Community Oncology Pharmacists Should Learn How to Manage Adverse Events Related to New Therapies for Acute Myeloid Leukemia

Natasha Khrystolubova, RPh, BPharm, BCOP, the director of Pharmacy Clinical Services and Rx To Go Pharmacy with Florida Cancer Specialists & Research Institute in Fort Myers, Florida, discusses how the shifting treatment paradigm for acute myeloid leukemia (AML) will impact the community oncologist at the 65^th American Society of Hematology (ASH) Annual Meeting & Exposition, taking place December 9-12, 2023, in San Diego, California. Khrystolubova will provide insight on why communication between care teams is so important, how the community pharmacist is equipped to help patients to manage adverse reactions, and adaptive care with the emergence of new therapies.

PT Staff: What should community oncology pharmacists understand about the shifting treatment paradigm for AML?

Natasha Khrystolubova, RPh, BPharm, BCOP: There are new oral inhibitors and oral medications in AML, and those are specific to target AML as we understand more and more of disease, the biology of the disease, or genomics of the disease. We can see not just venetoclax (Venclexta; AbbVie, Genentech) come into the market (which is very powerful in the AML) but isocitrate dehydrogenase 1 (IDH1) inhibitors, IDH2 inhibitors, and FLT3 inhibitors, which are very powerful drugs as well.

These may be used in not just induction consolidation, but now we are moving into menins [too], so we must make sure there are pharmacists understand the side effects, how to manage them, how to monitor them, and also how to work with academic centers and see how they are also changing how these drugs are applied in therapies. What we see in the venetoclax, what I learned from a session from last night (Friday 12/08 symposia called Achieving ''Next-Level'' Care in AML: Conversations on Targeted Platforms, Emerging Immunotherapies, and Implications for Precision Medicine) that we see a lot of different schedules of venetoclax used in academic centers; this could be 7-14 days, it could be 5 days, [or] it could be 21 days. We need to really understand why it's happening, and how we can change the use of this drug so that it doesn't affect the patient's quality of life (QoL) or lab, so we need to work together.

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PT Staff: How can community oncology pharmacists facilitate better communication and relations with AML treatment centers?

Natasha Khrystolubova, RPh, BPharm, BCOP: That is a great question. We, in community oncology, work with our physicians who are in touch with the academic centers or AML centers. So they have a lot of, not just communication, but also referrals to AML centers, and they follow directions from these AML centers. There's a lot of research going on in AML as well. So we follow the guidelines, and we also look at the electronic medical record (EMR) to see how our physicians decide to treat the patients. We do a lot of clarifications based on labs, and there's [ongoing] communication, not just among pharmacists, but also with the physicians and academic centers. Because our focus is on the patient, we really want to make sure that the QoL in is not affected, and those side effects are prevented as well.

PT Staff: What is the role of the community oncology pharmacist as part of the AML patient care team? What can the pharmacists do to improve patient outcomes?

Natasha Khrystolubova, RPh, BPharm, BCOP: In AML, because it's such an acute disease and it's so genomically-driven now, it's what we learn. So the pharmacist, we don't really make a decision about what treatment is going to be applied to specific patients, but we definitely need to make sure that we look and monitor the labs, and not just in the beginning of the treatment, but as patients stay in therapy— the labs change now there's a lot of also combinations are used in AML now.

We will looking forward is more and more combinations are coming to the market with venetoclax. For example, today (12/09) there was presentation on the use of venetoclax with selinaxor (Xpovio; Karyopharm Therapeutics) which is very powerful drug when it comes to the side effects. So we really need to remember what we will have learned from previous use of selinexor that will come to fruition eventually. So [we need to learn] how we're going to manage these patients.

PT Staff: What are menin inhibitors and how could they be administered to patients with AML? What should the community oncology pharmacists be on the lookout for with this new therapeutic?

Natasha Khrystolubova, RPh, BPharm, BCOP: Menin inhibitors target histone-lysine N-methyltransferase 2 (KMT2) or the nucleophosmin-1 (NPM1) population of patients positive for this targets alterations. So these drugs are coming to community oncology for the treatment of patients for relapsed/refractory AML who have the KMT2 alterations or NPM1 mutations. We have seen from the presentations today that this drug is going to be used as a single agent, or in combination with drugs like venetoclax, for example, with a chemotherapy with oral azacytidine, and so we're going to see the side effects. And these patients will be in community oncology.

We need to understand the mechanism of action, the side effects that we need to manage— what [we could] expect, for example, is that some of these menin indicators have QTc prolongation, and some of these menin inhibitors, or actually all of them, have differentiation syndrome because of the mechanism of action. So we really need to pay attention to that; we need to understand that we need to counsel patients so they know the side effects to expect, and we need to monitor them closely.