LONG TERM CARE MEDICATIONS MANAGEMENT INITIATIVE JULY Prepared by the Long-Term Care Medications Management Working Group

Transcription

1 LONG TERM CARE MEDICATIONS MANAGEMENT INITIATIVE JULY 2016 (last updated July 28, 2016) Prepared by the Long-Term Care Medications Management Working Group Drug Classes for Consideration Angiotensin Converting Enzyme (ACE) Inhibitors +/- Diuretic Angiotensin II Receptor Blockers (ARB) Calcium Channel Blocker (non-dihydropyridine) Proton Pump Inhibitors (PPI) Long-Acting Anticholinergic Muscarinic Receptor Antagonists (LAMA) Bisphosphonates Serotonin Norepinephrine Reuptake Inhibitors

2 EXECUTIVE SUMMARY This initiative is a new demonstration project focused on improving medication management in Ontario Long- Term Care Homes (LTCH). The project aims to further enhance the quality of care delivered to residents and increase medication safety by increasing the use of safe, effective and less expensive drugs within the same therapeutic categories in order to support streamlined medication selection. The project, which will begin in September 2016 for a period of one year, and will rely on the clinical judgment of pharmacists and prescribers (e.g., LTC physicians and nurse practitioners) to make sure that each resident s drug therapy remains clinically effective and safe while at the same time provides good value to the health care system. This initiative is fully supported by the Ministry of Health and Long-Term Care (the ministry ). This project was developed by a multi-disciplinary working group with participation from pharmacists who specialize in Long-Term Care, as well as physicians, representatives from LTCH associations and ministry staff. Additional input from clinical experts (physicians, pharmacists and nurses) was incorporated into the development of the project drug list. The Long Term Care Medications Management Working Group which has a cross section of representatives from the LTC sector including: Pharmacy representatives Ontario Pharmacists Association Neighbourhood Pharmacy Association of Canada Ontario Long Term Care Homes Association Ontario Association of Non-Profit Homes & Services for Seniors Physician representatives Ontario Long Term Care Physicians group Ontario Medical Association Ministry of Health & Long Term Care This initiative will first be discussed with LTCH residents at their upcoming quarterly medication review or through the MedsCheck LTC process. Residents will experience no change to their current level and quality of care, nor will there be any change to their monthly drug costs. As with any change to a resident s care plan, any recommendations to changes in their medications will be discussed with the resident or their substitute decision maker and consent to participate will be sought by a member of the resident s care team as per the usual process. The resident has the choice to accept the recommended changes or remain on the same drugs. Any cost savings from switching to the less expensive drugs will be reinvested into Ontario s health care system, and will support the government s ability to continue to fund new, safe and effective medications for people covered under the government drug programs, including the Ontario Drug Benefit (ODB) program that provides coverage to residents of LTCH. Responsible management of health care is part of the government s plan to build a better Ontario through its Patients First: Action Plan for Health Care and this demonstration project aligns with the plan s objectives. Information about this demonstration project will be shared directly with LTCH residents and will also be shared with stakeholders including LTCH Administrators and Associations, seniors groups and other health care partners. Relevant Frequently Asked Questions documents are available. This demonstration project will be monitored and evaluated. Questions about this demonstration project may be directed to LTC@opatoday.com.

3 KEY ELEMENTS OF THE LONG TERM CARE MEDICATION MANAGEMENT DEMONSTRATION PROJECT Voluntary model No separate LTC Formulary Targeted and alternative molecules selected o Various targeted molecules over seven therapeutic areas o Clinical rationale provided for each transition o Good value for the health care system Three alternative molecules are generally included for each category where possible, including crushability and tubefeeding options where they exist. Frequently asked questions documents for residents/substitute decision makers, health care providers and other stakeholders are available at: IMPORTANT NOTE Given that drug prices, official indications, backorder status and the availability of new generics change routinely, this protocol document is considered to be dynamic and subject to frequent revision. As changes are made to the protocol, every effort will be made by the partnering organizations to communicate to clinicians on the nature of the revisions as soon as they are known. However, clinicians are encouraged to routinely check for the most recent version of this protocol document which will be posted on the Ontario Pharmacists Association website at

