Oral Chemotherapy Program at THP Dr. Katherine … Day/Documents/Oral...•Adherence Assessment •...
Transcript of Oral Chemotherapy Program at THP Dr. Katherine … Day/Documents/Oral...•Adherence Assessment •...
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Oral Chemotherapy Program at THP
Dr. Katherine Enright MD, MPH, FRCPC
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What is Oral Chemotherapy?
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Oral Chemotherapy is…
Classic Chemotherapy Drugs:• Capecitabine (Xeloda)• Hydroxyurea (Hydrea)• Melphalan• Chlorambucil
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…The evil we know
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Oral Chemotherapy is also…..Ibrutinib (Imbruvica)Palbociblib (Ibrance)
Imetelstat
Crizotinib (Xalkori)Sunitinib(Sutent)
Sorafenib (Nexavar)Regorafinib (Strivaga
Olaparib (Lynparza)
Gefitinib (Iressa)Erlotinib (Tarceva)Afinitib (Gilotref)
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Oral Chemotherapy is…Imatinib (Gleevec) in Chronic Myelogenous Leukemia
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Oral Chemotherapy is…- Ibrutinib in Chronic Lymphocytic Leukemia
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Oral Chemotherapy is…Gefitinib in EGFR + NSCLC
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Oral Chemotherapy is…Crizotinib in ALK + NSCLC
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Oral Chemotherapy is the future
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Oral vs. IV Chemotherapy
Parenteral (IV) Medications
Patient's role is passive
Patient is recipient of treatment
Provider dictate treatments
Provider monitors and manages side effects
Potential for non-adherence low (and self evident)
Provider responsible for procurement (storage, safe handling and disposal)
Oral Medications
Patient’s role is active
Patient self-administers the medications
Provider collaborates with patient about the treatment
Patient is actively involved in early symptom recognition and management
Potential for medication non-adherence is high
Patient is responsible for medication procurement (safehandling, storage, disposal)
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Oral Chemotherapy Delivery Process
Treatment Decision Prescribing Dispensing Medication
AdministrationPatient
Monitoring
Safe handling, patient education and incident reporting
Safe Labelling
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Partnering with the Patient
Improving patient education
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“The belief in one’s capability to organize and execute the courses of action required to manage positive situations”
Self – EfficacyAlbert Bandura (1986)
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Oral Chemotherapy Care Plans
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Partnering with Oncology Pharmacists
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Oral Chemotherapy Care Pathway Pilot
Cycle 1
Cycle 2
Cycle 3
RN
Pharmacist
•Education•Care Plan Review
•“Teach Back”•Toxicity Assessment•Adherence Assessment
•Rx verification•Drug-drug interactions•Counselling
•“Teach Back”•Toxicity Assessment•Adherence Assessment
• Pilot: March 2, 2015 – May 30, 2015
• Who: 2 Physician/RN Teams at CVH Site (GI/Breast/Lung/GU) (N = 20)
• Inclusion : All new starts on oral chemotherapy (Hormones excluded)
• Pilot Team: Oral Chemotherapy Pharmacist & Nurse Practitioner
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Oral Chemotherapy Care Pathway Pilot
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Dose Modification for toxicity
Drug Discontinuation
CPOE Prescriptions
Pharmacy Interventions
Adherence Assessment
MOATT Assessment
Pilot Baseline
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Oral Chemotherapy Care Pathway Pilot
3 3
4
0
2
4
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Discontinuation Dose Delay Dose reduction
Baseline Pilot
Type of Dose Modification due to Toxicity
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Partnering with Retail Pharmacy
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Oral Chemotherapy Pharmacist
• Specialty knowledge of oncology• Access to drug
• Community pharmacy may not have in stock (delay in treatment)
• Access to necessary information to double check the Rx
• (blood work, other tests, history, intention, course of treatment, etc.)
• Ease of access to the prescriber
• Drug-Drug Interactions• CYP P450 system
• Drug-Food interactions• Patient Monitoring • Cost
• Out of pocket, 3rd party, special funding programs, ODB access
• Adherence
Advantage over community pharmacist
Main Focus of Oncology Pharmacist
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Pharmacy Pilot – CVH Site
Critical Interventions
(4)
Interventions requiring a
change to Rx (78)
Potential Drug
interactions (126)
Herbal/CAM interventions
(116)
Adherence Interventions
(33)
Problem: Identified patient not taking anticoagulant as previously prescribed before starting agent with pro-thrombotic potential
Intervention: Patient educated as per risk, started both
Problem: Irbesartan / enzalutamide interaction
Intervention: PCP contacted to change irbesartan to olmesartan
Problem: Dose not adjusted for decreased CrCl.
Intervention: Dose adjusted
Problem: Patient on combination regimen confused drug schedules
Intervention: Dose Calendar provided
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Next Steps for Oral Chemotherapy
- Partnering with Patients• Pilot of various tools to enhance self efficacy underway (Q-site hematology group)• Care plan usability review with PFAC planned
- Partnering with Pharmacy• Sustainability plan to integrate oncology pharmacy at CVH site and expand across THP in
development
- Partnering with Primary Care Physicians ?• Communication of Care Plans to PCP• Toxicity management• Enhance care coordination / communication