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Rx in Underwriting A Special Presentation for CHOLHUA Hank George, FALU, CLU, FLMI Cheesehead HATS OFF, CHOLHUA! You are a role model for excellence as a professional underwriters’ association! Greetings from your neighbors on the frozen tundra! Hank George Officer-at-(too)-Large WAHLU MUC comes to Packer Country Bears’ Refugees Welcome! September 15-17 Hyatt Regency- Milwaukee Followed by an ECG interpretation seminar created by Lori Ammons [email protected] Rx = Dx Tell me what he’s taking… and I’ll tell you what he’s got! Generic Name vs. Proprietary Name(s) • Bupropion is Wellbutrin (depression), Aplezin (depression) and Zyban (quit smoking aide) • Fluoxetine is Prozac (depression and n+1 other things!) and Sarafem (PMS) The BEST PRACTICE Rx paradigm typically consists of… • 1st line Rx – used most - BEST CASE? • 2nd line Rx – used when one or more first line drugs have unacceptable side effects/don’t work; sometimes used in combination with first line • 3rd line Rx – more potent, more side effects; used when 1st and 2nd line both fail, or as adjuvant – WORST CASE? • “Compassionate use” – refractory cases (felbamate in seizure disorders, etc.) – WORST CASE! Rx Profiles 2010 Why rapidly-increasing use? • • • • • • Low cost Perceived value Rapid access/teleinterview-compatible Credibility Action-friendly (act without confirmation) No notable producer-customerregulatory/legislative pushback • 70%+ hit rate > MIB • Older age business + polypharmacy What are the 5 Key Elements? • • • • • All Rx paid for with Rx card Sequence of prescribing Dose Rx compliance (adherence) Name and contact information for prescribing physician Noncompliance with Rx • In a cohort of 112,902 statin users, only 40% were taking the drug at least 80% of the time AFTER 1 YEAR! • Psychiatric drugs have the worst compliance • Compliance is a marker for the Healthy Adherer Effect spanning a spectrum of favorable health habits RISKTAKING BEHAVIOR • Non-compliance is a major 6 Subtle Pearls • Total dose taken + times taken per day/ other interval – does it pinpoint reason for use/disease severity? • One drug replaces another – why? < 1 month (side effects); > 1 month (lack of efficacy) • One drug added to another – why? • Refills – consistent with compliance? • Mode of delivery – pill, injection (IV, IM, intrathecal), transdermal, dissolving wafer, inhaler, nasal/oral spray, topical ointment, suppository – does it pinpoint reason for use/disease severity? • Subtle synergies – inhaler for “asthma” + and 3 courses of winter antibiotics = COPD? The “Off-Label” Pandemic! • 1 in 4 scripts for unapproved indications • Subtly promoted by pharmaceutical companies • Physicians free to do so if there is a clinical study supporting efficacy • Most common in psychiatric, cardiovascular contexts! Take gabapentin for example… Gabapentin Uses • 2nd line generalized seizure disorders • Bipolar I + II • Neuropathic pain in diabetes, etc. • Social phobia, panic disorder • Restless leg syndrome • ??? (since I last looked!) How often do prescription drugs affect the results of routine screening blood tests? Often enough to… …justify an 800+ page reference book on this subject, published by the American Association for Clinical Chemistry! Rx Effects on Blood Tests Generalizations • • • • Most drugs do it at least rarely Most effects are minimal and transient Most do not result in any harm to the patient Many effects are capable of altering test results significantly enough to change underwriting actions, especially when solely for test results • LFTs, BUN. Creatinine, glucose most vulnerable • The first question in any unexplained test elevation: What Rx is he taking? Statins and Liver enzymes • Statins raise ALT ≥ 3 x ULN in 0.3% to 1.5% of cases, depending on dose – and countless more to a lesser degree • AST to a lesser extent; GGT unaffected • Elevations are harmless and normalize when the drug