4 Angiotensin Converting Enzyme (ACE) Inhibitors +/- Diuretic

5 1) Drug Class: Angiotensin Converting Enzyme (ACE) Inhibitor +/- Diuretic Targeted Molecule(s) Drug Alternative(s) Clinical Rationale Summary Perindopril (Coversyl) Trandolapril (Mavik) Captopril (Capoten) Enalapril (Vasotec) Quinapril (Accupril) Fosinopril (Monopril) Cilazapril (Inhibace) Lisinopril (Prinivil/Zestril) Perindopril/Indapamide (Coversyl Plus) Primary/Preferred: Ramipril (Altace) Secondary: Lisinopril (Zestril) Crushable/Tubefeed Option (if any): Lisinopril (Zestril) for tubefeeding or dispersing in water immediately prior to administration Primary/Preferred: Ramipril/Hydrochlorothiazide (Altace HCT) Secondary: Lisinopril/Hydrochlorothiazide (Zestoretic) Crushable/Tubefeed Option (if any): Perindopril/Indapamide (Coversyl Plus) is the only option.dissolve in water and administer immediately (no stability data) Cost Comparison of ACE Inhibitors Using Equipotent Doses for Hypertension Similar adverse effects. Monitor SCr, K+, BP Similar food/drug interactions. CHEP guidelines do not point to using one ACE inhibitor over another or one thiazide/thiazide-like diuretic over another Both combinations contain thiazide or thiazide-related molecules. ACE Inhibitors at Equivalent Doses Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Perindopril (Coversyl) 4mg * DAILY $ $ Trandolapril (Mavik) 1mg * DAILY $ $ Captopril (Capoten) 25mg BID $ $ Enalapril (Vasotec) 10mg DAILY $ $ Quinapril (Accupril) 10mg DAILY $ $ Fosinopril (Monopril) 10mg DAILY $ $ Cilazapril (Inhibace) 2.5mg DAILY $ $ Lisinopril (Prinivil) 10mg DAILY $ $ Lisinopril (Zestril) 10mg DAILY $ $ Ramipril (Altace) 2.5mg DAILY $ $ Perindopril (Coversyl) 8mg * DAILY $ $ Captopril (Capoten) 50mg BID $ $ Trandolapril (Mavik) 2mg DAILY $ $ Enalapril (Vasotec) 20mg DAILY $ $ Fosinopril (Monopril) 20mg DAILY $ $ Quinapril (Accupril) 20mg DAILY $ $ Cilazapril (Inhibace) 5mg DAILY $ $ Lisinopril (Prinivil) 20mg DAILY $ $ Lisinopril (Zestril) 20mg DAILY $ $ Ramipril (Altace) 5mg DAILY $ $ Perindopril (Coversyl) 8mg * DAILY $ $ Captopril (Capoten) 100mg BID $ $ Benazepril (Lotensin) 20mg BID $ $ Trandolapril (Mavik) 4mg * DAILY $ $ Enalapril (Vasotec) 20mg BID $ $ Fosinopril (Monopril) 20mg BID $ $ Cilazapril (Inhibace) 5mg BID $ $ Lisinopril (Prinivil) 20mg BID $ $ Lisinopril (Zestril) 20mg BID $ $ Quinapril (Accupril) 40mg DAILY $ $ Ramipril (Altace) 10mg DAILY $ $ *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee Lower Dose Intermediate Dose Higher Dose

