Adult Sepsis Guidelines Children's Sepsis Guidelines
Adult ICU Liberation Guidelines PANDEM Guidelines for Children and Infants
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John M. Allen, PharmD, BCPS, BCCCP, FCCM; Siu Yan Amy Yeung, PharmD, BCP; Kevin W. Hatton, MD, FCCM As drug shortages and increasing drug costs have become more common in today’s healthcare environment, so too has public awareness about these issues. Recent headlines in major news media have garnered much attention, with stories on shortages ranging from intravenous fluids used for fluid resuscitation and sterile drug compounding1 to lack of parenteral opioids for pain management2 to the unavailability of EpiPen autoinjectors for treatment of anaphylaxis.3 Likewise, there has been significant press coverage of specific instances of astronomically increased drug pricing for certain drugs. Armed with this new information, many patients and family members are keenly aware of drug shortages and increasing drug costs and the potentially negative impact they can have on patient safety. In this article, we will provide critical care clinicians with some practical ways to communicate with patients and family members about the use of alternative drug therapies due to drug shortages or rising drug costs. One scenario in which alternative drug therapies are sometimes used is as a means to reduce or mitigate rising drug costs.4,5 In the critically ill patient, this scenario may occur with historically inexpensive vasoactive agents whose prices have recently increased, such as vasopressin, isoproterenol, and sodium nitroprusside. A well-informed patient or family member may question a vasopressor strategy for septic shock that does not include vasopressin or an antihypertensive therapy for dissection that does not include sodium nitroprusside. Today, many hospitals use alternative therapies in both of these situations, and critical care clinicians should be prepared for questions about the use of these alternative treatments. An appropriate response could be that the alternative agents have similar efficacy and adverse event profiles, and that the high-cost agents may not therefore be the best option for the patient. This response demonstrates to the family that the alternative agents are not being used solely for financial reasons but that an appropriate evaluation of therapies, including financial ramifications, was used in selecting appropriate therapies for the patient. Additionally, highlighting that the alternative agents have similar mechanisms of action and that they are routinely used in similar situations can be another way to allay any potential concerns about using a different pharmacologic agent. Another scenario occurs with the ongoing drug shortages that challenge many hospital systems. During the recent intravenous fluid shortage, for example, many hospitals used strategies that delivered lifesaving medications (e.g., vasopressors, antibiotics, electrolytes) in nonconventional ways such as enteral or intramuscular routes or via intermittent intravenous pushes, rather than infusions. In addition, the recent parenteral opioid shortage that many hospitals experienced led to the increased use of enteral opioids and alternative analgesic medications (e.g., acetaminophen, lidocaine, nonsteroidal antiinflammatory drugs). Both of these experiences created opportunities for critical care specialists to discuss the reasons for medication changes to routine therapies and to reinforce that these alternative routes of medication delivery were as efficacious as parenteral therapy and could even be preferred to other methods of administration in some situations. Last, patients and families may find that an alternative was also substituted for a patient’s home medication when that medication was not available or not on the hospital’s approved formulary. In addition, some patients’ acute illness may also necessitate substituting an alternative for a patient’s home medication. One example that illustrates both of these scenarios is the use of long-acting beta-agonist and long-acting muscarinic antagonist inhalers. Patients on these inhalers are often transitioned to nebulized agents, including short-acting beta-agonist and/or muscarinic antagonist therapies, during hospitalization because of either the patient’s acute condition (e.g., chronic obstructive pulmonary disease exacerbation) and/or hospital formulary restrictions (e.g., automatic substitution of inhalers with nebulizers). In these situations, clinicians should explain the reason for the switch and assure patients and families that medications with similar mechanisms of action and efficacy are being used. If a therapeutic substitution occurred during hospitalization and the clinician’s intent is to return to the patient to his/her previous home medication regimen on discharge, the clinician should ensure that the patient and family understands that the alternative medication will not be prescribed on discharge to avoid duplication of therapy. Educate patients and/or their family members that home regimens should be resumed after hospitalization. Drug shortages and changing drug prices create a number of challenges for clinicians and hospital systems providing care to critically ill patients. Hospital systems have developed many different approaches to these challenges, including the use of therapeutically similar alternate therapies and alternate routes of medication delivery; however, little has been said about the challenges of communicating these approaches to patients and families. We have highlighted three potential situations and opportunities to discuss how changes to traditional therapeutic options can be discussed with patients and families. Regardless of the reason for the change, an open, transparent, and frank discussion with patients and families is likely key to assuaging doubts or concerns about the therapeutic changes. References