INTERN MEDICATION GUIDE

INTERN MEDICATION
GUIDE

2020

Updated by A Given, Pharmacy December 2019

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 INTERN MEDICATION GUIDE

Table of Contents:
Table of Contents: .......................................................................................................................................... 2
PHARMACY CONTACT NUMBERS ............................................................................................................... 4
MEDICATION MANAGEMENT PLAN ............................................................................................................. 5
ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC) ...................................................................... 6
Background Rationale ............................................................................................................................ 6
Overview ................................................................................................................................................ 6
Patient Identification ............................................................................................................................... 7
Allergies & Adverse drug reactions (ADR) .............................................................................................. 7
Numbering of medication charts ............................................................................................................. 8
Venous Thromboembolism (VTE) prevention.......................................................................................... 8
Regular Medication Orders ..................................................................................................................... 9
Frequency (Guidance Only).................................................................................................................. 10
Approved Abbreviations ....................................................................................................................... 10
Prescriber identification: ....................................................................................................................... 11
Variable Dose Medications ................................................................................................................... 12
Warfarin dosing .................................................................................................................................... 12
When required (PRN) medication orders .............................................................................................. 13
Stat Dose Orders ................................................................................................................................. 13
Phone Orders....................................................................................................................................... 13
Ceasing Medication Orders .................................................................................................................. 14
Limited Duration Medication Orders ...................................................................................................... 15
Less than daily administration............................................................................................................... 15
Re-writing Medication Charts ................................................................................................................ 15
HIGH DOSE OPIATES/INSULIN .................................................................................................................. 16
INTRAVENOUS THERAPY ORDER CHART ................................................................................................ 17
OTHER MEDICATION CHARTS .................................................................................................................. 18
DISCHARGE PRESCRIPTIONS................................................................................................................... 19
What needs to be included: .................................................................................................................. 20
Drugs of Addiction (DA) ........................................................................................................................ 21
PHARMACEUTICAL BENEFITS SCHEME (PBS)......................................................................................... 21
Authority PBS prescriptions .................................................................................................................. 21
PBS website......................................................................................................................................... 23
TNH MEDICATION GUIDE ........................................................................................................................... 25
Prescribing Unfamiliar Medications ....................................................................................................... 25
Other documents/forms you may be asked to complete: ....................................................................... 25
ANTIMICROBIAL STEWARDSHIP PROGRAM ............................................................................................ 26
Antibiotic Guidance (iGuidance) ........................................................................................................... 26
The Direct Oral Anticoagulants (DOACs) .............................................................................................. 27
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 INTERN MEDICATION GUIDE

ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION ........................................................................ 28

Sepsis of unclear focus ........................................................................................................................ 28
Vancomycin dosing .............................................................................................................................. 28
Acute Cystitis ....................................................................................................................................... 29
Catheter-associated UTI....................................................................................................................... 29
Pyelonephritis ...................................................................................................................................... 29
Prostatitis ............................................................................................................................................. 30
Cellulitis ............................................................................................................................................... 30
Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) ........................................................ 30
Community Acquired Pneumonia.......................................................................................................... 31
Aspiration Pneumonia .......................................................................................................................... 31
Hospital Acquired Pneumonia............................................................................................................... 32
Peritonitis due to perforated viscus ....................................................................................................... 32
Acute cholecystitis ................................................................................................................................ 33
Ascending cholangitis........................................................................................................................... 33
Acute Appendicitis................................................................................................................................ 33
Acute diverticulitis................................................................................................................................. 33
Acute pancreatitis................................................................................................................................. 34
Infected pancreatic necrosis / pancreatic abscess ................................................................................ 34
GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE ...................................................... 34
HANDY MEDICATION GUIDES ................................................................................................................... 35
Endocrinology ...................................................................................................................................... 35
End of Life Care ................................................................................................................................... 35
Vascular Device Protocols ............................................................................................................................ 36
Fluid Prescribing ........................................................................................................................................... 37
Rule of 1’s – oversimplified but memorable........................................................................................... 37
The Real Rules: Correct but easy to forget! .......................................................................................... 37
ON-LINE TRAINING ..................................................................................................................................... 38
COMMON MEDICATION CHEAT SHEET………………………………………………………………………….39

This booklet was created by the Pharmacy Department.

Available from: Medical Education Unit (MEU), located at Level 2, NH – Education, NCHER - Northern Centre
Health Education & Research. Telephone: 8468 0758

Please advise suggestions/amendments to: Pharmacy Department

(Team Leader for Education x58664)

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PHARMACY CONTACT NUMBERS
Pharmacists are always willing to help all medical staff.
All ward pharmacists are also available on MEDTASKER.

Ward pharmacist Extension

Emergency 52696
Emergency – Admissions (for MMP completion) 0447163874
SSU and CDU 0447141711
Ward 1 – Day Oncology 52094
Ward 2 – Children’s Unit 52205
Ward 3 52350
Ward 4 52472
Ward 5– Cardiology 58447
Ward 6– Observation Unit 52473
Ward 7 – Psychiatry 1 58994
Ward 8 - Psychiatry 2 52885
Ward 9 - DPU 52662
Ward 11/12 – Maternity & Special Care Nursery 52205
Ward 13 52884
Ward 14 52459
Ward 16 52477
Ward 17 - ICU 52532
Ward 18 52474
Speciality pharmacist
Oncology 52094
Renal / Dialysis 58387
Antimicrobial stewardship 58452
Hospital in the home (HITH) 52967
Clinical Trials 58571
Palliative Care 0439920501
Dispensary
Inpatient 58572
Outpatient 58571
Discharges 52204
Manufacturing 58578
Director of Pharmacy 58560
Deputy Director of Pharmacy 58561
Associate Director of Pharmacy 52663
Team Leader – Medicine 52661
Team Leader – Surgical 52662
Team Leader – Oncology + Women’s and Children’s 52094
Team Leader – Education, Development and Research 52664
Team Leader – Quality Use of Medicines & Safety 52665

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MEDICATION MANAGEMENT PLAN

The Medication Management Plan (MMP) is where pharmacists document a patient’s medication history and
reconcile it against the drug chart. It also includes how the patient manages their medications and any issues
identified with their medications and the medication chart. It is usually filed with the medication charts in the
patient’s folder.

Medication changes
during admission

Identified issues for review.

Action outcome once
reviewed.

Medication list including

reconciliation

Admission medication
risk assessment
Discharge Planning

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ADULT NATIONAL INPATIENT MEDICATION CHART (NIMC)

Background Rationale

 Drug therapy errors occur in 5-20% of drug administration in Australian hospitals1

 43% of adverse drug events are preventable 2
 Medication interventions save lives, reduce length of stay, reduce admissions and reduce costs 3
1
Australian Council for Safety and Quality in Health Care. July 2002.
2
Wilson RM, Runciman WB, Gibberd RW et al. Med J Aust 1995; 163: 458-71
3
Dooley MJ, Allen KM, Doecke CJ et al. BJCP 2004; 57: 513-21

Overview

Front

“Regular medications” section VTE prophylaxis

section

Back
PRN section

STAT doses

Phone orders

Good
prescribing
principles
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National Inpatient Medication Chart (continued)
Patient Identification

ALL medication charts must have correct patient identification details i.e. bradma
Significant medication errors can occur when patient identification is incorrect or incomplete

 Affix patient ID label (i.e. large bradma) on both allocated pages

 Check labels are correct, initial

 Print patient name and check label is correct

for the patient on both allocated pages.

Allergies & Adverse drug reactions (ADR)

 Re-exposure is a preventable cause of significant harm

 Not all ADRs are clinically significant

ADR box on ALL medication charts needs to be completed.

 If patient has nil known allergies or unknown allergy status, TICK appropriate box, sign, print name and
date entry.
 If known ADR note drug name and reaction details, sign, print name and date entry. Attach ADR sticker
to pages 3 and 4.
 If any amendments or additions are made to the ADR box, initials and date of entry required.

No known allergies: Known allergies – complete all sections:

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National Inpatient Medication Chart (continued)

Numbering of medication charts

 All medication charts should be numbered using roman numerals e.g. 1 of 2, 2 of 3, etc.

Venous Thromboembolism (VTE) prevention

 Patients ≥16yrs must have VTE Risk Assessment completed (form on the front of medication chart)
 Day patients without regular mediation chart may be exempt
 MUST be completed by medical staff:

i. Identify risk by completing the VTE Risk Assessment Tool (front page of medication chart)
ii. Determine appropriate prophylaxis
iii. Order ALL prophylaxis (chemical and/or mechanical) on Medication Chart

VTE Risk Screen

NOTE: This section only for VTE PROPHYLAXIS. VTE treatment (i.e. therapeutic doses) needs to be charted
as a regular medication.

