin-resistant S. aureus (MRSA), also known as community-acquired (CA)-MRSA have been isolated from otherwise healthy individuals. These strains frequently carry the Panton-Valentine Leukocidin (PVL) leukotoxin and belong to spa type 8; USA300 genotype, which is the most common strain causing CA-MRSA infections in the U.S. The clinical course of infections with PVL-positive S.aureus strains appears to be more severe than infection from PVL-negative strains. Bacteremia due to these strains has been reported in children, adolescents and adults. It is not known if methcillin-resistance or infection with CA-MRSA strains adversely affects outcome in children with cancer. Colonization of MRSA in healthy children has increased significantly since 2001 and has shown to be a risk factor for subsequent infection. However the prevalence of nasal and rectal colonization with MRSA; in particular with PVL-positive strains and the relationship between colonization and infection is not known in children or adults with cancer. Methods The epidemiology of MRSA and methicillin-sensitive S.aureus (MSSA) bacteremia and prevalence of MRSA nasal and rectal colonization in children with cancer was retrospectively studied from 2000 to 2007. Medical record review included patient demographics, underlying disease and antimicrobial susceptibility patterns of the MRSA and MSSA bacteremia isolates. Molecular typing was performed by polymerase chain reaction (PCR) on all isolates for detection of the PVL genes. Staphylococcus cassette chromosome (SCC) mec and spa typing was performed on all PVL-positive MRSA and MSSA bacteremia isolates and MRSA isolates causing colonization and infection. Demographic and treatment variables were compared between patients with MRSA and MSSA bacteremia and patients with PVL-positive and PVL-negative MRSA and MSSA bacteremia using exact two-sample Wilcoxon rank sum test or robust rank sum test for unequal variances and Fisher's exact chi-square test. The trend of MRSA/MSSA bacteremia and MRSA colonization was evaluated by logistic regression models. Results Ten (19%) MRSA and 42 (81%) MSSA isolates from clinically distinct infectious bacteremic episodes were collected from 52 patients with cancer during the eight year study period. The proportion of cancer patients with MRSA, or MSSA bacteremia did not change significantly over the duration of the study. A third of the patients, 17 (33%), had complications. Thirty-eight (73%) of the bacteremic episodes were catheter-related. Catheters were removed significantly more often for MRSA infections than for MSSA infections for persistently positive blood cultures or complications (p=0.003). Subcutaneous ports was removed significantly more often than Hickman catheters (p= 0.005). The number of patients with persistently positive MRSA bacteremia were higher as compared to MSSA bacteremia (p= 0.004). Methicillin resistance was associated with decreased susceptibility to erythromycin (p=0.0003) and gentamicin (p=0.03). The difference in PVL positivity between MRSA and MSSA was statistically significant (P=0.01). None of the other variables studied including complications were significantly different between patients with MRSA or MSSA bacteremia or between patients with PVL-positive and PVL-negative S.aureus bacteremia. The number of patients colonized with MRSA compared to the total number of samples tested increased significantly between 2000-2001 and 2006-2007 (p=0.0007). PVL-positivity was associated both with increased colonization (p=0.004) and with an increased risk of infection (p=0.0005). There was a discordance in the spa types between the colonization and infection isolates. Conclusions This report represents the first description of the epidemiology of S.aureus bacteremia and colonization including analysis of PVL-positive strains in children with cancer. Methicillin-resistance or PVL-positivity did not appear to be associated with a worse outcome in our patient population. The number of patients colonized with MRSA increased significantly during this time period. PVL-positivity was associated with an increased risk of colonization and infection. Further studies are needed to confirm these observations in patients with cancer. Disclosures: No relevant conflicts of interest to declare.

