Drug Information Resources: An Overview

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Drug Information ResourcesAn Overview

• Rob Barcelona, PharmD, BCPS
• Clinical Pharmacy Specialist, CICU

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Objectives

• Utilize drug information sources available at
  University Hospitals Case Medical Center
• Describe UHCare functionality as it relates to
  Pharmacy Services
• List dosing and monitoring of specific patient
  populations and medications

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Pharmacy Clinical Resources

• Clinical on Call Pager 30558
• Rotates among all clinical specialists
• CICU Rob Barcelona 30274
• SICU Wes Bush 30393
• Infectious Diseases Ron Cowan 31960
• NSU Jason Makii 37884
• MICU Andreea Popa 31503
• Transplant Raelene Trudeau 38643

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Tertiary Resources

• Condense, digest, and summarize information from
  primary and other resources
• Provide rapid access to information
• Limitations
• Currency of the resource (i.e., how long ago was
  that information published?)
• Accuracy of information
• Incompleteness (e.g., over the counter
  medications not contained)
• Examples include MICROMEDEX, textbooks,
  UpToDate, review articles, and encyclopedias

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UH Case Medical Center Specific Resources

• Anticoagulation Therapy and Anticoagulation
  Reversal
• Adult IV Medication Guidelines
• Antimicrobial Usage
• Restricted Medications
• Drug Specific Guidelines (e.g., antibiotic locks,
  IVIG, etc.)

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Where can resources be found?
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Lexi - Comp Online

• gt 4,000 monographs of medications and nearly 30
  fields with each drug monograph
• Both text and on-line in UpToDate
• Information includes
• Dosing
• Pharmacology
• Pharmacokinetics
• Pregnancy/lactation considerations
• Adverse reactions
• Drug interactions
• Nutrition/herb interactions

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MICROMEDEX

• Available from UH Pharmacy website
  http//intranet.uhhs.com/pharmnet/
• Facts on drugs, teratogenicity, toxicology, and
  alternative medicine
• On-line version of the Physicians Desk Reference
• Very comprehensive and contains the following
• Dosing
• Pharmacology
• Pharmacokinetics
• Drug interactions, cautions
• Clinical applications
• References
• Limitations difficulty in finding information
  and frequency of updates

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UHCMC Adult IV Guidelines
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The Internet

• Many resources available using the Internet
• Should be utilized only if other databases or
  references fail to provide any valid information
• Limitations include lack of quality control and
  imprecise searching that may lead to many
  undesired hits
• Information found may not come from a verifiable
  source and potentially could be inaccurate,
  possibly leading to patient harm
• If UHCMC has guidelines, protocols, or ordersets,
  use those developed by UHCMC staff

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Conclusion

• Variety of resources are available
• Familiarize yourself with the on-line resources,
  databases, and textbook references in finding
  drug information
• If all else fails, ask your pharmacist

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More on Resources and EMR stuff

• Andreea Popa PharmD, BCPS
• MICU Clinical Pharmacy Specialist

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MICU and other resources
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Why does the pharmacist call you???

• Invalid order/need further clarification
• Renal Dosing
• Drug interactions
• Restricted drug

• Bad Orders
• Non-formulary drug
• Drug on short supply
• Duplicate orders

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What happens after you place an order?

• Pharmacist actively looks for the orders on the
  different units (2-3 units per pharmacist 60
  -100 pts)
• Looks at all medication orders for that patient,
  diagnosis and pertinent labs

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User Schedule Ordering
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Verification Screen
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Order verification

• If no questions order is verified and a label
  prints ? technician prepares drug ? pharmacist
  checks drug again ? drug leaves for delivery to
  respective nursing units
• Controlled substances, emergency meds ? OMNICELL
• If need something urgent call area pharmacist

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EMR issues..

