THERAPEUTICS MANUAL Methodist Healthcare – Memphis Hospitals

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Methodist Healthcare – Memphis Hospitals
THERAPEUTICS
MANUAL
Fifth Edition
June 2008
2
Dear Colleague:
The Methodist Healthcare-University Hospital Department of Pharmacy is pleased to
provide you with a copy of the fifth edition of the Therapeutics Manual. Due to the
overwhelming response to the manual, updates and new information have been
included to enhance your practice.
The first section includes patient safety information. Unapproved abbreviations and
high-risk medications are highlighted in this section. It also highlights which
medications are restricted by physician specialty.
The next section includes Pharmacy & Therapeutics approved protocols. Additions to
this version include protocols for antibiotic lock therapy, antihypertensives, RCN, and
diltiazem.
The Methodist specific guidelines and consensus guidelines sections have been
updated to include information on factor IX products, dofetilide, AOC/LOC, epoetin,
lithium, warfarin, titrating parameters, and deep sedating agents.
The purpose of this manual is to provide concise drug information to aid you in your
daily practice.
Sincerely,
Bob Lobo, Pharm.D, BCPS
Assistant Director, Clinical Pharmacy
Disclaimer: As there are new guidelines, policies, and procedures that are approved
periodically for use at Methodist Healthcare-University Hospital, this book may
contain information that is out of date. Consult the Molli website for the most up to
date information. Also, with the ever changing medical literature, some of the
information contained may be out of date. Consult the medical literature for the most
recent information.
-COST INFORMATIONAverage Wholesale Price
$<$10
$$$10-30
$$$$30-50
$$$$$50-70
$$$$$>$70
3
THERAPEUTICS MANUAL, 5th EDITION
- TABLE OF CONTENTS -
I.
PHARMACY SERVICES
Page
-Methodist Healthcare-University Pharmacy Department
7-8
-Methodist Healthcare-Memphis Hospitals Departments of Pharmacy 7-8
II.
PATIENT SAFETY
-Unapproved Abbreviations
-High Risk Medications
-Adverse Drug Event Reporting
-Specific Medication Prescribing Guidelines
9
10-11
12
13
PHARMACY & THERAPEUTICS COMMITTEE APPROVED
PROTOCOLS
-Aminoglycoside, Once Daily Dosing Protocol (Pharmacy-Run)
-Amphotericin B Bladder Irrigation Protocol
-Delirium Tremens Protocol
-Drotrecogin (Xigris®) Contraindications
-Glycoprotein IIb/IIIa Inhibitors Dosing Protocol
-Heparin Protocol
-Heparin-induced Thrombocytopenia Protocol
-Morphine PCA Protocol and Hydromorphone PCA Protocol
-Intensive Insulin Protocol
-Pediculosis Protocol
-Sliding Scale Insulin Protocol/Hypoglycemia Protocol
-Solu-medrol for Spinal Cord Injury Protocol
-Thrombolytic for Catheter Clearance Protocol
-Antibiotic Lock Therapy
-Antihypertensive Protocol
-RCN Protocol
-Diltiazem (Post CV Afib)
14-15
16
17
18-19
20
21
22-24
25-26
27-28
29
30
31
32-33
34-35
36-37
38
39
III.
4
IV.
V.
METHODIST SPECIFIC GUIDELINES
-Guidelines for Use – Colchicine
-Guidelines for Electrolyte Replacement
Magnesium
Phosphate
Potassium
-Initiating Peripheral and Total Parenteral Nutrition (TPN)
-Automatic IV to PO Conversion Criteria
-Factor IX Products
-Dofetilide (Tikosyn)
-AOC/LOC
-Epoetin guidelines
-Lithium guidelines
-Warfarin guidelines
-Titrating parameters
-Deep sedating agents
CONSENSUS GUIDELINES
Summary of Consensus Guidelines
-Cardiovascular
Hyperlipidemia Therapy (NCEP)
Hypertension Therapy (JNC-VII)
VTE Prophylaxis and Treatment (ACCP)
Perioperative Management of Warfarin
Congestive Heart Failure Therapy (ACC/AHA)
Acute Myocardial Infarction Therapy (ACC/AHA)
-Respiratory
Asthma Guidelines (NHLBI)
Acute Asthma Management (NHLBI)
Chronic Obstructive Pulmonary Disease (NHLBI/WHO)
-Diabetes
Diabetes Mellitus Guidelines (ADA)
Diabetic Ketoacidosis Management
-Infectious Disease
Bacterial Endocarditis, Prevention Guidelines
HIV/AIDS Guidelines (NIH)
Empiric Fungal Therapy Guidelines
-Other
Acute Ischemic Stroke Guidelines
General Pain Guidelines
Page
40
41-42
43-44
45
46-50
51-52
53-54
55-56
57
58-59
60
61
62-63
64
65-66
67-69
70-74
75-77
78
79-83
84-86
87-92
93-95
96-97
98-105
106-108
109-110
111-116
117
118-119
120-125
5
VI.
TABLES
-Renal Dysfunction Dosing Adjustment Guidelines
-Therapeutic Drug Monitoring Guidelines
-Opioid Analgesic Dose Equivalents
-Fentanyl Conversion
-Fentanyl Pharmacist Checklist
-Opioid Cross Allergenicity
-Corticosteroid Equivalents
-IV Push Rates
-Vancomycin Dosing Guidelines
-Enoxaparin Dosing
VII. MISCELLANEOUS
-Category D and X Drugs in Pregnancy
-Drugs that Should Not Be Crushed or Chewed
-Common Calculations
-ACLS Guidelines
-CMS Measures
-Notes Pages
Page
126-133
134-136
137-139
140
141-142
143-144
145
146-147
148
149
150-153
154-155
156
157-161
162
163-171
6
METHODIST HEALTHCARE - MEMPHIS HOSPITALS
DEPARTMENTS OF PHARMACY
University (516-8295)
Administrative Director of Pharmacy
Asst. Director, Clinical Services
Asst. Director, Pharmacy Operations
Pharmacy Manager
Pharmacy Manager
Alison Apple, D.Ph., M.S.
Bob Lobo, Pharm.D., BCPS
Wayne Segars, Pharm.D., M.S.
Ben Smith, Pharm.D.
Joyce Broyles, Pharm.D., BCNSP
418-3072
418-0040
418-1151
418-0112
418-0045
Clinical Pharmacy Specialists
Ambulatory Care
Cardiology
Critical Care
Emergency Department
Neuro Critical Care
Internal Medicine
Nutrition/ID
Solid Tumor Oncology
Oncology
Solid Organ Transplant
Solid Organ Transplant
Anne Reaves, Pharm.D.
Carrie Oliphant, Pharm.D., BCPS
Chris Finch, Pharm.D., BCPS
Laurimay Laroco, Pharm.D.
April Hurdle, Pharm.D., BCPS
Justin Usery, Pharm.D., BCPS
Joyce Broyles, Pharm.D., BCNSP
Carli Nesheiwat, Pharm.D., BCOP
Sundae Stelts, Pharm.D.
Amy Krauss, Pharm.D., BCPS
Jennifer Lehneman, Pharm.D.
418-4111
418-0048
418-0050
516-2889
418-4108
418-4090
418-0045
418-0051
516-7385
418-0043
418-4105
University of Tennessee Faculty
Sold Organ Transplant
Internal Medicine
Internal Medicine
Nephrology
Ben Duhart, M.S., Pharm.D.
Larry Hak, Pharm.D., BCPS
Tim Self, Pharm.D.
Joanna Hudson, Pharm.D.
532-3856
524-7566
448-6465
448-2655
Central Pharmacy/IV Room
Location (Phone):
Ground Tower/Link
Hours of Operation:
7 Days a Week
(516-8812)
24 Hours a day
Patient Care Area Pharmacist (PCAP)
Locations (Phone):
PCAP 6 - 6 Tower
PCAP 7 - 7 Tower
PCAP 8 - 8 Tower
PCAP A – 8 Thomas
PCAP B – 2 Sherard
(2664)/418-4034
(2750)/418-3322
(2884)/418-4091
(8089)/418-4060
(2485)/418-4059
Hours of Operation:
7AM-3PM
Sunday-Saturday
Critical Care Satellite
Location (Phone):
4 Tower
(8331)/418-4108
7
Hours of Operation:
Oncology Satellite
Location (Phone):
Hours of Operation:
Surgery Satellite
Location (Phone):
Hours of Operation:
7 Days a Week
3 Crews
(7050)/418-4069
Monday-Friday
7AM-6:30PM
Saturday-Sunday
7AM-3PM
3 Thomas
Monday-Friday
Outpatient Pharmacy
Location (Phone):
1 Tower
Hours of Operation:
Monday-Friday
Transplant Satellite
Location:
Hours of Operation:
NORTH (384-5206)
Director of Pharmacy
Pharmacy Manager
Nutrition
Hours of Operation:
7AM-11PM
7 East
Monday-Friday
Saturday-Sunday
(8186)
5AM-11PM
(8168)
8:30AM-4PM
(7065)/418-3320
7AM-11PM
7AM-3PM
Linda Lipsky, D.Ph.
Amanda LaBuda, Pharm.D.
Kaleb Brown, Pharm.D.
7 Days a Week, 24 Hours a day
SOUTH
(516-3747)
Director of Pharmacy
Phyllis Weaver, M.S.
Clinical Pharmacy Coordinator Peggy Yam, Pharm.D., BCPS
Hours of Operation:
7 Days a Week, 24 Hours a day
GERMANTOWN
(516-6977)
Clinical Pharmacy Coordinator Jeff Cooper, Pharm.D.
Nutrition
Elizabeth Betchick, Pharm.D.,
BCNSP
Nutrition
Nicole Hamlett, Pharm.D.
OR/SDS/Cath Lab
Martha Gardner
Hours of Operation:
418-9101
418-4414
269-2901
418-5325
418-4952
418-5298
418-4860
418-4859
418-4856
7 Days a Week, 24 Hours a day
METHODIST EXTENDED CARE HOSPITAL (516-2111, fax: 516-2331)
Hours of Operation:
M-F 8AM to 5:30PM
Weekends and Holidays 7AM to 3:30PM
8
Unapproved Abbreviations
Memphis City-Wide Standardized List
The following abbreviations may not be used in any clinical documentation, including
all types of orders, progress notes, consultation reports, and operative reports.
Abbreviation to Avoid
U
IU
Other Unacceptable
Variations
u
I.U., iu, i.u.
QD
QOD
Q.D., qd, q.d.
Q.O.D., qod, q.o.d.
MS
MSO4
MgSO4
Recommended Approach
Write out “units”
Write out “international
units”
Write out “daily”
Write out “every other
day”
Write out “morphine
sulfate”
Write out “morphine
sulfate”
Write out “magnesium
sulfate”
Use “leading zero”for
doses<1 (e.g. 0.4)
Write “2” instead of “2.0”
Doses without
“leading zero”
Avoid use of trailing
zeros
AU, AD, AS, AL, OS,
au, ad, as, al, os, od, ou, a.u.,
Indicate “each eye,”
OD, OU
a.d., a.s., a.l., o.s., o.d., o.u.
“left ear,” etc.
Mcg
µg
The abbreviations to avoid cannot be used in any form, upper or lower case, with or
without periods.
These unapproved abbreviations have been identified by the JCAHO as having a high
probability of being misinterpreted and resulting in a medication error.
9
High Risk Medications
 Chemotherapeutic agents:
 Verbal orders not accepted
 Standard Chemotherapy Order Form
 Order requires an Attending physician’s signature
 Standard medication reference (Facts and Comparisons Chemotherapy
Handbook®)
 Pharmacy and Nursing double-check system
 Concentrated electrolytes:
 No concentrated KCl (undiluted) in patient care areas
 Diluted KCl infusions not floor-stocked
 KCl infusions limited to 60 mEq per bag
 Max infusion rates:
- 10 mEq/hr not on a cardiac monitor
- 20 mEq/hr if on cardiac monitor
 MHT (Malignant Hematology and Transplant) may have a higher concentration
of KCl:
- Labeled with fluorescent green labels
- Restricted to MHT unit
- Must be infused in a central line
- Two nurses must verify pump rate
 NaCl 23.4% not floor stocked (exception: hemodialysis)
 NaCl 23.4% separated from other NaCl in hemodialysis
 NaCl 3% premix bags not floor stocked
 Drotrecogin alfa (Xigris®):
 Restricted to “credentialed” ID physicians, pulmonologists, and critical care
physicians
 Standardized order form
 Educational materials for Nursing and Pharmacy on MOLLI
 Heparin (UFH) /Low Molecular Weight Heparins
(LMWH)/Fondaparinux/Direct Thrombin Inhibitors (DTIs):
 Standardized heparin protocol
 Heparin not started until 12 hours after the last LMWH dose
 HIT protocol required when DTI used; page clinical specialist at 533-3381
 LMWH Bridging Program
 Hydromorphone and morphine:
 Higher concentrations of morphine not available as floorstock
 “MSO4” and “MS” not accepted for morphine
10
 Medication labels and MAR use TALL man letters: “HYDROmorphone”
 Insulin:
 Standard sliding scale insulin protocol
 “U” not accepted for units
 Only “Regular” and “N” insulins floor-stocked
 One formulary brand of insulin (Novolin® products)
 Pharmacy enters all insulin doses
 Standard concentration for insulin infusions (1 unit per ml)
 Insulin infusions double checked by nursing
 Insulin products in the pharmacy arranged by duration of action
 Medication labels and MAR use TALL-man letters: NovoLOG and NovoLIN
 Neuromuscular blockers:
 Not routinely floor-stocked
 Segregated from other medications
 Epidural/spinal analgesia:
 No orders for sedatives, narcotics, anticoagulants, or clopidogrel without
discussion with anesthesia
 Patient Controlled Analgesia (PCA) pumps:
 No meperidine PCA protocol
 Nursing double checks the PCA
 Standard PCA protocols for morphine and HYDROmorphone
11
Reporting Adverse Drug Events: Medication Errors and Adverse
Drug Reactions
Why Report?
Adverse Drug Event reports are used to identify problems within the medication use
system. From them, the Medication Safety Committee is able to identify improvement
opportunities in medication care and delivery.
Adverse Drug Reactions (ADR):
Defined: any response to a drug that is noxious and unintended and that occurs at
doses used in man for prophylaxis, diagnosis or therapy, excluding
intentional and accidental overdose and drug abuse.
Medication Errors/Occurrences:
Briefly defined: any error in the medication use process (prescribing, transcribing,
preparation/dispensing, administration, or monitoring), including omissions and errors
that did not reach the patient. The error may or may not cause patient harm.
Complete an “Occurrence Report.” The physician can request verbally that nursing or
pharmacy complete a report. Orders for completion of reports should not be written in
the medical record.
All adverse drug reactions, medication errors, and occurrences should be reported in
Safeguard (available on the Molli website). If you are unable to report in Safeguard,
inform the patient care coordinator or pharmacist so that they can report the adverse
drug reaction, medication error, or occurrence.
12
Specific Medication Prescribing Guidelines
The following drugs are considered “on-formulary” at MH-MH hospitals, but
carry certain restrictions on prescribing.
Generic
name
Bosentan
Brand
name
Tracleer®
Budesonide
Caspofungin
Entocort®
Cancidas®
Cinacalcet
Sensipar®
Daptomycin
Cubicin®
Dofetilide
Tikosyn®
Ibutilide
Corvert®
Linezolid
Zyvox®
Nesiritide
Natrecor®
Quinupristin/ Synercid®
dalfopristin
Voriconazole Vfend®
Ziprasidone
Geodon®
Restriction(s)
Must be prescribed by a pulmonologist or
cardiologist
Must be prescribed by a gastroenterologist
Must be prescribed by an infectious disease
physician, a pulmonologist, or a
hematology/oncology/BMT physician
Must be prescribed by a nephrologist for
new orders or any physician may prescribe if
it’s a “continue home med” order
Must be prescribed by an infectious disease
physician or a pulmonologist
Physician must be authorized by
manufacturer.
Must be prescribed by a cardiologist; patient
should be on a telemetry unit
Must be prescribed by an infectious disease
physician or a pulmonologist
Must be prescribed by a cardiologist; may
also be prescribed by an ER physician after
consultation with a cardiologist and if BNP
> 400 pg/ml. Patient must be on a telemetry
unit. Patient must fail IV diuretic.
Must be prescribed by an infectious disease
physician
Must be prescribed by an infectious disease
physician, a pulmonologist, or a
hematology/oncology/BMT physician
Must be prescribed by a psychiatrist;
Automatic stop of 72 hours; Max dose of 40
mg/24 hrs; documented failure of
haloperidol
Alternative
N/A
Prednisone
Ampho B,
Abelcet®,
Fluconazole
Calcium,
Phosphate
binders,
Vitamin D sterols
Vancomycin
N/A
N/A
Vancomyin
IV Nitroglycerin,
IV diuretic
Vancomycin
Ampho B,
Abelcet®,
Fluconazole
Haloperidol
13
Extended Interval Aminoglycoside Pharmacy Protocol
PHYSICIAN:
Order “__________per pharmacy protocol”. Specify drug.
NOTE: This is a pharmacy-run protocol
PHARMACIST: Follow Steps 1-10
Step 1: Determine if patient is candidate for protocol. If an exclusion exists, the
pharmacist should contact the clinical specialist on call (533-3381) for assistance.
The physician must be informed that the patient is not a good candidate for pulse-dose
therapy and offer to dose the patient using standard dosing recommendations and
pharmacokinetic monitoring.
Exclusions:
unstable renal function, pediatric patient, ascites, burns>20% BSA,
pregnancy, dialysis patient (any type)
Step 2: If patient does not have an exclusion, calculate Dosing Weight (DW):
1. DW = Actual Body Weight (ABW) unless ABW is > 1.2 X Ideal Body
Weight (IBW)
2. If ABW is > 1.2 X IBW, use the following equation to determine dosing
weight:
DW = 0.4(ABW-IBW) + IBW
IBW (male): 50 kg + 2.3 (inches > 5 feet)
IBW (female): 45 kg + 2.3 (inches > 5 feet)
Step 3: Calculate and order one time dose (all doses should be diluted in 100 ml of
fluid, and infused over 1 hour). Please round to the nearest 10 mg.
Initial Dose: ____ mg/kg X _______________ kg (DW) = ______________mg
(gentamicin/tobramycin – 5 mg/kg; amikacin – 20 mg/kg)
NOTE: up to 7 mg/kg gentamicin/tobramycin or 28 mg/kg amikacin may be
requested by physician
Step 4: Order additional monitoring.
• Order twenty hour random level.
• Order serum creatinine if needed.
Step 5: Document actions in patient chart.
• Document initial actions in a note in the patient chart. This should include
indication for use, serum creatinine, dose, and any other pertinent issues.
Step 6: Enter orders into computer system
• Enter aminoglycoside protocol code (Aminp) into patient profile on computer,
as well as the order for the aminoglycoside dose.
14
• Fill out flow sheet and leave for the next pharmacist.
• Notify clinical specialist on call (533-3381).
Step 7: The next day, determine dosing interval based upon twenty hour random
level using the following guidelines.
Gentamicin & Tobramycin 20-hour concentration
<1.5 mcg/ml
Continue initial dose every 24 hours.
1.5-2.5 mcg/ml
Continue initial dose every 48 hours.
>2.5 mcg/ml
Obtain a second serum concentration 12-24 hours later; estimate the
elimination half-life, and adjust the interval to approximately 4-5 times
the half-life (keep on practical intervals – see below).
Amikacin 20-hour concentration
<6 mcg/ml
Continue initial dose every 24 hours.
6-10 mcg/ml
Continue initial dose every 48 hours.
>10 mcg/ml
Obtain a second serum concentration 12-24 hours later; estimate the
elimination half-life, and adjust the interval to approximately 4-5 times
the half-life (keep on practical intervals – see below).
• Formula for calculation of half life from two random levels using these two
formulas:
(1) K = LN (first level/second level)
time elapsed between the two levels
(2) Half – life = 0.693/K
Please note: LN is a natural log
First, calculate K using formula (1), then using the K you calculated in formula (1)
calculate half-life utilizing formula (2). After a half life is obtained, multiply it by
either 4 or 5 to get a practical dosing interval. For example, if a half life was
estimated to be 11 hours, 4 times 11 would give 44 hours; 5 times 11 would give 55
hours – the “practical” interval would be 48 hours.
Step 8: Order dose/interval based on guideline interval. Specify when dose is to
be given. Document results in patient chart.
Step 9: Monitor patient and update patient flow sheet daily. Order trough levels
every 4-7 days (more often if needed). Document days of therapy, serum creatinine,
and action planned or taken in patient chart daily.
Step 10: Adjust interval as needed, utilizing above guidelines.
15
Amphotericin B Bladder Irrigation Protocol
PHYSICIAN:
Order as “Amphotericin B Bladder per Protocol”
PHARMACIST: Input into computer as “amph12.5irr”
Send label for admixture
NURSE:
Conduct steps #2 through #5
1. Admix amphotericin B 12.5mg in 250ml sterile water.
2. Insert triple-lumen urethral catheter.
3. Instill solution into bladder, cross-clamp X 1.5 hours.
4. Drain.
5. Repeat above procedure on day 2; no further treatment unless specifically ordered
by physician.
16
Alcohol Withdrawal Syndrome Prophylaxis and Treatment Protocol
Instructions for use on reverse side. Use of this protocol requires MD authorization.
1.
Implement Withdrawal Syndrome (DT) Precautions
2.
Thiamine 100 mg po daily x 3 days
Folic Acid 1 mg po daily x 3 days
Therapeutic multivitamin 1 tablet po daily
If patient unable to take PO:
Thiamine 100 mg IV, Folic Acid 1 mg IV in NS 100 mL daily x 3 days
Select one or more from the following:
*1
3. Patient at Low Risk for alcohol withdrawal delirium :
(This regimen preferred for patients with COPD or respiratory illness)
 Lorazepam 1 mg PO or IV q 1 hr prn early withdrawal symptoms. (Riker Goal=4)
4.
Patient at High Risk for alcohol withdrawal delirium *2:
 Lorazepam 1 mg PO or IV q 1 hr prn early withdrawal symptoms and scheduled lorazepam 2 mg
PO or IV q 4 hr X 12 doses followed by 1 mg q 6 hr X 6 doses, then discontinue lorazepam.
Nurse: Document Riker score on MAR prior to each scheduled dose. Hold dose if patient sedated
or Riker score < 4.
5.
Alcohol withdrawal delirium (Delirium Tremens) Treatment Regimen*3:
Nurse: Document time and date of DT onset:________________
Notify MD of DT’s immediately and inquire regarding ICU transfer.
Begin Lorazepam 2 mg IV q 15 minutes prn and haloperidol 5 mg IV q 4 hr prn severe agitation (Riker Goal = 4). Only give
haloperidol after patient has received at least 10 mg lorazepam.
6.
Physician’s Signature: __ ______________________________________________
Riker Sedation/
Agitation Level
(7)
Dangerous Agitation
(6)
Very agitated
(5)
Agitated
Sedation
Goal
Description
Pulls at IV; Tries to remove catheters; Climbs over bedrail; Strikes staff; Thrashes from side to side
Does not calm despite frequent verbal reminding of limits;
Requires physical constraints
Anxious or mildly agitated; Attempts to sit up; Calms down to verbal instructions
Calm; Awakens easily; Follows commands
(4)
Calm & cooperative
(3)
Sedated
(2)
Very sedated
(1)
Unarousable
Difficult to arouse; Awakens to verbal stimuli or gentle shaking but drifts off again;
Follows simple commands
Arouses to physical stimuli but does not communicate or follow commands; May move spontaneously
Minimal or no response to noxious stimuli; Does not communicate or follow commands
General Information:
DTs occur when early alcohol withdrawal symptoms are not promptly recognized and treated. Treatment with
benzodiazepines should reduce or eliminate withdrawal symptoms.
Early alcohol withdrawal symptoms to monitor all patients for include:
GI Complaints: Nausea, vomiting, anorexia
Peripheral Nervous System Hyperactivity: Tremor, tachycardia, tachypnea, hypertension, fever, and
diaphoresis
17
Drotrecogin alfa (Xigris) Guidelines and Standard Orders
*Prescribing is limited to ID and Pulmonary/Critical Care physicians and the
patient MUST be in the ICU*
1.
2.
3.
4.
Has life support been discussed? Is there reasonable expectation of survival?
Documented/suspected infection present & being appropriately
treated? Infectious source: _________________________________
Central venous access obtained?
Has the patient received adequate fluid resuscitation?
5.
Are >2 SIRS criteria present?
(a. HR > 90; b. RR > 20 or PaCO2 < 32; c. Temp > 38°C or < 36°C; d. WBC
>12, <4, or >10% bands)
6.
Has > 1 sepsis-induced organ failure below occurred in the last 48 hrs &
persisted?
a.
Cardiac: SBP <90 or MAP <70 for > 1 hr or need for vasopressor
therapy
b.
Renal: UOP <0.5ml/kg/hr for > 2 hr
c.
Hematologic: recent, unexplained decrease in PLT count to <80,000 or
>50% decrease in previous 3 days
d.
Lactic acidosis: pH <7.3 or base deficit > 5 with lactate >1.5 times
normal
e.
Respiratory: PaO2/FiO2 ratio <250
f.
Other {i.e. CNS (altered consciousness, ↓ GCS), Hepatic (T.Bili >2
mg/dl x 2 days)}:____________________________
7.
Are the following contraindications absent?
a.
Active (significant) bleeding from any source
b.
GI bleed requiring transfusion in the last 72 hrs
c.
<3 months post hemorrhagic CVA, or <2 months s/p intracranial/spinal
surgery or head trauma
d.
History of intracerebral AV malformation, cerebral aneurysm, or mass
lesion of the CNS
e.
Presence of an epidural catheter, or <12 hrs post surgery requiring
general or spinal anesthesia
f.
Known hypersensitivity to drotrecogin alfa (activated)
8.
The following conditions that may increase risk for adverse events with
drotrecogin alfa have been carefully considered & the benefits of therapy
outweigh the potential risks?
a.
INR>3
b.
Recent (in the last 7 days) use of glycoprotein IIb/IIIa inhibitors
18
c.
d.
e.
f.
g.
h.
i.
j.
k.
Recent (in the last 3 days) use of thrombolytics
Anticoagulation with LMWH /heparin (in the last 12 hrs)
Warfarin, aspirin >650 mg/day, or other platelet inhibitors (in the last 7
days)
Cirrhosis with portal hypertension
Known bleeding disorder (i.e. hemophilia) or hypercoagulable state (i.e.
protein C deficiency)
PLT count < 30,000 (even if PLT count is increased after transfusions)
<3 months post ischemic stroke
<6 weeks post GI bleed
Recent surgery (within the last 30 days)
9.
Discontinue drotrecogin alfa for signs/symptoms of bleeding and 2 hours prior
to any surgical or invasive procedure; resume infusion per M.D. instructions.
10.
CBC daily x 4 (while receiving drotrecogin alfa).
11.
If the answer to questions 1-8 is YES, start drotrecogin alfa by continuous
infusion at 24 mcg/kg/hr for a total duration of 96 hrs. Infuse drotrecogin
alfa through a dedicated IV line.
Patient weight (kg) _______________
Weight must be documented to ensure accurate dosing
19
Glycoprotein IIb/IIIa Inhibitor Dosing Protocols/Orders
1. SCr: ___________ mg/dl
Is patient on dialysis Y
N
2. Platelet count ____________
If labs are > 48 hrs old obtain labs as STATs.
Initial dosing will be based on CrCl > 30ml/min until labs return.
2. Patient’s Weight: __________ kg
Height: ___________ cm
4. Check one drug and corresponding dose:
____ Abciximab (ReoPro®)
If platelet count < 100,000, abciximab is contraindicated and will not be given.
0.25mg/kg IV bolus followed by 0.125mcg/kg/min IV infusion (max 10
mcg/min)
ReoPro will automatically be discontinued 12 hours after PCI unless indicated:
Discontinue ReoPro at: _______________
____ Eptifibatide (Integrilin®)
If patient is on dialysis, eptifibatide is contraindicated and will not be given.
If calculated CrCl < 50 ml/min (based on actual body weight), the infusion rate
will be automatically reduced to 1mcg/kg/min.
a. ______ ACS dose: 180mcg/kg IV bolus over 1 min followed by
2mcg/kg/min IV infusion
b. ______ Cath lab dose: 180mcg/kg bolus x 2, 10 minutes apart.
Continuous 2mcg/kg/min IV infusion following first bolus.
(Note: this dose is only for initiating Integrilin in the cath lab at the onset
of PTCA/stent.)
Integrilin will be automatically discontinued 24 hours after PCI unless
indicated:
Discontinue Integrilin at: _______________
_________________________________________ M.D.
20
(Place Patient Sticker Here)
PHYSICIAN’S ORDERS
HT:
cm
WT:
kg
DATE:
Allergies:
TIME:
P&T STANDARD HEPARIN PROTOCOL
(For use at Methodist Germantown, MECH, North, SNF, South, and University Hospitals.)
(This protocol is not intended for use in stroke patients nor pediatric patients).
1. Verify indication; DVT / PE? [ ] No [ ] Yes (Contact physician if indication not specified).
2. Is patient on any other form of heparin (enoxaparin / dalteparin / fondaparinux)?
[ ] No [ ] Yes
If No; Go to step 3
If Yes;
• Discontinue all other forms of heparin
• If on full dose anticoagulation, delay Heparin bolus / infusion for 12 hours after last dose
• If on prophylaxis doses, no delay is necessary
3. If patient has IM injection orders, Call MD for clarification (IM injections not recommended while on Heparin; may
vaccinate if aPTT less than 110 seconds).
4. Labs: (do not interrupt Heparin Infusion to collect labs nor collect from Heparin infusion IV line or distally).
• Start second IV line access (INT) for blood draws if necessary.
• Obtain baseline aPTT and CBC without diff. (if not done in previous 48 hours)
• Call MD if baseline or subsequent platelet count is less than 100,000 / mm3 or if platelet count decreases by 50% from
baseline
• CBC without differential every AM
• aPTT six hours after starting infusion (order as “time priority”)
• aPTT every AM after Heparin Infusion begun and therapeutic range (aPTT 65 – 110 seconds) achieved.
5. Give Heparin Initial Bolus prior to beginning infusion
Indication is NOT DVT / PE
Indication is DVT / PE
Heparin Bolus IV push
Heparin Bolus IV push
[ ] No bolus per physician order
[ ] Weight less than 90 kg, give 5,000 units
[ ] Weight less than 50 kg, give 2,500 units
[ ] Weight 90–110 kg, give 7,500 units
[ ] Weight greater than 50 kg, give 5,000 units
[ ] Weight greater than 110 kg, give 10,000 units
6. Initial rate after bolus (use standard Heparin pre-mixed concentration of 20,000 units / 500 ml D5W).
Indication is NOT DVT / PE
Indication is DVT / PE
[ ] If weight equal to or greater than 58 kg,
[ ] If weight equal to or greater than 87kg
initial rate is: 25 ml/hr.
initial rate is: 38 ml/hr
[ ] If weight less than 58 kg, calculate initial rate. Initial rate = [ ] If weight less than 87 kg, calculate initial rate. Initial rate=
Weight (in kg) divided by 2.3 =
ml/hr
Weight (in kg) divided by 2.3=
ml/hr
7. Titration
aPTT Value
(in seconds)
≤ 49.9 sec
50-64.9 sec
65-110 sec
110.1-124.9 sec
≥ 125 sec
Additional Action
Rate Change (in ml/hr)
Give bolus
(same dose as initial bolus
N/A
N/A
N/A
Hold infusion for 1 hour
Increase rate by 240 units / hr (6 ml / hr)
Increase rate by 120 units / hr (3 ml / hr)
Maintain same rate
Decrease rate by 120 units / hr (3 ml / hr)
Decrease rate by 240 units / hr (6 ml / hr)
Additional Labs (order as
“time priority)
Repeat aPTT in 6 hours
Repeat aPTT in 6 hours
N/A
Repeat aPTT in 6 hours
Repeat aPTT 6 hours after
infusion resumed
8. Update Heparin Protocol Flow Record (including all aPTT and platelet values, boluses, rates, and changes).
9. Discontinue daily CBC without Differential and daily aPTT when Heparin Protocol discontinued.
Physician Signature:
Physician Number:
Date/Time
RN Signature:
066-P&T-MED-0707-VER2HPR-UNG
Date/Time
CANARY - CHART
•
WHITE - PHARMACY
21
(Place Patient Sticker Here)
PHYSICIAN’S ORDERS
HT:
cm
WT:
Allergies: _H_e_p_a_r_in
DATE:
kg
TIME:
HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) PROTOCOL
ARGATROBAN
Orders completed by Nursing
1. Page Clinical Pharmacy Specialist / Coordinator for initiation and daily follow-up.
2. Order CBC without differential DAILY.
3. Draw baseline aPTT prior to infusion.
4. STAT aPTT 2 hours after the start of the continuous infusion and 2 hours after any rate change.
5. Stop all heparin or low-molecular weight heparin, including flushes or locks
6. Label all IV sites or catheters as “NO HEPARIN”
7. Adjust rate of infusion based upon Argatroban Dose Adjustment Instructions.
APTT
(seconds)
Greater than
90
45-90
Less than 45
8.
9.
10.
11.
ARGATROBAN DOSE ADJUSTMENT INSTRUCTIONS
(Use Standard Concentration 1 mg / mL)
Dose Adjustment /Monitoring
***(Maximum rate NOT TO EXCEED 10 mcg/kg /min or
ml / hour)***
Stop infusion for 1 hour and then restart at 50% slower rate.
(Reminder - Draw aPTT 2 (two) hours after each rate change)
Continue at current rate. Draw aPTT in AM
Increase infusion rate by 20%. (Reminder - Draw aPTT 2 (two) hours after each rate change)
Document the initiation, the rate, rate changes, and discontinuation on the HIT Protocol Flow Record.
Document time of drawing and results of each aPTT value on the HIT Protocol Flow Record.
Discontinue daily CBC and aPTT when Argatroban is discontinued.
If any two sequential aPTTs exceed 90 seconds, page the Clinical Pharmacy Specialist / Coordinator at
Orders for Pharmacist
1. Order bilateral lower extremity ultrasound for DVT if not done
2. Discontinue active orders for any heparin or LMWH and add to allergy list
Initial Maintenance Infusion:
Total Bilirubin
Equal to or less than 1.5 mg / dL
Exceeds 1.5 mg / dL
Equal to or less than 1.5 mg / dL AND Patient critically ill
3. Enter initial infusion rate
.
Dose
2 mcg / kg / min
0.5 mcg / kg / min
1 mcg / kg / min
mL/hr
Oral Anticoagulation (Physician Orders)
❏ Warfarin Dosing Service to follow & begin anticoagulation with warfarin after platelet count recovery & when physician
specifies.
❏ Do not consult Warfarin Dosing Service. MD to manage warfarin.
Physician Signature:
Warfarin Management Recommendations (Not Orders)
1.
Do not start warfarin until platelets greater than (> 100-150/mm3).
2.
Use doses no greater than 5 mg to initiate warfarin therapy
3.
Minimum of 5 days overlap with argatroban and warfarin.
4.
NOTE: Argatroban prolongs the INR, therefore it must overlap with warfarin until INR greater than 4
5.
If rate is less than 2 mcg/kg/min stop infusion
a. Obtain INR 4-6 hours after stopping argatroban infusion
b. If INR 2-3 (therapeutic), continue with warfarin monotherapy
c. If INR less than 2 (sub-therapeutic) resume argatroban at previous rate & repeat procedure the following day
6.
If rate is greater than 2 mcg/kg/min reduce to 2 mcg/kg/min
a. Obtain INR in 4-6 hours, if INR greater than 4, stop argatroban
b. Obtain INR 4-6 hours after stopping argatroban infusion
c. If INR 2-3 (therapeutic), continue with warfarin monotherapy
d. If INR less than 2 (sub-therapeutic) resume argatroban at previous rate & repeat procedure the following day
Physician Number:
Date/Time
RN Signature:
202-P&T
Date/Time
CANARY - CHART
•
WHITE - PHARMACY
22
(Place Patient Sticker Here)
PHYSICIAN’S ORDERS
HT:
cm
WT:
kg
Allergies:
DATE:
H_e_p_a_ri_n
TIME:
HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) PROTOCOL
FONDAPARINUX (ARIXTRA)
Orders completed by Nursing
1. Page Clinical Pharmacy Specialist / Coordinator for initiation and daily follow-up.
2. Order CBC without differential DAILY
3. Discontinue lepirudin or argatroban, obtain aPTT every 4 hours until aPTT is less than 45 seconds prior to start of
fondaparinux
4. Stop all heparin or low molecular weight heparin, including flushes or locks
5. Label all IV sites or catheters as “NO HEPARIN”
6. Document medication administration on MAR (Do not use HIT Flow Record).
Orders for Pharmacist
1. Order bilateral lower extremity ultrasound for DVT if not done
2. Discontinue active orders for any heparin or LMWH and add to allergy list
3. Discontinue lepirudin or argatroban if patient is currently receiving
4. Do not start fondaparinux until aPTT is less than 45 seconds if patient has previously received lepirudin, argatroban, or
heparin
5. Dose based on criteria below:
If NOT acute HIT:
Weight
Greater than 50 kg
Dose
2.5 mg subcutaneously every Day
If acute HIT or thrombosis is present:
Weight
Dose
Less than 50 kg
5 mg subcutaneously every Day
50-100 kg
7.5 mg subcutaneously every Day
Greater than 100 kg
10 mg subcutaneously every Day
6. Give
mg subcutaneously every Day.
Oral Anticoagulation (Physician Orders)
❏ Warfarin Dosing Service to follow & begin anticoagulation with warfarin after platelet count recovery & when physician
specifies.
❏ Do not consult Warfarin Dosing Service. MD to manage warfarin.
Warfarin Management Recommendations (Not Orders)
1. Do not start warfarin until platelets greater than (> 100-150 / mm3)
2. Use doses no greater than 5 mg to initiate warfarin therapy
3. Minimum of 5 days overlap with fondaparinux and warfarin
4. Must overlap warfarin with fondaparinux until therapeutic INR for 2 consecutive days
Physician Signature:
Physician Number:
RN Signature:
Date/Time
Date/Time
MR
204-P&T
CANARY - CHART
•
WHITE - PHARMACY
23
(Place Patient Sticker Here)
PHYSICIAN’S ORDERS
HT:
cm
DATE:
WT:
kg
Allergies: _H_e_p_a_r_in
TIME:
HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) PROTOCOL
for LEPIRUDIN (REFLUDAN)
Orders completed by Nursing
1. Page Clinical Pharmacy Specialist / Coordinator for initiation and daily follow-up.
2. Order CBC without differential daily.
3. Draw baseline aPTT prior to infusion, then aPTT 4 hours after the start of the continuous infusion and 4 hours after any rate
change.
4. Stop all heparin or low-molecular weight heparin, including flushes or locks
5. Label all IV sites or catheters as “NO HEPARIN”
6. Discontinue daily CBC and aPTT when Lepirudin is discontinued.
7. Adjust rate of infusion based upon Lepirudin (Refludan) Dose Adjustment Instructions.
LEPIRUDIN DOSE ADJUSTMENT INSTRUCTIONS
APTT (seconds)
Dose Adjustment /Monitoring
Greater than 75 Stop infusion 2 hours and then restart at 50% slower rate. Draw aPTT 4 hours after rate change
45-75
