MUEs conducted on frequently prescribed, expensive drug therapy help to identify misuse of medications. Protocols that empower pharmacists to accurately assess treatment can improve patient care while minimizing direct drug costs.
None of the 10 patients whose step-down therapy had failed were started on a medication known to relax LES tone while theywere participating in the step-down program. Furthermore, compared with the sample population, they showed no differences in BMI, length of treatment with a PPI, or use of gastrointestinal-exacerbating medications such as prednisone and nonsteroidal anti-inflammatory drugs (NSAIDs).
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Another way to relieve symptoms of GERD is through lifestyle modifications. One such change that can reduce symptoms is weight loss. The National Institutes of Health (NIH) has defined obesity as a BMI of 28 kg/m2 or greater; therefore, most of the patients contacted were at increased risk for GERD symptoms as a result of their obesity.
Our attempt to develop step-down therapy may have been limited by the method of communication that was chosen. Bias may have been introduced, because only patients who were accessible by telephone were included. Therefore, potentially successful candidates may have unintentionally been excluded. Face-to-face interaction might be superior to telephone conversation in attempts to educate patients about their drug therapy. Objective evaluation of patients’ understanding of verbal directions was not addressed and is a concern because low literacy levels are common among this population. Written directions might have benefited the hearing-impaired.
Compliance is essential to evaluate the success of a step-down program; unfortunately, pill counts were not implemented as part of this protocol because interaction with patients was performed by telephone. Obtaining refill histories would not have been an accurate method of determining adherence, because only short-term assessments were required for completion of the protocol.
Another barrier to evaluating compliance might be the inability to change the directions on the current prescription bottle label. Most veteran patients exhibit polypharmacy, which can impede compliance. Therefore, if patients were confused, they might have reverted to the instructions originally printed on the label instead of implementing the regimen discussed by telephone.
Future research incorporating a step-down approach to PPI therapy should include baseline symptomatology coupled with more objective questioning regarding lifestyle modifications and other medications used to treat symptoms. Using the validated GERD-HRQL scale during both baseline and follow-up questioning would provide a more objective assessment of symptom severity and frequency, increase internal consistency, and provide replicable measurements.
Although cost should never be the sole determining factor in prescribing medication therapy, it may be a limiting factor and should be considered. Lansoprazole canadian accounted for more than 12,000 prescriptions filled and almost $780,000 of the VA Medical Center’s pharmacy budget for 1999. The results of this study are extrapolated to an annual per-patient savings in direct drug cost of $504 for patients who were stepped down to daily lansoprazole therapy.
Although it is common for practitioners to continue prescribing therapeutic drugs that have benefited patients, it is most often appropriate to incorporate the use of the lowest effective dose into the clinical decision-making process in order to avoid adverse drug events and to minimize the costs. Guidelines may assist practitioners in providing optimal care, but they do not always indicate the use of the lowest effective drug dose.
Although limitations exist with our process, we suggest that once-daily dosing of lansoprazole generic is as effective as twice-daily dosing in approximately 60% of our patients and that this plan is also more economical. If symptoms persist with a once-daily PPI, patients may benefit from the addition of another, less expensive medication, such as ranitidine drug.