link-Pharmacy Newsletter 052011 - St. Mary's Hospital

Pharmacy
Newsletter
May
2011
Pantoprazole New Formulary Proton Pump Inhibitor
Catie Brackin, PharmD, Pharmacy Practice Resident
Proton pump inhibitor (PPI) use at St. Mary’s Hospital is widely distributed among the many different
PPIs available on the market. St. Mary’s does have preferred PPIs (omeprazole oral tablets,
lansoprazole oral suspension, and esomeprazole intravenous solution), however, the use of nonpreferred,
more expensive PPIs have increased, making the total cost of PPIs in 2010 just over
$94,000. A medication class review was initiated at the beginning of 2011 due to new contract
prices and the increased frequency of patients admitted and continued on the most recent PPI
introduced to the market, dexlansoprazole (Dexilant®).
Comparisons of the various PPIs have shown some small differences, primarily in bioavailability
and plasma concentrations. As these differences can be overcome by interchanging the PPI with
another of an equivalent dose, these differences are of questionable clinical importance and do
not justify the selection of one agent over another. In general, all PPIs are considered to be
equivalent at their standard doses. No evidence exists to support clinical superiority of any one
PPI over another. Considering the wide disparity in cost among the PPIs available and the knowledge
that one PPI is as effective as another, it is justifiable to narrow the formulary PPIs for oral,
liquid, and intravenous use.
Overview of Approved PPI Formulary Changes Effective May 17, 2011:
Implement therapeutic interchange for oral PPIs with pantoprazole tablets as the preferred
agent. May use lansoprazole 2 nd line if patient failed on pantoprazole or if patient was taking
prior to admission.
Continue with the compounded lansoprazole suspension as the formulary oral liquid.
Use only lansoprazole disintegrating tablets as the formulary PPI for administration through all
enteral tubes.
Change the formulary intravenous PPI to pantoprazole injection.
Remove omeprazole, esomprazole, rabeprazole, and dexlansoprazole from the formulary.
These will be obtainable for individual nonformulary requests only.
Inside this issue:
Pharmacy and
Therapeutics
Committee Actions
Formulary Access
on Intranet
2
2
Falls Prevention 2
PPMI Recommendations
3
Pharmacy Move 3
Ceftaroline for
Cellulitis
4
Drug Shortages 4
New lower contract prices and formulary changes will provide a projected annual cost savings of
nearly 33% ($30,952.06). Standard order sets will be automatically updated, and the therapeutic
substitution table below will be integrated into the electronic health record. Please contact the
pharmacist if the patient requires a nonformulary PPI.
Oral Dose Frequency Dose Frequency
Esomeprazole
Omeprazole
Rabeprazole
Dexlansoprazole
20 mg Daily 40 mg Daily
40 mg Daily 40 mg Daily
40 mg BID Pantoprazole 40 mg BID
10 mg Daily 20 mg Daily
20 mg Daily 40 mg Daily
40 mg Daily 40 mg Daily
20 mg BID 40 mg Daily
20 mg Daily 40 mg Daily
20 mg BID 40 mg BID
30 mg Daily 20 mg Daily
60 mg Daily 40 mg Daily

Pharmacy and Therapeutics Committee Actions
Kate Rotzenberg, PharmD
From the March 23rd meeting:
Formulary Status Changes
IV Acetaminophen (Ofirmev®) has
been added to formulary at St.
Mary’s Hospital. The full monograph
is available on St. Mary’s Intranet
through the Pharmacy link.
Ceftaroline (Teflaro®) has been
added to formulary at St. Mary’s Hospital,
restricted to use by Infectious
Disease. The full monograph is available
on St. Mary’s Intranet through
the Pharmacy link.
Dabigatran (Pradaxa®) has been
added to formulary at St. Mary’s Hospital
(Tier 2 Dean Health Plan). The
full monograph is available on St.
Mary’s Intranet through the Pharmacy
link. A 6 month medication use
evaluation will be conducted on prescribing
and outcomes and will be
presented at the September meeting.
Drug Class Reviews
Proton Pump Inhibitor Review—
Therapeutic interchange policy approved
for pantoprazole, in effect
May 2.
Nasal Steroid Review—A therapeutic
interchange is planned for the near
future pending input from OB and
ENT. This is a cost savings program
similar to the Qvar® substitution implemented
last year.
Policy Changes
Renal Dosing Policy updated for new
additions to formulary and clarify use
of high-dose piperacillin-tazobactam
Best Practice Alert was approved for
consideration of Hematology consult
when IV direct thrombin inhibitors
ordered
New policy approved for timing of
prophylactic enoxaparin to meet
SCIP measures and accommodate
planning invasive procedures. Order
sets to be updated.
