A Raptor Clawing at Lemons

Hello all, from the chemo suite, cycle #14. I wasn’t going to write a blog this cycle because there wasn’t a whole lot new to report. I remain “healthy”, all my blood counts are within normal limits, and overall, I feel great. It seems that when I’m thinking what to write about for the next post, if anything, something always pops up last minute.

Today I reference the raptor (think hawk or eagle) we all know very well, but this isn’t such a rapturous story. Rapturous versus raptor – two very different meanings.

I’ll jump right in today to keep this short. For the last 3-4 cycles of chemo, I felt I was constipated for 3-4 days following chemo – not a good thing when you have a stent in your rectal-sigmoid junction. And although I didn’t experience any nausea or vomiting from the chemo, my stomach has felt a bit off 3-4 days following chemo during that same time span, all issues I had not experienced throughout the earlier treatments. I attributed it to cumulative toxicity from several of my cancer drugs, especially oxaliplatin which I know can cause delated toxicity even though I no longer receive it.

As I was observing a very competent nurse today preparing for my treatment, I noticed two odd things. I generally am not peering at the labels of each IV bag or syringe that is injected into the side port of the IV tubing. But, the yellow appearing drug solution with a 5cc syringe did catch my eye (good call Dr. Hannah Fudin – it was clear yellow tape around the syringe barrel to help identify the drug and reduce potential for error. That was scary because another anti-cancer drug called methotrexate is the same yellow color and would come in the same size syringe. What a disaster tha would be!).  As the nurse was about to inject my anti-emetic (anti-nausea) medicine I noticed that the label on the syringe was for granisetron, the half-life of which is 9-hours. Translation? At the 9-hour mark after receiving this drug, the blood levels are at 50% of the initial levels. Recall that I receive 2 cancer killing drugs on day-1, and then go home with a continuous 46-hour infusion, which totals 72 hours! For previous treatments, as far as I knew, I was not receiving granisetron – I was receiving palonosetron, the half-life of which is 40 hours. So as above, at 40 hours, there is 50% of the initial blood levels. Considering I have a three-day regimen of chemo (just one medication in the ambulatory infusion days 2-3), palonosetron would therefore seem like the superior choice, especially since it has a lower risk of constipation and gastrointestinal side effects compared to granisetron.

When I questioned the nurse prior to her pushing in the syringe plunger for the granisetron, she went to double check. She quickly returned and informed me that my insurance company (BCBS-Federal) stopped covering that medication in late November 2021 and so the internal pharmacy here changed the medication to the less expensive granisetron. Both drugs are what we pharmacy nerds call 5-HT3 antagonists (aka, serotonin type 3 antagonists).  I don’t know about you all, but I feel it is wrong for an insurance company to make that decision without informing me, and I also feel it is wrong that nobody in the oncology practice informed me of the change.  Now I know why my gastrointestinal symptoms changed, as timewise, it perfectly aligns with my symptoms outlined above. I feel like I need to be a “hawk” hovering over every step of my treatment – God help those without a medical background. If I hadn’t looked down, I would never have known.  I asked the nurse to have a prior authorization request submitted to the insurer. Of course the insurance carrier doesn’t want to pay for the more expensive one. And, as “coincidence” would have it, BCBS made this decision the very same week I met my out-of-pocket payments in 2021.  Coincidence?  I doubt it, but I will find out. The good news is that the nurse reported to me that the request to BCBS has already been submitted for palonosetron per my request (that was about 10:45AM). If what I suspect is true, that BCBS changed their coverage specifically for my individual case based on meeting my out-of-pocket expenses, I believe that is illegal. I will check on the legality, and if I’m right, BCBS will have to answer to the Department of Health and Human Services, not to me. Oh goodie – I can’t wait to find out! Moreover, I specifically chose to be on esomeprazole (to protect against GI bleed from chronic NSAID use) over other similar medications in that class due to drug interactions with palonosetron I originally was receiving.  The specifics of those interactions were “painfully” outlined in a previous lemonade blog post. UPDATE: I initially was told that a prior authorization approval from BCBC-Federal would take about 3-days. At 5:00PM I received a call that the palonosetron was approved – interesting, right?

What should have happened?

1. The insurance company should have immediately notified me prior to this change, as they do when there is a formulary change with a drug I am receiving from a community pharmacy.
2. The doctor (if he/she even knew) should have informed me of this change in November.
3. The RN administering the drug should have told me there was a change to my medications in November when it happened.
4. The oncology group invoices should specifically delineate each individual drug at each billing, the cost of that drug, and the fee to administer them, including ancillary supplies such as tubings, specialty needles, syringes, and the like. Instead, it says “drug administration”, so I certainly would not have known from the invoice either.

On another front, you’ll recall in my last blog that I submitted a letter to the Executive Director of my oncology practice regarding my allowance to disconnect my home infuser.  That letter was sent by certified mail and signed for on 12/23/2021. All I’ve heard about that is crickets. I’m going to give this person the benefit of the doubt and assume (s)he was out for the holidays and is still catching up.  Eventually I will make a telephone call to their office and request a face-to-face virtual meeting.

I’m planning back-to-back vacations very soon to COVID heaven in Florida, where we are planning to see some family and friends (no vaccinations, no visitation rights). Then after returning to Albany, this will be followed by a rendezvous with my son Jason for long relaxing weekend (I can’t remember the two of us just hung out along for that length of time, if ever since his sisters were born). Well actually, there was that wild pharmacy convention about 25-years ago at Disney with our residents – that was a blast! And all this fun and relaxation will come just prior to the anticipated arrival of two new grandbabies. Stay tuned for updates and photos.

Until then, stay safe. This includes vaccinations, wearing masks, and flying as a raptor at your medical visits. My advice is to always be professional, inquisitive, and cordial, but let them know you’re on top of things, or at least that you’re interested and want to be updated and informed about any and all changes and decisions surrounding your medical care.

To be fair, especially in our current COVID environment, your medal caregivers and pharmacists may be more stressed than you. Here is a perfect example hot off the press by my good friend and colleague, Dr. Michael Schatman, Pain Management Providers in the Era of COVID-19: Who is Taking Care of Those Who Provide Care?

Comments are enthusiastically welcomed. I love receiving comments on various social media sites (Facebook, Linkedin, Twitter), but please also paste those comments on here if you have time! Cheers!