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ISHLT 2016 Pharmacy and Pharmacology Council Review: PHARMing for Answers?

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Edward Horn, PharmD, BCPS
Allegheny General Hospital
Pittsburgh, PA, USA

This year's ISHLT Annual Meeting provided a tremendous amount of education content, not only for pharmacists, but for all individuals involved in advancing the care of our patient populations. Among the many sessions, I would like to focus on two presymposium Wednesday sessions - Anticoagulation in MCS: Can We Do Better? and Lifecycle Journey of the Hepatitis C Heart Failure Patient. Both of these sessions featured a multidisciplinary approach to managing these complicated patient populations.

In the MCS session, the entire spectrum from thrombosis to bleeding in MCS was covered by Dr. Ulrich Jorde. Dr. Doug Jennings then discussed issues surrounding inherited thrombophilia in MCS patients and the potential impact on the use of antithrombotic therapy. Dr. Anna Meyer presented challenges in monitoring INRs and options of improving monitoring modalities with respect to vitamin K antagonists. Dr. Chris Hayward discussed the advantages and disadvantages of monitoring unfractionated heparin with aPTT or Xa testing. Dr. Robert Page reviewed available monitoring technology for antiplatelet therapy in MCS. Finally, Dr. Nir Uriel highlighted nuances of gastrointestinal bleeding, acquired von Willebrand disease, and novel treatment approaches to this common adverse consequence of MCS therapy.

Clinical Pearls from the Anticoagulation in MCS Session:

  • Utilize log files to assist in understanding HVAD thrombosis
  • Inherited thrombophilia is rare in MCS; however, when present it may not necessitate increasing INR target above usual for MCS
  • Concordance between monitoring modalities for heparin in MCS is low; Xa monitoring may provide more reliable heparin dosing
  • Many platelet monitoring modalities exist, but none reigns superior in MCS
  • There are other agents besides octreotide in the management of GI bleeding in MCS, including thalidomide, danazol, doxycycline. VEGF may also play an important role.

The Lifecycle Journey symposiums have typically been the prominent PHARM council presentation at the ISHLT Annual meeting. This year's symposium covered issues surrounding the newer therapies that have been dubbed 'game changers' in the management of hepatitis C. The symposium was moderated by Dr. Jerrica Shuster and Dr. Andreas Zuckerman; Dr. Adam Cochrane reviewed treatment options for Hepatitis C and guideline statements regarding Hepatitis C treatment and immunosuppression. Dr. Paolo Grossi discussed the interplay between Hepatitis C, CMV and cardiac transplant outcomes. Dr. Michael Shullo then reviewed the importance of how various immunosuppressants can impact Hepatitis C replication and resultant clinical outcomes. Dr. Donna Mancini then reviewed data surrounding malignancy in cardiac transplant. Dr. Deborah Meyers rounded out the symposium with a passionate discussion regarding palliative cares issues in the heart failure and heart transplant patient population.

Clinical Pearls from the Lifecycle Journey of the Hepatitis C Patient Session:

  • Patients with sustained viral response to novel Hepatitis C therapy, monitoring for HCV viral replication may not be needed once immunosuppression is initiated.
  • Drug interactions are prevalent through both cytochrome and p-glycoprotein pathways
  • HCV and CMV co-infection may place patients at greater risk for coronary artery vasculopathy
  • Bolus doses of corticosteroids could negative impact outcomes with respect to HCV more than other immunosuppressive agents
  • Employ risk factor modification and enhanced surveillance for malignancy, especially prostate or breast cancer
  • Introduction of palliative care early in the disease process can assist in symptom management

Disclosure Statement: The author has no conflicts of interest to disclose.

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