Drug Information Drug Information Resources:Resources:

An OverviewAn Overview

Rob Barcelona, PharmD, BCPSRob Barcelona, PharmD, BCPS

Clinical Pharmacy Specialist, CICUClinical Pharmacy Specialist, CICU

ObjectivesObjectives

Utilize drug information sources Utilize drug information sources available at University Hospitals Case available at University Hospitals Case Medical CenterMedical Center

Describe UHCare functionality as it Describe UHCare functionality as it relates to Pharmacy Servicesrelates to Pharmacy Services

List dosing and monitoring of specific List dosing and monitoring of specific patient populations and medicationspatient populations and medications

Pharmacy Clinical Pharmacy Clinical ResourcesResources

Clinical on Call Pager 30558Clinical on Call Pager 30558– Rotates among all clinical specialistsRotates among all clinical specialists

CICU: Rob Barcelona 30274CICU: Rob Barcelona 30274

SICU: Wes Bush 30393 SICU: Wes Bush 30393

Infectious Diseases: Ron Cowan 31960Infectious Diseases: Ron Cowan 31960

NSU: Jason Makii 37884NSU: Jason Makii 37884

MICU: Andreea Popa 31503MICU: Andreea Popa 31503

Transplant: Raelene Trudeau 38643Transplant: Raelene Trudeau 38643

Tertiary ResourcesTertiary Resources

Condense, digest, and summarize information from Condense, digest, and summarize information from primary and other resourcesprimary and other resources

Provide rapid access to informationProvide rapid access to information

Limitations: Limitations: – Currency of the resource (i.e., how long ago was that Currency of the resource (i.e., how long ago was that

information published?)information published?)– Accuracy of informationAccuracy of information– Incompleteness (e.g., over the counter medications not Incompleteness (e.g., over the counter medications not

contained)contained)

Examples include MICROMEDEXExamples include MICROMEDEX®®, textbooks, , textbooks, UpToDateUpToDate®®, review articles, and encyclopedias, review articles, and encyclopedias

UH Case Medical UH Case Medical Center Specific Center Specific

ResourcesResources Anticoagulation Therapy and Anticoagulation Anticoagulation Therapy and Anticoagulation

ReversalReversal

Adult IV Medication GuidelinesAdult IV Medication Guidelines

Antimicrobial UsageAntimicrobial Usage

Restricted MedicationsRestricted Medications

Drug Specific Guidelines (e.g., antibiotic Drug Specific Guidelines (e.g., antibiotic locks, IVIG, etc.)locks, IVIG, etc.)

Where can resources Where can resources be found?be found?

Lexi - CompLexi - Comp®® Online™ Online™

> 4,000 monographs of medications and nearly 30 > 4,000 monographs of medications and nearly 30 fields with each drug monographfields with each drug monograph

Both text and on-line in UpToDate® Both text and on-line in UpToDate®

Information includes:Information includes:– DosingDosing– PharmacologyPharmacology– PharmacokineticsPharmacokinetics– Pregnancy/lactation considerationsPregnancy/lactation considerations– Adverse reactionsAdverse reactions– Drug interactionsDrug interactions– Nutrition/herb interactionsNutrition/herb interactions

MICROMEDEXMICROMEDEX®®

Available from UH Pharmacy website: Available from UH Pharmacy website: http://intranet.uhhs.com/pharmnet/

Facts on drugs, teratogenicity, toxicology, and alternative Facts on drugs, teratogenicity, toxicology, and alternative medicinemedicine

On-line version of the PhysiciansOn-line version of the Physicians’’ Desk Reference Desk Reference

Very Very comprehensivecomprehensive and contains the following: and contains the following: – DosingDosing– PharmacologyPharmacology– PharmacokineticsPharmacokinetics– Drug interactions, cautionsDrug interactions, cautions– Clinical applicationsClinical applications– ReferencesReferences

Limitations: difficulty in finding information and frequency of Limitations: difficulty in finding information and frequency of updatesupdates

UHCMC Adult IV UHCMC Adult IV GuidelinesGuidelines

The InternetThe Internet

Many resources available using the InternetMany resources available using the Internet

Should be utilized Should be utilized onlyonly if other databases or if other databases or references fail to provide any valid informationreferences fail to provide any valid information

Limitations include lack of quality control and Limitations include lack of quality control and imprecise searching that may lead to many undesired imprecise searching that may lead to many undesired ““hitshits””

Information found may not come from a verifiable Information found may not come from a verifiable source and potentially could be inaccurate, possibly source and potentially could be inaccurate, possibly leading to patient harmleading to patient harm

If UHCMC has guidelines, protocols, or ordersets, use If UHCMC has guidelines, protocols, or ordersets, use those developed by UHCMC staffthose developed by UHCMC staff

