The C&W PT&N Committee welcomed members from Health Authorities outside of PHSA to join our deliberations regarding recommendations to the Provincial Pharmacy and Therapeutics Committee regarding pediatric medication issues.

1. Policies & Procedures:

The following policies & procedures have been approved and are being reformatted for posting on the C&W intranet:

Dose Standardization for Oral Medications

• The Dose Standardization Policy was established in 1996 in order to optimize the standard pre-packs stored in the Pyxis medstations.

• The policy permits the rounding of doses of oral medications up to 20% to align with commercially available tablet sizes and/or pre-packaged unit dose amounts of liquid formulations. Physicians can specify “do not round dose” if desired.

• The policy only applies to patients weighing more than 5 kg and older than 3 months of age. There is a list of oral medications that are excluded and will not have their dosage rounded (including chemotherapy agents). Link to BCCH Policy

• If pharmacy rounds a dose, the change will be communicated back to the prescriber and health care team via a pre-printed order form.

IV Fentanyl Women’s Hospital

• Fentanyl may now be administered by nurses via the IV direct route in areas outside of the Delivery suite,OR/PAR in BC Women’s Hospital, The BC Women’s Parenteral Drug monograph and fentanyl policies have been updated to reflect the change.

Octreotide

• IV intermittent route of administration has been approved when used in the management of chylothorax. Drug Dosage Guidelines and Parenteral Drug Manual monographs have been updated to reflect the change.

2. Additions to Formulary:

Provincial Formulary Alignment - A province-wide formulary is being created. The goal is to align the formularies in all institutions across BC. The committee is

reviewing the impact on Children’s & Women’s Hospitals.

The following medication has been added to formulary:Carbetocin - For caesarian sections to reduce blood transfusions. More information, education, and a parenteral drug monograph will be forthcoming over the next few months.

3. Medication Backorders:We continue to face shortages of a number of medications. The Pharmacy Department continues to monitor supplies and usage. In cases where we anticipate supply issues within a period of 4 weeks or less, pharmacy will coordinate alternate source or therapeutic agents for patients. We are reviewing all affected medications in a systematic fashion in order to minimize the impact on direct patient care.

Current medications of concern include:Pancuronium (anticipate supply issue at end of August 2012 lasting until late 2013)Loxapine injection (currently, unknown duration)Aminophylline (end of August to end of October 2012)

Please continue to switch to enteral route for all medications as soon as clinically feasible. Updates are available on the C&W Intranet page “Sandoz” button and are provided on an as needed basis for stock issues that directly affect patients and prescribers at BC Children’s Hospital, BC Women’s Hospital, Sunny Hill and Child & Adolescent Mental Health.

4. Pre-Printed Orders:

The following pre-printed orders were approved:

BC Women’s Hospital:o CL1100 app B second trimester Post-Deliveryo CP0700 app A Postpartum Vag PhysRM o CP0700 app B Postpartum CS Physo CV0700 app A VTE prescribers orders

BC Children’s Hospital:o Low dose dopamine on 3B o Orders for the febrile infant under 60 dayso Cardiac catherization (x2)

- Post Cardiac Catherization- Post Cardiac Catherization 3M

o Renal Transplant orders (x3)- Pre and Intraop Renal Transplant- Prescribers orders for PICU Post Renal

Transplant- Prescriber’s Orders for Post Renal

Transplant

Pharmacy Informer

Summer 2012

Updates  from  C&W  Pharmacy,  Therapeu7cs,  and  Nutri7on  (PT&N)  Commi=ee  Roxane  Carr,  BScPharm,  PharmD  and  

Don  Hamilton,  BScPharm  

Children's and Women's Health Centre of BC, Department of Pharmacy

Pater hoc audiens non potuit filium arguere ulterius

MAG-CP: Magnesium Sulphate (MgSO4) for Fetal Neuroprotection of the Preterm Infant

Dane De Silva and Dr. Laura Magee

Preterm birth is the leading cause of infant death, illness, and disability in Canada and worldwide. Despite marked improvements in survival rates of preterm infants, the risk of neurodevelopment impairment, including cerebral palsy (CP), is substantial and not improving. The overall prevalence of CP is 2-2.5 per 1000 live births, but the risk is up to 80-fold higher for babies born at <28 weeks. Strategies to reduce CP are urgently needed. MgSO4 for fetal neuroprotection has been shown to improve the neurodevelopmental outcomes of children born preterm through randomized controlled trial evidence. As such, the Society of Obstetricians and Gynaecologists of Canada (SOGC) published new guidelines recommending use of MgSO4 for fetal neuroprotection in the setting of imminent preterm birth at <32 weeks, whereby imminent preterm birth is defined as active labour ≥4cm cervical dilation with or without preterm premature rupture of membranes (PPROM), or planned preterm birth for fetal or maternal indications, and it does not include PPROM without labour.

