BACKGROUND: In the Veterans Health Administration,
patiromer is a formulary medication restricted by prior authorization and criteria-for-use (CFU). Historically,
patiromer approval was restricted by step
therapy, requiring prescribers to trial
sodium polystyrene sulfonate (SPS). OBJECTIVE: To describe clinical scenarios leading to
patiromer initiation by characterizing patient experience with primary
hyperkalemia treatment modalities, especially SPS. METHODS: All veterans who initiated
patiromer between January 1, 2016, and February 28, 2021, with
chronic kidney disease and dispensed SPS during the 3 months preceding
patiromer were included. A structured chart-review process was used to abstract prior authorization
drug request notes to characterize
patiromer approval and patient experience with primary
pharmacotherapy. Results were reported with descriptive frequencies and proportions. RESULTS: Three hundred thirty-one veterans met inclusion criteria. Primary justification for
patiromer initiation included continuation of
patiromer initiated outside the Veterans Health Administration or during inpatient stay (5.7%) and SPS inventory shortage (25.4%). CFU justification was mentioned in 83.7% of notes and, among those with CFU justification, SPS treatment was documented in 68.7%. Clinician statements indicating that SPS was ineffective occurred in 65 (41.7%) and statements of safety concerns (either observed or potential) in 37 (23.7%) veterans. CONCLUSIONS:
Patiromer approval is multifactorial, and clinicians often opted to avoid long-term SPS use because of safety concerns, lack of consistent availability, and concerns about its appropriateness for longterm
hyperkalemia management. DISCLOSURES: Drs Patel and Sauer received funding from Otsuka Canada
Pharmaceutical Inc. to study the use of
patiromer in the VHA. This material is the result of work supported with resources and the use of facilities at the VA
Salt Lake City Health Care System. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. Drs Qualls and Pinnell are supported by the VA Advanced Fellowship Program in Medical Informatics with the Office of Academic Affiliations. This work was funded through a partnered research mechanism. Otsuka Canada
Pharmaceutical Inc. was not involved in development or review of this manuscript.