Innovations in Administration—Spotlight on On-Body Injectors

Drs Ailawadhi, Mikhael, and Faiman discuss the evolving landscape of subcutaneous administration and on-body injector innovation in multiple myeloma.

To learn more, view the full series: Subcutaneous Solutions: The Evolving Landscape of Drug Administration in Multiple Myeloma Care. 

Dr Joseph Mikhael: Well, hello and welcome to this wonderful series entitled Subcutaneous Solutions: The Evolving Landscape of Drug Administration in Multiple Myeloma Care. My name is Dr Joseph Mikhael, and I'm privileged to be joined by some outstanding faculty today as we kick off this first chapter entitled, “Innovations in Administration—Spotlight on On-Body Injectors.” And if you're not familiar with on-body injectors, you will be familiar with on body injectors by the end of this chapter and the subsequent chapters that are coming. I noted that I am joined today by some extraordinary faculty, which include Dr Sikander Ailawadhi who comes to us from Mayo Clinic in Florida, from Dr Beth Faiman, who joins us from Cleveland Clinic. Sikander, Beth, always great to see your faces. We have a short amount of time, but we have a lot of great things to discuss, and we want to start really just thinking together about how things have evolved in the whole world of oncology.  

I am not going to comment on anyone's age, but the 3 of us have been around long enough to remember the days where chemotherapy was the bald and barf kind of chemotherapy, and we always gave it intravenously and it typically took multiple hours, but it's been remarkable how this has really changed and evolved as we've wanted to make things more convenient for patients, have less of a burden on the healthcare system of patients having to be in the clinic or in the IV center for longer periods of time. And so, I just thought I would open it up to you, maybe Beth first, to comment on this great evolution that we've seen.  

Dr Beth Faiman: Yeah, absolutely. I think we've all been in the myeloma care space for 20 to 30 years, and we always just gave IV or high doses of chemotherapy, and that is not the case anymore. We have innovative monoclonal antibodies, we have CAR T-cell therapies, and we've really changed from just primarily intravenous delivery of therapy to now SUBQ, IV, and the combination therapy. So, it's really been nice to accommodate patients and the different schedules, again, are evolving as well. So, we have the FDA group therapies, and the NCCN guidelines are continuously evolving. What do we have? Version 2.2026 currently of the NCCN guidelines. So, it's nice to see some of the therapies that we'll be discussing later on will be mentioned in those guidelines. The SUBQ especially has led to faster treatment times and improved patient comfort and convenience as well getting in and out of the center. And I think that'll be discussed further later on as well.  

Dr Joseph Mikhael: Yeah, absolutely. I mean, it's not like I want to be anti-IV because in some ways there are strengths of IV, there's obviously great compliance. We're there with the patients, we have the conversations with them, we can deliver certain molecules, but I agree with you that the main shift has really been to subcutaneous administration now, and remarkable how many more therapies we've gone in that direction. So Sikander, maybe I ask your perspective on things. Why is this so important that we've gone and had this really quite tidal shift in moving from IV to subcutaneous administration?  

Dr Sikander Ailawadhi: I think Joe, that's a very important question is in why this shift and what is it helping us achieve? So, if you take a step back and think about the fact that our drugs have overall improved quite a bit, our patients are, thanks to that whole frame shift, our patients are living longer. So, we must, as clinicians, as a science community, as advocacy groups, must think of how to give that life back to a patient where they do not have that short finite survival. But our myeloma patients who are diagnosed today could be living well in excess of 10 years. Now, what we don't want is them tied to a pole, tied to a chair, repeated hours, days, months in the clinics, offices, hospitals, et cetera. So, I think that frame shift, that kind of huge shift in making the treatments more convenient, more accessible, more compliant with the patient's own lifestyle is a huge step to move the patients towards that quality of life so that they are no longer a cancer patient. They are an individual who is living with cancer.  

Dr Joseph Mikhael: Beautifully said, my friend. Of course, this is driven by the fact that it's not just we've just sort of switched from an IV needle to a SUBQ needle. Often, we've had dramatically less volume. We've been able to do it over much shorter periods of time using a considerably smaller needle. But now, I would argue that we've even had another wave of innovation in this whole concept of an OBI, or on-body injector device, that now even takes us a step further. Beth, and I wonder if you can talk to us a little bit about the OBI. What is it? What makes it different than just a regular subcutaneous shot?  

Dr Beth Faiman: Yeah, absolutely. So currently, the standard of care for newly diagnosed relapsed myeloma patients includes the delivery of anti-CD38 monoclonal antibodies. Traditionally, when we started in 2015, that was an intravenous formulation. Then we had in 2020 another anti-CD38 monoclonal antibody that was FDA approved as well, intravenously. In the middle of that, we had daratumumab hyaluronidase formulation that was FDA approved. While that has changed the landscape of how less infusion related reactions with the daratumumab SUBQ versus the IV, less chair time for those patients. So, that innovation really helped, but it is a large volume that can cause—it's a large gauge needle. I think it's a 24-gauge needle we use in our institution, but it demands the same physical effort from the nurses and those that administer it, and then it can be uncomfortable for the patients.  

Now, the OBI technology is something that's new. It's a wearable injector that adheres to the body, does not require sustained physical effort, and it's just with isatuximab, and it doesn't have the hyaluronidase so it's just a lighter liquid, so you can administer it through a 30-gauge needle. So, that's a lot more comfortable, and we'll talk later on about the clinical data that surrounds the preferences of this versus the other. But we have OBIs, currently pegfilgrastim, and for PNH, we have the OBI injector as well. So, it's exciting to think about the opportunity that potentially, in the future, this might be available to our myeloma patients, the on-body injector for more comfort potentially, and for convenience of the nurses and the patients as well.  

