P&T News: July 1996, Vol. 17, No. 1, Part B
Pharmacy and Therapeutics Subcommittee of the University
Hospital Advisory Committee and the Pharmcy Department
Peer Review Status: Internally Peer Reviewed
Duplicate Prescription
The Duplicate Prescription System at the UIHC is structured to
produce an original and exact copy of the medication order. Under
this system, the Department of Pharmaceutical Care is authorized to
dispense the take-home supply of medication from the copy of the
prescription and return the original prescription to the patient to
obtain continuing supplies in the local community. The use of other,
nonstandard prescription blanks within the UIHC is not authorized.
The "essential elements" of a prescription are depicted in the preceding figure of a UIHC prescription and described below:
(A) Patient name, address, hospital number, birthdate and date prescription is written. This information may be transmitted to the prescription by using the patient's addressograph plate. The hospital number is essential to assure that the intended patient receives, and is billed for, the correct medication.
(B) The name, strength, and quantity of the drug. Medications should be ordered by the generic name, not by the proprietary or trade names.
Hospital policy and the Joint Commission on Accreditation of Healthcare Organizations standards permit the use of drug name abbreviations in medication orders only if the abbreviation has been specifically approved by the hospital and it appears on a published list. "Coined" abbreviations such as HCTZ, AZT and ddC are not acceptable medical abbreviations, may be misinterpreted, and may cause drug errors. Medication orders that contain nonapproved drug name abbreviations are not valid. Pharmacists are authorized to withhold dispensing of medications ordered via nonapproved abbreviations. The approved drug name abbreviations are provided on pages 57-58 (gray-colored section) in the 1996 Formulary and Handbook; approved medical abbreviations are found beginning on page 155 of the pink-colored section.
A separate prescription blank must be used for each drug prescribed.
For Drug Enforcement Administration (DEA) narcotics and controlled substances, including anabolic steroids, the quantity should be written in words as well as numbers to prevent alteration of the prescription.
The quantity of drug to be dispensed should be indicated; it may be further clarified by a check in the appropriate box to indicate to the pharmacist to dispense a prepackaged quantity or the exact quantity. Outpatient prescriptions should be written for no more than a 30-day supply with continuing supplies to be prescribed as refills. In order to minimize patient delays, the pharmacist is authorized to round the quantity dispensed to the nearest available prepackage quantity (usually a one-month supply) only for prescriptions with refills authorized. (See pages 69-71 in the gold-colored section in the front of the 1996 Formulary and Handbook for listing of the prepackage drugs which are provided for patient convenience.)
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Outpatient Prescription Medication Supply Limits |
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The United States Supreme Court has ruled that medications purchased by hospitals (at special institutional prices) must be for inpatient use or for dispensing a limited take-home supply. The following rules must apply:
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(C) Directions to the patient. Clear and concise directions will assist your patient in the appropriate use of the medication. "Take as directed" should be avoided. Your patient may forget or confuse verbal directions or lose a separate note. The Department of Pharmaceutical Care will complete a patient medication calendar for tapered or intermittent dosage schedules. The "PRN" designation should include the purpose of the medication (e.g., PRN sleep, PRN pain).
(D) Signature, printed name, physician code. In addition to signing the prescription, print your name legibly below your signature along with your UIHC 4-digit physician code, and indicate your practitioner status by circling the appropriate initials to the right of the signature line. This will facilitate communications with health care practitioners throughout the state who have a need to accurately identify the prescriber and it will also decrease the possibility of forgery. To prevent illegal drug diversion, supplies of prescription blanks may not be signed by the prescriber in advance of use. Prescriptions must only be signed by the prescriber at the time prescriptions are written for a specific patient. Physician assistants must also indicate the name of their supervising physician in the designated space.
(E) DEA number. Your personal Drug Enforcement Administration (DEA) registration number or the UIHC DEA registration number with your personal 4-digit physician code must be included on all prescriptions for drugs classified as controlled substances. This step is a safety mechanism to prevent prescription forgery because each DEA number can be checked to verify its validity. When your DEA number is omitted, it is illegal for any pharmacy to fill the prescription. Pharmacy does not have a list of every physician's DEA number; therefore, this omission causes your patient to be inconvenienced until the deficiency is corrected.
When physician assistants prescribe DEA Schedule III, IV or V drugs, the prescription must also contain the DEA number of the supervising physician and the physician assistant's license number. Physician assistants are not authorized to prescribe DEA Schedule II drugs and advanced registered nurse practitioners are not authorized to prescribe any controlled substances within the UIHC.
