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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Understand the regimen-related toxicities of immunosuppression medications used for allogeneic stem cell transplantation (SCT).

  • Differentiate the presenting features of immunosuppressive medication adverse events from other medications.

  • Design appropriate pharmacotherapeutic plans for patients who develop toxicity from immunosuppression.

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PATIENT PRESENTATION

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Chief Complaint

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The patient is being seen for follow-up in clinic and has developed bothersome tremors and headaches. He was seen recently by his PCP for dyslipidemia and hypertension and has had changes in his medication regimen.

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HPI

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Jacob Weber is a 45-year-old man who presents to the BMT clinic 75 days post HLA-matched unrelated donor allogeneic stem cell transplantation for high-risk AML. His preparative regimen consisted of thiotepa (5 mg/kg IV Q 12 H × 3 doses) and cyclophosphamide (60 mg/kg IV Q 24 H × 2 doses). His GVHD prophylaxis regimen consisted of tacrolimus and sirolimus, both starting on day 3. His hospital course was complicated by febrile neutropenia, acute kidney injury, mucositis, and diarrhea. These complications had resolved at the time of discharge approximately 6 weeks ago. Two weeks ago, he developed a skin rash and diarrhea and was diagnosed with grade 2 acute GVHD. He was started on prednisone 90 mg (1 mg/kg) orally BID, and fluconazole was switched to posaconazole 300 mg orally once daily. His PCP also added gemfibrozil 600 mg orally twice daily to his lipid regimen.

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Today, his main complaints are headache and tremors with movement such as typing or holding a cup. He reports taking his hospital discharge dose of tacrolimus 2 mg orally twice daily and sirolimus 2 mg orally once daily.

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PMH

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High-risk AML treated with idarubicin and cytarabine induction, followed by high-dose cytarabine × 1 cycle. He was started on amlodipine at hospital discharge for newly-diagnosed hypertension. Dyslipidemia was managed previously with atorvastatin and recently with addition of gemfibrozil.

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FH

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Married with two children. Father is deceased from atherosclerotic heart disease.

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Meds (at Day +75)

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  • Posaconazole 300 mg PO daily

  • Esomeprazole 40 mg PO daily

  • Tacrolimus 2 mg PO twice daily

  • Prednisone 90 mg PO twice daily

  • Valacyclovir 500 mg PO twice daily

  • Amlodipine 10 mg PO daily

  • Prochlorperazine 10 mg PO Q 8 H PRN nausea/vomiting

  • Sirolimus 2 mg PO once daily

  • Dapsone 100 mg PO daily

  • Atorvastatin 10 mg PO daily

  • Gemfibrozil 600 mg PO BID

  • Triamcinolone 1% cream—apply twice daily to chest and shoulders

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All

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Sulfa → urticaria

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ROS

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Worsening “annoying” motor tremors that interfere with activities of daily living such as typing and drinking. Patient also reports dull headache that started about a week ago.

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Physical ...

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