Discussion
The Committee was presented with the updated version of "Initiation of
GP IIb/IIIa Inhibitors on the General Medical Units". The policy describes
the indications and recommendations for the use of glycoprotein IIB-IIIA inhibitors
in the management of Acute Coronary Syndrome. The Committee approved the guidelines
with the following suggested revisions:
The Committee approved the guidelines with the above recommendations and recommends that a Provider Order Entry template be created within POE to assist with ordering and proper administration.
Discussion
The Committee was informed that the prefilled syringes are indefinitely backordered
from the manufacturer. The Nursing Practice Manual states that nurses are able
to make 1mg/ml intravenous morphine solutions using the 100mg/4ml or 250mg/10ml
prefilled syringes only. Due to the unavailability of the prefilled syringes,
pharmacists will prepare all narcotic mixes for patients on general care units.
Nurses working in intensive care units or those certified to make IV's are allowed
to make intravenous solutions on general care units. Currently, morphine injection
in a concentration of 15mg /ml in a 20 (300mg vial) ml vial is stocked on most
units. This will be replaced with a 10mg/ml 10 ml vials in order to simplify
calculations.
The Committee is in agreement with the above procedural changes.
Discussion
The Committee was presented with a request to add intravenous lansoprazole to
the Formulary. An open-label, single-center, two-period study was conducted
to evaluate the pharmacodynamics of 30 mg of intravenous lansoprazole and 30
mg of oral lansoprazole in 29 healthy subjects. The primary pharmacodynamic
endpoints were pentagastrin-stimulated, maximum acid and basal acid output.
Subjects received oral lansoprazole for 7 days and were then switched to intravenous
lansoprazole for 7 days. Maximal acid and basal acid output were measured at
baseline and 21 hours following the last oral and intravenous dose of lansoprazole.
This study demonstrated that these therapies were equivalent. Based on these
results and the cost of therapy, oral proton pump inhibitor therapy should be
used unless absolutely contraindicated. The use of the intravenous formulation
will require approval of the GI Unit. The Pharmacy will provide a lansoprazole
daily usage report to the GI Unit for review and further assessment.
The Committee approved intravenous lansoprazole with the following restrictions:
treatment of documented erosive esophagitis, endoscopically-proven gastrointestinal
bleeding, or documented Zollinger-Ellison Syndrome where esomeprazole cannot
be administered nasogastrically or enterally and if intravenous ranitidine is
contraindicated or has been documented to be inadequate to control gastric pH.
Discussion
The Committee was presented with a request to add nesiritide (Natrecor) to the
Formulary. Nesiritide is a recombinant human B-type natriuretic peptide, which
is a cardiac hormone that regulates cardiovascular homeostasis and fluid volume
during states of volume and pressure overload. Nesiritide reduces pulmonary
capillary wedge pressure and improves dyspnea in patients with acute decompensated
congestive heart failure. Nesiritide can cause symptomatic hypotension comparable
to nitroglycerin. The duration of symptomatic hypotension with nesiritide is
longer (2.2 hours versus 0.7 hour) when compared to nitroglycerin. Until more
studies are available, use of nesiritide should be limited to those patients
who are refractory to standard therapy. A monograph for use by the nursing staff
will be provided. The Pharmacy will develop a "criteria for use" evaluation
tool for ongoing review of the use of nesiritide.
The Committee approved nesiritide with the following restrictions: Restricted
to heart failure patients going to transplant only who are refractory to standard
therapy. A member of the Heart Failure group must approve the use of the nesiritide.
Discussion
The Committee was presented the past year's inpatient utilization of pegfilgrastim
(Neulasta). A Drug Use Review revealed that the drug is being administered within
7 days of discharge 75% of the time. The pharmacoeconomic breakeven point when
compared to the daily dosing of filgrastim is 8.5 days, given that pegfilgrastim
is administered once per chemotherapy cycle. The Oncology/Hematology Group has
endorsed restricting pegfilgrastim to outpatient use only. The pharmacy has
estimated a $200,000 savings by this intervention.
The Committee has approved the following restriction to pegfilgrastim - restricted to outpatient use only.
Discussion
The Committee was presented with a request from the Pharmacy that submissions
for new drugs or policies pertaining to drugs have representative Provider Order
Entry (POE) screenshots submitted with the request and approved by the Drug
Therapy Committee before implementing within the POE system.
The Committee is in agreement with this process. This will hopefully streamline the process and reduce turnaround time.
The Committee approved this request.
Discussion
The Committee was presented with the 2004 Adult Code Cart Medication Reference
Guidelines. The guidelines review all the medications on the code cart and incorporate
ACLS Guidelines, Drug Information Handbook, and clinical practice. They will
be kept on all adult code carts as a reference.
The Committee approved the guidelines.
Discussion
The Committee was presented the minutes of the June meeting. A concern was raised
regarding the discussion of the hematopoetic growth factors. The minutes reflected
limiting access via POE to erythropoetin. A recommendation was proposed that
an erythropoetin COE template for myelodysplastic syndrome (MDS) be developed.
Given the technological limitation of this type of intervention, a recommendation
for an alternative approach was made. A pop-up screen to direct clinicians to
use darbepoetin will be investigated, as there is a significant financial incentive
for the hospital. Phase One of the Partners ordering process of hematopoetic
products collects appropriate laboratory data to support the use of these products.
Recommended dosing schemes and algorithms are the next phase of the project.
Further work needs to be done to ensure a system of checks and balances to determine
if clinicians are compliant with the guidelines and to assess the feasibility
of appropriate inpatient and outpatient dosing.
The Committee is in agreement, and more discussion is to follow.
Discussion
The Committee was presented with information discussed at the Semi Annual Infectious
Disease Subcommittee meeting of June 9, 2004. The recommendations are:
Representatives from Emergency Services expressed concern during the discussion
regarding the approval process through the Emergency Department for first-time
doses of certain restricted antibiotics. The Committee recommended that Emergency
Service and the ID Department discuss this outside of the meeting and make recommendation
at an upcoming meeting.
The Committee approved the recommendations.
Discussion
The Committee was presented with the 2004 Mass General Hospital for Children
Neonatal (<1 month) Dosing Guidelines. The card has undergone several revisions
and was vetted through several pediatric subspecialties. The card will be made
available to all pediatric staff.
The Committee approved the 2004 Card.