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Archived Message board
responses |
| Question: | Posted by Alicia
Large, Pharm.D. on March 07, 2001 at 10:22:59:
Why do you list an expiration date of 1 day for fluconazole if it is transferred? Do you know where you received this information? Thanks |
| Responses: | Posted by D. McAuley on March 07, 2001
at 12:54:03:
Micromedex Posted by Alicia Large, Pharm.D. on March 08, 2001 at 15:30:45:
FYI: I contacted Pfizer. -------------------- |
| Question: | Posted by Susan
Lang on March 06, 2001 at 11:50:32:
With oral neomycin no longer avaiable what is the receommended pre-op
antibiotic for bowel surgery. |
| Responses: | Posted by D. McAuley on March 06, 2001
at 12:42:44: I was not aware of this... We currently are not
facing any problems with availability of neomycin at our institution.
There has been studies which have replaced erythromycin base with
metronidazole, however I am not aware of any studies which have replaced
neomycin. My only suggestion would be attempt a medline search using the
program I have set up on this site: If I find additional info I will post it here.. -------------------- A superficial search produced the following studies: Am J Surg 1986 Apr;151(4):437-42 A prospective randomized trial was performed to compare oral neomycin
and erythromycin with single-dose intravenous metronidazole and
ceftriaxone in elective colorectal surgery. The study was discontinued
after 60 patients were entered. The overall rate of infection was 41
percent in the oral neomycin and erythromycin group (n = 29) compared
with 9.6 percent in those who received intravenous metronidazole and
ceftriaxone (n = 31) (p less than 0.01). Infections in the oral group
were principally due to resistant Staphylococcus aureus, Bacteroides
fragilis, and Escherichia coli. Preoperative administration of oral
neomycin and erythromycin was associated with a significant reduction of
Escherichia coli counts (1 X 10(7) to 3 X 10(5) organisms/ml, p less
than 0.05) compared with the intravenous group, but there was no
significant reduction in the counts of Bacteroides fragilis (2 X 10(8)
to 1 X 10(7) organisms/ml) and there was an increase in the counts of
Clostridia (2 X 10(4) to 1 X 10(6) organisms/ml). These results indicate
that single-dose systemic prophylaxis with appropriate antibiotics is
superior to oral neomycin and erythromycin.
Current opinion favors the use of antimicrobial prophylaxis in all
operations for acute appendicitis. In clinical trials with placebo
controls, the reduction in the rate of postoperative infectious
complications is most apparent in perforated and/or gangrenous
appendicitis, but benefits are also seen in nonperforated appendicitis
and even in those with a normal appendix. In elective colorectal
operations, it has been established that all patients should receive
prophylactic antibiotics. The choices are an oral bowel preparation
consisting of neomycin or kanamycin combined with erythromycin or
metronidazole; a parenteral antimicrobial drug such as cefoxitin or
cefotetan; or a combined oral/parenteral regimen. Risk factors for
postoperative wound infection include a prolonged duration of surgery
(greater than 3.5 hours) and rectal resection. The most popular
prophylactic regimen employed by American surgeons, particularly in the
presence of adverse risk factors, is oral neomycin/erythromycin along
with a short course (one to three doses) of a systemic cephalosporin
active against anaerobes. |
| Question: | Posted by j.
cecil on March 04, 2001 at 14:28:59:
Please help explain diluting drugs. If I want to give 1 mg of versed and the vial I have contains 5mg/ml how do I dilute this so that final concentration contains 1mg/ml? Please include formula used and explanation. Thanks. |
| Responses: | Posted by . on March 04, 2001 at 15:48:11: Instead of diluting the vial you could give 0.2 ml of a 5 mg/ml solution and this would give you 1 mg. If you want to dilute it, use a simple ratio. You need 1 mg/ml, and you have 5 mg/ml which is a 1:5 ratio, therefore take 1 ml of the 5 mg/ml solution and dilute it with 4 ml (this is the same as 1 part out of 5). The total volume will be 5ml, and the final concentration will be 5 mg/5 ml or 1 mg/ml. Here is another example: you have 25 mg/ml of aminophylline and you need 10 mg/ml. The ratio is 10/25 or 2/5. Using this ratio you would take 2 ml of 25mg/ml of aminophylline and add 3 ml. This will create a solution that contains 50mg/ 5ml which is 10mg/ml. |
| Question: | Posted by MichRph on February 28, 2001
at 20:03:25:
P&T is considering adding the direct thrombin inhibitor
bivalirudin(Angiomax) for use in PCI. |
| Responses: | Posted by D. McAuley on February 28,
2001 at 23:00:53:
Bivalirudin looks like a promising replacement for heparin in this
setting. Currently its only FDA approved indication is in treating
patients with unstable angina who are undergoing percutaneous
transluminal coronary angioplasty. A statement released by the company
