Stage III Abdominal Diffuse Large

B-cell Lymphoma (DLBCL)

NORHAYATI BINTI DIN

PRP HTAA
15TH NOVEMBER 2017
Patient Demographic
• Name : MM
• MRN : 10
• Age : 30.7 years old
• Gender : Male
• Height : 170cm
• Weight : 72.6 kg
• Date of Admission : 6/11/2017
Chief Complaint
• Referred from IIUMMC for continuation
of care
• Lymphoma
History of Presenting Illness
• Epigastric pain x 1/12
• Jaundice
• Dark coloured urine
• Loss of weight – 9kg in 2months
• Unable to sleep d/t pain
• No fever
• No night sweat
Past Medical History
• NKMI
• NKDA

Past Medication History

• Nil
Social/Family History
• Ex-smoker (stop 1 year ago)
• Non- drug abuse
• Denied family history of malignancy
Vital Sign on Admission
Blood pressure (BP) 128/88 mmHg
Pulse rate (PR) 103 beats/min
Respiratory rate (RR) 20 rate/min
Temperature 37 ˚C
SpO2 99 % ↓RA
Diagnosis
• Staged III DLBCL – TRO spinal
infiltration
Vital Signs
Date BP HR SpO2 Respiratory Pain Score
(mmHg) (beats/min) (%) ↓RA Rate
(Breaths/mi
n)
6/11 133/89 100 99 20 0
7/11 123/88 101 99 20 0
8/11 126/76 96 99 20 2
9/11 121/92 97 99 20 2
10/11 114/85 93 99 20 1
11/11 105/73 98 99 20 0
Body Temperature
Full Blood Count
Normal Range 6/11 9/11 13/11

TWBC 4 – 11 x 109 /L 19.3 15.68 15.15

Hb 11.5 – 16.5 g/dL 9.9 9.8 8.8

PCV 45-52% 27.7 26.9 25.5

Plt 150 – 400 x 109/L 527 435 313

ANC 2.0 – 7.0 x 109 /L 16.58 14.1 14.68

Renal Profile
Normal Range 6/11 9/11 13/11
Urea 1.7-8.3mmol/L 2.8 2.1 2.0
Na+ 135-145mmol/L 124 130 129

K+ 3.5-5.0mmol/L 3.9 3.2 3.4

Cl- 96-106mmol/L 86 96 98
SCr 64-122umol/L 36 47 44
CrCl 105-150ml/min 272.36 208.62 222.84

Ca2+ 2.1-2.6mmol/L 2.29 2.3 2.14

Mg2+ 0.7-1.3mmol/L 0.86 0.86 0.84

PO4- 0.8-1.45mmol/L 1.11 1.05 0.83

Liver Profile
Normal
6/11 9/11 13/11
Range

Albumin 35-50 g/L 30 28 26

T. bilirubin <20 umol/L 251.4 227 183
T. protein 66-87 g/L 67 61 55
ALP 53-141 u/L 477 454 506
ALT <32 u/L 125 106 137
AST 5 - 34 u/L 135 104 117
Others

Normal Range 6/11 9/11 13/11

UA 4.0 - 8.5 mg/dL 127 89 <60

LDH 0 - 248 u/L 531

Input/Output Chart
6/11 7/11 8/11 9/11 10/11 11/11 12/11

Input 1458 3016 3146 2664 4224

Output 700 1850 2700 2100 2850

Balance +758 1166 +446 +564 +1374

 Medications
Medication Date Start Date Stop Indication

IV Amoxicillin + clavulanic acid 1.2g stat & 7/11 13/11 Spiking temperature
TDS
IV Gentamicin 240mg stat & OD 12/11 13/11
IV Fluconazole 200mg stat & BD 13/11 13/11
IV Cefepime 2g STAT & TDS 13/11 Ongoing Febrile Neutropenia
IV Vancomcin 1g STAT & 500mg QID 13/11 Ongoing
IVD 6 pints of N/S 6/11 Ongoing Hydration
T. Gabapentin 300mg ON 7/11 Ongoing Peripheral neuropathy

T. Prednisolone 55mg BD 8/11 Ongoing RDA-EPOCH Chemo

regime
C. Tramadol 50mg tds 6/11 12/11 Pain management

C. Celecoxib 200mg OD 8/11 Ongoing

T. Oxycontin 5mg PRN 8/11 13/11

T. Oxycontin 10mg BD
 Medications
Medication Date Start Date Stop Indication

T. Ranitidine 150mg BD 8/11 Ongoing Stress ulcer prophylaxis

T. Paracetamol 1g 15 min before 8/11 8/11 Rituximab premedication
Rituximab
IV Hydrocortisone 100mg stat before 8/11 8/11
Rituximab
IV Chlorpheniramine 10mg stat before 8/11 8/11
Rituximab
IV Granisetron 3mg OD x 5/7 8/11 12/11 Chemotherapy-induced Nausea
and Vomiting prophylaxis
T. Metoclopramide 10mg PRN 8/11 Ongoing Vomiting
T. Allopurinol 300mg OD 8/11 Ongoing Tumor lysis syndrome
prophylaxis
T. Slow K 1.2g stat & tds 9/11 Ongoing Hypokalemia
Pharmaceutical Care Issues
• Management of DLBCL
• Management of Cancer pain
 Management of DLBCL
Description Management In Ward
Management
DLBCL is the most common General management: The patient is started
lymphoma, representing 1. It is recommended that patients with on RDA-EPOCH
31% of the non-Hodgkin advanced stage disease be treated with regime.
lymphomas (NHLs), and it is 6–8 cycles of R-CHOP-21.
rapidly fatal if untreated. 2. Dose-adjusted EPOCH (etoposide,
prednisolone, vincristine,
Disease staging based on cyclophosphamide, doxorubicin) with
Ann Arbor Staging: rituximab (DA-EPOCH-R) has also
Stage III: Involved of LN been reported to have significant
regions on both sides of activity, especially in GCB-type
diaphragm, accompanied by DLBCL, in a Cancer and Leukemia
localized involvement of an Group B (CALGB) multicentre phase
associated extralympatic II study (Wilson et al, 2008, 2012).
organ or site. (British journal of Hematology)

