The Script WinterWinter 2019, Spring2019, 2017, Issue Issue Issue 810 10

The Script A Publication of the Department of Pharmacy, Norman Regional Health System The 2018-2019 NRHS Pharmacy Residents By Alex Ehrhart, Pharm.D., Katie Sullivan, Pharm.D., Danielle Trierweiler, Pharm.D., and In This Issue: Christopher Brown, Pharm.D., BCPS Norman Regional Health System offers a 12-month accredited Post Graduate Year 1 (PGY1) The 2018-2019 NRHS Pharmacy Residents..1 Pharmacy Residency that begins each year in July. It allows the residents to accelerate their growth beyond entry-level competencies, to refine their clinical skills in a broad range of dis- ease states, and to provide evidence-based patient-centered medication therapy. Residents Penicillin Skin Testing ...... 2 are also cross-trained in distribution activities and can be found staffing at the Porter campus on Monday through Thursday evenings. In addition to clinical rotations, staffing, and other Critical Medication Shortages...... 3 requirements; each resident undertakes a major project during their residency presenting their research at local and national pharmacy conferences throughout the year. On-line Outpatient Prescription Services. . 4

Alex Ehrhart is from Norman What’s All The Hype About Probiotics? . . . 5 and graduated from Southwest- ern Oklahoma State University Pharmacy and Therapeutics Committee College of Pharmacy in May Update ...... 5 2018. Her current pharmacy

interests include emergency Converting Between ...... 6 medicine and pediatrics. Throughout the year, Alex will be working on her major re- search project entitled “Pharmacy impact on narcotic overrides in a community hospi- tal emergency department.” After completion of her residen- Please share your thoughts, comments From left to right: Alex Ehrhart, Katie Sullivan, and Danielle Trierweiler cy, Alex plans to obtain certifi- and/or suggestions with us. cation as a board certified pharmacotherapy specialist and pursue a career as a clinical phar- macist. Do you have an idea for a story? Is there Katie Sullivan grew up in the northwest suburbs of Chicago and completed her Bachelors of information we can provide you? Science from the University of Wisconsin-Madison. She graduated with her Pharm.D. from the University of Minnesota and her areas of interest include oncology, infectious disease, and All correspondence concerning internal medicine. Her major residency research project involves reimbursement analysis for the oncology clinic and is entitled, “Pharmacist role in streamlining medication selection based The Script should be sent to: on reimbursement data.” She is currently planning on pursuing a clinical pharmacist position after residency and obtaining board certification in pharmacotherapy. Christopher Brown, Pharm.D., BCPS

Danielle Trierweiler is from colorful Erie, Colorado. She completed her Pharm.D. at The Univer- 3300 HealthPlex Pkwy sity of Wyoming School of Pharmacy where she was active in student engagement and devel- opment. Danielle’s professional interests include ambulatory care, patient education and em- Norman, OK 73072 powerment, pharmacy practice advancement, and clinical pharmacy management. Her major [email protected] project is titled "Impact of a pharmacist-driven AUC-based therapeutic drug monitoring ap- proach on outcomes in patients at increased risk for vancomycin-associated nephrotoxicity.” Upon completion of her residency, Danielle plans to pursue a career as a board certified am- bulatory care pharmacist where she hopes to improve patient care through meaningful, pa- tient-centered interaction and clinical services.

You have likely seen the residents with the unit-based clinical pharmacists on both campuses as they continue their rotations. Please continue to make our residents feel welcome!

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Penicillin Skin Testing By Jaclyn Coffey, Pharm.D.