For Best Practice Guidelines / Policy / Risk Assessment Form, refer to: Venous Thromboembolism (VTE)
Prevention Guidelines on Prompt or use the following link:
Haematology - Thrombosis & Haemostasis Protocols

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National Inpatient Medication Chart (continued)

Regular Medication Orders

ALL orders must include:

 Date started not date written
o when rewriting an order, write the date of first prescribing, not the re-write date
 Generic prescribing unless a combination product or Insulins (refer to Combinations stocked at
Northern Health list)
 Dose, frequency and route – only use acceptable abbreviations as per the “Good prescribing
principles” on the NIMC
 Doctor to enter dosing times – not including times frequently leads to missed doses
 Slow release box must be ticked where appropriate. Also include show release abbreviation in
order.
 Document indication.
 SIGN all orders. Unsigned orders are not legal and therefore are not able to be administerede
nurses can not administer the medication annot be administered.

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 INTERN MEDICATION GUIDE
National Inpatient Medication Chart (continued)

Frequency (Guidance Only)

Write the frequencies and administration times for all medications charted.
Omitted medication times lead to medications being missed affecting patient’s treatment.

If a medication is to be given with food, chart meal times: 08:00, 12:00, 18:00

Intravenous antibiotics – should be prescribed by hours (i.e. q6h) and times should reflect this dosing

**Warfarin dosing: 16:00 hours** This is to ensure orders are completed before home team leave the hospital

Approved Abbreviations

Route of administration
Abbreviation Meaning
PO Oral
NG Nasogastric
subling Sublingual
subcut Subcutaneous
IV Intravenous
IM Intramuscular
PR Per rectum
PV Per vagina
top Topical
neb Nebulised
Inh Inhaled

Units of measure and concentration

Abbreviation Meaning
g gram(s)
International unit(s) International unit(s)
unit(s) unit(s)
L litre
mg milligram(s)
mL millilitre(s)
microg / microgram(s) microgram(s)
% percentage
mmol millimole
Please see the ‘Good prescribing principles’ section on the back of the Northern Health ‘National inpatient
medication chart’ for more details.

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National Inpatient Medication Chart (continued)
Prescriber identification:

You know who you are but it’s sometimes very difficult to match a signature to an individual’s identity and
pagers and roles change frequently.

Health professionals (Pharmacists, Nurses and other prescribers) need to be able to easily identify who has
prescribed what.

Please sign; print your name and your pager number at least once on each NIMC and all schedule 8 orders
that you prescribe on (see below).

All medication orders need to be signed to be made legal. Nursing staff cannot administer an order that has not
been signed. This can lead to treatment delays.

ABBREVIATIONS to AVOID!
Prescribing Principles: Avoid U or IU:
1. Plain English, Legible- PRINT drug names mistaken for ‘0’. i.e. 4U can be interpreted as
2. Use Generic Drug Names 40.
(a) Exemption for combination products (i.e. Targin,
Instead- write the word ‘Units’
Seretide)
(b) Exemption for medication with significant Avoid ug/ µg:
bioavailability issues (i.e. tacrolimus, mistaken for mg.
cyclosporine)
3. Write drug names in full. Instead- write the word ‘microg’
4. NEVER abbreviate any drug name e.g. HCT, MTX, Avoid o.d. or OD:
ISMN, GTN.
Mistaken for BD.
Exemption: indication of slow release and immediate
release (Tramadol SR or Tramadol IR) Instead- write mane/ midi/ nocte
5. Do not use chemical names/symbols. Add Trailing ‘0’ after decimal point:
6. Do not include the salt of the chemical unless it is
clinically significant 1.0mg can be mistaken for 10mg.
Example: mycophenolate mofetil vs. mycophenolate Instead- write 1mg
sodium Avoid leading ‘0’ before decimal point:
7. Dosing:
a. Use words or numbers (i.e. 1, 2). .1mg can be mistaken as 1mg.
b. Do not use roman numerals (i.e. ii, v) Instead- write 0.1mg
c. Use metric units (i.e. gram or mL).
d. Do not use apothecary units (i.e. minims or Avoid SC and SL:
drams) can be mistaken for each other
e. For oral liquid preparations, prescribe the Instead- write “subcut(aneous)” or
dose in milligrams or grams(if applicable). “subling(ual)”
f. Express the dosage frequency unambiguously
(for example “three times a week”) Avoid Fractions:
8. Avoid acronyms or abbreviations for medical terms 1/7 could be ‘for 1 day’ or ‘once daily’ or ‘for
and procedure names on orders or prescriptions. one week’
Refer to the Australian Commission on Safety and Other unacceptable abbreviations: qd/ QD, qod/
Quality in Healthcare website for more details QOD/ symbols

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National Inpatient Medication Chart (continued)

Variable Dose Medications

This section allows ordering of medications requiring variable dosing based on lab results or as a reducing
protocol e.g. prednisolone, tobramycin, gentamicin.
Each dose needs to be individually prescribed and signed for by the prescriber.

Warfarin dosing

This section is for warfarin dosing only.

 Brand of warfarin needs to be circled. Warfarin brands are NOT interchangeable.
 Document indication and target INR.
 Document INR result.
 Each dose needs to be individually prescribed and signed for by the prescriber.
 Always prescribe dose once INR result is back to avoid under or over dosing.


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National Inpatient Medication Chart (continued)

When required (PRN) medication orders

PRN Orders must also include:

Hourly frequency

Maximum dose in 24 hours

Indication

To give clear administration and maximum daily dose

Check all sections of the medication chart to ensure over-dosing does not occur e.g. paracetamol 1g QID
regular plus PRN dosing.

Stat Dose Orders

This is section is for doses that are to be given immediately - “STAT”.

If the medication is to be continued regularly, e.g. IV antibiotics, ensure that a regular order is also charted.
When charting STAT order, checks all sections of the medication chart to prevent administration of excess
doses.
Communicate all STAT orders with the nursing staff to ensure medications ordered are given in a timely
manner, preventing delays.

Phone Orders

Nursing staff may contact you for a phone order. These orders need to be repeated to a second nurse and
signed by the authorising doctor within 24 hours

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National Inpatient Medication Chart (continued)

Ceasing Medication Orders

 Orders must NOT be obscured
 Doctor to put single line through order and two lines after the last dose in the administration
record section
 Write CEASE, the reason, date and sign

CORRECT WAY TO CEASE AN ORDER:

INCORRECT WAY TO CEASE AN ORDER:

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National Inpatient Medication Chart (continued)

Limited Duration Medication Orders

 Ordered only for certain days
 Block out day/times when NOT to be given
 Indicate using (X)

Less than daily administration

 Specify frequency clearly
 If weekly – specifiy day to be given
 Box days when medication is to be given
 Block out day/times when NOT to be given - Indicate using (X)

Re-writing Medication Charts

 Care should be taken when rewriting medication charts. Fatal errors have occurred due to lapses in
concentration. Where possible, all efforts should be taken to prevent disruption.
 When complete it is best practice to inform the nursing and/or pharmacy staff that the medication chart has
been rewritten to allow double checking.

Remember DRS
DATE
REASON
SIGNATURE

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HIGH DOSE OPIATES/INSULIN
HIGH DOSE
VERIFICATION
Date__/__/__ Initial __/__

Unintentional prescribing of high dose opiates and inuslin is to be avoided by the application of a “high dose
sticker”.
Doses greater than soluble insulin 50 units or oral Morphine 30mg (equivalent dose in table below) require the
following procedure to be followed:
 Prescribers are to affix the high dose sticker in the NIMC left margin next to the medicine, and sign and
date. This acknowledges the prescriber has checked and verified the dose prescribed is intended
 A table of high doses for medicines will be provided in the Medicines Prescribing Policy, Pharmacy
Operating Procedure and Medicines Administration Policy
 If prescriber has not attached a sticker, the nurse contacts the prescriber/unit doctor and requests
prompt action. No administration of the medicine by nurses are permitted unless sticker has been
applied
 Stickers are made available on wards from pharmacy
 Medication chart re-writes are to have a new sticker applied by the doctor at the time of re-writing the
chart
 Clinical areas/scenarios excluded: syringe drivers; patient controlled analgesia; intensive care patients;
“stat” doses in Emergency Department; anaesthetics department
 This is for all formulations (not just oral) for inpatient prescriptions only

Equivalent doses of oral morphine 30mg

Parenteral dose
Drug Oral dose
IV/SC
Buprenorphine 800micrograms Sublingual 400micrograms
Codeine 200 to 240mg n/a
Fentanyl 100 to 150micrograms
Hydromorphone 6 to 7.5mg 1.5 to 2mg
Methadone 10mg 5mg
Morphine 30mg 10mg
Oxycodone 15 to 20mg 10mg
Pethiine 75 to 100mg IM
Sufentanil 10micrograms SC
Tapentadol SR 75 to 100mg n/a
Tramadol 150mg 100 to 120mg

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INTRAVENOUS THERAPY ORDER CHART

