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Azithromycin CI: hepatic dysfxn w/ prior use Warnings: -QT prolongation Zithromax, Z-Pak (D,food,SE) -Hepatotoxicity 500mg on Day 1, then 250mg Days 2-5 *No renal dose adjustment Clarithromycin CI: hepatic dysfxn w/ prior use; current lovastatin or simvastatin use; colchicine in RI/HI; h/o QT...

Azithromycin CI: hepatic dysfxn w/ prior use Warnings: -QT prolongation Zithromax, Z-Pak (D,food,SE) -Hepatotoxicity 500mg on Day 1, then 250mg Days 2-5 *No renal dose adjustment Clarithromycin CI: hepatic dysfxn w/ prior use; current lovastatin or simvastatin use; colchicine in RI/HI; h/o QT prolongation or ventricular arrhythmias Warnings: -QT prolongation -Hepatotoxicity Biaxin (D,SE) -Major CYP3A4 inhibitor -Caution in pts with CAD PO: 250-500mg Q12H or 1g XL daily *Dose adjust for CrCl <30 *Do not refrigerate reconstituted oral suspension Erythromycin CI: hepatic dysfxn w/ prior use; current lovastatin or simvastatin use Warnings: -QT prolongation -Hepatotoxicity E.E.S, Ery-Tab, Erythrocin (D,SE) -Major CYP3A4 inhibitor 400mg PO QID *No renal dose adjustment *Refrigerate oral suspension Trimethoprim/sulfamethoxazole -SS: 400mg SMX/80mg TMP -DS: 800mg SMX/160 mg TMP CI: sulfa allergy, pregnancy/bf, folate deficiency anemia, severe RI/HI, <2months old Bactrim, Septra (D,CI,food,SE) Warnings: G6PD def; Blood dyscrasias; SJS/TEN, TTP; Teratogenic *Mod-strong CYP2C8 and 2C9 inhibitor SE: -crystalluria, photosensitivity hemolytic anemia, hyperkalemia Daptomycin, IV only Warnings: -Eosinophilic pneumonia (Not used for pneumonia!) -Myopathy/rhabdo -False ↑PT/INR (but not bleed risk) -Peripheral neuropathy Cubicin (Warnings, monitoring, use) Monitor CPK weekly (dc if >10,000 units/L or >1,000 + muscle pain) neuropathy, dyspnea Approved for complicated SSTI, MRSA; active against both sp. of VRE, E. faecium & E. faecalis Linezolid CI: MAOI within 14 days Warnings: -Myelosuppression -Peripheral/optic neuropathy -Serotonin syndrome Zyvox (CI, Warnings, Monitoring, use, D) -Hypoglycemia Monitor CBC weekly MRSA, VRE (E. faecium & E. faecalis) PO/IV: 600mg Q12H *No renal dose adjustment Minocycline Warnings: ≤8yo, pregnant/bf Minocin, Solodyn, Dynacin (Warnings, D) -photosensitivity -drug-induced lupus PO/IV: 200mg x1 f/b 50-100mg Q12H Doxycycline Warnings: ≤8yo, pregnant/bf Vibramycin (D, Warnings) photosensitivity PO/IV: 100mg bid WF (for GI upset) +8oz H₂0; sit upright 30min to avoid esophageal irritation *No renal dose adjustment Tigecycline BBW: ↑risk of death, use only when alternative treatments are not suitable Warnings: Hepatotoxicity, pancreatitis, photosensitivity, avoid in <8yo, ↓cure rates in VAP -Do not use for bloodstream infxns (lipophilic) Tygacil (BBW, warnings, D, coverage) IV: 100mg x 1, then 50mg bid *Reconstituted soln is yellow/orange *No renal dose adjustment Covers: MRSA, VRE, GN, anaerobes, and atypicals but LACKS activity against the "3 Ps" -Pseudomonas, Proteus, Providencia Liposomal Amphotericin B Used as initial tx for many invasive infxns including Cryptococcal meningitis, histoplasmosis, mucormycosis BBW: Death d/t errors confusing lipid based (AmBisome, Abelcet) & conventional deoxycholate→ max 1.5mg/kg/day, requires pre-med AmBisome (Use, BBW, SE) *verify product name/dose if >1.5mg/kg/day *OD can cause cardiopulmonary arrest SE: infusion-rxns; thrombophlebitis, ↓K, MG, nephrotoxicity Injection: 3-6mg/kg/day Fluconazole Fungal meningitis (Penetrates CNS) *Reliable activity against C. albicans & C. tropicalis Warnings: hepatotoxicity, SJS, avoid in pregnancy; *strong inhibitor of 3A4, 2C9, 2C19 Diflucan (D,SE) SE: ↑ LFTs, QT prolongation PO/IV ratio is 1:1; 500-800mg daily Vaginal candidiasis: 150mg po x1 * ↓dose 50% for CrCl <50 Flucytosine (5-FC) Used with amphoB for invasive Cryptococcal meningitis or Candida infxns Ancobon (use, BBW, SE) BBW: Extreme caution in pts with RI, monitor hematologic, renal & hepatic status closely SE: myelosuppresion (dose related), ↑Sc, BUN, hepatitis, ↑bilirubin, many CNS effects, hypoglycemia, ↓K Terbinafine (Rx = po) I: onychomycosis Lamisil (I,W,D) W: hepatotoxic 250mg po daily (6 wks for fingernail, 12 wks toenail) Nystatin Mycostatin, Bio-Statin (I,D) Thrush: Swish and swallow 4-5 times daily -Vaginal insert: 100,000 unit x 2 weeks Voriconazole *DOC for Aspergillus CI: use of 3A4 inducers: PPE PCORNSS, ergot alkaloids pimozide, quinidine, ritonavir, sirolimus, terfenadine, astemizole, barbiturates Warnings: Hepatotoxicity, optic neuritis, phototoxicity, avoid in pregnancy, QT prolongation, infusion rxns, SJS; strong 3A4 inhibitor & substrate Vfend, Vfend IV (I, CI, warnings, SE D) SE: visual changes (20%), ↑LFTs, Scr, CNS toxicities, ↓K, BG LD: 5mg/kg IV Q12H x2 MD: 4mg/kg IV Q12H or 200mg po Q12H Target trough: 1-5mcg/mL *CrCl <50: oral vori preferred (SBECD IV vehicle accumulates) *take on empty stomach Posaconazole CI: use of sirolimus, atorvastatin, lovastatin, simvastatin, quinidine Warnings: QT prolongation, med errors (tablet & suspension are not interchangeable), neurotoxicity Noxafil (CI, warnings, admin) with vincristine Oral treatment preferred if eGFR <50 *Take with a full meal Caspofungin (IV) Candidemia Cancidas Given once daily; no renal dose adjustment Warnings: histamine mediated rxns, ↑ LFTs, SJS Micafungin Candidemia/esophageal candidiasis Mycamine Given once daily; no renal dose adjustment Warnings: histamine mediated rxns, ↑ LFTs, SJS Iron Sucrose (IV) Total dose needed to replenish iron stores: 1,000mg; can be given in a single infusion Venofer *Give by slow IV infusion to ↓risk of hypotension SE: All parenteral iron products carry a risk for hypersensitivity rxns (including anaphylaxis) Ferumoxytol (IV iron) BBW: serious/fatal anaphylactic rxns Feraheme *Slow IV infusion to ↓risk of hypotension Total dose needed to replenish iron stores: 1,000mg; can be given in a single infusion Injection (IM/deep SC) Lozenges, tablets, SL liquid Nasal solution (Nascobal): one nostril once weekly Cyanocobalamin (B12) -Formulations,CI,Warnings CI: Cobalt or vitamin B12 allergy (intradermal test dose recommended if suspected sensitivity prior to intranasal or injectable use) Warnings: parenteral products may contain aluminum (accumulation can cause CNS & bone toxicity in RI) or benzyl alcohol (can cause fatal toxicity & "gasping syndrome" in neonates) Filgrastim (Neupogen) Pegfilgrastim (Neulasta) Colony Stimulating Factors: stimulate WBC production, ↓ time pt is at risk for infxn d/t neutropenia & ↓ mortality from infxn when given as ppx Neupogen & -IV/SC, started 24-72H AFTER chemo Neulasta Indication: all patients with >20% chance of chemo-induced febrile neutropenia SE: bone pain, arthralgias, myalgias, fever, rash; pts should report any signs of enlarged spleen (upper L abdominal pain or respiratory distress syndrome) Neulasta: do not give within 14 days prior to next chemo cycle Meperidine (opioid, CII) 50-150mg IM/PO q3-4h prn *short DOA (3hrs) Demerol (D,DOA,Uses,SE,) *No longer recommended as an analgesic *Used off-label for post-op rigors (shivering) SE: serotonergic; CNS toxicity including seizures (esp. in renal impairment) Morphine ER (po) -15-200mg po Q8-12H prn MS Contin, Kadian, Roxanol, Oramorph, Avinza (D) Kadian: capsule contents can be sprinkled on food Infumorph, Duramorph (D) Morphine IR for IV injection 2.5-5 mg Q3-4H prn (opioid-naive) Hydrocodone/acetaminophen 2.5-10/325mg po q4-6h prn Norco, Lortab, Lorcet, Vicoden (D) BBW: Starting 3A4 inhibitors (or stopping inducers) can cause fatal OD Hydrocodone/ibuprofen 5-7.5/200mg po q4-6h prn Vicoprofen, Ibudone (D) BBW: Starting 3A4 inhibitors (or stopping inducers) can cause fatal OD Oxycodone IR 5-20mg po q4-6hr Roxicodone (D, BBW) *Lower dose/avoid in renal impairment BBW: Starting 3A4 inhibitors (or stopping inducers) can cause fatal OD Oxycodone CR BBW: Starting 3A4 inhibitors (or stopping inducers) can cause fatal OD OxyContin (D, BBW) 10-80mg po bid *Lower dose/avoid in renal impairment Oxycodone/acetaminophen (IR) BBW: Starting 3A4 inhibitors (or stopping inducers) can cause fatal OD Percocet, Endocet (D, BBW) 2.5-10/325mg po q4-6hr *Lower dose/avoid in renal impairment Percodan (D) Oxycodone/aspirin (IR) 4.83/325mg po q6h prn (max 12 tabs/hr) Methadone BBW: QT prolongation; Major 3A4 substrate: starting inhibitors or stopping inducers can cause fatal OD Dolophine (D,I,BBW) *Opioid addiction, chronic pain 2.5-10mg q8-12hr Hydromorphone BBW: Risk of med errors with high potency (HP) injection (use in opioid-tolerant pts only) Dilaudid HP (10mg/mL) vs Dilaudid (1mg/mL) Dilaudid (D -PO/IV, BBW) 1.5mg IV/IM = 7.5mg PO = 10mg morphine IV/IM = 30mg morphine PO Fentanyl injection Sublimaze (D IM/IV, BBW) BBW: mod-strong 3A4 inhibitors ↑ effects; potential med errors when converting between dosage forms Fentanyl patch Med Guide 1 patch q72 Duragesic (D, BBW) *Apply on upper arm, chest or back BBW: mod-strong 3A4 inhibitors ↑ effects; potential med errors when converting between dosage forms; avoid exposing patch to external heat Fentanyl IR transmucosal lozenge Med Guide Only indicated for cancer BTP 200mcg x up to 4 BTP episodes/day. Actiq (D, I) REMS: requires documentation of pt's opioid tolerance with each Rx BBW: mod-strong 3A4 inhibitors ↑ effects; potential med errors when converting between dosage forms I: pain, cough *Converted to morphine by 2D6: avoid 2D6 inhibitors; risk of respiratory depression in ultra-rapid metabolizers BBW: resp. depression / death (including children who received codeine after tonsillectomy or Codeine (CV) adenoidectomy & nursing infants of mothers who were ultra-rapid metabolizers) CI: <12 yo; <18 yo following tonsillectomy/adenoidectomy Nalbuphine Mixed opioid agonist/antagonist (not a C.S.) Nubain, Nalpain (I,Max) I: pain in labor/anesthesia max 160mg/day Tramadol, CIV Med Guide IR: 50-100mg po q4-6h prn (Max 400 mg/day) Ultram (D, CI, SE, sched) *Requires conversion to active metabolite by 2D6: avoid 2D6 inhibitors CI: <12 yo; <18 yo following tonsillectomy/adenoidectomy SE: Seizure, serotonin syndrome risks Tapentadol, CII (opioid & NE reuptake inhibitor) Med Guide Nucynta (D,SE, sched) 50-100mg q4-6 hr prn SE: Seizure, serotonin syndrome risk *less GI effects than other opioids Narcan (D) Naloxone nasal spray 4 mg in one nostril; may need to repeat dose(s) in alternating nostrils Nalmefene Revex (I) Opioid antagonist *for opioid OD Naltrexone Med Guide Opioid antagonist for alcohol and opioid dependence ReVia, Vivitrol ReVia = daily po tablet Vivitrol = monthly IM injection -25mg po x 1, then 50mg po qd on Day 2 Isoniazid I: TB (included in latent and active TB regimens) BBW: severe/fatal hepatitis CI: active liver dz, previous severe adverse rxn to INH INH (D,BBW,I,SE) Warnings: peripheral neuropathy (supplement pyridoxine/B6 25mg/d); drug-induced lupus; hemolytic anemia; agranulocytosis, optic neuritis D: 300mg po daily on an empty stomach Rifampin CI: use with protease inhibitors SE: ↑LFTs, orange body fluids, (+) Coombs test, flu-like syndrome Max dose: 600mg po daily, take on empty stomach Rifadin (CI, SE, D, DDIs) Potent inducer of 1A2, 2C8, 2C9, 2C19, 3A4 and P-gp Warfarin: very large ↓ in INR is common Oral contraceptives: ↓ efficacy DOACs: should be avoided Peginterferon alfa 2a & 2b -2a: Pegasys 180 mcg SC qw Pegasys & PegIntron (D, BBW) -2b: PegIntron 1.5mcg/kg SC qw *BBW: worsening autoimmune system, infection, psych problems, ischemic problems, blood problems Ribavirin (po for HCV) Med Guide I: HCV in combination with DAAs and/or IFNɑ BBW: teratogenic; not effective for monotherapy of HCV; hemolytic anemia CI: Pregnancy, women of childbearing potential, male partners of pregnant women, hemoglobinopathies, CrCl <50, autoimmune hepatitis, use of didanosine Ribasphere, Rebetol, Copegus (BBW,CI,SE) SE: insomnia, anorexia, myalgias, hypothyroidism Monitoring: CBC + diff, PLTs, e-lytes, LFTs/bili, HCV-RNA, TSH, monthly pregnancy tests Note: avoid pregnancy during & for 6 months after completion. 2 forms of BC req'd during & for 6 months post-tx (also applies to female partners of males who are being treated) *Combo SEs: anemia, birth defects, eye problems Simeprevir I: Hep C genotype 1 & 4 Olysio (I,D,food,SE) D: 150mg po qd x 12 weeks + PEG-IFN/RBV or sofosbuvir *Take w/ food *SEs: anemia, requiring ESA, photosensitivity Acyclovir I: HSV-1 & HSV-2, invasive HSV including HSV encephalitis (IV); shingles Warnings: TTP/HUS in immunocompromised; maintain hydration, infuse slowly over 1H to prevent renal damage; ↑LFTs, neutropenia, seizures Zovirax (I,D,food) *Dose based on IBW, even in obese pts PO: 200-800mg 5x daily Topical cream: Apply 5x daily for 4 days (can be used on oral or genital sores) Valacyclovir I: HSV, shingles Valtrex (I,D) Shingles: 1g po TID x7 days *Prodrug of acyclovir Famciclovir Famvir (I,D) I: HSV, shingles -Shingles: 500mg po tid x 7 days w/in 72 hrs onset Ganciclovir I: DOC for CMV disease BBW: myelosuppression; carcinogenic, teratogenic Cytovene (I, BBW, SE, W) SE: thrombocytopenia, neutropenia, leukopenia; ↑ Scr Hazardous Drug: special handling req'd Reproductive potential: females should use contraception during tx + 30 days after, males for 90 days ValGANciclovir *Prodrug of ganciclovir I: DOC for CMV disease BBW: myelosuppression; carcinogenic, teratogenic Valcyte (I, BBW, SE, W) SE: thrombocytopenia, neutropenia, leukopenia; ↑ Scr; retinal detachment (monitor) Hazardous Drug: special handling req'd Reproductive potential: females should use contraception during tx + 30 days after, males for 90 days Amantadine I: Parkinson's: for initial tremor Symmetrel (I,D) D: 100mg po bid or tid W: Psychosis, livedo reticularis (mottled purplish discoloration of the lower extremities) - d/c SE: Dizziness (light-headedness), orthostasis Oseltamivir I: flu tx and ppx; preferred in pregnancy Warnings: neuropsychiatric events, SJS Tamiflu (I,D,SE,age,time to start) Tx: 75mg po BID x 5 d Ppx: 75mg po QD x 10 d *Dose adjust for CrCl <60 Zanamivir I: flu tx and ppx Relenza (I,D,ROA,age) Tx: 10mg po BID x 5 d Ppx: 10mg po QD x 10 d *oral inhalation *for >/= 7 yoa Foscarnet Foscavir (BBW) BBW: only for CMV retinitis in immunocompromised pts and acyclovir-resistant HSV; renal impairment, seizures Dornase alfa Pulmozyme (I,D) I: cystic fibrosis D: 2.5mg nebulizer qd or bid if needed Atenolol Max dose: 100mg qd *Cardioselective Tenormin (max,BBW,COi,SE) BBW: Do not stop abruptly to avoid acute tachycardia, HTN and/or ischemia *CI: diabetes, asthma/COPD, bradycardia, heart block *SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Metoprolol tartrate *IR *Cardioselective Lopressor (Max,BBW,CI,SE) *Max: 450mg/d (doses are bid) *BBW: Do not stop abruptly to avoid acute tachycardia, HTN and/or ischemia *CI: diabetes, asthma/COPD, bradycardia, heart block *SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Metoprolol succinate β1 selective -HTN: Max 400mg/day Toprol XL (I,max,BBW,CI,SE) -HF Target dose: 200mg/d BBW: Do not stop abruptly CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Esmolol *IV only for HTN emergency β1 selective Brevibloc (I,BBW,CI,SE) BBW: Do not stop abruptly CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Ranolazine I: stable ischemic heart dz (inhibits late Na current & ↓ intracellular Ca) *Little to no effect on HR or BP CI: Cirrhosis, strong 3A4 inhibitors & inducers Ranexa (CI, W, M) W: QT prolongation M: ECG, K, renal function Dosed BID *500mg BID when used with mod3A4 inhibitors (diltiazem, verapamil) *Max 20mg simvastatin if used together Propranolol (Nonselective) IR: 80mg BID, ER: 80mg QD (Max for both: 640mg/d) *Take with food Inderal (D,food,BBW,CI,SE) BBW: Do not stop abruptly CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Timolol (Nonselective) 40mg po BID Blocadren (D,BBW,CI,SE) BBW: Do not stop abruptly CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Timolol eye drops I: Glaucoma CI: asthma/COPD, bradycardia, CHF Timoptic, Betimol (I,CI,SE) Caution: arrhythmias, diabetes, depression, thyroid dz SE: bronchospasm, ↓ HR/BP, ↓ libido, depression Dosed BID Bepreve Bepotastine eye drops 2nd gen antihistamine Ciprodex Ciprofloxacin/dexamethasone ear drops Timolol/dorzolamide I: Glaucoma Cosopt (I,CI,SE) CI: sulfa allergy, kidney disease SE: metallic taste, HA, hypokalemia Labetalol (Nonselective; also blocks α1) 800mg po BID (Max: 2400mg/d) *Take with food Normodyne, Trandate (I,food,BBW,CI,SE) BBW: Do not stop abruptly CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, weight gain, fluid retention, fatigue, dizziness Carvedilol, nonselective BB, also blocks α1 BBW: Do not stop abruptly to avoid acute tachycardia, HTN and/or ischemia CI: diabetes, asthma/COPD, bradycardia, heart block SE: dyslipidemia, wt gain, fluid retention, fatigue, dizziness Coreg (BBW,CI,SE,D) 3.125-25 mg po BID with food HF target dose: 25mg po BID 6.25mg IR = 20 mg CR Carteolol I: glaucoma Ocupress (I,CI,SE) *CI: asthma/COPD, bradycardia, CHF, depression or MG *SE: bronchospasm, bradycardia, low BP and libido, CNS depression Betaxolol I: glaucoma Betoptic (I,CI,SE) *CI: asthma/COPD, bradycardia, CHF, depression or MG *SE: bronchospasm, bradycardia, low BP and libido, CNS depression Diltiazem I: HTN, angina Cardizem (I,max,SE) Max dose: 120mg/day qd, bid or tid SE: bradycardia, gingival hyperplasia, constipation Verapamil I: HTN, angina Max dose: 120mg/day qd, bid or tid Calan, Isoptin, Verelan, Covera (I,max,SE) *non-DHP (more cardioselective) *Preferred if CKD and nephropathy *SE: bradycardia, gingival hyperplasia, constipation *Ok to give in HF if EF is normal Amlodipine I: HTN, angina Max dose: 10mg/d CI: CHF, do not give w/ BB if acute MI Norvasc (I,max,CI,SE) SE: reflex tachycardia, HA, flushing, edema, gingival hyperplasia Major 3A4 substrate: Max 20mg simvastatin Felodipine ER I: HTN, angina Plendil (I,max,CI,SE) Max dose: 10mg/d CI: CHF, do not give w/ BB if acute MI SE: reflex tachycardia, HA, flushing, edema Isradipine CR I: HTN, angina DynaCirc (I,CI,SE) Max dose: 10mg/d CI: CHF, do not give w/ BB if acute MI SE: reflex tachycardia, HA, flushing, edema Nicardipine I: HTN, angina 60mg BID or TID Cardene (I,D,CI,SE) CI: CHF, do not give w/ BB if acute MI SE: reflex tachycardia, HA, flushing, edema Nifedipine ER I: HTN, angina Adalat CC, Procardia XL (I,max,CI,SE) Max dose: 90mg/d CI: CHF, do not give w/ BB if acute MI SE: reflex tachycardia, HA, flushing, edema Doxazosin alpha blocker (nonselective) I: BPH, HTN (2ⁿᵈ or 3ʳᵈ line) Cardura (I,D,SE) IR: start 1mg QHS, titrate slowly (orthostasis/syncope esp. w/ 1st dose) Cardura XL: take 4mg w/ BF; can leave a ghost tablet in stool *must taper off Prazosin I: HTN (2ⁿᵈ or 3ʳᵈ line), BPH Minipress (I,D,SE) D: 5mg po bid or tid (for both indications) *Caution: syncope, dizziness, fatigue --> Titrate *must taper off Terazosin (Non-selective α blocker) I: BPH, HTN (2ⁿᵈ or 3ʳᵈ line), BPH Hytrin (I,D,SE) BPH: start 1mg po QHS, titrate slowly (1st dose syncope) *Normal dose: 10mg QHS (max 20mg) *must taper off Clonidine ER I: ADHD Kapvay 0.1mg QHS (max 0.4mg/day) *must be tapered off to ↓ risk of rebound hypertension, nervousness & anxiety Guanfacine ER I: ADHD 1mg daily (max 4mg/day with stimulants, or 7mg/day when used alone) *Do not take with high-fat meal (↑ absorption) Intuniv W/ strong 3A4 inducers double dose W/ strong 3A4 inhibitors: ↓ dose 50% Must be tapered off to ↓ risk of rebound HTN, nervousness, anxiety Clonidine I: resistant HTN or pts who can't swallow, ADHD *off-label: opioid withdrawal, anxiety and sleep D: Catapres, Catapress TTS-1,2,3 (I,D,apply,SE) -0.1-0.3 mg po BID -0.1, 0.2, 0.3 mg/24 hr/wk *Apply to upper outer arm or chest and rotate site weekly *Caution: bradycardia, dry mouth, fatigue, depression, psych rxns, impotence, rebound HTN *must taper off Methyldopa D: 500mg BID (max 3000mg/d) *SE: lupus sx, hepatitis, myocarditis, hemolytic anemia Aldomet (D,SE) *Caution: bradycardia, dry mouth, fatigue, depression, psych rxns, impotence, rebound HTN *preferred in pregnancy *must taper off Reserpine I: HTN (old drug) Serpasil (I,D,SE) Caution: bradycardia, depression *must taper Hydralazine I: HTN Apresoline (I,D,SE) D: 75mg po qid *SE: lupus *Caution: reflex tachycardia Minoxidil I: HTN Loniten (I,D,SE) D: 40mg po qd *SE: hair growth *Caution: reflex tachycardia Chlorothiazide (IV/PO) [Thiazide] I: HTN, edema D: 500-2000 mg qd in 1-2 divided doses CI: Sulfa allergy Diuril SE: metabolic alkalosis, ↓K, Na, Mg, and ↑BG, TG, Chol, UA, Ca Not effective if CrCl < 30 *Can ↓Lithium renal CL and lead to toxicities HCTZ/triamterene I: HTN, edema D: 1-2 tabs po qd Dyazide, Maxzide *CI: Sulfa allergy *SE: metabolic alkalosis, decreases K+, Na+ and Mg2+, increases BG, TG, Chol, uric acid and Ca2+ *Diuretic of choice if no renal impairment Hydrochlorothiazide [Thiazide] I: HTN, edema D: 12.5-50mg PO QD *CI: Sulfa allergy Microzide *SE: metabolic alkalosis, ↓ K+, Na+, Mg2+, and ↑ BG, TG, Chol, uric acid and Ca2+ *Diuretic of choice if no renal impairment Not effective if CrCl < 30 *Can ↓Lithium renal CL and lead to toxicities Chlorthalidone I: HTN D: 12.5 - 25mg QD CI: Sulfa allergy Thalidone (I,D,CI,SE) SE: metabolic alkalosis, ↓K, Na, Mg, ↑BG, TG, Chol, UA, Ca *Better at ↓ BP than loop diuretics, 1st line agent Not effective if CrCl < 30 *Can ↓Lithium renal CL and lead to toxicities Metolazone [thiazide] I: HTN, edema D: target dose 20mg/d Zaroxolyn (I,D,CI,SE) *CI: Sulfa allergy *SE: metabolic alkalosis, decreases K+, Na+ and Mg2+, increases BG, TG, Chol, uric acid and Ca2+ *Ok if there's renal dysfunction Indapamide [thiazide] I: HTN, edema Lozol (I,D,CI,SE) D: Target dose 2.5mg/d CI: Sulfa allergy SE: metabolic alkalosis, ↓K, Na, Mg, ↑BG, TG, Chol, UA, Ca Furosemide I: HTN, HF, edema D: Target dose 40mg po BID (max: 600mg/d) CI: sulfa allergy Lasix (I,D,CI,SE,loop equal) SE: metabolic alkalosis, Decreases K+, Na+, Mg2+, Ca2+ and bone density, increases BG, TG, Chol, and uric acid *IV: Ototoxicity and avoid use w/ aminoglycosides *Equivalency: BTFE = 1:20:40:50 Torsemide I: HTN, HF, edema D: Target dose 10mg qd *CI: sulfa allergy *SE: metabolic alkalosis, Decreases K+, Na+, Mg2+, Ca2+ and bone density, increases BG, TG, Chol, and Demadex (I,D,CI,SE) uric acid *Requires K+ supp *Diuretic of choice for renal disease *IV: Ototoxicity and avoid use w/ aminoglycosides *Equivalency: BTFE = 1:20:40:50 Bumetanide I: HTN, HF, edema D: Target dose: 1mg po bid *CI: sulfa allergy *SE: metabolic alkalosis, Decreases K+, Na+, Mg2+, Ca2+ and bone density, increases BG, TG, Chol, and Bumex (I,D,CI,SE) uric acid *Requires K+ supp *Diuretic of choice for renal disease *IV: Ototoxicity and avoid use w/ aminoglycosides *Equivalency: BTFE = 1:20:40:50 Ethacrynic acid I: HTN, HF, edema SE: metabolic alkalosis, ↑BG, TG, Chol, uric acid ↓K+, Na+, Mg²⁺, Ca²⁺, BMD *IV: Ototoxicity; avoid use w/ aminoglycosides Edecrin (I,D,SE) *Diuretic of choice for renal disease *only loop that is ok in sulfa allergy 25-50mg po daily *Equivalence: BTFE = 1:20:40:50 Triamterene [K+ Sparing Diuretics] I: HTN, glaucoma, edema Dyrenium D: 300mg po qd *SE: metabolic acidosis, Increase K+, decrease Ca2+, gout *CI if CrCl <30 Amiloride I: HTN, glaucoma, edema D: 20mg po qd Midamor (I,D,SE,CI) *K+-sparing diuretic *SE: metabolic acidosis, Increase K+, decrease Ca2+, gout *CI if CrCl <30 Spironolactone I: HF (decreases morbidity), HTN D: 25-50mg po qd Aldactone (I,D,SE,CI) *K+-sparing diuretic *SE: gynecomastia, metabolic acidosis, Increase K+, decrease Ca2+, gout *CI: pregnancy, CrCl <30 Eplerenone (aldosterone antagonist) I: HF (EF <35% or post-MI for EF <40%), HTN CI: pregnancy, Scr >2, CrCl <30, K>5 Inspra (I,D,SE,CI) SE: ↑K+ D: 25-50mg po qd HF target dose: 50 mg daily Benazepril I: HTN BBW: pregnancy, bilateral renal artery stenosis Lotensin (I,D,BBW,SE) SE: metabolic acidosis, ↑K+, dry cough, angioedema *Avoid w/ NSAIDs bc of renal damage 10-40mg po daily or in 2 divided doses Captopril I: HTN, HF Target dose: 50mg po tid Capoten (i,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema, dry cough *Avoid NSAIDs - renal damage Enalapril I: HTN, HF Target dose: 20mg po qd Vasotec (i,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema, dry cough *Avoid NSAIDs - renal damage Fosinopril I: HTN, HF Target dose: 40mg po qd Monopril (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema, dry cough *Avoid NSAIDs - renal damage Lisinopril I: HTN, HF Target dose: 20mg po qd Zestril, Prinivil (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema, dry cough *Avoid NSAIDs - renal damage Moexipril I: HTN, HF Target dose: 15mg po qd Univasc (i,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Quinapril I: HTN, HF Target dose: 40mg po qd Accupril (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Ramipril I: HTN, HF Target dose: 10mg po qd Altace (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Candesartan I: HTN, HF Target dose: 32mg po qd Atacand (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Irbesartan I: HTN, HF Target dose: 300mg po qd Avapro (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Losartan I: HTN, HF Target dose: 50-100mg po qd Cozaar (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Valsartan I: HTN, HF Target dose: 320mg po qd Diovan (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Olmesartan I: HTN, HF Target dose: 40mg po qd Benicar, (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: sprue-like enteropathy; metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Telmisartan I: HTN, HF Target dose: 80mg po qd Micardis (I,D,BBW,SE) BBW: pregnancy, bilateral renal artery stenosis SE: metabolic acidosis, ↑K+, angioedema *Avoid NSAIDs - renal damage Aliskiren I: HTN Target dose: 300mg po qd Tekturna (I,D,BBW,SE, food) *BBW: pregnancy, bilateral renal artery stenosis *SE: metabolic acidosis, increase K+, dry cough, angioedema *Avoid w/ NSAIDs bc of renal damage *High fat meals decreases absorption Lovastatin IR I: high cholesterol Mevacor (I,D,CI,SE,food) D: 20 po qd or bid with food (Max: 80mg/d) CI: Pregnancy *Caution: rhabdomyolysis, myopathy Atorvastatin I: high cholesterol D: 10-80mg po qd Lipitor (I,D,CI,SE) *CI: Pregnancy *Caution: rhabdomyolysis, myopathy *medium-high intensity Fluvastatin IR I: high cholesterol D: 20-80mg po qd Lescol (I,D,CI,SE,time) *CI: Pregnancy *Caution: rhabdomyolysis, myopathy *low-medium intensity *Take at bedtime Rosuvastatin I: high cholesterol D: 5-20mg po qd Crestor (I,D,CI,SE) *CI: Pregnancy *Caution: rhabdomyolysis, myopathy *medium-high intensity Pravastatin I: high cholesterol D: 10-80mg po qd Pravachol (I,D,CI,SE) *CI: Pregnancy *Caution: rhabdomyolysis, myopathy *low-medium intensity Simvastatin I: high cholesterol D: 10-40mg po qd Zocor (I,D,CI,SE,time) *CI: Pregnancy *Caution: rhabdomyolysis, myopathy *low-medium intensity *Take at bedtime Ezetimibe I: high cholesterol Zetia (I,D,SE,adj) D: 10mg po qd *Caution: myopathy *Can be used w/ statin Niacin (B3) Niaspan = Extended release (Rx) I: TG >500 CI: peptic ulcer, bleeding Niaspan ER, Niacor, Niacin (I,D,age,CI,SE,time,food) W: ↑uric acid, ↑BG, myopathy/rhabdo if used w/ statin 500mg po QHS after lowfat snack ; pregnant/BF: 18mg daily (Max 2g/day; tolerability ↓ w/ doses >1gm - flushing/itching) *Taking WF helps with tolerability, slows absorption Colesevelam I: high cholesterol D: 6 tabs po qd Welchol (I,D,CI,SE) *CI: bowel obstruction *SE: constipation, gas, bloating (Welcol has less GI SEs) *OK w/ statins and hepatic disease *2nd line Colestipol I: high cholesterol D: max 16g tab/d or 30g powder/d Colestid (I,D,CI,SE) *CI: bowel obstruction *SE: constipation, gas, bloating *OK w/ statins and hepatic disease *2nd line Cholestyramine I: high cholesterol *CI: bowel obstruction Questran, Prevalite (I,CI,SE) *SE: constipation, gas, bloating *OK w/ statins and hepatic disease *2nd line Gemfibrozil I: TG >500 CI: liver/renal/gallbladder disease Lopid (I,D,CI,SE,food) SE: rhabdomyolysis, myopathy *Avoid w/ statin D: 600mg po bid 30min before BF/dinner Fenofibrate I: high TG D: 145mg po qd Tricor, Triglide, TriLipix, Antara (I,D,CI,SE,food) *CI: liver/renal/gallbladder disease *SE: rhabdomyolysis, myopathy *Avoid w/ statin *Take w/ food Nitroglycerin SL tablet I: angina attack and prevention CI: PDE-5 inhibitors ͒ , riociguat SE: HA, flushing, tingling in mouth, hypotension, dizziness, syncope Nitrostat, Nitroquick (I,D,CI,SE,food) 0.3-0.6 mg q5m, max 3 doses in 15 min *call 911 if 1ˢᵗ dose does not relieve CP ͒avanifil in past 12H, sildenafil or vardenafil in past 24H or tadalafil in past 48H *Avoid alcohol Nitroglycerin spray (short acting) I: angina attack and prevention CI: PDE-5 inhibitors ͒, riociguat SE: HA, flushing, stinging in mouth, hypotension, dizziness, syncope *Don't shake *Prime (5 sprays for Nitrolingual, 10 sprays for NitroMist) NitroMist, Nitrolingual Pump Spray (I,D,CI,SE,food,set up) *Spray 1-2 (0.4mg) sprays onto or under tongue, do not inhale spray *Close mouth after spraying *Try not to swallow quickly or spit Max 3 doses in 15 min ͒avanifil in past 12H; sildenafil or vardenafil past 24H; tadalafil past 48H *Avoid alcohol Nitroglycerin transdermal patch I: angina prevention (long acting NTG) CI: PDE-5 inhibitors SE: HA, flushing, hypotension, dizziness, syncope Minitran, Nitro-Dur (I,D,CI,SE,food) *Avoid alcohol 0.1-0.8mg/hr *Wear on for 12-14H, off for 10-12H, rotate sites, can be worn anywhere above knees (chest preferred) Nitroglycerin ointment 2% I: angina prevention (long acting NTG) CI: PDE-5 inhibitors SE: HA, flushing, hypotension, dizziness, syncope *Avoid alcohol Nitro-BID (I,D,CO,SE) Dosed BID (6H apart, with 10-12H nitrate-free interval) Measure dose with dosing applicator supplied with the tube. Apply to chest, or other desired area. Do not rub into the skin. Tape applicator into place. *Can stain clothing, cover completely Isosorbide mononitrate IR/ER tablet I: stable ischemic heart disease (long acting nitrate) Monoket, Imdur IR product: use BID, separated by 8H ER product: use QAM Nitroglycerin infusion D5W Low dose: venous dilator, high doses: arterial dilator I: Myocardial ischemia, uncontrolled HTN Tridil (I,D,CI,SE,food) CI: SBP <90, use w/ PDE-5 inhibitors or riociguat Warnings: severe hypotension, ↑ ICP SE: HA, tachycardia, tachyphylaxis w/i 24-48H of cont administration *Requires non-PVC container (glass, polyolefin) Isosorbide dinitrate (long acting) I: angina prevention, HF w/ hydralazine (BiDil) -Standard add-on in AA or ACEI/ARB intolerance d/t renal insufficiency, hyperkalemia, or hypotension CI: PDE-5 inhibitors (sildenafil, tadalafil) Isordil (I,D,CI,SE,food) SE: HA, flushing, hypotension, dizziness *Avoid alcohol Initial Dose: 10 mg po TID Target Dose: 40mg po TID Clopidogrel Med Guide I: ACS, recent MI/stroke; PAD or CAD to ↓ risk of clot, stable ischemic heart dz in ASA allergy BBW: Prodrug, converted to active metabolite by 2C19, test to check genotype & avoid in 2C19 poor metabolizers Plavix (I,D,SE,test,CI) *Avoid w/ omeprazole, esomeprazole SE: bleeding, bruising, pruritis W: ↑ risk of thrombosis is dc prematurely, TTP ACS: 300-600mg po LD MD: 75mg po daily Ticagrelor I: ACS BBW: ASA maintenance doses >100mg ↓ effectiveness of ticagrelor (only use in ACS x1); avoid when CABG likely, stop 5 days before any surgery Brillinta LD: 180mg MD: 90 mg BID x1year, then 60mg BID *Tablets can be crushed & mixed w/ water to be swallowed or given via NG tube Major 3A4 substrate, avoid w/ strong inducers or inhibitors Prasugrel I: ACS in patients who are to be managed with PCI BBW: bleeding, do not initiate if CABG likely, stop 7 days prior to elective surgery CI: serious bleeding; h/o TIA or stroke *Not recommended in pts >75 unless pt is high risk (prior MI, DM) Effient LD: 60mg po no later than 1H after PCI MD: 10 mg po daily with ASA (5mg if wt<60kg) *Dispense in original container Ticlopidine I: ACS, recent MI/stroke, PAD Ticlid (I,D,SE) D: 250mg BID SE: bleeding, bruising, risk of neutropenia, hematopoietic d/o Abciximab (IV GP-IIb/IIIa inh) I: PCI only D: 0.25mg/kg bolus pre-PCI, then 0.125mcg/kg/min x 12hr Reopro (I,D,SE,ROA,storage) SE: thrombocytopenia, bleeding, hypotension *refrigerate *filter Eptifibatide I: ACS + PCI D: 180mcg/kg bolus, then 2mcg/kg/min x 25h Integrilin (I,D,ROA,SE,storage) *IV only *SE: thrombocytopenia, bleeding, hypotension *refrigerate *protect from light Dipyridamole I: TIA/stroke prevention Persantine (I,D,SE) D: 75-100mg po QID *SE: CP, HA, dizziness, angina exacerbation, abnormal ECG Aspirin/dipyridamole I: TIA/stroke prevention Aggrenox (I,D,SE) D: 25mg/200mg po BID *SE: HA, dyspepsia, N/D, bleeding Cilostazol Pletal (I,D) I: intermittent claudication D: 100mg po bid 30 min before or 2 hrs after meals x 3 months Pentoxifylline Trental (I,D) I: intermittent claudication D: 400mg po TID Disopyramide I: Class 1a AAD: blocks Na/K channels, ventricular arrhythmias W: hypotension, HF, BPH/urinary retention, glaucoma, myasthenia gravis (d/t anticholinergic effects) Norpace(I,SE,CI,food) SE: ↑ QT interval, anticholinergic, hypotension *Take on empty stomach I: Class 1a AAD: arrhythmia BBW: ↑ mortality in AF/AFl; control AV conduction before initiating CI: FQs (QT prolongation), ritonavir, thrombocytopenia, TTP, myasthenia gravis W: hepatotoxicity, hemolysis (avoid in G6PD def), can cause + Coombs test Quinidex (Quinidine) (I,BBW,SE,food,DDI) SE: DILE, diarrhea, stomach cramping, cinchonism (overdose: tinnitus, hearing loss, blurred vision, delirium) *Take WF or milk to ↓ GI upset *DDI w/ digoxin (↓digoxin by 50%), warfarin, grapefruit and non-DHP CCBs I: Class 1a AAD: blocks Na/K channels, ventricular arrhythmias BBW: agranulocytosis (monitor closely in 1st 3 months & periodically thereafter); positive ANA which can result in DILE; reserve for life-threatening ventricular arrhythmias Pronestyl (Procainamide) SE: hypotension, rash (I,BBW,SE) Active metabolite NAPA is renally cleared, ↓ dose when CrCl <50 *Th. Range: 4-10 mcg/mL Lidocaine I: Class 1b AAD: refractory VT/cardiac arrest CI: allergy to corn Xylocaine (I,DDI,monitor) W: Caution in elderly & pts w/ HI or HF *Monitor LFTs *DDI that ↑ lidocaine: amiodarone, BB, non-DHP CCBs, grapefruit, macrolides, etc Amiodarone Med Guide I: Class III AAD: blocks K channels; broad spectrum (Safe in HF and post MI) BBW: pulmonary toxicity, hepatotoxicity. Use only for life-threatening arrhythmias d/t toxicities. Patients should be hospitalized when loading dose is given. CI: iodine hypersensitivity W: Thyroid (hypo more common), optic neuropathy, photosensitivity (blue skin discoloration), peripheral neuropathy, SJS Cordarone, Nexterone SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, constipation, tremor, DILE (I,D,SE,monitor,food) M: ECG, BP, HR, e-lytes, pulm (X-ray) at BL & annually, LFTs at BL & Q6months, TSH at BL & Q3- 6months, eye exams *Avoid in pregnancy/BF *Non-PVC container for infusions >2H (PVC tubing is ok). 