The number of clinically relevant gene-based guidelines and recommendations pertaining to drug prescribing continues to grow. Incorporating gene-drug interaction information into the drug-prescribing process can help optimize pharmacotherapy outcomes and improve patient safety. However, pharmacogenomic implementation barriers exist such as integration of pharmacogenomic results into electronic health records (EHRs), development and deployment of pharmacogenomic decision support tools to EHRs, and feasible models for establishing ambulatory pharmacogenomic clinics. We describe the development of pharmacist-managed pharmacogenomic services within a large health system. The Clinical Pharmacogenetics Implementation Consortium guidelines for HLA-B*57:01-abacavir, HLA-B*15:02-carbamazepine, and TPMT-thiopurines (i.e., azathioprine, mercaptopurine, and thioguanine) were systematically integrated into patient care. Sixty-three custom rules and alerts (20 for TPMT-thiopurines, 8 for HLA-B*57:01-abacavir, and 35 for HLA-B*15:02-anticonvulsants) were developed and deployed to the EHR for the purpose of providing point-of-care pharmacogenomic decision support. In addition, a pharmacist and physician-geneticist collaboration established a pharmacogenomics ambulatory clinic. This clinic provides genetic testing when warranted, result interpretation along with pharmacotherapy recommendations, and patient education. Our processes for developing these pharmacogenomic services and solutions for addressing implementation barriers are presented.

Irinotecan alone appears to be the most cost-effective second-line regimen for patients with gastric cancer. Paclitaxel may be cost-effective if the WTP threshold was set at $160,000/QALY gained.

Introduction Various health care professionals provide dedicated anticoagulation management services (AMS). There is limited literature describing head‐to‐head trials comparing outcomes among different types of AMS. Objectives The primary objective is to compare all‐cause hospitalizations between pharmacist‐ and nurse‐managed AMS. The secondary objectives are to characterize admissions, readmissions, and emergency department visits. Methods This study is a retrospective, observational cohort. Patients were included if they were 18 y of age or older and had an anticoagulation management consult for either the pharmacist‐ or nurse‐managed anticoagulation clinics from July 1, 2013 to June 30, 2014. Patients were excluded if they had a lapse of 10 wk without a point‐of‐care International normalized ratio draw or had a duration of warfarin management less than 2 wk. The study period included the duration of warfarin management or up to 1 y of warfarin management after the initial consult, whichever was shorter. Results A total of 824 and 547 patients were identified in the pharmacist‐ and nurse‐managed groups, respectively. A total of 250 patients were randomized in each arm. After accounting for exclusion criteria, 242 and 245 patients were included in the pharmacist‐ and nurse‐managed groups, respectively. Baseline characteristics differed between the groups based on poverty status, race, stroke risk score, previous admissions, and international status. The primary outcome occurred in 55 (22.7%) of the pharmacist‐managed patients and 86 (35%) of the nurse‐managed patients (P = 0.002). When accounting for differences in baseline characteristics, there was a statistically significant decrease in all‐cause hospitalizations in the pharmacist group (odds ratio = 0.63; 95% confidence interval [0.39‐0.98]). Indication for warfarin, types of admissions, emergency department visits, and 30‐d readmissions was similar between the groups. Time in therapeutic range was different between the groups. Conclusion This hypothesis‐generating study found a difference in AMS performed by pharmacists and nurses. Pharmacists reduced hospitalization rates within the first year of AMS.

No abstract

e22023 Background: Aprepitant is an antiemetic that antagonizes the substance P neurokinin-1 receptor. Fosaprepitant is an intravenous prodrug of aprepitant and is FDA-approved for the prevention of chemotherapy-induced nausea and vomiting (CINV) in adults. Although the FDA extended approval of oral aprepitant to children and adolescents for CINV, pediatric patients have challenges obtaining aprepitant due to insurance or have difficulty taking oral medications during chemotherapy. Fosaprepitant is a logical alternative but data are lacking for safe and effective dosing in children. In 2015, fosaprepitant was added to our hospital formulary for pediatric patients receiving moderate to highly emetogenic chemotherapy. The fosaprepitant dose established was 150mg for weight ≥30kg or 3mg/kg/dose for < 30kg. There is also potential for overall cost savings to our institution. Fosaprepitant is about half the cost of aprepitant using equivalent adult doses. Methods: This retrospective chart review was considered exempt from IRB.All pediatric patients who received fosaprepitant between April 2015 and October 2016 while inpatient were included.Patients undergoing bone marrow transplant were excluded from the study.The primary objective was to determine safety of fosaprepitant. To evaluate safety, incidence of infusion related reactions related to fosaprepitant administration were assessed. Secondary objectives include efficacy of fosaprepitant in pediatric patients and evaluation of cost savings. To evaluate efficacy, the use of breakthrough antiemetics, documented emesis, and Adapted Rhodes Index for Nausea and Vomiting score were collected. Descriptive statistics were used for all data analyses on a per cycle basis. Results: A preliminary safety evaluation of 20 patients ages 9 months through 16 years received 87 doses of fosaprepitant for CINV prophylaxis.Six patients < 30kg received weight-based dosing; the other 14 patients received a dose of 150mg.One patient experienced an infusion related reaction from fosaprepitant but symptoms resolved after the infusion was stopped. Conclusions: Fosaprepitant appears to be safe and cost-effective to prevent CINV in children.