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PHARMAGRAM
...an educational memo from your Pharmacy and Therapeutics Committee
January, 2002
Famotidine (Pepcid®) Replacing Ranitidine (Zantac®) as Preferred H-2 Blocker:
Famotidine will now be the preferred H-2 blocker, replacing ranitidine. Reasons for the change are the
significant cost difference and the less frequent daily dosing of the parenteral dosage form. Pharmacists will
write autosubstitution orders for other prescribed H-2 blockers.
Corrections: Hyaluronidase (Wydase®)Treatment and Nesiritide (Natrecor®) Use
The December PharmaGram failed to specify that treatment of parenteral nutrition infiltrates with the limited
supply of hyaluronidase is approved for the Neonatal Intensive Care Unit only. My apology for any confusion
this may have caused.
Nesiritide, a natriuretic peptide, used for acute exacerbation of heart failure, may also be administered to
patients in the Emergency Department and on the 5th Floor in the Gerlach Building, as well as the ICUs and
Intermediate ICU (3400).
Parenteral to Oral Conversion of H-2 Blockers and Proton Pump Inhibitors:
Audits of parenteral use of the H-2 blocker ranitidine (Zantac®) and the proton pump inhibitor, pantoprazole
(Protonix®) showed that about half the patients were also receiving either an oral/enteral diet or other oral
medications. Studies have shown equivalent efficacy of these oral gastric acid blocking products. In
consultation with the Gastroenterology service, the P&T Committee has agreed to allow for substitution of
the parenteral product when a patient is taking an oral diet or other oral medications. Excluded from the
protocol are patients in the ICU’s, pediatrics or when a ‘Do Not Substitute’ request is written with an order for
the parenteral dosage form. Pharmacists will write an order for the switch and will follow the dosages
recommended in Autosubstitution guidelines, including the use of omeprazole suspension for patients unable
to take the solid dosage form.
Conversions Between Solid and Liquid Dosage Forms:
Many times a patient’s capability to swallow a solid or liquid dosage form changes during their
hospitalization. Effective February 1, the P&T Committee has approved a protocol which will allow nurses to
write an order altering the dosage form based on the patient’s swallowing ability. Physicians would need to
be contacted for extended-release, antiarryhthmic and immunosuppressive agents; and drugs with a narrow
therapeutic index or with known bioavailability problems (ex. phenytoin (Dilantin®).
Drotrecogin alpha (Xigris®) and Montelukast (Singulair ®) added to the Formulary:
Drotrecogin alpha, also known as recombinant activated protein C, was recently FDA approved for reduction
of mortality associated with severe sepsis. Following strict criteria in a recently reported study, a 96-hour
infusion of drotrecogin alpha resulted in a 6.1% absolute reduction in mortality. The P&T Committee
approved this drug, but, due to the drug cost and side effect potential, restricted prescribing to physicians
with expertise on the drug’s use and to it’s initiation in the ICU’s.
Montelukast, a leukotriene receptor antagonist indicated for the prophylaxis and chronic treatment of asthma
in adults and children, was added to the Formulary. It is available in 10mg tablets and 4 mg and 5 mg
chewable tablets.
Droperidol (Inapsine®) Use Restricted:
As a result of increased reports of Torsades and the addition of a ‘Black Box Warning’ to the product
information, droperidol may now only be used if the Q-T interval on ECG is demonstrated to be of acceptable
duration prior to administration of the drug.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
February, 2002
Kaletra ® and Bivalrudin (Angiomax®) added to the Hospital Formulary:
Kaletra ® is a combination of lopinavir, a new protease inhibitor, and ritonavir (Norvir®) and is approved for
the treatment of patients with HIV infection. The normal recommended dose is 400mg lopinavir/100mg
ritonavir (3 capsules or 5 mls of the liquid formulation) twice a day. Numerous, potential drug-drug
interactions are possible since ritonavir is known to interfere with the P-450 enzyme system. Both the
capsules and liquid product need to be stored in the refrigerator.
Bivalrudin, is a direct thrombin inhibitor, which was recently approved by the FDA and is indicated for
patients with unstable angina who are undergoing coronary angioplasty. Studies have not conclusively
shown this drug to be better than unfractionated heparin. Bivalrudin was approved for use in the Cath Lab in
treating patients with a history of heparin-induced thrombocytopenia or other heparin sensitivities.
