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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
Vivelle-DOT
Estradiol transdermal system

MOA: estrogen causes a decrease in LH and more stable temperature control.

Indication: hormone replacement therapy for women who are in the perimenopause or menopause. The decrease in estrogen production from the ovaries causes an increase in LH, which can result in hot flashes and night sweats. Sleep can be disturbed, and mood changes may be present. Due to a decline in estrogen in the vaginal mucosa, vaginal dryness, burning and painful intercourse may be present.
- Estrogen improves bone density and has historically been used to prevent postmenopausal osteoporosis, but is not strong enough to be used for treatment.

Dose: twice-a-week application

Side effects: (refer to estrogen risk notecard)
- Dizziness, lightheadedness, HA
- Stomach upset, bloating, nausea, weight changes
- Increased/decreased libido, breast tenderness
Zovirax topical
Acyclovir
Creon
Pancreatin is a mixture of several digestive enzymes produced by the exocrine cells of the pancreas. It is composed of amylase, lipase and protease. This mixture is used to treat conditions in which pancreatic secretions are deficient, such as surgical pancreatectomy, pancreatitis and cystic fibrosis.
Azor
Amlodipine and Olmesartan
Pentasa
Mesalamine (Long-acting)

Indication: Mild-mod Crohn's

Dose: 1g QID/d (which is four 250mg capsules, or two 500mg capsules) QID for a total of 4g/d
Procrit
Epoetin alpha ; ESA
Other ESA is Darbepoetin (Aranesp)

* In order to be able to prescribe ESAs for cancer, the prescriber must be enrolled and certified by the ESA APPRISE Oncology Program. The pt must sign a form that states they have received counseling about risks and benefits.
* The pt must receive the ESA's MedGuide when therapy begins and at least monthly if continuing

Indication: Anemia from chemotherapy
- ESAs should only be used if the Hgb level is <10 g/dL and pt is symptomatic

Dose: SC usually Qweekly
Darbepoetin: SC usually Q2-3 wks (less frequent dosing)

Side effects:
- HTN, hypotension, arthralgias/myalgias/back pain, injection site pain, edema, fatigue and HA

Tx is associated w/:
- CHF, chest pain
- Thrombosis, arrhythmias, CV death
- (some cases) acceleration of tumor growth
Pataday
Olopatadine ; allergic conjunctivitis??
Differin
Adapalene cream/solution ; Acne ; Preg Categ C (however, retinoids are not recommended for use during pregnancy or breastfeeding)

MOA: topical "retinoid-like" - chemical compound related to vitamin A

Dose: begin w/ a reduced frequency of application (every second or third day) and shorter duration of contact (washing off the application after a period of time), to improve tolerance
- Wash only w/ mild soap twice daily
- Takes 4-12 weeks to see response

Side effects:
- Burning and irritation, esp. in the early weeks of therapy
- Limit sun exposure; your skin will burn more easily
- Use of salicylic acid scrubs or astringents while starting a retinoid will cause worse irritation
Premarin vaginal cream
Conjugated estrogens cream

Indication: hormone replacement therapy for women who are in the perimenopause or menopause.
- Vaginal products are most useful for pts who have vaginal symptoms (dryness, painful intercourse) only, since these do not expose the women to risks from systemic estrogen.
Zyprexa Zydis
Olanzapine orally disintegrating tabs
Tussionex
hydrocodone and chlorpheniramine

Hydrocodone is a 3A4 substrate
Victoza
Liraglutide ; diabetes (only in Type-2)

Black-box: thyroid C-cell carinomas seen in rats and mice - unknown if this could happen in humans.

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

Dose: 0.6, 1.2 or 1.8 mg SC daily
- Given w/o regard to meals
- Can be stored at room temp for up to 30 days

Side effects:
- More weight loss and less hypoglycemia than w/ exenatide
- N/V/D, HA, pancreatitis (nausea is the primary side effect)
Humalog KwikPen
Insulin lispro injection
Arixtra
Fondaparinux
Qvar HFA
Beclomethasone HFA ; 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

Dose: (soln, do not need to shake)
- Low dose: 80-240 mcg/d
- Medium dose: >240-480 mcg/d
- High dose: >480 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
Tarceva
Erlotinib ; Tyrosine Kinase Inhibitor (TKI)

MOA: Epidermal Growth Factor Receptor (EGFR) TKI - decreasing growth, invasion, metastasis, angiogenesis, and resistance to apoptosis.

Indication: cancer

Dose: PO, 1 hr before or 2 hrs after meal

Side effects:
- Hepatotoxicity, GI perforation, severe skin rxns, eye damage, nephrotoxicity
Monitor bilirubin, transaminases

Drug interactions:
* ALL TKIs have sign drug interactions w/ the CYP450 system, esp. 3A4
Xyzal
Levocetirizine ; allergic rhinitis/conjunctivitis

MOA: 2nd gen antihistamine - blocks histamine at the H1-receptor
- Onset of action is faster than other 2nd gen agents (onset ~1hr)
- 1st line for pts w/ mild-mod allergic rhinitis

Dose: oral for allergic rhinitis, eyedrop for conjunctivitis
Elmiron
Pentosan Polysulfate
Propecia
Finasteride ; used for hair loss ; Preg Categ X

MOA: 5-alpha reductase inhibitor - inhibits the 5-alpha reductase enzyme, which blocks the conversion of testosterone to DHT.

(Proscar is also Finasteride, but is used for BPH)

Dose: 1 mg Q daily
- Do not dispense w/ someone on finasteride (Proscar) for BPH
- Only for men

Side effects: lower dose than Proscar - lower risk of sexual side effects
CellCept
Mycophenolate Mofetil ; transplant/immunosuppression
(Other brand name: Myfortic- delayed release)

Black-box: (1) increase risk of infxn and increase development of lymphoma and skin malignancies ; (2) associated w/ increase risk of congenital malformations and spontaneous abortions when used during pregnancy ; (3) IV should be administered under the supervision of a physician experienced in immunosuppressive therapy

MOA: antiproliferative agent - inhibits T-lymphocyte proliferation by altering purine synthesis

Dose: 1-1.5 g BID (on empty stomach to avoid variability in absorption)
- CellCept and Myfortic should not be used interchangeably due to differences in absorption

Side effects:
- Diarrhea, leukopenia, sepsis, vomiting
- Myelosuppression
- Hyper- and hypotension, edema, tachycardia
- Pain, hyperglycemia, hypokalemia
- Increased risk of getting skin cancer

Drug interactions:
- Can decrease levels of OC's
- Levels can be decreased by antacids, cyclosporine, metronidazole, PPIs, FQs, sevelamer, bind acid resins, and rifamycin derivatives
Skelaxin
Metaxalone ; muscle relaxant/spasticity agent

Dose: 800 mg TID-QID, prn

Side effects:
- Excessive sedation, dizziness, confusion (aux labels: may cause drowsiness - do not operate machinery)
- Do not overdose in elderly (eg. start low, titrate carefully), watch for additive side effects
- Caution w/ use of concurrent agents that are CNS depressants - alcohol, hypnotics, BZDs, opioids

Other agents:
- Carisoprodol (Soma)
- Baclofen (Lioresal)
- Cyclobenzaprine (Flexeril)
Betaseron
Interferon-beta-1b

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
Temodar
Temozolomide ; Alkylator

MOA: cross link DNA and prevent cell replication

Indication: Cancer

Side effects: myelosuppression, N/V, alopecia
Flector
Diclofenac patch ; topical pain agent

MOA: NSAID for OA

Dose: apply to affected area TID-QID
Pegasys
Pegylated interferon-alpha-2a

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: used for HBV and HBC

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
Prandin
Repaglinide ; diabetes

MOA: Meglitinide - stimulates insulin secretion from the pancreas. Do not use w/ sulfonylureas due to similar MOA.

(Max dose: 16mg daily)
A1c < 8%: 0.5 mg TID
A1c >/ 8%: 1-2 mg TID
- Take 15-30 mins before meals (skip dose if you plan to skip meal)

Side effects:
- Hypoglycemia
- Weight neutral - benefit over sulfonylureas

Drug interactions: 3A4 substrate
- Gemfibrozil increases Prandin concentrations and can decrease BG: recommend fenofibrate instead.
Veramyst
Fluticasone furoate ; Allergic rhinitis
(Fluticasone propionate = Flonase)

MOA: intranasal corticosteroid

Indication: 1st line treatment 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)

Counseling:
- Need to prime before using if for the first time
- Need to reprime if device has not been used for 30 days or more, cap has been left off the bottle for 5 days or longer
Intuniv
Guanfacine ext-rel ; ADHD

MOA: non-stimulants (2nd line agent for ADHD), agonist at the alpha2A subtype of NE receptors

Dose: 1-4 mg
- Do not take w/ high-fat meal (increases absorption)
- Cannot interchange w/ other guanfacine formulations

Side effects:
- GI: upper GI pain, nausea, decrease appetite
- CNS: somnolence (high incidence), HA, fatigue, increased lethargy
Clobex
Clobetasol propionate (lotion, spray, shampoo)
Potency: 0.05% steroid
Use: psoriasis
Humulin N, Novolin N
NPH, diabetes
Intermediate insulin

- Give 15 mins before meals
- Peaks: anywhere from 4-14 hrs, which may cause hypoglycemic symptoms - this is why the AACE tx algorithm prefers a basal insulin for long-term control
Lasts: up to 24 hrs
Effient
Prasugrel

Black-box: bleeding risk - can cause significant and fatal bleeding

MOA: inhibitor of the P2Y12 receptor on platelets

Indication: indicated for the reduction of thrombotic events in pts w/ ACS who are to be managed w/ PCI

Dose:
- LD: 60 mg
- MD: 10 mg PO daily (5 mg daily if pt < 60 kg)

Side effects:
- Bleeding, TTP (rare), possible increase risk of CA
- Drug is not recommended in pts >/ 75 yo due to increase risk of fatal and intracranial bleeding
- Do not start in pts likely to undergo CABG surgery and d/c 7 days prior to any surgery

Contraindications: active pathological bleed, pts w/ a hx of TIA or stroke

Drug interactions:
- May increase INR in pts on warfarin; can increase bleeding risk in pts on chronic NSAIDs
Neulasta
Pegfilgrastim (Pegylated G-CSF)
- Neutropenia Prevention w/ a CSF

Others include:
- Sargramostin (Leukine, GM-CSF)
- Filgrastim (Neupogen, G-CSF)

MOA: colony stimulating factors for neutropenia (low neutrophil count) w/ chemotherapy use

Indication: Sargramostin is indicated to use in stem cell transplantation whereas Filgrastim and Pegfilgrastim are indicated in febrile neutropenia.

* Normal neutrophil count: 1500
- An absolute neutrophil count (ANC) of < 500 mm3 places the pt at a high risk for a poor outcome. An ANC of < 100 mm3 is a severe risk.

Side effects:
- Bone pain
Colcrys
Colchicine ; Acute Gout ; Preg Categ C

Dose: 1.2 mg orally (this is two 0.6 mg tablets) followed by 0.6 mg in 1 hr (NEW recommendation is to not exceed a total of 1.8 mg or 3 doses)
- You should not take the 2nd dose if you have upset stomach, nausea or diarrhea. Report any serious stomach upset, or other issues, to your doctor.
- Wait at least 3 days before initiating another course of therapy

Side effects: GI (N/V/D, abdominal pain) ; Rare (myelosuppression and neuromyopathy and death possible if overdosed - check dosing and enzyme inhibitors)

Drug interactions: CYP3A4 substrate and P-gp substrate.
- Check if combined w/ strong 3A4 inhibitors (eg. clarithromycin) or strong P-gp inhibitors (eg. cyclosporine).
- If using a mod 3A4 inhibitor, the max dose is 2 tablets (x1) - and wait at least 3 days prior to an additional dose.
- Reported cases of myopathy and rhabdo in pts taking colchicine + statin or fibrate. Avoid.
Activase
Alteplase (t-PA, rt-PA)
Thrombolytic
Preg Categ C

MOA: recombinant tissue plasminogen activator (rt-PA) causes fibrinolysis by binding to fibrin in a thrombus (clot) and converts plasminogen to plasmin
- Used in stroke, ACS?

