• Benign Prostatic Hyperplasia
  • Hormone Therapy
  • Genomic Testing
  • Next-Generation Imaging
  • UTUC
  • OAB and Incontinence
  • Genitourinary Cancers
  • Kidney Cancer
  • Men's Health
  • Pediatrics
  • Female Urology
  • Sexual Dysfunction
  • Kidney Stones
  • Urologic Surgery
  • Bladder Cancer
  • Benign Conditions
  • Prostate Cancer

GnRH Agonist/Antagonist Ordering: Workflow Hurdles


Digging into the logistics of advanced prostate cancer management, keynote speakers consider challenges faced with the electronic systems used to request or order therapy.


Aaron Berger, MD: I think limiting the choices is certainly important … from a practice workflow, and ordering and management of supplies and making sure nothing goes missing … We typically will have the authorization folks to try the mesylate since we’ve had luck with that, and the lack of mixing needs and that ... stuff. But then … if it’s not approved then basically on the clinical schedule on our EMR [electronic medical record] it’ll be in big, bold letters, what the patient is supposed to be getting, because clearly, these are different J codes between the acetate and the mesylate. What you don’t want to do is to just say, ‘A patient is here for an ADT injection,’ and then your staff grabbed the wrong thing, and it wasn’t approved, because this is not like IM leuprolide acetate and subQ leuprolide acetate where it’s the same J code. If you grabbed the wrong drug and they get mesylate vs acetate, you’re basically eating that cost because … that’s not what was authorized, at least for … a lot of payers. If you don’t have the specific drug and their specific J code in the authorization, you definitely can run into problems. Trying to keep it simple like we’ve talked about, stick to 6 months is our goal as well. It sounds like Chris has already done that. And limiting the options I think … from an operational standpoint is just going to make things easier moving forward for everyone’s practice.

Paul R. Sieber, MD: Chris, you were going to comment then.

Christopher M. Pieczonka, MD: Paul, you posed the question I think about how we … navigate ... these choices that exist in the landscape. I shared earlier that in our practice, we’ve limited androgen deprivation therapy to … 3 physicians and 3 nurse practitioners across the entire spectrum. We’ve made an operational decision to have mesylate be in first position. So when a determination is made for androgen deprivation therapy, let’s say by the radiation oncologist, we end up having a consult with one of our ADT specialists and we are trying to get approval for mesylate first. If insurance says no, then they’ll have something different. And the reason for that is because we feel strongly that it’s going to make...everything more institutionalized and more operationally efficient. To that end, we didn’t talk about this, but we’re also taking those patients on a renewal basis. Aaron touched on this earlier about really, do patients care if they’re getting one needle or another? We’re taking the people who may have been on acetate, and as they’re coming up for renewal, we’re looking to see if they can be switched to mesylate, again, with the thought that as we organically move forward, that we’ll be a mesylate-only practice or—I shouldn’t be that strong—that we will be predominantly mesylate only as we...move those patients over from acetate to mesylate as they’re coming in for their injections over a 6- to 12-month cycle.

Paul R. Sieber, MD: Richard, you probably got the most complex of it. It sounds like when you order it, you just ... check, give them ADT and whatever the insurance tells you to do. Is that an unreasonable statement, or is that the problem that you run into on the West Coast sometimes?

Richard David, MD, FACS: I think much like what Chris was saying is, we have our first-choice drug, which is typically the mesylate, and we’ll try and get that authorized first. And oftentimes, we’ll get a response back: ‘That’s not in our formulary. We want you to use one of these drugs.’ … It all gets sorted out in the prior authorization process.

Paul R. Sieber, MD: I guess what happens to us is we do the same thing, I think everyone’s mentioned we basically stock 3 things. We stock mesylate; we stock degarelix in case of an emergency, we need something right away; and we stock relugolix, but relugolix runs into the problem with part D, in getting it covered so we are limiting ourselves to 3 agents that we don’t run the spectrum of multiple different agents as Chris alluded to. We stick with 6 months. It just makes more sense.

Transcript is AI-generated and edited for clarity and readability.

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