Cost Effective Medicine

1
Cost Effective Medicine

• Julienne Kirk, PharmD.
• Courtney Blackwell, PharmD. Candidate

2
Case 1

• 48 year old male with a PMH of HTN and
  hyperlipidemia. He last cholesterol profile
  showed a TC of 205, LDL 135, HDL 42 and TG 139.
  You ask how he pays for his medication and he
  tells you in his current construction job there
  is no drug coverage. He had a anterior MI 1 year
  ago.
• What should you think about for pharmacotherapy
  treatment regimen. His current medications
  include Lipitor 10 mg daily(89.99) and Toprol XL
  50 mg daily (32.99). He was taking generic
  Plavix 75 mg daily(135.99 brand) but it was
  withdrawn. He pays 258.97 for his meds per month.

3
Cholesterol Goals

• LDL
• TG
• HDL 45 men 55 women
• Does patient have CV Risk Equivalents (CRE) or CV
  Risk Factors?

JAMA 2001 2852486-97, Grundy SM et al.
Implications of Recent Clinical Trials for the
NCAP ATP III Guidelines. Circulation
2004110227-239.
4
CV Risk Equivalent (CRE) defined as

• Clinical forms of atherosclerotic disease
• Clinical CHD
• Symptomatic carotid artery disease
• Peripheral arterial disease
• Abdominal aortic aneurysm
• Diabetes
• Multiple risk factors that confer a 10 yr risk
  for CHD 20 (Framingham score)

5
CV risk factors

• Cigarette Smoking
• High Blood Pressure
• 130/85
• antihypertensive medication
• Low HDL
• If HDL 60mg/dL counts as a negative risk
  factor, subtract 1 from your total count

• Family History of CHD
• father/brother
• mother/sister
• Age
• men 45yrs
• women 55yrs

6
LDL Goals

• Risk Category LDL Goal
• 2 CREs or 1 CREMRF (very high risk)
• (uncontrolled DM, recent acute coronary
  syndrome,
• metabolic syndrome, smoker)
• 1 CRE (high risk)
• (10-yr risk for CHD 20)
• 2 Risk Factors and 10-yr risk for CHD
• 10-20
• 0-1 Risk Factor

JAMA 2001 2852486-97, Grundy SM et al.
Implications of Recent Clinical Trials for the
NCAP ATP III Guidelines. Circulation
2004110227-239.
7
Case 1

• Alternatives to current regimen
• Simvastatin (Zocor ) 10 mg 54.99
• Metoprolol Succinate ER 25 mg 25.99
• Lovastatin 10, 20 mg 4.00
• Pravastatin 10, 20, 40 mg 4.00

Prices www.walgreens.com / www.drugstore.com
8
ACEIs - Approximate Dose Conversions

• Captopril 6.25mg TID Enalapril 2.5mg BID
  Lisinopril 5mg daily Benazepril 5mg daily
  Ramipril 1.25mg BID
• Captopril 12.5mg TID Enalapril 5mg BID
  Lisinopril 10mg daily Benazepril 10mg daily
  Ramipril 2.5mg BID
• Captopril 25mg TID Enalapril 10g BID
  Lisinopril 20mg daily Benazepril 20mg daily
  Ramipril 5mg BID
• Captopril 50mg TID Enalapril 20g BID
  Lisinopril 40mg daily Benazepril 40mg daily
  Ramipril 10mg BID

9
Potency of the STATINS

• LDL lowering at each dose
• Statin 5 mg 10 mg 20 mg 40 mg 80 mg
• Atorvastatin 38 45 51 55
• Fluvastatin 17 24 32
• Lovastatin 24 32 40
• Pravastatin 24 33 40
• Rosuvastatin 43 50 55 62
• Simvastatin 30 36
  41 49
• TG Rosuvastatin Atorvastin ? 23-26 Dose
  related
• Simvastatin ?15-18
• Pravastatin ? 13
• HDL ? 5-12

10
Drug Interactions

• 3A4 pathway Lovastatin, Simvastatin,
  Atorvastatin
• Cyclosporine, erythromycin, clarithromycin,
  telithromycin
• Itraconazole, ketoconazole
• Fluoxetine, sertraline
• Use pravastatin/rosuvastatin when in doubt
• Warfarin 2C9
• Fluvastatin (worst)
• Rosuvastatin (to be determined)
• All statins have shown to increase INR, monitor
  within 7 days

11
Drug Interactions

• Fibrates
• Avoid gemfibrozil if possible with
• Lovastatin
• Simvastatin
• Atorvastatin

