2026 Eastern States Conference

Authors
Saqib Khan, PharmD; Eric Boateng, PharmD, BCOP; Sonjela Bulku, PharmD, MS; Scott Tam, PharmD, BS; Momina Qureshi, PharmD; Kyoung-Sil Kang, PharmD, BCPS, BCOP

Learning objective
At the conclusion of this presentation, participants will be able to identify the onset timeline of pembrolizumab-associated hypothyroidism and describe the corresponding patterns of initiation of thyroid hormone replacement treatment in adult patients.

Self-assessment question
Which of the following best describes pembrolizumab-associated hypothyroidism?

1. It usually occurs before treatment initiation
2. It is a common immune-related adverse event that may occur weeks to months after starting therapy
3. It occurs only in patients receiving combination immunotherapy
4. It does not affect the quality of life or cancer treatment

Background
While Pembrolizumab has been shown to improve outcomes in solid tumors, it may cause hypothyroidism. Real-world data on the time to onset in underserved outpatients are limited. This study evaluates the time to onset of hypothyroidism after pembrolizumab initiation.

Methods
This is a retrospective study of patients who received at least 3 doses of pembrolizumab between January 2023 to July 2025. Patients included had a baseline thyroid-stimulating hormone (TSH) before pembrolizumab initiation. Patients with pre-existing hypothyroidism, on thyroid hormone treatment, or prior thyroidectomy were excluded. Data collected included demographics, cancer type, pembrolizumab dose and treatment dates, TSH and free thyroxine levels, date of hypothyroidism diagnosis, and date of thyroid hormone replacement therapy initiation. The primary endpoint is the time from pembrolizumab initiation to the onset of hypothyroidism. Secondary endpoints include time from documented hypothyroidism to thyroid hormone replacement therapy, as well as the proportion of patients remaining untreated at 30 days post diagnosis.

Results
A total of 38 patients met the inclusion criteria. The mean age was 66.3 ± 12.5 years, and 71.1% were female. The majority of patients were identified as Hispanic/Latino (52.6%) or Black (34.2%). The most common cancer type was breast (39.5%), followed by lung (21.1%) and uterine (15.8%), with a mean of 11.3 ± 6.6 treatment cycles. Hypothyroidism, defined as TSH greater than 10 mIU/L, occurred in 11 of 38 patients (28.9%). Of these, 45.5% developed hypothyroidism within 3 months of initiation, 18.2% between 3 and 6 months, and 36.4% after 6 months. Of the 11 patients diagnosed, 5 (45.5%) initiated levothyroxine within 30 days, while 6 (54.5%) remained untreated at 30 days post-diagnosis.

Conclusion
Pembrolizumab-associated hypothyroidism occurred in nearly 29% of patients, with over one-third presenting after 6 months of therapy. More than half of diagnosed patients remained untreated at 30 days, identifying a critical gap in timely clinical management. These findings support ordering TSH and free T4 together at every monitoring visit, continuing surveillance beyond 3 months, and implementing structured follow-up workflows to ensure prompt treatment initiation in underserved outpatient populations.

