1. 2011 Updated Essential Pharmacopeia for Interventional Radiology
Natanel Jourabchi, Edward W. Lee, Antoinette S. Gomes, Christopher T. Loh, David Liu, Justin P. McWilliams and Stephen T. Kee
Interventional Radiology Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Los Angeles, CA USA 90095
Learning Objectives: Background Conclusion and/or Teaching Points
1. Review the most recent literature on the most commonly used medications in IR is progressively becoming a more clinical and independent discipline, with a wide array of disease processes to treat 1. An effective knowledge and understanding of the most commonly used medications in IR is
interventional radiology (IR), including antibiotics, anti-platelet and antithrombotic and manage from head to toe. IR specific pharmacology is becoming increasingly important as interventionalists are essential for patient safety and effective disease management in this progressively clinical discipline
agents through compilation of this information into an easy to use IR specific treating complicated acute conditions while managing chronic conditions. With the increasing number of direct referrals, 2. Familiarity with the indications, mechanisms of actions, side effects, doses, and costs of these
pharmacopeia. IR physicians sometimes even take on the role of primary physician, and must have a working knowledge of available drugs is the pharmacological foundation for ensuring patient safety and effective disease
2. Review and compare the indications, mechanisms of action, side effects, doses, medications for improving their patients’ health. Safely and effectively managing these varying medical conditions management.
and cost for each medication. pharmacologically may prove difficult, especially for physicians-in-training. Thus, an up-to-date IR specific 3. To provide the best and most innovative medical care for our patients, interventional radiologists
3. Draw attention to recent advances in and the future of pharmacologic treatments pharmacopeia containing essential pharmacological information for commonly used medications in IR would be a useful must be aware of recent advances in, and the future of, pharmacologic treatment in IR.
in IR. resource for training interventional radiologists.
Antibiotic prophylaxis Antibiotics Anti-platelet agents: anti-thrombotic event prophylaxis
Potential Generic
Procedure Organisms Routine prophylaxis (Brand name) Dose Peds Class/ Price
Dose Mechanism Coverage Clearance Caution Generic (Brand Time of
Encountered Dose Class (Mechanism) Time of Offset Clearance Caution Price
name) Onset
Abscess drainage S aureus, S epidermidis, (i) 1–2 g cefoxitin IV every 6 hours, or Ampicillin 0.5-2 g 100-400 1 g vial:
(percutaneous) Corynebacterium spp; aerobic (ii) 1–2 g cefotetan IV every 12 h, or 81 mg (36):
IV/IM mg/kg/day Penicillin; Inhibits GP inc $8.64 Irreversibly inhibits
GNs and anaerobes (iii) 1 g ceftriaxone IV every 24 h, or $11.99
Q6h IV/IM Q4-6h bacterial cell wall enterococci Renal Allergy 81-325 mg COX-1 and 2: Inhibits formation GI intolerance
(iv) 3 g ampicillin/sulbactam IV every 6 h Aspirin (ASA) 1 hr 7-10 days Renal 325 mg
synthesis and GNR PO QD of thromboxane A2  inhibiting Active bleeding
(100):
Arterial closure device placement S aureus, S epidermidis Not standard (unless high risk: 1 g cefazolin IV) platelet aggregation
$11.99
Ampicillin 1.5-3 g 100-400 mg 1.5 g vial:
Angiography/Angioplasty/Stent, S aureus, S epidermidis Not standard (unless high risk: 1 g cefazolin IV) /sulbactam (Unasyn®) IV Q6h ampicillin/kg/ $3.18 Loading
Penicillin with Irreversibly blocks ADP
