Pharmacy and Therapeutics Committee Actions Formulary:
- Doripenem (Doribax®) – Antibiotic
- Palonosetron (Aloxi®) – Antiemetic for delayed chemotherapy nausea and vomiting.
- Antineoplastic Class: Pemetrexed (Alimta®), paclitaxel protein-bound (Abraxane®), fulvestrant (Faslodex®), doxorubicin liposomal (Doxil®), cetuximab (Erbitux®)
Dutasteride (Avodart) : Antiinfective Class: Imipenem (Primaxin®), tetracycline, rifabutin (Mycobutin®), ertapenem (Invanz®), methenamine (Hiprex®) Antineoplastic Class: Aldesleukin (Proleukin®), alemtuzumab (Campath®), busulfan (Myleran®), floxuridine (FUDR), goserelin (Zoladex®), lomustine (CeeNU®), mechlorethamine (Mustargen®), procarbazine (Matulane®), thiotepa
IV Administration Guideline
- Propofol (Diprivan®) – Added Pediatric Intensivists for procedural sedation in PICU and ED
- Ketamine (Ketalar®) – Added Imaging Departments (MRI, CT, Radiology)
- Terbutaline IV – Deleted
FENTANYL (DURAGESIC®) PATCH MEDICATION SAFETY:
The FDA issued a Boxed Warning for fentanyl (Duragesic®) patch to be used only in opioid-tolerant patients who have been receiving a total daily dose that is at least equivalent to the 25mcg/hr patch.
Patients must meet both criteria prior to initiation of fentanyl patch therapy at PTMC.
Daily opioid doses equivalent to fentanyl 25mcg/hr patch are:
- Morphine 15mg IV or 60mg PO per day
- Dilaudid 3mg IV or 12mg PO per day
- Oxycodone 30mg PO per day
- Vicodin 5/500 PO – 9 tablets per day
- Tylenol #3 PO 9 tablets per day
- Norco 10/325 PO – 4 tablets per day
Opioid tolerance is defined as receiving the above equivalent dose for more than 7 days.
Dose adjustments of the patch, if needed, may only be made 3 days after the initial dose and 6 days thereafter for subsequent adjustments. Nursing Staff: Document on nursing notes that patient is opioid tolerant. Pharmacy Staff: Verify that patient is opioid tolerant and document in CAMIS prior to dispensing fentanyl patch.
ADR CASE STUDIES FROM P&T
CASE #1: A 75 year old male admitted for hip fracture. Post-op, the patient had orders for Vicodin 1 tablet q4hr prn for mild pain and Dilaudid 2 mg IM q4hr for severe pain but had not received either on a regular basis for the past 24 hours. Fentanyl (Duragesic®) patch 50 mcg/hr was ordered and applied on the patient. Patient became unresponsive 36 hours later. O2 sat was 46%, cyanotic lips, and nail beds were purple. Code blue was initiated and the patient was treated with naloxone (Narcan®) IV x 3, O2 5 Liters (O2 sat to 94%) and transferred to ICU.
- Fentanyl patch is not initiated for acute post operative pain and not for mild or intermittent pain responsive to PRN therapy.
- This patient should have been initiated on the 25 mcg/hr patch if the patient was to receive it for chronic pain.
- This patient was not opioid-tolerant (did not receive opioids in the amount equivalent to the patch strength for the past 7 days).
CASE #2: A 78 year old 95 Kg opioid naïve male was admitted for surgery.
3/16 07:30 Hydromorphone 2 mg IM (q3hr prn)
11:15 Hydromorphone 2 mg IM
16:15 Hydromorphone 2 mg IM
19:35 Hydromorphone 2 mg IM
3/17 04:00 Patient found unresponsive
Patient did well after surgery but was found unresponsive by the nurse after Dilaudid® (hydromorphone) 2 mg IM x 4 doses (8 mg) administration during the previous 12 hours. Code Blue initiated, patient intubated, and transferred to ICU.
Consider the potency of Dilaudid® (hydromorphone) when prescribing to elderly opioid naïve patients.
Dilaudid® 2 mg ˜ morphine 14 mg
Dilaudid® 8 mg ˜ morphine 56 mg
CASE #3: A 90 year old male came to ED with generalized weakness and black stool.
Lab: PTT = 51 Hg = 16.5 Hct = 50 Scr = 1.73 Estimated CrCl = 28mL/min
Dabigatran (Pradaxa®) 150mg po q12hr
(started a few days prior to admit)
Amlodipine 2.5 mg po daily
Rosuvastatin 5 mg po every other day
Propranolol 20 mg po bid
Temazepam 30 mg po prn bedtime
This patient has a reduced renal function and the manufacturer recommends giving dabigatran at the lower dose of 75 mg twice a day for patients with CrCl 15 – 30 mL/min.
ADVERSE DRUG REACTIONS
1st Quarter ADR Report 2011
The rate for the first quarter 2011 is 4%, higher than 3.5% of the 4th quarter 2010. Classes of medications most frequently associated with inpatient ADRs were analgesics, anti-infective, and anti-diabetic agents. Dilaudid® (hydromorphone) is the most frequently reported medication in the analgesic class. The two severity L2 Dilaudid ADR reactions were from a 2 mg dose in patients older than 70 years old. Hydromorphone 2 mg is approximately equivalent to 14 mg of morphine.
Severity L2 or greater ADR medications:
L2: Hydromorphone 2mg IM – respiratory arrest
L2: Hydromorphone 2mg IM – respiratory arrest
Physicians are reminded to consider the potency of Dilaudid® (hydromorphone). Initial dose for elderly opioid naïve patients should be less than 1 mg.
Alina Lopo, M.D., Ph.D.
Director, Pharmacy Services
Krist Azizian, Pharm.D.