Drug Therapy Committee Highlights:
August 2003
Volume XIII, Issue 9
DTC Old Business
| Abelcet versus Ambisome
formulary conversion consideration DEFERRED PENDING FURTHER INFORMATION |
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| Discussion The Committee was presented with the Formulary consideration to convert to amphotericin lipid complex (Abelcet) from liposomal amphotericin (Ambisome). The Formulary conversion of systemic use of amphotericin lipid complex will be deferred until more data collection and analysis can be concluded. Ambisome will remain available until further notice. |
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| ARB Utilization
Revisited APPROVED |
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| Discussion The Committee was presented with a comprehensive review of all angiotensin receptor blockers (ARBs) with input provided by the Pharmacy and the Hypertension and Renal Units. The Committee recommends the following actions to the formulary:
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| Use of concentrated
sodium chloride (23.4%) to reduce intracranial pressure restricted to Neuro
ICU APPROVED WITH RESTRICTIONS |
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| Discussion The Committee approved the guidelines for the use of concentrated sodium chloride (23.4%) for the emergent reduction of intracranial pressure and has restricted its use to the neuroscience ICU or in the presence of an attending neurologist only. Please refer to the online Critical Care guidelines for further information. |
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DTC New Business
| Guidelines
for Maintaining Supplemental Emergency Equipment Kits/Totes/Travel Boxes
APPROVED |
| Discussion The Committee approved the Guidelines for Maintaining Supplemental Emergency Equipment Kits/Totes/Travel Boxes on Patient Care Units with no suggested revisions. |
| Low molecular
weight heparin (LMWH) assessment tool APPROVED |
| Discussion The Committee was presented with the Low Molecular Weight Heparin (LMWH) computer-based interactive tutorial and assessment tool. The tool is designed to educate and assess comprehension of the pharmacists relative to the Hospital's initiative to convert from unfractionated heparin to low molecular weight heparin. This tool was well received by the Committee with many accolades. The Committee recommended the tutorial be made available as a hospital-wide program for all caregivers. Refer to anticoagulation guidelines for further details. |
| PCHI Triptan
of Choice APPROVED: PCHI YELLOW |
| Discussion The Committee was presented with the PCHI triptan of choice options. The Committee agreed to add eletriptan (Relpax) to the yellow tier of the PCHI Grid. Almotriptan (Axert) and zolmitriptan (Zomig) will remain in the yellow tier. The Committee approved all other triptans to remain in the red tier of the PCHI Grid |
| Quarterly
ADR report for Apr 1-June 1, 2003 APPROVED |
| Discussion The Committee was presented with the quarterly Adverse Drug Reaction (ADR) report for Apr 1-June 1, 2003. The numbers for reporting are down from the previous quarter due to an operational flaw. A Drug Therapy newsletter article will be prepared by the ADR co-chair Colleen Collins to emphasize the importance of reporting ADRs and to increase the awareness of reporting among our colleagues. The Committee recommended reviewing other automated ADR reporting systems to enhance our current ADR reporting system. The Committee recommended incorporating an ADR reporting system within POE and LMR to encourage and support the ease of reporting ADRs . The goal is to target inpatient as well as outpatient ADR reporting by streamlining the process by which we collect the data. |
| Standard of
Practice for Antineoplastic Agents for Chemo and Non-Chemo Uses APPROVED |
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Discussion
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| Standard of
Practice for Monoclonal Agents: Muromonab-CD3, Infliximab, Rituximab, Daclizumab,
Etanercept APPROVED |
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Discussion
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| Use of Urokinase
for Acute Stroke Patients in the Neuro-Radiology Intervention Suite APPROVED WITH RESTRICTIONS |
