Pharmacy Committee Research Articles

DD-008 Prospective study on restricted-use antibiotics: ertapenem, linezolid, tigecycline and daptomycin

BackgroundBecause of antibiotic resistance problems and their frequently inappropriate use, these drugs have often been the target of attempts to restrict their use.PurposeTo analyse the appropriateness of the use of...

CP-004 Evaluation of the efficacy and safety of bevacizumab in the treatment of macular oedema secondary to retinal vein occlusion

BackgroundAfter evaluation of ranibizumab and bevacizumab by the Pharmacy and Therapeutics Committee of a tertiary hospital, for the treatment of macular oedema secondary to retinal vein occlusion (RVO), based on...

OHP-002 Financial impact of the use of bevacizumab in the treatment of macular oedema secondary to retinal vein occlusion

BackgroundAfter the Pharmacy and Therapeutics Committee of a tertiary hospital had evaluated ranibizumab and bevacizumab for the treatment of macular oedema secondary to retinal vein occlusion (RVO) based on the...

Dolutegravir.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The February 2014 monograph topics are sofosbuvir, simeprevir capsules, ibrutinib, hydrocodone extended-release capsules, and eslicarbazepine. The DUE/MUE is on sofosbuvir.

Getting Out From Behind the Paraffin Curtain

In the course of a 30-year practice, I have had the opportunity to track the professional trajectories of more than a few pathologists, from entry level to midcareer and beyond. Patterns of success and failure emerge, so I am compelled to share some of my observations with trainees and newly minted practicing pathologists. It should go without saying that among the first obligations of any physician is mastery of the technical approach to the specialty. This is especially important in pathology, as from day one we are expected to deliver accurate and timely consultations with a very low error rate. I am pleased to say that the cognitive skills of newly trained pathologists have only risen steadily with time, and most all of them pass over that first very high bar with little apparent difficulty. The fractional distillation of careers—from failure, to mediocrity, to excellence—seems to be more a function of other personality traits and practice habits. I can summarize the most desirable of these as an eagerness to get out from behind the paraffin curtain, that zone of comfort at the microscope, where the well-trained pathologist can relax with a cup of coffee and a stack of slide folders. As viewed from behind the curtain, the ideal workday is one in which the biopsies are adequate, the histologic findings pathognomonic, and the diagnoses brief, definitive, and powerful. As we all know, those ideal workdays are infrequent. Biopsies are unrepresentative, histologic findings ambiguous, and important clinical information absent and difficult to obtain. From 23 years of practice in a general community hospital, I am all too familiar with the frustrations that arise in handling those very nontextbook cases. I discovered early on that relief would come only by venturing out from behind the paraffin curtain. I started by spending time with the radiology staff, reviewing images and discussing biopsy strategy prior to the procedure. I also encouraged the gastroenterology staff to call me to the endoscopy suite when they encountered any puzzling or otherwise unusual finding. Additionally, I began to spend time in surgery, reviewing the operative schedule the afternoon before, noting cases that were likely to attract consultation, and appearing in the operating room as the procedure was getting underway. These ministrations outside the laboratory, although time consuming, were eventually rewarded not only with specimens of greater technical quality but with a boost in my own self-confidence as a diagnostician. An unexpected side effect of these adventures was an introduction to hospital politics.

The Role of Pharmacy and Therapeutic Committees in Pharmacovigilance and Drug Safety

The Role of Pharmacy and Therapeutic Committees in Pharmacovigilance and Drug Safety

Behavior Changes by Interactional Model of Communication on Physician Prescription

Each hospital has their specific Formulary formulated by Pharmacy and Therapy Committee. Physician should write the prescription based on Formulary, except in special patient condition. In fact, many prescriptions aren't written based on Formulary. Effort must be done to persuade physician to prescribe based on Formulary. Quasi experimental was applied in 30 physicians in one hospital. The Physician was divided into two groups, control and module intervention. Module explains about how Formulary was formulated by the Committee and handed to the physician by Interactional Model of Communication. Theory of Reasoned Action and Theory of Planned Behavior were used in this research. Additional variables, Locus of control, Willingness and Intention were added to this theory. The aims of this study are to increase physician prescription based on Formulary. Interactional Model of Communication expected showed an influence on willingness and intention to prescribe based on Formulary. Interactional Model of Communication expected can influence physician behavior. Statistical analysis T test, linier regression and ANOVAs was applied and the result showed Interactional Model of Communication significantly correlated with Willingness (p < 0,05).Willingness also correlated with Intention to prescribe based on Formulary. Interactional Model of Communication is correlated as comprehensive with physician prescription behavior.

