Multiple myeloma is the second most common type of hematologic malignancy. It is a B-cell malignancy that affects the bone marrow and often results in thrombocytopenia as well as renal dysfunction. Treatment options range from oral and intravenous chemotherapy to bone marrow transplantation and supportive care. Carfilzomib was approved by the U.S. Food and Drug Administration in 2012 as a treatment option for patients with refractory multiple myeloma who have received at least two previous therapies and have demonstrated recent disease progression. According to the product labeling, the frequency of tumor lysis syndrome (TLS) is less than 1% in patients treated with carfilzomib. To our knowledge, no postmarketing events of TLS have been reported or published. We describe a 55-year-old man with relapsed multiple myeloma who developed a case of TLS that occurred after he received his first two doses of carfilzomib therapy on days 1 and 2; he also had chronic kidney disease secondary to his neoplastic disease. Beginning on day 4, his uric acid levels spiked to critical levels, prompting the use of rasburicase, which returned the levels to within normal limits. His phosphorus and creatinine levels increased during days 5 and 6. On day 8, the patient died, likely due to a combination of disease progression and the adverse effects of treatment. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patient's development of TLS and carfilzomib therapy. The Hill criteria were used as a secondary measure to ensure causality, which also suggested a link between the patient's development of TLS and the administration of carfilzomib. This case report shows that even the most unlikely of adverse events may occur with medications, especially in the case of a new or recently approved medication. Caution must be taken when deciding to treat and when choosing hydration and premedications with regard to biologic and chemotherapeutic medications. In this case, additional hydration may have been considered. Although given the extent of the adverse reaction combined with the patient's underlying renal dysfunction, extra fluid may or may not have proven beneficial. The use of prophylactic rasburicase or allopurinol could have been considered, but these measures are not typically used with multiple myeloma due to the low incidence of TLS. All things considered, this unlikely adverse reaction may occur in certain patients. If other cases such as this occur, it may be advisable to use TLS prophylaxis in the future in certain patient populations, including those with renal dysfunction or worsening disease states.

Patients receiving immunosuppressive agents are at higher risk of developing invasive fungal infections, and all patient medications should be reviewed to identify those with potential antifungal properties.

Background: The optimal antiplatelet therapy regimen in the early post-operative CABG period is not well researched. Several studies have proven that use of clopidogrel and aspirin prior to surgery increases bleed risks, but very few studies have examined this therapy post-operatively. Due to the limited amount of data surrounding this topic, the goal of this study was to determine if single or dual antiplatelet therapy had better outcomes in those status-post CABG surgery. Methods: This was a retrospective, single center, cohort study performed at Saint Joseph Hospital in Lexington, Kentucky. Data was reviewed through the Society of Thoracic Surgeons (STS) database, pharmacy medication dispensing records, as well as manual chart review. The primary composite endpoint of the study consisted of in-hospital mortality, ischemic or thrombotic events, bleeding events, restenosis rates, and 30-day readmission rates. Results: The number of events with regard to the primary composite endpoint was 32 events with combination therapy and 39 events with aspirin monotherapy (p = 0.39). A greater decrease in hemoglobin and hematocrit was seen in the aspirin monotherapy group (p = 0.02 and p = 0.047). Patients with prior CVA or TIA were more commonly placed on combination therapy after surgery (p = 0.018). There were no differences in outcomes when type of antiplatelet therapy and type of CABG were analyzed. Conclusions: There was no difference seen between single versus dual antiplatelet therapy regarding the primary composite endpoint. There was an increase in bleeding events with aspirin monotherapy as defined by TIMI criteria as well as a statistically significant decrease in Hgb and HCT with aspirin monotherapy. Patients with previous CVA/TIA were more likely to receive combination therapy. The average number of vessels grafted per surgery was lower in the off-pump surgery cohort.

Background Prophylaxis with granulocyte colony-stimulating factors (G-CSFs) reduce the severity and duration of chemotherapy-induced neutropenia. Currently, the use of G-CSF prophylactic treatment to prevent neutropenia and its complications varies widely in clinical practice with no standardization for intermediate-risk chemotherapy regimens. Objective: The purpose of this study was to assess neutropenic outcomes in patients receiving intermediate-risk chemotherapy regimens who receive primary versus secondary prophylactic G-CSFs. Methods: This is a retrospective, multicenter cohort study of patients who received intermediate risk chemotherapy regimens and at least one dose of G-CSF therapy. 121 patients were included and were divided into primary (n = 76) or secondary prophylaxis (n = 45) groups. The primary outcome for this study was the incidence of neutropenic episodes per course of treatment. The secondary outcomes included the percentage of patients who experienced delays in chemotherapy doses, the number of chemotherapy dose reductions, and the number of subsequent treatment delays. Results: The incidence of neutropenic episodes over the course of therapy was 0.42 episodes in the primary group compared to 1.52 episodes in the secondary group (p < 0.05). 10.5% of patients in the primary group versus 54.3% of patients in the secondary group experienced chemotherapy dose delays (p < 0.05). There were no statistically significant differences in chemotherapy dose reductions or in the average number of FN risk factors between groups. Conclusion: This retrospective, cohort study determined that patients receiving intermediate risk chemotherapy regimens should receive primary prophylaxis, regardless of risk factors in order to decrease episodes of neutropenia and chemotherapy dose delays.