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Pharmacy Newsletter

Pantoprazole New Formulary Proton Pump Inhibitor

Catie Brackin, PharmD, Pharmacy Practice Resident

Proton pump inhibitor (PPI) use at St. Mary's Hospital is widely distributed among the many different PPIs available on the market. St. Mary's does have preferred PPIs (omeprazole oral tablets, lansoprazole oral suspension, and esomeprazole intravenous solution), however, the use of nonpreferred, more expensive PPIs have increased, making the total cost of PPIs in 2010 just over $94,000. A medication class review was initiated at the beginning of 2011 due to new contract prices and the increased frequency of patients admitted and continued on the most recent PPI introduced to the market, dexlansoprazole (Dexilant®). Comparisons of the various PPIs have shown some small differences, primarily in bioavailability and plasma concentrations. As these differences can be overcome by interchanging the PPI with another of an equivalent dose, these differences are of questionable clinical importance and do not justify the selection of one agent over another. In general, all PPIs are considered to be equivalent at their standard doses. No evidence exists to support clinical superiority of any one PPI over another. Considering the wide disparity in cost among the PPIs available and the knowledge that one PPI is as effective as another, it is justifiable to narrow the formulary PPIs for oral, liquid, and intravenous use. Overview of Approved PPI Formulary Changes Effective May 17, 2011: Implement therapeutic interchange for oral PPIs with pantoprazole tablets as the preferred agent. May use lansoprazole 2nd line if patient failed on pantoprazole or if patient was taking prior to admission. Continue with the compounded lansoprazole suspension as the formulary oral liquid. Use only lansoprazole disintegrating tablets as the formulary PPI for administration through all enteral tubes. Change the formulary intravenous PPI to pantoprazole injection. Remove omeprazole, esomprazole, rabeprazole, and dexlansoprazole from the formulary. These will be obtainable for individual nonformulary requests only. New lower contract prices and formulary changes will provide a projected annual cost savings of nearly 33% ($30,952.06). Standard order sets will be automatically updated, and the therapeutic substitution table below will be integrated into the electronic health record. Please contact the pharmacist if the patient requires a nonformulary PPI.

Oral Dose 20 mg 40 mg Esomeprazole 40 mg 10 mg 20 mg 40 mg Omeprazole Rabeprazole Dexlansoprazole 20 mg 20 mg 20 mg 30 mg 60 mg Frequency Daily Daily BID Daily Daily Daily BID Daily BID Daily Daily Pantoprazole Dose 40 mg 40 mg 40 mg 20 mg 40 mg 40 mg 40 mg 40 mg 40 mg 20 mg 40 mg Frequency Daily Daily BID Daily Daily Daily Daily Daily BID Daily Daily

May 2011

Inside this issue: Pharmacy and Therapeutics Committee Actions 2

Formulary Ac2 cess on Intranet

Falls Prevention 2

PPMI Recommendations


Pharmacy Move 3

Ceftaroline for Cellulitis Drug Shortages



Pharmacy and Therapeutics Committee Actions

Kate Rotzenberg, PharmD

From the March 23rd meeting: Formulary Status Changes IV Acetaminophen (Ofirmev®) has been added to formulary at St. Mary's Hospital. The full monograph is available on St. Mary's Intranet through the Pharmacy link. Ceftaroline (Teflaro®) has been added to formulary at St. Mary's Hospital, restricted to use by Infectious Disease. The full monograph is available on St. Mary's Intranet through the Pharmacy link. Dabigatran (Pradaxa®) has been added to formulary at St. Mary's Hospital (Tier 2 Dean Health Plan). The full monograph is available on St. Mary's Intranet through the Pharmacy link. A 6 month medication use evaluation will be conducted on prescribing and outcomes and will be presented at the September meeting. Drug Class Reviews Proton Pump Inhibitor Review-- Therapeutic interchange policy approved for pantoprazole, in effect May 2. Nasal Steroid Review--A therapeutic interchange is planned for the near future pending input from OB and ENT. This is a cost savings program similar to the Qvar® substitution implemented last year. Policy Changes Renal Dosing Policy updated for new additions to formulary and clarify use of high-dose piperacillin-tazobactam Best Practice Alert was approved for consideration of Hematology consult when IV direct thrombin inhibitors ordered New policy approved for timing of prophylactic enoxaparin to meet SCIP measures and accommodate planning invasive procedures. Order sets to be updated.

