Idaho Medicaid Drug Utilization Review Program

1. Idaho Medicaid Drug Utilization Review Program 18 April 2013

2. ADURS (American Drug Utilization Review Society) February 21-23, 2013 Scottsdale, Arizona Representatives present from 40 state Medicaid programs 109 total participants

3. ADURS • Round Table presentations from state Medicaid representatives • Recurrent Issues • Opioid therapy for non-malignant pain • Psychotropic medications in children • Suboxone therapy

4. ADURS • Opening Session • Health Care Reform: How States are Responding • Speaker was from the National Conference of State Legislatures

5. ADURS • Continuing Education Topics • Collaborative Care – How to increase safe use of psychotropic medications in children and adolescents. • Hemophilia 101 • Medicaid Fraud and Abuse • Managed Care Medicaid

6. ADURS • Continuing Education Topics • Carving the Prescription Benefit Back In to Medicaid • 340(b) Programs • New Drugs 2013

7. Follow-up to Previous Reviews • Atopic Dermatitis • P&T Committee Narcotic Analgesic Studies

8. Atopic Dermatitis • The P&T Committee requested a DUR on this drug class to include patterns of use, presence or absence of step up therapy from steroids, specialty of prescribers and geographic region differences of prescribing patterns. The DUR should include an educational piece on risks of these agents compared to risks from steroids since many practitioners seem to be using these agents to spare patients from steroid exposure. • DUR completed April 2012 and it was felt that the medications were being used appropriately based on the data presented and these findings were presented to the P&T Committee.

9. Atopic Dermatitis • The P&T Committee asked at their October 2012 meeting for the DUR Board to look at how frequently these medications were being filled. • A review of paid claims between 10/01/2011 and 10/01/2012 was done.

10. Atopic Dermatitis • Conclusions: • Overall only 13 of the 436 patients (3%) filled their Elidel/Protopic more than once every other month. • Of those 13 patients, 7/13 were filling prescriptions for topical steroids at least as often as prescriptions for Elidel/Protopic. • For the 6 patients with no or infrequent topical steroid fills over the same time period, should any action be taken (e.g. send a DUR letter asking for chart notes)?

11. Atopic Dermatitis • Educational Document included in the Packet

12. Atopic Dermatitis

13. Atopic Dermatitis • #201 • 9 year old male • 11 Elidel claims in one year; only 3 topical steroid claims in the same time period • Still filling Elidel monthly. • Family Medicine prescriber; no derm diagnosis in electronic profile. • Send letter.

14. Atopic Dermatitis • #5 • 39 yr male • 10 Protopic claims in one year/ no topical steroid claims in the same time period. • Family Medicine prescriber; only derm diagnosis is ICD-9 757.39 specified skin anomalies. • Protopic last filled 12-20-12 so do NOT send letter as not currently receiving it.

15. Atopic Dermatitis • #8 • 60 year old female • 9 Protopic claims in one year; no steroid claims. • Family Medicine prescriber; diagnosis – eczema. • Patient died in 2012 (pulmonary hypertension) so do not send letter.

16. Atopic Dermatitis • #127 • 13 yr male • 9 Elidel claims in one year; no topical steroids.  Last paid claim for topical steroid was in 2006. Elidel last filled 1-17-13. • Pediatric prescriber; no derm diagnosis in electronic profile. • Send letter.

17. Atopic Dermatitis • #75 • 41yr female • 8 Protopic claims; 1 steroid claim. • Family Medicine; atopic dermatitis/eczema. • Protopic was last filled 11-29-12 so do not send letter.

18. Atopic Dermatitis • #399 • 7 Elidel claims in one year; zero steroid claims. • Pediatrics; atopic dermatitis/eczema. • Elidel last filled 9-19-12 so do not send letter.

