Top 200

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Drugs.com Top 200 + dosing

Aricept

Donepezil ; Alzheimer's

MOA: ACH-I, inhibits centrally-active acetylcholinesterase, the enzyme responsible for hydrolysis (breakdown) of acetylcholine, which results in increased ACh

Dose:
- 5-10 mg QHS for mild-mod disease (start at 5 mg due to risk of dizziness, falls, nausea), given at night to help w/ nausea (all other Alzheimer's PO meds are dosed BID, or Qdaily if long-acting)
- 23 mg for advanced disease (minimal additional benefit)
- Aricept ODT 5 or 10 mg also available (recommend to decrease GI side effects)

Side effects:
- **GI: N/V, loose stools
- Bradycardia, fainting

Drug interactions:
- Use caution w/ drugs that can lower HR (beta blockers, diltiazem/verapamil, digoxin) and w/ drugs that cause dizziness (APs, antihypertensives, alpha blockers, skeletal muscle relaxants, hypnotics, opioids, etc.) due to the risk of dizziness and falls
- Drugs that have anticholinergic effects can reduce the efficacy of this medicine

Exelon, Exelon Patch

Rivastigmine ; Alzheimer's

MOA: ACH-I, inhibits centrally-active acetylcholinesterase, the enzyme responsible for hydrolysis (breakdown) of acetylcholine, which results in increased ACh

Dose: 1.5-6 mg BID WITH FOOD (start at 1.5 mg twice daily)
- 4.6 & 9.5 mg/24 hr patch (recommend Exelon Patch to decrease GI side effects)
- Apply patch to upper/lower back, upper arm, or chest; rotate application site. After 24 hrs, remove the patch. Do not use the same site w/in 14 days.

Side effects:
- **GI: N/V, loose stools
- Bradycardia, fainting

Razadyne, Razadyne ER

Galantamine ; Alzheimer's

MOA: ACH-I

Dose: 4-24mg BID
- ER: start at 8mg Qdaily, THEN increase to 16-24mg

*Same effects as Aricept and Exelon

Namenda, Namenda XR

Memantine ; Alzheimer's

MOA: blocks NMDA which inhibits glutamate from binding to NMDA receptors and decreases abnormal activation

Dose:
- IR First start: 5mg once daily (titrate weekly) to 10mg BID
- XR First start: 7mg daily (titrate weekly) to 28mg Qdaily (XR caps can be opened & sprinkled in applesauce) WITH FOOD
- Mostly excreted in urine; do not exceed 5 mg BID if CrCl < 30 mL/min
- Namenda solution also available (do not mix w/ water or other liquids)

Side effects:
- Dizziness, diarrhea/constipation, HA
- Rare: flu-like symptoms, arthralgia, UTIs, urinary retention, small risk seizures

Nexium

Esomeprazole ; GERD

Dose: 20, 40 mg
- Granules for susp 10, 20, 40 mg/pk
- Injection 20, 40 mg/mL

Administration:
- Capsules can be opened and mix w/ 1 tbsp applesauce - eat stat
- Granules: mix w/ 1 tbsp water, leave 2-3 min to thicken, rinse
- Can mix capsule contents w/ 50ml water for NG tube admin

Side effects:
- CNS: HA, dizziness, anxiety
- Can increase risk of C.diff GI infections
- Increased risk of osteoporosis/fracture w/ long-term use
- Can increase INR if using warfarin (monitor)
- Can increase risk of pneumonia in hospitalized pts

Drug interactions:
- Caution w/ concurrent use of itraconazole, ketoconazole, calcium carbonate and iron, due to reduced absorption from increased pH
- PPIs inhibit 2C19: do not use w/ erlotinib (Tarceva, TKI), nelfinavir, mesalamine; and caution w/ 2C19 substrates: MTX, phenytoin, saquinavir, voriconazole and warfarin. This may prevent conversion of clopidogrel to the active form.

Lipitor

Atorvastatin ; Hyperlipidemia ; Preg Categ X

MOA: reduce cholesterol by reducing the activity of HmG-CoA reductase, an enzyme in the liver that catalyzes the rate-limiting step in cholesterol synthesis

Dosage forms: 10-, 20-, 40-, and 80-mg tablet

Dose: 10-80 mg (Equivalent dose = 10 mg)
- Do not exceed 10 mg/d simvastatin in pts taking cyclosporine, danazol, or gemfibrozil
- Do not exceed 20 mg/d simvastatin in pts taking amiodarone or verapamil
- Do not exceed 40 mg/d simvastatin in pts taking diltiazem

Drug interactions (for SAL - Simvastatin, Atorvastatin, Lovastatin) - all 3A4 substrates
- Increased risk of muscle damage w/ amiodarone and other 3A4 inhibitors such as azole antifungals (flu, itra, keto, posa, and vori), grapefruit products, cyclosporine, diltiazem, verapamil, macrolide antibiotics, protease inhibitors, telithromycin, etc.

Plavix

Clopidogrel ; Antiplatelet

Black-box: decrease effectiveness in poor CYP2C19 metabolizers. Effectiveness depends on the activation to an active metabolite by 2C19. Tests to check 2C19 genotype can be used as an aid in determining a therapeutic strategy. 2C19 inhibitors (omeprazole, esomeprazole, fluoxetine, etc.) may block conversion to active drug.

MOA: inhibitor of the P2Y12 receptor on platelets

Indication: for all pts w/ ACS, unless pt is going for CABG surgery; antiplatelet in angina when ASA in CI; antiplatelet for stroke prevention

Dose:
- LD: 300-600 mg
- MD: 75 mg daily
- Dose for stroke prevention: 75 mg daily

Side effects: bleeding, rash, diarrhea
Rare, but serious: Thrombotic thrombocytopenic purpura (TTP) - have pts report fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, or neurological changes.

Contraindications: active pathological bleed (eg. PUD, ICH)

Drug interactions: clopidogrel is a prodrug metabolized by CYP2C19
- Avoid use, if possible, w/ other agents that increase bleeding risk, including other antiplatelets (although clopidogrel is generally used w/ low-dose ASA), NSAIDs, anticoagulants, ginkgo, etc.
- Avoid concomitant use w/ strong/mod 2C19 inhibitors (omeprazole, esomeprazole, other PPI's, cimetidine, etravirine, efavirenz, fluconazole, ketoconazole, voriconazole, fluoxetine, fluvoxamine, modafinil, topiramate, etc.)

Advair Diskus

Salmeterol (Serevent Diskus) + fluticasone propionate ; LABA + inhaled corticosteroid

Black-box: increase risk of asthma-related deaths. Do not use LABA as monotherapy; need to have persistent asthma pts on long-term control therapy.

Indication: Asthma, COPD
- Indicated for ages >/4

Dose: usual dose is 1 inhalation BID (Q12h), except the HFA is 2 inhalations BID
- Use 30 mins before exercise for EIB

Side effects:
- Tremor, tachycardia
- Hypokalemia, QT-prolongation
- Dysphona, oral candidiasis (thrush), cough, hoarseness, URTI's (rinse mouth/throat w/ warm water and spit out or use a space device)

Counseling:
- Rinse mouth w/ water after breathing-in the medicine. Spit the water out.
- Always keep the diskus in a dry place.

OxyContin IR and CR

Oxycodone IR and CR (CII)

BOXED warning: healthcare provider should be able to report abuse, misuse and diversion. New formulation called "Oxycontin OP" contains polyethylene oxide to supposedly deter abuse - substance forms a gel when mixed w/ water.

Dose:
- IR: 5, 10, 15, 20, 30 mg
- CR: 10, 15, 20, 30 (60, 80, 160 mg only for opioid-tolerant pts)
- Avoid high fat meals w/ higher doses

Drug interactions: 3A4 substrate
- Avoid use w/ 3A4 inhibitors - will increase oxycodone levels

Abilify

Aripiprazole ; 2nd-gen AP (Schizo, psychosis, bipolar, adj tx for depression) ; Preg Categ C

ALL APs (black-box):
- increase mortality in elderly pts w/ dementia-related psychosis.
- suicidality if used as adjunctive tx for resistant depression (olanzapine, aripiprazole).

MOA: DA and 5-HT receptor blocker

Dose: 10-30 mg Qdaily
- Adj tx for depression: 2-5 mg/d, can increase to 15 mg/d

Class side effects:
- Sedation
- QT-prolongation risk
- NMS risk - less than typicals
- EPS risk - less than typicals

Special side effects:
- Anxiety, insomnia
- Constipation
- No/less weight gain
- CYP3A4 substrate

Singulair

Montelukast

MOA: Leukotriene receptor antagonist (LTRA) of leukotriene D4 (LTD4). Helps decrease airway edema, constriction and inflammation.

Indication: Asthma, COPD, allergic rhinitis (not any more effective than antihistamines or pseudoephedrine)

Dose: 10 mg QD, take in the evening (take 2 hrs before exercise for EIB)
- Age 6 mos - 5 years: take 4 mg daily
- Age 5-14 years: take 5 mg daily

Caution: neuropsychiatric events have been reported. Pts should notify doctor if develop signs of aggressive behavior, hostility, agitation, depression, suicidal thinking.

Side effects:
- HA, dizziness
- Abdominal pain, increase LFTs
- URTIs, Churg-Strauss syndrome (rare)

Drug interactions: MAJOR 2C9 substrate

Seroquel, Seroquel XR

Quetiapine ; 2nd-gen AP (Schizo, psychosis, bipolar) ; Preg Categ C

MOA: DA and 5-HT receptor blocker

Dose: 400-800 mg, divided BID
- XR: Take at night w/o food, or light meal (food increases absorption) 200-400 mg, once daily

Special side effects:
- Orthostasis
- Eye exam for cataracts is recommended at beg of tx
- Weight gain
- Increase lipids/glucose
- CYP3A4 substrate

Crestor

Rosuvastatin ; Hyperlipidemia ; Preg Categ X

MOA: statin

Dosage form: 5-, 10-, 20-, 40-mg tablet

Dose: 5-40 mg (Equivalent dose = 5 mg)
- Dosage adjustment required in pts w/ severe renal impairment (CrCl < 30 mL/min)

Drug interactions:
- May increase INR for pts taking warfarin; monitor
- Cyclosporine can increase rosuvastatin, do not exceed 5 mg of rosuvastatin
- With the combination of lopinavir and ritonavir, do not exceed 10 mg
- Gemfibrozil: combo should be avoided

Cymbalta

Duloxetine ; SNRI
- Depression, GAD
- Peripheral neuropathy

Contraindication: uncontrolled narrow-angle glaucoma

Dose:
- Depression: 40 mg (20 mg BID), up to 60 mg
- Neuropathic pain: 30-60 mg/d

SNRI class effects: increase BP, HR, sexual side effects (20-50%) include decreased libido, ejaculation difficulties, anorgasmia, increased sweating (hyperhydrosis), restless leg

Special side effects:
- Nausea, dry mouth, somnolence, fatigue, decreased appetite
- 2D6 inhibitor

Actos

Pioglitazone ; diabetes

Black-box: may cause or exacerbate HF
FDA "early" alert (2010) - possible risk bladder cancer

Contraindications: HF NYHA 3 or 4

MOA: Thiazolidinedione - peroxisome proliferator-activated receptor y agonists; increases peripheral insulin sensitivity (increases insulin entry into muscle cells, insulin sensitizers)

**Dose: 15-45 mg once daily w/ or w/o food (MAX: 45 mg daily)

Side effects:
- Peripheral edema, weight gain, macular edema, CHF, increased fracture risk
- Hepatic: when ALT > 3x normal or s/sx hepatitis, d/c therapy. Monitor liver enzymes before start of therapy and periodically thereafter.
- Cardiovascular risk: use caution in CHF, can cause fluid retention, peripheral edema, HF decompensation - contraindicated in NYHA 3 or 4
- Pioglitazone is better for lipids (increases HDL), while Rosiglitazone increases HDL AND LDL

Lexapro

Escitalopram
Indication: Depression, GAD
Preg Categ

MOA: SSRI

Dose: 10 mg/d (can increase to 20 mg/d)

Class effects:
- Sexual side effects (20-50%): include decreased libido, ejaculation difficulties, anorgasmia
- GI effects
- HA
- SIADH
- Restless leg syndrome

Drug interactions:
- Increased bleeding risk if taken concurrently w/ warfarin, dabigatran, antiplatelets or other agents that increase bleeding risk
- MAOIs and hypertensive crisis: 2 wks washout period if going to or from a MAOI

Special effects: 3A4 substrate

Zyprexa

Olanzapine ; 2nd-gen AP/Atypical (Schizo, psychosis, bipolar, adj tx for depression)
- Preg Categ C

MOA: antagonism of dopamine and serotonin type 2 receptor sites

Dose: 10-20 mg QHS (taking at night b/c it is long-acting and sedating)
- Zyprexa Zydis (Zyprexa oral disintegrating tablet)

Special side effects: high metabolic risks
- Weight gain
- Increase lipids/glucose

Spiriva

Tiotropium ; Long-acting anticholinergic

MOA: Anticholinergics block the action of acetylcholine and decrease cyclic guanosine monophosphate (cGMP) at parasympathetic sites in bronchial smooth muscle causing bronchodilation.

Indication: COPD

Dose: 1 capsule inhaled daily via the Handihaler device (requires 2 puffs)
- Do NOT swallow capsules of tiotropium
- Always store capsules in the sealed blisters. Remove capsule right before use. If more capsules are opened to air, they should not be used and should be thrown away.
- Clean the HandiHaler device w/ warm water. Check for any powder buildup.

Caution: use in pts w/ myasthenia gravis, narrow-angle glaucoma, benign prostatic hyperplasia, or bladder neck obstruction
- Combivent contains soya lecithin - caution in pts w/ a peanut allergy

Side effects: dry mouth (much more common w/ tiotropium than w/ ipratropium, which is short-acting), URTIs, pharyngeal irritation, etc.

Lantus

Insulin Glargine ; diabetes
Basal insulin, 24-hr insulin

Preg Categ C (should not be recommended in gestational diabetes)

- Dosed once or twice daily. If dosed once daily, they are usually given at bedtime to ensure no mixing occurs w/ other insulins (which are usually given at mealtimes)
- Onset of action: ~1 hr
- Duration: ~24 hrs and DO NOT peak

Side effect: may sting a little when injecting

Lyrica

Pregabalin (CV) ; Preg Categ C
- Anticonvulsant (used as adj tx for partial seizures)
- Neuropathic pain
- Anxiety (produces slight euphoria, which can help pts w/ anxiety)

MOA: binds to voltage-gated Ca2+ channels w/in the CNS, inhibiting excitatory NT release.

Dose: start 75 mg BID, up to 300 mg/d
- Decrease dose if CrCl < 60 mL/min

Side effects:
- Dizziness, somnolence, blurred vision
- Slight euphoria
- Peripheral edema/weight gain

Effexor, Effexor XR

Venlafaxine
Indication: Depression, GAD, PD, SAD
Preg Categ

MOA: SNRI

Dose: 150-375 mg
- Different generics of venlafaxine - check orange book

Special side effects:
- GI effects (use XR if venlafaxine IR causes GI issues)
- Increase diastolic BP (usually seen at doses of 100-300 mg/d), increased sweating
- Insomnia

3A4 substrate

Concerta

Methylphenidate; ADHD ; Preg Categ

MOA: stimulant

Dose: 18, 27, 36, 54 mg ER tabs
- OROS system: capsule's outer coat dissolves fast to give immediate action, and the rest is released slowly (provides IR/ER release)
- Daytrana (Methylphenidate patch): applied each morning to the hip
- Concerta LA are all QAM

Levaquin

Levofloxacin ; antibiotic ; Preg Categ C

Black-box: tendon inflammation and/or rupture (risk is increased w/ concurrent corticosteroid use, organ transplant pts, and pts > 60yo)

MOA: Fluoroquinolone - inhibits bacterial DNA topoisomerase IV and inhibits DNA-gyrase (topisomerase II), promotes breakage of double-stranded DNA.
- Bactericidal, concentration-dependent kill
- Can be used in PCN-allergic pts

Coverage: extensive activity against gm(-), gm(+), and some atypical

Dose:
- CrCl > 50: 500 mg QD
- CrCl 20-49: 500 mg, then 250 mg QD
- CrCl < 20: 500 mg, then 250 mg Q48h

Side effects:
- GI, skin (rash/photosensitivity), arthropathy in children, crystalluria, QT-prolongation

Celebrex

Celecoxib ; Preg Categ D

NSAID black-box: (1) CV- NSAIDs may cause an increase of serious CV thrombotic events, MI, and stroke, which can be fatal, (2) GI risks- NSAIDs cause an increased risk of serious GI adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal (3) CABG- contraindicated for peri-op pain in the setting of CABG surgery

MOA: Cox-2 selective NSAID
- Lower risk of GI complications, but increased risk MI/stroke (avoid w/ CVD risk - which is dose related, do not use higher doses in CVD-risk pts)
- Renal complications

Indication: OA, RA, acute pain, ankylosing spondylitis, Familial Adenomatous Polyposis (FAP)

Dose:
- OA: 200 mg Qdaily-BID
- RA: 100-200 BID

Contraindicated w/ sulfa allergy

Januvia

Sitagliptan ; Type-2 diabetes

MOA: DPP4-inhibitor - incretin enhancer: incretin hormones are released by the intestine throughout the day and in response to a meal. Incretins stimulate the pancreas to release insulin and the liver to decrease glucose production.

Dose: 100 mg daily (can start 50 mg)
- CrCl < 30 ml/min, including dialysis: 25 mg
- Take once daily in the morning, w/ or w/o food

Side effects: well tolerated
- NO hypoglycemia or weight gain
- Nasopharyngitis, upper resp infections, HA
- Allergic rxns/rash: can cause allergic rxns - itchy skin, rash, possibility of hives and trouble breathing -> see doctor at once
- New warnings about acute pancreatitis - (s/sx of pancreatitis: severe stomach pain that does not go away, w/ or w/o vomiting. The pain can radiate from the abdomen through to the back.)

Suboxone tabs and sublingual film

Buprenorphine + Naloxone (to block opioid if used) - CIII

- Suboxone is used as an alternative for methadone. Used Qdaily for addiction.
- To prescribe Suboxone, prescribers need Drug Addiction Treatment Act (DATA2000) waiver. If they have it, the DEA number will start w/ X.

Counseling:
- Caution w/ use of concurrent agents that are CNS depressants
- Prolongs the QT-interval, do not use w/ other QT-prolonging agents or in pts at risk of arrhythmia

NovoLog

Insulin aspart ; rapid-acting "meal-time" insulin

Time to onset: 15 mins (given 15 mins before meals)
Lasts: ~5 hrs

Viagra

Sildenafil ; Erectile dysfunction

MOA: phosphodiesterase type 5 inhibitor - following sexual stimulation (which is required), PDE5 inhibitors increase blood flow to the penis, causing an erection

Dose: (available in 25, 50, 100 mg)
- Start at 50 mg, take ~1 hr before intercourse
- In elderly pts (age > 65): start w/ 25 mg
Best when taken on empty stomach, avoid w/ fatty food
- In PAH (Revatio) is dosed 20mg TID, taken approximately 4-6hrs apart, w/ or w/o food

Side effects:
- May cause dizziness or a sudden drop in BP
- HA, flushing, runny nose, stomach pain/indigestion
- Priapism (< 2%) - if erection lasts for > 4 hrs, get medical help right away
- Sudden vision loss in one or both eyes - get medical help right away. May cause permanent vision loss
- Other visual problems: blurred vision, increased sensitivity to light, bluish haze, temporary difficulty distinguishing b/w blue and green (greenish tinge around objects)
- Sudden decrease or loss of hearing have been reported, usually in one ear. Tinnitus is another rare, but possible, side effect

Drug interactions:
- Contraindicated w/ nitrate medications - increases the potential for excessively low BP
- If a pt w/ ED has taken a PDE5 inhibitor and then develops angina, nitroglycerin should not be used until after 24h for sildenafil or vardenafil and after 48h for tadalafil. Other anti-anginal and anti-ischemic therapies may be used - such as beta blockers, CCBs, ASA, morphine, statins and PCI.
- Caution w/ PDE5-I and concurrent alpha blocker therapy: PDE5-Is and alpha-adrenergic blocking agents are both vasodilators w/ BP lowering effects - additive effects on BP may be anticipated. Pts should be on stable alpha-blocker therapy before PDE5-I and the lowest doses of PDE5-I should be used to initiate therapy. Vice versa.

Tricor

Fenofibrate, Fenofibric Acid ; Hyperlipidemia

MOA: activates PPARalpha, causing decreased hepatic TG secretion, increased lipoprotein lipase activity (which increases VLDL clearance) and increases HDL
- Decreases LDL and TG (but can increase LDL when TGs are high), and increases HDL

Dose: 48-145 mg/d (once daily)

Side effects:
- GI: abdominal pain, heartburn (dyspepsia, indigestion), constipation, nausea
- (Rare) can cause cholelithiasis (calculi, or gallstones in the gallbladder)
- Myopathy, increases in liver enzymes

Contraindications:
- Severe liver disease, unexplained liver fxn abnormalities
- Severe renal disease
- Gallbladder disease
- Biliary cirrhosis

Drug interactions:
- When used in combo w/ statins, fenfibrates have less risk of myopathies (and rhabdo) than gemfibrozil. Only TRILIPIX has the indication for use w/ a statin. Monitor liver enzymes w/ all use of a fibrate, statin, or the 2 drug classes in combination.
- Fibrates may increase the effects of sulfonylureas and warfarin.

Provigil

Modafinil (CIV), requires MedGuide

Dose: 200 mg Qdaily

MOA: like stimulants, increases the release of monoamines (specifically the catecholamines NE and DA) from the synaptic terminals. However, it also elevates hypothalamic histamine levels, thus promoting wakefulness.

Indication: used to improve wakefulness in adult pts w/ excessive sleepiness associated w/ narcolepsy, obstructive sleep apnea/hypopnea syndrome, and shift work sleep disorder

Side effects:
- CNS: HA, dizziness, feeling nervous or agitated, trouble sleeping (insomnia)
- GI: nausea, diarrhea
- Dry mouth, risk of severe rash

Drug interactions: 3A4 substrate

Zetia

Ezetimibe ; Hyperlipidemia ; Preg Categ

MOA: intestinal cholesterol absorption inhibitor; decreases LDL, TG and increases HDL
- Also combined w/ simvastatin (Vytorin)

Indication: used alone (usually when a statin cannot be tolerated) or in combo w/ a statin or fenofibrate for addtl decrease in LDL

Dose: 10 mg daily

Side effects: well-tolerated
- May cause upper RTI's, abdominal pain, diarrhea, arthralgias, HA, erythema multiforme

Contraindications: none - however, use caution w/ any liver dz, especially if using statins concurrently. Liver enzymes increase more w/ the combo than w/ a statin alone.

Drug interactions:
- When ezetimibe and cyclosporine are given together, the concentration of both can increase; monitor levels of cyclosporine
- When used w/ statins, monitor liver enzymes and have pt monitor clinical symptoms
- If using warfarin, monitor INR/bleeding

Geodon oral

Ziprasidone ; 2nd-gen AP (Schizo, psychosis, bipolar) ; Preg Categ C

MOA: DA and 5-HT receptor blocker

Dose: 60-100 mg BID
- Geodon IM: 10-20 mg

Special side effects:
- Contraindicated w/ QT risk
- CYP3A4 substrate

Vytorin

Simvastatin/Ezetimibe ; Hyperlipidemia ; Preg Categ X

MOA: statin + intestinal cholesterol absorption inhibitor

Dosage form: 10/10, 10/20, 10/40, 10/80 mg tablets

Dose: 10/10 - 10/80 mg QHS

Ambien, Ambien CR

Zolpidem (CIV) ; Non-BZD used for insomnia.

