Jan to May 2021 Clinical Guidelines Pharmacy Notes

2020 was a wild ride but now that the US is recovering, work resumes. As research continues to grow, it is our responsibility as healthcare providers to stay updated on evidence-based medicine in order to optimize treatment and safety for patients. The most important part of the battle is learning where to find your resources.

Provided below are key points focused on medication therapy on clinical guidelines from the first half of 2021. These can also be found in the pharmguides.com search. Happy reading!

February 2021

Hypertrophic Cardiomyopathy (AHA/ACC 2020)

  • Pharmacologic Management of Symptomatic Patients With Obstructive hypertropic cardiomyopathy (HCM)
    • In patients with obstructive HCM and symptoms attributable to left ventricular outflow tract obstruction (LVOTO), nonvasodilating beta-blockers, titrated to effectiveness or maximally tolerated doses, are recommended. If beta-blockers are ineffective or not tolerated, substitution with non-dihydropyridine calcium channel blockers (eg, verapamil, diltiazem) is recommended.
    • For patients with obstructive HCM
      • who have persistent severe symptoms attributable to LVOTO despite beta-blockers or non-dihydropyridine calcium channel blockers, either adding disopyramide in combination with 1 of the other drugs, or SRT performed at experienced centers, is recommended.
      • And acute hypotension who do not respond to fluid administration, intravenous phenylephrine (or other vasoconstrictors without inotropic activity), alone or in combination with beta-blocking drugs, is recommended.
      • And persistent dyspnea with clinical evidence of volume overload and high left- sided filling pressures despite other HCM GDMT, cautious use of low-dose oral diuretics may be considered
      • Discontinuation of vasodilators (eg, angiotensinconverting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers) or digoxin may be reasonable because these agents can worsen symptoms caused by dynamic outflow tract obstruction.
      • And severe dyspnea at rest, hypotension, very high resting gradients (eg, >100 mm Hg), as well as all children <6 weeks of age, verapamil is potentially harmful

Lyme Disease (AAN/IDSA/ACR 2021)

  • Treatment of Acute Neurologic Manifestations of Lyme Disease
    • In patients with Lyme disease–associated meningitis, cranial neuropathy, radiculoneuropathy, or with other peripheral nervous system (PNS) manifestations, we recommend using IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline over other antimicrobials for 14-21 days.
    • If patient does have involvement of brain or spinal cord, IV over oral antibiotics is recommended.
    • Lyme disease–associated facial nerve palsy, we make no recommendation on the use of corticosteroids in addition to antibiotics (no recommendation; knowledge gap).
  • Preferred Antibiotic Regimens
    • Treatment of Lyme Carditis – using IV ceftriaxone over oral antibiotics until there is evidence of clinical improvement and then switching to oral antibiotics to complete treatment for 14–21 days of total antibiotic therapy over longer durations of treatment (weak recommendation, very-low-quality evidence).
      • Oral antibiotic choices for Lyme carditis are doxycycline, amoxicillin, cefuroxime axetil, and azithromycin.
    • Lyme Arthritis: Oral antibiotic therapy for 28 days
    • Borrelial Lymphocytoma: oral antibiotic therapy for 14 days
    • Acrodermatitis Chronica Atrophicans: oral antibiotic therapy for 21–28 days over shorter durations

Diabetes Management in Chronic Kidney Disease (KDIGO 2020)

  • Treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications be titrated to the highest approved dose that is tolerated
  • Recommend treating patients with T2D, CKD, and an eGFR <30 ml/min per 1.73 m2 with an SGLT2i

Asthma Update for Adolescents and Adults (NAEPP 2020)

  • Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy).
  • In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended.
  • Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy.
  • A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended.
  • Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma).
  • Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma.

von Willbrand Disease (ASH/ISTH/NHF/WFH 2021)

