Download Antipsychotic Utilization: Oregon State Medicaid

Antipsychotic Utilization:
Oregon State Medicaid
Ann M. Hamer, PharmD BCPP
This presentation was made possible by a grant from the State Attorney General
Consumer and Prescriber Education Program which is funded by the multi-state settlement
of consumer fraud claims regarding the marketing of the prescription drug Neurontin
Background
 In 2004, Warner-Lambert (now a division of
Pfizer, Inc.) paid $430 million to settle claims
that it was using continuing education grants
to promote off-label uses of Neurontin.
Background
 The 50 state attorneys general who accepted
the settlement of the Neurontin case have
used $21 million to establish the Consumer
and Prescriber Grant Program,
www.ohsu.edu/cpgp/, designed to provide
healthcare professionals and consumers
information related to prescription drugs and
their marketing.
Objectives
 Develop critical skills to promote an evidence-based approach




to the medical literature;
Create awareness of the persuasive marketing practices of the
pharmaceutical industry;
Assess the impact that pharmaceutical costs can have on other
healthcare priorities;
Balance the ethical responsibility to the patient vs. the ethical
needs of society in prescribing practices; and
Develop skepticism about off-label indications for a drug without
compelling evidence-based research that supports such use.
Methods
 Academic Detailing
 Focused on the utilization of behavioral health
medications
 Didactic Lectures
 Focused on the evaluation of medical
literature and pharmaceutical marketing
 Web-Based Tutorials
 Focused on the evaluation of medical
literature and pharmaceutical marketing
Topic Selection
 Antipsychotics

After specialty pharmaceuticals, antipsychotics
are the most expensive drug class for the
Oregon Health Plan



Costing approximately $3.2 million each quarter
Drug class where small changes can have a
big impact on overall cost
Provides a good example of some off-label
use
Antipsychotic Utilization Profile
Antipsychotic Prescribing Rate—State
4000
3500
Unique Patients
3000
2500
2000
1500
1000
500
0
HAL
PER
ABIL
GEO
RISP
SERO
ZYP
Antipsychotic Prescribing Rate—State
28%
4000
3500
Unique Patients
3000
2500
2000
1500
2%
1000
500
0
HAL
PER
ABIL
GEO
RISP
SERO
ZYP
Antipsychotic Prescribing Rate—
Lifeworks NW
41%
70
60
Unique Patients
50
40
30
20
2%
10
0
HAL
PER
ABIL
GEO
RISP
SERO
ZYP
Antipsychotic Prescribing Rate—
Comparison
40%
35%
Unique Patients
30%
25%
20%
15%
10%
5%
0%
HAL
PER
ABIL
Lifeworks
GEO
RISP
State
SERO
ZYP
Antipsychotic Selection
 Cost is a factor in treatment selection when
all else is considered equal.
Abilify
Risperdal
Antipsychotic Selection
 Cost is a factor in treatment selection when
all else is considered equal.
Abilify
Generic Risperidone
Antipsychotic Utilization Profile
Seroquel Dosing*—State
Daily Seroquel Dose
High Dose
(>800mg)
Therapeutic Dose
(300-800mg)
Low Dose
(<300mg)
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*Reflects use of dose for ≥90 days
Seroquel Dosing*—State
Daily Seroquel Dose
High Dose
(>800mg)
Therapeutic Dose
(300-800mg)
14%
Low Dose
86%
(<300mg)
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*Reflects use of dose for ≥90 days
Seroquel Dosing*—Lifeworks
Daily Seroquel Dose
High Dose
(>800mg)
Therapeutic Dose
(300-800mg)
31%
Low Dose
69%
(<300mg)
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*Reflects use of dose for ≥90 days
Seroquel
 69% of patients on therapy for 90 or more days were
on low dose (<300mg/day).

Total n=24
 31% of patients on therapy for 90 or more days were
on therapeutic dose (300-800mg/day)

Total n=6
 No patients were on duplicate antipsychotic therapy
with Seroquel for 90 or more days.
 Roughly 50% of patients started on Seroquel
maintain treatment for 90 or more days.
Low Dose Seroquel
 The use of Seroquel as a sedative has not
been studied and efficacy and safety are
questionable.
 Adverse effects = anticholinergic side effects,
hypotension, hyperprolactinemia, metabolic
abnormalities, agitation and akathisia.
Low Dose Seroquel
 Cases of Seroquel misuse and abuse have
been reported in the medical literature.

