AIMS Handbook June 2019

Section/Topic Page
Cardiovascular
Atrial Fibrillation Rate Control 3
Direct Oral Anticoagulants (DOACs) 4-5
Heart Failure 6-7
Hypertension Goals and IV Agents 8
Central Nervous System (CNS)
Delirium 9-11
Endocrine
Diabetic Ketoacidosis 12-13
Glucocorticoid Conversion 14
Hyperthyroidism 15
Hypothyroidism 16
Insulin Dosing Considerations 17
Insulin Formulations 18
Fluids, Electrolytes, and Nutrition (FEN)
Calcium Replacement 19
Enteral Nutrition 20
Enteral Nutrition Formulary 21
Iron Replacement 22
Magnesium Replacement 23
Maintenance and Replacement Fluids 24
Parenteral Nutrition 25-26
Phosphorus Replacement 27-28
Potassium Replacement 29
Gastrointestinal (GI)
Ascites 30
Constipation 31
Hepatic Encephalopathy 32
Pancreatitis 33-34
Spontaneous Bacterial Peritonitis (SBP) 35
Varices 36
Infectious Diseases (ID)
Aminoglycoside Dosing 37
Antibiogram 38-39
Antimicrobial Restriction Policy 40
Cellulitis and Diabetic Foot Infections 41-42
Cephalosporin guidelines 43
Clostridium difficile Infection 44
Community Acquired PNA 45
Compounded Oral Vancomycin Information 46
HAP/ Aspiration PNA 47
1
Infectious Diseases (ID) Continued
Identification of Bacteria (gram positive/negative) 48-49
Intra-abdominal Infections 50
Penicillin Allergy Assessment 51
Spontaneous Bacterial Peritonitis (SBP) 52
Urinary Tract Infections 53
Vancomycin Dosing 54
IV to PO
IV to PO Conversions 55
Nephrology
Calcimimetics and Vitamin D analogs 56
Erythropoietins (ESA) 57
Phosphate Binders 58
Pain management
Equianalgesic Conversion Table 59
PCA Dosing Guidelines 60
Perioperative Medications
Perioperative Management of Medications 61-62
Prophylaxis (PPX)
Stress Ulcer Prophylaxis 63-64
VTE prophylaxis 65
Respiratory
Asthma 66
COPD Exacerbation and Maintenance 67-68
Inhaler Formulary 69
2
Atrial Fibrillation Rate Control Medications
Drug Loading Dose Usual Dose Range Adverse Effects Notes
Metoprolol 2.5-5 mg IV* every 2 -5 IR (tartrate): Bradycardia, BB are effective and commonly
minutes (max total dose: 25-100 mg BID hypotension, used agents for rate control in
15 mg over a 15 minute dizziness, AFib (AFFIRM)
period) ER (succinate): 50-400 fatigue, 1st Initiate cautiously in patients
mg once daily degree AV block with decompensated HF
Diltiazem Initial bolus: 0.25 mg/kg 5-15 mg/h IV infusion Peripheral Avoid in decompensated HF with
actual body weight (ABW) edema, HA, 1st reduced EF
IV* over 2 minutes; ACLS 120-360 mg PO daily degree AV block,
recommends 15-20mg bradycardia, Potential for decreased clearance
Initially consider IR dizziness, and increased T1/2 with
Repeat bolus (after 15 formulations for hypotension continuous infusions > 24 h
minutes if inadequate easier titration (ex:
response): 0.35 mg/kg diltiazem IR 30mg Consider lower starting dose in
ABW over 2 minutes; ACLS 4x/day elderly
recommends 20-25mg
Digoxin 0.25 mg IV, may repeat 0.125-0.25 mg PO AV block, Onset of action: PO→ 1-2 hours,
every 6 hours up to 1.5 daily ventricular IV→ 5-60 minutes
mg/24 h arrhythmias, Peak effect 6-8 hrs
Elderly: Avoid as 1st- N/V, dizziness, Trough concentrations should be
- Reduce by 50% in ESRD line therapy; if used, confusion, visual obtained 5-7 days after initiation
do not exceed 0.125 disturbances of therapy or any dose changes
mg/day in patients (blurred or and any time digoxin toxicity is
≥65 yrs yellow vision) suspected.
- Goal 0.8-1.2 ng/mL (consider
goal < 1 ng/mL in the elderly)
*IV administration of a beta-blocker or non-DHP CCB is recommended to slow ventricular heart rate in the acute setting
in patients without pre-excitation (Grade Ib).
IV to PO
Metoprolol Conversion IV to PO – 2:5
Metoprolol 5mg IV q6hrs → metoprolol tartrate 25mg PO BID or
metoprolol succinate ER 50mg PO daily
Diltiazem Oral daily dose = [rate (mg/h) x 3 + 3] x 10

3 mg/h IV = 120 mg PO daily
Digoxin Conversion IV to PO: 4:5 for maintenance dosing

0.1 mg IV = 0.125 mg PO
0.2 mg IV = 0.25 mg PO
References
January CT, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2014;64(21):e1-e76.
Lexi-Comp. Lexi-Drugs. Wolters Kluwer Health. Hudson, OH. Accessed April 2018.
St. Vincent Indianapolis Policy: Medications for IV to PO Conversion, last updated May 2014. PolicyStat #1922512.
3
Direct Oral Anticoagulants
Apixaban (Eliquis)* Rivaroxaban (Xarelto)*
MOA Factor Xa Inhibitor Factor Xa Inhibitor
Indications - Nonvalvular Afib -Nonvalvular Afib
- VTE treatment -VTE treatment
- VTE prophylaxis s/p knee/hip -VTE prophylaxis s/p knee/hip
arthroplasty arthroplasty
Usual Afib: 5 mg PO BID Afib: 20 mg PO daily
Starting If ≥2 of the following 2.5 mg PO CrCl 15-50 mL/min 15 mg PO Daily
Dose and -Age ≥ 80 years BID (CrCl for Rivaroxaban is
Dose -Weight ≤ 60 kg based on ACTUAL body
Adjustment -SCr ≥ 1.5 mg/dL weight)
VTE treatment: 10 mg PO BID x 7 days, CrCl <15 ml/min Avoid use
then 5 mg PO BID
SCr > 2.5 mg/dL or Avoid use VTE treatment: 15 mg PO BID x 21 days,
CrCl < 25 mL/min then 20 mg PO daily
CrCl < 30 mL/min Avoid Use
VTE prophylaxis knee or hip arthroplasty: VTE prophylaxis knee or hip arthroplasty:
2.5 mg PO BID x 12 days for knee, 2.5 mg 10 mg PO daily x 10 – 35 days
PO BID x 35 days for hip
CrCl < 30 ml/min Avoid use CrCl < 30 ml/min Avoid use
Drug - CYP3A4 and p-gp inhibitors/inducers - CYP3A4 and p-gp inhibitors/inducers
Interactions -rifampin: avoid -rifampin: avoid
#
Conversions Warfarin to Apixaban: Start when INR < 2 Warfarin to Rivaroxaban: Start when INR
Enoxaparin to Apixaban: 1st dose of <3
apixaban when next enoxaparin dose Enoxaparin to Rivaroxaban: 1st dose of
due rivaroxaban when next enoxaparin dose
st
Apixaban to Enoxaparin: 1 dose of due
enoxaparin when next apixaban dose Rivaroxaban to Enoxaparin: 1st dose of
due enoxaparin when next rivaroxaban dose
due
Reversal No targeted agent (use KCentra and FFP) No targeted agent (use KCentra and FFP)
Agents (Andexanet FDA approved May 2018) (Andexanet FDA approved May 2018)
Dialyzable No No
2
Significant In patients with a BMI > 40 kg/m or weight > 120 kg, suggest avoiding use of DOACs
weight due to lack of clinical data in this population.
cutoffs Patients with weight < 50 kg were not well represented in studies.
*Formulary agent
# CYP3A4 inhibitors: azole antifungals, macrolides, amiodarone, H2RAs, SSRIs, non-DHP CCB;
CYP3A4 inducers: carbamazepine, phenytoin, phenobarbital, rifampin;
P-gp inhibitors: amiodarone, atorvastatin, propranolol, non-DHP CCB, tacrolimus, grapefruit;
P-gp inducers: dexamethasone, phenytoin, rifampin
4
Direct Oral Anticoagulants
Dabigatran (Pradaxa)* Edoxaban (Savaysa)
MOA Direct Thrombin Inhibitor Factor Xa Inhibitor
Indications -Nonvalvular Afib -Nonvalvular Afib
-VTE treatment - VTE treatment
-VTE prophylaxis s/p hip arthroplasty
Usual Afib: 150 mg PO BID Both indications: 60 mg PO daily
Starting
Dose and CrCl 15-30 mL/min 75 mg PO CrCl > 95 mL/min Use not
(CrCl for Dabigatran is BID recommended
Dose
based on ACTUAL body
Adjustment
weight)
CrCl < 15 mL/min Avoid use CrCl 15-50 mL/min 30 mg PO daily
VTE treatment: 150 mg PO BID (after 5- CrCl <15 ml/min Avoid use
10 days of parenteral anticoagulant)
CrCl < 30 mL/min Avoid use VTE treatment: See above
VTE prophylaxis in hip arthroplasty:
110 mg x 1 then 220 mg PO daily
CrCl <30 ml/min Avoid use ≤ 60 kg 30 mg PO daily
Concomitant dronedarone or
ketoconazole and CrCl 30-50
ml/min:75 mg PO BID
Drug - p-gp inhibitors/inducers - p-gp inhibitors/inducers
Interactions# - rifampin: AVOID - rifampin: AVOID
Conversions Warfarin to Dabigatran: Start when INR Warfarin to Edoxaban: Start when INR ≤
<2 2.5
Enoxaparin to Dabigatran: 1st dose of Enoxaparin to Edoxaban: 1st dose of
dabigatran when next enoxaparin dose edoxaban when next enoxaparin dose
due due
Dabigatran to Enoxaparin: 1st dose of Edoxaban to Enoxaparin: 1st dose of
enoxaparin when next dabigatran dose enoxaparin when next edoxaban dose
due due
Reversal Idarucizumab (Praxbind): 5g IV bolus (2 No targeted agent (use KCentra and FFP)
Agents vials, each contain 2.5g) no more than
15 minutes apart
Dialyzable Yes, ~60% dialyzable No
Significant In patients with a BMI > 40 kg/m2 or weight > 120 kg, suggest avoiding use of
weight DOACs due to lack of clinical data in this population.
cutoffs Patients with weight < 50 kg were not well represented in studies.
References: 1. DeCaterina R, et al. Clin Res Cardiol 2017 DOI 10.1007/s00392-017-1102
2. January CT, et al. Circulation. 2014;130:e199-e267.
3 Weitz JL, et al. CHEST. 2012;141(2 Suppl):e120S-1
5
HEART FAILURE EXACERBATION **Use ”Diuretic Guideline for HF Exacerbation” Orderset
A. Admission Checklist
 Utilize Heart Failure Admission order set (when available) and
order:  Establish and document dry weight
 Daily weights  Establish total daily dose (TDD) of home diuretics (in PO furosemide
 Strict I/O equivelents)
 Daily BMP  Convert to PO furosemide equivalent dose if needed (see
 AHA Step 1 Diet with 2g Na restriction below for conversion)
 Telemetry  Continue home heart failure regimen if able
 K+ protocol  If Cr ≥ 2.75 on admission: Recommend early Cardiology or Renal
 Cardiac Rehab phase I consultation
 Dietician referral  Start discharge planning with case management.
B. Volume Management
Total Daily Dose (TDD) (in PO furosemide equivalents)
<160mg or diuretic naïve ≥160mg, Low BP or K <3.0
Diuretic Conversions
Furosemide Torsemide Bumetanide

Intermittent Bolus Furosemide Infusion
Start TDD IV BID or 40mg IV Give TDD IV x 1 as bolus
PO 40 mg 20 mg 1 mg
BID if not on home diuretic followed by (TDD/24) mg/hr
IV 20 mg 20 mg 1 mg
Assessing Response
6 Hours 24 Hours Treatment Failure
Example:
• No response x 48hr
• Urination < 300 • If UOP < 2000 mL
mL increase to TID
consider specialist • Home regimen: Torsemide 20 mg PO BID
consultation.
• Dose x 1.5 now dosing Treatment Success • TDD in PO furosemide equivalents: 80 mg
• New bolus/ • If UOP > 5L decrease
infusion dose dosing by 50%
• Continue regimen
until euvolemic then
40 mg T = 20 mg T
• If on infusion dosing convert to oral x mg F 40 mg F
and no response x diuretics.
24 hours, consider • If Cr increase by • Would start the Intermittent Bolus
specialty
consultation
50% consider de- pathway:
escalation/
conversion to PO.
6
• Furosemide 80 mg IV BID
C. Guideline Directed Medical Therapy (2013 ACCF/AHA Guidelines)
Meds to use caution or

