Embed Size (px)
Citation preview
We welcome your thoughts, comments and/or suggestions.
Do you have an idea for a story? Is there information we can provide you?
All correspondence concerning The Script should be sent to:
Lisa Mayer, Pharm.D., BCPS 901 N Porter Ave., Box 1308
Norman, OK 73071
The Script A Publication of the Department of Pharmacy, Norman Regional Health System
Cockcroft-‐Gault vs MDRD. . . . . . . . . 1
Pharmacy and Therapeutics Committee Update. . . . . . . . . . . . . . 2
New Clinical Pharmacy Program. . . . . . . . . . . . . . . . . . . . . . . 2
Fleet® Enemas Missing From Patient Units! . . . . . . . . . . . . . 3
The Unwanted Effects Of Drugs . . . . . . . . . . . . . . . . 3
Flu Shot Myths Debunked . . . . . . . . 4
Ordering Whodunit . . . . . . . . . . . . . 4
Welcome Our New Pharmacy Residents . . . . . . . . . . . . . 5
Drug Shortages . . . . . . . . . . . . . . . . . 5
Medication Safety. . . . . . . . . . . . . . . 6
Is a medication missing from your eMAR or does it need retimed? Please send pharmacy a MAR clarification with your request. This is the preferred method of communication with the Pharmacy. This helps to limit the number of phone calls to the
pharmacy, which in turn reduces the number of distractions to the pharmacists. Limiting these distractions improves patient care by reducing medication errors while improving the efficiency of the pharmacy to profile medications.
The Script
In This Issue:
Fal l 2012, Issu e 2
While the gold standard for evaluating kidney disease is direct measurement of the glomerular filtration rate (GFR), this approach is often clinically impractical. Drug manufacturers are advised to follow the 1998 Food and Drug Administration (FDA) guidance for industry to utilize the Cockcroft–Gault equation as a basis for drug-‐dosing recommendations. As a result, manufacturer-‐provided label information for products approved for marketing by FDA typically make dosing recommendations using this strategy, and clinicians employ this approach for medication adjustments in practice. The modification of diet in renal disease (MDRD) equation was developed as an alternative approach for staging renal disease and previous studies have confirmed the estimated GFR (eGFR) to be an accurate means of detecting chronic kidney disease. Both Cockcroft-‐Gault and MDRD are commonly used serum creatinine-‐based equations to estimate renal function; however, there are important differences between the two measures.
The Cockcroft-‐Gault equation CrCl (mL/min) = [(140 – age) × (weight in kg)]/ (72 × SCr) × (0.85 if female) Estimates creatinine clearance (CrCl), the renal clearance of endogenous creatinine Uses a patient’s age, sex, serum creatinine (SCr) concentration, and weight. Race is not considered Use of ideal body weight is recommended for estimating renal function except when the patient’s actual body weight is less than ideal
The MDRD equation GFR (mL/min/1.73 m2) = 186 × (SCr)– 1.154 × (age)– 0.203 × (0.742 if female) × (1.210 if African American) Estimates GFR adjusted for body surface area Uses a patient’s age, sex, race, and SCr concentration. Weight is not considered, so it’s not recommended for use in patients with extremes in muscle mass and diet This equation has not been validated in patients older than 70 years of age, but an MDRD-‐ derived eGFR may still be a useful tool
Key differences between renal function estimates Most medications are renally dosed based on CrCl from Cockcroft-‐Gault Given that SCr is dependent on muscle mass, weight is likely to have an effect on CrCl A person with a greater muscle mass will naturally produce a higher level of creatinine, regardless of their renal function When weight is considered, the same SCr level leads to different CrCl (see example below)
Estimated Kidney Function in Two White Male Patients Both Aged 62 with SCr Levels of 2 mg/dL, but with Different Body Weights
Despite the difference in weight, both patients have the same estimated glomerular filtration rate (eGFR) because the MDRD calculation is adjusted for body surface area.