Continue at current rate. Draw aPTT in AM
Increase infusion rate by 20%. Draw aPTT 4 hours after rate change
Less than 45
8. If any two sequential aPTTs exceed 75 seconds, page the Clinical Pharmacy Specialist / Coordinator at
9. Document the time of initiation, the rate, rate changes, and discontinuation on the (HIT) Protocol Flow Record.
10. Document time of drawing and results of each aPTT value on the Protocol Flow Record.
.
Orders for Pharmacist
1. Order bilateral lower extremity ultrasound for DVT if not done.
2. Discontinue active orders for any heparin and LMWH and add to allergy list
3. Calculate CrCL (Cockroft-Gault Equation) & document in medical record. Call MD to recommend argatroban
if CrCL < 30 mL/min.
Optional Bolus: Appropriate if life-threatening thrombosis and low bleeding risk
CrCL (mL/min)
Dose
0.2 mg/kg
less than 60
greater than 60
0.4 mg/kg
Administer bolus over 1 minute
4. If bolus indicated, circle;
Yes
No;
Enter bolus dose (if applicable)
Initial Maintenance Infusion: (Use standard concentration of 0.4 mg / mL)
CrCL (mL/min)
Dose
15-29
0.01 mg/kg/hr
30-44
0.03 mg/kg/hr
45-60
0.05 mg/kg/hr
>60
0.1 mg/kg/hr
5. Enter initial infusion rate
RN Signature:
mg
Dose limit
1.1 mg/hr (max rate of 2.8 mL/hr)
3.3 mg/hr (max rate of 8.3 mL/hr)
5.5 mg/hr (max rate of 13.7 ml/hr)
11 mg/hr (max rate of 27.5 mL/hr)
mL/hr
Oral Anticoagulation (Physician Orders)
❏ Warfarin Dosing Service to follow and begin anticoagulation with
warfarin after platelet count recovery and when physician specifies.
❏ Do not consult Warfarin Dosing Service. MD to manage warfarin.
Physician Signature:
Dose limit
Not to exceed 22 mg
Not to exceed 44 mg
Physician Number:
Warfarin Management Recommendations (Not Orders)
1.
Do not start warfarin until platelets greater than (> 100-150/mm3).
2.
Reduce infusion until aPTT 45–50 seconds prior to starting warfarin.
3.
Use doses no greater than 5 mg to initiate warfarin therapy
4.
Minimum of 5 days overlap with lepirudin and warfarin.
5.
When INR greater than 2 for two days, stop lepirudin.
Date/Time
Date/Time
24
Adult Patient Controlled Analgesia (PCA) Orders
This form should be used for all new PCA orders and dose modifications.
Physician: Check ONE of the boxes below and complete. Each blank must be complete in the
appropriate section for order processing.
MorPHINE PCA Per Protocol
For opioid naïve patients
(concentration: 1 mg/mL)
MorPHINE PCA (non-protocol)
(concentration: 1 mg/mL)
Basal rate: none unless box checked below
Basal rate:
Bolus/demand dose:
Bolus/demand dose: ____mg/dose
Delay (lockout):
1 mg/dose
10 minutes
1 hour limit:
6 mg per hour
______per hour
Delay (lockout):
_____minutes
1 hour limit:
______per hr
7 mg per hour if basal rate selected
Add basal rate:
1 mg per hour
HYDROmorphone PCA per protocol
(Dilaudid) For opioid naïve patients
(concentration: 1 mg/mL)
HYDROmorphone PCA (non-protocol)
(Dilaudid) (concentration: 1 mg/mL)
Basal rate: none unless box checked below
Basal rate:
Bolus/demand dose:
0.2 mg/dose
Bolus/demand dose: ____mg/dose
Delay (lockout):
10 minutes
Delay (lockout):
1 hour limit:
1.2 mg per hour
1 hour limit:
______per hour
_____minutes
____per hour
1.4 mg per hour if basal rate selected
Add basal rate:
0.2 mg per hour
Non-protocol PCA Orders
(medication):________________________________________
Basal rate (if needed):
_________________per hour
Bolus/demand dose:
_________________mg/dose
Delay (lockout):
1 hour limit:
_________________minutes
_________________per hour
Physician Signature:
Physician Number:
Date/Time
_____________________________________________________________
RN Signature:
Date/Time
_____________________________________________________________
25
(Place Patient Sticker Here)
Maximally Concentrated PCA Order for Adults
Only those experienced with the management of patients with very high opiate tolerance may
prescribe a maximally concentrated PCA. This protocol is intended for patients with high opioid
requirements, i.e. at least equivalent to morPHINE 50 mg IV per shift or HYDROmorphone 50
mg IV per shift. For patients with lower requirements, use the “Adult Patient Controlled
Analgesia (PCA) Orders form.
Physician: Select ONE of the opioids below and complete the dosing information:
MorPHINE PCA – maximally concentrated
(Maximum concentration: 5 mg/mL)
Basal rate dose:
______________________ per hour
Bolus/demand dose: ______________________ mg/dose
Delay (lockout):
______________________
1 hour limit:
______________________
HYDROmorphone (Dilaudid) PCA
(Maximum concentration: 10 mg/mL)
Basal rate dose:
______________________ per hour
Bolus/demand dose: ______________________ mg/dose
Delay (lockout):
______________________
1 hour limit:
______________________
Physician Signature:
Physician Number:
Date/Time
___________________________________________________________________
RN Signature:
Date/Time
26
CRITICAL CARE –
INTENSIVE INSULIN THERAPY
Page 1 of 2
HT:
cm
WT:
kg
DATE &
TIME
DA
TE
&
PROGRESS RECORD
PHYSICIAN’S ORDERS AND DIET
Note Progress of Case, Complications, Consultations, Change in
Diagnosis, Condition on Discharge, Instructions to Patient.
RESTRICTION:
Patients must be in an intensive care unit
PHYSICIAN
1) Order “Intensive Insulin Protocol.”
2) All patients must have a blood glucose (BG) > 150 mg/dL x 2 measurements
3) This is NOT for the treatment of DKA.
PHARMACIST
1) D/C all previous insulin orders (including insulin in TPN) and antidiabetic medication orders.
2) Verify patient is receiving some source of exogenous glucose (e.g. tube feeds, D5, TPN) prior to initiating infusion.
3) Standard IV Insulin Infusion: 100 units Regular Human Insulin/100 ml NS (Final conc: 1 unit/ml)
NURSING
1) If patient has insulin in TPN, contact Nutrition Support Team to remove insulin from TPN with next bag change.
2) Stat serum potassium (K+)before starting insulin infusion, if no recent K+ available. If K+ is <3.3 call MD for K+
replacement orders before starting insulin infusion.
3) Change insulin drip every 24 hours.
4) Check bedside BG before starting infusion and Q1H.
Change to Q2H Accuchecks when BG has remained in the goal range for 4 hours.
If BG remains within goal range for 4 consecutive Q2H Accuchecks (8 hours), may decrease Accuchecks to Q4H.
5) Resume Q1H Accuchecks any time the infusion is stopped & restarted, for any infusion rate change or change in
nutrition infusion rates.
6) Document infusion rate and BG values on flow sheet.
7) HOLD insulin infusion if TPN or continuous enteral feeds are stopped for any reason unless the patient is receiving
another source of exogenous glucose. (e.g.D10W, D5W). Resume insulin infusion when TPN/enteral feedings are
resumed. Resume insulin at the previous rate if TPN/enteral feedings are resumed at the previous rate.
If TPN/enteral feedings are resumed at a different rate check BG 1 hr after feedings are resumed and start insulin
protocol from the beginning.
HOLD insulin infusion if patient is out of the ICU for a procedure. Restart upon return to ICU.
8) Discontinue intensive insulin protocol when patient is transferred from the ICU and initiate standard insulin sliding scale
orders unless otherwise indicated by MD.
Goal: The goal is to maintain serum glucose from 80 to 150 mg/dL.
Initiating the Insulin Drip:
Glucose:
151-190 mg/dL
IVP Bolus:
2 units
Initial Rate:
1 unit/hr
191-240 mg/dL
4 units
2 units/hr
241-300 mg/dL
6 units
3 units/hr
301-400 mg/dL
10 units
4 units/hr
>400 mg/dL
14 units & call MD
4 units/hr
1) **If BG drops by more than 100 mg/dL from previous reading at any time, decrease rate by 50% and recheck
BG in 1 hr.**
2) **If BG drops by more than 50 mg/dL from the previous reading at any time, decrease rate by 25% and recheck
BG in 1 hr.**
223-P&T-PULM/CC-0906-VER2
27
DATE &
TIME
PHYSICIAN’S ORDERS AND DIET
DATE &
TIME
PROGRESS RECORD
Note Progress of Case, Complications, Consultations, Change in
Diagnosis, Condition on Discharge, Instructions to Patient.
Adjust insulin rate as follows: (target blood glucose range 80-150 mg/dL)
Drip Rate
Drip Rate
Drip Rate
Drip Rate
Drip Rate
Glucose
1-3 units/hr
4-6 units/hr
7-10 units/hr 11-14 units/hr 15-18 units/hr
Drip Rate
>18 units/hr
<60 mg/dL
D/C infusion and give 1 amp D50 IVP: Call MD and recheck glucose in 15 min.
1. If glucose remains less than 60 mg/dL, repeat 25ml D50 IVP every 15 minutes until
glucose >80 mg/dL.
2. When glucose >100mg/dL, restart insulin infusion at 1/2 the previous rate (rounded to the
nearest whole unit).
61-79 mg/dL
D/C infusion and recheck glucose in 1 hr.
1. If glucose remains less than 80 mg/dL, repeat 25ml D50 IVP every 15 minutes until
glucose >80 mg/dL and call MD.
2. When glucose >100mg/dL, restart insulin infusion at 1/2 the previous rate (rounded to the
nearest whole unit).
Glucose
Drip Rate
1-3 units/hr
Drip Rate
4-6 units/hr
No Changes Now – If glucose
continues to decrease
80-150 mg/dL >20mg/dL over 2 consecutive
Accuchecks; decrease rate by
1 unit/hr
Drip Rate
Drip Rate
Drip Rate
7-10 units/hr 11-14 units/hr 15-18 units/hr
No Changes Now – If glucose
continues to decrease
>20mg/dL over 2 consecutive
Accuchecks; decrease rate by
2 units/hr
No Changes Now – If glucose
continues to decrease
>20mg/dL over 2 consecutive
Accuchecks; decrease rate by
4 units/hr
Drip Rate
1-3 units/hr
Drip Rate
4-6 units/hr
Drip Rate
Drip Rate
Drip Rate
7-10 units/hr 11-14 units/hr 15-18 units/hr
151-190 mg/dL
Increase drip
by 0.5 units/hr
Increase drip
by 1 unit/hr
Increase drip
by 1.5 units/hr
Increase drip
by 2 units/hr
Increase drip
by 2.5 units/hr
191-240 mg/dL
Increase drip
by 1 unit/hr
Increase drip
by 2 units/hr
Increase drip
by 3 units/hr
Increase drip
by 4 units/hr
Increase drip
by 5 units/hr
Increase drip
241-300 mg/dL
by 1 unit/hr
Increase drip
by 2 units/hr
Increase drip
by 3 units/hr
Increase drip
by 4 units/hr
Increase drip
by 5 units/hr
301-400 mg/dL
Increase drip
by 2 units/hr
Increase drip
by 3 units/hr
Increase drip
by 4 units/hr
Increase drip
by 5 units/hr
Increase drip
by 6 units/hr
>400 mg/dL***
Increase drip
by 2 units/hr
Increase drip
by 3 units/hr
Increase drip
by 4 units/hr
Increase drip
by 5 units/hr
Increase drip
by 6 units/hr
Glucose
Drip Rate
>18 units/hr
Drip Rate
>18 units/hr
CALL
physician
for a
new order
***If still >400 mg/dL after 1 hr – Call MD
28
ADULT Pharmacological Protocol for Pediculosis (lice) & Scabies
PHYSICIAN:
Write order for “Lice/scabies treatment per protocol.”
PHARMACIST: Input orders into computer for permethrin.
For lice: input “PRN” orders for 7 days later with note: “Contact
pharmacy for dose if live lice still present”
For scabies: input “PRN” orders for 14 days later with note:
“Contact pharmacy for dose if live mites still present”
Dispense permethrin 1% (NIX) with “nit comb”
NURSE:
Contact Infection Control.
See Protocol below.
Protocol - Head Lice:
• Wash hair, rinse with water, towel dry
• Apply 1% permethrin - Use sufficient volume to saturate hair and scalp
• Leave drug in contact with hair for 10 minutes
• Rinse with water
• Remove nits using “nit comb” while hair is still wet
Individuals should remove the nits for aesthetic reasons or to decrease diagnostic
confusion. A fine toothed “nit comb” can be used to make nit removal easier. The
comb should be used on wet hair in order to remove the nits; combing dry hair
does not seem to have the same effect.
• Repeat application if live lice present 7 days after initial treatment
Protocol - Scabies:
• Apply 30 gm of 5% permethrin for the average adult - no prior bathing required
• Apply to entire skin from jawline downwards, including all skin folds, groin,
navel, external genitalia, and the skin under the nails
• Remove 8 to 14 hours after application by washing
• Repeat application if living mites present 14 days after initial treatment
Pregnancy:
Permethrin (or pyrethrins with piperonyl butoxide) is the treatment of choice for pubic
lice in pregnant women as designated by the Centers for Disease Control and
Prevention (CDC). Although not specifically mentioned, permethrin could also be
used if other body areas of a pregnant woman are infested with lice (i.e., the head). It
is classified as pregnancy category B.
29
Sliding Scale Regular/NovoLOG Insulin Protocol
*Use regular insulin unless NovoLOG is specifically stated by
physician*
Regular Human Insulin (NovoLIN) OR
Insulin Aspart (NovoLOG)
1.
2.
Standardized Sliding Scale
0-60
Initiate Hypoglycemic Protocol (see below)
61-150
No Insulin
151-200
3 units SQ
201-250
5 units SQ
251-300
8 units SQ
301-350
10 units SQ
351-400
12 units SQ
>400
15 units SQ and call MD
Accuchecks AC and HS, or Q6h if patient is NPO, on TPN or on continuous
tube feedings.
HYPOGLYCEMIA PROTOCOL ORDERS
Patient symptomatic, but responsive:
1. Check blood glucose per meter.
2. If blood glucose <60 mg/dL:
A. Give ½ cup fruit juice without
sugar or 4 oz 2% milk AND if
symptoms occur prior to
mealtime, allow patient to eat
without delay.
B. Wait 15 minutes after juice or
milk.
C. If symptoms are absent,
procedure complete
D. If symptoms are present, recheck
blood glucose.
E. Repeat treatment until blood
glucose > 80mg/dL, or
symptoms relieved
1.
2.
3.
4.
Patient unresponsive:
Check blood glucose per meter.
If blood glucose < 60 mg/dL:
A. If IV present, give 50 gm D50W.
If no IV present, give 1 ml
glucagon SQ with an insulin
syringe.
B. Wait 5 minutes after D50W.
Wait 20 minutes after glucagon.
C. Recheck blood glucose.
If patient responsive after 1 & 2:
A. Give 8 oz 2% milk and 1 bread
exchange.
B. Wait 15 minutes.
C. Recheck blood glucose.
D. Repeat oral treatment until blood
glucose > 80 mg/dL.
If patient unresponsive after 1 & 2
A. Draw stat lab blood glucose.
B. Give 50-100 grams D50W IV.
Do not wait on lab results.
C. Notify MD for further order
30
METHYLPREDNISOLONE (SOLU-MEDROL) PROTOCOL FOR
SPINAL CORD INJURY
1.
2.
•
3.
Methylprednisolone 30 mg/kg IV over 15 minutes STAT
Maintenance infusion (begun 45 min after end of bolus infusion):
Begin 5.4mg/kg/hr IV in 500ml normal saline
Continue infusion for:
□ 23 hours if dose started 0 to 3 hours post injury
□ 47 hours if dose started 3 to 8 hours post injury
4. Start Methodist sliding scale insulin per protocol with accuchecks every 6 hours
Methylprednisolone Spinal Cord Injury Protocol: Instructions for Preparation
and Administration
1. Bolus infusion
•
30 mg / kg IV in 50 ml of 0.9% normal saline over 15 minutes
2.
•
•
•
Maintenance infusion:
Started 45 min after end of bolus infusion
5.4mg/kg/hr IV in 500ml normal saline at 22ml/hr.
Reconstitute dose with fluid from 500ml normal saline bag. Total volume should equal 500ml
normal saline.
• See table for preparing the maintenance infusion
• Two bags needed to complete the 47 hour infusion
Patient weight
(kilograms)
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
Dose (milligrams) to add to 500
ml 0.9% normal saline
5,600 mg
6,200 mg
6,800 mg
7,500 mg
8,100 mg
8,700 mg
9,300 mg
9,900 mg
10,600 mg
11,200 mg
11,800 mg
12,400 mg
13,000 mg
13,600 mg
14,300 mg
14,900 mg
15,500 mg
Infusion rate
(milliliters/hour)
22
22
22
22
22
22
22
22
22
22
22
22
22
22
22
22
22
31
Thrombolytic Protocol for Declotting of Central Venous Access Devices
Methodist Healthcare – Memphis Hospitals
PHYSICIAN: Order as “Thrombolytic protocol for catheter clearance”
PHARMACIST: Input into computer.
Dispense Cathflo Activase vial and diluent (sterile water for injection, nonbacteriostatic)
NURSE: Place completed copy of protocol in orders section of the medical record.
Consult steps #1 through #6
1
1. Obtain Cathflo Activase (alteplase) from pharmacy after specifying the
type of catheter (or lumen volume) and number of lumens requiring
treatment.
2. Alteplase is not compatible with heparin or bacteriostatic solutions. If possible,
remove any heparinized saline or bacteriostatic NS from the catheter lumen
by aspiration or flushing, followed by flushing with non-bacteriostatic NS.
1
3. Prepare the solution:
1 a. Withdraw 2.2 ml of sterile water for injection (non-bacteriostatic)
2 b. Inject the 2.2 ml sterile water for injection (non-bacteriostatic) into
alteplase vial, directing the stream
3 into the powder. If slight foaming occurs, let the vial stand undisturbed
to allow large bubbles to dissipate.
4 c. Swirl vial gently until contents are completely dissolved. DO NOT
SHAKE.
2
4. Instilling the solution:
a. Inspect solution for foreign matter and discoloration
1 b. Withdraw 2 ml (2 mg) of reconstituted solution from vial into a 5 cc
luer lock syringe.
2 c. Instill alteplase dose (2 mg) slowly into catheter.
3 d. Allow the alteplase to dwell at least 30 minutes prior to aspirating.
4 e. If unable to aspirate, allow alteplase to dwell an additional 90 minutes
(120 minutes total) before re-attempting aspiration.
5 f. Label catheter “Do not use” until alteplase is removed.
6 g. If catheter clears, aspirate 4 to 5 mls of blood then flush catheter per
standard policy (see policy 006-002).
3
5. If patency is not restored, the alteplase dose may be repeated once.
32
6. If a repeat dose is necessary, allow at least a 1-2 hour dwell time (up to
overnight, if circumstance permits) prior to attempting aspiration. If the
catheter has not cleared, notify physician for additional orders.
Catheter
Dialysis Catheter
PermaCath
Central Line
(Single thru Quad)
Inner Volume
1.9-2.3 ml
1.9-2.3 ml
0.35-0.5 ml
PICC
Port-A-Cath (+
access device)
Hickman Catheter
Pherese-Flo
Catheter
Red line
Blue line
White line
Arrow Pheresis
Catheter
Blue line (12 G)
Red line (12 G)
Blue line (16 G)
0.4 ml
1.4 ml
Dose of Alteplase
2 mg in 2 ml
2 mg in 2 ml
2 mg in 2 ml
1.3 ml
1.7 ml
1.5 ml
0.9 ml
2 mg in 2 ml
1.3 ml
1.2 ml
0.35 ml
2 mg in 2 ml
Initiated per order of Dr._________________ / __________________RN
33
Antibiotic Lock Therapy Protocol for Intraluminal Catheter Infections
Methodist Healthcare - Memphis Hospitals
RESTRICTION: This protocol is restricted to infectious disease physicians and
nephrologists.
PHYSICIAN:
1 Physicians may order the protocol by writing "__________ per lock therapy
protocol”
2 Physicians must specify the antibiotic needed (list below), if heparin is needed (see
list below), and the number of lines/lumens the lock is to placed in. Physicians should
consult with nursing as to the administration of other medications through the line
being treated.
3 Antibiotics available for protocol use are:
Antibiotic
Amikacin
Ampicillin
Cefazolin
Ciprofloxacin
Gentamicin
Levofloxacin
Vancomycin
Concentrations
2 mg/ml
2 mg/ml
5 mg/ml
2 mg/ml
2 mg/ml
2 mg/ml
2 mg/ml
Compatible with 100
units/ml heparin
No, immediate precipitation
Yes
Yes
No, immediate precipitation
No, immediate precipitation
No, immediate precipitation
No, immediate precipitation*
*Conflicting data available - may use if prescriber insists.
1 All antibiotics will be placed in normal saline; 5 mls of solution will be dispensed
per treatment per lumen.
2 Lock therapy will run for 14 days, unless other orders are received by physician.
3 Other antibiotics may be used as literature and stability data permit, upon consult
with clinical specialist on call.
PHARMACIST:
1 Consult with nurse to determine number of syringes needed for administration.
For example, if line is to be used for bolus medications, one syringe will be needed to
use after each administration of bolus medication (q8 = three syringes). If line is not
to be used for medication administration, one syringe daily should be prepared.
2 Enter orders for appropriate antibiotic lock solution, utilizing concentrations above
and normal saline as diluent. Place 14 days stop in computer (unless other orders have
been specified by prescriber).
3 If heparin is requested, review compatibilities chart above. NOTE: heparin is
incompatible with most of the antibiotics used. Call prescriber to resolve difficulties.
4 IV room will prepare solutions utilizing dilutions of standard antibiotic
34
concentrations. This syringe will be labeled with the following information:
Antibiotic Name/Antibiotic concentration Antibiotic Lock
Protocol stock solution Expires: 14 days Date of preparation
Example: a protocol written for vancomycin antibiotic lock, final volume to be
5 mL.
The standard vial concentration of vancomycin is 100 mg/mL. However, the
concentration used
for the dose of vancomycin in this protocol is 10 mg/ml. To prepare this
concentration, the
following steps should be completed:
Dilute 1000 mg vial (1 gram) with 10 ml SWFI to give 100 mg/ml (solution A)
Take 1ml of solution A and dilute with 9 ml of SWFI or normal saline to yield 10
mg/ml stock
(solution B)
NURSE:
1 Place completed copy of protocol in orders section of the medical record.
2 Instill medication in lumen of affected catheter, as ordered by physician.
1 3.
Medication administration in lines receiving antibiotic therapy - it is vital
that lines undergoing antibiotic lock treatment receive the maximum dwell time with
the therapy. If the physician requires that other medication be infused through the
lumen being treated, the following procedure should be used.
1 Prior to administration of bolus medication, withdraw the antibiotic lock solution.
2 Flush lumen with normal saline.
3 Administer the ordered medication.
4 Flush lumen with normal saline.
5 Instill new antibiotic lock solution.
If continuous medications are infused through one or more lumens of a multilumen catheter undergoing antibiotic luck therapy, lumens will be alternated
with antibiotic lock solution and continuous medications every 12 hours.
4.
If no medications are needed to be infused through the lumen being treated,
instill new antibiotic solution every 24 hours.
35
Intravenous Anti-Hypertensive Protocol
Not recommended for Acute Ischemic Stroke patients
For University Hospital Only PHYSICIAN: Check one intravenous
antihypertensive medication
[ ] Diltiazem drip: 5 mg/hr. Titrate by 2.5 to 5 mg/hr as often as every 15
minutes to desired effect specified by MD or goal MAP range is achieved.
Maximum dose is 15 mg/hr.
[ ] NitroGLYcerin drip: 5 mcg/min. Titrate by 5 mcg/min as often as every 3 – 5
minutes to desired effect specified by MD or goal MAP range is achieved.
Maximum dose is 200 mcg/min.
Note: Nitroglycerin may be the preferred drug patients with acute coronary
syndromes or CHF.
[ ] NitroPRUsside drip: 0.5 mcg/kg/min. Titrate by 0.5 mcg/kg/min as often as
every 3 –5 minutes to desired effect specified by MD or goal MAP range is
achieved. Maximum dose is 10 mcg/kg/min.
Note: Nitroprusside is typically the drug of choice except in patients with renal
failure or neurosurgical
patients.
[ ] NiCARdipine drip: 5 mg/hr. Titrate by 2.5 mg/hr as often as every 15
minutes to desired effect specified by MD or goal MAP range is achieved.
Maximum dose is 15 mg/hr.
Note: Nicardipine may be the preferred agent in neurosurgical patients
NURSE: Baseline characteristics
Blood Pressure: ______________________________
Mean Arterial Pressure: ________________________
Heart Rate: __________________________________
Serum Creatinine: ____________________________
Goal within 2 hours Reduce MAP by NO MORE THAN 25% within the first
2 hours of infusion initiation.
Calculation:
_____(Baseline MAP) x 0.75 = _________ (25% reduction)
** reduce BP gradually without exceeding goal range**
Goal between 2 and 6 hours Continue infusion to achieve a 6 hour BP range
of 150 –170 / 90 – 100
36
AFTER ADMISSION TO ICU After 6 hour goal is achieved and transfer to ICU,
begin the following scheduled and PRN medications in order to maintain BP: 140-160
/ 90-100 mmHg
Oral medications to initiate after 6 hour goal is met:
Scheduled medications PRN medications for systolic BP > 160 mmHg
[ ] ________________________________________
[] Labetalol 10 – 20 mg IV q 30 min PRN []
________________________________________
[] Clonidine 0.1 mg PO q 1 hr PRN []
________________________________________
[] Hydralazine 10 – 20 mg IV q 4 hrs PRN []
________________________________________
[] Enalaprilat 0.625 – 1.25 mg IV q 6 hrs PRN
[] Other: __________________________
6 – 12 hours after oral medications started, begin to wean continuous infusion while utilizing
PRN’s.
PHARMACIST: Evaluate patient for oral therapy if intravenous regimen
exceeds 48hrs.
Physician Signature:
__________________________________________
37
Radiocontrast Nephropathy Prophylaxis Protocol/Orders
Risk factors: Diabetes, Heart Failure, Age > 75, SCr > 1.5 or Estimated GFR < 60 ml/min
Patient weight: ___________ kg
_____Standard Regimen
Sodium Bicarbonate—150 mEq/150 mL in 850 ml of D5W (Total volume: 1 liter)
Pre-contrast: Start infusion at 3 ml/kg/hr for 1 hour prior to procedure
Post-contrast: Continue infusion at 1 ml/kg/hr for 6 hours
AND
___Acetylcysteine (Mucomyst) 600 mg/ 3 ml solution po BID x 4 doses or _____ doses
___Acetylcysteine (Mucomyst) 1200 mg/ 3 ml solution po BID x 4 doses or _____ doses
Other regimen:__________________________________________________________________
_____Emergent Procedure Regimen
**Reserved for patients presenting with ST segment elevation MI or a condition requiring a
procedure to performed in less than 1 hour.**
Acetylcysteine (Acetadote) 1200 mg IV x 1given prior to the procedure, then Acetylcysteine
(Mucomyst) 1200 mg PO BID x 4 doses
AND
Normal Saline 0.9% 1000 ml to infuse at a rate of 1 ml/kg/hr x 12 hours post procedure.
________________________________________ M.D.
38
Post CV Surgery Diltiazem Atrial Fibrillation Protocol
**Do NOT use in heart failure patients*
RESTRICTION NOT for use in heart failure patients For use only with the CABG PostOp Caretrack
Guidelines:
Intended for patients who, within 72 hours of open-heart surgery, experience
1 – Sudden onset of atrial fibrillation (confirmed by 12-lead ECG) AND
2 – Accompanied by either ventricular response >120 beats per minute (bpm) lasting greater than
30 minutes OR symptoms such as lightheadedness, chest pain, dyspnea, dizziness or hypotension.
PHARMACIST 1. Input diltiazem bolus and drip with 72 hour automatic stop but do not send unless
nurse requests.
2. Place in NOTE field: "call Rx for dose if patient develops afib (per protocol)."
NURSING
1. Monitor patient for atrial fibrillation signs and symptoms.
1 Initiate protocol per guidelines (above), and place completed copy of protocol in orders section
of the medical record.
2 Call pharmacy for diltiazem drip when needed.
DO NOT USE IN HEART FAILURE PATIENTS
Give Diltiazem 0.25 mg/kg IV over 2 minutes (maximum dose = 20 mg).
After 15 minutes:
1
If HR < 120 bpm, start Diltiazem infusion at 10 mg/hour.
1 2. If HR > 120 bpm and SBP > 100 mmHg, rebolus with Diltiazem 0.35 mg/kg IV (maximum
dose = 25 mg). Then, after 15 minutes,
2 a. Start Diltiazem infusion at 10 mg/hour.
3 b. If HR > 120 bpm and SBP > 100 mmHg, may increase diltiazem infusion in 5 mg increments,
up to 20 mg/hour
2 If HR < 120 bpm for at least 2 hours, start Diltiazem 60 mg po q6h and discontinue
infusion 2 hours after first oral dose.
1 4. If HR > 120 bpm after 4 hours, call the Cardiologist.
2 Call cardiologist if still symptomatic and/or:
SBP < 100 mmHg,
ventricular response > 120 bpm at maximum dose,
diltiazem not tolerated,
chest pain
3 Discontinue Diltiazem infusion when patient converts to sinus rhythm OR if patient has adverse
effects from Diltiazem (e.g., AV block, bradycardia, hypotension, decreased cardiac output).
4 Notify Cardiologist during rounds in AM after initiation of protocol.
5 Patient is to remain on Cardiac Surgery Pathway and participate in all activities, including
cardiac rehabilitation, if not symptomatic.
39
Colchicine Guidelines
These guidelines apply for when colchicine is used for acute gout attacks.
PHARMACIST: Complete steps before dispensing doses>0.6 mg TID
I.
Contraindications (If present, call MD and do not dispense)
Diagnosis of ESRD and Liver Failure Combined
Neutropenia (WBC<3500/mm3)
II.
Precautions
Age > 65 years
Renal dysfunction (est. CrCl < 50 ml/min)
III.
Cumulative Dose Limits- IV Colchicine:
When determining the patient’s cumulative dose, you must add together all
doses used to treat the acute attack, and not just what the patient had in the last
24 hours. When IV and PO doses of colchicine are given for an acute attack,
you must add these doses together in order to determine the total cumulative
dose.
If no precautions, the maximum cumulative dose is 4 mg.
If one or more precautions present, the maximum cumulative
dose is 2 mg.
Once a cumulative dose limit is reached in a patient that has received IV
colchicine, no further colchicine (even for prophylaxis) may be given for at
least one week in those patients without precautions, or 3 weeks in patients with
precautions.
Daily Dose Limits- PO Colchicine:
If no precautions, the maximum daily dose is 8 mg.
If one or more precautions present, the maximum daily dose is 4 mg.
*When an order for PRN colchicine is entered into Cerner do not send any doses until
the drug is requested by nursing staff. When doses are requested you must check the
history to ensure that the maximum cumulative dose has not been exceeded. Always
check to see if patient has received any doses of IV colchicine.
40
MANAGEMENT OF HYPOMAGNESEMIA
CAUSES: Dietary deficiency/malnutrition, intestinal loss (diarrhea, laxative use),
alcoholism, drug-induced renal losses (amphotericin B, cisplatin,
diuretics, aminoglycosides)
SIGNS/SYMPTOMS:
Muscle weakness, vertigo, ataxia, seizures, anxiety, psychosis, confusion,
paresthesias, cardiac arrhythmias
GUIDELINES FOR REPLACEMENT*
Serum Magnesium
IV Supplementation
Oral Supplementation
Concentration
Severe Hypomagnesemia
(Mg < 1mEq/L)
Symptomatic
If life threatening cardiac
arryhythmia, 2gm Mg
sulfate may be pushed over
1 min in 10 ml of NS.
If no emergency, give 4 gm
IVPB over 2-4 hours.
(Repeat x 1 if still
symptomatic). Repeat
serum Mg level in 8 hours,
add 2-4 gm Mg sulfate to
IVF daily, and monitor Mg
level daily until stable.
Not Recommended
Asymptomatic
4 gm Mg sulfate IVPB over
2-4 hours. Repeat Mg level
in 8 hours.
Not recommended
41
Mod. Hypomagnesemia
(Mg 1-1.4 mEq/L)
Symptomatic
Give 2-4 gm Mg sulfate
IVPB over 2-4 hours and
repeat if still symptomatic.
Add 2-4 gm to IVF daily.
Not recommended
Asymptomatic
2-4 gm Mg sulfate IVPB
over 2-4 hours
Give 2 g Mg sulfate IVPB
over 2 hours
Mg Oxide 400 mg BID-TID
Mild Hypomagnesemia
(Mg 1.5-1.8 mEq/L)
Mg Oxide 400 mg daily-BID
*In patients with normal renal function. If renal insufficiency is present, magnesium should be
administered at ½ recommended dose to avoid magnesium toxicity.
TREATMENT:
IV replacement is recommended for the acute replacement of magnesium
deficiency. Oral replacement is used primarily for maintenance therapy
due to the poor PO absorption of magnesium and the likelihood of
inducing diarrhea with excessive oral magnesium. Up to 50% or more of
a dose of IV magnesium will be excreted in the urine, making repeat
dosing and serum concentration monitoring necessary.
MONITOR:
Serum concentrations q8-12h during initial tx phase if severe, then q24h
following stabilization (Mg>1.4 mEq/L). Full stabilization should occur
within 7 days.
DISCONTINUE TX:
Discontinue therapy if patient develops hypotension (SBP < 80 mmHg),
bradycardia (<60 bpm), hypermagnesemia, or absence of deep tendon
reflexes.
42
MANAGEMENT OF HYPOPHOSPHATEMIA
CAUSES: Refeeding syndrome, intracellular shifts (glucose administration,
insulin therapy, corticosteroid therapy), phosphorous deficiency (chronic
alcoholism, vitamin D deficiency), decreased absorption (antacids,
sucralfate), increased excretion (diuretics, hyperparathyroidism)
SIGNS/SYMPTOMS:
Cardiac dysrhythmias, respiratory failure, muscle weakness, numbness,
tingling, confusion, lethargy, seizures, immune dysfunction, osteomalacia
(chronic deficiency)
GUIDELINES FOR REPLACEMENT*
Serum Phosphorous
IV Supplementation
Oral Supplementation
Concentration
(NaPhos or Kphos)
PO4 < 1.0 mg/dL
0.64 mmol/kg Phos over 6-8
Not recommended
hours
PO4 1.0-2.4 mg/dL
0.32 mmol/kg Phos over 4-6
hours
2 packets Neutra Phos K or
Neutra Phos BID (if no IV
access)
PO4 2.5-3.0 mg/dL
0.16 mmol/kg Phos over 2-4
hours
1 packet (Neutra Phos K or
Neutra Phos) BID
* In patients with normal renal function. If renal insufficiency is present, ½ recommended
replacement dose should be given.
** Round PO4 doses to the nearest increment of 3. Typical doses are 15, 21, 30, or 45 mmol. **
** Each 15mmol PO4 should be infused over 2 hours.**
PHOSPHOROUS PRODUCTS:
IV:
Na Phosphate (3 mmol PO4 and 4 mEq Na per ml)
K Phosphate (3 mmol PO4 and 4.4 mEq K per ml)
Oral: Neutra Phos (8 mmol PO4, 7 mEq Na, and 7 mEq K)
Neutra Phos K (8 mmol PO4 and 14 mEq K)
43
MONITOR:
Serum phosphorous and calcium concentrations q12-24 hours during
initial therapy, then every 1-3 days following stabilization.
Concentrations may increase rapidly with IV replacement; thus, serum
phosphorus levels should be measured prior to additional dosing.
DISCONTINUE TX:
Discontinue therapy if the patient develops hypocalcemia and/or
hyperphosphatemia. Monitor Ca x Phos product. (If [Ca++] x [Phos]
>70, the patient is at increased risk for metastatic calcification and organ
damage.) Phosphorus should be replaced more cautiously if concomitant
hypercalcemia is present.
44
MANAGEMENT OF HYPOKALEMIA
CAUSES: GI losses (nasogastric suction, vomiting, diarrhea, laxative use), renal
losses (Mg depletion, diuretics, levodopa, steroids, amphotericin),
intracellular shift (albuterol, insulin, metabolic alkalosis)
SIGNS/SYMPTOMS:
Cardiac dysrhythmias, muscle weakness/cramps, paralysis, respiratory
distress, ileus, urinary retention, constipation
TREATMENT:
Infusion rates should not exceed 10 mEq/hr without concurrent ECG
monitoring (A higher rate of 20 mEq/hr may be used with monitoring. In
emergency situations only, a 40 mEq/hr rate can be used with continuous
ECG monitoring).
Hypomagnesemia should also be corrected during potassium
replacement.
GUIDELINES FOR REPLACEMENT*
IV Supplementation
Serum Potassium
Oral Supplementation1
Concentration
K+ < 3.0 mEq/L
40 mEq IV KCl X 2; repeat
N/A
+
K level 2-4 hours after the
last infusion
+
K 3.0-3.2 mEq/L
30 mEq IV KCl X 2
40 mEq x 2
+
K 3.2-3.5 mEq/L
40 mEq IV KCl X 1
20-40 mEq x 2
*
In patients with normal renal function. If renal insufficiency is present, more cautious replacement
with ½ of the recommended doses should be given.
1
Oral supplementation can replace IV supplementation if patient is asymptomatic and can take PO.
If there is ongoing K+ losses (diuretic therapy, NG suction, etc), patients may require maintenance
oral or IV supplementation after they are adequately replaced.
MONITOR:
Serum K+ concentrations q6-12h during early phases of tx if initial
K+ <3.0 meq/L, and then q12-24h following stabilization (> 3.5
mEq/L). Stabilization should occur in 24-48 hours. In patients
with serum K+ <2.5 mEq/L, amount K+ given should not be > 80
mEq without repeated measurements of serum K+ concentrations.
45
Guidelines for Initiating Peripheral and
Total Parenteral Nutrition
Parenteral nutrition (PN) is indicated for patients with nonfunctional GI tracts or those
unable to ingest adequate calories orally or enterally. PN should be considered after
3-5 if adequate calories cannot be provided via the enteral route.
Initial orders for central parenteral nutrition (TPN) must be written on the approved
