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10/4/18

Clinical Pearls UNMH Pharmacy Residents Jessica Lewis-Gonzalez, PharmD Valentin Pacuraru, PharmD Amre Elmaoued, PharmD Siena Meador, PharmD Ngoc-Yen Pham, PharmD

Management of Adverse Effects of PD1/PDL1 Inhibitors

Jessica Lewis-Gonzalez, PharmD PGY-1 Pharmacy Resident University of New Mexico Hospitals

1 10/4/18

Objectives

¡ Pharmacist ¡ Technician § Evaluate and assess the § Identify management of management of adverse adverse effects of the effects of the PD1/PDL1 PD1/PDL1 inhibitors inhibitors

Wait…which drugs are those again???

¡ PD1 Inhibitors ¡ PDL1 Inhibitors § Pembrolizumab § Atezolizumab (Tecentriq) (Keytruda) § Avelumab (Bavencio) § Nivolumab (Opdivo) § Durvalumab (Imfinzi)

• These are IV cancer chemotherapy medications that are administered most commonly in the outpatient setting at infusion centers.

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Why is this important to you?

Adverse Events to be Aware of:

¡ Immune related adverse events § Dermatologic § GI § Hepatic § Endocrine § Other less common inflammatory events

Postcow. Jour Clin Onc. 2015.

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Grading of Adverse Events

¡ Per Common Terminology Criteria for Adverse Events (CTCAE):

NIH,NCI. Common Terminology Criteria for Adverse Events V. 5.0. 2017.

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Treatment of Adverse Events (In General)

¡ Grade 1: Mild, asymptomatic § Management: Observation, intervention not needed ¡ Grade 2: Moderate § Management: Local or noninvasive intervention indicated § Will likely need low-dose oral prednisone /methylprednisolone and may be able to continue treatment ¡ Grade 3: Several or medically significant but not immediately life- threatening § Management: Stop immunotherapy, hospitalization indicated, high dose prednisone /methylprednisolone ¡ Grade 4: Life-threatening consequences § Management: Urgent intervention, will permanently stop immunotherapy ¡ Grade 5: Death related to AE

NIH,NCI. Common Terminology Criteria for Adverse Events V. 5.0. 2017.

Derm Adverse Event - Maculopapular Rash

Grade Hold Steroids Other Immunotherapy

1 Moderate-potency Topical emollient topical 2 Consider holding High-potency topical Topical emollient AND/OR low-dose prednisone /methylprednisolone 3/4 High-potency topical + Urgent Derm low-dose prednisone Consult /methylprednisolone (increase dose if no improvement)

NCCN. Management of Immunotherapy-Related Toxicities(Version 1.2018).

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GI Adverse Event- Diarrhea/Colitis

Grade Hold Steroids Permanently DC Other Immunotherapy

1 Consider holding Loperamide, hydration 2 IV methylprednisolone 1mg/kg/day 3 IV Consider Inpatient methylprednisolone Supportive Care (consider resuming 2mg/kg/day after resolution) 4 IV Consider Inpatient methylprednisolone Supportive Care 2 mg/kg/day (NCCN). Management of Immunotherapy-Related Toxicities(Version 1.2018).

Hepatic Adverse Event- Acute Pancreatitis

Grade Hold Steroids Permanently DC Other Immunotherapy

1 Consider Gastroenterology Referral

2 Low-dose prednisone/ methylprednisolone 3/4 High-dose prednisone/ methylprednisolone

(NCCN). Management of Immunotherapy-Related Toxicities(Version 1.2018).

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Low-dose vs High-dose steroids

¡ Low-dose corticosteroids for grade 2: § prednisone or methylprednisolone 0.5–1 mg/kg/day ¡ High-dose corticosteroids for grade 3 and 4: § prednisone or methylprednisolone 1–2 mg/kg/day ¡ Tapering off systemic corticosteroids over 4–6 weeks after symptoms have resolved to Grade 1 or 2

Rudzki, JD. Memo Springer. 2018.

Summary

¡ When it comes to immune-related adverse events with checkpoint inhibitors – Steroids are your friends! § Topical § Low-dose § High-dose ¡ When patients present to the hospital on a PD-1/PDL-1 inhibitor with an acute event: § Consider drug as a potential cause § Grade the reaction (if caused by drug) § Treat based on grading

7 10/4/18

Approach to the Patient with & and QTc Prolongation

Valentin Pacuraru, PharmD PGY-1 Pharmacy Resident University of New Mexico Hospitals

Learning Objectives

Pharmacists Technicians • Define the • Identify the extent of QTc five most prolonging commonly effect of used drugs for several N/V N/V that medications. impact QTc.

