How ILD Pharmacists Shape Treatment Decisions: Kyle Fischer, PharmD, on Collaboration, Safety, and Specialty Care

In interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), treatment decisions hinge on close collaboration between pulmonologists and pharmacists. In this interview with Pharmacy Times, Kyle Fischer, PharmD, APh, a clinical staff pharmacist at Keck Medicine of USC Specialty Pharmacy, shares how his role has evolved within a specialty pharmacy model, the real-world interventions that have changed prescribing, and the training and clinical relationships that build credibility in this highly specialized space.

Q: When a pulmonologist is weighing treatment options for a patient with ILD or PAH, what does that conversation actually look like from your seat — and how has your role in those discussions evolved over time?
Kyle Fischer, PharmD, APh: I think predominantly for me, the physicians here guide therapy, so they obviously have a plan of what they want to do for the patient. I think one of the biggest things my role comes into play is if a patient is experiencing a side effect from a therapy. I can relay that information back over to the doctor if, for whatever reason, the patient does not have an appointment upcoming with the pulmonologist to discuss that side effect sooner. So from that, that is usually how we relate or guide therapies.

From my perspective, question 2: A lot of times, patient-centered characteristics—so, like, if you have liver disease or if you have kidney disease, things like that—also drive drug therapy for certain antifibrotics and things like that. So if I catch something that the physician might have missed, or I see lab data that is probably not going to be aligning with that therapy, I can relay that information back to the doctor, and we can switch therapies then and there.

Q: Drug interactions and comorbidities can get incredibly complex in this patient population. Can you walk us through a real-world scenario where your clinical input directly changed a prescribing decision, and what that pharmacist–physician collaboration looked like in practice?
Fischer: Some real-world scenarios, I guess, where we have made modifications: we have a new antifibrotic out, nintedanib (Ofev; Boehringer Ingelheim). It does have some strong cytochrome P450 (CYP) interactions. So just from our end, I was able to identify a patient who was taking voriconazole, a strong CYP3A4 inhibitor. Our provider prescribed the higher dose of Ofev, which is recommended to be dose-adjusted in the presence of a CYP3A4 inhibitor like that. So I was able to relay that information to the pulmonologist, and then we got a new order sent out for the patient before the higher dose was dispensed.

So that is one little thing that we have discovered so far with our journey on the new antifibrotic. I guess we could talk about other antifibrotics, too. With pirfenidone (Esbriet; Genentech), we do have to worry about drug–drug interactions with other antithrombotics and things like that. So those are other things we have to be vigilant about, especially in a population where it is usually older adults. You do have more frailty, but it is more complex, so you have to be vigilant about all the medications they are taking and their different disease states, just to make sure that the drug itself is not going to cause more harm.

Q: For a pharmacist who wants to develop expertise in ILD, what is the honest roadmap — the training, the relationships, the clinical exposure — that actually builds credibility in this space?
Fischer: So I guess for myself, I kind of ended up in this position in a weird way. It just kind of fell into my lap, so to speak. I have been a part of my institution for a long time. I did residency here at the University of Southern California (USC). I was a pharmacist for the outpatient pharmacies, and then the pulmonology position opened up at the specialty pharmacy.

So having connections within my institution really helped get me here. I would say, leverage those if you have those. And I do think having a strong clinical background really helps—not only in the clinic, but also at the specialty pharmacy. So I would advocate for doing a residency and then building connections within your network. Yeah.

Q: This is still a relatively niche area of specialty pharmacy. Were there moments early in your career where you had to advocate for the pharmacist’s role on the care team, and how did you make that case?
Fischer: I was fortunate enough that most of my role was already laid out. Prior to having an interstitial lung disease (ILD) pharmacist or antifibrotic pharmacist at USC, the space was already set up to handle patients with cystic fibrosis. That is how the original specialty pharmacy position got started — it was through cystic fibrosis — and then it expanded over the years to encompass ILD as well.

So when I started my position, that role was already established here. The pharmacist was integrated into the clinic and there as a resource for the providers. When I started, the doctors knew who to ask questions to, and that has been really nice. I know other institutions are trying to establish similar models, where you have, in an academic setting, the specialty pharmacy pharmacist go to the clinic and help the providers there. That is the model we have across all the disease states at our specialty pharmacy, not just ILD.

Q: A patient comes to you already established on a therapy dispensed by an outside specialty pharmacy — maybe a hub pharmacy tied to the manufacturer. What does your intake and reconciliation process look like, and where do the gaps most commonly appear?
Fischer: So if we are taking in a new prescription from an outside pharmacy, we are still going to have to do all of our normal checks that we would do. I imagine if it is a continuation of therapy, there is probably not going to be much that I am going to need to intervene on, but I am still going to take in that prescription and have all my checks done as well.

Typically, I will still do a chart review. We have access to the electronic medical record (EMR) here at the pharmacy, so we will go in and look up patient-centered characteristics — like their diseases, the diagnosis, and any other laboratory data. We also have access to the medications they are taking, so we will do a medication review. I will do a drug interaction analysis, a drug–disease analysis, and then after everything has been resolved from our end — disease-specific and drug–drug specific — we will go ahead and do a clinical assessment and then dispense the medication.

After the medication has been dispensed to the patient, we do contact them to do a consultation, and we have to resolve some other things there, too — just making sure that their medication list is updated and accurate to ensure we did not miss anything from the EMR, and then updating things from there. So yeah, I would treat new prescriptions coming to us like any new prescription, so to speak.