Statin dosing

Pharmacy & Therapeutics Committee News May 2013

New Automatic Substitution: Ipratropium/Albuterol Inhalation

Combivent metered dose inhaler (MDI) is being changed to a propellant free spray which is not compatible with mechanical
ventilators. Less than a one week supply of the MDI inhalers (old format) exist in SJH Inventory. A recent DUE revealed only 2-10
doses of the 100 dose canister are administered before it is discontinued. The remaining doses are wasted at great expense.
Based upon this information, the following was approved by the P&T fast-track process:
For all patients nebulized albuterol/ipratropium (Duoneb) will be automatically substituted for any Combivent order. This will solve
the issue of ventilator compatibility and because each dose is an individual unit, there will be no waste. This also will save SJH a very
large sum of money while maintaining care of the patient and benefit of the drug.
If Ordered
Combivent (Ipratropium/Albuterol) Metered Dose Inhaler DuoNeb 3ml nebule (Ipratropium/Albuterol) Combivent (Ipratropium/Albuterol) Respimat DuoNeb 3ml nebule (Ipratropium/Albuterol)
Intravenous Multivitamin Injection (MVI--adult) Shortage
There is a nationwide shortage of IV Multivitamins (Adult). In an effort to avoid complete exhaustion of MVI inventory, SJH will
follow ASPEN shortage management guidelines (administration of MVI only 3x/week) while the supply remains tenuous. Effective
immediately, MVI will be added into TPNs made on M-W-F. No other days will be accommodated because this will increase waste.
This automatic reduction will remain in effect until the IV MVI supply becomes stable.

Canagliflozin (Invokana) PO is Non-formulary

Canagliflozin is FDA approved as an adjunctive therapy in patients with type 2 diabetes mellitus. In controlled clinical trials, the
adjusted mean HgbA1c difference vs placebo was -1.16% (monotherapy), -0.77% (combined with metformin) and -0.73% (combined
with insulin). Significant safety issues that may impact hospitalized patients include symptomatic hypotension, increased serum
creatinine with decreased GFR and hyperkalemia. Patients at increased risk for hypotension include the elderly, especially if taking
diuretics and/or medications that interfere with the renin-angiotensin-aldosterone systems or patients with low diastolic blood
pressure. Patients with hypovolemia are at greater risk for canagliflozin induced renal changes and hyperkalemia is more likely to
occur in patients taking an ACEI or ARB. Canagliflozin also causes UTI (5.9%), genital mycotic infections (female 11.4%; male
4.2%) and vulvovaginal pruritis (3%).
Based upon this information, the P&T Committee approved the following:
1. Non-formulary, not stocked, no patient’s own medication.
2. The pharmacist will automatically discontinue the order.
Lovenox (enoxaparin) and Renal Impairment
Enoxaparin is cleared by the kidneys. There is a linear relationship between anti-Factor Xa plasma clearance and creatinine clearance
which indicates decreased clearance of enoxaparin in patients with reduced renal function. Area under the curve increases
significantly in patients with creatinine clearance less than 30ml/min and in dialysis patients. Renally impaired patients are at greater
risk of serious bleeding when exposed to enoxaparin.
Based upon FDA information and medical literature, the P&T Committee has re-affirmed the following Hospital Policy:
Patients with a calculated creatinine clearance less than 10ml/min (Cockcroft-Gault, not eGFR), or patients on dialysis (CRRT, PD,
HD) or patients in acute renal failure should be managed with heparin, NOT enoxaparin.
Automatic Substitutions
The following miscellaneous automatic substitutions were approved to increase efficiency, decrease waste and inventory costs and
will be performed by the pharmacist.
If Ordered
Folbee; Folbee Plus; Diatx; Foltx; Nephrovite Or similar vitamins Niferex 150; Ferrex 150; Ferrex 150 Forte Ferrex 150 Forte Plus; Ferrogel; Slow Fe; Hematinic Forte or Any long acting iron supplement Docusate 50mg For more information on Pharmacy & Therapeutics Committee actions, please contact Karen Whalen, Drug Information Pharmacist 448-6519.



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