Title: Characterizing institutional uses of vedolizumab for immune checkpoint inhibitor (ICI) colitis
Authors: Amrit Pabla, PharmD; Christopher Wang, PharmD, BCOP; Lina Shao, PharmD, BCOP; Aliyah Pabani MD, MPH; Joanna Melia, MD; Vi Gilmore, PharmD, BCPS
Abstract 
Objective: This study aims to characterize institutional prescribing patterns of vedolizumab prior to and after implementation of formulary restriction changes and evaluate its clinical outcomes among patients with ICI colitis at Johns Hopkins Medicine. 
Methods: This retrospective, single-health system study evaluated adult patients with ICI colitis that received vedolizumab from July 2024 to July 2025. Patients were included if they received at least one dose of ICI therapy, had a diagnosis of ICI colitis, and received at least one dose of vedolizumab. Patients were excluded if they were less than 18 years of age. The objectives of this study were to characterize the prescribing practices of vedolizumab for ICI colitis 6-months before and after implementation of formulary restriction changes in January 2025, report efficacy and safety outcomes of vedolizumab for ICI colitis and to characterize ICI rechallenges for patients who had resolution of their ICI colitis.
Results: A total of 23 patients were included, of which 12 patients were in the pre- implementation cohort, and 11 were in the post- implementation cohort. The median age was 71 years old, 38% were female, and all patients were white. Most patients had melanoma (48%) and received combination ICI therapy (61%). Vedolizumab was prescribed first-line following steroids in 91% of patients. A second immunosuppressant agent was required in 17% of patients for refractory symptoms. Infections occurred in 35% of patients, with median time to first infection of 37 days. Readmission for recurrent ICI symptoms occurred in 13% of patients, and ICI rechallenges occurred in 30% of patients. All patients with a rechallenge had no recurrent symptoms.
Conclusions: This study characterizes the institutional prescribing patterns of vedolizumab at a single center health system and adds to existing literature supporting the use of vedolizumab for steroid refractory ICI-colitis.
Self-Assessment Question: (True/False) Vedolizumab is a non-steroidal immunosuppressant option for treating steroid refractory ICI induced colitis.

Title: Impact of Adding Abatacept to Antithymocyte Globulin for Acute Graft-Versus-Host Disease Prophylaxis in Matched Unrelated Donor Hematopoietic Stem Cell Transplantation 

Authors: Daniel Wroblewski, PharmD; Carissa Ganihong, PharmD, BCOP; Maribel Pereiras, PharmD, BCPS, BCOP; Simon Gelman, PhD ; Siddhartha Reddy, MD; Michele Lyne Donato, MD

Objective: Compare abatacept and rabbit antithymocyte globulin combination therapy versus rabbit antithymocyte globulin (rATG) acute graft-versus-host disease (GVHD) prophylaxis outcomes in matched unrelated donor hematopoietic stem cell transplantation (HSCT).

Self Assessment Question: (T/F): Abatacept inhibits alloreactive T-cell proliferation and cytokine production while preserving other aspects of immune function.

Background: This study evaluates survival, GVHD, chimerism, and safety outcomes in patients receiving abatacept and rATG combination therapy versus rATG alone for acute GVHD prophylaxis in matched unrelated donor HSCT.

Methods: This single-center, retrospective, observational study included patients undergoing their first allogeneic HSCT from a 10/10 matched unrelated donor for acute myeloid leukemia or myelodysplastic syndrome at Hackensack University Medical Center between January 1, 2019 and December 31, 2024. The primary outcome was GVHD-free, relapse-free survival (GRFS) at 1 year. Secondary outcomes included cumulative incidence of grade 2-4 and grade 3-4 acute GVHD (aGVHD) by day 180 after transplantation, incidence of chronic GVHD (cGVHD) at 1 year, time to neutrophil and platelet engraftment, full donor chimerism at day 30 and day 90 after transplantation, relapse-free survival (RFS) at 1 year, and overall survival (OS) at 1 year. Safety outcomes, including incidence of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation within the first 100 days post-transplantation, documented adverse reactions to abatacept, and non-relapse mortality (NRM) at day 180 and 1 year, were also evaluated.

Results: 
Among 155 patients, 76 received abatacept and rATG and 79 received rATG alone for GVHD prophylaxis. Bone marrow stem cell source and favorable performance status were more common in the rATG arm, while post-transplant maintenance was more frequent in patients receiving abatacept and rATG. Otherwise, baseline characteristics were similar among groups. At 1 year, GRFS was lower with abatacept and rATG prophylaxis (10% vs 30%, p=0.018), as was NRM at day 180 (1.3% vs 8.9%) and 1 year (6.6% vs 19%, p=0.02). cGVHD by 1 year was higher with abatacept and rATG prophylaxis (mild-severe: 73.2% vs 50.7%, p=0.009; moderate-severe: 38% vs 14.5%, p=0.002). EBV reactivation by day 100 was more common with rATG alone (63.3% vs 30.3%, p=0.0001). 