ACEi/ARB* • All patients with HFrEF
avoid in HFrEF
Amphetamines
• Carvedilol and Metoprolol succinate CCB (except amlodipine)
Beta Blocker* • All STABLE patients with HFrEF Cilostazol
Corticosteroids
Itraconazole
Aldosterone • Spironolactone or Eplerenone Metformin
Antagonist • NYHA class II-IV and EF <35% Minoxidil
NSAIDS
Pregabalin
Hydralazine • African American with NYHA III-IV TZDs
and Nitrate • Replacement for ACEi/ARB if unable to take
• Sacubitril and Valsartan

ARNI • NOT recommended to initiate in the hospital
*Target doses associated with mortality benefit
D. Discharge Planning
 Work with case management well before discharge day
 All patients admitted with a heart failure exacerbation must have a follow up appt scheduled prior to discharge
 If possible utilize Healthy Transitions Clinic (HTC)
 HTC will triage to HF clinic, NP/PA, or PCP
 If not possible must have appointment with a practitioner within 7 days
 Daily weights – educate on 3lbs in 24 hours or 5lbs in one week weight gain – contact physician.
 Recommend an individualized low sodium diet. 7
 Heart failure educator should see patient prior to discharge.
Blood Pressure Goals & IV Antihypertensives
Blood Pressure Goals (ACC/AHA 2017 HTN guidelines)
Population Blood Pressure Goals
Younger population <130/80 mm Hg
Elderly patients (≥65 years) Community Dwelling: <130/80 mm Hg
Patients with significant disease burden: tailored to individual patient
Acute CVA (first 72 hours) Eligible for TPA: <185/110 mm Hg; once tPA given maintain <180/105 mm Hg
No TPA given: <220/120 mm Hg with goal to lower BP by 15% in 1st 24 h
Acute CVA (>72 hours) <130/80 unless previously without HTN and BP is <140/90
Common Intravenous Antihypertensive Medications¶

Medication Starting Dose Max Dose Onset/ Adverse Effects/Monitoring Cost
Duration
Diltiazem 10-15 mg bolus, 5 mg/h infusion 15 mg/h 2-5 min/ ↓HR, heart block $
30 min-10 h
Enalaprilat 1.25 mg Q6H [given over 5 min] 5 mg q6h 15 min/ ↑ SCr/Acute renal failure, HA, dizziness, $
12-24 h orthostasis
Hydralazine 5-10 mg IV Q4-6H PRN 40 mg/dose 5-20 min/ Fluid/salt retention, tachyphylaxis, prolonged $
2-12 h effect in renal dysfunction
Labetalol Load: 20 mg THEN 20-80 mg 300 mg 2-5 min/ ↓HR, orthostasis, dizziness, N/V, dizziness, $$
Q4-6H OR 1-2 mg/min infusion 2-18 h scalp tingling, fatigue
Metoprolol 2.5 mg Q6H 15 mg per 20 min/ ↓HR, bradycardia, dizziness, fatigue, $

[2.5 mg IV = 6.25 mg PO] dose 5-8 h depression, 1st degree heart block
Nitroglycerin 5 mcg/min 200 2-5 min/ Severe hypotension, reflex tachycardia, HA $$

[↑ 5 mcg/min q5 min until 20 mcg/min 3-5 min
mcg/min reached then may ↑ 10-
20 mcg/min q5 min]
¶Not all inclusive list
References
Hardy YM, Jenkins AT. Hypertensive Crises: Urgencies and Emergencies. US Pharm 2011;26(3): Epub.
Lexi-Comp. Lexi-Drugs. Wolters Kluwer Health. Hudson, OH. Accessed May 2018.
Varon J. Treatment of Acute Severe Hypertension: Current and Newer Agents. Drugs 2008; 68(3):283-297.
Whelton PK, et al. Hypertension. 2018;71:1269-1324.
8
Delirium
Confusion or change in mental status
Confusion Assessment Method (CAM) Precipitating factors

1. Acute and fluctuant mental status change
2. Inattention
•Medications (see next page)
3. Altered level of consciousness •Specific medications
4. Disorganized thinking •Polypharmacy (>5 medications)
*diagnosis of delirium: presence of 1 and 2 plus •Acute illness
either 3 or 4 •Organ insufficiency (renal, liver, heart)
•Dehydration
•Electrolyte abnormalities/acid-base
•Hypoglycemia
Negative Positive
•Immobilization
•Use of restraints
-Detailed H&P to include •Use of foley catheter
Prevention precipitating factors
strategies -Intervention to control
behavior for patient safety
Non-Pharmacologic
If ineffective or if the patient is
harmful to themselves or staff
9
Pharmacologic
Medications associated with delirium
• Tricyclic Antidepressants (TCAs)

• Antihistamines
Anticholinergics • H2RA blockers
• Other antidepressants (paroxetine, mirtazapine)
• Promethazine, Prochloroperazine
• Benzodiazepines
CNS medications • Sedative hypnotics (zolpidem)
• Anticonvulsants
• Fluoroquinolones
Miscellaneous • Corticosteroids
• Skeletal muscle relaxants
• Opioid analgesics
agents • Digoxin • Oxybutynin
10
Non-Pharmacologic interventions Pharmacologic interventions
*First line* *Second line*
•Access to hearing aids, glasses First line agents AS NEEDED for

•AVOID physical restraints agitation:
•Bedside sitters (requires order) •Haloperidol 0.25-0.5 mg PO Q4H PRN
•Encourage Family presence and •Haloperidol 0.25-0.5 mg IV Q4H PRN
involvement •Risperidone 0.25 mg PO Q4H PRN
•Maintain hydration and nutrition
•Minimize tethers as able– foley, SCDs, For patients with alcohol withdrawal,
IV lines neuroleptic malignant syndrome or
•Mobilize patient seizure disorder:
•Up in chair for meals, PT •Lorazepam 0.5-1 mg PO or IV Q4H
evaluation PRN agitation
•Normalize sleep-wake cycle
•Orienting stimuli Consider for maintenance:
•Clocks, calendars, familiar •Quetiapine 12.5-25 mg PO QHS or BID
objects •Risperidone 0.25 mg PO QHS or BID
•Reassurance and reorientation
11
References: Am J Psychiatry. May 1999;156(5 Suppl):1-20. Drugs and Aging. 2011;28(9):737-48.

Diabetic Ketoacidosis
12
Diabetic Ketoacidosis
Fluid resuscitation is directed at expansion of intravascular, interstitial, and
intracellular volume and restoration of renal perfusion. Aggressive resuscitation
of a DKA patient results in a more robust response to low dose insulin therapy.
Correction of serum sodium is important prior to the selection of IVF for volume
resuscitation. Sodium can be falsely low in the presence of hyperglycemia and
Fluid must be corrected to accurately assess sodium abnormalities. (for each
Resuscitation 100mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected
sodium value)
D5W may be added to IVF once plasma glucose reaches 200-250mg/dL. The
addition of exogenous glucose will assist in preventing hypoglycemia and
minimize the risk of cerebral edema associated with rapid shifts in serum
osmolality as blood glucose concentrations rapidly decline.
Potassium
Total body potassium depletion, insulin therapy, correction of acidosis, and
volume expansion all lead to a decrease in potassium concentration. Insulin
treatment should be delayed until potassium is > 3.3 mEq/L to avoid life-
threatening arrhythmias and respiratory muscle weakness.
Electrolyte Bicarbonate
Replacement Bicarbonate therapy offers no advantage in improving cardiac or neurologic
functions except when pH <6.9.
Phosphate
Phosphate replacement has failed to show any beneficial effects on the clinical
outcome of DKA. Replacement may be considered in patients with cardiac
dysfunction, anemia, respiratory depression, or when phosphate is <1 mg/dL.
Continuous IV infusion of regular insulin is the preferred insulin of choice in DKA
due to its rapid onset of action, short half-life and ease of titration. An initial IV
Insulin bolus dose of regular insulin 0.1 units/kg, followed by an infusion of 0.1
Therapy units/kg/hr is recommended to adequately suppress hepatic ketone body
production. Titration of the infusion is based on blood glucose response
according to the algorithm.
Resolution of DKA
Resolution of DKA and transition to subcutaneous insulin may be considered when the blood
glucose concentration is <200 mg/dL AND at least 2 of the following criteria are met:
1. Serum bicarbonate ≥ 15 mEq/L
2. pH > 7.3
3. Anion gap ≤ 12 mEq/L
The IV infusion of insulin should be discontinued 1-2 hours AFTER the administration of
subcutaneous insulin to prevent recurrence of hyperglycemia and/or ketoacidosis.
Reference: Diabetes Care. 2009;32(7):1335-41
13
Comparison of Glucocorticoid Preparations
Relative anti- Relative

Equivalent Doses Duration of
inflammatory mineralocorticoid
(mg) actions (hours)
activity activity
Cortisone 25 0.8 0.8 8-12
Dexamethasone 0.75 30 0 36-72
Fludrocortisone N/A 10 125 12-36
Hydrocortisone 20 1 1 8-12
Methylprednisolone 4 5 0.5 12-36
Prednisolone 5 4 0.8 12-36
Prednisone* 5 4 0.8 12-36
Triamcinolone 4 5 0 12-36
*Physiologic dose of prednisone is ~5mg daily or equivalent.
Available at: http://www.micromedexsolutions.com. Accessed May 2018.
https://www.uptodate.com
14
Hyperthyroidism
Hyperthyroidism (non-emergent)
• Symptomatic management:
• Beta blocker (goal HR <90): Propranolol 10 mg PO TID
• Anti-thyroid drugs:
• Methimazole 10 mg PO daily: preferred agent, except in 1st trimester of pregnancy
• Propylthiouracil (PTU) 50 mg PO TID
• Adverse reactions: pruritic rash, hepatotoxicity, arthralgias, abdominal pain, fatigue,
agranulocytosis
• Monitoring: WBC, LFTs
• Adjunct: Potassium iodide
Thyroid storm
• Burch-Wartofsky Point Scale ≥ 45 points
Iodine (SSKI) 5 drops

PTU* 500 mg IV load Propranolol* 60 mg (250 mg) PO Q6H Hydrocortisone* 100
then 250 mg IV Q4H PO Q4H (start 1 hour after mg IV Q8H
PTU in severe storm)
15
*Blocks conversion of T4 to T3
Thyroid 2016;26(10):doi.org/10/1089/thy.2016.0029
Hypothyroidism
Hypothyroidism (non-emergent)
• Levothyroxine (T4) is preferred agent
• Administration considerations:
• Initial dose: 1.6 mcg/kg (based on IBW)
• Taken on empty stomach
• Patients to consider lower initial dose (25-
• Separate from calcium and iron
50 mcg/day):
supplements by 4 hours
• Initial TSH of <10 IU/ml
• Pharmacokinetics:
• Elderly
• Onset: 3-5 days
• Patients with cardiac disease
• Half Life: 7 days (euthyroid) and 9 days
• Recheck TSH in 4-6 weeks
(hypothyroid)
• Due to drug properties, do not need to start
IV levothyroixine in patients that are NPO
for < 5-7 days
Myxedema Coma
Maintenance dose: May consider addition of

