Rx – All “C” 4

MUSCLE STRAIN

Comment: Usual length of treatment for acute injury is approximately 5 days.
Acetaminophen for IV Infusion see Pain page 306
Narcotic Analgesics see Pain page 308
Parenteral Corticosteroids see page 511
Oral Corticosteroids see page 509

SKELETAL MUSCLE RELAXANTS

• baclofen (C)(G) 5 mg tid; titrate up by 5 mg every 3 days to 20 mg tid; max 80 mg/day
  Pediatric: not recommended
  Lioresal Tab: 10*, 20*mg
  Comment: baclofen is indicated for muscle spasm pain and chronic spasticity associated with multiple sclerosis and spinal cord injury or disease. Potential for seizures or hallucinations on abrupt withdrawal.
• carisoprodol (C)(G) 1 tab tid or qid
  Pediatric: not recommended
  Soma Tab: 350 mg
• chlorzoxazone (NE)(G) 1 caplet qid; max 750 mg qid
  Pediatric: not recommended
  Parafon Forte DSC Cplt: 500*mg
• cyclobenzaprine (B)(G) 10 mg tid; usual range 20-40 mg/day in divided doses; max 60 mg/day x 2-3 weeks or 15 mg ext-rel once daily; max 30 mg ext-rel/day x 2-3 weeks
  Pediatric: <15 years: not recommended
  Amrix Cap: 15, 30 mg ext-rel
  Fexmid Tab: 7.5 mg
  Flexeril Tab: 5, 10 mg
• dantrolene (C) 25md daily x 7 days; then 25 mg tid x 7 days; then 50 mg tid x 7 days; max 100 mg qid
  Pediatric: 0.5 mg/kg daily x 7 days; then 0.5 mg/kg tid x 7 days; then 1 mg/kg tid x 7 days; then 2 mg/kg tid; max 100 mg qid
  Dantrium Tab: 25, 50, 100 mg
  Comment: dantrolene is indicated for chronic spasticity associated with multiple sclerosis and spinal cord injury or disease.
• diazepam (C)(IV) 2-10 mg bid-qid; may increase gradually
  Pediatric: <6 months: not recommended; >6 months: initially 1-2.5 mg bid-qid; may increase gradually
  Diastat Rectal gel delivery system: 2.5 mg
  Diastat AcuDial Rectal gel delivery system: 10, 20 mg
  Valium Tab: 2, 5, 10 mg
  Valium Intensol Oral Solution Conc oral soln: 5 mg/ml (30 ml w. dropper) (alcohol 19%)
  Valium Oral Solution Oral soln: 5 mg/5 ml (500 ml) (wintergreen spice) metaxalone (B) 1 tab tid-qid
  Pediatric: not recommended
  Skelaxin Tab: 800*mg
• methocarbamol (C)(G) initially 1.5 g qid x 2-3 days; maintenance, 750 mg every 4 hours or 1.5 g 3 times daily; max 8 g/day
  Pediatric: <16 years: not recommended
  Robaxin Tab: 500 mg
  Robaxin 750 Tab: 750 mg
  Robaxin Injection 10 ml IM or IV; max 30 ml/day; max 3 days; max 5 ml/ gluteal injection q 8 hours; max IV rate 3 ml/min
  Vial: 100 mg/ml (10 ml)
• nabumetone (C)
  Pediatric: not recommended
  Relafen Tab: 500, 750 mg
  Relafen 500 Tab: 500 mg
• orphenadrine citrate (C)(G) 1 tab bid
  Pediatric: not recommended
  Norfl ex Tab: 100 mg sust-rel
• tizanidine (C) 1-4 mg q 6-8 hours; max 36 mg/day
  Pediatric: not recommended
  Zanafl ex Tab: 2*, 4**mg; Cap: 2, 4, 6 mg

SKELETAL MUSCLE RELAXANT/NSAID COMBINATIONS

Comment: aspirin-containing medications are contraindicated with history of allergictype reaction to aspirin, children and adolescents with Varicella or other viral illness, and 3rd trimester pregnancy.

• carisoprodol/aspirin (C)(III)(G) 1-2 tabs qid
  Pediatric: not recommended
  Soma Compound Tab: caris 200 mg/asa 325 mg (sulfi tes)
• meprobamate/aspirin (D)(IV) 1-2 tabs tid or qid
  Pediatric: not recommended
  Equagesic Tab: mepro 200 mg/asa 325*mg

SKELETAL MUSCLE RELAXANT/NSAID/CAFFEINE COMBINATIONS

• orphenadrine/aspirin/caff eine (D)(G)
  Pediatric: not recommended
  Norgesic 1-2 tabs tid-qid
  Tab: orphen 25 mg/asa 385 mg/caf 30 mg
  Norgesic Forte 1 tab tid or qid; max 4 tabs/day
  Tab: orphen 50 mg/asa 770 mg/caf 60*mg

SKELETAL MUSCLE RELAXANT/NSAID/CODEINE COMBINATIONS

• carisoprodol/aspirin/codeine (D)(III)(G)
  Pediatric: not recommended
  Soma Compound w. Codeine 1-2 tabs qid
  Tab: caris 200 mg/asa 325 mg/cod 16 mg (sulfi tes)

TOPICAL/TRANSDERMAL NSAIDs

• capsaicin (B)(G) apply tid-qid prn to intact skin
  Pediatric: <2 years: not recommended; =2 years: apply sparingly tid-qid prn
  Axsain Crm: 0.075% (1, 2 oz)
  Capsin Lotn: 0.025, 0.075% (59 ml)
  Capzasin-P (OTC) Crm: 0.025% (1.5 oz); Lotn: 0.025% (2 oz)
  Dolorac Crm: 0.025% (28 g)
  Double Cap (OTC) Crm: 0.05% (2 oz)
  R-Gel Gel: 0.025% (15, 30 g)
  Zostrix (OTC) Crm: 0.025% (0.7, 1.5, 3 oz)
  Zostrix HP (OTC) Emol crm: 0.075% (1, 2 oz)
• capsaicin 8% patch (B) apply up to 4 patches for one 60-minute application to clean dry skin; may prep area with topical anesthetic; wear nonlatex gloves; patches may be cut to size/shape; treatment may be repeated every 3 months; remove with cleansing gel aft er treatment
  Pediatric: <18 years: not recommended
  Qutenza Patch: 8% 1640 mcg/cm (179 mg; 1 or 2 patches, each w. 1-50 g tube cleansing gel/carton)
• diclofenac epolamine transdermal patch (C; D =30 wks) apply one patch to affected area bid; remove during bathing; avoid non-intact skin
  Pediatric: not recommended
  Flector Patch Patch: 180 mg/patch (30/carton)

ORAL NSAIDs

• diclofenac (C)
  Pediatric: <18 years: not recommended
  Zorvolex take on empty stomach; 35 mg tid; Hepatic impairment: use lowest dose
  Gelcap: 18, 35 mg
• diclofenac sodium (C)
  Pediatric: <18 years: not recommended
  Voltaren 50 mg bid-qid or 75 mg bid or 25 mg qid with an additional 25 mg at HS if necessary
  Tab: 25, 50, 75 mg ent-coat
  Voltaren XR 100 mg once daily; rarely, 100 mg bid may be used
  Tab: 100 mg ext-rel

For an expanded list of Oral Prescription NSAIDs see page 501

ORAL NSAIDS/PPI COMBINATIONS

• esomeprazole/naproxen (C)(G) 1 tab bid; use lowest eff ective dose for the shortest duration swallow whole; take at least 30 minutes before a meal
  Pediatric: <18 years: not recommended
  Vimovo Tab: nap 375 mg/eso 20 mg ext-rel; nap 500 mg/eso 20 mg ext-rel
  Comment: Vimovo is indicated to improve signs/symptoms, and risk of gastric ulcer in patients at risk of developing NSAID-associated gastric ulcer.

COX-2 INHIBITORS
Comment: Cox-2 inhibitors are contraindicated with history of asthma, urticaria, and allergic-type reactions to aspirin, other NSAIDs, and sulfonamides, 3rd trimester of pregnancy, and coronary artery bypass graft (CABG) surgery.

• celecoxib (C)(G) 100-400 mg daily bid; max 800 mg/day
  Pediatric: <18 years: not recommended
  Celebrex Cap: 50, 100, 200, 400 mg
• meloxicam (C)(G) initially 7.5 mg once daily; max 15 mg once daily
  Pediatric: <2 years: not recommended; =2 years: 0.125 mg/kg; max 7.5 mg once daily
  Mobic Tab: 7.5, 15 mg; Oral susp: 7.5 mg/5 ml (100 ml) (raspberry)
  Vivlodex Cap: 5, 10 mg

TOPICAL/TRANSDERMAL NSAIDS

• capsaicin (B)(G) apply tid-qid prn to intact skin
  Pediatric: <2 years: not recommended; =2 years: apply sparingly tid-qid prn
  Axsain Crm: 0.075% (1, 2 oz)
  Capsin Lotn: 0.025, 0.075% (59 ml)
  Capzasin-P (OTC) Crm: 0.025% (1.5 oz); Lotn: 0.025% (2 oz)
  Dolorac Crm: 0.025% (28 g)
  Double Cap (OTC) Crm: 0.05% (2 oz)
  R-Gel Gel: 0.025% (15, 30 g)
  Zostrix (OTC) Crm: 0.025% (0.7, 1.5, 3 oz)
  Zostrix HP (OTC) Emol crm: 0.075% (1, 2 oz)
• capsaicin 8% patch (B) apply up to 4 patches for one 60-minute application to clean dry skin; may prep area with topical anesthetic; wear nonlatex gloves; patches may be cut to size/shape; treatment may be repeated every 3 months; remove with cleansing gel after treatment
  Pediatric: <18 years: not recommended
  Qutenza Patch: 8% 1640 mcg/cm (179 mg; 1 or 2 patches, each w. 1-50 g tube cleansing gel/carton)
• diclofenac epolamine transdermal patch (C; D =30 wks) apply one patch to affected area bid; remove during bathing; avoid nonintact skin
  Pediatric: not recommended
  Flector Patch Patch:180 mg/patch (30/carton)
• diclofenac sodium (C; D =30 wks)(G) apply gel qid prn; avoid non-intact skin
  Pediatric: not recommended
  Voltaren Gel Gel: 1% (100 g)

TOPICAL/TRANSDERMAL LIDOCAINE

• lidocaine transdermal patch (C)(G) apply one patch to aff ected area for 12 hours (then off for 12 hours); remove during bathing; avoid non-intact skin
  Pediatric: not recommended
  Lidoderm Patch: 5% (10 cm x14 cm; 30/carton)