Evaluation of Pharmacy and Therapeutic (P&amp;T) Committee member knowledge, attitudes and ability regarding the use of comparative effectiveness research (CER) in health care decision-making

Comparative effectiveness research (CER) is a constellation of research methods designed to improve health care decision making. Educational programs that improve health care decision makers' CER knowledge and awareness may ultimately lead to more cost-effective use of health care resources. This study was conducted to evaluate changes in CER knowledge, attitudes, and ability among Pharmacy and Therapeutics (P&T) Committee members and support staff after attending a tailored educational program. Physicians and pharmacists from two professional societies and the Indian Health Service who participated in the P&T process were invited via email to participate in this study. Participants completed a questionnaire, designed specifically for this study, prior to and following the 4-hour live, educational program on CER to determine the impact on their related knowledge, attitudes, and ability to use CER in decision-making. Rasch analysis was used to assess validity and reliability of subsections of the questionnaire and regression analysis was used to assess programmatic impact on CER knowledge, attitude, and ability. One hundred and forty of the 199 participants completed both the pre- and post-CER session questionnaires (response rate=70.4%). Most participants (>75%) correctly answered eight of the ten knowledge items after attending the educational session. More than 60% of the respondents had a positive attitude toward CER both before and after the program. Compared to baseline (pretest), participants reported significant improvements in their perceived ability to use CER after attending the session in these areas: using CER reviews, knowledge of CER methods, identifying problems with randomized controlled trials, identifying threats to validity, understanding of evidence synthesis approaches, and evaluating the quality of CER (all P values<0.001). The questionnaire demonstrated acceptable reliability and validity evidence (limited evidence of construct under-representation and construct irrelevant variance). The CER educational program was effective in increasing participants' CER knowledge and self-perceived ability to evaluate relevant evidence. Improving knowledge and awareness of CER and its applicability is a critical first step in improving its use in health care decision making.

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Introduction: Therapeutic hypothermia (TH) is the standard of care for unresponsive survivors of cardiac arrest (CA). TH may significantly affect the pharmacokinetics of unfractionated heparin (UFH) due to alterations in temperature-dependent enzymatic reactions. We previously studied the effect of TH on patients anticoagulated with UFH and showed significant elevations in activated partial thromboplastin times (aPTT). A revised UFH dosing protocol using a bolus of 40 Units/kg followed by an infusion of 7 Units/kg/hr was developed based on data gathered from our previous study. Methods: ICU patients prescribed therapeutic UFH and dosed using our modified TH dosing protocol (MP) were prospectively studied and compared to our historical control group (CG), dosed using our standard protocol. The protocol was approved by the Detroit Medical Center's Pharmacy & Therapeutics Committee and Wayne State University, Investigational Review Board. Heparin dose, duration and indication, as well as aPTT (in seconds) were collected, per protocol. The upper limit of aPTT in our lab is 200 sec. Major and minor bleeding events were recorded. Results: Twenty one patients were dosed using the MP and were compared to 48 control patients. There was no difference in baseline demographic data or indication for anticoagulation between groups. Patients in the MP group started with lower UFH bolus and starting rates than the CG, 2900 ± 670 vs 5200 ± 1475 Units, p<0.001, and 7 ± 1 vs 14 ± 4 Units/kg/hr, p<0.001, respectively. Initial aPTT was 60 ± 34 vs 153 ± 52 sec, p<0.001. This represents an increase of 2 ± 1 vs 5 ± 2 times baseline PTT. More patients achieved initial aPTT in target range using the modified protocol, 55% vs 6%, p<0.001. Average aPTT during TH was 63 ± 35 vs 131 ± 57 sec, p<0.001. The dose required to achieve target PTT at any time during TH was 7.1 ± 1 vs 6 ± 1 Units/kg/hr, p=0.78. Once patients were re-warmed heparin requirements were similar between groups. There was no difference in hospital or ICU length of stay, or in overall ICU and hospital mortality. No major bleeding events occurred during TH in the MP group, compared to 3 (6.5%) in the CG, p=0.54. All 3 major bleeding events occurred in patients whose aPTT was reported as greater than 200 seconds. Conclusions: Standard heparin dosing protocols are not appropriate in patients undergoing TH, and result in significantly prolonged aPTTs during the 24 hour cooling phase. A modified UFH dosing approach should be applied during TH to avoid supra-therapeutic heparin dosing. We recommend a 40 Unit per kilogram bolus dose and a 7 Unit/kg/hour starting rate during TH, with further adjustments based on aPTT. This reduced dosing protocol may reduce the incidence of severe bleeding events during hypothermia.

