INTERN MEDICATION GUIDE 2020 - Northern Doctors · INTERN MEDICATION GUIDE Page 6 ADULT NATIONAL...
Transcript of INTERN MEDICATION GUIDE 2020 - Northern Doctors · INTERN MEDICATION GUIDE Page 6 ADULT NATIONAL...
INTERN MEDICATION GU IDE
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INTERN MEDICATION GUIDE
2020
Updated by A Given, Pharmacy December 2019
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Table of Contents:
Table of Contents: .......................................................................................................................................... 2
PHARMACY CONTACT NUMBERS ............................................................................................................... 4
MEDICATION MANAGEMENT PLAN ............................................................................................................. 5
ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC) ...................................................................... 6
Background Rationale ............................................................................................................................ 6
Overview ................................................................................................................................................ 6
Patient Identification ............................................................................................................................... 7
Allergies & Adverse drug reactions (ADR) .............................................................................................. 7
Numbering of medication charts ............................................................................................................. 8
Venous Thromboembolism (VTE) prevention .......................................................................................... 8
Regular Medication Orders ..................................................................................................................... 9
Frequency (Guidance Only) .................................................................................................................. 10
Approved Abbreviations ....................................................................................................................... 10
Prescriber identification: ....................................................................................................................... 11
Variable Dose Medications ................................................................................................................... 12
Warfarin dosing .................................................................................................................................... 12
When required (PRN) medication orders .............................................................................................. 13
Stat Dose Orders ................................................................................................................................. 13
Phone Orders ....................................................................................................................................... 13
Ceasing Medication Orders .................................................................................................................. 14
Limited Duration Medication Orders ...................................................................................................... 15
Less than daily administration............................................................................................................... 15
Re-writing Medication Charts ................................................................................................................ 15
HIGH DOSE OPIATES/INSULIN .................................................................................................................. 16
INTRAVENOUS THERAPY ORDER CHART ................................................................................................ 17
OTHER MEDICATION CHARTS .................................................................................................................. 18
DISCHARGE PRESCRIPTIONS ................................................................................................................... 19
What needs to be included: .................................................................................................................. 20
Drugs of Addiction (DA) ........................................................................................................................ 21
PHARMACEUTICAL BENEFITS SCHEME (PBS) ......................................................................................... 21
Authority PBS prescriptions .................................................................................................................. 21
PBS website ......................................................................................................................................... 23
TNH MEDICATION GUIDE ........................................................................................................................... 25
Prescribing Unfamiliar Medications ....................................................................................................... 25
Other documents/forms you may be asked to complete: ....................................................................... 25
ANTIMICROBIAL STEWARDSHIP PROGRAM ............................................................................................ 26
Antibiotic Guidance (iGuidance) ........................................................................................................... 26
The Direct Oral Anticoagulants (DOACs) .............................................................................................. 27
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ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION ........................................................................ 28
Sepsis of unclear focus ........................................................................................................................ 28
Vancomycin dosing .............................................................................................................................. 28
Acute Cystitis ....................................................................................................................................... 29
Catheter-associated UTI ....................................................................................................................... 29
Pyelonephritis ...................................................................................................................................... 29
Prostatitis ............................................................................................................................................. 30
Cellulitis ............................................................................................................................................... 30
Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) ........................................................ 30
Community Acquired Pneumonia.......................................................................................................... 31
Aspiration Pneumonia .......................................................................................................................... 31
Hospital Acquired Pneumonia............................................................................................................... 32
Peritonitis due to perforated viscus ....................................................................................................... 32
Acute cholecystitis ................................................................................................................................ 33
Ascending cholangitis ........................................................................................................................... 33
Acute Appendicitis ................................................................................................................................ 33
Acute diverticulitis................................................................................................................................. 33
Acute pancreatitis ................................................................................................................................. 34
Infected pancreatic necrosis / pancreatic abscess ................................................................................ 34
GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE ...................................................... 34
HANDY MEDICATION GUIDES ................................................................................................................... 35
Endocrinology ...................................................................................................................................... 35
End of Life Care ................................................................................................................................... 35
Vascular Device Protocols ............................................................................................................................ 36
Fluid Prescribing ........................................................................................................................................... 37
Rule of 1’s – oversimplified but memorable ........................................................................................... 37
The Real Rules: Correct but easy to forget! .......................................................................................... 37
ON-LINE TRAINING ..................................................................................................................................... 38
COMMON MEDICATION CHEAT SHEET………………………………………………………………………….39
This booklet was created by the Pharmacy Department. Available from: Medical Education Unit (MEU), located at Level 2, NH – Education, NCHER - Northern Centre Health Education & Research. Telephone: 8468 0758
Please advise suggestions/amendments to: Pharmacy Department (Team Leader for Education x58664)
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PHARMACY CONTACT NUMBERS Pharmacists are always willing to help all medical staff. All ward pharmacists are also available on MEDTASKER.
Ward pharmacist Extension
Emergency 52696
Emergency – Admissions (for MMP completion) 0447163874
SSU and CDU 0447141711
Ward 1 – Day Oncology 52094
Ward 2 – Children’s Unit 52205
Ward 3 52350
Ward 4 52472
Ward 5– Cardiology 58447
Ward 6– Observation Unit 52473
Ward 7 – Psychiatry 1 58994
Ward 8 - Psychiatry 2 52885
Ward 9 - DPU 52662
Ward 11/12 – Maternity & Special Care Nursery 52205
Ward 13 52884
Ward 14 52459
Ward 16 52477
Ward 17 - ICU 52532
Ward 18 52474
Speciality pharmacist
Oncology 52094
Renal / Dialysis 58387
Antimicrobial stewardship 58452
Hospital in the home (HITH) 52967
Clinical Trials 58571
Palliative Care 0439920501
Dispensary
Inpatient 58572
Outpatient 58571
Discharges 52204
Manufacturing 58578
Director of Pharmacy 58560
Deputy Director of Pharmacy 58561
Associate Director of Pharmacy 52663
Team Leader – Medicine 52661
Team Leader – Surgical 52662
Team Leader – Oncology + Women’s and Children’s 52094
Team Leader – Education, Development and Research 52664
Team Leader – Quality Use of Medicines & Safety 52665
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MEDICATION MANAGEMENT PLAN
The Medication Management Plan (MMP) is where pharmacists document a patient’s medication history and reconcile it against the drug chart. It also includes how the patient manages their medications and any issues identified with their medications and the medication chart. It is usually filed with the medication charts in the patient’s folder.
Medication list including reconciliation
Admission medication risk assessment Discharge Planning
Identified issues for review. Action outcome once reviewed.
Medication changes during admission
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ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC)
Background Rationale
Drug therapy errors occur in 5-20% of drug administration in Australian hospitals1 43% of adverse drug events are preventable2 Medication interventions save lives, reduce length of stay, reduce admissions and reduce costs3
1 Australian Council for Safety and Quality in Health Care. July 2002.
2 Wilson RM, Runciman WB, Gibberd RW et al. Med J Aust 1995; 163: 458-71
3 Dooley MJ, Allen KM, Doecke CJ et al. BJCP 2004; 57: 513-21
Overview
Front
Back
“Regular medications” section VTE prophylaxis section
PRN section
STAT doses
Phone orders
Good prescribing principles
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National Inpatient Medication Chart (continued)
Patient Identification
ALL medication charts must have correct patient identification details i.e. bradma Significant medication errors can occur when patient identification is incorrect or incomplete
Affix patient ID label (i.e. large bradma) on both allocated pages Check labels are correct, initial
Print patient name and check label is correct for the patient on both allocated pages.
Allergies & Adverse drug reactions (ADR)
Re-exposure is a preventable cause of significant harm Not all ADRs are clinically significant
ADR box on ALL medication charts needs to be completed.
If patient has nil known allergies or unknown allergy status, TICK appropriate box, sign, print name and date entry.
If known ADR note drug name and reaction details, sign, print name and date entry. Attach ADR sticker to pages 3 and 4.
If any amendments or additions are made to the ADR box, initials and date of entry required.
No known allergies: Known allergies – complete all sections:
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National Inpatient Medication Chart (continued) Numbering of medication charts
All medication charts should be numbered using roman numerals e.g. 1 of 2, 2 of 3, etc.
Venous Thromboembolism (VTE) prevention
Patients ≥16yrs must have VTE Risk Assessment completed (form on the front of medication chart) Day patients without regular mediation chart may be exempt MUST be completed by medical staff:
i. Identify risk by completing the VTE Risk Assessment Tool (front page of medication chart) ii. Determine appropriate prophylaxis iii. Order ALL prophylaxis (chemical and/or mechanical) on Medication Chart
NOTE: This section only for VTE PROPHYLAXIS. VTE treatment (i.e. therapeutic doses) needs to be charted as a regular medication.
For Best Practice Guidelines / Policy / Risk Assessment Form, refer to: Venous Thromboembolism (VTE) Prevention Guidelines on Prompt or use the following link: Haematology - Thrombosis & Haemostasis Protocols
VTE Risk Screen
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National Inpatient Medication Chart (continued)
Regular Medication Orders
ALL orders must include: Date started not date written
o when rewriting an order, write the date of first prescribing, not the re-write date Generic prescribing unless a combination product or Insulins (refer to Combinations stocked at
Northern Health list) Dose, frequency and route – only use acceptable abbreviations as per the “Good prescribing
principles” on the NIMC Doctor to enter dosing times – not including times frequently leads to missed doses Slow release box must be ticked where appropriate. Also include show release abbreviation in
order. Document indication. SIGN all orders. Unsigned orders are not legal and therefore are not able to be administerede
nurses can not administer the medication annot be administered.
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National Inpatient Medication Chart (continued) Frequency (Guidance Only) Write the frequencies and administration times for all medications charted. Omitted medication times lead to medications being missed affecting patient’s treatment.
If a medication is to be given with food, chart meal times: 08:00, 12:00, 18:00
Intravenous antibiotics – should be prescribed by hours (i.e. q6h) and times should reflect this dosing **Warfarin dosing: 16:00 hours** This is to ensure orders are completed before home team leave the hospital
Approved Abbreviations
Route of administration
Abbreviation Meaning
PO Oral
NG Nasogastric
subling Sublingual
subcut Subcutaneous
IV Intravenous
IM Intramuscular
PR Per rectum
PV Per vagina
top Topical
neb Nebulised
Inh Inhaled
Units of measure and concentration Abbreviation Meaning
g gram(s)
International unit(s) International unit(s)
unit(s) unit(s) L litre
mg milligram(s)
mL millilitre(s)
microg / microgram(s) microgram(s)
% percentage
mmol millimole
Please see the ‘Good prescribing principles’ section on the back of the Northern Health ‘National inpatient medication chart’ for more details.
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National Inpatient Medication Chart (continued)
Prescriber identification: You know who you are but it’s sometimes very difficult to match a signature to an individual’s identity and pagers and roles change frequently. Health professionals (Pharmacists, Nurses and other prescribers) need to be able to easily identify who has prescribed what. Please sign; print your name and your pager number at least once on each NIMC and all schedule 8 orders
that you prescribe on (see below). All medication orders need to be signed to be made legal. Nursing staff cannot administer an order that has not been signed. This can lead to treatment delays.
Prescribing Principles:
1. Plain English, Legible- PRINT drug names 2. Use Generic Drug Names
(a) Exemption for combination products (i.e. Targin, Seretide)
(b) Exemption for medication with significant bioavailability issues (i.e. tacrolimus, cyclosporine)
3. Write drug names in full. 4. NEVER abbreviate any drug name e.g. HCT, MTX,
ISMN, GTN. Exemption: indication of slow release and immediate release (Tramadol SR or Tramadol IR)
5. Do not use chemical names/symbols. 6. Do not include the salt of the chemical unless it is
clinically significant Example: mycophenolate mofetil vs. mycophenolate sodium
7. Dosing: a. Use words or numbers (i.e. 1, 2). b. Do not use roman numerals (i.e. ii, v) c. Use metric units (i.e. gram or mL). d. Do not use apothecary units (i.e. minims or
drams) e. For oral liquid preparations, prescribe the
dose in milligrams or grams(if applicable).
f. Express the dosage frequency unambiguously (for example “three times a week”)
8. Avoid acronyms or abbreviations for medical terms and procedure names on orders or prescriptions. Refer to the Australian Commission on Safety and Quality in Healthcare website for more details
ABBREVIATIONS to AVOID!
Avoid U or IU:
mistaken for ‘0’. i.e. 4U can be interpreted as 40.
Instead- write the word ‘Units’
Avoid ug/ µg:
mistaken for mg.
Instead- write the word ‘microg’
Avoid o.d. or OD:
Mistaken for BD.
Instead- write mane/ midi/ nocte
Add Trailing ‘0’ after decimal point:
1.0mg can be mistaken for 10mg.
Instead- write 1mg
Avoid leading ‘0’ before decimal point:
.1mg can be mistaken as 1mg.
Instead- write 0.1mg
Avoid SC and SL:
can be mistaken for each other
Instead- write “subcut(aneous)” or “subling(ual)”
Avoid Fractions:
1/7 could be ‘for 1 day’ or ‘once daily’ or ‘for one week’
Other unacceptable abbreviations: qd/ QD, qod/ QOD/ symbols
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National Inpatient Medication Chart (continued) Variable Dose Medications
This section allows ordering of medications requiring variable dosing based on lab results or as a reducing protocol e.g. prednisolone, tobramycin, gentamicin. Each dose needs to be individually prescribed and signed for by the prescriber.
Warfarin dosing
This section is for warfarin dosing only.
Brand of warfarin needs to be circled. Warfarin brands are NOT interchangeable. Document indication and target INR. Document INR result.
Each dose needs to be individually prescribed and signed for by the prescriber. Always prescribe dose once INR result is back to avoid under or over dosing.
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National Inpatient Medication Chart (continued) When required (PRN) medication orders
PRN Orders must also include:
Hourly frequency
Maximum dose in 24 hours
Indication
To give clear administration and maximum daily dose Check all sections of the medication chart to ensure over-dosing does not occur e.g. paracetamol 1g QID regular plus PRN dosing.
Stat Dose Orders
This is section is for doses that are to be given immediately - “STAT”. If the medication is to be continued regularly, e.g. IV antibiotics, ensure that a regular order is also charted. When charting STAT order, checks all sections of the medication chart to prevent administration of excess doses. Communicate all STAT orders with the nursing staff to ensure medications ordered are given in a timely manner, preventing delays.
Phone Orders Nursing staff may contact you for a phone order. These orders need to be repeated to a second nurse and signed by the authorising doctor within 24 hours
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National Inpatient Medication Chart (continued)
Ceasing Medication Orders
Orders must NOT be obscured Doctor to put single line through order and two lines after the last dose in the administration
record section Write CEASE, the reason, date and sign
CORRECT WAY TO CEASE AN ORDER:
INCORRECT WAY TO CEASE AN ORDER:
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National Inpatient Medication Chart (continued)
Limited Duration Medication Orders
Ordered only for certain days
Block out day/times when NOT to be given
Indicate using (X)
Less than daily administration
Specify frequency clearly
If weekly – specifiy day to be given
Box days when medication is to be given
Block out day/times when NOT to be given - Indicate using (X)
Re-writing Medication Charts
Care should be taken when rewriting medication charts. Fatal errors have occurred due to lapses in concentration. Where possible, all efforts should be taken to prevent disruption.
When complete it is best practice to inform the nursing and/or pharmacy staff that the medication chart has been rewritten to allow double checking.
Remember DRS
DATE REASON SIGNATURE
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HIGH DOSE OPIATES/INSULIN
Unintentional prescribing of high dose opiates and inuslin is to be avoided by the application of a “high dose sticker”. Doses greater than soluble insulin 50 units or oral Morphine 30mg (equivalent dose in table below) require the following procedure to be followed:
Prescribers are to affix the high dose sticker in the NIMC left margin next to the medicine, and sign and date. This acknowledges the prescriber has checked and verified the dose prescribed is intended
A table of high doses for medicines will be provided in the Medicines Prescribing Policy, Pharmacy Operating Procedure and Medicines Administration Policy
If prescriber has not attached a sticker, the nurse contacts the prescriber/unit doctor and requests prompt action. No administration of the medicine by nurses are permitted unless sticker has been applied
Stickers are made available on wards from pharmacy
Medication chart re-writes are to have a new sticker applied by the doctor at the time of re-writing the chart
Clinical areas/scenarios excluded: syringe drivers; patient controlled analgesia; intensive care patients; “stat” doses in Emergency Department; anaesthetics department
This is for all formulations (not just oral) for inpatient prescriptions only Equivalent doses of oral morphine 30mg
Drug Oral dose Parenteral dose
IV/SC
Buprenorphine 800micrograms Sublingual 400micrograms
Codeine 200 to 240mg n/a
Fentanyl 100 to 150micrograms
Hydromorphone 6 to 7.5mg 1.5 to 2mg
Methadone 10mg 5mg
Morphine 30mg 10mg
Oxycodone 15 to 20mg 10mg
Pethiine 75 to 100mg IM
Sufentanil 10micrograms SC
Tapentadol SR 75 to 100mg n/a
Tramadol 150mg 100 to 120mg
HIGH DOSE
VERIFICATION
Date__/__/__ Initial __/__
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INTRAVENOUS THERAPY ORDER CHART
This chart used to prescribe and administer intravenous (IV) therapy such as: o Fluids
e.g. 0.9% Saline, 5% Glucose, 0.45% Saline +5% Glucose, Hartmans o Electrolyte infusions
E.g. Potassium, magnesium, phosphate o Medications requiring continuous infusions
E.g. pantoprazole, octreotide
ALL IV charts need to be numbered Affix patient
bradma here
The date of the infusion
The time of the infusion
The fluid to be given OR the fluid the
medication is to be
diluted in
The medication added to the fluid.