6 Comparison of ACE inhibitor/diuretic Combination Products Combination Products ACE Inhibitors Combination Products (as listed on the ODB Formulary) Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Perindopril/Indapamide (Coversyl Plus) 2mg/0.625mg* DAILY $ Perindopril/Indapamide (Coversyl Plus) 4mg/1.25mg* DAILY $ Perindopril/Indapamide (Coversyl Plus) 8mg/2.5mg* DAILY $ Ramipril/Hydrochlorothiazide 2.5mg/12.5mg DAILY $ Ramipril/Hydrochlorothiazide 5mg/12.5mg DAILY $ Ramipril/Hydrochlorothiazide 5mg/25mg DAILY $ Ramipril/Hydrochlorothiazide 10mg/12.5mg DAILY $ Ramipril/Hydrochlorothiazide 10mg/25mg DAILY $ Enalapril/Hydrochlorothiazide 5mg/12.5mg DAILY a a Enalapril/Hydrochlorothiazide 10mg/25mg DAILY a a Cilazapril/Hydrochlorothiazide 5mg/12.5mg DAILY $ Lisinopril/Hydrochlorothiazide 10mg/12.5mg (Type Z) DAILY $ Lisinopril/Hydrochlorothiazide 10mg/12.5mg (Type P) DAILY $ Lisinopril/Hydrochlorothiazide 20mg/12.5mg (Type Z) DAILY $ Lisinopril/Hydrochlorothiazide 20mg/12.5mg (Type P) DAILY $ Lisinopril/Hydrochlorothiazide 20mg/25mg (Type Z) DAILY a a Lisinopril/Hydrochlorothiazide 20mg/12.5mg (Type P) DAILY a a Quinapril/Hydrochlorothiazide 10mg/12.5mg DAILY $ Quinapril/Hydrochlorothiazide 20mg/12.5mg DAILY $ Quinapril/Hydrochlorothiazide 20mg/25mg DAILY $ a Denotes manufacturer price, product not covered by Ontario Drug Benefit *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

7 Angiotensin II Receptor Blockers (ARB)

8 2) Drug Class: Angiotensin II Receptor Blocker (ARB) Targeted Molecule(s) Drug Alternative(s) Clinical Rationale Summary Eprosartan (Teveten) Olmesartan (Olmetec) Valsartan (Diovan) Candesartan (Atacand) Irbesartan (Avapro) Losartan (Cozaar) Eprosartan/Hydrochlorothiazide (Teveten Plus) Olmsertan/Hydrochlorothiazide (Olmetec Plus) Valsartan /Hydrochlorothiazide (Diovan HCT) Candesartan/Hydrochlorothiazide Irbesartan/Hydrochlorothiazide Losartan/Hydrochlorothiazide Primary/Preferred: Telmisartan (Micardis) Secondary: Valsartan (Diovan) Crushable/Tubefeed Option (if any): Candesartan or Valsartan or Telmisartan Primary/Preferred: Telmisartan/Hydrochlorothiazide (Micardis Plus) Secondary: Valsartan/Hydrochlorothiazide (Diovan HCT) Crushable/Tubefeed Option (if any): No options available.look to change Rx to individual agents dosed separately Similar adverse effects. Monitor SCr, K+, BP Similar food/drug interactions. All ARB-diuretic combinations contain hydrochlorothiazide. Cost Comparison of ARBs Using Equipotent Doses for Hypertension Lower Dose Intermediate Dose Higher Dose ARB at Equivalent Doses Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Eprosartan (Teveten) 600mg * DAILY $ $ Olmesartan (Olmetec) 10mg * DAILY $ $ Losartan (Cozaar) 50mg DAILY $ $ Irbesartan (Avapro) 150mg DAILY $ $ Valsartan (Diovan) 80mg DAILY $ $ Candesartan (Atacand) 8mg DAILY $ $ Telmisartan (Micardis) 40mg DAILY $ $ Eprosartan (Teveten) 400mg * BID $ $ Olmesartan (Olmetec) 20mg * DAILY $ $ Losartan (Cozaar) 100mg DAILY $ $ Irbesartan (Avapro) 300mg DAILY $ $ Valsartan (Diovan) 160mg DAILY $ $ Candesartan (Atacand) 16mg DAILY $ $ Telmisartan (Micardis) 40mg DAILY $ $ Eprosartan (Teveten) 400mg * BID $ $ Olmesartan (Olmetec) 40mg * DAILY $ $ Losartan (Cozaar) 100mg DAILY $ $ Irbesartan (Avapro) 300mg DAILY $ $ Valsartan (Diovan) 320mg DAILY $ $ Candesartan (Atacand) 32mg DAILY $ $ Telmisartan (Micardis) 80mg DAILY $ $ *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

