1
|
Gleeson PK, Morales KH, Hvisdas C, LaCava AF, Harhay MO, Rank MA, Apter AJ, Himes BE. Factors Associated With Asthma Biologic Prescribing and Primary Adherence Among Adults in a Large Health System. J Allergy Clin Immunol Pract 2023; 11:1834-1842.e4. [PMID: 36907354 PMCID: PMC10330036 DOI: 10.1016/j.jaip.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND The availability of asthma biologics may not benefit all patients equally. OBJECTIVE We sought to identify patient characteristics associated with asthma biologic prescribing, primary adherence, and effectiveness. METHODS A retrospective, observational cohort study of 9,147 adults with asthma who established care with a Penn Medicine asthma subspecialist was conducted using Electronic Health Record data from January 1, 2016, to October 18, 2021. Multivariable regression models were used to identify factors associated with (1) receipt of a new biologic prescription; (2) primary adherence, defined as receiving a dose in the year after receiving the prescription, and (3) oral corticosteroid (OCS) bursts in the year after the prescription. RESULTS Factors associated with a new prescription, which was received by 335 patients, included being a woman (odds ratio [OR] 0.66; P = .002), smoking currently (OR 0.50; P = .04), having an asthma hospitalization in the prior year (OR 2.91; P < .001), and having 4+ OCS bursts in the prior year (OR 3.01; P < .001). Reduced primary adherence was associated with Black race (incidence rate ratio 0.85; P < .001) and Medicaid insurance (incidence rate ratio 0.86; P < .001), although most in these groups, 77.6% and 74.3%, respectively, still received a dose. Nonadherence was associated with patient-level barriers in 72.2% of cases and health insurance denial in 22.2%. Having more OCS bursts after receiving a biologic prescription was associated with Medicaid insurance (OR 2.69; P = .047) and biologic days covered (OR 0.32 for 300-364 d vs 14-56 d; P = .03). CONCLUSIONS In a large health system, primary adherence to asthma biologics varied by race and insurance type, whereas nonadherence was primarily explained by patient-level barriers.
Collapse
Affiliation(s)
- Patrick K Gleeson
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christopher Hvisdas
- The Ambulatory Care Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pa
| | - Anthony F LaCava
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Akron, Ohio
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz, and Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Andrea J Apter
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| |
Collapse
|
2
|
Greiwe J, Honsinger R, Hvisdas C, Chu DK, Lang DM, Nicklas R, Apter AJ. Boxed Warnings and Off-Label Use of Allergy Medications: Risks, Benefits, and Shared Decision Making. J Allergy Clin Immunol Pract 2022; 10:3057-3063. [PMID: 36064185 DOI: 10.1016/j.jaip.2022.08.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 12/14/2022]
Abstract
The Food and Drug Administration is tasked with evaluating the efficacy and safety of a drug. Despite having a regimented appraisal process in place, safety evidence can emerge during clinical trials as well as from observations and studies conducted after the drug has been on the market, which might require a boxed warning. The boxed warning is the most severe warning that the Food and Drug Administration can give to an approved drug. It is commonly referred to as a Black Box Warning because it is outlined in the package insert by a thick black box to garner the attention of prescribers and patients. There are currently more than 400 medications that have boxed warnings, and the information addressing major risks associated with a particular drug may, appropriately or inappropriately, influence patient and clinician decision making. Health care professionals must use the best evidence and clinical judgment in determining whether to prescribe medications with these warnings. Use of an approved drug at dosages or for indications other than what it was originally licensed for is referred to as "off-label" and is legal, commonplace, and may be evidence-based. All drugs may expose patients to possible harm, so prescribers have an obligation to discuss the best available evidence regarding benefits and harms so that patients can participate in shared decision making.
