Archived Message board responses
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CAN U PROVIDE ME WITH A CHART OF DRUG INTERACTIONS, SOMETHING THAT INCLUDES DRUGS NAMES AND SEVERITY OF INTERACTIONS FOR EACH REACTION (AS e.g. mild, moderate, severe.

Recommend using Doctor Koop's site located here: http://www.drugchecker.drkoop.com/apps/drugchecker/DrugMain?cob=drkoop

• Dr. Koop's Site

AN 82Y/O WOMEN HAS BELOW THE KNEE AMPUTATIONS (BOTH LEGS). HOW DO I ACCOUNT FOR THIS WHEN DOSING TOBRAMYCIN?

In Reply to: TOBRAMYCIN/AMPUTEE DOSING posted by SHAWN KELLEY, RPH on August 11, 2001 at 16:06:10:

A similar question was asked in an earlier post. Here is the response:

Many practitioners will use the patient�s pre-amputated height to calculate an estimated ideal body weight and then use this info to calculate an estimated creatinine clearance. It should be noted that the reliability of these empiric equations declines proportionately with the significance of the amputation(s). Your next step will depend on the severity of the underlying infection. If the patient is critical and you are dosing a patient on an aminoglycoside, you can obtain two levels off the first dose and then calculate an elimination rate constant as well as the volume of distribution. If the condition is not critical, the impact of your estimation should not have a profound effect on the eventual steady state concentrations. As with most consults, the patients underlying clinical status (e.g. hydration status, cardiac and renal function, etc) play a much greater role. In sum, because of the multiplicity of clinical tools available to you, the overall impact of an estimation can be notably reduced�� Note: without being given the specifics regarding this patient, it is very likely that the actual body weight will be used to estimate the creatinine clearance (eg ABW < IBW). If this is a critical patient, then the best approach would be to obtain levels off the first dose as noted above.

Repligen Corporation is developing a drug to possibly help symptoms of autism. It is secretin, a gastrointestinal hormone that stimulates the pancreas to release bicarbonate in response to gastric acid. For more details their website is http://www.repligen.com

Please search the National Institutes of Health website:
National Center for Complementary and Alternative Medicine (NCCAM)  http://nccam.nih.gov/

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Posted by Lori Huber on August 29, 2001 at 13:35:43:

II have read a lot of articles that deal with a restrictive diet for autistic children. It is a very strict diet that limits many products, but most parents that have tried it swear by it. Almost any web site dealing with autism would point you in the right direction.

Is anyone aware of a commercially available kit for process validation, other than the "Attack" kit??

Process validation and an overview is provided by Millipore: http://www.millipore.com/biopharm/qa.nsf/docs/hospitalvalidate
Millipore

Any information on stability of fat emulsion in 3in1?
Some hospitals are only hanging lipids for 12 hours because of the possibilty of growth at room temp. Also
dose 1.2mic filter prevent growth?

J Pharm Biomed Anal 2001 Mar;24(5-6):1099-109
Analysis of all-in-one parenteral nutrition admixtures by liquid chromatography and laser diffraction: study of stability.

Sforzini A, Bersani G, Stancari A, Grossi G, Bonoli A, Ceschel GC.

Pharmacy Service, S. Orsola-Malpighi University Hospital, 40126 Bologna, Italy. [email protected]

All-in-one parenteral nutrition admixtures are complex lipid emulsions (oil/water) which require absolute sterility, stability and no precipitates. Particle diameter must be in the range 0.4--1 microm in order to mime the size of chylomicra. Added vitamins must not degrade during infusion time (24 h). In this study, the physicochemical stability of parenteral nutrition admixtures was tested in the course of time at different storage temperatures. Two liquid chromatographic methods, based on solid phase extraction (SPE), were developed for fat-soluble vitamin determination. Stability studies were carried out on three industrial lipid emulsions and on six compounded all-in-one admixtures. They were stored at three different temperatures: 4 degrees C (storage), 25 degrees C (compounding) and 37 degrees C (infusion); then they were analyzed at starting time and at 24, 48 and 72 h after compounding. Particle diameter was determined by means of Laser Particle Sizer Analysette 22, which uses laser diffraction technique (light scattering -- reverse Fourier optics). Fat-soluble vitamins (retinol palmitate and alpha-, delta-, gamma-tocopherol) were determined in admixtures with a branded vitamin compound called Idroplurivit Liofilizzato. Samples were extracted by SPE on C(18) cartridges, then they were separated by reversed-phase liquid chromatography (LC) and detected by ultraviolet detection (retinol palmitate) and electrochemical detection (tocopherols). Laser diffraction analysis pointed out that particle size did not change in the course of time at the tested temperatures. LC analysis showed that vitamins interact each other and degrade after compounding at different times and storage temperatures; only retinol palmitate is stable at 37 degrees C. Retinol palmitate recovery was 98%, coefficient of variation (CV) 5.4%, detection limit 25 microg/l, limit of quantitation 75 microg/l and there were not interfering substances. Tocopherols average recovery was 99%, CV 3.5%, detection limit 15 ng/l and limit of quantitation 50 ng/l. In conclusion, all-in-one parenteral admixtures were proved to be physically stable under analysis conditions, but degradation of retinol palmitate and tocopherols requires admixtures with vitamins to be infused within 24 h after compounding.