Avoid Adding Flavoring Agents to Colyte® and Miralax®:
Colyte ® and Miralax® are cathartics that contain polyethylene glycol as the primary ingredient, that acts as
an osmotic agent. When a sweetened flavoring agent is added to these products, colonic bacteria can
produce hydrogen and methane gas as a byproduct of the carbohydrate metabolism. Bloating, irritability and,
in extreme cases, bowel rupture have been reported when this combination was used.
Droperidol (Inapsine®) Deleted off the Formulary:
Because of recent FDA warnings and fatal arrhythmic events associated with the use of droperidol, the
Pharmacy and Therapeutics Committee voted to remove this product from the Formulary.
Considerations When Ordering and Choosing Enoxaparin (Lovenox®):
Some things to consider before ordering enoxaparin include:
minimal information on dosing and pharmacokinetics in obese patients*
no reliable dosage information for patients with renal dysfunction*
order the desired dose, avoid ordering 1 mg/kg
round doses to the nearest 10mg (pre-filled syringes are 30, 40, 60, 80, 100mg)
DVT prophylactic doses of 40mg once a day is preferred for medical, general surgery, and stroke
patients.
*Consider using heparin which can be monitored with PTT in these patients.
OSF Saint Francis Medical Center Formulary Available on the Web:
The latest edition of the Hospital Formulary is now available on the Web. Improvements are still being made,
but you can get at the Formulary by going to the OSF web site at www.osfhealthcare.org, under the Library
and Resource section, click on ‘Pharmacist’ and then click on ‘Formulary.’
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
March, 2002
Ziprasidone (Geodon®) and Aggrenox ® added to the Hospital Formulary:
Ziprasidone, a non-traditional anti-psychotic indicated for the treatment of schizophrenia, was added to the
Formulary. Because of its potential to cause QT prolongation and fatal arrhythmias, a special pre-printed
order form must be used when prescribing this drug. The form provides conditions that must be met, such as
12 lead ECG, normal potassium and magnesium levels and no significant interacting drugs, before the drug
can be dispensed or administered.
Aggrenox®, which is a combination of aspirin and dipyridamole, has been shown through clinical trials, to be
effective in preventing recurrent stroke. Previously an autosubstitution was utilized for this drug. The
formulary addition was based on usage, convenience of drug administration and minimal additional cost.
Drotrecogin (Xigris®) Prescribing:
Prescribing drotrecogin, also known as activated Protein C, will be restricted to attending physicians only, be
restricted to patients in an intensive care unit during initiation of therapy, and must be ordered using a preprinted order form specific for this drug. The Drotrecogin Order Form provides qualifications that must be
met, and checked off, before this drug can be dispensed. This action was taken based on the significant cost
of therapy (average $7000 per patient) and potential significant side effects.
Clinical Pharmacy Services and Drug Information Availability:
Clinical services, such as pharmacokinetic dosing of aminoglycosides and vancomycin, drug dosing in
renally impaired patients, patient education and identification of adverse drug reactions, are available
throughout Saint Francis Medical Center. In addition, a drug information service is now fully staffed
8 AM – 4:30 PM, Monday through Friday. Phone numbers, pagers and areas covered are listed below.
Location Phone Pager Hours Available Days
Main Pharmacy 655-2285 --- 6:30 AM – 11 PM 7 days
Gerlach Pharmacy 655-2050 --- 24 hours 7 days
Gerlach 5000-5100 --- 497-4663 7 AM – 3:30 PM Mon - Fri
Gerlach 4000-4100 --- 655-9772 7 AM – 3:30 PM Mon - Fri
Pediatrics --- 679-5926 7 AM – 3:30 PM Mon - Fri
3400 – 4 Surg --- 497-9198 7 AM – 3:30 PM Mon - Fri
1700 – 2700 --- 497-9288 7 AM – 3:30 PM Mon - Fri
Surgery 655-3471 --- 7 AM – 9:15 PM Mon - Fri
St. Jude Clinic 624-9862 497-6716 6:30 AM – 3 PM Tues,Fri
Center for Health 683-4723 679-3334 6 AM – 3:00 PM Mon - Fri
Clinic Pharmacy 624-9534 --- 8 AM – 4:30 PM Mon - Fri
Drug Information 655-2382 679-5928 8 AM – 4:30 PM Mon - Fri
ADE Hotline 655-6805 --- 24 hours 7 days
Correction: Web Address for Formulary:
The latest edition of the Hospital Formulary is available through the OSF Library and Resource web site at
http://library.osfsaintfrancis.org/. Then click on ‘Pharmacist’ and then click on ‘Formulary.’ The web address
in the last PharmaGram was incorrect.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
April, 2002
Imatinib (Gleevec®) and Atorvastatin (Lipitor®) added to the Hospital Formulary:
Imatinib and atorvastatin were added to the Formulary. Imatinib, which is FDA approved for the treatment of
chronic myeloid leukemia, is an oral agent with mild to moderate side effects.
