Nesiritide utilization evaluation in a university teaching hospital.

BACKGROUND AND OBJECTIVES: Nesiritide is a new vasodilator approved for decompensated heart failure (DHF). Compared with nitroglycerin, nesiritide improves haemodynamics and symptoms in the first 3 h of therapy. However, nesiritide is more expensive than nitroglycerin (US$380-1500 daily vs. US$2-5 daily). Since its approval in the US in late 2001, nesiritide use has increased dramatically in our institution. Nesiritide has become a focus of our multidisciplinary drug utilization initiative, aimed at performing a nesiritide utilization evaluation (NUE) and developing a nesiritide usage guideline. METHODS: Medical records of patients who received nesiritide from 1 October 2003 to 31 March 2004 were reviewed. Nesiritide utilization pattern was presented to the initiative group for guideline development. RESULTS: A total of 162 records were reviewed. A 22.6% of inappropriate usage was reported. The most significant inappropriate usage was in patients who received the agent for precardiac valvular surgery optimization, followed by those for diuresis in non-cardiac-related fluid overload states. The median duration of nesiritide therapy was 6 days (range 1-94). The median length of stay (LOS) in our institution was 14 days (National statistics DHF LOS: 5.3 days). Eliminating inappropriate nesiritide usage can lead to a potential of US$141 886 savings per year. CONCLUSION: Based on the results, a 48-h nesiritide restriction policy was implemented. Usage beyond 48 h requires Heart Failure Service approval. Future NUE will evaluate the effectiveness of this policy. The overall management of DHF also needs to be evaluated to improve efficiency of care.

Guanfacine use in children with attention deficit hyperactivity disorder.

The role of guanfacine in ADHD remains unclear. It may be reasonable to initiate a trial of guanfacine in a patient who has not responded to or cannot tolerate other agents due to adverse effects or drug dependence, or in a patient who develops motor tics. However, large placebo-controlled, double-blind, comparative trials involving guanfacine, stimulants, and/or TCAs are necessary to fully determine the role of guanfacine in the treatment of ADHD. Presently, behavioral modification is considered a first-line therapy and may be sufficient in mild cases of ADHD. Pharmacologic intervention or a combination of pharmacotherapy and behavioral modification should be tried in patients who cannot be adequately controlled with nonpharmacologic treatment. The stimulants still are considered first-line pharmacotherapy; however, guanfacine may have a role as a second- or third-line agent in patients who do not respond to or cannot tolerate stimulants or TCAs.