State Medicaid programs did not make use of prior authorization to promote safer prescribing after rosiglitazone warning

Association of formulary restrictions and initiation of an SGLT2i or GLP1-RA among Medicare beneficiaries with type 2 diabetes

BACKGROUND

Use of SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1-RA) among older adults with type 2 diabetes (T2D) has been limited.

OBJECTIVE

To examine factors associated with initiation of an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D in the early years after their market approval, with a particular focus on formulary restrictions (e.g. prior authorization, step therapy requirements, higher co-pays).

METHODS

A retrospective cohort study using data from a 5% random sample of Medicare beneficiaries with T2D followed from 1/1/2015-12/31/16. Formulary restrictiveness was defined as: (1) the number of target drugs (i.e. SGLT2is or GLP1-RAs) included in tiers 1-3 of a beneficiary's formulary (greater number of drugs in tiers 1-3 being less restrictive) and (2) the number of drugs without prior authorization or step therapy (requirement to try less expensive drugs prior to "stepping up" to more expensive therapies). We used multivariable logistic regression models to estimate the association between measures of formulary restrictiveness and initiation of a target drug, controlling for patient demographics, diabetes duration, clinical comorbidities, and provider specialty.

RESULTS

Among 112,985 beneficiaries with T2D, 5,619 (5%) initiated an SGLT2i or GLP1-RA. After adjusting for baseline characteristics, patients enrolled in formularies with ≥ 2 target drugs available in tiers 1-3 had 17% higher odds of initiating an SGLT2i or GLP1-RA (aOR 1.17, 95% CI 1.05-1.31) compared to patients enrolled in formularies with 0 drugs available in tiers 1-3. There was no significant association between the number of drugs without prior authorization or step therapy requirements and initiation of a target drug (aOR 0.96, 95% CI, 0.85-1.09). Age 75 years or older (vs < 65, aOR 0.23, 95% CI 0.21-0.26) and black race (vs white, aOR 0.65, 95% CI 0.59-0.71) were associated with lower odds of initiating a target drug.

CONCLUSIONS

Having a greater number of target drugs available on less expensive formulary tiers is associated with increased odds of initiating an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D.

Medicare Prescription Drug Plan Formulary Restrictions After Postmarket FDA Black Box Warnings

BACKGROUND

The boxed warning (also known as "black box warning") is one of the FDA's strongest safety actions for pharmaceuticals. After the FDA issues black box warnings for drugs, prescribing changes have been inconsistent. Formulary management may provide an opportunity to restrict access to drugs with serious safety concerns.

OBJECTIVE

To examine Medicare prescription drug plan formulary changes after new FDA postmarket black box warnings and major updates to preexisting black box warnings.

METHODS

In this cohort study, we identified each drug that received a new FDA postmarket black box warning or a major update to a preexisting black box warning from January 2008 through June 2015 and examined its formulary coverage. The main outcome measure was the proportion of Medicare prescription drug plan formularies providing unrestrictive coverage immediately before the black box warning, at least 1 year after the warning and at least 2 years after the warning. Unrestrictive formulary coverage was defined as coverage of a drug without prior authorization or step-therapy requirements.

RESULTS

Of 101 new black box warnings and major updates to preexisting warnings affecting 68 unique drug formulations, the mean percentage of formularies providing unrestrictive coverage changed from 65.4% (95% CI = 59.6%-71.2%) prewarning; 62.6% (95% CI = 56.3%-68.9%, P = 0.04) at least 1 year postwarning; and 61.9% (95% CI = 55.4%-68.5%, P = 0.10) at least 2 years postwarning.

CONCLUSIONS

The mean percentage of Medicare prescription drug plan formularies providing unrestrictive coverage decreased modestly by approximately 3 percentage points after drugs received postmarket FDA black box warnings. Formulary restrictions may present an underused mechanism to reduce use of potentially unsafe medications.

DISCLOSURES

This study was supported by a student research grant received by Solotke and provided by the Yale School of Medicine Office of Student Research under National Institutes of Health training grant award T35DK104689. Karaca-Mandic, Shah, and Ross acknowledge support from Agency for Healthcare Research and Quality (AHRQ) grant R01 HS025164, which studies factors associated with de-adoption of drug therapies shown to be ineffective or unsafe. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors assume full responsibility for the accuracy and completeness of the ideas presented. Ross has received support from the following: the U.S. Food and Drug Administration (FDA) as part of the Centers for Excellence in Regulatory Science and Innovation (CERSI) program; Johnson and Johnson through Yale University to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices; the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers for Medicare & Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting; the AHRQ to examine community predictors of health care quality; and the Laura and John Arnold Foundation, which established the Collaboration for Research Integrity and Transparency at Yale University. Shah has received support from the FDA as part of the CERSI program. In addition, he has received support through the Mayo Clinic from CMS, AHRQ, National Science Foundation, and Patient-centered Outcomes Research Institute. Karaca-Mandic has provided consulting services to Precision Health Economics and Tactile Medical for work unrelated to this manuscript. Dhruva and Solotke have no conflicts of interest to report.

