The Pharmacist’s Role in Myelofibrosis Management

Kathryn E. Kennedy

As a nurse practitioner in hematology, mainly in the outpatient setting, I work very closely with you and the other members of the pharmacy team, Sarah. Can you give our readers an overview of your role as a pharmacist in a hematology clinic, and how you support your colleagues and our myelofibrosis patients?

Sarah Profitt

Sure. I am an oncology-trained pharmacist and I have been in malignant hematology for about 6 years. Our roles and responsibilities in clinic are pretty adaptive. We try to adapt our role to the needs of the patient or the disease group or our providers. I think our biggest role as medication experts in the oncology field is staying on top of the ever-changing landscape. In myelofibrosis, we've had lots of new medications approved by the FDA in the last few years. They each come with a unique profile of toxicities,  recommendations for managing those toxicities, and interactions with other medications. So I find one of my biggest roles is providing education for our providers on ongoing data and new medications, and then helping them manage those medications for their patients.

Typically, when a provider determines that they'd like to start a new medication for a patient with myelofibrosis, we tend to talk over the case together. We talk about the patient and their comorbidities, and we definitely look at any other medications the patient is taking. We talk about whether that specific myelofibrosis treatment is appropriate for the patient as well as the dose. From my perspective, I'm looking at how the drug is metabolized, how the patient's organ function plays into their dose, and also at the patient’s up-to-date medication list to uncover any drug interactions.

Kathryn E. Kennedy

I find that one of the things you, as a pharmacist, help me with most is the monitoring requirements for some of these drugs. It's hard to keep straight which drug, for example, requires EKGs or which one we need to get specific labs for. But you and our other pharmacy colleagues always help us keep track of those things.

Sarah Profitt

From your side of things as a nurse practitioner, what are you talking to the patient about when you're making the decision to start a new drug? Are you taking patient preferences into account? How do those conversations tend to go in clinic?

Kathryn E. Kennedy

In clinic we're taking into account many different things. First, is this a medication-naïve patient, or is this a switch from another drug? Yes, of course we take patient preference into account but we look at other things as well. If they have issues with adherence, maybe a once a day drug is better. Why are we starting the drug? If we're switching from one drug to another the first thing I consider is the reason. Is it for drug failure, side effects, new symptoms, counts?

I’m taking into consideration their counts before I make a treatment recommendation; if the patient is already super anemic, then I probably don't want to start ruxolitinib. If they're already very thrombocytopenic, then I might want to think about pacritinib. And then, if they're already very anemic, maybe momelotinib is the drug for them. Lastly, if we have several treatment options available, we also consider possible side effects. I also talk to you about organ function and drug interactions. I might pick a drug with less interactions if all options are available to us.

Sarah Profitt

Yeah, absolutely. There's a lot to take into consideration before we even start someone on a treatment.

Kathryn E. Kennedy

There's a lot of discussion, education, and shared decision-making that goes on behind the scenes. Then as we begin treatment, there are potential hematologic toxicities to watch for. There’s certainly prescribing information that guides your practice here, but we’re also looking at other things, like, is patient feeling better? Should we push this just a little bit longer, despite the hematologic toxicities, and watch them because they're feeling so much better? Maybe their counts are going to come up after a week of treatment. There's a lot of art and science behind that decision.

Sarah Profitt

Financial toxicity is another aspect we try to take into account when making therapy choices. In our clinic, we're grateful to have a specialty pharmacy that includes a group of pharmacists and technicians who help us get these patients the medications they need. Their role is very instrumental. When we know someone needs to start a treatment, we involve the specialty pharmacy to do a benefits investigation. They figure out if a specific medication requires a prior authorization and what type of copay is involved. The specialty pharmacy team is also great about finding grants to help patients with copays if they qualify for that, or financial assistance programs, either from independent companies or drug manufacturers. These new targeted agents are expensive, and I know it's a big consideration for you as the provider as you talk with patients about going on oral chemotherapy.

Kathryn E. Kennedy

Yes, I am so grateful to our specialty pharmacy colleagues. We’re very fortunate to work in an academic medical institution with all of these resources that can help provide improved care for our patients. But what about APPs in community practices who might not have access to the same resources? What would your recommendation be for them?

Sarah Profitt

That's a great question. A lot of our patients are being treated in the community. There may be a pharmacist available in those settings, maybe from the retail side or the specialty side, or perhaps from the clinical side as well. But I know a lot of community practices don't have those resources. One thing I have found really helpful, in my practice as an oncology pharmacist, is using the resources provided by drug companies. Our medical science liaisons (MSLs) from industry have been incredibly helpful when we've had really unique questions or specific questions that require a piece of data that we just can't find in the literature. I would encourage community providers and community APPs to know who your MSL is for these products and have a good relationship with them. They are really helpful resources. Also, the package labeling itself gives a lot of guidance in terms dose adjustments for toxicities.

Kathryn E. Kennedy

I will also often go to UpToDate, which has information pulled directly from the package labeling. I find it easier to digest. NCCN Guidelines have been helpful for me as well. It’s also important to remember that referral to a tertiary center is an option. At our academic institution, we often work very closely with our community providers, and then those patients can have the benefits of an embedded pharmacist or specialized team. They can have all of the things that we offer at an academic medical institution behind them while still receiving care in the community locally.

Sarah Profitt

Yeah, absolutely. A lot of collaboration goes on between community and academic centers. 

Kathryn E. Kennedy

One of the other things I come to you, as the pharmacist, with all the time is, when can I expect to see a response? Myelofibrosis treatments are not like leukemia treatments, where a patient can start a drug and overnight see their white count drop; it can take some time. Where can community APPs look for that information?

Sarah Profitt

Knowing what to expect in terms of response is definitely helpful for you in terms of monitoring. When am I going to see this patient back? When am I going to schedule them for labs? It’s also helpful for setting shared expectations with the patient. The patient needs to be empowered with that information when they start treatment or when they switch treatments. I typically go to the clinical trial supporting the medication’s approval. Sometimes the clinical trials are very upfront, and they say the time to response was “X”. Other times it requires a little bit more digging. If it's not immediately obvious, I’ll look at how was the trial conducted and see when the investigators assessed response. We typically see that in the clinical trial publication, but you can often get to it through the supplemental appendix or the protocol itself, which are often available online. I look at when in the trial disease was assessed, and that helps us get an idea of when we expect the drug to start working.

Kathryn E. Kennedy

Communicating with the patient in terms of time to response is very important when starting a new medication because they will get so disappointed when they come in 2 weeks later and their platelets are still 30.

Sarah Profitt

Yes, it’s all about setting expectations.

Kathryn E. Kennedy

So let's say you're a community practice provider, and you don't know the name of the trial. How do you find the information you need?

Sarah Profitt

You can find specific trial information in a couple of ways. NCCN Guidelines are really great for this. Whenever you look up NCCN recommendations, it will have cited references, which can direct you to the clinical trial. And often a drug manufacturer's website also has cited references.

Kathryn E. Kennedy

Thanks for making the time to talk about the pharmacist’s role today, Sarah.

Sarah Profitt

My pleasure, Kate. I look forward to our next chat.