Xopenex, Formulary or Non-Formulary

[Sparda29]

It's non-formulary at my hospital but for some reason we still stock it. I was fighting with a doctor and the nurses about this for like 4 hours. They send an order for Xopenex, I auto-interchange it to Albuterol. I did this like 4-5 times tonight. Finally when I go on my break, the nurse decides to come in and yell at the other pharmacist who timidly gives them the Xopenex.

Nurse apparently gave the pharmacist some sob story about the patient being an 8 year old child, albuterol not working, and HR is 178.

I don't think that qualifies to get Xopenex. If Albuterol didn't work, Xopenex isn't gonna work either.

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[owlegrad]

We stock it at my hospital for some reason but I don't recall ever seeing it dispensed.

Any reason you didn't communicate with the prescriber after say the third substitution?

 

[Sparda29]

We stock it at my hospital for some reason but I don't recall ever seeing it dispensed.

Any reason you didn't communicate with the prescriber after say the third substitution?

Too busy to be calling for interchanges, the rule is that we automatically do it without talking to the prescriber. It's just me, another pharmacist, and a tech. I figured that they were just being dumb in ordering 1X dose every 4 hours rather than putting in a standing order for q4h prn.

 

[ethyl]

Too busy to be calling for interchanges, the rule is that we automatically do it without talking to the prescriber. It's just me, another pharmacist, and a tech. I figured that they were just being dumb in ordering 1X dose every 4 hours rather than putting in a standing order for q4h prn.

There's exceptions in some formulary subs for pediatrics in critical care units or ER's. It's mostly to accommodate various doubtful physicians. It seems for every study (funded by Sunovion) that showed an increase HR or other side effect from albuterol vs. xopenex, there will always be another independently funded study showing there is no difference.

 

[ethyl]

You've got to pick your battles. I wouldn't make a habit out of saying "no" to physicians. Offer them an alternative, if they deny the alternative, give them what they want and document everything.
If it was something incredibly expensive, non-formulary AND something you don't stock, absolutely you should say no and offer the formulary alternative. Most hospitals with closed formularies have protocols that encourage you to say 'no' if they deny your formulary alternative. A manager will support you in such a case... but a complaint over something as little as Xopenex is not worth it.

 

[KARM12]

Learn to pick your battles...if you go around saying no and being a jerk to other HCP's, that will get you in trouble pretty fast...not worth it.

 

[Sparda29]

You know what happened after the other pharmacist gave them one dose of the Xopenex. They ****ing came back for more. And that's how this **** starts. What's next, Nexium and Diovan?

What I figure is gonna end up happening is that the director simply won't order any more of the Xopenex, let our current supply run out, and then all we tell them is, nope, not in stock and we won't be ordering any either.

 

[rxlea]

You're already making waves. I give you less than a year.

 

[confettiflyer]

learn to pick your battles...if you go around saying no and being a jerk to other hcp's, that will get you in trouble pretty fast...not worth it.

+1

 

[Sparda29]

You're already making waves. I give you less than a year.

DOP has got my back. I spoke to him about the issue already.

 

[bacillus1]

Do you maybe have criteria for use where xopenex is not auto-subbed?

 

[awval999]

It's non-formulary at our hospital with two exceptions: PEDS and/or ER with a documented HR > 100. And yes, if my partner was being an ass about it like you were I would have sent up the Xopenex.

Look-- I'm not going to nickle and dime a PEDS ER patient over Xopenex. It's just not good patient care and it's just not good for interpersonal HCP dynamics.

First, do no harm.

 

[Sparda29]

Do you maybe have criteria for use where xopenex is not auto-subbed?

Nope, it absolutely should not be dispensed. We used to dispense it, but the policy was changed, and now all we have left is the remnants of the stock.

