CASES OF INAPPROPRIATE USE

MRAD GroupSeptember Interventions

60 year old female with diagnosis of major depressive disorder

Problem: Duplicate therapy Patient was filling citalopram 20 mg (SSRI) for

depression Provider requested paroxetine 30 mg (SSRI) to be

added to regimen Intervention:

Discussed duplication in therapy and recommended increasing dose of citalopram, switch to different SSRI, or alternative antidepressant

Provider accepted recommendations Unnecessary Cost: Non-significant Potential Negative Health Risk:

Increased risk for serotonin syndrome

30 year old male with diagnosis of depression

Problem- Inappropriate prescribing Patient on Latuda 40mg for depression and provider

increasing dose to Latuda 60 mg Latuda 60 mg is not a commercially available dose

(wanted Latuda 40mg and 20mg)

Intervention Contacted provider and recommended d/c Latuda

and initiate SSRI/SNRI Provider agreed to d/c Latuda and initiate Celexa

Unnecessary cost Approximate expenditure per year for 40mg

daily: $6,634 Potential negative health consequence

Uncontrolled depression

46 year old male with diagnosis of hypertension

Problem- Poor adherence No medications for hypertension filled since 3/2013

Intervention Contacted provider regarding poor adherence Nurse stated systolic blood pressure during last visit 170, yet patient

refused to go to hospital Notified nurse that patient has not filled any anti-hypertensives since

3/2013 Patient only filled nifedipine ER 90mg daily on 7.24.13

Patient has a 2-week follow-up visit with provider and stress echo scheduled

Nurse to reiterate non-compliance with provider and will relay recommendations to restart first-line medications and counsel patient on adherence Nurse was aware that minoxidil will be approved for 1 month only

Unnecessary Cost Approximate expenditure per year for 40mg daily: Not significant

Potential negative health consequences Organ damage, stroke, transient ischemic attacks, heart disease/failure,

peripheral artery disease, end stage renal disease and potential dialysis, retinopathy, etc.

53 year old female with diagnosis of type 2 diabetes

Problem- Unnecessary medications Patient with diabetes receiving Actos 45mg, Januvia

100mg, metformin 850mg, Humalog 100 units/ml, and Lantus 100 units/ml

Intervention Contacted provider and recommended d/c Actos and

Januvia and optimize insulin regimen Most recent HgbA1c was 10.6%

Provider agreed to d/c medications and reevaluate patients therapy at next office visit

Unnecessary cost Approximate expenditure per year: $3,317

Potential negative health consequences Uncontrolled diabetes, macro/microvascular

complications

63 year old male with diagnoses of hypertension and dyslipidemia

Problem – Drug Interaction Patient receiving amlodipine 10 mg for Hypertension and

simvastatin 40 mg daily for dyslipidemia New FDA warning: simvastatin should not exceed 20 mg when

used in combination with amlodipine due to increased risk of rhabdomyolysis

Intervention: Contacted provider and recommended to switch simvastatin 40 mg to

atorvastatin 20 mg (equivalent dose) Provider agreed with recommendations and initiated atorvastatin 20 mg

Update (9/18/13): Patient filled atorvastatin 20 mg on 9/13/13

Unnecessary cost: Approximate expenditure per year: Not significant

Potential negative health consequence: Increased risk of rhabdomyolysis

26 year old female with a diagnosis of depression

Problem – Non-compliance Provider requesting citalopram 40mg (max recommended

dose) Patient has not filled citalopram 20 mg since 2.26.13

Intervention Contacted provider and explained patient’s non-compliance

with citalopram Provider unaware of situation

Recommended initiating citalopram at starting dose Provider agreed to start citalopram at 20 mg daily

Unnecessary Cost Approximate expenditure per year: Non-significant

Potential negative health consequences Increased risk of side effects (QT prolongation, etc.)

