https://medica-musc.researchcommons.org/musc-ptupdate/1025/thumbnail.jp

Bush, Paul W.

Garrison, Kelli L.

MacFall, Holly M.

Medical University of South Carolina

English

MEDICA@MUSC (Medical University of South Carolina)

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 8-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Kelli L. Garrison Medical University of South Carolina Holly M. MacFall Medical University of South Carolina Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Garrison, Kelli L.; and MacFall, Holly M., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 26. https://medica-musc.researchcommons.org/musc-ptupdate/26 This Newsletter is brought to you for free and open access by MEDICA. It has been accepted for inclusion in Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals by an authorized administrator of MEDICA. For more information, please contact medica@musc.edu.             Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                 August 2006   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina      Editorial Staff  Paul W. Bush, PharmD, FASHP Director, Department of Pharmacy Services  Kelli L. Garrison, PharmD Coordinator, Drug Information Services Associate Editor Newsletter Layout  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor    In This Issue   • MICROMEDEX® Healthcare Series: A Review  • An Overview of Heat-related Illnesses  • Medication Safety Alert: Promethazine Extravasation  • MED•U•WAY Program to             Focus on Women and Heart Disease  • Formulary Update MICROMEDEX® Healthcare Series: A Review MICROMEDEX® Healthcare Series is a suite of clinical deci-sion support databases that pro-vides a wide range of informa-tion designed to meet the needs of health care professionals.  It is the official point-of-care clinical knowledge reference in the Medical Center.    MICROMEDEX® Healthcare Series is available through the MUSC Library’s home page un-der Drug Information.  It may be accessed on campus or from a remote location provided that the user has a network account with login and password.     Recently, MICROMEDEX® has changed to a Internet version; therefore, the look of the database has changed (Figure 1) and two new databases have been added (ie, Lab Advisor™ and IV IN-DEX®)  MICROMEDEX® Healthcare Se-ries is updated monthly, except for the Drugs section, which is up-dated weekly.  However, it is im-portant to understand that not all of the information in each data-base is updated monthly.      The Main Keyword Search on the main page retrieves information within Drugs, Toxicology, Dis-ease, and Lab databases.  It is im-portant to remember that it is a keyword search only; therefore, multiple terms may be needed to Figure 1. MICROMEDEX® Main Page Pharmacy & Therapeutics Update   Page 2 fertility, teratogenicity, and lactation.  It is comprised of REPROTEXT®, REPROTOX®, Shepard’s Catalog of Teratogenic Agents, and TERIS®.    IV INDEX® System provides easy access to data that will help ensure accurate IV compatibility deci-sions can be made.  This database features the compatibility of drugs, solutions, and total par-enteral nutrition when in solution, during Y-Site administration, or within a syringe.  Lab Advisor™ features detailed information on over 600 labora-tory tests.  This database helps guide clinicians to identify the ap-propriate test and interpret the re-sults.  In addition, Lab Advisor™  contains information on medica-tions known to cause false posi-tive or negative results, tips to minimize patient discomfort asso-ciated with tests, and links to rele-vant information on diseases, medications, and toxicologic sub-stances.   MICROMEDEX® Healthcare Se-ries also offers a number of clini-cal calculators and algorithms.  These may be found under the Main tab.  Topics covered include the following: antidote dosing and nomograms, clinical references and calculators, dietary considera-tions and guidelines, differential diagnosis, dosing tools, drug clas-sifications, drug comparisons, im-munization and prophylaxis, labo-ratory values, measurement calcu-lators and conversions, and pediat-ric and pregnancy references.    mobileMICROMEDEX™ offers handheld information for the per-find the most relevant informa-tion.    DRUGDEX® includes drug evaluation monographs and drug consults.  Drug evaluation m o n o g r a p h s  p r o v i d e  a comprehensive review on a particular agent.  Each monograph is presented in a standardized, easy-to-follow format.  Mono-graph components include dosing information, pharmacokinetics, cautions, adverse side effects, clinical applications, etc.  Drug consults present patient-related, referenced responses to important clinical questions.   