Survey of hospital policies regarding low-molecular-weight heparins

A Review and Assessment of Drug-Induced Thrombocytosis

OBJECTIVES

The purpose of this article is to review the current literature on drug-induced thrombocytosis with the goal of critically assessing causality and providing a comprehensive review of the topic. Thrombopoietic growth factors, such as thrombopoietin-receptor agonists (romiplostim and eltrombopag) and erythropoietin are not included in our review.

DATA SOURCES

The literature search included published articles limited to the English language and humans in MEDLINE, EMBASE, and Web of Science databases. MEDLINE/PubMed (1966 to September 2018) was searched using the MeSH terms thrombocytosis/chemically-induced and thrombocytosis/etiology. EMBASE (1980 to September 2018) was searched using the EMTAGS thrombocytosis/side effect. Web of Science (1970 to September 2018) was searched using the search term thrombocytosis. References of all relevant articles were reviewed for additional citations and information.

STUDY SELECTION AND DATA EXTRACTION

Review articles, clinical trials, background data, case series, and case reports of drug-induced thrombocytosis were collected, and case reports were assessed for causality using a modified Naranjo nomogram.

DATA SYNTHESIS

Drug-induced thrombocytosis, a form of reactive thrombocytosis cannot be easily differentiated from more common etiologies of reactive thrombocytosis. In all, 43 case reports of drug-induced thrombocytosis from a wide variety of drugs and drug classes were reviewed using a modified Naranjo probability scale that included criteria specific for thrombocytosis.

CONCLUSIONS

Drug-induced thrombocytosis is a relatively rare adverse drug reaction. The strongest evidence of causality supports low-molecular-weight heparins and neonatal drug withdrawal. Weaker evidence exists for all-trans retinoic acid, antibiotics, clozapine, epinephrine, gemcitabine, and vinca alkaloids.

ePrescribing: Reducing Costs through In-Class Therapeutic Interchange

INTRODUCTION

Spending on pharmaceuticals in the US reached $373.9 billion in 2014. Therapeutic interchange offers potential medication cost savings by replacing a prescribed drug for an equally efficacious therapeutic alternative.

METHODS

Hard-stop therapeutic interchange recommendation alerts were developed for four medication classes (HMG-CoA reductase inhibitors, serotonin receptor agonists, intranasal steroid sprays, and proton-pump inhibitors) in an electronic prescription-writing tool for outpatient prescriptions. Using prescription data from January 2012 to June 2015, the Compliance Ratio (CR) was calculated by dividing the number of prescriptions with recommended therapeutic interchange medications by the number of prescriptions with non-recommended medications to measure effectiveness. To explore potential cost savings, prescription data and medication costs were analyzed for the 45,000 Vanderbilt Employee Health Plan members.

RESULTS

For all medication classes, significant improvements were demonstrated - the CR improved (proton-pump inhibitors 2.8 to 5.32, nasal steroids 2.44 to 8.16, statins 2.06 to 5.51, and serotonin receptor agonists 0.8 to 1.52). Quarterly savings through the four therapeutic interchange interventions combined exceeded $200,000 with an estimated annual savings for the health plan of $800,000, or more than $17 per member.

CONCLUSION

A therapeutic interchange clinical decision support tool at the point of prescribing resulted in increased compliance with recommendations for outpatient prescriptions while producing substantial cost savings to the Vanderbilt Employee Health Plan - $17.77 per member per year. Therapeutic interchange rules require rational targeting, appropriate governance, and vigilant content updates.

Survey of hospitals for guidelines, policies, and protocols for anticoagulants

PURPOSE

A survey of community hospitals that are part of a national group purchasing organization (GPO) was conducted to assess the formulary status of currently available anticoagulants, assess the current status of anticoagulant prescribing guidelines and the existing scope of such guidelines, and identify perceptions about the appropriateness of the use of anticoagulants in community hospitals in the United States.

METHODS

A Web-based survey of acute care hospitals that were members of a leading health care resource management and GPO was conducted. The survey was sent to 224 hospitals.

