Description
Scenario 1
You see a 45-year-old male patient in your clinic who presents with right calf pain for a few days. On initial examination the patient stated he is living in a homeless shelter and does not have reliable transportation to the clinic. He states he has taken medications in the past, but if he has to take too many drugs he will get confused as to what to take at which time.
After your workup and imaging studies, you diagnose the patient with an acute deep vein thrombosis. You now must decide on treatments for this patient. Here are the treatment options you have researched that would be appropriate for this patient. Included are some key points about the regimens to consider when evaluating which regimen would be a rational drug selection.
Drug Effectiveness Cost to Patient (with no insurance) Monitoring Bleeding Risk
Apixaban (Eliquis) Good $89/ month (but 30-day free supply card available) Baseline labs: Lytes, renal and hepatic function, PT/PTT, & CBC (then Q1-2 months thereafter) Low (except for trauma)
Rivaroxaban (Xarelto) Good $81/month Baseline labs: Lytes, renal and hepatic function, PT/PTT, & CBC (then Q1-2 months thereafter) Low (except for trauma)
Enoxaparin (Lovenox) + warfarin Good Lovenox: $214/day x5 days
Warfarin: $4/day (drug on Walmart $4 list) Baseline labs: Lytes, renal and hepatic function, PT/PTT, CBC. (The PT/IRN Q2 days until INR stable at 2.0-3.0, then weekly x1 month, then Q2-3 months thereafter if IRN stable at warfarin dose) Moderate
For Scenario 1, please explain which regimen you would choose and why. Describe your thought process utilizing the WHO 6-step process for rational drug selection.
Scenario 2
You are working in a primary care clinic and are visited by a drug representative who presents you with information on a new product the drug company is now making available. This new product is a combo medication containing Lisinopril 20 mg with 25 mg hydrochlorothiazide (HCTZ). The rep explains this new formulation was created to decrease the pill burden for patients and better ensure compliance. The rep states the new combo tablet will be sold under the brand name Combopress, and currently there is no generic equivalent available. The rep knows that you have many patients in your practice who are currently taking Lisinopril 20 mg, along with 25 mg HCTZ. The rep leaves a box of 100 individually wrapped tablets for you to use as patient samples. Before the rep leaves, you ask about the cost to the patients. The rep states that because the drug is not generic, a monthly supply without insurance will cost approximately $310. With most insurance companies, the patient’s co-pay will be between $55-$100 per month. Currently, your patients who are on the individual tablets pay between $8-$15 per month with insurance.
For Scenario 2, using rational drug selection (including the WHO 6-step process and the “I Can PresCribE A Drug’” mnemonic), please discuss what you would do with this information in regards to treating your patients. Include your thoughts for which type of patients Combopress would be appropriate and would not be appropriate, as well as how and why you came to this conclusion.