POISINDEX®, located under the Toxicology tab or through the Main Keyword Search, is divided into two main sections:  product and substance identification and poisoning management protocols.  The product and substance identification portion contains information on over one million products.  Information on pre-scription medications, industrial products, and over-the-counter preparations is included.  The poi-soning management protocol monographs include information regarding clinical effects, labora-tory/monitoring, treatment, range of toxicity, kinetics, pharmacol-ogy/toxicology, and physiochemi-cal properties.  MARTINDALE® is the official compendium of the Royal Pharmaceutical Society of Great Britain.  This is a useful reference when trying to gather information on foreign medications.  IDENTIDEX® identifies tablets and capsules by product imprint code. This is particularly useful when the practitioner is trying to identify a patient’s medications brought into the Medical Center from home.  DRUG-REAX® allows the practitioner to enter a patient’s medications and check for drug-d r u g ,  d r u g - f o o d ,  d r u g -laboratory, and drug-alcohol interactions. In addition, the practitioner may also screen for drug-disease contraindications. DRUG-REAX®  enables the user to screen for potential cross-allergenicity reactions.   DISEASEDEX® General Infor-mation and DISEASEDEX® Emergency Medicine provide detailed, evidence-based etiol-ogy and treatment information for each medical condition and provides recommendations for appropriate care including both in-depth and summary informa-tion.  CareNotes™ Instructions provide practitioners with important patient education materials to use when counseling or teaching patients. This database can be found under the Patient Ed  tab.  Instructions are available in English and Spanish and may be customized with  patient-specific information.  Information on medications, diseases, and de-vices is provided.  Materials are written at the eighth-grade reading level.    REPRORISK® is a collection    of reproductive risk databases that covers the effects of medica-tions or chemicals on all aspects of reproduction including Page 3 Pharmacy  & Therapeutics Update make the outdoor temperature feel even hotter, which is known as the heat index.4  When tem-peratures are extremely high along with increased humidity, evaporation from the skin is slowed making it much more difficult for the body to maintain a normal temperature.1,3    Those individuals at the highest risk for heat-related illnesses in-clude children, elderly, patients with chronic illness, and those that are overweight.3  Addition-ally, some medications may make patients more sensitive to the sun and its effects.5  Such medications include alpha ago-nists, anticholinergics, beta blockers, calcium channel block-ers, diuretics, ethanol, and some antidepressants.5     Heat-related deaths are prevent-able. Therefore, it is important to know the signs, symptoms, pre-vention strategies, and treatment measures for such adverse events.  Air conditioning is the number one prevention tech-nique against extreme heat.1,3  For families without air condi-tioning, visiting public places that have air conditioning such as the library, movie theater, or shopping mall may be a healthy option.1-3 Another important method is maintaining proper hydration.1-3  It is important to remind patients not to wait until they are thirsty to drink.  Fluids containing caffeine, alcohol, and sugar should be avoided as they can promote water loss.  Fluid-restricted patients should consult their physician to discuss how much extra fluid they can safely ingest.1-3  Additionally, sweating Extreme heat can cause a variety of conditions in people who are exposed and not adequately pro-tected.  More people die from ex-treme heat than from hurricanes, lightning, tornadoes, floods, and earthquakes combined.1,2  An excessive heat event is defined as a prolonged period when tem-peratures reach greater than 10 ºF above the normal high tempera-ture for that region.1,2  Urban areas may be more susceptible to the effects of excessive heat because asphalt and concrete absorb the sun’s energy and retain it longer than bare earth.2,3  Therefore, ur-ban areas do not get as much relief from the heat at night.  This phe-nomenon is referred to as the ‘urban heat island effect.’3  High humidity along with excessively high temperatures can accelerate the onset of heat-related illnesses.  The combination of high tempera-tures and elevated humidity can removes salt and minerals from the body that need to be replaced in order to maintain fluid bal-ance.1  Many sports drinks contain these minerals that are lost through sweating; however, peo-ple who are on a low sodium diet should contact their physician be-fore drinking sports drinks.    