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MEPERIDINE INJECTION PCA with meperidine doses greater than 10 mg/kg/day is not recommended or therapy for longer than 72 hours in patients with normal renal function. 

        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.

MEPERIDINE INJECTION,  PCA  300MG/30ML
MEPERIDINE SYRUP
MEPERIDINE TABLET
Meropenem Meropenem is non-formulary, autosubstitute with Imipenem/Cilastatin in patients with CrCl >30

The pharmacist will check the patientís 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

 

 

Micafungin Micafungin is Non Formulary, use anidulafungin
  • 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 anidulafuginís 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
  • Anidulafunginís 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

 

Monoclonal Antibodies P&T/MEC allow Chemotherapy, monoclonal antibodies, and IVIG orders to be rounded up or down by 5% to minimize wastage.
Moxifloxacin Autosubstitute with Levofloxacin

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 drugís indication and patients renal function to ensure appropriate substitution and renal dosing adjustment.

Dosage Recommendations Per Package Insert

 

Levofloxacin Auto Substitution

Moxifloxican Ordered

Acute Bacterial Exacerbation of Chronic Bronchitis

500mg Q24H x 5-7 days

400 mg Q24H

Acute Bacterial Sinusitis

750mg Q24H 10-14 days

400 mg Q24H

Community Acquired Pneumonia

750mg Q24H x 5 days

400 mg Q24H

Nosocomial Pneumonia

750 mg Q24H x 7-14 days

 NOT INDICATED

intra-abdominal

Do not auto substitute. Call the physician and recommend 750 mg Q24H (plus metronidazole 500 q6h)

400 mg Q24H

Uncomplicated UTI

250mg Q24H x 3 days      

 NOT INDICATED

Complicated UTI

250mg Q24H x 10 days

 NOT INDICATED

Acute Pyelonephritis

250mg Q24H x 10 days

 NOT INDICATED

Chronic Bacterial Prostatitis

500 mg Q24H x 28 days

 NOT INDICATED

Uncomplicated Skin & Skin Structure Infection

500 mg Q24H 7-10 days

400 mg Q24H

Complicated Skin and Skin Structure Infection

750 mg Q24H 7-14 days

400 mg Q24H

 

Methylprednisolone sodium succinate In the event of brand name product shortage, generic product may be diluted with sterile water for injection as it is extremely water soluble.
   

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