Atorvastatin was added since it is on a number of outpatient health plan formularies and is one of the most
prescribed cholesterol lowering agents. Pravastatin (Pravachol®) will remain on the Formulary and serve as
the substitute for all other ‘statin’ drugs.
Fexofenadine XR (Allegra XR®) autosub and Heparin Infusion Non-Overrideable:
Orders for fexofenadine XR 180 mg will be autosubstituted by the pharmacist with three 60 mg regular
fexofenadine capsules. The half-life of fexofenadine is 14-18 hours and the kinetic data is identical between
the two products, when equal once daily doses are used.
Heparin 25,000 unit in 500ml infusion bags will no longer be available to nursing through the SureMed®
machines without prior pharmacist approval. Pharmacists can detect duplicate drug therapy or check for
patient drug allergies prior to dispensing without causing significant delays in therapy. Bolus doses of
heparin will still be available for emergencies prior to pharmacist review.
Formulary Deletions:
Glacial acetic acid, flexible collodian and intravenous colchicine were removed from the Formulary due to
potential or actual risks or adverse drug events that have been reported.
Low-Molecular Weight Heparin Dalteparin (Fragmin®) added to the Formulary:
A significantly lower acquisition cost compared to enoxaparin (Lovenox®) and once daily dosing for most
indications were two reasons dalteparin was added to the Formulary. Although enoxaparin is still on the
Formulary, it is hoped that physicians will consider switching to dalteparin whenever clinically appropriate. A
comparison list of enoxaparin with dalteparin with usual doses is given below.
Indication Enoxaparin Dalteparin
DVT prophylaxis 30mg subcut BID 5000 units subcut daily
or 40mg subcut daily
DVT prophylaxis post hip 30mg subcut BID 2500 units subcut 6hrs postop
replacement or 40mg subcut daily then 5000 units subcut daily
DVT/PE treatment 1 mg/KG subcut BID 200 units/KG subcut daily
or 1.5 mg/KG subcut daily maximum of 18,000 units daily
Drug-specific Pre-printed Physician Orders:
Look for pre-printed physician order forms for the following drugs. They are complete, contain useful
information and help speed the ordering process.
Heparin-Cardiology Iron Dextran (InFed) tPA – Ischemic Stroke
Heparin-Medicine (High Bolus) Potassium Replacement (SICU) Nesiritide (Natrecor)
Heparin-Neurology (Low Bolus) RSV IG (Respigam) Infusion Dofetilide (Tikosyn)
Insulin Sliding Scale (Nephrology) Enoxaparin Acute Coronary Synd Morphine PCA
Insulin Sliding Scale (Medicine) Propofol (Diprivan) Infusion Infliximab (Remicade)
Reteplase for Dialysis Graft Thromb Abciximab (ReoPro) Ziprasidone (Geodon)
Warfarin Ortho INR Protocol Eptifibatide (Integrilin) Rocuronium (Zemuron)
Drotrecogin (Xigris) Thymoglobulin/Muromonab (OKT3)
Fentanyl Adult Postop Analgesia Hydromorphone (Dilaudid) PCA
Morphine, Fentanyl, Midazolam Weaning (CHOI)
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PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
May, 2002
Policy to Promote Inclusion of ‘Dose per Kilogram’ for Pediatric Drug Orders:
In order to prevent prescribing errors in the pediatric patient population, the P&T Committee for the
Children’s Hospital of Illinois is encouraging prescribers to include ‘dose / KG’ with each drug order. The
order sheet should also provide the current weight of the patient. An example would be a 4 KG child with an
order for Ampicillin 200mg (50mg/KG) IV every 6 hrs.
