Following is a P and T Committee update (from the April 23^rd meeting).  Starting date for specific programs is May 1^st, 2013, 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.

tafluprost (Zioptan) ophthalmic solution– This is a new prostaglandin analog indicated to treat elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension.  It is similar to generic latanoprost with safety and efficacy issues, but is much more expensive.  There is already an established formulary interchange program with this drug class with latanoprost as the “formulary workhorse” drug.  Tafluprost was classified as non-formulary, not stocked, and was added to the automatic interchange to latanoprost (tafluprost 0.0015% 1 drop q pm to latanoprost 0.005% 1 drop q pm). 

acyclovir-hydrocortisone (Xerese) topical - This topical cream contains acyclovir 5% and hydrocortisone 1% and is indicated for early treatment of recurrent herpes labialis to reduce the likelihood of cold sores and to shorten the lesion healing time.  The most common adverse reactions are dermatological in nature.  The cost of Xerese is $286 versus about $182 for giving the individual components separately (both acyclovir 5% and hydrocortisone 1% creams are both on the formulary).  Xerese was classified as non-formulary, not stocked, and if ordered the separate components should be dispensed.  The patient may use their own Xerese if necessary. 

butorphanol  (Stadol) nasal spray – This product is available in a 2.5 mL bottle, each spray delivers approximately 1 mg, and about 8 – 12 sprays are available from each bottle depending on frequency of priming.  The drug is well absorbed from the nasal mucosa and achieves serum levels similar to the parenteral product.  Analgesic effect is produced within 15 minutes and duration of action is about 4 – 5 hrs.  The cost is $11.40 for 2.5 mL.  This product offers another option in regards to drug administration route for pain management at a reasonable cost, and was classified as a formulary agent.

cabozantinib (Cometriq) – This new drug is indicated for progressive, metastatic medullary thyroid cancer and is being studied for metastatic resistant prostate cancer and renal cancer.  The dose is 140 mg orally once daily and the cost is about $400 per day.  There are various situations requiring dosage adjustments.  The drug is supplied by a specialty pharmacy directly to the patient and the hospital cannot order.  It was classified as “non-formulary, not stocked”, and the patient must use their own supply if needed in the hospital.  Initiation should be deferred to the outpatient setting.  Rare use is expected.

pomalidomide (Pomalyst) – This new thalidomide analog is indicated for refractory multiple myeloma in patients who have received at least two prior treatment options.  The normal dose is 4 mg orally daily and it is given for 21 days in a 28 day cycle, and dose must be adjusted for hematological toxicities.  Various ADRs are associated with its use.  The drug costs about $500/day.  It is supplied through specialty pharmacies and only sent directly to the patient, and the hospital cannot order.  It was classified as “non-formulary, not stocked”, and the patient must use their own supply if needed in the hospital.  Initiation should be deferred to the outpatient setting.  Rare use is expected.

caffeine tablets – Caffeine 200 mg tablets have been requested for use by CV Surgery to help prevent caffeine withdrawal headache in patients having surgery but unable to drink their regular coffee.  In most cases the 200 mg dose will be given for 1 dose in the morning prior to surgery.   It was approved as a formulary agent, restricted to CV Surgery. 

zolpidem Dosing Update – Based on updated pharmacokinetic information showing delayed elimination of this drug in females, the FDA has issued new dosing recommendations.  The newly recommended dose in female patients is 5 mg.  An automatic dose adjustment in females from 10 mg to 5 mg was approved, if zolpidem was started in the hospital.  If the patient has been on zolpidem 10 mg as a chronic outpatient medication (i.e. taken in outpatient setting for over 30 days), then the 10 mg dose should not be changed.  This dosing adjustment will affect a few other hypnotics that are converted to zolpidem in the hospital. eszopiclone 3 mg and ramelteon 8 mg, if started in the hospital are normally converted to zolpidem 10 mg, but in females the converted dose should be 5 mg.  For Ambien CR 12.5 mg and zaleplon 10 mg for female patients, the conversion should also be to zolpidem 5 mg. 

Meperidine MUE – An MUE reviewing oral meperidine use in 60 patients found that 60% of these patients had a documented allergy to opioids and most of them received only a few doses of the drug for a short time period.  Most of the use of oral meperidine was with the surgery areas of Orthopedics, OB/GYN, and Plastics.  Almost 20% of patients with documented opioid allergy had no alternative pain medication ordered except for meperidine.  It was approved to continue oral meperidine tablets as a formulary agent, but restrict use to patients having a documented allergy to another opiate drug.