https://medica-musc.researchcommons.org/musc-ptupdate/1019/thumbnail.jp

Berensen, Nannette M.

Bush, Paul W.

Davis, Kelli L.

MacFall, Holly M.

Medical University of South Carolina

Moorman, Krystal L.

English

https://medica-musc.researchcommons.org/musc-ptupdate/1021/thumbnail.jp

MEDICA@MUSC (Medical University of South Carolina)

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 4-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 22. https://medica-musc.researchcommons.org/musc-ptupdate/22 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. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/22       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                                    April 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina     Editorial Staff   Paul W. Bush, PharmD, MBA, FASHP Director, Department of  Pharmacy Services  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Services Editor  Kelli L. Davis, PharmD Drug Information Specialist Associate Editor Newsletter Layout  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor  Krystal L. Moorman, PharmD Drug Information Practice Resident Assistant Editor      In This Issue  • Joint Commission on Accreditation of Healthcare Organizations’ 2006 National Patient Safety Goals  • Look-alike, Sound-alike Medications at MUSC  • MED•U•WAY Program to Focus on Sickle Cell Disease  • Discontinuation of Streptokinase and Urokinase  • Formulary Update Joint Commission on Accreditation of             Healthcare Organizations’ 2006 National Patient Safety Goals By: Kristen Garris, PharmD Pharmacy Practice Resident The purpose of the Joint             Commission on Accreditation  of Healthcare Organiza-tions’ (JCAHO) National Patient Safety Goals (NPSGs) is to pro-mote specific improvements in patient safety. NPSGs focus on problematic areas in health care and describe evidence- and ex-pert-based solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high qual-ity health care, NPSGs focus on system-wide solutions, wherever possible.   NPSGs are derived primarily from informal recommendations made in the JCAHO safety newsletter, Sentinel Event Alert. As sentinel events are reported to JCAHO, a sentinel event advi-sory group works to develop goals that focus on system-wide solutions in order to prevent sub-sequent events from occurring, thereby enhancing the quality of care received within JCAHO-accredited institutions.   As with JCAHO standards, ac-credited organizations are evalu-ated for continuous compliance with the specific requirements as-sociated with NPSGs. The follow-ing goals and requirements are those pertaining to hospitals only.  New goals and requirements are italicized.  Goal 1: Improve the accuracy of patient identification.  • Requirement 1A:  Use at least 2 patient identifiers when             administering medications or blood products, when taking blood samples and other speci-mens, or when providing any other treatments or procedures. Acceptable identifiers may             be the individual’s name,         an assigned identification num-ber, telephone number, photo-graph, or other person-specific            identifier.  Goal 2: Improve the effectiveness of communication among all    caregivers.  • Requirement 2A:  For verbal or telephone orders or for tele-phonic reporting of critical test results, verify the complete or-der or test result by having the person receiving the order or Pharmacy & Therapeutics Update   Page 2 test result read back the com-plete order or test result.  When-ever possible, the receiver of the order should write down the complete order or test result or enter it into a computer, and then read it back to confirm with the individual who gave the order or test result.   • Requirement 2B:  Standardize a list of abbreviations, acro-nyms, and symbols that are not to be used in the organization.  A list is provided in MUSC-MC policy C-21, Use of Abbrevia-tions.  • Requirement 2C: Measure, assess, and take action to im-prove the timeliness of report-ing and the timeliness of receipt by the responsible licensed caregiver of critical test results and values.  • Requirement 2E:  Implement          a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.  Hand offs include up-to-date informa-tion regarding the patient’s      care, treatment and services, condition, and any recent or          anticipated changes.  Interrup-tions during hand offs should be limited to minimize the possi-bility that information would fail to be conveyed or would            be forgotten.  Goal 3: Improve the safety of us-ing medications.  • Requirement 3B:  Standardize and limit the number of drug concentrations available.  This can be interpreted as eliminat-ing use of the “rule of six” in the Children’s Hospital.  • Requirement 3C: Identify and annually review a list of look-alike, sound-alike medi-cations used in the organiza-tion, and take action to prevent errors involving the inter-change of these agents.  The specific medications and strategies chosen at MUSC are described on pages 3 and 4.  • Requirement 3D:  Label all medication containers (eg, sy-ringes, medicine cups, basins), or other solutions on and        off the sterile field in pe-rioperative and other proce-dural settings.  Goal 7: Reduce the risk of healthcare-associated infections.  • Requirement 7A:  Comply with current Centers for Dis-ease Control and Prevention hand hygiene guidelines.  This information is posted at www.cdc.gov/handhygiene/.  • Requirement 7B:  Manage all identified cases of unantici-pated death or major perma-nent loss of function related to a healthcare-associated infec-tion as sentinel events.  These unanticipated deaths and inju-ries meet the definition of a sentinel event and are required to undergo a root cause analy-sis.  Goal 8: Accurately and com-pletely reconcile medications across the continuum of care.  • Requirement 8A:  Implement          a process for obtaining and documenting a complete list of the patient’s current medica-tions upon admission to the          organization.   • Requirement 8B:  A complete list of the patient’s medications is communicated to the next provider of service whenever a patient is referred or transferred to another setting, service, prac-titioner, or level of care within or outside the organization.  Goal 9:  Reduce the risk of patient harm resulting from falls.  • Requirement 9B:  Implement a fall reduction program and evaluate the effectiveness of the program.  Further information on NPSGs and implementation expectations is posted at www.jcaho.org.                     In an effort to improve our com-pliance, Quality Management is currently posting the NPSGs throughout the organization and drafting posters to raise awareness regarding other JCAHO require-ments such look-alike, sound-alike medications and the univer-sal protocol for preventing wrong site, wrong procedure, or wrong person surgery.   Look-alike, Sound-alike           Medications at MUSC By: Katie Namtu Pharmacy Practice Resident In 2001, the Joint Commission on Accreditation of Healthcare Or-ganizations (JCAHO) published a Sentinel Event Alert on look-alike, sound-alike medications (LASAs).  Since then, this initiative has been added to the 2006 National Patient Safety Goals (NPSGs).  Based on the goals, an organization must choose a minimum of 10 look-Page 3 Pharmacy  & Therapeutics Update  Page 3 The Pharmacy and Therapeutics Committee recently approved the following changes:  Additions: Effective April 17, 2006 Rifaximin (Xifaxan®) 200-mg tablet  Moxifloxacin (Avelox®) 400-mg tablet and 400-mg/mL intravenous solution  Added with restriction: Effective date pending 17-alpha hydroxyprogesterone caproate will be restricted for use in women with a history of spontaneous preterm birth, sin-Formulary Update gleton gestation, and who are receiving prenatal care.  Change in restriction: Effective April 17, 2006 Nesiritide (Natrecor®) is re-stricted for prescribing by cardi-ology or cardiothoracic surgery attending physicians and fellows for patients with documented acutely decompensated heart failure.  Line extensions: Effective April 17, 2006 Lorazepam (various) 0.5-mg/mL extemporaneously prepared oral suspension  Trimethobenzamide (Tigan®) 300-mg capsule  Kaletra® 200-mg/50-mg tablet  Olanzapine (Zyprexa®) 5-, 15-, and 20-mg tablet  Pregestimil® RTF Formula 3-ounce bottle  Deletions: Effective April 17, 2006 Gatifloxacin (Tequin®) 200- and 400-mg tablet, 200- and 400-mg/mL intravenous solution  Lorazepam (various) 2-mg/mL oral suspension  Trimethobenzamide (Tigan®) 250-mg capsule  Kaletra® 133.3-mg/33.3-mg capsule  Thiethylperazine (Torecan®) 5-mg/mL injection  Humulin® 50/50 100-units/mL vial alike, sound-alike medication combinations.    The Medication Safety Team has chosen 10 medication combina-tions that are potentially problem-atic (see page 4).  Errors associ-ated with these medications can lead to serious adverse drug reac-tions (ADRs). In addition, strate-gies were developed to prevent medications errors due to look-alike, sound-alike medications and are as follows.  • Tall man lettering on preprinted order forms, computerized screens, and medication labels • Storage segregation in the  pharmacies and AcuDose-Rx® cabinets • Alert stickers posted in                  the pharmacy areas and Acu-Dose-Rx® cabinets • Specific labeling of the medica-tion pockets in the AcuDose-Rx® cabinets • Alternate distribution and stor-age systems for insulin products • Staff awareness of the differ-ences between conventional and lipid-based formulations MED•U•WAY Conference to Focus on Sickle Cell Disease T h e  n e x t  M E D • U • W A Y conference will focus on the practical management of sickle cell disease.  The program will be held on Thursday, May 18, 2006, at 12:00 PM, in 2 West Amphitheater.    The featured speakers will be  Sherron Jackson, MD, Division of Pediatric Hematology/Oncology, N. Robert Axon, MD, Division of General Internal Medicine and Geriatrics; Dominic Ragucci, PharmD, BCPS, Department of Pharmacy Services; and Brenda Gumm-Carey, RN, Nurse Case Manager, Clinical Effectiveness.  Attendees will receive 1 credit hour of continuing education, and lunch is provided. Discontinuation of                Streptokinase and Urokinase Streptokinase (Streptase®) and urokinase  (Abbokinase®) have been discontinued by their manufacturers.  Currently, the clinical pharmacy staff is work-ing with the primary users of these medications to determine appropriate alternatives.  If you have any additional questions regarding this issue, please con-tact Heather Kokko, PharmD, at kokko@musc.edu.  Pharmacy & Therapeutics Update   Page 4 PROBLEMATIC MEDICATION NAMES POTENTIAL ERRORS AND CONSEQUENCES Chemotherapeutic Agents CISplatin (Platinol®)  CARBOplatin (Paraplatin®) Doses for carboplatin generally exceed the maximum safe dose of cisplatin.  Severe toxicity and death have been associ-ated with accidental cisplatin administration. PACLItaxel (Taxol®)  DOCEtaxel (Taxotere®) Confusion between these medications may result in serious adverse outcomes since they have different dosing recommen-dations and are used for the treatment of different cancers. DACTINOmycin (Cosmegen®)  DAUNOrubicin (Cerubidine®) Confusion between these medications may result in serious adverse outcomes since they have different dosing recommen-dations and are used for the treatment of different cancers. DOXOrubicin (Adriamycin®, Rubex®)  DAUNOrubicin (Cerubidine®) Confusion between these medications may result in serious adverse outcomes since they have different dosing recommen-dations and are used for the treatment of different cancers. VinBLAStine (Velban®)   VinCRIStine (Oncovin®) Due to name similarity, fatal errors have occurred when pa-tients were given vincristine at a higher vinblastine dose. Conventional versus Liposomal Chemotherapeutic Agents  DOXOrubicin, CONVENTIONAL (Adriamycin®, Rubex®)  DOXOrubicin LIPOSOMAL (Doxil®)  DAUNOrubicin, CONVENTIONAL (Cerubidine®)  DAUNOrubicin LIPOSOMAL (Daunoxome®)   PACLItaxel, CONVENTIONAL (Onxol™, Taxol®)  PACLItaxel, LIPOSOMAL (Abraxane™)   Cytarabine, CONVENTIONAL (Cytosar-U®)  Cytarabine, LIPOSOMAL (DepoCyt™) These products are not interchangeable. Lipid-based formula-tion dosing guidelines differ significantly from conventional dosing. Accidental administration of the liposomal product, instead of the intended conventional product, has resulted in death. Opioid Analgesics CONVENTIONAL morphine oral liquid (MSIR®)   Morphine CONCENTRATED liquid (Roxanol®) Concentrated (20 mg/mL) morphine has been confused with conventional strengths (eg, 2 mg/mL and 4 mg/mL). HYDROmorphONE injection (Dilaudid®)   MorphINE injection (various) These products are not interchangeable. Fatal errors have oc-curred when hydromorphone was confused with morphine. For equianalgesic dosing information, please refer to the opioid analgesic comparison chart at http://www.musc.edu/pharmacyservices/medusepol/opioidanalgesicfinal.pdf. Insulin Products  Novolin R Novolin NPH Novolin 70/30 Similar names, strengths, and concentration ratios have led to numerous medication errors.  For more information regarding the insulin products, please refer to the insulin products com-parison chart at http://www.musc.edu/pharmacyservices/medusepol/InsulinComparisonChart.pdf. Aspart  (Novolog®) Lispro (Humalog®) - NF Novolog 70/30 Humalog 75/25 - NF Glargine (Lantus®) Humulin® R U-500 Amphotericin   Amphotericin B desoxycholate (Amphocin®, Fungizone®)   Amphotericin B cholesteryl sulfate complex (Amphotec®) – NF   Amphotericin B liposomal (Ambisome®)   Amphotericin B lipid complex (Abelcet®) -NF These products are not interchangeable.  Doses of the lipid-based products are higher and vary from product to product. Confusion between these products has resulted in episodes of severe and sometimes fatal outcomes. Other Medications   LaMOTRIgine (Lamictal®)  LaMIVUdine (Epivir®) These medications are from different medication classes.  Pa-tients erroneously receiving one of these medications could experience adverse outcomes and would not receive the in-tended treatment for their illness. Bupropion (Wellbutrin® SR)  Bupropion (Wellbutrin® XL) - NF These formulations are not interchangeable.  The sustained release (SR) product is typically dosed twice daily, and the extended release (XL) formulation is dosed once daily. ‡ Nonformulary (NF) products 

Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals, March/April 2006

https://medica-musc.researchcommons.org/musc-ptupdate/1023/thumbnail.jp

Garrison, Kelli L.

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 6-1-2006 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 Krystal L. Moorman 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.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 24. https://medica-musc.researchcommons.org/musc-ptupdate/24 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                                    June 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   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  Krystal L. Moorman, PharmD Drug Information Practice Resident Assistant Editor     In This Issue   • Formulary Changes for Insulin Products  • Enhancements to the Online MUSC-MC Formulary of Accepted Drugs   • Changes for the Mayday Orange Tackle Boxes   • Did You Know…  • Formulary Update Formulary Changes for Insulin Products Hospitalized patients who have hyperglycemia either have pre-existing diabetes, have undiag-nosed diabetes, or have hyper-glycemia due to factors associ-ated with hospitalization (eg, medications, stress, surgery).  Epidemiological studies and data from clinical trials suggest that, regardless of the diagnosis of diabetes, hyperglycemia during hospitalization is associated with increased morbidity and mortal-ity.  However, control of the pa-tient’s blood glucose in the hos-pital has not been a therapeutic priority until the last few years.1,2    In 2004, the Medical Center in-troduced the Diabetes Manage-ment Service (DMS) as part of a hospital initiative to offer spe-cialized care to patients with dia-betes or problems with hypergly-cemia.  Since that time, DMS has developed numerous tools to improved care of these patients, including revised insulin order forms, adult hypoglycemia pro-tocol, and clinical pathways to aid nurses.  With the advent of these practice changes, issues with insulin products still arise. Insulin is frequently reported to be associated with significant risk when used inappropriately, making it a commonly recognized high-alert medication.4-6 From 2003 to 2005, insulin products ranked second at MUSC among the list of most frequently reported agents with medication occur-rences.4  Currently, the goal is to minimize medication misadven-tures associated with insulin prod-ucts and standardized treatment of patients with hyperglycemia.  DMS recommends that patients receive a long-acting insulin (ie, Novolin® NPH or insulin glargine [Lantus®]) as a basal insulin with a rapid-acting insulin (ie, insulin aspart [Novolog]) for meal cover-age.  Correction insulin can be added to the rapid-acting insulin if hyperglycemia occurs despite the scheduled insulin regimens.  The correction protocols replace the sliding scale protocols.  Due to these recommendations, the formulary status of selected insulin products has been changed.  The rationale is to en-sure safe use of insulin.  The goal is to decrease the number of insu-lin products in order to decrease the opportunity for error.  The use of regular insulin for subcutane-ous dosing will be restricted to practitioners from DMS.  This Pharmacy & Therapeutics Update   Page 2 Figure 1.  Educational Poster for Formulary Insulin Changes product will still be available for the following intravenous uses: continuous infusions, parenteral nutrition, hyperkalemia, insulin pumps, pediatric dilutions, and deceased organ donors.  Insulin aspart (NovoLog®) will be the in-sulin of choice for meal coverage and correction.  Other changes include the deletion of NovoLIN® 70/30 and the addition of Novo-LOG® Mix 70/30.  Both Novo-LOG® and NovoLOG® Mix 70/30 are 1:1 conversions with regular insulin and NovoLIN 70/30, re-spectively.    The formulary effective date of these change is July 1, 2006.  DMS has provided education re-garding these changes to all of the departments and educational post-ers have been posted in patient care areas (Figure 1).   Enhancements to the Online MUSC-MC           Formulary of                       Accepted Drugs The MUSC-MC Formulary of  Accepted Drugs is a list of medi-cations that are approved for      use at the Medical Center.  The goal of the of the formulary is      to provide the most safe, effica-cious, and cost-effective treatment to our   patients.    The formulary is available at www.formluaryproductions.com/musc, and the link can be found on the MUHA Intranet Page.  The online formulary contains medica-tions and respective formulations that are approved for use at the Medical Center, comments re-garding restrictions, links to medi-cation-specific preprinted order forms, and links to the Micro-medex monograph, patient edu-cation leaflet, and PubMed cita-tions for each medication.  The online formulary may also be downloaded to a PDA through AdvantGo.  To download the formulary, follow the instruc-tions provided on the Web site.    Recently, the main page of the Web site has been updated to provide access to relevant infor-mation regarding medication use (Figure 2).  Additions include links to the Pharmacy and Thera-peutics Update: Drug Information for Health Care Professionals newsletters, Automatic Therapeu-tic Substitution Protocols, Formu-lary Restricted Medications, Drug Information Resources, Medica-tion Safety Resources, Drug Shortage Resources, and Useful Healthcare Internet Sites.     The Drug Information Resources section provides links to the adult Page 3 Pharmacy  & Therapeutics Update Figure 2. MUSC-MC Formulary Of Accepted Drugs Web site and pediatric continuous infusion guidelines, adult and pediatric in-travenous push medication ad-ministration charts, adult and pe-diatric electrolyte guidelines, and other guidelines and charts perti-nent to medication use.  In addi-tion, this section provids a link to the Medicare Part D and Medicaid formularies.  The Medication Safety section provides links to the 2006 Na-tional Patient Safety Goals, MUSC looks-alike, sounds-alike medications, medications with black-box warnings, oral formula-tions that should not but crushed or chewed, and the order writing guidelines with prohibited abbre-viations.  The Drug Shortage Resource sec-tion provided links to the MUSC drug shortage Web site and infor-mation available through the Food and Drug Administration (FDA) and the American Society of HealthSystem Pharmacists.  Useful healthcare internet sites have been compiled to assist healthcare professionals with information for themselves and their patients.  The sites for healthcare professionals include the FDA, Centers for Disease Control and Prevention (CDC), eMedicine, MDConsult, Med-scape, MerckMedicus, National Guideline Clearinghouse, Na-tional Library of Medicine, and UpToDate.  For consumers, eMedicine - Consumer Edition, KidsHealth, and MedlinePlus provide information regarding disease states and medications.  For any questions regarding this site, please contact the Drug In-formation Center at 2-3896 or druginfo@musc.edu.  Changes for the          Mayday Orange           Tackle Boxes These changes were necessary   to place first-line medications needed for any mayday in the OTBs, and to allow the eventual removal of the “Anaphylaxis Kits” from the floors.  The effec-tive date is August 31, 2006; how-ever, specific notification will be sent when this occurs.  The updated OTBs will have dated blue labels (July 5, 2006) on the boxes identifying the additions and deletions, as well as revised content lists and patient charge sheets.  As the current OTBs are returned to the Distribution Cen-ter, they will be exchanged with the refurbished, updated boxes.  Any questions about the changes or use of the safety shield needles should be referred to Donna Bar-rio, PharmD, Coordinator, Phar-macy Support Services, at 2-1363 or barriodj@musc.edu.  Other information regarding may-d a y s  c a n  b e  f o u n d  a t w w w . m c i n t r a n e t . m u s c . e d u /mayday/. After a recent review by the Mayday Committee, the orange tackle boxes (OTBs) will un-dergo changes to certain prod-ucts and medications (See Ta-bles 1 and 2).   Did You Know... The Human Papillomavirus (HPV) Virus Vaccine (Gardasil®), manufactured by Merck, is the first vaccine developed to prevent cervical cancer, precancerous genital lesions and genital warts due to HPV.  The vaccine is highly effective against 4 types of the HPV virus, including 2 that cause about 70% of cervical can-cer. Those who have not acquired HPV would get the full benefits of the vaccine. Pharmacy & Therapeutics Update   Page 2 Items Removed Quantity Epinephrine 1-mL ampule (1 mg/mL) 2 Lidocaine 2% 100-mg/5-mL syringe 1 21 g 1-inch ‘plain’ needles 12 TB syringes with ‘plain’ needles 5 Epinephrine 1-mg/mL vial label that reads          “FOR HIGH DOSE EPI ONLY” -- Items Added Quantity Adenosine 6-mg/5-mL syringe 3 Amiodarone 150-mg/3-mL vial 2 Diphenhydramine 50-mg/mL (1-mL) vial 1 Methylprednisolone sodium succinate                   500-mg vial 1 21 g 1-inch Safety Shield (eclipse) needles 8 TB syringe with Safety Glide needles 5 Epinephrine 30-mL vials (1 mg/mL) label that reads “FOR SC OR ET USE ONLY” -- Amiodarone dilution instruction sheet with           5% dextrose solution (50 mL) and 30-mL syringe -- Table 2.  Items Added to the Orange Tackle Boxes Table 1. Items Removed from the Orange Tackle Boxes  Formulary Update The  Pharmacy   and  Therapeutics  Committee recently approved the following actions:  Additions: Effective June 19, 2006 Vytorin® 10/10-, 10/20-, 10/40-, and  10/80-mg tablets    Effective July 1, 2006 NovoLog® Mix 70/30 100-units/10-mL vials  Addition with Restriction: Effective June 19, 2006 Cetuximab (Erbitux®)  100-mg/50-mL single-use vials   Restriction Added: Effective July 1, 2006 As part of the initiative to limit the use of regular insulin (Novolin® R), the subcutaneous administra-tion of this product will be re-stricted to the Diabetes Manage-ment Service.  100-units/10-mL vials   Line Extensions: Effective June 19, 2006 Sarna® Lotion 7.5-oz bottles  Albuterol/ipratropium (DuoNeb®) 3-mL unit-dose vials  Deletions: Effective June 19, 2006 Rabies vaccine (RabAvert®) 1-mL injection   Effective July 1, 2006 Novolin® 70/30  100-units/10-mL vials  Page 4 CDC Advisory Committee on Im-munization Practices (ACIP) rec-ommends that the HPV vaccine be routinely administered to all girls when they are between 11 and 12 years of age.  Additionally, the ACIP recommendation allows for the vaccination of girls beginning at 9 years old as well as vaccina-tion of girls and women between 13 and 26 years of age.  The vac-cine should be administered be-fore onset of sexual activity (ie, before women are exposed to the viruses), but females who are sexually active should still be vac-cinated.  FDA has approved the first ge-neric version of Zoloft tablets (sertraline), as well as a liquid concentrate (sertraline hydrochlo-ride).  Sertraline is indicated for the treatment of major depres-sive disorder (MDD) in adults and anxiety-related disorders.  FDA has completed the safety assessments of telithromycin (Ketek®), which is indicated for the treatment of acute exacerba-tion of chronic bronchitis, acute bacterial sinusitis, and commu-nity acquired pneumonia.  Telithromycin has been associ-ated with rare cases of serious liver injury and liver failure with 4 reported deaths and 1 liver transplant.  FDA determined that additional warnings are required within the product labeling.  Physicians and patients are en-couraged to be aware of signs and symptoms of liver problems.  

