·        Pantoprazole (Protonix), injection and oral, is the proton pump inhibitor of choice, with automatic substitution for omeprazole (Prilosecâ), rabeprazole (Aciphexâ),  Lansoprazole (Prevacidâ), and other oral proton pump inhibitors unless the physician has checked the dispense as written block.

Lanoprazole Solutabs, 15 mg or 30 mg, may be mixed with water and placed down a very small bore pediatric feeding tube. The granules do not clump or adhere to the tube. 

Pantoprazole IV Criteria for use

·        Criteria for use of IV Proton Pump Inhibitors (PPIs) are list below.  If a patient does not meet criteria the pharmacist will call the physician and/or leave a chart note recommending conversion to oral therapy.

• Initial treatment of patients with active upper GI tract bleeding, until they can tolerate oral therapy, usually after three days of therapy.
• Initial treatment of patients with Zollinger-Ellison syndrome, until they can tolerate oral therapy
• Stress-ulcer prophylaxis for critical care patients
• Patients who require PPI therapy who can not tolerate oral or NG PPI therapy

·        Patients on IV proton pump inhibitors will have an order entered for the oral route allowing the nurse to use the oral route when the patient is tolerating oral therapy. Proton pump inhibitors may be given by the oral route if the patient does not have active gastrointestinal bleeding, malabsorption syndrome, short bowel syndrome, severe diarrhea, uncontrolled nausea and vomiting, continuous nasogastric suctioning, and is not at risk for aspiration. 

·        Depot Lupron is recommended for outpatient use, as its action is time dependent and is indicated for treatment of chronic conditions that may be treated on an outpatient basis.  Depot Lupron provides serum levels that plateau within two days after dosing and remain relatively stable for 4-5 weeks.  Injection of Depot Lupron initially stimulates pituitary gonadotropins followed by prolonged suppression.  Repeated dosing at monthly intervals results in decreased secretion of gonadal steroids; consequently, tissues and functions that depend on gonadal steroids for their maintenance become quiescent. The biological effect is strictly time-dependent and not concentration-dependent.

·        Pharmacy will not routinely stock Depot Lupron.

·        Pharmacy will order and provide Lupron Depot 7.5 mg for patients who are hospitalized and who are not anticipated to be discharged within the next 5 days.  Pharmacists will determine if the patient is nearing discharge before dispensing Lupron.

·        Lupron will only be dispensed for FDA approved indications.  Pharmacists will verify the indication before dispensing Lupron.

Levalbuterol is non-formulary. Albuterol has been previously approved for automatic substitution at an equivalent dose for levalbuterol (two times levalbuterol dose at the same frequency).

·        All patients receiving levalbuterol (those who have orders stating dispense as written) will be converted to an equivalent dose of albuterol after 48 hours of therapy, unless they are allergic to albuterol, receiving levalbuterol at home, or have acute atrial fibrillation. Objective parameters will be monitored by respiratory therapy (heart rate, tremors, nervousness, and blood gases if ordered) from start of levalbuterol to 48 hours after albuterol is started. If a clinically significant decline is not seen, albuterol will be continued. DUE Montoring form

·      Data will be collected on all patients, during levalbuterol administration and after conversion to albuterol. This information will be presented to the committee for their review. (see accompanying monitoring tool).

·        Currently Levalbuterol accounts for 19% of doses, but 87% of $125,628 in total cost
 

•         Levetiracetam injection is formulary restricted to the following patients:

•    Patients unable to take oral levetiracetam

•         Oral bioavailability is 100% and is unaffected by food or enteral nutritional products

•         Equivalent IV and oral doses result in equivalent Cmax, Cmin, and total systemic exposure

•         levetiracetam injection cost approximately 13 times more than the oral tablets

•        Status epilepticus after benzodiazepines (lorazepam) and fosphenytoin have failed

•         No randomized control trials have been completed for this indication. Only case reports are available.

•        Levetiracetam oral tablets cost $2.27 per 500 mg versus $29.15 per 500 mg injection ($58.30 for 1000 mg, and $175 for 3000 mg injection). Fosphenytoin injection cost $120.76 per 1000 mg

•         Pharmacist will contact ordering physicians to convert to oral therapy when the patient is able to take oral medications or has a functional feeding tube.

Linezolid is restricted for treatment of documented serious vancomycin resistant Enterococcus faecium infections when no other alternative is available.

Doxycycline and nitrofurantoin are recommended for susceptible VRE lower urinary tract infections.

Linezolid is not recommended for treatment of other documented infections unless the patient is allergic/intolerant to all other antibiotics demonstrating activity against the pathogen.

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

Loratadine (Claritinâ) and Claritin D 12 hour (5 mg with 120 of pseudoephedrine) are the P&T recommended formulary non-sedating antihistamines with automatic substitution for desloratadine (Clarinexâ) fexofenadine (Allegraâ 30, 60, 180 mg), Allegra Dâ (60 mg fexofenadine with 120 mg pseudoephedrine), Allegra D 24 Hourâ (180 mg fexofenadine and 240 mg pseudoephedrine), cetirizine (Zyrtecâ), and Semprex D (8 mg acrivastine with 60 mg pseudoephedrine). They will be stocked in the following dosage forms: Claritin 10 mg, Clartin D 12 hour, and as the syrup 1 mg/ml for pediatric patients.

 P&T/MEC APPROVED 11/2000, updated 3/21/07

*Note Claritin dosage in renal impairment, clcr < 30 ml/min, or hepatic failure: 2-5 years old 5 mg every other day, 6 years and older 10 mg every other day.