Yinning Tablet, a hospitalized preparation of Chinese herbal formula for hyperthyroidism, ameliorates thyroid hormone-induced liver injury in rats: Regulation of mitochondria-mediated apoptotic signals

ETHNOPHARMACOLOGICAL RELEVANCE

Hyperthyroidism is closely associated with liver injury. The preliminary clinical observation suggests that Yinning Tablet, a hospitalized preparation of traditional Chinese formula for hyperthyroidism, improves not only hyperthyroidism, but also hyperthyroidism-associated liver injury.

AIM

To evaluate the effect and underlying mechanisms of Yinning Tablet on thyroid hormone-induced liver injury.

MATERIALS AND METHODS

Female rats were orally administered L-thyroxine (1 mg/kg) once daily for 60 days, and co-treated with the carefully identified Yinning Tablet extract (0.6-2.4 g/kg) during the last 30 days. Blood and liver variables were determined enzymatically, histologically, by ELISA, radioimmunoassay, Real-Time PCR or Western blot, respectively.

RESULTS

Co-treatment with the extract attenuated L-thyroxine-induced increases in serum alanine transaminase and aspartate transaminase activities, the ratio of liver weight to body weight, cytoplasmic vacuolization in hepatocytes, infiltrated inflammatory cells and confused structures in liver tissue, accompanied by attenuation of increased serum triiodo-l-thyronine concentration and hepatic deiodinase type I overexpression in rats. Importantly, Yinning Tablet suppressed L-thyroxine-triggered hepatic Bax, cleaved caspases-3, -8 and -9 protein overexpression, and Bcl-2 protein downregulation. Furthermore, the increases in cytochrome c protein expression, Ca²⁺-ATPase activity and malondialdehyde content, and decreases in activities of Na⁺/K⁺-ATPase, catalase, superoxide dismutase and glutathione peroxidase, and total antioxidant capacity in liver tissue were attenuated.

CONCLUSION

The present results suggest that Yinning Tablet ameliorates thyroid hormone-induced liver injury in rats by regulating mitochondria-mediated apoptotic signals. Our findings go insight into the pharmacological basis of the hospitalized preparation for treatment of hyperthyroidism-associated liver injury.

Impact of removal and restriction of me-too medicines in a hospital drug formulary on in- and outpatient drug prescriptions: interrupted time series design with comparison group

BACKGROUND

The study covered in- and out-of-hospital care in a region in north-western Spain. The intervention evaluated took the form of a change in the hospital drugs formulary. Before the intervention, the formulary contained four of the five low molecular weight heparins (LMWHs) marketed in Spain. The intervention consisted of withdrawing two LMWHs (bemiparin and dalteparin) from the formulary and restricting the use of another (tinzaparin), leaving only enoxaparin as an unrestricted prescription LMWH. Accordingly, the aim of this study was to evaluate the effect on in- and outpatient drug prescriptions of removing and restricting the use of several LMWHs in a hospital drugs formulary.

METHODS

We used a natural, before-after, quasi-experimental design with a control group and monthly data from January 2011 to December 2016. Based on data drawn from official Public Health Service sources, the following dependent variables were extracted: defined daily doses (DDD) per 1000 inhabitants per day (DDD/TID), DDD per 100 stays per day, and expenditure per DDD.

RESULTS

The two compounds that were removed from the formulary registered an immediate decrease at both an intra- and out-of-hospital level (66.6% and 55.6% for bemiparin and 73.0% and 92.2% for dalteparin, respectively); similarly, the compound that was restricted also registered an immediate decrease (36.1% and 9.0% at the in- and outpatient levels, respectively); in contrast, the remaining LMWH (enoxaparin) registered an immediate, significant increase at both levels (44.9% and 32.6%, respectively). The intervention led to an immediate reduction of 6.8% and a change in trend in out-of-hospital cost/DDD; it also avoided an expenditure of €477,317.1 in the 21 months following the intervention.

CONCLUSIONS

The results indicate that changes made in a hospital drugs formulary towards more efficient medications may lead to better use of pharmacotherapeutic resources in its health catchment area.

The Few. The Effective. The Cheapest. The Waste-Free Formulary

The Pacific Business Group on Health in developing a "waste-free formulary" that it hopes all purchasers could use. Such a formulary would be limited to drugs with proven clinical utility and among those, the low-cost alternatives. It is using a number of algorithms to evaluate medications.

Development and implementation of an academic cancer therapy stewardship program

OBJECTIVES

Antibiotic stewardship is an integral aspect of hospital care, limiting the potential for resistance while working to minimize waste. A similar system is needed in oncology, given the rapid proliferation of new therapies and the challenges of navigating a complicated reimbursement environment. A "cancer therapy stewardship program" has never been described in the literature. Here, we detail our efforts to design and implement such a program and share lessons learned to inform future projects.

STUDY DESIGN AND METHODS

For 1 year, a hematologist-oncologist (the "cancer therapy steward") at Mount Sinai Hospital was in charge of addressing all requests for nonformulary or off-label chemotherapeutic and supportive medications and regimens. Requests consisted of the rationale for use and supporting data from medical journal articles. This pilot initiative was focused mainly on inpatient malignant hematology.

RESULTS

Sixty-seven requests were made by 23 physicians, and all requests were ultimately approved. Requests tended to fall into 3 categories: 1) use of a single drug in a setting not approved by the FDA, 2) use of multiple drugs in novel combinations not approved by the FDA, and 3) adding novel drugs to existing FDA-approved regimens.

CONCLUSIONS

Our cancer therapy stewardship program yielded many useful insights into how our physicians face challenging clinical situations. It also helped to improve overall clinical quality and patient care by emphasizing the importance of value-based care and evidence-based medicine. Expanding this program will likely lead to many interesting experiments aimed at improving medical education and research, patient safety outcomes, and clinical quality.

