ࡱ>  !` 0bjbj\\ >>$O TB ''''d *t B 6 44^444555       @ht  c55cc  44c4 4 4 c 0  4~4 &'m ="U=06_vD l5n1F Qd Q[555  X5556ccccB B d *@B B *B B B   Medication tables The medication tables that follow list medications commonly used in palliative medicine. They may serve as a reference tool for clinicians in the United States. Several caveats should be noted: the dosage forms may not be limitedthe ones listed and will likely change over time only the common adverse effects (AE) and drug interactions are listed the listed trade names either represent the only product available, or one that is commonly known For a complete, uptodate list of the products available, adverse effects, and drug interactions, refer to the current PDR. Adverse effects Adverse effects may be allergic, idiosyncratic, or doserelated extensions of known effects. They may increase with the number of different medications and the dosage. In the presence of liver or renal failure, adverse effects may emerge if dosage/frequency is not adjusted downward. If adverse effects occur, reduce or stop offending medications and provide appropriate antidotes. As medications may have many effects, they may also produce many different adverse effects. In some instances, they occur frequently enoughbe grouped as below: Adverse Effect GroupPossible Adverse Effectsanticholinergic AEDry mouth, decreased GI motility, constipation, tachycardia, urinary retention, mydriasis (= pupil dilatation), cycloplegia (= paralysis of ciliary muscle, of accommodation ( blurred vision). May leadrestlessness, confusion, hallucinations, memory impairment and delirium. May precipitate acute glaucomaCNS excitationEuphoria, restlessness, agitation, vivid dreams, nightmares, hallucination, myoclonus (jerks/twitches), focal motor or grand mal seizuresExtra pyramidal (EPS)Early effects (usually dose related): acute dystonic reactions: torticollis (= cervical muscle spasm ( unnatural twisting of head), opisthotonos (= a tetanic spasm with head and heels bent backward, body bowed forward), tics, grimacing, dysarthria, oculogyric crisis. Rx diphenhydramine 25(50 mg PO: IM, IV q 4 h PRN parkinsonian reactions: tremor, bradykinesia, rigidity, abnormalities of gait and posture. Rx benztropine (Cogentin () 1(2 mg IV, IM acutely then 1(2 mg PO daily(bid akathisia: sense of constant motor restlessness. Rx benztropine 1(2 mg PO dailybid Late effects: tardive dyskinesia: involuntary movements of lips, tongue, jaws, extremities. May persist indefinitely after medication is stopped. Antidopaminergic drugs may suppress these movementsHypersensitivity Rash, urticaria, bronchospasm, laryngeal or angioneurotic edema. In extreme cases, anaphylactic shock.Signs of electrolyte imbalance, dehydrationDry mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain/cramps, muscle fatigue, hypotension (may be orthostatic), oliguria, tachycardia, nausea/vomitingUpper gastrointestinal (GI)Nausea, vomiting, dyspepsia. May include erosions, ulceration, bleeding. Rx misoprostol 200 (g PO q 6 h or histamine H2 receptor antagonists (see Antacids)  Abbreviations, Symbols Routes of AdministrationPOper os, by mouthPRper rectum, by the rectumIMintramuscularIVintravenousSCsubcutaneousSLsublingualTDtransdermalOthersCOX2Cyclooxygenase2 selective inhibitor. may have less gastrointestinal, renal, and antiplatelet adverse effectsER Extended/sustained release (extended/sustained release tablets must be taken intact, never broken or crushed)IR Immediate release (tabs are IR unless noted)ODTOrally dissolving tabsMAOIMonoamine oxidase inhibitorNANot availableNSNormal salineNSAIDNonsteroidal antiinflammatory drugPDR Physicians Desk Reference, Medical Economics Company, Inc., 1999SSRISelective serotonin reuptake inhibitorTCATricyclic antidepressant( Upper dose limited only by need and adverse effects Fixeddose combinations not recommended in young children Dose varies depending on condition being treatedJ Insufficient experience in the pediatric population. If these drugs need be used, consultation is appropriateJJ Insufficient experience in the pediatric Population for this indication, although the drug may be used for other reasons. If these drugs needbe used, consultation is appropriate Medication information resources Micromedex Healthcare Series, Thompson Healthcare, Inc. 2005 Goodman & Gilman's The Pharmacologic Basis of Therapeutics, Tenth Edition, McGraw-Hill Medical Publishing Division, 2001 American Hospital Formulary Service (AHFS) Drug Information 2005, American Society of Health-System Pharmacists, Bethesda, MD Palliative Care Formulary, Second Edition, Radcliffe Medical Press, UK, 2002 Medication table alphabetical index This alphabetic index is included to assist in locating a specific medication in the tables that are sorted by Therapeutic Group Medications in the miscellaneous group appear at the end of the medication tables. Generic nameTherapeutic groupGeneric nameTherapeutic groupGeneric nameTherapeutic groupAcetaminophenAnalgesicFlurbiprofenAnalgesicNortriptylineDepressionAcetylsalicylic acid (ASA)AnalgesicFosphenytoinMiscellaneousOctreotideDiarrheaAlbuterolDyspneaFurosemideAscitesOlanzapineDeliriumAlginic acidNauseaGabapentinPainOmeprazoleNauseaAlprazolamAnxietyGlycerinConstipationOndansetronNauseaAluminum or magnesium hydroxide ConstipationGlycopyrrolateDryingOrphenadrineMiscellaneousAmitriptylineDepressionHaloperidol DeliriumOxandroloneAnorexiaAtropineDryingHesperidinsAnalgesicOxazepamAnxietyAttapulgite DiarrheaHyaluronidaseMiscellaneousOxybutyninMiscellaneousBaclofenMiscellaneousHydrocodoneCoughOxycodoneAnalgesicBelladonna & opiumMiscellaneousHydrocodone + AcetaminophenAnalgesicOxycodone + Acetaminophen AnalgesicBethanecholMiscellaneousHydrocodone + IbuprofenAnalgesicOxycodone + Aspirin combinationsAnalgesicBisacodylConstipationHydromorphoneAnalgesicParoxetineDepressionBismuth subsalicylateDiarrheaHydroxyzineMiscellaneousPemolineDepressionBupropionDepressionHyoscyamine DryingPerphenazineDeliriumCapsaicinPainIbuprofenAnalgesicPhenazopyridineMiscellaneousCarbamazepinePainImipramineDepressionPhenobarbitalSedationCelecoxibAnalgesicIndomethacinAnalgesicPhenytoinMiscellaneousChlorpromazineDeliriumKetoprofenAnalgesicPiroxicamAnalgesicCholine magnesium trisalicylateAnalgesicKetorolacAnalgesicPrednisoneSteroidsCimetidineNauseaLactuloseConstipationProchlorperazineNauseaClomipramineDepressionLansoprazoleNauseaPromethazineNauseaClonazepamAnxietyLevorphanolAnalgesicProtriptylineDepressionCodeine AnalgesicLidocaine PainPsylliumConstipationCodeine + acetaminophenAnalgesicLidocaine + prilocainePainQuetiapineDeliriumCyclobenzaprineMiscellaneousLoperamideDiarrheaQuinine sulfateMiscellaneousCyproheptadineMiscellaneousLorazepam AnxietyRanitidineNauseaDantroleneMiscellaneousMagnesium citrateConstipationRisperidoneDeliriumDesipramineDepressionMagnesium hydroxideConstipationSalsalateAnalgesicDexamethasoneSteroidsMeclizineMiscellaneousScopolamineDryingDextroamphetamineDepressionMegestrol acetateAnorexiaSennosidesConstipationDextromethorphanCoughMethadoneAnalgesicSertralineDepressionDiazepamAnxietyMethocarbamolMiscellaneousSilver sulfadiazineSkinDiclofenacAnalgesicMethylphenidateDepressionSimethiconeMiscellaneousDicyclomineMiscellaneousMetoclopramideNauseaSodium phosphateConstipationDiflunisalAnalgesicMetolazoneAscitesSorbitolConstipationDiphenhydramineDeliriumMetronidazoleSkinSpironolactoneAscitesDiphenoxylateDiarrheaMexiletine PainSucralfate NauseaDocusate sodium or calciumConstipationMidazolamAnxietySulindacAnalgesicDoxepinDepressionMineral OilConstipationTheophyllineDyspneaDronabinolNauseaMirtazapineDepressionTramadolAnalgesicDroperidolNauseaMisoprostol NauseaTrazodoneDepressionEtodolacAnalgesicMorphine, ERAnalgesicTrimethobenzamideNauseaFamotidineNauseaMorphine, IRAnalgesicTrimipramineDepressionFentanylAnalgesicNabumetoneAnalgesicValproic acidPainFlavoxateMiscellaneousNandrolone decanoate AnorexiaVenlafaxineDepressionFlecainidePainNaproxenAnalgesicZolpidemInsomniaFludrocortisone acetateSteroidsNefazodoneDepressionFluoxetineDepressionNifedipineMiscellaneous Common analgesics Generic nameTrade name(s)Dosage forms availableTime CmaxElimination tRoute of eliminationUsual dosingRecommended maximum dosingAcetaminophenAcetaminophen (paracetamol)Various, Tylenol Plain and Extra Strength are examplestabs: 325, 500 mg elixir: 80 mg/0.8 ml, 160 mg/5 ml supp: 120, 325, 650 mg, 81 mg chewPO: 12 hr PR: 107288 minutes (1.8-4.8 hr) 24 hr in normal individualsLiver metabolism: 25% on first pass through the liver Renal Excretion: 1%4% unchanged325650 mg PO PR q 4 h routinely or PRN650 mg PO PR q 4 h (4 g/24h )NSAIDs and ASAAcetylsalicylic acid (ASA) (salicylic acid derivative)Various, Aspirin is an examplecaplets, tabs: 325, 500, 975 mg children's tab: 80 mg EC tabs: 81, 325, 500 mg elixir: 80 mg/ supp: 300, 600 mgPO: buffered tablet: 20 minutes PO: effervescent solution: 15 minutes 4.7 9 hr (average 6 hr) The half-life is dose relatedLiver metabolism Renal Excretion: 5.6% 35.6%325 650 mg PO, PR q 4 h routinely or PRN650 mg PO PR q 4 h (5 g/24h )Celecoxib (COX 2 selective)Celebrex cap:100, 200, 400 mgPO: H" 3 hr11 hrLiver metabolism: extensive