Collaborative Physician-Pharmacist Managed Multiple Myeloma Clinic Decreases Polypharmacy, Improves Guideline Adherence, and Prevents Treatment Delays
Authors: Sweiss Karen , Calip Gregory Sampang , Wirth Scott , Rondelli Damiano , Patel Pritesh 
Published: October 2019

Abstract
Multiple myeloma is a complex disease requiring adherence to treatment and supportive care guidelines, patient education, medication management, and timely delivery of anti-myeloma drugs to achieve optimal patient care. Clinical pharmacists play an important role in the management of cancer patients and could potentially assist in several aspects of care. We hypothesized that a multidisciplinary collaborative physician-pharmacist multiple myeloma (MM) clinic would reduce polypharmacy, improve adherence to MM guidelines as well as reduce delays in receiving oral anti-myeloma therapy.
Under the collaborative model, an oncology pharmacist provided consultation on all patients in a specialist myeloma clinic. This included reviewing medications, providing medications lists. ensuring physician adherence to supportive care guidelines, managing treatment-related side effects and navigating issues involving access to oral specialty medications. Outcome measures were compared to those of patients being treated by the same physician during the previous year, where ad-hoc pharmacist consultation was available (traditional clinic).
The collaborative clinic led to significant improvements in adherence to supportive medications such as bisphosphonates (96% vs. 68%, p=0.0002), calcium and vitamin D (100% vs. 41%, p<0.001), acyclovir (100% vs. 58%, p=0.0009), and Pneumocystis jirovecii pneumonia (PJP) prophylaxis (100% vs. 50%, p<0.0001). Appropriate VTE prophylaxis in immunomodulatory agent (IMiD)-treated patients was prescribed in 100% vs. 83% of patients (p=0.0035). The median time to initiation of bisphosphonate (5.5 vs. 97.5 days, p<0.001) and PJP prophylaxis (11 vs. 40.5 days, p<0.0001) after autologous transplant was shortened in the collaborative clinic. Furthermore, the number (85% vs. 21%, p<0.0001) and duration (7 days vs. 15 days, p=0.002) of delays in obtaining IMiD therapy, was also significantly reduced.
We also observed improved medication management in patients treated in the collaborative clinic. These patients took fewer medications on average (9 vs. 7, p=0.045). Although the median number of myeloma-related medications (medications related to treatment or supportive care for MM) was higher (2 vs. 4, p<0.0001), the number of non-myeloma-related medications was lower (7 vs. 3, p<0.0001) in patients seen in the collaborative clinic. We then compared minor (5 to 9 medications) and major (≥10 medications) polypharmacy overall and specific to non-myeloma-related medications between the two clinics. Any type of polypharmacy (≥5 medications) was highly prevalent among patients in both the traditional and collaborative clinics (93% and 84% respectively, p=0.22). Despite this, the collaborative clinic was successful in reducing any type of polypharmacy (71 vs. 33%, p=0.0003), including both minor (48 vs. 28%, p=0.06) and major (23 vs. 5%, p=0.02) polypharmacy of non-myeloma-related medications. We used modified Poisson regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) with adjustment for age, gender, race, ISS stage, protein subtype, new diagnosis, prior or current IMiD, PI or ASCT, and total number of prior treatments. We found significantly reduced risk of having a higher number of medications among patients in the collaborative clinic (RR 0.79, 95% CI 0.67-0.93; p=0.004). Risk of major polypharmacy in all medications was not significantly different between the two clinics (RR 0.67, 95% CI 0.35-1.28; p=0.226); although, there was a significantly lower risk of having any polypharmacy of non-myeloma-related medications (RR 0.41, 95% CI 0.25-0.67; p<0.001) in the collaborative clinic.
Here we show that incorporating another sub-specialized individual such as a clinical pharmacist into the care of multiple myeloma patients resulted in increased adherence to core supportive care measures and a reduction in delays in acquiring oral IMiDs. Importantly, although we illustrate a high incidence of polypharmacy among patients in both clinics, consultation by a pharmacist led to a significant reduction in the number of non-myeloma-related medications. The collaborative model may be of benefit in the management of other complex malignant diseases and further studies in other cancer clinics are warranted. Impact on long term clinical outcomes will also highlight the potential benefits of this collaborative model of patient care.

Disclosures
Patel: Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria.