...an educational memo from your Pharmacy and Therapeutics Committee

September, 2000

Due to manufacturing problems, there may be a delay or shortage in the availability of this year’s trivalent influenza vaccine (A/New Caledonia, A/Panama and B/Yamanashi). Eventually, all patients whom you would routinely vaccinate should be able to receive their fall "flu shot". Vaccination of individuals at high risk for complications from influenza and their close contacts should proceed routinely. Early vaccine programs should focus on elderly patients, high-risk patients and health care personnel. It was decided at the last OSF System P&T Committee meeting that OSF will adhere to CDC recommendations (http://www.cdc.gov/od/oc/media/pressrel/r2k0622a.htm). In brief, the recommendations are to delay organized vaccine programs until early to mid-November. We recommend posting a list of "high-risk patients" for patient reference in your office (http://…/r2k0622h.htm). Please check with your pharmacy supplier throughout October and November to see when your supply will arrive.

Patient-controlled analgesia (PCA) is a cornerstone of pain management for moderate to severe pain. Fentanyl is an excellent choice as a narcotic (opioid) analgesic and the subcutaneous route adds a measure of safety by dispersing the drug more slowly than the intravenous route. The pre-printed order form for using fentanyl PCA is available on all patient care units, as are the subcutaneous catheters. The order form includes important adjuvant drug orders for NSAID or acetaminophen, opioid-constipation, nausea and vomiting and respiratory depression. The check-boxes on the order form make it easy to complete the complicated ordering process for PCA analgesia.

Morphine can also be ordered by the PCA route. Using the pre-printed order prompts the prescriber to order naloxone (Narcan®) prn for respiratory depression. The morphine pre-printed orders are not as complete for adjuvant drug orders as are the fentanyl subcutaneous PCA. Meperidine (Demerol®) PCA is no longer on the formulary.

Prescribers completing the OSF SFMC inpatient Formulary Addition Request Form are now asked to declare whether they have a conflict of interest with the manufacturer of the drug product. The Pharmacy and Therapeutics Committee approved the new Formulary Addition Request form. Use of the new form is effective immediately.

Hyaluronidase is a proteolytic enzyme that spreads an extravasated drug through the subcutaneous tissue following an IV extravasation incident. This reduces damage by diluting the drug in the subcutaneous tissue. OSF SFMC has an active protocol for the triage and treatment of non-cancer chemotherapy extravasation occurrences.

Currently, hyaluronidase is in short supply. The use of subcutaneous hyaluronidase injections is recommended for IV extravasation of "hypertonic solutions, antibiotics/antimicrobials and aminophylline". This extensive list of drugs could exhaust our supply of hyaluronidase. We do not want this to happen.

Additionally, some oncologists use subcutaneous hyaluronidase for the treatment of IV extravasation of certain cancer chemotherapy drugs – epipodophyllotoxins (etoposide or teniposide), paclitaxel and vinca alkaloids (vinblastine, vincristine, vindesine or vinorelbine). Because the cancer chemotherapy drugs are not currently included in the OSF SFMC procedure for extravasations, the use of hyaluronidase requires an order.

Until the shortage is over, we ask that hyaluronidase be used to treat only the following IV extravasation incidences: concentrated potassium chloride infusions (10mEq/50ml, 20mEq/50ml, 20mEq/100ml), calcium chloride or calcium gluconate infusions and certain cancer chemotherapy drugs (etoposide, teniposide, paclitaxel, vinblastine, vincristine, vindesine or vinorelabine). For other drugs on the hyaluronidase list, follow the procedure, except for the administration of hyaluronidase.

Physicians are prescribing IV magnesium sulfate infusions more frequently for inpatients with cardiac (antiarrhythmic), endocrine (hypothyroidism) and renal (glomerulonephritis) conditions. Traditional uses in OB/GYN (preeclampsia seizures), alcoholism (seizures) and malnutrition have continued to require significant oral and IV therapy.

IV magnesium sulfate for infusion is available by ordering a 1g/100ml bag. On some units, these pre-mix bags will be available in the SureMed. The Committee approved a maximum infusion rate of 2g/hour for all magnesium sulfate peripheral IV infusions. Infusions of higher concentrations or faster rates are not allowed for patients on general units who are not on telemetry. You can also add magnesium sulfate to the patient’s existing large volume parenteral.

The following units are exempt from this policy: units with telemetry beds, special care units, emergency department, OB/GYN, psychiatry and CHOI. These units can use higher concentrations and faster rates of infusion of IV magnesium sulfate solution.

A protocol was approved for using one or two doses of alteplase in occluded central venous catheters in pediatric patients. These include external, subclavian catheters (Hickman®, double lumen Hickman® and Broviac®types) and internal, femoral vein, subcutaneously-tunneled catheters (Portocath®, Infusaport® and Lifeport® types). The alteplase protocol can be used for PICC lines and temporary central lines. The dose of alteplase is 1mg/1ml or 1.5mg/1.5ml, depending upon the internal volume of the catheter. The protocol requires a physician order. Only nurses trained in the procedure can initiate and carry out the procedure. Pharmacy needs at least 30 minutes to thaw out the frozen alteplase syringes. The physician is notified in cases where the occluded line does not have blood return or will not flush. The procedure takes one to three hours.

A temporary shortage of drug product has prompted the development of the following autosubstitution policy. When you order prochlorperazine injectable (10mg or 0.1-0.15mg/kg in CHOI), your patient will receive promethazine injectable (25mg or 0.25mg/kg in CHOI). The promethazine injectable ampules (25mg/ml) will be available in the SureMed machine. Pharmacy will notify the patient care units whenever the autosubstitution is necessary. Thank you for your understanding of this situation. We will return to our normal procedure when the shortage of prochlorperazine is over.

Removed from the formulary in July, nifedipine immediate-release 10mg gelatin capsules have been added back onto the formulary. Oral, immediate-release nifedipine 10mg gelcaps are restricted for use in the treatment of procedure-related coronary vasospasm, and are available for use only in the operating room, the coronary catheterization lab and the cardiovascular intensive care unit (CVICU). All cases in which the drug is used will be reviewed by the CV Outcome Manager.

Oral immediate-release nifedipine cannot be used for the treatment of hypertension at OSF SFMC and it cannot be administered sublingually, due to concerns about its toxicity. Instead of writing for oral nifedipine, other drugs that may be used for rapid treatment of hypertension include labetalol (NormodyneÒ , TrandateÒ 1-2mg/kg IV bolus), clonidine (CatapresÒ 0.1mg PO/SL q 1hr up to 1mg/24hr)

(July) pantoprazole (Protonix®) – oral (and soon-to-be-marketed IV) proton pump inhibitor

for the short-term prophylaxis and treatment of erosive esophagitis. The company is still developing the IV formulation. The oral dose is 40mg daily. We now have two oral proton pump inhibitors on the OSF SFMC inpatient formulary, the other one being lansoprazole (Prevacid®).