Microsoft word - 08 medication monitoring iv to po interchange 02.13.doc

Pharmacy Department Policies and Procedures MEDICATION MONITORING:

The oral route of administration may be ideal so long as the medication achieves the desired
concentrations in blood and/or the targeted site(s) of action. Patients often start on parenteral
therapy, but as their condition improves, they are often candidates for continuation with oral
therapy. Available oral formulations have high oral bioavailability and equivalent potency. The
conversion from intravenous (IV) to oral (PO) formulations of the same medication while
maintaining equivalent potency is known as “sequential therapy”.
Much of the beneficial data on IV to PO therapy interchange stem from the conversion of
antimicrobial medications. Studies have shown that appropriate conversion from IV to PO
antimicrobial therapy can decrease the length of hospitalization without adversely affecting patient
outcome and may improve patient care by reducing the risk of intravascular catheter infection
because of shorter line dwell times and less endoluminal contamination.1-8 Additional benefits of IV
to PO conversion include reduced hospital cost, greater patient comfort and easier ambulation9.
Furthermore, the use of oral medications may decrease nursing personnel time.

This policy outlines IV to PO conversion considerations and specific criteria for the substitution and
therapeutic interchange of medications as set forth by the SHC Pharmacy and Therapeutics
Committee, the Antimicrobial Subcommittee, and the Antimicrobial Stewardship Team.

A. If the patient is being considered for an IV to PO conversion, the clinical pharmacist (and/or
Antimicrobial Stewardship Team in the case of antimicrobials) can examine the route of therapy and determine if it is clinically appropriate to perform a sequential, parenteral to oral therapy switch. B. If the patient meets the approved criteria for transition to oral therapy (Section F), the clinical pharmacist will enter the new order using “per Protocol” order mode and enter a standardized i-Vent in the patient's medical record detailing the conversion. C. The covering provider will be notified when the sequential switch occurs. The provider has the option to switch back to the intravenous route if parenteral therapy is preferred. D. The Antimicrobial Stewardship Team will report findings and feedback to the Antibiotic E. The Pharmacy Department will review and report findings and feedback for non-antimicrobial medications at departmental meetings every quarter for the first year (2013), then every year thereafter. Inclusion
Able to adequately absorb oral medications via the oral, gastric tube, or Pharmacy Department Policies and Procedures Not displaying signs of shock, not on vasopressor blood pressure support Additional requirements for antimicrobials:
o Afebrile for at least 24 hours (temperature ≤100°F or ≤37.8°C) o Heart o Systolic blood pressure ≥90 mm Hg (without vasopressor drugs) o Signs and symptoms of infection improvement according to assessment:  Improving WBC and differential counts Persistent nausea and vomiting, diarrhea Exclusion
Patient with the following GI conditions: Criteria
o Ileus or suspected ileus with no active bowel sounds o Patient is known to have a malabsorption syndrome o Proximal resection of small intestines o High nasogastric (NG) tube output or requiring continuous GI suction Wernicke's encephalopathy (for thiamine interchange) Acute pain (for IV acetaminophen interchange) Myxedema coma or if endocrine consulting (for IV levothyroxine) Additional exclusions for antimicrobials:
Patient has a serious or life threatening infection: o Meningitis, endocarditis, intracranial abscesses, osteomyelitis, o Inadequately drained abscesses and empyema o Severely immunocompromised (solid organ transplant, bone marrow G. Intravenous to Oral Dose Conversion, Pricing, and Bioavailability Medication
Intravenous Dose
Oral Equivalent
daily ($5.83) * restricted to feeding tube use only                                                              1 Serum levels do not consistently correspond to the FAMOTIDINE dose or the degree of gastric acid inhibition  Pharmacy Department Policies and Procedures interchange if for Wernicke’s Encephalitis H. Antimicrobial Intravenous to Oral Dose Conversion Medication
Intravenous Dose
Oral Equivalent
1 single strength = 80 mg TMP ($0.06/tablet)
Pharmacy Department Policies and Procedures 1. Nathwani D, Tillotson G, Davey P. Sequential antimicrobial therapy--the role of quinolones. J Antimicrob Chemother. Apr 1997;39(4):441-446. 2. Vogel F. Sequential therapy in the hospital management of lower respiratory infections. The American journal of medicine. Dec 29 1995;99(6B):14S-19S. 3. Davey P, Nathwani D. Sequential antibiotic therapy: the right patient, the right time and the right outcome. The Journal of infection. Jul 1998;37 Suppl 1:37-44. 4. Bernig T, Weigel S, Mukodzi S, Reddemann H. Antibiotic sequential therapy for febrile neutropenia in pediatric patients with malignancy. Pediatric hematology and oncology. Jan-Feb 2000;17(1):93-98. 5. Skoutelis AT, Gogos CA, Maraziotis TE, Bassaris HP. Management of brain abscesses with sequential intravenous/oral antibiotic therapy. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology. May 2000;19(5):332-335. 6. Pablos AI, Escobar I, Albinana S, Serrano O, Ferrari JM, Herreros de Tejada A. Evaluation of an antibiotic intravenous to oral sequential therapy program. Pharmacoepidemiology and drug safety. Jan 2005;14(1):53-59. 7. Buyle F, Vogelaers D, Peleman R, Van Maele G, Robays H. Implementation of guidelines for sequential therapy with fluoroquinolones in a Belgian hospital. Pharmacy world & science : PWS. Jun 2010;32(3):404-410. 8. Wilcox MH. Implementation of sequential therapy programs--a microbiologist's view. The Journal of infection. Jul 1998;37 Suppl 1:51-54. 9. Kuper K. Chapter 29. Intravenous to Oral Therapy Conversion. Competence Assessment Tools for Health-System Pharmacies Fourth Edition, Copyright, 2008, ASHP. 10. Micromedex online, accessed September 30, 2012 11. Lexi-comp online accessed September 30, 2012

This procedure is kept in the Pharmacy Policies and Procedure Manual Denise Gin, Pharm.D, BCPS; Lina Meng, Pharm.D. BCPS; Craig Sterling, Pharm.D.; Paul Mohabir, M.D.; Thomas Weiser, MD MPH: 12/2012 Pharmacy and Therapeutics Committee: 05/2012, 02/2013 This document is intended only for the internal use of Stanford Hospital and Clinics (SHC). It may not be copied or otherwise used, in whole, or in part, without the express written consent of SHC. Any external use of this document is on an AS IS basis, and SHC shall not be responsible for any external use. Direct inquiries to the Director of Pharmacy, Stanford



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