HP
`
`AMERICAN JOURNAL OF HOSPITAL PHARMACY
`
`Reframing pharmacys leadership
`relationship and scholarship
`
`Drug therapy during cardiac arrest
`
`Methods used by pharmacy departments
`to identify drug interactions
`
`Annual
`
`index
`
`Official journal of the
`American Society of Hospital Pharmacists
`
`Abraxis EX2038
`Actavis LLC v Abraxis Bioscience LLC
`1PR201701101 1PR201701103 1PR201701104
`
`

`

`AMERICAN JOURNAL OF HOSPITAL PHARMACY
`
`December 1993
`
`Volume 50
`Number 12
`
`Coden AIHPA9
`ISSN 00029289
`
`2458 News
`After developing bladder tumor
`pharmacist calls for national
`cancer registry
`States surpass OBRA 90
`patient counseling requirements
`International guidelines for pharmacy
`practice approved at 53rd HP
`congress in Tokyo
`Patient care gaining importance
`in Japanese pharmacy practice
`Audrey St Jean Wittenburg
`Alcohol rivals myocardial
`infarction
`as cause of hospitalization
`in elderly people
`Jump in cigarette taxes would lower
`demand NCI panel concludes
`More than 1 million report
`using steroids
`Medicare project
`increases influenza
`vaccination rate predicts lower
`hospital costs
`Pharmacy school applications
`enrollments grew in 1992
`entrylevel degrees dropped
`slightly
`MedWatch update Pharmacists
`submit over half of product
`problem reports
`HMO spending for outpatient
`pharmaceuticals held steady
`in 1992
`Contract pharmacy services grew
`in 1992
`
`2484 ASHP Affiliates
`Vermont Society helps promote
`adverse drug reaction reporting
`Handson patient care explored
`at Nevada Society meeting
`Montana Society annual meeting
`features psychopharmacy
`management clinical skills
`Raehl Bond discuss pharmaceutical
`care at Idaho Society meeting
`New Mexico Society Balloon Fiesta
`meeting draws attendees from 18
`states
`
`AIH
`
`2497 ASHP Foundation Reports
`Atlanta Midyear activities kick off
`Foundations 25th anniversary
`Literature awards to be presented
`in Atlanta
`Foundation awards Demonstration
`Project Grants New Pharmacy
`Practice Researcher Grant
`Pharmacists complete dialysis
`traineeship
`Anticoagulation traineeship program
`expands in 1993
`Funding available
`for state conferences
`on pharmaceutical care
`
`2508 Questions and Answers
`Outpatient drug discounts for
`hospitals with a disproportionate
`share of indigent patients
`
`Resident Forum
`2511 Student
`ASHP summer internship
`
`2515 Frontline Pharmacist
`Treatment for ailing
`
`staffmanagement
`communication
`
`2318 Letters
`Precipitation of paclitaxel
`during infusion by pump
`Robert W Pfeifer Karen N Hale
`
`Suzanne Emerson Cronqulst
`Michelle Daniels
`Incompatibility of labetalol
`hydrochloride and furosemide
`John Zeisler Cheri Magna
`Sports pharmacy clerkship
`Sally 1 Sato Donna L Weingart
`Kenneth L Brier
`Topical polyhexamethylene
`biguanide pool cleaner
`for treatment of acanthamoeba
`keratitis Edmond Yee
`Richard Fiscella Tien Mat Winarko
`Advice on submitting papers
`Gregory Gousse
`Thomas G Burnakis
`Difficulties in assessing appropriate
`ondansetron use
`
`Lewis R Schwarz Gerald M Higa
`Mark D Peters II Jeffrey A Reitz
`Lois M lessen Kimberly S Long
`Perceived usefulness of supplement
`on rising pharmaceutical costs
`Michael I Melby
`Fred D Chatelahi John P Santell
`
`2452 Am Hosp Pharm Vol 50 Dec 1993
`
`

`

`journal of the American Society of Hospital Pharmacists
`Official
`A OrIdis
`EXeCtleVe Vice President
`Copyright C 1993
`American Society of Hospital Pharmacists Inc
