Therapeutic substitutions // IV to PO substitution

The interview process of which to obtain an accurate and up to date patient medication list

Definition of med history

• The comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy

• In effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns.

• Should include a comparison of the existing and previous med regimens and should occur at every transition of care

• Completed by physicians and APPs NOT PHARMACISTS

What is a med reconciliation ?

• Patients do not bring accurate medication lists/bottles to hospital 

  • List is not up to date, does not include OTCs, herbals, etc. 

• Patients acute state

  • Altered mental status, intubated, intoxicated

• Language/cultural barriers

• Poor communication

• Poor care coordination and continuation 

  • Medication admin records from outside facilities 

• Lack of one clinician responsible for transitions

• Time and priority

What are challenges of medication reconciliation?

1. Inappropriate dose adjustment when switching

2. Adverse drug effect 

3. Duplication of therapy on discharge

4. Drug interactions

1. Describe how medication reconciliation, formulary, and therapeutic interchange may lead to medication errors in an inpatient setting.

• PPI

• Statins

• H2 blockers

• Inhaled corticosteroids

• Topical products

• Insulin

What drugs are commonly included in therapeutic interchange tables?

• Chemotherapy

• HIV meds

• Immunosuppressive agents

• Anti-epileptics

What drugs are commonly excluded in therapeutic interchange tables?

• Intact and functioning GI tract of patient

• Patients clinical status

• Indication for medications

• Monitoring parameters for IV meds

How do we determine switching an IV to PO med?

• Easier to administer

• Decrease risk of infusion-related events

• Saves money

Why would we convert an IV med to PO?

• fluconazole

• levetiracetam

• levofloxacin

• linezolid

• esomeprazole

• moxifloxacin

• metronidazole

• methylprednisolone

“Fluids levitate leverage’s line esophagus more metronically methylated”

What medications are the bioavailability the same between IV and PO, therefore IV dose = PO Dose?

• Metoprolol

• Acyclovir

• Diltiazem

• Narcotics

• Levothyroxine

• Ciprofloxacin

What medications are the bioavailability NOT the same between IV and PO, therefore IV dose is NOT PO Dose?