INTERN MEDICATION GUIDE 2020 - Northern Doctors · INTERN MEDICATION GUIDE Page 6 ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC) Background Rationale Drug therapy errors occur in

INTERN MEDICATION GU IDE

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INTERN MEDICATION GUIDE

2020

Updated by A Given, Pharmacy December 2019


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Table of Contents:

Table of Contents: .......................................................................................................................................... 2

PHARMACY CONTACT NUMBERS ............................................................................................................... 4

MEDICATION MANAGEMENT PLAN ............................................................................................................. 5

ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC) ...................................................................... 6

Background Rationale ............................................................................................................................ 6

Overview ................................................................................................................................................ 6

Patient Identification ............................................................................................................................... 7

Allergies & Adverse drug reactions (ADR) .............................................................................................. 7

Numbering of medication charts ............................................................................................................. 8

Venous Thromboembolism (VTE) prevention .......................................................................................... 8

Regular Medication Orders ..................................................................................................................... 9

Frequency (Guidance Only) .................................................................................................................. 10

Approved Abbreviations ....................................................................................................................... 10

Prescriber identification: ....................................................................................................................... 11

Variable Dose Medications ................................................................................................................... 12

Warfarin dosing .................................................................................................................................... 12

When required (PRN) medication orders .............................................................................................. 13

Stat Dose Orders ................................................................................................................................. 13

Phone Orders ....................................................................................................................................... 13

Ceasing Medication Orders .................................................................................................................. 14

Limited Duration Medication Orders ...................................................................................................... 15

Less than daily administration............................................................................................................... 15

Re-writing Medication Charts ................................................................................................................ 15

HIGH DOSE OPIATES/INSULIN .................................................................................................................. 16

INTRAVENOUS THERAPY ORDER CHART ................................................................................................ 17

OTHER MEDICATION CHARTS .................................................................................................................. 18

DISCHARGE PRESCRIPTIONS ................................................................................................................... 19

What needs to be included: .................................................................................................................. 20

Drugs of Addiction (DA) ........................................................................................................................ 21

PHARMACEUTICAL BENEFITS SCHEME (PBS) ......................................................................................... 21

Authority PBS prescriptions .................................................................................................................. 21

PBS website ......................................................................................................................................... 23

TNH MEDICATION GUIDE ........................................................................................................................... 25

Prescribing Unfamiliar Medications ....................................................................................................... 25

Other documents/forms you may be asked to complete: ....................................................................... 25

ANTIMICROBIAL STEWARDSHIP PROGRAM ............................................................................................ 26

Antibiotic Guidance (iGuidance) ........................................................................................................... 26

The Direct Oral Anticoagulants (DOACs) .............................................................................................. 27


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ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION ........................................................................ 28

Sepsis of unclear focus ........................................................................................................................ 28

Vancomycin dosing .............................................................................................................................. 28

Acute Cystitis ....................................................................................................................................... 29

Catheter-associated UTI ....................................................................................................................... 29

Pyelonephritis ...................................................................................................................................... 29

Prostatitis ............................................................................................................................................. 30

Cellulitis ............................................................................................................................................... 30

Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) ........................................................ 30

Community Acquired Pneumonia.......................................................................................................... 31

Aspiration Pneumonia .......................................................................................................................... 31

Hospital Acquired Pneumonia............................................................................................................... 32

Peritonitis due to perforated viscus ....................................................................................................... 32

Acute cholecystitis ................................................................................................................................ 33

Ascending cholangitis ........................................................................................................................... 33

Acute Appendicitis ................................................................................................................................ 33

Acute diverticulitis................................................................................................................................. 33

Acute pancreatitis ................................................................................................................................. 34

Infected pancreatic necrosis / pancreatic abscess ................................................................................ 34

GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE ...................................................... 34

HANDY MEDICATION GUIDES ................................................................................................................... 35

Endocrinology ...................................................................................................................................... 35

End of Life Care ................................................................................................................................... 35

Vascular Device Protocols ............................................................................................................................ 36

Fluid Prescribing ........................................................................................................................................... 37

Rule of 1’s – oversimplified but memorable ........................................................................................... 37

The Real Rules: Correct but easy to forget! .......................................................................................... 37

ON-LINE TRAINING ..................................................................................................................................... 38

COMMON MEDICATION CHEAT SHEET………………………………………………………………………….39

This booklet was created by the Pharmacy Department. Available from: Medical Education Unit (MEU), located at Level 2, NH – Education, NCHER - Northern Centre Health Education & Research. Telephone: 8468 0758

Please advise suggestions/amendments to: Pharmacy Department (Team Leader for Education x58664)


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PHARMACY CONTACT NUMBERS Pharmacists are always willing to help all medical staff. All ward pharmacists are also available on MEDTASKER.

Ward pharmacist Extension

Emergency 52696

Emergency – Admissions (for MMP completion) 0447163874

SSU and CDU 0447141711

Ward 1 – Day Oncology 52094

Ward 2 – Children’s Unit 52205

Ward 3 52350

Ward 4 52472

Ward 5– Cardiology 58447

Ward 6– Observation Unit 52473

Ward 7 – Psychiatry 1 58994

Ward 8 - Psychiatry 2 52885

Ward 9 - DPU 52662

Ward 11/12 – Maternity & Special Care Nursery 52205

Ward 13 52884

Ward 14 52459

Ward 16 52477

Ward 17 - ICU 52532

Ward 18 52474

Speciality pharmacist

Oncology 52094

Renal / Dialysis 58387

Antimicrobial stewardship 58452

Hospital in the home (HITH) 52967

Clinical Trials 58571

Palliative Care 0439920501

Dispensary

Inpatient 58572

Outpatient 58571

Discharges 52204

Manufacturing 58578

Director of Pharmacy 58560

Deputy Director of Pharmacy 58561

Associate Director of Pharmacy 52663

Team Leader – Medicine 52661

Team Leader – Surgical 52662

Team Leader – Oncology + Women’s and Children’s 52094

Team Leader – Education, Development and Research 52664

Team Leader – Quality Use of Medicines & Safety 52665


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MEDICATION MANAGEMENT PLAN

The Medication Management Plan (MMP) is where pharmacists document a patient’s medication history and reconcile it against the drug chart. It also includes how the patient manages their medications and any issues identified with their medications and the medication chart. It is usually filed with the medication charts in the patient’s folder.

Medication list including reconciliation

Admission medication risk assessment Discharge Planning

Identified issues for review. Action outcome once reviewed.

Medication changes during admission


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ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC)

Background Rationale

Drug therapy errors occur in 5-20% of drug administration in Australian hospitals1 43% of adverse drug events are preventable2 Medication interventions save lives, reduce length of stay, reduce admissions and reduce costs3

1 Australian Council for Safety and Quality in Health Care. July 2002.

2 Wilson RM, Runciman WB, Gibberd RW et al. Med J Aust 1995; 163: 458-71

3 Dooley MJ, Allen KM, Doecke CJ et al. BJCP 2004; 57: 513-21

Overview

Front

Back

“Regular medications” section VTE prophylaxis section

PRN section

STAT doses

Phone orders

Good prescribing principles


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National Inpatient Medication Chart (continued)

Patient Identification

ALL medication charts must have correct patient identification details i.e. bradma Significant medication errors can occur when patient identification is incorrect or incomplete

Affix patient ID label (i.e. large bradma) on both allocated pages Check labels are correct, initial

Print patient name and check label is correct for the patient on both allocated pages.

Allergies & Adverse drug reactions (ADR)

Re-exposure is a preventable cause of significant harm Not all ADRs are clinically significant

ADR box on ALL medication charts needs to be completed.

If patient has nil known allergies or unknown allergy status, TICK appropriate box, sign, print name and date entry.

If known ADR note drug name and reaction details, sign, print name and date entry. Attach ADR sticker to pages 3 and 4.

If any amendments or additions are made to the ADR box, initials and date of entry required.

No known allergies: Known allergies – complete all sections:


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National Inpatient Medication Chart (continued) Numbering of medication charts

All medication charts should be numbered using roman numerals e.g. 1 of 2, 2 of 3, etc.

Venous Thromboembolism (VTE) prevention

Patients ≥16yrs must have VTE Risk Assessment completed (form on the front of medication chart) Day patients without regular mediation chart may be exempt MUST be completed by medical staff:

i. Identify risk by completing the VTE Risk Assessment Tool (front page of medication chart) ii. Determine appropriate prophylaxis iii. Order ALL prophylaxis (chemical and/or mechanical) on Medication Chart

NOTE: This section only for VTE PROPHYLAXIS. VTE treatment (i.e. therapeutic doses) needs to be charted as a regular medication.