If the order is for fluid only, put a dash in this
box
The rate of the infusion i.e. the duration
Write minutes as: x/60 Write hours as: x/24
If the rate is to change according to a protocol,
write APP (as per protocol)
All orders need to be signed to be a
legal order. Nursing staff cannot
administer without a
signature
The volume of the fluid to be administered. Needs to be ordered in millilitres
(mL)
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OTHER MEDICATION CHARTS – discuss with pharmacy/Registrar if unsure how to use MEDICATION CHARTS
Long-stay medication chart o Used for long stay patients at BH and BECC and for GEM@Home patients
Residential Care Interim Medication Chart o Must be completed for ALL patients returning to a residential aged care facility with any changes
to their regular medications (Additions or cessations). Original is sent to the ACF, a copy is kept for the medical record
Bolton-Clarke Drug Chart o Must be completed for ALL patients being discharged with RDNS for medication support. Chart
must include ALL medications, not just medications the nurses will be administering
TCP Medication Chart o Standardised medication chart for in-patient TCP. Supplied by the TCP team
ESA Dialysis Medication Chart
PAEDIATRICS and NEONATES
Paediatric medication charts o Charts are colour coded for specific age groups – check carefully o Patient weight should always be documented on the chart
Asthma Pulse therapy sticker (attached to paediatric chart when needed)
Paediatric IV orders and Fluid Balance Chart
Neonatal Unit Fluid Order and Fluid Balance Chart
ANALGESIA
Syringe Driver Orders for Subcutaneous Infusions o Includes syringe driver documentation for nursing staff, for palliative care patients
Intravenous Analgesic Infusion Order form o Used for PCA orders
Non-Intravenous analgesic infusion order o Used for non-IV analgesic infusions (i.e. subcutaneous lignocaine)
Local Analgesia Order
Use for local analgesia (i.e. epidural administration)
ANTI-COAGULATION
Heparin Infusion Chart o Northern Health standard prescription is 50,000 units in 500mL.
Warfarin Discharge Plan o To be completed for ALL patients being discharged on warfarin. Must be faxed to the pathology
company/G.P. managing the warfarin
HITH – warfarin dosing chart o Used by HITH for dosing warfarin patients
OTHER
TPN Parenteral Nutrition Order Chart o To be completed by ICU consultant ONLY
CHARM medication chart o Chemotherapy is prescribed on the CHARM electronic medication system
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DISCHARGE PRESCRIPTIONS
ALL patients require a discharge prescription written on discharge if they are to be commenced on new
medications or if there are any changes to their regular medications.
Discharge prescriptions are PBS prescriptions. To be able to prescribe on the PBS, you need to have a PBS prescriber number. This is different to your provider number.
You must write a separate prescription if another prescriber has already prescribed an item for the patient's treatment on the same prescription form. i.e. you cannot write on a prescription signed by another prescriber.
Must include your name, prescriber number and contact number - this can be your phone number or pager number on the prescription form. Authorised nurse practitioners and authorised midwives must also include a prescriber type
Hospital prescriptions include 3 copies: o Patient or pharmacist copy (top, green carbon copy) o Medicare/DVA copy (middle, blue carbon copy) o Medical records copy (bottom, red carbon copy)
For a pharmacy to be able to dispense a prescription, they need the top 2 copies (green and blue)
The red copy is to be detached and filed in patient’s medical record.
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Discharge Prescriptions What needs to be included:
1. Hospital name, address, telephone number and hospital provider number - this is printed on every hospital prescription form
2. Authority prescription identification number is required when requesting a PBS authority approval
3. Patient's name, address, date of birth, hospital number and location (attach bradma on all 3 copies)
a. Patient's Medicare number - have this available when seeking a PBS Authority approval for Authority required medicine. It is included on the hospital bradma.
b. Patient's entitlement details c. Handwrite the patient's name under the bradma. This is allows you to check the correct bradma
has been attached to the script.
4. Select the appropriate box - PBS or RPBS (repat patients) 5. Patient's weight if applicable 6. Medicine name and form, for example, tablets, capsules or injections 7. Medicine strength 8. Dose instructions for use 9. Quantity to be dispensed – refer to PBS website for quantities. You can NOT write PBS as the quantity. 10. Number of repeats if permitted and required. Usually we don’t write repeats on discharge as we want to
encourage to the patient to see their GP for follow up. o Drugs of addictions (DAs) – the quantity to be supplied needs to be written in words and figures.
E.g. To order Targin 14 tablets, quantity to be written as: 14, fourteen 11. Pharmacist to indicate whether the medicine is to be supplied 12. Approval number and additional notes on the prescription:
o if the medicine requires prior Authority approval, and you have obtained an Authority approval number, write the approval number in this column
o if the medicine is listed in the Schedule as Authority required (STREAMLINED), write the specific streamlined authority code in this column
o if your patient is not eligible for a PBS subsidy for a medicine, and you want to have a medicine supplied as non-PBS, write non-PBS in this column
o any other notes you feel may be relevant to the pharmacist 13. Your name, prescriber number and contact number
o If the prescriber number is not included, or illegible, the prescription cannot be dispensed. o Your prescriber number is different to your provider number o Include a contact number in case the pharmacist needs to verify the prescription. If you cannot
be contacted, and thereby the prescription cannot be dispensed, this causes delays in treatment and possibly the need for the patient to return to hospital for a new prescription.
14. Prescriber type if you are an authorised nurse practitioner (NP) or authorised midwife (MW) 15. Your signature and the date form is written
o if the prescription is not signed, it is not a legal prescription and cannot be dispensed.
Write in clear, legible handwriting
Illegible writing can lead to significant medication errors and patient harm
Illegible writing/missing information may make a prescription not valid for dispensing resulting in delays to treatment or the patient needing to return to
hospital for a new prescription to be written
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Discharge Prescriptions
Drugs of Addiction (DA) When prescribing DAs on discharge, the quantity to be supplied should be enough to cover 3 to 5 days
of analgesia requirements. Be mindful not to overprescribe DAs as this can lead to addiction.
You can prescribe less that the PBS quantity or pack size. Pharmacists can easily break packs.
The quantity to be supplied needs be written in both words and figures.
PHARMACEUTICAL BENEFITS SCHEME (PBS)
Authority PBS prescriptions Authority required benefits fall into two categories
o Authority required (via phone call) and o Authority required (STREAMLINED) (via PBS website)
Authority required
This type pf approval is required if you want to prescribe a quantity in excess of the PBS quantity (e.g. long term antibiotics or Clexane®) or if the medication has specific criteria as per the PBS website (e.g. ciprofloxacin).
Approval of authority PBS prescriptions by Chief Executive may be sought by calling the Department of Human Services Telephone Authority Applications Free call service (1800 888 333). (phone number is located on the bottom of the red copy of the hospital prescription)
To obtain approval, you need to supply the patient’s Medicare number and name, prescription number, your name and PBS prescriber number.
If approval is granted, the operator will give you an authority number that needs to be written on the prescription e.g. Z1234AB
Authority required (STREAMILINED)
This type pf approval is required if you want to prescribe a medication that is only subsidised by the PBS for certain indications (e.g. clopidogrel, pregabalin, olanzapine).
Some of these medications have multiple indications with different authority numbers. Ensure you choose the correct indication and authority number (e.g. 1234) is written on the prescription
Click the Authority required tab to see the criteria.
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Pharmaceutical benefits Schedule (PBS)
Click the Authority required (STREAMLINED) tab to see the criteria.