preprinted order form. The Nutrition Support Team is automatically consulted on all
new TPN patients. TPN orders must be written by 1600 daily, and all TPNs are hung
at 2100 daily.
Recommended Monitoring:
•
CMP, Mg, & PO4 day #1; BMP, Mg, & PO4 days #2-4;
then CMP/BMP, Mg, & PO4 at least twice weekly thereafter
•
Blood glucose monitoring with sliding scale regular
insulin Q6H. More frequent monitoring may be necessary
for diabetics, critically ill patients, and patients on steroids.
•
Baseline and weekly serum triglycerides (hold lipids for
levels >300)
•
Baseline nitrogen balance (24 hr UUN) except in acute and chronic renal failure
(ARF/CRF)
•
Initial and weekly prealbumin levels
•
Daily weights
•
Daily input and output (I/O)
•
Relevant clinical information affecting nutrition support, such as medication
changes (steroids, insulin, diuretics, propofol, oral electrolyte supplements, etc),
fluid status (IV fluids, NG output, vomiting, diarrhea, etc), other nutrition
sources (initiation of tube feeding or oral diet), decreased or increased acuity of
illness, wound healing issues, clinical course (surgery, radiology findings,
temperature curve)
Calorie Requirements:
•
Most patients require 25-35 total kcal/kg/day depending on acuity of illness and
baseline nutritional status.
•
Calories should be based on the patient’s ideal body
weight (IBW) if actual weight is 100-130% of IBW. If actual weight is >130%
then an adjusted weight should be used. If actual weight is <100% IBW, then
actual weight should be used.
Males: IBW(kg) = 50 + (2.3 x inches >5 ft)
Females: IBW(kg) = 45.5 + (2.3 x inches >5 ft)
Adjusted wt (kg) = (ABW-IBW)0.4 + IBW
46
•
•
•
Dextrose provision should not exceed 25 kcal/kg/day.
Lipids should provide ~30% (max 50%) of a patient’s non-protein calories
(NPC). Total lipid/day should be limited to <1g/kg/day in most patients.
Calculation of calories:
Dextrose: 3.4 kcal/gram
Protein: 4 kcal/gram
Lipid: 20% = 2 kcal/mL (20% lipid emulsion 250ml=500 kcal)
Protein Requirements
Protein requirements for most patients are 1-1.5 gm/kg/day. Severely ill/stressed
patients may require up to 2 gm/kg/day. Patients with acute renal failure or end-stage
hepatic disease require protein restriction (0.6-1 gm/kg/day). Patients with chronic
renal insufficiency may tolerate 1-1.2 gm/kg/day, and patients receiving hemodialysis
may tolerate 1.2-1.4 gm/kg/day. Monitor BUN and serum creatinine to assess for
protein tolerance.
Lipid Requirements
Intralipid should be given to most patients receiving PN if tolerated. Lipids may be
administered twice weekly, every other day, or daily. Lipids may be given in the TPN
(3-in-1) or as a separate piggyback. Lipids should be held for triglyceride levels
>300. Patients receiving propofol infusions (formulated as 10% lipid emulsion)
should not receive IV lipids, and patients who are tolerating some po intake may not
require IV lipids to meet their nutrition support goals. In order to avoid essential fatty
acid deficiency (EFA), the length of time without any nutritional source of lipids (PO
or IV) should not exceed 3-4 weeks. 20% Intralipid 250 ml (50g) given twice weekly
is sufficient to prevent EFA. If lipids are given as a separate piggyback (not added to
the TPN bag), each bag should be infused over 12 hours.
General TPN Guidelines
The hospital preprinted TPN order form includes a standard adult TPN formula. This
formula is not acceptable for all patients, especially patients with renal insufficiency;
therefore, the formula should be modified as necessary.
Standard Adult TPN Formula
Dextrose
Amino Acids
NaCl
NaAcetate
KCl
KPO4
•
20%
4.25%
40 mEq/L
20 mEq/L
20 mEq/L
22 mEq/L
Magnesium
CaGluc
MVI
Trace elements
8 mEq/L
4.7 mEq/L
1 vial/day
3 ml/day
Central venous access should be confirmed and documented on the TPN order
form. TPN solutions should be initiated at rates of 40-50 mL/hr and advanced
47
•
•
•
•
•
•
•
•
toward goal rate daily in increments of 20-30 ml/hr as tolerated. Alternatively,
TPN may be initiated at goal rate, but with a decreased dextrose final
concentration (10-12%). In this case, the dextrose final concentration should be
advanced daily by 4-5% per day as tolerated. (Protein concentration can be
started at goal.)
Diabetic and glucose intolerant patients (pancreatitis, steroid therapy, postop
hyperglycemia) should be started at a lower infusion rate (or lower dextrose
concentration) to assess tolerance and avoid adverse events.
An acceptable blood glucose (BG) while on TPN is 100-150 mg/dL. TPN rate
or dextrose should not be increased in patients with blood glucose monitoring
consistently above 200 mg/dL.
Insulin may be added to the TPN solution to help manage
hyperglycemia. Orders for insulin must be written in units/L. The typical
starting dose of insulin is 10-20 units/L with adjustment as needed based on
blood glucose levels.
Patients at risk for volume overload (i.e. ARF/CRF, congestive heart failure)
may require more concentrated TPN formulas to deliver their required calories
in a smaller fluid volume. TPN infusion rate should be discussed with the
responsible physician if questions regarding fluid restriction arise.
Malnourished patients at risk for Refeeding Syndrome require greater than
standard amounts of potassium, phosphorus, and magnesium in the initial TPN
formulas. TPN should be initiated at a low rate or a low final concentration of
dextrose (10%), and electrolytes must be monitored closely and replaced as
indicated. TPN rate or formula should not be advanced until electrolytes are
within normal limits.
Patients with ARF/CRF generally need 0-50% of the
standard potassium, phosphorus, and magnesium in TPN. The standard
electrolyte orders are not appropriate in these patients. Electrolyte levels should
be monitored closely.
Patients with ARF/CRF, congestive heart failure (CHF),
and hepatic disease with ascites are often volume overloaded and have
increased total body Na (even though serum Na may be low or normal).
Patients with these disease states should start with 0-50% of standard Na in
their TPN, as Na may exacerbate their condition. Monitor serum Na and daily
I/Os closely. *Note: 1/4NS ~40meq Na/L; 1/2NS ~80meq Na/L; NS ~160 meq
Na/L.* Total Na (all salts) in TPN should not exceed 160 meq/L. Low Na
levels should respond to changes in Na content or total volume of IV fluids
and/or TPN and should not be “bolused” as they are usually a reflection of
positive fluid balance and not a true Na deficiency. Fluid status should be
evaluated carefully and discussed with physician if needed.
Electrolytes should be ordered as mEq/L.
48
Standard electrolyte intakes assuming no organ dysfunction:
Electrolyte
Standard Intake (Daily)
Calcium
10-15 mEq/day
Magnesium
8-20 mEq/day
Phosphate
20-40 mmol/day
Sodium
1-2 mEq/kg/day + sodium losses
Potassium
1-2 mEq/kg/day
Acetate
As needed to maintain acid-base balance
Chloride
As needed to maintain acid-base balance
PPN Guidelines
The hospital supplies a premixed PPN formula (Clinimix) which can be utilized for
short-term nutritional support (5-7 days). PPN is not recommended when central vein
access is feasible because PPN may not provide adequate calories and is associated
with thrombo-phlebitis and volume overload. (Large volumes of fluid are needed to
provide calories at a low osmolarity.)
Clinimix Composition*
Dextrose
10%
Ca
Amino Acids
4.25%
Acetate
Na
35 mEq/L
Cl
K
30 mEq/L
PO4
Mg
5 mEq/L
(Total calories = 510 kcals/L)
4.5 mEq/L
70 mEq/L
39 mEq/L
15 mMol/L
*Clinimix also availabe WITHOUT electrolytes
Alternative PPN formulas may be written if the standard Clinimix formula is
inappropriate and TPN is not feasible. Total osmolarity of PPN should not exceed
1000mosm/L.
•
•
•
All orders for PPN (except premixed formulas) must be
initially written on a preprinted PPN/TPN order form.
Maximum dextrose concentration for PPN is D10%.
Due to lack of stability data and osmolarity issues, addition of
ingredients to premixed solutions is strongly discouraged.
If additional additives are desired, an individualized PPN/TPN formula should
be written.
Patients receiving PPN as sole source of nutrition should also receive lipids (i.e.
20% Intralipid –250 ml daily or 2-3 times per week) to provide additional
calories and prevent essential fatty acid deficiency.
1. Standard for specialized nutrition support: adult hospitalized patients. Nutrition in Clinical
Practice 17:384-391, 2002.
49
2. Guidelines for the use of parenteral and enteral nutrition in adult and
pediatric patients. JPEN 26:1 supplement, 2001.
50
Automatic IV to PO Conversion Criteria
Antibiotics
Background:
Studies have shown that switching a patient from IV to oral therapy can decrease the
length of stay in the hospital, and it may also improve patient outcomes. This
conversion is conducted primarily by clinical or other well-trained pharmacists.
Criteria for Patient Eligibility2:
1) Patient is receiving intravenous therapy with one or more of the following
antibiotics:
 azithromycin
 ciprofloxacin
 clindamycin
 fluconazole
 gatifloxacin
 levofloxacin
 linezolid
 metronidazole
 ofloxacin
 voriconazole
 trimethoprim-sulfamethoxazole (exception: AIDS patient)
2) Patient shows improvement in signs and symptoms of infection, which were
3)
4)
5)
6)
present when therapy was started, including improvement in cough and dyspnea.
Patient is afebrile (<100º F) on two occasions 8 hours apart.
White blood cell count (WBC) is <15,000/mm3 and decreasing.
Patient has a functioning GI tract, as indicated by one of the following:
 Receiving scheduled medications prescribed orally
 In the absence of routine oral meds, tolerating an advancing diet X > 24h
If the overall clinical response is otherwise favorable, it may not be necessary to
wait until the patient is afebrile before making the switch to oral therapy.
51
Exclusions:
Pharmacy will not independently initiate an IV-to-PO change on any patient with the
following characteristics:
1) AIDS
2) Neutropenia (ANC < 1,500)
3) Organ transplant patient
4) Malabsorption syndrome.
Procedure:
If IV therapy has been continued for at least 2 days as defined above, a checklist will
be completed. If all criteria are met, an order will be written in the chart for
conversion to oral therapy; the conversions are listed below:
IV Antibiotic Dose
Azithromycin
500mg q24h
Ciprofloxacin
200mg q12h
Clindamycin
900mg q8h
600mg q8h
Fluconazole any dose
Gatifloxacin any dose
Levofloxacin any dose
Linezolid any dose
Metronidazole any dose
Ofloxacin any dose
TMP/SMX any dose
Voriconazole 4 mg/kg q12h
Equivalent PO Dose
azithromycin
250mg q24h
ciprofloxacin
250mg q12h
clindamycin
450mg q6h
300mg q6h
equivalent dose & interval
equivalent dose & interval
equivalent dose & interval
equivalent dose & interval
equivalent dose & interval
equivalent dose & interval
equivalent dose & interval
voriconazole 200mg q12h (>40kg)
Checklists will be retained for each patient; pharmacy will review the patient’s status
at least 48 hours after the conversion, and note the status as indicated on the checklist.
References:
1. Vfend package insert. New York, NY: Pfizer Inc.; 2002 May.
2. American Thoracic Society Guidelines for the Management of Adults with Community-acquired
Pneumonia: Diagnosis, Assessment of Severity, Antimicrobial Therapy, and Prevention. Am J
Respir Crit Care Med. 2001;163:1730-1754.
Histamine H2 Antagonists
Pharmacists may convert IV famotidine to oral famotidine if the following criteria are
met:
1. Patient is receiving at least one routinely-administered oral medication.
2. Patient is receiving and tolerating any form of oral feedings.
52
Review of “Factors”: Bebulin®, Benefix®, Mononine®, NovoSeven®
What you should know
Each of these products is different! They cannot be interchanged. Some
situations to think about:
You receive an order for Factor IX 2000 units IV STAT. Which product should
you use? First, check to see which products we have in stock then call the
physician to determine which product he/she wants. Write an order clarification
in the chart or have the physician write it.
You receive an order for Bebulin 500 units IV STAT. When you check the
refrigerator you notice we are out of Bebulin. Should you substitute Benefix or
Mononine? No! Call the physician and let him/her know that we are out of
Bebulin and ask which product he/she would like to use.
Note below that really only 2 products have been studied for life-threatening
bleeding due to warfarin: Bebulin VH® and NovoSeven®.
Bebulin VH® (Factor IX Complex, Vapor Heated)
Obtained from human plasma, this product is a concentrate of the vitamin Kdependent
clotting factors, II, VII (low levels), IX, and X. It may also be referred
to as Prothrombin Complex Concentrate (PCC). It is dosed in international units
of factor IX. Note that vials may contain varying amounts of factor IX, and the
number of units per vial will be indicated on the box and/or vial. This product is
indicated for use of hemorrhage in hemophilia B patients but has become
popular for off-label use of reversal of warfarin in life-threatening bleeding. It
should be combined with FFP and vitamin K in the treatment of warfarin toxicity
due to its short duration of action.
Benefix® (Coagulation Factor IX, Recombinant)
This product is a recombinant form of factor IX and is not obtained from human
plasma. It is dosed in international units of factor IX, and each vial usually
contains 250, 500, or 1000 international units. It is indicated for the treatment
and prevention of hemorrhage in patients with hemophilia B. It has not been
studied for the off-label use of warfarin reversal.
Mononine® (Coagulation Factor IX, Human)
This product is a concentrate of factor IX from human plasma and is indicated for
the prevention and control of bleeding in hemophilia B. It contains nondetectable
levels of factors II, VII, and X, and therefore, should not be used for
the treatment of warfarin toxicity. It is dosed in international units of factor IX,
and when reconstituted correctly, each mL contains 100 international units.
NovoSeven® (Coagulation Factor VIIa, Recombinant)
This product is the recombinant form of activated factor VII and is indicated for
the treatment and prevention of bleeding in Hemophilia A or B patients with
53
inhibitors to factors VIII or IX and also in patients with congenital deficiencies of
factor VII. It has been studied for hemorrhage due to warfarin toxicity,
spontaneous intracerebral hemorrhage and trauma. At MUH, we stock the 4.8
mg vial although it is available as 1.2 mg and 2.4 mg vials. The 4.8 mg vial costs
approximately $4000 and expires in 3 hours after reconstitution. When used for
warfarin toxicity, it should also be combined with FFP and Vitamin K.
54
Dofetilide (Tikosyn)
Overview
Dofetilide is a Class III antiarrhythmic agent that selectively inhibits the potassium
current and prolongs the refractory period. It is indicated for conversion of atrial
fibrillation/flutter to normal sinus rhythm. Dosing is based on QTc and calculated
creatinine clearance. A 12-lead EKG will be performed to calculate QTc after each
dose.
Contraindications/Cautions
Contraindicated with:
• Verapamil
• Cimetidine
• Ketoconazole
• Prochlorperazine
• Megestrol
• Trimethoprim (alone or in combination with sulfamethoxazole)
Contraindicated in patients with:
• Congenital or acquired long QT syndromes (baseline QTc>440 msec or 500
msec in
patients with ventricular conduction abnormalities.
• Severe renal impairment (calculated creatinine clearance <20 ml/min)
• Known hypersensitivity to the drug
Caution in patients:
• Receiving other drugs that may deplete potassium or magnesium, prolong
the QT interval, or interact with dofetilide’s pharmacokinetics (see
Micromedex for an extensive list, or see www.tikosyn.com.
• With severe hepatic failure. The use of dofetilide has not been evaluated in
this patient population.
Dosing
Only MDs who have gone through the “certified prescriber” process with Pfizer may
initially prescribe dofetilide. It may be continued as a home medication by noncredentialed physicians.
Electrolytes (potassium, magnesium) must be normal prior to initiation and during the
administration of dofetilide.
Initial dose:
Calculated Creatinine Clearance
>60 ml/min
40 to 60 ml/min
Dofetilide Starting dose
Dofetilide 500 mcg po q12h
Dofetilide 250 mcg po q12h
55
20-39 ml/min
<20 ml/min
Dofetilide 125 mcg po q12h
CONTRAINDICATED
Second dose: 2 to 3 hours after first dose, QTc is obtained. The physician must
review the ECG before the second dose is given. If QTc has increased >15% from
baseline or is >500 msec (550 msec in presence of ventricular conduction
abnormality), notify physician so that s/he may reduce the dose according to the
following table.
If starting dose based on
Creatinine clearance is:
500 mcg po q12h
250 mcg po q12h
125 mcg po q12h
Then adjust dose (for QTc prolongation) to:
250 mcg po q12h
125 mcg po q12h
125 mcg po qd starting 24h after 1st dose
Subsequent dosing: 2 to 3 hours after each dose (2nd to 5th doses) QTc is determined
to avoid resultant ventricular arrhythmias. No further downward dose titration of
dofetilide is recommended unless QTc>500 msec (550 msec in presence of ventricular
conduction abnormalities) then DISCONTINUE dofetilide.
Side effects:
Torsade de pointes, Headache (11%), chest pain (10%), and dizziness (8%).
Pharmacy will provide patient education on dofetilide and contact the patient’s
outpatient Pharmacy to ensure it is stocked.
56
Antacid of Choice and Laxative of Choice
Antacid of choice and laxative of choice orders are standardized.
Antacid of choice includes:
• Maalox Max- 10 to 15 ml every 6 hour PRN
Laxatives of choice include:
• Milk of Magnesia (MOM)- 30 ml daily PRN
Or
• Bisacodyl tabs (Dulcolax)- 5-10 mg daily, up to 30 mg daily
If the patient does not respond or does not want the indication medications, the
physician should be contacted for specific orders:
• Antacid/laxative of choice orders will appear on the MAR as the indicated drugs
• Antacid/laxative of choice will be designated in the note field in the MAR.
57
Epoetin Guidelines and Procedures
Interchange
Darbepoetin
25 mcg weekly
40 mcg weekly
60 mcg weekly
100 mcg weekly
150 mcg weekly
200 mcg weekly
Epoetin
2000 units TIW
3000 units TIW
5000 units TIW
8000 units TIW
10,000 units TIW
20,000 units TIW
Dosing and Administration Guidelines:
Outpatient area
May use either epoetin or darbepoetin (do not
interchange)
Weekly doses or biweekly
doses
Dose cap
One time orders
Administration
Doses other than 10,000,
20,000, or 40,000 units
Stability of syringe
Dose changes
Scheduling
Should be changed to TIW dosing
Examples:
10,000 units once weekly – divide by 3 – 3333
units – round to 3000 units TIW
40,000 units weekly to 10,000 units TIW
25,000 units TIW
Any doses greater than that should be
interchanged to 25,000 units TIW.
Interpret as usual – one time orders may be
given
SQ only on the nursing floor – not IV or in the
dialysis unit
Should be drawn up from the 20,000 unit MDV
7 days under refrigeration
None allowed after 72 hours of initial epoetin
order
Doses written on Tuesday, Thursday, or
Saturday should be put on the
Tue, Thur, Sat schedule.
Doses written on Sunday, Monday,
Wednesday, or Friday should be put
on the Mon, Wed, Fri schedule.
P and T Approved Indications:
 End stage renal disease (ESRD) on dialysis
 Chronic kidney disease NOT on dialysis
 Anemia in zidovudine-treated HIV patients
 Cancer patient actively on chemotherapy
58
 Reduction of allogenic blood transfusion in surgery patient
 Myelodysplastic Syndrome
Contraindications/Warnings against use:
 Indication not P & T approved or unclear
 Patient has uncontrolled hypertension (BP>185/110)
 Hemoglobin greater than 12 g/dL
 ESA used for active bleeding
59
Lithium Dispensing
All patients will have their plasma lithium concentration checked within 24 hours of
admission if they have been taking lithium prior to admission. The pharmacy will not
dispense lithium unless a level has been ordered. This policy should reduce the
likelihood that patients with unrecognized lithium intoxication will continue to receive
lithium after admission.
1. When an order is written to continue lithium from another treatment setting
(including home), the pharmacist will review the laboratory orders and/or results
to ensure that a lithium level has been ordered prior to dispensing lithium.
2. If a lithium level has not been ordered, the pharmacist will order a lithium level
according to the following procedure:
a. If the last lithium dose was taken greater than 10 hours ago, order the
lithium level “stat”, so that it is drawn before the next dose is given. (The
optimum time for drawing lithium levels is approximately 12 hours from
the last dose.)
b. If the last lithium dose was taken less than 10 hours ago, order the lithium
level for the next morning unless one of the following problems is present:
i. Vomiting
ii. Diarrhea
iii. Ataxia
iv. Slurred speech
v. Confusion
3. If any one of the signs/symptoms of lithium toxicity above is present, do not
dispense lithium and contact the prescriber immediately. The patient may not
receive lithium until a stat serum concentration has eliminated the possibility of
lithium intoxication.
4. Signs and symptoms of lithium toxicity will be printed on the MAR.
60
Guidelines for Initiating Warfarin Therapy
Coumadin Dosing Service is available by consult; write an order for Coumadin
Dosing per Pharmacy to initiate the service.
1.
2.
3.
4.
5.
6.
7.
Initiation and maintenance dosing of warfarin should commence with an
average dose of 5 mg daily. This dose usually results in an INR of 2 within 4-5
days.
Starting doses of < 5 mg might be appropriate for elderly patients and patients
with impaired nutrition, liver disease, or at high risk for bleeding.
Loading doses (i.e. > 10 mg) are not recommended.
Patients receiving concomitant drugs that effect warfarin metabolism will
require closer monitoring. See table below for common drug interactions.
Heparin treatment can be discontinued when the INR has been therapeutic for 2
consecutive days (usually requires an overlap of 4-5 days.)
Low molecular weight heparin (LMWH) therapy as a bridge to therapeutic INR
has been established for DVT/PE treatment.
Home LMWH therapy may be evaluated and initiated by paging the Clinical
Pharmacy Specialist (533-3381).
Non-Inclusive List of Common Interactions with Warfarin
Drug
Effect on INR
Amiodarone
↑↑
Carbamazepine
↓
Ciprofloxacin
↑↑
Fibrates (Gemfibrozil, fenofibrate)
↑
Fluconazole
↑↑
Isoniazid (INH)
↑
Macrolides (Erythromycin, Clarithromycin) ↑
Metronidazole
↑↑
Nafcillin
↓↓
Primidone, Phenobarbital
↓
Propafenone
↑↑
Rifabutin, Rifampin
↓↓
Rosuvastatin
↑
Sulfamethoxazole/Trimethoprim
↑↑
Tetracyclines
↑
Voriconazole
↑
Hansten and Horn's Drug Interactions Analysis and Management, Facts and Comparisons, 2004.Adapted from The
Seventh ACCP Conference On Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. 2004; 126(3).
61
Titrating Medications in the Critical Care Unit
Catalog Number
Facility Manuals
Service Categories
Team Members Performing
Committee(s) / Council(s) Review Responsibility
Service Area(s) Review Responsibility
Population Served
Inpatient / Outpatient
Approval Date(s)
Effective Date(s)
Replaces
Education Requirements
Patient Medical Record Requirements
Associated Supplies
Equipment Requirements
Alliance, Fayette, Germantown, MECH, North,
South, University
ALL
RN
P&T, Critical Care Committee, CPC
Pharmacy, Critical Care
Adult
Inpatient
11/28/05
N/A
Instruction
Critical Care Record
POLICY:
A complete “titrate” order includes the drug name, route, starting dose, how to titrate the
medication, and desired goal. If orders for these medications are not complete, then this policy
should be utilized.
PURPOSE: To provide a standardized method for titrating or weaning medications in the
intensive care unit and to prevent titrating or weaning too quickly.
TEAM MEMBERS PERFORMING
Registered nurses
PROCEDURE / PROCESS:
Medications
Vasopressor Agents
1
Dopamine
1
Initial Rate
Titration scale
(for titrating and
Maximum rate
2
weaning purposes)
2.5 mcg/kg/min
Dobutamine
2.5 mcg/kg/min
Norepinephrine
2 mcg/min
Epinephrine
1 mcg/min
2.5 mcg/kg/min as
often as every 10 min
to desired effect per
MD orders
2.5 mcg/kg/min as
often as every 10 min
to desired effect per
MD orders
2 mcg/min every 5-10
min to desired effect
per MD orders
1 mcg/min as often as
every 5 min to desired
effect per MD orders
20 mcg/kg/min
20 mcg/kg/min
90 mcg/min
3
100 mcg/min
3
62
Vasopressin
0.02 units/min
Phenylephrine
50 mcg/min
Antihypertensive Agents
Nicardipine
Nitroprusside
Nitroglycerin
1
5 mg/hr
0.5 mcg/kg/min
5 mcg/min
Esmolol
50 mcg/kg/min
Labetalol
2 mg/min
Diltiazem
1
Sedation Agents
Lorazepam
Midazolam
Propofol
Fentanyl
5 mg/hr
Double dosage as
needed every 30 min
to desired effect per
MD orders
10 mcg/min as often
as every 5 min to
desired effect per MD
orders
0.1 units/min
2.5 mg/hr as often as
every 15 min to
desired effect per MD
orders
0.5-1 mcg/kg/min as
often as every
3-5 min to desired
effect per MD orders
5 mcg/min every 3-5
min to
desired effect per MD
orders
50 mcg/kg/min as
often as every 5 min
to desired effect per
MD orders
1 mg/ min as often as
every 10 min to
desired effect per MD
orders
2.5-5 mg/hr as often
as every 15 min to
desired effect per MD
orders
15 mg/hr
360 mcg/min
10 mcg/kg/min
3
200 mcg/min
300 mcg/kg/min
Unknown
(Watch for
bradycardia)
15 mg/hr
0.5 mg/hr
0.5 mg/hr as often as
7 mg/hr
every 15 min to Riker
scale per MD
1 mg/hr
0.5 mg/hr as often as
7 mg/hr
every 10 min to Riker
scale per MD orders
See Sedation Protocol for dosing guidelines
0.5 mcg/kg/hr
0.5 mcg/kg/hr as
10 mcg/kg/hr
often as every 10 min
to desired effect per
MD orders
1
Can be titrated on stepdown unit
The physician must indicate a desired effect (desired blood pressure, Riker scale, etc.) and must be called for clarification if not.
3 Recommended maximum rate; no real max rate exists in literature.
2
63
MEMO
To: All Pharmacists
Re: Deep Sedating Agents for Moderate Sedation
Some time ago, there was debate about whether or not physician should be able to use
"deep sedatives" for the purpose of moderate sedation (e.g. propofol for pacemaker
insertion).
The medical staff defines deep sedating agents as:
• etomidiate
• ketamine
• methohexital
• propofol
• pentothal
Anesthesiologists, ED physicians, and critical care physicians may use these drugs for
deep sedation but must be "credentialed."
64
Summary of “Consensus” Guidelines
In view of the growing complexity of medical care and the proliferation of trials
related to management of patients, many organizations are choosing to invest
significant efforts in an evidence-based approach to define guidelines for care. The
following is a partial list of publications available which help to define “best
approach” to the use of drugs for prevention and/or treatment of various disorders.
Other guidelines are developed in greater detail in other sections of this handbook.
The National Guideline Clearinghouse (www.guideline.gov) may also be referred to
for Internet links to various organizations/publications.
Guideline/Disorder
Anemia: Cancer and Treatment
Related
Antithrombotic therapy
Atrial Fibrillation
Dementia
Lipid Management
Management of Menopause
Unstable Angina
Hypertension
COPD, Acute Exacerbations
Community-acquired
Pneumonia
Community-acquired
Pneumonia
HIV/AIDS, Antiretroviral
Therapy
HIV/AIDS, Prevention Opp.
Infections
Myocardial Infarction
Neutropenic Fever, Cancer
Patients
Hematopoietic ColonyStimulating Factors
Infectious Diseases
Intravascular Catheter
Sepsis, Hemodynamic Support
Organization
National Comprehensive
Cancer Network
American College of Chest
Physicians
American College of Physicians
American Academy of
Neurology
National Cholesterol Education
Program
Am. Assoc. of Clinical
Endocrinology
ACC/AHA
National Heart, Lung, and
Blood Institute
ACP-ASIM/ACCP
Infectious Diseases Society of
America
American Thoracic Society
US Dept. Health & Human
Services
CDC/USPHS
ACC/AHA
Infectious Diseases Society of
America
American Society of Clinical
Oncology
Infectious Diseases Society of
America
Infectious Diseases Society of
America
Am College Critical Care
Medicine
Reference
www.nccn.org
www.chestnet.org
Chest 2004;126(3):s1-696.
Ann Intern Med
2003;139:1009-17
Neurology 2001;56:1143-66
JAMA 2001;285(5/16):2486-97
Endocrine Practice
2006;12:315-77
www.acc.org
www.nhlbi.nih.gov
Ann Intern Med 2001;134:60020
Clin Infect Dis 2003;37:140533
Am J Respir Crit Care Med
2001;163:1730-54
www.aidsinfo.nih.gov
www.aidsinfo.nih.gov
www.acc.org
www.nccn.org
JCO Oct 20 2000;3558-3585
www.idsociety.org
http://www.cdc.gov
Crit Care Med 1999;27:639-60
65
Sinusitis
Tuberculosis
Sinus/Allergy Health
Partnership
National Surgical Infection
Prevention Project & Centers
for Medicare Svcs
American Thoracic Society
Urinary Tract InfectionsWomen
Urinary Tract Infections - Longterm Care
Infectious Diseases Society of
America
Society for Healthcare
Epidemiology Of America
Surgical Infection Prophylaxis
Otolaryngol Head Neck Surg
2000;123 (supplement 1)
Clin Infect Dis 2004;38:170615
Am J Resp Crit Care Med
2003;167:603-67.
Clin Infect Dis 1999;29:745-58
Infect Cont Hosp Epidemiol
2001; 22(3):167-75l
66
Hyperlipidemia Therapy (NCEP Guidelines)
Risk Category1
Very high risk*:
LDL Goal
< 70 mg/dL
High risk:
CHD or CHD risk
equivalents**
Moderately high risk:
2 + risk factors
(10-year risk 10-20%)
Moderate risk:
2+ risk factors
(10-year risk <10%)
Lower risk:
0-1 risk factor
< 100 mg/dL
Lifestyle Changes
> 100 mg/dL
Drug Therapy
> 100 mg/dL
(if <100 mg/dL, drug
tx optional)
< 130 mg/dL
> 130 mg/dL
> 130 mg/dL
(100-129 mg/dL,
consider drug tx)
< 130 mg/dL
> 130 mg/dL
> 160 mg/dL
< 160 mg/dL
> 160 mg/dL
> 190 mg/dL
(160-189 mg/dLdrug tx optional)
*
Very high risk factors include: CHD + (1) multiple major risk factor (especially diabetes), (2)
severe and poorly controlled risk factors (especially cigarette smoking), (3) multiple risk factors of
the metabolic syndrome, (4) patients with acute coronary syndrome (PROVE-IT).
**
CHD equivalents include: peripheral artery disease, abdominal aortic aneurysm, symptomatic
carotid artery disease, diabetes mellitus, multiple risk factors that confer a 10-year risk for CHD
>20%.
Major Risk Factors That Modify LDL Goals2
•
•
•
•
Current cigarette smoking
Hypertension
Low HDL cholesterol (< 40 mg/dL)
Family history of premature Coronary Heart Disease (CHD)
(CHD in male first-degree relative < 55 years; CHD in female first-degree
relative <65 years)
• Age (Male > 45 years; Female > 55 years)
Negative risk factor (remove one risk factor if present)
• High HDL cholesterol (> 60 mg/dL)
1
Grundy SM, Cleeman JI, et al. Implications of recent clinical trials for the National Cholesterol
Education Program Adult Treatment Panel III Guidelines. Circulation 2004;110:227-239.
2
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA
2001;285:2486-2497.
67
LIPID LOWERING AGENTS
Drug Class
HMG-CoA
reductase
inhibitors
(statins)
Lipid
Effects
LDL ↓1862%
HDL ↑ 515%
TG ↓ 730%
Aspirin + statin
See above
Bile acid
sequestrants
LDL ↓ 1530%
HDL ↑ 35%
TG ↔ / ↑
Nicotinic acid
LDL
25%
HDL
35%
TG
50%
LDL
42%
HDL
30%
TG
44%
LDL
18%
HDL
TG
9%
Nicotinic acid +
statin
Absorption
inhibitor
↓ 5↑ 15-
Available Agents
Dosing range
Cost
Atorvastatin (Lipitor)*
Fluvastatin (Lescol)
Lovastatin (Mevacor)+
Pravastatin
(Pravachol)+*
Rosuvastatin
(Crestor)*
Simvastatin (Zocor)+*
ASA + pravastatin
(Pravigard PAC)
Cholestyramine
(Questran)+*
Colestipol (Colestid)+
Colesevelam
(WelChol)*
10-80mg/day
20-80mg/day
10-80mg/day
10-80mg/day
5-40mg/day
5-80mg/day
$-$$$$$
81/20325/80mg/day
4-24 gm/day
5-30 gm/day
3.75-4.375
gm/day
$$$$$
Immediate/sustainedrelease niacin+*
Niacin extendedreleased (Niaspan)*
1.5-6 gm/day
$-$$
1-2 gm/day
$$-$$$$
$$$$$$$$
↓ 20↓ 30↑ 20-
Niacin extended-release 500/20+ lovastatin (Advicor) 2000/40
mg/day
$$$$$
Ezetimibe (Zetia)*
$$$$$
↓ 32↓ 17-
10 mg daily
↑ 1%
↓ 7-
68
Absorption
inhibitor
+ statin
Fibric acids
+
Generic available
LDL
60%
HDL
10%
TG
31%
LDL
20%
HDL
20%
TG
50%
↓ 45-
Ezetimibe + simvastatin 10/10-10/80
mg/day
(Vytorin)
$$$$$
Fenofibrate (Tricor)*
Fenofibrate micronized
(Lofibra)
Gemfibrozil (Lopid) +*
$$$$$$$
↑ 6↓ 23↓ 5↑ 10↓ 20-
54-160
mg/day
67-200
mg/day
1200mg/day
*MH-MH formulary medications
69
Hypertension Therapy
JNC-VII Recommendations
CATEGORY
Normal
Prehypertension
Hypertension, Stage 1
Hypertension, Stage 2
SYSTOLIC BP, mm Hg
< 120
120-139
140-159
> 160
DIASTOLIC BP, mm Hg
< 80
80-89
90-99
> 100
Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal BP (<140/90 mm Hg or <130/80 mm Hg
for those with diabetes or chronic kidney disease)
Initial Drug Choice
Hypertension without
compelling indications
Hypertension with
compelling indications
Stage 1 Hypertension
Stage 2 Hypertension
Thiazide-type diuretic for
most. May consider ACE
inhibitor, ARB, β-blocker,
calcium channel blocker, or
combination
2-Drug combo for most
(Usually Thiazide-type
diuretic and ACE-I, or
ARB, or β-blocker, or
Calcium channel blocker)
Drug(s) for the
compelling indication
Other antihypertensive
drugs as needed
Not at Goal BP
Optimize dosages or add additional drugs until goal blood pressure is achieved
General Principles of Initiating Therapy:
1. Initiate therapy with the lowest dose possible, slowly titrating upward.
70
2. Optimal formulation should provide 24 hour efficacy with once daily dosing to
enhance compliance, lower cost and allow for a more constant lowering of blood
pressure.
3. Most patients with hypertension will require 2 or more antihypertensive
medications to achieve their BP goals.
4. When BP is more than 20/10 mm Hg above goal, initiating therapy with 2 drugs
should be considered.
Compelling Indications for Individual Drug Classes
Compelling Indication
Initial Therapy Options
Heart Failure
Thiazide diuretic, β blocker, ACE inhibitor,
ARB, Aldosterone receptor blocker
Post-myocardial infarction
β blocker, ACE inhibitor, Aldosterone
receptor blocker
High risk for coronary disease
Thiazide diuretic, β blocker, ACE inhibitor,
Calcium channel blocker
Diabetes
Thiazide diuretic, β blocker, ACE inhibitor,
ARB, Calcium channel blocker
Chronic kidney disease
ACE inhibitor, ARB
Recurrent stroke prevention
Thiazide diuretic, ACE inhibitor
Pregnancy
Methyldopa, β blocker, Vasodilator
DRUG
β BLOCKERS
INITIAL DOSE
TARGET DOSE
Atenolol (Tenormin)†
Bisoprolol (Zebeta)†
Metoprolol tartrate
(Lopressor)†
Metoprolol succinate
(Toprol XL)
Pindolol (Visken)†
25-50 mg daily
2.5-5 mg daily
50-100 mg bid
Propranolol (Inderal,
Inderal LA)†
40 mg bid,
60-80 mg daily
50-100 mg daily
5 mg bid
50-100 mg daily
2.5-20 mg daily
100-450 mg in 2-3
divided doses
100-400 mg daily
MAXIMUM
DOSE
100 mg daily
40 mg daily
450 mg/day
400 mg daily
10-30 mg in 2-3
60 mg/day
divided doses
160-480 mg in divided 640 mg/day
doses,120-160 mg/day
† Available in generic preparations. *Only formulary products are listed.
DRUG
ACE INHIBITORS
INITIAL DOSE
TARGET DOSE
Benazepril (Lotensin)† 5-10 mg daily
20-40 mg daily or in
divided doses
MAXIMUM
DOSE
80 mg/day
71
Captopril (Capoten)†
12.5-25 mg bid or 50 mg tid
tid

