Pharmacists assess oral granisetron use

Pharmacist-run program saves $27,600 annually

Oral granisetron tablets have become the antiemetic order of the day for chemotherapy patients at 940-bed Hartford (CT) Hospital. An eight-month trial from August 1995 to March 1996 — replacing IV granisetron with a daily 2 mg oral dose for highly emetogenic inpatient chemotherapy, and replacing oral odansetron with a 1 mg dose for moderate treatment — has decreased patient nausea and vomiting overall, while saving the hospital $27,600 a year in direct drug costs. Little or no drug waste is being reported, and there are significant time savings from the elimination of IV setup and administration on the hospital floor.

Under the guidelines now in place, pharmacists automatically replace IV orders with the 1 mg or 2 mg tablet doses without oncologist consultation, says assistant director of pharmacy Richard Gannon, PharmD. "It’s definitely going well," he says. "The only time we don’t use the tablets is if the patient has a pre-existing problem." Such problems usually amount to nausea or emesis upon admission or any related intestinal obstruction that prevents patients from absorbing or simply keeping the pills down.

Gannon also notes that a 10 or 20 mg dose of IV dexamethasone is being given as an adjunct to the tablets and that any PRN dosing with granisetron has been eliminated under the current guidelines.

"That’s where a waste of money can also happen. You could easily double your cost by using just one PRN dose a day. We know that sticking with that one daily dose is the most effective treatment," he says.

The hospital’s pharmacy has been charged with patient assessment upon admission, daily response rates, food intake, and overall dosage compliance. Gannon says pharmacists assess any current nausea or vomiting upon admission, as well. The patient’s chemotherapy history and any risk factors are then determined.

He notes that women react more to the therapy than men and that younger women react more than their older peers. Bouts of morning sickness that may have accompanied pregnancy or even common "seasickness" predict lower tolerance of the treatment. Also, patients who consume 10 or more alcoholic drinks each week often react better to chemotherapy than those who don’t drink.

After the patient’s criteria and dosage have been determined, a PYXIS automated dispensing machine provides tablets right in the patient’s unit. "In terms of timing, when the chemotherapy is begun, the patient is ready for it. We have all the antiemetics available on admission and automatic dispensing," Gannon says. He adds that any nausea or vomiting will occur around four hours after chemotherapy, and by then the granisetron tablets are in the patient’s system.

Most chemotherapy patients at Hartford are admitted for two to five days, he says, with pharmacists tracking medication response each day.

Before the eight-month study, pharmacists noted that highly emetogenic chemotherapy patients on granisetron IV had an 83% complete response, meaning no vomiting and mild nausea. Those receiving oral ondansetron as moderately emetogenic had an 80% complete response. Under the new treatment, 109 of 135 patients on highly emetogenic chemotherapy given one daily 2 mg dose of oral granisetron — or 80.7% — had a "complete" response, while the best result, a 98.3% complete response, was from 58 of 59 patients with moderately emetogenic chemotherapy given 1 mg of oral granisetron.

Bringing costs down

Sixteen patients on highly emetogenic chemo-therapy had a "major" response (one to two emetic events), while five each had either a "minor" response (three to four emetic events) or a "treatment failure" (more than four cases of vomiting). All 28 patients on low-emetogenic chemotherapy had a complete response.

Now 14 months under the protocol, Hartford Hospital has completed a progressive regime toward cutting medication costs. Originally the hospital was spending about $30,000 a month on Zolfran IV antiemetics, before switching to a granisetron IV at about $10,000 to $12,000 a month, Gannon says. That IV treatment was still about $135 per patient, he says, while the current tablets cost about $30 apiece. The hospital’s overall medication budget for antiemetic treatment of chemotherapy patients has been reduced by $2,300 a month.

Before implementing the changes, the hospital’s oncologists, oncology nurses, and therapeutics committee reviewed and approved the guidelines, after which the new antiemetics guidelines were distributed separately to those departments and throughout the pharmacy.

Gannon approached the protocol by presenting a written program to the hospital’s therapeutics committee, and he attended monthly meetings of the oncology staff, passing out 3" • 5" file cards outlining the protocol to each doctor. Inservices included lectures presented to nurses on the oncology unit. The nurses, he says, "were our best allies. They were able to make quick changes any time they saw an IV order."

He also conducted one-on-one training with each pharmacist. "Some of them didn’t really have patient contact, and with this program we needed that on a daily basis," he says, referring to admission assessment and follow-up interviews on patient reaction to the oral granisetron. "We also found that patients would ask related questions about their chemotherapy, so it helped to educate the pharmacy staff in the treatment also," Gannon notes.

[Editor’s note: For more information, contact Richard Gannon, PharmD, Assistant Director of Pharmacy, Hartford Hospital, 80 Seymour St., Hartford, CT 06102. Telephone: (860) 545- 2003.]