 This chart used to prescribe and administer intravenous (IV) therapy such as:
o Fluids
 e.g. 0.9% Saline, 5% Glucose, 0.45% Saline +5% Glucose, Hartmans
o Electrolyte infusions
 E.g. Potassium, magnesium, phosphate
o Medications requiring continuous infusions
 E.g. pantoprazole, octreotide
ALL IV charts need to
Affix patient be numbered
bradma here

The date of The time of The medication added to All orders need to
the infusion the infusion the fluid. be signed to be a
If the order is for fluid legal order. Nursing
The fluid to be given only, put a dash in this staff cannot
OR the fluid the box administer without a
medication is to be signature
diluted in

The volume of the fluid to The rate of the infusion

be administered. Needs i.e. the duration
to be ordered in millilitres Write minutes as: x/60
(mL) Write hours as: x/24
If the rate is to change
according to a protocol,
write APP (as per
protocol)

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OTHER MEDICATION CHARTS – discuss with pharmacy/Registrar if unsure how to use
MEDICATION CHARTS
 Long-stay medication chart
o Used for long stay patients at BH and BECC and for GEM@Home patients
 Residential Care Interim Medication Chart
o Must be completed for ALL patients returning to a residential aged care facility with any changes
to their regular medications (Additions or cessations). Original is sent to the ACF, a copy is kept
for the medical record
 Bolton-Clarke Drug Chart
o Must be completed for ALL patients being discharged with RDNS for medication support. Chart
must include ALL medications, not just medications the nurses will be administering
 TCP Medication Chart
o Standardised medication chart for in-patient TCP. Supplied by the TCP team
 ESA Dialysis Medication Chart

PAEDIATRICS and NEONATES

 Paediatric medication charts
o Charts are colour coded for specific age groups – check carefully
o Patient weight should always be documented on the chart
 Asthma Pulse therapy sticker (attached to paediatric chart when needed)
 Paediatric IV orders and Fluid Balance Chart
 Neonatal Unit Fluid Order and Fluid Balance Chart

ANALGESIA

 Syringe Driver Orders for Subcutaneous Infusions

o Includes syringe driver documentation for nursing staff, for palliative care patients
 Intravenous Analgesic Infusion Order form
o Used for PCA orders
 Non-Intravenous analgesic infusion order
o Used for non-IV analgesic infusions (i.e. subcutaneous lignocaine)
 Local Analgesia Order
Use for local analgesia (i.e. epidural administration)

ANTI-COAGULATION

 Heparin Infusion Chart

o Northern Health standard prescription is 50,000 units in 500mL.
 Warfarin Discharge Plan
o To be completed for ALL patients being discharged on warfarin. Must be faxed to the pathology
company/G.P. managing the warfarin
 HITH – warfarin dosing chart
o Used by HITH for dosing warfarin patients

OTHER
 TPN Parenteral Nutrition Order Chart
o To be completed by ICU consultant ONLY
 CHARM medication chart
o Chemotherapy is prescribed on the CHARM electronic medication system

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DISCHARGE PRESCRIPTIONS

 ALL patients require a discharge prescription written on discharge if they are to be commenced on new
medications or if there are any changes to their regular medications.
 Discharge prescriptions are PBS prescriptions. To be able to prescribe on the PBS, you need to have a
PBS prescriber number. This is different to your provider number.
 You must write a separate prescription if another prescriber has already prescribed an item for the
patient's treatment on the same prescription form. i.e. you cannot write on a prescription signed by
another prescriber.
 Must include your name, prescriber number and contact number - this can be your phone number or
pager number on the prescription form. Authorised nurse practitioners and authorised midwives must
also include a prescriber type
 Hospital prescriptions include 3 copies:
o Patient or pharmacist copy (top, green carbon copy)
o Medicare/DVA copy (middle, blue carbon copy)
o Medical records copy (bottom, red carbon copy)
 For a pharmacy to be able to dispense a prescription, they need the top 2 copies (green and blue)
 The red copy is to be detached and filed in patient’s medical record.

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Discharge Prescriptions

What needs to be included:

1. Hospital name, address, telephone number and hospital provider number - this is printed on every
hospital prescription form
2. Authority prescription identification number is required when requesting a PBS authority approval
3. Patient's name, address, date of birth, hospital number and location (attach bradma on all 3 copies)

a. Patient's Medicare number - have this available when seeking a PBS Authority approval for
Authority required medicine. It is included on the hospital bradma.
b. Patient's entitlement details
c. Handwrite the patient's name under the bradma. This is allows you to check the correct bradma
has been attached to the script.

4. Select the appropriate box - PBS or RPBS (repat patients)

5. Patient's weight if applicable
6. Medicine name and form, for example, tablets, capsules or injections
7. Medicine strength
8. Dose instructions for use
9. Quantity to be dispensed – refer to PBS website for quantities. You can NOT write PBS as the quantity.
10. Number of repeats if permitted and required. Usually we don’t write repeats on discharge as we want to
encourage to the patient to see their GP for follow up.
o Drugs of addictions (DAs) – the quantity to be supplied needs to be written in words and figures.
E.g. To order Targin 14 tablets, quantity to be written as: 14, fourteen
11. Pharmacist to indicate whether the medicine is to be supplied
12. Approval number and additional notes on the prescription:
o if the medicine requires prior Authority approval, and you have obtained an Authority approval
number, write the approval number in this column
o if the medicine is listed in the Schedule as Authority required (STREAMLINED), write the specific
streamlined authority code in this column
o if your patient is not eligible for a PBS subsidy for a medicine, and you want to have a medicine
supplied as non-PBS, write non-PBS in this column
o any other notes you feel may be relevant to the pharmacist
13. Your name, prescriber number and contact number
o If the prescriber number is not included, or illegible, the prescription cannot be dispensed.
o Your prescriber number is different to your provider number
o Include a contact number in case the pharmacist needs to verify the prescription. If you cannot
be contacted, and thereby the prescription cannot be dispensed, this causes delays in treatment
and possibly the need for the patient to return to hospital for a new prescription.
14. Prescriber type if you are an authorised nurse practitioner (NP) or authorised midwife (MW)
15. Your signature and the date form is written
o if the prescription is not signed, it is not a legal prescription and cannot be dispensed.

Write in clear, legible handwriting

Illegible writing can lead to significant medication errors and patient harm

Illegible writing/missing information may make a prescription not valid for

dispensing resulting in delays to treatment or the patient needing to return to
hospital for a new prescription to be written

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Discharge Prescriptions

Drugs of Addiction (DA)

 When prescribing DAs on discharge, the quantity to be supplied should be enough to cover 3 to 5 days
of analgesia requirements. Be mindful not to overprescribe DAs as this can lead to addiction.
 You can prescribe less that the PBS quantity or pack size. Pharmacists can easily break packs.
 The quantity to be supplied needs be written in both words and figures.

PHARMACEUTICAL BENEFITS SCHEME (PBS)

Authority PBS prescriptions

 Authority required benefits fall into two categories
o Authority required (via phone call) and
o Authority required (STREAMLINED) (via PBS website)

Authority required
 This type pf approval is required if you want to prescribe a quantity in excess of the PBS quantity (e.g.
long term antibiotics or Clexane®) or if the medication has specific criteria as per the PBS website (e.g.
ciprofloxacin).

Click the Authority required tab to see the criteria.

 Approval of authority PBS prescriptions by Chief Executive may be sought by calling the Department of
Human Services Telephone Authority Applications Free call service (1800 888 333). (phone number is
located on the bottom of the red copy of the hospital prescription)
 To obtain approval, you need to supply the patient’s Medicare number and name, prescription number,
your name and PBS prescriber number.
 If approval is granted, the operator will give you an authority number that needs to be written on the
prescription e.g. Z1234AB

Authority required (STREAMILINED)

 This type pf approval is required if you want to prescribe a medication that is only subsidised by the PBS
for certain indications (e.g. clopidogrel, pregabalin, olanzapine).
 Some of these medications have multiple indications with different authority numbers. Ensure you
choose the correct indication and authority number (e.g. 1234) is written on the prescription

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Pharmaceutical benefits Schedule (PBS)

Click the Authority required (STREAMLINED)

tab to see the criteria.

