Best Practices for Prophylactic Therapy in Hemophilia A - Episode 5

Role of Specialty Pharmacies in the Management of Hemophilia A

A panel of experts discuss the role of specialty pharmacies in managing hemophilia A as well as transitioning patients from the inpatient to outpatient care setting.

Jonathan Ogurchak, PharmD, CSP: We talked a lot about the different types of regimens. I’d like to move on now to talk about how these regimens may lend themselves to site of care considerations, particularly in the outpatient setting. I know that there’s a lot that goes into that transition of care for patients when they’re going from inpatient to the outpatient care setting. What sort of oversight is needed? Who all needs to be involved really? I guess Dr. Sidonio, we can start with you. What does that ideal transition look like from your perspective to help to move those patients from one site of care to the next?

Robert Sidonio, Jr., MD, MSc: Transition of care is always a complicated topic and we’re always working on it. Obviously, the hemophilia treatment center has a collaborative team model. A lot of people are involved. We have our pharmacists. We have our nurses, the providers, including nurse practitioners and then nurses. We need all of those people to make sure there’s an effective transition. Also, the social worker plays a large role in this as well. Sometimes they uncover some home situations in which one drug may be not as optimal. In addition, obviously, the specialty pharmacy is really critical with the services that they provide. Because remember, if you had a young child and now, he/she had a significant bleeding event and now you’re saying we have to go on prophylaxis, it’s not an option anymore. You have to be able to have those specialty pharmacies to manage it; to be able to go to their house in order to help administer the Factor. They have to be very patient, make sure the kid is in a proper environment, and you have to create a situation where you’re not causing emotional trauma to the child because they can develop post-traumatic stress disorder. We have some kids in which they have to sometimes get versed before we see them in clinic because they’re so traumatized by the multiple attempts. We just think about it saying that “It’s only twice a week or three times a week Factor VIII,” but we don’t always think about every attempt, maybe 5 attempts. It may be an hour of drama in that family. Thus, we have to really think about all of those things when we’re transitioning patients. We have to make sure that our patients are well educated, and they understand that if they’re on emicizumab that they have to use Factor VIII to treat those bleeding events. We also have to make sure they understand that the bleeding events they had on Factor VIII alone or on demand may be more dramatic. The bleeds may be larger, and it may be more subtle when they’re on emicizumab. Furthermore, we have a lot of complacency issues as well. For a patient, it’s great that he/she hasn’t bled in a year or two, for example, but sometimes he/she forgets that he/she needs to call us if he/she has an achy ankle and he/she says “Well, I don’t know if it’s that.” Beforehand he/she would call us earlier. Maybe he/she is waiting to call us because maybe it’s not as dramatic of a bleed because it’s being mitigated by emicizumab.

Jonathan Ogurchak, PharmD, CSP: You mentioned, Dr. Sidonio, about specialty pharmacies and the role that they play with the management of hemophilia. Dr. Kuhn, would you be able to comment a little bit about how they really play a true role on the management of the patient?

Alexis Kuhn, PharmD, BCOP: Absolutely. As Dr. Sidonio mentioned, specialty pharmacists have a huge role in the management of these patients. As a pharmacist myself, I’m biased but I don’t work in a specialty pharmacy, so I give all the kudos and credit to my colleagues who do work in the specialty pharmacy setting. I know that they are uniquely positioned to play a huge role in the management of these patients. On the clinic side, when we’re seeing the patients, we’re seeing their labs, we’re ordering the medications, and then sending them on their way. The specialty pharmacists are there on the back end really making that plan and putting it into action. Earlier we had mentioned financial barriers are a concern. This is one thing where our specialty pharmacists, specifically the pharmacists and technicians, I should say, really carry a significant burden and really help to adjudicate some of those insurance coverage issues and really help to work with the insurance and tease out some of those prior authorizations to allow us to actually get the drug to the patient. Then, similarly, as sitting in a position where they’re the ones dispensing the medication, they are able to provide some of that crucial education along with how exactly this drug is working. We can give it a name and we can say how it works, but until the vial is in hand there’s sort of a disconnect. Thus, that specialty pharmacist can help bridge that divide and really with the supplies that the patient is actually using, kind of make that connection and ensure that the family knows exactly what product they’re getting and exactly how that works. For example, whether they need to reconstitute it, how to access the device and administer the drug itself, etc. Then, along with that education piece, from a dispensing history, if a specialty pharmacist knows that a patient is on prophylaxis and he/she sees routine dispenses over time but then suddenly there’s a gap and this patient hasn’t filled their Factor in a while, he/she can reach out to the patient and assess, for example, is there a new barrier that has come up that has limited his/her ability to continue filling prophylaxis? Has he/she changed goals? Is this a conversation that’s being had with the provider or is this something happening within the patient’s home? As a result, specialty pharmacists really can kind of serve as a sleuth on that end and really identify these problems.

Jonathan Ogurchak, PharmD, CSP: That’s great. I think you covered that very nicely Dr. Kuhn.

Transcript edited for clarity.