DEPARTMENT OF PHARMACY Therapeutic Interchange Update A MEMBER OF SAINT PETER’S HEALTHCARE SYSTEM
SERVICES
254 Easton Avenue
The following drug interchanges were approved at the
New Brunswick, New Jersey 08901
May 2009 and Pharmacy and Therapeutics meeting
Department of Pharmaceutical Services
Non-Formulary Formulary
PharmaFacts
Randa Abdelal, Pharm. D.
Pharmacy Clinical Coordinator All adult Xopenex (Levalbuterol) nebulizer solution doses Albuterol nebulizer solution 2.5 mg
(732) 745-8600 (Ext. 8732)
Xopenex metered dose inhaler Albuterol metered dose inhaler
Pager: 732-651-4604
(Any dose and frequency) (Same dose and frequency)
Azmacort® 100mcg (Triamcinolone) (Any interval) Fluticasone 44mcg (Flovent®) (Same interval)
Volume 4, Issue 2 May 2009
A MEMBER OF SAINT PETER’S HEALTHCARE SYSTEM Rozerem (Ramelteon) 8mg Ambien 5mg po hs
Lunesta (Eszopiclone) 2mg
Renax® and Diatx-Zn® MVI 1 po daily Nephrocaps® MVI 1 po daily Safety Alerts
Xyzal (Levocetirizine) 5 mg po daily Loratadine 10 mg po daily
Megace ES 625 mg po daily Megace 800 mg po daily 1. FDA revises ceftriaxone calcium these products may result in controlled and monitored.
Department of Pharmacy Services alert - FDA issued an update transmission of serious viruses such Only a few selected registered
Joseph Dicubellis, M.P.H Folic Acid 0.4 mg po daily Folic Acid 0.5 mg po daily 4/21/2009 to a previous alert on the as hepatitis, HIV, or other blood- physicians have the ability to
Director of Pharmacy
interaction of ceftriaxone borne pathogens. ISMP has prescribe the drug and physicians
Randa Abdelal, Pharm.D. – Editor
(ROCEPHIN) with calcium containing published similar alerts on several have to make a special application
Pharmacy Clinical Coordinator
products, based on reported fatali- occasions including hazard alerts in to the FDA and the Drug
Joaquim Noronha, M.D.
ties involving neonates. The update the March 27, 2008 and February Enforce-ment Agency. Federal law
Chairman, Pharmacy & Therapeutics
We are now on the described revisions to the warnings 12, 2009 issues. does not restrict the prescribing,
Committee
Saint Peter’s University Hospital where the FDA now recommends dispensing or administering of
homepage under that ceftriaxone and calcium- 3. Safety Brief: XL or x1? methadone to a narcotic addicted
“SPUH Formulary and Drug Info”! containing products may be used A number of hospital employees patient so long as it is for the
concomitantly in patients >28 days who were proofing dictated reports purposes of alleviating pain if such
of age, using the precautionary indicated to ISMP that the prescribing is medically appropriate
recommendations noted because commonly used drug name suffix within standards set by the medical
the risk of precipitation is low in “XL” looked very much like x1 community. All hospitals MUST keep
this population. FDA had previously (times one), which could be good records to document the
recommended, but no longer confusing. Indeed, ISMP once physician is treating a pain
recommends, that in all age groups received a report about syndrome & NOT the disease of
ceftriaxone and calcium-containing misinterpretation of an order narcotic addiction. However, it is
products should not be written for “Procardia 90 mg XL” as permitted for hospitals to
administered within 48 hours of one 90 mg x1. This led to the adminis- temporarily maintain treatment of
another. For information, visit: tration of nine immediate-release, inpatients already enrolled in an
www.fda.gov/cder/drug/InfoSheets/HCP/ 10 mg PROCARDIA (NIFEdipine) established methadone
ceftriaxone042009HCP.htm. capsules and the patient's transfer maintenance program. Both the
to the ICU. patient’s status at a designated
2. FDA echoes concern about detoxification program & assurance
Prefilled Syringes - A recent FDA 4. Methadone for Detox Or Pain? of the proper prescribed dosage
alert issued last month warned that Methadone prescriptions for the must be verified by the pharmacist
prefilled syringes, such as insulin treatment of drug addiction are prior to proceeding with any
pens and cartridges, are never to be not easily available. The prescriptive methadone detox orders.