5 mg daily
10-40 mg daily or in
Enalapril (Vasotec )†
divided doses

20-40 mg daily or in
Fosinopril (Monopril )† 10 mg daily
divided doses

10 mg daily
20-40 mg daily
Lisinopril (Prinivil ,

Zestril )†
7.5 mg daily
7.5-30 mg daily or in
Moexipril (Univasc)
divided doses

4 mg daily
4-8 mg daily
Perindopril (Aceon )

20-80 mg daily or in
Quinapril (Accupril )† 10 mg daily
divided doses

2.5-5 mg daily
2.5-20 mg daily or in
Ramipril (Altace )
divided doses

1-2 mg daily
2-4 mg daily
Trandolapril (Mavik )
150 mg tid
40 mg/day
80 mg/day
80 mg daily
30 mg/day
16 mg daily
80 mg/day
20 mg/day
8 mg daily
† Available in generic preparations
*All ACE inhibitors are on formulary.
ANGIOTENSIN II RECEPTOR BLOCKERS (ARB)
DRUG
INITIAL DOSE
TARGET DOSE
MAXIMUM
DOSE

25-50 mg daily
25-100 mg daily or in 100 mg/day
Losartan (Cozaar )
divided doses

80-160 mg daily 80-320 mg daily or in 320 mg/day
Valsartan (Diovan )
divided doses
*Only formulary ARBs are listed.
DRUG
Thiazide Diuretics
Chlorthalidone †
Hydrochlorothiazide †
Metolazone
(Zaroxolyn)†
Loop Diuretics*
Bumetanide (Bumex)†
Furosemide (Lasix)†
DIURETICS
INITIAL DOSE TARGET DOSE
MAXIMUM
DOSE
25 mg daily
25-100 mg daily
12.5 mg daily
25-100 mg daily
1.25-2.5 mg daily 5-10 mg daily
100 mg daily
200 mg daily
10 mg daily
0.5-2 mg 1-2
times/day
10-40 mg daily
Increase as needed
10 mg/day
Increase by 20-40
mg as needed
240 mg bid
72
Torsemide (Demadex)†
5-10 mg daily
Aldosterone Receptor Blockers
50 mg daily
Eplerenone (Inspra)
Spironolactone
25 mg daily

(Aldactone )†
Double the dose as
needed
200 mg daily
50-100 mg daily
25-200 mg daily or
in divided doses
100 mg daily
200 mg/day
*
Furosemide 40 mg=10-20 mg of torsemide=1 mg of bumetanide
† Available in generic preparations
All listed agents are formulary.
DRUG
CALCIUM CHANNEL BLOCKERS
(Not short acting, immediate release agents)
INITIAL DOSE TARGET DOSE
Nondihydropyridines
Diltiazem
(Cardizem†, Tiazac†)
30 mg tid,
240-360 mg in 3-4
180-240 mg daily doses, 240-360 mg
daily
40 mg bid,
80 mg tid,
120 mg daily
120-240 mg daily
Verapamil (Calan,
Isoptin, Verelan)†
Dihydropyridines
Amlodipine (Norvasc)† 2.5-5 mg daily
Nifedipine (Adalat CC)† 30 mg daily
20 mg daily
Nisoldipine (Sular)
5-10 mg daily
30-60 mg daily
20-40 mg daily
MAXIMUM
DOSE
360 mg/day
360 mg/day
10 mg daily
120-180 mg daily
60 mg daily
† Available in generic preparations. *Only formulary calcium channel blockers are listed.
73
DRUG
Doxazosin (Cardura)†
Terazosin (Hytrin)†
α-BLOCKERS
(Not Initial Monotherapy)
INITIAL DOSE
TARGET DOSE
1 mg daily
1 mg qhs
1-16 mg daily
1-5 mg qhs
MAXIMUM
DOSE
16 mg daily
20 mg qhs
† Available in generic preparations
Only formulary alpha blockers are listed.
CENTRAL α-AGONISTS and Other Centrally Acting Drugs
(Not Initial Monotherapy)
DRUG
INITIAL DOSE
TARGET DOSE
MAXIMUM
DOSE

0.2-1.2 mg bid,
2.4 mg/day
Clonidine (Catapres †, 0.05-1 mg bid,

0.1 mg patch
0.1-0.3 mg every week 0.6 mg/week
Catapres TTS )
every week
Methyldopa
250 mg bid-tid
500 mg-2 g in 2-4
3 g/day

divided doses
(Aldomet )†

Guanafacine (Tenex )†
1 mg qhs
1-3 mg qhs
3 mg qhs
Reserpine †
0.05-0.1 mg daily 0.1-0.25 mg daily
0.5 mg daily
† - Available in generic preparations
All listed agents are formulary.
DRUG
Hydralazine
(Apresoline)†
Minoxidil (Loniten)†
DIRECT VASODILATORS
(Not initial Monotherapy)
INITIAL DOSE
TARGET DOSE
10 mg qid
25-50 mg qid
MAXIMUM
DOSE
300 mg daily
2.5-5 mg daily
10-40 mg daily
100 mg daily
† - Available in generic preparations.
All listed agents are formulary.
Adapted from The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289:2560-2572;May 21, 2003.
74
VTE Prophylaxis and Treatment:
Selected Recommendations from ACCP
Indication
VTE Prophylaxis
Do not use aspirin for VTE prophylaxis
Use mechanical methods (GCS or IPC) if
bleeding risk is high
Laparoscopic procedures + VTE risk factors
Minor surgery, age <40, no risk factors)
General surgery (moderate risk)*
General surgery (high risk)**
General surgery (very high risk)***
Gynecologic surgery (no risk)
Gynecologic surgery (major surgery)
Gynecologic surgery (major surgery with
malignancy)
Urologic surgery (low or no risk)
Urologic surgery (major, open)
Urologic surgery (with multiple risk factors)
Hip replacement/ hip fracture surgery
Elective knee replacement
Neurosurgery
Trauma, Spinal cord injury
Ischemic stroke
General medical patient (admitted for CHF or
resp. illness or confined to bed and have
additional risk factors)
ICU patients
Therapy
LDUFH or LMWH, IPC or GCS
Early and aggressive mobilization
LDUFH q12h or LMWH
LDUFH q8h or LMWH
LMWH or LDUFH q8h + IPC/GCS
Early and aggressive mobilization
LDUFH q12h or LMWH or IPC
LDUFH q8h or LMWH, consider
adding IPC/GCS
None recommended
LDUFH or LMWH or GCS or IPC
GCS +/- IPC with LDUFH or LMWH
LMWH or fondaparinux or warfarin
(INR 2-3) for at least 10 days.
Consider using extended prophylaxis
for up to 28-35 days post-operatively.
LMWH or fondaparinux or warfarin
(INR 2-3)
IPC with or without GCS
LMWH continued through
rehabilitation
LDUFH or LMWH
LDUFH or LMWH
LDUFH or LMWH
75
Indication
Treatment of Thromboembolism
Indication
Atrial Fibrillation
Prior TIA or Stroke
Any one of the following: History of
hypertension or systemic embolism or
diabetes or systolic heart failure or mitral
stenosis or rheumatic mitral valve disease
Age > 75
Age 65-75 years and no other risk factors
Age <65 years and no other risk factors
Therapy
Begin anticoagulation while awaiting
test results when clinical suspicion is
high.
LMWH or UFH IV for at least 5 days.
Overlap with warfarin until INR is in
therapeutic range and stable.
UFH is preferred in severe renal
insufficiency.
LMWH for the first 3-6 months should
be considered for patients with VTE
and cancer.
Elastic compression stockings for 2
years after an episode of DVT reduces
risk for post-thrombotic syndrome.
Therapy
Warfarin (target INR 2.5, range 2-3)
Warfarin (target INR 2.5, range 2-3)
Warfarin (target INR 2.5, range 2-3)
Warfarin (target INR 2.5, range 2-3) or
ASA 325 mg/day
Aspirin 325 mg/day
76
Indication
Prosthetic Heart Valves
Aortic bileaflet or tilting disk valves
Aortic bileaflet valves + atrial fibrillation
Mitral bileaflet or tilting disk valves
Caged ball or caged disk valves
Mechanical valves + atrial fibrillation or MI
or left atrial enlargement or systolic heart
failure or systemic embolism despite
therapeutic INR
Bioprosthetic valves (aortic or mitral)
Indication
Ischemic Stroke/TIA
Secondary Prevention
Non-cardioembolic stroke
Therapy
Warfarin (target INR 2.5, range 2-3)
Warfarin (target INR 3, range 2.5-3.5)
Warfarin (target INR 3, range 2.5-3.5)
Warfarin (target INR 3, range 2.5-3.5)
+ ASA 80mg daily
Warfarin (target INR 3, range 2.5-3.5)
+ ASA 80mg daily
Warfarin (goal INR 2-3) x 3 months
then either no anticoagulation or ASA
80mg daily
Therapy
ASA 50-325 mg daily or the
combination of ASA 25 mg and
extended release dipyridamole 200 mg
BID or clopidogrel 75 mg.
VTE = venous thromboembolism, LDUFH = low-dose-unfractionated heparin, LMWH = lowmolecular-weight heparin, ASA = aspirin, GCS = graduated compression stockings, IPC =
intermittent pneumatic compression
*
Moderate Risk: Minor surgery in patients with additional risk factors; non-major surgery in
patients aged 40-60 years, with no risk factors; major surgery and age <40 with no risk
factors
**
High Risk: Non-major surgery in patients > 60 or with additional risk factors; major surgery
in patients > 40 years or with additional risk factors
***
Very High Risk: Major surgery in patients > 40 and history of VTE, cancer,
hypercoagulable state; major trauma, spinal cord injury
Adapted from The Seventh ACCP Conference On Antithrombotic and Thrombolytic Therapy:
Evidence-Based Guidelines. 2004; 126(3): 163S-703S.
77
Perioperative Management of Patients Who Require
Discontinuation of Warfarin
Risk of Thromboembolism
Low annual risk
(<4%)
Example
Atrial fibrillation and
no risk factors or stroke;
VTE > 90 days ago
Recommendation
Withhold warfarin
Moderate annual risk
(4-7%)
Mechanical aortic valve
Withhold warfarin;
Optional bridging
w/ LMWH or UFH
High annual risk
(>70%)
Mechanical mitral valve;
Atrial fib.+ hx of stroke;
Recent VTE (<90 days)
Withhold warfarin
and bridge w/
LMWH or UFH
If preoperative
anticoagulation is
critical
Mechanical mitral valve
and recent TIA
Withhold warfarin
and bridge with IV
heparin until 5 hrs
preop and obtain
baseline aPTT
• In most cases, warfarin is stopped 4-5 days preoperatively, allowing the INR to
return to normal by the time of the procedure. The period of time without warfarin
may be reduced to two days by giving oral vitamin K 2.5 mg
48 hours prior to the procedure.
• LMWH may be used until 24 hours preoperatively and restarted 12-24 hours
postoperatively (“bridging”) in order to limit the amount of time the patient is
without anticoagulation.
INR: International Normalized Ratio, LMWH: Low Molecular Weight Heparin, VTE: Venous thromboembolism
Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants. A systematic review. Arch
Intern Med. 2003;163:901-908.
Ansell J, Hirsh J, Poller L, et al. The pharmacology and management of the vitamin k antagonists. The 7th ACCP
consensus conference on antithrombotic and thrombolytic therapy. Chest 2004;126:204S-233S.
78
CHRONIC HEART FAILURE THERAPY (ACC/AHA)
New York Heart Association Functional Classification:
Class I:
Patients with cardiac disease but without limitations of physical
activity. Ordinary physical activity does not cause undue fatigue,
dyspnea, or palpitation.
Class II:
Patients with cardiac disease that results in slight limitations of physical
activity. Ordinary physical activity results in fatigue, palpitation,
dyspnea, or angina.
Class III:
Patients with cardiac disease that results in marked limitation of
physical activity. Although patients are comfortable at rest, less than
ordinary activity will lead to symptoms.
Class IV:
Patients with cardiac disease that results in an inability to carry
on physical activity without discomfort. Symptoms of congestive heart
failure are present at rest. With any physical activity, increased
discomfort is experienced.
Criteria Committee, New York Heart Association, Inc. Diseases of the Heart and Blood Vessels.
Nomenclature and Criteria for Diagnosis, 7th ed. Boston, Little, Brown, 1973.
Classification Based on Disease Progression- 2005 Guidelines
Stage A: Patient at high risk for developing heart failure but has no structural heart
disease (Examples: HTN; CAD; DM; History of cardiotoxic drug therapy or alcohol
abuse, History of rheumatic heart fever; Family history of cardiomyopathy)
Stage B: Patient with structural heart disease who has never developed symptoms of
heart failure (Examples: Previous MI; Left ventricular hypertrophy; Left ventricular
dilatation; Asymptomatic valvular heart disease)
Stage C: Patient with past or current heart failure symptoms associated with
underlying structural heart disease
Stage D: Patient with end-stage disease who requires specialized treatment strategies
such as mechanical circulatory support, continuous inotropic therapy, cardiac
transplantation or hospice care.
*This classification is intended to complement but not replace the New York Heart Association
functional classification, which primarily gauges the severity of symptoms in patients who are in
Stage C or D.
79
Therapy
Stage A:
1. Control blood pressure (angiotensin converting enzyme (ACE) inhibitors and beta
blockers preferred).
2. Lifestyle modifications- smoking cessation, exercise, discourage alcohol and illicit
drug use.
3. Treat lipid abnormalities in accordance with recommended guidelines.
4. Begin ACE inhibitors in patients with a history of atherosclerotic vascular disease,
diabetes mellitus, or hypertension and associated cardiovascular risk factors.
Stage B:
1. Same recommendations as Stage A.
2. Initiate ACE inhibitor (ARB may be used if intolerant of ACE inhibitor) and beta
blocker therapy post-myocardial infarction.
Stage C:
1. Same recommendations as Stage A and B.
2. Drugs for routine use: ACE inhibitors, beta blockers, diuretics.
3. Potential therapies: aldosterone antagonists, digoxin, angiotensin receptor blockers
(ARBs), or hydralazine + isosorbide dinitrate.
Stage D:
1. Same recommendations as Stage A-C.
2. Possible IV inotropic therapy, heart transplantation, ventricular assist devices,
and/or hospice care.
ACE Inhibitors should be used in all patients with an ejection fraction
< 40% unless contraindicated. Absolute contraindications include: angioedema,
pregnancy, and bilateral renal artery stenosis. Relative contraindications include:
cough, SCr > 3.0, and significant hyperkalemia.
β blockers should be used in all stable patients who are taking maximally tolerated
doses of ACE inhibitors plus/minus digoxin. Recommended beta blockers include
bisoprolol, metoprolol XL, and carvedilol. Absolute contraindications include: HR
<50, SBP < 90 mm Hg, and second or third degree heart block without a pacemaker.
Relative contraindications include: bronchoconstrictive disease.
Diuretics should be prescribed for all patients with symptoms of heart failure.
Diuretics should not be used alone even if the symptoms of heart failure are well
controlled. Loop diuretics are the preferred diuretic agents for use in most patients
with heart failure. If a patient experiences a 1-2 kg weight gain, double the loop
diuretic dose. If this fails, metolazone can be added for several days. If hypotension
or azotemia is observed, the rapidity of diuresis should be decreased. Overdosing of
80
diuretics can lead to volume depletion, which may increase the likelihood of
hypotension with ACE inhibitors and risk of renal insufficiency. Nonsteroidal antiinflammatory drugs may cause diuretic resistance and should be avoided in patients
with heart failure.
Digoxin usage in heart failure was defined by the Digitalis Investigation Group. The
results of the trial indicate that patients concurrently on ACE inhibitors and diuretics
found benefit from digoxin by decreasing the number of hospitalizations, but
mortality was not significantly affected. Digoxin can be added in patients with
continued heart failure symptoms despite standard therapy. A subanalysis of the DIG
trial showed an increase in mortality in patients with digoxin serum levels > 1. Goal
digoxin level for heart failure is 0.5-0.8 ng/ml.
Aldosterone antagonists have been shown in clinical trials to reduce morbidity and
mortality in heart failure patients. The RALES trial, was designed to evaluate the
addition of spironolactone (Aldactone®) to standard heart failure therapy in Class III
and IV heart failure patients. The EPHESUS trial, investigated eplerenone (Inspra®)
in patients post-myocardial infarction with Class II-IV heart failure. The current
guidelines recommend consideration in patients with moderately severe to severe
symptoms of HF and reduced ejection fraction who can be carefully monitored.
Obtain baseline labs prior to initiation (K+< 5.5 mmol/L and CrCl >30 ml/min).
Angiotensin Receptor Blockers (ARBs) that are approved for HF (candesartan,
valsartan) are a reasonable alternative in patients who are ACE inhibitor intolerant.
They should not be used in patients who have no prior use of an ACE inhibitor or in
patients who are tolerating an ACE inhibitor. At this time, ARBs should be
considered in patients who experience cough while receiving an ACE inhibitor. Use
with caution in patients with a history of angioedema to ACE inhibitors.
The combination of hydralazine and isosorbide dinitrate should be considered when
ACE inhibitors are not tolerated because of angioedema, renal insufficiency,
hyperkalemia or cough. In addition, the A-HeFT trial (N Engl J Med 2004;351:204957.) found a mortality reduction from the combination of hydralazine and isosorbide
dinitrate in African American patients who were receiving standard therapy (ACE
inhibitor, diuretic, beta blocker).
Amlodipine and felodipine are the only calcium channel blockers that can be safely
used in patients with heart failure.
Therapy for Diastolic Dysfunction:
Goals: control BP, HR, blood volume and ischemia.
Therapy: ACE inhibitors, beta blockers.
81
DRUG
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Zestril,
Prinivil)
Quinapril (Accupril)
Ramipril (Altace)
DRUG
ACE INHIBITORS
INITIAL DOSE
TARGET
DOSE
6.25 mg tid
50 mg tid
2.5 mg bid
10-20 mg bid
5-10 mg daily
20-40 mg daily
5 mg daily
20-40 mg daily
MAXIMUM COST/
DOSE
Month
100 mg tid
$$
20 mg bid
$$
40 mg daily
$$$
40 mg daily
$$
5 mg bid
20-40 mg bid
1.25-2.5 mg daily 10 mg daily
40 mg bid
10 mg daily
$$$
$$$$$
ANGIOTENSIN RECEPTOR BLOCKERS
INITIAL DOSE
TARGET
MAXIMUM COST/
DOSE
DOSE
Month
4 mg daily
4-16 mg daily 32 mg daily
$$$$
Candesartan
(Atacand)
Valsartan (Diovan)
DRUG
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Metoprolol XL
(Toprol)
DRUG
Spironolactone
(Aldactone)
Eplerenone (Inspra)
40 mg bid
40-160 mg bid
BETA BLOCKERS
INITIAL DOSE
TARGET
DOSE
1.25 mg daily
2.5-10 mg
daily
3.125 mg bid
25 mg bid
12.5-25 mg daily 200 mg daily
160 mg bid
$$$$
MAXIMUM COST/
DOSE
Month
10 mg daily
$$$
50 mg bid
200 mg daily
$$$$$
$$$
ALDOSTERONE ANTAGONISTS
INITIAL DOSE
TARGET
MAXIMUM COST/
DOSE
DOSE
Month
25 mg daily
25-50 mg daily 50 mg daily
$$
25 mg daily
50 mg daily
50 mg daily
$$$$$
HYDRALAZINE & ISOSORBIDE DINITRATE
DRUG
INITIAL DOSE
TARGET
MAXIMUM COST/
DOSE
DOSE
Month
Hydralazine
10-25 mg bid
75 mg tid
100 mg tid
$

