How we would monitor patient 3
| Potential late effects . | Therapeutic exposure . | Screening recommendations . |
|---|---|---|
| Cataracts | • Corticosteroids | • History of visual acuity annually |
| • TBI (1320 cGy) | • Annual ophthalmologic examination | |
| Neurocognitive dysfunction | • Methotrexate (32 g/m2) | • Annual screening for educational/ vocational difficulties |
| • Cytarabine (17.5 g/m2) | • Formal neuropsychological evaluation if difficulties identified | |
| • TBI (1320 cGy) | ||
| Hypothyroidism | • TBI (1320 cGy) | • Serum TSH and free T4 annually |
| Cardiomyopathy | • Doxorubicin (240 mg/m2) | • History and PE annually for signs/symptoms of CHF |
| • Echocardiogram annually | ||
| • Aggressive management of hypertension, diabetes, and dyslipidemia (goal: maintain systolic BP <120 mm Hg, HbA1C ≤6.5%, LDL <100 mg/dL, total cholesterol <200 mg/dL) | ||
| • Health promotion: Smoking cessation, diet rich in fruits and vegetables, physical activity per ACS guidelines | ||
| Diabetes | • TBI (1320 cGy) | • Fasting serum glucose or hemoglobin A1C every 2 y |
| • Corticosteroids | ||
| Dyslipidemia | • TBI (1320 cGy) | • Lipid panel every 2 y |
| • Sirolimus | ||
| Hypertension | • Corticosteroids | • Annual manual BP monitoring |
| Pulmonary toxicity | • TBI (1320 cGy) | • History and PE for chronic cough, shortness of breath |
| • Pulmonary function tests at 1 y after BMT, then as clinically indicated | ||
| • Assure that patient received post-BMT immunizations, particularly pneumococcal (PCV, 3 doses; PPSV23, 1 dose) because of history of chest radiation | ||
| • Assure that patient receives yearly influenza vaccine | ||
| Renal toxicity | • Methotrexate (32 g/m2) | • Renal function panel (serum creatinine, electrolytes) 1y post-BMT (or at baseline visit) and then as clinically indicated |
| • Ifosfamide (18 g/m2) | • Urinalysis for proteinuria, and BP monitoring yearly | |
| • Carboplatin (1.6 g/m2) | ||
| • Sirolimus | ||
| • TBI (1320 cGy) | ||
| Gonadal dysfunction | • Ifosfamide (18 g/m2) | • LH, FSH, testosterone at 1 y after BMT or baseline visit, then as clinically indicated |
| • Carboplatin (1.6 g/m2) | • History of sexual dysfunction and fertility problems | |
| • Cyclophosphamide (11.7 g/m2) | ||
| • TBI (1320 cGy) | ||
| Osteonecrosis | • Corticosteroids | • Appropriate surgical and physical therapy intervention of the affected joint |
| • Sirolimus | • History and PE annually of other joints | |
| • TBI (1320 cGy) | • Radiography/MRI (in the event of symptoms) | |
| Osteoporosis | • Corticosteroids | • DXA scan 1 y after BMT, then as clinically indicated |
| • Sirolimus | ||
| • Methotrexate (32 g/m2) | ||
| Peripheral neuropathy | • Vincristine (8 mg/m2) | • Targeted history and PE 1 y post-BMT and then as clinically indicated |
| • Carboplatin (1.6 g/m2) | ○ Looking for signs/symptoms of abnormal sensations/sensory loss, loss of balance, foot drop, etc. | |
| t-MN | • Doxorubicin (240 mg/m2) | • Annual history and physical examination (for signs and symptoms of anemia and thrombocytopenia) up to 10 y after BMT |
| • Ifosfamide (18 g/m2) | • Laboratory evaluation (complete blood count with differential, bone marrow biopsy) only if clinically indicated | |
| • Carboplatin (1.6 g/m2) | ||
| • Etoposide (3.1 g/m2) | ||
| • Cyclophosphamide (11.7 g/m2) | ||
| Subsequent solid neoplasms | • TBI (1320 cGy) | • Annual history and physical examination, including oral cavity, external genitalia, neck for thyroid nodules, and full skin examination |
| • Ultrasound and fine needle aspiration (if palpable thyroid nodule identified) | ||
| Immunologic complications, including functional asplenia and associated life-threatening infections | • Prolonged immunosuppression related to GVHD and its treatment | • Assure that post-BMT immunizations are complete, particularly pneumococcal series (PCV, 4 doses); Haemophilus influenza type b (Hib, 3 doses); meningococcal (MCV-4, 2 doses; MenB, 2-3 doses); influenza (yearly); and HPV-9 (3 doses recommended for immunocompromised males through age 26 y) |
| • Do not administer live vaccines (MMR, varicella) until patient is at least 2 y after transplantation, off immunosuppressant therapy for 1 y, and off IVIG for at least 8 mo | ||
| • Consider Pneumocystis and antifungal prophylaxis until patient is off immunosuppressant therapy | ||
| Immunologic complications, including functional asplenia and associated life-threatening infections (cont'd) | • Provide patient with anticipatory guidance regarding risk of life-threatening infections; advise obtaining medical alert bracelet/card noting functional asplenia | |
| • Physical examination and blood culture at time of any febrile illness ≥101°F (38.3°C) to evaluate degree of illness and potential source of infection | ||
| • Administration of long-acting parenteral antibiotic (eg, ceftriaxone) and continued close medical monitoring is advised while awaiting blood culture results; hospitalization and broadening of antimicrobial coverage may be necessary in some clinical circumstances (eg, toxic appearance, marked leukocytosis, neutropenia, previous history of serious infections) |