Impact of Pharmacy Intervention on the Use of Proton-Pump Inhibitors in the Hospital Setting

Determine effectiveness of pharmacy-driven medical staff training regarding proton-pump inhibitor (PPI) therapy. This study was performed in two parts. Part I evaluated baseline PPI usage within the hospital. Part II evaluated the effect of pharmacy-driven medical staff education on PPI prescribing patterns. Data were collected retrospectively via electronic chart review. Passavant Area Hospital in Jacksonville, Illinois, is a 99-bed community hospital. Patients' profiles were selected if administration of at least one PPI was electronically charted during their hospital stay. Patients discharged from the emergency department were not included in the study. There were a total of 1,089 charts reviewed (Part I: N=565; Part II: N=524). The average patient age was 66.5 years. Part I results were presented to the pharmacy and therapeutics (P&T) committee and medical staff. A series of three educational presentations were subsequently given to medical staff. Part II results were reported to the P&T committee, with further interventions to be determined after consulting with hospital administration and medical staff. Improvement of appropriate acute PPI therapy. Secondary outcome measures included duration of acute therapy and continuation of chronic therapy. There was improvement in the appropriate usage of PPI for stress ulcer prophylaxis (SUP) (P=0.1216), decreased chronic PPI therapy (P=0.0054), and increased documentation of PPI indication (P=0.0365). A decrease of appropriate acute duration of PPI for SUP was also observed (P<0.0001). Appropriate initiation of acute and continuation of chronic PPI therapies improved. Appropriate duration of use declined in SUP patients. Pharmacy interventions have an overall positive impact on appropriate use of PPI therapy.

Characterization of pharmacy services in Portuguese prisons: a national survey.

The primary purpose of this paper is to collect reliable information to characterize the pharmacy services in Portuguese prisons. The secondary purpose is to develop a set of suggestions for improving these services and, therefore, improve the health services provided to the inmate population. A three pages survey was developed that included questions covering the characterization of prison health teams, pharmacy services and pharmacy activities. This survey was sent to all Portuguese prisons, with capacity higher than 50 prisoners. The response rate was of 87.5 per cent. It was found that only 6.1 per cent of prisons had pharmacists and that in 63 per cent the guards still participated in pharmacy activities. There were not Pharmacy and Therapeutics Committees in 94 per cent of prisons and 94.4 per cent did not present adequate storage conditions for drugs. Only 51.7 per cent of prisons had computers in the pharmacy and only 3.4 per cent had access to the internet. This study found that there is a gap between public and prison pharmacy services, since most prison pharmacies in Portugal are solely locals of storage and distribution of drugs, with no effective management nor promotion of drug rational use. This paper is the first study about pharmacy services in Portuguese prisons. The information collected could be very useful to improve the Portuguese prison pharmacy services provided to prisoners.

Prothrombin Complex Concentrate

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The December 2013 monograph topics are vortioxetine, mechlorethamine gel, brimonidine tartrate topical gel, obinutuzumab, and miltefosine. The DUE/MUE is on vortioxetine.

Health care decision makers' use of comparative effectiveness research: report from a series of focus groups.

Comparative effectiveness research (CER) is a helpful approach to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about the most effective interventions. To (a) identify the factors necessary to increase the use of the Agency for Healthcare Research and Quality's (AHRQ) CER reviews in hospitals and managed care organizations; (b) assess current awareness and implementation of CER materials in these facilities and organizations; and (c) inform development of content for a workshop on CER. Pharmacy and therapeutics (PT) committee members and supportive personnel were recruited to participate in focus groups conducted at national health professional meetings. Prior to the sessions, each participant completed a prefocus group questionnaire evaluating the organization and process of the respondent's PT committee, as well as the respondent's role in the PT committee and awareness of AHRQ CER reports. Each session consisted of a focused discussion about CER and sources of evidence for PT monographs, and each participant completed a ballot to rank topics of importance for inclusion in a CER workshop for health care professionals involved in the PT process. Overarching themes were later identified using qualitative analysis of the transcripts of the focus group sessions. Thirty-nine (68%) pharmacists and 18 (32%) physicians involved in the PT process participated in 1 of 7 focus groups. Almost half of the participants had 6-15 years experience with the PT process. Participants represented health plans, hospitals, and health care systems. Two-thirds indicated they were aware of AHRQ's Effective Health Care Program's CER reviews, yet only 26% reported using the reviews in their organizations. The overarching themes reflected the need for timely and conclusive CER information; the role of the pharmacist as central to evidence synthesis for the PT process; and the need for educational programs in online formats that are designed primarily for pharmacists. Health care decision makers identified timeliness as a key factor for facilitating the use of AHRQ CER reviews and guides in hospitals and managed care organizations. To facilitate integration of CER into the decision-making process, it is imperative that key stakeholders have access to comprehensive and timely information. While the majority of participants indicated that they were aware of AHRQ CER reviews, few had used them in the PT process.

