ANC equation
ANC = WBC * (% seg neuts + % bands)
Neutropenia ANC < 500
Must have ANC > 1500 to be eligible for chemotherapy
Dexrazoxane
Prevent cardiomyopathy in doxorubicin > 300 mg/m2
Give 10% of doxo dose as dexrazoxane
Also used for extravasation
Amifostine
Use for nephrotoxicity from cisplatin
Leucovorin
Use after MTX doses > 1000, rescue tx in MTX > 500
Can add on glucarpidase but do not administer leucovorin 2 hours before or afterwards
Tumor lysis syndrome
Rasburicase tx, use allopurinol or fluids as prophylaxis
Increased uric acid
Hypercalcemia (cancer related)
Ca > 14
Fluids, loop diuretics, bisphosphonates, calcitonin
Corrected Ca equation
= (4-albumin)* 0.8 + Ca
Normal is 12-14
use if albumin < 3.5
Leapfrog Hospital Safety Grades
VA hospitals, critical access hospital excluded
Issued 2x per year
Barcode scanning on med admin one of the criteria - goal is to reduce preventable mistakes
HEDIS
NCQA - part of CMS
Not required to report to HEDIS, but used for ratings
IRB required members
5 members
1 scientific, 1 nonscientic, 1 not affiliated with org, and one that represents perspectives of research participants
Cost Benefit
Cost effectiveness
Cost minimize
cost utilization
Cost Benefit: Looks at tx + costs saved with benefit outcomes
Cost effectiveness: Looks at measured clinical uses or outcomes (years of lives saved)
Cost minimize: Compares therapies
Cost utilization: Looks at mortality / QALY
ivabradine (Corlanor)
Used in HF EF < 35% and on max tolerated BB with HR > 70 bmp.
ADE: bradycardia, atrial fibrillation, HTN
Lowers hospitalizations
Criteria for antibiotics in COPD
Dyspnea OR increase sputum volume
+ increased sputum purulence
OR mechanical ventilation
Augmentin, macrolide, doxycyline if GOLD 1 or 2
Levo/cipro if GOLD 3 or 4 (pseudo coverage)
Theoyphilline
MOA - phosphodiesterase inhibitor, methylxanthine. No longer recommended for acute tx of asthma
Can lower seizure threshold
FEV cut-off's GOLD 1 GOLD 2 GOLD 3 GOLD 4
GOLD 1 >= 80%
GOLD 2 50-79%
GOLD 3 30-49%
GOLD 4 < 30%
Pneumococcal vaccine recommendations
Age 19-64 w/ chronic medical condition (give if FEV1 < 40%) - 1 dose of PPSV23
Immunocompromised > 19 yoa: 1 dose PPSV13, 8 weeks later PPSV23, then 5 years later booster PPSV23
65 and older - PPSV 13 and PPSV 23 one year later
Hyponatremia
If due to dehydration, give NaCl 0.9%, check in q4h
Na < 120, symptomatic - use hypertonic saline NaCl 3%
1 mEq/L/hr (severe), 0.5 mEq/L/hr in moderate. Can give NaCl 0.45% to slow down the rise.
Do not correct more than 10-12mEq per 24 hours, or > 18 mEq in 48 hours.
Treating hypokalemia will help increase Na as well! If Euvolemic or edematous, fluid restriction (<800mL/day) or vasopressin antagonists like tolvaptan
Med induced = thiazides, antiepileptics, SSRI’s, hypothyroid, SIADH
Hypernatremia
Na > 145 - caused by dehydration, sodium retention, brain injuries. Requires H2O! Must give by mouth or via D5W, never SW infusion!
If hypotensive, can give NaCl 0.9%
Hypokalemia
K < 3.5
Causes: insulin, beta agonists (albuterol), alkalosis, hypothermia, diuretics, GI losses
K 3-3.5 –> PO KCl 40-80 mEq/day
K 2-3 –> IV or PO (IV 10-20 mEq/hr)
K < 2 give 20 - 40 mEq/hr IV (ECG monitor)
Divide doses > 60 mEq to reduce GI SE
Max peripheral IV is 60-80 mEq
Don’t mix K in dextrose
Hyperkalemia
K > 5; if > 6.5 it is an emergency !
If symptomatic:
- Calcium gluc 1 g IV push to reduce cardiac risk
- Insulin 10 units IV + 25-50 g glucose via 50% IVpush
- Sodium bicarbonate 50 mEq IV push
- Albuterol 10-20 mg neb (if on BB, pt will not respond - not as effective)
If asx, give sodium polystyrene sulfonate alone 15 g q6h
Causes: succ, K sparing diuretics, acei, arbs, trimethoprim. If CAD, CHF, DM - higher risk of sudden death
Hypomagnesium / hypermagnesium
Mg < 1.7
Oral supplementation, mag oxide - SE is diarrhea
1-4 g slow IV infusion, lower dose by 50% in renal
Can give push if emergency
Mg > 2.3
0.9% NaCl, loops, IV calcium if sx
Hypocalcemia
Corrected Ca if Ca < 8.5 Sx: muscle twitch/seizure CaCl 1g via central line CaGluc 2-3 g via peripheral line max rate 60 mg/min
Hyperpcalcemia
Due to malignancy: NaCl 0.9% plus bisphosphonate (zolendronic acid 4 mg IV - can take up to 7 days for nadir to be reached) + calcitonin (if symptomatic)
Medicare Access and CHIP Reauth Act (MACRA)
Fee for service to a value-based or pay for performance model
NDA
ANDA
INDA
NDA - Submitted after Phase III studies before market approval
ANDA - generic drugs, submitted 3-5 years after market exclusivity by brand company. Retain a 180 day exclusivity of generic product.
INDA - used for new drug, new indication, off-label use. Must be submitted after pre-clinical trials, before Phase I trials.
Orange Book
A - both pharmaceutical equivalents and bioequivalent, may be interchanged
B - pharmaceutical equivalents only, cannot be interchanged
Biosimilars - purple book, availavlee for biological products after 12 years exclusivity
Medwatch Form FDA 3500, 3500A, 3500B
Form 3500 - voluntary reporting by HCP, can disclose PHI
Form 3500A - IND reporters, manufacturers, distributors, etc
Form 3500B - Consumers and patients
HITECH Act
Promote healthcare information tech, authorizes DHHS to promote
CMS gives financial incentives for “meaninful use” of EMR (under ARRA)
Orphan Drug Act
Grants, assistance, for patient populations of < 200,000
Grants market exclusivity for 7 years after FDA approval
Grants 20 year patent life (starts when molecule is invented)
New Drug Process
Preclinical trials > INDA > Phase I: PK/PD in ~ 50 human volunteers > Phase 2: Indication for drug in several hundred patients > Phase 3: Efficacy and safety evaluation > NDA > Phase 4: Postmarketing studies
Drug causes of SIADH
SSRI’s
Carbamazepine
Barbiturates
Narcotics