Immunity to malaria is complex, due to the replicative cycle of the parasite through intracellular and extracellular phases. Cellular and humoral immunity are necessary to contain the infection; it is more complicated in patients who regular receive immunosuppressive treatment.
Purpose
To report a case of malaria after recent kidney transplantation without recent exposure to an endemic area.
Material and methods
The patient was a 42-year-old man who presented to the hospital after 2 days of nausea, vomiting, fever, headache and malaise. He was from Nigeria and had lived in Spain since 2004. His medical history was significant for renal transplantation from a live donor a month before this episode. Regarding the donor, the 58-year-old man was HLA identical with normal examination results, including PCR negative for Leishmania spp and Plasmodium spp. Blood smears were negative. Concerning his medical history, he had malarial disease 6 years previously.
Results
Haemogram showed normal range levels except for lower platelet count and increased serum creatinine. Blood smears demonstrated Plasmodium falciparum and parasitaemia at 1%. Blood was sent to the laboratory for PCR confirmation. The patient was started on treatment with Quinimax (a combination of four alkaloids related to quinine) and doxycycline adjusted dose, for 7 days. This treatment required special follow-up for glycaemia. Also, renal function was monitored and immunosuppressive drug levels (tacrolimus–prednisolone) were measured, owing to interaction with malaria drug treatment. Dose adjustment was required. No parasitaemia was found after malaria treatment. The patient was discharged with follow-up appointments.
Conclusion
To date, there are some cases of malaria after kidney transplantation with unknown origin; it could be considered a recrudescence years after exposure. In conclusion, routine malaria prophylaxis treatment is likely necessary for renal transplantation and in the post-transplantation period for patients from endemic areas although they do not have to have had recent contact, especially if the donor is also from an endemic areas. No conflict of interest
Recent publications indicate that there are currently certain unmet needs shown by patients, highlighting the rapid onset of action and the persistence of the drug related to the increase in quality of life and the decrease in the stigma of the pathology. The appearance of new therapeutic targets presents us with a hopeful future in the treatment of psoriasis. In this context, it is of interest to know the persistence of gulselkumab, the first anti-IL 23 marketed in 2017.
Aim and Objectives
To evaluate the persistence and complete skin clearance of guselkumab in all patients with moderate-severe psoriasis in our hospital.
Material and Methods
Retrospective descriptive study conducted from the first prescription of guselkumab, May 2019, to September 2022. The electronic clinical record and the Farmatools application were used to record the following variables: age, sex, previous biological treatments, duration of therapy, posology and Psoriasis Area and Severity Index (PASI). The guselkumab regimen was 100 mg subcutaneously at weeks 0 and 4, followed by a maintenance dose of 100 mg every 8 weeks, in some patients the dose interval is longer in maintenance adjusted for drug response.
Results
Forty-four patients were included (52% men), aged 54 ± 13 years. 50% of the patients were treated with a previous line, 39% with 2 or more lines, and 11% were naive for monoclonal antibody (mAbs). Two patients discontinued during induction due to primary failure and one due to adverse reaction. There were 2 losses to follow-up. The overall mean persistence was 758 ( ± 312 days). Currently 32 patients continue in treatment with guselkumab, 61% presented PASI 0 in the last clinical evaluation. 34% have an optimised schedule: 22% every 10–12 weeks, 9% every 16 weeks, and one patient takes it every 24 weeks.
Conclusion and Relevance
High levels of persistence and level of clearance of guselkumab in our clinical practice, which 90% of patients have been previously treated with mAbs, are in line with the 5 year results presented by Reich K. et al.
References and/or Acknowledgements
1. Zozaya, Néboa, et al. Unmet Needs in the Management of Moderate-to-Severe Psoriasis in Spain: A Multidimensional Evaluation. Acta Dermato-Venereologica (2022).
Administration of continuous infusion of vancomycin is an alternative to administration of this drug.