How drug life-cycle management patent strategies may impact formulary management

Drug manufacturers may employ various life-cycle management patent strategies, which may impact managed care decision making regarding formulary planning and management strategies when single-source, branded oral pharmaceutical products move to generic status. Passage of the Hatch-Waxman Act enabled more rapid access to generic medications through the abbreviated new drug application process. Patent expirations of small-molecule medications and approvals of generic versions have led to substantial cost savings for health plans, government programs, insurers, pharmacy benefits managers, and their customers. However, considering that the cost of developing a single medication is estimated at $2.6 billion (2013 dollars), pharmaceutical patent protection enables companies to recoup investments, creating an incentive for innovation. Under current law, patent protection holds for 20 years from time of patent filing, although much of this time is spent in product development and regulatory review, leaving an effective remaining patent life of 7 to 10 years at the time of approval. To extend the product life cycle, drug manufacturers may develop variations of originator products and file for patents on isomers, metabolites, prodrugs, new drug formulations (eg, extended-release versions), and fixed-dose combinations. These additional patents and the complexities surrounding the timing of generic availability create challenges for managed care stakeholders attempting to gauge when generics may enter the market. An understanding of pharmaceutical patents and how intellectual property protection may be extended would benefit managed care stakeholders and help inform decisions regarding benefit management.

Leveraging hospital formularies for improved prescribing

Hospital formularies, guided by the Pharmacy and Therapeutics Committee, exist to optimize medication use by identifying and designating drugs of choice to guide rational prescribing, ultimately reducing patient risk and costs and improving patient outcomes. Guidelines and a framework exist to guide critical evaluations of medications for formulary listing; however, there may be opportunities to improve and standardize how a formulary change could be instituted in Canadian hospitals. A formulary change at an Ontario hospital revealed that there are some key challenges to the formulary change process including the importance of a robust project plan, appropriate resources, healthcare staff education, and acceptance.

Cost implications of formulary decisions on oral anticoagulants in nonvalvular atrial fibrillation

BACKGROUND

Nonvalvular atrial fibrillation (AF) is a major public health issue. The major complication of AF is an increased risk of stroke. Warfarin, long used for stroke prophylaxis in AF patients, has a narrow therapeutic window and numerous food and drug interactions necessitating regular laboratory monitoring. New oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban) may meet the need for predictable anticoagulation with fixed, unmonitored dosing.

OBJECTIVE

To review costs of monitoring, bleeding, and stroke in AF patients to analyze costs of anticoagulants for stroke prophylaxis in AF patients.

METHODS

A literature search on the costs of treating AF used PubMed/MEDLINE databases (to April 2012) focusing on studies in the United States. Key words or MeSH terms were used, such as "observational studies," "oral anticoagulants," "warfarin," "cost of bleeding," "cost of stroke," and "cost of INR monitoring."

RESULTS

The literature focused mainly on short-term, in-hospital expenditures and less on long-term care costs. Annual overall costs per patient for treating AF in the United States ranged from $18,454 to $38,270. Annual incremental costs of treating AF ranged from $8,705 to $16,311. Annual inpatient costs ranged from $7,841 to $22,582 per patient. Annual costs of anticoagulation monitoring ranged from $291 to $943 per patient. Intracranial hemorrhage and major gastrointestinal bleeding with oral anticoagulants were uncommon but expensive: 1-year costs ranged from $7,584 to $193,804. Annual direct costs of stroke in AF patients ranged from $23,143 to $37,620 (incremental cost of $7,824 to $8,232 vs. AF patients without stroke).

CONCLUSIONS

AF-associated direct costs are high and can be broken into costs of warfarin monitoring and direct costs of managing consequences of anticoagulant therapy-stroke and bleeding.

Do educational meetings and group detailing change adherence to drug formularies in hospitals? A cluster randomized controlled trial

PURPOSE

The aim of this study was to examine whether educational meetings and group detailing could increase the use of drugs from the ward lists or the drug formulary in hospitals.

METHODS

Twelve medical wards from two hospitals were randomized into three groups: control, basic and extended intervention. All wards had a ward list review before interventions. Moreover, the basic intervention consisted of an educational meeting, and the extended intervention included two group detailing sessions. The proportion of drugs used from the ward list or hospital drug formulary (HDF) was the primary outcome. Data (defined daily doses [DDDs], numbers and cost [Euros]) on drugs sold to the wards were retrieved from the two hospitals from 1 July 2011 to 31 August 2012.

BASELINE DATA

from July to September 2011, and follow-up data: from June to August 2012.

RESULTS

The proportion of formulary drugs used increased for the extended intervention group (0.04, range -0.02 to 0.09) and basic intervention group (0.03, range -0.03 to 0.09) in comparison with a decrease in the control group (-0.01, range -0.03 to -0.02). The interventions did not significantly change odds for selecting drugs from the formulary in comparison with the control group (basic intervention: OR 1.09 [95 % CI 0.81 to 1.46]; extended intervention: OR 1.00 [95 % CI 0.75 to 1.35]).

CONCLUSIONS

In this study, educational meetings and group detailing do not significantly improve adherence to ward lists or HDF. The adherence to the formularies at baseline was relatively high, which may explain why the interventions did not have a significant effect.

Assessment of new drugs in a tertiary hospital using a standardized tool

OBJECTIVE

To describe the profile of new drugs evaluated by the Pharmacy and Therapeutics committee in a tertiary hospital using a standardized tool, the Guideline for the Introduction of New Drugs in the Formulary (GINF form), as main objective.

MATERIALS AND METHODS

Retrospective observational study of drugs was assessed during 2008-2011. Variables related to the drug, the request, and the result of the evaluation were collected based on information contained in the GINF form and in the assessment reports.

RESULTS

63 of 75 assessed drugs (84%) were included in the hospital formulary. Only one drug (1%) was included without any restrictions. The rest of them were included as therapeutic equivalents (23%) or under specific recommendations (61%). Half of the drugs (6) not included had insufficient evidence of effectiveness compared with current treatments. Haematology and Medical Oncology were found to be the most active medical services in the application process. There was a high prevalence of drugs that had more than one advanced clinical trial (phase III and/or phase IV). Furthermore, 28% of assessed drugs were associated with a financial burden of more than ?10,000 per year for our hospital. Highquality information was provided by applicants to the P&T committee for drugs that were finally included. However, the relationship between the information provided to the P&T committee and its decision was not statistical significance.

CONCLUSION

The requests received were primarily related to drugs intended for parenteral use and most of them were antineoplastic drugs. The medical departments most heavily represented were Haematology and Oncology.

