COMPLETED - Vaccines, Compounding, Med Safety, TB, Contraceptives

Ovulation test detect…

Pregnancy test detect…

Ovulation test detect rise in LH (will also notice increase in temp)

Pregnancy test detect rise of beta-HCG

MOA of COC

• Estrogen →

• Progestin →

• Both →

Indications of COC

• (3)

NOT for…

MOA of COC

• Estrogen → Inhibition of LH surge and FSH secretion (ovulation)

• Progestin → Alteration in cervical mucus (sperm can’t get to egg)

• Both → Cycle control

Indications of COC

• Menstrual cycle irregularity

• Acne, hirsutism

• Prevention of menstrual migraine

NOT for STI prevention

DDI for COC

• (3)

Day 1 start vs Sunday start (how to, benefits)

DDI

• Griseofulvin → CYP3A4 inducer

• CYP3A4 substrate → avoid CYP3A4 inducers and inhibitors

• COC decrease conc of lamotrigine by 45-60%

Day 1 start vs Sunday start

• Begin on the first day of your period → eliminated need for contraception

• Begin first Sunday after period begins → prevent period on weekends

Contraindications of combined oral contraceptives

…cancer

Hx of…

Severe…disease

…with…

Uncontrolled…

Age…who…

Breast and endometrial cancer

Hx of stroke and VTE

Severe hepatic disease

Migraine with aura

Uncontrolled HTN (>160/100)

**Age over 35 yo who smoke heavily (15 cig)**

Emergency Contraception for unprotected sex

OTC → (1) → use within…

Rx → (2) → use within…

Weight → If BMI…or weight… → use …

-

Ella

OTC → Levonorgestrel 1.5 mg tab (Plan B, My Way) → use within 3 days (no age restriction)

Rx →

• Ulipristal 30 mg tab (Ella) → selective progesterone receptor modulator

• Copper IUD → avoid in Wilson’s disease and pelvic inflammatory disease

• Both use within 5 days

Weight → BMI >25 or weight >75 kg → use Copper IUD (levonorgestrel and Ulipristal less effective)

Norethindrone

Class

Give when…

• (2)

Initate on…, what kind of pills

Considered missed dose if…

Missed dose instructions →

Class → “Mini-pill” (progestin only pills)

Give in patients who don’t want to use estrogen…

• Worried about clots (estrogen)

• Patient is early postpartum and breastfeeding → estrogen reduction in milk production

-

Initiate on the 1st day of menses. No placebo

Considered missed dose if >3 hrs late

Missed dose instructions → take 1 pill now, continue 1 pill at usual time tmr, backup for 48 hrs, emergency contraception with recent unprotected sex (within 5 days)

Generic

Depo-Provera → dosing, formulation

Depo-Provera 104 → dosing, formulation

Both frequency

ADE →

Medroxyprogesterone (progestin only)

Depo-Provera → 150 mg IM

Depo-Provera 104 → 104 mg SubQ

Both given by PCP every 3 months

ADE → weight gain

Remember Prempro (Medroxyprogesterone + Estrogen)

Missed doses

1 dose →

2 doses →

2 doses in week 3 or 3 doses anytime →

1 dose → take 2 doses ASAP. No backup needed

2 doses → Take 2 doses ASAP. Backup for 7 days

2 doses in week 3 or 3 doses anytime → Finish active tab then start new pack. Backup for 7 days.

Chewable COC (2)

Minastrin Fe, Femcon Fe

Fe = has iron → drink w water to avoid constipation

NuvaRing

Generic

Used for…

Discard →

Etonorgestrel + EE

Used for 3 weeks

Stored in the fridge, can be out of the fridge for 4 months

Discard → throw in trash, dont flush (limit environmental release)

Yaz / Yasmin (→ generic)

Yaz →

Drospirenone + EE

Has Drospirenone → good for acne

Yaz → shorter periods with fewer placebo days

Slynd

Generic

Only …pill that...

• (2)

Good for…

ADE →

Equivalent to…

Drospirenone

Only progestin only pill that...

