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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

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Rx in UnderwritingA Special Presentation forCHOLHUA

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

WAHLU


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


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


GenericNamevs.Proprietary Name(s)

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

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


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 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?

  • AllRx paid for with Rx card

  • Sequenceof prescribing

  • Dose

  • Rx compliance (adherence)

  • Name and contact information forprescribingphysician


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

  • 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!

  • 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

  • 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…


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


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 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?

  • Barbiturates

  • Hydantoin (Dilantin)

  • Carbamazepine (Tegretol, etc.)

  • Valproic acid (Depakote, Depakene)

  • Oxcarbazepine (Trileptal)

  • Fosphenytoin (Cerebyx)

  • Herbal compound kava


CardiovascularRxPearls +RED FLAGS


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


  • 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

  • Bepridil (Vascor) =refractory stable angina

  • Nimodipine (Nimotop) =subarachnoid hemorrhage


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!


PSYCHIATRICPHARMACOLOGYGEMS


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?

  • 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 [email protected]


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


  • 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-SalientRx Tidbits


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)

  • 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 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 & COMPLEMENTARYtherapiesmatter to us?


  • 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 knowWHY when they’re taking…

  • Hawthorn

  • Shark cartilage

  • Mistletoe

  • Silymarin

  • Glycyrrhizin

  • SAMe


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