MOA: acts selectively at the BZD receptors to increase GABA

Indication: preferred over BZDs for 1st line tx of insomnia due to decrease abuse, dependence and tolerance (still has potential for abuse and dependence)

Dose:
- Ambien: 5-10 mg
- Ambien CR: 6.25-12.5 mg
- Zolpimist: spray into mouth over tongue (1 spray = 5 mg ; 2 sprays = 10 mg). Prime the bottle if 1st-time.
- Edluar SL tablets: 5-10 mg
- Do NOT take w/ fatty food, a heavy meal or alcohol
- Most patients using Ambien CR would find the same benefit w/ zolpidem generic

Side effects:
- Somnolence, dizziness, lightheadedness, ataxia (difficulty w/ coordination)
- "Pins and needles" feeling on skin
- May cause parasomnias (unusual actions while sleeping-of which the pt may not be aware)
- **(Rare) abnormal thoughts and behavior
- Withdrawal symptoms if used longer than 2 wks. You may also have more trouble sleeping the first few nights after the medicine is stopped. The problem usually goes away on its own after 1-2 nights.

Drug interactions:
- Caution w/ the use of non-BZDs w/ potent 3A4 inhibitors (eg. ritonavir, indinavir, saquinavir, atazanavir, ketoconazole, itraconazole, erythromycin and clarithromycin)
- Additive effects w/ sedating drugs, including most pain meds, muscle relaxants, antihistamines, the antidepressant mirtazapine (Remeron), trazodone, alcohol, etc.
Drug interaction: 3A4 substrate

Lunesta

Eszopiclone (CIV) ; Non-BZD (insomnia)

MOA: acts selectively at the BZD receptors to increase GABA

Indication: preferred over BZDs for 1st line tx of insomnia due to decrease abuse, dependence and tolerance. Still has potential for abuse and dependence.

Dose: 1-3 mg
- 1mg if difficulty falling asleep
- 2mg if difficulty staying asleep
- 3mg if helpful for longer duration
- Do NOT take w/ fatty food, a heavy meal or alcohol

Side effects:
- Somnolence, dizziness, ataxia
- Lightheadedness
- "Pins and needles" feeling on skin
- May cause parasomnias (unusual actions while sleeping-of which the pt may not be aware)
- (Rare) abnormal thoughts and behavior
- Withdrawal symptoms if used longer than 2 wks

Drug interactions:
- Caution w/ the use of non-BZDs w/ potent 3A4 inhibitors (eg. ritonavir, indinavir, saquinavir, atazanavir, ketoconazole, itraconazole, erythromycin and clarithromycin)
- Additive effects w/ sedating drugs, including most pain meds, muscle relaxants, antihistamines, the antidepressant mirtazapine (Remeron), trazodone, alcohol, etc.

Lidoderm

Lidocaine 5% patches ; topical pain agent for localized pain

Indication: approved for shingles (postherpetic neuralgia)

Dose: apply to affected area 1-3 times/d for 12h
- Can cut into smaller pieces (before removing backing)
- Do not apply more than 3 patches at one time
- Do not cover w/ heating pads/electric blankets

Side effects: minor topical burning, itching, rash

Lantus SoloSTAR

Insulin Glargine ; diabetes

Basal insulin, 24-hr insulin
- Dosed once or twice daily. If doses once daily, they are usually given at bedtime to ensure no mixing occurs w/ other insulins (which are usually given at mealtimes)

Onset of action: ~1 hr
Duration: ~24 hrs and DO NOT peak

Side effect: may sting a little when injecting

Vyvanse

Lisdexamfetamine (prodrug of dextroamphetamine) ; ADHD

MOA: stimulant

Dose: 30, 50, 70 mg caps
- Can mix capsule contents w/ water, drink stat
- QAM, w/ or w/o food

Prodrug: may have decreased risk abuse - cannot be injected or snorted

Aciphex

Rabeprazole ; GERD

MOA: PPI - irreversibly binds to parietal cells; blocks final step in acid production

Dose: 20 mg
- PPIs are taken daily, before breakfast. If this fails, BID (2nd dose before dinner) can be tried.

Side effects:
- CNS: HA, dizziness, anxiety
- Can increase risk of C.diff GI infections
- Increased risk of osteoporosis/fracture w/ long-term use
- Can increase INR if using warfarin (monitor)
- Can increase risk of pneumonia in hospitalized pts

Drug interactions:
- Caution w/ concurrent use of itraconazole, ketoconazole, calcium carbonate and iron, due to reduced absorption from increased pH
- PPIs inhibit 2C19: do not use w/ erlotinib (Tarceva, TKI), nelfinavir, mesalamine; and caution w/ 2C19 substrates: MTX, phenytoin, saquinavir, voriconazole and warfarin. This may prevent conversion of clopidogrel to the active form.

Counseling:
- If taking long-term, ensure that calcium and vitamin D intake is optimal. Recommend calcium citrate formulations (improved absorption in basic pH).
- If planning to stop this medicine, "taper" to avoid "acid rebound"
- Do not use for occasional mild stomach upset: this can be effectively treated w/ an antacid (such as calcium carbonate) or a strong medication such as famotidine (the generic for Pepcid)
- If you are using for more than 14 days and heartburn persists, consult your doctor.
- Do not crush/chew any capsules.

Nasonex

Mometasone ; Allergic rhinitis

MOA: intranasal corticosteroid

Indication: 1st line tx for mod-severe rhinitis

Dose:
- Adult: 2 sprays in each nostril daily
- Ages 2-11 yo: 1 spray in each nostril daily

Side effects:
- Local irritation -> burning or stinging
- Nasal bleeding
- Nasal septal perforation (rare)

Lovenox

Enoxaparin ; LMWH

Dose:
- Prophylaxis: 30 mg SC Q12h, or 40 mg SC QD
(If CrCl < 30 ml/min use 30 mg SC QD)

- Treatment: 1 mg/kg SC Q12h, or 1.5 mg/kg SC QD (If CrCl < 30 ml/min use 1mg/kg SC QD)

Administration:
- Choose area on R or L side of abdomen, at least 2 inches from belly button
- Do not expel air bubble in the syringe prior to injection
- Pinch an inch or the area to make a fold. Insert full length of the needle straight down - at 90 degree angle - into fold.
- Do not rub the site of injection - can lead to bruising.

Adderall, Adderall XR

Dextroamphetamine and amphetamine IR/ER ; ADHD

MOA: stimulant

Dose:
- IR: 5-30 mg scored tabs (given QAM or BID w/o regard to meals; first dose on awakening, additional dose 4-6h later)
- ER: 5-30 mg ER caps (QAM w/ or w/o food), cap can be opened and sprinkled on applesauce (if not warm and used right away)

ProAir HFA

Albuterol ; SABA

MOA: bind to beta 2 receptors causing relaxation of bronchial smooth muscle, resulting in bronchodilation

Indication: Asthma, COPD, DOC for exercise induced bronchospasm

Dose: 1-2 inhalations Q4-6h
- If using SABA > 2d/wk, then need to increase maintenance therapy

Side effects:
- Tremor, shakiness, lightheadedness
- Cough, palpitations, tachycardia
- Hypokalemia, hyperglycemia

Counseling:
- Shake well before each use. Prime prior to first use (3-4 sprays into the air away from face) and again if inhaler has not been used for > 2 wks.
- Throw the inhaler away when you have used 200 spray.
- Store at room temperature.

Truvada

Tenofovir + emtricitabine ; HIV

Niaspan

Niacin (extended release) ; Hyperlipidemia

MOA: inhibits VLDL production (which decreases LDL and TGs) and decreases the removal of HDL (causing increased HDL)

Dosage forms: 500, 750, 1000 mg

Dose: 500 mg QHS x 4 wks, then 1000 mg QHS x 4 wks
- Can increase to 1500-2000 mg QHS (MAX: 2 g daily)
- Taken at bedtime w/ a low-fat snack
- ASA should be taken 30 mins before the dose
- Tablets are not interchangeable (eg. 3 of 500 mg does not equal 2 of 750 mg)

Side effects:
- Flushing, pruritis (itching), HA, diarrhea, dizziness, rash, hyperpigmentation, decreased platelet counts, decreased phos levels
- Hyperglycemia, hyperuricemia (or gout), hepatotoxicity

Contraindications:
- Active liver disease
- Active PUD
- Arterial bleeding
- (use w/ caution w/ gout)

Drug interactions:
- Watch for other drugs that are potentially hepatotoxic being used concurrently - this includes combo use w/ statins (may also cause increased risk of myopathy)
- Use caution in combination w/ resins

Humalog

Insulin lispro ; diabetes
Rapid-acting "meal-time" insulin

Time to onset: 15 mins (given 15 mins before meals)
Lasts: ~5 hrs (duration of action is shorter than regular insulin)

- Clear and can be mixed w/ other insulins (NOT glargine or detemir). When they are used in mixtures, they are in the pre-mixed formulations (such as Novolog 70/30, 75/25, 50/50).

Cialis

Tadalafil ; Erectile dysfunction

MOA: phosphodiesterase type 5 inhibitor - following sexual stimulation (which is required), PDE5 inhibitors increase blood flow to the penis, causing an erection

Dose: (available in 2.5, 5, 10 and 20 mg)
- Start at 10 mg WITH or WITHOUT food, taken ~1 hr before intercourse or 2.5-5 mg daily (for men who use Cialis > 2 times/wk)
- Decrease dose to 5-10 mg w/ renal impairment
- Do not exceed 10 mg w/ hepatic impairment

Special side effect: back pain

Symbicort

Formoterol (Foradil Aerolizer) + budesonide (Pulmicort)

Black-box: increase risk of asthma-related deaths. Do not use LABA as monotherapy; need to have persistent asthma pts on long-term control therapy.

Indication: (For >/ 12 yo) Asthma, COPD

Dose: 1 capsule via Aerolizer BID, 2 inhalations BID ; place 1 capsule in aerolizer and puncture only once. DO NOT swallow the capsule. Capsules stable at room temp for 4 mos.
- Use 15 mins before exercise for EIB

Side effects:
- Tremor, tachycardia
- Hypokalemia, QT-prolongation

Counseling:
- 2 puffs in the morning and 2 puffs in the evening everyday
- Rinse mouth after each use.
- Throw away when counter reaches zero or 3 months after you take Symbicort out of its foil pouch
- Prime before use, and prime again if not used for more than 7 days or if you drop it
- Clean the inhaler every 7 days

Flovent HFA

Fluticasone ; inhaled corticosteroid

MOA: inhibits the inflammatory response, depresses migration of PMN leukocytes, fibroblasts, etc. to prevent inflammation

Indication: inhaled steroids are first-line for long term control of all ages w/ persistent asthma
- Indicated for 1-8 years of age

Side effects:
- Dysphonia (impairment to produce voice sounds), oral candidiasis (thrush), cough, hoarseness, URTI's, etc.
- To prevent oral candidiasis, rinse mouth and throat w/ warm water and spit out or use a spacer device

Counseling:
- Must prime inhaler before use, and prime again if you have not used it in more than 7 days
- Rinse mouth after each use.
- Clean the inhaler at least once a week after your evening dose.
- Store at room temperature.

Seroquel XR

Quetiapine fumurate

Combivent

Ipratropium bromide (Atrovent HFA) + albuterol

MOA: Short-acting anticholinergic + SABA. Anticholinergics block the action of acetylcholine and decrease cyclic guanosine monophosphate (cGMP) at parasympathetic sites in bronchial smooth muscle causing bronchodilation.