Conclusion: 
The addition of abatacept to rATG-based GVHD prophylaxis was associated with inferior GRFS at 1 year, driven by a higher incidence of cGVHD.  It was also associated with improved NRM , with similar rates of aGVHD in patients undergoing MUD allogeneic HSCT. Similar results were reported in prior studies where abatacept-based prophylaxis showed benefit in aGVHD, NRM, and relapse, but not cGVHD. Further studies are warranted to clarify the role of abatacept and rATG prophylaxis in this setting.

Evaluation of multidrug-resistant organisms in prolonged cefepime versus levofloxacin use through engraftment in allogeneic stem cell transplant recipients
Harry Grant Woodard, PharmD1, May Aziz, PharmD, BCOP1, Rebekah Dyer, PharmD, BCPS,1 William Clark, MD2, Christina E. Maguire, PharmD, BCIDP, AAHIVP11Virginia Commonwealth University Health System Department of Pharmacy Services 2Virginia Commonwealth University Department of Hematology and Oncology

Learning objective: Audience members will be able to explain the risks and benefits of early de-escalation of antibiotic therapy for neutropenic fever in allogeneic stem cell transplant recipients.

Background: The purpose of this project is to evaluate rates of multidrug-resistant organisms (MDROs) between prolonged cefepime use through allogeneic stem cell transplant (SCT) engraftment versus de-escalation to levofloxacin to help guide clinical decisions.

Methods: This is a single-center retrospective review of SCT recipients from 7/1/23 to 10/2/25. Patients who received prophylactic levofloxacin that was escalated to cefepime at neutropenic fever (NF) onset were included. Exclusion criteria were MDRO within the past 6 months, documented source of infection, and use of gram-negative coverage other than cefepime. Patients were categorized into two groups: early de-escalation (cefepime < 7 days) versus late de-escalation (> = 7 days of empiric therapy). Statistical analyses were performed using JMP software. For normally distributed data, chi-square tests and Fischer’s exact tests were used when appropriate. For non-normally distributed data, Kruskal Willis tests were utilized. A p-value of < 0.05 was considered statistically significant. The primary outcome is rate of MDROs in the early and late de-escalation groups. Key secondary outcomes include rates of repeat NF, graft-versus-host disease (GVHD), repeat admissions, and length of stay.

Results: Forty-two of 125 patients met inclusion criteria. Baseline characteristics were well balanced between groups. There was one documented MDRO infection within each group within 90 days of fever resolution (p = 1.0).  There were higher rates of repeat NF in the early de-escalation group (29.41% vs. 4%, p = 0.0318) ranging from one to eleven days after the initial NF episode. In patients treated for infection within 90 days of NF resolution, there was a numerically higher rate of culture positivity in the early de-escalation group (80% vs. 36.36%, p = 0.0805). Additionally, there was a trend towards higher rates of gut GVHD (41.67% vs 65%, p=.20) in the late de-escalation group.

Conclusions: This study found no difference in MDRO infection between SCT patients with early versus late de-escalation of antibiotic therapy, with low rates overall. Increased rates of repeat NF in the early de-escalation group and numerical increases in gut GVHD in the prolonged therapy group highlight the challenging balance between benefits and risks of prolonged antibiotic therapy after SCT. Larger studies should be completed to further characterize antibiotic stewardship in this population.

Learning Question:
What are the side effects of prolonged broad spectrum antibiotic therapy? Select all that apply.

