Hospital Pharmacy - September 2017 - 522

720508
research-article2017

HPXXXX10.1177/0018578717720508Hospital PharmacySieg and Gass

Letter to the Editor

Bivalirudin Medication Use Evaluation
and Cost Savings Initiative

Hospital Pharmacy
2017, Vol. 52(8) 522-526
© The Author(s) 2017
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https://doi.org/10.1177/0018578717720508
DOI: 10.1177/0018578717720508
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Adam C. Sieg1 and Jennifer A. Gass2

Abstract
Bivalirudin is a parenteral anticoagulant that elicits its effect through inhibition of both free and clot bound-thrombin.
Inhibition of thrombin serves as a unique mechanism for anticoagulation when compared to heparin as thrombin serves as
the final common pathway for the intrinsic and extrinsic coagulation cascades. Due to unclear benefit over heparin, concerns
regarding reversibility, and most importantly cost its use as a parenteral anticoagulant varies by institution. A recent drug
expenditure review within our institution noted a significant increase in the contribution bivalirudin had on the overall drug
budget. In an effort to establish the rationale for the cost increase, a medication use evaluation was performed. While it was
discovered that 625 out of 1364 days of bivalirudin therapy were potentially avoidable, an equally important discovery was
the amount of waste that was associated with bivalirudin therapy. Calculating daily requirements for bivalirudin indicated
that 60% of patients required less than 100 mg per day. Within this article, we describe a cost-savings initiative to reduce
bivalirudin waste and the resulting cost-avoidance following implementation.
Keywords
anticoagulation, drug information, pharmacoeconomics, pharmacy administration, bivalirudin
The use of parenteral anticoagulants is common within the
hospital setting for prophylaxis and treatment of various conditions. While heparin is the most frequently utilized intravenous anticoagulant, the use of bivalirudin has emerged as a
viable option in certain clinical scenarios.1 Specifically, it is
approved for use in percutaneous transluminal coronary
angioplasty, and percutaneous coronary intervention with the
use of glycoprotein IIb/IIIa inhibitors.2 In addition, it is frequently utilized, with significant supporting data, in patients
with heparin-induced thrombocytopenia (HIT).3-6 Bivalirudin
is a direct thrombin inhibitor and differs mechanistically from
heparin as it inhibits the final common pathway in the intrinsic and extrinsic coagulation cascades. In addition, it has the
unique ability to bind both free and clot-bound thrombin.
The routine utilization of bivalirudin at many hospitals has
been limited, to this point, by the lack of a reversal agent, no
proven benefit over heparin, and potentially, the cost over
alternative agents. With bivalirudin being utilized and evaluated in more clinical scenarios, formulary issues may arise
due to the cost discrepancy between bivalirudin and heparin.
Recently, a review of drug expenditures showed a large
increase in the contribution bivalirudin had on the overall
drug budget at our institution. It was noted that over a 2-year
period, utilization had increased 4-fold with a 15-fold
increase in the in-patient utilization (Figure 1). The following describes a subsequent cost savings initiative to optimize
utilization of bivalirudin while reducing waste.

Figure 1. In-patient bivalirudin utilization: Bivalirudin annual
purchasing.

University of Kentucky, Lexington, USA
Memorial Hermann-Texas Medical Center, Houston, USA

Corresponding Author:
Adam C. Sieg, Clinical Pharmacist Specialist, Heart Transplant/MCS,
University of Kentucky 800 Rose Street, Room H-110 Lexington, KY
40536-0293, USA.
Email: adam.sieg@uky.edu

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