June 2013 Medication Utilization Evaluations …

1 June 2013. Medication Utilization Evaluations Special Interest 1. Pain management in total joint procedures: Pain management in post- Articles orthopedic surgery patients is shared by anesthesiology and orthopedic surgery. The MUE found that of patients had duplicate Medication Medication Use orders, particularly for opioids, and had Medication orders that were Evaluations not adjusted for renal dysfunction. Recommendations included implementation of a CPOE alert for oxycodone ER products prescribed for Approved Indications patients 70 years old that requires an MD override, a dose checking alert for PPI Use to pharmacy for hydromorphone based on renal dysfunction, and addition of a nursing communication regarding pain management in patients with a Update: Hetastarch 6%.

2 Tunneled nerve catheter. Shortage plans, order 2. Utilization of fentanyl transdermal patches: In a follow-up to a 2009 MUE sets, and policy on fentanyl transdermal patches, appropriate prescribing of fentanyl updates patches and Utilization of the checklist by pharmacists was reviewed. The MUE found that prescribing was appropriate for 55% of the orders system- Upcoming P&T Agenda wide, and the checklist was completed on only 23% of orders. Items Recommendations included further pharmacist education on use of the checklist and development of an electronic checklist for prescribers to complete at the time of order entry.

3 The P&T committee agreed and endorsed expediting development of the electronic checklist. 3. Utilization of tolvaptan/conivaptan: Use of tolvaptan and conivaptan at the adult hospitals in the Methodist LeBonheur Healthcare system between October 30, 2012 and April 16, 2013 was reviewed. The MUE found that 0. patients at University and North and 1 patient at Germantown met FDA- approved indications and current prescribing restrictions for use of a vaptan. Recommendations from the results were to remove cirrhosis as an Contributing Writer: indication for tolvaptan use, based on a recent change in the drug's Jane Revollo, labeling.

4 Editors: 4. Utilization of ceftaroline: Ceftaroline is a new antibiotic approved for use in Tifany Derheimer, acute bacterial skin and skin structure infections (SSIs) and Kerry Cleveland, , community acquired pneumonia. The MUE found that ceftaroline is often Chair of P&T Committee being used empirically for SSIs. Recommendations included removing References: prescribing MD restrictions, restricting use to patients that meet one of the LexiComp, following criteria: culture positive for MRSA, history of resistance to MRSA, clinical or microbiologic failure of other agents as deemed by MD, continuation of outpatient therapy, patient allergies and/or intolerance to other agents.

5 The new restrictions will be implemented upon information technology's build of the restrictions in CPOE. All P&T decisions and actions described herein have been approved by the Medical Executive Committee Approved Indications for Proton Pump Inhibitor Use Based on the findings from a 2011 MUE, which found that 64% of patients receiving a proton pump inhibitor (PPI) did not have an indication for use, leading to $155,000 in excess annual system-wide drug costs, a CPOE alert was previously approved by the P&T and Medical Executive committees.

6 Based on a combination of national guidelines and MLH physician feedback, the approved indications for PPI use will include: Admitted to ICU and mechanically ventilated Coagulopathy (platelets <50,000 or INR > without warfarin). Continuation of home Medication CNS injury GERD/PUD or GI bleed Long-term use of NSAID/ASA, anticoagulant/antiplatelet, or high-dose steroids Sepsis Vasopressor/inotropic therapy Other (MD to enter the indication in the order comments). During Medication ordering, the physician will have to select an indication to complete order entry.

7 Update: Hetastarch 6% in NaCl Upon further review, Hetastarch 6% will remain on the adult formulary at Methodist LeBonheur Healthcare. However, it will be restricted to use only for surgical procedures in Jehovah's Witness patients. Pharmacy will continue to stock Hetastarch 6%. Shortage plans, order sets, and policy updates I. Dextrose 50% shortage Dextrose 50% in water Luer-lock syringes are still on national shortage. An action plan was approved by the P&T committee. The Drug Shortage Team will continue to monitor and, if necessary, will implement the plan and provide education to the affected staff members.

8 Pharmacy will continue to compound and dispense doses of D50, as needed. II. The following policies were reviewed and approved: Controlled Drugs Inventory and Administration, Secondary Container Labeling for Medications Prepared Outside of Pharmacy, Assessment, Re-assessment, and Plan of Care Policy (Home Infusion). The updated policies have been posted on MOLLI under Clinical and Systems Policies. III. The following ordersets were reviewed and approved: TIA Observation Plan, Diabetes without Ketoacidosis Observation Plan, Dehydration Observation Plan, UTI without Sepsis Observation Plan, Hypotension-Unknown Etiology Observation Plan, Known Seizure Disorder Observation Plan, Discharge Plan, Hyperkalemia Observation Plan Upcoming P&T Agenda Items: Asthma Product Review, Bupivacaine Liposomal (Exparel), Bosentan dispensing guidelines and revised restrictions, Medication Use Evaluations (MUEs).

9 2013-2014 MUE list, Parenteral Fentanyl Utilization Review, Dexmedetomidine Use evaluation Next P&T Meeting: August 1, 2013.