Choose the appropriate indication and write the Streamline code on the prescription. If the patient doesn’t meet one of these criteria, close this tab and open up another tab (some
medications have multiple tabs)
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Pharmaceutical benefits Schedule (PBS)
PBS website o www.pbs.gov.au o The website can be found via the Shortcuts menu (Pharmaceutical Benefits Schedule) o Include information about:
If the medication is covered by the PBS, and for what indication Maximum quantity (and repeats) that can be prescribed If an authority is required
PBS Homepage
This shows the maximum packs/units and repeats that can be prescribed on the PBS
Search for medication here
Click on the item/dose you need to look up
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Pharmaceutical benefits Schedule (PBS)
Note: you can prescribe less than maximum quantity – packs can be broken
If you want to prescribe more than the maximum quantity and repeats, you need to obtain an Authority (see Authority required in this booklet)
Examples: a. Cephalexin 500mg BD for 5 days (=10 capsules) b. Cephalexin 500mg QID for 10 days (=40 capsules i.e. 1 pack + 1 repeat) c. Cephalexin 500mg QID for 1 month (=120 capsules – above maximum quantity, needs authority)
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TNH MEDICATION GUIDE
Prescribing Unfamiliar Medications It is the responsibility of all prescribers to check the indication and dosage and precautions of unfamiliar medications. Northern Health encourages the use of evidence based guidelines. These are available on every computer/desktop. In particular, Therapeutic Guidelines® (eTG), up-to-date®, Australian Medicines Handbook® (AMH), eMims ®, hospital policies on PROMPT. Speciality areas (e.g. palliative care, paediatrics, oncology, psychiatric medicine) have reference tools available for staff online through the library section of the intranet.
REFE-RENCE
Treatment Guidelines
Indication Dose Admini-stration
guidelines
Adverse effects
Precautions/ Contra-
indications
Drug interactions
TDM Brands
Australian Medicines Handbook
(AMH)
Therapeutic Guidelines
(eTG)
MIMs online
Australian Injectable
Drug Handbook
Compatibility information
Northern Health policies
(PROMT) **not all
drugs have a NH plicy)
Antibiotic Guidance
PBS website
Other documents/forms you may be asked to complete: Individual patient usage (IPU) form
- to obtain approval to prescribe a medication not on the hospital’s formulary
Special Access Scheme (SAS) form - To obtain approval via the TGA to prescribe and use a medication not marketed in Australia
Notification of Drug Dependant person - To notify DHHS of patients who are on opioid replacement therapy (e.g. methadone, Suboxone®)
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ANTIMICROBIAL STEWARDSHIP PROGRAM Antibiotic Guidance (iGuidance) GuidanceMS is an online approval system for restricted antimicrobials that forms part of Northern Health’s Antimicrobial Stewardship program. It guides prescribers through the appropriate indication and dose of restricted antimicrobials and generates electronic approvals. The indications and durations are based on the current Therapeutic Guidelines:Antibiotic. For indications outside of current guidelines – limited duration electronic approval can be obtained, prior to consultation with Infectious Diseases. An approval number for a restricted antimicrobial must be obtained within 24 hours of initiation and written on the chart (to ensure adherence to hospital policy and obtain supply from Pharmacy)
The following antimicrobials are restricted at Northern Health :
RESTRICTED ANTIMICROBIALS – HOME TEAM TO GET GUIDANCE
HIGHLY RESTRICTED – ID APPROVAL ONLY – ID TEAM TO GET GUIDANCE
Aciclovir IV Ciprofloxacin Moxifloxacin Amikacin Fosfomycin Rifabutin
Azithromycin Famciclovir Norfloxacin Amphotericin IV Fusidic acid Rifampicin
Cefepime Fluconazole Oseltamivir Anidulafungin Ganciclovir Rifaximin
Cefotaxime
Gentamicin (ID approval if > 48h)
Piperacillin/ tazobactam
Aztreonam Imipenem Teicoplanin
Ceftazidime Meropenem Valaciclovir Caspofungin Linezolid Tigecycline
Ceftriaxone Metronidazole IV Vancomycin Colistin Pristinamycin Tobramycin IV
EMERGENCY DEPARTMENT ONLY (New Daignosis): DOACs (Apixaban, Dabigatran and Rivaroxaban) require guidance approval prior to supply
Daptomycin Quinupristin/ dalfopristin
Valganciclovir
Ertapenem Vorinazole
Those listed above are the more commonly used restricted antimicrobials; see the GuidanceMS homepage for a complete list. Please note that GuidanceMS is also used to obtain approvals for the use of the NOACs (apixaban, dabigatran and rivaroxaban) only in emergency department for new diagnosis. See “Anticoagulants” section of handbook for more information.
Antibiotic approvals can be obtained via the “Antibiotic guidance” link in the Clinical Shortcuts folder (on any PC in the hospital)
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ANTIMICROBIAL STEWARDSHIP PROGRAM cont. Your username & password are the same as the one you use to access other hospital systems eg. CPF. Follow the prompts to obtain approval for your patient.
Once an approval number is obtained, please write it on the chart, in the indication section or on the yellow “Guidance approval no.____” sticker placed on the chart by a pharmacist (if there is one):
Approvals generated by Guidance MS have the format of XXX-0000-0. The first for numbers (XXX-0000-0) are the day and month the approval was obtained, and the last number (XXX-0000-0) indicates the number of days the antimicrobial is approved for. For example, an approval number of XXX-2502-3 indicates that the approval was obtained on 25 February and is valid for 3 days. ID will need to be contacted if antibiotic is to continue once approval is expired via MEDTASKER.
If you have any problems accessing GuidanceMS or obtaining approvals, please contact the Antimicrobial Stewardship Pharmacist, via MEDTASKER or ex 58452.
The Direct Oral Anticoagulants (DOACs) As of October 2019, the prescribing of DOACs at Northern Health has changed from beinging highly restricted to reduced restriction. Approval for their use needs to be obtained via the GuidanceMS system, this is only valid for new diagnosis of VTE in the EMERGENCY Department. (see above Antimicrobial Stewardship program section on how to access GuidanceMS and explanatory notes).
Information on all the anticoagulants, including guidelines on dosing, reversal and switching from warfarin to a DOAC or vice versa, can be found on the Haematology department page on the intranet. From the intranet homage select “Department and Services” then “Haematology” and then “Anticoagulant Drug Management” or use the following link: Haematology - Thrombosis & Haemostasis Protocols
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ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION
Sepsis of unclear focus
Vancomycin dosing
…..
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Antibiotic Prescribing guidelines by condition cont. Acute Cystitis
Catheter-associated UTI
Pyelonephritis
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Antibiotic Prescribing guidelines by condition cont. Prostatitis
Cellulitis
Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
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Antibiotic Prescribing guidelines by condition cont. Community Acquired Pneumonia
Aspiration Pneumonia
Treat as CAP or HAP and if no improvement after 48hours then do the following;
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Antibiotic Prescribing guidelines by condition cont. Hospital Acquired Pneumonia
Peritonitis due to perforated viscus
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Antibiotic Prescribing guidelines by condition cont.
Acute cholecystitis
Ascending cholangitis
Acute Appendicitis
Acute diverticulitis
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Antibiotic Prescribing guidelines by condition cont.
Acute pancreatitis
Infected pancreatic necrosis / pancreatic abscess
GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE
HANDY MEDICATION GUIDES
Endocrinology
ALWAYS PRESCRIBE AS “UNITS”
DRUG DOSE/UNIT ROUTE FREQUENCY
Insulin Top Up Scale Novorapid (preferred) /Actrapid/ Humalog T1DM BSL 10-14 BSL 14.1- 18 BSL >18 T2DM: BSL 10-14 BSL 14.1- 18 BSL >18
2 units 4 units 6 units 4 units 6 units 8 units
subcut
With-meals TDS PRN
Novorapid Infusion (50 units Novorapid in 50mL 0.9% NaCl = 1 unit/ml)
1/24 BSL’s (mmol /L)
Novorapid Infusion See Diabetes – Insulin/Gluocse Lowering Medicines policy
IV
Consult Endocrine Registrar before commencing
ALWAYS PRESCRIBE INSULIN IN BRAND NAMES Ultra-short acting (immed pre-meal): Novorapid; Apidra; Humalog, Fiasp. Short acting (≤ 30 min pre-meal): Actrapid, Humulin R. Mixed insulin (with food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50, Ryzodeg 70/30. Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane FASTING GUIDELINES for INSULIN: If on Long-Acting Insulin (Lantus or Levemir) Continue these at full/reduced dose
If on Short-Acting Insulin Withhold
If on Pre-mixed Insulin (humulog/ novomix/ mixtard) Give 50% of the Insulin dose as Protophane
End of Life Care
DRUG DOSE/UNIT ROUTE FREQUENCY
Morphine 2.5 – 5 mg
(depending on
tolerance)
subcut PRN (no frequency)
Fentanyl
(if renal impairment)
25 – 50 microg subcut PRN (no frequency)
Midazolam 2.5 - 5 mg subcut every 1 hour PRN
Metoclopramide 10 – 20 mg subcut QID PRN
Glycopyrrolate 0.2 - 0.4 mg subcut 4 hourly (max1.2 mg)
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Vascular Device Protocols
PICC Bard Groshong brand: (closed end catheter with 3 way valve): Does not require heparin flush/lock Pulsating flush with 20mL normal saline post access and weekly if not in use
Implanted port device (intravenous) Heparin locked using 500 units of heparin in 5 mL of saline (ie 100 units per mL) post access or monthly if not in use.
