Fall 2014

PharmaPhacts

August & October Pharmacy and malignancies, in patients undergoing myeloablative Therapeutics Committee Update chemotherapy followed by marrow transplantation).

Vedolizumab (Entyvio®) – – Approved formulary status ADDITIONS: Voriconazole (VFend®) – Approved formulary status of with restriction to outpatient use only. This product is injectable and oral voriconazole. This product is utilized as a second-line agent for the treatment of Crohn indicated for treating Aspergillus (more active than Disease and Ulcerative Colitis in patients who fail itraconazole), most species of Candida, Fusarium spp. traditional therapies or anti-TNF therapies. Similar to and Scedosporium spp. Voriconazole is a anti-TNF agents, the product should not be used in the substrate/inhibitor of CYP 2C19, 2C9 and 3A4. setting of active infections including TB, CMV, and Monitoring of voriconazole levels is recommended sepsis. Care should be taken not to stack particularly in patients with invasive fungal infections. It immunosuppressive on to this therapy as it may increase is categorized as Pregnancy category D. the risk of PML. Live vaccines should only be used concurrently if benefit outweighs risks. Denosumab (Prolia® and Xgeva®) – Approved formulary status of Prolia® and Xgeva® with restriction DELETIONS: to outpatient use only. Denosumab is a monoclonal Iron Sucrose (Venofer®) – Ascension has released a antibody that has separate indications, dosing regimens new SBAR to reduce inpatient formulary IV iron and corresponding brand names. Prolia® is indicated for products to iron dextran (Infed®) and sodium ferric both men and women with osteoporosis at high risk for gluconate (Ferrlecit®). The committee approved fractures. Xgeva® is indicated for the prevention of removing Venofer® from inpatient formulary. skeletal-related events in patients with bone metastasis from solid tumors. Both bisphosphonates and Tetanus Toxoid – No longer manufactured. denosumab share common adverse effects (i.e. hypocalcemia, jaw necrosis). No additional safety Nicotine Lozenges – Other nicotine dosage forms concerns were identified with denosumab other than the available (ex: gum, inhalation, and patch) possible confusion between brand names and indications. THERAPEUTIC INTERCHANGES: Adalimumab (Humira®) – Add Humira® to formulary Neupogen® to Granix® – The committee approved with restriction to inpatients with GI indication. Granix therapeutic interchange with Neupogen with the Adalimumab is an anti-TNF agent that has the advantage exception of when Neupogen is ordered for IV use in of subcutaneous dosing. Abbvie has a Patient Access which case Neupogen will be dispensed as written. Program that supplies the first inpatient dose to the Approved weight range dosing: >70 kg = 480 mcg, hospital when adalimumab (Humira®) is initiated for the ≤ 70kg = 300 mcg. diagnosis of Crohn’s Disease or Ulcerative Colitis. Permanent Removal of MVI from Banana Bag – Due TBO-Filgrastim (Granix®) – This product is a to supply chain disruptions with injectable MVI and the biosimilar to filgrastim (Neupogen®). Ascension has greater priority need to have it available for TPN patients. released a position statement that these agents are The injectable MVI will not be provided with Banana therapeutically equivalent with regards to their indication Bag orders for alcoholic patients. for prevention of febrile neutropenia and safety profile. Dosing of Granix® is similar to Neupogen® (5 mcg/kg) SHORTAGES: for this indication. Weight range dosing that is currently Please refer to the CSM Drug Shortage intranet page at approved for Neupogen® can be utilized with Granix®. http://contribute.columbia- The exclusion to this interchange would be when stmarys.org/pharmacy/shortages.html for a listing of Neupogen® was ordered by the IV route for a specific shortages and resources. indication (example: febrile neutropenia in non-myeloid

