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Rx in Underwriting A Special Presentation for C H O L H U A. Hank George, FALU, CLU, FLMI Cheesehead. HATS OFF, CHOLHUA! You are a role model for excellence as a professional underwriters’ association! Greetings from your neighbors on the frozen tundra! Hank George Officer-at-(too)-Large

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Rx in underwriting a special presentation for c h o l h u a

Rx in UnderwritingA Special Presentation forCHOLHUA

Hank George, FALU, CLU, FLMI

Cheesehead


Rx in underwriting a special presentation for c h o l h u a

HATS OFF, CHOLHUA!

You are a role model for excellence as a professional underwriters’ association!

Greetings from your neighbors

on the frozen tundra!

Hank George

Officer-at-(too)-Large

WAHLU


Rx in underwriting a special presentation for c h o l h u a

MUC comes toPackerCountryBears’Refugees Welcome!September 15-17Hyatt Regency- MilwaukeeFollowed by an ECG interpretation seminar created by Lori [email protected]


Rx dx tell me what he s taking and i ll tell you what he s got

Rx = DxTell me what he’s taking…and I’ll tell you what he’s got!


Generic name vs proprietary name s

GenericNamevs.Proprietary Name(s)

  • BupropionisWellbutrin (depression), Aplezin (depression) andZyban (quit smoking aide)

  • FluoxetineisProzac (depression and n+1 other things!) andSarafem (PMS)


The best practice rx paradigm typically consists of

The BEST PRACTICERx paradigm typically consists of…

  • 1st line Rx – used most -BEST CASE?

  • 2nd line Rx – used when one or more first line drugs have unacceptable side effects/don’t work;sometimes used in combination with first line

  • 3rd line Rx –more potent, more side effects;used when 1st and 2nd line both fail, or as adjuvant –WORST CASE?

  • “Compassionate use” – refractory cases (felbamate in seizure disorders, etc.) –WORST CASE!


Rx profiles 2010 why rapidly increasing use

Rx Profiles 2010Why rapidly-increasing use?

  • Low cost

  • Perceived value

  • Rapid access/teleinterview-compatible

  • Credibility

  • Action-friendly (act without confirmation)

  • No notable producer-customer-regulatory/legislative pushback

  • 70%+ hit rate > MIB

  • Older age business + polypharmacy


What are the 5 key elements

What are the 5 Key Elements?

  • AllRx paid for with Rx card

  • Sequenceof prescribing

  • Dose

  • Rx compliance (adherence)

  • Name and contact information forprescribingphysician


Non compliance with rx

Noncompliance with Rx

  • In a cohort of 112,902 statin users,only 40% were taking the drug at least 80% of the timeAFTER 1 YEAR!

  • Psychiatric drugs have the worst compliance

  • Compliance is a marker for theHealthy Adherer Effectspanning a spectrum of favorable health habits

  • Non-compliance is a majorRISK-TAKING BEHAVIOR


6 subtle pearls

6 Subtle Pearls

  • Total dose taken + times taken per day/ other interval – does it pinpoint reason for use/disease severity?

  • One drug replaces another – why?< 1 month (side effects); > 1 month (lack of efficacy)

  • One drug added to another– why?

  • Refills – consistent with compliance?

  • Mode of delivery – pill, injection (IV, IM, intrathecal), transdermal, dissolving wafer, inhaler, nasal/oral spray, topical ointment, suppository – does it pinpoint reason for use/disease severity?

  • Subtle synergies–inhaler for “asthma” + and 3 courses of winter antibiotics = COPD?


The off label pandemic

The “Off-Label” Pandemic!

  • 1 in 4 scripts for unapproved indications

  • Subtly promoted by pharmaceutical companies

  • Physicians free to do so if there is a clinical study supporting efficacy

  • Most common in psychiatric, cardiovascular contexts!

    Take gabapentin for example…


Gabapentin uses

Gabapentin Uses

  • 2nd line generalized seizure disorders

  • Bipolar I + II

  • Neuropathic pain in diabetes, etc.

  • Social phobia, panic disorder

  • Restless leg syndrome

  • ??? (since I last looked!)


How often do prescription drugs affect the results of routine screening blood tests often enough to

How often do prescription drugs affect the results of routine screening blood tests?Often enough to…


Rx in underwriting a special presentation for c h o l h u a

…justify an 800+ page reference book on this subject, published by the American Association for Clinical Chemistry!


Rx effects on blood tests generalizations

Rx Effects on Blood TestsGeneralizations

  • Most drugs do it at least rarely

  • Most effects are minimal and transient

  • Most do not result in any harm to the patient

  • Many effects are capable of altering test results significantly enough to change underwriting actions, especially when solely for test results

  • LFTs, BUN. Creatinine, glucose most vulnerable

  • The first question in any unexplained test elevation:What Rx is he taking?


Statins and liver enzymes

Statins and Liver enzymes

  • Statins raise ALT ≥ 3 x ULN in 0.3% to 1.5% of cases, depending on dose – and countless more to a lesser degree

  • AST to a lesser extent; GGT unaffected

  • Elevations are harmless and normalize when the drug is withdrawn

  • LFTs should be rechecked at 6 weeks and annually thereafter by prescribing MD

  • Key question:is the elevation caused by the statin…or something else?


Which drugs really cause isolated ggt elevation

Which drugs REALLY cause isolated GGT elevation?