Choose the appropriate indication and write the Streamline

code on the prescription. If the patient doesn’t meet one of
these criteria, close this tab and open up another tab (some
medications have multiple tabs)

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Pharmaceutical benefits Schedule (PBS)

PBS website
o www.pbs.gov.au
o The website can be found via the Shortcuts menu (Pharmaceutical Benefits Schedule)
o Include information about:
 If the medication is covered by the PBS, and for what indication
 Maximum quantity (and repeats) that can be prescribed
 If an authority is required
PBS Homepage

Search for medication here

Click on the item/dose

you need to look up

 This shows the maximum packs/units and repeats that can be prescribed on the PBS

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Pharmaceutical benefits Schedule (PBS)

 Note: you can prescribe less than maximum quantity – packs can be broken
 If you want to prescribe more than the maximum quantity and repeats, you need to obtain an Authority (see
Authority required in this booklet)
 Examples:
a. Cephalexin 500mg BD for 5 days (=10 capsules)
b. Cephalexin 500mg QID for 10 days (=40 capsules i.e. 1 pack + 1 repeat)
c. Cephalexin 500mg QID for 1 month (=120 capsules – above maximum quantity, needs authority)

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TNH MEDICATION GUIDE
Prescribing Unfamiliar Medications

It is the responsibility of all prescribers to check the indication and dosage and precautions of unfamiliar
medications. Northern Health encourages the use of evidence based guidelines. These are available on every
computer/desktop. In particular, Therapeutic Guidelines® (eTG), up-to-date®, Australian Medicines Handbook®
(AMH), eMims ®, hospital policies on PROMPT. Speciality areas (e.g. palliative care, paediatrics, oncology,
psychiatric medicine) have reference tools available for staff online through the library section of the intranet.

Admini- Precautions/
REFE- Treatment Adverse Drug
Indication Dose stration Contra- TDM Brands
RENCE Guidelines effects interactions
guidelines indications
Australian
Medicines
Handbook
(AMH)
Therapeutic
Guidelines
(eTG)

MIMs online

Australian
Injectable Compatibility
Drug information
Handbook
Northern
Health
policies
(PROMT)
**not all
drugs have
a NH plicy)
Antibiotic
Guidance
PBS
website

Other documents/forms you may be asked to complete:

 Individual patient usage (IPU) form
- to obtain approval to prescribe a medication not on the hospital’s formulary
 Special Access Scheme (SAS) form
- To obtain approval via the TGA to prescribe and use a medication not marketed in Australia
 Notification of Drug Dependant person
- To notify DHHS of patients who are on opioid replacement therapy (e.g. methadone, Suboxone®)

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ANTIMICROBIAL STEWARDSHIP PROGRAM

Antibiotic Guidance (iGuidance)

GuidanceMS is an online approval system for restricted antimicrobials that forms part of Northern Health’s Antimicrobial
Stewardship program. It guides prescribers through the appropriate indication and dose of restricted antimicrobials and
generates electronic approvals. The indications and durations are based on the current Therapeutic Guidelines:Antibiotic.
For indications outside of current guidelines – limited duration electronic approval can be obtained, prior to consultation
with Infectious Diseases. An approval number for a restricted antimicrobial must be obtained within 24 hours of
initiation and written on the chart (to ensure adherence to hospital policy and obtain supply from Pharmacy)

The following antimicrobials are restricted at Northern Health :

RESTRICTED ANTIMICROBIALS – HOME TEAM TO HIGHLY RESTRICTED – ID APPROVAL ONLY – ID

GET GUIDANCE
TEAM TO GET GUIDANCE

Aciclovir IV Ciprofloxacin Moxifloxacin Amikacin Fosfomycin Rifabutin

Azithromycin Famciclovir Norfloxacin Amphotericin IV Fusidic acid Rifampicin

Cefepime Fluconazole Oseltamivir Anidulafungin Ganciclovir Rifaximin

Gentamicin (ID
approval if > 48h) Piperacillin/
Cefotaxime Aztreonam Imipenem Teicoplanin
tazobactam

Ceftazidime Meropenem Valaciclovir Caspofungin Linezolid Tigecycline

Ceftriaxone Metronidazole IV Vancomycin Colistin Pristinamycin Tobramycin IV

EMERGENCY DEPARTMENT ONLY (New Daptomycin Valganciclovir

Daignosis): Quinupristin/
DOACs (Apixaban, Dabigatran and Rivaroxaban) dalfopristin
require guidance approval prior to supply Ertapenem Vorinazole

Those listed above are the more commonly used restricted antimicrobials; see the GuidanceMS homepage for a
complete list.

Please note that GuidanceMS is also used to obtain approvals for the use of the NOACs (apixaban, dabigatran and
rivaroxaban) only in emergency department for new diagnosis. See “Anticoagulants” section of handbook for more
information.

Antibiotic approvals can be obtained via the “Antibiotic guidance” link in the Clinical Shortcuts folder
(on any PC in the hospital)

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ANTIMICROBIAL STEWARDSHIP PROGRAM cont.

Your username & password are the same as the one you use to access other hospital systems eg. CPF.
Follow the prompts to obtain approval for your patient.

Once an approval number is obtained, please write it on the chart, in the indication section or on the yellow
“Guidance approval no.____” sticker placed on the chart by a pharmacist (if there is one):

Approvals generated by Guidance MS have the format of XXX-0000-0. The first for numbers (XXX-0000-0) are
the day and month the approval was obtained, and the last number (XXX-0000-0) indicates the number of days
the antimicrobial is approved for. For example, an approval number of XXX-2502-3 indicates that the approval
was obtained on 25 February and is valid for 3 days. ID will need to be contacted if antibiotic is to continue
once approval is expired via MEDTASKER.

If you have any problems accessing GuidanceMS or obtaining approvals, please contact the
Antimicrobial Stewardship Pharmacist, via MEDTASKER or ex 58452.

The Direct Oral Anticoagulants (DOACs)

As of October 2019, the prescribing of DOACs at Northern Health has changed from beinging highly restricted
to reduced restriction. Approval for their use needs to be obtained via the GuidanceMS system, this is only valid
for new diagnosis of VTE in the EMERGENCY Department. (see above Antimicrobial Stewardship program
section on how to access GuidanceMS and explanatory notes).

Information on all the anticoagulants, including guidelines on dosing, reversal and switching from warfarin to a
DOAC or vice versa, can be found on the Haematology department page on the intranet. From the intranet
homage select “Department and Services” then “Haematology” and then “Anticoagulant Drug Management” or
use the following link:
Haematology - Thrombosis & Haemostasis Protocols

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ANTIBIOTIC PRESCRIBING GUIDELINES BY CONDITION

Sepsis of unclear focus

Vancomycin dosing

…..
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 INTERN MEDICATION GUIDE
Antibiotic Prescribing guidelines by condition cont.

Acute Cystitis

Catheter-associated UTI

Pyelonephritis

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Antibiotic Prescribing guidelines by condition cont.

Prostatitis

Cellulitis

Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)

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Antibiotic Prescribing guidelines by condition cont.

Community Acquired Pneumonia

Aspiration Pneumonia

Treat as CAP or HAP and if no improvement after 48hours then do the following;

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Antibiotic Prescribing guidelines by condition cont.

Hospital Acquired Pneumonia

Peritonitis due to perforated viscus

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Antibiotic Prescribing guidelines by condition cont.

Acute cholecystitis

Ascending cholangitis

Acute Appendicitis

Acute diverticulitis

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 INTERN MEDICATION GUIDE

Antibiotic Prescribing guidelines by condition cont.

Acute pancreatitis

Infected pancreatic necrosis / pancreatic abscess

GENERAL SURGICAL UNIT ANTIBIOTIC PROPHYLAXIS GUIDE

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 HANDY MEDICATION GUIDES
Endocrinology
ALWAYS PRESCRIBE AS “UNITS”

DRUG DOSE/UNIT ROUTE FREQUENCY

Insulin Top Up Scale
Novorapid (preferred)
/Actrapid/ Humalog

T1DM
BSL 10-14 2 units
BSL 14.1- 18 4 units subcut
BSL >18 6 units With-meals TDS PRN

T2DM:
BSL 10-14 4 units
BSL 14.1- 18 6 units
BSL >18 8 units
Novorapid Infusion Novorapid Infusion
(50 units Novorapid in See Diabetes – IV Consult Endocrine
50mL 0.9% NaCl = 1 Insulin/Gluocse Registrar before
unit/ml) Lowering Medicines commencing
1/24 BSL’s (mmol /L) policy

ALWAYS PRESCRIBE INSULIN IN BRAND NAMES

Ultra-short acting (immed pre-meal): Novorapid; Apidra; Humalog, Fiasp.
Short acting (≤ 30 min pre-meal): Actrapid, Humulin R.
Mixed insulin (with food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50,
Ryzodeg 70/30.
Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane

FASTING GUIDELINES for INSULIN:

If on Long-Acting Insulin (Lantus or Levemir)

 Continue these at full/reduced dose

If on Short-Acting Insulin
 Withhold

If on Pre-mixed Insulin (humulog/ novomix/ mixtard)

 Give 50% of the Insulin dose as Protophane

End of Life Care

DRUG DOSE/UNIT ROUTE FREQUENCY

Morphine 2.5 – 5 mg subcut PRN (no frequency)
(depending on
tolerance)
Fentanyl 25 – 50 microg subcut PRN (no frequency)

(if renal impairment)

Midazolam 2.5 - 5 mg subcut every 1 hour PRN
Metoclopramide 10 – 20 mg subcut QID PRN
Glycopyrrolate 0.2 - 0.4 mg subcut 4 hourly (max1.2 mg)
 INTERN MEDICATION GUIDE

Vascular Device Protocols

PICC
Bard Groshong brand: (closed end catheter with 3 way valve):
Does not require heparin flush/lock
Pulsating flush with 20mL normal saline post access and weekly if not in use

Implanted port device (intravenous)

Heparin locked using 500 units of heparin in 5 mL of saline (ie 100 units per mL) post access or
monthly if not in use.

