Chronic Lymphocytic Leukemia: Oral Oncolytic Complexities


Expert panelists Michael Reff, RPh, MBA; Troy Trygstad, PharmD, MBA, PhD; and Kirollos Hanna, PharmD, BCPS, BCOP, reflect on the complex paradigm of managing chronic lymphocytic leukemia and discuss how challenges with comorbid conditions or prescription control might be overcome.


Michael Reff, RPh, MBA: One thing to build on is in this world of CLL [chronic lymphocytic leukemia], there’s a lot of innovation that’s occurred in the last couple of years. Products and more indications with certain products. There’s also this doublet effect that we see in our clinics, in which you have an IV [intravenous] with an oral, and that coordination of care is critical. Specifically, a good example is in CLL. What was the term you used?

Troy Trygstad, PharmD, MBA, PhD: Disintegrated.

Michael Reff, RPh, MBA: Disintegrated.

Troy Trygstad, PharmD, MBA, PhD: You’re selling to me, and I’m buying on a medically disintegrated dispensing service. This feels like a disintegrated service because you’re breaking the continuity of things, right?

Michael Reff, RPh, MBA: Yes, exactly. So Christina’s example is a great example, and then there are multiple examples with different disease states in which the service can fall apart as opposed to come together when that continuity is not allowed to occur because of payer constraints.

Troy Trygstad, PharmD, MBA, PhD: Sure. And for CLL, as to Kirollos’ point, I could have comorbidities. I could have prostate cancer. I could have diabetes. I could have dementia. Right? So there are many complex dynamics at play. There’s the driving chronic condition, which may actually be dementia because it’s a chronic illness. But in this instance you could have this be the driving condition, but there are all these other conditions that need to be coordinated as well. Right?

Michael Reff, RPh, MBA: Sure, absolutely.

Troy Trygstad, PharmD, MBA, PhD: And so do you also then, in these medically integrated dispensing services, provide these other medications? Do you coordinate with local pharmacies? What does that look like when there’s this comorbid situation?

Kirollos Hanna, PharmD, BCPS, BCOP: So we do our best when we need to branch out or stay internal to coordinate that patient care. But then again, we’re limited. Our hands are tied, and when we lose control of that prescription, that’s the biggest thing. Especially as Mike was saying, there are a number of doublet therapies or combination therapies at ASH [the American Society of Hematology Annual Meeting & Exposition] 2018. Look at the number of combination therapies that are being looked at in CLL: ibrutinib plus etc, venetoclax plus etc. For all these oral oncolytics, we need to be able to provide everything for that patient all at once to really optimize that therapy, especially with some of these medications, such as venetoclax. There is significant risk for developing tumor lysis syndrome. So these patients are not receiving their allopurinol, for example, as tumor lysis prophylaxis, or other medications that we’re not able to get these to them in a timely manner. We need to know whether the patient needs to be admitted for their titration. That gap in care just really needs to be addressed.

Troy Trygstad, PharmD, MBA, PhD: So it’s patient specific. And you have a specific care plan with specific procurements, specific follow-up.

Michael Reff, RPh, MBA: I was just going to add that there’s 1 other element, probably multiple elements, to keep talking about regarding this medically integrated dispensing service and what it means to us and how we know it provides better value to all the stakeholders in the oral space. There’s 1 tool that I know our organizations, or our clinics...

Troy Trygstad, PharmD, MBA, PhD: And your organization is?

Michael Reff, RPh, MBA: Is NCODA, the National Community Oncology Dispensing Association. We have quality standards, and part of those quality standards is taking a look at cost avoidance. And there’s 1 thing that these 2 practices do very well, and it has everything to do with that coordination of care. So whether these practices are dispensing that oral therapy themselves within the 4 walls of their practice or whether or not they have the visibility to track the oral prescriptions that are filled at the mail-order pharmacy, the practices utilize the electronic medical records to ensure that patients aren’t getting refills for the sake of being refilled.

And there are a couple of obvious things that come to mind when you say that. “Well, you’re taking cost out of the system.” So we track that at our practices, and we track the cost avoidance nationally. So for the prostate cancer patient who is due for a scan halfway through the month, maybe just refill half of that prescription, not the whole 30-day supply, because they’re out 12 months, and you know that they may have a holiday or switch of therapy.

Troy Trygstad, PharmD, MBA, PhD: It sounds like judicious use and stewardship.

Michael Reff, RPh, MBA: Stewardship. Doing the right things for the right reason. As we were saying, working with the electronic medical records to ensure that the patients don’t have refills for the sake of just having refills and that they are managing their oral oncolytic therapies more closely. There’s not only a cost-avoidance aspect to this, but there’s also an adverse-event risk management that can occur. There are multiple examples in which a mail-order pharmacy will, because of time, mail a prescription on day 24 or day 25 because it will take 2, 3, or 5 days for that to get from 1 state to another state. And in those 4 or 5 days, they may have seen the provider, like Christina, and Christina may say, “Let’s hold on that,” or, “Let’s go from 100 mg down to 75 mg.” And then what occurs is the patient goes home. A couple of days later, they get that prescription in the mail, and they think that Christina changed her mind and wants her to be on 100 mg versus the 75 mg. And then additional toxicities and confusion can occur from that. So it’s not only a cost-avoidance aspect. It’s also a health and appropriate therapies aspect.

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