`All rights reserved
`
`AJHP Is a federally registered trademark
`
`printed on acid free paper effective with Volume 49 January 1992
`
`Editorial
`2529 Compassionate dispensing
`
`Special Feature
`2533 Refraining pharmacys
`leadership relationship and
`scholarship
`
`Calvin H Knowlton
`
`Reports
`2538 Drug therapy during cardiac arrest
`in two hospitals
`Barry E Bleske Wendy K Wheatley
`Kevin A Townsend Marc L hazard°
`John E Billi and Michael J Shea
`
`2548 Methods used by pharmacy
`departments to identify
`drug interactions
`Sona Elarnian Mary Lea Gora and
`Laura Roeder Symes
`
`2550 Interaction of sucralfate
`with antibiotics used for selective
`decontamination of the
`
`tract
`
`gastrointestinal
`Barbara Feron Coin G Adair
`Sean P Gorman and Bony McClurg
`
`Notes
`2554 Procedure for evaluating
`nonformulary drug orders
`Gene T lay Robert A Quercia
`Gregory Gousse Moses S S Chow and
`Richard Quintiliani
`
`2561
`
`2584
`
`2566
`
`Stability of nitroglycerin
`as nitroglycerin concentrate
`for injection stored in plastic
`syringes
`Paul S Driver End larvi and
`Peggy L Gratzer
`
`ASHP Report
`Acknowledgment
`to
`reviewersNovember
`1 1992 to October
`31 1993
`AMP Continuing Education
`ASHP journal continuing
`education instructions and
`enrollment form
`
`2569
`
`Career Opportunities
`
`2584
`
`CP Digest
`
`2604
`
`Current Literature
`
`Journal References
`Book Reviews Bad Prescription for the
`First Amendment FDA Censorship
`of Drug Advertising and Promotion
`Kaplar William L Fong
`Geriatric Dosage Handbook
`1993
`Senna Belzer Higbee
`Nathan Rawls
`Manual
`for Pharmacy Technicians
`American Society of Hospital
`Pharmacists Dada Gallo
`Books Received
`
`2615 Advertising Index
`
`2556 Comparison of concurrent and
`retrospective methods of detecting
`adverse drug reactions
`Janet J Madsen
`
`At Large
`Context of a transition
`
`2616
`
`2617
`
`Annual
`
`Index
`
`2558
`
`2559
`
`Medication administration records
`for drugs given during surgery
`Patti R Hawkins
`
`Stability of cimetidlne
`hydrochloride and of clindamycin
`phosphate in water for injection
`stored in glass vials at two
`
`temperatures
`Milap C Nalurta Richard S Morosco and
`Thomas F Hippie
`
`after
`C Richard Talley
`Managing nor
`Catherine Nichols Klein
`
`Associate Edgar
`Morticiedift Eavelorment
`Guy R Hasegawa
`Jane L Miller
`Cheryl A Thompson
`Editorial Undoes Director
`Nancy Tarleton Landis
`
`Senior Assistant Editors
`Stephen R Kepple
`Audrey St Jean Wittenburg
`
`Production Monomer
`Wende K Mack
`
`Assistant Production Managor
`
`Margery M Wiltainuth
`Advertising Placement Mummer
`Nasrine L Sabi
`
`Technical Assistants
`
`Carol A Cavanaugh
`Yvonne M Yirka
`
`EdltoratLarge
`
`William A Zellmer
`
`Contributing Editors
`Michael A Amantea
`David B Brushwood Susan A Cantrell
`Robert DeChristoforo Janice FL Minor
`Charles E Myers Robert M Veatch
`Mary L Wallace
`
`Editorial Board
`Albert L Carver Wayne F Conrad
`Frederic R Curtiss Charles E Daniels
`Susan S Fish William A Gouvela
`R David Lauper Patricia Lee
`James B Lombard Gary H Magnus
`Michael J Melby William F McGhan
`Douglas F Miller 1avid W Newton
`Edward 0 Hold Louise R Rodriguez
`William F Smith Jorja J Sturek
`Lawrence A Trissel Lee A Wanke
`David A 7ilz
`
`Stetlatkial Consultant
`Charles A Rohde
`
`OMee
`7272 Wisconsin Avenue
`Bethesda MD 20814
`3016573000
`Fax 3016574258
`
`Advertising Representathar
`William McCausland Associates
`Inc
`PO Itox 189
`Pitman NJ 08071
`6095895454