A Health Plan's Formulary Led To Reduced Use Of Extended-Release Opioids But Did Not Lower Overall Opioid Use

Many insurers are using formulary design to influence opioid prescribing, but it is unclear if these changes lead to reduced use or just substitution between opioids. We evaluated the effect of a new prior authorization process implemented in July 2015 for extended-release (ER) oxycodone by Blue Shield of California. Compared to other commercially insured Californians, among 880,000 Blue Shield enrollees, there was a 36 percent drop in monthly rates of ER opioid initiation relative to control-group members, driven entirely by decreases in ER oxycodone initiation and without any substitution toward other ER opioids. This reduction was offset by a 1.4 percent relative increase in the rate of short-acting opioid fills. There was no significant change in the overall use of any opioids prescribed, measured as morphine milligram equivalents. This suggests that though insurers can play a meaningful role in reducing the prescribing of high-risk ER opioids, a formulary change focused on ER opioids alone is insufficient to decrease total opioid prescribing.

Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes

BACKGROUND

High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes.

METHODS

Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy.

RESULTS

Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills &lt; 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy.

CONCLUSIONS

Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.

Geographic Variation in Rosiglitazone Use Surrounding FDA Warnings in the Department of Veterans Affairs

BACKGROUND

Geographic variation in the use of prescription drugs, particularly those deemed harmful by the FDA, may lead to variation in patient exposure to adverse drug events. One such drug is the glucose-lowering drug rosiglitazone, for which the FDA issued a safety alert on May 21, 2007, following the publication of a meta-analysis that suggested a 43% increase in the risk of myocardial infarction with the use of rosiglitazone. This alert was followed by a black box warning on August 14, 2007, that was updated 3 months later. While large declines have been documented in rosiglitazone use in clinical practice, little is known about how the use of rosiglitazone and other glucose-lowering drugs varied within the Department of Veterans Affairs (VA), surrounding the FDA alerts. Understanding this variation within integrated health care systems is essential to formulating policies that enhance patient protection and quality of care.

OBJECTIVE

To document variation in the use of rosiglitazone and other glucose- lowering drugs across 21 Veterans Integrated Service Networks (VISNs).

METHODS

We conducted a retrospective analysis of drug use patterns for all major diabetes drugs in a national cohort of 550,550 veterans with diabetes from 2003 to 2008. This included the time periods when rosiglitazone was added to (November 2003) and removed from (October 2007) the VA national formulary (VANF). We employed multivariable logistic regression models to statistically estimate the association between a patient's location and the patient's odds of using rosiglitazone.

RESULTS

Aggregate rosiglitazone use increased monotonically from 7.7%, in the quarter it was added to the VANF (November 4, 2003), to a peak of 15.3% in the quarter when the FDA issued the safety alert. Rosiglitazone use decreased sharply afterwards, reaching 3.4% by the end of the study period (September 30, 2008). The use of pioglitazone, another glucose-lowering drug in the same class as rosiglitazone, was low when the FDA issued the safety alert (0.4%) but increased sharply afterwards, reaching 3.6% by the end of the study period. Insulin use increased monotonically; metformin use remained relatively flat; and sulfonylurea use exhibited a general declining trend throughout the study period. Statistically significant geographic variation was observed in rosiglitazone use throughout the study period. The prevalence range, defined as the range of minimum to maximum use across VISNs was 3.7%-12.4% in the first quarter (January 1 to March 31, 2003); 1.0%-5.5% in the last quarter of study period (July 1 to September 30, 2008); and reached a peak of 9.6%-25.5% in the quarter when the FDA safety alert was issued (April 1 to March 31, 2007). In 5 VISNs, peak rosiglitazone use occurred before the FDA issued the safety alert. The odds ratio of using rosiglitazone in a given VISN varied from 0.55 (95% CI = 0.52-0.59; VISN 10) to 1.58 (95% CI = 1.50-1.66; VISN 15), with VISN 1 being the reference region. The variation was higher in the periods after the FDA issued the safety alert. Much less variation was observed in the use of pioglitazone, metformin, sulfonylurea, and insulin.