19. Atopic Dermatitis • Comments/Questions?

20. P&T Committee Narcotic Analgesic Studies

21. Narcotic Analgesic Update Participants Receiving Over 500 mg Morphine Equivalents per Day

22. Original Review • Generated profiles for the top 150 recipients by total narcotic claim count from the recipients who had at least one narcotic claim in each of the 24 months of the period ending December 2011 • Time Period: May 1, 2011 through December 31, 2011 • All profiles were hand reviewed by Idaho Medicaid Pharmacists

23. Daily Morphine Equivalents Lowest = 10 mg Highest = 2421 mg

24. Participants Receiving Over 500 Morphine Equivalents in 2011 Study • Original study 5/1/2011 – 12/31/2011 • 30 participants > 500 morphine mg equivalents • Follow-up study of these 30 participants 6/1/2012-11/30/2012

25. Data on 30 Original Participants

26. Follow-up Request • Letter (see packet) sent 2/13/2013 • Included patient medication profile and Board of Pharmacy controlled substance report • Requested Chart Notes and Documentation for most recent 6 months • Evaluation and monitoring of pain relief • Evaluation for improvement in daily function • Potential misuse/abuse • Current treatment plan • Pain contract • Random urine screen results

27. Participant Review • 5 of 6 participants’ prescribers returned documentation • Case Presentations • Top User no longer receiving: Chris Johnson • Most complex user: Jane Gennrich • Remaining 4 users: Tami Eide

28. Current Interventions/Outcomes Studies • Zolpidem High Dose • Migraine Prevention • Prophylaxis Utilization in Chronic Triptan Utilizers • Botulinumtoxin Products • Testosterone enanthate/cypionate (injectable) • Psychotropic Medications in Foster Children • Two (2) or more concomitant stimulant medications • long-acting plus short-acting ok

29. Zolpidem High Dose • On January 10, 2013 the United States Food and Drug Administration (FDA) notified the public of new information regarding the safety of certain drugs that contain zolpidem. (See packet for copy of Drug Safety Announcement) • The NEW immediate release zolpidem dose for women is being lowered from 10 mg to 5 mg. • The NEW extended release zolpidem dose for women is being lowered from 12.5 mg to 6.25 mg. • For men, the new labeling recommends that the same lower doses be considered (zolpidem immediate release 5 mg or zolpidem ER 6.25 mg).

30. Zolpidem High Dose • A report was run looking at paid claims between October 1, 2012, and December 31, 2012, to identify the number of Idaho Medicaid recipients who had received zolpidem:

31. Zolpidem High Dose • Patients were selected if they had doses above the NEW recommended doses. • Letters were sent to 877 prescribers about 1,984 patients on 1/18/2013. • As of 4/16/2013, 246 responses have been received (28% response rate.) • See packet for copy of the letter.

32. Zolpidem High Dose • Criteria Paragraph • On January 10, 2013, the Food and Drug Administration (FDA) published a safety announcement regarding the  popular insomnia medication zolpidem (trade names Ambien, Ambien CR, Edluar, Zolpimist). The announcement included two important messages: • First, the FDA provided new, lower bedtime dosing recommendations on zolpidem immediate and extended release products. • Next, the FDA reminded the public about safety concerns around driving or performing other activities requiring alertness the morning after use. • The risk of next-morning impairment is highest for women, who may eliminate the medication more slowly.  Impairment is also greater in those taking the extended release formulation (Ambien CR/zolpidem ER).  Manufacturers will be revising the product labeling to reflect the following: • The NEW immediate release zolpidem dose in women is being lowered from 10 mg to 5 mg. • The NEW extended release zolpidem dose in women is being lowered from 12.5 mg to 6.25 mg. • For men, the new labeling will recommend the same lower doses be considered (zolpidem 5 mg or zolpidem ER 6.25 mg).

33. Zolpidem High Dose: • Note that providers may choose more than one selection per response. • Reviewed and have or will modify the treatment 126 • Will use this information in care of future patients 120 • Information clinically useful: plan to monitor 113 • Reviewed and do not believe adjustment is needed 72 • Attempted to modify therapy unsuccessfully 15 • Not my patient, never has been 5

34. Zolpidem High Dose: Comments of Interest • “Patient is stable” (numerous similar responses) • “will discuss with patient” • “chronic sleep disorder. Pt. with chronic sleep problem nightly and does not sleep without zolpidem” • “dose was initially changed, had worsening of symptoms and strongly favored higher dose” • “attempts made to lower dosage or taper off without success. The pt listed are long term complicated pts and to effectively recess her has been reviewed previously. Thanks” • “lower doses do not help. I still treat patients not studies.”

