Ohio Region
Drug Therapy
ADVISORY Crestor to Atorvastatin
Conversion
(Paul Bandfield, PharmD, Formulary Management Services)
 All strengths of atorvastatin (10, 20, 40 and 80mg) have
recently been added to the Commercial formulary
 Atorvastatin is on the generic tier for members with a
Commercial HMO benefit and tier 2 nonpreferred generic for
members with a Medicare Part D benefit
 All strengths of rosuvastatin (Crestor) are non-formulary for
Commercial HMO members and tier 4 nonpreferred brand for
members with a Medicare Part D benefit
 Since atorvastatin is available at a generic copay, members
converted from Crestor to atorvastatin will save an average of
$200 annually depending on an individual member’s copay
structure
 Atorvastatin is indicated for primary and secondary prevention
of cardiovascular events
 Atorvastatin is metabolized by the cytochrome P450 3A4
enzyme (CYP3A4) and has many of the same interactions as
simvastatin and lovastatin
o Unlike simvastatin, atorvastatin is not currently listed as
having a clinically significant interaction with amlodipine
o Although interactions have been documented between
atorvastatin with amiodarone, diltiazem or verapamil, no
maximum interacting doses of atorvastatin have been
advised by the Food and Drug Administration (FDA)
 Crestor undergoes minimal hepatic metabolism (about 10%),
primarily via CYP2C9 enzyme; there is essentially no metabolism
via CYP3A4, indicating a low propensity for interactions
compared to other statins
 Approximately 25 patients can be treated with atorvastatin
80mg for the same cost as treating one patient with Crestor 40mg
or 20mg
 Table 1 provides equipotent doses for Crestor and atorvastatin
Table 1: Daily Dose Providing Similar LDL-Lowering
20mg (47%-55%)
5mg 10mg (46-52%)
(45%) 20 mg (47%-55%) 40 mg (55%-63%)
20mg
Atorvastatin
40 mg (50%)
80 mg (55%-60%)
(43%)
Conversions
 Earlier in 2012, a therapeutic interchange from Vytorin
10/80mg and 10/40mg to atorvastatin 80mg was approved by the
Ohio Pharmacy and Therapeutics Committee
 The Crestor to atorvastatin initiative is a conversion and not a
therapeutic interchange
 Ohio Kaiser Permanente pharmacists will contact OPMG and
Network prescribers for conversion of each qualifying patient
individually
o Members with a documented allergy to atorvastatin or who
are taking medications with clinically significant interactions
to atorvastatin will not be converted
o Each converted member will receive a letter explaining the
conversion
Crestor
Issue 7
July 2012
Network Edition
 Conversions will be conducted according to the following:
Crestor Dose
Consider Conversion to
Crestor 40mg → Atorvastatin 80mg
Crestor 20mg → Atorvastatin 80mg or 40mg
Crestor 10mg → Atorvastatin 40mg
Crestor 5mg → Atorvastatin 20mg
Affordable Care Act: $0
Contraceptive Benefit
(Alynn Anzevino, PharmD, Manager, Formulary Management Services and
Pharmacy Benefits)
• The Affordable Care Act requires insurance plans to provide
access to prescription contraception with zero dollar patient cost
share
• KP will offer a $0 contraceptive copay for formulary products
for Commercial plans effective after August 1, 2012 and when the
plan renews
o For example, if a plan renews on November 2, the member
would pay their current copays for contraceptives between
August 1 and November 1 and would pay $0 copay after
November 1
• If HMO member receives a formulary exception for a
nonformulary contraceptive, it will be covered at $0 copay
• The zero patient cost share does not apply to Commercial plans
exempt from covering contraceptives
Potential Administration Errors
with Rotarix
(Paul Bandfield, PharmD, Formulary Management Services)
 In 2006, RotaTEQ, the first rotavirus vaccine, was approved by
the FDA
 RotaRIX became available in 2008 and is the preferred product
at KP facilities since it is a two-dose regimen
 Since these two products both contain rotavirus and have
similar names, there is a significant potential for confusion and
mix-ups
 Both RotaRIX and RotaTEQ are oral vaccines and should never
be given intramuscularly
 RotaRIX is supplied as a 2-dose regimen for infants
o Usually given at the 2-month (age 6 weeks+) and 4-month
well child visits
o A 4-week interval is required between the first and second
doses
o Manufacturer-supplied diluent in a prefilled oral applicator
is used to reconstitute the vial of lyophilized vaccine with the
supplied vial adaptor
o The final oral dose is 1mL; Refer to the vaccine’s approved
labeling for reconstitution instructions
(Continues on reverse side)
Issue 7 — Network Edition
(Continued from reverse side)
 RotaTEQ is supplied as a squeeze packet designed for
dispensing the oral dose to the patient
o RotaTEQ is given in 3 doses to infants at the 2, 4, and 6
month well child visits
o Patients who started dosing with RotaTEQ should complete
the series with the same product
Recommendations
 Always store complete packages of RotaRIX and do not
separate the contents
