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All correspondence concerning The Script should be sent to:

Lisa Mayer, Pharm.D., BCPS 901 N Porter Ave., Box 1308

Norman, OK 73070 lmayer@nrh-ok.com

The Script A Publication of the Department of Pharmacy, Norman Regional Health System

Stress  Ulcer  Prophylaxis:    It’s  Not  for  Everyone    .  .  .  .  .  .  .  .  .  .  .  .    1  

Pharmacy  and  Therapeutics  Committee  Update.  .  .  .  .  .  .  .  .  .  .  .  .  .    2  

Drug  Shortages  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .    2  

Too  Much  of  a  Good  Thing?      New  Dosing  Recommendations    for  a  Popular  Sleep  Aid  .  .  .  .  .  .  .  .  .  .      3  

Multidose  Medication    Dispensing  at  Discharge    .  .  .  .  .  .  .  .  .      3  

Medications  to  Avoid    in  the  Elderly:  The  Beers  List  .  .  .  .  .  .    4  

Black  Box  Warnings  .  .  .  .  .  .  .  .  .  .  .  .  .      4  

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:

Summer 201 3, Iss ue 3

Gastric  acid  suppression  therapy  is  frequently  overprescribed  in  the  hospital  setting,  primarily  for  the  purposes  of  providing  stress  ulcer  prophylaxis.  Although  the  use  of  proton  pump  inhibitors  (PPI,  e.g.  Protonix®,   Prevacid®)   and   histamine-­‐2   receptor   antagonists   (H2RA,   e.g.   Pepcid®)   are   generally  considered  safe,   they  are  often  prescribed   for  patients  where  prophylaxis   is  not   indicated.    Current  literature  suggests  the  use  of  acid  suppression  therapy  may  be  linked  to:  

! Clostridium  difficile-­‐associated  disease:  By   increasing  gastric   pH,   there   is   an   increased   risk   of  enteric  infections  with  invading  pathogens  like  Clostridium  difficile.    

! Pneumonia:  Agents  that  increase  gastric  pH  allow  for  bacterial  colonization  in  the  stomach  and  may   be  aspirated.    Alternatively,  decreasing  acidity  of  extragastric   regions  enables  bacteria   to  colonize  in  areas  like  the  larynx  and  lungs  directly.  

! Fractures  of   the  hip,  wrist,  and  spine:  Calcium   insolubility  related  to  an   increase  in  gastric  pH  may  lead  to  calcium  malabsorption  in  patients  using  high-­‐dose  therapy  or  those  who  have  been  on  long-­‐term  therapy  of  one  year  or  greater.  

! Increased  length  of  hospital  stay  ! Increased  medical  costs  

To   help   reduce   unnecessary   exposure   to   acid   suppression   therapy   and   stop   therapy   upon   patient  transfer  between   floors  and  at  discharge,  use  the  following  algorithm  to  determine  if  patients  meet  criteria  for  stress  ulcer  prophylaxis:    

 

Stress Ulcer Prophylaxis: It’s Not for Everyone By Shamama Burney, Pharm.D.

Is#pa&ent#on#PPI#or#H2RA#at#home?#

Pa&ent#has#one#of#the#following#risks:#•  Coagulopathy:.#

•  Platelet#Count##<#50,000/m3#•  Interna&onal#Normalized#Ra&o#(INR)#>#1.5#

•  Mechanical.ven3la3on.(>#48#hours)#•  History.of.GI.ulcera3on.or.bleeding.(within#one#year#before#admit)#

•  Two.or.more.addi3onal.risk.factors:.•  Sepsis#•  ICU#stay#>#7#days#•  Occult#bleeding#las&ng#≥#6#days#•  Use#of#highVdose#cor&costeroids#

•  Special.Pa3ent.Popula3ons:.•  Head#injury#with#Glascow#Coma#Score#(GCS)#<#10#•  Thermal#injury#to#>#35%#of#body#surface#area#(BSA)#•  Par&al#hepatectomy#or#hepa&c#failure#•  Mul&ple#trauma#•  Transplant#pa&ents#(periopera&ve)#•  Spinal#cord#injuries#

Criteria#not#met#SUP.Not.Required.

