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Rx in Underwriting A Special Presentation for C H O L H U A

Rx in Underwriting A Special Presentation for C H O L H U A. Hank George, FALU, CLU, FLMI Cheesehead. HATS OFF, CHOLHUA! You are a role model for excellence as a professional underwriters’ association! Greetings from your neighbors on the frozen tundra! Hank George Officer-at-(too)-Large

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Rx in Underwriting A Special Presentation for C H O L H U A

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  1. Rx in UnderwritingA Special Presentation forCHOLHUA Hank George, FALU, CLU, FLMI Cheesehead

  2. HATS OFF, CHOLHUA! You are a role model for excellence as a professional underwriters’ association! Greetings from your neighbors on the frozen tundra! Hank George Officer-at-(too)-Large WAHLU

  3. MUC comes toPackerCountryBears’Refugees Welcome!September 15-17Hyatt Regency- MilwaukeeFollowed by an ECG interpretation seminar created by Lori Ammonslammons444@aol.com

  4. Rx = DxTell me what he’s taking…and I’ll tell you what he’s got!

  5. GenericNamevs.Proprietary Name(s) • BupropionisWellbutrin (depression), Aplezin (depression) andZyban (quit smoking aide) • FluoxetineisProzac (depression and n+1 other things!) andSarafem (PMS)

  6. The BEST PRACTICERx paradigm typically consists of… • 1st line Rx – used most -BEST CASE? • 2nd line Rx – used when one or more first line drugs have unacceptable side effects/don’t work;sometimes used in combination with first line • 3rd line Rx –more potent, more side effects;used when 1st and 2nd line both fail, or as adjuvant –WORST CASE? • “Compassionate use” – refractory cases (felbamate in seizure disorders, etc.) –WORST CASE!

  7. Rx Profiles 2010Why rapidly-increasing use? • Low cost • Perceived value • Rapid access/teleinterview-compatible • Credibility • Action-friendly (act without confirmation) • No notable producer-customer-regulatory/legislative pushback • 70%+ hit rate > MIB • Older age business + polypharmacy

  8. What are the 5 Key Elements? • AllRx paid for with Rx card • Sequenceof prescribing • Dose • Rx compliance (adherence) • Name and contact information forprescribingphysician

  9. Noncompliance with Rx • In a cohort of 112,902 statin users,only 40% were taking the drug at least 80% of the timeAFTER 1 YEAR! • Psychiatric drugs have the worst compliance • Compliance is a marker for theHealthy Adherer Effectspanning a spectrum of favorable health habits • Non-compliance is a majorRISK-TAKING BEHAVIOR

  10. 6 Subtle Pearls • Total dose taken + times taken per day/ other interval – does it pinpoint reason for use/disease severity? • One drug replaces another – why?< 1 month (side effects); > 1 month (lack of efficacy) • One drug added to another– why? • Refills – consistent with compliance? • Mode of delivery – pill, injection (IV, IM, intrathecal), transdermal, dissolving wafer, inhaler, nasal/oral spray, topical ointment, suppository – does it pinpoint reason for use/disease severity? • Subtle synergies–inhaler for “asthma” + and 3 courses of winter antibiotics = COPD?

  11. The “Off-Label” Pandemic! • 1 in 4 scripts for unapproved indications • Subtly promoted by pharmaceutical companies • Physicians free to do so if there is a clinical study supporting efficacy • Most common in psychiatric, cardiovascular contexts! Take gabapentin for example…

  12. Gabapentin Uses • 2nd line generalized seizure disorders • Bipolar I + II • Neuropathic pain in diabetes, etc. • Social phobia, panic disorder • Restless leg syndrome • ??? (since I last looked!)

  13. How often do prescription drugs affect the results of routine screening blood tests?Often enough to…

  14. …justify an 800+ page reference book on this subject, published by the American Association for Clinical Chemistry!

  15. Rx Effects on Blood TestsGeneralizations • Most drugs do it at least rarely • Most effects are minimal and transient • Most do not result in any harm to the patient • Many effects are capable of altering test results significantly enough to change underwriting actions, especially when solely for test results • LFTs, BUN. Creatinine, glucose most vulnerable • The first question in any unexplained test elevation:What Rx is he taking?

  16. Statins and Liver enzymes • Statins raise ALT ≥ 3 x ULN in 0.3% to 1.5% of cases, depending on dose – and countless more to a lesser degree • AST to a lesser extent; GGT unaffected • Elevations are harmless and normalize when the drug is withdrawn • LFTs should be rechecked at 6 weeks and annually thereafter by prescribing MD • Key question:is the elevation caused by the statin…or something else?

