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

January, 2002

Famotidine will now be the preferred H-2 blocker, replacing ranitidine. Reasons for the change are the significant cost difference and the less frequent daily dosing of the parenteral dosage form. Pharmacists will write autosubstitution orders for other prescribed H-2 blockers.

The December PharmaGram failed to specify that treatment of parenteral nutrition infiltrates with the limited supply of hyaluronidase is approved for the Neonatal Intensive Care Unit only. My apology for any confusion this may have caused.

Nesiritide, a natriuretic peptide, used for acute exacerbation of heart failure, may also be administered to patients in the Emergency Department and on the 5^th Floor in the Gerlach Building, as well as the ICUs and Intermediate ICU (3400).

Audits of parenteral use of the H-2 blocker ranitidine (Zantac®) and the proton pump inhibitor, pantoprazole (Protonix®) showed that about half the patients were also receiving either an oral/enteral diet or other oral medications. Studies have shown equivalent efficacy of these oral gastric acid blocking products. In consultation with the Gastroenterology service, the P&T Committee has agreed to allow for substitution of the parenteral product when a patient is taking an oral diet or other oral medications. Excluded from the protocol are patients in the ICU’s, pediatrics or when a ‘Do Not Substitute’ request is written with an order for the parenteral dosage form. Pharmacists will write an order for the switch and will follow the dosages recommended in Autosubstitution guidelines, including the use of omeprazole suspension for patients unable to take the solid dosage form.

Many times a patient’s capability to swallow a solid or liquid dosage form changes during their hospitalization. Effective February 1, the P&T Committee has approved a protocol which will allow nurses to write an order altering the dosage form based on the patient’s swallowing ability. Physicians would need to be contacted for extended-release, antiarryhthmic and immunosuppressive agents; and drugs with a narrow therapeutic index or with known bioavailability problems (ex. phenytoin (Dilantin®).

Drotrecogin alpha, also known as recombinant activated protein C, was recently FDA approved for reduction of mortality associated with severe sepsis. Following strict criteria in a recently reported study, a 96-hour infusion of drotrecogin alpha resulted in a 6.1% absolute reduction in mortality. The P&T Committee approved this drug, but, due to the drug cost and side effect potential, restricted prescribing to physicians with expertise on the drug’s use and to it’s initiation in the ICU’s.

Montelukast, a leukotriene receptor antagonist indicated for the prophylaxis and chronic treatment of asthma in adults and children, was added to the Formulary. It is available in 10mg tablets and 4 mg and 5 mg chewable tablets.

As a result of increased reports of Torsades and the addition of a ‘Black Box Warning’ to the product information, droperidol may now only be used if the Q-T interval on ECG is demonstrated to be of acceptable duration prior to administration of the drug.