THE PHARMACY ADVISOR
A Publication of the Beth Israel Deaconess Medical Center
Department of Pharmacy and Pharmacy & Therapeutics Committee
Volume 1, Issue 1
July 2002
From the Editors:
The Pharmacy Advisor is a new publication of the Department of
Pharmacy and the Pharmacy & Therapeutics Committee. This
monthly newsletter will feature articles regarding medication use at
Beth Israel Deaconess Medical Center and in addition will include
relevant topics in pharmaceutical care. Included in each publication
will be updates from the Pharmacy and Therapeutics Committee
including formulary additions, therapeutic drug class reviews,
medication-related policies and prescribing guidelines, targeted
medication use evaluations and medication safety and adverse drug
reaction reports. Informational bulletins will update caregivers to
current drug shortages and will provide recommendations for
alternate therapies. Clinical Pharmacy Pearls will be included to
provide information on topics such as drug interactions,
pharmacokinetic considerations in drug prescribing and general drug
information. Articles relating to pharmacoecomonics will provide
insight on the economic impact of the pharmaceutical care we
provide.
Your comments and suggestions for future articles and topics are
welcome.
INSIDE THIS ISSUE
1
Formulary Update:
Famotidine is selected as the preferred parenteral H2
Receptor Antagonist on the BIDMC Inpatient Formulary
Formulary Additions: Cefepime (Maxipime™); Zoledronic
Acid (Zometa™); Darbepoetin (Aranesp™); Tenofovir
(Viread™); Valganciclovir (Valcyte™)
2
POE: Top 10 hints to improve medication ordering
3
Medication Safety: Safety concerns with transcription
and the use of abbreviations
4
Drug Shortages
The Pharmacy Advisor is a publication of the Department Of
Pharmacy and the Pharmacy & Therapeutics Committee at
the Beth Israel Deaconess Medical Center, Boston, MA 02215
Writing/Editorial Board:
Katherine Giampietro, PharmD
Christopher McCoy, PharmD
Lisa Saubermann, PharmD
Diane Soulliard, PharmD
Bruce Bistrian, MD, Co-Chair P&T
James Heffernan, MD, Co-Chair P&T
Francis P. Mitrano, M.S., RPh
P&T Formulary Update
Famotidine Selected as the Preferred Parenteral H2Receptor Antagonist on the BIDMC Formulary
H2 receptor antagonists (H2RA) are indicated in the
therapy and treatment of duodenal ulcer, gastric ulcer,
control of gastric pH in critically ill patients, symptomatic
relief in gastritis, gastroesophageal reflux, active benign
ulcer, and pathological hypersecretory conditions. Four
H2RA s are currently used in the United States, three of
which (cimetidine, famotidine and ranitidine) are available
for parenteral administration.
The pharmacodynamic and therapeutic properties of the
H2RAs suggest that these agents are equally effective for all
indications and the available parenteral formulations should
be considered therapeutically equivalent, as should the oral
formulations.
Based on famotidine’s favorable safety profile, minimal
drug interactions, once or twice daily parenteral
administration and competitive cost, the Pharmacy &
Therapeutics Committee (P&T) voted to replace parenteral
ranitidine with famotidine as the preferred parenteral H2RA
on formulary.
In alignment with the outpatient PSN formulary, ranitidine
will remain as the preferred oral H2RA on formulary.
Treatment with oral or enteral medication is recommended
for clinically stable patients with a functional GI tract.
For those patients requiring parenteral therapy, the usual
dose of IV famotidine is 20mg IV q12 hours. Parenteral
famotidine is available in premixed minibags containing
20mg famotidine in 50ml iso-osmotic sodium chloride.
Each dose is administered over 15-30minutes. Higher doses
may be required in some hospitalized patients with
pathological hypersecretory conditions or intractable ulcers.
Dose adjustment for patients with renal impairment:
CrCl: >50 ml/minute: 20mg IV q12h
CrCl: < 50 ml/minute: 20mg IV q24h
Some newer references suggest that further dose reduction
to 20mg q48h is warranted for CrCl < 30ml/minute.
