·        Meperidine is not recommended for patients receiving hemodialysis, CAVH, and CAPD due to accumulation of normeperidine.

·        Meperidine is not recommended for IV/IM use for postoperative pain control, as its duration of action is short. Morphine or hydromorphone are recommended as they have a longer duration of action.

·        Meperidine is not recommended for use in patients > 65 years old or in patients with renal dysfunction (creatinine clearance < 50 ml/min). Renal clearance of normeperidine is equivalent to creatinine clearance.

·        Meperidine is not recommended as first line opioid therapy

·        Appropriate uses for meperidine are:

·        Post-anesthesia, drug (amphotericin), or blood-induced shivering

·        Management of brief procedure pain

·        Oral meperidine is not recommended for formulary inclusion due to high first pass metabolism, requiring a dose 3 times higher than injectable for equivalent analgesia. Conversion to normeperidine is increased when meperidine is administered by the oral route.

·        Agency for Health Care Policy and Research recommends that oral meperidine not be used for pain management and that injectable meperidine be restricted to patients who have a true allergy or intolerance to other opioids.

·        Meperidine inhibits serotonin reuptake, resulting in increased CNS serotonin, particularly in the brainstem.

The pharmacist will check the patient’s indication and renal function before making the substitution.

As the dosage and frequencies may not be the same the pharmacist should write an order in the chart when changing to Primaxin.

Below is the package insert

• 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

Levofloxacin (Levaquin) is the preferred fluoroquinolone and will be automatically substituted for other fluoroquinolones (ciprofloxacin, ofloxacin, and moxifloxacin), unless the physician has checked the dispense as written block or when Cipro is being used for osteomyelitis.

Pharmacists will check the drug’s indication and patients renal function to ensure appropriate substitution and renal dosing adjustment.