• Interactions
• Gemfibrozil
• Niacin
• Cyclosporine
• Verapamil
• Diltiazem
• Amiodarone
• Grapefruit 200 ml not with lovastatin,
  simvastatin, atorvastatin

12
Drug Interactions

• Lovastatin
• The dose of lovastatin should not exceed 20 mg
  daily in patients receiving concomitant
  medication with cyclosporine, gemfibrozil, other
  fibrates or lipid-lowering doses (1 g/day) of
  niacin.
• The dose of lovastatin should not exceed 40 mg
  daily in patients receiving concomitant
  medication with amiodarone or verapamil. The
  combined use of lovastatin at doses higher than
  40 mg daily with amiodarone or verapamil should
  be avoided unless the clinical benefit is likely
  to outweigh the increased risk of myopathy.

Lovastatin, Mevacor Product Info 2002
13
Hypertension 4 Examples

• Atenolol 25 mg 30
• Chlorthalidone 25 mg 30
• Diltiazem 60 mg 60
• Lisinopril 10 mg 30
• Furosemide 40 mg 30
• Metoprolol 50 mg 60
• Spironolactone 25 mg 30
• Propanolol 20 mg 60

www.target.com / www.walmart.com
14
Case 1

• Plavix
• Clopidogrel, the generic version of Plavix, was
  originally released during the summer of 2006.
  However, the generic version was removed from the
  market a short time later because of a patent
  dispute between the generic (Apotex) and brand
  (Bristol-Myers) company. Bristol-Myers maintains
  that their patent protection runs until November
  2011.

15
Case 2

• 59 year old female with a PMH significant for
  COPD and now a 6 day h/o productive cough, fever
  with occasional chills. She smokes 1 PPD. Some
  weakness, but no respiratory distress. - nv,
  headache, MS change or diarrhea. PE. - VS - RR-
  22 (unlabored) bp-120/60 p-108 temp- 101. Pulse
  ox - 91
• Medications Atrovent and Advair Inhalers
• Chest - rales at lung bases RL. No wheezing,
  scattered rhonchi
• CXR - Patchy RLL pneumonia

16
IDSA Guidelines - CAP in Outpatients

• Recommended treatments for CAP in outpatients
  are
• Previously healthy
• No recent antibiotic therapy macrolide or
  doxycycline
• Recent antibiotic therapy a respiratory
  fluoroquinolone, an advanced macrolide plus high
  dose amoxicillin, or an advanced macrolide plus
  high dose amoxicillin-clavulanate

Adapted from Mandell LA et al. Clin Infect Dis.
2003 1405-1433
17
IDSA Guidelines - CAP in Outpatients

• Recommended treatments for CAP in outpatients
  are
• Comorbidities (COPD, malignancy, diabetes, renal
  or CHF)
• No recent antibiotic therapy an advanced
  macrolide or respiratory fluoroquinolone
• Recent antiobiotic therapy a respiratory
  fluroquinolone alone or an advanced macrolide
  plus beta-lactam
• Suspected aspiration with infection Augmentin
  or clindamycin
• Influenza with bacterial superinfection a
  beta-lactam or respiratory fluoroquinolone

Adapted from Mandell LA et al. Clin Infect Dis.
2003 1405-1433
18
Case 2

• Cost of current medications
• Advair 250/50 185.22
• Atrovent 0.03 64.63

Prices www.walgreens.com / www.drugstore.com
19
Case 2

• Cost of treatment for pneumonia
• No recent antibiotic therapy
• Azithromycin 500 mg daily x 7 days 151.55
• Clarithromycin XL 500 mg pack 233.99
• Doxycycline 100 mg BID x 10 days 4.00
• Recent Antibiotic therapy
• Moxifloxacin 400 mg daily for 7-14 days 326.95
• Amoxicillin 1 gram TID 10-14 days 15.98
• Augmentin XR (1000/62.5) Two 1000 mg tablets
  every 12 hours for 7-10 days 96.30

Prices www.walgreens.com / www.drugstore.com
20
Antibiotics 4 Examples

• Amoxicillin 500 mg 30
• Cephalexin 500 mg 30
• Ciprofloxacin 500 mg 30
• Metronidazole 500 mg 14
• Penicillin VK 250 mg 28
• SMZ/TMP DS 800/160 20
• Tetracycline 500 mg 60

www.target.com / www.walmart.com
21
Case 3

• 55 year old AA male with A1C of 9.6. PMH HTN,
  type 2 diabetes, hyperlipidemia, ED, and OA
• BP 144/90, Lipids TC 176, LDL 92, HDL 53, TG
  157, microalb 30 mg/L (15 mg/g), 73 inches wt.
  185.
• Meds Lipitor 10 mg daily (89.99), generic
  Norvasc 10 mg daily (64.00), Metformin 500 mg
  bid (4.00). He currently pays 157.99 per month
  for his medications.
• Only checks glucose occasionally, complaining of
  cost of meds