NARCOLEPSY

STIMULANTS

• amphetamine sulfate (C)(II) administer fi rst dose on awakening, and additional doses at 4- to 6-hour intervals; usual range 5-60 mg/day
  Pediatric: <6 years: not recommended; 6-12 years: 5 mg daily in the AM; may increase by 5 mg/day at weekly intervals; >12-18 years: initially 10 mg in the AM; may increase by 10 mg daily at weekly intervals
  Evekeo initially 10 mg once or twice daily at the same time(s) each day; may increase by 10 mg/day at weekly intervals; max 40 mg/day
  Pediatric: <6 years: not recommended; 6-12 years: initially 5 mg once or twice daily at the same time(s) each day; may increase by 5 mg/day at weekly intervals; max 40 mg/day; >12 years: same as adult
  Tab: 5, 10 mg
• armodafinil (C)(IV)(G) OSAHS: 50-250 mg once daily in the AM; SWSD: 150 mg 1 hour before starting shift ; reduce dose with severe hepatic impairment
  Pediatric: <17 years: not recommended
  Nuvigil Tab: 50, 150, 200, 250 mg
• modafinil (C)(IV)(G) 100-200 mg q AM; max 400 mg/day
  Pediatric: <17 years: not recommended
  Provigil Tab: 100, 200*mg
  Comment: Provigil also promotes wakefulness in patients with shift work sleep disorder and excessive sleepiness due to obstructive sleep apnea/hypopnea syndrome.
• sodium oxybate (B) take dose at bedtime while in bed and repeat 2.5-4 hours later; titrate to eff ect; initially 4.5 grams/night in 2 divided doses; may increase by 1.5 g/
  night in 2 divided doses; max 9 g/night
  Pediatric: <16 years: not recommended; =16 years: same as adult
  Xyrem Oral soln: 100, 200*mg
  Comment: Xyrem is used to reduce the number of cataplexy attacks (sudden loss of muscle strength) and reduce daytime sleepiness in patients with narcolepsy. Contraindicated with alcohol or CNS depressant (may impair consciousness; may lead to respiratory depression, coma, or death). Prepare both doses prior to bedtime and do not attempt to get out of bed aft er taking the fi rst dose. Place both doses within reach at the bedside. Set the bedside clock to awaken for the second dose. Dilute each dose in 60 ml (1/4 cup, 4 tblsp) water in child resistant dosing containers. Food signifi cantly reduces the bioavailability of sodium oxybate; take at least 2 hours aft er ingesting food.

STIMULANTS

• dextroamphetamine sulfate (C)(II)(G) initially start with 10 mg daily; increase by 10 mg at weekly intervals if needed; may switch to daily dose with sust-rel spansules when titrated
  Pediatric: <3 years: not recommended; 3-5 years: 2.5 mg daily; may increase by 2.5 mg daily at weekly intervals if needed; 6-12 years: initially 5 mg daily-bid; may increase by 5 mg/day at weekly intervals; usual max 40 mg/day; >12 years: initially 10 mg daily; may increase by mg/day at weekly intervals; max 40 mg/day 10
  Dexedrine Tab: 5*mg (tartrazine)
  Dexedrine Spansule Cap: 5, 10, 15 mg sust-rel
  Dextrostat Tab: 5, 10 mg (tartrazine)
• dextroamphetamine saccharate/dextroamphetamine sulfate/amphetamine aspartate/amphetamine sulfate (C)(II)(G)
  Adderall initially 10 mg daily; may increase weekly by 10 mg/day; usual max 60 mg/day in 2-3 divided doses; fi rst dose on awakening and then q 4-6 hours prn
  Pediatric: <6 years: not indicated; 6-12 years: initially 5 mg daily; may increase weekly by 5 mg/day; usual max 40 mg/day in 2-3 divided doses; >12 years: same as adult
  Tab: 5**, 7.5**, 10**, 12.5**, 15**, 20**, 30**mg
  Adderall XR
  Pediatric: <6 years: not recommended; 6-12 years: initially 10 mg daily in the AM; may increase by 10 mg weekly; max 30 mg/day; 13-17 years: initially 10 mg daily; may increase to 20 mg/day aft er 1 week; max 30 mg/day; Do not chew; may sprinkle on apple sauce
  Cap: 5, 10, 15, 20, 25, 30 mg ext-rel
  Comment: Adderall is also indicated to improve wakefulness in patients with shift -work sleep disorder and excessive sleepiness due to obstructive sleep apnea/hypopnea syndrome.
• dexmethylphenidate (C)(II)(G) take once daily in the AM
  Pediatric: <6 years: not recommended; =6 years: same as adult
  Focalin initially 2.5 mg bid; allow at least 4 hours between doses; may increase at 1 week intervals; max 40 mg/day
  Tab: 2.5, 5, 10*mg (dye-free)
  Focalin XR 20-40 mg q AM; max 40 mg/day
  Tab: 5, 10, 15, 20, 30, 40 mg ext-rel (dye-free)
• methamphetamine (C)(II)(G)
  Desoxyn Granumets
  Pediatric: <6 years: not recommended; =6 years: initially 5 mg daily bid; may increase by 5 mg/day at weekly intervals; usual eff ective dose; 20-25 mg/day
  Tab: 5, 10, 15 mg sust-rel
• methylphenidate (regular-acting) (C)(II)(G)
  Methylin, Methylin Chewable, Methylin Oral Solution usual dose 20-30 mg/day in 2-3 divided doses 30-45 minutes before a meal; may increase to 60 mg/day
  Pediatric: <6 years: not recommended; =6 years: initially 5 mg twice daily before breakfast and lunch; may increase 5-10 mg/week; max 60 mg/day
  Tab: 5, 10*, 20*mg; Chew tab: 2.5, 5, 10 mg (grape) (phenylalanine); Oral soln: 5, 10 mg/5 ml) (grape)
  Ritalin 10-60 mg/day in 2-3 divided doses 30-45 minutes ac; max 60 mg/day
  Pediatric: <6 years: not recommended; =6 years: initially 5 mg bid ac (before breakfast and lunch); may gradually increase by 5-10 mg at weekly intervals as needed; max 60 mg/day
  Tab: 5, 10*, 20*mg
• methylphenidate (long-acting) (C)(II)
  Concerta initially 18 mg q AM; may increase in 18 mg increments as needed; max 54 mg/day; do not crush or chew
  Tab: 18, 27, 36, 54 mg sust-rel
  Metadate CD (G) 1 cap daily in the AM; may sprinkle on food; do not crush or chew
  Pediatric: <6 years: not recommended; =6 years: initially 20 mg daily; may gradually increase by 20 mg/day at weekly intervals as needed; max 60 mg/day
  Cap: 10, 20, 30, 40, 50, 60 mg immed- and ext-rel beads
  Metadate ER 1 tab daily in the AM; do not crush or chew
  Pediatric: <6 years: not recommended; =6 years: use in place of regular-acting methylphenidate when the 8-hour dose of Metadate-ER corresponds to the titrated 8-hour dose of regular-acting methylphenidate
  Tab: 10, 20 mg ext-rel (dye-free)
  Ritalin LA 1 cap daily in the AM
  Pediatric: <6 years: not recommended; =6 years: use in place of regular-acting methylphenidate when the 8-hour dose of Ritalin LA corresponds to the titrated 8-hour dose of regular-acting methylphenidate; max 60 mg/day
  Cap: 10, 20, 30, 40 mg ext-rel (immed- and ext-rel beads)
  Ritalin SR 1 cap daily in the AM
  Pediatric: <6 years: not recommended; =6 years: use in place of regular-acting methylphenidate when the 8-hour dose of Ritalin SR corresponds to the titrated 8-hour dose of regular-acting methylphenidate; max 60 mg/day
  Tab: 20 mg sust-rel (dye-free)
• methylphenidate (transdermal patch) (C)(II)(G) 1 patch daily in the AM
  Pediatric: <6 years: not recommended; =6 years: initially 10 mg patch daily in the AM; may increase by 5-10 mg/week; max 60 mg/day
  Transdermal patch: 10, 15, 20, 30 mg
• pemoline (B)(IV) 18.75-112.5 mg/day; usually start with 37.5 mg in AM; increase weekly by 18.75 mg/day if needed; max 112.5 g/day
  Pediatric: <6 years: not recommended; =6 years: same as adult
  Cylert Tab: 18.75*, 37.5*, 75*mg
  Cylert Chewable Chew tab: 37.5*mg
  Comment: Monitor baseline serum ALT and repeat every 2 weeks thereaft er.

NAUSEA/VOMITING PROPHYLAXIS (FOR PREVENTION OF MOTION SICKNESS AND POST-OP NAUSEA AND VOMITING)

Anticholinergic Agents

• scopolamine (C)
  Scopace 0.4-0.8 mg 1 hour before travel; may repeat in 8 hours
  Pediatric: not recommended
  Tab: 0.4 mg
  Transderm Scop 1 patch behind ear at least 4 hours before travel; each patch is effective for 3 days
  Pediatric: not recommended
  Transdermal patch: 1.5 mg (4/carton)

MILD NAUSEA

• phosphorylated carbohydrate solution (C)(G) 1-2 tblsp q 15 minutes until nausea subsides; max 5 doses/day
  Pediatric: 1-2 tsp q 15 minutes until nausea subsides; max 5 doses/day
  Emetrol (OTC) Soln: dextrose 1.87 g/fructose 1.87 g/phosphoric acid 21.5 mg per 5 ml (4, 8, 16 oz)

Cannabinoid

• dronabinol (C)(III) initially 5 mg/m2 1-3 hours before chemotherapy; then q 2-4 hours prn; max 4-6 doses/day, 15 mg/m2
  Marinol Cap: 2.5, 5, 10 mg (sesame seed oil)
• nabilone (C)(II) 1-2 mg bid; max 6 mg/day in 3 divided doses; initially 1-3 hours before chemotherapy; may give 1-2 mg the night before chemo; may continue 48 hours aft er each chemo cycle
  Cesamet Cap: 1 mg (sesame seed oil)

Antihistamines

• diphenhydramine (C)(G) 10-50 mg IV or deep IM q 6-8 hours prn; max 400 mg/day
  Pediatric: 5 mg/kg/day in 4 divided doses; max 300 mg/day
  Benadryl Vial: 50 mg/ml (1 ml single-use); 50 mg/ml (10 ml multi-dose); Amp: 50 mg/ml (1 ml); Prefi lled syringe: 50 mg/ml (1 ml)
• meclizine (C)(G) Travel: 25-50 mg 1 hour prior to travel; repeat every 24 hours;
  Vertigo of vestibular origin: 25-100 mg/day in divided doses
  Pediatric: 5 mg/kg/day in 4 divided doses; max 300 mg/day
  Antivert Tab: 12.5, 25, 50*mg; Amp: 50 mg/ml (1 ml)
  Vial: 50 mg/ml (1 ml single-use); 50 mg/ml (10 ml multi-dose)
  Bonine (OTC) Cap: 15, 25, 50 mg; Tab: 12.5, 25, 50 mg;
  Chew tab/Film-coat tab: 25 mg
  Dramamine II (OTC) Tab: 25 mg
  Zentrip Strip: 25 mg orally-disint

