Substitute 2000 ml of Colytely and 4 bisacodyl 5 mg delayed release tablets for prescriptions written for Halflytely.  2000 ml of Colytely has the same active ingredients as 2000 ml of Halflytely.  Mix 4 liters of water with Colytely and then dispense 2 liters to patient.  Throw out remainder.

Oral administration: Swallow all four bisacodyl delayed release tablets with water (do not chew or crush).  Wait for a bowel movement (or a maximum of 6 hours) then drink 1 glass (8 oz) of the solution every 10 minutes.  Drink all the solution.  

Anticoagulation in Neuraxial Blockade

• The following medications must receive approval of the anesthesiologist prior to administration in patients with epidural catheters:
  • Low molecular weight heparins, including, [Lovenox (enoxaparin), Fragmin (Dalteparin)]
  • Factor Xa inhibitors: Arixtra (fondaparinux)
  • Direct thrombin Inhibitors: Angiomax (bivalirudin), argatroban, Refludan (lepirudin)
  • 2b/3a platelet inhibitors: Integrilin (eptifibatide), ReoPro (abciximab), Aggrastat (tirofiban)
  • Full dose or continuous infusion heparin (not low dose heparin, 5000 units SC q12h)
  • Platelet inhibitors: Ticlid (Ticlopidine), Plavix (Clopidogrel)
  • IV Thrombolytics (not catheter clearance protocols), Activase (alteplase), TNK (tenecteplase), streptokinase
• Pharmacy will enter the pharmacy computer system that will print on the MAR for all patients with epidural catheters: Do not administer the following medications without approval of anesthesia to patients with epidural catheters: Lovenox (enoxaparin), Fragmin (dalteparin), Arixtra (fondaparinux), Angiomax (bivalirudin), argatroban, Refludan (lepirudin), Integrilin (eptifibatide), ReoPro (abciximab), Aggrastat (tirofiban), therapeutic dose heparin, Ticlid (ticlopidine), Plavix (clopidogrel), Activase (alteplase), TNK (tenecteplase), streptokinase or other anticoagulants unless approved by the anesthesiologist on call. Minidose subcutaneous heparin (5000 units Q12 hours), Celebrex, and NSAID may be administered.  The SMS note is EPID. 

Specific Recommendations from The American Society of Regional Anesthesia and Pain Medicine Consensus Conference on Neuraxial Anesthesia and Anticoagulation include:

• Preoperative Warfarin
  • Chronic warfarin therapy should be stopped 4-5 days prior to neuraxial anesthesia.
    • Normal range INR values are associated with normal hemostasis when discontinuing chronic warfarin therapy.
  • INR should be measured prior to initiation of neuraxial block
• Postoperative Warfarin
  • The analgesic solution used for neuraxial block should be tailored to minimize the degree of sensory and motor block.
  • INRs < 1.5 are associated with normal hemostasis on initial of warfarin
    • INR should be < 1.5 when the epidural catheter is pulled
  • Warfarin should be withheld or reduced in patients with indwelling neuraxial catheters when the INR is > 3.
• Preoperative LMWH
  • Needle placement should be no sooner than
    • 24 hours after therapeutic doses of Lovenox (DVT/PE treatment)
    • 10-12 hours after prophylaxis with single daily dose of LMWH
• Postoperative LMWH
  • Lovenox should be given no sooner than 2 hours after catheter removal and should be delayed 24 hours postoperatively if blood is present during needle or catheter placement.
  • LMWH (twice daily dosing prophylaxis regimens,)
    • Initiated postoperatively should start no earlier than 24 hours postoperatively
    • If continuous technique used, remove catheter at least 2 hours before 1^st dose of LMWH
  • LMWH (Single daily dosing prophylaxis regimens)
    • First dose 6-8 hours postoperatively
    • Second dose of LWMH should be given no sooner than 24 hours after the first dose.
    • Catheter should be removed a minimum of 10-12 hours after the last dose of LMWH
    • Lovenox should be given no sooner than 2 hours after catheter removal and should be delayed 24 hours postoperatively if blood is present during needle or catheter placement.
• Antiplatelet Medications
  • Plavix (Clopidogrel) should be discontinued 7 days prior to neuraxial blockage.
  • Ticlid (Ticlopidine) should be discontinued 10-14 days prior neuraxial blockage.
• 2b/3a Inhibitors:
  • 2b/3a inhibitors (Integrilin, Aggrastat) should be discontinued 8 hours prior to neuraxial blockage
  • Reopro (abciximab) should be discontinued 24-48 hours prior to neuraxial blockage.
• Heparin
  • Heparin intravenous
    • Start heparin > 1 hour after neuraxial technique
    • Remove catheter 2-4 hours after heparin infusion stopped, assess coagulation status prior to neuraxial catheter removal
  • Combining neuraxial techniques with intraoperative anticoagulation with heparin during vascular surgery seems acceptable with the following cautions:
    • Avoid this technique in patients with other coagulopathies
    • Heparin administration should be delayed for 1 hour after needle placement
    • Indwelling neuraxial catheters should be removed 2-4 hours after the last heparin dose and the patients coagulation status is evaluated and re-heparinization should occur 1 hour after catheter removal
    • Monitor the patient postoperatively to provide early detection of motor block and consider use of minimal concentration of local anesthetics to enhance the early detection of a spinal hematoma
  • Cardiopulmonary bypass
    • Full dose heparin should be discontinued 2-4 hours prior to neuraxial catheter remove.
    • Neuraxial blocks should be avoided in patients with known coagulopathy from any cause
    • Surgery should be delayed 24 hours in the event of a traumatic tap
    • Time from instrumentation to systemic heparinization should exceed 60 minutes
    • Epidural catheters should be removed when normal coagulation is restored
  • Subcutaneously Heparin
    • Low dose heparin 5000 units subcutaneously q12 hours may be used. If therapy last longer than 4 days, platelets should be monitored prior to neuraxial block and catheter removal.
• Systemic Thrombolytics
  • Patients receiving fibrinolytic and thrombolytic drugs should be cautioned against receiving spinal or epidural anesthetics except in highly unusual circumstances. Data are not available to clearly outline the length of time neuraxial puncture should be avoided after discontinuation of these drugs.

