Hospital Pharmacy - September 2017 - 523
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Sieg and Gass
Table 1. Baseline Demographics.
Age, y
Gender (male)
History of significant bleed/bleeding
disorder
History of clotting/clotting disorder
Indication for anticoagulation
MCS
Long-term devices (HeartMate II,
HeartWare HVAD)
Temporary devices (intra-aortic
balloon pump, ECMO, Tandem,
CentriMag)
Syncardia
DVT/PE
Atrial fibrillation
Valve
Other thrombus (PA, atrial)
Acute coronary syndrome
Other
Indication for bivalirudin
HIT (suspected or confirmed)
Suspected pump thrombosis
Other
4T score
0-3
4-5
6-8
Days of heparin therapy prior to
starting bivalirudin
Days of bivalirudin therapy
Restarted on heparin after HIT negative
62 (22-92)
44 (78%)
7 (12%)
a
14 (25%)
30 (54%)
14 (47%)b
13 (43%)b
3 (10%)b
8 (14%)
5 (9%)
4 (7%)
4 (7%)
2 (4%)
3 (5%)
47 (84%)
5 (9%)
4 (7%)
37 (66%)
14 (25%)
5 (9%)
8 days (1-26)a
24.4 days (1-151+)a
6 (18%)c
Note. Values reported in number (percent) unless otherwise indicated.
MCS = mechanical circulatory support; ECMO = extracorporeal
membrane oxygenation; DVT = deep vein thrombosis; PE =
pulmonary embolism; PA = pulmonary artery; HIT = heparin-induced
thrombocytopenia.
a
Average with minimum-maximum range.
b
Percentages based on total of 30 MCS devices.
c
33 total patients were HIT negative.
Bivalirudin Utilization and Identifying
Waste
We retrospectively reviewed bivalirudin use at our institution in hospitalized patients who received bivalirudin
therapy for more than 24 hours over a 6-month period. A
total of 56 patients meet the inclusion criteria for the analysis which equated to 1364 days of bivalirudin therapy
(Table 1). Patients on mechanical circulatory support
comprised the majority of bivalirudin use (54%), with the
predominate indication being suspected or confirmed
HIT (84%). The average duration of heparin therapy prior
to starting bivalirudin was 8 days (range: 1-26 days),
with bivalirudin being utilized for a median of 9.5 days
and mode of 6 days (range: 1-151+). While our institution
does invoke a medication formulary, bivalirudin can be
utilized without meeting specific criteria for use or
preapproval.
Patients who were put on bivalirudin for suspected HIT
were further evaluated for appropriateness by assessing
heparin enzyme-linked immunosorbent assays and serotonin release assay testing. The results demonstrated that
46% (625 out of 1364 days) of bivalirudin utilization
occurred after either a negative enzyme-linked immunosorbent assays or negative serotonin release assay test (Figure
2). While the authors identified this as a potential area for
stewardship, assessment of patients receiving appropriate
bivalirudin therapy suggested waste was potentially occurring. Reviews of individual patient requirements per day
indicate that only 13% of patients were requiring 250 mg or
more per day of bivalirudin to achieve and maintain therapeutic anticoagulation (Figure 3). Furthermore, our data
indicated that 60% of patients were requiring less than 100
mg of bivalirudin per day.
Minimizing Waste
Within the package insert, bivalirudin is recommended to
be diluted to a concentration of 5 mg/mL (250 mg in 50-mL
solution) or 0.5 mg/mL (250 mg in 500-mL solution).
Historically, our institution has prepared bivalirudin by
mixing a vial (250 mg) with a 250-mg bag of solution
(dextrose 5% or normal saline) to achieve a 1 mg/mL concentration.2 We calculated drug waste per patient per day
to evaluate the overall cost of the waste. Based on this simplistic approach, utilizing a 250-mg bag for a patient who
is only requiring 100 mg per day represents potential waste
of 60% of the vial cost ($884.75 per vial based on 3Q14
Payment Allowance Limits for Medicare Part B) per day of
drug.7 With 60% of all patients during the analysis requiring <100 mg per day, for the entire study duration (1364
days) there is a theoretical cost savings of ~$434 000 over
the 6-month study period.
Change in Preparation
Consideration into alternative bag sizes was based on ease
of preparation, feasibility, and overall cost savings. A bag
size of 100 mL was chosen for several reasons. First, in an
effort to maintain the same drug concentration, this was the
only realistic option. A 50-mL bag size was considered as
well; however, it was felt that continuous infusion bag
changes would become too cumbersome for nurses, especially for patients who were receiving >200 mg per day.
Second, the average number of patients receiving bivalirudin per day during the analysis was 4.8. There were 150
days during the study analysis when 5 or more patients were
receiving bivalirudin. Based on these points, we were able
to prepare five 100-mL bags with the use of 2 vials.