MODERATE TO SEVERE NAUSEA

Phenothiazines

• chlorpromazine (C)(G) 10-25 mg PO q 4 hours prn or 50-100 mg rectally q 6-8 hours prn
  Pediatric: <6 months: not recommended; =6 months: 0.25 mg/lb orally q 4-6 hours prn or 0.5 mg/lb rectally q 6-8 hours prn
  Thorazine Tab: 10, 25, 50, 100, 200 mg; Spansule: 30, 75, 150 mg sust-rel; Syr: 10 mg/5 ml (4 oz; orange custard); Conc: 30 mg/ml (4 oz); 100 mg/ml (2, 8 oz);
  Supp: 25, 100 mg
• perphenazine (C) 5 mg IM (may repeat in 6 hours) or 8-16 mg/day PO in divided doses; max 15 mg/day IM; max 24 mg/day PO
  Pediatric: not recommended
  Trilafon Tab: 2, 4, 8, 16 mg; Oral conc: 16 mg/5 ml (118 ml); Amp: 5 mg/ml (1 ml)
• prochlorperazine (C)(G) 5-10 mg tid-qid prn; usual max 40 mg/day
  Compazine Pediatric: <2 years or <20 lb: not recommended; 20-29 lb: 2.5 mg daily bid prn; max 7.5 mg/day; 30-39 lb: 2.5 mg bid-tid prn; max 10 mg/day; 40-85 lb: 2.5 mg tid or 5 mg bid prn; max 15 mg/day
  Tab: 5, 10 mg; Syr: 5 mg/5 ml (4 oz) (fruit)
  Compazine Suppository 25 mg rectally bid prn; usual max 50 mg/day
  Pediatric: <2 years or <20 lb: not recommended; 20-29 lb: 2.5 mg daily-bid prn; max 7.5; mg/day; 30-39 lb: 2.5 mg bid-tid prn; max 10 mg/day; 40-85 lb: 2.5 mg tid or 5 mg bid prn; max 15 mg/day
  Rectal supp: 2.5, 5, 25 mg
  Compazine Injectable 5-10 mg tid or qid prn
  Pediatric: <2 years or <20 lb: not recommended; =2 years or =20 lb: 0.06 mg/kg x 1 dose
  Vial: 5 mg/ml (2, 10 ml)
  Compazine Spansule 15 mg q AM prn or 10 mg q 12 hours prn usual max 40 mg/day
  Pediatric: not recommended
  Spansule: 10, 15 mg sust-rel
• promethazine (C)(G) 25 mg PO or rectally q 4-6 hours prn
  Pediatric: <2 years: not recommended; =2 years: 0.5 mg/lb or 6.25-25 mg q 4-6 hours prn
  Phenergan Tab: 12.5*, 25*, 50 mg; Plain syr: 6.25 mg/5 ml; Fortis syr: 25 mg/5 ml; Rectal supp: 12.5, 25, 50 mg
  Substance P/Neurokinin 1 Receptor Antagonist
• aprepitant (B)(G) administer with corticosteroid and 5-HT-3 receptor antagonist; Day 1 of chemotherapy cycle: 125 mg 1 hour prior to chemotherapy Day 2 & 3: 80 mg in the morning
  Pediatric: <6 months: years: not recommended; =6 months: use oral suspension (see mfr pkg insert for dose by weight
  Emend Cap: 40, 80, 125 mg (2 x 80 mg bifold pck; 1 x 25 mg/2 x 80 mg trifold pck); Oral susp: 125 mg pwdr for oral suspension, single dose pouch w dispenser; Vial: 150 mg pwdr for reconstitution and IV infusion 5-HT-3 Receptor Antagonists
  Comment: Th e selective 5-HT-3 receptor antagonists indicated for prevention of nausea and vomiting associated with moderately to highly emetogenic chemotherapy.
• dolasetron (B) administer 100 mg IV over 30 seconds, 30 min prior to administration of chemotherapy or 2 hours before surgery; max 100 mg/dose
  Pediatric: <2 years: not recommended; 2-16 years: 1.8 mg/kg; >16 years: same as adult
  Anzemet Tab: 50, 100 mg; Amp: 12.5 mg/0.625 ml; Prefi lled carpuject syringe: 12.5 mg (0.625 ml); Vial: 100 mg/5 ml (single- use); Vial: 500 mg/25 ml (multidose)
• granisetron
  Kytril (B) administer IV over 30 seconds, 30 min prior to administration of chemotherapy; max 1 dose/week
  Pediatric: <2 years: not recommended; =2 years: 10 mcg/kg
  Tab: 1 mg; Oral soln: 2 mg/10 ml (30 ml; orange); Vial: 1 mg/ml (1 ml singledose; preservative-free); 1 mg/ml (4 ml multi-dose) (benzyl alcohol)
  Sancuso (B) apply 1 patch 24-48 hours before chemo; remove 24 hours (minimum) to 7 days (maximum) aft er completion of treatment
  Transdermal patch: 3.1 mg/day
  Sustol (NE) administer SC over 20-30 seconds (due to drug viscosity) on Day 1 of chemotherapy and not more frequently than once every 7 days; CrCl 30-59 mL/min:
  repeat dose no more than every 14th day; CrCl <30 mL/min: not recommended; for patients receiving MEC, the recommended dexamethasone dosage is 8 mg IV on Day 1; for patients receiving AC combination chemotherapy regimens, the recommended dexamethasone dosage is 20 mg IV on Day 1, followed by 8 mg PO bid on Days 2, 3 and 4; if Sustol is administered with an NK1 receptor antagonist, see that drug’s mfr pkg insert for the recommended dexamethasone dosing
  Pediatric: <18 years: not established
  Syringe: 10 mg/0.4 ml ext-rel; prefi lled single-dose/kit
  Comment: At least 60 minutes prior to administration, remove the Sustol kit from refrigeration; activate a warming pouch and wrap the syringe in the warming pouch for 5-6 minutes to warm it to room temperature.
• ondansetron (C)(G)
  Oral Forms: Highly emetogenic chemotherapy: 24 mg x 1 dose 30 min prior to start of single-day chemotherapy; Moderately emetogenic chemotherapy: 8 mg q 8 hours x 2 doses beginning 30 minutes prior to start of chemotherapy; then 8 mg q 12 hours x 1-2 days following
  Pediatric: <4 years: not recommended; 4-11 years, moderately emetogenic chemotherapy: 4 mg q 4 hours x 3 doses beginning 30 min prior to start; then 4 mg q 8 hours x 1-2 days following
  Zofran Tab: 4, 8, 24 mg
  Zofran ODT ODT: 4, 8 mg (strawberry) (phenylalanine)
  Zofran Oral Solution Oral soln: 4 mg/5 ml (50 ml) (strawberry) (phenylalanine);
  Parenteral form: see mfr pkg insert
  Zofran Injection Vial: 2 mg/ml (2 ml single-dose); 2 mg/ml (20 ml multidose); 32 mg/50 ml (50 ml multi-dose); Prefi lled syringe: 4 mg/2 ml, single-use (24/carton)
  Zuplenz Oral Soluble Film: 4, 8 mg oral-dis (10/carton) (peppermint)
• palonosetron (B)(G) Chemotherapy: administer 0.25 mg IV over 30 seconds, 30 min prior to administration of chemo; max 1 dose/week or 1 cap 1 hour before chemo; Postop: administer 0.075 mg IV over 10 seconds immediately before induction of anesthesia
  Pediatric: <1 month: not recommended; 1 month to 17 years: 20 mcg/kg; max 1.5 mg single-dose; infuse over 15 minutes beginning 30 minutes prior to administration of chemo
  Aloxi Vial (single-use): 0.075 mg/1.5 ml; 0.25 mg/5 ml (mannitol)

ANTI-DOPAMINERGIC (PROMOTILITY) AGENTS

• metoclopramide (B)(G) 10 mg 30 minutes before each meal and at HS for 2-8 weeks
  Metozolv ODT ODT: 5, 10 mg (mint)
  Reglan Tab: 5, 10*mg
  Comment: metoclopramide is contraindicated when stimulation of GI motility may be dang6erous. Observe for tardive dyskinesia and Parkinsonism. Avoid concomitant drugs which may cause an extrapyramidal reaction (e.g., phenothiazines, haloperidol).

Substance P/Neurokinin-1 (NK-1) Receptor Antagonist

• rolapitant (NE) take 180 mg in a single dose 1-2 hours before chemotherapy treatment; administer in combination with dexamethasone and 5-HT3 receptor antagonist
  Pediatric: not established
  Varubi Tab: 90 mg fi lm-coat
  Comment: Varubi is indicated in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with emetogenic cancer chemotherapy.

SUBSTANCE P/NEUROKININ-1 (NK-1) RECEPTOR ANTAGONIST/5-HT-3 RECEPTOR ANTAGONIST COMBINATION

• netupitant/palonosetron (C) take one cap approximately 1 hour prior to chemotherapy; administer in combination with dexamethasone
  Pediatric: not established
  Akynzeo Gelcap: netu 300 mg/palo 0.5 mg
  Comment: Akynzeo is indicated in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with emetogenic cancer chemotherapy.

NERVE AGENT POISONING

• atropine sulfate (NE)(G) 2 mg IM
  Pediatric: <15 lb: not recommended; =15-40 lb: 0.5 mg IM; =40-90 lb: 1 mg IM; >90 lb: same as adult
  AtroPen Pen (single-use): 0.5, 1, 2 mg (0.5 ml)

NON-24 SLEEP-WAKE DISORDER
Comment: For other drug options (stimulants, sedative hypnotics), see Insomnia page 242, Sleepiness: Excessive, Shift Work Sleep Disorder page 400

MELATONIN RECEPTOR AGONIST

• tasimelteon (C) take 1 gelcap before bedtime at the same time every night; do not take with food
  Pediatric: not established
  Hetlioz Gel cap: 20 mg

OREXIN RECEPTOR ANTAGONIST

• suvorexant (C)(IV) use lowest eff ective dose; take 30 minutes before bedtime; do not take if unable to sleep for =7 hours; max 20 mg
  Pediatric: not recommended
  Belsomra Tab: 5, 10, 15, 20 mg (30/blister pck)

OBESITY
Comment: Target BMI is 25-30 (=27 preferred).

STIMULANTS

• amphetamine sulfate (C)(II)
  Evekeo initially 5 mg 30-60 minutes before meals; usually up to 30 mg/day
  Pediatric: <12 years: not recommended; =12 years: same as adult
  Tab: 5, 10 mg

LIPASE INHIBITOR

• orlistat (X)(G) 1 cap tid 1 hour before or during each main meal containing fat
  Pediatric: <12 years: not recommended; =12 years: same as adult
  Alli (OTC) Cap: 60 mg
  Xenical Cap: 120 mg
  Comment: For use when BMI >30 kg/m2 or BMI >27 kg/m2 in the presence of other risk factors (i.e., HTN, DM, dyslipidemia).

ANOREXIGENICS

Sympathomimetics
Comment: Side eff ects include hypertension, tachycardia, restlessness, insomnia, and dry mouth.

