A 75-year-old male outpatient with cardiac disease, diabetes, chronic renal insufficiency and iron deficiency anemia was prescribed linezolid 600 mg twice daily for a methicillin-resistant Staphylococcus aureus diabetic foot osteomyelitis. After one week, his blood counts were consistent with baseline values. The patient failed to return for subsequent blood work. On day 26, he was admitted to hospital with acute renal failure secondary to dehydration, and was found to be pancytopenic (erythrocytes 2.5x10(12)/L, leukocytes 2.9x10(9)/L, platelets 59x10(9)/L, hemoglobin 71 g/L). The patient was transfused, and linezolid was discontinued. His blood counts improved over the week and remained at baseline two months later.The patient's decline in blood counts from baseline levels met previously established criteria for clinical significance. Application of the Naranjo scale indicated a probable relationship between pancytopenia and linezolid.Clinicians should be aware of this rare effect with linezolid, and prospectively identify patients at risk and emphasize weekly hematological monitoring.
Background: Toxicity management is a challenge with cancer treatment, including oral anticancer drugs. A review of claims data showed that a majority of publically funded oral anticancer drugs were filled in the community where pharmacists may not necessarily possess the specialized knowledge, skills, and experience required to provide effective patient care. A survey of community pharmacists in Ontario was conducted to identify the behaviours and preferences of community pharmacists specific to the management of treatment-related toxicities in order to standardize cancer care in this area. Methods: An electronic questionnaire was distributed to approximately 5000 community pharmacists. The 21-question survey gathered information on the demographic profile of the pharmacists, basic geographic and socioeconomic variables associated with their practice setting, current toxicity management practices, education and training needs, and preferences for communicating with other providers. Results: Of 349 pharmacists, almost all (94.9%) were interested in managing chemotherapy-related toxicities as part of their work, but the majority (77.1%) did not feel that their current level of pharmacy training has provided them with an oncology education sufficient for the demands of their practice. Approximately 52% of respondents indicated that they have reached out to the health care provider at a cancer centre, and of those, 72.7% reported that their questions were resolved within 48 h. More than half of all survey respondents (53.9%) indicated that they would prefer to receive a response within 12 h from cancer centres. Conclusions: The results of this study support the need to provide community pharmacists with oncology-specific training and timely correspondences from providers at prescribing institutions in order to manage toxicities.
255 Background: The use of immune checkpoint inhibitor medications (ICIs) in the province of Ontario, Canada has increased in volume by almost 4 fold between 2015/16 to 2017/18 and has expanded from use primarily in melanoma to lung, genitourinary, and other cancers. Lack of widespread clinical experience with ICIs and provincial variation in the management of the potentially life-threatening immune-related adverse effects (irAEs) was identified as a safety and quality gap. Cancer Care Ontario (CCO) set out to develop user-friendly health care provider and patient resources to facilitate a standard approach to ICI toxicity management in Ontario. Methods: A multidisciplinary working group of oncology clinicians with ICI experience reviewed available literature and current approaches to ICI toxicity management. An iterative consensus-building process was used to develop a practical guideline. This was circulated to an external expert review panel for content validity. Complementary patient/caregiver information was created based on best practices in health literacy and input from patient and family advisors. All resources were made publicly available via the CCO website and disseminated broadly to relevant stakeholders. Results: A user-friendly clinical practice guideline was created. It contains a description of irAEs associated with ICIs, guidance on the general management of irAEs, detailed algorithms describing the assessment and management of ten specific irAEs, and general considerations for patients on ICIs. A toolkit was developed with direct links to the algorithms, a customizable wallet card, a “Dear Healthcare Professional” letter template, and a patient information sheet. The guideline and toolkit webpages were accessed over 1500 times in the first month, suggesting that broad dissemination has been successful. Informal reports of guideline implementation were received from several Ontario hospitals. Conclusions: Careful analysis of the available literature and application of oncology professionals’ expertise resulted in evidence-informed, consensus-based practical resources to help facilitate safe, standardized ICI toxicity management across the Ontario health care system.
185 Background: Cancer Care Ontario’s Drug Formulary is a web-based drug information resource. Patient information is currently provided as single-drug information sheets, with a limited number of multi-drug regimen information sheets (RIS) for breast and lung cancer treatments. Patients identified a need to create additional, high-quality, “user-friendly” RIS. Objectives of this project were to 1) engage patients and caregivers in RIS redesign; 2) evaluate the original vs a redesigned model RIS; and 3) use the model RIS template to create additional RIS across disease sites. Methods: The project team included a patient and family advisor (PFA) and clinical and research experts. This was a qualitative study between August 2017 to May 2019. A focus group (FG) was conducted with 5 PFAs to identify and prioritize drug information needs. A model RIS was designed, incorporating FG input and health literacy best practices. RIS were evaluated through blinded comparative cognitive interviews with 13 PFAs, to assess RIS for usability, understandability and content relevance. Evaluation informed iterative revisions. RIS were also evaluated by clinical and education experts using the Patient Education Materials Assessment Tool (PEMAT). An RIS style guide was developed to inform the creation of future RIS. Ethics approval was obtained from the University of Toronto. Results: The FG prioritized information on regimen details, Dos and Don’ts while on treatment, drug interactions, side effects and contact information. Guidance was provided on simplifying language, highlighting important information and aesthetics. Cognitive interviews consistently reported preference for model RIS over original RIS in most domains. PEMAT scores for original versus model RIS were 64% and 94% respectively (for understandability) and 60% and 82% respectively (for actionability). To date, the style guide has informed the creation of RIS for 10 high-use regimens. Conclusions: PFA and clinician co-design along with health literacy best practices informed measurable improvements in RIS. The style guide will enable the future creation and ongoing evaluation of high-quality RIS to enhance the cancer treatment experience for patients and caregivers.
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