Medication Update: May 2006
Medication Update is a bi-monthly newsletter of the Pharmacy and Therapeutics Committee for physicians, pharmacists and nurses.
New Formulary Drugs
Nesiritide (Natrecor®)
Nesiritide is a recombinant human brain natriuretic peptide that is used as a vasodilator in patients with acutely decompensated heart failure.
It is a vasodilator that binds to guanylate cyclase receptor on vascular smooth muscle and endothelial cells, which leads to an increase in intracellular cyclic GMP and resulting in smooth muscle cell relaxation.
This drug has not been approved by the FDA for pediatric use.
Side effects include hypotension, increased serum creatinine, and potential arrhythmia. It is administered as a continuous infusion and is restricted to Cardiac ICU and Cardiac Surgery services.
Aldendronate (Fosamax®)
This oral bisphosphonate has been added to the formulary for treating osteoporosis.
It is taken weekly and should be administered on an empty stomach with water only and patient must sit or stand upright for 30 minutes to minimize esophagitis due to local irritant effect of the tablets.
To avoid drug interaction, calcium supplements or antacids should not be given for at least 30 minutes after aldendronate.
Tetravalent Meningococcal Conjugate vaccine (MCV4) (Menactra™)
This vaccine is for immunization of patients 11-55 years of age for the prevention of infection caused by Neisseria meningitis groups.
As compared to MPSV4 (Menomune) that has been available since the 1970s, MCV4 possibly has longer duration of immune response.
| Population | MCV4 | MPSV4 |
|---|---|---|
| General | Single dose at age 11-12y or high school entry, and all college freshman living in dormitories | Not recommended for routine vaccination |
| Groups at increased risk for meningococcal disease* | Single dose ages 11-55y | Single dose ages 2-10y Single dose ages > 55y |
* Travelers to countries with epidemic meningococcal, persons with certain medical conditions (persons >=2 years with terminal complement deficiencies or anatomic or functional asplenia) and other high risk groups (see MMWR 2005;54 [RR-7]:1-21).
Other Formulary Issues
Dexmedetomidine as an adjunct to general anesthesia
P&T committee approved the use of dexmedetomidine restricted to the use by anesthesia department for the patients who:
- cannot tolerate the respiratory and hemodynamic effects of propofol as an adjunctive agent for general anesthesia
- cannot use propofol because of contraindications (soy or egg allergies, etc)
- require neurologic monitoring
Modification of antiviral drug restrictions
All antiretroviral agents used for the treatment of HIV and all oral anti-CMV drugs, including valganciclovir, now require approval by the ID consult service. Oral ganciclovir will be removed from the formulary.
Formulary deletions
- Humulin L and Perdiem granules (discontinued by manufacturers)
- Neutra-Phos-K (due to low use product with high potential for error) – K-Phos Neutral tablets and Neutra-Phos packets remain on formulary
Clarifications of "What's New? FDA approval 2005" in March 2006 issue
This drug list comprises of new drugs approved by FDA in 2005 and by no means indicates that they are all available from our pharmacy. Drugs that are not approved by P&T committee are considered non-formulary agents and should be processed according to hospital policy.
Ketogenic Diet Guideline of Care
The ketogenic diet is becoming an increasingly popular treatment option for young patients with refractory epilepsy. It has long been observed that fasting can decrease seizure frequency in patients with seizure disorders.
The ketogenic diet was introduced over 80 years ago as a way to mimic the body's response to starvation. Consumption of a diet high in fats and low in carbohydrates and protein stimulates the production of ketone bodies, as occurs during starvation.
Studies have demonstrated the efficacy of the ketogenic diet in refractory epilepsy; however, the mechanism by which ketogenesis reduces seizures remains largely unknown.
Because the diet is calorie restrictive and typically composed of 80% fat by weight, hypoglycemia and constipation are common side effects. Initiating the ketogenic diet as an inpatient allows for close monitoring of vital signs and blood glucose.
Due to the severe carbohydrate restriction, all medications should be switched to sugar free, low carbohydrate forms, so that carbohydrate sources from foods (primarily fruits and vegetables) can be maximized.
Since the ketogenic diet is so restrictive, it is deficient in many vitamins and minerals. All patients placed on it should receive a daily multivitamin as well as calcium supplementation.
