Regulatory requirements › Formulary review

The annual formulary review, as twenty class reviews.

The Joint Commission requires the drugs available for dispensing to be reviewed at least annually on emerging safety and efficacy information, and prescribes no method for doing it. ASHP recommends breaking the review into a rotating class schedule. This is that schedule for an inpatient hospital, covering 114 drug classes across twenty blocks.

Every formulary differs, and that is expected. What a class review can answer, and a drug list cannot, is whether the lineup is coherent: a formulary carrying pitavastatin but not rosuvastatin, or four carbapenems, or both phenytoin and fosphenytoin, has decisions in it that nobody made on purpose. 59 coherence checks are flagged below.

The other half of the job is what moved. A drug list does not change; the guidelines under it do, which is what "emerging safety and efficacy information" means in the standard. 38 recent changes are recorded against the classes they affect, each dated by its source so a stale one is visible rather than quietly wrong.

Every coherence check is labelled with what it rests on. Guideline means the governing guideline says so. Converged practice means many institutions reached it independently, which is weaker than a rule and stronger than an opinion. Unvalidated means it is reasoning from class logic that has not been checked against real formularies, and should be read as a question to ask rather than an answer. Most checks here are still unvalidated, and saying so is more useful than implying otherwise.

The review document

Four sections, from the published class review methodology. Keeping the format identical across classes is what makes the year's reviews comparable and what lets someone other than the author complete one.

Section 1

Current agents in the class

Every formulary agent in the class with strength, dosage form and any restriction, plus the non-formulary agents in the class that were requested during the period.

Section 2

Utilization

Doses or units dispensed and acquisition cost for the period, formulary and non-formulary, with the trend against the prior period. Non-formulary volume is the signal that the formulary no longer matches practice.

Section 3

Requests, safety signals and evidence changes

Formulary addition and deletion requests, new or revised guidelines, boxed warnings, recalls, shortages, ISMP alerts and any local medication events involving the class.

Section 4

Recommendations

Additions, deletions, restrictions, therapeutic interchanges and order set changes, each with a named implementation owner and a date. A recommendation with no owner does not reach a patient.

The schedule

One or two blocks a month covers the formulary within twelve months. Order is deliberate: the highest volume and fastest moving classes come first, so the year starts where the evidence changes most.

1

Beta-lactam antibacterials

Anti-infectives

The largest class by volume in most hospitals, the one most affected by annual guideline movement, and the one where stewardship restriction and formulary structure interact.

Natural and aminopenicillins

Expectedpenicillin G aqueous, penicillin G benzathine, ampicillin, amoxicillin
Situationalpenicillin V potassium, amoxicillin-clavulanate

Antistaphylococcal penicillins

Expectednafcillin, oxacillin, dicloxacillin

Coherence checkunvalidatedCarrying neither nafcillin nor oxacillin is a real gap: methicillin-susceptible S. aureus bacteremia treated with vancomycin has worse outcomes, so the definitive agent has to be on the shelf.

Extended-spectrum penicillins with inhibitor

Expectedpiperacillin-tazobactam, ampicillin-sulbactam

Cephalosporins, first and second generation

Expectedcefazolin, cefuroxime, cefoxitin
Situationalcephalexin, cefotetan

Cephalosporins, third and fourth generation

What has changed
  • 2025 community-acquired pneumonia guidance shortened durations for most uncomplicated cases, which changes the stop dates embedded in order sets more than it changes agent choice.
Expectedceftriaxone, ceftazidime, cefepime
Situationalcefdinir, cefpodoxime, cefotaxime

Coherence checkunvalidatedCeftriaxone and cefepime are near universal. Carrying ceftazidime as well needs a stated antipseudomonal or stewardship reason now that cefepime covers most of the same ground.

Anti-MRSA and siderophore cephalosporins

Situationalceftaroline, cefiderocol

Coherence checkunvalidatedCefiderocol is a last-line agent and its presence should be tied to a restriction policy and an ID approval pathway, not to open formulary status.

Carbapenems

What has changed
  • Expanded oral step-down options for resistant gram-negatives reduce the case for carrying every carbapenem.
Expectedmeropenem, ertapenem
Situationalimipenem-cilastatin, doripenem

Coherence checkunvalidatedMeropenem plus ertapenem covers nearly all inpatient need. Carrying all four carbapenems is a common finding with no therapeutic rationale and a stewardship cost.

Novel beta-lactam and inhibitor combinations

What has changed
  • IDSA updated its antimicrobial-resistant gram-negative guidance for 2026, including revised dosing and alignment with current CLSI breakpoints. Local empiric guidance built on the earlier version should be re-checked.
  • The same update moved several oral options forward for ESBL organisms, which changes discharge planning more than inpatient therapy.
Situationalceftazidime-avibactam, ceftolozane-tazobactam, meropenem-vaborbactam, imipenem-relebactam

Coherence checkunvalidatedAlmost no hospital needs all four. Selection should follow the local antibiogram and the resistance mechanisms actually seen, and each should carry ID approval. This is the highest-cost decision in the block.

CoverageWhat the 2026 ESBL guidance changes at discharge How the 2025 pneumonia guidelines changed order sets

Monobactam

Situationalaztreonam

Coherence checkunvalidatedJustified mainly as the severe beta-lactam allergy option. If the hospital runs a penicillin allergy delabeling program, aztreonam use should be falling.