CVCs
Do not require heparin locking (they have a positive pressure device [CLC 2000] attached to each
lumen).

For further information refer to clinical services manual on management of each central venous
access device.

“Length of stay for vascular devices”:

 Peripheral Cannulas, changed 72 hourly (unless medical emergency where asepsis is not
used, must be changed within 12 hours)

 CVC: yellow (7 days) CVC: Blue (2 weeks)

 Implanted Port device: around 2,000 needle sticks (can stay indefinitely/must be surgically
removed in most cases)

FOR ACCES TO SIMULATOR MODELS CONTACT THE EDUCTION CENTRE EXT. 58732.

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Fluid Prescribing

Rule of 1’s – oversimplified but The Real Rules: Correct but easy
memorable to forget!
Water losses Fluid requirements
st
Urine output: 0.5 – 1 ml/kg/hr 1 10 kg = 4ml/kg/hr
2nd 10 kg = 2ml/kg/hr
Insensible losses: 0.5 ml/kg/day Thereafter = 1ml/kg/hr
eg. 50 kg person: 40 + 20 + 30 ml/hr = 90
Water requirements 1.5 – 2 ml/kg/hr ml/hr
90 kg person: 40 + 20 + 70 ml/hr =
130 ml/hr
Salt requirements
Precautions
Sodium: 0.5 – 1mmol/kg/day
CCF/renal failure/very elderly
Potassium: 0.7 – 1mmol/kg/day Reduce rate and monitor UO / fluid balance
Febrile / septic / post-op
Increase Na and H2O
Solutions Change to NSaline or Hartmanns
All 1L solutions come +/- 30 mmol KCI Increase rate
Monitor urine output / fluid balance
0.9% saline 150 mmol/L sodium (& NB: fluid balance should be +ve because of
chloride) ‘third space’ losses
5% Dextrose 278 mmol/L dextrose
4% Dextrose + 1/5 saline 30 mmol sodium & 216 Other ‘Rules’
mmol dextrose 1. All clinicians get the fluid balance assessment
Hartmanns or wrong sometimes. This can be a difficult area,
Compound Sodium Lactate so:
(CSL) 129mmol sodium, 5mmol When in doubt – ASK EARLY
potassium, 2mmol calcium If your first intervention does not work – ASK
AGAIN
Gelofusine synthetic albumin + If you are doing something for the 1st time –
145mmol sodium GET ADVICE

2. Monitoring volume status and renal function:

Recipe 1 Urine output is an early and useful sign
1-1.5ml/kg/hr 4% Dextrose & 1/5 saline +30 mmol/L BP, HR & urea are late signs (too late!)
KCI
3. Responding to oliguria
Oliguria = hypovolaemia until proven
Recipe 2 otherwise
1-1.5ml/kg/hr Treatment of oliguria = IV volume challenge
1L Normal Saline + 30 mmol KCI (2.5-10ml/kg for 1-2 hrs. Use colloid if
1L 5% dextrose + 30 mmol KCI concerned re APO/CCF)
1L 5% dextrose +/- 30 mmol KCI Complex patients usually need urinary
catheter and strict fluid balance.
Diuretics DO NOT ‘kick-start’ the kidneys
Diuretics indicated for fluid overload NOT
oliguria.

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ON-LINE TRAINING

Online modules are available from the National

Prescribing Service.

http://learn.nps.org.au/

The following online module is compulsory to complete:

The Antimicrobial stewardship pharmacist will be following up evidence of completion. If you have
completed these courses during university, you do not need to redo them.

We recommend completing the following modules:

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 INTERN MEDICATION GUIDE

Common Medication Cheat Sheet

⚠ Always ASK IF UNSURE, below summarised from AMH/eTG ⚠ Northern JMSA

ANALGESIA
DRUG DOSE ROUTE FREQ COMMENTS
Paracetamol 1g PO/PR/IV QID - IV only if NBM and unable to have PR
Panadeine Forte 1-2 tabs PO QID/ 4Hrly PRN - Beware in liver impairment
(500/30mg) - Maximum of 4g paracetamol in 24hrs
Panadol Osteo 1-2 tabs PO TDS - every 4-6hrly Consider TDS in
(665mg SR) elderly/starving/liver/renal imp
- Be careful combining paracetamol
orders. Check stat/PRN
Ibuprofen 200-400mg PO TDS max Fever - X if CKD (eGFR<30)/GI
Indomethacin 100mg PR BD Renal colic bleed, diabetic, elderly,
Naproxen IR 250-500mg PO BD max Menstrual IHD, post
pain neurosurgery,
NSAIDS

Ketorolac 10mg stat IM 4-6 Hrly PRN Used in ED anticoagulated

then 10- max 90mg /24hr for mild- - Careful: PUD, CCF,
30mg mod pain HTN, asthma
Diclofenac 25-50mg PO TDS Menstrual dehydration, coag
100mg PR BD pain disorders,
Celecoxib 400mg stat PO 12-24 Hrly MSK/soft - Use for <2wks +
then max 5 days tissue consider PPI
200mg Lower bleed - Lowest dose, shortest
Daily risk time
- Do not use multiple
NSAIDs in one patient
Oxycodone IR 2.5-10mg PO QID PRN Preferred in - All opioids: resp
Oxycodone SR 5 - 10mg PO BD renal depression,
(Oxycontin) impairment sedation, constipation,
Fentanyl 30 - subcut 2-4 Hrly (CrCl dependence
150microg <30ml/min) - careful: BP drop,
Morphine 2.5-5mg subcut QID PRN accumulates ↓seizure threshold
in CKD - ↓dose requirements
with age – start low
OPIOIDS

- consider aperients +
antiemetic
Tramadol IR 50-100mg PO/IV QID PRN - X epilepsy, hyperbaric tx, SSRI, elderly
(>30min Usual max (max 300mg), confused
IV) 400mg - Less sedation/resp
depression/abuse/constipation
Tapentadol IR: 50- PO 4-6Hrly PRN - min opiate effects/serotonergic
(Palexia) 100mg syndrome risk; prefer in CKD
SR: 50mg PO BD; max 500mg - X if on MAO-I (e.g. phenelzine,
tranylcypromine)
Targin CR 10/5mg PO BD oxycodone + naloxone (2.5/1.25mg,
5/2.5mg etc.)
Reversal of opiates Naloxone 40microg subcut/IV. Life threatening 100-200microg. Short half-life <1hr, may
require repeat doses
Amitriptyline 10-25mg PO nocte;max150mg Tricyclic antidepressant. Careful: BPH,
hyperthyroid, epilepsy
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 INTERN MEDICATION GUIDE
NEUROPATHIC

Pregabalin 75mg PO Daily or BD Reduce dose renal imp; start low in

elderly/frail (25mg)
Gabapentin 100-300mg PO nocte SE: drowsy, dizzy; lower opioid doses.
Non-PBS indication
Consider Ketamine infusion/Lignocaine/nerve block, Acute Pain Service pager #779
Tamsulosin CR 400mcg PO Daily Renal colic: Bladder/ureter spasms.
Non-PBS indication
Hyoscine 20-40mg IV/IM QID PRN For colicky abdominal pain
(Buscopan) 10-20mg PO TDS-QID PRN IV maximum 100mg/day

ANTIEMETICS
DRUG DOSE ROUTE FREQ COMMENTS
Metoclopramide 5-10mg PO/IV/ TDS PRN X bowel Dopamine
(Maxalon) subcut max 30mg D, obstruction/perf + antagonists
5 days pheochromocytoma / - X Parkinson’s
DOPAMINE

<20yo disease
Prochlorperazine 12.5mg IV TDS PRN vertigo; avoid if CNS - beware
(Stemetil) 5– PO TDS PRN depression oculogyric crisis
10mg (tardive
Droperidol 0.625mg IV QID PRN X IHD/arrhythmia dyskinesia)
Domperidone 10mg PO TDS PRN Preferred for Parkinson’s – won’t cross
blood-brain barrier
5HT3 ANTAGONIST

Ondansetron 4-8mg PO/IV/SL TDS PRN Post op/chemo/RT 5HT3 Antagonist

(Zofran) - careful:
Granisetron 1mg IV TDS PRN SE: prolonged QT
constipation/headache - transient ↑AST
& ALT
Cyclizine 12.5- Slow BD - TDS Careful: CCF, SE: urinary Antihistamine
50mg IV/PO retention - sedation
Promethazine 12.5- IM / PO 4-6Hrly PRN Careful: Epilepsy, -urinary retention
(Phenergan) 25mg max 100mg Parkinson’s, respiratory
D depression

