1. PHA 499
Medications Cost Effectiveness in Hospital
Pharmacies
Presented by:
Maura Andary

2. Introduction:
A hospital’smissionistoensure adequate patientcare;however,thismissioncomesata cost.The cost
burdeninvolvesthe buildingblocks,operationrooms,emergencydepartment,healthcare personnel,
and lastbut notleast,medications.The PharmacyandTherapeuticscommitteesinmosthospitalswork
on the formulary medicationselection, medicationmaintenance, medicationuse evaluation,medication
safetyevaluation,treatmentguidelines,policiesandprocedures,continuouseducation…Outof all the
listedresponsibilities,medicationselectioniscurrentlythe majorchallenge. Thisselectionshouldbe
basedon a balancedequilibriumbetweensafety,efficacy,andcost.Costeffectivenessremainstodate a
weakpointinhospital formularies.Thisisdue tothe lackof adequate costeffectivenessanalysisbythe
pharmacistsandphysicians,the lackof independentsponsorshiptothe hospitals,andinadequate
expertisein financialandeconomicevaluation 7
.AtNDShospital,the chief pharmacisthasalready
succeededinusingthe mostcosteffective alternative whenitcomestoantifungals.Futureplanstarget
antibiotics, anticoagulantsin hemodialysis, etc…
Methods:
A retrospective studywasconductedon15 patientprofilesinNotre Dame desSecoursHospital inJbeil,
Lebanon.A data collectionsheetwasfilledforeachpatientcase byreferringtopatientprofilesand
assistance of nurses.Several patientcategorieswereincludedinthe study:The firstcategoryincludes
patientsondialysistakingeitherLovenox®orheparin.The secondcategoryincludespatientson oral or
parenteral voriconazole,andpatientsfromthe thirdcategorywere eitheron oral or parenteral
levofloxacin.Moreover,several patientcategorieswereexcludedsuchasneonates(<1months),patients
withalteredconsciousness,patientsunable totolerate oral intake,andfinallythose whohave any
contraindicationtoanypreviouslymentioneddrug.
These patientswere evaluatedbasedontheiroral tolerability,anddrugswere assessedbasedontheir
equivalentefficacywhenswitchingbetweenparenteral and oral orbetweentwodrugsfromthe same
therapeuticclassbasedontheircosteffectiveness.
Results:
In the Pool DialysisUnit,six patientprofileswereinvestigatedforthe use of parenteral anticoagulants.
Two patientswere onLovenox®(Enoxaparin) while fourotherswere onUnfractionatedHeparin2500IU
or 5000IU.

3. Initials Department Diagnosis Treatment and
Duration
Cost of
medication (L.L.)
S.B Pool Renal
Dialysis
End Stage Renal Failure Lovenox® 10 mg
2 timesperweek
10,000/syringe
N.C Pool Renal
Dialysis
Indeterminate Nephritis Heparin5000 IU
3 timesperweek
7,084/25000IU
J.Y Pool Renal
Dialysis
DiabeticNephropathy Heparin2500 IU
3 timesperweek
7,084/25000IU
M.K Pool Renal
Dialysis
CKD Heparin5000 IU
3 timesperweek
7,084/25000IU
N.Y Pool Renal
Dialysis
PolycysticKidneyDisease Heparin5000 IU
3 timesperweek
7,084/25000IU
R.H Pool Renal
Dialysis
ChronicAllograft
Nephropathy
Lovenox® 10mg
2 timesperweek
10,000/syringe
All patientshave nomajororgan impairmentother thanrenal disorders.Ideally,those dialysispatients
shouldall receive unfractionatedheparinasitis clearedthroughnonrenal mechanisms 6
,butsome
physiciansstill insistonenoxaparindue tothe fearof HeparinInducedThrombocytopenia(HIT).What is
importantto note isthat HIT can also occur withenoxaparin.Sonotonlyisheparinbetterdue torenal
impairment,butalsodue tocost 5
.The 25000IU vial of heparin,whichcanbe usedfor more thanone
dialysissession,islessexpensivethanone syringe of enoxaparin.Infact,mostLebanese hospitalsuse
onlyunfractionatedheparininthe dialysisunit.
Lovenox.com©

