Drug Therapy Committee Meeting Highlights
June 2004
Volume XIV, Issue 6

Formulary Request Eplerenone (Inspra)
Approved with restrictions

Discussion
The Committee was presented with the request to add eplerenone (Inspra) to the Formulary. Eplerenone is a selective aldosterone receptor blocker indicated for the treatment of hypertension and congestive heart failure after an acute myocardial infarction. The primary advantage of eplerenone over spironolactone is a potentially lower incidence of endocrine-related adverse effects, such as gynecomastia, breast pain and tenderness. Monitoring serum potassium is recommended. The Committee approved the addition of eplerenone (Inspra) to the Formulary with the following restriction to physicians when ordering: reserved for patients intolerant to spironolactone (i.e. experiencing gynecomastia and/or breast pain and tenderness from spironolactone).

Formulary Request Tiotropium Bromide (Spiriva)
Approved

Discussion
The Committee was presented with the request to add tiotropium bromide inhalation powder (Spiriva HandiHaler) to the Formulary. Tiotropium is indicated for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Tiotropium is an long-acting antimuscarinic/anticholinergic, CFC-free agent with equal affinity among the subtypes of muscarinic receptors, M1 to M5. The drug inhibits the lung's M3-receptors at
the smooth muscle leading to bronchodilation, with a duration of action of more than 24 hours. Tiotropium has demonstrated improved lung function and clinical symptoms in patients with COPD. In long-term studies, tiotropium has reduced the frequency of exacerbations while improving lung function, lowering the chances of exacerbation. Compliance issues can be eliminated with this once-a-day regimen as compared to shorter-acting agents. A cost analysis was provided to the Committee comparing tiotropium, ipratropium and ipratropium/albuterol: $4.10/day, $1.92/day and $1.96/day, respectively. Based on the above information, the Committee found tiotropium to have a favorable cost-benefit ratio. Tiotropium will replace ipratropium for the majority of patients with moderate to severe COPD with the exception of patients on mechanical ventilation unable to use the tiotropium delivery system form. The Committee has approved the addition of tiotropium bromide inhalation (Spiriva HandiHaler) to the Formulary.