·        Pantoprazole (Protonix), injection and oral, is the proton pump inhibitor of choice, with automatic substitution for omeprazole (Prilosecâ), rabeprazole (Aciphexâ),  Lansoprazole (Prevacidâ), and other oral proton pump inhibitors unless the physician has checked the dispense as written block.

Lanoprazole Solutabs, 15 mg or 30 mg, may be mixed with water and placed down a very small bore pediatric feeding tube. The granules do not clump or adhere to the tube.

Pantoprazole IV Criteria for use

·        Criteria for use of IV Proton Pump Inhibitors (PPIs) are list below.  If a patient does not meet criteria the pharmacist will call the physician and/or leave a chart note recommending conversion to oral therapy.

• Initial treatment of patients with active upper GI tract bleeding, until they can tolerate oral therapy, usually after three days of therapy.
• Initial treatment of patients with Zollinger-Ellison syndrome, until they can tolerate oral therapy
• Stress-ulcer prophylaxis for critical care patients
• Patients who require PPI therapy who can not tolerate oral or NG PPI therapy

·        Patients on IV proton pump inhibitors will have an order entered for the oral route allowing the nurse to use the oral route when the patient is tolerating oral therapy. Proton pump inhibitors may be given by the oral route if the patient does not have active gastrointestinal bleeding, malabsorption syndrome, short bowel syndrome, severe diarrhea, uncontrolled nausea and vomiting, continuous nasogastric suctioning, and is not at risk for aspiration. 

Papain / Urea / Chlorophllin Ointment

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

Pharmacy will autosubstitute oral Hectorol for injectable Hectorol, injectable Zemplar, and oral Zemplar at an equivalent dose in patients who can take oral medications. If the patient is unable to take oral use injectable Hectorol.

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

• Paxil CR and paroxetine immediate release are equally effective and tolerable; generic paroxetine will be autosubstituted for Paxil CR at the equivalent dose (80% of the Paxil CR Dose).

·        Pegfilgrastim (Neulasta^TM)  is non formulary.  It lacks adequate additional benefit for the hospitalized individual as compared to filgrastim (Neupogenâ) and is much more expensive.

·        Automatically substitute with filgrastim (Neupogenâ) 5mcg/kg/day, rounded to the closest vial size (300 mcg or 480 mcg) when pegfilgrastim (Neulasta^TM) is ordered for inpatients.

Pegfilgrastim OPIC Monitoring Form 6/06

Phenylephrine 50 mg / 250 ml

Phenylephrine 100 mg / 250 ml, Standard Concentration for Severe Hypotension

·        Posaconazole (Noxafil^®) suspension is recommended for formulary addition for the following FDA approved indications:

o       Posaconazole oral suspension, 105 ml with 40 mg/ml, is indicated for prophylaxis of invasive Aspergillus and Candida infections in patients 13 years of age and older who are at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with Graft versus Host Disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy

§        Hematopoietic stem cell transplant (HSCT) recipients with Graft versus Host Disease (GVHD): Posaconazole was not shown to be statistically superior to fluconazole

§        Hematologic malignancies with prolonged neutropenia from chemotherapy:  Posaconazole was shown to be statistically superior to fluconazole

o       Treatment of oropharnygeal candidiasis refractory to fluconazole or itraconazole. 

·        Pharmacy Monitoring

o       Pharmacy will ensure that orders are entered to be given with food to increase the bioavailability.

§        The package insert recommends each dose to be given with a full meal or liquid nutritional supplement such as Boost Plus.

§        Posaconazole’s prophylaxis should start 24 hours after the last anthracycline dose in patients receiving chemotherapy

o       Pharmacy will monitor for interacting drugs and notify the physician as needed.

§        Posaconazole should not be administered with rifabutin, phenytoin, and cimetidine due to a 50% decrease in posaconazole serum levels. (Note: other H₂ antagonist and PPIs do not interact)

§        Contraindicated with ergot alkaloids as ergotism may result; cisapride, pimozide (Orap), halofantrine (antimalarial), and quinidine due to increase serum levels of these drugs which may lead to increased QTc interval and torsades de pointes.

§        Cyclosporin and tacrolimus require dosage reductions as their levels are increased.

o       Patients allergic to itraconazole will probably react to posaconazole. Physicians will be contacted if patients are allergic to itraconazole.

o       Doses above 800 mg per day are not recommended as higher serum levels and AUC are not achieved.

o       A serum level is recommended 5-8 days after starting therapy to verify absorption. If levels are lower than 500 ng/ml a dosage increase, change in time of administration, or increased frequency of administration is needed.

Note: Voriconazole (Vfend)  200 mg q12 hours cost $60 per day for oral and  $199 per day for IV.

·        Orders for small volume potassium chloride infusions will be converted to the closest available premix concentration to give the ordered amount of potassium chloride using the table below. 

o       Example: 50 meq/500 ml over 5 hours peripheral will be converted to 10 meq/100 ml premix for 5 doses.

·        The base fluid for small volume potassium chloride infusions will be sterile water as the premixed bags contain sterile water for injection and have an osmolarity of 200-799 mOsmol/l depending on the concentration (10meq/100 to 20 meq/50 ml). Orders for other base fluids will be changed to the premixed bags. 

^*If potassium < 2.5 meq/liter and the patient is symptomatic 40 meq/hour may be administered to intensive care patients.  Hourly serum potassium determinations should be drawn to avoid severe hyperkalemia and/or cardiac arrest.

Symptoms of hypokalemia include: fatigue, malaise, generalized muscle weakness, respiratory failure, paralysis; EKG changes include T wave flattening or inversion, U waves, or ST segment depression, and arrhythmias.

 Small volume infusions of Potassium chloride are available from the pharmacy in premixed bags of:

10 meq/100 ml (Preferred peripheral concentration)

10 meq/50 ml (Preferred central concentration)

20 meq/100 ml (Cardiac monitoring required, peripheral or central use)

20 meq/50 ml (Cardiac monitoring required, central line only)

Recommended maximum dose should not usually exceed

• 10 meq/hour or 200 meq for a 24 hour period if the serum potassium level is greater than 2.5 meq/liter per product package insert
• 40 meq/hour or 400 meq for a 24 hour period if the serum potassium level is less than 2.5 meq/liter.

Protocol below approved by P&T/MEC approved 2001 at MRMC,

·        IV phosphate repletion should be limited to treatment of moderate to severe hypophosphatemia.

·        Mild to moderate serum phosphate levels may be treated with oral products.

·        When serum phosphate is > 1.5-2 mg/dl IV treatment may be switched to the oral route.

·        If serum potassium is > 3.5 meq/L sodium phosphate is recommended for IV treatment.

·        The use of lean body weight is recommended when calculating the dose.

·        Monitor serum phosphorus, calcium, magnesium, and potassium every six hours, along with blood pressure.

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