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Disclaimer to the On-line Edition
This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.
Place Form in Patient's Chart
Fax Copy to Pharmacy





London Health Sciences Centre
CISAPRIDE APPROVAL FORM


Cisapride is usually a safe drug. However some common risk factors have been identified which may put babies at risk for prolongation of the Q-T interval and life threatening torsades de pointes. These include:

  1. PATIENT DEMOGRAPHICS
    Premature infants (born at less than 36 weeks gestational age) from 0 through 3 months after the delivery date.

  2. DRUG INTERACTIONS
    The following medications are contraindicated with the concurrent use of cisapride. They inhibit cytochrome P450-3A4 enzyme, which metabolizes cisapride, leading to increased cisapride levels:
    • Antifungals: fluconazole, itraconazole, or ketoconazole.
    • Antibiotics: clarithromycin, erythromycin.

    There are additional medications that may interact with cisapride. for a more extensive list contact your pharmacist.

  3. CONCURRENT CONDITIONS
    • Pre-existing prolonged ECG QT interval
    • Renal or hepatic insufficiency
    • Ventricular arrythmias, and CHF
    • Electrolyte disturbances such as hypokalemia, hypomagnesemia
    • Respiratory Failure

Please carefully assess the need for cisapride. If cisapride is required, inform the infant's family of the risk/benefit and sign this form indicating that your are aware of the risk factors. Please ensure this form is faxed to pharmacy with your order. Place signed form in chart.

Note: Infants should have a baseline ECG performed before commencing cisapide therapy. This should be repeated at 1 week and thereafter as per clinical judgement.

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