Medical Professional Publications

Pharmacy and Therapeutics Committee Updates

(From the July 2014 Issue of MedStat)

For more detailed information, contact Kimberly Novak at Kimberly.Novak@NationwideChildren.org.

The following actions were taken at the June 5 Pharmacy & Therapeutics Committee meeting.

The LPIP for RN Administration of Ondansetron was APPROVED. Implementation will be scheduled for a later date after EPIC Best Practice Alerts (BPAs) are reconfigured for RN alerting and after RN education is provided.

Clinic stock lists for Primary Care Red/Primary Care Yellow/Olentangy Primary Care/Sharon Woods Primary Care, Hilltop Primary Care, Primary Care with Teen Clinic: Linden Primary Care, and Primary Care with Teen Clinic: Near East Primary Care/Eastland Primary Care/Northland Primary Care/Westside Primary Care/Whitehall Primary Care were APPROVED.

The Pyxis override list for C5A1/C5A2/C5A3 was APPROVED

A Remifentanil Medication Use Evaluation waspresented reviewing use in 33 PICU and NICU patients from October 2012 through October 2013. Remifentanil is a short-acting opioid that is used most commonly in adjunct with other medications for general anesthesia, rapid sequence intubation, operating room (OR) extubation, and sedation. With a terminal half-life of ten to twenty minutes, remifentanil is an ideal opioid to use when a patient requires awakening trials during their course. The main indication of use is for sedation following a traumatic brain injury in PICU patients and for OR extubation in the NICU. Doses of remifentanil were started at a normal or low dose based on indication and were titrated appropriately. Most patients were transitioned to fentanyl infusion, as needed opioids, acetaminophen, PCA, or NCA when remifentanil was discontinued. The equivalent cost of using fentanyl in these patients would have been $13,012.67 less than the cost of remifentanil. However, as remifentanil use was generally short-term and for indications requiring awakening trials, it was recommended to maintain formulary status at this time for these indications. Additional methods to reduce waste for OR procedures will be investigated.  Remifentanil was APPROVED for maintenance on formulary

An Evaluation of Inpatient and Outpatient Posaconazole Use was presented reviewing non-formulary prescription of posaconazole oral suspension in calendar year 2013.  A total of 14 patients received 19 courses, 59% of which were initiated as outpatient therapy. The majority (84%) of patients received posaconazole for treatment of invasive fungal infection, with 89% of patients receiving previous antifungal therapy (voriconazole in 53% of courses). The majority of patients were prescribed posaconazole by the Pulmonary, Oncology, and Bone Marrow Transplant medical services.  Infectious Diseases consultation was obtained in 63% of courses. No consults were obtained for patients on the Pulmonary service, and 60% of Bone Marrow Transplant patients did not have a consult. A recommendation was made to consider addition of posaconazole to the formulary with criteria for use as supported by the formulary addition request and accompanying monograph.

Posaconazole (Noxafil®) was APPROVED for formulary addition (oral suspension as well as the newly-released delayed-release tablet and injection formulations) for treatment and prophylaxis of invasive fungal infections with prescribing limited to patients admitted to Infectious Diseases or in consultation with Infectious Diseases. The monograph will be posted on the P&T intranet website. A review of formulary drug use will be presented in six months.

A Treprostinil Medication Use Evaluation was presented reviewing inpatient non-formulary prescription of inhaled and subcutaneous treprostinil in calendar year 2013. Pulmonary arterial hypertension (PAH) is a rare, life-threatening disorder that results in progressive increase in pulmonary vascular resistance and ultimately, right ventricular failure. Prostacyclins are one class of medications that are available to manage PAH. Treprostinil is a newer prostacyclin that can be administered via inhalation and continuous subcutaneous or intravenous infusion. The dosing schedule, preparation, and administration requirements make treprostinil an attractive alternative to epoprostenol which requires a dedicated central venous line and can result in rebound PAH if therapy is interrupted due to a very short half-life. Seven patients received 9 treatment courses, and 8 of 9 courses involved a Cardiology consult. While used infrequently, treprostinil is appropriately used as a last line option for patients with severe pulmonary hypertension refractory to other therapies (most often iloprost, sildenafil, and bosentan). The dosing used in these patients was consistent with the labeling and with best available evidence. A recommendation was made to consider addition of treprostinil to the formulary with criteria for use as supported by the formulary addition request and accompanying monograph.

Treprostinil (Remodulin® and Tyvaso®) was APPROVED for formulary addition for both parenteral and inhaled formulations for use in pulmonary arterial hypertension. The following ordering instructions will be added in Epic: This medication should only be initiated in consultation with a pulmonary hypertension specialist. The monograph will be posted on the P&T intranet website. A review of formulary drug use will be presented in six months.

The 1st Quarter 2014 Non-formulary Medication Use Report was presented for informational purposes.

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