Biol Blood Marrow Transplant 20 (2014) S286eS296

PHARMACY

444Evaluation of Electrolyte Repletion and Infection Rates inHematopoietic Cell Transplant Patients Receiving H-2Receptor Antagonists or Proton Pump InhibitorsKatelyn Smith 1, Mandy Gatesman 1, May Aziz 1, William Clark 2,Spencer Harpe 1. 1 Pharmacy, Virginia CommonwealthUniversity, Richmond, VA; 2 Internal Medicine, VirginiaCommonwealth University, Richmond, VA

At Virginia Commonwealth University Health System, he-matopoietic cell transplant (HCT) patients receive protonpump inhibitors (PPI) during their admission to preventchemotherapy-induced gastroduodenal injury. Prior to 2012,most patients were also discharged on PPI to reduce thefrequency of ulcers and upper gastrointestinal (GI) symp-toms after HCT.Adverse effects of PPI therapy may include magnesiumdeficiency, 1,2 increases in Clostridium difficile infection,3 andan increased risk of community-acquired pneumonia.4

Compared to PPI therapy, H-2 receptor antagonists (H2RA)have less pronounced and prolonged acid suppressionwhichcontributes to an advantageous side effect profile. Since HCTpatients are subject to low electrolyte levels5 and increasedrisks of infection at baseline, we sought to determine theassociation between PPI use and electrolyte repletion andinfection rates and whether the use of H2RA was associatedwith reduced risk of these complications.A retrospective, matched cohort study was conductedfrom September 30, 2010 through March 31, 2013. Patients18 years or older receiving H2RA therapy post-HCTadmission were matched by transplant type and prepara-tory regimen to patients receiving PPI. Matched pairs wereevaluated for four weeks post-discharge. In addition tobaseline characteristics, data collected included theamount and frequency of electrolyte repletion via a stan-dard institutional protocol, rates of infection (positivecultures, use of antibiotics, radiologic evidence of pneu-monia), and patient-reported GI symptoms. Data wereanalyzed with descriptive statistics, paired t-tests, andMcNemar’s Chi square test.Twenty-six matched pairs were included. Patients receivingPPI required significantly more magnesium repletion inweeks 1, 3, and 4 post-discharge. During weeks 1, 3, and 4,significantly more patients receiving H2RA therapy went anentire week without repletion versus patients receiving PPI.Although the magnitude or frequency of potassium or cal-cium repletion were generally higher among PPI users, thesedifferences were not statistically significant. The number ofpatients with evidence of infection was not significantlydifferent between groups. Compared to patients on H2RAtherapy, significantly more patients receiving PPI reported GIsymptoms.H2RA therapy deserves serious consideration in place of PPI,when possible, for HCT patients post-discharge.References:

1. Arch Intern Med 2011;171(15):1391-2.2. Am J Kidney Dis 2010;56(1):112-6.3. Arch Intern Med 2010;170(9):772-8.4. JAMA 2004;292(16):1955-60.5. Nephrol Dial Transplant 2008; 23: 359-363.

445Impact of Bone Marrow Transplant (BMT) Pharmacist(pharma) Interventions on Outcomes in Patients (pts)Undergoing Transplantation at an Academic MedicalCenterJayde Bednarik 1, Jessica Baron 2, Delila Katz 1, Karen Smethers 3,Muthalagu Ramanathan 4, Jan Cerny 5, Natasha Fortier 6,Lindsey Shanahan 6, Tzafra Martin 7, Laura Petrillo-Deluca 8,Rajneesh Nath 9. 1 Pharmacy, UMass Memorial Medical Center,Worcester, MA; 2MD Anderson, Houston, TX; 3 AscensionHealth, St. Louis, MO; 4Hematology/Oncology Section BMT,UMASS Memorial University Campus, Worcester, MA; 5Divisionof Hematology/Oncology, University of Massachusetts,Worcester, MA; 6Hematology/Oncology - BMT, UMassMemorial Medical Center, Worcester, MA; 7Hematology/Oncology Section BMT, UMass Memorial Medical Center,Worcester, MA; 8Hematology/Oncology, UMass MemorialMedical Center, Worcester, MA; 9Hematology/Oncology,Section BMT, UMass Memorial Medical Center, Worcester, MA