Cockcroft-Gault vs MDRD for Estimation of Renal Function By Lisa Mayer, Pharm.D., BCPS
Patient Weight Age SCr Cockcroft-‐Gault MDRD 60 kg (132 lb) 62 years 2 mg/dL 33 mL/min 36 mL/min/1.73 m2
100 kg (220 lb) 62 years 2 mg/dL 54 mL/min 36 mL/min/1.73 m2
Fal l 2012, Issu e 2 The Script
2
Pharmacy and Therapeutics Committee Update By Brad Foster, Pharm.D.
Drug Indication Usual Dose Dosage and Strength P&T Action
Actemra® (tocilizumab)
Rheumatoid arthritis 4 mg/kg IV every 4 weeks; may be increased to 8 mg/kg based on clinical response
20 mg/mL (4 mL, 10 mL, 20 mL vials for injection)
Added to Formulary for Outpatient Use
Commit® (nicotine lozenge)
Smoking cessation aid If smoke within 30 minutes of waking: 4 mg; otherwise use 2 mg according to dosing schedule
2 mg and 4 mg lozenges Added to Formulary
Exelon Patch® (rivastigmine)
Mild-‐to-‐moderate Alzheimer’s dementia; Mild-‐to-‐moderate Parkinson’s-‐related dementia
Initial 4.6 mg/24 hr; if well tolerated may be increased to 9.5 mg/24 hr and then to 13.3 mg/24 hr (max dose)
4.6 mg/24 hr, 9.5 mg/24 hr, 13.3 mg/24 hr patch
Added to Formulary
Invega sustenna® (paliperidone palmitate)
Schizophrenia; Schizoaffective disorder
Initial dose is 234 mg IM on day 1,156 mg IM one week later, then maintenance dose of 39-‐234 mg monthly
39 mg, 78 mg, 156 mg, 234 mg suspension for injection
Not Added to Formulary
Latuda® (lurasidone)
Schizophrenia Initial dose is 40 mg daily with a maximum recommended dose of 160 mg/day
20 mg, 40 mg, 80 mg tablets Added to Formulary
Lipitor® (atorvastatin)
Primary and secondary prevention of cardiovascular disease; Dyslipidemia
10 mg to 80 mg daily 10 mg, 20 mg, 40 mg, 80 mg tablets
Added to Formulary
Natrecor® (nesiritide)
Acute decompensated heart failure
Optional bolus of 2 mcg/kg followed by continuous infusion at 0.01 mcg/kg/min
1.5 mg injection, powder for reconstitution
Removed from Formulary
Niaspan® (niacin extended-‐release)
Dyslipidemia Initially 500 mg at bedtime for 4 weeks, then 1 g at bedtime for 4 weeks; adjust to response and tolerance to max of 2 g/day
500 mg, 750 mg, 1000 mg extended release tablets
Added to Formulary
Orencia® (abatacept)
Rheumatoid arthritis <60 kg: 500 mg IV; 60-‐100 kg: 750 mg IV; >100 kg: 1000 mg IV; dose is repeated at 2 weeks and 4 weeks; then every 4 weeks
250 mg injection, powder for reconstitution
Added to Formulary for Outpatient Use
Saphris® (asenapine)
Schizophrenia; Bipolar disorder
Initial dose is 5 mg twice daily, may increase to 10 mg twice daily
5 mg and 10 mg sublingual tablets
Not Added to Formulary
Stalevo® (carbidopa/levodopa/entacapone)
Parkinson’s disease Dosed based on response with maximum daily dose of 8 tablets of Stalevo® 50, 75, 100, 125, or 150 and 6 tablets of Stalevo® 200
50/12.5/200, 75/18.75/200, 100/24/200, 125/31.25/200, 150/37.5/200, 200/50/200 mg carbidopa/levodopa/ entacapone tablets
Added to Formulary
New Clinical Pharmacy Program - Renal Dose Adjustment of Medications By Lisa Mayer, Pharm.D., BCPS
The Pharmacy and Therapeutics Committee recently approved a Renal Dosing Policy allowing pharmacy to automatically adjust certain medications based on a patient’s current renal function. The table below lists those medications currently approved for automatic adjustment by pharmacy. Additional medications will be submitted for approval at future P&T Committee Meetings. Pharmacy will contact the physician regarding any medications that are either contraindicated or not recommended based on a patient’s CrCl; they will not automatically discontinue these medications. Pharmacists will be adjusting these medications based on the patient’s CrCl, estimated using the Cockcroft-‐Gault equation. In addition to dose-‐adjusting medications for patients with reduced renal function, pharmacy will re-‐adjust the dose when/if the patient’s renal function improves. Since this program started in late April 2012 through the end of December 2012, the pharmacy has made a total of 1,716 interventions. Please feel free to contact the pharmacy department if you have any questions or concerns regarding any medication change.