Questions this review has to answer
  • Does the antibiogram still support the empiric regimens built into the order sets?
  • Which novel agents were used, for what organisms, and did ID approve each course?
  • Is there a penicillin allergy evaluation pathway, and is aztreonam use trending down?
  • Are IV to oral conversion criteria current for the oral agents in the class?
  • Which agents in this class were on shortage during the period, and did the workaround get retired when supply recovered?
2

Non-beta-lactam antibacterials

Anti-infectives

Glycopeptides and lipoglycopeptides

What has changed
  • AUC-guided vancomycin monitoring replaced trough-only monitoring in the consensus guideline. A department still dosing to troughs alone is working from a superseded standard.
Expectedvancomycin IV, vancomycin oral
Situationaldalbavancin, oritavancin, telavancin

Coherence checkunvalidatedLong-acting lipoglycopeptides are usually a discharge-avoidance or IV-access decision rather than a clinical one. If one is on formulary, the review should show who approves it and whether it actually avoided admissions.

CoverageMRSA nares screening and when it does not apply

Oxazolidinones

Expectedlinezolid
Situationaltedizolid

Lipopeptide

Expecteddaptomycin

Fluoroquinolones

What has changed
  • Accumulated FDA warnings on tendinopathy, aortic aneurysm, neuropathy and dysglycaemia have moved these from workhorse to restricted in most stewardship programs.
Expectedciprofloxacin, levofloxacin
Situationalmoxifloxacin

Coherence checkunvalidatedThree fluoroquinolones is rarely defensible after the tendon, aortic and neuropathy warnings. Most hospitals can justify two, and many restrict all three.

Aminoglycosides

Expectedgentamicin, tobramycin
Situationalamikacin, plazomicin

Macrolides and ketolides

Expectedazithromycin
Situationalerythromycin, clarithromycin

Coherence checkunvalidatedErythromycin often survives on formulary only for its prokinetic use. If so, the review should say that plainly so it is not mistaken for an anti-infective option.

Tetracyclines and glycylcyclines

Expecteddoxycycline
Situationalminocycline, tigecycline, eravacycline, omadacycline

Coherence checkunvalidatedTigecycline carries an all-cause mortality warning. Its continued presence should be tied to a specific indication rather than to habit.

Sulfonamides and others

Expectedtrimethoprim-sulfamethoxazole, metronidazole, nitrofurantoin, clindamycin

Polymyxins

Situationalcolistimethate, polymyxin B

Clostridioides difficile therapy

What has changed
  • Fidaxomicin is now preferred over oral vancomycin for an initial episode in the IDSA and SHEA focused update. Cost is a legitimate reason to differ, but the reason should be recorded.
Expectedvancomycin oral, fidaxomicin
Situationalbezlotoxumab

Coherence checkunvalidatedCurrent guidance favours fidaxomicin over oral vancomycin for initial episodes. A formulary carrying only oral vancomycin should record why, since cost is a legitimate reason but should be a stated one.

Questions this review has to answer
  • Is vancomycin dosing on AUC-guided monitoring, and does the protocol match the current consensus guideline?
  • How many fluoroquinolone courses were empiric, and is a restriction warranted?
  • Which agents require therapeutic drug monitoring, and is the service resourced for it?
  • Does the C. difficile pathway match current guidance, and if not, is the reason recorded?
3

Antifungals and antivirals

Anti-infectives

Azole antifungals

Expectedfluconazole, voriconazole, posaconazole
Situationalisavuconazonium, itraconazole

Coherence checkunvalidatedVoriconazole and posaconazole both require therapeutic drug monitoring. If neither has a monitoring protocol, the formulary is carrying risk it is not managing.

Echinocandins

Expectedmicafungin
Situationalcaspofungin, anidulafungin, rezafungin

Coherence checkunvalidatedOne echinocandin covers nearly all inpatient need. Carrying two or three is usually contract history rather than a clinical decision.

Polyenes and others

Expectedamphotericin B liposomal
Situationalamphotericin B deoxycholate, flucytosine

Coherence checkunvalidatedConventional amphotericin persists on many formularies purely on cost. If it is stocked, there should be an explicit statement of when it may be used, because the nephrotoxicity difference is not subtle.

Anti-influenza

Expectedoseltamivir
Situationalbaloxavir, peramivir

Herpesvirus antivirals

Expectedacyclovir IV, valacyclovir
Situationalganciclovir, valganciclovir, foscarnet, letermovir

Hepatitis and HIV agents

Situationaltenofovir, entecavir, integrase inhibitor single-tablet regimens

Coherence checkunvalidatedInpatient HIV continuation is the main driver. The real question is whether the formulary can continue a patient's home regimen without interruption, which is a medication reconciliation problem as much as a formulary one.

COVID-19 therapeutics

Situationalremdesivir, nirmatrelvir-ritonavir
Questions this review has to answer
  • Are azole levels being drawn, and what proportion are in range?
  • Can the formulary continue a home antiretroviral regimen without a gap on admission?
  • Is the influenza antiviral pathway ready before the season rather than during it?
4

Anticoagulants, antiplatelets and reversal

Hematology high alert

Unfractionated and low molecular weight heparins

What has changed
  • Heparin supply remains exposed to a narrow upstream source base. Shortage planning for this class should be written before it is needed.
Expectedheparin, enoxaparin
Situationalfondaparinux, dalteparin

CoverageWhy your drug shortage strategy is probably wrong

Direct oral anticoagulants

Expectedapixaban, rivaroxaban
Situationaldabigatran, edoxaban

Coherence checkunvalidatedMost hospitals carry two DOACs and continue the others from home supply. The review should confirm the renal dose adjustment logic in the EHR matches each agent, since this is a frequent source of error.