 Be aware of “spare” parts (e.g., syringes, adaptors, vials) that
may be in stock supply areas, as this could be an indicator that
the vaccine is being reconstituted or administered incorrectly
Safety Update: QT Prolongation
With Ondansetron Use
(Andrea Nixon, PharmD, Formulary Management Services)
 FDA informed healthcare professionals that preliminary results
from a clinical study suggests ondansetron (Zofran) may prolong
the QT interval in a dose-dependent manner, which could predispose patients to develop an abnormal and potentially fatal
heart rhythm, torsades de pointes
 GlaxoSmithKline announced changes to ondansetron drug
label to remove the 32mg single intravenous dose
 Updated label states intravenous ondansetron can be used in
adults and children with chemotherapy-induced nausea and
vomiting at 0.15mg/kg up to a maximum of 16mg per dose,
administered every 4 hours for three doses
 No single intravenous ondansetron dose should exceed 16mg
 New information on QT prolongation does not change any of
the recommended oral dose regimens for ondansetron including
the single oral dose of 24mg for chemotherapy induced nausea
and vomiting or the recommended lower intravenous
ondansetron dose to prevent post-operative nausea and vomiting
 Electrolyte abnormalities should be corrected prior to the
infusion of ondansetron
 More information can be found at:
http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm
FDA Alerts
Hospira Injectable Drug Products: Recall - Visible
Particulates from Defective Glass Vials
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAler
tsforHumanMedicalProducts/ucm312048.htm
Leucovorin Calcium Injection (Bedford Laboratories): Recall Visible Particulate Matter
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAler
tsforHumanMedicalProducts/ucm310782.htm
Vecuronium Bromide For Injection Preservative Free
(Bedford Laboratories): Recall - Particulate Matter
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAler
tsforHumanMedicalProducts/ucm310210.htm
Initiatives
Inter-Regional Clinical Pharmacy Services
Subcommittee (ICPSS) Initiatives
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

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Dulera preferred over Advair and Symbicort
OxyContin use discouraged over other long-acting opioids
Atorvastatin preferred over Vytorin and Crestor
Skeletal muscle relaxant use discouraged in elderly
Hydroxyzine use discouraged in elderly
Pharmacy Conversion Team Projects
 Half-Tab Initiatives
 ProAir day supply review
 Sumatriptan day supply review
July 2012
Current Half-Tab Initiatives
Abilify
Crestor
Levitra
Nuvigil Viagra
Aricept
Imitrex
Lexapro* Paxil
Zocor
Celexa
Lamictal
Lipitor
Provigil Zoloft
*Both brand and generic tablet products are half-tab initiatives
Formulary Changes
The Ohio Regional Pharmacy & Therapeutics Committee approved
the following formulary changes.
 The KP Ohio Region Drug Formulary is available by accessing the
Lexicomp Online Formulary through the Internet
(http://online.lexi.com/login) using login and password: ohkprx
 Formulary changes are updated in Lexicomp on their respective
effective dates
Commercial Additions
Drug
Interferon Beta-1a (Avonex Pen) 30mcg/0.5mL
Lenalidomide (Revlimid) 2.5mg Tab
Effective Date
7.19.12
8.7.12
Commercial Deletions
Drug
Acetic Acid Vaginal Gel
Amino Acid-Urea (Amino-Cerv) Cervical Cream
Atropine (Sal-Tropine) 0.4mg Tab
Ezetimibe/Simvastatin (Vytorin) 10/80mg Tab
Scopolamine (Scopace) 0.4mg Tab
Effective Date
8.7.12
8.7.12
8.7.12
8.7.12
8.7.12
Medicare Part D Tier Changes
Drug
Abatacept (Orencia) 125mg/mL Inj
Alglucosidase Alfa (Lumizyme) 50mg Inj
Belatacept (Nulojix) 250mg Inj
Belimumab (Benlysta) 120mg Inj
Calcium Acetate (Phoslyra) 667mg/5mL Sol
Canakinumab (Ilaris) 180mg Inj
Deferiprone (Ferriprox) 500mg Tab
Glycopyrrolate (Cuvposa) 1mg/5mL Sol
Glucarpidase (Voraxaze) 1000Unit Inj
Icatibant Acetate (Firazyr) 30mg/3mL Inj
Levetiracetam 5mg/mL, 10mg/mL, 15mg/mL
Inf
Pertuzumab (Perjeta) 420mg/14mL Inj
Nilotinib (Tasigna) 150mg Tab
Rilpivirine (Edurant) 25mg Tab
Telaprevir (Incivek) 375mg Tab
Treprostinil (Tyvaso) 0.6mg/mL Sol
Effective DateNew Tier
2.7.12 - Tier 5
2.7.12 - Tier 5
1.1.12 - Tier 5
2.7.12 - Tier 5
1.1.12 - Tier 3
2.7.12 - Tier 5
2.7.12 - Tier 5
1.1.12 - Tier 3
7.3.12 - Tier 5
1.1.12 - Tier 5
7.3.12 - Tier 4
7.3.12 - Tier 4
2.7.12 - Tier 5
7.3.12 - Tier 3
1.1.12 - Tier 5
1.1.12 - Tier 5
Medicare Part D Deletions
Drug
Drotrecogin alfa (Xigris) 5mg Inj
Effective Date
1.1.12
Criteria Updates
Atypical Antipsychotics
Beta-Adrenergic Blockers
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Glucagon-Like Peptide-1 (GLP-1)
Receptor Agonist
Long-Acting Insulins
Tapentadol (Nucynta)
Revised 07.12
Revised 07.12
Revised 07.12
Revised 07.12
Revised 07.12
Revised 07.12
Revised 07.12
Inquiries
Ohio Regional Formulary Management/Drug Information Service
(8:30 a.m. — 5:00 p.m. Mon — Fri, excluding holidays)
E-mail: oh.drug.info@kp.org
Pager for urgent inquiry: (216) 568-3133
References are available upon request