Navigating Treatment Options, Optimizing Care for Patients With CLL

Pharmacy Times interviewed leukemia clinical pharmacy specialist Jenna Ciervo, PharmD, BCOP, Memorial Sloan Kettering Cancer Center, to discuss chronic lymphocytic leukemia (CLL). Ciervo highlights the involvement in care and factors that contribute to treatment selection, hurdles and access to care, and the oncology pharmacist’s impact and role in this patient population.

Pharmacy Times: What is your role as a pharmacist in managing chronic lymphocytic leukemia (CLL)?

Jenna Ciervo: So, as 1 of the leukemia pharmacists—we have 4 different pharmacists that are all kind of covered the leukemia service—we rotate between the inpatient and outpatient settings. On a monthly basis, we kind of will go on the inpatient round on the team and then on the other months, we'll be in the clinic helping providers with like new visits…So for CLL, we work with all of the CLL providers, whether it be inpatient or outpatient, but I think the majority of the treatments are in the outpatient setting. So that's where we really kind of shine with our help there. Mainly in the clinics, we'll see all of the new patients that come in with CLL that are either seeking second opinions or looking to establish care, and then we'll help with drug education, therapy selection, and assisting providers with any information they need regarding treatments.

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?

Ciervo: We are pretty involved with our CLL patients. As I said, we'll see all the new visits and then we'll meet with the providers kind of talk through their disease states, [and then] deciding whether they even need treatment or not. And then once we determine that, then we really go into selecting the best therapies for the patients, and then once that's selected, we'll review their medication list, go through potential drug interactions and comorbidities to make sure that the therapy is appropriate. And then once that's all done, we'll help with providing education to the patients, and then if there's any issues with denials or appeals that need to be done will also assist with those. So, we kind of help with all aspects of [involvement], even coming down to drug acquisition.

Pharmacy Times: What is the process for identifying the best treatment for an individual patient with CLL, which can be complex in this patient population?

Ciervo: Yeah, I feel like—especially since this is like a diagnosis of elderly patients—people can have a ton of comorbidities [and take] a ton of meds. So, it's really just starting out by like looking at…their comorbidities is probably first, because that will help narrow down between which treatments we want to look at. Also, the disease characteristics of what their CLL is like, there’s visit different types of cytogenetics and mutation status, so that comes into consideration too. Starting with comorbidities…for example, if people have cardiac comorbidities, maybe we'll want to stay away from like the BTK inhibitors because we know they tend to have more cardiac [adverse effects] versus a [venclexta]-based regimen. So, we take a look into that, and then diving into the drug interaction standpoint can be sometimes challenging, especially with a lot of different cardiac meds as well. I feel like those are most of our problematic meds.

Pharmacy Times: What are some of the more challenging comorbidities in terms of treatment selection for this patient population?

Ciervo: I think most people do have some cardiac history, but the ones I'm thinking of would be people with arrhythmias, I feel like our antiarrhythmics can be challenging to deal with, such as AFib meds, rhythm control…But usually, when I see things like amiodarone, it just sparks a red flag in my head, because it tends to be always problematic. So, we'll just try to figure out how to navigate kind of those situations.

Pharmacy Times: What are some other factors you consider during treatment selection for patients with CLL?

Ciervo: I think it kind of goes into what I've talked about a little bit, so looking at first [the patient’s] disease characteristics in terms of CLL and then looking at their age and comorbidities. I think something that's important that comes into mind is patient preference. We do have therapies that are time-limited that patients can potentially get, such as like our [venclexta]-based [therapies] with an anti-CD20. Those can be timed-definitive therapies, versus something like a BTK inhibitor, that's more of a long-term, lifetime-long medication. So, patient preference is something that comes into play if they don't have any reason why they couldn't get either of the therapies. Then access to care as well, because our [venclexta]-based regimens tend to require more monitoring upfront, so requires people to—sometimes—have to be admitted for initiation of treatment for up to 5 weeks, whereas the BTK inhibitors don't require admission for initiation. Access to care is going to be something that comes into play. Then the last part of that is going to be the drug interaction standpoint as well.

Pharmacy Times: What are some of the ways you help patients address hurdles around access to care and treatment?

Ciervo: We have a lot of support for our patients, I feel like it's actually a little bit easier than you would think. The admissions are usually [around] 2 days every week for 5 weeks for the [venclexta] ramp up. If we need to help coordinate transport and things like that, we have services and teams that are really great at doing that. We also have regional sites. For example, if patients met criteria where they didn't actually require a hospital admission, but they needed monitoring in a clinic, we do have regional sites around New Jersey, in Westchester, and Long Island that can be a little bit more accessible for patients. So, if [patients] do meet the criteria for outpatient initiation, they can kind of do that there in the clinic setting and not even have to come into the city for admission to the hospital. [That’s] definitely something that we navigate pretty frequently because a lot of people come here from [different] places, and they're like, “How can I get treated here?” and we'll kind of figure that out.

Pharmacy Times: How do you counsel patients with CLL on treatment for this disease?

Ciervo: I think adherence and compliance is just important for all medications. That’s 1 of the number 1 biggest things that we’ll counsel on, and how to take the medication appropriately is going to be another thing. So, with their [medication] requires food, or if it has to be taken at a certain time of day, we'll definitely go through all of that stuff. And then I think the [adverse effects] portion of it is probably the most impactful for patients, especially if they're going to be on a lifelong medication, they want to know what's going to happen to [them] if [they] take this for the rest of [their] life. It helps that we provide the education to help ease patients, like anxiety, and just understand that, like if anything comes up [that] we're here and ready to deal with it. But just encouraging them that overall, these medications are really well-tolerated, and again, we're always here as a resource in case something comes up that they have questions on.

Pharmacy Times: Are there any other interventions you recommend to patients with CLL?

Ciervo: There are some…I guess, they're kind of supportive measures, but a lot of the BTK inhibitors can cause increased risk of bleeding, so [we] recommend things like [using] a soft bristle toothbrush to avoid anything too abrasive on the gums to prevent like bleeding.

But [recommendations] supplement-wise, typically no, supplements actually are problematic in our eyes for the most part, because a lot of patients with CLL do a lot of research, and there's some information about some things that can potentially help with their CLL, which actually can potentially have drug interactions. So, for the most part, we don't recommend supplements unless a patient is deficient in something, like vitamin D, B12, things that we can kind of check in their labs. So, supplementation typically not, but really just a lot of the other supportive measures…healthy diet, monitoring blood pressure, staying on top of vaccinations is super important for CLL patients, so we do a large majority of recommending those and encouraging patients to stay up to date on their vaccinations.

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 affect treatment?

Ciervo: I think, in general, pharmacy involvement on any team has been shown to improve outcomes and provide better outcomes for patients and can help to optimize care. So, I think with our involvement with the CLL patients, it really helps to provide a blanket for less anxiety for patients, because they feel more educated, they feel like they are empowered, know how to take their medications, and when to reach out or what to reach out about.

And then on the other side of that, with being a resource for providers, I think it's super impactful, our involvement, and it's amazing being able to work with our providers here and being involved in clinical trials as well, [we’re] kind of seeing what things are going to look like in the future. I think we have such a big involvement, especially with odd [adverse effects] that might come up or unique situations where we might need to do something quicker, like an escalated [venclexta] ramp up has occurred a few times for patients that are admitted. So, we provide a lot of like support and education for our providers in those difficult and challenging situations, I think our impact is amazing and great. The absence, I feel like our providers would definitely feel it. We provide so much [when it comes to] looking into the nitty-gritty details, that they would definitely feel our absence and I'm sure they very much appreciate our help there.