Purpose
To evaluate the clinical efficacy and incidence of adverse effects with a regimen of vancomycin as a continuous infusion.
Material and methods
This was an observational retrospective study of the use of vancomycin in a child diagnosed with ganglioneuroblastoma L2. The information was obtained from the electronic clinical history (SELENE) and the pharmacy service managing software (FARMATOOLS). The programme used for monitoring the pharmacokinetics of drugs is PKS.
Results
The patient was a 4-year-old admitted to the paediatric ward of a hospital with febrile neutropenia after receiving the second cycle of chemotherapy (cyclophosphamide+vincristine+adriamycin). Empirical antibiotic therapy was started: vancomycin (15 mg/kg/6 hours) and amikacin (15 mg/kg/24 hours). Vancomycin trough levels obtained during the first 3 days of treatment were very low (2 µg/mL) so a continuous infusion of vancomycin was started. With 60 mg/kg/24 hours of vancomycin, steady state plasma concentration (Css) of 12.1 µg/mL were obtained. Optimal Css levels for vancomycin for prophylaxis treatment are 15–20 µg/mL. Because of persistent fever and worsening of clinical status, the dose was increased to vancomycin 70 mg/kg/day and optimal plasma levels were obtained (17.5 µg/mL). The dose of amikacin was maintained at 15 mg/kg/24 hours, obtaining optimal plasma levels (trough level <1 µg/mL and peak level 30–40 µg/mL). Antibiotic treatment was continued for 7 days and the child had a good response.
Conclusion
Administration of continuous infusion vancomycin reached therapeutic levels with good clinical efficacy and no evidence of renal injury, so it is a therapeutic strategy for patients with low levels of drugs in plasma. Moreover, it is a more comfortable administration, with decreased nursing workloads and less manipulation of intravascular catheters. We need more paediatric studies to evaluate the efficacy and safety of these patients using this type of administration.
References and/or acknowledgements
Pharmacokinetics manual pharmacy service. Data sheet of vancomycin and amikacin. Clinical Report. Evaluation of a paediatric continuous-infusion vancomycin therapy guideline (Susan McKamy, Tempe Chen, Michelle Lee, Peter J Ambrose). No conflict of interest
Multiple sclerosis (MS) is a chronic and inflammatory neurological disease in which focal demyelination occurs in the CNS. Dimethyl fumarate (DMF) is indicated for the treatment of adult patients with relapsing-remitting multiple sclerosis. It is administered orally. The dose is 240 mg twice daily; 120 mg twice daily for the first 7 days.
Purpose
Our goal was to analyse the profile of patients and tolerability of DMF.
Material and methods
A retrospective observational study was constructed from October 2014 to May 2015. SAP software was used for medical history, nursing and recording dispensations of patients treated with DMF. Data recorded were: age, sex, EDSS, pretreatment, analytical performed and adverse reactions.
Results
16 patients, 11 women and 5 men, with a mean age of 39.31 years (16–63) were analysed. Mean EDSS was 2.4 (1–4.5). DMF was prescribed as the firstline treatment in 5 patients (31.25%), as secondline in 7 (43.75%), as the third treatment in 3 (18.75%) and as the fourth treatment in 1 (6.25%). DMF was given immediately before treatment with interferon beta-1b 250 µg in 4 patients, interferon beta-1a 30 µg and 44 µg interferon beta-1a in 3 and glatiramer acetate 1. In all cases, the reason for the change was pain and skin reactions, flu-like syndrome uncontrolled in two cases and radiographic progression in one. All patient analyses were performed to assess renal function, liver function and blood count 1 month after starting treatment, and at 3 and 6 months. 5 (31.25%) patients had mild to moderate disease at baseline, 1 (6.25%) patient experienced flushing and elevated liver transaminases more than three times the normal value and 3 (18.75%) patients had major digestive problems, with 2 (12.5%) suspending treatment despite starting treatment using a gradual protocol: doses of 120 mg-0–120 mg for the first week, 120 mg-0–240 mg for the second and third weeks, and full dose 240 mg-0–240 mg from the fourth week, trying to reduce subsequent doses. Mean duration of treatment with DMF was 4.56 months (2–8).
