Welcome to our new and improved e-newsletter — redesigned to make it easier for you to read and find the information you’re most interested in, faster.
We're also pleased to announce the launch of Clinical Matters, a new section featuring the thoughts and observations of our clinical experts on important healthcare topics. With 200+ years of collective experience in medicine, pharmacy, and nursing, our team is looking forward to sharing their experience and knowledge with you.
In this Issue:
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The Path of Least Resistance: Using Data, Tools, and Technology to Improve Antimicrobial Stewardship
Arti N. Bhavsar, Pharm.D., Clinical Solutions Executive, Truven Health Analytics
As a clinical pharmacist, I’m not surprised that the tendency to over-prescribe broad-spectrum antibiotics remains widespread. It’s estimated that 30 percent of antibiotics prescribed are unnecessary (1). And despite our best efforts, the data show that we continue to incorrectly prescribe antibiotics – up to 50 percent of the time – contributing to unintended complications, such as Clostridum Difficile infection and antibiotic resistance (2).
Clearly, improving antibiotic prescribing reduces risk and leads to better patient outcomes. This is further evidenced in recent findings published in Vital Signs by the Centers for Disease Control and Prevention (CDC), “Improving Antibiotic Use among Hospitalized Patients”:
- Antibiotic optimization and reduction of overall antibiotic use is still a key area of opportunity
- Information is essential to closely manage antimicrobial use, such as: when is an antimicrobial prescribed, is it appropriate “conducting an antimicrobial time-out”, can the regimen be optimized, tracking prescribing and resistance patterns
It goes on to ask us to consider these findings:
- If we decreased the use of broad-spectrum antibiotics by 30 percent, we could potentially decrease the incidence of Clostridium difficile infection in these patients by 26 percent
- By curbing overall antibiotic use in 5 percent of our patients, we could contribute to the recommended necessary reduction in the broad spectrum category
To that end, then, how do we improve antibiotic prescribing? How do we make changes quickly, and measure the impact? Technology is one way we can create change in a scalable, cost effective way – to drive change quickly with few resources. But, a single technology solution can only do so much. And, technology alone will not broadly impact the largest and most critical factor at play – or hospital culture and prescribing practices. How then do we create credible, sustainable change? Simply put, it’s about the data – collected on an enterprise level, extracted from every applicable source analyzed in real-time and made visible at the point of care where it matters most. With the right tools and organizational processes in place – to track prescribing and resistance patterns, to manage antibiotic use, and to implement interventions, such as “antibiotic time-outs” to improve prescribing – clinicians are able to access information when they are making decisions, in their workflow, and make informed, empowered decisions on prescribing.
What should your technology solution include to put data to work and clinicians at ease in their adoption of these practices? Here is an example for a program on antimicrobial stewardship to make change quickly:
- Real-time surveillance including patient identification
- Clinical knowledge to guide dose optimization
- Antibiogram creation to study prescribing and resistance patterns
- Analytics to understand the impact at a population level
How are you using technology to improve antibiotic use at your facility? Do you employ any of the technological tools described above? What are your barriers to clinician adoption of new prescribing practices – do you think these tools would help? Share your thoughts on how to move mountains in prescribing practices to create change with real impact fast!
(1) Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003;163:972–8.
(2) Dellit TH, Owens RC, McGowan JE Jr, et al; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–77.
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Access Micromedex Drug Information, Anywhere, Anytime With Two New Mobile App Options
The Micromedex® Drug Information app, which was previously free to any Apple® device user, was retired on March 31.
In its place, there are now two apps to choose from. Each app has the same functionality and provides the same evidence-based clinical decision support content you've come to rely on from our entire portfolio of mobile apps. Select the one that's right for you:
Have an Internet-based subscription to Micromedex? Download Free Micromedex Drug Reference for Internet Subscribers.
Don't have an Internet-based subscription to Micromedex? Or work at multiple facilities and don't want to worry about entering an annual password? Download Micromedex Drug Reference Essentials.
- Micromedex Drug Reference Essentials is a great low-cost option for those who want access to trusted Micromedex drug information content, but don't have access to an Internet subscription to Micromedex 2.0. The annual fee is only $2.99.
We're here to help!
Click here for more information about this change, including Frequently Asked Questions.
