Designing Best Practices to Better Manage Patients on Oral Cancer Medications

Positive quality interventions (PQIs) are part of a nationwide effort to standardize and improve oncology dispensing practices. They are best practices that are meant to be highly specific to a drug and help pharmacies and clinicians ensure that a patient-centric model exists, explained speakers during a workshop at the National Community Oncology Dispensing Association (NCODA) Spring Forum 2018, held March 1-3 in Dallas, Texas.

NCODA’s PQIs are designed by clinical pharmacists to improve overall management of patient’s receiving oral cancer medications. With the first PQI created in 2014, NCODA currently has 11 with more coming, explained Neal Dave, PharmD, of Texas Oncology. Dave has designed PQIs for management of the adverse effects of regorafenib in metastatic colorectal cancer and managing the treatment of polycythemia vera. There is a PQI for almost every drug, he added.

Julianne Orr, PharmD, of Indiana University Health Simon Cancer Center, had written NCODA’s PQI for olanzapine use in chemotherapy-induced nausea and vomiting (CINV), and walked through how a PQI is developed and the final PQI for olanzapine.

The PQI begins with what happens when there is an order for a moderately emetogenic chemotherapy or highly emetogenic chemotherapy. First, the pharmacist screens for appropriate antiemesis medications, and if olanzapine is not initially included, the PQI recommends considering the addition of 5 to 10 mg daily of olanzapine for the first 4 days of chemotherapy.

The PQI also includes when to consider a lower dose, such as for elderly or over-sedated patients, and emphasizes using caution when prescribing olanzapine with metoclopramide or haloperidol.

Finally, the PQI includes patient-centered activities that are recommended. In the cast of olanzapine, these include patient education—such as why patients should only take the drug during days 1 through 4 and what CINV is and medications prescribed to treat it—and encouraging patient compliance.

“These PQIs are really meant to be a combination of the guidelines and what’s indicated, and our clinical opinions and what we see in the real world,” Orr explained.

The workshop then used opioid-induced constipation as an example, with attendees brainstorming how they would create a PQI process. The PQI draft that had been created began with lifestyle consultation before a prescription drug is considered. These include a baseline assessment of the patient’s normal bowel habits, as well as understanding what other medications a patient is on, such as something that causes diarrhea.

Education is also important since it is not uncommon for patients to come in for a visit already suffering from fecal impaction. This can be prevented by informing the patient what foods to avoid that would constipate someone normally, as well as what they can eat or do, such as stay hydrated and move around, to help alleviate constipation.

If the patient continues to be constipated even after those consultations, then prescription medications should be considered to help alleviate the constipation.