A successful program to optimize use of Amphotericin B Lipid Complex (ABLC) at an academic medical center

Lipid-based antifungal products have been developed, and some may reduce nephrotoxicily and infusion-related side-effects, compared to standard amphotericin B (AmB). However, questions remain about optimal daily and cumulative dosing strategies, and no published data exists demonstrating outcome advantages. Enthusiasm for these products is tempered by the enormous price difference compared to AmB. Therefore, we devised a three-tiered strategy to optimize use of ABLC, the first of these to be licensed. First, dispensing of ABLC required ID consultation and approval; further, an ID physician had to review the patient's course and re-write the order every 3 days. Second, we devised a dosing algorithm minimizing waste by using 100 mg dosing increments, rounding up or down on alternate days. Third, a Parenteral Admixture Policy was initiated requiring daily confirmation that an order was still active prior to preparation. Adult and Pediatric ID consultants agreed on the following guidelines for approval decisions: presence of a documented, invasive fungal infection, anticipated survival >72 hrs, AND one of the following: baseline or development of renal insufficiency, or continued infection despite > 1 week AmB. We prospectively collected data about ABLC requests and patient outcomes. Over 6 months, there were 49 ID consults for ABLC, in 36 patients, resulting in 20 approvals meeting guidelines (41%), 17 approvals not meeting guidelines (35%), and 12 denials (24%). We estimated cost avoidance between $166,350-$305,360, based on AWP. ID initial and continued evaluation resulted in the greatest cost avoidance, mostly the result of prompt discontinuation of ABLC when appropriate. Given patient complexity, ID consultation, rather than a protocol-based approach, is supported by our data where a substantial proportion of approvals did not meet our own guidelines.

Duke Scholars

Author Richard Howard Drew Medicine, Infectious Diseases

Author John Robert Perfect Medicine, Infectious Diseases

Author Carol Dukes Hamilton Medicine, Infectious Diseases