Profressor of Pharmacy Practice
Department of Pharmacy Practice
Massachusetts College of Pharmacy and Health Sciences
Clinical Pharmacy Specialist in Infectious Diseases
Saint Vincent Hospital
Linda M. Spooner, PharmD, BCPS, FASHP, FCCP, has no relevant conflicts of interest to disclose.
It is exciting to reflect on how much progress we have made in the management of chronic HCV infection during the past 30 years. We have advanced from interferon monotherapy in the early 1990s, with its poor tolerability and low sustained virologic response (SVR) rates, to the introduction of all-oral, direct acting antiviral (DAA) regimens in the mid-2010s, which have minimal adverse events and excellent cure rates. Now that we are in a new era of HCV management, pharmacists can have a critical role in assisting patients in obtaining care, adhering to their treatment and follow-up visits, and achieving SVR.
Pharmacists Have a Key Role on the HCV Patient Care Team
Various providers have roles in optimizing the management of patients infected with HCV. Prescribers, nurses, clinic staff, social workers, and pharmacists collaborate to identify patients in need of treatment and to obtain medication through the prior authorization process, as these medications continue to be quite costly. Navigating the healthcare system can be overwhelming to patients in this situation. Thus, keeping the lines of communication open among all team members is vital, and keeping the patient updated on the status of treatment approval is crucial to engagement in care. Pharmacists in the ambulatory, specialty, and community pharmacy settings can improve treatment outcomes through identification of barriers that prevent continuity of care and through improvement of adherence via patient counseling and monitoring.
Applying Medication Therapy Management (MTM) Services
Pharmacists in a variety of practice settings can apply the principles and activities of MTM to their patients who are undergoing treatment for HCV infection. We tend to think of MTM for patients living with hypertension, diabetes, asthma, and hyperlipidemia. However, it should be recognized that patients with HCV infection would also benefit greatly from MTM services. Pharmacists can assist with HCV regimen selection, provide patient counseling, monitor response to therapy, assess for adverse events, evaluate drug–drug interactions, and improve access and adherence to therapy, all in an effort to improve patient outcomes. Participation in and documentation of these activities can further assist the other providers in caring for the patient.
One of the key components of MTM includes identification of medication-related problems. There is significant potential for drug–drug interactions that can have an impact on the effectiveness of HCV medications, and pharmacists can intervene on this front to prevent therapeutic failures. For example, the absorption of some DAAs (eg, ledipasvir/sofosbuvir and sofosbuvir/velpatasvir) is reduced by acid suppressors, including proton pump inhibitors, histamine 2 receptor antagonists, and antacids. There are many caveats to concomitant use of these agents, and because acid suppressors are available without a prescription, many patients will use them without the knowledge of their HCV care provider. As another example, some statins are not recommended to be used in combination with protease inhibitor–containing HCV regimens or must be dose limited when used in combination (eg, glecaprevir/pibrentasvir and elbasvir/grazoprevir). Through a patient profile review and discussion with the patient, a complete list of prescription, nonprescription, complementary, and alternative medications can be obtained and assessed to determine if there are any interactions that would compromise the effectiveness of the HCV regimen or result in toxicity. Encouraging patients to disclose all of their medications, including those obtained from specialty pharmacies, will improve the accuracy of this review and permit us to inform providers of any potential issues.
The Crucial Importance of Patient Counseling
Patient education is a cornerstone of MTM, and pharmacists are in an ideal position to provide this to our patients before, during, and after completion of HCV treatment. We assess individual considerations when selecting treatment options, such as insurance coverage, concomitant medications, adverse event profiles, and lab results. We also discuss the importance of adherence to medication dosing and follow-up office visits, and we can identify and assist with resolving potential adherence obstacles. Overall, we serve as motivators, supporters, listeners, and communicators for our patients throughout the continuum of their HCV care.
Pharmacists: How have you incorporated aspects of MTM into the care of your patients with HCV infection?
Other healthcare providers: How can pharmacists improve the care of your patients with HCV infection?
Please join the conversation by leaving your thoughts and ideas in the discussion section below.