Deciding which drugs get onto the formulary: a value-based approach

OBJECTIVES

Hospitals, physicians, payers, and patients face economic and ethical decisions about the use of biotechnology drugs, commonly called specialty medications. These often target a small population, have data based on smaller clinical trials, are expensive, and may have questionable advantage. This is a result of how the Food and Drug Administration (FDA) approves medications, which is based only on safety and efficacy. Cancer drugs, once approved by the FDA, regardless of cost or value must be covered by Medicare. Some states have laws requiring additional coverage as well. All of this has created an unintended consequence: It has driven up costs with questionable evidence to support the medication's value, placing patients, payers, and providers in an ethical conflict. In this new era of health care transformation, health care leaders must focus on creating value to support a sustainable health system. Christiana Care Health System's Value Institute has designed a new model to evaluate specialty medications, using value as its main criterion.

METHODS

This article describes the process and outcomes using a new value model for evaluating specialty medications for a hospital formulary. It also introduces a new criterion of evaluation entitled "Societal Benefit" that provides a rating on quality- of-life issues. With measurable factors of efficacy, risk, cost, and quality-of-life concerns, our methodology provides a more balanced approach in the evaluation of specialty medications.

RESULTS

Specialty medications are the fastest growing segment of drug expense, and it is hard to understand how these medications will be sustainable under health care reforms. Unlike other countries, the United States has no national agency providing cost-effectiveness review; review occurs, if at all, at a local level. Laws governing Medicare and most private insurers' coverage of FDA-approved medication and some clinical quality standards conflict with cost-effectiveness, making this type of review difficult. Finally, because these medications affect the health system as a whole, it is a great example to begin to support health care reform.

CONCLUSIONS

Hospitals need to challenge the value of specialty medication. Although our model will continue to evolve, value is now our central consideration when selecting specialty medications to be added to the formulary. We share this experience to encourage other hospitals to design their own approach to this vital issue.

Ceftaroline fosamil use in hospitalized patients with acute bacterial skin and skin structure infections: Budget impact analysis from a hospital perspective

PURPOSE

The budgetary impact of adding ceftaroline fosamil to a hospital formulary for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) was evaluated.

METHODS

A three-year hospital budget impact model was constructed with three initial treatment options for ABSSSIs: ceftaroline fosamil, vancomycin plus aztreonam, and other vancomycin-containing regimens. The target population was hospitalized adult patients with an ABSSSI. Clinical cure rates with initial treatment were assumed to be similar to those from ceftaroline fosamil clinical trials. Patients who did not respond to initial treatment were assumed to be treated successfully with second-line antimicrobial therapy. Length of stay and cost per hospital day (by success or failure with initial treatment) were estimated based on a large database from more than 100 U.S. hospitals. Other model inputs included the annual number of ABSSSI admissions, projected annual case growth rate, proportion of ABSSSI target population receiving vancomycin-containing regimen, expected proportion of ABSSSI target population to be treated with ceftaroline fosamil, drug acquisition cost, cost of antibiotic administration, and cost of vancomycin monitoring. Sensitivity analysis using 95% confidence limits of clinical cure rates was also performed.

RESULTS

The estimated total cost of care for treating a patient with an ABSSSI was $395 lower with ceftaroline fosamil ($15,087 versus $15,482) compared with vancomycin plus aztreonam and $72 lower ($15,087 versus $15,159) compared with other vancomycin-containing regimens.

CONCLUSION

Model estimates indicated that adding ceftaroline fosamil to the hospital formulary would not have a negative effect on a hospital's budget for ABSSSI treatment.

Patented drug extension strategies on healthcare spending: a cost-evaluation analysis

BACKGROUND

Drug manufacturers have developed "evergreening" strategies to compete with generic medication after patent termination. These include marketing of slightly modified follow-on drugs. We aimed to estimate the financial impact of these drugs on overall healthcare costs and also to examine the impact of listing these drugs in hospital restrictive drug formularies (RDFs) on the healthcare system as a whole ("spillover effect").

METHODS AND FINDINGS

We used hospital and community pharmacy invoice office data in the Swiss canton of Geneva to calculate utilisation of eight follow-on drugs in defined daily doses between 2000 and 2008. "Extra costs" were calculated for three different scenarios assuming replacement with the corresponding generic equivalent for prescriptions of (1) all brand (i.e., initially patented) drugs, (2) all follow-on drugs, or (3) brand and follow-on drugs. To examine the financial spillover effect we calculated a monthly follow-on drug market share in defined daily doses for medications prescribed by hospital physicians but dispensed in community pharmacies, in comparison to drugs prescribed by non-hospital physicians in the community. Estimated "extra costs" over the study period were €15.9 (95% CI 15.5; 16.2) million for scenario 1, €14.4 (95% CI 14.1; 14.7) million for scenario 2, and €30.3 (95% CI 29.8; 30.8) million for scenario 3. The impact of strictly switching all patients using proton-pump inhibitors to esomeprazole at admission resulted in a spillover "extra cost" of €330,300 (95% CI 276,100; 383,800), whereas strictly switching to generic cetirizine resulted in savings of €7,700 (95% CI 4,100; 11,100). Overall we estimated that the RDF resulted in "extra costs" of €503,600 (95% CI 444,500; 563,100).

CONCLUSIONS

Evergreening strategies have been successful in maintaining market share in Geneva, offsetting competition by generics and cost containment policies. Hospitals may be contributing to increased overall healthcare costs by listing follow-on drugs in their RDF. Therefore, healthcare providers and policy makers should be aware of the impact of evergreening strategies.

Implementing the new oral anticoagulants into the hospital formulary

The new oral anticoagulants may prove to be one of most significant innovations in clinical practice in the past 60 years. Apixaban and rivaroxaban are direct inhibitors of Factor Xa, while dabigatran inhibits Factor IIa. The predictable pharmacological profile of these new agents allows physicians to prescribe these drugs without the need for routine coagulation monitoring, which is the mainstay of warfarin therapy. In addition, these new agents have not been shown to have any food interactions and minimal drug-drug interactions, interactions are limited to the p-glycoprotein (p-Gp) transporter or cytochrome P450 (CYP450) system, each drug is unique in its drug interaction profile, as will be discussed below. These unique pharmacokinetics profiles may usher in for clinicians a new era of managing thromboembolic disorders. In this article, the pharmacology of these new oral anticoagulants will be reviewed along with the major clinical trials evaluating the use of these agents for thromboembolic prophylaxis in patients undergoing total hip and knee arthroplastic surgery, the treatment of venous thromboembolic disorders and stroke prevention in atrial fibrillation. Am. J. Hematol., 2012. © 2012 Wiley Periodicals, Inc.