RESULTS

Of 224 hospitals, 127 participated in the survey, a response rate of 59.6%. Warfarin, unfractionated heparin (UFH), and enoxaparin were the anticoagulants most commonly included (>80%) on the hospitals' drug formularies. Guidelines relating to the use of UFH and low-molecular-weight heparins (LMWHs) existed in approximately 87.4% and 55.1% of responding hospitals, respectively, followed by warfarin and direct thrombin inhibitors (DTIs) (approximately 44.1% and 30.7%, respectively). Among hospitals without guidelines, 78.2%, 72.1%, 65.4%, 50.0%, and 41.4% reported that such guidelines would be useful if they included LMWHs, warfarin, DTIs, UFH, and fondaparinux, respectively. Guidelines for prophylaxis of venous thromboembolism (VTE), appropriate drug selection, and dosing for VTE prophylaxis and treatment existed in 59.8%, 53.5%, and 43.3% of the hospitals, respectively.

CONCLUSION

The study found that a sizable percentage of the responding community hospitals did not have guidelines, protocols, or policies related to the use of anticoagulants. Further, those hospitals without such guidelines commonly reported a need for clinical practice guidelines.

Treatment of Cancer-Associated Thrombosis: Distinguishing Among Antithrombotic Agents

The risk of cancer-associated thrombosis can be substantial, depending on tumor type, extent of cancer, and type of treatment. Unfractionated heparin and warfarin have been used in the prevention of cancer-associated thrombosis, but low-molecular-weight heparin (LMWH) is widely used for the prevention of venous thromboembolism in high-risk patients. Long-term management with warfarin is associated with close monitoring, an increased risk of drug interactions, and bleeding. LMWHs may offer an alternative outpatient treatment strategy for prophylactic treatment because of their simpler dosing, more predictable anticoagulant activity, and improved safety profile. Clinical trials examining the treatment of venous thromboembolism with LMWH in patients with cancer suggest a survival advantage for the treated groups. Subtle differences in the pharmacokinetics of available LMWHs exist, and each LMWH should be regarded as a distinct drug. Pharmacists should be aware of the US Food and Drug Administration-approved uses for each LMWH, dosing options, and the advantages and disadvantages of available delivery systems for various patient populations. Pharmacists can play a major role in educating patients and other health care professionals on risk factor recognition, patient risk stratification, and proper agent selection for prevention and treatment of cancer-associated thrombosis.

Factors that influence prescribing within a therapeutic drug class

RATIONALE, AIMS AND OBJECTIVES

The decision to prescribe one drug instead of another within the same therapeutic class may be influenced by a variety of drug-related, direct, or indirect factors; but little is known about which considerations are most important in such choices. The low-molecular-weight heparins (LMWHs) represent a class of drugs that are commonly used and for which therapeutic equivalence has been debated in the literature. The purpose of this study was to identify and compare factors perceived by doctors and clinical pharmacists to be influential in prescribing decisions among LMWHs.

METHODS

Doctors and clinical pharmacists were interviewed to elicit information and to rank factors that influence the prescribing and use of LMWHs in community hospitals in the United States. For each factor, the mean and median of the rating were determined along with the frequency distribution across ratings. The non-parametric Mann-Whitney U-test was used to examine differences between doctors and clinical pharmacists.

RESULTS

Both groups considered efficacy, formulary status, and policies restricting drug use to be highly influential in the decision to use one LMWH instead of another. Compared to clinical pharmacists, doctors rated personal experience as more influential, whereas they rated drug cost and prescribing guidelines lower.

CONCLUSIONS

These findings suggest that doctors and clinical pharmacists differentiate between LMWHs based on differences between products and because of hospital administrative programs (such as drug formularies). This information may be of value in designing programs to alter medication use.

Impact of Prescribing Guidelines for Inpatient Anticoagulation

BACKGROUND

Anticoagulants are widely used and represent a class of drugs that are problem-prone and have a high potential for adverse patient outcomes. As such, these drugs may be amenable to the use of prescribing guidelines. However, relatively little has been published on the effect of such guidelines on clinical outcomes or costs of care.

