Heparin Weight Based IV Drip Protocol

   The need for specific IV heparin weight-adjusted dosing protocols for different indications has emerged as evidence based practice. The “initial dose” of IV heparin for VTE treatment is weight-based at 80  units/kg/bolus and 18 unit/kg/hr infusion. The need for a “lower dose” in cardiac indications is endorsed by the ACC/AHA and the 2008 Chest guide-lines.

 

ACCP CHEST Guidelines 2008:

NSTEMI ACS: Heparin bolus: 60-70 units/kg (max.5,000) followed by infusion of 12-15 units/kg/hr (max.1,000 unit/hr).

STEMI :Heparin bolus: 60 units/kg (max.4,000) and infusion of 12 units/kg/hr (max 1,000 unit/hr).

 

Work is underway on a new Heparin IV Order Set with the following two treatment options:

1)  60 units/kg bolus and 12 units/kg/hour 

     (new lower dose for cardiac indications)

2)   80 units/kg bolus and 18 units/kg/hour  

  (recommended dose for the treatment of DVT/PE)

Bolus dose preferences will need to be specified by the physician on the form.   Look for this new order set to be rolled out in March or April !

 

 

 HFA Inhalers

  

The widely used chlorofluorocarbon (CFC) propellant in inhalers reduces the ozone layer that protects the earth from the sun’s harmful rays. As part of a multi-year phase out, CFC inhalers are longer be available after Dec. 31, 2008.

HydroFluoroAlkane (HFA) is an environmentally friendly propellant that is being used as a replacement for CFC.

Considerations for HFA Inhalers

·         HFA inhalers might taste, feel, and smell different than CFC inhalers. Puffs may feel warmer and  less forceful.

·         At least once a week the actuator should be washed and air dried.

·         HFA inhalers generally need to be primed less frequently. The instructions on the inhaler should be followed.

·         The “float test” should not be used to see if the  inhaler has doses left. This method is not reliable, and may damage the inhaler.

·         All of the available HFA inhalers need to be shaken very vigorously compared to CFC inhalers.  Shake 15-20 times before use.

·         Patients should be instructed to inform their physician if they experience any problems.

 

                                                                     

                          

  

  

ADDITIONS to the FORMULARY Oct.& Dec. P&T

  

Alvimopan (Entereg®)       

    Alvimopan (Entereg®) was approved by the P&T committee for short-term use to accelerate GI recovery following partial or small bowel resection surgery with primary anastomosis. It is only approved for short-term use in hospitalized patients in hospitals enrolled in the Entereg Access Support and Education (EASE) program. Alvimopan (Entereg®) is a potent, selective opioid antagonist with more potent mu-receptor antagonism than Naloxone. The recommended dose to accelerate GI recovery is 12 mg orally administered prior to surgery followed by 12 mg twice daily  beginning the day after surgery for a  maximum of 7 days or until patient discharge. Patients should receive no more than 15 doses total.

   Alvimopan (Entereg®) is contraindicated in patients who have received therapeutic doses of opioids for more than 7 consecutive days prior to surgery.

   Alvimopan’s (Entereg®) efficacy was evaluated in 4 U.S. studies.  A standardized accelerated post- operative care pathway was implemented. The primary endpoint for all studies was time to achieve resolution of postoperative ileus. This GI2 endpoint is : toleration of solid food and first bowel movement. In all four studies, patients receiving Entereg had their discharge order written approximately 13 to 21 hours sooner compared to patients who received placebo. 

  An ongoing review of the patients who receive Entereg® will be presented back to P&T to evaluate the drug cost vs. reduced LOS.

 

Bendamustine HCL (Treanda®)

    Bendamustine HCL (Treanda®) is a bifunctional alkylating agent indicated for the treatment of patients with chronic lymphocytic leukemia (CLL).

   The most common adverse reactions, occurring in at least 15% of patients, have included Neutrogena, pyrexia, thrombocytopenia, nausea, anemia, leucopenia, & vomiting.

   The recommended dose of Bendamustine for CLL is 100 mg/m² IV over 30 minutes on days 1 and 2 of a 28-day cycle, repeated for up to 6 cycles. Bendamustine appears effective in the therapy of treatment-naive and rituximab-refractory CLL.  It also appears to be effective in the treatment of NHL and will be added to formulary for treatment of these indications.

Formulary Denials

·         Paliperidone Extended-Release tabs. (Invega®) for treatment of schizophrenia.

·         Levetiracetam (Keppra XR®) Extended-Release tablets for seizures denied. Regular Keppra will be substituted.