CONCLUSIONS

Our results show statistically significant variation in the way VISNs within the VA responded to the FDA alerts, suggesting a need for mechanisms that disseminate information and guidelines for drug use in a consistent and reliable manner. Further study of regions that adopted ideal practices earlier may provide lessons for regional leadership and practice culture within integrated health care systems.

Influence of health warnings on the use of rosiglitazone and pioglitazone in an area of Spain: A time-series study

Background:

Throughout 2007 and January 2008, several glitazones health warnings were published on rosiglitazone myocardial infarction risk. The impact of such warnings on glitazones prevalence of utilization has been extensively studied in the United States but only in one European country (England), which has showed different pattern from US studies. The aim of this study is to evaluate the impact of such safety warnings on glitazones utilization in an area of another European country.

Methods:

We calculated the number of defined daily doses per thousand inhabitants per day of glitazones each month during the period from 2006 to 2008 in a health area of Spain. We analyzed the data graphically and through a segmented regression analysis.

Results:

Rosiglitazone defined daily doses per thousand inhabitants per day were growing before the safety warnings, after the warnings a change in trend occurred and rosiglitazone utilization showed a downturn slope. Pioglitazone defined daily doses per thousand inhabitants per day were stable before the safety warnings, and a linear growth was observed after the safety warnings. Throughout the study period, rosiglitazone defined daily doses per thousand inhabitants per day were higher than pioglitazone defined daily doses per thousand inhabitants per day until near the end of 2008.

Conclusion:

Despite the fact that cardiovascular warnings affected rosiglitazone and not pioglitazone, rosiglitazone was more utilized than pioglitazone until near the end of 2008 which is a pattern similar to the one found in another European studies in England, but very different from studies in the United States, where rosiglitazone was less utilized than pioglitazone from the first month after rosiglitazone cardiovascular safety warnings.

Disparities in Discontinuing Rosiglitazone Following the 2007 FDA Safety Alert

BACKGROUND

Responsiveness to the Food and Drug Administration (FDA) rosiglitazone safety alert, issued on May 21, 2007, has not been examined among vulnerable subpopulations of the elderly.

OBJECTIVE

To compare time to discontinuation of rosiglitazone after the safety alert between black and white elderly persons, and across sociodemographic and economic subgroups.

RESEARCH DESIGN

A cohort study.

SUBJECTS

Medicare fee-for-service enrollees in 2007 who were established users of rosiglitazone identified from a 20% national sample of pharmacy claims.

MEASURES

Outcome of interest was time to discontinuation of rosiglitazone after the May alert. We modeled the number of days following the warning to the end of the days' supply for the last rosiglitazone claim during the study period (May 21, 2007-December 31, 2007) using multivariable proportional hazards models.

RESULTS

More than 67% of enrollees discontinued rosiglitazone within six months of the advisory. In adjusted analysis, white enrollees (hazard ratio=0.90; 95% confidence interval, 0.86-0.94) discontinued rosiglitazone later than the comparison group of black enrollees. Enrollees with a history of low personal income also discontinued later than their comparison group (hazard ratio=0.84; 95% confidence interval, 0.81-0.87). There were no observed differences across quintiles of area-level socioeconomic status.

CONCLUSIONS

White race and a history of low personal income modestly predicted later discontinuation of rosiglitazone after the FDA's safety advisory in 2007. The impact of FDA advisories can vary among sociodemographic groups. Policymakers should continue to monitor whether risk management policies reach their intended populations.

Novel Therapeutics for Diabetes: Uptake, Usage Trends, and Comparative Effectiveness

The number of available therapies for treating type 2 diabetes has grown considerably in recent years. This growth has been fueled by availability of newer medications, whose benefits and risks have not been fully established. In this study, we review and synthesize the existing literature on the uptake, efficacy, safety, and cost-effectiveness of novel antidiabetic agents. Specifically, we focus on three drug classes that were introduced in the market recently: thiazolidinediones (TZDs), dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Not surprisingly, we find that the usage trends reflect the efficacy and safety profile of these novel drugs. The use of TZDs increased initially but decreased after a black-box warning was issued for rosiglitazone in 2007 that highlighted the cardiovascular risks associated with using the drug. Conversely, DPP-4 inhibitors and GLP-1 receptor agonists gained market shares due to their efficacy in glycemic control as an add-on treatment to metformin. DPP-4 inhibitors were the most commonly prescribed agents among the three novel drug classes, likely because they are relatively less expensive, have better safety profile, are administered orally, and are weight neutral. Sitagliptin was the most preferred DPP-4 inhibitor. The level of evidence on the comparative effectiveness, safety, and cost implications of using novel antidiabetic agents remains low and further studies with long-term follow-ups are needed.

