Medication Route Interchange - Adult - Inpatient Clinical Practice Guideline Table of Contents SCOPE ...................................................................................................................................... 2 METHODOLOGY ...................................................................................................................... 3 INTRODUCTION ....................................................................................................................... 3 RECOMMENDATIONS .............................................................................................................. 4 UW HEALTH IMPLEMENTATION ............................................................................................. 5 REFERENCES: ......................................................................................................................... 6 APPENDIX A ............................................................................................................................. 7 CPG Contact for Content: Name: Carin Bouchard, PharmD, BCPS Phone Number: 263-8967 Email Address: cbouchard@uwhealth.org Guideline Update Author: Cindy Gaston, PharmD, BCPS Coordinating Team Members: Carin Bouchard, PharmD, BCPS Review Individuals/Bodies: Paul Rutecki, MD; Joseph Holt, MD; Barry Fox, MD; Luke Schultz, PharmD Committee Approvals/Dates: Medication Use Evaluation Committee – August 2015 Pharmacy & Therapeutics Committee – September 2015 (Interim update May 2018) Release Date: September 2015 Next Review Date: September 2018 Note: Active Table of Contents -- Click to follow link CPG Contact for Changes: Name: Philip Trapskin, PharmD, BCPS Phone Number: 265-0341 Email Address: ptrapskin@uwhealth.org Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Executive Summary Guideline Overview This purpose of this guideline is to identify medications clinically appropriate to automatically change the route of administration based on bioavailability, safety and efficacy data. This document provides criteria for safe and effective change in route of medication administration for inpatients (between parenteral and enteral and within the enteral route including administration via various feeding tubes). Companion Documents Medication Route Interchange Protocol Dosing of Medications in Patients Receiving Continuous Enteral Feedings – Clinical Practice Guideline Adult Enteral Nutrition Support Handbook UW Health Electrolytes (Intravenous – Adult – Inpatient Clinical Practice Guideline UW Health Electrolytes (Oral and Enteral) – Adult – Inpatient Clinical Practice Guidelines UW Health Fosphenytoin and Phenytoin - Pediatric/Adult – Clinical Practice Guideline UW Health Intravenous Administration of Formulary Medications – Adult – Inpatient Clinical Practice Guideline Pertinent UW Health Policies & Procedures Hospital Administrative Policy 8.17 - Administration of Medications Hospital Administrative Policy 8.33 – High Alert Medication Administration Patient Resources – none Scope Intended Users: Pharmacists, nurses, midlevel providers, physicians CPG objective(s): 1. Identify criteria for safe and effective interchange of medication routes including intravenous, oral and feeding tube administration. 2. Identify medications clinically appropriate to change the administration route based on bioavailability, pharmacokinetic, safety and efficacy data. Target Population: Adult inpatients Interventions and Practices Considered: Providing the safest and most appropriate route of administration for medications included in this guideline. Major Outcomes Considered: Medication orders with the appropriate route of administration Guideline Metrics: Compliance with the route interchange guideline and protocol. