Pharmacists’ Role for Transitioning from IV to SQ

The panel of pharmacists provides input on pharmacists’ role in managing novel therapeutic agents and transitioning patients from IV to SQ dosing.

Jacob Kettle, PharmD, BCOP: What have you found to be key for you as a pharmacist, to be successful in initiating some of these transitions?

Allison Butts, PharmD, BCOP: Part of it is honestly some lead time to work out the payers and what product they’re going to pay for. I’ll knock on wood, but we’ve not had a lot of pushback at this point with payers, and our use of the subcutaneous products. I anticipate that will change as more of them come on the market. Having the time to reconcile whether we have prior authorization for this particular dosage form is step 1. Beyond that, it is about educating our colleagues in nursing and over on the staff-pharmacist side of things to make sure everybody is clear on which therapy is intended and about which product, as you pointed out, you’re going to use to make that dose for that patient. Those are 2 points we’ve come up with.

The last 1 I’ll mention is about what that transition looks like. For us [at the University of Kentucky], we made the decision to implement the subcutaneous therapy with new starts to these drugs rather than switching everybody across the board. As you said, we don’t live in a vacuum in which you could just make 1 change and apply it to everybody like that. With some of our metastatic patients who have been on trastuzumab for a very long time, we’ve slowly gone ahead and started talking to them about switching.

It’s good to know that we’ve got at least 3 weeks to get the new drug authorized and make sure that everything is updated with what the plan is for that patient. As we get more of these subcutaneous products, and as we figure out whether the subcutaneous trastuzumab-pertuzumab combination product is something that we’re going to take on, there are going to be more and more hurdles with those order sets.

Another hurdle we’ve come up with is that you have to build all these things into your EHR [electronic health record] and come up with your mechanism of how these are ordered. What if a payer declined the 1 that was ordered? What’s the process for getting the authorized drug ordered in the system to make sure that gets fixed before the patient gets to their chair? It’s complicated. The more variety you have and the more options you have, the more potential for error there is. You have to think it through and be pragmatic with how you’re practicing.

Jacob Kettle, PharmD, BCOP: That’s a fabulous point. It is probably the biggest gift but also the biggest burden, this abundance of therapeutic options we have. It is critical that day in and day out, we focus on the patient experience. That’s what I try to emphasize on our approach to care [at the University of Missouri Health Care]; that’s what will separate us from other institutions or anybody else. That’s what we have to lean on: For our patients and those in our community who are going through a difficult season in their lives, how can we assure them through that, the best way possible? You’re absolutely right. These are great tools to achieve that, but they come with a huge potential for error. That’s where communication, communication, communication among staff is so critical.

I’m sure you’re in the same boat as me, but it’s difficult to keep up with the pace of change and keep folks on board. That’s a consideration for me with the administration. While a lot of these drugs may make perfect sense to go live with, what 3 other things have you implemented in the last month that you’re still trying to get through? You can’t move too fast with some of these things because you’re going to end up having failed rollout, and you’re going to end up with less-than-successful experiences due to the potential for error and all those kinds of things.

I’m curious: Is there anything—in terms of monitoring parameters or adverse events—from your perspective, especially in the clinic, that changes when you move from an IV [intravenous] to subcutaneous dose?

Allison Butts, PharmD, BCOP: Of course, the main thing is how you’re infusing it and what the route of administration is. You worry a bit more about injection site reactions versus more frank infusion reactions. We are still premedicating patients the same for the IV and subcutaneous dose forms to avoid that as much as possible, but that’s the main difference. We don’t see a lot of other differences in terms of rash, diarrhea, or drops in cardiac function: all those typical anti—HER2 [human epidermal growth factor receptor 2] adverse effects. We’ve not seen changes, and the studies didn’t point to any major changes to the toxicity profile or needs for alternative monitoring.