CVCs Do not require heparin locking (they have a positive pressure device [CLC 2000] attached to each lumen). For further information refer to clinical services manual on management of each central venous access device.
“Length of stay for vascular devices”:
Peripheral Cannulas, changed 72 hourly (unless medical emergency where asepsis is not
used, must be changed within 12 hours)
CVC: yellow (7 days) CVC: Blue (2 weeks)
Implanted Port device: around 2,000 needle sticks (can stay indefinitely/must be surgically
removed in most cases)
FOR ACCES TO SIMULATOR MODELS CONTACT THE EDUCTION CENTRE EXT. 58732.
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Fluid Prescribing
Rule of 1’s – oversimplified but memorable
The Real Rules: Correct but easy to forget!
Water losses Urine output: 0.5 – 1 ml/kg/hr Insensible losses: 0.5 ml/kg/day Water requirements 1.5 – 2 ml/kg/hr Salt requirements Sodium: 0.5 – 1mmol/kg/day Potassium: 0.7 – 1mmol/kg/day Solutions All 1L solutions come +/- 30 mmol KCI 0.9% saline 150 mmol/L sodium (&
chloride) 5% Dextrose 278 mmol/L dextrose 4% Dextrose + 1/5 saline 30 mmol sodium & 216
mmol dextrose Hartmanns or Compound Sodium Lactate (CSL) 129mmol sodium, 5mmol
potassium, 2mmol calcium Gelofusine synthetic albumin +
145mmol sodium Recipe 1 1-1.5ml/kg/hr 4% Dextrose & 1/5 saline +30 mmol/L
KCI Recipe 2 1-1.5ml/kg/hr 1L Normal Saline + 30 mmol KCI 1L 5% dextrose + 30 mmol KCI 1L 5% dextrose +/- 30 mmol KCI
Fluid requirements
1st 10 kg = 4ml/kg/hr
2nd
10 kg = 2ml/kg/hr Thereafter = 1ml/kg/hr eg. 50 kg person: 40 + 20 + 30 ml/hr = 90 ml/hr 90 kg person: 40 + 20 + 70 ml/hr = 130 ml/hr
Precautions
CCF/renal failure/very elderly Reduce rate and monitor UO / fluid balance Febrile / septic / post-op Increase Na and H2O Change to NSaline or Hartmanns Increase rate Monitor urine output / fluid balance NB: fluid balance should be +ve because of
‘third space’ losses Other ‘Rules’
1. All clinicians get the fluid balance assessment wrong sometimes. This can be a difficult area, so: When in doubt – ASK EARLY If your first intervention does not work – ASK AGAIN If you are doing something for the 1
st time –
GET ADVICE
2. Monitoring volume status and renal function: Urine output is an early and useful sign BP, HR & urea are late signs (too late!)
3. Responding to oliguria Oliguria = hypovolaemia until proven otherwise Treatment of oliguria = IV volume challenge (2.5-10ml/kg for 1-2 hrs. Use colloid if concerned re APO/CCF) Complex patients usually need urinary catheter and strict fluid balance. Diuretics DO NOT ‘kick-start’ the kidneys Diuretics indicated for fluid overload NOT oliguria.
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ON-LINE TRAINING
Online modules are available from the National Prescribing Service. http://learn.nps.org.au/ The following online module is compulsory to complete:
The Antimicrobial stewardship pharmacist will be following up evidence of completion. If you have completed these courses during university, you do not need to redo them.
We recommend completing the following modules:
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Common Medication Cheat Sheet
⚠ Always ASK IF UNSURE, below summarised from AMH/eTG ⚠
ANALGESIA
DRUG DOSE ROUTE FREQ COMMENTS
Paracetamol 1g PO/PR/IV QID - IV only if NBM and unable to have PR - Beware in liver impairment - Maximum of 4g paracetamol in 24hrs - every 4-6hrly Consider TDS in elderly/starving/liver/renal imp - Be careful combining paracetamol orders. Check stat/PRN
Panadeine Forte 1-2 tabs (500/30mg)
PO QID/ 4Hrly PRN
Panadol Osteo 1-2 tabs (665mg SR)
PO TDS
Ibuprofen 200-400mg PO TDS max Fever - X if CKD (eGFR<30)/GI bleed, diabetic, elderly, IHD, post neurosurgery, anticoagulated - Careful: PUD, CCF, HTN, asthma dehydration, coag disorders, - Use for <2wks + consider PPI - Lowest dose, shortest time - Do not use multiple NSAIDs in one patient
Indomethacin 100mg PR BD Renal colic
Naproxen IR 250-500mg PO BD max Menstrual pain
Ketorolac 10mg stat then 10-
30mg
IM 4-6 Hrly PRN max 90mg /24hr
Used in ED for mild-mod pain
Diclofenac 25-50mg PO TDS Menstrual pain 100mg PR BD
Celecoxib 400mg stat then
200mg Daily
PO 12-24 Hrly max 5 days
MSK/soft tissue
Lower bleed risk
Oxycodone IR 2.5-10mg PO QID PRN Preferred in renal
impairment (CrCl
<30ml/min)
- All opioids: resp depression, sedation, constipation, dependence - careful: BP drop, ↓seizure threshold - ↓dose requirements with age – start low - consider aperients + antiemetic
Oxycodone SR (Oxycontin)
5 - 10mg PO BD
Fentanyl 30 - 150microg
subcut 2-4 Hrly
Morphine 2.5-5mg subcut QID PRN accumulates in CKD
Tramadol IR 50-100mg PO/IV (>30min
IV)
QID PRN Usual max
400mg
- X epilepsy, hyperbaric tx, SSRI, elderly (max 300mg), confused - Less sedation/resp depression/abuse/constipation
Tapentadol (Palexia)
IR: 50-100mg
PO 4-6Hrly PRN - min opiate effects/serotonergic syndrome risk; prefer in CKD - X if on MAO-I (e.g. phenelzine, tranylcypromine)
SR: 50mg PO BD; max 500mg
Targin CR 10/5mg PO BD oxycodone + naloxone (2.5/1.25mg, 5/2.5mg etc.)
