July 27, 2020
By: Drew Stenger and Jon Easter, RPh
Long before the COVID-19 pandemic was spreading across the globe, the U.S. was already facing an epidemic in healthcare that was spreading, costly, and ultimately unsustainable relative to healthcare spending. That epidemic is the incidence of chronic disease. Ninety percent of the total cost of healthcare in the U.S. is attributed to chronic conditions, like diabetes, heart disease, and chronic lung disorders. More than half of Americans have at least one chronic condition, with 40% having more than one. The downstream impact on patients, caregivers, providers, and payers is staggering. According to recent research from the RAND corporation, patients with 5 or more chronic conditions fill 51 prescriptions on average and have a 24% chance of being admitted to the hospital during the course of a year. The point is that managing medication regimens to treat chronic conditions at an individual patient level is hard work. Pharmacists, as medication experts, are in the best position to solve the medication optimization problem, and we’re working everyday with providers to step up and make an impact —more on that in our MedOpt2019 blog.
Enter COVID-19. Identifying, testing, and approving medications that are both safe and effective at treating the virus takes medication optimization to a whole new level of complexity. The coronavirus pandemic has been a puzzling time within the medical community. Although being used in the United States, the data supporting hydroxychloroquine and remdesivir to treat COVID-19 is still limited and mixed, leaving providers uncertain.
Initial support for the use of hydroxychloroquine came from French and Chinese research teams. The data was met with as much skepticism as it was enthusiasm, and the authors noted that more studies were needed to fully investigate risks and benefits. Last week, the VA found that hydroxychloroquine, with or without azithromycin, did not lower the use of ventilators or risk of death. In the time since the initial positive data, hydroxychloroquine also gained a reputation for increasing complications in underlying cardiac and renal disease. Beyond safety and efficacy, the supply chain of the immunosuppressant is at risk, as patients currently using hydroxychloroquine are now trying to source a medication that’s in shortage.
Remdesivir, an antiviral medication discovered through an academic-corporate partnership between Gilead and the Baric lab at the UNC Gillings School of Public, has been the most recent hot topic in potential COVID-19 therapies. Preliminary data, just as for hydroxychloroquine, was weak but positive. Initial follow up data from The University of Chicago was also promising, yet remdesivir momentum seemingly collapsed after the WHO inadvertently posted study data from Gilead trending (although not powered) towards failing to speed the improvement of patients with COVID-19. In most recent news, the remdesivir roller coaster ride continues, as Federal health regulators have authorized the emergency use of the antiviral medication after NIH studies showed it shortened time to recovery in some patients.
Enter the Expanding the Role of the Pharmacist to Better Optimize Medications
Despite these turbulent times, and the prevalence of conflicting treatment evidence, the pharmacy community has remained steadfast and active as medication management experts in serving patients and advocating for expanded services to maintain access to care. Pharmacists working in both community and ambulatory care have successfully secured their piece of the coronavirus-relief-effort pie. The HHS released statements in early April granting pharmacists the authorization to order and administer COVID-19 tests, which affords pharmacists the opportunity to demonstrate the vital role they play in convenient access to important public health services. Pharmacists are also witnessing shifts within the telehealth paradigm, which provides an enhanced ability to support providers and patients with medication optimization services in light of ‘stay at home’ policies. Current HHS legislation has enhanced the flexibility of telehealth services eligible for reimbursement during the COVID emergency, allowing pharmacists to provide even more telehealth incident-to Medicare eligible providers. CMS has also transformed the requirements of “direct supervision” for pharmacists providing telehealth services, which can now be satisfied virtually using real-time audio/video technology. This policy modification offers a real-world glimpse into ASHP advocacy efforts, as the organization has been pushing for telehealth services to be provided under “general supervision” instead of “direct supervision.”
Through the pandemic, we’re all looking at what good can come from this crisis. We firmly believe that safe and effective treatments will emerge to fight COVID-19. We also believe that expanding the role of the pharmacist to ensure the right patient receives the right medication at the right time will lead to better healthcare and improved patient outcomes. We look forward to ‘getting to the other side’ of the curve and are excited about the innovations to come. Stay safe everyone!
P.S. Please see these three useful resources that we’ve found:
The American Pharmacists Association has published a useful fact sheet highlighting contraindications, precautions, and counseling points for all therapies currently being studied for COVID-19 treatment.
See the National Community Pharmacists Association’s website for a short video on how to file for a CLIA Certificate of Waiver to administer COVID-19 tests.
Visit the Covid-19 TrialsTracker, created by TranspariMED, for an easily accessible guide to locate primary trial manuscripts and data as well as current research locations.
Drew Stenger is a fourth year Doctorate of Pharmacy student at the UNC Eshelman School of Pharmacy and Jon Easter is the Director of the Center for Medication Optimization at the UNC Eshelman School of Pharmacy and a Registered Pharmacist.