For Best Practice Guidelines / Policy / Risk Assessment Form, refer to: Venous Thromboembolism (VTE) Prevention Guidelines on Prompt or use the following link: Haematology - Thrombosis & Haemostasis Protocols

VTE Risk Screen

https://prompt.nh.org.au/prompt/Search/download.aspx?filename=22362584/32258383/40481485.pdf


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Regular Medication Orders

ALL orders must include: Date started not date written

o when rewriting an order, write the date of first prescribing, not the re-write date Generic prescribing unless a combination product or Insulins (refer to Combinations stocked at

Northern Health list) Dose, frequency and route – only use acceptable abbreviations as per the “Good prescribing

principles” on the NIMC Doctor to enter dosing times – not including times frequently leads to missed doses Slow release box must be ticked where appropriate. Also include show release abbreviation in

order. Document indication. SIGN all orders. Unsigned orders are not legal and therefore are not able to be administerede

nurses can not administer the medication annot be administered.


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National Inpatient Medication Chart (continued) Frequency (Guidance Only) Write the frequencies and administration times for all medications charted. Omitted medication times lead to medications being missed affecting patient’s treatment.

If a medication is to be given with food, chart meal times: 08:00, 12:00, 18:00

Intravenous antibiotics – should be prescribed by hours (i.e. q6h) and times should reflect this dosing **Warfarin dosing: 16:00 hours** This is to ensure orders are completed before home team leave the hospital

Approved Abbreviations

Route of administration

Abbreviation Meaning

PO Oral

NG Nasogastric

subling Sublingual

subcut Subcutaneous

IV Intravenous

IM Intramuscular

PR Per rectum

PV Per vagina

top Topical

neb Nebulised

Inh Inhaled

Units of measure and concentration Abbreviation Meaning

g gram(s)

International unit(s) International unit(s)

unit(s) unit(s) L litre

mg milligram(s)

mL millilitre(s)

microg / microgram(s) microgram(s)

% percentage

mmol millimole

Please see the ‘Good prescribing principles’ section on the back of the Northern Health ‘National inpatient medication chart’ for more details.


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Prescriber identification: You know who you are but it’s sometimes very difficult to match a signature to an individual’s identity and pagers and roles change frequently. Health professionals (Pharmacists, Nurses and other prescribers) need to be able to easily identify who has prescribed what. Please sign; print your name and your pager number at least once on each NIMC and all schedule 8 orders

that you prescribe on (see below). All medication orders need to be signed to be made legal. Nursing staff cannot administer an order that has not been signed. This can lead to treatment delays.

Prescribing Principles:

1. Plain English, Legible- PRINT drug names 2. Use Generic Drug Names

(a) Exemption for combination products (i.e. Targin, Seretide)

(b) Exemption for medication with significant bioavailability issues (i.e. tacrolimus, cyclosporine)

3. Write drug names in full. 4. NEVER abbreviate any drug name e.g. HCT, MTX,

ISMN, GTN. Exemption: indication of slow release and immediate release (Tramadol SR or Tramadol IR)

5. Do not use chemical names/symbols. 6. Do not include the salt of the chemical unless it is

clinically significant Example: mycophenolate mofetil vs. mycophenolate sodium

7. Dosing: a. Use words or numbers (i.e. 1, 2). b. Do not use roman numerals (i.e. ii, v) c. Use metric units (i.e. gram or mL). d. Do not use apothecary units (i.e. minims or

drams) e. For oral liquid preparations, prescribe the

dose in milligrams or grams(if applicable).

f. Express the dosage frequency unambiguously (for example “three times a week”)

8. Avoid acronyms or abbreviations for medical terms and procedure names on orders or prescriptions. Refer to the Australian Commission on Safety and Quality in Healthcare website for more details

ABBREVIATIONS to AVOID!

Avoid U or IU:

mistaken for ‘0’. i.e. 4U can be interpreted as 40.

Instead- write the word ‘Units’

Avoid ug/ µg:

mistaken for mg.

Instead- write the word ‘microg’

Avoid o.d. or OD:

Mistaken for BD.

Instead- write mane/ midi/ nocte

Add Trailing ‘0’ after decimal point:

1.0mg can be mistaken for 10mg.

Instead- write 1mg

Avoid leading ‘0’ before decimal point:

.1mg can be mistaken as 1mg.

Instead- write 0.1mg

Avoid SC and SL:

can be mistaken for each other

Instead- write “subcut(aneous)” or “subling(ual)”

Avoid Fractions:

1/7 could be ‘for 1 day’ or ‘once daily’ or ‘for one week’

Other unacceptable abbreviations: qd/ QD, qod/ QOD/ symbols


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National Inpatient Medication Chart (continued) Variable Dose Medications

This section allows ordering of medications requiring variable dosing based on lab results or as a reducing protocol e.g. prednisolone, tobramycin, gentamicin. Each dose needs to be individually prescribed and signed for by the prescriber.

Warfarin dosing

This section is for warfarin dosing only.

Brand of warfarin needs to be circled. Warfarin brands are NOT interchangeable. Document indication and target INR. Document INR result.

Each dose needs to be individually prescribed and signed for by the prescriber. Always prescribe dose once INR result is back to avoid under or over dosing.


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National Inpatient Medication Chart (continued) When required (PRN) medication orders

PRN Orders must also include:

Hourly frequency

Maximum dose in 24 hours

Indication

To give clear administration and maximum daily dose Check all sections of the medication chart to ensure over-dosing does not occur e.g. paracetamol 1g QID regular plus PRN dosing.

Stat Dose Orders

This is section is for doses that are to be given immediately - “STAT”. If the medication is to be continued regularly, e.g. IV antibiotics, ensure that a regular order is also charted. When charting STAT order, checks all sections of the medication chart to prevent administration of excess doses. Communicate all STAT orders with the nursing staff to ensure medications ordered are given in a timely manner, preventing delays.

Phone Orders Nursing staff may contact you for a phone order. These orders need to be repeated to a second nurse and signed by the authorising doctor within 24 hours


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Ceasing Medication Orders

Orders must NOT be obscured Doctor to put single line through order and two lines after the last dose in the administration

record section Write CEASE, the reason, date and sign

CORRECT WAY TO CEASE AN ORDER:

INCORRECT WAY TO CEASE AN ORDER:


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Limited Duration Medication Orders

Ordered only for certain days

Block out day/times when NOT to be given

Indicate using (X)

Less than daily administration

Specify frequency clearly

If weekly – specifiy day to be given

Box days when medication is to be given

Block out day/times when NOT to be given - Indicate using (X)

Re-writing Medication Charts

Care should be taken when rewriting medication charts. Fatal errors have occurred due to lapses in concentration. Where possible, all efforts should be taken to prevent disruption.

When complete it is best practice to inform the nursing and/or pharmacy staff that the medication chart has been rewritten to allow double checking.

Remember DRS

DATE REASON SIGNATURE


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HIGH DOSE OPIATES/INSULIN

Unintentional prescribing of high dose opiates and inuslin is to be avoided by the application of a “high dose sticker”. Doses greater than soluble insulin 50 units or oral Morphine 30mg (equivalent dose in table below) require the following procedure to be followed:

Prescribers are to affix the high dose sticker in the NIMC left margin next to the medicine, and sign and date. This acknowledges the prescriber has checked and verified the dose prescribed is intended

A table of high doses for medicines will be provided in the Medicines Prescribing Policy, Pharmacy Operating Procedure and Medicines Administration Policy

If prescriber has not attached a sticker, the nurse contacts the prescriber/unit doctor and requests prompt action. No administration of the medicine by nurses are permitted unless sticker has been applied

Stickers are made available on wards from pharmacy

Medication chart re-writes are to have a new sticker applied by the doctor at the time of re-writing the chart

Clinical areas/scenarios excluded: syringe drivers; patient controlled analgesia; intensive care patients; “stat” doses in Emergency Department; anaesthetics department

This is for all formulations (not just oral) for inpatient prescriptions only Equivalent doses of oral morphine 30mg

Drug Oral dose Parenteral dose

IV/SC

Buprenorphine 800micrograms Sublingual 400micrograms

Codeine 200 to 240mg n/a

Fentanyl 100 to 150micrograms

Hydromorphone 6 to 7.5mg 1.5 to 2mg

Methadone 10mg 5mg

Morphine 30mg 10mg

Oxycodone 15 to 20mg 10mg

Pethiine 75 to 100mg IM

Sufentanil 10micrograms SC

Tapentadol SR 75 to 100mg n/a

Tramadol 150mg 100 to 120mg

HIGH DOSE

VERIFICATION

Date__/__/__ Initial __/__


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INTRAVENOUS THERAPY ORDER CHART

This chart used to prescribe and administer intravenous (IV) therapy such as: o Fluids

e.g. 0.9% Saline, 5% Glucose, 0.45% Saline +5% Glucose, Hartmans o Electrolyte infusions

E.g. Potassium, magnesium, phosphate o Medications requiring continuous infusions

E.g. pantoprazole, octreotide

ALL IV charts need to be numbered Affix patient

bradma here

The date of the infusion

The time of the infusion

The fluid to be given OR the fluid the

medication is to be

diluted in

The medication added to the fluid.

