·        Calcitriol has an increased incidence of hypercalcemia and hyperphosphatemia when compared to doxercalciferol and paricalcitol.  Calcitriol will remain on formulary for use to increase calcium in post parathyroidectomy patients.

·      Pharmacy will auto substitute oral Hectorol for injectable Hectorol, injectable Zemplar, and oral Zemplar at an equivalent dose in patients who can take oral medications. Hectoral injection will be auto substituted for those who can not take oral.

Reference: K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

1 mcg of doxercalciferol inj. is approximately equivalent to 2.5 mcg of paricalcitol inj. or 0.75 mcg calcitriol inj.

Paricalcitol oral 72% bioavailable, doxercalciferol oral 42% bioavailable

• Calcium chloride injection (P&T review) will be available in the Pyxis stations in the OR, PACU, and ED, and will remain in the code carts.
• Calcium chloride is restricted to use in emergent situations and is best infused via a central catheter due to the risk of extravasation and tissue necrosis when infused peripherally.

• Calcium gluconate is the standard for intravenous supplementation. 

Dosing Information

• Intravenous supplementation calcium is used for severe and/or acute symptomatic hypocalcemia (serum calcium < 7.5mg/dL or ionized calcium < 0.9 mmol/L) when rapid correction is needed (see chart below). 
• Calcium gluconate or chloride have been used for patients with serum potassium above 7 milliequivalents/liter (mEq/L) and electrocardiographic (ECG) evidence of severe hyperkalemia
  • 1 g of calcium gluconate (10 ml of 10% solution) over 2 to 3 minutes with continuous ECG monitoring
  • 300 to 400 milligrams of calcium chloride (3 to 4 milliliters of 10% solution) over 2 to 5 minutes with continuous ECG monitoring.
  • If the patient is receiving digoxin calcium should be used with extreme caution. In this case 1 g of calcium gluconate in 100 ml of D5W infused over 20-30 minutes is recommended.

-      Severe hypocalcemia is defined as total serum calcium < 7.5mg/dL or ionized calcium < 0.9mmol/L

-        1g calcium chloride = 13.6 mEq calcium; 1g calcium gluconate = 4.56 mEq calcium

-        Maximum rate of injection should not exceed 0.8-1.5 mEq calcium per minute because of the potential risk for cardiac arrhythmias associated with rapid calcium infusion.

-        Since an IV bolus may only be effective for 2 hours or less, severe hypocalcemia may not be corrected with intermittent boluses.  A continuous infusion may be required.  Calcium levels should be monitored at least every 6 hours during the infusion and infusion rate adjusted to avoid recurrent symptomatic hypocalcaemia.  The underlying cause should be treated or long-term therapy started, and the IV infusion should be gradually tapered.

-        Hypocalcemia due to citrated blood transfusion can be treated by administering 1.35 mEq of calcium for each 100ml of blood transfused (1 g of calcium gluconate or 4.56 mEq per unit of blood).

-        Routine monitoring of serum calcium levels every 24-48 hours is recommended in the ICU setting.

-        The calcium should be diluted in dextrose and water or saline, because concentrated calcium solutions are irritating to veins

-     Concomitant hypomagnesemia must be corrected first in order to correct hypocalcemia.

• Calcium gluconate, (P&T review), is the standard for intravenous supplementation. See above for more detail on dosing

• Calcium chloride is restricted to use in emergent situations and is best infused via a central catheter due to the risk of extravasation and tissue necrosis when infused peripherally

Dialysis of Drugs Text 2006

Peritoneal Dialysis Text 2006

• Anidulafungin (Eraxis) is formulary. Caspofungin (Cancidas) and Micafungin are non formulary and should not be stocked. Please recommend Eraxis when ever you get an order for Cancidas or Micafungin.
  • Fluconazole is the drug of choice for esophageal candidiasis and hematopoietic stem cell transplant (HSCT).  It is also the primary agent for febrile neutropenia 400-800 mg/day, candidemia 400 mg/day, and other candida infections 400 mg/day.
  • Voriconazole is the drug of choice for aspergillus.

   

Advantages of anidulafungin over other echinocandins.

• Anidulafungin is not a substrate, inhibitor or inducer of cytochrome P450 enzymes. It has only one known drug interaction (cyclosporine), but anidulafugin’s does not require a dosage adjustment
  • Medications studied include rifampin, cyclosporine, tacrolimus, voriconazole, and amphotericin B
• Anidulafungin has the longest half-life (26 hours) and the lowest protein binding (84%) of the echinocandins.
• Anidulafungin is chemically degraded in the body and is not metabolized by the cytochrome P450 system
• Anidulafungin does not require dosage adjustment for liver or renal dysfunction
• Anidulafungin is less expensive than other echinocandins
• Anidulafungin provides higher free levels than caspofungin and micafungin
• Anidulafungin’s adverse effect profile appears to be better than other echinocandins
• Antifungal spectrums of echinocandins are equivalent.
  • Anidulafungin has a broad spectrum activity against Candida (including those strains that are resistant to polyenes and azoles), non-albicans strains and Aspergillus species. Potential synergy with azoles against Aspergillus has been demonstrated in vitro. It is inactive against Cryptococcus neoformans, Trichosporon spp., Zygomycetes and Fusarium. All echinocandins are less active against C. parapsilosis
• Anidulafugin is the only echinocandin that has been studied in a randomized control trial versus fluconazole in candidemia and other invasive candida infections (phase three clinical trial, not published)

