Financial Burdens of BTKi Therapy

Brian Koffman, MD, and Roy Beveridge, MD, discuss the financial burdens of Bruton tyrosine kinase inhibitor therapy and considerations for oral therapy vs infusion therapy.

Ryan Haumschild, PharmD, MS, MBA: We talked about BTK [Bruton tyrosine kinase] inhibitors, but it’s important to talk about not only the clinical aspects but also the financial burdens and future considerations. Dr Koffman, what are some of the financial burdens of BTKi [BTK inhibitor] therapy that you’d like to highlight? What are some of the considerations of oral therapy vs infusion therapy?

Brian Koffman, MD: There’s been a revolution in oncolytics with the shift toward more responsibility for the patient. That responsibility is remembering when to take their medication but also having to pay for it because in CLL [chronic lymphocytic leukemia], in particular, the average age of diagnosis is 70 to 71. Most of these individuals—not all, but most—are on Medicare. Depending on the Medicare plan, they could be looking at significant co-pays. That will change in a few years with the Inflation Reduction Act [of 2022], and that’s good for patients. But right now, that’s a huge issue for patients.

As I said earlier, patients will sometimes make the financial decision. I’ve certainly seen patients say, “I’m not going to start my therapy in September because I’m going to get 3 months and then I go through the doughnut hole. Are you kidding me? I’m not going to start my therapy. I’m going to wait until January.” Maybe they shouldn’t be waiting 3 months because their disease is taking off. I’ve seen that done a lot, and the patients just can’t afford it. They’re getting therapy that they can get at the doctor’s office, which is covered. That’s a significant issue, and we need to have more resources to help those patients.

We have some resources for patients who are below a certain level of the federal poverty level. But these are buckets that fill up with funding and then empty, and they’re not always available. You have to be a sophisticated patient or have somebody working at a specialty pharmacy or helping you in the private insurance setting…. Patients often get help because the companies can help subsidize that co-pay and make it easier for the patients to get the drugs. It’s less of a financial burden if you’re not on a government-funded [plan], so that’s paying for your drugs.

Ryan Haumschild, PharmD, MS, MBA: Between the oral and IV [intravenous] therapies, there are other issues. The out-of-pocket expenses for patients are higher. When patients are on IV therapy, sometimes there’s transportation vulnerability. Can they get there to receive their medication? Are they able to do it outside the financial vulnerabilities we’ve spoken about? Those are important because you want to make sure the patient is taking the medication correctly. Sometimes you know they’ve shown up and gotten that infusion [because] they’re adherent to the therapy. With BTK inhibitors, we reduce that transportation vulnerability, but we put more onus on the patient for adherence. Those are trade-offs between the 2. But ultimately, if we can have patients be adherent to a BTKi inhibitor, reduce their adverse effects, and keep them on therapy longer, that can be a great thing, especially when you think about the financial burden. But we’ve got to work collaboratively with our payer colleagues.

Brian Koffman, MD: Let me add something. We know from the CML [chronic myeloid leukemia] community, which is more mature in terms of oral therapies, that the leading cause of patients progressing was nonadherence to their medications—[patients] got sick of taking the meds because of adverse events and other things. For patients with CLL, we have those same concerns. When you’re looking at a therapy that you’ve taken until progression or until intolerance, it’s a problem. That’s another issue. The responsibility shifts, but you don’t have a sense of that. Are you taking the medicine? If you don’t show up to your appointment, the nurse from the doctor’s office is going to call you and say, “You had an appointment. What’s going on?” If you don’t take your pills for 3 days, or you forget to take them because you’re going on a vacation, nobody is calling you; nobody knows. When the pharmacy calls and says, “You’re due for your next prescription,” you say, “Send it”—even though you have half a bottle sitting there. That’s a significant issue, and responsibility shifts to the patients. Sometimes those patients aren’t being responsible for that for a lot of other reasons. They may have comorbidities or other issues. They may have a big pill burden that they’re already taking. Even if they can afford them, but that’s another issue.

Roy Beveridge, MD: The CML story is a great analogy. They’re a decade ahead of what we’re talking about with CLL. The first-generation, Gleevec [imatinib], is highly effective for the vast majority of patients. The physician community came up with different lines of therapy, which made the second- and third-generation drugs much more acceptable, even though they were much more expensive. But the same problems occur with physician reading of test results. What I just quoted you for CLL is still being quoted for CML in terms of not following patients every 3 to 6 months for monitoring of disease. The analogies are remarkable.

Transcript edited for clarity.

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