Vitamin K antagonist

Expectedwarfarin

Parenteral direct thrombin inhibitors

Expectedargatroban
Situationalbivalirudin

Antiplatelets

Expectedaspirin, clopidogrel
Situationalticagrelor, prasugrel, cangrelor, eptifibatide, tirofiban

Coherence checkunvalidatedCarrying prasugrel without a stated cath lab protocol is a common finding. Its contraindication in prior stroke or TIA makes an unrestricted listing a safety issue.

Thrombolytics

What has changed
  • Stroke guidance now supports tenecteplase as an alternative to alteplase, and many programs have converted. The switch is a systems change, not a drug swap: weight-based single bolus versus bolus plus infusion.
Expectedalteplase
Situationaltenecteplase

Coherence checkunvalidatedMany stroke programs have moved to tenecteplase. If both are stocked, the review should confirm which is the default in each protocol, because carrying two thrombolytics with unclear roles is a look-alike risk.

CoverageWhy the stroke guideline change is really about systems

Reversal and antidotes

What has changed
  • Andexanet alfa was voluntarily withdrawn from the US market on 22 December 2025 by the manufacturer in consultation with the FDA. This was a safety withdrawal rather than a supply interruption. The ANNEXA-I postmarketing trial found thrombosis in 14.6% against 6.9% with usual care, and thrombosis-related death in 2.5% against 0.9%, at 30 days. It remains available in some other countries as Ondexxya.
  • Any order set, reversal policy or protocol still naming andexanet alfa needs rewriting, and this is the kind of change that survives in an order set long after the drug is gone.
Expectedprotamine, vitamin K, four-factor PCC
Situationalidarucizumab
Justifyandexanet alfa (withdrawn in the US, see below)

Coherence checkunvalidatedIf a DOAC is on formulary, the review should state what reverses it and where that agent is stocked. A formulary with apixaban and no documented reversal pathway is the gap most likely to be found during an event review rather than a survey. With andexanet alfa off the US market, four-factor PCC is the practical factor Xa pathway for most hospitals, and that decision should be written into the reversal policy with a dose rather than left implied.

CoverageWhy the disappearance of andexanet is a documentation problem

Questions this review has to answer
  • Does every anticoagulant have a documented reversal pathway and a stocking location?
  • Do the renal dose adjustment rules in the EHR match each DOAC's labeling?
  • Is the anticoagulation management service covering every agent on the formulary?
  • Which agents in this class appear in the local medication event data?
  • Is the heparin nomogram current, and does it match the ISMP guidance on standard concentrations?
5

Heart failure and antihypertensives

Cardiovascular

ACE inhibitors

Expectedlisinopril (long-acting), enalapril / enalaprilat (IV), captopril (short-acting)
Situationalramipril, benazepril, quinapril, fosinopril

Why the class carries what it carriesNot a count. Published formulary decision processes converged on an intravenous agent plus one oral agent from each duration tier, short-acting, intermediate and long-acting. Captopril is the short-acting tier and earns its place for titration in unstable patients, which is why it survives on formularies that otherwise standardise hard. Beyond one agent per tier, additional oral ACE inhibitors are usually home-therapy continuations and are better handled by therapeutic interchange than by stocking, which is what roughly nine in ten hospitals do.

Coherence checkconverged practiceAsk which tier each agent occupies rather than how many there are. A formulary with four long-acting agents and no short-acting one has a real gap despite looking well stocked. Cost also runs opposite to intuition here. Lisinopril is usually the cheapest and oral enalapril is not, so a cost argument for consolidation has to be checked against actual acquisition price rather than assumed.

Angiotensin receptor blockers

What has changed
  • The 2025 hypertension guideline changed risk estimation more than it changed drug selection. Order sets built around the old calculator need checking, but the agents themselves did not move.
Expectedlosartan, valsartan
Situationalolmesartan, irbesartan, candesartan, telmisartan

Why the class carries what it carriesUnlike the ACE inhibitors, the ARBs do not separate cleanly by duration tier and no intravenous agent exists, so the tier argument does not apply. What drives the count is intolerance handling and home-therapy continuation. Valsartan carries the heart failure and post-infarction evidence and candesartan the heart failure evidence, so an agent kept for those indications is a stated reason rather than duplication.

Coherence checkconverged practiceTwo agents plus a documented therapeutic interchange covers most institutions. Before deleting, check which agents your prescribers actually continue from home, because an interchange nobody follows generates non-formulary requests instead of savings.

CoverageThe 2025 hypertension guideline and the new calculator

ARNI

Expectedsacubitril-valsartan

Beta blockers

Expectedmetoprolol tartrate, metoprolol succinate, carvedilol, esmolol, labetalol
Situationalatenolol, bisoprolol, propranolol, nebivolol

Coherence checkunvalidatedHeart failure benefit is established for carvedilol, metoprolol succinate and bisoprolol. If the formulary carries metoprolol tartrate only, the review should address the substitution risk at discharge.

Calcium channel blockers

Expectedamlodipine, diltiazem IV and oral, nifedipine ER, verapamil
Situationalnicardipine, clevidipine

Coherence checkunvalidatedNicardipine and clevidipine overlap almost entirely. Carrying both needs a stated reason, usually volume restriction in the neuro or cardiac population.