| Discussion The Committee approved the guidelines for the use of urokinase in the Neuro-Radiology Intervention suite with no suggested revisions. This protocol is restricted to Neuro-Interventional Radiology physicians only. Refer to the protocol below for further information. |
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PROTOCOL
FOR IA THROMBOLYTICS (CHEMICAL AND/OR MECHANICAL) FOR ACUTE STROKE
USE OF UROKINASE IN THE NEURO-RADIOLOGY INTERVENTION SUITE Goal: Provide catheter guided intra-arterial thrombolysis in stroke patients who do not qualify for NINDS Protocol tPA. Patients who present to the Emergency Department within 3 hours of onset and have the following criteria met will receive tPA at a dose of 0.9 milligram/kilogram (maximum, 90 milligrams). Ten percent of the dose is administered as an intravenous bolus, followed by the remaining 90 percent given as a continuous infusion over 60 minutes IA Inclusion Criteria: 1 A major neurologic deficit attributable to an acute ischemic stroke, and thought to be due to large vessel occlusion (basilar, vertebral, internal carotid). 2 A significant neurologic deficit expected to result in major long-term disability 3 Non-contrast CT scan showing no hemorrhage or well-established infarct 4 Treatment within 6 hours of established, non-fluctuating deficits due to Anterior Circulation (carotid/MCA) stroke. The window of opportunity for treatment is less well defined in posterior circulation (Vertebral/ Basilar) ischemia, and patients may have fluctuating, reversible ischemic symptoms over many hours or even days and still be appropriate candidates for therapy.
Absolute Exclusion Criteria: 1 Mild or rapidly improving deficits 2 Hemorrhage on CT; well-established acute infarct on CT; any other CT diagnosis that contraindicates treatment (tumor, abscess, etc.) 3 Known CNS vascular malformation or tumor 4 Bacterial endocarditis 5 Life expectancy < 1 year from other causes 6 Known or suspected hypersensitivity to urokinase. 7 Other thrombolytic therapy in the last 72 hours.
Relative Contra-Indications: 1 Significant trauma within 3 months (includes CPR with chest compressions within past 10 days) 2 Stroke within 3 months 3 History of intracranial hemorrhage; or symptoms suspicious for subarachnoid hemorrhage 4 Major surgery within past 14 days 5 Minor surgery within past 10 days, including liver and kidney biopsy, thoracocentesis, lumbar puncture 6 Arterial puncture at a non-compressible site within past 14 days. 7 Pregnant (up to 10 days postpartum) or nursing woman 8 Gastrointestinal, urologic, or respiratory hemorrhage within past 21 days 9 Known bleeding diathesis (includes renal and hepatic insufficiency) 10 Peritoneal dialysis or hemodialysis 11 PTT > 40 sec; PT > 15 (INR > 1.7); platelet count < 100,000 12 Seizure at onset of stroke (This relative contra-indication is intended to prevent treatment of patients with a deficit due to postictal Todd's paralysis or with seizure due to some other CNS lesion that precludes thrombolytic therapy. If rapid diagnosis of vascular occlusion can be made, treatment may be given.) 13 Glucose < 50 or > 400 (This relative contra-indication is intended to prevent treatment of patients with focal deficits due to hypo- or hyperglycemia. If the deficit persists after correction of the serum glucose, or if rapid diagnosis of vascular occlusion can be made, treatment may be given.) Patients who present beyond 3 hours and less than 8 hours and/or have contraindications to receiving tPA will be brought to the Interventional Neuro-Radiology Suite for either mechanical clot disruption or catheter directed intra-arterial urokinase. The decision will be made at the time of catheterization by the neuro-interventionalist. Procedure: A kit of 5 vials of urokinase (UK) injection 250,000 units will be kept in the Neuro-Radiology Suite for use in this patient population only. Approved physicians are James Rabinov, Johnny Pryor, and Joshua Hirsch. Patients will receive IA UK in 250,000 unit aliquots up to a maximum of 1.25 million units. UK 250,000 units will be reconstituted with 5 mls of sterile water for injection and administered slowly over 10-15 minutes with angiograms in between. |