Reversal of opiates Naloxone 40microg subcut/IV. Life threatening 100-200microg. Short half-life <1hr, may require repeat doses
Amitriptyline 10-25mg PO nocte;max150mg Tricyclic antidepressant. Careful: BPH, hyperthyroid, epilepsy
NSA
IDS
OP
IOID
S
Northern JMSA
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Pregabalin 75mg PO Daily or BD Reduce dose renal imp; start low in elderly/frail (25mg)
Gabapentin 100-300mg PO nocte SE: drowsy, dizzy; lower opioid doses. Non-PBS indication
Consider Ketamine infusion/Lignocaine/nerve block, Acute Pain Service pager #779
Tamsulosin CR 400mcg PO Daily Renal colic: Bladder/ureter spasms. Non-PBS indication
Hyoscine (Buscopan)
20-40mg IV/IM QID PRN For colicky abdominal pain IV maximum 100mg/day 10-20mg PO TDS-QID PRN
ANTIEMETICS
DRUG DOSE ROUTE FREQ COMMENTS
Metoclopramide (Maxalon)
5-10mg PO/IV/ subcut
TDS PRN max 30mg D,
5 days
X bowel obstruction/perf +
pheochromocytoma / <20yo
Dopamine antagonists - X Parkinson’s disease - beware oculogyric crisis (tardive dyskinesia)
Prochlorperazine (Stemetil)
12.5mg IV TDS PRN vertigo; avoid if CNS depression 5 –
10mg PO TDS PRN
Droperidol 0.625mg IV QID PRN X IHD/arrhythmia
Domperidone 10mg PO TDS PRN Preferred for Parkinson’s – won’t cross blood-brain barrier
Ondansetron (Zofran)
4-8mg PO/IV/SL TDS PRN Post op/chemo/RT 5HT3 Antagonist - careful: prolonged QT - transient ↑AST & ALT
Granisetron
1mg
IV
TDS PRN SE: constipation/headache
Cyclizine 12.5-50mg
Slow IV/PO
BD - TDS Careful: CCF, SE: urinary retention
Antihistamine - sedation
-urinary retention Promethazine (Phenergan)
12.5-25mg
IM / PO 4-6Hrly PRN max 100mg
D
Careful: Epilepsy, Parkinson’s, respiratory depression
ALLERGIC REACTIONS
DRUG DOSE ROUTE FREQ COMMENTS
Loratadine 10mg PO Daily X hepatic impairment
Less sedating antihistamine Indication: chronic urticaria, allergic rhinitis Cetirizine 10mg PO Daily X renal
impairment
Promethazine (Phenergan)
25-50mg PO/IM Daily - X anaphylaxis, can worsen hypotension; sedating antihistamine - Careful: Epilepsy, Parkinson’s, respiratory depression
Hydrocortisone 100mg IV STAT 5mg/kg, max 200mg. Consider in anaphylaxis with wheeze
Adrenaline 500microg 0.5mL of 1:1000
IM STAT PRN 3-5min
- Anaphylaxis: no absolute contraindications to adrenaline - Inject into mid antero-lateral thigh
NEU
RO
PA
THIC
D
OP
AM
INE
5
HT3
AN
TAG
ON
IST
A
NTI
-HIS
TAM
INES
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ANTI DIARRHOEALS
DRUG DOSE ROUTE FREQ COMMENTS
Loperamide 4-8mg PO Daily/TDS Max 16mg D
Chronic diarrhoea, intestinal stoma
- Avoid: intestinal obstruction/severe ulcerative colitis/ hepatic impairment - for symptomatic treatment
4mg stat
PO 2mg PRN after each motion
Acute diarrhoea
RESPIRATORY
DRUG DOSE ROUTE FREQ COMMENTS
Salbutamol (Ventolin/Asmol)
2.5 - 5mg Neb QID PRN/STAT
- short-acting beta2 agonist (SABA) - SE: tachycardia, hyperglycaemia, hypokalaemia
2-12 puffs via spacer
Inh
Ipratropium Bromide (Atrovent)
500microg/2.5mL Neb QID PRN/STAT
- anti-cholinergic/short-acting anti-muscarinic (SAMA) - SE: headache/nausea/taste disturbance
42mcg (2 puffs) Inh
Tiotropium Bromide (Spiriva)
2.5mcg (Respimat)
2 puffs
Inh Daily Withhold if also on ipratropium - LAMA, careful in renal impairment - 2.5mcg = Respimat, 18mcg = Handihaler 18mcg: 1 puff Inh Daily
Indacaterol (Onbrez Breezhaler)
150/300mcg 1 puff
Inh Daily - long acting beta2 agonist (LABA) - asthma: always use LABA with ICS
Fluticasone (Flixotide)
50/125/250mcg 1-2 puffs
Inh BD Inhaled corticosteroids (ICS) - SE: dysphonia, oropharyngeal candidiasis, pneumonia, glaucoma, bone density loss - rinse mouth with water after use
Budesonide (Pulmicort)
100/200/400mcg 1-2 puffs
Inh BD
Budesonide/formoterol (Symbicort)
1-2 puffs Specify strength
Inh BD - Turbuhaler: 100/6; 200/6; 400/12mcg - Rapihaler: 50/3; 100/3; 200/6mcg (with spacer)
Flucticasone/Salmeterol (Seretide)
1-2 puffs Specify strength
Inh BD - MDI: 50/25; 125/25; 250/25mcg (with spacer) - Accuhaler: 100/50; 250/50; 500/50mcg
Fluticasone/vilanterol 1 puff Inh Daily - 100/25; 200/25mcg; Breo Ellipta
Prednisolone 30-50mg (usually 50mg)
PO Mane with food
(5-14D course)
- wean dose if continued longer than a week - SE: HTN/hyperglycaemia/PUD/insomnia
Normal saline 5mL Neb PRN Loosen secretions/relieves breathlessness
Bromhexine 8-16mg PO TDS Reduces mucous viscosity (mucolytic)
COPD: consider smoking cessation/pneumococcal+influenza vaccines/chest physio
ICS/
LAB
A
ICS
SAB
A
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ANTIBIOTICS
Refer to Antimicrobial Guidelines on PROMPT, eTG, ID or AMS for advice **BE AWARE OF ALLERGIES** (*requires Guidance)
DRUG DOSE ROUTE FREQ COMMENTS
Amoxycillin 500mg PO 8 Hrly
- COPD infective exac. (bronchitis) 5-7 days.
1g PO 8 Hrly
Mild-mod CAP: 5-7D + doxycycline . Mild aspiration pneumonia: 7-10D. Severe CAP; step down from IV to complete 7-14 D
Amoxycillin-clavulanic acid (Augmentin
Duo/Forte)
500/125mg PO 12 Hrly
UTI: 5 Days female, 7 Days male
875/125mg PO 12 Hrly
Dose of all other indications. Consider reduced dose in ESRF
Benzylpenicillin 1.2g IV 6 Hrly
Moderate CAP / Aspiration pneumonia 7-10D. Dose and frequency higher in more severe infections e.g. endocarditis
Flucloxacillin 2g IV 6 Hrly
Severe cellulitis 10-14D (Max. oral 1g QID empty stomach)
Phenoxymethylpenicillin 500mg PO 12 Hrly
Acute pharyngitis/Tonsillitis: 10D. Poor systemic absoption
Piperacillin-tazobactam (Tazocin)*
4.5g IV 8 Hrly
See Guidance for standard indications. 12 Hrly if CrCl <20
12 Hrly
Febrile neutropenia and critically ill (ICU)
Ceftriaxone* 1g IV Daily See guidance for standard indications including pneumonia (+azithromycin) and pyelonephritis
2g IV 12 Hrly
Meningitis + benzylpenicillin (+/- IV acyclovir)
Cefepime* 2g IV 8 Hrly
Febrile Neutropenia. Has anti-pseudomonas activity
Cefalexin (cephalexin) 500mg PO 12 Hrly
UTI (acute cystitis): 5D females, 7D males
1g PO 12 Hrly
Penicillin allergy: mild HAP (+/- metro)
1g PO 6 Hrly
Pyelonephritis 14D / Mild cellulitis 7-10D
Cefazolin (Cephazolin) 2g IV 8 Hrly
Penicillin allergy: severe cellulitis 10-14D (+/- vanc). Pre-op prophylaxis as single dose
Ciprofloxacin* 500mg BD 12 Hrly
See Guidance for standard indications. Check ECG & interactions with other QT prolonging drugs. Oral form on empty stomach. Excellent oral bioavailability
400mg IV 12 Hrly
Moxifloxacin* 400mg PO/IV Daily Penicillin hypersensitive: severe CAP/Asp Pneum/HAP check ECG
Azithromycin* 500mg PO/IV Daily Severe CAP (+ ceftriaxone). Good oral absorption
Clindamycin (contact ID if obese)
450mg PO 8 Hrly
MRSA activity or for penicillin hypersensitivity. For moderate aspiration pneumonia/SSTI
450mg IV 8 Hrly
BET
A-L
AC
TA
MS
CEP
HA
LOSP
OR
INS
Q
UIN
OLO
NE
S
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Metronidazole (IV*)
500mg IV 12 Hrly
Activity against anaerobic organisms eg in severe aspiration pneumonia (+ ceftriaxone) and Perf viscus (+ ceftriaxone) 400mg PO 12
Hrly
400mg PO 8 Hrly
Mild C.difficile 10D (oral vancomycin in mod-severe)
Doxycycline 100mg PO 12 Hrly
Give with food, risk of oesophageal ulceration. COPD 5-7D/ CAP (+ amoxicillin) duration depends on severity
Vancomycin* (contact ID for dosing
advice if required)
Refer to Vancomycin dosing guidelines (based on weight
& renal function)
See Guidance for standard indications. Dose adjust on levels MRSA activity - add to standard therapy if MRSA known colonised or risk of / severe infections. Beware VRE.
Trimethoprim 300mg PO Night Bacteriostatic/UTI: 3Days females, 7Days males
Trimethoprim-Sulfamethoxazole
(Bactrim)
160/800mg PO 3 times Per wk.