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Am J Health Syst Pharm 1995 Mar 15;52(6):623-34
Physicochemical stability of total nutrient admixtures. Driscoll DF, Bhargava HN, Li L, Zaim RH, Babayan VK, Bistrian BR.

New England Deaconess Hospital, Nutrition/Infection Laboratory, Boston, MA 02215, USA.

The effect of six independent factors on the stability of i.v. nutritional emulsions was studied. Forty-five i.v. nutritional admixtures were prepared, each containing the following: (1) amino acids (range, 2.5-7%), (2) hydrated glucose (range, 5-20%), (3) lipid emulsion (range, 2-5%), (4) monovalent cations (range, 0-150 meq/L), (5) divalent cations (range, 4-20 meq/L), and (6) trivalent cations (range, 0-10 mg of elemental iron/L). Stability assessments included particle-size analysis, pH determination, and visual inspection. Sizing and counting of fat particles was achieved by using light obscuration and dynamic light scatter methods. Light obscuration and visual assessments were performed at 0, 6, 12, 24, and 30 hours. Dynamic light scatter and pH determinations were performed at 0 and 30 hours. Multiple stepwise regression analysis revealed that trivalent cation concentration was the only variable that affected the stability of nutritional emulsions (p < 0.00001), accounting for approximately 60% of the potentially dangerous increases in fat particle sizes observed. In addition, a percentage of large fat particles (> 5 microns in diameter) greater than 0.4% was associated with unstable emulsions. However, this instability was visibly evident only 65% of the time. Changes in mean globule diameter, cream-layer thickness, and pH did not reveal instability in these emulsions. Emulsions in which > 0.4% of the initial fat concentration consists of particles of > 5 microns in diameter are likely to become unstable. Of the six factors studied, the trivalent cation in iron dextran was most disruptive to lipid-based parenteral nutrient admixtures.

Anyone know of a good on-line list of medications that can/cannot be broken or crushed?

The link in the clinical protocols section has been updated, but here it is:
http://www.factsandcomparisons.com/assets/hospitalpharm/Crush-2000.pdf

I am trying to find a nomogram for determination of body surface area from height and weight that is for children and adults that I can copy from the computer

http://www.sci.mus.mn.us/heart/lessons/nomogram_adult.htm

A local urologist has asked if there is any new drug entity other than SSRI's available or soon to be available for the treatment of premature ejaculation. I cannot find anything in the usual channels. He thinks he read something in an Italian journal.
Does anyone have any new info on this topic?
Thanks in advance.

Many patients have responded to therapy with a quinolone such as ciprofloxacin. This is due to the high incidence of prostatitis in patients presenting with premature ejaculation. Other patients (those without prostatitis) may respond to increasing dosages of clomipramine or similar agents. Here are a few abstracts and there findings:

Urology 2001 Aug;58(2):198-202
Prevalence of chronic prostatitis in men with premature ejaculation.
Screponi E, Carosa E, Di Stasi SM, Pepe M, Carruba G, Jannini EA.
Division of Medicine of Reproduction and Sexology, Department of Experimental Medicine, University of L'Aquila, L'Aquila, Italy.