  • In patients with VWD with a history of severe and frequent bleeds, long-term prophylaxis is recommended
  • In patients for whom desmopressin is a valid treatment option (primarily type 1 VWD) and who have a baseline VWF level of <0.30 IU/mL, it is recommended to perform a trial of desmopressin and treating based on the results in addition to tranexamic acid or factor concentrate. In these patients, the panel suggests against treating with desmopressin in the absence of desmopressin trial results
  • In patients with VWD and cardiovascular disease who require treatment with antiplatelet agents or anticoagulant therapy, it is recommended over no treatment
  • Goal targeting both FVIII and VWF activity levels of ≥0.50 IU/mL for at least 3 days after surgery
  • In patients undergoing minor surgery or minor invasive procedures, the panel suggests increasing VWF activity levels to ≥0.50 IU/mL with desmopressin or factor concentrate with the addition of tranexamic acid
  • The panel suggests giving tranexamic acid alone over increasing VWF activity levels to ≥0.50 IU/mL with any intervention in patients with type 1 VWD with baseline VWF activity levels of >0.30 IU/mL and a mild bleeding phenotype undergoing minor mucosal procedures
  • Women’s Health
    • Either hormonal therapy (combined hormonal contraception [CHC] or levonorgestrel-releasing intrauterine system) or tranexamic acid is recommended over desmopressin to treat women with VWD with heavy menstrual bleeding who do not wish to conceive
    • Tranexamic acid is recommended over desmopressin to treat women with VWD and heavy menstrual bleeding who wish to conceive
    • In women with VWD for whom neuraxial anesthesia during labor is deemed suitable, the panel suggests targeting a VWF activity level of 0.50 to 1.50 IU/mL over targeting an activity level of >1.50 IU/mL to allow neuraxial anesthesia
    • Use of tranexamic acid is recommended over not using it in women with type 1 VWD or low VWF levels (and this may also apply to types 2 and 3 VWD) during the postpartum period)

March 2021

Gonococcal Infection (CDC, 2020)

  • CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.

Gout (American College of Rheumatology, 2020)

  • Allopurinol is the preferred first line urate-lowering therapy (ULT) including for moderate-to-severe chronic kidney disease stage >3.
    • Use a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day) recommended.
    • Dose titrate based on serial serum urate (SU) with target of <6mg/dl.
  • When initiating ULT, concomitant antiinflammatory prophylaxis therapy for duration of at least 3–6 months was strongly recommended.
  • For gout flares: colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

Acute calculus cholecystitis (2020 World Society of Emergency Surgery)

  • When a patient is diagnosed with presence of common bile duct stones, early laparoscopic cholecystectomy is the standard when possible.
  • Empiric antibiotic treatment should be based on most frequently isolated microorganisms with consideration of resistance. In biliary infections, Gram-negative aerobes, such as Escherichia coli and Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis are the most commonly isolated bacteria.
    • If bile/serum >5 good penetration antibiotics include: piperacillin/tazobactam, tigecycline, amoxicillin/clavulanate, ciprofloxacin, ampicillin/sulbactam, ceftriaxone, levofloxacin, penicillin G
    • If bile/serum<1, low penetration antibiotics include: cefotaxime, meropenem, cftazidime, vancomycin, amikacin, gentamicin, cefepime, imipenem

Valvular Heart Disease (ACC/AHA, 2020)

  • There are stages A, B, C, and D of valvular heart disease based on symptoms, the valves, and severity. In patients with severe aortic regurgitation who have symptoms and/or LV systolic dysfunction (Stage C2 and D) but a prohibitive surgical risk, GDMT for reduced LVEF with ACEI/ARBs, and/or sacubitril/valsartan recommended. In stages B and C, treatment of hypertension is recommended.
  • For patients with valvular heart disease and atrial fibrillation, use the CHA2DS2-VASc score to determine using oral anticoagulation to prevent thromboembolic events with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.
  • Typically valvular heart disease patients also experience hypertension and hyperlipidemia, treat according to guideline directed medical therapy (GDMT) with statins, ACEI/ARBs.