0.22micron filter. Incompatible w/ heparin (flush line) *3A4/P-gp substrate; mod 2C9/2D6 inhibitor | When starting amio, ↓digoxin 50% & ↓warfarin 30-50% | max 20mg simva & 40mg lovastatin | do not use w/ sofosbuvir d/t bradycardia Sotalol I: Class III AAD: AF/AFl BBW: Initiate/↑dose in hospital w/ cont ECG monitoring; CrCl determines dosing interval→ QT Betapace (I,D,SE) prolongation ∝ concentration CI: QTc >450 msec, bronchospastic condition, CrCl <40, K <4 SE: bradycardia, fatigue, bronchoconstriction, HF D: 160mg po bid; CrCl <60: ↓frequency Digoxin I: add-on for HF, AF W: vesicant - avoid extravasation SE: dizziness, mental disturbances M: ECG, BP, e-lytes, renal fxn, digoxin lvl (drawn 12-24H after dose) Toxicity: Initial= N/V, loss of appetite, bradycardia. Severe= blurred/double vision, greenish-yellow halos, confusion, delirium, prolonged PR intervals, arrhythmias ↓K, ↓Mg, ↑Ca : ↑risk of dig toxicity *K+ 4-5 to avoid toxicity *Antidote: Digibind or DigiFab Lanoxin, Digitek (I,W,SE,Tox,D) 125-250 mcg po daily *CrCl <50: ↓ dose or frequency. *Th. Range, HF: 0.5-1 | AF: 0.8-1.2 *↓ dose by 25% when going from po→IV *(+) inotrope, (-) chronotrope P-gp substrate, inhibitors ↑ Dig levels: amiodarone, dronedarone, quinidine, verapamil, erythromycin, clarithromycin, itraconazole, propafenone & many others. ↓dig dose 50% w/ amio or dronedarone. Isotrentinoin Med Guide, iPLEDGE REMS I: severe acne Accutane, Absorica, Amnesteem, Claravis, Myorisan, Sotret, BBW: pregnancy (2 forms of BC, informed consent) Zenatane (I,BBW,SE) *No pregnancy one month before, during & x1 month after tx *Full effect in 3-5 months *SE: dryness Permethrin 5% (Rx) Elimite (I,application) I: head lice, scabies *May repeat in 7 days after initial application Permethrin 1% I: head lice Nix (I,application) *OTC for >1 yoa *May repeat in 7 days after initial application Calcium acetate I: control of hyperphosphatemia (ESRD on dialysis) Phoslyra, Phoslo, Calphron (I,D,SE) D: 1334mg w/ meal SE: GI effects, hypercal Sevelamer I: Hyperphosphatemia (occurs as CKD progresses, & contributes to ↑ PTH which can lead to bone dz/fractures) CI: bowel obstruction Renagel, Renvela (I,CI,W,M,D) Warnings: can ↓ dietary absorption of vits D, E, K and folic acid; consider supplementation Monitor: Ca, PO4, HCO3, Cl, PTH D: 800-1,600mg po TID WF, titrate based on PO4 levels Lanthanum MedGuide: Warning for GI obstruction, sev. constipation I: ↓ serum phosphorus (CKD) SE: N/V/D, stomach pain Fosrenol (I,D,SE) 1500 mg QD (upto 4500mg) with or right after meals Chewable tablets Oral powder - sprinkle on applesauce or similar (does not dissolve in liquids) Cinacalcet: ↑Ca-receptor sensitivity of parathyroid gland: ↓PTH, ↓Ca, ↓PO4 I: Hyperparathyroidism in dialysis pts, parathyroid carcinoma CI: Hypocalcemia Warnings: Caution if h/o seizures Sensipar (I,CI,W,SE,M,D) SE: hypocalcemia, paresthesia, myalgia M: Ca, PO4, PTH D: 30-180mg po daily WF Amphojel, DermaMed (I) Aluminum hydroxide I: antacid, skin protectant TUMS (I)Calcium carbonate I: antacid Calcitriol (Vit D3) Rocaltrol (I,SE) I: hypocalcemia in hypoparathyroidisim, 2ndary hyperparathyroism in CKD SE: excessive vit D, hypercal Drisdol (I) Ergocalciferol (Vit D2) I: hypoparathyroidism Levothyroxine (T4) I: hypothyroidism; myxedema coma (IV) D: 1.6 mcg/kg/day (IBW) with water 60min before BF or QHS (3H after last meal) *If CAD: start 12.5-25mcg QD Euthyrox, Levoxyl, Synthroid, Tirosint, Unithroid (I,D, BBW, CI, SE) BBW: thyroid supplements are ineffective & potentially toxic when used for obesity or weight loss, esp. if euthyroid; high doses ↑ risk of serious or life-threatening effects esp. with anorectic drugs (e.g. sympathomimetic amines) CI: uncorrected adrenal insufficiency SE: ↓BMD; If dose too high: ↑HR, palpitations, sweating, wt loss, arrhythmias, irritability Thyroid desiccated *Natural porcine-derived thyroid with both T3 & T4 *Not preferred, but some feel better using it Armour Thyroid BBW: thyroid supplements are ineffective & potentially toxic when used for obesity or weight loss, esp. if euthyroid; high doses ↑ risk of serious or life-threatening effects esp. with anorectic drugs (e.g. sympathomimetic amines) CI: uncorrected adrenal insufficiency SE: ↓BMD; If dose too high: ↑HR, palpitations, sweating, wt loss, arrhythmias, irritability Liothyronine (T3) I: hypothyroidism; myxedema coma (but IV levothyroxine preferred) D: PO 25mcg QD (25-75 mcg QD maintenance) Cytomel, Triostat (BBW,I,D) BBW: thyroid supplements are ineffective & potentially toxic when used for wt loss, esp. if euthyroid; high doses ↑ risk of serious or life-threatening effects esp. with anorexants (e.g. sympathomimetic amines) CI: uncorrected adrenal insufficiency SE: ↓BMD; If dose too high: ↑HR, palpitations, sweating, wt loss, arrhythmias, irritability Methimazole I: hyperthyroidism D: 5mg po Q8H SE: GI upset, drug-induced lupus erythematosus, hepatitis, agranulocytosis, taste perversion Tapazole (I,D, BBW,SE) BBW: PTU preferred over methimazole in 1ˢᵗ trimester of pregnancy (↑risk of fetal abnormalities from methimazole) Methimazole often recommended for 2ⁿᵈ & 3ʳᵈ trimesters (d/t ↑risk of liver toxicity from PTU) Propylthiouracil MedGuide I: hyperthyroidism, thyroid storm D: 50-150mg po Q8H PTU (BBW,I,D,SE) SE: GI upset, drug-induced lupus erythematosus, hepatitis, agranulocytosis, taste perversion BBW: hepatotoxicity; preferred in 1ˢᵗ trimester of pregnancy (↑risk of fetal abnormalities from methimazole) Methimazole often recommended for 2ⁿᵈ & 3ʳᵈ trimesters (d/t ↑risk of liver toxicity from PTU) Mesalamine (5-ASA) Canasa: Suppository (retain ≥1-3H) Rowasa: Enema (retain ≥30min) Canasa Asacol HD, Lialda: ER tabs Rowasa Apriso, Delzicol, Pentasa: ER caps Asacol HD, Lialda Apriso, Delzicol, Pentasa I: ulcerative colitis, induction tx for acute flares, and maintenance (I, formulations) Counseling: suppositories/enemas stain fabric, flooring, painted surfaces, marble, granite, vinyl & enamel Imodium Loperamide Diphenoxylate/atropine, CV Lomotil I: Diarrhea D: 1-2 tab QID AC Pepto-Bismol Bismuth subsalicylate Kaopectate Bismuth subsalicylate Metamucil Psyllium Nujol Mineral oil Milk of Magnesia (I) Magnesium hydroxide I: antacid, laxative Miralax (I) Polyethylene glycol I: constipation Glycolax Polyethylene glycol Pramlintide (SQ) MedGuide SymlinPen 120, SymlinPen 60 (BBW,I) BW: hypoglycemia I: T1DM, T2DM Lactulose Constulose, Enulose, Gemnerlac, Kristalose (I,D) I: constipation, portal systemic encephalopathy, overt heapatic encephalopathy D: 16.7g (25mL) Q1-2h until at least 2 loose stools, titrate to 2-3 bowel movements Bisacodyl Dulcolax (I,D) I: Bowel cleansing (enema only), constipation D: PO 5-15mg QD; rectal 1 enema QD Exlax, Senokot, (I)Senna I: constipation Docusate sodium (PO/rectal) Colace (I,ROA,D) I: stool softener D: PO 240mg QD; rectal 1 enema QD-TID Metformin [Biguanide] Max PO: 2g - 2.55g per day SE: lactic acidosis, VitB12 deficiency Glucophage, Glumetza, Fortamet, Riomet CI: eGFR<30, acute or chronic metabolic acidosis (includes DKA) BBW: lactic acidosis *Take WITH FOOD to ↓GI sxs Glipizide (PO) [SU] PO IR: 5mg 30min before BF (max 40mg/d); doses >15mg should be divided BID PO XL: 5mg with BF (max 20mg/d) Glucotrol SE: hypogly, weight gain, hemolytic anemia in G6PD deficiency CI: DKA, sulfa allergy Glyburide (PO) [SU] D: 2.5-5mg with BF (max 20mg/d) SE: hypogly, weight gain, hemolytic anemia in G6PD deficiency Micronase, Diabeta, Glynase CI: DKA, sulfa allergy On Beers List Renal elimination of active metabolite Glimepiride (PO). [SU] D: 1-2mg with BF (max: 8mg/d) SE: hypogly, weight gain, hemolytic anemia in G6PD deficiency Amaryl (I,D,SE) CI: DKA, sulfa allergy On Beers List XL Formulation - OROS system - ghost cap Nateglinide (PO) [Meglitinide] Starlix D: 60-120mg TID 1-30 min before meals SE: hypogly, weight gain Repaglinide (PO) [Meglitinide] D: 0.5-2 mg 15-30 min before each meal (TID AC) Max: 16mg/day Prandin SE: hypogly, weight gain CI: concurrent use of gemfibrozil Pioglitazone [TZD -PPARgamma agonist] D: 15-30mg QD (max 45mg/d) Med Guide Actos (BBW,I,D,SE) BBW: Can cause or exacerbate HF CI: NYHA Class III/IV HF SE: bladder cancer, edema, weight gain, fractures, hepatotoxicity Canagliflozin [SGLT2 inhibitor] D: 100mg before BF (max 