Rx in Underwriting
A Special Presentation
for
CHOLHUA
Hank George, FALU, CLU, FLMI
Cheesehead
HATS OFF, CHOLHUA!
You are a role model for excellence as a
professional underwriters’ association!
Greetings from your neighbors
on the frozen tundra!
Hank George
Officer-at-(too)-Large
WAHLU
MUC comes to Packer Country
Bears’ Refugees Welcome!
September 15-17
Hyatt Regency- Milwaukee
Followed by an
ECG interpretation seminar created
by Lori Ammons
lammons444@aol.com
Rx = Dx
Tell me what he’s taking…
and I’ll tell you what he’s got!
Generic Name
vs.
Proprietary Name(s)
• Bupropion is Wellbutrin (depression),
Aplezin (depression) and Zyban (quit
smoking aide)
• Fluoxetine is Prozac (depression and
n+1 other things!) and Sarafem (PMS)
The BEST PRACTICE Rx
paradigm typically consists of…
• 1st line Rx – used most - BEST CASE?
• 2nd line Rx – used when one or more first
line drugs have unacceptable side
effects/don’t work; sometimes used in
combination with first line
• 3rd line Rx – more potent, more side effects;
used when 1st and 2nd line both fail, or as
adjuvant – WORST CASE?
• “Compassionate use” – refractory cases
(felbamate in seizure disorders, etc.) –
WORST CASE!
Rx Profiles 2010
Why rapidly-increasing use?
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Low cost
Perceived value
Rapid access/teleinterview-compatible
Credibility
Action-friendly (act without confirmation)
No notable producer-customerregulatory/legislative pushback
• 70%+ hit rate > MIB
• Older age business + polypharmacy
What are the 5 Key Elements?
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All Rx paid for with Rx card
Sequence of prescribing
Dose
Rx compliance (adherence)
Name and contact information
for prescribing physician
Noncompliance with Rx
• In a cohort of 112,902 statin users, only 40%
were taking the drug at least 80% of the
time AFTER 1 YEAR!
• Psychiatric drugs have the worst compliance
• Compliance is a marker for the Healthy
Adherer Effect spanning a spectrum of
favorable health habits
RISKTAKING BEHAVIOR
• Non-compliance is a major
6 Subtle Pearls
• Total dose taken + times taken per day/ other
interval – does it pinpoint reason for use/disease
severity?
• One drug replaces another – why? < 1 month
(side effects); > 1 month (lack of efficacy)
• One drug added to another – why?
• Refills – consistent with compliance?
• Mode of delivery – pill, injection (IV, IM,
intrathecal), transdermal, dissolving wafer, inhaler,
nasal/oral spray, topical ointment, suppository –
does it pinpoint reason for use/disease severity?
• Subtle synergies – inhaler for “asthma” + and
3 courses of winter antibiotics = COPD?
The “Off-Label” Pandemic!
• 1 in 4 scripts for unapproved
indications
• Subtly promoted by pharmaceutical
companies
• Physicians free to do so if there is a
clinical study supporting efficacy
• Most common in psychiatric,
cardiovascular contexts!
Take gabapentin for example…
Gabapentin Uses
• 2nd line generalized seizure
disorders
• Bipolar I + II
• Neuropathic pain in diabetes, etc.
• Social phobia, panic disorder
• Restless leg syndrome
• ??? (since I last looked!)
How often do prescription
drugs affect the results
of routine screening
blood tests?
Often enough to…
…justify an 800+ page
reference book on this
subject, published by
the American
Association for Clinical
Chemistry!
Rx Effects on Blood Tests
Generalizations
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Most drugs do it at least rarely
Most effects are minimal and transient
Most do not result in any harm to the patient
Many effects are capable of altering test
results significantly enough to change
underwriting actions, especially when solely
for test results
• LFTs, BUN. Creatinine, glucose most
vulnerable
• The first question in any unexplained test
elevation: What Rx is he taking?
Statins and Liver enzymes
• Statins raise ALT ≥ 3 x ULN in 0.3% to 1.5% of
cases, depending on dose – and countless
more to a lesser degree
• AST to a lesser extent; GGT unaffected
• Elevations are harmless and normalize when
the drug is withdrawn
• LFTs should be rechecked at 6 weeks and
annually thereafter by prescribing MD
• Key question: is the elevation caused by
the statin…or something else?
Which drugs REALLY cause
isolated GGT elevation?
