Inside the Frontlines of BTCE Care: Pharmacists on Managing a New Toxicity Era

As bispecific T-cell engagers (BTCEs) move quickly into mainstream oncology practice, pharmacists are taking on a central role in managing their unique safety demands. In this interview at the Hematology/Oncology Pharmacy Association 2026 Annual Conference, frontline oncology pharmacists Emilie Aschenbrenner, PharmD, BCOP, and Megan May, PharmD, BCOP, FHOPA, FAPO, share how they’re navigating unfamiliar toxicities, reshaping patient education, and building monitoring systems that keep pace with rapidly expanding use. Their insights reveal a field adapting in real time—as both the promise and the complexity of BTCE therapy continue to grow.

Q: What role does the pharmacist specifically play in a multidisciplinary toxicity management team, and how do you make sure that role is well-defined and not duplicated by other team members?

Emilie Aschenbrenner, PharmD, BCOP: It's a little bit tricky. My background is primarily in acute care, although I am moving into more of a heme coordinator operations role, where we work toward our outpatient step-up. I'd say that sometimes it is a multidisciplinary management where you're both kind of assessing your grading together. But really, I feel that one of the important roles of the pharmacist is in that early identification of toxicity management—recommending the appropriate doses: “This is a grade 2. We don't need to give tocilizumab. This patient is very frail and hypotensive. We've tried the steroids.” So I think it's really our role as medication specialists, highlighting what is appropriate to give depending on the grade of toxicity when we're talking about cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Therapies like epcoritamab have several days of dexamethasone after, so giving the patient an extra dose of dex. I think that's really where we can stand out. Generally, my APP is already escalating to the physician if there’s a problem or bolusing the patient with IV fluids, outpatient or inpatient. So I think that's where we really fit.

Megan May, PharmD, BCOP, FHOPA, FAPO: Other things that we do at my institution: I am in charge of all the patient education. So for me or one of my 3 partners, if you are starting a bispecific T-cell engager, your first stop is through pharmacy to do usually about an hour-long education session with us.

Another way that pharmacists play a role at my institution is helping utilize our electronic medical record (EMR) to its full capacity. Pharmacy was in charge of getting the order sets built for providers. If they do have CRS, they can click “grade 1,” and then it pre-populates what to do and can put the orders in the chart for them. We also created flow sheets for our nursing staff so they are able to assess CRS and ICANS quickly, and it clearly lays out: these are the questions you ask; this is the monitoring you need to do. Again, we are just trying to make it as flawless as we can and making sure people are aware of the order sets and the flow sheets—our nurses and our providers—because if they don't know we even have that available, they're not using it. So we make sure we are educating all the staff on the resources we have available at the institution.

Q: How do you approach grading and managing toxicities when a patient presents in a community setting that may not have the same resources or rapid response infrastructure as a larger center?

May: One thing we do at my institution is during that education session, we talk about what emergency room they are going to go to if they have a problem. Of course, we prefer them to go to either our emergency room or one of our other hospitals across the state. But if that's not possible, we will go ahead and identify: this is the emergency room you're going to go to if this happens. We can make sure that staff is well educated—sending over an email or trying to do a phone call, making sure they know about bispecific T-cell engagers.

One thing we did at our institution: if you show up to a Baptist facility, we actually have a banner in our EMR that pops up that this patient received a bispecific T-cell engager in the last 3 months, and it tells them they need to be assessing for CRS and ICANS. It also links out to our policy and procedures for giving T-cell engagers and how to manage and recognize CRS and ICANS.

Aschenbrenner: I would say we leverage some similar tools at Froedtert Medical College. For our community sites within Froedtert Health, and we partner with another health system to the north, ThetaCare, we have ensured that all of our emergency departments have rescue medications. We also leverage the electronic medication administration record (EMAR)—so for the banner and OPA, for any level of provider, nurse, APP, physician—that will fire and link out to our guideline.

Again, you may have a patient who leaves the health system, and we're still working on that. That is why patient education is so important. But if you standardize, per Megan's point—we have the flow sheets for neurotoxicity, we have the flow sheets for CRS, we have standardized dot phrases that nurses can enter that show the grade and escalation of care. We have done our work to try to prevent mismanagement of these toxicities. But once in a while, you're not going to be able to share your health record or manage.

