Found in practice. Joint Formulary. Joint Formulary. Embedded into practice. Embedded into practice. As above. As above.

Transcription

1 IPSWICH HOSPITAL ADULT THERAPEUTIC SUBSTITUTION REGISTER FOR PHARMACISTS What s New? New Substitutions Added exclusion criteria of Recommended by psychiatry to escitalopram switch Enoxaparin 40mg to 20mg if egfr<30ml/min Diprobase/E45/QV/Zerobase to Epimax Doublebase to Isomol Gliclazide M/R 30mg od to Gliclazide 80mg od Aqueous cream is switched to ZeroAQS cream Hydromol and Epaderm ointment are switched to zeroderm ointment Balneum cream switch to imuderm cream Atorvastatin 20mg od is first line with simvastatin 40mg nocte being second line Co-amoxiclav 375mg + amoxicillin 250mg substituted to co-amoxiclav 625mg deleted Fybogel mebeverine to separate components Co-amoxiclav 375 or 625 dispersible to Coamoxiclav suspension 250/62 per 5ml Carbocistiene step down dose Addition of Incruse (Umeclidinium) as an alternative option to Glycopyronnium inhaler for patients already using an Ellipta device Seretide and Symbicort switch to Relvar or Fostair inhaler Adcal D3/Calceos chewable tabs to Calci-D chewable tabs Alogliptin 12.5mg/Metformin1g combination tablet (Vipdomet) 1BD into Alogliptin25mg OD and Metformin 1g BD as separate components Comment of Only if patient has swallowing difficulties or for enteral tube use added where solid dosage form can be substituted to liquid form Formatted table to include conditions, exclusions and notes Wording changed for doxazocin notes Lactulose prn to regular substitution deleted Addition of Selegiline tablets to lyophilisate formulation Addition of Sevelamer hydrochloride to Sevelamer carbonate Rationale Found in practice Patient safety- adherence to trust thromboprophylaxis guidelines In line with formulary preparation of gliclazide In line with NICE recommendation CG181 Embedded into practice Embedded into practice As per CCG guidance for COPD patients As above As above Clarity Clarity Clarity Not appropriate to practice. Alternative options should be discussed with the prescriber Fixed dose as per BNF Latest Update (RC/ET) approved at Medicines Optimisation Committee on 16 December 2016 Originally written by Emma Travers (Clinical Pharmacy Manager) Page 1 of 8

2 Therapeutic substitutions to enable administration to patients with swallowing difficulties or those with an enteral feeding tube may be reversed by the pharmacist if the condition of the patient improves and tablets/capsules are suitable once more. Alogliptin 12.5mg/Metformin1g combination tablet (Vipdomet) 1bd Alogliptin25mg od Metformin 1g bd Aqueous cream Asasantin MR Dipyridamole 200mg SR & Aspirin 25mg BD Asasantin MR Dipyridamole 200mg SR & Aspirin 25mg BD ZeroAQS cream Clopidogrel Patients with an allergy to clopidogrel Dipyridamole syrup 100mg QDS & Aspirin 75mg OD ONLY if swallowing difficulties AND an allergy to clopidogrel See above Balneum cream Calceos /Adcal D3 chewable tablets one bd or two od Calceos /Adcal D3 chewable tablets one od Calceos /Adcal D3 tablets Adcal D3 caplets 2bd Adcal D3 caplets 2od or 1bd imuderm cream Calci-D one tablet od Calci-D half tablet od Adcal D3 dissolve at equivalent dose Only if patient has swallowing Calci-D one tablet od Calci-D half tablet od Caution- Patients on Adcal D3 2 BD are likely to be on the caplets which are half the strength of an Adcal D3 chewable tablet Carbocysteine 750mg tds Carbocysteine 750mg bd COPD patients Patient has been taking carbocysteine at the higher dose for more than 4 weeks Patient is no longer productive of sputum or no longer having problems clearing sputum Patients not admitted Page 2 of 8

