BTK inhibitors, a class of oral targeted therapies, are increasingly being considered as treatments for multiple B cell malignancies. Many of these therapies are prescribed to be taken outside of a hospital or infusion center and require coordination of care and safety monitoring and communication with the oncologist’s office for the patient and their family as well as the community-based health care professionals.
Care coordination among hematologists, oncologists, primary care providers, pharmacists, and other healthcare professionals is important for effective management of patients with B-cell malignancies receiving BTK inhibitor therapy. Patients and their caregivers must have a clear understanding of their respective roles and responsibilities and know when to contact the healthcare team.
Establishing Clear Communication Between Care Teams
There are many healthcare providers involved in a patient’s care. There is a specialist team treating the patient’s cancer. There might be the patient’s primary care providers who are treating the patient for hypertension, diabetes, cardiovascular disease or other chronic conditions.
Relevant information such as name of the BTK inhibitor, dose, reason for prescribing that particular BTK inhibitor, previous therapies, relevant lab results, comorbidities and other medications need to be communicated to the healthcare team.
Primary care professionals need to know when there are changes in the health of their patients and the oncology team need to know when new medicines, a new acute illness or a new procedure is to be considered for their patients.
Medication Reconciliation and Drug Interactions
Interactions with other medicines can occur through the cytochrome P450 enzymes. Each of the BTK inhibitors has a unique interaction profile, therefore the product information for the individual BTK inhibitor should be checked by the community pharmacist or primary care healthcare professional before prescribing or recommending any other medicines for the patient’s condition.
It is advisable for the patients to have a complete list of all their medications, including prescription, non-prescription, vitamins, herbal or dietary supplements. A copy of this list needs to be given to the healthcare provider before any new medication is prescribed.
Healthcare providers must be aware of potential drug interactions before prescribing additional medications to patients taking BTK inhibitor treatment. Although most prescribed medications are expected to have minimal interaction with BTK inhibitors, all interactions need to be checked prior to prescribing or recommending any additional medications to patients on BTK inhibitor treatment.
Monitoring Laboratory Values
It is possible that even when specialists are monitoring patients with CLL, there are abnormal values that can be picked up by community-based health care professionals such as primary care physicians, nurses and pharmacists whilst they are delivering care to patients with a variety of health problems.
The monitoring of parameters such as complete blood counts (full blood counts) for most BTK inhibitors is required as there is a risk of developing cytopenias (such as neutropenia, anemia and thrombocytopenia). Some medicines require monitoring of other parameters (such as liver function tests) for individual medicines or clinical situations.
When abnormal results are found, it is very important that the treating hematologist or oncologist is contacted to assess the findings and to determine if the abnormal results are related to the treatment, an infection, disease progression or another medical problem.
The patient needs to be informed of the reasons for having the blood test and the implications of the results in relation to their treatment.
Recognizing Infection Early
Patients with CLL and other B-cell malignancies have compromised immunity due to their malignancy and/or treatment. Therefore, early recognition and management of infection is crucial.
A patient with CLL, or treated for B-cell malignancies, can develop an infection. They may have a fever or chills, cough or shortness of breath. If the patient is experiencing any of these symptoms they should contact their healthcare provider. Individual patient circumstances must be taken into consideration and vaccinations given on an individual basis. In most cases these will be given by community health care professionals and need to be coordinated with the patient’s treating oncology team.
Bleeding and Cardiovascular Monitoring
Any unusual bruising or bleeding such as bleeding from cuts taking longer than usual to stop, blood in urine or stools, etc must be reported. Patients on BTK inhibitor treatment need to be reminded of the potential for increased risk of bleeding, while on treatment, particularly if on anticoagulants or antiplatelets as well.
Medications including some medicines for heart conditions and some pain medications can increase the risk of bleeding. These include anticoagulants (e.g. warfarin) and antiplatelets (e.g. aspirin) medicines. Patients and their family/caregivers must inform the healthcare team of any changes to their medicines.
Patients with a history of cardiac disease or those with risk factors for cardiac disease need to be monitored for cardiac arrhythmias including but not limited to atrial fibrillation/atrial flutter, while on BTK inhibitor therapy.
BTK inhibitors can cause cardiac arrhythmias such as atrial fibrillation and atrial flutter. Patients with existing heart disease or with risk factors for heart disease should report any of the following symptoms to their doctor immediately. These symptoms might occur suddenly and would otherwise be attributed to cancer or its treatment. Palpitations, dizziness, fainting, shortness of breath and chest discomfort are examples.
Supporting Adherence to Oral Therapy
Adherence to cancer treatment is the patient’s and their caregiver’s responsibility. Often this treatment consists of oral medication, which is given on an outpatient basis. This is in contrast to infused cancer treatment, which is given in a hospital setting.
Community-based health care, especially by pharmacists and nurses, is crucial to check whether patients have the necessary knowledge of oral cancer drugs. For example, do they know how often they have to take their medication, what to do if a dose is missed and how to store the medication. Community-based health care personnel can also check if there are any problems with regards to the prescription of the oral cancer drug and other problems with treatment that patients or their caregivers might experience.
Patients and their family/caregivers should contact the patients’ treating healthcare team for further evaluations and possible interventions if patients experience any adverse drug reactions.
Coordinating Around Procedures and Acute Illness
It is also important to note that for dental treatment, and other invasive procedures (e.g. surgery), patients on BTK inhibitors may need to be evaluated by the healthcare team before starting the procedure. This might be medicine specific, procedure specific or patient specific, and must be in line with the prescribing information for that specific medicine.
Management of patients on BTK inhibitors for dental procedures and for surgeries is highly variable and must be based on the latest information from prescribing information for individual medicines. An acute illness or hospitalization may require a review of the patient’s cancer treatment. A list of the patient’s current medications, as well as relevant laboratory results, should be reviewed by the treating healthcare team.
Patient and Caregiver Education
Patients and their caregivers may benefit from understanding the purpose of the treatment and maintaining up-to-date information about the medications being used.
The role of caregivers in patients’ treatment is very important. Patients’ caregivers remind them of taking their oral cancer medication, accompany them to all their medical appointments, follow up on the required laboratory tests, and report any changes in their patients’ symptoms. It is also very important for the patients and their caregivers to have written information about the patients’ cancer treatment and the oral targeted therapy medications that they are taking. The patients and their caregivers should also have an updated list of the patients’ medications. This written information and the patients updated lists of medications will enable the patients and their caregivers to know what to tell the various healthcare providers that are involved in the patients’ cancer care.
A Multidisciplinary Approach to Community-Based Care
Improving the care of patients with cancer who are on BTK inhibitor drugs for long periods of time requires a collaborative approach and can involve multiple health care professionals, for example the patient’s primary care physician and other health care professionals as deemed necessary.
Multiple health care professionals, i.e. hematologists, oncologists, primary care physicians, pharmacists, nurses etc., play a role in the care of a patient treated with oral BTK inhibitors. They may help identify any adverse effects of these oral BTK inhibitors early enough, reduce the risk of any unnecessary and potentially harmful medication errors, support the patients in taking their oral targeted cancer drugs correctly and report any changes in health of their patients to the appropriate cancer specialists.
Effective management of long term oral targeted cancer therapy requires clear communication, a process of medication reconciliation, monitoring lab results, early detection of problems, and proper education provided to patients and caregivers.
Medical Disclaimer: The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, clinical guidelines, or a recommendation for any specific treatment.