Indication: COPD

Dose: 2 inhalations QID

Caution: use in pts w/ myasthenia gravis, narrow-angle glaucoma, benign prostatic hyperplasia, or bladder neck obstruction
- Combivent contains soya lecithin - caution in pts w/ a peanut allergy

Side effects: dry mouth (much more common w/ tiotropium), URTIs, pharyngeal irritation, etc.

Lovaza

Omega-3 Acid Ethyl Esters ; Hyperlipidemia

MOA: various mechanisms to decrease TGs, including reducing TG synthesis and transport and increase degradation
- Decreases TGs, increases HDL, can increase LDL up to 44%

Indication: for TG use when TGs are >/ 500 mg/dL in addition to a low-fat diet

Dosing: start at 2 caps daily, can increase to 4 daily

Side effects:
- Dyspepsia, nausea, burping (eructation), taste perversion

Drug interactions:
- Theoretical risk of heightened bleeding risk (esp. doses > 3 g/d). With warfarin, monitor INR/bleeding. Use caution w/ use of ASA or clopidogrel or other agents that can increase bleeding risk.

Solodyn

Minocycline ; antibiotic ; Preg Categ D

MOA: tetracycline - inhibits protein synthesis by binding to 30S ribosomal subunit ; bacteriostatic

Indication: used for MRSA and MRSE when vancomycin or other agents are not considered appropriate

Dose: 50-100 mg Q12h

Drug Interactions:
- Tetracycline absorption is impaired by antacids containing magnesium, aluminum, or calcium, iron-containing preparations, sucralfate, bile acid resins, or bismuth subsalicylate - separate doses (take 1-2hrs before or 4hrs after)
- May ↑INR in pts taking warfarin
- Can ↓effectiveness of oral contraceptives
- Many anticonvulsants ↓levels of tetracyclines. Avoid concomitant use w/ retinoic acid derivatives (eg. isotretinoin)

Detrol LA

Tolterodine ER ; overactive bladder

MOA: (anticholinergic) muscarinic receptor antagonist that competes w/ acetylcholine receptor, thus blocking contractions of the detrusor muscle

Dose: 2-4 mg PO QD
- Do not exceed 2 mg/d when administered w/ potent 3A4 inhibitors

Side effects:
- Dry mouth, constipation, dry eyes/blurred vision, urinary retention, cognitive impairment (oxybutynin and tolterodine esp.)
- Dizziness, drowsiness
- Extended-release formulations have less incidence of dry mouth than their IR counterparts

Contraindications:
- Urinary retention, bladder outlet obstruction, gastric retention, decreased gastric motility, uncontrolled narrow angle glaucoma, and in pts w/ hypersensitivity to the compound

Drug interactions:
- Additive effects w/ other medications that have anticholinergic side effects

AndroGel

Testosterone (meter-dose pumps or foil packets)

Black-box: (1) Pts w/ BPH treated w/ androgens are at an increased risk of worsening of s/sx of BPH. (2) Secondary exposure to testosterone in children and women can occur w/ use of testosterone. Cases of secondary exposure resulting in virilization (development of sex differences) of children have been reported.

Indication: use of testosterone replacement is controversial: the primary risk is whether the use of testosterone increases prostate cancer risk. Testosterone can also increase cholesterol levels and cause liver damage. An accepted use for testosterone replacement is in men w/ low prostate cancer risk who have a low testosterone level and a related condition, such as low muscle mass.

Dose: need to prime pump before usage

Side effects:
- Increased creatinine, hepatotoxicity risk
- Increased appetite, sensitive nipples, and acne

Contraindications: breast or prostate cancer

Enbrel, Enbrel Sureclick

Etanercept ; TNFalpha inhibitor

Disepense MedGuide
- Black-box: All TNF-inhibitors carry bbw for risk of serious infxns (including TB, invasive fungal and other opportunistic infxns). All pts should be evaluated for TB before starting these drugs. Pts w/ latent TB should start prophylactic treatment. Retest TB annually.
- ALL TNF-blockers require TB test prior to admin (and annually), monitor signs and symptoms of infection, WBC

Contraindications: TNFalpha inhibitors can cause HF exacerbation - they are CI in NYHA III/IV. Use caution/lower doses in milder HF.

MOA: TNFalpha inhibitor (TNF promotes the inflammatory response, and this group of meds suppresses it)

Indication: severe RA
- Usually MTX is 1st-line, and the biologic DMARDs Etanercept and Adalimumab are add-on. However, if the initial presentation is severe, these can be started as initial therapy.

Dose: 25 mg SC twice/wk or 50 mg SC once/wk (thigh, abdomen, upper arm)
- Do not shake, requires refrigeration (allow the med to warm to room temp before injecting - takes 15-30 mins)
- Do not use biologics in combination
- Do not use live vaccines if using these drugs

Precautions:
- Can cause neurological rxns, demyelinating dz, malignancies, HepB reactivation, HF, auto-immunity (lupus), and immunosuppression. They should not be used in combo w/ other biologics or live vaccines.
- Bone marrow suppression, hepatitis, monitor LFTs, reactiv of HepB
- Injection site rxns, HA, URTI's, nasopharyngitis, rash, increase LFT's

Valtrex

Valacyclovir ; Herpes Zoster (shingles) and genital herpes

Benicar HCT

Olmesartan medoxomil + hydrochlorothiazide

Gleevec

Imatinib ; Tyrosine Kinase Inhibitor (TKI)

Dose: PO, WITH water and full meal
- NO grapefruit juice

Side effects: leukopenia, thrombocytopenia, N/V/D, fluid retention, edema, skin rashes
- Can cause liver damage (and other "ibs")

Drug interactions:
* ALL TKIs have sig drug interactions w/ the CYP450 system, especially 3A4

Humira, Humira Pen

Adalimumab ; human monoclonal antibody
"li" = anti-inflammatory
"mu" = human
"mab" = monoclonal antibody

Disepense MedGuide
- Black-box: All TNF-inhibitors carry bbw for risk of serious infxns (including TB, invasive fungal and other opportunistic infxns). All pts should be evaluated for TB before starting these drugs. Pts w/ latent TB should start prophylactic treatment. Retest TB annually.
- ALL TNF-blockers require TB test prior to admin (and annually), monitor signs and symptoms of infection, WBC

Contraindications: TNFalpha inhibitors can cause HF exacerbation - they are CI in NYHA III/IV. Use caution/lower doses in milder HF.

MOA: TNFalpha inhibitor

Indication: severe RA, UC/Crohn's
- For RA: Usually MTX is 1st-line, and the biologic DMARDs Etanercept and Adalimumab are add-on. However, if the initial presentation is severe, these can be started as initial therapy.

Dose: 40 mg SC every other wk (if not taking MTX, can increase dose to 40 mg SC weekly)
- Do not shake, requires refrigeration
- Do not use biologics in combination
- Do not use live vaccines if using these drugs

Precautions:
- Can cause neurological rxns, demyelinating dz, malignancies, HepB reactivation, HF, auto-immunity (lupus), and immunosuppression. They should not be used in combo w/ other biologics or live vaccines.
- Bone marrow suppression, hepatitis, monitor LFTs, reactiv of HepB
- Injection site rxns, HA, URTI's, nasopharyngitis, rash, increase LFT's

Humanized - may have decreased antibody development

Synthroid, Levothroid, Levoxyl

Levothyroxine (T4) ; Preg Categ: A
MOA: T4 that is converted to T3 (more active form)

Dose: Take on an empty stomach w/ a full glass of water 30 mins before breakfast. Start w/ (12.5 mcg in elderly) or 25-50 mcg/day ; usual dosing range (100-125 mcg/day) ; check AB-rating of generic to brand

Drug interactions:
- Decrease absorption (separate 2 hrs before or 4 hrs after): cholestyramine, Ca, Mg, Al (antacids) iron supplements, sucralfate, sodium polystyrene (SPS, Kayexalate), orlistat (Xenical, Alli), chromium
- Decrease levels: estrogen and hepatic inducers
- Others: beta-blockers, amiodarone, steroids, and PTU may decrease the effect of levothyroxine by decreasing the conversion of T4 to T3
- Thyroid hormone effects: increase effect of anticoagulants, decrease digoxin/theophylline levels, decrease antidiabetic agent effects

Counseling:
- Tell your doctor if you become pregnant during treatment; it is likely that your dose will need to be increased during pregnancy or if you plan to breast-feed
- Take on an EMPTY STOMACH w/ a full glass of water 30 mins before breakfast
- Some pts will notice a slight reduction in symptoms w/in 1-2 wks, but the full metabolic response to thyroid hormone therapy is often delayed for a month or two before people start to feel completely normal
- May need to take this medicine every day for the rest of your life
- Need to be tested on a regular basis (at least annually)

Xalatan

Latanoprost ; Glaucoma ; Preg Categ C

MOA: Prostaglandin Analog - increase aqueous outflow

Dose: once daily at night. Cannot be administered w/ contact lenses - remove and wait 15 min prior to re-insertion. Store unopened bottles in the fridge.
- Do not use this medicine if you are also using Bimatoprost (Latisse), to increase eyelash growth, w/o your doctor's approval. Latisse may reduce the effectiveness of the glaucoma medicine.

Side effects: increase in brown pigment in the iris and gradual changes in eye color may occur; eyelash growth and pigmentation may increase; skin on the eyelids and around the eyes may darken.
Excessive tearing, eye pain, or lid crusting.

Premarin tabs

Conjugated estrogens tablet

Indication: hormone replacement therapy for women who are in the perimenopause or menopause.

Drug interactions: 3A4 substrate

Strattera

Atomoxetine ; ADHD

Black-box (dispense MedGuide): warning for risk of suicidal ideation in children

MOA: non-stimulants (2nd line agent for ADHD), selective NE reuptake inhibitor

Dose: 10-100 mg caps Qdaily or BID
- Do not open capsule - it's an irritant

Side effects:
- GI: GI pain, nausea, anorexia, constipation
- CNS: dizziness, somnolence, irritability
- Rash/pruritis
- Possibility of worsened menstrual cramps, impotence, decreased libido
- Increase HR or BP
- Urinary retention
- Liver injury (rare)

Drug interactions:
- Contraindicated w/ MAOIs: 2 wk washout required

Ventolin HFA

Albuterol ; SABA

MOA: bind to beta 2 receptors causing relaxation of bronchial smooth muscle, resulting in bronchodilation

Indication: Asthma, COPD, DOC for exercise induced bronchospasm

Dose: 1-2 inhalations Q4-6h
- If using SABA > 2d/wk, then need to increase maintenance therapy

Side effects:
- Tremor, shakiness, lightheadedness
- Cough, palpitations, tachycardia
- Hypokalemia, hyperglycemia

Counseling:
- Shake well before use. Prime prior to first use (3-4 sprays into the air away from face) and again if inhaler has not been used for > 2 wks.

Loestrin 24 Fe

Ethinyl estradiol and Norethindrone

MOA: monophasic COCs (all active pills contain the same level of hormones)

Counseling:
- Start on the Sunday following the onset of menses
- Start on 1st day of menses - if COCs are started w/in 5 days after the start of the period, no back up method of birth control is needed; protection is immediate
- Missed pills for COCs: first check if it was a placebo pill - no action will be required
- Missed 1+ pills in week 1: take as soon as you remember and continue the same pack. Use back-up for 7 days, and consider EC if unprotected sex w/in past 5 days
- Missed 1-2 pills in week 2 or 3: take as soon as you remember and continue the same pack. When you get to the placebo pills, skip them, and go straight to a new pack
- Missed 3+ pills in week 2 or 3: take pas soon as you remember, and continue the same pack. When you get to the placebo pills, skip them, and go straight to a new pack. Use back-up for 7 days, and consider EC if unprotected sex before 7 consecutive active pills were taken.