Renal Excretion: 27% Less than 3% of a dose is eliminated as unchanged drug Feces: 57%100200 mg PO bid200 mg PO bidCholine magnesium trisalicylate (salicylic acid derivative)Trilisate tab: 500, 750, 1000 mg salicylate elixir: 500 mg/5 mlPO: tab: 1.52 hr Elixir:: 3.5 hr212 hr Dosedependent; higher doses produce longer half-lifeHydrolysis in GIsalicylates Liver metabolism Renal Excretion: 5.6%35.6% 11.5 g PO q 12 h or 0.51.0 g PO q 8 h1.5 g PO q 8 h (4.5 g/24h )Diclofenac (acetic acid derivative)Various, Cataflam , Voltaren are examplesIR tabs: 50 mg ER tabs: 25, 50, 75, 100 mg (with 200 mcg misoprostol: Arthrotec 50, 75 mg)IR: (diclofenac potassium): 1 hr (range 0.332 hr) ER: (diclofenac sodium): 2 hr (range 14 hr) PR: 30 minutes2 hrLiver metabolism: extensive firstpass Renal Excretion: 65% Bile: 35%IR: 5075 mg PO PR q 68 h or ER 75100 mg PO q 812 h50 mg IR PO q 6 h or 75 mg ER PO q 8 h (225 mg/24h )Diflunisal (salicylic acid derivative)Various, Dolobid is an exampletabs: 500 mgPO: 23 hr812 hr Half-life is dependent on the dose Liver metabolism: extensive Renal Excretion: 80%90% Feces: less than 5%250500 mg PO q 812 h500 mg PO q 8 h (1.5 g/24h )Etodolac (acetic acid derivative)Various, Lodine is an exampleIR tabs: 200, 300, 400, 500 mg ER tabs: 400, 500, 600 mgPO IR: 12 hr PO ER: 312 hr67 hrLiver metabolism: extensive Renal Excretion: 72% Feces: 16%200500 mg PO q 612 h400 mg PO q 8 h ER: 1,200 mg dailyFlurbiprofen (propionic acid derivative)Various, Ansaid is an exampletabs: 50, 100 mgPO: 1.52 hr5.7 hrLiver metabolism: extensive Renal Excretion: 95%50100 mg PO q 12 h200300 mg/24h Ibuprofen (propionic acid derivative)Various, Motrin is an exampletabs: 200, 400, 600, 800 mg elixir: 40 mg/1 ml, 100 mg/5 mlPO: 1.41.9 hr1.82 hrLiver metabolism: extensive Renal Excretion: Major route200800 mg PO q 68 h800 mg PO q 6 h (3.2 g/24h )Indomethacin (indole)Various, Indocin is an exampleIR tabs: 25, 50 mg ER tabs: 75 mg supp: 25 mg/5 mlPO: 2 hr 4.5 hrLiver metabolism: extensive Renal Excretion: 60% H" 26% eliminated as unchanged drug Feces: 33%25 75 mg PO q 8 12 h or 75 mg ER PO q 12 24 h50 mg PO q 6 h (200 mg/24h )Ketoprofen (propionic acid derivative)Various, Orudis is an examplecap: 12.5, 50, 75 mg ER tabs: 100, 200 mgPO IR: 1.22 hr PO ER: 6.89.2 hr24 hr ER is 5.4 +/ 2.2 hrLiver metabolism Renal Excretion: 80%; Bile: up to 40%150200 mg PO/24h IR: q 68 h ER: q 1224 h75 mg PO q 6 h (300 mg/24h )Ketorolac (acetic acid derivative)Various, Toradol is an exampletab: 10 mg inj: 15, 30 mg/mlPO: 44 minutes IM: 3045 minutes IV: 13 minutes5.6 hrLiver metabolism Renal Excretion: 92% excreted in the urine; (60.6%) as unchanged drug Feces: 5.9%6.3%10 mg PO qid or 60 mg IM, IV loading dose, then 1030 mg IM, IV q 6 h40 mg PO/24h or 120 mg IM, IV /24h Nabumetone Various, Relafen is an exampletab: 500, 750 mgPO: 36 hrNabumetone (prodrug): unknown Active metabolite (6methoxy2naphthylacetic acid): 24 hrLiver metabolism: extensive Renal Excretion: 80% Feces: 10% 12 g PO q 1224 h1 g PO q 12 h (2 g/24h )Naproxen (propionic acid derivative)Various, Naprosyn is an exampleIR tabs: 220, 275, 250, 375, 500, 550 mg ER tab: 375, 500 mgPO IR: naproxen: 24 hr, naproxen sodium: 12 hr PO ER: 3 hr Topical, gel: 24 hr1215 hrLiver metabolism: extensive Renal Excretion: 95% 250500 mg PO q 812 h500 mg PO q 8 h (1.5 g/24h )Piroxicam (oxicam) Various, Feldene is an examplecaps: 10, 20 mgPO: 35 hr50 hr; range:3086 hr Liver metabolism: extensive Renal Excretion: moderate; 5%10% of a dose is eliminated as unchanged drug Feces: small1020 mg PO q 1224 h20 mg PO q 12 h (40 mg/24h )Salsalate (salicylic acid derivative)Various, Disalcid is an exampletabs: 500, 750 mgPO: 1.4 hr1 hrLiver metabolism: < 1% appears as unchanged salsalate. The remainder is excreted as salicylic acid or metabolites of salicylic acid.1,0001,500 mg PO bid3,000 mg/daySulindac (indole)Various, Clinoril is an exampletabs: 150, 200 mgPO: 1 hrSulindac: 7.8 hr Active Metabolite: 16.4 hrLiver metabolism: extensive Sulindac has no pharmacologic activity and must be metabolizedthe pharmacologically active metabolite Renal Excretion: 50% Feces: 25%150 mg PO q 12 h200 mg PO q 12 h (400 mg/24h )OpioidsCodeine (alone) (methylmorphine, naturally occurring opioid metabolized into morphine)Various IR tabs: 15, 30, 60 mg elixir: 15 mg/5 ml inj: 15, 30 mg/mlPO: 12 hr IM: 30 minutes PR: 30 minutes 2.53.5 hrLiver metabolism: 2489% (metabolized to morphine) Renal Excretion: 90% (316% of unchanged drug) Feces: about 5%1560 mg PO, SC, IM q 4 h routinely or q 1 h PRN 600 mg/24h Codeine + acetaminophen combinationsVarious, Tylenol # 3, 4 are examplestabs: 30, 60 mg codeine + 325 mg acetaminophen (may include caffeine, butalbital)Codeine: PO: 12 hr Codeine PR: 30 min APAP: PO: 12 hr APAP: PR: 107288 minAcetaminophen: 4 hr Codeine: 2.53.5 hrCodeine and Acetaminophen: see above.12 tabs PO q 4 h routinely or PRNlimited to 12 tabs/24h by acetaminophenFentanylVarious, Duragesic, Actiq, Sublimaze are examplespatch: 25, 50, 75, 100 mcg/hr lozenge: 200, 400, 600, 800, 1200, 1600 mcg inj: 50 mcg/mlEpidural: 30 minutes Transmucosal: 20 40 minutes Transdermal patch: 24 72 hrH" 4 hr Transdermal patch: 17 hrLiver metabolism: to inactive metabolites Renal Excretion: 75% (metabolites); 10% (unchanged drug) Feces: 9%patch: 25 ( mcg/h q 72 h lozenge: 200 (g q 1 h titrate PRNlimited only by need and adverse effectsHydrocodone + acetaminophenVarious, Vicodin, Lortab, Norco are examplestabs: 5/500, 5/325, 7.5/325, 7.5/500, 7.5/750, 10/325, 10/500, 10/660 elixir: 7.5/500 in 15 mlPO: 1.3 hr for hydrocodoneHydrocodone: 3.84.5 hr Acetaminophen: see aboveLiver metabolism: Acetaminophen: see above Hydrocodone: extensive active metabolites Renal excretion: 26%12 tabs PO q 46 h routinely or PRNlimited to 4 g acetaminophen in 24 h Hydrocodone + ibuprofenVicoprofentab: 7.5/200PO: within 2 hr (both components)Hydrocodone 3.84.5 hr Ibuprofen 1.82 hr Liver metabolism: see above Renal excretion: see above12 tabs PO q 46 h routinely or PRNlimited2,400 mg ibuprofen in 24 hHydromorphoneVarious, Dilaudid, Palladone are examplesIR tabs: 2, 4, 8 mg ER capsules: 12, 16, 24, 32 mg elixir: 1 mg/ml inj: 1, 2, 4, 10 mg/ml powder: 250 mg/vial supp: 3 mgPO IR: 4860 minutes PO ER: 12 16.5 hr Epidural: 8 minutesIR: H" 3-4 hr Liver metabolism: extensive Renal excretion: As hydromorphone 1.3% 13.2% Conjugates: 22% 51%1 ( mg: PO q 4 h routinely or q 1 h PRN, SC, IM q 3 h routinely or q 30 min PRN, SC, IV q 1 h via infusion + breakthrough q 30 min PRNlimited only by need and adverse effectsLevorphanolLevoDromorantab: 2 mg PO: 1 hr 11 hr; With chronic PO dosing, the half-life can be as long as 30 hrLiver metabolism: extensive Renal excretion: extensive as conjugate2( mg PO q 68 hlimited only by need and adverse effectsMeperidine (pethidine) (synthetic opioid not relatedmorphine, Useful for rigors)Various, Demerol is an exampletabs: 50, 100 mg inj: 50, 75, 100 mg/ml syrup: 10mg/1ml, 25 mg/1 ml, 50 mg/5 mlPO: H" 1 hr IM: 25 minutes Meperidine 3.2 3.7 hr Active metabolite: 24 48 hr Liver metabolism: 50% first pass through the liver Renal Excretion: 0.5% 5.2% (average 2.2%) unchanged Active metabolite, normeperidine, excreted 0.6% 21% (average 6.2%) unchanged in the urine50150 mg PO IM, SC, IV q 4 h PRN NOT RECOMMENDED FOR CHRONIC DOSING as active metabolite, normeperidine may produce adverse effects150 mg q 34 h, 9001200 mg/24h MethadoneVarious, Dolophine is an exampletab: 5, 10, 40 mg elixir: 1, 2, 10 mg/mlPO: 24 hrMethadone: 23 hr Metabolite: 39.848 hr After a single PO dose, half-life is biphasic with an initial phase range of 1224 hr and a secondary phase of up to 55 hrLiver metabolism: 4 times greater after PO administration than after IM administration 5 mg PO q 8 h Titrate dose q 35 days duedelayed clearancelimited only by need and adverse effectsMorphine, IRVariousIR tabs: 10, 15, 30 mg elixir: 1, 2, 20 mg/ml supps: 5, 10, 20, 30 mg inj: 1, 2, 8, 10, 15, 25, 50 mg/mlBuccal: 5 hr (range 1.512 hr) Colostomy, suppository: 0.51 hr Epidural/Intrathecal: 510 minutes IV/IM: 1060 minutes Inhalation (nebulized): 1045 minutes PO IR: 1 hr PO ER: 8.4 hr PO ER: capsules (Avinza): 30 minutes PR: using PO ER: 5.46.7 hr PR: supp IR: 0.75 1 hr SC: 30 minutes4 hrLiver metabolism: H" 90% of a given dose is conjugated morphine 3 glucuronide (M3G) and morphine 6 glucuronide (M6G-active) Renal Excretion: 90% (metabolites and free drug) within 24 hr The pharmacokinetics of morphine are altered in renal failure. Clearance is decreased. M3G and M6G accumulate several fold with associated risk of toxicity Feces: 710%1( mg: PO PR q 4 h Routinely or q 1 h PRN, SC, IM q 3h routinely or q 30 min PRN, or SC, IV q 1 h via infusion + breakthrough q 30 min PRNlimited only by need and adverse effectsMorphine, ERcapsule: Kadian tabs: OraMorphER, MS Contin Avinza Kadian capsules: 20, 50, 100 mg (q 1224 h) MSContin tabs: 15, 30, 60, 100, 200 mg (q 812 h) OraMorphER tabs: 15, 30, 60, 100 mg (q 812 h) (Kadian capsules may be opened and pellets mixed with fluids or soft food)10( mg: PO/PR q 824 h routinely only (depending on product). Provide breakthrough doses using IR morphine q 1 h PRN.limited only