• Has placebo

• Does not need backup if missed 1 pill

Good for acne

ADE → hyperkalemia (anti-mineralocorticoid activity)

3 mg Drospirenone = 25 mg spironolactone

Remember Yaz / Yasmin -> Drospirenone + EE

Lybrel

Generic

Unique

ADE

Levonorgestrel + EE

No placebo days

ADE→ Early breakthrough bleeding that decreases with time

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Natazia

Generic

…phase

Need…

Dienogest + estradiol valerate (not the usual ethinyl estradiol)

4-phase OC

Need backup for 9 days when starting (not the usual 7)

Remember Ortho Tri-Cyclen → norgestimate + EE

Seasonique, Quartette

Generic

…cycle

Unique tabs

Levonorgestrel + ethinyl estradiol

Extended cycle preparation (91 days)

Unique tabs → 84 active, 7 days low EE (not placebo)

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Xulane

Formulation changed…for…with.,..

Associated with… → increased risk of…

If patch fails off for…

• (2)

Transdermal patch changed once weekly for 3 weeks with 1 patch free week

Associated with increased estrogen exposure than COC → may increase risk of VTE

If patch fails off for…

• <24 hrs → just put back on

• >24 hrs → new patch + backup 7 days

Contraceptive diaphragm

What is it, how does it work

Always use with…

Avoid with…

Reusable female contraceptive device blocks sperm entry to cervix

Always use with spermicide (nonoxynol 9)

Avoid with oil based lubricants (deterioration)

Duavee

Generic

Indication

ADE

Bazedoxifene (SERM) + Estrogen

Hormone replacement therapy for intact uterus but with SERM instead of progestin

• SERM still protects against estrogen-induce endometrial effects (alt to progestin)

• Estrogen still helps with…

  • Vasomotor symptoms in menopause

  • Prevention of postmenopausal osteoporosis

ADE -> clots (SERM)

Osphena

Generic, class

Indication

ADE → (2)

Ospemifene (SERM)

Non-estrogen option for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

ADE→ hot flashes, clots (like all SERMs)

Remember Vagifem = estrogen vag tab for same indication

Remember Clomiphene (Clomid) = SERM for infertility

Vagifem

Formulation for what indication

Do NOT….NOT

Estradiol vaginal tab indicated for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

Do NOT take during pregnancy. NOT birth control

Does not have systemic absorption → wont cause clots

Remember Osphemifene (Osphena) = SERM for same indication

Prometrium

Class

Avoid in…

Progesterone

Avoid in peanut allergy

Presentation

Yeast infection →

Bacterial Vaginosis →

Yeast infection → itching, no smell, check for DM

Bacterial Vaginosis → fishy odor, used metronidazole or secnidazole

Gyne-Lotrimin → generic

Monistat → generic

Vagistat → generic

Indication

Insert…

Gyne-Lotrimin → Clotrimazole

Monistat → Miconazole

Vagistat → Tioconazole

All OTC for yeast infection

Insert at night

Clomid

Generic, class

Indicated for…by…

Clomiphene (SERM)

Indicated for infertility by inducing ovulation (may cause clots)

Remember Osphemifene (Osphena) = SERM for menopausal atrophic vaginitis

Annovera Vaginal Ring

Generic

vs Nuvaring

Segestrol (progestin) + EE

Similar to Nuvaring (Etonorgestrel + EE) but use the same ring for the whole year

Prempro → generic

Premarin → generic

Indication, when to use what

Hormone replacement therapy

Prempro (Medroxyprogesterone + Estrogen)

Premarin (Estrogen only)

After hysterectomy → switch to Premarin and eliminate progestin’s protection of the uterus to prevent estrogen-induced endometrial cancer → keep estrogen just for postmenopausal vasomotor symptoms treatment and osteoporosis prevention

Remember Depo-Provera → Medroxyprogesterone

ClimaraPro → contains…

Menostar, Climara, Fempatch → contains…

Formulation, frequency

Hormone replacement therapy

ClimaraPro → contains progestin + estrogen

Menostar, Climara, Fempatch → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied ONCE WEEKLY (vs Combipatch, Vivelle, Minivelle TWICE WEEKLY)

