Inappropriate ESA Use Reduced by Pharmacy Protocol

Ordering process cut the number of epoetin alfa doses by 71% and medication costs by 69%.
Ordering process cut the number of epoetin alfa doses by 71% and medication costs by 69%.

Implementation of a pharmacy-managed prescribing protocol for erythropoiesis stimulating agents (ESAs) may promote more prudent use of the agents and decrease medication costs in the hospital setting, according to study findings presented at the National Kidney Foundation's 2014 Spring Clinical Meetings in Las Vegas.

Methodist University Hospital in Memphis, Tenn., developed a protocol requiring ESA prescribers to specify the FDA-approved indication and to verify the following: adequate iron indices (transferrin saturation above 20% and serum ferritin level above 100 ng/mL for non-dialysis chronic kidney disease patients, above 200 ng/mL for hemodialysis patients, and above 800 ng/mL for cancer patients); hospital length of stay of at least 3 days; and no contraindications, including uncontrolled hypertension with blood pressure above 185/110 mm Hg, a hemoglobin level above 12 g/dL or, in a cancer patient, a hemoglobin level of 10 g/dL or higher, active bleeding, or curative cancer. Pharmacists verified compliance with the prescribing criteria before dispensing an ESA.

The study, led by Joanna Q. Hudson, PharmD, of the University of Tennessee Health Science Center in Memphis, compared epoetin alfa use before and after initiation of the protocol (February/March 2010 vs. February/March 2011) among 43 inpatients. These patients included 35 (81%) on dialysis, 3 (7%) with chronic kidney disease not on dialysis, 2 (5%) with cancer, and 3 (7%) with other indications.

The number of epoetin doses decreased from 983 pre-protocol to 289 post-protocol, a 71% decrease, Dr. Hudson's group reported. The number epoetin alfa units used dropped from 10.6 million to 3.2 million, a 69% decrease. The cost of treatment decreased from $95,413 to $29,379, a 69% decrease.

Dr. Hudson and her colleagues found that prescribers generally complied with the ordering process, but the study revealed areas where additional education was warranted, such as the need for adequate iron indices prior to ESA initiation. Of the 70 instances of noncompliance, 38 (54%) involved a ferritin level below the defined threshold and 15 (21%) involved a transferrin saturation below 20%.

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