Protonix

Pantoprazole ; GERD

MOA: PPI - irreversibly binds to parietal cells; blocks final step in acid production

Dose: 20, 40 mg
- Granules for susp 40 mg/pk - pantoprazole oral susp only in apple juice/applesauce and taken ~30 min before meal. Sprinkle intact. Stir slightly.
- For NG tube, mix in syringe in 10 ml apple juice, rinse w/ small aliquots of apple juice.
- Injection (Protonix IV) 40 mg

Side effects:
- CNS: HA, dizziness, anxiety
- Can increase risk of C.diff GI infections
- Increased risk of osteoporosis/fracture w/ long-term use
- Can increase INR if using warfarin (monitor)
- Can increase risk of pneumonia in hospitalized pts

Drug interactions:
- Caution w/ concurrent use of itraconazole, ketoconazole, calcium carbonate and iron, due to reduced absorption from increased pH
- PPIs inhibit 2C19: do not use w/ erlotinib (Tarceva, TKI), nelfinavir, mesalamine; and caution w/ 2C19 substrates: MTX, phenytoin, saquinavir, voriconazole and warfarin. This may prevent conversion of clopidogrel to the active form.

Boniva

Ibandronate ; Osteoporosis

MOA: bisphosphonate

Dose: 150 mg Q monthly
- Also available as 2.5 mg Qdaily and 3 mg IV Q3 months

Restasis

Cyclosporine Emulsion eye drops ; Dry Eyes ; Preg Categ C

MOA: immunosuppressant agent

Requires MedGuide: the emulsion from individual single-use vial is to be used immediately after opening and the remaining contents discarded. Do not allow tip of vial to touch the eye or any surface, may contaminate. Do not administer while wearing contact lenses (may be reinserted 15 mins afterwards).

Side effects (unusual): burning/stinging/pain, redness, itching, blurred vision, feeling something is in the eye, or eye discharge

Femara

Letrozole ; Aromatase Inhibitor

MOA: blocks the enzyme (aromatase) - prevents conversion to active estrogen to reduce cell growth in breast CA

Indication: breast CA

Dose: PO

Side effects:
- N/V, lethargy/fatigue, rash, menopause symptoms, hot flashes
- Decreases bone density and increases risk for osteoporosis: consider calcium and vit D supplementation, weight bearing exercise, DEXA screening

*Note: LEg = FEMur

NovoLog Mix 70/30

70% insulin aspart protamine suspension + 30% insulin aspart injection (rDNA origin)

Evista

Raloxifene ; Antiestrogen/SERM

Black-box: increase risk of thromboembolic events (DVT, PE, MI, stroke) w/ all antiestrogens/SERMs

MOA: selective competitive inhibitor for estrogen-binding receptor - block estrogen in breast tumors, but act as estrogen agonists in other tissues

Indication: for breast CA in HR+ tumors ; also used for osteoporosis in women at risk of breast CA

Dose: 60 mg (PO) daily

Side effects:
- Menopausal symptoms, hot flashes, flushing, N/V, edema, weight gain
- HTN, mood changes, amenorrhea, vaginal bleeding/discharge, skin changes
- Decreases risk endometrial cancers
- Decreases osteoporosis and hyperlipidemia
- Favorable lipid effects (decreases TC and LDL); no effect on HDL and TGs

Contraindications:
- AVOID if risk of blood clots or previous thromboembolism
- Pregnancy
- Severe hepatic dysfunction

Byetta

Exenatide ; diabetes

MOA: Glucagon-like peptide agonist (GLP-1 receptor agonist) that acts as an incretin mimetic - increases insulin and decreases glucagon secretion. Also slows gastric emptying; promotes satiety and weight loss.

Indication: can be used as mono- or combination therapy ONLY IN TYPE-2 DM.

Dose: 5 mcg and 10 mcg pens
- Start w/ 5 mcg SC BID, w/in 30-60 mins before the morning and evening meal, at least 6hrs apart. Can increase to 10 mcg SC after 1 month. Never inject after a meal, b/c of the risk of hypoglycemia.
- Given SC in thigh, abdomen (preferred) or upper arm.
- Can be stored at room temp for up to 30 days.

Side effects:
- Nausea (primary SE), vomiting, diarrhea
- Weight loss for all pts (usually ~5 lbs)
- Pancreatitis (fatal and non-fatal) can occur. Do not use w/ hx of pancreatitis, gallstones, alcoholism, or high TGs!!
- Renal: use caution w/ mod impairment, avoid in severe impairment (CrCl < 30 ml/min)

Janumet

Sitagliptin + Metformin ; diabetes

50/500, 50/1000

Asacol

Mesalamine

Dose: 800mg (two 400mg tablets) TID/d, for a total of 2.4g/d
- Asacol HD: 1.6g (two 800mg tablets) TID/d for a total dose of 4.8g/d; swallow whole, may see a ghost tablet in feces

Indication: for more mod-inflammation symptoms w/ UC and Crohn's

Side effects:
- HA, nausea, abdominal pain, flatulence
- Pancreatitis

Contraindications: hypersensitivity to salicylates or any component of the formulation

Drug interactions: avoid concomitant use w/ antacids, H2-RA's, or PPI's

Vesicare

Solifenacin ; overactive bladder

MOA: (anticholinergic) muscarinic receptor antagonist that competes w/ acetylcholine receptor, thus blocking contractions of the detrusor muscle

Dose: 5-10 mg PO QD
- Do not exceed 5 mg/d when administered w/ potent 3A4 inhibitors

Side effects:
- Dry mouth, constipation, dry eyes/blurred vision, urinary retention, cognitive impairment (oxybutynin and tolterodine esp.)
- Dizziness, drowsiness
- Extended-release formulations have less incidence of dry mouth than their IR counterparts

Contraindications:
- Urinary retention, bladder outlet obstruction, gastric retention, decreased gastric motility, uncontrolled narrow angle glaucoma, and in pts w/ hypersensitivity to the compound

Trilipix

Fenofibrate, Fenofibric Acid ; Hyperlipidemia

MOA: activates PPARalpha, causing decreased hepatic TG secretion, increased lipoprotein lipase activity (which increases VLDL clearance) and increases HDL
- Decreases LDL and TG (but can increase LDL when TGs are high), and increases HDL

Dose: 48-145 mg/d (once daily)

Side effects:
- GI: abdominal pain, heartburn (dyspepsia, indigestion), constipation, nausea
- (Rare) can cause cholelithiasis (calculi, or gallstones in the gallbladder)
- Myopathy, increases in liver enzymes

Contraindications:
- Severe liver disease, unexplained liver fxn abnormalities
- Severe renal disease
- Gallbladder disease
- Biliary cirrhosis

Drug interactions:
- When used in combo w/ statins, fenfibrates have less risk of myopathies (and rhabdo) than gemfibrozil. Only TRILIPIX has the indication for use w/ a statin. Monitor liver enzymes w/ all use of a fibrate, statin, or the 2 drug classes in combination.
- Fibrates may increase the effects of sulfonylureas and warfarin.
- Bile acid sequestrants (resins) decrease fibrate absorption.

Copaxone

Glatiramer acetate ; multiple sclerosis

Focalin, Focalin XR

Dexmethylphenidate IR, Dexmethylphenidate ER
- ADHD , (CII)

MOA: stimulant

Dose:
- IR: 2.5-10 mg tabs BID, 4+ hrs apart, w/ or w/o food
- ER: 5-20 mg caps QAM, cap can be opened and sprinkled on applesauce (if not warm and used right away)

Reyataz

Atazanavir

Drug interactions: 3A4 substrate

Arimidex

Anastrozole ; Aromatase inhibitor

MOA: blocks the enzyme (aromatase) - prevents conversion to active estrogen to reduce cell growth in breast CA

Indication: breast CA

Dose: PO

Side effects:
- N/V, lethargy/fatigue, rash, menopause symptoms, hot flashes
- Decreases bone density and increases risk for osteoporosis: consider calcium and vit D supplementation, weight bearing exercise, DEXA screening

*Note: ARIM Is a NASTy TROl

Chantix

Varenicline ; Smoking Cessation ; Preg Categ C

MedGuide required
Black-box: serious neuropsychiatric events including depression, suicidal ideation, suicide attempt and completed suicide have been reported. Stop taking this medication if pts become hostile, agitated, depressed, or have changes in behavior or thinking that are not typical for the pt.

MOA: partial neuronal alpha4beta2 nicotinic receptor agonist (agonizes a4b2 subypte of the nicotinic ACh receptor). Also stimulates DA activity to a small degree, resulting in reduced cravings and other withdrawal symptoms.

Indication: smoking cessation. Combo w/ NRTs not recommended due to nicotine antagonist properties.

Dose: start one week before the quit date
- Days 1-3: 0.5 mg QD
- Days 4-7: 0.5 mg BID
- Days 8 (quit date) and beyond: 1 mg BID
- Take w/ food and full glass of water, and use lower dosage to decrease N/V. Take 2nd pill at dinner rather than bedtime to decrease insomnia.
- Reduce dose w/ CrCl < 30 mL/min

Side effects:
- GI: nausea (~30% and dose dependent), abnormal dreams, constipation, flatulence, vomiting
- Angioedema, hypersensitivity rxns, and serious skin rxns have occurred.
- If pt has CV disease they can use if stable but need to STOP smoking - varenicline may exacerbate CVD

Counseling:
- Start taking the medication 1 week (7 days) before the quit date. This allows the medication to build up in the body. May continue to smoke during this time. Try to stop smoking on the quit date.

Sensipar

Cinacalcet

Cinacalcet (INN) is a drug that acts as a calcimimetic (i.e. it mimics the action of calcium on tissues) by allosteric activation of the calcium-sensing receptor that is expressed in various human organ tissues. It is sold by Amgen under the trade name Sensipar in North America and Australia and as Mimpara in Europe. Cinacalcet is used to treat secondary hyperparathyroidism (elevated parathyroid hormone levels), a consequence of having end-stage renal disease.[1]. Cinacalcet is also indicated for the treatment of hypercalcemia in patients with parathyroid carcinoma.[2]

Cinacalcet is indicated for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease on dialysis and hypercalcemia in patients with parathyroid carcinoma.

Opana, Opana ER

Oxymorphone (CII)

Dose: Take on EMPTY stomach (most other analgesics are w/ food to help avoid stomach upset) ; NO ALCOHOL
- IR: 5-10 mg PRN
- ER: 5-30 mg BID

Must use low doses in elderly, renal or mild liver impairment - there will be higher drug concentrations in these pts.

Contraindications:
- Mod-to-severe liver impairment

Yaz

Ethinyl estradiol / Drospirenone

Popular COC b/c it decreases bloating, PMS symptoms, weight gain

- The progestin drospirenone is a K+ sparing diuretic. There is a risk of increased K+; and caution must be used w/ K+ sparing agents (K+ sparing diuretics like spironolactone, K+ supplements like Klor-Con, salt substitutes like KCl, ACEIs, ARBs, heparin).
- Avoid use if kidney, liver, or adrenal gland disease.
- This type of progestin may put pts at a slightly higher risk of clotting, and should be avoided in women w/ clotting risk.