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TIPS & TRICKS
How to Impact Medication-Related HCAHPS Scores Today
How are pharmacists using their medication expertise to impact patient satisfaction and boost medication-related HCAHPS scores?
- Taking every opportunity to explain to their patients why they are taking new medications — when prescribed, at first dose, and at discharge
- Using terms patients are familiar with, such as "side effect" to describe potential problems
- Giving patient-specific medication handouts and discharge instructions
How are pharmacists using Micromedex Solutions to boost HCAHPS scores?
- Leveraging talking points for clinicians, in the Clinical Teaching section of the Micromedex drug summary in Micromedex Medication Management. Talking points highlight the most pertinent medication information from the product insert and other sources, to educate patients on medication use, safety, and side effects
- Using integrated Micromedex Patient Education to improve access to powerful patient engagement tools to promote positive patient outcomes
- Giving patients high-quality, evidence-based corresponding patient-specific educational handouts and discharge instructions, ensuring clinical consistency across the care continuum
Start impacting medication-related HCAHPS scores today. Click here to read "Filling the Gap in Patient Education: Solutions to Boost HCAHPS Scores" under "Solution Sheets" in our digital download library.
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IN THE SPOTLIGHT
Hospital Reduces Surgery-Related Mortality With Mobile IT
Norfolk and Norwich University Hospital is considered to be among the best hospitals in England for quality of care. And with mobile technology, the hospital reduced mortality rates associated with surgery-related complications by 86 percent. How? The hospital implemented Micromedex 360 Care Insights to gain mobile access to patient-specific data and real-time clinical surveillance — at any time, from any location — to ensure early and timely intervention.
Click here to watch Dr. Edward Cheong, a surgeon at Norfolk and Norwich University Hospital, share how he and his colleagues are improving patient outcomes using Micromedex 360 Care Insights. Select "Reducing Mortality Rates With Mobile Apps and Real-Time, Patient-Specific Data" under "Videos".
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New Time-Saving Enhancements in Micromedex 360 Care Insights Promote Antimicrobial Stewardship
Now available in Pharmacy Intervention and Infection Prevention, part of the Micromedex® 360 Care Insights Suite of products, are enhancements to help clinicians manage antibiotic therapy and avoid antibiotic resistance:
- Addition of Antibiogram to Pharmacy Intervention (already available in Infection Prevention), giving pharmacists the ability to further promote and strengthen their facility’s antimicrobial stewardship program
- Auto-population of important patient-specific clinical data, including patient demographics, medications, vital signs, laboratory results, and test results into patient intervention forms saving clinicians’ time and reducing documentation and reporting errors
- Ability to view antimicrobial susceptibility reports by facility, department, and patient class (e.g. inpatient) to easily manage antibiotic therapy and reduce antimicrobial resistance
Click here to learn more about 360 Care Insights.
New Hosting Model for Real-Time Clinical Surveillance Saves Valuable Resources
Hospitals nationwide are partnering with Micromedex Solutions to improve patient care and safety through real-time, interoperable surveillance solutions and outcome analytics.
A new hosting option is available for Micromedex 360 Care Insights. The hosted option, a recent enhancement to the product, allows hospitals or healthcare systems to transmit patient-specific clinical data to secure servers at Truven Health, saving valuable space and information technology resources, resulting in reduced costs.
Learn more at micromedex.com/360-care-insights.
New 360 Care Insights Enhancement for Informed Decision Making During Downtime
Many hospitals are leveraging Micromedex 360 Care Insights as an enterprise-wide, real-time clinical surveillance solution that allows their clinicians facility-wide to utilize a single technology to access patient data and clinical decision support, even during unplanned outages, for informed decision making and better patient outcomes. A printable Medication Administration Report (MAR) is now available and provides clinicians with access to ordered and administered medication information for their patients ,for confident decisions, even during downtime and unscheduled outages.
Click here to learn more about Micromedex 360 Care Insights.
Introducing Micromedex Solutions Consulting Services
Hospitals are increasingly facing complex challenges to meet new and changing healthcare reform objectives and initiatives. And in many cases, hospitals have few resources available to effectively navigate these challenges.
