Biosimilar strategic implementation at a large health system

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PURPOSE

This article highlights one health system's response to the market influx of biosimilars with the establishment of a process for formulary review and selection of preferred agents and support for therapeutic interchanges.

SUMMARY

Through assessment of available literature, insurance payor coverage, and manufacturer-anticipated approvals of biosimilars, a strategic stance was developed to guide biosimilar order preparation, review, adoption, and implementation. The electronic medical record (EMR) is prepared for biosimilar implementation at least 6 to 12 months ahead of anticipated formulary review. The review includes assessment of a class (reference product and available biosimilars) after at least 2 biosimilars become available. Key health-system departments and clinicians are enlisted to support review of clinical, safety, and economic implications. Implementation of a preferred product relies on standard education, formulary availability, and staff awareness to address any perceived patient safety concerns and gather provider support. The standard steps developed now apply to all future biosimilar reviews, adoption plans, and ongoing monitoring. Barriers evaluated include changes in payor coverage and challenges in preparation of the EMR for future biosimilars, meeting precertification team education needs, and providing operational support for pharmacy inventory.

CONCLUSION

To date, use of 5 preferred biosimilar products has led to significant cost savings to the institution, and the process has been endorsed by providers. The institution's successes can be attributed to clear communication with stakeholders and the development of a deliberate process, led by a multidisciplinary leadership team, for managing formulary, safety, and operational barriers in a thoughtful and systematic manner.

1405. Infectious Causes of Chronic Meningitis in HIV-Negative Patients: A Case Series

Background

Chronic meningitis can be defined as inflammation of the cerebrospinal fluid (CSF) with the presence of >5 white blood cells/mm³ of CSF for 4 weeks. There is little literature available on defining the infectious causes or risk factors of chronic meningitis, and there are no studies that have looked at mortality in this group of patients. Our aim for this study was to evaluate the epidemiology, risk factors, and mortality of infectious causes of chronic meningitis within our healthcare system.

Methods

A total of 59 cases were identified through a systematic retrospective review from our electronic medical record database from 2004 to 2018 and were identified by having the presence of two consecutive lumbar punctures with a white blood cell count in CSF >5 WBC/mL³ in a 4-week period, or by having 4 weeks of meningeal symptoms with one lumbar puncture with >5 WBC/mL³. All cases were manually reviewed. We excluded patients with diagnosis of human immunodeficiency virus (HIV) infection. We included a review of comorbidities that could impair the immune system such as diabetes mellitus, alcohol use, chronic kidney disease (CKD) stage III or greater use of chemotherapy, immunotherapy, or chronic use of steroids and previous transplant recipients. The study was approved by the institutional review board

Results

59 cases of chronic meningitis attributable to an infectious etiology were identified. The most common pathogens were Borrelia burgdorferi (37%), Cryptococcus sp. (27%), and Candida sp. (10%). Other etiologies which were less common included viral etiologies (13%). Finally, there were two cases secondary to Streptococcus pneumonia. Regarding the total number of patients with the comorbidities studied, 13 (22%) had diabetes, 12 (20%) had CKD, 12 (20%) were under some form of chemo/immunotherapy including chronic steroid use and 3 (5%) of patients were transplant recipients.

Conclusion

Our study identified common infectious pathogens causing chronic meningitis in a rural, HIV-negative population. Our findings indicate that cryptococcus should be considered even within HIV-negative individuals, and Lyme disease should be considered in all endemic areas. Mortality was significant among patient with cryptococcal meningitis, where patients with Lyme meningitis did very well.

Disclosures

All authors: No reported disclosures.

Diffuse Ischemic Strokes and Sickle Cell Crisis Induced by Disseminated Anaplasmosis: A Case Report

We present a 26-year-old female with HbSC disease who presented to the emergency department multiple times with pain and shortness of breath, eventually developing unresponsiveness and a brief episode of pulseless electrical activity. She was admitted to the intensive care unit with multisystem organ failure and found to have diffuse ischemic strokes. Infectious workup revealed disseminated anaplasmosis and babesiosis, which had likely caused sickle cell crisis, atypical hemolytic-uremic syndrome, and ischemic brain injury. She was started on eculizumab therapy as well as antimicrobial therapy with doxycycline, clindamycin, and atovaquone. The patient was given tracheostomy and a percutaneous feeding tube. Unfortunately, she did not have significant neurologic recovery after prolonged hospital stay and was discharged to a skilled nursing facility with significant neurologic burden.