Improving Luspatercept Dosing for Patients With MDS: The Impact of Pharmacist-Led Interventions at AON

Pharmacy Times® interviewed Brooke Peters, PharmD, BCOP, clinical pharmacy services manager, pharmacy operations at American Oncology Network (AON) in Fort Myers, Florida, on a study presented at the Society of Hematologic Oncology 2024 Annual Meeting titled: Evaluating the impact of an electronic medical record [EMR] alert on appropriate dosing of luspatercept [Reblozyl; Bristol Myers Squibb] in patients with low-risk myelodysplastic syndromes (MDS) in a community oncology network. According to Peters, the study was conducted at AON due to concern that necessary dose escalations were not always following FDA-labeled guidelines, leading to delays in achieving optimal dosing.

We wanted to take a look at luspatercept dosing to determine if providers were appropriately escalating doses for patients to achieve red blood cell transfusion independence. Image Credit: © sovova - stock.adobe.com

Pharmacy Times: What was the impetus for this study at AON?

Brooke Peters, PharmD, BCOP: In early 2022, we wanted to take a look at luspatercept dosing to determine if providers were appropriately escalating doses for patients to achieve red blood cell (RBC) transfusion independence. Our average luspatercept dose was lower than expected, so we were concerned that perhaps necessary dose escalations were being missed, or escalated doses were not being selected according to labeled mg/kg dosing.

We performed a drug use evaluation at that time for patients previously/currently treated at our practices with luspatercept. We found that while most providers were identifying the need for dose-escalation appropriately, doses selected for escalations were not always according to FDA-labelling, resulting in cases where patients required more escalations (and therefore more time) before the therapeutic or maximum dose was reached. Therefore, in February of 2022, we added additional verbiage to orders within our luspatercept treatment plans in an effort to make dose escalation instructions more clear. Later in 2023, we wanted to take a look at the impact of the treatment plan changes in case our efforts, if replicated at other facilities, could improve care for MDS patients outside of AON.

Pharmacy Times: What is the significance of the EMR alert successfully improving appropriate dosing for patients with low- to intermediate-risk MDS treated with luspatercept within practice?

Peters: We found that fewer patients in cohort 2 (post-intervention) vs cohort 1 (pre-intervention) experienced inappropriate dosing (P=0.0003; 2.6% vs 33.3%). This meant that when an escalation was indicated due to continued RBC transfusion dependence, more patients in cohort 2 were escalated to doses approved for MDS rather than to lower-dose, and more slow escalations were seen in cohort 1. Though not statistically significant, we did see that among patients requiring dose escalation, the median time to highest dose in the first 6 months was 12 weeks in cohort 2 vs 15 weeks in cohort 1 (P=0.5329), meaning patients were receiving therapeutic doses numerically sooner in cohort 2. To evaluate the clinical impact of the intervention, we evaluated the proportion of patients who had either reached the maximum dose or were RBC transfusion independent at week 16, an outcome used in previous studies with luspatercept. Though not statistically significant, a greater percentage of cohort 2 vs 1 patients were on maximum dose or achieved RBC transfusion independence at week 16 (P=0.0987; 82.1% vs 66.7%). Ultimately in our sample at AON, we saw that patients were becoming transfusion independent sooner, which improved quality of life and reduced cost of care. Any small intervention that improves concordance with FDA-labelling and may improve patient care and outcomes is certainly worthwhile.

Pharmacy Times: What is the significance of these results for pharmacy practice at AON?

Peters: These results bring attention to the value of small but meaningful pharmacist interventions. Within our organization, our team of pharmacists makes many interventions such as this to improve patient care and safety. While we cannot possibly evaluate the impact of every single intervention, this study is a good example of the purpose of these interventions. All it takes to improve patient outcomes is one team member identifying a potential issue, investigating to determine the cause, and implementing a solution. Thankfully at AON, our team of pharmacists is able to work collaboratively with fantastic interdisciplinary colleagues among nurses, providers, financial teams, and more, to implement effective solutions to problems or challenges we face in oncology.

Pharmacy Times: What are some additional EMR interventions that could be used in pharmacy practice that could be beneficial to improve dosing for MDS?

Peters: We are always looking for ways to incorporate artificial intelligence to improve care, including for drug dose/selection for MDS. Other interventions that could further improve care include: provider notification/pop-up for patients who qualify for luspatercept (up-front, or after failure on ESA), and provider notification/pop-up for patients who remain transfusion-dependent after at least 2 consecutive doses at present dose level, requiring dose-escalation. The latter intervention requires better integration of blood transfusion data/orders, which can be a challenge in community oncology where transfusions are often administered at an outside facility.