May 2016
Volume: 5  Issue: 5
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Colorectal Cancer Screening
Expanded Use of Automated Immunochemical Fecal Occult Blood Test (iFOBT)
Dr. Gyorgy Abel, Medical Director of Clinical Chemistry at Lahey, recently presented a timely Grand Rounds on CRC Screening using Automated Immunochemical fecal occult blood testing (iFOBT).  Here are some highlights:
  • Despite an increase in CRC screening with colonoscopy/sigmoidoscopy, colorectal cancer (CRC) is the second leading cause of cancer related death in the US after lung cancer.
  • 50-60% of CRC deaths are preventable with screening.
  • The American College of Gastroenterology recommends colonoscopy every 10 years as the preferred CRC strategy for average-risk screening (eg. Persons 50 or older without other risk factors for CRC).
  • Of the FOBT technologies - guaiac (gFOBT) or fecal immunochemical test (FIT/iFOBT) - patients are more likely to be compliant with the FIT/iFOBT as they do not need to change diet or medications to collect the sample, and sample collection takes less effort.
  • While both gFOBT and FIT/iFOBT are proven to reduce death from CRC, FIT/iFOBT offers greater sensitivity and specificity, hence the rationale for Lahey-wide expansion of automated FIT CRC screening assay (refer to slides 15-17 for a look at the sample collection tube, instrument and patient instructions for collection).
  • Dr. Abel's comments about Cologuard Fecal DNA test:
    • Not as good as a colonoscopy
    • A little more sensitive than FIT but lower specificity (though better than FIT for serrated polyps)
    • Not recommended by US Preventive Services Task Force
    • Sample collection is more involved (300 grams and requires packaging of full BM)
    • Potential for high cost to the patient, even with insurance
    • Specimen is processed in Wisconsin
    • Not recommended as routine alternative or replacement of current automated FIT CRC screening program.
  • In the works but not ready for prime time...a DNA blood test for CRC screening!  Overall patient compliance? 99%.
  • On a side note, education of Lahey employed practices regarding the automated FIT CRC screening process is complete. Work has begun with private offices to tackle how to order the testing in the non-Epic world.
Click here to access full deck of slides.
  
Prescription Drug Monitoring Program
Consent and Pain Management Agreements
Addiction Services
What you need to know...
The MA Prescription Drug Monitoring Program (PMP) provides prescribers with prior 12 month history of a patient's narcotic, benzodiazepine and amphetamine-type stimulant prescriptions. All prescribers of these medications SHOULD BE PMP ENROLLED.  Practice delegates can also be enrolled to access PMP information. Throughout 2016 PMP will transform into an improved on-line tool called MassPAT (Massachusetts Prescription Awareness Tool) with the following changes:
  • Streamlined log-in
  • Multi-state info
  • Simplified Delegate Enrollment & Usage
  • 24 Hour Data
  • EMR Integration
All prescribers, unless specifically exempted, are REQUIRED to use the prescription monitoring program in the following circumstances:
  
* Prior to prescribing a narcotic drug in Schedule II or III to a patient for the first time
* Each time the prescriber issues a prescription to a patient for any drug in Schedule II or III that "has been determined by the Department of Public Health to be commonly misused or abused and which has been designated as a drug that needs additional safeguards in guidance to be issued by the Department of Public Health;" (DPH states these are currently only Schedule II and II narcotics; stimulants such as Adderall are CURRENTLY excluded)
* Prior to prescribing a benzodiazepine to a patient for the first time.
 
Prescribers are NOT REQUIRED to use the PMP in the following circumstances:
 
* When providing medical care to hospice patients
* When treating a patient in an Emergency Department and prescriber does not anticipate writing a prescription for a controlled substance in Schedules II through V during that encounter with the patient; OR prescribe more than a five-day supply of a controlled substance in Schedules II through V
* When emergency care is required and, in prescriber's professional opinion, utilization of the prescription monitoring program is likely to result in patient harm
* When providing medical care to hospital inpatients
* When delivering a controlled substance in a single dose or in a quantity that is essential for the immediate and proper treatment of the patient, until it is possible for the patient to have a prescription filled by a pharmacy;
* When it is not reasonably possible to use the PMP, including when the system is not operational due to temporary technological or electrical failure;
* When examining or treating a pediatric patient who is less than 8 years old.
  
Prescribers are encouraged to use a Consent Form for chronic opioid therapy.
  
Per 2016 MA Opioid Prescribing Requirements, a Pain Management Agreement is required when prescribing extended-release opioids such as Oxycontin. The agreement includes patient agreement to urine and serum toxicology screens at the prescribers discretion.
  
Lahey Health Behavioral Health Addiction Services such as Psychiatric Emergency, Outpatient Counseling, Discover Program (referral form), Opiate Addiction Treatment Program, Vivitrol Program,  Detoxification Treatment et. can be accessed through line below:
  
  
In This Issue
Metformin in Mild to Moderate Renal Impairment
FDA recently approved labeling changes, expand the use of metformin
in patients with mild to moderate renal impairment. Recommendations are now based on eGFR/1.73m2, rather than SrCr measurements to account for additional important parameters such as patient age, gender, and/or weight. Prior recommendations were against use in patients with high SrCr due to potential development of lactic acidosis.
  
New Recommendations:
  • Before starting metformin, obtain patient's eGFR
  • Metformin is contraindicated in patients with eGFR < 30ml/min/1.73m2
  • Not recommended to start metformin with eGFR between 30-45ml/min/1.73m2

 

  • Only start metformin at an eGFR above 45 mL/min/1.73 m2, continue it with assessment of the risks as it falls below 45 mL/min/1.73 m2, and then stop it altogether if and when the eGFR falls below 30 mL/min/1.73 m2.

 

  • Discontinue metformin at or before iodinated contrast imaging in patients with 30-60ml/min/1.73m2 eGFR; patients with history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hrs after imaging procedure; restart metformin if renal function stable.
What is not recommended as part of the new labeling is what some think is appropriate, which is a reduction in the dose of metformin by about 50% in those with an eGFR between 30 and 45 mL/min/1.73 m2.
 
Epic currently reports eGFR in ml/min ONLY. Efforts are being make to provide reporting in ml/min/1.73m2
  
  
NEPHO Clinical Newsletter
Produced by Northeast Physician Hospital Organization
For more information contact: 
Carol Freedman, RPh, MAS, CGP 
Clinical Pharmacist NEPHO 
Louis Di Lillo M.D., Northeast PHO Medical Director 
  
cfreed@nhs-healthlink.org | http://www.nepho.org
500 Cummings Center
Suite 6500
Beverly, MA 01915

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Northeast Phycician Hospital Organizaion | 500 Cummings Center | Suite 6500 | Beverly | MA | 01915