Page 33 - Christiana Care Focus April 2019

FORMULARY UPDATE | March 2019
Fentanyl and methadone are thought to be relatively safe because they are converted to inactive metabolites, but they require management and careful monitoring by experienced practitioners.2
With any suspected overdose where respiratory depression is found, treatment needs to be provided with antagonists like naloxone, which can cross the blood brain barrier to reverse respiratory depression. Multiple doses of the antagonist may be needed. The half-life of naloxone is shorter than most opioids and frequent retreatment or IV infusion may be warranted.
In conclusion, while there is limited clinical data (case reports) supporting specific dosing recommendations in patients with renal failure, it is best practice, as recommended by the CDC guideline,
References
to start low dosages and titrate slowly until a therapeutic effect is achieved.7 Generally speaking, opioids should be used with caution in patients with CKD. It is important to note that with decreased renal function, dose and frequency of opioids may need to be adjusted, especially when used for chronic pain. 1, 8
For more information on treating pain in advanced CKD and dialysis patients:
Coalition for Supportive Care of Kidney Patients: Treating Pain in Advanced CKD & Dialysis Patients: Clinical Algorithm & Preferred Medications, 2016. Available at: https://www.kidneysupportivecare. org/Files/TreatingPaininlateCKD11-2016.aspx. 
1. MallappallilM,SabuJ,FriedmanEA,Salifu,M:Whatdoweknowaboutopioidsandthekidney?Int.J.Mol.Sci.2017,18(1),223.
2. IshidaJH,McCullochCE,SteinmanMA,GrimesBA,JohansenKL:Opioidanalgesicsandadverseoutcomesamonghemodialysispatients.ClinJAmSocNephrol13:746-753,2018.
3. CoalitionforSupportiveCareofKidneyPatients:TreatingPaininAdvancedCKD&DialysisPatients:ClinicalAlgorithm&PreferredMedications,2016.Availableat:https://www. kidneysupportivecare.org/Files/TreatingPaininlateCKD11-2016.aspx. Accessed March 4, 2019.
4. DeanM:Opioidsinrenalfailureanddialysispatients.JPainandSymptomManagement28;5:497-504,2004.
5. MercadanteS,ArcuriE.Opioidsandrenalfunction.Journalofpain.5;1:2-19,2004.
6. ConwayBR.Opiatetoxicityinpatientswithrenalfailure.BMJ332:345-346,2006.
7. CDC Guideline for Prescribing Opioids for Chronic Pain. https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf. Accessed March 3, 2019.
8. GelotS,NakhlaE:Opioiddosinginrenalandhepaticimpairment.USPharm39(8):34-38,2014.
| Pharmacy Services
Medication – Generic/Brand Name
Bictegravir-Emtricitabine-Tenofovir Alafenamide/ Biktarvy
Medication – Generic/Brand Name
Bacitracin/Neomycin/ Polymyxin B / Hydrocortisone Ointment/Cortisporin Ointment
Neomycin/Polymyxin B / Hydrocortisone Cream/ Cortisporin Cream
Strength/Size
Bictegravir 50 mg, emtricitabine 200 mg, and tenofovir alafenamide 25 mg tablet
Comment
Use/Indication
Treatment of HIV-1 infection
Comment
Only infectious disease physicians can initiate new treatment for hospitalized patients. All prescribers can order treatment to continue during hospitalization.
Removed from Christiana Care Formulary because unavailable currently, and infrequent use historically. Neomycin/Polymyxin B /Bacitracin Ointment (Triple Antibiotic Ointment) remains available.
Removed from Christiana Care Formulary because unavailable currently, and infrequent use historically.
FOCUS • APRIL 2019 31
ADDITIONS DELETIONS