Reimbursement of Subcutaneous Versus IV Dosing in Multiple Myeloma

Ola Landgren, MD, PhD: I had 1 question I wanted to bring up. When it comes to the use of all the antibodies, daratumumab we already mentioned, daratumumab is probably becoming subcutaneous, too.

John Fox, MD, MHA: Sure.

Ola Landgren, MD, PhD: …There are a lot of other antibodies in development. Some of them also probably heading towards that. From the payer perspective, what do you think about subQ [subcutaneous] versus IV [intravenous] dosing? Are they an important prospect?

John Fox, MD, MHA: No, not really. …There’s got to be a reduced cost because you’re not in an infusion chair. But I don’t anticipate the cost of the drug is going to be any different. The benefits will accrue to the patient. They’re both still administered by a physician so the patient cost sharing should be very similar. As we said, pure infusion reactions, less chair time—who would argue with that?

Ola Landgren, MD, PhD: Right. Do you have any other perspectives on that?

Sundar Jagannath, MD: No. Especially for elderly patients this is a dramatic improvement because the infusion-related reactions are down. For the younger patients, obviously, they are productive, they spend their day at office, or whatever. Coming to get a subQ in 10 minutes and going back to work is good.

Ola Landgren, MD, PhD: Yeah.

John Fox, MD, MHA: Here’s a real question for you. If this is safer, easier, and faster, could we do this in the home?

Ola Landgren, MD, PhD: Patients are already asking about it.

John Fox, MD, MHA: Yeah. I’m from Michigan, and if you have to travel 70 miles to get your infusion for a 5-minute subQ injection, can I do that at home? Is it safe enough in the future that we could do that under strict guidelines?

Sundar Jagannath, MD: There are many drugs once you have gone through the threshold. …For immuno-oncology antibodies, typically the first 2 infusions you have to monitor closely, and if they didn’t have any infusion reaction, subsequent infusions have been without any infusion reaction. …We have actually been able to reduce steroids. Because there are a lot of steroids in the early phase of it, we’ve been able to reduce steroids aggressively for this patient. So that would be correct. In that case, there are some other subQ like bortezomib, etcetera. They never really took off as a home administration as far as I could tell. I do not know how it develops in this fashion.

John Fox, MD, MHA: Yeah. But bortezomib is a weekly subQ infusion for injections, right? Yeah.

Ola Landgren, MD, PhD: But I think it’s a very important question you are addressing. I think there are obviously multiple aspects here both in medical and probably liability and other things—if things go wrong, who’s responsible, and things like that.

John Fox, MD, MHA: ...We get a lot of drugs in the home today, including monoclonal antibodies. Remicade, or infliximab, is an example, If I've got a patient on DRd [daratumumab, lenalidomide, and dexamethasone]—the lenalidomide, or Revlimid, is oral and the dexamethasone is oral, too—why do I need to come into the physician's office? But if we could leverage the simplicity of that subQ injection, why wouldn't we take it a step further?

Ola Landgren, MD, PhD: I think it’s a great idea. I like it a lot. I mentioned to you that the mass spectrometry technology where you can screen 100 mL of serum in 10 seconds, and figure out if there is MRD [minimal residual disease] or not, why couldn’t samples be collected and shipped to the labs, or things like that in the future?

John Fox, MD, MHA: In the home.

Ola Landgren, MD, PhD: Maybe that could even be the device that you could check at home, we don’t know that, such as a pregnancy test or so. So, the future is kind of exciting.