• benzphetamine (X)(III) initially 25-50 mg daily in the mid-morning or mid-aft ernoon; may increase to bid-tid as needed
  Pediatric: not recommended
  Didrex Tab: 50*mg
• naltrexone/bupropion (X) swallow whole; avoid high-fat meals; initially 10 mg bid; evaluate weight loss aft er 12 weeks; discontinue if less than 5% weight loss
  Pediatric: <18 years: not recommended
  Contrave Tab: nal 8 mg/bup 900 mg ext-rel
• methamphetamine (C)(II) 10-15 mg q AM
  Pediatric: <12 years: not recommended; =12 years: same as adult
  Desoxyn Tab: 5, 10, 15 mg sust-rel
• phendimetrazine (C)(III)
  Pediatric: <12 years: not recommended; =12 years: same as adult
  Bontril PDM 35 mg bid-tid 1 hour ac; may reduce to 17.5 mg (1/2 tab)/dose; max 210 mg/day in 3 divided doses
  Tab: 35*mg
  Bontril Slow-Release 105 mg in the AM 30-60 minutes before breakfast
  Cap: 105 mg slow-rel
• phentermine (C)(IV)
  Pediatric: <16 years: not recommended; =16 years: same as adult
  Adipex-P (G) 1 cap or tab before breakfast or 1/2 tab bid ac
  Cap: 37.5 mg; Tab: 37.5*mg
  Fastin (G) 1 cap before breakfast
  Cap: 30 mg
  Ionamin (G) 1 cap before breakfast or 10-14 hours prior to HS
  Cap: 15, 30 mg
  Suprenza ODT (X)(IV) dissolve 1 tab on top of tongue once daily in the morning, with or without food; use lowest eff ective dose
  Tab: 15, 30, 37.5 mg orally-disint
  Comment: Contraindicated with history of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension, during or within 14 days following the administration of an MAOI, hyperthyroidism, glaucoma, agitated states, history of drug abuse, pregnancy, nursing).

Sympathomimetic/Antiepileptic Combination

• phentermine/topiramate ext-rel (X)(IV)(G) initially 3.75 mg/23 mg daily in the AM x 14 days; then increase to 7.5 mg/46 mg and evaluate weight loss on this dose after 12 weeks; if =3% weight loss from baseline, discontinue or increase dose to 11.25 mg/69 mg x 14 days; then increase to 15 mg/92 mg and evaluate weight loss on this dose aft er 12 weeks; if =5% weight loss from baseline, discontinue by taking a dose every other day for at least one week prior to stopping; max 7.5 mg/46 mg for moderate to severe renal impairment or moderate hepatic impairment.
  Pediatric: <16 years: not established; =16 years: same as adult
  Qsymia
  Cap: Qsymia 3.75/23: phen 3.75 mg/topir 23 mg ext-rel
  Qsymia 7.5/46: phen 7.5 mg/topir 46 mg ext-rel
  Qsymia 11.25/69: phen 11.25 mg/topir 69 mg ext-rel
  Qsymia 15/92: phen 15 mg/topir 92 mg ext-rel
  Comment: Side eff ects include hypertension, tachycardia, restlessness, insomnia, and dry mouth. Contraindicated with glaucoma, hyperthyroidism, and within 14 days of taking an MAOI. Qsymia 3.75/23 and Qsymia 11.25/69 are for titration purposes only.

Serotonin 2C Receptor Agonist

• lorcaserin (X)(G) 10 mg bid; discontinue if 5% weight loss is not achieved by week 12
  Pediatric: <18 years: not recommended
  Belviq Tab: 10 mg fi lm-coat
  Comment: Belviq is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes). Serotonin 2C receptor agonists interact with serotonergic drugs (selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase
  inhibitors (MAOIs), triptans, bupropion, dextromethorphan, St. John’s wort); therefore, use with extreme caution due to the risk of serotonin syndrome.

GLUCAGON-LIKE PEPTIDE-1 (GLP-1) RECEPTOR AGONIST

• liraglutide (C) administer SC in the upper arm, abdomen, or thigh once daily; escalate dose gradually over 5 weeks to 3 mg SC daily; Week 1: 0.6 mg SC daily; Week 2: 1.2 mg SC daily; Week 3: 1.8 mg SC daily; Week 4: 2.4 mg SC daily; Week 5: 3 mg SC daily;
  Pediatric: <18 years: not recommended
  Saxenda Soln for SC inj: 6 mg/ml multi-dose prefi lled pen (3 ml; 3, 5 pens/carton)
  Comment: Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes). Not indicated for treatment of T2DM. Do not use with Victoza, other GLP-1 receptor agonists, or insulin. Contraindicated with personal or family history of medullary thyroid carcinoma (MTC) and multiple endocrine neoplasia syndrome (MENS) type 2. Monitor for signs/symptoms pancreatitis. Discontinue if gastroparesis, renal, or hepatic impairment.

OBSESSIVE-COMPULSIVE DISORDER (OCD)

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
Comment: Co-administration of SSRIs with TCAs requires extreme caution.
Concomitant use of MAOIs and SSRIs is absolutely contraindicated. Avoid other serotonergic drugs. A potentially fatal adverse event is Serotonin Syndrome, caused by serotonin excess. Milder symptoms require HCP intervention to avert severe symptoms which can be rapidly fatal without urgent/emergent medical care. Symptoms include restlessness, agitation, confusion, hallucinations, tachycardia, hypertension, dilated pupils, muscle twitching, muscle rigidity, loss of muscle coordination, diaphoresis, diarrhea, headache, shivering, piloerection, hyperpyrexia,
cardiac arrhythmias, seizures, loss of consciousness, coma, death. Abrupt withdrawal or interruption of treatment with an antidepressant medication is sometimes associated with an Antidepressant Discontinuation Syndrome which may be mediated by gradually tapering the drug over a period of two weeks or longer, depending on the dose strength and length of treatment. Common symptoms of the Serotonin Discontinuation Syndrome include fl u-like symptoms (nausea, vomiting, diarrhea, headaches, sweating), sleep disturbances (insomnia, nightmares, constant sleepiness), mood disturbances (dysphoria, anxiety, agitation), cognitive disturbances (mental confusion, hyperarousal), sensory and movement disturbances (imbalance, tremors, vertigo, dizziness, electric-shock-like sensations in the brain, oft en described by sufferers as “brain zaps.”

• fluoxetine (C)(G)
  Prozac initially 20 mg daily; may increase aft er 1 week; doses >20 mg/day may be divided into AM and noon doses; max 80 mg/day
  Pediatric: <7 years: not recommended; 7-17 years: initially 10 mg/day; may increase aft er 2 weeks to 20 mg/day; range 20-60 mg/day; range for lower weight children 20-30 mg/day
  Cap: 10, 20, 40 mg; Tab: 30*, 60*mg; Oral soln: 20 mg/5 ml (4 oz) (mint)
  Prozac Weekly following daily fl uoxetine therapy at 20 mg/day for 13 weeks, may initiate Prozac Weekly 7 days aft er the last 20 mg fl uoxetine dose
  Pediatric: not recommended
  Cap: 90 mg ent-coat del-rel pellets
• fluvoxamine (C)(G)
  Luvox initially 50 mg q HS; adjust in 50 mg increments at 4-7 day intervals; range 100-300 mg/day; over 100 mg/day, divide into 2 doses giving the larger dose at HS
  Pediatric: <8 years: not recommended; 8-17 years: initially 25 mg q HS; adjust in 25 mg increments q 4-7 days; usual range 50-200 mg/day; over 50 mg/day, divide into 2 doses giving the larger dose at HS
  Tab: 25, 50*, 100*mg
  Luvox CR initially 100 mg once daily at HS; may increase by 50 mg increments at 1 week intervals; max 300 mg/day; swallow whole
  Pediatric: <18 years: not recommended
  Cap: 100, 150 mg ext-rel
• paroxetine maleate (D)(G)
  Pediatric: not recommended
  Paxil initially 20 mg daily in AM; may increase by 10 mg/day at weekly intervals as needed; max 60 mg/day
  Tab: 10*, 20*, 30, 40 mg
  Paxil CR initially 25 mg daily in AM; may increase by 12.5 mg at weekly intervals as needed; max 62.5 mg/day
  Tab: 12.5, 25, 37.5 mg cont-rel ent-coat
  Paxil Suspension initially 20 mg daily in AM; may increase by 10 mg/day at weekly intervals as needed; max 60 mg/day
  Oral susp: 10 mg/5 ml (250 ml) (orange)
• sertraline (C) initially 50 mg daily; increase at 1 week intervals if needed; max 200 mg daily
  Pediatric: <6 years: not recommended; 6-12 years: initially 25 mg daily; max 200 mg/day; 13-17 years: initially 50 mg daily; max 200 mg/day
  Zoloft Tab: 15*, 50*, 100*mg; Oral conc: 20 mg per ml (60 ml [dilute just before administering in 4 oz water, ginger ale, lemon-lime soda, lemonade, or orange juice]) (alcohol 12%)

TRICYCLIC ANTIDEPRESSANT (TCA) COMBINATIONS

• clomipramine (C)(G) initially 25 mg daily in divided doses; gradually increase to 100 mg during fi rst 2 weeks; max 250 mg/day; total maintenance dose may be given at HS
  Pediatric: <10 years: not recommended; =10 years: initially 25 mg daily in divided doses; gradually increase; max 3 mg/kg or 100 mg, whichever is smaller
  Anafranil Cap: 25, 50, 75 mg
• imipramine (C)(G)
  Tofranil initially 75 mg/day; max 200 mg/day
  Pediatric: adolescents initially 30-40 mg/day; max 100 mg/day
  Tab: 10, 25, 50 mg
  Tofranil PM initially 75 mg/day; max 200 mg/day
  Pediatric: not recommended
  Cap: 75, 100, 125, 150 mg

ONYCHOMYCOSIS (FUNGAL NAIL)

ORAL AGENTS

• griseofulvin, microsize (C)(G) 1 g daily for at least 4 months for fi ngernails and at least 6 months for toenails
  Pediatric: 5 mg/lb/day; see page 579 for dose by weight
  Grifulvin V Tab: 250, 500 mg; Oral susp: 125 mg/5 ml (120 ml; alcohol 0.02%)
• griseofulvin, ultramicrosize (C) 750 mg in a single or divided doses for at least 4 months for fi ngernails and at least 6 months for toenails
  Pediatric: <2 years: not recommended; =2 years: 3.3 mg/lb in a single or divided doses
  Gris-PEG Tab: 125, 250 mg
• itraconazole (C)(G) 200 mg daily x 12 consecutive weeks for toenails; 200 mg bid x 1 week, off 3 weeks, then 200 mg bid x 1 additional week for fi ngernails
  Pediatric: not recommended
  Sporanox Cap: 100 mg; Soln: 10 mg/ml (150 ml) (cherry-caramel)
  Pulse Pack: 100 mg caps (7/pck)
• terbinafi ne (B)(G) 250 mg daily x 6 weeks for fi ngernails; 250 mg daily x 12 weeks for toenails
  Pediatric: not recommended
  Lamisil Tab: 250 mg

TOPICAL AGENTS
Comment: File and trim nail while nail is free from drug. Remove unattached infected nail as frequently as monthly. For use with mild to moderate onychomycosis of the fi ngernails and toenails, without lunula involvement due to Trichophyton rubrum immunocompetent patients as part of a comprehensive treatment program. For use on nails and adjacent skin only. Apply evenly to entire onycholytic nail and surrounding 5 mm of skin daily, preferably at HS or 8 hours before washing; apply to nail bed, hyponychium, and under surface of nail plate when it is free of the nail bed; apply over previous coats, then remove with alcohol once per week; treat for up to 48 weeks.