• Gut GVHD
• Dyspnea
• Clostridium difficile infections 
• Development of multi-drug-resistant organisms 

     The objective of this project is to increase awareness and utilization of the Pharmacy Dose Adjustment Standard Operating Procedure and Veterans Health Information Systems and Technology Architecture (VistA) Chemotherapy Manager Business Rules to promote cost savings within the Veterans Affairs Medical Center. Through pharmacist education and evaluation of current practices, the goal of this project is to enhance appropriate dose rounding of weight based parental medications administered in the outpatient infusion clinic.

     This quality improvement project will consist of three phases including baseline assessment, educational intervention, and post intervention evaluation. The primary outcome is to evaluate change in utilization of the Pharmacy Dose Adjustment Procedure and VistA Chemotherapy Manager Business Rules dose adjustment allowances for weight based parental medications administered in the infusion clinic. A retrospective review of medication orders from the previous six months will be conducted. Data will be collected on weight based parental medications using VistA reporting tools.

     For each medication order, the prescribed dose and corresponding vial size will be analyzed to determine whether the dose was appropriately rounded in accordance with our procedure. The SOP states rounding to 10% for non-chemotherapies ordered in CPRS is appropriate. The SOP states chemotherapeutic agents are not to be followed by the SOP, so orders must follow the VistA Chemotherapy Manager business rules which allow for 5% rounding. Orders will be categorized into no intervention or opportunities for intervention groups.

     Pharmacist education will be provided including a review of the procedure and business rules, guidance on appropriate dose rounding, and emphasis on the importance of following procedures given potential cost savings. Pharmacists will complete a pre-test and a post-test consisting of a patient case to evaluate effectiveness of education. A medication order review will be completed six months post education and will evaluate change in dose adjustment procedure utilization. The secondary outcome is cost savings and will be analyzed using inventory records from our wholesaler.

Title
Evaluation of pneumococcal antibody titer levels in allogeneic hematopoietic stem cell transplant 
 
Authors
Robyn Turner, PharmD; Rebekah Dyer, PharmD, BCPS 
 
Learning Objective  
Develop a plan for subsequent pneumococcal immunizations based on pneumococcal antibody titer levels. 
 
Background/Objective
To determine the number of allogeneic hematopoietic stem cell transplant (HSCT) recipients with protective pneumococcal antibody titer levels of ≥0.35 μg/mL at Virginia Commonwealth University Health System (VCUHS). 
 
Methods
This was a single-center, retrospective, observational project evaluating pneumococcal antibody titer levels from January 2022 to December 2024.  Adult patients who underwent an allogeneic HSCT, received at least one dose of pneumococcal polysaccharide vaccine (PPSV) or pneumococcal conjugate vaccine (PCV), and had at least one pneumococcal antibody titer panel drawn were included.  The World Health Organization defines protective levels as ≥0.35 μg/mL for PCV serotypes, while expert opinion suggests ≥1.3 μg/mL for PPSV serotypes.  At VCUHS, a level of ≥1.3 μg/mL has been considered protective, regardless of the serotype.  Because thirteen of fourteen serotypes in the VCUHS titer panel are contained in PCV20, this project evaluated whether the lower threshold confers protection.  Protective antibody titer levels were defined as 75% (10/13) of serotypes meeting either threshold.  Data were collected from the electronic medical record and the Virginia Immunization Information System.   
 
Results
There were forty-five patients included.  Using antibody titer level threshold of ≥1.3 μg/mL and ≥0.35 μg/mL, 10 patients (22%) and 26 patients (57%) had protective antibody titer levels, respectively (p=0.0024).  One patient had confirmed invasive pneumococcal disease (IPD).  Although the primary objective of patients with protective antibody titer levels at the lower threshold compared to the higher threshold met significance, the small sample size limited the ability to evaluate potential confounding factors associated with meeting the threshold for protective antibody titer levels. 
 
Conclusion(s)
The number of patients with protective antibody titer levels based on the lower threshold of ≥0.35 μg/mL was significant.  This suggests that the lower threshold may be appropriate to confer protection against IPD in patients who underwent an allogeneic HSCT because only one patient had confirmed IPD.  Updating internal guidance documents to define protective antibody titer levels using the lower threshold may be warranted.   
 