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Methodology A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) developed by the American Heart Association and American College of Cardiology (Figure 1.) has been used to assess the Quality and Strength of the Evidence in this Clinical Practice Guideline.1 Figure 1. Quality of Evidence and Strength of Recommendation Grading Matrix Introduction The enteral route of medication administration is preferred over the intravenous route for improved safety, increased patient comfort, and decreased cost.2 The intravenous route of medication administration is classified as an independent risk factor for having an adverse drug event (ADE) and is considered a high- risk activity due to the potential for error resulting from the multiple necessary complex steps.3-5 Studies demonstrate that intravenous medication administration is associated with a 3% higher risk for ADE per each medication administered.4 The magnitude of harm resulting from these errors has also contributed to its high-risk classification.4,5 Furthermore, enteral administration may reduce the risk of intravenous catheter related infections, medication incompatibilities, and thrombophlebitis.2,6 Increased costs, length of stay, and significantly higher mortality (versus other medication errors) have all been linked to intravenous administration of medications.7,8 Intravenous administration of medications should be minimized whenever possible by encouraging conversions to oral route whenever possible.4 Enteral medication is associated with decreased cost in comparison to intravenous medications and associated lines, sets, and infusion pumps necessary for administration. Early interchange to oral medications has been linked to shorter lengths of stay without clinical outcome compromise, independent of ADEs.9,10 Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Criteria for inclusion of medications in the guideline were high oral bioavailability and good enteral tolerance.11 Medications were included in this guideline based upon clinical data confirming tolerability and high oral bioavailability. Recommendations 1. Parenteral to enteral 1.1. To initiate the parenteral to enteral interchange, which includes medications administered orally or via feeding tubes, the medication must be listed in Table 1. In addition, patients must meet all inclusion criteria and none of the exclusion criteria. 1.2. Inclusion Criteria (Class 1, Level C) 1.2.1. Patient must have a diet order and be tolerating either a clear liquid or more advanced diet or must be tolerating enteral tube feedings.9 1.2.2. For antibiotics, patient’s fever and white blood cell count must be down trending for the past 24 hours.11,12 1.3. Exclusion Criteria (Class 1, Level C) 1.3.1. Patient is unable to swallow, is strict NPO and without feeding tube, or refuses oral medications.9 1.3.2. Severe vomiting or diarrhea has been documented within the past 24 hours or patient has an acute condition that affects gastrointestinal absorption (i.e., gastrointestinal obstruction or bleed, ileus, grade III or IV mucositis, gastrointestinal transit time too short for absorption, malabsorption syndromes, partial/total removal of the stomach, or short bowel syndrome. 1.3.3. Patient is hemodynamically unstable (sustained heart rate >100 beats/minute, respiratory rate >24 breaths/minute, systolic blood pressure <90 mmHg or on high- doses of vasopressors in presence of shock).13 1.3.4. Patient requires continuous tube feedings that cannot be interrupted and patient requires a medication known to bind to enteral nutrition formulas.13 1.3.5. Patient with endocarditis, meningitis, brain abscess, orbital cellulitis, CNS infection, osteomyelitis, or endophthalmitis that should be treated with intravenous antibiotic therapy.12 2. Enteral to parenteral 2.1. For a patient to be eligible for the enteral to parenteral interchange the medication must be listed in Table 1 and the patient must meet one or more of the following clinical criteria. 2.2. Inclusion Criteria (Class 1, Level C) 2.2.1. Patient is unable to tolerate oral medications or has failed a swallow study and does not have a feeding tube in place.9 2.2.2. Patient has an acute condition that affects gastrointestinal absorption (i.e., gastrointestinal obstruction or bleed, severe diarrhea, ileus, severe vomiting or grade III or IV mucositis).13 2.2.3. Patient is nutritionally compromised and parenteral administration of medication is clinically warranted to minimize the amount of time the enteral nutrition is interrupted (e.g., phenytoin, fluoroquinolones, etc.).13 2.2.4. Patient has had an NPO order for two days or more.9 2.2.5. Patient requires continuous gastric suctioning.13 2.3. Exclusion criteria 2.3.1. Acetaminophen, isavuconazole, posaconazole, and voriconazole cannot be converted from enteral to parenteral formulation. 