Roger Williams Medical Center a CharterCare Health Partner Presenter: Mark Curtis RPh Clinical Informatics Pharmacist

 Discuss the current ASBMT Conditioning Regimen Recommendations  Recognize the importance of chemo dosing on outcomes  Demonstrate how a dosing calculator can support doctors, pharmacists and nursing in safe patient therapy  Review the findings from a retrospective review of patients from 2010 through 2014.

 Recognize the current ASBMT Conditioning Regimen Recommendations  Recognize the importance of appropriate chemotherapy dosing  Understand how accurate calculations are needed before the preparation of chemotherapy

Roger Williams Medical Center a CharterCare Health Partner Presenter: Mark Curtis RPh Clinical Informatics Pharmacist Has no financial disclosures to report

DrugsRecommended Dosing Busulfan use AIBW25 for all mg/kg dosing Carmustine use BSA until TBW>120% then use AdjBSA25 Cyclophosphamide use TBW until TBW>120% of IBW then use AIBW25 Cytarabine use BSA (based on TBW) Etoposide mg/kg use AIBW25 for all mg/kg dosing Etoposide BSA use BSA (based on TBW) Fludarabine use BSA (based on TBW) Melphalan use BSA (based on TBW) rATG use TBW for mg/kg dosing Reference:J.Bubalo et al. Biol Blood Marrow Transplant 20 (2014)

REGIMENChemo Drugs Day -6 Day -5 Day -4 Day -3 Day -2 Day -1 DAY 0 BEAM Carmustine 300 mg/m2X Etoposide 100 mg/m2 daily XXXX Cytarabine 100 mg/m2 Q12H XXXX Melphalan 140 mg/m2 X

 Doctors, Nurses, Pharmacists all helped test the calculator  Regimen selection, patient metrics, and dose calculations were all tested for accuracy  Over 80 different patient examples were used for testing  Any discrepancy between the calculator and the manual calculation were reviewed and reconciled

 109 patients transplanted at RWMC between 2010 and 2014  Transplant types included Auto, Allo (MRD/MUD) and Cord Blood  Reviewed dosing variances between the current ASBMT recommendations and the administered dose  Two groups: those with out a variance and those who had a variance

Outcomes were reviewed:  Days to Engraftment of ANC and Platelets  Relapse rates  Survivor rates It is very difficult to confirm cause and effect….

Dosing Variances (Table 1) ConditioningTransplant TypeN Calc Dose Same Calc Dose Variance BEAMAUTO23815 Bu/CyALLO MUD826 Bu/CyALLO MRD202 Flu/BuALLO MUD18315 Flu/BuALLO MRD707 Flu/Cy /TBICord Blood642 Melphalan 140AUTO Melphalan 200AUTO19811 Totals

Dosing Variances by Drug (Table 2) ConditioningDrugsNHighLow Wrong AdjBSA Wrong AIBW BEAM Carmustine BEAM Etoposide BEAM Cytarabine BEAM Melphalan Bu/Cy Busulfan Bu/Cy Cyclophosphamide Flu/Bu Fludarabine Flu/Bu Busulfan Flu/Cy/TBI Fludarabine Flu/Cy/TBI Cyclophosphamide Melphalan 140Melphalan261*15 0 Melphalan 200Melphalan Totals *error in BSA calculation

 Some regimen specific differences in time to engraftment between the two groups.  Possible some differences in relapse and survivor rates  Numbers are not enough in each group to be statistically significant

 The calculator supports consistent and accurate regimen dosing that follows the latest ASBMT recommendations.  There may be some Possible clinical benefit to strictly following the ASBMT recommendations

Kimberly Loftus Transplant Coordinator RWMC Alejandro Carvajal, MD RWMC Todd Roberts MD Medical Director of BMT RWMC

1. Which of the following statements is not true about BMT Conditioning Regimens? A. Dose adjustments are always done using the same method, regardless of the drug being used. B. When Adjusted Ideal Body Weight is used it is the AIBW25. C. BMT conditioning regimen calculations can be complex. D. The intensity of therapy is important to patient outcomes 2. True or False: Using the calculator improves dosing accuracy and may improve outcomes.

1. Which of the following statements is not true about BMT Conditioning Regimens? A. Dose adjustments are always done using the same method, regardless of the drug being used. B. When Adjusted Ideal Body Weight is used it is the AIBW25. C. BMT conditioning regimen calculations can be complex. D. The intensity of therapy is important to patient outcomes 2. True or False: Using the calculator improves dosing accuracy and may improve outcomes.