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