Q&A: Antiretroviral Formulary Protocol Cuts Costs, Eases Workflow

At Howard University Hospital, HIV regimens used to be the medications staff pharmacists didn’t want to touch. Under a standardized antiretroviral therapy (ART) formulary protocol, however, any pharmacist can convert a patient’s home regimen and dose it for better outcomes as well as professional empowerment.

“The administrative workflow efficiency really took [away] a lot of this ‘[complex] patients living with HIV, scary medication, don’t want to touch this, only the real specialists should touch this’ [mindset],” Nicholas Rebold, PharmD, MPH, BCIDP, AAHIVP, assistant professor of infectious diseases in the Department of Clinical & Administrative Pharmacy Sciences at the Howard University College of Pharmacy, told Drug Topics®. “Any pharmacist can now make an appropriate transition for these patients on their home regimen.”

In part 2 of our discussion with Rebold, he dives deeper into his team’s protocol, moving aside from the value of the protocol itself, which he highlighted in part 1, and exploring more regarding how the protocol can transform care and empower the overall role of pharmacists on the care team.

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Drug Topics: How do pharmacist-led education and face-to-face consultations influence patient knowledge and satisfaction during antiretroviral switches?

Nicholas Rebold: One of the things we were a little worried about when starting this protocol is, yes, in practical terms, we are taking [a patient] who’s living with HIV, their single-tablet regimen, their outpatient medication, and changing it to an equivalent amount of their antiretroviral medication inpatient, which [comes] in different manufacturer pills [and] may come as 1, 2, or even 3 pills. With that, the early adoption of this protocol had a lot of education going up to the patients to make sure they were [fine] with this protocol switch. The primary care team was also informed that this is how the switch, ‘translates from home,’ in terms of their home regimen, to the inpatient [setting] and their inpatient regimen. And we had some graphics to make sure it could translate well for a lot of the residents and interns and pharmacists on the team.

And what we found is that the patients were actually very well receptive to this change. We, in some respects, used a lot of the terminology as similar to other therapeutic interchange drugs. For certain patients on certain statin medications outpatient, inpatient we only have a certain selection that we use. So, we convert your outpatient statin to this statin at a different dose to make sure it’s equivalent and that we have [it] available if you don’t have your home regimen. That really led a lot of our patients to honestly be pretty receptive to the switch. We only had, I would say, [fewer than 5 of] the 60 [patients] from this protocol actually not want to do the switch at all and refuse any other HIV medications. That has actually gone even down further since we’ve had this protocol on for a long period of time.

And I think now, in terms of those face-to-face consultations for a new hospital or a newer service seeking to implement something like this to really make sure patients with HIV have accessible options, especially in complex regimens, there’s a lot of cost pressure on inpatient pharmacies, especially around HIV therapy. With these single-tablet regimens, that can be much, much more expensive than some of their generic alternatives. This is a great way to actually make sure to free up some money for a lot of these patients to actually get appropriate and equivalent care, and to use that money for more important things, like meds-to-beds, to make sure [their] readmission rates go down even further, and making sure they get appropriate follow-up on discharge.

Drug Topics: How does standardizing antiretroviral formulary protocols impact overall medication costs and administrative workflow efficiency?

Nicholas Rebold: I think for standardizing the antiretroviral formulary protocol, it really took a significant chunk of that medication cost for the inpatient pharmacy down significantly, at least at our hospital. I’ll give general ranges, but we’re seeing [Biktarvy], the most common antiretroviral therapy for HIV, at about $90 to $100 per pill. And so inpatient, that becomes a significant, high drug spend, which really impacts the inpatient pharmacy’s ability for pharmacist hours, tech hours, [and] spending on other drugs that might have some significant benefit.

[In terms of] access, at our hospital, [we were] actually debating whether we even should have Biktarvy on formulary. We would have waves of different patients with HIV, and then the stock would go down. Then we wouldn’t have it, then we’d have to borrow it.

[We made] this protocol formulary instead, [with] components that would give the equivalent coverage for HIV: dolutegravir [(Tivicay)], which is still relatively expensive, but only about $60 to $70 a pill for us; and then generic Truvada, which is tenofovir disoproxil fumarate and emtricitabine, [which] is only $2 a pill. So really, it took a drug costing about $90 to $100 to about $65 to $75. That’s about a 25% reduction and probably the biggest transition we make for a lot of our patients with HIV.

But even further, separating those generic medications to those individual meds from those single-tablet regimens made a lot of the changes and that workflow for pharmacists a lot easier. [They could] adjust the frequency and adjust the dose for those patients who often do come in with significant renal dysfunction, either from sepsis or from other things going on in an inpatient context.

The administrative workflow efficiency really took [away] a lot of this ‘[complex] patients living with HIV, scary medication, don’t want to touch this, only the real specialists should touch this’ [mindset]. Any pharmacist can now make an appropriate transition for these patients on their home regimen, if they don’t have their home regimen with them, and can appropriately dose it according to their renal function [and] liver function and still appropriately cover that patient, while feeling empowered because of this protocolized initiative that looks very similar to statin therapeutic interchanges. It’s really treating these antiretroviral treatment drugs just like we do every other disease state, every other drug, so these patients living with HIV can really get the same level of care that we do for a lot of these other disease states.

READ MORE: HIV Resource Center