Maintaining Cross-Specialty Communication Can Help Mitigate the Impact of Cancer Drug Shortages

In the first quarter of 2023, drug shortages hit a 10-year high in the United States. Forty-seven new drugs went into shortage, with chemotherapy drugs in the top 5 undergoing shortages, according to Sol Atienza, PharmD, BCOP, a clinical oncology pharmacy coordinator at Advocate Aurora Health in Milwaukee, Wisconsin. Atienza further explained that the impact of drug shortages on the patient population expands beyond access alone and includes increased health care costs, compromised patient care, missed doses, medication errors, and increased patient anxiety and stress.

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During a roundtable webinar with oncology pharmacists hosted by the Hematology/Oncology Pharmacy Association (HOPA) in partnership with the Association of Community Cancer Centers (ACCC) and Association of VA Hematology and Oncology (AVAHO), those in attendance indicated that oncology pharmacists are prepared to treat patients and help them overcome the effects of oncology drug shortages.

“As clinical specialists, we’re uniquely situated and qualified to be the voice of calm in these storms,” said Mahta Mahmoudieh, PharmD, ACCC representative and hematology/oncology pharmacy clinical specialist at Inova Health System in Tucson, Arizona. Mahmoudieh explained that to effectively combat drug shortages—both when shortages are occurring and before they happen—clinicians must proactively plan and prepare strategies. Strategies include maintaining a close relationship with drug buyers and drafting restriction criteria before they are needed, according to Mahmoudieh.

Jeffrey Pilz, PharmD, MPA, MS, BCPS, HOPA representative and assistant director of pharmacy, medication safety, and drug policy at The Ohio State University Wexner Medical Center in Columbus, expanded on these preparatory strategies further, noting that one basic strategy clinicians can use is “keeping track of what mitigation strategies have worked well for [their] institution.” Additionally, Pilz discussed forming a drug shortage group that can individually address the shortage-related issues that arise and escalate the collective response based on the severity of the shortage and its associated impact. This group can then plan for making decisions about drug allocation and alternatives for patients who can’t receive a certain drug.

Peter Stuessy, PharmD, BCOP, HOPA representative and clinical pharmacy specialist in oncology at Aurora Health Care in Milwaukee, said appropriate preparation for drug shortages can also include stocking strategies. Specifically, there are practical procedures that oncology pharmacists can employ to ensure drug supply is in appropriate excess of immediate need in order to maintain supply in the case of a shortage. “Some of these [drugs] are cyclical; you know they’re going to pop up again,” Stuessy said. “On those targeted agents, you want to make sure you’re keeping that extra supply on hand if your inventory space can handle it and if your bottom line can handle it.”

Once the target drug is on hand, it’s up to pharmacists to undertake the necessary restrictions to stretch out doses if a shortage occurs, according to Stuessy. Dose rounding, including rounding to the closest vial size on single doses, and scheduling as many patients as possible on the same day to receive treatment can help eliminate waste and ensure that you “give drugs to as many patients as possible,” Stuessy said.

Collaboration is another key feature of being able to treat patients in times of crisis. Natalie Osagie, PharmD, BCPS, BCOP, AVAHO representative and clinical pharmacy specialist in hematology/oncology from the Department of Veterans Affairs in Columbia, Missouri, echoed recommendations from Pilz. “Having a committee or a work group is very vital. These include all stakeholders…. It’s a one-stop shop to make decisions on what can be done,” she said.

Including a variety of perspectives from across the spectrum of treatment providers in the drug shortage group can ensure close communication between partners is shared. Osagie noted that she keeps her drug providers on speed dial.

“Frequent communication, being totally transparent with clinical providers, wholesalers, drug suppliers, [and] payers, [is essential]. You need to make sure everyone knows about the struggles you’re having,” said Sarah Hudson-DiSalle, PharmD, RPh, HOPA representative and pharmacy manager of the Medication Assistance Program and Reimbursement Services at The Ohio State University Wexner Medical Center.

Established relationships with providers are even more critical when procuring drug supply or alternatives for drugs in shortage, and having an expansive infrastructure of sources can provide multiple options for doing so. “If you’re fortunate enough to have those multiple sources already built out…you [could] leverage those to get a fraction of your historical percentage, [setting] you up for a longer period before you have to take some of the more critical actions for mitigation,” Pilz said.

The second half of the webinar focused on the carboplatin and cisplatin chemotherapy shortages, which are affecting patients and pharmacists across the US. A variety of factors, including the shutdown of a manufacturing plant in India and the subsequent spike in demand for the drugs, have led to this current shortage. The panelists discussed options available for treatment alternatives and policy initiatives.

Sarah Hayward, PharmD, BCOP, HOPA representative and clinical pharmacy specialist at the University of Oklahoma Health Stephenson Cancer Center in Oklahoma City, spoke of the consistent evidence that points to platinumbased therapies being used with curative intent—which can’t be said for the potential use of all alternatives. This leaves a lack of options available for substitution for these therapies.

For this reason, Hayward noted that quickly released guidelines from organizations such as the Society of Gynecologic Oncology (SGO) that detail the appropriate next steps when dealing with the carboplatin and cisplatin shortages are critical. “What’s been really fantastic is [that] SGO was very quick to come out with alternative recommendations for individual disease sites, in specific regards to these shortages,” Hayward said.

Furthermore, maintaining communication with specialists in different oncology fields through a drug shortage group can help to more quickly identify the patients who should be prioritized due to their treatment needs and ensure the best treatment possible is provided, Mahmoudieh explained. “[Bringing providers from different specialties in] a group early on to discuss who needs it most [and] where there [is] truly a lack of alternative therapies [has] been really successful in my practice. [It allows us] to be able to get those discussions going up front [and] influence prescribing practices right away,” she said.

Ultimately, the FDA needs to take “really integral steps” to better plan for drug shortages, such as by providing and enforcing plans to ensure that stockpiles of specific drugs that are often in shortage are full and ready to be used, according to Hudson-DiSalle. To do this, it will take partnerships between pharmacists, suppliers, and legislators. “It takes [all of us] to collaborate,” Hudson-DiSalle said.

Throughout the panel discussion, the overarching themes were the importance of collaboration, communication, and partnership to mitigate the potential impact of drug shortages on patients with cancer. Further, the panelists agreed that it remains key to lobby providers to refill supply of platinum-based chemotherapy drugs and keep an eye on the importance of ethically providing treatment to as many patients as possible.

Reference

Critical conversations: navigating drug shortages and empowering oncology pharmacists. Hematology/Oncology Pharmacy Association. Accessed August 21, 2023. https://www.hoparx.org/about-us/advocacy-awareness/training/drug-shortages-webinar/