Transcript Drug Information Resources by Mr. Barcelona

Drug Information Resources:
An Overview
Rob Barcelona, PharmD, BCPS
Clinical Pharmacy Specialist, CICU
Objectives
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Utilize drug information sources available at
University Hospitals Case Medical Center
Describe UHCare functionality as it relates
to Pharmacy Services
List dosing and monitoring of specific
patient populations and medications
Pharmacy Clinical Resources
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Clinical on Call Pager 30558
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Rotates among all clinical specialists
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CICU: Rob Barcelona 30274
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SICU: Wes Bush 30393
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Infectious Diseases: Ron Cowan 31960
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NSU: Jason Makii 37884
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MICU: Andreea Popa 31503
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Transplant: Raelene Trudeau 38643
Tertiary Resources
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Condense, digest, and summarize information from primary
and other resources
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Provide rapid access to information
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Limitations:
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Currency of the resource (i.e., how long ago was that
information published?)
Accuracy of information
Incompleteness (e.g., over the counter medications not
contained)
Examples include MICROMEDEX®, textbooks, UpToDate®,
review articles, and encyclopedias
UH Case Medical Center
Specific Resources
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Anticoagulation Therapy and Anticoagulation
Reversal
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Adult IV Medication Guidelines
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Antimicrobial Usage
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Restricted Medications
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Drug Specific Guidelines (e.g., antibiotic locks,
IVIG, etc.)
Where can resources be
found?
Lexi - Comp® Online™
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> 4,000 monographs of medications and nearly 30 fields with
each drug monograph
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Both text and on-line in UpToDate®
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Information includes:
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Dosing
Pharmacology
Pharmacokinetics
Pregnancy/lactation considerations
Adverse reactions
Drug interactions
Nutrition/herb interactions
MICROMEDEX®
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Available from UH Pharmacy website:
http://intranet.uhhs.com/pharmnet/
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Facts on drugs, teratogenicity, toxicology, and alternative medicine
On-line version of the Physicians’ Desk Reference
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Very comprehensive and contains the following:
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Dosing
Pharmacology
Pharmacokinetics
Drug interactions, cautions
Clinical applications
References
Limitations: difficulty in finding information and frequency of updates
UHCMC Adult IV Guidelines
The Internet
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Many resources available using the Internet
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Should be utilized only if other databases or references fail to
provide any valid information
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Limitations include lack of quality control and imprecise
searching that may lead to many undesired “hits”
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Information found may not come from a verifiable source and
potentially could be inaccurate, possibly leading to patient
harm
If UHCMC has guidelines, protocols, or ordersets, use those
developed by UHCMC staff
Conclusion
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Variety of resources are available
Familiarize yourself with the on-line
resources, databases, and textbook
references in finding drug information
If all else fails, ask your pharmacist
More on Resources …
and EMR stuff
Andreea Popa PharmD, BCPS
MICU Clinical Pharmacy Specialist
MICU and other resources
Why does the pharmacist
call you???
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Invalid order/need
further clarification
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Bad Orders
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Non-formulary drug
Renal Dosing
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Drug interactions
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Restricted drug
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Drug on short
supply
Duplicate orders
What happens after you place
an order?
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Pharmacist actively looks
for the orders on the
different units (2-3 units
per pharmacist; 60 -100
pts)
Looks at all medication
orders for that patient,
diagnosis and pertinent
labs
User Schedule Ordering
Verification Screen
Order verification
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If no questions order is verified and a label prints
 technician prepares drug  pharmacist checks
drug again  drug leaves for delivery to respective
nursing units
Controlled substances, emergency meds 
OMNICELL
If need something urgent: call area pharmacist
EMR issues…..
 Standard administration times
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QD: 9:00
BID: 09:00; 21:00  12 hours off drug
TID: 09:00; 14:00; 21:00  12 hours off drug
QID: 09:00; 13:00; 17:00; 21:00  12 hours off drug
– Q 24, Q 12, Q 8, Q 6: Timing of these is dependent
on ordering/nursing administration; subsequent doses
are automatically scheduled based on the first dose
Routine, now, stat and
time critical….
