P H A R M A G R A M
...an educational memo from your Pharmacy and Therapeutics Committee
June, 2004
Parenteral Prochlorperazine (Compazine®) Is Available:
For about 2 years the parenteral form of prochlorperazine has been unavailable due to material shortages and production problems. During this interim period the Pharmacy and Therapeutics Committee had authorized an auto-substitution to promethazine (Phenergan®) and pre-printed physician orders were changed to reflect the unavailability of this drug. The return of prochlorperazine injection is welcomed since it is a very effective antiemetic, with a low side effect profile in comparison to a number of other antiemetics and is less costly than the serotonin receptor antagonists (i.e. ondansetron (Zofran ®, granisetron (Kytril®).
NPO Orders- Don’t Forget to Hold the Scheduled Insulin!
Insulin glargine (Lantus®) is a product that delivers controlled insulin levels over a 24 hour period. In a recent review of insulin glargine usage here at Saint Francis Medical Center, there were1426 vials dispensed over a 12 month period. During approximately this same period almost 250 patients required a hypoglycemic rescue medication (i.e. IV Dextrose or glucagon). Although the medical records were not individually reviewed for cause and effect, the Adverse Drug Event Reports completed by Quality Management indicate insulin glargine as a frequent cause of hypoglycemic events.
The following case reported at the ADE Subcommittee illustrates how ‘easy’ a hypoglycemic event can occur. A patient admitted to the nephrology service was scheduled for an orthopedic procedure in the afternoon, and orders for NPO were written that morning. The patient received his usual insulin glargine that morning, went to the afternoon procedure and became hypoglycemic overnight. The patient was treated without further sequela.
In response to these episodes a warning message will appear on the Medication Administration Record with insulin glargine orders stating “HOLD if NPO.” Please remember to check for any scheduled insulin orders when writing orders for NPO and adjust insulin orders accordingly.
Drug Deletions and Autosubstitutions:
At the last Pharmacy and Therapeutics Committee meeting, the following actions were taken:
Ø Lente insulin was deleted due to very low usage and potential confusion with Lantus® insulin.
Ø Fluticasone (Flonase®) was approved as the ‘preferred’ intranasal corticosteroid, based on efficacy, frequency of administration, cost and approved use in children and adults. An autosubstitution of all other intranasal corticosteroids to fluticasone by pharmacists was approved.
Ø An autosubstitution for the newest HMG Co-A Reductase Inhibitor, rosuvastatin (Crestor®), to atorvatstatin (Lipitor®) was approved to allow time to evaluate for potential, unknown side effects of rosuvastatin.
New ‘Dosage Range’ Order Policy Approved:
A new policy regarding drug orders with dose or frequency ranges (ex. Acetaminophen 325-650mg q3-4hrs prn) will be implemented. The recommended interpretation of such orders will be to use the lowest dose initially (a higher dose may be used for analgesic orders if the pain scale score is greater than 5 and risk of adverse effect is low) . An additional incremental dose may be given if needed, but this dose is not to exceed the maximum dose per range and time period. Using the example, a 325mg tablet would be used as the initial dose (unless the pain is ‘severe’). If an additional acetaminophen dose is needed within 3 hours of the initial dose, then only one other 325mg tablet may be given.
A prescription using a dosing interval range (ex. q 3-4 hrs) will use the shortest time interval indicated. In the example above, every 3 hours prn will be range implemented.
ADE (Adverse Drug Event) Hotline: 655-6805
Drug Information Service – 655-2382 (Mon-Fri; 8am – 4pm)