Self-Assessment Question 
 
Why was it important to evaluate the lower threshold of ≥0.35 μg/mL in this project? 
 
A. It is the standard used for all pneumococcal serotypes at VCUHS 
B. It is the established threshold for PPSV serotypes
C. Thirteen of fourteen serotypes in the VCUHS titer panel are contained in PCV20
D. It eliminates the requirement for pneumococcal revaccination in HSCT recipients 
 
Disclosures
The authors and contributors have no conflicts of interest to disclose.

Authors: Elise Hildebrandt, PharmD; Sara Bouberhan, MD; Joseph Elijah, PharmD, BCOP, BCPS

Learning Objective: Describe the real-world effectiveness of mirvetuximab soravtansine-gynx (MIRV) ± bevacizumab in patients with platinum-resistant ovarian cancer (PROC) treated at Massachusetts General Hospital (MGH).

Background/Objective: PROC has limited treatment options. MIRV improved outcomes in FORWARD II and MIRASOL, leading to FDA approval for folate receptor alpha (FRα)-high disease. Real-world data remain limited. This study evaluates MIRV ± bevacizumab in PROC at MGH.

Methods: This single-center retrospective case series included adults (≥18 years) treated at MGH with platinum-resistant ovarian, fallopian tube, or primary peritoneal cancer and FRα expression of 25-100%. Eligible patients received MIRV ± bevacizumab with a cycle 1 starting dose ≥ 5 mg/kg using adjusted ideal body weight and routine premedications per the MIRV package insert. Patients enrolled in MIRV clinical trials or who had not received the recommended premedications were excluded. Primary outcomes were progression-free survival (PFS), best overall response (BoR), time on treatment (ToT), and duration of response (DoR); the secondary outcome was overall survival (OS). Baseline characteristics were summarized descriptively. PFS and OS were estimated using Kaplan-Meier methods with log-rank comparisons. BoR, DoR, and ToT were summarized overall and compared between platinum-free interval (PFI) subgroups (<3 vs 3-6 months) using Mann-Whitney U and chi-square tests where appropriate.

Results: A total of 61 patients were included: 3 (4.9%) had FRα expression 25-49%, 7 (11.5%) had 50-74%, and 51 (83.6%) had ≥ 75%. Twenty-four patients (39.3%) had a PFI <3 months and 37 (60.7%) had a PFI of 3-6 months. Median PFS, DoR, and OS were 4.99, 3.04, and 9.66 months. No complete responses were observed; 10 (16.4%) achieved partial response (PR), 24 (39.3%) had stable disease (SD), and 13 (21.3%) had progressive disease (PD). Four patients (7.3%) discontinued due to toxicity. Patients with PFI of 3-6 months had a numerically longer DoR, though this was not statistically significant (p = 0.383). BoR did not differ significantly by PFI (p = 0.876), although more patients experienced PR or SD in the 3-6 month group.

Conclusions: Among patients with platinum-resistant FRα-positive ovarian cancer, MIRV demonstrated modest real-world activity, with lower PFS, BoR, and OS compared to MIRASOL and FORWARD II. Similar to MIRASOL, most patients achieved SD rather than PR despite comparable prior lines of therapy. Although not statistically significant, patients with longer PFI tended to have longer DoR, suggesting potential benefit in this subgroup.

Self-Assessment Question:
Which statement most accurately reflects the real-world outcomes of MIRV in PROC patients at MGH?

