Advances and Best Practices in the Utilization of Novel Agents in Metastatic Breast Cancer - Episode 19
Kate Jeffers, PharmD: There are a couple of different options for patients to get oral oncolytics, specifically the CDK4/6 inhibitors. They can be dispensed from a specialty pharmacy, which means that we send a prescription off to some pharmacy somewhere and it’s then mailed to the patient, to their home, typically overnight, usually at no charge to the patient. But some of them vary. Some of the oral oncolytics can actually be dispensed from your neighborhood pharmacy, whatever that may be, depending on the specialty restriction distributions. All of the CDK4/6 inhibitors do have some specialty restriction, so you’re usually not able to send those to a neighborhood pharmacy. There’s also in-office dispensing. These are providers’ offices or physician offices dispensing to the patients. I know this exists with some oral oncolytics. It’s not something that I’ve ever seen or had experience with, so I’m not able to speak too much on that one.
And then there’s this new kind of term coming up: “Medically integrated dispensing,” which is kind of a blend of that in-office dispensing and the specialty pharmacies. So it’s kind of putting the specialty pharmacy within an organization. So the hospital I work for, for example, our organization does have a specialty pharmacy, and it’s using the clinic pharmacist to help integrate into that dispensing. The goals of the medically integrated dispensing being that you’re able to hopefully reduce cost.
So with oral oncolytics and with these agents, specifically with palbociclib and ribociclib causing neutropenia, you often will need dose adjustments within those first couple of months. And so, if the patient receives a shipment of their medication at the higher dose and now they’ve come into the doctor’s office and are told it has to be dose reduced, they have to get a new prescription, which can lead to drug waste. And so, the medically integrated dispensing kind of puts both of those things together, in that the drug’s not dispensed until the lab results come back. And it’s typically done right there in the office once the lab results are back and we know the dosing. So it helps to improve patient care and patient safety, really focusing on cost avoidance and getting the patient the correct medication that they need at the correct time and looking at reducing waste.
The manufacturers have a lot of different options. Some of them are kind of dose-titration packs or patient-education packs. For various oral oncolytics that have certain side effects, the manufacturers will have kits that they send out with the first dispense for patients. That can be done either through the specialty pharmacy or through medically integrated dispensing. I know our in-house pharmacy does have some of those kits that they prescribe for patients. We have some of the kits specifically for the CDK4/6 inhibitors in the office. We’ll give these to patients when they’re starting treatment, depending on which specialty pharmacy they’re getting their medication from. It may or may not give them that kit, and we do want to make sure they get that information with these agents.
We also have dose-exchange programs. So abemaciclib specifically has a dose-exchange program that allows for a patient who has a dose change to send back whatever drug they have that they don’t need—so whatever that change in dose is—and they are redispensed at the correct dosing. I believe that’s at minimal to no charge to the patient. And so, again, the goal of that is to help decrease cost for the patient, making sure the patient is getting the correct medication. And that turnaround time in that dose exchange is, I believe, anywhere from 24 to 48 hours. So pretty quick dispensing.
The downside with a specialty pharmacy or something that you do have to send out for is, if you are going to do that dose change, the prescription typically has to be processed. Unfortunately with oral oncolytics, they are typically expensive and often need a prior authorization. And with a dose change, often that means a new prior authorization. It’s not just the same thing. And so, then you have the delay in waiting for the prior authorization. If the specialty pharmacy does or does not have that drug in stock or that strength in stock, you might have a delay in getting the drug and then a delay in shipment for the prescription.
We see this commonly. These delays become a problem in the winter time. Being in a snowy state, we will often see delays because of snowstorms, not just here in our state but also elsewhere in the country. If pharmacies aren’t able to get their supply in, they’re not able to dispense. And so sometimes medically integrated dispensing can help in that aspect because those medications are on site. Again, it doesn’t help if your pharmacy doesn’t have it in stock because of whatever weather issues are going on. But you’re able to get the medication to the patient a little bit faster when you have more control of it kind of on an onsite-type set up.
In terms of communicating back with the oncologist for any of the oral oncolytics, specifically with the CDK4/6 inhibitors, we do use our electronic medical record system. So we’ll do in-baskets back-and-forth to the providers. We also document, from an education perspective, in the clinic. We document in-progress notes. So any kind of phone calls or information that we provide to the patient or have with the patient, we will document in a note for the provider to be able to see. If it is something that is important or that may or may not need a dose change, we’ll directly send that chart to the provider to review.
We do document all of our adherence and toxicity in the electronic medical record as well as through some flow sheets that are developed. And then all of those are available to the oncologists. They’re able to pull those directly into their progress notes, and not just the oncologists but also our advanced practitioners. Those are all able to be pulled directly into the progress notes. And so, we really try to make our system, in terms of the adherence and the toxicities and the phone calls, be as transparent as possible, which is fantastic. But that can also lead to a lot of stuff to review.
And so, if it is something that really needs an answer from the oncologist, I try to directly message that versus hoping they read it through 2 or 3 different notes. Or if it’s something that’s really important, I’ll actually go walk up to the provider and say, “Hey, so and so is happening. What can we do for this patient?” Or, “This is what my recommendation would be. How do you want to approach it from here?” So I think we rely on electronics these days, but that face-to-face communication is always good. And if you have that opportunity to talk one-on-one with the oncologist, you can often get a lot more accomplished in a lot simpler fashion. And so, face-to-face communication is always preferred, especially if it’s something that’s more urgent.