If the order is for fluid only, put a dash in this

box

The rate of the infusion i.e. the duration

Write minutes as: x/60 Write hours as: x/24

If the rate is to change according to a protocol,

write APP (as per protocol)

All orders need to be signed to be a

legal order. Nursing staff cannot

administer without a

signature

The volume of the fluid to be administered. Needs to be ordered in millilitres

(mL)


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OTHER MEDICATION CHARTS – discuss with pharmacy/Registrar if unsure how to use MEDICATION CHARTS

Long-stay medication chart o Used for long stay patients at BH and BECC and for GEM@Home patients

Residential Care Interim Medication Chart o Must be completed for ALL patients returning to a residential aged care facility with any changes

to their regular medications (Additions or cessations). Original is sent to the ACF, a copy is kept for the medical record

Bolton-Clarke Drug Chart o Must be completed for ALL patients being discharged with RDNS for medication support. Chart

must include ALL medications, not just medications the nurses will be administering

TCP Medication Chart o Standardised medication chart for in-patient TCP. Supplied by the TCP team

ESA Dialysis Medication Chart

PAEDIATRICS and NEONATES

Paediatric medication charts o Charts are colour coded for specific age groups – check carefully o Patient weight should always be documented on the chart

Asthma Pulse therapy sticker (attached to paediatric chart when needed)

Paediatric IV orders and Fluid Balance Chart

Neonatal Unit Fluid Order and Fluid Balance Chart

ANALGESIA

Syringe Driver Orders for Subcutaneous Infusions o Includes syringe driver documentation for nursing staff, for palliative care patients

Intravenous Analgesic Infusion Order form o Used for PCA orders

Non-Intravenous analgesic infusion order o Used for non-IV analgesic infusions (i.e. subcutaneous lignocaine)

Local Analgesia Order

Use for local analgesia (i.e. epidural administration)

ANTI-COAGULATION

Heparin Infusion Chart o Northern Health standard prescription is 50,000 units in 500mL.

Warfarin Discharge Plan o To be completed for ALL patients being discharged on warfarin. Must be faxed to the pathology

company/G.P. managing the warfarin

HITH – warfarin dosing chart o Used by HITH for dosing warfarin patients

OTHER

TPN Parenteral Nutrition Order Chart o To be completed by ICU consultant ONLY

CHARM medication chart o Chemotherapy is prescribed on the CHARM electronic medication system


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DISCHARGE PRESCRIPTIONS

ALL patients require a discharge prescription written on discharge if they are to be commenced on new

medications or if there are any changes to their regular medications.

Discharge prescriptions are PBS prescriptions. To be able to prescribe on the PBS, you need to have a PBS prescriber number. This is different to your provider number.

You must write a separate prescription if another prescriber has already prescribed an item for the patient's treatment on the same prescription form. i.e. you cannot write on a prescription signed by another prescriber.

Must include your name, prescriber number and contact number - this can be your phone number or pager number on the prescription form. Authorised nurse practitioners and authorised midwives must also include a prescriber type

Hospital prescriptions include 3 copies: o Patient or pharmacist copy (top, green carbon copy) o Medicare/DVA copy (middle, blue carbon copy) o Medical records copy (bottom, red carbon copy)

For a pharmacy to be able to dispense a prescription, they need the top 2 copies (green and blue)

The red copy is to be detached and filed in patient’s medical record.


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Discharge Prescriptions What needs to be included:

1. Hospital name, address, telephone number and hospital provider number - this is printed on every hospital prescription form

2. Authority prescription identification number is required when requesting a PBS authority approval

3. Patient's name, address, date of birth, hospital number and location (attach bradma on all 3 copies)

a. Patient's Medicare number - have this available when seeking a PBS Authority approval for Authority required medicine. It is included on the hospital bradma.

b. Patient's entitlement details c. Handwrite the patient's name under the bradma. This is allows you to check the correct bradma

has been attached to the script.

4. Select the appropriate box - PBS or RPBS (repat patients) 5. Patient's weight if applicable 6. Medicine name and form, for example, tablets, capsules or injections 7. Medicine strength 8. Dose instructions for use 9. Quantity to be dispensed – refer to PBS website for quantities. You can NOT write PBS as the quantity. 10. Number of repeats if permitted and required. Usually we don’t write repeats on discharge as we want to

encourage to the patient to see their GP for follow up. o Drugs of addictions (DAs) – the quantity to be supplied needs to be written in words and figures.

E.g. To order Targin 14 tablets, quantity to be written as: 14, fourteen 11. Pharmacist to indicate whether the medicine is to be supplied 12. Approval number and additional notes on the prescription:

o if the medicine requires prior Authority approval, and you have obtained an Authority approval number, write the approval number in this column

o if the medicine is listed in the Schedule as Authority required (STREAMLINED), write the specific streamlined authority code in this column

o if your patient is not eligible for a PBS subsidy for a medicine, and you want to have a medicine supplied as non-PBS, write non-PBS in this column

o any other notes you feel may be relevant to the pharmacist 13. Your name, prescriber number and contact number

o If the prescriber number is not included, or illegible, the prescription cannot be dispensed. o Your prescriber number is different to your provider number o Include a contact number in case the pharmacist needs to verify the prescription. If you cannot

be contacted, and thereby the prescription cannot be dispensed, this causes delays in treatment and possibly the need for the patient to return to hospital for a new prescription.

14. Prescriber type if you are an authorised nurse practitioner (NP) or authorised midwife (MW) 15. Your signature and the date form is written

o if the prescription is not signed, it is not a legal prescription and cannot be dispensed.

Write in clear, legible handwriting

Illegible writing can lead to significant medication errors and patient harm

Illegible writing/missing information may make a prescription not valid for dispensing resulting in delays to treatment or the patient needing to return to

hospital for a new prescription to be written


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Discharge Prescriptions

Drugs of Addiction (DA) When prescribing DAs on discharge, the quantity to be supplied should be enough to cover 3 to 5 days

of analgesia requirements. Be mindful not to overprescribe DAs as this can lead to addiction.

You can prescribe less that the PBS quantity or pack size. Pharmacists can easily break packs.

The quantity to be supplied needs be written in both words and figures.

PHARMACEUTICAL BENEFITS SCHEME (PBS)

Authority PBS prescriptions Authority required benefits fall into two categories

o Authority required (via phone call) and o Authority required (STREAMLINED) (via PBS website)

Authority required

This type pf approval is required if you want to prescribe a quantity in excess of the PBS quantity (e.g. long term antibiotics or Clexane®) or if the medication has specific criteria as per the PBS website (e.g. ciprofloxacin).

Approval of authority PBS prescriptions by Chief Executive may be sought by calling the Department of Human Services Telephone Authority Applications Free call service (1800 888 333). (phone number is located on the bottom of the red copy of the hospital prescription)

To obtain approval, you need to supply the patient’s Medicare number and name, prescription number, your name and PBS prescriber number.

If approval is granted, the operator will give you an authority number that needs to be written on the prescription e.g. Z1234AB

Authority required (STREAMILINED)

This type pf approval is required if you want to prescribe a medication that is only subsidised by the PBS for certain indications (e.g. clopidogrel, pregabalin, olanzapine).

Some of these medications have multiple indications with different authority numbers. Ensure you choose the correct indication and authority number (e.g. 1234) is written on the prescription

Click the Authority required tab to see the criteria.


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Pharmaceutical benefits Schedule (PBS)

Click the Authority required (STREAMLINED) tab to see the criteria.

