Glenn Irani,M.D.

PHARMACY AND THERAPEUTICS NEWSLETTER

VOLUME 5.1 March 2,000 Susan Wee, Pharm.D.,EDITOR
PHARMACY AND THERAPEUTICS COMMITTEE ACTIONS

Formulary Additions:
Name: Synercid" 500 mg vial
Generic name: Quinupristin/dalfopristin
(See New Drug on the following section)

Non-formulary request:
Tamiflu was not added to the formulary. All orders for Tamiflu require a
non-formulary request form to be forwarded to the department of pharmacy.

Formulary Deletion:
Disopyramide (Norpace & Norpace CR"), Tocainide (Tonocard"), Betaxolol (Kerlone") Penbutolol (Levatol"), Pindolol (Visken"), Timolol (Blocadren"), Acebutolol (Sectral"), Potassium extended release 8 mEq (Slow K), Potassium Chloride powder (K-Lor") were deleted from the formulary based on low usage.
Please use:
Micro-K 8mEq for Slow-K"
KCl liquid for K-Lor"

POLICY AND PROCEDURES
Vancomycin Order Form
Starting March 1st, ALL vancomycin orders must be written on the Vancomycin
Order Form. Hemodialysis and peritoneal dialysis usage are the exceptions.
After initial audit of the Vancomycin Order Forms, the following recommendation
was made regarding the use of the form. Write the dose and the frequency of vancomycin.
Complete the form for renewal and transfer vancomycin order. Complete the appropriate section of the form. e.g for suspected penicillin resistant pneumonia, complete the "Empiric" section and not the "Treatment section".

URGENT DRUG NEWS!
Methylprednisolone IV (Solu-Medrol") is unavailable from the manufacturer, Pharmacia & Upjohn. This shortage is projected to last till the end of April 2000. If the patient is able to take other oral medication or if the patient has an NG tube, please prescribe oral predisone. The conversion factor to use is 1.25. For example, Solu-Medrol" 40mg IV is equivalent to prednisone 50mg tablet. For NPO patients, dexamethasone IV is an alternate agent. The conversion factor to use is 0.2. For example, Solu-Medrol" 40 mg IV is equivalent to dexamethasone 8 mg IV. The Pharmacy and Therapeutics Committee chairman has approved a temporary automatic substitution policy until Solu-Medrol" is available from the
manufacturer.

New Drug: Synercid"(quinupristin/dalfopristin)
Synercid" is the first of a new class of antimicrobial agents known as streptogramins. Both agents are bacteriostatic when used in combinations; they are synergistic and become bactericidal for some organisms. The Pharmacy and Therapeutics Committee approved this antibiotic with the restriction to be prescribed by infectious disease specialists. Indication: Synercid" is indicated for the treatment of serious or life-threatening infections associated with vancomycin-resistant Enterococcus faecium (VREF) bacteremia. The serum concentration of Synercid" at therapeutic dose does not reach the MIC of vancomycin-resistant Enterococcus Faecalis. Therefore Synercid" is not recommended for the treatment of infections by the vancomycin-resistant Enterococcus faecalis. Synercid" is also active against Methicillin resistant Staphylococcus aureus. It would only be an alternate agent for treatment of infection associated with MRSA in patients who are allergic to vancomycin.
Dose: 7.5 mg/kg q8hr for VREF 7.5 mg/kg q12hr x 7 days for skin and skin structure infections. Older pediatric patients (>16years) used the same doses in clinical studies. No adjustment of dose needed for renally impaired patients or geriatric patients. Patients with
hepatic dysfunction may require a dosage reduction. Pharmacology: Synercid" works by rreversibly binding to the 50S and 70S ribosomes, which results in the inhibition of protein synthesis. Precautions: Venous irritation may occur following intravenous administration of
Synercid". Dilute 500mg in at least 250ml of 5% dextrose to minimize venous irritation.
Adverse Drug Reaction: Arthralgia and myalgia may occur, and may be prevented by decreasing the frequency of administration to every 12 hours. Nausea, diarrhea, vomiting, rash, and hyper-bilirubinemia also may occur.