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

https://medica-musc.researchcommons.org/musc-ptupdate/1020/thumbnail.jp

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 3-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 21. https://medica-musc.researchcommons.org/musc-ptupdate/21 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. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/21       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                                 March  2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina     Editorial Staff  Paul W. Bush, PharmD, MBA, FASHP Director, Department of  Pharmacy Services  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Services Editor  Kelli L. Davis, PharmD Drug Information Specialist Associate Editor  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor  Krystal L. Moorman, PharmD Drug Information Practice Resident Assistant Editor Newsletter Layout     In This Issue  • FDA Issues Advisory on Benzocaine Spray  • Automatic Therapeutic Substitution for Angiotensin Converting Enzyme Inhibitors  • Gatifloxacin is Contraindicated in Patients with Diabetes  • MED•U•WAY Program to             Focus on Percent Carbohydrate-deficient Transferrin Screening  • Therapeutic Alternative to Cefotetan  • Formulary Update  The Food and Drug Administra-tion (FDA) issued a public health advisory regarding the use of benzocaine spray (Hurricaine®, Topex®, Ceta-caine®) on February 10, 2006.1  Benzocaine spray is a local anes-thetic used to numb the mouth and throat during minor surgical procedures such as endoscopy and bronchoscopy.1,2  When used appropriately, benzocaine may occasionally cause methe-moglobinemia.1,2  Methemoglo-binemia has also resulted due to medication errors and using ben-zocaine for a longer duration or in a higher dose than is recom-mended.1    Methemoglobinemia occurs due to either increased methemoglo-bin production or decreased methemoglobin reduction.3,4 Methemoglobin is a form of he-moglobin in which the ferrous irons of heme have been oxi-dized to the ferric state.3,4  Methemoglobin is unable to bind oxygen.3,4 In methemoglobine-mia, the oxygen affinity of fer-rous heme in the hemoglobin tetramer is increased, resulting in a “left-shifted” oxygen dissocia-tion curve and impaired oxygen delivery to the tissues.3,4  As a re-sult, patients with increased con-centrations of methemoglobin have a functional anemia.3,4    The FDA advisory states that  practitioners should consider sev-eral things when using benzocaine spray during procedures requiring tube placement in the larynx or pharynx.  First, benzocaine spray can result in dangerous concentra-tions of methemoglobin.  Up to 35% of benzocaine applied to mu-cous membranes is absorbed sys-temically.1  Absorption is in-creased when the product is ap-plied to inflamed tissue.  Sec-ondly, patients with asthma, bron-chitis, chronic obstructive pulmo-nary disease (COPD), heart dis-ease, or those who smoke have an increased risk of complications if they develop methemoglobinemia and may benefit from alternative therapeutic agents.    There are also certain patients who have an increased risk of developing methemoglobinemia.1,3,4  These patients include infants; patients with hemoglobin M disease; and patients with deficiencies in glu-cose-6-phosphate dehydrogenase (G6PD), NADH-methemoglobin reductase, and pyruvate kinase.1,3,4 FDA  Issues Advisory on  Benzocaine Spray By Krystal Moorman, PharmD Drug Information Practice Resident Pharmacy & Therapeutics Update  Lidocaine is a reasonable alterna-tive for both patient groups.  FDA recommends that practitio-ners use the minimum amount of benzocaine needed to reduce the risk of methemoglobinemia.  Ac-cording to the product labeling, the recommended dose of Hurri-caine® spray is 1 spray in a less-than-1-second burst.  For Ceta-caine®, sprays in excess of 2 sec-onds are contraindicated.  Topex® is typically administered in 2 to 3 metered sprays, and the maximum dose is 5 sprays.    Patients who receive benzocaine spray should be carefully moni-tored for signs of methemoglo-binemia including pale gray- or blue-colored skin, headache, light-headedness, shortness of breath, anxiety, fatigue, and/or tachycar-dia.  FDA cautions practitioners that methemoglobinemia makes pulse oximetry unreliable.  Methe-moglobin concentrations should be measured using a co-oximeter.1,3  Patients who are thought to have high concentra-tions of methemoglobin should be treated promptly.  Additional information may be found at: www.fda.gov/cder/ drug/ advisory/benzocaine.htm. Effective March 15, 2006, angio-tensin converting enzyme inhibi-tors (ACEIs)  will be included in  Page 2 Automatic Therapeutic Substitution:  Angiotensin Converting Enzyme Inhibitors  By Krystal Moorman, PharmD Table 1: Oral ACE-inhibitor Dosing Conversion the  automatic therapeutic substi-tution (ATS)  program.  The pro-tocol specifies that orders writ-ten for benazepril, enalapril, fos-inopril, moexipril, perindopril, quinapril, ramipril, and trandola-pril will be converted to lisino-pril (Table 1).  Captopril and enalaprilat are excluded from this ATS.  This ATS is applica-ble to adult inpatients.  If a phy-sician  does not want a patient to receive lisinopril, he/she must write the order for the desired ACEI, include “dispense as writ-ten” in the order, and provide appropriate clinical justification.   Therapeutic  Alternative to Cefotetan  AstraZeneca announced that it would discontinue production of cefotetan in February 2005. Therefore, the Anti-infective Subcommittee has made the fol-lowing recommendation regard-ing alternative therapy for pa-tients undergoing abdominal sur-gery:  cefazolin 1 to 2 g in com-bination with metronidazole 500 mg, administered intravenously.   If you need additional informa-tion, please contact the Drug In-formation Center at  2-3896.   Order Written As Converted To Benazepril 5 mg, Daily Lisinopril 5 mg, Daily Benazepril 10 mg, Daily Lisinopril 10 mg, Daily Benazepril 20 mg, Daily Lisinopril 20 mg, Daily Benazepril 40 mg, Daily Lisinopril 40 mg, Daily Enalapril 5 mg, Daily Lisinopril 5 mg, Daily Enalapril 10 mg, Daily Lisinopril 10 mg, Daily Enalapril 20 mg, Daily Lisinopril 20 mg, Daily Enalapril 40 mg, Daily Lisinopril 40 mg, Daily Fosinopril 5 mg, Daily Lisinopril 5 mg, Daily Fosinopril 10 mg, Daily Lisinopril 10 mg, Daily Fosinopril 20 mg, Daily Lisinopril 20 mg, Daily Fosinopril 40 mg, Daily Lisinopril 40 mg, Daily Moexipril 3.75 mg, Daily Lisinopril 5 mg, Daily Moexipril 7.5 mg, Daily Lisinopril 10 mg, Daily Moexipril 15 mg, Daily Lisinopril 20 mg, Daily Moexipril 30 mg, Daily Lisinopril 40 mg, Daily Perindopril 2 mg, Daily Lisinopril 5 mg, Daily Perindopril 4 mg, Daily Lisinopril 10 mg, Daily Perindopril 8 mg, Daily Lisinopril 20 mg, Daily Perindopril 16 mg, Daily Lisinopril 40 mg, Daily Quinapril 5 mg, Daily Lisinopril 5 mg, Daily Quinapril 10 mg, Daily Lisinopril 10 mg, Daily Quinapril 20 mg, Daily Lisinopril 20 mg, Daily Quinapril 40 mg, Daily Lisinopril 40 mg, Daily Ramipril 1.25 mg, Daily Lisinopril 5 mg, Daily Ramipril 2.5 mg, Daily Lisinopril 10 mg, Daily Ramipril 5 mg, Daily Lisinopril 20 mg, Daily Ramipril 10 mg, Daily Lisinopril 40 mg, Daily Ramipril 20 mg, Daily Lisinopril 40 mg, Daily Trandolapril 1 mg, Daily Lisinopril 5 mg, Daily Trandolapril 2 mg, Daily Lisinopril 10 mg, Daily Trandolapril 4 mg, Daily Lisinopril 20 mg, Daily Trandolapril 8 mg, Daily Lisinopril 40 mg, Daily Page 3 Pharmacy  & Therapeutics Update  Page 3 Bristol-Myers Squibb (BMS) an-nounced changes to the prescrib-ing information for gatifloxacin (Tequin®).  