Mineralocorticoid receptor antagonists

What has changed
  • Finerenone gained a heart failure indication, extending this class beyond the diabetic kidney disease population it was previously boxed into.
Expectedspironolactone
Situationaleplerenone, finerenone

CoverageFinerenone's new frontier, and the warning in it

SGLT2 inhibitors for heart failure

What has changed
  • SGLT2 inhibitors are guideline-directed therapy across the ejection fraction range, including HFpEF, and independent of diabetes status. A formulary listing them only under diabetes is out of date.
  • 2026 ADA guidance moves SGLT2 inhibitors and GLP-1 receptor agonists earlier, toward use from diagnosis rather than after metformin failure.
  • The early eGFR dip after initiation is expected and haemodynamic, not injury. Protocols that trigger discontinuation on that dip are causing avoidable therapy loss.
Expecteddapagliflozin or empagliflozin

Coherence checkunvalidatedNow guideline-directed therapy for heart failure regardless of diabetes status. A formulary that still lists these only under diabetes is out of date.

CoverageWhy a crashing eGFR might be good news Why heart failure therapy got a radical remake

Other heart failure agents

What has changed
  • The emphasis has moved from sequential titration over months to rapid initiation of all four pillars within weeks, which changes discharge planning and follow-up more than it changes the formulary.
Situationalivabradine, digoxin, vericiguat, hydralazine, isosorbide dinitrate

CoverageThe three-month countdown on heart failure therapy

Other antihypertensives

Situationalclonidine, hydralazine IV, minoxidil, methyldopa

Coherence checkunvalidatedMethyldopa is largely an obstetric agent now. If the hospital has no obstetric service, its presence is worth questioning.

Questions this review has to answer
  • Are all four pillars of guideline-directed heart failure therapy available and in the order sets?
  • Which agents have a therapeutic interchange, and is the interchange table current?
  • Do IV to oral transitions exist for the antihypertensives used in critical care?
6

Antiarrhythmics, vasopressors and inotropes

Cardiovascular high alert

Antiarrhythmics

Expectedamiodarone, adenosine, digoxin, lidocaine
Situationalprocainamide, sotalol, flecainide, propafenone, dofetilide, ibutilide

Coherence checkunvalidatedDofetilide and sotalol require inpatient initiation with QT monitoring. If either is on formulary, the review should confirm the monitoring protocol exists.

Vasopressors

Expectednorepinephrine, epinephrine, phenylephrine, vasopressin
Situationaldopamine, angiotensin II

Coherence checkunvalidatedDopamine has largely been displaced by norepinephrine. Continued stocking should be tied to a specific use rather than to inertia.

Inotropes

Expecteddobutamine, milrinone

Pulmonary vasodilators

Situationalepoprostenol, treprostinil, inhaled nitric oxide, sildenafil
Questions this review has to answer
  • Are vasopressor concentrations standardised and in the smart pump library?
  • Does the code cart contents list match the current resuscitation guidance?
  • Which infusions are permitted peripherally, and for how long?
7

Lipid-lowering agents

Cardiovascular

Statins

What has changed
  • 2026 lipid guidance returned to explicit LDL targets rather than intensity alone, which changes what the discharge order has to achieve and makes the intensity-based interchange table insufficient on its own.
  • 2025 acute coronary syndrome guidance moved toward earlier combination therapy rather than statin monotherapy escalation, so ezetimibe now belongs in the discharge conversation.
Expectedatorvastatin, rosuvastatin, simvastatin, pravastatin
Situationallovastatin, fluvastatin
Justifypitavastatin

Coherence checkunvalidatedThe formulary has to support all three intensity tiers, which in practice means atorvastatin and rosuvastatin at high intensity. Pravastatin earns its place on drug interactions, for the transplant and HIV populations. Pitavastatin is the classic incoherence: it offers little the others do not, at substantially higher cost, and a formulary carrying it without rosuvastatin has no defensible rationale.

CoverageWhy the 2026 lipid guidelines change the target Beyond the max statin: the 2025 ACS guideline

Cholesterol absorption inhibitor

What has changed
  • Ezetimibe has moved from add-on afterthought to early combination in acute coronary syndrome guidance.
Expectedezetimibe

CoverageWhat the 2025 ACS guideline changes about the drugs

PCSK9 inhibitors and siRNA

Situationalevolocumab, alirocumab, inclisiran

Coherence checkunvalidatedRarely initiated inpatient. The real question is whether the formulary can continue a patient already on one, and whether the discharge pathway is defined.

Other lipid agents

Situationalfenofibrate, gemfibrozil, icosapent ethyl, bempedoic acid, niacin

Coherence checkunvalidatedGemfibrozil with a statin is a known myopathy interaction. If both are on formulary, an interaction alert should exist.

Questions this review has to answer
  • Does the formulary support high, moderate and low intensity statin therapy?
  • Is there a statin intensity therapeutic interchange, and is the table current?
  • How is a patient on a PCSK9 inhibitor handled on admission and at discharge?
Guidelines to check against
8

Insulin and diabetes agents

Endocrine high alert

Rapid and short-acting insulins

What has changed
  • Inpatient continuous glucose monitoring and automated insulin delivery now have explicit ADA guidance, which raises a policy question most hospitals have not answered: whether a patient may continue their own pump and sensor.
Expectedinsulin aspart or lispro, regular insulin

Coherence checkunvalidatedOne rapid analogue is enough. Carrying aspart and lispro and glulisine at once is a look-alike risk with no therapeutic benefit, and it is one of the more common findings in this class.

CoverageMost hospitals are not ready for the new rules

Intermediate and long-acting insulins

Expectedinsulin glargine, NPH
Situationalinsulin detemir, degludec

Concentrated insulins

Situationalinsulin glargine U-300, insulin regular U-500

Coherence checkunvalidatedU-500 is a recurring source of tenfold errors. If it is stocked, the review should confirm the storage separation, the dedicated syringe and the independent double check are in place.