Background: Multidisciplinary collaboration leads toimprovement in pt outcomes when clinical pharmas areengaged in various settings. Clinical pharma integration inthe BMT setting has increased as these programs expand.There is an absence of literature defining the benefit ofclinical pharma involvement in this area of practice. UMassMemorial Medical Center is a large academic medical centerperforming 108 allogenic transplants since 2010. In August2010, the medical center implemented the integration of ahealth-system clinical pharma to the BMT team. This studyaims to determine the impact of a health- system basedclinical pharma on pt outcomes and associated costs in theBMT setting.Methods: Records for pts receiving an allogeneic stem celltransplant (ASCT) from January 2008 to August 2012 werereviewed. The primary outcome measure was difference inlength of stay (LOS) for ASCT prior to and after pharmaintegration on the BMT team. Secondary outcome measuresinclude number of readmissions within 30 days, overallsurvival at 100 days, duration of intravenous (IV) antimi-crobial therapy, duration of IV immunosuppressive therapy(IST), and duration of oral IST.Results: 106 pts were identified and included for analysis. 45were transplanted prior to pharmacist implementation and61 were after BMT. Baseline demographics were similar be-tween the two groups. In the pre and post group, the mostcommon indication for transplant was AML (40% vs. 51%) andthe most common source was a matched unrelated donor(60% vs. 62%). The majority of pts in both groups receivedmyeloablative regimens (80% vs. 69%). LOS was decreased inthe after group but was not statistically significant (24.8 vs.22.9 days, p¼ 0.43).100-day survival (80% vs. 88.5%, p¼0.23)and readmission within thirty days were not significantlychanged (42.2% vs. 37.7%, p¼0.64). Days of IV antibacterials,antivirals and antifungals were all decreased, but were notstatistically significant. Days on IV IST were significantlydecreased (21.4 vs. 11.3 days, p¼0.001) showing a reciprocalincrease in oral IST use (4.9 vs. 9.1 days, p¼0.001). Costsbenefits were assessed using 2013 WAC prices. Cost savingswere reported as $3,083 per pt, for a total benefit sinceimplementation of $184,985 or $92,493 per year.Conclusion: Our analysis demonstrates significant im-provements in cost saving with the implementation of apharma in the BMT setting, specifically allogeneic pts. While

Table 1Results Fosaprepitant vs. Control, Overall Assessment Period

Control(n¼70)

FOS(n¼43)

No emesis (%) 65.7 81.4

Abstracts / Biol Blood Marrow Transplant 20 (2014) S286eS296 S287

not statistically significant, our results did show a trend indecreased LOS, readmission at 30 days, and use of antimi-crobials. Use of IV IST were significantly decreased. Incor-poration of clinical pharma should be strongly considered inthis pt population.

Day(s) of melphalan (%) 98 99Days 1-5 post-melphalan (%) 66 84

Complete response (%)(no emesis or breakthrough antiemetic use)

1.4 4.7

Emetic episode per patient (mean) 0.76 0.28Breakthrough antiemetic doses per patient (mean) 9.6 9.98Complete protection (%)(no emesis, breakthrough antiemetics,

or significant nausea)

- 9.7*

No nausea (%)(<5 mm on 100 mm VAS)

- 16.1*

No significant nausea (%)(<25 mm on 100 mm VAS)

- 35.5*

*For 31 evaluable subjects

446Association Between Tacrolimus Levels and Outcomesafter Allogeneic Hematopoietic Stem Cell TransplantationChristina Carracedo 1, Laura Wiggins 2, Ashley Richards 2.1 University of Kentucky HealthCare, Lexington, KY; 2 UF HealthShands Hospital, Gainesville, FL