61 year old female with diagnosis of hypertension and dyslipidemia

Problem: Drug Interaction Patient receiving simvastatin 40mg for dyslipidemia and

amlodipine 10mg for HTN New FDA warning: simvastatin should not exceed 20 mg when

used in combination with amlodipine

Intervention: Contacted provider and discussed FDA labeling regarding

dose limitations for simvastatin with concurrent amlodipine therapy

Recommended switching atorvastatin 20mg (equivalent dosing to simvastatin 40 mg)

Provider agreed with recommendation Unnecessary Cost:

Approximate expenditure per year: Not significant Potential Negative Health Risk:

Increased risk for myopathy, rhabdomyolysis

56 year old female with diagnosis of dyslipidemia

Problem – Inappropriate Therapy Patient with dyslipidemia and diabetes receiving fenofibrate

160 mg and pravastatin 20 mg Patient taking low dose statin and fibrate therapy

Intervention Contacted provider to obtain lipid panel

07.02.13 TG=98, LDL=70, HDL=46, TC=136 01.29.13 TG=117, LDL=91, HDL=45, TC=159 Peak TG=233 in 2011

Recommended increasing dose of pravastatin since LDL near goal and d/c fenofibrate since TG levels within normal range

Provider agreed to increase pravastatin to 40 mg daily and d/c fenofibrate

Unnecessary cost Approximate expenditure per year: not significant

Potential negative health consequences Increased risk of rhabdomyolysis

42 year old female with a diagnosis of migraines

Problem - Inappropriate Therapy Patient with migraines receiving nortriptyline 75 mg daily

New request for divalproex ER 500 mg for migraines

Intervention: Contacted provider and spoke with nurse Explained that adding on an agent is not appropriate therapy Recommended tapering off nortriptyline and increasing divalproex

dosing as appropriate Nurse agreed with recommendation and physician will reevaluate

patient at next visit

Unnecessary cost: Approximate expenditure per year: Not significant

Potential negative health consequence: Uncontrolled migraine headaches Increased pill burden

59 year old male with diagnosis of type 2 diabetes

Problem-Therapeutic product interchange Patient with diabetes Receiving multiple diabetic medications (oral and insulin)

Lantus 100 units/mL and Januvia 100 mg

Intervention Contacted provider and spoke with nurse Recommended optimization of insulin or use of metformin or

sulfonylurea if preferring to use PO agent Faxed recommendations per RN request Provider agreed to d/c Januvia and initiated glipizide ER 5 mg

Unnecessary cost Approximate expenditure per year : $3,084

Potential negative health consequences Uncontrolled diabetes, increased risk of marco/microvascular

complications

32 years old woman with diagnosis of bipolar disorder

Problem-inappropriate therapy Patient with bipolar disorder initiated on Latuda 20mg

without trying any other atypical antipsychotic or mood stabilizer

Intervention Contacted provider and had a conversation regarding

trying other atypical antipsychotics as they have more data to support use in bipolar disorder Provider chose Latuda because he thought he could choose

any preferred antipsychotic Prescriber was very appreciative about this information

and will initiate olanzapine and taper Latuda Unnecessary cost

Approximate expenditure per year : $6,634 Potential negative health consequences

Uncontrolled bipolar disorder

52 year old female with diagnosis of hypertension

Problem-Duplicate therapy Patient Receiving ramipril 10mg (ACE-I) and lisinopril

5mg (ACE-I) Intervention

Contacted provider and recommended d/c one agent and optimizing the dose of the other agent

Provider agreed to d/c ramipril and will consider increasing dose of lisinopril

Unnecessary cost Approximate expenditure per year: Not significant

Potential negative health consequences Hyperkalemia and hypotension

36 year old male with diagnosis of schizoaffective disorder

Problem- Multiple strengths being requested, unclear dosing, therapeutic interchange Requests were being submitted for quetiapine IR and ER 200 mg daily +

300 mg twice daily, but patient had filled 100 mg daily + 400 mg twice daily

Intervention Contacted provider regarding unclear total daily dosing Per nurse, patient was not supposed to be on quetiapine 100 mg daily

+ 400 mg twice daily Office was not aware that pharmacy had been incorrectly filling

remaining refills, rather than filling new order Reiterated that XR tabs were not preferred Provider and nurse agreed to switch to IR tabs and would notify

pharmacy about incorrect filling/dosage change Unnecessary Cost

Approximate expenditure per year: $16,495

Potential negative health consequences Potential for relapse/uncontrolled schizoaffective symptoms