Oral and non-insulin injectables

What has changed
  • 2026 ADA guidance stops SGLT2 inhibitors three days before scheduled surgery, and four days for ertugliflozin, to reduce euglycaemic ketoacidosis risk. This is a concrete perioperative rule that most preoperative instructions do not yet carry.
  • GLP-1 receptor agonists now carry perioperative guidance on aspiration risk and holding intervals, which is an anaesthesia and endoscopy workflow question as much as a pharmacy one.
  • 2026 ADA guidance supports GLP-1 receptor agonists in type 1 diabetes with BMI above 30, or 27.5 in Asian American patients, which is new.
  • Inpatient GLP-1 receptor agonist data remain limited to stable populations, so most protocols still hold them on admission.
Expectedmetformin, glipizide
Situationalsitagliptin, linagliptin, empagliflozin, dapagliflozin, GLP-1 receptor agonists

Coherence checkunvalidatedMost agents in this group are held inpatient. The review should state which are continued, which are held, and whether the EHR reflects that, since the answer drives a large share of medication reconciliation work.

CoverageWhat the ADA changed for hospitalised diabetes technology Rethinking the eGFR dip on SGLT2 inhibitors

Hypoglycemia treatment

Expecteddextrose 50%, glucagon
Questions this review has to answer
  • Is there one rapid-acting analogue, or several with no stated reason?
  • Are insulin concentrations, storage and labeling aligned with ISMP best practices?
  • Does the hypoglycemia protocol exist on every unit that stocks insulin?
  • How are GLP-1 receptor agonists handled around procedures and on admission?
9

Thyroid, corticosteroids and bone agents

Endocrine

Thyroid

Expectedlevothyroxine oral and IV, methimazole
Situationalliothyronine, propylthiouracil

Coherence checkunvalidatedPTU is preferred in the first trimester and in thyroid storm. If the hospital has an obstetric or ICU service, its absence is a gap rather than a saving.

Corticosteroids

Expectedmethylprednisolone, prednisone, hydrocortisone, dexamethasone
Situationalfludrocortisone, budesonide

Bone and calcium

Expectedcalcium, vitamin D, alendronate
Situationalzoledronic acid, denosumab, calcitonin, teriparatide

Adrenal and pituitary

Situationaldesmopressin, octreotide, cosyntropin

Gout and hyperuricaemia

What has changed
  • Treat-to-target serum urate, allopurinol first line even in kidney disease, and three to six months of anti-inflammatory prophylaxis during titration are all strong recommendations and all three are routinely skipped.
  • Starting allopurinol at 100 mg and stopping there is the common failure. The dose is a starting dose, not a maintenance dose.
Expectedallopurinol, colchicine, prednisone
Situationalfebuxostat, probenecid, pegloticase

Coherence checkunvalidatedAllopurinol is first line including in chronic kidney disease, which is the opposite of long-standing practice. A formulary that restricts allopurinol by renal function, or positions febuxostat as the renal alternative, is working from superseded guidance and carrying the febuxostat cardiovascular warning for no reason.

CoverageWhy gout treatment stops too early: the 300 mg myth

Menopausal and genitourinary hormone therapy

What has changed
  • The FDA removed several boxed warnings from low-dose vaginal estrogen after more than two decades, on the grounds that systemic absorption is minimal. Local order sets, patient education and any pharmacy-driven restriction built on the old label need revisiting.
Expectedvaginal estrogen, estradiol
Situationalconjugated estrogens, progesterone, ospemifene, prasterone

Coherence checkunvalidatedLocal vaginal estrogen and systemic hormone therapy are not the same risk profile and should not share a warning or a restriction. A formulary treating them identically is carrying a labeling error that the FDA itself has now corrected.

CoverageThe 22-year mistake on vaginal estrogen

Questions this review has to answer
  • Is the IV to oral levothyroxine conversion documented and used?
  • Do steroid equivalency references in the order sets match the current table?
10

Opioids and analgesic adjuvants

Pain and sedation high alert

Opioids, parenteral

Expectedmorphine, hydromorphone, fentanyl
Situationalremifentanil, sufentanil, methadone IV

Coherence checkunvalidatedMorphine and hydromorphone confusion is one of the most frequently reported error pairs. The review should confirm concentration standardisation and storage separation rather than assuming it.

Opioids, oral

Expectedoxycodone, hydrocodone-acetaminophen, morphine oral, methadone
Situationaltramadol, codeine, oxymorphone, tapentadol

Coherence checkunvalidatedCodeine and tramadol both depend on CYP2D6 and carry pediatric contraindications. Carrying both alongside oxycodone rarely adds anything.

Non-opioid analgesics

What has changed
  • A first-in-class non-opioid analgesic entered the market at a price point that forces an explicit formulary position rather than a default addition. The decision turns on whether it displaces opioid exposure enough to justify the cost.
Expectedacetaminophen oral and IV, ibuprofen, ketorolac
Situationalcelecoxib, naproxen, diclofenac, indomethacin

Coherence checkunvalidatedIV acetaminophen is a cost outlier. The review should show the criteria that restrict it to patients who genuinely cannot take oral, or it becomes a budget line nobody owns.

