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Pharyngitis: To treat or not to treat? 340B Price Guide Review

When patients present with a severe sore throat and fever, it is hard not to automatically prescribe antibiotics. We want our patients to get better quickly, and the complications of untreated strep throat such as rheumatic fever and glomerulonephritis can be concerning. However, only 5-15% of adult cases of pharyngitis are caused by Group A β-hemolytic Streptococcus (GABHS).1 Most cases are actually caused by viruses such as influenza or the common cold. Identifying patients that would most benefit from antibiotic therapy can prevent unnecessary side effects of these medications and antibiotic resistance.

The recommended way to approach diagnosis of a patient with pharyngitis is to look for the four cardinal symptoms of strep throat and to order a Rapid Antigen Test (RAT) for at risk patients. Cultures can be reserved for patients who are not improving over time or patients not responding to antibiotics.

Symptoms Points

Fever 1

Absence of cough 1

Tender anterior cervical adenopathy 1

Tonsillar swelling or exudates 1

Age:

< 15 years + 1

15 – 45 years 0

> 45 years - 1

Total Score

Recommended Action

-1 – 0

No culture needed, no antibiotics needed

1 – 3

Order RAT, give antibiotics if positive

4 – 5

Order RAT, consider empiric therapy

The drug of choice for GABHS is penicillin. Surprisingly, resistance has not yet developed to this treatment; therefore it continues to be the preferred choice of therapy. Cephalosporins, macrolide antibiotics, or clindamycin can be used in patients with a penicillin allergy if tolerated, however erythromycin is no longer recommended due to increased resistance. The recommended duration of treatment is 10 days.3

Recommended Antibiotic Regimens for GABHS3

Antibiotic

Recommended Dosage

340B Price

Approximate Retail Discount Program

Penicillin VK

Adults: 250mg QID or

500mg BID

Pediatrics: 250mg BID –TID

$22

$22

$22

$5

$5

$5

Amoxicillin

50 mg/kg/day or 25 mg/kg BID

$22

$5 to $10

Cephalexin

20 mg/kg BID

$22

$5 to $15

Azithromycin

12 mg/kg/day

$22

$13 to $42

Clindamycin

7 mg/kg TID

$23

$30 to 60

340B Prices
Generally, the difference between 340B and pharmacy retail pricing is very little when treating pharyngitis. Programs such as Walgreens W-Card allow patients to purchase a variety of medications at a discount price, often lower than what the 340B program can offer. Letting the patient know about these programs can be very helpful. Medications that are likely to be less under a retail pharmacy program are listed on the 340B Price Guide and are indicated with a “W”.

References
1. “Acute pharyngitis in adults: Physician information sheet” Centers for Disease Control and Prevention, 25 Jun, 2012.Web. 30 Apr, 2014.
2. Vincent, Miriam T., Nadhia Celestin, and Aneela N. Hussain. "Pharyngitis."American family physician 69.6 (2004): 1465-1470.
3. Shulman, Stanford T., et al. "Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America." Clinical infectious diseases 55.10 (2012): e86-e102

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Torey Lam, Pharm.D.

Publisher

 

 

 

 

 

 

 

 

Lauren Hedges

Pharm.D. Candidate 2015

OSU/OHSU College of Pharmacy

 

The 340B Drug Pricing Program is managed by the Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA). For more information visit: www.hrsa.gov/opa This material is provided for general informational purposes of 340B Drug Prices only and is not an endorsement of any prescription product referenced herein. For information as to the clinical use or efficacy of a referenced product, please contact the manufacturer. 340B Price Guide makes no representations and provides no warranties as to the effectiveness or suitability for use of any prescription product referenced herein. Any referenced cost is provided as an estimate only and the actual cost is subject to change at any time and without notice. 340B Price Guide does not guarantee that the cost represented herein will be the actual and pharmacy shall at all times collect amounts due as indicated at the time of adjudication and shall be reimbursed per the terms of its agreement.'