Originally published by our sister publication Pharmacy Practice News
By Gina Shaw
The vast majority of providers accept pharmacist-initiated recommendations to screen for hepatitis B virus in patients started on oral oncolytics, according to a new study presented at NASP 2024, in Nashville, Tenn.
These interventions led to a significant increase in the percentage of patients screened, which optimized patient safety before initiating treatment, reported Anthony Angyal, PharmD, a clinical oncology pharmacist for Cleveland Clinic Specialty Pharmacy (CCSP).
Ensuring optimal HBV screening is particularly important in the cancer setting, Dr. Angyal noted. “Patients with a history of HBV infection are at increased risk for HBV reactivation once initiated on immunosuppressive medication, such as oral anticancer therapy,” he explained.
Despite a number of leading health organizations, including the American Association for the Study of Liver Diseases, American Society of Clinical Oncology, CDC and National Comprehensive Cancer Network, recommending that all patients be screened for HBV before starting initiation of anticancer therapy, this screening is less likely to be completed in the oral oncolytic setting.
“When patients are started on intravenous therapies, particularly stronger immunosuppressive agents like rituximab, providers are more likely to complete this screening,” Dr. Angyal said. “But we observed that HBV screening was less common when oral oncolytics are initiated.”
To help close this HBV screening gap, those involved in the CCSP initiative began sending a message to prescribers in the electronic health record (EHR) upon scheduling delivery of oral oncolytics, reminding them of the recommendations and suggesting that they order a blood panel for HBV. “Pharmacists also assess for completion of HBV screening and provide recommendations accordingly to optimize treatment safety given the serious repercussions with HBV reactivation, including liver failure and death,” he said.
The study included all patients who received care from a Cleveland Clinic oncology or hematology provider and had an oral anticancer medication dispensed through CCSP from May 1 to Aug. 31, 2023. Among 483 patients, 84 (17.4%) initially received HBV screening before treatment. After pharmacists provided HBV screening recommendations for 229 out of 399 (57.4%) patients not screened, providers accepted 73.4% of these recommendations.
The appropriate full HBV panel was completed for 160 (63.5%) of all 252 screened patients. Seven (2.8%) patients had evidence of past HBV infection and two started antiviral prophylaxis.
“Although that is a small number of patients, it is definitely impactful, because had prophylaxis not been initiated, they would have been at risk of viral reactivation and potential hepatic failure as well as complications with their cancer treatment,” Dr. Angyal said.
He noted that only about two-thirds of screened patients in the study had received the appropriate full HBV panel, as opposed to the remaining patients with a partial panel, whose full immunity thus could not be fully assessed. “As a result, we changed the verbiage of the message to request that providers order the specific full panel, per the recommendations,” Dr. Angyal said. “We also would like to set it up so that we can send the HBV panel order in the EHR, and send directly to the prescriber for their signature, because we know that they’re busy.”
Going forward, Dr. Angyal said he would also like to add a step for pharmacists to remind physicians to take action with panels that show no immunity or past infection by prompting patients to receive vaccination for hepatitis B to minimize risk for future infection.
Dr. Angyal reported no relevant financial disclosures.