Navigating Operational Challenges With Bispecifics in R/R MM: Insights From HOPA 2024

Pharmacy Times interviewed Kirollos Hanna, PharmD, BCPS, BCOP, FACCC, director of pharmacy, Minnesota Oncology and assistant professor of pharmacy, Mayo Clinic College of Medicine, on his presentation at the Hematology/Oncology Pharmacy Association (HOPA) Annual Conference 2024 in Tampa, Florida titled “Key Considerations for Operationalizing Bispecifics in Relapsed or Refractory Multiple Myeloma.”

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Pharmacy Times: What are some common challenges pharmacists may be experiencing in operationalizing bispecifics at their facilities, and do you have recommendations for overcoming these challenges?

Kirollos Hanna, PharmD, BCPS, BCOP, FACCC: Challenges that you'll see as we operationalize bispecifics, both pharmacy facing and health care system facing, is building external relationships to support patients. So, I think you'll see 3 different models of how bispecifics are initiated at institutions. You have a large institution—has experience with bispecifics; they have a process built out; the facility is ready. And these institutions initiate patients, whether in the hospital or the outpatient setting, they have monitoring already in place, and they follow that patient.

The second model is you might have a smaller system, or maybe a community practice, their barrier is developing a relationship with a local practice or a nearby practice that can help get patients started on therapy. You'll still need that practice to be ready, but then also your practice to be ready for maintenance because there's these 2 phases, right? The ramp up, where you have the high risk of these adverse events, so being able to work with that institution to establish care for that patient. But when it's time to bring that patient back to your own institution, what does that look like? Who is talking to whom? Are you just getting an [sic] or a progress note, and that's what you're relying on for how the patient did? Or is their provider to provider communication, pharmacist to pharmacist communication, whoever that's a member of the care team to really understand how did patient X do as they were ramped up? Did they develop any CRS [cytokine release syndrome], any ICANS [immune effector cell-associated neurotoxicity syndrome] were any supportive care measures required to help this patient, and then you can safely transition that patient to maybe like a community or a smaller practice.

The other side of it, and this is sort of a big barrier, if institutions are not interested or desire to be ready for bispecific administration, you're going to lose that patient ultimately, because that patient will either go to a large center that's equipped and stays there, or that patient might go to a large center that's equipped that ramps up the patient, and then another small center or another practice might take on that patient. So that is one barrier that I think institutions need to work through. Because we're all different systems. The budgets and the economics and the finance teams are all different of how we're paid for these drugs.

The other aspect that I would say is also a barrier for institutions that's going to be important to work through is if and when your patient reports an adverse event, what does it look like in terms of recommending them to go to the emergency room, especially if you're a small practice that's not affiliated with a hospital? Patient is calling me, they have a 101 [degree] fever, we have concern for a grade 2 CRS, for example, that they're having shortness of breath and other complications, which [emergency department] is going to be equipped to support this patient? They may need tocilizumab (Actemra; Genentech, Inc) in stock. Does that system have it? Do they have hematologists that are familiar with CRS and ICANS management because those are things that they do. So, these are things that I think people are going to see as barriers and they do have to develop these types of relationships.

So, I think in terms of recommendations, open communication between these systems [is important]. Like I said, these therapies are unavoidable and we're going to see a robust growth within the space across both hematology and solid cancers. So, as we continue to learn more and communicate system to system, I think you could develop good processes that safely allow patients to navigate through what health care already is—it's already extremely complex, but developing these relationships and these communication strategies will provide a good continuity of care for patients.