Two random questions

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JerryPharmD

JerryPharmD

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1) Are Procrit/Epogen substitutable for each other? Cannot find anything definative.

2) Case question. Pt is 16 days post abdominal gunshot wound. Has had 3 GI surgeries, was on prednisone and TPN. Imipenem and vanco are empiric abx therapy. Pt presents with preliminary blood culture + for yeast. I start caspofungin for Candida. Do I need to worry about voriconazole for cryptococcus coverage?

6.02 x 10^23 thanks 😀
 
JerryPharmD said:
1) Are Procrit/Epogen substitutable for each other? Cannot find anything definative.

2) Case question. Pt is 16 days post abdominal gunshot wound. Has had 3 GI surgeries, was on prednisone and TPN. Imipenem and vanco are empiric abx therapy. Pt presents with preliminary blood culture + for yeast. I start caspofungin for Candida. Do I need to worry about voriconazole for cryptococcus coverage?

6.02 x 10^23 thanks 😀
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I better not be doing your homework.

Procrit and Epogen are the same compound..both manufactured by Amgen. Ortho Biotech company somehow got the marketing rights to Epogen-Procrit from Amgen...and is calling it the Procrit. They can only market it for nephrology indications.....but can't control what the end user does with it once purchased. Amgen sells the Epogen.

Erythropoetin Stimulating Agent - ESA has received a lot of press lately and is on a significant decline in use. Procrit is preferred because OB gives a much better contract pricing compared to Epogen. But Amgen is more interested in marketing Aranesp - Darbepoetin and Neulasta and has a very screwy rebate program with marketshare. Your typical academician and hospital clinical pharmacists are clueless in how to play the ESA game for maximum cost savings.

So is that the crap they're teaching you at school? Use Imipenem for gunshot wound? You tell me why Imipenem is necessary over other anaerobic covering ABX... Vanco I can understand. And why are you using Cancidas for candida? You can't think of other drug that covers Candida and Cryptococcus instead of Cancidas and Vori? Who came up with this little clinical case study?
 
JerryPharmD said:
2) Case question. Pt is 16 days post abdominal gunshot wound. Has had 3 GI surgeries, was on prednisone and TPN. Imipenem and vanco are empiric abx therapy. Pt presents with preliminary blood culture + for yeast. I start caspofungin for Candida. Do I need to worry about voriconazole for cryptococcus coverage?
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2) Why would you need voriconazole for cryptococcus (ie, why would not fluconazole be the drug of choice)? Why was an echinocandin started empirically, what risk factors does the patient have for non-albicans Candida (as well as considering the source of fungemia, likely gastrointestinal)? I think high dose fluconazole would have been my recommendation.
 
Priapism321 said:
2) Why would you need voriconazole for cryptococcus (ie, why would not fluconazole be the drug of choice)? Why was an echinocandin started empirically, what risk factors does the patient have for non-albicans Candida (as well as considering the source of fungemia, likely gastrointestinal)? I think high dose fluconazole would have been my recommendation.
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You just gave him the answer to a very very simple question a P2 can look up!!!!!!!!
 
But what the heck are they teaching in RX schools??? Cancidas and Vori empiric therapy for Candida??? Indiscriminate use of Primaxin???
 
ItsOverZyvox said:
But what the heck are they teaching in RX schools??? Cancidas and Vori empiric therapy for Candida??? Indiscriminate use of Primaxin???
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The vori was going to be for potential cryptococcus blood stream infection, get it straight.
 
Priapism321 said:
The vori was going to be for potential cryptococcus blood stream infection, get it straight.
Click to expand...


I didn't feel like typing that out....but look at my previous post. I addressed that! I'll take my ID pharmacist to beat you up.
 
New Candida guidelines Spring 2009 (will probably be more like Winter 2010 judging how fast the IDSA works). Still waiting on these damn Vancomycin Therapeutic Monitoring guidelines to be published (now slated for late Fall 2008).
 
Man..you don't really need Vanc guideline do you?
 
ItsOverZyvox said:
I didn't feel like typing that out....but look at my previous post. I addressed that! I'll take my ID pharmacist to beat you up.
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Damn it, if I remember correctly, it is a female no?
 
ItsOverZyvox said:
Man..you don't really need Vanc guideline do you?
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Not really, but I think it will be interesting to see what they have to say since it is a joint guideline with ASHP and SIDP.
 
Priapism321 said:
Damn it, if I remember correctly, it is a female no?
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yeah!!! Inservicing her this week... she knows more than I..by a lot...
Heck..I had forgotten Colistin has detergent properties... I relearn everyday!
 