day IV Q6h GPC, GNR, dose 300
Beta-lactamase Renal Allergy Clopidogrel receptors  prevents activation Renal, GI intolerance 75 mg (30):
Biopsy Transrectal: anaerobes and aerobic For transrectal, only: anaerobes mg PO, 8 hr 7-10 days
inhibitor (Plavix®) of GPIIb/IIIa receptor complex hepatic Active bleeding $165.99
(percutaneous) GN, Streptococcus spp 80 mg gentamicin IV/IM plus 250 mg ciprofloxacin BID PO for 5 d then 75 mg
 reducies platelet aggregation
PO QD
Central venous access S aureus, S epidermidis No consensus, Case/Pt dependent: (eg, immunocompromised pts prior to Cefazolin (Ancef®) 1 g vial:
1st Gen. Inhibits the activity of adenosine
(inc Tunneled) chemo and those with hx of catheter infection) $3.12
1 g cefazolin IV 1-2 g IV 25-100 Cephalosporin : GP inc S. Allergy, deaminase and
25 mg
Q6-8h mg/kg/day Inhibits bacterial aureus and S. Renal Can cause C. Dipyridamole 75-100 mg phosphodiesterase  increased
2.5 hr T1/2=12 hours Hepatic Allergy (100):
Chemoembolization S aureus, S epidermidis, (i) 1.5–3 g ampicillin/sulbactam IV IV/IM Q6-8h cell wall epidermidis dif (Persantine®) PO QID adenosine and cyclic AMP 
$29.99
(Hepatic) Streptococcus spp, (ii) 1 g cefazolin and 500 mg metronidazole IV synthesis inhibit platelet aggregation and
Corynebacterium spp, and/or (iii) 2 g ampicillin IV and 1.5 mg/kg gentamicin cause vasodilation
enteric flora (iv) 1 g ceftriaxone IV
(iv) if penicillin-allergic, vancomycin or clindamycin plus aminoglycoside Ceftriaxone 1-2 g IV 50-100 3rd Gen. 1 g IVPB: Irreversibly blocks ADP Active bleeding,
(Rocephin®) Q12-24h mg/kg/day Cephalosporin GNR, $47.91 receptors  prevents activation Liver disease 250 mg
Embolization S aureus, S epidermidis, 1 g ceftriaxone IV
IV Q12-24h anaerobesent Biliary and Ticlopidine 250 mg
(renal or splenic ) Streptococcus spp, Allergy of the GPIIb/IIIa receptor 1-3 hr 7-10 days Hepatic Neutropenia, (30):
erococci, B. renal (Ticlid®) PO BID
Corynebacterium spp, and/or complex  reduces platelet thrombocyto- $79.99
enteric flora Fragilis aggregation penia. TTP
Embolization S aureus, S epidermidis, (i) 1 g cefazolin IV, or
Ciprofloxacin (Cipro®) 400-600 18-30 2nd Gen. 200 mg/20
(uterine artery) Streptococcus
spp, and/or E coli
(ii) 900 mg clindamycin IV plus 1.5 mg/kg gentamicin, or
(iii) 2 g ampicillin IV, or mg IV or mg/kg/day fluoroquinolone : Tendon ml vial: $2.58 Anticoagulants
PO Q8- Inhibits DNA- GNR, per 20ml
(iv) 1.5–3 g ampicillin/sulbactam IV rupture,
(v) if penicillin-allergic, can use vancomycin 12h gyrase pseudomonas Renal and
QT Generic Prophyla
, Staph. Hepatic
Gastrostomy and S aureus, S epidermidis, For pull Gastrostomy: 1g cefazolin IV prolongation,C. Tx Class/ Monitori Time of Time of Clearance
aureus (Brand ctic Reversal Caution Price
gastrojejunostomy tube placement Corynebacterium spp diff Dosing Mechanism ng Onset Offset
name) Dosing
GU procedures E coli, Proteus, Klebsiella, (i) 1 g cefazolin IV, or Gentamycin 1.2-3 2-2.5 Aminoglycoside: 40 mg/ml
Enterococcus (ii) 1 g ceftriaxone IV, or Hg, Hct,
(Garamycin®) mg/kg IV mg/kg/dose Inhibits bacterial vial: $2.47 Adjust to
(ii) 1.5–3 g ampicillin/sulbactam IV, or Reversible aPTT, Raises INR 100 mg/mL
Q8hr Q8h protein synthesis Renal and per 2ml 2 aPTT 1.5-3 x
(iv) 2 g ampicillin IV and 1.5 mg/kg gentamicin IV, or GN Renal Argatroban direct thrombin signs/sx Immediate 2-4 hr Renal, GI None as well as (2.5):
(v) If penicillin-allergic, can use vancomycin or clindamycin and ototoxic mcg/kg/min initial
inhibitor of aPTT $1350.03
baseline
Aminoglycoside bleeding
Hepatic/biliary interventions Enterococcus spp, Streptococcus (i) 1 g ceftriaxone IV, or Bolus 0.75-