Patients with a penicillin allergy have fewer antibiotic treatment options and are often unable to receive first line treatment options. Furthermore, alternative antibiotics tend to be more expensive, have more severe side effects, and increase the risk of bacteria developing resistance. Less than 10% of patients reporting a penicillin allergy are truly allergic and therefore penicillin skin testing can be beneficial for many patients. Hypersensitivity to penicillin wanes over time and about 80% of patients with an IgE-mediated penicillin allergy lose their sensitivity after 10 years. Penicillin skin testing is used to determine if a patient has a true IgE mediated allergy to penicillin antibiotics. An IgE mediated allergy, also known as type I hypersensitivity reaction, is an imme- diate reaction that usually includes urticaria, pruritus, erythema, flushing, and/or anaphylaxis. Patients are not test- ed if they have a history of a non-IgE mediated allergy such as Stevens Johnson Syndrome, toxic epidermal necroly- sis, hemolytic anemia, or etc. When a penicillin allergic patient is identified by pharmacy, the patient will first be interviewed to determine if they qualify for penicillin skin testing. Patients who qualify will potentially undergo a two-step skin test. The first is a scratch test using histamine (positive control), saline (negative control), diluted penicillin G, and PRE-PEN®. These antigens are placed on the patient’s skin and the skin is scratched. In order to move to the next step the histamine (positive control) must be positive and the other antigens must be negative. If the patient has been on antihista- mines the penicillin skin test can not be performed until the antihistamine is out of their system, typically 48 hours. The second part is an intradermal test using saline (negative control), diluted penicillin G, and PRE-PEN®. In order for the patient to be considered not allergic to penicillin none of the antigens can be positive. This test takes about an hour to complete and has proven to have a 97-99% negative predictive value, which means that sub- jects with a negative test result have a 97-99% probability of truly not being allergic to penicillin. Patients will be educated on their results and patients with a negative penicillin skin test have their penicillin allergy removed from the medical record and a ‘not penicillin allergic’ tag added to their allergy list.

Scratch test Intradermal Test

Penicillin skin testing can be beneficial for patients and positively impact them for the rest of their lives by allowing them to get first-line treatment, cheaper antibiotics, and antibiotics with less severe side effects. From implementa- tion in April 2018 through September we have screened 426 patients, and 46 patients received orders for the penicillin skin test. Of those, 42 patients successfully received the penicillin skill test in which 8 were positive (allergic to penicil- lin) and 34 were negative for penicillin allergy.

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Critical Medication Shortages By Donna Wilk, CPhT Medication Action Plan Abciximab Injection (Reopro) Unavailable with no release date. Currently using CONCENTRATED Aggrastat for intra-coronary use only in Cath lab Unavailable with an estimated release date of January 2019. Caffeine citrate injection was approved for use as alternative Aminophylline Injection when doing Adenosine challenges as well as for Lexiscan reversal during chemically induced stress test. Bacteriostatic Water Injection Unavailable with no estimated release date. Sterile water and Bacteriostatic Saline remain available. Bupivacaine w/Epinephrine Currently only 0.5% is available on daily allocation with an estimated release date of December 2018 to 1st quarter 2020. Injection Currently the 1gram SDVs are the only available product with an estimated release date of December 2018 to 3rd Quarter Cefazolin Injection 2019. 2gm premix bags have been unloaded from Pyxis Med Stations and are being dispensed patient specific from main pharmacy. The sole manufacturer Pfizer, has discontinued all presentations of this product. Current stock within the Health System Cefotaxime Injection expires at the end of this year. Unavailable with an estimated release date of 2nd quarter 2019. Currently restricted use to seizures only. Pharmacy is unit Injection dosing product from MDV, however due to stability it has been removed from toxemia carts and is now located in 2WCP Pyxis. Unavailable with an estimated release date of December 2018 to 1st quarter 2020. Current stock is reserved for those pa- Diphenhydramine Injection tients who cannot tolerate PO Benadryl (solution/capsule) or IM/PO Vistaril. Erythromycin Lactobionate Unavailable with an estimated release date of 4th quarter 2019. Injection Product is currently on a daily allocation with an estimated release date of December 2018 to January 2019. NRHS has Injection extra supply on hand at this time. Fluorescein Sodium Ophthal- Unavailable with an estimated release date of December 2018 to 2nd quarter 2019. Currently have Flucaine (proparacaine/ mic Strips fluorescein) Eye drops as an alternative. Hepatits B Vaccine We are out of stock of Recombivax and have converted to Engerix B. Product is expected to release sometime in 2019. Iron Dextran Injection Unavailable. Last reported release date was November 2018; no new release date provided by manufacturer at this time. MDVs are unavailable with an estimated release date of December 2018 to 3rd quarter 2019. Currently stock premixed Labetalol Injection syringes from QuVa for all Labetalol orders. Supply is starting to improve with an estimated release date of December 2018 to 1st quarter 2020. NRHS is no longer com- Lidocaine Injection pounding buffered lidocaine except for nursery/neonatal intensive care unit patients. Alternative options include: bupiva- caine, chloroprocaine, ropivacaine, and EMLA cream. Lidocaine Topical Jelly Unavailable with no release date. Morphine Injection All strengths are currently on allocation with estimated release dates of December 2018 to 1st quarter 2019. All prefilled presentations and empty PCAs are currently unavailable with no release date. The reason for this shortage is PCAs – prefilled and empty an issue with the manufacturer of the PCA device itself (ICU formerly Hospira). At this time, the health system has a good supply of Morphine, Fentanyl and Dilaudid PCAs as well as the empty PCA cartridges. Sincalide Injection Unavailable with no release date. Unavailable with an estimated release date of December 2018 to 2nd quarter 2019. Current stock at the NRHS is reserved Sodium Phosphate Injection for use in neonatal TPNs. Talc, Sterile Unavailable with no release date. (bovine) Topical Unavailable with no estimated release date. Currently stocking Recothrom as an alternative option. Solution **This table is not inclusive. If you wish to see all reported nationwide shortages please refer to https://www.ashp.org/Drug-Shortages/Current-Shortages.

