Antipsychotic Utilization: Oregon State Medicaid

Ann M. Hamer, PharmD BCPP

This presentation was made possible by a grant from the State Attorney General Consumer and Prescriber Education Program which is funded by the multi-state settlement

of consumer fraud claims regarding the marketing of the prescription drug Neurontin

Background

In 2004, Warner-Lambert (now a division of Pfizer, Inc.) paid $430 million to settle claims that it was using continuing education grants to promote off-label uses of Neurontin.

Background

The 50 state attorneys general who accepted the settlement of the Neurontin case have used $21 million to establish the Consumer and Prescriber Grant Program, www.ohsu.edu/cpgp/, designed to provide healthcare professionals and consumers information related to prescription drugs and their marketing.

Objectives

Develop critical skills to promote an evidence-based approach to the medical literature;

Create awareness of the persuasive marketing practices of the pharmaceutical industry;

Assess the impact that pharmaceutical costs can have on other healthcare priorities; 

Balance the ethical responsibility to the patient vs. the ethical needs of society in prescribing practices; and

Develop skepticism about off-label indications for a drug without compelling evidence-based research that supports such use.

Methods

Academic Detailing Focused on the utilization of behavioral health

medications Didactic Lectures

Focused on the evaluation of medical literature and pharmaceutical marketing

Web-Based Tutorials Focused on the evaluation of medical

literature and pharmaceutical marketing

Topic Selection

Antipsychotics After specialty pharmaceuticals, antipsychotics

are the most expensive drug class for the Oregon Health Plan

Costing approximately $3.2 million each quarter Drug class where small changes can have a

big impact on overall cost Provides a good example of some off-label

use

Antipsychotic Utilization Profile

Antipsychotic Prescribing Rate—State

0

500

1000

1500

2000

2500

3000

3500

4000

HAL PER ABIL GEO RISP SERO ZYP

Uni

que

Pat

ient

s

Antipsychotic Prescribing Rate—State

0

500

1000

1500

2000

2500

3000

3500

4000

HAL PER ABIL GEO RISP SERO ZYP

Uni

que

Pat

ient

s

2%

28%

Antipsychotic Prescribing Rate—Lifeworks NW

0

10

20

30

40

50

60

70

HAL PER ABIL GEO RISP SERO ZYP

Uni

que

Pat

ient

s

2%

41%

Antipsychotic Prescribing Rate—Comparison

0%

5%

10%

15%

20%

25%

30%

35%

40%

HAL PER ABIL GEO RISP SERO ZYP

Uni

que

Pat

ient

s

Lifeworks State

Antipsychotic Selection

Cost is a factor in treatment selection when all else is considered equal.

Abilify Risperdal

Antipsychotic Selection

Cost is a factor in treatment selection when all else is considered equal.

Abilify

Generic Risperidone

Antipsychotic Utilization Profile

Seroquel Dosing*—State

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Dose

(<300mg)

Therapeutic Dose

(300-800mg)

High Dose

(>800mg)

Dai

ly S

eroq

uel D

ose

*Reflects use of dose for ≥90 days

Seroquel Dosing*—State

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Dose

(<300mg)

Therapeutic Dose

(300-800mg)

High Dose

(>800mg)

Dai

ly S

eroq

uel D

ose

*Reflects use of dose for ≥90 days

14%

86%

Seroquel Dosing*—Lifeworks

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Dose

(<300mg)

Therapeutic Dose

(300-800mg)

High Dose

(>800mg)

Dai

ly S

eroq

uel D

ose

*Reflects use of dose for ≥90 days

31%

69%

Seroquel

69% of patients on therapy for 90 or more days were on low dose (<300mg/day). Total n=24

31% of patients on therapy for 90 or more days were on therapeutic dose (300-800mg/day) Total n=6

No patients were on duplicate antipsychotic therapy with Seroquel for 90 or more days.

Roughly 50% of patients started on Seroquel maintain treatment for 90 or more days.