by need and adverse effectsOxycodone (alone)IR: various ER: OxyContin IR tabs: 5, 10, 15, 30 mg ER tabs: 10, 20, 40, 80 mg elixir: 1, 20 mg/ml PO IR: 1.6 hr PO ER: 2.13.2 hrPO IR: 4 hr PO ER: 4.58 hrLiver metabolism: extensive Renal Excretion: extensive with approximately 20% unchanged5( mg IR PO PR q 4 h routinely, or q 1 h PRN or 10( mg ER PO q 12 hlimited only by need and adverse effectsOxycodone + Acetaminophen combinationsVarious, Percocet is an example5 mg oxycodone + 325 mg acetaminophen 5/500,7.5/325, 7.5/500, 10/325, 10/650 (may include caffeine)See above 4 hr for oxycodone 24 hr for acetaminophenSee above 12 tabs PO q 4 h routinely or PRNlimited to 12 tabs/24h by acetaminophenOxycodone + Aspirin combinations Various, Percodan is an example5 mg oxycodone + 325 mg ASA (may include caffeine)See aboveOxycodone: 4 hr ASA: 4.79 Renal Excretion: approximately 20% unchanged See above12 tabs PO q 4 h routinely or PRNlimited to 12 tabs/24h by ASATramadolUltram tab: 50 mgPO: 2 hrTramadol: 6.3 hr Metabolite: 7.4 hrLiver metabolism: extensive Renal Excretion: 30% excreted in the urine as unchanged drug, 60% of the dose is excreted as metabolites12 tabs PO q 6 h2 tabs PO q 6 hExtracted and updated from: Ferris FD, Flannery JS, McNeal HB et al, eds. Medication Table, in Module 4: Palliative Care, A Comprehensive Guide for the Care of Persons With HIV Disease. Toronto, Ontario: Mount Sinai Hospital and Casey House Hospice; 1995:162166. Physicians' Desk Reference. Montvale, NJ: Medical Economics Company, Inc; 1999. Equianalgesic Doses of Opioid AnalgesicsOral/Rectal Dose (mg)AnalgesicParenteral Dose (mg)150Codeine50Fentanyl0.05015Hydrocodone3Hydromorphone12Levorphanol1150Meperidine (pethidine)5015Morphine510Oxycodone  When converting or from transdermal fentanyl patches, published data suggest that a 25 mg patch is equivalent to 45 135 mg of oral morphine/24h. However, clinical experience suggests that most patients will use the lower end of the range of morphine doses, ie, for most patients 25 mg is H" 50 mg of oral morphine/24h Other medications used in palliative care Generic nameTrade name(s), dosage formsTime CmaxElimination tRoute of eliminationAdult dosesPediatric dosesAdverse effectsCommon interactionsAnorexia (appetite stimulants)Megestrol acetate Progestin for appetite stimulationMegace (: tabs: 20, 40 mg suspension: 40 mg/ml PO: tablet: 13 hr PO: suspension: 35 hr13105 hr (mean 34 hr)Liver metabolism: 58%. Renal Excretion: 57%78% Feces: 8% and 30% doses up800 mg PO daily may be useful:&gynecomastia deep vein thrombophlebitis, pulmonary embolism alopecia hyperglycemia dyspnea vaginal bleeding following withdrawal none significantNandrolone decanoate Anabolic steroidDeca Durabolin (: inj: 100, 200 mg/ml IM: 24 hr6 8 daysLiver metabolism: Renal excretion: unchanged Nandrolone and its metabolites50 100 mg IM q 3 4 wk up 12 wk may repeat after 4- wk rest:&nausea, vomiting, peptic ulcer diarrhea increased or decreased libidoPO: anticoagulants oxyphenbutazone insulinOxandrolone Anabolic steroid for weight gainVarious, Oxandrin ( is an example: tabs: 2.5, 10 mgIM: 24 hr6 8 daysLiver metabolism: Renal Excretion: unchanged Oxandrolone, 29%2.5 mg bid qid for 2 4 wk, then intermittently maintain weightd" 0.1 mg/kgcholestatic jaundice elevated liver function tests virilizationanticoagulants Anxiety (anxiolytics)Alprazolam Benzodiazepine Various, Xanax ( is an example: tabs: 0.25, 0.5, 1, 2 mgPO: 0.8 to 2 hours 11.2 hoursLiver metabolism: extensive Renal Excretion: 80% Feces: 7%0.250.5 mg bid-tid (max 4 mg/24 h):&drowsiness ataxia fatigue confusion weakness dizzinessCNS depressants disulfiram cimetidine levodopa anticonvulsants psychotherapeutic agentsClonazepam Benzodiazepine Long half-lifeVarious, Klonopin ( is an example: Tabs/wafers: 0.5, 1, 2, 0.125, 0.25 mgPO: 1 4 hr PR: 10 30 minutes30 40 hrLiver metabolism: highly metabolized Renal Excretion: 0.5% 1%0.25 3 mg PO q 8 12 h (max 20 mg/24h ):&:&nausea rashCNS depressantsDiazepam Benzodiazepine Long half-lifeVarious, Valium ( is an example: tabs: 2, 5, 10 mg elixir: 1, 5 mg/ml inj: 5 mg/ml PR gel: 5mg/unit PR supp:compoundedPO: 0.891.32 hr IV: 8 minutes IM: 1 hr PR gel:1.5 hr 0.832.25 days Active metabolites 40194 hrLiver metabolism extensive Renal Excretion: 75%210 mg PO, IM, IV q 68h seizures: 510 mg IV q 510 min PRN0.10.8 mg/kg/24h PO q 6 hdrowsiness confusionCNS depressantsLorazepam Benzodiazepine Intermediate half-life Various, Ativan ( is an example: tabs: 0.5, 1, 2 mg SL tabs: 0.5, 1, 2 mg solution: 2 mg/ml inj: 2, 4 mg/ml PO: 2 hr IM: 13 hr SL: 60 minutes12 hr Metabolites: 1218 hrLiver metabolism: 75% Renal Excretion: 88% Feces: 7%sleep: 14 mg PO nightly PRN anxiolytic: 0.51 mg PO q 68 h (max 6 mg/24h) sedation: 14 mg PO q 14 h PRN (may require 2050 mg/24h or more) seizures: 34 mg IV, SC, SL q 510 min PRN :&:&drowsiness confusionCNS depressantsMidazolam Benzodiazepine Short half-lifeVersed (: inj: 1, 2, 5 mg/mlIM: 45 minutes PR: 20 50 minutes1.8 6.4 hrLiver metabolism: extensive Renal Excretion: 45% 57%1 5 mg SC, IV, IM q 3h PRN or 0.5 5.0 mg/h SC continuous infusion seizures: 1 5 mg SC, IV, IM q 1 h PRN (generally used as an IV or SC infusion due short half-life):&:&drowsiness confusionCNS depressantsOxazepam Benzodiazepine Moderate half-lifeVarious, Serax ( is an example: tabs: 10, 15, 30 mgPO: 2 3 hr2.8 8.6 hrLiver Metabolism: moderate Renal Excretion: 50% unchanged drug30 120 mg PO / 24 h (in divided doses):&:&drowsiness confusionCNS depressantsAscites (diuretics)Furosemide Loop diureticVarious, Lasix ( is an example: tabs: 20, 40, 80 mg oral soln: 10 mg/ml inj: 10 mg/mlPO: 60120 minutes IV: 610 min30120 minutesLiver metabolism: approximately 10% Renal Excretion: 60%90% Bile: 6%9% Feces: 7%9%20240 mg PO / IV daily bidinitial dose: 12 mg/kg/24h PO q 68 h (may increase up 8 mg/kg/24h)bloating, epigastric distress nausea/vomiting hypersensitivity gynecomastiaantihypertensives indomethacin aminoglycosides alcoholMetolazone DiureticVarious, Zaroxolyn ( is an example: tabs: 2.5, 5, 10 mg8 hr814 hrMetabolism: site unspecified Renal Excretion: 56.1%2.5 20 mg PO daily:&:&tinnitusbarbiturates opioidsSpironolactone DiureticVarious, Aldactone ( is an example: tabs: 25, 50, 100 mgPO: 1 3 hr1.3 1.4 hr Active metabolite: 8.9 23 hrLiver metabolism: extent not reported Renal Excretion: 47%57%50250 mg PO dailybid14 mg/kg/24h in 1, 2, 3, or 4 divided dosesgynecomastia salicylatesConstipation (laxatives)Aluminum or Magnesium Hydroxide Antacids Many tabs and liquids available over the counter.Onset of action: dependent upon the ability of the antacidsolubilize in the stomach and react with the hydrochloric acid Aluminum hydroxide :Slow Magnesium hydroxide: FastDuration of action in fasting patients may range from 20 to 60 minutes. When given 1 hr after meals, the acidneutralizing effect may be prolonged up to 3 hrNA1530 ml or 12 tabs PO q 2 h PRN (avoid Mg if renal failure present, use Al)infant: 2.55 ml PO q 12h child: 515 ml PO pc and nightly alkalosis Mg can ( diarrhea Al can ( constipation Hypophosphatemia direct binding or elevated gastric pH may alter drug absorption, i.e., ACE inhibitors, benzodiazepines, cephalosporins, chlorpromazine, histamine H2 receptor antagonists, corticosteroids, digoxin, hypoglycemics, PO: iron, isoniazid, ketoconazole, metronidazole, nitrofurantoin, NSAIDs, quinidine, salicylates, phenytoin, tetracycline, theophyllines, valproic acid, vitamins C, DBisacodyl Laxative Various, Dulcolax ( is an example: tab: 5 mg supp: 10 mg enema: 10 mg in 5 mlInitial response: PO: 612 hr PR: 1560 minutesNARenal Excretion: minimal Feces: extensive510 mg PO / PR dailytid510 mg PR or 0.3 mg/kg PO PRNdiarrhea cramps dehydration electrolyte depletion nausea/vomitingnone significantDocusate sodium or calcium Anionic surfactant that emulsifies, wets, and disperses feces Various, Colace, ( Surfak ( are examples: caps, tabs: 50, 100, 240, 250 mg syrup: 20 mg/5 ml, 50 mg/5 ml drops: 10 mg/mlInitial response: PO: 13 days NAExcreted in bile/feces100200 mg PO dailytid5 mg/kg/24h PO as a single daily dosemild abdominal cramping bitter tastemineral oilGlycerin Contact irritant laxative Various: supp: 96% glycerin Initial response: PR: 1530 minutes3045 minutesLiver metabolism: 80% Renal Excretion: 10%20%1 supp PR dailybid1/21 supp PR PRN rectal irritation none significantLactulose Osmotic laxative Various: syrup: 10 g/15 mlInitial response: PO: 2448 hrNAColon: extensive: lactulose is metabolized by colonic bacteria Renal Excretion: 3% 1560 ml PO dailytid510 ml PO once dailyflatulence cramps nauseaantibiotics PO: neomycin antacidsMagnesium citrate Osmotic cathartic laxative that draws fluid into the gut, distends the intestine, and results in increased peristalsis Various, CitroMag ( is an example: PO solution: 168 mEq mg/240 mlInitial response: PO: 0.53 hrNANA50150 ml PO dailytid (not recommended)4 ml/kg POlarge watery stools cramps caution in renal patientsnone significantMagnesium hydroxide Osmotic cathartic laxative Phillips Milk of Magnesia (: liquid: 400 mg/5 ml tab: 311 mg NANANA1530 ml PO dailyqid PRNno informationdiarrheanone significantMineral Oil Irritant