IV Drug Compatibility

Kaveh Teimori
Msc. PHARM
- Regional Health Care Pharmacy, Region Västra Götaland
- Hospital Company, Armed Forces Centre for Defence Medicine, Swedish Armed Forces
Sahlgrenska Universitetssjukhuset
Amount of drugs > amount of entrances

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Incompatbility
▪ Two or more drugs react phsyiochemically together in
syringe, CVC, PVC etc
▪ Reaction occurs independently of the patient (”in vitro”)
▪ NOT TO BE CONFUSED with drug interactions

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Amount of drugs > amount of entrances

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 Different type of incompatibility reactions
Reaction Clinical significance
Chemical reaction Drug effect change

Destabilized emulsion Occluded catheter

Precipitation Embolization

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Multi Lumen CVC

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Precipitation
• May SOMETIMES be observed by the naked eye

Furosemide inj in vancomycin inf. Photo: Kaveh Teimori & Hannah Colldén

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Destabilized Emulsion

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 Risk Factors

• Large pH-differences between drug A and drug B

• Concentration (both active substance and excipients)
• Diluting
• Exponation/reaction time
• Emulsions… (formulation)

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 Basic/alacaline pH
• Acyclovir (pH 11 - 11,5)
• Gancyclovir (pH 11)
• Furosemide (pH 8 - 9,3)
• Rifampicin (pH 7,8 – 8,8)
• Thiopental (pH 10 - 11)
• Sulfamethoxazole-trimethoprim (pH 10)
• Meropenem (pH 8 - 9)
• Pantoprazole (pH 9 - 11)
• Incompatible with many drugs
• Higher risk associated with higher concentration (injections)

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Precipitation & Solubility

Henderson–Hasselbalch
pH = pKa + log ([A-]/[HA])

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 Varying Complexity
Furix Parenteral Nutrition
• Furosemide Alanine
• Sodium hydroxide Arginine
• Sodium chloride Glycine
• Water for injection Histidine
Isoleucine
Leucine
Lysine (as acetate)
Methionine
Phenylalanine
Proline
Serine

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Taurine
Threonine
Tryptophan
Tyrosine
Valine
Calcium chloride dihydrate
Sodium glycerophosphate (hydrate)
Magnesium sulphate heptahydrate
Potassium chloride
Sodium acetate trihydrate
Zinc sulphate heptahydrate
Glucose monohydrate
Soya-bean oil, refined
Medium-chain triglycerides
Olive oil, refined
Fish oil, rich in omega-3-acids

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morphine oxicodone

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Fosphenytoin vs Phenytoin

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Fosphenytoin vs Phenytoin

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 TPN (Total Parenteral Nutrition)
• Complex mixes
• Additions according to admixing guides
• Risk of precipitation: calcium, phosphate
• ”Drugs that are added should never be given as
injection”
• Crystal precipitation from TPN described in patients
on TPN, rare but usually fatal

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McNearney T, Bajaj C, Boyars M, Cottingham J. Digestive Diseases and Reedy JS, Kuhlman JE, Voytovich M. Chest. 1999;115(3):892-895.
Sciences. 2003;48(7):1352–1354.

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 Ringer’s acetate
• Contains both calcium and magnesium which may cause
incompatibilities
• Predominantly utilized in Scandinavia → information scarcity

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 Best Practice
• Pause and flush between injections
• Observe the lumen
• Reference the compatibility

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Information from Manufacturers

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 Information from SmPC

Pantoprazole
This medicinal product must
not be mixed with other
medicinal products except
those mentioned in section
6.6.
Paracetamol
This medicinal product must not
be mixed with other medicinal
products except for dilution with
0.9% sodium chloride or 5%
glucose solution

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 Information from SmPC
Ipramol (nebuliser solution)

Sapimol (nebuliser solution)

6.2 Incompabilites

NEVER mix Sapimol 0,5 mg/2,5 mg per 2,5 ml

nebuliser solution with other medicinal
products in the same nebuliser.

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Compatibility and Swedish Medical Products Agency

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Compatibility and Swedish Medical Products Agency

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 ADVERSE CASE

• Bradley JS, Wassel RT, Lee L, Nambiar S. Pediatrics 2009;123;e609

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Set your priorities (straight)!

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 Risk vs. Reward

Drug Benefit Compatibility

Stability
Shelf life

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Measures Taken

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INQUIRIES

ASSESSMENTS

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 Blandbarhetsdatabasen
• Over 2500 drug combinations
• Used in most of Swedish regions
• Cooperation with Rikshospitalet, Oslo
• blandbarhet.vgregion.se

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Thank you for your attention!

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Contact
▪ Kaveh Teimori
blandbarhetsansvarig apotekare VGR
kaveh.teimori@vgregion.se

blandbarhet@vgregion.se

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