Con&nue#medica&ons#if#home#medica&ons#con&nued#by#MD#

Criteria#met#Start.SUP.

Transfer#out#of#ICU#or#discharge#from#NRHS#

ReFEvaluate.Need.for.SUP#

YES#

NO#

NO#

Stress Ulcer Prophylaxis (SUP) Algorithm in ICU

YES#

YES#

The Script Summer 2013 , Is sue 3

Pharmacy and Therapeutics Committee Update Drug   Indication   Usual  Dose   Dosage  and  Strength   P&T  Action  

Cyklokapron®    (tranexamic  acid)  

Blood  loss  reduction  with  total  knee  replacement;  prevention  of  perioperative  bleeding  associated  with  cardiac  and  spinal  surgery  

10  mg/kg  over  10  min  before  inflation  of  tourniquet  with  a  second  dose    (10  mg/kg)  administered  immediately  after  tourniquet  release;  various  other  dosing  dependent  upon  indication  

100  mg/mL  (10  mL)  intravenous  solution  

Added  to  formulary  

Humira®    (adalimumab)  

Crohn’s  disease   Initial:  160  mg  (given  as  4  injections  on  day  1  or  as  2  injections  daily  over  2  consecutive  days),  then  80  mg    2  weeks  later.      Maintenance:    40  mg  every  other  week  beginning  day  29.  

20  mg/0.4  mL  and  40  mg/0.8  mL  subcutaneous  kit  

Added  to  formulary  -­‐  restricted  to  initiation  dose,  ordered/provided  by  Gastroenterologist  through  AbbVie  

Merrem®  (meropenem)  

Multiple  infectious  indications  

0.5-­‐2  g  every  8  hours   500  mg  and  1  g  injection,  powder  for  reconstitution  

Added  to  formulary  with  restrictions  

Pataday®  (olopatadine)  

Allergic  conjunctivitis   1  drop  instilled  into  each  affected  eye  daily  

0.2%  (2.5  mL)  ophthalmic  solution  

Added  to  formulary  

Primaxin®  (imipenem/cilastatin)  

Multiple  infectious  indications  

250-­‐1000  mg  every  6-­‐8  hours    (maximum:  4  g/day)  

250  mg  and  500  mg  injection,  powder  for  reconstitution  

To  be  removed  from  formulary  after  current  supply  is  depleted  

Relistor®  (methylnaltrexone)  

Opioid-­‐induced  constipation   Dosing  is  according  to  body  weight:  administer  1  dose  every  other  day  as  needed  (maximum:  1  dose/24  hours)  

8  mg/0.4  mL  and  12  mg/0.6  mL  subcutaneous  solution  

Added  to  Formulary  

Renvela®  (sevelamer)  

Control  of  serum  phosphorous  

800-­‐1600  mg  three  times  daily  with  meals  

0.8  g  powder  for  oral  suspension   Added  to  formulary    

Tradjenta®  (linagliptin)  

Type  2  diabetes   5  mg  once  daily   5  mg  tablet   Added  to  formulary  

Vimpat®  (lacosamide)  

Partial  onset  seizure   Initial:  50  mg  twice  daily  (may  be  increased  at  weekly  intervals  to    100  mg  daily).      Maintenance:  200-­‐400  mg  daily  

50,  100,  150,  and  200  mg  tablets;  10  mg/mL  oral  solution;    10  mg/mL  (20  mL)  intravenous  solution  

Added  to  formulary  

Welchol®  (colesevelam)  

Dyslipidemia  and  type  2  diabetes  

3.75  g  once  daily  or  1.875  g  twice  daily   625  mg  tablets  and  3.75  g    granules  for  oral  suspension  

Added  to  formulary  

Drug Shortages

By Sonal Yang, Pharm.D., BCPS and Donna Wilk, CPhT

Acyclovir  IV  

Aminophylline  IV  

Morphine  (Duramorph®)  Intrathecal  

Propofol  IV  

Sodium  bicarbonate  IV  

   Medications  with  Resumed  Availability  

                                                                                                                 Critical  Medication  Shortages      

Medication   Action  Plan  

Dextrose  50%  IV    Pharmacy   has   received   a   small   supply   for   code   carts   and   critical  areas   (ER,   ICU/CVICU,   PCU/CVU,   OR/PACU,   cath   lab).   All   other  areas  to  continue  using  Dextrose  10%  250mL  bags.  