Combipatch → contains…

Vivelle, Vivelle Dot, Minivelle → contains…

Formulation, frequency

Hormone replacement therapy

Combipatch → contains progestin + estrogen

Vivelle, Vivelle Dot, Minivelle → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied TWICE WEEKLY (vs ClimaraPro, Climara, Menostar, Fempatch ONCE WEEKLY)

Ortho Tri-Cyclen → generic

Triphasil 28 → generic

Both …

Ortho Tri-Cyclen → norgestimate + EE

Triphasil 28 → levonorgestrel + EE

Both triphasic COC

Note that any COC containing “…7/7/7” or “Tri” are all triphasic

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Danazol

Class, indication

Preg

Synthetic androgen for endometrosis

Pregnancy Category X

Lysteda

Generic

Class → MOA (avoid in..)

Tranexamic acid

Antifibrinolytic med → prevents break down of clots (avoid in any hx of thrombosis)

Latent TB Tx

Not contagious, but positive reaction to skin test

Rifamycin preferred

• 4 months of Rifampin QD

• 3 months of Isoniazid + Rifampin QD

• 3 months of Isoniazid + Rifapentine Q weekly

Alt → 9 months of Isoniazid + Vitamin B6

Positive PPD test (aka…)

Read within…after …

At least 5 mm →

At least 10 mm →

• (4)

At least 15 mm →

Cause of a false positive test →

Positive PPD test (aka TB skin test)

Read within 48-72 hrs after intradermal injection of tuberculin material

At least 5 mm → HIV immunocompromise, close connect to patient with active TB

At least 10 mm →

• immunocompromised (all else)

• Children <4 yo

• Inmates

• Nursing home, homeless shelter, hospital worker/resident

At least 15 mm → no risk factors

Cause of a false positive test → Bacillus Calmetter-Guerin (BCG) vaccination

Isoniazid

ADE (2)

DDI → CYP → (2)

Regards to food

…mg/kg up to…mg

ADE

• Hepatoxicity (Rifampin, Isoniazid, Pyrazinamide, Bedaquiline all go through the liver)

• Peripheral neuropathy → add pyridoxine (Vit B6)

DDI → CYP inhibitor (vs Rifampin) → increases theophylline and warfarin levels

Empty stomach (just like Rifampin)

5 mg/kg up to 300 mg (vs Rifampin 10 mg/kg up to 600 mg)

Rifampin

ADE

• (3)

• ADE → never pair with…

DDI → CYP →

Regards to food

…mg/kg up to…mg

ADE

• RED-ampin → RED/orange/brown fluid discoloration

• Flu like symptoms

• Thrombocytopenia

• Hepatotoxicity → never pair with PI and NNRTIs

  • (Rifampin, Isoniazid, Pyrazinamide, Bedaquiline all go through the liver)

DDI → CYP inducer → decrease effectiveness of oral contraceptives and warfarin

Empty stomach (just like Isoniazid)

10 mg/kg up to 600 mg (vs Isoniazid 5 mg/kg up to 300 mg)

Rifamate → generic

Rifatere → generic

Frequency, Regards to food

Rifamate → Isoniazid + Rifampin (RI)

Rifatere → Isoniazid + Rifampin + Pyrazinamide (RIP)

QD, Empty stomach (bc of Rifampin)

Rifapentine

Frequency, regards to food

Weekly, with food (vs Rifampin QD, empty stomach)

Same ADE as Rifampin

Pyrazinamide

ADE

TB

ADE → hyperuricemia, hepatotoxicity

RIP (Rifampin, Isoniazid, Pyrazinamide) + Bedaquiline all go through the liver)

Ethambutol

ADE

…exam

Goes through the…

ADE → hyperuricemia (just like pyrazinamide)

EYE-thambutol → need eye exam for visual acuity and red-green color discrimination

Goes through the kidneys (Rifampin, Isoniazid, Pyrazinamide, Bedaquiline all go through the liver)