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Morbidity, Mortality and Costs Associated with Venous Thromboembolism in Hospitalized Patients with Cancer

Blood ◽

10.1182/blood.v128.22.4751.4751 ◽

2016 ◽

Vol 128 (22) ◽

pp. 4751-4751

Author(s):

Gary H. Lyman ◽

Eva Culakova ◽

Marek S. Poniewierski ◽

Nicole M. Kuderer

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Hospital Mortality ◽

Cancer Patients ◽

Length Of Hospital Stay ◽

Infectious Complications ◽

Hospitalized Patients ◽

Annual Rate ◽

Patients With Cancer ◽

Time Period

Background: Venous thromboembolism (VTE) represents a leading cause of morbidity and mortality among hospitalized patients with cancer. Methods: Hospitalization data reported on adult cancer patients at US academic medical centers and affiliated hospitals between 1995 and 2012 were analyzed. Cancer diagnosis, presence of VTE, comorbidities and complications were based on ICD-9-CM codes. Major comorbidities considered were diabetes, and cerebrovascular, peripheral-vascular, heart, liver, and lung renal disease. In patients with multiple hospitalizations during the time period, a randomly selected hospitalization was utilized in the analysis. Hospitalization cost estimates were inflation adjusted to 2015 US dollars. Results: Nearly 6 million hospitalizations of 3,146,388 individual patients with cancer from more than 200 institutions were evaluated. VTE was reported in 8.4% of patients when all admissions are considered during the time period. When a single selected hospitalization is considered for each patient, VTE was reported in 166,547 (5.3%) of individual patients including 56,125 (1.8%) with pulmonary embolism (PE). The annual rate of VTE increased progressively from 3.5% in 1995 to over 6.5% in 2012 with the rate of PE nearly tripling from 0.8% in 1995 to 2.3% in 2012. For hospitalized patients receiving cancer chemotherapy, the annual rate of VTE more than doubled from 3.6% in 1995 to 8.3% in 2012. VTE was reported in 5.2%, 5.8% and 5.4% of patients with solid tumors, lymphoma, and leukemia, respectively (Table). Rates of VTE were greatest among patients with pancreatic (10.2%), gastric (7.1%) or other abdominal malignancies except colorectal cancer (9.2%) as well as those with ovarian (7.1%), lung (6.8%) and esophageal cancers (6.3%). The risk of VTE increased progressively from 2.3% in those with no comorbidities to over 11% for patients with 4 or more comorbid conditions. The strongest risk factors for VTE were infectious complications including sepsis (14%), invasive candidiasis (16%), pneumonia (11%) and IV line infections (14%).During this same time period, imaging related to VTE actually decreased with significantly lower rates of CT, vascular ultrasound and ventilation perfusion lung scans reported. In-hospital mortality was reported in 5.5% of cancer patients without VTE and in 15.0% of those with VTE including 19.4% of those with pulmonary embolism. In-hospital mortality during this time period decreased by approximately one-third in cancer patients both with and without VTE. While reported rates of VTE increased, the length of hospital stay shortened for patients with as well as without VTE during this period. Average costs per hospitalization adjusted to 2015 dollars for patients with and without VTE were $37,352 and $19,994, respectively. The estimated average inflation adjusted daily cost of hospitalization for patients with cancer and VTE increased nearly 50% between 1995 ($2,256) and 2012 ($3,297). Conclusions: VTE reported among hospitalized patients with cancer has increased significantly during the period of observation along with the cost of hospitalization while in-hospital mortality and imaging rates have decreased. However, patients with additional major medical comorbidities are at exceptionally high risk of serious complications including in-hospital mortality. Disclosures Lyman: Amgen: Research Funding. Kuderer:Janssen Scientific Affairs, LLC: Consultancy, Honoraria.

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Adverse reactions of targeted therapy in cancer patients: a retrospective study of hospital medical data in China

BMC Cancer ◽

10.1186/s12885-021-07946-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Ruofei Du ◽

Xin Wang ◽

Lixia Ma ◽

Leon M. Larcher ◽

Han Tang ◽

...