Dose: 0.9 mg/kg (MAX: 90 mg) --> 10% of dose given as a bolus, remaining dose to be infused over 60 mins. Tx must be initiated w/in 3 hrs (possibly up to 4.5 hrs) of symptom onset

Side effects:
- Bleeding
- Hypotension
- ICH
- Fever

Contraindications: active bleed, recent surgery, PLT count <100K, high INR/aPTT, previous ICH, severe hypertension (>185/110), seizure w/ stroke onset, etc.
Zyloprim
Allopurinol ; Prophy tx for chronic gout ; Preg Categ C

MOA: xanthine oxidase inhibitor (blocks UA production)

Dose: Take once daily WITH MEAL to reduce stomach upset. 50-200 mg daily, higher for tumor lysis prophylaxis can be divided. Dose adjustment if CrCl < 20 ml/min.

Side effects: precipitation of acute attacks, nausea, skin rash (can rarely develop into toxic epidermal necrolysis or SJS). Monitor LFTs.

Counseling:
- It may take up to several weeks for this medicine to have an effect and you may have more gout attacks for several months after starting this medicine while the body removes extra uric acid. If this happens, you can use different medicine for the acute attack.
- If you get a rash, notify your doctor. The rash could become serious. If the rash looks serious, you should be seen quickly.
Persantine
Dipyridamole ; Antiplatelet

MOA: inhibits thrombus formation when given chronically and causes vasodilation when given at high doses over a short time

Indication: used in combination (modified release version) with ASA for secondary prevention of stroke and TIA

Overdose antidote: aminophylline
Latisse
Bimatoprost ; Eyelash hypotrichosis ; Preg Categ C

MOA: decreases intraocular pressure by increasing the outflow of aqueous humor. May increase the % and duration of hairs in the growth phase, resulting in eyelash growth.

Do not use concurrently w/ same class for glaucoma w/o MDs approval (using PAs more frequently decreases effectiveness).
Timoptic, Timoptic-XE
Timolol 0.25% and 0.5% ; glaucoma

MOA: nonselective beta blocker - reduces aqueous humor production

Dose: Timoptic is QD or BID ; Timoptic-XE is a gel taken QD

Side effects:
- Burning, stinging, or itching of the eyes or eyelids
- Changes in vision
- Increased sensitivity of the eyes to light

This is a nonselective beta blocker; and although most medicine stays local, it is best to try and avoid in asthma, COPD, chronic bronchitis, emphysema, or advanced cardiac disease - some pts will have exacerbated symptoms - especially if used incorrectly
Haldol
Haloperidol ; 1st-gen AP (Schizo, psychosis, Tourette syndrome)
- Preg Categ C

MOA: DA blockers

Dose: 0.5-2 mg BID-TID, up to 100 mg/d
- Haldol decanoate (given every 4 wks)

Side effects: may have more EPS than the other 1st-gen APs
-

Drug interactions: 3A4 substrate
Clozaril
Clozapine ; 2nd-gen AP (Schizo, psychosis) ; Preg Categ B
- Only indicated if failed to respond to tx w/ standard AP txs, or had sig ADRs - must be on registry and have WBC/ANC monitored. WBC must be >3500/mm3 and ANC >2000/mm3

Dose: 300-900 mg, divided (start at 25 mg and titrate)
- FazaClo ODT contains phenylalanine (cannot be given to pts w/ PKU)

Special side effects:
- Risk of agranulocytosis (dangerously low WBC) and seizures
- Myocarditis (rare hypersensitivity rxn)
- Weight gain
- Increase lipids/glucose
- Clozapine, Olanzapine, Risperidone, and Quetiapine (all have risk of weight gain, elevated lipids, BP, and BG) - monitor.
- CYP3A4 substrate
Dilantin
Phenytoin ; Anticonvulsant ; Preg Categ D

Dose: 100 mg TID, up to 600 mg/d
- IV to PO: 1:1
- Mix injection in NS only; max infusion rate 50 mg/min - if faster, can cause severe bradycardia, hypotension
- Saturable, or Michaelis-Menten kinetics; a small increase in dose can cause a big increase in serum level

Tx range: 10-20 mcg/mL
- If the albumin is low (< 3.5 g/dL), the true phenytoin level will be higher than it appears - adjust w/ this formula: PHT correction = PHT measured/[(0.2 x alb)+0.1]

Side effects: sedation, cognitive impairment
Serious adverse effects: serious skin reactions (SJS/TEN), behavior changes, blood dyscrasias, hepatotoxicity, "purple glove" syndrome if IV extravasates

Toxicity symptoms:
- Ataxia/slurred speech
- Nystagmus (wobbly eye balls)
- Diplopia/blurred vision
- Lethargy/drowsiness

With chronic therapy:
- Skin thickening of facial features
- Lupus-like syndrome
- Connective tissue disorders/gingival hyperplasia (medicine can damage the gums in mouth - brush/floss regularly)
- Hirsutism
- Peripheral neuropathy
- Osteomalacia/osteoporosis
- VitD, calcium, folate deficiency: consider supplementation

Drug interactions: STRONG CYP 3A4 and 2C9 inducer
- Lowers concentration of many drugs, including other anticonvulsants (carbamazepine, valproate, lamotrigine), birth control pills, warfarin, etc.
- High protein-binding (95%); it can displace other highly-protein bound drugs, and others can displace phenytoin
- Do not give w/ tube feeds (hold tube feeds 2 hr prior and 2 hrs after dosing)
- Calcium supplements should be given at separate times
Cerebyx
Fosphenytoin ; Anticonvulsant ; Preg Categ D

Prodrug (IV/IM) ; 1.5 mg Fos = 1 mg PHT
- Used to push drug faster, in acute cases
- Can mix FosPHT in NS or D5W
Tegretol, Tegretol XR
Carbamazepine ; Anticonvulsant (many seizure types), trigeminal neuralgia, primary bipolar mania; Preg Categ D
Other names: Carbatrol, Epitol

Black-box:
(1) Serious skin rxns, including SJS/TEN: if Asian ancestry MUST be tested for HLA-B*1502 allele prior to therapy; if positive, cannot be used (unless benefit clearly outweighs the risk)
(2) Aplastic anemia and Agranulocytosis (decrease WBC)

Dose: initial (100-200 mg BID, or QD if XR) ; maintenance (400-1800 mg/d)

Sz Tx range: 6-12 mcg/mL

Side effects:
- HA, dizziness, drowsiness, fatigue
- Nausea, blurred vision, diplopia

Occasional/Rare:
- Hepatotoxicity: check LFTs
- Lupus-like syndrome
- SIADH/Low Na+ level

Drug interactions: STRONG CYP3A4 inducer and autoinducer (it is a 3A4 substrate itself)
- Will decrease the levels of many drugs, including oral contraceptives, other seizure meds that are 3A4 substrates (eg. VA), levothyroxine, warfarin and others
- CYP3A4 inhibitors/inducers will increase and decrease carbamazepine levels
- Avoid use of grapefruit products
Trileptal
Oxcarbazepine ; Anticonvulsant (partial seizure) ; Preg Categ C

Dose: 300-800 mg BID (start w/ 300 mg daily in CrCl < 30 ml/min)

Tx range: 12-30 mcg/mL

Side effects: GI effects, sedation, diplopia, ataxia

Others:
- Serious skin reactions, including SJS and TEN (if rash w/ carbamazepine, 20-30% x-sens w/ oxcarbazepine)
- Hyponatremia: monitor serum Na+ levels, signs of CNS depression and seizure frequency

Drug interactions: less than carbamazepine
- WEAK 2C19 inhibitor and WEAK 3A4 inducer - will increase phenytoin and doses >1200 mg and decrease OCs (significant - do not use OCs w/ either carbamazepine or oxcarbazepine)
Depakene, Stavzor
Valproate or valproic acid ; Anticonvulsant (many seizure types), Primary Bipolar Mania ; Preg Categ D

Black-box:
(1) Hepatic failure: LFTs must be checked prior to start, and periodically after - do NOT use in liver disease
(2) Teratogenicity: including neural tube defects (such as spina bifida)
(3) Pancreatitis: has been fatal in children and adults (notify doctor if you experience N/V/abdominal pain, or loss of appetite)

Dose: solns or liquid-filled caps; swallow whole - Depakene caps contain liquid which will cause irritation to the mouth and throat; take w/ full glass of water and food to help avoid stomach upset
- Initial: 125-250 mg BID
- Maintenance: 15-45 mg/kg/d
- Sz Tx range: 50-100 mcg/mL

Tx range: 50-100 mcg/mL

Side effects:
- GI upset, sedation
- Alopecia (tx w/ selenium and zinc), tremor, weight gain, thrombocytopenia (decreased platelets)

Drug interactions:
- VA can increase levels of amitriptyline, nortriptyline, carbamazepine, lamotrigine, lorazepam, phenobarbital, warfarin, and zidovudine
- Use special caution w/ valproate and lamotrigine due to risk of serious rash
- Salicylates may displace VA from protein-binding site, leading to toxicity and valproate can displace phenytoin from albumin, resulting in toxicity
- Carbapenems (imipenem, etc.) can decrease the levels of VA leading to seizures
Depakote
Divalproex ; Anticonvulsant (many seizure types), migraine prophylaxis ; Preg Categ D

Black-box:
(1) Hepatic failure: LFTs must be checked prior to start, and periodically after
(2) Teratogenicity: including neural tube defects (such as spina bifida)
(3) Pancreatitis: has been fatal in children and adults

Dose: delayed-release or sprinkle-filled caps (125 mg)
- Initial: 125-250 mg BID
- Maintenance: 15-45 mg/kg/d
Cannot sub Depakote ER for the delayed release tabs
- Migraine prophylaxis: 250-500 mg twice daily

Tx range: 50-100 mcg/mL

Side effects:
- GI upset, sedation
- Alopecia (tx w/ selenium and zinc), tremor, weight gain, thrombocytopenia (decreased platelets)
Zarontin
Ethosuximide ; Anticonvulsant (DOC for absence seizures) ; Preg Categ (none)

Dose: 250-500 mg/d

Others: blood dyscrasias, SLE, effects on renal and hepatic fxn

Drug interactions:
- VA can increase/decrease ethosuximide
- Strong inducers (phenytoin, phenobarbital, primidone, carbamazepine) can decrease lamotrigine
Klonopin
Clonazepam (CIV) ; Benzodiazepine (seizures, anxiety) ; Preg Categ D

Dose: 0.5 mg BID-TID, Max: 20 mg/d
- For anxiety: 0.125-2 mg PRN

Side effects:
- Somnolence, dizziness/ataxia, cognitive impairment, depression, mood changes, physiological dependence, tolerance
Zonegran
Zonisamide ; Anticonvulsant (adj tx for partial seizures) ; Preg categ C

Dose: 100-600 mg/d

Side effects: HA, confusion, somnolence
- Anorexia, weight loss
- Serious skin rxns (SJS/TEN)
- Oligohydrosis/hyperthermia (in children), limit sun/hydrate
- Nephrolithiasis (kidney stones), hydrate
- Metabolic acidosis
- Agranulocytosis, aplastic anemia

Drug interactions: 3A4 substrate - look for 3A4 inducers/inhibitors

Not to be used in pts w/ sulfa allergy!!
Luminal, Barbital
Phenobarbital (CIV) ; Barbiturate (seizures) ; Preg Categ C

MOA: enhances GABA and increases seizure threshold. Long-acting barbiturate w/ sedative, hypnotic, and anticonvulsant properties.