Choose the appropriate indication and write the Streamline code on the prescription. If the patient doesn’t meet one of these criteria, close this tab and open up another tab (some

medications have multiple tabs)


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PBS website o www.pbs.gov.au o The website can be found via the Shortcuts menu (Pharmaceutical Benefits Schedule) o Include information about:

If the medication is covered by the PBS, and for what indication Maximum quantity (and repeats) that can be prescribed If an authority is required

PBS Homepage

This shows the maximum packs/units and repeats that can be prescribed on the PBS

Search for medication here

Click on the item/dose you need to look up

http://www.pbs.gov.au/


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Note: you can prescribe less than maximum quantity – packs can be broken

If you want to prescribe more than the maximum quantity and repeats, you need to obtain an Authority (see Authority required in this booklet)

Examples: a. Cephalexin 500mg BD for 5 days (=10 capsules) b. Cephalexin 500mg QID for 10 days (=40 capsules i.e. 1 pack + 1 repeat) c. Cephalexin 500mg QID for 1 month (=120 capsules – above maximum quantity, needs authority)


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TNH MEDICATION GUIDE

Prescribing Unfamiliar Medications It is the responsibility of all prescribers to check the indication and dosage and precautions of unfamiliar medications. Northern Health encourages the use of evidence based guidelines. These are available on every computer/desktop. In particular, Therapeutic Guidelines® (eTG), up-to-date®, Australian Medicines Handbook® (AMH), eMims ®, hospital policies on PROMPT. Speciality areas (e.g. palliative care, paediatrics, oncology, psychiatric medicine) have reference tools available for staff online through the library section of the intranet.

REFE-RENCE

Treatment Guidelines

Indication Dose Admini-stration

guidelines

Adverse effects

Precautions/ Contra-

indications

Drug interactions

TDM Brands

Australian Medicines Handbook

(AMH)

Therapeutic Guidelines

(eTG)

MIMs online

Australian Injectable

Drug Handbook

Compatibility information

Northern Health policies

(PROMT) **not all

drugs have a NH plicy)

Antibiotic Guidance

PBS website

Other documents/forms you may be asked to complete: Individual patient usage (IPU) form

- to obtain approval to prescribe a medication not on the hospital’s formulary

Special Access Scheme (SAS) form - To obtain approval via the TGA to prescribe and use a medication not marketed in Australia

Notification of Drug Dependant person - To notify DHHS of patients who are on opioid replacement therapy (e.g. methadone, Suboxone®)


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ANTIMICROBIAL STEWARDSHIP PROGRAM Antibiotic Guidance (iGuidance) GuidanceMS is an online approval system for restricted antimicrobials that forms part of Northern Health’s Antimicrobial Stewardship program. It guides prescribers through the appropriate indication and dose of restricted antimicrobials and generates electronic approvals. The indications and durations are based on the current Therapeutic Guidelines:Antibiotic. For indications outside of current guidelines – limited duration electronic approval can be obtained, prior to consultation with Infectious Diseases. An approval number for a restricted antimicrobial must be obtained within 24 hours of initiation and written on the chart (to ensure adherence to hospital policy and obtain supply from Pharmacy)

The following antimicrobials are restricted at Northern Health :

RESTRICTED ANTIMICROBIALS – HOME TEAM TO GET GUIDANCE

HIGHLY RESTRICTED – ID APPROVAL ONLY – ID TEAM TO GET GUIDANCE

Aciclovir IV Ciprofloxacin Moxifloxacin Amikacin Fosfomycin Rifabutin

Azithromycin Famciclovir Norfloxacin Amphotericin IV Fusidic acid Rifampicin

Cefepime Fluconazole Oseltamivir Anidulafungin Ganciclovir Rifaximin

Cefotaxime

Gentamicin (ID approval if > 48h)

Piperacillin/ tazobactam

Aztreonam Imipenem Teicoplanin

Ceftazidime Meropenem Valaciclovir Caspofungin Linezolid Tigecycline

Ceftriaxone Metronidazole IV Vancomycin Colistin Pristinamycin Tobramycin IV

EMERGENCY DEPARTMENT ONLY (New Daignosis): DOACs (Apixaban, Dabigatran and Rivaroxaban) require guidance approval prior to supply

Daptomycin Quinupristin/ dalfopristin

Valganciclovir

Ertapenem Vorinazole

Those listed above are the more commonly used restricted antimicrobials; see the GuidanceMS homepage for a complete list. Please note that GuidanceMS is also used to obtain approvals for the use of the NOACs (apixaban, dabigatran and rivaroxaban) only in emergency department for new diagnosis. See “Anticoagulants” section of handbook for more information.

Antibiotic approvals can be obtained via the “Antibiotic guidance” link in the Clinical Shortcuts folder (on any PC in the hospital)


Page 27

ANTIMICROBIAL STEWARDSHIP PROGRAM cont. Your username & password are the same as the one you use to access other hospital systems eg. CPF. Follow the prompts to obtain approval for your patient.

Once an approval number is obtained, please write it on the chart, in the indication section or on the yellow “Guidance approval no.____” sticker placed on the chart by a pharmacist (if there is one):

Approvals generated by Guidance MS have the format of XXX-0000-0. The first for numbers (XXX-0000-0) are the day and month the approval was obtained, and the last number (XXX-0000-0) indicates the number of days the antimicrobial is approved for. For example, an approval number of XXX-2502-3 indicates that the approval was obtained on 25 February and is valid for 3 days. ID will need to be contacted if antibiotic is to continue once approval is expired via MEDTASKER.

If you have any problems accessing GuidanceMS or obtaining approvals, please contact the Antimicrobial Stewardship Pharmacist, via MEDTASKER or ex 58452.

The Direct Oral Anticoagulants (DOACs) As of October 2019, the prescribing of DOACs at Northern Health has changed from beinging highly restricted to reduced restriction. Approval for their use needs to be obtained via the GuidanceMS system, this is only valid for new diagnosis of VTE in the EMERGENCY Department. (see above Antimicrobial Stewardship program section on how to access GuidanceMS and explanatory notes).

Information on all the anticoagulants, including guidelines on dosing, reversal and switching from warfarin to a DOAC or vice versa, can be found on the Haematology department page on the intranet. From the intranet homage select “Department and Services” then “Haematology” and then “Anticoagulant Drug Management” or use the following link: Haematology - Thrombosis & Haemostasis Protocols

https://prompt.nh.org.au/prompt/Search/download.aspx?filename=22362584/32258383/40481485.pdf


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ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION

Sepsis of unclear focus

Vancomycin dosing

…..


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Antibiotic Prescribing guidelines by condition cont. Acute Cystitis

Catheter-associated UTI

Pyelonephritis


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Antibiotic Prescribing guidelines by condition cont. Prostatitis

Cellulitis

Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)


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Antibiotic Prescribing guidelines by condition cont. Community Acquired Pneumonia

Aspiration Pneumonia

Treat as CAP or HAP and if no improvement after 48hours then do the following;


Page 32

Antibiotic Prescribing guidelines by condition cont. Hospital Acquired Pneumonia

Peritonitis due to perforated viscus


Page 33

Antibiotic Prescribing guidelines by condition cont.

Acute cholecystitis

Ascending cholangitis

Acute Appendicitis

Acute diverticulitis


Page 34

Antibiotic Prescribing guidelines by condition cont.

Acute pancreatitis

Infected pancreatic necrosis / pancreatic abscess

GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE

HANDY MEDICATION GUIDES

Endocrinology

ALWAYS PRESCRIBE AS “UNITS”

DRUG DOSE/UNIT ROUTE FREQUENCY

Insulin Top Up Scale Novorapid (preferred) /Actrapid/ Humalog T1DM BSL 10-14 BSL 14.1- 18 BSL >18 T2DM: BSL 10-14 BSL 14.1- 18 BSL >18

2 units 4 units 6 units 4 units 6 units 8 units

subcut

With-meals TDS PRN

Novorapid Infusion (50 units Novorapid in 50mL 0.9% NaCl = 1 unit/ml)

1/24 BSL’s (mmol /L)

Novorapid Infusion See Diabetes – Insulin/Gluocse Lowering Medicines policy

IV

Consult Endocrine Registrar before commencing

ALWAYS PRESCRIBE INSULIN IN BRAND NAMES Ultra-short acting (immed pre-meal): Novorapid; Apidra; Humalog, Fiasp. Short acting (≤ 30 min pre-meal): Actrapid, Humulin R. Mixed insulin (with food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50, Ryzodeg 70/30. Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane FASTING GUIDELINES for INSULIN: If on Long-Acting Insulin (Lantus or Levemir) Continue these at full/reduced dose

If on Short-Acting Insulin Withhold

If on Pre-mixed Insulin (humulog/ novomix/ mixtard) Give 50% of the Insulin dose as Protophane

End of Life Care

DRUG DOSE/UNIT ROUTE FREQUENCY

Morphine 2.5 – 5 mg

(depending on

tolerance)

subcut PRN (no frequency)

Fentanyl

(if renal impairment)

25 – 50 microg subcut PRN (no frequency)

Midazolam 2.5 - 5 mg subcut every 1 hour PRN

Metoclopramide 10 – 20 mg subcut QID PRN

Glycopyrrolate 0.2 - 0.4 mg subcut 4 hourly (max1.2 mg)


Page 36

Vascular Device Protocols

PICC Bard Groshong brand: (closed end catheter with 3 way valve): Does not require heparin flush/lock Pulsating flush with 20mL normal saline post access and weekly if not in use

Implanted port device (intravenous) Heparin locked using 500 units of heparin in 5 mL of saline (ie 100 units per mL) post access or monthly if not in use.