• ciclopirox (B)
  Pediatric: not established
  Penlac Nail Lacquer Topical soln (lacquer): 8% (6.6 ml w. applicator)
• efinaconazole (C)
  Pediatric: not established
  Jublia Topical soln: 5% (10 ml w. brush applicator)
• tavaborole (C)
  Pediatric: not established
  Kerydin Topical soln: 10% (10 ml w. dropper)

OPHTHALMIA NEONATORUM: CHLAMYDIAL PROPHYLAXIS

• erythromycin ophthalmic ointment 0.5-1 cm ribbon into lower conjunctival sac of each eye x 1 application
  Ilotycin Ophthalmic Ointment Ophth oint: 5 mg/g (1/8 oz)
  Comment: Th e following treatment regimens are published in the 2015 CDC Sexually Transmitted Diseases Treatment Guidelines. Treatment regimens are presented by generic drug name first, followed by information about brands and dose forms.

RECOMMENDED REGIMENS

Regimen 1

• erythromycin base 50 mg/kg/day in 4 doses x 14 days

Regimen 2

• erythromycin ethylsuccinate 50 mg/kg/day in 4 doses x 14 days

DRUG BRANDS AND DOSE FORMS

• erythromycin base (B)(G)
  Pediatric: <45 kg: 30-50 mg in 2-4 divided doses x 7-10 days; =45 kg: same as adult
  Ery-Tab Tab: 250, 333, 500 mg ent-coat
  PCE Tab: 333, 500 mg
  Comment: erythromycin may increase INR with concomitant warfarin, as well as increase serum level of digoxin, benzodiazepines and statins.
• erythromycin ethylsuccinate (B)(G)
  Pediatric: 30-50 mg/kg/day in 4 divided doses x 7 days; may double dose with severe infection; max 100 mg/kg/day for at least 14 days; see page 574 for dose by weight
  EryPed Oral susp: 200 mg/5 ml (100, 200 ml) (fruit); 400 mg/5 ml (60, 100, 200 ml (banana); Oral drops: 200, 400 mg/5 ml (50 ml) (fruit); Chew tab: 200 mg wafer (fruit)
  E.E.S. Oral susp: 200, 400 mg/5 ml (100 ml) (fruit)
  E.E.S. Granules Oral susp: 200 mg/5 ml (100, 200 ml) (cherry)
  Comment: erythromycin may increase INR with concomitant warfarin, as well as increase serum level of digoxin, benzodiazepines and statins.

OPHTHALMIA NEONATORUM: GONOCOCCAL
Comment: Th e following prophylaxis and treatment regimens for gonococcal conjunctivitis is published in the 2015 CDC Sexually Transmitted Diseases Treatment Guidelines.

Regimen 1

• erythromycin 0.5% ophthalmic ointment 0.5-1 cm ribbon into lower conjunctival sac of each eye x 1 application
  Ilotycin Ophthalmic Ointment Ophth oint: 5 mg/g (1/8 oz)

Regimen 2

• ceft riaxone (B)(G) 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg
  Pediatric: 1 g IM in a single dose
  Rocephin Vial: 250, 500 mg; 1, 2 g

OPIOID DEPENDENCE OPIOID WITHDRAWAL SYNDROME
Safety labeling for all immediate-release (IR) opioids has been issued by the FDA. Th e boxed warning includes serious risks of misuse, abuse, addiction, overdose, and death. Th e dosing section off ers clear steps regarding administration and patient monitoring including initial dose, dose changes, and the abrupt cessation of treatment in physical dependence. Chronic maternal use of opioids during pregnancy can lead to potentially lifethreatening neonatal opioid withdrawal. Th e American Pain Society (APS) has released new evidence-based clinical practice guidelines that include 32 recommendations related to post-op pain management in adults and children.

NARCOTIC ANALGESIC

• methadone (C) Narcotic Detoxification: 15-40 mg daily in decreasing doses not to exceed 21 days; Narcotic Maintenance: >21 days; see mfr pkg insert
  Pediatric: not established
  Dolophine Tab: 5, 10 mg; Dispersible tab: 40 mg (dissolve in 120 ml orange juice or other citrus drink); Oral conc: 5, 10 mg/5 ml; 10 mg/10 ml
  Comment: methadone maintenance is allowed only by approved providers with strict state and federal regulations.

OPIOID ANTAGONIST

• naltrexone (C)
  Pediatric: not established
  ReVia 50 mg daily
  Tab: 50 mg
  Vivitrol 380 mg IM once monthly; alternate buttocks
  Vial: 380 mg

OPIOID PARTIAL AGONIST-ANTAGONIST
Comment: Belbuca, Butrans, Probuphine, and Subutex maintenance are allowed only by approved providers with strict state and federal regulations. Th ese drugs are potentiated by CYP3A4 inhibitors (e.g, azole antifungals, macrolides, HIV protease inhibitors) and antagonized by CYP3A4 inducers (monitor for opioid withdrawal). Concomitant NNRTIs (e.g., efavirenz, nevirapine, etravirine, delavirdine) or PIs (e.g., atazanavir with/without ritonavir): monitor. Risk of respiratory or CNS depression with concomitant opioid analgesics, general anesthetics, benzodiazepines, phenothiazines, other tranquilizers, sedative/hypnotics, alcohol, or other CNS depressants. Risk of serotonin syndrome with concomitant SSRIs, SNRIs, TCAs, 5-HT3 receptor antagonists, mirtazapine, trazodone, tramadol, MAO inhibitors.

• buprenorphine (C)(III)
  Pediatric: <16 years: not established
  Belbuca apply buccal fi lm to inside of cheek; do not chew or swallow; Opioid naïve: initially 75 mcg once daily-q 12 hours x at least 4 days; then, increase to 150 mcg q 12 hours; may increase in increments of 150 mcg q 12 hours no sooner than every 4 days; max 900 mcg q 12 hours; see mfr pkg insert for conversion from other opioids; Severe hepatic impairment or oral mucositis: reduce initial and titration doses by half
  Buccal film: 75, 150, 300, 450, 600, 750, 900 mcg (60/pck) (peppermint)
  Butrans Transdermal System apply one patch to clean, dry, hairless, intact skin on the upper outer arm, upper chest, upper back, or side of chest every 7 days; rotate sites and do not re-use a site for at least 21 days; Opioid naïve or oral morphine <30 mg/day or equivalent: one 5 mcg/hour patch; Converting from oral morphine equivalents 30-80 mg/day: taper current opioids for up to 7 days to =30 mg/day oral morphine equivalents before starting; then initiate with 10 mcg/hour patch; may use a short-acting analgesic until effi cacy is attained; increase dose only after exposure to previous dose x at least 72 hours; max one 20 mcg/hour patch/week; Conversion from higher opioid doses: not recommended
  Transdermal patch: 5, 7.5, 10, 15, 20 mcg/hour (4/pck)
  Probuphine initiate when stable on buprenorphine =8 mg/day; insertion site is the inner side of the upper arm; 4 implants are intended to be in place for 6 months; remove the implants by the end of the 6th month and insert four new implants on the same day in the contralateral arm; if a new implant is not inserted on the same day as removal of a previous implant, maintain the patient on the previous dose of transmucosal buprenorphine (i.e., the dose from which the patient was transferred to Probuphine treatment).
  Subdermal implant: 74.2 mg of buprenorphine (equivalent to 80 mg of buprenorphine hydrochloride)
  Comment: Healthcare providers who prescribe, perform insertions and/or perform removals of Probuphine must successfully complete a live training program, and demonstrate procedural competency prior to inserting or removing the implants. Further information: visit www.ProbuphineREMS.com or call 1-844-859-6341
  Subutex (G) 8 mg in a single dose on day 1; then 16 mg in a single dose on day 2; target dose is 16 mg/day in a single dose; dissolve under tongue; do not chew or swallow whole
  SL tab (lemon-lime) or SL fi lm (lime): 2, 8 mg (30/pck)

OPIOID PARTIAL AGONIST-ANTAGONIST/OPIOID ANTAGONIST
Comment: Bunabail, Suboxone, Sucartonone, Troxyca ER, and Zubsolv maintenance are allowed only by approved providers with strict state and federal regulations.