ALLERGIC REACTIONS
DRUG DOSE ROUTE FREQ COMMENTS
Loratadine 10mg PO Daily X hepatic Less sedating antihistamine
ANTI-HISTAMINES

impairment Indication: chronic urticaria,

Cetirizine 10mg PO Daily X renal allergic rhinitis
impairment
Promethazine 25-50mg PO/IM Daily - X anaphylaxis, can worsen hypotension; sedating
(Phenergan) antihistamine
- Careful: Epilepsy, Parkinson’s, respiratory
depression
Hydrocortisone 100mg IV STAT 5mg/kg, max 200mg. Consider in anaphylaxis with
wheeze
Adrenaline 500microg IM STAT - Anaphylaxis: no absolute contraindications to
0.5mL of PRN 3- adrenaline
1:1000 5min - Inject into mid antero-lateral thigh

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 INTERN MEDICATION GUIDE

ANTI DIARRHOEALS
DRUG DOSE ROUTE FREQ COMMENTS
Loperamide 4-8mg PO Daily/TDS Chronic - Avoid: intestinal
Max 16mg D diarrhoea, obstruction/severe
intestinal stoma ulcerative colitis/ hepatic
4mg PO 2mg PRN after each Acute diarrhoea impairment
stat motion - for symptomatic treatment

RESPIRATORY
DRUG DOSE ROUTE FREQ COMMENTS
SABA

Salbutamol 2.5 - 5mg Neb QID - short-acting beta2 agonist (SABA)

(Ventolin/Asmol) 2-12 puffs via Inh PRN/STAT - SE: tachycardia, hyperglycaemia,
spacer hypokalaemia
Ipratropium Bromide 500microg/2.5mL Neb QID - anti-cholinergic/short-acting anti-
(Atrovent) 42mcg (2 puffs) Inh PRN/STAT muscarinic (SAMA)
- SE: headache/nausea/taste
disturbance
Tiotropium Bromide 2.5mcg Inh Daily Withhold if also on ipratropium
(Spiriva) (Respimat) - LAMA, careful in renal impairment
2 puffs - 2.5mcg = Respimat, 18mcg =
18mcg: 1 puff Inh Daily Handihaler
Indacaterol 150/300mcg Inh Daily - long acting beta2 agonist (LABA)
(Onbrez Breezhaler) 1 puff - asthma: always use LABA with ICS
Fluticasone 50/125/250mcg Inh BD Inhaled corticosteroids (ICS)
(Flixotide) 1-2 puffs - SE: dysphonia, oropharyngeal
ICS

Budesonide 100/200/400mcg Inh BD candidiasis,

(Pulmicort) 1-2 puffs pneumonia, glaucoma, bone
density loss
- rinse mouth with water after use
Budesonide/formoterol 1-2 puffs Inh BD - Turbuhaler: 100/6; 200/6;
(Symbicort) Specify strength 400/12mcg
- Rapihaler: 50/3; 100/3; 200/6mcg
ICS/LABA

(with spacer)
Flucticasone/Salmeterol 1-2 puffs Inh BD - MDI: 50/25; 125/25; 250/25mcg
(Seretide) Specify strength (with spacer)
- Accuhaler: 100/50; 250/50;
500/50mcg
Fluticasone/vilanterol 1 puff Inh Daily - 100/25; 200/25mcg; Breo Ellipta
Prednisolone 30-50mg PO Mane with - wean dose if continued longer
(usually 50mg) food than a week
(5-14D - SE:
course) HTN/hyperglycaemia/PUD/insomnia
Normal saline 5mL Neb PRN Loosen secretions/relieves
breathlessness
Bromhexine 8-16mg PO TDS Reduces mucous viscosity
(mucolytic)
COPD: consider smoking cessation/pneumococcal+influenza vaccines/chest physio

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ANTIBIOTICS
Refer to Antimicrobial Guidelines on PROMPT, eTG, ID or AMS for advice **BE AWARE OF ALLERGIES**
(*requires Guidance)
DRUG DOSE ROUTE FREQ COMMENTS
Amoxycillin 500mg PO 8 - COPD infective exac. (bronchitis) 5-7 days.
Hrly
1g PO 8 Mild-mod CAP: 5-7D + doxycycline . Mild
Hrly aspiration pneumonia: 7-10D. Severe CAP; step
down from IV to complete 7-14 D
Amoxycillin-clavulanic 500/125mg PO 12 UTI: 5 Days female, 7 Days male
BETA-LACTAMS

acid (Augmentin Hrly

Duo/Forte) 875/125mg PO 12 Dose of all other indications. Consider reduced
Hrly dose in ESRF
Benzylpenicillin 1.2g IV 6 Moderate CAP / Aspiration pneumonia 7-10D.
Hrly Dose and frequency higher in more severe
infections e.g. endocarditis
Flucloxacillin 2g IV 6 Severe cellulitis 10-14D (Max. oral 1g QID empty
Hrly stomach)
Phenoxymethylpenicillin 500mg PO 12 Acute pharyngitis/Tonsillitis: 10D. Poor systemic
Hrly absoption
Piperacillin-tazobactam 4.5g IV 8 See Guidance for standard indications. 12 Hrly if
(Tazocin)* Hrly CrCl <20
12 Febrile neutropenia and critically ill (ICU)
Hrly
Ceftriaxone* 1g IV Daily See guidance for standard indications including
pneumonia (+azithromycin) and pyelonephritis
2g IV 12 Meningitis + benzylpenicillin (+/- IV acyclovir)
CEPHALOSPORINS

Hrly
Cefepime* 2g IV 8 Febrile Neutropenia. Has anti-pseudomonas
Hrly activity
Cefalexin (cephalexin) 500mg PO 12 UTI (acute cystitis): 5D females, 7D males
Hrly
1g PO 12 Penicillin allergy: mild HAP (+/- metro)
Hrly
1g PO 6 Pyelonephritis 14D / Mild cellulitis 7-10D
Hrly
Cefazolin (Cephazolin) 2g IV 8 Penicillin allergy: severe cellulitis 10-14D (+/-
Hrly vanc). Pre-op prophylaxis as single dose
QUINOLONES

Ciprofloxacin* 500mg BD 12 See Guidance for standard indications. Check

Hrly ECG & interactions with other QT prolonging
400mg IV 12 drugs. Oral form on empty stomach. Excellent
Hrly oral bioavailability
Moxifloxacin* 400mg PO/IV Daily Penicillin hypersensitive: severe CAP/Asp
Pneum/HAP check ECG
Azithromycin* 500mg PO/IV Daily Severe CAP (+ ceftriaxone). Good oral
absorption
Clindamycin 450mg PO 8 MRSA activity or for penicillin hypersensitivity.
(contact ID if obese) Hrly For moderate aspiration pneumonia/SSTI
450mg IV 8
Hrly

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 INTERN MEDICATION GUIDE

Metronidazole (IV*) 500mg IV 12 Activity against anaerobic organisms eg in severe

Hrly aspiration pneumonia (+ ceftriaxone) and Perf
400mg PO 12 viscus (+ ceftriaxone)
Hrly
400mg PO 8
Mild C.difficile 10D (oral vancomycin in mod-
Hrly
severe)
Doxycycline 100mg PO 12
Give with food, risk of oesophageal ulceration.
Hrly
COPD 5-7D/ CAP (+ amoxicillin) duration depends
on severity
Vancomycin* Refer to Vancomycin dosing See Guidance for standard indications. Dose
(contact ID for dosing guidelines (based on weight adjust on levels
advice if required) & renal function) MRSA activity - add to standard therapy if MRSA
known colonised or risk of / severe infections.
Beware VRE.
Trimethoprim 300mg PO Night Bacteriostatic/UTI: 3Days females, 7Days males
Trimethoprim- 160/800mg PO 3 Pneumocystis jiroveci (carinii) pneumonia (PJP)
Sulfamethoxazole times prophylaxis in immunosuppressed patients. Give
(Bactrim) Per Mon/Weds/Fri (with food) Caution in renal
wk. impairment / with meds that can raise potassium

APERIENTS
DRUG DOSE ROUTE FREQ COMMENTS
Docusate + Senna 1-2 tabs PO Nocte - X GI obstruction/perforation risk Stool
(Coloxyl & Senna) or BD - Careful: softener +
dehydration/hypokalaemia stimulant
Lactulose 20ml PO Daily -↑doses required in hepatic encephalopathy (30-
or BD 45ml QID)
OSMOTIC LAXATIVE