(Apresoline )
Isosorbide dinitrate
10 mg tid
40 mg tid
80 mg tid
$
Hydralazine/isosorbide 37.5/20 mg tid
37.5/20 mg75/40 mg tid
$$$$

75/40 mg tid
(BiDil )
82
VARIOUS DIURETICS
INITIAL DOSE
TARGET
DOSE
MAXIMUM
DOSE
Hydrochlorothiazide
12.5 mg daily
25-100 mg
daily
200 mg daily
Loop Diuretics
Furosemide (Lasix)
10-40 mg daily
As needed, inc. 240 mg bid
by 20-40 mg
Double the
200 mg daily
dose as needed
DRUG
Torsemide (Demadex) 10-20 mg daily
(Equal to 40 mg
furosemide)
Miscellaneous Diuretics
Metolazone
2.5 mg daily

(Zaroxolyn )
5-10 mg daily
10 mg daily
COST
(30 D
supply)
$
$
$$
$$-$$$
*All listed agents are formulary with the exception of Atacand and BiDil.
CrCl
(ml/min)
50
10
20
30
40
50
60
70
80
90
100
0.125
0.125
0.125
0.125
0.125
0.25
0.25
0.25
0.25
0.25
DAILY DOSES OF DIGOXIN
Body weight (kg)
60
70
80
dose (mg)
0.125
0.125
0.125
0.125
0.125
0.25
0.125
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.375
90
100
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.375
0.375
0.375
0.25
0.25
0.25
0.25
0.25
0.375
0.375
0.375
0.5
0.5
The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with
heart failure. N Engl J Med 1997;336:525-33.
Adapted from 2005 Guideline update for the diagnosis and management of chronic heart failure in
the adult: report of the American College of Cardiology/ American Heart Association task force on
practice guidelines. www.acc.org; www.americanheart.org
83
Acute Myocardial Infarction (AMI) Therapy
AHA/ACC Guidelines 2004 Update1
Drug
Class of Recommendation
Aspirin
I. Initial dose of 162-325 mg orally and continued indefinitely at a
daily dose of 75-162 mg to all patients without a true aspirin allergy.
Clopidogrel
I.
1. In patients who have had a PCI procedure, continue in combination
with aspirin for at least 1 month after bare metal stent placement and
up to 12 months in patients who are not at high risk for bleeding.
After drug eluting stent placement (sirolimus, paclitaxel), patients
should receive 12 months of therapy in combination with aspirin if
they are not at high risk of bleeding2.
2. In patients in whom CABG is planned, withhold for at least 5 days,
preferably for 7.
3. Alternative to aspirin in patients with hypersensitivity or major
gastrointestinal intolerance.
Reperfusion I.
therapy1. STEMI patients should undergo evaluation for reperfusion therapy.
Thrombolysis 2. Fibrinolysis is generally preferred if: invasive strategy is not an
option, or delay to invasive strategy.
Heparin
LMWH
III.
1. ST elevation, time to therapy >24 hours ischemic pain resolved
2. ST depression only
I.
1. IV in patients undergoing percutaneous or surgical revascularization
2. IV in patients treated with selective thrombolytics (alteplase,
reteplase, tenecteplase)
3. IV in patients treated with nonselective thrombolytic agents
(streptokinase, anistreplase, urokinase) who are at high risk for
systemic emboli.
4. Monitor platelet counts daily.
IIa. IV or SQ UFH or SQ LMWH in patients not treated with
thrombolytics without a contraindication for at least 48 hours.
IIb.
1. It may be reasonable to administer in patients given streptokinase.
2. Prophylaxis for DVT with SQ UFH or SQ LMWH.
IIb. Acceptable alternative to UFH for patients < 75 without significant
renal dysfunction receiving thrombolytic therapy.
III.
1. LMWH is not an alternative to UFH in patients > 75 receiving
thrombolytic therapy.
2. LMWH is not an alternative to UFH in patients < 75 with
significant renal dysfunction receiving thrombolytic therapy.
84
GP2b3a
inhibitors
IIa. Reasonable to start treatment with abciximab as early as possible
before primary PCI (w/ or w/out stenting) in patients with STEMI.
IIb. Treatment with tirofiban or eptifibatide may be considered before
primary PCI (w/ or w/out stenting) in patients with STEMI.
Beta Blockers I. Oral beta blocker therapy to patients without a contraindication,
Irrespective of thrombolytic or primary PCI therapy. Continue
indefinitely.
IIb. IV beta blockers to STEMI patients without contraindications,
especially if tachyarrhythmia or hypertension is present.
ACE
I. Patients within the first 24 hours of anterior infarction, pulmonary
Inhibitors
congestion or LVEF < 40% in the absence of hypotension or
known contraindications.
IIa. All other patients within the first 24 hours
IIb. The combination of ACE inhibitor and ARB may be considered in
patients with persistent symptomatic heart failure and EF < 40%.
III. An IV ACE inhibitor should not be given within the first 24 hours
due to risk of hypotension.
Angiotensin I. Administer to patients who are intolerant of ACE inhibitors who
receptor
have clinical or radiological signs of HF or EF < 40%.
blocker
(ARB)
Aldosterone I. Patients without significant renal dysfunction or hyperkalemia who
blocker
are receiving therapeutic doses of ACE inhibitor, have LVEF < 40%
and symptomatic heart failure or diabetes.
Nitroglycerin I.
1. IV within the first 48 hours for persistent ischemia, CHF or
hypertension.
2. Oral or topical nitrates are useful beyond the first 48 hours for
treatment of recurrent angina if their use does not preclude therapy
with beta blockers and ACE inhibitors.
III.
1. SBP < 90 mm Hg or > 30 mm Hg below baseline, severe
bradycardia, tachycardia, or suspected RV infarction.
2. Phosphodiesterase inhibitor use within the last 24 hours.
Calcium
IIa. Verapamil or diltiazem in patients with contraindications to beta
Channel
blockers or for relief of ongoing ischemia or control of RVR with
Blockers
Afib in the absence of CHF, LV dysfunction or AV block.
III.
1. Nifedipine (short acting) is contraindicated
2. Diltiazem and verapamil are contraindicated in patients with acute
MI and associated LV dysfunction or CHF.
Lipid
See lipid lowering guidelines
Therapy
Obtain lipid panel within 24 hours of admission.
Warfarin
I.
85
Estrogen
Replacement
Therapy
1. Alternative to clopidogrel in aspirin allergic patients w/out stent
placement.
2. Presence of Afib
3. LV thrombus (for at least 3 months)
IIa. LV dysfunction and extensive wall motion abnormalities
IIb. Severe LV dysfunction with or without CHF
III.
1. HRT with estrogen plus progestin for secondary prevention should
not be given to postmenopausal women after STEMI.
2. Women already taking HRT at time of AMI should discontinue
therapy. Weigh risks vs. benefits if patient wishes to continue
HRT.
1. American College of Cardiology. ACC/AHA Guidelines for the Management of Patients with STelevation Myocardial Infarction http://www.acc.org/clinical/guidelines/stemi (accessed 2004 September).
2. Grines CL, Bonow RO, et al. AHA/ACC/SCAI/ACS/ADA Scientific Advisory. Prevention of
premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents.
Circulation 2007;115:813-8.
The ACC/AHA classification system for procedures and treatments:
Class I:
Evidence and/or general agreement that treatment is beneficial, useful,
and effective.
Class II:
Conflicting evidence and/or a divergence of opinion about the
usefulness/efficacy.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Evidence and/or general agreement that treatment is not useful/effective
and in some cases may be harmful.
86
Asthma Guidelines
CLASSIFICATION OF ASTHMA SEVERITY:
Step 1: Intermittent
Symptoms < 2 days/week; asymptomatic and normal PEF between
exacerbations; exacerbations are brief (from a few hours to a few days);
intensity may vary; nocturnal symptoms < 2 nights/month.
FEV1 or PEF > 80%
Step 2: Mild Persistent
Symptoms > 2 days/week but < 1x/day; exacerbations may affect
activity; nocturnal symptoms 3-4 nights/month.
FEV1 or PEF > 80%
Step 3: Moderate Persistent
Daily symptoms; daily use of short-acting beta2 agonist; exacerbations affect
activity; exacerbations > 2 times a week (may last days); nocturnal symptoms >
1 night/week.
FEV1 or PEF > 60% -< 80%
Step 4: Severe Persistent
Continual symptoms; limited physical activity; frequent exacerbations;
nocturnal
symptoms are frequent.
FEV1 or PEF < 60%
ASTHMA THERAPY BASED ON CLASSIFICATION
Step 1: Intermittent
Long Term Control: None needed.
Quick Relief:
Short acting inhaled beta2-agonist (not ipratropium) as needed for
symptoms. (Use of these agents more than twice a week may indicate the
need to initiate long-term control therapy.)
Step 2: Mild Persistent
Long Term Control:
1. Preferred: Inhaled corticosteroid (low dose) with spacer device
2. Alternative: Cromolyn or nedocromil.
3. Alternative: Montelukast or zafirlukast.
4. Alternative: Theophylline SR
Quick Relief:
Short acting inhaled beta2-agonist as needed for symptoms.
87
Step 3: Moderate Persistent
Long Term Control:
1. Preferred: Inhaled corticosteroid (low dose) and long-acting inhaled
beta2-agonist, especially for night-time symptoms
OR
inhaled corticosteroids (medium dose). Consider short course of oral
corticosteroids (2 mg/kg/day, not to exceed 60mg/day).
2. Alternative: Low dose inhaled corticosteroids with either a leukotriene
modifier (montelukast or zafirlukast) OR theophylline SR OR zileuton
Quick Relief:
Short-acting inhaled beta2-agonist as needed for symptoms.
Step 4: Severe Persistent
Long Term Control:
Inhaled corticosteroids (medium-high dose) and long-acting inhaled
beta2-agonists and consider short course of oral corticosteroids (2
mg/kg/day, not to exceed 60mg/day).
Quick Relief:
Short acting inhaled beta2-agonist as needed for symptoms.
Medications for Asthma and COPD
DRUG
SHORT-ACTING BETA2-AGONISTS
HOW SUPPLIED
DOSE
Albuterol
(Proventil,Ventolin,
ProAir® HFA)
Levalbuterol
(Xopenex)
Levalbuterol (Xopenex®
HFA)
Metaproterenol
(Alupent)
Pirbuterol (Maxair)
90 mcg/puff; 200 puffs
2 puffs Q 4-6 hrs,
max 12 puffs/day
0.63 mg/3 ml solution
1.25 mg/3 ml solution
45 mcg/puff; 200 puffs
0.63 mg Q 6-8 hrs
via nebulizer
1-2 puffs Q 4-6
hours
2-3 puffs Q 3-4 hrs,
max 12 puffs/day
2 puffs Q 4-6 hrs,
max 12 puffs/day
2 puffs Q 4-6 hrs
75 mg/puff; 100 puffs
150 mg/puff; 200 puffs
200 mcg/puff; 400 puffs
Terbutaline (Brethaire) 200 mcg/puff; 300 puffs
DRUG
INHALED CORTICOSTEROIDS
HOW
DOSE
COMPARATIVE
COST
(30 Day)
$
$$$$
$$$$
$$$$
$$
$$
COST
88
SUPPLIED
Beclomethasone 42 mcg/puff;
CFC (Beclovent, 80,200 puffs
84 mcg/puff
Vanceril)
(DS); 40,120
puffs
Beclomethasone 40 mcg/puff;
HFA
80 mcg/puff

(Q-var )
Budesonide
90 mcg/inhal
Flexhaler
(60 doses)

180 mcg/inhal
(Pulmicort )
(120 doses)
Budesonide
200 mcg/inhal
Turbuhaler
®
(200 doses)
(Pulmicort )
Flunisolide
250 mcg/puff;

100 puffs
(AeroBid )
Fluticasone HFA
(Flovent)
Triamcinolone
(Azmacort)
DRUG
2 puffs
tid-qid
(42 mcg)
2 puffs bid
1-2
inhalations
bid
2 puffs bid
DAILY DOSES
Low: 4-12 puffs
Medium: 12-20
puffs
High: > 20 puffs
(30 Day)
$$$
Low: 2-6 puffs
Medium: 6-16 puffs
High: >16 puffs
Low: 1-2 inhal.
Medium: 2-3 inhal.
High: > 3 inhal.
Low: 2-4 puffs
Medium: 4-8 puffs
High: > 8 puffs
$$$
$$$
$$$$$
44 mcg/puff
110 mcg/puff
220 mcg/puff;
60, 120 puffs
2-4 puffs bid Low: 2-6 puffs
$$$
(44 mcg)
Medium: 2-6 puffs
(110 mcg)
High: > 6 puffs (110
mcg)
100 mcg/puff;
2 puffs tidLow: 4-10 puffs
$$$
240 puffs
qid;
Medium: 10-20
4 puffs bid
puffs
High: > 20 puffs
SYSTEMIC CORTICOSTEROIDS
EQUIVALENT
GC
MC
DOSE (mg)
POTENCY
POTENCY
Short-acting
Cortisone
Hydrocortisone
Intermediate-acting
Prednisone
Prednisolone
Methylprednisolone
Dexamethasone
25
20
0.8
1
0.8
1
5
5
4
0.75
4
4
5
20-30
0.8
0.8
0.5
0
Notes: GC: Glucocorticoid MC: Mineralocorticoid
89
LONG-ACTING INHALED/NEBULIZED BETA2-AGONIST
**NOT FOR ACUTE RELIEF**
DRUG
HOW SUPPLIED
DOSE
COST
(30 Day)
Salmeterol (Serevent
50 mcg/inhalation;
1 inhalation Q 12
$$$$

60 inhalations
hrs
Diskus )

12 mcg/inhalation;
1 puff Q 12 hrs
$$$$
Formoterol (Foradil )
60 inhalations
Arformoterol*
15 mcg/2 mL nebulized 15 mcg twice daily
$$$$
®
(Brovana )
solution
*Only used in COPD
LONG-ACTING INHALED BETA2-AGONIST/INHALED
CORTICOSTEROIDS
**NOT FOR ACUTE RELIEF**
DRUG
HOW SUPPLIED
DOSE
Fluticasone/Salmeterol
(Advair Diskus®)
Fluticasone/Salmeterol
(Advair® HFA)
Budesonide/Formoterol
(Symbicort® MDI)
DRUG
Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo®, Zyflo
CR®)
*Not indicated for COPD
DRUG
100/50, 250/50, 500/50
mcg/inhalation
45/21, 115/21, 230/21
mcg/inhalation
80/4.5 mcg/inhalation
160/4.5 mcg/inhalation
1 inhalation Q 12
hours
2 inhalations Q 12
hours
2 inhalations Q 12
hours
LEUKOTRIENE MODIFIERS*
DOSAGE FORM
DOSE
10 mg tablet
20 mg tablet
600 mg tablet, 1200
mg tablet
10 mg daily
20 mg bid
4 times/day, twice
daily
MAST CELL STABALIZER
HOW SUPPLIED
DOSE
Cromolyn Sodium (Intal) 1 mg/puff
2 puffs qid
COST
(30 Day)
$$$$
$$$$
COST
(30 Day)
$$$$
$$$
$$$$
COST (30
Day)
$$$
90
THEOPHYLLINE
MAINTENANCE DOSE FOR ACUTE SYMPTOMS
POPULATION GROUP
ORAL
I.V.
THEOPHYLLINE AMINOPHYLLINE
(mg/kg/day)
(mg/kg/hr)
Children 9-12y, and adolescent daily
smokers of cigarettes or marijuana, and
otherwise healthy adult smokers < 50 y
16
0.9
Adolescents 12-16y (nonsmokers)
13
0.7
Otherwise healthy
nonsmoking adults
10
0.5
(including elderly patients)
(not > 900 mg/day)
Cardiac decompensation, cor
5
0.25
pulmonale and/or liver dysfunction
(not > 400 mg/day)
**
Aminophylline dose x 0.8 = Theophylline dose
DRUG
Slo-Bid
Slo-Phyllin
Theo-Dur
Uniphyl
**
ORAL THEOPHYLLINE PRODUCTS
AVAILABLE
DOSAGE FORMS
STRENGTHS
50 mg, 75 mg,
Timed release capsules
100 mg, 125 mg,
(8-12 hr dosing)
200 mg, 300 mg
100 mg, 200 mg
Immediate release
tablets
100 mg, 200 mg,
Timed release tablets
300 mg, 450 mg
(8-24 hr dosing)
400 mg, 600 mg
Timed release tablets
(24 hr dosing)
DRUG
Albuterol (Proventil)
COST
(30 Day)
$$
ORAL BETA2-AGONISTS
DOSAGE FORMS
DOSE
2 mg tablets
4 mg extended release
Terbutaline (Brethine) 2.5 mg, 5 mg tablets
2-4 mg tid-qid,
extended release 4-8 mg
Q 12 hrs; max 32 mg/day
5 mg Q 6 hrs
$$
$$
$$
COST
(30
Day)
$
$$$
$$$
91
ANTICHOLINERGIC MEDICATIONS
DRUG
18 mcg/puff, 200
puffs
0.25mg/ml nebulized
2-3 puffs Q 6 hrs
COST (30
Day)
$
0.25 mg Q 6 hrs
$
Tiotropium# (Spiriva) 18 mcg/inhalation
*Typically used in COPD or acute asthma. # Used only in COPD
1 inhalation daily
$$$$
Ipratropium*
(Atrovent)
DOSAGE FORMS
DOSE
Monitoring Pharmacotherapy:
1. Patient adherence to the regimen
2. Inhaler technique (use of spacer)
3. Level of usage of prn inhaled short-acting beta2 agonist
4. Frequency of oral corticosteroid “burst” therapy
5. Changes in inhaled anti-inflammatory dose or other long-term-control medications
6. Peak Flow Meter monitoring
Patient Education:
1. Always use a spacer with inhalers to improve effectiveness of therapy.
2. Wait 1 minute after each inhalation before repeating
3. Use beta2 agonist followed by inhaled steroids.
4. Rinse mouth after using an inhaled steroid.
Adapted from the recommendations of the National Heart, Lung, and Blood Institute’s National
Asthma Education and Prevention Program Expert Panel Report III: Guidelines for the diagnosis and
management of asthma, August 2007.
92
Acute Asthma Management
The main therapies in the emergency department and hospital: supplemental oxygen,
inhaled-beta2-agonists, systemic corticosteroids, and ipratropium (dose and frequency
vary with severity).
Albuterol 1 unit dose = 2.5 mg albuterol
Ipratropium 1 unit dose = 0.5 mg ipratropium
Initial Assessment
• FEV1 or PEF >40%
-Oxygen to achieve O2 saturation >90%
-Inhaled beta2-agonist (Albuterol 10-15 mg continuous nebulization over 1 hr
OR 2.5-5 mg nebulization Q 20 minutes)
-Oral steroids if no immediate response or if patient recently on oral steroids
(Prednisone 40-60 mg po now & daily; may give Solu-Medrol 40 mg IV if
unable to take po)
• FEV1 or PEF<40%
-Oxygen to achieve O2 saturation ≥ 90%
-Inhaled beta2-agonist (Albuterol 10-15 mg continuous nebulization over 1 hr
OR 2.5-5 mg nebulization Q 20 minutes) and anticholinergic (Ipratropium 0.5-1
mg continuous nebulization over 1 hr or 0.25-0.5 mg nebulization Q 20
minutes)
-Oral steroid (Prednisone 40-60 mg po now & daily; may give Solu-Medrol 40
mg IV if unable to take po)
Repeat Assessment (after 1 hr of treatment)
• Moderate exacerbation (FEV1 or PEF 40-69%)
-Inhaled short-acting beta2-agonist (Albuterol 2.5-5 mg continuous nebulization
over 1 hr)
-If oral steroids not already given, administer Prednisone 40-60 mg po now &
daily; may give Solu-Medrol 40 mg IV if unable to take po
-Continue treatment 1-3 hours, provided there is improvement; make admit
decision in <4 hours
• Severe exacerbation (FEV1 or PEF <40%)
-Oxygen to achieve O2 saturation >90%
-Inhaled short-acting beta2-agonist (Albuterol 2.5-5 mg continuous nebulization
over 1 hr) + inhaled anticholinergic (Ipratropium 0.25-0.5 mg continuous
nebulization over 1 hr)
-Systemic steroid (Prednisone 40-60 mg po now & daily; may give SoluMedrol 40 mg IV if unable to take po)
93
Repeat Assessment (after 1 hr of treatment)
• Good response (FEV1 or PEF ≥ 70%)
-Discharge home: continue treatment with inhaled beta2-agonist; consider
inhaled corticosteroid; continue course of oral corticosteroid; patient education
• Incomplete response (FEV1 or PEF 40-69%)
-Admit to hospital: inhaled beta2-agonist; systemic corticosteroid; oxygen to
maintain O2 saturation >90%
• Poor response (FEV1 or PEF <40%; PCO2 >42 mmHg)
-Admit to hospital Intensive Care
-Inhaled beta2-agonist hourly or continuously
-IV corticosteroid
-Oxygen to achieve O2 saturation >90%
-Possible intubation and mechanical ventilation
Medications for Acute Asthma Exacerbations
INHALED SHORT-ACTING BETA2-AGONISTS
MEDICATIONS
DOSAGES
COMMENTS
Albuterol
Nebulizer solution
2.5 - 5 mg q 20 min for Only selective beta2-agonists are
(5 mg/mL)
3 doses, then 2.5 - 10
recommended. For optimal delivery,
mg
dilute aerosols to minimum of 3 mL at
q 1-4 hours prn, or 10- gas flow of 6-8 L/min
15 mg/hour
continuously
HFA MDI (90
4-8 puffs q 20 min up
As effective as nebulized therapy if
mcg/puff)
to 4 hours, then q 1-4
patient is able to coordinate inhalation
hours prn
maneuver. (Use spacer)
Levalbuterol
Nebulizer solution
1.25-2.5 mg q 20 min
Typically reserved for albuterol
(1.25mg/3ml)
for 3 doses, then 1.25 – intolerance, failures, or tachycardia
0.63 mg of levalbuterol is equivalent to
5 mg q 1-4 hours prn,
1.25 mg of albuterol
or 5-7.5 mg/hour
continuously
HFA MDI (45
1-2 puffs q 4-6 hours
Typically reserved for albuterol
mcg/puff)
intolerance, failures, or tachycardia
Pirbuterol
MDI (200 mcg/puff)
See albuterol dose.
Has not been studied in severe asthma
exacerbations.
94
SYSTEMIC (INHALED) BETA-AGONISTS
MEDICATIONS
DOSAGES
COMMENTS
Epinephrine 1:1000
0.3-0.5 mg q 20 min for No proven advantage of systemic
(1 mg/mL)
3 doses sq
therapy over aerosol
Terbutaline
0.25 mg q 20 min for 3
No proven advantage of systemic
(1 mg/mL)
doses sq
therapy over aerosol
MEDICATIONS
Ipratropium bromide
Nebulizer solution
(0.25 mg/mL)
MDI (18 mcg/puff)
MEDICATIONS
Prednisone
Methylprednisolone
Prednisolone
ANTICHOLINERGICS
DOSAGES
COMMENTS
0.5 mg q 30 min for 3
doses then q 2-4 hours
prn
4-8 puffs prn
May mix in same nebulizer with
albuterol. Should not be used as
first-line therapy; should be added
to beta2-agonist therapy for more
severe cases
Dose delivered from MDI is low
and has not been studied in
asthma exacerbations.
CORTICOSTEROIDS
DOSAGES
COMMENTS
120-180 mg/day in 3 or For outpatient “burst” use 40-60
4 divided doses for 48
mg/day in single or divided doses
hours, then 60-80
for adults (children –1-2
mg/day until PEF
mg/kg/day, maximum 60 mg/day)
reaches 70% of
for 3-10 days.
predicted or personal
best.
Adapted from the Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No
02-5074. 8/07
95
Chronic Obstructive Pulmonary Disease (COPD) Recommendations
Stage
Characteristics
I: Mild
FEV1/FVC < 70%;
FEV1 80% predicted
With or without symptoms (cough, sputum)
II: Moderate
FEV1/FVC < 70%;
50% < FEV1 < 80% predicted with or without
chronic symptoms (cough, sputum, dyspnea)
III: Severe
FEV1/FVC < 70%;
30% < FEV1 < 50% predicted
Repeated exacerbations
and increased shortness of breath
IV: Very Severe
FEV1/FVC < 70%;
FEV1 < 30% predicted plus
respiratory failure or clinical signs of right heart
failure
96
COPD Therapy Based on Classification
Stage
Therapy
I: Mild
Short-acting bronchodilator as
needed
II: Moderate
Maintenance treatment with one or
more bronchodilators
Rehabilitation
Inhaled glucocorticosteroids if significant
symptoms and lung function response
III: Severe
Regular treatment with one or
more bronchodilators
Rehabilitation
Inhaled glucocorticosteroids if significant
symptoms and lung function response or if
repeated exacerbations
IV: Very Severe
Regular treatment with one or
more bronchodilators
Inhaled glucocorticosteroids if significant
symptoms and lung function response or if
repeated exacerbations
Treatment of complications
Rehabilitation
Long-term oxygen therapy if respiratory failure
Consider surgical options
NOTE: See asthma section for a list of medications and doses
Adapted from the recommendations of the NHLBI/WHO: Global Initiative for Chronic Obstructive
Lung Disease. 2006 Update
97
Diabetes Mellitus Guidelines
Criteria for the Diagnosis of Diabetes Mellitus1
1. A fasting plasma glucose (FPG) of > 126mg/dL (after no caloric intake for at least
8 hours).
2. A casual plasma glucose (taken at any time of day without regard to meals)
>200mg/dL, accompanied by symptoms of increased thirst, urination and
unexplained weight loss.
3. An oral glucose tolerance test (OGTT) value of > 200mg/dL during the two-hour
sample.
1
These criteria should be confirmed by repeat testing on a different day.
Pre-diabetes- Hyperglycemia not sufficient to meet the diagnostic criteria for diabetes;
formerly categorized as impaired glucose tolerance (IGT) or impaired
fasting glucose (IFG).
• IFG = FPG 100 mg/dl to 125 mg/dl
• IGT = 2 hour plasma glucose 140 mg/dl to 199 mg/dl
Pre-diabetes is considered a risk factor for future diabetes and
cardiovascular disease.
Testing for Gestational Diabetes Mellitus (GDM)1
Plasma Glucose
50g Screening Test2
100g Diagnostic Test3
(fasting not required)
(fasting required)
Fasting
95 mg/dL
1-h
140mg/dL (if present, indicates
180 mg/dL
2-h
need for 100g diagnostic test)
155 mg/dL
3-h
140 mg/dL
1
Fasting plasma glucose of >126 or casual plasma glucose >200 meets the threshold
for diagnosis and precludes the need for a glucose challenge.
2
Screening should be performed (unless otherwise indicated) between 24-28 weeks
of
gestation.
3
Diagnosis of GDM requires any two of the four plasma glucose values obtained
during the test to meet or exceed the listed glucose values.
Screening for GDM may not be necessary in pregnant women who meet all of the
following criteria: <25 years of age, normal body weight, no first-degree relative
with diabetes, have no history of abnormal glucose metabolism or
poor obstetric outcome, and not Hispanic, Native American,
Asian-, African-American or Pacific Islander.
98
Recommendations for Adults with Diabetes Mellitus
Glycemic control
A1c
Preprandial plasma glucose
Peak postprandial plasma glucose
<7.0%
90-130 mg/dl
<180 mg/dl
Blood pressure
<130/80 mmHg
Lipids (see hyperlipidemia guidelines)
LDL
Triglycerides
HDL
<100 mg/dl
<150 mg/dl
>40 mg/dl
Concepts in setting glycemic goals:
• Goals should be individualized
• Certain populations (children, pregnant women, and elderly) require special
considerations
• Less intensive goals may be indicated in patients with severe or frequent
hypoglycemia
• More intensive goals may further reduce microvascular complication at the cost of
increasing hypoglycemia.
• Postprandial glucose may be targeted if HbA1c goals are not met despite reaching
preprandial glucose goals.
Correlation between HbA1c Level and Mean Plasma Glucose
A1c (%)
mg/dl
mmol/l
6
135
7.5
7
170
9.5
8
205
11.5
9
240
13.5
10
275
15.5
11
310
17.5
12
345
19.5
American Diabetes Association Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care. 2004;27 (supplement 1).
Pharmacologic Therapy of DM Type 2
Step 1: NONPHARMACOLOGIC THERAPY
-Diet
99
-Exercise
-If glycemic goals not achieved, progress to Step 2.
-If patient is very symptomatic, ketotic, pregnant, has severe hyperglycemia, or
unrecognized DM Type 1, progress to Step 4.
Step 2: MONOTHERAPY
-Obese patient: metformin (preferred) or a thiazolidinedione
-Non-obese patient: sulfonylurea or insulin secretagogue (alternative:
metformin)
-If glycemic goals not achieved, progress to Step 3.
Step 3: COMBINATION THERAPY
-Sulfonylurea + metformin
-Alternative: add thiazolidinedione to step 2 monotherapy
-If fasting plasma glucose is at goal, but patient has elevated post-prandial
glucose, consider adding an alpha glucosidase inhibitor.
-If glycemic goals are not achieved, progress to Step 4.
Step 4: INSULIN
-Metformin + NPH or insulin glargine
-Sulfonylurea + metformin + NPH or insulin glargine
Other options:
-Thiazolidinedione + insulin (This combination is not recommended for patients
with or at risk of heart failure.)
-NPH BID
-NPH + regular BID (70/30 insulin)
-Multiple (3 or more) injections)
Adapted from:
1. American Diabetes Association Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus. Diabetes Care. 2004;27 (supplement 1).
2. UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulfonylureas or
insulin compared with conventional treatment and risk of complications in type 2 diabetes
(UKPDS 33). Lancet. 1998; 352: 837-53.
3. UK Prospective Diabetes Study Group: Effect of intensive blood-glucose control with metformin
on patients with type 2 diabetes (UKPDS 34). Lancet. 1998; 352: 854-65.
Lets try some text
100
Agents for Diabetes Mellitus Type 2
Oral
Biguanides
Sulfonylureas
Potentiate
Hypoglycemia
Stimulate Insulin
Secretion from
Pancreas
Effect on Fasting
Plasma Glucose
Effect on HbA1c
Effect on Lipids
Yes
No
Alphaglucosidase
Inhibitors
No
Thiazolidinediones
Meglitinides
No
Yes
Yes
No
No
No
Yes
lowers
60-70mg/dL
lowers
1.5-2%
N/A
lowers
60-70mg/dL
lowers
1.5-2%
↓ LDL, TG
↑ HDL
↓
$-$$
lowers
20-30mg/dL
lowers
0.7-1%
N/A
lowers
35-40 mg/dL
lowers 1-1.2%
lowers
60-70 mg/dL
lowers
1.5-2%
N/A
↓ TG,
↑ HDL, LDL
↑
$$$$$+
N/A
Effect on Weight
↑
$-$$
$$$
Price
TG = triglycerides
LDL = low-density lipoprotein
HDL = high-density lipoprotein
Comparison Chart of Orally Administered Hypoglycemic Agents
First Generation Oral
Second Generation
Sulfonylureas
Oral Sulfonylureas
Acetohexamide Chlorpropamide
Glipizide
Glyburide
Glimepiride