Orange Medication Stickers on Patient ID Bracelet means Patient has a Drug Patch:
Medication patches containing drugs such as fentanyl, clonidine, nicotine, scopolamine, and nitroglycerin are
a common means of drug administration. Unfortunately these patches can be hidden from view and this can
and has led to similar drugs being co-administered with undesired, additive pharmacologic results. Starting
this month, if a patient has a patch applied to their skin, an orange sticker with the drug name written on it will
be attached to the wristband used for patient identification. The label is large enough to be seen, but will not
cover the patient’s name on the band.
Formulary Changes: Paregoric Removed and Finasteride (Proscar®) Added:
Paregoric, which is a rarely prescribed antidiarrheal with potentially significant side effects, was removed
from the Formulary. Although alpha-blockers are the usual first line choice in treating benign prostatic
hypertrophy, finasteride was added to the Formulary for those patients who benefit from this alternative drug
therapy.
Verbal Verification of Physician Telephone Orders:
To avoid errors with telephone orders, nurses, pharmacists and all others authorized to receive physician
telephone orders are requested to repeat the orders back to the prescriber for verification.
Dosage Forms That Should Not be Crushed:
Either because it is a sustained-release dosage form, has a disagreeable taste or needs to be protected from
the acidic environment of the stomach, the following are some drug products that should not be crushed or
chewed.
Asacol ® (mesalamine) Humabid LA ® (guaifenisin)
Dulcolax ® (bisacodyl) Imdur ® (isosorbide mononitrate)
Calan SR ®, Isoptin LA ® (verapamil) Inderal LA ® (propranolol)
Cardizem SR and CD ® (diltiazem) Macrobid ® (nitrofurantoin)
Colace ® (docusate) Micro K ® (potassium chloride)
Creon ® (pancrelipase) MS Contin ® (morphine sulfate) Depakene ® (valproic acid) Procardia XL ®, Adalat
CC ® (nifedipine)
Depakote® (divalproex) Sinement CR ® (levodopa/carbidopa)
Diamox Sequels® (acetazolamide) Slobid ®, Theodur ® (theophylline)
Ecotrin ® (aspirin) Toprol XL ® (metoprolol)
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
June, 2002
New Drugs Added to the OSF Hospital Formulary:
Valganciclovir (Valcyte®), which is a pro-drug of ganciclovir (Cytovene®), is an antiviral agent used in the
treatment of cytomegalovirus retinitis. Valganciclovir offers an alternative to oral and intravenous ganciclovir,
with the advantage of once- or twice-daily oral administration. It appears to achieve ganciclovir levels
comparable to those achieved with intravenous ganciclovir and the adverse effects are comparable to the
parent drug.
Cilostazol (Pletal®) is a selective phosphodiesterase inhibitor used in the treatment of intermittent
claudication. In doses of 100mg twice a day, cilostazol has shown moderate improvements in walking
distance and may prove useful as an alternative to pentoxifylline (Trental®).
Advair® is a combination of fluticasone and salmeterol, which is administered twice daily as a dry powder
inhaler, and is indicated for the long term maintenance therapy of asthma. The fluticasone portion is available
in 100mcg, 250mcg and 500mcg strengths, and the salmeterol is fixed at 50mcg for the three fluticasone
doses. Advantages include reduced cost with one inhaler and less frequent drug administrations compared
to the use of separate drug inhalers.
Restricting Use of Home Medications:
Due to considerable processing time, the potential for lost medications and possible medication errors, the
use of home medications will no longer include oral medications that are on the Hospital Formulary and are
readily available within the Pharmacy.
Autosubstitution for Oxybutynin XR (Ditropan XR®):
As per Pharmacy and Therapeutics Committee approval, pharmacists will be able to substitute regular
release oxybutynin for orders of oxybutynin XR. Since oxybutynin XR is available in 5mg, 10mg and 15mg
dosage sizes, the same milligrams per day divided either twice or three times a day will be used.
Availability of DigiFab® (Digoxin Immune FAB (Ovine), a generic version of DigiBind®:
DigiFab®, a generic version of Digibind®, will soon become available as current supplies of DigiBind® are
exhausted. Digoxin Immune FAB is indicated for the treatment of patients with potentially life-threatening
digoxin toxicity or overdose. Each vial of DigiFab® contains 40mg of purified digoxin-specific FAB, which will
bind approximately 0.5mg of digoxin. Dosing of DigiFab® is the same as DigiBind, but will cost over $150
less per vial.