We’re here to help. Introducing Micromedex Solutions Consulting Practice, offering professional services in key areas to help hospitals advance their organizational goals. From identifying cost efficiencies in medication management, to designing compliance and population management programs that meet clinical imperatives while driving toward financial objectives – Micromedex Solutions has proven, trusted clinicians and clinical IT healthcare specialists to help healthcare organization better evaluate and prepare for the changes ahead.
For more information, visit micromedex.com/clinical-consulting.
New Micromedex CareNotes Enhancements Benefit Patients and Clinicians
When it comes to educating and engaging your patients, you can rely on Micromedex CareNotes® for high-quality, consistent, evidence-based patient education and instructions.
The following enhancements are now available:
- Simplified workflow that allows you to quickly select, customize, package, and print patient education handouts at the point of care.
- Simpler, actionable medication instructions for your patients, designed to promote patient activation and support HCAHPS initiatives.
- Enhanced imagery that complements and enriches education documents, and enhances patients' understanding and comprehension of health topics that are difficult to explain.
Click here to learn more.
Micromedex Patient Education Medication Instructions now Available in Brazilian Portuguese
Micromedex Patient Education offers education for every patient, in multiple languages, to ensure that patients receive the health education they need in the language they best understand. Education documents are available in 15 languages, and Medication instructions are now available in Brazilian Portuguese.
Visit micromedex.com/carenotes to learn more.
Enhanced Functionality to Connect with Your Consumers Now Available in Micromedex Consumer Health Education Featuring SmartEngage
With Micromedex Consumer Health Education featuring SmartEngage™, you provide high quality, evidence-based health information, easily accessible via the web and mobile devices, to your patients and consumers, as well as to your community. Enhanced functionality is now available to help you connect your consumers and patients to your hospital’s services:
- Easily drive consumers to take specific actions linked directly within the content, such as making an appointment
- Connect visitors to service-line specific pages on your website directly from health information articles
- Edit health information articles to include your hospital’s brand, standards and guidelines
Visit micromedex.com/smartengage to learn more.
Micromedex Mobile Apps now Available in Latin America
Access to Micromedex Mobile Apps is now available to customers in Latin America. All apps contain the industry’s most trusted evidence-based drug information, and are backed by the same thorough, unbiased editorial process used for all Micromedex solutions.
These valuable tools are now available, without charge, exclusively to Micromedex Internet Subscribers.
Visit micromedex.com/mobile for more information.
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CLINICAL CONTENT UPDATES
Selected New Drug Approvals
U.S. Food and Drug Administration (FDA)
Apremilast (Otezla):Approved for the treatment of adult patients with active psoriatic arthritis.
Droxidopa (Northera):Approved for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure, dopamine beta-hydroxylase deficiency, and non-diabetic autonomic neuropathy.
Factor IX Fc fusion protein recombinant (Aprolix):Approved for use in adults and children who have Hemophilia B for treatment and prophylaxis of bleeding episodes, perioperative management, and routine prophylaxis of bleeding episodes.
Florbetaben F 18 (Neuraeq):Approved for PET imaging of β-amyloid neuritic plaque density in the brains of adult patients with cognitive impairment evaluated for Alzheimer’s Disease and other causes of cognitive decline.
Metreleptin (Myalept):Approved as an adjunct to diet as replacement therapy to treat the complications of leptin deficiency in patients with congenital or acquired generalized lipodystrophy.
Miltefosine (Impavido):Approved in adults and adolescents 12 years or older for the treatment of visceral, cutaneous, and mucosal leishmaniasis.
Propranolol (Hemangeol):Approved for proliferating infantile hemangioma requiring systemic therapy.
Tasimelteon (Hetlioz):Approved for the treatment of nNon-24-hour sleep-wake disorder.
Testosterone undecanoate (Aveed):Indicated for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone.
European Medicines Agency Approvals
Dapagliflozin propanediol/metformin hydrochloride oral tablets (Xigduo):Approved in adults 18 years or older with type 2 diabetes as an adjunct to diet and exercise to improve glycemic control.
New FDA-Approved Indications
Apixaban:Now approved for prophylaxis of deep vein thrombosis following hip or knee replacement surgery.
Entecavir:Approval expanded to include children 2 years or older with chronic hepatitis B virus infection.