9 Comparison of ARB Combination Products Combination Products ARB Combination Products (as listed on the ODB Formulary) Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Olmesartan medoxomil/hydrochlorothiazide 20mg/12.5mg * DAILY $ Olmesartan medoxomil/hydrochlorothiazide 40mg/12.5mg * DAILY $ Olmesartan medoxomil/hydrochlorothiazide 40mg/25mg * DAILY $ Eprosartan/Hydrochlorothiazide 600mg/12.5mg * DAILY $ Telmisartan/Amlodipine 40mg/5mg * DAILY $ Telmisartan/Amlodipine 40mg/10mg * DAILY $ Telmisartan/Amlodipine 80mg/5mg * DAILY $ Telmisartan/Amlodipine 80mg/10mg * DAILY $ Losartan/Hydrochlorothiazide 100mg/25mg DAILY $ Losartan/Hydrochlorothiazide 50mg/12.5mg DAILY $ Losartan/Hydrochlorothiazide 100mg/12.5mg DAILY $ Irbesartan/Hydrochlorothiazide 150mg/12.5mg DAILY $ Irbesartan/Hydrochlorothiazide 300mg/12.5mg DAILY $ Candesartan/Hydrochlorothiazide 32mg/12.5 DAILY $ Irbesartan/Hydrochlorothiazide 300mg/25mg DAILY $ Candesartan/Hydrochlorothiazide 16mg/12.5 DAILY $ Valsartan/Hydrochlorothiazide 160mg/12.5mg DAILY $ Valsartan/Hydrochlorothiazide 160mg/25mg DAILY $ Valsartan/Hydrochlorothiazide 80mg/12.5mg DAILY $ Valsartan/Hydrochlorothiazide 320mg/12.5mg DAILY $ Valsartan/Hydrochlorothiazide 320mg/25mg DAILY $ Telmisartan/Hydrochlorothiazide 80mg/12.5mg DAILY $ Telmisartan/Hydrochlorothiazide 80mg/25mg DAILY $ *denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

10 Calcium Channel Blockers (non-dihydropyridine)

11 3) Drug Class: Calcium Channel Blocker (non-dihydropyridine) Targeted Molecule(s) Drug Alternative(s) Clinical Rationale Summary Diltiazem extended-release tablet (Tiazac XC) Primary/Preferred: Diltiazem SR extended-release capsule (Diltiazem T) Secondary: Diltiazem LA Crushable/Tubefeed Option (if any): Diltiazem SR.capsules may be opened and contents sprinkled on cool temp food. Swallow granules whole with no chewing. Follow with drink of water. Lack of evidence showing improved clinical outcomes when using Tiazac-XC as compared to other long acting diltiazem formulations Tiazac-XC is given at bedtime, while other formulations are given in the morning. Monitor BP and symptoms of angina during transition. Pharmacokinetic differences between formulations may result in the need for dosage adjustments. Cost Comparison of Diltiazem Formulations Using Equipotent Doses for Hypertension 120 mg Diltiazem Formulations at Comparable Doses Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Diltiazem (Tiazac XC) 120mg ER tab * DAILY $ Diltiazem 120mg LA cap DAILY $ Diltiazem 120mg SR cap DAILY $ mg 240 mg Diltiazem (Tiazac XC) 180mg ER tab * DAILY $ Diltiazem 180mg LA cap DAILY $ Diltiazem 180mg SR cap DAILY $ Diltiazem (Tiazac XC) 240mg ER tab * DAILY $ Diltiazem 240mg LA cap DAILY $ Diltiazem 240mg SR cap DAILY $ mg Diltiazem (Tiazac XC) 300mg ER tab * DAILY $ Diltiazem 300mg LA cap DAILY $ Diltiazem 300mg SR cap DAILY $ *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

