rasburicase in 2017 Criteria for appropriate administration Uric acid gt 8 mg dL Concomitant allopurinol Concomitant fluids Flat dose of 3 mg or 6 mg administered Minimum of 24 hours between doses ID: 780943
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MethodsRetrospective chart review of all UIHC adult oncology patients that received rasburicase in 2017.Criteria for appropriate administration:Uric acid > 8 mg/dLConcomitant allopurinolConcomitant fluidsFlat dose of 3 mg or 6 mg administeredMinimum of 24 hours between dosesExamined parameters relevant for rasburicase use including:Rasburicase dosePre- and post-dose uric acid levelMonitoring times of uric acid levelsConcomitant ordering of allopurinol and fluids
ObjectivesDetermine appropriateness of rasburicase use at University of Iowa Hospitals and Clinics (UIHC) in order to:Improve patient outcomesProvide cost savings
BackgroundInappropriate prescribing is an issue often found in healthcare that leads to increased costs and unfavorable patient outcomes.Tumor lysis syndrome (TLS) is an oncologic emergency resulting in high uric acid level which can lead to acute kidney injury. Risk associated with high uric acid can be mitigated with IV fluids, to decrease concentrations, and allopurinol, to prevent further formation. Rasburicase is a recombinant form of uricase and is used to break down uric acid in TLS.
ConclusionsMajority of rasburicase use at UIHC is appropriate and effective but there is still significant room for improvementImprovement in appropriate ordering could provide significant cost-savings
DiscussionDiverse set of reasons for inappropriate rasburicase administration, with no concomitant allopurinol administration as the most common factor Overall uric acid lowering is observed in patients after rasburicase administrationInappropriate ordering leads to high amount of unnecessary costs
Evaluation of Rasburicase Administration at University of Iowa Hospitals and ClinicsKatie Gaspar, Ahmed Abdeldagir, Christine Behrendt, Michael Boller, Alec Gates
Results
Future Directions
Practice guidelines for the appropriate use of rasburicase in TLS at UIHC in order to:
reduce medication errorsachieve better patient outcomesimprove cost savings
Total of 84 rasburicase administrations across 62 adult patients9 patients with consecutive doses5 patients with non-consecutive doses63% of administrations appropriate58% met initial criteria3 cases withheld fluids in heart failure1 case withheld allopurinol due to allergy
References
1. Davidson MB, Thakkar S, Davix JK, Bhandarkar ND, Wong A, Schreiber MJ. Pathophysiology, clinical consequences, and treatment of tumor lysis syndrome. The American journal of medicine. 2004;116(8):546-554.
2. Dinnel, Jennifer et al. “Rasburicase in the Management of Tumor Lysis: An Evidence-Based Review of Its Place in Therapy.” Core Evidence 10 (2015): 23–38. PMC. Web. 19 Aug. 2018.3. Chiang J, Chan A, Lian T, et al. Management of tumor lysis syndrome with a single fixed dose of rasburicase in Asian lymphoma patients: a case series and literature review. Asia-Pacific journal of clinical oncology. 2011;7(4):351-356.4. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2008;26(16):2767-2778.5. Holdsworth MT, Nguyen P. Role of i.v. allopurinol and rasburicase in tumor lysis syndrome. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2003;60(21):2213-2222; quiz 2223-2214.6. “Rasburicase.” IBM Micromedex, IBM Corporation , 20 July 2018.7. “RED BOOK Search Results.” IBM Micromedex, IBM Corporation , 4 June 2018
Assumes patients receiving rasburicase inappropriately would not have received the drug at all, or would have received an appropriate dose
Cost analysis based on wholesale price of $993 for 1.5 mg rasburicase vial