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IV Push Levothyroxine Mue Final

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221 views21 pages

IV Push Levothyroxine Mue Final

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IV Push Levothyroxine (Synthroid®)

Medication Usage Evaluation


Dec 2020
Morgan Samuelson, PharmD
PGY1 Pharmacy Resident - Ball Memorial Hospital
Objectives

• Review levothyroxine PO/IV indications and associated costs


• Summarize 2019 IV push levothyroxine MUE
• Discuss background, methods, and results of current 2020 MUE
• Recommend steps for improvement of compliance to
Levothyroxine IV Push restrictions
Background
Off-Label IV
FDA Approved Oral Indications
Indications
• Deceased organ donor
Hypothyroidism management
(congenital or acquired of any etiology) • Cardiogenic shock
• S/P thyroidectomy with
malabsorption
FDA Approved IV • Pregnancy
Indications • Replacement for patients
unable to receive oral
Myxedema coma therapy
Background

Levothyroxine
100 mcg • 53 cents per tablet
tablet
Levothyroxine
• $103 per vial ~ 200x more expensive
100 mcg vial
2019 Levothyroxine IV Push MUE

33% of IV push orders were for appropriate indications


‘Appropriate’ indication defined as: myxedema coma, organ donation
following brain death, s/p thyroidectomy, pediatric patients, pregnancy,
endocrinology consult, and strict NPO ≥ 72 hours

23% of orders for patients NPO were strictly NPO for ≥ 3 days
$294,000 annually in cost-avoidable drug expenditure for IUH
Levothyroxine IV Push Restrictions
Implemented June 9, 2020

Delays initiation of IV levothyroxine orders by 72 hours unless:


Pediatric patients (less than 18 years-old)
Levothyroxine continuous infusion (Organ donation
following brain death)
Orders recommended by endocrine staff
Strict NPO (including medications) ≥ 72 hours
Myxedema coma
Status post thyroidectomy with malabsorption
Pregnancy

*Cerner alerts were utilized to facilitate compliance to the restrictions


2020 Follow-Up MUE

Objective Assess compliance of new restriction across the entire IU Health


system

Primary Endpoints  % of approved IV push administrations


 Average # of IV push administrations/month
Inclusion Criteria IV push administrations between 6/9 – 9/8/2020

 Outpatients
Exclusion Criteria  Patients < 18 years of age
 Continuous infusion levothyroxine
 Med ordered without administered doses
Methods

Retrospective review of 70 randomly selected charts


Proportional to total patients receiving IV push levothyroxine across all
facilities

First administration analyzed for patients with multiple administrations


Proportionated # of Charts
IU Health Facility # of Patient Encounters
Reviewed
Arnett 7 5

Ball Memorial 16 12

Bedford 3 2
Bloomington 9 6

Methodist 23 17

North 14 10
Saxony 2 1

University 19 14

West 4 3
Total 97 70
IU Health Facility Approved Use, n (%)

Arnett (n=5) 2 (40)

Ball Memorial (n=12) 5 (42)

Bedford (n=2) 2 (100)


Bloomington (n=6) 2 (33)
Methodist (n=17) 8 (47)
North (n=10) 4 (40)
Saxony (n=1) 0 (0)
University (n=14) 6 (43)
West (n=3) 1 (33)
Total (n=70) 30 (43)
Analysis of Approved vs. Unapproved
Use by Provider Specialty
Urology

Transplant

Thoracic Surgery
Pulmonary

Plastic Surgery

Otolaryngology

Multiple Trauma

Internal Medicine

Hospitalist

General Surgery

Gastroenterology

Critical Care Medicine

Cardiovascular Surgery

0 2 4 6 8 10 12 14 16 18 20
Unapproved Use Approved Use
A v e r a g e # o f I V P u s h A d m in is t r a ti o n s p e r
Analysis of Number of IV Push Administrations

350

300

250

200

150 310

100

136
50

0
2019 MUE 2020 MUE
Proportion of Approved vs. Unapproved Use

# of Reviewed Charts
70

60

50 40
47
40

30

20

30
10
23

0
2019 MUE 2020 MUE

Approved Use Unapproved Use


Analysis of Use that Met Restriction Criteria

S/P
Thyroid-
ectomy
9%
Suspected
Endo Consult Myxedema
31 %
Coma
19 %

Inappropriate Appropriate
Use Use NPO Orders ≥ 72 Hours
57 % 43 % 41 %
Analysis of Use that Did Not Meet Restriction Criteria

97% of patients (n=39) were on a thyroid product at home but were not
NPO for ≥ 72 hours before inpatient initiation
 Levothyroxine PO (n=34) or IV (n=3)
 Liothyronine (n=2)

2.5% of patients (n=1) were S/P total laryngectomy


Summary
Decrease in unapproved IV push use from 67% in 2019 to 57%
Decrease in average number of IV push orders/month from 310 to 136
Limitations
 Modifications to criteria from 2019 MUE
 System alerts updated in September 2020
Recommendations

Adjust verbiage or boldness on the “Levothyroxine Route Restrictions”


clinician/pharmacist alerts
 Emphasize patients must be NPO for at least 72 hours unless exclusion
criteria are met

An additional MUE in Spring 2021 to:


 Track improvement
 Assess improvements from September 2020 alert modifications and
further verbiage updates
Old Alert: New Alert:
References
1. Levothyroxine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com.
Accessed 08/07/2020
2. Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., ... & Sawka, A. M. (2014). Guidelines
for the treatment of hypothyroidism: prepared by the American thyroid association task force on thyroid hormone
replacement. Thyroid, 24(12), 1670-1751
3. Spinasanta S. Clinical evaluation of hospital in-patient use of intravenous levothyroxine. Presented at the 84th Annual
Meeting of the American Thyroid Association. Retrieved from
http://www.endocrineweb.com/professional/meetings/clinical-evaluation-hospital-patient-use-intravenous-
levothyroxine
Questions

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