Evaluation of denosumab in adult oncology patients for the prevention of skeletal related events across a large academic health system.

INTRODUCTION: Denosumab (Xgeva®) and zoledronic acid (Zometa®) are widely utilized for prevention of skeletal related events (SREs) in oncology patients. Drug costs, renal function, ease and logistics of administration, and adverse effect profile are factors frequently considered by patients and/or providers when selecting an optimal agent. Given the significantly higher drug cost of denosumab compared to zoledronic acid, an evaluation of our institution's denosumab use and investigation into opportunities to shift denosumab administrations to zoledronic acid and/or to lower cost sites-of-care was warranted. METHODS: A single-center, multi-site, retrospective, observational analysis of the electronic medical record (EMR) was conducted for adult oncology patients who received denosumab 120 mg for prevention of SREs from October 1st, 2018 to September 30th, 2019 at three institutions within our health system. Additional information was collected to characterize the patient population based on cancer diagnosis, renal function, and concomitant calcium and vitamin D supplementation. Our primary objective was to evaluate if the use of denosumab met current formulary restrictions of the health system. RESULTS: In total, 304 adult oncology patients received 1411 doses of denosumab for the prevention of SREs. The majority of reviewed patients had a primary oncology diagnosis of breast (35%) or lung (24%) cancer. Of the patients who received denosumab, 278 (93%) met the health system's current formulary restrictions. The majority of patients who did not meet formulary restrictions were those with multiple myeloma (MM) (20/22; 91%). Of the 304 patients reviewed, 70 had the appropriate parameters in the EMR to calculate creatinine clearance (CrCl) using Cockcroft-Gault Equation. Of those 70 patients, 59 (84%) would have been eligible to receive zoledronic acid instead of denosumab given that their CrCl >30 mL/min with no documented intolerance to bisphosphonates. Concurrent use of calcium and vitamin D is recommended when using denosumab. Based on the most recent prior to admission (PTA) medication list obtained from the 304 patients evaluated, 222 (73%) had both calcium and vitamin D listed as "taking". CONCLUSIONS: Within our health system, denosumab is restricted to those who meet formulary restrictions. Additional education is recommended to help limit the use of denosumab, specifically in MM, to reduce drug costs when zoledronic acid is also an appropriate first-line agent.

Limited distribution networks stifle competition in the generic and biosimilar drug industries.

A limited distribution network (LDN) restricts the distribution channel for a pharmaceutical drug to 1 or a very small number of distributors. This strategy may allow for more effective allocation of drugs in shortage and is purported to help ensure the safe distribution of high-risk drugs to small patient populations. However, in recent years, some drug companies, including Turing Pharmaceuticals, have used LDNs to prevent generic and biosimilar companies from accessing samples of drug products necessary to perform testing required by the FDA for generic and biosimilar drug applications. LDNs also hamper provider access to pharmaceuticals and facilitate price gouging. This paper synthesizes existing knowledge on the misuse of LDNs to thwart competition, clarifies the relationship between limited distribution and the FDA Risk Evaluation and Mitigation Strategies, discusses proposed federal legislation under consideration to address this issue, and offers several policy options to remedy this anticompetitive practice, including authorizing the FDA to require the sale of approved drug products to generic and biosimilar drug developers.

Time-kill Kinetics of a Novel Antimicrobial Silver Wound Gel Against Select Wound Pathogens.

UNLABELLED: New treatments are needed as infection risk associated with diabetic, venous, and pressure ulcers are becoming more prevalent as comorbidities of obesity, aging, and major disease. Postsurgical, burn, and immunocompromised patients are also at an increased risk of wounds and infection. Silver has been utilized in treating various wounds associated with infections and, although highly effective, caution is required for use beyond 2 weeks due to potential silver cytotoxicity. To overcome this obstacle, an antimicrobial wound gel (CelaCare Technologies, Inc, Dallas, TX) was designed to allow low concentrations of a proprietary silver salt combined with acemannan, which has been demonstrated to aid wound healing. MATERIALS AND METHODS: This study's objective was to determine the time-kill kinetics of the antimicrobial wound gel vs 4 commercial topical silver products against 6 common wound pathogens and Bacillus subtilis as a spore-forming bacteria. RESULTS: The antimicrobial wound gel achieved a 2.9 log reduction in growth of Pseudomonas aeruginosa within 30 minutes, a 2.3 log reduction in Streptococcus pyogenes within 8 hours, a 2.1 log reduction in methicillin-resistant Staphylococcus aureus within 48 hours, a 2.3 log reduction in S. aureus within 24 hours, a 4.1 log reduction in Escherichia coli within 30 minutes, a 2.9 log reduction in B. subtilis within 60 minutes, and a 3.4 log reduction in Candida albicans within 90 minutes. Overall, the antimicrobial wound gel demonstrated broad antimicrobial coverage against all wound pathogens evaluated, and it was comparable to, or better than, other tested topical silver products containing substantially higher silver concentrations. CONCLUSION: The broad-spectrum antimicrobial activity of the wound gel indicates it could become a product alternative to current commercial products.