OTHER MEDICATION USE INITIATIVES: LAST MONTH’S POP QUIZ Intranasal Delivery of Medications – Intranasal Management of circulatory shock (hypovolemic, midazolam and fentanyl are approved to be used in ED distributive, hemorrhagic) or other systemic oncotic for both campuses. An ED policy and procedure will be abnormalities have been long controversial and managed developed in conjunction with this initiative. with either crystalloids (i.e. NS or LR) and/or colloids (i.e. albumin). Which of the following uses for albumin Rasburicase (Elitek) Guidelines for Use – A protocol is DOES NOT HAVE evidence-based support and should being developed based on a position statement from not be used for such an indication? Ascension for the use of rasburicase for the prevention and treatment of hyperuricemia associated tumor lysis A. Traumatic brain injury syndrome (TLS). For treatment of TLS, the B. Large volume paracentesis (defined as > 5 liters) recommendation includes implementing a single dose C. Spontaneous bacterial peritonitis protocol (0.2 mg/kg) with a maximum dose of 6 mg D. Thermal Injury (after > 4 L crystalloid 18-26 hours followed by requisite uric acid monitoring (i.e. uric acid after thermal injury and burns > 30% BSA) level must be > 8 mg/dL) for a repeat dose to be ordered. Prophylaxis of TLS in high risk patients will be driven Answer: A based on disease state criteria and lab monitoring. See: http://csmintranet.columbia- THIS MONTH’S POP QUIZ stmarys.org/pharmacy/documents/Affinity- The Drug Enforcement Administration has reclassified SBARS201408RasburicaseSBAR06-19-14V1.pdf all medications containing hydrocodone to: FAQ’s: http://csmintranet.columbia- A. Schedule I stmarys.org/pharmacy/documents/Affinity- B. Schedule II SBARS201408RasburicaseFAQs07-07-14V1.pdf C. Schedule III

D. Schedule IV IVIG Inpatient Prescribing Criteria – Ascension has released an SBAR on the appropriate prescribing of IVIG for inpatients as it relates to indications, dose, patient Update From The Advisory Committee acuity and dosing weight. Privigen is the preferred IVIG for Immunization Practices for Prevnar® product because of its versatility as a 10% ready to use (PCV13) and Pneumovax® (PPSV23) liquid product. Carimune is a product that can be used if The Advisory Committee on Immunization Practices a patient does not tolerate Privigen. For patients with (ACIP) recently updated their recommendations for the anti-IgA antibodies of the IgE type, Gammagard S/D is use of Prevnar® and Pneumovax® in adults. ACIP now the preferred agent. The committee agreed to the recommends all adults with certain immuno- appropriate indications as outlined by the SBAR as well compromised conditions or patients 65 years of age or as deferring therapy to the outpatient setting in scenarios older receive a dose of Prevnar coordinated with a dose where the IVIG is elective or routine (not urgent or Pneumovax. Prevnar and Pneumovax SHOULD NOT emergent). Likewise, the criteria and formulas for dosing be given at the same office visit. Only one dose of weight in the setting of obesity were approved. See: Prevnar is needed in an adult lifetime. The CDC has http://csmintranet.columbia- published an excellent guidance document and FAQ’s on stmarys.org/pharmacy/documents/Affinity- typical patient vaccination scenarios on when to SBARS201408-IVIGSBAR07-28-14V1.pdf vaccinate and with what vaccine. See: Inpatient Algorithm: http://www.cdc.gov/vaccines/vpd-vac/pneumo/vac- http://csmintranet.columbia- PCV13-adults.htm#recommendations stmarys.org/pharmacy/documents/IVIG- AlgorithmforInpatientIVIG.pdf CSM Pharmacy Mission Statement FAQ’s: The purpose of Columbia St Mary’s Pharmacy Services is to http://csmintranet.columbia- optimize medication therapy and patient outcomes. stmarys.org/pharmacy/documents/Affinity- PharmaPhacts Editor: SBARS201408-IVIGFAQs.pdf John Canepa, R.Ph. CSM Ozaukee Pharmacy Clinical Coordinator Management of Clostridium Difficile Infection (CDI) Phone: 262-243-8381 or by Vocera 243-6707 Ascension has published a position statement around the E-mail: [email protected] management of CDI. As of 9/16/14, a new powerplan Yun Johnson, PharmD, PhD, R.Ph (CDIFF Infection (CDI) subphase) based off of this CSM Milwaukee Pharmacy Clinical Coordinator position statement has been available. Please utilize this Phone: 414-291-1070 or by Vocera 291-1995 powerplan when CDI is strongly suspected or confirmed. E-mail: [email protected]