Chapter 159: Hematopoietic Stem Cell Transplantation: Many Meds, Many Interactions Level III

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LEARNING OBJECTIVES

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.

PATIENT PRESENTATION

Chief Complaint

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.

HPI

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.

PMH

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.

FH

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

Meds (at Day +120)

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