Chapter 18 IV Drug Compatatibility, Administation and Degaration

- The Handbook on Injectable Drugs (formerly called Trissels) or the King Guide to Parenteral
Admixtures (commonly called Kingsd) are th e primary compatibility and stability
resesources, along with the drugs packet insert.
- Some drug info databastes such as Micromedex, Clinical Pharmacology and Lexi-Comp have an IV
comp database that can used in a clinical setting.
- Practice News and Hospital Pharmacy are handy references.

Incompatatbilites

Phycisical Incompatibilites occur:

Physical Incompatibilites- commly dues to compounds binding together and forming a
precipate which may or may not be visible and can be quickly fatal if preceipitate travels to the
lungs.
1. The container (drugs that cannot be placed in PVC containters)
2. The solution (diluents- primarily dextrose or saline)
3. Other drugs, such as phenytoin binding to dextrose or calcium binding to
phosphate;drug-drug incompatibility can occur when drugs are mixed in the same
syringe or container, or during Y site admin.

Drugs and Intraventous PVC Contains

Most use DEHP as a plasticizer to make the platic flexible. The DEHP is a concern as it can
have an effect on male fertility.

2 main problems
1. PVC LEACHING DHEP into the solution
a. Leaching - DHEP can leach from PVC - need to use non-PVC bags and polyethylene
lined tubing

Drugs w/ Leaching Issues

Tacrolimus,
Temsirolimus
Trniposide
Cabazitaxel
Docetaxel
paclitaxel,
amiodarone
1. Tic Tac Toe, craving delicious pho!

2. SORPTION the drug moves into the container

a. Sorption is when the PVC bag pulls in some of the drug - instead use polyolefin or glass
containers

Drugs w/ Sorption issues

ACLS----TIN

Amiodarone (for infusion >2hrs)

Caramustine
Lorazepam
Sufentanil
Thiopental
Regular insulin
Nitroglycerin

***Drugs that have trouble with PVC containers can be placed polyoefin containers

Drugs (Saline ONLY)

Ampicillin
Abatacept (Orencia)
Ampicillin/Sulbactam (Unasyn)
Azacitidine (Vidaza) (NS or LR)
Belimumab (Benlysta)
Casofungin (Cancidas (NS or LR)
Daptomycin (Cubicin) (NS or LR)
Idarucizumab (Praxbind)
Phenytoin
Ertapenem (Invanz)
Infliximab (Remicade)
Iron Sucrose (Venofer)
Sodium Ferric Gluconate Complex (Ferrlecit)
Natalizumab (Tysabri)
Trastuzumab (Herceptin)

Dextrose Only (No Saline)

Amphotericin B (all formulations)

Carfliziomib (Kyprolis)
Mycophenonlate (CellCept IV)
Pentamidine
Quinuprisitin/Dalfropristin (Synercid)
Sulfamethoxazole/Trimethoprim (Bactrim)

Addititve compatibility- when two drugs are mixed- incompat

Y-Site Injection Compatility (1:1)- Cefepime:gent- compatitbility

Ampho B- precip. With Zosyn and acyclovir

Heparin- precip.- nitroglycerin, ateplase and hyrodmorphone

Caspofungin- has many Y-site incompat

IV quniolones are incompat with Y-site infusion with MANY drugs.

When incompat exists with long or contin infusi9ons, additional IV sites may be required.

FILTERS

1. 0.22 um- most fluids

2. 1.22 um- most liquids
Ampules- must use filter needles

Common Drugs with Filter Requirements

Filter with 0.22um, unless noted

Abatacept (Orencia)
Abciximab (ReoPro)
Amiodarone (continuous inf)
Digioxin Immune Fab (DigiFab)
Golimumab (Simponi)
Infliximab (Remicade)
Isavuconazonium (Cresemba)
Lipids (not all, 1.2 micron)
Lorazepam (Ativan)
Mannitol (Osmitrol)
Phenytoin (Dilantin)
Parenteral Nutrition
Thiotepa

Filter during preparation only:

Amphotericin B, liposomal, and lipid complex (Abelcet, AmBisome)

Select IV Drugs That Do Not Require Refrigeration

Acetaminophen (Ofirmev)
Acyclovir--------REFRIGERATION CAUSES CRYSTALLIZATION
Deferoxamine (Desferal)
Dexmedetomidine (Precedex)
Enoxaparin (Lovenox)
Furosemide-----------REFRIGERATION CAUSES CRYSTALLIZATION
Hydralazine
Levetiracetam (Keppra)
Metronidazole (Flagyl)
Pentamidine
Propofol (Diprivan)
Moxifloxacin (Avelox)
Phenytoin
Sulfamethoxazole/Trimethoprim (Bactrim)
Valproate

Stability- Effects of Time, Temp, Light, Agitation

- As a drug remains in solution longer the likelihood of a chemical rxn occurring increases.

- Ex. Zosyn- normally given as an intermittent infusion (fewer compatibility issues)---; however,
Zosyn (piperacillin/tazobactam) extended infusions are useful because they obtain a higher
 time above the MIC (T>MIC)(how PCN kill)in oder to counter durg resistance with some of
the common nosocomial pathogens, including Psuedomons, Enterobacter, and
Acinetobacter.

- The higher T>MIC is beneficial, but the longer infusion times result in compatibility issues with
other hospital drugs like azithromycin, ciprofloxacin, tobramycin, vancomycin, other
antibotics and insulin and even some vasopressors can occur with longer infusions.

- Higher temperatures promote chemical rxns- which why the majority are kept cold

- Light causes phot-o is some cases it can destroy the drug in other cases in can increase the
toxicity.

- 1. Amber vial

- 2. Original packinging (foil overwrap or box) until admin

- 3. Protective bags

- 4. Protective tubing

Drugs protect from light during admin

Antracyclines- Danurubicin, Doxyrubicin, Epirubicin, Idarubicin

Dacrbazine (if extravasates, protect exposed tissues from light)
Doxycycline
Epoprostenol (Flolan)
Micafungin (Mycamine)
Nitroprusside (Nitropress)
Pentamidine
Phytonadione

Agitation destroys some drugs

Hormones and other proteins

Ateplases
Immune globulins
Insulins
Rasburicase
VACCINES (zoster.

Quinupristin/dalfopristin (Synercid)-, etanercept (Enbrel) are some of the drugs that for a foam
and should be swirled with when reconstintuting.
DO NOT SHAKE; WAIT FOR FOAM TO DISSOLVE.

IV DISCOLORATION

Most cases---discoloration = oxidation or decomposition

Nitroprusside- Light- decomp- orange, dark brown, or blue liquid. If discol, do not use
Chlorpromazine- slightly yellowed color is okay. Do not use if darker than light yellow
Dacarbazine- Turns pink if drug decomoped, DO NOT USE
Dobuatamine- Oxidation turns the liquid slightly pink, but POTENTCY IS NOT LOST
Dopamine- A slightly yellowed color is acceptable. Do NOT USE IF DARKER THAN SLIGHT
YELLOW.
Norepi- Oxidation turns the liquid brown. IF Discolored DO NOT USE.
Epi- Oxidation turns the liquid pink, then brown. If discolored, do not use.
ISO- Exposure to aire, light or increace in temp turns the liquid pink or Darker, If discolored do not
use.
Morphine- If solution is dark do not use.
Tigecycline- Reconstituted solution is yellow/orange, do not use if green/black.

AND THE OPPOSITE: Do no use the antidote Cyanokit if the solution is not dark red.

DO NOT USE IF PARTICULATES ARE IN THE SOLUTION