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Staying alert

September 1, 2006
by LARRY E. FIELDS, MD, MBA
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Medco uses prescription drug alerts to ensure patient safety and decrease costs

Behavioral medications have gained widespread use and now account for 11% of total pharmacy plan costs, according to Medco Health Solutions' 2006 Drug Trend Report . The number of adults using antidepressants increased 17% from 2001 through 2005, while the number of patients using antipsychotic and ADHD drugs during that period rose 13% and 88%, respectively. Potentially contributing to this overall growth is the fact that the newer behavioral medications have fewer side effects than their predecessors, but concerns about safety have not gone away.

Integrated data-based health and safety systems can prevent medication errors by accessing medical, pharmacy, and laboratory records, reviewing the data for potential risks, and alerting physicians and pharmacists about potential problems. One such system, Medco's RationalMed Patient Health and Safety System, issued more than 319,000 alerts to pharmacists and doctors in 2005 regarding behavioral medications (approximately one-fifth of RationalMed's 1.5 million alerts last year). Therapy changes from the alerts resulted in more than $7 million in pharmacy savings for benefit providers participating in the RationalMed program, which had 9 million enrollees in 2005. But beyond the drug cost savings, by catching problems before they occur, these programs can substantially cut down on the additional medical care and hospital costs often associated with prescription drug errors.

Senior patients are particularly vulnerable to medication-related problems. In fact, members at least 65 years old accounted for more than 37% of RationalMed's behavioral medication alerts last year, resulting in 19% of the savings garnered through the program. In general, seniors take more medications, see more physicians, and use more pharmacies than younger patients and, therefore, are at a greater risk of medication-related problems. According to a 2005 Medco report on senior polypharmacy, about 1 in 4 seniors received prescriptions from 5 or more doctors, 1 in 20 were prescribed medications by 8 or more physicians, and nearly one-quarter of these seniors filled their prescriptions at 3 or more pharmacies, with some using as many as 11 different pharmacies in 1 year.

On top of that, seniors are affected by drugs differently because of their liver's diminished ability to metabolize drugs and the kidneys’ diminished ability to excrete them. Reduced drug elimination often extends the half-life of drugs, which means prescribers should alter how they are administered. Unfortunately, inappropriate doses of prescription drugs often are taken by older patients. The most common side effects of excessive dosing with antidepressants, anxiety treatments, and sleeping pills in senior patients are confusion and drowsiness, resulting in a greater likelihood of falls or car accidents.

While behavioral medication safety issues are particularly worrisome when it comes to seniors, these drugs can be problematic in patients of all ages. For example, while ADHD drugs’ cardiovascular risks and potential interactions with other drugs are serious side effects, almost 44% of the 6,397 alerts associated with ADHD treatments in RationalMed's general population related to excessive dosing. RationalMed also sent more than 3,600 alerts in 2005 for excessive dosing of antidepressants. Excessive dosing results when a patient receives higher doses than what is recommended on the label or more than what is appropriate for the patient's age.

Duplicate therapies are another source of RationalMed's drug safety alerts. Taking two drugs from similar categories can lead to an overdose or exaggerate a treatment's side effects. Duplicate therapies were the second-largest source of RationalMed alerts for antipsychotic drugs, finishing only behind adverse drug interactions as a potential problem. Stopping duplicate behavioral therapies generated more than $220,000 in savings last year.

Using antidepressants for too long accounted for approximately half of the RationalMed alerts for behavioral medications. About 4 to 6 months after an anti-depressant starts to take effect, the dose typically is reduced to two-thirds of the effective therapeutic dose. The drug gradually is decreased and then discontinued over an additional 2- to 3-month period to prevent cholinergic rebound or withdrawal symptoms. For highly recurrent, severe, or chronic depression, antidepressant medication typically is prescribed on a continual basis. Therapy changes from these alerts resulted in savings of almost $4 million.

While savings derived from effective management of drug utilization is a high priority for benefit providers, enhanced medication safety should be the overriding objective for all parties involved. The complexity and associated health risks of these drugs underscore the need for effective tools to strengthen the communication between doctors and pharmacists to enhance care. Using integrated data-based health and safety systems is one way to reduce the possibility of side effects and to lower healthcare costs.

Larry E. Fields, MD, MBA, is Director of Clinical Product Development at Medco Health Solutions. He has worked for the U.S. Department of Health and Human Services as a Senior Executive Advisor to the Assistant Secretary for Health.

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