Formulary Access on Intranet

Kate Rotzenberg, PharmD

A link to the formulary is now available on St. Mary's Intranet below the Pharmacy link. This document is an Excel spreadsheet arranged alphabetically by generic drug name and contains 1,970 entries based on inventory. Included information: Brand and generic drug name Strength Dosage form To search the list, use ctrl-F (hold down the Control key and type F) anywhere in the document. A box will appear and the user may search by any word contained in the document. Less is more--type only part of the drug name to avoid misspelling. This will take the user to the first entry that meets the search criteria, use the arrow for each subsequent entry. Non-formulary items, even if used frequently, are not on this list. Limitations of the current list: Reflects what the pharmacy orders, not necessarily what is prepared for patient use Does not identify drugs restricted to specific prescribing groups Cannot be grouped by drug class Does not identify cost differences Future versions of the formulary listing may incorporate some of this information.

Fall Prevention: Helping Our Patients Walk the Line

Randi Stouffer, PharmD, MPH, BCPS, CGP

In 2002, the National Quality Forum declared that patient death or disability resulting from an in-hospital fall was a "serious reportable event." In 2008, Medicare stopped reimbursing hospitals for the care provided to treat the sequelae of such "never events," and other insurers quickly followed CMS's example. Given that a fall with injury increases a patient's length of stay by 12 days, with over $4000 in increased costs (Bates et al., 1995), hospitals have increased their efforts to prevent patient falls. At St Mary's, our patients sustain more falls than the national average, but are less often injured. Regardless of injury, however, the cost per fall has been Page 2 estimated at $351 (Boswell et al., 2001). The House-Wide Quality Improvement committee has introduced measures to reduce the fall rate, including interdisciplinary fall huddles (including pharmacists) after each patient fall on 4SW and 5SW. While initial results indicate that the fall huddles are creating a safer environment, evidence is still accumulating and the model is being fine-tuned before house-wide roll-out. The QI committee recognizes the demands upon pharmacists' time, especially during centralized hours, but the drugrelated information and advice have been Pharmacy Newsletter valuable during fall huddles. It is hoped that the advent of patient acuity scoring will lead to a more proactive approach by pharmacists, allowing intervention before a fall occurs.

Pharmacy Practice Model Initiative Recommendations: Current Status

Kate Rotzenberg, PharmD

The American Society of HealthSystem Pharmacists held a Pharmacy Practice Model Summit last November and recently issued their recommendations. The objectives of the Pharmacy Practice Model Initiative are to: 1. Create a framework for a pharmacy practice model that ensures provision of safe, effective, efficient, accountable, and evidencebased care for all hospital/health system patients; Determine patient care-related services that should be consistently provided by departments of pharmacy in hospitals and health systems and increase demand for pharmacy services by patients/caregivers, healthcare professionals, healthcare executives, and payers; Identify the available technologies to support implementation of the practice model, and identify emerging technologies that could impact the practice model; Support the optimal utilization and deployment of hospital and healthsystem pharmacy resources through development of a template for a practice model which is operational, practical, and measurable; and 5. Identify specific actions pharmacy leaders and staff should take to implement practice model change including determination of the necessary staff (pharmacy leaders, pharmacists, and technicians) skills and competencies required to implement this model. document interventions in the medical record. undergo yearly competencies. participate in telepharmacy through after-hours review of medication orders at outside hospitals. As we push ourselves to exceed, some activities to pursue in the future may include: Establishing a patient medication complexity index for prioritization of patient review; Participation in discharge medication reconciliation and education; Establishing methods to track and trend pharmacist interventions; Establishing "tech-check-tech" distributive pharmacy functions.


St. Mary's Pharmacy Department meets many of the recommendations from the summit through our current practice model. St. Mary's pharmacists: are assigned to specific units based on patient acuity and/or census. participate in interdisciplinary patient rounds. review patient charts at the time of processing medication orders and daily for comprehensive review. dose selected medications for renal function and pharmacokinetic parameters per policy.