Babesiosis (IDSA 2020)

  • Preferred treatment of Babsiosis include atovaquone plus azithromycin or clindamycin plus quinine based on patient factors

Pulmonary Disease in Sjögren’s (ACR 2021)

  • Includes 52 clinical recommendations on management of pulmonary manifestations in Sjorgen’s. These points are excluded to the main pharmacological points.
  • Lung Involvement
    • Symptomatic vocal cord cystic lesions (“bamboo nodules”): voice therapy, inhaled corticosteroids, or intra-lesional corticosteroid injection
    • Asthma/COPD: as per clinical practice guidelines (i.e. inhaled corticosteroids and beta-agonists, avoid anticholinergics to prevent drying of secretions)
    • Bronchiolitis: trial of inhaled corticosteroids +/- macrolides
    • If xerotrachea concern: nebilized saline and secretagogues
    • Smoking cessation for all patients
  • Interstitial Lung Disease (ILD)
    • Many of the pharmacological interventions are based on the severity of the Sjögren’s-ILD.
      • Moderate: shortness of breath on exercise (NYHA II) or PFTs restricted to FVC between 60% and 80% predicted or Dlco between 40% and 70% predicted.
        • Systemic corticosteroids.
        • MMF or azathioprine should be considered when long-term steroid use is contemplated and steroid-sparing immunosuppressive therapy is required.
          • Second-line therapies: If initial treatment with MMF or azathioprine is insufficient or not tolerated in Sjögren’s patients with ILD who are symptomatic and in whom PFTs or HRCT demonstrated moderate-severe impairment, subsequent second-line maintenance drugs may include rituximab and calcineurin inhibitors, cyclosporine, or tacrolimus.
        • The use of antifibrotic therapy such as nintedanib should be tried as a second-line maintenance therapy either alone or in combination with immunomodulatory agents in Sjögren’s patients with progressive fibrotic ILD who are symptomatic and in whom PFTs or HRCT demonstrated moderate-severe impairment.
      • Severe/high: shortness of breath at rest (NYHA III, IV) or PFTs with FVC < 60% predicted or Dlco < 40% predicted.
        • In Sjögren’s patients with ILD who are rapidly progressive or present with acute respiratory failure, a trial of high-dose corticosteroids (such as IV methylprednisolone) is recommended. Alternative etiologies, such as infections or lymphoproliferative disorders, must be considered.
        • In a Sjögren’s patient with ILD who has acute or subacute hypoxic respiratory failure requiring hospitalization, despite initial therapies, rituximab or cyclophosphamide should be considered in addition to high-dose corticosteroids.
      • Vaccination: All Sjögren’s patients must be immunized against influenza and pneumococcal infection (Prevnar and Pneumovax) in accordance with Centers for Disease Control and Prevention guidelines.

Psoriasis with topical therapy (Joint AAD–NPF 2020)

  • Topical medications are the most common agents used to treat mild to moderate psoriasis patients. They are frequently used as adjunctive therapies for patients on phototherapy, systemic, or biologic therapy.
  • The guideline reviews pharmacologic and non-pharmacology therapy to treat psoriasis in adults: topical Steroids, topical Tacrolimus and Pimecrolimus, vitamin D analogues, tazarotene, moisturizers, salicylic acid, anthralin, coal tar, biologic agent combination, non-biologic combination (Methotrexate, Cyclosporine, Acitretin, Apremilast)

COVID-19 Vaccination in Cancer Patients  (NCCN 2021)

  • Patients with active cancer and those on treatment should be prioritized for vaccination and should be immunized when any vaccine
  • Vaccination should be delayed for at least 3 months following hematopoietic cell transplantation (HCT) or engineered cellular therapy (eg, chimeric antigen receptor [CAR] T-cells) to maximize vaccine efficacy.

Acromegaly Management (Pituitary Society 2021)