The following IV dose conversion will be utilized:
Cimetidine IV
Ranitidine IV
Famotidine IV
300mg q6h
50mg q8h
20mg q12h
900mg /day
continuous
infusion
150mg /day
continuous
infusion
40 mg /day
continuous
infusion
The Pharmacy Advisor 1
Pharmacy’s Top 10 Helpful Hints for Effective Use of Provider Order Entry (POE) for:
Medications, IV Therapy and Parenteral Nutrition Orders
Provider Order Entry (POE), our computerized order entry system, is now live on the West Campus in all in-patient nursing units and
critical care areas. POE brings technological advances to the methods we use to write patient-care orders and the POE menu is
comprised of 14 different types of order entry options. With relation to the medication ordering component of POE, order-entry
options include “medications,” “IV Therapy” and “TPN” orders. In addition to facilitating medication selection, POE provides
additional information during the medication order-entry process regarding: dosing, allergies, connections to relevant laboratory
information and drug interactions. In recognition of the complex nature of the medication order-entry process, some of the highlights of
POE order entry are described here.
To initiate the order writing process in POE, an entry for one of the 14 menu options is selected in the web-based system. Prescribers
are guided through nursing-unit census and patient selection screens to the specific order options. Within the medication order options,
“quick-pick” medication lists are available to facilitate medication selection. Prescribers may select medications from this list or should
the desired medication not be found here, medication selection can be performed by entering the generic name of the drug in the space
provided. The medication order screens have been designed to provide default dosing and schedules within usual dose ranges. Patientspecific dosing outside of these ranges must be manually entered. Throughout the medication order-entry process, various alerts and
rules have been programmed into the POE system to make the order-entry process safe, accurate and user-friendly.
Upon completion of a medication, IV or parenteral nutrition order, prescribers electronically sign the order and the information is
transmitted to pharmacy for review. Subsequent to this review and if no interventions are required, the pharmacist acknowledges the
order. The order is then available to nursing for review and acknowledgement and it is this process that generates a medication
administration label that includes instructions for administration to the patient.
Members of the pharmacy department have identified the following helpful hints for effective use of POE,
regarding the entry of Medications, IV Therapy and TPN orders.
1.
Avoid the unnecessary use of abbreviations to enter a medication order. Popular abbreviations or slang terms are not linked
to the available medication options.
2.
Use generic names to search for medications. Many medications have multiple brand names that are not programmed into the
POE system. Medications are programmed using the generic name.
3.
Search for medications using the first 3 or 4 letters of the generic name only. Spelling errors often result in a failure to find
the desired formulary medication. A misspelled medication is unrecognized by POE and generates a non-formulary medication
request form. Entering the first 3 or 4 letters of the generic name will provide a list of all formulary matches and will facilitate
medication selection.
4.
Radiological agents are not ordered using the “medication” option in order entry. Radiological agents are ordered using the
“general care” option.
5.
“Free water boluses,” orders for “water” or “water sips” are not ordered using the “medication” option. These items are
ordered using the “general care” option.
6.
Do not enter drug doses or schedule information in the “comments” section of the Medication or IV Therapy order.
Dosing and schedule information should be included in the programmed fields of the medication order. Including this information
in the “comments” section may lead to “errors of omission” as the pharmacist or nurse may not readily detect this information upon
review.
7.
Use the “Medication” option to enter orders for replacement electrolytes that will be given as intermittent or small
volume boluses. Orders for potassium, calcium, magnesium and phosphate replacement are available in the “medication” option
of order entry. This option is particularly useful for sliding scale therapy. Continuous infusions of maintenance electrolytes are
ordered using the IV Therapy order option.
8.
When changing formulations (e.g. IV to PO) the provider must discontinue the current order and enter a new order for
the new formulation. Medications have been programmed based on specific dosing and schedule information. Avoid using the
“change” order for this function, because medication specific alerts may not be linked to the original compound.
9.
ID approval must be obtained prior to specified antibiotics being dispensed by pharmacy. It is the responsibility of the
prescribing physician to contact the ID fellow on call for approval for targeted antibiotics. When ordering antibiotics requiring ID
approval, POE provides a direct link to the page system, to facilitate this call. To avoid treatment delays, it is advisable to contact
the ID fellow on call as soon as possible when ordering an ID restricted antibiotic.