Doryx

Doxycycline delayed release; antibiotic ; Preg Categ D

MOA: tetracycline - inhibits protein synthesis by binding to 30S ribosomal subunit ; bacteriostatic

Coverage: atypicals, spirochetes, Rickettsial disease, anthrax, syphilis, acne

Dose: Take WITH food to decrease GI irritation
- 100 mg Q12h (PO or IV)
- Do not dose adjustment in renal impairment

Side effects:
- GI upset (take w/ 8oz water and remain upright for 30 mins to minimize GI irritation)
- Skin (rash/photosensitivity, exfoliative dermatitis)
- Colitis
- Tooth discoloration (in children)
- Fixed drug eruption (skin lesion seen w/ fluconazole, ciprofloxacin, doxycycline, clarithromycin)

Drug Interactions:
- Tetracycline absorption is impaired by antacids containing magnesium, aluminum, or calcium, iron-containing preparations, sucralfate, bile acid resins, or bismuth subsalicylate - separate doses (take 1-2hrs before or 4hrs after)
- May ↑INR in pts taking warfarin
- Can ↓effectiveness of oral contraceptives
- Many anticonvulsants ↓levels of tetracyclines. Avoid concomitant use w/ retinoic acid derivatives (eg. isotretinoin)

Contraindications:
- Children /< 8yo, pregnancy

Actoplus Met

Pioglitazone + Metformin ; diabetes

5/500
15/850

Humira

Adalimumab ; RA

Avelox

Moxifloxacin ; antibiotic ; Preg Categ C

Black-box: tendon inflammation and/or rupture (risk is increased w/ concurrent corticosteroid use, organ transplant pts, and pts > 60yo)

MOA: Fluoroquinolone - inhibits bacterial DNA topoisomerase IV and inhibits DNA-gyrase (topisomerase II), promotes breakage of double-stranded DNA.
- Bactericidal, concentration-dependent kill
- Can be used in PCN-allergic pts

Coverage: extensive activity against gm(-), gm(+), and some atypical

Dose: does not need dosage adjustment in renal impairment

Side effects:
- GI, skin (rash/photosensitivity), arthropathy in children, crystalluria, QT-prolongation

NuvaRing

Ethinyl estradiol and Etonogestrel

- Insert ring b/w day 1 and 5 of menses
- If ring is out > 3hrs during week 1, rinse w/ cool to luke-warm water and reinsert ; use backup method for 1 wk while the ring is in place, consider EC if intercourse w/in last 5 days
- If ring is out < 3 days during week 2 or 3, rinse and reinsert ring
- If ring is out >/ 3 days during week 2 or 3, rinse and reinsert ring and use backup for 7 days
- Can be stored at room temp for up to 4 months - refrigerated at pharmacy

Renvela

sevelamer carbonate

Ortho Tri-Cyclen Lo

Ethinyl estradiol / Norgestimate

Lamictal, Lamictal ODT, Lamictal CD (chewable), Lamictal XL

Lamotrigine ; Anticonvulsant (adj tx for partial seizures), primary bipolar mania ; Preg Categ C

Black-box: serious skin rxns, including SJS and TEN (co-administration of VA increases risk)

Dose: titration schedule to decrease rash ; Max: 400 mg/d ; divide BID unless using XR

Side effects: HA, sedation, diplopia, ataxia

Drug interactions:
- VA increases lamotrigine levels >2-fold
- Strong inducers (phenytoin, phenobarbital, primidone, carbamazepine) will decrease lamotrigine levels

2010 FDA warning: increase risk of aseptic meningitis

Avalide

Irbesartan and HCTZ
ARB + diuretic

Xopenex, Xopenex HFA

Levalbuterol ; SABA

MOA: bind to beta 2 receptors causing relaxation of bronchial smooth muscle, resulting in bronchodilation

Indication: Asthma, COPD, DOC for exercise induced bronchospasm

Dose: 1-2 inhalations Q4-6h
- If using SABA > 2d/wk, then need to increase maintenance therapy

Side effects:
- Tremor, shakiness, lightheadedness
- Cough, palpitations, tachycardia
- Hypokalemia, hyperglycemia

Counseling:
- Shake well before use. Prime prior to first use (3-4 sprays into the air away from face) and again if inhaler has not been used for > 2 wks.

Actonel

Risedronate

Dexilant, Kapidex (ext-rel)

Dexlansoprazole ; GERD

Dose: 30-60 mg
- Capsules can be opened and mixed w/ applesauce - take right away

Side effects:
- CNS: HA, dizziness, anxiety
- Can increase risk of C.diff GI infections
- Increased risk of osteoporosis/fracture w/ long-term use
- Can increase INR if using warfarin (monitor)
- Can increase risk of pneumonia in hospitalized pts

Drug interactions:
- Caution w/ concurrent use of itraconazole, ketoconazole, calcium carbonate and iron, due to reduced absorption from increased pH
- PPIs inhibit 2C19: do not use w/ erlotinib (Tarceva, TKI), nelfinavir, mesalamine; and caution w/ 2C19 substrates: MTX, phenytoin, saquinavir, voriconazole and warfarin. This may prevent conversion of clopidogrel to the active form.

Invega

Paliperidone ; 2nd-gen AP (Schizo, psychosis) ; Preg Categ C

MOA: DA and 5-HT receptor blocker (active metabolite of risperidone)

Dose: 3-12 mg Qdaily (3 mg if CrCl < 50 ml/min)

Special side effects:
- Tachycardia, HA, anxiety
- CYP3A4 substrate (mod)

Welchol

Colesevelam ; Hyperlipidemia ; Preg Categ C

MOA: bile acid binding resin - binds bile acids (that are derived from cholesterol) in the intestines and block reabsorption. Therefore, these bile acids are eliminated in the stool.
- Decreases LDL, increases HDL and TG either increases or stays the same

Indication: used when statins cannot be tolerated, or in combination if statin alone is insufficient, or to help lower postprandial glucose. WelChol is approved for lipids (decreases LDL) and DM2 (decreases A1c by ~0.5%).

Side effects:
- Constipation (may need dose reduction) - check for other constipating drugs or constipation and counsel appropriately (laxative senna or stool softener docusate); maintain adequate fluid intake
- Abdominal pain, nausea
- Can increase TGs (~5%)
- Decreases absorption of other drugs

Contraindications:
- Bowel obstruction
- TG > 500
- Hx of hypertriglyceridemia-induced pancreatitis

Drug interactions:
- Phenytoin and levothyroxine: give 4 hrs before WelChol
- Glyburide, OCs (E+P), give 4 hrs before WelChol
- Warfarin, monitor INR frequently during initiation
- Niaspan is taken at night, but make sure it's separated from resins by 4-6 hrs
- Separate fenofibrate products by 4-6 hrs
- Take MV at another time, due to possible risk of decreasing A, D, E, and K (mostly K) absorption

Avonex

Interferon-beta-1a lyophilized

Black-box: may cause or aggravate fatal or life-threatening autoimmune disorders, psychiatric symptoms (including depression +/or suicidal behavior), ischemic disease and/or infection. STOP THE DRUG if this happens.

Indication: tx of relapsing forms of multiple sclerosis (MS)

Side effects:
- Flu-like symptoms 1-2 hrs after administration (fever, chills, malaise, tachycardia, arthralgia, myalgia, diaphoresis - can last 24 hrs) - can pretreat w/ APAP, antihistamine
- CNS: fever, HA, chills and fatigue (~50%), blurry vision, depression, anxiety
- Muscle-Bone-Joint Pain: muscle weakness, joint pain, back pain
- Endocrine/Metabolic: hypothyroidism (~4%), hyperthyroidism (~1%), decrease CA, PO4, increase BG, libido changes, sexual dysfxn
- CV: chest pain, arrhythmias, hypotension, syncope, murmurs, palpitations, edema
- GI: dry mouth, anorexia, cough, ulcerative colitis, increase TGs, pancreatitis
- Dermatologic: bruising, diaphoresis, skin lesions
- Bone marrow suppression: neutropenia, lymphopenia and anemia
- High increases in liver enzymes are expected

Topamax

Topiramate ; Anticonvulsant (adj tx for partial seizures), migraine prophylaxis ; Preg Categ C

Dose: 6-wk titration schedule (sprinkle caps 15 and 25 mg)
- Migraine prophylaxis: 50-200 mg once daily

Side effects:
- Oligohydrosis/hyperthermia (mostly in children), limit sun/hydrate
- Nephrolithiasis (kidney stones), keep hydrated
- Paresthesias (tingling/prickling), fatigue, dizziness, somnolence, nervousness, psychomotor slowing, difficulty w/ memory, difficulty w/ concentration/attention, confusion
- Weight loss - may be benefit
- Acute myopia and secondary narrow-angle glaucoma
- Decrease sodium bicarb concentrations - co-administration w/ valproate increases risk of hyperammonemia

Entocort EC

Budesonide ; oral steroid

Indication: used for acute flare ups w/ UC and Crohn's until acute flares resolve or weight is regained

Dose: 9 mg/d - DO NOT crush, chew or break open the capsule
- Take w/ a full glass of water before a meal
- If used > 2 weeks taper dose off to avoid withdrawal symptoms

Side effects:
- If used long-term, assess bone density, consider use of bisphosphonates, optimize calcium and vit D intake
- Short-term: fluid retention, emotional instability (euphoria, mood swings depression, insomnia), if high dose acute rise in blood glucose, possible rise in BP
Long-term: adrenal suppression/Cushing's syndrome, impaired wound healing, hypertension, hyperglycemia, cataracts, osteoporosis, etc.

Drug interactions:
- 3A4 substrate; potent inhibitors (ketoconazole, itraconazole, ritonavir, etc.) will require a budesonide dose reduction
- Avoid the use of grapefruit products when using this medication

Counseling:
- Tell your doctor if you have changes in the shape or location of body fat, high BP, severe HA, fast or uneven HR, blurred vision), or a general ill feeling w/ HA, tiredness, N/V
- If using this med long-term, you should have your BP and blood sugar monitored on a regular basis.
- Do not use grapefruit products w/ this medication.
- Avoid being near people who are sick or have infections.

Aggrenox

Dipyridamole ER + Aspirin ; Antiplatelet

Indication: secondary prevention of stroke and TIA

Dose: 200 mg/25 mg BID

Side effects:
- HA (>10%)
- Dyspepsia, abdominal pain, nausea, diarrhea
- Bleeding

Travatan, Travatan Z

Travoprost ; Glaucoma ; Preg Categ C

MOA: Prostaglandin Analog - increase aqueous outflow

Dose: once daily at night. Cannot be administered w/ contact lenses - remove and wait 15 min prior to re-insertion.
- Do not use this medicine if you are also using Bimatoprost (Latisse), to increase eyelash growth, w/o your doctor's approval. Latisse may reduce the effectiveness of the glaucoma medicine.

Side effects: increase in brown pigment in the iris and gradual changes in eye color may occur; eyelash growth and pigmentation may increase; skin on the eyelids and around the eyes may darken.
Excessive tearing, eye pain, or lid crusting.

Isentress

Raltegravir ; HIV

Avandia

Rosiglitazone ; diabetes

Black-box: (1) may cause or exacerbate HF, (2) increased risk of MI
FDA "early" alert (2010) - possible risk bladder cancer
REMS requirements
Not in any guidelines. Restricted use (2010) due to CVD risk.
- FDA restricts the use of Avandia to pts w/ type2 DM who cannot control their diabetes on other meds due to data suggesting increased risk of CV events, such as heart attack and stroke

MOA: Thiazolidinedione - peroxisome proliferator-activated receptor y agonists; increases peripheral insulin sensitivity (increases insulin entry into muscle cells, insulin sensitizers)

**Dose: 2-8 mg once daily (w/ or w/o food)

Side effects:
- Peripheral edema, weight gain, macular edema, CHF, increased fracture risk
- Hepatic: when ALT > 3x normal or s/sx hepatitis - monitor liver enzymes before start of therapy and periodically thereafter
- Cardiovascular risk: use caution in CHF, can cause fluid retention, peripheral edema, HF decompensation - contraindicated in NYHA 3 or 4.
- Rosiglitazone increases both LDL AND HDL

Prevacid SoluTab

Lansoprazole ; GERD

Dose:
24-H OTC: 15 mg
Rx: 15, 30 mg
SoluTab: 15, 30 mg (contains phenylalanine, caution in pts w/ PKU)

Administration:
- Lansoprazole capsules can be opened (not crushed) and mixed w/ 40 ml of apple juice for NG tube delivery
- SoluTab can be added to 4 ml of water for NG tube delivery

Side effects:
- CNS: HA, dizziness, anxiety
- Can increase risk of C.diff GI infections
- Increased risk of osteoporosis/fracture w/ long-term use
- Can increase INR if using warfarin (monitor)
- Can increase risk of pneumonia in hospitalized pts

Drug interactions:
- Caution w/ concurrent use of itraconazole, ketoconazole, calcium carbonate and iron, due to reduced absorption from increased pH
- PPIs inhibit 2C19: do not use w/ erlotinib (Tarceva, TKI), nelfinavir, mesalamine; and caution w/ 2C19 substrates: MTX, phenytoin, saquinavir, voriconazole and warfarin. This may prevent conversion of clopidogrel to the active form.

