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Executive Summary

STREPTOKINASE USE AT LOS ANGELES CEDARS-SINAI HOSPITAL INCREASED TO 67% of the hospital's thrombolytic utilization during the six-month period of April through October 1991, up from 16% of use in the previous 12-month period. The sharp jump in streptokinase use at the 1,200-bed private hospital in West Los Angeles coincides with two events: (1) the March discussion at the American College of Cardiology meeting of the ISIS-3 comparison of three thrombolytics; and (2) the initiation of an effort by the hospital pharmacy at Cedars-Sinai to shift use to streptokinase by prepackaging a thrombolysis kit for the emergency room. With the increased streptokinase use, Cedars-Sinai Hospital cut its drug expenditures for thrombolytics from $ 8,500 per month in the twelve months from April 1990-March 1991 to $ 4,000 per month in the recent six-month period. Cedars-Sinai pharmacy clinical coordinator Emmanuel Saltiel reported the change in thrombolytic use patterns at a Dec. 10 presentation at the American Society of Hospital Pharmacists annual mid-year meeting in New Orleans. Saltiel described Cedars-Sinai as a major California cardiology center with 120 affiliated cardiologists. The Los Angeles hospital's experience is indicative of the general trends in the thrombolytic field, where Genentech's Activase (tPA) has been losing sales momentum. In the three months ended Sept. 30, the company reported tPA sales of $ 46.7 mil., down from $ 50 mil. in the second quarter of this year and also slightly lower than the comparable quarter in 1990. The prepackaging of streptokinase in an administration kit for the Cedars -Sinai emergency room began in April of this year, Saltiel said. The kit, called the SK-Tray, was designed, Saltiel explained, to offset the perception of the medical staff that tPA and APSAC (Eminase from SmithKline-Beecham and Upjohn) were easier to administer than streptokinase. The perception of greater convenience of the two more expensive agents was one of the major reasons that a previous effort at Cedars-Sinai to shift the use of tPA to streptokinase had failed. The SK-Tray includes a 1.5 mil. IU vial of streptokinase with the necessary infusion equipment, heparin and a 75 mg baby aspirin. The hospital's inpatient director of cardiology suggested a change in guidelines to urge streptokinase use after the 1990 publication of the GISSI-2 results, Saltiel noted. That recommendation, however, went generally unheeded. While there was a drop in Activase use (down to 57%) in 1990, streptokinase use in 1990 remained relatively low. Eminase was the big gainer at Cedars-Sinai after GISSI-2, increasing to 28% of the hospital's thrombolytic use. Eminase has been the big loser at Cedars -Sinai with the development of the SK-Tray. Saltiel reported to ASHP that "APSAC is disappearing rapidly" from use at his hospital. The pharmacy department at Cedars-Sinai, Saltiel observed, is going to recommend deletion of Eminase from its formulary before the end of the year. For two-and-a-half years from late 1987 until May of 1990, while Activase was the exclusive thrombolytic at Cedars-Sinai, the hospital was spending about $ 11,400 per month on thrombolytics, Saltiel noted. The hospital spent $ 356,000 on Activase purchases during that period. With the recent ascendancy of streptokinase, the hospital has reduced that figure to about $ 4,000 per month. Saltiel estimated that those reductions are saving the hospital about $ 100,000 on an annual basis. In a press release, Cedars-Sinai pharmacy director Rita Shane estimates that a national switch from Activase to streptokinase could "save as much as $ 66 mil." The press release was prepared by Phase V Communications for Cedars-Sinai under a grant from Kabi-Pharmacia, the maker of Kabikinase. Cedars-Sinai uses that brand of streptokinase in its prepackaged tray. Kabi-Pharmacia included a sample of the SK-Tray in an exhibit at the ASHP mid- year meeting.

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