Category Archives: Clinical practice

DiphenhydrAMINE Injection Shortage 10.15.18

To:            Physicians, Nursing, Pharmacy

From:     Maryna Shayuk, MD, Chair Pharmacy and Therapeutics

                  Alan Mader, Pharmacy Operations Coordinator

Date:        October 15, 2018

Re:            Diphenhydramine Injection Shortage



Diphenhydramine injection supply is critically low. Estimates indicate less than a 2 week supply throughout NM Northwest system.


Diphenhydramine has been on shortage. Pharmacy Purchasing has been able to obtain orders up to this point.


In order to maintain the limited supply for crash cart exchange, sequestering to pharmacy and therapeutic substitution will need to be instituted.


Pharmacy will sequester remaining supply from Pyxis machines to the Pharmacy Department.   Therapeutic Substitution will take place as follows:

Injection to PO – For all patients who can take PO in equivalent dose.

If unable to take PO – Therapeutic substitution to Promethazine Injection in equivalent dose.   Doses greater than 25 mg – consult with MD.


Updated Guidelines for Prevention of Perinatal Hepatitis B

Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC) published a summary of existing recommendations and provided updated and new recommendations on the prevention of hepatitis B virus infection in the United States.

The new and updated recommendations are:

General Recommendations:

  • For all medically stable infants weighing ≥2,000 grams at birth and born to HBsAg-negative mothers, the first dose of hepatitis B vaccine should be administered within 24 hours of birth.
  • Permissive language for delaying the birth dose that was previously used in the recommendations has been removed.

Identification and Management of HBV-Infected Pregnant Women:

  • All hepatitis B surface antigen (HBsAg) positive pregnant women should be tested for hepatitis B DNA to guide the use of maternal antiviral therapy during pregnancy for the prevention of hepatitis B virus transmission.
    • A brief summary of the American Association for the Study of Liver Diseases (AASLD) guidelines for the use of maternal antiviral therapy to reduce perinatal Hepatitis B virus transmission is also included in the MMWR.

Management of Infants Born to Women Who Are HBsAg-Positive:

  • Infants born to women for whom HBsAg testing results during pregnancy are not available but have other evidence suggestive of maternal hepatitis B virus infection (presence of maternal HBV DNA, maternal HBeAg is positive, or the mother is known to be chronically infected with hepatitis B) should be managed as if born to an HBsAg-positive mother.
  • For infants who are transferred to a different facility after birth, staff at the transferring and receiving facilities should communicate with each other regarding the infant’s HepB vaccination and receipt of hepatitis B immune globulin (HBIG) to ensure prophylaxis is administered in a timely manner.

Management of Infants Born to Women with Unknown HBsAg Status

  • If it is not possible to determine the mother’s HBsAg status (e.g., where confidential safe surrender of infant occurs shortly after birth), the vaccine series should be completed according to the recommended schedule for infants born to HBsAg-positive mothers. Post-vaccination serologic testing and revaccination, if needed, is recommended for these infants.
  • For HBsAg-negative infants born to HBsAg-positive women who show no serologic immune response after receiving the initial HepB vaccine series, revaccinate the infant with a single challenge dose of HepB vaccine and repeat serologic testing (HBsAg and anti-HBs) one to two months later. If the infant remains HBsAg negative and has an anti-HBs of <10 mIU/mL following single dose revaccination, complete the second series on schedule with the two additional Hep B vaccine doses followed by post-vaccination serologic testing one to two months after the final dose.
    • Alternatively,basedonclinicalcircumstancesorparentpreference,HBsAg-negative infants born to HBsAg-positive women who show no serologic immune response after receiving the initial HepB vaccine series may instead be revaccinated with a second 3- dose series and retested one to two months after the final dose of vaccine.
    • As a reminder, post vaccination serologic testing of the infant should include HBsAg and anti-HBs. Anti-HBs testing should be performed using a method that allows detection of the protective concentration of anti-HBs (> 10mIU/mL).

Influenza Vaccination in Patients with Egg Allergy


January 11, 2018

Influenza Vaccination in Patients with Egg Allergy

David J. Amrol, MD reviewing Greenhawt M et al. Ann Allergy Asthma Immunol 2018 Jan .

All available flu vaccines are safe in all egg-allergic patients.

Sponsoring Organizations: American Academy of Allergy, Asthma, and Immunology (AAAAI); American College of Allergy, Asthma, and Immunology (ACAAI)

Target Audience: All providers who administer influenza vaccines


Historically, patients with egg allergy have been told to avoid flu vaccines, because most flu vaccines are produced in embryonated chicken eggs; the concern was that a vaccine might contain residual egg protein, which could lead to anaphylaxis. Many studies have shown that flu vaccines are safe for egg-allergic patients, but many physicians still have been hesitant to vaccinate such patients. This updated practice parameter incorporates recent data on flu vaccine safety in egg-allergic patients, including children.

