INSIGHTS FROM: AJAI CHARI, MD, MOUNT SINAI HEALTH SYSTEM; DANIEL VERINA, NP, MOUNT SINAI HEALTH SYSTEM
Wednesday, May 27, 2020
Ajai Chari, MD: Danny, you bring up some important points. Starting with hepatitis, what’s your approach if somebody does have, say, not just hepatitis B surface antibody, which is more consistent with a vaccination, but perhaps hepatitis B core antibody present as well, suggestive that they’ve been exposed before? How do you approach that patient if you’re thinking about DARA [daratumumab]?
Daniel Verina, NP: That’s important. I think on a patient’s list, sometimes they don’t even know they were exposed and have the actual virus themselves. So number 1, is explaining to them that they were probably past exposed and they never knew or had any symptoms from it. We would treat them with upfront medication, but it would not hinder us from treating them with the daratumumab.
Another factor with daratumumab, which you also mentioned in combination with other drugs, is that besides hepatitis B, it can reactivate the herpes zoster or shingles virus. So patients should be put on an antiviral medication prior to starting the drug itself. And if they are in combination with the IMiDs [immunomodulatory drugs], you would want them to be on some type of baby aspirin or something a little bit stronger.
Ajai Chari, MD: Yes, and I think going back to the hepatitis point, I completely agree if somebody has been exposed to hepatitis and is about to start daratumumab, we could start drugs like tenofovir or entecavir, depending on your local hepatology preference, to suppress the reactivation of hepatitis B. But the other thing that’s important is to also monitor the hepatitis B PCR [polymerase chain reaction] to ensure that we’re staying ahead of that. Danny, can you speak to the ways that we do it at Mount Sinai Health System—because one might forget to order the type and screen or do the hepatitis serology—are there some practical recommendations for those in the community for not forgetting to do those things?
Daniel Verina, NP: I think one of the challenges is whether you’re using paper versus electronic record keeping. At Mount Sinai, we have incorporated in all first use of daratumumab that they have the hepatitis serology panels drawn plus a type and screen as a control factor. We also have as a practice initiated, whether we do it every 6 months or up to 1 year, we check their hepatitis. If their antibodies surface, we will recheck them within a year, but if they do have a positive, we monitor them every 6 months to make sure that it is under better control.
Ajai Chari, MD: And then in clinical trials, it is actually every 3 months, hepatitis B PCR. One other point relating to your testing, the question is if a patient, let’s say, has been getting daratumumab, but they have an emergency, let’s say they may be in a car accident and show up at an emergency room or they’ve started daratumumab in an outside hospital and they’re coming to you for subsequent care. It’s important that we know how to deal with that because if you don’t have that baseline type and screen pre-daratumumab, some of the strategies to deal with that are you can use trypsin or other enzymes to strip away the daratumumab and then type the red cell without the daratumumab coating, keeping in mind that it can also denature the Kell antigen, so you have to give Kell-negative blood. But also at baseline some centers do full genotypic or phenotypic characterization of the red cell.
*Note: Subcutaneous daratumumab is now approved in the United States and Europe.