Applications forms for personal DEA registration at the UIHC and instructions for completion are available at the Pharmacy Office, Room CC-101 GH.
(F) Drug allergies. The patient's mediation allergies should be specified in this space on one of the prescriptions for each set of prescriptions. If there are no known allergies, please check the box next to "NKA.. The pharmacist will obtain or confirm allergy information with the patient as necessary at the time the prescription is presented to the Ambulatory Care Pharmacy.
(G) Containers without safety closures. "Childproof" containers with safety closures are used for dispensing all prescription medications (with limited exceptions) in accordance with the Federal Poison Prevention Packaging Act of 1970. You may indicate the need for nonsafety closures for a patient for whom childproof containers may cause difficulty by checking the designated box.
(H) Refill designation. Always circle "no refills" or specify the number of times and/or the last date the prescription may be refilled. "PRN. is not a valid refill designation.
Prescriptions may be refilled at the Department of Pharmaceutical Care only for hospital staff and dependents at the same address, or for patients whose medications are not commercially available. Prescriptions for this eligible patient group (excluding controlled substances) may be refilled a maximum of 11 times or for 12 months - whichever is less.
Prescriptions for DEA controlled substances in Schedules III, IV and V may be refilled a maximum of five times or for six months - whichever is less. Prescriptions for Schedule II controlled substances may not be refilled.
(I) Indication for Use. The indication for use should be specified in this space for each prescription. This information permits the pharmacist to reinforce physician instructions with the patients and helps the patient understand what the medications are for. Federal regulations require the pharmacist to obtain information on the patient's disease state(s) so that appropriate utilization review and counseling can occur.
Discharge Prescriptions for Inpatients
The Department of Pharmaceutical Care provides discharge
medication counseling for all patients of the UIHC.
To allow for proper prescription review and processing and to provide medication counseling for patients on the inpatient care units, discharge prescriptions to be filled by the Department of Pharmaceutical Care should be written and forwarded to Pharmacy the day prior to discharge.
Prescriptions for Clinic Patients
Prescriptions forwarded to the Department of Pharmaceutical Care
for patients being seen in the clinics should note when the patient
will call for the prescription and in what clinic the patient was
seen. This allows timely preparation and clarification if necessary.
Telephoned Prescriptions
Prescription orders for "take home medications" are not permitted
to be telephoned to the Department of Pharmaceutical Care except in
case of an emergency or at the request of those patients who are
enrolled in the UI Care or UI Select health plans. In emergency
situations, the prescription order must be countersigned by the
prescribing physician or dentist within 72 hours. This policy is
intended to reduce prescription forgeries and to provide the
mechanism for a double check on written prescription orders as a
safety measure. Physician assistants and advanced registered nurse
practitioners may not dictate oral orders for any medications which
are to be prepared or dispensed within the UIHC.
Unused Supplies of Medication
Iowa law mandates that for the protection of the public health
and safety, medications that have been dispensed to outpatients may
not be accepted for return, exchanged, or resold. Therefore, the
Department of Pharmaceutical Care may not accept medication returns
or issue credit to patients who request return of unused supplies of
medication. If the patient's reaction to a newly prescribed
medication cannot be anticipated, it may be prudent to initially
prescribe less than a 30-day supply. Continuing supplies may then be
obtained as refills once it is determined that the patient can
tolerate the medication.
Prescriptions for House Staff
he UIHC medical care program permits house staff physicians and
dentists to write prescriptions for a one month or less supply of
medications stocked at UIHC, if medically necessary, for themselves
and members of their immediate family (defined as a spouse or child
living with the house staff member) at no charge. Hospital policy
requires that prescriptions for Schedule II narcotics written for
immediate family and personal use must be signed by another member of
the staff who possesses a personal DEA registration number.
To minimize waiting time for clinic and discharge patients, house staff are asked to plan ahead so that refills and new prescriptions for nonurgent medications are presented one day and picked up the following day. This will allow Pharmacy staff to fill house staff prescriptions at less busy times.
Storage of Prescription Blanks
To reduce the incidence of theft of UIHC prescription blanks and
to reduce illegal drug diversion, access to UIHC prescription blanks
is limited. Prescription pads and single prescription blanks are
stored only in secure centralized locations (e.g., medical conference
rooms or medication preparation rooms) of the ambulatory care clinics
and inpatient care units. Patients, visitors, and unauthorized
hospital staff members should not have access to these locations.
Prescription blanks must not be stored in patient examination rooms.
Authorized prescribers may carry prescription blanks in their
jacket/coat pockets.