Streptomycin

Think…→

Think aminoglycoside →

• nephrotoxicity, ototoxicity, neuromuscular blockade

• avoid in pregnancy

Sirturo

Used for…

Administered by…

ADE →

Bedaquiline

Used for drug resistant-TB

Administered by directly observed therapy (DOT)

ADE → QTc prolongation, hepatotoxicity (Rifampin, Isoniazid, Pyrazinamide, Bedaquiline all go through the liver)

Pretomanid

Part of regimen for …

Part of regimen for drug resistant TB → Bedaquiline, Linezolid, Pretomanid

Preferred Regimen to treat active TB

1st 8 weeks → RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol)

Next 18 weeks → RI (Rifampin, Isoniazid)

Immunization recommendations created by…

Where to find info on vaccines →

…Book to find information on common vaccines

…Book for international travels

Immunization recommendations created by ACIP

Where to find info on vaccines → CDC website

Pink Book to find information on common vaccines

Yellow Book for international travels

Live vaccines

Names

Formulations

…in,…gauge

Injection: degree, placement

Wait time btwn doses if not given on the same day

CI in… (3)

Avoid until

• …months after…(2)

MMR, Varicella, Yellow Fever, FluMist (nasal spray). Vivotif Berna (Rabies)

SQ (MMR, Varicella, YF)

5/8th inch, 23-25 gauge

Inject at 45 degrees in fatty tissue over triceps

28 days

CI in…

• Pregnant

• Immunocompromised (AIDS, severe thrombocytopenia)

  • HIV vs AIDS → CI only if CD4 <200, all except FluMist which is CI regardless of CD4 count

• Neomycin / Gelatin allergy

Avoid until

• 3 months after chemo

• 1 month after immune modulators or high dose steroids (>/ 20 mg prednisone for more than 2 weeks

Flu vaccines

Given to everyone aged…

Any can be given with…allergy

Kids aged …, if never been vaccinated must get

Given to everyone at least 6 months old

Any can be given with egg allergy

Kids 6 months to 8 yo, if never been vaccinated must get 2 flu vaccines (4 weeks apart) the first time and then once yearly per usual

Fluzone, Afluria → age

Fluzone HD, Fluad → age

Inattentuated flu vaccine

Fluzone, Afluria → >6 months

High dose Fluzone, Fluad → >65 yo

…vaccine

Flublok →…vaccine, age

FluMist → …vaccine, formulation, age

Influenza vaccine

Flublok → recombinant vaccine, 18-49 yo

FluMist → live vaccine, nasal spray, 2-49 yo

Vaxneuvance → PCV, # doses

Prevnar 20 → PCV, # doses

Capvaxive → PCV

…pneumococcal vaccines

All approved for ages … except …

Formulation

Vaxneuvance → PCV15, 4 doses

Prevnar 20 → PCV20, 4 doses

Capvaxive → PCV21

-

Conjugated pneumococcal vaccines

All approved for ages at least 6 months except Capvaxive (>18 yo)

IM

Pneumvax

PPSV…

…vaccine

Unique formulation

Only indicated in patients who are…aged…(2)

Do NOT use if patient has had…

PPSV23

PolySaccharide vaccine, doesnt work as well as conjugated, will need to revaccinate

IM (like all pneumococal vaccines) but also SQ

• Only vaccine that comes SQ but not live

Only indicated in patients who are at least 2 yo

• 2-50 who are high risk OR all 50 yo

• Patients who have gotten Vaxneuvance (PCV15) a year ago and need a booster

Do NOT use if patient has had PCV20 or 21

Pneumoccoal vaccine

All kids < 2 yo get…

Kids 2-18 yo who are high risk get (2)

Adults 19-50 yo who are high risk and adults >50 yo get (2)

All kids < 2 yo get PCV15 or 20

Kids 2-18 yo who are high risk get

• PCV20 and be done OR

• PCV15 followed by PPSV23

Adults 19-50 yo who are high risk and adults >50 yo get

• PCV20 or 21 and be done OR

• PCV15 followed by PPSV23

Patients considered high risk for pneumococcal vaccine

Smoker, asthma, COPD

Chronic condition (CHF, DM, liver disease, alcoholism)