• buprenorphine/naloxone (C)(III)
  Bunavail administer one buccal fi lm once daily at the same time each day; target dose is 8.4/1.4 once daily; place the side of the Bunavail fi lm with the text (BN2, BN4, or BN6) against theinside of the cheek; press and hold the fi lm in place for 5 seconds; maintenance is usually 2.1/0.3 to 12.6/2.1 once daily
  Pediatric: <16 years: not recommended; =16 years: same as adult
  SL film:
  Bunavail 2.1/0.3 bup 2.1 mg/nal 0.3 mg (30/carton)
  Bunavail 4.2/0.7 bup 4.2 mg/nal 0.7 mg (30/carton)
  Bunavail 6.3/1 bup 6.3 mg/nal 1 mg (30/carton)
  Comment: A Bunavail 4.2/0.7 mg buccal fi lm provides equivalent buprenorphine exposure to a Sucartonone 8/2 mg sublingual tablet.
  Suboxone (G) adjust dose in increments/decrements of 2 mg/0.5 mg or 4 mg/1 mg once daily buprenorpnine/naloxone, based on the patient’s daily dose of buprenorphine, to a level that suppresses opioid withdrawal signs and symptoms; Recommended target dosage: 16 mg/4 mg as a single daily dose; Maintenance dose: generally in the range of 4 mg/1 mg to 24 mg/6 mg per day; higher once daily doses have not been demonstrated to provide any clinical advantage
  Pediatric: not established
  SL tab, SL fi lm:
  Suboxone 2/0.5 bup 2 mg/nal 0.5 mg (lime) (30/bottle)
  Suboxone 8/2 bup 8 mg/nal 2 mg (lime) (30/bottle)
  Sucartonone adjust in 2-4 mg of buprenorphine/day in a single dose; usual range is 4-24 mg/day in a single dose; target dose is 6 mg/day in a single dose; dissolve under tongue; do not chew or swallow whole
  Pediatric: <16 years: not recommended; =16 years: same as adult
  SL film (lime):
  Sucartonone 2/0.5 bup 2 mg/nal 0.5 mg (30/pck)
  Sucartonone 4/1 bup 4 mg/nal 1 mg (30/pck)
  Sucartonone 8/2 bup 8 mg/nal 2 mg (30/pck)
  Sucartonone 12/3 bup 12 mg/nal 3 mg (30/pck)
  Zubsolv initial induction with buprenorphine sublingual tabs; administer as a single dose once daily; titrate dose in increments of 1.4/0.36 or 2.9/0.72 per day; recommended target dose is 11.4/2.9 per day; usual max 17.2/4.2 per day
  Pediatric: <16 years: not recommended; =16 years: same as adult
  SL tab:
  Zubsolv 1.4/0.36 bup 1.4 mg/nal 0.36 mg
  Zubsolv 2.9/0.72 bup 2.9 mg/nal 0.71 mg
  Zubsolv 5.7/1.4 bup 5.7 mg/nal 1.4 mg
  Zubsolv 8.6/2.1 bup 8.6 mg/nal 2.1 mg
  Zubsolv 11.4/2.9 bup 11.4 mg/nal 2.9 mg
  Comment: One Subutex 5.7/1.4 SL tab is bioequivalent to one Sucartonone 8/2
  SL fi lm.
• oxycodone/naloxone (C)(II) Opioid-naïve and opioid non-tolerant: initially 10 mg/1.2mg q 12 hours; Opioid tolerant: single doses greater than 40 mg/4.8 mg, or a total daily dose greater than 80 mg/9.6 mg are only for use in patients for whom tolerance to an opioid of comparable potency has been established; swallow whole, or sprinkle contents on applesauce and swallow immediately without chewing
  Pediatric: <18 years: not recommended
  Troxyca ER
  Cap: Troxyca ER 10/1.2 oxy 10 mg/nalox 1.2 mg ext-rel
  Troxyca ER 20/1.2 oxy 20 mg/nalox 2.4 mg ext-rel
  Troxyca ER 30/1.2 oxy 30 mg/nalox 3.6 mg ext-rel
  Troxyca ER 40/1.2 oxy 40 mg/nalox 4.8 mg ext-rel
  Troxyca ER 60/1.2 oxy 60 mg/nalox 7.2 mg ext-rel
  Troxyca ER 80/1.2 oxy 80 mg/nalox 9.6 mg ext-rel
  Comment: Opioid tolerant patients are those taking, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid.

OPIOID-INDUCED CONSTIPATION (OIC)

• lubiprostone (C) swallow whole; take with food and water; initially 24 mcg bid; Moderate hepatic impairment (Child Pugh Class B): 16 mg bid; Severe hepatic impairment (Child Pugh Class C): 8 mg bid
  Pediatric: not recommended
  Amitiza Cap: 8, 24 mg
• methylnaltrexone bromide (C) administer 12 mg SC once daily or once every other day, in the upper arm, abdomen, or thigh; max one dose/24 hrs; discontinue other laxatives; <38 kg-14 kg: 0.15 mg/kg; 38-<62 kg: 8 mg; 62-114 kg: 12 mg; CrCl <30 mL/min: reduce dose by half
  Pediatric: not established
  Relistor Vial: 8 mg/0.4 ml; 12 mg/0.6 ml single-use (7/carton); Prefi lled syringes (7/carton)
• naloxegol (C) swallow whole; take on an empty stomach; initially 25 mg once daily in the AM; discontinue other laxatives; CrCl <60 mL/min: 12.5 mg
  Pediatric: not established
  Movantik Tab: 12.5, 25 mg

OPIOID OVERDOSE

OPIOID ANTAGONISTS

• nalmefene (B) initially 0.25 mcg/kg IV, IM, or SC, then incremental doses of 0.25 mcg/kg at 2-5 minute intervals; cumulative max 1 mcg/kg; if opioid dependency suspected use 0.1 mg/70 kg initially and then proceed as usual if no response in 2 minutes
  Pediatric: not recommended
  Revex Amp: 100 mcg/1 ml (1 ml); 1 mg/ml (2 ml)
• naloxone (B)(G) 0.4-2 mg; repeat in 2-3 minutes if no response
  Pediatric: 0.01 mg/kg initially, repeat in 2-3 minutes at 0.1 mg/kg if response inadequate
  Evzio Prefi lled autoinjector: 0.4 mg/0.4, 2 mg/0.4 ml IM/SC only
  Comment: Evzio 2 mg/0.4 ml comes with 2 autoinjectors and one trainer. Th is strength is indicated for the emergency treatment of known or suspected opioid overdose manifested by CNS depression. If the electronic voice instruction system does not operate properly, Evzio will still deliver the intended dose of naloxone when used according to the printed instructions on the fl at surface of the autoinjector label. Evzio cannot be administered IV. Due to the short duration of action of naloxone, as compared to opioids which are longer acting, monitoring of the patient is critical as the opioid reversal eff ects of naloxone may wear off before the eff ects of the opioid.
  Narcan Vial/Amp: 0.4 mg/ml (1 ml), 1 mg/ml (2 ml); Prefi lled syringe: 0.4 mg/ml (1 ml), 1 mg/ml (2 ml) IV, IM, or SC (parabens-free)
  Narcan Nasal Spray position supine with head tilted back; 1 spray in one nostril; if an additional dose is needed, spray into the opposite nostril
  Nasal spray: 4 mg/0.1 ml, single dose, single use (2 blister pcks, each w a single nasal spray/carton)

OSGOOD-SCHLATTER DISEASE

Acetaminophen for IV Infusion see Pain page 306
Oral Prescription NSAIDs see page 501
Other Oral Analgesics see Pain page 308
Topical/Transdermal NSAIDs see Pain page 307
Parenteral Corticosteroids see page 511
Oral Corticosteroids see page 509
Topical Analgesic and Anesthetic Agents see page 499

OSTEOARTHRITIS

Acetaminophen for IV Infusion see Pain page 306
Oral Prescription NSAIDs see page 501
Other Oral Analgesics see Pain page 308
Topical/Transdermal NSAIDs see Pain page 307
Parenteral Corticosteroids see page 511
Oral Corticosteroids see page 509
Topical Analgesic and Anesthetic Agents see page 499

TOPICAL ANALGESICS

• capsaicin (B)(G) apply tid to qid prn to intact skin
  Pediatric: <2 years: not recommended; =2 years: same as adult
  Axsain Crm: 0.075% (1, 2 oz)
  Capsin Lotn: 0.025, 0.075% (59 ml)
  Capzasin-P (OTC) Crm: 0.025% (1.5 oz); Lotn: 0.025% (2 oz)
  Dolorac Crm: 0.025% (28 g)
  Double Cap (OTC) Crm: 0.05% (2 oz)
  R-Gel Gel: 0.025% (15, 30 g)
  Zostrix (OTC) Crm: 0.025% (0.7, 1.5, 3 oz)
  Zostrix HP (OTC) Emol crm: 0.075% (1, 2 oz)
  Comment: Provides some relief by 1-2 weeks; optimal benefi t may take 4-6 weeks.

ORAL SALICYLATE

• indomethacin (C) initially 25 mg bid to tid, increase as needed at weekly intervals by 25-50 mg/day; max 200 mg/day
  Pediatric: <14 years: usually not recommended; >2 years, if risk warranted: 1-2 mg/kg/day in divided doses; max 3-4 mg/kg/day (or 150-200 mg/day, whichever is less); <14 years, ER cap not recommended
  Cap: 25, 50 mg; Susp; 25 mg/5 ml (pineapple-coconut, mint) (alcohol 1%);
  Supp: 50 mg; ER Cap: 75 mg ext-rel
  Comment: indomethacin is indicated only for acute painful fl ares. Administer with food and/or antacids. Use lowest eff ective dose for shortest duration.

ORAL NSAIDs
See more Oral NSAIDs page 501

• diclofenac (C)
  Pediatric: <18 years: not recommended
  Zorvolex take on empty stomach; 35 mg tid; Hepatic impairment: use lowest dose
  Gelcap: 18, 35 mg
• diclofenac sodium (C)
  Pediatric: <18 years: not recommended
  Voltaren 50 mg bid to qid or 75 mg bid or 25 mg qid with an additional 25 mg at HS if necessary
  Tab: 25, 50, 75 mg ent-coat
  Voltaren XR 100 mg once daily; rarely, 100 mg bid may be used
  Tab: 100 mg ext-rel

ORAL NSAIDs PLUS PPI

• esomeprazole/naproxen (C)(G) 1 tab bid; use lowest eff ective dose for the shortest duration swallow whole; take at least 30 minutes before a meal
  Pediatric: <18 years: not recommended
  Vimovo Tab: nap 375 mg/eso 20 mg ext-rel; nap 500 mg/eso 20 mg ext-rel
  Comment: Vimovo is indicated to improve signs/symptoms, and risk of gastric ulcer in patients at risk of developing NSAID-associated gastric ulcer.

COX-2 INHIBITORS
Comment: Cox-2 inhibitors are contraindicated with history of asthma, urticaria, and allergic-type reactions to aspirin, other NSAIDs, and sulfonamides, 3rd trimester of pregnancy, and coronary artery bypass graft (CABG) surgery.

• celecoxib (C)(G) 100-400 mg daily bid; max 800 mg/day
  Pediatric: <18 years: not recommended
  Celebrex Cap: 50, 100, 200, 400 mg meloxicam (C)(G) initially 7.5 mg once daily; max 15 mg once daily
  Pediatric: <2 years: not recommended; =2 years: 0.125 mg/kg; max 7.5 mg once daily
  Mobic Tab: 7.5, 15 mg; Oral susp: 7.5 mg/5 ml (100 ml) (raspberry)
  Vivlodex Cap: 5, 10 mg

INTRA-ARTICULAR INJECTION

• sodium hyaluronate (B) using strict aseptic technique, administer by intra-articular injection (into the synovial space) once weekly for the prescribed number of weeks (see mfr pkg insert); aft er preparing the injection site and attaining local analgesia, remove joint synovial fl uid or eff usion prior to injection
  Pediatric: not recommended
  Gelsyn-3 Syringe: 8.4 mg/ml (2 ml) prefi lled
  Hyalgan Vial: 20 mg (2 ml); Prefi lled syringe: 20 mg (2 ml)
  Hylan Syringe: 48 mg/6 ml (6 ml) prefi lled
  Synvisc One Syringe: 46 mg/6 ml (6 ml) prefi lled

OSTEOPOROSIS

Comment: Indications for bone density screening include: Postmenopausal women not receiving HRT, maternal history of hip fracture, personal history of fragility fracture, presence of high serum markers of bone resorption, smoker, height >67 inches, weight <125 lb, taking a steroid, GnRH agonist, or antiseizure drug, immobilization, hyperthyroidism, posttransplantation, malabsorption syndrome, hyperparathyroidism, prolactinemia. The mnemonic ABONE [Age >65, Bulk (weight <140 lbs at menopause), and Never Estrogens (for more than 6 months)], represent other indications for bone density screening. Foods high in calcium include almonds, broccoli, baked beans, salmon, sardines, buttermilk, turnip greens, collard greens, spinach, pumpkin, rhubarb, and bran. Recommended Daily Calcium Intake: 1-3 years: 700 mg; 4-8 years: 1000 mg; 9-18 years: 1300 mg; 19-50 years: 1000 mg: 51-70 years (males): 1000 mg; =51 years (females): 1200 mg; pregnancy or nursing: 1000-1300 mg
Recommended Daily Vitamin D Intake: >1 year: 600 IU; 50+ years: 800-1000 IU.

