NSAIDs

A Program for Cost Minimization

Newfoundland Pharmaceutical Association

Section I - Introduction

An Ad Hoc Committee was established by the Department of Health and Community Services to provide advice on the use of Non Steroidal Anti-inflammatory Drugs (NSAIDs). The Committee consisted of representatives from:

• Newfoundland and Labrador Medical Association
• Newfoundland Pharmaceutical Association
• School of Pharmacy, Memorial University
• Department of Health and Community Services
• Faculty of Medicine, Memorial University

The Committee agreed that:

• Most NSAIDs are equally effective as analgesics and anti-inflammatory agents when administered in appropriate doses. New NSAIDs do not possess greater analgesic and anti-inflammatory activity than older NSAIDs.
• Most NSAIDs are associated with side effects including GI intolerance, GI ulceration, nephrotoxicity and CNS disturbances. Studies have attempted to rank NSAIDs according to their side effect profiles. These studies indicate that some NSAIDs (Indomethacin) are more frequently associated with side effects than other NSAIDs (Ibuprofen); however, many show side effects with similar frequency.
• Notwithstanding the similar analgesic and anti-inflammatory efficacy of NSAIDs, patients exhibit variability in their therapeutic and adverse responses to NSAIDs. Patient preferences may play a bigger role in possible side effects than a specific NSAID.
• Patients considered at high risk for NSAID induced gastropathy include patients requiring chronic NSAID treatment (>3 months) and meeting one of the following:

• age > 60 years
• previous history of peptic ulcer disease
• concurrent steroid use

These patients may benefit from prophylaxis with misoprostol.

Section II - Cost Analysis and Proposed Cost Minimization Strategy

The Department of Health and Community Services wishes to provide physicians and pharmacists with information concerning the cost of NSAIDs. It is hoped that by raising cost awareness, the Department may achieve a reduction in the expenditure of NSAIDs thus eliminating the need for restrictive measures. Through the process of the review of NSAID use, the Ad Hoc Committee also noted that:

• NSAIDs differ in price ranging from $3.00 per month to $73.00 per month. If health care professionals were to prescribe the lower priced NSAIDs rather than the higher priced NSAIDs, the Drug Program could realize an annual savings of approximately $500,000.00.
• With more than 20 NSAIDs on the market, the potential exists for minimizing cost without compromising patient outcomes. A cost comparison chart is provided, products in the chart are listed, with their benefit status, in ascending order of monthly cost. Brand costs are not included as the Drug Program reimburses pharmacies for the lowest priced generic.

Example:

If Sodium Naproxen 550mg were changed to Naproxen 500mg, the NLPDP would save approximately $108,000.00 annually!

At this time, all NSAIDs will retain their current status of open benefit or special authorization.  
Requests for special authorization will be assessed according to recommendations provided to the Department from the Ad Hoc Committee. Special authorization will be considered if the patient has failed to respond to a 4 - 6 week trial of a minimum of 3 NSAIDs or has developed side effects. The following recommendations provide for patients with disease states or concurrent medications which limit the choice of NSAIDs.

Approval for NSAID will be provided under the following circumstances:

1. for patients who are on medications which interact with benefit NSAIDs.
2. where the use of benefit NSAIDs are contraindicated. Contraindications to the use of individual NSAIDs include renal, GI, hepatic, cutaneous, CNS, haematologic and hypersensitivity adverse reactions.
3. when a physician chooses to prescribe an NSAID for patients who currently are on an anticoagulant, approval for nabumetone will be considered.

Section III - Procedure for Special Authorization

All requests should be made in writing by the prescribing physician, if possible, to the NLPDP. Telephone calls will be accepted; however, all requests will be assessed in the order they are received.

Please include:

• patient name
• specific diagnosis
• past NSAID use (drug, dose duration of treatment and response)
• name, strength, and dosage of requested NSAID
• clinical evidence supporting the use of the drug
• prescribing physician

Further information to expedite approvals:

• drug card identification
• patient address, telephone number
• pharmacy

Information should be forwarded to:

Newfoundland and Labrador Prescription Drug Program
Department of Health and Community Services
P. O. Box 8700
St. John's, NF
A1B 4J6
Telephone: 709-729-4584
Toll Free: 1-888-222-0533
Fax: 709-729-2851

Anyone wishing references for this document, may contact the Department of Health and Community Services at the telephone/fax numbers listed above or you may access our website page at /health/nlpdp.