shared among patients. Sharing of authority by physicians is highly
Inside This Issue… Swine Flu Scare Raises Concern of Tamiflu Resistance
Safety Alarms ............................................1
Swine Flu Scare Raises Concern on Anti-viral drug Tamiflu must be which we presently seem to be
Tamiflu Resistance ......................................1 used with care to avoid the new doing, then these drugs may be life
Formulary Additions ..................................2
strain of swine flu developing saving. The main take home
resistance, an expert on infectious message here is that this drug must
Common Drugs Known to
diseases has warned. The drug, not be used as a general prophylac-
Affect INR Levels ........................................2 developed by Swiss pharmaceutical tic, but should be administered
Pharmacy Interventions ............................2 firm Roche, would be one of the within 12 hours of a
Anticoagulant Resistance: A Relevant primary defenses against a patient showing flu
Issue in Sewer Rat Control? ......................3 pandemic. The fear is, if we use it symptoms. Initiating
inappropriately, there is a higher treatment too late
Major Routes of Elemination for
chance of resistance developing would reduce its effec-
Most Common Antimicrobial Classes ........3 very fast. If we manage to prevent tiveness and increase the
Therapeutic Interchange Update................4 the development of resistance, chances of resistance.

Volume 4, Issue 2 PharmaFacts Page 2 Volume 4, Issue 2 PharmaFacts Page 3
Pharmacy Interventions and Trending for Total Doses Dispensed Warfarin Resistance: A Relevant Issue…OR Not?
from January thru April 2009
Warfarin is the most widely populations. It was found that the RESULTS:
Interventions – Pharmacy and Therapeutic prescribed oral anticoagulant, prevalence of resistance was A low level of anticoagulant
Summary but there is greater than 10-fold investigated in six sewer locations resistance was found in the
Date Prepared: 2009-05-06 A MEMBER OF SAINT PETER’S HEALTHCARE SYSTEM
interindividual variability in the in Copenhagen and its suburban sewers regardless of control
Period Reported: 2009-01-01 –– 2009-04-30 dose required to attain a area by means of the blood strategy. Surprisingly, none of the
Key Statistics therapeutic resposne. There has clotting response test and rats, including the resistant rats,
been some speculation this might amplification refractory mutation had resistance-related mutations
be due to interactions caused by system polymerase chain reaction in the VKORC1 gene.
two genes, the warfarin metabolic analysis, and by additional
enzyme CYP2C9 and warfarin sequencing of the VKORC1 gene. CONCLUSION:
target enzyme, vitamin K epoxide The sewer locations were chosen The results of this study suggest
reductase complex 1 VKORC1. In to represent three different that the genetic background of
UNACCEPTABLE response to this concern, a study control strategies: anticoagulant resistance may ahve
was conducted in Copenhagen to (i) No anticoagulant use for to be redefined in respect to the
ABBREVIATIONS: provide knowledge on the approximately 20 years resistance-related canges in the
prevalence of resistance and how (ii) No anticoagulant use for the VKORC1 gene.
• QD, QOD, U, IU
different control strategies have last 5 years
• MS, MSO4, MGSO4 affected its prevalence. This study (iii) Continuous use for several
was performed among sewer rat decades up to the present.
• Must Have a Zero Before
A Decimal Point
• No Zeros After A Decimal
Point Major Routes of Elemination for Most Common Antimicrobial Classes
Common Drugs Known to HEPATIC RENAL
Affect INR Levels
When Given with Warfarin
Chloramphinicol Nafcillin Most B-Lactams Gemifloxacin
INR INR
Elevation Depression
Cefoperazone Linezolid Aminoglycosides Vancomycin
Amiodarone Rifampin
Ciprofloxacin Secobarbital Doxycycline Isoniazide/ Rifampin/ Monobactams Nitrofurantoin
Ethambutol
TMP/SMX Carbamazepine
Metronidazole Phenytoin Minocycline Pyrazinamide Carbapenems Fluconazole
Fluconazole Phenobarbital
Total Pharmacy Savings From Interventions Moxifloxacin Itraconazole Polymycin B Acyclovir
Fluvastatin Primidone
Isoniazide St. John’s Wort Total Interventions Total Interventions Accepted Total Savings Macrolides Caspofungin Colistin Valacyclovir
Lovastatin Cigarette 4042 99.85% $203,696
smoking Telithromycin Micafungin Ciprofloxacin Famciclovir
Phenylbutazone
Charbroiled
Sertraline
food Clindamycin Anidulafungin Ofloxacin Valgaciclovir
Gemfibrozil Formulary Additions: Metronidazole Ketoconazole Levofloxacin Tetracycline
Ethanol
• Micardis (Telmisartan) - An angiotensin II
Clarithromycin receptor blocker for the treatment of Tigecycline Voriconazole Gatifloxacin Flucytosine
hypertension
Erythromycin
• Lexiscan - (Regadenoson) - A diagnostic
Quinupristin/ Posaconazole Amantadine Daptomycin
Vorconazole agent dalfopristin Rimantadine