ESTROGEN REPLACEMENT THERAPY
Comment: estrogen plus progesterone is indicated for postmenopausal women with an intact uterus. estrogen monotherapy is indicated in women without a uterus. The following list is not inclusive; for more estrogen replacement therapies see Menopause page 264)

• estradiol (X)
  Alora initially 0.05 mg/day apply patch twice weekly to lower abdomen, upper quadrant of buttocks or outer aspect of hip
  Transdermal patch: 0.025, 0.05, 0.075, 0.1 mg/day (8, 24/pck)
  Climara initially 0.025 mg/day patch once/week to trunk
  Transdermal patch: 0.025, 0.0375, 0.05, 0.075, 0.1 mg/day (4, 8, 24/pck)
  Estrace 1-2 mg daily cyclically (3 weeks on and 1 week off )
  Tab: 0.5, 1, 2*mg (tartrazine)
  Estraderm initially apply one 0.05 mg/day patch twice weekly to trunk
  Transdermal patch: 0.05, 0.1 mg/day (8, 24/pck)
  Menostar apply one patch weekly to lower abdomen, below the waist; avoid the breasts; alternate sites; Transdermal patch: 14 mcg/day (4/pck)
  Minivelle initially one 0.0375 mg/day patch twice weekly to trunk area; adjust after one month of therapy
  Transdermal patch: 0.025, 0.0375, 0.05, 0.075, 0.1 mg/day (8/pck)
  Vivelle initially one 0.0375 mg/day patch twice weekly to trunk area; use with an oral progestin to prevent endometrial hyperplasia
  Transdermal patch: 0.025, 0.0375, 0.05, 0.075, 0.1 mg/day (8, 48/pck)
  Vivelle-Dot initially one 0.05 mg/day patch twice weekly to lower abdomen, below the waist; use with an oral progestin to prevent endometrial hyperplasia
  Transdermal patch: 0.025, 0.0375, 0.05, 0.075, 0.1 mg/day (8, 24/pck)
• estradiol/levonorgestrel (X) apply 1 patch weekly to lower abdomen; avoid waistline; alternate sites
  Climara Pro Transdermal patch: estra 0.045 mg/levo 0.015 mg per day (4/pck)
• estradiol/norethindrone (X) 1 tab daily
  Activella (G) Tab: estra 1 mg/noreth 0.5 mg
  FemHRT 1/5 Tab: estra 5 mcg/noreth 1 mg
• estradiol/norgestimate (X) one-1mg estradiol tab daily x 3 days, then 1-estradiol 1 mg/norgestimate 0.09 mg tab once daily x 3 days; repeat this pattern continuously
  Ortho-Prefest Tab: estra 1 mg/norgest 0.09 mg (30/blister pck)
• estrogen, conjugated (equine) (X)
  Premarin 1 tab daily
  Tab: 0.3, 0.45, 0.625, 0.9, 1.25, 2.5 mg
• estropipate, piperazine estrone sulfate (X)(G)
  Ogen 0.625-1.25 mg daily cyclically (3 weeks on and 1 week off )
  Tab: 0.625, 1.25, 2.5 mg
  Ortho-Est 0.75-6 mg daily cyclically (3 weeks on and 1 week off )
  Tab: 0.625, 1.25 mg

ESTROGENS, CONJUGATED/ESTROGEN AGONIST-ANTAGONIST COMBINATION

• estrogen, conjugated/bazedoxifene (X)
  Duavee 1 tab daily
  Tab: conj estra 0.45 mg/baze 20 mg

CALCIUM SUPPLEMENTS
Comment: Take calcium supplements aft er meals to avoid gastric upset. Dosages of calcium over 2000 mg/day have not been shown to have any additional benefit.
calcium decreases tetracycline absorption. calcium absorption is decreased by corticosteroids.

• calcitonin-salmon (C)
  Fortical 200 IU intranasally daily; alternate nostrils each day
  Nasal spray: 200 IU/actuation (30 doses, 3.7 ml)
  Miacalcin Nasal spray 200 IU spray in one nostril once daily; alternate nostrils each day
  Nasal spray: 200 IU/actuation (30 doses, 3.7 ml)
  Miacalcin Injection 100 units SC or IM every other day
  Vial: 200 units/ml (2 ml)
  Comment: Supplement diet with calcium (1 g/day) and vitamin D (400 IU/day).
• calcium carbonate (C)(OTC)(G)
  Rolaids chew 2 tabs bid; max 14 tabs/day
  Chew tab: 550 mg
  Rolaids Extra Strength chew 2 tabs bid; max 8 tabs/day
  Chew tab: 1000 mg
  Tums chew 2 tabs bid; max 16 tabs/day
  Chew tab: 500 mg
  Tums Extra Strength chew 2 tabs bid; max 10 tabs/day
  Chew tab: 750 mg
  Tum Sultra chew 2 tabs bid; max 8 tabs/day
  Chew tab: 1000 mg
  Os-Cal 500 (OTC) 1-2 tab bid to tid
  Chew tab: elemental calcium carbonate 500 mg
• calcium carbonate/vitamin d (C)(G)
  Os-Cal 250+D (OTC) 1-2 tab tid
  Tab: elemental calcium carbonate 250 mg/vit d 125 IU
  Os-Cal 500+D (OTC) 1-2 tab bid-tid
  Tab: elemental calcium carbonate 500 mg/vit d 125 IU
  Viactiv (OTC) 1 tab tid
  Chew tab: elemental calcium 500 mg/vit d 100 IU/vitamin k 40 mcg
• calcium citrate (C)(G)
  Citracal (OTC) 1-2 tabs bid
  Tab: elemental calcium citrate 200 mg
• calcium citrate/vitamin d (C)(G)
  Citracal +D (OTC) 1-2 cplts bid
  Cplt: elemental calcium citrate 315 mg/vit d 200 IU
  Citracal 250+D (OTC) 1-2 tabs bid
  Tab: elemental calcium citrate 250 mg/vit d 62.3 IU

VITAMIN D ANALOGS
Comment: Concurrent vitamin D supplementation is contraindicated for patients taking calcitrol or doxercalciferol due to the risk of vitamin D toxicity.

• calcitrol (C) Predialysis: initially 0.25 mcg daily; may increase to 0.5 mcg daily; Dialysis: initially 0.25 mcg daily; may increase by 0.25 mcg/day at 4-8 week intervals; usual maintenance 0.5-1 mcg/day; Hypoparathyroidism: initially 0.25 mcg q AM; may increase by 0.25 mcg/day at 4- to 8-week intervals; usual maintenance 0.5-2 mcg/day
  Pediatric: Predialysis: <3 years: 10-15 ng/kg/day; =3 years: initially 0.25 mcg daily; may increase to 0.5 mcg/day; Dialysis: not recommended; Hypoparathyroidism: initially 0.25 mcg daily; may increase by 0.25 mcg/day at 2-4 week intervals; usual maintenance (1-5 years) 0.25-0.75 mcg/day, (>6 years) 0.5-2 mcg/day
  Rocaltrol Cap: 0.25, 0.5 mcg
  Rocaltrol Solution Soln: 1 mcg/ml (15 ml, single-use dispensers)
• doxercalciferol (C) initially 0.25 mcg q AM; may increase by 0.25 mcg/day at 4-8 week intervals; usual maintenance 0.5-2 mcg/day
  Pediatric: initially 0.25 mcg daily; may increase by 0.25 mcg; 0.25 mcg/day at 2-4 week intervals; usual maintenance (1-5 years) 0.25-0.75 mcg/day, (=6 years) 0.5-2 mcg/day
  Hectorol Cap: 0.25, 0.5 mcg

BISPHOSPHONATES (CALCIUM MODIFIERS)
Comment: Biphosphonates should be swallowed whole in the AM with 6-8 oz of plain water 30 minutes before fi rst meal, beverage, or other medications of the day.
Monitor serum alkaline phosphatase. Contraindications include abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia, inability to stand or sit upright for at least 30 minutes postdose, patients at risk of aspiration, and hypocalcemia. Co-administration of biphosphonates and calcium, antacids, or oral medications containing multivalent cations will interfere with absorption of the bophosphonate. Therefore, instruct patients to wait at least half hour after taking the biphosphonate before taking any other oral medications.

• alendronate (as sodium) (C) take once weekly, in the AM, 30 minutes before the first food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and aft er the first food of the day; CrCl <35 mL/min: not recommended with
  Pediatric: not recommended
  Binosto dissolve the effervescent tab in 4 oz (120 ml) of plain, room temperature, water (not mineral or fl avored); wait 5 minutes aft er the effervescence has subsided, then stir for 10 seconds, then drink
  Tab: 70 mg eff ervescent for buff ered solution (4, 12/carton) (strawberry)
  Fosamax (G) swallow tab whole; dosing regimens are the same for men and postmenopausal women; Prevention: 5 mg once daily or 35 mg once weekly; Treatment: 10 mg once daily or 70 mg once weekly
  Tab: 5, 10, 35, 40, 70 mg
• alendronate/cholecalciferol (vit d3) (C)(G) take 1 tab once weekly, in the AM, with plain water (not mineral) 30 minutes before the fi rst food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and aft er the fi rst food of the day
  Pediatric: not recommended
  Fosamax Plus D
  Tab: Fosamax Plus D 70/2800: alen 70 mg/chole 2800 IU
  Fosamax Plus D 70/5600: alen 70 mg/chole 5600 IU
• ibandronate (as monosodium monohydrate) (C)(G)
  Pediatric: not recommended
  Boniva take 2.5 mg once daily or 150 mg once monthly on the same day; take in the AM, with plain water (not mineral) 60 minutes before the fi rst food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and aft er the fi rst food of the day
  Tab: 2.5, 150 mg
  Boniva Injection administer 3 mg every 3 months by IV bolus over 15-30 seconds; if dose is missed, administer as soon as possible; then every 3 months from the date of the last dose
  Prefi lled syringe: 3 mg/3 ml (5 ml)
  Comment: Boniva Injection must be administered by a health care professional.
• risedronate (as sodium) (C)(G) take in the AM; swallow whole with a full glass of plain water (not mineral); do not lie down (remain upright) for 30 minutes afterward
  Pediatric: not recommended
  Actonel take at least 30 minutes before any food or drink; Women: 5 mg once daily or 35 mg once weekly or 75 mg on two consecutive days monthly or 150 mg once monthly; Men: 35 mg once weekly
  Tab: 5, 30, 35, 75, 150 mg
  Atelvia 35 mg once weekly immediately aft er breakfast
  Tab: 35 mg del-rel
  risedronate/calcium (C) 1 x 5 mg risedronate tab weekly plus 1 x 500 mg calcium tab on days 2-7 weekly
  Actonel with Calcium Tab: risedronate 5 mg and Tab: calcium 500 mg (4 risedronate tabs + 30 calcium tabs/pck)
• zoledronic acid (D)(G)
  Pediatric: not recommended
  Reclast administer 5 mg via IV infusion over at least 15 minutes mg once a year (for osteoporosis) or once every 2 years (for osteopenia or prophylaxis)
  Bottle: 5 mg/100 ml (single-dose)
  Comment: Reclast is indicated for the treatment of postmenopausal osteoporosis in women who are at high risk for fracture and to increase bone mass in men with primary or hypogonadal osteoporosis who are at high risk for fracture. Administered by a health care professional. Contraindicated in hypocalcemia.
  Zometa Bottle: 4 mg/5 ml administer 4 mg via IV infusion over at least 15 minutes every 3-4 weeks; optimal duration of treatment not known
  Vial: 4 mg/5 ml (single-dose)
  Comment: Zometa is indicated for the treatment of hypercalcemia of malignancy.
  The safety and efficacy of Zometa in the treatment of hypercalcemia associated with hyperparathyroidism or with other nontumor-related conditions has not been established.

