Antiulcer therapy: an exercise in formulary management.

The purpose of formulary management is to contain costs while preserving quality care. A pharmacy cost review can identify key areas where limiting the agents used could lower costs. H2-receptor antagonists represent such agents. At UC Davis Medical Center, H2-receptor antagonists were found to be one of the highest-cost drug groups in the hospital. Seventy percent of H2-receptor antagonist use was for intravenous prophylaxis of stress ulcer. After a committee review of available data, H2-receptor antagonists were considered therapeutically equivalent. Cimetidine was chosen as the primary H2-receptor antagonist because of an estimated 36% cost savings. Inpatient H2-receptor antagonist use changed from 90% ranitidine prior to the decision to 90% cimetidine after the decision. A monitoring program revealed that there were similar numbers of elevated drug levels for theophylline, phenytoin, and lidocaine before and after the programmatic change. There was no difference in numbers of patients with theophylline toxicity on cimetidine or ranitidine. The incidence of bleeding from stress ulcer was 1.4% in the year following the change to cimetidine use. With aggressive review and utilization of scientific data, cost-saving H2-receptor antagonist restriction decisions can be made that do not compromise quality care.