Download PAMC IV to PO Conversion

Intravenous to Oral Conversion Program
Background: Many hospitals across the country, including several in the Providence Health System, have P&T approved
programs whereby pharmacists automatically switch patients from IV to oral dosage forms of selected drugs if certain criteria are
met. Oral dosage forms of many drugs with high bioavailability result in serum levels sufficient to achieve desired therapeutic
outcomes. The oral absorption characteristics, kinetics and tissue penetration of some agents, combined with the ease and safety
of the enteral route, make oral the route of choice. These programs offer several benefits:
Reduction of adverse events associated with IV administration: line infections and resultant systemic infections, phlebitis
Easier and faster dispensing and administration leading to improved safety and reduction in labor required
Patient comfort with earlier discontinuation of IV’s
Potential facilitation of discharge leading to decreased length of stay
Decreased costs and charges related to lower drug costs (PAMC est. annual $25,000 to $50,000), and decreases in
preparation time (PAMC est. 200 doses /month), supplies, infusion devices, adverse events and possibly length of stay.
Advantages over current process: Currently pharmacists screen patients and leave notes for physicians suggesting a switch when
criteria are met. The switch may be delayed 1 or more days depending on when the physician sees the note. Pharmacists look
back to determine if the switch has occurred. Auto conversion would avoid delays and conserve pharmacist time. (PAMC: 59
suggestions in August 2005, 86% conversion rate via notes.)
Proposal: The pharmacist will switch medications listed in the table from IV to oral following the procedure below. A physician
may write “do not convert to oral” when the original order is written, and may reverse a conversion done by a pharmacist by
rewriting an order for the IV form, noting the reason. These actions automatically exclude the patient from the automatic
conversion program for the remainder of the admission.
The pharmacist will:
1. Review medication profile and/or worksheet for targeted drugs. See attached list.
2. Review patient chart and/or consult with nursing to determine if patient fits criteria for IV to oral conversion using following:
Criteria to initiate medication route switch:
a) Tolerating food/enteral feedings (full or liquid diet or better), OR taking/tolerating other oral medications.
b) No contraindications to oral medications.
c) For tube administration: Functioning nasogastric (NG) tube or J-tube and not on NG suction
(See “e” under criteria listed below). Avoid quinolones when patients on tube feedings.
d) For antibiotics: a-c above plus afebrile for at least 24 hours, improving trend in WBC, stable vital signs.
Criteria indicating that the patient is NOT a candidate for IV to PO conversion:
a) Nothing by mouth (NPO) status, with or without NG suction.
b) Inability to swallow or aspiration risk. Examples include stroke, comatose or obtunded patients, patients with head and
neck tumors or cranial nerve abnormalities interfering with function of the tongue or hypopharynx.
c) Recurrent nausea and vomiting in past 24 hours. If it is uncertain whether oral medications can be kept down, parenteral
administration may be preferred
d) GI transit time is too short or long for absorption. Examples include diarrhea in past 24 hours, inflammatory bowel
disease, gastroparesis, enterocutaneous fistula, short bowel syndrome, ileus or suspected ileus or no active bowel sounds.
e) Continuous or intermittent nasogastric suctioning.
f) GI obstruction. Achalasia (esophageal stricture at the gastroesophageal junction) may interfere with swallowing solid
dosage forms.
g) Malabsorption syndrome.
h) Patients receiving vasopressors. GI blood flow may be compromised, reducing oral absorption.
i) Active GI bleeding in past 48 hours. Confer with MD for proton pump inhibitor dose after continuous infusion
j) Patient refuses to take oral medications.
k) Antibiotics: Cystic fibrosis, Presence of infection with a high risk of treatment failure: Examples: meningitis, cerebral
aspergillosis, peritonitis, endocarditis, severe systemic fungal infections, osteomyelitis, staph or pseudomonas
pneumonia, lung abscess, necrotizing soft tissue infection.
Immunocompromised patients. Examples: Neutropenia, Post-transplant, HIV infection, Sickle-cell anemia, Anatomic or
functional asplenia. Confer with physician for UTIs and other moderate infections.
NICU fungal prophylaxis with fluconazole: Use IV route while NICU patient has an IV
-1-
3.
4.
5.
6.
Use judgement, defer an automatic change and confer with the physician depending on clinical circumstances.
Reassess daily, patients excluded from auto-conversion on first assessment.
Write an order in the patient chart indicating the medication has been changed “per P&T IV to PO guidelines” and why.
Document conversions and related communications in the pharmacy medication profile under the drug.
MEDICATION LIST
DRUG/
Bioavailability
Azithromycin
(Zithromax®) 34-52%*
Ciprofloxacin
(Cipro®)
60-80%
Doxycycline 90-100%
(Vibramycin)
Esomeprazole
(Nexium)
90%
Famotidine
(Pepcid®)
50%**
Fluconazole
(Diflucan®)
90%
Gatifloxacin
(Tequin®)
96%
Lansoprazole
(Prevacid) 80-90%
Levofloxacin
(Levaquin)
99%
Linezolid
(Zyvox®)
100%
Metronidazole
(Flagyl)
100%
Moxifloxacin
(Avelox)
90%
Pantoprazole
(Protonix®)
77%
Ranitidine
(Zantac)
50%
IV DOSE (Adult)
ORAL DOSE
Same dose and interval
Adult 200-400mg q 12 hours
Ped 15-30mg/kg/day divided q 12
hours
250-500mg q 12 hours
Ped 20-40 mg/kg/day divided q 12 hours
Avoid giving with tube feedings
Same dose and interval
Same dose and interval
Confer with MD post continous infusion
Same dose and interval
Same dose and interval
NICU fungal prophylaxis: IV route while IV in
Same dose and interval
Avoid giving with tube feedings
Same dose and interval
Confer with MD post continuous infusion
Same dose and interval
Avoid giving with tube feedings
Same dose and interval
Same dose and interval
Same dose and interval
Avoid giving with tube feedings
Same dose and interval
Confer with MD post continuous infusion
Adult 150 mg twice daily
Adult 50 mg q 8 hour
Ped 2-4 mg/kg/day divided every
6-8 hours to 150 mg/day
Ped Esophagitis 5-10 mg/kg/day divided twice daily
to 600mg/day GERD to 300mg/day
Ulcer
2-4 mg/kg/day divided twice daily
to 300mg/day treat, 150mg/day maint
Sulfamethoxazole/
Same dose and interval
Trimethoprim
Confer with MD for high dose treatment of PCP – may
need to give smaller oral doses 3 to 4 times daily
(Bactrim) 90-100%
Voriconazole
6mg/kg q12h x 2 doses, then
• Patient less than 40 kg, Same dose and interval up
(Vfend®)
96%
4 mg/kg q 12 hours (maintenance
to 150mg q 12 hours
dose)
• Patient 40 kg or more, Same dose and interval up
to 300mg q 12 hours
Do not change to oral form for treatment of cerebral
aspergillosis without consulting with a physician.
*Recommended oral dosing is lower than recommended IV for respiratory infections of the same severity. Highly concentrated in
tissues (10 to 100x serum) and phagocytes, and is sustained at high levels for 4 to 7 days after drug is discontinued
**Manufacturer recommends IV doses of 20 q12h and total daily PO doses of 20 to 40 mg
.
\\phsapamcfiler1\Pharmacy\P&T\IV to PO PAMC2005.doc
-2-