Prescribing calls

Prescribing calls

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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.
Waitemata DHB correction of hyperglycaemia guideline (August 2017)
  • 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
    1. Simple analgesia e.g. paracetamol +/- NSAID
    2. “Weak” opioides e.g. tramadol or codeine
    3. Titrate up opiates e.g. morphine or oxycodone
  • It may be necessary to “get on top” of the pain first with some IV boluses, then once the patient is comfortable, some low-dose long acting analgesia may be all that is required.
  • If possible, please avoid opiates in young patients (e.g. <25 years) as there is a strong link between opiate exposure in the young and subsequent drug and alcohol dependance and abuse. First do no harm!

Sleeping tablets

  • Very common request on evening and ward calls
  • Balance benefit with risk
    • Patients need sleep to recover from the illness, so don’t withhold unnecessarily
    • However don’t contribute to an avoidable fall
  • Zopiclone (NZF)
    • 7.5 – 15 mg PO nocte
    • Generally first line unless the patient already uses an alternative
  • Quetiapine (NZF)
    • Antipsychotic, not indicated for insomnia
    • However patient who have tried it tend to swear by it
    • Use as a sleeping tablet in low dose (e.g. 25 mg) is off-label, so generally avoid unless the patient already uses it.
  • Benzodiazepines
    • Temazepam (NZF) 10 – 20 mg PO nocte
    • Generally avoid benzos unless you are experienced with their use, as they have many interactions and dependance is rapid.

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