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Informatics in Pharmacy

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Surgical Prophylaxis

August 26, 2018 By Dr. G, PharmD

  • You must administer surgical prophylaxis at the time of the first incision or as close as possible.  Redose if surgery is longer than four hours.  No need for post-op, except in cardiac procedures.
  • Usually use cefazolin 2 g (3 g for patients above 120 kg), ceftriaxone, cefotetan, cefoxitin 2 g, clindamycin 900 mg, vancomycin 15 mg/kg
  • Cefazolin 2g is preferred in most cases, one dose unless surgery > 4 hours or cardiac procedures
    • Prophylaxis by surgical procedure
      • GI: Cefazolin 2g
      • Billary: Cefazolin, cefoxitin, cefotetan or ceftriaxone 2g, or amp/sulbactam 3g
      • Appendectomy: cefoxitin or cefotetan 2g or cefazolin + metronidazole (anaerobic coverage)
      • Colorectal: cefazolin or ceftriaxone 2g + metronidazole with or without neomycin and erythromycin
      • Gynocological: cefazolin, cefoxitin or cefotetan 2g
      • Cardiac: cefazolin or cefuroxime 2g
      • Orthopedic – cefazolin 2g
      • Urologic: None

Seizures: Epilepsy

August 13, 2018 By Dr. G, PharmD

*See the seizure medication table  for quick reference.
*Seizure Emergencies

Epilepsy Treatment Options:

Know doses for narrow therapeutic index drugs like phenytoin, but mostly need to know what kind of seizure and major side effects that would cause you to choose a different therapy. Also know REMS programs.

  • Benzos can be used as adjunctive, short-term therapy (clorazepate, clonazepam, diazepam or lorazepam)
  • Brivaracetam
  • Carbamazepine – Beware of Stevens Johnsons syndrome with carbamazepine, induced its own metabolism, pharmacogenomic considerations (HLA-B testing in Asians), blood disorders
  • Eslicarbazepine
  • Ethosuximide – Absence seizures
  • Felbamate in severe, refractory seizures.  Severe side effects: aplastic anemia, liver damage.  Adjunct for Lennox-Gestault
  • Fosphenytoin
  • Gabapentin – Also for peripheral neuropathy
  • Lacosamide – partial onset seizure, increases suicidal ideation
  • Lamotrigine – Adjunct for partial, bipolar, Lennox-Gestault. Valproate inhibits the metabolism (must lower dose).  Carbamazepine induces metabolism.  Titrate to avoid Stephen-Johnson’s syndrome.  Estrogen induces metabolism (increase dose).  Good for patients with sexual dysfunction
  • Levetiracetam – partial and myoclonic, traumatic brain injury, adjust in renal dysfunction
  • Oxcarbazepine – no auto-induction, partial, bipolar, causes hyponatremia, some cross sensitivity with carbamazepine. Good for sexual dysfunction.
  • Perampanel – neuropsychiatric effects
  • Phenobarbital – partial and generalized, not for absence seizures, used for anxiety too.
  • Phenytoin – Dose-related effects include nystagmus, ataxia, drowsiness, cognitive impairment. Non-dose related effects include gingival hyperplasia, hirsutism, acne, rash, hepatotoxicity, coarsening of facial features. Therapeutic range: 10-20 mg/ml.   Michaelis–Menten saturable kinetics, so dose accordingly.
    • Dose titration:
    • < 7 mg – increase 100 mg daily
    • 7-12 increase 50 mg daily
    • > 12 increase by 30 mg or less
  • Pregabalin: reduce dose in renal dysfunction
  • Valproate: good for absence seizures, migraine and partial complex seizures.  Causes neural tube defects, beware in women of childbearing age.  Can increase anemia.
  • Primidone: Metabolized to phenobarbital.  Also used for tremor.
  • Tigabin: Use as an adjunct in partial seizures, may cause seizures
  • Topiramate: Adjunct for partial seizures or Lennox-Gestault. Warning in open-angle glaucoma.
  • Vigabatin: SHARE Rems program.  Causes retinal dysfunction.
  • Zonisamide: Avoid in sulfa allergy, decreases the ability to sweat, increases kidney stones.

*******No Valproic Acid in potentially pregnant patients***********

Also avoid: phenytoin, carbamazepine, and phenobarbital, but not as severely.  Try to use a single agent.

May DC epilepsy meds if:

  1. Seizure free for at least 2 years on medication
  2. Single type of partial or primary seizure
  3. Normal neurological exam and normal IQ
  4. EGG normal

Drugs that can induce seizures: tramadol, FQs, bupropion, imipenem/cilastatin, benzo withdrawal

Electrolytes that can induce seizures: hyponatremia, hypernatremia, hypercalcemia.