liothyronine (T3)
Levothyroxine IV 200-500 0.8 mcg/kg IV
mcg x 1 5 mcg x 1 then 2.5 mg IV
1.6 mcg/kg PO (started Q8H until pt clinically
when pt clinically stable) stable
Initial targets are symptomatic improvement, not labs (T3, TSH)
16
Thyroid 2014;24(12): doi.org/10.1089/thy.2014.0028
Insulin Dosing Considerations
Initiation
Insulin naïve Total Daily Dose (TDD): 0.1-0.2 units/kg*
-All basal OR
-50% basal, 50% prandial
Carb Ratio for Prandial Insulin: 500/TDD = 1 unit insulin per X g carbs
Insulin drip to SQ Stable BG for at least 6-8 hours
Multiply rate in units/hr x 24 h = TDD
Reduce TDD by 20%
-50% basal
-50% prandial (div. 3 meals or carb ratio)
Titration
Basal Increase by 2-4 units or 10-15% until FBG 71-150 mg/dL
Decrease by 4 units or 10-20% for hypoglycemia (BG < 70 mg/dL)
Prandial Increase by 1-2 units or 10-15% until PPG 130-180 mg/dL
Decrease by 2-4 units or 10-20% for hypoglycemia (BG < 70 mg/dL)
*Consider lower starting doses in patients with renal impairment, the elderly, or when in combination
with oral DM meds
To find the outpatient DM script:
St. Vincent Health Dovenet site Patient Care Portal (Nursing portal)Clinical Resources Diabetes
Management (icon in center of page) Physician resources Find the file labeled “_Retail Script 6.2017” or
“_Testing supplies.Retail script 7.2017”.
References
Inzucchi SE, et al. Management of hyperglycemia in type 2 diabetes mellitus: a patient centered approach. Position statement of the American Diabetes Association and the European Association
for the Study of Diabetes. Diabetes Care. 2012;35(6):1364-1379.
American Diabetes Association. Standards of Medical Care in Diabetes – 2015. Diabetes Care. 2015;38(Suppl. 1):S1-S93.
17
Insulin Products
Insulin Name (Brand) Onset Peak Duration
Rapid-Acting
Insulin lispro (Humalog) 15-30 min 0.5-2.5 h 3-5 h
Insulin aspart (Novolog)*** 15-30 min 1-3 h 3-5 h
Insulin glulisine (Apidra) 15-30 min 1-3 h 3-4 h
Insulin oral inhalation (Afrezza) 15 min 0.75 h 2.5-3 h
Short-Acting
Insulin regular (Humulin R, Novolin R)*** 30-60 min 2.5-5 h 4-12 h
Intermediate-Acting
Insulin NPH (Humulin N, Novolin N)*** 1-2 h 4-12 h 14-24 h
Long-Acting
Insulin detemir (Levemir)*** 3-4 h 3-9 h 6-23 h
* Consider BID dosing with doses >60 units
Insulin glargine (Basaglar, Lantus, Toujeo) 3-6 h No peak 11-24 h
* Consider BID dosing with doses >60 units
Insulin degludec (Tresiba) ~1h 12 >24 h
Combinations
Insulin NPH 70% + insulin regular 30% (Humulin 70/30, 30 min 2-12 h 18-24 h
Novolin 70/30)
Insulin aspart protamine 70% + insulin aspart 30% 15-30 min 1-4 h 18-24 h
(Novolog 70/30)
Insulin lispro protamine 75% + insulin lispro 25% 15-30 min 1-6.5 h 14-24 h
(Humalog 75/25)
Insulin lispro protamine 50% + insulin lispro 50% 15-30 min 1-6.5 h 14-24 h
(Humalog 50/50)
Insulin aspart and insulin degludec (Ryzodeg 70/30) 20 min ~2 h >24 h
***= formulary agent Lexi-Comp. Lexi-Drugs. Wolters Kluwer Health. Hudson, OH. Accessed May 2018.
18
Calcium (8.4-10.5 mg/dL) and Ionized Calcium (1.12-1.32 mg/dL)
• Total calcium: Calcium concentration must be interpreted with respect to serum albumin as 40-60% of
total calcium is bound to albumin
Corrected Calcium = (4-Alb observed) 0.8 + Ca observed
• IV Calcium Gluconate is the preferred salt due to reduced risk of extravasation and tissue necrosis
associated with calcium chloride (CaCl). Use of CaCl is reserved for patients with emergent conditions and
must be administered via a central line
o 1 gram calcium gluconate = 4.65 mEq elemental calcium
o 1 gram calcium chloride = 13.6 mEq elemental calcium
• Other considerations:
o Assess and replete magnesium as appropriate.
o Consider risk of calcium–phosphate precipitation in soft tissues when repleting calcium in
patients with hyperphosphatemia (>6 mg/dL).
o Aggressive repletion can lead to life-threatening cardiac arrhythmias. USE CAUTION in patients
with hypokalemia, patients on digoxin, patients with bradycardia and patients with renal
insufficiency
o Rapid administration is NOT RECOMMENDED and is associated with hypotension, bradycardia
or asystole
Degree of Hypocalcemia Replacement Dose

Mild to Moderate No replacement recommended
(inonized calcium 1-1.11 mmol/L)
Severe or symptomatic IV calcium gluconate 2 grams for 2 hours x 2 doses

(ionized calcium: ≤0.99 mmol/L) Infuse at a rate not to exceed 1 gram/hour
(4 grams total = 18.6 mEq)
Repeat calcium level with AM labs. Allow a minimum of 6-8 hours after completion of infusion to allow
adequate time for distribution.
Electrolyte replacement resources

1. Brown KA, et al. A new graduated dosing regimen for phosphorus replacement in patients receiving nutrition support. JPEN 2006; 30:209-214.
2. Dickerson RN. Guidelines for the intravenous management of hypophosphatemia, hypomagnesemia, hypokalmia, and hypocalcemia. Hospital Pharmacy
2001;36:1201-1208
3. Dickerson RN, Morgan LM, Croce MA et al. Treatment of moderate to severe acute hypocalcemia in critically ill trauma patients. JPEN 2007; 31:228-233.
4. Grissinger M. Adding lidocaine to IV potassium infusions can cause safety problems. P&T 2008; 33(2):70-75.
5. ISMP’s List of High-Alert Medications. Available at: https://www.ismp.org/tools/highalertmedications.pdf. Accessed May 20, 2015.
6. Kraft MD,et al. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health-Syst Pharm. 2005; 62:1663-82.
7. Lim ET, Kloo ST, Tweed WA. Efficacy of lignocaine in alleviating potassium chloride infusion pain. Anaesth Intens Care 1992; 20:196-198.
8. Phosphate Products. Available at: https://dovenet.stvincent.org/sites/Indianapolis/Pharmacy/NeoPeds/PharmacistInfo/Phosphate Products 6-2014.pdf.
Accessed May 20, 2015.
9. Pucino F et al. Patient tolerance to intravenous potassium chloride with and without lidocaine. Drug Intell Clin Pharm 1988; 22:676-9.
10. Ruskin K, Rosenbaum SH. Chapter 6: Miscellaneous Drug Problems, Drug Extravasation. Anesthesia Emergencies, 2011. 133-135. New York: Oxford
University Press, Inc.
19
Specialized Nutrition Support
Oral Supplements
Product Name Ensure® High Ensure Ensure Clear® Nepro® with

Protein Enlive® Carb Steady®
Indication for Use High protein PO High-calorie Clear-liquid PO Dialysis (stage 5
Supplement PO supplement CKD)
Supplement
Nutrition Values per 8 fl oz 8 fl oz 6.8 fl oz 8 fl oz
Calories 160 350 200 425
Protein (g) 16 20 7 19.1
Fat (g) 2 11 0 22.7
Carbohydrate (g) 19 44 (45 Choc) 43 37.9
Suitable for Lactose Yes Yes Yes Yes
Intolerance*
Gluten-Free Yes Yes Yes Yes
*Not for individuals with galactosemia
Printed courtesy of Abbott Nutrition, a division of Abbott Laboratories. For more information, visit abbottnutrition.com.
Enteral Nutrition (EN)
• EN can be delivered through temporary access including naso/oral gastric and small bowel feeding
tubes as well as more permanent PEG, PEGJ, and PEJ tubes.
• Maintains structural and functional integrity of the mucosa
• Hold tube feeds 1 hour before and 1 hour after interacting medications (i.e. levothyroxine, phenytoin)
CONTRAINDICATIONS for EN: NOT CONTRAINDICATIONS for EN:

Bowel obstruction Bowel anastomosis - EN may hasten healing
High-output fistula refractory to EN Ileus
Massive bowel resection refractory to EN Gastric bleed (exception of a massive GIB)
High risk for non-occlusive bowel necrosis Pancreatitis
Hemodynamic instability or intestinal ischemia Malabsorption
Guidelines for Initiation of Enteral Nutrition:
• Volume: The total volume is determined by the number of calories and protein needed
• Concentration: Tube feeds should be started at full strength
• Rate: Initial rates range from 10-50 mL/hour. Contraindications to rate advancement include abdominal
distention, nausea, cramping, diarrhea, vomiting, residual volume >250 mL. Note: Continuous 24-hour
tube feeds are generally best tolerated.
• Additional daily free water needs: General guidelines are 1 mL/kcal for adults
• Prevention of feeding-tube occlusions: Literature suggests routine water flushes with a minimum of 20
mL of water pre/post-medication administration
20
St. Vincent Indianapolis Hospital Enteral Nutrition Formulary
Standard Tube Feeding Formulas Specialty Formulas Peptide-based Special Modular

order
Category High Isotonic Concentrated High calorie, Diabetes Renal Hepatic Peptide- Peptide- Elemental Protein
protein calories, HP HP (Dialysis) based, HP based, HP
(HP)
with
fiber
Product name Jevity® Osmolite® 1 Osmolite® 1.2 Osmolite® 1.5 Glucerna® Nepro® with NutriHep® Vital® High Vital AF 1.2 Vivonex® RTF Pro-Stat® Sugar Free
1.2 Cal Cal Cal Cal 1.2 Cal Carb Steady® Protein Cal®
Indications for HP, conc Isotonic HP, conc HP, conc 35% cal from Renal for pts Hep insuf For acute ill Helps manage 10% from fat, Protein in low volume
use calories without fiber calories w/o calories w/o carb and on dialysis or liver dz obese, mech inflammation severe protein, related to state 1&2
with fiber fiber, volume 45% from fat (CKD 5) with vent crit ill or and promote fat pressure ulcers,
fiber restriction enceph crit ill with GI GI tolerance malabsorption wounds, muscle loss
refractory impairment syndrome,
to select
treatment trauma/surgery
early post-op
feeding
Nutrient 1L 1L 1L 1L 1L 1L 1L 1L 1L 1L 30mL
values per
Cal/mL 1.2 1.06 1.2 1.5 1.2 1.8 1.5 1 1.2 1 100cals/serving
Nonprotein 0.98 0.88 0.98 1.25 0.96 1.48 1.34 0.65 0.9 0.8 NL
cal/mL
Protein (g) 55.5 44.3 55.5 62.7 60 81 40 87.5 75 50g as AA 15
Fat (g) 39.3 34.7 39.3 49.1 60 96 21.2 23.2 53.9 11.6 0
Carbs (g) 169.4 143.9 157.5 203.6 114.5 161 290 112 110.6 176 10
Osmolality 450 300 360 525 720 745 790 353 425 630 NL
(mOsm/kg
H2O)
ML to meet 1000 1321 1000 1000 1250 944 1000 1422 1185 1500 NA
100%RDIs*
Na (mg) 1350 930 1340 1400 1110 1060 160 1400 1266 700 50
K (mg) 1850 1570 1810 1800 2020 1060 1320 1600 1688 1200 20
Water (g) 807 842 820 762 805 727 760 836 811 848 NL
Fiber (g) 18 0 0 0 16.1 12.6 NL 0 5.1 NL NL
Ok in lactose Y Y Y Y Y Y Y Y Y Y Y
intolerance?
Gluten-free Y Y Y Y Y Y Y Y Y Y Y
Nonprotein 110:1 125:1 110:1 125:1 100:1 121:1 209:1 47:1 75:1 111:1 NL
cal/N Ratio
NL – Not listed on corporate website

NA – Not applicable
21
*To meet key vitamins and minerals
Intravenous & Oral Iron Comparison
Please utilize the “Iron (IV) Adult Orders” or “Iron (PO) Adult Orders” order-sets in Sunrise
Intravenous Products* Ferric Gluconate Iron Dextran (INFeD) Iron Sucrose (Venofer) –
(Ferrlecit) Nonformulary (substituted
to ferric gluconate)
Labeled Indication(s) CKD* (hemodialysis Iron deficiency anemia CKD* (Non-dialysis
dependent-only) patients dependent/hemodialysis &
receiving ESA’s peritoneal dialysis)
Test dose required? No Yes- 25 mg No
Black box warning? No Yes-Risk for Anaphylactic- No

type reactions
Dosing 125 mg q24 h x 8 doses Infusion: May give up to 100 mg q24 h x 10 doses
250 mg q24 h x 4 doses 1000 mg over 4-6 hours 200 mg q24 h x5 doses
(preferred) 300 mg q24 h x 3 doses
Post-dose Observation 30 min 60 min after test dose; 30 30 min
min after remainder
Comments Less risk of anaphylactoid May give total iron dose Less risk of anaphylactoid
reactions in one infusion reactions
*IV iron is preferred in HD patients (during dialysis sessions) on ESA therapy due to absorption concerns; however non-dialysis & peritoneal dialysis
patients may take either PO or IV.
Oral Products Iron Polysaccharide Complex Ferrous Sulfate Ferrous Gluconate

(Niferex/Ferrex 150)
Recommended 150 mg PO daily or BID 325 mg PO 2-4 times per 324 mg 1-2 tablets PO
dose day 2-4 times/day
Elemental iron 150 mg 65 mg 38 mg
per tablet
Comments Contains folic acid, vitamin B12, Requires acidic environment (empty stomach) for
and citric acid (aids in absorption; consider giving with ≥200 mg Vitamin C
absorption)
Recommend starting frequency at once a day and
More expensive than other gradually titrate dose to assess tolerance and
options prevent constipation; consider adding stool
softener/stimulant
Safety Concerns
Infusion Rates: Higher infusion rates of iron (than recommended) can lead to vasoactive reactions due to the
presence of unbound/free iron in circulation resulting in ↓ BP, acute edema of extremities, onset of diarrhea.
Iron Toxicity: A maximum of 1000 mg in a 14 day period is recommended. Supratherapeutic amounts of iron
can lead to the following: N/V, diarrhea, lethargy, confusion, vasodilation, ↓ BP, blood loss, GI hemorrhage,
noncardiogenic pulmonary edema, acute renal failure, hepatic necrosis, convulsions, coma, and cardiac
failure.
Medication Package Inserts found at dailymed.org. Accessed May 2018.
Comparison of Oral Iron Supplements. Pharmacist’s Letter/Prescriber’s Letter 2008: 24(8): 240811.
22
Magnesium (1.6-2.6 mg/dL)
• Hypomagnesemia can cause concomitant refractory hypokalemia and hypocalcemia.
• Rapid administration is NOT RECOMMENDED and is associated with enhance renal elimination and
hypotension. Infuse at a rate not to exceed 1 gram/hour
• 1 gram magnesium sulfate = 8 mEq magnesium
• USE CAUTION in renal insufficiency (acute or chronic): Give ≤50% of the initial dose
• Oral replacement therapy is not recommended due to lack of absorption and osmotic induced diarrhea
Serum Magnesium Concentration IV Magnesium Replacement Dose

1.3-1.5 mg/dL 4 grams
1-1.2 mg/dL 2 grams every 2 hours x 3 doses (6 grams total)
< 1 mg/dL 4 grams every 4 hours x 2 doses (8 grams total)
Recommend repeat magnesium level in 36-48 hours. Concentrations may appear falsely elevated
within 24 hours of IV replacement due to delayed distribution.