In addition to controlled storage, prescription blanks are serialized, and dispersal of all prescription pads and storage destination is documented by Pharmacy staff. These procedures permit a trace of lost or stolen prescription blanks.
Medication Orders Written By Physician Assistants and Advanced
Registered Nurse Practitioners
Physician assistants and advanced registered nurse practitioners
may write medication and treatment orders only when acting pursuant
to policies or protocols approved by the Clinical Service Head and
reviewed and approved by the Professional Practice Subcommittee.
Copies of established protocols shall be provided to the Department
of Pharmaceutical Care by the Clinical Service Heads or the
Professional Practice Subcommittee.
Physician assistants and advanced registered nurse practitioners shall not have the author" to limit substitution or standardization pursuant to Pharmacy and Therapeutics Subcommittee protocols and shall not be authorized to override protocol or restricted drug indications.
For further information on prescribing discharge and outpatient medications, please consult pages 59-71 in the gold-colored section of the 1996 Formulary and Handbook or call the Department of Pharmaceutical Care.
Jane C. Blayney, Pharm.D.
Peer Review Status: Interally reviewed by Helmut G.
Schrott, M.D., Director of the Lipid Research Center, Associate
Professor, Department of Internal Medicine and David A. Chappell,
M.D., Associate Professor, Department of Internal Medicine
The HMG-CoA reductase inhibitors, along with niacin and the bile-acid binding resins, are the cornerstone of drug therapy for treating hyperlipidemia. Selection of an antilipidemic agent should be based on the amount of low density lipoprotein cholesterol (LDL-C) lowering desired according to a patient's risk factors for coronary heart disease (CHD), other concomitant disease states, and cost. In difficult to treat patients, combination therapy may be beneficial and more cost-effective. Because the HMG-CoA reductase inhibitors as a class comprise agents of similar efficacy and adverse effect profiles, only the most cost- effective agents should be utilized. Because of high cost, UIHC has chosen to no longer stock lovastatin. Fluvastatin, pravastatin, and simvastatin are available and currently on formulary. When identifying the best regimen for your patient, take into account the following steps (based on National Cholesterol Education Program guidelines):
STEP 1: Determine Patient Risk Factors for Coronary Heart Disease
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CHD Risk Factors Other than LDL - Cholesterol | |
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Positive Risk Factors |
Negative Risk Factors |
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Age: Males 45 years or more, Females more than 55 years or premature menopause without estrogen replacement therapy Family history of premature CHD Cigarette Smoking Hypertension Diabetes mellitus Low HDL-C, less than 35 mg/dl |
High HDL-C level, 60 mg/dl or more [If HDL-C level is greater than 60 mg/dl, subtract one risk factor because high HDL-C levels decrease CHD risk] |
STEP: 2 Identify Goal LDL Level
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No CHD, less than 2 risk factors |
No CHD, greater than 2 risk factors |
CHD, with or without risk factors |
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Current LDL-C 190 or greater |
Curent LDL-C 160 or greater |
Current LDL-C 130 or greater |
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Inidicate Drug Treatment |
Inidicate Drug Treatment |
Inidicate Drug Treatment |
STEP 3: Select Agent According to Desired LDL-C Reduction
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LDL-C Reduction |
Agents |
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up to 20% |
8 to 16 gm cholestyramine or 2 to 3 gm niacin or 20 to 40 mg fluvastatin |
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20 to 30% |
20 to 40 mg fluvastatin or 5 to 10 mg simvastatine or 20 mg pravastatin or 3 to 4 gm niacin or 12 to 16 gm cholestyramine |
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greater than 30% |
10 to 40 mg simvastatin or 20 to 40 mg pravastatin |
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greater than35% |
20 to 40 mg simvastatin or combination therapy with: 1) low dose statin and resin or niacin; or 2) niacin and cholestyramine |
STEP 4: Identify Any Patient conditions Which May Affect Selection of Therapy
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Condition |
Action |
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Diabetes mellitus or Gout |
Avoid niacin |
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Severe liver disease [liver function tests greater than 3 times the upper limit of normal (ULN)] |
Avoid niacin and HMG-CoA reductase inhibitors |
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Increased triglyceries (more than 200 mg/dl) |
Niacin is a good choice; caution when using resin binding agents as they can increase triglycerides |
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Drug Interactions |
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Resins - multiple drugs (e.g., statins, warfarin, digoxin, levothyroxine, and many others) |
Resins may decrease absorption of other drugs given concurrently; take other drugs 1 hr before or 4 to 6 hrs after resin. |
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Simvastatin - Warfarin |
Simvastatin may slightly increase hypoprothrombinemic response; monitor PT |
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Statins - Gemfibrozil |
Watch for creatine kinase (CK) elevations more than 10 x ULN as rhabdomyolysis may occur in 1/6 of patients with CK elevations more than 10 x ULN. |
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Post-menopausal women |
Consider hormone replacement therapy |
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Low HDL-C, less than 35 mg/dl |
Niacin raises HDL-C better than the HMG-CoA reductase inhibitors or cholestyramine |
STEP 5: Consider Cost to Patient
STEP 6: Re-evaluate Therpay
In after 8 weeks of therapy the patient is not reaching goal, consider increasing dose or trying combination therapy with1) statin plus niacin or cholestyramine; or 2) niacin and cholestyramine.