Droperidol  IV   Conserving  use  when  possible  

Papaverine  IV  Used   in   CABG   and   AV   fistula   surgeries.     Using   combination   of  verapamil,   nitroglycerin,   heparin   and   sodium   bicarbonate   in   LR  instead.  

Sincalide  IV  (Kinevac®)   Consolidating   outpatient   cases   at   Porter.   Preparing   doses   in  pharmacy  to  conserve  use.  

TPN  components  (electrolytes,  multivitamins,  trace  elements,  lipid  emulsion)  

Conserving  use  of   TPNs  when  possible.  Adult  multivitamins   (MVI)  added   to   TPNs   on   Mon,   Wed,   Fri   only;   will   continue   use   in  rallypacks;  MVI  will  not  be  added  to  bariatric  post-­‐op   IV  fluids   for  now.   Pediatric   MVI   use   is   not   restricted   at   this   time.     Adult   and  pediatric  trace  elements  also  remain  on  shortage  -­‐  minimizing  use  when  possible.  

The Script Summer 2013 , Is sue 3

Multidose Medication Dispensing at Discharge By Sarah Payne, Pharm.D.

The   NRHS   Pharmacy   and   Therapeutics   (P&T)   Committee   recently   decreased   the  dose   of   zolpidem   (Ambien®)   based   on   recommendations  made  by   the  U.S.   Food  and  Drug  Administration  (FDA).  The  FDA  made  this  recommendation  based  on  new  data   showing   zolpidem   blood   levels   in   some   patients   may   be   high   enough   the  morning   after   use   to   impair   activities   that   require   alertness,   including   driving.    Women  eliminate  zolpidem  from  their  bodies  more  slowly  than  men.    This  means  that  women  are  at  an  increased  risk  of  impaired  cognitive  function  than  men  with  the   same   dose.     This   lower   dose   of   zolpidem  will   decrease   the   amount   of   drug  present   in   the   blood   in   the  morning   hours.     The   FDA   notified  manufacturers   to  recommend   a   lower   dose   of   zolpidem   in   women,   but   encouraged   health   care  professions   to   consider   a   lower   dose   for  men   as   well.     The   approved   dosing   at  NRHS  for  immediate-­‐release  zolpidem  is  5  mg  in  all  patients.    Data  also  show  that  the   risk   for   next-­‐morning   impairment   is   highest   for   patients   taking   zolpidem  extended-­‐release.     Therefore,   dosing   was   also   lowered   for   extended-­‐release  

zolpidem  products   to   6.25  mg.   Pharmacy   has   started   automatically   interchanging   higher-­‐strength   zolpidem  orders   to   the   recommended  dosing  approved  by  the  P&T  committee.  

Too Much of a Good Thing? New Dosing Recommendations for a Popular Sleep Aid

By Sarah Payne, Pharm.D.

 

Multidose   medications   include   inhalers,   insulin   pens,   and   topical   medications,   including   nasal   and   ophthalmic   preparations.   They   are  commonly  dispensed  to  patients  during  their  stay  at  the  hospital  and  continued  after  discharge.    There  are  a  few  things  to  know  about  these  special  medications  that  make  them  unique.    

First,   these   medications   have   different   requirements   for   labeling   depending   on  their   use   in   the   hospital   or   as   outpatient.     The   most   common   discrepancies  between   inpatient  and  outpatient  prescription   labels   include   the   requirement   for  the   address   and   phone   number   of   the   dispensing   pharmacy   and   prescribing  physician's   name   on   the   outpatient   prescription   label.     The   important   thing   for  most  is  to  recognize  that  the  label  requirements  are  different.    

