A specialist clinical pharmacist in the SCT outpatient clinic resulted in regular and effective intervention contributing to improved medication management and adherence.
Allogeneic stem cell transplantation (SCT) is a complex procedure that requires specialized medication management. Providing clinical pharmacy services in the ambulatory setting is warranted, as medications are a common source of confusion for SCT patients and their carers. These patients were routinely managed via traditional ambulatory dispensary services. The successful implementation of a clinical pharmacy service to the SCT unit ambulatory clinic allowed for regular contact and review by an experienced clinical pharmacist. This new service was evaluated within the context of a research project. The clinical pharmacist's presence in the ambulatory setting resulted in the identification and rectification of many medium to high risk medication related problems. The clinical pharmacist also contributed towards improved overall adherence. Other institutions are encouraged to implement and evaluate clinical pharmacy services to their ambulatory settings for SCT and other complex chronic patients.
Backsummarised what is known about antiretroviral drug interactions and the challenge to manage them. The drug interactions were divided into three groups -useful, contraindicated and those requiring dose adjustments or additional management. An example of an useful drug interaction is using ritonavir to boost protease inhibitor levels. Nearly all protease inhibitor-containing regimens include ritonavir to ensure protease inhibitor levels are in excess of the minimum effective concentration for the full dosing interval. Using ritonavir to boost protease inhibitor levels can produce a more forgiving regimen. The term 'forgiveness' describes the ability of a regimen to achieve and sustain viral suppression, despite suboptimal adherence and the occasional missed dose. Data were presented assessing the 'forgiveness' of atazanavir/ritonavir (300/100 mg) daily, versus lopinavir/ ritonavir (800/200 mg) daily and (400/100 mg) twice daily. 1 Results showed that lopinavir/ritonavir daily is less forgiving than atazanavir/ritonavir daily.Data from the GRACE study were presented and showed the interesting difference in ritonavir exposure between males and females. 2 This multicentre phase IIIb trial assessed gender and race differences in efficacy, safety and tolerability of darunavir/ritonavir over 48 weeks. A pharmacokinetic substudy showed that although body mass indexes and weights were similar in male and female groups, median exposure to ritonavir was approximately 70% higher in female compared to males, and there was wide variability. This result was difficult to explain as the body mass indexes were the same, but postulated that perhaps fat distribution or hormonal influence may play a role. Some drug-drug interactions are so marked that coadministration is contraindicated, such as protease inhibitor inhibition of CYP3A4 resulting in dangerously high levels of the co-administered drug, e.g. simvastatin. Alternatively, enzyme induction or inhibition by a co-administered drug, e.g. rifampicin, resulting in diminished atazanavir/ritonavir levels. Often these drug interactions are not well studied as the theoretical risks predict perilous outcomes.Many drug interactions can be managed with dose adjustments, e.g. maraviroc a substrate of CYP3A4 (standard dose 300 mg twice daily) when co-administered with drugs that inhibit CYP3A4 (e.g. itraconazole, most protease inhibitors) the dose is reduced to 150 mg twice daily. Conversely, when maraviroc is co-administered with drugs that induce CYP3A4 (e.g. efavirenz, etravirine) the dose is increased to 600 mg twice daily. Management of potential drug interactions with maraviroc is going to require vigilance as there will be an increased need to check other medications the patient might be taking.The take-home message was that HIV patients often attend multiple clinics, including specialists, their general practitioner and others, and that a greater awareness needs to be adopted to reduce the likelihood of drug interaction mismanagement.
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