1. If you have heart problem or are frail,

your options include RCEPP. RCDOP,
DA-EPOCH-R, RCEOP, and RGCVP.
(NCCN, 2017)
RDA-EPOCH REGIME
• D - Dose
• A - Adjusted
• E - Etoposide
• P - Prednisolone
• O - Oncovin (Vincristine)
• C - Cylophosphamide
• H – Hydroxydaunorubicin (Doxorubicin)
• R - Rituximab
 Management of Cancer Pain
Description
In a systematic review on
symptom prevalence in
patients with incurable
cancer, pain was the second
most common symptom with
a pooled prevalence of 71% .
Management In Ward Management
General management: The patient was given:
1. The route of administration is oral • C. Celecoxib 200mg
as far as possible OD
2. Dosing of analgesic should be • C. Tramadol 50mg
according to a fixed time schedule tds
3. The choice of analgesic should be • T. Oxycontin 5mg
guided by the WHO analgesic PRN
ladder. • T. Oxycontin 10mg
4. Paracetamol or NSAIDs are the BD
drugs of choice for mild cancer
pain Pain score:
5. Weak opioids which include 8/11- 9/11 -> 2
tramadol, dihydrocodeine and 10/11 -> 1
codeine are mainly used for mild to Pt complained of pain
moderate cancer pain. for a few days.
(CPG of Management of Cancer Pain) The management was
appropriate.
Management of Cancer Pain
Drug Related Problems
1. Inadequate drug for Rituximab premedication
2. Inappropriate dose of T. Ranitidine
3. Inappropriate frequency of IV. Cefepinme
Inadequate drug for Rituximab
Premedication
Description
8/11
Patient is on day 0 of RDA-
EPOCH REGIME.
T. Paracetamol 1g 15 min before
Rituximab , IV Hydrocortisone
100mg stat before Rituximab,
and IV Chlorpheniramine 10mg
stat before Rituximab was not
given.
Justification
1. T. Paracetamol 1g 15 min before
Rituximab IV Hydrocortisone
100mg stat before Rituximab,
and IV Chlorpheniramine 10mg
stat before Rituximab should be
given on day 0 of RDA-EPOCH
REGIME.
(Rituximab product Leaflet)
Recommendation
1. Suggest to give T.
Paracetamol 1g 15 min
before Rituximab IV
Hydrocortisone 100mg
stat before Rituximab, and
IV Chlorpheniramine
10mg stat before
Rituximab
Outcome:
8/11: Suggestion was
accepted and premedication
drugs was given.
Inadequate dose of T. Ranitidine
Description Justification Recommendation
8/11 T. Ranitidine should be given 1. Suggest to change to T.
Patient is given T. Ranitidine 150mg q12hour for stress-ulcer Ranitidine 150mg BD.
40mg BD. prophylaxis.
8/11: Suggestion was
accepted.

(Medscape)
Inappropriate frequency of IV Cefepime
Description Justification Recommendation
13/11 1. IV Cefepime should be given 2g 1. Suggest to change to IV
Patient is given IV Cefepime 2g TDS for first line treatment of febrile Cefepime 2g STAT &
STAT & OD. neutropenia. TDS.
Patient has no renal impairment.
Outcome:
13/11: Suggestion was
accepted.

(NAG 2014)
Role of Pharmacist
• Counsel the patients regarding post chemo – what are
the conditions to be expected by patients
• Wear mask and not go to crowded places
• Only eat full cooked meals and eat fruit that has skin.
• To go to hospital immediately if has fever
• Counsel patient on the traditional medications such
belalai gajah, daun rama-rama, keladi tikus dll.
• Counsel on the management of extravasation.
• Emphasizes on the compliance towards
chemotherapy regime.
Conclusion
• Patient is currently on day 5 of RDA-EPOCH
regime.
• Patient continues current antibiotics in
ward.
References
• Ministry of Health Malaysia.(2014). National Antibiotic Guideline.
• Ministry of Health Malaysia.(2015). Clinical Pharmacokinetics
Pharmacy Handbook.
• Ministry of Health Malaysia.(2010). Clinical Practice Guideline
Management of Cancer Pain.
• Lexicomp. (2016). Drug information handbook with international
trade names index. Hudson,Ohio: Lexi-Comp.
• García-Suárez, J., Bañas, H., Arribas, I., De Miguel, D., Pascual, T.,
& Burgaleta, C. (2007). Dose-adjusted EPOCH plus rituximab is an
effective regimen in patients with poor-prognostic untreated diffuse
large B-cell lymphoma: results from a prospective observational
study. British Journal Of Haematology, 136(2), 276-285.
http://dx.doi.org/10.1111/j.1365-2141.2006.06438.x
• [Guideline] National Comprehensive Cancer Network. NCCN
Clinical Practice Guidelines in Oncology: Non-Hodgkin's
Lymphomas Version 1.2016. Accessed: November 13, 2017.
THANK YOU