December 13, 2017
Bone marrow transplant patients are living longer than ever, but that longer life expectancy puts them at higher risk of complications due to vaccine-preventable diseases.
Ensuring that these patients are revaccinated after transplantation proved challenging at St. Luke’s Mountain States Tumor Institute (MSTI) in Boise, Idaho, until an immunization-certified pharmacist helped manage the program. The pharmacist ensures patients’ oncologists order the correct vaccines and that the vaccines are ready to be administered when patients arrive at MTSI’s infusion center. The pharmacist also assists the infusion center’s nurses with the vaccination process and performs medication reconciliations based on recommendations from oncologists.
Robert Mancini, PharmD, BCOP, an oncology pharmacist at MSTI, shared his thoughts on the benefits of involving pharmacists in the management of bone marrow transplant patients and how their expertise can lead to safer, more effective post-transplant care.
Why is vaccination especially important for this patient population?
They require high-dose, intensive chemotherapy, which essentially wipes out their immune systems. If they didn’t receive a reinfusion of progenitor cells—early lineage of white blood cell lines in the immune system—they wouldn’t recover from chemotherapy. The reinfusion creates a brand new immune system, so patients need to be revaccinated after transplantation, regardless of their vaccination history.
Our transplant patients receive a standard set of vaccines: diphtheria, tetanus, pertussis, polio, haemophilus influenzae type B, pneumococcal 13, and hepatitis B. Many patients require pediatric doses of the vaccines, which are often higher than adult doses. We currently treat only autologous transplant patients. They receive their own stem cells and are therefore not on immunosuppression after transplantation, so we administer the first set of vaccines at 6 months post-transplant, the second set at 12 months, and the third set at 24 months. The live MMR vaccine can pose a risk to an incompletely reconstituted immune system, so it’s given at least 2 years out from transplant.
What challenges did you face when ensuring transplant patients received the vaccines they needed?
Patients get 5 or 6 vaccines in a single clinic visit without benefit of the combo vaccines that are available for pediatric patients. Trying to manage vaccine supplies proved difficult. We saw that patients weren’t receiving their vaccines, were getting the wrong ones, or were getting them at the wrong times.
In addition, the vaccines were not typically given at our health system’s adult outpatient clinics, so they might not always be in stock. Plus, having them in stock across the health system required buying boxes of 10 vaccines for individual sites. In some instances, only a single vaccine would be used before the entire box outdated. We’re now trying to coordinate vaccination of these patients at our main clinic in Boise, where all transplant patients are seen, to streamline the process.
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How can pharmacists help manage the vaccinations of post-implant patients?
They can help with the administration, ordering, and distribution of vaccines, and can help ensure indicated vaccines are given properly. In the context of the bigger picture, pharmacists are expert in differentiating between live and inactivated vaccines and identifying the right doses for patients. Ultimately, they can play an important role in the coordination of the vaccination process. In addition, the dosing of antibiotic prophylaxis for these patients can be complex. Some medications don’t always require daily dosing schemes, so patients need to be aware that dosing may change frequently and may be different on various days of the week. Plus, the more medications patients take, the higher their risk of medication errors and issues with medication reconciliation.
Pharmacists also perform medication reconciliations for these patients. Why is that important for this population?
Immunosuppression is a big issue in allogeneic transplant patients, so it can be tough to manage drug interactions and therapeutic drug monitoring. Knowing about potential drug interactions, the timing of doses, and the timing of peaks and troughs are factors pharmacists can manage better than other providers. Many transplant patients take multiple prophylactic medications at various times throughout their treatments, so managing when the therapies should and shouldn’t be administered is paramount. Patients shouldn’t receive more than they need, but they should be protected during the immune reconstitution phase, which puts them at risk of certain infections, some of which vaccines cannot protect against. Prophylaxis drugs are also very expensive. In some situations, saving a couple unnecessary doses could pay a pharmacist’s salary for a month or even an entire year.
Does the involvement of pharmacists in the vaccination process help promote the expanding roles they’re playing in patient care?
We found that pharmacists improved the overall care of transplant patients and demonstrated another area where they can apply their expertise in the context of a multidisciplinary team. Pharmacist involvement helped standardize the vaccination process, reduced potential vaccination errors, and identified and corrected medication discrepancies that were missed by nurses and medical assistants. Regardless of whether or not state laws permit pharmacists to vaccinate patients, most states do allow for collaborative practice. That means pharmacists can ensure vaccine doses are prepared on time, accurate, and administered properly. Pharmacists need to be involved in more aspects of patient care, and this was a step in the right direction.