Making therapeutic decisions with ongoing drug shortages Dr. Roland Halil, BSc(Hon), BScPharm, ACPR, PharmD Pharmacist, Bruyere Academic Family Health Team Assistant Professor, Department of Family Medicine, University of Ottawa [email protected]November, 2013
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Making therapeutic decisions with ongoing drug shortages Dr. Roland Halil, BSc(Hon), BScPharm, ACPR, PharmD Pharmacist, Bruyere Academic Family Health.
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Making therapeutic decisions with ongoing drug shortages
Dr. Roland Halil, BSc(Hon), BScPharm, ACPR, PharmD
Pharmacist, Bruyere Academic Family Health TeamAssistant Professor, Department of Family Medicine, University of Ottawa
1) Drug Shortages. A Guide for Assessment and Patient Management. CPhA 20102) Darrell Issa (CA-49), Chairman U.S. House of Representatives Committee on Oversight and Government Reform. FDA’s Contribution to the Drug Shortage Crisis. U.S. HOUSE OF REPRESENTATIVES, 112TH CONGRESS, COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, JUNE 15TH, 2012
Don’t Panic!The (Relatively) Good News
• Most shorted drugs are: – Injectables
• Less commonly used in primary care– Can be obtained within a reasonable delay
• Most patients can ‘make do’– Competing manufacturers can handle part of the
demand to increase supply– Therapeutic alternatives exist
• Four Steps of Rational Prescribing • A logical process for finding alternatives
Options
• First, lay out therapy options: – Drug A– Drug B– Drug C– Non-drug options D, E, & F– No treatment
• (Always an option!)
Rational Prescribing Needs a Process to Provide Structure
1. Efficacy2. Toxicity3. Cost 4. Convenience
1. What’s it going to do for me?
2. What’s the catch?3. How much is this
going to run me?4. How much work is
this going to be?
1. Efficacy – Ask About…1. Hard outcomes:
a) Reduction in mortality?b) Reduction in morbidity?
2. Surrogate outcomes:• Clinically relevant?
3. Then, “What is the quality of this evidence?” • Meta-analysis?• Randomized Controlled Trial?• …• Case series?• Anecdotal evidence?
1. Efficacy
• If there is no efficacy, why waste your time on the potential toxicity, cost and inconvenience of a drug?
• If there is proven efficacy at the population level, then balance this against the potential toxicity to the individual.
2. Toxicity – Ask About…
Bothersome Severe
Common Not legal
Rare Who cares
2. Toxicity
• N.B. RCTs are usually powered to show differences in efficacy, not always toxicity. – Efficacy endpoint: ~ 1 in 5000 – Toxicity endpoint: ~ 1 in 20,000
• So, might need > 4 RCTs to see statistical signals of toxicity after a drug reaches market.
• Age is important: • Newer agents = Less Safety Data• Older agents = More Safety Data
3. Cost – Ask About…
• Patient cost vs Societal cost
• Covered by provincial drug plan? – By private plans?
4. Convenience – Ask About…
• What is the likelihood of compliance?1. Frequency of administration?
– Daily vs QID?
2. Special restrictions? – PO vs IV? – Home vs Office vs Hospital therapy?
3. Many interactions?4. Special monitoring requirements?5. Constraints in supply?