10. Parenteral Nutrition order deadline is 1:00 PM. All orders for parenteral nutrition must be entered into POE and signed by the
provider before 1:00 PM. POE will not accept orders for TPN after 1:00 PM. When the deadline is missed the provider may order
a “Quick Mix” peripheral nutrition formula to hold the patient over until the next day when therapy may be reassessed.
In addition to the POE features mentioned above, POE has a “feedback” link (located in the heading of the “census” page) that is
accessible to all POE users. The purpose of this feature is to provide a mechanism to convey issues and comments regarding the POE
process. This information is reviewed by the Department of Information Services and is invaluable with regard to process improvement.
The Pharmacy Advisor 2
Medication Reliability
Safety concerns with transcription
and the use of abbreviations
Identification and avoidance of medication errors is a priority
at BIDMC. Inaccuracies in transcription as well as in the
manual transferring of pertinent information from one record
to another has long been implicated as a potential source for
medication errors. Illegible handwriting, similar drug names
and abbreviations have all contributed to this problem.
Electronic medical records and computerized provider order
entry (POE) have automated many of the manual steps
involved in writing in the medical record; however the accuracy
of this information remains dependent on the accuracy of the
information source and the accurate transfer of this
information into the electronic system.
Computerized medication order selection, default dosing to
common drug regimens and the use of standardized
concentrations for infusions (in particular heparin, insulin and
narcotics) are functions within POE, which can minimize
medication errors. When these options are by-passed and freetext order writing is utilized, the potential for a patient to
receive the wrong drug or wrong dose is escalated.
The continued use of abbreviations and shortcuts for drug
ordering and dosing, even within POE, have demonstrated the
ability to lead to medication errors. Transcription and
abbreviation errors are exemplified by the following case. A
patient recently admitted to the medical center had been
receiving epoetin alfa, 20,000 units weekly as an outpatient.
This regimen was written throughout the patient’s medical
record and had been documented as both 20,000 U and also as
20 MU. On admission, the epoetin dose was obtained from
the record and although 20,000 units was available as a default
dose selection for epoetin in POE, it was not selected. The
dose was manually entered as 20 MU and misinterpreted to
mean 20 million units. This dosing error managed to be
processed through the system without initial detection and was
identified as a “near miss” when it was finally recognized as
inappropriate and corrected.
FDA Approved
The learning point from this case is that the unnecessary use of
abbreviations should be avoided. Mistakes can occur when
abbreviations such as (MU) are used and to mean million units
when written as penicillin 2MU and thousand units when
written epoetin 20 MU.
It is important to remember that such errors in transcription
can occur even with electronic systems that have steps built in
to prevent errors in prescribing. When warnings or alerts are
overridden in POE, care must be taken to ensure the
appropriateness of the medication order. Ultimately, the
health care provider must evaluate each computerized drug
order as is the process with written orders to ensure that the
order makes practical sense. In both of the mentioned
examples, the full dose should be written and the word “units”
used in place of the abbreviated “U.”
The Institute for Safe Medication Practices recommends that
the same safety measures, with regard to eliminating the
unnecessary use of abbreviations, be instituted for electronic
order writing. They further recommend that this safety
measure be applied to other documents (e.g., order forms,
protocols, care maps, computer-generated medication
administration records, prescription labels, and in-house
newsletters). Let’s follow this recommendation.
Formulary Update:
The following medications have recently been approved for addition to
the BIDMC formulary
Cefepime (Maxipime™): Cefepime hydrochloride is a semi-synthetic,
broad-spectrum cephalosporin antibiotic for parenteral administration.
FDA Approved Indications: Cefepime is indicated in the treatment of
moderate-to-severe pneumonia, uncomplicated skin and skin structure
infections, complicated and uncomplicated urinary tract infections
(UTIs) including pyelonephritis, complicated intra-abdominal infections
in adults (w/metronidazole). Cefepime is also indicated for empiric
therapy in febrile neutropenia.