`Fax 6095827611
`
`Vol SO Dec 1993 Am 1 Hasp Pharm 2453
`
`

`

`LETTERS
`
`Precipitation
`of paclitaxsi
`during infusion by pump
`Robert W Pfeifer
`7s Is
`Karen N Hale
`Suzanne Emerson Cronquist
`Michelle Daniels
`
`Incompatibility of
`labetalol hydrochloride
`and furosemide
`2S21
`
`John Zeisler
`Cheri Alagna
`
`Sports pharmacy
`clerkship
`2522
`
`Sally J Sato
`Donna L Weingart
`Kenneth L Brier
`
`Topical
`polyhexamethylene
`biguanide pool cleaner
`for treatment of
`acanthamoeba keratltis
`Edmond Yee
`Richard Fiscella
`Tien Kim Winarko
`
`Advice on submitting
`papers
`2523
`
`Gregory uousse
`Thomas G Burnakis
`
`Difficulties in assessing
`appropriate ondansetron
`use
`2523
`
`Lewis R Schwarz
`Gerald M Higa
`Mark D Peters II
`Jeffrey A Reitz
`Lois M lessen
`Kimberly S Long
`
`Perceived usefulness
`of supplement on rising
`costs
`pharmaceutical
`Michael I Melby
`2526
`Fred D Chatelain
`John P Sante
`
`The Letters column is a forum for rapid exchange of ideas among
`readers of AJHP Liberal criteria are applied in the review of submissions
`to encourage contributions to this column
`The Letters column includes the following types of contributions
`1 comments addenda and minor updates on previously published
`work 2 alerts on potential problems in practice 3 observations
`comments on trends in drug use 4 opinions on public health issues of
`interest to pharmacists in institutional settings 5 comments on ASH
`activities and 6 human interest items about life as a pharmacist
`
`or
`
`Short papers on practice innovations and other original work are
`in the Notes section rather than in Letters
`included
`
`2518 Am J Hosp Pharm Vol 50 Dec 1993
`
`Precipitation of paclitaxel
`during infusion by pump
`
`Taxol Bristol
`Paclitaxel
`Myers Squibb Oncolo
`gy is administered as a
`iv in
`24 hour continuous
`fusion The use of an infu
`sion control device has
`been recommended When
`diluted to a final concen
`tration of 03 to 12 mg
`mL paclitaxel has been re
`ported to be visually and
`chemically stable for up to
`27 hours at room tempera
`ture and under ambient
`
`light
`
`use of
`Investigational
`paclitaxel at our institution
`began in September 1991
`Doses of paclitaxel were
`
`prepared in 1000 mL of 5
`
`dextrose injection in glass
`bottles and infused through
`vented polyethylene lined
`solution administration
`sets 2C7552s Baxter
`Healthcare Corporation
`and 022µm filters Millex
`GV Millipore Volumetric
`infusion pumps FloGard
`models 6200 single cham
`ber and 6300 dual cham
`ber Baxter were used
`these pumps infuse fluid by
`linear peristalsisa series of
`rollers move against a small
`
`segment of polyvinyl chlo
`ride PVC tubing in a peri
`staltic motion that resem
`bles pushing the fluid
`along the tubing path
`In August 1992 we re
`ceived sporadic reports of
`fluffy white precipitate in
`paclitaxelexposed solution
`administration sets The
`
`precipitate appeared
`throughout the section of
`tubing distal to the pump
`chamber but not in the
`glass bottle or the tubing
`leading to the chamber
`The precipitation apparent
`ly began in the section of
`PVC tubing that came into
`direct contact with the
`peristaltic rollers of the
`pump When precipitation
`was observed the solution
`administration set and fil
`ter were changed and the
`balance of the infusion was
`administered Partial doses
`were not remade because
`precipitation was not found
`In the glass bottles In most
`cases precipitation was ob
`served near the end of the
