News
N e ws
New gout treatment approved
T akeda Pharmaceutical Company
Limited on February 13 announced
the approval of febuxostat, a xanthine
oxidase inhibitor, for the reduction of
elevated serum uric acid levels in patients
with gout.
Febuxostat, which Takeda will sell in
the United States as Uloric oral tablets,
is intended for the long-term manage-
ment of gout. FDA-approved labeling for
febuxostat cautions against the use of the
drug in patients who have elevated serum
uric acid levels without a diagnosis of gout.
Gout is a painful arthritic disorder
caused by a buildup of uric acid crystals
in joints and soft tissues.
The labeling for febuxostat states that
the drug, at therapeutic concentrations,
decreases serum uric acid levels by block-
ing xanthine oxidase but is not believed
to affect other enzymes involved in pu-
rine and pyrimidine synthesis.
Febuxostat is contraindicated in pa-
tients receiving azathioprine, mer-
captopurine, or theophylline because
plasma concentrations of these drugs
may increase to toxic levels as febuxostat
inhibits their metabolic enzyme.
The labeling states that patients who
begin treatment with febuxostat or other
uric-acid-reducing drugs often suffer
gout flares that do not necessitate dis-
continuing therapy. These patients may
benefit from up to six months of prophy-
lactic treatment with a nonsteroidal anti-
inflammatory drug or colchicine during
the initiation of febuxostat treatment.
Febuxostat recipients in clinical tri-
als were more likely than those treated
with allopurinol to have a cardiovascular
thromboembolic event. According to the
labeling, these events—which included
death and nonfatal heart attack and
606 Am J Health-Syst Pharm—Vol 66 Apr 1, 2009
stroke—have not been causally linked to
febuxostat use.
Clinical trial participants who re-
ceived febuxostat were also more likely
than allopurinol recipients to have
elevated liver enzyme levels. The label-
ing recommends that febuxostat users
undergo periodic testing of liver func-
tion and monitoring for cardiovascular
events.
In clinical trials, the most frequent
adverse events reported among fe-
buxostat recipients were nausea, rash,
joint pain, and liver function test value
abnormalities.
Febuxostat tablets will be sold in 40-
and 80-mg strengths. The 40-mg tablets
will be packaged in bottles of 30, 90, and
Inhaled anesthetics present cost-saving
opportunity
A
     simple intervention at Montefiore
    Medical Center in the Bronx, New
York, has produced substantial savings
on inhaled anesthetics, says Frank Aroh,
clinical pharmacy manager for anesthesi-
ology and surgical services.
The saving—estimated at more than
$100,000 from March 2007 to April
2008—resulted from reducing the use of
desflurane in favor of sevoflurane in the
operating suite. During that period, des-
flurane use gradually decreased from 225
to 58 bottles per month, and sevoflurane
500 each, and the 80-mg tablets will be
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packaged in bottles of 30, 100, and 1000
each. Both strengths will also be avail-
able in 100-tablet unit dose packages for
hospitals.
The recommended starting dosage for
febuxostat is 40 mg taken once daily. The
dosage can be increased to 80 mg daily
if serum uric acid levels do not fall to
6 mg/dL or lower as early as two weeks
after initiating therapy.
Alan MacKenzie, president of Takeda’s
North American division, said in a state-
ment that febuxostat is the first new gout
treatment in 40 years. Takeda did not an-
nounce a launch date for the drug.
—Kate Traynor
DOI 10.2146/news090028
use increased from 169 to 224 bottles per
month.
“Our goal was set out to increase the
amount of sevoflurane that we use and
decrease the amount of desflurane,” Aroh
said.
Sevoflurane is more expensive per
unit than desflurane. But three bottles
of desflurane are needed to maintain
the same level of anesthesia as one bottle
of sevoflurane, making that agent less
expensive for the hospital to use, Aroh
explained.

To get the anesthesiologists to reduce
their desflurane use, Aroh first investi-
gated why they seemed to prefer the drug
to sevoflurane or isoflurane, which he
called the medical center’s “workhorse”
anesthesia agent.
Aroh said Montefiore has about 50
staff anesthesiologists and the same
number of anesthesiology residents.
Overall, he found, many of the physi-
cians’ decisions to use desflurane were
unrelated to clinical issues.
“What we found is that 90% of the
time, they use desflurane because it’s in
the room, not because it’s a drug that
they really think they want for that case,”
Aroh said. “If it’s there, nobody wants to
reach out for something else.”
A review of the literature indicated that
patients anesthetized with desflurane can
be extubated about two minutes sooner
than those given sevoflurane, an advantage
Aroh did not believe to be meaningful.