8 10/4/18

QTc Prolongation and risk of Torsades de Pointes

Torsades

https://pedemmorsels.com/prolonged-qtc/

Defining QTc Prolongation

QTc Values by Age and Sex (ms) 1 – 15 y/o Adult Males Adult Females Normal <440 ms <430 ms <450 ms Borderline 440 – 460 ms 430 – 450 ms 450 – 470 ms Prolonged >460 ms >450 ms >470 ms

Clinically Significant QTc Prolongation

• >500 ms

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Torsades de Pointes Risk Factors

¡ Female Sex ¡ Hypokalemia and/or Hypomagnesemia ¡ Bradycardia ¡ Recent Cardioversion ¡ Structural Heart Disease ¡ Digoxin Therapy ¡ Baseline QT Prolongation ¡ Rapid IV infusion of QT prolonging medications ¡ Pharmacokinetic Interactions

Li M. P T. 2017 Lin YL. Pharmacoepidemiol Drug Saf. 2009

Risk Scoring Option Tisdale Risk Score Risk Factor Points QTc Interval Risk Stratification Age >68 1 Risk Category Risk Score Female Gender 1 Loop Diuretic 1 Low <7 Potassium <3.5 mEq 2 QTc >450 on Admit 2 Acute MI 2 Moderate 7 – 10 2+ QTc Prolonging Drugs 3 Sepsis 3 Heart Failure 3 High >11 One QTc Prolonging Med 3 Maximum Risk Score 21 Tisdale JE. Can Pharm J 2016

10 10/4/18

Approaching Nausea and Vomiting

Treat the Underlying Etiology First Gastroparesis Infectious Medication Induced Electrolyte or Fluid Abnormality GI Obstruction/Inflammation GERD Diabetes Related

Common Inpatient Medications for Nausea and Vomiting

Ondansetron

Olanzapine

Trimetho-

Haloperidol

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Alternate Agents for Nausea & Vomiting

Dexamethasone • Best data for PONV and CINV • Side effects limit use in simple N/V Inhaled Isopropyl Alcohol • Promising ED data including superiority to Benzodiazepines • Most appropriate for withdrawal, anxiety, and anticipatory related nausea

April MD et al. Ann Emerg Med 2018 Beadle KL. Ann Emerg Med. 2016

Haloperidol

Published evidence D2 Receptor of QTc prolongation Antagonist ranging from 8 ms – 35 ms

Multiple publications of IM, IV, Sol, and Tab torsadogenesis and cardiac dysrhythmia Wenzel-seifert K. Dtsch Arztebl Int. 2011 Van noord C . J Clin Psychopharmacol. 2009

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Ondansetron

Published evidence of Serotonin-3 Receptor QTc prolongation Antagonist ranging from 4 ms – 32 ms

Few published cases of torsades or IV, IM, Sol, Tab, ODT, dysrhythmia, but and PO Film associated high IV

doses (32 mg) Brygger L. Expert Opin Drug Saf. 2014 Poluzzi E. PLoS ONE 10. 2015

Promethazine

H1 and D2 Receptor Published Evidence Antagonist of QTc prolongation

Low torsadogenic IM, IV, PR, Sol, and potential Tab available

Jo SH. . Pharmacol Res. 2009 Owczuk R. Anaesthesia. 2009

13 10/4/18

Metoclopramide

Published D2 Receptor evidence of QTc Antogonist prolongation

Few published case reports of IV, IM, Sol, Tab, cardiac and ODT Smith HS. Ann Palliat Med. 2012 decompensation Smith HS. Ann Palliat Med 2012 Chou CC Chang Gung Med J 2001 Ellidokuz E. Aliment Pharmacol Ther. 2003

Prochlorperazine

Published evidence D2 Receptor of QTc Antagonist prolongation, particularly in vitro

Few case reports of prochlorperazine IM,IV, PR, Sol, and contributing to an Tab arrhythmia

Aström-lilja C. Pharmacoepidemiol Drug Saf. 2008

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Olanzapine

D2 Receptor Published evidence Antagonist of QTc prolongation

Few case reports of PO, IM, and IV torsades with IV forms available formulation

Czekalla J. J Clin Psychiatry. 2001 Suzuki Y. Human Psychopharmacology. 2011 Lam YWF. Brown University Psychopharmacology . 2015