Acyclovir (Zovirax®)
Ampicillin
Cephalexin (Keflex®)
DAPTOmycin (Cubicin®)
Ertapenem (INVanz®)
Levofloxacin (Levaquin®)
Nitrofurantion (Macrobid®, Macrodantin®)
Sulfamethoxazole/ Trimethoprim (Bactrim®)
Allopurinol (Zyloprim®)
Ampicillin/ Sulbactam (Unasyn®)
Cetirizine (Zyrtec®)
Desvenlafaxine (Pristiq)
Famotidine (Pepcid®)
Loratadine (Claritin®) ± pseudoephedrine
Oseltamivir (Tamiflu®)
Amoxicillin (Amoxil®)
Aztreonam (Azactam®)
Ciprofloxacin (Cipro®)
DULoxetine (Cymbalta®)
Fluconazole (Diflucan®)
Metformin (Glucophage®) ± rosiglitazone ± glyburide
Piperacillin/ Tazobactam (Zosyn®)
Amoxicillin/ Clavulanate (Augmentin®)
CefTAZidime (Fortaz®)
Dabigatran (Pradaxa®)
Enoxaparin (Lovenox®)
Imipenem/Cilastatin (Primaxin®)
MetroNIDAZOLE (Flagyl®)
SitaGLIPtin (Januvia®)
Fal l 2012, Issu e 2 The Script
3
The Unwanted Effects of Drugs By Sarah Payne, Pharm.D.
Fleet® Enemas have been moved to the pharmacy, so that patients’ renal function can be assessed prior to order entry. Nursing will need to assess the patient’s renal function prior to administration, in case of decrease in renal function between the time of order and
administration, particularly in the case of PRN orders.
Physicians will be contacted asking for verification of Fleet® Enema use or selection of alternative agents when the following conditions are met:
1) Patient’s CrCl ≤ 30 mL/min 2) Patient’s serum creatinine ≥ 1.5 mg/dL 3) Patient’s serum creatinine has tripled within the previous 72 hours
Manufacturer’s labeling for Fleet® Enema contraindicates its use in patients with: congestive heart failure, clinically significant impairment of renal function, known or suspected GI obstruction, paralytic ileus and dehydration. It also states to use caution in patients: with impaired renal function, taking medications known to prolong the QT interval, who are 65 years of age or older, and those taking medications known to affect renal perfusion or function or hydration status. The package insert also states that administration of more than one enema in 24 hours can be harmful.
An error was reported in the August 9, 2012 ISMP Safety Alert Bulletin regarding an elderly patient with acute renal failure who suffered hyperphosphatemia after administration of two Fleet® enemas during her hospitalization. The patient required daily hemodialysis after developing severe hyperphosphatemia (PO4 = 19.9 mg/dL) and then secondary hypocalcemia (Ca = 5.4 mg/dL).
Each Fleet® enema contains 7 gm of dibasic sodium phosphate and 19 gm of monobasic sodium phosphate (more than 160 mmol of phosphate per dose). The over-‐the-‐counter status of Fleet® enemas may contribute to underestimation of the risk associated with their use.
