Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1 - Episode 15

Denise O'Dea: Options for Treatment and Reimbursement After Dose Reduction

What are the options for treatment access and reimbursement in this patient, who required dose reduction for diarrhea?

Afatinib is a medication of Boehringer Ingelheim, which has a fabulous program called Solutions Plus for patients, and they actually do a drug exchange. Many of these drugs are very expensive and insurance will only pay on a monthly basis. If a patient has to dose reduce shortly into the treatment, 2 to 3 weeks in, the patient may not have the insurance coverage to get another prescription filled at a lesser dose within the 1-month timeframe.

There is a drug exchange program where the practitioner or prescriber can write a new prescription for the lesser dose and send that in, and the patient will get that medication, a 1-month supply, and then they get an envelope where they send back the pills that they have left of the higher dose. And there’s no expense to the patient and no recharging the insurance for another dose within a month. They needed to have nine pills at least left in the cycle for them to participate. If they have less, you would contact Solutions Plus and there are many options for help with reimbursement, [including] access to free drug if the patient qualified. In this situation with Ingrid, she could get a dose exchange and proceed without much delay in her treatment.


Ingrid C. is a 62-year-old corporate accountant from San Antonio, Texas. Her medical history is notable for depression, which is being treated with an SSRI, and she has no history of smoking.

At the start of busy tax season, she presents to her PCP with back and chest pain, a persistent cough, and intermittent dyspnea.

Her cardiac workup is negative, and her PCP orders a chest x-ray, which shows bilateral lung nodules and a large upper right lung mass with pleural effusion; she is referred for a follow-up CT scan.

The CT confirms the presence of multiple lung nodules and additional lesions in the thoracic vertebra; she is referred for further diagnostics.

Core biopsy of her lung mass shows adenocarcinoma stage IV; mutational testing showsEGFRdel 19.

Her performance status was 1.0 at diagnosis.

Ingrid has a family vacation in Tuscany planned for next year, and hopes to be able to keep her travel plans; her oncologist initiates her on afatinib 40 mg daily.

She returns to her oncologist in 2 weeks with persistent diarrhea (>5 stools/d) that has not responded to antidiarrheal medications, which were suggested by the nursing team, and her normal work day is being affected.

Her oncologist reduces her afatinib dose to 30 mg/day, and she continues therapy.

Nine weeks after initiating therapy, she reports to the nursing team symptoms of redness and swelling in her fingers and fingernails, and management strategies are recommended.

At her next follow-up 2 months later, her CT scan shows the right lung mass to be stable, with no new lesions. She has improved symptomatically.

Her diarrhea has improved sufficiently to allow her to resume her normal work load; her paronychia has been effectively managed with vinegar soaking and topical antibiotics.