title: Formulary management of recombinant factor VIIa at an academic medical center.
abstract: BACKGROUND
  Recombinant human coagulation factor VIIa (rVIIa) is a procoagulant indicated for treatment of bleeding in patients with hemophilia. A large proportion of rVIIa utilization is for off-label administration in nonhemophiliac patients with acute hemorrhage. Concerns of potentially inappropriate use, safety, and cost of rVIIa led to efforts to standardize use of this agent.
  
  
  OBJECTIVE
  To comparatively describe the utilization of rVIIa upon implementation of an evidence-based guideline at a university hospital.
  
  
  METHODS
  With advisory direction from a multidisciplinary task force, an evidence-based guideline for use of rVIIa was developed, approved, and fully implemented. Assessment of appropriateness of use and retrospective review were required for all cases. Effects of these actions were evaluated by auditing and comparing rVIIa use in patients treated in two 6-month observation periods before and after guideline implementation. Outcomes assessed were proportions of patients deemed appropriate to receive rVIIa, compliance with dosing recommendations, and acquisition costs.
  
  
  RESULTS
  Twenty-two and 29 patients were treated in the periods before and after guideline implementation, respectively. Patient characteristics were similar, except more cardiothoracic surgeries were performed in patients treated before implementation of the guideline. Indications for rVIIa use were judged appropriate in 21 (95.5%) before-cases and in all (100%) after-cases. The dose was compliant in 1 (4.6%) before-case and 27 (93.1%) after-cases (p < 0.001). Mean dosages of rVIIa administered were 81.8 microg/kg and 45.3 microg/kg in before- and after-cases, respectively (p < 0.001). During the respective periods of observation, amounts of rVIIa purchased monthly averaged 42.6 mg and 21.8 mg, a 49% difference. Semiannual expenditures for rVIIa decreased approximately $110,000 following guideline implementation. Patient outcomes were similar.
  
  
  CONCLUSIONS
  A guideline based on currently available evidence can serve to sustain the clinical appropriateness of rVIIa therapy and substantially decrease costs.
authors.affiliation: Department of Pharmacy Practice; Clinical Assistant Professor, College of Pharmacy and Health Sciences Center, Mercer University, Atlanta, GA, USA.
authors.forename: Phillip S
authors.initials: PS
authors.lastname: Owen
authors.forename: Larry K
authors.initials: LK
authors.lastname: Golightly
authors.forename: Robert
authors.initials: R
authors.lastname: MacLaren
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Ferretti
authors.forename: David B
authors.initials: DB
authors.lastname: Badesch
mesh_terms: D000208:Acute Disease; D006348:Cardiac Surgical Procedures / Q000706:statistics & numerical data; D003029:Coagulants / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D003120:Colorado; D004305:Dose-Response Relationship, Drug; D016527:Drug Costs / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine / Q000458:organization & administration; D015942:Factor VIIa / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D005572:Formularies, Hospital as Topic; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006470:Hemorrhage / Q000188:drug therapy* / Q000209:etiology; D006785:Hospitals, University; D006801:Humans; D017410:Practice Guidelines as Topic; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D003029:Coagulants; D011994:Recombinant Proteins; C103587:recombinant FVIIa; D015942:Factor VIIa