Routine, now, stat and
time critical….
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Amlodipine 5 mg daily
– Routine: if passed 9 am, first dose schedule for RN to give
next day at 9 am
– (99% of ALL medication orders defaulted to routine)
– Now: one dose will be sent now and than next day at 9 am
– STAT: generates a red flag for the pharmacist  urgent
order  first dose now then next day at 9 am (regardless
what time now, could be 9 PM)
– TIME CRITICAL: you select the time for the 1st dose and the
subsequent doses will be automatically scheduled q 24 hours from
the time of first dose (if ordered Q24H)
Routine, now, stat and
time critical….
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Cipro 400 mg IVPB q 24 hours
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Routine: scheduling of first dose related
to ordering time
Now and Stat: create a yellow/red
flag for verification
TIME CRITICAL: you select the time for the 1st
dose and the subsequent doses will be
automatically scheduled q 24 hours from the time
of first dose!
Ordering IV Heparin:
Loading dose, infusion, repeat bolus
Pearls:
1. Most of lab work is pre-checked
2. If running continuous infusion, ALWAYS order the repeat boluses
3. Open Dosing: Never order the open dosing unless Heme/Onc or
Vascular Medicine involved
Electrolyte Ordering
Units, units…….
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MMF grams
vs.
milligrams
Premixed antibiotics,
customizing the dose
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So, how do I
order:
– 1,000 mg
– 500 mg or
– 2,000 mg of
vancomycin
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Restricted Ordersets and
REMS
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Pulmonary
Hypertension
Hemodialysis/CVVH
Chemotherapy
Dofetilide (Tikosyn)
Non-formulary
drugs
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REMS (Risk
Evaluation and
Mitigation Strategy)
– > 200 REMS Drugs
– > 30 Drugs have
Elements to Assure
Safe Use
– > 20 REMS Drugs
require informed
consent
Other Ordersets…
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Admission Ordersets
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Pneumonia Orderset
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Most patients do not need an IV PPI…
Antibiotics default to routine
Antibiotic selections in alphabetical order vs.
preferred
Tylenol OD
Generic Questions
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When calling pharmacy for drug info
questions:
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4.
Ask to talk to a pharmacist
Tell them who you are/contact info
Give them patient name and location
Give them synopsis of case and relevant
clinical information to get most appropriate
answer (what you are treating,other drugs,
renal function, etc.)
Drug Dosing in Special
Populations
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Renal Failure
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Intermittent vs Continuous Hemodialysis
vs Ultrafiltration
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Obese/Low weight
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Geriatrics
Estimating Renal Function
Cockcroft and Gault equation:
CrCl = (140 - age) x IBW / (Scr x 72)
(x 0.85 for females)
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IDMS-traceable MDRD Study Equation
Conventional units
GFR (mL/min/1.73 m2) = 175 x (Scr)-1.154
x (Age)-0.203 x (0.742 if female) x (1.212 if
African American)
Drug Levels
Drug
Timing
Notes
Vancomycin
Trough 30 minutes prior to 4th dose
Individualized dosing for
patients with renal
dysfunction
Immunosuppressants
Trough levels within 1 hour of dose
(0600, 1800)
Contact Transplant Service
for guidance
Phenytoin
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Trough concentration
Within 2-3 days of initiation
Within 1 hour of load to
determine maintenance or
need to reload
NO
need for daily levels
Order free levels in patients
with renal failure and/or low
albumin
Aminoglycosides
Traditional:
trough with 3rd dose
and peak 30 minutes after end of
infusion
Extended: trough with 2nd dose
Depends on traditional vs.
extended dosing
Digoxin
Trough concentration
Must be drawn at least 6
hours post-dose
Heparin assay, Lovenox
4 hours post-3rd dose
Use in extremes of body
weight, pregnancy, renal
dysfunction
Questions?????