Graft-versus-host-disease (GVHD) is a life threateningcomplication of allogeneic hematopoietic stem cell trans-plantation (HSCT). The calcineurin inhibitor tacrolimus iscommonly used in combination with other immunosup-pressants to prevent GVHD; however the optimal serumtarget concentration for tacrolimus in this population re-mains unknown. A retrospective review was conducted todetermine whether an association exists between tacrolimusconcentrations and transplant-related outcomes, specificallyacute GVHD, as well as the rate of renal toxicity and mor-tality. Data from 203 patients who underwent an allogeneicHSCT from a related (n¼95) or unrelated (n¼108) donorbetween January 1, 2003 and December 31, 2011 at a largeacademic hospital was analyzed. Sixty-two (31%) patientsdeveloped acute GVHD within the first 30 days followingallogeneic stem cell transplant. Median tacrolimus concen-trations at day 0, 7, 14, and 28 were 11.2, 13.8, 13.5 and 10.2ng/mL, respectively among those who developed acuteGVHD. Patients who did not develop acute GVHD had similartacrolimus concentrations of 10.4,13.1,12.3 and 9.9 ng/mL forthe same respective time points. Serum tacrolimus concen-trationswere similar across all grades of GVHD and therewasno correlation between drug concentrations with respect torenal toxicity. Patients who developed renal dysfunction(n¼18) had tacrolimus concentrations similar to the medianconcentration of the entire cohort, including those who didnot experience renal toxicity. Overall mortality among the203 included patients was 49%. Mortality was higher amongpatients who developed acute GVHD (55%) than in patientswho did not experience the disease (47%). The results of thisanalysis support previous conclusions that tacrolimus bloodconcentrations are not associated with acute GVHD withinthe first 30 days post allogeneic HSCT.

447Fosaprepitant for the Prevention of Nausea and Vomitingin Patients Receiving BEAM or High-Dose MelphalanConditioning Regimens for Autologous HematopoieticStem Cell TransplantationStephen M. Clark 1,2, Lindsay Schaack 2, David DeRemer 1,2,Vamsi Kota 1, Amber Bradley Clemmons 1,2. 1 Georgia RegentsMedical Center, Augusta, GA; 2University of Georgia College ofPharmacy, Augusta, GA

Chemotherapy-induced nausea and vomiting (CINV) occursfrequently during hematopoietic stem cell transplantation(HSCT) despite prophylactic therapy with serotonin antago-nists and corticosteroids. Aprepitant, an oral neurokinin-1(NK1) inhibitor, has been considered as add-on prophylactictherapy; however, to date no published studies have inves-tigated the injectable NK1 inhibitor fosaprepitant (FOS) inHSCT. The purpose of this study is to assess the ability of FOS

to reduce emesis after BEAM and high-dose melphalanautologous HSCT.The use of a 150 mg fosaprepitant IV x 1 prior to melphalanbecame standard practice at our institution in the summer of2012 for BEAM and high-dose melphalan regimens. Weperformed an IRB approved cohort study comparing patientswho prospectively receive FOS to a historical cohort who didnot receive FOS. The primary endpoint was overall percent-age of patients with no emesis during the assessment period(first day of melphalan through five days after melphalanadministration). Secondary endpoints include number ofemetic episodes per patient, number of breakthrough anti-emetic doses per patient, and complete response rate (noemesis or breakthrough antiemetic use). Patients in the FOScohort also recorded nausea on a 100 mm visual analog scale(VAS) daily allowing for additional exploratory endpoints ofcomplete protection rate (complete response plus no sig-nificant nausea), no significant nausea (< 25 mm on 100 mmVAS), and no nausea (< 5mmon 100mmVAS) to be assessedfor that single cohort. A sample size of 70 patients per cohortwas deemed necessary based on an estimated 40% no emesisin control group for 80% power at alpha¼0.05 to detect a 25%absolute increase in patients with no emesis.Seventy consecutive patients who received BEAM or high-dose melphalan without FOS were included in the historicalcohort and 43 patients have received FOS in the prospectivecohort. Interim results suggest the addition of FOS improvedthe percentage of patients with no emesis and the number ofemetic episodes per patient. Exploratory endpoints in theFOS cohort which included patient reported nausea assess-ments on a VAS are encouraging as a third of patients re-ported no significant nausea during the overall assessmentperiod. Based on these promising interim results, enrollmentin the FOS cohort is ongoing.

448Administration of Rabbit Anti-Thymocyte Globulin:Slowing Infusion Rate over a 4 Day Course withAggressive Use of Pre-Medications May Decrease ATGRelated Infusion ReactionsAmber Bradley Clemmons 1,2, Megan E. Hartranft 1,2,Vamsi Kota 1, Jeremy Pantin 1, Farrukh T. Awan 1, Huda Salman 1

, Anand Jillella 1. 1 Georgia Regents Medical Center, Augusta,GA; 2 University of Georgia College of Pharmacy, Augusta, GA

Anti-thymocyte globulin (ATG) during conditioning forallogeneic HSCT is often accompanied by infusion reactions;