2001;36:1201-1208
23
Maintenance and Replacement Fluids
Na Cl K Ca Lactate Glucose mOsm/L

(mEq/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L) (g/L)
LR 130 109 4 3 28 -- 273
NS 154 154 -- -- -- -- 308
0.45% NaCl 77 77 -- -- -- -- 154
D5W -- -- -- -- -- 50 252
D10W -- -- -- -- -- 100 505
D5NS 154 154 -- -- -- 50 560
D5-1/2NS 77 77 -- -- -- 50 406
D5LR 130 109 4 3 28 50 525
NS + 150 304 154 -- -- -- -- 608
NaHCO3
Fluid Pearls
LR
• Isotonic
• Lactate converted to bicarb which can help correct acidosis
• 1,000 ml fluid volume = 250 ml intravascular volume expansion
D5W
• Equivalent to “free water”
• 1,000 ml fluid volume = 100 ml intravascular volume expansion
NS
• Isotonic
• Risk for hypernatremia and hyperchloremic metabolic acidosis
• 1,000 ml fluid volume = 250 ml intravascular expansion
Maintenance Fluids:
• Common methods of estimating the daily volume in children and adults

o Administer 100 mL/kg for the first 10 kg, followed by 50 mL/kg for the next 10–20 kg (i.e., 1500 mL for
the first 20 kg) plus 20 mL/kg for every kg greater than 20 kg
or
o Administer 20–40 mL/kg/day (for adults only)
o Adjust fluids according to the individual patient’s input, output and estimated insensible loss
• A typical maintenance intravenous fluid is D5W with 0.45% sodium chloride plus 20–40 mEq of potassium
chloride per liter. The potassium chloride content can be adjusted for the individual patient.
24
Parenteral Nutrition (PN)
PN is indicated for patients who have been unable to meet their nutritional needs enterally or are anticipated to be unable to meet their nutritional
needs enterally for at least 7 days due to a nonfunctional GI tract, the physiological inability to obtain enteral access, or a valid medical reason for
avoiding the provision of EN. In all cases a good faith effort must be made to provide the patient with enteral nutrition (if not contraindicated due
to disease state) before initiating PN therapy.
PN Prescribing:
All PN orders must be received by 1400 to be processed for 2100 hang time
• Patient must have central venous access and baseline lab values within the last 24 hours
• Patients should be relatively stable from a fluid, electrolyte, and metabolic standpoint before initiation of PN
• Upon initiation, determine total fluid requirements for patient
o Review and adjust all sources of fluid for the patient including IV piggybacks and maintenance fluids to avoid fluid overload. Clarify
the total rate of IVF desired if maintenance fluids are not discontinued.
o Remove all electrolytes and caloric additives from maintenance fluids. This consolidates all maintenance electrolyte and caloric
sources to the PN.
Pearls for PN Entry:

• Pharmacy referral to co-manage the PN
• Considerations
o Recommended labs for nutrition support
o POC blood glucose monitoring Q6h x 48 hours
o Correction scale insulin for patients with existing/ expected hyperglycemia
o Basal insulin for patients with Type 1 Diabetes Mellitus
Monitoring Nutrition Support

Baseline Day 1: CMP, magnesium, phosphorus, serum triglycerides, and ionized calcium
Days 2-4: BMP, magnesium, and phosphorus
Maintenance CMP, magnesium, phosphate every Monday and Thursday
**Triglycerides and ionized calcium every Monday if patient is on TPN**
Weights Daily with Strict Ins and Outs
Blood Glucose POC Q 6 hours x 48 hours after TPN initiation
25
26
Phosphorus (2.5-4.7 mg/dL)
• Maximum infusion rate of 7 mmol phosphate/hour
Sodium phosphate: Potassium phosphate:

Preferred when potassium ≥ 4 mEq/L Preferred when potassium < 4 mEq/L
1 mmol of provides 1.33 mEq sodium 1 mmol of provides 1.47 mEq potassium
Serum Phosphorus IV Phosphorus

Potassium Content Sodium Content
Concentration Replacement Dose
1.8-2.4 mg/dL 15 mmol 22.1 mEq 20 mEq
15 mmol every 2 hours x 2
1.1-1.7 mg/dL 44.1 mEq 39.9 mEq
doses
15 mmol every 2 hours x 3
<1.1 mg/dL 66.2 mEq 59.9 mEq
doses
Repeat phosphorus level with AM labs.

2001;36:1201-1208
27
Potassium Phosphate and Sodium Phosphate Oral/Enteral Products
• Oral or enteral phosphorus replacement may not be as effective due to lack of absorption and laxative effect
• Do NOT give more than 16 mmol (tablets) or 20.3 mmol (solution) per dose; do not exceed 4 doses/day.
Ordered Item Sunrise Item Name Ingredients Route of

Phosphorous Potassium
Sodium Administration
POTASSIUM and SODIUM containing products (Oral only)
POTassium POTassium PHOS- 250 mg 45 mg 298 mg Oral only
PHOSphate-SODium SOD PHOS 250mg- (8 mmol) (1.1 mEq) (13 mEq)
PHOSphate Tab 45mg-298mg Tab

(K-Phos -Neutral,
Phospha 250™ K-Phos-Neutral
Neutral)
• Tablet Phospha 250
Neutral
POTassium Acid- POTassium Acid 250 mg(8 88 mg 134 mg Oral only
SODium Acid Phosph Phos-SODium Acid mmol) (2.3 mEq) (5.8 mEq)
Tab Phos 305-700mg
(K-Phos® No. 2) Tab
• Tablet
K-Phos® No. 2
POTassium Phos - NaK packet 250 mg 280 mg 160 mg Oral or Feeding
PHOSphate-SODium (8 mmol) (7.1 mEq) (13 mEq) Tube
PHOSphate
(Phos - NaK)
• Powder packet
POTASSIUM ONLY containing products (Oral or enteral- enteral route preferred agent)
POTassium Acid K-Phos Original 114 mg 144 mg None Oral or feeding
PHOSphate (POTassium Acid (3.68 mmol) (3.7 mEq) tube
(K-Phos® ORIGINAL) PHOSphate Oral)
• Tablet 1000mg Can be dissolved
in 180 to 240 mL
POTassium Acid water for
PHOSphate Oral administration.
28
Potassium (3.6-5.1 mg/dL)
• Evaluate serum magnesium: appropriate magnesium electrolyte replacement is needed to correct
hypokalemia
• For every 10 mEq KCl given anticipate a rise of 0.1 mg/dL in serum potassium
• Maximum infusion rate of 10 mEq potassium per hour (non-ICU patients)
Serum K Oral Supplement IV Supplement

(mg/dL)
KCl Eff 25 mEq KCl 20 mEq IVPB
3.4-3.7 KCl Liquid 20 mEq
KCl Eff 50 mEq KCl 20 mEq IVPB Q2H x 2 doses

3.1 – 3.3
KCl Liquid 40 mEq (Total of 40 mEq)
KCl 20 mEq IVPB Q2H x 4 doses

<3 KCl Eff 50 mEq Q4H x 2 doses (100 mEq total) (Total of 80 mEq)
KCl Liquid 40 mEq Q4H x 2 doses (80 mEq total)
Repeat potassium level should be no sooner than 2 hours after oral supplementation or 1 hour after IV
replacement. Obtain with AM labs if non-emergent.

2001;36:1201-1208
29
Ascites
Diuretics in Ascites
• Dietary sodium restriction (2000 mg per day) and oral diuretics are first line therapy for
the management of ascites
o In general, a ratio of 100mg:40mg (spironolactone:furosemide) maintains
normokalemia
 Initial therapy: 100mg PO spironolactone and 40mg PO furosemide daily
 Maximum dose: 400mg PO spironolactone and 160mg PO furosemide daily
Role of Albumin in Paracentesis

• Post-paracentesis albumin may not be necessary after a single paracentesis removing
less than 4-5L of fluid
• If >5L of fluid removed, administer 6-8g of 25% albumin IV for each liter of fluid
removed (round to nearest 25g)
o Ex. If 8L removed, administer 50g IV (8L x 6-8g/L =48-64g  rounded to 50g)
Reference: Runyon et al. AASLD Guidelines 2012.
30
Constipation
Pharmacological Stool Softeners and Laxatives
Brand Name Generic Name Mechanism of Action
Colace® Docusate Stool softener
Senokot® Senna Stimulant laxative
Senokot-S® Docusate-Senna Stool softener/Stimulant laxative
combination
Dulcolax® (suppository) Bisacodyl Stimulant laxative
Fleet® Enema Sodium bisphosphate- Osmotic laxative
Sodium phosphate enema
Miralax® Polyethylene Glycol 3350 Osmotic laxative
Non-Pharmacological Laxatives
“Soap Suds” Enema Milk and Molasses Osmotic laxative
Pharmacological Agents Indicated for Opioid-Induced Constipation (OIC)
Movantik® (oral tablet) Naloxegol Mu-opioid receptor antagonist
Relistor® (Subcutaneous Methylnaltrexone Mu-opioid receptor antagonist
injection)
Amitiza® (oral tablet) Lubiprostone Chloride-channel agonist (increases
intestinal fluid secretion)
St. Vincent Criteria for Mu-opioid Receptor Antagonists
• Patient’s constipation must be related to chronic opioid use.
• Patient must have failed 72 hours of aggressive laxative treatment.
o At least 2 laxatives with a different mechanism of action utilized for 72 hours.
• Dosing must not exceed one dose in a 24 hour period.
• Naloxegol should be used in patients with enteral access (may be crushed and
administered via NG tube). Methylnaltrexone should be reserved for patients without
enteral access.
OIC Medication Dosing Reference
Medication Dosing Renal Adjustment
Naloxegol 25mg PO in the AM CrCl < 60: 12.5mg PO in the AM
Methylnaltrexone Indication: CrCl < 30ml/min: Administer
OIC in chronic non-cancer pain 50% of the normal dose
12mg SubQ daily
OIC with adv. illness
<38kg: 0.15mg/kg daily
38 to <62kg: 8mg daily
62 to 114kg: 12mg daily
>114kg: 0.15mg/kg daily
*Lubiprostone 24mcg PO BID No adjustments necessary
*Lubiprostone is dosed 8mcg po BID when used for IBS-C
References: Lexi-Comp® Ascension TAG Criteria for Methylnaltrexone April 2016
31
Hepatic Encephalopathy
-Routine monitoring of serum ammonia is not recommended
Medication Acute Episode Maintenance/Prevention
Lactulose Oral or NG: 30 ml (20 grams) every 1-2 30ml (20 grams) 3-4
-Preferred agent hours until a soft or loose bowel times per day titrated to
movement 2-3 soft bowel
movements/day
NPO: 300 ml (200 grams) enema retained
for 30-60 min, may repeat every 4-6 hours
Rifaximin* 400 mg PO Q8H for 5-10 days 550 mg PO BID
Metronidazole* 500 mg PO Q8H ----
Neomycin* 1 gram Q6H x 5 days ----
*Treatment with multiple antibiotic agents is not recommended
Reference: Vilstrup, et al. Hepatol. 2014;60(2):715-35.
32
Acute Pancreatitis
American Gastrointestinal Association 2018 Guidelines
1. Goal directed fluid management
2. AVOID prophylactic antibiotics, including severe and necrotizing pancreatitis
3. Early (within 24 hours) oral feeding as tolerated
Fluids in Pancreatitis
1. No difference in LR or NS
2. Rate varies in studies:
1. 100-500 ml/hr for 24 hours
2. Total in 24 hours: 3-4L
Nutrition in Pancreatitis
1. In mild pancreatitis, oral feedings can be started immediately if N/V and abdominal
pain are not present. Initiation of a low fat solid diet appears to be as safe as a clear
liquid diet.
2. In severe pancreatitis, enteral nutrition is recommended. Avoid parenteral nutrition
unless the enteral route is not available, not tolerated or not meeting caloric
requirements.
3. Nasogastric delivery and nasojejunal delivery of enteral feedings appear comparable in
efficacy and safety.
33 World J Gastroenterol 2014;20(48):18092-103.
Gastroenterology 2018;154(4):1096-1101
Medications that Cause Pancreatitis
(Not all inclusive)
*=Agents with the strongest association in the medication class
Amiodarone Angiotension converting enzyme Angiotensin receptor blockers