The changes include an updating of the existing warn-ing on hypo- and hyperglycemia and a contraindication for use in patients with diabetes. The changes also include information identifying other risk factors for developing hypo- or hyperglyce-mia including advanced age, renal insufficiency, and concomitant use of glucose-altering medica-tions.  Additional information is p o s t e d  a t  w w w . f d a . g o v /m e d w a t c h / s a f e t y / 2 0 0 6 /tequin_DHCP.pdf.  Listed below are formulary alter-natives to gatifloxacin for patients with diabetes.  Clinicians should consider patient- and pathogen characteristics when choosing an alternative.  These recommenda-tions apply to situations in which gatifloxacin would be an appropri-ate therapeutic choice—not neces-sarily first-line treatment for a par-ticular disease state.  Acute bacterial exacerbation of chronic bronchitis:  Augmentin® 875 mg, administered orally, twice daily; Unasyn® 1.5 to 3 g, administered intravenously, every 6 hours; cefuroxime 750 mg to 1.5 g, administered intravenously, every 8 hours; cefotaxime 1 g, ad-ministered intravenously, every 8 to 12 hours; ceftriaxone    1 g, ad-ministered intravenously, daily.  Acute sinusitis:  Augmentin® 875 mg, administered orally, twice daily.  Community acquired pneumo-nia:   Previously healthy patients be-ing treated as outpatients– azithromycin 500 mg, adminis-tered orally, once, then 250 mg, administered orally, daily in combination with amoxicillin     1 g, administered orally, 3 times daily.    Patients with comorbidities who have not recently received anti-biotics and are being treated as outpatients – azithromycin       500 mg, administered orally, once, then 250 mg, administered orally, daily.     Patients with comorbidities who have recently received antibiot-ics – cefpodoxime 200 mg, ad-ministered orally, every 12 hours or amoxicillin 1 g, administered orally, 3 times daily.   Non-ICU patients — ceftriaxone    1 g, administered intravenously, daily with azithromycin 500 mg, administered intravenously, daily.           ICU patients – ceftriaxone          2 g, administered intravenously, daily with azithromycin 500 mg, administered intravenously, daily.  Uncomplicated cystitis: Fluoro-quinolones are only recom-mended if the local E. coli resis-tance to Septra® is at least 20%.  In these cases, it is necessary to substitute a nonformulary fluoro-quinolone (FQ). Moxifloxacin should not be used to treat uri-Gatifloxacin is         Contraindicated in    Patients with Diabetes By Krystal Moorman, PharmD nary tract infections due to inade-quate urine concentration.    Complicated urinary tract infec-tions: Zosyn® 3.375 g, adminis-tered intravenously, every 6 hours; ampicillin 500 mg, administered intravenously, every 6 hours in combination with gentamicin.  Pyelonephritis:  O u t p a t i e n t  t r e a t m e n t —Augmentin® 875 mg, adminis-tered orally, twice daily; Septra® DS, administered orally, twice daily.    Hospital treatment —  ampicillin 500 mg, administered intrave-nously, every 6 hours in combina-tion with gentamicin; ceftazidime 2 g, administered intravenously, every 8 hours; Zosyn® 3.375 g administered intravenously, every 6 hours; Unasyn®   3 g, adminis-tered intravenously, every 6 hours.  Patients should be treated for      14 days.  Uncomplicated urethral and cervical gonorrhea or acute, un-complicated rectal infection in women due to Neisseria gonor-rheae: ceftriaxone 125 mg, ad-ministered intramuscularly, once or cefpodoxime 400 mg, adminis-tered orally, once in combination with azithromycin 1 g, adminis-tered orally, once or doxycycline 100 mg, administered orally, twice daily, for 7 days.  Patients who require FQ therapy may be treated with levofloxacin or moxifloxacin.  For further as-sistance selecting an antibiotic regimen, please contact the phar-macist in your area or the Drug Information Center at  2-3896. Pharmacy & Therapeutics Update   Page 4 The Pharmacy and Therapeutics Committee recently approved the following formulary changes, ef-fective March 15, 2006:  Additions with Restrictions: Palonosetron (Aloxi®) Prescribing will be restricted to physicians on the hematol-ogy/oncology services for patients who have failed therapy with on-dansetron.  Dexmedetomidine (Precedex®) Prescribing will be restricted for use during awake craniotomies.    Formulary Update Changes in Restrictions: Bevacizumab (Avastin®) The restriction for bevacizumab was revised to allow intravitreal administration by an ophthal-mologist on an individual basis for patients experiencing treat-ment failure with photodynamic therapy and pegaptanib.  Patients will be required to sign an in-formed consent prior to receiv-ing this therapy.  The formulary effective date will be assigned once the institutional review board has approved the informed consent and a mechanism for reimbursement has been estab-lished.  Automatic Therapeutic Substi-tution:  Orders written for benazepril, enalapril, fosinopril, moexipril, perindopril, quinapril, ramipril, and trandolapril will be con-verted to lisinopril.   This ATS will be applicable to adult pa-tients.  Captopril and enalaprilat are excluded from this ATS.  Line Extensions: Nifedipine (various) 4-mg/mL extemporaneous oral solution  Morphine (various) 0.2- and 1-mg/mL extempora-neous intravenous dilution  Lorazepam (various) 0.2-mg/mL extemporaneous                  intravenous dilution  Aripiprazole (Abilify®) 5-mg tablets  Deletions: Salicylic acid (Keralyt®) 6% gel [30 grams] 0.9% sodium chloride with benzyl alcohol injection 2.5-mL syringe  Lidocaine (various) 2.5% ointment  Metyrapone (various) 250-mg capsule  Prednisolone phosphate (various) 0.125% ES solution  Neomycin (various) 0.5% ointment [15 grams]  Barium sulfate (EZPaque®) 96% w/w suspension  Methybenzethonium (Diaparene®) ointment [60 grams]  Masse Breast Cream® cream [60 grams]  Humulin ultralente insulin            (Humulin® U) 100 units/mL  Iothalamate meglumine                     (Cysto-CONRAY® II)   500-mL bottle  Gadodiamide injection (Omniscan®) 5-mL vial  Iodixanol (Visipaque®) 270-mg/mL [100- and 150-mL vial]; 320-mg/mL [100-mL vial]  Iohexol (Omnipaque®) 180-, 240-, 300-, and 350-mg vi-als  Iopamidol (Isovue®) 370-mg vial  Didanosine (Videx®) 25-, 50-, 100-, 150-, and 200-mg chewable tablets  Ramipril (Altace®)  1.25-, 2.5-, 5-, and 10-mg tablets  The next MED•U•WAY will focus on percent carbohydrate-deficient transferrin (CDT) screening for heavy alcohol use.  The program will be held on Thursday,  April 20, 2006, at 1 2 : 0 0  P M ,  i n  2  W e s t Amphitheater.    The featured speakers will be  Karen Stanley, APRN, BC, Psy-chiatric Consultation Liaison Nurse; Raymond Anton, MD, Dis-tinguished University Professor of Psychiatry and Director for the Center of Drug and Alcohol Pro-grams; Peter Miller, PhD, Profes-sor of Psychiatry; and Cynthia Dominick, MHA, Manager of the Clinical Neurobiology Laboratory.  Attendees will receive 1 credit hour of continuing education.   MED•U•WAY Conference to Focus on the Role of Percent Carbohydrate-deficient Transferrin Screening for Heavy Alcohol Use 

