Homecare for Bortezomib Safe and Reduces Hospital Visits in Myeloma Patients

Becky McCall

November 11, 2020

Home administration of bortezomib (Velcade), as a once or twice-weekly subcutaneous self-injection is safe in patients with myeloma, significantly reducing hospital visits, and likely improving quality of life, a study shows.

The majority (43 of 52 patients) successfully self-administered bortezomib and completed the course. Also, hospital visits for those on the so-called Homecare programme reduced by 50%, with most visits comprising a fortnightly drug pick up from the drive-through pharmacy.

The work was presented as a poster by lead author, Kanchana De Abrew, a haematology registrar at University Hospital Southampton NHS Foundation Trust at this year’s virtual British Society of Haematology (BSH) meeting. De Abrew conducted the study while at Queen Alexandra Hospital, Portsmouth.

"We wanted to minimise patient visits to hospital because with travel time and waiting time, patients can easily find a visit takes up a whole morning, so this relates to their quality of life as well as having financial implications for patients”, De Abrew told Medscape News UK in an interview. It also reduced the impact on day units and improved capacity for other services.

Dr De Abrew noted that the study was conducted in the pre-COVID-19 era, but that the current enhanced threat of infection only served to reinforce the benefits of self-administration at home and avoiding unnecessary hospital visits.

"This project could easily be set up in other hospitals and some other centres have already contacted us about this. It might suit rural areas," she added.

'Safe and Effective'

Dr Matthew Jenner, consultant haematologist for University Hospital Southampton NHS Foundation Trust, who was not involved in the study, remarked that the study demonstrated another way to deliver bortezomib outside of hospital in addition to home care services that require trained nurses to administer treatment. "With a modest amount of training of the patient and family, it is both a safe and effective way of delivering treatment. This reduces hospital visits for the patient and frees up much needed capacity for heavily stretched chemotherapy units, creating space for other newer treatments that require hospital attendance.

“It is of benefit all round to both the patients undertaking self-administration and those who benefit from improved capacity,” added Dr Jenner.

Avoiding Hospital Visits

Myeloma patients are already immunosuppressed prior to treatment and then this worsens once on treatment. Once they are sitting in a clinic environment they are surrounded by similarly immunosuppressed patients, so their risk is heightened further.

Figures suggest myeloma cases are on the increase. Annually, the UK sees around 5800 new cases of myeloma and incidence increased by a significant 32% between 1993-1995 and 2015-2017. These figures were reflected in the patient numbers at the Queen Alexandra Hospital where the study was carried out. Many patients receive bortezomib, which forms the backbone of four National Institute for Health and Care Excellence (NICE) approved regimens.

“Patients are living longer so in the early 2000s patients had a life expectancy of 2 to 3 years, whereas now patients live for around 5 years. Also, the scope and lines of treatments have increased a lot. Over 50% of patients are likely to have bortezomib at some point in their management,” explained De Abrew.

Bortezomib is given once or twice-weekly as a subcutaneous injection, and this usually continues for approximately 6 to 8 months with four to six cycles. Administering the drug in hospital requires around a half-hour slot placing considerable burden on the Haematology Day Unit resources, and this can adversely affect the patient experience with waiting times and the need for frequent hospital visits.

Patient or Relatives Taught to Self-administer at Home

In 2017, clinical nurse specialists taught suitable patients to self-administer bortezomib in the Homecare protocol. Patients collected a 2 week supply of the drug. The protocol aimed to improve patient quality of life by reducing hospital visits, and increasing capacity in the Haematology Day Unit. Since the start of the programme in 2017, the majority (71) of myeloma patients at Portsmouth have been treated through the homecare programme.

Dr De Abrew conducted a retrospective review of patients who received bortezomib between January and October 2019 aimed at determining the effectiveness of the Homecare programme. To this end, she measured the proportion able to commence the Homecare protocol; the proportion successful in completing treatment on the Homecare protocol; the amount of additional clinical nurse specialist time required to support the Homecare protocol; and the number of associated adverse incidents.

A total of 52 bortezomib-treated patients were included in the study. Patients were only excluded if they were on a different combination of drugs that required hospital visits, or inpatient care for other reasons. Three patients ceased the drug - two due to toxicity, and one due to rapid progression.  The average age of patients was 74 years, and 55.8% were using bortezomib as first-line, 36.5% second-line and the remainder third-line or more.

The vast majority started the Homecare protocol (45/52), and 25 self-administered and 17 received a relative’s help. A total of 43 completed the self-administration protocol with two reverting to hospital assistance. Bortezomib was given for four to six cycles lasting around 6 to 8 months.

Clinical nurse specialists trained 38 patients for homecare, with an average training time of 43 minutes. Two of these patients were considered unsuitable for self-administration. The remainder were trained by ward nurses or did not require training having received bortezomib previously.

A total of 20 patients required additional clinical nurse specialist time requiring an average of 55 minutes. Of those requiring additional support: seven needed re-training; two needed the first dose delivered by a nurse specialist; two requested help from the haematology unit; and nine wanted general extra support, for example, help with injection site queries (usually administered to the abdominal area), reassurance during administration, syringe queries, administrative queries, and queries around spillages.

"Importantly, patients always have the phone number of the nurse specialist at hand. But most people managed okay, and even if they needed additional support they still got there,” remarked De Abrew.

In terms of adverse events, there were six in total. These included three reported spillages (with no harm caused), and three experienced injection site incidents (rash, pain). “We found a low number of reported adverse events," she said.

Dr De Abrew added that generally, many more medications were being converted to subcutaneous formulations in myeloma and other haematology conditions. "Perhaps these results could inform self-administration of other drugs. In haematology, we get so many new drugs come through every year, but we don’t get the increased resources to manage this in the day units. Broadening self-administration could really help with capacity as well as improve quality of life for the patients."

"These results show that it can be done!" she said. 

COI: Dr De Abrew declares no relevant conflicts of interest. Dr Jenner declares receiving honoraria from Janssen who manufacture branded Velcade (bortezomib).

British Society of Haematology (BSH) 2020. Presented as a poster. Abstract number PO-12.

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