* Patients with at least 1 dose of study drug and a positive culture for Candida species for a normally sterile site, clinical cure or improvement and documented or presumed microbiological eradication

** Patients with C. krusei (fluconazole not active), candida endocarditis, osteomyelistis, and meningitis were excluded from the study

Cephalexin or cephradine will be automatically substituted for cefadroxil depending on their availability and cost. The pharmacy buyer will determine which product, cephalexin or cephradine, is carried.

Recommendations for Surgical Prophylaxis: MEC Approved

·       Use 2 gm of cefazolin (Ancef) for patients weighing greater than 100 kg.

Auto-substitute ceftazidime for cefepime.  The spectrums and cost are similar including cost in renal impaired patients. 

Ceftazidime is automatically substituted for Cefoperazone.

Ceftriaxone is automatically substituted for cefotaxime except for treatment of intra-abdominal infections and neonatal infections.

Please review the table below for alternatives to cefoxitin/cefotetan when shortages occur (Cefoxitin Shortage: Recommended Alternatives 9/06).

• Patients with symptoms of CNS infections empirically, or evidence of CNS infections susceptible to ceftriaxone, should be given 2 gram doses of ceftriaxone at a dosing interval of every 12 hours.  Patients with gonococcal endocarditis may also require twice daily dosing.  Patients with endocarditis, febrile neutropenia, osteomyelitis, and Lyme disease should receive ceftriaxone 2 gram given daily.
• All other indications for ceftriaxone should be treated with 1 gram daily dosing.  Pharmacists will call the physician or leave a note for the physician recommending conversion to 1 gram daily unless the patient meets one of the above indications. If pneumococcal resistance is a concern Levaquin may be added and it covers atypical pathogens.

Safety Warning for Neonates (Letter from company, PI 5/07),  ASHP clarification

Cetriaxone should not be administered concurrently with calcium-containing solutions or products in newborns because of the risk of precipitation. Calcium containing solutions or products must not be administered within 48 hours of the last administration of ceftriaxone.

 *See above for times when ceftriaxone 2 gm per day is indicated

Non formulary,  ceftriaxone is automatically substituted except for surgical prophylaxis where cefazolin is recommended.

Cephalexin or cephradine will be interchanged depending on availability and cost. The pharmacy buy will determine which product is carried. 

Note cephalothin is no longer manufactured.

Loratadine (Claritinâ) and Claritin D 12 hour (5 mg with 120 of pseudoephedrine) are the P&T recommended formulary non-sedating antihistamines with automatic substitution for desloratadine (Clarinexâ) fexofenadine (Allegraâ 30, 60, 180 mg), Allegra Dâ (60 mg fexofenadine with 120 mg pseudoephedrine), Allegra D 24 Hourâ (180 mg fexofenadine and 240 mg pseudoephedrine), cetirizine (Zyrtecâ), and Semprex D (8 mg acrivastine with 60 mg pseudoephedrine). They will be stocked in the following dosage forms: Claritin 10 mg, Clartin D 12 hour, and as the syrup 1 mg/ml for pediatric patients.

 P&T/MEC APPROVED 11/2000, updated 3/21/07

*Note Claritin dosage in renal impairment, clcr < 30 ml/min, or hepatic failure: 2-5 years old 5 mg every other day, 6 years and older 10 mg every other day.

Physician Ordering Form

            Famotidine, the P&T preferred H₂ antagonist, will be automatically substituted for ranitidine, cimetidine, nizatidine, other H₂ when ordered by the IV or oral route unless the physician has checked the dispense as written block or the patient is allergic to famotidine.

Dosage Conversion:

Cimetidine                                                         Famotidine

            300 mg q6-8H                                       20 mg q12H

            300 mg q12-24H                                    20 mg q24H

            400 mg QHS                                         20 mg QHS

            400 mg BID                                           10 mg BID or 20 mg QHS

            400 mg QID                                          20 mg BID

            800 mg QHS                                         40 mg QHS

            800 mg BID                                           20 mg BID

Ranitidine

            50 mg q6-8H IV                                     20 mg q12H

            50 mg q12-24H IV                                 20 mg q24H

            150 mg QD                                           20 mg QD

            150 mg BID                                           20 mg q12h

            300 mg QHS                                         40 mg QHS

Nizatidine

            150 mg QD                                           20 mg QD

            150 mg BID                                           20 mg BID

            300 mg QHS                                         40 mg QHS

·        Do not substitute Levaquin when ciprofloxacin is used for osteomyelitis.

( ) are oral doses of ciprofloxacin

Substitute 2000 ml of Colytely and 4 bisacodyl 5 mg delayed release tablets for prescriptions written for Halflytely.  2000 ml of Colytely has the same active ingredients as 2000 ml of Halflytely.  Mix 4 liters of water with Colytely and then dispense 2 liters to patient.  Throw out remainder.