laxative that penetrates and softens feces and may interfere with water reabsorption Various Initial response: PO: 68 hr PR: 515 minutesNANot absorbed1545 ml PO dailybid1 ml/kg PO nightlyanal leakage nausea abdominal cramps lipid pneumoniadocusate salts fat-soluble vitamins (A, E, D, K)Psyllium Bulkforming laxativeVarious, Metamucil ( is an example: fiber wafers: 3.4 g unflavored powder: 7 g/tsp orange powder: 3.4 g/2 tspNot absorbed Initial response: PO: 1224 hr (up3 days)NANot absorbed1 packet (10 ml) dailytid, or 1 tsp unflavored powder (2 of flavored) PO daily, or 2 wafers PO daily (must mix with at least 240 ml of water)1/41/2 of adult doseensure good fluid intake, dehydration will worsen constipation hypersensitivitynone significantSennosides Contact cathartic laxative that stimulates colonic peristalsis Various, Senokot ( is an example: tab: 8.6 mg sup: 30 mg syrup: 1.7 mg/ml granules: 15 mg/tspInitial response: PO: 612 hr PR: 0.5 2 hrNAFecal and/or renal12 tabs PO dailytid (available combined with docusate)310 ml of Senokot syrup PO bidnausea abdominal crampsnone significantSodium phosphate Osmotic cathartic laxative that draws fluid into the gut, distends the intestine, and results in increased peristalsis Various, Fleet Enema ( is an exampleInitial response: PR: 0.53 hrNANA1 enema PR dailybidone pediatric or adult Fleet enema PRNrectal irritation abdominal crampsnone significantSorbitol Osmotic laxative Various: syrup: 10 g/15 mlInitial response: PO: 0.53 hrNALiver metabolism:fructose1560 ml PO dailytid510 ml PO dailyflatulence cramps nauseaantibiotics PO: neomycin antacidsCough (anti-tussives)Dextromethorphan AntitussiveVarious combination preparations: cap: 30 mg syrup: 30 mg/5 mlPO: 22.5 hr1.43.9 hr Metabolites: 3.45.6 hrLiver metabolism: rate of metabolism varies among individuals Renal excretion: extensive1545 mg PO q 46 h PRN (max 120 mg/24h )1 mg/kg/24h q 68 hnausea/vomiting dizziness sedation GI disturbancesCNS depressants MAOIsHydrocodone Antitussive opioidVarious, Hycodan ( is an example: tab: 5 mg syrup: 5 mg/5 mlPO IR: 1.3 hr PO ER: 3.4 hr3.84.5 hrLiver metabolism: extensive Renal Excretion: 26%510 mg PO q 46 h PRN0.1 mg/kg PO q 4 h PRNlightheadedness dizziness sedation nausea/vomiting constipation hypersensitivityCNS depressants TCAs MAOIsDelirium (antipsychotics and EPS antidotes)Chlorpromazine Dopaminergic antiemetic, sedating neuroleptic, hiccups Various, Thorazine ( is an example: tabs: 10, 25, 50, 100, 200 mg liquid: 100 mg/ml inj: 25 mg/ml supp: compounded PO: 2.8 hr IM: 1 4 hr IV: 2 4 hr6 hrLiver metabolism: extensive PO: undergoes extensive first pass metabolism Renal Excretion: 23%PO, PR, IM, IV q 6 12 h nausea, hiccups: 25 50 mg PO PR, IM, q 8 12 h PRN antipsychotic dose: :& antiemetic: 2 mg/kg/24h PO, IV q 4 6 hhaloperidol (not as sedating) anticholinergic AE EPS sedation hypotension itchyCNS depressants anticonvulsants barbiturates lithiumDiphenhydramine H1 histamine receptor antagonist Various, Benadryl ( is an example: caplets: 25, 50 mg elixir: 12.5 mg/5 ml childrens liquid: 6.25 mg/5 ml inj: 50 mg/ml cream: 1, 2% PO: 24 hr48 hr Metabolites: 8.610 hrLiver metabolism: 50% large firstpass effect2550 mg PO, IV tidqid, or 1050 mg IM, IV q 4 h PRN or Routinely (max 400 mg/24h ) 5 mg/kg/24h PO IM, IV q 46 h PRN or routinely sedation dizziness confusion nausea/vomiting hypersensitivity arrhythmiasCNS depressants Ephedrine MAOIsHaloperidol Dopaminergic antiemetic, nonsedating neurolepticVarious, Haldol ( is an example: tabs: 0.5, 1, 2, 5, 10, 20 mg liquid: 2 mg/ml inj: 5 mg/ml PO: 26 hr IM: 20 minutes21 hr (range: 1038 hr)Liver metabolism: Renal Excretion: 3340% Feces: 15%0.55 mg PO SC, IM q 46 h PRN or routinely :&diarrhea sedation hypotension hypersensitivityalcohol anticholinergics barbiturates, ( blockers cimetidine, clonidine disulfiram l dopa, lithium metoclopramide meperidine phenytoin pyrimethamine SSRIs, TCAs trazodone, valproate vitamin COlanzapine Atypical neurolepticVarious, Zyprexa ( is an example: tabs: 2.5,, 5, 7.5, 10, 15, 20 mg ODT: 5,10 15, 20 mg Inj: 10 mg/vialPO: 6 hr IM: 1545 minutes2154 hr (mean 30 hr)Liver metabolism: extensive Renal Excretion: 57% Feces: 30%2.5 mg PO daily and advance to 510 mg/24h:&:&dizziness hypotension hyperkinesia somnolence nausealevodopa carbamazepinePerphenazine NeurolepticVarious, Trilafon ( is an example: tabs: 2, 4, 8, 16 mg concentrate: 16 mg/5 mlPO: 4 8 hr9.5 hr (range, 8.4 12.3 hr)Liver Metabolism: extensive 8 16 mg PO bidqid (max 64 mg/24h, 24 mg/24h in ambulatory patients)haloperidol (not as sedating) anticholinergic AE EPS sedation hypotension itchinessCNS depressants anticonvulsants barbiturates lithiumQuetiapine Atypical neurolepticVarious, Seroquel ( is an example: tabs: 25, 100, 200, 300 mgPO: 1.5 hr 6 hrLiver metabolism: extensive firstpass Renal Excretion: 70%73% Feces: 2021%25 mg PO bid and titrate:&:&dizziness hypotension hyperkinesia somnolence nausealevodopa carbamazepineRisperidone Atypical neurolepticVarious, Risperdal ( is an example: tabs: 0.25 , 0.5, 1 ,2, 3 ,4 mg ODT: 0.5, 1, 2 mg syrup: 1 mg/mlPO tabs: 1 2 hr PO solution: 1 hr PO: 20 30 hr Metabolites: 21 30 hrLiver metabolism: extensive0.5 mg PO bid and titrate weekly:&:&EPS dizziness hypotension hyperkinesia somnolence nausealevodopa carbamazepineDepression (antidepressants and stimulants)Amitriptyline Tricyclic antidepressant for neuropathic painVarious, Elavil ( is an example: tabs: 10, 25, 50, 75, 100, 150 mg PO: 4 hr 15 hr (range: 9 25 hr)Liver metabolism: H"50% of dose is metabolized to nortriptyline Renal excretion:start with 10 25 mg PO nightly tid and if no adverse effect, increase q 3 4 days in 25 mg increments:&anti cholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsBupropion AntidepressantVarious, Wellbutrin,( Zyban ( are examples: caps: 75, 100 mg ER: 100, 150, 200 mgPO IR: 2 hr PO ER: 3 hr14 hr Metabolites: 2037 hrLiver metabolism: Considerable first pass effect Renal Excretion: 87% Feces: 10%100 mg PO bid or 150 mg ERstart (max 300 mg/24h):&agitation constipation dizziness dry mouth headache insomniaalcohol anticoagulants, PO: antidiabetic agents antihistamines benzodiazepines ( blockers carbamazepineClomipramine Tricyclic antidepressant for neuropathic pain Anafranil( caps: 25, 50, 75 mgPO: 26 hr 19 hr37 hr Metabolite: 5477 hr Liver Metabolism: extensive first pass effect Renal Excretion: 51%60% Feces: 24%32% 25 mg PO daily and titrate25 mg PO daily up3 mg/kg or 100 mg daily, whichever is smalleranticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizures alcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsDesipramine Tricyclic antidepressant for neuropathic painVarious, Norpramin ( is an example: tabs: 10, 25, 50, 75, 100, 150 mgPO: 3 6 hr14.3 24.7 hr Liver metabolism: extensive first pass effect Renal Excretion: H" 70%10 25 mg PO daily and titrate :&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizures alcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs SympathomimeticsDextroamphetamine StimulantVarious, Dexedrine ( is an example: tabs: 5, 10 mg ER: 5, 10, 15 mgPO IR: tablets: 60180 minutes PO ER: capsules: H" 7 8 hr7 34 hr, mean 12 hr Liver metabolism: extensive Renal Excretion: 17% 73%5 mg PO q 9 am and noon start and titrate (avoid late afternoon and evening doses as these can interfere with sleep):&:&nervousness insomnia dizziness nausea/vomiting cardiac effects delirium hypersensitivityMAOIs pressor agents guanethidine bretylium warfarin anticoagulants TCAs phenylbutazoneDoxepin Tricyclic antidepressant for neuropathic pain Prominent histamine H1 receptor antagonist Various, Sinequan ( is an example: caps: 10, 25, 50, 75, 100, 150 mgPO: 30 60 minutes 825 hr mean: 16.8 hr Metabolites: 33.280.7 hr mean 51.3 hrLiver metabolism: to active metabolite Renal Excretion: 0.5%1025 mg PO nightly and titrate:&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsFluoxetine Selective serotonin reuptake inhibitor (SSRI) antidepressantProzac (: caps: 10, 20, 40 mg liquid: 20 mg/5 ml 90 mg timedrelease capsulePO: 68 hr46 days, chronic administration Metabolites: 416 daysLiver metabolism: extensive active metabolite, norfluoxetine Renal Excretion: 60% Feces: 12%start with 2.55 mg PO nightly if no sideeffects, increase gradually q 1wk (max 80 mg/ 24 h, may take 45 wkrealize effect, reduce dose for elderly, hepatic and renal failure):&astrenia constipation, diarrhea dizziness dry mouth headache insomnia, somnolencealcohol anticoagulants, PO: antidiabetic agents antihistamines benzodiazepines ( blockers carbamazepineImipramine Tricyclic antidepressant for neuropathic painVarious, Tofranil ( is an example: tabs: 10, 25, 50, 75, 100, 150 mgPO: 1 hr618 hr Metabolite: Desipramine 1236 hrLiver metabolism: extensive firstpass effectdesipramine Renal Excretion: 0.050.1% (desipramine only) Imipramine metabolites are excreted in urine1025 mg PO daily and titrate:&:&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsMethylphenidate Stimulant AntidepressantVarious, Ritalin ( is an example: IR tabs: 5, 10, 20 mg ER tabs: 20 mg ER caps: 10, 20, 30, 40 mg Concerta ER tab: 18, 27, 36, 54 mg PO IR: 13 hr PO ER: 68 hr PO: 27 hr; mean 3 