Pharmacy Updates

Pharmacy and Therapeutics Committee Actions Formulary:

Additions:

  • Doripenem (Doribax®) – Antibiotic
  • Palonosetron (Aloxi®) – Antiemetic for delayed chemotherapy nausea and vomiting.
  • Antineoplastic Class: Pemetrexed (Alimta®), paclitaxel protein-bound (Abraxane®), fulvestrant (Faslodex®), doxorubicin liposomal (Doxil®), cetuximab (Erbitux®)

Deletions:

Dutasteride (Avodart) :
Antiinfective Class: Imipenem (Primaxin®), tetracycline, rifabutin (Mycobutin®), ertapenem (Invanz®), methenamine (Hiprex®)
Antineoplastic Class: Aldesleukin (Proleukin®), alemtuzumab (Campath®), busulfan (Myleran®), floxuridine (FUDR), goserelin (Zoladex®), lomustine (CeeNU®), mechlorethamine (Mustargen®), procarbazine (Matulane®), thiotepa

Policy Update:

IV Administration Guideline

  • Propofol (Diprivan®) – Added Pediatric Intensivists for procedural sedation in PICU and ED
  • Ketamine (Ketalar®) – Added Imaging Departments (MRI, CT, Radiology)
  • Terbutaline IV – Deleted

FENTANYL (DURAGESIC®) PATCH MEDICATION SAFETY:

The FDA issued a Boxed Warning for fentanyl (Duragesic®) patch to be used only in opioid-tolerant patients who have been receiving a total daily dose that is at least equivalent to the 25mcg/hr patch.

Patients must meet both criteria prior to initiation of fentanyl patch therapy at PTMC.

  • Daily opioid doses equivalent to fentanyl 25mcg/hr patch are:
    • Morphine 15mg IV or 60mg PO per day
    • Dilaudid 3mg IV or 12mg PO per day
    • Oxycodone 30mg PO per day
    • Vicodin 5/500 PO – 9 tablets per day
    • Tylenol #3 PO 9 tablets per day
    • Norco 10/325 PO – 4 tablets per day
  • Opioid tolerance is defined as receiving the above equivalent dose for more than 7 days.

Dose adjustments of the patch, if needed, may only be made 3 days after the initial dose and 6 days thereafter for subsequent adjustments. Nursing Staff: Document on nursing notes that patient is opioid tolerant. Pharmacy Staff: Verify that patient is opioid tolerant and document in CAMIS prior to dispensing fentanyl patch.

ADR CASE STUDIES FROM P&T

CASE #1: A 75 year old male admitted for hip fracture. Post-op, the patient had orders for Vicodin 1 tablet q4hr prn for mild pain and Dilaudid 2 mg IM q4hr for severe pain but had not received either on a regular basis for the past 24 hours. Fentanyl (Duragesic®) patch 50 mcg/hr was ordered and applied on the patient. Patient became unresponsive 36 hours later. O2 sat was 46%, cyanotic lips, and nail beds were purple. Code blue was initiated and the patient was treated with naloxone (Narcan®) IV x 3, O2 5 Liters (O2 sat to 94%) and transferred to ICU.

RECOMMENDATIONS:

  1. Fentanyl patch is not initiated for acute post operative pain and not for mild or intermittent pain responsive to PRN therapy.
  2. This patient should have been initiated on the 25 mcg/hr patch if the patient was to receive it for chronic pain.
  3. This patient was not opioid-tolerant (did not receive opioids in the amount equivalent to the patch strength for the past 7 days).

CASE #2: A 78 year old 95 Kg opioid naïve male was admitted for surgery.

DATE TIME
3/16 07:30 Hydromorphone 2 mg IM (q3hr prn)
MEDICATION
11:15 Hydromorphone 2 mg IM
16:15 Hydromorphone 2 mg IM
19:35 Hydromorphone 2 mg IM
3/17 04:00 Patient found unresponsive

Patient did well after surgery but was found unresponsive by the nurse after Dilaudid® (hydromorphone) 2 mg IM x 4 doses (8 mg) administration during the previous 12 hours. Code Blue initiated, patient intubated, and transferred to ICU.

RECOMMENDATIONS: Consider the potency of Dilaudid® (hydromorphone) when prescribing to elderly opioid naïve patients.
Dilaudid® 2 mg ˜ morphine 14 mg
Dilaudid® 8 mg ˜ morphine 56 mg

CASE #3: A 90 year old male came to ED with generalized weakness and black stool.
Lab: PTT = 51 Hg = 16.5 Hct = 50 Scr = 1.73 Estimated CrCl = 28mL/min
Dabigatran (Pradaxa®) 150mg po q12hr
Home Medications:
(started a few days prior to admit)
Amlodipine 2.5 mg po daily
Rosuvastatin 5 mg po every other day
Propranolol 20 mg po bid
Temazepam 30 mg po prn bedtime

RECOMMENDATIONS: This patient has a reduced renal function and the manufacturer recommends giving dabigatran at the lower dose of 75 mg twice a day for patients with CrCl 15 – 30 mL/min.

ADVERSE DRUG REACTIONS

1st Quarter ADR Report 2011

The rate for the first quarter 2011 is 4%, higher than 3.5% of the 4th quarter 2010. Classes of medications most frequently associated with inpatient ADRs were analgesics, anti-infective, and anti-diabetic agents. Dilaudid® (hydromorphone) is the most frequently reported medication in the analgesic class. The two severity L2 Dilaudid ADR reactions were from a 2 mg dose in patients older than 70 years old. Hydromorphone 2 mg is approximately equivalent to 14 mg of morphine.
Severity L2 or greater ADR medications:
L2: Hydromorphone 2mg IM – respiratory arrest
L2: Hydromorphone 2mg IM – respiratory arrest
RECOMMENDATIONS :
Physicians are reminded to consider the potency of Dilaudid® (hydromorphone). Initial dose for elderly opioid naïve patients should be less than 1 mg.

Chairperson

Alina Lopo, M.D., Ph.D.

Director, Pharmacy Services

Krist Azizian, Pharm.D.

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