Heparin Induced Trombocytopenia

Agatroban HIT Protocol, P&T Review:

• The dosing and monitoring protocol on the physician preprinted order form will be used when argatroban is ordered for treatment of heparin-induced thrombocytopenia (HIT)
• The preprinted physician order form will be used for all orders.
• Pharmacy will send the infusion rates charts and the rate change dosing chart when dispensing argatroban, see links below.

Argatroban Non Cath Lab 250 mg / 250 ml (normal liver function),

Argatroban Non Cath Lab 250 mg / 500 ml for Patients With Liver Dysfunction

Rate Change Based on aPTT Dosing Chart for Nursing

Hepatic Disease Score Calculator

Argatroban Monitoring Algorithm if Concurrent Warfarin administered

Articles and other info

Advances in Anticoagulation, A Clinical Update for the Pharmacist Workbook

Heparin-induced thrombocytopenia in intensive care patients

            Famotidine, the P&T preferred H₂ antagonist, will be automatically substituted for ranitidine, cimetidine, nizatidine, other H₂ when ordered by the IV or oral route unless the physician has checked the dispense as written block or the patient is allergic to famotidine.

Dosage Conversion:

Cimetidine                                                         Famotidine

            300 mg q6-8H                                       20 mg q12H

            300 mg q12-24H                                    20 mg q24H

            400 mg QHS                                         20 mg QHS

            400 mg BID                                           10 mg BID or 20 mg QHS

            400 mg QID                                          20 mg BID

            800 mg QHS                                         40 mg QHS

            800 mg BID                                           20 mg BID

Ranitidine

            50 mg q6-8H IV                                     20 mg q12H

            50 mg q12-24H IV                                 20 mg q24H

            150 mg QD                                           20 mg QD

            150 mg BID                                           20 mg q12h

            300 mg QHS                                         40 mg QHS

Nizatidine

            150 mg QD                                           20 mg QD

            150 mg BID                                           20 mg BID

            300 mg QHS                                         40 mg QHS

·        Novolog (insulin aspart) will be auto-substituted for Humalog (Lispro) as the onset and duration are similar and Novolog is less expensive. 

·        NovoLog Mix 70/30 will be used in place of Humalog Mix 75/25 and Novolin 70/30. NovoLog Mix 70/30 improves postprandial blood sugar control compared to Novolin 70/30 and control is similar to Humalog 75/25. NovoLog Mix 70/30 is on Premier contract and is less expensive than Humalog Mix 75/25.

·        Humalog Mix 75/25 and NovoLog Mix 70/30 (rapid acting mixes) produce similar blood sugar control and may be therapeutically interchanged.

·        Pharmacy will automatically substitute the most cost-effective, rapid-acting biphasic mix.

·        This conversion is recommended during hospitalization only.

Hypertensive Emergencies in Acute Ischemic Stroke: Pathophysiology and Management 12/06