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The Script Winter 2019,Spring 2017, Issue Issue 810

On-line Outpatient Prescription Services By Carly Holmes, Pharm.D. and Christopher Brown, Pharm.D., BCPS

Want to access your prescriptions online? Here’s how! 1. Under the resources tab on the intranet, select “Prescription On-Line Account”. (Refer to image on right) 2. If you already have an account, select “Log In”. (Refer to image below) 3. If you do not have an account, select “Register” on the upper right hand side of the screen. Complete the registration information. Call the phar- macy at 307-1964 during outpatient prescription hours (7 am to 6 pm Monday-Friday) and ask to have your online account activated. After hours, you can call the refill line at 307-3332 and leave a message asking to have your online account activated. Please spell your last name, give a date of birth and call back phone number. (Refer to image below)

4. You may also download the Rx2Go app for your mobile device. From the Rx2Go app you can request refills by scan- ning the barcode on your prescription vial. (Refer to image on left)

5. From the Rx2Go app “Dashboard”, you can see prescriptions ready for pickup, overdue, due soon, and prescriptions with no refills remaining. No refills? No problem! You can request refills from your physician’s office with your online account. Look under “Ready for pickup” to see exactly which medications are ready and what your copay is in advance. (Refer to image on right) 6. You can go under “Profiles” to print a list of recent medications from doctor’s office visits and other appointments. A “pocket profile” shows the medications you have filled in the past 6 months. (Refer to image on right) 7. You can even check the status of your refill request online! 8. “Will call” or “refrigerator” means your prescription is ready for pickup. “Input” means your prescription is being processed. 9. You can even update your phone number and address under the “Patient Info” section.