`24 hour infusion period
`The concentration of these
`solutions ranged from 02
`
`Continued on page 2521
`
`affiliations
`
`Letters need not be submitted with AJHPs manuscript checklist The
`following conditions however must be adhered to 1 the body of the
`than two typewritten pages 2 the use of
`letter must be no longer
`references and tables should be minimized 3 the authors names
`and mailing addresses must be typed at the end of the letter
`in the format used by AMP and 4 the entire letter
`including
`tables and authors names must be typed doublespaced an
`references
`plain white paper not letterhead Following acceptance of a letter
`the
`authors are required to sign an exclusive publication statement and a
`to revision by the
`copyright transferal form All letters are subject
`editors Authors do not receive proofs of edited letters
`
`

`

`Continued from page 2518
`
`to 03 mgmL
`The use of paclitaxel vials
`and solution administra
`tion sets from other lots did
`
`not prevent precipitation
`We notified the National
`Cancer Institute NCI and
`sent samples of tubing with
`precipitate for analysis At
`that time NCI had received
`no similar report of precipi
`tation In November 1992
`following an amendment
`to NCI treatment referral
`center protocol 9103 we
`the volume of a
`decreased
`24 hour dose of paclitaxel
`to 500 mL we also began
`dividing the total daily
`dose into two 12 hour infu
`sions 250 mL each to de
`crease the length of time
`during which the drug
`could precipitate Over the
`next six weeks 18 incidents
`of precipitation in approx
`imately 150 doses occurred
`in solution administration
`
`sets used to infuse paclitax
`el 038058 mgmL
`Similar problems have
`been reported with tenipo
`side Vumon BristolMyers
`Squibb Oncologyz which
`also contains polyoxyethyl
`ated castor oil and alcohol
`According to the manufac
`turer supersaturated solu
`tions of teniposide rapidly
`precipitate after formation
`of seed crystals a process
`that may be accelerated by
`agitation Agitation suffi
`cient
`to induce precipita
`tion could be produced by
`a mechanical pumping ac
`tion We suggest
`that a sim
`ilar event occurs with our
`method of paclitaxel ad
`ministration
`Further studies have been
`performed Various types of
`agitation and manipulation
`appeared to induce precipi
`tation earlier than was seen
`in the static samples Also
`higher paclitaxel concen
`trations began to precipi
`
`tate sooner than lower
`concentrations However
`
`precipitation was not seen
`when another group re
`peated the procedure with
`the solutions and equip
`ment that we routinely use
`to infuse paclitaxel Trissel
`LA personal communica
`tion 1993 Feb 12
`We have not completely
`resolved our problem with
`precipitation despite inter
`ventions to minimize agita
`tion of paclitaxel solutions
`Another more costly op
`tion we are considering is
`to use cassette type
`positive displacement vol
`umetric pump systems
`eg Flo Gard model 8000
`
`Baxter for administering
`paclitaxel We would appre
`ciate receiving suggestions
`or hearing about others ex
`periences with paclitaxel
`Infusion solutions
`
`1 BristolMyers Squibb Compa
`ny Taxol package insert
`Princeton NJ 1992 Dec
`2 Strong DK Morris LA Precipi
`tation of teniposide during in
`fusion Am Hasp Phann
`1990 47512518 Letter
`3 Bogardus JB Kaplan MA Car
`penter JP Precipitation of ten
`iposide during infusion
`response Am Hosp Phann
`1990 475189 Letter
`Robert W Pfeifer MS