Problem at the hospital is, the ER nurses think that just because they work in the ER, they can come running over to pharmacy at any time and get something without waiting for it. I had someone come to the window and push a nurse who was from the hospice division of the hospital out of the way just to say, "I need magnesium 2 gm stat." No order, no paperwork, nothing.

 

[Praziquantel86]

I was under the impression that the cost difference between Xopenex and albuterol is minimal at this point...it's just not a fight worth getting into anymore. Learn to lose the small battles so you can win the big ones.

As a side note: your ER doesn't have mag in it?

 

[Sparda29]

I was under the impression that the cost difference between Xopenex and albuterol is minimal at this point...it's just not a fight worth getting into anymore. Learn to lose the small battles so you can win the big ones.

As a side note: your ER doesn't have mag in it?

Apparently not. Might be in the Pyxis but apparently a lot of nurses don't like working with it.

 

[gnuel]

In the actual Xopenex package insert itself, it shows that Xopenex resulted in greater increase in HR than equipotent dose of albuterol and the adverse event incidence is the same...I don't understand why prescribers want to use it. Good drug reps I guess.

 

[WVUPharm2007]

It just went generic. Once the price falls a tad, this argument will go straight to the "who cares" department.

 

[Its Z]

Xopenex has been generic for a while but the pricing hasn't dropped.... it still cost 30 times more than generic albuterol ....


But since more strengths of xopenex has gone generic, maybe pricing is down.

However, xopenex vs. albuterol is still a valuable fight.

It proves a point of marketing based medicine instead of evidence based.

xopenex is nothing more than r-albuterol, the active component of racemic albuterol mixture.
So equivalent dose of xopenex and albuterol are therapeutically equivalent.

The s-albuterol is beta inert. It's that simple.

However in peds who may metabolize albuterol slowly, double the amount of albuterol in the racemic mixture may result in a delayed elimination thereby potentially causing more cardiovascular effects, in theory.

Package insert will show that the rate of tachycardia is 2.7...for both xopenex and albuterol...

In the end.... same **** different price.

It was a battle worth fighting. And if there's still a big discrepancy in pricing, it's a fight worth fighting. The total spend of xopenex can range widely...and penny saved is penny earned.
And just because you didn't fight this battle doesn't mean they'll give you a freebie on the next fight.

Don't walk away from a fight. Fight it with a smile and make it feel like it was their idea and they won. That's what makes you successful.

Not staying in your comfort zone and use the "choose your battle" card.

This is one time I will side with Sparda. I like to see more of this kind of stuff from him.

 

[Its Z]

F**k that BS. Brand xopenex is $5.89 and generic is $3 per dose. Albuterol 10 cents.

Go fight the battle! NOW!

 

[cycloketocaine]

F**k that BS. Brand xopenex is $5.89 and generic is $3 per dose. Albuterol 10 cents.

Go fight the battle! NOW!

Lol. Sadly we have the most open formulary I have ever seen. Want Xopenex? Sure! Want any anti microbial under the sun? Why not?

There has been talk of clamping down the formulary...but no one will touch it because of possible prescriber backlash.

Hell, we still use brand Orapred liquid because "it tastes better" compared to prednisolone. I can't remember the cost difference off-hand, but it is ungodly.

 

[rxlea]

Lol. Sadly we have the most open formulary I have ever seen. Want Xopenex? Sure! Want any anti microbial under the sun? Why not?

There has been talk of clamping down the formulary...but no one will touch it because of possible prescriber backlash.

Hell, we still use brand Orapred liquid because "it tastes better" compared to prednisolone. I can't remember the cost difference off-hand, but it is ungodly.

Don't get me started. I tried to fight the xopenex battle with someone. I'm just a lowly ******ed student that shouldn't be listened to. Go figure.

 

[ucrx]

I would have fought this battle. At my PGY1 hospital (I haven't really seen xopenex ordered since) we restricted xopenex to the NICU. We had a childrens' hospital next door so those were our only pedi patients. I also would have called the physician to let them know about our autosub and formulary restrictions when I saw the second order. If they really insisted, I'd let them try 1 dose and make them monitor HR. If it stayed elevated- no more xopenex.

