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Patients on systemic glucocorticoids for graft-versus-host disease (GVHD) after hematopoietic cell transplant are susceptible to invasive fungal infections (IFI), which greatly contribute to morbidity and mortality. We evaluated the efficacy of prophylactic treatment options (voriconazole versus fluconazole or itraconazole) for IFI by performing a retrospective review of patients on glucocorticoids for GVHD given voriconazole (n = 97), fluconazole (n = 36), or itraconazole (n = 36). IFI developed in 7/72 (10%) patients on fluconazole/itraconazole versus 2/97 (2%) on voriconazole (P = 0.03) within the first 100 days of glucocorticoids. Five patients developed Aspergillus IFI on fluconazole/itraconazole (7%), compared to none on voriconazole (0%) (P = 0.008); Aspergillus IFI resulted in death in all 5 patients. We found that IFI occurred in patients who received an initial dose of at least 2 mg/kg/day of prednisone or equivalent; when the analysis was restricted to these patients, the hazard ratio (0.39; 95% confidence interval: 0.08–1.86) was consistent with a protective effect of voriconazole compared with fluconazole/itraconazole, although this subset analysis did not reach significance. Overall survival at 100 days after start of glucocorticoids was 77% in patients given fluconazole/itraconazole and 85% in those given voriconazole (P = 0.22). Our results suggest that voriconazole is more effective than fluconazole/itraconazole in preventing IFI, especially aspergillosis, in patients receiving glucocorticoids posttransplant.

5-fluorouracil is a chemotherapeutic agent that plays an important role in the treatment of various cancers including head and neck and gastrointestinal malignancies. Therapy with 5-fluorouracil is rarely associated with cardiotoxic effects including angina, heart failure, myocardial infarction and cardiac arrest, resulting in discontinuation at the expense of sub-optimal treatment of the targeted malignancy. In this article, we review the literature reported on 5-fluorouracil-associated cardiotoxicity and present a case of a patient who experienced chest pain on 5-fluorouracil. The cardiac symptoms subsided after initiation of capecitabine, the oral formulation of 5-fluorouracil. To our knowledge, this is only the second reported case where 5-fluorouracil was successfully replaced by capecitabine without recurrence of cardiac symptoms. Capecitabine may be a viable option for patients who develop 5-fluorouracil-induced chest pain. However, large clinical trials are warranted to confirm these findings. Currently, there is insufficient evidence to recommend an optimal approach for safe and effective alternative treatment for patients who experience 5-fluorouracil-induced cardiac adverse events.

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709 Background: Oxaliplatin is an important component of therapy for multiple gastrointestinal cancers. The incidence of hypersensitivity reaction (HSR) to oxaliplatin is approximately 10%, and about 3% are serious in nature (Grade 3 or 4). Data on management of hypersensitivity reactions is limited to small case series, with scarce information on the success rates of rechallenging patients who have previously reacted. Methods: We conducted a retrospective review of patients who had a documented hypersensitivity (HSR) to oxaliplatin utilizing our internal adverse event reporting system from January 1, 2007 until December 31, 2012. Results: 44 patients met inclusion criteria for this study. The majority had a grade 1 or 2 reaction (n = 36 or 81.82%). Seven patients had a grade 3 reaction and one patient experienced a grade 4 reaction. 29 patients were rechallenged with oxaliplatin during subsequent courses. Infusion durations were extended in 79% of cases, and additional premedications were administered in 90%. Two patients were treated with a desensitization protocol, which consisted of serial dilutions of oxaliplatin (given over approximately 8 hours) with a two-stage premedication regimen. With these measures, seventeen of the twenty-nine patients (66%) were able to receive 3 or more additional infusions, thirteen (45%) received 5 or more additional infusions, and 4 (14%) we able to receive 10 or more additional infusions. Conclusions: Our review of hypersensitivity reactions to oxaliplatin demonstrates that the majority of patients experience mild (Grade 1 or 2) reactions and are able to be successfully rechallenged in subsequent courses with modifications in the infusion rate and premedications. The use of these treatment strategies may prevent premature discontinuation of an important backbone drug for the treatment of gastrointestinal malignancies.