2.3.2. In liver, kidney and pancreas transplant patients, ganciclovir for treatment of CMV disease or other viral infection cannot be converted from enteral to parenteral formulation without a prescribing provider order. 3. Enteral to enteral (oral to feeding tube and feeding tube to oral) 3.1. Medication orders with an enteral route of administration are eligible for this interchange. An initial medication order must be documented in the medical record to initiate the interchange. The pharmacist will modify the medication order based on the below inclusion criteria and evaluation of assessment criteria. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions 3.2. Assessment Criteria (Class 1, Level C) 3.2.1. Evaluation of available alternative dosage forms including an assessment of formulation appropriateness and modification of dosage and/or frequency of product if therapeutically warranted. 3.2.2. Assessment of drug pharmacokinetic parameters including the site of drug action, bioavailability, absorption characteristics and the effects of food on drug absorption. 3.2.3. Evaluation of the type of feeding tube and placement location within the gastrointestinal tract. 3.2.4. Assessment and modification of dosage and/or frequency if therapeutically warranted (i.e., phenytoin capsules to phenytoin suspension). A pharmacist is also permitted to modify an extended release product to an immediate release product if listed in Appendix A, Table 2 (i.e., divalproex sodium to valproic acid solution). 3.3. Oral to Feeding Tube Inclusion Criteria (Class 1, Level C) 3.3.1. To qualify for the oral to enteral interchange an enteral feeding tube there must be documentation of appropriate placement and approval for use 3.3.2. Extended Release to Immediate Release Product Inclusion Criteria (Class 1, Level C) 3.3.2.1. A patient is currently ordered an extended release product and no longer able to take medications by mouth and qualifies for conversion to administration by feeding tube. 3.3.2.2. Extended release product for conversion is listed in Appendix A, Table 2. 3.4. Feeding Tube to Oral Inclusion Criteria (Class 1, Level C) 3.4.1. To initiate a feeding tube to oral interchange the patient must have passed a swallow study as documented in the EMR. 3.4.2. Immediate Release to Extended Release Product Inclusion Criteria (Class 1, Level C) 3.4.2.1. A patient who had previously been converted to immediate release product from extended release product who now qualifies for feeding tube to oral inclusion criteria (3.2.1). 3.4.2.2. Extended release product for conversion is listed in Appendix A, Table 2. 4. Documentation 4.1. Medication orders meeting the above criteria for the change in the route of administration are subject to interchange as soon as the patient meets the established criteria. 4.2. Once a patient meets the criteria, the pharmacist will discontinue the current medication order and automatically convert the medication to the appropriate corresponding dosage form by placing an order in the EMR. 4.3. The pharmacist will document all protocol directed route interchanges in the electronic health record. UW Health Implementation Potential Benefits/Harms: Benefits of guideline implementation include decreased length of stay, decreased cost of medication therapy, increased patient comfort, and decreased risk associated with intravenous administration of medications. Qualifying Statements As new data becomes available for safety and efficacy of route administration of medications recommendations may change. Implementation Plan/Tools 1. Guideline will be housed on U-Connect in a dedicated folder for CPGs. 2. Links to this guideline will be updated and/or added in appropriate Health Link or equivalent tools. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Disclaimer CPGs are described to assist clinicians by providing a framework for the evaluation and treatment of patients. This Clinical Practice Guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. References: 1. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2013;61(2):213-265. 2. Cyriac JM, James E. Switch over from intravenous to oral therapy: A concise overview. J Pharmacol Pharmacother. 2014;5(2):83-87. 3. Berdot S, Gillaizeau F, Caruba T, Prognon P, Durieux P, Sabatier B. Drug administration errors in hospital inpatients: a systematic review. PLoS One. 2013;8(6):e68856. 4. Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Analysis of risk factors for adverse drug events in critically ill patients*. Crit Care Med. 2012;40(3):823-828. 5. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf. 2011;20(12):1027-1034. 6. Vijayakumar A, Sharon EV, Teena J, Nobil S, Nazeer I. A clinical study on drug-related problems associated with intravenous drug administration. J Basic Clin Pharm. 2014;5(2):49-53. 7. Jewesson P. Cost-effectiveness and value of an IV switch. Pharmacoeconomics. 1994;5(Suppl 2):20-26. 8. Parker SE, Davey PG. Pharmacoeconomics of intravenous drug administration. Pharmacoeconomics. 1992;1(2):103-115. 9. Fischer MA, Solomon DH, Teich JM, Avorn J. Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients. Arch Intern Med. 2003;163(21):2585-2589. 10. Mertz D, Koller M, Haller P, et al. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chemother. 2009;64(1):188-199. 11. Kuper KM. Intravenous to Oral Therapy Conversion. In. Murdaugh, ed. Competance Assessment Tools for Health-System Pharmacies. 4th ed. Bethesda, MD: American Society of Health-System Pharamcits, Inc.; 2008: 347-360. 12. Przybylski KG, Rybak MJ, Martin PR, et al. A pharmacist-initiated program of intravenous to oral antibiotic conversion. Pharmacotherapy. 1997;17(2):271-276. 13. Ramirez JA. Antibiotic streamlining: development and justification of an antibiotic streamlining program. Pharm Pract Manag Q. 1996;16(3):19-34. 14. Lexicomp Online® , Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; Accessed March 28, 2018. 15. Ho BP, Lau TT, Balen RM, Naumann TL, Jewesson PJ. The impact of a pharmacist-managed dosage form conversion service on ciprofloxacin usage at a major Canadian teaching hospital: a pre- and post-intervention study. BMC Health Serv Res. 2005;5:48. 16. Dickerson RN, Maish GO, 3rd, Minard G, Brown RO. Clinical relevancy of the levothyroxine-continuous enteral nutrition interaction. Nutr Clin Pract. 2010;25(6):646-652. 17. Fish LH, Schwartz HL, Cavanaugh J, Steffes MW, Bantle JP, Oppenheimer JH. Replacement dose, metabolism, and bioavailability of levothyroxine in the treatment of hypothyroidism. Role of triiodothyronine in pituitary feedback in humans. N Engl J Med. 1987;316(13):764-770. 18. Budde K, Glander P, Diekmann F, et al. Enteric-coated mycophenolate sodium: safe conversion from mycophenolate mofetil in maintenance renal transplant recipients. Transplantation proceedings. 2004;36(2 Suppl):524s-527s. 19. Pisegna JR. Switching between intravenous and oral pantoprazole. J Clin Gastroenterol. 2001;32(1):27-32. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Appendix A Table 1. Medications Approved for Parenteral and Enteral Route Interchange *See LexiComp “Do not crush” list for applicability of crushing tablets. Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes Acetaminophen*14 *Do not convert from enteral to parenteral without provider order. 1000 mg IV Acetaminophen 1000 mg orally 1 to 1 dosing 650 mg IV 650 mg orally 325 mg IV 325 mg orally Azithromycin14 250 mg IV Azithromycin 250 mg orally daily 1 to 1 dosing 500 mg IV 500 mg orally daily Ciprofloxacin2,11,15 200 mg IV every 12h Ciprofloxacin Tablet 250 mg orally twice daily For administration via feeding tube see Lexicomp administration information Do not administer suspension via a feeding tube 400 mg IV every 12h 500 mg orally twice daily 400 mg IV every 8h OR 600 mg IV every 12h 750 mg orally twice daily Dexamethasone11 2 mg IV Dexamethasone 2 mg orally 1 to 1 dosing 4 mg IV 4 mg orally 6 mg IV 6 mg orally 10 mg IV 10 mg orally Doxycycline2 100 mg IV Doxycycline 100 mg orally 1 to 1 dosing Fosphenytoin11 18-20 mg IV Phenytoin Equivalent (PE)/kg (loading) Phenytoin 18-20 mg/kg in 2-3 divided doses orally (given 2 to 4 hours apart use suspension or chew tabs) Round to nearest 100 mg and 30 mg capsule strength when converting to capsules. Round to nearest 25 mg for chew tab and 50 mg for suspension. For administration via feeding tube see Lexicomp administration information, Lexicomp food interactions, and Fosphenytoin and Phenytoin Guideline 4-6 mg IV PE/kg/day Chew tabs/suspension: 4-6 mg/kg/day in 2 divided doses Capsules: 1-2 divided doses orally (once daily if dose <400 mg) Fluconazole11 100 mg IV Fluconazole 100 mg orally 1 to 1 dosing 200 mg IV 200 mg