• Standard administration times
• QD 900
• BID 0900 2100 ? 12 hours off drug
• TID 0900 1400 2100 ? 12 hours off drug
• QID 0900 1300 1700 2100 ? 12 hours off
  drug
• Q 24, Q 12, Q 8, Q 6 Timing of these is
  dependent on ordering/nursing administration
  subsequent doses are automatically scheduled
  based on the first dose

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Routine, now, stat and time critical.
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Routine, now, stat and time critical.

• Amlodipine 5 mg daily
• Routine if passed 9 am, first dose schedule for
  RN to give next day at 9 am
• (99 of ALL medication orders defaulted to
  routine)
• Now one dose will be sent now and than next day
  at 9 am
• STAT generates a red flag for the pharmacist ?
  urgent order ? first dose now then next day at 9
  am (regardless what time now, could be 9 PM)
• TIME CRITICAL you select the time for the 1st
  dose and the subsequent doses will be
  automatically scheduled q 24 hours from the time
  of first dose (if ordered Q24H)

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Routine, now, stat and time critical.

• Cipro 400 mg IVPB q 24 hours
• Routine scheduling of first dose related to
  ordering time
• Now and Stat create a yellow/red flag for
  verification
• TIME CRITICAL you select the time for the 1st
  dose and the subsequent doses will be
  automatically scheduled q 24 hours from the time
  of first dose!

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Ordering IV Heparin Loading dose, infusion,
repeat bolus

• Pearls
• Most of lab work is pre-checked
• If running continuous infusion, ALWAYS order the
  repeat boluses
• Open Dosing Never order the open dosing unless
  Heme/Onc or
• Vascular Medicine involved

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Electrolyte Ordering
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Units, units.

• MMF grams vs. milligrams

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Premixed antibiotics, customizing the dose

• So, how do I order
• 1,000 mg
• 500 mg or
• 2,000 mg of vancomycin ????

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Restricted Ordersets and REMS

• Pulmonary Hypertension
• Hemodialysis/CVVH
• Chemotherapy
• Dofetilide (Tikosyn)
• Non-formulary drugs

• REMS (Risk Evaluation and Mitigation Strategy)
• gt 200 REMS Drugs
• gt 30 Drugs have Elements to Assure Safe Use
• gt 20 REMS Drugs require informed consent

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Other Ordersets

• Admission Ordersets
• Most patients do not need an IV PPI
• Pneumonia Orderset
• Antibiotics default to routine
• Antibiotic selections in alphabetical order vs.
  preferred
• Tylenol OD

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Generic Questions

• When calling pharmacy for drug info questions
• Ask to talk to a pharmacist
• Tell them who you are/contact info
• Give them patient name and location
• Give them synopsis of case and relevant clinical
  information to get most appropriate answer (what
  you are treating,other drugs, renal function,
  etc.)

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Drug Dosing in Special Populations

• Renal Failure
• Intermittent vs Continuous Hemodialysis vs
  Ultrafiltration
• Obese/Low weight
• Geriatrics

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Estimating Renal Function

• Cockcroft and Gault equation
• CrCl (140 - age) x IBW / (Scr x 72)   
•   (x 0.85 for females)
• IDMS-traceable MDRD Study Equation Conventional
  unitsGFR (mL/min/1.73 m2) 175 x (Scr)-1.154 x
  (Age)-0.203 x (0.742 if female) x (1.212 if
  African American)

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Drug Levels
Drug Timing Notes
Vancomycin Trough 30 minutes prior to 4th dose Individualized dosing for patients with renal dysfunction
Immunosuppressants Trough levels within 1 hour of dose (0600, 1800) Contact Transplant Service for guidance
Phenytoin Trough concentration Within 2-3 days of initiation Within 1 hour of load to determine maintenance or need to reload NO need for daily levels Order free levels in patients with renal failure and/or low albumin
Aminoglycosides Traditional trough with 3rd dose and peak 30 minutes after end of infusion Extended trough with 2nd dose Depends on traditional vs. extended dosing
Digoxin Trough concentration Must be drawn at least 6 hours post-dose
Heparin assay, Lovenox 4 hours post-3rd dose Use in extremes of body weight, pregnancy, renal dysfunction
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Questions?????