Zagazig University Faculty of Pharmacy

Hospital Pharmacy -Pharmacy Practice

Department

Research Project
Hospital Formulary
Presented
By:

Student Name: Menna Osama Mahmoud Elbayaa

Academic Year: 4th
Seat Number: 8785
Student ID: 051500613
Student Code: 20612015202293
Phone Number:01149850965

Under the Supervision of:

Dr. Shereen Sabry

2020
Contents
Hospital Formulary Definition ...................................................................................1

Hospital Formulary Parts ...........................................................................................1

Preparation of Formulary ...........................................................................................3

Advantages and Disadvantages..................................................................................5

Advantages .............................................................................................................5

Disadvantages ........................................................................................................5

Pharmacist Role .........................................................................................................6

Hospital Formulary Clinical Case..............................................................................7

Case presentation ...................................................................................................7

Treatment Protocol.................................................................................................8

Clinical Case According to Market Drugs. ................................................................9

References ................................................................................................................11
Hospital Formulary Definition
The hospital formulary is a continuously revised compilation of pharmaceutical
dosage agents, including their formulation and other traits, reflecting the current
medical staff judgment. The system is a process that enables the medical staff, with
the help of therapeutic committee and pharmacy, to select and evaluate
pharmaceutical medical agents and the appropriate dosage forms which are
considered to be most effective in the care of the patient. Hospital formulary system
provides essential process information for procuring, prescribing, dispensing and
administration of the pharmaceutical drug under non-proprietary generic names and
instance where drugs have both names [1].

Hospital Formulary Parts

There are three main parts in hospital formulary according to their objectives:

Hospital Policies and Procedures

 Drug use
 PTC description (pharmacy and therapeutic committee)
 Hospital’s regulations on prescribing, dispensing and administration of drugs.
 Rules for medical representatives, emergency drug products
 Information on using Formulary
 Pharmacy operating procedures [2]

Drug Products Listing

 Formulary item entries: alphabetically within the therapeutic class and
alphabetically by generic name
 Information type: dosage forms, dosage strength, packaging, adult dose, pediatric
dose, cost and administration route

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 Drug product listing indexes: pharmacological/therapeutic index and brand
name/generic name [2]

Special Information (figure 1)

 Hospital approved abbreviations
 Equivalent dosage of similar pharmaceutical drugs
 List of dialyzable poisons
 Poison control information
 List of sugar free drugs
 Metric conversion table
 Table of drug interactions [2]

Figure 1. General information tab from a children hospital formulary.

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Preparation of Formulary
The hospital formulary must be visually pleasing, professional in appearance and
easily readable, and must be composed of a title page, names and titles of PTC
members, information on hospital’s procedures and policies concerning drugs, table
of contents, products accepted for hospital use and appendix. Formulary Contents
are:

Introduction

 Drugs used in the formulary lists

 Abbreviations lists [3]

Basic information of each drug (figure 2)

 Item’s safety profile

 Efficacy for specific condition’s treatment
 Adverse effect
 Interactions profile
 Item’s availability
 Pharmacokinetic characteristics
 Patient acceptability
 Dosage forms available
 Cost [3]

Supplementary information on each drug

 Patient therapy information

 Brand names and prices
 Storage guidelines
 Labelling information [3]

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Prescribing and dispensing guidelines

 Reporting adverse drug reaction

 Prevention of adverse drug reaction
 Prescription writing principles [3]

General drug use and advice

 Special instructions as in breast feeding, pregnancy, kidney or liver diseases

 Snake and insect’s bite treatment
 Use of intravenous drugs
 Antidotes and poisoning information [3]

Miscellaneous section

 Diagnostic tools
 Children’s dosage
 Metric units
 Renal adjustments [3]

Figure 2. Special information tab in online hospital formulary.

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Advantages and Disadvantages
Advantages
1. Educational value
2. Cost effective prescribing (if two drugs are bioequivalent, then the hospital
selects the least expensive one to list in formulary.
3. Safety and continuous care
4. Rational prescription of drugs is based on evidence-based medicine and well
controlled clinical trials
5. Cost containment
6. Efficient storage and procurement
7. Evidence based practices (clinical trials and studies are conducted by healthcare
team allowing the application of experience, evidence and knowledge to patient
care and drug selection)
8. Patients can have access to novel investigational drugs and treatments [4]

Disadvantages
1. The hospital formulary deprives the physician of his right to prescribe his drug
and brand of choice.
2. The hospital formulary system in many occasions, the hospital formulary enables
the pharmacist to act as the only judge on which drugs and drug brands are to be
dispensed or purchased.
3. Although purchasing the drugs in bulk and at a reduced-price rate, the system
does not reduce drugs prices for patients or third-party payer.
4. Inferior quality drugs are allowed to be purchased in institutions where there is
not a pharmacy staff [4]

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Pharmacist Role
Pharmacists have a vital role in the formulary management process. Often
pharmacist will guide the activities of the pharmacy and therapeutic committee
assuring optimal medication management. The pharmacist responsibilities include
all of the following:

 Analyze and spread clinical, health economic and scientific information

regarding a therapeutic class or specific drug for review by the pharmacy and
therapeutic committee.
 Follow up with research when required
 Carrying out pharmacoepidemiologic studies
 Finding adequate literature to use in PTC decision making
 Carry out research into local hospital clinical outcomes as well as
pharmacoeconomic assessments to be used in decision-making regarding the
decrease of costs of operation and improvement of drug and service outcomes
 Establish P&T meeting agenda
 Record and archive P&T committee actions (figure 3)
 Communicate pharmacy and therapeutic committee decisions to other health care
professionals as medical staff, pharmacy and patient care staff.
 Analyze data and conduct drug use evaluation.
 Participate in clinical trials in the preparation of placebos or test treatments,
monitoring drug and test subject distribution and collecting and analyzing data
[3].

