Adverse drug reaction increases six-fold from the second decade to the eighth decade of life, from 10 adverse events per 10,000 persons to 60 per 10,000. This is especially important to oncology patients. J.F. Knudsen, PhD, MD, a research associate at New Hope Cancer Center in Hudson, Fla., and other researchers performed a retrospective cohort study on cancer patients at a community-based, university-affiliated medical practice who had multiple comorbidities. The researchers determined the potential for adverse reactions and also physicians' responses to risk arising from drug interactions.

At the time of the survey in 2006, the patients took an average of 9.1 prescription and nonprescription drugs, and they took an average of three chemotherapy and supportive drugs.

Surprisingly, the oncologists failed to modify treatment when alerted to potential drug-drug interactions. They acknowledged little communication with pharmacists regarding their patients' drug burden and potential for interactions, even though software to alert for drug interactions was in place in the pharmacies.

Also, physicians cited a lack of pharmacokinetic and pharmacodynamic guidance from which to modify drug protocols, confidence in their ability to manage various degrees of toxicity, and disinterest in deviating from published standard-of-care regimens.

"Oncologic practices could be a lot safer if doctors realized the drug-drug interactions and developed guidelines to mitigate impact," says Knudsen. "If you look at hospital admissions secondary to side effects from chemotherapy, the impact is monumental. Managed care can be alert to drug-drug interactions by supporting patients through appropriate interventions that can alleviate the effects of toxicity," says Knudsen.

Vigilance at all levels of care can provide a better understanding of the interactions between comorbid conditions in patients with cancer.

Overview of potential pharmacokinetic interactions

Drug absorption, distribution, metabolism, and elimination change with age. Little guidance is available regarding drug interaction in the elderly oncology patient.

Compound Relevant enzyme P-glycoprotein substrate Elimination In vitro protein binding
Carboplatin Renal Not bound
Paclitaxel CYP 2C8, CYP 3A + Liver 89–98 %
Fluorouracil DPD 0 Liver Unknown
Leucovorin 0 Unknown Unknown
Rituximab 0 Unknown Unknown
Cyclophosphamide CYP 2C9 0 Metabolism (25 % in urine) Low
Cisplatin CYP 3A4/CYP 2B6 0 Renal 90%
Etopside CYP 3A + Biliary 97%
Doxorubicin CYP 3A5 + Biliary 75%
Irinotecan
Source: Sokol KC, et al. Polypharmacy in older oncology patients and the need for an interdisciplinary approach to side-effect management. J Clin Pharm and Ther. 2007;32:169–175.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.