OBJECTIVES: To investigate the prevalence of chronic prostatitis in men with premature ejaculation. The etiology of premature ejaculation is currently considered psychological in nature. However, the possibility that urologic, hormonal, or neurologic factors may contribute to this condition should be considered in its management. METHODS: We evaluated segmented urine specimens before and after prostatic massage and expressed prostatic secretion specimens from 46 patients with premature ejaculation and 30 controls by bacteriologic localization studies. The incidence of premature ejaculation in the subjects with chronic prostatitis was also evaluated. RESULTS: Prostatic inflammation was found in 56.5% and chronic bacterial prostatitis in 47.8% of the subjects with premature ejaculation, respectively. When compared with the controls, these novel findings were statistically significant (P <0.05). CONCLUSIONS: Considering the role of the prostate gland in the mechanism of ejaculation, we suggest a role for chronic prostate inflammation in the pathogenesis of some cases of premature ejaculation. Since chronic prostatitis has been found with a high frequency in men with premature ejaculation, we stress the importance of a careful examination of the prostate before any pharmacologic or psychosexual therapy for premature ejaculation.
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J Gend Specif Med 2000 Jul-Aug;3(5):45-52
Sexual pharmacology in the 21st century.
Rosen RC.
Department of Psychiatry, Center for Sexual and Marital Health, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

Sexual dysfunction is highly prevalent in both sexes. Considerable progress has been made in the development of new pharmacologic treatments since the approval of sildenafil in 1998. A variety of oral erectogenic agents are available or are in late-phase development, including centrally active dopamine agonists (e.g., sublingual apomorphine), peripheral nonselective alpha-blockers (e.g., oral phentolamine), and other phosphodiesterase type-5 inhibitors (e.g., vardenafil). These drugs have recently been evaluated for the treatment of female sexual arousal disorder, although results to date have been inconclusive. Pharmacologic therapies have also been proposed for the treatment of premature ejaculation and hypoactive sexual desire disorder. Strong evidence exists for the value of serotonergic drugs (e.g., selective serotonin reuptake inhibitors) in the treatment of premature ejaculation. Further research is needed, particularly on the effects of these drugs on female sexual dysfunction.

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BJU Int 2001 Mar;87(4):357-60
Effective daily treatment with clomipramine in men with premature ejaculation when 25 mg (as required) is ineffective.
Rowland DL, De Gouveia Brazao CA, Koos Slob A.
Department of Family and Population Health, Johns Hopkins School of Health &, Hygiene, Baltimore, MD, USA. [email protected]

OBJECTIVE: To determine whether men with premature ejaculation who fail to respond to 25 mg clomipramine as needed improve when taking 10-30 mg clomipramine daily. SUBJECTS AND METHODS: Four men with premature ejaculation whose ejaculation latencies increased minimally or not at all when taking 25 mg clomipramine as needed participated in a prospective 12-week study consisting of four treatment phases, beginning with baseline (0 mg) and progressing through increasing daily doses of 10, 20, and 30 mg clomipramine. The subjects maintained daily logs of their sexual activities and estimated their ejaculatory response, sexual arousal and penile rigidity during intercourse. The subjects were contacted 8-15 weeks after the experiment to assess their satisfaction with and continued use of clomipramine. RESULTS: There was a dose-response effect on ejaculatory latency with increasing levels of clomipramine; 30 mg increased the latency from 25 s to 220 s, a clinically significant increase. In addition, 30 mg taken daily was significantly more effective than 25 mg as required. Other variables of sexual response (sexual interest, arousal and penile rigidity) were unaffected. At follow-up all four subjects expressed satisfaction and three continued the dose. CONCLUSION: Men with premature ejaculation who do not respond to clomipramine 'as required' are probably not insensitive to pharmacological treatment, but may simply require higher doses or a different regimen. All four subjects improved when taking daily clomipramine at varying doses. These results suggest that if initial treatment is unsuccessful, 20-30 mg daily clomipramine should be considered.

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Arch Esp Urol 2000 Nov;53(9):856-8
Comparison of the efficacy of fluoxetine alone vs. fluoxetine plus local lidocaine ointment in the treatment of premature ejaculation.
Atan A, Basar MM, Aydoganli L.
Ankara Numune Hospital, 1st Urology Clinic, Ankara, Turkey.