ItsOverZyvox said:
yeah!!! Inservicing her this week... she knows more than I..by a lot...
Heck..I had forgotten Colistin has detergent properties... I relearn everyday!
Click to expand...

But is she hot?
 
There's a new vanco guideline coming out? Hey maybe they'll finally tell me what population Vd I should use to make my initial random guess of an adjustment rather than throwing a dart at a dartboard featuring the numbers 0.5-0.9 scattered about...then the results will be just as unpredictable, but the facade of doing **** right from the get go will be there...and that's all that really matters.
 
WVUPharm2007 said:
There's a new vanco guideline coming out? Hey maybe they'll finally tell me what population Vd I should use to make my initial random guess rather than throwing a dart at a dartboard featuring the numbers 0.5-0.9 scattered about...then the results will be just as unpredictable, but the facade of doing **** right from the get go will be there...and that's all that really matters.
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0.7L/kg grasshopper.
 
WVUPharm2007 said:
Says you. Others say otherwise. At my facility we use 0.9. And amazingly, we don't get as many overdoses as I would have expected. Maybe the people in W PA. have mutant kidneys.
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your facility is wrong.
 
ItsOverZyvox said:
your facility is wrong.
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That's what I said. Oh well. I'm trying not to ruffle too many feathers my first few months there. We still are capping Lovenox at 150mg, too...despite the fact that I provided a copy of what the latest ASHP position paper said...which was do anti-Xa labs in those > 190kg...and if that's not available, give it to 'em anyway until they bruise...I kinda got the brush off. I didn't push it any further. It's really inconsequential...until someone gets HIT and sues us for not using a LMWH...

It's a weird place...I think the hospitalists there respect me more than the other pharmacists there do. Perhaps because I'm the first new grad they've had there in 10+ years and they associate new grad with "no idea what he's doing" because back in their day they really didn't.
 
ItsOverZyvox said:
your facility is wrong.
Click to expand...

I say you are both wrong we use 0.8 at my retail pharmacy....Smooths the peaks and troughs out nicely.....According the the CCCP, ASCP, DTPA revised guidelines and the geneva convention that is the correct dosing if you are south of the primary prime meridian....

Get with the program.....

I mock what I do not understand....GO RETAIL!!!! $1 generics!!!!!!
 
Speaking of which, how do you fancy big city folks find out when new guidelines drop? Is there a service or something that will send me an email that says "Hey, dummy, JNC8 came out. Go read that before you look stupid." I don't have the connections or something, hell.
 
MountainPharmD said:
I say you are both wrong we use 0.8 at my retail pharmacy....Smooths the peaks and troughs out nicely.....According the the CCCP, ASCP, DTPA revised guidelines and the geneva convention that is the correct dosing if you are south of the primary prime meridian....

Get with the program.....

I mock what I do not understand....GO RETAIL!!!! $1 generics!!!!!!
Click to expand...

Hey, you do something I don't know how to do. Bill insurance. I'd be dangerous as hell in a retail pharmacy. Man would die of a heart attack by the time it took me to get him his damn Toprol...
 
WVUPharm2007 said:
Hey, you do something I don't know how to do. Bill insurance. I'd be dangerous as hell in a retail pharmacy. Man would die of a heart attack by the time it took me to get him his damn Toprol...
Click to expand...

I have techs that bill insurance.....I can count on one hand the number of times I have called an insurance company.....
 
WVUPharm2007 said:
Speaking of which, how the hell do you *******s find out when new guidelines drop? Is there a service or something that will send me an email that says "Hey, dummy, JNC8 came out. Go read that ****s." I don't have the connections or something, hell.
Click to expand...

Well, the nature of what I do and with the network of collegues I work with, this information spreads quickly for us. Maybe you should join ACCP or ASHP or your state's WVSHP Listserve. I do get chit all the time from ASHP and TSHP also. But if you're interested, you can get all IDSA Guideline for free...just goodle it.
 
ItsOverZyvox said:
Well, the nature of what I do and with the network of collegues I work with, this information spreads quickly for us. Maybe you should join ACCP or ASHP or your state's WVSHP Listserve. I do get chit all the time from ASHP and TSHP also. But if you're interested, you can get all IDSA Guideline for free...just goodle it.
Click to expand...

I can get my hands on anything through WVU. They let alums access their online journals. It's the whole "hey twitstick, this just came out, go read it" part I need help with. If ASHP had this, I'd join...
 