hrLiver metabolism: rapid and extensive Renal Excretion: less than 1% unchanged5 mg PO q 9 am and noonstart and titrate 2040 mg/24h reported (avoid late afternoon and evening doses as these can interfere with sleep):&:&nervousness insomnia dizziness nausea/vomiting cardiac effects delirium hypersensitivityMAOIs pressor agents guanethidine bretylium warfarin anticoagulants TCAs phenylbutazoneMirtazapine Atypical antidepressantRemeron (: tabs: 7.5, 15, 30, 45 mg ODT: 15, 30, 45 mgPO: 1.5 2 hr20 40 hrLiver metabolism: extensive Renal Excretion: 75% Feces: 15%15 mg PO nightly:&somnolence dizziness weight gainalcohol diazepam Nefazodone Antidepressant Serzone ( : tabs: 50, 100, 150, 200, 250 mgPO: 0.5 2 hr1.9 5.3 hr Metabolites: 2 33 hrLiver metabolism: extensive first pass metabolism Renal Excretion: 55% Feces: 20% 30%100 mg PO bid and titrate :&dizziness drowsiness dry mouth headache nausea constipation blurred vision hypersensitivity anticholinergics antihypertensives CNS depressants digoxin cisapride triazolobenzodiazepines MAOIs phenothiazines phenytoin SSRIs Nortriptyline Tricyclic antidepressant for neuropathic painVarious, Pamelor ( is an example: caps: 10, 25, 50, 75 mg solution: 10 mg/5 mlPO: 1 hr 1539 hrLiver metabolism: extensive Renal Excretion: 2% 1025 mg PO daily and titrate:&:&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsParoxetine SSRI antidepressantPaxil (: IR tabs: 10, 20, 30, 40 mg ER tabs: 12.5, 25, 37.5 mg Suspension: 10 mg/5 ml PO IR: 38 hr PO ER: 610 hr1522 hrLiver metabolism: extensive Renal Excretion: 65%67% Feces 36%37%start 20 mg PO nightly if no side effects, increase 10 mg PO q 12 wk (max 50 mg PO daily, may take 34 wkrealize effect, reduce dose for elderly, hepatic and renal failure) :&asthenia constipation, diarrhea dizziness dry mouth headache insomnia somnolenceMAOIs (avoid) neuroleptics nifedipine pentazocine phenothiazines phenytoin theophyllinePemoline StimulantVarious, Cylert ( is an example: tabs: 18.75, 37.5, 75 mgPO: 2 4 hr7 13 hrLiver metabolism: N/A Renal Excretion: 50% (unchanged)37.5 mg PO q am and titrate (112 mg/24h reported) (follow liver function tests):&:&liver failure nervousness insomnia dizziness nausea/vomiting delirium hypersensitivityMAOIs pressor agents guanethidine bretylium warfarin anticoagulants TCAs phenylbutazoneProtriptyline Tricyclic antidepressant for neuropathic painVivactil ( tabs: 5, 10 mgPO: 812 hr54198 hrLiver metabolism: extensive Renal Excretion: slow rate of excretion (50% over 2 weeks)5 mg PO tid and titrate:&:&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsSertraline SSRI antidepressant Zoloft (: tabs: 25, 50, 100 mg conc. solution: 20 mg/mlPO: 48 hr24 hr Metabolites: 62104 hrLiver metabolism: extensive Renal Excretion: 40%45% Feces: 40%45%start with 50 mg PO nightly, if no side effects, increase gradually q 1 wk (max 200 mg/24h ) :&asthenia constipation, diarrhea dizziness dry mouth headache insomnia, somnolencealcohol anticoagulants, PO: antidiabetic agents antihistamines benzodiazepines ( blockers carbamazepineTrazodone Antidepressant SedativeVarious, Desyrel ( is an example: tabs: 50, 100, 150, 300 mgPO: 0.5 2 hr7.1 hrLiver metabolism: extensive Renal Excretion: 70% 75% Feces: 21%start with 50 mg PO nightly, if no adverse effects, increase q 7 or more days up 400 mg/24h :&dizziness drowsiness dry mouth headache nausea priapism no risk of withdrawal hypersensitivity anticholinergics antihypertensives CNS depressants digoxin general anesthetics MAOIs phenothiazines phenytoin SSRIs Trimipramine Tricyclic antidepressant for neuropathic painSurmontil (: caps: 25, 50, mgPO: 2 hr23 hrLiver metabolism: extensive 25 mg PO daily and titrate:&:&anticholinergic AE arrhythmias, QRS prolongation drowsiness nausea/vomiting orthostatic hypotension seizuresalcohol anticoagulants barbiturates cimetidine clonidine CNS depressants histamine H2 receptor antagonists MAOIs sympathomimeticsVenlafaxine Atypical antidepressantEffexor (: caps: 25, 37.5, 50, 75, 100 mg ER: 37.5, 75, 150 mg PO IR: 12 hr PO ER: 5.5 hr5 hr Metabolite: 11 hrLiver metabolism: extensive firstpass effect to active metabolite Renal Excretion: 36%60%37.5 mg PO bid or 75 mg/24h ER. Start lower in some patients:&asthenia constipation, diarrhea dizziness dry mouth headache insomnia, somnolencealcohol anticoagulants, PO: antidiabetic agents antihistamines benzodiazepines ( blockers carbamazepineDiarrhea (antidiarrheals)Attapulgite AntidiarrhealKaopectate(: tabs: 300 mg/chewable tab 600 mg/regular strength tab 750 mg/extra strength tab suspension: 600 mg/15 ml in childrens 600 mg/15 ml in regular 750 mg/15 ml in extra strength Not absorbedNANA30 ml or 2 tabs PRN (max 6 doses = 12 tabs/24h ) suspension: 36 y: 7.5 ml 612 y: 15 ml > 12 y: 30 mlnone significantnone significant Bismuth subsalicylate AntidiarrhealVarious, PeptoBismol ( is an example: liquid: 17.6 mg/ml tab: 262 mg PO: (salicylate): 1.85 hrBismuth: 2172 days Salicylic Acid: 25 hr Intestinal wall, extent unknown Renal Excretion: Bismuth, 0.003%; Salicylate 95% Feces: Bismuth, 99%30 ml or 2 tabs PO q h PRN (max 8 doses = 240 ml or 16 tabs/24h) < 2 y: :& 2 4 y: 5 ml PO q h PRN 5 9 y: 7.5 ml or tab PO q h PRN 10 14 y: 15 ml or 1 tab PO q h PRN blackens tongue & feces constipation direct binding or altered gastric pH may alter drug absorption, see antacids, Al or Mg hydroxide antacidsDiphenoxylate Synthetic opioid, relatedmeperidine Inhibits excessive gastric motilityVarious in combination with atropine, Lomotil ( is an example: tabs: 2.5 mg with atropine 0.025 mg liquid: 2.5 mg/5 ml PO: 2 hr 2.5 hrLiver metabolism: extensive Renal Excretion: 14% Feces: 49%2.55 mg PO dailyqid (max 20 mg/24h ) (avoid in hepatic failure)0.30.4 mg/kg/24h PO bidqid uncommon may potentiate the effect of phenothiazines, barbiturates, TCAs Loperamide Synthetic opioid, relatedmeperidineVarious, Imodium ( is an example: caplets: 2 mg caps: 2 mg liquid: 1 mg/5 ml PO cap: 5 hr PO liquid: 2.5 hr 715 hrLiver metabolism: significant first pass Renal Excretion: 1% Feces: 25%40%4 mg PO first dose then 24 mg after each unformed stool (max daily dose 16 mg/24h)2 y or older: H" 0.2 mg/kg/24h PO bid tidabdominal pain constipation dizziness dry mouth nausea/vomiting hypersensitivity cholestyramine Octreotide Synthetic octapeptide analogue of somatostatin. Inhibits secretion of the gastroenteropancreatic endocrine system, reducing volume of intestinal secretionsSandostatin(: inj: 50, 100, 200, 500, 1000 (g LAR: 10, 20, 30 mgSC: 1530 minutes1.5 hrLiver metabolism: extensive Renal Excretion: 32%100 (g SC q 8 h for 48 h or 10 (g/h continuous SC, IV infusion and titrate110 mcg/kg bidtidgenerally well toleratedcimetidine cyclosporineDrying (anticholinergics)Atropine Antimuscarinic anticholinergicVarious: inj: 0.1, 0.4, 0.5 1.0 mg/ml in multiple combination PO tablets PO: 1 hour IM: 30 minutes  Biphasic: initial ~ 2 hours; final: 12.5 to 38 hoursLiver metabolism: 45% Renal excretion: 30-50% unchanged0.40.6 mg SC, IM, IV q 34 h routinely or prn 0.010.02 mg/kg SC, IM, IV CNS and cardiac excitation (atropine only) anticholinergic AE photophobia palpitations, tachycardia (atropine only) constipation difficulty urinatingantacids, histamine H2 receptor antagonists may interfere with absorption amantadine, quinidine haloperidol phenothiazines MAOIs TCAsGlycopyrrolate AnticholinergicRobinul (: tab: 1, 2 mg inj: 0.2 mg/ml PO: 90 minutes IM: 10 minutes2.2 33.4 minutesRenal Excretion: 48.5%0.1 0.4 mg IM, IV q 4 6 h PRN:&anticholinergic AEantacids slow K levodopa digoxin phenothiazines amantadine antiparkinsonian agents glutethimideHyoscyamine Antimuscarinic anticholinergicVarious, Levsin,( Cystospaz( are examples: tab: 0.125 mg drops: 0.125 mg ER: 0.375 mg PO SR: 2.5 hr3.5 hr ER: H" 7 hrRenal Excretion: majority of hyoscyamine excreted unchanged in urine within 12 hr0.125 0.25 mg PO SL q 4 h routinely or PRN (max 1.5 mg/24h )210 y: 0.251.0 ml PO q 4 h routinely or PRN drowsiness (scopolamine) nausea/vomiting delirium, comasome antihistamines digoxin ketoconazole Scopolamine Antimuscarinic anticholinergic Various, TransdermScop ( is an example: inj: 0.4 mg/ml patch: contains 1.5 mg, releases 1.0 mg in 3 days 4 hr9.5 hr Liver metabolism: Extensive Renal Excretion: 1% (oral), 34% (transdermal)0.30.6 mg SC, IV, IM q 4 h8 h PRN or by continuous SC, IV infusion, or 12 patch(es) behind alternating ears q 72h (patch takes 12 hachieve maximum blood levels, and 12 h after removal of last patchclear scopolamine from the blood) (wash hands thoroughly after applying patch)not indicated for children may precipitate acute confusion or dementia like picture, acute glaucoma. Discontinue immediately contraindicated in the presence of dementia, delirium, or glaucoma treat excess with physostigmine IV hypersensitivityantacids, histamine H2 receptor antagonists may interfere with absorption amantadine, quinidine haloperidol phenothiazines MAOIs TCAs Dyspnea (bronchodilators)Albuterol Inhaled adrenergic agonistVarious, Ventolin ( is an example: MDI: 6.8, 17 g canister = 100 (g/puff 0.5%, 0.83% inhalation solution syrup: 2 mg/5 ml tab: 2, 4 mgAerosol Inhalation: 34 hr SL: 23 hr ER: 6 hr PO: 14 