22
Diabetes 4 Examples

• Glimepiride 2 mg 30
• Glipizide 10 mg 60
• Glyburide 5 mg 30
• Metformin 1000 mg 60
• Metformin ER 500 mg 60

www.target.com / www.walmart.com
23
Case 3

• Other options to consider for the patient since
  he has diabetes
• Lisinopril 2.5, 5, 10, 20 mg 4.00
• Benazepril 5, 10, 20, 40 mg 4.00
• Aspirin 81 mg (1000 count) 22.29
• Lovastatin 10, 20 mg 4.00
• Pravastatin 10, 20, 40 mg 4.00

24
Case 4

• 65 year old obese woman with Type 2 DM, diabetic
  nephropathy, and HTN. She works as a seamstress.
  She c/o hand pain and stiffness and R knee pain
  stiffness.
• She has been taking APAP 1gm QID regularly for 1
  month. It has helped with the pain, somewhat,
  but she still has significant pain and is asking
  for something stronger.
• She takes the following medications Glipizide
  10mg BID, Lisinopril 10mg daily, HCTZ 25mg daily,
  ASA 81mg daily.

25
Pharmacotherapy for OA

• Acetaminophen (APAP) lst line therapy
• COX-2-specific inhibitor should be considered
  when APAP is ineffective or inflammation is
  present
• Celecoxib
• NSAIDs/salicylates
• Ibuprofen
• Naproxen
• Nabumetone

American College of Rheumactology
26
Pharmacotherapy Guidelines for OA

• Corticosteroid Injections (intra-articular)
• Hyaluronic Acid Derivatives
• Hyalgan 10 mg/mL (2) 132.99
• Topical
• Capsaicin cream 16.71   
• therapy is individualized for each patient

American College of Rheumactology
27
Pharmacotherapy Guidelines for OA

• Adjunctive Therapy
• Glucosamine
• 500 mg TID
• Chondroitin
• 1200 mg/day
• Box of 120 29.99

Prices www.walgreens.com / www.drugstore.com
28
Side Effects

• APAP
• Hepatotoxicity can occur with overdose

• NSAIDs/Salicylates
• Should not be used in pts with HTN
• Nausea
• Diarrhea
• Abdominal pain
• Dyspepsia

29
Side Effects

• COX-2 Inhibitors
• GI toxicity
• Dyspepsia
• Ulcerations/bleeds
• Renal toxicity
• Hyperkalemia
• Hyponatremia

• Hepatoxicity
• CNS toxicity
• Drowsiness
• Confusion
• Dizziness
• CV effects
• Fluid retention

30
Side Effects

• Narcotics
• Sedation
• Constipation
• Nausea
• Vomiting
• Orthostatic hypotension

• Syncope
• Dysphoria
• Confusion
• Respiratory depression

31
Side Effects

• Glucosamine
• GI discomfort
• Fatigue
• Skin rash
• May alter serum glucose levels

• Chondroitin
• Prolonged bleeding time
• Nausea

32
Anti-inflammatory 4 Examples

• Dexamethasone 0.5 mg 30
• Diclofenac 75 mg 60
• Ibuprofen 800 mg 30
• Indomethacin 25 mg 60
• Meloxicam 7.5, 15 mg 30
• Naproxen 375, 500 mg 60
• Methylprednisolone 4 mg dosepack
• Prednisone 2.5, 5, 10, 20 mg 30
• Triamcinolone 0.1 cream 15GM

www.target.com / www.walmart.com
33
Case 5

• 56 year old WM comes into the clinic complaining
  of not being able to sleep for the past 4 months.
  He has no PMH. He also says he has had trouble
  staying focused at work and doesnt care about
  his job. He used to exercise every day, but now
  he just wants to come home and do nothing. He is
  under a lot of stress at work. He also says he is
  tired all of the time.
• What pharmacotherapy would you consider for this
  patient?