Dose: 60-200 mg QD, or BID (half-life: 100 hrs) ; Primidone (Mysoline) is pro-drug of phenobarbital

Tx range:
- Adults: 20-40 mcg/mL
- Children: 15-30 mcg/mL

Side effects:
- Serious skin rxns (SJS/TEN)
- Somnolence (MAJOR sedation)
- Cognitive impairment
- Dizziness/ataxia
- Depression, mood changes
- Osteoporosis
- Dependence, tolerance, hang-over effect
- Anemia

Drug interactions: hepatic inducer
- Both phenobarbital and primidone are STRONG CYP inducers, including 3A4 - look for substrates. These two drugs will lower the levels of many drugs that are hepatically metabolized.
Prozac, Sarafem, Prozac Weekly
Fluoxetine
Indication: Depression, OCD, PD
Preg Categ

MOA: SSRI

Dose: 10-40 mg/d ; 90 mg weekly
- Fluoxetine can be activating - take dose in AM

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 side effects:
- Can be stopped suddenly d/t long half-life
- MAOIs and hypertensive crisis: 5 wks washout period if going from fluoxetine to an MAOI (2 wks if going from an MAOI to fluoxetine)
- 2D6 and 2C19 inhibitor
Paxil, Paxil CR
Paroxetine
Indication: Depression, GAD, OCD, SAD, PD, PTSD
Preg Categ

MOA: SSRI

Dose: IR (10-40 mg/d) ; CR (25-62.5 mg/d)
- Each 10 mg IR = 12.5 mg CR
- Paxil CR was promoted to help w/ GI side effects when paroxetine generic became available - but the IR formulation does not usually cause much stomach problems.

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 side effects:
- Can cause anticholinergic SEs (least selective agent) and can be sedating
- 2D6 inhibitor
Luvox, Luvox CR
Fluvoxamine
Indication: Depression, OCD, SAD
Preg Categ

MOA: SSRI

Dose: 100-300 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 side effects:
- Has the most drug interactions (1A2, 2D6, 2C9, 2C19, 3A4 inhibitor)
Zoloft
Sertraline
Depression, OCD (pedes and adults), PD, SAD
Preg Categ

MOA: SSRI

Dose: 50-200 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
Celexa
Citalopram
Indication: Depression, OCD, PD
Preg Categ

MOA: SSRI

Dose: 20-40 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

Drug interactions: 3A4 substrate
Pristiq
Desvenlafaxine ER ; Depression ; Preg Categ

MOA: SNRI

Dose: 50 mg daily

Class effects:
- Sexual side effects (20-50%): include decreased libido, ejaculation difficulties, anorgasmia
- Increased BP, HR, sweating
- Restless leg syndrome
- Possibility of mood changes - requires MedGuide and monitoring

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 side effects:
- Same as Effexor, including BP increase - monitor BP w/ any dose, increased sweating
- Mydriasis, caution w/ increase IOP
- Ghost shell in feces
Elavil
Amitriptyline ; Depression, neuropathic pain (not indicated but commonly used), migraine prophylaxis

MOA: TCA - 5HT and NE reuptake inhibitor (and blocks ACh and histamine receptors - which contribute to the SE profile)

Dose:
- Neuropathic pain: 10-50 mg QHS
- Depression: 100-150 mg BID
- Migraine prophylaxis: 10-150 mg per day, usually given QHS

Side effects: uncommon w/ low doses used for pain, but could include:
- Cardiotoxicity (QT-prolongation) w/ overdose - can be used for suicide - counsel carefully
- Orthostatic hypotension, tachycardia, anticholinergic - dry mouth, blurred vision, urinary retention, constipation
Pamelor
Nortriptyline ; Depression ; Preg Categ

MOA: TCA - 5HT and NE reuptake inhibitor (and blocks ACh and histamine receptors - which contribute to the SE profile)

Dose:
- Depression: 25 mg TID-QID
Remeron, Remeron Soltab
Mirtazapine ; Depression

MOA: blocks a-adrenergic receptors, enhances central noradrenergic and serotonergic activity

Dose: 15-45 mg QHS
- Good choice for frail, thin elderly w/ depression who have insomnia
- Soltab is a ODT tab

Side effects:
- Increased appetite, weight gain
- Dry mouth, DIZZINESS, SEDATION
- Agranulocytosis (rare)

Drug interactions: 3A4 substrate
Eskalith, Lithobid
Lithium ; Primary bipolar mania ; Preg Categ D

Dose: start at 900 mg/d, divided ; then 900-1200 mg/d, divided

Tx range: 0.6-1.2 mEq/L (some acutely manic cases may need up to 1.5 initially)
- Toxicity > 1.5 mEq/L (coarse hand tremor, vomiting, persistent diarrhea, confusion, ataxia)
- Toxicity > 3 mEq/L (CNS depression, arrhythmias, seizures, irreversible brain damage, coma)

Side effects:
- GI upset (take w/ meals or change to ER forms)
- Cognitive effects, cogwheel rigidity, fine hand tremor, weight gain
- Polyuria/polydipsia, hypothyroidism
- Cannot use w/ renal impairment: lithium is 100% renally cleared - and if not eliminated, toxicity will result - maintain adequate fluid intake

Drug interactions:
- Increase lithium levels: decreased salt intake, NSAIDs, ACEIs, ARBs, dehydration (and caution w/ diuretics), metronidazole
- Decrease lithium levels: increased salt intake, caffeine, theophylline
- Increase risk of 5HT-syndrome if given w/ lithium: SSRIs, SNRIs, triptans, linezolid and other serotonergic drugs
- Increase neurotoxicity risk (ataxia, tremors, nausea) w/ lithium in combination w/ these: verapamil, diltiazem, phenytoin, carbamazepine

Monitor BMP, renal fxn, thyroid fxn (TSH, T4)
Ativan
Lorazepam (CIV) ; BZD

MOA: potentiate GABA, an inhibitory NT, causing CNS depression

Indication: short-term relief for anxiety, insomnia

Dose: 0.5-2 mg PRN (for anxiety), QHS (for insomnia)

Side effects:
- Potential for abuse
- Physiological dependence and tolerance w/ chronic use
- Drowsiness, dizziness, ataxia, lightheadedness
- Anterograde amnesia (difficulty remembering what happened after you had taken the medicine)
- Withdrawal symptoms

- L-O-T (Lorazepam, Oxazepam (Serax), Temazepam): considered less potentially harmful for elderly or w/ liver impairment since it is metabolized to inactive compounds (glucuronides)

IV:
- Keep refrigerated
- Glass, filter
- Protect from light
- Short stability (stable for 1 day)
Xanax
Alprazolam (CIV) ; BZD

Indication: short-term relief for anxiety

Dose: 0.25-2 mg PRN

Side effects:
- Potential for abuse
- Physiological dependence and tolerance w/ chronic use
- Drowsiness, dizziness, ataxia, lightheadedness
- Anterograde amnesia (difficulty remembering what happened after you had taken the medicine)
- Withdrawal symptoms

Drug interactions: 3A4 substrate
Librium
Chlordiazepoxide (CIV) ; BZD

Indication: short-term relief for anxiety, alcohol withdrawal

Indication: short-term relief for anxiety, insomnia

Dose: 5-25 mg PRN
Side effects:
- Potential for abuse
- Physiological dependence and tolerance w/ chronic use
- Drowsiness, dizziness, ataxia, lightheadedness
- Anterograde amnesia (difficulty remembering what happened after you had taken the medicine)
- Withdrawal symptoms
Valium
Diazepam (CIV) ; BZD

MOA: inhibits GABA (inhibitor NT), causing CNS depression

Indication: short-term relief for anxiety, alcohol withdrawal, muscle spasticity

Dose: 2-10 mg PRN for anxiety

Side effects:
- Potential for abuse
- Physiological dependence and tolerance w/ chronic use
- Drowsiness, dizziness, ataxia, lightheadedness
- Anterograde amnesia (difficulty remembering what happened after you had taken the medicine)
- Withdrawal symptoms

Drug interactions: 3A4 substrate
Buspar
Buspirone

Indication: Anxiety - no abuse of physiological potential, as compared to the BZDs

MOA: 5-HT1 partial agonist

Dose:
- Start w/ 7.5 mg BID, can increase by 5 mg/d Q2-3 days until 30 mg/d, if needed
- Usual range: 20-30 mg/d (max 60 mg/d)
- Takes 2-4 weeks for optimal effect
- When switching from a BZD for buspirone, the BZD should be tapered slowly
- Comes in a Dividose tablet designed to make dose adjustments easy. Each tablet is SCORED and can be broken accurately on the score lines into thirds.

Side effects:
- No potential for abuse, tolerance or physiological dependence
- N/D, HA, lightheadedness, excitement
- Avoid use if severe KIDNEY or LIVER dysfunction

Drug interactions: CYP3A4 substrate
- Do not use w/ MAOIs
- 3A4 inhibitors (eg. erythromycin, diltiazem, verapamil) may increase concentration - consider dose reduction
- Consider dose increase w/ 3A4 inducers (rifampin)
- Avoid consuming large amts of grapefruit juice

Counseling:
- Take this med by mouth, usually 2 or 3 times a day or as directed w/ or w/o food, but it is important to choose one way and always take it that way
- Grapefruit may increase the amt of buspirone in your bloodstream
- Use this medication regularly in order to get the most benefit from it. When this medication is started, symptoms of anxiety (eg. restlessness) may sometimes get worse before they improve. It make take up to a month or more to get the full effect of this medication.
Restoril
Temazepam (CIV) ; BZD

MOA: potentiate GABA, an inhibitory NT, causing CNS depression

Indication: insomnia

Dose: 7.5-15mg QHS

Side effects:
- Potential for abuse
- Physiological dependence and tolerance w/ chronic use
- Drowsiness, dizziness, ataxia, lightheadedness
- Anterograde amnesia (difficulty remembering what happened after you had taken the medicine)
- Withdrawal symptoms

- L-O-T (Lorazepam, Oxazepam (Serax), Temazepam): considered less potentially harmful for elderly or w/ liver impairment since it is metabolized to inactive compounds (glucuronides)
Theophylline
MOA: blocks phosphodiesterase causing increase cAMP which promotes release of epinephrine from adrenal cells. This results in bronchodilation, diuresis, CNS and cardiac stimulation.

Indication: Asthma

Tx range: 5-15 mcg/mL (peak level)

Drug interactions: MANY; MAJOR substrate of 1A2 and 3A4, follows Michaelis-Menten (saturable) kinetics (similar to phenytoin and voriconazole)
- Increase theophylline levels due to 1A2 inhibition: OCs, zafirlukast, zileuton, acyclovir, cimetidine, ciprofloxacin, ethinyl estradiol, fluvoxamine, isoniazid
- Increase theophylline levels due to 3A4 inhibition: amiodarone, azole antifungals, clarithromycin, cyclosporine, erythromycin, diltiazem, verapamil, lovastatin, simvastatin, atorvastatin, PI's, etc.
- Increase theophylline levels due to other mechanisms: allopurinol, erythromycin, propranolol, ephedrine, and possibly w/ other systemic bronchodilators (and possibly phenylephrine, pseudoephedrine)
- Decrease theophylline levels: carbamazepine, phenobarbital, phenytoin, primidone, rifampin, ritonavir, tobacco/marijuana smoking, St. John's wort, tipranavir/ritonavir, high protein diet, low carb diet, thyroid hormones
- Theophylline will decrease lithium (theophylline will increase renal excretion of lithium) and will decrease zafirlukast
Zyban
Bupropion SR ; Smoking Cessation ; Preg Categ C

MedGuide required
Black-box: Not approved for use in children, not approved for bipolar, increase risk of suicidal thinking and behavior in young adults w/ depression or other psychiatric disorders

MOA: blocks neural re-uptake of DA and/or NE and blocks nicotinic acetylcholinergic receptors

Indication: smoking cessation - can be used in combo w/ NRT. Beneficial for smokers w/ hx of depression - do not use in pts taking any other form of bupropion.