Formulary Access on Intranet
Kate Rotzenberg, PharmD
A link to the formulary is now available on
St. Mary’s Intranet below the Pharmacy
link. This document is an Excel spreadsheet
arranged alphabetically by generic
drug name and contains 1,970 entries
based on inventory.
Included information:
Brand and generic drug name
Strength
Dosage form
To search the list, use ctrl-F (hold down
the Control key and type F) anywhere in
the document. A box will appear and the
user may search by any word contained
in the document. Less is more—type
only part of the drug name to avoid misspelling.
This will take the user to the first
entry that meets the search criteria, use
the arrow for each subsequent entry.
Non-formulary items, even if used frequently,
are not on this list.
Limitations of the current list:
Reflects what the pharmacy orders,
not necessarily what is prepared for
patient use
Does not identify drugs restricted to
specific prescribing groups
Cannot be grouped by drug class
Does not identify cost differences
Future versions of the formulary listing
may incorporate some of this information.
Fall Prevention: Helping Our Patients Walk the Line
Randi Stouffer, PharmD, MPH, BCPS, CGP
In 2002, the National Quality Forum declared
that patient death or disability
resulting from an in-hospital fall was a
"serious reportable event." In 2008,
Medicare stopped reimbursing hospitals
for the care provided to treat
the sequelae of such "never events," and
other insurers quickly followed CMS's
example. Given that a fall with injury
increases a patient's length of stay by 12
days, with over $4000 in increased costs
(Bates et al., 1995), hospitals have increased
their efforts to prevent patient
falls. At St Mary's, our patients sustain
more falls than the national average, but
are less often injured. Regardless of
injury, however, the cost per fall has been
estimated at $351 (Boswell et al., 2001).
The House-Wide Quality Improvement
committee has introduced measures to
reduce the fall rate, including interdisciplinary
fall huddles (including pharmacists)
after each patient fall on 4SW
and 5SW. While initial results indicate
that the fall huddles are creating a safer
environment, evidence is still accumulating
and the model is being fine-tuned
before house-wide roll-out.
The QI committee recognizes the demands
upon pharmacists' time, especially
during centralized hours, but the drugrelated
information and advice have been
valuable during fall huddles. It is hoped
that the advent of patient acuity scoring
will lead to a more proactive approach by
pharmacists, allowing intervention before
a fall occurs.
Page 2
Pharmacy Newsletter

Pharmacy Practice Model Initiative Recommendations: Current Status
Kate Rotzenberg, PharmD
The American Society of Health-
System Pharmacists held a Pharmacy
Practice Model Summit last November
and recently issued their recommendations.
The objectives of the Pharmacy
Practice Model Initiative are to:
1. Create a framework for a pharmacy
practice model that ensures
provision of safe, effective, efficient,
accountable, and evidencebased
care for all hospital/health
system patients;
2. Determine patient care-related services
that should be consistently
provided by departments of pharmacy
in hospitals and health systems
and increase demand for
pharmacy services by patients/caregivers,
healthcare professionals,
healthcare executives,
and payers;
3. Identify the available technologies
to support implementation of the
practice model, and identify emerging
technologies that could impact
the practice model;
4. Support the optimal utilization and
deployment of hospital and healthsystem
pharmacy resources
through development of a template
for a practice model which is operational,
practical, and measurable;
and
5. Identify specific actions pharmacy
leaders and staff should take to
implement practice model change
including determination of the necessary
staff (pharmacy leaders,
pharmacists, and technicians) skills
and competencies required to implement
this model.
St. Mary’s Pharmacy Department
meets many of the recommendations
from the summit through our current
practice model. St. Mary’s pharmacists:
are assigned to specific units
based on patient acuity and/or census.
participate in interdisciplinary patient
rounds.
review patient charts at the time of
processing medication orders and
daily for comprehensive review.
dose selected medications for renal
function and pharmacokinetic
parameters per policy.
document interventions in the
medical record.
undergo yearly competencies.
participate in telepharmacy through
after-hours review of medication
orders at outside hospitals.
As we push ourselves to exceed, some
activities to pursue in the future may
include:
Establishing a patient medication
complexity index for prioritization of
patient review;
Participation in discharge medication
reconciliation and education;
Establishing methods to track and
trend pharmacist interventions;
Establishing “tech-check-tech” distributive
pharmacy functions.
Pharmacy Moves into New Space
Kate Rotzenberg, PharmD
The Phase 1 construction is finally
complete and the pharmacy staff have
moved into their new space as of May
2. The new pharmacy is located
across from the current inpatient
pharmacy behind the Northwest elevators
on the B level.