Carnitine, found in milk and red meats, has also been found deficient in patients placed on these diets. Levocarnitine is available as a supplement in tablet form (the liquid base is sucrose syrup).
Once the ketogenic state is established, even slight excesses of carbohydrates can rapidly reverse the ketogenic state and lower the seizure threshold. Therefore, most liquid medications and chewable tablets should be avoided.
Upon admission, all patients on the ketogenic diet will have 'Ketogenic diet' entered as an allergy in CIS. This will notify all practitioners and cue them to review the 'Ketogenic diet guideline of care.'
A list of medications and their carbohydrate content can be found online under Policy and Procedure ketogenic diet [link only accessible from within Children's network] and should be consulted prior to initiating any drug therapy.
Administration of Oral Ciprofloxacin and Information for Patient Teaching
What is Ciprofloxacin?
Ciprofloxacin is an antibiotic that has excellent activity against bacterial infections caused by Pseudomonas aeruginosa. It is commonly used in adults and children with cystic fibrosis and is FDA approved for use in children with complex urinary tract infections.
Available in many forms – as tablets (250 mg, 500mg & 750mg are on our formulary), suspension, intravenous product, and eye drops – ciprofloxacin is a broad coverage antibiotic with excellent penetration into lung fluid and many other body tissues.
Does Ciprofloxacin interact with other medications?
Yes, taking ciprofloxacin with antacids, sucralfate, iron, calcium or magnesium containing supplements can bind the medication and prevent it from reaching the site of the infection.
Dairy products contain calcium and therefore can also affect ciprofloxacin absorption. Ciprofloxacin decreases the clearance of a few other medications, potentially increasing their side effects (theophylline, warfarin and cyclosporine).
What is the best way and time of day to take oral Ciprofloxacin?
Ciprofloxacin can be taken with or without food. Based on data provided by Bayer HealthCare, dairy products, as part of a meal, can be taken with this antibiotic.
The food dilutes out the divalent cations sufficiently to prevent any significant decrease in ciprofloxacin absorption.
What are the recommendations for administering ciprofloxacin if a child takes iron, magnesium or calcium supplements or antacids?
Ciprofloxacin can be taken with iron, magnesium or calcium containing supplements (including fortified juices) as long as it is with a meal.
Studies have found that the absorption of ciprofloxacin is not significantly affected by these minerals if other food sources are taken at the same time.
Feeding tubes and Ciprofloxacin
Ciprofloxacin suspension contains medium-chain triglycerides which can clog a feeding tube, and flushing with water will not clear out the line.
Therefore, it is not recommended to administer ciprofloxacin suspension through a feeding tube.
Teaching information for families: Ciprofloxacin liquid suspension and young children
Always be sure to shake the suspension for 5 seconds. Ciprofloxacin suspension is a complex system that masks the bitterness of the medication. Most children tolerate the strawberry-flavored suspension without problem.
For a child who has difficulty with the taste we suggest the following:
- Give the liquid in the middle of a meal so that the food masks the taste.
- Give the child a small amount of a favorite food just after the liquid-chocolate, ice cream, and fruit jams/preserves are excellent taste maskers.
- Suggest that the child swallows the medication without chewing it. There are small solid pieces (microcapsules) of ciprofloxacin in the liquid formulation that if chewed will cause a bitter taste. Using an oral syringe can make it easier for a child to take the suspension.
What side effects should families watch for?
This medication can make the skin more sensitive to sunlight. Avoid prolonged sun exposures and use sunscreens if the child is outside for a prolonged period of time.
Ciprofloxacin can also cause upset stomach or nausea. If this occurs try taking the medication with food.
Suggest that the family calls their health care provider if a child develops severe diarrhea, joint or muscle pain, upset stomach or nausea that continues despite giving the medication with food.
Credits
Editors
- Anny Chan, PharmD
- Eric Harvey, PharmD, MBA, BCPS
P&T Chairs
- Janet Englund, MD
- Eric Harvey, PharmD, MBA, BCPS
Address
Children's Hospital and Regional Medical Center P&T Committee
4800 Sand Point Way NE
P.O. Box 5371/R-3409
Seattle, WA 98105