Best Dosing Time for Insulin Glargine (Lantus®)
Insulin glargine is one of the newer insulin products to be approved and provides a sustained, basal level of
insulin throughout the 24-hour dosing period from a single daily dose. According to the manufacturer, the
best clinical response is when insulin glargine is administered at bedtime, rather than in the morning, and this
is the time that was use in the clinical studies on this drug.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
July, 2002
Enoxaparin (Lovenox®) Now Preferred Over Dalteparin (Fragmin®) due to Manufacturer’s
New Pricing- Autosubstitution Approved:
Reacting to a recent significant cost reduction, the Pharmacy and Therapeutics Committee has decided to,
once again, have enoxaparin as the preferred low molecular weight heparin. As part of this decision, all
orders for prophylactic doses of dalteparin will be automatically substituted by the pharmacists to once daily
40mg of enoxaparin.
Things to Consider When Prescribing Enoxaparin (Lovenox®):
DVT prophylactic doses of 40mg once a day is preferred for medical, general surgery, and stroke
patients. Patients at high risk or undergoing total knee surgery may require enoxaparin 30mg every 12
hours.
minimal information on dosing and pharmacokinetics in obese (greater than 150 KG) patients*
no reliable dosage information for patients with renal dysfunction*
prophylactic use: usual dose is 40mg SC once daily
DVT therapy: see www.tagpeoria.org for orders. Avoid only writing 1 mg/kg, include total dose.
round doses to the nearest 10mg (pre-filled syringes are 30, 40, 60, 80, 100mg)
*Consider using unfractionated heparin, which can be monitored with PTT in these patients.
Formulary Additions:
Brimonidine (Alphagan®), an ophthalmic solution with alpha-adrenergic agonist activity and indicated for the
treatment of open-angle glaucoma or ocular hypertension.
Tenofovir (Viread®), a reverse transcriptase inhibitor used to treat HIV infections. Due to the anticipated low
usage of this particular agent, it may not be immediately available from the inpatient pharmacy.
Bosentan (Tracleer®), an oral endothelin receptor antagonist indicated for treatment of pulmonary arterial
hypertension and a potential alternative for epoprostenolol (Flolan®). Ordering of this product is patient
specific and the manufacturer must be contacted prior to prescribing.
Isotretinoin (Accutane®) Being Considered for Non-Formulary Status:
Consideration is being made for removing isotretinoin from the Formulary due to new FDA requirements and
restrictions to prescribing, potential confusion with another trans-retinoic acid product tretinoin (Vesanoid®)
and the low usage within the hospital. The P&T Committee invites open comments about this issue until
August 2, 2002.
Raloxifene (Evista ®) Not Added to the Formulary:
Continuation of raloxifene, which is currently indicated for the treatment or prevention of osteoporosis in
postmenopausal women, is not viewed as being clinically necessary during an acute hospitalization. The use
of raloxifene has been associated with thromboembolic events if it is not held several days prior to surgery
and/or during immobility. The P&T Committee voted to deny formulary status for raloxifene based on this
information.
Metoprolol, Enalaprilat and Lidocaine Intravenous Products Made Non-Overrideable
To ensure that a pharmacist reviews all drug orders for prescribing accuracy, intravenous metoprolol,
enalaprilat and lidocaine will now be non-overrideable in the SureMed machines. Lidocaine for emergency
use will still be immediately available on the emergency code carts.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
August, 2002
Enoxaparin (Lovenox®) Patient Assistance Program:
A Patient Assistance Program is available for indigent patients who cannot pay for their medication and
could otherwise be treated with the low molecular weight heparin, enoxaparin, as an outpatient. Patient
qualification is based on family income being below twice the 2001 HHS Poverty guidelines. For example, a
family of one or two members would qualify if their annual income is less than $17,180 or $23,220,
respectively. For more information and a Patient Assistance form, contact the Vascular Case Manager or the
Discharge Planning Office (655-2311).
Multivitamin Product Added to Parenteral Nutrition Contains Vitamin K:
The multivitamin product used in the parenteral nutrition solutions has recently been modified by the
manufacturer and now contains 150 micrograms of vitamin K. Therefore, additional supplemental vitamin K
(i.e. vitamin K 10mg IM weekly) is probably unnecessary given this change in formulation.