Multiple Sclerosis

August 13, 2018 By Dr. G, PharmD

Acute Relapses:

  • Methylprednisone 1g/day in divided doses for 3-5 days.
  • Oral prednisone 1250 mg every other day for 5 days
  • Intravenous adrenocortical hormones.

DMARDs-

  1. Alemtuzumab – Can cause thyroid disorder, infusion reactions, increased infections (screen for herpes and TB before giving), may risk some cancers, vaccinate 6 weeks prior to therapy, avoid live vaccines during treatment.
  2. B – interferon – flu-like symptoms, injection site problems
  3. Dimethyl fumarate – GI and skin reactions
  4. Glatiramer acetate – injection site reactions, chest pain, shortness of breath,
  5. Fingolimod – Contraindicated in mi, unstable angina and stroke, heart failure class III/ IV monitor for bradycardia, avoid he vaccines.
  6. mitoxantrone – only second line due to toxicity. Can cause leukemia-like disease
  7. Natalizumab – relapsing forms, only through special program due to leukoencephalopathy risk.
  8. Teriflunomide – Secondary, hepatotoxicity, neutropenia, increased infection risk.

Fatigue: non-pharmacologic (rest, sleep management, cooling) or amantadine or methylphenidate
Spasticity: Baclofen or tizanidine
Walking Impairment: Dalfampridine (K+ Channel Blocker): may cause seizures, UTI, insomnia
Pseudobulbar affect: Dextromethorphan/Quinidine

Schizophrenia

August 13, 2018 By Dr. G, PharmD

Diagnosis:

  • Brief Psychiatric Rating Scale (BPRS)
  • Positive and Negative Symptom Scale (PANSS) – 7-point, 30 item scale.  Requires a 45-minute interview
  • Positive Symptom Rating Scale (PSRS) – 1-7 scale
  • Brief Negative Symptoms Assessment (BNSA) 1-6 scale

Treatment:

  • Antipsychotics are the first line
  • The Joint Commission recommends 1 antipsychotic unless:
    • 3 failed attempts at monotherapy
    • A plan to taper to monotherapy
    • Augmentation of clozapine
    • Other documentation

Antipsychotics:

  • First-generation:
    • Mostly treat positive symptoms (hallucinations, delusions, disorganized behavior)
    • All lower seizure threshold, cause weight gain, liver toxicity, QT prolongation
    • Low potency (anticholinergic > EPS)
      • Chlorpromazine (blue-grey skin, also treats hiccups, N/V, RLS) and thioridazine
    • High potency (EPS>>anticholinergic)
      • Fluphenazine (comes in depot shot), haloperidol (depot too), loxapine (bronchospasm risk), perphenazine, trifluoperazine (don’t give greater than 6 mg/day longer than 12 weeks)
    • Smoking may increase metabolism, so may need to decrease dose if patients quits, especially olanzapine and clozapine
  • Second Generation (aka atypical):
    • Treats mostly positive symptoms, but can improve negative symptoms as well.  Cause less extrapyramidal symptoms and tardive dyskinesia. Overall, 2nd generations are better tolerated.
    • Some seizure threshold lowering, risk for diabetes and hyperlipidemia, some QT prolongation, hyperprolactinemia, antihistamine effects
    • Weight gain worst to least: clozapine > olanzapine > risperidone, paliperidone, iloperidone, quetiapine > ziprasidone, aripiprazole, lurasidone
    • Clozapine only for refractory cases due to agranulocytosis risk.  Monitor ANC.  If <1000, interrupt therapy, if <500 stop.
      • May add lamotrigine to clozapine. No data for other anticonvulsants
    • Olanzapine should never be taken with lorazepam.
    • Risperidone has greater EPS and TD with 6mg or more dosing.
    • Ziprasidone has more QT prolongation than others.
    • Aripiprazole has more akathisia, low EPS and TD
    • Iloperidone causes orthostasis if not properly titrated
    • Paliperidone s the active metabolite of risperidone.
    • All patients prescribed second-generation antipsychotics should be monitored for weight, blood pressure, fasting, glucose, lipids and waist circumference.
    • Benzos may be useful during the acute phase
  • Neuroleptic malignant syndrome:
    • Can occur with any agent, but more common with high potency first-generation antipsychotics
    • Manifested by agitation, confusion, changing levels of consciousness, fever, tachycardia, labile blood pressure, sweating.
    • High mortality rate.
    • Treatment: Discontinue agent, give supportive therapy including fluids and cooling.  Bromocriptine and dantrolene can be used.

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