Dose: 150 mg QAM for 3 days, then 150 mg BID (take the doses at least 8 hrs apart)
- Start 1-2 weeks before quit date
- Do not exceed 450 mg/d due to seizure risk

Side effects:
- Anticholinergic: dry mouth, constipation, insomnia
- HA, migraine, N/V
- Tremors/seizures (dose-related)
- NO sexual dysfunction unlike many other ADs
- Delays weight gain, can be used w/ CVD risk
- (Rare) some people have severe allergic rxns to bupropion - STOP and call doctor

Contraindications: hx of seizures, eating disorder, use of MAOI w/in the previous 14 days - 2 week washout required

Counseling:
- It takes about 1 wk for the medication to start working. For your best chance of quitting, you should not stop smoking until you have been taking for 1 week. Set a date to stop smoking during the second week of starting this medication.
Thalitone
Chlorthalidone ; Thiazide diuretic
Dose: 12.5-25 mg (Max: 50 mg)
Microzide
Hydrochlorothiazide (capsule) ; Thiazide diuretic
Dose: 12.5-25 mg (Max: 50 mg)
Zaroxolyn
Metolazone ; Thiazide-like diuretic
Dose: 2.5-5 mg (Max: 20)
Lasix
Furosemide ; Loop diuretic
Dose: 20-80 mg daily, or divided (most pts take divided doses), can go higher

Store at room temp. Refrigeration may result in precipitation or crystallization. Crystals may dissolve upon warming to room temp. Do not use if solution is yellow in color.
Light sensitive
IV to oral ratio = 1:2
Aldactone
Spironolactone ; Aldosterone antagonists/Potassium-sparing diuretics

MOA: interfere w/ K+ and Na+ exchange in the DISTAL TUBULE, retain K+, decrease Ca2+ excretion and increase Mg2+ loss

Indication: shown to decrease morbidity and mortality in HF - they are not used to deplete fluid but used to provide additional symptom relief and increase survival in advanced HF.
- In HTN, not used as monotherapy, but are commonly used in combo w/ HCTZ (Maxzide/Dyazide) to counter the thiazide's mild K+ loss and help (a little) w/ BP.

Dose:
- NYHA 3 and 4 HF: 25-50 mg/d
- HTN: 50-100 mg/d

Side effects:
- Gynecomastia, menstrual irregularities, hair loss
- Increase K+ (can be significant); check K+ before initiating (do not start if K+ > 5 mEq/L), monitor and stop if > 5.5 mEq/L - higher risk if decreased renal fxn (consider very high risk if CrCl < 30 mL/min)
- Possible increase in CH, TG, BG, LFTs, BUN/Scr

Drug interactions:
- ACEI/ARBs may increase risk of hyperkalemia
- Lithium generally should not be given w/ diuretics b/c diuretics reduce lithium's renal clearance and add a high risk of lithium toxicity
- Do not use NSAIDs concurrently in HF (which should be avoided in HF anyway)
- Stop or lower doses of K+ supplements
Inspra
Eplerenone ; Aldosterone antagonists/Potassium-sparing diuretics

Indication: shown to decrease morbidity and mortality in HF - they are not used to deplete fluid but used to provide additional symptom relief and increase survival in advanced HF.
- In HTN, not used as monotherapy, but are commonly used in combo w/ HCTZ (Maxzide/Dyazide) to counter the thiazide's mild K+ loss and help (a little) w/ BP.

Dose:
- CHF, post MI: 25-50 mg/d
- HTN: 50-100 mg/d

Side effects:
- Less gynecomastia (than spironolactone)
- Increase K+ (can be significant); check K+ before initiating (do not start if K+ > 5 mEq/L), monitor and stop if > 5.5 mEq/L - higher risk if decreased renal fxn (consider very high risk if CrCl < 30 mL/min)
- Possible increase in CH, TG, BG, LFTs, BUN/Scr

Drug interactions: 3A4 substrate
- ACEI/ARBs may increase risk of hyperkalemia
- Lithium generally should not be given w/ diuretics b/c diuretics reduce lithium's renal clearance and add a high risk of lithium toxicity
- Do not use NSAIDs concurrently in HF (which should be avoided in HF anyway)
- Stop or lower doses of K+ supplements
Cleviprex
Clevidipine IV ; DHP CCB (used for acute care)
Dose: 1-16 mg/hr

Do not use in soy or egg allergy
Comes in a lipid emulsion (milky white color). Hung vials need to be discarded after 4 hrs.
Zocor
Simvastatin ; Hyperlipidemia ; Preg Categ X

MOA: statin

Dosage form: 5-, 10-, 20-, 40-, and 80-mg tablet

Dose: 10-80 mg QHS (Equivalent dose = 20 mg)

Drug interactions (for SAL - Simvastatin, Atorvastatin, Lovastatin)
- 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.
Pravachol
Pravastatin ; Hyperlipidemia ; Preg Categ X

MOA: statin

Dosage form: 10-, 20-, 40-, 80-mg tablet

Dose: 10-80 mg (Equivalent dose = 40 mg)
- Good option if DI's
Mevacor, Altoprev
Lovastatin ; Hyperlipidemia ; Preg Categ X

MOA: statin

Mevacor dosage form: 10-, 20-, 40-mg tablet
- Dose: 20-80 mg/d w/ evening meal
- Equivalent dose = 40 mg

Altoprev dosage form: 10-, 20-, 40-, 60-mg tablet
- Dose: 10-60 mg/d QHS (extended-release lovastatin)

Drug interactions (for SAL - Simvastatin, Atorvastatin, Lovastatin)
- 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.
Lescol, Lescol XL
Fluvastatin ; Hyperlipidemia ; Preg Categ X

MOA: statin

Lescol dosage form: 20-, 40-mg capsule
Lescol XL dosage form: 80-mg tablet

Dose: 20-80 mg (Equivalent dose = 80 mg)
- Take at bedtime
- XL (80 mg) take at any time

Drug interactions: 2C9 substrate
- Monitor pts taking warfarin
Lopid
Gemfibrozil ; 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: 600 mg BID, 30 mins before breakfast and dinner

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.
BiDil
Isosorbide dinitrate/hydralazine ; HF

MOA: ISDN is mainly a venous vasodilator. Its dilatory properties result from increased cGMP and subsequent relaxation of vascular smooth muscle

Dose: 20-37.5 mg - start 1 TID, can increase to 2 TID, as tolerated

Side effects:
- HA, dizziness, tachycardia
- Lupus-like syndrome: report fever, joint/muscle aches, fatigue
- No nitrate tolerance

CI: with PDE5-I's
Lanoxin, Digitek
Digoxin

Contraindicated in 2nd or 3rd degree AV block w/o pacemaker, VF/VT, WPW w/ Afib.

Indication: for symptom improvement (increases QOL) in HF, and used as antiarrhythmic in Afib.

MOA: inhibits Na+/K+ ATP-ase pump. Positive inotrope (increases contraction and CO), and negative chronotrope (decreases HR).

Dose: 0.125-0.25 mg daily
- Watch for renal impairment (decrease dose to 0.125 mg every other day or less frequently)
- Dig is mostly renally cleared, and partially hepatically. Decreased renal fxn requires a decreased digoxin dose, or, if acute renal failure, the digoxin should be held.

Tx range for CHF: 0.5-0.8 ng/mL (higher range for Afib)
- Antidote: Digibind or DigiFab

- First signs of toxicity: N/V, loss of appetite, decreased HR
- Severe toxicity: visual disturbances (blurred or yellow vision), hallucinations, delirium, confusion, HA, dizziness, arrhythmias - PR prolongation, ST segment depression, tachyarrhythmias

Drug interactions:
- Beta-blockers and non-DHP CCBs have additive effects on decreasing HR
- Increased digoxin levels w/ amiodarone, quinidine, verapamil, erythromycin, clarithromycin, azole antifungals, cyclosporine, propafenone, PI's and a few others: dose reduction likely required
- Hypokalemia (K+ < 3.5 mEq/L) will increase risk of digoxin toxicity
- Decreased digoxin absorption/levels w/ cholestyramine, colestipol, spironolactone, St. John's Wort, etc.
ReoPro
Abciximab ; chimeric monoclonal antibody

Indication: Cardiovascular disease - used in medical management of ACS or for those going for an intervention (PCI +/- stent)

MOA: GP IIb/IIIa receptor antagonist - blocks fibrinogen binding to the GP IIb/IIIa receptors on platelets, preventing PLT aggregation.
Integrilin
Eptifibatide

Indication: used in medical management of ACS or for those going for an intervention (PCI +/- stent)

MOA: GP IIb/IIIa receptor antagonist - blocks fibrinogen binding to the GP IIb/IIIa receptors on platelets, preventing PLT aggregation.
Aggrastat
Tirofiban

Indication: used in medical management of ACS or for those going for an intervention (PCI +/- stent)

MOA: GP IIb/IIIa receptor antagonist - blocks fibrinogen binding to the GP IIb/IIIa receptors on platelets, preventing PLT aggregation.
Nitrostat
Nitroglycerin SL tabs

Indication: used for immediate relief of angina. Can be used initially if pt has CI to beta-blocker therapy or can be used in combo w/ beta-blockers as add on.
- Call 911 if chest pain doesn't go away after the first dose of SL or spray. Can continue to take additional doses (up to 3) at 5-min intervals while waiting for the ambulance to arrive.

MOA: reduces cardiac O2 demand by decreasing left ventricular pressure and preload; causes vasodilation of veins and arteries (minor effect)

Dose: 0.4 mg
- Counsel pts to dose so they have a 12-hr nitrate free period to decrease tolerance.

Side effects: HA, dizziness (should take the medicine while sitting down, pts should not eat, drink, or smoke for at least 5-10 mins after use of the product or while experiencing chest pain)

Drug interactions:
- If pt has recently used a phosphodiesterase-5 inhibitor like sildenafil (Viagra, Revatio), tadalafil (Cialis, Adcirca), or vardenafil (Levitra), he/she should avoid use of nitroglycerin
Nitromist, Nitrolingual Pump Spray
Nitroglycerin sublingual spray

Indication: used for immediate relief of angina. Can be used initially if pt has CI to beta-blocker therapy or can be used in combo w/ beta-blockers as add on.
- Call 911 if chest pain doesn't go away after the first dose of SL or spray. Can continue to take additional doses (up to 3) at 5-min intervals while waiting for the ambulance to arrive.

MOA: reduces cardiac O2 demand by decreasing left ventricular pressure and preload; causes vasodilation of veins and arteries (minor effect)

Dose: 0.4 mg
- Counsel pts to dose so they have a 12-hr nitrate free period to decrease tolerance.