While MgSO4 is inexpensive and used routinely in Canada for eclampsia prophylaxis and treatment, there are ongoing controversies preventing widespread implementation and administration of MgSO4 into clinical practice, including the known effect of higher doses on newborn respiratory drive and the potential for increased neonatal resuscitation requirements; inadequately studied outcomes (such as overall functioning beyond 2 years of age); and a lack of understanding about the mechanism of action of MgSO4.

The following have been recommended by the guidelines and are in place at BC Women’s Hospital:

• Tocolysis should be discontinued if antenatal MgSO4 has been started for fetal neuroprotection

• MgSO4 may be administered before tocolytic drugs have been cleared from maternal circulation, and if nifedipine has been given for tocolysis or hypertension, there is no contraindication to the use of MgSO4 for fetal neuroprotection

• A loading dose of 4 grams magnesium sulphate IV over 30 minutes, followed by a 1 gram per hour maintenance infusion should be given ideally four hours before birth until delivery, and should be discontinued if delivery is no longer imminent or a maximum of 24 hours of therapy has been administered

• Monitoring should be done according to local magnesium protocols for pre-eclampsia/eclampsia

• MgSO4 should not be used for ‘threatened’ preterm birth <32 weeks, though it is still cost-effective even if given

• Administration will not increase neonatal resuscitative requirements according to the most reliable data from clinical trials

Unfortunately, dissemination of results is not usually enough to change practice. MAG-CP will be the first managed knowledge translation (KT) project of national SOGC Clinical Practice Guidelines across Canada.

MAG-CP aims to conduct managed KT by providing maternity care practitioners across Canada with:

• essential knowledge about use of MgSO4 for fetal neuroprotection, an understanding of potential barriers to and facilitators of use of MgSO4 for fetal neuroprotection in their centre, which may be characteristics of individual care providers, relationships between care providers, or the organizational culture of their site;

• educational tools, such as informational posters, pre-printed orders, pocket cards, decision algorithms; and

• feedback on use (and potential overuse) of MgSO4 for fetal neuroprotection in practice as well as the associated maternal or perinatal outcomes.

Audit of practice and outcomes will be accomplished through the database of the Canadian Perinatal Network (CPN), a national network consisting of Canadian health care researchers in tertiary perinatal centres. The CPN links with the well-established Canadian Neonatal Network (CNN) and the Canadian Perinatal Surgery Network (CAPSNet).

For more information, an e-learning module has been put together that summarizes the relevant evidence based on the SOGC guidelines, includes questions and answers to test your knowledge, includes reference materials and educational tools, and introduces barriers to practice change to initiate discussion. It can be accessed directly from www.AdvancingIn.com or through the CME link on the SOGC webpage.

Reference:

Magee L et al. SOGC Clinical Practice Guideline. Magnesium sulphate for fetal neuroprotection. J Obstet Gynaecol Can 2011;33(5):516-29

The C&W Pediatric Drug Dosage Guidelines Sixth Edition has now been published. One copy will be distributed free of charge to pharmacists, staff physicians, fellows, residents, and nurse practitioners at C&W. Copies will also be made available on the nursing units.

The C&W Pediatric Drug Dosage Guidelines will also available for purchase from the C&W Bookstore: www.bookstore.cw.bc.ca

Standardization of Continuous Opioid Infusions

Lisa Krueckl, RN, BSN, MBA and Bernadette Kondor (BScPharm)

On May 15th Children’s Hospital implemented standard concentrations for all continuous opioid infusions throughout the hospital. This change was initiated to meet the accreditation required organizational practice

for standardizing concentrations available across the organization. Prior to May 15th, different systems (standard concentrations in PICU and NICU, non-standard concentrations in other areas) existed in the organization. The change makes practice consistent throughout the organization.

Highlights:

•Pre-printed order forms are updated to align with the ordering and administration of standard concentration continuous opioid infusions.

•Continuous opioid infusions are ordered in terms of DOSE in mcg/kg/hr (not as rate in mL/hr)

•Pumps are programmed with mcg/kg/hour DOSE (rather than mL/hour rate)o When the mcg/kg/hour DOSE is entered into the pump, the pump calculates and auto-populates

the mL/hour rateo Nurses are responsible for independently double checking the dose (mcg/kg/hour) to rate (mL/

hour) calculation•The following morphine standard concentrations are available:

Note that the standard diluents and concentrations may not be substituted.

