Hospital Pharmacy

Managed health care has changed the way health services are provided and paid for. It is still evolving. Many pharmacists have already felt the impact of these changes. This continuing feature illuminates the many facets of managed care with special emphasis placed on how these changes may affect pharmacists working in health systems. The expertise provided by pharmacists will be needed to fulfill the potential of affordable, comprehensive, and quality health care as promised by managed care. Pharmacists must understand what is happening, why it is happening, and what is likely to happen in the future. To be an active and effective player, you must understand what is happening on the field.

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column reviews various issues related to the preparation, dispensing, and administration of cancer chemotherapy, both commercially available and investigational.

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), to discuss methods of prevention, and to promote reporting of ADRs to the FDA's medWatch program (1-800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.

The Formulary Information Exchange (The F.I.X.) is an online drug information service available to subscribers of The Formulary Monograph Service. In this column, we present samples of recent dialog on The F.I.X. If you would like more information on The Formulary Monograph Service or The F.I.X., please call 800-322-4349.

The Human Genome Project, an international effort, is ushering in an era of molecular medicine with newer and better approaches to the prevention, diagnosis, and treatment of human genetic diseases. Biotechnology, or genetic engineering, can be defined as the alteration of cells or biological molecules for specific applications. Biotechnology has contributed — and will contribute — to many major medical advances. To respond to the biotechnology revolution in health care, pharmacists must become familiar with this new field. With a state-of-the-art understanding of disease processes and drug effects, pharmacists will be ideally prepared to educate patients about disease states and the roles of old and new drugs in treatment plans.

The physical compatibility of gatifloxacin injection (Tequin, Bristol-Myers Squibb) with 110 other drugs during simulated Y-site injection was evaluated by visual observation and turbidity measurement, and by electronic particle content assessment if appropriate. Five-milli-liter samples of gatifloxacin injection 2 mg/mL in 5% dextrose injection were combined with 5 mL samples of 110 other drugs. The secondary test drugs included anti-infectives, analgesics, antihistamines, diuretics, steroids, and other supportive care drugs. Visual examinations were performed with the unaided eye in normal diffuse fluorescent light and using a Tyndall beam. The turbidity of each sample was measured as well. Most of the test drugs were compatible with the gatifloxacin admixture during the 4-hour observation period. However, 14 drugs resulted in physical incompatibilities when combined with the admixture. Gatifloxacin admixtures should not be administered simultaneously with these incompatible drugs.

Three hundred and thirty four patients receiving aminoglycosides and/or vancomycin therapy for at least 72 hours were retrospectively reviewed for the development of nephrotoxicity. The patients' vancomycin and aminoglycoside serum concentrations were monitored by our clinical pharmacokinetics service. The average age, weight, and serum creatinine of the patients were 67.8 years, 71.3 kg, and 1.03 mg/dL, respectively. Nephrotoxicity occurred in 30 patients, but only 8 of these cases of renal toxicity (2.4%) were attributed to the use of vancomycin and/or aminoglycosides. The remaining 22 patients had other factors known to contribute to renal failure. Nephrotoxicity with aminoglycosides was more frequent than with vancomycin (2.8% versus 1.1%, respectively). Alarmingly, the frequency of renal toxicity increased by about four-fold when vancomycin was administered concomitantly with an aminoglycoside. Although further analysis is needed, preexisting renal impairment seems to be the major contributing factor for nephrotoxicity in our study.

With the rapid pace of immunologic research, it is more important than ever for readers to understand rational immunodiagnosis, immunopro-phylaxis, and immunotherapy. This column is intended to help you ensure proper immunologic drug use in your practice.

Each month, subscribers to The Formulary® Monograph Service receive five to six researched monographs on drugs that are newly released or are in late Phase III trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation (DUE) is also provided each month. The monographs are published in printed Form and on diskettes that allow customization. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board called The Formulary InFormation Exchange (The F.I.X). All topics pertinent to clinical pharmacy are discussed on The F.I.X.

Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The November 1999 Formulary monographs are on rapacuronium, rabeprazole, zaleplon, alosetron, and ganirelix acetate. The DUE is on zaleplon.

This bimonthly column will keep readers up-to-date on the Internet as a source of drug information. Examples of using the Internet to answer inquiries and prepare for committee meetings will be taken from the authors' experiences at a drug information center. A list of reliable web sites—as well as some examples of sites that have not been useful—will be included in each column.

This monthly feature will help readers keep current on new drugs, new indications and dosage forms, and safety-related changes in labeling or use. Each month, new information will be added to the table (shown in bold type) and older information will be removed. Efforts have been made to ensure the accuracy of the information; however, if there are any questions, let us know at hospitalpharmacy@drugfacts.com

Practicing clinicians come across uses of pharmacologic agents that may not always be listed in the usual references. For example, glycerin injection for nerve block, H₂ antagonists in colorectal cancer, or colchicine for systemic sclerosis may represent novel, hard-to-find clinical applications. If you have encountered a new and/or unusual use of a drug, submit the information to this Hospital Pharmacy feature.

Hospital Pharmacy welcomes contributions to this column. Articles originally published in pharmacy department newsletters are reprinted here. Material is selected because of its educational value to pharmacists or because it demonstrates the type of information of interest to newsletter readers. If you wish to have your newsletter material considered for publication in this column, mail a copy—along with a computer disk containing the document—to Neil M. Davis, Editor-in-Chief, Hospital Pharmacy, 1143 Wright Drive, Huntingdon Valley, PA 19006-2721.

To help readers monitor the most important developments in specialized areas associated with hospital pharmacy practice, Hospital Pharmacy commissions Basic Bibliographies by guest editors, who have expertise in their respective fields. These guest editors survey the relevant literature and rank approximately 15 to 20 references that represent the most significant scientific (theoretical and empirical) and practice contributions in their respective areas. The more fundamental are listed first so that persons with limited time can select readings appropriate to their needs.