CVCs Do not require heparin locking (they have a positive pressure device [CLC 2000] attached to each lumen). For further information refer to clinical services manual on management of each central venous access device.

“Length of stay for vascular devices”:

Peripheral Cannulas, changed 72 hourly (unless medical emergency where asepsis is not

used, must be changed within 12 hours)

CVC: yellow (7 days) CVC: Blue (2 weeks)

Implanted Port device: around 2,000 needle sticks (can stay indefinitely/must be surgically

removed in most cases)

FOR ACCES TO SIMULATOR MODELS CONTACT THE EDUCTION CENTRE EXT. 58732.


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Fluid Prescribing

Rule of 1’s – oversimplified but memorable

The Real Rules: Correct but easy to forget!

Water losses Urine output: 0.5 – 1 ml/kg/hr Insensible losses: 0.5 ml/kg/day Water requirements 1.5 – 2 ml/kg/hr Salt requirements Sodium: 0.5 – 1mmol/kg/day Potassium: 0.7 – 1mmol/kg/day Solutions All 1L solutions come +/- 30 mmol KCI 0.9% saline 150 mmol/L sodium (&

chloride) 5% Dextrose 278 mmol/L dextrose 4% Dextrose + 1/5 saline 30 mmol sodium & 216

mmol dextrose Hartmanns or Compound Sodium Lactate (CSL) 129mmol sodium, 5mmol

potassium, 2mmol calcium Gelofusine synthetic albumin +

145mmol sodium Recipe 1 1-1.5ml/kg/hr 4% Dextrose & 1/5 saline +30 mmol/L

KCI Recipe 2 1-1.5ml/kg/hr 1L Normal Saline + 30 mmol KCI 1L 5% dextrose + 30 mmol KCI 1L 5% dextrose +/- 30 mmol KCI

Fluid requirements

1st 10 kg = 4ml/kg/hr

2nd

10 kg = 2ml/kg/hr Thereafter = 1ml/kg/hr eg. 50 kg person: 40 + 20 + 30 ml/hr = 90 ml/hr 90 kg person: 40 + 20 + 70 ml/hr = 130 ml/hr

Precautions

CCF/renal failure/very elderly Reduce rate and monitor UO / fluid balance Febrile / septic / post-op Increase Na and H2O Change to NSaline or Hartmanns Increase rate Monitor urine output / fluid balance NB: fluid balance should be +ve because of

‘third space’ losses Other ‘Rules’

1. All clinicians get the fluid balance assessment wrong sometimes. This can be a difficult area, so: When in doubt – ASK EARLY If your first intervention does not work – ASK AGAIN If you are doing something for the 1

st time –

GET ADVICE

2. Monitoring volume status and renal function: Urine output is an early and useful sign BP, HR & urea are late signs (too late!)

3. Responding to oliguria Oliguria = hypovolaemia until proven otherwise Treatment of oliguria = IV volume challenge (2.5-10ml/kg for 1-2 hrs. Use colloid if concerned re APO/CCF) Complex patients usually need urinary catheter and strict fluid balance. Diuretics DO NOT ‘kick-start’ the kidneys Diuretics indicated for fluid overload NOT oliguria.


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ON-LINE TRAINING

Online modules are available from the National Prescribing Service. http://learn.nps.org.au/ The following online module is compulsory to complete:

The Antimicrobial stewardship pharmacist will be following up evidence of completion. If you have completed these courses during university, you do not need to redo them.

We recommend completing the following modules:

http://learn.nps.org.au/


Page 39

Common Medication Cheat Sheet

⚠ Always ASK IF UNSURE, below summarised from AMH/eTG ⚠

ANALGESIA

DRUG DOSE ROUTE FREQ COMMENTS

Paracetamol 1g PO/PR/IV QID - IV only if NBM and unable to have PR - Beware in liver impairment - Maximum of 4g paracetamol in 24hrs - every 4-6hrly Consider TDS in elderly/starving/liver/renal imp - Be careful combining paracetamol orders. Check stat/PRN

Panadeine Forte 1-2 tabs (500/30mg)

PO QID/ 4Hrly PRN

Panadol Osteo 1-2 tabs (665mg SR)

PO TDS

Ibuprofen 200-400mg PO TDS max Fever - X if CKD (eGFR<30)/GI bleed, diabetic, elderly, IHD, post neurosurgery, anticoagulated - Careful: PUD, CCF, HTN, asthma dehydration, coag disorders, - Use for <2wks + consider PPI - Lowest dose, shortest time - Do not use multiple NSAIDs in one patient

Indomethacin 100mg PR BD Renal colic

Naproxen IR 250-500mg PO BD max Menstrual pain

Ketorolac 10mg stat then 10-

30mg

IM 4-6 Hrly PRN max 90mg /24hr

Used in ED for mild-mod pain

Diclofenac 25-50mg PO TDS Menstrual pain 100mg PR BD

Celecoxib 400mg stat then

200mg Daily

PO 12-24 Hrly max 5 days

MSK/soft tissue

Lower bleed risk

Oxycodone IR 2.5-10mg PO QID PRN Preferred in renal

impairment (CrCl

<30ml/min)

- All opioids: resp depression, sedation, constipation, dependence - careful: BP drop, ↓seizure threshold - ↓dose requirements with age – start low - consider aperients + antiemetic

Oxycodone SR (Oxycontin)

5 - 10mg PO BD

Fentanyl 30 - 150microg

subcut 2-4 Hrly

Morphine 2.5-5mg subcut QID PRN accumulates in CKD

Tramadol IR 50-100mg PO/IV (>30min

IV)

QID PRN Usual max

400mg

- X epilepsy, hyperbaric tx, SSRI, elderly (max 300mg), confused - Less sedation/resp depression/abuse/constipation

Tapentadol (Palexia)

IR: 50-100mg

PO 4-6Hrly PRN - min opiate effects/serotonergic syndrome risk; prefer in CKD - X if on MAO-I (e.g. phenelzine, tranylcypromine)

SR: 50mg PO BD; max 500mg

Targin CR 10/5mg PO BD oxycodone + naloxone (2.5/1.25mg, 5/2.5mg etc.)

Reversal of opiates Naloxone 40microg subcut/IV. Life threatening 100-200microg. Short half-life <1hr, may require repeat doses

Amitriptyline 10-25mg PO nocte;max150mg Tricyclic antidepressant. Careful: BPH, hyperthyroid, epilepsy

NSA

IDS

OP

IOID

S

Northern JMSA


Page 40

Pregabalin 75mg PO Daily or BD Reduce dose renal imp; start low in elderly/frail (25mg)

Gabapentin 100-300mg PO nocte SE: drowsy, dizzy; lower opioid doses. Non-PBS indication

Consider Ketamine infusion/Lignocaine/nerve block, Acute Pain Service pager #779

Tamsulosin CR 400mcg PO Daily Renal colic: Bladder/ureter spasms. Non-PBS indication

Hyoscine (Buscopan)

20-40mg IV/IM QID PRN For colicky abdominal pain IV maximum 100mg/day 10-20mg PO TDS-QID PRN

ANTIEMETICS


Metoclopramide (Maxalon)

5-10mg PO/IV/ subcut

TDS PRN max 30mg D,

5 days

X bowel obstruction/perf +

pheochromocytoma / <20yo

Dopamine antagonists - X Parkinson’s disease - beware oculogyric crisis (tardive dyskinesia)

Prochlorperazine (Stemetil)

12.5mg IV TDS PRN vertigo; avoid if CNS depression 5 –

10mg PO TDS PRN

Droperidol 0.625mg IV QID PRN X IHD/arrhythmia

Domperidone 10mg PO TDS PRN Preferred for Parkinson’s – won’t cross blood-brain barrier

Ondansetron (Zofran)

4-8mg PO/IV/SL TDS PRN Post op/chemo/RT 5HT3 Antagonist - careful: prolonged QT - transient ↑AST & ALT

