Pharmacy & Therapeutics Committee News May 2013 New Automatic Substitution: Ipratropium/Albuterol Inhalation Combivent metered dose inhaler (MDI) is being changed to a propellant free spray which is not compatible with mechanical ventilators. Less than a one week supply of the MDI inhalers (old format) exist in SJH Inventory. A recent DUE revealed only 2-10 doses of the 100 dose canister are administered before it is discontinued. The remaining doses are wasted at great expense. Based upon this information, the following was approved by the P&T fast-track process: For all patients nebulized albuterol/ipratropium (Duoneb) will be automatically substituted for any Combivent order. This will solve the issue of ventilator compatibility and because each dose is an individual unit, there will be no waste. This also will save SJH a very large sum of money while maintaining care of the patient and benefit of the drug. If Ordered Interchange
Combivent (Ipratropium/Albuterol) Metered Dose Inhaler DuoNeb 3ml nebule (Ipratropium/Albuterol) Combivent (Ipratropium/Albuterol) Respimat
DuoNeb 3ml nebule (Ipratropium/Albuterol)
Intravenous Multivitamin Injection (MVI--adult) Shortage There is a nationwide shortage of IV Multivitamins (Adult). In an effort to avoid complete exhaustion of MVI inventory, SJH will follow ASPEN shortage management guidelines (administration of MVI only 3x/week) while the supply remains tenuous. Effective immediately, MVI will be added into TPNs made on M-W-F. No other days will be accommodated because this will increase waste. This automatic reduction will remain in effect until the IV MVI supply becomes stable. Canagliflozin (Invokana) PO is Non-formulary Canagliflozin is FDA approved as an adjunctive therapy in patients with type 2 diabetes mellitus. In controlled clinical trials, the adjusted mean HgbA1c difference vs placebo was -1.16% (monotherapy), -0.77% (combined with metformin) and -0.73% (combined with insulin). Significant safety issues that may impact hospitalized patients include symptomatic hypotension, increased serum creatinine with decreased GFR and hyperkalemia. Patients at increased risk for hypotension include the elderly, especially if taking diuretics and/or medications that interfere with the renin-angiotensin-aldosterone systems or patients with low diastolic blood pressure. Patients with hypovolemia are at greater risk for canagliflozin induced renal changes and hyperkalemia is more likely to occur in patients taking an ACEI or ARB. Canagliflozin also causes UTI (5.9%), genital mycotic infections (female 11.4%; male 4.2%) and vulvovaginal pruritis (3%). Based upon this information, the P&T Committee approved the following: 1. Non-formulary, not stocked, no patient’s own medication. 2. The pharmacist will automatically discontinue the order. Lovenox (enoxaparin) and Renal Impairment Enoxaparin is cleared by the kidneys. There is a linear relationship between anti-Factor Xa plasma clearance and creatinine clearance which indicates decreased clearance of enoxaparin in patients with reduced renal function. Area under the curve increases significantly in patients with creatinine clearance less than 30ml/min and in dialysis patients. Renally impaired patients are at greater risk of serious bleeding when exposed to enoxaparin. Based upon FDA information and medical literature, the P&T Committee has re-affirmed the following Hospital Policy: Patients with a calculated creatinine clearance less than 10ml/min (Cockcroft-Gault, not eGFR), or patients on dialysis (CRRT, PD, HD) or patients in acute renal failure should be managed with heparin, NOT enoxaparin. Automatic Substitutions The following miscellaneous automatic substitutions were approved to increase efficiency, decrease waste and inventory costs and will be performed by the pharmacist. If Ordered Interchange
Folbee; Folbee Plus; Diatx; Foltx; Nephrovite
Or similar vitamins Niferex 150; Ferrex 150; Ferrex 150 Forte
Ferrex 150 Forte Plus; Ferrogel; Slow Fe; Hematinic Forte or Any long acting iron supplement Docusate 50mg
For more information on Pharmacy & Therapeutics Committee actions, please contact Karen Whalen, Drug Information Pharmacist 448-6519.
Board of Trustees appoints Mike Allegra as UTA General Manager. John Inglish assumes new role as Chief Executive Officer and Bruce Jones assumes expanded role as General Counsel and President of Government Resources. The Boa rd of Trus tees of the Utah Transit Authori ty (UTA) is pleased to announce that Michael Allegra will succeed John Inglish as general manager of UTA. Effecti ve toda y,
ANALES DE LITERATURA CHILENAAño 2, Diciembre 2001, Número 2, 103-119EL REALISMO ARTÍSTICO DE LA HECHIZADA Muy bien este trabajo pudo admitir otras maneras de ser presentado al lector. Sin embargo, nuestra percepción de la novela del Fernando Santiván nos sugiere laimagen de una fuerte unidad en la concepción de esta obra y un estrecho vínculo conel momento histórico de su publicación.