Recent pharmacy updates

Zosyn, Enoxaparin, DOAC indications, IV acetaminophen, albuterol and Duoneb

There have been a few recent updates in pharmacy:

• “Per pharmacy” order changes for Zosyn and Enoxaparin. Use the orders pictured below when ordering Zosyn and Enoxaparin for DVT prophylaxis. The “per pharmacy” orders associated with these indications will be or have been retired. The historical “per pharmacy” orders imply a consult and a greater level of engagement than the department can provide (such as progress notes, full chart review, etc.) for these meds. The pharmacy will continue to monitor both drugs for changes related to renal function and weight for the initial indication, and the orders below have built-in decision support to help provide a more accurate initial dose than historical defaults can provide.

• DOAC (direct acting oral anticoagulant) indications: Xarelto (rivaroxaban), Eliquis (apixaban) and Pradaxa (dabigatran) orders require an indication when ordering them. When the indication is unknown, pharmacists spend a significant amount of time determining the indication to ensure that the correct dose or renal adjustment is chosen. Asking the entering providers to choose the appropriate indication (if known) will help the pharmacists greatly to ensure the right dose is being given. There will be a “home medication, indication unclear” for those instances where you don’t know, either:

• Changes pending to IV acetaminophen restrictions: The cost of IV acetaminophen has come down significantly and the restrictions have been re-evaluated by the P&T Committee. A change in Epic that will allow ordering of 24 hours of therapy at a time (i.e. q6h x4 doses or q6h PRN x4 doses) is pending. The order will be available paired with an order for acetaminophen tablet, liquid or suppository, so that IV acetaminophen can be more available for patients who cannot tolerate the oral or rectal administration.
• Frequency required for albuterol and Duoneb orders: Albuterol and Duoneb require a frequency when being ordered. Because of the historical default, many of these orders are being scheduled for patients without a history of respiratory illness. When asked, the ordering provider was happy to bless a PRN order instead, and had ordered a scheduled dose mostly because it was the default in Epic.
• Duplicate therapy: In part because of an acute and severe shortage of both Duoneb and ipratropium, pharmacists and respiratory therapists will remove orders for ipratropium if revefenacin (a LAMA agent) is already ordered. This will help stretch the limited supply.