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Prescribing calls
Sam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets.
Insulin
* Generally treat any blood glucose of 20 or above.
* Target range:
* Inpatient: 7 – 14 mmol/L
* Outpatient: 4 – 10 mmol/L
* Achieving target 60% of the time is quite good!
* Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery.
* Correct BSLs with a rapid acting insulin (Novorapid)
* Correction doses should be given at meals and no more frequently than 4 hourly.
* If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment.
* Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia.
* Don’t use ActRapid – it works slowly subcut so should only be used IV.
* Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior.
* Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK.
Antiemetics
* Cyclizine (NZF)
* Antihistimine
* Classic, old-school, and effective
* Great for non-iatrogenic nausea and vomiting
* Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly
* 25 – 50 mg PO/IV TDS PRN
* Ondansetron (NZF)
* Serotonin antagonist
* Newer, but not necessarily better antiemetic
* Primarily indicated for PONV and chemotherapy-induced nausea
* Can be constipating
* Can reduce the effectiveness of tramadol, so avoid co-prescription
* 10 mg PO/IV TDS PRN
* Metoclopramide (NZF)
* Dopamine antagonist
* Gastric stimulant, avoid in suspected small bowl obstruction
* Avoid co-prescribing with droperidol and prochlorperizine
* Avoid in Parkinson’s disease
* Avoid in under 20 year olds due to risk of oculogyric crisis
* 10 mg PO/IV TDS PRN
* Domperidone (NZF)
* Somewhat interchangeable with metoclopramide, but no IV formulation
* Does not cross BBB, so preferred in Parkinson’s disease
* 10 mg PO TDS PRN
* Droperidol (NZF)
* Dopamine antagonist
* Usually prescribed by anaesthetics for PONV
* 0.625–1.25 mg IV Q6H PRN
* Scopoderm patch (NZF)
* Nonspecific antimuscarinic
* Usually prescribed by anaesthetics for PONV
* 1 patch Q72H
* Prochlorperazine (NZF)
* Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily
* Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above
* Don’t confuse with chlorpromazine!
Analgesia
* Pain assessment
* Try to get some kind of assessment documented e.g. verbal pain score
* Pain ladder
* Simple analgesia e.g. paracetamol +/- NSAID
* “Weak” opioides e.g. tramadol or codeine
* Titrate up opiates e.g. morphine or oxycodone
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By Sam HolfordSam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets.
Insulin
* Generally treat any blood glucose of 20 or above.
* Target range:
* Inpatient: 7 – 14 mmol/L
* Outpatient: 4 – 10 mmol/L
* Achieving target 60% of the time is quite good!
* Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery.
* Correct BSLs with a rapid acting insulin (Novorapid)
* Correction doses should be given at meals and no more frequently than 4 hourly.
* If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment.
* Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia.
* Don’t use ActRapid – it works slowly subcut so should only be used IV.
* Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior.
* Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK.
Antiemetics
* Cyclizine (NZF)
* Antihistimine
* Classic, old-school, and effective
* Great for non-iatrogenic nausea and vomiting
* Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly
* 25 – 50 mg PO/IV TDS PRN
* Ondansetron (NZF)
* Serotonin antagonist
* Newer, but not necessarily better antiemetic
* Primarily indicated for PONV and chemotherapy-induced nausea
* Can be constipating
* Can reduce the effectiveness of tramadol, so avoid co-prescription
* 10 mg PO/IV TDS PRN
* Metoclopramide (NZF)
* Dopamine antagonist
* Gastric stimulant, avoid in suspected small bowl obstruction
* Avoid co-prescribing with droperidol and prochlorperizine
* Avoid in Parkinson’s disease
* Avoid in under 20 year olds due to risk of oculogyric crisis
* 10 mg PO/IV TDS PRN
* Domperidone (NZF)
* Somewhat interchangeable with metoclopramide, but no IV formulation
* Does not cross BBB, so preferred in Parkinson’s disease
* 10 mg PO TDS PRN
* Droperidol (NZF)
* Dopamine antagonist
* Usually prescribed by anaesthetics for PONV
* 0.625–1.25 mg IV Q6H PRN
* Scopoderm patch (NZF)
* Nonspecific antimuscarinic
* Usually prescribed by anaesthetics for PONV
* 1 patch Q72H
* Prochlorperazine (NZF)
* Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily
* Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above
* Don’t confuse with chlorpromazine!
Analgesia
* Pain assessment
* Try to get some kind of assessment documented e.g. verbal pain score
* Pain ladder
* Simple analgesia e.g. paracetamol +/- NSAID
* “Weak” opioides e.g. tramadol or codeine
* Titrate up opiates e.g. morphine or oxycodone