He said desflurane may be preferable
in obese patients, because that drug is
less readily absorbed than sevoflurane in
adipose tissue. But overall, he said, there
are few situations for which evidence
supports desflurane as the better of the
two drugs.
“If you ask me which gas is the ideal
gas, I would say sevoflurane,” Aroh said.
Although both drugs are indicated for
the induction and maintenance of anes-
thesia in adults, the medical center uses
desflurane for anesthesia maintenance
only, he explained.
Desflurane is much more commonly
associated with airway reactions than
sevoflurane when used to induce anes-
thesia by mask, according to the prod-
ucts’ FDA-approved labeling. Aroh said
patients at Montefiore are first given an
i.v. agent for anesthesia induction before
receiving desflurane by mask.
With the support of the anesthesiol-
ogy department’s vice chairman, a deci-
sion was made to remove desflurane
vaporizers from every operating room
(OR), leaving in place vaporizers with
sevoflurane and isoflurane. Desflurane is
brought in on request when an anesthe-
siologist believes the drug is necessary for
a specific case.
“This was a collaborative effort be-
tween pharmacy and anesthesiology,”
Aroh said. “We got the vice chairman to
buy into the program. And then we got
the information to all of the anesthesi-
ologists. Most of them, I would say 90%
of them, were receptive.”
“We preach evidence-based practice,”
Aroh said. “Our job as pharmacists is to go
back and discuss these things with the phy-
sicians and say, ‘Listen, I understand that
this is your preferred agent. But look at the
literature; look what we’ve found. There is
nothing that supports that that is a better
drug than this one. You might have been
trained with this one, but it doesn’t mean
that the other one is not better.’ ”
But he cautioned that the support staff
who stock the ORs must also be included
in the planning for this type of initiative
to work.
“If you take a vaporizer for desflurane
and put it in, say, room 1, because you
have a case that requires desflurane for
a particular patient, when that case is
finished someone needs to go in room
1 and remove that desflurane vaporizer
and put back the sevoflurane vaporizer,”
Aroh said. “If you don’t do that, all your
desflurane vaporizers are going to creep
back into all the rooms.”
Aroh credited the success of the proj-
ect to the good professional relationship
between the hospital’s pharmacy and
anesthesiology departments and the
foundation laid during previous formu-
lary initiatives.
He said the hospital has achieved
savings in the past with neuromuscular
blocking drugs and fentanyl products by
convincing anesthesiologists that less-
expensive agents can perform as well as
costlier ones.
“There are so many agents you can do
the same thing with, but you have to have
somebody who is dedicated to anesthesi-
ology to do that,” Aroh said.
“I work with the anesthesiologists on
a daily basis,” he said. “It’s one of those
areas that are very tough to break into.
But once you get in, you find that they
become your best friend.”
Aroh said anesthesiologists, like phar-
macists, learn pharmacology, and an-
Am J Health-Syst Pharm—Vol 66 Apr 1, 2009
News
esthesiologists put that knowledge into
practice for their patients.
“I don’t think there are any other phy-
sicians that understand the drugs more
than the anesthesiologists understand
their drugs,” he said. “When you speak to
them, you’re talking to them in the same
sense that you would talk to any pharma-
cist, so they will understand what you say
and where you’re coming from.”
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Aroh said pharmacy residents at
Montefiore can get exposure to anesthe-
siology through an elective rotation that
he oversees, and pharmacy students also
attend rotations in the anesthesiology
and surgical services areas.
He said exposing pharmacists to this
environment broadens their ability to
manage drug use in the hospital.
“With anesthesiology, the issue is,
we’re not up there,” Aroh said. “Nobody
wants to put on the scrubs and go in and
understand the practice and be able to
make an impact.”
Aroh likened the issue to pharmacy
practice in the intensive care unit (ICU).
“If you don’t have somebody in the
ICU, you wouldn’t understand the prac-
tice of an ICU, therefore you can’t make
an impact in the ICU,” he said.
­—Kate Traynor
DOI 10.2146/news090029
New drugs and
dosage forms
Temozolomide for injection (Temodar,
Schering): An injectable formulation, for ad-
ministration by i.v. infusion, was added to the
product line.
Tobramycin and dexamethasone
ophthalmic suspension (TobraDex ST, Alcon):
The combination product is indicated for the
topical treatment of corticosteroid-responsive
inflammatory ocular conditions for which a
corticosteroid is indicated and where superficial
bacterial ocular infection or a risk thereof exists.
Trypan blue ophthalmic solution
(MembraneBlue, Dutch Ophthalmic USA): The
0.15% sterile stain is indicated for use as an aid
during surgical extraction of the contents of the
vitreous chamber of the eye.
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