OBJECTIVE: The present study compares the efficacy and side effects of fluoxetine alone vs. fluoxetine plus local lidocaine ointment in the treatment of premature ejaculation. METHODS: Forty-three patients suffering from premature ejaculation were studied. The exclusion criteria were erectile dysfunction, loss of libido, alcohol and substance abuse, mental retardation, diabetes mellitus, thyroid disease, hypotension, previous use of these drugs and urogenital infections. The patients' ages ranged from 19 to 48 years (mean age 28 +/- 1.6). They had regular sexual lives. They had normal psychiatric consultation and the Glombock Rast Sexual Satisfactory Test (GRISS) psychiatric test were in accordance with premature ejaculation. RESULTS: The patients were assigned to two groups. Twenty-six patients, aged 21 to 36 years (mean age 27), received only fluoxetine 20 mg/day (1 capsule) for a week which was later increased to 40 mg/day (2 capsules). Seventeen patients, aged 19 to 48 years (mean age 31), were given fluoxetine 20 mg/day plus local application of lidocaine ointment. The patients and partners were re-evaluated 8 weeks after the treatment. The results were classified as unsuccessful, improvement and cure. The chi-square test was used for statistical analysis. In the fluoxetine group, 8 (30.8%) patients cured, 11 (42.2%) showed improvement and there were 7 failures (26.9%). In the combination treatment group, 9 (52.9%) patients cured, improvement was observed in 5 (29.4%) and failure in 3 (17.6%). Side effects in group I were observed in 6 patients (23%) and in 5 (29.4%) in group II. There were no statistical differences between the two groups according to the side effects (p > 0.01). No patients were excluded from the study due to side effects. CONCLUSION: The combination of fluoxetine plus local application of lidocaine ointment was found to be more effective than fluoxetine alone in the treatment of premature ejaculation. However, the results should be confirmed in further studies with a placebo group to rule out the placebo effect.

Trying to find a good list of sound alike drug names that might be valuable in educating the nurses about.

Regards,
Nathan Hughes

It appears a similar list available at the USP site: http://www.usp.org/frameset.htm?http://www.usp.org/reporting/review/rev_076.htm

DOES ANYONE HAVE A GOOD NURSE DRIVEN ALCOHOL WITHDRAWAL POLICY? OUR PHYSICIANS ARE NOT HAPPY WITH OUR CURRENT POLICY WHICH HAS NURSING SERVICE ASSESS AND SCORE THE PATIENT FOR WITHDRAWAL SYMPTOMS AND THEN DETERMINE THE APPROPRIATE BENZO DOSE TO ADMINISTER.

 JAMIE I couldn't find a withdrawal policy but this website has lots of alcohol related links.
http://www.medscout.com/diseases/mental/alcohol_dependence/index.htm

CAN WE MADE LIST OF MEDS THOSE CONTAIN SUGAR IN IT; SO IT CAN HELPFUL DIABETIC PATIENT.

The reference that most health care providers use is the "Drug Topics Red Book." It is doubtful that you will find a copy of the list of medications that are sugar-free on the internet. Duplication of the list contained in the reference mentioned above would be a violation of copyright. If this information is relevant to your practice or is for your own individual needs, I would recommend purchasing the reference. Check out the web link below....   2001 Red Book

DOES ANYONE HAVE (AND WILLING TO SHARE)A PROTOCOL OR GUIDELINES FOR USAGE OF AMIODARONE IN THE ACUTE CARE SETTING, (IE) VT/VFIB EMERGENCY SITUATION THANKS!

Wyeth just did an inservice for us they have a lot of info charts etc that explain the new guidelines. Also look at www.acls.net the new guidelines are included now.

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Posted by nate on October 31, 2001 at 19:49:20:

Look for the acls guidelines.
Acute vt/vfib per acls is 300 amiodarone iv push followed by a repeat 150 push if needed (along with shock, epi, etc)

We have an order to skin test a patient before giving them
a one gram dose of Ancef. Does anyone have a protocol
for doing skin testing for allergy.

I would recommend using Pre-Pen (follow instructions in the package insert). Your goal is to exclude IgE-mediated reactions (anaphylaxis, angioedema etc). If the skin test is negative you have a greater than 97% confidence level that an IgE-mediated reaction will not occur. Protocols are available for a skin prick test or intradermal test. Here is a quick summary on the subject:

http://courses.washington.edu/pharm560/Fall_Pharm560/PenicillinsCephalosporins.pdf
Washington.edu - PDF document

Does anyone have information related to using Lidocaine for anesthetic ID prior to IV starts.

If no allergies exist, you can inject small aliquots of lidocaine (0.1 to 0.2 ml) around the area of venopuncture. You may also want to consider the use of EMLA cream which was created for this very purpose.

