Following is a P and T Committee update (from the November 18^th meeting).  Starting date for specific programs is November 24th, unless otherwise noted.  This information should soon be available in the formulary notebooks, the formulary website, and Formulary One-Source.  Please let me know if you have any questions or comments.  Don’t forget to check the “New Drug Monitoring Spotlight” section of the website, which provides important monitoring information about newly approved drugs.  Also, attached is the updated version of the “Not Stocked, Not Ordered” drug list with the new additions highlighted in red.

Below is the memo with links to the drug monographs, protocols, and formulary documents. Click to access the full P&T packet for this month, or here to access the P&T packet archive.

posaconazole Intravenous (Noxafil) – This is the parenteral form of the drug, indicated for treatment / prophylaxis of invasive fungal infection, involving difficult to treat infections  such as asperigillosis, fusariousis, zygomucosis, candidiasis, in refractory immunocompromised patients (i.e. HSCT patients with GVHD, hematological malignancy patients with prolonged neutropenia).  It is also FDA approved for treatment of oropharyngeal candidiasis including refractory cases.   It is dosed 300 mg IV  q 12 hrs. for the first 24 hrs, then 300 mg IV once daily.  Intravenous administration is associated with similar ADRs and drug interactions as the oral dosage form.  Contract price is $328 per 300 mg dose, while intravenous fluconazole costs in the range of $4 - $5 per dose.  Posaconazole intravenous was approved for formulary status, restricted to use by infectious disease physicians for use in immunocompromised patients for resistant and difficult to treat fungal infections.

abacavir-dolutegravir-lamiVUDine (Triumeq) – This is a combination drug to treat HIV, and is given once daily.  Triumeq contains dolutegravir 50 mg, abacavir 600 mg, and lamivudine 300 mg.   There are various ADRs and drug interactions associated with these 3 drugs being given together.  This product costs $70 per day.  It was classified as non-formulary, not stocked, and if Triumeq is ordered the 3 drugs should be dispensed separately.  Rare use are expected.

olodaterol (Stiverdi Respimat) – This is a long acting beta-agonist in inhaler form, indicated for chronic treatment of COPD, and dosed once daily.   It is available in a 14 day and 28 day supply, costing $69 and $148, respectively, and is similar in efficacy and safety to salmeterol and formoterol. Formoterol is available in a 6 day supply costing about $27, and is the current formulary interchange agent for this drug class.  Olodaterol was classified as non-formulary, not stocked, and 5 mcg once daily should be interchanged to Foradil 12 mcg bid. 

efinaconazole (Jublia) topical – This topical azole agent is used to treat onchomycosis of toenails due to Trichophyton rubrum and Trichophyton mentagrophytes.  It is applied once daily for 48 weeks.  A 4 mL bottle of solution costs $427 and lasts for about 6 weeks.  This drug was classified as non-formulary, not stocked;  if the patient needs to use this agent in the hospital, they should use their own supply.  Initiation should be deferred to the outpatient setting.

propranolol (Hemangeol) oral solution (4.28 mg/mL) – This product is indicated for treatment of proliferating infantile hemangioma requiring systemic therapy, and is intended to be started on infants 5 weeks – 5 months of age.  The dose is titrated up to 1.7 mg/kg bid.  The cost is $375 for 120 mL.  There is a generic propranolol oral solution available in a 4 mg/mL concentration, costing $37 for 500 mL.   Hemangeol was classified as non-formulary, not stocked, and the generic drug will be substituted for Hemangeol on a 1 mg:1 mg basis. 

macitentan (Opsumit) – This oral drug is indicated for treatment of pulmonary arterial hypertension (PAH), is an endothelin receptor antagonist, and is dosed once daily.  It is pregnancy category X and a REMS program requires physician certification to prescribe, pharmacy certification to dispense, and female patients must be enrolled in the OPSUMIT REMS monitoring program.  The drug can be ordered through Accredo Specialty Pharmacy.  Macitentan was classified as non-formulary, not stocked, and the patient should use their own supply while in the hospital.  Initiation should be deferred to the outpatient setting where the proper certifications can be arranged, financial management planned, and patient counseling conducted. 

treprostinil (Orenitram) ER – This oral product is indicated for treatment of pulmonary arterial hypertension, and the dose is titrated up to an average dose of  3 – 4 mg bid.  It is a prostacycline analog and acts by vasodilation of pulmonary and systemic vascular beds, inhibition of platelet aggregation, and inhibition of smooth muscle cell proliferation.  The normal cost is in the $200 - $300 / day range.  The drug was classified as non-formulary, not stocked, and the patient should use their own drug while in the hospital.  Initiation should be deferred to the outpatient setting where financial management plans can be developed and patient counseling given.

argaTROBan Protocol Update – The protocol format was updated to assist with ease of use, and several newer anticoagulants were added to the statement regarding discontinuing of other anticoagulants before argaTROBan is started.  The “high” dose adjustment was omitted, and a choice of initial infusion rates depending on the clinical situation was added. 

ertapenem (Invanz) – This drug is renally excreted, and dosage adjustment is recommended for CrCl < 30 mL/min and with hemodialysis. The dose for CrCl < 30 is 500 mg once daily.   This drug was approved for automatic pharmacist renal dose adjustment according to the labeling guidelines.

Tablet to Liquid Conversion by Pharmacists – It was approved for pharmacists to automatically convert solid oral medication formulations to liquid or immediate-release /crushable formulations to facilitate medication administration in patients with difficulty swallowing solid oral dosage forms.  This activity is now described in the pharmacy policy titled “Route Conversion for Oral to NG / OG/ G Tube / Drug Product Selection for Enteral Routes.