Methodological approaches to evaluate the impact of FDA drug safety communications

BACKGROUND

When the US FDA approves a new prescription drug there is still a great deal remaining to be learned about the safe and proper use of that product. When new information addressing these topics emerges post-approval, the FDA may issue a Drug Safety Communication (DSC) to alert patients and physicians. The effectiveness of the communication-how drug safety messaging conveyed in FDA DSCs changes patient or prescriber behavior-may depend on multiple factors, including the way physicians and patients learn about the information, their understanding of the issues conveyed, and their perception of the importance of the information. In 2013, the FDA issued two DSCs addressing critical new warnings related to products containing the sedative/hypnotic zolpidem.

OBJECTIVE

In this article, we describe a core set of research initiatives that can be used to study how zolpidem-related DSCs affected subsequent physician and patient decision making.

METHODS

These research initiatives include analyzing drug utilization patterns and related health outcomes; comparing zolpidem-containing products against a comparator with similar indications [eszopiclone (Lunesta)] not covered by the 2013 DSCs; and surveying patients and qualitatively evaluating the dissemination of information regarding these drugs in traditional and social-media channels.

CONCLUSIONS

Using an integrated, multidisciplinary approach, we can obtain information that can be used to optimize regulatory communications by seeking to understand the impact of the information contained in FDA risk communications.

Rosiglitazone use and associated adverse event rates in Canada: an updated analysis

Background

We previously reported on the change in the use of rosiglitazone-containing products (RCP) and adverse event reporting rates in Canadian patients between 2004 and 2010. The present study extends this analysis to include the January 2011 to December 2012 time period.

Methods

RCP utilization rates were obtained from IMS Health Brogan’s longitudinal de-identified patient database, LRx. GlaxoSmithKline’s global adverse events database was used to extract adverse events (AE), serious adverse events (SAE), and cardiac adverse events (CAE) reported in Canadian patients receiving RCP from April 2004 to December 2012. The patient utilization information from the LRx database was used to estimate rates per 100,000 patients.

Results

An estimated 182,841 patients were dispensed RCP prescriptions between April 2004 and December 2012. The total number of patients using RCP decreased by 85 % from 2011 to 2012. From its peak use in 2007, the number of patients filling a prescription decreased 97 %. A total of 1069 AEs were reported during the study period, of which 32 AE’s were reported from Jan 2011 to Dec 2012. The average monthly reporting rates of AE’s, SAE’s and CAE’s over 2011–2012 were 10.8/100,000 patients, 9.1/100,000 patients and 5.0/100,000 patients, respectively.

Conclusions

The utilization of RCP in Canada has significantly declined. The significance of the adverse event rate information presented is uncertain and must be evaluated within the context of the well known factors that can influence AE reporting rates, as well as limitations to the methods used to estimate these reporting rates.

Association between unemployment rates and prescription drug utilization in the United States, 2007-2010

BACKGROUND

While extensive evidence suggests that the economic recession has had far reaching effects on many economic sectors, little is known regarding its impact on prescription drug utilization. The purpose of this study is to describe the association between state-level unemployment rates and retail sales of seven therapeutic classes (statins, antidepressants, antipsychotics, angiotensin-converting enzyme [ACE] inhibitors, opiates, phosphodiesterase [PDE] inhibitors and oral contraceptives) in the United States.

METHODS

Using a retrospective mixed ecological design, we examined retail prescription sales using IMS Health Xponent™ from September 2007 through July 2010, and we used the Bureau of Labor Statistics to derive population-based rates and mixed-effects modeling with state-level controls to examine the association between unemployment and utilization. Our main outcome measure was state-level utilization per 100,000 people for each class.

RESULTS

Monthly unemployment levels and rates of use of each class varied substantially across the states. There were no statistically significant associations between use of ACE inhibitors or SSRIs/SNRIs and average unemployment in analyses across states, while for opioids and PDE inhibitors there were small statistically significant direct associations, and for the remaining classes inverse associations. Analyses using each state as its own control collectively exhibited statistically significant positive associations between increases in unemployment and prescription drug utilization for five of seven areas examined. This relationship was greatest for statins (on average, a 4% increase in utilization per 1% increased unemployment) and PDE inhibitors (3% increase in utilization per 1% increased unemployment), and lower for oral contraceptives and atypical antipsychotics.

CONCLUSION

We found no evidence of an association between increasing unemployment and decreasing prescription utilization, suggesting that any effects of the recent economic recession have been mitigated by other market forces.