  • Injectable SRL
    • Older age, female sex, lower IGF-I levels, and tumor T2 MRI hypointensity at baseline predict more favorable long-term biochemical responses to primary lanreotide 120 mg therapy every 4 weeks.
    • Recent studies confirm that extended-dosing intervals (> 4 weeks) for 120 mg lanreotide may be effective among selected patients previously controlled with long-acting SRLs.
    • Several studies confirm efficacy of pasireotide LAR for some patients uncontrolled on lanreotide or octreotide LAR. However, rates of treatment-induced hyperglycemia and DM are high, requiring careful monitoring for glycemic side effects.
  • Pegvisomant
    • Ten-year follow-up from ACROSTUDY shows a 73% biochemical control rate with very low rates of transient elevated transaminases and 6.8% exhibiting tumor growth visible on MRI.
    • Pegvisomant use in patients with DM improves glucose metabolism independent of IGF-I control, but does not affect glycemic endpoints in patients without DM.
    • Patients with DM and those with a higher BMI require higher doses of pegvisomant and more rapid up-titration to achieve IGF-I normalization.
  • Combination therapy with SRL + pegvisomant
    • Low-dose octreotide LAR or lanreotide plus weekly pegvisomant is a cost-effective and efficacious option for patients requiring combination therapy.
    • Combination of pasireotide plus pegvisomant can yield biochemical control rates exceeding 70% even when pegvisomant doses are kept low. However, the addition of pegvisomant does not ameliorate the high rates of pasireotide-induced hyperglycemia.
    • Patient selection for combination pasireotide plus pegvisomant should be carefully considered.

April 2021

Nasopharyngeal Carcinoma (ASCO/CSCO, 2021)

  • Nasopharyngeal carcinoma (NPC) is a unique head and neck cancer. NPC almost exclusively relies on (chemo-)radiotherapy to achieve disease control in most presentations, particularly in the definitive treatment of stage II to IVA disease.
  • Stage II-IVA nasopharyngeal carcinoma
    • For all patients with nasopharyngeal carcinoma (NPC), intensity-modulated radiotherapy (IMRT) with daily image guidance should be offered.
  • Stage III-IVA (except T3N0) (AJCC 8th) NPC, induction chemotherapy should be offered in addition to concurrent chemoradiotherapy
    • NPC who do not receive induction chemotherapy plus concurrent chemoradiotherapy, then concurrent chemoradiotherapy plus adjuvant chemotherapy should be offered
    • For patients with T3N0 (AJCC 8th) NPC, concurrent chemoradiotherapy should be offered. Adjuvant or induction chemotherapy may also be offered
  • Concurrent Chemotherapy
    • For all patients with NPC without contraindications, concurrent cisplatin, given weekly (40 mg/m2) or once every 3 weeks (triweekly) (100 mg/m2, or at least 80 mg/m2), should be offered along with radiotherapy
    • For all patients with NPC without contraindications, in the concurrent chemotherapy setting, 3 doses of triweekly or 7 doses of weekly cisplatin should be attempted to achieve a cumulative dose of at least 200 mg/m2
    • If contraindication to cisplatin, nedaplatin (100 mg/m2 triweekly) may be offered for concurrent chemoradiotherapy.
    • If contraindication to platinum-based chemotherapy, fluoropyrimidines (eg, capecitabine, 5-fluorouracil, and tegafur) with concurrent radiotherapy may be offered
  • Induction Chemotherapy
    • For all patients with NPC receiving induction chemotherapy, platinum-based induction regimens should be offered. The following regimens may be used in the absence of medical contraindications: GP (gemcitabine: 1,000 mg/m2 d1, d8; cisplatin 80 mg/m2 d1) or TPF (docetaxel 60-75 mg/m2 d1; cisplatin 60-75 mg/m2 d1; 5-fluorouracil 600-750 mg/m2 per day, continuous intravenous infusion d1-5); others include PF (cisplatin 80-100 mg/m2 d1; 5-fluorouracil 800-1,000 mg/m2 per day, continuous intravenous infusion d1-5), PX (cisplatin 100 mg/m2 d1; capecitabine 2000 mg/m2 per day, d1-14), and TP (docetaxel 75 mg/m2 d1; cisplatin 75 mg/m2 d1)
    • The regimens should be administered every three weeks for a total of three cycles, or at the minimum two cycles
    • Chemoradiotherapy should be commenced within 21-28 days from the first day of the last cycle of induction chemotherapy
  • Adjuvant Chemotherapy
    • For all patients with NPC receiving adjuvant chemotherapy, PF (cisplatin 80 mg/m2 d1 or 20 mg/m2 per day, d1-5; 5-fluorouracil 1,000 mg/m2 per day, continuous intravenous infusion d1-4, or 800 mg/m2 per day, continuous intravenous infusion d1-5) administered every 4 weeks for a total of 3 cycles should be offered
    • If contraindication to cisplatin, carboplatin (AUC 5) may be combined with 5-fluorouracil
    • If contraindication to platinum-containing chemotherapy, the use of non–platinum-based regimens remains experimental at this time and should not be offered routinely outside the context of a clinical trial