revealed the following: Clinical studies of Angiomax in more than 4,000
patients with new onset angina, angina at rest, or with accelerating
episodes of the condition showed a 22% sustained decrease in the risk of
death, MI or revascularization compared with patients on heparin. There
still is a lack of studies comparing other therapies. Here is an
abstract from a journal as early as August of 2000 revealing the
scarcity of studies: Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York, USA. OBJECTIVE: This paper examines the rationale for using direct thrombin inhibitors in the management of acute coronary syndrome (ACS). BACKGROUND: With traditional management of ACS using aspirin and unfractionated heparin (UH), refractory angina and new myocardial infarction (MI) continue to develop. Growing understanding of the pathophysiology of ACS has led to the search for more effective therapies directed toward preventing formation of fibrin- and platelet-rich thrombi in the coronary arteries. Current pharmacologic approaches include use of direct thrombin inhibitors (lepirudin, desirudin, and bivalirudin). METHODS: We reviewed all published clinical trials abstracted in MEDLINE from 1966 to April 2000, excluding pilot studies enrolling <500 patients. RESULTS: Use of lepirudin at medium doses (0.4-mg/kg bolus + 0.15 mg/kg/h) resulted in lower rates of death, new MI, and refractory angina at 7 days compared with UH (3.0% vs 6.5%; P = 0.047), although the incidence of minor bleeding was increased (7.6% vs 4.5%; P < 0.05). Bivalirudin was as effective as UH in preventing complications after percutaneous coronary intervention (11.4% vs 12.2%; NS) and carried a lower bleeding risk (7.8% vs 19.2%; NS); however, its use in the management of ACS has not been studied. Desirudin used at low doses (0.1-mg/kg bolus + 0.1 mg/kg/h) in large-scale clinical trials in patients with acute MI treated with alteplase or streptokinase appeared to be at least as effective as UH (8.9% vs 9.8% at 30 days; NS). However, its therapeutic index was narrow, since it was associated with significantly more moderate bleeding (8.8% vs 7.7%; P < 0.05). CONCLUSIONS: All clinical trials to date have studied relatively short-term use (3-5 days) of direct thrombin inhibitors, and long-term benefits on morbidity and mortality have not been demonstrated. Until further data are available, direct thrombin inhibitors should be restricted to use as a possible alternative in patients who require anticoagulant therapy but experience UH-induced thrombocytopenia. Here is a study (abstract) that strengthens the argument of heparin's inadequacies: Bates SM, Weitz JI. The mechanism of action of thrombin inhibitors. J
Invasive Cardiol 2000 Dec;12 Suppl F:27F-32 Although heparin is widely used to treat arterial thrombosis, it has limitations in this setting. These limitations reflect heparin's inability to inactivate fibrin-bound thrombin, a major stimulus for thrombus growth, and the fact that heparin is neutralized by platelet factor 4, large quantities of which are released from platelets at the site of plaque rupture. Heparin also has a propensity to bind non-specifically to other plasma proteins. Because plasma levels of these heparin-binding proteins vary from patient to patient, the anticoagulant response to heparin is unpredictable and careful laboratory monitoring is necessary to ensure that an adequate anticoagulant effect is achieved. Direct thrombin inhibitors, such as bivalirudin and hirudin, overcome many of the limitations of heparin. These agents inhibit fibrin-bound thrombin, as well as fluid-phase thrombin. Direct thrombin inhibitors also produce a more predictable anticoagulant response than heparin because they do not bind to plasma proteins and are not neutralized by platelet factor 4. Bivalirudin appears to have a wider therapeutic window than hirudin. Because this may permit administration of higher doses of bivalirudin, this agent may also have an efficacy advantage over hirudin. Differences observed between hirudin and bivalirudin demonstrate that not all direct thrombin inhibitors have the same risk-benefit profile. And finally, a link to the press release for Angiomax. |
| Question: | Posted by Bob
DeVore on February 23, 2001 at 16:40:26:
Dave, ever heard of freezing oral solutions for later use in off site locations? Thinking about using reconstituted oral antibiotics in unit-of-use containers (ie. oral syringes) and freezing them to be used at a later date in the ER. Would also need stability info for frozen expiration date and stability after microwaving (?) in order to administer the dose. We currently recon and send a whole multi dose container of oral antibiotic solution and send the whole thing to the ER for each patient. thanks, Bob DeVore |
| Responses: | Posted by D.
McAuley on February 23, 2001 at 19:17:54: Bob, we currently do not have
any guidelines set up for the freezing of oral antibiotics. Many of the
oral antibiotics have what I call a non-linear stability curve.