 

[WVUPharm2007]

Interestingly, at my poorly run former hospital, Xopenex just wasn't available. If someone ordered it, we told them we couldn't get it. Racemic albuterol or nothing. Always seemed to work for us.

 

[group_theory]

It proves a point of marketing based medicine instead of evidence based.

xopenex is nothing more than r-albuterol, the active component of racemic albuterol mixture.
So equivalent dose of xopenex and albuterol are therapeutically equivalent.

The s-albuterol is beta inert. It's that simple.

However in peds who may metabolize albuterol slowly, double the amount of albuterol in the racemic mixture may result in a delayed elimination thereby potentially causing more cardiovascular effects, in theory.

Package insert will show that the rate of tachycardia is 2.7...for both xopenex and albuterol...

In the end.... same **** different price.


Not staying in your comfort zone and use the "choose your battle" card.

This is one time I will side with Sparda. I like to see more of this kind of stuff from him.

I agree with It's Z - I don't think xopenex is any different than albuterol. However, they have a very effective market-based medicine campaign and as a result, many PCPs (and parents) are led to believe in the wonders and miracles of Xopenex over plain albuterol.

In the ER or acute setting, when you have the nurses and parents insisting that the child can't get albuterol and needs Xopenex - you pick your battles. You can try to argue with the anxious parent and nurse that albuterol works just as well (and get paged every minute for persistent tachycardia with "see, you should have written for Xopenex"), and creating mistrust between the parents and her healthcare provider ("he doesn't know my child, he's a know-it-all doctor who didn't listen to me, I know my child best and Xopenex works while Albuterol doesn't"). You pick your battles, and Xopenex vs Albuterol is something that the parents and pharmacy can fight over ... I might order Xopenex, and if pharmacy refuses, then I'll just tell the nurse and parents that the pharmacy refuse to dispense (or its not available). I don't care what the child gets, as long as the child actually gets treatment instead of arguing over the bioavailable of stereo enantiomers and its cost. Sometimes we focus so much on "stupid doctor for not following formulary" or "stupid doctor for not listening to the parents/nurses" or the nurse going "stupid pharmacist for not giving the xopenex", we forget that there is a patient who probably needs the meds at that moment. You pick your battle. In an acute situation, the last thing I need is to create antagonism between the parents and her healthcare providers (in an already anxious environment) - if the pharmacist wants to fight that battle, then it's the pharmacist's prerogative. If I really want Xopenex available on formulary (or more readily available), then I'll just have to make my case to the hospital's P&T committee.

My hospital has Xopenex limited to pediatrics. When I take care of kids, albuterol is my first line drug unless the parents insist on Xopenex. Then I would order Xopenex. Usually the peds pharmacist will see the heart rate, approve it for 1 dose, and if there is improvement in HR, will approve its continued inpatient use (personally I think the improvement in HR is due to the fact the child can BREATH instead of xopenex/albuterol receptor effects). If it doesn't improve, then continued xopenex order is not approved.

I have only Rx Xopenex inhaler once for an adult and it was in an outpatient setting where the patient asked for it (and had coupons) and was not interested in albuterol (or Maxair). It's not available for inpatient adult use unless there are extreme circumstances.


So you pick your battles. I'm more interested in convincing parents that a virus should not be treated with antibiotics, and that vaccines is not a vast medical-pharmaceutical-industrial conspiracy to turn kids into zombies (television/ipad/xbox/ps3 have done that without our help). If you want to fight with the parents about xopenex vs albuterol, be my guest.

*just my perspective. Different providers and different hospitals will provide different experiences and perspectives.

 

[Its Z]

XopeneX and albuterol arent stereo enantiomers. Active components are identical
r-albuterols. Same molecule.