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

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Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 5-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 23. https://medica-musc.researchcommons.org/musc-ptupdate/23 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. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/23       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                                    May 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   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  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Center Editor  Kelli Davis, PharmD Drug Information Specialist Associate Editor  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor Newsletter Layout  Krystal Moorman, PharmD Drug Information Practice Resident Assistant Editor   In This Issue   • Medication Error Prevention Strategies in the Pediatric Population   • Did You Know…  • Prescribing Restricted Formulary Medications: How You Can Help Us Help You  • Dexmedetomidine Guidelines for Use  • Formulary Update Medication Error Prevention Strategies  in the Pediatric Population By Elisabeth Mouw, PharmD Pharmacy Practice Resident Pediatric patients often require medication therapy during their childhood and require special consideration because they are at an increased risk for medication-related errors.1-8  Young children have less developed communica-tion skills compared with adults, which impedes feedback to health care professionals about potential adverse effects or mis-takes in medication administra-tion.5 In addition, children are less likely to ask health care pro-fessionals about their care.4   Pediatric patients may be up to      3 times more likely than adult patients to experience a medica-tion error.2  Pediatric patients are most likely to experience medi-cation errors due to health care professionals being unfamiliar with pediatric dosage forms and weight-based dosing.2,4  The medication use cycle in-cludes prescribing, transcription, preparation, dispensing, admini-stration, and monitoring.2  The most commonly reported errors are the administration of an in-correct dose or incorrect fre-quency, the administration of an inappropriate medication for the condition being treated, the pre-scribing of the wrong route of ad-ministration for a medication, and failure to perform follow-up monitoring for adverse reactions and drug interactions.2  The lack of information regarding pediatric doses and dosage forms may also increase the risk of errors.2   Some strategies to help reduce medication errors include stan-dardizing order forms with weight-based dosing and allergy information as required compo-nents of the order.  Standardizing weight measurements (ie, only expressing body weight in kilo-grams) across the organization decreases confusion regarding weight-based dosing.2  MUSC or-der forms may be accessed at www.musc.edu/cce/ORDFRMS/.  In addition, by encouraging em-ployees to report errors, more de-tailed information can be obtained regarding pediatric medication errors, and better policies can be Pharmacy & Therapeutics Update   Page 2 developed and implemented.2,4,7 Medication errors occurring at MUSC should be reported on the Patient Safety Net (PSN) Website which can be accessed using the UHC PSN icon located on every LYNX workstation.  Prescribers should be encouraged to write legibly using unambigu-ous language.2,4  Orders for pedi-atric patients should be written based on weight, and prescribers should ensure that the prescribed dose does not exceed the usual adult dosage.2  In addition, pre-scribers should ensure that they are using the patient’s current weight when writing orders.2  Be-cause medication errors are most likely to occur when orders are written for intravenous fluids, or-ders should be written to include dose and volume, as well as quan-tifying additives per liter, and also including the rate at which the so-lution is to be administered.2  All instructions should be written out to eliminate confusion and vague instructions.  Institutions should establish prohibited abbreviations, and all orders that are written us-ing these abbreviations should be clarified.2  Prescribers should avoid the use of terminal and lead-ing zeroes.2  For example, orders for 5 milligrams of a medication should be written as 5 milligrams as opposed to 5.0 milligrams.2  The use of terminal zeros may lead to a pharmacist misinterpret-ing the order as 50 milligrams, resulting in a 10-fold overdose.2  The names of medications should be spelled out and not abbrevi-ated, and generic names should be used in place of brand names.2  Physicians should also be required to print their name along with a signature and contact number.2 The MUSC policy regarding medication orders may be ac-cessed at www.musc.edu/medcenter/policy/Med/C78.pdf, and the policy regarding prohib-ited abbreviations may be ac-cessed at www.musc.edu/medcenter/policy/Med/C21.pdf.  Pharmacists working in chil-dren’s hospitals should ensure that all medication orders are written according to organiza-tional guidelines.2,4  Pharmacists can work with prescribers to help ensure that all medications ordered are in an easy-to-administer dosage form and that there are no cross-sensitivities with allergies or interactions with pre-existing medications.2   In addition, all orders requiring calculations should be rechecked for accuracy, and all confusing orders should be clarified.2  Studies have shown that errors are less likely to occur when a clinical pharmacist is present on rounds or is involved in dosing medications.2,7  Pharmacists can also be involved with medication histories and discharge counsel-ing to help ensure that parents are familiar with pediatric medi-cation administration.2,4,8    Nurses are usually the last step in the medication use cycle be-fore the medication reaches the patient.  The nursing staff should be encouraged to recheck all pre-vious calculations and verify all medication orders before admin-istering medications to the pa-tient.2  In addition, nurses should frequently consult with parents to ensure that all questions are answered regarding medication therapy.2,4 Technology can play a significant role in decreasing medication er-rors. Some examples include com-puterized prescriber order entry, computerized medication admini-stration records, automated phar-macy systems, bar-coding, “smart” intravenous devices, and computerized discharge prescrip-tions and instructions.5  Through instituting policies and procedures, integrating technology appropriately into the organiza-tion, and continued training, medi-cation errors in pediatric patients can be reduced.  Did You Know... Acute phosphate nephropathy as-sociated with the use of oral so-dium phosphates (OSP) (eg, Fleet®  Phospho-soda®) for bowel cleansing has been reported by the Food and Drug Administration.  Individuals at increased risk of acute phosphate nephropathy in-clude those of advanced age, those with kidney disease or decreased intravascular volume, and those using medications that affect renal perfusion or function.  Use of OSP in patients with kidney disease, impaired renal function or perfu-sion, dehydration, or uncorrected electrolyte abnormalities should be avoided. Also, the recom-mended doses of OSP should not be exceeded, and the concomitant use of laxatives containing sodium phosphate should be avoided. Pa-tients should be adequately hy-drated during bowel cleansing, and baseline and post-procedural laboratory values should be evalu-ated in patients at risk for serious adverse events. Page 3 Pharmacy  & Therapeutics Update The  Pharmacy   and  Therapeutics  Committee recently approved the following actions that became ef-fective May 15, 2006: Formulary Update Additions: Acamprosate (Campral®) 333-mg enteric-coated tablets   Additions with Restriction: Suboxone® 2/0.5- and 8/2-mg sublingual tablets   Palifermin (Kepivance™) 6.25-mg vials   Deletions: Urokinase (Abbokinase®) 9000- and 250,000-IU injections   Streptokinase (Streptase®) 250,000-, 750,000-, and 1,500,000-IU injections   Lipisorb® nutritional supplement 8-oz cans   Vasocon-A® 0.5-oz ophthalmic drops   Accuzyme®  Spray 33-mL bottles   Line Extentions: Risperidone (Risperdal® M-Tab®) 3- and 4-mg orally disintegrat-ing tablets   Accuzyme® Ointment 6- and 30-g tubes   Temporary Product  Replacement: Perflutren lipid microspheres (Definity®)  2-mL vial   Change in Restriction: Dexmedetomidine (Precedex®)  2-mL vials [100 micrograms/mL] Dexmedetomidine (Precedex®),  is a relatively selective alpha2 agonist with sedative properties. This medication is significantly more costly than similar alterna-tives (eg, propofol, midazolam).   An interdisciplinary group was convened to develop guidelines for appropriate use of dexmede-tomidine. The group was led by Holly MacFall, PharmD, and consisted of Alice Boylan, MD; Julio Chalela, MD; Jack Crum-bley, MD; and Susan Harvey, MD. Frank Mielck, MD; Joel Cochran, MD; Fred Tecklen-burg, MD; and Sally Webb, MD, were also consulted during the development of the guidelines. The guidelines are printed on page 4 and are posted online at w w w m u s c . e d u /pharmacyservices/medusepol/DexmedetomidineGL.pdf. Dexmedetomidine The Pharmacy and Therapeutics Committee recently approved standardized scripting for physi-cians to use when writing orders for restricted formulary medica-tions.  By using standardized wording, physicians will improve the efficiency with which a phar-macist can process an order for a restricted medication.  Scripting of orders for restricted formulary medications will also assist the pharmacist processing the order to determine whether the intent of the restriction is met.  An addi-tional benefit is that fewer tele-phone calls will be made by phar-macists to physicians for order clarification. The following exam-ples illustrate the use of scripting orders for restricted formulary medications.  Approved scripting appears in boldface.  An internal medicine physician (Dr. Barton) wants to prescribe linezolid for a patient on 8 West. The formulary restriction on line-zolid specifies that when it is used outside of an intensive care unit, a consult must be obtained from an attending or fellow on the infec-tious diseases service.  The order that Dr. Barton writes is as fol-lows: linezolid 600 mg, IV, Q12H, verbal approval obtained from Dr. Cantey on ID Consult Service concerning formulary restriction.    A pediatrician (Dr. Noyes) wants to prescribe meropenem for a pe-diatric patient who weighs 22 kilograms.  The formulary restrict- Prescribing  Restricted   Formulary Medications:  How You Can Help Us   Help You ion on meropenem specifies that this agent may be used in pa-tients with cystic fibrosis.  The order that Dr. Noyes writes is as follows:  meropenem 440 mg, IV, Q8H (60 mg/kg/day), pa-tient has cystic fibrosis con-cerning formulary restriction.  Physicians who prescribe re-stricted formulary medications are asked to use the approved scripting.  The Medical Center Formulary System Policy C-82 has been revised to reflect this practice. Formulary restrictions are noted in the electronic for-mulary, and an alphabetic listing is available at www.musc.edu/pharmacyservices/DI/restricts.pdf. Pharmacy & Therapeutics Update   Page 2  e 4 MUSC Dexmedetomidine (Precedex®) Guidelines for Use  Prescribing is restricted to physicians with deep sedation privileges or attending-level physicians and fellows practicing in a critical care setting or anesthesiology.   Dexmedetomidine may be used for the following indications in adult patients, for no greater than 24 hours.1  Generally initiate a loading dose of 1 microgram/kg over 10 to 30 minutes (consider longer load [ie, 30 min-utes] for patients ≥ 65 years of age).  A loading dose should be followed by a maintenance infusion of 0.2 to 0.7 micrograms/kg/hr.  Dose reductions should be considered in patients with renal or hepatic impairment.  ‡Sedation of initially intubated and/or mechanically ventilated adult patients in the ED, OR, or ICU with an absolute or relative contraindication to propofol, benzodiazepines, and/or opioids (eg, hypersensitivity, hypertriglyceridemia) 1  ‡Awake craniotomy in adult patients 2-8  ‡Extubation of ICU and post-operative adult inpatients in an ICU or PACU when unable to wean using propofol, benzodiazepines, or opioids or when they are contraindicated  9-19  ₤Sedation prior to ECT in adult patients with a history of postictal agitation 20  ‡Intubated and nonintubated adult neurology patients, in an ICU, requiring sedation and fre-quent neuroassessment when other short-acting titratable sedatives are contraindicated or inef-fective 8, 13, 21-25     ‡Awake fiberoptic intubation 26-29 or ₤bronchoscopy in adult patients with difficult airways whose comorbidities may increase risk for developing hypoxemia and/or hypercapnia during intubation and/or patients in which hypoxemia and/or hypercapnia could significantly increase morbidity or mortality (eg, head trauma, history of sleep apnea, morbid obesity)  ‡Bariatric surgery in adult patients (immediate postoperative period only) 30-37  ‡Sedation or agitation in pediatric patients in an ED, OR, PACU, ICU, or radiology with an abso-lute or relative contraindication to propofol, benzodiazepines, chloral hydrate, and/or ketamine (eg, hypersensitivity, sedation failure, respiratory depression, paradoxic agitation) provided ap-propriate monitoring is in place 38-40  ‡Literature to support dexmedetomidine use ₤Lack of literature to support dexmedetomidine use   Level of sedation using SAS Blood pressure every 5 minutes for first 30 minutes, then every 15 minutes Heart rate Continuous oximetry Telemetry Renal function Restrictions Dosing Guidelines and Indications Monitoring Parameters References available upon request 

