| GENERIC NAME |
|
| Calcitriol |
Calcitriol is the preferred
vitamin D analog (P&T review), for use in post parathyroidectomy patients (to prevent
hypocalcemia). All other patients will be automatically converted to
doxercalciferol oral or doxercalciferol injection for those who can not take
oral.
·
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.
|
Dosage Equivalence (mcg) |
|
Calcijex (calcitriol) Injection |
Zemplar (paricalcitol) Injection |
Zemplar (paricalcitol)
Oral |
Hectorol (doxercalciferol) Injection |
Hectorol Oral
(doxercalciferol) |
|
0.2 |
0.7 |
1 |
0.3 |
0.5 |
|
0.4 |
1.4 |
2 |
0.6 |
1.5 |
|
0.75 |
2.5 |
4 |
1 |
2.5 |
|
1.5 |
5 |
8 |
2 |
5 |
|
2.25 |
7.5 |
10 |
3 |
7.5 |
|
3 |
10 |
14 |
4 |
10 |
|
3.75 |
12.5 |
18 |
5 |
12.5 |
|
4.5 |
15 |
20 |
6 |
15 |
|
5.25 |
17.5 |
24 |
7 |
17.5 |
|
6 |
20 |
28 |
8 |
20 |
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 |
-
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.
|
Condition |
Calcium Salt
|
Intermittent Dosage |
Continuous Infusion Dosage |
|
Mild to moderate
hypocalcemia, asymptomatic and unable to take oral calcium |
Gluconate |
1-2 g (4.56-9.12 mEq)
in 100 ml D5W or 0.9% NaCl over 30-60min; may repeat every 6 hrs prn |
NA |
|
Severe
hypocalcemia, symptomatic |
Gluconate (preferred)
Or
Chloride |
3 g calcium
gluconate
Or
1 g calcium
chloride (13.6 mEq) over 10 minutes; may repeat prn |
NA |
|
Severe
hypocalcemia, symptomatic; refractory to intermittent bolus doses |
Gluconate (preferred)
Or
Chloride |
Not applicable |
0.03-0.12 g per hour
of elemental calcium
calcium gluconate
(0.336-1.32 g per hour)
Or
calcium chloride
(0.112-0.441 g per hour)
|
|
Severe
hyperkalemia with electrocardiographic evidence of severe
hyperkalemia |
Gluconate (preferred) |
1 g of calcium
gluconate (10 ml of 10% solution) over 2-3 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 Injection |
- 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
|
|
Calfactant |
Calfactant (Infasurf)
Dosing |
|
CAPD |
The follow adobe files may be found on the
http://www.nephrologypharmacy.com/ web site
Dialysis
of Drugs Text 2006
Peritoneal Dialysis Text 2006 |
| Caspofungin |
Removed from formulary, use anidulafungin,
P&T review
- 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)
|
Efficacy Analysis: Global Success
(MITT)*
in Patients with Candidemia and other Candida Infections**, Package Insert |
|
Time Point |
Eraxis
200 mg LD, 100 mg/day
N=127 |
Fluconazole
800 mg LD, 400 mg/day
N=118 |
Treatment Difference %, (95% C.I) |
|
End of IV Therapy |
75.6% |
60.2% |
15.4% (3.9, 27) (SS) |
|
End of IV Therapy (candidemia) |
75.9% (88/116) |
61.2%
(63/103) |
14.7(2.5,26.9) (SS) |
|
End of All Therapy |
74% |
56.8% |
17.24% (2.9, 31.6) (SS) |
|
2 Week Follow-up |
64.6% |
49.2% |
15.4% (0.4, 30.4) (SS) |
|
6 Week Follow-up |
55.9% |
44.1% |
11.84% NS |
|
Overall Study Mortality |
22.8% |
31.4% |
NS |
|
Mortality During Study Therapy |
7.9% |
14.4% |
NS |
|
Mortality Attributed to Candida |
1.6% |
4.2% |
NS |
* 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
|
| Cefadroxil |
Autosubstitute with
Cephradine or Cephalexin
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.
|
Cefadroxil Ordered |
Cephradine or Cephalexin Substitute |
|
500 mg q 12h |
500 mg q6h |
|
1 gm q12h |
1 gm q6h |
|
Commonly Recommended Adult Doses |
Cephalexin
|
Cephradine |
|
Usual:
250 mg-1 gm q 6H |
Usual:
500mg q 6H-1g q 6H |
|
Strep pharyngitis,
skin, uncomplicated cystitis:
500mg q 12H |
Uncomplicated
pneumonia, skin, UTI:
500 mg q 6H
|
|
Severe:
500 mg q 6H |
Severe:
500mg –1 g q 4h |
|
Cefadroxil |
Cephradine |
|
UTI:
500 mg q 12H- 1g q 12H |
Usual:
500mg q 6H-1g q 6H |
|
Skin:
500 mg q 12H |
Uncomplicated
pneumonia, skin, UTI:
500 mg q 6H |
|
|
Severe:
500 mg-1g q 4H |
|
| Cefazolin |
Surgical Prophylaxis
Recommendations for Surgical Prophylaxis: MEC
Approved
·
Use 2 gm of cefazolin (Ancef) for
patients weighing greater than 100 kg.