Exforge

Amlodipine and valsartan
ARB and CCB

Lumigan

Bimatoprost ; Glaucoma ; Preg Categ C

MOA: Prostaglandin Analog - increase aqueous outflow

Dose: once daily at night. Cannot be administered w/ contact lenses - remove and wait 15 min prior to re-insertion.
- Bimatoprost (Latisse) is indicated for eyelash hypotrichosis (to increase eyelash growth) - do not use concurrently w/ same class for glaucoma w/o MDs approval (using PAs more frequently decreases effectiveness)

Side effects: increase in brown pigment in the iris and gradual changes in eye color may occur; eyelash growth and pigmentation may increase; skin on the eyelids and around the eyes may darken.
Excessive tearing, eye pain, or lid crusting.

Caduet

Amlodipine + Atorvastatin

Actonel 150

Risedronate

Risperdal, Risperdal Consta

Risperidone ; 2nd-gen AP (Schizo, psychosis, autism, bipolar) ; Preg Categ C

MOA: DA and 5-HT receptor blocker

Dose: 4-16 mg, divided
- Risperdal Consta is a 2 wk injection (25-50 mg); also used as adjunct tx for bipolar w/ either lithium or valproate)
- Risperdal oral soln can be mixed w/ water, coffee, orange juice, and low-fat milk; NOT compatible w/ cola or tea

Special side effects:
- Hyperprolactinemia, can lead to galactorrhea
- Orthostasis
- Weight gain
- Increase lipids/glucose (same w/ olanzapine, clozapine, quetiapine)
- Fluoxetine and paroxetine have been shown to increase the plasma concentration of risperidone up to 4-fold

Prograf

Tacrolimus ; transplant/immunosuppression

Black-box: (1) increased susceptibility to infxn and possible development of lymphoma; (2) IV should be administered under the supervision of a physician experienced in immunosuppressive therapy

Dose: IV/PO ratio is 1:3
- Take on EMPTY stomach (food decreases rate and extent of absorption)

Side effects:
- Tremor, HA, diarrhea, hypertension, hyperglycemia, hyperlipidemia, hyper/hypokalemia, hypomagnesemia, hypophosphatemia
- QT prolongation, nephrotoxicity, neurotoxicity

Drug interactions: 3A4 substrate
- Avoid grapefruit juice and strong 3A4 inhibitors/inducers

Ciprodex otic

Ciprofloxacin + dexamethasone ; ear drop

Indication: fight bacteria and reduce inflammation caused by bacteria

Vigamox

Moxifloxacin ; antibiotic eye drop

Kadian

Morphine

Dose: Qdaily or BID
*Do NOT crush or chew long-acting opioids
*Can be opened and the beads put down a NGT for control over 24hrs, or can sprinkle on applesauce
- Adjust in renal impairment

Allergy information: x-reactivity-if allergic, don't use one of the following (codeine, hydrocodone, hydromorphone, oxycodone)

Side effects:
- GI, CNS (sedation, dizziness), skin rxns, constipation, resp depression (opioid overdose)

Coreg, Coreg CR

Carvedilol ; Non-selective alpha & beta blocker

Dose: TAKE W/ FOOD (decreases dizziness by delaying absorption)
- HTN:
- IR: 6.25 mg BID , or
- CR: 20-80 mg
- HF (titrate Q 2 wks, decrease dose if HR < 55):
- IR: start IR 3.125 mg BID (max: 50 BID) , or
- CR: 10 mg/d (max: 80)

- Carvedilol CR is less bioavailable than carvedilol IR, therefore dose conversions are not mg per mg.
- Coreg CR capsule may be opened and beads sprinkled over applesauce - eat right away

Drug interactions: 2D6 substrate (check for interactions)
- Rifampin lowers carvedilol serum levels by 70% (quinidine, fluoxetine, paroxetine and other inhibitors of 2D6 may increase levels of metoprolol and carvedilol)
- Carvedilol increases cyclosporine, may require dose reduction

Levitra

Vardenafil ; Erectile dysfunction

MOA: phosphodiesterase type 5 inhibitor - following sexual stimulation (which is required), PDE5 inhibitors increase blood flow to the penis, causing an erection

Dose: (available in 5, 10 and 20 mg)
- Start at 10 mg, take ~1 hr before intercourse
- In elderly pts (age > 65): start w/ 5 mg (also use this lower starting dose for pts w/ moderate hepatic impairment)
- Staxyn ODT
- Best when taken on empty stomach, avoid w/ fatty food

Side effects:
- May cause dizziness or a sudden drop in BP
- HA, flushing, runny nose, stomach pain/indigestion
- Priapism (< 2%) - if erection lasts for > 4 hrs, get medical help right away
- Sudden vision loss in one or both eyes - get medical help right away. May cause permanent vision loss
- Other visual problems: blurred vision, increased sensitivity to light, bluish haze, temporary difficulty distinguishing b/w blue and green (greenish tinge around objects)
- Sudden decrease or loss of hearing have been reported, usually in one ear. Tinnitus is another rare, but possible, side effect

Drug interactions:
- Contraindicated w/ nitrate medications - increases the potential for excessively low BP
- If a pt w/ ED has taken a PDE5 inhibitor and then develops angina, nitroglycerin should not be used until after 24h for sildenafil or vardenafil and after 48h for tadalafil. Other anti-anginal and anti-ischemic therapies may be used - such as beta blockers, CCBs, ASA, morphine, statins and PCI.
- Caution w/ PDE5-I and concurrent alpha blocker therapy: PDE5-Is and alpha-adrenergic blocking agents are both vasodilators w/ BP lowering effects - additive effects on BP may be anticipated. Pts should be on stable alpha-blocker therapy before PDE5-I and the lowest doses of PDE5-I should be used to initiate therapy. Vice versa.

Maxalt

Rizatriptan ; migraine
(Maxalt-MLT disint tabs are also available - good for N/V, dysphagia)

MOA: triptan - 5HT1 receptor agonists. Blood vessels in the brain become dilated during a migraine attack and the triptans, by binding to 5HT1-receptors, causes cranial vessel constriction, inhibiting neuropeptide release and decrease pain transmission.
- Shorter half-life and faster onset

Dose: 5 mg and 10 mg, can repeat x 1 after 2 hrs

Side effects: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness
- Triptan sensations: include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

Contraindications:
- Pts w/ cerebrovascular disease or uncontrolled HTN
- MAOIs (Imitrex, Maxalt and Zomig are CI w/ MAOIs)

Drug interactions:
- FDA warning about combining triptans w/ serotonergic drugs such as SSRIs and SNRIs. Counsel pts on both medications to report restlessness, sweating, poor coordination, confusion, hallucinations.

Keppra, Keppra XR

Levetiracetam ; Anticonvulsant (adj tx for several seizure types) ; Preg Categ C

Dose: 500-1500 mg BID

Side effects: somnolence, dizziness
- Hematologic abnormalities, hepatotoxicity
- Weight loss
- Asthenia (muscle weakness/malaise)

No significant DDIs!!

Prevacid

Lansoprazole ; GERD

Dose:
- OTC: 15 mg
- Rx: 15, 30 mg

Administration:
- Lansoprazole capsules can be opened (not crushed) and mixed w/ 40 ml of apple juice for NG tube delivery

Bystolic

Nebivolol ; B-1 selective and increase NO

MOA: increases NO and causes peripheral (arterial) vasodilation

Indication: HTN, benefit in clinical trials for HF but no FDA indication

Dose: 5-40 mg/d (Max: 40 mg)
- CrCl < 30 mL/min or liver impairment, start 2.5 mg/d

Side effects:
- HA, fatigue, dizziness
- Nausea, diarrhea

Nuvigil

Armodafanil (CIV), requires MedGuide
- R-isomer of modafinil; similar drug

Dose: 150-250 mg Qdaily

MOA: like stimulants, increases the release of monoamines (specifically the catecholamines NE and DA) from the synaptic terminals. However, it also elevates hypothalamic histamine levels, thus promoting wakefulness.

Indication: used to improve wakefulness in adult pts w/ excessive sleepiness associated w/ narcolepsy, obstructive sleep apnea/hypopnea syndrome, and shift work sleep disorder

Side effects:
- CNS: HA, dizziness, feeling nervous or agitated, trouble sleeping (insomnia)
- GI: nausea, diarrhea
- Dry mouth, risk of severe rash

Zyvox

Linezolid ; antibiotic ; Preg Categ C

MOA: oxazolidinone class - binds to bacterial 23S ribosomal RNA of the 50S subunit, inhibiting bacterial translation and protein synthesis ; bacteriostatic

Indication: txs MRSA, VRE faecium and sometimes VRE faecalis

Dose: 400-600 mg Q12h (PO/IV)
- IV: infuse over 30-120 mins
- No dose adjustment in renal impairment

Side effects:
- Myelosuppression (monitor CBC) - duration related
- HA (up to 11%)
- Diarrhea
- ↑pancreatic enzymes (monitor LFTs, BUN, Scr, Tbili, lipase)
- Optic neuropathy

Drug Interactions:
- A weak MAOI: avoid tyramine containing foods and alcohol; avoid serotonergic agents (ie. TCA's, MAOI's, SSRI's, SNRI's) as they may cause serotonin syndrome. Avoid amphetamines, meperidine, dextromethorphan, etc. Adrenergic agents may cause hypertensive crisis. Avoid products containing caffeine, tyrosine, tryptophan, or phenylalanine (avoid in phenylketonuria pts b/c the drug contains phenylalanine).

Storage/compatibilities:
- Store oral susp at room temp

Lialda

Mesalamine (long-acting)

Indication: Mild-mod Crohn's

Dose: 1.2-4.8 mg/d (each tab is 1.2mg)

Enablex

Darifenacin ; overactive bladder

MOA: (anticholinergic) muscarinic receptor antagonist that competes w/ acetylcholine receptor, thus blocking contractions of the detrusor muscle

Dose: 7.5-15 mg PO QD
- Do not exceed 7.5 mg/d when administered w/ potent 3A4 inhibitors

Side effects:
- Dry mouth, constipation, dry eyes/blurred vision, urinary retention, cognitive impairment (oxybutynin and tolterodine esp.)
- May cause the most constipation
- Dizziness, drowsiness
- Extended-release formulations have less incidence of dry mouth than their IR counterparts

Contraindications:
- Urinary retention, bladder outlet obstruction, gastric retention, decreased gastric motility, uncontrolled narrow angle glaucoma, and in pts w/ hypersensitivity to the compound

Forteo

Teriparatide injection

Black-box: osteosarcoma ; caution in Paget's Dz (chronic dz, enlarged/misshapen bones), prior skeletal radiation, bone metastases, and hypercalcemia due to risk of osteosarcoma

MOA: stimulates new bone formation and depresses osteoclast activity

Indication: used in pts w/ osteoporosis who are at high risk for having fractures, or have already had an osteoporotic fracture, or have OP and need to take long-term steroids, or who cannot tolerate bisphosphonates.

