Pharmacy Times interviewed Kyle Farina, PharmD, BCPS, BCOP, leukemia clinical pharmacy specialist/coordinator at The Mount Sinai Hospital, on the role of the pharmacist in the management of chronic lymphocytic leukemia (CLL). Farina highlights the multifaceted role of pharmacists in CLL management, encompassing patient care, treatment decision support, and safety considerations.
Pharmacy Times: What is your role as a pharmacist in managing chronic lymphocytic leukemia (CLL)?
Key Takeaways
- Pharmacist's Integral Role: The pharmacist plays a crucial role in the management of CLL in both inpatient and outpatient settings. In the inpatient setting, the focus is on supportive care and managing adverse effects, while in the outpatient setting, it includes medication acquisition, counseling, adherence, and toxicity monitoring.
- Variability in Involvement: The pharmacist's involvement in the patient care team varies based on the practice setting (community hospital vs academic center) and the setting (inpatient vs outpatient). In the inpatient setting, the pharmacist is more involved in monitoring toxicities and initiating therapies, while in the outpatient setting, there is more time for patient interaction and addressing barriers to adherence.
- Treatment Decision Factors: The process of identifying the best treatment for an individual with CLL involves considering disease-specific characteristics, patient comorbidities, and patient-specific factors. Factors such as cytogenetic abnormalities, cardiac history, renal dysfunction, and patient preferences guide the selection of therapy.
- Impact of Pharmacist Guidance: The pharmacist's input is impactful in treatment decisions, particularly in terms of drug interactions, dosing recommendations, and therapy selection. However, the level of independent decision-making varies based on state laws, and in New York State, pharmacists contribute to the interdisciplinary team but do not have complete independent decision-making authority.
- Value of Oncology Pharmacist: Farina explains that the presence of an oncology pharmacist on the patient care team is highly valuable. The pharmacist's role includes communication with patients to address medication issues, managing toxicities, ensuring adherence, and providing expertise in drug interactions and dosing adjustments. The absence of an oncology pharmacist may hinder patient care and safety.
Kyle Farina, PharmD, BCPS, BCOP: I think that the pharmacist can have an integral role in the management of CLL, both in the inpatient and outpatient spaces. I think more when I'm on the inpatient side of things is a little bit more supportive care, management of side effects of potential treatment options, whereas in the outpatient space, there's a little bit more involvement in the acquisition of medications, counseling of medications, medication adherence, in addition to the toxicity monitoring that patients may have.
Pharmacy Times: What is your involvement level on the patient care team for patients with CLL, and does that involvement vary depending on any factors in particular?
Farina: So, the involvement with the treatment team, I think, varies a little bit depending on what your practice setting is, whether you're in more of a community style hospital versus a large academic teaching center. And then I think also the role can vary, again, depending on more inpatient versus outpatient settings. In the inpatient space, you're more involved with the monitoring of toxicities and initiation of therapies, you're getting some of the sicker patients who require acute admission and more supportive care and a higher level of monitoring, where in the outpatient space, those patients are a little less acute, you can take a little bit more time to chat with them, monitor barriers to adherence, monitor [whether their] able to acquire [their] medications, do you have insurance claims, prior authorizations that you could potentially help resolve and help with oral oncolytic acquisition?
Pharmacy Times: What is the process for identifying the best treatment for an individual patient with CLL?
Farina: So, I think when you're thinking about therapy options for CLL, knowing that there's really kind of 3 to 4 mainstays of therapy, it really comes down to disease-specific characteristics in the form of cytogenetic abnormalities, but also patient-specific comorbidities, and patient-specific factors. I know we have our BTK inhibitors, which have shown efficacy in this disease state as monotherapy or in combination with some of our CD20 antibodies. But they might not be the best option for someone who has significant cardiac history knowing some of that toxicity profile. So that might shift us more towards a [venclexta (Venetoclax; AbbVie and Genentech)] based approach that doesn't have that same cardiotoxicity or vice versa.
Someone who has some renal dysfunction [who is] a little bit older, we’re a little bit more concerned with tumor lysis syndrome or infection risk in someone. We may stay away from [venclexta] as a first line option, and then we may favor some of our more BTK inhibitor type therapies.
As more data comes out, we're starting to get into the era of all oral combinations BTK [venclexta], with no infusions, so maybe taking someone's favorability of coming into clinic for an IV infusion, we always assess whether we would want more definitive levels of therapy, set duration, finite duration versus indefinite therapy. So, all of those culminate into kind of the ideal first choice for a patient.
Pharmacy Times: What impact does your guidance have on treatment decisions for patients with CLL, and do you have independent decision making in terms of treatment decisions?
Farina: In terms of independent decision making, a lot of this I think is going to be driven by state legislature and laws and what pharmacy practice allows pharmacists to be able to do. Speaking strictly from a New York state perspective, there is a much higher barrier to pharmacists being independent practitioners, whereas in other states, pharmacists are able to serve as their own independent providers or CDTM is a little bit easier to acquire.
So, at the moment for me in New York State, my decision making really just goes into the pot as part of the interdisciplinary medical team, I would never be the sole person who makes the decision and sends the prescription. However, my input is impactful. Pharmacist input is impactful in terms of drug interactions, is there something we need to avoid? This is the dosing we need to send out at this point because of XYZ, we need to do this ramp up this way if we're going to choose this therapy, or why I would pick one therapy over another.
So do I have the complete independent decision making process in New York State? Absolutely not. But do I feel as a clinical pharmacist in New York State that I can work with my team to really optimize and potentially sway the decision one way or another? Absolutely.
Pharmacy Times: What is the value of the oncology pharmacist on the patient care team for patients with CLL, and how might the absence of an oncology pharmacist effect treatment?
Farina: I mean, I will be very biased in saying this as a clinical pharmacist, but I think every oncology team and every specialty should potentially have a clinical oncology pharmacist specialized for that team. Regarding CLL for patient care, you're talking with them, you're understanding why they may not be able to take their medications if they are experiencing side effects, you are there frontline communicating with them to be able to help the patients manage their toxicities and keep them on medication that otherwise could be making them feel pretty sick. So, I think from the patient perspective, there's a huge benefit to having us there on the frontline helping to manage CLL.
Even really, just from the more medical laboratory side of things, all of these medications now in the frontline have drug-drug interactions. There are specific dose adjustment recommendations, specific monitoring parameters, where dose reductions may be warranted, that a provider may miss or an NP may not be as familiar with, and we're right there to catch that—this is our bread and butter. If you're starting one therapy that requires the ramp up, I've mentioned this in a previous section that you'll see before this, but you know, you can be there to say this is the schedule, go over it with the patient.
So, I think that there's a huge benefit and the loss of not having someone there who's trained in the drugs specifically, does I think hinder patient care overall from just the patient comfort level and keeping them adherent to their medications. But I also think there's a huge safety component that pharmacists will contribute to, to the institution and treatment for CLL.
