Abstract

A patient with a failed bone marrow transplant on paediatric intensive care unit (PICU) was commenced on Favipiravir as part of management to suppress Respiratory Syncytial Virus (RSV) on the background of Severe Combined Immunodeficiency Disease (SCID). As a non-formulary and unlicensed medication, this was approved via the Trust’s Medicines Management pathway based on relevant literature, expert opinion, and anecdotal information from another children’s hospital. Known adverse reactions of enteropathy, hepatitis and hyperuricemia were balanced up against the risk of the child dying from untreated pneumonitis. Medicines supply was sourced from Japan and the product was assessed, over labelled, and released by the Quality Control team before dispensing to the ward. Drug dosing was communicated to the medics. Drug administration was via the nasogastric (NG) tube; the pharmacist provided advice on crushing and dispersing in water for NG administration.

Favipiravir levels were required for dose optimisation however this could only be conducted by a laboratory in France. Trough and peak bloods had to be obtained on treatment day 7 which were then centrifuged and frozen awaiting international courier delivery, thus maintaining the cold chain. The Pharmacist liaised between the medical, nursing, laboratory and transport teams in addition to the recipient laboratory professor in France to facilitate this complex process. Favipiravir level results were returned to pharmacy via email, 11 days after being taken on the ward, and these showed a low trough level< 0.25micrograms/ml. The pharmacist liaised with the testing professor in France, a pharmacologist and the patient’s consultant and it was agreed to increase the dose frequency from twice daily to three times a day. Furthermore, the M1 metabolite level was measured to ensure sufficient metabolic clearance to avoid toxicity. Following this, repeated bloods were taken after 7 days of the increased dosing regimen and delivered following the previous process, again orchestrated by the pharmacist. This showed the drug level had increased and it was agreed was optimal for this patient.

The patient received the proposed medication in a timely manner and the nursing team were provided with clear information on how to administer it. Monitoring was successfully overseen by the ward pharmacist leading to dose optimisation and ensuring safe use of a medication which was unfamiliar to the multi-disciplinary team (MDT).

This event shows the value the ward pharmacist can add to patient care, medication safety and optimisation in a secondary care setting. Excellent organisational and communication skills were demonstrated to various teams, departments, NHS trusts and organisations. Leadership qualities were displayed by the pharmacist taking responsibility for a medication related issue, but one which was not necessarily part the core job role and would usually be done by the medical team. The logistical management improved rapport with various groups and ultimately boosted the reputation of pharmacy within the hospital teams. Other pharmacy departments could learn from this example and take the lead on novel aspects of medicines management within their sectors.