Ventura County Medical Center/Santa Paula Hospital
Pharmacy and Therapeutics Committee
DRUG FORMULARY
Restricted Drug Use Criteria
May 2012
Alteplase (tPA Activase®)
1. Treatment of acute nonhemorrhagic stroke (as per VCMC Protocol)
2. Massive pulmonary embolus with hemodynamic compromise (pulmonary consult
required)
3. Thrombolysis of clot-occluded catheters
Amphotericin B Lipid Complex (ABLC; Abelcet®)
Documented invasive fungal infection refractory to full course of amphotericin B
deoxycholate. Requires an Infectious Disease Consult.
Amikacin
Treatment of infections due to GNRs documented or suspected to be resistant to
Gentamicin and Tobramycin.
ANTI-NEOPLASTIC DRUGS:
Restricted to patients being consulted and treated by HEMATOLOGY/ONCOLOGY
Aztreonam:
1. Treatment of aerobic gram negative infections in patients with documented history
of severe penicillin and/or beta-lactam allergy in which an aminoglycoside may
need to be avoided.
2. In serious gram-negative infections in urinary tract infections, especially those
involving Pseudomonas aeruginosa, concurrent use with an aminoglycoside is
necessary for optimal treatment.
Capsofungin (Cancidas®)
1. Treatment of invasive Aspergillus infection in patients refractory to or intolerant of
other antifungal treatment.
2. Treatment of Candida resistant to fluconazole.
Carbapenems, with the exception of Ertapenem (see below)
Requires an Infectious Disease Consult.
Ceftazimide (Fortaz®)
1. Treatment of infections due to Pseudomonas aeruginosa or other gram negative
rods resistant to other cephalosporins, in conjunction with an aminoglycoside (or
in place of AG when their use is contra-indicated).
2. Empirical treatment of infections presumed due to Pseudomonas aeruginosa.
3. Empirical treatment of febrile neutropenia, ± an AG.
4. Empirical treatment of meningitis in neonates.
Ciprofloxacin (Cipro®)
Use limited to suspected or proven Pseudomonas aeruginosa infections.
Clozapine (Clozaril®) ---Psychiatry consult required.
Treatment of refractory schizophrenic or schizoaffective disorders following patient
enrollment in the Clozapine Patient Management System.
Colistimethate (Colistin®)
Restricted to approval by Infectious Disease Consult.
Daptomycin
Restricted to approval by Infectious Disease Consult.
Entanercept (Enbrel®)
Treatment of refractory rheumatoid arthritis, as per VCMC P&T.
Flecainide (Tambocor®)---Cardiology consult required
Treatment of refractory life-threatening ventricular arrhythmia.
Imipenem/Cilastatin (Primaxin®)
1. Use of imipenem is limited to therapy of hospital (or nursing home) acquired polymicrobial infections (i.e. gram positive/negative, aerobic/anaerobic) where
pathogens resistant to aminologycosides, extended-spectrum penicillins, and
cephalosporins are documented; empirical use should be avoided.
2. Plays an important role in the treatment of ESBL-producing strains.
3. Imipenem should NOT be used for community-acquired infections, monotherapy of
serious enterococcal, MRSA, MRSE, Pseudomonas, or “Pseudomonad” infections,
or as surgical prophylaxis.
4. Pneumonia with shock, MDRO (Multi Drug Resistant Organism) in the ICU setting.
5. Intra-abdominal infection with shock, MDRO/no MDRO risk.
Infliximab (Remicade®)
1. Treatment of refractory Crohn’s Disease, as per VCMC Protocol.
2. Treatment of refractory rheumatoid arthritis, as per VCMC Protocol.
Levoalbuterol (Xopenex®)
1. Documented intolerance/side effects to albuterol in adult and pediatric patients.
2. Documented decrease in side effects when given albuterol.
3. Patient with corrected or uncorrected cardiac disease.
Linezolid (Zyvox®)
1. Infectious Disease Consult is required.
2. Restricted to documented vancomycin resistant entercoccus.
3. Unknown source of infection causing septic shock.
4. Pneumonia with septic shock with MDRO
Meperidine (Demerol®)
1. Prevention or treatment of drug induced or blood product-induced rigors or postanesthesia shivering.
2. Pre- and post-analgesia where fast onset and short duration improve patient care.
3. Acute episodes of moderate to severe pain in patients with adverse reactions,
allergies, or unsuccessful pain management with first line opiods in equi-analgesic
doses.
Moxifloxacin (Vigamox®) Opthalmic Solution
Treatment of serious ophthalmic infections in the ED. Limited to ophthalmologist
use.
Nesiritide (Natrecor®)
1. Restricted to use in patients with Class IV heart failure of moderate to severe
intensity.
2. Heart failure resistant to loop diuretics and nitroglycerin, with clinical signs of
volume overload.
3. Attending physician order required.
Nimodipine (Nimotop®)
Use limited to treatment of patients with subarachnoid hemorrhage.
Quinupristin/Dalfopristin (Synercid®)
Approval by Infectious Disease Consult.
Rasburicase (Elitek®)
Restricted to pediatric hematology/oncology patients with cancer known to cause
tumor lysis syndrome with heavy tumor burden at diagnosis, uric acid > 7mcg/dl, SCr
> 7 times baseline, decreased urine output and/or metabolic abnormalities.
Retaplase (Retavase®)
Thrombolytic therapy for acute Q-wave MI, as per VCMC Protocol.
Vancomycin
Use limited to metronidazole refractory or life-threatening C. difficile enterocolitis. All
vancomycin oral therapy needs to be initiated by an Attending physician.
Voriconazole
Requires an Infectious Disease Consult.
Tigecycline (Tygacil®)
Requires an Infectious Disease Consult.