A prescription for improving drug formulary decision making

Gordon Schiff and colleagues present a new tool and checklist to help formularies make decisions about drug inclusion and to guide rational drug use.

Optimization education after project implementation: sharing "lessons learned" with staff

Implementations involving healthcare technology solutions focus on providing end-user education prior to the application going "live" in the organization. Benefits to postimplementation education for staff should be included when planning these projects. This author describes the traditional training provided during the implementation of a bar-coding medication project and then the optimization training 8 weeks later.

Anticonvulsant use after formulary status change for brand-name second-generation anticonvulsants

BACKGROUND

Anticonvulsant medications are commonly used for off-label indications. However, managed care organizations can restrict utilization of medication to indicated uses only.

OBJECTIVE

To evaluate the pattern of off-label use of second-generation anticonvulsants after implementing a formulary change.

METHODS

We did a retrospective analysis of an administrative pharmacy claims database for a managed care plan with more than 1 million members continuously enrolled during 2004-2005. The study evaluated off-label use and explored pharmacy utilization patterns (by physician specialty, region, plan type, age, sex, copayment) across the study population following the formulary change.

RESULTS

A total of 10,185 patients had at least 1 pharmacy claim (total of 137,638 claims) for a second-generation anticonvulsant during the study period. Most members were female (68%), and 4.9% were <18 years old. A total of 3986 of 4698 patients (84.8%) and 4600 of 5487 patients (83.8%) had anticonvulsants prescribed for off-label use in 2004 and 2005, respectively (P = .162). The off-label usage pattern varied for individual anticonvulsants in 2004 and 2005 (P <.050), which may have been because of the change to nonpreferred coverage. Primary care physicians accounted for 41.3% of the prescribing of second-generation anticonvulsants for off-label uses, followed by neurologists (9.4%), psychiatrists (2.8%), and other (46.5%). The coverage change resulted in cost savings for the plan of $0.16 per member per month.

CONCLUSIONS

The off-label usage pattern varied for individual anticonvulsants in 2004 and 2005. Future considerations for controlling off-label use may include requiring prior authorization and provider education.

The cost effectiveness and budget impact of natalizumab for formulary inclusion

BACKGROUND

Crohn's disease (CD) and multiple sclerosis (MS) are debilitating autoimmune diseases, which represent a substantial cost burden in the context of managed care. As a corollary, there is an unmet pharmacotherapeutic need in patient populations with relapsing forms of MS, in addition to populations with moderately to severely active CD with evidence of inflammation who have experienced an inadequate response to other mainstream therapies. The purpose of this study was to analyze the clinical and economic data associated with natalizumab (Tysabri) and to determine the potential impact of its formulary inclusion in a hypothetical health plan.

FINDINGS

Regarding MS, the implemented cost-effectiveness and budget-impact models demonstrated an anticipated reduction in relapse rate of 67% over 2 years, and a total therapy cost of $72,120 over 2 years, equating to a cost per relapse avoided of $56,594. With respect to the model assumptions, the market share of natalizumab would experience an increase to 8.5%, resulting in a total per-member, per-month healthcare cost increase of $0.003 ($0.002 for pharmacy costs and $0.001 for medical costs). Regarding CD, over a 2-year period outlined by the model, natalizumab produced the highest average time in remission, steroid-free remission, and remission or response in comparison to the other agents. The mean total costs associated with the initiation of natalizumab, infliximab, and adalimumab were $68,372, $62,090, and $61,796, respectively. Although natalizumab's costs were higher, the mean time spent in remission while on this medication was 4.5 months, as opposed to 2.4 months for infliximab and 2.9 months with adalimumab. This shift in market share was used to estimate the change in total costs (medical + pharmacy), and the per-member per-month change for the model's base case was calculated to be $0.035.

LIMITATIONS

The aforementioned cost-effectiveness results for natalizumab in the treatment for CD and MS were limited by the model's predetermined assumptions. These assumptions include anticipated reduction in relapse rate after 2 years of therapy and acquisition costs in the MS model, as well as assuming a certain percentage of patients were primary and secondary failures of TNFalpha inhibitor therapy in the CD model.

CONCLUSION

The evidence presented here demonstrates that natalizumab provides clinical practitioners with another tool in their fight against both MS and CD, albeit by way of a different mechanism of action. After a thorough review of the evidence, the authors find that natalizumab has been shown to be relatively cost effective in the treatment of both conditions from a payer perspective; the therapy adds a new option for those patients for whom conventional treatment was unsuccessful.

Introduction of ertapenem into a hospital formulary: effect on antimicrobial usage and improved in vitro susceptibility of Pseudomonas aeruginosa

After ertapenem was added to the formulary of a 344-bed community teaching hospital, we retrospectively studied its effect on antimicrobial utilization and on the in vitro susceptibility of various antimicrobial agents against Pseudomonas aeruginosa. Three study periods were defined as preintroduction (months 1 to 9), postintroduction but before the autosubstitution of ertapenem for ampicillin-sulbactam (months 10 to 18), and after the policy of autosubstitution (months 19 to 48) was initiated. Ertapenem usage rose slowly from introduction to a range of 36 to 48 defined daily doses/1,000 patient days (DDD) with a resultant decrease in ampicillin-sulbactam usage due to autosubstitution. Imipenem usage peaked 6 months after the introduction of ertapenem and started to decline coincidently with the increased use of ertapenem. During the second period, imipenem usage decreased (slope = -1.28; P = 0.002). Prior to the introduction of ertapenem, the susceptibility of P. aeruginosa to imipenem increased from 61 to 81% at month 7 but then decreased slightly to 67% at month 9. After the introduction of ertapenem, susceptibility continued to increase; the increasing trend was significant (slope = 1.74; P < 0.001). In the third period, the median susceptibility (interquartile range) was 88% (82 to 95%). This change appeared related to decreased imipenem usage. For every unit decrease in the monthly DDD of imipenem, there was an increase of 0.38% (P = 0.008) in the susceptibility of P. aeruginosa to imipenem in the same month. Ertapenem was effective in our antimicrobial stewardship program and may have helped improve the P. aeruginosa antimicrobial susceptibility to imipenem by decreasing the unnecessary usage and selective pressure of antipseudomonal agents.

