Pharmacist-Led Workflows Support Safe Outpatient BiTE Therapy in Multiple Myeloma

In an interview with Pharmacy Times, Nicole McMullin, regional clinical pharmacist at American Oncology Network, discussed the oncology pharmacist’s role in supporting outpatient bispecific T-cell engager therapy for multiple myeloma and the safety protocols AON uses to monitor patients during step-up dosing.

McMullin explained that AON regional clinical pharmacists receive a notification through the organization’s internal service system when a patient is ordered a BiTE therapy for all-outpatient administration. Once notified, pharmacists review the patient’s chart and create alerts to indicate that the patient is receiving bispecific therapy. This is important because treatment delays may require specific redosing protocols or repeat step-up dosing, making visibility across the care team essential. Pharmacists also place chart memos so that anyone accessing the record is aware of the patient’s therapy and related safety considerations.

During step-up dosing initiation, the regional clinical pharmacist also sends the clinic a detailed email outlining the requirements that must be in place before outpatient treatment begins. This includes confirming that the patient meets selection criteria, determining whether the provider wants to use prophylactic tocilizumab, ensuring patient education has been completed, and sharing standard operating procedures in a centralized format. Pharmacists also review the chemotherapy plan and confirm that supportive care measures are in place.

McMullin emphasized that the major safety concerns with outpatient BiTE therapy are cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. To address these risks, AON developed CRS and ICANS monitoring policies as well as nurse triage documents to standardize how symptoms are assessed and escalated. Patients receiving outpatient step-up dosing are provided a monitoring kit that includes a blood pressure cuff, thermometer, and pulse oximeter. For the first 3 days after step-up dosing, patients monitor their symptoms and vital signs every 6 hours at home. They are also prescribed “pill-in-pocket” dexamethasone, which can be administered promptly if symptoms develop and the clinic team determines intervention is needed.