Sevelamer (Renagel ®) Added to Formulary:
Sevelamer (Renagel®) is a nonabsorbable cationic polymer indicated for the reduction of serum phosphate
in patients with end-stage renal disease. This product was added to the Formulary as an alternative or
supplement to the calcium and aluminum containing phosphate binding agents. Although not specifically
studied, the product information suggests coadministration with antiarrhythmics and seizure medication
should be avoided within 1-2 hours of dosing with sevelamer to circumvent binding and reduced absorption.
Tetanus and Diphtheria Vaccine Drug Supplies Restored:
During the shortage, supplies of diphtheria and tetanus vaccine decreased nationally by 40%. Currently stock
levels of this vaccine have been restored. Persons who were deferred from routine vaccinations may now
receive the booster dose.
Pantoprazole (Protonix®) IV Drug Administration:
Pantoprazole (Protonix®) is currently the only FDA approved proton pump inhibitor that can be administered
intravenously. The undiluted drug must be refrigerated and, once it is reconstituted, is stable for up to 12
hours at room temperature. IV administration is over 15 minutes, or not to exceed
3 mg/min. Because of precipitates that form upon reconstitution, pantoprazole must be administered in a
dedicated IV line with the inline filter provided with the product . A 0.22-micron inline filter, which is available
on some IV administration sets, may be used as an alternative.
Complete Written Orders for ‘PRN’ Medications:
To avoid errors when prescribing ‘as needed’ or ‘PRN’ medications, be sure to include the allowable
frequency and the indication as to when the medication should be given. For example, avoid promethazine
25mg IM PRN . Such orders are considered incomplete and will prompt a request for clarification. A more
complete order is promethazine 25mg IM every 4 hours PRN nausea.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
September, 2002
Increased Cost and Renal Function Side Effects Associated with Fenofibrate (Tricor®)
Compared to Gemfibrosil (Lopid®):
Fenofibrate (Tricor®), which is not on the OSF Saint Francis Formulary, is a fibric acid derivative and has
become one of the more commonly prescribed agents for the treatment of hypertriglyceridemia. A survey of
local pharmacies showed that patients will pay $52-58 more per month for Tricor 160mg taken daily
compared to the approved Formulary drug gemfibrosil 600mg taken twice daily. In addition, 6 case reports
and an investigative study (Pharmacotherapy 2001;21:1145 and Lancet 2001;358:39) have implicated
fenofibrate with reduced renal function. Gemfibrosil has not been shown to affect renal function. Physicians
are asked to consider these factors when choosing between these agents.
National Safety Goals for 2003 Set by Joint Commission:
Beginning January 1, 2003, JCAHO surveyors will assess an organization’s implementation of the 6 National
Patient Safety Goals. The Goals are summarized below:
Improve Accuracy of Patient Information: Use 2 patient identifiers (neither can be room number) whenever
taking blood samples or administering medications or blood products.
Improve Effectiveness of Communication: Implement a process for taking verbal or telephone orders that
requires verification ‘read back’ by the person receiving the order. Standardize abbreviations, acronyms and
symbols.
Improve Safety of High-Alert Drugs: Remove concentrated electrolytes from patient care units and
standardize available drug concentrations.
Eliminate Wrong-Site, Wrong-Patient, Wrong-Procedure Surgery: Create a preoperative verification process
to confirm that appropriate documents (medical records, imaging studies) are available. Implement a process
to mark the surgical site and involve the patient in the marking process.
Improve the Safety of Infusion Pumps: Ensure free-flow protection on all intravenous infusion pumps.
Improve Effectiveness of Clinical Alarm Systems: Implement regular preventive maintenance and testing of
alarm systems.
Isotretinoin (Accutane®) Changed to Non-Formulary Status:
The Pharmacy and Therapeutics Committee voted to remove isotretinoin from the Formulary. The decision
was based on new FDA requirements, restrictions to prescribing, potential confusion with another transretinoic acid product tretinoin (Vesanoid®) and the low usage within the hospital
‘Resume Home Medications’ Not a Valid Pharmacy Order:
Medication orders must list each individual drug with doses, routes of administration and frequency. This is a
Joint Commission regulation and hospital policy. Orders such as "Resume home medications’ cannot be
accepted as a valid medication order.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
October, 2002
Autosubstitution of Imipenem/Cilastin (Primaxin®) to Meropenem (Merrem®):
The Pharmacy and Therapeutics Committee approved the autosubstitution of imipenem/cilastin to
meropenem for adult patients. Meropenem’s usual adult dose for patients with normal renal function is
1 gm IV every 8 hours. Physicians who order imipenem in doses greater than 500mg every 6 hrs, will be
contacted to choose an appropriate meropenem dose. Imipenem will be available for treating pancreatic
abscess infections if the physician indicates ‘dispense as written’ with their order.