Removing Meperidine from the Health-System Formulary—Frequently Asked Questions

Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.

Results of an intervention in an academic Internal Medicine Clinic to continue, step-down, or discontinue proton pump inhibitor therapy related to a tennessee medicaid formulary change

BACKGROUND

In July 2005, the State of Tennessee Medicaid Program (TennCare) announced formulary changes for proton pump inhibitors (PPIs) to be implemented in August 2005. Prior to these changes, pantoprazole was the only preferred PPI, and there were no restrictions to its use. The revised formulary included 3 preferred PPIs (esomeprazole, lansoprazole, and omeprazole OTC), all of which required prior authorization (PA). In order to obtain an approved PA for a PPI, the patient was required to have either (a) a diagnosis of erosive esophagitis, Barrett's esophagus, Schatzki's ring, a pathological hypersecretory condition (e.g., Zollinger-Ellison syndrome, multiple endocrine adenoma), grade III-IV gastroesophageal reflux disease (GERD), non-steroidal anti-inflammatory drug gastropathy, significant gastrointestinal bleed; or (b) another indication for acid suppression therapy (e.g., GERD, hyperacidity in cystic fibrosis, gastric or duodenal ulcer, gastroparesis) with a history of failure of prior therapy with a histamine-2 receptor antagonist (H2-blocker). The internal medicine clinic of a regional medical center implemented an intervention to address these changes in formulary status of PPIs.

OBJECTIVE

To (a) describe the process used by an internal medicine clinic to ensure that patients requiring acid suppression therapy received appropriate treatment according to revised TennCare formulary criteria without unnecessary interruption of therapy, and (b) assess self-reported symptom control 8 months after intervention in the patients who either discontinued therapy or stepped-down to H2-blocker therapy.

METHODS

This study involved TennCare patients in an internal medicine clinic who received a new or refill prescription for pantoprazole between April 20 and June 20, 2005, from the medical center's outpatient pharmacy. A clinical pharmacist and an internal medicine physician collaborated to develop a protocol for adjusting acid suppression therapy. A clinical pharmacist reviewed medical records for all patients identified to verify indications for acid suppression therapy and review medication history. Patient telephone interviews were also conducted for patients whose indication or medication history could not be determined by chart review. Patients who met TennCare criteria for PPI therapy were continued on PPI therapy after a PA was obtained (PA group). Patients who had a documented indication for acid suppression therapy but did not meet the PA criteria for PPI therapy were changed to H2-blocker therapy (step-down group). Patients without a documented indication for acid suppression therapy were discontinued from acid suppression therapy (discontinue therapy group). A follow-up chart review and patient telephone interview were conducted 8 months after the intervention for patients in the step-down and discontinue therapy groups. The purpose of this follow-up review was to determine (a) the proportion of patients who were taking acid suppression therapy, (b) the type of acid suppression therapy (PPI or H2-blocker), and (c) self-report of adequate control of symptoms (defined as symptoms once weekly or less).

RESULTS

Of 135 TennCare beneficiaries who were active patients of the internal medicine clinic and received a prescription from the outpatient pharmacy for PPI therapy (pantoprazole) between April 20 and June 20, 2005, 6 patients were excluded because they reported stopping PPI therapy on their own. Of the remaining 129 patients, 18 (14.0%) did not have an indication for PPI therapy and acid suppression therapy was discontinued (discontinue therapy group), 40 (31.0%) met the TennCare PA criteria for continuation of PPI therapy (PA group), and 71 (55.0%) did not meet the TennCare PA criteria and were stepped down to a H2-blocker (step-down group). At the 8-month follow-up, acid suppression therapy was assessed in 68 patients (21 patients were lost to follow-up): 13 patients (19.1%) had resumed PPI therapy; 38 (55.9%) were using an H2-blocker; and 17 (25.0%) were not using acid suppression therapy. Telephone interviews were completed for 45 of the 75 patients in the step-down and discontinue therapy groups who did not receive an escalation in acid suppression therapy after the initial intervention (i.e., who did not make a change from H2-blocker therapy to PPI therapy or from no acid suppression therapy to H2-blocker or PPI therapy). Twenty-eight patients (62.2%) reported symptoms once per week or less; 14 patients (31.1%) reported symptoms more often than once weekly. Symptom control was unable to be determined in 3 patients (6.7%) because of incomplete information obtained from the patient during the interview.

CONCLUSIONS

After a proactive collaboration between physicians and clinical pharmacists in response to changes in TennCare formulary criteria for PPIs, more than one-half of patients were stepped down to H2-blocker therapy, and 14% were discontinued from acid suppression therapy. Among the step-down or therapy discontinuation patients for whom data were available at the 8-month follow-up, 81% were still using either an H2-blocker or no acid suppressing therapy at all, and 19% had resumed PPI use.

The concept of medical auditing

The contribution of drug utilisation studies on national, regional and local levels, to the quality control or audit of drug therapy is discussed. Two major types of audit, self-audit and peer-group audit, are outlined and examples presented illustrating how the concept of audit may be applied to therapeutics with special reference to drug information centres, feedback of drug prescribing data, and drug formularies. When drug information on prescribing practice from these sources is disseminated to the prescribers without value judgements being made, the component of self-audit is predominant in contrast to drug information dealing with prescribing appropriateness, in which peer-group opinion is expressed. Methods of capturing and disseminating data on prescribing practice which could be used in the auditing process are described. However, the greatest contribution to therapeutic audit lies with those responsible for medical training who should foster the quality of selfcriticism and the quest for high standards of prescribing practice in their students.

Antimicrobial stewardship programs: how to start and steer a successful program

BACKGROUND

Antimicrobial stewardship programs (ASPs) promote the appropriate use of antimicrobials by selecting the appropriate dose, duration, and route of administration. The appropriate use of antimicrobials has the potential to improve efficacy, reduce treatment-related costs, minimize drug-related adverse events, and limit the potential for emergence of antimicrobial resistance.

OBJECTIVE

To summarize ASP tactics that can improve the appropriate use of antimicrobials in the hospital setting. Several measures can be used to implement such programs and gain multidisciplinary support while addressing common barriers.