Cochlear implant, Cerebrospinal fluid leakage

Immunocompromised, asplenia, sickle cell anemia

Energix-B, Recombivax HB

…vaccine

Formulation

Given to all…

• If mother has Hep B → infant must get

Number of doses - time btwn doses

Interchangeable Hep B vaccines

IM

Given to all neonates before leaving the hospital

• If mother has Hep B → infant must get Hep B IG and Hep B vaccine

3 doses - 0, 1, 6 months

Heplisav-B → at least 18 yo, 2 doses, 1 month apart

HPV (Gardasil 9) also 3 doses but at 0, 2, 6 months

Heplisav-B

…vaccine

Age at least…

Number of doses,…month apart

Hep B vaccine

At least 18 yo

2 doses, 1 month apart

(vs Energix-B, Rebcombivax HB → neonates, 3 doses)

Who should get Hep B vaccine

All neonates before leaving the hospital (Hep B - Birth)

All patients aged 19 to 59 yo (including DM)

Patients aged 60 yo and older with risk factors (think blood)

• IV drug users, inmates

• HIV, HD, healthcare workers (→ blood transmission)

• Chronic liver disease (ie patients with Hep C, would get both Hep B and A vaccine)

• Sexually active (>1 partner in 6 months), male-male sex, patients seeking treatment for STD

Havrix

VAQTA

…vaccine

Number of doses

Given to…

• (3)

Transmitted…

Hep A vaccine

2 doses

Given to

• Kids 1-2 yo

• Patients traveling outside the U.S. (esp where Hep A is common)

• Same as Hep B → IV drug user, chronic liver, male-male sex

Transmitted fecal-oral route (vs Hep B → blood route)

Tetanus / Diphtheria / Pertussis vaccines

Covers…

DTaP (Daptacel, Infanrix) for children aged…(# doses)

Tdap (Adacel, Boostrix) as… at age …

• Also for …

• vs DTaP

Td every … after …

Covers Clostridium tetani, Corynebacterium diphtheriae, Bordetella pertussis

DTaP (Daptacel, Infanrix) for children <7 yo (5 doses)

Tdap (Adacel, Boostrix) as a booster at age 11-12 yo

• Also for pregnant patients in their 3rd trimester (27-36 weeks)

• Lower case “d” and “p” → lower conc of these components vs DTaP

Td every 10 years after 1 dose of Tdap

Daptacel, Ifanrix

…vaccine

DTaP vaccine

Adacel, Boostrix

…vaccine

Tdap vaccine

Adacel → Adult

Boostrix → Booster

Vaccine given to/as

• Booster at age 11-12 yo after given DTaP (Daptacel, Ifanrix) or

• Unvaccinated adults

MMR

Covers …

…vaccine → Formulation

Storage

…inch, …gauge

Given to patients aged… (# doses)

Covers Measles, Mumps, Rubella

Live vaccine → SQ

Only vaccine that can be stored in the diluent fridge or powder freezer (diluent not in freezer)

Given to patients 1 yo and again at 4-6 yo (2 doses)

Proquad

Contains…

Storage

Contains MMR + Varicella

Fridge or freezer (bc contains MMR)

Varivax, VAR

…vaccine → Formulation

Storage

Given to patients … (# doses)

• Same ages as

Live, Varicella vaccine → SQ

Freezer (diluent in fridge or RT, NOT frozen)

Given to patients 1 yo and again at 4-6 yo (2 doses)

• Same ages as MMR → either give the 2 vaccines at the same time or just get Proquad (MMR + Varicella)

VariZIG, VZIG

…given…after…to…

Varicella IG given 4 days after Shingles exposure to reduce severity of chickenpox

Can give to infants <1 yo for passive immunity (only get vaccine >1 yo)

…vaccine

AtivHIB, Hiberix → # doses

PedvaxHIB → # doses

Approved in

• Ages…or

• High risk patients

  • Condition → # doses (2)

