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PILOT Prescription Renewal - UW Health – Adult/Pediatric - Transplant

PILOT Prescription Renewal - UW Health – Adult/Pediatric - Transplant - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Prescription Renewal Delegation Protocols


Delegation Protocol Title: PILOT Prescription Renewal - UW Health – Adult/Pediatric - Transplant

Delegation Protocol Applies To: UW Health Transplant Program

Target Patient Population:
Patients with prescriptions written by physicians in the UW Health Transplant Clinics

Delegation Protocol Champion:
Didier Mandelbrot, MD – Department of Abdominal Transplant
Richard Cornwell, MD – Department of Pulmonary Transplant
Ravi Dhingra, MD – Department of Cardiac Transplant

Responsible Department:
Department of Pulmonary Transplant
Department of Abdominal Transplant
Department of Cardiac Transplant

Purpose Statement:
To delegate authority from providers in UW Health Transplant Program to clinical staff to renew
prescriptions for the medications identified in this protocol and to order the laboratory tests identified in
this protocol if needed to renew the prescription.

Who May Carry Out This Delegation Protocol:
Registered nurses (RNs), medical assistants (MAs), and pharmacists (RPhs) in UW Health Clinics who
have successfully completed training in the prescription renewal process.

Guidelines for Implementation:
1. The staff will review the medical record to verify:
1.1. The order details of the requested renewal match the original order details, including dose, route,
frequency, provider and any additional instructions for use. If the details in the requested
renewal are different than the original order, the provider will be contacted for clarification before
any orders are placed.
1.2. The patient meets all of the renewal requirements specified in the medication catalog, including
any office visit, laboratory result or vital sign criteria (see Appendices A and B).
2. If all requirements are met, the prescription may be renewed for a quantity sufficient to provide
medication up to the next office visit or as specified for the medication.
3. If the patient is overdue for an office visit or any required testing, a bridging supply, as specified, may
be ordered to prevent interruption of therapy. In addition, staff will order any overdue laboratory tests
and contact the patient to have the laboratory work done, or to schedule an office visit if needed.
4. If any of the required laboratory tests or vital signs are outside of the defined limits, a provider must
be consulted before placing any orders.
5. The following cannot be renewed by staff under this protocol and must be routed to a provider for
signature.
5.1. Medications not specified in this protocol
5.2. Controlled substances

Order Signing Mode:
Medication Orders Laboratory/Diagnostic Test Orders
RNs, RPHs Protocol/policy without Cosign Cosign required Protocol/Policy
MAs Cosign required Protocol/Policy Cosign required Protocol/Policy

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Approved By:
UW Health Ambulatory Protocol Committee –
UW Health Laboratory Committee –
UWHC Pharmacy and Therapeutics Committee – Chair Approval 8/15/2017
UWHC Medical Board – Chair Approval 8/15/2017
Effective Date: 8/15/17
Scheduled for Review: March 2018
Appendix A. UW Health Transplant Medications for Prescription Renewal
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Appendix A. UW Health Transplant Medications for Prescription Renewal
Generic Name Common Brand
Names Labs
Interval Between
Office Visits Other Max Supply
amphotericin (inhaled)
Every 1 month and within normal
limits
• Ca, Mg, K
1 month
May refill only when
being used for chronic
condition or
prophylaxis
30 days with
0 refills
belatacept NULOJIX
Every 12 months and within
normal limits
• urine protein
12 months 90 days with
4 refills
cyclosporine
GENGRAF,
NEORAL,
SANDIMMUNE
Every 3 months and within normal
limits
• Cr
• K
• cyclosporine level
Every 12 months and within
normal limits
• CBC
• Mg, Ca
• Glucose
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
12 months 90 days with
0 refills
denosumab PROLIA
Every 12 months and within normal
limits
• Ca, Phos, Mg
• vitamin 25(OH)D
12 months
May refill only when
being used for chronic
condition
Should have BMD
evaluated at least
every 2 years
90 days with
4 refills
entecavir BARACLUDE
Every 12 months and within normal
limits
• AST, ALT, Tbili
• HBV PCR or HIV PCR
• Cr
12 months
90 days with
4 refills
everolimus ZORTRESS
Every 3 months and within normal
limits
• Cr
• everolimus level
Every 12 months and within
normal limits
• CBC
• Glucose
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
• Urine protein
12 months 90 days with
0 refills
fosfomycin Monurol
Every 12 months and within normal
limits
• Cr
12 months
May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
isavuconazonium sulfate Cresemba
Every 12 months and within normal
limits
• AST, ALT, Tbili, Alk Phos
• Cr
12 months
May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

itraconazole Sporanox
Every 12 months and within normal
limits
• AST, ALT, Tbili, alk phos
• Ca, Mg, K
• itraconazole level
12 months
May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
lamivudine Epivir
Every 12 months and within normal
limits
• AST, ALT, Tbili
• HBV PCR or HIV PCR
• Cr
12 months
90 days with
4 refills
mycophenolate CELLCEPT, MYFORTIC
Every 12 months and within normal
limits
• WBC
12 months 90 days with
4 refills
penicillin v potassium
Every 12 months and within normal
limits
• Cr
12 months
May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
pentamidine inh NEBUPENT
12 months
May refill only when
being used for chronic
condition or
prophylaxis
as per
previous
prescription
posaconazole Noxafil
Every 12 months and within normal
limits
• AST, ALT, Tbili, alk phos
• CBC
• Ca, Mg, K
• Cr
• posaconazole level
12 months May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
sirolimus RAPAMUNE
Every 3 months and within normal
limits
• Cr
• sirolimus level
Every 12 months and within
normal limits
• CBC
• Glucose
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
• Urine protein
12 months 90 days with
0 refills
tacrolimus
PROGRAF,
ASTAGRAF XL,
ENVARSUS XR
Every 3 months and within normal
limits
• Cr
• K
• tacrolimus level
Every 12 months and within
normal limits
• CBC
• Mg, Ca
• Glucose
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
12 months 90 days with
0 refills
trimethoprim Primsol
Every 12 months and within normal
limits
• Cr
• K
12 months
May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

valganciclovir Valcyte
Every 12 months and within normal
limits
• CBC
• Cr
• CMV PCR
12 months May refill only when
being used for
prophylaxis
90 days with
4 refills
voriconazole Vfend
Every 12 months and within normal
limits
• AST, ALT, Tbili, alk phos
• CBC
• Ca, Mg, K
• Cr
• voriconazole level
12 months May refill only when
being used for chronic
condition or
prophylaxis
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org