Granisetron

1mg

IV

TDS PRN SE: constipation/headache

Cyclizine 12.5-50mg

Slow IV/PO

BD - TDS Careful: CCF, SE: urinary retention

Antihistamine - sedation

-urinary retention Promethazine (Phenergan)

12.5-25mg

IM / PO 4-6Hrly PRN max 100mg

D

Careful: Epilepsy, Parkinson’s, respiratory depression

ALLERGIC REACTIONS


Loratadine 10mg PO Daily X hepatic impairment

Less sedating antihistamine Indication: chronic urticaria, allergic rhinitis Cetirizine 10mg PO Daily X renal

impairment

Promethazine (Phenergan)

25-50mg PO/IM Daily - X anaphylaxis, can worsen hypotension; sedating antihistamine - Careful: Epilepsy, Parkinson’s, respiratory depression

Hydrocortisone 100mg IV STAT 5mg/kg, max 200mg. Consider in anaphylaxis with wheeze

Adrenaline 500microg 0.5mL of 1:1000

IM STAT PRN 3-5min

- Anaphylaxis: no absolute contraindications to adrenaline - Inject into mid antero-lateral thigh

NEU

RO

PA

THIC

D

OP

AM

INE

5

HT3

AN

TAG

ON

IST

A

NTI

-HIS

TAM

INES


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ANTI DIARRHOEALS


Loperamide 4-8mg PO Daily/TDS Max 16mg D

Chronic diarrhoea, intestinal stoma

- Avoid: intestinal obstruction/severe ulcerative colitis/ hepatic impairment - for symptomatic treatment

4mg stat

PO 2mg PRN after each motion

Acute diarrhoea

RESPIRATORY


Salbutamol (Ventolin/Asmol)

2.5 - 5mg Neb QID PRN/STAT

- short-acting beta2 agonist (SABA) - SE: tachycardia, hyperglycaemia, hypokalaemia

2-12 puffs via spacer

Inh

Ipratropium Bromide (Atrovent)

500microg/2.5mL Neb QID PRN/STAT

- anti-cholinergic/short-acting anti-muscarinic (SAMA) - SE: headache/nausea/taste disturbance

42mcg (2 puffs) Inh

Tiotropium Bromide (Spiriva)

2.5mcg (Respimat)

2 puffs

Inh Daily Withhold if also on ipratropium - LAMA, careful in renal impairment - 2.5mcg = Respimat, 18mcg = Handihaler 18mcg: 1 puff Inh Daily

Indacaterol (Onbrez Breezhaler)

150/300mcg 1 puff

Inh Daily - long acting beta2 agonist (LABA) - asthma: always use LABA with ICS

Fluticasone (Flixotide)

50/125/250mcg 1-2 puffs

Inh BD Inhaled corticosteroids (ICS) - SE: dysphonia, oropharyngeal candidiasis, pneumonia, glaucoma, bone density loss - rinse mouth with water after use

Budesonide (Pulmicort)

100/200/400mcg 1-2 puffs

Inh BD

Budesonide/formoterol (Symbicort)

1-2 puffs Specify strength

Inh BD - Turbuhaler: 100/6; 200/6; 400/12mcg - Rapihaler: 50/3; 100/3; 200/6mcg (with spacer)

Flucticasone/Salmeterol (Seretide)

1-2 puffs Specify strength

Inh BD - MDI: 50/25; 125/25; 250/25mcg (with spacer) - Accuhaler: 100/50; 250/50; 500/50mcg

Fluticasone/vilanterol 1 puff Inh Daily - 100/25; 200/25mcg; Breo Ellipta

Prednisolone 30-50mg (usually 50mg)

PO Mane with food

(5-14D course)

- wean dose if continued longer than a week - SE: HTN/hyperglycaemia/PUD/insomnia

Normal saline 5mL Neb PRN Loosen secretions/relieves breathlessness

Bromhexine 8-16mg PO TDS Reduces mucous viscosity (mucolytic)

COPD: consider smoking cessation/pneumococcal+influenza vaccines/chest physio

ICS/

LAB

A

ICS

SAB

A


Page 42

ANTIBIOTICS

Refer to Antimicrobial Guidelines on PROMPT, eTG, ID or AMS for advice **BE AWARE OF ALLERGIES** (*requires Guidance)


Amoxycillin 500mg PO 8 Hrly

- COPD infective exac. (bronchitis) 5-7 days.

1g PO 8 Hrly

Mild-mod CAP: 5-7D + doxycycline . Mild aspiration pneumonia: 7-10D. Severe CAP; step down from IV to complete 7-14 D

Amoxycillin-clavulanic acid (Augmentin

Duo/Forte)

500/125mg PO 12 Hrly

UTI: 5 Days female, 7 Days male

875/125mg PO 12 Hrly

Dose of all other indications. Consider reduced dose in ESRF

Benzylpenicillin 1.2g IV 6 Hrly

Moderate CAP / Aspiration pneumonia 7-10D. Dose and frequency higher in more severe infections e.g. endocarditis

Flucloxacillin 2g IV 6 Hrly

Severe cellulitis 10-14D (Max. oral 1g QID empty stomach)

Phenoxymethylpenicillin 500mg PO 12 Hrly

Acute pharyngitis/Tonsillitis: 10D. Poor systemic absoption

Piperacillin-tazobactam (Tazocin)*

4.5g IV 8 Hrly

See Guidance for standard indications. 12 Hrly if CrCl <20

12 Hrly

Febrile neutropenia and critically ill (ICU)

Ceftriaxone* 1g IV Daily See guidance for standard indications including pneumonia (+azithromycin) and pyelonephritis

2g IV 12 Hrly

Meningitis + benzylpenicillin (+/- IV acyclovir)

Cefepime* 2g IV 8 Hrly

Febrile Neutropenia. Has anti-pseudomonas activity

Cefalexin (cephalexin) 500mg PO 12 Hrly

UTI (acute cystitis): 5D females, 7D males

1g PO 12 Hrly

Penicillin allergy: mild HAP (+/- metro)

1g PO 6 Hrly

Pyelonephritis 14D / Mild cellulitis 7-10D

Cefazolin (Cephazolin) 2g IV 8 Hrly

Penicillin allergy: severe cellulitis 10-14D (+/- vanc). Pre-op prophylaxis as single dose

Ciprofloxacin* 500mg BD 12 Hrly

See Guidance for standard indications. Check ECG & interactions with other QT prolonging drugs. Oral form on empty stomach. Excellent oral bioavailability

400mg IV 12 Hrly

Moxifloxacin* 400mg PO/IV Daily Penicillin hypersensitive: severe CAP/Asp Pneum/HAP check ECG

Azithromycin* 500mg PO/IV Daily Severe CAP (+ ceftriaxone). Good oral absorption

Clindamycin (contact ID if obese)

450mg PO 8 Hrly

MRSA activity or for penicillin hypersensitivity. For moderate aspiration pneumonia/SSTI

450mg IV 8 Hrly

BET

A-L

AC

TA

MS

CEP

HA

LOSP

OR

INS

Q

UIN

OLO

NE

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Metronidazole (IV*)

500mg IV 12 Hrly

Activity against anaerobic organisms eg in severe aspiration pneumonia (+ ceftriaxone) and Perf viscus (+ ceftriaxone) 400mg PO 12

Hrly

400mg PO 8 Hrly

Mild C.difficile 10D (oral vancomycin in mod-severe)

Doxycycline 100mg PO 12 Hrly

Give with food, risk of oesophageal ulceration. COPD 5-7D/ CAP (+ amoxicillin) duration depends on severity

Vancomycin* (contact ID for dosing

advice if required)

Refer to Vancomycin dosing guidelines (based on weight

& renal function)

See Guidance for standard indications. Dose adjust on levels MRSA activity - add to standard therapy if MRSA known colonised or risk of / severe infections. Beware VRE.

Trimethoprim 300mg PO Night Bacteriostatic/UTI: 3Days females, 7Days males

Trimethoprim-Sulfamethoxazole

(Bactrim)

160/800mg PO 3 times Per wk.