  • Barbiturates

  • Hydantoin (Dilantin)

  • Carbamazepine (Tegretol, etc.)

  • Valproic acid (Depakote, Depakene)

  • Oxcarbazepine (Trileptal)

  • Fosphenytoin (Cerebyx)

  • Herbal compound kava


Cardiovascular rx pearls red flags

CardiovascularRxPearls +RED FLAGS


Prils sartans

“- prils”+“- sartans”

  • ACE inhibitors and angiotensin II receptor blockers

  • Widely used in hypertension

  • ACE inhibitor #1 choice in heart failure + subclinical systolic dysfunction

  • Both used in early (microalbuminuria) diabetic/prediabetic nephropathy prophylaxis…even in the absence of hypertension


Phosphodiesterase 5 enzyme inhibitors a k a denafils not just for wishful old geezers any longer

Phosphodiesterase-5 Enzyme InhibitorsA/K/A “- denafils”…not just for wishful old geezers any longer!


Rx in underwriting a special presentation for c h o l h u a

  • Sildenafil is VIAGRAfor ED andREVATIOfor pulmonary hypertension

  • TadalafilisCIALISfor ED andADCIRCAfor pulmonary hypertension

  • VardenafilisLEVITRA andNUVIVAfor ED and is likely to be approved for pulmonary hypertension

  • These drugs have also been shown to be effective inachieving pregnancy in women with increased endometrial thicknessand in“female sexual dysfunction” syndrome


Beware solitary ccb indications

BEWARE solitary CCB indications

  • Bepridil (Vascor) =refractory stable angina

  • Nimodipine (Nimotop) =subarachnoid hemorrhage


More on statins

More on statins…

  • Manufacturers’ dream: 30,000,000!

  • Used prophylactically in patients with borderline/normal lipids

  • Wide range of pleiotropic effects beyond just lowering LDL-C, raising HDL-C and lowering triglycerides

  • 10+% increased riskof T2DM affirmed by meta-analysis

  • RED FLAG: patient discharged from a hospital on statin for the first time!


Psychiatric pharmacology gems

PSYCHIATRICPHARMACOLOGYGEMS


Rx in underwriting a special presentation for c h o l h u a

SSRI antidepressants have more off-label uses than any drug class How’s this beauty?Sertraline (Zoloft) for thestaggering riskNight Eating Syndrome…another impairment-wannabe


How many do you recognize

How many do you recognize?

  • Asenapine (Saphris)– schizophrenia and BP I

  • Trazodone(Oleptro)–(Desyrel redux) MDD

  • Paliperidone(Invega, Sustenna)– antipsychotic

  • Iloperidone(Fanapt)– schizophrenia and BP I

  • Desvenlafaxine(Pristiq)– MDD

  • Guanfacine(Intuniv)– ADHD


Stay current on rx hot notes monthly e newsletter free esther@hankgeorgeinc com

Stay Current on Rx!HOT NOTES™Monthly [email protected]


How many potential adjuvant drugs for refractory severe major depressive disorder can you think of

How many potential adjuvant drugs for REFRACTORY SEVEREmajor depressive disordercan you think of?


Rx in underwriting a special presentation for c h o l h u a

  • Folates (folic acid)

  • Thyroid hormone

  • Omega-3 fish oils

  • Lithium carbonate

  • Buspirone (BuSpar) @ 40 mg

  • Selegiline (Emsam) patch

  • Modafinil (Lyrica)

  • Riluzole (Rilutek) – ALS drug

  • Various novel antipsychotics


Additional underwriting salient rx tidbits

Additional Underwriting-SalientRx Tidbits


Metformin glucophage

Metformin(Glucophage)

The #1 drug in

BEST CASEtype 2 diabetes

just happens to also be widely used fornonalcoholic fatty liver disease (NAFDL),

polycystic ovary syndrome (PCOS),

metabolic syndrome,

prediabetic states

and (potentially), weight loss!


Finasteride propecia proscar

Finasteride (Propecia, Proscar)

  • Is indicated for baldness and benign prostatic hyperplasia (BPH)

  • Is used off-label in prostate cancer prevention and Tourette syndrome

  • Lowers PSA – potentially causing a “false-negative” result when screening a person at high enough perceived risk to justify prophylaxis!


Not too long ago there were no approved drugs for fibromyalgia now we have 3

Not too long ago, there were no approved drugs for fibromyalgiaNow we have 3:

  • Duloxetine (Cymbalta) –also used in MDD and diabetic neuropathic pain

  • Modafinil (Lyrica) –used for sleep disorders and many other reasons

  • Savella (milnacipran) –an antidepressant approved only for fibromyalgia


Why do alternative complementary therapies matter to us

Why do ALTERNATIVE & COMPLEMENTARYtherapiesmatter to us?


Rx in underwriting a special presentation for c h o l h u a

  • Fastest growing domain of healthful intervention

  • Used disproportionatelyby college-educated, higher-income applicants

  • In cancer patients, useddisproportionately in those with metastatic disease and/or following relapse from conventional Rx

    Should be on EVERY drilldown!


You want to know why when they re taking

You want to knowWHY when they’re taking…

  • Hawthorn

  • Shark cartilage

  • Mistletoe

  • Silymarin

  • Glycyrrhizin

  • SAMe


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