hr36.5 hrLiver metabolism: to active metabolites 64%98% Feces:1.2-7% after PO dose 10.2-12% after inhalation2.55.0 mg solution diluted 4.0 ml with NS nebulized q 4 h PRN, or 23 puffs metered dose inhaler q 4 h PRN 24 mg PO tidqid0.03 ml/kg in 3 ml normal saline via nebulizer PRN child over 12: 2 mg PO qidtremor nervousness tachycardiaCNS stimulants levodopa propranolol MAOIs TCAsTheophylline BronchodilatorVarious, TheoDur( is an example: tabs: 100, 125, 200, 300, 450, 600 mgPO onceaday dosage form: 11 hr612 hr, adultsLiver metabolism: extensive Renal Excretion: 10%13%, adultsstart with 200300 mg PO q 12 h every 3 days, increase 50100 mg q 12 h until response or toxicity (monitor blood levels)6 wk1 y: 615 mg/kg/24h q 68 h 112 y: 20 mg/kg/24h q 812 h 1216 y: 18 mg/kg/24h q 12 hnervousness restlessness dizziness insomnia palpitations nausea/vomitingadenosine barbiturates carbamazepine phenytoin rifampin cimetidineInsomnia (hypnotic sedatives)Zolpidem Nonbenzodiazepine hypnoticVarious, Ambien ( is an example: tabs: 5, 10 mg1.62.0 hr22.6 hrLiver metabolism: extensive Renal Excretion: less than <1% 96% of a dose appears as metabolites in the bile, urine and feces510 mg PO nightly:&:&drowsiness dizziness lightheadednessCNS depressants Nausea (antacids, antinauseants)Cimetidine H2 receptor antagonist, antacid Various, Tagamet ( is an example: tabs: 200, 300, 400, 800 mg liquid: 300 mg/5 ml inj: 300 mg/2 ml PO: 45 90 minutes IM:15 minutes2 hr Metabolites: 2.2 hrLiver metabolism: extensive Renal Excretion: 48%75% Feces: 23% Bile: less than 2%300 mg PO qid ac + hs, or 400600 mg PO q 12 h, or 800 mg PO nightly, or 300 mg IV q 6 h (max 2400 mg/24h , reduce dose for renal failure) 112 y: 2025 mg/kg/24h PO: IV q 46 h < 1 y: 20 mg/kg/24h PO: IV q 46 h (reduce dose for renal failure) cognitive abnormalities, especially if hepatic or renal function is impaired leukopenia, thrombocytopenia ketoconazole hypoglycemics theophylline food, antacids, sucralfate propantheline Dronabinol Synthetic cannabinoid antiemetic and appetite stimulantMarinol (: caps: 2.5, 5, 10 mg PO: 1 hr1936 hr Metabolites: 4953 hrLiver metabolism: extensive Renal Excretion: 10%15% Feces: 35%50%2.5 mg PO q 812 h and titrate:&ataxia, blurred vision depression dizziness, vertigo drowsiness dry mouth headache hallucinations a cannabis  high hypersensitivity marijuana alcohol barbiturates benzodiazepines opioids Droperidol Dopaminergic antiemeticInapsine( inj 2.5 mg/mlIM: 24 hr IV: 24 hr2 hr Metabolite: 812 hrLiver metabolism: extensive Renal Excretion: 75% Feces: 22% (1150%)2.55 mg q 34 h212 years of age: 0.050.06 mg/kg/dose IV/IM q 46 hdiarrhea sedation hypotension hypersensitivityalcohol anticholinergics barbiturates, (blockers cimetidine, clonidine disulfiram levodopa, lithium metoclopramide meperidine phenytoin pyrimethamine SSRIs, TCAs trazodone, valproate vitamin CFamotidine H2 receptor antagonist Various, Pepcid ( is an example: tabs: 10, 20, 40 mg inj: 10 mg/ml PO: 1 3.5 hr2.6 4 hrLiver metabolism: 30% 35% Renal Excretion: 25% 70% Feces: 50%20 40 mg PO daily, or 10 20 mg IV q 12 h :&headache malaise dizziness, vertigo somnolence insomniawarfarin anticoagulants benzodiazepines ( blockers TCAs cephalosporinsLansoprazole H+, K+ATPase inhibitor Prevacid (: PO caps: 15, 30 mg Granule Packets: 15, 30 mg ODT: 15, 30 mg IV: 30 mg/vialPO entericcoated granules: 1.53 hr ODT: 1.82.0 hr0.91.5 hr Metabolites: 3 hrLiver metabolism: extensive Renal Excretion: 14%25% Bile: 67%15 30 mg PO daily:&generally well toleratedphenytoin warfarin anticoagulants benzodiazepines corticosteroids digoxin ketoconazole sucralfate Metoclopramide Dopaminergic antiemetic, prokinetic Various, Reglan ( is an example: tabs: 5, 10 mg liquid: 1 mg/ml inj: 5 mg/ml IV: 15 minutes PO: 60160 minutes PR: 13 hr SC: 30 minutes56 hrLiver metabolism: Renal Excretion: 70%85% Feces: 2% 510 mg PO IM, SC, IV tidqid, h ac and hs (reported as continuous SC, IV infusion)0.5 mg/kg/24h PO tidqid, h ac + hs dizziness gynecomastia, galactorrhea, amenorrhea abdominal cramps ( risk of perforation if bowel obstructed hypersensitivityalcohol, anticholinergics barbiturates, (blockers cimetidine, clonidine disulfiram, levodopa, lithium metoclopramide meperidine phenytoin, pyrimethamine SSRIs, TCAs trazodone, valproate vitamin CMisoprostol Prostaglandin E1 analogue for gastric protection from NSAIDsCytotec (: tabs: 100, 200 (g PO: 9 15 minutes2040 minutesLiver metabolism: extensive Renal Excretion: 80% Feces: 15%100200 (g PO q 6 h, after food 200 (g PO bid may be sufficient for NSAID prophylaxis (reduce in renal failure):&diarrhea, abdominal pain, flatulence nausea/vomiting headachesalicylic acidOmeprazole H+, K+ ATPase inhibitor Prilosec (: tab: 10, 20, 40 mg PO: 0.5 3.5 hr0.5 1 hrLiver metabolism: extensive (inactive metabolites) Renal Excretion: 77% Bile: excretion of metabolites (16 19%)20 40 mg PO daily (do not exceed 20 mg/24h with liver failure):&generally well toleratedphenytoin warfarin anticoagulants benzodiazepines corticosteroids digoxin disulfiram phenytoin Ondansetron Serotonin 5 HT3 receptor antagonist antiemeticZofran (: tab: 4, 8 mg inj: 2 mg/ml soln: 4 mg/5 ml ODT: 4, 8 mgPO: 1 2.2 hr IM: 0.38 hr IV: end of infusion (30 min) 3 5.5 hrLiver metabolism: extensive Renal Excretion: 44% 60% Feces: 25% 4 16 mg PO, IV q 8 h:&headache constipation flushing/warmth in the head or epigastrium hypersensitivityCNS depressants anticonvulsants lithiumProchlorperazine Dopaminergic antiemetic, phenothiazine neurolepticVarious, Compazine( is an example: tabs: 5, 10 mg liquid: 5 mg/5 ml supp: 2.5, 5, 25 mg inj: 5 mg/ml1.55 hr6.89 hrLiver metabolism: extensive520 mg PO PR, IM, IV, PR q 4 h PRN or routinely0.5 mg/kg/24h PO: PR bidtiddrowsiness dizziness hypotension EPSalcohol, anticholinergics barbiturates, (blockers cimetidine, clonidine disulfiram, levodopa, lithium metoclopramide meperidine phenytoin, pyrimethamine SSRIs, TCAs trazodone, valproate vitamin CPromethazine Histamine H1 receptor antagonist antiemeticPhenergan ( tab: 25, 50 mg supp: 12.5, 25, 50 mg syrup 6.25 mg/5 mlIM: 23 hr inj: 25 mg/ ml 715 hrLiver metabolism: extensive First pass metabolism12.525 mg PO / PR q 46 h0.5 mg/lb PO/PR q 46 hdrowsiness dry mouth blurred visionCNS depressants anticholinergics Ranitidine H2 histamine receptor antagonist antacidVarious, Zantac ( is an example: tabs: 75, 150, 300mg caps:150, 300mg inj: 25 mg/ml syrup: 15 mg/ ml PO: 0.52 hr IM: 15 minutes 23 hrLiver metabolism: Renal Excretion: 30%70%150 mg PO bid or 300 mg PO daily (300 mg PO bid may be used for up4 wkpromote healing) 50 mg IV, IM q 68 h 2.53.8 mg/kg/24h PO bid nausea/vomiting constipation diarrhea abdominal discomfort druginduced hepatitis impotence gynecomastia hypersensitivity phenytoin probenecid procainamide quinidine acetaminophen Sucralfate Polysaccharide that bindsulcer tissue in the esophagus, duodenum and stomachprovide a barrier from acidVarious, Carafate ( is an example: tab: 1 g suspension: 1 g/10 mlInitial response: 1 hrDuration PO: 6 hrSucralfate is not metabolized; any amount of sucrose octasulfate and aluminum absorbed is excreted unchanged in the urine Renal Excretion: 0.52.2% Feces: 90%1 g PO qid ac + HS 2 g PO q 12 h (may add antacids, but dont use within h of sucralfate dose as acid is requiredactivate sucralfate) :&constipation, diarrhea nausea, gastric discomfort dry mouth pruritus sleepiness, vertigo AI buildup may occur with renal failureno antacids within h of dose, no H2 blockers tetracycline phenytoin digoxin ketoconazole theophylline ciprofloxacin norfloxacinTrimethobenzamide Antiemetic, unclear mechanism of action. 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72%seizures: 100 mg PO bid400 mg PO tid hiccups: 100200 mg PO bidtid (start low & increase q 34 days, monitor blood levels) initial dose 10 mg/kg/24h bidtid increase dose if necessary, up30 mg/kg/24h aplastic anemia cardiovascular effects ataxia blurred vision confusion drowsiness vertigo headache hepatic effects nausea/vomiting hypersensitivity alcohol calciumchannel blockers corticosteroids erythromycin, doxycycline haloperidol isoniazid lithium MAOIs (avoid) metoclopramide other anticonvulsants psychoactive agents theophylline warfarin anticoagulants Flecainide Class 1C antiarrhythmic for neuropathic painTambocor (: tabs: 50, 100, 150 mgPO: 1.56 hr PO cap: 18 hr 722 hrLiver metabolism: extensive Renal Excretion: 81% 90% Feces: 4% 6%start with 50 mg PO q 12 h increase 50 mg q 12 h every 4 or more days (max 300 mg/24h ) (adjust for hepatic or renal impairment):&may cause ventricular or other arrhythmias CHF dizziness visual disturbances (blurred vision, diplopia, photophobia) headache nausea dyspnea other antiarrhythmics cimetidine digoxin propranolol phenytoin phenobarbital rifampin carbamazepine Gabapentin Antiepileptic, for neuropathic painNeurontin (: caps: 100, 300, 400, 600, 800mg syrup: 250 mg/5 mlPO: 1.54 hr57 hrNot metabolized Renal Excretion: 76%81% unchanged in the urine Feces: 10%23%100300 mg PO tid and titrate (3,600 mg/24h has been reported):&somnolence dizziness fatiguealter for renal function cimetidine PO: contraceptives antacidsLidocaine Anesthetic: relieve pain due mucositis, oro pharyngeal, perianal and skin lesions/ulcers. Endotracheal spray may be used during painful dressing changesVarious, Xylocaine ( is an example: topical liquid: 4% viscous: 2% oral & endotracheal spray: 10% jelly: 2% ointment: 5% Inj: 5, 10, 20 mg/ ml IV infusion: 8mg/ml in D5WIM: 30 minutes2 hr Initial response: topical (2% jelly): 35 minutes1.52 hr Metabolites: 16 hrLiver metabolism: 90% Renal Excretion: H"90%viscous: 15 ml PO q 3h PRN, gargle, spit or swallow (mix 50/50 with antacid make more palatable) liquid/spray: apply affected areas PRN jelly: apply urethra before catheterization (max 200 mg/24h ) 5 15 ml swish and spit q 4 h PRN (max 3 mg/kg/24h)no fluids or food within 60 min of PO: ingestion (interferes with second stage of swallowing) systemic administration may cause CNS excitation or depression, ventricular or other arrhythmias hypersensitivity bupivacaine if given systemically: other antiarrhythmics, amiodarone (blockers cimetidine MAOIs phenytoin TMPSMXLidocaine + Prilocaine Anesthetic combinationrelieve pain associated with local proceduresEMLA (: cream: 25 mg lidocaine and 25 mg prilocaine/gm patch: 1 g cream topical, cream: 24 hr topical periodontal gel: 30 minutes lidocaine 12 hr prilocaine 10150 minutesLiver metabolism: lidocaine (extensive), prilocaine (extent unknown) Renal Excretion: lidocaine 90% apply patch, or a thick layer of cream. Cover with an occlusive dressing for at least 1 h priora painful procedure (may remain up to 5 hr) apply as for adults (not recommended for infants < 6 months, or children 612 months receiving Rx for methemoglobin) mild local reactions, i.e., edema, itching, transient paleness, erythema, initial burning none significantMexiletine Class 1B arrhythmic used for neuropathic painMexitil (: caps: 150, 200 mg PO: 1 4 hr IM: 15 minutes 2 hr6 17 hrLiver metabolism: extensive Renal Excretion: H"8% 15%start with 100 mg PO q 8 h, increase 100 mg q 8 h every 3 or more days (max 1200 mg/24h ) (adjust for hepatic impairment) :&may cause ventricular or other arrhythmias upper GI distress lightheadedness tremor other antiarrhythmics phenytoin, phenobarbital, rifampin, carbamazepine cimetidine theophylline metoclopramide avoid diets/medications that acidify urine tobacco, smoking Valproic acid Antiepileptic for neuropathic painDepakene,( Depakote (: tabs: 125, 250, 500 mg syrup: 250 mg/5 ml soln: 250 mg/5 ml Valproate sodium inj: 100 mg/ ml Depakene capsules: 250 mg Depakote Enteric coated sprinkle capsules: 125mg Depakote ER release tab: 250, 500 mgPO: valproic acid Capsules Depakene(: 14 hr PO: divalproex tablet: 48 hr PO: divalproex sprinkle capsule: 3.34.8 hr PO: divalproex sodium extendedrelease tablet: 417 hr PO: sodium valproate solution: 1.2 hr Intravenous, Depacon(: At the end of a 1 hr infusion PR: diluted Valproic acid syrup: 3.1 hr617 hrLiver metabolism: extensive Renal Excretion: 70%80% Bile: 7% Lung: 218%seizures: start at 15 mg/kg/24h, increase wkly by 510 mg/kg/24h upmax 60 mg/kg/24h (above 250mg, divide into 3 doses/24h ) hiccups, neuropathic pain: 250 mg PO bidqid same as adult dosing ataxia, tremor, sedation inhibition of platelet aggregation nausea/vomiting thrombocytopenia hypersensitivity alcohol antacids ASA barbiturates clonazepam phenytoin Sedation (barbiturate)Phenobarbital Barbiturate antiepileptic and sedativeVarious: tabs: 15, 30, 60, 100 mg elixir: 20 mg/5 ml inj: 65, 130 mg/mlPO: 812 hr IM: 1 hr IV: 15 minutes1.54.9 daysLiver metabolism: partial Renal Excretion: 21% unchanged sedation: 100130 mg PO, IM, IV q 6 h or by continuous infusion 15 mg/h (starting low and titrating upward until sedation is achieved) seizures: 60120 mg IV, IM, PR q 1020 min PRNseizures: initial dose 20 mg/kg IV maintenance dose: children under 3 mo 56 mg/kg/24h bid children over 3 mo 35 mg/kg/24h biddrowsiness headache hypersensitivity nausea/vomiting diarrheaCNS depressants anticoagulants corticosteroids antidepressants griseofulvin doxycycline PO: contraceptives AnticonvulsantsSkin (antibiotics)Metronidazole Topical and PO antibiotic particularly for malodorous skin ulcers Various, Flagyl,( MetroGel ( are examples: tab: 250 mg caps: 375, 500, 750 mg cream: 10% vag inserts: 500 mg inj: 5mg/mLPO: 12 hr IV: end of infusion PR: 3 hr Topical: 812 hr614 hrLiver metabolism: extensive Renal Excretion: 60%80% Feces: 6%15%for skin ulcers apply layer of cream over affected area(s) tidqid and if extensive, 250500 mg PO/IV q 8 hskin ulcers: as for adultsanorexia diarrhea dry mouth furred tongue nausea/vomiting neurologic deterioration peripheral neuropathies unpleasant, metallic taste hypersensitivity alcohol astemizole (avoid) barbiturates warfarin anticoagulants disulfiram lithium terfenadine (avoid) Silver sulfadiazine Topical antibiotic particularly for malodorous skin ulcersVarious: cream: 1%NA10 hrRenal Excretion: 60%apply layer of cream over affected area(s) bid (use with caution in hepatic or renal impairment)same as for adultsuse with caution in patients sensitivesulfa leukopenia hypersensitivityPO: hypoglycemics phenytoin cimetidineSteroids (glucocorticoids and mineralocorticoids)Dexamethasone Glucocorticoid Various, Decadron ( is an example: tabs: 0.5, 0.75, 2, 4, 6 mg elixir: 0.5 mg/ml inj: 4, 10 mg/ml PO cap: 3.17 hr PO elixir: 1060 minutes PO tabs: 12 hrPlasma: 1.882.23 hr Biological duration of action: 3654 hrLiver metabolism: partial Renal Excretion: up to 65% Bile: small extent0.58 mg PO, IV, IM, SC dailyq 6 h (single doses of 40100 mg IV may be usedeffect an acute response (dosage may needbe tapered slowlyavoid adrenocorticoid insufficiency on withdrawal) increased risk of infection, particularly opportunistic infections gastritis, gastric ulceration/bleeding, nausea/vomiting pancreatitis wasting, particularly proximal muscles thinning of skin, bowel (possible perforation), impaired wound healing salt, water retention, hypertension, cushingoid statehepatic microsomal enzyme inducers estrogens NSAIDs K+ depleting drugs anticholinesterase agents PO: anticoagulants CyclosporineFludrocortisone acetate MineralocorticoidFlorinef (: tab: 0.1 mg PO: 1.7 hr3.5 hrLiver metabolism: extensive0.1 0.2 mg PO daily (may combine with glucocorticoid)50200 (g PO daily increased risk of infection, especially fungal, TB, other opportunistic infections salt, water retention, hypertension hypokalemia K+ depleting drugsPrednisone GlucocorticoidVarious: tabs: 1, 2.5, 5, 20, 50 mg Soln: 1, 5mg/mlPO: 1.3 hrPlasma: 2.63 hr Biological duration of action: 1236 hrLiver metabolism: extensive (metabolized to the biologically active steroid, prednisolone) 580 mg PO daily hyperglycemia euphoria, insomnia, mood swings, personality changesdepressionpsychosis withdrawal may leadadrenocortical insufficiency, flair in joint pain may suppress reactionsskin tests notbe used in presence of herpes zoster hepatic microsomal enzyme inducers estrogens NSAIDs K+ depleting drugs anticholinesterase agents PO: anticoagulants CyclosporineMiscellaneousBaclofen Muscle relaxantVarious, Lioresal ( is an example: tabs: 10, 20 mgPO: 2 hr36.8 hrLiver metabolism: limited Renal Excretion: 69% 85% Feces: 10 % 5 20 mg PO bid tid (max 120 mg/24h):&nausea/vomiting sedation dizziness weakness neuropsychiatric disturbances genitourinary effectsCNS depressantsBelladonna & Opium Anticholinergic + opioid Relief of pain due smooth muscle spasmVarious: belladonna/opium: 16.2/30 mg 16.2/60 mgNANARenal excretion: Belladonna 33%1 PR q 6 h PRN :&anticholinergic AE photophobia constipation difficulty urinating somnolenceantacids, histamine H2 receptor antagonists may interfere with absorption amantadine, quinidine haloperidol phenothiazines MAOIs TCAsBethanechol Cholinergic stimulant Various, Urecholine( is an example: tabs: 5, 10, 25, 50 mgNANAUnknown10 50 mg PO tid qid, or 2.5 10 mg SC tid qid:&cholinergic stimulation, including sweating, salivation, flushing, decreased BP, nausea, abdominal pain, diarrhea, bronchospasmanticholinergic drugs atropine quinidine procainamide sympathomimeticsCyclobenzaprine Muscle relaxantVarious, Flexeril (is an example: tab: 5, 10 mgPO: 3.9 hr18 hrLiver metabolism: extensive Renal Excretion: 1% 2040 mg daily in divided doses (max 60 mg/24h):&drowsiness dry mouth dizziness fatigue nausea/vomiting confusionTCAs MAOIs CNS depressants anticholinergicsCyproheptadine H1 receptor antagonistVarious, Periactin ( is an example: tab: 4 mg syrup: 2 mg/5 mlPO: 6 9 hr16 hrLiver metabolism: 57% Renal Excretion: 40% Feces: 2%20%420 mg PO ( q 46 h (max 32 mg/24h)24 mg bidtid depending on age and weight (max 16 mg/24h)sedation dizziness confusion nausea/vomiting arrhythmias hypersensitivity CNS depressants ephedrine MAOIs Dantrolene Muscle relaxantDantrium (: caps: 25, 50, 100 mg inj: 20 mg/vialPO: 48 hr8.7 hrLiver metabolism: 80% of the absorbed dose as metabolites2550 mg PO dailyqid:&muscle weakness slurred speech drowsiness dizziness diarrhea nausea/vomiting malaise hepatic effectsverapamil CNS depressantsDicyclomine Anticholinergic antispasmodic Various, Bentyl (is an example: tabs: 10, 20 mg syrup: 10 mg/5 ml inj: 10 mg/mlPO: 60 90 minutes1.8 hrRenal Excretion: 79.5% Feces: 