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Drug Therapy Committee Highlights: March 2003
Volume XIII, Issue 4

Formulary Requests:

Telmisartan (Micardis):  Deferred Pending Further Information

The Committee was presented with the request to add telmisartan to Formulary.  Telmisartan is an angiotensin receptor blocker (ARB) with a 24-hour half-life and less than 1% renal excretion.  The benefit of the drug being almost completely excreted by the feces and whether this offers any advantage to ARBs currently on the formulary remains to be determined.  A discussion arose in regard to the other ARBs currently on formulary, their utilization and other commercially available products.  Currently, candesartan, irbesartan, losartan, olmesartan, and valsartan are on Formulary.  A review of all commercially-available ARBs and additional information regarding telmisartan's mode of elimination and whether this agent provides significant benefit over other ARBs will be prepared and presented at a meeting in the next several months.

Ketogenic Diet Considerations: Calci-Mix (Calcium Carbonate), Multivitamin (Centrum MDI SF):  Approved for Formulary Addition

The Committee was presented with the request to add the Calci-mix and Centrum MDI (SF) products to Formulary.  Both products are currently used for the pediatric ketogenic diet.  The Committee has agreed to the addition of both Calci-mix and Centrum MDI to the Formulary for use in pediatrics only.

Repaglinide (Prandin):  Approved for Formulary Addition

The Committee was presented with the request to add repaglinide to Formulary.  Repaglinide belongs to a new chemical class called meglitinides, which stimulate insulin secretion from the beta cells in the pancreas.  It has a fast onset and short duration of action, which allows dosing at mealtimes.  Repaglinide is a reasonable alternative for patients who are allergic to sulfonamides; it also has minimal renal excretion.  The Committee approved the addition of repaglinide to the Formulary.

Sildenafil (Viagra):  Approved with the following restrictions:  For Pulmonary Hypertension written by pulmonary attending only

The Committee was presented with the request to add sildenafil to Formulary.  Sildenafil is a phosphodiesterase inhibitor which causes preferential pulmonary vasodilation and improves gas exchange in patients with pulmonary arterial hypertension.  Sildenafil may be used alone or in combination with epoprostenol therapy.  The use of sildenafil as an initial agent in the management of pulmonary hypertension has limited success and may delay patients going on to parenteral therapy.  The Committee has approved the addition of sildenafil to Formulary with the following restrictions:

-For use in pulmonary arterial hypertension by attending physicians only.

Zonisamide (Zonegran): Approved

The Committee was presented with the request to add zonisamide to Formulary.  Zonisamide is a sulfonamide chemically unrelated to other antiepileptic drugs which is FDA-approved for adjunctive use in adults with partial seizures.  Zonisamide offers an alternative as adjuvant therapy for refractory patients.  Zonisamide has also had good success in ketogenic diet patients.  The Committee approved the addition of zonisamide to the Formulary.

Fentanyl Practice Change:  Approved

The Committee was presented with the current intravenous fentanyl use guidelines.  Members of the Critical Care Committee were concerned that the current critical care guidelines state "a patient must be ventilated except when induction doses for intubation are being given.  Fentanyl must be administered in the presence of a physician trained in airway management”, which limits the use of IV fentanyl to ICUs only.  Fentanyl has limited use as an analgesic.  However, when patients are being maintained on epidural or intravenous fentanyl for analgesia, they need not occupy an ICU bed.  Continued use of fentanyl in patients from other institutions being admitted to MGH on PCA or on continuous infusions of the drug will be considered on a case-by-case basis.  The Committee suggested adding a caution statement to the guidelines as well as the following revisions:

Remove:

-"Patient must be ventilated except when induction doses for intubation are being given. Fentanyl must be administered in the presence of a physician trained in airway management.

-"Each ICU director must obtain, in writing, approval from the medical quality assurance board for the use of this drug.”

                             

PCHI Grid 2003: Approved            

The Committee was presented with the updated PCHI Grid 2003. Of note, changes made under the oral contraceptives were made to reflect the current brand and generic alternatives available.  The grid is also available on-line under the Drug Formulary Look Up Tool and is updated once a year.  The Committee agreed upon the changes and has no suggested revisions.

http://oi.mgh.harvard.edu/pcoi/frontpage_frames.asp

             

ED Use of Abciximab (ReoPro ) and Guidelines for Management of STEMI Patients:  Not Approved

The Committee was presented with a request for the use of abciximab (ReoPro) in the Emergency Department as part of management of patients with ST segment elevated myocardial infarction.  The use of abciximab in the ED for STEMI patients was discussed with members of the Emergency Department, who noted that there is collaboration between the ED staff and the Interventional Cardiology Staff.  The concern is that when a patient is admitted through the ED with a STEMI and cardiology wants to use abciximab, the ED does not stock this.  The current literature does not support the use of abciximab over eptifibatide (Integrilin) in this patient population and ED does not want to have abciximab stocked in the ED.  The Committee recommends the use of eptifibatide for patients in the ED.  Abciximab is restricted to use by cath lab attending physicians.

Revised "New Drug Formulary Request Form": Approved

The Drug Therapy Committee has implemented a new form to be completed for Formulary addition requests.  The form is available on the PCOI page under “useful forms”.   Individuals requesting any new drugs be added to the Formulary should complete this form and forward to Margaret Clapp, MS, RPh, Director of Pharmacy at Massachusetts General Hospital.