Haemophilus Influenza type B (Hib) vaccines

AtivHIB, Hiberix → 4 doses

PedvaxHIB → 3 doses

Approved in

• Ages 2 MONTHS to 5 YEARS or

• High risk patients

  • Asplenia and splenectomy → 1 dose

  • Stem cell transplant → 3 doses

…vaccine covering…

Menveo → age

MenQuadfi → age

Given to patients

• Aged…, give booster at …

• High risk patients (revaccinate…if remains high risk)

  • (3 groups)

Meningococcal vaccine covering A, C, Y, W

Menveo → at least 2 month

MenQuadfi → at least 2 years

Given to patients

• Aged 11-12 yo, give booster at 16 yo

• High risk patients (revaccinate every 5 years if remains high risk)

  • HIV

  • College students (close courters)

  • Travel for Hajj pilgrimage to Mecca

TrumenBa, Bexsero

…vaccine covering…

Only patients aged…with…

Revaccinate…if remains high risk

Meningococcal vaccine covering B (vs Menveo, MenQuadfi covering A, C, Y, W)

Only patients at least 10 yo with high risk of meningococcal B infections (ie asplenia, sickle cell disease)

Revaccinate every 2-3 years if remains high risk

Gardasil 9

…vaccine

FDA approved for ages…, CDC recommends starting at ages…

Standard dosing → # of doses at…intervals months

• Patients ages…can get # doses

HPV vaccine → protects against genital warts, cervical cancer, anal cancer

• HPV types 16 and 18 are responsible for most cervical cancer causes

FDA approved for 9-45 yo, CDC recommends starting at 11-12 yo

Standard dosing → 3 doses at 0, 2, 6, months

• Patients 9-14 yo can get 2 doses

Remember Hep B (Engerix-B, Recombivax HB also 3 doses but at 0, 1, 6 months)

RZV

…vaccine

FDA approved in patients…, CDC recommends…

Also approved in adults …

Formulation

Number of doses, interval months

Storage after reconstitution

Note that…

Shingrix Recombinant Zoster Vaccine

FDA approved in patients at least 50, CDC recommends at least 60

Also approved in adults at least 18 yo who are immunocompromised

IM, not live (like Varicella)

2 doses at 0 and 2-6 months after

Refrigerate after reconstitution for 6 hrs

Note that cant give shingles to someone else, but can get chickpox

…vaccine given if traveling to avoid what organism

Typhim Vi

Vivotif Berna

Both age, formulation, live vs not, x week before, # doses, regards to food

Typhoid vaccine given if traveling to avoid Salmonella Typhi poisoning

Typhim Vi → at least 2 yo, IM, not live, 2 weeks before travel

Vivotif Berna → at least 6 yo, oral capsules, live, 1 week before travel, empty stomach, 4 doses

YF-VAX

…vaccine given to patients…(transmitted through…)

Given when, booster given when

Formulation

CI in…allergy

Age

Yellow fever vaccine given to patients traveling to South America and Africa (transmitted through mosquitoes)

10 days before travel, booster given every 10 years with continued risk

SQ bc live vaccine

CI in egg allergy

At least 9 months

Vaccines for patients with asplenia and sickle cell anemia

Pneumococcal

Meningitis

Hib

Remember DM → pneumococcal, influenza, Hep B

Remember asthma/COPD → Pneumococcal, Influenza, COVID-19

Imovax, RabAvert

Vaccine given to…to prevent…

If already bitten →

Vaccine given to veterinarians, cavers, bat handlers to prevent rabies

If already bitten → give Rabies IG (RIG) and then 5 vaccine doses

Abryso

Arexvy

mRESVIA

…vaccine

All approved for…

Storage

• Abryso and Arexvy → …, use within…

• mRESVIA → …

Abryso indicated in

CDC recommends vaccine in… (2)

RSV vaccines

All approved for >/ 60 yo

Storage

• Abryso and Arexvy → fridge, use within 4 hrs

• mRESVIA → freezer

Abryso indicated in pregnant patients 32-36 week gestation to pass RSV Ab through placenta to the child

CDC recommends vaccine in…

• All patients at least 75 yo

• Patients 60-74 yo with risk factors

TwinRix

Combo of what vaccines

Age approval

Hep A and Hep B

At least 18 yo

Immunizations for Travel

Hep A/B

Meningococcal (Hajj)