| Potential late effects . | Therapeutic exposure . | Screening recommendations . |
|---|---|---|
| Cataracts | • Corticosteroids | • History of visual acuity annually |
| • TBI (1320 cGy) | • Annual ophthalmologic examination | |
| Neurocognitive dysfunction | • Methotrexate (32 g/m2) | • Annual screening for educational/ vocational difficulties |
| • Cytarabine (17.5 g/m2) | • Formal neuropsychological evaluation if difficulties identified | |
| • TBI (1320 cGy) | ||
| Hypothyroidism | • TBI (1320 cGy) | • Serum TSH and free T4 annually |
| Cardiomyopathy | • Doxorubicin (240 mg/m2) | • History and PE annually for signs/symptoms of CHF |
| • Echocardiogram annually | ||
| • Aggressive management of hypertension, diabetes, and dyslipidemia (goal: maintain systolic BP <120 mm Hg, HbA1C ≤6.5%, LDL <100 mg/dL, total cholesterol <200 mg/dL) | ||
| • Health promotion: Smoking cessation, diet rich in fruits and vegetables, physical activity per ACS guidelines | ||
| Diabetes | • TBI (1320 cGy) | • Fasting serum glucose or hemoglobin A1C every 2 y |
| • Corticosteroids | ||
| Dyslipidemia | • TBI (1320 cGy) | • Lipid panel every 2 y |
| • Sirolimus | ||
| Hypertension | • Corticosteroids | • Annual manual BP monitoring |
| Pulmonary toxicity | • TBI (1320 cGy) | • History and PE for chronic cough, shortness of breath |
| • Pulmonary function tests at 1 y after BMT, then as clinically indicated | ||
| • Assure that patient received post-BMT immunizations, particularly pneumococcal (PCV, 3 doses; PPSV23, 1 dose) because of history of chest radiation | ||
| • Assure that patient receives yearly influenza vaccine | ||
| Renal toxicity | • Methotrexate (32 g/m2) | • Renal function panel (serum creatinine, electrolytes) 1y post-BMT (or at baseline visit) and then as clinically indicated |
| • Ifosfamide (18 g/m2) | • Urinalysis for proteinuria, and BP monitoring yearly | |
| • Carboplatin (1.6 g/m2) | ||
| • Sirolimus | ||
| • TBI (1320 cGy) | ||
| Gonadal dysfunction | • Ifosfamide (18 g/m2) | • LH, FSH, testosterone at 1 y after BMT or baseline visit, then as clinically indicated |
| • Carboplatin (1.6 g/m2) | • History of sexual dysfunction and fertility problems | |
| • Cyclophosphamide (11.7 g/m2) | ||
| • TBI (1320 cGy) | ||
| Osteonecrosis | • Corticosteroids | • Appropriate surgical and physical therapy intervention of the affected joint |
| • Sirolimus | • History and PE annually of other joints | |
| • TBI (1320 cGy) | • Radiography/MRI (in the event of symptoms) | |
| Osteoporosis | • Corticosteroids | • DXA scan 1 y after BMT, then as clinically indicated |
| • Sirolimus | ||
| • Methotrexate (32 g/m2) | ||
| Peripheral neuropathy | • Vincristine (8 mg/m2) | • Targeted history and PE 1 y post-BMT and then as clinically indicated |
| • Carboplatin (1.6 g/m2) | ○ Looking for signs/symptoms of abnormal sensations/sensory loss, loss of balance, foot drop, etc. | |
| t-MN | • Doxorubicin (240 mg/m2) | • Annual history and physical examination (for signs and symptoms of anemia and thrombocytopenia) up to 10 y after BMT |
| • Ifosfamide (18 g/m2) | • Laboratory evaluation (complete blood count with differential, bone marrow biopsy) only if clinically indicated | |
| • Carboplatin (1.6 g/m2) | ||
| • Etoposide (3.1 g/m2) | ||
| • Cyclophosphamide (11.7 g/m2) | ||
| Subsequent solid neoplasms | • TBI (1320 cGy) | • Annual history and physical examination, including oral cavity, external genitalia, neck for thyroid nodules, and full skin examination |
| • Ultrasound and fine needle aspiration (if palpable thyroid nodule identified) | ||
| Immunologic complications, including functional asplenia and associated life-threatening infections | • Prolonged immunosuppression related to GVHD and its treatment | • Assure that post-BMT immunizations are complete, particularly pneumococcal series (PCV, 4 doses); Haemophilus influenza type b (Hib, 3 doses); meningococcal (MCV-4, 2 doses; MenB, 2-3 doses); influenza (yearly); and HPV-9 (3 doses recommended for immunocompromised males through age 26 y) |
| • Do not administer live vaccines (MMR, varicella) until patient is at least 2 y after transplantation, off immunosuppressant therapy for 1 y, and off IVIG for at least 8 mo | ||
| • Consider Pneumocystis and antifungal prophylaxis until patient is off immunosuppressant therapy | ||
| Immunologic complications, including functional asplenia and associated life-threatening infections (cont'd) | • Provide patient with anticipatory guidance regarding risk of life-threatening infections; advise obtaining medical alert bracelet/card noting functional asplenia | |
| • Physical examination and blood culture at time of any febrile illness ≥101°F (38.3°C) to evaluate degree of illness and potential source of infection | ||
| • Administration of long-acting parenteral antibiotic (eg, ceftriaxone) and continued close medical monitoring is advised while awaiting blood culture results; hospitalization and broadening of antimicrobial coverage may be necessary in some clinical circumstances (eg, toxic appearance, marked leukocytosis, neutropenia, previous history of serious infections) |