Schuh, Michael J.

Patient is an HLA-B*57:01 positive, 43-year-old male with a history of diabetes type II and admission 10 weeks ago at another institution for pubic symphysis osteomyelitis and associated pseudomonas. Cefepime IV was started and the patient presented with fevers, aches, agranulocytosis, thrombocytopenia and rash as a suspected side effect of cefepime after 3 weeks of treatment. Cefepime was replaced with piperacillin-tazobactam and symptoms resolved. Question to be resolved is whether an HLA-B*57:01 positive, abacavir sensitive patient could have an agranulocytosis cross reaction to cefepime.

Traditional definitions of polypharmacy may largely not account for the market proliferation of herbal and dietary supplements, cannabis products, or incorporate the new science of pharmacogenomics (PGx). Polypharmacy is encountered by most pharmacists providing patient care in many settings. The “polypharmacist” can assist patients and providers with solving medication-related problems (MRPs) in this new and challenging environment of supplements and cannabis products by utilizing traditional pharmacology and pharmacokinetic principles, including PGx, broadly across many medical disciplines. One may encounter polypharmacy more in the geriatric population, though in an age of supplements and cannabis proliferation, polypharmacy is increasingly being encountered at younger ages. Not only is polypharmacy training at best fragmented in pharmacy curricula, but it may also not account for the above-mentioned products that may use the same metabolic pathways to increase drug interactions and adverse drug reactions (ADRs) regarding prescription medications. Polypharmacy being more formally prioritized in pharmacist training may better prepare pharmacists for commonly encountered polypharmacy and can be a viable model of practice.

Clinical pharmacists with experience may identify prescribing patterns resulting in iatrogenic disease, which is commonly encountered in geriatric populations where polypharmacy is common. Serotonin toxicity is one toxidrome clinicians may identify, where specific medications are used in treatment. As a result of their pharmacology training, pharmacists may identify toxidromes caused by medications that other clinicians may overlook. Pharmacogenomic (PGx) testing can provide added insight into a potentially iatrogenic cause for serotonin toxicity, because testing can elucidate how well an individual patient may metabolize serotonergic medications. Using PGx as a resource in addition to clinical experience, pharmacists can better guide therapy in the geriatric, polypharmacy population to avoid serotonin toxicity.

AbstractPatients with inflammatory bowel disease (IBD) are at a high risk of developing invasive pneumococcal infection both before and after they are diagnosed. The Advisory Committee on Immunization Practices now endorses use of 2 new pneumococcal conjugate vaccines, PCV15 (Vaxneuvance) and PCV20 (Prevnar 20), for patients who have never received a pneumococcal conjugate vaccine or those with unknown vaccination history. Previous studies have shown that pneumococcal vaccination can decrease the risk of developing severe pneumococcal disease; therefore, it is important that patients with IBD receive pneumococcal vaccination. This report aims to inform clinicians who care for patients with IBD about the changes in immunization practices, as it pertains to pneumococcal vaccination and provides appropriate direction on administering vaccination series.

This is a patient case exploring the importance of evaluating herbal and dietary supplements and how they may impact drug-drug and drug-gene implications based on pharmacogenomics test results. Even though herbal supplements are considered natural by many patients, which is often the reason for starting them, herbal supplements may still be metabolized by the same pathways as other medications, potentially contributing to drug-drug, drug-herb, and drug-gene interactions, and therefore, potentially impacting a patient’s response to medications.

Objective: To report pharmacogenomics post-related bradykinesia secondary to phenoconversion in an elderly post-bilateral lung transplant patient. Summary: The patient was a 68-year-old double lung transplant patient taking the immunosuppressant and CYP3A4/5 substrate tacrolimus concomitantly with 2 CYP3A4/5 inhibitor medications, fluconazole and diltiazem. This drug combination post-dosing resulted in debilitating bradykinesia 1-2 hours after dosing, increasing the risk of falls and possible increased mortality and morbidity risk. Conclusion: Taking tacrolimus in combination with CYP3A4/5 inhibitors may increase neurologic adverse effects resulting in increased fall and associated increased mortality and morbidity risk.

Objective: To report a case of chronic anticholinergic toxicity in a referred, pharmacogenomics (PGx), polypharmacy patient. Summary: The patient is a 67-year-old male who was referred to the polypharmacy service for a PGx consult. This patient has had episodic fever of unknown origin, general cutaneous vasodilation, tremors, jerks, and brain fogginess which have been unexplained. He has seen specialists from infectious disease, rheumatology, endocrinology, and neurology with no contributory condition causing these symptoms, so he was referred for PGx testing and evaluation by the polypharmacy pharmacist. Conclusion: This case demonstrates the importance of pharmacist-patient consultations and how a PGx consult may expose polypharmacy medication-related problems of greater significance than the PGx indication for the consult. In addition, the case demonstrates positive interprofessional collaboration between pharmacists and physicians to more effectively solve complex medication-related problems that may not be easily diagnosed through objective lab or diagnostic testing.