inhibitors (enalapril*, captopril, (losartan*, irbesartan)
lisinopril, benazepril, ramipril)
Azathioprine Ceftriaxone Cyclosporine
Estrogens Furosemide Isoniazid
Lamivudine Linezolid Methyldopa
Metronidazole Nelfinavir Penicillin
Procainamide Propofol Salicylates
Statins (pravastatin*, simvastatin*, Steroids (dexamethasone*, Sulfamethoxazole and
fluvastatin, lovastatin, rosuvastatin) prednisone, prednisolone ) sulfamethoxazole/trimethoprim
Tamoxifen Thiazides Valproic acid
Pancrealipase replacement in chronic pancreatitis

In patients with exocrine pancreatic insufficiency (EPI) can consider pancrealipase
(Creon®) replacement. Patients with diarrhea (steatorrhea), weight loss and
flatulence/abdominal distention may have EPI
Initial dose (based on lipase): 500 units/kg/meal

Creon products (lipase content): 3000, 6000, 12000, 24000 and 36000
34
Core Evid 202;7:77-91
Clin Gastroenterol Hepatol 2007;5:648.
Spontaneous Bacterial Peritonitis (SBP)
Initial Treatment
First-line Therapy Ceftriaxone 1-2g IV q 24 hours x 5-10 days
3rd generation cephalosporin

Second-line Therapy Ciprofloxacin 400mg IV q 12 hours x 5-10 days
Fluoroquinolone (cephalosporin
allergic patients)
Secondary Prophylaxis
First-line Therapy Ciprofloxacin 500mg PO daily
Fluoroquinolone
Second-line Therapy 1 double strength tablet (800mg SMX/160mg TMP)
PO daily
Sulfamethoxazole/Trimethoprim
• Treatment is recommended in patients with an ascitic polymorphonuclear (PMN)
leukocyte count >250cells/mm3 and signs/symptoms of infection
• Secondary prophylaxis is recommended to reduce SBP recurrence
Variceal Bleeding
Management of Acute Hemorrhage
Medication Dose Duration Purpose
Octreotide 50mcg IV bolus, followed by 2-5 days Induce splanchnic
50mcg/hr IV infusion vasoconstriction to
control bleed
*May repeat bolus in first hour if
ongoing bleeding
Antibiotics – choose one of the following
Ceftriaxone 1g IV q 24 hours 7 days* Primary spontaneous
bacterial peritonitis (SBP)
prophylaxis
Ciprofloxacin 400mg IV q 12 hours 7 days* SBP prophylaxis in
patients allergic to
cephalosporins
• *Patients admitted with any GI bleed (variceal bleed, gastric ulcer, etc) with cirrhosis
should be started on primary SBP prophylaxis for 7 days or until the bleed is resolved
(whichever is shorter)
• Consider referral to GI for endoscopy and possible variceal ligation
• After management of the acute episode, propranolol may be initiated for prevention of
future variceal bleeding episodes (20-40mg po BID; max 320mg/day in patients without
ascites and 160mg/day in patients with ascites)
• Patients currently taking propranolol should have propranolol held during acute bleed
Reference: Hepatol. 2017;65(1):310-335
36
Adult Aminoglycoside Dosing
Step 1: Order pharmacy referral for aminoglycoside management
Step 2: Assess renal function
Step 3: Determine type of infection (severe/invasive or UTI)
Step 4: Calculate ideal body weight for dosing
Step 5: Order extended interval gentamicin/tobramycin (5-7mg/kg) if critically ill and ≥30mL/min OR
conventional interval gentamicin/tobramycin (3mg/kg) if mild infections or CrCl <30mL/min
Step 6: With the help of pharmacy, dose adjust based on levels
Extended Interval: Order one time dose with 12-14 hour post-infusion level then work
with pharmacy to select appropriate interval
Conventional Interval: Based on renal function. Peaks and troughs must be drawn with
this dosing method (goal peak 8-10mg/L; goal trough ≤1mg/L)
*Hemodialysis patients dose 1.5-2mg/kg post-HD;

CRRT patients dose 2mg/kg Q24h
Endocarditis Synergy Dosing (gentamicin only):

* • Streptococcal: 3mg/kg Q24h
• Staphylococcal/Enterococcal: 1mg/kg Q8h
37
Any Source – All Emergency Department
(% susceptible; first isolates only)
Piperacillin/Tazobactam
Nitrofurantoin (urine)
Ampicillin/sulbactam
St. Vincent Hospital
2001 W. 86th Street Indianapolis, IN
Meropenem†
Levofloxacin§
Total Isolates
Ciprofloxacin
Ceftazidime†
Gentamicin¤
Vancomycin
Clindamycin
Ceftriaxone
Cefepime¥
Cefazolin‡
Ampicillin
Oxacillin
MIC Breakpoints (mcg/mL) ≤8 ≤8 ≤4 ≤8 ≤4 ≤1 ≤0.25 ≤4 ≤0.5 ≤1 ≤32 ≤16 ≤2
SUSCEPTIBILITY PATTERNS OF
Citrobacter koseri 50 90 100 96 100 100 100 81 100 100 COMMON ISOLATES
Gram Negative
Escherichia coli 1451 51 60 86 93 91 79 93 100 94 96 76
Klebsiella pneumoniae 330 0 88 93 95 94 96 97 99 38 97 90 2018 ANTIBIOGRAM

Proteus mirabilis 185 85 92 95 99 98 78 95 100 0 100 84
Pseudomonas aeruginosa 230 94 95 89 93 96 96
MIC Breakpoints (mcg/mL) ≤8 ≤0.5 ≤4 ≤2 ≤32 ≤2 ≤2 ≤2
Enterococcus faecalis 310 100 87 99 99

Microbiology Lab 803-0050
Gram Positive
MRSA 187 0 0 72 100 100 0 97 99

Infection Control 338-2094
MSSA 235 100 100 82 100 100 100 100 100 Pharmacy 338-2991
Coagulase-Negative Staph. 167 55 55 60 89 100 56 71 100
Blank cells indicate drug not tested or drug not indicated

† Susceptibility breakpoint for P. aeruginosa for ceftazidime is ≤8; ciprofloxacin ≤ 0.5; meropenem is ≤2
‡ FDA breakpoints differ from CLSI- Vitek reports based on FDA breakpoints; CLSI breakpoint is ≤ 2 for all Enterobacteriaceae infections except
uncomplicated UTIs
¥ Cefepime susceptible and susceptible dose-dependent (SDD) breakpoints for Enterobacteriaceae are ≤2 and ≤8, respectively
§ Susceptibility breakpoint for enterococcus for levofloxacin ≤2; vancomycin ≤4 ***CONFIDENTIAL***
¤ Gentamicin should always be used in combination with other active agents against staphylococcal infections
Not to be shared with drug representatives
Any Source – All Inpatient Tips for appropriate inpatient antimicrobial use:
(% susceptible; first isolates only)
Piperacillin/Tazobactam
Nitrofurantoin (urine)
Ampicillin/sulbactam
Meropenem†
Levofloxacin§
Total Isolates
Ciprofloxacin
Ceftazidime†
Gentamicin¤
Vancomycin
Clindamycin
Ceftriaxone
Penicillin G
Cefepime¥
Cefazolin‡
Ampicillin
Oxacillin
MIC Breakpoints (mcg/mL) ≤ ≤
≤8 ≤8 ≤4 ≤8 ≤4 ≤1 ≤4 ≤2 ≤32 ≤16 ≤2
0.25 0.5
Enterobacter cloacae 38 100 97 97 100 22 88 100
Escherichia coli 477 49 57 79 88 86 74 91 100 96 93 75
Gram Negative
Klebsiella oxytoca 41 0 79 64 97 94 100 100 100 81 95 94

Klebsiella pneumoniae 173 0 80 90 92 92 94 97 96 36 91 92
Proteus mirabilis 94 90 97 93 99 98 88 97 100 99 91
Pseudomonas aeruginosa 201 89 88 91 95 96 91
Serratia marsescens 41 100 95 97 100 100 0 97 100
≤
MIC Breakpoints (mcg/mL) ≤8 ≤4 ≤2 ≤32 ≤2 ≤2 ≤2
0.5
Enterococcus faecalis
201 100 85 98 99
Gram Positive
Enterococcus faecium
45 31 17 25 33
MRSA 247 66 99 100 0 97 100

MSSA 303 100 100 83 100 100 100 98 100
Coagulase-Negative Staph.
154 55 56 73 93 100 55 74 100
Blank cells indicate drug not tested or drug not indicated

Useful Resources:
† Susceptibility breakpoint for P. aeruginosa for ceftazidime is ≤8; ciprofloxacin ≤ 0.5; meropenem is ≤2 Get Smart for Healthcare
‡ FDA breakpoints differ from CLSI- Vitek reports based on FDA breakpoints; CLSI breakpoint is ≤ 2 for all Enterobacteriaceae infections except http://www.cdc.gov/getsmart/healthcare/
uncomplicated UTIs IDSA Practice Guidelines
¥ Cefepime susceptible and susceptible dose-dependent (SDD) breakpoints for Enterobacteriaceae are ≤2 and ≤8, respectively www.IDSA.org
§ Susceptibility breakpoint for enterococcus for levofloxacin ≤2; vancomycin ≤4 About Antimicrobial Resistance
¤ Gentamicin should always be used in combination with other active agents against staphylococcal infections https://www.cdc.gov/drugresistance/about.html
Antimicrobial Restriction Policy*
The following antimicrobials are restricted to ID approval:
• ID approval is:
• Formal ID consult
• Discussion with ID provider to assess the use of restricted antimicrobial
• Without ID approval
• 48 hour stop date will be placed by pharmacist until ID approval can be obtained or different
antimicrobials are chosen
Adults
amphotericin B deoxycholate (Fungizone®) fosfomycin (Monurol®)
amphotericin B liposome (AmBisome®) foscarnet (Foscavir®)
anidulafungin (Eraxis®) ganciclovir (Cytovene®)
aztreonam (Azactam®) isavuconazonium (Cresemba®)
ceftaroline (Teflaro®) linezolid (Zyvox®)
ceftazidime-avibactam (Avycaz®) meropenem (Merrem®)
ceftolozane-tazobactam (Zerbaxa®) meropenem/vaborbactam (Vabomere™)
cidofovir (Vistide®) posaconazole (Noxafil®)
colistimethate sodium (Coly-Mycin® M) quinupristin/dalfopristin (Synercid®)
daptomycin (Cubicin®) tigecycline (Tygacil®)
ertapenem (Invanz®) voriconazole (Vfend®)
fidaxomicin (Dificid®)
*Please refer to the Antimicrobial Restriction Policy on PolicyStat for the complete policy.
40
Cellulitis Treatment Algorithm (non-purulent)
Diabetic Foot Infections Empiric

Treatment: vancomycin (dosed per
pharmacy) PLUS cefepime 2g q 8 h* PLUS
metronidazole 500mg q 8 h
41
Cellulitis Treatment Algorithm (purulent)
Diabetic Foot Infections Empiric Treatment: vancomycin (dosed per pharmacy)