Trimethobenzamide

No published D2 Receptor evidence of QTc Antagonist prolongation

No published PO and IM forms evidence of available torsadogenesis

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Ranking Torsadogenic Risk

1) Haloperidol 2) Ondansetron 3) Promethazine 4) Olanzapine 5) Metoclopramide 6) Prochlorperazine 7) Trimethobenzamide Isbister GK. Br J Clin Pharmacol. 2013

Final Thoughts

• No one size fits all answer

• QTc prolongation ≠ torsadogenic risk

• Additional risk factors are important

• Risk/Benefit is a patient specific decision

• Medication choice should be based on risk/benefit, patient specific characteristics, and route

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Alternative Uses of Haloperidol

Amre Elmaoued, PharmD PGY-1 Pharmacy Resident University of New Mexico Hospitals

Objectives

¡ Pharmacists: § Evaluate some alternative uses of haloperidol

¡ Technicians: § Identify some off-label uses of haloperidol

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Haloperidol - D2 Antagonist

Mechanism of Action ¡ 1st generation (a.k.a. ) ¡ FDA Indication: § Psychosis § Schizophrenia ¡ Typical Dosing: 0.5-2 mg two- three times daily

Psychopharmacology Institute. (n.d.)

Haloperidol - Characteristics

D2 Activity High

5HT2 Activity Medium

Muscarinic Low Activity

Alpha-1 Low adrenergic Activity

Antihistamine Low Activity

Psychopharmacology Institute. (n.d.)

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IM Lactate for IV

¡ Lerner et. al. (1978): Brief Psych Baseline 4 Hours 24 Hours Rating Scale § Randomized 40 patients to haloperidol or diazepam § Both received via IV route Diazepam 28.5 11.4 6.3

Haloperidol 30.5 3.8 8 ¡ FDA Warning (2007): § Increased risk of QTc ¡ Both equally effective prolongation has been seen ¡ Doses § Studies are showing lower § Haloperidol = 15mg start. 10mg q 1hr. Total average ~ 20-35mg dose, <2mg, no increased § Diazepam = 10-15 mg start. 5-10mg q1hr. Total ~30-40mg QTc ¡ More withdrawal associated with haloperidol Duprey M. S,Int Car Med. 2016 Lerner, Y. Am of Psy. 1979 Hatta, K. J Clin Psy. 2001

Off-Label Uses • Intractable headaches • Intractable hiccups • Agitation/Rapid Tranquilization • Chorea of Huntington disease • Nausea/Vomiting • Delirium in the ICU • Obsessive-compulsive disorder

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Intractable Headaches

¡ Compared haloperidol 5mg IV vs. metoclopramide 10mg IV § Emergency Department, N= 64 ▪ 31 haloperidol ▪ 33 metoclopramide

¡ All patients were pretreated with 25mg ¡ VAS measured 0, 20, 40, 60, 80 min

Gaffigan, M. E., J Emerg Med. 2015

Agitation/Rapid Tranquilization

¡ Dose: haloperidol lactate 2.5mg-10 mg IM

Ostinelli, E. G. et al. Cochrane Database Syst Rev. 2017

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Nausea/Vomiting

¡ Usual Dose: 0.5mg - 2.5mg QD or BID ¡ Studied in: § Cancer § Palliative Care § Post-Operative Nausea and Vomiting

Nausea/Vomiting

Response Complete Partial Response No Response Failure Response Patient-rated 8 12 10 3 Day 2 (n = 33) Patient-rated 7 10 2 4 Day 5 (n = 23) Observer-rated 8 15 4 2 Day 2 (n = 29) Observer-rated 6 9 3 1 Day 5 (n = 19)

Adapted from Hardy, J. R., et al. J Pain Symptom Manage. 2010.

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Nausea/Vomiting

Response Response Response (CR + PR) n/N(%) (All Patients) n/N(%) Patient-rated Day 2 (n = 33) 20/33 (60) 20/42 (47)

Patient-rated Day 5 (n = 23) 17/23 (74) 17/42 (40)

Observer-rated Day 2 (n = 29) 23/29 (79) 23/42 (54)

Observer-rated Day 5 (n = 19) 15/19 (78) 15/42 (35)

Adapted from Hardy, J. R., et al. J Pain Symptom Manage. 2010.

