Intravenous Versus Oral Delivery: Medical Benefits

A discussion on the economic impact that intravenous versus oral therapy has for institutions and patients.

Cody Steeves, PharmD, BCOP: As far as the difference in the medical benefits for IV [intravenous] versus oral therapy, especially the economic impact on institutions as well as patients, what have you seen in your practice with that?

Alison Duffy, PharmD, BCOP: I think as we've talked about, more patients are receiving medications at home, certainly due to COVID-19 [coronavirus disease 2019], but in general, there are fewer visits to the clinic, and to the infusion center to get chemotherapy, depending on if patients are going to get combination therapy or not.

I'd already mentioned, but to reiterate, overall there are fewer hospitalizations for toxicities such as infections, and neutropenic fever, and even some of the cardiac toxicities. I think we're getting better at managing those and preventing those, and switching to therapies sooner.

Some of the economic challenges we've seen have been the timely approval of the oral and the IV therapy together because of pharmacy benefits and medical benefits, and so that can be a challenge, especially if a patient's disease is very aggressive. If they have progressed on ibrutinib it would be really important to start their subsequent therapy very quickly, or it can progress to Richter transformation.

The economic challenges in improving can be a barrier. As pharmacists, anything we can do to facilitate the approval process, and in the clinic I can certainly help with the prior authorization process.

As pharmacists in a dispensing situation, helping that facilitation and the delivery and work flow perspective can be helpful, too. The economic impact on patients from an oral perspective can be greater; those therapies can be far more expensive. I've found that can be a challenge, and as we mentioned before, potentially a reason to use intravenous therapy.

However, over time there are a number of great patient assistance programs that I've been involved with our financial assistance team in, enrolling patients either in a copay assistance program, or a drug company program. So I think, fortunately, we've found that many patients qualify for those programs, but it can be challenge. What about you? What has been your experience?

Cody Steeves, PharmD, BCOP: I agree with all that. I think, like you mentioned, the oral therapies are almost staggering in their costs, and that's based on a lot of factors. Every manufacturer sets the cost based on a lot of research that goes into the medications, but then of course, it falls back on the patient.

Like you mentioned, a lot of patients in general are going to rely on that assistance program. With these therapies we're mentioning all being on label, that's usually very doable to get assistance for the patients. But again, nothing's guaranteed, so the assistance may dry up, and we have to work with all of our programs on that. I think economics often can go hand-in-hand with adherence, too, with the access to a ride to the clinic or however a patient may get there.

If they have a history of nonadherence to oral therapies, the office may want to take that into account when they make decisions on treatments. Like acalabrutinib BID [twice a day]; if they already were having poor adherence on the once-daily dosing, then is the [twice a day] dosing the best option to switch to if they progress? So a lot of factors to consider as we work through all the potential options of therapy for these patients.