Dosing: Administer IV infusion over 30 minutes.
Empiric therapy for febrile neutropenic patients: 2 g IV Q8H.
Non-neutropenia indications: 1-2 g IV q12H.
Dosage adjustment required in patients with renal insufficiency. Refer to
BIDMC Pharmacy Renal Dosage Guidelines.
BIDMC Restrictions: Cefepime has been approved for formulary use
without restriction in the treatment of febrile neutropenia. ID Approval
will be required for all other indications.
______________________________________________________________________
Zoledronic Acid (Zometa™): Zoledronic acid is a newly approved
parenteral bisphosphonic acid.
FDA Approved Indications: Zoledronic acid is indicated in the
treatment of hypercalcemia of malignancy and as adjunct therapy in
multiple myeloma and bone metastases of solid tumors.
Dosing: Administer by IV infusion over at least 15 minutes.
Hypercalcemia of malignancy (albumin-corrected serum calcium > 12
mg/dL): max 4 mg IV as a single-dose infusion; allow at least 7 days
before retreating. Multiple myeloma or bone metastases: 4 mg every 3-4
weeks.
______________________________________________________________________
Darbepoetin (Aranesp™):Darbepoetin is a long-acting epoetin analog.
FDA Approved Indication: Darbepoetin is indicated for the treatment
of anemia associated with chronic renal failure, including patients on
dialysis and not on dialysis. Darbepoetin has recently received approval
for the treatment of anemia associated with cancer chemotherapy.
Dosing: Administer by IV or SC injection once every 1-2 weeks. Do
not increase more frequently than once per month. For patients not
currently on epoetin alfa: Initially 0.45 mcg/kg once weekly. Adjust
based on hemoglobin levels (target not to exceed 12 g/dL); reduce dose
if hemoglobin increases more than 1 g/dL in any 2-week period. To
convert patients currently receiving epoetin alfa to darbepoetin and for
dose titration, refer to Aranesp package insert.
BIDMC Restrictions: Outpatient treatment of anemia associated with
chronic renal failure. New oncology indications to be reviewed at P&T.
______________________________________________________________________
Tenofovir (Viread™): Tenofovir disoproxil fumarate is the oral salt
form of tenofovir, a nucleotide reverse transcriptase inhibitor.
FDA Approved Indication: Tenofovir is indicated for use in the
treatment of human immunodeficiency virus (HIV) infection in
combination with other antiretroviral agents.
Dosing: The recommended dose is 300 mg po qd, with food, to
increase the extent of absorption
______________________________________________________________________
Valganciclovir (Valcyte™): Valganciclovir, an antiviral agent, is the
valyl ester prodrug of ganciclovir.
FDA Approved Indication: Valganciclovir is indicated for the
treatment of AIDS-related cytomegalovirus (CMV) retinitis.
Dosing: Take with food. Induction: 900mg twice daily for 21 days.
Maintenance: 900mg once daily. Renal impairment: (CrCl <60 mL/min):
reduce dose. Refer to BIDMC Pharmacy Renal Dosage Guidelines.
The Pharmacy Advisor 3
DRUG SHORTAGES
A National Problem with Patient-Care Implications
National Drug Shortages continue to have a significant impact on
the provision of pharmaceutical care to our patients. Although
some short-term shortages are able to be handled seamlessly by
pharmacy, other long-term shortages require more significant
multi-disciplinary management and have the potential to have
greater impact on the healthcare system and patient care.
To address the resultant problems attributable to drug shortages,
it is important to understand that the reasons for shortages are
multifactorial and involve all segments of the supply chain.
Reasons for drug shortages include lack of raw materials,
manufacturing difficulties with product production or secondary
to FDA enforcement of good manufacturing practices,
manufacturer business decisions leading to the discontinuation of
products or a delay in production and increased product
utilization in the face of lower manufacturer and wholesaler
inventories and safety stock. Frequently, pharmaceuticals are
only available from a single or small number of manufacturers
and if issues arise with one of the manufacturers, the remaining
suppliers may have difficulty meeting the increased demands.