Side effects: HA, dizziness (should take the medicine while sitting down, pts should not eat, drink, or smoke for at least 5-10 mins after use of the product or while experiencing chest pain)

Drug interactions:
- If pt has recently used a phosphodiesterase-5 inhibitor like sildenafil (Viagra, Revatio), tadalafil (Cialis, Adcirca), or vardenafil (Levitra), he/she should avoid use of nitroglycerin

For pump spray: instruct pts to spray 5 times into the air to prime the pump the first time they use it and prime once if they have not used the med for 6wks or more. Do NOT shake.
Cordarone, Pacerone
Amiodarone ; Preg Categ D

Black-box: (1) lung damage, (2) liver toxicity, (3) exacerbation of arrhythmias, making them more difficult to tolerate or reverse

MOA: class III antiarrhythmic - increases the refractory period by blocking potassium channels

Dose: 200-400 mg QD WITH meal
- If changing PO to IV, decrease PO dose 50%

IV therapy should be in polyolefin or glass (Non-PVC), or for <2 hrs in PVC bags. Need to be given thru a filtered line. Has SHORT STABILITY.
- D5W
- Light sensitive
- Do not refrigerate
- Half-life: 40-55 days

Side effects: (obtain baseline liver, thyroid, and pulmonary tests)
- Hypotension
- Hypothyroidism/hyperthyroidism (more hypo)
- Increase LFTs
- Constipation, ataxia, photosensitivity
- Corneal micro-deposits (recommend regular eye exams), slate blue skin discoloration

Drug interactions: mod 2C9, 2D6 and 3A4 inhibitor, 2C8 and 3A4 substrate, and P-gp inhibitor
- The following meds must have the doses decreased 30-50% when starting amiodarone: digoxin, warfarin, quinidine and procainamide
- Electrolyte abnormalities should be corrected before starting therapy
- Do not use grapefruit juice/products when using amiodarone
- Use lower doses of lova, ator, simvastatin
Multaq
Dronedarone ; Preg Categ X

MOA: class III antiarrhythmic - increases the refractory period by blocking potassium channels
- Less side effects than amiodarone (less thyroid problems, ocular effects, photosensitivity, QT prolongation) BUT more dangerous in HF (and more nausea and diarrhea)

Dose: 400 mg BID - WITH meals
- Half-life: 13-19 hrs

Side effects: N/D, abdominal pain, asthenia, mild increase in SCr

Contraindications:
- HF (class IV and any class w/ recent hospitalizations)
- HR < 50
- Concomitant use of strong 3A4 inhibitors
- Concomitant use of drugs that prolong the QT interval

Drug interactions: mod 2D6 and 3A4 inhibitor
- Avoid use w/ inhibitors and inducers of 3A4 and other antiarrhythmics
- If using digoxin, reduce dose of digoxin by 50%
- Caution w/ the use of statins at higher doses (use lower doses of lova, ator, simvastatin)
Nolvadex
Tamoxifen ; 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: 10-20 mg PO QD-BID

Side effects:
- Menopausal symptoms, hot flashes, flushing, N/V, edema, weight gain
- HTN, mood changes, amenorrhea, vaginal bleeding/discharge, skin changes
- Corneal changes, decreased color perception
- INCREASES risk endometrial cancers
- INCREASES osteoporosis and hyperlipidemia
- CYP2D6 polymorphism 4/5 results in shorter disease free survival - consider alternative therapy (eg. aromatase inhibitor)
Cytoxan
Cyclophosphamide ; Alkylator

MOA: cross link DNA and prevent cell replication

Indication: cancer

Side effects: myelosuppression, N/V, alopecia
- Bladder toxicity w/ high-dose cyclophosphamide and ALL doses of ifosfamide give MESNA (Mesnex) to protect against HEMORRHAGIC CYSTITIS and also ensure adequate hydration
Ifex
Ifosfamide ; Alkylator

MOA: cross link DNA and prevent cell replication

Indication: cancer

Side effects: myelosuppression, N/V, alopecia
- Bladder toxicity w/ high-dose cyclophosphamide and ALL doses of ifosfamide give MESNA (Mesnex) to protect against hemorrhagic cystitis and also ensure adequate hydration
Matulane
Procarbazine

MOA: cross link DNA and prevent cell replication

Indication: cancer

Side effects: myelosuppression, N/V, alopecia
- Procarbazine is a MAOI w/ neurologic and CV (hypertensive crisis) toxicity - avoid sympathomimetic amines or foods w/ high tyramine content

*Note: MAT drove a PROCAR in tuLANE
Adriamycin
Doxorubicin ; Anthracyclines

MOA: work by several mechanisms, including intercalation into DNA, inhibiting top II, and creating oxygen-free radicals that damage cells

Indication: nonphase specific cancer agent
- Very effective but use limited by cardiac toxicity and N/V

Side effects:
- Myelosuppression, N/V, alopecia, mucositis, hyperpigmentation, red urine and body secretions
- High risk of severe tissue damage w/ extravasation - ANTIDOTE: dexrazoxane (Totect) or dimethyl sulfoxide
- Serial monitoring of cardiac output is necessary at baseline and w/ continued therapy - With doxorubicin: give dexrazoxane (Zinecard) when cumulative dose > 300 mg/m2
- Cardiotoxicity: decrease risk by not exceeding max lifetime dose (400-500 mg/m2)
* Epirubicin (Ellence) max lifetime dose is 900 mg/m2
MTX, Trexall
Methotrexate ; folate antimetabolite
- Preg Cate X

MOA: works on the S-phase of cancer replication; MTX is a folate antimetabolite (folate needs to be reduced for DNA synthesis) thus preventing DNA synthesis

Indication:
- MTX/Trexall: used for cancer
- Rheumatrex: used for RA, UC, Crohn's

Dose:
- Cancer: 7.5-25 mg Q weekly
- RA (lower doses): 7.5-22.5 mg Q weekly
- Some pts are told to divide the once weekly
dose in half and take it two days/week
- UC/Crohn's: 7.5-20 mg Q weekly

Side effects:
- MYELOSUPPRESION, mucositis, hepatic and renal toxicity (renal is dose-related, maintain hydration - high concentrations may exceed renal solubility, leading to MTX crystallization)
- Pulmonary toxicity/pneumonitis (monitor)
- Red-tender palms and feet (hand-foot syndrome)
- Antidote: leucovorin or levoleucovorin - for chemo doses or in overdose (leucovorin is the active form of folic acid bypassing the enzyme block of dihydrofolate reductase by MTX)

Contraindications:
- Active infectious disease or pneumonitis
- WBC < 3,000/mm3
- PLT < 50,000/mm3
- LFTs > 2x ULN
- CrCl < 30 mL/min
- Pregnancy, breastfeeding

Drug interactions: 2C19 substrate
- Active transport of MTX is decreased by ASA, NSAIDs, PCNs, and probenecid - resulting in increased toxicity (avoid concurrent use)
- NSAIDs should not be used w/ high-dose MTX. Caution is advised if you also take ASA. NSAIDs/ASA may be used w/ low-dose MTX such as for tx of RA if directed by doctor.
- Do not drink alcohol when using this medicine, since alcohol can also damage the liver.

Monitor CBC, LFT's
Erbitux
Cetuximab ; Chimeric monoclonal antibodies

MOA: inhibits epidermal growth factor receptor, thus inhibiting growth factors required for cell growth and decreases cell survival

Indication: colorectal cancer, head and neck cancer

Pharmacogenomics: K-ras mutation indicates possible poor response - Colorectal cancer does NOT respond to cetuximab if pt has a K-ras mutation (~40% of pts). Wild-type (or normal) K-ras colorectal cancer has double the overall survival. Must test for K-ras mutations before tx.
Herceptin
Trastuzumab ; Monoclonal antibodies

MOA: inhibit growth factors required for cell growth and decrease cell survival - targets ErbB2 on breast cancer cells

Pharmacogenomics: trastuzumab binds to and reverses effects of overactive HER2 receptors; HER2 gene is over-expressed in ~25% of early-stage breast tumors. Must be >2+ by Immunohistochemical (IHC) testing to respond/use this

Side effects: cardiomyopathy (manigesting as CHF, decreased LVEF), pulmonary toxicity
- Avoid concurrent use w/ anthracyclines due to additive cardiotoxicity
Thalomid
Thalidomide ; immunomodulators

MOA: decreases angiogenesis

Dose: PO - take at least 1 hr after dinner

Preg Categ X - all pharmacies and prescribers must be enrolled in the System for Thalidomide Education and Prescribing Safety (STEPS) program to dispense
Revlimid
Lenalidomide ; immunomodulators

MOA: decreases angiogenesis

Dose: PO

Preg Categ X - only available under restricted distribution program RevAssist - pt, prescriber and pharmacist must be registered w/ RevAssist

Side effects: DVT and PE - seek medical care if develop SOB, CP, or arm/leg swelling
Rituxan
Rituximab ; Cell surface targeted monoclonal antibodie
"tu" = cancer
"xi" = chimeric
"mab" = monoclonal antibody

Black-box (4):
(1) Severe and fatal infusion related rxns, usually w/ the first infusion
(2) Progressive multifocal leukoencephalopathy (progressive damage/inflammation of the brain) due to JC virus infxn
(3) Tumor lysis syndrome leading to acute renal failure and dialysis may occur following the first dose
(4) Severe and fatal mucocutaneous rxn (SJS, TEN, etc.) can occur

MOA: targets CD20+ on B cells - kills the cancer but also releases cytokines

Indication: non-hodgkin lymphoma, alt tx in RA

Indication: cancer, RA (given w/ MTX)

Dose: 1 g IV on day 1 and 15
- Need to pre-medicate w/ steroid, diphenhydramine and APAP: infusions must be given in hospital or clinic since they can be fatal! (Rituximab-induced cytokine release infusion rxns and sequelae)
- Start infusion at 50 mg/h, can increase to 400 mg/h if no rxn
Platinol
Cisplatin ; Platinum-Based Compound

MOA: X-links DNA, leading to apoptosis

Side effects:
- NEPHROTOXICITY - vigorous hydration and sometimes mannitol use to avoid renal failure (also w/ CARBOPLATIN)
- Electrolyte wasting (requiring Mg2+ and K+ supplementation)
Amifostine (Ethyol) may also be used prophylactically
- Hypersensitivity rxns (including anaphylaxis) - may pretreat w/ steroids and antihistamines
5-FU
Fluorouracil ; pyrimidine analog antimetabolite

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

Indication: cancer

Dose: for chemo, given w/ leucovorin to increase efficacy of 5-FU

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

Side effects: MYELOSUPPRESION (more a problem w/ bolus dosing), mucositis (more a problem w/ CI), dermatitis/photosensitivity, diarrhea, cardiotoxicity, edema, hand-foot syndrome (with CI)
Taxol
Paclitaxel ; Taxane

MOA: inhibit microtubule function and angiogenesis, leading to dysfunctional microtubule bundling

Side effects: anaphylaxis, hypersensitivity rxn (78%) due to polyoxyethylated castor oil solvent system - PRETREAT w/ dexamethasone, diphenhydramine, and H2-blocker
* Abraxane is a paclitaxel albumin-bound formulation, has less HSN rxns and does not require pre-medication
* Do not use w/ PVC admin sets
Taxotere
Docetaxel ; Taxane

MOA: inhibit microtubule function and angiogenesis, leading to dysfunctional microtubule bundling

Side effects: hypersensitivity rxn, anaphylaxis rxn (RARE)
- Cardio-Pulmonary: fluid retention, pericardial effusion, pleural effusion and edema (41-70%) - PRETREAT w/ dexamethasone 8 mg BID x 3 days
Camptosar
Irinotecan ; Topoisomerase I inhibitors

Pharmacogenomic testing: those who are homozygous for the UGT1A1*28 allele are at an increased risk for neutropenia

Side effects:
- Myelosuppression, N/V/D, alopecia, dyspnea
- Acute diarrhea is a cholinergic symptom including tearing, etc. - treat w/ atropine. Delayed diarrhea treat w/ loperamide (up to 24 mg/d)
Zoladex
Goserelin ; LHRH agonist

MOA: initially increases the production of androgens and estrogens; followed by down regulation through a negative feedback loop resulting in suppressed gonadotropin release, LH, and FSH, resulting in a chemical castration/oophorectomy