34
Side Effects of Antidepressants

• SSRIs
• Nausea (highest with sertraline)
• Insomnia (fluoxetinesertralinecitalopramlexapro
  paroxetine)
• Headache
• Sedation (highest with paroxetine
  citalopramlexapro
• fluoxetinesertraline)
• Dry mouth (highest with paroxetine)
• Cardiac history

• TCAs
• Sedation
• Hypotension
• Weight gain
• Sexual dysfunction
• Dries everything
• Use with caution in patients with history of MI

35
Side Effects of Antidepressants

• SNRIs
• Nausea
• Headache
• Increase BP with doses 200 mg/d
• Sexual dysfunction

• Bupropion
• Increased energy/activation
• Little anticholinergic
• Sedation
• Sexual dysfunction
• Weight gain

36
Case 5

• May consider these options
• SSRI first line therapy
• Lexapro 10 mg 80.31
• TCA
• Nortriptyline 25 mg 9.99
• SNRI
• Venlafaxine 75 mg 60.99
• Bupropion XL 300 mg 129.99

37
Antidepressant 4 Examples

• Amitriptyline 75 mg 30
• Citalopram 40 mg 30
• Fluoxetine 10 mg 30
• Paroxetine 20 mg 30
• Trazodone 100 mg 30
• Doxepin 25 mg 30

www.target.com / www.walmart.com
38
Case 6

• 65 year old AA female was recently diagnosed with
  CHF and Afib.
• Her labs include EF(30), BP 118/80, Na (138),
  Mg (2.0), BUN(20), SCr (0.8).
• She is currently on Coreg 3.125 mg BID (115.55),
  Furosemide 40 mg daily (4.00), Altace 10 mg
  daily (63.99), and Warfarin 5 mg (4.00).
• The cost of her current regimen is 187.54.

39
Stages of Heart Failure

• Stage A
• HF risk factors
• no heart disease
• no symptoms
• Stage B
• Heart disease
• no symptoms

• Stage C
• Prior or current HF symptoms
• Stage D
• Refractory HF symptoms

AHA/ACC HF guidelines 2005
40
Stages of Heart Failure Treatment

• Stage A
• Treat risk factors
• Avoid toxins
• ACEI in selected patients
• Stage B (in selected patients)
• ACEI
• Beta-blockers

• Stage C
• Diuretics
• ACEI
• Beta-blockers
• Aldosterone antagonists
• Digitalis
• Stage D
• Palliative therapy
• Heart transplant
• Mechanical assist device

AHA/ACC HF guidelines 2005
41
Stage A Recommendations
Patients at high risk for developing HF

• Treatment per contemporary guidelines
• Lipids, DM, HTN, atherosclerotic disease,
  ventricular rate control in patients with Afib,
  etc.
• Patient education avoidance of behaviors that
  increase HF risk smoking, excessive alcohol,
  cocaine, amphetamines)

• Thiazide diuretic-based BP treatment has
  repeatedly prevented HF in a wide range of
  patients
• ACEIs and beta-blockers are also effective
• Ca blockers alpha-blockers are less effective
  in preventing HF
• ARBs (losartan and irbesartan) have decreased HF
  in patients with Type 2 diabetes and nephropathy

AHA/ACC HF guidelines 2005
42
Stage B Recommendations
Structural abnormalities or remodeling without
history of HF symptoms

• Class 1 recommendations
• All class 1 recommendations for Stage A
• ACEIs and beta-blockers if history of MI or LVEF
  
• Carvedilol
• Toprol XL
• Bisoprolol
• ARB for post MI patients intolerant of ACEIs

AHA/ACC HF guidelines 2005
43
Stage B Recommendations

• Structural abnormalities or remodeling without
  history of HF symptoms

• Class 2a recommendations
• ACEIs ARBs may benefit patients with HTN and
  LVH without HF symptoms
• ARBs may benefit low EF patients intolerant of
  ACEIs
• ICD for selected patients

• Class 3 recommendations
• Avoid Digoxin (unless beta-blocker fails to
  control ventricular rate in Afib patients)
• Avoid Ca blockers with negative inotropic effects

AHA/ACC HF guidelines 2005
44
Stage C Recommendations
Current or prior HF symptoms

• Class 1 recommendations
• All Class 1 recommendations for Stages A B
• Diuretics sodium restriction if evidence of
  fluid retention
• ACEIs
• Beta-blockers
• Carvedilol
• Toprol XL
• Bisoprolol
• ARBs if ACEI intolerant
• Candesartan
• Valsartan
• Avoid drugs that worsen HF (NSAIDs including
  COX-2 inhibitors, most antiarrhythmics, and most
  Ca blockers)

AHA/ACC HF guidelines 2005
45
Stage C Recommendations
Current or prior HF symptoms