Beef-Lung Heparin and Danaparoid (Orgaran®) Discontinued by Manufacturers:
Two anticoagulants, beef-lung heparin and danaparoid are being discontinued by their respective
manufacturers. Heparin sodium (porcine derived) will continue to be available and be used as the
replacement for the beef-lung product. Danaparoid is low molecular weight heparinoid which has been rarely
used in clinical practice.
Changing Manufacturers for Insulin Products :
The Pharmacy is changing from Lilly's Humulin® insulin product line (Regular, NPH, Lente, 70/30 and
Humalog) to Novo Nordisk’s (formerly Squibb Pharmaceutical) Novolin® (Regular, NPH, Lente, 70/30 and
Novolog) insulins. After consultation with endocrinology and recognizing both products to be equally safe and
efficacious, the P&T Committee approved the product conversion. This change was prompted by a
significant decrease in the price of the Novo Nordisk insulin products. There will be no change for Humulin
50/50, Ultralente or insulin glargine (Lantus®). Children are excluded from this conversion until a final
decision has been made.
Formulary Maintenance by the Pharmacy and Therapeutics Committee:
The P&T Committee consists of 31 voting physicians and 8 non-voting members, who represent support
services and hospital administration. Maintenance of the Drug Formulary is among several areas of
responsibility of this Committee. Physicians may request a drug to be added to the Formulary by completing
a Formulary Addition Request form which is available from the Pharmacy Department. The Drug Analysis
Work Group Subcommittee researches and reviews each drug request. Using a balanced scorecard
approach which considers efficacy, safety, patient’s acceptance and cost, this Subcommittee makes
recommendations to the P&T Committee for drug product approval, denial or removal. If judged by a
patient’s physician to be clinically necessary, a one-time or one patient use of a non-Formulary product may
be requested by the prescribing physician completing a Non-Formulary Request form (available from the
Pharmacy Department) and contacting the P&T Committee Chairman.
Fosphenytoin (Cerebyx®) Pre-Printed Physician Orders:
The dose of fosphenytoin, a parenteral agent used to treat seizures, must be dosed using Phenytoin
Equivalents (PE). In order to prevent potential dosing errors, a pre-printed order sheet, which will be
available soon, must be used when prescribing this drug.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
OSF Saint Francis Medical Center, Peoria, Illinois
...an educational memo from your Pharmacy and Therapeutics Committee
November, 2002
Hyaluronidase for Extravasation is Available:
The only manufacturer of hyaluronidase (Wydase®) discontinued production several months ago. Because
this product plays an important role in the treatment of certain types of extravasations, the Pharmacy will
now prepare and currently has in stock, hyaluronidase 150 units/ml for injection. The approved use for this
hyaluronidase product will be limited to the treatment of extravasations involving selected chemotherapeutic
agents, calcium chloride, calcium gluconate, dextrose (10% or greater), parenteral nutrition (TPN,PPN),
phenytoin (Dilantin®), potassium (bolus or infusion), sodium bicarbonate, mannitol, acyclovir (Zovirax®),
chloramphenicol, gentamicin, nafcillin, penicillin, vancomycin and aminophylline. Please refer to the Drug
Administration Policy for administration procedures.
Formulary Additions:
The following pharmaceuticals were added to the hospital Formulary:
Nateglinide (Starlix®) – is a novel nonsulfonylurea oral antidiabetic agent indicated for treatment of patients
with Type 2 diabetes. Nateglinide is rapidly absorbed and is administered 1 to 30 minutes before meals and
may be used in combination with metformin.
Alemtuzumab (Campath®) – is indicated for the treatment of B-cell chronic lymphocytic leukemia in-patients
who have been treated with alkylating agents and who have failed fludarabine therapy. This item will not
normally be stocked in the Pharmacy until requested for use.
