Antifungal effects of yeast-derived rhu-GM-CSF in patients receiving high-dose chemotherapy given with or without autologous stem cell transplantation: a retrospective analysis

Systemic fungal infections (SFI) in patients receiving high-dose chemotherapy (HDC) are a frequent cause of morbidity and mortality. Preclinical studies have reported augmented antifungal activity of monocytes, macrophage cells, and neutrophils exposed to certain colony-stimulating factors (CSF), including GM-CSF. We conducted a retrospective descriptive epidemiologic study to examine the characteristics of 145 consecutive patients receiving HDC administered with or without autologous stem cell transplantation (ASCT) and who subsequently received either GM-CSF and G-CSF, G-CSF alone, GM-CSF +/- IL-3 or no CSF. The analysis of this patient population sought to define the incidence of SFI and its relationship to therapy with monocyte/macrophage-stimulating (MMS group) cytokines (GM-CSF and G-CSF; GM-CSF +/- IL-3) or to cytokines which do not result in monocyte/macrophage stimulation (NMMS group, G-CSF alone or no CSF). Risk factors for the development of SFI were balanced between the MMS (n = 70) and NMMS (n = 75) groups. Two patients (2.9%) in the MMS and nine patients (12%) in the NMMS groups developed SFI. The risk ratio for developing SFI in the NMMS group compared to the MMS group was 4.20 (P = 0.023). This relationship was confounded, however, by the diagnosis of hematologic tumor or solid tumor (RR = 3.15, P = 0.082). SFI was the primary cause or major contributing factor in five of the 10 total deaths in our study population. Four SFI-related deaths occurred in the NMMS group and one SFI-related death occurred in the MMS group. Our data suggest a protective role for GM-CSF, IL-3 or other MMS cytokines in preventing SFI in patients receiving HDC. This should be further investigated as a potential complementary approach to conventional strategies in antifungal prophylaxis for patients receiving HDC.

Irreversible, severe congestive cardiomyopathy occurring in association with interferon alpha therapy

Interferon alpha is a biologic agent with demonstrated anti-tumor activity in a variety of hematologic and solid malignancies. Many patients treated with interferon experience acute toxicity manifested as a flu-like syndrome of fever, chills, myalgias, and malaise. However, fatigue, anorexia, bone marrow suppression, nausea, vomiting, dizziness, and confusion may also occur. Cardiotoxicity is a rare complication of interferon therapy that most frequently presents as transient episodes of hypotension and tachycardia, with few significant life-threatening cardiovascular effects reported. A small number of cases of suspected interferon-induced cardiomyopathy, all of which improved after discontinuing interferon, have recently been documented. We report a patient with multiple myeloma who developed severe congestive cardiomyopathy while receiving interferon alpha that did not reverse subsequent to discontinuation of interferon therapy. Although the patient had previously received doxorubicin, the presence on endomyocardial biopsy of a prominent intracellular lipid accumulation within myocytes and only grade 2 anthracycline cardiotoxicity suggested that other or additional factor(s) contributed to the severity of this patient's cardiomyopathy. Etiologies of cardiac dysfunction other than interferon and doxorubicin were excluded. While a direct cause-effect relationship between interferon alpha and irreversible congestive cardiomyopathy cannot be firmly established in this case report, patients who either concurrently or sequentially receive interferon and anthracyclines should be carefully monitored for evidence of cardiac toxicity.

Effectiveness of clinical pharmacist interventions in a hemodialysis unit

Many patients with end-stage renal disease are treated with a complex pharmacotherapeutic regimen that requires constant and thorough monitoring. The role of a clinical pharmacist in contributing to the care of patients receiving long-term hemodialysis in an outpatient dialysis unit was assessed. Therapeutic interventions provided routinely by the clinical pharmacist were recorded and then categorized and evaluated by two independent clinical pharmacists with expertise in nephrology pharmacotherapeutics. Of the 205 interventions recorded, 97.6% were initiated by the clinical pharmacist and 91.7% were accepted by the medical team; 80.9% were judged to have primarily affected the quality of care. The purposes of interventions were drug selection in 32.2% of cases, drug discontinuation in 19.0%, dose selection in 24.4%, and therapeutic monitoring in 24.4%. Most interventions were initiated in response to abnormal laboratory test results. When the interventions were ranked according to clinical significance, 34.6% were involved with the preservation of major organ function and 62.4% with improvement of the quality of care to acceptable standards. Of all the interventions accepted by the medical team, 90.5% resulted in positive patient outcome; 7.9% resulted in no observable change or had no effect on outcome. The results demonstrate the potential influence and effectiveness of clinical pharmacy interventions on the drug therapy of patients receiving long-term hemodialysis.

Vascular access thrombosis during recombinant human erythropoietin therapy

The increased incidence of vascular access thrombosis (VAT) associated with recombinant human erythropoietin (r-HuEPO) therapy is multifactorial and controversial. Sixty-three hemodialysis patients who received > or = 12 weeks of r-HuEPO therapy were prospectively followed for the incidence of VAT. Those who experienced VAT (Group 1) were compared with those who did not (Group 2). The patients initially received r-HuEPO 50 U/kg intravenously three times a week. The dose was adjusted for a target hematocrit (t-Hct) of 30-33%. Twenty-five of the 63 patients (40%) experienced VAT (Group 1). These patients were older (mean, 54.0 +/- 14.0 years versus 47.3 +/- 15.0 years, p = 0.08). There was no difference between Groups 1 and 2 with respect to the baseline Hct level (21.5 +/- 2.9% versus 21.4 +/- 4.3%), the number of patients who achieved t-Hct (20 versus 28), and the mean time to reach t-Hct (18.6 +/- 15.1 weeks versus 16.9 +/- 16.2 weeks). However, 20 of 25 Group 1 patients (80%) were diabetic compared with only 18 of 38 Group 2 patients (47%, p = 0.0169, by Fisher's exact test). In addition, the types of vascular access differed markedly between the two groups: arteriovenous (AV) grafts/AV fistulae/Permcaths, Group 1: 21/3/1 versus Group 2: 15/21/2, p = 0.0018. It was concluded that the occurrence of VAT in r-HuEPO treated patients was not related to the patient's hematologic response to the drug, but rather, it depended upon the integrity of the patient's vasculature and the type of vascular access used.