Pediatric Pharmacotherapy Clinical Pearls Caitlin Lozorak, PharmD PGY2 Pediatric Pharmacy Resident Palmetto Health Children’s Hospital March 13, 2016

Disclosure I have no disclosures or conflicts of interest at this time regarding the subject matter of this presentation.

Please note that this Power Point presentation is an educational tool that is general in nature. It is not intended to be an exhaustive review of the subject matter or the opinion of Palmetto Health. Materials presented in this presentation should not be considered a substitute for actual statutory or regulatory language. Always refer to your legal counsel and the current edition of a referenced statute, code and/or regulation for precise language.

Objectives Upon completion of this program, the participant should be able to: Explain principles of basic pediatric pharmacology including: Weight-based dosing Developmental pharmacology Drugs in Pregnancy/Breastfeeding Pediatric pharmacotherapy references

Weight-based Dosing Primary dosing method for pediatrics unit (mcg,mg,gram) / kg (weight) / DOSE unit (mcg,mg,gram) / kg (weight) / DAY Be mindful of MAXIMUM doses Do not exceed adult maximum doses Patients >12 years old and/or > 50 kg Similar to adult dosing / = PER Always need to be mindful if per dose or per day and then splitting total into divided doses. ALWAYS use a calculator

Developmental Pharmacology “Pediatrics does not deal with miniature men and women, with reduced doses and the same class of disease in smaller bodies, but… has its own independent range and horizon.” - Dr. Abraham Jacobi, the father of American Pediatrics N Engl J Med 2003;349:1157-67.

Absorption Enteral Absorption Intramuscular Absorption Changes in pH Elevated in neonates Immature biliary function Delayed gastric emptying Delayed intestinal motility Decreased rate of absorption Intramuscular Absorption Reduced skeletal-muscle blood flow Decreased muscle movement for drug dispersion N Engl J Med 2003;349:1157-67.

Absorption Rectal Absorption Topical Intrapulmonary Contractions may cause expulsion of drug Good blood flow and absorption Topical Increased absorption Use with caution Intrapulmonary Systemic exposure may occur N Engl J Med 2003;349:1157-67.

Distribution  volume of distribution for hydrophilic medications Especially neonates and young infants  protein binding Increased free drug  distribution across blood brain barrier Immature blood brain barrier in neonates and young infants N Engl J Med 2003;349:1157-67.

Metabolism Delayed maturation of drug-metabolizing enzymes Phase I Cytochrome P-450’s Change remarkedly during development Phase II Conjugation and glucuronidation decreased Increases with age Blood esterases Decreased in neonates N Engl J Med 2003;349:1157-67.

Elimination Renal Decreased GFR Renal maturation  GFR increases with age Adult values at 8-12 months of age Neonates – record urine output as a more accurate portrayal of renal function. N Engl J Med 2003;349:1157-67.

Drugs in Pregnancy/Breastfeeding Recent change to “Pregnancy and Lactation Labeling Rule” Effective June 2015 No longer A,B,C,D,X Based off of human vs. animal data Instead of lettering system narrative risk summary Allows patients and physicians to decide risk vs. benefit on their own Image: www.fda.gov

Pediatric Drug References Comprehensive drug references Lexicomp / Pediatric and Neonatal Lexi-Drugs Micromedex / Neofax Pediatric and Neonatal Dosage Handbook / Drug Information Handbook Harriet Lane Handbook Pediatric Pharmacotherapy Textbook (ACCP) Intravenous Resources Pediatric Injectable Drugs (Teddy Bear book) Handbook of Injectable Drugs (Trissel’s) Gahart’s Intravenous Medications

Pediatric Drug References Infectious Disease Red Book Guidelines (IDSA, AAP, etc.) Nelson’s Pediatric Antimicrobial Therapy Harriet Lane Handbook on Antimicrobial Therapy Drugs in Pregnancy & Lactation Brigg’s Miscellaneous Guidelines on specific disease states Journal Articles

Questions?? Caitlin.Lozorak@palmettohealth.org