Second,  multidose  medications  require  an  order  from   the  prescribing  physician  to  be  continued  outpatient.    This  can  be  thought  of  as  a  prescription.    No  prescription  medication  can  be  procured  without  a  prescription  in  the  outpatient  setting.    In  the  hospital,   the   requirement   for   a   prescription   still   is   present,   but   the   practitioner's  orders   are   considered   "prescriptions".     To   meet   the   requirement   of   outpatient  prescriptions,  when  continuing  multidose  medications  at  discharge,  the  prescribing  physician  can   indicate   that   the  medication   is   to  be   continued  at  discharge  on   the  medication  reconciliation  form  or  the  physician  can  write  an  order.    

Last,  outpatient  prescriptions  require  counseling.    Some  of  the  medications  that  are  being  dispensed  at  discharge  have  not  been  used  by  the  patient  before  admission  into   the   hospital   or   could   have   been   taken   the   wrong   way   by   the   patient   as   an  outpatient.     Whenever   dispensing   medications,   or   giving   the   patient   a   new  prescription,   the   patient   should   be   counseled.     This   is   the   same   for   multidose  medications.    Counseling  should  include  verbal  instructions,  a  prescription  handout,  or  even  a  demonstration  in  some  instances.      

As  you  may  have  noticed,  inhaler  labeling  has  changed  slightly  by  the  addition  of  a  new  label  to  the  bag  in  which  the  inhaler  is  stored.  This  label  allows  the  inhaler  the  patient  has  used  during  their  admission  to  be  dispensed  to  them  at  discharge!     In  the  future,  all  multidose  medications  can  be  dispensed  using  this  same  process.    

 

3

Black Box Warnings By Stefanie Stogsdill, Pharm.D., BCPS

 

 

All  medications   have   therapeutic   actions   and   have   the   potential   to   cause   serious   side   effects,  may   contain   life-­‐threatening   risks  and  have  important   safety   concerns.   Some  medications   even   carry   a   black   box   warning.   So   what   is   a   black   box  warning  and  how  did  it  get  its  name?  

A  boxed  warning,  also  known  as  a  black  box  warning,  is  a  type  of  alert  that  appears  on  the  package  insert  for  certain  prescription  medications  to  alert  healthcare  providers  about   important  safety  concerns,  such  as   serious   side   effects   or   life-­‐threatening   risks.     The   black   box   warning   got   its   name   due   to   the   black  border   that   surrounds   the  warning   information.   The  Food  and  Drug  Administration   (FDA)   is   the  agency  that   stipulates   which   medications   have   black   box   warnings.   Black   box   warnings   are   required   when  medications   cause   serious   undesirable   effects   (such   as   fatal,   life-­‐threatening   or   permanently   disabling  adverse   reactions)   compared   to   the   potential   benefit   of   the   medication.   The   FDA   requires   that   the  warning   provide   a   concise   summary   of   the   adverse   side   effects   and   risks   associated   with   taking   the  medication.   This   information   may   help   patients   and   providers   decide   if   this   is   the   most   appropriate  medication   or   if   an   alternative   can   be   used.   The   FDA   can   require   recall   and/or  withdrawal  of   products  based  upon  the  occurrence  of  adverse  effects  that  are  serious  enough  to  require  black  box  warnings.    

The  FDA  requires  medications  with  a  black  box  warning  to  have  medication  guides  containing  consumer  information   regarding  how  to  safely  use  the  medication.  Medication  guides  should  be  given  to  patients  when  these  medications  are  filled  at  an  outpatient  pharmacy.  Some  common  medications  with  black  box  warnings  include  rosiglitazone,  fluoroquinolones,  atypical  antipsychotics  and  many  antidepressants.  

Medication Safety Medications to Avoid in the Elderly: The Beers List

By Stefanie Stogsdill, Pharm.D., BCPS  

Inappropriate  medication  use  is  a  serious  problem  in  the  elderly  that  can  lead  to  adverse  drug  events  that  require  additional  health  care  costs  and  services.  Thirty  percent  of  hospital  admissions  in  elderly  patients  may  be  linked  to  drug-­‐related  problems  or  toxic  effects.  Adverse  drug  events  have  been  linked  to  preventable  problems   like  depression,  constipation,   falls,  immobility,  confusion  and  hip  fractures   in  our  elderly  patients.  