For additional info, here are a couple of online references: Postgradmed and also here: EMLA cream etc

Intravenous admixtures containing famotidine are stable for 14 days (possibly longer). Extrapolating vial stability with admixture stability is an interesting topic. Here are a few studies regarding the admixture side of things:

Ann Pharmacother 1993 Apr;27(4):422-6

Stability of famotidine in polyvinyl chloride minibags and polypropylene syringes and compatibility of famotidine with selected drugs.  Keyi X, Gagnon N, Bisson C, Desmarais M, LeBel M. Laboratoire de Pharmacocinetique Clinique, Universite Laval, Quebec, Canada. OBJECTIVE: (1) to determine the stability of famotidine 200 micrograms/mL in admixtures with dextrose 5% injection (D5W) and NaCl 0.9% injection (NS) in polyvinyl chloride (PVC) minibags and polypropylene syringes, at room temperature (22 degrees C), protected and unprotected from light for 15 days; and (2) to evaluate the visual compatibility of famotidine with 34 selected drugs for four hours at room temperature. DESIGN: Concentration of famotidine samples was determined on day 0 and again on days 3, 6, 9, 12, and 15 by a stability-indicating HPLC. Inspection for visual and pH changes was also performed at these time intervals. RESULTS: More than 95 percent of the day 0 famotidine concentration remained in all samples over the 15-day study period. During this period, all samples remained clear and colorless and no change in absorbance at 450 and 540 nm was observed. The pH of the samples also remained unchanged. Famotidine 2000 micrograms/mL was found to be compatible with 33 selected drugs; only furosemide was found to be incompatible. A white precipitate was observed when an equal volume of famotidine 2000 micrograms/mL in NS was mixed with furosemide 3000 micrograms/mL in D5W. The concentration of famotidine in the supernatant gradually decreased during the 4-hour study period. At 0.5, 1.0, 2.0, and 4.0 hours after mixture of famotidine with furosemide, famotidine concentrations were 97.5, 23.6, 21.7, and 17.2 percent of the initial famotidine concentration, respectively. CONCLUSIONS: Our results show that famotidine 200 micrograms/mL was stable in admixture with D5W and NS in PVC minibags and polypropylene syringes when these solutions were stored at room temperature, protected and unprotected from light for 15 days. Famotidine 2000 micrograms/mL in NS was compatible with 33 of the drugs, and was incompatible with furosemide.

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DICP 1989 Jul-Aug;23(7-8):588-90 Stability of intravenous famotidine stored in polyvinyl chloride syringes. Bullock LS, Fitzgerald JF, Mazur HI. Department of Pediatrics, Indiana University School of Medicine, Indianapolis.

The stability of intravenous famotidine in dextrose 5% injection (D5W), NaCl 0.9% injection (NS), and sterile water for injection stored in polyvinyl chloride (PVC) syringes at 4 degrees C for 14 days was studied. The concentration of famotidine samples was determined at time 0, 7 days, and 14 days by reverse-phase high-performance liquid chromatography. Samples were inspected for visual changes and tested for changes in pH. Results of the HPLC analysis indicated that the famotidine samples remained within 94-100 percent and 99-103 percent of the time 0 concentrations at 7 and 14 days, respectively. Repeated measures analysis of variance demonstrated a significant time effect on famotidine concentration as concentrations changed over time (p less than 0.01). This change was small in magnitude, however, and concentrations decreased at 7 days and increased at 14 days. Famotidine is stable at a concentration of 2 mg/mL in D5W, NS, and sterile water for injection stored in PVC syringes at 4 degrees C for 14 days.

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J Clin Pharm Ther 1988 Oct;13(5):329-34
Chemical stabilities of famotidine and ranitidine hydrochloride in intravenous admixtures. Das Gupta V, Parasrampuria J, Bethea C. Department of Pharmaceutics, University of Houston, TX 77030.

The chemical stabilities of famotidine and ranitidine hydrochloride solutions in 5% dextrose and 0.9% sodium chloride injections have been studied using high-performance liquid chromatographic methods (HPLC). Both the drugs were stable for at least 15 days (loss in potency of less than 10%) at 25 degrees C and 63 days at 5 degrees C. Both drugs were comparatively less stable in 5% dextrose injection than in 0.9% sodium chloride injection. The loss in the potency of phenol, which is added as a preservative to ranitidine hydrochloride injection, was significant in both the vehicles. However, the addition of preservative in a single dose vial is not considered necessary.

Message:I am trying to locate any articles related to the subject of hypersensitivity to tincture of Iodine. One pharmacist referred me to an article by a Reynolds, 1990 in JAMA regarding this subject, but I was unable to locate it on any serach engine. (It was on Micromedex Druginfo.) Can you help, please?

Immunological
Hypersensitivity reactions including angioedema and/ or serum sickness-like reactions may be noted.
http://www.inchem.org/documents/pims/pharm/iodine.htm    Iodine