SUMMARY

Implementation of an ASP requires a multidisciplinary approach with an infectious diseases physician and a clinical pharmacist with infectious diseases training as its core team members. As identified by recently published guidelines, 2 proactive strategies for promoting antimicrobial stewardship include: (1) formulary restriction and pre-authorization, and (2) prospective audit with intervention and feedback. Other supplemental strategies involve education, guidelines and clinical pathways, antimicrobial order forms, de-escalation of therapy, intravenous-to-oral (IV-to-PO) switch therapy, and dose optimization. Several barriers exist to successful implementation of ASPs. These include obtaining adequate administrative support and compensation for team members. Gaining physician acceptance can also be challenging if there is a perceived loss of autonomy in clinical decision making.

CONCLUSION

ASPs have the potential to reduce antimicrobial resistance, health care costs, and drug-related adverse events while improving clinical outcomes. The efforts and expense required to implement and maintain ASPs are more than justified given their potential benefits to both the hospital and the patient.

A survey of Pharmacy and Therapeutic committees across Canada: scope and responsibilities

BACKGROUND

Pharmacy and Therapeutics (P&T) committees have traditionally evaluated and developed policies for the clinical use of medications and for ensuring safe and effective drug use and administration.

OBJECTIVE

The objective of this study was to determine the current activities of hospital P&T committees across Canada.

METHODS

Surveys were mailed to 856 (693 English, 163 French translations) Canadian hospitals (acute, chronic or rehabilitation) across Canada. Questions consisted of information on P&T membership, scope and responsibilities. Completed surveys were returned by fax. All data was entered into Excel and analyzed for descriptive statistics.

RESULTS

123 surveys were returned, representing 207 hospitals, for an effective response rate of 24%. Four hospitals returned incomplete surveys. Surveys were returned from all areas of Canada, except the territories. On average, P&T committees met six times per year. The average size of the committees was 11 members, with physicians comprising half the membership. Pharmacists and nurses had equal representation; other members were community representatives, dieticians, quality assurance personnel and/or administrators. The top responsibilities of the P&T committee were inpatient formulary management (93% of respondents), drug-use policy making (92%), adverse drug reaction monitoring (83%), patient safety (80%) and drug-use monitoring (80%). Subcommittees were utilized by 46% of P&T committees including antimicrobial (38%), medication safety (25%) and nutrition (14%). Economic evaluations were most frequently completed by a pharmacist who had some previous pharmacoeconomic experience.

CONCLUSION

This survey reports on the current status and responsibilities, namely formulary management and policy making, of P&T committees in Canada.

Formulary access using a PDA-based drug reference tool: does it affect prescribing behavior?

We assessed the association between formulary access via a handheld drug reference tool and utilization of generic (Tier 1) and non-generic, non-formulary (Tier 3) medications. In a retrospective before-after study of physician prescribing behavior for patients in a large, national health plan, physicians with formulary access using Epocrates(TM) showed smaller (0.5%) increases in Tier 3 prescribing over time compared to physicians without such access.

Using cost-effectiveness analysis to sharpen formulary decision-making: the example of tiotropium at the Veterans Affairs health care system

OBJECTIVE

To identify a cost-saving subset of criteria for the use of tiotropium at a Veterans Affairs Medical Center based on a cost-effectiveness analysis with ipratropium as the comparator.

METHODS

Retrospective analysis of electronic medical records for the calendar year 2004 was conducted. The sample was drawn from a population at the Baltimore Veterans Affairs Medical Center that had a confirmed diagnosis of chronic obstructive pulmonary disease (COPD) and had filled prescriptions for ipratropium. The tiotropium sample was based on a modeled cohort of COPD patients who had received tiotropium. The analysis was conducted from the perspective of the Veterans Affairs Health Care System. The outcome was the incremental cost-effectiveness of tiotropium versus ipratropium.

RESULTS

The incremental cost-effectiveness ratio (ICER) was $2360 per avoided exacerbation. Tiotropium cost-effectiveness increased with COPD severity and was cost-saving in patients with very severe disease (ICER = $-1818) and in patients with a previous COPD-related hospitalization (ICER = $-4472). The ICER was most sensitive to the relative effectiveness and price of tiotropium. Results identified the levels of treatment effectiveness and price beyond which tiotropium would become cost-saving relative to ipratropium.

CONCLUSIONS

The results support the existing Veterans Affairs practice of offering tiotropium to patients with COPD-related hospitalizations. Periodic review of the effectiveness data to determine whether tiotropium would be cost-saving in patients with very severe COPD is suggested. Cost-effectiveness analyses that identify practical criteria-for-use should become an integral part of the formulary process.

Antimicrobial stewardship

In response to the global antibiotic resistance crisis, antimicrobial stewardship programs have emerged throughout the United States. Effective programs integrate several strategic methods, including evaluation and feedback regarding the necessity and appropriateness of antimicrobial therapy, staff education, and formulary restrictions. Multidisciplinary teams as well as institutional support are needed to form effective subcommittees to monitor national and local surveillance reports and resistance patterns, and to update antibiograms. Computerized decision support programs have been effective and successful methods of antimicrobial stewardship and can be a powerful tool in stewardship programs. Successful programs have reduced not only institutional resistance rates, but also morbidity, mortality, and cost.

Rule-based standardised switching of drugs at the interface between primary and tertiary care

INTRODUCTION

Changes in drug treatment are frequently mandatory with hospital admission and discharge because hospital drug formularies are generally restricted to about 3000 drugs as compared to the many times this number - 62,000 in Germany - that are commercially available. Without computerised support, the process involved with switching drugs to a corresponding generic or a therapeutic equivalent is time-consuming and error-prone.

METHODS

We have developed and tested a standardised interchange algorithm for subsequent implementation into a computerised decision support system that switches drugs to the corresponding generic or a therapeutic equivalent if they are not listed on the hospital drug formulary.

RESULTS

The algorithm was retrospectively applied to the medication regimens of 120 patients (774 prescribed drugs containing 886 active ingredients) at their time of admission to surgical wards. Of the prescribed drugs, 52.8% (409/774) were part of the hospital drug formulary, thereby rendering a switch unnecessary. The 365 drugs not listed consisted of 392 active ingredients that were successfully switched to a corresponding generic (84.7%) or a therapeutic equivalent (10.2%). No specific switching procedures were defined for only 2.3% (20/886) of the active ingredients. In these cases, the drugs were either discontinued (4/20) or special drug classes, current diseases or co-medication required manual switching (8/20), or the drugs were continued unchanged and ordered from a wholesaler (8/20).

