Best Practices in Multidisciplinary Care in AML - Episode 12

How Maintenance Therapy Has Impacted AML Treatment

Cole McCoy, PharmD, considers if maintenance therapy is standard of care and what is involved with appropriate transitions upon discharge.

Ryan Haumschild, PharmD, MS, MBA: We're talking about maintenance therapy. Danielle, I know you deal with patients a lot, and you're at a leading innovative center, but do you feel like maintenance therapy is currently the standard of care? How would you like to see the use of maintenance therapy change in the next coming years?

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: It's standard of care now, NCCN [national Comprehensive Cancer Network] endorsed. We're utilizing it quite a bit. I think educating some of our community referrals is important because sometimes when newer drugs are coming out, they're not using it as often. We're using it a ton because we have a lot of AML [acute myeloid leukemia] patients, but for somebody who's not seeing these patients as often, they're not as comfortable prescribing or want input from a bigger facility to make sure they're doing the right thing. Maintenance therapy, like all therap[ies] for AML, will change in the upcoming years, [with] more options to choose from [to] select appropriately for each patient.

Ryan Haumschild, PharmD, MS, MBA: As that maintenance therapy continues and we talk about orals, there are barriers to access. It's under the pharmacy benefit, not necessarily the medical benefit. Sometimes there are certain specialty pharmacies [that] navigat[e] that process. If you're transitioning a patient on oral therapy back to the community, describe some of those transition barriers you have to work through and discharge protocols.

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: Oftentimes, we take charge of getting the medication. We're used to getting the medication, working with insurances [for] copay assistance, things like that. Before discharging them back to their referring physician, we make sure they have their supply. Usually, we send at least 11 refills so they don't have an issue moving forward. Good communication with the referring physician is important about expected follow up. Sometimes we see patients every few months to keep ourselves in the loop and make sure everything's going OK. It's important to make sure they're set up and have everything they need before leaving us.

Ryan Haumschild, PharmD, MS, MBA: Dr. McCloskey, anything you want to add [for when] you're getting ready to transition these patients? Danielle gave us a great background, but [are there] any other conversations that you have [when] referring patients back into the community setting?

James McCloskey, MD: This interaction and dialogue with the community is important. I tell most of the people that are referred to me that I could not do the job of a community oncologist. As oncologists, we've become jaded about the therapy [for] elderly patients with AML. I think we had a learned sense of futility. [It’s] important to impress upon folks who aren't doing this every day that this is a substantial benefit to our patients, that we can all work together to make sure this works and helps make the process easier. These improvements are not insubstantial, and they = should impact not only our decisions on treatment as they finish consolidation but all the way at the beginning when we consider the benefit of induction for those patients. It’s a game changer. As we transition back, we often are reiterating that because I think too often, these patients have been offered palliative therapies or maybe no therapy because we didn't have good therapies. This is a great example of how that's changed, so hopefully, we're sending those patients back with clear recommendations for their management.

Ryan Haumschild, PharmD, MS, MBA: I like that transition and handoff. When talking about considerations with the use of different agents to get in front of some of the adverse events, [we want] to make sure we're getting ahead of these things, that we're not chasing them with the patient [and are] setting them up for success. That's the way I think of it sometimes as a pharmacist in the pharmacy department or part of the treatment team. Dr. McCoy, talk to me about some of the key considerations you have with antiemetics and other supporting therapy with oral agents. How do you educate and advise patients? Do you build this into your order sets and your treatment pathways? Give us a little more context around the proactive management of some of these adverse events.

Cole McCoy, PharmD: With oral azacitidine, some of the biggest adverse events are nausea, vomiting, diarrhea. As I mentioned before, taking an antiemetic prior to taking the oral azacitidine will really alleviate a lot of those symptoms, [as well as] prescribing a backup as-needed medication that you can take on top of that. What is the best time of day to take this medication? Should you take it in the morning? Should you take it in the evening and maybe sleep through most of those nausea symptoms? The other toxicity, even though it's mostly grade 1 and grade 2, as Dr. McCloskey said, and not really grade 3 is that myelosuppression. Patients going through treatment have been coached on this before, but they could become neutropenic. They must make sure they know what they do if they spike a fever, as well as monitor their other blood counts. The ones we coach them on in particular with this medication are that nausea, vomiting, and potentially diarrhea. There are other over-the-counter medications that can help mitigate those as well.

This transcript has been edited for clarity.