3 with an exacerbation of COPD Citalopram tablets 10mg Citalopram tablets 20mg Citalopram oral drops 40mg/ml 8mg (0.2ml, 4 drops) 16mg (0.4ml, 8 drops) Only if patient has swallowing Use this bioequivalence to calculate other doses Ciprofloxacin 200mg IV BD Ciprofloxacin 500mg po BD Patient is unable to tolerate oral fluids Patient has ongoing or potential problems with GI absorption, D&V Ciprofloxacin 400mg IV BD (unless on ITU/HDU/paediatrics) Infections other than those for which Ciprofloxacin is recommended in the Antibiotic Guidelines or where notes are unclear For both these latter exclusions consult microbiologist for advice Clexane 40mg od Clexane 20mg od Only if egfr is <30ml/min. Co-amoxiclav 1.2g iv tds and metronidazole 500mg iv tds OR coamoxiclav 375mg po tds and metronidazole po 400mg tds Co-codamol 30/500 Desloratidine 5mg daily Diclofenac 50mg tds Co-amoxiclav 1.2g iv tds OR coamoxiclav 375mg po tds both as monotherapy (i.e. cross off/discontinue metronidazole). Paracetamol & codeine Loratidine 10mg daily Naproxen 500mg BD Suspicion or evidence of Clostridium difficile, protozoa infection or bacterial vaginosis. In these cases above, metronidazole should continue. Page 3 of 8

4 Digoxin 125mcg tablet Digoxin elixir 100mcg/2ml Only if patient has swallowing Use this bioequivalence to calculate other doses Diltiazem any brand Diprobase / E45/ QV/ Zerobase Diltiazem generic (prescription altered to generic diltiazem only) Epimax Dipyridamole 200mg SR BD Dipyridamole Syrup 100mg QDS Only if patient has swallowing Doublebase Isomol Doxazosin XL Doxazosin New initiation and escalation should be discussed with the prescriber initiate with doxazosin 1mg od and titrate upwards Enteric coated aspirin and prednisolone Non enteric coated (pharmacist to cross through ec of the prescription) Escitalopram 5mg Citalopram 10mg Where the patient has responded to escitalopram but not to citalopram Generalise Anxiety Disorder Obsessive Compulsive Disorder Recommended by psychiatry Intolerance to citalopram. Escitalopram equates to approximately half the dose of citalopram; use this equivalence to calculate other doses Esomeprazole 20mg daily Omeprazole 20mg daily Patients prescribed Esomeprazole 40mg daily Omeprazole 40mg daily esomeprazole in accordance with trust guidelines (see formulary) Lansoprazole 15 or 30mg daily Omeprazole 20mg daily Patients prescribed Pantoprazole 20mg daily Omeprazole 20mg daily lansoprazole FasTab for Pantoprazole 40mg daily Omeprazole 20mg daily admin via enteral Rabeprazole 10mg daily Omeprazole 20mg daily feeding tubes, or Rabeprazole 20mg daily Omeprazole 20mg daily orodispersable tabs for Page 4 of 8

5 Any PPI and Clopidogrel prescription swallowing difficulties IV pantoprazole (see below) H. Pylori eradication regime (see formulary) Previous lack of response to or intolerance of / allergy to other PPIs Lansoprazole 30mg daily Endorse the chart CAPSULES ensure this is also transferred to TTA Felodipine MR (for patients who need administration via an enteral feeding tube) Amlodipine (and endorse the prescription with administration guidance) Ferrous tablet formulations Ferrous fumarate syrup 140mg (45mg iron)/5ml For example: FeSO4 200mg (65mg iron) TDS = 195 mg iron per day switch to Ferrous Fumarate 140mg (45mg iron)/5ml 10ml (90mg iron) BD = (180mg iron per day) Calculate the total daily dose of iron received with the existing prescription and convert this to the nearest convenient volume of the fumarate syrup to provide approx the same daily dose of iron dividing the dose as appropriate. Ferrous fumarate tablets Ferrous sulphate tablets Check iron content in BNF and switch to closest equivalent dose of iron as ferrous sulphate tablets Page 5 of 8