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 Figure 3. PTC issues of discussion.

Hospital Formulary Clinical Case

Case presentation
A 10-month old female weighing 8 kilograms presented to the emergency
department 3.5 hours after ingesting 13 iron tablets of 200 mg strength and 60 mg
elemental iron in each one of them with a total dose of 780 mg or 130 mg per kg,
which was prescribed to the mother for her pregnancy. The child complained of
repeated vomiting with increase irritability. Vomiting was continuous in the
emergency department containing red colored unabsorbed drug. The child was
irritable with severe signs of dehydration showed by decreased skin turgor, dry oral
mucosa and sunken eyes. Her respiratory rate was 44/minute without any evidence
of increased breathing working, her heart rate was 110/min, her blood pressure was
just below the fifth centile for her age 68/40 mmHg and her capillary refill was 2-3
second [5]

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Treatment Protocol
The child was immediately administered oxygen with a non-rebreathing face mask
and put inn fluid therapy to treat her severe dehydration. She was also given antacids
and antiemetics for her gastric irritation. After that, she was transported to the
pediatric ICU where she underwent complete bowel irrigation using polyethylene at
a dose of 30 ml/kg/h after 30 minutes of her arrival until she started passing clear
stool. She was also put on definitive therapy using IV deferoxamine within 2 hours
of her admission at 15 mg/kg/h dose. Although the iron ingested dose was lethal,
with child presenting clear signs of toxicity in the form of metabolic acidosis, sever
dehydration and vomiting, and after consulting the health care team especially the
pharmacist, the conclusion was to start the child on deferoxamine intravenously and
supportive care as she was interactive and responsive with her serum iron in the
range of serious toxicity of 350-500 µg/dl and not in the fatal zone of more than
1000 µg/dl. The healthcare team also for an exchange transfusion and made
arrangements for this case as precaution for any worsening. However, within 6 hours
of therapy the child became normo-volemic and started to accept breastmilk.
Deferoxamine was administered for a total of 12 hours. After completion, iron levels
returned to normal and Deferoxamine discontinued [5].

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 Figure 4. Picture of deferoxamine information from children hospital formulary.

Clinical Case According to Market Drugs.

A 36-year-old Indonesian woman presented herself to a dermatologist with several
bilateral facial papules and pustules involving mostly the two thirds of the inner
cheeks. Small scattered inflammatory pustules and papules involving the nose, chin
and upper lip were also present. Facial erythema was primarily perilesional; minimal
telangiectasias were also present. The patient reported rosacea history of 7-years and
reported that the current flare, which was more time persistent than past flares, began
about 4 months ago. She had never experienced ocular symptoms. She reported
"sensitive" facial skin and reported that certain types of skin astringents, cleansers,
sunscreen and moisturizers caused redness, itching and stinging. These signs and
symptoms were noticed especially during flares but in some occasions also during
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periods of remission period. The patient was not using any rosacea drugs other than
topical metronidazole. She was not using any other topical products, including OTC
medications, oral treatments, any cosmetic, professional facial procedures and
treatments or topical corticosteroids. Her medical history and a review of systems
were ordinary. Her surgical history was positive for a tubal ligation and
appendectomy [6].

The patient was advised to avoid sunlight, heat, hot beverages, spicy foods, vinegar,
alcoholic beverages, topical products with astringents, stress, calcium channel
blockers, nitrates and vigorous exercise in hot weather as these things can trigger
flares. When out doors high spf sunscreen can be used and she should also use non-
soap cleansers. She was prescribed finacea 15% (topical azelaic acid) for 12 weeks
and accutane 10 mg (low dose isotretinoin) daily for 12 months [6].

Figure 5. Picture of marketed accutane and finacea in state formulary.

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References
[1] Rübesam, T., Jain, M., & Pioch, E. (2013). Relevant Decision-Making Criteria
in German Hospital Formularies. Value In Health, 16(7), A456. doi:
10.1016/j.jval.2013.08.770

[2] Boucher, B. (2010). Formularies, Pharmacists, and Influences on the Decision-

Making Process. Pharmacotherapy, 30(6, part 2), 33S-34S. doi:
10.1592/phco.30.pt2.33s

[3] Hospital Formularies Decision-Making Process. (2020). Retrieved from, from

https://www.cadth.ca/hospital-formularies-decision-making-process

[4] Sutters, C. (2005). THE MANAGEMENT OF A HOSPITAL FORMULARY.

Journal Of Clinical Pharmacy And Therapeutics, 15(1), 59-76. doi: 10.1111/j.1365-
2710.1990.tb00357.x

[5] Sankar, J., Shukla, A., Khurana,, R., & Dubey, N. (2013). Near fatal iron
intoxication managed conservatively. Case Reports, 2013(jan31 1),
bcr2012007670-bcr2012007670. doi: 10.1136/bcr-2012-007670

[6] Del Rosso, J. (2018). Case Studies in Rosacea: A 36-Year-Old Woman With a
7-Year History of Rosacea. Retrieved 13 June 2020, from
https://www.medscape.org/viewarticle/745093

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