Managed Care - November 2008 - (Page RSV10)

mal respiratory status. Toward these ends, the mainstays of therapy are gentle suctioning of nasal secretions; adequate hydration (but not to the point of overhydration) and nutrition (intravenously if necessary and if aspiration is a concern); and oxygenation, although there is some debate about when oxygen should be provided. In routine cases of RSV bronchiolitis, chest X-rays or complete blood counts are of little help in guiding therapy. Pharmacologic options that have been studied as treatments for RSV bronchiolitis include bronchodilators, corticosteroids, antiviral agents, and leukotriene receptor antagonists. The vast majority of patients with RSV bronchiolitis should not receive bronchodilators, as they have not been shown to reduce the rate of hospitalization, and they provide only modest short-term clinical benefit in patients with mild or moderate bronchiolitis (Kellner 1996). However, there may be a subpopulation of patients with reactive airway disease who will respond to a bronchodilator. Nebulized racemic epinephrine or albuterol are often used in the inpatient hospital or emergency room. For outpatients, albuterol would be preferred, because it produces less of a rebound effect than racemic epinephrine and is safer to use at home. Therefore, if there is a consideration of discharge from the ER or physician’s office, albuterol should be tried. Bronchodilators should be continued only if there is an objective response to therapy. Systemic corticosteroids may provide minimal reductions in the length of stay in infants hospitalized with bronchiolitis (Garrison 2000); however, there is not sufficient evidence to support their use. Furthermore, data on potential harm are lacking. AAP guidelines (AAP 2006) state that corticosteroids are not effective and are not indicated in hospitalized infants with RSV bronchiolitis. Likewise, no data support the use of inhaled corticosteroids in RSV bronchiolitis (Viswanathan 2003). Use of the antiviral agent ribavirin generally is not recommended because it is difficult to use, has a high cost, and confers potential risks to caregivers and marginal benefits. In the Pediatric Investigators Collaborative Network on Infections in Canada study (Law 1997), there was no statistically significant association with any outcome measure in ribavirin-treated ventilated subsets, regardless of risk group. In highly selected situations, AAP (2006) states that “A decision about ribavirin administration should be made on the basis of the particular clinical circumstances and experience of the physician.” The rationale for using the leukotriene receptor antagonist montelukast is that leukotriene release may contribute to the development of reactive airway disease after RSV bronchiolitis. A pilot study (Bisgaard 2003) suggested that montelukast may be efficacious in treating recurrent respiratory symptoms in children postRSV bronchiolitis, but a larger study (Bisgaard 2008) found that montelukast did not improve respiratory Keys to successful palivizumab immunoprophylaxis • Screen all patients to determine high-risk infants that require immunoprophylaxis • Immunize with palivizumab before hospital discharge; provide parent education • Secure approval of required doses from insurers/ health plans before onset of the local RSV season • Give subsequent doses monthly at home (intervals of 30 days from last dose) • Track all patients for compliance • Track patient outcomes regarding hospitalizations and any adverse events Source: Based on author recommendations symptoms in this population. Because of insufficient data, this treatment is not recommended. There is no indication for antibiotics in the treatment of RSV bronchiolitis because it is a viral disease; however, some patients develop bacterial pneumonia secondary to the RSV infection. If a patient has been doing well 3 or 4 days into the course of bronchiolitis but suddenly develops a high fever and more tachypnea, a secondary bacterial infection should be suspected. Otitis media can be treated with antibiotics (AAP 2006). In general, there is low risk for serious bacterial infections, and if present in young infants, they are usually from the urinary tract. Improving compliance The key to optimizing protection against serious RSV infections in high-risk patients is compliance. In a study of 10,390 infants receiving palivizumab (Berger 2003), noncompliant patients had a 2.2-fold increased risk of hospitalization (1.4 versus 3.1 percent; P<.001). Compliance was defined as having, on average, 35 or fewer days between palivizumab doses. A strategy for improving compliance and outcomes through home-based delivery of palivizumab injections has been recently reported (Hand 2003, Golombek 2004). In a study of 236 infants (Hand 2003), home care was linked to a 20 percent increase in compliance rates, fewer hospitalizations, and fewer unscheduled medical visits. In a study of 1,446 infants (Golombek 2004), periodic nursing visits to a home, compared with a pediatrician’s office, resulted in greater completion of recommended doses (98 versus 89 percent; P<.001) and a lower rate of hospitalizations (0.93 versus 3.57 percent; P<.001). At Schneider Children’s Hospital (SCH), we have had direct experience with home-based delivery of palivizumab immunoprophylaxis. Through an independent 5year study (Frogel 2004) conducted between 1998 and 2003, we have demonstrated that the coordination of efforts between a NICU and a pediatric practice using 10 MANAGED CARE / SUPPLEMENT

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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