Our quarterly newsletter is a great way to stay up-to-date on emerging clinical information, medication safety issues, and Larkin s Hospital medication policies and procedures. Hot Topics: Transitions of Care Importance of Transitions of care The Joint Commission developed the National Patient Safety standards for hospitals discussing the safely use of medications and the importance of effective communication among providers as a priority. An area that has the potential for medication errors is when patients move from one health care provider or setting to another. Medication errors increase mortality rates, length of hospital stays, and readmission. The Center for Medicare and Medicaid Services (CMS) enacted strategies to reduce readmissions and limit unnecessary cost. CMS will not fully reimburse for a related diagnosis, such as myocardial infarction, chronic heart failure, or pneumonia, if readmission occurs within 30 day of a discharge from the same or another hospital. By reducing readmission rates, hospitals have a significant impact on improving patient care. One approach for reducing readmission rates is to improve the transitions of care from hospitals to other healthcare settings. Transition of care includes different type of services and settings designed to promote the safe and transfer of patients between levels of health care and other care settings. It plays an important role in elderly patients with multiple chronic conditions and complex therapeutic regimens. Elderly patients receive care from many providers and move more often within health care settings. Therefore, poor communication among healthcare providers, incomplete transfer of information, and inadequate education to patients may improve the providing quality of care of our patents. An effective transfer requires well-timed, accurate, and sufficient communication of between healthcare providers, so the next healthcare provider assumes responsibility for patient care. Transition can improve outcomes and patient satisfaction, decrease cost, and ensure that patients understand ways to seek help when needed. The FDA has deemed the drug shortage problem a national crisis. The following medications are drug shortages at Larkin Community Hospital: Cefepime (Maxipime) Shortage: 1gm and 2gm Option: Ensure appropriate use and consider alternatives when possible Editor: Marlene Calix Director: Ana Bendeck, RPh Clinical pharmacist: Teresita Martin, PharmD Luis Marquez, RPh Indhira Acosta, PharmD Estela Trimino, PharmD, BCPS Pharmacy resident: Marlene Calix Page 1 of 5
Clinical Corner Summary of the Clinical Practical Guidelines for Anticoagulation (AC) Conversion among parenteral anticoagulation From/To Enoxaparin Fondaparinux Stop heparin and start LMWH at the time the next dose of heparin would be given Stop heparin and start at the time the next dose of heparin would be given within 2 hours after discontinuation of heparin Enoxaparin (Lovenox) Initiate heparin when next enoxaparin dose is Initiate parenteral AC when next enoxaparin dose is when next enoxaparin dose is Fondaparinux (Arixtra) Stop fondaparinux and give the first the dose of heparin at the same time the next dose of fondaparinux would have been given Stop fondaparinux and give first dose of LMWH at the time the next dose of fondaparinux would have been given when next fondaparinux dose is No hepatic failure: Start heparin within 2 Hepatic insufficiency: Start heparin within 2-4 Start LMWH within 2 Hepatic insufficiency: Start LMWH within 2-4 Start fondaparinux within 2 hours of stopping Hepatic insufficiency: Start fondaparinux within 2-4 hours of stopping Conversion from parenteral to oral anticoagulation for the treatment of VTE From/To Warfarin Dabigatran Apixaban or Rivaroxaban Overlap heparin with warfarin for at least 5 days and until INR is in therapeutics range for 24 hours Discontinue heparin infusion and initiate dabigatran 2 hours later Initiate Apixaban or Rivaroxaban within 2 hours after discontinuation of heparin Enoxaparin (Lovenox) Overlap therapeutic enoxaparin dose with warfarin for at least 5 days and until INR is >2.0 for 24 hours Discontinue LMWH and administer dabigatran 0-2 hours before the next administration of LMWH Initiate Apixaban or Rivaroxaban when next enoxaparin dose expected to be given Fondaparinux (Arixtra) Overlap Fondaparinux with warfarin for at least 5 days and until INR is >2.0 for 24 hours Start Fondaparinux alone and after a minimum of 5 days, stop Fondaparinux. Give first dose of dabigatran or Initiate Apixaban or rivaroxaban when next Fondaparinux dose is Page 2 of 5
Conversion among the oral anticoagulation From/To Warfarin Dabigatran Apixaban Rivaroxaban Warfarin (Coumadin) dabigatran when INR <2 when INR <2 rivaroxaban when INR <2 (Manufacture when INR <3) Dabigatran (Pradaxa) CrCl>50ml/min: start warfarin 3 and stop dabigatran 3 days later CrCl >30ml/min, wait 12 dabigatran to initiate CrCl >30ml/min, wait 12 rivaroxaban to initiate CrCl 30-50ml/min: start warfarin and stop dabigatran 2 days later CrCl 15-30ml/min: start warfarin and stop dabigatran 1 day later CrCl<30ml/min, wait 24 dabigatran to initiate CrCl<30ml/min, wait 24 rivaroxaban to initiate CrCl<15ml/min: not recommended Apixaban (Eliquis) Rivaroxaban (Xarelto) Discontinue and begin a parenteral anticoagulant and warfarin at the time the next dose of is due; discontinue the parenteral anticoagulant when INR reaches an acceptable range Discontinue rivaroxaban and initiate both a parenteral anticoagulant and warfarin at the time the next dose of rivaroxaban would have been taken Discontinue and begin taking the new non-warfarin usual time of the next schedule dose of Discontinue rivaroxaban and initiate the time that the next rivaroxaban dose would have been taken Discontinue rivaroxaban and initiate the time that the next rivaroxaban dose would have been taken Discontinue and begin taking the new non-warfarin usual time of the next schedule dose of Page 3 of 5