•Standard concentration opioid syringes are:o prepared centrally in pharmacyo barcoded o stored in Pyxis® fridges on 2B, 3B, 3M, 3R, ED, PICU, and PACU

•Continuous opioid infusions are infused via Alaris syringe pumps and are programmed using a separate pump profile within the Alaris drug library. This means that all opioid infusions outside of the PICU/NICU will need to run on a separate Alaris “PCU/Brain”

•As previously, for areas other than PICU/NICU, morphine infusions for patients less than 3 months, fentanyl infusions and hydromorphone infusions are ordered and managed by the Acute Pain Service.

•As previously, morphine infusions for patients greater than 3 months are ordered and managed by any service.

•Previous pre-printed order forms contained simple analgesic, antiemetic and antipyretic agents; these are now available on a separate pre-printed order form

Ciclesonide: New Inhaled Corticosteroid on FormularyMaggie Chui, BScPharm

Reviewed by: Sheldon Spier, MD

BackgroundCiclesonide (Alvesco®) is a new inhaled corticosteroid that was added on the BC Children’s Formulary. It has been approved by Health Canada for asthma treatment in children greater than or equal to six years old.(1) Some unique pharmacokinetic properties include (2,3):

• Pro-drug that is inactive until it reaches the lung where it is converted into the active metabolite desisobutyryl-ciclesonide (des-CIC)

• Low bioavailability, rapid clearance, high serum protein binding all serve to minimize the systematic exposure

• Apparent lack of clinically relevant effect on HPA axis function

Clinical EvidenceIn multiple placebo controlled trials with varying doses of ciclesonide, urine and serum cortisol levels, growth velocity and incidence of total or serious adverse events were comparable to placebo.(4-7) When compared with other inhaled corticosteroids such as fluticasone and budesonide, ciclesonide appears to be equivalent in terms of efficacy and may offer potential benefits in terms of toxicity.(8-12) Some potential advantages of ciclesonide include:

• Less effect on lower leg growth rate when compared to fluticasone.(10)• Less effect on twenty four hour urine cortisol compared with fluticasone and budesonide.(8,9,11) • A case report of four children with adrenal suppression due to inhaled fluticasone, normalization of

HPA-axis function was also found after switching to ciclesonide.(13)

What You Need to Know• Ciclesonide is prescribed based upon the severity of asthma and response to treatment. Significant

improvements in asthma symptoms may be seen within 4 to 7 days. Titrate to lowest effective dose (Table 1).

• Once daily dosing should be considered as an outpatient basis once asthma is well controlled.• Use with valved chamber (Aerochamber ®) is recommended. Although the fit of the ciclesonide into the

Aerochamber® may not be perfect, the manufacturer reassures prescribers that the clinical effects of the aerochamber will not be affected.

• Adverse effects: dysphonia, hoarseness and oral thrush may be present but less prevalent than other inhaled corticosteroids. Rinse mouth after inhalation.

• Only ciclesonide 200 mcg/puff inhalers will be carried on formulary at BC Children’s. Any orders for Ciclesonide 100 mcg twice daily will be automatically substituted to 200 mcg once daily.

References1. Alvesco ® (ciclesonide inhalation aerosol). Drug Product Monograph. Nycomed Canada Inc. 2009. 2. Kelly H. Comparison of Inhaled Corticosteroids: An Update. Annals of Pharmacotherapy 2009;43:519-527.3. Ahmet A, Kim H, Spier S. Adrenal Suppression: A Practical Guide to the Screening and Management of this Under-Recognized complication of Inhaled Corticosteroid Therapy. Allergy, Asthma & Clinical Immunology 2011;7:13.4. Pedersen S et al. Efficacy and safety of three ciclesonide doses vs placebo in children with asthma: The rainbow study. Respiratory medicine 2010:104;1618-1628.5. Brand P et al. Ciclesonide in wheezy preschool children with a positive asthma predictive index or atopy. Respiratory Medicine 2011:105;1588-1595.6. Skoner D et al. Assessment of long-term safety of inhaled ciclesonide on growth in children with asthma. Pediatrics 2008;121:e1-e13. 7. Gefland E et al. Once daily ciclesonide in children : efficacy and safety in asthma. Journal of Pediatrics 2004;148:377-83.8. Vermeluen J et al. Randomized comparison of the efficacy and safety of ciclesonide and budesonide in adolescent with severe asthma. Respiratory Medicine 2007;101:2182-2191.9. von Berg A et al. Comparison of the efficacy and safety of ciclesonide 160 mcg once daily vs budesonide 400 mcg once daily in children with asthma. Pediatric Allergy and Immunolgy 2007;18:391-400.10. Agertoft L et al. Lower leg growth rates in children with asthma during treatment with ciclesonide and fluticasone propionate. Pediatric Allergy and Immunolgy 2010;21:e199-205.11. Pedersen S et. al. A Comparative study of inhaled ciclesonide 160mcg/day and fluticasone propionate 176mcg/day in children with asthma. Pediatric Pulmonology 2006;41:954-961.12. Pedersen S et al. Efficacy and safety of ciclesonide once daily and fluticasone propionate twice daily in children with asthma. Pulmonary Pharmacology & Therapeutics. 2009;22:214-220. 13. Heller M et al. Reversal of adrenal suppression with ciclesonide. Journal of Asthma 2010;47:337-339.