Canagliflozin.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The November 2013 monograph topics are dolutegravir, levomilnacipran, ibrutinib, serelaxin, and polynuclear iron (III)-oxyhydroxide (PA21). The DUE/MUE is on dolutegravir.

PEG-J Administration of Therapeutic Agents for Neurological Disorders: Levodopa-Carbidopa Intestinal Gel for Advanced Parkinsonʼs Disease

Purpose: To determine whether PEG-J administration of levodopa-carbidopa intestinal gel (LCIG) is an effective method for the treatment of advanced Parkinson's disease (PD). Methods: Levodopa is the most effective treatment for PD. With advanced disease, irregular gastric emptying impedes standard oral levodopa effectiveness leading to “On”/”Off” motor fluctuations and dyskinesias. Two phase 3 clinical studies enrolled advanced PD patients with persistent motor fluctuations despite optimized oral therapy. For this novel treatment, involving the collaboration of neurologists and gastroenterologists, all patients underwent a PEG-J procedure for infusion of LCIG (or placebo gel) directly to the proximal jejunum. A 12-week, randomized, double-blind, double-dummy trial compared the effectiveness of LCIG with standard oral levodopa (LC-oral) at reducing motor fluctuations and improving quality of life. A 54-week open-label international trial examined the long-term safety and efficacy of LCIG. “Off” time (when medication is no longer effective and motor symptoms return), the Unified Parkinson's Disease Rating Scale (UPDRS) and the 39-item Parkinson's Disease Questionnaire (PDQ-39) were examined. Adverse events (AEs) were recorded. Results: 71 patients were enrolled in the double-blind, double-dummy trial (n=37 LCIG, 34 LC-Oral), with a mean PD duration of 10.9 years. The reduction in “off” time (P<0.01), improvement in UPDRS Part II (activities of daily living) score (P<0.01) and improvement in PDQ-39 Summary Index (P<0.05) was greater in the LCIG group than in the LC-oral group. Three hundred fifty four patients were enrolled in the long-term, open-label study. As with the double-blind trial, “off” time, UPDRS Part II score and PDQ-39 Summary Index versus baseline were improved at all visits (through Week 54; P<0.01). Most patients (97% in double-blind, 91% in open-label) experienced at least 1 AE; serious AEs occurred in 17% (double-blind) and 31% (open-label). AEs led to discontinuation in 4.2% (double-blind) and 7.6% (open-label). Most AEs were known AEs associated with either levodopa, underlying PD or the procedure and the device. Conclusion: Intrajejunal infusion of LCIG via PEG-J is a novel approach for the long-term delivery of medication in gel form, which improved motor fluctuations and the quality of life in advanced PD patients with limited treatment options. The range of PEG-J complications was within standard ranges reported in the literature and was not increased in this ambulatory patient cohort. Disclosure - Michael Epstein: Dr. Epstein served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Dr. Epstein also serves as a lecturer for AbbVie. David Johnson: Dr. Johnson served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Robert Hawes: Dr. Hawes served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Nathan Schmulewitz: Dr. Schmulewitz serves as a medical advisor and speaker for AbbVie. Arvydas Vanagunas: Dr. Vanagunas has received compensation from AbbVie and CVS Caremark's Pharmacy & Therapeutics Committee for serving as a consultant and has been a scientific advisory board member for AbbVie. Cindy Zadikoff: CZ was a study investigator and has received compensation from AbbVie for serving as a consultant and participating in scientific advisory boards. Rod Gossen: served as executive secretary for this study and is employed by a consulting agency under contract with AbbVie. Susan Eaton, Krai Chatamra, Weining Robieson, Jordan Dubow and Janet Benesh are employees of AbbVie and hold AbbVie stock and/or stock options. AbbVie participated in the study design, research, data collection, analysis and interpretation of data, writing, reviewing, and approving the publication. Michelle M. Koutsantonis, of AbbVie, provided medical writing assistance in the development of this publication. This research was supported by an industry grant from AbbVie.

Assessment of new drugs in a tertiary hospital using a standardized tool.