orally 400 mg IV 400 mg orally Ganciclovir (IV)14 FOR CMV PROPHYLAXIS For kidney and pancreas transplant patients, may convert to oral when tolerating oral# Based on Creatinine Clearance Valganciclovir (PO) Based on Creatinine Clearance Valganciclovir is the oral prodrug of ganciclovir Note: CrCl cut-offs vary from IV to PO formulation Dose-reduced valganciclovir is a risk factor > 70 mL/min 5 mg/kg every 24 hr > 60 mL/min 900 mg once daily 50‐69 mL/min 2.5 mg/kg every 24 hr 40‐59 mL/min 450 mg once daily 25‐49 mL/min 1.25 mg/kg every 24 hr 25‐39 mL/min 450 mg once every OTHER day Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes For liver transplant patients, may convert to oral after transfer from ICU to General Care# 10‐24 mL/min 0.625 mg/kg every 24 hr 10-24 mL/min450 mg twice weekly for ganciclovir-resistant CMV. Consider alternative prophylaxis approaches or select the higher dose for borderline or improving creatinine clearance. #For ganciclovir, if BMI > 30 kg/m2, use adjusted body weight. If BMI < 30 kg/m2, use actual body weight < 10 mL/min (HD) 0.625 mg/kg three times weekly after hemodialysis <10 mL/min or HD 100mg three times weekly after hemodialysis *If oral solution is not covered by insurance, 450 mg twice weekly administered post-HD on M/F or Tu/Sa is reasonable Ganciclovir (IV)14 FOR CMV TREATMENT If ganciclovir is used for treatment of CMV disease (or other viral infection), the route interchange may NOT be used. If ganciclovir is used for CMV prophylaxis, please see row above for conversion to PO valganciclovir. Isavuconazole*14 *Do not convert from enteral to parenteral without provider order. 372 mg (isavuconazole 200 mg) every 8 h Isavuconazole 372 mg (isavuconazole 200 mg) every 8 h 1 to 1 dosing Lacosamide14 50 mg IV Lacosamide 50 mg orally 1 to 1 dosing 100 mg IV 100 mg orally 150 mg IV 150 mg orally 200 mg IV 200 mg orally Levetiracetam11 500-1500 mg IV Levetiracetam 500-1500 mg orally 1 to 1 dosing Levofloxacin14 500-750 mg IV once daily Levofloxacin 500-750 mg PO once daily For administration via feeding tube see Lexicomp administration information, Lexicomp food interactions Levothyroxine11,16,17 15 mcg/day IV Levothyroxine 25 mcg orally daily Parenteral dose should be approx. 80% of oral dose16,17 For administration via feeding tube see Lexicomp administration information 35 mcg/day IV 50 mcg orally daily 50 mcg/day IV 75 mcg orally daily 75 mcg/day IV 100 mcg orally daily 85 mcg/day IV 125 mcg orally daily 100 mcg/day IV 150 mcg orally daily 125 mcg/day IV 175 mcg orally daily 150 mcg/day IV 200 mcg orally daily Linezolid11 600 mg IV Linezolid 600 mg orally 1 to 1 dosing Metoclopramide14 10 mg IV Metoclopramide 10 mg orally 1 to 1 dosing Metronidazole14 500 mg IV Metronidazole 500 mg orally 1 to 1 dosing Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes Methylprednisolone14 4 mg IV Prednisone 5 mg orally Moxifloxacin2 400 mg IV Moxifloxacin 400 mg orally 1 to 1 dosing For administration via feeding tube see Lexicomp administration information Mycophenolate mofetil (CellCept)14,18 Kidney, liver, pancreas transplant patients ONLY 250 mg IV every 12 h Mycophenolate mofetil generic 250 mg twice daily *When converting 1000 mg from IV to enteral, base enteral dose on home regimen or UW Health transplant regimens. 500 mg IV every 12h 500 mg twice daily 750 mg IV every 12h 750 mg twice daily 1000 mg IV every 12h 1000 mg 2-3 times daily* Mycophenolate mofetil (CellCept)14,18 Kidney, liver, pancreas transplant patients ONLY 250 mg IV every 12 h Mycophenolate sodium (Myfortic) 180 mg twice daily *When converting 1000 mg from IV to enteral, base enteral dose on home regimen or UW Health transplant regimens. 500 mg IV every 12h 360 mg twice daily 750 mg IV every 12h 540 mg twice daily 1000 mg IV every 12h 720 mg 2-3 times daily* Ondansetron14 4mg IV Ondansetron orally disintegrating tablet (ODT) 4mg ODT 1 to 1 dosing Pantoprazole11,19 40 mg IV Pantoprazole 40 mg orally 1 to 1 dosing Phenobarbital 1-3 mg/kg/day IV (2 divided doses) Phenobarbital 1-3 mg/kg/day orally (1-2 divideddoses) Only maintenance dosage qualifies for interchange Phenytoin2,11 18-20 mg IV PE/kg (loading) Phenytoin 18-20 mg/kg in 2-3 divided doses orally Round to nearest 100 mg and 30 mg capsule strength when converting to capsules. Round to nearest 25 mg for chew tab and 50 mg for suspension. For administration via feeding tube see Lexicomp administration information, Lexicomp food interactions, and Fosphenytoin and Phenytoin Guideline 4 to 6 mg/kg IV/day Chew tabs/suspension: 4-6 mg/kg/day in divided doses Capsules: 1-2 divided doses orally (once daily if dose <400 mg) Posaconazole*14 *Do not convert from enteral to parenteral without provider order. 