- SE: flatulence + very sweet taste

Macrogol 3350 1-2 sachets PO Daily - faecal impaction: up to 8 sachets within 6hrs, max
(Movicol / or BD 3D
Marovic) - risk of fluid + electrolyte imbalance (↓risk
compared to saline lxtves)
Microlax enema 1 PR STAT - rectal onset: 2-30min Saline laxatives
sorbitol /sodium - beware: patients w - once only medication
citrate/ sodium heart - also used in bowel
lauryl sulfoacetate failure/renal prep
Fleet enema 1 PR STAT impairment, risk - can cause considerable
sodium phosphate of GI fluid + electrolyte
monobasic/ obstruction/perforation imbalance
sodium phosphate - monitor electrolytes
dibasic
Note: optimise Magnesium level (Hypomagnesaemia linked to constipation)

SEDATIVES
DRUG DOSE ROUTE FREQ COMMENTS
Temazepam 5-10mg PO Nocte/STAT Max 20mg, lower for - short term use, low
elderly dose
Zolpiclone 3.75- PO Nocte/STAT - X myasthenias gravis, - Risk: over-sedation,
7.5mg up to 4 weeks pulm ataxia,
Zolpidem IR 5mg PO Nocte/STAT insufficiency, alcohol confusion, resp
intake depression,
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 INTERN MEDICATION GUIDE

- ! psych sx may memory impairment,

worsen, falls
Melatonin XR 2mg PO Nocte/STAT SE: back pain, arthralgia//limited evidence//up to
13wks
Diazepam 5-20mg PO Per AWS Preferred option. Alcohol Withdrawal
Max. 120mg Low dose in elderly. Scale
Oxazepam alt. in liver + thiamine 300mg
imp/frail IM/IV 5D
REFER TO AWS POLICY
Haloperidol 0.25- PO/IM STAT - Beware EPSE up to - oral before IM
(acute 0.5mg 48hrs post - onset 30-60min
ANTI PSYCHOTICS

psychosis) - Low incidence - avoid benzodiazepine

hypotension - SE: long QTc,
Olanzapine 2.5mg PO/IM STAT SE: hyprglycma/periph hypotension,
(acute (wafer) odma confusion,
psychosis) Careful: hepatic anticholinergic
impairment effects, acute EPSE
Risperidone 0.5mg PO STAT - risk cerebrovascular
(acute (wafer) event
psychosis) Careful: renal/hepatic
impairmnt
Seek advice before medicating for disturbed behaviour/ AVOID CHARTING PRN. Refer to Delirium &
Cognitive Impairment Management Policy
Benztropine 1-2mg PO/IM STAT Reverse EPS (acute dystonia); anticholinergic
Promethazine 5mg PO Nocte/STAT Sedating antihistamine, see ‘Analgesia’ section
above

ANTICOAGULATION – see Thrombosis & haemostasis Guideline on Prompt

DRUG DOSE ROUTE FREQ COMMENTS
Aspirin 100mg PO Daily Elderly: consider taking with PPI (GI bleed risk)
Cyclo-oxygenase 300mg PO STAT Suspected ischaemic chest pain
ANTIPLATELET

inhibitor
Dipyridamole MR 200/25mg PO BD 2ndry prevent stroke/TIA; Daily for 1 week (with
+Aspirin 100mg aspirin)
Clopidogrel 75mg PO Daily Response variability ++ Load P2Y12
300mg antagonist
Ticagrelor (+aspirin) 90mg PO BD SE: dyspnoea, ventricular pauses; (liver
Load 180mg metabolism)
Prasugrel (+aspirin) 10mg PO Daily High risk of major bleeding; Load
60mg
Prophylactic 40mg SubCut Daily 20mg if: LMWH
clexane CrCl<30/<50kg/frail/low risk Inactivate IIa+Xa
Therapeutic clexane 1mg/kg SubCut BD Dose to closest 5-10mg. BD via anti-
HEPARINS

(enoxaparin) 1.5mg/kg SubCut Daily preferred for inpts. Daily for thrombin III
HITH. 1mg/kg/day if CrCl<30 binding
Prophylactic heparin 5000 SubCut BD/TDS Monitor APTT 6hrs post, ½ life 1hr, hepatic
units clearance
Therapeutic heparin APP SubCut IV inf. Antidote: protamine IV 1mg/100unit (risk: fish
allergy/vasectomy)

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Dabigatran 150mg PO BD X prosthetic HV, Careful: GI bleed <12m. Consider

(Pradaxa) 110mg PO BD 110mg: CrCl 30-50, >75yo, <50kg or as per
direct thrombin bleed/clot risk. Reversal=Idarucizumab
DOACS

inhibitor
Apixaban 5mg PO BD X CrCl<25; Interacts with CYP3A4 Factor Xa inh
(Eliquis) 2.5mg PO BD P-gp inhs. 2.5mg BD if ≥ 2 of: Careful liver
<60kg, >80yo, Cr >133 imp Apixaban
Rivaroxaban 20mg PO Daily X prosthetic HV/ CrCl<30. 15mg D a/w fewer
(Xarelto) if CrCl 30-49 major bleeds
Warfarin (Brand INR 2-3 PO D at Loading: 5mg D for 2D, 3mg in certain situations
specific: 4pm (see above guideline and adjusting as per INR) INR
Coumadin/Marevan) INR 2.5-3.5 if mechanical lags by ~2days
heart valve
Vitamin K1 0.5 - PO/IV stat Warfarin reversal: dependent on bleeding / INR
10mg
Warfarin reversal for life threatening IV Vit K 10mg + Prothrombinex-VF 50 units/kg + fresh frozen
bleed+INR≥1.5 plasma 150-300mL
GASTROINTESTINAL
DRUG DOSE ROUTE FREQ COMMENTS
Mg + Al 10-20mL PO PRN Antacid; take 1-3hr post meal; Careful: CCF; aka
hydroxide Gastrogel
Pink Mix 30mL PO stat Prescribe as Lignocaine viscus 10mL + Gastrogel 20mL
Ranitidine 150mg PO BD H2 antagonist; PUD/GORD; careful: salt restriction,
renal impairment
Pantoprazole 40mg PO/IV Daily GORD: 4-8wk course; 30-60min pre-meal; all PPIs
40mg IV *BD 3 similar efficacy *bleeding peptic ulcers intermittent
PPI

days bolus vs. infusion same efficacy. X long term use b/c
Esomeprazole 20mg PO Daily ?risks: ↓Mg, #, C.diff, CKD, pneumonia
Relief with pink mix DOES NOT rule out ischaemic cause for epigastric pain
CARDIOVASCULAR Northern JMSA
DRUG DOSE ROUTE FREQ COMMENTS
Atorvastatin 10-80mg PO Daily Monitor LFT/CK; SE: rhabdomyolysis, myopathy
LIPID REDUCING

(Lipitor) HMG-CoA reductase inhibitor; consider cease if

Rosuvastatin 5-40mg PO Daily LE<10yrs
(Crestor)
Ezetimibe 10mg PO Daily Add to statin to meet LDL target Not
Fenofibrate 145mg PO Daily  triglycerides (+statin) CrCl<60 together
dose X pancreatitis
Perindopril arginine 2.5-10mg PO Daily ACEi; Caution: renal impairment, ↑K+,
Perindopril 2-8mg PO Daily angioedema, African descent, NSAIDS. Check
HTN

erbumine salt before prescribing, TNH keep both

Irbesartan 75-300mg PO Daily ARB; Caution: pt w angioedema on ACEi, renal
impairment; X ACEi
Metoprolol tartrate 12.5- PO BD HTN B-blocker; start low, go slow (double
HTN/CCF

100mg dose 2-4wks)

Metoprolol MR 23.75- PO Daily CCF cease slowly =avoid rebound HTN; start
190mg when pt stable
Spironolactone 12.5-50mg PO Daily HTN K+sparing aldosterone antagonist; SE:
(aldactone/spiractin) 25mg PO Daily CCF hyperkalaemia, respiratory/metabolic

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 INTERN MEDICATION GUIDE

acidosis; X prostate cancer.

Antiandrogenic effect:
gynaecomastia/sexual dysfunction
Frusemide 20-40mg PO Mane ± Loop diuretic; Titrate to response, monitor
(Lasix – lasts ~6 hrs) 40mg PO = 20mg IV midi weight+electrolytes
CCF

(max SE: metabolic alkalosis, hyperuricaemia,

1g/24h) ↓electrolytes
Hydrochlorothiazide 12.5-25mg PO Mane Thiazide; HTN. Careful: new onset DM, hypo K,
HTN

hypo Na; X gout.