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

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Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 1-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 19. https://medica-musc.researchcommons.org/musc-ptupdate/19 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. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/19       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                            January 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina     Editorial Staff   Paul W. Bush, PharmD, MBA, FASHP Director, Department of  Pharmacy Services  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Services Editor  Kelli L. Davis, PharmD Drug Information Specialist Associate Editor Newsletter Layout  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor  Krystal L. Moorman, PharmD Drug Information Practice Resident Assistant Editor       In This Issue   • Evaluation of Propofol Usage  and Selected Adverse Events              in Adult Patients: Medication  Use Evaluation Results   • MED•U•WAY Program to             Focus on Moderate Sedation - Best Practices to Ensure           Patient Safety  • Use of Prohibited Abbreviations  Background: Propofol has a rapid onset and short duration of action once discontinued; there-fore, it is often used to provide sedation for patients in whom frequent neurologic evaluations may be necessary. Although pro-pofol is a highly effective seda-tive agent, it has been associated with many adverse effects.1,2   Adverse effects commonly asso-ciated with propofol include hy-potension, which is usually dose-related and occurs more fre-quently following bolus admini-stration, bradycardia, and pain upon injection. In addition, rare cases of metabolic acidosis, rhabdomyolysis, hyperkalemia, and/or cardiac failure have been reported.1,2  Propofol is manufactured as a phospholipid emulsion that has the potential to cause hyper-triglyceridemia and subsequent pancreatitis when high doses are used or when it is used for pro-longed periods of time.  Patients at risk of hyperlipidemia should be monitored for increases in serum triglycerides as well             as elevations in pancreatic            enzymes.   Propofol requires a dedicated             infusion catheter when adminis-tered as a continuous infusion be-cause of the potential for drug in-compatibilities and line infections.  The manufacturer suggests that the propofol infusion bottle and tubing should not hang for longer than 12 hours.1,2   Purpose: The purpose of this medication use evaluation (MUE) was to assess propofol usage and selected adverse events in adult patients.   Methods: Patients were identified for review based on records from the automated medication dispens-ing system (AcuDose-Rx®) or the pharmacy order entry system (MSMeds™) from August 2004 to April 2005.    Patients were eligible for inclu-sion if they were at least 18 years of age and received propofol dur-ing their hospitalization.  In addi-tion to patient demographics, the following data were obtained: ad-mitting diagnosis, attending and prescribing physicians, service, location, indication, dose, admini-stration method, pharmacist order review status, and adverse events. Evaluation of Propofol Usage and Selected               Adverse Events in Adult Patients Medication Use Evaluation Results Pharmacy & Therapeutics Update  The adverse events included pain on injection, bradycardia (ie, heart rate less than 60 beats per minute), hypotension (ie, systolic blood pressure less than 90 mmHg or a mean arterial pressure less than       60 mmHg), hypertriglyceridemia (ie, triglycerides greater than             200 mg/dL), elevations in amylase and lipase concentrations (ie, con-centrations greater than 130 and 50 IU/L, respectively), and meta-bolic acidosis (ie, pH less than or equal to 7.25, arterial HCO3 less than 19 mEq/L, anion gap greater than 12).  Concomitant analgesic medications and documentation of propofol infusion bottle or tubing changes were also recorded.    Results: There were 124 patients and 137 records included in the data analysis.  Of these patients, 63 (46%) were male, 73 (53%) were female, sex was unknown for 1 (1%) patient. The average age of the patients was 57 years (range 15 to 90 years).  The aver-age patient weight was 82 kg (range 44 to 171 kg).  A written order for propofol was documented in the chart 85%                (n = 116) of the time and an order was present in MSMeds™ 88%            (n = 121) of the time.  Orders for propofol were not documented in the chart 15% (n = 21) of the time and orders were not found in MSMeds™ 12% (n = 16) of the time. The absence of these records may indicate emergent administra-tion of propofol, transfer of the patient from the operating room to another unit, or lack of documen-tation.  The formulary restriction for propofol use was followed in 96% (n = 131) of the orders docu-mented.    Propofol was ordered for the following indications: continu-ous sedation (n = 92, 67%); con-tinuous sedation during surgery or a procedure (n = 14, 10%); surgery (n = 16, 12%); and pro-cedure (n = 7, 5%).  The indica-tion for propofol use was not documented for 5 (6%) encoun-ters.  One hundred nineteen (87%) patients received propofol via continuous infusion, com-pared with 13 (9%) patients re-ceiving intravenous push.    The average initial continuous infusion rate was 38 mcg/kg/min (range 9 to 150 mcg/kg/min), which is higher than the initial rate (5 mcg/kg/min) recom-mended by the manufacturer for initial ICU sedation and the clinical practice guidelines by the Society of Critical Care Medicine.1,2   The infusions con-tinued for an average of 2.8 days (range 1 to 17 days).  The mini-mum average daily rate for con-tinuous infusion was 33 mcg/kg/min (range 0.85 to 150 mcg/kg/min), while the maximum aver-age daily rate was                       49 mcg/kg/min (range 4.9 to  168 mcg/kg/min).  These aver-age daily rates are consistent with those reported in the prod-uct labeling (5 to 50 mcg/kg/min).  Three patients had an          average maximum daily dose that exceeded the dose recom-mended in the MUSC Continu-ous Infusion Guidelines                for Adult Patients (ie, 5 to                  100 mcg/kg/min).    The average intravenous              push dose administered was      1.53 mg/kg (range 0.0027 to   2.4 mg/kg) and patients received 1.8 doses on average.  The aver-age dose is consistent with the doses recommended for induction of general anesthesia (ie, 0.5 to            2 mg/kg).  The average total dose given via intravenous push was 1.7 mg/kg (range 0.0027 to             3.6 mg/kg).  Adverse events that were evalu-ated are listed in Table 1.  For the 13 patients who received propofol via intravenous push, pain on in-jection was monitored for and subsequently documented in 1 pa-tient.  Blood pressure was moni-tored in 12 (92.3%) patients, and 3 (23%) patients experienced hy-potension. Systolic and diastolic blood pressures decreased from baseline by an average of 24% and 30%, respectively (range, 14 to 35%, 17 to 43%,  respectively).  Heart rate was monitored in 12 (92.3%) patients, and bradycardia occurred in 1 (8%) patient.  Metabolic acidosis was assessed in 108 patients (79%), but only occurred in 9 patients (6.5%).  In patients who received propofol via continuous infusion for at least 72 hours (n = 35), triglycerides were monitored in 12 (34%) patients, and elevated triglycerides oc-curred in 6 patients.  Amylase and lipase concentrations were moni-tored in 10 (29%) patients who received propofol for at least 72 hours, and elevations occurred in 2 patients.  Propofol bottle and/or tubing changes were recorded in only 40 records (29%).   Conclusion:  Propofol is being used for appropriate indications in adult patients.  The initial doses used for continuous infusion and the documented adverse events  Page 2 Page 3 Pharmacy  & Therapeutics Update  Page 3 MED•U•WAY Conference to Focus on Moderate Sedation The  nex t  MED•U•WAY conference will focus on moderate sedation and the best practices to ensure patient safety.  The program will be held on Thursday,  February 16, 2006,     at 12:00 PM, in 2 West Ampitheater.    The featured speakers will be  Gary Haynes MD, PhD, Depart-ment of Anesthesia and Pe-rioperative Medicine, Marc La-pointe, PharmD, BCPS, BCNSP, Associate Professor, Department of Pharmacy and Clinical Sci-ences, and Phyllis Malpas, RN, MA, GCRN, Manager Endo-scopy.  The objectives are as follows:  • Define moderate sedation and the best practice initia-tives that promote patient safety.  • Identify and manage patients who extend beyond the mod-erate level of sedation. Use of Prohibited               Abbreviations  By:  Amy Bain, PharmD Candidate Medication errors significantly affect iatrogenic morbidity and mortality and increase healthcare costs.1,2  In a case control study by Classen and colleagues, medica-tion errors were shown to increase length of hospital stay by up to 5 days compared with matched con-trols.2 Costs related to medication errors, in a large health system, could be driven into the millions based on the estimated $6,000 in-creased cost per error per hospital stay.1   Many commonly encoun-tered errors are a result of unsafe prescribing practices, and about 11% of these are a result of the use of dangerous abbreviations.1    Current institutional policies tar-geted to meet the Joint Commis-sion on Accreditation of Health-care Organizations (JCAHO) ac-creditation standards prohibit the use of dangerous abbreviations in handwritten documentation.2  The purpose of this regulation is to reduce preventable prescribing errors in order to improve patient safety.  The policy applies to all types of handwritten documenta-tion including orders, medication-related documentation in the medical record, and preprinted • Describe the what, how, and why of reporting sedation           related adverse events.  Attendees will receive 1 credit hour of continuing education and lunch is provided.  MED•U•WAY is sponsored by the Pharmacy and Therapeutics Committee.    Monitoring                Documented                      n (%) Occurrence                Documented                                n (%) Bradycardia* 12 (92) 1 (8) Hypotension* 12 (92) 3 (23) Pain on injection* 1 (8) 0 (0) Amylase and lipase elevations† 10 (29) 2 (20) Hypertriglyceridema† 12 (34) 6 (50) Metabolic acidosis 108 (79) 9 (8)   * Monitored only in patients receiving propofol via intravenous push (n = 13)   † Monitored only in patients receiving propofol via continuousinfusion for at least          72 hours (n = 35) Table 1. Monitoring for and Occurrence of Selected Adverse Events are higher than those reported in the literature.  Practitioners should be educated regarding appropriate dosing, duration of therapy, moni-toring parameters, and adverse events.   Process Improvements: Inser-vices will be provided to the pro-fessional staff regarding propofol use and appropriate monitoring parameters.  A standardized pro-pofol initiation order form will be developed with weight-based dos-ing, titration guidelines, pertinent monitoring parameters.  An entry will be placed on the medication administration record to enhance documentation of propofol infu-sion bottle and tubing changes.  MUE Team: This MUE was  conducted by Brent Anderegg, Courtney Bickford, Wendy Bull-lington, Brandy Causey, Anne McDonnnell, Nicole Weimert,  Ca thy  Worra l l ,  Nanne t t e Berensen, and Holly MacFall, and Kelli Davis.  References and supporting docu-mentation for this MUE are avail-able upon request. Pharmacy & Therapeutics Update  Prohibited                     Abbreviation Intended Meaning Misinterpretation Absence of a                   preceding zero (.5 mg) 0.5 mg The decimal point may not be seen or copied, resulting                 in a 10-fold overdose. Presence of a                trailing zero (5.0 mg) 5 mg The decimal point may not be seen or copied, resulting             in a 10-fold overdose. µg, mcg, or ug microgram This may be mistaken for “mg” when handwritten and may result in an overdose. qd, q.d., or QD every day The period after the “q” has been mistaken for “I,”          and the medication is administered “QID” (4 times daily) rather than daily. qod, q.o.d, or QOD every other day This may be mistaken as “q.d.” or “q.i.d” if the “o” is            poorly written. MgSO4 magnesium sulfate This may be mistaken for morphine sulfate. U or u unit or umbilicus This may be mistaken as a 0 or 4, resulting in overdose                 (4U seen as “40” or 4u seen as “44”). IU international unit This may be misread as IV (intravenous). MS, MSO4 morphine sulfate This may be mistaken for magnesium sulfate. Table 2. Prohibited Abbreviations Based on MUSC-MC Policy C-21  Page 4 order forms.  The exceptions to this policy include laboratory re-sults or reports and vendor com-puted generated documents (ie, medication administration record [MAR]).  The MUSC-MC policy C-21 enti-tled Use of Abbreviations is sum-marized below.  • No abbreviations found on    the list of Prohibited Abbrevia-tions may be used when docu-menting in the patient's inpa-tient or outpatient medical re-cord (Table 2).  • Practitioners should be imme-diately contacted via pager upon discovery of use of a pro-hibited abbreviation in the or-ders section of the medical re-cord, and the order should be rewritten. • If a prohibited abbreviation is used in any other section of the medical record, the author should be contacted as soon as possible and the informa-tion should be rewritten.  • Prohibited abbreviation use will be monitored via record review, and trends that are identified will be reported to a department director or chair, as necessary.  • Names of medications should never be abbreviated (eg, AZT, HCTZ, Neo).   • Abbreviations are not allowed in an informed consent docu-ment or when documenting final diagnoses.  • Any request to change this list may be submitted to the Medical Records  Committee.  • The list of Prohibited Abbre-viations will be reviewed annu-ally or at the discretion of the Medical Director and/or the Medical Records Committee.  Reduction of medication errors is ultimately dependent on the com-mitment of individual healthcare professionals to observe the MUSC-MC policies regarding safe medication practices.  Avoid-ing the use of dangerous abbrevia-tions enables all practitioners and hospital staff to contribute to the improvement of patient safety.     Policies regarding the use of ab-breviations and other policies re-lated to patient safety may be found at musc.edu/medcenter/policy/Med/clintoc.html.  References are available upon request. 