Fleet® Enemas Missing from Patient Units! By Betsy Nelson, Pharm.D., BCPS
With so many patients coming to the hospital with a long list of medications and medication allergies, it is becoming increasingly important to understand the difference between an adverse drug reaction and an allergy. A drug allergy occurs when the immune system reacts to a medication triggering an allergic reaction. Drug allergy symptoms can range from mild to severe. Some of the most common mild symptoms include hives, rash, or fever. Moderate to severe symptoms range from facial swelling and difficulty breathing to anaphylaxis and death. Treatment of a drug allergy may include: antihistamines (e.g. Benadryl® to relieve mild symptoms such as rash, hives, and itching), bronchodilators (e.g. albuterol to reduce moderate wheezing or cough), corticosteroids (topical, oral, or intravenous), and epinephrine (by injection to treat anaphylaxis).
A drug side effect is a sensitivity to a medication that results in an unwanted consequence. A drug side effect does not involve the immune system, like an allergy, and does not prevent the patient from taking the medication. Most adverse reactions are mild, including stomach upset, headache, nausea, soreness, dizziness, and cough, but some are more serious, such as bleeding or low blood pressure, and require medical attention. Treatment of a side effect includes adjusting the dosage of medication, use of a second medication to treat adverse symptoms caused by the first medication, and discontinuing the medication. All opioids medications can cause the release of histamine from mast cells into the skin, which in turn can cause hives, sneezing, itching, and asthma. These are all often mistaken for allergies, but in fact are a known side effect of opioids. Another example is stomach upset that commonly occurs with aspirin, which is a known side effect of the medication and is often mistaken as an allergy. Please see “To Code or Not to Code? Allergies and ADRs That Is” on page 6 for information on how to enter a medication as an adverse reaction versus an allergy in MEDITECH.
When medications are listed as an allergy, but in truth are side effects, there are several consequences that can occur. First, this may cause a treatment delay. If the medication that the patient states an allergy to is prescribed then the pharmacist profiling the order has to call the nurse or doctor to get a medication clarification. This can take some time and can delay the patient getting the correct treatment. Second, the patient can receive a suboptimal treatment. In the case of a listed aspirin allergy when the patient has a heart attack, he/she will not be given aspirin and as a result, the patient may experience a drastically different outcome.
The best way to investigate a patient's reaction to the drug is to discuss what type of reaction the patient has experienced, his/her history with the medication, and past tolerance or intolerance of similar medications to get a full picture of the reaction. This information can help the health care provider determine if the reaction is an adverse reaction or an allergy; therefore, a medication appropriate for treatment can be given without causing unpleasant or unsafe reactions. If a question arises as to whether a reaction is an adverse reaction or allergy, then please call a pharmacist. We would love to help you!
Fal l 2012, Issu e 2 The Script
4
Congratulations to the following pharmacists who are now Board Certified Pharmacotherapy Specialists! The pharmacy now has a total of 11 pharmacists with BCPS certification.
Fran Esfahani Jenny Stemm Stefanie Stogsdill Karen Thompson
We hear various statements every year about why people just don’t want to get the flu shot. The following are the most common flu shot myths that just aren’t true.
1) “The flu shot causes the flu.” The viruses in the flu shot are dead, so they can’t cause the flu. The most common side effect of the flu shot is a sore arm. Even the “active” FluMist® nasal spray cannot cause the flu because the viruses are weakened. The side effects that occur are runny nose, wheezing, and headache. So why do people say they get the flu after they get the flu shot? This is likely due to the fact that flu shots are given at the same time of year when most respiratory illnesses occur. Another important point is that the flu shot does not take effect for about a week after it is administered, so you can still get the flu during that time.
2) “The flu is just a bad cold.” The flu tends to come on quicker and last longer than a typical cold. The most common side effects are fever, sore throat, body aches, fatigue, headaches, and a runny or congested nose. The flu can also cause life-‐threatening complications like pneumonia and other secondary bacterial infections.
3) “I never get the flu. I don’t need a flu shot.” When healthy people get the flu shot, it can actually help protect the weak from the flu by preventing its spread among healthcare providers. So it benefits not just you, but your patients as well!
Flu Shot Myths Debunked By Sarah Payne, Pharm.D.
Ordering Whodunit By Sarah Payne, Pharm.D.
4
From the status board
When new orders are acknowledged When an order is viewed
Recently, there has been a lot of confusion as to the source of medication orders. Practitioners are moving towards Computerized Physician Order Entry (CPOE), which eliminates the need for paper orders. During this transition period, physicians and pharmacists can either enter orders electronically via Provider Order Management (POM) or write orders in the paper chart.
