Physician Update

INTEGRIS System Formulary Updates

Therapeutic Interchange Updates to be initiated by April 15, 2018.

  • The formulary probiotic of choice for adults will be changed to saccharomyces boulardii (Florastor) in adults. In very rare cases probiotics have been found to be pathogenic in the severely ill and immunocompromised. Probiotic use in this population is not recommended. Pediatric patients will not be part of the probiotic interchange because VSL#3 granules (Lactobacillus and Bifidobacterium combination product) for oral suspension use may still be warranted in this population. 
  • The Proton Pump Inhibitor Therapeutic Interchange Policy has been updated to replace use of pantoprazole (Protonix) granules for oral suspension with the First-omeprazole oral suspension. This allows for simplification of the interchange to a product already being utilized for pediatric and neonatal populations at INTEGRIS and will avoid the tube-clogging issues that have occurred with the pantoprazole granules dosage form. This switch may also result in a cost-savings for INTEGRIS.
  • The Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Therapeutic Interchange Policy currently converts agents in this class to the formulary DPP-4 of choice linagliptin (Tradjenta). This policy was revised to clarify that DPP-4 inhibitor/metformin combination products will be converted to linagliptin and metformin as linked but separate orders within Epic. 
  • The Non-sedating Antihistamine Interchange was updated to include fexofenadine. At this time loratadine, desloratadine, levocetirizine, and fexofenadine will be interchanged to the formulary non-sedating antihistamine of choice cetirizine (Zyrtec). 

Ambulatory Infusion Center Formulary updates

  • The third interleukin-5 antagonist benralizumab (Fasenra) for subcutaneous injection was added to the formulary restricted to outpatient administration. Benralizumab is also indicated for add-on treatment of severe asthma with eosinophilic phenotype and follows previously available agents in this class including subcutaneous mepolizumab (Nucala) and IV infusion reslizumab (Cinqair) in patients meeting coverage criteria set forth by third party payers. 
  • The tumor necrosis factor alpha agent certolizumab pegol (Cimzia) lyophilized powder for subcutaneous administration was added to the formulary for outpatient administration in patients meeting criteria for this dosage form instead of the prefilled syringe for self-administration in the home setting. Patients must also be screened annually for TB and hepatitis B with evidence submitted to the infusion center due to Boxed Warning recommendations.
  • Rabies postexposure vaccination schedule deviations of up to seven days after the initial dose was approved by the Formulary Integration Committee as an allowable deviation. The CDC human rabies prevention recommendations state that every effort should be made to adhere to the postexposure vaccine schedule; however, minor deviations of up to 7 days do not require re-initiation of the series. Substantial deviations exceeding 7 days would require serologic testing 7-14 days after administration of the final dose in the series to confirm immune status.  
  • The antiresorptive agent order set (paper only at this time) has undergone revisions to the vitamin D deficiency and calcium/vitamin D supplementation pre-dose criteria section. This order set continues to be a mandatory order set for ordering injectable agents for osteoporosis and Paget’s disease in the outpatient infusion setting including zoledronic acid IV infusion (Reclast), ibandronate IV injection (Boniva), and denosumab subcutaneous injection (Prolia). 

Acute Care Formulary

  • Alum and silver nitrate may no longer be provided as bladder irrigations for treatment of hemorrhagic cystitis (formulary removal as bladder irrigants). Compounding sterile bladder irrigations from non-sterile ingredients constitutes high-risk compounding. No INTEGRIS pharmacy department is licensed to conduct high risk compounding according to the USP <797> Sterile Compounding Standards. Alternatives for hemorrhagic cystitis include tranexamic acid oral tablets or IV injection given via bladder instillation or intravenously. 
  • Methylene blue is a potent monoamine oxidase inhibitor and may precipitate serotonin syndrome when given systemically (i.e., IV infusion) in patients on other serotonergic medications such as the antibiotic linezolid (Zyvox) or serotonergic antidepressants including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors. Methylene blue given IV for treatment of catecholamine-resistant vasoplegic shock post cardiopulmonary bypass and for treatment of other life-threatening indications warrant administration of methylene blue even in patients with a history of serotonergic antidepressant use within 5 weeks prior to the methylene blue dose or linezolid use within the previous 36 hours. After the IV methylene blue order has been processed and dispensed for administration, the pharmacist will communicate the interaction to the provider to discontinue active orders for serotonergic agents if appropriate and/or recommend a heightened level of monitoring for development of serotonin syndrome. Use of methylene blue as a local dye not administered IV is not high risk for the serotonin syndrome drug interaction.
  • Restrictions for Clevidipine (Cleviprex), an ultra-rapid acting calcium channel blocker infusion, have been relaxed to allow its use as an initial IV blood pressure-lower agent for any indication (previously limited only to stroke and neurologic surgery indications). Use continues to be restricted to the emergency department, intensive care unit, and operating room setting. At INTEGRIS Baptist and INTEGRIS Southwest Medical Center, the patient should be transitioned to nicardipine or other more cost-effective agent as soon as possible after the initial need for ultra-rapid blood pressure control has resolved. USE CAUTION: clevidipine (Cleviprex) looks very similar to propofol (Diprivan) (also available as a milky-white solution in a premixed glass bottle).


Contact Julia Chiappe, Pharm.D., BCPS