Esomeprazole:Now approved to reduce the risk of rebleeding of gastric or duodenal ulcers following therapeutic endoscopy in adults.
Ibrutinib:Now approved for chronic lymphocytic leukemia (CLL) patients who have received at least one previous therapy.
Oxycodone hydrochloride/acetaminophen oral extended-release tablets (Xartemis XR):New extended release dose form approved for management of acute pain severe enough to require opioid treatment.
Posaconazole intravenous solution (Noxafilin):New IV solution approved for the prophylaxis of invasive Aspergillus infections in severely immunocompromised patients who are at high risk of infection. The injection is indicated in adult patients only. The oral suspension and delayed-release tablets are indicated in patients 13 years or older.
Apixaban:Black box warning revised to address increased risk of stroke when discontinuing apixaban in nonvalvular atrial fibrillation patients.
Estradiol/norethindrone acetate: Now contraindicated in patients with known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders.
Valproic acid oral delayed-release capsules (Stavzor): New safety information related to the risk of fatal liver failure in patients with mitochondrial disease associated in patients with POLG mutations.
Dronedarone: Released from REMS.
Metreleptin:Required REMS to certify prescribers and pharmacies to minimize the risk of adverse events due to developing neutralizing anti-metreleptin antibodies and the increased risk of lymphoma and to limit population exposure to the drug.
Rivaroxaban:Released from REMS.
Testosterone undecanoate:Required REMS to certify prescribers and healthcare facilities to minimize the risk of adverse outcome, including anaphylaxis, with testosterone therapy.
New Off-Label Indications
Bevacizumab for the treatment of Hereditary hemorrhagic telangiectasia-associated epistaxis (Favors efficacy; Recommended in some)
Cisplatin for the treatment of triple negative breast cancer (Favors efficacy; Recommended in some)
Methylene blue for hypotension (Favors efficacy; Recommended in some)
Rilonacept for the prevention of gouty arthritis during initiation of urate-lowering therapy (Favors efficacy; Recommended in some)
Rituximab for the treatment of relapsing remitting multiple sclerosis (Efficacy inconclusive; Recommended in some)
Thalidomide for the treatment of systemic mast cell disease (Favors efficacy; Recommended in some)
2014 CDC Immunization Recommendations: Immunizations, for both children and adults were updated in multiple topics
In Micromedex: Search on such topics as Pneumonia and influenza to highlight some of the immunization update. All disease topics that cover childhood diseases for which there are immunizations have been updated and can be searched on by name to take you to the dashboard for access to detailed monograph.
Applicable drug monographs and the following Drug Consults have also been updated: Childhood Immunization Schedule - United States 2014; Immunization of Adults 19 years or older – ACIP 2014.
2014 Department of Health and Human Services Guidelines For the Use of Antiretroviral Agents in Pediatric HIV Infection:HIV Infection; AIDS topic was updated with the most recent treatment guidelines by the Department of Health and Human Services on the use of antiretroviral agents in children, focusing on the appropriate medication management of HIV-infected children, especially treatment-naïve patients.
In Micromedex: Enter AIDS in search box and select HIV Infection; AIDS dashboards to be taken to the summary or detailed monographs on the topic.
ACOG Guideline of Drug Therapy for Hypertension During Pregnancy:Hypertension in Pregnancy – Drug Treatment Drug Consult updated.
Guidelines for the Treatment of Hypertension:Hypertension in Adults – Drug Therapy Recommendations Drug Consult updated with recommendations from the American Society of Hypertension/International Society of Hypertension, the Eighth Joint National Committee (JNC 8), and American Heart Association/ American College of Cardiology/Centers for Disease Control and Prevention guidelines.
Other Significant Updates
Apixaban: Revised dosing recommendations in patients with end-stage renal disease maintained with hemodialysis.
Dabigatran vs warfarin:In a meta-analysis of 11 studies in patients undergoing radiofrequency catheter ablation of atrial fibrillation, there were no differences in thromboembolic events, and major or minor bleeding rates between prophylactic anticoagulation with dabigatran compared with warfarin – under the Atrial fibrillation – Thromboembolic disorder, Prophylaxis indication and the same in comparative efficacy.
Dexmedetomidine:Premedication with Dexmedetomidine reduced the incidence of fentanyl- and sufentanil-induced cough and was more effective than midazolam.
