This is the third in a series detailing some of the general factors to consider around patient adherence to oral medications, and ways to support patients receiving neratinib.

Conversation With Wendy H. Vogel, MSN, FNP, AOCNP®

Q: Besides the cost, have you had any other patient challenges? And if so, what are some other reasons that patients have struggled with adherence? Can you pro­vide some examples?

A: The process of getting the medicine is sometimes difficult for patients. With any kind of specialty pharmacy, delays in get­ting medicine are occasionally an issue. This has been better with our office now that the advanced practitioners are signing the oral oncolytics orders. They’re not getting missed sitting in some doctor’s in-basket. We have a dedicated RN and LPN, and all they do is work on oral oncolytics and get them to patients.

Q: How do you manage patients through these various different types of challenges?

A: Having a system in place is really important. The way we do it is not the only way, but having a set system so that every­body knows what everybody else is doing ensures that management is the same for every patient.

We also have a system where we flag cer­tain patients who are considered high risk for nonadherence. I can email my nurse manager in the office and say, “Okay, this patient is going to have problems. This patient is going to need closer follow-up.” She’ll assign an RN to call those patients weekly, every other week, or whatever is appropriate.

Q: What education or advice do you per­sonally provide directly to patients?

A: When we order a new medication I’m always talking about it, how we’re going to take care of you, and so on. Obviously, our nurses are giving more in-depth informa­tion in terms of what they’ll be taking, how they’ll be taking it, the side effect manage­ment, when to call us, and so on. Another key thing we’re doing is giving treatment calendars, even for oral therapies. We do this for IV therapy anyway, but for oral drugs, particularly those with side effects like neratinib that require additional medi­cation, putting it on a calendar gives patients something to refer to every day. “So, I’m on day 33. What am I supposed to take today?” They see it in writing and we keep a copy of it in the chart so that anybody who goes into patient charts knows where they’re supposed to be in their treatment.

Q: What advice would you give your nurse colleagues about helping patients stay on neratinib treatment?

A: Stay in touch with patients in what­ever way is appropriate. It’s about creating touch points in your system and with your patients, whether it’s educational touch points, follow-up touch points, face-to-face touch points, and so on.

Q: How have you managed patients through side effects to help them stay on neratinib treatment?

A: Here’s a funny thing: our first nera­tinib patient actually had constipation. Unbelievable. Her phone call back to the office the first week, about three days into it, is “I can’t poop.” She was so good with her loperamide that she couldn’t poop. So, we backed off a little bit on that. It’s let­ting the patient know what to expect. She knew she was supposed to have diarrhea, but she knew she wasn’t supposed to have constipation.

Now, if you get somebody on triage that got that call, they’re going to give them the usual, “Take your anti-constipation medicine,” response, which would not have been appropriate for this patient; just backing off a little bit on her loperamide resolved that problem. Written instruc­tions are very, very important for patients, as well as the medication calendar and anything that you can give them to take home so they can refer to when you’re not there.

Q: Why is it important to keep a patient on a full year of treatment?

A: If we want to get the results that we saw in the clinical trial, we absolutely have to keep them on for optimal outcome. It’s like you’re either pregnant or you’re not. You’re not a little bit pregnant. You have to either give it or don’t. If you want to keep them on that drug, it’s like in Tennessee, we say, “Ride that horse as long as you can.” You want to keep them on a good drug at the right dose and manage the side effects so that they’re getting adequate treatment for optimal outcome.

Q: What should nurses be aware of and focus on when managing patients receiv­ing neratinib?

A: Diarrhea can be dangerous, or even life threatening, if not managed properly. I think that’s really important. The need to recognize that diarrhea can be severe and quick. But the diarrhea associated with neratinib can be managed, and management should be proactive rather than reactive. The healthcare professional should ask specific questions about patients’ diarrhea, to qualify it and quantify it.

In follow-up, you also need to ask specific questions about adherence. It’s not enough to ask, “Are you taking your medicine every day?” Every patient is probably going to say yes, because they want to be a good patient. It might be better to ask, “How many pills did you miss this week?” or “How many pills did you miss over the past month?”

That kind of gives them permission to say, “Well, I don’t take it on Sundays,” or what­ever, because patients tend to want to be provider pleasers.

Read the other articles in this series:

ONS member Wendy H. Vogel, MSN, FNP, AOCNP®, is an oncology nurse practitioner at Wellmont Cancer Institute in Kingsport, TN. She received her BS in Nursing at Tennessee Technological University and her MS in Nursing in the Family Nurse Practitioner Program at East Tennessee State University. Vogel is an advanced oncology certified nurse practitioner through the Oncology Nursing Certification Corporation and a certified family nurse practitioner through the American Nurses Credentialing Center.

Vogel has experience in oncology, educa­tion, cancer prevention, and public speak­ing. She is an associate editor of the Journal of the Advanced Practitioner in Oncology and has also published in several other journals and newsletters. She is a founding board member of APSHO, the Advanced Practitioner Society in Hematology and Oncology. She received the 2012 ONS Mary Nowotny Excellence in Cancer Nursing Education Award and the American Journal of Nursing Book of the Year award for co-editing the Advanced Oncology Nursing Certification Review and Resource Manual: Instructor’s Resource. She has lectured at national and international conferences on oncology topics.

Vogel received compensation for her contribution to this initiative. Disclosure: This material was sponsored by Puma Biotechnology, Inc.