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The Drug Utilization Review Board held their quarterly meeting on Thursday January 14, 2016 to discuss and vote on retrospective DUR, prospective prior authorization proposals, and retrospective drug use criteria for outpatient use in the Vendor Drug Program.
 
Retrospective Drug Utilization Review, Larry Dent (Xerox Heritage, LLC)

  • Retrospective DUR interventions were sent out for the appropriate use of Clozapine, management of Rheumatoid arthritis management, and bipolar disorder management
  • Report on recent retrospective DUR interventions outcome
    • Antibiotic prescribing state savings were over $372,000 in the last year
    • Drugs abuse management state savings were over $108,000 in the last year
    • Medication adherence management state savings were over $685,000 in the last year
  • Retrospective DUR Proposal for chronic non-cancer pain management
    • Intervention designed to improve appropriate and effective management of chronic non-cancer pain (CNCP) with opiate analgesics
    • Emerging concerns about respiratory depression in children 17 and younger receiving tramadol
    • FDA advisory panel recommended that codeine should be removed from OTC cough and cold remedies and a contraindication for individuals less than 18 years of age for treatment of cough or pain
    • Intervention type: Cover letter with individual patient profiles
    • Performance Indicators
      • Coordination of Care: Use of multiple opiates from multiple prescribers
        • In patients with CNCP, obtaining opiate analgesics from more than one physician may suggest possibility of inadequate pain relief and pain management
      • Underutilization of long-acting opiates
        • Excessive use of short-acting opiate analgesics may indicate inadequate pain relief
      • Increased Risk of Adverse Event: Tramadol Use with Renal or Hepatic Disease
        • Patients with renal disease or cirrhosis are at increased risk of adverse events if tramadol IR/ODT is not prescribed at recommended dosages
      • Potential Drug-Drug Interactions involving Tramadol and SSRIs
        • Patients with potential drug-drug interactions are at increased risk of having an adverse drug event
      • Increased Risk of Adverse Event: Pediatric use of codeine
        • Codeine’s activity depends on a certain enzyme pathway in the liver that partially converts the drug into morphine
      • Increased Risk of Adverse Event: Pediatric use of Tramadol
        • Tramadol is not FDA-approved for use in individuals less than 18 years of age, however data shows it is being used “off-label” in the pediatric population
        • It is converted in the liver to the active form of the opioid, called O-desmethyltramadol
      • Patients who are ultra-rapid CYP2D6 metabolizers may develop toxic blood levels
    • Intervention is approved by the board
  • Retroactive DUR proposal for Attention Deficit Hyperactivity Disorder (ADHD) medication management
    • Intervention to ensure the safe and effective use of the medications for ADHD as established by practice guidelines, other recently published literature, and Food and Drug Administration prescribing information
    • ADHD is most common childhood developmental disorder
    • Prevalence rate of 8-10% in school children
    • Intervention type: cover letter and individual patient profiles
    • Performance Indicators
      • High-Dose use of ADHD medications
        • Risk for adverse events with ADHD medications, including serious and possibly fatal cardiac complications, increases as the dose of the agent increases
      • Overutilization of C-II Stimulants
        • C-II stimulant ADHD medications have potential for abuse
        • Over-utilization has become a growing concern
      • Risk of suicidal ideation with Atomoxetene
      • Dose Consolidation
        • By consolidating dosages, medication compliance may increase and pharmaceutical expenditure may decrease
    • Intervention Approved
  • Retroactive DUR proposal for Stroke Prevention
    • Purpose is to reduce the risk of stroke in high risk patients by encouraging the utilization of appropriate drug therapies in accordance with currently recognized clinical practice guidelines, consensus statements, and medical literature
    • 795,000 people in the US experience a stroke each year
    • In 2009 stroke accounted for nearly 1 out of every 19 deaths in the US
    • Intervention type: cover letter and individual patient profiles
    • Performance Indicators
      • Underutilization of anticoagulation therapy
        • Atrial fibrillation is a major independent risk factor for stroke
        • Estimating stroke risk for patients can help providers balance the risk versus benefit of long-term antithrombotic therapy for primary and secondary stroke prevention
      • Non-adherence with oral anticoagulation therapy
        • Adherence to prescribed medication is important to realize the full benefit of therapy
      • Discontinuation of oral anticoagulation therapy
        • Current stoke and AF guidelines recommend long-term anticoagulation for stroke prevention in high risk atrial fibrillation patients
      • Warfarin monitoring
        • Routine monitoring of Warfarin in therapy is important because both the safety and effectiveness of warfarin therapy depend on maintaining the INR within a defined therapeutic range
      • Increased risk of adverse drug events with antiplatelet medications
        • Some medical conditions may predispose patients to adverse events with antiplatelet therapy
      • Increased risk of adverse drug events with oral anticoagulant medications
        • Some medical conditions may predispose patients to adverse events with oral anticoagulant therapy
      • Duplicate anticoagulant therapy
        • Duplicate within-class drug therapy has not been shown to increase efficacy and may increase the risk of adverse drug events
      • Duplicate antiplatelet therapy
        • Has not been shown to increase efficacy and may increase the risk of adverse drug events
      • High dose antiplatelet therapy
        • Doses exceeding recommendations will not provide additional effects and may increase the risk of adverse events
      • High dose anticoagulant therapy
        • Will not provide additional effects and may increase the risk of adverse events
      • Non-adherence with antihypertensive, antilipemic and antiplatelet therapy in those at risk for stroke
        • Hypertension, hyperlipidemia and established cardiovascular disease are all independent modifiable risk factors for stroke
        • Management of these conditions is an important component of stroke prevention
      • Drug-drug interactions with oral anticoagulants
        • Increased concentrations of oral anticoagulant drugs, resulting from drug interactions, can put patients at an increased risk of bleeding
        • Decreased concentration of oral anticoagulants, resulting from drug interactions, can put patients at an increased risk of a stroke
    • Intervention Approved

 
Prospective prior authorization proposals, Christina Faulkner (Health Information Designs, LLC)

  • Neuropathic Pain – Lyrica Edits
    • Drugs requiring prior authorization
      • List of drugs requiring prior authorization for this clinical edit
    • Prior authorization criteria logic
      • Is the client older than or equal to 18 years?            
        • The board changes this to 12 years
        • If no, deny
        • If yes, move on
      • Does the client have a diagnosis of partial seizure disorder in the last 730 days?
        • The board gets rid of this question
      • Does the client have a diagnosis of postherpetic neuralgia, fibromyalgia, or neuropathic pain associated with either diabetic neuropathy or spinal cord injury in the last 730 days?
        • The board gets rid of this question
      • Does the client have more than 3 claims for controlled substances (excluding the incoming claim) and more than 3 providers in the last 30 days?
        • The board gets rid of this question
      • Does the client have a diagnosis of pregnancy in the last 310 days?
        • If yes move on
        • If no – approve
      • Does the client have a diagnosis to negate the pregnancy diagnosis in the last 310 days?
        • If yes, approve
        • If no, deny
      • Logic diagram
        • Visual depiction of the clinical edit criteria logic
      • Collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes)
      • References
      • Board approves
  • Cialis
    • Cialis is not currently on the formulary because the Social Security Act prohibits any medicine which sole purpose is to treat ED
    • Need to add diagnosis check for BPH to allow it on the formulary
    • Board decides not to take action on this, and to leave it to the next board if they decide to take it up

 
Retrospective drug use, criteria outpatient use in Vendor Drug Program, Jennifer Seltzer (University of Texas at San Antonio)

 
Meeting adjourned