12 Proton Pump Inhibitors (PPI)

13 4) Drug Class: Proton Pump Inhibitors (PPIs) Targeted Molecule(s) Drug Alternative (s) Clinical Rationale Summary Omeprazole (Losec) Lansoprazole (Prevacid) Pantoprazole (Pantoloc) Esomeprazole (Nexium) Primary/Preferred: Pantoprazole Magnesium (Tecta) Secondary: Rabeprazole (Pariet) Crushable/Tubefeed Option (if any): Omeprazole DR capsules (not tabs!) can be opened. Pellets must be ingested whole and can be mixed with soft food like applesauce, to be immediately swallowed. Comparable administration instructions, adverse effects and drug interactions Cost Comparison of PPIs Using Equipotent Doses PPIs at Equivalent Doses Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Esomeprazole (Nexium) 10 mg DAILY a a Pantoprazole (Tecta) 20mg DAILY a Omeprazole (Losec) 10mg DAILY a Pantoprazole (Pantoloc) 20mg DAILY a a Lansoprazole (Prevacid) 15mg DAILY $ Rabeprazole (Pariet) 10mg DAILY $43.95 Esomeprazole (Nexium) 20 mg DAILY a a Pantoprazole (Tecta) 40mg DAILY $68.44 Lansoprazole (Prevacid) 30mg DAILY $ Omeprazole (Losec) 20mg DAILY $ Pantoprazole (Pantoloc) 40mg DAILY $ Rabeprazole (Pariet) 20mg DAILY $87.89 Lower Dose Higher Dose a Denotes manufacturer price, product not covered by Ontario Drug Benefit *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

14 Long-acting Anticholinergic Muscarinic Antagonists (LAMA)

15 5) Drug Class: Long-acting anticholinergic muscarinic antagonists (LAMA) Targeted Molecule(s) Drug Alternative(s) Clinical Rationale Summary New starts for the first six months. Considerations to keep in mind: For COPD (Seebri, Spiriva, Spiriva Respimat): All three products carry the indication for use in COPD, with similarities in clinical efficacy and safety outcomes. Could be considered for a therapeutic switch except in the case of severe allergy to milk proteins where Spiriva would be recommended. Glycopyrronium (Seebri) Tiotropium (Spiriva) For Asthma (Spiriva Respimat): Only Spiriva Respimat carries an additional indication as an add-on maintenance bronchodilator treatment in adult patients with asthma who remain symptomatic on a combination of inhaled corticosteroid and a long acting β2 agonist and who experienced one or more severe exacerbations in the previous year. Both Glycopyrronium and Tiotropium are used once daily. Education would be necessary on use of Spiriva or Spiriva Respimat device if switching. Cost Comparison of LAMAs Using Equipotent Doses LAMAs at Comparable Doses Dosing Frequency Cost per Dose Cost per Resident per Year Glycopyrronium (Seebri) 50mcg * (COPD only) DAILY $ Tiotropium (Spiriva) 18mcg Cap * (COPD only) DAILY $ Tiotropium (Spiriva Respimat) 2.5mcg/Actuation* DAILY $ (60 actuations per pack) (COPD/Asthma) *Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