Typhoid (salmonella)

Yellow Fever (South America and Africa)

Vaccine Storage

Fridge →

Frozen →

Fridge → 36 to 46 F (2 to 8 C)

Frozen → -58 to 5 F (-50 to -5 C)

Vaccines for patients with DM

Pneumococcal, Influenza

Hep B (3 dose series for 19-59 yo)

Remember asplenia/sickle cell anemia → Pneumococcal, Meningitis, Hib

Remember asthma/COPD → pneumococcal, influenza, COVID

IM vaccines

…gauge in ALL age groups

Preferred placement (2, based on age)

Length (3, based on weight)

22-25 gauge in ALL age groups

90 degree angle (vs live SQ 45 degrees)

Preferred placement (2)

• Age up to 2 yo → thigh

• Age 3 and up → deltoid

Length (3)

• Usually 1 inch

• 5/8th inch can be used if weight 130 lb or less

• 1.5 inch → obese patients (female >90 kg, males >118 lb)

COVID vaccines

Approved in all adults…and

Individuals…who are high risk

FDA approved in all adults 65 yo and older

Individuals at least 6 months who are at high risk

• Age 4 yo or younger

• Pregnant

• Immunocompromised

Vaccines

Takes…to work

Persist for at least…post vaccination

Takes 2 weeks to work

Persist for at least 6-8 months post vaccination

Vaccines for patients with asthma/COPD

Pneumococcal, Influenza

COVID-19

Remember asplenia/sickle cell anemia → Pneumococcal, Meningitis, Hib

Remember DM → pneumococcal, influenza, Hep B

Compounding pharmacies are licensed/registered by…

Accreditation →

Compounding pharmacies are licensed/registered by State Board of Pharmacy

Accreditation → Pharmacy Compounding Accreditation Board (PCAB) voluntary

Compounding vs Manufacturing

Compounds:

• NOT FDA approved

• Prepared for specific patient

• Does NOT replicate commercially available drug products

Manufacturing:

• FDA approved

• Mass produced

Which compounded products MUST be sterile

Injections, inhalations and ophthalmic (eye) ointments must be sterile (otic products dont need to be)

Oral suspension/solution, topicals dont need to be sterile

USP standard ->

Non-sterile -> USP… (use…)

Sterile preparation -> USP…

Hazardous -> USP…

USP standard -> national standards for compounding

Non-sterile -> USP 795 (use purified water)

Sterile preparation -> USP 797

Hazardous -> USP 798

ISO (International Organization of Standardization) 

Sterile compounding hood and Biological Safety Cabinets -> ISO class..

Buffer room -> ISO class..

Ante room (btwn common pharmacy area and clean room) -> ISO class..

Sterile compounding hood and Biological Safety Cabinets -> ISO class 5 air 

Buffer room -> ISO class 7 air

Ante room (btwn common pharmacy area and clean room) -> ISO class 8 air 

Category 1, 2, and 3 CSP all use the same ISO classes, except for immediate use products (ie things that are used in the ER)

Before getting ready to enter clean room

• Remove coat, hat, makeup, artificial nails and jewelry

• Gowning from dirtiest to cleanest: toe → head → face

  • Shoes cover, hair cover, facial mask

  • Wash hands up to elbows

  • Dry hands with non-shedding disposable towels

  • Low lint gown

  • Clean hands again with alcohol based hand rub

  • Enter clean room, put on gloves (2 sets for chemo

  • Santizes the gloves with 70% sterile isopropyl alcohol and allow gloves to dry

Chemo agents should be compounded with…like biological safety …-> prevent…

What protection

Red bin ->  

Blue bin ->

Yellow bin ->

Black bin ->

Non-hazardous preparations -> horizontal flow

Chemo agents should be compounded with glass shield protecting compounder in vertical flow like biological safety class II cabinets -> prevent bone marrow suppression 