42 PLUS cefepime 2g q 8 h* PLUS metronidazole 500mg q 8 h
Cephalosporin Utilization Guidelines
Cephalosporin Indications
Cefepime - Critically ill patients with signs/symptoms of infection
*May be substituted with - Patients with MULTIPLE risk factors for MDROs
piperacillin/tazobactam in absence of - Severe diabetic foot infection patients
concomitant vancomycin or - Severe IAI
ceftazidime in instance of cefepime - Patients with suspected hospital-acquired infections (≥48 after
shortage admission)
- Febrile neutropenia
Ceftriaxone - Non-critically ill patients with IAI, CAP, complicated-UTI, meningitis‡
- Patients presenting from the community with FEW risks for MDROs
- Aspiration pneumonia
- Mild to moderate diabetic foot infections
Cefazolin - Mild IAI in patients without risk for MDRO
- Surgical prophylaxis (refer to St. Vincent Protocol)
- Non-purulent SSTI
- Uncomplicated UTI
- De-escalation for infections with susceptible clinical isolates
MDRO-multidrug-resistant organisms; IAI-intraabdominal infection; CAP-community-acquired pneumonia; UTI-
urinary tract infection; SSTI-skin and soft-tissue infection
†Not all indications require cephalosporin monotherapy. Additional antibiotics may be warranted for specific
indications based on national guidelines and hospital protocol.
‡Cefotaxime is preferred in neonatal patients with concern43for meningitis
Clostridium difficile Infections
44
Community-Acquired Pneumonia
CURB-65
Confusion (disorientation to person, place or time) 0-1: outpatient therapy
Uremia (BUN > 20 mg/dl) 2: inpatient admission (floor)
Respiratory rate (≥30 breaths/min) ≥3: inpatient admission (ICU)
Blood pressure (SBP < 90 mmHg or DBP < 60 mmHg)
65 years old
Without pseudomonal risk (IV therapy) Convert to PO when patient taking PO and
clinically improving
• Mild to moderate: Ampicillin/sulbactam
3g IV Q6H + Azithromycin 500 mg IV • Amoxicillin/clavulanate 875mg PO BID or
Q24H x 3 days Cefuroxime 500mg BID x 5 days +
• Severe: Ceftriaxone 1g IV Q24H x 5 days Azithromycin 500 mg PO Daily x 3 days
+ Azithromycin 500 mg IV Q24H x 3 days • PCN allergy: Levofloxacin 750 mg PO Q24H
x 5 days
• PCN allergy: Levofloxacin 750mg IV Q24H
x 5 days
Procalcitonin
Aspiration pneumonia • Order within 24 hours of
admission to rule out
• Ampicillin/sulbactam 3 g IV Q6H bacterial infection for all CAP
patients patients with
• PO conversion: Amoxicillin/clavulanate 875 mg PO BID
alternative diagnoses in the
• PCN allergy: Clindamycin 600 mg IV Q8H differential
45
• PO conversion: Clindamycin 300-450 mg PO TID
Compounded Vancomycin Solution *As of June 2018*
Cost Bills Time Needed

Pharmacy Location Phone Number
(for 5,000 mg) Insurance? for Preparation
St. Vincent Pharmacy 2001 W. 86th St, Indianapolis, IN 317-338-3950 $117# Yes 1-2 hours
46260
Dr. Aziz Pharmacy 7320 E. 82 St. Indianapolis, IN 46256
nd (317) 842-5771 $125 Yes Same day
Nora Apothecary 1101 E. 86th St. Indianapolis, IN 46240 1-800-729-0276 $256 No Same day
Meridian North 9002 N. Meridian St., Suite 106B (317) 846-6654 $175 No 24-48 hours
Pharmacy Indianapolis, IN 46260
CVS* 1375 W. 86th St. Indianapolis, IN (317) 253-6427 $132 Yes 24 hours
46260
Eagle Highland Pharmacy 9010 Crawfordsville Rd. Indianapolis, (317) 299-3771 $125 No 1 hour
IN 46234
1330 W. 86 St. Indianapolis, IN
th (317) 819-0286
$90 Same day
46260
1650 E. Raymond St. Indianapolis, IN (317) 784-7979
Walgreens* $240# Yes Same day
46203
100 N. Memorial Dr. New Castle, IN (765) 521-0189
$240# Same day
47362
11700 N. Meridian St. Carmel, IN (317) 688-3040
$76+ 30-40 min
46032
IU Health Retail 550 N. University Blvd. Indianapolis, (317) 944-3445
$77.55 Yes 1 hour
Pharmacies IN 46202
705 Riley Hospital Dr., ROC 1201 (317) 944-2335
varies 24-48 hours
Indianapolis, IN 46202
#Commercially available vancomycin solution: may be available at other pharmacies not listed here
46
*Select locations only; the locations listed are always able to, whereas other locations may be capable provided that advanced notice is given
Hospital Acquired (HAP) Pneumonia and Aspiration Pneumonia
Aspiration pneumonia
HAP (IV therapy)
Healthcare associated/severe periodontal
• Cefepime EI 2g IV Q8H
disease/alcoholism:
• PCN severe allergy: Meropenem 500 mg • Piperacillin/tazobactam EI 4.5 g IV Q8H
IV Q6H
• PCN minor allergy: Cefepime EI 2g IV Q8H
• IF high suspicion of Pseudomonas: Add + Clindamycin 600mg IV Q8H
gentamicin
• PCN severe allergy: Meropenem 500mg
• IF MRSA risk factors: Add Vancomycin and IV Q6H + Clindamycin 600mg IV Q8H
order MRSA Nasal PCR
• IF high suspicion of Pseudomonas: Add
gentamicin
Duration: 7 days
• IF MRSA risk factors: Add Vancomycin and
order MRSA Nasal PCR
Duration: 7 days
47
48
49
Intra-Abdominal Infections
Mild/Moderate Severe
-Including: diverticulitis, cholecystitis* -APACHE II score >15, poor nutritional status,
perforated or abscessed appendicitis significant CV disease, inability to achieve
adequate source control
Ceftriaxone 2g IV Q24H +
Piperacillin/tazobactam EI 4.5g IV Q8H
Metronidazole 500 mg IV Q8H
PCN allergy listed as minor/rash/unknown:
PCN allergy: Ciprofloxacin 400 mg IV Q12H + Cefepime EI 1 g IV Q8H + Metronidazole 500 mg
Metronidazole 500 mg IV Q8H IV Q8H
PCN allergy listed as severe/anaphylaxis:

*for cholecystitis: do NOT need metronidazole
Meropenem 500mg Q6H
Duration: 4-7 days with adequate source Duration: 4-7 days with adequate source
control control
*Convert to PO when patient taking PO
and clinically improving
Oral Therapy:
1. Cephalexin 500 mg PO Q8H + Metronidazole 500 mg PO Q8H
2. Amoxicillin/ Clavulanate 875 mg PO BID
PCN allergy: Ciprofloxacin 500 mg PO Q12H +50 Metronidazole 500 mg PO Q8H
Penicillin Allergy Assessment
BACKGROUND*
• A penicillin allergy is the most common medication allergy, reported in approximately 10% of patients.
• Incomplete reaction histories and exaggerated concerns regarding the risk of cross-reactivity often lead
to the unnecessary avoidance of beta-lactam use in patients with reported penicillin allergies.
• Recent data has suggested this cross reactivity is much lower
o 1-5% in cephalosporins with similar side chains (first generations cephalosporins: cephalexin,
cefazolin, etc)
o 0-1% in cephalosporins with dissimilar side chains (third and fourth generation cephalosporins:
ceftriaxone and cefepime)
o 0-5% cross-reactivity between penicillins and carbapenems
• Aztreonam does not cross‐react with penicillin or cephalosporin antibodies (exception: ceftazidime) so
can be considered an option the treatment of gram‐negative infections in patients with type I beta‐
lactam allergies.
Penicillin Allergy Assessment

Does this patient have a history of Steven Johnson’s Syndrome, Toxic Yes
Use a non-beta-lactam antibiotic
Epidermal Necrolysis, or other severe non-Type 1 reaction (e.g. hepatitis,
blistering) due to a beta-lactam?
No
Nausea, vomiting, diarrhea, or other
What was the patient’s reaction?
non-hypersensitivity event
Difficulty breathing, Adverse effect, beta-lactams can be

throat closing, used safely
Hives
tongue/lip/facial swelling
OR patient unsure
The incidence of anaphylaxis is < 0.015%.
No Consider a cephalosporin with a dissimilar
Have they ever tolerated a beta-lactam?
side chain (penicillin cross reactivity < 2%)
or aztreonam. If the patient has a history
Yes, amoxicillin or Yes, a first Yes, a third or fourth of cefepime or piperacillin-tazobactam
amoxillin-clavulanate generation generation resistant isolates, consider meropenem. If
cephalosporin cephalosporin a cephalosporin or meropenem is given,
request to have the nurse monitor the
Any cephalosporin patient for the 1st hour after the dose.
Any cephalosporin Third or fourth
(except cefoxitin),
(except cefoxitin) generation
ampicillin, or
can be used safely cephalosporin can be
REFERENCES
piperacillin-tazobactam
used safely
can be used safely
* Please see the Penicillin Allergy Assessment Guideline attached to the Antimicrobial Stewardship Policy on PolicyStat
for complete information and references.
51
Spontaneous Bacterial Peritonitis (SBP)
Initial Treatment
First-line Therapy Ceftriaxone 1-2g IV q 24 hours x 5-10 days
3rd generation cephalosporin

Second-line Therapy Ciprofloxacin 400mg IV q 12 hours x 5-10 days
Fluoroquinolone (cephalosporin
allergic patients)
Secondary Prophylaxis
First-line Therapy Ciprofloxacin 500mg PO daily
Fluoroquinolone
Second-line Therapy 1 double strength tablet (800mg SMX/160mg TMP)
PO daily
• Treatment is recommended in patients with an ascitic polymorphonuclear (PMN)
leukocyte count >250cells/mm3 and signs/symptoms of infection
• Secondary prophylaxis is recommended to reduce SBP recurrence
Urinary Tract Infections
Uncomplicated cystitis Complicated cystitis &

• Cefazolin 1g IV Q8h pyelonephritis
• B-lactam allergy (CrCl • Risk factors: male,
≥30mL/min): Nitrofurantoin genitourinary anatomical
100mg BID abnormality (ex. catheter,
• B-lactam allergy (CrCL tumor), immunosuppression
<30mL/min): Ciprofloxacin • Ceftriaxone 1g IV Q24h
500mg Q24h • B-lactam allergy: Ciprofloxacin
500mg PO Q12h
Duration: 5 days
Duration: 7-14 days
• Review previous cultures and

*Do not treat asymptomatic broaden therapy as necessary
bacteriuria EXCEPT in pregnant for history of MDR organisms
patients
Adult Vancomycin Dosing
Step 1: Order pharmacy referral for vancomycin management
Step 2: Assess renal function
Step 3: Determine type of infection (severe/invasive or SSTI)
Step 4: Order weight based loading dose (25-30mg/kg x 1) if critically ill or obese
Step 5: Order weight based maintenance dose (15mg/kg per dose) at specific interval based on renal
function below
Step 6: With the help of pharmacy, dose adjust based on trough levels
*Hemodialysis patients dose post-HD;

CRRT patients dose Q24h
Goal Troughs (level drawn ≤1 hour prior to Goal Random levels (special populations):
the next dose): • Pre-Hemodialysis: 25-30mg/L
• Non-severe infections: 10-20mg/L • Continuous infusion (24hr): 20-30mg/L
• Severe infections (meningitis, sepsis,
bacteremia, etc.): 15-20mg/L 54
IV to PO Conversions
Drug IV:PO
Antimicrobials
Azithromycin (Zithromax®) 1:1
Ciprofloxacin (Cipro®) 4:5
Clindamycin (Cleocin®) 2:1
Doxycycline (Vibramycin®) 1:1
Fluconazole (Diflucan®) 1:1
Levofloxacin (Levaquin®) 1:1
Linezolid (Zyvox®) 1:1
Metronidazole (Flagyl®) 1:1
Rifampin (Rifadin®) 1:1
Trimethoprim/ 1:1
Sulfamethoxazole (Bactrim®)
Voriconazole (Vfend®) 1:1
Cardiovascular
Digoxin (Lanoxin®) 4 : 5 (for maintenance doses)
Enalaprilat 1 : 4*
Metoprolol (Lopressor®) 2 : 5*
Anti-epileptics
Divalproex (Depakote®) 1 : 1 (for maintenance doses)
Lacosamide (Vimpat®) 1 : 1 (for maintenance doses)
Levetiracetam (Keppra®) 1 : 1 (for maintenance doses)
Phenytoin (Dilantin®) 1 : 1 (for maintenance doses)
Gastrointestinal
Famotidine (Pepcid®) 1:1
Metoclopramide (Reglan®) 1:1
Pantoprazole (Protonix®) 1:1
Vitamins/Supplements
Folic Acid 1:1
Thiamine 1:1
Other
Levothyroxine (Synthroid®) 1 : 2**
Lorazepam (Ativan®) 1:1
*Examples: Enalaprit 2.5mg IV q6hrs → enalapril 5mg PO BID or enalapril 10mg PO daily
Metoprolol 5mg IV q6hrs → metoprolol tartrate 25mg PO BID or

metoprolol succinate ER 50mg PO daily
**IV Levothyroxine: If NPO, IV levothyroxine is held for 7 days then given every 3 days with daily starting on day 7.
Change to po as soon as clinically possible.
St. Vincent Indianapolis Policy: Medications for IV to PO Conversion, last updated May 2014. PolicyStat #1922512.
55
End Stage Renal Disease
Effect of PTH-suppressive therapies on biochemical parameters
PTH Calcium Phosphorus