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Barbiturates
Hydantoin (Dilantin)
Carbamazepine (Tegretol, etc.)
Valproic acid (Depakote, Depakene)
Oxcarbazepine (Trileptal)
Fosphenytoin (Cerebyx)
Herbal compound kava
Cardiovascular
Rx
Pearls
+
RED FLAGS
“- prils” + “- sartans”
• ACE inhibitors and angiotensin II
receptor blockers
• Widely used in hypertension
• ACE inhibitor #1 choice in heart failure
+ subclinical systolic dysfunction
• Both used in early (microalbuminuria)
diabetic/prediabetic nephropathy
prophylaxis… even in the absence of
hypertension
Phosphodiesterase-5
Enzyme Inhibitors
A/K/A “-
denafils”
…not just for wishful old
geezers any longer!
• Sildenafil is VIAGRA for ED and REVATIO
for pulmonary hypertension
• Tadalafil is CIALIS for ED and ADCIRCA for
pulmonary hypertension
• Vardenafil is LEVITRA and NUVIVA for ED
and is likely to be approved for pulmonary
hypertension
• These drugs have also been shown to be
effective in achieving pregnancy in women
with increased endometrial thickness and in
“female sexual dysfunction” syndrome
BEWARE
solitary CCB indications
• Bepridil (Vascor) =
refractory stable
angina
• Nimodipine (Nimotop) =
subarachnoid
hemorrhage
More on statins…
• Manufacturers’ dream: 30,000,000!
• Used prophylactically in patients with
borderline/normal lipids
• Wide range of pleiotropic effects
beyond just lowering LDL-C, raising
HDL-C and lowering triglycerides
• 10+% increased risk of T2DM affirmed
by meta-analysis
• RED FLAG: patient discharged from a
hospital on statin for the first time!
PSYCHIATRIC
PHARMACOLOGY
GEMS
SSRI antidepressants have more
off-label uses than any drug class
How’s this beauty?
Sertraline (Zoloft)
for the
staggering risk
Night Eating Syndrome
…another impairment-wannabe
How many do you recognize?
• Asenapine (Saphris) – schizophrenia
and BP I
• Trazodone (Oleptro) – (Desyrel redux)
MDD
• Paliperidone (Invega, Sustenna) –
antipsychotic
• Iloperidone (Fanapt) – schizophrenia
and BP I
• Desvenlafaxine (Pristiq) – MDD
• Guanfacine (Intuniv) – ADHD
Stay Current on Rx!
HOT NOTES™
Monthly e-Newsletter
FREE
esther@hankgeorgeinc.com
How many
potential adjuvant drugs
for
REFRACTORY SEVERE
major depressive
disorder
can you think of?
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Folates (folic acid)
Thyroid hormone
Omega-3 fish oils
Lithium carbonate
Buspirone (BuSpar) @ 40 mg
Selegiline (Emsam) patch
Modafinil (Lyrica)
Riluzole (Rilutek) – ALS drug
Various novel antipsychotics
Additional
UnderwritingSalient
Rx Tidbits
Metformin (Glucophage)
The #1 drug in
BEST CASE type 2 diabetes
just happens to also be widely used for
nonalcoholic fatty liver disease
(NAFDL),
polycystic ovary syndrome (PCOS),
metabolic syndrome,
prediabetic states
and (potentially), weight loss!
Finasteride (Propecia, Proscar)
• Is indicated for baldness and benign
prostatic hyperplasia (BPH)
• Is used off-label in prostate cancer
prevention and Tourette syndrome
• Lowers PSA – potentially causing
a “false-negative” result when
screening a person at high enough
perceived risk to justify prophylaxis!
Not too long ago, there were no
approved drugs for fibromyalgia
Now we have 3:
• Duloxetine (Cymbalta) – also used in
MDD and diabetic neuropathic pain
• Modafinil (Lyrica) – used for sleep
disorders and many other reasons
• Savella (milnacipran) – an
antidepressant approved only for
fibromyalgia
Why do
ALTERNATIVE
&
COMPLEMENTARY
therapies
matter to us?
• Fastest growing domain of healthful
intervention
• Used disproportionately by
college-educated, higher-income
applicants
• In cancer patients, used
disproportionately in those with
metastatic disease and/or following
relapse from conventional Rx
Should be on EVERY drilldown!
You want to know WHY
when they’re taking…
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Hawthorn
Shark cartilage
Mistletoe
Silymarin
Glycyrrhizin
SAMe