• MIRV resulted in high rates of CR with minimal adverse events, and outcomes were comparable across PFI groups
• MIRV demonstrated modest activity with the majority of patients achieving PR or SD
• MIRV showed minimal activity with no disease activity, and most patients discontinued due to toxicity, with significant differences based on PFI
• MIRV led to durable responses in a majority of patients, with OS exceeding 12 months regardless of PFI

Title: Evaluation of guideline-directed venous thromboembolism prophylaxis in high-risk ambulatory cancer patients
Authors: Srivishnu Vardhan Parasaram, PharmD; Julie Shupp, PharmD, BCOP; Jorge Aguilera, PharmD, BCPS
Learning Objective: Audience members will be able to evaluate institutional adherence to NCCN/ASCO guideline-directed venous thromboembolism (VTE) prophylaxis in ambulatory cancer patients.
Background/Objective: Cancer-associated thrombosis is a significant cause of morbidity and mortality in oncology patients. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines recommend consideration of VTE prophylaxis for high-risk ambulatory cancer patients initiating systemic chemotherapy, defined by a Khorana Score of 2 or greater. This study aimed to determine the rate of appropriate VTE prophylaxis prescribing at John R. Marsh Cancer Center within Meritus Health and to evaluate associated clinical outcomes.
Methods: This retrospective observational study evaluated adults aged 18 and older presenting with a new cancer diagnosis and initiating chemotherapy at John R. Marsh Cancer Center between January 1, 2024 and December 31, 2024. Baseline Khorana Scores were calculated to stratify VTE risk. Patients were excluded if they were receiving therapeutic anticoagulation for a pre-existing condition (e.g., atrial fibrillation, secondary prophylaxis), had a documented absolute contraindication to anticoagulation, were pregnant, or received treatment exclusively at an outside facility. The primary outcome was the rate of appropriate VTE prophylaxis prescribing based on NCCN guidelines. Secondary outcomes included the incidence of VTE events, major bleeding events, and all-cause mortality, stratified by Khorana Score, management appropriateness, and metastatic status.
Results: A total of 167 patient charts were included for analysis. Guideline-adherent VTE prophylaxis management was observed in 67.1% of patients (n=112), with 55 patients (32.9%) managed inappropriately based on their baseline Khorana Score. Of the entire cohort, only 3 patients (1.8%) were prescribed pharmacologic thromboprophylaxis, reflecting a very low overall prescribing rate despite the high proportion of high-risk patients. VTE events occurred in 9.8% (n=11) of appropriately managed patients compared to 25.5% (n=14) of inappropriately managed patients, a statistically significant difference (p=0.015; RR 2.60, 95% CI 1.27–5.33). Patients with a Khorana Score ≥2 experienced VTE at a rate of 24.6% compared to 10.0% in low-risk patients (p=0.023; RR 2.46, 95% CI 1.19–5.06). Major bleeding events occurred in 3.0% of the overall cohort (n=5); no statistically significant differences were observed across any subgroup, though the analysis was limited by the low event count. All-cause mortality occurred in 24.0% of the cohort (n=40), with significantly higher rates observed in patients with a Khorana Score ≥2 (36.8% vs. 17.3%, p=0.009) and in inappropriately managed patients (38.2% vs. 17.0%, p=0.005).
Conclusion: Adherence to NCCN/ASCO VTE prophylaxis guidelines at our institution was 67.1%, with an overall pharmacologic prophylaxis prescribing rate of only 1.8%, suggesting that guideline-concordant management in this population is largely driven by appropriate withholding of prophylaxis in low-risk patients rather than active prescribing in high-risk patients. Inappropriately managed patients experienced significantly higher rates of VTE, demonstrating the clinical consequences of non-adherence. All-cause mortality differences across subgroups likely reflect underlying cancer burden and disease severity rather than VTE-attributable death, as cause of death was not captured. While provider hesitance regarding anticoagulation is understandable given bleeding risk and potential treatment delays, this study highlights a meaningful quality improvement opportunity. The occurrence of VTE in low-scoring patients and variable outcomes among high-scoring patients also suggest the Khorana Score alone may have limited precision in this population, underscoring the need for prospective evaluation and potentially more individualized risk stratification tools.