For your consideration
Combination Drugs: Benefit or Burden?
There are good reasons to combine drugs in fixed-dose combinations (FDCs). Drugs for HIV/AIDS, oral contraceptives, antihypertensives, anti-Parkinson’s, antibiotics, and some to treat tuberculosis are just a few examples. Combinations can simplify treatment, improve patient compliance, reduce prescribing errors and inadequate regimens, and may reduce drug supply management problems and cost. Studies have shown that these combinations are safe and effective, and there is plenty of evidence that FDCs improve compliance. Patients appreciate the convenience and the reduced co-pays (for one pill instead of two). But not all combinations make sense.
Sometimes drugs are combined for reasons other than therapeutic benefit. Drug companies create FDCs as a way to extend their proprietary rights, increase prices, and improve marketability. It is much less costly for them to combine existing drugs than to develop new ones. The FDA does not usually require additional studies before approving a combination product, as long as there is good data on the components and no concerns about safety issues.
One of those later drugs that we receive clinical calls regarding is Cosensi (amlodipine and celecoxib). Cosensi was approved by the FDA in July 2018 and is “indicated for patients on long-term treatment with celecoxib for osteoarthritis and have hypertension.” The FDA recommends that celecoxib be taken at the lowest possible dose for the shortest possible time. When/if analgesic therapy is no longer needed, celecoxib should be discontinued, and amlodipine monotherapy initiated.
Cosensi is available in 2.5mg/200mg, 5mg/200mg and 10mg/200mg and is dosed once daily. The cost for one-month (30 tablets) ranges between $1100 and $1500 per month. Uncombined, amlodipine is $25-$50/month and celecoxib is $150/month.
For your consideration
Potassium Tablets vs Liquid
Potassium comes in many formulations including tablets, capsules, granules, and liquid. The tablets and capsules are the most common and the least expensive. Occasionally we receive calls for clinical consultation for a patient having difficulty swallowing the large potassium tablets. The clinician is considering switching the patient to the liquid form and is wanting to know the cost.
Liquid potassium is available in 473ml bottles at 20meq/15mls. That is approximately 30 doses at $9.85/dose or $295/bottle. If the patient is using 40meq that 473ml bottle is approximately $600. Potassium tablets and capsules cost $30-$60/month.
If a patient is having difficulty swallowing their potassium tablets or capsules, we recommend the following from the K-Dur package insert:
K-Dur capsules may be opened and the contents sprinkled into applesauce, pudding, etc. In the case where a patient has a feeding tube, these contents can also be mixed in liquid and put down a G-tube or PEG tube.
K-Dur tablets:
- Break the tablet in half and take each half separately with a glass of water.
Prepare an aqueous (water) suspension as follows:
- Place the whole tablet(s) in approximately ½ glass of water (4 fluid ounces).
- Allow approximately 2 minutes for the tablet(s) to disintegrate.
- Stir for about half a minute after the tablet(s) has disintegrated.
- Swirl the suspension and consume the entire contents of the glass immediately by drinking or using a straw.
- Add another 1 fluid ounce of water, swirl, and consume immediately.
- Then, add an additional 1 fluid ounce of water, swirl, and consume immediately.
Aqueous suspension of K-Dur tablets that is not taken immediately should be discarded. The use of other liquids for suspending K-Dur tablets is not recommended.
For your consideration
Social Isolation & Disenfranchised Grief
As the incidence of COVID-19 infections continues to increase nationally, social isolation has substantially impacted the elder population in general and the hospice population in particular. Significant links have been found between social isolation and the increased risk of early mortality among older and seriously ill patients.
As COVID-19 cases and fatalities continue to climb, so does growing concern among hospice providers over the effects of isolation on the quality and experience of end-of-life care. Social isolation contributes to an increase in mental health issues such as depression, anxiety, and delirium in those who are terminally ill. Since patients, families, hospitals, and long-term nursing facilities remain under COVID-19 precautions, frontline hospice staff are not being allowed to make in-person visits, making it more likely that these mental health issues could be underrecognized and underdiagnosed. One strategy being employed is increased collaboration with referring facilities, psychiatric disciplines, and primary physicians as hospices work to support isolated patients and their families.