The Pharmacy Department held an
Open House on Monday, April 25 for
interested staff, providers and volunteers.
The Phase 1 space consists
of 5,304 square feet for the distributive
pharmacy functions. The Phase
2 space, anticipated to be complete
in August 2012, will house the Pharmacy
offices, conference/break
rooms, and staff support areas and
consists of 2,521 square feet.
The Pharmacy renovation includes
the installation of the MedCarousel
® —technology that utilizes barcode
scanning when dispensing
medications to reduce errors and provide
efficient inventory.
Other features include the new clean
room, which is USP compliant
and has a separate chemotherapy
compounding room. The layout of
the Phase 1 area is more efficient for
the staff and provides an improved
work environment.
Contact information remains the
same in the new pharmacy (x6551).
Thank you to all the Pharmacy staff
who volunteered during the Open
House and the big move to make the
transition as smooth as possible.
Page 3
Pharmacy Newsletter

Pharmacy
Editor: Kate Rotzenberg, PharmD
Drug Information Pharmacist
Katherine_Rotzenberg@ssmhc.com
700 S. Park St.
Madison, WI 53715
Phone: 608-258-6551
Fax: 608-258-5626
Ceftaroline (Teflaro ® ) in Cellulitis Treatment
Geri Naymick, PharmD, Antibiotic Stewardship Pharmacist
Ceftaroline is an “advanced generation” cephalosporin recently
approved by the FDA for skin and skin structure infections . It is
similar to the first and second generation cephalosporins with
activity toward gram positive (S. pneumoniae, MSSA, macrolide-resistant
S. pyogenes, and S. agalactiae) and gram
negative organisms (H. influenzae, E. coli, K. pneumoniae, K.
oxytoca). Unlike other generation cephalosporins, ceftaroline
has activity against MRSA, making it unique to the cephalosporin
family. Its activity includes MSSA, CA-MRSA, vancomycin-intermediate
(VISA) and vancomycin-resistant (VRSA) S.
aureus. The MIC 90 for community or hospital acquired MRSA
ranges from 0.25-1 mcg/ml. It does not cover pseudomonas,
Enterococcus or ESBL producers.
Ceftaroline appears to be an attractive antibiotic for cellulitis
treatment. Besides its broad antibacterial spectrum for uncomplicated
skin infections, there is a lack of drug interactions with
a low side effect profile. However, it requires dosing every 12
hours, a hindrance if outpatient treatment is considered. As an
alternative, providing ceftaroline on an in-patient basis for initial
therapy with transition to once-daily daptomycin in the outpatient
ID Infusion Clinic would be a cost-effective measure.
Daptomycin 500 mg vial costs approximately $230 compared to
$84 for twice daily ceftaroline vials. Patient cost reflects a
greater economic difference as daptomycin is dosed by weight
and can average about $500-1,000.
Status of Drug Shortages
Kate Rotzenberg, PharmD
To gain clinical experience with ceftaroline, the Infectious Disease
department would like ceftaroline to be ordered in patients
with cellulitis with a suspicion of MRSA. Infectious Disease
department must be consulted for facilitation of discharge to the
infusion clinic. Ceftaroline is dosed 600 mg every 12 hours;
pharmacy will adjust for decreased renal function. Crossreactivity
with other beta-lactams (penicillins, cephalosporins,
carbapenems) is established.
Reference: Medical Letter Jan 2011
Page 4
Adult amino acids (Clinisol®)
shortage is resolved.
Clevidipine (Cleviprex®) became
available in mid-April on a limited
basis (50mL only) .
Diltiazem injection shortage is resolved.
Erythromycin injection is currently
on back order, none is available for
use at this time.
Hyaluronidase injection continues to
be unavailable. For medications that
extravasate, continue to use the Extravasation
Policy on the intranet and
follow all steps without hyaluronidase.
Ibuprofen lysine (Neoprofen®) is
on back order. Indomethacin injection
is being used as an alternative
for PDA closure in neonates.
Lorazepam (Ativan®) bulk vial for
injection is now available for compounding
infusions, shortage is resolved.
Norepinephrine (Levophed®) injection
shortage has been resolved.
Propofol (Diprivan®) continues to
be in nationwide shortage. Manufacturers
continue to work with the FDA,
but cannot confirm a date when the
shortage will be resolved. At this
time, the pharmacy has been able to
maintain a supply of propofol.
Vitamin A injection remains on back
order.
Please consult with your pharmacist if you
have any questions related to drug shortages.
Pharmacy Newsletter