A Drug Use Evaluation of Alteplase 2 mg Vials at Kingston General Hospital

Abstract

Background: Alteplase, a recombinant tissue plasminogen activator, is a high alert medication with many indications. In Fiscal 2015, the expenditure of alteplase 2 mg vials increased by 64% at Kingston General Hospital (KGH), despite formulary restrictions and no change in acquisition cost. Applicable restrictions include: catheter occlusion, transcatheter thrombolysis, provocative mesenteric angiography, and intrapleural fibrinolysis. KGH Pharmacy Services is responsible for the drug budget to ensure expenditures are evidence-based and reflect value for money. Objective: To assess appropriateness of the use of alteplase 2 mg vials at KGH because of the high and increasing expenditure. Methods: A prospective, observational, drug use evaluation of alteplase was conducted over 52 days between October and December 2015, including all adult patients dispensed alteplase 2 mg vials during their hospital or renal unit visit. Patient demographics, adherence to KGH restrictions and evidence-based use, completeness of documentation, and wastage were analyzed. Results: A total of 100 courses of therapy (50 renal unit, 50 non-renal unit) were included. Overall, 48% adhered to restrictions, 4% renal unit and 92% non-renal unit. Ninety-four percent of orders outside restrictions were evidence-based. Occluded central venous catheter (87%) and dialysis lock (88%) were the most common indications in non-renal unit and renal unit patients, respectively. Electronic and written orders were correct 54% of the time (90% renal unit and 12% non-renal unit); the most frequent discrepancies included incorrect route and not following hospital policy or standards. No wastage was identified for 88% of renal unit orders. Wastage was unclear in 32% of non-renal unit patients as documentation was inconsistent, with 16% of orders having no documentation of administration. Conclusion: The results support implementation of additional physician order sets for alteplase, revising KGH restrictions to reflect evidence-based practice, and preparing 10 mg doses of alteplase in the pharmacy to improve medication prescribing, documentation, patient safety, and minimize cost. Key words: alteplase, cost, safety, drug use evaluation, evidence-based Word Count: 306