Not only does the pandemic negatively impact end-of-life care for patients but can be a source of disenfranchised grief for the patient’s loved ones. Disenfranchised grief refers to any grief that goes unacknowledged or invalidated by social norms. This type of grief is often minimized or not understood by others, which makes it particularly hard to process and work through. This disenfranchisement can extend and intensify the grieving experience, interfere with a person’s processing of grief and lead to decreased social support during bereavement. It may also exacerbate sadness, anger, guilt, and loneliness. Some bereaved individuals self-disenfranchise, in which they question the validity of their own experience. This is what hospices are finding during the pandemic.
According to the medical experts, it is quite likely, even with the introduction of viable vaccines, that COVID-19 will be a part of our daily lives well into the coming year. Thus, continued social isolation and disenfranchised bereavement will be a challenge for hospice professionals. This will challenge hospices to provide innovative ways to provide adequate end-of-life care involving goal setting, alternate care sites, and consultation services.
JAMA Network September 2020
Hospice & Palliative Care of Buffalo, NY
Regulatory Center
Hospice Related Provisions in COVID Relief and Funding Bill
Prior to Christmas 2020, Congress passed the Consolidated Appropriations Act of 2021, an almost 6,000-page year-end legislative package. The bill provides $2.3 trillion in spending. In that bill, the following items are directly related to hospice and palliative care.
- Rural Access to Hospice Act (H.R. 2494/S.1190)
- “Helping Our Senior Population in Comfort Environments” Act or the “HOSPICE” Act (H.R.5821)
- Extension of IMPACT Act cap calculation adjustment
- Sequestration Relief
- Provider Relief Funding
- Modifications to and Clarifications for the Paycheck Protection Program
For more detail and continued follow-up regarding the impact of these provisions check with your state hospice association, NHPCO or NAHC.
Updated
Drug Shortage List
These shortages are due either to manufacturing delays or shortage of raw ingredients. This is not an inclusive list, but the listed drugs may be used for hospice patients, especially in the inpatient setting. For a complete list of drugs on shortage follow this link:
The FDA is warning that drug shortages, especially those used to treat critically ill COVID-19 patients, will continue into 2021. The reasons cited for these shortages are raw materials (27%), manufacturing issues (37%), delays/capacity (27%). Although the FDA has regulatory oversight of the pharmaceutical industry, it cannot require a pharmaceutical company to: 1) make a drug, even if it is a medically necessary drug, 2) make more of a drug, 3) change how much and to whom a drug is distributed.
NOTE: Any items marked with a pill icon are new from the previous month’s newsletter
To close click the X in the top right hand corner.
About the Author
David Bougher
Senior VP of Regulatory Affairs
David is a seasoned veteran of the hospice world and an essential member of the Wise Hospice Options clinical team.
Education:
RN, BSN
Experience:
- Former hospice COO
- 20 Years of education & training experience
- 10 Years of experience at Wise Hospice Options
Connect
- (800) 856-9757 Ext: 203
- dbougher@wiseop.com
Follow
Wise Clinical leadership
Deanna Rice
Vice President
Clinical Services
drice@wiseop.com
(800) 856-9757:
EXT. 216
Tino Vilches
Senior Vice President
Clinical Services
tvilches@wiseop.com
(800) 856-9757:
EXT. 208
Available
Wise Hospice Options Services
Please reach out to your account manager for assistance with maximizing your available services, or for potential upgrades to your current system.
EHR Interface Integrations
Demographic & medication interfaces with over 11 EHR's.
E-Prescribing
Web-based prescribing platform for Schedule II's.
24/7 Support
On-demand clinical or technical assistance fast.
EHR Medication Profiling
Med reviews done inside your EHR system.
Advanced Reporting
Drill down into your pharmacy utilization trends.
Clinical Education
Hospice oreiented courses designed for your hospice staff.
Pharmacy Network Access
Unrestricted access to every pharmacy within our network.
Web-based Refills
Send and identify available refills for your patient population.