CoverageThe $232.50 paradox on the newest non-opioid

Adjuvants

Expectedgabapentin, lidocaine patch
Situationalpregabalin, ketamine, duloxetine, IV lidocaine infusion

Opioid use disorder and reversal

Expectednaloxone, buprenorphine, methadone
Situationalnaltrexone, buprenorphine extended-release

Coherence checkunvalidatedNaloxone availability at discharge is a stewardship expectation now. If the formulary carries no take-home naloxone pathway, that is a finding waiting to happen.

Questions this review has to answer
  • Are opioid concentrations standardised and reflected in the smart pump library?
  • Do the multimodal pathways appear as defaults in the surgical order sets?
  • What is the discharge quantity standard, and does the EHR default match it?
  • Is buprenorphine initiation possible on any unit, or only with a consult?
11

Sedation, anesthesia and neuromuscular blockade

Pain and sedation high alert

Sedatives

Expectedpropofol, dexmedetomidine, midazolam, lorazepam
Situationalketamine, etomidate

Benzodiazepines and reversal

What has changed
  • Critical care sedation guidance continues to favour non-benzodiazepine sedation, propofol or dexmedetomidine, over benzodiazepine infusions for most ventilated patients, on delirium and ventilator days.
  • Deprescribing pressure in older adults has grown, and admission is a common point of inappropriate continuation. A formulary review that does not look at discharge prescribing is missing where the harm accumulates.
Expectedlorazepam, midazolam, diazepam, flumazenil
Situationalchlordiazepoxide, clonazepam, alprazolam

Coherence checkunvalidatedThree parenteral benzodiazepines with different potencies and durations is a concentration and look-alike risk. The review should confirm which is the default for each indication: status epilepticus, procedural sedation, alcohol withdrawal and palliative use are four different answers, and leaving them unstated is how substitution errors happen. Flumazenil is not a routine reversal agent and its availability should not imply otherwise, since it can precipitate seizures in the benzodiazepine-dependent patient.

Neuromuscular blockers

Expectedrocuronium, succinylcholine, cisatracurium
Situationalvecuronium

Coherence checkunvalidatedParalytics are the highest-consequence look-alike risk in the hospital. The review should confirm segregated storage, auxiliary labeling and removal from any unit that cannot ventilate, and vecuronium's continued presence alongside rocuronium should be justified rather than assumed.

Reversal agents

Expectedneostigmine, glycopyrrolate
Situationalsugammadex

Local anaesthetics

What has changed
  • Local anaesthetic systemic toxicity guidance is well established and unglamorous, and the recurring finding is not that the protocol is wrong but that the lipid emulsion is in the pharmacy rather than at the point of use.
  • Multimodal and opioid-sparing pathways have expanded regional and infiltration techniques into more services, which widens where these agents are handled.
Expectedlidocaine, bupivacaine, lidocaine with epinephrine, lidocaine topical
Situationalropivacaine, liposomal bupivacaine, chloroprocaine, mepivacaine, EMLA or lidocaine-prilocaine

Coherence checkunvalidatedThe safety question in this class is not agent selection, it is whether lipid emulsion rescue is stocked and reachable wherever these are used in volume, including areas outside the operating room such as emergency, endoscopy and labour and delivery. A formulary carrying bupivacaine in a procedural area with no rescue pathway is the gap. Liposomal bupivacaine costs many multiples of the standard product and needs a stated indication rather than open availability.

Questions this review has to answer
  • Are neuromuscular blockers segregated and removed from units that cannot ventilate?
  • Is lipid emulsion rescue stocked wherever local anesthetics are used in volume?
  • Does propofol use have a documented sedation depth monitoring expectation?
12

Antiepileptics and neurology agents

Neurology

Antiepileptics, parenteral

Expectedlevetiracetam, fosphenytoin, valproate, lacosamide
Situationalphenobarbital, brivaracetam, phenytoin

Coherence checkunvalidatedCarrying both phenytoin and fosphenytoin invites a dosing error, since one is expressed in phenytoin equivalents and the other is not. Most hospitals should carry one, and the review should say which and why.

Antiepileptics, oral

Expectedlevetiracetam, valproate, carbamazepine, lamotrigine, topiramate
Situationaloxcarbazepine, zonisamide, clobazam, phenobarbital

Parkinson disease

Expectedcarbidopa-levodopa
Situationalrotigotine patch, amantadine, entacapone, pramipexole

Coherence checkunvalidatedMissed levodopa doses cause real harm within hours. A formulary with only oral forms and no transdermal or enteral pathway should note how an NPO patient is managed.

Stroke and neurovascular

What has changed
  • Tenecteplase is now an accepted alternative to alteplase in stroke guidance, and the operational change is larger than the pharmacological one.
Expectedalteplase or tenecteplase, nimodipine

CoverageThe new stroke guidelines are really about systems

Multiple sclerosis and neuromuscular

Situationalmethylprednisolone high dose, IVIG, pyridostigmine

Migraine

Expectedsumatriptan, metoclopramide
SituationalCGRP antagonists, dihydroergotamine
Questions this review has to answer
  • Is there a documented pathway for continuing home antiepileptics in an NPO patient?
  • Does the levodopa timing expectation appear anywhere in nursing policy?
  • Are therapeutic drug monitoring assays available for the agents that need them?
13

Antipsychotics, antidepressants and substance use

Psychiatry

Antipsychotics, oral

Expectedhaloperidol, olanzapine, quetiapine, risperidone, aripiprazole
Situationalziprasidone, paliperidone, clozapine, lurasidone

Coherence checkunvalidatedClozapine requires REMS enrollment and absolute neutrophil count monitoring. If it is on formulary, the review should confirm the monitoring and dispensing pathway exists, because carrying it without one is worse than not carrying it.