6 Fluvastatin 20mg-80mg daily Pravastatin 10mg-40mg daily Atorvastatin 20mg od Or Simvastatin 40mg nocte (see notes) Use atorvastatin 20mg od first line If patient has had an adverse effect/allergic reaction to Atorvastatin, Simvastatin 40mg nocte should be given Transplant patients Patient taking ciclosporin, azole antifungals, macrolide antibiotics, protease inhibitors, gemfibrozil, fusidic acid/sodium fusidate HIV dyslipidaemia This guidance also supports the omitting of doses of statins on the drug chart whilst an interacting medicine is prescribed e.g. clarithromycin Note Patients taking amlodipine, diltiazem, amiodarone,ranolazine or verapamil should receive maximum dose simvastatin 20mg nocte Patients taking other fibrates (except fenofibrate and gemfibrozil) should receive max dose of 10mg daily Patients with egfr <10ml/min should only receive Simvastatin 10mg Fybogel mebeverine Gaviscon or Gaviscon advance any dose volume Ispagula husk sachets and mebeverine equivalent doses Peptac 10-20ml (children 6-12 years: 5-10ml) after meals and at bedtime. 1 Fybogel mebeverine sachet is equivalent to 1 sachet of Ispagula husk and a 135mg mebeverine tablet Gaviscon sachets remain on formulary for paediatrics Gliclazide 30mg M/R od Gliclazide 80mg od Doses higher than gliclazide M/R 30mg OD- consult with medical team for appropriate dosing regimen as divided doses of standard release gliclazide may be needed. Monitor BMs Hydromol and Epaderm ointment Indapamide SR 1.5mg daily Laxido Zeroderm ointment Indapamide 2.5mg daily Macrogol Page 6 of 8

7 Levofloxacin 500mg IV od-bd Levofloxacin 250mg IV od-bd Levofloxacin 125mg IV od-bd Levofloxacin 500mg po od-bd Levofloxacin 250mg po od-bd Levofloxacin 125mg po od-bd Patient is unable to tolerate oral fluids Patient has ongoing or potential problems with GI absorption, D&V Infections other than those for which Levofloxacin is recommended in the Antibiotic Guidelines or where notes are unclear consult micro for advice NSAID topical (ANY) for musculoskeletal conditions Ibuprofen 5% topical Omeprazole 40mg iv Pantoprazole 40mg iv Allergy/intolerance to pantoprazole Child health Peppermint water any volume 1-2 Peppermint oil capsules up to TDS Swallow whole with water. Phenytoin 100mg caps/tabs Phenytoin suspension 90mg/15ml Only if patient has swallowing Use this bioequivalence to calculate the dose Pregabalin (new initiations for neuropathic pain) Gabapentin (see supporting newsletter for doses including those in renal impairment). Gabapentin previously ineffective at maximum tolerated dose or not tolerated. Prescribed by Pain or Diabetes Consultants. Risedronate 35mg once a week Alendronate 70mg once a week Patients under the care Risedronate 5mg daily Alendronate 70mg once a week of Consultant Rheumatologists Pagets Disease Patient intolerant of alendronate Page 7 of 8

8 Selegiline 10mg od Selegiline 1.25 mg oral lyophilisate Only if patient has swallowing Doses lower than 10mg OD Sevelamer hydrochloride Sevelamer carbonate No dose conversion needed. Endorse chart with correct product Seretide 250 Evohaler 2 puffs bd Seretide accuhaler puff bd (DPI) Symbicort turbohaler 200/6 2 puffs bd (DPI) Symbicort turbohaler 400/6 1 puffs bd (DPI) Relvar ellipta 92/22 1 puff od (DPI) OR Fostair 100/6 2 puffs bd (MDI) COPD patients only Asthma patients Inhaler switch should be DPI to DPI or MDI to MDI (+/- spacer) where good inhaler technique OR the inhaler device chosen to match other inhalers also used by the patient (e.g. you may choose to switch seretide evohaler to relvar ellipta if the patient is also using an umeclidinium ellipta device) Sodium Fusidate 500mg tab Fusidic Acid 750mg liquid Only if patient has swallowing Timolol 0.5% bd Spiriva handihaler 18mcg 1 puff od or Respimat 2.5mcg 2 puffs od (tiotropium) Timolol 0.25% bd Seebri (glycopyrronium) 55mcg 1 puff od OR Incruse Ellipta (umeclidinium) 55mcg 1 puff od COPD patients only Asthma patients Usually the switch will be Handihaler (or Respimat) to Breezhaler. However if a patient is already using an Ellipta (e.g. Relvar) device then switch to Incruse Ellipta Triptans (oral, non-formulary) Sumatriptan 50mg orally Allergy to Sumatriptan Annotate chart with dosing guidance Vitamin B Co Vitamin B Co Strong Zolpidem 10mg Zopliclone 7.5mg Mental Health Trust patients excluded from therapeutic substitution. Page 8 of 8