Background Current workforce shortages within the hematopoietic stem cell transplant field necessitate capitalizing on the role of oncology-trained pharmacists. Working within an agreed-upon protocol, pharmacists are able to expand patient care delivery through optimal medication therapy management. Methods An electronic survey was developed by the Advocacy & Policy Working Committee of the American Society for Blood and Marrow Transplantation Pharmacy Special Interest Group and distributed to pharmacists involved in the care of hematopoietic stem cell transplant patients. The primary objective was to assess the current state of collaborative practice agreements in the hematopoietic stem cell transplant setting. Results Forty-eight responses representing 41 institutions were returned. Respondents were mostly female (67%) and practiced in the adult setting (83%). Reponses represented a range of practice experience in hematopoietic stem cell transplant with the majority of the hematopoietic stem cell transplant positions (83%) funded by the department of pharmacy at an academic medical center. Of the 48 responses, 22 (46%) respondents reported having collaborative practice agreements in place; 10 (21%) respondents did not currently have collaborative practice agreements, but were planning to implement them; and 16 (33%) respondents did not have collaborative practice agreements at their institution. Clinical activities performed under a collaborative practice agreement included medication selection and dosing modifications, therapeutic drug monitoring, supportive care management, and management of comorbid conditions and chronic diseases. The most commonly cited barrier to establishing collaborative practice agreements was the inability to secure reimbursement for services provided. No respondents reported a negative impact on job satisfaction. Conclusions The results of this survey provide the pharmacy community with a robust understanding of the current landscape of hematopoietic stem cell transplant pharmacy collaborative practice agreements.

Objective The primary objective was to analyze the initial tacrolimus concentrations achieved in allogeneic hematopoietic stem cell transplantation patients using the institutional dosing strategy of 1 mg IV daily initiated on day +5. The secondary objectives were to ascertain the tacrolimus dose, days of therapy, and dose changes necessary to achieve a therapeutic concentration, and to identify patient-specific factors that influence therapeutic dose. The relationships between the number of pre-therapeutic days and incidence of graft-versus-host disease and graft failure were delineated. Methods A retrospective chart review included adult allogeneic hematopoietic stem cell patients who received tacrolimus for graft-versus-host disease prophylaxis in 2012. Descriptive statistics, linear and logistic regression, and graphical analyses were utilized. Results Ninety-nine patients met the inclusion criteria. The first concentration was subtherapeutic (<10 ng/ml) in 97 patients (98%). The median number of days of tacrolimus needed to achieve a therapeutic trough was 10 with a median of two dose changes. The median therapeutic dose was 1.6 mg IV daily. Approximately 75% of patients became therapeutic on ≤2 mg IV tacrolimus daily. No relationship was found between therapeutic dose and any patient-specific factor tested, including weight. No relationship was found between the number of days of therapy required to achieve a therapeutic trough and incidence of graft-versus-host disease or graft failure. Conclusion An initial flat tacrolimus dose of 1 mg IV daily is a suboptimal approach to achieve therapeutic levels at this institution. A dose of 1.6 mg or 2 mg IV daily is a reasonable alternative to the current institutional practice.

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practice change was implemented in 2012 to include ATG as part of the conditioning regimen for recipients of MRD HCT. Methods: Patients at least 18 years old who received HCT from an HLA 8/8 MRD for a hematologic malignancy were included. The control group was comprised of patients who did not receive ATG and received HCT between . The ATG group was comprised of patients who received rabbit ATG (Thymoglobulin) 3mg/kg in divided doses from day -3 to day -1, and received HCT between Jan 1, 2012 to June 30, 2014. The primary endpoint is incidence of grade II-IV aGVHD occurring up to 100 days post-HCT. Secondary endpoints include immunosuppression free survival (IFS), overall survival (OS), relapse, nonrelapse mortality (NRM), and infection rates. Continuous measures were compared using two-sample independent t-tests or Wilcoxon signed-rank test and categorical measures with chisquare tests. Time to event outcomes were measured using the log-rank test and the Grey's test to account for competing events. Results: There were 37 patients in the ATG group and 24 patients in the control group. Median age in both groups was 51 years. Baseline characteristics were well matched in the ATG vs. control groups: male sex (49% vs 58%), peripheral blood stem cell source (97% vs 96%), myeloablative conditioning (89% vs 100%), and GVHD prophylaxis with cyclosporine and methotrexate (84% vs 75%). All patients engrafted. Grade II-IV and grade III-IV aGVHD occurred in 19% and 29% (p¼0.35) and 11% and 21% (p¼0.29) of patients in the ATG and control groups, respectively. At day 100 post-HCT there was no difference in cytomegalovirus reactivation (41% vs 33%, p¼0.57) or Epstein-Barr virus reactivation (24% vs 8%, p¼0.17), but there was a trend towards an increase in BK cystitis requiring treatment (16% vs 0%, p¼0.07) in the ATG vs control group. At day 180 post-HCT there was no difference in OS (86% vs 79%, p¼0.49), relapse (16% vs 8%, p¼0.46), or NRM (14% vs 17%, p¼0.72) between the ATG and control groups. IFS at day 180 post-HCT was greater in the ATG vs control group (65% vs 38%, p¼0.04) (Figure 1). Conclusion: The addition of ATG to the conditioning regimen in MRD HCT did not significantly reduce the incidence of aGVHD. However, more patients receiving ATG were off immunosuppression at 180 days post-HCT compared with those not receiving ATG, possibly reflecting a reduction in chronic GVHD. Our findings demonstrate the need for randomized trials to evaluate the overall impact of ATG on outcomes of MRD HCT.