Medications that require special handling

1. Medications that require special handling • Drugs that require IV infusion sets that don’t have PVC or DHEP plasticizer (soft Plastic) • Nitroglycerin • Nitroprusside • Paclitaxel, • Fat Emulsions • Amiodarone • Should use Glass or non PVC bags (stiff plastic)

2. IV Drugs that are light sensitive and should be covered during infusions with aluminum or amber colored sleeves (>90 UV light filter out) • Nitroprusside (VERY light sensitive) • Norepinephrine (Levophed®)(blue discoloration ) • Levofloxacin (Levaquin®) • Linezolid (Zyvox®) • Phytondione (Vitamin K) Injections • If a drug is light sensitive they will be made in brown amber vials. Reconstituted solutions should be covered. If the drug will be used immediately protect from light may not be necessary>> consult with pharmacist

3. IV Drugs with specific dilution requirements • Phenytoin Injection (Dilantin ®) • Must use NS or give undiluted slowly • Dilution with D5W can cause precipitation of crystals “salting out” • Use at least a 5 micron filter during IV infusion • Sulfametoxazole/Trimethoprim Injection(Bactrim®) • Use D5W, not NS • Infusion over 60-90 minutes • Levothyroxine Injection (Synthroid®) • Mix with NS • Administer immediately • Most IV administration sets contain in line filters of 5 microns or less to filter out precipitates during infusions

4. Medication that cause photosensitivity in Patients • It’s the responsibility of the pharmacist to advise patients using these drugs to wear protect clothing when in the day sunlight and using these drugs • This reaction does not always happen but when it does may cause a severe sun burn type reaction

5. Outdated Medication Warning • Remember that expired tetracycline products are unsafe. • Expired tetracycline products can cause Fanconi’s syndrome, a disorder of the kidney that can produce dangerous electrolyte abnormalities in patients • When in doubt, discard these medications

6. US FDA publishes the Orange Book • Orange Book publishes ratings data on drug therapeutic equivalence between drugs • Most States define an acceptable generic substitution as one where the drugs are therapeutically equivalent • For drugs to be consider therapeutically equivalent to each other, they must have a rate of AB or AA • Drugs that have B ratings are not therapeutically equivalent and substitution between them is not permitted • Pharmacists are to determine substitutability

7. FDA restricted drugs • Some drugs have strong side effects such that the FDA mandate special rules in the marketing of these drugs • Prior to 2007,FDA restricted drug program was called RiskMAP, risk mitigation action plans • After 2007 the new standards are called REMS, risk mitigation evaluation and mitigation strategies • For some drugs the REMS involves distributing PPI with each script (Oral Contraceptives, Hormone products (Estradiol), Accutane, and Inhaler products); others involve drug manufacturer to set up registries of patients, prescribers and pharmacies

8. REMS Special programs

9. Commercially Prepared dehydrated powder medications for oral use • Products: Amoxicillin, Augmentin, Clindamycin, Zithromycin, and may other antibiotics • Once mixing these antibiotics with water: a 14 day expiration is used under refrigeration • Exceptions: Augmentin (amoxicillin/clavulunate potassium) and Biaxin (clarithromycin) are both 10 days • Remember these, very common

10. Medications that should be dispensed in Original Container • Some medications should, according to package insert information, be dispensed in the original manufacturer’s container • Label will contain a disclaimer: “Pharmacist: Dispense in bulk container provided by manufacturer” • Often container will contain a silicone pellet bag in the container called a “dessicant” to absorb excessive mositure

11. Drugs that require original container dispensing • Pradaxa®capsules: (Dabigatran) • Tekturna ®: Aliskiren Tablets • Augmentin XR® Tablets: (amoxicillin/Clavulanate) • Sandimmune®, Gengraf ® Capsules and oral solution: Cyclosporine • Nitroglycerin SL tablets: all brands • Pancrelipase capsules: Creon®, Viokase ® • Most HIV meds: Truvada ®, Atripla ®, Norvir ®