Q&A: Subcutaneous Daratumumab Eases Myeloma Time Burden

Angel wings can be used to make injections easier for patients and nurses.

The reduction of chair time that subcutaneous daratumumab (Darzalex Faspro) offers individuals living with multiple myeloma allows them a more flexible treatment schedule, says Gina Fries, PA-C, a nurse practitioner at University of Rochester Medical Center.

Due to the chronic nature of multiple myeloma, patients are likely to spend high amounts of time receiving treatment, compounding the burden of cancer-related issues in a patient’s life. Subcutaneous daratumumab allows patients to receive treatment in much shorter appointments, giving patients more freedom. The therapy is also very well-tolerated, further reducing the toll of cancer treatment for those with multiple myeloma.

Fries expanded on this in an interview with Oncology Nursing News.

Oncology Nursing News: When did you start working with subcutaneous daratumumab?

Fries: I have worked with multiple myeloma patients for 5 and a half years. I’ve been a physician assistant for 25 years. When I first started with myeloma, it was only the infusion version of daratumumab. And goodness, it was either 6 months or a year into it that the subcutaneous version came out, and literally the day we got it in stock in our cancer center, we switched every single patient over to it because it had the same efficacy and was so much quicker. Patients love it because nobody wants to sit there for hours to begin with, but myeloma patients spend huge percentages of their lives in infusion centers, so it was very significant for them.

How is subcutaneous daratumumab a more practical choice for patients?

Fries: The patients benefit in multiple ways. First of all, less time of their life is spent in the infusion center, but also when it’s a long infusion time, patients have trouble getting the time that they want. With the subcutaneous version, they can get a time frame that might work better for them. For example, maybe it’s a younger myeloma patient who still works now, they can come in at the end of their workday and get their injection so that they don’t have to take a day off work for a long infusion.

How can nurses proactively manage reactions to the injection?

Fries: We give premedications to reduce reaction. … We do this standard Tylenol, Benadryl, dexamethasone combination that is for multiple drugs, including daratumumab infusions and subcutaneous injections. For the very first 4 doses of subcutaneous daratumumab, we give montelukast beforehand. It’s not in the package insert that it’s needed, but when subcutaneous daratumumab first came out, we weren’t doing it, and we had a total of maybe 3 patients who had a late infusion reaction with chest tightness and shortness of breath who needed to go to the emergency department. That’s 3 patients too many. Now we give every patient the 4 doses of montelukast before the first 4 doses of daratumumab, and that fixed that issue. Second cycle and going forward, we, for the majority of patients, either drop or dose reduce the Benadryl from 50 mg to 25 mg, and we frequently drop the Tylenol and just continued the dexamethasone.

What should nurses know before giving a subcutaneous daratumumab injection?

Fries: Angel wing needles can be used by the infusion nurses, just so they don’t have to stand so close, right up towards the patient, since it’s an injection into the abdomen. Other than that, the infusion nurses just need to be trained correctly to know to give it over the proper slow 5-minute time frame. If the infusion nurse gives it more rapidly, it can be more uncomfortable, and that’s going to probably slightly increase the risk of some local skin irritation. When the local skin irritation occurs, all we advise is Benadryl, steroid cream, cool compresses, and they typically resolve within a couple of days.

What questions do patients have when starting treatment with subcutaneous daratumumab?

Fries: The most confusing part for patients is the dosing schedule in the beginning. The biggest thing is giving the patients printed up copies of their treatment calendars so that they know what to expect and when their life will be less tied to the infusion center and they can start traveling again.

By far the most common question is, “What side effects am I going to have?” We typically use daratumumab in newly diagnosed patients, and so newly diagnosed patients with myeloma still are under the impression that they’re going to be losing their hair and having terrible vomiting and diarrhea, because they have visions of, for example, a patient with breast cancer or colon cancer going through treatment.

It’s reassuring them that when it’s lifelong cancer and lifelong treatment, we are not going to beat them up with side effects like that, and reassuring them how tolerable daratumumab is and that the side effects are typically mild and very manageable. That’s first and foremost of the questions. I think the other big questions we get is that they’re told it’s monthly, but in the beginning, it’s not. It’s just multiple visits. It’s helpful for patients to go over that treatment schedule with them so they understand when they’re going to be coming less frequently, and that we’re reassuring them that they aren’t getting a lower dose of medicine when they switch to monthly, and that they’re not going to have an adverse issue with their myeloma coming out of remission from that.

What should more providers know about subcutaneous daratumumab?

Fries: The biggest issue is so many small offices do things out of habit, so for years, daratumumab was not necessarily written as first line therapy for myeloma. But now, for several years, it has been, and studies show that daratumumab can be a better regimen for patients to get a better and longer remission if it’s used in the first line. So it would be good for smaller offices to realize … that daratumumab truly is indicated for these patients, as opposed to some other treatment regimens that have just been used for ages.

This transcript has been edited for clarity and conciseness.