1. DUR Board Meeting March 12, 2008 West Virginia Department of Health and Human Resources Bureau for Medical Services Drug Utilization Review Board

2. DUR Board Meeting March 12, 2008 DUR Interventions –Review of monthly DUR cycles, profile review by DUR Review Committee, includes review of Lock-In cases –Methadone – general warning intervention letter –Pain Management – long term use of short acting narcotics –Polypharmacy – 20 or more different drugs –Atypical antipsychotic utilization – review of criteria for duplicate therapy, impact on diabetes, unlabeled uses

3. DUR Board Meeting March 12, 2008 Monthly DUR Review Committee Monthly DUR Review Committee –Committee meets the last Monday of the month –200 DUR cases – high risk score patients, includes those with multiple providers and criteria exceptions –50 Lock-In cases –Lock-In re-review and annual review cases

4. DUR Board Meeting March 12, 2008  DUR Review Committee September to December 2007  1,472 DUR Cases generated  2,073 prescriber letters generated  1,858 mailed  215 letters not mailed due to bad prescriber address or hospital DEA number.  404 responses - 22% Response rate  Pharmacy response rate is 27%

5. DUR Board Meeting March 12, 2008  DUR Review Committee  Case evaluation response  312 responses to the evaluation question ”I have reviewed the enclosed information and found it to be……” 87 Extremely useful 87 Extremely useful 131 Useful 131 Useful 17 Somewhat useful 17 Somewhat useful 50 Neutral 50 Neutral 27 Not Useful 27 Not Useful

6. DUR Board Meeting March 12, 2008 Methadone Utilization Methadone Utilization –All patients taking Methadone during October 2007 –297 patients and letters mailed 11/29/07 –Letter had general warning about Methadone toxicities –12 letters could not be mailed or returned due to bad address –114 responses – 39% response rate

7. DUR Board Meeting March 12, 2008 Methadone Utilization Methadone Utilization –114 responses – 39% response rate 89 patient continuing without a problem 89 patient continuing without a problem 7 no longer my patient 7 no longer my patient 5 will reassess and modify therapy 5 will reassess and modify therapy 4 has appointment to discuss therapy 4 has appointment to discuss therapy 2 tried to modify therapy, symptoms returned 2 tried to modify therapy, symptoms returned 3 ER or on call prescriber 3 ER or on call prescriber 1 tried to modify patient non-cooperative 1 tried to modify patient non-cooperative 1 not seen patient recently 1 not seen patient recently 1 response did not discuss therapy 1 response did not discuss therapy

8. DUR Board Meeting March 12, 2008 Pain Management – long term use of short acting narcotics  Patients taking 4 or more doses per day of short acting agent for 90 days and no long acting agent  389 prescriber letters generated  54 deleted, hospital DEA or bad address  335 letters mailed 12/26/07  79 responses (22% response rate)

9. DUR Board Meeting March 12, 2008 Pain Management – long term use of short acting narcotics 34 patient continuing without a problem 34 patient continuing without a problem 13 has appointment to discuss therapy 13 has appointment to discuss therapy 11 no longer my patient 11 no longer my patient 5 will reassess and modify therapy 5 will reassess and modify therapy 5 tried to modify patient non-cooperative 5 tried to modify patient non-cooperative 4 tried to modify therapy, symptoms returned 4 tried to modify therapy, symptoms returned 3 ER or on call prescriber 3 ER or on call prescriber 1 not seen patient recently 1 not seen patient recently 1 response did not discuss therapy 1 response did not discuss therapy 1 unaware what others ere precribing 1 unaware what others ere precribing 1 patient deseased 1 patient deseased

10. DUR Board Meeting March 12, 2008 Polypharmacy Polypharmacy –patients with more than 20 different drugs during each month of a three month period –Different drug label name, could be same drug different dose –4 th quarter 2007, 584 recipients, 1,598 prescribers –Prescribers will receive a letter with a list of patients names and ID numbers and an abbreviated 3 month drug history profile for each patient on the list –Otherwise many prescribers would have received many letters –General response form will not be patient specific

11. DUR Board Meeting March 12, 2008 Criteria for atypical antipsychotic agents  Therapeutic duplication of atypical agents – criteria alerts at GCN level which is drug/dose combination  1,381 criteria exceptions - many could be same drug different dose  Atypical agents and worsening diabetes – any atypical agent and a drug for the treatment of diabetes or diabetes diagnosis will trigger alert  1,197 criteria exceptions  Atypical agents not FDA approved for dementia in elderly  11 criteria exceptions Several high dose, dose optimization and drug–drug, drug–disease interaction criteria

12. DUR Board Meeting March 12, 2008 Criteria for atypical antipsychotic agents Criteria for atypical antipsychotic agents  criteria not active for WV but will be next month  Low dose quetiapine (<200mg) for sedative use  Multiple atypical agents, 3 or more atypical agents within 30 days  Multiple antipsychotic agents - 3 or more of any antipsychotic agent within 30 days

13. DUR Board Meeting March 12, 2008 Atypical Antipsychotic Agents Maximum Quantity Limits Abilify® 5 mg; 15 mg - 1 tablet per day Geodon® 20 mg; 40 mg - 2 capsules per day Invega® 3 mg, 6 mg; 9 mg - 1 tablet per day Risperdal 0.25 mg; 0.5 mg; 1 mg; 2 mg - 2 tablets per day Seroquel® 25 mg - 4 tablets per day Zyprexa® 2.5 mg; 5 mg; 7.5 mg - 1 tablet per day Zyprexa® Zydis® 5 mg - 1 tablet per day