300mg/d) Med Guide BBW: ↑ risk of amputations Invokana CI: eGFR<30, ESRD or dialysisterm SE: AKI, UTI, keto acidosis, weight loss, ↑ urinary frequency, volume depletion, thirst, hypotension, ↑ LDL, fractures, hyperkalemia ↓ CV risk in pts with T2DM & ASCVD Rosiglitazone (TZD) Med Guide I: T2DM, ↓A1c 0.5-1.5% BBW: Can cause/exacerbate HF, ↑ risk of MI Avandia (BBW,I,D,SE) CI: NYHA Class III/IV HF SE: edema, weight gain, HF, fractures, hepatotoxicity, ovulation in premenopausal women D: 4-8mg QD (max 8mg/d) Dapagliflozin [SU] D: 5mg QAM (max 10 mg/d) Med Guide Farxiga CI: eGFR<30 SE: AKI, UTI, ketoacidosis, weight loss, ↑ urinary frequency, volume depletion, thirst, hypotension, ↑ LDL, risk of bladder cancer Empagliflozin [SU] D: 10 mg QAM (max 25 mg/d) Med Guide Jardiance CI: eGFR<30 SE: AKI, UTI, DKA, weight loss, ↑ urinary frequency, volume depletion, thirst, hypotension, ↑ LDL ↓ CV risk in pts with T2DM & ASCVD Sitagliptin [DPP4 inhibitor] Med Guide T2DM, ↓A1c 0.5-0.8% Januvia Warnings: Acute pancreatitis, arthralgia SE: peripheral edema *CrCl 30-49: 50mg; CrCl <30: 25mg Saxagliptin [DPP4 inhibitor] T2DM, ↓A1c 0.5-0.8% W: Acute pancreatitis, arthralgia, risk of HF Onglyza SE: peripheral edema 2.5-5mg po QAM (eGFR <45: 2.5 mg daily) Linagliptin [DPP4 inhibitor] T2DM, ↓A1c 0.5-0.8% W: Acute pancreatitis, arthralgia Tradjenta SE: peripheral edema 5mg po QAM (no renal dose adj.) Alogliptin T2DM, ↓A1c 0.5-0.8% W: Acute pancreatitis, arthralgia, HF, hepatotoxicity Nesina SE: peripheral edema 25mg po QAM (CrCl 30-59: 12.5mg; CrCl <30: 6.25mg) Exenatide [GLP1 agonist] Med Guide T2DM, ↓A1c 0.5-1.5% Warnings: pancreatitis; avoid in severe GI dz, including gastroparesis Byetta SE: nausea, weight loss D: 5 mcg SC BID within 60 min meals x1month; can ↑ to 10 mcg SC BID *Discard pen after 30days *ESRD or CrCl <30: not recommended Exenatide [GLP1 agonist] Med Guide T2DM, ↓A1c 0.5-1.5% BBW: risk of thyroid C-cell carcinomas CI: personal or family h/o thyroid cancer or multiple endocrine neoplasia (MEN2) Bydureon, Bydureon BCise Warnings: pancreatitis; avoid in severe GI dz, including gastroparesis SE: nausea, weight loss, serious injection-site rxns D: 2mg SC once weekly ESRD or CrCl <30: not recommended Liraglutide [GLP1 agonist] Med Guide T2DM (↓A1c 0.5-1.5%), ↓ CV risk in diabetics with ASCVD BBW: risk of thyroid C-cell carcinomas CI: personal or family h/o thyroid cancer or multiple endocrine neoplasia (MEN2) Victoza Warnings: pancreatitis; avoid in severe GI dz, including gastroparesis SE: nausea, weight loss Stable at room temp x30 days D: 0.6 mg SC daily x1week, then 1.2 mg SC daily; can ↑ to 1.8 mg SC daily Saxenda for weight loss Dulaglutide Med Guide T2DM, ↓A1c 0.5-1.5% BBW: risk of thyroid C-cell carcinomas Trulicity CI: personal or family h/o thyroid cancer or multiple endocrine neoplasia (MEN2) Warnings: pancreatitis; avoid in severe GI dz, including gastroparesis SE: nausea, weight loss D: 0.75mg SC once weekly, can ↑ to 1.5mg SC once weekly Lixisenatide T2DM, ↓A1c 0.5-1.5% W: pancreatitis; avoid in severe GI dz, including gastroparesis SE: nausea, weight loss Adlyxin (I, W, SE, D) 10mcg SC daily within 60min before BF x14days then ↑ to 20mcg daily eGFR <15: not recommended Acarbose (PO) I: T2DM D: 25mg TID with the first bite of each meal (max 100mg TID) Precose (I,D) Glucose tablets req'd to treat hypoglycemia; cannot be treated with sucrose (table sugar, fruit juice, candy) Miglitol (PO) I: T2DM Glucose tablets req'd to treat hypoglycemia; cannot be treated with sucrose (table sugar, fruit juice, Glyset (I,D) candy) D: 25mg TID with first bite of each meal (max 100mg TID) Lispro (rapid acting insulin ) *Give up to 15min before or immediately after meals Onset: ~15 min Humalog, Admelog Peak: ~1H DOA: 2-3H Refrigerate; stable at room temp for 28 days Aspart (rapid acting insulin) *Give up to 15min before or immediately after meals Novolog, Fiasp Onset: 10-30min Peak: 0.5-3H DOA: 3-5H Apidra Glulisine (rapid acting) **** Regular insulin (short-acting) I: T1DM, T2DM (SQ) Give 30 min before meals *Insulin of choice for IV solutions, including TPN Humulin R *Available without Rx Onset: 15-30 min Peak: 2.5-5H DOA: 4-12H Regular insulin (short-acting) Novolin R Onset: 15-30 min Peak: 2.5-5H DOA: 4-12H NPH (intermediate acting insulin) *Cloudy appearance *Can mix with rapid or short acting insulins, draw up rapid or short acting insulin first (clear before cloudy) Novolin N *Available without Rx Onset: 1-2H Peak: 4-12H DOA: 14-24H NPH (intermediate acting insulin) *Cloudy appearance *Can mix with rapid or short acting insulins, draw up rapid or short acting insulin first (clear before cloudy) Humulin N *Available without Rx Onset: 1-2H Peak: 4-12H DOA: 14-24H Glargine -long acting insulin *acidic pH: can sting upon injection *Do not mix with other insulins Lantus, Toujeo, Basaglar Onset: 3-4H (Toujeo: 6H) Peak: N/A DOA: ≥24H Detemir -long acting insulin *If given once daily, dose with evening meal or qhs *Do not mix with other insulins Levemir (I,D,SE) Onset: 3-4H Peak: N/A DOA: 6-23H (dose-dependent) Colchicine (PO) Med Guide Colcrys, Gloperba, Mitigare (I,D) I: Gout Ppx: 0.6mg QD-BID (max 1.2mg/d) Tx: 1.2mg at first sign of flare, in 1H 0.6mg (max 1.8mg on day 1), then 0.6mg QD-BID until flare resolves Allopurinol - XO inhibitor, ↓ UA production I: Chronic management of gout (ppx of future attacks) W: HLA-B*5801 testing in Asians: ↑risk of SJS; BM suppression, hepatotoxicity SE: Rash, acute gout attacks, nausea, diarrhea, ↑LFTs Aloprim, Zyloprim (I,W,SE,D) Start: 100mg po once daily after a meal (to ↓nausea) ↑by 100mg/day q2-5wks until UA <6mg/dL *doses >300mg should be divided BID *max 800mg/day Ppx for acute gout flares (NSAIDs or colchicine) recommended for first 3-6 months Probenecid I: Gout: ↑ uric acid excretion W: Precipitates acute gout (Colcrys/NSAID x3-6months); avoid in G6PD deficiency 250mg po BID x 1-2wks f/b 500mg BID (max 2g/d) Benemid (I,D) *Avoid in CrCl <50 Probenecid ↓ renal CL of other meds: - Beta lactams: PCNs/Cephs/Carbapenems - Methotrexate - Salicylates Gels: apply at same time each morning; flammable until dry. ⋄1% - upper arms, shoulders and/or abdomen ⋄1.62% should only be applied to upper arms or shoulders (not the abdomen) BBW: secondary exposure to testosterone in children can occur causing virilization; children should AndroGel avoid contact w/ any unwashed or unclothed application sites CI: breast/prostate cancer, pregnancy, breast-feeding W: ↑ risk of breast/prostate ca, CV events, VTE, dyslipidemia, gynecomastia HI, priapism, may worsen BPH SE: ↑ appetite, ↑ Scr, sensitive nipples, acne, edema, hepatotoxicity, ↓ sperm count Alendronate Med Guide Fosamax, Binosto (I,D,SE) I: osteoporosis D: PO 70mg Qwkly or 10mg Qd (TX); PO 35mg Qwkly or 5mg QD (prevention) Bone fractures, bone/joint/muscle pain, GI irritation, hypocal, ocular effects, ONJ Ibandronate (PO/IV) MedGuide I: Osteoporosis in postmenopausal females Boniva (food,I,D,SE) SE: bone fx, bone/joint/muscle pain, GI irritation, ↓Ca , ONJ 150mg po once monthly or 3mg IV q 3 months *take in upright position with full glass water, avoid lying down for 60 min (↓GI effects) Zoledronic acid MedGuide I: Osteoporosis