In this episode I’ll:
1. Discuss an article on cost effective C diff treatment.
2. Answer the drug information question “Can phenobarbital be used as monotherapy in patients with severe alcohol withdrawal?”
3. Share a tip for responding to inpatient medical emergencies
Lead author: Diana Ford
Published in American Journal of Health-System Pharmacy June 2018
Recent Clostridium difficile infection guidelines recommend the first line treatment for mild-to-moderate disease be vancomycin or fidaxomycin, and that metronidazole no longer be used as first line monotherapy. The authors of this study evaluated the cost-effectiveness of these initial treatment strategies for mild-to-moderate Clostridium difficile infection (CDI) in hospitalized patients.
The authors designed decision-analytic models to compare initial treatment with metronidazole, vancomycin, and fidaxomicin. The model that served as the primary one included 1 recurrence, and the secondary model included up to 3 recurrences. The authors used variables from published literature and based costs on a healthcare system perspective. The primary outcome was the incremental cost-effective ratio (ICER) between initial treatment strategies.
In the primary model, the overall percentage of patients cured was about 94% for metronidazole, 95% for vancomcyin, and 96% for fidaxomycin. The authors calculated that the expected costs per case were $1,553.01, $1,306.62, and $5,095.70, respectively. In both models, vancomycin was more effective and less costly than metronidazole, resulting in negative incremental cost-effective ratios.
If vancomycin was selected from the new guidelines recommendations, a hospital currently treating initial episodes of mild-to-moderate CDI with metronidazole could expect to save $246.39–$388.37 per case treated by using vancomycin for initial therapy.
The authors concluded:
A decision-analytic model revealed vancomycin to be cost-effective, compared with metronidazole, for treatment of initial episodes of mild-to-moderate CDI in adult inpatients. From the hospital perspective, initial treatment with vancomycin resulted in a higher probability of cure and a lower probability of colectomy, recurrence, persistent recurrence, and cost per case treated, compared with metronidazole. Use of fidaxomicin was associated with an increased probability of cure compared with metronidazole and vancomycin, but at a substantially increased cost.
This is a very timely study that supports the new IDSA recommendations for C diff treatment. The use of fidaxomycin as initial therapy did slightly increase the chance of cure, but costs were increased dramatically. Therefore vancomycin is now the logical choice for initial treatment of mild to moderate C diff. The recommended dose is 125 mg orally 4 times daily for 10 days.
Drug information question
Q: Can phenobarbital be used as monotherapy in patients with severe alcohol withdrawal?
Phenobarbital is a very effective option for treating severe alcohol withdrawal. Phenobarbital has beneficial effects on GABA-ergic and glutamatergic receptors, the two most important receptor targets in the management of alcohol withdrawal.
In the context of starting with phenobarbital and using it as monotherapy, I believe the respiratory depression risk is low, comparable to benzos.
The main issue I would be concerned about is that to safely use phenobarb monotherapy (and not co-mingle it with benzos), there must be very good coordination starting in the ED and moving to the floors / ICU. If the ED starts with phenobarb and the floor starts with benzos, they will likely be caught unprepared for the respiratory depression that follows.
Tip for responding to inpatient medical emergencies
When responding to an inpatient rapid response call for a patient who has an altered mental status, don’t forget to check a fingerstick blood glucose value. This is a simple intervention that can be easily missed. Even if the patient is not on any hypoglycemic agents, this is still a worthwhile test as medication error, liver disease, critical illness, or insulinoma may all contribute to hypoglycemia in a non-diabetic inpatient.
For more tips like these for responding to code blue and emergency calls, I have written the book: A Pharmacist’s Guide to Inpatient Medical Emergencies.
This book is for hospital pharmacists and pharmacy residents who want to learn and refine the clinical skills necessary to be a valuable member of the hospital code blue / medical emergency team.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.