Background:

1. Use of Telephone Prescription Renewal Requests with Order Checks to Systematically Assess Renal Dosing Jamie Young, Pharm.D.; Bonnie Dugoni, Pharm.D.; Julio R. Lopez, Pharm.D.; Phebe Kwon, Pharm.D.; Jeanene Nehira, Pharm.D. VA Northern California Health Care System (VANCHCS) Martinez, CA

2. Background: • Evaluate the clinical impact of telephone care program pharmacists reviewing medication dosing for patients identified by the order check emails. • Neither VISTA nor CPRS provide drug-specific renal dosing warnings at the point of prescribing or prescription verification by the pharmacist.

3. Renewal Order Check Auto Email: Renewal Requests with Order Checks PATIENT PRESCRIPTION Last, First name 200001233 *Est. CrCl: 27.1 (CREAT: 2.55 mg/dL [H] 9/29/10 1:02:29 pm BUN: 32 mg/dL [H] 9/29/10 1:02:29 pm) [Est. CrCl based on modified Cockcroft-Gault equation using Adjusted Body Weight (if ht > 60 in.)] Estimated CrCl if less then 50 ml/min (CPRS Order Check *Estimated CrCl if <50 is enabled at the system level) (VANCHCS – Audio renewal program launched mid September 2010)

4. Findings: • Between 9/13/10 and 10/28/10, 359 patient profiles were reviewed. Forty-one dosing interventions were made; two of which required discontinuation of therapy. • Allopurinol > Gabapentin > Ranitidine Alendronate > Colchicine > Losartan, Acyclovir, Famciclovir, Sotalol, Valgancyclovir, Tramadol, Probenecid, Metformin, Hydrochorthiazide, Ciprofloxacin, NSAIDS

5. Contact Information: Jamie Young, Pharm.D. Manager, Pharmacy Telephone Care Program VANCHCS – 119 150 Muir Road Martinez, CA 94553 Jamie.young@va.gov 925-372-2180