Amlodipine 2.5-10mg PO Daily Dihydropyridine CCB; X cardiogenic shock, CCF;
SE: peripheral oedema
Glyceryl trinitrate 5- Top On at 8 Symptoms dictate timing. nitrate-free 12hrs to
Patch 15mg/24hr off at 8 avoid tolerance
Anginine© (GTN) ½ to 1 Subling 5min PRN Check BP; max 3 doses; X ↑ICP, hypovolemia,
(600mcg) PDE5i use (sildenafil)
Nitrolingual© (GTN) 400mcg Subling 5min PRN Nitrolingual – spray Anginine – tabs. Check
expiry. SE: flushing/H’ache
DIABETES
PRESCRIBE INSULIN IN BRAND NAME TO AVOID CONFUSION
DRUG DOSE ROUTE FREQ COMMENTS
Novorapid variable SC w meals TDS T2DM: 10-14 (4u), 14.1-18 (6u), 18.1-22 (8u),
(insulin aspart) Onset: 10-20min; PRN/ sliding ≥22.1 (10u)
max:1-3hrs scale T1DM: 10-14 (2u), 14.1-18 (4u), 18.1-22 (6u),
INSULINS

≥22.1 (8u)
Long acting: Lantus/Toujeo; Levemir; Humulin, Protaphane. Ultra-short acting (immed pre-meal):
Novorapid; Apidra; Humalog. Short acting (≤ 30 min pre-meal): Actrapid, Humulin R. Mixed insulin (with
food): Novomix 30; Humalog Mix25 or 50; Humulin 30/70, Mixtard 30/70 or 50/50, Ryzodeg 70/30
Insulin fasting guidelines: Long-acting = cont at full/reduced dose; Short-acting = WH; Pre-mixed
(humulog/novomix/mixtard)=50% dose as protophane
Metformin IR: PO Daily-TDS (max Careful: CrCl<30 (lactic acidosis risk); biguanide
(Diabex) 500mg- 3g/24h) WH: septic/fasting/min oral intake/AKI; take
1g with food
XR: 0.5g- Daily (max
2g 2g/24h)
Gliclazide IR 80mg PO Daily-BD with Max Sulfonylureas; careful: acute
diamicron/glyade food 320mg D illness; weight+
MR 30- PO Daily with food Max X T1DM, ketoacidosis;
60mg 120mg D hypoglycaemia risk ++
Sitagliptin 25- PO Daily DPP4 inhibitor Careful:
100mg sulfonylurea/insulin/ACEi/CrCl<50
Linagliptan 5mg PO Daily ?Risk: infection/pancreatitis; no weight gain
Exenatide 5microg SC BD (pre-meal) GLP1 agonist. Use: if obese. SE: pancreatitis
(Byetta) Bydureon: 2mg SubCut weekly (SR) Careful: sulfnylrea/insulin/hx gallbladder
disease X CrCl<30
Dapagliflozin 10mg PO Daily SGLT2 inhibitor SE: UTI; Careful:
Empagliflozin 10mg PO Daily insulin/sulfnylurea/diuretics/CrCl<60
Acute serious illness, prolonged fasting or
other risk factors for DKA - WH
Pioglitazone 15mg PO Daily (max X ?bladder Ca, ketoacidosis, T1DM, insulin SE:
45mg) worsen CCF, #, wht

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 INTERN MEDICATION GUIDE

END OF LIFE CARE

DRUG DOSE ROUTE FREQ COMMENTS
Morphine 2.5-5mg SC PRN (no freq) Pain/resp distress, depends on
tolerance
Fentanyl 25-50mcg SC PRN (no freq) Pain, preferred if renal impairment
Midazolam 2.5-5mg SC Every 1hr PRN Agitation
Metoclopramide 10-20mg SC QID PRN Nausea/Vomiting
Glycopyrrolate 0.2-0.4mg SC Q4H (max Respiratory secretions
1.2mg)

FLUID/ELECTROLYTE REPLACEMENT
(NB: 1mmol/L = 1mM) ALWAYS CHECK IF UNSURE
Potassium 3.5-5.2 mM (>4.0 if cardiac hx) – recheck Magnesium 0.7-1.1mM (>1.0 if cardiac hx) – recheck
in 4hrs↓/1hr↑ in 6-12hrs↓
+
3mmol/L serum K = -200mM K (-0.5mmol serum = Intracellular cation, linked to ↓K AND ↓Ca AND
100mM K+ deficit) metabolic alkalosis
↓Hypokalaemia: ?loss from GI or ↓Hypomagnesemia: ?malnutrition/GI loss
urine/hypoglycaemia/hypomagnesemia? (NGT/diarrhoea)/renal loss?
Slow K 8mM 16-48 mmol/24h O MagSup Mg 1.55mM/t Ṫ-ṪṪ D-BD;
Oral

(4hr) K+/tab dependent on level aspartate careful CKD

Chlorve 14mM adjusted on response I 0.9% NaCl 100mL + ≥1/24 severe if
+
scent K /tab V MgSO4 10mM <0.4mM
(0hr)
0.9% NaCl 1000mL + ≥3/24 Rate can’t ↑Hypermagnesemia:
IV

KCl 30mM exceed ?antacid/CKD/lithium/rhabdomyolysis

0.29% NaCl 100mL + ≥1/24 10mmol IV 2.2mM calcium aim urine outpt 60mL/hr;
KCl 10mM isotnic KCl/Hr gluconate 100mL IV 0.9%NaCl
15min
↑Hyperkalaemia: ?haemolysed sample (check w Sodium 135-145mM – recheck in 6hrs↓/4hrs ↑
VBG)/AKI?
Resonium 30g PO/PR Frusemide 40-80mg IV stat ↓Hyponatremia:
stat (1-3hrs) ?diuretics(HCT)/SSRI/SiADH/hyperglycaemia/organ
failure
50% dextrose IV 50mL+10units Salbutamol 5mg 0.9% Fluid restrict ~500mL < urine Consider
Novorapid/20min neb x2 NaCl IV output SiADH if:
Phosphate 0.75-1.5mM (* if <0.3] – recheck in NB: Na ∆ must ≤0.5mM/hr; ≤10mM/D [serumNa]
3hrs↓ ↓Na=cerebral oedema; ↑Na=osmotic <130mM
↓Hypophosphatemia: demyelination serum
2+ Osm/L
?malnutrition/antacid/↑PTH/↓VitD?/↓Ca
<275mmo
l/kg
urine
Osm/L
>100mmo
l/kg
[urineNa]
> 30Mm

O Phosph 16.1mM/ta 1-2tabs D-TDS, SE: ↑Hypernatremia: ?water loss (DI, thiazide,
ate b diarrhoea burns)/IV iatrogenic
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 INTERN MEDICATION GUIDE

Sandoz
0.9% NaCl ≥3/24 KH2PO RARELY oral 5% 0.45% NaCl IV 4%
IV

250mL + PO4 4 use IV wat dextros dextrose+0.18%N

10mM SE: er e IV aCl (4+1/5th)
2+
0.9% NaCl ≥2/2 NaH2PO4 ↓Ca /te Na↓ must Water deficit=0.5(serum Na-
250mL + PO4 4 tany ≤0.5mM/hr; 140)/140
10mM ≤10mM/D
↑Hyperphosphatemia: ?CKD/cell lysis/ ↓PTH Calcium 2.15-2.55mM corr Alb – recheck in 4hrs↓
O Calcium carbonate Lanthanum/Sevelamer ↓Hypocalcaemia: ?↓VitD/↓Mg/↓PTH
1.25g BD/TDS TDS (para/thyroidectomy)
Fluid Requirements 0.9%NaCl 100mL+calcium 20min Oral
gluconate 4.4mM maintena
Assume: euvolemic, X renal/heart failure, X 0.9%NaCl 900mL+calcium 50mL/ nce w
abnormal loss/elect disturbance gluconate 22mM hr food:
Calcitriol
0.25mcg
BD
CaCO3
1.5g BD
4ml/kg/hr 1st Regimen One (1L Regimen Two ↑Hypercalcaemia: ?malignancy/1 ↑PTH
10kg body bags) (1L bags) Rehydrate: 4-6L/24 aim UO Bisphos
weight 0.9% NaCl+30mM 2 bags: 30mM 0.9% NaCl IV ~60ml/hr phonat
2ml/kg/hr 2nd KCl KCl + 0.9% NaCl 250mL + pamidronate 60- 2- e:
10kg body 5%dxtrse+30mM 4%dextrse+0. 90mg IV 4/ X
weight KCl 18%NaC 2 CrCl<30
1ml/kg/hr 5% dextrose 1 bag: 4 ≤1mg/
remainder 4%+1/5th min
Sodium: 1-2 Infusion rate: 8/24 usual; 10- If malignancy, consider long term Check
mmol/kg/day 12/24 frail,old clodronate o 2.4-3.2g BD Vit D
Potassium: NB: 4% dextrose+0.18% NaCl = 4% NB: for fluid balance urine output = early sign;
0.5-1 and a fifth BP/HR/urea = late signs
mmol/kg/day

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 INTERN MEDICATION GUIDE

The pharmacist is not the

purple pen drug police.

The pharmacists are here to

support you, improve
medication safety and to
promote patient-centred care

Page 49