(Dymelor )
(Diabinese )
(Glucotrol )
(Diabeta ,
(Amaryl)
Micronase)
Starting
Dose
(mg/day)
Dosing
Range
500 mg
100-250 mg
5-10 mg
2.5-5.0 mg
1-2 mg
250-1500 mg
100-500 mg
2.5-40 mg
1.25-20 mg
1-8 mg
↑
$$$$
Biguanides
Metformin
(Glucophage)
(Glucophage
XR)
850-1000 mg
500 mg XR
1000-2500 mg
2000 mg XR
101
# Daily
Doses
1-2 (divide if
dose >1000 mg)
1
1-2 (divide if 1-2 (divide if
dose > 15
dose > 10
mg)
mg)
Elimination
Half-life
Onset
Comments
renal
6-8 hours
1 hour
Take at the
same time each
day
renal
36 hours
1 hour
Take 30 min
before meals
renal
2-4 hours
1-3 hours
Take 30 min
before meals
renal, fecal
10 hours
2-4 hours
Take 30 min
before meals
1
renal, fecal
5-9 hours
2-3 hours
None
2-3 (give 3 times
daily if dose
>2000 mg)
XR: 1-2 times
daily, usually with
evening meal
renal
5.5 hours
1-3 hours
Give w/meals,
contraindicated in
patients with CHF
requiring therapy
and in males with
SCr >1.5
(females >1.4)
All listed agents are formulary.
Starting
Dose
(mg/day)
Dosing
Range
# Daily
Doses
Elimination
Comparison Chart of Orally Administered Hypoglycemic Agents, cont.
Alpha-Glucosidase
Thiazolidinediones
Meglitinides
Inhibitors
Acarbose
Miglitol
Pioglitazone
Rosiglitazone
Repaglinide
Nateglinide





(Precose )* (Glyset )
(Actos )*
(Avandia )*
(Prandin )*
(Starlix)*
75 mg
75 mg
15-30 mg
4 mg
1.5-6 mg
180-360 mg
150-300 mg
15-45 mg
4-8 mg
1.5-12 mg
180-360 mg
3
150-300
mg
3
1
fecal
renal
renal
1-2 (divide if
dose>4 mg)
renal, fecal
preprandially,
2-4 times daily
fecal
preprandially,
2-4 times daily
renal, fecal
102
Half-life
2 hours
2 hours
3-7 hours
3-4 hours
1 hour
1-2 hours
Onset
1 hour
Data
unavailable
Give with
first bite of
meal
1 hour
30-60 minutes
60-90 minutes
20 minutes
Patients who
skip a meal
should skip the
dose; if a meal
is added, add a
dose
Patients who
skip a meal
should skip the
dose; if a meal
is added, add a
dose
Comments
Give with
first bite of
meal
Obtain liver
Obtain liver
enzymes at
enzymes at
initiation and
initiation and
every 2 months every 2 months
for the first year for the first year
*Formulary agent
Insulin Products Comparison
Brand
Generic
Onset (hr)
Duration (hr)
Rapid Acting
HumaLOG®
<0.25
3-4
Lispro
®
*NovoLOG
Aspart
0.5
3-5
Short Acting (Only insulin that can be given IV/IM)
HumuLIN® R
Regular
0.5-1
3-6
®
*NovoLIN R
Intermediate Acting
HumuLIN® N NPH
2-4
10-16
®
*NovoLIN N
*NovoLIN® L Lente
3-4
16-20
®
HumuLIN L
Long Acting
*HumuLIN® U Ultralente
6-10
18-24
Comments
Administer 30 min. before meals; clear and
colorless
Administer 30-60 min. before meals; clear and
colorless
Cloudy suspension
Cloudy suspension; Do not mix with NPH or
Regular insulin
Cloudy suspension; Do not mix with NPH or
Regular insulin
103
*Lantus®
Glargine
4
Only long acting insulin that is clear; Do not
mix with any other insulin
*Formulary Agent
104
Insulin Products Comparison
Mixtures
HumuLIN®
70/30
*NovoLIN®
70/30
HumuLIN®
Mixture 50/50
*HumaLOG®
Mixture 50/50
HumaLOG®
Mixture 75/25
*NovoLOG®
Mixture 70/30
70% NPH/30%
regular insulin
50% NPH/50%
regular insulin
50% lispro
protamine/50%
lispro
75% lispro
protamine/25%
lispro
70% aspart
protamine/30%a
spart
0.5
16-18
Administer 30-45 min. before meal; cloudy
suspension; do not mix with other insulin
Administer 30-45 min. before meal; cloudy
suspension; do not mix with other insulin
Administer 15 min. before meals; cloudy
suspension; do not mix with other insulin
Administer 15 min. before meals; cloudy
suspension; do not mix with other insulin
Administer 15 min. before meals; cloudy
suspension; do not mix with other insulin
*Formulary Agent
105
Diabetic Ketoacidosis (DKA) Management
Patient Assessment and Initial Work Up:
1. History and physical exam with emphasis on the following:
a. Precipitating factors (infection, omission or inadequate use of insulin,
new onset diabetes, etc)
b. Airway patency
c. Level of consciousness
d. Volume status
2. Initial work up includes the following:
a. Blood chemistries
b. Blood glucose (finger stick)
c. Blood and urine ketones
d. CBC with differential
e. ABG
f. Urinalysis
g. If appropriate, obtain chest film, ECG, and blood cultures to evaluate the
cause while patient is being hydrated.
3. Diagnosis
a. Hyperglycemia (serum glucose > 250 mg/dL)
b. Low bicarbonate (HCO3 < 15 mEq/L)
c. Low pH (pH < 7.3)
d. Ketonemia 1:2 dilution
e. Ketonuria: moderate
Fluid and Electrolytes:
4. After initial chemistries are drawn:
a. Give 1 L 0.9% sodium chloride solution in the first hour.
b. Follow with 0.45% sodium chloride solution at 200-1000 mL/hr depending
on blood pressure, urine output and volume status.
c. Do not exceed 5 L in 8 hours and follow I/Os strictly. Most patients require
4-8 L of fluid in the first 24 hours.
d. Consider placing a pulmonary artery catheter if patient has a history of heart
failure or renal failure or is elderly.
5. Begin potassium therapy if urine output adequate (no renal failure). If initial
potassium is:
a. < 3.3 mEq/L: potassium supplements may be given in IV fluids at 40 mEq/L
(consider half as KCL and half as K phosphate if phosphate < 2.5 mEq/L).
b. > 3.3 but < 5.5 mEq/L and urine output adequate: potassium supplements
may be given in IV fluids at 20-30 mEq/L (consider half as KCL and half as
K phosphate if phosphate < 2.5 mEq/L).
106
c. > 5.5 mEq/L: do not give potassium supplements.
Repeat serum K every 1-2 hours for the first few hours, then subsequent levels
every 4-6 hours as needed.
6. Bicarbonate therapy is not given for a pH > 7.
a. For a pH < 7 but > 6.9: give 1 ampule (44 mEq) sodium bicarbonate over 1
hour.
b. For a pH < 6.9: give 2 ampules (88 mEq) of sodium bicarbonate over 1 hour.
Repeat ABG’s every 2 hours until pH > 7. If initial pH > 7, there is no need to
repeat ABG’s. Follow HCO3 on chemistries every 2 hours until HCO3
normalizes, then subsequent levels every 4-6 hours as clinically indicated.
Insulin Therapy:
7. With the diagnosis of DKA confirmed and at least 1 L of saline infused, consider
one of the following:
a. MILD DKA:
Loading dose: 0.4 units/kg of regular insulin (½ as IV push and ½ as SQ)
followed by 0.1 units/kg/hr (IM/SQ) of regular insulin
-ORb. MODERATE/SEVERE DKA:
Regular insulin bolus of 0.15 units/kg IV followed by a continuous infusion
of Regular insulin at 0.1 units/kg/hr (regular insulin 100 units / 100mL NS)
8. Obtain plasma glucose hourly, chemistries (Chem 10) every 2 hours for the first
few
hours, then subsequent measurements every 4-6 hours as clinically needed.
9. If plasma glucose does not fall by at least 10% in the first hour, double the rate of
the continuous insulin infusion or reload insulin with IM/SQ regimen. (see #7
above) Don’t allow the blood sugar to fall at a rate > 100mg/dl/hr.
After at least a 10% decrement of plasma glucose, continue insulin infusion at 7-10
units/hr or equivalent IM/SQ insulin regimen until plasma glucose reaches 200
mg/dL.
Resolving Diabetic Ketoacidosis:
10. Once plasma glucose reaches 250 mg/dL, change IV fluid to
D51/2 NS at 100-300 mL/hr.
11. Monitor plasma glucose hourly and adjust insulin drip or equivalent IM/SQ
insulin regimen (i.e. if the insulin drip is @ 5 units/hr, the equivalent SQ regimen
is 5 units every hour) to keep glucose in the 100-200 mg/dL range. Continue
intravenous insulin drip or equivalent insulin regimen until DKA is controlled
(plasma glucose < 200mg/dL, HCO3 > 15 mEq/L, and pH > 7.3). Measure serum
ketones if uncertain why acidosis is persisting.
107
It is estimated that it takes twice as long for HCO3 and pH to reach desired levels
as it does for glucose to reach 200 mg/dL. The goals above can be achieved by
using glucose infusions to prevent hypoglycemia while insulin therapy continues.
Complications of therapy include but are not limited to: cerebral edema, ARDS,
hyperchloremic acidosis, hypoglycemia and hypokalemia.
12. When patient is alert and able to take food by mouth, begin ADA diet. Also,
begin NPH insulin regimen appropriate for patient 30 minutes prior to breakfast
and evening meal with the following sliding scale regular human insulin (RHI) SQ
before meals and at bedtime. Discontinue insulin drip 1 hour after first SQ dose of
insulin.
Glucose
Insulin
<150
0 units RHI
150-200
5 units RHI
201-250
10 units RHI
251-300
15 units RHI
>300
20 units RHI
Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care
2004 Jan;27(Suppl 1):S94-102.
108
Prevention of Bacterial Endocarditis
Endocarditis prophylaxis recommended only for:
- high risk categories listed below PLUS
- dental procedures that involve manipulation of the gingival tissue or the
periapical region of teeth or perforation of the oral mucosa
• High risk categories
1. Prosthetic cardiac valve
2. Previous bacterial endocarditis
3. Congenital heart disease (CHD)
- Unrepaired cyanotic CHD, including palliative shunts and conduits
- Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
- Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
4. Cardiac transplantation recipients who develop cardiac valvulopathy
• Endocarditis prophylaxis not recommended for:
- Any other form of CHD not listed above
- GI or GU procedures
109
Prophylactic regimens for dental procedures
Situation
Medication
Regimen
Oral
Amoxicillin
2 gm PO 1 hour before procedure
Unable to take oral
Ampicillin
2 gm IM or IV
or
medications
Cefazolin or 1 gm IM or IV
ceftriaxone
30 min before procedure
Penicillin allergy--oral
Cephalexin
2 gm PO 1 hour before procedure
Clindamycin 600 mg PO 1 hour before procedure
Azithromycin 500 mg PO 1 hour before procedure
or
Clarithromycin
Penicillin allergic and
Cefazolin or 1 gm IM or IV 30 min before
unable to take PO
ceftriaxone
procedure
medications
Clindamycin 600 mg PO 1 hour before procedure
Adapted from Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, et al. Prevention of infective endocarditis.
Circulation 2007;115:1-20.
110
Human Immunodeficiency Virus (HIV) and
Acquired Immunodeficiency Syndrome (AIDS)
Guidelines
The U.S. Department of Health and Human Services routinely issues guidance
documents for the management of HIV infection. This table provides a summary of
these recommendations for antiretroviral therapy (October 2006). For complete
guidelines and updates, please refer to: www.aidsinfo.nih.gov.
Indications for Initiating Antiretroviral Therapy for the Chronically HIV-1
Infected Patient
Clinical Category
CD4+ T Cell
Plasma HIV
Recommendation
Count
RNA
AIDS-defining illness
or severe symptoms*
(AI)
Any value
Asymptomatic
(AI)
< 200/mm3
Asymptomatic
(BII)
> 200/mm3
but < 350/mm3
Any value
Treat
Any value
Treat
Any value
Treatment should be
offered
following full
discussion of pros
and cons with each
patient
Asymptomatic
(CII)
> 350/mm3
> 100,000
Asymptomatic
(DII)
> 350/mm3
< 100,000
Most clinicians
recommend
deferring therapy,
but some
clinicians will treat
Defer therapy
111
Antiretroviral Regimens Recommended for Treatment of HIV-1 Infection in
Antiretroviral Naïve Patients
Choose 1 from Column A + 1 from Column B
Column A (NNRTI or PI)
Column B (Dual NRTI)
NNRTI
Efavirenz
OR
PI
Preferred
Atazanavir + ritonavir OR
Fosamprenavir + ritonavir OR
Lopinavir/ritonavir (twice daily)
Emtricitabine/tenofovir OR
Lamivudine/zidovudine
NNRTI
Nevirapine
OR
Alternative
Abacavir/lamivudine
OR
PI
Atazanavir OR
Fosamprenavir OR
Fosamprenavir + ritonavir OR
Lopinavir/ritonavir (once daily)
Didanosine + (emtricitabine or
lamivudine)
Medications Used for HIV/AIDS
Name
Abacavir (ABC, Ziagen®)
NRTI
Didanosine
(ddI, Videx EC)
Strength
300 mg tabs,
20 mg/ml
oral solution
125, 200,
250, or 400
mg EC
capsules
Emtricitabine
(FTC, EmtrivaTM)
200 mg
capsules, 10
mg/ml
solution
Dosing
300 mg bid or
600 mg daily
Regard to food
Without regard
to meals
Wt > 60 kg:
400 mg daily
(250 mg with
tenofovir)
Empty stomach
Wt < 60 kg:
250 mg daily
(200 mg with
tenofovir)
200 mg capsule Without regard
once daily or
to meals
240 mg
solution once
daily
112
Lamivudine
(3TC, Epivir®)
Stavudine
(d4T, Zerit®)
150 and 300
mg tablets, 10
mg/ml oral
solution
15, 20, 30, 40
mg capsules,
1 mg/ml oral
solution
150 mg bid or
300 mg daily
Without regard
to meals
Wt > 60 kg:
40 mg bid
Without regard
to meals
Wt < 60 kg:
30 mg bid
1 tab daily
Tenofovir
(TDF, Viread®)
300 mg tabs
Zidovudine
(AZT, ZDV, Retrovir®)
100 mg
300 mg bid or
capsules, 300 200 mg tid
mg tablets, 10
mg/ml IV
solution, 10
mg/ml oral
solution
Without regard
to meals
Without regard
to meals
Combinations
Abacavir + zidovudine ABC 300mg
+
+ lamivudine
(ABC+ZDV+3TC,
Trizivir®)
Abacavir + lamivudine
(ABC + 3TC, Epzicom®)
Emtricitabine + tenofovir
(FTC + TDF, TruvadaTM)
NNRTI
Lamivudine + zidovudine
(3TC + ZDV, Combivir®)
Efavirenz + emtricitabine
+ tenofovir
(EFV + FTC + TDF,
AtriplaTM)
Delavirdine
(DLV, Rescriptor)
ZDV 300mg
+
3TC 150mg
ABC 600mg
+
3TC 300mg
FTC 200mg
+
TDF 300mg
3TC 150mg +
ZDV 300mg
EFV 600 mg
+
FTC 200 mg
1 tablet bid
Without regard
to meals
1 tablet daily
Without regard
to meals
1 tablet daily
Without regard
to meals
1 tablet bid
Without regard
to meals
Without regard
to meals
1 tablet daily
+
TDF 300mg
100, 200 mg
tabs
400 mg tid
Without regard
to meals
113
Nevirapine
(NVP, Viramune)
Efavirenz
(EFV, Sustiva)
200 mg tabs
or 50 mg/5ml
oral
suspension
50, 100, 200
mg capsules
or 600 mg
tablets
200 mg daily x
14 days, then
200 mg bid
Without regard
to meals
600 mg HS
Empty stomach,
avoid high fat
meal
114
Medications Used for HIV/AIDS
Name
Strength
Dosing
Amprenavir
(APV, Agenerase)
50 mg caps, 15
mg/ml oral
solution (not
interchangeable
on a mg/mg
basis)
100, 150, 200
mg caps
1400 mg bid (oral
solution)
Atazanavir
(ATV, ReyatazTM)
PI
Darunavir
(DRV, PrezistaTM)
Fosamprenavir
(fAPV, LexivaTM)
300 mg tablet
700 mg tabs
400 mg daily
(300 mg + 100 mg
ritonavir if taken
with efavirenz or
tenofovir)
600 mg + ritonavir
100 mg bid
ARV-naïve
patients:
1400 mg bid
OR
1400 mg + ritonavir
200 mg daily
OR
700 mg + ritonavir
100 mg bid
Regard to
food
Avoid
high fat
meal
W/ food
W/food
Without
regard to
meals
PI-experienced
patients (Daily not
recommended):
700mg + ritonavir
100mg bid
Coadministration
w/ efavirenz (fAPV
boosted only):
700 mg + ritonavir
100 mg bid
OR
1,400mg + ritonavir
300mg daily
115
Indinavir (Crixivan)
200, 333, 400
mg caps
800 mg q8hrs
OR
800 mg + ritonavir
100-200 mg q12hrs
1 hour
before or
2 hours
after meal
Lopinavir/ritonavir
(LPV/r, Kaletra)
Caps: 133.3 mg/
33.3 mg
Tabs: 200mg/
50 mg
Solution:
400 mg/100 mg
per 5 ml
250, 625 mg tabs
50 mg/g oral
powder
400 mg/100 mg
twice daily
W/food
Ritonavir
(RTV, Norvir)
100 mg caps
OR
600 mg/7.5 ml
solution
Saquinavir
(SQV, Invirase)
200 mg hard gel
caps, 500 mg
tabs
600 mg q12hrs
W/food
(as sole PI)
OR
100-400 mg in 1-2
divided doses (as PI
booster)
1000 mg + ritonavir W/food
100 mg bid
Tipranavir
(TPV, Aptivus®)
250 mg capsules
500 mg + ritonavir
100 mg twice daily
Enfuvirtide
(T20, FuzeonTM)
90 mg/1 mL inj
90 mg SC bid
Fusion
Inhibitors
Nelfinavir
(NFV, Viracept)
OR
800 mg/200 mg
once daily
1250 mg bid
OR
750 mg tid
W/food
W/food
116
Drug Treatment for Fungal Infections
For the latest guidelines please refer to: http://www.idsociety.org
Empiric Treatment for suspected candidal infections may be considered in febrile
patients with the following risk factors:
•
•
•
•
•
•
•
•
•
Prolonged use of antibacterial antibiotics
Immunosuppression
Colonization by candida of multiple nonsterile sites
Central venous catheters
Hyperalimentation
Surgery (especially surgery that transects the gut wall)
Prolonged ICU stay
Urinary tract instrumentation
Advanced Age
Typical Antifungal Doses
Antifungal
Fluconazole
Itraconazole
Voriconazole*
Posaconazole#
Caspofungin*
Amphotericin B
Amphotericin B lipid
complex
Daily Dose (range)
Dose Adjustment with Renal
Impairment
IV or PO: 400 mg (200- Yes
800)
200 mg (100-400)
Intravenous use not
recommended with a CrCl < 30
ml/min
IV:6 mg/kg q12h x 2
Intravenous use not
doses, then 4 mg/kg
recommended with a CrCl < 30
q12h
ml/min
PO: 200 mg bid
200 mg tid
No
70 mg x 1, then 50 mg
No
0.5 mg/kg (0.25-1.5)
No
5 mg/kg
No
*
#
Restricted to ID, Critical Care/Pulmonary, and Heme/Onc
Restricted to ID and Heme/Onc
References:
1)
Pappas PG, et al. Guidelines for Treatment of Candidiasis. CID 2004;38:161-189.
2)
O’Grady, et al. Practice Guidelines for evaluating new fever in critically ill adult patients.
CID 1998; 26:1042-59.
3)
Slain DS, et al. Intravenous itraconazole. Ann Pharmacother 2001;35:720-729.
4)
Prescribing Information. Http://www.sporanox.com
117
Acute Ischemic Stroke Guidelines
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Fever is associated with increased morbidity/mortality. The source of any fever
following stroke should be ascertained and treated with antipyretics.
Optimal management of hypertension remains controversial. Blood pressure
may fall spontaneously if patient is allowed to rest in a quiet room, bladder is
emptied, and headache or pain controlled. There is no proven benefit for
lowering blood pressure in patients with acute ischemic stroke, and
antihypertensive agents should be withheld unless DBP > 120 or SBP >220
mmHg. When treatment of blood pressure is necessary, a reasonable goal
would be to lower blood pressure by ~15% during the first 24 hours. In
particular, “prn” orders for oral antihypertensives should be avoided. Consider
one of the following options:
• Labetalol 10-20 mg IV prn SBP >220 OR DBP>120. May repeat or double
dose every 10 min until max. of 300 mg OR Labetalol 10 mg IV followed
by an infusion of 2-8 mg/min to achieve 15% reduction in BP
• Nicardipine 5 mg/hour IV infusion. Titrate by 2.5 mg/hr every 5 min. to
max. of 15 mg/hr until 15% reduction in BP (NOTE: cost ~ $300 per day!)
• If DBP>140: Nitroprusside 0.25 mcg/kg/min IV infusion, titrate to achieve a
15% reduction in BP.
• In patients who have preexisting hypertension and are neurologically stable,
antihypertensive medications should be restarted at ~24 hours unless a
specific contraindication exists.
Use of IV rtPA per protocol is recommended for patients who can be treated
within 3 hours of symptom onset. Potential complications of IV rtPA include
bleeding and angioedema.
Use of intra-arterial thrombolysis is an option for patients with major stroke of
less than 6 hours duration due to large vessel occlusions of the MCA. Use in
patients with basilar artery occlusion should be individualized.
Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first
24 hours after stroke is associated with poor outcomes, and thus hyperglycemia
should be treated in patients with acute ischemia stroke.
Low dose subcutaneous heparin or LMWH or IPC is strongly recommended to
prevent DVT in immobilized patients (grade A recommendation).
Published guidelines specifically state that anticoagulation with full doses of
heparin or LMWH is NOT recommended for patients with acute ischemic
stroke (grade A).
ASA 325 mg should be given within 24-48 hours after stroke onset.
The administration of clopidogrel alone or in combination with aspirin is not
recommended for the treatment of acute ischemic stroke.
Early mobilization and comprehensive rehabilitation measures are strongly
recommended.
Corticosteroids are not recommended for the management of cerebral edema
and increased ICP following ischemic stroke.
118
Parenteral anticoagulation should not be prescribed until a brain imaging study has
excluded the possibility of a primary intracranial hemorrhage. The level of
anticoagulation should be closely monitored if a patient is receiving one of these
medications.
Stroke. 2007;38:1655-1711
119
Pain Guidelines:
• Non-opioid analgesics (e.g., acetaminophen, NSAIDs) are useful in both acute
and chronic pain. They are recommended in most analgesic regimens for
patients unless the patient has a contraindication to using them.1
o Acetaminophen
 Little/no anti-inflammatory effect and does not damage the gastric
mucosa1
 Food and Drug Administration (FDA) maximum recommended dose
is 4 grams/day2
 Based on recent evidence, the American Liver Foundation
recommends a maximum dose of 3 grams/day3
 Not recommended in neutropenic patients
o NSAIDs1 (Examples include: ketorolac, ibuprofen, naproxen, and
ketoprofen)
 NSAIDs can produce gastrointestinal disturbances (nausea, vomiting,
heartburn, dyspepsia, ulceration, GI bleed)
• In patients where protection against ulcers is warranted,
consider a proton pump inhibitor
• Use the lowest possible dose for the shortest amount of time
o Ketorolac (Toradol®) use should be limited to 5 days
because of increased risk for GI hemorrhage
 NSAIDs can induce renal insufficiency
• Add an opioid analgesic to a non-opioid in a patient with acute pain or
chronic cancer-related pain if the pain is not controlled.1
o Opioids are available in combination with non-opioids (e.g, oxycodone with
acetaminophen)
CAUTION: be cautious of the amount of acetaminophen in combination
products, especially if being used in conjunction with other acetaminophen
containing products
o All opioids are metabolized by the liver and should be used with caution in
patients with moderate-to-severe liver impairment, impaired ventilation,
bronchial asthma, increased intracranial pressure, moderate-to-severe renal
impairment and paralytic ileus.
Table 1: Selected Opioids that are morphine-like agonists4
Opioid
Oral
Parenteral
Precautions/Contraindica
equianalge equianalgesi tions
sic dose
c dose (mg)
(mg)
Morphine
30
10
-May accumulate in renal
impairment-has active
metabolites
120
Hydromorphone
7.5
1.5
-May accumulate in renal
impairment-NO active
metabolites
Oxycodone
20
Not
-May accumulate in renal
applicable
impairment-has some
active metabolites
Methadone*
Not
Not
-Dose titration should be
applicable applicable
done cautiously-takes about
4-5 days to reach steady
Contact
Contact
pharmacy
pharmacy for state levels
for dosing dosing
-Caution in older adults
Oxymorphone
10
Not
-May accumulate in renal
applicable
impairment-has some
active metabolites
* Dosing is dependent on individual patient characteristics.
• Tramadol is a weak opioid agonist that also inhibits the reuptake of serotonin
and norepinephrine. Tramadol lowers the seizure threshold; therefore, do not
use in doses greater than 400 mg per day.1
• Fentanyl is available in a transdermal patch, lozenge, buccal tablet,
iontophorectic transdermal system, and IV formulations. The patch is not
intended for acute pain which includes post-operative pain.1
• The route, dosage, and schedule of the analgesic needs to be individualized.1
o The oral route is preferable for analgesic administration.
o The intramuscular route has the disadvantages of painful administration, and
wide fluctuations in absorption.
o The intravenous bolus route provides the most rapid onset for analgesia.
Intravenous infusion route provides steady state blood concentrations of
opioids and may be helpful in chronic pain conditions. Use extreme caution
in opioid-naïve patients. Do not use opioids such as methadone and
levorphanol in this way due to their long elimination half-lives.
o Transdermal route
 fentanyl patch (Duragesic®)
 fentanyl iontophorectic transdermal system (Ionsys®)
o Oral transmucosal route
 Fentanyl citrate lozenge (Actiq®)
 Fentanyl buccal tablet (Fentora™)
o Rectal route is an alternative to those patients who cannot tolerate
medications through the oral route.
o PCA: See PCA protocol on pages 19 and 23 of the therapeutics manual.
o Opioid titration should be individualized and adjusted to patient tolerance or
emergence of adverse effects.
121
• If the pain is present most of the day, then analgesics should be administered
on a regular basis (not PRN).1
o a PRN order for a supplementary opioid should be used if necessary for
breakthrough pain
• Familiarize yourself with dose and time course of opioids1
o Sustained release regimens
 To determine a sustained-release regimen, treat patient for 24-48
hours with an immediate-release opioid to determine the total daily
dose of opioid required. Once the total daily dose of opioid is
determined, prescribe 2/3 of the total daily opioid dose as sustained
release preparation and provide the remainder of the dose as PRN
immediate-release opioid.
• To change to a new opioid or different route, use the equianalgesic table.
• Be able to recognize and treat the side effects of opioids.1
o The most common side effects of opioids include sedation, constipation,
nausea, vomiting, itching, and respiratory depression. Patients generally
gain tolerance to most opioid-induced adverse effects following several days
of therapy.
o Ways to manage side effects include
 Change the dosing regimen or route of the drug in order to aim for
more constant blood levels
 Use a different opioid
 Use multidrug and multimodal therapy
• E.g., utilize an NSAID or an adjunct medication in order to
reduce the dose of the opioid
 Use another drug that counteracts the adverse effect of the opioid
• Sedation
o May be partially counteracted with a stimulant for
patients receiving chronic opioid therapy (e.g., caffeine,
dextroamphetamine, methylphenidate)
(The addition of a stimulant is not generally required for
short-term opioid usage since patients gain tolerance to
this adverse effect with continued use of the medication)
• Constipation (Patients NEVER gain tolerance to this adverse
effect).
o Ensure that patient is on an appropriate bowel
prophylaxis regimen
o Patients who are taking opioids should take a stimulating
laxative (e.g, senna, bisacodyl) in order to increase bowel
motility with or without a stool softener according to
stool consistency
122
o A stool softener alone is not sufficient
• Nausea and Vomiting
Consider rotating to another opioid OR
o For opioid induced nausea and vomiting consider adding
a phenothiazine (prochlorperazine) or prokinetic agent
(metoclopramide)
o For motion-exacerbated nausea (due to vestibular
disturbance) consider an antiemetic with antihistamine
properties such as meclizine or scopolamine
o For more severe or uncontrolled nausea consider a 5HT3
antagonist (e.g., ondansetron)
• Itching
Consider rotating to another opioid OR
o Manage with antihistamines (e.g., diphenhydramine,
promethazine, hydroxyzine, loratadine)
• Respiratory depression
o Monitor patient closely for respiratory depression
o If needed, use an opioid antagonist (e.g, naloxone)
• Do not use meperidine due to its hazards such as neurotoxicity risk. Be aware
the potential hazards such as psychomimetic effects of mixed agonistantagonists (e.g., pentazocine).1
• Adjunctive agents
o Glucocorticoids (e.g, dexamethasone)1
 May decrease pain caused by edema—These may also be used for the
management of bone pain
o Bisphosphonates such as pamidronate and zoledronate and radionuclides
such as strontium may be useful as adjuncts for metastatic bone pain1
o Anticonvulsants1
 Useful in neuropathic pain states (e.g., postherpetic neuralgia and
trigeminal neuralgia)
 Examples include gabapentin, pregabalin, phenytoin, carbamazepine,
sodium valproate, clonazepam, topiramate, oxycarbazapine,
lamotrigine, and zonisimade
• Gabapentin is the most studied for pain and requires a dose
reduction in renal insufficiency
o Tricyclic antidepressants1
 May be useful in diabetic neuropathy and postherpetic neuralgia
 Relatively contraindicated in patients with coronary artery disease
because they can worsen arrhythmias
 Examples include nortriptyline, desipramine, amitriptyline, and
imipramine
o SNRI (Serotonin/norepinephrine reuptake inhibitor)4
123
 Cymbalta® (duloxetine)
• May be useful for the management of pain which is associated
with diabetic neuropathy
o Local anesthetics (e.g., EMLA cream, lidocaine patches)1
 EMLA cream (lidocaine and prilocaine) may be useful for topical
dermal anesthesia or post-herpetic neuralgia
 Topical lidocaine patches may be useful for postherpetic neuralgia
o Skeletal muscle relaxants/antispasmodic agents (e.g., carisoprodol,
cyclobenzaprine)1
 May be useful for acute muscle injury
o Topical Agents (e.g., capsaicin)1
 May be useful in peripheral neuropathic pain and arthritic pain
Terminology:1
• Tolerance:
o A state of adaptation in which being exposed to a drug induces changes
that cause a decrease in one or more of the drug’s effects over the course
of time
• Physical dependence:
o A state of adaptation in which withdrawal symptoms may occur after
abruptly stopping, quickly decreasing the dose, decreasing the blood
level of a drug, and/or by administering an opioid antagonist.
Withdrawal symptoms may be prevented by slowly tapering a patient off
of the opioid.
 Symptoms of withdrawal include anxiety, tachycardia, and
sweating
o Dependence is NOT addiction and this natural phenomena can occur
with other classes of medications (e.g., antihypertensives)
• Addiction: Continued use of a medication despite harm (to self or others)
o A chronic, neurobiologic disease with genetic, psychosocial, and
environmental factors that influence its manifestations
o Behaviors involved include: impaired control of drug use, compulsive
use of the drug, craving of the drug, and drug-seeking behavior
o Pseudoaddiction
 A term used to describe behaviors that a patient may exhibit when
their pain is under treated.
 These behaviors generally resolve when a patient’s pain is
effectively treated.
References:
1. Principles of analgesic use in the treatment of acute pain and cancer pain.
American Pain Society. Fifth edition.
2. Letter from the Department of Health and Human Services. October 2005.
www.fda.gov. Accessed August 24, 2007.
124
3. American Liver Foundation Issues Warning on Dangers of Excess
Acetaminophen. http://www.liverfoundation.org/about/news/33/ Accessed
August 22, 2007.
4. Adapted table from: principles of analgesic use in the treatment of acute pain
and cancer pain. American Pain Society. Fifth edition.
5. Lexi-Comp Online: Duloxetine. Last updated on 8/10/2007.
125
SELECTED DRUGS THAT REQUIRE RENAL DOSING ADJUSTMENT
DRUG
Amikacin (Amikin)
Gentamicin
(Garamycin)
Tobramycin (Nebcin)
Cefazolin (Ancef)
Cefadroxil (Duricef®)
Cephalexin (Keflex)
Cefdinir (Omnicef®)
AMINOGLYCOSIDES
NORMAL DOSE
RENAL ADJUSTMENT
Varies depending on indication
Clcr ≥60 mL/minute: Administer every 8 h
Clcr 40-60 mL/minute: Administer every 12 h
Clcr 20-40 mL/minute: Administer every 24 h
Clcr <20 mL/minute: Loading dose, then monitor
levels
Varies depending on indication
Clcr ≥60 mL/minute: Administer every 8 h
Clcr 40-60 mL/minute: Administer every 12 h
Clcr 20-40 mL/minute: Administer every 24 h
Clcr <20 mL/minute: Loading dose, then monitor
levels
Varies based on indication
Clcr ≥60 mL/minute: Administer every 8 h
Clcr 40-60 mL/minute: Administer every 12 h
Clcr 20-40 mL/minute: Administer every 24 h
Clcr 10-20 mL/minute: Administer every 48 h
Clcr <10 mL/minute: Administer every 72 h
CEPHALOSPORINS
250 mg to 2 g every 6-12 h
Clcr 10-30 mL/minute: Administer every 12 h
Clcr <10 mL/minute: Administer every 24 h
1-2 g/day in 2 divided doses
Clcr 10-25 mL/minute: Administer every 24 h
Clcr <10 mL/minute: Administer every 36 h
250-1000 mg every 6h
Clcr >10 mL/minute: 250-500 mg every 8-12 h
Clcr <10 mL/minute: 250-500 mg every 12-24 h
300 mg twice daily or 600 mg once daily
Clcr <30 mL/min: 300 mg once daily
126
Cefoxitin (Mefoxin®)
1-2 g every 6-8 h
Cefaclor (Ceclor)
250-500 mg tid
Cefuroxime (Zinacef)
Cefixime (Suprax)
Oral: 250-500 mg twice daily
I.M., I.V.: 750 mg to 1.5 g every 6-8 h or 100150 mg/kg/day in divided doses every 6-8 h
400 mg/day divided every 12-24 h
Ceftizoxime (Ceftizox)
1-4 g every 8-12 h
Cefepime (Maxipime)
1-2 g q6-12h
Clcr 21-60 mL/minute or with renal hemodialysis:
Administer 75% of the standard dose
Clcr <20 mL/minute or with CAPD: Administer
50% of the standard dose
Clcr 50-79 mL/minute: Administer 500-1500 mg
every 8 h
Clcr 5-49 mL/minute: Administer 250-1000 mg
every 12 h
Clcr 0-4 mL/minute: Administer 500-1000 mg
every 48 h or 250-500 mg every 24 h
See package insert for details
Clarithromycin
(Biaxin)
MACROLIDES
250-500 mg every 12 h or 1000 mg (two 500
mg extended release tablets) once daily
Clcr <30 mL/minute: Half the normal dose or
double the dosing interval
Erythromycin (various)
Varies- see package inserts
Clcr <10 mL/minute: see package inserts
Clcr 30-50 mL/minute: Administer 1-2 g every 8-12
h
Clcr 10-29 mL/minute: Administer 1-2 g every 1224 h
Clcr 5-9 mL/minute: Administer 0.5-1 g every 1224 h
Clcr <5 mL/minute: Administer 0.5-1 g every 24-48
h
50-100% normal dose
CrCl <10 administer 50% normal dose
Clcr 10-20 mL/minute: Administer every 12 h
Clcr <10 mL/minute: administer every 24 h
PENICILLINS
127
Amoxicillin
(Amoxil/Trimox)
250-500 mg every 8 h or 500-875 mg twice
daily
Clcr 10-30 mL/minute: 250-500 mg every 12 h
Clcr <10 mL/minute: 250-500 mg every 24 h
Ampicillin (Polycillin)
IV
250-500 mg every 6 h
Penicillin G (various)
Varies depending on indication
Piperacillin (Pipracil)
2-4 g/dose every 4-6 h
Piperacillin/
Tazobactam (Zosyn)
3.375 g every 6 h or 4.5 g every 6-8 h
Ampicillin/Sulfactam
(Unasyn®)
Amoxicillin/
Clavulonate
(Augmentin®)
1.5-3 g every 6 h
Clcr >50 mL/minute: Administer every 6 h
Clcr 10-50 mL/minute: Administer every 6-12 h
Clcr <10 mL/minute: Administer every 12-24 h
Clcr >10 mL/minute: Administer full loading dose
followed by 1/2 loading dose given every 4-5 h
Clcr <10 mL/minute: Administer full loading dose
followed by 1/2 loading dose given every 8-10 h
Clcr 20-40 mL/minute: Administer 3-4 g every 8 h
Clcr <20 mL/minute: Administer 3-4 g every 12 h
Clcr 20-40 mL/minute: Administer 2.25 g every 6 h
(3.375 g every 6 h for nosocomial pneumonia)
Clcr <20 mL/minute: Administer 2.25 g every 8 h
(2.25 g every 6 h for nosocomial pneumonia)
Clcr 15-29 mL/minute: Administer every 12 h
Clcr 5-14 mL/minute: Administer every 24 h
Clcr <30 mL/minute: Do not use 875 mg tablet or
extended release tablets
Clcr 10-30 mL/minute: 250-500 mg every 12 h
Clcr <10 mL/minute: 250-500 every 24 h
250-500 mg every 8 h or 875 mg every 12 h
®
Ciprofloxacin (Cipro )
Levofloxacin
(Levaquin)