• Class 1 recommendations
• Exercise training
• ICD in select patients
• Aldosterone antagonists reasonable if moderately
  severe to severe HF symptoms

• Class 2a recommendations
• Digoxin may decrease HF hospitalizations
• Addition of combined hydralazine nitrate
  reasonable in patients with persistent symptoms
  who already maximized on ACEI and beta-blocker
• ICD in select patients

AHA/ACC HF guidelines 2005
46
Stage C Recommendations
Current or prior HF symptoms

• Class 2b recommendations
• Combined hydralazine and nitrate reasonable in
  patients intolerant to ACEIs and ARBs
• Renal insufficiency
• Hyperkalemia
• Angioedema

• Class 3 recommendations
• Avoid routine use of ACEI, ARB, aldosterone
  antagonist
• Avoid routine Ca blockers
• Avoid long term IV positive inotropes

AHA/ACC HF guidelines 2005
47
Stage D Recommendations
Refractory end-stage HF

• Class 1 recommendations
• Control of fluids
• Referral for transplant
• Referral to HF program
• Discuss end-of-life options with patient family
• Inform patient of option to inactivate ICD
• Class 2a recommendations
• Consider LV assist device if 1 year mortality
  50
• Class 3
• Avoid routine intermittent IV inotropics

AHA/ACC HF guidelines 2005
48
Case 6

• Alternative option for ACE-I
• Lisinopril 10 mg 4.00
• Enalapril 10 mg 4.00
• Metoprolol Succinate ER 25.99
• Toprol XL 100 mg 44.99

Approximate Dose Conversions Atenolol 25mg
daily Metoprolol 25mg BID Toprol XL 50mg
daily Carvedilol 6.25mg BID Atenolol 50mg daily
Metoprolol 50mg BID Toprol XL 100mg daily
Carvedilol 12.5mg BID Atenolol 100mg daily
Metoprolol 100mg BID Toprol XL 200mg daily
Carvedilol 25mg BID
49
Cardiac 4 Examples

• Digitek 0.125 mg 30
• Digitek 0.25 mg 30
• Warfarin 5 mg 30 (this is the only strength
  available)

www.target.com / www.walmart.com
50
Recently Approved Generics

• Analgesic
• Fentanyl 200 mcg 499.99
• Antibiotics
• Azithromycin Z-PAK 45.99
• Clarithromycin XL 500 mg 209.99
• Corticosteriod
• Fluticasone 59.99

• Actiq 200 mcg 730.09
• Zithromax Z-PAK 63.99
• Biaxin XL 500 mg
• 306.68
• Flonase 85.94

Prices www.walgreens.com / www.drugstore.com
51
Recently Approved Generics

• Antihypertensive
• Metoprolol Succinate Er 25 mg 25.99
• Trandolapril 2 mg 37.99
• Amlodipine 10 mg 64.00
• Amlodipine Benazepril 10/20 mg (price
  unavailable)
• Cholesterol
• Simvastatin 10 mg 54.99
• Depression
• Sertraline 100 mg 63.99
• Bupropion XL 300 mg 129.99
  

• Toprol XL 25 mg 32.99
• Mavik 2 mg 45.99
• Norvasc 10 mg 73.67
• Lotrel 10/20 mg 116.99
• Zocor 10 mg 90.99
• Zoloft 100 mg 93.99
• Wellbutrin XL 300 mg 176.99

Prices www.walgreens.com / www.drugstore.com
52
Recently Approved Generics

• Sleep Aid
• Zolpidem 10 mg 114.99
• BPH
• Finasteride 5 mg 84.99
• Incontinence
• Oxybutynin 10 mg 89.99
• Antiemetic
• Ondansetron 8 mg 1048.95

• Ambien 10 mg 147.99
• Proscar 5 mg 105.99
• Ditropan XL 10 mg 112.99
• Zofran 8 mg 1167.89

Prices www.walgreens.com / www.drugstore.com
53
Generics in the future?

• Clopidogrel (Plavix)
• Risperidone (Risperdal)
• Alendronate (Fosamax)
• Ipratropium and Albuterol (DuoNeb )
• Terbinafine (Lamisil)

• Lansoprazole
• (Prevacid )
• Donepezil (Aricept )
• Valproic Acid and Derivatives (Depakote )
• Cetirizine (Zyrtec )
• Desloratadine
• (Clarinex )

54
4 Program

• Designed to make medications affordable
• Includes 14 of the top 20 prescribed medications
• Applies to up to a 30 day supply at commonly
  prescribed dosages
• Complete list of medications can be found at
  www.walmart.com or www.target.com