Presenters: Steven Gilmore, PharmD, BCOP, McKesson Specialty Health, The Woodlands, TX; Melissa Carroll, PharmD, McKesson Specialty Health, The Woodlands, TX
Co-Authors: Elizabeth Koselke, PharmD, BCOP, McKesson Specialty Health, The Woodlands, TX; Shannon Hough, PharmD, BCOP, McKesson Specialty Health, The Woodlands, TX
BACKGROUND: Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency, resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Single, fixed-dose rasburicase administration has been evaluated as an effective strategy in the management of hyperuricemia in the hospital setting, but it has not yet been validated within ambulatory community oncology practices. The US Oncology Network (TUSON) is affiliated with approximately 1400 physicians within 500 cancer treatment locations throughout the United States and served as the location for this intervention.
OBJECTIVE: To evaluate and optimize the dosing strategy for rasburicase in the management of TLS-associated hyperuricemia in TUSON.
METHOD: TUSON reviewed and revised a networkwide guideline to standardize rasburicase dosing from a previously recommended fixed dose of 4.5 mg or 7.5 mg to 3 mg or 6 mg for outpatient rasburicase use for the management and prevention of TLS. Additional updates included changes to the standard order template names and default rasburicase dosing. The electronic health records (EHRs) were reviewed retrospectively. A structured data export from the EHRs was used to evaluate rasburicase dosing in all patients who received a rasburicase dose within TUSON as a primary end point. A retrospective chart review of randomly selected patients evaluated the secondary end points and rasburicase dose, pre- and postrasburicase uric acid levels, and internal guideline concordance. The primary outcome was the mean dose of rasburicase among all patients who received rasburicase treatment over a period of 3 months before and after the guideline revision. The secondary outcomes included the internal guideline concordance, indication, and uric acid normalization (<8 mg/dL) within 24 hours of receiving the rasburicase dose(s).
RESULTS: The primary analysis included 291 patients (N = 128 prerevision and N = 163 postrevision). The primary outcome of mean rasburicase dose was reduced in the postrevision population compared with the prerevision population (mean, 6.2 mg prerevision vs 4.5 mg postrevision). A total of 50 patients were included for the secondary analysis, including 25 patients each in the prerevision and postrevision populations. Guideline concordance was identified in 12 patients (48%) and 16 patients (64%), and uric acid normalization occurred in 14 patients (56%) and 16 patients (64%) before and after the guideline revision, respectively. In addition, repeat rasburicase dosing was reduced after the guideline revision (24% prerevision vs 12% postrevision).
CONCLUSION: Guideline revision and EHR modification resulted in a 27% reduction in the mean rasburicase dose and a 50% reduction in repeat rasburicase dosing, without a negative impact on clinical efficacy; this is associated with potential cost-savings in a large network of community oncology practices. In addition, guideline concordance increased after revision.
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