Indication: used for prostate CA in males and endometriosis, fibroids and breast CA in females

Dose: monthly to every four month injections at the medical office (subcutaneous depot injections)

Side effects:
- Men: hot flashes, bone pain, impotence, injection site pain/swelling, gynecomastia, peripheral edema
- Decreases bone density and increases risk for osteoporosis: consider calcium and vitamin D supplementation, weight bearing exercise and DEXA screening
- An initial surge in LH, FSH, and testosterone - estrogen can cause a disease flare (in pts at risk, start an antiandrogen/antiestrogen prior to the LHRH agonist)
Fosamax
Alendronate ; Bisphosphonate
Dose:
- Prevention: 5 mg Qdaily or 35 mg Qweekly
- Treatment: 10 mg Qdaily or 70 mg Qweekly (alone or w/ Vit D3)
Actonel
Risedronate ; Bisphosphonate
Dose:
- 5 mg PO Qdaily or 35 mg Qweekly , or
- 75 mg on 2 consecutive days/month , or
- 150 mg once monthly
Boniva
Ibandronate ; Bisphosphonate

Dose:
- 150 mg Qmonthly
- Also available as 2.5 Qdaily and 3 mg IV Q3months
Reclast
Zoledronic Acid ; injectable bisphosphonate

Indication: tx and prevention of osteoporosis, Paget's

Dose:
- Reclast: 5 mg infusion 1x/yr
- Zometa: 4 mg monthly (used for hypercalcemia of malignancy)
- Do not use Reclast w/ Zometa (same drug used for hypercalcemia of malignancy)

Side effects:
- Low serum calcium can occur - aggravated if on AGs, should not be used concurrently
Deltasone
Prednisone

Dose (for acute gout attack): 0.5 mg/kg/d x 1, then decrease by 5 mg each day
- Also used for transplant/immunosuppression

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
Plaquenil
Hydroxychloroquine ; Non-Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARD's)

Indication: used in mild RA

Dose: 200-400 mg/d WITH food or milk

Side effects:
- HA, N/V/D, vertigo, ataxia
- Nightmares
- Urticaria, rashes, alopecia, bleaching of hair
- (Retinopathy): Photophobia, blurred vision, abnormal color vision, corneal changes - obtain eye exam w/in first year
Sulfazine
Sulfasalazine ; Non-Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARD's) - derivative of 5-ASA (mesalamine)

Indication: used in mild RA, UC, Crohn's

Dose: Take WITH food and 8oz of water to prevent crystalluria
RA: 1 g BID
UC/Crohn's: 4-6 g/d
- Impairs folate absorption, may give 1 mg/d folate supplement

Side effects:
- HA, GI upset, N/V/D
- Photosensitivity (>10%), rash, etc.
- Yellow-orange coloration of skin/urine

Contraindications:
- Sulfa or salicylate allergy
- GI or GU obstruction

Counseling:
- Do not use if you have an allergy to sulfa or salicylates
- You may experience loss of appetite, HA, nausea, stomach pain or upset stomach or a rash
- Pts w/ any of these symptoms should see their physician immediately: sore throat, pale or yellowed skin or fatigue
- Use protection if you are out in the sun (clothing, sunscreen) as you will burn more easily
- The medicine may make your urine or skin turn an orange-yellowish color
Arava
Leflunomide ; Non-Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARD's)

Black-box: Preg categ X - must have negative pregnancy test before starting this medication and use 2 forms of birth control
- If you want to get pregnant, wait 2 yrs after discontinuation or give cholestyramine

Indication: used in mild RA, can use +/- MTX (but increase risk of liver toxicity)

Dose: 20 mg Qdaily

Side effects: hepatotoxicity, diarrhea, URTIs, alopecia, rash, etc.
- Monitor LFTs and CBC at baseline and monthly for first 6 months
Remicade
Infliximab ; TNF-alpha inhibitor
"li" = inflammation
"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

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.
- Alternative 1st line in mod-severe UC/Crohn's - alone, or w/ AZA

Dose:usually given w/ MTX
- 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

* Special effects:
- Infusion rxns: hypotension, fever, chills, pruritis (may pretreat w APAP, antihistamine, steroids)
- Delayed HSN 3-10 days after admin (fever, rash, myalgia, HA, sore throat)

* Note: Remicade (sounds like gernade) INFLIcted damage.
Solu Medrol
Methylprednisolone, Triamcinolone

Used for acute gout attack: intra-articular injection (into joint); systemic side effects unlikely
Tamiflu
Oseltamivir ; antiviral

MOA: neuraminidase inhibitor - inhibits the neuraminidase enzyme which affects the release of viral particles, thereby reducing the amt of virus in the body

Indication: antiviral treatment of pts w/ influenza (including H1N1) - recommended for pts w/ confirmed or suspected influenza who have severe, complicated, or progressive illness or who are hospitalized. Also indicated for prophylaxis in pts at risk for infxn who were exposed to the virus.

Dose: START w/in 48 hrs of symptoms
- Available in capsule and suspension
- Tx: 75 mg BID x 5 days
- Prevention: 75 mg QD x 10 days
Decrease dose in renal function

Side effects:
- Aches and pain, rhinorrhea, dyspepsia and URTIs
- Rare: sudden confusion, delirium, hallucinations, unusual behavior, or self-injury; more often in children
Relenza
Zanamivir ; antiviral

MOA: neuraminidase inhibitor - inhibits the neuraminidase enzyme which affects the release of viral particles, thereby reducing the amt of virus in the body

Indication: antiviral treatment of pts w/ influenza (including H1N1) - recommended for pts w/ confirmed or suspected influenza who have severe, complicated, or progressive illness or who are hospitalized. Also indicated for prophylaxis in pts at risk for infxn who were exposed to the virus.

Dose: START w/in 48 hrs of symptoms
- Available as dry oral inhalation powder, uses blisters (unwrap) in a Diskhaler device
- Tx: 10 mg (two 5 mg inhalations) twice daily
- Prevention: 10 mg (two 5 mg inhalations) once daily

Do NOT use if chronic resp diseases such as asthma or COPD due to risk of bronchospasm
Bentyl
Dicyclomine ; Antispasmodic

MOA: anticholinergic/antispasmodic

Indication: useful in UC

Dose: 10 mg AC and QHS

Side effects:
- Anticholinergic: dry mouth, urinary retention, dry/blurry vision, constipation
- Confusion, tachycardia
Canasa
Mesalamine suppository

Indication: 1st line for UC mild-mod distal disease

Dose: 1 g rectally QD or 1 g 3x/wk

Counseling:
- For best results, empty your rectum (have a bowel movement) just before using. Keep the suppository in your rectum for 3 hrs or all night, if possible.
Rowasa
Mesalamine enema

Indication: 1st line for UC mild-mod distal disease

Dose: 2-4 g/d

Counseling:
- Remove bottle from pouch and shake well
- Remain in position for at least 30 mins, preferably, all night
Ditropan XL
Oxybutynin XL ; overactive bladder

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

Dose: 5-30 mg PO QD

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
Trusopt
Dorzolamide ; glaucoma

MOA: carbonic anhydrase inhibitors - reduce aqueous humor production

Dose: TID

Side effects: bitter or unusual taste (5-10%)
Cosopt
Dorzolamide HCl + Timolol ; glaucoma

MOA: carbonic anhydrase inhibitors + nonselective beta blocker - reduce aqueous humor production

Dose: TID

Side effects: bitter or unusual taste (5-10%)
Alphagan
Brimonidine ; glaucoma

MOA: adrenergics - increase aqueous outflow, reduce production

Dose: TID

Side effects: can cause macular edema (swelling of the macula, the center part of the retina) and eye irritation
Transderm Scop
Scopolamine 3-day patch ; motion sickness

MOA: anticholinergic - primarily for motion sickness and occasionally used inpatient

Dose: 1.5 mg delivered over 3 days
- Applied behind ear

Side effects: dry mouth, dizziness, stinging eyes (if touch eyes after handling patch), pupil dilation
- (Rare): confusion, hallucinations, tachycardia
- Drowsiness - no alcohol, this drug causes significant drowsiness - do not use in children
Antivert
Meclizine ; motion sickness

MOA: 1st generation antihistamine

Dose: 12.5-25 mg

Side effects: highly sedating and causes anticholinergic side effects (dry mouth, urinary retention, constipation, dry/blurry vision, tachycardia)
Sandimmune
Cyclosporine ; transplant/immunosuppression
Neoral, Gengraf - Cyclosporine modified
Black-box: (1) renal impairment, (2) increase risk of lymphomas and other malignancies, (3) increase risk of infection, may cause hypertension, (4) dose adjustments made under direct supervision of a experienced physician, (5) increase risk of skin cancer (increased risk w/ other immunosuppressants, cold tar, radiation, and UVB light)

MOA: calcineurin antagonists - suppresses cellular immunity by inhibiting T-lymphocyte activation

Dose: Cyclosporine modified (Gengraf/Neoral) has increased bioavailability compared to cyclosporine and cannot be used interchangeably
- If taking oral soln, do not administer from plastic or Styrofoam cup. May dilute NEORAL w/ orange juice or apple juice. May dilute SANDIMMUNE w/ milk, chocolate milk, or orange juice.

Side effects:
- HTN, hypertriglyceridemia
- Hirsutism, tremor, edema, nephropathy, hypertrichosis, gingival hyperplasia, neurotoxicity

Drug interactions: 3A4 substrate and mod 3A4 inhibitor, P-gp inhibitor
- Avoid grapefruit juice
- 3A4 inhibitors can increase levels of cyclosporine and 3A4 inducers can decrease levels of cyclosporine
- Caution against the use of other agents that can cause nephrotoxicity and agents that can increase BP
TOBI
Tobramycin inhaled soln ; inhaled antibiotic

Indication: CF pts >/ 6yo who are colonized w/ Pseudomonas to reduce infxn/hospitalization

Dose: 300 mg via nebulizer Q12h x 28 days, followed by 28 days off cycle
- Ready to use ampules
- Recommended to store in fridge; can be kept at room temp up to 28 days
- Do not use TOBI if it is cloudy, if there are particles in the solution
- Do not expose to intense light
- Take doses as close to 12 hrs apart (and not less than 6 hrs apart)

Side effects:
- Ototoxicity, tinnitus, dizziness, bronchospasm
- Little systemic absorption
Mucomyst
Acetylcysteine ; mucolytic

MOA: promotes clearance of mucus (used for CF, also used for APAP toxicity). As a mucolytic, it is given in a nebulizer.

It has questionable benefit in CF as it may damage lung tissue and promote bronchitis, whereas Pulmozyme does not and is the preferred mucolytic agent.
Pulmozyme
Dornase alfa ; mucolytic

MOA: promotes clearance of mucus - selectively cleaves DNA, thus reducing mucous viscosity and therefore, improving airflow in the lung and the risk of infections may be decreased.