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

Medical University of South Carolina MEDICA Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals 2-1-2006 Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals Medical University of South Carolina Paul W. Bush Medical University of South Carolina Nannette M. Berensen Medical University of South Carolina Kelli L. Davis Medical University of South Carolina Holly M. MacFall Medical University of South Carolina See next page for additional authors Follow this and additional works at: https://medica-musc.researchcommons.org/musc-ptupdate Recommended Citation Medical University of South Carolina; Bush, Paul W.; Berensen, Nannette M.; Davis, Kelli L.; MacFall, Holly M.; and Moorman, Krystal L., "Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals" (2006). Pharmacy & Therapeutics Update: Drug Information for Health Care Professionals. 20. https://medica-musc.researchcommons.org/musc-ptupdate/20 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. Authors Medical University of South Carolina, Paul W. Bush, Nannette M. Berensen, Kelli L. Davis, Holly M. MacFall, and Krystal L. Moorman This newsletter is available at MEDICA: https://medica-musc.researchcommons.org/musc-ptupdate/20       Pharmacy & Therapeutics   Update       Drug Information        for Health Care Professionals                            February 2006   MUSC MEDICAL UNIVERSITY  OF SOUTH CAROLINA   Drug Information Center Medical University of South Carolina Department of Pharmacy Services Charleston, South Carolina     Editorial Staff  Paul W. Bush, PharmD, MBA, FASHP Director, Department of  Pharmacy Services  Nannette M. Berensen, PharmD, BCPS Manager, Drug Information Services Editor  Kelli L. Davis, PharmD Drug Information Specialist Associate Editor  Holly M. MacFall, PharmD, BCPS Drug Information Specialist Associate Editor  Krystal L. Moorman, PharmD Drug Information Practice Resident Assistant Editor Newsletter Layout        In This Issue  • Evaluation of Propofol Usage and Selected Adverse Events in Pediatric Patients: Medication Use Evaluation Results  • MED•U•WAY Program to             Focus on Hospital Acquired Pneumonia  • Did You Know…  • Formulary Update  Background: Propofol is a sedative-hypnotic agent with a short onset and offset of action.  It is often used to provide seda-tion for patients requiring fre-quent neurologic evaluations.1,2,3  Propofol is approved for con-tinuous sedation in adults in the intensive care unit.  However, its use for continuous sedation in pediatric patients is not recom-mended due to concerns of pro-pofol infusion syndrome.2  Pro-pofol infusion syndrome is a life-threatening condition that manifests as metabolic acidosis, lipemia, bradycardia, myoglo-binuria, cardiac failure, and rhabdomyolysis in pediatric pa-tients who receive high-dose propofol for an extended length of time.2,4  In an evaluation of studies and case reports of pro-pofol infusion syndrome in the pediatric intensive care unit (PICU), Okamoto and col-leagues recommended that cau-tion be used for propofol doses higher than 4 mg/kg/hr or for a treatment duration longer than 48 hours.2  Conversely, several prospective studies have demon-strated safety and efficacy with the use of propofol in pediatric patients for procedural sedation and sedation in the emergency de-partment.5-7  Other adverse effects associated with propofol include hypoten-sion, bradycardia, pain on injec-tion, hyperlipidemia, metabolic acidosis, and line infection.  Pa-tients should be monitored for these effects.  A slow infusion rate is recommended to reduce the risk of hypotension and apnea.1    Pain on injection is a common oc-currence, but may be decreased or prevented with an injection of li-docaine 1% prior to propofol ad-ministration.1  Because propofol is a phospholipid emulsion, it may increase the risk of hypertriglyc-eridemia, which could induce pan-creatitis.  In order to prevent line infections, lines should be changed every 12 hours.   Purpose: The purpose of this medication use evaluation (MUE) was to assess propofol usage and selected adverse events in pediat-ric patients, evaluate monitoring practices, and devise methods for improving safety.   Evaluation of Propofol Usage and Selected         Adverse Events in Pediatric Patients   Medication Use Evaluation Results Pharmacy & Therapeutics Update  Methods: Patients were identified for review based on records from the automated medication dispens-ing system (AcuDose-Rx®) or the pharmacy order entry system (MSMeds™) from August 2004 to April 2005.    Data collected included patient demographics, admitting diagno-sis, attending and prescribing phy-sicians, service, location, indica-tion, dose, method of administra-tion, pharmacist order review status, and selected adverse events.  The adverse events as-sessed included pain on injection, bradycardia, hypotension, hyper-triglyceridemia, elevations in amylase and lipase concentrations, and metabolic acidosis.  Concomi-tant sedative medications and documentation of propofol bottle and/or tubing changes were also recorded.    Analysis: There were 69 patients and 78 records included in the analysis.  Of the 78 records identi-fied, 6 had no documentation of propofol administration on the given date, and 1 patient’s medi-cal record could not be obtained.    Of the 69 cases identified, 41 (59%) were female and 28 (41%) were male.  Twenty-seven (38%) patients were African American, 30 (42%) were Caucasian, and 1 (1%) was Hispanic.  The average age was 10 years, with a range of 2 months to 33 years.  The aver-age weight was 39.9 kilograms, with a range of 3.5 to 137 kilo-grams.  Of note, the weight for 2 patients was not reported.  A written order for propofol was documented in the chart in 47 (66%) cases, and an order was present in MSMeds™ in 9 (13%) cases.  Orders for propofol were not documented in the chart 30% (n = 21) of the time, and orders were not found in MSMeds™ 86% (n = 61) of the time.  The absence of these records may indicate emergent administration of propofol, transfer of the pa-tient from the operating room to another unit, or lack of docu-mentation.  The formulary re-striction was met for 100% of the cases.  Propofol was ordered for the fol-lowing indications:  continuous sedation (n = 8, 12%), proce-dural sedation (n = 56, 79%), surgery (n = 6, 8%), and con-tinuous sedation during surgery (n = 1, 1%).  Propofol was ad-ministered via intravenous (IV) push in 59 (83%) cases and via continuous infusion (CI) in 11 (15%) cases.  One patient re-ceived propofol by both meth-ods.  Propofol was administered via a peripheral line in 38 (54%) cases and a central line in 29 (41%) cases.  The type of IV line used for propofol administration could not be determined in 4 (6%) cases.  Of the 38 cases of peripheral administration, topical lidocaine was applied in 25 (66%) cases.  A total of 31 (50%) patients received lido-caine.  The average initial dose given via IV push was 1.4 mg/kg (range: 0.4 to 4.3 mg/kg).  On average, patients received ap-proximately 3 doses during the procedure to maintain sedation (range: 1 to 11 doses).  The aver-age total dose given via IV push was 2.6 mg/kg (range: 0.5 to     7.8 mg/kg).  The average initial dose given via C I  w a s  2 9 . 6  m i c r o -grams/kg/minute (range: 25 to 50 micrograms/kg/minute).  No pa-tients received propofol via CI for greater than 72 hours.  The mini-mum average daily dose required was 24.2 micrograms/kg/minute (range: 0.83 to 50 micro-grams/kg/minute) and the maxi-mum average daily dose required was 33.7 micrograms/kg/minute (range: 25 to 50 micro-grams/kg/minute).  Adverse events (AEs) that were evaluated included pain on injec-tion, bradycardia, hypotension, hypertriglyceridemia, elevations in amylase and lipase, and meta-bolic acidosis.  Documentation  of appropriate monitoring for AEs was also assessed.  