Keyword(s):

Targeted Therapy ◽

Cancer Patients ◽

Adverse Reactions ◽

Cox Regression ◽

Target Therapy ◽

Skin Damage ◽

Data Set ◽

Patients With Cancer ◽

Number Of Patients ◽

Significant Difference

Abstract Background The adverse reactions (ADRs) of targeted therapy were closely associated with treatment response, clinical outcome, quality of life (QoL) of patients with cancer. However, few studies presented the correlation between ADRs of targeted therapy and treatment effects among cancer patients. This study was to explore the characteristics of ADRs with targeted therapy and the prognosis of cancer patients based on the clinical data. Methods A retrospective secondary data analysis was conducted within an ADR data set including 2703 patients with targeted therapy from three Henan medical centers of China between January 2018 and December 2019. The significance was evaluated with chi-square test between groups with or without ADRs. Univariate and multivariate logistic regression with backward stepwise method were applied to assess the difference of pathological characteristics in patients with cancer. Using the univariate Cox regression method, the actuarial probability of overall survival was performed to compare the clinical outcomes between these two groups. Results A total of 485 patients were enrolled in this study. Of all patients, 61.0% (n = 296) occurred ADRs including skin damage, fatigue, mucosal damage, hypertension and gastrointestinal discomfort as the top 5 complications during the target therapy. And 62.1% of ADRs were mild to moderate, more than half of the ADRs occurred within one month, 68.6% ADRs lasted more than one month. Older patients (P = 0.022) and patients with lower education level (P = 0.036), more than 2 comorbidities (P = 0.021), longer medication time (P = 0.022), drug combination (P = 0.033) and intravenous administration (P = 0.019) were more likely to have ADRs. Those with ADRs were more likely to stop taking (P = 0.000), change (P = 0.000), adjust (P = 0.000), or not take the medicine on time (P = 0.000). The number of patients with recurrence (P = 0.000) and metastasis (P = 0.006) were statistically significant difference between ADRs and non-ADRs group. And the patients were significantly poor prognosis in ADRs groups compared with non-ADRs group. Conclusion The high incidence of ADRs would affect the treatment and prognosis of patients with cancer. We should pay more attention to these ADRs and develop effective management strategies.

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Impact of cancer on emergency department outcomes.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18618 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18618-e18618

Author(s):

Alexander S. Qian ◽

Edmund M. Qiao ◽

Vinit Nalawade ◽

Rohith S. Voora ◽

Nikhil V. Kotha ◽

...

Keyword(s):

Emergency Department ◽

Risk Stratification ◽

Hospital Mortality ◽

Hospital Admission ◽

Cancer Patients ◽

Metastatic Cancer ◽

Inpatient Admission ◽

Cancer Site ◽

Patients With Cancer ◽

Increased Risk

e18618 Background: Cancer patients frequently utilize the Emergency Department (ED) for a variety of diagnoses, both related and unrelated to their cancer. Patients with cancer have unique risks related to their cancer and treatment which could influence ED-related outcomes. A better understanding of these risks could help improve risk-stratification for these patients and help inform future interventions. This study sought to define the increased risks cancer patients face for inpatient admission and hospital mortality among cancer patients presenting to the ED. Methods: From the National Emergency Department Sample (NEDS) we identified patients with and without a diagnosis of cancer presenting to the ED between 2016 and 2018. We used International Classification of Diseases, version 10 (ICD10-CM) codes to identify patients with cancer, and to identify patient’s presenting diagnosis. Multivariable mixed-effects logistic regression models assessed the influence of cancer diagnoses on two endpoints: hospital admission from the ED, and inpatient hospital mortality. Results: There were 340 million weighted ED visits, of which 8.3 million (2.3%) occurred in patients with a cancer diagnosis. Compared to non-cancer patients, patients with cancer had an increased risk of inpatient admission (64.7% vs. 14.8%; p < 0.0001) and hospital mortality (4.6% vs. 0.5%; p < 0.0001). Factors associated with both an increased risk of hospitalization and death included older age, male gender, lower income level, discharge quarter, and receipt of care in a teaching hospital. We identified the top 15 most common presenting diagnoses among cancer patients, and among each of these diagnoses, cancer patients had increased risks of hospitalization (odds ratio [OR] range 2.0-13.2; all p < 0.05) and death (OR range 2.1-14.4; all p < 0.05) compared to non-cancer patients with the same diagnosis. Within the cancer patient cohort, cancer site was the most robust individual predictor associated with risk of hospitalization or death, with highest risk among patients with metastatic cancer, liver and lung cancers compared to the reference group of prostate cancer patients. Conclusions: Cancer patients presenting to the ED have high risks for hospital admission and death when compared to patients without cancer. Cancer patients represent a distinct population and may benefit from cancer-specific risk stratification or focused interventions tailored to improve outcomes in the ED setting.

