Oral therapy for HR-MDS: addressing patient adherence
Bruce Feinberg, DO: Ryan, with the apothecary’s hat, we now have oral therapies for this disease. We talked about an oral HMA [hypomethylating agent], and we got lenalidomide. You mentioned it in passing before, but when it comes to the providential over the distribution of this agent and the extent to which it affects the quality of patient outcomes, what do we know about it?
Ryan Haumschild, PharmD, MS, MBA: I’ll put on my payer hat and health hat for this one because it applies to both. As we know, Revlimid has limited distribution. We know that only pharmacies that originally dispensed the drug can dispense under the REMS [Risk Evaluation and Mitigation Strategy] requirement, and so it happened. But more and more we are seeing healthcare systems – be it Yale University, Emory Healthcare or elsewhere – starting to develop their own healthcare system or IDN [integrated delivery network]-own specialty pharmacy.
For Amer, with those oral therapies we mentioned, it’s a class effect on all worlds. You have to manage them very carefully. You are still giving chemotherapy or an anti-cancer drug as if you were being infused at the IV center. We’re just not there in person. We need to create really good oversight of education. Is everything documented in the EMR [electronic medical record]? Are we filing over the EMR so we have good notes and reconciliation?
I’ll tip our hat a little. At Emory Healthcare, we published an article that spoke to our patients about oral cancer medications. We measured our results against PBM [pharmacy benefit manager]-own specialist pharmacies. For the same provider, we looked at the adherence and duration of treatment of these agents independently of the provider, but looked at the differences in the pharmacy. In a specialty pharmacy owned by IDN, adherence was 25% better. We just talked about patients staying successful in this treatment class. They begin to work out the difference in patient outcome based on where drugs are delivered within that integration.
Finally, the time to treatment was 4 days faster. When I think about these treatments and I’m a provider and I want to get a patient up and running, as Amer mentioned, they’re transfusion dependent for a while as they ramp up. The earlier you can start, the better it is for the patient. I see this comes into play, especially when you are being closely monitored and the patient calls and says, “I have some rate-limiting toxicities.” The specialty pharmacy can stop this dispensing. Or they get a call from the patient and they can put that note in the spreadsheet and Amer can then review it when he processes the patient. This is the best patient care model there can be.
Bruce Feinberg, DO: Tracey, earlier you talked about a wearable or some other means of communicating with the patient on a daily basis. To what extent will advocacy organizations like yours begin to push these types of solutions? It’s not like they don’t exist. That reminds me of telemedicine. It existed for two decades before COVID-19 and now it suddenly revolutionized medicine. But the solution didn’t come now, it happened decades ago. The ability to bring everyone involved together was what was needed. Unfortunately, we needed a disaster for that. It seems like there is a need. It’s difficult for someone on Ryan’s team or Amer’s team to call and check on this patient every day when resolutions are already in place. To what extent is the advocacy community trying to say, “It’s time?” Just like with telemedicine, it was about time. It is about time this happened. There’s no reason it shouldn’t.
Tracey Iraca: Absolutely. It is so important to ensure that the pill is taken each day as it should, or before the time it should be. Anyone with aging parents knows that my parents keep saying, “I forgot to take my pills.” How do we prevent this from happening? Maybe it’s a mobile app. Maybe it’s a reminder if they use mobile devices like an iPad or a phone where they get or set reminders. Maybe she speaks to her care team and says, “Someone has to be in charge.” Who is there to make sure they get their medication? We check several areas. In some cases, it may be someone on the team, whether it’s a nurse, a social worker, or someone who checks frequently, even if it’s not every day, to make sure they remember to take their medication.
Bruce Feinberg, DO: The problem is the efficiency of text or push based, that’s a simple answer. When you get your appointment for a haircut you will receive an SMS: “Please confirm, yes, press 1”. For a reservation in a restaurant a day before “Please confirm”. It’s so universal, except in healthcare where it could be so differentiating in terms of quality. Amer, what do you think still needs to be done to support these patients for all the reasons we’ve talked about? It almost feels like daily communication is so valuable.
Amer Zeidan, MBBS, MHS: Very good education. In addition to what has been mentioned, the fact that even though this is an oral pill, there could still be toxicities and issues. It is very important to communicate very well with the doctors. I must emphasize that the idea of oral therapy is not just a convenience for the patient, since he does not have to come. From our side, all of our infusion chairs are constantly busy. Trying to find an IV chair for a patient to get medication for 5 days can be quite a problem, so that gives us more chair time.
But also on the patient side, many patients cannot get intravenous infusions without having a port at all times. These ports can be associated with infection and complications. In particular, as I mentioned, patients who do not require transfusions do not need a port and they do not need to come. The chair is open. There can be many benefits that need to be quantified as they could likely pay for other services that could be provided to patients, such as these educational tools and how to ensure patients are compliant and remembering their medications to take It is important to remember that oral therapy is not suitable for every patient as there are certainly patients who are not as compliant and will not opt for the blood test. There are situations where you need to consider whether or not this is a good candidate for this therapy?
Bruce Feinberg, DO: Ryan, you have been in a very progressive practice, doing the research you describe and the way you have expanded your care teams, including pharmacists. Has there been talk of using a portable text-based solution to try and increase connectivity?
Ryan Haumschild, PharmD, MS, MBA: That’s what we’re looking for. There’s a lot of excitement surrounding wearables. We’ve seen it more in the realm of chronic diseases with high blood pressure. We’ve even seen it in hyperlipidemia where there’s constant surveillance of the familial type and if we look at some of the types of endocrinology I’d like to see something in that area.
We do an internal evaluation with a smart capsule where we know how many times they actually touched or opened it when a patient opens the storage place of their medication. Then, also as in clinical trials, we match the pills as patients bring them in to check for persistence in that regard. We’re excited about wearables and some of the technologies that can exist in this space and what they can possibly do to improve compliance or that we’re able to identify non-compliance early and intervene instead of always reaching out and having to use our work in this way.
Transcript edited for clarity.