WVUPharm2007 said:
I can get my hands on anything through WVU. They let alums access their online journals. It's the whole "hey twitstick, this just came out, go read it" part I need help with. If ASHP had this, I'd join...
Click to expand...

ASHP do have it yo... they send out new publication notices. I'm sure there are better ways... Pri can probably help.
 
ItsOverZyvox said:
ASHP do have it yo... they send out new publication notices. I'm sure there are better ways... Pri can probably help.
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It'll have to wait until tomorrow, he's probably asleep. As a resident, he probably has to be there at 5:30AM or something. If I had residents I'd make them get there at 5:30AM. Just imagine the busy work that would be completed before you even walked in the door.
 
WVUPharm2007 said:
It'll have to wait until tomorrow, he's probably asleep. As a resident, he probably has to be there at 5:30AM or something. If I had residents I'd make them get there at 5:30AM. Just imagine the busy work that would be completed before you even walked in the door.
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Here is a free service. It will fill up your email box...

http://www.medscape.com/home
 
WVUPharm2007 said:
Cool. Added to my daily rotation of websites to look at.
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dude...free subscription...they'll send you new info several times a day. All day long... as it happens. All medical related stuff..you can choose pharmacy only...
 
MountainPharmD said:
I say you are both wrong we use 0.8 at my retail pharmacy....Smooths the peaks and troughs out nicely.....According the the CCCP, ASCP, DTPA revised guidelines and the geneva convention that is the correct dosing if you are south of the primary prime meridian....

Get with the program.....

I mock what I do not understand....GO RETAIL!!!! $1 generics!!!!!!
Click to expand...
They're just guidelines... 😴
 
PharmDstudent said:
They're just guidelines... 😴
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That's how I used to look at it until I started getting paid to keep up with it. That changes the whole paradigm. Something about school...and paying people to tell you what to do. I'm so glad I'm out of pharmacy school. I can learn **** on my own terms and the rate and willingness at which I learn has increased exponentially.
 
The only way that we can learn about unfamiliar topics, eg infrequent situations and diseases that only come up every blue moon, is if an "experienced" professor tells us about it. I think it's a weak form of teaching, and it's only interesting for that moment in time and until they move on to another topic. Studying the info is an absolute drag!!!

I am very dissatisfied with Therapeutics, which should make it easy for everyone to understand why I think "clinical" pharmacy and residencies are
so unappealing.
Here we are sitting in class learning about diseases and how to manage them... After a while, all of the diseases just run together and the only challenge that's left is differentiating between what's what. 🙄

I wish I could explain my prospective a little better, but I have to get fitted for a dental crown. That should be fun! 😛
 
So Zpack.....

1) If random patient comes with an rx for Epogen and all I have is Procrit in the same strength, can I fill it with the Procrit without calling the doc and without someone coming to take me away in handcuffs? (thanks for the refresher on EPO, but most of that is old hat🙂)

2) The case was kinda crappy that they gave us, He had a 30 point systolic drop to 100 over something and has been in the hospital for 16 days. Would you really use fluconazole with the worry of non-albicans species? Disregard the antibacterials that he's on; the were started initially by someone else. I'm gonna wait till he de-escalates till changing those (He meets the criteria for SIRS)

Priapism

My reasoning for starting caspo is that his infection is likely nosocomial related, and what I was provided with is that approx 50% of these are non-albicans and therefore fluconazole resistant. That and the high mortality rate (prelim blood culture for yeast) associated with the condition warranted something greater than flu. Let me know how I'm wrong as I'm sure I am. 😕

My homework is already done. I'm attempting to prevent a new fistula formation by making sure all my bases are covered.

Keep in mind I'm just playing on paper and am still sheltered by the ivory walls of academia.:hardy:
 
Last edited:
JerryPharmD said:
So Zpack.....


2) The case was kinda crappy that they gave us, He had a 30 point systolic drop to 100 over something and has been in the hospital for 16 days. Would you really use fluconazole with the worry of non-albicans species? Disregard the antibacterials that he's on; the were started initially by someone else. I'm gonna wait till he de-escalates till changing those (He meets the criteria for SIRS)

:
Click to expand...

High-dose fluconazole covers cryptococcus - but why were you worried about that? Does he have any specific risk factors?

