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subcutaneous treatment regimen. The cost of therapy in the home care group was $701, hospital group $2,701, and continuous subcutaneous antiemetic therapy $4,432 (Figure 1). CONCLUSION A trial of safer, proven, lower cost pharmacologic treatments could save health plans a great deal of money. A reasonable course of action would be to require a trial of ondansetron ODT or a short IV ondansetron regimen as a last resort before prior authorization of therapies that cost between $4,000 and $11,000 per patient. With the advent of generic ondansetron, additional savings to the health plan may be available, as most service providers of continuous subcutaneous ondansetron therapy have not renegotiated their price to reflect the decreased acquisition cost. The daily drug cost was reduced from approximately $200 for an average daily dose to about $15 per day. Although plans have adjusted formulary pricing, this remains invisible because the drug price is bundled in the total cost of service. On the other hand, it might be more prudent to deny coverage, as many health plans have already decided, for two expensive options that have scant scientific support, an unknown safety profile, and high cost compared to alternatives. REFERENCES American College of Obstetricians and Gynecologists (ACOG). Nausea and vomiting of pregnancy; 2004 Apr. 13 p. (ACOG practice bulletin; no. 52). Arsenault MY, Lane CA, MacKinnen CJ. The management of nausea and vomiting of pregnancy. (SOGC clinical practice guidelines). J Obstet Gynaecol Can 2002:24:817–31. Atackovic G, Navioz Y, Moretti ME, Koren G. The safety of higher than standard doses of doxylamine-pyridoxine (Diclectin) for nausea and vomiting of pregnancy. J Clin Pharmacol 2001; 41:842–5. Berkovitch M, Elbirt D, Addis A, SchulerFaccini L, Ornoy A. Fetal effects of metoclopramide therapy for nausea and vomiting of pregnancy. N Engl Med 2000; 343(6):445–6. Berkovitch M. Metoclopramide for nausea and vomiting of pregnancy: a prospective multicenter international study. Am J Perinatol 2002; 19(6): 311–6. Borelli F, Capasso R, Aviello G, Pittler MH, Izzo AA. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol 2005;105:849–56. Briggs GG. Freeman RK. Yaffe SJ. Drugs in pregnancy and Lactation, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999. Broussard CN, Richter JE. Nausea and vomiting of pregnancy. Gastroenterol Clin N Am 1998; 27:123–151. Buttino L Jr., Gambon S. Coleman S. Home subcutaneous metoclopramide therapy for hyperemesis gravidarum. In: Koren G, Bishai R, editors. Nausea and vomiting of pregnancy: state of the art 2000. First International Conference of Nausea and Vomiting of Pregnancy. Toronto: Motherisk; 2000. P 84–9. Buttino L JR, Coleman SK, NK Bergauer, C Gambon, GJ Stanziano. Home subcutaneous metoclopramide therapy for hyperemesis gravidarum. J Perinatol 2000; 20 (6): 359–62. Buttino L, Gambon C. Home subcutaneous metoclopramide therapy for hyperemesis gravidarum. Prim Care Update Ob Gyns 1998; 5(4):189. Cordero JF et al: Is Bendectin a teratogen? J Am Med Assoc 1981; 245:2307–10. Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea and vomiting during pregnancy. Br J Gen Pract 1993; 43:245–8. Goodwin TM. Hyperemesis gravidarum. Clin Ob & Gyn 1998; 41 (3): 597– 605. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software. Leathem A. Safety and efficacy of antiemetics used to treat nausea and vomiting in pregnancy. Clin Pharm 1986;5:660–8. Levichek Z, Atanackovic G, Oepkes D, Maltepe C, Einarson A, Magee L, et al. An evidence-based treatment algorithm for nausea and vomiting of pregnancy. The Motherisk Program, Toronto, 2000. Can Fam Phys 2002; 48: 267–8, 277. Lombardi DG, Istwan NB, Rhea DJ, O’Brien JM. Measuring outpatient outcomes of emesis and nausea management in pregnant women. Man- aged Care. 2004; 13(11):48–51. Mazzota P, Magee LA. A risk-benefit assessment of pharmacological and non-pharmacological treatments for nausea and vomiting of pregnancy. Drugs 2000; 50(4): 781–800. Naef RW 3r, Chauhan SP, Roach H, Roberts WE, Travis KH, Morrison JC. Treatment for hyperemesis gravidarum in the home: an alternative to hospitalization. J Perinatol. 1995; 15(4): 289–92. O’Brien B, Naber S. Nausea and vomiting during pregnancy: effects on the quality of women’s lives. Birth 1992; 19:138–43. Portnoi G, et al. The safety and effectiveness of ginger for the treatment of nausea and vomiting of pregnancy. Am J Obstet Gynecol 2003; 189(5): 1374–1377. Seto A, Einarson T, Koren G. Pregnancy outcome following first trimester exposure to antihistamines: Meta analysis. Am J Perinat 1997; 14(3): 119–24. Sorenson HT, Nielsen GL, Christensen K, Tage-Jensen U, Ekbom A, Baron J. Euromap study group, birth outcome following maternal use of metoclopramide. Br J Pharmacol 2000; 49(3): 264–8. Sullivan CA, Johnson CA, Roach H, Martin RW, Stewart DK, Morrison JC. A Pilot study of intravenous ondansetron for hyperemesis gravidarum. Am J Obstet Gynecol. 1996; 174(5): 1565–8. DECEMBER 2008 / MANAGED CARE 45

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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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