Other simple heat prevention strategies include wearing loose and light-colored clothing, avoid-ing overexertion when outdoors, taking plenty of breaks in the shade, wearing sunscreen, sched-uling outdoor activities in the early morning or late evening, and always having someone else pre-sent.1    Heat exhaustion occurs when peo-ple exercise heavily and become volume depleted from excessive sweating.3,5  This can develop in a few hours or over a period of sev-eral consecutive days of heat ex-posure.1,6  Signs and symptoms include profuse sweating, head-ache, dizziness, malaise, nausea, vomiting, chills, muscle weak-ness, hypotension, and tachycar-dia.5  People exhibiting signs or symptoms of heat exhaustion should be moved to a cool area, their legs should be elevated to promote blood flow, and they should be given plenty of cool flu-ids.1,5,6  However, fluids should not be too cold, as this can induce stomach cramps.1  Recovery should occur within a few hours.5  If the person continues to show symptoms of heat exhaustion for more than     24 hours, or if their condition worsens, they should seek immediate medical attention as heat exhaustion can rapidly di-gress to heat stroke.5,6   An Overview of  Heat-related Illnesses By:  Ashley Holt, PharmD Candidate sonal digital assistant. Information on medications, alternative medi-cines, and acute care and toxicol-ogy management is available free for MICROMEDEX® customers.  These databases may be downloaded to any handheld de-vice running on a compatible sys-tem.  To download your free sub-scription,  click on the Handheld PDA tab and follow the easy in-structions.  If you would like to request a training session in your work area, please contact the MUSC Drug Pharmacy & Therapeutics Update   Page 2 Heat stroke is the most dangerous form of heat-related illness, as it can be life-threatening if not treated quickly.5,7  During heat stroke, the body is producing heat faster than it can dissipate it.5  In this situation the body temperature rises to over 104 ºF, and if the fe-ver is not controlled it can cause organ damage.  Changes in mental status can be seen and can range from personality changes to coma.7  Other symptoms of heat stroke include a rapid heart rate, rapid and shallow breathing, in-creased or decreased blood pres-sure, absence of sweating, hot and dry skin that is red in color, head-ache, nausea, and syncope.1,5,7    There are 2 types of heat stroke: classic heat stroke and exertional heat stroke.5  Classic heat stroke occurs mostly in underlying chronic conditions that either im-pair thermoregulation or prevent removal from a hot environment.  Exertional heat stroke usually oc-curs in younger, healthy individu-als upon strenuous activity in a hot environment.    If someone is having symptoms of heat stroke they should be imme-diately moved to a cooler environ-ment and medical assistance should be sought.  Augmentation of evaporative cooling is consid-ered the treatment of choice.  Other cooling methods include placing the patient in a cool bath or shower, wrapping the patient with a cool, wet sheet, or applying ice packs to the axillae, neck, and groin areas. The patient’s body temperature should be monitored at all times.1,7  Pharmacotherapy is not required for heat stroke.  Extreme heat can also cause heat cramps.1,3  This is characterized by muscle pain and uncontrolla-ble spasms.  Cramps most com-monly occur after heavy physi-cal exertion and increased sweat-ing.1,3  Although heat cramps are not as severe as heat exhaustion or stroke, they are often a pre-cursor to more severe conditions if interventions are not taken.  A person experiencing heat cramps should cease all physical activ-ity, move to a cooler location, and drink plenty of fluids (ie, clear juice or a sports drink).1  Medical attention may be needed if the cramps are still present after 1 hour.1    Heat rash is another relatively minor condition caused by ex-cessive sweating during hot, hu-mid weather.1  Heat rash usually occurs in young children, but it can occur at any age.  The rash appears as a red cluster of le-sions that look like pimples or blisters.  These lesions usually occur on the neck, upper chest, in the groin, under the breasts, and on the elbow.1  The area af-fected should be kept dry and cool.  Baby powder can help de-crease the discomfort.  Creams or ointments should be avoided, as they hold moisture in and can worsen the symptoms.1    The key to reducing heat-related illnesses is prevention.  Under-standing and using appropriate prevention measures will de-crease the occurrence of heat-related illnesses.   References available upon request. Page 4 Medication Safety Alert:  Promethazine Extravasation Promethazine (Phenergan®) is a commonly prescribed antihista-mine that is used for sedation, mo-tion sickness, and nausea and vomiting.  