Street name = “quell” and “Susie-Q”
Antipsychotic Utilization Profile
Quarterly Summary—Comparison
2006 Q4
Risperdal & perphenazine,
% of all AP use,
excluding clozapine and select
1st generation AP
2007 Q1
2007 Q2
2007 Q3
0%
10%
20%
30%
40%
50%
Lifeworks
60%
State
70%
80%
90%
100%
Quarterly Summary—Comparison
2006 Q4
Risperdal & perphenazine,
% of all AP use,
excluding clozapine and select
1st generation AP
2007 Q1
2007 Q2
Goal?
2007 Q3
0%
10%
20%
30%
40%
50%
Lifeworks
60%
State
70%
80%
90%
100%
Quarterly Summary—Comparison
2006 Q4
Percent of Seroquel patients
on therapeutic dose
2007 Q1
2007 Q2
2007 Q3
0%
10%
20%
30%
40%
50%
Lifeworks
60%
State
70%
80%
90%
100%
Quarterly Summary—Comparison
2006 Q4
Percent of Seroquel patients
on therapeutic dose
2007 Q1
2007 Q2
Goal?
2007 Q3
0%
10%
20%
30%
40%
50%
Lifeworks
60%
State
70%
80%
90%
100%
Antipsychotics—Cost
Drug
Cost*
haloperidol
$23
perphenazine
$45
clozapine
$210
Risperdal
$250
*Avg retail cost for 30-days to OHP
Risperdal M-Tab
$310
1st QTR 2007
Excludes rebate
Geodon
$310
Invega
$340
Abilify
$440
Abilify Discmelt
$450
Zyprexa
$460
Seroquel (>300mg/d)
$530
Zyprexa Zydis
$550
Antipsychotics—Cost
Drug
Cost*
haloperidol
$23
perphenazine
$45
clozapine
$210
Risperdal
$250
*Avg retail cost for 30-days to OHP
Risperdal M-Tab
$310
1st QTR 2007
Excludes rebate
Geodon
$310
DC
Invega
$340
DC
Abilify
$440
Abilify Discmelt
$450
Zyprexa
$460
Seroquel (>300mg/d)
$530
Zyprexa Zydis
$550
DC
DC
Antipsychotic Dose Optimization
 From October 2006 through September 2007


323 antipsychotic dose optimization change
forms have been sent
Expected savings per change = $220



323 X 60% = 194
194 X $220 = $42,680
$42,680 X 12 = $512,160
Identification of Specialty Practice:
Primary Care and Psychiatry
Antipsychotic Prescribing Rate—
Psychiatry Specialty
1800
1600
Unique Patients
1400
1200
1000
800
600
400
200
0
HAL
PER
ABIL
GEO
RISP
SERO
ZYP
Unique Patients
Antipsychotic Prescribing Rate—
Psychiatry and Primary Care
1800
1600
1400
1200
1000
800
600
400
200
0
HAL
PER
ABIL
Psychiatry
GEO
RISP
Primary Care
SERO
ZYP
Antipsychotic Prescribing Rate—
Psychiatry and Primary Care
40%
35%
% Patients
30%
25%
20%
15%
10%
5%
0%
HAL
PER
ABIL
Psychiatry
GEO
RISP
Primary Care
SERO
ZYP
Seroquel Dosing*—Psychiatry
Specialty
Daily Seroquel Dose
High Dose
(>800mg)
Therapeutic Dose
(300-800mg)
19%
Low Dose
81%
(<300mg)
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*Reflects use of dose for ≥90 days
Seroquel Dosing*—Psychiatry and
Primary Care
High Dose
Daily Seroquel Dose
(>800mg)
13%
Therapeutic Dose
(300-800mg)
19%
Low Dose
87%
(<300mg)
81%
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Psychiatry
Primary Care
*Reflects use of dose for ≥90 days
Quarterly Summary—Seroquel
(% of patients within therapeutic dose range)
2006 Q4
2007 Q1
2007 Q2
2007 Q3
-10%
0%
10%
20%
Psychiatry
30%
Primary Care
40%
50%
60%
Quarterly Summary—RISP + PER
(% of AP use)
2006 Q4
2007 Q1
2007 Q2
2007 Q3
-10%
0%
10%
20%
Psychiatry
30%
Primary Care
40%
50%
60%
Key Points
 Risperdal and perphenazine are cost-
effective treatment alternatives

Risperdal will be generic in 2008
 Seroquel is not recommended for use as a
sedative/hypnotic