Pharmacy Moves into New Space

Kate Rotzenberg, PharmD

The Phase 1 construction is finally complete and the pharmacy staff have moved into their new space as of May 2. The new pharmacy is located

consists of 2,521 square feet. The Pharmacy renovation includes the installation of the MedCarousel®--technology that utilizes barcode scanning when dispensing medications to reduce errors and provide efficient inventory. Other features include the new clean room, which is USP <797> compliant and has a separate chemotherapy compounding room. The layout of the Phase 1 area is more efficient for the staff and provides an improved work environment. Contact information remains the

same in the new pharmacy (x6551). Thank you to all the Pharmacy staff who volunteered during the Open House and the big move to make the transition as smooth as possible.

across from the current inpatient pharmacy behind the Northwest elevators on the B level. The Pharmacy Department held an Open House on Monday, April 25 for interested staff, providers and volunteers. The Phase 1 space consists of 5,304 square feet for the distributive pharmacy functions. The Phase 2 space, anticipated to be complete in August 2012, will house the Pharmacy offices, conference/break rooms, and staff support areas and

Page 3

Pharmacy Newsletter


700 S. Park St. Madison, WI 53715 Phone: 608-258-6551 Fax: 608-258-5626

Editor: Kate Rotzenberg, PharmD Drug Information Pharmacist [email protected]

Ceftaroline (Teflaro® ) in Cellulitis Treatment

Geri Naymick, PharmD, Antibiotic Stewardship Pharmacist

Ceftaroline is an "advanced generation" cephalosporin recently approved by the FDA for skin and skin structure infections . It is similar to the first and second generation cephalosporins with activity toward gram positive (S. pneumoniae, MSSA, macrolide-resistant S. pyogenes, and S. agalactiae) and gram negative organisms (H. influenzae, E. coli, K. pneumoniae, K. oxytoca). Unlike other generation cephalosporins, ceftaroline has activity against MRSA, making it unique to the cephalosporin family. Its activity includes MSSA, CA-MRSA, vancomycin-intermediate (VISA) and vancomycin-resistant (VRSA) S. aureus. The MIC90 for community or hospital acquired MRSA ranges from 0.25-1 mcg/ml. It does not cover pseudomonas, Enterococcus or ESBL producers. Ceftaroline appears to be an attractive antibiotic for cellulitis treatment. Besides its broad antibacterial spectrum for uncomplicated skin infections, there is a lack of drug interactions with a low side effect profile. However, it requires dosing every 12 hours, a hindrance if outpatient treatment is considered. As an alternative, providing ceftaroline on an in-patient basis for initial therapy with transition to once-daily daptomycin in the outpatient ID Infusion Clinic would be a cost-effective measure. Daptomycin 500 mg vial costs approximately $230 compared to $84 for twice daily ceftaroline vials. Patient cost reflects a greater economic difference as daptomycin is dosed by weight and can average about $500-1,000. To gain clinical experience with ceftaroline, the Infectious Disease department would like ceftaroline to be ordered in patients with cellulitis with a suspicion of MRSA. Infectious Disease department must be consulted for facilitation of discharge to the infusion clinic. Ceftaroline is dosed 600 mg every 12 hours; pharmacy will adjust for decreased renal function. Crossreactivity with other beta-lactams (penicillins, cephalosporins, carbapenems) is established. Reference: Medical Letter Jan 2011

Status of Drug Shortages

Kate Rotzenberg, PharmD

Adult amino acids (Clinisol®) shortage is resolved. Clevidipine (Cleviprex®) became available in mid-April on a limited basis (50mL only) . Diltiazem injection shortage is resolved. Erythromycin injection is currently on back order, none is available for use at this time. Hyaluronidase injection continues to be unavailable. For medications that extravasate, continue to use the Extravasation Policy on the intranet and follow all steps without hyaluronidase. Page 4 Ibuprofen lysine (Neoprofen®) is on back order. Indomethacin injection is being used as an alternative for PDA closure in neonates. Lorazepam (Ativan®) bulk vial for injection is now available for compounding infusions, shortage is resolved. Norepinephrine (Levophed®) injection shortage has been resolved. Propofol (Diprivan®) continues to be in nationwide shortage. Manufacturers continue to work with the FDA, but cannot confirm a date when the shortage will be resolved. At this time, the pharmacy has been able to Pharmacy Newsletter maintain a supply of propofol. Vitamin A injection remains on back order. Please consult with your pharmacist if you have any questions related to drug shortages.


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