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Altered Tryptophan and Neopterin Metabolism In Cancer Patients

Pteridines ◽

10.1515/pteridines.1998.9.1.29 ◽

1998 ◽

Vol 9 (1) ◽

pp. 29-32

Author(s):

Hiromi Iwagaki ◽

Akio Hizuta ◽

Yasuki Nitta ◽

Noriaki Tanaka

Keyword(s):

Nicotinic Acid ◽

Cancer Patients ◽

Immune Activation ◽

Cancer Cachexia ◽

Healthy Controls ◽

Patients With Cancer ◽

Time Period ◽

Ifn Γ ◽

Acid Pathway ◽

High Level

Summary Plasma 5-hydroxytryptamine (serotonin), tryptophan and neopterin levels were measured in patients with depressive cancer cachexia and in healthy controls during the same time period. Patients with advanced cancers had significantly raised neopterin, a marker of endogenous gamma-interferon (IFN-γ) production, but decreased serotonin and tryptophan levels. IFN-γ induces a high level of indoleamine dioxvgenase (IDO), a tryptophan degrading enzyme, which in turn increases metabolism along the tryptophan- nicotinic acid pathway, resulting in decreased synthesis of serotonin. These results suggest that persistent immune activation occur in patients with cancer cachexia, resulting in disorders involving tryptophan metabolism.

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Prevention of venous thromboembolism in cancer patients: current approaches and opportunities for improvement

Oncology Reviews ◽

10.4081/oncol.2011.34 ◽

2011 ◽

pp. 191-204

Author(s):

Alpesh N. Amin ◽

Steven B. Deitelzweig

Keyword(s):

At Risk ◽

Venous Thromboembolism ◽

Cancer Patients ◽

Assessment Model ◽

Major Surgery ◽

Medical Illness ◽

Patients With Cancer ◽

Increased Risk ◽

National Quality ◽

American Society

Venous thromboembolism (VTE), a common complication in patients with cancer, is associated with increased risk of morbidity, mortality, and recurrent VTE. Risk factors for VTE in cancer patients include the type and stage of cancer, comorbidities, age, major surgery, and active chemotherapy. Evidence-based guidelines for thromboprophylaxis in cancer patients have been published: the National Comprehensive Cancer Network and American Society for Clinical Oncology guidelines recommend thromboprophylaxis for hospitalized cancer patients, while the American College of Chest Physician guidelines recommend thromboprophylaxis for surgical patients with cancer and bedridden cancer patients with an acute medical illness. Guidelines do not generally recommend routine thromboprophylaxis in ambulatory patients during chemotherapy, but there is evidence that some of these patients are at risk of VTE; some may be at higher risk while on active chemotherapy. Approaches are needed to identify those patients most likely to benefit from thromboprophylaxis, and, to this end, a risk assessment model has been developed and validated. Despite the benefits, many at-risk patients do not receive any thromboprophylaxis, or receive prophylaxis that is not compliant with guideline recommendations. Quality improvement initiatives have been developed by the Centers for Medicare and Medicaid Services, National Quality Forum, and Joint Commission to encourage closure of the gap between guideline recommendations and clinical practice for prevention, diagnosis, and treatment of VTE in hospitalized patients. Health-care institutions and providers need to take seriously the burden of VTE, improve prophylaxis rates in patients with cancer, and address the need for prophylaxis across the patient continuum.

