Assessment of integrated specialty pharmacy services as a medication optimization strategy for rifaximin in hepatic encephalopathy patients

Abstract Background: Lactulose non-adherence has been identified as a factor for recurrent episodes of hepatic encephalopathy (HE). Treatment guidelines recommend adding rifaximin (Xifaxan1) to lactulose for ongoing management after an overt HE recurrence on lactulose alone to reduce the risk of further episodes and HE-related hospitalizations. Clinical observations suggested that rifaximin therapy is not initiated in patients upon HE-related hospital discharge where indicated. Aims: Integrate the CHI Health Specialty Pharmacy medication access coordinator (MAC) into the cascade of care of patients during an HE-related hospitalization to optimize access to and initiation of rifaximin upon discharge. Methods: Retrospective assessment of integrated MAC assistance in the CHI Health gastroenterology clinic from 26 September 2018 to 31 March 2019. Hospitalized patients were identified using TheraDoc2 reporting. Inclusion criteria: rifaximin ordered during an HE-related hospital admission at CHI Health. Exclusion criteria: discharge care assignment to an alternative physician group or facility. Primary outcome: the percentage of patients initiated on rifaximin upon hospital discharge via the integrated MAC. Secondary outcomes: cases requiring benefits verification and financial assistance, and number of rifaximin prescriptions acquired by the CHI Health Specialty Pharmacy. Results: A total of 40 patients met the inclusion criteria during the assessed timeframe. Thirty-one patients were excluded, 27 to other groups and 4 to facilities. Integrated MAC assistance was utilized for the remaining 9 patients and 100% were initiated on rifaximin upon discharge. Of those, 4 required benefits prior authorizations, 2 qualified for manufacturer patient assistance and 3 received sample medication. CHI Health Specialty Pharmacy acquired 2 rifaximin prescriptions. Conclusions: Integrated MAC assistance in a health-system gastroenterology clinic optimizes rifaximin access and initiation in patients following an HE-related hospitalization. It is anticipated that more patients going forward will qualify for MAC assistance due to a reduction in the community physician groups providing care at CHI Health. Further evaluation is warranted to determine whether medication optimization results in improved adherence and reduced readmissions in this population.