To describe the profile of new drugs evaluated by the Pharmacy and Therapeutics committee in a tertiary hospital using a standardized tool, the Guideline for the Introduction of New Drugs in the Formulary (GINF form), as main objective. Retrospective observational study of drugs was assessed during 2008-2011. Variables related to the drug, the request, and the result of the evaluation were collected based on information contained in the GINF form and in the assessment reports. 63 of 75 assessed drugs (84%) were included in the hospital formulary. Only one drug (1%) was included without any restrictions. The rest of them were included as therapeutic equivalents (23%) or under specific recommendations (61%). Half of the drugs (6) not included had insufficient evidence of effectiveness compared with current treatments. Haematology and Medical Oncology were found to be the most active medical services in the application process. There was a high prevalence of drugs that had more than one advanced clinical trial (phase III and/or phase IV). Furthermore, 28% of assessed drugs were associated with a financial burden of more than ?10,000 per year for our hospital. Highquality information was provided by applicants to the P&T committee for drugs that were finally included. However, the relationship between the information provided to the P&T committee and its decision was not statistical significance. The requests received were primarily related to drugs intended for parenteral use and most of them were antineoplastic drugs. The medical departments most heavily represented were Haematology and Oncology.

Evaluation of new antimicrobials for the hospital formulary. Policies restricting antibiotic use in hospitals

In Spain, the inclusion of new antibiotics in hospital formularies is performed by the Infection Policy Committee or the Pharmacy and Therapeutic Committee, although now the decision is moving to a regional level. Criteria for the evaluation of new drugs include efficacy, safety and cost. For antimicrobial drugs evaluation it is necessary to consider local sensibility and impact in bacterial resistance to determinate the therapeutic positioning.There is compelling evidence that the use of antibiotics is associated with increasing bacterial resistance, and a great number of antibiotics are used incorrectly. In order to decrease the inappropriate use of antibiotics, several approaches have been proposed. Limiting the use of antimicrobials through formulary restrictions, often aimed at drugs with a specific resistance profile, shows benefits in improving antimicrobial susceptibilities and decreasing colonization by drug-resistant organisms. However, the restriction of one agent may result in the increased utilization of other agents. By using antibiotic cycling, the amount of antibiotics is maintained below the threshold where bacterial resistance develops, thus preserving highly efficient antibiotics. Unfortunately, cumulative evidence to date suggests that antibiotic cycling has limited efficacy in preventing antibiotic resistance. Finally, although there is still little clinical evidence available on antibiotic heterogeneity, the use of most of the existing antimicrobial classes could limit the emergence of resistance.This review summarizes information regarding antibiotic evaluation and available restrictive strategies to limit the use of antibiotics at hospitals with the aim of curtailing increasing antibiotic resistance.

Empty Shelves, Full of Frustration: Consequences of Drug Shortages and the Need for Action

Empty Shelves, Full of Frustration: Consequences of Drug Shortages and the Need for Action

Tofacitinib.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The May 2013 monograph topics are ado-trastuzumab emtansine, pomalidomide, mipomersen, pasireotide diaspartate, and glycerol phenylbutyrate. The DUE/MUE is on atypical antipsychotics, extended release.

PHP47 - ABC Analysis Of Pharmaceuticals In A Resource Limited Rural Hospital In India

The Pharmacy and Therapeutic Committee in the hospital planned to study the aggregate medicine use in the hospital. After implementation of the Essential Drug List (EDL) 2011, it was important to know the consumption and cost contributed by each pharmaceuticals in the list so that further revisions could be done on the list annually. The study was conducted for one year using Always Better Control (ABC) analysis of pharmaceuticals in the EDL. Pharmaceuticals from the EDL were categorized for A (70%) B (20%) C (10%) categories. The calculations were done from a period of January 11, 2011 to January 11, 2012 using the data from the hospital billing database. The total annual drug expenditure (ADE) was Rs. 2,61,78,251. Out of 311 pharmaceuticals in the list, 47 (15%) were in A group, 60 (19%) were in B group and the remaining 204 (66%) were in C group. In the A group 45% of the pharmaceuticals were belong to ATC category J (Antimicrobials). Out of the top 10 pharmaceuticals, the costlier one was Anti D Immunoglobulin costing Rs. 1995. But it came on sixth position as the consumption was lesser than the other ones in the top. The first one was Lopinavir-Ritonavir combination with an annual cost of 13, 76529. Insulin was on fourth position with an annual expenditure just short of one million Indian Rupees. The top 10 include 3 anti-virals and 2 anti-bacterial preparations showing the high consumption and costs of the anti-microbial agents. The least unit cost in the A category was Rs. 0.18 for ferrous sulphate – folic acid combination. Antimicrobilas consumed major resources of the charity hospital. Control on antimicrobial prescription with updated protocols and adoption of government free supply of anti-retroviral drugs will substantially reduce the hospital budget on medicines.