October 16, 2009 Ms. Barbara Newman Farm Bureau Insurance C/o Adjusters’ Choice 5100 Greenwood Circle Minneapolis, MN 55331 RE:
Dear Ms. Newman; I recently had the pleasure of conducting a pharmacist drug review of Ms. Joyce Kaye on October 16, 2009. This review was conducted on behalf of your client, Sister of Grace Long Term Care, and a workers compensation injury sustained by their employee Ms. Kaye on February January 19, 2009. This retrospective Pharmacist Drug Review (PDRx) has been prepared solely for the benefit of Farm Bureau Insurance and in conjunction with the examination of the following records:
• Corvel Corp. QRC Progress Reports (12 pages: 8/9/09-9/9/09, 7/8/09-8/5/09,
• Lac Qui Parle Clinic of Madison Physician’s Progress notes (29 pages: 1/14/09-
• Prescription Tax insurance Summary, Liebe Drug, MN (6/30/09-8/4/09)
• Working Rx Prescription Invoices (35 pages: 1/27/09 – 7/14/09)
• Physician Communications (Dr. Larry Lockwood, 7/1/09; Dr. Larry Lockwood,
• Radiology Reports (CDI Waite Park, 5/22/09, 3/13/09, 2/28/09, 2/10/09; St.
Cloud Hospital, 4/17/09; Brown Clinic 3/27/09; West Central Radiological
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 2 of 11
Associates, 3/20/09, 3/3/09, 1/21/09; Chippewa County –Montevideo Hospital 3/3/09)
• Madison Hospital Physical Therapy Evaluation/Progress Notes (1/15/09-8/20/09)
In issuing this report, we have based our analysis on the facts in the records provided and professional reference sources identified in Appendix A. We have not undertaken an independent investigation of such facts. Any changes in the facts may vary the analysis contained in this report.
The opinions expressed herein are as the date hereof, and we assume no obligation to update or supplement such opinions to reflect any new facts or circumstances. The information contained in this report is for informational purposes only and is not intended to take the place of a physician’s Independent Medical Evaluation or to deny medical care to the claimant. ADPR does not in ay way purport to impair, limit, dictate, or direct a physician’s professional judgment in the care and treatment of the claimant through this report. Any changes in the claimant’s medication regiment are to be made strictly at the discretion and professional judgment of the prescribing physician. This report contains healthcare information that is privileged, confidential, and proprietary in nature, and as such, is exempt from disclosure under applicable federal and state laws and regulations. Claimant Name: Joyce G. Kaye
Work Comp Injury Diagnosis: Right lumbar strain secondary to repositioning patients Date of Injury: 1/19/09 Other (non-workers’ comp related) Conditions:
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 3 of 11 Prescription History:
Drug: Oxycodone/APAP and generics there of Strength Quantity Prescriber Strength Quantity Prescriber Strength Quantity Prescriber Strength Quantity Prescriber IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 4 of 11 Drug: Prevacid
Strength Quantity Prescriber Strength Quantity Prescriber
Drug: Senokot /Senna S (contains docusate sodium 100mg)
Strength Quantity Prescriber Strength Quantity Prescriber Strength Quantity Prescriber Strength Quantity Prescriber IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 5 of 11 Other Drugs
Prochlorperazine Strength Quantity Prescriber
CLINICAL ASSESSMENT 1. Are there medications in the claimant’s current drug regiment that may not be related to his or her workers’ compensation injury?
Yes. Drug therapy problem #1: The use of Ditropan XL (oxybutynin) does not appear to be related to this claimant’s occupational injury of lumbar strain or to the associated therapy. Ditropan XL is used to treat urinary incontinence. The progress notes indicate that this claimant has a history of overactive bladder and has been taking this medication to treat this condition.
Recommendation: Discontinue coverage of this medication unless the prescribing physician can provide justification for its use relative to this injury. Desired clinical outcome: To assure that coverage is provided for appropriate, cost-effective drug therapy for only those conditions relating to the occupational injury.
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 6 of 11
Drug therapy problem #2: The use of Prevacid does not appear to be related to this claimant’s occupational injury of lumbar strain or to the associated therapy. Prevacid is used to treat a variety of gastrointestinal problems including peptic ulcer, gastritis, and gastroesophageal reflux disease (GERD). The progress notes indicate that this patient has a history of GERD for which she has been prescribed this medication. Furthermore, the treatment of uncomplicated GERD, Prevacid therapy is recommended for up to 8 weeks (1), and prescriptions for this drug have been billed since at least 2/18/09. For this reason, the use of Prevacid should be re-evaluated.
Recommendation: Discontinue coverage of this medication unless the prescribing physician can provide justification of its use relative to the injury. If (contrary to the diagnosis for GERD mentioned in the progress notes) Prevacid is actually being used to protect the stomach from the other medications used to treat the claimant’s work related injury, there are more cost effective and equally efficacious medications that could be used for that purpose, including antacids, ranitidine, and famotidine. Desired clinical outcome: To assure that coverage is provided for appropriate, cost-effective drug therapy for only those conditions relating to the occupational injury.
2. Are there any unmet opportunities for generic substitution in the claimant’s drug regimen? 3. Have any potentially significant drug-drug interactions been identified in this claimant’s therapy?
Drug therapy problem #3: Potential drug-drug interaction between Bextra (valdecoxib) and Coumadin (warfarin). Severity-High. Bextra (a nonsteroidal anti-inflammatory drug or NSAID) may potentiate the anticoagulant effect of warfarin. Various NSAIDS may exhibit pharmacokinetic and/or pharmacodynamic interactions with warfarin, primarily by affecting protein binding of warfarin. In addition, NSAIDS may be problematic if administered to a patient receiving warfarin due to their effects on platelet aggregation and potential for causing gastritis. NSAIDS should be used cautiously in patients receiving warfarin.
