Neratinib dispensing

[Clayton Wong]

Hi,

Probably a silly question, but anyone else finds difficulty with dispensing neratinib, especially for patients with dose reductions.
Any staff reporting safety concern, or has anyone done a risk assessment?
Any tips on how to count them in an easy and convenient way? It's getting rather annoying counting...

TIA
Clayton

[CALUM Polwart]

I guess you won't find many people using it in the NHS unless it's through an expanded access program. The NICE approved indication was killed off by Pertuzumab.

The UK/EU love a blister pack. The US loves a bottle.

How hazardous do we perceive neratanib really is? I'm not volunteering to lick the bottle without some loperamide on standby - but compared to methotrexate and chlorambucil it's probably safer. They are film coated so I assume there isn't a load of dust?

Is the problem because they are oval? So a triangle doesn't work.

Us oldies will remember counting many a capsule with a capsule tray and a spatula...

BUT - the alternative is to stick to whole packs and change the supply length. Possibly not your aim when finding optimal reduced dose but if stable that makes sense surely?

Is the private sector using loads of this?

[Clayton Wong]

Would have thought there bound to have some node -ve patients completing Tras and move onto it, or is the general consensus that the prospect of almost certainty of diarrhoea outweigh the potential benefit?

I agree the risk from handling is minimal, but I am pretty sure someone somewhere in our pharmacy world would have thought about it and thought the other way. Just throwing it out there to see what other thinks.

TBH, the issue is more the counting, the triangle doesn't work ofc, but the capsule tray isn't much more useful - the size of the tablets are so small they don't sit very well in those trays that were designed for the bigger capsule size. The quantity required doesn't help either. It's just an all round nightmare.

Dispensing whole bottle - funding potentially is an issue, some insurances are very "on it" with the quantity supplied to the patients, and self-paying patients won't necessarily want to be charged more than they have to pay - so we don't tend to deviate from the exact quantity. Asking the clinician to prescribe the number of cycles that will match the final quantity to number of whole bottles (even for stable patients) probably isn't justified.

We are not using loads of them in Wimbledon, but it's enough to make you question life choices having to dispense/countercheck quantity every month. And I think the usage may increase if the company can't recoup what they have spent from the public sector...

[David Barber]

Our outpatient dispensary just dispense whole bottles. We've never had a problem getting reimbursement. Depending on the dose, the patients eventually accumulate enough that you can skip a dispensing episode.

[CALUM Polwart]

Yeah I was thinking - here is a bottle of 240 tablets. You are taking 5 tablets a day so instead of lasting 40days, It will last 48 days. Change the Rx to not specify a duration but a Qty. Increase follow-up gaps? Maybe if you are making money from seeing patients that's a bad thing? Over the course of a year, a patient will probably need 9 bottles.

NICE approval is for:

1. people who had residual disease after neoadjuvant surgery. They'd be eligible for Kadcyla; which disqualifies them from neratinib. So with the exception of very rare patients who might for some reason be ineligible for Kadcyla, I think its a drug that had a very limited time of use in NHS.

2. anyone who didn't have neoadjuvant Tx - but only had trastuzumab. The node +ve patients should get pertuzumab. So it leaves node negative patients who generally had very small disease if they didn't get neoadjuvant Tx. The T1 patients on the forest plots in ExteNET didn't benefit. Finding a patient who you think will benefit is like looking for a needle in a haystack. If they had bigger disease, were node negative and didn't get neoadjuvant pertuzumab its likely a comorbidity issue which makes neratinib not high on my list of favourites!

No evidence of improved survival at 8 years. (Not even a sniff of improved survival!)

I'm curious how much NHS funded use there is. We cant tell that from SACT / other sources. Always good to know if our non-existent use makes us an outlier....

@DavidBarber - are yours expanded access?

[David Barber]

Not expanded access. It's the exact group of patients you describe (those who didn't get neoadj tx). Pretty small cohort. We're a reasonable sized centre and it's 2-3 per year

[Laura Mcewan]

This has come up recently for us. Patients on DR not needing full packs but what to do with remainder. Do any of you have any more up to date information?

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