Conclusion
DMF was accepted well by patients after oral administration despite its side effects (mainly flushing and gastrointestinal effects) that appeared at the start of drug treatment. The adverse reaction profile observed was similar to that described in the product information.
References and/or Acknowledgements
http://www.aemps.gob.es/medicamentosUsoHumano/informesPublicos/docs/IPT-dimetilfumarato-tecfidera.pdf No conflict of interest.
Characterizing the epidemiology of circulating respiratory pathogens during the COVID-19 pandemic could clarify the burden of acute respiratory infections and monitor outbreaks of public health and military relevance. The US Department of Defense supported 2 regions for influenza-like illness and severe acute respiratory infections surveillance, one in the Middle East through US Naval Medical Research Unit EURAFCENT, and another in Latin America through US Naval Medical Research Unit SOUTH. During 2020‒2022, coinciding with the COVID-19 pandemic, we collected a total of 16,146 nasopharyngeal and oropharyngeal swab samples from sentinel sites in Jordan (n = 11,305) and Latin America (n = 4,841). Samples were tested for SARS-CoV-2, influenza, and other respiratory pathogens. SARS-CoV-2 was the most frequently detected pathogen during 2020; other respiratory pathogens had distinct temporal and frequency distributions according to geographic location. Our findings support the need for continued sentinel surveillance as a vital tool for assessing the burden of respiratory diseases globally.
The commercialisation of fixed-dose combination meant an improvement in antiretroviral therapy (ART). With generics we have the opportunity to maintain the therapy at a lower cost, but we complicate the dosage regimen again.
Purpose
To assess the effect in costs of a two-pill, generic-based regimen compared with a branded coformulated regimen, and to project the potential annual savings in the first year of a switch to generic-based ART. We replaced Triumeq® (ABC/3TC/DTG) by a combination of Tivicay® (DTG) +generic ABC/3TC, and Atripla® (TDF/FTC/EFV) by Truvada® (TDF/FTC)+generic EFV.
Material and methods
We selected and analysed all patients who received Atripla® (TDF/FTC/EFV) and Triumeq® (ABC/3TC/DTG) from June 2016 to September 2017. Data were collected from the medication consumption files of the institution. We analysed the records related to the treatment. The economic savings associated with the change of treatment were quantified.
Results
313 patients were analysed, 108 (34.5%) initially treated with Atripla® and 205 (65%) initially treated with Triumeq®. A total of 252 (80.5%) patients were switched to a new treatment (162 patients with Triumeq® and 90 patients whith Atripla®), four (1,27%) of whom returned to initial treatment for adverse effects. A total of 61 patients were not changed. The main reason for opposing the change was the difficulty in adherence 17 (27.8%), followed by patient refusal four (6.5%) The change to Triumeq® meant a saving of €22.380/month and the change to Atripla® a saving of €10.100/month. This represents a total saving of €389.772/year.
Conclusion
Generics formulations in ART is an opportunity to contain pharmaceutical costs in hospitals. Changes in therapy produced a low rate of adverse reactions (1.27%) and a cost saving of €389.772/year. It requires adherence data to be able to affirm that this strategy decreases costs without prejudice to the patient.
References and/or Acknowledgements
All staff of our pharmacy service No conflict of interest
Atypical haemolytic uraemic syndrome (aHUS) is a severe life threatening disease with progression to end stage renal disease. Eculizumab, a humanised anti-C5 monoclonal antibody targeting the activated complement pathway, has been introduced as a therapy against aHUS.
Purpose
To demonstrate the efficacy and safety of eculizumab in brief and sustained interruption of the thrombotic microangiopathy process, increase in the number of platelets and significant improvement in renal function in the long term with important reductions in the need for dialysis and plasmapheresis.