Re: Guidelines. Guidelines are the bestest. Someone else does all the work for you and outlines how you can treat the vast majority of the cases you encounter. One thing I love about ID is that it offers you the freedom to be a little creative at times. Lots of opportunity for critical thinking if you want to. 😍

Say you were the order-entry pharmacist and received the initial Primaxin order. At least at my hospital, Primaxin is restricted to ID. When you called the doc to say "no Primaxin for you!" what would you initially recommend?
 
njac said:
High-dose fluconazole covers cryptococcus - but why were you worried about that? Does he have any specific risk factors?

Re: Guidelines. Guidelines are the bestest. Someone else does all the work for you and outlines how you can treat the vast majority of the cases you encounter. One thing I love about ID is that it offers you the freedom to be a little creative at times. Lots of opportunity for critical thinking if you want to. 😍

Say you were the order-entry pharmacist and received the initial Primaxin order. At least at my hospital, Primaxin is restricted to ID. When you called the doc to say "no Primaxin for you!" what would you initially recommend?
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Cefoxitin or cefotetan should be sufficient
 
true.

But what do we actually use in the real world?

(kidding. sort of.)
 
JerryPharmD said:
pip/tazo or cefotaxime?
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How is Cefotaxime's anaerobe coverage?

Zosyn is an option but cheaper is either Cipro/Flagyl or Ceftriaxone/Flagyl. Those are the two I see the most empirically.

My understanding is that Cefotetan and Cefoxitin have unreliable availability but are also have shorter half lives and require more frequent dosing.
 
JerryPharmD said:
0 bacteroides, 0 clostridium...it's for peritoneal infections without perforation...oops
Click to expand...

exactly. So cefotaxime + flagyl is an option as well, and while the flagyl is q6h it's nice that ceftriaxone is q24h. The less frequent the dosing (hopefully) the fewer doses to be missed...
 
njac said:
exactly. So cefotaxime + flagyl is an option as well, and while the flagyl is q6h it's nice that ceftriaxone is q24h. The less frequent the dosing (hopefully) the fewer doses to be missed...
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Gosh, reading this reminds me of how poorly I'm going to do on my ID exam tomorrow. I'm still struggling with categorizing all of the cephalosporins in my head as far as coverage and generation!
 
I didn't have a lot of trouble with that, but like I said, I work in a hospital and I love ID.

But I just thought of one - 2nd generation = almost purely gram negative. They cover for stuff when you go number 2 or something along that line. And the longer the name the higher up the generation...
 
ItsOverZyvox said:
Man..you don't really need Vanc guideline do you?
Click to expand...

WVU may not need them but the rest of the world does. I hope they try to explain the nephrotoxicity issue further. And that increasing interval increases trough. And that we really do not give a flying kite about the peak.

One hospital I did a rotation at started everyone (practically. your kidneys had to be the suck to go Q24H) on 1 gm IV Q12H. And we had a morbidly obese patient from an outside hospital come in receiving 1750 mg Q12H. 😕

Or last night, a 31 y/o incarcerated man with lovely kidney function (CrCl >120 mL/min using both IBW and ABW in CG), already failed Bactrim/Clinda, Vanco 1 gm IV Q12H.
 
JerryPharmD said:
So Zpack.....

1) If random patient comes with an rx for Epogen and all I have is Procrit in the same strength, can I fill it with the Procrit without calling the doc and without someone coming to take me away in handcuffs? (thanks for the refresher on EPO, but most of that is old hat🙂)

2) The case was kinda crappy that they gave us, He had a 30 point systolic drop to 100 over something and has been in the hospital for 16 days. Would you really use fluconazole with the worry of non-albicans species? Disregard the antibacterials that he's on; the were started initially by someone else. I'm gonna wait till he de-escalates till changing those (He meets the criteria for SIRS)

Priapism

My reasoning for starting caspo is that his infection is likely nosocomial related, and what I was provided with is that approx 50% of these are non-albicans and therefore fluconazole resistant. That and the high mortality rate (prelim blood culture for yeast) associated with the condition warranted something greater than flu. Let me know how I'm wrong as I'm sure I am. 😕

My homework is already done. I'm attempting to prevent a new fistula formation by making sure all my bases are covered.

Keep in mind I'm just playing on paper and am still sheltered by the ivory walls of academia.:hardy:
Click to expand...

You need to find Package Insert for Procrit and Epogen online and make the comparison.

That being said.... you're saying that this instituion has a history of 50% non-albicans? If so, do you have PNA-FISH technology to identify which non albican it is? It only takes 2 hours. Also, which non albican is it...glabrata or krusei? That's important because one can be susceptible to high dose fluconazole but the other isn't.
 
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