35. Zolpidem High Dose: Comments of Interest • “He has multiple sclerosis. Ambien was discontinued. Where is the form for why my patient was abruptly stopped on Advair which had been effective and helpful for the pt, why was my input not important then.” • “I will change my prescribing habits. Have only given 1 dose.” • “I’m the physician. Waste of my time.” • “I already know.” • “Will change dose to Ambien 5mg” • “Patient has not responded to a lower dose” • “I did not prescriber this medicine to my knowledge” • “Both patients were (are) pregnant”

36. Zolpidem High Dose: Comments of Interest • “tolerates well, has taken since April 2009” • “The benefits outweigh the risks” • “I will attempt to modify therapy with pts as recommended” • “But the patient is a male, not female” • “He tolerates the current dose without side effects” • “address at their next visit. Had already heard about the FDA announcement” • “I am not an Idaho Provider. This is not my patient.”

37. Zolpidem High Dose Payment Amount to Pharmacy: 12/12 - $25,787; 3/13 - $24,555

38. Zolpidem High Dose • Thoughts/Comments?

39. Migraine Prevention • Idaho Medicaid paid over $770,000 worth of pharmacy claims for the Triptan class of medication in 2012. • There were more than 7,200 claims paid for in 2012. • The question the Idaho DUR Board is beginning to investigate is “Are these medications being used appropriately and are recipients getting the appropriate treatment for the prevention of migraines?”

40. Migraine Prevention • Epidemiology • Migraines affect approximately 11% of the adult populations in Western Countries. • In the United States, more than 30 million people have at least 1 migraine per year. • Gender • Before puberty more common in boys than girls. • In people over 12 years of age, the prevalence increases in both males and females peaking at age 30-40 years. • The ratio of female-to-male increases from 2.5:1 at puberty to 3.5:1 at age 40.

41. Migraine Prevention: recipients with paid triptan claim between 1/1/2012 and 12/31/2012 • Gender (Idaho Medicaid Population) • Overall Average Age: 35 (range 4 – 78) • Average Age Females: 35 (range 6 – 68) • Average Age Males: 31 (range 4 – 78)

42. Migraine Prevention: recipients with paid triptan claim between 1/1/2012 and 12/31/2012

43. Migraine Prevention: recipients with paid triptan claim between 1/1/2012 and 12/31/2012

44. Migraine Prevention: recipients with paid triptan claim between 1/1/2012 and 12/31/2012

45. Migraine Prevention • Epidemiology • Race • Caucasians > African Americans > Asians • Geography • Americas > Europe/Middle East > Asia > Africa • Economic Impact • Estimated at more than $2.5 billion per year in cost of medical care (Direct costs) • Estimated at more than $13 billion per year in loss of productive time (Indirect costs).

46. Migraine Prevention • Medical Diagnosis (based on direct questionnaires) • 1989 – 38% of sufferers • 1999 – 48% of sufferers • Prognosis • Chronic condition with severity and frequency diminishing with advancing age. • Treatment • Abortive • Preventative

47. Migraine Prevention • Preventative Therapy • Taken in absence of headache with the goal of reducing the frequency and severity of the migraine, make acute attacks respond better to abortive therapy, and ultimately improve the patient’s quality of life. • 3 primary classes of medications that are effective: antiepileptics, antidepressants, and antihypertensives. • Botulinum toxin A will be discussed in greater detail in slides to follow. • Please refer to handout in packet regarding the evidenced based guideline update .

48. Migraine Prevention • Idaho Medicaid Numbers • In 2012 there were 5,022 unique recipients with a Migraine Diagnosis in their electronic medical record. • Of these 5,022 recipients, 1,258 had a triptan claim in their profile. • Side note: In 2012 there were 2,367 unique recipients with a triptan claim • Of these 1,258 recipients, 281 (22%) had a claim for one of the Level A Medications as described in the Evidence-based guideline update.

49. Migraine Prevention • Next Steps???

50. Migraine Prevention • References • http://www.neurology.org/content/78/17/1337.full.html • http://www.neurology.org/content/78/17/1346.full.html • http://www.neurology.org/content/63/12/2215.full.html • http://emedicine.medscape.com/article/114256-overview • http://www.medscape.com/viewarticle/429665_print