Month: February 2012

ifttt Medical Applications

I’ve started using the new web service ifttt. It stands for If This Then That. It allows one to use the internet to create various tasks in a If This Than That structure. The This part is what they call a Trigger. It’s the event that has to happen to trigger the task. Triggers can be such things as every time you add a video to your YouTube favorites or every time a photo is tagged with your name in Facebook.

If a task is triggered, then an Action is done. For example every time you add that YouTube favorite, an email is sent to your friend saying you found another YouTube gem, or you get a text message to your phone when you get a photo tagged in Facebook.

These Triggers and Actions come from what they call Channels. This includes such things as Facebook, Twitter, email, and phone calls. They currently have 41 Channels, and growing. This gives enormous possibilities.

Finally one can share created Tasks, in what they call Recipes, that others can download.

I created some recipes with medical tasks in mind. I wrote reminders to take one’s medications. This can be done with a text message or phone call. You could use it for yourself, or set up an account for a friend or family member that needs help remembering to take their pills. You can find the recipes at: http://ifttt.com/people/ginsberg.

Limiting Medication, But Not Really

Once again, CVS Caremark wasted my time. On 1/27/12 they sent me a copy of a letter they sent my patient saying they only provided a limited supply of tramadol to my patient because it’s subject to plan quantity limits. The directions I wrote said that she could take up to 8 pills per day. I only wrote for 60 pills, though, so I didn’t understand why the letter.

It took me about 10 minutes, but a customer representative said I could have ordered 240 pills at a time and it should have gone through. He didn’t know why the letter went out. I pointed out that besides the fact that his company wasted paper and postage mailing out the letters, it probably caused my patient to be concerned, and it wasted my time. He apologized and said the coverage should not be a problem. I said that surely this wasn’t the only mistaken letter they’ve sent out and said he should pass this on to his supervisor.

Mistakes happen, but the answer should not be, as Gilda Radner said, “Never mind!” Instead organizations should apologize and try to figure out why it happened, and what can be done to prevent it from happening in the future. When a pharmacy benefit manager, such as CVS Caremark, does otherwise, the message is they don’t care if they waste doctor’s time.

Acid Revelations – Acid Reducers and Asthma in Children

The Journal of the Medical Association recently published an article about the use of lansoprazole (Prevacid) for children with poorly controlled asthma. It had been thought that gastoesophageal reflux disease (GERD) contributed to asthma exacerbations because acid would come up from the stomach and get into the lungs.

By putting tubes down the nose and into the stomach and esophagus it was known that children often have reflux when they have breathing problems, even without having heartburn symptoms. Proton pump inhibitors (PPI’s) such as lansoprazole, omeprazole (Prilosec), pantoprazole (Protonix) and others, markedly decrease the amount of acid produced in the stomach. Even if the contents reflux into the esophagus (think of an old fashioned coffee percolator), there would be less irritation if it was less acidic.

In adults with asthma and reflux symptoms, studies have shown the PPI’s help their lung function. Despite lack of conclusive studies showing benefits in children, its use in them markedly increased between 2000 and 2005. It made intuitive sense and the medications seemed pretty safe.

In this study children with poorly controlled asthma without gastroesophageal reflux (GER) symptoms not only did not do better with lansoprazole, they had more adverse events with increased respiratory infections. There were also six times as many activity related fractures in those on the medication. Although it didn’t quite reach statistical significance because of the relatively small numbers, the PPI’s are known to be associated with osteoporosis in adults.

This illustrates the important difference in statistics between association and causation. Just because two things occur together, doesn’t meant that one causes the other, and even so, it doesn’t mean treating one will treat the other. There is an old joke of a man walking around carrying an umbrella on a sunny day. “Why are you carrying an umbrella when it’s not raining,” asked his friend. “To keep the tigers away,” he replied. “But there are no tigers around here,” his friend objected. “See, it works,” he answered.

The accompanying JAMA editorial called the use of proton pump inhibitors for asthma a case of, “therapeutic creep.” That’s using medications beyond what the scientific evidence shows. This is not necessarily wrong. For example I commonly recommend vitamin D for my patients even though we still don’t have definitive evidence. In such cases, though, it’s good to remember the limits of what we know and beware of potential risks. As Hippocrates reportedly first said, Primum non nocere – First do no harm.

Even my dog’s veterinarian suggested using using over-the-counter Zantac or Pepcid for reflux because my dog sometimes threw up on the rug. Now I don’t feel so bad that I ignored her advice.

Prior Prior Authorization

I prescribed Chantix for one of my patients recently. CVS Caremark faxed us a, “CLINICAL PRIOR AUTHORIZATION CRITERIA REQUEST FORM”. It said to complete the form then fax it to them. Once received they would fax a, “DRUG SPECIFIC CRITERIA FORM”.

Why couldn’t they just have sent the specific criteria form in the first place? It didn’t take long to fill out the first form, but why should I have to sign my name twice for one medication for one patient? In addition someone had to take the time to sort through the office faxes and then get it to me, and my nurse had to fax it back, then had to send the fax confirmation to shredding, not to mention that we are paying for the paper, ink and electricity for these faxes.

Chantix only has one use, to help people stop smoking. Why should there be any criteria for coverage? Either cover it or don’t. Maybe they want to know if the patient tried generic bupropion first (actually they subsequently asked if they were taking it at the same time). Well they could have checked their records and seen that the patient was prescribed it in the past and conclude that it didn’t work. They asked if the patient would be monitored for depression. Sure, that is a reported side effect of the medication. But it’s not like CVS Caremark is asking if I know the side effect of all the medications I prescribe.

Pharmacy Benefit Managers like CVS Caremark should stop over burdening physicians with needless paperwork.