Multiple Myeloma (EHA/ESMO, 2021)

  • Patients with standard- or intermediate-risk smouldering MM do not need immediate therapy.
  • For fit newly diagnosed multiple myeloma patients, aged <70 years, without comorbidities, induction followed by high-dose therapy (HDT) with autologous stem cell transplantation (ASCT) and lenalidomide maintenance is the recommended treatment.
    • Induction regimen: A three-drug combination, including at least bortezomib and dexamethasone, has been the standard of care.

Blood Pressure in Chronic Kidney Disease (KDIGO, 2021)

  • Targeting a sodium intake <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with high BP and CKD
  • Adults with high BP and CKD goal systolic blood pressure to be <120mmHg
  • Start renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with high BP, CKD, and severely increased albuminuria (G1–G4, A3) without diabetes
  • Start RASi (ACEi or ARB) for people with high BP, CKD, and moderately increased albuminuria (G1–G4, A2) without diabetes
  • Start RASi (ACEi or ARB) for people with high BP, CKD, and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes
  • Avoid any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in patients with CKD, with or without diabetes
  • Recommend dihydropyridine calcium channel blocker (CCB) or an ARB be used as the first-line antihypertensive agent in adult kidney transplant recipients

Advanced Hepatocellular Carcinoma (ASCO, 2020)

  • Atezolizumab + bevacizumab (atezo + bev) may be offered as first-line treatment of most patients with advanced HCC, Child-Pugh class A liver disease, Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0-1, and following management of esophageal varices, when present, according to institutional guidelines.
  • If contraindications to atezolizumab and/or bevacizumab, tyrosine kinase inhibitors sorafenib or lenvatinib may be offered as first-line treatment of patients with advanced HCC, Child-Pugh class A liver disease, and ECOG PS 0-1.
  • Second-line therapy with a tyrosine kinase inhibitor may be recommended for appropriate candidates.

Chronic Pain in Children (WHO, 2020)

  • In children with chronic pain, physical therapies may be used, either alone or in combination with other treatments
    • Psychological management through cognitive behavioural therapy and related interventions (acceptance and commitment therapy, behavioural therapy and relaxation therapy) may be used
  • Medicines other than acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids that may help to relieve pain alone or in combination with paracetamol, NSAIDs or opioids. Typically, these adjuvant medicines are used for pain refractory to acetaminophen, NSAIDs or opioids or when opioid therapy is contraindicated
  • In children with chronic pain associated with life-limiting conditions, morphine may be given by appropriately trained healthcare providers, under the principles of opioid stewardship

May 2021

Anaplastic Thyroid Cancer (ATA, 2021)


Short-Course Antibiotic Prescribing (ACP, 2021)

  • The American College of Physicians says 5 days of therapy often is best practice in bronchitis with COPD exacerbations, community acquired pneumonias, urinary tract infections, and cellulitis.

Optimizing Care for Heart Failure (ACC 2021)

  • HFrEF Stage C: ARNI/ACEI/ARB (ARNI preferred) AND evidence-based beta blocker (carvedilol, metoprolol succinate, or bisoprolol)
    • Add aldosterone antagonist for patients with eGFR>30 or creatinine < 2.5 in males, <2 in females, potassium <5, NYHA Class II-IV
    • Add SGLT2 inhibitor for patients meeting eGFR >30 for dapagliflozin and >20 for empagliflozin before initiation
    • Add diuretic for patients with fluid overload
    • Add hydralazine + isosorbide dinitrate for Black patients NYHA class III-IV
    • Add ivabradine for patients with resting heart rate > 70 on maximally tolerated beta blocker dose in sinus rhythm, NYHA class II-III

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