Collapse
Affiliation(s)
- Justin Greiwe
- Bernstein Allergy Group, Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Richard Honsinger
- Los Alamos Medical Care Clinic Ltd, Los Alamos, NM; Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Christopher Hvisdas
- Department of Pharmacy Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pa
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| |
Collapse
|
3
|
Hvisdas C, Goode N, Lee K, Kim D, Silvey M, Kasbekar N. Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report. J Am Coll Clin Pharm 2022. [DOI: 10.1002/jac5.1712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Christopher Hvisdas
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Natalie Goode
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Kevin Lee
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Diane Kim
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Michael Silvey
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Nishaminy Kasbekar
- Department of Pharmacy Penn Presbyterian Medical Center University of Pennsylvania Health System Philadelphia Pennsylvania USA
| |
Collapse
|
4
|
Hvisdas C, Louisias M, Laidlaw TM, Akenroye A. Addressing disparities in biologic drug development in the United States. J Allergy Clin Immunol 2021; 148:1154-1156. [PMID: 34530019 DOI: 10.1016/j.jaci.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/11/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Christopher Hvisdas
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pa
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Division of Pediatric Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
| |
Collapse
|
5
|
Mukaddam MA, Hvisdas C, Sulaj A, Patel K, Tran R. Experience With Anti-Sclerostin Antibody for Osteoporosis Patient With End-Stage Renal Disease on Hemodialysis. J Endocr Soc 2021. [PMCID: PMC8089248 DOI: 10.1210/jendso/bvab048.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Romosozumab is a sclerostin inhibitor indicated for treatment of postmenopausal osteoporosis. Sclerostin inhibits Wnt/Beta-catenin signaling pathway. When sclerostin is inhibited, stimulation of this pathway leads to increased bone formation and production of osteoprotegerin, which also decreases bone resorption. Patients with chronic kidney disease (CKD) demonstrate increased levels of sclerostin that negatively correlates with the rate of bone formation; however, data is lacking for use of romosozumab in this patient population. The report herein details the experience of use of romosozumab in a patient with end-stage renal disease (ESRD) on hemodialysis (HD). Clinical Case: A 37-year-old old African American male was referred after multiple rib fractures and severe non-traumatic T8 compression fracture with nerve compression. His past medical history includes lupus nephritis and cerebritis, ESRD on HD since age 22 status post (s/p) failed renal transplant, and tertiary hyperparathyroidism complicated with fracture in iliac brown tumor and mediastinal parathyromatosis s/p three parathyroid surgeries. Bone mineral density by DXA (g/cm2, Z-score) were as follows: lumbar spine (0.700, -4.0) femoral neck (0.676, -3.8), total hip (0.628,-4.0), 1/3 radius(0.443,-6.2). No prior exposure to antiresorptive or osteoanabolic agents. Pertinent labs included serum calcium 8.5 mg/dL (nl 8.9–10.3 mg/dl), albumin 4.2 g/dL, alkaline phosphatase 319 U/L (nl 38–126), Phosphorus 3.1 mg/dL (2.4–4.7), Creatinine 5.62 mg/dl, 25-OH Vitamin D 31 ng/mL (nl 25 - 80), intact parathyroid hormone 17.9 pmol/L (nl 1.6–6.9). Patient was in excruciating pain and not a surgical candidate due to poor bone quality. Osteoanabolic therapy was recommended given the severity of osteoporosis; however, teriparatide and abaloparaitde were contraindicated given comorbidities. The patient was offered off-label use of Romosozumab with clear understanding that the drug is not approved for this indication and safety/efficacy data in ESRD is not known. The boxed warning regarding increased risk of stroke, myocardial infarction and death were discussed and patient was willing to proceed. Repeat DXA after eleven monthly doses of Romosozumab resulted in a remarkable improvement in bone mineral density at all sites: lumbar spine (+47%), femoral neck (+41%), total hip (+28%), 1/3 radius (+20%). Patient tolerated medication with no side effects or fractures. Serum calcium was monitored prior to initiation and before every dose. No doses were held due to abnormal laboratory values or side effects. Conclusion: This case report summarizes successful experience with the use of Romosozumab in one patient with ESRD on HD with favorable outcomes.
