Ask the Pharmacist Q2 2020

Questions submitted by readers and answered by the CLL Society Medical Advisory Board

Remember that we cannot give medical advice and any suggestions should be reviewed with your treating doctors.

By Thomas E Henry III, MBA, RPh, CPh

My father is in remission for PH+ ALL but has relapsed CLL.  He is currently on 100 mg dasantinib for the ALL with a plan to start ibrutinib in the near future.  His oncologists have held off treating the CLL out of concern that he may need to decrease/discontinue the dasantinib.  They report no known others who are on both of these medications concurrently. Any recommendations regarding this?  If you could please include your credentials in your response it would be greatly appreciated.  Thanks in advance.

Here is the answer from Tom Henry, our pharmacist and a CLL patient.

In response to your query, I performed a drug-drug interaction check using two tools that I rely upon heavily.  Neither source shows a “known” interaction between these two medications.  This does not immediately mean these medications are safe together because as you mention, this combination has been used infrequently, if ever.  I take the negative interaction report to mean that at least in theory, there are no incompatibilities such as both drugs metabolized by the same organ or same enzyme.  I think the actions of the physician being cautious is appropriate, given the lack of information around concurrent use. 

You don’t address whether your father is experiencing CLL related symptoms that are intolerable.  Perhaps the physician is opting to control the more aggressive of the two leukemias?

This case may be a good candidate for the CLL Society’s Expert Access program where physicians who specialize in CLL look at the entire medical record of a patient, which gives them the overall picture of the patient and allows them to render a second opinion. 

Thomas E. Henry III, MBA
Registered Pharmacist in 23 states
Consultant Pharmacist (Florida)
Prior Chief Pharmacy Officer at Moffitt Cancer Center (Tampa) and Roswell Park Cancer Center (Buffalo)

Answer by Dr. Koffman:  Remember that we cannot give medical advice and any suggestions should be reviewed with your treating doctors.  I agree that you might get more benefit from our free online Expert Access program that would allow a CLL expert to review the medical records and then provide a 30- minute HIPAA compliant online visit with that expert to answer questions, and to provide ideas and notes to take to the local treating doctor.  A diagnosis of CLL and USA residence are the only requirements.  Here is the link to apply:

https://cllsociety.org/cll-society-expert-access/

 

Is it OK to take cefixime and cefuroxime at the same time?  Actually, government doctor has prescribed the above two at the same time.

Here is the answer from Tom Henry, our pharmacist and a CLL patient.

These two drugs both belong to the class of antibiotic drugs known as cephalosporins.  It is uncommon to use two cephalosporins at the same time but in this case, it may make sense in that they kill different bacteria.  It appears that your physician is not 100% sure what organism is infecting you, so he is taking a broad-spectrum approach. Cefixime has better gram-negative coverage, whereas the cefuroxime is stronger on the gram-positive organisms.  I’d say take both for now.  If the physician was able to get some type of culture to identify the specific bacteria, he/she may tell you to only continue with one.  Hope this helps…

 

Should I stop taking Omega 3 Fish Oil while taking Imbruvica?

Here is the answer from Tom Henry, our pharmacist expert.

Since both Imbruvica and Fish Oil caps have blood thinning properties, it is advisable to stop the Fish Oil until you can speak to your CLL doctor or the Clinical Pharmacist on your CLL team. When I started Imbruvica, the Clinical Pharmacist had me stop Fish Oil, Curcumin and Vitamin E, for this reason.

 

On the Covid-19 webinar conducted on 3/27/2020, I heard Tom Henry mention something about Fish Oil supplements (something about it being an ‘anticoagulant’??).  I have early stage, ‘wait & observe’ (no treatment / therapy at this time) CLL and I have taken Fish Oil supplements for years.  However, is this something I should re-evaluate? 

Here is the answer from Tom Henry, our pharmacist expert.

Thanks for attending our COVID-19 webinar!  Yes, I did mention that fish oil caps have anticoagulant properties.  I think this of concern primarily for patients who are on either ibrutinib or acalabrutinib treatment because they too have anticoagulant properties.  It may also be important to consider for patients on watch and wait, or other treatments if their platelet count is low.

It’s really important that when we give our medication histories to our CLL provider that we include vitamins, supplements, OTC medications, in addition to prescription medications so that our care team has the best information to guide your personalized care.

 

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Thomas Henry is a Registered Pharmacist and CLL Patient. He is President and Senior Consultant for Burlington Consulting Associates a company that provide consulting services to health-systems nationwide. He has a forty year career in pharmacy and has served as Chief Pharmacy Officer at two Top-15 Comprehensive Cancer Centers, Moffitt (Tampa, FL) and Roswell Park, (Buffalo, NY).