Side Effects

D2 Activity High Extrapyramidal Very High TRANSLATES TO Side Effects

5HT2 Activity Medium Very Low Effects Muscarinic Low Activity Hypotensive Very Low Alpha-1 Low Effects adrenergic Activity Antihistamine Low Sedating Effects Very Low Activity

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Side Effects- QTc Prolongation

Unmodifiable risk factors Potentially modifiable risk RISK FACTORS factors CONSIDERATIONS Female Gender Hypokalemia or severe hypomagnesaemia ¡ Baseline ECG Increasing age Bradycardia ¡ If giving IV haloperidol, monitor ECG closely Genetically long QT syndrome > 1 QTc prolonging medication ¡ Discontinue multiple medications Family history of sudden death History of previous drug- Meds that cause electrolyte with QTc prolongation induced QT prolongation abnormalities or may cause ¡ QTc > 500ms à considered risk renal or hepatic dysfunction for TdP

Structural heart disease/LV Starvation or obesity § >450ms for males à considered dysfunction prolonged Impaired elimination due to High drug concentrations due § >470ms for females renal or hepatic disease to overdose or rapid IV administration

Rapid Update: Recently Approved Antimicrobials

Siena Meador, PharmD PGY-1 Pharmacy Resident University of New Mexico Hospitals

23 10/4/18

Objectives

¡ Pharmacist: § Discuss the role of recently approved antimicrobial therapies

¡ Technician: § Identify recently approved antimicrobial therapies

Baxdela™ delafloxacin

https://jamanetwork.com/journals/jama/article-abstract/2646700

24 10/4/18

FDA Approved Indications

¡ Fluoroquinolone for the treatment of K. P. acute bacterial skin E. coli pneumoniae aeruginosa and skin structure infections (ABSSSI) in

adults ≥18 years old E. Certain Certain Streptococcus Staphylococcus faecalis spp. spp.

Baxdela™ (delafloxacin) [package insert]. 2017.

Dosing

¡ By mouth § 450 mg tablet every 12 hours § Not renally adjusted § Without regard to food ¡ Intravenous eGFR Dose Interval ≥30 300 mg 12 hours 15-29 200 mg 12 hours <15 or dialysis Not recommended, consider switching to tablet

Baxdela™ (delafloxacin) [package insert]. 2017.

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Warnings/Adverse Effects

¡ Black Box Warnings ¡ Adverse Reactions § Tendinitis/tendon rupture § Nausea (8%) § Peripheral neuropathy § Diarrhea (8%) § Central nervous system effects § Headache (3%) § Exacerbation of muscle § Transaminase elevations (3%) weakness in myasthenia gravis § Vomiting (2%) ¡ Contraindication § Hypersensitivity ¡ Requires a medication guide ¡ Warnings § C. difficile-associated diarrhea § Drug-resistant bacteria

Baxdela™ (delafloxacin) [package insert]. 2017.

Place in Therapy

¡ Limited benefit over other fluoroquinolones but more expensive ¡ Most skin and skin structure infections are caused by Gram positive bacteria ¡ Gram negative coverage is not usually indicated

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Vabomere™ meropenem/vaborbactam

http://www.vabomere.com

FDA Approved Indications

¡ Carbapenem + β- lactamase inhibitor for K. the treatment of E. coli pneumoniae complicated UTI, including pyelonephritis, in Enterobacter adults ≥18 years old cloacae spp

Vabomere™ (meropenem and vaborbactam) [package insert] 2017.

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Dosing

¡ Intravenous eGFR Dose Interval Minimum diluent

≥50 4 gm 8 hours 250 mL 30-49 2 gm 8 hours 125 mL 15-29 2 gm 12 hours 125 mL <15 or dialysis 1 gm 12 hours 70 mL ¡ Only compatible with normal saline ¡ All doses are administered over 3 hours

Vabomere™ (meropenem and vaborbactam) [package insert]. 2017.

Warnings/Adverse Effects

¡ Contraindication ¡ Adverse effects § Hypersensitivity (1.8%) § Headache (8.8%) § Phlebitis/infusion reactions ¡ Warnings (4.4%) § Seizures § Diarrhea (3.3%) § Other CNS experiences § Nausea (1.8%) § Neuromotor impairment § Transaminase elevations § Reduced valproic acid levels (1.8%) § Thrombocytopenia § Pyrexia (1.5%) § C. difficile-associated diarrhea § Hypokalemia (1.1%) § Drug-resistant bacteria

Vabomere™ (meropenem and vaborbactam) [package insert]. 2017.

