The Impact of Evolving Treatment Options in Multiple Myeloma, Part 9

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Multiple myeloma experts comment on clinician education of novel therapies in the pipeline for multiple myeloma and discuss optimal routes of administration for currently available drugs.

Bruce A. Feinberg, DO: Tom, one of the big questions we had, that much innovation happening, you’re going to introduce a new drug on your formulary, you’ve got tens of doctors, how did they get brought up to speed? How are they educated? Is it being done through a pharmacist? Are you bringing in a KOL [key opinion leader] from Hackensack or another local institution? How do you introduce these new therapies especially when it’s one disease but every doctor in your practice probably manages the myeloma, so they all have to be—it’s like being a pilot. You’ve got zero tolerance for error and you’ve got to raise that bar for everybody. How do you do it?

Thomas Ollis, MS, RPh: Two times a week, we have what we call clinical huddles. On Tuesdays and Fridays, we have a zoom session where our prescribers will jump on, we also have doctors, pharmacists, and nurses. Everybody jumps on, and usually it’s a KOL, it could be an MSL [medical science liaison] from one of the drug companies or they will get a thought leader prescriber. That’s the big way we do it now especially in this COVID-19 era where the specialists aren’t getting into the offices to be able to talk to them.

Bruce A. Feinberg, DO: What time of the day do you do this?

Thomas Ollis, MS, RPh: We do it early. We do 7 a. m. and 8 a. m.

Bruce A. Feinberg, DO: 7 a. m. and 8 a. m. you do it twice a week.

Thomas Ollis, MS, RPh: We do it 7 a. m. and 8 a. m. 1 day, 2 pieces, and then a repeat performance on Friday.

Bruce A. Feinberg, DO: The same.

Thomas Ollis, MS, RPh: This way we get…

Bruce A. Feinberg, DO: One drug or one disease a week.

Thomas Ollis, MS, RPh: Right.

Bruce A. Feinberg, DO: What percentage of your doctors are attending? Are you tracking the compliance?

Thomas Ollis, MS, RPh: We do. We probably get upwards of 35% to 40% and I think that’s a lot on each…

Bruce A. Feinberg, DO: Wait, 35% to 40% of the entire practice at each week or on a given call.

Thomas Ollis, MS, RPh: On a given call, not total.

Bruce A. Feinberg, DO: Do you think that overall across the prescribers it’s 80%?

Thomas Ollis, MS, RPh: It depends on the topic. It depends on the topic. If it’s multiple, if…go ahead.

Bruce A. Feinberg, DO: A new drug release is going to be higher than something that is already established.

Thomas Ollis, MS, RPh: Absolutely.

Bruce A. Feinberg, DO: Who selects the topics?

Thomas Ollis, MS, RPh: The companies will usually approach me and say we would like to do something, so I work with our Chief Medical Officer and we look at what we want to bring to our prescribers and our doctors. We don’t want to waste anyone’s time.

Bruce A. Feinberg, DO: Just a heads up. Since we just are doing a national broadcast, you are going to get a lot more calls about that program after this…

Thomas Ollis, MS, RPh: Good. Absolutely.

Bruce A. Feinberg, DO: It’s going to happen. I am trying to think, what do we need to cover…I felt good about what we did in CAR T [chimeric antigen receptor T-cell therapy] and the BCMA [B-cell maturation antigen] pathway drugs. Is there anything else that we really didn’t touch on? Do you guys think we missed an opportunity here in terms of future thinking?

Thomas Ollis, MS, RPh: We didn’t talk about dosage forms. We have DARA [daratumumab (Darzalex)], intravenous [IV], subcutaneous [subQ]. I don’t know if that matters. It might matter on the office side.

Bruce A. Feinberg, DO: Just because of the route of administration?

Thomas Ollis, MS, RPh: Yes, route of administration, it’s a little quicker to give subQ or DARA.

Joseph Mikhael, MD: A whole lot quicker. I mean, you’re talking hours down to 5 minutes.

Bruce A. Feinberg, DO: What is the Velcade [bortezomib] use now subQ to IV?

Joseph Mikhael, MD: It’s almost exclusively subQ.

Ryan Haumschild, PharmD, MS, MBA: Almost all subQ.

Joseph Mikhael, MD: Because we see less neuropathy with it and even less thrombocytopenia with it. It’s the DARA that has gone through the recent change where we have gone from very lengthy up to 8- to 9-hour infusions down to a 5 minute subcutaneous infusion. Although obviously it takes a little bit longer than that by the time the patient is brought in and so on but that has been one shift. I don’t know if that is an important focus of yours.

Bruce A. Feinberg, DO: I think it’s really interesting because with Velcade there was a story. There was actually a toxicity difference, so clinically it wasn’t the same drug even though it was the same drug in the way it behaved in the body. You had the efficacy preserved but you had less toxicity.

Joseph Mikhael, MD: I can argue the same here though because there are significantly fewer infusional reactions. One of the challenges of giving daratumumab intravenously was that at least a third if not half of patients had some degree of clinically significant infusional reaction, and that number has gone down dramatically as we give it subcutaneously.

Bruce A. Feinberg, DO: I think that’s a great call out, Tom. This is really meaningful across the listening audience and certainly in the practice world. But there is a big question when it is subQ, especially with the pharmacy piece and patients. Are patients’ self-administering with the subQ or are they coming in and you’re administering the subQ?

Thomas Ollis, MS, RPh: No, absolutely not. Patients are not self-administering, and I don’t ever see a patient self-administering these products. If we want to do a pegfilgrastim at home, maybe we can do that, but we are certainly not doing daratumumab, or Velcade, or anything like that.

Bruce A. Feinberg, DO: Uniform, Ryan, Joe?

Ryan Haumschild, PharmD, MS, MBA: Yes, we do it subQ. We bring the patients in, and I think it works really well. I think we are always trying to be patient centric, so what does the future look like, right now doing subQ for daratumumab has been really patient centric at maximizing their time. But I think in the future who knows what is in store.

Bruce A. Feinberg, DO: I think the pressure has got to be there. It has been happening with RA [rheumatoid arthritis] where the thinking was, of course not, they will come in, but that didn’t happen.

Joseph Mikhael, MD: Being part of an international community, there are countries around the world making it feasible to be able to have home administration of some of these medications. Our system is of course structured differently, God Bless America, but maybe there are opportunities to look at to make it even more patient friendly, especially after the initial infusions where the risk of a reaction still exists but goes down dramatically after the first few whereby it could definitely be delivered in a more patient-friendly setting.


Transcript Edited for Clarity