Adverse Drug Reaction Winners:

Tarzana: George Merritt, CC (Medical Records)
Encino: Linda Brown, Pharm. D. (Pharmacy)
The winners received $50.00 each.


ADVERSE DRUG REACTIONS:
The ADR reports for 1999 were 279 (1.98%). This is an increase compared to the 180 events (1.1%) of 1998. The national benchmark is 6%. There were 4 severe reactions. The first reaction was a cerebral hemorrhage in the previous stroke site in a patient receiving Heparin & Coumadin. The second reaction was severe heart block with concurrent use of Betapace, Inderal LA, and Digoxin. The third reaction was a severe heparin induced thrombocytopenia (HIT). The last reaction was a hypersensitivity reaction to Taxol.

4th quarter ADR of 1999:

ANTIBIOTIC: Unasyn, Ancef, Claforan, Ceclor Levaquin , Biaxin, ampicillin,
vancomycin, Primaxin
NARCOTIC/SEDATIVES: Duramorph, Demerol x4, Dilaudid x1, Dilaudid PCA x 2,
morphine PCA, morphine IV, Vicodin, Restoril x 2, Ativan, Halcion
ANTIPSYCHOTIC: Haldol, Remeron,
CARDIOVASCULAR: Lopressor x 2, Cardizem CD
Monopril, digoxin x 7, Zestril, enalapril x 2, Lotensin KCL x 1, spironolactone
x 2, NTG patch, Rythmol
ANTICOAGULANTS: Coumadin, Lovenox, Integrilin
ANTIDIABETIC: Glucotrol XL x 2, glyburide
OTHER: Compazine, Taxol, colchicine, hydroxyurea, Hemabate, Lomotil, Dilantin

MEDICATION OCCURRENCES
During the year 1999, 298 events were reported at Encino­Tarzana Regional Medical Center (ETRMC). 77 events (26%) were prescribing; 92 events (31%) were transcription & verification; 42 events (14%); 44 events (14%) were dispensing; 80 events (27%) were administration; and 7 events (2%) were monitoring. In some cases, more than one source or process step may have contributed to one medication occurrence. The proximal causes were reviewed and tabulated: 34% were due to rule violations and 14% were due to lack of drug knowledge. A task force has been formed to find contributing factors through a root cause analysis for the administration errors. The team's recommendations were to educate the staff
regarding the medication administration process using the flow chart; to increase the standard of annual competencies; and to analyze the administration occurrences in detail during the medication error sub-committee.

DRUG UTILIZATION REVIEW (DUE)
Study of the usage of eptifibatide (Integrilin") during the 4th quarter found
that dramatic improvement has been made in the area of dosage. 100% of
Percutaneous Coronary Intervention dose (135 mcg/kg load and 0.5 mcg/kg/min
infusion) met criteria as well as for renal adjustment dose. This is a 100%
improvement compared to 1st and 2nd quarter study. This improvement was felt to
be due to the Continuing Medical Education (CME) as well as the in-service of
the hospital staff.

Study of the usage of risperidone (Risperdal") during the 4th quarter found that
the documentation of effects and adverse drug reactions were not done in
consistent manner. The study also showed that all the adverse drug reactions
were found in patients who had concomitant CNS depressive medications. All
prescribers are advised to use caution when prescribing resperidone with other
CNS depressive medications such as benzodiazepines.

DRUG NEWS
Rifampin drug interaction
Rifampin has been successfully used as an adjunct to vancomycin therapy in
several clinical conditions of MRSA infections. With the increased incidences of
MRSA, precribers see drug interactions involving rifampin more than ever.
Rifampin is an enzyme inducer and gradually reduces the serum concentration of
other target drugs over one to two weeks. The normalization of the serum drug
level of target drugs may take even longer after rifampin has been discontinued.

The target drugs are oral contraceptives, cyclosporine, tacrolimus,
clarithromycin, mexiletine, diazepam, triazolam, zidovudine, oral digoxin,
buspirone, glucocorticoids, ketoconazole, warfarin, metoprolol, theophylline,
and sulfonylureas. Careful monitoring of the target drug effect is needed when
initiating rifampin therapy or discontinuing the therapy.