Clinical twisters: Post-MI medicine too costly

August 22, 2005

A 75-year-old woman, G.D., is in the ER for chest pain that has now been diagnosed as heartburn. She is given lansoprazole (Prevacid, TAP) samples. Five months ago she had an acute myocardial infarction (MI) with stent placement. She was discharged on a daily regimen of clopidogrel (Plavix, Sanofi-Aventis) 75 mg, aspirin 80 mg, ezetimibe (Zetia, Merck/Schering-Plough) 10 mg, atorvastatin (Lipitor, Pfizer) 20 mg, sublingual nitroglycerin, metoprolol timed-release 50 mg, and valsartan (Diovan, Novartis) 160 mg.

A 75-year-old woman, G.D., is in the ER for chest pain that has now been diagnosed as heartburn. She is given lansoprazole (Prevacid, TAP) samples. Five months ago she had an acute myocardial infarction (MI) with stent placement. She was discharged on a daily regimen of clopidogrel (Plavix, Sanofi-Aventis) 75 mg, aspirin 80 mg, ezetimibe (Zetia, Merck/Schering-Plough) 10 mg, atorvastatin (Lipitor, Pfizer) 20 mg, sublingual nitroglycerin, metoprolol timed-release 50 mg, and valsartan (Diovan, Novartis) 160 mg. She also has chronic obstructive pulmonary disorder (COPD) requiring tiotropium (Spiriva, Boehringer Ingelheim) daily and fluticasone 440 mcg twice a day. G.D. admits she takes her medication sporadically because she cannot afford it. The intern requests your assistance. What do you suggest?

I want to focus on her limited resources, trying to find cost-saving alternatives without sacrificing her overall health. In this patient, I question prescribing lansoprazole when less expensive nonprescription alternatives (antacids, famotidine, ranitidine, omeprazole) exist.

Next, turning to her recent MI with stent placement, I probably wouldn't alter clopidogrel and aspirin therapy, as alternatives (warfarin) would require increased monitoring. A lipid panel is needed to evaluate ezetimibe and atorvastatin. Results would dictate suggestions such as stopping one medication and/or adding an alternative and monitoring. Valsartan could be replaced with a generic ACE inhibitor with similar results. Metoprolol should be monitored closely for complications. She may also benefit from adding a diuretic.

Steven J. Bultje, Pharm.D.Senior Care PharmacistAdvanced Pharmacy Consulting ServicesSioux Falls, S.D.

My greatest concern for G.D. is the barriers in taking her medications as prescribed to treat chronic conditions. Medication-related problems are a significant cause of morbidity and mortality-especially in the elderly. If she is admitting to sporadically not taking her medications due to cost, it is likely this occurs often. Cost can be managed through drug selection, help with finding assistance programs, and/or education of the real "cost" associated with noncompliance when no acceptable alternative is available. Changes that could reduce cost include:

By making these changes, G.D. would save about $300/month in drug cost. However, "cost" is more than simply drug cost, and clinical factors must be considered in optimizing G.D.'s drug regimen.

There are many programs available to help seniors-and, of course, Medicare Part D will be available Jan. 1, 2006. I'd direct her to the state groups to see what assistance she qualifies for.

Lisa Hettich, Pharm.D., CGPGrowing Well Inc.Cloverdale, Ind.