ConclusionConclusion

Variety of resources are availableVariety of resources are available

Familiarize yourself with the on-line Familiarize yourself with the on-line resources, databases, and textbook resources, databases, and textbook references in finding drug references in finding drug informationinformation

If all else fails, ask your pharmacist If all else fails, ask your pharmacist

More on Resources … More on Resources … and EMR stuffand EMR stuff

Andreea Popa PharmD, BCPSAndreea Popa PharmD, BCPS

MICU Clinical Pharmacy MICU Clinical Pharmacy SpecialistSpecialist

MICU and other MICU and other resourcesresources

Why does the Why does the pharmacist call you??? pharmacist call you??? Invalid order/need Invalid order/need

further further clarificationclarification

Renal DosingRenal Dosing

Drug interactionsDrug interactions

Restricted drugRestricted drug

Bad OrdersBad Orders

Non-formulary Non-formulary drugdrug

Drug on short Drug on short supplysupply

Duplicate ordersDuplicate orders

What happens after you What happens after you place an order?place an order?

Pharmacist actively Pharmacist actively looks for the orders on looks for the orders on the different units (2-3 the different units (2-3 units per pharmacist; 60 units per pharmacist; 60 -100 pts)-100 pts)

Looks at all medication Looks at all medication orders for that patient, orders for that patient, diagnosis and pertinent diagnosis and pertinent labs labs

User Schedule User Schedule OrderingOrdering

Verification ScreenVerification Screen

Order verificationOrder verification

If no questions order is verified and a label If no questions order is verified and a label prints prints technician prepares drug technician prepares drug pharmacist checks drug again pharmacist checks drug again drug leaves drug leaves for delivery to respective nursing unitsfor delivery to respective nursing units

Controlled substances, emergency meds Controlled substances, emergency meds OMNICELL OMNICELL

If need something urgent: If need something urgent: callcall area area pharmacistpharmacist

EMR issues…..EMR issues…..

Standard administration timesStandard administration times– QD: 9:00QD: 9:00– BID: 09:00; 21:00 BID: 09:00; 21:00 12 hours off drug 12 hours off drug– TID: 09:00; 14:00; 21:00 TID: 09:00; 14:00; 21:00 12 hours off drug 12 hours off drug– QID: 09:00; 13:00; 17:00; 21:00 QID: 09:00; 13:00; 17:00; 21:00 12 hours off 12 hours off

drugdrug

– Q 24, Q 12, Q 8, Q 6: Timing of these is Q 24, Q 12, Q 8, Q 6: Timing of these is dependent on ordering/nursing administration; dependent on ordering/nursing administration; subsequent doses are automatically scheduled subsequent doses are automatically scheduled based on the first dosebased on the first dose

Routine, now, stat and Routine, now, stat and time critical….time critical….

Routine, now, stat and Routine, now, stat and time critical….time critical….

Amlodipine 5 mg dailyAmlodipine 5 mg daily– RoutineRoutine: if passed 9 am, first dose schedule for RN to : if passed 9 am, first dose schedule for RN to

givegive next daynext day at 9 am at 9 am – ((99% of ALL medication orders defaulted to 99% of ALL medication orders defaulted to

routineroutine))

– NowNow: one dose will be sent now and than next day at 9 : one dose will be sent now and than next day at 9 amam

– STATSTAT: generates a red flag for the pharmacist : generates a red flag for the pharmacist urgent urgent order order first dose now then next day at 9 am first dose now then next day at 9 am (regardless (regardless what time now, could be 9 PM)what time now, could be 9 PM)

– TIME CRITICALTIME CRITICAL: you select the time for the 1: you select the time for the 1stst dose and the dose and the subsequent doses will be automatically scheduled q 24 hours subsequent doses will be automatically scheduled q 24 hours from the time of first dose (if ordered Q24H)from the time of first dose (if ordered Q24H)

Routine, now, stat and Routine, now, stat and time critical….time critical….

Cipro 400 mg IVPB q 24 hoursCipro 400 mg IVPB q 24 hours– RoutineRoutine: scheduling of first dose : scheduling of first dose

related to ordering timerelated to ordering time– Now and Stat: create a Now and Stat: create a

yellow/red flag for verificationyellow/red flag for verification– TIME CRITICALTIME CRITICAL: you select the time for the : you select the time for the

11stst dose and the subsequent doses will be dose and the subsequent doses will be automatically scheduled q 24 hours from automatically scheduled q 24 hours from the time of first dose!the time of first dose!

Ordering IV Heparin: Ordering IV Heparin: Loading dose, infusion, repeat Loading dose, infusion, repeat

bolusbolus

Pearls:1. Most of lab work is pre-checked2. If running continuous infusion, ALWAYS order the repeat boluses3. Open Dosing: Never order the open dosing unless Heme/Onc or Vascular Medicine involved

Electrolyte OrderingElectrolyte Ordering

Units, units…….Units, units…….