300 mg IV daily Posaconazole 300 mg PO daily delayed-release tablet 1 to 1 dosing Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes Potassium Chloride 10 mEq - 40 mEq IV Potassium Chloride 10 mEq - 40 mEq orally 1 to 1 dosing Doses ≥ 40 mEq should be given in increments of 20mEq at 2-hour intervals See: Guideline for Use of Oral and Enteral Electrolytes in Adults Rifampin 600 mg IV Rifampin 600 mg orally 1 to 1 dosing Sulfamethoxazole- trimethoprim 320/1600 mg Sulfamethoxazole -trimethoprim 320/1600 mg 1 to 1 dosing 160/800 mg 160/800 mg Valproic Acid 10-15mg/kg/day IV (divided every 6hr) Divalproex Valproic Acid solution Immediate release 3-4x orally daily; delayed release 2-3 x orally daily; 10-15mg/kg/day Round dose to nearest tablet strength Voriconazole*2 *Do not convert from enteral to parenteral without provider order. 4 mg/kg IV every 12h or 200-400 mg IV every 12 Voriconazole 4 mg/kg PO every 12h (susp) or 200-400 PO every 12h Round to the nearest tablet strength using tablets For administration via feeding tube see Lexicomp administration information Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Table 2. Oral to Enteral Tube Route Interchanges Oral Formulation Dose/Frequency Enteral Tube Formulation Dose/Frequency Notes Bupropion ER 150 to 400 mg/day Bupropion 50 to100 mg 3-4 times daily 1 to 1 daily dose conversion with increased frequency Carbamazepine ER 200 mg/day Carbamazepine 200 mg/day in divided doses Same total daily dosage divided two to four times daily 400 mg/day 400 mg/day in divided doses 600 mg/day 600 mg/day in divided doses 800 mg/day 800 mg/day in divided doses Carbidopa/levodopa 25/100 mg ER 25/100 to 200/800 mg twice daily Carbidopa/levodopa 25/100 mg 40/160 to 320/1280 mg/day in divided doses Convert dose based on levodopa equivalents. Give 80% of the total daily levodopa ER dose as immediate release levodopa. Divide calculated total daily dose into three or four times daily dosing. Round doses to the nearest 50 mg. Diltiazem HCL ER 24hr 120 mg/day Diltiazem 30 mg four times daily 180 mg/day 45 mg four times daily 240 mg/day 60 mg four times daily 300 mg/day 75 mg four times daily Divalproex Sodium ER 500 mg/day Valproic Acid Solution 500 mg/day in divided doses Same total daily dosage divided three times daily 1000 mg/day 1000 mg/day in divided doses Isosorbide Mononitrate ER 30 mg/day Isosorbide Mononitrate 10 mg TID Patient must have at least 12 hour nitrate-free period Metoprolol Succinate ER 25 mg/day Metoprolol Tartrate 12.5 mg twice daily Same total daily dosage 50 mg/day 25 mg twice daily 100 mg/day 50 mg twice daily 200 mg/day 100 mg twice daily Morphine Sulfate ER 90 mg/day Morphine Sulfate 15 mg every 4 hr Only listed doses may be converted; all other doses require provider order 180 mg/day 30 mg every 4 hr 270 mg/day 45 mg every 4 hr Oxycodone ER 30 mg/day Oxycodone 5 mg every 4 hr Only listed doses may be converted; all other doses require provider order 60 mg/day 10 mg every 4 hr 90 mg/day 15 mg every 4 hr Potassium Chloride ER 10 mEq Potassium Chloride Solution 10 mEq 1 to 1 conversion at same frequency 20 mEq 20 mEq Probiotic capsule 1 cap daily Probiotic suspension 1.2 mL daily 2 caps daily 2.4 mL daily Propranolol SR 60 mg/day Propranolol 20 mg three times daily 80 mg/day 20 mg four times daily 120 mg/day 30-40 mg 3-4 times daily 160 mg/day 40 mg four times daily Venlafaxine ER 75 to 225 mg/day Venlafaxine 37.5 to 75 mg 2-3 times daily 1 to 1 dose conversion Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Oral Formulation Dose/Frequency Enteral Tube Formulation Dose/Frequency Notes Verapamil HCL ER 120 mg/day Verapamil 40 mg three times daily 180 mg/day 60 mg three times daily 240 mg/day 80 mg three times daily Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 03/2022 Effective 3/21/2022. Contact CCKM@uwhealth.org for previous versions Scope Methodology Methodology Introduction Recommendations UW Health Implementation References: Appendix A