Purpose There is very little data on the effect of combining methods to better predict and improve oral antineoplastic adherence in cancer patients. The goal of this study was to evaluate the effectiveness of an intensive pharmacist intervention at the beginning of oral antineoplastic therapy versus nurse-led control group on adherence. Methods This was a prospective, randomized, open-label controlled trial performed in a single center hematology/oncology outpatient service to compare the effectiveness of repetitive pharmacist educational intervention on adherence rates measured at four and eight weeks after prescribing oral antineoplastic medication compared to a nurse-led control group. Both groups included investigator pill counts and self-report adherence questionnaires. Results Two-hundred patients were enrolled between 2009 and 2015. Fourteen of the 101 (14%) patients in the pharmacist group and 7 (7%) of the 99 patients in the nurse-led control group dropped out ( p = 0.166). The majority of patients who remained in the study were 90–100% adherent to oral antineoplastic therapy in both groups. The pharmacist group slightly underperformed at Pill Count 2, possibly due to barriers for non-adherence. Statistically significant correlations associated with non-adherence were forgetfulness ( p = 0.009), wanting to avoid side effects ( p = 0.02), feeling depressed or overwhelmed ( p = 0.032), or falling asleep before taking medication ( p = 0.048) in both groups. Conclusion The combination of pill count and patient self-report adherence is a way of improving oral antineoplastic adherence. However, significant barriers to adherence were identified such as forgetfulness, wanting to avoid side effects, feeling depressed or overwhelmed, and falling asleep before taking medications.

Drug-interaction issues continue to present a major dilemma for the clinician caring for complex patients such as those infected with HIV. The inherent possibility of a drug interaction is magnified by the multitude of drugs being administered in highly-active antiretroviral therapy (HAART). In addition, other classes of medications are used to alleviate side effects, reduce toxicities associated with HAART, or treat concomitant diseases. The modification of one drug by another substance or drug-drug interaction is the main focus of this article. Drug-drug interactions may result in toxicity, treatment failure, or loss of effectiveness and can significantly affect a patient’s clinical outcome. An understanding of the fundamental mechanisms of HIV drug-drug interactions may allow for the early detection or avoidance of troublesome regimens and prudent management if they develop. Although HIV drug interactions are usually thought of as detrimental, resulting in a loss of therapeutic effect or toxicity, some drug interactions such as ritonavir boosted protease inhibitor–based antiretroviral treatments are beneficial and are commonly used in clinical practice. Therefore, pharmacists need to understand drug interaction mechanisms, remember key drug interactions, and vigilantly monitor patients for potential complications.

A variety of adverse drug reactions (ADRs) affecting many organ systems may be observed with antiretroviral therapy (ARV), and they can be differentiated into short- and long- term effects, class effects, or individual drug effects. Commonly seen ADRs include dermatological reactions, associated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) and some protease inhibitors (PIs), and gastrointestinal problems, a major side effect of PIs and of some nucleoside reverse transcriptase inhibitors (NRTIs). Metabolic complications are frequently reported in HIV-infected patients on ARV and often coexist. Lipodystrophy, hyperinsulinemia/hyperglycemia, and bone disorders (osteoporosis, osteonecrosis) are mainly associated with PIs, while lactic acidemia/acidosis are primarily a problem of NRTIs. Hyperlipidemia may be caused by almost all PIs, few NRTIs, and NNRTIs. All antiretroviral drug classes may cause both asymptomatic and symptomatic hepatotoxicity, although nevirapine is the agent most implicated in hepatic events. More drug-specific ADRs include nephrotoxicity (indinavir and tenofovir), central nervous system problems (efavirenz), hematological disturbances (zidovudine), and hypersensitivity reactions (abacavir). Anticipation of ADRs may influence a patient’s decision to delay ARV or to choose specific and potentially less active agents. Occurrence of ADRs may significantly impact a patient’s quality of life and drug adherence. Pharmacists counseling HIV-infected patients should be aware of common ADRs with ARV and potential management strategies.

An 81-year-old female with a 50 year history of bipolar disorder and no known history of liver dysfunction LEA RC SERWETMAN PharmD, at time of writing, Clinical Rotation in Acute Care, Advanced Pharmacy Experiential Program, Objective: To report a case of rash and liver dysfunction associated with lamotrigine treatment.Case Summary: An 81-year-old woman with a history of bipolar disorder presented to the emergency department with complaints of fever, chills, nausea, and headache. Two weeks prior to presentation, liver enzymes were normal. Lamotrigine 50 mg/day and sustained-release bupropion 200 mg/day were started after discontinuation of citalopram. The patient had previous exposure to bupropion and documented rash with exposure to penicillin and sulfa. On admission, laboratory tests revealed slightly elevated liver enzymes and slightly low serum albumin. All medications were continued. On hospital day 3, a diffuse maculopapular rash developed on the patient's chest, abdomen, neck, and upper extremities, which was pruritic and warm to the touch. Both lamotrigine and bupropion were discontinued. Liver enzymes increased to more than 3 times the upper limit of normal, and serum albumin decreased. Liver function tests improved on day 6, and the rash resolved. Discussion:Predictive risk factors associated with lamotrigine-induced rash and liver dysfunction include rapid dose titration, previously reported rash with other medications, age, and concurrent interacting medications. More serious adverse effects, such as Stevens-Johnson syndrome and fulminant hepatic failure, have also been associated with lamotrigine treatment. If rash appears at any time during treatment, lamotrigine must be discontinued. According to the Naranjo probability scale, an association between lamotrigine and rash and liver dysfunction could be considered probable in this case. Conclusions:A faster than recommended dose titration may lead to lamotrigine-induced adverse effects such as rash and liver dysfunction in patients with risk factors.

Anemia begins early in the course of declining kidney function and is a frequent complication of chronic kidney disease. Both anemia and chronic kidney disease are underdiagnosed and undertreated. Anemia is associated with significantly increased risk of morbidity and mortality, including increased risks of left ventricular hypertrophy and heart failure. Although the detrimental effects of anemia are more common in patients with advanced chronic kidney disease, it has been suggested that correcting anemia in early stage kidney disease may improve health-related quality of life and also delay the progression to end-stage kidney disease. The identification of anemia in early stage chronic kidney disease and its aggressive management may also improve cardiovascular complications. Anemia of chronic kidney disease is predominantly a result of abnormal erythropoietin production and iron deficiency. Anemia may be the result of kidney failure itself, blood losses, nutritional deficiencies, and endocrine disorders. Guidelines and protocols for treating anemia can assist practitioners in identifying patients with anemia, treating anemia, evaluating response to treatment, and modifying treatment based on response. Erythropoeisis-stimulating agents have been shown to be effective in treating anemia in predialysis and dialysis patients. Iron supplementation is usually required in patients receiving erythropoeisis-stimulating agent therapy or with iron deficiency. Successfully managing anemia of chronic kidney disease with treatment strategies that accommodate patient lifestyle and improve compliance is paramount. Primary care physicians play an important role in the care of patients with kidney disease, as does collaboration with other medical professionals involved in their care.

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