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What’s All The Hype About Probiotics? By Mona Kamali, Pharm.D., PGY-1 Resident Clostridium difficile-associated diarrhea (CDAD) is one of the most serious forms of antibiotic-associated diarrhea (AAD) and is a leading cause of healthcare-associated infections. Last year at NRHS, the rates of healthcare-associated Clostridium difficile infec- tion (HCA CDI) increased significantly. HCA CDI includes the total incidence of Healthcare Facility-Onset C. difficile infection (HO- CDI) and Community-Onset Healthcare Facility-Associated CDI (CO-HCFA CDI). Increasing evidence shows probiotics may reduce the incidence of AAD and CDI by up to 50 percent or more. Currently, NRHS is evaluating whether the use of probiotics, specifi- cally Bio-K plus® (pictured below) will reduce the incidence of AAD and HCA CDI as well as the associated costs. For the study, patients were divided into two groups: Group 1 (July 1 to September 30, 2017) - pre-implementation of probiotic protocol and Group 2 (January 16 to April 17, 2018) - post- implementation of probiotic protocol. An Insti- tutional Review Board approved probiotic protocol allows pharmacists to initiate Bio-K Plus® (Lactobacillus acidophilus, casei, and rhamnosus) 1 capsule [50 billion colony forming units] by mouth or per tube twice daily for eligible patients during the post-intervention period. Patients are included if they are 18 years of age or older and receiving antibiotics while admitted to an acute care unit at NRHS. Patients are excluded if they are pregnant, lactating, receiving antibiotics for surgical prophylaxis only or unable to be fed through the gastrointestinal tract. Probiotics should be administered with the first dose of antibiotics, preferably within 2 days of antibiotic initiation, and to continue for 5 days after completion of antibiotics. Clinical pharmacists monitor all eligible patients through a clinical surveillance system to ensure probiotics are ap- propriately ordered. The primary outcome for the study was the incidence of AAD and HCA CDI in hospital- ized patients receiving antibiotics and probiotics compared to those not receiving probiotics. Secondary outcomes include adverse effects, potential cost savings, and timing of initial probiotic administration. During the pre-intervention interim (July 1 to September 30, 2017), 16.2 patients per 10,000 patient days had HCA CDI (HO-CDI: n=13.8; CO-HCFA CDI: n=2.4) versus 8.9 patients per 10,000 patient days (HO-CDI: n=6.9; CO-HCFA CDI: n=2) in the post- intervention interim (January 16 to April 17, 2018). Overall, the incidence of HCA CDI and HO-CDI decreased by 45% and 50%, re- spectively. Incidence of AAD per 10,000 patient days decreased by 30.3% from the pre-intervention to the post-intervention peri- od. Based on the reduction of incidence of HCA CDI and AAD, there is a potential annual healthcare cost savings of $173,073.

Pharmacy and Therapeutics Committee Update Dosage and Drug Labeled Indication Usual Dose P&T Action Strength Prophylaxis of venous thromboembolism (VTE) in adults 160 mg on day 1, fol- Betrixaban hospitalized for an acute illness who are at risk for throm- 40 mg and 80 NOT added to lowed by 80 mg once (Bevyxxa®) boembolic complications due to moderate or severe re- mg capsules formulary daily for 35 to 42 days stricted mobility and other risk factors for VTE. Maintenance treatment of airflow obstruction in patients 100 mcg/62.5 Fluticasone/vilanterol/ with chronic obstructive pulmonary disease (COPD) and to One inhalation once mcg/25 mcg umeclidinium (Trelegy Added to formulary reduce COPD exacerbations in patients with a history of daily dry powder Ellipta®) exacerbations. inhaler Low dose: 400 mg IV bolus, then 4 mg/min IV infusion for up to 120 Reversal of anticoagulation in patients treated with apixa- Formulary decision Andexanet Alfa min ban or experiencing life-threatening or uncon- 100 mg vials postponed until (Andexxa®) High dose: 800 mg IV trolled bleeding. early 2019 bolus, then 8 mg/min IV infusion for up to 120 minutes Management of hypertension when oral therapy is not 25 mg and 50 Clevidipine (Clevipex®) 1 to 2 mg/hour IV Added to formulary feasible or not desirable. mg vials 50 mg vial Added to formulary 10 mg/mL oral Treatment of partial onset seizures in patients with epilep- with restriction to Brivaracetam (Briviact®) 50 mg IV/PO twice daily solution; 10, sy as monotherapy or adjunctive therapy. home medication 25, 50, 75, and continuation only 100 mg tablets