It is also a known vesi-cant, which is extremely caustic to the intima of blood vessels and surrounding tissue.    Due to the properties of the pro-methazine (pH between 4 and 5.5), severe tissue injury can occur regardless of the route of par-enteral administration, although intravenous and inadvertent in-traarterial or subcutaneous ad-ministration results in more sig-nificant complications (eg, burn-ing, erythema, pain, swelling, se-vere spasm of vessels, thrombo-phlebitis, nerve damage, paralysis, abscess, tissue necrosis, gan-grene).    Several cases of promethazine ex-travasation were detailed in the August 10, 2006, edition of the ISMP Medication Safety Alert.  The actual incidence of extravasa-tion is unknown; however, patient harm may be occurring more fre-quently based on adverse event reports submitted, articles in the literature, and lawsuits.  There-fore, safe administration of pro-methazine is to necessary to re-duce the risk of harm in our pa-tients.  Along with manufacturer recommendations, the following strategies should be followed: • Limit the concentration to          25 mg/mL.  • Consider using a lower start-ing dose such as 6.25 or             Page 3 Pharmacy  & Therapeutics Update Formulary Update The  Pharmacy   and  Therapeu-tics Committee recently ap-proved the following actions:  Additions: Effective August 15, 2006 Atazanavir (Reyataz®)  100-, 150-, and 200-mg  capsules   Fosamprenavir calcium (Lexiva®)  700-mg tablets   Emtricitabine (Emtriva®)  200-mg capsule and 10-mg/mL oral solution   Nepafenac (Nevanac®)  0.1% ophthalmic suspension   Restriction Removal: Effective August 15, 2006 Ziprasidone intramuscular injec-tion (Geodon®) will be available on an unrestricted basis.  Changes in Restrictions: Effective August 15, 2006  Ropivacaine (Naropin®)  Prescribing is restricted to the anesthesiology service or by pa-tient location in the pain clinic.   Nondepolarizing muscle        relaxants  All nondepolarizing muscle re-laxants that are currently formu-lary restricted (ie, atracurium Page 5 T h e  n e x t  M E D • U • W A Y Conference will focus on women and heart disease.  The program will be held on Thursday,  September 21, 2006, at 12:00 PM, in 2 West Amphitheater.    The featured speakers will be Marian Taylor, MD,  Assistant Professor, Division of Cardiology, Anne Spencer, PharmD, BCPS, Associate Professor, College of Pharmacy, and Christine Mancine, RN, Clinical Nurse Leader, Heart and Vascular Center. besylate, mivacurium chloride, pancuronium bromide, ro-curonium bromide, vecuronium bromide) now have the same formulary restriction.  Prescrib-ing is restricted to the anesthesi-ology service or by patient loca-tion in the emergency depart-ment or intensive care unit.   Mercaptopurine (Purinethol®)  Prescribing is restricted to phy-sicians on the hematology/oncology service or to attending physicians or fellows on the gas-troenterology and gastrointesti-nal surgery service for patients who have inflammatory bowel disease (ie, Crohn’s disease, ul-cerative colitis).   Automatic Therapeutic Sub-stitution (ATS) Effective August 15, 2006 DuoNeb® nebulization solution has been added to the ATS pro-gram.  The protocol is located on the Formulary and Drug In-formation Resources Web site.   Line Extensions: Effective August 15, 2006 Urokinase (Abbokinase®)  250,000-units/5-mL injection   Pregabalin (Lyrica®)  25-mg capsule   Deletions: Effective August 15, 2006 Tuberculin (Tubersol®)  1-TU/0.1-mL and  250-TU/0.1-mL vials   Sulfacetamide/prednisone (CetaPred®)  3.5-gram ophthalmic ointment Med•U•Way to Focus on Women and  Heart Disease Attendees will receive 1 credit hour of continuing education, and lunch is  provided.  MED•U•WAY is sponsored by the Pharmacy and Therapeutics Committee.  12.5 mg, especially in elderly patients. • Require further dilution of the        25 mg/mL strength to reduce vesicant effects and enable slower administration.  Dilute the 25 mg/mL strength in 10 to 20 mL of NS or D5W  and administer through a running IV line. • Give through a large-bore vein, preferably through a cen-tral access site.  Promethazine should not be administered through hand or wrist veins. • The patency of the access site should be verified  before ad-ministration. Of note, aspira-tion of dark blood does not preclude intra-arterial place-ment of the needle because blood can become discolored when in contact with pro-methazine. • Educate patients prior to ad-ministration about the signs and symptoms of extravasa-tion and have them report any symptoms immediately. 

Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals, August 2006

https://medica-musc.researchcommons.org/cgi/viewcontent.cgi?article=1025&context=musc-ptupdate

Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals

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