Due to a shortage of raw material, isoproterenol is at critically low levels. This has caused physicians and pharmacists to seek out alternative drugs for the limited number of indications where isoproterenol is used. Isoproterenol has been removed from the emergency carts do to minimal usage and the very low priority of this drug in the recent ACLS guidelines. Dobutamine has been used as an alternative in heart transplant and electrical cardiac stimulation procedures. Sublingual nitroglycerin has been shown to be effective in tilt-table testing for syncope. In the meantime, the manufacturer plans to resume production of isoproterenol when a new raw material supplier can be identified.

Several changes have taken place over the recent past that has caused the Pharmacy and Therapeutics Committee to re-evaluate and adjust the Formulary status of two oral benzodiazepines. Up until this recent change, alprazolam was the preferred, oral, short acting benzodiazepine over the use of lorazepam. Due to increasing concerns about drug interactions with alprazolam, acquisition cost reductions and availability of unit dose packaging of generic lorazepam, the Formulary status has now been reversed. Orders for alprazolam will now be autosubstituted with lorazepam. Dosage will be adjusted to a 1:2 ratio; such that 0.5mg alprazolam will be substituted with 1mg lorazepam. Following the guidelines for P&T Committee approved substitutions, the pharmacist will write an order indicating this change.

Tolterodine, a drug indicated for urinary incontinence and overactive bladder, has been added to the OSF St Francis Formulary. Oxybutynin (Ditropan), will remain on the Formulary and is the preferred agent for this indication. Tolterodine may offer an alternative to those patients who experience intolerable side effects from oxybutynin. Prescribers should be aware that oxybutynin is available also in a liquid dosage form and the acquisition cost for tolterodine is $1.08 for the 2mg tablet whereas the cost for oxybutynin is $0.11 for the 5mg tablet.

Patients who are concomitantly receiving macrolides (ex. Erythromycin) or an –azole antifungal agent (ex. Fluconazole, itraconazole) may be at increased risk of side effects from tolerodine.

Avoid Q.D. The period after the ‘Q’ can be interpreted as an "I" Use ‘daily’

Avoid SC This can be mistaken for "SL’ for sublingual Write out subcutaneous

Avoid TIW Can be mistaken for TID Write 3 times a week or specify days

Avoid "s" Can be misinterpreted as ‘with’ Usually not needed

(Ex. Lidocaine 1% s epinephrine should be written as lidocaine 1%)