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Success of Online CME at Improving Knowledge and Confidence Around Guideline-Directed Management of Cancer-Associated Thrombosis

Blood ◽

10.1182/blood-2020-137153 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 13-13

Author(s):

Caroline Padbury ◽

Margaret Harris ◽

Michael LaCouture ◽

Jelena Spyropoulos

Keyword(s):

Clinical Practice ◽

Venous Thromboembolism ◽

Cancer Patients ◽

Treatment Guidelines ◽

Conflicts Of Interest ◽

Oral Anticoagulants ◽

Roundtable Discussion ◽

Patients With Cancer ◽

Cancer Associated Thrombosis ◽

Post Assessment

Title:Success of Online CME at Improving Knowledge and Confidence Around Guideline-Directed Management of Cancer-Associated Thrombosis Study Objectives:Recent guidance statements recommend the use of direct oral anticoagulants (DOACs) as primary thromboprophylaxis in ambulatory patients with cancer who are starting chemotherapy and in patients with cancer and acute venous thromboembolism at low risk of bleeding and no drug-drug interactions.[Farge 2019; Key 2020] Yet, many clinicians lack knowledge and confidence with integrating DOACs into management strategies for patients with cancer in accordance to guideline recommendations.[Cushman 2015; Khorana 2016] We sought to determine if online continuing medical education (CME) could improve the knowledge and confidence of hematologists/oncologists regarding guideline-directed use of DOACs in the management of cancer-associated thrombosis. Methods:This CME intervention comprised of a 30-minute online video-based roundtable discussion among experts in the field of cancer-associated thrombosis management. Responses to 3 multiple-choice, knowledge questions and 1 self-efficacy, 5-point Likert scale confidence question were analyzed using a repeated pairs pre-/post-assessment study design. A chi-square test (P <.05 is considered significant) assessed pre- to post-activity change . The activity launched December 23, 2019, and data were collected through February 24, 2020. Results:In total, 71 Hematologists/Oncologists were included in this study. Overall, there were knowledge and confidence improvements seen among all groups from pre- to post-assessment: 27% of hematologists/oncologists (P<.01) improved at identifying guideline-directed therapy regarding recommended thromboprophylaxis in patients with cancer per guideline recommendations.27% of hematologists/oncologists (P<.01) improved at selecting guideline-appropriate treatment options for cancer-associated thrombosis.44% of hematologists/oncologists had an increase in confidence in managing thrombosis in patients with cancer. Continued educational gaps: 25% of hematologists/oncologists failed to select guideline recommended DOAC therapy for thromboprophylaxis in cancer patients.45% of hematologists/oncologists failed to select guideline recommended DOAC therapy for treatment of thrombosis in cancer patients.66% of hematologists/oncologists still remain at only a rating of 1 to 3 on a scale of 1 to 5 in their confidence managing thrombosis in patients with cancer. Conclusion:This study demonstrates the success of online, CME-accredited, video-based roundtable discussion with experts in the field on significantly improving knowledge and confidence of hematologists/oncologists related to the guideline-recommended use of DOACs in the management of cancer-associated thrombosis. Continued gaps were also identified for future educational targets. Sources of support: Developed through an independent educational grant from Janssen in partnership with the University of Chicago. References: Cushman M, Creager MA. Improving awareness and outcomes related to venous thromboembolism. JAMA. 2015;314(18):1913-4. Farge D, Frere C, Connors JM, et al. 2019 International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. The Lancet Oncology. 2019;20(10):e566-581. Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2020 Feb 10;38(5):496-520. Khorana AA, Yannicelli D, McCrae KR, et al. Evaluation of US prescription patterns: are treatment guidelines for cancer-associated venous thromboembolism being followed? Thromb Res. 2016 Sep;145:51-3. Disclosures No relevant conflicts of interest to declare.