Collapse
Affiliation(s)
- Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher Hvisdas
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Anisa Sulaj
- Philadelphia College of Pharmacy, Philadelphia, PA, USA
| | - Kruti Patel
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Richie Tran
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| |
Collapse
|
6
|
Hvisdas C. Revefenacin, a once-daily, long-acting muscarinic antagonist, for nebulized maintenance therapy in patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm 2021; 78:1184-1194. [PMID: 33821890 PMCID: PMC8083528 DOI: 10.1093/ajhp/zxab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This article reviews the efficacy and safety of revefenacin, the first once-daily, long-acting muscarinic antagonist, when delivered via a standard jet nebulizer in patients with chronic obstructive pulmonary disease (COPD). SUMMARY Revefenacin 175 µg is indicated for the maintenance treatment of patients with moderate to very severe COPD. Preclinical studies showed that revefenacin is a potent and selective antagonist with similar affinity for the different subtypes of muscarinic receptors (M1-M5). Furthermore, prevention of methacholine- and acetylcholine-induced bronchoconstrictive effects was dose dependent and lasted longer than 24 hours, demonstrating a long duration of action. In phase 2 and 3 trials, treatment with revefenacin was demonstrated to result in statistical improvements in pulmonary function (≥100 mL, P < 0.05) vs placebo, including among patients with markers of more severe disease and those who received concomitant long-acting β-agonists or long-acting β-agonists together with inhaled corticosteroids. Revefenacin was also demonstrated to have efficacy similar to that of tiotropium. The clinical trial findings indicated no significant difference between revefenacin and tiotropium with regard to rates of adverse events. Overall, revefenacin was well tolerated, with COPD worsening/exacerbation, dyspnea, headache, and cough among the most common adverse events noted in the clinical trials. CONCLUSIONS Revefenacin treatment delivered via nebulization led to improvements in lung function in patients with COPD. It was also generally well tolerated, with no major safety concerns. Revefenacin provides a viable treatment option for patients with COPD and may be a suitable alternative for those with conditions that may impair proper use of traditional handheld inhalers.
Collapse
Affiliation(s)
- Christopher Hvisdas
- Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
7
|
Hvisdas C, Gleeson PK, Apter AJ. Cost considerations for clinicians prescribing biologic drugs: Who pays? J Allergy Clin Immunol 2020; 146:266-269. [PMID: 32325143 DOI: 10.1016/j.jaci.2020.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Christopher Hvisdas
- Ambulatory Care Department of Pharmacy, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pa
| | - Patrick K Gleeson
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J Apter
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| |
Collapse
|
8
|
Swisher R, Blaine N, Hvisdas C. Is specialty patient care affected by exclusivity? Am J Health Syst Pharm 2019; 76:1821-1822. [DOI: 10.1093/ajhp/zxz211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Regina Swisher
- Department of Pharmacy Penn Presbyterian Medical Center Philadelphia, PA
| | - Natalie Blaine
- Department of Pharmacy Penn Presbyterian Medical Center Philadelphia, PA
| | | |
Collapse
|
9
|
Hvisdas C, Lordan A, Pizzi LT, Thoma BN. US Propofol Drug Shortages: A Review of the Problem and Stakeholder Analysis. Am Health Drug Benefits 2013; 6:171-175. [PMID: 24991355 PMCID: PMC4031712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Drug shortages have increased in recent years in the United States, with a majority involving sterile injectable drugs. Propofol, a sterile injectable drug, is frequently used as a sedative, thanks to its rapid onset of action and a short recovery period. However, propofol is complicated and expensive to manufacture, and recent events involving major manufacturers have led to shortages of the drug in the United States. OBJECTIVES To review the events leading to the shortage of propofol and to discuss how the shortage is affecting various healthcare stakeholders, as an example of the systemwide problem of drug shortages in the United States. DISCUSSION Manufacturers currently have little economic incentive to produce propofol, a generic drug whose production is costly and carries a high liability. The enforcement of good manufacturing practices by the US Food and Drug Administration is beneficial for the safety of US citizens, but it can inherently lead to a sudden halt in the manufacturers' production of drugs. Hospitals are affected because they must develop a plan to address current and potential shortages, including restricting the use of medications that have a shortage and shifting to alternative agents. CONCLUSION The shortage of propofol significantly impacted the delivery of care in the United States in 2009, and various stakeholders are working to increase the existing supply of propofol and to investigate the use of alternative medications when the supply runs short. The case of propofol presented in this article is used to illustrate a systemwide view of the impact of drug shortages on the US healthcare system.
Collapse
Affiliation(s)
- Christopher Hvisdas
- Doctor of Pharmacy students, Department of Pharmacy Practice, Jefferson School of Pharmacy, Philadelphia, PA
| | - Andrea Lordan
- Doctor of Pharmacy students, Department of Pharmacy Practice, Jefferson School of Pharmacy, Philadelphia, PA
| | - Laura T Pizzi
- Associate Professor, Department of Pharmacy Practice, Jefferson School of Pharmacy, Philadelphia, PA
| | - Brandi N Thoma
- Clinical Pharmacy Specialist, Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, PA
| |
Collapse
|