`Karen N Hale Clinical
`
`Clinical Specialist
`
`Specialist
`
`Investigational Drug Service
`Department of Pharmacy
`The Ohio State University
`Hospitals
`The Arthur G James Cancer
`Hospital and Research
`Institute
`410 West Tenth Avenue
`Columbus OH 432101228
`
`we received a
`Before
`copy of the above let
`ter BristolMyers Squibb
`was not aware of clinical or
`laboratory conditions in
`which paclitaxel precipitat
`ed during infusion by peri
`staltic pump or with a
`specific type of infusion
`device
`The paclitaxel package
`insert cautions against the
`use of plasticized polyvinyl
`
`chloride PVC equipment
`or devices The infusion set
`described by Mr Pfeifer and
`Ms Hale contains a small
`amount of PVC tubing in a
`segment where the PVC
`tubing comes in direct con
`tact with the peristaltic
`rollers of the pump howev
`er a laboratory simulation
`at another institution did
`not produce paclitaxel pre
`cipitation
`Since paclitaxel became
`
`commercially available in
`December 1992 the com
`pany has received fewer
`than a dozen reports of pre
`cipitation Information on
`the drug concentration in
`fusion set and infusion
`pump used when the drug
`precipitated has not always
`been provided In most cas
`es when this information
`was provided precipitation
`occurred in a PVCcontain
`ing segment of tubing
`For the mechanism of
`
`Letters
`
`the reported precipitation
`to be identified precipita
`tion would have to be re
`producible under
`controlled conditions Per
`haps the sample size used
`by Mr Trissel during simu
`lation was too small to rep
`the small number of
`resent
`
`occurrences in clinical
`
`practice
`Finally we would like to
`emphasize the selection of
`infusion sets appropriate
`for the infusion pump cho
`sen and the avoidance of
`PVC equipment as directed
`in the paclitaxel package
`insert
`
`Suzanne Emerson
`Cronquist Manager
`
`Michelle Daniels MD
`
`Medical Director
`
`Drug Information
`Medical Affairs
`
`BristolMyers Oncology
`Division
`PO Box 450
`Princeton NJ 085434500
`
`Incompatibility of labetalol
`hydrochloride and furosemide
`We report
`
`the apparent
`incompatibility of la
`betalol hydrochloride and
`furosemide injections
`A 60 year old woman
`was receiving labetalol hy
`drochloride Normodyne
`Schering Laboratories Ken
`ilworth NJ lot 2 DDF 102
`16 mgmL in 5 dextrose
`
`iv
`
`injection by continuous
`infusion at 30 mghr for
`treatment of systolic hyper
`tension Furosemide 40 mg
`10 mgmL Elkins Sinn
`Cherry Hill NJ lot 033021
`was to be given by iv
`push Less than 05 mL of
`furosemide had been inject
`ed into the port of the labe
`talol iv line when white
`precipitation was noted No
`further furosemide was in
`jected and the iv line was
`flushed with 09 sodium
`chloride injection
`
`The patient suffered no
`detectable adverse drug re
`action from this event The
`incompatibility was con
`firmed in the pharmacy de
`partments laminar airflow
`hood by using injectable
`solutions from the same
`lots and in the same con
`centrations as the patient
`received
`
`Schering Laboratories
`could provide no previous
`reports of this incompati
`bility Newandee K Drug
`Information Manager per
`sonal communication
`1993 Jul 16 This incom
`patibility is not described
`in Trissels Handbook
`on In
`jectable Drugs We suspect
`the incompatibility is due
`to the difference in solu
`tion pH between labetalol
`hydrochloride pH 34 and
`furosemide pH 893
`
`Vol 50 Dec 1993 Am J Hosp Pharm 2521
`
`