Material and methods
Observational, retrospective and descriptive study of a patient with aHUS. The information was obtained from the electronic clinical history (SELENE) and the pharmacy service managing software (Farmatools).
Results
The patient was a 60-year-old woman who was hospitalised with renal failure symptoms (Cr 16.6 mg/dL) associated with severe anaemia (Hb 4.5 g/dL) and thrombopenia (platelets 111 000 U/µL) without previous infection. She was started on alternative renal therapy and red blood cell transfusion. Autoimmune studies were requested detecting ANCA+ antibodies and so steroid treatment was started, associated with cyclophosphamide with no response. Due to thrombopenia persistence, we decided to start plasmapheresis with good response, stabilising haemoglobin and increasing the platelet count; however, renal failure function and MAT parameters persisted. From the time of admission (7 January 2015 to 22 February 2015), she needed 14 plasmapheresis sessions and 2 cyclophosphamide boluses with active haemolysis pattern and so was dependent on substitutive renal therapy. The patient started this therapy on 22 February 2015 with 4 doses, 900 mg/week, with good response. No further transfusions or plasmapheresis were needed, with an increase in platelet count (50 000 to 135 000 U/µL) and creatinine (7 to 5.42 mg/dL). After a week without this drug, analytical values got worse (platelets 111 000 U/µL and creatinine 11.71 mg/dL), and so eculizumad was authorised as maintenance therapy, 1200 mg/15 days. After a month with this maintenance therapy, the result was an increase in platelet count up to 182 000 mg/dL, haemoglobin increase to 9.1 g/dL and creatinine increase to 7.33 mg/dL.
Conclusion
FDA, EMA and AEMPS have approved the use of eculizumab for treating aHUA. With this good response in this clinical case, eculizumab was effective in aHUS. However, the treatment's high cost requires correct pathological identification in patients, so each case should be studied by a multidisciplinary team (haematology, nephrology and pharmacy).
References and/or Acknowledgements
Eculizumab summary of product characteristics. No conflict of interest.
Essential thrombocythaemia (ET) is an uncommon myeloproliferative disorder with an elevated platelet count. ET occurring in pregnancy has been reported to be mainly associated with first trimester abortion, preterm delivery, intrauterine growth retardation, placental abruption and preeclampsia.
Purpose
To describe the case of a pregnant patient diagnosed with essential thrombocythaemia who could not remain untreated due to complications of the disease.
Materials and methods
35-year-old female patient diagnosed with essential thrombocythaemia untreated for months so she could try for a baby reached platelet counts of 1,118,000/mL. In the first month of pregnancy this could not be left untreated because complications can arise as such microthrombosis in blood vessels, leading to a high incidence of abortions in these patients. The treatment requested from pharmacy services for this case was interferon alpha-2 beta (IFN α-2b) which has shown no teratogenicity compared to other alternatives such as hydroxyurea or anagrelide. Low-dose acetylsalicylic acid is contraindicated in patients with platelet counts of more than a million/mL, due to the possibility of acquired Von Willebrand syndrome. Interferon alfa has not been approved for the indication of essential thrombocythaemia so its off-label use required approval by the hospital management. 3 MUI of IFN α-2b were administered twice weekly IV during gestation.
Results
Platelet counts decreased gradually from the beginning of treatment passing from 1,118,000/mL to 680,000/mL in two weeks, then 602,000/mL in the third month, in the fourth month 530,000/mL, 487,000/mL in the fifth month, in the sixth month 462,000/mL and in the seventh month 328,000/mL. During week 29 + 2 gave birth by emergency Caesarean section because of severe preeclampsia. Despite the complications, mother and child progressed favourably.
Conclusions
Essential thrombocythaemia is a difficult to treat disease in pregnancy. Sometimes you have to use drugs off-label. In this case, the IFN α-2b successfully reduced the platelet count during pregnancy. No conflict of interest.