Computer-guided academic detailing as part of a drug benefit program.

A service for identifying opportunities for drug cost savings in managed care plans and intervening by giving drug information to physicians is described. A clinical pharmacy company developed a computerized drug-use-review program to (1) identify and track variances in prescribing from drug-use criteria, (2) formulate plans for correcting the variances, and (3) document the impact of those interventions on drug costs. The software program weights prescriptions claims data against drug-use criteria to identify opportunities to save money. Savings opportunities for drug costs are defined as the net difference between the cost of the prescription claim and the lower, criteria-based cost. Episodes of potential savings are grouped by variables such as drug, physician, patient, and pharmacy, and each group is characterized by its total potential for cost savings. The groups are ranked to identify drug therapy problems that most contribute to the cost of medication misuse to the client. Pharmacists counsel identified physicians and enter the responses into a database for economic analyses. From September through December 1993, the software program was used to review 167,684 prescription claims totaling $4,368,576 in drug expenditures for enrollees in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Potential drug cost savings totaling nearly $280,000 were identified. Academic detailing by the company's pharmacists resulted in a saving in drug costs of more than $12,000 per month for the first three months after the detailing. Pharmacists at a clinical pharmacy company decreased drug costs for a managed care organization by using a software program to identify the drug costs with the greatest potential for savings and the physicians associated with those costs; the physicians were targeted for academic detailing.

Anaphylactoid reaction following ketorolac tromethamine administration.

OBJECTIVE: To report a case of an anaphylactoid reaction to injectable ketorolac tromethamine in a patient with no prior history of allergies or risk factors associated with nonsteroidal anti-inflammatory drug-induced hypersensitivity reactions. CASE SUMMARY: A 37-year-old man without a significant medical history presented to an emergency department with vague, dull, left-sided chest pain. Myocardial infarction was ruled out based on an unremarkable electrocardiogram, chest X-ray, and laboratory data that were within normal limits. Sublingual nitroglycerin 0.4 mg, magnesium/aluminum hydroxide gel 30 mL, and intravenous ranitidine 50 mg were administered without resolution of symptoms. Ketorolac tromethamine 60 mg was administered intramuscularly with resolution of symptoms. The patient was discharged; however, within 30 minutes, he returned to the emergency department with facial swelling, shortness of breath, and chest tightness. Multiple doses of aerosolized albuterol and intravenous methylprednisolone and diphenhydramine were administered, resulting in a slight improvement of symptoms. The patient was admitted for a complete cardiac evaluation that proved negative. The allergic symptoms resolved and the patient was discharged without medication after a three-day hospitalization. DISCUSSION: Ketorolac tromethamine is the first injectable nonsteroidal antiinflammatory drug approved for short-term pain management. A review of the literature revealed no similar cases of anaphylactoid reaction. CONCLUSIONS: Healthcare professionals must be aware of the potential risks of anaphylactoid reactions, especially in light of the increased use of injectable ketorolac in the ambulatory setting and availability of the oral formulation.

Therapeutic drug monitoring. Practical considerations for primary care physicians.

Primary care physicians who understand the complexities of drug dosing may be able to provide their patients with more effective pharmacologic therapy. Standard or empirical methods of dosing are appropriate for most agents. The evolution of pharmacokinetics and clinically useful drug assays has led to pharmacokinetic dosing, a more sophisticated and exact method of dosing certain agents.