Dr Joseph Mikhael: Of course, as you noted, being an on-body device that gets adhered to the skin, we push a button for the studies as we'll discuss with multiple myeloma, takes about 12, 14 minutes to administer. It actually doesn't have to be administered by nurse. It's even raising the question, we might be able to do this outside of our usual therapy units, maybe even someday at home. Sikander, what do you think about that? Do you think that is an innovation that would be good for our patients and for the healthcare system?  

Dr Sikander Ailawadhi: Joe, you are raising this, and it literally gives me goosebumps thinking that we can give drugs to patients in the comfort of their home. I mean, what more can we expect when we think about improving the quality of life of our patients? So, you started off by asking a question about IV versus SUBQ. One common discussion we have, all of us have with our patients is a patient walks into the clinic, they've been given this diagnosis of cancer, and say multiple myeloma, and their fear is the cancer, but they're also significantly afraid of the treatment, the traditional concept of chemotherapy. Now, just imagine that same patient being told that they're not getting a traditional chemotherapy drug; they're getting a targeted immunotherapy drug, and they don't have to sit in a chemo unit. They could potentially get it outside at their home. That is phenomenal.  

That is just amazing. So, as Beth mentioned very nicely, there are other drugs which have been used this way, the on-body injector for the Onpro or the GCSF. You put it on, the patient goes home, it gives the shot at a certain time, and the patient peels it off, disposes off. Now, we're talking about that same technology or similar technology for immunotherapy, front and center drugs that are anti-cancer, not just supportive care. So, to me, that is huge. The patients, you can imagine if this technology is utilized and the patients are potentially using it in combination with oral drugs, so be it, they can potentially get this someday at their home. In addition to convenience, quality of life, et cetera, I think one major question that this gap, this may be able to bridge, would be access. There are several areas where patients may not have the opportunity to travel to or go to the healthcare system because of rural far-flung areas, et cetera. Now suddenly, if the healthcare system can come to the patient rather than the patient having to go to the healthcare system, I think that's a huge innovation.  

Dr Joseph Mikhael: Well, you both summarized this in a beautiful way, and really, hopefully as an appetizer for our subsequent chapters, have given us a really great sense of the evolution of care to not only provide a more effective therapy, but provide it in a more convenient manner for our patients in a way that reduces the burden on the system, whether it's the nurses in the IV unit or simply having patients in the hospital. I think the promise of OBI, or of on-body injectors, is tremendous. I want to take a moment to thank everyone for joining us today. In particular, our amazing faculty here, Dr Faiman and Dr Ailawadhi, for their insight and for their experience with this. And lastly, before we sign off, I really want to encourage our audience to continue the series to dive into chapter 2, which is actually called “Deep Dive—On-Body Injectors Versus Intravenous Administration,” where we have greater opportunity to understand the potential value of OBI. So, thank you very much for joining us today. 

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Sikander Ailawadhi, MD 
Dr Sikander Ailawadhi is a professor with the Division of Hematology-Oncology at Mayo Clinic in Jacksonville, Florida. His career focus has been on the treatment of plasma cell disorders with core research efforts in understanding the epidemiology and pathophysiology of these disorders and evaluating the benefit of various therapeutic strategies in different populations based on racial-ethnic and socioeconomic diversity. He has worked on the development of novel therapeutics by means of conducting several phase 1 through phase 3 clinical trials for novel drugs, including cellular therapy such as CAR T-cell treatment. Dr Ailawadhi also leads Mayo Clinic’s International Cancer Center and is focused on expanding and implementing the Mayo model of care and vision across the world. 

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Joseph Mikhael MD, MEd, FRCPC, FACP, FASCO 
Dr Joseph Mikhael is a professor in the Clinical Genomics and Therapeutics Division at the Translational Genomics Research Institute (TGen), an affiliate of City of Hope Cancer Center. He is also the chief medical officer of the International Myeloma Foundation (IMF) and director of myeloma research at the HonorHealth Research Institute. He is the principal investigator of many clinical trials, primarily in relapsed multiple myeloma. Dr Mikhael also serves as the treasurer on the executive board of the American Society of Hematology. Dr Mikhael has published over 200 peer-reviewed articles and lectures internationally on a regular basis. He leads the IMF’s diversity efforts, namely the M-Power project in the African American community. He is also the chair of the Diversity, Equity, and Inclusion Council at TGen. Dr Mikhael is heavily involved in training future researchers, mentoring junior faculty, and finding ways to enhance access to novel agents worldwide. 

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Beth Faiman, PhD, MSN, APN-BC, BMTCN, AOCN, FAAN, FAPO 
Dr Beth Faiman is an adult nurse practitioner in the Department of Hematology/Oncology at the Cleveland Clinic, a Case Comprehensive Cancer Center member under the Cancer Prevention, Control, and Population Research Program, and editor-in-chief of the Journal of the Advanced Practitioner in Oncology. She is also the editor of several books and author of numerous chapters and papers. In 2013, Dr Faiman was co-chair of the first Nursing Symposium at the International Myeloma Workshop and subsequent conferences. She has served on the American Board of Internal Medicine Maintenance of Certification Committee and as associate editor of the American Society of Hematology Clinical News. In 2023, Dr Faiman was given the NP/PA Educator of Distinction Award in Multiple Myeloma, and in 2022, she was named the Top NP in Hematology/Oncology and inducted as an inaugural Fellow of Advanced Practice in Oncology. Dr Faiman is a distinguished fellow in the American Academy of Nursing. She remains an active author, presenter, mentor, and educator on hematology, oncology, cellular therapies, and supportive cancer care.