Pneumocystis jiroveci (carinii) pneumonia (PJP) prophylaxis in immunosuppressed patients. Give Mon/Weds/Fri (with food) Caution in renal impairment / with meds that can raise potassium
APERIENTS
DRUG DOSE ROUTE FREQ COMMENTS
Docusate + Senna (Coloxyl & Senna)
1-2 tabs PO Nocte or BD
- X GI obstruction/perforation risk - Careful: dehydration/hypokalaemia
Stool softener + stimulant
Lactulose 20ml PO Daily or BD
-↑doses required in hepatic encephalopathy (30-45ml QID) - SE: flatulence + very sweet taste
Macrogol 3350 (Movicol / Marovic)
1-2 sachets PO Daily or BD
- faecal impaction: up to 8 sachets within 6hrs, max 3D - risk of fluid + electrolyte imbalance (↓risk compared to saline lxtves)
Microlax enema sorbitol /sodium citrate/ sodium
lauryl sulfoacetate
1 PR STAT - rectal onset: 2-30min - beware: patients w heart failure/renal impairment, risk of GI obstruction/perforation - monitor electrolytes
Saline laxatives - once only medication - also used in bowel prep - can cause considerable fluid + electrolyte imbalance
Fleet enema sodium phosphate
monobasic/ sodium phosphate
dibasic
1 PR STAT
Note: optimise Magnesium level (Hypomagnesaemia linked to constipation)
SEDATIVES
DRUG DOSE ROUTE FREQ COMMENTS
Temazepam 5-10mg PO Nocte/STAT Max 20mg, lower for elderly
- short term use, low dose - Risk: over-sedation, ataxia, confusion, resp depression,
Zolpiclone 3.75-7.5mg
PO Nocte/STAT up to 4 weeks
- X myasthenias gravis, pulm insufficiency, alcohol intake
Zolpidem IR 5mg PO Nocte/STAT
OSM
OT
IC L
AX
AT
IVE
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- ! psych sx may worsen,
memory impairment, falls
Melatonin XR 2mg PO Nocte/STAT SE: back pain, arthralgia//limited evidence//up to 13wks
Diazepam 5-20mg PO Per AWS Max. 120mg
Preferred option. Low dose in elderly.
Oxazepam alt. in liver imp/frail
Alcohol Withdrawal Scale
+ thiamine 300mg IM/IV 5D
REFER TO AWS POLICY
Haloperidol (acute
psychosis)
0.25-0.5mg
PO/IM STAT - Beware EPSE up to 48hrs post - Low incidence hypotension
- oral before IM - onset 30-60min - avoid benzodiazepine - SE: long QTc, hypotension, confusion, anticholinergic effects, acute EPSE
Olanzapine (acute
psychosis)
2.5mg PO/IM (wafer)
STAT SE: hyprglycma/periph odma Careful: hepatic impairment
Risperidone (acute
psychosis)
0.5mg PO (wafer)
STAT - risk cerebrovascular event Careful: renal/hepatic impairmnt
Seek advice before medicating for disturbed behaviour/ AVOID CHARTING PRN. Refer to Delirium & Cognitive Impairment Management Policy
Benztropine 1-2mg PO/IM STAT Reverse EPS (acute dystonia); anticholinergic
Promethazine 5mg PO Nocte/STAT Sedating antihistamine, see ‘Analgesia’ section above
ANTICOAGULATION – see Thrombosis & haemostasis Guideline on Prompt
DRUG DOSE ROUTE FREQ COMMENTS
Aspirin Cyclo-oxygenase
inhibitor
100mg PO Daily Elderly: consider taking with PPI (GI bleed risk)
300mg PO STAT Suspected ischaemic chest pain
Dipyridamole MR +Aspirin
200/25mg PO BD 2ndry prevent stroke/TIA; Daily for 1 week (with 100mg aspirin)
Clopidogrel 75mg PO Daily Response variability ++ Load 300mg
P2Y12 antagonist
(liver metabolism)
Ticagrelor (+aspirin) 90mg PO BD SE: dyspnoea, ventricular pauses; Load 180mg
Prasugrel (+aspirin) 10mg PO Daily High risk of major bleeding; Load 60mg
Prophylactic clexane
40mg SubCut Daily 20mg if: CrCl<30/<50kg/frail/low risk
LMWH Inactivate IIa+Xa
via anti-thrombin III
binding
Therapeutic clexane (enoxaparin)
1mg/kg SubCut BD Dose to closest 5-10mg. BD preferred for inpts. Daily for HITH. 1mg/kg/day if CrCl<30
1.5mg/kg SubCut Daily
Prophylactic heparin 5000 units
SubCut BD/TDS Monitor APTT 6hrs post, ½ life 1hr, hepatic clearance Antidote: protamine IV 1mg/100unit (risk: fish allergy/vasectomy)
Therapeutic heparin APP SubCut IV inf.
AN
TI P
SYC
HO
TIC
S A
NTI
PLA
TEL
ET
H
EPA
RIN
S
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Dabigatran (Pradaxa)
direct thrombin inhibitor
150mg PO BD X prosthetic HV, Careful: GI bleed <12m. Consider 110mg: CrCl 30-50, >75yo, <50kg or as per bleed/clot risk. Reversal=Idarucizumab
110mg PO BD
Apixaban (Eliquis)
5mg PO BD X CrCl<25; Interacts with CYP3A4 P-gp inhs. 2.5mg BD if ≥ 2 of: <60kg, >80yo, Cr >133
Factor Xa inh Careful liver
imp Apixaban a/w fewer
major bleeds
2.5mg PO BD
Rivaroxaban (Xarelto)
20mg PO Daily X prosthetic HV/ CrCl<30. 15mg D if CrCl 30-49
Warfarin (Brand specific:
Coumadin/Marevan)
INR 2-3 PO D at 4pm
Loading: 5mg D for 2D, 3mg in certain situations (see above guideline and adjusting as per INR) INR lags by ~2days INR 2.5-3.5 if mechanical
heart valve
Vitamin K1 0.5 - 10mg
PO/IV stat Warfarin reversal: dependent on bleeding / INR
Warfarin reversal for life threatening bleed+INR≥1.5
IV Vit K 10mg + Prothrombinex-VF 50 units/kg + fresh frozen plasma 150-300mL
GASTROINTESTINAL
DRUG DOSE ROUTE FREQ COMMENTS
Mg + Al hydroxide
10-20mL PO PRN Antacid; take 1-3hr post meal; Careful: CCF; aka Gastrogel
Pink Mix 30mL PO stat Prescribe as Lignocaine viscus 10mL + Gastrogel 20mL
Ranitidine 150mg PO BD H2 antagonist; PUD/GORD; careful: salt restriction, renal impairment
Pantoprazole 40mg PO/IV Daily GORD: 4-8wk course; 30-60min pre-meal; all PPIs similar efficacy *bleeding peptic ulcers intermittent bolus vs. infusion same efficacy. X long term use b/c ?risks: ↓Mg, #, C.diff, CKD, pneumonia
40mg IV *BD 3 days
Esomeprazole 20mg PO Daily
Relief with pink mix DOES NOT rule out ischaemic cause for epigastric pain
CARDIOVASCULAR
DRUG DOSE ROUTE FREQ COMMENTS
Atorvastatin (Lipitor)
10-80mg PO Daily Monitor LFT/CK; SE: rhabdomyolysis, myopathy HMG-CoA reductase inhibitor; consider cease if LE<10yrs Rosuvastatin
(Crestor) 5-40mg PO Daily
Ezetimibe 10mg PO Daily Add to statin to meet LDL target Not together Fenofibrate 145mg PO Daily triglycerides (+statin) CrCl<60
dose X pancreatitis
Perindopril arginine 2.5-10mg PO Daily ACEi; Caution: renal impairment, ↑K+, angioedema, African descent, NSAIDS. Check salt before prescribing, TNH keep both
Perindopril erbumine
2-8mg PO Daily
Irbesartan 75-300mg PO Daily ARB; Caution: pt w angioedema on ACEi, renal impairment; X ACEi
Metoprolol tartrate 12.5-100mg
PO BD HTN B-blocker; start low, go slow (double dose 2-4wks)
cease slowly =avoid rebound HTN; start when pt stable
Metoprolol MR 23.75-190mg
PO Daily CCF
Spironolactone (aldactone/spiractin)
12.5-50mg PO Daily HTN K+sparing aldosterone antagonist; SE: hyperkalaemia, respiratory/metabolic 25mg PO Daily CCF
DO
AC
S
Northern JMSA
PP
I
LIP
ID R
EDU
CIN
G
HTN
/CC
F H
TN
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acidosis; X prostate cancer. Antiandrogenic effect:
gynaecomastia/sexual dysfunction
Frusemide (Lasix – lasts ~6 hrs)
20-40mg PO Mane ± midi (max
1g/24h)
Loop diuretic; Titrate to response, monitor weight+electrolytes
SE: metabolic alkalosis, hyperuricaemia, ↓electrolytes
40mg PO = 20mg IV
Hydrochlorothiazide 12.5-25mg PO Mane Thiazide; HTN. Careful: new onset DM, hypo K, hypo Na; X gout.