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Place in Therapy

¡ Carbapenem-resistant enterobacteriaceae (CRE) ¡ Does NOT have improved efficacy against multidrug resistant Pseudomonas spp. or Acinetobacter spp.

¡ Limited by dosing and administration requirements

Solosec™ secnidazole

https://www.solosec.com

29 10/4/18

FDA Approved Indications

¡ Nitroimidazole for Bacteriodes Gardnerella the treatment of spp. vaginalis bacterial vaginosis in women ≥18 Mobiluncus Prevotella spp. years old spp.

Megasphaera- like type I/II

Solosec™ (secnidazole) [package insert]. 2017.

Dosing

¡ Single dose of 2 grams (1 packet) ¡ Sprinkle over applesauce, yogurt, or pudding ¡ Consume within 30 minutes ¡ Do not chew or crunch the granules ¡ May be followed with a glass of water ¡ Do NOT dissolve in any liquid

Solosec™ (secnidazole) [package insert]. 2017.

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Warnings/Adverse Effects

¡ Contraindication ¡ Adverse effects § Hypersensitivity § Headache (3.6%) § Nausea (3.6%) ¡ Warnings § Dysgeusia (3.4) § Vulvo-vaginal candidiasis § Vomiting (2.5%) (9.6%) § Diarrhea (2%) § Risk for carcinogenicity § Abdominal pain (2%) § Drug resistance § Vulvovaginal pruritus (2%)

Solosec™ (secnidazole) [package insert]. 2017.

Place in Therapy

¡ Only single-dose treatment for bacterial vaginosis ¡ Beneficial for patients with adherence concerns ¡ May be useful in hospital-owned outpatient clinics

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SHINGRIX™ Zoster Vaccine Recombinant, Adjuvanted

https://www.shingrix.com/index.html

FDA Approved Indication/Dosing

¡ For the prevention of herpes zoster in adults ≥50 years old ¡ Two vaccine series, 2 to 6 months apart ¡ 0.5 mL injected intramuscularly ¡ 2 vials per injection ¡ Keep refrigerated, do not freeze

Image from gsksource

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Warnings/Adverse Effects

¡ Contraindication ¡ General reactions § Severe allergic reaction to § Myalgia (44.7%) any component or after a § Fatigue (44.5%) previous dose § Headache (37.7%) § Shivering (26.8%) ¡ Local reactions § Fever (20.5%) § Pain (78%) § GI symptoms (17.3%) § Redness (38.1%) § Swelling (25.9%)

SHINGRIX™ (Zoster Vaccine Recombinant, Adjuvanted) [package insert]. 2017.

Place in Therapy

¡ Advisory Committee on Immunization Practices (ACIP): § Vaccinate all immunocompetent patients ≥50 years old

§ Recombinant herpes zoster is preferred over the live zoster vaccine

§ Adults previously vaccinated with the live zoster vaccine should be revaccinated with Shingrix

Dooling KL, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines.

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Prevention of Hepatitis B reactivation in patients receiving Rituxan therapy

Ngoc-Yen Pham, PharmD. PGY-1 Pharmacy Resident University of New Mexico Hospitals

Learning Objectives

¡ Pharmacists: § Formulate an appropriate recommendation to manage patients with Hepatitis B who require immunotherapy management with Rituxan

¡ Technicians: § Identify the therapies used to manage patients with Hepatitis B who require immunotherapy management with Rituxan

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Rituxan (rituximab)

Monoclonal Boxed Indications antibody warnings

Non-Hodgkin Lymphoma Infusion reaction Chronic Lymphocytic Mucocutaneous Reactions Anti-CD20 directed Leukemia ( CLL) Hepatitis B Reactivation on B-lymphocytes Rheumatoid arthritis Progressive Multifocal Vasculitis leukoencephalopathy

Rituxan (rituximab) [prescribing information].

