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After completing this case study, the reader should be able to:
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.
Recommend optimal therapeutic plans, taking into account drug interactions, efficacy, safety, and patient adherence in postallogeneic SCT patients.
Design appropriate pharmacotherapeutic plans for patients who develop toxicity from immunosuppression.
The patient is being seen for follow-up in clinic and has developed bothersome headache and tremors with movement such as typing or holding a cup. She was seen recently by her PCP for dyslipidemia and hypertension and has had changes in her medication regimen.
Brenda Langer is a 68-year-old woman who presents to the BMT clinic 120 days post HLA-matched unrelated donor allogeneic SCT for high-risk AML. Her 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). Her GVHD prophylaxis regimen consisted of tacrolimus and sirolimus, both starting on day –3. Her hospital course was complicated by febrile neutropenia, acute kidney injury, mucositis, and diarrhea. These complications had resolved at the time of discharge on day +20. Two weeks ago, she developed a skin rash and diarrhea and was diagnosed with grade 2 acute GVHD. She was started on prednisone 90 mg (1 mg/kg) orally BID, and fluconazole was switched to posaconazole 300 mg orally once daily. Her PCP also added gemfibrozil 600 mg orally twice daily to her lipid regimen.
High-risk AML treated with idarubicin and cytarabine induction, followed by high-dose cytarabine × 1 cycle. She was started on amlodipine at hospital discharge for newly diagnosed hypertension. Dyslipidemia was managed previously with atorvastatin and recently with addition of gemfibrozil.
Married with two children. Father is deceased from atherosclerotic heart disease.
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
Atorvastatin 10 mg PO daily
Gemfibrozil 600 mg PO BID
Triamcinolone 1% cream—apply twice daily to chest and shoulders