Drug Information Resources: An Overview

1. Drug Information Resources:An Overview Rob Barcelona, PharmD, BCPS Clinical Pharmacy Specialist, CICU

2. 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

3. 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

4. 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

5. 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.)

6. Where can resources be found?

10. Lexi - Comp® Online™ • > 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

13. 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

18. UHCMC Adult IV Guidelines

19. 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

20. 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

21. More on Resources … and EMR stuff Andreea Popa PharmD, BCPS MICU Clinical Pharmacy Specialist

22. MICU and other resources

27. Invalid order/need further clarification Renal Dosing Drug interactions Restricted drug Bad Orders Non-formulary drug Drug on short supply Duplicate orders Why does the pharmacist call you???

28. 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

29. User Schedule Ordering

30. Verification Screen

31. 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

32. EMR issues….. • Standard administration times • QD: 9:00 • BID: 09:00; 21:00  12 hours off drug • TID: 09:00; 14:00; 21:00  12 hours off drug • QID: 09:00; 13:00; 17:00; 21:00  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

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

34. Routine, now, stat and time critical…. • Amlodipine 5 mg daily • Routine: if passed 9 am, first dose schedule for RN to givenext dayat 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)

35. 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!

36. Ordering IV Heparin: Loading dose, infusion, repeat bolus • Pearls: • Most of lab work is pre-checked • If running continuous infusion, ALWAYSorder the repeat boluses • Open Dosing: Never order the open dosing unless Heme/Onc or • Vascular Medicine involved

37. Electrolyte Ordering

38. Units, units……. • MMF grams vs. milligrams

39. Premixed antibiotics, customizing the dose • So, how do I order: • 1,000 mg • 500 mg or • 2,000 mg of vancomycin ????

40. Pulmonary Hypertension Hemodialysis/CVVH Chemotherapy Dofetilide (Tikosyn) Non-formulary drugs REMS (Risk Evaluation and Mitigation Strategy) > 200 REMS Drugs > 30 Drugs have Elements to Assure Safe Use > 20 REMS Drugs require informed consent Restricted Ordersets and REMS

42. 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

43. 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.)

44. Drug Dosing in Special Populations • Renal Failure • Intermittent vs Continuous Hemodialysis vs Ultrafiltration • Obese/Low weight • Geriatrics

45. Estimating Renal Function • Cockcroft and Gault equation: CrCl = (140 - age) x IBW / (Scr x 72)      (x 0.85 for females) • IDMS-traceable MDRD Study EquationConventional 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)

46. Drug Levels

47. Questions?????