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Prevention of venous thromboembolism in cancer patients: current approaches and opportunities for improvement

Oncology Reviews ◽

10.4081/oncol.2011.191 ◽

2011 ◽

Vol 5 (3) ◽

pp. 191

Author(s):

Alpesh N. Amin ◽

Steven B. Deitelzweig

Keyword(s):

At Risk ◽

Venous Thromboembolism ◽

Cancer Patients ◽

Assessment Model ◽

Major Surgery ◽

Medical Illness ◽

Patients With Cancer ◽

Increased Risk ◽

National Quality ◽

American Society

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P54 Pneumocystis jirovecii prophylaxis in patients on rituximab

Rheumatology ◽

10.1093/rheumatology/kez416.021 ◽

2019 ◽

Vol 58 (Supplement_4) ◽

Cited By ~ 1

Author(s):

Kishore Warrier1 ◽

Catherine Salvesani ◽

Samundeeswari Deepak

Keyword(s):

Risk Factors ◽

T Cell ◽

B Cells ◽

B Cell ◽

Conflicts Of Interest ◽

Pneumocystis Jirovecii ◽

Current Evidence ◽

Pneumocystis Jirovecii Pneumonia ◽

Number Of Patients ◽

Increased Risk

Abstract Background Rituximab is a chimeric monoclonal antibody that depletes the B cell population by targeting cells bearing the CD20 surface marker and is used widely in the management of paediatric rheumatological conditions like juvenile systemic lupus erythematosus (JSLE), juvenile dermatomyositis (JDM), mixed connective tissue disease (MCTD) and juvenile idiopathic arthritis (JIA). Pneumocystis jirovecii pneumonia (PCP) is a potentially fatal opportunistic infection associated with congenital and acquired defects in T cell–mediated immunity. Our guideline did not recommend prophylaxis against PCP for patients on rituximab, unlike patients on cyclophosphamide, who are on cotrimoxazole until three months after cessation of the treatment. Cyclophosphamide is an alkylating agent which affects both B and T lymphocytes. Following the death of 16 year-old girl with JSLE due to PCP, the team reviewed the possible contributing factors, undertook a review of literature and discussed this at multi-disciplinary meetings involving the microbiology and immunology teams. This patient was found to have other risk factors for PCP – low CD4 T cells, concomitant use of corticosteroids and hypogammaglobulinaemia (IgG 3.0g/L). Although there is limited evidence that rituximab on its own increases the risk of PCP, there is emerging data that B cells may have a role in the protection against pneumocystis. Following the review, it was concluded that children on rituximab and an additional immunosuppressant (including corticosteroids) should receive prophylactic cotrimoxazole to cover PCP. Methods Retrospective audit carried out by the team to look at adherence to the new guideline regarding the use of cotrimoxazole for PCP prophylaxis in patients who have had rituximab between August 2017 and May 2019. Results P54 Table 1 Total number of patients who had rituximab 10 Number of patients who had other immunosuppressants concomitantly / recently (within previous 3 months) 7 Number of patients on rituximab monotherapy 2 Number of patients who are 6 months post-treatment 1 Number of patients with other risk factors for PCP 1 (hypogammaglobulinaemia) Number of patients who are eligible for prophylaxis, as per the guideline 8 (7 for concomitant immunosuppression and 1 for hypogammaglobulinaemia) Number of patients on cotrimoxazole 7 (87.5%) - one of the patients is on methotrexate, which is advised not to combine with cotrimoxazole We achieved 87.5% compliance in prescribing cotrimoxazole for PCP prophylaxis to all rheumatology patients receiving rituximab alongside another immunosuppressant agent; the one patient who this was not adhered to was due to potential adverse drug pharmacodynamic interaction between cotrimoxazole and methotrexate. Conclusion Although the current evidence points to increased risk of PCP in patients with inherited and iatrogenic defect of T cell function, there is emerging evidence that B cells may have a role too. Hence more work is required to determine the risk of PCP in patients on B cell targeted therapy (BCTT) and the need for prophylaxis. Conflicts of Interest The authors declare no conflicts of interest.

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