Ryan Haumschild, PharmD, MS, MBA: When we talk about pathways, how are proteasome inhibitors being utilized? Are they built out in multidrug regimens? Do providers have to add them individually to some of these combination therapies? I’d love to start there and then I’ve got some additional questions.

Gabe Hinojosa, PharmD, BCOP: Absolutely. That’s a great question. Our proteasome inhibitors, we see them throughout our pathways. So we’re going to see proteasome inhibitors in the frontline treatment setting. We’re going to see it through multiple phases of relapse, both aggressive and indolent, and we have those plans all outlined. So our pharmacists are able to be a part of that multidisciplinary team and really build those protocols and build them the way we feel best aligns with those pathways. But we do see the proteasome inhibitor sprinkled throughout all phases of myeloma therapy. We do have our multidrug regimens built. A big part of our job is to build those with the proteasome inhibitor already in it. We try to avoid adding a proteasome inhibitor or adding any drug for that matter into the treatment plan that wasn’t already built that way. A lot of that is for safety concerns as well as just making sure that we’re monitoring everything appropriately. So when we build these plans in the multidrug plans, we’re able to build in specific treatment monitoring recommendations through nursing and provider communication orders. We’re able to build in specific labs within specific time intervals to monitor these patients, specifically tailoring the monitoring to that regimen. We try to avoid the adding, [and not] turn this 3-drug regimen into a 4-drug regimen by adding it. If that is a 4-drug regimen that we want to approach, then that’s something that we discuss with the disease state team and build that protocol once we’ve reviewed the data and determined that is an appropriate regimen for that patient within that clinical pathway.

Ryan Haumschild, PharmD, MS, MBA: You bring up a great point because if 1 regimen was created for a 3-drug regimen and you’re adding the fourth, how do we know the labs are going to get pulled in? How do we know the precertification in the ongoing monitoring is pulled in? That’s so essential to the oversight of the patient. Your specific treatment in clinical pathways is really innovative. I think it leverages the expertise of individuals like Dr Anderson and yourself to create the best treatment decision. But we know sometimes internally developed pathways could conflict with payer pathways. We know a lot of institutions when we’re using venetoclax [Venclexta] for translocation 11;14, we were running into issues early on before some of the insurance companies did their updates. So when we think about your treatment regimens and the way you use proteasome inhibitors, do you ever bump into insurance not agreeing with your internal pathway? What do you do to make sure you get that patient on therapy in a timely manner?

Gabe Hinojosa, PharmD, BCOP: Luckily that doesn’t happen often, but as we all know, healthcare constantly changes and we’re thankful for that because that means that we’re getting better and we’re offering better care to the patients. Sometimes this data comes out and is very convincing and we want to make changes faster than the payers have been able to adjust their clinical pathways. So this does come up. Luckily, we’re generally able to resolve these issues fairly quickly and the pharmacists are able to play a big role in that. Generally, the payers are OK with providing coverage and adjusting their acceptance for certain regimens, given that specific clinical criteria are met and that we can provide specific data to show that yes, this is a preferred and a good option for this specific patient, as you mentioned, the venetoclax in patients with certain mutations. By providing that data, pulling that clinical research, typing a letter maybe summarizing those findings, and then including that patient-specific data showing that they have these mutations, and they meet these criteria, we generally don’t have issues getting the payers to agree.

Ryan Haumschild, PharmD, MS, MBA: Excellent. And Dr Anderson, I’ll pose that question to you as well. Just being someone who’s been there at your institution for a while, when you’re developing your internal pathways, your order sets, do you look to see what your local payers are doing? Or do you say, we’re going to do what we think is most evidence-based, establish that, and then if we start to have pushback from payers, we’ll navigate that through a peer-to-peer or appeal?

Larry Anderson, MD, PhD, FACP: We’ll certainly look toward national guidelines, NCCN [National Comprehensive Cancer Network] guidelines, things like that before pulling out a brand-new regimen. And otherwise, at least make sure the data looks sound, and typically that’s going to involve a peer-to-peer with insurance if it’s something that’s not a standard regimen. So I’ll get the pleasure of speaking to the insurance company typically and see if I can get that approved. But a lot of times, we have to rely on some of those national guidelines to drive what’s going to be accepted by payers.

Transcript edited for clarity.