Pneumocystis jiroveci (carinii) pneumonia (PJP) prophylaxis in immunosuppressed patients. Give Mon/Weds/Fri (with food) Caution in renal impairment / with meds that can raise potassium

APERIENTS


Docusate + Senna (Coloxyl & Senna)

1-2 tabs PO Nocte or BD

- X GI obstruction/perforation risk - Careful: dehydration/hypokalaemia

Stool softener + stimulant

Lactulose 20ml PO Daily or BD

-↑doses required in hepatic encephalopathy (30-45ml QID) - SE: flatulence + very sweet taste

Macrogol 3350 (Movicol / Marovic)

1-2 sachets PO Daily or BD

- faecal impaction: up to 8 sachets within 6hrs, max 3D - risk of fluid + electrolyte imbalance (↓risk compared to saline lxtves)

Microlax enema sorbitol /sodium citrate/ sodium

lauryl sulfoacetate

1 PR STAT - rectal onset: 2-30min - beware: patients w heart failure/renal impairment, risk of GI obstruction/perforation - monitor electrolytes

Saline laxatives - once only medication - also used in bowel prep - can cause considerable fluid + electrolyte imbalance

Fleet enema sodium phosphate

monobasic/ sodium phosphate

dibasic

1 PR STAT

Note: optimise Magnesium level (Hypomagnesaemia linked to constipation)

SEDATIVES


Temazepam 5-10mg PO Nocte/STAT Max 20mg, lower for elderly

- short term use, low dose - Risk: over-sedation, ataxia, confusion, resp depression,

Zolpiclone 3.75-7.5mg

PO Nocte/STAT up to 4 weeks

- X myasthenias gravis, pulm insufficiency, alcohol intake

Zolpidem IR 5mg PO Nocte/STAT

OSM

OT

IC L

AX

AT

IVE


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- ! psych sx may worsen,

memory impairment, falls

Melatonin XR 2mg PO Nocte/STAT SE: back pain, arthralgia//limited evidence//up to 13wks

Diazepam 5-20mg PO Per AWS Max. 120mg

Preferred option. Low dose in elderly.

Oxazepam alt. in liver imp/frail

Alcohol Withdrawal Scale

+ thiamine 300mg IM/IV 5D

REFER TO AWS POLICY

Haloperidol (acute

psychosis)

0.25-0.5mg

PO/IM STAT - Beware EPSE up to 48hrs post - Low incidence hypotension

- oral before IM - onset 30-60min - avoid benzodiazepine - SE: long QTc, hypotension, confusion, anticholinergic effects, acute EPSE

Olanzapine (acute

psychosis)

2.5mg PO/IM (wafer)

STAT SE: hyprglycma/periph odma Careful: hepatic impairment

Risperidone (acute

psychosis)

0.5mg PO (wafer)

STAT - risk cerebrovascular event Careful: renal/hepatic impairmnt

Seek advice before medicating for disturbed behaviour/ AVOID CHARTING PRN. Refer to Delirium & Cognitive Impairment Management Policy

Benztropine 1-2mg PO/IM STAT Reverse EPS (acute dystonia); anticholinergic

Promethazine 5mg PO Nocte/STAT Sedating antihistamine, see ‘Analgesia’ section above

ANTICOAGULATION – see Thrombosis & haemostasis Guideline on Prompt


Aspirin Cyclo-oxygenase

inhibitor

100mg PO Daily Elderly: consider taking with PPI (GI bleed risk)

300mg PO STAT Suspected ischaemic chest pain

Dipyridamole MR +Aspirin

200/25mg PO BD 2ndry prevent stroke/TIA; Daily for 1 week (with 100mg aspirin)

Clopidogrel 75mg PO Daily Response variability ++ Load 300mg

P2Y12 antagonist

(liver metabolism)

Ticagrelor (+aspirin) 90mg PO BD SE: dyspnoea, ventricular pauses; Load 180mg

Prasugrel (+aspirin) 10mg PO Daily High risk of major bleeding; Load 60mg

Prophylactic clexane

40mg SubCut Daily 20mg if: CrCl<30/<50kg/frail/low risk

LMWH Inactivate IIa+Xa

via anti-thrombin III

binding

Therapeutic clexane (enoxaparin)

1mg/kg SubCut BD Dose to closest 5-10mg. BD preferred for inpts. Daily for HITH. 1mg/kg/day if CrCl<30

1.5mg/kg SubCut Daily

Prophylactic heparin 5000 units

SubCut BD/TDS Monitor APTT 6hrs post, ½ life 1hr, hepatic clearance Antidote: protamine IV 1mg/100unit (risk: fish allergy/vasectomy)

Therapeutic heparin APP SubCut IV inf.

AN

TI P

SYC

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TIC

S A

NTI

PLA

TEL

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EPA

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Dabigatran (Pradaxa)

direct thrombin inhibitor

150mg PO BD X prosthetic HV, Careful: GI bleed <12m. Consider 110mg: CrCl 30-50, >75yo, <50kg or as per bleed/clot risk. Reversal=Idarucizumab

110mg PO BD

Apixaban (Eliquis)

5mg PO BD X CrCl<25; Interacts with CYP3A4 P-gp inhs. 2.5mg BD if ≥ 2 of: <60kg, >80yo, Cr >133

Factor Xa inh Careful liver

imp Apixaban a/w fewer

major bleeds

2.5mg PO BD

Rivaroxaban (Xarelto)

20mg PO Daily X prosthetic HV/ CrCl<30. 15mg D if CrCl 30-49

Warfarin (Brand specific:

Coumadin/Marevan)

INR 2-3 PO D at 4pm

Loading: 5mg D for 2D, 3mg in certain situations (see above guideline and adjusting as per INR) INR lags by ~2days INR 2.5-3.5 if mechanical

heart valve

Vitamin K1 0.5 - 10mg

PO/IV stat Warfarin reversal: dependent on bleeding / INR

Warfarin reversal for life threatening bleed+INR≥1.5

IV Vit K 10mg + Prothrombinex-VF 50 units/kg + fresh frozen plasma 150-300mL

GASTROINTESTINAL


Mg + Al hydroxide

10-20mL PO PRN Antacid; take 1-3hr post meal; Careful: CCF; aka Gastrogel

Pink Mix 30mL PO stat Prescribe as Lignocaine viscus 10mL + Gastrogel 20mL

Ranitidine 150mg PO BD H2 antagonist; PUD/GORD; careful: salt restriction, renal impairment

Pantoprazole 40mg PO/IV Daily GORD: 4-8wk course; 30-60min pre-meal; all PPIs similar efficacy *bleeding peptic ulcers intermittent bolus vs. infusion same efficacy. X long term use b/c ?risks: ↓Mg, #, C.diff, CKD, pneumonia

40mg IV *BD 3 days

Esomeprazole 20mg PO Daily

Relief with pink mix DOES NOT rule out ischaemic cause for epigastric pain

CARDIOVASCULAR


Atorvastatin (Lipitor)

10-80mg PO Daily Monitor LFT/CK; SE: rhabdomyolysis, myopathy HMG-CoA reductase inhibitor; consider cease if LE<10yrs Rosuvastatin

(Crestor) 5-40mg PO Daily

Ezetimibe 10mg PO Daily Add to statin to meet LDL target Not together Fenofibrate 145mg PO Daily triglycerides (+statin) CrCl<60

dose X pancreatitis

Perindopril arginine 2.5-10mg PO Daily ACEi; Caution: renal impairment, ↑K+, angioedema, African descent, NSAIDS. Check salt before prescribing, TNH keep both

Perindopril erbumine

2-8mg PO Daily

Irbesartan 75-300mg PO Daily ARB; Caution: pt w angioedema on ACEi, renal impairment; X ACEi

Metoprolol tartrate 12.5-100mg

PO BD HTN B-blocker; start low, go slow (double dose 2-4wks)

cease slowly =avoid rebound HTN; start when pt stable

Metoprolol MR 23.75-190mg

PO Daily CCF

Spironolactone (aldactone/spiractin)

12.5-50mg PO Daily HTN K+sparing aldosterone antagonist; SE: hyperkalaemia, respiratory/metabolic 25mg PO Daily CCF

DO

AC

S

Northern JMSA

PP

I

LIP

ID R

EDU

CIN

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/CC

F H

TN


Page 46

acidosis; X prostate cancer. Antiandrogenic effect:

gynaecomastia/sexual dysfunction

Frusemide (Lasix – lasts ~6 hrs)

20-40mg PO Mane ± midi (max

1g/24h)

Loop diuretic; Titrate to response, monitor weight+electrolytes

SE: metabolic alkalosis, hyperuricaemia, ↓electrolytes

40mg PO = 20mg IV

Hydrochlorothiazide 12.5-25mg PO Mane Thiazide; HTN. Careful: new onset DM, hypo K, hypo Na; X gout.