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Efficacy and Cost of Combination Therapy | ||
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Combination |
LDL-C Decrease |
Reference |
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Pravastatin 40 mg/d & Niacin 0.5-1 gh BID |
49% |
Am J Cariol 1994,73:339-45 |
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Pravastatin 20 mg/d & Cholestyramine 24 mg/d |
47% |
Clin Pharmacol Ther 1990;48:201-7 |
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Pravastatin 40 mg/d & Cholestyramine 24 gm/d |
53% |
Clin Pharmacol Ther 1990;48:201-7 |
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Simvastatin 10 mg/d & Niacin 1.5 gm/d |
33% (HDL increase 33%, TGs decrease 28%) |
Atherosclerosis 1994;109:323 |
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Simvastatin 10 mg/d & Colestipol 10 gm/d |
42% |
Clin Cardiol 1994;17(2):59-64 |
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Simvastatin 40 mg/d & Colestipol 15 gm/d |
57% |
Curr Ther Res 1988;44:802-6 |
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Fluvastatin 20 mg/d & Niacin 3 gm/day |
43% |
Am J Cardiol 1994 73:25D-9D |
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Fluvastatin 10-20 mg/day & Cholestyramine 8 mg/d |
31% |
Ann Intern Med 1994;120:537-43 |
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Lovastatin 20 mg/d & Niacin 1.2 gm/d |
37% |
Am J Cardiol 1995;76:182-4 |
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Lovastatin 20 mg/d & Cholestyramine 8 gm/d |
44% |
J Am Coll Cardiol 1991;17:188A |
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Lovastatin 20 mg/d & Colestipol 10 mg/d |
48% |
Am J Cardiol 1995;75:34-9 |
Drugs Added to Stock
ACARBOSE Tablets: 50 ma, 100 mg Acarbose (Precose[R] - Bayer) tablets are indicated as an adjunct to diet and exercise for the management of non-insulin dependent diabetes mellitus.
CETIRIZINE Capsules: 5 ma, 10 mg Cetirizine (Zyrtec[R] - Pfizer) is a relatively non-sedating antihistamine indicated for the symptomatic relief of seasonal and perennial allergic rhinitis and chronic idiopathic urticaria.
DOCETAXEL Injection: 20 mg and 80 mg vials Docetaxel (Taxotere[R] - Rhone-Poulenc Rorer) is an antineoplastic agent indicated for the treatment of refractory breast cancer.
GANCICLOVIR Intravitreal Implant: 4.5 mg Ganciclovir intravitreal implants (Vitrasert[R] - Chiron) are indicated for the treatment of CMV retinitis in patients with AIDS. [NOTE: Restricted to Ophthalmology.]
GEMCITABINE Injection: 200 mg and 1000 mg vials Gemcitabine (Gemzar[R] - Lilly) is an antineoplastic agent indicated for the treatment of locally advanced or metastatic adenocarcinoma of the pancreas.
OXYTETRACYCLINE WITH POLYMYXIN B Ophthalmic Ointment: 3.5gtube This product (Terramycin[R] with Polymyxin B - Pfizer) is indicated for the treatment of infections of the cornea and conjunctive.
TOPOTECAN Injection: 4mg vial Topotecan (Hycamtin[R] - SKB) is an antineoplastic agent indicated for the treatment of refractory metastatic ovarian cancer.
VITAMIN B COMPLEX WITH ASCORBIC ACID CAPSULES This product (NephroCapst[R]) provides a cost-effective replacement for NephroVite Rx[R] and Berocca[R] tablets.
Drugs Deleted From Stock
ASTEMIZOLE (Hismanal[R]) TABLETS Replaced with cetirizine tablets.
VITAMIN B COMPLEX WITH ASCORBIC ACID (NephroVite Rx[R] and Berocca[R]) TABLETS Replaced with NephroCap[R] capsules.