Vitamin D analogues ↓ ↑ ↑
Cinacalcet ↓ ↓ ↓
Etelcalcetide ↓↓ ↓↓ ↓
Clin Kidney J. 2018 Feb;11(1): 80–8.
Aust Prescr. 2010;33:34-7.
Calcimimetics* Vitamin D analogs*
Cinacalcet (Sensipar®) – PO on formulary Calcifediol (Rayaldee®) - NF
Etelcalcetide (Parsabiv®) – nonformulary (NF) Calcitriol (Rocaltrol®) – IV and PO on

formulary
Doxercalciferol (Hectoral®)– IV and PO on

formulary
Paricalcitol (Zemplar®) – IV formulary; PO - NF
*See Lexicomp for dosing information based on indication and stage of kidney disease.
56
Erythropoiesis-stimulating Agents in Renal Disease
Initiation Recommendations:
Figure 1. Management of anemia of chronic kidney disease based on KDIGO and KDOQI guidelines.
CKD = chronic kidney disease; ESA = erythropoiesis-stimulating agent; Fe = iron; Hb = hemoglobin; RBC = red blood cell; TIBC = total iron-binding capacity.
Pearls:
• Do not initiate until 7 days after home dose
• Use with caution, if at all, in patients with a history of stroke or cancer
• Use the lowest possible dose of ESA to prevent blood transfusion
• Do not exceed a hemoglobin greater than 13 g/dL
Darbepoetin alfa (Aranesp) is the erythropoiesis-stimulation formulary agent *

• Advantage of less-frequent dosing
• May be administered subcutaneously or intravenously
TOTAL Weekly Epoetin alfa (Procrit) Dose Darbepoetin alfa (Aranesp) mcg/week
<2,500 units 6.25 mcg
2,500 to 4,999 units 12.5 mcg
5,000 to 10,999 units 25 mcg
11,000 to 17,999 units 40 mcg
18,000 to 33,999 units 60 mcg
≥34,000 100 mcg
*Inpatient darbepoetin orders will be capped at 100 mcg per System P&T approved guidelines and Ascension Health Initiatives
57
End Stage Renal Disease Phosphate Binders
Phosphate MOA Initial dose /max Advantages Disadvantages

Binder dose
Aluminum Insoluble 320mg TID* Inexpensive Short term use

hydroxide** phosphate Max: 640mg TID*
complexes in
gut
Calcium Insoluble CC: 500-600mg TID* Less expensive Hypercalcemia
carbonate phosphate CA: 1334mg TID*
(CC)** complexes in Max: Total daily dose
gut (including diet)
Calcium acetate should not exceed
(CA) (Phoslo®)** 2000mg of elemental
calcium
Sevelamer Anion Initial: 800mg TID* Calcium free $$, High pill burden,
hydrochloride** exchange resin Max: ~4000mg TID* bloating
(Renvela®)
Lanthanum Insoluble Initial: 500 mg TID* Low pill burden $$$, GI adverse effects
Carbonate** phosphate Max: 1500mg TID*
(Fosrenol®) complexes in
gut
Sucroferric Ligand Initial: 500mg po TID* Low pill $$$, GI adverse effects
Oxyhydroxide exchange iron- Max: 1000mg po TID* burden,
(Velphoro®) based minimal
compound systemic abs
*To be administered with meals

** Formulary agent
References
Aust Prescr 2017;40:9-14.
58
Pain Management: Opioids
Opioid Equianalgesic Table
Medication IV Oral
FentaNYL 100 mCg (0.1 mg) N/A Converting Opioids
Buprenorphine 0.3 mg 0.4 mg (SL) 1. Calculate total daily dose of current opioid(s).
(for pain management) 2. Calculate dose of new opioid agent using
HYDROcodone N/A 30 mg equianalgesic ratio in conversion table above.
HYDROmorphONE 1.5 mg 7.5 mg 3. Reduce dose by 50% for cross-tolerance (if
Methadone The conversion ratio of methadone is patient’s pain is not well controlled reduce by
variable. Please refer to other 25-30%). Convert to long acting opioid if
references. necessary.
MorPHINE 10 mg 30 mg 4. Add rescue doses (IR) of same opioid if
OxycoDONE N/A 20 mg possible- should be about 10% of total daily
OxyMORPHone 1 mg 10 mg opioid dose.
Online Calculator: http://www.globalrph.com/narcotic.cgi
Transition to Transdermal FentaNYL Patch
Transdermal FentaNYL Fentanyl Patch Clinical Pearls
IV or IM** MorPHINE Oral** MorPHINE Patch Strength • Not intended for conversion of
(mg/ day) (mg/ day) mCg/HOUR patch to PO or IV. Contact
Pharmacy for dose
45-59 12.5
recommendation.
10 – 22 60 – 134 25
23 - 30 135-179 25 + 12.5 • Starting at or increasing doses
31 – 37 180 – 224 50 greater than 50 mCg/hour is not
38 - 45 225 - 269 50 + 12.5 recommended.
46 – 52 270 – 314 75 • For doses greater than 100
53 - 60 315 - 359 75 + 12.5 mCg/hour, contact pharmacy.
61 – 67 360 – 404 100
59
https://dovenet.stvincent.org/sites/Indianapolis/Pharmacy/Pain%20Management%20Resources/Opioid%20Equianalgesic%20Table%20Aug%202015.pdf#search=equianalgesic%20opioids
PCA Dosing Guidelines – Usual starting doses—to be used as a guide.
Opioid Naïve Patients
Available via “PCA Adult Orders – Opioid Naive” Orderset
Loading Dose Demand Dose Dosing Interval 4 Hour Limit
MorPHINE 2 mg 1 mg 10 mins 20 mg
HYDROmorphONE 0.4 mg 0.2 mg 10 mins 4 mg
FentaNYL 20 mCg 10 mCg 10 mins 200 mCg
Opioid Tolerant Patients (Patients taking the equivalent of at least 60 mg of oral morphine/day for 7+ days)
Available via “PCA Adult Orders – Opioid Tolerant” Orderset
Loading Dose Demand Dose Dosing Interval 4 Hour Limit
MorPHINE 4 mg 2 mg 10 mins 40 mg
HYDROmorphONE 0.8 mg 0.5 mg 10 mins 10 mg
FentaNYL 30 mCg 20 mCg 10 mins 400 mCg
PCA Clinical Pearls

• Continuous rates should NOT be used in opioid naïve patients
• Patients on PCA must be on continuous pulse oximetry
• MorPHINE is not recommended for the elderly due to active metabolites. Use with caution in patients with renal failure.
References:
Duragesic Package Insert. Revised 4/2014.
Pratt N, et al. San Diego Patient Safety Taskforce: Patient Controlled Analgesia Guidelines of Care. December 2008.
Weber LM, Ghafoor VL, Phelps P. Am J Health-Syst Pharm. 2008; 65: 1184-91.
McPherson ML. (2010) Demystifying opioid conversion calculations: a guide for effective dosing. Bethesda, MD. American Society of Health-System Pharmacists.
60
Medication Considerations in the Perioperative Period
Thrombotic Risk Factors

Low Moderate High*
Atrial Fibrillation CHA2DS2-VASc = CHA2DS2-VASc = 2-4 CHA2DS2-VASc > 4
0-1 Stroke within 3 months
Mitral Valve Replacement
Multiple mechanical
heart valves
Venous Thromboembolic Thromboembolic disease Thromboembolic disease
Thromboembolism disease > 1 year within 3-12 months < 3 months
ago Recurrent DVTs Serious thrombophilia
Active oncological
disease
Mild thrombophilia
*Bridging with LMWH is recommended in the perioperative period in patients at high risk for thrombosis
Surgical Bleeding Risk

Minor Tooth extraction, minor skin procedures, endoscopic ENT procedure
Moderate Abdominal surgery, orthopedic surgery, urology, reconstructive surgery
High Spinal cord, neurosurgery, cardiovascular surgery
Management of Perioperative Anticoagulation

Drug Bleeding Risk Hold For Resume
Minor 2-3 days 12-24 hours
Warfarin
Mod-high 5 days 12-24 hours
Minor-Mod 6 hours 24 hours
UFH
High 6 hours 48-72 hours
Minor-Mod 24 hours 24 hours
LMWH
High 24 hours 48-72 hours
1-2 days (CrCl≥50)
Minor-Mod 24 hours
Dabigatran 3-5 days (CrCl<50)
High 3-5 days 48 hours
1-2 days (CrCl>60)
Minor-Mod 24 hours
Rivaroxaban 3-5 days (CrCl≤60)
1-2 days (CrCl>60)
Minor-Mod 24 hours
Apixaban 3-5 days (CrCl≤60)
61
Medication Considerations in the Perioperative Period
Management of Perioperative Antiplatelet Therapy
Drug Recommendation
Aspirin May continue. Consider holding for 5-7 days if at high risk for bleeding.
Dipyridamole Hold 1 day before surgery
Clopidogrel* Hold 5 days before surgery
Ticagrelor* Hold 5 days before surgery
Prasugrel* Hold 7 days before surgery
*P2Y12 Inhibitors should be continued in the perioperative period for patients at risk of thrombosis including:
ACS within 3 months, bare-metal stent placement within 6 weeks, & drug-eluting stent placement within 12
months
Management of Other Perioperative Medications

Drug/Drug Class Recommendations
ACE-Inhibitors Last dose may be given the day prior to surgery.
ARBs Last dose may be given the day prior to surgery.
Renin-inhibitors Last dose may be given the day prior to surgery.
Diuretics Last dose may be given the day prior to surgery.
Niacin Last dose may be given the day prior to surgery.
Fibrates Last dose may be given the day prior to surgery.
Cholestyramine Last dose may be given the day prior to surgery.
Colestipol Last dose may be given the day prior to surgery.
Oral Diabetic Last dose may be given the day prior to surgery. Metformin should be
Medications held for 24-48 hours prior to surgery.
Insulin Usual doses should be given the day before the surgery. Use rapid-acting
insulin in the perioperative period to manage hyperglycemia.
MAOIs Titrate off and discontinue 2 weeks prior to surgery. If MAOI safe
anesthesia is used, MAOIs can be continued in the perioperative period.
SSRIs May continue until the day of surgery. SSRIs can increase the risk of
bleeding. In patients at high-risk of bleeding, consider holding the agent
for 4-5 half-lives to allow complete clearance of the medication.
Medications Safe to Continue in the Perioperative Period

Anti-arrhythmics Beta Blockers Glucocorticoids* TCAs
Alpha Agonists CCBs Nitrates Thyroid Hormones
Alpha Blockers Digoxin Statins
*Patients taking more than 5mg/day of prednisone may experience HPA suppression. Supplemental doses of
hydrocortisone may be necessary in these patients.
References:
CHEST.2012;141(2):e326S-e350S Thromb Haemost. 2013;110(3):515-522 Acta Anaesthesiol Belg. 2011;62(4):193-201
Clin Lab Med. 2014;34(3):637-654 New Eng J Med. 2013;368:2113-2124 J Clin Pharm Ther. 2011;36:446-467
62
Stress Ulcer Prophylaxis
General Treatment Guidelines
• Literature does not support stress ulcer prophylaxis outside of the ICU environment
• Discontinue stress ulcer prophylaxis if no other appropriate treatment indications or risk factors once
patient is transferred to medical floor
• Discontinue acid – suppressive therapy treatment prior to discharge unless clearly indicated
Rate of clinically important bleeding* related to Stress Ulcers

*Hypotension or decrease in HgB of at least 2g/dL plus transfusion of two units of blood in 24 hours
• ICU patients – 1 to 5 %
• Medical patients without risk factors – < 0.1%
Risk Factors for Stress Ulcers
MAJOR Risk Factors MINOR Risk Factors