4. Moreover,fourpatientprofilesfromthe Internal Medicine Floorandone patientprofilefromthe ICU
were studiedforthe intake of VFEND® (IV Voriconzale).
Initials Department Diagnosis Treatment
duration
A.T ICU ARDS inducedby
chemotherapy
Notspecified
R.N Internal Medicine Esophageal candidiasis 14 days
N.S Internal Medicine Candidemia 14 days
N.J Internal Medicine Invasive Aspergillosis 6 weeks
A.S Internal Medicine Invasive Aspergillosis 12 weeks
The patientsmentionedabove cantolerate oral intake,have nomajororganimpairment,orany
contraindicationtoanydosage formof voriconazole.The costof one 200 mg vial of V-FEND® is268,895
L.L. while the oral formcosts59,370 L.L / 200mg tablet 4
. A studywas done on35 patientswithinvasive
fungal infectionsinthe Netherlands 2
.Itwasa retrospective,observationalstudyintendedtotestthe
safety andefficacyof oral versusintravenousvoriconazole.Bothdosage formswere usedforthe same
treatmentduration,andtheyshowedtohave comparable efficacy.The riskof hepatotoxicitywasalso
comparable.Moreover,the oral formhasa goodbioavailabilityandisrecommendedforpatientswho
have renal insufficiency,since the IV formiscontraindicatedinpatientswithaCrCl < 50mL/min 1
.
Heroza.org©

5. On the otherhand,four patientprofileswere investigatedforthe use of IV levofloxacinin the Internal
Medicine department:
Initials Department Diagnosis Treatment
Duration
M.R Internal Medicine Nosocomial Pneumonia 10 days
S.N Internal Medicine ChronicBacterial
Prostatitis
10 days
R.G Internal Medicine Acute bacterial sinusitis 14 days
N.T Internal Medicine Acute pyelonephritis 5 days
The patientsmentionedabove cantolerate oral intake,have nomajororganimpairment,orany
contraindicationto anydosage formof levofloxacin.The costof 100ml (5mg/mL) bottle of levofloxacin
IV is 26,733 L.L while the oral formis6,190L.L / 500 mg tablet 4
.The requireddose of levofloxacinforthe
treatmentof pneumonia,sinusitis,prostatitis,orpyelonephritisisusually500 mg PO or IV daily 1
.A
studyconductedinSwitzerlandaimedatcomparingthe efficacyof oral levofloxacintosequential
levofloxacintherapyinpatientswithCommunityAcquiredPneumonia(CAP) 3
.Itwas a randomized,
prospective study done overa12 monthsperiodon129 hospitalizedpatients,excludingthe onesinthe
ICU. Resultsshowedthatafull course of oral levofloxacinwasasefficaciousasstartingwithIV andthen
switchingtoPO.The authors statedthat itleadto major“drug acquisitionsavings”forthe hospital.
Discussion:
Data was collectedoveraperiodof one weekonly,andthe sample size wassmall.Anotherlimitation
isthat most of the data andpatientprofilesare notcomputerized,whichmighthave ledtosome
missinginformation.The challengingaspectof thisstudyisthatphysiciansstill insistonthe IV dosage
formsfor hospitalizedpatients. However,the use of POlevofloxacinorvoriconazole willdecreasethe
cost on the hospital pharmacyandeventuallythe patient. Onthe otherhand,the dialysissessionbudget
will be usedmore efficientlyif heparinisusedinsteadof Lovenox®,thusmoneywill be investedon
betterequipmentandpatientcare. The chief pharmacisthasalreadysucceededinusingthe POformof
voriconazole, whichisbyitself apromisingstep.

6. Conclusion:
The implementationof the desiredchangeswillrequiresome time andeffortformthe healthcare team
and the hospital’sadministration. Actionshouldbe takenduringthe upcomingPharmacyand
Therapeuticscommittee meetinginordertoimplement those adjustmentstothe formulary. Itmaynot
appearas an urgentmatter; however,the sooneractionistaken,the more the hospital caninveston
otheraspectsof healthcare,ratherthanthe overwhelmingcostof medications. Eventually,apatient’s
stay inthe hospital will be more costeffective.

7. References:
1. AmericanPharmacistsAssociation.DrugInformationHandbook.23rd
edition.Lexicomp;2014-
2015
2. Arkel C,De Marie S, HollanderJ,LevinM, LugtenburgP,RijndersB. Incidence of voriconazole
hepatotoxicityduringintravenousandoral treatmentforinvasive fungal infections. Journalof
AntimicrobialChemotherapy. March2006; 57:1248-1250
3. CalandraT, ComettaA,Erard V,Lamy O, WasserfallenJ. Cost-effectivenessof full-course oral
levofloxacininsevere community-acquiredpneumonia. EurRespirJ. 2004;24: 644-648
4. Drugs PublicPrice List.Available at http://www.moph.gov.lb/Drugs/Pages/Drugs.aspx .
AccessedJune 9,2015
5. Garces E, VictorinoJ.EnoxaparinVersusUnfractionatedHeparinasAnticoagulantfor
ContinuousVenovenoushemodialysis:arandomizedopenlabel trial. RenalFailure. January
2010; 32: 320-327
6. Haemodialysisguidelines.Availableat
http://www.renal.org/guidelines/modules/haemodialysis#s7 .AccessedJune 9,2015
7. SloanFA,WilsonA,Whetten-GoldsteinK. Hospital pharmacydecisions,costcontainment,and
the use of cost-effectivenessanalysis. SocSci Med. August1997; 45: 523-533