The lack of suitable alternative agents, the use of unfamiliar
substitutes, patient safety concerns, and a lack of advanced
warning of impending shortages have all been noted as major
concerns.
Among the negative impacts of drug shortages are the costs of
reallocating resources to manage the shortage, the risks associated
with an increased potential for adverse drug reactions and
medication errors, increased drug expenditures, and patient and
prescriber inconvenience.
At BIDMC, the pharmacy department regularly reviews drug
shortages and determines if needed product can be obtained from
alternate sources. If product is not available, potential alternate
therapies are reviewed and contingency plans formulated. For
immediate patient care needs relating to products that are
unavailable, a pharmacist will contact prescribers directly to discuss
therapy and make recommendations for treatment. Updates
regarding current drug shortages will be featured regularly in The
Pharmacy Advisor to alert health care providers to both short and
long-term drug shortages.
Both the FDA and The American Society of Health-System
Pharmacists (ASHP) maintain websites that specifically address
drug shortages. The FDA Website (www.fda.gov) lists the drugs in
short supply along with the reason for the shortage. The ASHP
website ( http://www.ashp.org/shortage/) lists the drugs in short
supply, and provides suggestions for alternative therapy and
guidelines on managing Drug Product Shortages.
The following list contains several of the products currently affected by ongoing shortage and the impact to inpatients at
BIDMC. For additional information regarding these and other national drug shortages, please refer to the link on the
Pharmacy page of the BIDMC intranet. This link connects to the ASHP website, which provides detailed information
regarding medications affected by shortages.
Antiemetics:

Prochlorperazine injection, Compazine Spansules, and Compazine syrup: nationwide back order due to increased demand for
product and a delay in obtaining raw material. Prochlorperazine rectal suppositories and oral tablets are not affected by this
shortage and can be prescribed as appropriate. Consider metoclopamide and promethazine for patients requiring
parenteral antiemetic therapy.
Diuretics:


Chlorothiazide (Diuril™) injection: Merck would not provide a reason for the shortages of Diuril injection and oral suspension.
Currently, no product is available from the manufacturer.
Furosemide: Furosemide is on nation-wide back order because Aventis, Wyeth, and Watson stopped making the product and the
remaining manufacturers have not yet been able to meet the increased demand for their furosemide products. BIDMC has been
receiving intermittent shipment and currently has furosemide injection in stock.
Parenteral Steroids:





Betamethasone (Celestone™ Soluspan): nationwide back order since late 2000 because of increased demand for the product.
Schering-Plough has limited supplies of betamethasone acetate and betamethasone sodium phosphate injection available for use only
in labor and delivery settings. The company has increased production of this product but would not estimate when the shortage will
resolve. Schering-Plough has discontinued production of betamethasone sodium phosphate injection (Celestone ™ Phosphate).
BIDMC will comply with regulations to provide allocated betamethasone injection (Celestone™ Soluspan) for use only in
the labor and delivery settings.
Methylprednisolone acetate suspension injection (Depo-Medrol™) is on nationwide back order due to manufacturing problems.
Manufacturers are allocating limited shipments on a monthly basis. BIDMC is allocating this limited supply upon receipt.
Methylprednisolone sodium succinate (Solu-Medrol™) is on nationwide back order due to manufacturing problems. BIDMC
has been receiving intermittent shipments and currently has methylprednisolone sodium succinate (Solu-Medrol™)
injection in stock.
Triamcinolone diacetate injection (Aristocort™) and triamcinolone hexacetonide injection (Aristospan ™): manufacturing
difficulties and a raw material shortage. BIDMC does not have either Atristocort™ or Aristospan™ injection in stock.
Triamcinolone acetonide injection (Kenalog™-10, Kenalog™-40): nationwide back order due to increased demand. BIDMC has
been receiving intermittent shipments and currently has a limited supply of Kenalog injection in stock.
Narcotics:

Meperidine hydrochloride for injection: short supply due to a product recall and increased market demand. BIDMC has been
receiving intermittent shipments is allocating this limited supply upon receipt.
The Pharmacy Advisor 4