A typical retail pharmacy stocks hundreds or even thousands of individual prescription products. Just one active ingredient can be found in a dizzying array of dosages, forms and routes of administration. While the needs and preferences of individual patients will vary, there are some broad guidelines when it comes to choosing the most clinically appropriate and cost-effective options. Enclara has assembled guidance on five of the major considerations when selecting a particular product. However, it is always best to consult a qualified pharmacist when weighing alternatives.
Avoid Multi-Symptom Products
Products containing multiple drugs are sometimes more expensive than the individual medications they contain. However, the larger issue is that they can make it harder to adjust dosages, manage side effects and ensure patient safety. Duplication of therapy is also a risk when the same compound is included in multiple products in the patient medication profile. Prescribing their component compounds separately is typically preferred.
Exercise Caution With Extended-Release Medications
Extended-release medications simplify administration, allowing for a medication to be taken once or twice a day rather than every few hours. For patients already taking other medications at regular intervals, reducing the number of doses of one medication might not offer a meaningful difference and should be weighed against other factors. While extended-release drugs can still play an important role in delivering consistent, long-term relief of certain symptoms in end-of-life care, changes in digestion, metabolism and intake of food and liquids may also make their absorption less predictable.
Consider Crushing Tablets
Many medications are offered in powders or capsules, which can be sprinkled into food or mixed with juice or water. Some are also available as flavored liquids. While helpful in some cases, these options can be significantly more expensive and may present storage and dosing challenges. Crushing conventional tablets and mixing them with food or liquid may be a clinically appropriate alternative. Some can also be administered rectally. Not all tablets can be crushed, however. It is also important to consider the ability and willingness of caregivers to administer medications in this manner.
Know When to Split Higher Doses
Most drugs are available in multiple dosages. In some cases, splitting tablets can be a more cost-effective way to provide a medication. However, not all tablets can be split. Some are too small or lack scoring. Extended-release medications often use coatings, which require the tablet to be taken whole. Hospice formularies and prescribing guidelines will generally indicate when splitting is appropriate and preferred.
Reconsider Inhalers
Inhalers are pre-filled drug delivery devices and can be both expensive and inappropriate for some patients. Particularly with advanced disease, patients may lack the ability to use the inhaler correctly, leading to inconsistent and inadequate absorption of the active ingredient. Nebulizers offer the ability to administer inhaled medications at lower cost and with greater ease. For inhaled corticosteroids, oral administration may be indicated.
Additional Resources
- Enclara’s exclusive Medication Utilization Guidelines (MUGs)TM provides a wealth of information on managing common end-of-life symptoms. Clients can access MUGs through the E3 Pro™ app and website.
- Enclara’s ebook, Factors Influencing Hospice Pharmacy Spend, includes broad guidance on cost-effective symptom management, deprescribing and other strategies.
- The free Enclara resource, Approach to Rectal Administration: A Refresher, provides guidelines on an often-overlooked alternative to oral and injected administration.
