| 79-year-old patient on eltrombopag for idiopathic thrombocytopenia (ITP) |
| • Labs—platelets– 451 x 10 (3) uL |
| • Per Micromedex drug information on eltrombopag [17], dose adjustment required for platelet counts above 400 x 10(9)/L, in ITP. |
| • Provider messaged potential dose adjustment required. |
|
Safety: Thromboembolism (venous or arterial) may occur with excessive increases in platelet levels. Incidence of thrombosis in ITP– 6%. |
| Financial Implications: |
| “Treatment of an acute VTE on average appears to be associated with incremental direct medical costs of $12,000 to $15,000 (2014 US dollars) among first-year survivors, controlling for risk factors. Subsequent complications are conservatively estimated to increase cumulative costs to $18,000–23,000 per incident case. Annual incident VTE events conservatively cost the US healthcare system $7–10 billion each year for 375,000 to 425,000 newly diagnosed, medically treated incident VTE cases [18].” |
| 49-year-old patient on multiple CNS depressants, opioids, benzodiazepines, SSRI and z-drug at high doses |
| • Recommendation to consider medication tapers and consolidation of therapy. |
| • Patient mentions to provider they had previously used cannabis. Provider tests patient and they are positive for cannabis. |
| • Note to provider that components in marijuana can interfere with CYP450 enzymes competitively inhibiting the metabolism of other compounds [19]. This interaction could impact benzodiazepines, opioids and CYP2D6 which metabolizes SSRIs and could potentially explain need for increased doses. |
|
Safety: With the legalization of marijuana in many states, it is imperative for providers to question patients regarding the use of cannabis products. Medically complex patients with multiple comorbidities are at risk for adverse drug reactions. |
| Financial Implications: |
| “The average direct costs per patient caused by ADEs were USD $444.90 [95% CI: 264.4 to 625.3], corresponding to USD $21 million per 100,000 adult inhabitants per year. Inpatient care accounted for 53.9% of all direct costs caused by ADEs. For patients with ADEs, the average societal cost of illness was USD $6,235.00 [5,442.8 to 7,027.2], of which direct costs were USD $2,830.1 [2,260.7 to 3,399.4] (45%), and indirect costs USD $3,404.9 [2899.3 to 3910.4] (55%). The societal cost of illness was higher for patients with ADEs compared to other patients. ADEs caused 9.5% of all direct healthcare costs in the study population [20].” |
| 93-year-old patient on warfarin with unstable INR |
| • Patient on concomitant torsemide. |
| • Messaged provider regarding torsemide/warfarin interaction. |
| • Patient transitioned to apixaban after months of INR not within goal–INR supratherapeutic. |
|
Safety: Patient at risk of bleeding, increased fall risk and potential hemorrhage. |
|
Financial Implications: |
| “Most hospitalization expenditures after an anticoagulant-associated ADR were attributable to nursing costs (mean $33,189 per ADR) followed by pharmacy costs (mean $7,451 per ADR). ADRs which were determined to add incremental expense were associated with significant increases in total hospitalization cost (mean $118,429 vs. $54,858, p = 0.02) as well as cost after the ADR (mean $89,733 vs. $23,680, p = 0.004) compared with ADRs in which no incremental cost was determined to be incurred [21].” |