CONCLUSION

Using a standardised interchange algorithm, pre-admission drug regimens can successfully be switched to drugs on a hospital drug formulary. These findings suggest that a computerised decision support system will likely be useful to support this important practice.

Pharmacist recognition of and adherence to medication-use policies and safety practices

PURPOSE

Pharmacist recognition of and adherence to medication-use policies and safety practices were assessed.

METHODS

Simulation testing was used to assess the performance of pharmacists in hypothetical scenarios simulating real-life situations. Fifty test case medication orders were developed, some requiring specific intervention and some requiring no special action. Orders were classified into four categories: those posing safety concerns n ( = 16), those with formulary and product standardization issues (n = 4), those with pharmacy and therapeutics (P&T) committee restrictions (n = 4), and those requiring no special action (n = 26). Potential barriers to compliance were identified by the project team and the orders categorized accordingly. The orders were processed by 25 pharmacists using a simulation testing procedure. Data were analyzed by pharmacists' demographics, order category, and perceived barriers to compliance.

RESULTS

Pharmacists were correctly able to recognize 77.3% of test orders: 67.3% with safety concerns, 98.9% with formulary issues, and 98.5% with restrictions. Appropriate action was taken with 74.2% of test orders: 64.5% of safety orders, 96.6% of formulary orders, and 92.4% of restriction orders. There was no correlation between pharmacists' performance and demographic characteristics. The two barriers to correct response identified most often were ambiguous responsibility and low perceived level of importance.

CONCLUSION

Pharmacists generally recognized and took appropriate action with simulated medication orders that contained problems related to formulary or P&T committee restrictions. They were less able to recognize and act appropriately on orders with safety-related problems. Ambiguous responsibility and low perceived importance were the most significant factors contributing to noncompliance with P&T committee policies and guidelines.

The impact of formulary replacement of sildenafil by vardenafil at a local VA hospital

The National Veterans Administration (VA) changed its formulary agent for the treatment of erectile dysfunction from sildenafil to vardenafil in January 2006 for economic reasons. The objective of this study was to assess the impact of this formulary change on the patients at a local VA hospital. All non-formulary requests for sildenafil between January 2006 and September 2006 were reviewed. A total of 169 non-formulary requests were made for sildenafil while 7657 patients filled vardenafil prescriptions. Overall, the formulary change from sildenafil to vardenafil appeared to be well tolerated by the vast majority of patients at this local VA hospital. The substantial cost savings to the VA seem to be justified by the minimal adverse effects on men treated for erectile dysfunction.

Establishing a hospital program to improve antimicrobial use, control bacterial resistance and contain healthcare costs: the University of Louisville experience

Antimicrobials have been used in excess for decades. As a result, antimicrobial resistance and cost have increased. In response to this growing national problem, hospital antimicrobial teams were recom-mended in 1988, but few institutions have invested in comprehensive, interdisciplinary programs. The division of infectious diseases at the University of Louisville School of Medicine was a leader in 1990 by establishing an antimicrobial team at the University of Louisville Hospital and Veterans Affairs Hospital. This manuscript reviews the activities of the antimicrobial teams to create antimicrobial guidelines, evaluate antimicrobial use, and provide feedback to physicians. It also summarizes the successful impact the teams have had on optimizing antimicrobial use in the hospital by improving compliance with the guidelines, controlling resistant organisms, and preventing escalation of antimicrobial cost over the years.

Antibacterial treatment strategies in hospitalized patients: what role for pharmacoeconomics?

Antimicrobial agents continue to account for a significant portion of institutional pharmaceutical expenditures. Pharmacoeconomic analysis is a valuable tool in assessing antibacterial agents for their place in institutional formularies. This article reviews various types of pharmacoeconomic analyses, their respective limitations, and their roles in the antibacterial formulary decision-making process. We also discuss the current state of the antibacterial pharmacoeconomic literature, including the economic impact of antimicrobial resistance.

An informatics approach to assess pediatric pharmacotherapy: design and implementation of a hospital drug utilization system

Drug utilization in the inpatient setting can provide a mechanism to assess drug prescribing trends, efficiency, and cost-effectiveness of hospital formularies and examine subpopulations for which prescribing habits may be different. Such data can be used to correlate trends with time-dependent or seasonal changes in clinical event rates or the introduction of new pharmaceuticals. It is now possible to provide a robust, dynamic analysis of drug utilization in a large pediatric inpatient setting through the creation of a Web-based hospital drug utilization system that retrieves source data from our accounting database. The production implementation provides a dynamic and historical account of drug utilization at the authors' institution. The existing application can easily be extended to accommodate a multi-institution environment. The creation of a national or even global drug utilization network would facilitate the examination of geographical and/or socioeconomic influences in drug utilization and prescribing practices in general.

Can drug utilization help in promoting the more rational use of medicine? Experiences from Western Nepal

Drug utilization research describes the extent, nature and determinants of drug use in populations and aims to facilitate the more rational use of medicines. The departments of Pharmacology and Clinical Pharmacy at the Manipal College of Medical Sciences, Pokhara, Nepal are committed to promoting the more rational use of medicines. The departments run a Drug Information Center and a Pharmacovigilance Center in the teaching hospital. Over the last eight years, the departments have conducted drug utilization studies in the teaching hospital and the community. A few of these were of the intervention type and drug use was studied before and after the intervention. Members of the departments are on the hospital Drug and Therapeutics Committee. Educational initiatives to improve prescribing have been carried out in a few instances. Restricting the number of brands in the hospital pharmacy and creation of a hospital drug list has been carried out. The impact of these initiatives has been studied only in a few cases. Generic prescribing was found to be low. The educational initiatives to improve prescribing had only limited success. The hospital is in the process of framing antimicrobial use guidelines for various departments. A hospital formulary is under preparation. The influence of drug utilization studies on the prescribing patterns has been low to moderate. The department of Clinical Pharmacy runs a Medication Counseling Center in the hospital and teaches appropriate use of medicines to patients. The studies and initiatives to promote the more rational use of medicines should be continued and strengthened.

Survey of hospitals for guidelines, policies, and protocols for anticoagulants

PURPOSE

A survey of community hospitals that are part of a national group purchasing organization (GPO) was conducted to assess the formulary status of currently available anticoagulants, assess the current status of anticoagulant prescribing guidelines and the existing scope of such guidelines, and identify perceptions about the appropriateness of the use of anticoagulants in community hospitals in the United States.