Here’s how to tell from where the order originated: 1) S = Signed order 2) U = Unsigned order 3) N = No order necessary 4) PROVIDER = POM/CPOE order 5) zCPOE EDIT = The PROVIDER entered order was edited by a
pharmacist, creating a new order, but there is no written order to go with it
Fal l 2012, Issu e 2 The Script
5
Top 5 Pharmacy Order Entry Dates
December 18, 2012 -‐ 6462 orders January 8, 2013 -‐ 6428 orders August 28, 2012 -‐ 6379 orders November 26, 2012 -‐ 6377 orders June 5, 2012 -‐ 6300 orders
Welcome Our New Pharmacy Residents
Critical Medication Shortages
Medication Action Plan
Acyclovir IV Conserving use when possible. For adults being ruled out for viral meningitis – stopping acyclovir when the CSF HSV PCR is reported as negative
Aminophylline IV Conserving use when possible
Chloral hydrate PO Manufacturer discontinued production. Using midazolam PO instead.
Droperidol IV Conserving use when possible Exactacain® spray Changing to Hurricaine® spray Propofol IV Conserving use when possible Sodium bicarbonate syringes Using vials in code carts in place of prefilled syringes TPN components (amio acids, various electrolytes and multivitamins)
Conserving use when possible
Drug Shortages By Sonal Yang, Pharm.D., BCPS
Butorphanol IV Methotrexate IV
Fosphenytoin IV Metoclopramide IV
Furosemide IV Nalbuphine IV
Ketorolac IV Naloxone IV
Leucovorin IV Ondansetron IV
Medications with Resumed Availability
NRHS offers a yearlong accredited Pharmacy Residency program in general pharmacy practice that begins each year in July and ends in June of the following year. It allows pharmacists to accelerate their growth beyond entry-‐level competencies, to refine their clinical skills in a broad range of disease states and to provide evidence-‐based, patient centered medication therapy. Residents are also cross-‐trained in distribution, in the IV room and can be found staffing at the Healthplex on Monday through Thursday evenings.
This year, NRHS has three pharmacy practice residents: Shamama Burney, Sarah Payne, and Tiffany White. All are 2012 graduates from the University of Oklahoma College of Pharmacy, and all three intend to pursue a second year pharmacy specialty residency.
Shamama Burney was born in Pakistan and moved to California when she was five years old. She moved to Oklahoma four years ago for pharmacy school and considers herself a one-‐of-‐a-‐kind PakiCaliOkie! Shamama’s areas of interest include internal medicine and anticoagulation. She aspires to establish a career incorporating leadership and academia, as well as contributing to pharmacy literature in the near future.
Sarah Payne was born in raised in Moore, Oklahoma. Her pharmacy interests include ambulatory care, diabetes, infectious disease, and cardiology. She plans to pursue a specialized second year residency in ambulatory care.
Tiffany White is originally from Arkansas and moved to Oklahoma to teach science in 2005. She decided to go back to pharmacy school in 2008. Her pharmacy interests include infectious disease and cardiology, and she plans to pursue a specialized second postgraduate residency in cardiology.
Each resident undertakes a project during their residency, which they present at local and national pharmacy meetings. Shamama’s project focuses on the overuse of acid suppression therapy and its contribution to Clostridium difficile-‐Associated Disease (CDAD) and pneumonia. Sarah’s project involves changing the way bulk medications, like inhalers, are processed so they can be sent home with the patient. This would reduce the cost of requisition and disposal of bulk medications on the health care system. Tiffany’s project involves the conversion of anticoagulation protocols from activated partial thromboplastin time (aPTT) to antifactor Xa levels for monitoring of unfractionated heparin (UFH) infusions.
Left to right: Tiffany White, Sarah Payne, and Shamama Burney
6
To Code or Not to Code? Allergies and ADRs That Is. By Sarah Payne, Pharm.D.
