Current and Future Considerations in the Treatment of Relapsed/Refractory Multiple Myeloma - Episode 3
IV Versus Subcutaneous Daratumumab
Healthcare stakeholders comment on current practices managing patients with relapsed/refractory multiple myeloma during the COVID pandemic and discuss their comfort switching patients over from intravenous daratumumab to subcutaneous daratumumab.
Bhavesh Shah, RPh, BCOP: The other thing I probably need to touch upon, we are definitely in a pandemic, so has COVID-19 [coronavirus disease 2019] changed how we treat myeloma? Doug, do you have any perspective you want to share on that?
Douglas Braun, CSP, PharmD, RPh: Certainly, yes, because COVID-19 has affected everybody, and we have folks who are quarantined, folks who are scared to go out, and elderly folks who can’t get access to care. We are wondering, we may not know the fallout for years to come if patients aren’t getting diagnosed in a timely matter because they can’t get to their doctor, or they’re doing telehealth visits instead of going in and getting laboratory work. We just don’t know. But certainly, I think in our practice we have seen a greater shift of driving toward oral therapy as opposed to IV [intravenous] therapy during COVID-19.
Because of that, patients are nervous about getting out of their houses, and they are nervous to go into a clinic and sit through infusion times, when they can switch to an oral therapy and take their medication at home. It may be more expensive, but it certainly adds to the convenience factor, for folks who are working every day and can’t get to the clinics on a regular basis, or they could just take an oral pill and go about their day. So we have seen a greater drive toward oral therapy, certainly during this time, throughout the approval process as well, but certainly during COVID-19 periods.
Bhavesh Shah, RPh, BCOP: Yes, I can definitely share the same perspectives from our institution. One of the things we did was adopt subcutaneous therapy very fast when it came out. Because of COVID-19, we have a limited number of patients we can allow in out waiting room, so now we run into capacity issues in the clinic. By having a drug that facilitates an increase in time to delivery, we can reduce our chair time and increase our efficiency by 40%. We presented some data at ASH [the American Society of Hematology] recently that basically confirmed those numbers, converting patients to subcutaneous therapy, we were able to increase our efficiency by 40%.
I can imagine that could be very important for an institution that is struggling with the number of patients they can accommodate in their infusion center because of the social distancing that is required and the number of patients you can accommodate in the chairs and in the waiting room. I wanted to know if there are any other perspectives that others might want to share that they are doing because of COVID-19?
Douglas Braun, CSP, PharmD, RPh: It certainly makes a lot of sense because we know, especially with COVID-19, it is not just the closeness of the contact but the duration of contact with people who possibly are infected. If we can limit the amount of time that they are in the clinic or around other people by maybe choosing a subcutaneous daratumumab as opposed to intravenous, that will shorten the time they have to be in the chair. It’s going to make them less susceptible to the disease, is going to probably improve their quality of life because they’re going to feel a little more secure about not having that prolonged exposure.
Heather Pound, PharmD, BCPS, BCOP: Yes, we switched patients over pretty quickly as well. So I feel like we were also rapid adopters, mostly out of necessity to try to keep patients at home. Also, the convenience of, we have kept patients on IV premedications for cycle 1, certainly for doses 1 and 2, and then we switch them to all oral therapies, so there is not even an access of a line or adding a peripheral IV, which could be an additional infection risk for patients.
Bhavesh Shah, RPh, BCOP: One of the things that I wanted to ask was, we know that daratumumab subcutaneous doesn’t have data with all regimens. Did you guys get any pushback from providers, or are they comfortable using it with whatever regimen they were using the IV with?
Heather Pound, PharmD, BCPS, BCOP: Our providers were very comfortable switching everyone over. There were some patients who were very hesitant because they had been on IV dara [daratumumab] for a very long time, and they knew how it made them feel and they knew what to expect, and so they were hesitant to switch to a different formulation. Some of that was overcome with patient education and talking about the risk/benefit of switching from IV to a subcutaneous formulation. And some patients held firm. It was more of an adoption for the patients than it was on the provider level.
Ryan Haumschild, PharmD, MS, MBA: Bhavesh, I don’t know if you want me to weigh in too?
Bhavesh Shah, RPh, BCOP: Yes.
Ryan Haumschild, PharmD, MS, MBA: One thing I would like to chime in on is we also converted to subcutaneous therapy, and that was a huge hit among patients, providers, and nurses. But originally there was a lot of hesitation. And luckily, we have some leading providers in multiple myeloma, and my clinical pharmacy specialist in multiple myeloma was a huge part of educating patients when they came into clinic, so they’d expect it. And we saw a huge appreciation from the administration, as you mentioned, that we could get chair turnover and see the same number of patients when we are socially distancing patients, at the same time. Patients can get back to work or get back to the things that they enjoy outside of the infusion center. And for nursing too, they felt very comfortable with it after we did in-services training.
So now that is the standard, and if you are not getting subcutaneous therapy, you’re more the exception at this point. I think that has worked out really well for COVID-19, and as we are moving forward, paying attention to patient satisfaction and what they are looking for.
Transcript edited for clarity.