Voriconazole (Vfend®) – is indicated for the treatment of invasive aspergillosis and other serious fungal
infections which are refractory to other therapies. Voriconazole is available in parenteral and oral tablet
formulations. The intravenous administration is contraindicated in patients with creatinine clearances of 50
ml/min or less. There are many drug/drug interactions to be considered, including ones involving the P450
liver enzyme system. Voriconazole is more costly than fluconazole (Diflucan®), but offers a significant cost
advantage over amphotericin B lipid complex (Abelcet®). All orders for voriconazole will have a concurrent
utilization review by Infectious Disease and Pharmacy Services.
Risedronate (Actonel®) Not Approved for Inpatient Use:
Like alendronate (Fosamax®), risedronate must be taken with 6-8 ounces of water and the patient should
remain in an upright position for at least 30 minutes after the dose to reduce the risk for esophagitis,
esophageal erosion or ulcers. Since most hospitalized patients cannot comply with this administration
procedure and missing doses of this medication during hospitalization is unlikely to cause harm, risedronate
was not added to the Formulary and all prescribing and dispensing, including the use of the home
medication, is prohibited. Calcitonin (Miacalcin) may be considered as an alternative to risedronate and
alendronate if clinically necessary.
Torsemide (Demadex®) Denied Formulary Addition:
Based on the lack of clinical trials showing an advantage of torsemide over the approved Formulary loop
diuretics (furosemide (Lasix® and bumetanide (Bumex®) and the significant cost, the P&T Committee
denied adding torsemide to the Formulary.
Pantoprazole (Protonix®) Oral Liquid Available:
A pharmacy-compounded oral liquid formulation for pantoprazole is now available and will be used in place
of omeprazole oral suspension in adult patients unable to take the oral tablets.
Report Adverse Drug Events on the ADE Hotline – 655-6805
PHARMAGRAM
...an educational memo from your Pharmacy and Therapeutics Committee
December, 2002
Augmentin® Versus Augmentin XR® Confusion:
Augmentin ® is a combination of amoxicillin and clavulanate and is available in the following strengths:
250mg/125mg, 500mg/125mg and 875mg/125mg. The patent has expired on this product and the
manufacturer has now introduced a similar product called Augmentin XR ®. Augmentin XR ® contains
1000mg of amoxicillin and 62.6mg clavulante. It is important that healthcare providers be aware of this
difference and to include product strengths and suffixes associated with a drug name when prescribing drug
products such as these. Augmentin ® is on the Formulary, whereas Augmentin XR® is not.
New Telephone Medication Order Policy Effective January 1st:
A revised Telephone Medication Order Policy will require the ordering clinician to clearly identify themselves,
with their dictation numbers, and provide the patient’s full name, name and spelling of the medication, along
with the dose, route and frequency. The receiving clinician will write the order, including the date and time,
and then the patient’s name and medication order will be read back and verified by the prescriber. The
written order will include the notation ‘read back’ to assure compliance with this policy.
Parenteral Drug Administration is Not a Criteria for Hospitalization:
Occasionally an assumption is made that administration of intravenous medications is sufficient reason to
hospitalize a patient. Many oral versions of parenteral medications are nearly 100% absorbed and can be
safely and effectively used in place of the intravenous product. Homecare services frequently provide
parenterally administered medications to patients on an outpatient basis. Maintaining a patient on parenteral
medication increases hospital costs and is not sufficient criteria to not discharge a patient.
Additions to the Formulary:
A parenteral gold preparation used for rheumatoid arthritis, aurothioglucose (Solganol®) has been
discontinued by the manufacturer. In it’’s place the P&T Committee has added gold sodium thiomalate
(Myochrysine®).
Galantamine (Reminyl®) has join donepezil (Aricept®) on the Formulary for the treatment of Alzheimer’s
Disease. Tacrine (Cognex®) and rivastigmine (Exelon®) were denied Formulary addition due to the side
effect profiles or lack of comparative benefit to the drugs on Formulary.
Senokot S ® to Replace Peri Colace ®:
Casanthranol, which is contained in PeriColace®, is being removed from the market. Senokot S®, which
contains 8.6mg senna and 50mg docusate has been selected as the substitute for PeriColace®.. An
equivalent dose to 1 capsule of Peri Colace® would be 2 tablets of Senokot S®. Since there is not a Senokot
S® liquid formulation, Senokot ® liquid 5mls (8.8mg senna) given with docusate 15ml (50mg doucsate) will
be used as a subsitute for 15ml of PeriColace ® . Pharmacists have been approved to use these
substitutions for all PeriColace® orders .
Report Adverse Drug Events on the ADE Hotline – 655-6805