Metronidazole (Flagyl )
QUINOLONES
Oral: 250-750 mg every 12 h
I.V.: 200-400 mg every 12 h
250-500 mg every 24 hours; severe or
complicated infections: 750 mg every 24 h
7.5 mg/kg every 6 h
Refer to package insert
See package insert
OTHER ANTIBIOTICS
100% normal dose
Clcr <10 mL/minute: 50% normal dose
128
Aztreonam (Azactam)
2 g every 8 h
Tetracycline (various)
250-500 mg qid
Vancomycin
(Vancocin)
Ethambutol
(Myambutol®)
Meropenem (Merrem®)
1 g every 12 h
Pyrazinamide
(TebrazidTM)
Nitrofurantoin
(Furadantin®,
Macrobid®,
Macrodantin)
Septra
See package insert
See package insert
Clcr 15-30 mL/minute: Administer 50% of
recommended dose
Clcr <15 mL/minute: Use is not recommended
Trimethoprim
100 mg every 12 h or 200 mg every 24 h for
10 days; longer treatment periods may be
necessary for prostatitis (i.e., 4-16 weeks); in
the treatment of Pneumocystis carinii
pneumonia; dose may be as high as 15-20
mg/kg/day in 3-4 divided doses
Clcr 15-30 mL/minute: Administer 100 mg every 18
h or 50 mg every 12 h
Clcr <15 mL/minute: Administer 100 mg every 24 h
or avoid use
See package insert
1.5-6 g/day divided every 8 h
See package insert
50-75% normal dose
Clcr <10 mL/minute: 25% normal dose
250-500 mg every 12-24 h
Clcr <10 mL/minute: 250-500 mg every 24 h
1 g every 24 h
Clcr <10 mL/minute: 1g every 48-72 h
Clcr 10-50 mL/minute: Administer every 24-36 h
Clcr <10 mL/minute: Administer every 48 h
Clcr 26-50 mL/minute: Administer recommended
dose based on indication every 12 h
Clcr 10-25 mL/minute: Administer one-half
recommended dose every 12 h
Clcr <10 mL/minute: Administer one-half
recommended dose every 24 h
Clcr <50 mL/minute: Avoid use or reduce dose to
12-20 mg/kg/day
Clcr <60 mL/minute: Contraindicated
129
Imipenem/Cilastatin
(Primaxin)
Allopurinol (Zyloprim)
Disopyramide
(Norpace)
Enoxaparin (Lovenox®)
Famotidine (Pepcid)
Dosage based on imipenem content
I.V.: Weight ≥70 kg: 250-1000 mg every 6-8
h; maximum: 4 g/day. Note: For adults
weighing <70 kg, refer to Dosing Adjustment
in Renal Impairment
OTHER DRUGS:
See package insert
100-300 mg every 6-12 h
Treatment: 1.5mg/kg daily or 1 mg/kg every
12 h
Prophylaxis: 30 mg BID or 40 mg daily
20-40 mg hs
Gabapentin (Neurontin®) 900-3600mg per day
Ketorolac (Toradol®)
I.M.: 60 mg as a single dose or 30 mg every 6
h (maximum daily dose: 120 mg)
I.V.: 30 mg as a single dose or 30 mg every 6
h (maximum daily dose: 120 mg)
Oral: 20 mg, followed by 10 mg every 4-6 h;
do not exceed 40 mg/day; oral dosing is
intended to be a continuation of I.M. or I.V.
therapy only
See package insert
See package insert
Clcr 30-40 mL/minute: Administer every 8 h
Clcr 15-30 mL/minute: Administer every 12 h
or alter the dose as follows:
Clcr 30-<40 mL/minute: Reduce dose 50%
Clcr 15-30 mL/minute: Reduce dose 75%
Clcr <15 mL/minute: Administer every 24 h
Clcr <30 mL/minute:
Treatment: 1 mg/kg daily
Prophylaxis: 30 mg daily
Clcr <50 mL/minute: Manufacturer
recommendation: Administer 50% of dose or
increase the dosing interval to every 36-48 h (to
limit potential CNS adverse effects).
Clcr ≥60 mL/minute: 300-1200 mg tid
Clcr >30-59 mL/minute: 200-700 mg bid
Clcr >15-29 mL/minute: 200-700 mg daily
Clcr <15 mL/minute: 100-300 mg daily
Contraindicated in patients with advanced renal
impairment. Patients with moderately-elevated
serum creatinine should use half the recommended
dose, not to exceed 60 mg/day I.M./I.V
130
Meperidine (Demerol)
50-100 mg every 2-4 h
Morphine (various)
Starting dose: 1 mg every 3-4 h, acute pain
Metoclopramide
(Reglan)
Primidone (Mysoline®)
See package insert
Procainamide (Procan
SR, Pronestyl)
Sotalol (Betapace®)
125-250 mg/day at bedtime; increase by 125250 mg/day every 3-7 days; usual dose: 7501500 mg/day in divided doses 3-4 times/day
with maximum dosage of 2 g/day
See package insert
See package insert
Clcr 10-50 mL/minute: 75% normal dose
Clcr <10 mL/minute: 50% normal dose
75% normal dose
Clcr <10 mL/minute: 50% normal dose
Clcr <40 mL/minute: Administer at 50% of normal
dose
Clcr 50-80 mL/minute: Administer every 8 h
Clcr 10-50 mL/minute: Administer every 8-12 h
Clcr <10 mL/minute: Administer every 12-24 h
Oral:
Clcr 10-50 mL/minute: Administer every 6-12 h
Clcr <10 mL/minute: Administer every 8-24 h
I.V.:
Loading dose: Reduce dose to 12 mg/kg in severe
renal impairment.
Maintenance infusion: Reduce dose by one-third in
patients with mild renal impairment. Reduce dose
by two-thirds in patients with severe renal
impairment.
See package insert
ANTIVIRALS
Didanosine
Famciclovir
Ganciclovir
Lamivudine
See package insert
See package insert
Oral: 1000 mg 3 times/day with food or 500
mg 6 times/day with food
5 mg/kg/dose every 12 h or 5 mg/kg/day as a
single daily dose
See package insert
See package insert
See package insert
See package insert
See package insert
131
Stavudine
≥60 kg: 40 mg every 12 h
<60 kg: 30 mg every 12 h
Valacyclovir
Zalcitabine
See package insert
0.75 mg tid
Zidovudine
See package insert
Fluconazole
Flucytosine
Clcr >50 mL/minute:
≥60 kg: 40 mg every 12 h
<60 kg: 30 mg every 12 h
Clcr 26-50 mL/minute:
≥60 kg: 20 mg every 12 h
<60 kg: 15 mg every 12 h
Clcr 10-25 mL/minute, hemodialysis (administer
dose after hemodialysis on day of dialysis):
≥60 kg: 20 mg every 24 h
<60 kg: 15 mg every 24 h
See package insert
Clcr 10-40 mL/minute: 0.75 mg every 12 h
Clcr <10 mL/minute: 0.75 mg every 24 h
Clcr <15 mL/minute including hemo-/peritoneal
dialysis: 100 mg (oral) or 1 mg/kg (I.V.) every 6-8
h
ANTIFUNGALS
200-800 mg/day; duration and dosage depends No adjustment for vaginal candidiasis single-dose
on severity of infection
therapy
For multiple dosing, administer usual load then
adjust daily doses as follows:
Clcr ≤50 mL/minute (no dialysis): Administer 50%
of recommended dose or administer every 48 h
Oral: 50-150 mg/kg/day in divided doses
Clcr 20-40 mL/minute: Administer 37.5 mg/kg
every 6 h
every 12 h
Clcr 10-20 mL/minute: Administer 37.5 mg/kg
every 24 h
Clcr <10 mL/minute: Administer 37.5 mg/kg every
24-48 h, but monitor drug concentrations frequently
132
Itraconazole
100-400 mg/day; doses >200 mg/day are given
in 2 divided doses; length of therapy varies
from 1 day to >6 months depending on the
condition and mycological response
Not necessary; itraconazole injection is not
recommended in patients with Clcr <30 mL/minute;
hydroxypropyl-β-cyclodextrin (the excipient) is
eliminated primarily by the kidneys
Terbinafine
250-500 mg/day
Voriconazole
Oral: 100-300 mg every 12 h
I.V.: 6 mg/kg every 12 h for 2 doses; followed
by maintenance dose of 4 mg/kg every 12 h
Clcr <50 mL/minute: Oral administration is not
recommended
Clcr <50 mL/minute, accumulation of the
intravenous vehicle (SBECD) occurs. After initial
loading dose, oral voriconazole should be
administered to these patients, unless an assessment
of the benefit: risk to the patient justifies the use of
I.V. voriconazole.
133
Therapeutic Drug Monitoring
DRUG
SAMPLING
TIME
Amikacin
Trough:
30 minutes before
the dose
Peak: 30 minutes
after the infusion
has ended
Carbamazepine Trough
concentration
Digoxin
6 h after dose
Gentamicin
Lidocaine
Trough:
30 minutes before
the dose
Peak: 30 minutes
after infusion has
ended
6-24 h after start
of infusion
THERAPEUTIC
RANGE
Trough:
4-8 mcg/ml
Peak:
15-30 mcg/ml
MAJOR
SERUM
COMMENTS
ROUTE OF
HALF
ELIMINATION LIFE (nl)
Renal: 100%
1.5-3 h
Persistent high levels may
increase incidence of
ototoxicity and
nephrotoxicity.
4-12 mcg/ml
Hepatic: 99%
8-20 h
CHF: 0.5-1 ng/ml
Afib: 0.5-2.0
ng/ml
Trough:
0.5-2 mcg/ml
Peak:
3-10 mcg/ml
Renal: 75-85%
Hepatic: 15%
36-44 h
Renal: 100%
1.5-3 h
Persistent high levels may
increase incidence of
ototoxicity and
nephrotoxicity.
1.5-5 mcg/ml
Hepatic: > 90%
Renal: < 10%
1.2-2.2 h
Protein binding changes in
MI leads to elevated
concentration; metabolite
accumulates in renal
failure.
Active metabolite is
eliminated renally.
134
Therapeutic Drug Monitoring
DRUG
SAMPLING
TIME
Lithium
12 h after evening
dose
Phenobarbital
Trough
concentration
Phenytoin
Trough
concentration
Procainamide
(PCA)
1 h after loading
dose then every
24 h until stable
Quinidine
Trough
concentration
THERAPEUTIC
RANGE
Acute mania:
0.6-1.2 mEq/L
Bipolar:
0.8-1 mEq/L
Adults:
20-40 mcg/ml
Infants/children:
15-30 mcg/ml
Adults/children:
10-20 mcg/ml
Neonates:
8-15 mcg/ml
Free level 1-2
mcg/ml
PCA:
4-10 mcg/ml
NAPA:
15-25 mcg/ml
2-5 mcg/ml
MAJOR
SERUM
COMMENTS
ROUTE OF
HALF
ELIMINATION LIFE (nl)
Renal: 90%
14-28 h
Fluid and electrolyte
manipulations may cause
variations in steady-state
concentrations.
Hepatic: 80%
60-150 h Half-life is decreased in
Renal: 20%
children and is elevated in
cirrhosis, elderly, and by
valproic acid.
Hepatic: >95%
Dose &
Therapeutic range for total
concentra phenytoin concentration
- tion
decreases in ESRD and
dependent hypoalbuminemia.
Renal: 50%
Hepatic: 50%
2.5-5 h
Hepatic: 60-80%
Renal: 10-30%
5-7 h
Active metabolite, NAPA,
is eliminated in urine 90%
unchanged. NAPA
accumulates in renal
failure.
Hepatic cirrhosis & CHF
decrease clearance;
phenobarbital and
phenytoin increase
clearance.
135
Therapeutic Drug Monitoring
DRUG
SAMPLING
TIME
Theophylline
IV: 30 min after
load, then 12-18 h
after maintenance
PO: Trough conc.
Tobramycin
Trough:
30 minutes before
the dose
Peak: 30 minutes
after the infusion
has started
Trough
concentration
Valproic acid
Vancomycin
Trough:
immediately
before dose
THERAPEUTIC
RANGE
MAJOR
SERUM
ROUTE OF
HALF
ELIMINATION LIFE (nl)
COPD and asthma Hepatic: > 90%
6-8 h
5-15 mcg/ml
Renal: < 10%
Neonatal apnea:
6-13 mcg/ml
Pregnancy:
3-12 mcg/ml
Trough:
Renal: 100%
1.5-3 h
< 0.5-2 mcg/ml
Peak:
3-10 mcg/ml
Epilepsy:
50-100 mcg/ml
Mania:
50-125 mcg/ml
Hepatic: 95%
10 h
Trough:
5-20 mcg/ml
Renal: 90%
2.5-6 h
COMMENTS
Half-life is influenced by
factors affecting hepatic
enzymes.
Persistent high levels may
increase incidence of
ototoxicity and
nephrotoxicity.
Carbamazepine and
phenytoin decrease halflife; protein binding is
dependent on serum
concentration.
Monitor trough for possible
accumulation in renal
failure. Avoid checking
peak concentrations
(frequent errors).
136
Equianalgesic Doses for Select Opioids Used in Severe Pain1,2
Opioid
Morphine
HYDROmorph
one
*Meperidine
Oxycodone
Common Proprietary
Names
Immediate release:
MSIR, Roxanol®
Sustained release:
MS Contin®
Kadian® and Avinza®
Dilaudid®
Demerol®
Starting Dose
Usual Dosing
Interval
15-30 mg po
Oral
Equianalgesic
Dose
30 mg
Parenteral
Equianalgesic Dose
7.5 mg
1.5 mg
300 mg
75 mg
10 mg
3-4 hours
4-8 mg po
Not
Recommended
10-20 mg po
8-12 hours
12-24 hours
Oral: 3-6 hours
IV: 2-3 hours
3-4 hours
Immediate release:
20 mg
Not applicable
®
®
OxyIR , Roxicodone
4-6 hours
®
Percocet (combo
product with
12 hours
acetaminophen)
Sustained release:
Oxycontin®
*Not recommended according to the American Pain Society.
Please Note:
• The equianalgesic doses presented in the table are those for severe pain.
• When converting scheduled doses of opiates, decrease the amount of the new dose by 25-50% to account
for incomplete opioid cross tolerance. This reduction is not necessary when converting PRN doses.
Therefore, use the following formula to convert from one opioid to another:
Total daily dose of the new opioid = Total daily dose of the old opioid
Equianalgesic dose of new opioid
Equianalgesic dose of old opioid
137
Example Calculations:
Example 1:
An adult patient has a prescription for morphine 10 mg by mouth every four hours PRN pain. Calculate an equivalent
dose of ORAL hydromorphone PRN pain.
Step 1: Calculate the total daily dose of the old opioid (morphine):
Answer: 10 mg x 6= 60 mg (total daily dose of morphine)
Step 2: Look on the chart to see the equianalgesic dose for ORAL morphine compared to ORAL hydromorphone.
Answer: 30 mg of oral morphine is equal to 7.5 mg of oral hydromorphone.
Step 3: Substitute the values determined from steps 1 and 2 into the equation to solve for the total daily dose of the
new opioid or X.
Answer:
Total daily dose of hydromorphone (X) = 60 mg of morphine per day
7.5 mg of oral hydromorphone
30 mg of oral morphine
X times 30 = 60 times 7.5
30X= 450 mg
X = 15 mg for the total daily dose of hydromorphone
Step 4: Divide this total daily dose by the number of hours in between doses to get the appropriate regimen.
Answer: Hydromorphone can be given every 3 to 6 hours. Therefore, if you give it every 4 hours, the dose would be
2.5 mg (15 mg divided by 6) every 4 hours PRN pain.
Hydromorphone 2.5 mg PO is equianalgesic to a dose of Morphine 10 mg PO.
Example 2: A patient is talking Oxycontin® 40 mg by mouth twice daily for chronic pain. She also takes oxycodone
10 mg by mouth every 4 hours as needed for pain, which she uses about two times per day. Her insurance has
changed, and she must now use long-acting morphine (Morphine sulfate extended release) instead of long acting
oxycodone (Oxycontin®).
Step 1: Calculate the total daily dose of the old opioid:
Answer: (40 mg x 2 of Oxycontin®) + (10 mg x 2 of oxycodone)= 100 mg (total daily dose)
Step 2: Look on the chart to see the equianalgesic dose for ORAL oxycodone compared to ORAL morphine.
Answer: 30 mg of morphine=20 mg of oxycodone
Step 3: Substitute the values determined from steps 1 and 2 into the equation to solve for the total daily dose of the
new opioid X.
138
Answer:
Total daily dose of morphine (X) = 100 mg of oxycodone per day
30 mg of morphine
20 mg of oxycodone
X times 20 = 30 times 100
20X=3000 mg
X= 150 mg for the total daily dose of morphine
Step 4: Decrease the amount of the new dose by 25-50% to account for incomplete opioid cross tolerance when
converting from one opioid to another.
Answer: Reducing the dose of 150 mg by 25 to 50% would give a dose range of 75 to 112 mg of morphine per day.
Morphine sulfate extended release can be given every 12 hours.
Therefore, could use Morphine sulfate extended release 45 mg by mouth every 12 hours (90 mg per day).
References:
1. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. American Pain Society. Fourth edition. 1999.
2. Lexi Drugs (Comp + Specialties). July 3. 2007.
139
Fentanyl Conversion
Transdermal Fentanyl
Conversion
(Duragesic® 25, 50, 75, 100
mcg patch)
Not recommended for
pediatrics
Duragesic®
PO
Morphine
Equivalent
(mg/24 hr)
(mcg/hr)
45-134
25
135-224
50
225-314
75
315-404
100
405-494
125
495-584
150
585-674
175
675-764
200
765-854
225
855-944
250
945-1034
275
1035-1124
300
Oral transmucosal fentanyl citrate (OTFC)
(Actiq® 200, 400, 600, 800, 1200, 1600 mcg units)
Not recommended for pediatrics
Actiq® delivers fentanyl through the lining of the mouth
directly to the blood stream. Analgesia occurs in 5 to
15 minutes.
Instruct the patient to place Actiq® between the cheek
and the gum and actively suck on the medicine. The
patient can swab it around the check and swirl the
handle for the best results. Biting or chewing decreases
absorption. The entire unit should be used in 15
minutes unless pain relief is achieved before
completion.
Start treatment with the 200-mcg dose. A second dose
can be given approximately 30 minutes after the start of
the first dose. If several episodes of breakthrough pain
require more than one OTFC unit, consider an increase
to the next higher dosage strength.
Allow 12 to 16 hrs for patch
to be effective. Change patch
Keep all packaging and used product away from
every 48 to 72 hrs.
children and pets.
140
Pt. Name
Date
FIN#
MD
RPh:
Fentanyl Transdermal Patch (Duragesic→) Pharmacist Checklist
Form should be completed prior to processing medication. If order is a continuation of
patients’ home medication and dose, do not complete form and proceed with order entry.
Verify that patient was still receiving fentanyl patch at home.
Instructions:
Complete one of the two sections below. For new fentanyl transdermal orders, complete the
“Starting Dose” section. For transdermal fentanyl dose increases, complete the "Dose
Increase” section. If the answer is “YES” to each question in the appropriate section,
proceed with order processing. If any question is marked “NO”, the physician must be
contacted. If the order will not be processed by pharmacy, inform nursing not to apply
patch.
Starting dose:If not a starting dose, move to “Dose increase” section.
YES
NO Is fentanyl transdermal being prescribed for chronic pain?
(Contraindicated for the management of acute, mild, post-operative, or
intermittent pain) If transdermal fentanyl prescribed for acute pain, inform
physician of the contraindication and that pharmacy may not process the
order.
YES
NO Is the patient opioid-tolerant? Opioid-tolerant is defined as patients
who have been taking, for a week or longer, the equivalent of (see Table B):
• Oral morphine 60 mg per day
• Oral oxycodone 30 mg per day
• Oral hydromorphone (Dilaudid) 8 mg per day
If transdermal fentanyl prescribed for patient who is not opioid tolerant, inform
physician of patient’s opioid intake and package labeling for opioid nontolerant patients. Recommend maximizing use of PRN medications and to
consider prescribing patch in future if patient meets opioid-tolerant definition.
YES
NO Is the prescribed transdermal fentanyl dose lower than or equal to the
calculated equianalgesic patch dose? (See “Dose Conversion Guidelines” for
instructions on how to calculate the transdermal fentanyl starting dose using
long-acting and PRN opioids.)
If answer is “NO,” contact physician and recommend lower dose of patch per
calculated in Table A. If starting dose is >100 mcg patch, contact clinical
pharmacy specialist on-call to verify calculations and dose.
Dose increase: For patients already receiving transdermal fentanyl.
YES
NO For dose increases after the initial patch, has there been at least 3
days since the patch was initially placed? For other dose increases, has
it been at least 6 days?
If the answer is “NO,” contact physician and suggest maximizing PRN
medications. Fentanyl transdermal has a 17 hour t½ and should not be titrated
more frequently than listed above. Contact the clinical pharmacy specialist oncall if there are specific questions.
Was Physician contacted? No
Yes
If physician contacted, leave order clarification/telephone order in chart after discussion
with physician (D/C fentanyl, lower patch dose, etc.).
141
Dose Conversion Guidelines*
To convert patients from oral or parenteral opioids to transdermal fentanyl, use
the following steps:
1. Determine the opioid requirements from the previous 24 hours (including scheduled and
PRN opioid medications). Use the MAR to add the amount of PRN opioid doses
the patient has received.
2. If only one opioid (e.g. morphine) has been used over the last 24 hours, use Table A
below to determine the transdermal fentanyl requirements. If patient has received
more than one opioid (e.g. oxycodone plus hydromorphone, other combinations), use
Table B
to determine the total daily oral morphine equivalents and then oral morphine in Table
A to determine the equianalgesic transdermal fentanyl dose.
Current
Analgesic
Oral morphine
IV morphine
Oral oxycodone
Oral codeine
Oral
hydromorphone
IV
hydromorphone
IV meperidine
Recommended
transdermal
fentanyl dose
TABLE A:*
Dose Conversion Guidelines
Daily Dosage (mg/day)
60-134
10-22
30-67
150-447
8-17
135-224
23-37
67.5-112
448-747
17.1-28
225-314
38-52
112.5-157
748-1047
28.1-39
315-404
53-67
157.5-202
1048-1347
39.1-51
>404
>67
>202
>1347
>51
1.5-3.4
3.5-5.6
5.7-7.9
8-10
>10
75-165
⇓
25 mcg/hr
patch
166-278
⇓
50 mcg/hr
patch
279-390
⇓
75 mcg/hr
patch
391-503
⇓
100 mcg/hr
patch
>503
⇓
Consult
clinical
specialist
TABLE B:*
Equianalgesic Potency Conversion
Equianalgesic Dose
(mg)
Name
IV
PO
Morphine
10
30
Hydromorphone
1.5
7.5
Oxycodone
20
Meperidine
75
-Codeine
130
200
*The dose conversion tables listed above should not be used to convert
transdermal fentanyl to oral or parenteral opioids.
142
Opioid Allergy
Scenario 1: Patient has an intolerance – not an allergy:
The following signs do NOT suggest an allergy:
 Flushing
 Itching
 Sneezing
 Sweating
This reaction is most likely a result of histamine release from mast cells, a common side
effect of opioids and notan allergy.
Analgesic options include:
1. Switch to a nonopioid analgesic (NSAID, APAP)
2. Dose reduce the opioid
3. Dose reduce the opioid, and add/increase dose of nonopioid analgesic
4. Premedicate and concurrently medicate with an antihistamine (diphenhydramine 2550mg) and possibly an H2 blocker (famotidine 20 mg)
5. If the opioid is intravenously administered, reduce rate of infusion
6. Switch to an opioid that is less likely to cause a histamine release
Opioid
Codeine
Morphine
Meperidine
Fentanyl
Methadone
Propoxyphene
Hydrocodone
Hydromorphone
Oxycodone
Oxymorphone
Buprenorphine
Nalbuphine
Chemical Source
Natural
Natural
Synthetic
Synthetic
Synthetic
Synthetic
Semi-synthetic
Semi-synthetic
Semi-synthetic
Semi-synthetic
Semi-synthetic
Semi-synthetic
Histamine Releasing Ability
High
High
High
Low
Low
Unknown
Unknown
Low
Low
Low
Unknown
Unknown
Scenario 2: Patient has a TRUE allergy:
The following signs DO suggest an allergy:
 Hypotension (BP <90/60mmHg)
 Hives, maculopapular rash, erythema multiforme, pustular rash
 Difficulty breathing, speaking, or swallowing (i.e. bronchospasm)
 Swelling of face, lips, mouth, tongue, pharynx, or larynx (i.e angioedema)
This reaction is likely a true allergy.
Analgesic options include:
1. Switch to a nonopioid analgesic (NSAID, APAP)
2. The risk of cross-allergenicity between the chemical classes of opioids is low. If an
opioid is necessary, choose an opioid in a different class from the one that caused
the allergic reaction. For example, if meperidine, which is in class A, caused an
allergic reaction, try an opioid listed under class B or C instead.
a. Closely monitor the patient as it is possible to be allergic to more than one
class of opioids.
143
b. Note that Ultram (tramadol) and Ultracet (tramadol/APAP) are contraindicated
in patients allergic to ANY opioid.
Class A
meperidine
fentanyl
Class B
methadone
propoxyphene
propoxyphene/APAP
Class C
morphine
codeine
hydrocodone
oxycodone
oxymorphone
hydromorphone
nalbuphine
butorphanol
Example Situations:
1. You think the morphine drip is causing your patient to itch. It is possible the
morphine is causing a histamine release. What can you do?
Call the physician and ask him to order diphenhydramine 25-50mg PO q6-8 hours
while the patient is on the morphine drip, or, call the physician and ask him to d/c
the morphine and switch the patient to an equianalgesic dose of oxycodone which
doesn’t typically cause as much itching.
2. A patient presents in acute sickle cell crisis. He reports that “morphine gives me
hives all over my body”. What is your suggestion for pain control?
To control his pain, do not prescribe any opioids listed in the same class as
morphine. Try using an opioid from class A or B (see the above table for opioid
classes). It is still important to watch him closely in case he develops signs and
symptoms of an allergic reaction.
References:
1. Analgesic Options for Patients with Allergic-Type Opioid Reactions. Pharmacist’s
Letter/Prescriber’s Letter 2006;22(2):220201
2. Salijoughian M. Opioids: Allergy vs. Pseudoallergy. US Pharmacist. 2006;7:HS-5-HS9
3. Li, Fanny. Pharmacologically Induced Histamine Release: Sorting Out
Hypersensitivity Reactions to Opioids. Drug Therapy Topics. 2006;35(4):13-15
144
Glucocorticoid Comparison
Agent
Equivalent dose
(approximate mg)
Betamethasone
0.6-0.75
Dexamethasone
0.75
Hydrocortisone
20
Methylprednisolone 4
Prednisolone
5
Prednisone
5
Route of
administration
IM, IV, PO
IM, IV
IM, IV, PO
IM, IV, PO
PO
PO
Biologic half-life
(hours)
36-54
36-54
8-12
18-36
18-36
18-36
Methylprednisolone
Equivalent
Equivalent
dose (example)
dexamethasone dose
hydrocortisone dose*
40 mg Q6H
8 mg Q6H
200 mg Q6H
60 mg Q6H
12 mg Q6H
300 mg Q6H
80 mg Q6H
16 mg Q6H
400 mg Q6H
125 mg Q6H
24 mg Q6H
625 mg Q6H
*Hydrocortisone has significant mineralocorticoid potency and may cause significant
fluid retention
145
IV Push Rates for Adult Patients
MUST USE FILTER NEEDLE WHEN AMPULE IS USED
Drug
Rate of Administration
Acetazolamide
100-500 mg/min
Atropine
0.4 mg/min
Bretylium
Over 1 min*
Bumetanide
Calcium chloride
Calcium gluconate
Dexamethasone
(≤ 10 mg)
D50W
Diazepam
Digoxin
Diphenhydramine
Droperidol
Enalapril
Epinephrine
Over 1-2 min*
MAX 1mL/min
MAX 1mL/min
Diluent
Dilute each 500 mg in 5 mL
SWI
Undiluted
Undiluted in ventricular
fibrillation
Undiluted
Undiluted
Undiluted
Over 1 min*
Undiluted
3 ml/min
MAX 5 mg/min
≥ 5 min
25 mg over 1 min
1.25 mg over 1-2 min
Over 5-10 min*
0.1 mg/min
Bolus over 1-2 min, then
continuos infusion
Over 2 min*
Over 15-30 seconds*
MAX 20 mg/min
Test dose:
1,000 units/min
After test dose:
5,000 units/min
5 mg/1-5 min
500 mg/min
Over 2-3 min*
Test dose over 30 sec
MAX 50 mg/min
2-10 mcg/min
20 mg over 2 min
25-50 mg/min
MAX 2 mg/min
200 mg/kg over 3-5 min
Over 4-5 min*
Undiluted†
Undiluted
Undiluted or with NS (4 fold)
Undiluted
Undiluted
Undiluted
1:10,000 solution: Undiluted
Eptifibatide
Famotidine
Flumazenil
Furosemide
Heparin
Hydralazine
Hydrocortisone
Hydromorphone
Iron Dextran
Isoproterenol
Labetalol
Lidocaine
Lorazepam
Mannitol
Meperidine
Methylprednisolone
succinate
500 mg over 2-3 min
Undiluted
20 mg diluted with 5-10 mL NS
Undiluted
Undiluted
Undiluted
Undiluted
Dilute to 50 mg/mL
Undiluted†
Undiluted (test dose only)
Dilute with 10 mL NS
Undiluted
Undiluted
Dilute with equal volume of NS
Undiluted†
Dilute to 10 mg/mL
Reconstitute as directed: 40-125
mg/mL
146
Metoclopramide
2 min
Metoprolol
5 mg over 1-2 min
Midazolam
Over 2 min*
Morphine
Naloxone
Phenobarbital
Over 4-5 min*
0.4 mg over 15 sec
2 mcg/kg (bolus) over 60
seconds, followed by
continuos infusion
MAX 60 mg/min
Phentolamine
5 mg/min
Phenytoin
MAX 50 mg/min
Procainamide
20-50 mg/min
Prochlorperazine
MAX 5 mg/min
Promethazine
Each 25 mg over 1 min
MAX 25 mg/min
Propranolol
Sodium Bicarbonate
Verapamil
1 mg/min
1 mEq/kg over 1-3 min
5 mg over 2 min
Nesiritide
Undiluted (for doses 10 mg or
less)
Undiluted
Dilute 1 and 5 mg/mL with NS
Max Concentration 0.5 mg/mL
Undiluted
Undiluted in an emergency
Draw loading dose (6 mcg/mL)
from continuos infusion bag
Use a minimum of 3 mL of SWI
Dissolve 5 mg with 1 mL of
SWI
Undiluted
Dilute each 100 mg with 5-10
mL of D5W
Undiluted
Avoid IV route if possible (use
IM or oral). Inject IV into freely
flowing IV infusion set. If
patient complains of pain,
immediately stop injecting.
Undiluted†
Undiluted†
Undiluted through Y-tube
*Assume all doses are safe over time period when not specified.
†
Dilution not specified as required; assume undiluted.
D5W=dextrose 5% in water; SWI=sterile water for injection; NS=0.9% sodium chloride (normal saline)
147
Recommended Initial Vancomycin Dosing
Weight
(kg)
50
55
60
65
70
75
80
85
90
95
100
105
>110
30
40
50
500q24h 500q24h 500q12h
500q24h 500q24h 500q12h
500q24h 500q24h 500q12h
1000q24h 1000q24h 1000q24h
1000q24h 1000q24h 1000q24h
1000q24h 1000q24h 1000q24h
1000q24h 1000q24h 1000q24h
1000q24h 1000q24h 1000q24h
1000q24h 1000q24h 1000q12h
1000q24h 1000q24h 1000q12h
1000q24h 1000q24h 1000q12h
1000q24h 1000q24h 1000q12h
1000q24h 1000q24h 1000q12h
60
CrCl (mL/min)
70
500q12h
500q12h
500q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
500q12h
500q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
80
90
100
>110
500q12h
500q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
500q12h
500q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q12h
1000q8h
500q8h
500q8h
500q8h
1000q12h
500q8h
500q8h
500q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
1000q8h
**Dose is in mg
**Vancomycin Troughs should be drawn with the 3rd dose
Pharmacotherapy 1999;19(3):257-266
148
Enoxaparin (Lovenox) Indications and Dosages
INDICATION
Prevention of DVT:
(a) hip replacement
(b) knee replacement
(c) abdominal surgery
(d) high risk medical patients
Prevention of ischemic
complications of unstable angina
and non-Q-wave MI
Acute ST elevation MI in patients
receiving thrombolytics
< 75 years old
Acute ST elevation MI in patients
receiving thrombolytics
> 75 years old
Treatment of DVT:
(a) inpatient +/- PE
(b) outpatient no PE
DOSE
(subcutaneous injection)
RENAL DYSFUNCTION DOSE
(CrCl < 30 ml/min)
(a) 30 mg q 12 h, starting 12-24 h post-op or
40 mg q day, starting 12 h pre-op. Extended
prophylaxis with 40 mg once daily is
recommended for 3 weeks
(b) 30 mg q 12 h, starting 12 -24 h post-op
for up to 14 days
(c) 40 mg q day, starting 2 h pre-op until
ambulatory; for up to 12 days
(d) 40 mg daily until ambulatory
1 mg/kg q 12 h (with aspirin) for at least 2
days and until clinically stable
(a) 30 mg once daily
30 mg IV bolus, 1 mg/kg q 12 h (with
aspirin)
30 mg IV bolus,
1 mg/kg once daily
0.75 mg/kg q 12 h (with aspirin)
No bolus
1 mg/kg once daily
No bolus
(a) 1 mg/kg q 12 h, or 1.5 mg/kg once daily
for a minimum of 5 days and until warfarin
is in therapeutic range 2 days
(b) 1 mg/kg q 12 h as in (a) above
1 mg/kg once daily

