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Pharmacy and Therapeutic Committee Actions
August - October 2014
Intravenous Immune Globulin (IVIG) Guideline – Adults and Pediatrics
The IVIG guideline was updated to ensure cost-effective utilization of IVIG. Updates included the
establishment of evidence-based primary indications (first line therapy) and secondary indications
(second line therapy) for IVIG in addition to specific dosing recommendations. When determining an IVIG
dose for an adult patient, the dose should be calculated based on ideal body weight (IBW) in the non-
obese patient, unless the patient's actual body weight (ABW) is less than ideal body weight. In these
situations, actual body weight should be used. The adjusted body weight (AdjBW) is recommended for
calculating the IVIG dose for obese adult patents (greater than 130% of ideal body weight). Doses of IVIG
for obese pediatric patients will be at the discretion of the physician. Pharmacy will continue to round all
doses of IVIG to the nearest 5 grams (nearest whole vial size). For neonates and infants receiving doses
less than 10 grams, the dose will be rounded to the nearest gram. Privigen® IVIG 10% remains SHF's
formulary IVIG. Gammagard® IVIG 10% is available for doses less than 5 grams.
Intravenous Chlorothiazide (Diuril®)
Based on the lack of clinical evidence substantiating the benefit of IV chlorothiazide over IV loop diuretics
for managing edema and/or diuretic resistance, as well as the cost of IV chlorothiazide ($150/500 mg
dose), SHF Network P&T endorsed the following recommendations for IV chlorothiazide which reflect
current prescribing throughout the network.
Criteria for use in adult patients  Patient must have failed the following doses of loop diuretics either administered as IV push or continuous infusion and patient is unable to take oral thiazide (metolazone) therapy in combination with the intravenous loop diuretic. o Furosemide: 240 – 480mg/24hr o Bumetanide: 4 - 8mg/24hr o Torsemide: 120 - 240mg/24hr  Treatment failure of loop diuretic in combination with oral thiazide diuretic defined as urine output < 0.5mL/kg/hr. Other recommendations  Avoid combining both an IV loop diuretic and IV chlorothiazide into same infusion.  Maximum initial daily dose of IV chlorothiazide is not to exceed 1000 mg per day (500 mg IV BID).  Restrict IV chlorothiazide to nephrology, cardiology and pulmonology/intensivists.  Limit duration of IV chlorothiazide to 24 hours with requirements for re-ordering if additional therapy is warranted. Albumin Order Set - Adults
To promote cost-effective use of albumin prescribers will utilize the new network albumin order set in
COMPASS when ordering albumin for adult patients. The order set includes evidence-based indications,
dose and duration. It also provides a list of indications whereby albumin should not be ordered. The order
set will replace the previous albumin order sentences. For prescribers who order albumin for pediatric
patients, the CPOE order sentences have been updated to reflect evidence-based indications.
Stress Ulcer Prophylaxis
Although there are several initiatives currently in place within the Seton Healthcare Family to address
appropriate use of acid suppression therapy, including automatic IV to PO conversion and automatic
conversion of proton pump inhibitor to histamine receptor antagonist, a recent medication use evaluation
on a general medicine floor indicated that acid suppression therapy remains over-utilized. The Network
P&T committee approved an Adult SUP Guideline that establishes evidence-based criteria for use. In
addition, physicians and physician groups are being encouraged to remove acid suppression therapy from
the general admission orders sets (not including ICU admission order sets).
Formulary Status
 Dornase alfa (Pulmozyme®) is formulary, but restricted to one of two indications, mucolytic therapy
in cystic fibrosis patients or mucolytic therapy for empyema.  Budesonide (Entocort®) will remain non-formulary given the high cost and the low-risk of developing
long-term side effects while receiving a short course of conventional steroids. It is reasonable to initiate conventional steroid during hospitalization and transition therapy to CIR budesonide at discharge.  Clobazam (Onfi®) was changed to formulary with no restrictions.
 Ferumoxytol (Feraheme®) and Ferric carboxymaltose (Injectafer®) are non-formulary and will not be
stocked by pharmacy.  Posaconazole (Noxafil®) delayed-release tablet was added to formulary but restricted to Infectious
Disease physicians.  Plasma Protein Fraction (Plasmanate®) was removed from formulary.