ppx/tx (Reclast); Hypercalcemia of malignancy (Zometa) Zometa, Reclast (IV) (I;D;SE) SE: bone fx, ↓Ca, MSK pain, ocular infection, ONJ Reclast: Ppx: 5mg IV q 2 years; Tx: 5mg IV every year Zometa: IV 4mg Q3-4wks (Zometa) Risedronate Med Guide I: osteoporosis 5mg daily or 35mg weekly or 150mg monthly Actonel, Atelvia (I,D) Atelvia (delayed release risedronate) requires an acidic gut for absorption; H2RAs and PPIs should be avoided completely *Only oral bisphosphonate formulation that should be taken immediately after BF (only available as 35mg, once weekly) Raloxifene: SERM MedGuide I: tx/ppx of osteoporosis in postmenopausal women; breast cancer prophylaxis in postmenopausal women Evista (BW,I,D) BBW: ↑VTE risk CI: h/o DVT/PE SE: hot flashes, night sweats, viginal spotting/dryness, ↓ libido, ↓BMD (Ca/vit D supp) D: 60mg po QD Miacalcin, Fortical nasal spray (I)Calcitonin I: hypercal, postmenopausal osteoporosis Yaz, Yasmin, Gianvi, Jasmiel, Loryna, Nikki, Ocella, Syeda, Zarah, Estrogen/progestin Zumandimine (BW) BW: smoking+ CV events Levonorgestrel I: emergency contraception Plan B (I,D) D: 2 dose regimen= 0.75mg ASAP within 72H, then 0.75mg 12H after 1st dose; 1 dose regimen= 1.5mg ASAP within 72H Ulipristal Ella (I,D) I: emergency contraception D: 30mg ASAP, but within 120H (5 days) Premphase, Prempro (BW) Conjugated estrogens BW: endometrial cancer, CV disease, breast cancer, dementia Premarin (BW) Conjugated estrogens BW: endometrial cancer, CV disease, breast cancer, dementia Estradiol Alora, Climara, Delestrogen, Divigel, Dotti, Elestrin, Estrace, BBW: endometrial cancer, CV disease, breast cancer, dementia Evamist, Femring, Minivelle, Vivelle-dot (BW) I: vasomotor sx of menopause including hot flashes & night sweats Provera, depo-provera (BW) Medroxyprogesterone BW: CV disorders (DVT/PE, stroke, MI), breast cancer, dementia, bone loss) Cetirizine Zyrtec (I,D) I: allergic rhinitis/conjunctivitis, uritcaria D: 10mg QD Levocetirizine Xyzal (I,D) I: chronic idiopathic uritcaria, allergic rhinitis D: 5mg QD (PM) (upto 10mg BID) Loratadine Claritin (I,D) I: allergic rhinitis, uritcaria D: 10mg QD or 5mg BID Desloratadine Clarinex (I,D) I: chronic itiopathic urticaria, allergic rhinitis D: 5mg QD Fexofenadine Allegra (I,D) I: upper resp. allergy D: 60mg BID (max 120mg/d) or 180mg QD Diphenhydramine (PO/IM/IV) Benadryl (I,D) I: allergy, cold, motion sickness, uritcaria D: 25mg Q4-6H or 50mg Q6-8H Chlorpheniramine (OTC) I: 1st Gen Anti-HM: allergy, urticaria/pruritus, N/V, motion sickness Chlor-Trimeton (I,S,SE) D: IR 4mg Q4-6H; ER 12mg Q12H (max 24mg/24H) SE: CNS depression Hydroxyzine pamoate (PO/IM) I: antiemetic, anxiety, pruritis, hives Vistaril (I,D,SE,ROA) D: IM 25-100mg/d SE: CNS depression, QT risk Hydroxyzine HCl (IM/PO) I: antiemetic Atarax (ROA,I,D,SE) D: Im 25-100mg/d SE: CNS depression, QT risk Promethazine (PO/IM/IV) I: allergies, motion sickness, N/V, sedation BBW: resp depression, severe tissue injury (inj) Phenergan, Phenadoz, Promethegan (ROA,BW,I,D) CI: children <2yo D: 25mg QHS or 12.5mg before meals and at bedtime Pseudoephedrine (PO) I: nasal congestion Sudafed (I,D,max) D: IR 60mg Q4-6H; ER 120mg Q12H or 240mg Q24H (max) 3.6g/d limit or 9g/month limit Famotidine I: GERD Tablets/Oral Suspension/IV solution SE: B12 def w/ prolonged use, HA, dizziness, drowsiness Pepcid (I,D,SE) OTC: 10 mg po BID prn Rx: 20 mg po BID x 6 wks Ranitidine Zantac (I,D) I:GERD D: 75mg BID prn (upto 150mg BID for 2 weeks) Nizatidine (Rx only) H2RA: GERD, GI ulcer Axid (I,D) 150mg po BID x12wks Cimetidine I: duodenal ulcer, gastric ulcer, GERD, heartburn tagamet (I,D,SE) D: 300mg QID or 800mg QHS or 400mg BID (up to 8wks) SE: confusion, VItB12 deficiency Omeprazole (cap/tab) Med Guide I: GERD, H. Pylori, PUD Prilosec (I,D,SE) D: 10-40mg QD; H. pylori 20-40mg BID SE: C. Diff, fractures, ↓ Mg , VitB12 +Aspirin (Yosprala) - CV event prevention in pts at high GI risk Esomeprazole (cap, IV) Med Guide Nexium (roa,I,D,SE) I: erosive esophagitis, H. Pylori, GERD D: 20-40mg QD fo 4-8wks, then 20mg QD SE: C. Diff, fractures, hypomag, VitB12 Dexilant Dexlansoprazole I: GERD - only PPI that can be taken without regard to meals Lansoprazole (tab/cap) Med Guide I: GERD, PUD, H. Pylori Prevacid (I,SE,D) SE: C. Diff, fractures, hypomag, VitB12 Rx: 15mg po daily x8wks (max 30mg/d) OTC 15mg po daily x14days (max 15mg/d) Pantoprazole (IV, tab) MedGuide Protonix (I,D,SE) I: GERD D: 20mg QD (up to 40mg QD) SE: C. diff, fractures, GI infection, hypomag, VitB12 deficiency Rabeprazole (tab, sprinkle) MedGuide Aciphex (ROA,I,D,SE) I: duodenal ulcer, GERD, H. Pylori D: 20 mg QD <4-8 weeks SE: C. Diff, fractures, GI infection, hypomag, VitB12 deficiency Sucralfate Carafate (I,D) I: duodenal ulcer D: susp./tab 1 g QID for 4-8wks, then 1 g BID Misoprostol BW: women of child bearing potential (birth defects, abortion) Cytotec (BW,I,D,SE) I: NSAID-induced gastric ulcers D: 200mcg QID PO SE: abortifacient Prochlorperazine (tab/IM/IV/suppository) I: DA-R antagonist for CINV BBW: ↑mortality in elderly w/ dementia Compro, Compazine (I, BBW,W,SE, D) W: Avoid use in Parkinson's SE: sedation, NMS, QT prolongation, acute EPS, can ↓ seizure threshold 10mg PO/IV Q6H PRN (max 40mg/d) Metoclopramide (inj, tab, ODT, oral soln) Med Guide I: CINV, GERD w/ gastroparesis MOA: DA antagonist, 5HT-R blocker (chemoreceptor zone, higher doses), enhances GI motility & ↑LES tone BBW: Tardive dyskinesia (irreversible) - do not use >12wks CI: GI obstruction, perforation or hemorrhage, seizures, pheochromocytoma, combined with other drugs likely to cause EPS Reglan (I,MOA,BBW,W,SE,D) Warnings: EPS including acute dystonia, parkinsonian-like sx, rare neuroleptic malignant syndrome, depression SE: drowsiness, hypertension, pro-arrhythmic, diarrhea D: 10-15mg QID 30min before meals & at bedtime *CrCl <40: ↓dose 50% *Not recommended for use >12wks *Avoid use in pts with Parkinsons Ondansetron (PO/IM/IV) *IV doses >16mg not recommended (QT risk) Zofran, Zuplenz (ROA,I,D,SE) I: chemo-induced N/V D: 8mg BID PO;8mg or 0.15mg/kg (max 16mg/dose) SE: QT risk, SS Filgrastim I: AML, bone marrow transplant, chemo induced myelosuppression, hematopoietic radiation Neupogen, Granix, Nivestym, Zarxio (I,D) (Neupogen) D: SQ 10mcg/kg QD Pegfilgrastim Neulasta, Fulphila, Udenyca, Ziextenzo (I,D) I:prevention of chem induced neutropenia; hematopoietic radiation (neulasta) D: SQ 6mg Epoetin alfa (SQ/IV) Med Guide I: CKD or Cancer (on chemo) when Hgb <10 Given 3x/week IV/SC. Titrate based on Hgb levels; do not ↑ dose more frequently than once every 4wks. BBW: ↑risk of death, MI, stroke, VTE, thrombosis; use lowest effective dose to ↓ blood transfusions Epogen, Procrit (I, BBW) -Cancer: tumor progression or recurrence; not indicated when anticipated outcome is cure; d/c when Retacrit-biosimilar chemo completed -CKD: ↑MACE when Hgb >11 (↓ or stop when Hgb >10 for non-HD, and >11 for HD pts) -Peri-surgical: DVT ppx recommended d/t ↑DVT risk CI: uncontrolled HTN; IV route recommended for pts on HD Monitor: H/H, TSAT, serum ferritin, BP Darbepoetin Med Guide I: CKD or Cancer (on chemo) when Hgb <10 IV/SC: given every 1-4 weeks (t½ ix 3x longer than epoetin alfa). Titrate ba