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Transcript
RALTEGRAVIR (Isentress®) – nonformulary at UWHC
For up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/
RIBAVIRIN – capsules are nonformulary at UWHC
Usual Dose
Adult: (average of 1.1 g/day) 6 g in 300 mL sterile water aerosolized (UWHC cost/day $4,196.64).
Hepatitis C (200 mg capsules in combination with interferon alfa). If <75 kg 800 mg PO per day in 2 divided doses. If > 75
kg 1200 mg PO per day in 2 divided doses. (UWHC cost/day $1.36-2.04). Capsules may be effective for RSV in adults at
a dose of 1800 mg/day.
Indications
1. Respiratory syncytial virus infections – may be considered for use in treating:
a. infants at high risk for severe or complicated RSV infection, i.e., infants with congenital heart disease,
bronchopulmonary dysplasia, other chronic lung conditions, immunodeficiency, recent transplants, cancer
chemotherapy and selected premature infants.
b infants with lower respiratory tract infections who are severely ill
c. infants who are not initially that ill, but who are at increased risk for progressively severe disease, e.g., the very
young (<6 weeks), those with multiple congenital abnormalities, neurologic or metabolic diseases.
d. immunocompromised adults. Oral formulation may be as effective as aerosolized.
2. Hantavirus, Korean Hantaan virus, Lassa Fever virus and other susceptible viruses causing hemorrhagic fever
syndrome. Use intravenous form (see Comments).
3. RSV life-threatening pneumonia.
4. Hepatitis C infection. Use oral form in combination with PEG-interferon. Duration of treatment is typically 6-12 months.
Comments
Duration of therapy for inhalation is 3 to 5 days. Because of concerns regarding environmental exposure to aerosolized
ribavirin, refer to the Respiratory Therapy Ribavirin Policy and Procedure #2:29. The drug must be administered via a
Small Particle Aerosol Generator (SPAG-2). Although the product information warns that ribavirin aerosol should not be
used in infants requiring assisted ventilation because precipitation of the drug in the respiratory equipment may interfere
with ventilation, Respiratory Therapy has solved the problem by using high efficiency hydrophobic filtration of the
exhalation circuitry of the ventilator. Also, Respiratory Therapy scavenges into wall suction all excess ribavirin that is
administered regardless of the mode of administration. For suspected or overwhelming cases of RSV or Hantavirus
infection, consult the Infectious Disease Section for specific recommendations. Intravenous ribavirin is available only
through compassionate use protocols. For assistance in obtaining a supply of the drug contact the Pharmaceutical
Research Center (pager #2717). Dose adjust oral capsules in patients with renal dysfunction. Dose reductions are
recommended in patients with decreasing hemoglobin levels; in patients with no cardiac history, decrease oral dose to
600 mg/day (200 mg AM/400 mg PM) when hemoglobin <10 g/dL and discontinue ribavirin when hemoglobin goes below
8.5 g/dL. In patients with a cardiac history, decrease dose to 600 mg/day when hemoglobin decreases by 2 g/dL during
any 4-week treatment period; discontinue ribavirin when hemoglobin <12 g/dL.
Drug Interactions
Ribavirin has a number of serious interactions with non-nucleoside analogues, as follows:
• Abacavir – lactic acidosis, fatal and nonfatal
• Didanosine – lactic acidosis, fatal and nonfatal; increased mitochondrial toxicity; peripheral neuropathy; pancreatitis
• Lamivudine – lactic acidosis, fatal and nonfatal; hepatic decompensation
• Stavudine – lactic acidosis, fatal and nonfatal; decreased stavudine efficacy
• Zalcitabine – lactic acidosis, fatal and nonfatal
• Zidovudine – lactic acidosis, fatal and nonfatal; hepatic decompensation; decreased zidovudine efficacy;
neutropenia
Other drug interactions with ribavirin:
• Azathioprine – increased azathioprine-related myelotoxicity due to decreased clearance
• Interferon alfa-2B – increased severity of neuropsychiatric symptoms (depression, anger and hostility)