|
| Cefepime |
Autosubstitute with
Ceftazidime
Auto-substitute ceftazidime
for cefepime. The spectrums and cost are similar including cost in renal
impaired patients.
|
Cefepime Ordered |
Substitute Ceftazidime |
|
0.5 gm q12h |
0.5 gm q8h |
|
1
gm q12h |
1
gm q8h |
|
2
gm q12h |
2
gm q8h |
|
2
gm q8h |
2
gm q8h |
|
Adult Dosage |
|
Cefepime
Clcr
(ml/min) |
Cefepime Dosage |
Cost
per day |
Ceftazidime
Clcr (ml/min) |
Ceftazidime
Dosage |
Cost per day |
|
> 60 |
0.5-2
gm q8-12h |
$12.54-74.37 |
> 50 |
0.25
- 2 gm q8-12h |
$7.48-44.88 |
|
30 to
60 |
0.5-2
gm q12-24h |
$6.27-49.58 |
31 to
50 |
1 gm
q8-12h |
$14.96-22.44 |
|
11 to
29 |
0.5-2
gm q24h |
$6.27-24.79 |
16 to
30 |
1-1.5
gm q24h |
$7.48-14.96 |
|
< 11 |
0.25–1 gm q24h |
$6.27-12.49 |
6 to
15 |
0.5-0.75 gm q24h |
$3.74-7.48 |
|
|
|
|
<= 5 |
0.5-0.75 gm q48h |
$1.87-3.74 |
|
Hemodialysis |
0.25-1 gm q24h after dialysis |
|
|
0.5
gm q48h & 1 gm after dialysis on dialysis days |
|
|
Peritoneal dialysis |
0.5-2
gm q48h |
|
|
Loading dose 1 gm
Maintenance dose 0.5 gm q24h |
|
|
Adult Dosage Normal Renal Function |
|
|
|
|
Cefepime |
Ceftazidime |
|
Mild to Moderate uncomplicated or complicated UTI |
0.5-1 gm q12h |
0.5
gm q8-12h |
|
Severe uncomplicated or complicated UTI |
2
gm q12h |
1
gm q8h |
|
Moderate to Severe pneumonia |
1-2
gm q12h |
1-2
gm q8h |
|
Moderate-Severe Skin & Skin Structure |
2
gm q12h |
1-2
gm q8h |
|
Empiric Therapy for febrile neutropenia |
2
gm q8h |
2
gm q8h |
|
Cefepime Ordered |
Ceftazidime Substitute |
|
0.5 gm q12h ($12.54/day) |
0.5 gm q8h ($11.22) |
|
1
gm q12h ($25/day) |
1
gm q8h ($22.44) |
|
2
gm q12h ($49.59/day) |
2
gm q8h($44.89) |
|
2
gm q8h ($74.38/day) |
2
gm q8h ($44.89) |
|
| Cefoperazone |
Autosubstitute with
Ceftazidime Ceftazidime is
automatically substituted for Cefoperazone.
|
Cefoperazone Ordered |
Ceftazidime Substitution |
|
1 gm q12h |
1 gm q12h |
|
2 gm q12h |
2 gm q12h |
|
2 gm q8h |
2 gm q8h |
|
2 gm q6h |
2 gm q8h |
|
4 gm q6h |
2 gm q8h |
|
Common Adult
Doses |
|
Cefoperazone |
Ceftazidime |
|
Normal:
1-2 g q 12H |
Uncomplicated UTI:
500 mg q 8-12H |
|
|
Uncomplicated
pneumonia or mild skin infection:
0.5-1g q 8H
|
|
|
Bone /Joint:
2 g q 12H |
|
Severe: (6-12 gm perday)
1.5-4g q 6-12H |
Severe:
2g q 8H |
|
| Cefotaxime |
Autosubstitute with
Ceftriaxone
Ceftriaxone is automatically substituted for cefotaxime except for treatment of intra-abdominal infections
and neonatal infections.
|
Cefotaxime Ordered |
Ceftriaxone |
|
1 gm q12h |
0.5 gm q24h |
|
1 gm q6h |
1 gm q2 | |
|
