Hospice Pharmacia is pleased to announce the release of the Pharmaceutical Care Tool Kit & MUGs Version 5

1. Hospice Pharmaciais pleased to announce the release of thePharmaceutical Care Tool Kit& MUGs Version 5 May 2003 Doug Weschules, PharmD, Director of Clinical Programs Jill McMath, PharmD, Director of Education Heather K. Omlor, PharmD, VP Client Development Stephanie Zarus, PharmD, Chief Performance Officer

2. Pharmaceutical Care Tool Kit and MUGs • First published in 1996 • Limited distribution (<50 copies) • Less than a dozen guidelines • Designed in response to request by nurses in Samaritan Hospice, NJ

3. Pharmaceutical Care Tool Kit and MUGs 5th published release 15,000 copies & web posting Evidence Based and Peer Reviewed Systematic procedures for development, review and approval 21 external hospice expert reviewers 40 symptom management protocols

4. Pharmaceutical Care Tool Kit and MUGs Thanks to All External Reviewers! Jane Cornett, MD Hospice of Louisville Karen Cross, MD, Nathan Adelson Hospice Fran Davis, RN, CHPN, Hospice of Volusia Flagler Mitzi Ellman-Pecorella, RN, Wuesthoff Brevard Hospice Gwen Feather, RN, MS, Hope Hospice and Palliative Care Claire Forsyth, RPh, FASCP Pikes Peak Hospice Tara Friedman, MD, VITAS Helathcare, Philadelphia Elizabeth Galfo, MD, FACP, Hospice of St. Francis Paulette Hallihan, RN, BSN, Umass Memorial Hospice Robert LeFevre, MD, Community Hospice Inc. Debbie Luke, RN, BSN, Hospice of Coffee Regional Medical Center Tim Moored, RPh, Hospice of Michigan John Mulder, MD, alive Hospice Valerie Pompey, RN, MS, The Center for Hospice and Palliative Care, Inc. AJ Querciagrossa, RPh, OSF Hospice Richard Sarkis, MD, Hospice of Southwest Florida Diane Smith, MD, Hope Hospice and Palliative Care David Taylor, MD, MetroplitanHispice of Greater NY Alessandra Thompson, PharmD, The Hospices of the National Capital Region Terri Walter, RN, MSN, Hospice & Palliative Care of Western CO James Wright, MD, VITAS Healthcare, Dallas/FT. Worth

5. Pharmaceutical Care Tool Kit and MUGs Designed to provide: • HP standard operating procedures • Clinical tools for hospice nurses and pharmacists • Symptom management decision making support

6. The Hospice Pharmacia Pharmaceutical Care Tool KitVersion 5 Quick Guide to Services Updates and Changes

7. The Pharmaceutical Care Support Center (QGS-1) • The Pharmaceutical Care Assessment • Medication Care Plan Modification (detail) • Medication Distribution • Clinical Outcome Markers (new) • Endpoints • Outcomes • Documentation (Xeris/ARDS) Care Center Hours Clarified

8. Quick Guide to Services • Patient Enrollment (QGS-4) • Additional information requested by HP • Collaboration/Documentation by pharmacist • Medication Access (QGS-6) • Delivery from HP • Next Day PM is Standard; AM Delivery available upon request • 2nd Day Clarification—may arrive next day • Saturday—available in most service areas • Same Day Medications • Rejections at local pharmacies—include compounds/injectables

9. Quick Guide to Services • Planning for Emergencies (QGS-7) • Comfort Pak • ABHR names included • No refills on CPak meds • On Call • Pharmacist Cell Phone & New Admin On-Call number • Business Interruption/Disaster Planning (QGS-8) • Changes in Level of Care • Discharge responsibility (hospice) within 3 days • Definition of ‘discharge’

10. Quick Guide to Services • Infusion Therapy (QGS-11) • Not included for LTC under the per diem • ‘Authorization Required’ has been removed

11. Medication Use GuidelinesVersion 5

12. MUGs Version 5: Summary • Review new medication additions and deletions. • Discuss existing protocols with added algorithms. • Introduce additional Endpoints and Outcomes markers. • Discuss additional protocol ideas and medications to be considered for Version 6.

13. MUGs Version 5: Summary • Review new protocols with algorithms: • Nausea and vomiting • Dyspepsia • Secretions • Pruritis • Insomnia • Cachexia • Skin and skin structure infections • Genitourinary infections • Fever

14. MUGs Version 5: Nausea and VomitingCoverage Code: A • Algorithm format based on suspected etiology • Clarification of compounded medications available (ABHR, ABR, ABD) • Erythromycin added for motility-related nausea • Hydroxyzine pamoate (Vistaril®) added for anxiety-related component Common NMUG: Zofran® Page 37

16. MUGs Version 5: DyspepsiaCoverage Code: A • Algorithm format based on dyspepsia type • Ulcer-like • Reflux-like • Dysmotility-like • Twice daily dosing for H2blockers is now included under per-diem if once daily therapy fails • Must still assess appropriateness of dose based on age and renal impairment Page 21