Did you know that when an allergy or adverse reaction is “uncoded”, the interaction checker in MEDITECH is unable to check for potential interactions? For this reason, it is important to ensure all allergies and adverse reactions are entered so that they are “coded” in MEDITECH. It is easy! Just follow these steps:
1) When entering a new allergy or adverse reaction, start typing the first couple letters of the drug or allergen
2) Then hit the F9 button or the drop down arrow and select the appropriate coded allergy 3) Fill out the severity, whether it is an allergy or adverse reaction, and the type of reaction 4) Then save
That’s it! If you do not save the drug or other allergen as a coded allergy/adverse reaction, it will display “uncoded” in red.
If you see this, then use fewer letters to search for the allergy. In this example, aspirin was typed using its abbreviation. To correct this, just type AS or ASP then search through the coded allergies (F9 or arrow box on the right). If you are having problems inputting an allergy, please contact another healthcare professional or pharmacist for assistance.
Editor in Chief: Lisa Mayer, Pharm.D., BCPS Clinical Pharmacy Specialist
Contributors: Darin Smith, Pharm.D., BCPS, FASHP Director, Pharmacy Services and Performance Improvement
Brad Foster, Pharm.D. Manager, Clinical Pharmacy Services
Betsy Nelson, Pharm.D., BCPS Clinical Pharmacy Specialist
Stefanie Stogsdill, Pharm.D., BCPS Staff Pharmacist
Sonal Yang, Pharm.D., BCPS Staff Pharmacist
Shamama Burney, Pharm.D. Pharmacy Resident
Sarah Payne, Pharm.D. Pharmacy Resident
Tiffany White, Pharm.D. Pharmacy Resident
Medication Safety Accurate Patient Weights: The Weight of the Matter
By Shamama Burney, Pharm.D.
The Script The Quarterly Newsletter of the
Department of Pharmacy
Each day during their hospital admission, a patient’s weight is measured and documented in their medical record. Although a small task, the weight of a patient is not without significance because it is an important tool in medical decision-‐making. When deciding a patient’s fluid status, weight provides a quantifiable value to compare from one day to the next to help identify if a patient may be edematous or dehydrated. When determining nutritional status, Dietitians and Pharmacists use weight in calculating a patients nutrition needs to ensure a patient is receiving the appropriate number of calories. Weight is even used in selecting what equipment would be most suitable for a patient, including whether or not they would require specialty beds or lifts.
Perhaps one of the most important considerations for weight relates to certain medication therapies the patient will receive. An accurate weight is vital in determining a dose for a patient. Chemotherapeutic agents like cytarabine and paclitaxel are dosed according to body surface area, which is calculated based on body weight. Not only are these agents incredibly expensive, placing an unnecessary economic burden on the patient and the hospital if a falsely elevated weight were to be reported for a patient, but they are also quite toxic, which could lead to increased adverse effects. For medications like anticoagulants (e.g. enoxaparin (1 mg/kg) or heparin drips), the wrong weight could result in either under-‐dosing patients with a new DVT or PE so that they are at greater risk for clot extension, or overdosing patients which could contribute to increased bleeding risk. With medications that have a narrow therapeutic margin like vancomycin and gentamicin, weight could mean the difference between effective therapy, subtherapeutic dosing or the potential for toxicity. Weight is especially important regarding pediatric patients, since every medication they receive is dosed according to their weight, so inaccuracy is an error we cannot afford.
After weighing all of these considerations, it is evident that accuracy in weight is important. So the next time you need to weigh a patient, remember some of these helpful tips to obtain weight precisely the first time, every time:
Be consistent: Weigh the patient the same time every day, as weight can fluctuate throughout the day. Tare it up: Zero the bed so that the bed scale reflects the patient’s true weight. Remember to remove items such as SCDs and
blankets, which will falsely elevate the readings. Be mindful of units: When recording the weight in MEDITECH, pay careful attention to the units you are entering (i.e. kilograms vs
pounds). Compare to patient’s prior weight: This should be your final double-‐check every time you enter a weight And when in doubt, re-‐weigh: It is unlikely that a patient would gain 16 pounds overnight so take into consideration the patient’s
previously measured weight.
