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PRESCRIBING POLICIES:
4.6 PHARMACIST-MANAGED IV-PO
CONVERSION PROGRAM
POLICY
The oral dosage form for
treatment courses of select parenteral drugs will be promoted by
permitting pharmacists to review and change the route of administration
of selected medications in accordance to established criteria.
PROCEDURES
Pharmacy:
1. A clinical pharmacist will assess patients receiving the drugs listed
below to
determine if oral therapy is feasible.
2. If patients meet the criteria for oral conversion continues to need
medication is
clinically stable is capable of tolerating the oral dosage from and has
no factors
present e.g. gastrointestinal abnormalities or drug interactions that
would
adversely affect oral bioavailability, the pharmacist will write the
order for the
equivalent oral regiment, specifying the next administration time, in
the
Physician’s orders.
3. Pharmacist will document the rationale for the dosage form selection
in the
Progress Notes.
4. In collaboration with the prescribing physician and the balance of
the health care
team, the pharmacist will monitor patient for clinical progress and
medication
tolerability, and may convert the patient back to parenteral therapy as
required.
5. Pharmacists should ensure that “IV->PO Conversion Service”
comment-line is in
the PCIS system.
6. The pharmacist will consult with the physician prior to conversion
for antimicrobial
drugs listed in Group 3 in the table below or if antimicrobial therapy
is less than
48 hours.
List
of IV Drugs Eligible for Conversion to PO by a Pharmacist
1)
Antimicrobials –
Patients must receive 48 hours of IV antimicrobials before the
pharmacist
can convert to PO independently. If therapy is < 48 hours, pharmacist
must
consult with a physician.
Group 1
(similar AUC achieved with oral dosage form of same drug):
-
Ciprofloxacin
-
Clindamycin
-
Co-trimoxazole
-
Fluconazole
-
Moxifloxacin
-
Metronidazole
Group
2
(lower AUC achieved with oral dosage form of same drug):
-
Acyclovir will be converted to Valacyclovir
-
Ampicillin will be converted to Amoxicillin or
Amoxicillin-clavulanate
-
Cefazolin will be converted to Cephalexin
-
Cefuroxime will be converted to Cefuroxime axetil
-
Penicillin G will be converted to Penicillin V
Group 3
(different drug - selection based on pathogen susceptibility and no
contraindications to therapeutic alternative) - Note: Prior discussion
with prescribing physician is required.
-
Ceftriaxone will be converted to Fluoroquinolone
-
Imipenem-cilastatin will be converted to 1) Ciprofloxacin
+
Clindamycin/MetronidazoleOR 2) Amoxicillin-clavulanate + Ciprofloxacin
OR 3)
Moxifloxacin + Metronidazole
-
Cloxacillin will be converted to Cephalexin
-
Erythromycin will be converted to Clarithromycin
-
Ticarcillin-clavulanate will be converted to 1)
Ciprofloxacin +
Clindamycin/Metronidazole OR 2) Amoxicillin-clavulanate
+ Ciprofloxacin OR 3)
Moxifloxacin + Metronidazole
2)
Proton Pump Inhibitors
and H2 blockers - Patients must be taking other PO/NG meds or food
and there must be no endoscopically confirmed high risk acute
upper GI bleeding
peptic ulcer disease/rebleeding within past 72 hours
(“high risk” as per endoscopy
report = active bleed or hemorrhage or
presence of a non-bleeding visible vessel or
presence of adherent clot).
-
Pantoprazole IV (all IV pantoprazole doses, i.e.
pantoprazole IV infusions, 40mg IV
daily, 40mg IV BID) is converted to lansoprazole PO or lansoprazole fastabs (if
unable to swallow tablets)
-
Ranitidine IV is converted to PO form; dose adjusted for
renal dysfunction
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