Practice Pearl 3: Procedure for Transitioning and Patient Education

Experts review the procedures in an inpatient setting and discuss the patient education provided.

Luigi Brunetti, PharmD, MPH: Your anecdote about patients switching to emicizumab and the importance of saying, "Hey, you still need that factor VIII," ties in with the next clinical pearl I'd like the panel here to cover in transitioning patients. Typically, when transitioning an individual from inpatient to outpatient, or even transitioning someone from a factor VIII product to emicizumab, what are some important considerations? And perhaps, what is the procedure when transitioning from inpatient to outpatient?

Robert F. SIdonio, Jr, MD: I guess when you're talking about inpatient, you mean their product choice and such?

Luigi Brunetti, PharmD, MPH: Correct.

Robert F. Sidonio, Jr, MD: Yes, so in our pharmacy, we don't carry a lot of extended half-life products, I don't know how yours is.

Giles Slocum, PharmD: We do not have any extended half-life products on our formulation. I guess I'm trying to think of a situation for this.

Luigi Brunetti, PharmD, MPH: One of the thing that we do first if a patient is coming in, let's say they're coming into the hospital for whatever situation, we often will have the patient or family member bring their product in with them. And it's because we can't carry all these products.

Robert F. Sidonio, Jr, MD: Yes, there are so many of them. I don't know how many factor VIII products you guys have on formulary. We have a limited supply for cost savings.

Giles Slocum, PharmD: Exactly. That's a really good point. We use a consignment program at our institution for this reason: not even just the cost burden but the shear amount of factor VIII products that are available. We try to limit it to a recombinant and maybe a human plasma pool of each of these. And then we do use a therapeutic interchange for patients who are coming in. But like you mentioned, it someone's coming in, they're told by their HTC [hemophilia treatment center] that they have that extra dose at home to have available to them for any emergent bleeds or any time they need to go to an emergency department [ED] that may not even have factor VIII available.

So when they come in we do allow them to use home supply for a first dose, whether it's for a bleed in the ED, or if it's preoperative for a planned procedure or something like that. Those are the main ways our patients come in: bleeding through the ED, not bleeding through the ED, planned procedure, and maybe a transfer. And then after we use that 1-time dose, unless we hear from our hemophilia providers that there is a reason that we can't use the supply we have on formulary, we do therapeutically interchange them to our agent and roll with that.

Robert F. Sidonio, Jr, MD: That's important because in the older patients once they've gotten to 50 or 100 exposures, there have been some studies, and we just completed one called the ATHN 2 study in which we looked at patients who switched products and whether they developed an inhibitor. We had over 300 patients and nobody developed an inhibitor. And some fo those patients had a remote history of an inhibitor. That's really important, and you see other countries like Canada in which they switch their entire program to a factor product and everybody in the country essentially has to switch.

For the younger patients who haven't had a lot of exposures, you probably want to limit the different types of products. So bringing it in from home makes sense. We make those exceptions, but we have the same rule. They come to the emergency department, and we tell them to bring factor VIII. Of course, if they don't, then we supply it. And they're allowed to give that 1 dose. We also have a policy we set up in which they have to meet a long list of strict criteria, in which we could place an IV [intravenous drip] and let the parents give a follow-up dose at home. That's the biggest challenge for children obviously instead of admitting them, which has a high cost.

But once they get admitted, unless there's some really good reason, we're going to switch to whatever we have on formulary. And we have a couple of hospitals that we can switch with, our Scottish Rite Hospital and adult hospital can sometimes switch. And we do consignment for the really rare products. For factor XIII, we consign that one because it's pretty expensive, and you never know when you're going to use that, of course.

So we have the same sort of policy and that's why it's important when somebody gets admitted, we communicate as a team so they know. If somebody gets admitted and they're about to have some major surgery, the pharmacist does not want to find out about that last minute. They have to track down factor VIII and they don't want to keep 100 vials back there because they may not use it. It's really important to talk about that. And that is also included in our conversation when we talk to families: "This is what we have on formulary." So sometimes the family says, "Well, whatever you have on formulary, we're fine with using that, just so there's consistency." So we remind families what's on our formulary. And it doesn't change that much. It tends to be standard half-life products.

Luigi Brunetti, PharmD, MPH: We're getting a little ahead of our timeline, but I think it ties in nicely so it's important to bring this up. You mentioned how we should make patients aware that, "Hey, if you go to the emergency department, you should bring that factor VIII product with you."

Robert F. Sidonio, Jr, MD: Yes.

Luigi Brunetti, PharmD, MPH: So the education component I think is huge. When you arrive and you are an inpatient, let people know that you do have hemophilia. What is the product you're on, what dosage are you on? And, of course, do you belong to a hemophilia treatment center? And I would say this is probably an opportunity as well for those patients who are perhaps not part of an HTC on that transition out, to see if you can connect them to an HTC. Because we know that treatment outcomes are better for patients in an HTC.

Giles Slocum, PharmD: Yes.

Robert F. Sidonio, Jr, MD: We often will discover patients who haven't been seen by any, and we try to discuss with them and say, "We know you have a local hematologist, but we'd love to see you. We have this designation from the government. We have the funding. We have the resources." And oftentimes just telling them, "We have a social worker. We have a nurse or research nurse. We have access to studies. If there's a problem in school, we can send the nurse out to the school and educate them as well."

We always want to remind them of the resources and say, "This has all been set up for people like you. You should take advantage of this." But try to make that connection. And oftentimes—we were talking about transitioning from their products—for the most part we can utilize what we have in patients without any issues. And then of course, when they go home, we prescribe whatever they were previously on, or they may make a decision to switch. And that can be complicated depending on their insurance and what's available.