Levofloxacin 500- 10 3rd Gen. Tendon 250 mg (10):
spp, aerobic GNs (E coli, Klebsiella (ii) 1.5–3 g ampicillin/sulbactam IV, or 1mg/kg, then
(Levaquin®) 750mg mg/kg/dose Fluoroquinolone rupture, $119.91 Reversible
spp) Clostridium spp, Candida spp, (iii) 1 g cefotetan IV plus 4 g mezlocillin IV, or Bivalirudin 1.75-2.5 Renal, 250 mg vial:
IV Q24h Q24h None direct thrombin aPTT Immediate 1 hr None Bleeding
and anaerobes (iv) 2 g ampicillin IV plus 1.5 mg/kg gentamicin IV, or GP /GN Renal, GI QT (Angiomax®) mg/kg/hr
inhibitor
proteases $832.8
(v) if penicillin-allergic, can use vancomycin or clindamycin and prolongation,C. during
Aminoglycoside diff procedure
IVC filter placement S aureus, S epidermidis Not standard Dabigatran 150mg PO Reversible Hg, Hct, Immediate 24 hrs GI, Renal None GI upset, 150mg (60)
Metronidazole 500 mg 30 mg/kg/day Creates loss of 500 mg/100 (Pradaxa ®) BID direct thrombin aPTT, bleeding $243.00
(Flagyl®) IV or PO Q6h helical DNA ml: $2.5 per & platelet renal
Superficial venous insufficiency tx S aureus, S epidermidis Not standard Q12h structure Disulfram like 100ml aggregation function
Anaerobes Renal, hepatic reaction with inhibitor
Thrombolysis S aureus, S epidermidis Not recommended (unless high risk: 1 g cefazolin IV) EtOH
LMWH higher Platelets,
Protamine Bleeding, low
TIPS S aureus, S epidermidis, (i) 1 g ceftriaxone IV or 30 mg SQ ratio of occult 30 mg/0.3
Enoxaparin 1mg/kg SQ 1mg/mg HIT risk,
Corynebacterium spp, biliary (ii) 1.5–3 g ampicillin/sulbactam IV, or BID or antifactor Xa to blood, 3-5 hours 12-24 hr Renal mL (3):
Vancomycin 0.5-2 g 10-15 mg/kg Glycopeptide 1 g vial: (Lovenox®) BID (only 60% renal
pathogens, enteric Gramnegative (iii) If penicillin-allergic, can use vancomycin or clindamycin and 40mg QD antifactor IIa anti-Xa $256.46
(Vancocin®) IV Q12h Q6h (cell wall $6.74 effective) impairment
rods, anaerobes, Enterococcus spp Aminoglycoside activity levels
inhibitor) Aerobic and
Tumor ablation S aureus, S epidermidis, No consensus, Case/Pt dependent: CBC,
Streptococcus (i) 1.5 g ampicillin/sulbactam IV (liver);
anaerobic GP Antithrombin III- serum
inc multi- Renal, adjust Red man 2.5 mg/0.5
spp, and/or E coli (ii) 1 g ceftriaxone IV (renal); Fondaparinux 2.5 mg SQ 5-10mg SQ mediated creatinine, Caution in
resistant in RI syndrome Immediate 34-42 hrs Renal None mL (5):
(iii) 1 g cefazolin IV (bone) (Arixtra®) QD weight based inhibition of occult renal disease
$593.0
staphylococci. factor Xa blood
Vertebroplasty S aureus, S epidermidis, 1 g cefazolin IV , not VRE testing
(percutaneous ) Corynebacterium spp
I.V.:
IV gtt per Activates
5000 Units Immediate; 1000
Heparin local antithrombin III Plasma, Bleeding,
SQ Q8- aPTT SubQ: 1-3 hrs Protamine units/mL
(Hepalean®) nomogram  inactivates renal HIT
References: 12hr ~20-30 (10): $188.99
by aPTT thrombin
minutes
Venkatesan AM, et al. Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. J Vasc Interv Radiol. 2010 Nov;21(11):1611-30
Inhibition of Requires
Beddy P, et all. Antibiotic prophylaxis in interventional radiology--anything new? Tech Vasc Interv Radiol. 2006 Jun;9(2):69-76 Per local factors II, VII, heparin
Warfarin Hepatic 2 mg (30):
Epocrates Online Drugs [Internet]. San Mateo (CA): Epocrates, Inc. c2011. [continuously updated; cited 2011 March 21]. Available from: http://www.epocrates.com (Coumadin®)
2-5 mg/day nomogram IX, and X via γ- INR 24-72 hrs 5 days Vitamin K bridge when
$17.99
by INR Glut. starting
Faltas BA. New anticoagulant for a new era: review of recent data on dabigatran etexilate. Clin Adv Hematol Oncol. 2010 Oct;8(10):697-702. Carboxylase