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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