4CPS-114 Integration of a pharmacist into a geriatric department

Abstract

ALT), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP) and total bilirubin (TB)), dose, diagnosis, age and sex were registered.Microsoft Excel was used for the statistics calculation. Results 68 determinations in 38 patients (73.75% men; aged 64.84 ±11.29 years).Diagnosis: probable disease 21 (55.28%), possibility 12 (31.57%), prophylaxis 5 (13.15%).6 (15.8%) patients needed a change in treatment. 5 (83.33%) had the dose changed in order to maintain plasma levels between 1 and 5.5 mg/mL. In 1 patient (16.66%) voriconazole was substituted.28 (73.7%) started treatment with the dose of 200 mg/12 hours, whereas the rest (26.3%) has a higher dose. 60% of dose changes were in patients taking 200 mg/12 hours.A positive correlation existed between plasma levels of voriconazole and liver enzymes as well as with cholestasis markers (AST: r 2 =0.1817; ALT: r 2 =0.1118; GGT: r 2 =0.2528; PA: r 2 =0.2444 and TB: r 2 =0.4637).The Chi-square statistic was significant at p<0.05 for plasmatic levels over 3 mg/mL and AST/ALT over physiological range (35 U/L).The relative risk of presenting ALT over the physiological range is 3.12 and for AST 2.31 in patients with plasmatic levels of voriconazole >3 mg/mL respects the ones whose plasmatic levels were <3 mg/mL. Conclusion and relevanceVoriconazole TDM is a tool that can help to avoid treatment failure and adverse events. Its relationship with liver toxicity, which shows our data, TDM would help to prevent these side effects.