Key Recommendations

  • Flu vaccines should be administered annually to patients with egg allergy of any severity, with no need to ask recipients about egg-allergy status and no special precautions beyond those recommended for administering any vaccine to any patient. This recommendation applies to both injected and intranasal formulations (although the latter should not be used in the 2017−2018 flu season).
  • Non−egg-containing vaccines can be used but are not necessary or preferred over standard vaccines.
  • The intranasal live attenuated flu vaccine also might be used, if it’s shown to be efficacious and is approved for use.

Egg-allergic patients can be vaccinated safely with any available age-appropriate flu vaccine, with no special precautions, regardless of egg-reaction history (including anaphylaxis). Concern for egg allergy only adds another barrier to universal flu vaccination, and this practice parameter concludes by stating the following: “Vaccine providers and screening questionnaires do not need to ask about the egg allergy status of recipients of influenza vaccine.”

Editor Disclosures at Time of Publication

Disclosures for David J. Amrol, MD at time of publication

Consultant / Advisory boardCSL Behring; Horizon Pharmaceuticals

Greenhawt M et al. Administration of influenza vaccines to egg allergic recipients: A practice parameter update 2017. Ann Allergy Asthma Immunol 2018 Jan; 120:49. (

Did you know you can get ABIM MOC credits with

ABIM MOC completion can be done through 

Please see here for more information on the program.

Centegra offers access to for all providers in the health system. Just login from any network computer in the system.

Instructions on remote or mobile access can be found here.

Morphine Injection Shortage

Morphine Injection Shortage 10.18.2017

There is a nationwide shortage of morphine injection that expected to last until early to mid-November. The Pharmacy Department is running very low on supply and expects that the drug will become unavailable.  Please consider ordering an alternate injection product for pain management.  An opioid dose conversion chart is included below for your convenience.








Oral: Parenteral Ratio


Oral Morphine: Analgesic Ratio


Analgesic Duration


Half Life

Morphine30 mg10 mg3 : 11 : 14 – 6 hrs3 hrs
Oxycodone20 mg1.5 : 13 – 5 hrs4 – 5 hrs
Hydromorphone7.5 mg2 mg 4: 14: 13 – 4 hrs2 – 3 hrs
Fentanyl100 mcgSee Table B on page 21 hr3 – 12 hrs
Methadone20 mg10 mg2 : 1See Table C on page 24 – 12 hrs15 – 50 hrs
Codeine200 mg130 mg1.5 : 11 : 74 – 6 hrs3 hrs
Hydrocodone30 mg1 : 13 – 6 hrs3 – 4 hrs
Meperidine300 mg75 mg4 : 11 : 102 – 4 hrs2 – 3 hrs
Nalbuphine10 mg1 : 13 – 6 hrs5 hrs

pembrolizumab (KEYTRUDA) in Patients with Multiple Myeloma: FDA Statement – Two Clinical Trials On Hold

Keytruda (pembrolizumab) in Patients with Multiple Myeloma: FDA Statement – Two Clinical Trials on Hold
AUDIENCE: Oncology
ISSUE: Based on data from two recently halted clinical trials, the U.S. Food and Drug Administration today is issuing this statement to inform the public, health care professionals, and oncology clinical investigators about the risks associated with the use of Keytruda (pembrolizumab) in combination with dexamethasone and an immunomodulatory agent (lenalidomide or pomalidomide) for the treatment of patients with multiple myeloma. Keytruda (pembrolizumab) is not approved for treatment of multiple myeloma.
The FDA statement is based on review of data from two clinical trials (KEYNOTE-183 and KEYNOTE-185) evaluating the use of Keytruda (pembrolizumab) combined with other treatments in patients with multiple myeloma. On July 3, 2017, the FDA required that all patients in these trials be discontinued from further investigation with this drug, because interim results from both trials demonstrated an increased risk of death for patients receiving Keytruda (pembrolizumab) when it was combined with an immunomodulatory agent as compared to the control group (see statistical analysis section below). Merck & Co., Inc. was made aware of the issue through an external data monitoring committee recommendation and suspended the trials to enrollment on June 12, 2017. Continue reading

Johns Hopkins ABX Guides

Pharmacy Services has subscribed to Johns Hopkins ABX Guide for use by all associates at Centegra Health System to support our multidisciplinary approach to the Antimicrobial Stewardship Program Clinical Decision Support Tools and Education

Johns Hopkins ABX Guide is a comprehensive web source that provides regularly updated, evidence-based decision resources regarding antibiotics, diagnosis, pathogens, management of infections and vaccines.

Prior to the Guide, CHS did not have a specific detailed resource for antibiotics clinical decision support.

Johns Hopkins ABX Guide may be accessed through Unbound Medicine’s uCentral as follows:

FDA DRUG SAFETY COMMUNICATION: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women

Safety Announcement
[4-20-2017] The Food and Drug Administration (FDA) is restricting the use of codeine and tramadol medicines in children. Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children. These medicines should also be limited in some older children. Single-ingredient codeine and all tramadol-containing products are FDA-approved only for use in adults. We are also recommending against the use of codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants. Continue reading