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Adherence to Oral Oncolytics

Peter L. Salgo, MD; Steven L. D’Amato, RPh, BSPharm; Noa Biran, MD; Arturo Loaiza-Bonilla, MD, MSEd, FACP; and Carl T. Henningson, MD, outline the factors that affect adherence to oral oncolytics.
Published Online: Jan 30,2018

Peter L. Salgo, MD: Is that the major factor affecting adherence or are there other factors?

Steven L. D’Amato, RPh, BSPharm: There’s many factors that play into patient adherence. Certainly, when we look at a patient, there are a lot of medications now. What’s their cognitive ability to manage all of those medications? And if they don’t have the cognitive ability, do they have a support system in place, in their family, that can help keep them on track? We talk about the financial toxicity and patients being able to have access. We also look at other ways to help patients with adherence. It could be through frequent phone calls by our staff to patients, for example. The staff talks to them about their therapy and makes sure that they’re on track. There’s smart caps with some dispensing systems now. We have smartphone apps that will help patients with adherence and reminders. There’s a lot of technology developing that will help manage our patients in the adherence world.

Peter L. Salgo, MD: In regard to smart caps, I’m assuming you mean the cap on a bottle, which tells you that it’s been opened?

Steven L. D’Amato, RPh, BSPharm: It also can remind the patient when to take the medication.

Peter L. Salgo, MD: That’s mechanical. What about other stuff? In other words, patients feel bad when they take these drugs. They just stop taking them?

Noa Biran, MD: Oh yes, all the time.

Peter L. Salgo, MD: You say that with such abandon. “Oh yes, all the time!”

Noa Biran, MD: Yes. Patients are supposed to be on the pill for 21 days. After the first week, they’ll feel nauseated and just say, “I’m not going to take the rest.” They come in to the office and we notice that the disease doesn’t respond to therapy. Then we wonder why.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Yes. And they tell you, “I had to be on this. I only took it for about 5 days. I felt like crap and I didn’t want to call you.”

Peter L. Salgo, MD: They didn’t want to bother you?

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Yes.

Steven L. D’Amato, RPh, BSPharm: Then you reduce the dose and the specialty pharmacy sends the patient 90 days of the old dose, which ends up getting thrown out and wasted.

Noa Biran, MD: Right. Exactly.

Carl T. Henningson, MD: Sometimes the patients don’t tell you they’re not taking it.

Steven L. D’Amato, RPh, BSPharm: They don’t like to tell you that they’re having toxicity.

Carl T. Henningson, MD: There’s actually a study where they had some kind of monitor on the cap. For the patients in the trial, they looked at how compliant they were. And what they would do is they would miss doses here and there. And then, right before the doctor’s visit, they would remove like 10 pills to please the doctor, to let the doctor know that they were compliant.

Peter L. Salgo, MD: For a moment, I was really worried that they would take 10 extra pills.

Carl T. Henningson, MD: No. They wouldn’t take them. They would just throw them out.

Noa Biran, MD: They would remove them.

Steven L. D’Amato, RPh, BSPharm: The newest technology is to put the monitor right into the tablet. So, if the tablet is taken, it sends out an electronic…

Noa Biran, MD: Wow. I have not heard of that.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Didn’t they just approve one?

Peter L. Salgo, MD: They just approved it. I saw that in the newspaper. And now people are worrying about privacy. “You’re monitoring my gastrointestinal tract electronically.”

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Put a GPS on it.

Peter L. Salgo, MD: People are worried about them.

Noa Biran, MD: And then, you have some people that take extra pills.

Peter L. Salgo, MD: Wait, they take extra pills?

Noa Biran, MD: Yes. So, if you’re supposed to take the pill for 3 weeks in a row, they’ll take it, the extra, on the fourth week. Instead of 3 weeks in a row, they take it for 4 weeks in a row. The blood counts go down. It’s very dangerous. So, you have people who are taking more, and people who are taking less.

Carl T. Henningson, MD: Or they miss a pill. Then they double up for the next dose.