Enoxaparin compared with new anticoagulants for venous thromboembolism prophylaxis in orthopedic surgeries :Compared with enoxaparin, fondaparinux and rivaroxaban were significantly more effective; dabigatran 220 mg, apixaban, and bemiparin were similar; and dabigatran 150 mg was inferior for VTE prophylaxis during hip surgery or total knee replacement, according to a meta-analysis of 15 trials.
Oxaliplatin:Information related to oxaliplatin desensitization has been updated.
Ticagrelor vs Clopidogrel:Patients who received ticagrelor experienced a significant increase in spontaneous bleeding compared with clopidogrel in an analysis of the randomized Platelet Inhibition and Patient Outcomes (PLATO) trial (n=18,624).
Class Comparison of Selective Triptan Anti-Migraine Agents:Comparative dosage table including selective PK parameters, dose ranges, and max doses.
Class comparison – Phosphate-Binding Agents (Selected):DC includes – goals for serum phosphorus levels in patients with CKD, table comparison of available agents and includes pediatric considerations.
Angioedema:Updated to include more detail on recognition of the disorder and its management.
In Micromedex:Enter angioedema in search box to be taken to the detailed monograph on the topic.
Atrial fibrillation:Updated to include discussion of the use of newer anticoagulants to prevent stroke in nonvalvular AF.
In Micromedex:Enter atrial fibrillation in the search box to be taken to the detailed monograph on the topic.
Spinal cord tumors: Significant revision with emphasis on the proper designation of spinal cord tumors and recommended therapies.
In Micromedex:Search on spinal cord tumors to be taken to the detailed monograph on the topic.
Allergic conjunctivitis: Significant revision includes discussion on the proper management of allergic conjunctivitis, particularly with newer agents.
In Micromedex:Enter allergic conjunctivitis in the search box to be taken to the detailed monograph on the topic.
Afatinib inhibits tyrosine kinase autophosphorylation and is used for the first-line treatment of metastatic non-small cell lung cancer (NSCLC) in adults whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations. Overdose data are limited; however, overdose effects are anticipated to be an extension of adverse effects following therapeutic doses. Nausea, vomiting, asthenia, dizziness, headache, abdominal pain, and elevated amylase (less than 1.5 times upper limit of normal) have been reported with overdose.
Dabrafenib is a kinase inhibitor and is indicated for the treatment of unresectable or metastatic melanoma in adults with BRAF V600E mutation. Overdose of dabrafenib has not been reported; however, extension of adverse effects seen at therapeutic doses should be expected. The most commonly reported adverse effects include hyperglycemia, hyperkeratosis, hypophosphatemia, headache, pyrexia, arthralgia, papilloma, alopecia, and palmar-plantar erythrodysesthesia syndrome.
Trametinib is a kinase inhibitor and is indicated for the treatment of patients with unresectable or metastatic melanoma with BRAF V600E or V600K mutations. Exposure is uncommon, and overdose has not been reported. The most commonly reported adverse effects include rash, diarrhea and lymphedema. Elevated liver enzymes, anemia and hypoalbuminemia are also likely to occur with therapeutic use.
N-benzylpiperazine (BZP) is a synthetic sympathomimetic stimulant compound with properties similar to amphetamines. It has been used as a "rave" or "party" drug for its stimulant effects. It can produce feelings of euphoria and may be combined with other piperazine-based hallucinogens or stimulants. BZP is chemically similar in structure to amphetamines. Poisoning is not common, but may be severe. BZP is most often ingested as a tablet. Anxiety, vomiting, headache, palpitations and dilated pupils have been reported. Tachycardia and hypertension are common but generally not life threatening. High doses of BZP can cause sympathomimetic effects such as tachycardia, agitation and hypertension. Other serious adverse effects include mixed acidosis, alterations in CNS function, seizures, hyperthermia, acute renal failure, and rhabdomyolysis.
