Medical Professional Publications

Pharmacy and Therapeutics Committee Updates

(From the September 2014 Issue of MedStat)

For more detailed information, contact Kimberly Novak at

The following actions were taken at the August 7 Pharmacy & Therapeutics Committee meeting.

The LPIP: Influenza Vaccine Employee to Employee Administration was APPROVED.

The LPIP: Initiating Diagnostic Testing on Emergency Department Patients was APPROVED with edits.

Clinic medication stock lists for Pulmonary, Sports Medicine East, and Colorectal were APPROVED.

A Medication Use Evaluation of Ciprodex® for Non-otic Use waspresented reviewing topical use in 57 unique patients with 97 inpatient medication orders between December 2011 and December 2013.  During this time, 147 bottles of Ciprodex® otic suspension were dispensed for non-otic uses, correlating to $21,126.84 in acquisition costs.  The most common documented rationale for use was tracheostomy site bleeding, followed by continuation of home medication, and granulation tissue with duration of treatment ranging from 1 to 35 days (mean 7.1 days).  The majority of use was by ENT and Pulmonary Medicine.  Substitution of two separate generic products, ciprofloxacin 0.3% ophthalmic drops and dexamethasone 0.1% ophthalmic drops, for the Ciprodex® otic suspension would have resulted in cost savings of approximately $19,700 during this time period.  Recommendation: add an alternative therapy substitution pop-up alert in Epic directing prescribers to order ciprofloxacin 0.3% ophthalmic drops and dexamethasone 0.1% ophthalmic drops as an alternative to Ciprodex® otic suspension for inpatient non-otic use.  This alert would not be a hard stop alert.  The alternative therapy substitution alert was APPROVED.  An audit of this alert will be brought back for P&T Committee review at a later date.

Six-month formulary reviews were presented for the following medications: palonosetron and duloxetine.  Both were APPROVED for maintenance on formulary.

The combination HIV medication Emtricitabine and tenofovir (Truvada®) was APPROVED for formulary addition.  Single agents products are already on formulary.  The abbreviated monograph will be posted on the P&T intranet website. A review of formulary drug use will be presented in six months.

The updated policy PFC: XI-36:05 Controlled Substance: Accountability was APPROVED

The new non-formulary IV drug card: Coagulation Factor IX (recombinant), Fc Fusion Protein (Alprolix®) IV drug card was APPROVED.  It is now viewable in the online drug card database.

The updated IV drug card: Ketamine was presented but NOT approved.  It will be discussed within a working group, edited, and brought back to the P&T Committee at a later date.

Non-action items:

The 2nd Quarter 2014 Non-formulary Medication Use Report was presented for informational purposes. 

The updated LPIP: RN Administration of Epinephrine for Anaphylaxis was presented for informational purposes due to minor wording edits by the Medical Executive Committee.

Plans for implementation of the LPIP: RN Administration of Ondansetron were clarified.  Implementation is on hold pending resolution of two items: 1.) authorization by the Medical, Nursing, and Pharmacy Boards, and 2.) application of Epic alerts (BPAs, etc) for nurses entering verbal/per protocol orders.

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