Learning Objectives Recap prescribing errors and near misses APINCH Safely prescribe medications continuation National Inpatient Medication Chart NIMC Discharge prescription Go through Overview of PBS syste ID: 1046077
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1. Prescribing SummaryPharmacy Department
2. Learning ObjectivesRe-cap prescribing errors and near misses (APINCH)Safely prescribe medications (continuation):National Inpatient Medication Chart (NIMC)Discharge prescription- Go throughOverview of PBS systemResources for informationPrinciples of Renal dosingUnderstanding for Vancomycin dosingAsk questions anytime!
3. Prescribing Errors and Near Misses
4. National Inpatient Medication Chart (NIMC)-Adapted- FrontRegular Medications SectionVTE Prophylaxis SectionVariable DoseWarfarin DoseVTE Prophylaxis
5. National Inpatient Medication Chart (NIMC)-Adapted- Back“As Required” (PRN) SectionOnce-only orderTelephone orderPrescribing principles
6. Discharge PrescriptionEnsure prescriber no. is legible. Specify days for warfarin dosingDAs require quantity and no. of repeats in words and figuresWrite duration in days as well a quantity for short course medicationsChange combination product back on dischargeComplete ADR/allergy (medicine and reaction)
7. Pharmaceutical Benefits Scheme (PBS)PBS website: www.pbs.gov.auThe website can be found via the Shortcuts menu (Pharmaceutical Benefits Schedule)Include information about:If the medication is covered by the PBS, and for what indicationMaximum quantity (and repeats) that can be prescribedIf an authority is required (streamline vs telephone)Exercise to look up on PBS website:AtorvastatinCiprofloxacinPregabalin
8. Pharmaceutical Benefits Scheme (PBS)Authority required benefits fall into two categories 1. Authority required (via phone call)Prescribing quantity in excess of the PBS quantity OR Medication has specific criteria as per PBS websiteContact then via 1800 888 333If approval is granted, the operator will give you an authority number that needs to be written on the prescription e.g. Z1234AB2. Authority required (STREAMILINED) (via PBS website)prescribe a medication that is only subsidised by the PBS for certain indicationsEnsure you choose the correct indication and authority number (e.g. 1234) is written on the prescription
9. Resources REFERENCETreatmentGuidelinesIndicationDoseAdmini-stration guidelinesAdverse effectsPrecautions/Contra-indicationsDrug interactionsTDMBrandsAustralian Medicines Handbook (AMH) Therapeutic Guidelines (eTG) MIMs online Australian Injectable Drug Handbook Compatibilityinformation Northern Health policies(PROMPT)**not all drugs have a NH plicy) Antibiotic Guidance PBS website
10. Ms. PatientPC: 25year female came into hospital with suspected Osteomyelitis and AKI. Medical Condition: Epilepsy, spinal surgery (3 months ago). Allergies: Flucloxacillin- Anaphylaxis Medication: Carbamezapine CR 200mg mane.
11. Impaired renal functionYou need to prescribed oral Ciprofloxacin for the treatment of osteomyelitis as per sensitivities Her calculated GFR =20mL/minWhich resources do you look for dosage adjustment? Therapeutic Guidelines (eTG) Renal Handbook AMH
12. Impaired renal functionYou need to prescribed oral Ciprofloxacin for the treatment of osteomyelitis Her calculated GFR =20mL/min
13. Ms. Patient PC: 25year female came into hospital with suspected Osteomyelitis and AKI. Both issues have treated and ready for DischargeMedical Condition: Epilepsy, spinal surgery (3 months ago). Allergies: Flucloxacillin- Anaphylaxis Medication: Carbamezapine CR 200mg mane.
14. Drug InteractionsDischarge: You would like to prescribe Cyproterone with ethinylestradiol 2mg/35microg (Diane-35 ED) for Ms. Patient.Where would you look to see if there are any drug interactions?AMHStockley’s Drug InteractionsMIMSMicromedexCurrent medications: Carbamezapine CR 200mg mane
15. Drug InteractionsYou would like to prescribe Cyrproterone with ethinylestradiol 2mg/35microg (Diane-35 ED) for a patient on Carbamazepine.
16. Crushing medications and IV therapy? Your patient has a NG tube which requires all their oral medications to be crushed? Some medications if oral and is bioequivalent to IV can changed over.Where can you look for information?Don’t Rush to Crush Handbook- Available through Mims OnlineAustralian Injectable Drugs HandbookThe Northern Health Medication ProtocolYour patient is on;Pantoprazole EC 40mg maneCeftriaxone 1g mane
17. Crushing medications and IV therapy? Your patient is on;Pantoprazole EC 40mg maneCeftriaxone IV 1g mane
18. Crushing medications and IV therapy? Your patient is on;Pantoprazole EC 40mg maneCeftriaxone IV 1g mane
19. Medication ProtocolYour Patient is to start IV Vancomycin. Where do you look for information?Local hospital medication protocol Australian Injectable Drug HandbookMicromedexPolicy/Procedures (PROMPT)
20. Medication ProtocolTIP: always use the electronic version rather than downloaded version.
21. VancomycinIV: MRSA cover. Oral (NG or PR): C.diffWhy do we still struggle to dose it?Patient specific, based on…Renal functionWeightLoadingMaintenanceMonitoringAdjustingRequires Guidancehttps://guidance.nh.org.au
22. Principals of renal dosing These patients have the same Weight HeightCreatinine Is their renal function the same?No: need to factor in age and gender
23. Principals of renal dosing These patients have the same:CreatinineAgeeGFRIs the eGFR an accurate estimate of renal function?No, use the Cockroft-Gault formula to calculate CrCl (or use an online calculator!)
24. Creatinine ClearanceeTGAMH
25. Which weight should you use?These patients are both the same weightThese patients have BMIs within the normal range- actualThis patient’s BMI is 15- actual, but interpret with cautionReported eGFR based BSA 1.73m2
26. Which weight should you use?Summary‘Normal’ weight: Actual BWUnderweight: Actual BWHigh BMI & muscular: Actual BWHigh BMI & Obese: ideal or lean BW
27. Other things to consider…Current clinical pictureTrends in renal functionUrine outputHow the drug is clearedToxicity of drug – risk vs benefitAny nephrotoxic agents
28. Vancomycin-Loading Dosage55kg & CrCl: 45ml/min95kg & CrCl: >90ml/min75kg & CrCl 15ml/min
29. Vancomycin-Maintenance Dosage55kg & CrCl: 45ml/min95kg & CrCl: >90ml/min75kg & CrCl 15ml/min
30. Vancomycin- TDM
31. Vancomycin- Dosage Adjustment55kg & CrCl: 45ml/min95kg & CrCl: >90ml/min75kg & CrCl 15ml/min
32. Vancomycin SummaryDosed based on weight and renal functionFor patients of extremes of body weight <50kg, >120kg or BMI >35 discuss with ID/AMSTrough levels for monitoring at:48h for CrCl>20ml/min, GIVE the next dose24h for CrCl<20ml/min or RRT, WITHOLD next dose until level backAdjust dose based on levels, checking it has been taken at the correct timeLinear kineticsMonitor renal function until level is stable, with dose increasesIf the vancomycin levels are increasing – consider AKIAsk if you’re not sure!
33. Questions…