Dose: 20 mcg SC inj daily for max of 2 years

Side effects:
- Dizziness, increase HR (esp. w/ 1st few doses), injection site pain, HA, asthenia, arthralgia, rhinitis
- Mild or transient increase in serum calcium, increase uric acid

Viread

Tenofovir ; NRTI

MOA: NRTI - inhibits viral transcription

Indication: HIV, HepB (used for lamivudine-resistant HBV)

Dose: 300 mg PO daily
- CrCl 30-49: 300 mg Q48h
- CrCl 10-29: 300 mg Q72-96h

Side effects:
- Well-tolerated overall
- HA, fatigue, N/V
- Nasopharyngitis, nephrotoxicity (can decrease renal fxn)

Kaletra

Lopinavir/ritonavir

Maxalt MLT

Rizatriptan

- ODT formulation
- Migraine meds come in many formulations since migraines cause HAs

Xeloda

Capecitabine ; pyrimidine analog antimetabolite

MOA: (prodrug of 5-FU) - inhibits pyrimidine synthesis, and thus DNA synthesis

Indication: cancer

Dose: PO, take WITH meal

Pharmacogenomic testing for dihydropyrimidine dehydrogenase (DPD) deficiency - increase risk for severe toxicity

Side effects: myelosuppression, mucositis, dermatitis, diarrhea, cardiotoxicity, edema, more hand-foot syndrome than 5-FU

Drug interactions: 2C9 inhibitor
- Can increase INR up to 91% due to 2C9 inhibition; requires decrease warfarin dosage/INR monitoring

*Note: XELDa deCAPEtated him

Asmanex Twisthaler

Mometasone ; inhaled corticosteroid

MOA: inhibits the inflammatory response, depresses migration of PMN leukocytes, fibroblasts, etc. to prevent inflammation

Indication: inhaled steroids are first-line for long term control of all ages w/ persistent asthma
- Indicated for 1-8 years of age

Dose:
- Low dose: 220 mcg/d
- Medium dose: 440 mcg/d
- High dose: >440 mcg/d

Side effects:
- Dysphonia (impairment to produce voice sounds), oral candidiasis (thrush), cough, hoarseness, URTI's, etc.
- To prevent oral candidiasis, rinse mouth and throat w/ warm water and spit out or use a spacer device

Hyzaar

Losartan and HCTZ
ARB + diuretic

Fentora

Fentora SL pills (Fentanyl)

- Fentora SL is used for STAT relief, for acute breakthrough pain for CA pts

Contraindications:
- Opioid-naive pts

3A4 substrate

Pulmicort Respules

Budesonide ; inhaled corticosteroid

MOA: inhibits the inflammatory response, depresses migration of PMN leukocytes, fibroblasts, etc. to prevent inflammation

Indication: inhaled steroids are first-line for long term control of all ages w/ persistent asthma
- Indicated for 1-8 years of age

Dose:
- Low dose: 180-600 mcg/d
- Medium dose: >600-1200 mcg/d
- High dose: >1200 mcg/d

Side effects:
- Dysphonia (impairment to produce voice sounds), oral candidiasis (thrush), cough, hoarseness, URTI's, etc.
- To prevent oral candidiasis, rinse mouth and throat w/ warm water and spit out or use a spacer device

Ranexa

Ranolazine

MOA: selectively inhibits the late Na+ current; decreases intracellular Na+ and Ca2+; may decrease myocardial O2 demand
- Has no clinical effects on HR or BP
- More effective in males than females

Indication: add-on anti-anginal only for chronic angina, not for initial tx

Side effects:
- Prolongs the QT interval: risk for arrhythmias w/ 3A4 inhibitors

Drug interactions: MAJOR 3A4 substrate
- Should not be used w/ strong 3A4 inhibitors (eg. itraconazole, ketoconazole, clarithromycin, nefazodone, nelfinavir, ritonavir, indinavir, saquinavir)
- Limit the dose to 500 mg BID in pts taking mod CYP3A4 inhibitors (diltiazem, verapamil, aprepitant, erythromycin, fluconazole, and grapefruit juice)
- Should NOT be used w/ 3A4 inducers

RenaGel

Sevelamer

Sevelamer (rINN) (pronounced /sɛˈvɛləmər/, /sɛˈvɛləmɪər/) is a phosphate binding drug used to prevent hyperphosphatemia in patients with chronic renal failure. When taken with meals, it binds to dietary phosphate and prevents its absorption. It is marketed by Genzyme under the trade names Renagel (sevelamer hydrochloride) and Renvela (sevelamer carbonate).
Indications
Sevelamer is indicated for the management of hyperphosphataemia in adult patients with stage 4 and 5 chronic renal failure on hemodialysis.
[edit]Contraindications
Sevelamer therapy is contraindicated in hypophosphataemia or bowel obstruction.
[edit]Adverse effects
Common adverse drug reactions (ADRs) associated with the use of sevelamer include: hypotension, hypertension, nausea and vomiting, dyspepsia, diarrhea, flatulence, and/or constipation.
[edit]Other effects
Sevelamer can significantly reduce serum uric acid.[1] This reduction has no known detrimental effect and several beneficial effects, including reducing hyperuricemia, uric acid nephrolithiasis, and gout.

Prempro

Conjugated estrogens/medroxyprogesterone acetate tablet

Indication: hormone replacement therapy
- Women w/ a uterus should use products w/ both estrogen and progestin

Drug interactions: 3A4 substrate

Relpax

Eletriptan ; migraine

MOA: triptan - 5HT1 receptor agonists. Blood vessels in the brain become dilated during a migraine attack and the triptans, by binding to 5HT1-receptors, causes cranial vessel constriction, inhibiting neuropeptide release and decrease pain transmission.
- Shorter half-life and faster onset

Dose: 20 mg and 40 mg, can repeat after 2 hr
- Study showed eletriptan (Relpax) 40 mg was more effective than sumatriptan (Imitrex) 100 mg in relieving pain

Side effects: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness
- Triptan sensations: include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

Contraindications:
- Pts w/ cerebrovascular disease or uncontrolled HTN
- Contraindicated w/ strong CYP3A4 inhibitors

Drug interactions:
- FDA warning about combining triptans w/ serotonergic drugs such as SSRIs and SNRIs. Counsel pts on both medications to report restlessness, sweating, poor coordination, confusion, hallucinations.

Patanol

Olopatadine ; allergic conjunctivitis

MOA: antihistamine/mast cell stabilizer

Amitiza

Lubiprostone ; Laxative

MOA: activates chloride channels in the gut, leading to increased fluid in gut and movement

Dose: 24 MCG capsule TWICE DAILY WITH FOOD
- Can cut dose to once daily if nausea significant

Side effects:
- Nausea (30%)
- Abdominal pain & distention

Duragesic

Fentanyl patch (CII)

Dose: 12, 25, 50, 75, 100 microgram/h transdermal patch
- Change patch Q3d (occas. change Q48 - do not increase dose if pain is controlled but doesn't last long enough - shorten the interval)
- Analgesic effect of patch can be seen 8-16 hrs after application - do not stop other analgesic at first (decrease dose 50% for the first 12 hrs)
- Do not apply >1 patch each time and do not heat up patch/cover w/ heating pad or skin area before applying
- Apply to hairless skin (cut short if necessary) on flat surface (chest, back, flank, upper arm) and change every 72 hrs
- Do not switch generic fentanyl patches - try to use the same one
- Dispose patch in toilet or cut it up and put it in coffee grounds.

Contraindications:
- Opioid-naive pts

Vancocin HCl

Vancomycin ; antibiotic ; Preg Categ B (oral), C (injection)

MOA: glycopeptide antibiotic - inhibits bacterial cell wall synthesis by blocking glycopeptides polymerization by binding to D-alanyl-D-alanine (cell wall precursors) ; time dependent kill

Dose: DOC for MRSA infxns: 15 mg/kg Q8-12h IV
- Give IV over at least 60 mins at a concentration not to exceed 5 mg/ml
- Consider alternative agent when MIC of organism >/ 2 mcg/ml

Monitor:
- Troughs (15-20 mcg/ml - pneumonia) ; 10-15 mcg/ml otherwise
- Renal fxn - dose adjust in renal impairment

Side effects:
- Nephrotoxicity, ototoxicity - caution w/ the use of other nephrotoxic or ototoxic drugs (AG's)
- Red man syndrome (maculopapular rash due to a too rapid infusion rate), hypotension, flushing, neutropenia. Infuse slowly to reduce risk of red man syndrome (30 min for each 500mg of drug given).

Nasacort AQ

Triamcinolone ; Allergic rhinitis

MOA: intranasal corticosteroid

Indication: 1st line tx for mod-severe rhinitis

Dose:
- Adult: 1-2 sprays in each nostril daily
- Age 2-12 yo: 1-2 sprays in each nostril daily

Side effects:
- Local irritation -> burning or stinging
- Nasal bleeding
- Nasal septal perforation (rare)

Proventil HFA

Albuterol ; SABA

MOA: bind to beta 2 receptors causing relaxation of bronchial smooth muscle, resulting in bronchodilation

Indication: Asthma, COPD, DOC for exercise induced bronchospasm

Dose: 1-2 inhalations Q4-6h
- If using SABA > 2d/wk, then need to increase maintenance therapy

Side effects:
- Tremor, shakiness, lightheadedness
- Cough, palpitations, tachycardia
- Hypokalemia, hyperglycemia

Counseling:
- Shake well before use. Prime prior to first use (3-4 sprays into the air away from face) and again if inhaler has not been used for > 2 wks.

Advair HFA

Salmeterol (Serevent Diskus) + fluticasone propionate (Flovent); LABA + inhaled corticosteroid

Black-box: increase risk of asthma-related deaths. Do not use LABA as monotherapy; need to have persistent asthma pts on long-term control therapy.

Indication: Asthma, COPD
- Indicated for ages >/ 12

Dose: HFA is 2 inhalations BID (Q12h)
- Use 30 mins before exercise for EIB

Side effects:
- Tremor, tachycardia
- Hypokalemia, QT-prolongation
- Dysphona, oral candidiasis (thrush), cough, hoarseness, URTI's (rinse mouth/throat w/ warm water and spit out or use a space device)

Valcyte

Valganciclovir
- For CMV

Wellbutrin, Wellbutrin XL, Budeprion XL, Aplenzin

Bupropion
Indication: Depression, social anxiety disorder
Preg Categ

MOA: blocks reuptake of DA and NE

Dose: 150-300 mg daily

Side effects:
- Dry mouth, insomnia
- HA/migraine
- GI effects: N/V/constipation
- Tremors/seizures (dose-related) - do not exceed 450 mg/d due to seizure risk - do not use in seizure disorder

Oracea

Doxycycline ; antibiotic ; Preg Categ D

MOA: tetracycline - inhibits protein synthesis by binding to 30S ribosomal subunit ; bacteriostatic


Coverage: atypicals, spirochetes, Rickettsial disease, anthrax, syphilis, acne

Dose: Take on EMPTY stomach (1 hr before or 2 hrs after meals)
- 100 mg Q12h (PO or IV)

Side effects:
- GI upset (take w/ 8oz water and remain upright for 30 mins to minimize GI irritation)
- Skin (rash/photosensitivity, exfoliative dermatitis)
- Colitis
- Tooth discoloration (in children)
- Fixed drug eruption (skin lesion seen w/ fluconazole, ciprofloxacin, doxycycline, clarithromycin)

Drug Interactions:
- Tetracycline absorption is impaired by antacids containing magnesium, aluminum, or calcium, iron-containing preparations, sucralfate, bile acid resins, or bismuth subsalicylate - separate doses (take 1-2hrs before or 4hrs after)
- May ↑INR in pts taking warfarin
- Can ↓effectiveness of oral contraceptives
- Many anticonvulsants ↓levels of tetracyclines. Avoid concomitant use w/ retinoic acid derivatives (eg. isotretinoin)

Contraindications:
- Children /< 8yo, pregnancy

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