MMF grams MMF grams vs. vs. milligramsmilligrams

Premixed antibiotics, Premixed antibiotics, customizing the dosecustomizing the dose

So, how do I So, how do I order: order: – 1,000 mg 1,000 mg – 500 mg or 500 mg or – 2,000 mg of 2,000 mg of

vancomycin vancomycin ????????

Restricted Ordersets Restricted Ordersets and REMSand REMS

Pulmonary Pulmonary HypertensionHypertension

Hemodialysis/Hemodialysis/CVVHCVVH

ChemotherapyChemotherapy Dofetilide Dofetilide

(Tikosyn)(Tikosyn) Non-formulary Non-formulary

drugsdrugs

REMS (Risk REMS (Risk Evaluation and Evaluation and Mitigation Mitigation Strategy)Strategy)– > 200 REMS Drugs> 200 REMS Drugs– > 30 Drugs have > 30 Drugs have

Elements to Elements to Assure Safe UseAssure Safe Use

– > 20 REMS Drugs > 20 REMS Drugs require informed require informed consentconsent

Other Ordersets…Other Ordersets…

Admission OrdersetsAdmission Ordersets– Most patients do not need an IV PPI…Most patients do not need an IV PPI…

Pneumonia OrdersetPneumonia Orderset– Antibiotics default to routineAntibiotics default to routine– Antibiotic selections in alphabetical order Antibiotic selections in alphabetical order

vs. preferredvs. preferred

Tylenol ODTylenol OD

Generic QuestionsGeneric Questions

When calling pharmacy for drug info When calling pharmacy for drug info questions:questions:

1.1. Ask to talk to a pharmacistAsk to talk to a pharmacist

2.2. Tell them who you are/contact infoTell them who you are/contact info

3.3. Give them patient name and locationGive them patient name and location

4.4. Give them synopsis of case and relevant Give them synopsis of case and relevant clinical information to get most clinical information to get most appropriate answer (what you are appropriate answer (what you are treating,other drugs, renal function, etc.)treating,other drugs, renal function, etc.)

Drug Dosing in Special Drug Dosing in Special PopulationsPopulations Renal FailureRenal Failure

– Intermittent vs Continuous Intermittent vs Continuous Hemodialysis vs Ultrafiltration Hemodialysis vs Ultrafiltration

Obese/Low weightObese/Low weight

Geriatrics Geriatrics

Estimating Renal Estimating Renal FunctionFunction Cockcroft and Gault equation:Cockcroft and Gault equation:CrCl = (140 - age) x IBW / (Scr x 72)   CrCl = (140 - age) x IBW / (Scr x 72)   

    (x 0.85 for (x 0.85 for females) females)

IDMS-traceable MDRD Study EquationIDMS-traceable MDRD Study Equation Conventional unitsConventional unitsGFR (mL/min/1.73 m2) = GFR (mL/min/1.73 m2) = 175175 x (Scr)- x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) 1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if African American)x (1.212 if African American)

Drug LevelsDrug Levels

DrugDrug TimingTiming NotesNotes

VancomycinVancomycin Trough 30 minutes prior to 4Trough 30 minutes prior to 4thth dosedose

Individualized dosing for Individualized dosing for patients with renal patients with renal dysfunctiondysfunction

ImmunosuppressantsImmunosuppressants Trough levels within 1 hour of Trough levels within 1 hour of dose (0600, 1800)dose (0600, 1800)

Contact Transplant Contact Transplant Service for guidanceService for guidance

PhenytoinPhenytoin 1.1. Trough concentrationTrough concentration

2.2. Within 2-3 days of Within 2-3 days of initiationinitiation

3.3. Within 1 hour of load to Within 1 hour of load to determine maintenance determine maintenance or need to reloador need to reload

NO need for daily levelsNO need for daily levelsOrder free levels in Order free levels in patients with renal failure patients with renal failure and/or low albuminand/or low albumin

AminoglycosidesAminoglycosides Traditional: trough with 3Traditional: trough with 3rdrd dose and peak 30 minutes dose and peak 30 minutes after end of infusionafter end of infusionExtended: trough with 2Extended: trough with 2ndnd dosedose

Depends on traditional Depends on traditional vs. extended dosingvs. extended dosing

DigoxinDigoxin Trough concentrationTrough concentration Must be drawn at least 6 Must be drawn at least 6 hours post-dosehours post-dose

Heparin assay, LovenoxHeparin assay, Lovenox 4 hours post-34 hours post-3rdrd dose dose Use in extremes of body Use in extremes of body weight, pregnancy, renal weight, pregnancy, renal dysfunctiondysfunction

Questions?????Questions?????