 

[group_theory]

XopeneX and albuterol arent stereo enantiomers. Active components are identical
r-albuterols. Same molecule.

Yup. I mistyped above ... same bioactive molecule, different price


Further clarification - whether the child gets xopenex or albuterol doesn't matter, and you don't want to create unwanted antagonism between patient/family and healthcare providers. If the patient gets worse (needs continuous nebs, needs to be intubated, gets a pneumothorax from an asthma exacerbation, etc) - creating the mistrust at the onset will only complicate matters (and the parents/family members will think "well, if he only got xopenex as we told them, this could have been avoided")

So Xopenex vs Albuterol, in the big picture, doesn't really matter. Now if the parent is insisting on aminophylline instead of albuterol, or special herbal naturopathic juice instead of solumedrol ... then that is a battle worth fighting (and also try to find out why the parents are insisting on aminophylline - is there something in the child's history that I should know?)

I'm not someone who order Tudorza, Alvesco, and Brovana on every patient I see because the drug rep was hot

 

[ethyl]

Yup. I mistyped above ... same bioactive molecule, different price


Further clarification - whether the child gets xopenex or albuterol doesn't matter, and you don't want to create unwanted antagonism between patient/family and healthcare providers. If the patient gets worse (needs continuous nebs, needs to be intubated, gets a pneumothorax from an asthma exacerbation, etc) - creating the mistrust at the onset will only complicate matters (and the parents/family members will think "well, if he only got xopenex as we told them, this could have been avoided")

So Xopenex vs Albuterol, in the big picture, doesn't really matter. Now if the parent is insisting on aminophylline instead of albuterol, or special herbal naturopathic juice instead of solumedrol ... then that is a battle worth fighting (and also try to find out why the parents are insisting on aminophylline - is there something in the child's history that I should know?)

I'm not someone who order Tudorza, Alvesco, and Brovana on every patient I see because the drug rep was hot

 

[Carboxide]

Yup. I mistyped above ... same bioactive molecule, different price


Further clarification - whether the child gets xopenex or albuterol doesn't matter, and you don't want to create unwanted antagonism between patient/family and healthcare providers. If the patient gets worse (needs continuous nebs, needs to be intubated, gets a pneumothorax from an asthma exacerbation, etc) - creating the mistrust at the onset will only complicate matters (and the parents/family members will think "well, if he only got xopenex as we told them, this could have been avoided")

So Xopenex vs Albuterol, in the big picture, doesn't really matter. Now if the parent is insisting on aminophylline instead of albuterol, or special herbal naturopathic juice instead of solumedrol ... then that is a battle worth fighting (and also try to find out why the parents are insisting on aminophylline - is there something in the child's history that I should know?)

I'm not someone who order Tudorza, Alvesco, and Brovana on every patient I see because the drug rep was hot

Okay. Are you willing for that to come out of YOUR paycheck? Because money has got to come from somewhere and fact is it costs us money to dispense extremely expensive drugs, especially when there is no tangible benefit such as increased lifespan or faster recovery. Decreased pharmacy revenue means it comes out of MY raise, which this year didn't even cover increases in parking, let alone health care.

And before you answer, I have paid cash for patients' Rxs before out of my own pocket because the doctor decided to wait until close to send down the scripts and the patient did not have time to get money from home (seeing as they tell them to send their wallets home). I've never seen a doctor shell out. Ever. But every single person I work with has paid for someone at least once.

 

[Sparda29]

Ugh, I can't stand medically proficient parents. What happened to the days when they just did what you told them to do?

 

[atpsynthase]

Yeah, isn't it interesting and slightly counter-intuitive that with increasing education level, adherence, etc. decreases?

 

[npage148]

Yeah, isn't it interesting and slightly counter-intuitive that with increasing education level, adherence, etc. decreases?

The education level may be increasing but their science/medical knowledge isn't. They think they know what they are talking about but have no idea. It's a dangerous combination.