8.4%10 20 mg PO tid qid:&anticholinergic AEantacids slow K levodopa digoxin phenothiazines amantadine antiparkinsonian agents glutethimideFlavoxate Smooth muscle relaxantUrispas (: tab: 100 mgInitial response PO: 55 minutes 2 hrNALiver metabolism: Renal Excretion: 57%100 200 mg PO tid qid:&nausea/vomiting dry mouth headache drowsiness confusionnone significantFosphenytoin Antiepileptic injectable prodrug of phenytoinCerebyx (: inj: dosed as phenytoin equivalents IM: 30 minutes IV: immediate (at end of infusion)Conversion half-life of fosphenytoin to phenytoin is 15 minutes Phenytoin: 1228.9 hrLiver metabolism: to phenytoin which is metabolized extensively (95%) Bile excretionIM, SC, IV consult pharmacy for phenytoin equivalent determinationIM, SC, IV consult pharmacy for phenytoin equivalent determinationataxia, diplopia, dizziness, nystagmus confusion, drowsiness, hallucinations cardiovascular effects constipation depression gingival hyperplasia hematologic effects hepatic dysfunction hypotension megaloblastic anemia nausea/vomiting hypersensitivity avoid in pregnancy amiodarone, mexiletine, quinidine antihistamines benzodiazepines carbamazepine, valproic acid cimetidine chloramphenicol corticosteroids, salicylates cyclosPO:rine disulfiram doxycycline folic acid isoniazid, rifampin methadone phenobarbital TCAs, trazodone theophylline Hydroxyzine Histamine H1 receptor antagonistVarious, Atarax,( Vistaril ( are examples: caps: 10, 25, 50, 100 mg inj: 25 mg/ml, 50 mg/ml syrup: 10 mg/5 mlPO: 2 hr3 20 hr Cetirizine: 25 hrLiver metabolism: to Cetirizine, active25 mg PO tid qid PO/IV2 mg/kg/24h PO tid qiddrowsiness dry mouth dizziness headache nausea/vomiting bitter taste in mouth CNS depressants anticholinergics epinephrine Meclizine Histamine H1 receptor antagonistVarious, Antivert,( Bonine ( are examples: tab: 12.5, 25, 50 mgInitial response: PO: 1 hr6 hrLiver metabolism: probable Renal excretion: Metabolites Fecal: unchanged drug25100 mg PO dailyqiduse the adult dosedrowsiness dry mouth blurred visionCNS depressants anticholinergics Methocarbamol Muscle relaxantVarious, Robaxin ( is an example: tabs: 500, 750 mg inj: 100 mg/mlPO: 12 hr0.92 hrLiver metabolism: extensive500 mg PO tid qid (max 6000 mg/24h ):&drowsiness dizziness headache blurred vision nausea/vomiting hypersensitivityCNS depressants anticholinergics pyridostigmineNifedipine Calcium channel blocker HiccupsVarious, Adalat,( Procardia BCcdt'(efny(*VXdfhǷ倫q%h\OB*CJ\aJhnH phtH  h\O5CJh\OCJ\aJ$h2Sh\OCJaJmHnH sHtH h2Sh\OCJ\aJmHsHh2Sh\OCJNH\mHsHh2Sh\OCJ\mHsHh2Sh\OCJ\mHsH jh\OCJH*\ h\OCJ\h\OCJNH\,t2Xw)0?IT\e & Fd$If  & Fd$Ifpd$If^`peu3GTmnypd$If^`p d$IfFf  & Fd($If  & Fd$If & Fd$IfF`dh)29BXck & Fd($If & Fd$If  & Fd$Ifpd$If^`ph45EFUVLNln !56FHhj 34DEUVmnFVW]lh\O5CJNH jbh\OCJ\h\OCJ\aJ%h\OB*CJ\aJhnH phtH  jh\OCJH*\ h\O5CJh\OCJNH\ h\OCJ\Dkw$+;k{pd($If^`ppd$If^`p d$IfFfF & Fd$If.>p (;Gfp~pd$If^`p d$IfFf & Fd($If & Fd$If & Fd$If^`+ rr_ & Fd$If^` & Fd$If  & Fd$Ifpd($If^`ppd$If^`p"-3=EF]);V/pd$If^`p d$IfFf & Fd$If  & Fd$IflmPQabklwxH,.\t 46Jprʿ漢h2Sh\OCJNH\mHsHh2Sh\OCJ\mHsH h\O5CJh\OCJNH\aJh\OCJ\aJh\OCJ\aJ hMCJ\ jh\OCJH*\ h\OCJ\h\OCJNH\6/H8Z\t "JZV| d$IfFf & Fd$If^`  & 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4 laf4p T$pd<<$If^`pFf & Fd$If  & Fd$If /L^p0T4ly & Fd$If  & Fd$Ifpd$If^`p4LM^_lRS  BCIPQ]}~opwx jmh\OCJ\aJ jh\OCJH*\ h\O5CJh\OCJH*\h2Sh\OCJNH\mHsHh2Sh\OCJ\mHsHh\OCJ\aJ h\OCJ\h\OCJNH\?@JQd~'I]pd$If^`p d$IfFf & Fd$If  & Fd$If & Fd($If5EPa S  & Fd$Ifpd$If^`p d$IfFf  & Fd$If & Fd($If & Fd$If,FYfgu$pd<<$If^`pFf  & Fd$If & Fd($If & Fd$If guv*rtv(*Xd|T    xh\OCJH*\h2Sh\OCJ\mHsHh\OCJ\aJ%h\OB*CJ\aJhnH phtH h2Sh\OCJ\mHsHh\OCJNH\ jh\OCJH*\ h\O5CJh\OB*CJ\phh\O5B*CJaJphh\OCJH*\ h\OCJ\/uv*rv~~mmmmmmmmmpd$If^`p d$Ifxkd$$IfTl4    6D7  t 0    4 laf4p T v 6VXNdjppd$If^`p d($If d$IfFf & Fd($If & Fd$If  & Fd$If.Xn.Fdpz| 8>D d$IfFf6 & Fd($If & Fd$If  & Fd$Ifpd$If^`pDTY o x          !!4!T!d!" d$IfFfv & Fd$If  & Fd$Ifpd$If^`p , -     !!!!)!*!"""""####R#T#t####$$ $+$,$F$$$$%%W%X%{%|%&&&''z'|'''@(B(Z( jh\OCJ\h2Sh\OCJ\mHsHh2Sh\OCJ\mHsHh\OCJH*\h\OCJ\aJ%h\OB*CJ\aJhnH phtH  jh\OCJH*\ h\O5CJh\OCJNH\ h\OCJ\6""."B"R"r"""""""",#t######$pd$If^`p d$IfFf & Fd($If & Fd$If  & Fd$If$ $6$F$q$$$$$$$$$$$$$ %% d$IfFf & Fd($If & Fd$If  & Fd$Ifpd$If^`ppd($If^`p%*%:%E%L%%%&$&B&X&l&~&&&&&'''Z' d$IfFf. & Fd($If & Fd$If  & Fd$Ifpd$If^`pZ'''''(,(Z(r((((((()$):)j)))Ffn & Fd$If & Fd$If^`  & Fd$Ifpd$If^`pZ(n(((())))`*b******\+v+++++,,B,C,,,,,,,--.-:-P-Q-p-q-}------- . ...0.1...../////////ԭԭh\OCJH*\h\OCJNH\aJh\OCJNH\ jh\OCJH*\ h\O5CJh\OCJ\aJ%h\OB*CJ\aJhnH phtH  h\OCJ\ *h\OCJ\@)))))D*J*n******+$+8+Z+\+v+++Ff & Fd($If & Fd$If  & Fd$Ifpd$If^`p d$If+,(,K,,,,,-:-E-}------.".6.B.W.g.x.. & Fd$If  & Fd$Ifpd$If^`p....../"/0/;/G/R/f/p/~///////pd$If^`p d$IfFf & Fd($If & Fd$If  & Fd$If//////0000 181V1Z1\1l142>2I2J2L2M2q2r2z2{22222222233&3;33333334444&4p4Ƴh2Sh\OCJ\mHsHh\OCJH*\ h\O5CJh\OCJ\aJ$h2Sh\OCJaJmHnH sHtH h2Sh\OCJ\aJmHsHh2Sh\OCJ\mHsHh\OCJNH\ h\OCJ\ jh\OCJH*\1/0P0t0000 181l11111122&23242Ff& & Fd($If & Fd$If & Fd$If^`pd$If^`p42>2_222222223&3;3F3P3_3o333 d$If & Fd$If & Fd$If^`pd($If^`ppd$If^`p d$If333333333&4J4p4t444444505R5 & Fd($If & Fd$If  & Fd$Ifpd$If^`p d$IfFfbp4r4t4r55556;\@љҙ68XZf|67Gij~ÜĜ0ɾܵܧܵܵܵܵܵܵܵܵ܍ɍܵܵh2Sh\OCJ\mHsHh\OCJaJnH tH h2Sh\OCJ\mHsHh\OCJNH\h\OCJH*\U jh\OCJH*\ h\O5CJ h\OCJ\h\OCJ\aJ%h\OB*CJ\aJhnH phtH 7R5p5r5555#;P\ktuݘ@pd($If^`ppd$If^`p d$IfFf & Fd$If( are examples: IR tabs: 10, 20 mg ER tabs: 30, 60, 90 mgPO IR: 2045 minutes PO ER: 6 hr SL: 60 minutes22.5 hr Liver metabolism: extensive Renal Excretion: 70%80% Bile/Feces: 20%hiccups: 1020 mg PO, SL q 8 h or 3060 mg PO daily ERhypertension: 0.5 mg/kg/24h PO: q 8 h, increase as needed up1.5 mg/kg/24h dizziness lightheadedness headache insomnia palpitations nausea/vomitingcimetidine ranitidine propranololOrphenadrine Muscle relaxantNorflex (: tab: 100 mg inj: 30 mg/mlPO: 24 hr IM: 1 hr 13.2 20.1 hrLiver metabolism: Renal Excretion: 60%60 mg IM, IV q 12 h or 100 mg PO bid:&anticholinergic AE nausea/vomiting headache drowsinesspropoxyphene CNS depressantsOxybutynin For relief of urinary urgency, frequency, leakage, incontinence associated with a neurogenic bladder Various, Ditropan ( is an example: tab: 5 mg syrup: 5 mg/5 ml Oxytrol( Transdermal 3.9mg PO: 1 hr TD: NA1.12.3 hr Liver metabolism: primary site Renal excretion: less than 0.1%5 mg PO bidtid (max dose 20 mg daily) 3.9 mg TD twice weekly< 5rs: 0.5 mg/kg/24h PO qid > 5 y: 1015 mg/24h bidtid anticholinergic AEnone significantPhenazopyridine Anestheticrelieve dysuriaPyridium (: tabs: 100, 200 mg NANALiver Metabolism: Renal Excretion: 65%200 mg PO tid :&orange or red urine mild upper GI upset other AE are rare, including: headache transient acute renal failure methemoglobinemia hypersensitivity none significantPhenytoin Antiepileptic Various, Dilantin ( is an example: caps: 30, 100 mg infatabs: 50 mg suspension: 30 or 125 mg/5 ml inj: 50 mg/ml PO ER capsules: 412 hr IV with loading dose: 2025 minutesPO: 742 hr; value is variable duethe saturation kinetics IV: 1015 hrLiver metabolism: extent unknown Renal excretion: 2% Bile: most of the doseseizures, hiccups: start with 100 mg PO/IV tid and adjustachieve therapeutic blood levels (monitor blood levels) (if the person is unableswallow and IV access is not possible, parenteral solutions may also be administered PR) (see fosphenytoin) 6 mo3 y: 79 mg/kg/24h bidtid 46 y: 6.5 mg/kg/24h bidtid 79 y: 6 mg/kg/24h bidtid 1016 y: 35 mg/kg/24h bidtid ataxia, diplopia, dizziness, nystagmus confusion, drowsiness, hallucinations cardiovascular effects constipation depression gingival hyperplasia hematologic effects hepatic dysfunction hypotension megaloblastic anemia nausea/vomiting hypersensitivity avoid in pregnancy amiodarone, mexiletine, quinidine antihistamines benzodiazepines carbamazepine, valproic acid cimetidine chloramphenicol corticosteroids, salicylates cyclosPO:rine disulfiram doxycycline folic acid isoniazid, rifampin methadone phenobarbital TCAs, trazodone theophylline Quinine sulfate For nighttime leg crampsVarious: tab:260, 325 mgPO: 13.2 hr4.111.1 hrRenal Excretion: 12%30%200300 mg PO nightly PRN:&headache nausea/vomiting tinnitus confusion hypersensitivitymefloquine cardiac glycosides, cimetidineSimethicone Antiflatulent, particularly for gastric gasVarious combinations with antacids tab: 80, 125 mg susp: 40 mg/0.6mlInert: not absorbedNAFe@JZclyəԙ pd($If^`ppd$If^`p d$IfFf & Fd($If & Fd$If  & Fd$If Dn*Ddf|$GQb d($If d$IfFf & Fd($If & Fd$If  & Fd$Ifpd($If^`ppd$If^`pb~ٜ6Viz{ŝȝ˝ݝ d$IfFfR  & Fd$Ifpd($If^`ppd$If^`p01JKV{֝םL`89hi HI¡á12NOopz䥒$h2Sh\OCJaJmHnH sHtH h2Sh\OCJ\aJmHsH%h\OB*CJ\aJhnH phtH h\OCJNH\ jh\OCJH*\ h\O5CJ h\OCJ\h\OCJ\aJh\OCJaJnH tH 9ݝ.V(JL`~ğ!0I d$IfFf & Fd($If & Fd$If  & Fd$Ifpd$If^`pInנ]t;XzǢޢ 3?T & Fd$If  & Fd$Ifpd$If^`p-.ۣܣԦaz0rsh30h300JmHnHujh300JU h300Jh300JCJh=/jh=/Uh\OCJOJQJ\^JUh\OCJ\aJ%h\OB*CJ\aJhnH phtH  h\O5CJh\OCJNH\ h\OCJ\6Tduʣ-8DOcm{ä d$IfFf & Fd($If  & Fd$If & Fd$Ifä̤ܤ(6H\~ҦԦD d$IfFf & Fd($If & Fd$If  & Fd$Ifpd$If^`pΧ)Faz @8FfB   & Fd$Ifpd($If^`ppd$If^`pces: unchangedas per antacid directions 40120 mg PO qid PRN pc + hs (max daily dose = 500 mg) see directions 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