(b) 30 mg once daily
(c) 30 mg once daily
(d) 30 mg once daily
1 mg/kg once daily
1 mg/kg once daily
Other (non-formulary) Low molecular weight heparins include: Dalteparin (Fragmin ) and Tinzaparin (Innohep).
149
CATEGORY D AND X DRUGS IN PREGNANCY
**Non-inclusive list**
Not all listed products are formulary items.
FDA CATEGORIES D AND X FOR DRUG USE IN PREGNANCY1
Category D:
There is positive evidence of fetal risk but there may be certain
situations where the benefit might outweigh the risk (lifethreatening or serious diseases where other drugs are ineffective or
carry a greater risk).
Category X:
There is definite fetal risk based on studies in animals or humans or
based on human experience and the risk clearly outweighs any
benefit in pregnant women.
1
From Federal Register 1980;44:37434-37467.
ACE Inhibitors
Benazepril (D)
Captopril (D)
Enalapril (D)
Fosinopril (D)
Lisinopril (D)
Moexipril (D)
Perindopril (D)
Quinapril (D)
Ramipril (D)
Trandolapril (D)
Angiotensin II
Receptor Antagonists
Candesartan (D)
Eprosartan (D)
Irbesartan (D)
Losartan (D)
Olmesartan (D)
Telmisartan (D)
Valsartan (D)
Antiarrhythmics
Amiodarone (D)
See Beta Blockers
Antibiotics
Amikacin (D)*
Demeclocycline (D)
Chlortetracycline (D)
Doxycycline (D)
Methacycline (D)
Minocycline (D)
Kanamycin (D)
Streptomycin (D)
Sulfonamides (D)
Tetracycline (D)
Tobramycin (D)*
Anticonvulsants
Bromides (D)
Carbamazepine (D)
Ethotoin (D)
Phenytoin (D)
Phenobarbital (D)
Primidone (D)
Trimethadione (D)
Valproic Acid (D)
Antidepressants
Imipramine (D)
Nortriptyline (D)
Anti-Infectives
Trimetrexate (D)
Quinine (X)*
Ribavarin (X)
Povidone-Iodine (D)
Antifungals
Voriconazole (D)
Antilipemic Agents
Atorvastatin (X)
Fluvastatin (X)
150
Lovastatin (X)
Pravastatin (X)
Rosuvastatin (X)
Simvastatin (X)
Antineoplastics
See specialized reference
Barbiturates
Amobarbital (D)
Butalbital (D)
Mephobarbital (D)
Pentobarbital (D)
Phenobarbital (D)
Secobarbital (D)
Benzodiazepines
Alprazolam (D)
Chlordiazepoxide (D)
Clonazepam (D)
Clorazepate (D)
Diazepam (D)
Estazolam (X)
Flurazepam (X)
Lorazepam (D)
Midazolam (D)
Quazepam (X)
Beta Blockers
Acebutolol (D)
Atenolol (D)
Betaxolol (D)
Bisoprolol (D)
Carteolol (D)
Carvedilol (D)
Celiprolol (D)
Labetalol (D)
Mepindolol (D)
Metoprolol (D)
Nadolol (D)
Oxyprenolol (D)
Penbutolol (D)
Pindolol (D)
Propranolol (D)
Sotalol (D)
Timolol (D)
Central Nervous
System Drugs
Oxazepam (D)
Temazepam (X)
Triazolam (X)
Colchicine (D)
Primidone (D)
Imipramine (D)
Phencyclidine (X)
Levorphanol (D)**
Lithium (D)
Pentazocine (D)**
Meprobamate (D)
Methaqualone (D)
Chelating Agents
Penicillamine (D)
Diuretics
(D if used in gestational
hypertension)
Amiloride (B/D)
Bendroflumethiazide
(C/D)
Bumetanide (C/D)
Chlorothiazide (C/D)
Chlorthalidone (B/D)
Ethacrynic Acid (B/D)
Furosemide (C/D)
Hydrochlorothiazide
(B/D)
Indapamide (B/D)
Methyclothiazide (B/D)
Metolazone (B/D)
Polythiazide (C/D)
Spironolactone (C/D)
Triamterene (C/D)
Gastrointestinal Agents
Sulfasalazine (D)‡
Misoprostol (X)
Paregoric (D)**
Hematological Agents
Coumarin Derivatives
(X)*
Dicumarol (D)
Warfarin (X)*
Hormones/Steroids
Betamethasone (D)
Cortisone (D)
Clomiphene (X)
Danazole (D)
Dexamethasone (D)
Estradiol (X)
Estrogens, Conjugated
(X)
Estrone (X)
Ethinyl Estradiol (X)
Ethynodiol (D)
Fluoxymesterone (X)
Hormonal Pregnancy
Test Tablets (X)
Hydrocortisone (D)
Hydroxyprogesterone
(D)
Leuprolide (X)
Medroxyprogesterone
(D)
Mestranol (X)
Methimazole (D)
Methyltestosterone (X)
151
Mifepristone (X)
Norethindrone (X)
Norgestrel (X)
Oral Contraceptives (X)
Prednisolone (D)
Prednisone (D)
Propylthiouracil (D)
Tamoxifen (D)
Testosterone (X)
Triamcinolone (D)
Immunosuppressants
Azathioprine (D)
Miscellaneous
Bosentan (X)
Chlorpropamide (D)
Cigarette Smoking (X)
Cyclazocine (D)
Diethylstilbestrol (X)
Dihydroergotamine (X)
Ergotamine (X)
Ethanol (D/X)†
Iodinated Glycerol (X)
Iodine (D)
Levallorphan (D)
Methylene Blue (D)
Nalorphine (D)
Norepinephrine (D)
Leflunomide (X)
Quinidine (X)
Reserpine (D)
Thalidomide (X)
NSAIDS/Pain
Medications
Alfentanil (D)**
Aspirin (D)
Butorphanol (D)**
Celecoxib (D)
Codeine (D)**
Diclofenac (D)
Diflunisal (D)
Dihydrocodeine (D)**
Etodolac (D)
Fenoprofen (D)
Fentanyl (D)**
Flurbiprofen (D)
Hydrocodone (D)**
Hydromorphone (D)**
Ibuprofen (D)
Indomethacin (D)
Ketoprofen (D)
Ketorolac (D)
Meclofenamate (D)
Mefenamic Acid (D)
Meloxicam (D)
Meperidine (D)**
Methadone (D)**
Morphine (D)**
Nalbuphine (D)**
Nabumetone (D)
Naproxen (D)
Oxaprozin (D)
Oxycodone (D)**
Oxymorphone (D)**
Pentazocine (D)**
Phenylbutazone (D)
Piroxicam (D)
Propoxyphene (D)
Remifentanil (D)**
Sufentanil (D)
Sulindac (D)
Tolmetin (D)
Radiopharmaceuticals
Sodium Iodide I125 (X)
Sodium Iodide I131 (X)
Serums, Toxoids, &
Vaccines
Measles (X)
Mumps (X)
Rubella (X)
Smallpox (X)
TC-83 Venezuelan
Equine Encephalitis (X)
Yellow Fever (D)
Vitamins
Acitretin (X)
Calcifediol (C/D)***
Calcitriol (C/D)***
Cholecalciferol
(C/D)***
Dihydrotachysterol
(A/D)***
Ergocalciferol (A/D)***
Etretinate (X)
Isotretinoin (X)
Menadione (C/X)***
Tretinoin (systemic) (D)
Vitamin A (A/X)***
Vitamin D (A/D)
152
Most severe rating adapted from Briggs GG, Freeman RK, Yaffe SJ. Drugs in
Pregnancy and Lactation. Baltimore, Williams & Wilkins, 2005. See Briggs for
further information.
* Manufacturer’s rating
** If used for prolonged periods or high doses at term.
*** If used in doses above the recommended daily allowance.
†If used in large amounts or prolonged periods.
‡If given near term.
153
ORAL DRUGS THAT SHOULD NOT BE
CRUSHED OR CHEWED
Generally, drugs that should not be crushed include those that are enteric coated,
extended release, or sublingual tablets.
Adalat-CC
Aggrenox
Allegra - D
Asacol
Augmentin XR
Avinza
Avodart
Azulfidine EN
Biaxin XL
Bisacodyl
Calan SR
Carbatrol
Cardene SR
Cardizem
Cardizem CD, SR, LA
Cartia XT
Ceftin
CellCept
Charcoal Plus
Chloral Hydrate
Chromagen
Cipro(taste)
Cipro XR
Claritin D
Colace
Colestid
Compazine Spansule
Covera HS
Creon 5,10,20
Crixivan
Cytovene
Cytoxan
Depakene
Depakote
Depakote ER
Deseryl (taste)
Detrol LA
Dexedrine Spansule
Diamox Sequels
Dilacor - XR
Ditropan XL
Docusate
Dolobid
Donnatal Extentab
Dulcolax
Dynabac
Dynacirc CR
E.E.S. 400 Filmtab
Ecotrin
Effexor XR
E-Mycin
Entex LA
Entocort EC
Ery-Tab
Eryc
Erythrocrin Stearate
Erythromycin Base
Eskalith CR
Evista
Feldene
Feosol
Feratab
Fergon
Flomax
Fosamax
Gleevec
Glucophage XR
Glucotrol XL
Guaifed
Humabid DM, LA
Imdur
Inderal-LA
Indocin SR
Isoptin SR
Isordil Sublingual
Isosorbide Dinitrate SL
KCL Extended Release
K-Dur
Klor-Con
K-Lyte CL
Levbid
Lexxel
Lithobid
Lodine XL
Macrobid
Mag-Tab SR
Mestinon Timespan
Micro-K
MS Contin
Mucinex
Myfortic
Naldecon
Nexium
Niaspan
Nicobid
Nicotinic Acid
Nitrostat
Norflex
Norpace CR
Oramorph SR
Ornade Spansule
Oxycontin
Pancrease
Pancrecarb MS
Paxil CR
Pentasa
Perdiem
Phazyme
Plendil
Prevacid
Prilosec
154
Procan SR
Procanbid
Procainamide
Procardia
Procardia XL
Pronestyl-SR
Proscar
Protonix
Proventil Repetabs
Prozac capsule
Quinidex Extentab
Rescon JR
Rhythmol SR
Ritalin-SR
Sinemet CR
Slo-Bid
Slo-FE
Slo-Niacin
Slow-K
Slow-Mag
Sudafed 12 hour
Sular
Tavist - D
Tegretol-XR
Temodar
Tessalon Perles
Theo-24
Theobid
Theo-Dur
Thorazine Spansule
Tiazac
Topamax
Toprol XL
Trental
Ultrase
Ultrase MT
Uniphyl
Verelan
Videx EC
Volmax
Voltaren XR
Wellbutrin SR, XL
Xanax XR
155
Common Calculations
Anion Gap
Anion gap = sodium - (chloride + HCO3)
Body Surface Area
BSA (m2) =
Ht (in) x Wt (lb)
3131
or
BSA (m2) =
Ht (cm) x Wt (kg)
3600
Corrected Calcium for Albumin Level
[(Normal albumin - patient’s albumin) x 0.8] + measured serum calcium
Corrected Sodium
Corrected Na+ = measured Na+ + [1.5 x {(glucose - 150) ÷ 100}]
**Do not correct for glucose < 150.**
Correction of Serum Phenytoin Concentration for Albumin Level
• Adjusted concentration = measured concentration ÷ [(0.25 x albumin) + 0.1]
(normal renal function)
• Adjusted concentration = measured concentration ÷ [(0.1 x albumin) + 0.1]
(CrCl <10 ml/min)
Creatinine Clearance
CrCl (male) = (140-age) x IBW (kg)
72 x serum creatinine
CrCl (female) = CrCl (male) x 0.85
Dosing Weight (For use when ABW is > 1.2 x IBW)
Dosing Weight = 0.4 x (ABW - IBW) + IBW
Ideal Body Weight
IBW (male) = 50 + (2.3 x height in inches over 5 feet)
IBW (female) = 45 + (2.3 x height in inches over 5 feet)
Theophylline/Aminophylline Conversion
Aminophylline dose x 0.8 = Theophylline dose
156
ACLS Guidelines
Synchronized Cardioversion
Tachycardia with serious signs and
symptoms related to the tachycardia
If ventricular rate is >150 BPM,
prepare for immediate cardioversion.
Premedicate whenever possible
The regimen should include
a sedative (ex. diazepam, midazolam,
barbiturates) with or without an
analgesic agent (ex. fentanyl, morphine)
Synchronized cardioversion
VT
PSVT
100 J, 200 J
Atrial fibrillation
300 J, 360 J
Atrial flutter
157
ACLS Guidelines
Bradycardia Algorithm
Bradycardia, either absolute
(<60 BPM) or relative
Serious signs or symptomsa,b
No
Yes
Type II second degree
or Third degree AV
heart blocke?
No
Observe
Yes
Intervention sequence
c,d
• Atropine 0.5-1 mg
• TCP
• Dopamine 2-10
mcg/kg/min
• Epinephrine 2-10
mcg/min
Prepare for
transvenous pacer
a. Serious signs or symptoms must be related to the slow rate.
b. Do not delay TCP while awaiting IV access or for atropine to take effect if patient
is symptomatic.
c. Denervated transplanted hearts will not respond to atropine.
d. Atropine should be given in repeat doses every 3-5 min up to a total of 0.03-0.04
mg/kg. Use the shorter dosing interval (3 min) in severe clinical conditions.
e. Never treat third degree heart block plus ventricular escape beats with lidocaine.
158
ACLS Guidelines
Asystole Treatment Algorithm
•
•
•
•
Continue CPR
Intubate
Obtain IV access
Confirm asystole in more
than one lead
Consider possible causes:
• Hypoxia
• Hyperkalemia
• Hypokalemia
• Preexisting acidosis
• Drug overdose
• Hypothermia
a. Vasopressin 40 units IV may be given to
replace the first or second dose of
epinephrine.
b. Sodium bicarbonate 1 mEq/kg if patient
has known preexisting hyperkalemia.
Consider immediate
transcutaneous pacing (TCP)
Epinephrine 1 mg IV pusha,
repeat every 3-5 min*
Atropine 1 mg IV, repeat every
3-5 min up to a total of 0.030.04 mg/kg
Consider termination of efforts
159
ACLS Guidelines
Pulseless Electrical Activity (PEA) Algorithm
• Continue CPR
• Intubate immediately
• Obtain IV access
• Assess blood flow
Consider Possible Causes
- Hypovolemia
- Hypoxia
- Cardiac tamponade
- Massive pulmonary embolism
- Tension pneumothorax
- Hypothermia
Epinephrine 1 mg IV pusha, repeat
every 3-5 min
May give Vasopressin 40 units IV
once to replace 1st or 2nd dose of
epinephrine
- Drug overdoses such as tricyclics,
digitalis, beta blockers, calcium channel
blockers
- Hyperkalemiaa
- Acidosisb
- Massive acute myocardial infarction
a. Sodium bicarbonate 1 mEq/kg is Class I
if patient has known preexisting
hyperkalemia.
b. Sodium bicarbonate 1 mEq/kg for
preexisting acidosis responsive to
bicarbonate, TCA overdose, alkalinize
the urine or long arrest interval.
If PEA rate is slow
give atropine 1 mg IV
*Repeat q 3-5 min
to a total of
0.03-0.04 mg/kg
160
ACLS Guidelines
Ventricular Fibrillation/Pulseless Ventricular
Tachycardia (VF/VT) Algorithm
Defibrillate up to 3 times if needed
(200 J, 200-300 J, 360 J)
Persistent or
recurrent VT/VF
• Continue CPR
• Secure Airway (airway device, ensure effective oxygenation)
• Establish IV access
Epinephrine 1 mg IV push, repeat every 3-5 min
Or
Vasopressin 40 units IV single dose 1 time only
to replace 1st or 2nd epinephrine dose
Defibrillate 360 J
Consider antiarrhythmics:
•Amiodarone 300mg IV push (cardiac arrest dose), repeat 150mg IV x 1
for recurring VT/VF. Max cumulative dose: 2.2gm over 24 hours.
•Lidocaine 1-1.5mg/kg IV push then 0.5-0.75 mg/kg IV, max 3 doses or 3
mg/kg
•Magnesium 1-2 gm IV in polymorphic VT (torsades de pointes) and
suspected hypomagnesemic state.
Defibrillate 360 J, 30-60s after each dose of medication
Acceptable patterns are CPR-drug-shock (repeat),
CPR-drug-shock-shock-shock (repeat).
161
CMS Quality Indicators
Patients with acute myocardial infarction
• Recommended addition of aspirin at arrival to hospital
• Recommended aspirin at patient discharge
• Recommended ACE or ARB for patients with left ventricular systolic dysfunction
• Gave smoking cessation patient counseling
• Recommended beta blocker at discharge
• Recommended addition of beta blocker on arrival to hospital
CABG patients
• Recommended aspirin at patient discharge
• Got prophylactic antibiotics stopped within 24 hours of CABG
Heart failure patients
• Recommended ACE or ARB for patients with left ventricular systolic dysfunction
• Gave smoking cessation patient counseling
Pneumonia patients
• Recommended appropriate antibiotics consistent with current recommendations for
type of pneumonia
• Got blood culture collected before start of antibiotic
• Recommended influenza and pneumococcus vaccination
• Ensured that antibiotics received within four hours of hospital admission
• Gave smoking cessation patient counseling
Hip or knee replacement
• Ensured that antibiotic prophylaxis received within one hour of surgical incision
• Suggested appropriate antibiotic prophylaxis for procedure
• Got prophylactic antibiotics stopped within 24 hours of procedure
162
NOTES
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