Managing Oral Oncolytics During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has significantly altered how health care professionals treat patients on oral therapies and manage their care, with many strategies for treatment shifting to minimize the potential exposure to the virus for the vulnerable patient population.

In a Pharmacy Times® webcast, Katie Culos, PharmD, BCOP, a specialist in cellular therapy and hematology at Vanderbilt University Medical Center in Nashville, Tennessee, led a discussion with Katherine Lin, PharmD, BCPS, BCOP, of PANTHERx Rare Pharmacy in Pittsburgh, Pennsylvania, about the management of oral oncolytics during the COVID-19 pandemic, considering the many policies and procedures that have been implemented by providers for cancer care.

For example, Lin said that PANTHERx has imple-mented a robust infection control policy to identify and triage patients with any respiratory symptoms in an effort to decrease the exposure to others at her institution. “The screening does include the assessment of exposure risk, and we ask patients and our staff about any recent travel history or any exposure to an individual who has tested positive for COVID- 19,” Lin said.

Additionally, Culos mentioned that the pandemic is an evolving situation, with many questions about who constitutes essential staff and which patients absolutely need treatment.

Lin said PANTHERx has made alterations to treatments of patients undergoing therapy, with clinicians gravitating toward the selection of oral agents in place of intravenous options.

“For patients diagnosed with CLL [chronic lymphocytic leukemia] during the COVID-19 pandemic and needing to start therapy right away, the oral agents such as the BTK [Bruton tyrosine kinase] inhibitors ibrutinib and acalabrutinib have really…emerged and been considered the preferred agent[s],” Lin said.

“Generally at this time, we’re tending to shy away from chemoimmunotherapy in patients with CLL, so regimens like BR [bendamustine and rituximab] and FCR [fludarabine, cyclophosphamide, and rituximab]. The reason…is that these regimens do require frequent trips to the clinic to be infused and administered. And in general, they’re more myelosuppressive than the oral options,” Lin added.

Lin also said that clinicians should consider other available oral treatments, such as the BCL inhibitor venetoclax (Venclexta), although clinicians have been staying away from initiating it in patients with newly diagnosed disease. “Venetoclax requires either prolonged or frequent clinic visits, or hospitalization secondarily, when we’re dose-titrating secondary to the risk of TLS [tumor lysis syndrome] in this patient population,” she said. “So we really have shifted toward other treatment options if [they’re] viable… and exist. So not only has the outbreak influenced our selection of therapies, but it’s also changed and affected how we’re monitoring patients on therapy.”

Lin noted that clinicians cannot ignore the substantial psychological impact of the pandemic on patients with cancer, particularly their fear of increased vulnerability to the virus and of its effect on their ability to receive care if they become infected.

The role of the pharmacist in this transition of care depends on the setting in which they practice, according to Lin. “When you look at pharmacists who are practicing in an institutional setting, they [can] have [a real] impact…on the drug selection,” she said. “They have involvement with interprofessional cancer formulary committees that are looking at the clinical data, guidelines, and cancer pathways. And they have a role in selecting which agents we should be putting in which line of therapy, taking COVID-19 into account.”

Further, Lin mentioned that in practices where physicians are staffing in the clinics, the pharmacist can support oral oncolytic prescribing by performing a comprehensive evaluation of specific patient factors, including evaluation of a comorbid condition’s concomitant medication, dosing schedules, adverse effect (AE) profiles, and insurance hurdles.

Regarding informed decisions about oral oncolytics, Lin said the shift from administration of the drug in the clinic setting to administration in the home is the most notable dynamic.

“What we’ve done is [shift] the responsibility of following treatment plans [and] identifying and monitoring AEs from the providers over to the patient,” she said. “As a result, appropriate education for patients [and their caregivers] has to occur on when it’s appropriate to try to self-manage these AEs that may occur in the home setting [and] when they need to be escalated to a health care provider.”