Q: Patient selection is critical with BTCEs. What criteria do you weigh most heavily when evaluating whether a patient is an appropriate candidate, and are there red flags that would give you pause even for an otherwise eligible patient?

May: I'll talk about lung cancer—in particular, small cell lung cancer—because we are doing tarlatumab, or trying to do it mostly outpatient. For me, patient selection means: are they a candidate for the bispecific T-cell engager? And then the next step: are they a candidate for outpatient monitoring instead of having to do the observation route in a facility?

Things I look for: do they have a reliable caregiver? During education, I require the caregiver to come with the patient. If the caregiver—I don't think they're going to be able to reliably do the things we need them to do to monitor the patient—that's when we will go ahead and admit the patient for infusion of the bispecific T-cell engager.

Another consideration: how far away do the patients live from our facility? For example, with tarlatumab, it's recommended the patients stay within 1 hour of an appropriate health care facility for a total of 48 hours after the infusion. I have several patients driving 3 or 4 hours to get to our institution. We are really utilizing our social workers to get hotel vouchers or Lyft vouchers for our patients. We're able to help with that financial toxicity. But if they do live far away and we're not able to get lodging for them, that is when, again, I would consider doing admissions to monitor for that entire 48 hours.

Aschenbrenner: When we started trying to leverage more of our outpatient pathways, I was thinking like a clinical heme pharmacist specializing in heme malignancies—about the patient, about their disease state, about their line of therapy, about whether they had the reserve to be able to treat outpatient. But now, in working through the operations of these, to Megan's point, sometimes the caregiver situation is even more important than me saying, “This lymphoma patient has extensive lymphadenopathy, high risk—admit them. This patient has extensive bone marrow involvement as a multiple myeloma patient and is on the fifth-plus line of therapy—admit them.”

I think it's more that reliability. I can have a frail 85-year-old who has an amazing caregiver—a nurse who is a granddaughter—and we feel very comfortable. But I can have a young gentleman with no consistent caregiver that we might need to admit. We do not have a social work consult for every patient at current state, like we do for our CAR-T and bone marrow transplant patients, but that would be ideal future state, to Megan's point, so we can recognize that and provide the family with resources more immediately.

Q: What's one toxicity management lesson you learned the hard way—something that changed your practice or your institution’s protocols?

Aschenbrenner: I'll comment on our triage structure at an academic site. It looks a little bit different in our community setting, where our community oncologists rotate a pager. Despite our best efforts in an after-hours call structure to educate fellows and hospitalists coming through, we found those patients sometimes still slip through the cracks of being identified, even with the tools in the electronic medical record.

So we decided to build out an escalation pathway at our main academic site, leveraging our EPP pathways or triage pathways, because they are much more familiar with the toxicities, and we have staff that don't turn over quite as commonly. We also have the luxury of a 4-bed, 24-hour clinic. So they will lead toxicity management there, and they always have the opt-out—if this is a high-grade toxicity, we will direct you to the ED. Those pathways have ensured our patients can receive more safe and effective toxicity management or that we can triage them appropriately. So I guess the lesson learned: it's hard to continuously educate rotating staff. If there's a core team, that works a little bit better for our patients.

Q: Is there anything you’d like to add?

Aschenbrenner: With any new process, sometimes you feel like you're winning; sometimes you feel like you're not making progress. We did a really fantastic job of moving more of these therapies outpatient. Then there was a little less engagement from executives and some physicians. Now that these are evolving in combination therapy in the second-line setting and potentially moving into first line, we're going to have to get there again—leveraging our sites of care and being good financial stewards in our health care system. I would say: don't give up. At times it has been a little challenging to have champions in this process, and pharmacists feel like they're carrying a lot of the burden at times, but it's worth the effort.

May: Another thing is: you're not doing this alone. Even if you've never given a bispecific T-cell engager before, like Emilie just said, you need to start thinking about doing this. It's the way of the future—earlier lines of therapy, combination therapy, for example. But there are resources out there, so you don't need to recreate the wheel by yourself. There are organizations that have produced a lot of information—checklists for how to even start this process, checklists for “Are you ready to go? Do you have everything in place?” It might feel scary, but there are lots of resources you can utilize to make this process your own.