Antipsychotics, parenteral and long-acting

Expectedhaloperidol, olanzapine IM
Situationalpaliperidone palmitate, aripiprazole LAI, risperidone LAI

Antidepressants

Expectedsertraline, fluoxetine, escitalopram, bupropion, mirtazapine, trazodone
Situationalvenlafaxine, duloxetine, amitriptyline, nortriptyline

Coherence checkunvalidatedThe class carries a real continuation risk: abrupt discontinuation on admission causes withdrawal. The review should confirm the formulary can continue common home agents or has a documented substitution table.

Mood stabilisers

Expectedlithium, valproate, lamotrigine

Alcohol and substance withdrawal

Expectedlorazepam, thiamine, folic acid, multivitamin
Situationalphenobarbital protocol, gabapentin, clonidine

Opioid and alcohol use disorder

Expectedbuprenorphine, naltrexone, naloxone
Situationalacamprosate, disulfiram
Questions this review has to answer
  • Can a patient's home psychiatric regimen be continued without interruption?
  • Is there a QT monitoring expectation where antipsychotics are used in delirium?
  • Does the withdrawal protocol use symptom-triggered dosing, and is it current?
14

Acid suppression, antiemetics and hepatic agents

Gastrointestinal

Acid suppression

Expectedpantoprazole IV and oral, famotidine
Situationalomeprazole, esomeprazole, lansoprazole

Coherence checkunvalidatedOne IV proton pump inhibitor and one oral is enough. Multiple oral PPIs on formulary is a frequent finding and a straightforward deletion.

Stress ulcer prophylaxis

What has changed
  • The REVISE trial changed the balance for this indication, sharpening who genuinely benefits and reinforcing that prophylaxis started in the ICU should not follow the patient home.

Not a class so much as an indication, and the evidence has moved. The review should check that prophylaxis criteria exist and that patients are not discharged on a PPI started only for prophylaxis.

CoverageWhy we were wrong about ICU stress ulcers

Antiemetics

Expectedondansetron, prochlorperazine, metoclopramide, promethazine
Situationalaprepitant, palonosetron, olanzapine, scopolamine, dronabinol

Coherence checkunvalidatedPromethazine carries a boxed warning for severe tissue injury. If it is stocked, the review should confirm the administration standard, dilution and route restriction.

Laxatives and bowel regimens

Expecteddocusate, senna, polyethylene glycol, bisacodyl, lactulose
Situationalmethylnaltrexone, naloxegol, linaclotide

Hepatic and portal hypertension

Expectedlactulose, rifaximin, albumin, octreotide
Situationalterlipressin, midodrine

Inflammatory bowel disease

Situationalmesalamine, infliximab, vedolizumab, ustekinumab

Pancreatic and other

Expectedpancrelipase
Questions this review has to answer
  • Are stress ulcer prophylaxis criteria defined, and is deprescribing at discharge tracked?
  • Is promethazine restricted by route and concentration?
  • Does the antiemetic order set reflect current guidance for the surgical population?
15

Respiratory agents

Respiratory

Short-acting bronchodilators

Expectedalbuterol, ipratropium, albuterol-ipratropium

Long-acting bronchodilators and inhaled steroids

Expectedbudesonide-formoterol or fluticasone-salmeterol, tiotropium
Situationalumeclidinium-vilanterol, triple combination inhalers

Coherence checkunvalidatedInhalers are where formulary and home therapy diverge most. If the hospital cannot continue a patient's device, the review should document the substitution table and whether the patient is taught the new device before discharge.

Systemic agents

Expectedprednisone, methylprednisolone, magnesium sulfate
Situationalmontelukast, theophylline, roflumilast

Biologics for severe asthma

Situationalomalizumab, mepolizumab, benralizumab, dupilumab

Mucolytics, surfactant and pulmonary

Situationalacetylcysteine, dornase alfa, surfactant, inhaled antibiotics
Questions this review has to answer
  • Is there an inhaler substitution table, and does discharge teaching cover a device change?
  • Are nebulised versus metered-dose decisions driven by evidence or by habit?
  • Which respiratory agents are restricted to respiratory therapy administration?
16

Diuretics, electrolytes and fluids

Renal and fluids high alert

Diuretics

Expectedfurosemide, bumetanide, hydrochlorothiazide, chlorothiazide IV, spironolactone
Situationaltorsemide, metolazone, acetazolamide

Concentrated electrolytes

Expectedpotassium chloride, magnesium sulfate, calcium gluconate, sodium bicarbonate
Situationalpotassium phosphate, sodium phosphate, hypertonic saline, calcium chloride

Coherence checkunvalidatedConcentrated potassium chloride is the original never-event medication. The review should confirm it is not stocked in patient care areas outside defined exceptions, and that premixed bags are the default.

Crystalloids and volume expansion

What has changed
  • The accumulated trial evidence favours balanced crystalloids over saline in general ICU populations, with a probability of benefit high enough that many hospitals have changed their default.
  • The important exception is traumatic brain injury, where the lower sodium content of balanced solutions is a real concern and saline remains preferred. A single hospital-wide default without a neuro carve-out is the wrong conclusion from the right evidence.
  • Albumin remains indicated in specific settings such as large-volume paracentesis and spontaneous bacterial peritonitis, not as a general volume expander.
Expectedsodium chloride 0.9%, lactated Ringer, Plasma-Lyte or balanced alternative, dextrose 5%, dextrose 5% in 0.45% sodium chloride
Situationalalbumin 5%, albumin 25%, hypertonic saline 3%, sodium chloride 23.4%
Justifyhydroxyethyl starch

Coherence checkunvalidatedThe balanced crystalloid question now has enough evidence to deserve a stated institutional default rather than prescriber preference. Carrying both saline and a balanced solution with no guidance on which is first line means the choice is made by whatever is stocked closest. Hydroxyethyl starch has largely been abandoned on renal and mortality grounds; its continued presence needs a specific reason.

