Confirm tenecteplase indication and dose before use
TNKase (tenecteplase), a Genentech product, is an I.V. tissue plasminogen activator (tPA) and fibrinolytic agent approved for ST-elevation myocardial infarction (STEMI). This indication is displayed on the top panel of the carton (see TNKase (tenecteplase) carton), and the dosing regimen for this indication is printed on the inside flap of the panel. Many hospitals are now considering or are already using tenecteplase off-label for acute ischemic stroke, as it may have more favorable clinical outcomes compared with alteplase (http://www.ismp.org/ext/952). However, the dose for acute ischemic stroke (0.25 mg/kg, maximum dose of 25 mg) is very different from the tiered dosing for myocardial infarction, which is based on a weight range (maximum dose of 50 mg). For acute ischemic stroke, patients could receive a twofold overdose if healthcare professionals follow the dosing instructions for the only approved indication, myocardial infarction, as prominently displayed on the carton.
Using tenecteplase for both STEMI and acute ischemic stroke may also allow some healthcare facilities to avoid the routine use of ACTIVASE (alteplase), another tissue plasminogen activator. This could help avoid well-documented mix-ups due to the use of abbreviations, "TNK" for tenecteplase or TNKase, and "t-PA" or "TPA" for alteplase. Those involved in these mix-ups assumed that t-PA was shorthand for TNKase and attributed the error to confusion between TNK and TPA.
Determine if your organization can carry only one tissue plasminogen activator on formulary. If your hospital is considering the use of tenecteplase for acute ischemic stroke, risk reduction strategies may include removing the vial from the carton and storing the medication in a stroke kit or creating a stroke dosing card affixed to each carton. Review how the medication is ordered in the electronic health record and use order sets to guide the correct dose based on the indication. To avoid confusion, especially when transitioning from alteplase to tenecteplase, remove abbreviations from all order sets, order entry screens, automated dispensing cabinets, smart infusion devices, and treatment protocols. Healthcare professionals must be reminded to never use abbreviations for drug names; the full drug name should always be used. When possible, have the pharmacy prepare and dispense each dose.
PDMPs can identify duplicate opioid therapy
An older adult patient in the ED was unable to provide an accurate medication history due to an altered mental status. A pharmacist checked the state's prescription drug monitoring program (PDMP) and discovered that the patient had been taking multiple opioid medications prescribed by the same pain management provider. The patient had been started on HYDROmorphone extended-release (ER) 16 mg once daily for chronic back pain and hip arthritis, along with HYDROcodone 10 mg/acetaminophen 325 mg, one tablet every 8 hours as needed for breakthrough pain. Due to insurance coverage, the prescriber intended for the patient to taper off the HYDROmorphone ER and transition to morphine ER 60 mg twice daily as this was covered by the patient's insurance. The patient was advised to start with morphine ER 60 mg daily, and then to increase to twice daily if needed, but it is not clear if the patient immediately started on the twice-daily dose.
One day prior to the ED visit, the patient had started the newly prescribed morphine ER tablets and picked up a supply of HYDROmorphone ER 16 mg tablets.
Taking multiple opioids can lead to serious patient harm. Before prescribing and dispensing an opioid, confirm whether the patient is opioid-naive or opioid-tolerant, complete a thorough review of the patient's medication history, and access the state's PDMP to have a full understanding of the controlled substance medications and dosages a patient is taking. Patients should be provided with written instructions and must be counseled on when to start and stop opioids, including schedules for tapered doses and what to do if they experience adverse reactions related to opioid toxicity. Patients who take high doses of opioids should be provided with naloxone, and both the patient and their caregivers should be educated about when and how to use it. Patients should also be provided with resources about safe drug storage and disposal, including drug take-back locations.