Hepatitis B Virus (HBV) Serology

§ HBV surface antigen § Antibody to HBV surface antigen HBsAg § Indicates a person is infectious Anti-HBs § Indicates immunity

§ Total antibody to HBV core IgM § IgM antibody to HBV core antigen Anti-HBc antigen § Indicates recent/acute HBV § Indicates exposure to HBV Anti-HBc infection in ≤6 months

IgG § IgG antibody to HBV core antigen § HBV e antigen § Marker of past or current HBeAg § Marker of HBV replication Anti-HBc infection with HBV and infection

§ Correlates with the levels of HBV HBV DNA virus particles § Marker of HBV replication and infection

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Risk factors for HBV reactivation (HBVr)

§ Male gender ¡ HBV-DNA level § Lack of HBs antibody ¡ Anthracyclines/steroid use § HBsAg positive ¡ Transplantation

§ Presence of precore mutant ¡ Presence of lymphoma

Tsutsumi Y. World J Hepatol. 2013.

Management of HBV reactivation

Screen patients before immunosuppressive therapy

HBsAg+ HBsAg- HBsAg- vaccinations Anti-HBc + Anti-HBc + Anti-HBc-

High Prophylactic antiviral therapy Check HBV DNA

Moderate Assess Risk Prophylactic antiviral therapy Or monitoring

Pattullo V. Clin Mol Hepatol. 2016. Low Hwang J, Nat Rev Gastroenterol Hepatol. 2014. Monitoring Perrillo R. Gastroenterology. 2015.

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Risk Stratification for HBVr

Risk Groups HBVr drug estimates High-risk groups (>10%) B-cell depleting agents - Rituximab - Ofatumumab Anthracycline derivatives - Doxorubicin - Epirubicin Corticosteroids therapy ≥ 4 weeks (prednisone 20mg) Medium risk group (1% - 10%) TNF –α inhibitors Cytokines and integrin inhibitors kinase inhibitors Low-risk groups (<1%) Azathioprine, 6-mercaptopurine Methotrexate Intra-articular corticosteroids Pattullo V. Clin Mol Hepatol. 2016. Hwang J, Nat Rev Gastroenterol Hepatol. 2014. Perrillo R. Gastroenterology. 2015.

Prophylactic Antiviral therapy

Resistance Concerns Low barrier to Mutation and Lamivudine resistance resistance

Higher barrier Renal dose Entecavir of resistance adjustments

Renal dose Higher barrier adjustments Tenofovir of resistance nephrotoxicity Class Boxed warning: lactic acidosis and severe hepatomegaly with steatosis, acute exacerbation of HBV upon discontinuation

Han S. J Am Board Fam Med. 2015. Lampertico P. J Hepatol. 2017.

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Prophylaxis versus Pre-emptive therapy

Reference) Antivirals vs Antiviral timing Reactivation rates controls (n) Lau et lamivudine vs 1 week before chemotherapy or 0% verus 53% al.(2003) pre-emptive deferred until serological evidence (P = 0.002) treatment of HBV

Hsu et lamivudine vs On day 1 of chemotherapy and 11.5% versus 56% al.(2008) pre-emptive until 2 months after or started on (P = 0.001) treatment treatment if ALT levels >1.5xULN

Huang et entecavir vs pre- Before chemotherapy to 3 months At months 6, 12, and 18 0%, al.(2013) emptive after or at the time of HBV 0%, and 4.3% in the ETV treatment reactivation prophylactic group versus 8%, 11.2%, and 25.9% (P = .019)

Lau G. Gastroenterology. 2003. Hsu C. Hepatology. 2008. Huang Y. J Clin Oncol. 2013. Prophylaxis > pre-emptive therapy

Duration of therapy and monitoring

Guideline Duration Monitoring AGA 2-4 weeks prior to initiation and 6-12 LFTs and HBsAg levels: every 3 months months after last dose until 6 months after last dose

EASL Receiving Rituxan: at least 18 During prophylaxis: LFTs and HBV DNA months after cessation of therapy every 3 to 6 months Immunosuppressive therapy: at least 12 months After withdrawal: LFT and HBV DNA at least 12 months after ASCO Up to 12 months after cessation of HBV DNA and ALT levels every 3 therapy months during therapy

AGA: American Gastroenterological Association, EASL: European Association for the Study of the Liver is a European, ASCO: American Society of Clinical Oncology

Loomba R. Gastroenterology. 2017. Hwang J. J Oncol Pract. 2015. Pattullo V. Clin Mol Hepatol. 2016.

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Conclusions

¡ Prophylaxis treatment with nucleotide analogs is recommended in patients with moderate or high risk of HBVr

¡ Institution screening tools should include HBsAg, anti-HBc, and HBV DNA to assess the risk of reactivation prior to the initiation of Rituxan

Thank You

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