  17. Which drugs REALLY cause isolated GGT elevation? • Barbiturates • Hydantoin (Dilantin) • Carbamazepine (Tegretol, etc.) • Valproic acid (Depakote, Depakene) • Oxcarbazepine (Trileptal) • Fosphenytoin (Cerebyx) • Herbal compound kava

  18. CardiovascularRxPearls +RED FLAGS

  19. “- prils”+“- sartans” • ACE inhibitors and angiotensin II receptor blockers • Widely used in hypertension • ACE inhibitor #1 choice in heart failure + subclinical systolic dysfunction • Both used in early (microalbuminuria) diabetic/prediabetic nephropathy prophylaxis…even in the absence of hypertension

  20. Phosphodiesterase-5 Enzyme InhibitorsA/K/A “- denafils”…not just for wishful old geezers any longer!

  21. Sildenafil is VIAGRAfor ED andREVATIOfor pulmonary hypertension • TadalafilisCIALISfor ED andADCIRCAfor pulmonary hypertension • VardenafilisLEVITRA andNUVIVAfor ED and is likely to be approved for pulmonary hypertension • These drugs have also been shown to be effective inachieving pregnancy in women with increased endometrial thicknessand in“female sexual dysfunction” syndrome

  22. BEWARE solitary CCB indications • Bepridil (Vascor) =refractory stable angina • Nimodipine (Nimotop) =subarachnoid hemorrhage

  23. More on statins… • Manufacturers’ dream: 30,000,000! • Used prophylactically in patients with borderline/normal lipids • Wide range of pleiotropic effects beyond just lowering LDL-C, raising HDL-C and lowering triglycerides • 10+% increased riskof T2DM affirmed by meta-analysis • RED FLAG: patient discharged from a hospital on statin for the first time!

  24. PSYCHIATRICPHARMACOLOGYGEMS

  25. SSRI antidepressants have more off-label uses than any drug class How’s this beauty?Sertraline (Zoloft) for thestaggering riskNight Eating Syndrome…another impairment-wannabe

  26. How many do you recognize? • Asenapine (Saphris)– schizophrenia and BP I • Trazodone(Oleptro)–(Desyrel redux) MDD • Paliperidone(Invega, Sustenna)– antipsychotic • Iloperidone(Fanapt)– schizophrenia and BP I • Desvenlafaxine(Pristiq)– MDD • Guanfacine(Intuniv)– ADHD

  27. Stay Current on Rx!HOT NOTES™Monthly e-NewsletterFREEesther@hankgeorgeinc.com

  28. How many potential adjuvant drugs for REFRACTORY SEVEREmajor depressive disordercan you think of?

  29. Folates (folic acid) • Thyroid hormone • Omega-3 fish oils • Lithium carbonate • Buspirone (BuSpar) @ 40 mg • Selegiline (Emsam) patch • Modafinil (Lyrica) • Riluzole (Rilutek) – ALS drug • Various novel antipsychotics

  30. Additional Underwriting-SalientRx Tidbits

  31. Metformin(Glucophage) The #1 drug in BEST CASEtype 2 diabetes just happens to also be widely used fornonalcoholic fatty liver disease (NAFDL), polycystic ovary syndrome (PCOS), metabolic syndrome, prediabetic states and (potentially), weight loss!

  32. Finasteride (Propecia, Proscar) • Is indicated for baldness and benign prostatic hyperplasia (BPH) • Is used off-label in prostate cancer prevention and Tourette syndrome • Lowers PSA – potentially causing a “false-negative” result when screening a person at high enough perceived risk to justify prophylaxis!

  33. Not too long ago, there were no approved drugs for fibromyalgiaNow we have 3: • Duloxetine (Cymbalta) –also used in MDD and diabetic neuropathic pain • Modafinil (Lyrica) –used for sleep disorders and many other reasons • Savella (milnacipran) –an antidepressant approved only for fibromyalgia

  34. Why do ALTERNATIVE & COMPLEMENTARYtherapiesmatter to us?

  35. Fastest growing domain of healthful intervention • Used disproportionatelyby college-educated, higher-income applicants • In cancer patients, useddisproportionately in those with metastatic disease and/or following relapse from conventional Rx Should be on EVERY drilldown!

  36. You want to knowWHY when they’re taking… • Hawthorn • Shark cartilage • Mistletoe • Silymarin • Glycyrrhizin • SAMe

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