Amlodipine 2.5-10mg PO Daily Dihydropyridine CCB; X cardiogenic shock, CCF; SE: peripheral oedema
Glyceryl trinitrate Patch
5-15mg/24hr
Top On at 8 off at 8
Symptoms dictate timing. nitrate-free 12hrs to avoid tolerance
Anginine© (GTN) ½ to 1 (600mcg)
Subling 5min PRN Check BP; max 3 doses; X ↑ICP, hypovolemia, PDE5i use (sildenafil) Nitrolingual – spray Anginine – tabs. Check expiry. SE: flushing/H’ache
Nitrolingual© (GTN) 400mcg Subling 5min PRN
DIABETES PRESCRIBE INSULIN IN BRAND NAME TO AVOID CONFUSION
DRUG DOSE ROUTE FREQ COMMENTS
Novorapid (insulin aspart)
variable SC w meals TDS PRN/ sliding
scale
T2DM: 10-14 (4u), 14.1-18 (6u), 18.1-22 (8u), ≥22.1 (10u) T1DM: 10-14 (2u), 14.1-18 (4u), 18.1-22 (6u), ≥22.1 (8u)
Onset: 10-20min; max:1-3hrs
Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane. Ultra-short acting (immed pre-meal): Novorapid; Apidra; Humalog. Short acting (≤ 30 min pre-meal): Actrapid, Humulin R. Mixed insulin (with
food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50, Ryzodeg 70/30
Insulin fasting guidelines: Long-acting = cont at full/reduced dose; Short-acting = WH; Pre-mixed (humulog/novomix/mixtard)=50% dose as protophane
Metformin (Diabex)
IR: 500mg-
1g
PO Daily-TDS (max 3g/24h)
Careful: CrCl<30 (lactic acidosis risk); biguanide WH: septic/fasting/min oral intake/AKI; take
with food
XR: 0.5g-2g
Daily (max 2g/24h)
Gliclazide diamicron/glyade
IR 80mg PO Daily-BD with food
Max 320mg D
Sulfonylureas; careful: acute illness; weight+
X T1DM, ketoacidosis; hypoglycaemia risk ++
MR 30-60mg
PO Daily with food Max 120mg D
Sitagliptin 25-100mg
PO Daily DPP4 inhibitor Careful: sulfonylurea/insulin/ACEi/CrCl<50
?Risk: infection/pancreatitis; no weight gain Linagliptan 5mg PO Daily
Exenatide (Byetta)
5microg SC BD (pre-meal) GLP1 agonist. Use: if obese. SE: pancreatitis Careful: sulfnylrea/insulin/hx gallbladder
disease X CrCl<30 Bydureon: 2mg SubCut weekly (SR)
Dapagliflozin 10mg PO Daily SGLT2 inhibitor SE: UTI; Careful: insulin/sulfnylurea/diuretics/CrCl<60
Acute serious illness, prolonged fasting or other risk factors for DKA - WH
Empagliflozin 10mg PO Daily
Pioglitazone 15mg PO Daily (max 45mg)
X ?bladder Ca, ketoacidosis, T1DM, insulin SE: worsen CCF, #, wht
CC
F H
TN
INSU
LIN
S
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END OF LIFE CARE
DRUG DOSE ROUTE FREQ COMMENTS
Morphine 2.5-5mg SC PRN (no freq) Pain/resp distress, depends on tolerance
Fentanyl 25-50mcg SC PRN (no freq) Pain, preferred if renal impairment
Midazolam 2.5-5mg SC Every 1hr PRN Agitation
Metoclopramide 10-20mg SC QID PRN Nausea/Vomiting
Glycopyrrolate 0.2-0.4mg SC Q4H (max 1.2mg)
Respiratory secretions
FLUID/ELECTROLYTE REPLACEMENT
(NB: 1mmol/L = 1mM) ALWAYS CHECK IF UNSURE
Potassium 3.5-5.2 mM (>4.0 if cardiac hx) – recheck in 4hrs↓/1hr↑
Magnesium 0.7-1.1mM (>1.0 if cardiac hx) – recheck in 6-12hrs↓
3mmol/L serum K = -200mM K+ (-0.5mmol serum = 100mM K+ deficit)
Intracellular cation, linked to ↓K AND ↓Ca AND metabolic alkalosis
↓Hypokalaemia: ?loss from GI or urine/hypoglycaemia/hypomagnesemia?
↓Hypomagnesemia: ?malnutrition/GI loss (NGT/diarrhoea)/renal loss?
Slow K (4hr)
8mM K+/tab
16-48 mmol/24h dependent on level adjusted on response
O MagSup Mg aspartate
1.55mM/t Ṫ-ṪṪ D-BD; careful CKD
Chlorvescent (0hr)
14mM K+/tab
IV
0.9% NaCl 100mL + MgSO4 10mM
≥1/24 severe if <0.4mM
0.9% NaCl 1000mL + KCl 30mM
≥3/24 Rate can’t exceed
10mmol KCl/Hr
↑Hypermagnesemia: ?antacid/CKD/lithium/rhabdomyolysis
0.29% NaCl 100mL + KCl 10mM isotnic
≥1/24 IV 2.2mM calcium gluconate 100mL 15min
aim urine outpt 60mL/hr; IV 0.9%NaCl
↑Hyperkalaemia: ?haemolysed sample (check w VBG)/AKI?
Sodium 135-145mM – recheck in 6hrs↓/4hrs ↑
Resonium 30g PO/PR stat (1-3hrs)
Frusemide 40-80mg IV stat ↓Hyponatremia: ?diuretics(HCT)/SSRI/SiADH/hyperglycaemia/organ
failure
50% dextrose IV 50mL+10units Novorapid/20min
Salbutamol 5mg neb x2
0.9% NaCl IV
Fluid restrict ~500mL < urine output
Consider SiADH if: [serumNa]<130mM serum Osm/L <275mmol/kg urine Osm/L >100mmol/kg [urineNa] > 30Mm
Phosphate 0.75-1.5mM (* if <0.3] – recheck in 3hrs↓
NB: Na ∆ must ≤0.5mM/hr; ≤10mM/D ↓Na=cerebral oedema; ↑Na=osmotic demyelination ↓Hypophosphatemia:
?malnutrition/antacid/↑PTH/↓VitD?/↓Ca2+
O Phosphate
16.1mM/tab
1-2tabs D-TDS, SE: diarrhoea
↑Hypernatremia: ?water loss (DI, thiazide, burns)/IV iatrogenic
IV
Ora
l
INTERN MEDICATION GU IDE
Page 48
Sandoz
0.9% NaCl 250mL + PO4 10mM
≥3/24 KH2PO
4 RARELY use IV
SE: ↓Ca2+/te
tany
oral water
5% dextros
e IV
0.45% NaCl IV 4% dextrose+0.18%N
aCl (4+1/5th)
0.9% NaCl 250mL + PO4
10mM
≥2/24
NaH2PO4 Na↓ must
≤0.5mM/hr; ≤10mM/D
Water deficit=0.5(serum Na-140)/140
↑Hyperphosphatemia: ?CKD/cell lysis/ ↓PTH Calcium 2.15-2.55mM corr Alb – recheck in 4hrs↓
O Calcium carbonate 1.25g BD/TDS
Lanthanum/Sevelamer TDS
↓Hypocalcaemia: ?↓VitD/↓Mg/↓PTH (para/thyroidectomy)
Fluid Requirements 0.9%NaCl 100mL+calcium gluconate 4.4mM
20min Oral maintenance w food: Calcitriol 0.25mcg
BD CaCO3
1.5g BD
Assume: euvolemic, X renal/heart failure, X abnormal loss/elect disturbance
0.9%NaCl 900mL+calcium gluconate 22mM
50mL/hr
4ml/kg/hr 1st 10kg body weight 2ml/kg/hr 2nd 10kg body weight 1ml/kg/hr remainder
Regimen One (1L bags)
0.9% NaCl+30mM KCl
5%dxtrse+30mM KCl
5% dextrose
Regimen Two (1L bags)
2 bags: 30mM KCl +
4%dextrse+0.18%NaC 1 bag:
4%+1/5th
↑Hypercalcaemia: ?malignancy/1 ↑PTH
Rehydrate: 0.9% NaCl IV
4-6L/24 aim UO ~60ml/hr
Bisphosphonat
e: X
CrCl<30 ≤1mg/
min
0.9% NaCl 250mL + pamidronate 60-90mg IV
2-4/24
Sodium: 1-2 mmol/kg/day Potassium: 0.5-1 mmol/kg/day
Infusion rate: 8/24 usual; 10-12/24 frail,old
If malignancy, consider long term clodronate o 2.4-3.2g BD
Check Vit D
NB: 4% dextrose+0.18% NaCl = 4% and a fifth
NB: for fluid balance urine output = early sign; BP/HR/urea = late signs
IV
INTERN MEDICATION GU IDE
Page 49
The pharmacist is not the purple pen drug police.
The pharmacists are here to
support you, improve medication safety and to
promote patient-centred care