Pre/Post-surgery anticoagulation Anticoagulant/ Antiplatelet Before procedure Re-start of therapy Reversal agent Warfarin (Coumadin) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Enoxaparin (Lovenox) Stop warfarin therapy approximately 5 days before surgery CrCl >50ml/min Hold 1-2 days before procedure CrCl 30-50ml/min hold 2 days before surgery CrCl <30 hold for 2-5 days Hold at least 24 hours before procedure Hold at least 48 hours for elective surgery or invasive procedures with moderate - high risk high of bleeding Hold at least 24 hours for invasive procedures with low risk of bleeding Hold dose at least 24hours prior to surgery Restart after 12 to 24hours after surgery in conjunction with low dose heparin or LMWH if necessary His bleeding risk surgery: Vitamin K Praxbind Protamine sulfate Fondaparinux (Arixtra) Hold dose 6 hours before surgery Stop Fondaparinux approximately 72-96 hours Consider a shorter acting agent until the patient is tolerant to anticoagulation Protamine sulfate P&T Updates Recommendations for the substitution of Procainamide Procainamide forms part of the malignant crash cart. This medication is use as an option for irregular tachycardia caused by preexisted atrial fibrillation when electric cardioversion is ineffective or unfeasible, or atrial fibrillation returns. However, procainamide is unavailable in the hospital and for that reason other antiarrhythmic therapy should be considered as an options amiodarone, sotalol, and lidocaine. Therefore, procainamide was removed from the malignant crash cart and was replaced with amiodarone. Page 4 of 5
FDA MedWatch Safety Alerts The FDA communicates important new safety information gained through their medication reporting system, MedWatch or via MedWatch safety alerts. Clinicians are urged to report any adverse drug events through MedWatch. The following are some recent safety alerts: FDA drug safety communication: FDA warns about serious risk and death when combining opioid pain or coughs medicines with benzodiazepines; require its strongest warning The FDA is warning healthcare providers of the use of opioid pain medicines with benzodiazepines due to the cause of serious side effects, including difficult breathing and deaths. Opioids are used to treat pain and cough; as for benzodiazepines are used to treat anxiety, insomnia, and seizures. As a result, the FDA is adding a Boxed Warning, the strongest warning, to the drug labeling or prescription of opioid pain and prescription of opioid cough medicines, and benzodiazepines. The FDA recommends for healthcare providers to limit the use of opioid medicines with benzodiazepines or other CNS depressants. The use of opioids and benzo s should be limited to patients for whom alternative treatment options are not available. If these medications are prescribed concurrently then the dosage and duration of each drug should be minimize as much as possible. Testosterone and other anabolic androgenic steroids: FDA statement-risk associated with abuse and dependence The FDA made changes for all prescription testosterone products and added a new warning stating the abuse and dependence of androgenic steroids. Abuse of testosterone may lead to serious safety risks affecting the heart, brain, liver, mental health, and endocrine system. Individuals abusing high doses of testosterone have reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido, and insomnia. The new warning will alert prescribers about the abuse of testosterone produces and about the serious adverse events. The FDA recommends patients and prescriber or reporting adverse events or side effects related with the use of testosterone products. Medication Safety Fluoroquinolones are associated with disabling and possible permanent adverse effects of the tendons, muscles, nerves, and central nervous system. For that reason, the FDA recommends for fluoroquinolones reserved as the last option for patients with acute bacterial sinusitis, acute bacterial bronchitis, or uncomplicated urinary tract infection due to the risk of these major adverse events. The FDA evaluated post-marketing reports of adverse events associated with fluoroquinolones to reevaluate the relative risk and benefits in treating these infections. The FDA was able to identify 178 cases in which healthy patients had taken oral fluoroquinolones to treat these conditions and developed disabling irreversible side effects. The average duration of these effects was 14 months and up to 9 years. Three out of four cases occurred in patient s ages 30-59 years. The most common side effects that were seeing in the trials were tendinitis and tendon rupture, muscle pain or weakness, joint pain, peripheral neuropathy, and central nervous systems effects. The longest side effect that was reported in almost all cases was pain associated with the musculoskeletal adverse reaction. Therefore, fluoroquinolones should be avoided in patients who have experience serious adverse reactions. However, for serious infections the benefits outweigh the risks and it would be appropriate to maintain these antibiotics as a therapeutic option. Page 5 of 5