Amlodipine 2.5-10mg PO Daily Dihydropyridine CCB; X cardiogenic shock, CCF; SE: peripheral oedema

Glyceryl trinitrate Patch

5-15mg/24hr

Top On at 8 off at 8

Symptoms dictate timing. nitrate-free 12hrs to avoid tolerance

Anginine© (GTN) ½ to 1 (600mcg)

Subling 5min PRN Check BP; max 3 doses; X ↑ICP, hypovolemia, PDE5i use (sildenafil) Nitrolingual – spray Anginine – tabs. Check expiry. SE: flushing/H’ache

Nitrolingual© (GTN) 400mcg Subling 5min PRN

DIABETES PRESCRIBE INSULIN IN BRAND NAME TO AVOID CONFUSION


Novorapid (insulin aspart)

variable SC w meals TDS PRN/ sliding

scale

T2DM: 10-14 (4u), 14.1-18 (6u), 18.1-22 (8u), ≥22.1 (10u) T1DM: 10-14 (2u), 14.1-18 (4u), 18.1-22 (6u), ≥22.1 (8u)

Onset: 10-20min; max:1-3hrs

Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane. Ultra-short acting (immed pre-meal): Novorapid; Apidra; Humalog. Short acting (≤ 30 min pre-meal): Actrapid, Humulin R. Mixed insulin (with

food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50, Ryzodeg 70/30

Insulin fasting guidelines: Long-acting = cont at full/reduced dose; Short-acting = WH; Pre-mixed (humulog/novomix/mixtard)=50% dose as protophane

Metformin (Diabex)

IR: 500mg-

1g

PO Daily-TDS (max 3g/24h)

Careful: CrCl<30 (lactic acidosis risk); biguanide WH: septic/fasting/min oral intake/AKI; take

with food

XR: 0.5g-2g

Daily (max 2g/24h)

Gliclazide diamicron/glyade

IR 80mg PO Daily-BD with food

Max 320mg D

Sulfonylureas; careful: acute illness; weight+

X T1DM, ketoacidosis; hypoglycaemia risk ++

MR 30-60mg

PO Daily with food Max 120mg D

Sitagliptin 25-100mg

PO Daily DPP4 inhibitor Careful: sulfonylurea/insulin/ACEi/CrCl<50

?Risk: infection/pancreatitis; no weight gain Linagliptan 5mg PO Daily

Exenatide (Byetta)

5microg SC BD (pre-meal) GLP1 agonist. Use: if obese. SE: pancreatitis Careful: sulfnylrea/insulin/hx gallbladder

disease X CrCl<30 Bydureon: 2mg SubCut weekly (SR)

Dapagliflozin 10mg PO Daily SGLT2 inhibitor SE: UTI; Careful: insulin/sulfnylurea/diuretics/CrCl<60

Acute serious illness, prolonged fasting or other risk factors for DKA - WH

Empagliflozin 10mg PO Daily

Pioglitazone 15mg PO Daily (max 45mg)

X ?bladder Ca, ketoacidosis, T1DM, insulin SE: worsen CCF, #, wht

CC

F H

TN

INSU

LIN

S


Page 47

END OF LIFE CARE


Morphine 2.5-5mg SC PRN (no freq) Pain/resp distress, depends on tolerance

Fentanyl 25-50mcg SC PRN (no freq) Pain, preferred if renal impairment

Midazolam 2.5-5mg SC Every 1hr PRN Agitation

Metoclopramide 10-20mg SC QID PRN Nausea/Vomiting

Glycopyrrolate 0.2-0.4mg SC Q4H (max 1.2mg)

Respiratory secretions

FLUID/ELECTROLYTE REPLACEMENT

(NB: 1mmol/L = 1mM) ALWAYS CHECK IF UNSURE

Potassium 3.5-5.2 mM (>4.0 if cardiac hx) – recheck in 4hrs↓/1hr↑

Magnesium 0.7-1.1mM (>1.0 if cardiac hx) – recheck in 6-12hrs↓

3mmol/L serum K = -200mM K+ (-0.5mmol serum = 100mM K+ deficit)

Intracellular cation, linked to ↓K AND ↓Ca AND metabolic alkalosis

↓Hypokalaemia: ?loss from GI or urine/hypoglycaemia/hypomagnesemia?

↓Hypomagnesemia: ?malnutrition/GI loss (NGT/diarrhoea)/renal loss?

Slow K (4hr)

8mM K+/tab

16-48 mmol/24h dependent on level adjusted on response

O MagSup Mg aspartate

1.55mM/t Ṫ-ṪṪ D-BD; careful CKD

Chlorvescent (0hr)

14mM K+/tab

IV

0.9% NaCl 100mL + MgSO4 10mM

≥1/24 severe if <0.4mM

0.9% NaCl 1000mL + KCl 30mM

≥3/24 Rate can’t exceed

10mmol KCl/Hr

↑Hypermagnesemia: ?antacid/CKD/lithium/rhabdomyolysis

0.29% NaCl 100mL + KCl 10mM isotnic

≥1/24 IV 2.2mM calcium gluconate 100mL 15min

aim urine outpt 60mL/hr; IV 0.9%NaCl

↑Hyperkalaemia: ?haemolysed sample (check w VBG)/AKI?

Sodium 135-145mM – recheck in 6hrs↓/4hrs ↑

Resonium 30g PO/PR stat (1-3hrs)

Frusemide 40-80mg IV stat ↓Hyponatremia: ?diuretics(HCT)/SSRI/SiADH/hyperglycaemia/organ

failure

50% dextrose IV 50mL+10units Novorapid/20min

Salbutamol 5mg neb x2

0.9% NaCl IV

Fluid restrict ~500mL < urine output

Consider SiADH if: [serumNa]<130mM serum Osm/L <275mmol/kg urine Osm/L >100mmol/kg [urineNa] > 30Mm

Phosphate 0.75-1.5mM (* if <0.3] – recheck in 3hrs↓

NB: Na ∆ must ≤0.5mM/hr; ≤10mM/D ↓Na=cerebral oedema; ↑Na=osmotic demyelination ↓Hypophosphatemia:

?malnutrition/antacid/↑PTH/↓VitD?/↓Ca2+

O Phosphate

16.1mM/tab

1-2tabs D-TDS, SE: diarrhoea

↑Hypernatremia: ?water loss (DI, thiazide, burns)/IV iatrogenic

IV

Ora

l


Page 48

Sandoz

0.9% NaCl 250mL + PO4 10mM

≥3/24 KH2PO

4 RARELY use IV

SE: ↓Ca2+/te

tany

oral water

5% dextros

e IV

0.45% NaCl IV 4% dextrose+0.18%N

aCl (4+1/5th)

0.9% NaCl 250mL + PO4

10mM

≥2/24

NaH2PO4 Na↓ must

≤0.5mM/hr; ≤10mM/D

Water deficit=0.5(serum Na-140)/140

↑Hyperphosphatemia: ?CKD/cell lysis/ ↓PTH Calcium 2.15-2.55mM corr Alb – recheck in 4hrs↓

O Calcium carbonate 1.25g BD/TDS

Lanthanum/Sevelamer TDS

↓Hypocalcaemia: ?↓VitD/↓Mg/↓PTH (para/thyroidectomy)

Fluid Requirements 0.9%NaCl 100mL+calcium gluconate 4.4mM

20min Oral maintenance w food: Calcitriol 0.25mcg

BD CaCO3

1.5g BD

Assume: euvolemic, X renal/heart failure, X abnormal loss/elect disturbance

0.9%NaCl 900mL+calcium gluconate 22mM

50mL/hr

4ml/kg/hr 1st 10kg body weight 2ml/kg/hr 2nd 10kg body weight 1ml/kg/hr remainder

Regimen One (1L bags)

0.9% NaCl+30mM KCl

5%dxtrse+30mM KCl

5% dextrose

Regimen Two (1L bags)

2 bags: 30mM KCl +

4%dextrse+0.18%NaC 1 bag:

4%+1/5th

↑Hypercalcaemia: ?malignancy/1 ↑PTH

Rehydrate: 0.9% NaCl IV

4-6L/24 aim UO ~60ml/hr

Bisphosphonat

e: X

CrCl<30 ≤1mg/

min

0.9% NaCl 250mL + pamidronate 60-90mg IV

2-4/24

Sodium: 1-2 mmol/kg/day Potassium: 0.5-1 mmol/kg/day

Infusion rate: 8/24 usual; 10-12/24 frail,old

If malignancy, consider long term clodronate o 2.4-3.2g BD

Check Vit D

NB: 4% dextrose+0.18% NaCl = 4% and a fifth

NB: for fluid balance urine output = early sign; BP/HR/urea = late signs

IV


Page 49

The pharmacist is not the purple pen drug police.

The pharmacists are here to

support you, improve medication safety and to

promote patient-centred care

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INTERN MEDICATION GUIDE 2020 - Northern Doctors · INTERN MEDICATION GUIDE Page 6 ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC) Background Rationale Drug therapy errors occur in