60 or 6 U? Safe medication order writing is not a new topic. For years reports and statistics generated from organizations like the Institute for Safe Medication Practices (ISMP) and Accreditation Canada have highlighted potential and actual medication errors that have resulted from misinterpreted orders.

C&W Pharmacy and Therapeutics Committee recently updated their policy on Medication Order Requirements. This policy highlights the basics of elements required in an order:

1) Patient name and a second identifier (ex. MRN, date of birth)2) Date and Time3) Generic drug name (unless a combination product)4) Dose with correct SI unit5) Route of administration6) Frequency of dose7) Prescribers name, signature and College ID (pager or phone number also helps!)

You may have also noticed bright posters on units and in clinics showing which abbreviations are not to be used when hand- or type- writing a medication order or document. This list is also found on the back of Physicians Order Forms or in the appendix of the policy.

It is the responsibility of ALL healthcare professionals (HCP) to provide a clearly communicated medication order and also to model this practice to learners. When writing or communicating a medication order, HCP should provide all necessary medical details to ensure federal and provincial laws and regulations are met.

For more information, the policy can be found on Medworxx, search for policy name Medication Order Requirments or click: Medication Order Requirements (link to C&W policies)

Research, Education and AwardsJennifer Kendrick, BScPharm, PharmD

Editorial Board

Eva Cho, BScPharm (Editor) echo2@cw.bc.ca

Sonia Jeffries, BScPharm

Kendra Sih, BScPharm, PharmD

Roxane Carr, BScPharm, PharmD (PT&N Liaison)

Dom Khoo, BScPharm (IS&T Liaison)

June Yee, BScPharm (WH PT&N Liaison)

Editor’s CornerWe would like to thank Jennifer Kendrick for her contributions and work as Editor in the past 2 years, and welcome Kendra Sih to the editorial team! Please contact the Editor if you would like to be added to the distribution list. The Editorial team welcomes comments and ideas. We will be publishing select letters to the Editor in future editions.

ResearchElbe D, Lalani Z. Review of the pharmacotherapy of irritability of autism. J Can Acad Child Adolesc Psychiatry. 2012;21:130-46.

Dionne JM, Lou K, Er L, Collin K, White CT. Pharmaceutical cost distribution in childhood chronic kidney disease. Pediatr Nephrol 2012; May 1 [epub ahead of print].

Kendrick JG, Ma K, DeZorzi P, Hamilton D. Vomiting of Oral Medications by Pediatric Patients: Survey of Medication Redosing Practices. Can J Hosp Pharm. 2012;65:196-201.

Kiang TKL, Sherwin CM, Spigarelli MG, Ensom MHH. Fundamentals of Population Pharmacokinetic Modelling: Modelling and Software. Clin Pharmacokinet. 2012 Jun 7. doi: 10.2165/11634080-000000000-00000. [Epub ahead of print]

Samilski, J, Lau T, Elbe D, et al. Drug Use Evaluation of Moxifloxacin (Avelox) Using a Hand-Held Electronic Device At a Canadian Teaching Hospital. Pharm Ther 2012;37:291-9.

Thalakada R, Legal M, Lau TTY, Luey T, Batterink J, Ensom MHH. Development and Validation of a Novel Vancomycin Dosing Nomogram for Achieving High-Target Trough Levels at Two Major Canadian Teaching Hospitals. Can J Hosp Pharm. 2012;65:180-7.

Tseng A, Foisy M, Hughes CA, Kelly D, Chan S, Dayneka N, Giguere P, Higgins N, Hills-Nieminen C, Kapler J, La Porte CJL, Nickel P, Park-Wyllie L, Quaia C, Robinson L, Sheehan N, Stone S, Sulz L, Yoong D. Role of the pharmacist in caring for patients with HIV/AIDS: Clinical practice guidelines. Can J Hosp Pharm 2012;65:125-45.

AwardsDean Elbe received the BC Mental Health and Addiction Services “Best Value” Award of Excellence in May 2012.

EducationDean Elbe has completed the review and update of psychiatric medication information handouts for children and families, now available via the BC Mental Health & Addictions Services Kelty Mental Health website at: http://keltymentalhealth.ca/treatment/medications

Safe Medication Order WritingKendra Sih, BScPharm, PharmD