James K. McCloskey II, MD: These tend to be older patients, they tend to be patients with a lot of comorbidities. So, Danielle and Geeny, could you talk about how at Hackensack we really work as a team to care for these patients?

Danielle E. Marcotulli, APN: First, they’re in the office primarily, our patients with myelofibrosis [MF]. And they’re meeting nurse practitioners, the physician, nurse navigators, [the] nutritionist. Often these patients are experiencing weight loss, so we always consult with a nutritionist to see where they can help us. And [we order] medications for these patients and [decide] on a treatment plan. We have a team of nurses and oral chemotherapy coordinators who help us get these drugs for patients. We also run into a lot of issues where patients are already on a ton of different medications, or they have some … renal insufficiency. I think that’s really where we utilize Geeny the most; we email and call and ask her to look at a lot of our patients and see what can we do [regarding the dosage] or any kind of interactions, things like that.

Geeny Lee, PharmD: Just to piggyback on that, as a pharmacist, I’m always screening the patient’s medication list for drug-drug interactions. The metabolisms of the JAK inhibitors that we’ll talk about are really all slightly different. It’s difficult to comment on all of the interactions. But 1 interaction that is common to all 3 medications is with CYP3A4 inhibitors and inducers. So all 3 JAK inhibitors are CYP3A4 substrates, and they do have pertinent drug-drug interactions with various medications that inhibit or induce that enzyme. And depending on the interactions, we may need to either adjust doses, but for some we may actually have to avoid the coadministration of these medications altogether. We do have to pay close attention to patients’ medication list as a whole. And then, as Danielle alluded to, some medications do require dose adjustment in patients’ renal impairments. So that’s another thing that we have to consider when we’re selecting the appropriate dose for these patients.

James K. McCloskey II, MD: Absolutely. And I echo what Danielle says, that collaboration with the clinical pharmacist really is just priceless. It improves patient safety. And I think that we always have the ability to look at the data. But in a day-to-day practice, it is so common that we have a patient who falls outside of the parameters where we have good … data in the prescribing information about what to do; [we have] patients on dialysis, patients who otherwise might have some other liver dysfunction. We really need to treat these patients because they otherwise have an often-fatal hematologic malignancy, but we might be constrained by some of their other baseline organ function. And so it can be really helpful to collaborate with someone who has more insight into that. We also work with transplanters really closely. I think that from our perspective as we’re talking here today, to be clear, I am the myelofibrosis physician and I … know when to refer patients to the transplanter. But we really leave the transplant to our transplant specialist. And my job is to get the patient to transplant in the best condition that I can, at the most appropriate time, with the best control of their disease. And then the transplanter would take over. But that collaboration is also really important. I think if there are patients or audience members listening who maybe don’t have transplant at their facility, this is a really important relationship to establish if you’re taking care of patients with myeloid malignancies. Because we often need to work with the transplant team to get these patients to a bone marrow transplant, should that be indicated. Talk to us about … how we monitor these patients, how do we watch them in the clinic to make sure that they do well.

Danielle E. Marcotulli, APN: I think again, there’s such a wide spectrum of [patients with] myelofibrosis. We’re seeing them as often as we need to in clinic and that can greatly vary. There are some patients [with profound] cytopenia who may need their counts up [monitored] up to twice weekly for transfusional support. There are other patients who are doing fine; their counts are stable, and we’re seeing them every 2 weeks, every month, even every 2 months as long as they’re doing well on therapy. Besides monitoring their counts in the office, we’re also [checking] their spleen. As Dr McCloskey mentioned earlier, we’ve instituted doing at least a yearly ultrasound to see where we’re at, obviously more frequently if things are changing or the patient’s symptoms are worsening. And I think it’s really also important just to talk to the patient to see how they feel. Sometimes they feel OK, but could we make them feel better? Is there something different we can do to optimize … their quality of life and things like that?

Transcript is AI-generated and edited for clarity and readability.