Drug Information Resources:
An Overview
Rob Barcelona, PharmD, BCPS
Clinical Pharmacy Specialist, CICU

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Utilize drug information sources available at
University Hospitals Case Medical Center
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Describe UHCare functionality as it relates to Pharmacy Services
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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

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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)
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Examples include MICROMEDEX ® , textbooks, UpToDate ® , review articles, and encyclopedias

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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.)

®
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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

®
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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
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Limitations: difficulty in finding information and frequency of updates

UHCMC Adult IV Guidelines

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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
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If UHCMC has guidelines, protocols, or ordersets, use those developed by UHCMC staff

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Variety of resources are available
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Familiarize yourself with the on-line resources, databases, and textbook references in finding drug information
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If all else fails, ask your pharmacist

Andreea Popa PharmD, BCPS
MICU Clinical Pharmacy Specialist

MICU and other resources

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Invalid order/need further clarification
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Bad Orders
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Non-formulary drug
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Renal Dosing
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Drug interactions
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Drug on short supply
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Restricted drug
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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

Verification Screen

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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
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Controlled substances, emergency meds 
OMNICELL
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If need something urgent: call area pharmacist

 Standard administration times
– 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

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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 1 st dose and the subsequent doses will be automatically scheduled q 24 hours from the time of first dose (if ordered Q24H)

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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 1 st 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

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MMF grams vs. milligrams

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So, how do I order:
– 1,000 mg
– 500 mg or
– 2,000 mg of vancomycin
????

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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

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Admission Ordersets
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Most patients do not need an IV PPI…
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Pneumonia Orderset
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Antibiotics default to routine
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Antibiotic selections in alphabetical order vs. preferred
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Tylenol OD

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When calling pharmacy for drug info questions:
1.
Ask to talk to a pharmacist
2.
Tell them who you are/contact info
3.
Give them patient name and location
4.
Give them synopsis of case and relevant clinical information to get most appropriate answer (what you are treating,other drugs, renal function, etc.)

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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

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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)

Vancomycin
Drug
Immunosuppressants
Phenytoin
Aminoglycosides
Digoxin
Heparin assay, Lovenox
Drug Levels
Timing Notes
Trough 30 minutes prior to 4 th dose Individualized dosing for patients with renal dysfunction
Trough levels within 1 hour of dose
(0600, 1800)
Contact Transplant Service for guidance
1.
2.
3.
Trough concentration
Within 2-3 days of initiation
Within 1 hour of load to determine maintenance or need to reload
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Traditional: trough with 3 rd dose and peak 30 minutes after end of infusion
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Extended: trough with 2 nd dose
Trough concentration
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NO need for daily levels
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Order free levels in patients with renal failure and/or low albumin
Depends on traditional vs. extended dosing
Must be drawn at least 6 hours post-dose
4 hours post-3 rd dose Use in extremes of body weight, pregnancy, renal dysfunction