METHODS

A Web-based survey of acute care hospitals that were members of a leading health care resource management and GPO was conducted. The survey was sent to 224 hospitals.

RESULTS

Of 224 hospitals, 127 participated in the survey, a response rate of 59.6%. Warfarin, unfractionated heparin (UFH), and enoxaparin were the anticoagulants most commonly included (>80%) on the hospitals' drug formularies. Guidelines relating to the use of UFH and low-molecular-weight heparins (LMWHs) existed in approximately 87.4% and 55.1% of responding hospitals, respectively, followed by warfarin and direct thrombin inhibitors (DTIs) (approximately 44.1% and 30.7%, respectively). Among hospitals without guidelines, 78.2%, 72.1%, 65.4%, 50.0%, and 41.4% reported that such guidelines would be useful if they included LMWHs, warfarin, DTIs, UFH, and fondaparinux, respectively. Guidelines for prophylaxis of venous thromboembolism (VTE), appropriate drug selection, and dosing for VTE prophylaxis and treatment existed in 59.8%, 53.5%, and 43.3% of the hospitals, respectively.

CONCLUSION

The study found that a sizable percentage of the responding community hospitals did not have guidelines, protocols, or policies related to the use of anticoagulants. Further, those hospitals without such guidelines commonly reported a need for clinical practice guidelines.

Impact of hospital formularies on fluoroquinolone prescribing in emergency departments

OBJECTIVE

To examine factors associated with fluoroquinolone prescribing among adults receiving antibiotics for acute respiratory tract infections (ARIs) in emergency departments.

STUDY DESIGN

Cross-sectional.

METHODS

We analyzed data from 8 Department of Veterans Affairs medical centers and 7 nonfederal US hospitals. At each hospital, we randomly sampled 200 ARI visits with International Classification of Diseases, Ninth Revision discharge diagnoses for nonspecific upper respiratory infections, acute bronchitis, pharyngitis, sinusitis, and pneumonia between November 1, 2003, and February 29, 2004. Patient and provider factors associated with each visit were extracted from medical records. System characteristics were obtained by surveying pharmacy directors. Multivariable logistic regression was used to evaluate independent predictors of fluoroquinolone prescribing.

RESULTS

Fluoroquinolones accounted for 14% of these prescriptions. At hospitals with at least 1 unrestricted fluoroquinolone on formulary (n = 12), the average fluoroquinolone prescription rate was 17%, compared with a 6% prescription rate at hospitals where fluoroquinolone access was restricted by the hospital formulary (n = 3) (P < .0001). Factors associated with increased fluoroquinolone prescription rates were hospital admission (odds ratio [OR] = 1.8; 95% confidence interval [CI] = 1.1, 3.1) and the diagnoses of acute bronchitis (OR = 2.3; 95% CI = 1.3, 4.2), acute exacerbations of chronic bronchitis (OR = 2.6; 95% CI = 1.2, 5.6), and pneumonia (OR = 6.4; 95% CI = 3.3, 12.4). Restricted hospital status was associated with decreased fluoroquinolones accounted for 14% of the antibiotic prescriptions.

CONCLUSION

Hospital formulary policies represent a potentially important target for influencing outpatient drug prescribing in emergency departments.

Programme of stepping down from twice daily proton pump inhibitor therapy for symptomatic gastro-oesophageal reflux disease associated with a formulary change at a VA medical center

BACKGROUND

In July 2001, our Veterans' Affairs hospital changed its formulary proton pump inhibitor (PPI) from lansoprazole to rabeprazole. All patients previously receiving lansoprazole 30 mg twice daily were switched to rabeprazole 20 mg once daily.

AIM

To determine if patients with gastro-oesophageal reflux disease (GERD), who were previously managed on lansoprazole 30 mg twice daily, could be maintained on rabeprazole 20 mg once daily.

PATIENTS AND METHODS

Four hundred and thirty-five patients had received lansoprazole 30 mg twice daily for at least 12 months before the formulary change. Medical records were reviewed for 12 months before and after the formulary change.

RESULTS

There were 432 men and three women with a mean age of 66.7 years (range: 38-91). Two hundred and twelve patients were excluded. Of the remaining 223, 111 (50%) were maintained successfully on rabeprazole 20 mg once daily. Twenty-three (10%) stayed off all acid suppression during follow-up. The number of endoscopies and clinic visits did not significantly change during the follow-up. Fifty-six percent who had erosive oesophagitis failed a dose taper compared with 31% of those with endoscopy-negative GERD (P<0.025).

CONCLUSIONS

Most patients receiving twice daily PPI therapy for GERD could be maintained on once daily PPI or no acid suppression for 12 months of follow-up. Dose reduction was more successful in those without erosive oesophagitis.

Programme of stepping down from twice daily proton pump inhibitor therapy for symptomatic gastro-oesophageal reflux disease associated with a formulary change at a VA medical center

BACKGROUND

In July 2001, our Veterans' Affairs hospital changed its formulary proton pump inhibitor (PPI) from lansoprazole to rabeprazole. All patients previously receiving lansoprazole 30 mg twice daily were switched to rabeprazole 20 mg once daily.

AIM

To determine if patients with gastro-oesophageal reflux disease (GERD), who were previously managed on lansoprazole 30 mg twice daily, could be maintained on rabeprazole 20 mg once daily.

PATIENTS AND METHODS

Four hundred and thirty-five patients had received lansoprazole 30 mg twice daily for at least 12 months before the formulary change. Medical records were reviewed for 12 months before and after the formulary change.

RESULTS

There were 432 men and three women with a mean age of 66.7 years (range: 38-91). Two hundred and twelve patients were excluded. Of the remaining 223, 111 (50%) were maintained successfully on rabeprazole 20 mg once daily. Twenty-three (10%) stayed off all acid suppression during follow-up. The number of endoscopies and clinic visits did not significantly change during the follow-up. Fifty-six percent who had erosive oesophagitis failed a dose taper compared with 31% of those with endoscopy-negative GERD (P<0.025).

CONCLUSIONS

Most patients receiving twice daily PPI therapy for GERD could be maintained on once daily PPI or no acid suppression for 12 months of follow-up. Dose reduction was more successful in those without erosive oesophagitis.