17. MUGs Version 5: DyspepsiaCoverage Code: A • Famotidine (Pepcid®) added as additional treatment option • 20mg po qd - bid • Metoclopramide and Erythromycin added for motility-related dyspepsia

19. MUGs Version 5: SecretionsCoverage Code: A • Algorithm format based on thickness of secretions • Is goal of therapy for patient to expectorate them or not? • Hyoscyamine ER added (Levbid®) as a treatment option • Atropine injection added to protocol as a treatment option Page 55

21. MUGs Version 5: PruritusCoverage Code: A • Algorithm format based on topical or systemic therapy • Cholestyramine powder added for pruritus due to hepatic disease/jaundice • Hydroxyzine pamoate (Vistaril®) added as alternate antihistamine choice • More detail on topical preparations and strengths Page 53

24. MUGs Version 5: InsomniaCoverage Code: A • Algorithm format based on presentation of insomnia • Is patient having difficulty falling asleep or staying asleep? • Chloral hydrate reserved as 3rd line therapy choice Common NMUG: Ambien® Page 32

25. MUGs Version 5: InsomniaCoverage Code: A • Alprazolam added as an alternate benzodiazepine choice • Hydroxyzine pamoate (Vistaril®) added as alternate antihistamine choice

27. MUGs Version 5: CachexiaCoverage Code: C • Algorithm based on patient’s co-morbid conditions • If patient has a hx of GI bleed, immunosuppression, or osteoporosis, can use megestrol as 1st line • Cyproheptadine removed as treatment option due to lack of evidence demonstrating efficacy Page 63

29. MUGs Version 5: Skin & Skin Structure Infections Coverage Code: A • Algorithm recognizes treatment of fungating tumor separately • If metronidazole therapy for suspected fungating tumor fails, may go to either 1st or 2nd line antibiotic thereafter • Length of therapy is limited to 14 days • Therapy needs to be reassessed at this point • A new order for alternate antibiotic or extending current therapy needs to be procured Page 58

31. MUGs Version 5: Genitourinary InfectionsCoverage Code: A • Algorithm is based on whether UTI is uncomplicated or complicated • Complicated UTIs may proceed right to 2nd line agents • RN will need to provide clinical info qualifying why UTI is complicated; document in Xeris Page 61

32. MUGs Version 5: Genitourinary Infections Coverage Code: A • Length of therapy is limited to 14 days • Therapy needs to be reassessed at this point • A new request for alternate antibiotic or extending current therapy needs to be procured

34. MUGs Version 5: FeverCoverage Code: A • Algorithm based on response to previous therapy • Clinical information for quick reference • Types of fever patterns • Temperature conversion formulas • Common cancers associated with fever • Common medications associated with fever Page 25

36. MUGs Version 5: Pain Protocol UpdatesCoverage Code: A • Add Misoprostol as a therapeutic option for prevention of NSAID/steroid related GI symptoms • Clarify long acting-opioid policy to reflect that two different concurrent long-acting opioids are outside per-diem (Methadone is exception) • Clarify maximum daily dose of Gabapentin=3600mg in divided doses • Algorithm added for all pain protocols Common NMUGs: Ultram®, Celebrex®, Vioxx®

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46. MUGs Version 5: Constipation Coverage Code: A • Remove Docusate sodium/Casanthranol • Insert various types of enemas as therapeutic options • Some enemas may need 1-2 days to order into stock Common NMUG: Miralax® Page 12

47. MUGs Version 5: Gastrointestinal Symptoms Coverage Code:C • Rabeprazole (Aciphex®) added as an alternate PPI choice, 20-40mg daily • Statement removed that suggests PPIs are 2nd line therapy for this patient population (gastric, esophageal, pancreatic cancer) Common NMUG: Prevacid®, Protonix®, Nexium® Page 64

48. MUGs Version 5: Genitourinary Symptoms • Anorectal agents: Coverage Code: A • Hydrocortisone cream and supps clarified to be included • Spasm Coverage Code: A • B+O preparations include strengths • Frequency of administration increased to q6-8h prn • Related to malignancy Coverage Code: C • Doxazosin (Cardura®) added for prostate cancer patients only to treat dysuria, urethritis, urgency Common NMUG: Flomax® Page 28

49. MUGs Version 5: Delirium & DementiaCoverage Code: A • Add Risperidone (Risperdal®) as 2nd line agent for treatment of delirium • Patient must try and fail Haloperidol or Chlorpromazine, or relative contraindication must exist • Maximum dose of Risperidone =2mg/day under per-diem • Add subprotocol for sundowning • Risperidone is 1st line therapy for this subtype Common NMUGs: Zyprexa® and Aricept® Page 15

50. MUGs Version 5: DiarrheaCoverage Code: A • Remove Tincture of Opium as therapeutic option due to confusion with dosage form and availability issues • Paregoric clarified with generic name of Morphine, camphorated (0.4mg/ml) Page 20