Paramethoxyamphetamine (PMA) and paramethoxymethamphetamine (PMMA) are hallucinogenic amphetamines that are abused recreationally. These compounds have both sympathomimetic and serotonergic effects. Use of these substances is not common; they are much less widely abused than methamphetamine or ecstasy. However, small epidemics of fatal PMA and PMMA have been reported in several countries including the United States. Tachycardia, hypertension, headache, vomiting, agitation, delirium, involuntary movements and hallucinations are common. More severe tachycardia, hypertension, severe delirium and agitation are characteristic. Hyperthermia can develop and may be fatal. Seizures, coma, cardiac dysrhythmias, QRS prolongation, severe hyperkalemia, and hypoglycemia are also described with severe overdoses.
Analeptics:CNS stimulants doxapram, nikethamide, pentylenetetrazol, and bemegride.
Clavulanic Acid:Generally in combination products containing amoxicillin or ticarcillin.
Ibogaine:A hallucinogenic indole alkaloid.
Selected NeoFax and Pediatrics Content Updates
New Monographs and Calculators:albumin (human), darbepoetin alfa, ibuprofen, levalbuterol
Revised Monographs:acetaminophen, acetylcysteine, adenosine, alprostadil, alteplase, amikacin, beractant, caffeine citrate, calcium (oral), calfactant, chloral hydrate, darbepoetin alfa, dexamethasone, didanosine, Dtap vaccine, emtricitabine, enoxaparin, epoetin alfa, fentanyl, fluconazole, haemophilus b (Hib) conjugate vaccine, hepatitis B vaccine (recombinant), Hib conjugate/hepatitis B combination vaccine, ibuprofen, ibuprofen lysine, immune globulin (human), indomethacin, insulin, lamivudine, lopinavir/ritonavir, lucinactant, nafcillin, nevirapine, octreotide, omeprazole, oseltamivir, palivizumab, piperacillin/tazobactam, pneumococcal 13-valent conjugate vaccine (PCV13), poliovirus vaccine enhanced-inactivated, poractant alfa, propranolol, rotavirus vaccine (rotarix®), rotavirus vaccine (rotateq®), sildenafil, topiramate, vitamin D, zidovudine
Revised Infant Formulas: Enfamil® Lipil® with iron
New Monographs and Calculators:albumin (human); elosulfase alfa; entecavir; Factor ix (recombinant), fc fusion protein;
levalbuterol; metreleptin; miltefosine; zafirlukast
Revised Monographs:abacavir, acetaminophen, acetaminophen/codeine, acetylcysteine, adenosine, alprostadil, alteplase, amikacin, atazanavir, atorvastatin, azathioprine, beclomethasone, calcium (oral), carbamazepine, cephalexin, cetirizine, chloral hydrate, cromolyn, cyclosporine, darbepoetin alfa, darunavir, dexamethasone, diclofenac, didanosine, dolutegravir, DT/Td vaccine, Dtap vaccine, efavirenz, eletriptan, emtricitabine, enoxaparin, epoetin alfa, esomeprazole, etravirine, fentanyl, fluconazole, flunisolide, fosamprenavir, haemophilus b (Hib) conjugate vaccine, Hepatitis A vaccine, hepatitis B vaccine (recombinant), hib conjugate/hepatitis B combination vaccine (human) papillomavirus (HPV) vaccine, hydrocodone/acetaminophen, hypertonic saline, ibuprofen, immune globulin (human), indomethacin, influenza virus vaccine, insulin, ivacaftor, lamivudine, lopinavir/ritonavir, measles, mumps, rubella (MMR) virus vaccine, (live), measles, mumps, rubella, varicella (MMRV) vaccine, meningococcal vaccine, meningococcal/Hib conjugate combination vaccine, methotrexate, mometasone, montelukast, nafcillin, nevirapine, octreotide, omalizumab, omeprazole, oseltamivir, oxycodone/acetaminophen, palivizumab, pancrelipase, peginterferon alfa-2a, peginterferon alfa-2b, piperacillin/tazobactam, pneumococcal 13-valent conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPSV23), poliovirus vaccine enhanced-inactivated, propranolol, raltegravir, ribavirin, ritonavir, rotavirus vaccine (rotarix®), rotavirus vaccine (rotateq®), sildenafil, sumatriptan, tacrolimus, Tdap vaccine, tenofovir, topiramate, varicella virus vaccine, live, vitamin d, zanamivir, zidovudine, zileuton
Revised Infant Formulas:Enfamil® Lipil® with iron
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