Managed Care - December 2008 - (Page 42)

ered infants born with cardiac abnormalities and limb-reduction defects. But Bendectin is the most studied drug in pregnancy, and no credible evidence demonstrates a relationship between Bendectin use during pregnancy and congenital abnormalities (Jewell 2003). Since the withdrawal of Bendectin from the U.S. market, the incidence of HG has increased threefold while the drug remains available in Europe and Canada with no similar increase. Once conservative measures outside the purview of this article such as dietar y modifications, lifestyle changes, acupuncture, and acupressure have been shown to be ineffective, pharmacological intervention is warranted. Since many experts believe that HG is a progressive condition, treatment should be initiated as soon as the diagnosis is confirmed (ACOG 2004). The use of any medication in pregnancy demands weighing its known and unknown risks against the risks associated with the maternal condition. Health plans should be aware of the medications’ risk, efficacy, and cost when crafting coverage guidelines. The American College of Obstet- rics and Gynecology (ACOG) recommends that first-line treatment of NVP start with pyridoxine (vitamin B6) and that doxylamine be added if symptoms are not relieved shortly (ACOG 2004). Doxylamine is a histamine-1 receptor antagonist proven to be safe and effective for the treatment of NVP (Atanackovic 2001). It is marketed in the United States as Unisom Night Time Sleep Aid, which contains 25mg of doxylamine and is available over the counter. Many physicians treat NVP effectively with 10mg of pyridoxine and one halftablet of Unisom, which is approxi- Treatments for nausea and vomiting in pregnancy Drug Dimenhydrinate Pregnancy Category B Average Average daily dose cost per day 25–50mg po q6 hours 25–50 mg po q 6 hours ½ tablet po BID and 1 tablet at bedtime 10–25 mg po TID-QID 25–50 mg po Q 6 hours $0.35 Comments Considered a second/third line therapy (as an add-on to doxylamine/pyridoxine) per SOGC and ACOG guidelines. Diphenhydramine Doxylamine Pyridoxine Hydroxyzine B A A C $0.95 $0.49 $0.15 $3.50 May be combined with doxylamine In a large database review of the 828 newborns with exposure to hydroxyzine during the first trimester, 48 (5.8%) major birth defects were observed. (Briggs, GG) Three large studies concluded that meclizine is not a teratogen. (Briggs, et al) Considered a third/fourth line therapy (as an add-on to pyridoxine, doxylamine and promethazine or dimenhydrinate) per SOGC and ACOG guidelines. Meclizine Metoclopramide B B 25mg po Q 6 hours 5–10mg po Q 8 hours $1.85 $2.60 Metoclopramide Promethazine Ondansetron ODT (orally disintegrating tablet) Ondansetron B C B SQ by way of programmable pump 25mg po every 8 hours 8mg po q 12 hours $145 $2.19 $69.93 B SQ by way of programmable pump $380 42 MANAGED CARE / DECEMBER 2008

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

Managed Care - December 2008 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor ICD-10 Offers Huge Opportunity, Challenge Part D at a Crossroads Plans Can Weather the Financial Crisis DM vs. Medical Home? Tackle Prediabetes Reasonable Approach to Morning Sickness Formulary Files Tomorrow's Medicine Outlook

Managed Care - December 2008

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