Evaluation of Calcitonin Utilization in a Tertiary Healthcare - - PowerPoint PPT Presentation

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Evaluation of Calcitonin Utilization in a Tertiary Healthcare - - PowerPoint PPT Presentation

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Evaluation of Calcitonin Utilization in a Tertiary Healthcare Setting Nicolas LaPlante, PharmD Candidate Bret LaForge, PharmD Candidate Matthew Marston, PharmD, BCPS Objectives Review common etiologies and consequences of hypercalcemia

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Evaluation of Calcitonin Utilization in a Tertiary Healthcare Setting

Nicolas LaPlante, PharmD Candidate Bret LaForge, PharmD Candidate Matthew Marston, PharmD, BCPS

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Together We’re Stronger

Objectives

 Review common etiologies and consequences of hypercalcemia  Describe available treatment options for hypercalcemia  Discuss a recent medication use evaluation for injectable calcitonin conducted at Eastern Maine Medical Center

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Hypercalcemia presents with a range of clinical sequelae

  • 90% of cases are caused by either primary hyperparathyroidism or

malignancy

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Gastrointestinal Neurological Renal Cardiovascular Skeletal Nausea/Vomiting Confusion/delirium Polyuria/ Polydipsia Shortened QT- Interval Arthralgia Constipation Psychosis Nocturia Bradycardia Osteoporosis Anorexia Muscle weakness Nephrolithiasis Hypertension Abdominal pain Headaches Renal failure Arrhythmia

Marx SJ. N Engl J Med. 2000; 343:1863-75.

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Hypercalcemia of Malignancy (HCM)

  • Affects 44.2% of cancer patients1
  • Majority of HCM is caused by the production of parathyroid hormone-

related protein (PTHrP)

  • Osteolytic metastases (e.g. breast cancer, multiple myeloma) can also

raise serum calcium by increasing its release from bone

  • Multiple myeloma patients can present with asymptomatic

pseudohypercalcemia

  • Carries significant morbidity and mortality, with an inpatient mortality

rate of 6.8%2

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  • 1. Mirrakhimov AE. N Am J Med Sci. 2015; 7(11):483-493.
  • 2. Wright JD, Tergaas AI, Ananth CV, et al. Cancer Invest. 2015;33:331-9.
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Calcitonin

  • Endogenous hormone that regulates calcium homeostasis
  • Reduces bone remodeling and calcium reabsorption by the kidneys
  • Calcitonin for medical use is derived from salmon and is available as a

nasal spray and as a solution for injection

  • Tachyphylaxis tends to occur within 48-72 hours of use

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Marx SJ. N Engl J Med. 2000; 343:1863-75.

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Calcitonin: Price on the Rise

6 $62.74 $69.05 $69.29 $2,006.85 $2,321.14 $0.00 $500.00 $1,000.00 $1,500.00 $2,000.00 $2,500.00 2012 2013 2014 2015 2016

Cost per Vial (USD) Year

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Treatment Options: Comparative Prices

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Treatment Price per Dose (82 kg patient) Dosing Frequency

Calcitonin $2740.19 Every 6-12 hours Zoledronic Acid $72.00 Once; may repeat in 7 days Pamidronate $67.64 Once; may repeat in 7 days Denosumab $2512.80 Once every 4 weeks

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  • Retrospective analysis of all injectible calcitonin orders between the

dates of 01/01/2014 and 06/01/2016

8 Number of calcitonin orders: 68 Patients who received calcitonin: 32 (47%)

Medication Use Evaluation: Methods

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Medication Use Evaluation: Methods

  • Reviewed patient charts in EMMC’s electronic medical record to

determine the indications and durations of calcitonin use

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Dose Received by Indication

Hypercalcemia OVCF* Osteoporosis

*OVCF = osteoporosis vertebral compression fracture

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Results: Treatment Duration

5 10 15 20 25 30 48 hours or less Greater than 48 to 72 hours Greater than 72 hours Osteoporosis OVCF Hypercalcemia

*OVCF = osteoporosis vertebral compression fracture

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Cost-Savings Analysis

48-hour restriction $39,480/year 72-hour restriction $32,760/year 11

  • Restrict the use of injectable calcitonin use to hypercalcemia

Indications:

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Treatment of Hypercalcemia

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Saline Hydration IV Bisphosphonates Denosumab Calcitonin Dialysis

Mild Hypercalcemia Corrected Ca: 10-12 mg/dL Moderate Hypercalcemia Corrected Ca: 12-14 mg/dL Severe Hypercalcemia Corrected Ca: > 14 mg/dL *Any patients with moderate hypercalcemia who are symptomatic should be treated as severe cases

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Ionized Calcium Levels

  • Our lab reports ionized calcium based on whole blood samples

rather than spun-down plasma

  • This leads to discrepancies between our reference ranges and those

found in literature

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y = 0.1055x + 0.3044 R² = 0.6775 0.5 1 1.5 2 2.5 8 9 10 11 12 13 14 15 16 Ionized Calcium Corrected Serum Calcium

Serum Corrected Calcium / Ical Correlation

Linear Correlation P < 0.00001

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Summary

 Injectable Calcitonin has an important role in the treatment of hypercalcemia, but should be used with discretion due to rising prices  Calcitonin provides a rapid response while bisphosphonates begin to take effect, but tachyphylaxis begins to develop after 48-72 hours  Through an MUE conducted at Eastern Maine Medical Center, we discovered that a potential $32,760 per year could be saved by:

1. Restricting the duration of use for IV calcitonin to 72 hours 2. Limiting its use to severe hypercalcemia or symptomatic moderate hypercalcemia

 $39,480 could be saved if use was restricted to 48 hours

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Acknowledgements

 Eastern Maine Medical Center  Matthew Marston, PharmD, BCPS  Northern New England Clinical Oncology Society

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Evaluation of Calcitonin Utilization in a Tertiary Healthcare Setting

Nicolas LaPlante, nlaplante@une.edu Bret LaForge, laforgeb@husson.edu Matthew Marston, mjmarston@emhs.org

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References

1. Marx SJ. Hyperparathyroid and hypoparathyroid disorders. N Engl J Med. 2000; 343:1863-75. 2. Mirrakhimov AE. Hypercalcemia of malignancy: An update on pathogenesis and management. N Am J Med

  • Sci. 2015; 7(11):483-493.

3. Wright JD, Tergaas AI, Ananth CV, et al. Quality and Outcomes of Treatment of Hypercalcemia of

  • Malignancy. Cancer Invest. 2015;33:331-9.

4. Laroche M, Cantogrel S, Jamard B. Comparison of the analgesic efficacy of pamidronate and synthetic human calcitonin in osteoporotic vertebral fractures: a double-blind controlled study. Clin Rheumatol. 2006;25:683-686. 5. U.S. Food and Drug Administration. Background document for meeting of Advisory Committee for reproductive health drugs and drug safety and risk management advisory committee. March 5, 2013. Available at: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/ReproductiveHealt hDrugsAdvisoryCommittee/UCM34177 9.pdf 6. Ralston SH. Medical management of hypercalcemia. Br J Clin Pharmacol. 1992;34:11-20 7. Knopp JA, Diner BM, Blitz M, Lyritis GP, Rowe BH. Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int. 2005;16:1281–1290. 8. Wells G, Chernoff J, Gilligan JP, Krause DS. Does salmon calcitonin cause cancer? A review and meta-

  • analysis. Osteoporos Int. 2016;27:13–19.

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