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5-Fluorouracil (5-FU) is one of most frequently used chemotherapeutic medications for the treatment of many types of cancer in curative and palliative setting. It is important to recognize chemotherapy side effects and toxicities because some of these symptoms may indicate a clinical syndrome needing evaluation for a principal cause. We discuss a patient who developed severe mucositis requiring hospitalization after first use of Fluorouracil. Dihydropyrimidine dehydrogenase ( DPD) deficiency was suspected and was proven to be a cause of severe drug-related toxicity. Our patient is fifty six year old gentleman with stage III nasopharyngeal squamous cell carcinoma who developed two masses on right side of the neck and large posterior right nasopharyngeal mass. Patient was treated with concurrent chemotherapy with high dose of cisplatin along with radiation. Once completion of concurrent chemotherapy and radiation he was started on combination of 5-Fluorouracil and cisplatin. Three days after completion of ninety six hour continuous 5-flurouracil infusion patient developed severe mucositis. Clinical exam was consistent with swollen tongue and mouth and inability to clear oral secretions. Patient was tested for DPYD gene mutation. Testing showed heterozygous for the c.1679T>G(*13) variant in the DPYD gene consistent with predicted intermediate DPD activity (30-70% enzyme activity). About 80% of administered 5-fluorouracil is normally inactivated by DPD. A decrease in DPD enzymatic activity may lead to increased concentrations of 5-FU and elevated risk for severe toxicities. Standard dose of 5-FU was decreased by 50% with second cycle of chemotherapy. Patient tolerated the second cycle of chemotherapy well. Variants in the DPD gene can lead to reduced 5-FU catabolism resulting in severe toxicities. Some of the toxicities can cause death. It is important to screen for this deficiency and closely observe patients during chemotherapy treatment.

Targeted oral antineoplastic agents (OAs) have become a staple and rapidly growing field in the realm of cancer treatment. As with any chemotherapeutic/narrow spectrum agent, clinicians have to be aware of potential drug interactions that could interfere with therapy. Drug information databases are a common resource utilized to check for interactions between agents and patient's home medications. A major concern with OAs is that they are usually taken at home as well as picked up at a pharmacy by the patient themselves. With this kind of therapy adherence and patient side effect reporting becomes a concern. We wanted to determine the reliability of these databases for picking up potential interactions with patients on OAs. We accessed hospital records to find patients with various malignancies on OAs between the calendar year of 2013-2014, of which we found 876 that were screened for potential use of OAs. The goal was to find patients on OAs specifically and determine the number of drug interactions flagged by either drugs.com and/or Lexicomp®. In addition, the significance of the interaction as well as disagreements between databases were analyzed. A major interaction by Lexicomp® is defined as either a ‘D’ or an ‘X’ level interaction and on drugs.com is labeled ‘major.' Of the 876 screened we found 16 patients (one patient had tried 3 different agents, and another patient had tried two) on OAs. Lexicomp® flagged overall 42 interactions amongst all subjects, of which 17 were major interactions. Drugs.com flagged overall 44 interactions amongst all subjects, of which 11 were major interactions, being the more conservative of the two. Between the 2 databases there were 10 out of 18 major interactions that both were in agreement upon. These discrepancies are of concern in that clinicians hope that resources they utilize are incongruent with one another and allow them to practice in the safest manner in terms of avoided potential serious drug interactions whether it be harm to a patient or decreased effectiveness of the OA. Now that all patients have been screened, future research would be to determine the clinical significance of these interactions and whether or not they had an effect on patient outcomes.

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The startup of the Bill Gatton College of Pharmacy has allowed the introduction of novel means of engaging students in a variety of programs. The Concentration in Pharmacy Research (CPRx) is designed to give students focused experience in conducting research in Pharmaceutical Sciences and Pharmacy Practice. Initiated by faculty desire to engage PharmD students productively in the lab to augment our degree program, the CPRx arose because of student desire for recognition of their research efforts. The CPRx was formalized by developing a proposal that contained input from students, faculty and staff, passed through both departments and then the Faculty Council. Successful fulfillment of the CPRx requires students to complete a total of 12 credits in designated research elective courses, offered in both departments. A capstone APPE is also required where each student drafts a publication of his or her work and submits the paper for publication. The demand for research elective participation has been large. Currently, a total of 61 2nd and 3rd year PharmD students are enrolled in research courses. Of these, 15 are formally enrolled in the CPRx. To date, 73 abstracts and presentations and 25 peer-reviewed papers have been authored by Gatton students. The overall success of this program shows the powerful enthusiasm that arises from faculty and student engagement in active and productive research. The CPRx provides a unique means for Gatton students, especially those seeking residencies, to individualize their PharmD degree and enable greater success and diversity of career choices.

The US Food and Drug Administration (FDA) is encouraging the innovation of long-acting opioid formulations that are manipulation-resistant. The purpose of this commentary is to assess the benefits and limitations of abuse-deterrent opioid formulations (ADFs) and discuss their role in mitigating the current opioid epidemic. ADFs have been created with chemical properties that make it difficult for people who non-medically use prescription drugs to crush and dissolve opioid tablets, as well as by combining opioids with antagonists such as naloxone or naltrexone, which are released only when the dosage form has been manipulated or the drug is taken by a non-intended route. Despite these and other technologies, consensus regarding the effectiveness of these formulations in preventing non-medical use is lacking given the difficulty in obtaining post-marketing data. Researchers also question if the creation of abuse-deterrent drugs will have a positive effect on those struggling with a severe opioid-use disorder, fearing that current opioid users will simply find a new – perhaps more dangerous – drug of choice. Abuse-deterrent opioids are still opioids, and although they may make manipulation more difficult than non-ADF formulations, they are not “abuse proof.” The introduction of ADFs could provide a false sense of security among prescribers and dispensers, and we fear that ADFs may have a minimal impact on non-medical use of prescription opioids. Further epidemiological studies will be required to determine the large-scale impact of abuse-deterrent opioids in preventing opioid use disorder and its downstream consequences.

The next presentation will examine common gray areas of community pharmacy practice. For example: under what circumstances do pharmacists fill early, transferred controlled substance prescriptions for out-of-town patients; when do pharmacists sell syringes to patients without proof of medical need; and how do pharmacists determine that a buprenorphine prescriber is acting in a patient's best interest? These and other ethical or legal dilemmas challenge pharmacists as they try to balance identifying and preventing potential drug abuse and diversion with providing evidence-based, quality patient care. Based on data from pharmacists and pharmacy students, as well as established theory, presenters will describe typical approaches to decision-making. Multiple pharmacy cases will be discussed. Participants will learn how to integrate best-practice patient care systematically into common practice scenarios.