From Inpatient to Outpatient: A Pharmacy-Led Evolution in Transplant Care

At the HOPA Annual Meeting 2025, Erin Lexner, PharmD, BCPS, PGY2 oncology pharmacy resident at West Virginia University Medicine Cancer Institute in Morgantown, spoke with Pharmacy Times about the results of switching from inpatient CBV—cyclophosphamide (Cytoxan; Amneal Pharmaceuticals, Inc), carmustine (Gliadel Wafer; Azurity Pharmaceuticals, Inc) and etoposide (Etopophos; Bristol-Myers Squibb)— to outpatient BEAM—carmustine, etoposide, cytarabine (Cytosar-U; Meitheal Pharmaceuticals) and melphalan (Evomela; Acrotech Biopharma Inc)—as a standard conditioning regimen for patients undergoing autologous stem cell transplant.

Pharmacy Times: What factors led your team to consider switching from inpatient CBV to outpatient BEAM as the standard conditioning regimen?

Erin Lexner, PharmD, BCPS: Part of it was the 2018 etoposide shortage. So, switching between the 2 alleviated our use of etoposide. Additionally, provider preference and changes post the exposure of that. So CBV is our inpatient historical control versus BEAM, which is our current standard.

Pharmacy Times: Can you walk us through the key differences between the CBV and BEAM regimens in terms of administration, toxicity profiles, and patient experience?

Lexner: Our CBV regimen consists of an 8-day preparation regimen with carmustine, etoposide, and cyclophosphamide, while our BEAM uses carmustine, etoposide, melphalan, and cytarabine, administered over 6 days outpatient. The main difference between the 2, and being inpatient versus outpatient, is etoposide's dose—once daily versus twice daily.

Pharmacy Times: What did your study reveal about progression-free survival (PFS) when comparing inpatient CBV and outpatient BEAM?

Lexner: Progression-free survival in the first year was a little bit better in our CBV population versus our BEAM population of about 71% versus 63—I'm sorry, yeah, totally reverse that. Okay, progression-free survival was better for our BEAM population at 73% versus 61% for our CBV at the one-year interval. At the two-year, it was comparable within 57% versus 53%.

Pharmacy Times: What other findings from the study were of note?

Lexner: Overall, one of the major findings was the difference in median days admitted. We had a difference of 20 versus 7 days admitted, so 20 for our CBV inpatient versus 7 for our BEAM outpatient. And so, we considered that possibly a cost savings because we are saving 13 days inpatient with those resources.

Pharmacy Times: Can you share insights about the role of the pharmacist within these treatment settings?

Lexner: Ensure patient satisfaction, and also quality—patient satisfaction, quality, but effective, cost treatment. So being able to move the procedure of autologous stem cell transplant to the outpatient setting, we're able to utilize firms like the 340B cost model for our medications. In addition, patients are able to have a little bit more freedom to enjoy what they'd like in either like a family house or a hotel, depending on where they're located, instead of being admitted and under nursing care for 24/7.

Pharmacy Times: What barriers may stand in the way of successfully implementing outpatient BEAM?

Lexner: So, a lot of barriers that exist are just the resources available to institutions based what they able to grow or utilize. We are lucky at WVU where we have an organization like Family House where patients who might be from further out in the state are able to come and stay for the duration of the transplant care in the upfront settings, compared to other organizations who may not have that resource which limits their ability to move certain procedures to an outpatient setting.