Eye protections, double gloves

Hood recertified every 6 months

Red bin -> sharps 

Blue bin -> non-hazardous

Yellow bin -> trace hazardous

Black bin -> hazardous

• Warfarin, all nicotine products, chemo agents

• Estrogen, EPI

• Azathioprine, Cyclosporine,

• Phentermine, Physostigmine

• Any agents containing mercury, heavy metals or m-cresol

Non-hazardous preparations -> horizontal flow

Avoid…with iodine when compounding

Avoid stainless steel spatulas with iodine when compounding

Cream ->

…opaque

Gel ->

Lozenge aka

Elixir has … -> avoid with…

Cream -> opaque and non-greasy to moderately greasy 

Cream lotion paste opaque

Gel -> translucent, NOT greasy

Lozenge or torche

Elixir has alcohol -> avoid with Flagyl, Cefotetan and Disulfiram

Emulsion -> …that are normally immiscible 

Cream and lotion both…preparations

• Cream -> larger…% 

• Lotion -> larger…%

Emulsion -> liquid-in-liquid that are normally immiscible 

Cream and lotion both oil in water preparations

• Cream -> larger oil % 

• Lotion -> larger water %

Solution …mixture -> cannot tell the solid/liquid contents apart

Suspension: …-in-… particles (vs emulsion) -> must…

Solution homogenous mixture -> cannot tell the solid/liquid contents apart

Suspension: solid-in-liquid particles (vs emulsion) -> must shake before use

Eutectic mixture has a…than any of its components

Eutectic mixture has a melting point lower than any of its components

BUD

Category 1 CSPs

• …at RT 

• … in the fridge

Category 2 CSPs

• If non-sterile components 

  • RT ->

  • Fridge ->

• If sterile components

  • RT ->

  • Fridge ->

• Freezer ->

Immediate use CSP must be used within…

Category 1 CSPs

• 12 hrs at RT 

• 24 hrs in the fridge

Category 2 CSPs

• If non-sterile components 

  • RT -> 1 days

  • Fridge -> 4 days

• If sterile components

  • RT -> 4 days

  • Fridge -> 10 days

• Freezer -> 45 days

Immediate use CSP must be used within 4 hrs

Emulsifying agent

• Low HLB (…) are more…

  • -> better for…emulsions 

• High HLB (….) are more… 

  • -> better for…emulsions

Emulsifying agent

• Low HLB (<10) are more oil soluble 

  • Glycerol Monostearate (GMS) -> better for water-in-oil emulsions 

• High HLB (>10) are more water soluble 

  • Sodium Lauryl Sulfate -> better for oil-in-water emulsions

Think Low = Lipid

Single dose vials 

• If used in ISO Class 5 environment -> good for…

• If not -> good for…

Multi dose vials 

• Has…

• Good for…

Single dose vials 

• If used in ISO Class 5 environment -> good for 6 hours

• If not -> good for 1 hr 

Multi dose vials 

• Has preservatives 

• Good for 28 days

Balances must meet…standards

Weights can be picked up by…(never by hand)

If weighing ointment -> use…paper (wont break from all the oil)

Balances must meet national Bureau of Standards

Weights can be picked up by plastic tweezers (never by hand)

If weighing ointment -> use glassine weighting paper (wont break from all the oil)

What is an Autoclave? 

…used to sterilize…equipment and heat-resistant compounded products in 15-20 min

• Heat…

• Pressure…

Destroys…but NOT…

What is an Autoclave? 

Steam pressure chamber used to sterilize aqueous solutions equipment and heat resistant compounded products in 15-20 min

• Heat 121 C (249 F) 

• Pressure at 15 PSI

Destroys bacteria, viruses, fungi and spores but NOT endotoxins

Sterilization by filtration uses…micron filter

Can trap…, but NOT…

Must be capable of…

Sterilization by filtration uses 0.22 micron filter

Can trap bacteria and fungi, but NOT viruses or endotoxins

Must be capable of retaining 100% of a culture of 10^7 microorganisms of a strain of Brevundimonas (Pseudomonas) diminutas

Trituration -> Levigation -> Geometric dilution

Trituration (grinding dry powder) -> Levigation (add non-soluble liquid to continue grinding) -> Geometric dilution (adding diluent)