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 7 of 11
Recommendation: Re-evaluate continuing need for Bextra. Also, continued close monitoring of PT/INR (a measurement of clotting times) during combined therapy is called for. Desired clinical outcome: To provide appropriate, cost-effective therapy for the patient’s pain management while avoiding potentially serious interactions with other drugs in the regimen.
4. Do any duplications of therapy exist in this claimant’s medication regimen?
5. Do the current narcotic doses in this claimant’s regimen appear to be appropriate? No. Drug therapy problem #4: Duragesic (fentanyl transdermal patch) dosing frequency is not in accordance with manufacturer’s FDA-approved dosing guidelines. Duragesic is indicated in the management of chronic pain in patients who require continuous opioid analgesia for pain that cannot be manages with lesser means such as acetaminophen/opioid combinations, non-steroidal analgesics, or PRN dosing with short acting opioid. The majority of patients are adequately maintained with Duragesic administered every 72 hours (3). On several occasions, Duragesic was dispensed in quantities of 5 for a 10 days supply, and once as a 5 day supply. This would suggest that the medication was prescribed to be used every 48 hours, or every 24 hours, rather than the every 72 hours as recommended by the manufacturer. It should be pointed out that the most recent Duragesic prescription record provided indicates that a quantity of 5 was appropriately dispensed for a 15 day supply, so this may not be an ongoing issue.
Recommendation: Monitor quantity and days’ supply of new prescriptions for Duragesic. If necessary consult with physician regarding dosing guidelines. Desired clinical outcome: To assure that the claimant’s analgesic drug therapy is dosed appropriately and cost-effectively while adequately maintaining satisfactory control of claimant’s pain.
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 8 of 11
Drug therapy problem #5: Vicodin (Hydrocodone/APAP 5/500) dosing in excess of approved guidelines. The pharmacy billing records provided show that on more than one occasion, this medication was dispensed such that the claimant could be taking as many as 15 tablets, and on one occasion, 25 tablets, per day. This would equate to 7.5 to 12.5 grams of acetaminophen per day, far in excess of the recommended maximum of 4 grams per day, or in this case 8 tablets per day (4).
Recommendation: Monitor quantity and days’ supply for new prescriptions of Vicodin. If necessary, consult with physician regarding dosing guidelines. Desired clinical outcome: To provide appropriate, effective pain relief while avoiding potentially serious side effects that could result from excess dosing of Vicodin.
6. Does the current dosing of non-narcotic drugs appear to be appropriate?
7. Is the claimant demonstrating appropriate pharmacy utilization? No. Drug therapy problem #6: Claimant has had prescriptions filled for two similar medications at two different pharmacies within a 24 hour period. The prescription records provided show that Prevacid in the same strength, quantity, and days’ supply was dispensed on 2 subsequent days (7/2/09 and 7/3/09) at two different pharmacies. Also, Senna and Senna S, both laxatives, one with a stool softener, were dispensed on the same two dates at the same two pharmacies.
Recommendation: Closely monitor pharmacy utilization. Desired clinical outcome: To avoid double charges for the same medications as well as to prevent duplications of therapy and the potential for medications to be taken inappropriately.
8. Is the claimant demonstrating appropriate physician utilization? IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 9 of 11 9. Are there any other drug therapy problems that need to be addressed?
Drug therapy problem #7: Concurrent use of Bextra (valdecoxib) and Prevacid (lansoprazole). Prevacid is used for the treatment of peptic ulcer, GERD, and is often used to prevent NSAID induced gastritis. There is no clear rationale for its use with Bextra, a COX-2 inhibitor NSAID, which has a low incidence of causing gastrointestinal irritation.
Recommendation: Re-evaluate need for both these medications (see also Drug Therapy Problems #2 and #3 under questions 1 and 3), Desired clinical outcome: To provide rational, appropriate, and cost-effective therapy for this claimant.
FINANCIAL ANALYSIS Drug Therapy Problem #1: Discontinue coverage for Ditropan XL unless the prescribing physician can provide justification for its use relative to the injury.
Current Therapy NDC#
Drug Problem #2: Discontinue coverage of Prevacid unless the prescribing physician can provide justification for its use relative to the injury.
Current Therapy NDC# IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 10 of 11 Drug Therapy Problem #6: Monitor closes to prevent duplicate filling of like meds. Discontinue coverage for duplicate scripts for similar meds. Providing the Claimant with a retail pharmacy card will help to eliminate duplicate fills.
Current Therapy NDC#
Drug Therapy Problem #7: Either discontinue coverage of Prevacid due to its use unrelated to the injury or use Prilosec OTC 20mg in conjunction with Ibuprofen.
Current Therapy NDC# IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
October 16, 2009 Ms. Joyce Kaye Page 11 of 11 Recommended Alternative #2 NDC #
1. Accessed on 10/8/09 from Clinical Pharmacology, Gold Standard Multimedia
Inc., Prevacid Drug Information Monographs URL http://cp.gsm.com
2. Accessed on 10/8/09 from Clinical Pharmacology, Gold Standard Multimedia
Inc. Drug Interactions Report, URL: http://cpgsm.com
3. Excerpt, Product information: Duragesic, fentanyl transdermal system, Jannsen
Pharmaceutical Products, LP Titusville NJ 08560
4. Accessed on 10/8/09 from Micromedex Healthcare Series, Thomson Micromedex
Inc., Acetaminophen Drug Summary Information URL http://micromedex.com
IMEs • File Reviews • Pharmacy Reviews
5100 Greenwood Circle • Minneapolis, MN 55331-0891
952.474.6676 • Fax: 952.470.6686 • [email protected]
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