Since propofol was not administered for greater than 72 hours via CI, hypertrigyl-ceridemia and elevations in amy-lase and lipase were not moni-tored.  Pain on injection was monitored in 21 (30%) cases.  In 2 (10%) cases, pain on injection was re-ported.  One of the 2 patients re-ceived lidocaine prior to propofol administration.  Blood pressure was monitored in 68 (96%) cases, and hypotension was documented in 26 (38.%) of the monitored cases.  The systolic blood pressure decreased an average of 16%, with a range from a 13% increase to 32% decrease.  Diastolic blood pressure decreased an average of 25%, with a range from a 58% increase to a 54% decrease.  Heart rate was monitored in 66 (95%)  Page 2 Page 3 Pharmacy  & Therapeutics Update  Page 3 hance documentation of bottle and tubing changes.    MUE Team:  This MUE was conducted by Dawn Nieder-meier, Susan Staggs, Maggie Thomson, Jill Thompson, Nannette Berensen, Kelli Davis, and Holly MacFall.  References are available upon request. T h e  n e x t  M E D • U • WA Y Conference will focus on hospital acquired pneumonia.  The program will be held on Thursday,  March 16, 2006,     at 12 :00  PM,  in  2  Wes t Amphitheater.    The featured speakers will be  Patrick Flume, MD, Department of Pulmonary and Critical Care Medicine, Allergy, and Clinical Immunology; Cathy Worrall, BSN, PharmD, BCPS, BCNSP; and Janet Byrne, RN.  Attendees will receive 1 credit hour of continuing education, and  lunch  i s  provided .  MED•U•WAY is sponsored by the Pharmacy and Therapeutics Committee.  cases, and bradycardia was docu-mented in 5 (8%) of the monitored cases.  On average, the heart rate decreased by 25% (range: 10 to 42%).  Metabolic acidosis was defined as an anion gap of greater than 12.  Metabolic acidosis was monitored in 14 (19%) cases.  Metabolic aci-dosis was documented in 2 (3%) of the monitored cases.  In 1 of the cases, the patient’s condition may have contributed to the acidosis.  Propofol was administered via CI for greater than 12 hours in 4 pa-tients.  In 3 (75%) cases, the pro-pofol bottle and/or tubing changes were documented every 12 hours.    Of the 71 cases of propofol ad-ministration, 49 (69%) required other sedatives to be administered.  However, the type and dose of medication required was not docu-mented during this evaluation.  Conclusion:  These data support that propofol is primarily used in the intensive care units and in the operating room.  Doses used are similar to the required doses re-ported in the literature.  Practitio-ners should be educated regarding appropriate dosing, duration of therapy, monitoring parameters, and adverse events.    Process Improvements: Inser-vices were provided by clinical pharmacy staff to review proper dosing, and to re-educate the house staff regarding monitoring parameters and pertinent labora-tory measures (ie, triglycerides, amylase and lipase concentrations, and arterial blood gases).  An en-try will be placed on the medica-tion administration record to en-MED•U•WAY Conference to Focus on Hospital Acquired Pneumonia problems, myocardial infarction, and stroke in patients who have undergone coronary artery bypass graft surgery.  Physicians who use aprotinin should monitor for the occurrence of toxicity, particularly to the kidneys, heart, or central nervous system.  In addition, phy-sicians should consider limiting the use of aprotinin to those cases where the clinical benefit of re-duced blood loss is essential to the medical management of the pa-tients and the benefit outweighs potential risks.  FDA issued a public health advi-sory regarding potential liver tox-icity associated with telithromycin (Ketek®) following MedWatch reports and a case review in the  Annals of Internal Medicine that reported 3 cases of jaundice and abnormal liver function following administration of telithromycin. One patient recovered, 1 required a liver transplant, and 1 patient died.  When the livers of the latter 2 patients were examined in the pathology laboratory, massive tis-sue death was present. These 2 patients had reported some alco-hol use. All 3 patients had previ-ously been healthy and were not using other prescription drugs. FDA is also aware that these pa-tients were treated by physicians in the same geographic area. The significance of this observation is not clear at this time. FDA recently approved human insulin (rDNA origin) inhalation powder (Exubera®) for the treat-ment of adult patients with type 1 or type 2 diabetes mellitus for control of hyperglycemia. The product is expected to be commer-cially available by mid-2006. Did You Know... FDA issued a public health advi-sory on February 8, 2006, notify-ing physicians that aprotinin in-jection (Trasylol®) has been linked to a higher risk of  serious adverse   events  including  renal Pharmacy & Therapeutics Update   Page 4 The Pharmacy and Therapeutics Committee recently approved the following formulary changes:  Additions: Effective February 15, 2006 Histrelin acetate implant (Vantas®)  Additions with Restrictions: Effective February 15, 2006 Caspofungin (Cancidas®) will be restricted to physicians on the he-matology/oncology and infectious diseases services.   Iloprost (Ventavis®) will be re-stricted to attending physicians or fellows on the pulmonary and critical care services.  Automatic Therapeutic Substi-tutions (ATSs): Effective March 15, 2006 In adult patients, orders written for benazepril, enalapril, fosino-pril, moexipril, perindopril, quinapril, ramipril, and trandola-pril will be converted to lisinopril unless “dispense as written” is specified.     Effective February 15, 2006 In adult patients, orders written for ProMod® will be converted to Pro-Stat 64™ unless “dispense as written” is specified.  Changes in Restrictions: Effective February 15, 2006 Liposomal amphotericin B (AmBisome®) will be available on an unrestricted basis.  Linezolid (Zyvox®) will be re-stricted per infectious diseases service approval, as per clinical guidelines, or as specified on the hospital acquired pneumonia pre-printed order forms. Formulary Update Line Extensions: Effective February 15, 2006 Activated charcoal (EZ CHAR®) 25-gram pellets  Dipyridamole (various) 75-mg tablets  Deletions: Effective February 15, 2006 Bethanechol (Urecholine®) 5-mg/mL vials  Diethylstilbestrol (Stilphostrol®) 50-mg/mL vials  Tetramune® 0.5-mL vials  Activated charcoal                     (Actidose-Aqua®) 25-gram/120-mL liquid  Adderall® 12.5- and 15-mg tablets  Dibucaine (Nupercainal®) suppositories  Dipyridamole (various) 5-mg/mL injection  Echothiophate                         (Phospholine Iodide®) 0.03%, 0.06%, 0.125%, and 0.25% ophthalmic solutions  Epinephrine (various®) 0.5%, 1%, and 2% ophthalmic solutions  Hydroxyprogesterone caproate   injection (various) 250-mg/mL injection  Interferon alfa-2b (Intron A®) 5- and 3-mu/mL injection  Leflunomide (Arava®) 100-mg tablets  Lunelle® 50-mg/mL injection  Menotropins (Pergonal®) 75-unit/mL injection Methotrexate (various) 50-mg/mL injection  Methylprednisolone (Medrol®) 24-mg tablets  Methyltestosterone (Metandren®) 25-mg tablets  Nilutamide (Nilandron®) 50-mg tablets  Nitroglycerin (Nitrobid®) 9-mg extended-release capsules  Oral poliovirus vaccine (Orimune®) disposable pipettes  Perphenazine (various) 16-mg tablets  Promethazine/codeine (various) 5-mL elixir  Remifentanil (Ultiva®) 1- and 2-mg vials  Rivastigmine (Exelon®) 1.5-, 3-, and 4.5-mg capsules  Theophylline (Slo-Phyllin®) 125-mg extended-release cap-sules  Ticarcillin disodium (Ticar®) 3- and 20-g injection  Tocainide (Tonocard®) 600-mg tablets  Triamcinolone acetate (various®) 3-mg/mL injection  Triple sulfa (Sultrin®) vaginal cream and tablets  Urokinase (Abbokinase®) 5000-unit/mL injection  Ramipril (Altace®) 1.25-, 2.5-, 5-, and 10-mg tablets  Cefotetan (Cefotan®) 200-mg/mL injection 