Therapeutic Interchanges
A number of class reviews were conducted to re-evaluate current therapeutic interchanges, assess newer
agents within the classes, and achieve compliance with AH therapeutic initiatives.
 Respiratory Agents (Inhalers and Nebulization) – adults and pediatrics
Non-formulary Medication
Formulary Substitution
Beclomethasone, Budesonide, Ciclesonide, Fluticasone HFA (Flovent®) Flunisolide, Fluticasone DPI, Mometasone Budesonide/Formoterol (Symbicort®) Fluticasone/Salmeterol (Advair Diskus ®) Fluticasone/Salmeterol (Advair® HFA) Mometasone/Formoterol (Dulera®) Fluticasone/Vilanterol (Breo Ellipta®) Ipratropium (Atrovent®) MDI or Tiotropium (Spiriva®) DPI +/- albuterol Ipratropium/Albuterol (Combivent® Respimat) Indacaterol (Arcapta®) 1 cap inh daily Formoterol (Foradil®) 1 capsule inhaled Salmeterol (Serevent®) 1 inhaled Q12H Arformoterol (Brovana®) neb 15 mcg Q12H Albuterol nebulization 2.5 mg Q6H Formoterol (Perforomist®)neb 20 mcg Q12H  Neuromuscular blocking agents – adults
Non-Formulary Medication
Formulary Substitution
Cisatracurium 0.1 mg/kg Atracurium 0.4 mg/kg Cisatracurium 0.2 mg/kg Atracurium 0.5 mg/kg Cisatracurium continuous infusion Atracurium continuous infusion Standard is cisatracurium bolus followed by 3 Standard is atracurium bolus followed by 5 mcg/kg/min; titrate by 1 mcg/kg/min every 30 mcg/kg/min; titrate by 3 mcg/kg/min every minutes to achieve defined goal (range 1-10 30 minutes to achieve defined goal (range 5-  WBC Growth Factors - adults
Non-Formulary Medication
Formulary Substitution
Filgrastim (Neupogen®) 1 mcg TBO-filgrastim (Granix®) 1 mcg  Fenofibrate Products
Order Written
Formulary Substitution
Fenofibrate dose ≤ 100 mg Fenofibrate 54 mg Fenofibrate dose > 100 mg Fenofibrate 160 mg New Resources
There is a New Oral Anticoagulant Pharmacist's Guide that prescribers may find helpful. The guideline is
available on the Seton Anticoagulation Management web site (Seton Intranet > Clinical Resources >
Clinical Practice).
Nutrition Updates
 1.0 Peptide High Protein Formula is the designated generic name for Vital High Protein enteral
 The SHF TPN/PPN protocol was updated to state that adult peripheral parenteral nutrition (PPN) orders require a dietician's assessment prior to admixture.  The Enteral Nutrition-Drug Interactions Guideline for Administration was revised to reflect the following new recommendations: RECOMMENDED ACTION
Phenytoin (Dilantin®) Hold tube feeding 1 hour before and 1 hour after administration Ciprofloxacin (Cipro®) Hold tube feeding 1 hour before and 2 hours after administration Levofloxacin (Levaquin®) Hold tube feeding 1 hour before and 2 hours after administration Alendronate (Fosamax®) Consider discontinuing alendronate while patient is receiving tube feeds Voriconazole (Vfend®) Hold tube feedings 1 hour before and 1 hour after med administration
Critical Drug Shortages
For additional information, refer to the Pharmacy website (Clinical Resources → Department → Pharmacy
→ Documents → Drug Shortages).
 Ammonium chloride injection – unavailable from the manufacturer.
 Caffeine and Sodium Benzoate injection – unavailable from the manufacturer.
 Chromium chloride injection - unavailable from the manufacturer.
 Droperidol injection - unavailable from the manufacturer.
 Dye markers [Indigo Carmine, Indocyanine (IC) Green, Methylene Blue] – limited availability
 Fosphenytoin injection – unavailable from manufacturer; consider oral phenytoin when possible or
alternative IV therapy.  Multivitamins for Infusion, Adult and Pediatric – limited supply available.
 Nitroglycerin injection – limited availability. Consider alternative therapy.
 Sodium chloride concentrated solution for injection – limited availability.
 Succinylcholine injection – product is on allocation due to manufacturing delays.
For more information, references or inquiries pertaining to the topics discussed in this issue, cal ext. 11279 or email

Source: http://cds.seton.net/d/439