Best Practices for Transitioning from Intravenous to Subcutaneous Dosing - Episode 10
Practice Pearl 4: Financial Benefit of Subcutaneous Dosing
Experts move on to discuss the various levels of financial benefit with subcutaneous dosing.
Adam M. Brufsky, MD, PhD: Let's talk a little bit about cost here. There clearly are cost studies that have been done, but at Memorial Sloan Kettering Cancer Center [MSK], have you done anything like this in terms of cost?
Matthew J. Matasar, MD: It's not something that we've specifically studied, but when we're looking at cost, we look at different components to that. We have out-of-patient cost, out-of-pocket cost for the patients. There are system costs for MSK. And then there's practice-level cost in terms of utilization of resources. For out-of-pocket, my perspective is that it's a push for my patients, and certainly I haven't had anybody come back to me saying that there have been cost implications from that change.
Adam M. Brufsky, MD, PhD: Yes, that's a good question. So is there any different co-pay for a subcutaneous dose as opposed to an IV [intravenous] one?
Matthew J. Matasar, MD: My understanding is no.
Tim Peterson, PharmD, BCOP: Not that I'm aware of either. And if you look at what we talked about, the AWP [average wholesale price] costs, acquisition costs are pretty similar in the grand scheme of things. It's more about other costs, nursing time, and chair time cost.
Adam M. Brufsky, MD, PhD: And in terms of pharmacy costs.
Tim Peterson, PharmD, BCOP: Absolutely.
Adam M. Brufsky, MD, PhD: The preparation. You know? So really you have a single-unit dose. You draw it up, and you give it.
Tim Peterson, PharmD, BCOP: Yes.
Adam M. Brufsky, MD, PhD: Or you have to really prepare tubing and everything else.
Tim Peterson, PharmD, BCOP: Exactly. And the bigger difference is with trastuzumab requiring the reconstitution and then dilution, and I think, actually, speaking to the pharmacy preparation side of things, there's a lot more potential for mitigating some of the loss that we can have for these agents, right?
Adam M. Brufsky, MD, PhD: Right.
Tim Peterson, PharmD, BCOP: We have weight-based dosing for rituximab and for trastuzumab, and if for whatever reason the patient doesn't come to their appointment, it's already been premixed perhaps. We have a premixing process at MSK. So if we've premixed it and the patient doesn't come in, or you as the oncologist decide this is not a good day for trastuzumab or rituximab, we have that bag that's been prepared of 6 mg/kg of trastuzumab.
Adam M. Brufsky, MD, PhD: There's a couple thousand dollars at least.
Tim Peterson, PharmD, BCOP: Exactly. It's going to sit in our refrigerator for 24 hours to see whether we happen to have someone with the same dose.
Adam M. Brufsky, MD, PhD: That's a point. So you could use it on someone else if you had to.
Tim Peterson, PharmD, BCOP: Yes. But if we don't, that's a loss.
Adam M. Brufsky, MD, PhD: How common is that?
Tim Peterson, PharmD, BCOP: That's actually probably relatively common.
Adam M. Brufsky, MD, PhD: It is. I would assume it would be.
Tim Peterson, PharmD, BCOP: Exactly. And the same thing for rituximab, right, 375 mg/m2 or 500 mg/m2. We round surely, but to have someone come in within the 24 hours, is that still going to be stable? Versus a 1400-mg or 1600-mg syringe that's drawn up, you're much more likely to be able to use that and not have as much waste.
Adam M. Brufsky, MD, PhD: Was this just in time reconstitution? In other words, you don't reconstitute until you get the order that the person's here, or what do you do?
Tim Peterson, PharmD, BCOP: It depends. We have what we call a chemo-ready system. So for patients who are on long-term therapy with rituximab or some of our other antibody therapies, we will call them ahead of time and make sure that they should be OK to receive the drugs the next day, and then we'll prepare it so that it's in the clinic when they come for our appointment.
Adam M. Brufsky, MD, PhD: Got it.
Tim Peterson, PharmD, BCOP: So that's something where there's more potential for decreasing some of that loss and minimizing some of that if we have a standard flat dose.
Adam M. Brufsky, MD, PhD: Got is. And also, the chair time. Clearly the whole time the patient's there because it's tough. I'm assuming, at least if your clinic is like mine, they're still going to wait around for us. They're going to wait for their labs.
Matthew J. Matasar, MD: I don't know what you're talking about.
Adam M. Brufsky, MD, PhD: They're going in for their labs. You really raise a very good point, which is that yes, the actual infusion is 2 to 5 minutes, but can we cut down on all the rest of it? That's a good point.
Matthew J. Matasar, MD: Ultimately, we're trying to make our patients' lives better. And part of that is just being aware that their time sitting around waiting for us, waiting for labs, waiting for room, waiting in the chair, waiting for their car, is hard. The experience of receiving treatment is hard, and the availability of subcutaneous formulation can make it a little better.