Important Drug Interaction in inpatient pharmacy

[bacillus1]

we don't carry it on formulary - now that I think of it, I think I switched to doxy while they were in the hospital.

Problem is, the ACG guidelines recommend tetracycline...that's why I've been uncomfortable with saying no to the GI docs who want Pylera. BTW most of the Pylera I see is in the outpatient setting, since I approve all the GI non-formulary requests for our health system. I think 3 Pyleras this week...ugh, it's the bane of my existence. I talked to the ID pharmacist about it, and she agrees that we should be using Pylera as opposed to switching to a doxy containing regimen (unless the patient has significant renal impairment, of course). We were supposed to have a meeting with the chief of GI, but that never happened.

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[Zynx]

Problem is, the ACG guidelines recommend tetracycline...that's why I've been uncomfortable with saying no to the GI docs who want Pylera. BTW most of the Pylera I see is in the outpatient setting, since I approve all the GI non-formulary requests for our health system. I think 3 Pyleras this week...ugh, it's the bane of my existence. I talked to the ID pharmacist about it, and she agrees that we should be using Pylera as opposed to switching to a doxy containing regimen (unless the patient has significant renal impairment, of course). We were supposed to have a meeting with the chief of GI, but that never happened.

I would recommend doxy considering the cost benefit, plus our institutional reference (UpToDate) suggests is may be substituted when tetracycline is not available:
This is the specific reference cited, quality arguable, but better than nothing: Doxycycline-based quadruple regimen versus routine quadruple regimen for rescue eradication of Helicobacter pylori: an open-label control study in ... - PubMed - NCBI

 

[bacillus1]

I would recommend doxy considering the cost benefit, plus our institutional reference (UpToDate) suggests is may be substituted when tetracycline is not available:
This is the specific reference cited, quality arguable, but better than nothing: Doxycycline-based quadruple regimen versus routine quadruple regimen for rescue eradication of Helicobacter pylori: an open-label control study in ... - PubMed - NCBI

Yeah I've looked at all that and thought about it, discussing it with the ID pharmacist. It's hard to say no to a guideline-recommended therapy when it's available (just more expensive), and notice that UpToDate says "when not available". Plus sucks for the patient to take 4 pills that are different amount of times a day, especially if they are an old veteran with 20 other meds, like most of our patients. For an inpatient I would probably do doxy if we don't have Pylera in stock, so patient wouldn't miss any days of therapy. I guess I should stop talking about Pylera so people can talk about other interactions, or maybe I can derail this thread about the high cost of Rectiv (I am switching everyone to compounded nifedipine which is way cheaper).

 

[Dred Pirate]

Yeah I've looked at all that and thought about it, discussing it with the ID pharmacist. It's hard to say no to a guideline-recommended therapy when it's available (just more expensive), and notice that UpToDate says "when not available". Plus sucks for the patient to take 4 pills that are different amount of times a day, especially if they are an old veteran with 20 other meds, like most of our patients. For an inpatient I would probably do doxy if we don't have Pylera in stock, so patient wouldn't miss any days of therapy. I guess I should stop talking about Pylera so people can talk about other interactions, or maybe I can derail this thread about the high cost of Rectiv (I am switching everyone to compounded nifedipine which is way cheaper).

Inpatient vs outpatient is a different animal when it comes to taking pills multiple times per day - I get the advantage on the outpatient side. In house, I switched the one pt to doxy citing the same resource as above. I figured it was "not available" since it is not on our formulary lol

 

[PromisedNeverland]

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[Pharmacy Kid]

Working for the government you never see scripts like Aliskiren or Pylera.

 

[Monsterdaddy]

My hospitals generally order a trough before the 4th dose (3rd dose if Q24). Early vanco troughs ordered when you have a jump in SCr will help catch those patients who are especially sensitive to vanco before they get more severe kidney injury. Also helped catch a couple patients who accumulated huge amounts of vanco after a therapeutic trough. Yes it's not steady state but if it comes back at 18-20+ after only two doses I think you can safely say the steady state trough would be way supratherapeutic. But I always hedge my bet on early vanco troughs by adding a lab order for SCr on the same draw because it's not uncommon for lab to screw up the test or there is something wrong with the morning sample. If new SCr is back to baseline then I consider the morning SCr to be faulty. And if SCr continues to go up then you have a good case to hold vanco.

It really doesn't do any harm to do an early trough with an additional SCr.