Dose: 2.5 mg given in a nebulizer once daily for 6 months
Side effects: chest pain, voice alteration and throat irritation
BenzaClin
Benzoyl peroxide + 1% Clindamycin

Dose: get that MUST BE refrigerated once compounded (place a 3 month expiration date on the label following mixing)
- ABs should be used w/ a retinoid and discontinued when no longer needed (usually 6-8 weeks)

Side effects:
- BPO can bleach clothing, hair
- Limit sun exposure; your skin will burn more easily
Duac
Clindamycin + BPO topical gel

- Dispense w/ 60d expiration
- Apply QHS to affected areas
- Can store at room temp, do not freeze
- Limit sun exposure!
Accutane
Oral isotretinoin ; Acne ; Preg Categ X

Black-box: women who are pregnant or trying to get pregnant should never take this drug due to severe birth defects or miscarriage
- Can only be dispensed by a pharmacy registered and activated w/ the pregnancy risk management iPLEDGE program

Indication: only for the tx of severe recalcitrant nodular acne

Dose: comes in 10, 20, and 40 mg caps
- 0.5-1 mg/kg/d, divided BID WITH food (to increase absorption) for 15-20 wks
- Two forms of birth control are required w/ taking this medication (not the mini-pill)
- Female pts must sign pt information/informed consent form about birth defects warning
- Must have had 2 negative pregnancy tests prior to starting treatment

Side effects: arthralgias, skeletal hyperostosis, osteoporosis, psychiatric issues (such as depression, psychosis, and increase risk of suicide), decrease night vision (may be permanent), difficulty wearing contact lens (dry eyes/irritation), dry skin, chapped lips, increase cholesterol and blood glucose, transient chest pain and hearing loss, and photosensitivity
- Can cause liver damage

Drug interactions: do not use w/ vit A supplements, tetracyclines, steroids, progestin-only contraceptives, St. John's wort
Protopic
Tacrolimus ; atopic dermatitis

Dispense MedGuide - calcineurin inhibitors carry cancer risk

Dose: apply a thin layer only to the affected skin areas, twice daily
- Avoid use in children younger than 2 years of age
Aldara
Imiquimod cream ; external genital warts

MOA: immune response modifier

Indication: external genital warts, superficial basal cell carcinoma, actinic keratosis

Dose: apply 3x per week to external genital/perianal warts until there is total clearance for the max time of 16 wks
- Apply to entire treatment area before bedtime and rub in until the cream is no longer visible. Wash off after 8 hrs.
Bactroban
Mupirocin ; minor cuts/abrasions

- Rx antibiotic cream or ointment; very good staph/strep coverage
Taclonex
Calcipotriene and betamethasone ointment ; psoriasis

- If suspension: shake well
- Do not use > 4 weeks
- Do not use > 100 g ointment weekly
Revatio
Sildenafil ; PAH

Dose: 20 mg TID, taken 4-6 hrs apart

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.
Adcirca
Tadalafil ; PAH

Dose: 40 mg daily (20 mg daily if mild to moderate renal or hepatic impairment)
- Take 2, 20 mg tabs once a day
- For PAH, Adcirca is dosed 40 mg (two 20 mg tablets) taken once daily 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.
Imitrex
Sumatriptan ; 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:
- PO: 25, 50 and 100 mg, can repeat x 1 in 2 hrs
- Nasal spray: 5, 20 mg, can repeat x 1 in 2 hrs
- SC inj: 4, 6 mg, can repeat x 1 in 1 hr
- Sumatriptan has a nasal spray and a SC injection - fast onset for migraines that come on quickly, and avoids oral route.
- Shorter half-life and faster onset

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.
Blocadren
Timolol ; migraine prophylaxis
Dose: 10-15 mg twice daily
Xenical
Orlistat Rx ; weight loss

MOA: long-term lipase inhibitor, ~13 lbs in 1 yr, reduces 1/3 dietary fat
- Take MV w/ A, D, E, K and beta carotene at bedtime or separated by 2+ hours from Xenical

Dose: 120 mg w/ each meal containing fat

Side effects:
- GI: flatus w/ discharge, fecal urgency, fatty stool
Cayston
Aztreonam inhalation (for CF)
Glucophage, Glucophage XR
Metformin ; diabetes

MOA: decreases hepatic glucose production

Glucophage (max: 2550)
- 500, 850, 1000 mg
Glucophage XR (max: 2000)
- 500, 750, 1000 mg
Fortamet
Metformin ; diabetes

May see a lumpy tablet in the stool
Glumetza
Metformin ; diabetes

May see shell of the medicine in the stool
Avandamet
Metformin + rosiglitazone ; diabetes

500/1, 500/2, 500/4
1000/2, 1000/4
Glucovance
Metformin + glyburide (sulfonylurea)

250/1.25
500/2.5, 500/5
Metaglip
Metformin + glipizide

250/2.5, 500/2.5
500/5
Glucotrol, Glucotrol XL
Glipizide ; diabetes

MOA: Sulfonylurea - stimulates insulin secretion from the pancreas.

MAX: 20 mg daily
IR: 2.5-10 mg BID
XL: 2.5-10 mg daily (swallow whole)
Amaryl
Glimepiride ; diabetes

MOA: Sulfonylurea - stimulates insulin secretion from the pancreas.

2-4 mg (MAX: 8 mg daily)
Starlix
Nateglinide ; diabetes

MOA: Meglitinide - stimulates insulin secretion from the pancreas.

60 mg TID if near goal A1c ; otherwise 120 mg TID
- Take 15-30 mins before meals

Drug interactions: 3A4 substrate
Duetact
Pioglitazone + glimepiride

30/2, 30/4
Avandaryl
Rosiglitazone + glimepiride

4/1, 4/2, 4/4
Precose
Acarbose ; diabetes

MOA: Alpha-glucosidase inhibitor - prevents the digestion of carbohydrates - inhibits metabolism of sucrose to glucose and fructose

Dose: 25 mg w/ first bite of main meal - this med needs to be in the stomach w/ food
(MAX: 300 mg/d, divided)
- If you plan to skip a meal, don't take dose

Side effects:
- GI effects (flatulence, diarrhea) - titrate slowly
- Weight neutral
- Hepatic (rare): can increase liver enzymes, check Q3 months during 1st year
- GOOD: increase HDL and decrease TGs and CH
- Caution: these drugs do not cause low blood sugar by themselves - if you get low blood sugar from using this agent w/ a drug that causes low blood sugar (eg. insulin, sulfonylurea, meglitinide), you will need to purchase glucose tablets or gel to have on hand - cannot tx w/ sucrose (fruit juice, table sugar, candy)

Contraindications:
- Irritable bowel syndrome (IBS); intestinal obstruction
Glyset
Miglitol ; diabetes

MOA: Alpha-glucosidase inhibitor - prevents the digestion of carbohydrates - inhibits metabolism of sucrose to glucose and fructose

Dose: 25 mg w/ first bite of main meal - this med needs to be in the stomach w/ food
(MAX: 300 mg/d, divided)
- If you plan to skip a meal, don't take dose

Side effects:
- GI effects (flatulence, diarrhea) - titrate slowly
- Weight neutral
- Hepatic (rare): can increase liver enzymes, check Q3 months during 1st year
- GOOD: increase HDL and decrease TGs and CH
- Caution: these drugs do not cause low blood sugar by themselves - if you get low blood sugar from using this agent w/ a drug that causes low blood sugar (eg. insulin, sulfonylurea, meglitinide), you will need to purchase glucose tablets or gel to have on hand - cannot tx w/ sucrose (fruit juice, table sugar, candy)

Contraindications:
- Irritable bowel syndrome (IBS); intestinal obstruction
Elidel
Pimecrolimus Topical ; eczema
Zomig ZMT
Zolmitriptan ; migraine

- ODT formulation
Tracleer
Bosentan ; PAH

MOA: dual endothelin receptor antagonist

- Can cause liver damage
Casodex
Bicalutamide ; prostate CA

MOA: an oral non-steroidal anti-androgen used in the treatment of prostate cancer and hirsutism

- Can cause liver damage
Felbatol
Felbamate ; seizure/epilepsy

- Can cause liver damage

Drug interactions: 3A4 substrate
Uloric
Febuxostat ; gout

MOA: inhibitor of xanthine oxidase that is indicated for use in the treatment of hyperuricemia

- Allopurinol is used more b/c febuxostat is much more expensive (20K more/yr)
- May be safer in several renal impairment (no dose adjustment in mod renal disease)
- Has decreased risk for hypersensitivity rxns (decreased risk of serious skin rash - unlike allopurinol)
- Can cause liver damage - check LFTs at 2 and 4 months and periodically thereafter
Eulexin
Flutamide ; prostate CA

MOA: oral nonsteroidal antiandrogen drug primarily used to treat prostate cancer
Nizoral
Ketoconazole shampoo

- Available as a non-prescription shampoo called Nizoral A-D
- Used for dandruff, sometimes due to yeast overgrowth
- Rub shampoo in well and leave in for 5 mins, then rinse out
- Do not use if open sores on scalp
- Can cause alopeica, skin irritation
E-mycin, E.E.S., Ery-Tab
Erythromycin ; macrolide antibiotic

MOA: binds to the 50S ribosomal subunit, resulting in inhibition of RNA protein synthesis
- Can be used in PCN-allergic pts

Coverage: activity against gram(+), some gram(-), and good atypical coverage

Dose:
- E.E.S.: 400 mg QID
- Must refrigerate E.E.S. oral susp.

Side effects:
- GI (most w/ erythromycin), liver dysfunction, QT-prolongation

Drug interactions: ery and clari are MAJOR 3A4 inhibitors
- P-gp inhibitor
- Do not concurrently use agents that can prolong the QT interval
Prilosec
Omeprazole ; GERD

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

Dose:
OTC: 20 mg
Rx: 10, 20, 40 mg
- Can be made in a suspension for NG tube admin by mixing w/ Na bicarbonate (Zegerid, Zegerid OTC)


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.
Ultram, Ultram ER, Ryzolt ER tabs
Tramadol

Max dose: 400mg/d

*Lowers seizure threshold - avoid in pts w/seizure Hx
*Serotonin syndrome risk if used in combination w/ others, such as SSRIs, etc.

3A4 substrate
Desyrel
Trazodone

Antidepressant of the serotonin antagonist and reuptake inhibitor (SARI) class. It is a phenylpiperazine compound. Trazodone also has anxiolytic, and hypnotic effects. Trazodone has considerably less prominent anticholinergic (dry mouth, constipation, tachycardia) and sexual side effects than most of the tricyclic antidepressants (TCAs).
- Extremely sedating, careful w/ concurrent use w/ other sedating meds

Liver injury and 3A4 substrate
Symlin
Pramlintide ; diabetes

Black-box: co-administration w/ insulin may induce severe hypoglycemia (usually w/in 3hrs following administration)

Contraindicated in gastroparesis, or hypoglycemic unawareness

MOA: synthetic analog of the human neuroendocrine hormone, amylin.

**Used for both Type 1 and 2 DM: decrease meal-time insulins by 50% when starting this drug

Type-1: start at 15mcg immediately prior to meals - can titrate to 60mcg if no sig nausea

Type-2: start at 60mcg prior to meals - can increase to 120mcg if no sig nausea

Administered by SC inj to abdomen or thigh prior to meals
Opened vials can be refrigerated or kept at room temp for up to 28 days. Pens are good at room temp for 30 days.
Humulin R, Novolin R
Regular or "short-acting" insulin

Usually given as a mixture w/ the longer-acting: regular is drawn up first/clear, and then the NPH/cloudy is drawn up second. NPH in the mixture NPH/R: 70/30.
Time to onset: 30 mins (injected 30 mins prior to meal - before breakfast and dinner)
Lasts: ~4-6 hrs
Quinidine
Class IA antiarrhythmic

Black-box: may increase mortality in tx of AFib/AFlutter

Contraindications:
- CI in pts taking quinolones that prolong the QT-interval

Side effects:
- Diarrhea (35%), hypotension/syncope, QT prolongation
- Quinidine overdose can cause cinchonism (HA, tinnitus, hearing loss, nausea, diplopia)

Drug interactions:
- MAJOR 3A4 substrate
- STRONG 2D6 and 3A4 inhibitor
- Impt interactions: digoxin (decrease dose by 50%), warfarin (increases INR), grapefruit juice, verapamil, diltiazem, erythromycin
Procainamide
Class IA antiarrhythmic

Black-box: potentially fatal blood dyscrasias

Drug interactions:
- MAJOR 2D6 substrate
Marinol
Dronabinol ; antiemetic agent used in CA
(CIII)

MOA: dronabinol

Dose: TID-QID
- Refrigerate capsules

Side effects: euphoria, increased appetite (also used for anorexia in AIDS pts)
Benadryl, Sominex
Diphenhydramine

MOA: First generation antihistamine - compete w/ histamine H1 receptors

Indication: antihistamine used to relieve symptoms of allergy, hay fever and the common cold. Also used to prevent and tx nausea, vomiting and dizziness caused by motion sickness. Can also be used to help you relax and fall asleep, and occasionally used for involuntary movements and muscle stiffness from PD.
- 1st line for pts w/ mild-mod allergic rhinitis
- Effective in reducing symptoms of itching, sneezing, and rhinorrhea. They have little effect on nasal congestion.
- They help w/ allergic conjunctivitis.