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Converting Between Anticoagulants By Jaclyn Coffey, Pharm.D. and Christopher Brown, Pharm.D., BCPS Today there are many direct acting oral anticoagulants (DOACs) on the market and depending on the situation, there may be a need to switch from one to another. There is potential for mistakes and a lot of confusion regarding how to switch between them as many differences exist in regard to specific recommendations. Below is a chart that details how to convert between the most popular anticoagulants used at Norman Regional Health System (NRHS). Based on the new drip order sets (#0560, 0554, and 0569), antiXa level monitoring will be needed when converting from a DOAC to heparin as factor Xa inhibitors will interfere with antiXa levels. Conversion Between Anticoagulants Chart Rivaroxaban (Xarelto®) (Eliquis®) (Savaysa®) (Pradaxa®) Low molecular Start rivaroxaban less Start apixaban at the Start edoxaban Start dabigatran < 2 hours weight heparin than 2 hours prior to usual time of the next when next dose is prior to next dose. (LMWH) - the next dose. scheduled dose. due. Start LMWH or Arixtra® 12 Lovenox® Start LMWH or Ar- Start LMWH or Ar- Start LMWH or Ar- hours (CrCl > 30 mL/min) or (enoxaparin) or ixtra® when the next ixtra® when next dose ixtra® when next 24 hours (CrCl < 30 mL/min) dose is due. is due. dose is due. after the last dose of Arixtra® dabigatran. (fondaparinux) Start rivaroxaban Start apixaban when Start edoxaban 4 Start dabigatran when Paren- Parenteral when Parenteral AC Parenteral AC CI is hours after Paren- teral AC CI is stopped. CI is stopped. stopped. teral AC CI is Start Parenteral AC CI 12 (AC) Start Parenteral AC CI Start Parenteral AC CI stopped. hours (CrCl > 30 mL/min) or continuous infusion when the next dose is when next dose is Start Parenteral AC 24 hours (CrCl < 30 mL/min) (CI) due. due. CI when next dose after the last dose of is due. dabigatran. Start rivaroxaban Start apixaban when Start edoxaban Start dabigatran when INR < when INR is < 3. INR is < 2. when INR is < 2.5. 2. Start warfarin and Start warfarin and Start warfarin and CrCl > 50: start warfarin 3 parenteral AC the parenteral AC when parenteral AC when days before discontinuing Warfarin same day rivaroxaban next dose is due or next dose is due or dabigatran. is discontinued or some recommend to decrease dose of CrCl 30 to 50: start warfarin 2 (Coumadin®) overlap rivaroxaban continue apixaban edoxaban by 50% days before d/c dabigatran. with warfarin for > 2 until INR >2. and continue until CrCl 15 to 30: start warfarin 1 days. INR >2. day before d/c dabigatran. CrCl < 15: no recommenda- tions. DOAC Start new DOAC when the next dose of previous DOAC was scheduled.

The Script A Publication of the Department of Pharmacy

Editor in Chief: Contributors: Christopher Brown, Pharm.D., BCPS Lisa Mayer, Pharm.D., BCPS Mona Kamali, Pharm.D. Jaclyn Coffey, Pharm.D. Donna Wilk, CPhT Clinical Pharmacy Specialist Clinical Pharmacy Specialist PGY1 Pharmacy Resident Clinical Pharmacy Specialist Clinical Pharmacy Technician Michael Wisner, Pharm.D. Carly Holmes, Pharm.D. Alex Ehrhart, Pharm.D. Katie Sullivan, Pharm.D. PGY1 Pharmacy Resident Pharmacy Supervisor PGY1 Pharmacy Resident PGY1 Pharmacy Resident Danielle Trierweiler, Pharm.D. Lauren May, Pharm.D., BCPS Victoria Felder, Pharm.D., BCPS PGY1 Pharmacy Resident Clinical Pharmacy Specialist Clinical Pharmacy Specialist

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