Table of Contents for the Digital Edition of Hospital Pharmacy - September 2017
Pharmacy Transitions of Care and Culture
Bivalirudin Medication Use Evaluation and Cost Savings Initiative
Navigating the New Antimicrobial Stewardship Regulations
Safinamide
Biosimilar Substitution Laws
Evaluation of Corticosteroid Dose in Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Hazardous Drug Contamination of Drug Preparation Devices and Staff: A Contamination Study Simulating the Use of Chemotherapy Drugs in a Clinical Setting
A Case of Metronidazole Injection Infiltration Without Sequelae
Doubling Pharmacist Coverage in the Intensive Care Unit: Impact on the Pharmacists’ Clinical Activities and Team Members’ Satisfaction
Extended Stability of Epinephrine Hydrochloride Injection in Polyvinyl Chloride Bags Stored in Amber Ultraviolet Light–Blocking Bags
Formation of a Citywide Pharmacy Residents’ Collaborative Committee
Hospital Pharmacy - September 2017 - 513
Hospital Pharmacy - September 2017 - 514
Hospital Pharmacy - September 2017 - 515
Hospital Pharmacy - September 2017 - 516
Hospital Pharmacy - September 2017 - 517
Hospital Pharmacy - September 2017 - 518
Hospital Pharmacy - September 2017 - 519
Hospital Pharmacy - September 2017 - Pharmacy Transitions of Care and Culture
Hospital Pharmacy - September 2017 - 521
Hospital Pharmacy - September 2017 - Bivalirudin Medication Use Evaluation and Cost Savings Initiative
Hospital Pharmacy - September 2017 - 523
Hospital Pharmacy - September 2017 - 524
Hospital Pharmacy - September 2017 - 525
Hospital Pharmacy - September 2017 - 526
Hospital Pharmacy - September 2017 - Navigating the New Antimicrobial Stewardship Regulations
Hospital Pharmacy - September 2017 - 528
Hospital Pharmacy - September 2017 - 529
Hospital Pharmacy - September 2017 - 530
Hospital Pharmacy - September 2017 - 531
Hospital Pharmacy - September 2017 - Safinamide
Hospital Pharmacy - September 2017 - 533
Hospital Pharmacy - September 2017 - 534
Hospital Pharmacy - September 2017 - 535
Hospital Pharmacy - September 2017 - 536
Hospital Pharmacy - September 2017 - 537
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Hospital Pharmacy - September 2017 - 539
Hospital Pharmacy - September 2017 - 540
Hospital Pharmacy - September 2017 - 541
Hospital Pharmacy - September 2017 - 542
Hospital Pharmacy - September 2017 - 543
Hospital Pharmacy - September 2017 - Biosimilar Substitution Laws
Hospital Pharmacy - September 2017 - 545
Hospital Pharmacy - September 2017 - Evaluation of Corticosteroid Dose in Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Hospital Pharmacy - September 2017 - 547
Hospital Pharmacy - September 2017 - 548
Hospital Pharmacy - September 2017 - 549
Hospital Pharmacy - September 2017 - 550
Hospital Pharmacy - September 2017 - Hazardous Drug Contamination of Drug Preparation Devices and Staff: A Contamination Study Simulating the Use of Chemotherapy Drugs in a Clinical Setting
Hospital Pharmacy - September 2017 - 552
Hospital Pharmacy - September 2017 - 553
Hospital Pharmacy - September 2017 - 554
Hospital Pharmacy - September 2017 - 555
Hospital Pharmacy - September 2017 - 556
Hospital Pharmacy - September 2017 - 557
Hospital Pharmacy - September 2017 - 558
Hospital Pharmacy - September 2017 - A Case of Metronidazole Injection Infiltration Without Sequelae
Hospital Pharmacy - September 2017 - 560
Hospital Pharmacy - September 2017 - 561
Hospital Pharmacy - September 2017 - 562
Hospital Pharmacy - September 2017 - 563
Hospital Pharmacy - September 2017 - Doubling Pharmacist Coverage in the Intensive Care Unit: Impact on the Pharmacists’ Clinical Activities and Team Members’ Satisfaction
Hospital Pharmacy - September 2017 - 565
Hospital Pharmacy - September 2017 - 566
Hospital Pharmacy - September 2017 - 567
Hospital Pharmacy - September 2017 - 568
Hospital Pharmacy - September 2017 - 569
Hospital Pharmacy - September 2017 - Extended Stability of Epinephrine Hydrochloride Injection in Polyvinyl Chloride Bags Stored in Amber Ultraviolet Light–Blocking Bags
Hospital Pharmacy - September 2017 - 571
Hospital Pharmacy - September 2017 - 572
Hospital Pharmacy - September 2017 - 573
Hospital Pharmacy - September 2017 - Formation of a Citywide Pharmacy Residents’ Collaborative Committee
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