IV to PO

Question 1

INCLUSION criteria:

Answer 1

1. The patient is on a medication therapy listed in the protocol.
2. The patient is taking and tolerating other oral medications.
3. The patient is tolerating an oral diet (NG tube feeding exclusions listed below).
4. Clinical status is improving as demonstrated by, but not limited to, a trend towards:
   a. Afebrile (less than 100.4F) in past 24hr (for antimicrobials)
   b. WBC wnl (for antimicrobials)
   c. HR<100 bpm (as applicable)
   d. SBP>100mmHg (as applicable)
   e. Advancing diet

Question 2

Ondansetron

Answer 2

a. Do not convert for patients receiving chemotherapy or with chemotherapy planned

Question 3

APAP

Answer 3

IV Dose*
1gm IV q6-8h
(Note: IV APAP restrictions to be followed per P&T Committee)

PO Dose
975mg-1000mg PO q6-8h

PO Bioavailability
85-98%

Question 4

Ampicillin and sulbactam

Answer 4

IV Dose*
1.5 to 3 gm Q6h

PO Dose
Amoxicillin and clavulanate 875/125 mg Q12h

PO Bioavailability
Amoxicillin nearly complete oral absorption: AUC was 93% of intravenous

Question 5

Azithromycin

Answer 5

IV Dose*
250-500mg IV q24h

PO Dose
Same dose and interval

PO Bioavailability
38%

Question 6

Ceftriaxone

Answer 6

IV Dose*
1 gm or 2 gm q 24h

PO Dose
Cefdinir 300 mg Q 12h

PO Bioavailability
Capsule 16% to 21%; suspension 25%

Question 7

Chlorothiazide/ Hydrochlorothiazide

Answer 7

(Chlorothiazide)
500-1000mg IV q12-24h

(Hydrochlorothiazide)
12.5-100 mg PO q24h (max 50mg for HTN)

Question 8

Ciprofloxacin

Answer 8

200-400mg IV q8-24h
250-500mg PO q8-24h‡
60-80%

Question 9

Clindamycin

Answer 9

300-900mg IV q6-8h

150-450mg PO q6-8h

90%

Question 10

Digoxin (maintenance)

Answer 10

Arrhythmia: 0.125-0.5 mg IV q24h
HF: 2.4 to 3.6 mcg/kg IV/IM q24h

Same dose and interval

60-80%

Question 11

Doxycycline

Answer 11

100-200mg IV q12-24h

Same dose and interval

100%

Question 12

Ethacrynic Acid

Answer 12

0.5-1mg/kg IV

50-200mg PO/day
(consult with MD to determine best frequency, and titrate to effect)

100%

Question 13

Famotidine

Answer 13

20-40mg IV q12-24h

Same dose and interval

40-45%

Question 14

Fluconazole

Answer 14

100-400mg IV q24h

Same dose and interval

> 90%

Question 15

Folic Acid

Answer 15

1mg IV q24h

Same dose and interval

76-93%

Question 16

Fosphenytoin/Phenytoin

Answer 16

100-300mg** IV q8-24h

Same dose and interval‡

80-100%

Question 17

Levetiracetam

Answer 17

500-1500mg IV q24h
Same dose and interval
100%

Question 18

Levofloxacin

Answer 18

250-750mg IV q24h

Same dose and interval

50-80%

Question 19

Levothyroxine

Answer 19

25-100mcg IV q24h
IV dose is around 50% of oral dose*** ‡

Restricted to patients who have not received levothyroxine > 3 days AND cannot take orally.
(ex: 50mcg IV q24h=100mcg PO q24h)

50-80%

Question 20

Linezolid

Answer 20

600mg IV q12h

Same dose and interval

100%

Question 21

Metoclopramide

Answer 21

5-20mg IV q4-6h

Same dose and interval

80%

Question 22

Metronidazole

Answer 22

250-500mg IV q6-8h

Same dose and interval

100%

Question 23

Multivitamin

Answer 23

1 vial IV q24h

1 tablet PO q24h

100% RDA

Question 24

Ondansetron

Answer 24

4-8 mg per dose

Same dose and interval. *Add linked order for ODT (or regular tablet if ODT not available) and leave IV order, in the event that patient no longer meets criteria for PO

100%

Question 25

Pantoprazole

Answer 25

40mg IV q24h

Same dose and interval†

77%

Question 26

Thiamine

Answer 26

100mg IV q24h

Same dose and interval

5.3%

Question 27

Voriconazole

Answer 27

3 to 4 mg/kg IV q12 hours

200 mg PO q 12h

96%

Question 28

EXCLUSION criteria*:

Answer 28

1. Pediatric and neonatal patients.
2. The physician specifically indicates “do not convert to oral route” or similar instruction.
3. The patient is NPO (and no other medications are being administered orally).
4. The patient has diminished gut perfusion (i.e. shock, vasopressor therapy).
5. Persistent nausea and vomiting, diarrhea
6. The patient has compromised oral absorption (i.e. continuous NG suction, persistent N/V or diarrhea, active GIB, ileus, GI obstruction, reduced GI transit time from malabsorption or short bowel syndromes).
7. The patient is on continuous tube feeding, the tube feeding cannot be interrupted, and the medication being evaluated is known to interact with enteral formulas (i.e. fluoroquinolones, phenytoin, levothyroxine).
8. The patient is neutropenic (ANC<500 cells/mm3).
   * patients excluded may be eligible for conversion to oral therapy on a later date.