There was a real buzz after the pharmacy symposium at the International Society of Heart and Lung Transplant (ISHLT) annual conference this year in Montreal, with the audience and speakers breaking into groups to discuss aspects of the challenging real life case that had been presented as part of the Pharmacy and Pharmacology council's ‘Lifecycle Journey’ series. This series uses a developing case to create a panel-facilitated and audience-supported best practice-based discussion at predefined key ‘journey intervals.’ This year the session was titled: A Lifecycle Journey in Cystic Fibrosis and Lung Transplantation . In this session, members of the Pharmacy and Pharmacology and the Pulmonary Transplantation Councils focused on four ‘journey points,’ which include: (1) listing considerations and pretransplant infections, (2) perioperative and immediate postoperative management issues, (3) metabolic and interaction considerations to drug dosing and (4) immunomodulation strategies for the management of bronchiolitis obliterans syndrome. The first journey point proved thought-provoking, hearing the expert panel of pharmacists and physicians discuss their practice in managing a complex patient with resistant infections in order to ensure that the patient was in optimal condition at transplant. Unfortunately, need for suppression of Burkholderia cepacia complex and Mycobacterium abscessus prior to transplant is becoming all …
At this year's International Society of Heart and Lung Transplant (ISHLT) conference in San Diego, pharmacists have continued to make their mark. This is a society for all health professionals working in thoracic transplant, heart failure, advanced lung disease (particularly pulmonary hypertension (PH)) and mechanical cardiac support. What makes the ISHLT special for pharmacists is that not only is there is a pharmacist council for networking and sharing practice, but also pharmacists are totally integrated into the programme so that, at any educational session where medications are being discussed, pharmacists, as the recognised experts, are presenting evidence-based therapeutics to a multidisciplinary audience. This exciting model of collaboration means that pharmacists work with their peers (medical, nursing, scientists) to develop the overall programme, and that cross-discipline learning is the norm.
The pharmacy council did not shy away from tackling controversial topics at this years’ conference. Among many highlights was the latest instalment in the hugely successful ‘lifecycle journey’ series, which this year featured a case of decompensated PH in the setting of HIV. Dr Jean-Luc Vachiery presented the updated clinical classification of PH. This classification is essential reading for pharmacists involved in decisions regarding appropriate use of expensive targeted therapies for PH. Patricia Ging and Dr Patty Uber gave pharmacist-focused insights into management of the patient, considering therapeutic targets ranging from a simple assessment of compliance …
We present two cases of acute hepatotoxicity associated with elevated paracetamol (acetaminophen) levels in older patients. Both patients were receiving a standard European dose of oral paracetamol (2 × 500 mg QDS) with no risk factors for slowed metabolism (weight <50 kg, interacting medications, hepatic enzyme inducers, history of liver disease). Significantly, both patients had recently had a dose escalation from 'as needed' dosing to 4 g daily, and the medication was being administered by nursing staff. Our experience shows that even when prescribed appropriately at the usual therapeutic dosage, paracetamol can be hepatotoxic.
Osteoporosis after a lung transplant is common, with reported vertebral fracture rates of up to 30% [1]. Bisphosphonates, and calcium and vitamin D supplements may be less effective in patients who remain on steroid treatment [2]. Corticosteroids are more detrimental to spinal bone mineral density than to the hip [2]; however risk prediction systems use hip T-scores to predict risk and make treatment recommendations [3, 4]. We reviewed the prophylaxis of osteoporosis in a cohort of patients at the time of listing and up to 6 years post-transplant.
Purpose
We wished to identify: any potential for improvement in prescribing risk factors for clinically significant lumbar fractures the utility of currently available osteoporosis risk algorithms in this cohort.
Materials and Methods
We conducted a retrospective chart review (n = 27). Patients’ risk of fracture at the time of listing for transplant was calculated using three different methods including WHO charts and American College of Rheumatology algorithm for steroid-treated patients. We attempted to create a model to predict fracture in transplant recipients using known risk factors.
Results
At time of listing, all patients were taking at least 5 mg of prednisolone daily plus a bisphosphonate and appropriate calcium and vitamin D supplementation. Many already had osteoporotic T scores at this point. Fracture rates in our cohort are in line with published data, but substantially higher than those predicted from algorithms. Improvised algorithms using lumbar T scores were better at predicting risk than published methods. The only risk factor in our cohort that predicted subsequent fracture was lumbar spine T-score (Mean −1.2 versus −2.65 in the fracture group (P = 0.009)).
Conclusions
Current algorithms underestimate risk, new charts should be created using lumbar T-scores. Our results emphasise that current prophylaxis strategies are not successful in preventing fractures in those who have osteoporosis and remain on prednisolone. Early osteoporosis prophylaxis and alternative treatments are essential to prevent fractures.
References
Cohen A, Shane E, (2003). Osteoporosis after solid organ and bone marrow transplantation. Osteoporos Int 14, 617–30. Weinstein RS, (2011). Glucocorticoid-Induced Bone Disease. N Engl J Med 365, 62–70. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK. Online risk prediction tool. http://www.shef.ac.uk/FRAX/tool.jsp?country=1 (accessed 3 Nov 2011). Grossman JM, et al, (2010). American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res 62, 1515–26. No conflict of interest.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3cpath d='M200 752.362h200v300H200z' style='fill:%23fff;fill-opacity:1;stroke:none' transform='translate(0 -752.362)'/%3e%3cpath d='M400 752.362h200v300H400z' style='fill:%23ff883e;fill-opacity:1;stroke:none' transform='translate(0 -752.362)'/%3e%3c/svg%3e)