• Mechanical ventilation ≥ 48 hours • Hypoperfusion (Lactic Acid >2x ULN,
• Coagulopathy(Plt <50, 000, INR >1.5, MAP <65, on vasopressor)
or PTT >2x control) • Head/Spinal cord injury
• TBI (GCS<9) • History of GI ulcer or bleeding within
• Multiple trauma ( ≥3 organ systems last year
involved) • Postoperative transplantation
• Cervical spinal cord injury • High-dose corticosteroid (>250mg/day
• Severe burn (>35% BSA) hydrocortisone or steroid
equivalent/day)
• Major surgery which compromises
organ perfusion/function and results in
ICU admission
• Acute kidney injury(SCr ≥200%, U/O
<0.5ml/kg/hr >12 hours)
Patients in the ICU with any ONE MAJOR risk factor OR ≥ 2 MINOR risk factors are candidates for SUP therapy
American Society of Health-System Pharmacists. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst
Pharm. 1999;56:347.
Attridge, Rebecca L, et al. Internal Medicine: A Guide to Clinical Therapeutics. New York: McGraw-Hill Companies, Inc., 2013.
Print.
63
Formulary Treatment Options
Discontinue stress ulcer prophylaxis when risk factors resolve and patient has oral or enteral feeding
Drug/Dose Considerations ADE

H2 antagonist: Decreases gastric pH Thrombocytopenia, increased
Famotidine 20 mg risk of VAP, increased risk of C.
Case reports support the difficile diarrhea, constipation,
Routes: PO, NG, IV assumption that H2RAs are diarrhea, dizziness, headache
associated with
Frequency: BID thrombocytopenia; at platelet
-If CrCl < 50 ml/min: daily counts <50,000, the risk-
benefit ratio favors switching
to a PPI
PPI: Decreases gastric pH Abdominal pain, diarrhea,

Pantoprazole 40 mg headache, osteoporosis-related
First-line in patients with h/o fracture (chronic use), increased
Routes: PO, NG*, IV GI bleed or PUD, risk of VAP and CAP, increased
thrombocytopenia (<50,000) risk of C difficile diarrhea
Frequency: daily developed on H2RAs
*Tablets cannot be crushed:

Omeprazole solution 20 mg
(2 mg/ml) available as an
alternative
Sucralfate 1 gram Increased incidence of Drug interactions due to altered
clinically significant bleeding absorption (must administer
Routes: PO, NG versus H2RAs other medications 2 hours prior
to sucralfate to minimize drug
Frequency: 4x/day interactions), potential for
esophageal and GI bezoar
formation, elevated aluminum in
pts with CRT (use with caution)
Indications for Chronic Acid – Suppressive Therapy
• Upper GI bleeding – PPI

• Endoscopic findings of duodenal ulcer, erosive gastritis or esophagitis – PPI, H. pylori eradication
• Non-ulcer dyspepsia – H2RA, prokinetic agent, H. pylori eradication
• Maintenance treatment of ulcer disease – PPI outpatient
• Prevention of NSAID-induced bleeding or symptoms – PPI
• Concomitant anti-platelet (especially >1 agent)—PPI
• Home medication with appropriate indication prior to admission
64
Enoxaparin: VTE prophylaxis guidelines and Xa monitoring
Normal Weight Super Morbid
Morbid Obesity High Risk Patients
Use in Low Weight (Including Trauma) Obesity Use with Epidural or
(BMI >40kg/m2 to (hip/knee surgery or
Patient (<50kg) (>50kg & BMI (Excludes Trauma) Spinal Anesthesia
<50kg/m2) spinal cord injury)
<40kg/m2) (BMI >50kg/m2)
40 mg daily ONLY
CrCl > 30
30 mg daily 40 mg daily 40 mg Q12H 60 mg Q12H 30 mg Q12h (30 mg Q12h
mL/min
contraindicated)
Unfractionated
CrCl <30
Heparin 5000 units 30 mg daily 40 mg daily 60 mg daily 30 mg daily AVOID USE
mL/min
SQ BID
Adapted from P&T approved document “VTE prophylaxis Dosing” Approved June 2017
Monitoring
Anti-Xa levels Goal Xa levels
• Used in: obese, underweight, renal dysfunction, pregnancy Regimen Therapeutic Level
• How to order in Sunrise Clinical Manager (SCM):
Prophylaxis 0.2 – 0.5 units/mL
• Search “heparin level”
• Time to be drawn- 4 hours after 3rd dose Treatment (1 mg/kg q12h) 0.5-1.1 units/mL
Treatment (1.5 mg/kg q24h) 1-1.5 units/mL
Adjustment of Xa levels in therapeutic enoxaparin

Next Peak Anti-Xa Level
Anti-Xa Level Hold Next Dose Dose Change
(Drawn 4 hours after dose)
<0.35 No Increase by 25% 48 hours
0.35 – 0.49 No Increase by 10% 48 hours
References
0.5 – 1.1 No No Only if significant change in -CHEST. 2012; 141(2_suppl):e1S-801S.
-Ann Pharmacother. 2013;47(12):1717-1720.
renal function -Thromb Res. 2013;132:761-764.
1.11 – 1.5 No Decrease by 20% 48 hours -Thromb Res. 2010;125(3):220-223.
-Surg Obes Relat Dis. 2008;4:625-631.
1.51 – 2 3 hours Decrease by 30% 4 hours after next dose -Obes Surg 2002;12:19-24
>2 Until anti-Xa <0.5 Decrease by 40% Every 12 hours until anti-Xa- -Obes Surg. 2008;18:162-166.
-Am J Hematol. 2012;87(7):740-743.
units/mL level <0.5 units/mL -Thrombosis Research. 2005;116:41-50.
Asthma Therapy
STEP 5
STEP 4 Refer for

add-on
STEP 3 Med/high dose
therapy
STEP 1 STEP 2 (tiotropium,
ICS/LABA
PREFERRED Low dose anti-IgE, or
anti-IL5)
Low dose ICS ICS/LABA
CONTROLLER
Consider low dose Med/high dose Add tiotropium
Leukotriene receptor antagonist (LTRA) OR Add low
Alternative ICS Low dose theophylline
ICS OR low dose OR med/high dose oral
controllers ICS + LTRA (or + dose ICS + LTRA steroid
theoph) (or + theoph)
RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA OR low dose ICS/formoterol*
*Low-dose ICS/formoterol can be utilized in patients prescribed low dose budesonide/formoterol or low dose beclomethasone/fomoterol for
maintenance and reliever therapy. This is for outpatient only as beclomethasone/formoterol is not on formulary for inpatient use
Inhaled Corticosteroid Low Dose Medium Dose High Dose

Fluticasone furoate 100mcg daily N/A 200mcg daily
66
Reference: Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma(GINA) 2018.
COPD Exacerbation
Nebulizers: Antibiotic Use:
Albuterol/ipratropium (Duoneb®) Should be used in patients with the 3
2.5mg/0.5mg Q 4 to 6 hours scheduled cardinal symptoms:
and Q 1-4 hours prn SOB 1. increase in dyspnea
2. sputum volume
Alternative PRN: albuterol 2.5 mg Q1-4
3. sputum purulence
hours prn
OR
Steroids: if the patient has 2 cardinal symptoms and
Prednisone 40 mg PO x 5 days increased sputum purulence is 1 of the 2
k Organisms:
IV option: Methylprednisolone 60 mg
Haemophilus influenzae
daily, then transition to prednisone
Streptococcus pneumoniae
when appropriate
Moraxella catarrhalis
Home Medications:
Options:
-Consider holding home inhalers first 48
1. Azithromycin 500 mg day 1 then 250 mg
hours especially if prescribing short
days 2-5
acting beta agonists, anti-muscarinics
2. Doxycycline 100 mg PO BID
and systemic steroids
3. Amoxicillin/clavulanate 875 mg PO BID
-Aim to restart home inhalers prior to
discharge to assess inhaler technique Duration: 5-7 days
67
Reference: Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018.
COPD Maintenance Therapy
68
Reference: Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018.
St. Vincent Formulary Agents for COPD and Asthma
Drug Class Brand Name® Generic Name
SABA Proair®, Ventolin®, Proventil® Albuterol
SAMA Atrovent® Ipratropium
SABA + SAMA Duoneb® Albuterol/ipratropium
LAMA Incruse Ellipta® Umeclidinium
LABA Striverdi Respimat® Olodaterol
ICS Arnuity Ellipta® Fluticasone furoate
LABA + ICS Breo Ellipta® Fluticasone furoate/vilanterol
LAMA + LABA Anoro Ellipta® Umeclidinium/vilanterol
PDE-4 Inhibitor Daliresp® Roflumilast
Leukotriene Receptor Antagonist Singulair® Montelukast
PDE-3/PDE-4 Inhibitor Theo-24®, Theochron® Theophylline
• Albuterol is available as both a nebulizer and multi-dose inhaler
• Ipratropium and albuterol/ipratropium are available as a nebulizer only while in the hospital (there is a
multi-dose inhaler available for outpatient use)
• The Ellipta® series (Incruse, Arnuity, Breo and Anoro) are available only as a dry powder inhaler
• Olodaterol is available as a multi-dose inhaler
• Roflumilast is an oral tablet only indicated for COPD. Normal dosing is 500mcg PO daily
• Montelukast is an oral tablet indicated for asthma and allergic rhinitis. Normal dosing is 10mg PO daily
• Theophylline is available an oral tablet and liquid solution.
69
Dosing varies based on indication, age,
weight and dosage form. Goal serum level = 10-15mcg/mL

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Drug Loading Dose Usual Dose Range Adverse Effects Notes

Diltiazem Oral daily dose = [rate (mg/h) x 3 + 3] x 10

Digoxin Conversion IV to PO: 4:5 for maintenance dosing

Furosemide Torsemide Bumetanide

Meds to use caution or

• Sacubitril and Valsartan

*Target doses associated with mortality benefit

Common Intravenous Antihypertensive Medications¶

Metoprolol 2.5 mg Q6H 15 mg per 20 min/ ↓HR, bradycardia, dizziness, fatigue, $

Nitroglycerin 5 mcg/min 200 2-5 min/ Severe hypotension, reflex tachycardia, HA $$

Confusion Assessment Method (CAM) Precipitating factors

• Tricyclic Antidepressants (TCAs)

•Access to hearing aids, glasses First line agents AS NEEDED for

References: Am J Psychiatry. May 1999;156(5 Suppl):1-20. Drugs and Aging. 2011;28(9):737-48.

Relative anti- Relative

Cortisone 25 0.8 0.8 8-12

Dexamethasone 0.75 30 0 36-72

Fludrocortisone N/A 10 125 12-36

Methylprednisolone 4 5 0.5 12-36

Prednisolone 5 4 0.8 12-36

Prednisone* 5 4 0.8 12-36

Iodine (SSKI) 5 drops

Maintenance dose: May consider addition of

Corrected Calcium = (4-Alb observed) 0.8 + Ca observed

Degree of Hypocalcemia Replacement Dose

Severe or symptomatic IV calcium gluconate 2 grams for 2 hours x 2 doses

Electrolyte replacement resources

Product Name Ensure® High Ensure Ensure Clear® Nepro® with

Enteral Nutrition (EN)

CONTRAINDICATIONS for EN: NOT CONTRAINDICATIONS for EN:

Guidelines for Initiation of Enteral Nutrition:

Standard Tube Feeding Formulas Specialty Formulas Peptide-based Special Modular

NL – Not listed on corporate website

Black box warning? No Yes-Risk for Anaphylactic- No

Oral Products Iron Polysaccharide Complex Ferrous Sulfate Ferrous Gluconate

Serum Magnesium Concentration IV Magnesium Replacement Dose

Electrolyte replacement resources

Na Cl K Ca Lactate Glucose mOsm/L

• Common methods of estimating the daily volume in children and adults

Pearls for PN Entry:

Monitoring Nutrition Support

Sodium phosphate: Potassium phosphate:

Serum Phosphorus IV Phosphorus

Electrolyte replacement resources

Ordered Item Sunrise Item Name Ingredients Route of

Serum K Oral Supplement IV Supplement

KCl Eff 50 mEq KCl 20 mEq IVPB Q2H x 2 doses

KCl 20 mEq IVPB Q2H x 4 doses

Electrolyte replacement resources

Role of Albumin in Paracentesis

Amiodarone Angiotension converting enzyme Angiotensin receptor blockers

Pancrealipase replacement in chronic pancreatitis

Initial dose (based on lipase): 500 units/kg/meal

3rd generation cephalosporin

*Hemodialysis patients dose 1.5-2mg/kg post-HD;

Endocarditis Synergy Dosing (gentamicin only):

Escherichia coli 1451 51 60 86 93 91 79 93 100 94 96 76

Klebsiella pneumoniae 330 0 88 93 95 94 96 97 99 38 97 90 2018 ANTIBIOGRAM

Pseudomonas aeruginosa 230 94 95 89 93 96 96

MIC Breakpoints (mcg/mL) ≤8 ≤0.5 ≤4 ≤2 ≤32 ≤2 ≤2 ≤2

Enterococcus faecalis 310 100 87 99 99

MRSA 187 0 0 72 100 100 0 97 99

Blank cells indicate drug not tested or drug not indicated