is withdrawn • LFTs should be rechecked at 6 weeks and annually thereafter by prescribing MD • Key question: is the elevation caused by the statin…or something else? Which drugs REALLY cause isolated GGT elevation? • • • • • • • Barbiturates Hydantoin (Dilantin) Carbamazepine (Tegretol, etc.) Valproic acid (Depakote, Depakene) Oxcarbazepine (Trileptal) Fosphenytoin (Cerebyx) Herbal compound kava Cardiovascular Rx Pearls + RED FLAGS “- prils” + “- sartans” • ACE inhibitors and angiotensin II receptor blockers • Widely used in hypertension • ACE inhibitor #1 choice in heart failure + subclinical systolic dysfunction • Both used in early (microalbuminuria) diabetic/prediabetic nephropathy prophylaxis… even in the absence of hypertension Phosphodiesterase-5 Enzyme Inhibitors A/K/A “- denafils” …not just for wishful old geezers any longer! • Sildenafil is VIAGRA for ED and REVATIO for pulmonary hypertension • Tadalafil is CIALIS for ED and ADCIRCA for pulmonary hypertension • Vardenafil is LEVITRA and NUVIVA for ED and is likely to be approved for pulmonary hypertension • These drugs have also been shown to be effective in achieving pregnancy in women with increased endometrial thickness and in “female sexual dysfunction” syndrome BEWARE solitary CCB indications • Bepridil (Vascor) = refractory stable angina • Nimodipine (Nimotop) = subarachnoid hemorrhage More on statins… • Manufacturers’ dream: 30,000,000! • Used prophylactically in patients with borderline/normal lipids • Wide range of pleiotropic effects beyond just lowering LDL-C, raising HDL-C and lowering triglycerides • 10+% increased risk of T2DM affirmed by meta-analysis • RED FLAG: patient discharged from a hospital on statin for the first time! PSYCHIATRIC PHARMACOLOGY GEMS SSRI antidepressants have more off-label uses than any drug class How’s this beauty? Sertraline (Zoloft) for the staggering risk Night Eating Syndrome …another impairment-wannabe How many do you recognize? • Asenapine (Saphris) – schizophrenia and BP I • Trazodone (Oleptro) – (Desyrel redux) MDD • Paliperidone (Invega, Sustenna) – antipsychotic • Iloperidone (Fanapt) – schizophrenia and BP I • Desvenlafaxine (Pristiq) – MDD • Guanfacine (Intuniv) – ADHD Stay Current on Rx! HOT NOTES™ Monthly e-Newsletter FREE [email protected] How many potential adjuvant drugs for REFRACTORY SEVERE major depressive disorder can you think of? • • • • • • • • • Folates (folic acid) Thyroid hormone Omega-3 fish oils Lithium carbonate Buspirone (BuSpar) @ 40 mg Selegiline (Emsam) patch Modafinil (Lyrica) Riluzole (Rilutek) – ALS drug Various novel antipsychotics Additional UnderwritingSalient Rx Tidbits Metformin (Glucophage) The #1 drug in BEST CASE type 2 diabetes just happens to also be widely used for nonalcoholic fatty liver disease (NAFDL), polycystic ovary syndrome (PCOS), metabolic syndrome, prediabetic states and (potentially), weight loss! Finasteride (Propecia, Proscar) • Is indicated for baldness and benign prostatic hyperplasia (BPH) • Is used off-label in prostate cancer prevention and Tourette syndrome • Lowers PSA – potentially causing a “false-negative” result when screening a person at high enough perceived risk to justify prophylaxis! Not too long ago, there were no approved drugs for fibromyalgia Now we have 3: • Duloxetine (Cymbalta) – also used in MDD and diabetic neuropathic pain • Modafinil (Lyrica) – used for sleep disorders and many other reasons • Savella (milnacipran) – an antidepressant approved only for fibromyalgia Why do ALTERNATIVE & COMPLEMENTARY therapies matter to us? • Fastest growing domain of healthful intervention • Used disproportionately by college-educated, higher-income applicants • In cancer patients, used disproportionately in those with metastatic disease and/or following relapse from conventional Rx Should be on EVERY drilldown! You want to know WHY when they’re taking… • • • • • • Hawthorn Shark cartilage Mistletoe Silymarin Glycyrrhizin SAMe