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Student Name
Department of Nursing, Rasmussen University
NGR5172
Professor Name
Date
Medications Comparison and Recommendations
My job as the clinical educator of the pharmacy is to analyze new drugs that are under consideration to be introduced to the hospital formulary. This review aims to compare drugs in four therapeutic groups, namely, genitourinary, gastrointestinal, endocrine, and musculoskeletal, according to cost, efficacy, indications, and safety throughout the lifespan. The analysis guarantees the use of evidence-based decisions that can maximize patient outcomes, and at the same time cost-effective and persuade the use of medication in the facility.
Genitourinary
| Criteria | Fetroja (cefiderocol) | Elmiron (pentosan polysulfate sodium) |
| Indication | Multidrug-resistant Gram-negative bacterial-induced complicated urinary tract infections (cUTIs). | To alleviate bladder discomfort and pain, interstitial cystitis (bladder pain syndrome). |
| Cost (facility/patient) | Expensive; IV antibiotic; approximately a daily inpatient cost of around $1,000-1,200 of the hospital formulary antibiotics. | Middle-priced; oral chronic medication, approximately $400-600 per month, outpatient; infrequently applied in inpatient practice. |
| Efficacy | Known to be effective in resistant infections; fewer options. | Limited effectiveness; there are those patients who respond, and there are those patients who show slight improvement (Syed, 2021). |
| Lifespan considerations | Adults: approved; children: not established; should change dose in renal impairment; elderly: caution (Tan et al., 2023). | Adults; safety has not been determined in pediatrics; long-term use may cause pigmentary changes in the retina. |
| Summary/Recommendation | Very useful in severe infections; expensive yet medically necessary. | Minimal inpatient coverage; possible vision losses in the long term. |
Recommendation:
Among the two genitourinary agents, the Fetroja (cefiderocol) is to be included in the hospital formulary. It has the benefit of being, despite its high acquisition cost, lifesaving against multidrug-resistant Gram-negative infections, which is essential in acute inpatient care. It is to be added as a restricted antibiotic that needs infectious disease approval to be able to practice stewardship and cost control (Syed, 2021). Elmiron is, however, more likely to be used in chronic outpatient bladder pain and has low evidence of efficacy, as well as ocular toxicity. Elmiron is thus not a formulary home medication that should be continued in case of the need of the patients during admission.
Gastrointestinal
| Criteria | Trulance (plecanatide) | Amitza (lubiprostone) |
| Indication | Chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) in adults. | Chronic idiopathic constipation (CIC), opioid-induced constipation (OIC), and IBS-C in adult women. |
| Cost (facility/patient) | Moderates: retail of about $450-$650 per month; discount programs of manufacturers; used primarily out of patient. | Moderate to high; approximately, $400-700 a month; can be increased by insurance; line item could be higher. |
| Efficacy | Similar to lubiproston, it increases the frequency and consistency of stools; a one-dose regimen will increase compliance (Sharma & Badyal, 2024). | Good in CIC and OIC, but can increase nausea; twice-daily administration can lead to decreased compliance. |
| Lifespan considerations | Adult; safety not defined in children; low adverse event rate, minimal systemic absorption. | Adults; no or little pediatric data; contraindicated in Mechanical GI obstruction; pregnancy category C. |
| Summary/Recommendation | Good, well-met, and effective dosing schedule. | Good, but not so convenient, and more side effects. |
Recommendation:
As opposed to Amitza, Trulance (plecanatide) should be added to the formulary because of its higher efficacy in chronic idiopathic constipation and IBS-C, once-daily dosing, and better tolerance. Its low systemic absorption and low potential for major drug interactions render it safe to be used in inpatient continuation and outpatient transition. Patient costs can be decreased through manufacturer assistance programs (Brenner et al., 2024). The Amitza (lubiprostone) is still an option in certain patients, especially those who experience constipation caused by opioids; however, due to the increased incidence of nausea and the inconvenience that it causes, it is a secondary option. Thus, Trulance is more valuable to the facility and the patients.
