Freshta Poupal, RN, and Frannie Bell, NP, share their experiences with teclistamab in clinical practice.
Teclistamab-cqyv (Tecvayli) is a bispecific B-cell maturation antigen (BCMA)-directed CD3 T-cell engager that received accelerated approval last year for patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.1
When teclistamab was approved for relapsed and refractory multiple myeloma, it was the first bispecific monoclonal antibody approved for patients with this disease. Anytime a new class of drug is approved, nurses and other healthcare providers must learn best practices to be able to provide the highest level of care delivery. To that end, Oncology Nursing News® spoke with 2 individuals with Mount Sinai to get an institutional perspective on how these new treatments are changing their practice.
Leverage Caregivers in the Outpatient Setting
Freshta Poupal, RN, has been at Mount Sinai for nearly 7 years, after having spent about 6 years in the emergency department at NewYork-Presbyterian. Currently, she works in the infusion center at a satellite within their hospital.
When the teclistamab approval came through, the team was very excited to have a new BCMA-directed therapy to offer. Consequently, Poupal ended up being one of the first nurses to administer teclistamab on the outpatient side outside its approval.
She shared that, from the beginning, caregiver education has been crucial.
“We always have our oncology flow sheet that we fill out with every patient, and we make sure their toxicities are OK, to see if they are having any issues when they go home,” she said.
“With teclistamab, there is a higher risk for neurotoxicity,” she explained. “We want to make sure that, from baseline, when they are going home, they are not ending up with confusion. We try to pair that with family members who really know them—we see the patient and, yes, we see them often; but we do not see them as much as their husband or their wife or their kids do. They are the people helping us, [answering,] have you seen something off?”
Conduct a Baseline Assessment
One of the more challenging things in managing neurotoxicity is understanding a patient’s ICANS baseline, Poupal added, especially since patients with relapsed and refractory disease tend to be older and are therefore more likely to have dementia or similar conditions. Again, leveraging the family can be the best way to identify changes in neurocognition early on.
“The other day, I had a patient whose baseline ICANS score was so low… she wasn’t oriented to time and place,” she recalled. “I educated the family about the neurotoxicity and said, ‘Make sure you're watching out because I know you know her well.’”
“We have several elderly patients in our practice,” Frances Bell, NP, added. Bell has been an oncology nurse of over 10 years and has been working as a nurse practitioner at Mount Sinai for the past few years.
“Knowing their cognitive status at baseline and functional status before they go into the hospital is so important. For some elderly patients, we may do a more in-depth assessment prior to clearing the patient for the medication - this includes a frailty assessment, assessing their gait speed, and assessing their baseline cognitive status."
Bell’s team uses the Immune Effector Cell Associated Encephalopathy Score to assess a patient’s cognitive functioning at baseline. The test asks patients to identify the year, month, city, and hospital; to successfully name 3 objects in the room (pen, button, etc); to follow clear commands (eg, hold up 3 fingers, close your eyes and stick out your tongue); write a standard sentence; and to count backwards from 100 by 10. For each task they successfully complete, they get a point, which are added together for a total score.
After being admitted for the ramp-up dose, patients will receive their treatment in the outpatient setting. Often, they may harbor fears about managing adverse events outside of the hospital. Clear patient education is needed to demystify these treatments and help them understand when to call.
“The AEs do sound scary, and this definitely could be a barrier for some patients, initially,” Bell said. "When you're explaining a medication that has such a long list—as all medications can have a really long list of side effects that often can scare any patient—but specifically with CRS and neurotoxicities, it is important to educate the patient, so they know what to monitor for.”
When the patient is discharged, they revisit the patient education information that the in-patient team went over before the first injection. Once discharged, the outpatient team sees prior to the Day 8 dose.
“That visit, a lot of the times, is a reeducation session—because the education component was also done before they get into the hospital for the step-up dosing. We go through the education about cytokine release syndrome [CRS] and immune effector cell-associated neurotoxicity syndrome [ICANS], go over what to look for, and review important infection risk and prophylaxis information."
At each subsequent visit, they screen patients for signs of neurological toxicities and ask them if there have been any changes.
Bell’s team also ensures that each patient has their wallet card and teach them to show it to a provider if they ever go to the emergency department.
“We give each patient a wallet card to put in their wallets before they get into the hospital,” she said. “We also make sure that everyone has a healthcare proxy set up and documented electronically so that if there are any issues while they are in the hospital, we know who to contact and what their wishes are.”
The Growing Field of Bispecifics
Since the approval of teclistamab, the FDA has also approved talquetamab (Talvey) and elranatamab (Elrexfio) for this patient population, increasing the number of bispecific antibody treatments available for patients with relapsed/refractory multiple myeloma.
“With the approval of bispecific treatments for multiple myeloma, patients are living longer and seeing longer remissions later on their treatment of Multiple Myeloma” Bell told Oncology Nursing News. “We are seeing patients who have gone through 4+ lines of therapy and some many more, now be able to get a bispecific, who otherwise may have not been able to get onto a clinical trial due to age or various eligibility criteria that are able to greatly benefit."
According to the 2 nursing professionals, these medications are similar to administer from the nursing side. However, because they have different targets, their AE profiles can differ slightly.
“They are both biosynthetic, so they are very similar,” Poupal said. “With talquetamab, [the key] is making sure that the patient's nutrition is up to par, because it does cause side effects with the throat and [can affect] their ability to swallow.”
Bell agreed. “The biggest things [to recognize] is that depending on what the bispecific is targeting on the myeloma cell (GPRC5D vs BCMA), there could be a slightly different side effect profile," she said.