Myeloma Patients Could Self-administer Bortezomib at Home

Liam Davenport

April 02, 2019

GLASGOW — Patients with multiple myeloma are able to self-administer the proteasome inhibitor bortezomib (Velcade, Takedo Oncology) at home via subcutaneous injections, potentially improving quality of life and reducing healthcare resource utilisation, argue UK researchers.

Tanya Burton, a myeloma clinical nurse specialist at the University Hospital of Wales, Cardiff, and colleagues devised a plan for self-administration of the drug after seeing how much time their patients spent waiting at their clinic for a simple injection.

Working with the pharmacy department to establish the safety of the drug for taking home, and developing a care plan with physicians and the nursing team, they instructed patients on how to self-inject and deal safely with the equipment.

Early Benefits

Tanya Burton told an audience at the British Society for Haematology (BSH) Annual Scientific Meeting in Glasgow that their pilot project, which is still in its early stages, has already shown benefits for patients.

She said: "There’s a lot of lip service sometimes on the impact of quality of life but this really helps quality of life for the patients.

"It means they have less hospital visits and they feel that it’s something that they’re in control of. The experience is well tolerated, and they are enjoying it."

For the hospital, there are also benefits, in that "we are able to deliver key therapy closer to the home".

Burton continued: "Of course, nursing time is also money, so we’re saving there."

'Fantastic Idea'

Gordon Cook, professor of haematology at the University of Leeds, who co-chaired the session, commented: "It’s a really fantastic idea, and congratulations on bringing that to clinical practice".

Following her presentation, Prof Cook asked Burton what proportion of patients she thought would be able to move over to home self-administration, as there are patients in his clinic who "will never get anywhere near this, but there’s a lot of them who probably could".

She said that's not possible to say, as it’s a case of talking with patients and seeing how they respond.

Speaking to Medscape News UK, Burton said that, although the numbers of patients who have taken up home self-administration have so far been small, she and her colleagues are working with their pharmacy department to extend the approved stability time for the drug from the current 7 days to 28 days.

This will allow them to offer the option of self-administration to almost all the patients in their clinic currently treated with bortezomib, as they will be able to take home a month’s worth of treatments.

This, they hope, will have a significant impact not only on patients but also resource utilisation.

Common Haematological Cancer

Tanya Burton began her presentation by pointing out that myeloma is the second most common haematological cancer.

Moreover, improvements in management mean that 47% of patients survive at least 5 years after diagnosis, and 33% survive for more than 10 years.

The disease remains incurable, however, meaning that patients require ongoing treatment.    

In 2011, the National Institute for Health and Care Excellence (NICE) recommended bortezomib, combined with an alkylating agent and a corticosteroid, as an option for the first-line treatment of multiple myeloma.

This followed guidance in 2007 recommending the drug on its own as an option for progressive multiple myeloma patients at first relapse after one prior therapy.

In 2011, Prof Philippe Moreau and colleagues published data showing that giving bortezomib subcutaneously is not only non-inferior to standard intravenous administration in terms of efficacy but also had an improved safety profile.

Armed with this information, Burton and colleagues, who give bortezomib subcutaneously, initially looked at current practice in their clinic.

They found that patients spent an average of 2 hours waiting for a treatment that took only a few minutes to administer.

This was because bortezomib was seen as a "non-urgent" treatment that could be "fitted around" other appointments. 

The consequence was that patients were concerned over the amount of time they were spending waiting for a simple treatment, which left them feeling "less important" than other patients.

To address this, the team decided to explore whether they could help patients to be able to self-administer bortezomib at home.

Home Self-administration

They initially worked with the pharmacy department to determine the stability of the drug, agreeing that it could be considered stable for 7 days and therefore be taken home by patients for a week at a time.

Next, they wrote a step-by-step guide for patients and trained staff to empower them to teach and educate patients about self-administration.

They then addressed safety in the home, teaching patients about the safe handling of the drug and giving them a disposal unit for the needles.

The clinic already had a remote monitoring programme in live-in nurse assessments and 24-hour telephone access, the availability of which was reinforced to patients.

Finally, it was agreed that, in conjunction with the patient, the consultant and clinical nurse specialist would make the decision as to whether to proceed with home self-administration.

In practice, this means that, following the discussion over whether to proceed, the patient is assessed and then given the first cycle of treatment in the haematology day unit.

Blood tests are performed up to 7 days prior to the first dose, with repeat tests performed on day 8 post treatment.

Burton emphasised, however, that there is no need to wait for the results before proceeding if the first test was satisfactory.

Subsequent doses are then given in the clinic, but self-administered by the patient under supervision so that they can be assessed by the clinical nurse specialist, with the nurse checklist gone through every time.

Once the patient and clinical staff are satisfied, the patient is given the drug to take home, alongside further information and a checklist similar to that used by the nurses.

On the day of planned self-administration at home, the patient is followed up via telephone by the clinical nurse specialist.

In the post-presentation discussion, Burton was asked whether she had any issues over getting approval for home administration, given that this is typically not allowed for chemotherapy.

She replied that, as bortezomib is a proteasome inhibitor, "it’s not technically a chemotherapy, so you can argue that it’s not a chemotherapy" in terms of patients being allowed to take it away with them.

No funding or conflicts of interest declared.

Cook declares grant/research support from Celgene, Janssen, Takeda; honoraria from Amgen, Bristol-Myers Squibb, GlycoMimetics, Celgene, Janssen, Takeda, Sanofi.

BSH 2019: Abstract BSH19-OR-016. Presented April 2.

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