First   released   in   1991,   the   Beers  criteria,  or  Beers   List,  contains  a   list  of  medications   whose   potential   risks  outweigh   the   potential   benefits   when  utilized   in   the   elderly.   This   list   was  developed   by   a   group   of   12   clinicians  with  expertise  in  geriatrics  and  was  led  by   Dr.   Mark   Beers,   hence   the   name.  The  Beers   list  has  been  updated  twice,  with   the   last   revision   in   2003.   The   list  has   two   primary   groups:   medications  considered   potentially   inappropriate  regardless   of   diseases   or   conditions  present   and   a   list   of   medications  considered   potentially   inappropriate  when   used   in   seniors   with   certain  diseases  or  conditions.    

Many  of  the  medications  on  the  list  are  included  because  of  sedative  and  anticholinergic  effects.  The  CNS  depressive  medications  can  cause  sedation   and   cognitive   impairment   resulting   in   difficulty   with   self-­‐care   and   falls,   while   the   anticholinergic   medications   (e.g.  diphenhydramine  or  amitriptyline)  can  cause  cognitive  problems  by  adding  to  the  age-­‐related  decrease  in  cholinergic  transmission  as  well  as   cause   constipation   and   urinary   retention.   Some   frequently   utilized   medications   that   appear   on   the   Beers   list   include,   diazepam,  amiodarone,  clonidine,  diazepam  and  fluoxetine,  just  to  name  a  few.  The  Beers  list  should  be  used  as  a  helpful  guide  to  identify  potentially  inappropriate  medications   for  use   in  the  elderly,  but  ultimately   clinical   judgment  should  guide  practitioners’  use  of  any  medication  that  appears  on  the  Beers  list.    

 

Editor in Chief: Lisa Mayer, Pharm.D., BCPS Clinical Pharmacy Specialist

Contributors: Shamama Burney, Pharm.D. Pharmacy Resident

Sarah Payne, Pharm.D. Pharmacy Resident

Stefanie Stogsdill, Pharm.D., BCPS Staff Pharmacist

Donna Wilk, CPhT Clinical Pharmacy Technician

Sonal Yang, Pharm.D., BCPS Staff Pharmacist

The Script The Quarterly Newsletter of the

Department of Pharmacy

 

Medications  and  Drug  Classes  Potentially  Inappropriate  for  Use  in  the  Elderly  Amiodarone   Disopyramide  (H)   Mineral  oil  

Amitriptyline  (H)   Doxazosin  Muscle  relaxants  (carisoprodol,  cyclobenzaprine,  dantrolene,  methocarbamol,  orphenadrine)  -­‐  all  (L)  

Amphetamines   Doxepin  (H)   Nifedipine,  short-­‐acting  Barbiturates  (H)   Estrogens   Nitrofurantoin  Benzodiazepines,  long-­‐acting  (chlordiazepoxide  (H),  diazepam  (H),  flurazepam  (H),  oxazepam  (H),  temazepam)  

Ethacrynic  Acid   NSAIDs,  long-­‐term  use  of  full-­‐dose,  longer  half-­‐life,  non-­‐COX-­‐selective  types  (naproxen,  oxaprozin,  piroxicam)  

Chlorpheniramine   Ferrous  sulfate  >  325  mg/day   Oxybutynin,  short-­‐acting  Chlorpropamide  (H)   Fluoxetine   Pentazocine  (H)  

Cimetidine  Gastrointestinal  antispasmodics  (belladonna  alkaloids  (H),  clidinium-­‐chlordiazepoxide  (H),  dicyclomine  (H),  hyoscyamine  (H))  

Perphenazine-­‐amytriptyline  

Clonidine   Hydroxyzine   Promethazine  Clorazepate   Ketorolac   Reserpine  (L)  

Cyproheptadine   Meperidine  (H)   Stimulant  laxatives,  long-­‐term  use  except  with  opiate  analgesics  (bisacodyl)  

Desiccated  thyroid   Methyldopa  and  methyldopa/hydrochlorothiazide  (H)  

Ticlopidine  (H)  

Digoxin  >  0.125  mg/day  (H)   Methyltestosterone   Trimethobenzamide  (H)  H  =  high-­‐severity-­‐impact  medication,    L  =  low-­‐severity-­‐impact  medication  

 

4