Oral administration: Swallow all four bisacodyl delayed release tablets with water (do not chew or crush).  Wait for a bowel movement (or a maximum of 6 hours) then drink 1 glass (8 oz) of the solution every 10 minutes.  Drink all the solution.  

• Accuzyme and Ethezyme 830 are equivalent products containing identical amounts of active ingredients. Pharmacy will stock and autosubstitute the most cost effective product which is Ethezyme 830.
• Panafil and Ziox Ointment are equivalent products containing identical amounts of active ingredients. Pharmacy will stock and autosubstitute the most cost effective product which is Ziox.

Cholestyramine 3.5% in Aquaphor 420 g

Bethanechol Oral Suspension 5 mg/ml 30 ml

Baclofen Oral Suspension 5 mg/ml 30 ml

Clonazepam Oral Suspension 0.1 mg/ml 30 ml

Clonindine Oral Suspension 0.1 mg/ml 30 ml

Captopril Oral Suspension 0.75 mg/ml 50 ml

Diltiazem Oral Suspension 12 mg/ml 30 ml

Enalapril Oral Suspension 1 mg/ml 30 ml

Famotidine Oral Suspension 8 mg/ml 50 ml

Glycopyrrolate Oral Solution 0.2 mg/ml 20 ml

Greer's Goo (Modified) 30 g

Hydrochlorothiazide Oral Suspension 5 mg/ml 30 ml

Ibuprofen Suppository 100 mg and 400 mg

Indomethacin Suppository 25 mg and 100 mg

Ketoconazole Oral Suspension 20 mg/ml 30 ml

Ketamine Oral Solution 100 mg/ml 5 ml

Lansoprazole Oral Suspension 3 m/ml 30 ml

Metronidazole Oral Suspension 50 mg/ml 30 ml

Morphine Cream 0.15% 60 g

Morphine Oral Solution 0.4 mg/ml 10 ml

Nipple Ointment (Dr. Jack Newman's Formula) 134 g

Omeprazole Oral Suspension 2 mg/ml 30 ml

Phenylephrine Nasal Solution 0.125% 30 ml

Potassium Chloride Oral Solution 2 meq/ml 10 ml

Rifampin Oral Suspension 25 mg/ml 60 ml

Sildenafil Oral Suspension 2 mg/ml 30 ml

Sodium Chloride Oral Solution 4 meq/ml 30 ml

Spironolactone Oral Suspension 5 mg/ml 30 ml

Total Hip Solution for Irrigation 500 ml

Tripple Butt Paste  90 g

Ursodiol Oral Suspesnsion 20 mg/ml 30 ml

Vancomycin Oral Solution 50 mg/ml 40 ml

Water (Aqua) 20% in Aquaphor 60 g

·        Conivaptan is non formulary

o       Conivaptan is FDA approved for use in acute dilutional euvolemic hypotonic hyponatremia

·        3% Sodium Chloride injection it to be recommended as an alternative and may be used for the following conditions

• severe symptomatic euvolemic hypotonic hyponatremia when serum sodium is less than 125 mEq/l
• severe symptomatic hypervolemic hypotonic hyponatremia with loop diuretics when serum sodium is less than 125 mEq/l
• severe symptomatic hypovolemic hypotonic hyponatremia  when serum sodium is less than 125 mEq/l

*severe symptomatic hypotonic hyponatremia : confusion, ataxia, seizures, obtundation, coma, respiratory arrest

·        Dosing Tools for 3% Sodium Chloride Injection and a hyponatremia algorithm are available for or the physicians and pharmacists.

·        Patients will meet the following criteria to receive conivaptan

o       Serum sodium less than 130 mEq/l

o       Plasma osmolality less than 290 mOsm/kg H20

o       Euvolemic hyponatremia (absence of pitting edema or ascites)

·        Conivaptan infusions should not exceed 96 hours per the package insert

·        Patients receiving conivaptan will not have any of the following exclusion criteria:

o       Clinical evidence of dehydration or volume depletion

o       Hypervolemic hypotonic hyponatremia (CHF, cirrhosis with ascites, nephrotic syndrome, acute or chronic renal failure)

o       Contraindicated in hypovolemic hypotonic hyponatremia (burns, GI fluid losses, Addison’s disease)

·        Monitoring will include the following:

o       Serum sodium every 2 hours until the patient is asymptomatic then every 4-8 hours

o       Urine and serum osmolality and electrolytes (sodium and potassium) every 4-6 hours

§        Serum sodium should not increase any faster than 12 mEq/l in 1^st  24 hours and less than 20 mEq/l in 1^st  48 hours for acute hyponatremia, and less than 12 mEq/l 1^st 24 hours and less than 18 mEq/l 1^st 48 hours for chronic hyponatremia.

o       Urine volume

o       IV site for signs of phlebitis

·        Conivaptan injection should be infused into a large vessel and the IV site should be changed every 24 hours.

Please see the Hyponatremia page for articles on hyponatremia