CoverageThe 89% bet: your ICU's default fluid and the one exception

Potassium and phosphate binders

Expectedsodium polystyrene or patiromer, sevelamer, calcium acetate
Situationalsodium zirconium cyclosilicate, lanthanum

Coherence checkunvalidatedSodium polystyrene sulfonate carries a bowel necrosis concern. If newer binders are on formulary, the review should say when the older agent is still appropriate.

Renal replacement and related

Situationalregional citrate, dialysate additives
Questions this review has to answer
  • Is concentrated potassium chloride absent from patient care areas?
  • Is there a stated default crystalloid, and does the order set reflect it?
  • Are electrolyte replacement protocols nurse-driven, and are they current?
17

Blood products, factors and hematopoietic agents

Hematology

Factor concentrates and hemostatics

Expectedfour-factor PCC, fibrinogen concentrate, tranexamic acid
Situationalfactor VIIa, factor VIII, factor IX, desmopressin, aminocaproic acid

Coherence checkunvalidatedFactor products are among the highest cost line items in the pharmacy. Each should carry an approval pathway and a documented indication set, or the spend is uncontrolled by design.

Erythropoiesis stimulating agents

Situationalepoetin alfa, darbepoetin

Colony stimulating factors

Expectedfilgrastim
Situationalpegfilgrastim, biosimilars

Coherence checkunvalidatedBiosimilar conversion in this class is one of the clearest savings available. If the formulary still lists only the originator, the review should record why.

Iron products

Expectedferrous sulfate, iron sucrose
Situationalferric carboxymaltose, ferumoxytol, iron dextran

Anticoagulant reversal

See the anticoagulation block; reversal agents are reviewed with the agents they reverse.

Questions this review has to answer
  • Does every factor product have an approval pathway and an indication set?
  • Which biosimilars are available in this class, and has conversion been evaluated?
  • Is tranexamic acid protocolised for trauma and obstetric hemorrhage?
18

Immunosuppressants, biologics and transplant agents

Immunology

Calcineurin inhibitors and antiproliferatives

Situationaltacrolimus, cyclosporine, mycophenolate, azathioprine, sirolimus, everolimus

Coherence checkunvalidatedTacrolimus formulations are not interchangeable and the error is a serious one. If transplant patients are admitted at all, the review should confirm the EHR distinguishes immediate from extended release.

Biologic immunomodulators

Situationalinfliximab, adalimumab, rituximab, tocilizumab, abatacept, ustekinumab

Coherence checkunvalidatedBiosimilar availability changes this class every year. A class review that does not check biosimilar status is leaving the largest available saving untouched.

Immune globulins

ExpectedIVIG
SituationalSCIG, hyperimmune globulins

Antithymocyte and induction agents

Situationalantithymocyte globulin, basiliximab
Questions this review has to answer
  • Does the EHR prevent substitution between tacrolimus formulations?
  • Which biologics now have biosimilars, and what would conversion save?
  • Is there an approval pathway for IVIG, given the cost and periodic shortages?
19

Vaccines and immune globulins

Prevention

Routine inpatient vaccines

Expectedinfluenza, pneumococcal, hepatitis B, Tdap
SituationalCOVID-19, RSV, zoster, MMR, varicella

Post-exposure prophylaxis

Expectedtetanus immune globulin, hepatitis B immune globulin
Situationalrabies vaccine and immune globulin, varicella zoster immune globulin

Coherence checkunvalidatedRabies prophylaxis is low volume and high urgency. If it is not stocked, the review should document where it is obtained and how quickly, because discovering that during an exposure is too late.

Questions this review has to answer
  • Are standing orders in place for influenza and pneumococcal vaccination?
  • Where is rabies prophylaxis obtained, and what is the time to availability?
  • Do vaccine storage and temperature excursion procedures meet CDC requirements?
20

Antidotes, toxicology and emergency agents

Emergency

Common antidotes

Expectednaloxone, flumazenil, acetylcysteine, calcium gluconate, sodium bicarbonate, glucagon
Situationalfomepizole, methylene blue, hydroxocobalamin, physostigmine, pralidoxime, atropine

Chelators and heavy metals

Situationaldeferoxamine, succimer, calcium disodium EDTA, dimercaprol

Specialty antidotes

Situationaldigoxin immune Fab, crotalidae antivenom, lipid emulsion, glucarpidase, uridine triacetate

Coherence checkunvalidatedStocking decisions here should follow a written antidote stocking assessment based on the hospital's actual exposure risk, not on a generic list. The failure mode is discovering an antidote is not stocked while a patient is decompensating.

Questions this review has to answer
  • Is there a written antidote stocking assessment, and when was it last reviewed?
  • For antidotes not stocked, is the source and the time to obtain documented?
  • Do code cart and rapid response contents match the current resuscitation guidance?

Sources

Educational reference for licensed pharmacists. Not a formulary recommendation for any institution and not clinical advice. Agent groupings reflect common acute-care practice, not a standard of care. Verify every guideline against its current version, and make formulary decisions through your own P&T process.

Free reference card

The Patient Work-Up Sequence card

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