Dose: 25-50 mg Q4-6h (Max: 300 mg/d)

Side effects: due to the side-effect profile, DO NOT use in elderly
- CNS effects: sedation and cognitive impairment
- Peripheral anticholinergic side effects: dry mouth, urinary retention, dry/blurry vision, constipation
- Best to avoid w/ BPH (will worsen symptoms) and glaucoma (can elevate IOP), constipation, urinary retention

Counseling:
- When using this medicine, you will become sleepy. It can also make you feel confused and make it difficult to concentrate.
- Do not take w/ other medicines that can make you sleepy, unless directed by your doctor. Do not use alcohol w/ any sleep medicine.
- This medicine should not be used by pts w/ an enlarged prostate, or BPH, w/o getting their doctor's approval. It will temporarily make urination more difficult.
- Do not use this medicine if you have glaucoma.
- If you have problems w/ constipation, this medicine will worsen the constipation.
- The medicine can cause your eyes to become dry and your vision to become blurry. It can also cause dry mouth.
- This medicine can make it difficult to urinate (it will take longer for the urine to come out).
- Although this drug is meant to be sedating, some children will experience excitability instead.
- To prevent motion sickness, take your dose 30mins before starting activity such as travel. To help you sleep, take your dose about 30mins before bedtime.
Cytotec
Misoprostol ; PREG CATEG X

MOA: prostaglandin E1 analog; replaces gut-protective PG removed by NSAIDs

Indication: cytoprotective agents, used for GERD
- Also used for medical termination of pregnancy w/ mifepristone

Dose:
- Start at 100 MCG right after dinner (food should be in stomach)
- Increase (if tolerated) to 100 mcg QID or 200 mcg QID, right after meals

Side effects:
- SIGNIFICANT: diarrhea, abdom pain
- Use of psyllium (Metamucil) may help decrease diarrhea
Carafate
Sucralfate ; GERD

MOA: forms a complex by binding w/ positively charged proteins that protect the stomach lining against pepsin and HCl

Dose: 1 g tablets QID BEFORE meals and AT BEDTIME (usual)
- May be given 1 g Q4hrs for tx of active ulcer

Side effects:
- MAJOR: constipation - drink adequate fluids and use laxatives if directed
- Drug is in Al complex - can accumulate in severe renal dz (avoid)

Drug interactions:
- Avoid taking antacids w/in 30 mins before or after taking sucralfate
- Separate from many other drugs 2 hrs before, 4 hrs after (difficult to use)

Counseling:
- Discuss other drugs, including OTC products you are using, w/ the pharmacist. This drug can decrease the absorption of other medicines.
Reglan
Metoclopramide ; GERD

Contraindications: GI obstruction/perforation, hx of seizures

MOA: Dopamine antagonist. At higher doses, blocks 5HT-receptors in chemoreceptor zone, enhances response to ACh causing enhanced motility and accelerated gastric emptying (peristaltic speed).

Dose: 5mg, 10mg (solution, injection)
- 10 mg QID 30 min BEFORE meals and at bedtime
- Has short duration of action (must be present in gut when food is present), and given at bedtime to control evening reflux symptoms -
- **CrCl < 40 ml/min, decrease dose by 50%

Side effects:
- CNS: DIZZINESS (somnolence & fatigue up to 70%), restlessness, akathisia, confusion, depression
- SERIOUS ADRs due to DA-blockade: EPS, including Parkinsonism --> these symptoms are more common if the drug is not dose-adjusted w/ poor renal clearance (elderly) and in pediatrics
- CV (more common w/ IV dosing)

**Wrong choice of drug in pt w/ PD

Drug interactions:
- Do not use in pt receiving meds for PD (counter-effect)
- Caution for additive CNS effects, including dizziness, sleepiness, fatigue

Counseling:
- Contact your doctor right away if you experience any unusual body movements, such as shakiness, stiffness, or uncontrollable movements of the mouth, tongue, cheeks, jaw, arms, or legs
- Seek medical attention if you experience fever, sweating, severe muscle stiffness (rigidity) and confusion
Hytrin
Terazosin ; BPH

MOA: non-selective alpha blocker - relaxes the smooth muscle of the prostate and bladder neck to improve urine flow
- There are 3 types of alpha receptors: 1A (prostate primarily has these), 1B, and 1D; terazosin and doxazosin are non-selective and this results in more orthostasis/dizziness/fatigue/HA than the selective agents

Dose:
- Start at 1mg, up to 2-10mg Qdaily (titrate slow), usually at bedtime
- The non-selective agents are often given QHS to help w/ the initial "first dose" effect of orthostasis/dizziness. This requires careful counseling as the man likely has nocturia.

Side effects:
- Orthostatic hypotension, dizziness, fatigue (much less w/ selective agents) - can titrate Q3-4 wks, as-needed (to reduce dizziness,hypotension)
Cardura
Doxazosin ; BPH

Dose:
- Start 1-2 mg; up to 4-8 mg Qdaily (titrate slowly), usually at bedtime
Flomax, generic
Tamsulosin ; BPH

MOA: selective alpha-1A blocker - relaxes the smooth muscle of the prostate and bladder neck to improve urine flow. Significant decrease in incidence and severity of OH, dizziness/fatigue/hypotension/HA

Dose: 0.4 mg (usually), can increase to 0.8 mg
- You may see alpha blockers in women - used for bladder outlet obstruction
- Some men may also be using 5-alpha-reductase inhibitors to prevent prostate cancer (controversial at present)

Drug interactions:
- Caution w/ concurrent use w/ the PDE-5 inhibitors sildenafil, tadalafil and vardenafil due to additive effects on BP, dizziness. Pts should be stable on alpha-blocker therapy before PDE-5 inhibition and the lowest doses of the PDE5 inhibitors should be used to initiate therapy. Vice versa.
Uroxatral
Alfuzosin ; BPH

MOA: selective alpha-1A blocker - relaxes the smooth muscle of the prostate and bladder neck to improve urine flow.

Dose: 10 mg ER, after SAME MEAL DAILY (food increases absorption), swallow whole
- Caution w/ alfuzosin in CrCl < 30 ml/min
- You may see alpha blockers in women - used for bladder outlet obstruction
- Some men may also be using 5-alpha-reductase inhibitors to prevent prostate cancer (controversial at present)

Drug interactions: 3A4 substrate
- Caution w/ concurrent use w/ the PDE-5 inhibitors sildenafil, tadalafil and vardenafil due to additive effects on BP, dizziness. Pts should be stable on alpha-blocker therapy before PDE-5 inhibition and the lowest doses of the PDE5 inhibitors should be used to initiate therapy. Vice versa.
- Hepatic substrate - can increase w/ potent 3A4 inhibitors (ritonavir, itraconazole, ketoconazole, clarithromycin) - use w/ potent 3A4 inhibitors is contraindicated (eg. voriconazole)
- Do not use alfuzosin in pts at risk for QT prolongation or w/ other QT-prolongating drugs - extends QT interval
Rapaflo
Silodosin ; BPH

MOA: selective alpha-1A blocker - relaxes the smooth muscle of the prostate and bladder neck to improve urine flow. Significant decrease in incidence and severity of OH, dizziness/fatigue/hypotension/HA

Dose: 8 mg WITH food
- Silodosin dosed at 4 mg if CrCl 30-50 ml/min, and CI if CrCl < 30 ml/min, or in severe liver disease
- You may see alpha blockers in women - used for bladder outlet obstruction
- Some men may also be using 5-alpha-reductase inhibitors to prevent prostate cancer (controversial at present)
- Silodosin can cause retrograde ejaculation (stops w/ drug discontinuation) (2.8%)

Drug interactions:
- Caution w/ concurrent use w/ the PDE-5 inhibitors sildenafil, tadalafil and vardenafil due to additive effects on BP, dizziness. Pts should be stable on alpha-blocker therapy before PDE-5 inhibition and the lowest doses of the PDE5 inhibitors should be used to initiate therapy. Vice versa.
- Hepatic substrate - can increase w/ potent 3A4 inhibitors (ritonavir, itraconazole, ketoconazole, clarithromycin) - use w/ potent 3A4 inhibitors is contraindicated
- Cannot be used w/ strong P-gp inhibitors, such as cyclosporine
Proscar
Finasteride ; BPH ; Preg Categ X

MOA: 5-alpha reductase inhibitor - inhibits the 5-alpha reductase enzyme, which blocks the conversion of testosterone to DHT.
- Usually used in men w/ larger prostate size (40+ grams) or more severe symptoms; due to the slow-onset, often given w/ alpha-blocker
- 6 months of tx may be required for maximal efficacy

Dose: 5 mg Q daily
(Propecia is also Finasteride - used for hair loss): 1 mg Q daily
- Do not use in a pt using Propecia for hair loss; refer to prescriber

Side effects:
- Decreased libido (0-3%), decreased ejaculation (0.1-2.9%), impotence (0-4.4%) - sexual SEs decrease w/ time; and approach placebo levels at one year of use
- 5-alpha reductase inhibitors SHRINK the prostate and decrease PSA

Drug interactions: 3A4 and 3A5 substrate

Counseling:
- Women who are or may become pregnant should not handle the tablets. The semen of males using the medicine may also be harmful.
- Your doctor may perform blood tests or other forms of monitoring during tx w/ finasteride. This drug can reduce the amt of PSA in the blood.
- Tell your doctor if you experience any of the following: decreased sex drive, decreased volume of ejaculation, impotence, breast tenderness/enlargement.
- Taking cold meds such as decongestants and antihistamines may make your symptoms worse.
Avodart
Dutasteride ; BPH ; Preg Categ X

MOA: 5-alpha reductase inhibitor - inhibits the 5-alpha reductase enzyme, which blocks the conversion of testosterone to DHT. 5-alpha reductase inhibitors SHRINK the prostate and decrease PSA
- Affects both types of 5-alpha receptors (type 1 and 2), may have better efficacy than finasteride, not yet proven
- Usually used in men w/ larger prostate size (40+ grams) or more severe symptoms; due to the slow-onset, often given w/ alpha-blocker
- 6 months of tx may be required for maximal efficacy

Dose: 0.5 mg soft gel Q daily

Side effects:
- Decreased libido (0-3%), decreased ejaculation (0.1-2.9%), impotence (0-4.4%) - sexual SEs decrease w/ time; and approach placebo levels at one year of use

Drug interactions: 3A4 and 3A5 substrate

Counseling:
- Women who are or may become pregnant should not handle the tablets. The semen of males using the medicine may also be harmful.
- Your doctor may perform blood tests or other forms of monitoring during tx w/ finasteride. This drug can reduce the amt of PSA in the blood.
- Tell your doctor if you experience any of the following: decreased sex drive, decreased volume of ejaculation, impotence, breast tenderness/enlargement.
- Taking cold meds such as decongestants and antihistamines may make your symptoms worse.
Amerge
Naratriptan
Axert
Almotriptan