Favorable stability exists within a specific range of temperatures. Here
is an example (abstract for an amoxicillin study):
Am J Hosp Pharm 1986 Dec;43(12):3027-30 Concannon J, Lovitt H, Ramage M, Tai LH, McDonald C, Sunderland VB The stability of aqueous admixtures of amoxicillin sodium in both the liquid and frozen (solid) states was studied. Admixtures of amoxicillin sodium were prepared in sterile water for injection to a theoretical concentration of 10 mg/mL. For each experimental run, 2-mL aliquots of the admixture were placed in stoppered glass volumetric flasks and stored at temperatures ranging from 19.5 degrees C to -30 degrees C; 16 flasks were stored at each temperature. After equilibration for approximately 20 minutes, duplicate flasks at each temperature were removed from storage conditions for time-zero assay. Subsequently, duplicate flasks were assayed at various times, depending on the storage temperature, for up to 13 days or until more than 80% of the drug had degraded. All samples were assayed at least in duplicate using high-performance liquid chromatography. When amoxicillin solutions were in the liquid state (at temperatures between 19.5 and 0 degrees C), the time required for the amoxicillin concentration to decrease to 90% of its initial value (t90) increased as temperature decreased. However, between 0 degree C and -7 degrees C, the t90 of frozen solutions decreased from two days to 1.08 hours. As temperature declined further, the rate of degradation decreased until the solution was completely frozen; at -30 degrees C, the t90 had increased to 13 days. Amoxicillin sodium is unstable in aqueous solutions stored between 0 degrees C and -20 degrees C. If admixtures of this drug are to be frozen for later use, the storage temperature should be below -30 degrees C. ------- Posted by D. McAuley on February 23, 2001 at 21:14:01:On second thought, why complicate a simple process. I think the best way to accomplish this is not to reconstitute the antibiotics. Break up the doses into 250 or 500mg aliquots or whatever, and place into small unit of use plastic containers with a screw-on top (we currently use these in our outpatient methadone clinic). Create some batch labels with reconstitution information and storage requirements and your done�. What do you think�. |
| Question: | Posted by MichiganRPh
on February 15, 2001 at 16:22:26:
Bracing for a possible nation-wide succinylcholine shortage, what are other institutions planning on using for rapid-sequence intubation? |
| Responses: | Posted by D.
McAuley on February 15, 2001 at 23:44:38:I was not aware of the
impending shortage. Currently, there has not been any reports sent to
the FDA (see link below).The only viable alternative would be mivacron.
It has a similar onset and short duration of action. Zemuron has a
similar onset, however has a much longer duration of action. What do you
think?
Posted by Michiganrph on February 17, 2001 at 07:11:09:Although I I agree with the choice of mivacurium or possibly rocuronium, I think for the needs of rapid-sequence intubation I feel rapacuronium might be the best choice. Rap had a quicker onset of action and shorter duration when compared in a study. As far as the shortage, that was just the word up here in Flint. Any additional coments appreciated. Posted by D. McAuley on February 17, 2001 at 10:31:37: You are right, this is another possibility. I am including a link to some studies. It may take a little while to load (size: @ 90 kb).Comparisons |
| Question | Posted by abdulhamid
on February 09, 2001 at 08:43:13:
hello every body, |
| Responses: | Posted by D.
McAuley on February 09, 2001 at 14:21:48:
ReoPro is a protein solution and has the potential to form fine, translucent proteinaceous particles over the shelf life of the product. Filtration with either a 0.2 or 0.22 micron filter should remove any fine translucent particles, and should be performed as a routine precaution during dosage preparation. As stated in the prescribing information for ReoPro, solutions containing visibly opaque particles should NOT be used. To prepare ReoPro for bolus administration, withdraw the necessary amount of ReoPro for the bolus dose into a syringe. Filter the bolus injection using a sterile, non-pyrogenic, low protein-binding 0.2 or 0.22 micron filter. The prescribing information for ReoPro recommends the use of a Millipore SLGV025LS filter or equivalent. To prepare ReoPro for continuous infusion, withdraw the necessary amount of ReoPro for the continuous infusion into a syringe. Inject into an appropriate container of sterile 0.9% saline or 5% dextrose and infuse at the calculated rate via a continuous infusion pump. The continuous infusion should be filtered either upon admixture using a sterile, non-pyrogenic, low-protein-binding 0.2 or 0.22 �m syringe filter (Millipore SLGV025LS or equivalent) or upon administration using an in-line, sterile, non-pyrogenic, low-protein-binding 0.2 or 0.22 �m filter (Abbott #4524 or equivalent). Conversations with various filter manufacturers and/or Centocor and/or laboratory testing at Centocor indicate that the following filters are equivalent to Millipore SLGV025LS arranged by filter membrane composition 1. Cellulose acetate membrane Conversations from various filter manufacturers and/or Centocor and/or laboratory testing at Centocor indicate that the following filters (arranged by filter membrane composition) are equivalent to Abbott #4524: 1. Cellulose acetate membrane Reference: 1. Eli Lilly & Co. ReoPro Summary of Product Characteristics. May 1999. |
| Question: | Posted by Erin
Hanson on February 01, 2001 at 11:34:10:
What does the phrase "type b medication" mean? Especially if your pregnant. |
| Responses: | Posted by
D.McAuley, pharmacist on February 01, 2001 at 23:54:42:
This is the definition from the FDA. Most drugs in this category are
considered safe, however their may be exceptions. See the link below: |
| Question: | Posted by
D.McAuley on January 28, 2001 at 08:46:40:
What formula is everybody using out there to generate an empiric kel for vanco. Currently at our institution we are switching from: Vanco kel= 0.0016 x Crcl to kel= (0.00083 x crcl) + 0.0044 |
| Responses: | Posted by Tina Mosbacher on March 14, 2001 at 12:35:18: We use (0.00083 x crcl) + 0.0044 |