16 Bisphosphonates

17 6) Drug Class: Bisphosphonates Targeted Molecule(s) Drug Alternative(s) Clinical Rationale Summary Risedronate (Actonel DR) delayed release Risedronate (Actonel) Primary/Preferred: Alendronate (Fosamax)* Crushable/Tubefeed Option (if any): No viable options Actonel DR s only potential advantage is that it should be taken with food (not given on an empty stomach, ½ hour before a meal). This clinical advantage is diminished when considering the alternatives are given once a week or once a month. It offers no therapeutic advantage in dysphagia as Actonel DR must not be crushed and must be given upright with sufficient water (similar to other formulations). Also, it must not be given at the same time of day as calcium supplements. Cost Comparison of Bisphosphonates Bisphosphonates Dosing Frequency Cost per Tablet or Capsule Cost per Resident per Year Risedronate (Actonel DR) 35mg ** WEEKLY Risedronate (Actonel) 5mg DAILY Alendronate (Fosamax) 10mg DAILY Risedronate (Actonel) 150mg MONTHLY Alendronate (Fosamax) 70mg WEEKLY Risedronate (Actonel) 35mg WEEKLY *Ministry s current No Substitution policy can be applied based on documented patient responses and circumstances **Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed price. Does not include standard markup or pharmacist professional fee

18 Serotonin Norepinephrine Reuptake Inhibitors

19 7) Drug Class: Serotonin Norepinephrine Reuptake Inhibitor Targeted Molecule(s) Drug alternative(s) Clinical Rationale Summary Major depressive disorder or generalized anxiety disorder SNRI (venlafaxine) Duloxetine SSRI (citalopram, escitalopram, fluoxetine, (Cymbalta) fluvoxamine, paroxetine, sertraline) DPRI (bupropion) NaSSA (mirtazapine) Escitalopram (Cipralex MELTZ) Fibromyalgia, neuropathic pain GABA derivatives (gabapentin, pregabalin) For new starts only. Limit the use of Cymbalta (duloxetine) for LTC residents in the following circumstance: a. For major depressive disorder or generalized anxiety disorder after failure of an adequate trial of a selective serotonin reuptake inhibitor (SSRI) or other serotonin norepinephrine reuptake inhibitor (SNRI). Cost Comparison of Duloxetine and Drug Alternatives Agents Cost per Tablet or Capsule Cost per Dose per Resident per Year Duloxetine (Cymbalta) 60mg DR cap * $ Duloxetine (Cymbalta) 30mg DR cap * $ Bupropion (Wellbutrin)300mg SR tab $ Pregabalin (Lyrica) 150mg cap $ Pregabalin (Lyrica) 300mg cap $ Paroxetine (Paxil) 30mg tab $ Fluoxetine (Prozac) 20mg cap $ Escitalopram (Cipralex) 20mg tab $ Paroxetine (Paxil) 20mg tab $ Escitalopram (Cipralex) 10mg tab $ Citalopram (Celexa) 10mg $ Bupropion (Wellbutrin)150mg ER tab $ Pregabalin (Lyrica) 75mg cap $ Fluvoxamine (Luvox) 100mg tab $ Venlafaxine (Effexor) 150mg ER cap $ Venlafaxine (Effexor) 75mg ER cap $ Pregabalin (Lyrica) 50mg cap $ Mirtazapine (Remeron) 30mg tab $ Mirtazapine (Remeron) 45mg OD tab $ Citalopram (Celexa) 20mg $ Citalopram (Celexa) 40mg $ Bupropion (Wellbutrin)150mg SR tab $ Gabapentin (Neurontin) 400mg cap $ Fluvoxamine (Luvox) 50mg tab $ Mirtazapine (Remeron) 30mg OD tab $ Gabapentin (Neurontin) 300mg cap $ Venlafaxine (Effexor) 37.5mg ER cap $ Bupropion (Wellbutrin)100mg SR tab $ Mirtazapine (Remeron) 15mg OD tab $ Gabapentin (Neurontin) 100mg cap $ * Denotes products where a generic formulation is NOT available Ontario Drug Benefit listed formulary price. Does not include standard markup or pharmacist professional fee Cost per resident per year based on once daily administration