Low Dose Seroquel

The use of Seroquel as a sedative has not been studied and efficacy and safety are questionable.

Adverse effects = anticholinergic side effects, hypotension, hyperprolactinemia, metabolic abnormalities, agitation and akathisia.

Low Dose Seroquel

Cases of Seroquel misuse and abuse have been reported in the medical literature. Street name = “quell” and “Susie-Q”

Antipsychotic Utilization Profile

Quarterly Summary—Comparison

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Lifeworks State

Risperdal & perphenazine, % of all AP use,

excluding clozapine and select 1st generation AP

Quarterly Summary—Comparison

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Lifeworks State

Risperdal & perphenazine, % of all AP use,

excluding clozapine and select 1st generation AP

Goal?

Quarterly Summary—Comparison

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Lifeworks State

Percent of Seroquel patientson therapeutic dose

Quarterly Summary—Comparison

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Lifeworks State

Percent of Seroquel patientson therapeutic dose

Goal?

Antipsychotics—Cost

Drug Cost*

haloperidol $23

perphenazine $45

clozapine $210

Risperdal $250

Risperdal M-Tab $310

Geodon $310

Invega $340

Abilify $440

Abilify Discmelt $450

Zyprexa $460

Seroquel (>300mg/d) $530

Zyprexa Zydis $550

*Avg retail cost for 30-days to OHP1st QTR 2007Excludes rebate

Antipsychotics—Cost

Drug Cost*

haloperidol $23

perphenazine $45

clozapine $210

Risperdal $250

Risperdal M-Tab $310

Geodon $310

Invega $340

Abilify $440

Abilify Discmelt $450

Zyprexa $460

Seroquel (>300mg/d) $530

Zyprexa Zydis $550

*Avg retail cost for 30-days to OHP1st QTR 2007Excludes rebate

DC

DC

DC

DC

Antipsychotic Dose Optimization

From October 2006 through September 2007 323 antipsychotic dose optimization change

forms have been sent Expected savings per change = $220

323 X 60% = 194 194 X $220 = $42,680 $42,680 X 12 = $512,160

Identification of Specialty Practice: Primary Care and Psychiatry

Antipsychotic Prescribing Rate—Psychiatry Specialty

0

200

400

600

800

1000

1200

1400

1600

1800

HAL PER ABIL GEO RISP SERO ZYP

Uni

que

Pat

ient

s

Antipsychotic Prescribing Rate—Psychiatry and Primary Care

0200400600800

10001200140016001800

HAL PER ABIL GEO RISP SERO ZYP

Psychiatry Primary Care

Uni

que

Pat

ient

s

Antipsychotic Prescribing Rate—Psychiatry and Primary Care

0%

5%

10%

15%

20%

25%

30%

35%

40%

HAL PER ABIL GEO RISP SERO ZYP

Psychiatry Primary Care

% P

atie

nts

Seroquel Dosing*—Psychiatry Specialty

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Dose

(<300mg)

Therapeutic Dose

(300-800mg)

High Dose

(>800mg)

Dai

ly S

eroq

uel D

ose

81%

19%

*Reflects use of dose for ≥90 days

Seroquel Dosing*—Psychiatry and Primary Care

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Dose

(<300mg)

Therapeutic Dose

(300-800mg)

High Dose

(>800mg)

Psychiatry Primary Care

Dai

ly S

eroq

uel D

ose

81%

19%

*Reflects use of dose for ≥90 days

87%

13%

Quarterly Summary—Seroquel (% of patients within therapeutic dose range)

-10% 0% 10% 20% 30% 40% 50% 60%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Psychiatry Primary Care

Quarterly Summary—RISP + PER

(% of AP use)

-10% 0% 10% 20% 30% 40% 50% 60%

2007 Q3

2007 Q2

2007 Q1

2006 Q4

Psychiatry Primary Care

Key Points

Risperdal and perphenazine are cost-effective treatment alternatives Risperdal will be generic in 2008

Seroquel is not recommended for use as a sedative/hypnotic