Endocrine
| Criteria | Trulicity (dulaglutide) | Victoza (liraglutide) |
| Indication | Type 2 diabetes mellitus (T2DM) enhances glycemic control and decreases cardiovascular (CV) risk. | DM type 2; enhances glycemic control and lowers the risk of CV in patients at high risk. |
| Cost (facility/patient) | High; average retail $850-1000 per month; average dosing can cut down supply cost per month; insurance and copay schemes can be made. | High; same cost monthly; in daily dosage heightens patient supply use; exists of assistance programs. |
| Efficacy | Established A1C (~ -1.2 -1.5) reduction and CV benefit (REWIND trial); once-weekly dosage enhances compliance (Tan et al., 2023). | Confirmed A1C lowering (approximately 1.0 -1.5) and CV improvement (LEADER trial); effective but not as convenient with daily dosing. |
| Lifespan considerations | Adult approved; no pediatric data; contraindicated during pregnancy; safe at mild-moderate renal insufficiency. | Contraindicated in adults; restricted in children; should be avoided in pregnancy; pay attention to pancreatitis and thyroid C-cell risk (Viale et al., 2023). |
| Summary/Recommendation | The once-weekly dose, which is effective, increases adherence. | Effective and increased burden but daily. |
Recommendation:
Trulicity (dulaglutide) should be added to the formulary as the agonist of the GLP-1 receptor for type 2 diabetes. It provides excellent glycemic control, established cardiovascular advantage, as well as convenient dosing that is once a week, thus improving patient compliance and decreasing nursing administration workload (Sharma & Badyal, 2024). Trulicity is a superior choice in terms of continuity of care in both inpatient and outpatient care due to its weekly regimen and wide clinical acceptance as compared to the similar efficacy of both agents. The liraglutide (Victoza), which is not a formulary option, should still be considered as an option when the patient is already stable on daily treatment. Trulicity should be incorporated into the institution with endocrinology supervision and safe use education.
Musculoskeletal
| Criteria | Humira (adalimumab) | Orencia (abatacept) |
| Indication | Rheumatoid arthritis (RA), psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, and plaque psoriasis. | The majority of rheumatoid arthritis, psoriatic arthritis, and polyarticular juvenile idiopathic arthritis. |
| Cost (facility/patient) | High, about $5,000-6,000/month; however, several biosimilars and copay plans significantly decrease the cost. | Roughly high; approximately, between $5000-6,500 per month; there are fewer biosimilars, mainly infusions, and they raise the cost of facilities. |
| Efficacy | Strong clinical evidence; useful in various autoimmune diseases; fast and long-lasting effect. | Efficient in RA and some nonresponsive patients to TNF inhibitors; sluggish action (Viale et al., 2023). |
| Lifespan considerations | Adult and some childhood approvals; TB and hepatitis screening; no live vaccines. | Adults and children 2 years (JIA); risk of infection is equal; vaccination screening is a requirement. |
| Summary/Recommendation | Widespread, numerous biosimilars, cost-saving opportunities. | Works well in niche groups; greater load of infusion. |
Recommendation:
Humira (adalimumab) can be included in the formulary because of its broad spectrum of approved autoimmune indications, high level of efficacy, and because of the presence of lesser-priced biosimilars. It has a subcutaneous preparation, which can be easily administered, and the infusion is cheaper, an advantage to both the facility and patients (Bruna et al., 2023). Humira has comprehensive safety and monitoring policies, which have made it easy to provide familiarity to the providers and enable safe inpatient continuity. Orenica (abatacept) does not lose its value in patients who do not respond to TNF inhibitors, or even in children, but it can be retained as a non-formulary specialty-use drug. In general, Humira offers more therapeutic flexibility, efficiency in cost, and institutional formulary accessibility.
Conclusion
Upon reviewing all the categories, Fetroja, Trulance, Trulicity, and Humira will be placed in the formulary list as they have good clinical efficacy, safety profiles, and value when used by institutions. They both have therapeutic value and aid in continuity between inpatient and outpatient care. High-cost agents should be accompanied by restriction and stewardship to ensure an equitable balance between patient and financial benefits.
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References for NGR 5172 Deliverable 4 Medications Scenarios
Plecanatide improves abdominal bloating and bowel symptoms of irritable bowel syndrome with constipation. Digestive Diseases and Sciences, 69(5), 1731–1738. https://doi.org/10.1007/s10620-024-08330-y
Bruna, Matheus, Ana Cristina Medeiros-Ribeiro, Andrade, D., Junior, & Coelho, P. (2023). JAMA Network Open, 6(5), e2315872–e2315872. https://doi.org/10.1001/jamanetworkopen.2023.15872
Sharma, C., & Badyal, D. K. (2024). A review article on the role of plecanatide in irritable bowel syndrome with constipation and chronic idiopathic constipation. National Journal of Pharmacology and Therapeutics, 2(1), 11–13. https://doi.org/10.4103/njpt.njpt_3_24
Syed, Y. Y. (2021). Cefiderocol: A review in serious gram-negative bacterial infections. Drugs, 81(13), 1559–1571. https://doi.org/10.1007/s40265-021-01580-4
Tan, X., Liang, Y., Rajpura, J. R., Yedigarova, L., Noone, J., Xie, L., Silvio Inzucchi, & Adam de Havenon. (2023). Once-weekly glucagon-like peptide-1 receptor agonists vs dipeptidyl peptidase-4 inhibitors: cardiovascular effects in people with diabetes and cardiovascular disease. Cardiovascular Diabetology, 22(1), 319. https://doi.org/10.1186/s12933-023-02051-8
Viale, P., Sandrock, C., Ramírez, P., Gian María Rossolini, & Lodise, T. P. (2023). Annals of Intensive Care, 13(1), 52. https://doi.org/10.1186/s13613-023-01146-5
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