Implementation of hypercalcemia of malignancy guidelines to reduce treatment associated costsLori-belle Slone, PharmD, BCPS; Susan Samet, PharmD King’s Daughters Medical Center, Ashland, KY; Cardinal Health, Houston, TX

Background

Results

Conclusion

DisclosuresThe authors of this presentation have the following to disclose concerning possible financial or personal relationshipswith commercial entities that may have a direct or indirect interest in the subject matter of this presentation:Lori-belle Slone – Nothing to disclose

Susan Samet – Nothing to disclose

Methods

Objectives

• Single Medical Center; Retrospective review • Evaluation of average monthly medication costs prior to the

implementation of the pathway and dosing strategy to costs post implementation

• Evaluation of usage patterns of calcitonin prior to the implementation of the pathway to usage patterns post-implementation by retrospective review

• Pharmacy was challenged to find new ways to reduce pharmacy supply costs

• Calcitonin acquisition costs had been steadily increasing overthe past several years

• A shortage of bisphosphonates contributed to an acute increasein calcitonin use for hypercalcemia

• Review of hypercalcemia cases revealed opportunities in thefollowing areas:- Appropriate patient selection for the use of calcitonin- Calcitonin dose optimization- Selection of other more appropriate treatment agents

1. WalshJ, GittoesN, SelbyP. Emergency management of acute hypercalcaemia in adult patients. Available atwww.endocrinology.org/policy accessed 10/1/2019

2. Reid IR. Pharmacotherapy of Paget's disease of bone. Expert Opin Pharmacother 2012; 13 (5): 637-46.

References

• Determine the impact of guidelines on:- Average monthly medication spend for the treatment of

hypercalcemia of malignancy including:- Injectable bisphosphonates- Calcitonin

- Overall accumulated savings• Evaluate adherence to approved guidelines• Assess pathway’s impact to overall response to therapy

Usage Evaluation Completed Initial Education Post Implementation

• Average monthly spend injectable bisphosphonates and calcitonin- 12-month baseline: October 2017 to September 2018 - $13,863 per month- Targeted stakeholder education: October 2018 to January 2019 - $6,337 per month - Implementation of hypercalcemia of malignancy: February 2019 to August 2019 - $2,872 per month

• Overall savings to date: $107,039• Retrospective review of all calcitonin patients has shown appropriate response to therapy without any complications

• Use of a hypercalcemia pathway and calcitonin dose limits hasresulted in $107,039 of pharmacy cost savings over 11 months

• Pathway has optimized the treatment of hypercalcemia in thisinstitution without negatively impacting patient care

• Electronic health record changes have assisted in carestandardization and guideline implementation

• Stakeholder awareness of rising drug costs and involvement inguideline creation contributed to successful implementation

Hypercalcemia of Malignancy PathwayAsymptomatic

AND Corrected Calcium 12 mg/dL or lessAsymptomatic/Mildly SymptomaticAND Corrected Calcium > 12 mg/dL Moderate/Severely Symptomatic

IV Hydration (0.9% Sodium Chloride) 2-4 liters/day

IV Hydration PLUS IV Bisphosphonates (Pamidronate or Zoledronic Acid)

IV Hydration PLUS IV Bisphosphonates Consider Calcitonin 4 units/kg SubQ every12 hours for up to 4 doses (max dose 400 units)

INTERNALUSEONLY

INTERNALUSEONLY

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• Maintain the Cardinal Health color palette when possible. This includes charts and figures.

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