OBJECTIVE

To assess whether guidelines improve the appropriateness of prescribing, clinical outcomes, and costs associated with use of anticoagulants in a sample of community hospitals in the US.

METHODS

A retrospective analysis was performed of data voluntarily collected by 15 hospitals before (July—September 2001) and after (March—May 2002) implementation of anticoagulant prescribing guidelines. Statistical analyses of both patient- and hospital-level variables were conducted.

RESULTS

Implementation of the guidelines resulted in a significant increase in the proportion of anticoagulants that were prescribed appropriately (59.8% vs 86.9%; p < 0.001). The guidelines also resulted in a shift in the type of anticoagulants prescribed (decreased use of unfractionated heparin and increased use of low-molecular-weight heparins). There was suggestive evidence, although not statistically significant, that the guidelines resulted in fewer anticoagulant-associated adverse events (total bleeding RR 0.71) and lower costs (savings of $56.15 per patient per day).

CONCLUSIONS

While limitations existed with the study design, sufficient benefits were identified to warrant hospitals to consider use of these or similar guidelines on a routine basis. Clearly, additional study in this area would be useful.

Guidelines for Acute Decompensated Heart Failure Treatment

OBJECTIVE

To describe the development of guidelines for the treatment of acute decompensated heart failure (ADHF) in the emergency department/observation unit (ED-OU) setting for hospitals that are part of a group purchasing organization (GPO).

DATA SOURCES

A MEDLINE search (1966-March 2003) using the following search terms: cardiotonic agents; diuretic; dobutamine; heart failure, congestive; milrinone; natriuretic peptide, brain; nesiritide; nitroglycerin; vasodilator agents, was conducted.

STUDY SELECTION AND DATA EXTRACTION

Relevant articles in the English language were identified. All randomized studies and meta-analyses for each category of drugs were included.

DATA SYNTHESIS

A group consensus method was used to develop guidelines. An expert panel reviewed and revised the guidelines. The final guidelines were approved June 1, 2003, and are described here. They are organized based upon a patient's symptomatology at the time the diagnosis of ADHF is made. Patients with evidence of volume overload require intravenous diuretics and/or intravenous vasodilators to alleviate the symptoms of ADHF. Patients with signs and symptoms of low cardiac output require inotropic support to manage their ADHF. A timeline for diagnosis, treatment, reassessment, and disposition is provided and encourages an early, aggressive approach to treating patients with ADHF.

CONCLUSIONS

Hospitalization for ADHF is common and costly. Consensus guidelines for the treatment of ADHF did not previously exist, resulting in inconsistent and inefficient treatment. Consequently, hospitals struggling with the treatment of ADHF may find these guidelines and the process by which they were developed useful. THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT ACPE UNIVERSAL PROGRAM NUMBER: 407-000-04-015-H01

Hospital guidelines for use of low-molecular-weight heparins

OBJECTIVE

To describe the development of guidelines for initial use of low-molecular-weight heparins (LMWHs) and other anticoagulants in acute-care hospitals that are part of a national group purchasing organization (GPO).

DATA SOURCES

A systematic literature search (1970-December 2001) was conducted to identify evidence on the efficacy of various anticoagulants for initial therapy in deep-vein thrombosis and pulmonary embolism, and in treatment of acute coronary syndrome. A group consensus method was then used to develop guidelines. Guidelines were reviewed and revised by an internal expert panel as well as an external expert panel. Final guidelines were disseminated to GPO members and assistance was provided with implementation at the local level.

RESULTS

The final set of guidelines is described. The guidelines are organized based on recommended therapeutic options for each indication. For each option, consensus opinion is provided on the level of evidence that exists in the literature, comparisons of cost and convenience, and additional dosing information. The guidelines were disseminated along with supporting material to interested GPO member hospitals, and teleconferences were held to facilitate implementation at the local level. The guidelines were initially implemented at 18 hospitals across the country.

CONCLUSIONS

The process by which these guidelines were developed, plus the final set of guidelines, may be useful to hospitals and healthcare systems contemplating or engaged in a similar effort with this class of drugs.