SELECTIVE ESTROGEN RECEPTOR MODULATOR (SERMs)

• raloxifene (X)(G) 60 mg once daily
  Evista Tab: 60 mg
  Comment: Contraindicated in women who have history of, or current, venous thrombotic event.

HUMAN PARATHYROID HORMONE

• teriparatide (C) 20 mcg SC daily in the thigh or abdomen; may treat for for up to 2 years
  Pediatric: not recommended
  Forteo Multidose Pen Multi-dose pen: 250 mcg/ml (3 ml)
  Comment: Forteo is indicated for the treatment of postmenopausal osteoporosis in women who are at high risk for fracture and to increase bone mass in men with primary or hypogonadal osteoporosis who are at high risk for fracture.

BIOENGINEERED REPLICA OF HUMAN PARATHYROID HORMONE
bioengineered replica of human parathyroid hormone (C) initially inject mg IM into the thigh once daily; when initiating, decrease dose of active vitamin D by 50% if serum calcium is above 7.5 mg/dL; monitor serum calcium levels every 3 to 7 days after starting or adjusting dose and when adjusting either active vitamin D or calcium supplements dose
Natpara Soln for inj: 25, 50, 75, 100 mcg (2/pkg) multi-dose, dual-chamber glass cartridge containing a sterile powder and diluent
Comment: Natpara is indicated as adjunct to calcium and vitamin D in patients with parathyroidism.

OSTEOCLAST INHIBITOR (RANKL INHIBITOR)

• denosumab (X) for SC injection 60 mcg SC once every 6 months in the upper arm, abdomen, or upper thigh
  Pediatric: not established
  Prolia Vial/Pen: 60 mg/ml (1 ml) single-dose
  Comment: Prolia is indicated for the treatment of postmenopausal osteoporosis in women who are at high risk for fracture defined as a history of osteoporoticy fracture, or multiple risk factors for fracture, or patients who have failed or are intolerant to other therapy. Administered by a health care professional. Contraindicated in hypocalcemia.

OTITIS EXTERNA

OTIC ANALGESIC

• antipyrine/benzocaine/zinc acetate dihydrate (C) fill ear canal with solution; then insert a cotton pluge into meatus; may repeat every 1-2 hours prn
  Pediatric: same as adult
  Otozin Otic soln: antipyr 5.4%/benz 1%/zinc1% per ml (10 ml w. dropper)

OTIC ANTI-INFECTIVE

• chloroxylenol/pramoxine (C) 4-5 drops tid x 5-10 days
  Pediatric: <1 year: not recommended; 1-12 years: 5 drops bid x 10 days
  PramOtic Otic drops: chlorox/pramox (5 ml w. dropper)
• finafloxacin (C) otic 4-5 drops tid x 5-10 days
  Pediatric: <1 year: not recommended; =1 year: same as adult
  Xtoro Otic soln: 0.3% (5, 8 ml)
• ofloxacin (C)(G) 10 drops bid x 10 days
  Pediatric: <1 year: not recommended; 1-12 years: 5 drops bid x 10 days
  Floxin Otic Otic soln: 0.3% (5, 10 ml w. dropper; 0.25 ml, 5 drop singles, 20/carton)
  Comment: Floxin Otic is indicated for adult patients with perforated tympanic membranes and pediatric patients with PE tubes.

OTIC ANTI-INFECTIVE/CORTICOSTEROID COMBINATIONS

• chloroxylenol/pramoxine/hydrocortisone (C) drops 4 drops tid-qid x 5-10 days
  Pediatric: 3 drops tid-qid x 5-10 days
  Cortane B, Cortane B Aqueous Otic soln: chlo 1 mg/pram 10 mg/hydro 10 mg per ml (10 ml w. dropper)
  Comment: Cortane B Aqueous may be used to saturate a cotton wick.
• ciprofloxacin/hydrocortisone (C) susp 3 drops bid x 7 days
  Pediatric: <1 year: not recommended; =1 year: same as adult
  Cipro HC Otic Otic susp: cipro 0.2%/hydro 1% (10 ml w. dropper)
• ciprofloxacin/dexamethasone (C) 4 drops bid x 7 days
  Pediatric: <6 months: not recommended; =6 months: same as adult
  Ciprodex Otic susp: cipro 0.3%/dexa 1% (7.5 ml)
  Comment: Ciprodex is indicated for the treatment of otitis media in pediatric patients with tympanostomy tubes.
• colistin/neomycin/hydrocortisone/thonzonium (C) 5 drops tid or qid x 5-10 days
  Pediatric: 4 drops tid-qid x 5-10 days
  Coly-Mycin S Otic susp: 5, 10 ml
  Cortisporin-TC Otic Otic susp: colis 3 mg/neo 3.3 mg/hydro 10 mg/thon 0.5 mg per ml (10 ml w. dropper) (thimerosal)
• polymyxin b/neomycin/hydrocortisone (C) 4 drops tid-qid; max 10 days
  Pediatric: 3 drops tid-qid; max 10 days
  Cortisporin Otic Suspension Otic susp: poly b 10,000 u/neo 3.5 mg/hydro 10 mg per 5 ml (10 ml w. dropper)
  Cortisporin Otic Solution Otic soln: poly b 10000 u/neo 3.5 mg/hydro 10 mg per 5 ml (10 ml w. dropper)

OTIC ASTRINGENTS

• acetic acid 2% in aluminum sulfate (C) 4-6 drops q 2-3 hours
  Pediatric: same as adult
  Domeboro Otic Otic soln: 60 ml w. dropper
• acetic acid/propylene glycol/benzethonium chloride/sodium acetate (C) 3-5 drops q4-6 hours
  Pediatric: same as adult
  VoSol Otic soln: acet 2% (15, 30 ml)
• acetic acid/propylene glycol/hydrocortisone/benzethonium chloride/sod-ium acetate (C) 3-5 drops q 4-6 hours
  Pediatric: same as adult
  VoSol HC Otic soln: acet 2%/hydro 1% (10 ml)

OTIC ANESTHETIC/ANALGESIC COMBINATIONS

• antipyrine/benzocaine/glycerine (C) fill ear canal and insert cotton plug; may repeat q 1-2 hours as needed
  Pediatric: same as adult
  A/B Otic Otic soln: 15 ml w. dropper
• benzocaine (C) 4-5 drops q 1-2 hours
  Pediatric: <1 year: not recommended; =1 year: same as adult
  Americaine Otic Otic soln: 20% (15 ml w. dropper)
  Benzotic Otic soln: 20% (15 ml w. dropper)

SYSTEMIC ANTI-INFECTIVES
Comment: Used for severe disease or with culture.

• amoxicillin/clavulanate (B)(G) 500 mg tid or 875 mg bid x 10 days
  Augmentin Tab: 250, 500, 875 mg; Chew tab: 125, 250 mg (lemon-lime); 200, 400 mg (cherry-banana) (phenylalanine); Oral susp: 125 mg/5 ml (banana), 250 mg/5 ml (75, 100, 150 ml) (orange); 200, 400 mg/5 ml (50, 75, 100 ml) (orange) (phenylalanine)
  Pediatric: 40-45 mg/kg/day divided tid x 10 days or 90 mg/kg/day divided bid x 10 days see pages 556-557 for dose by weight
  Augmentin ES-600 Oral susp: 600 mg/5 ml (50, 75, 100, 125, 150, 200 ml) (strawberry cream) (phenylalanine) every 12 hours
  Pediatric: <3 months: not recommended; =3 months, <40 kg: 90 mg/kg/day in 2 divided doses; =40 kg: not recommended
  Augmentin XR 2 tabs q 12 hours x 7-10 days
  Pediatric: <16 years: use other forms; =16 years: same as adult
  Tab: 1000*mg ext-rel
• cefaclor (B)(G) 250-500 mg q 8 hours x 7-10 days
  Pediatric: <1 month: not recommended; 20-40 mg/kg bid or q 12 hours x 10 days; max 1 g/day; see page 558 for dose by weight
  Tab: 500 mg; Cap: 250, 500 mg; Susp: 125 mg/5 ml (75, 150 ml) (strawberry); 187 mg/5 ml (50, 100 ml) (strawberry); 250 mg/5 ml (75, 150 ml) (strawberry); 375 mg/5 ml (50, 100 ml) (strawberry)
  Cefaclor Extended Release
  Pediatric: <16 years: ext-rel not recommended; =16 years: same as adult
  Tab: 375, 500 mg ext-rel
• dicloxacillin (B) 500 mg qid x 7-10 days
  Pediatric: 12.5-25 mg/kg/day in 4 divided doses x 7-10 days; see page 571 for dose by weight
  Dynapen Cap: 125, 250, 500 mg; Oral susp: 62.5 mg/5 ml (80, 100, 200 ml)
• trimethoprim/sulfamethoxazole (C)(G)
  Pediatric: <2 months: not recommended; =2 months: 40 mg/kg/day of sulfamethoxazole in 2 doses bid x 10 days; see page 587 for dose by weight
  Bactrim, Septra 2 tabs bid x 10 days
  Tab: trim 80 mg/sulfa 400 mg*
  Bactrim DS, Septra DS 1 tab bid x 10 days
  Tab: trim 160 mg/sulfa 800 mg*
  Bactrim Pediatric Suspension, Septra Pediatric Suspension
  Oral susp: trim 40 mg/sulfa 200 mg per 5 ml (100 ml) (cherry) (alcohol 0.3%)
  Comment: trimethoprim/sulfamethoxazole is not recommended in pregnancy or lactation. CrCl 15-30 mL/min: reduce dose by 1/2; CrCl <15 mL/min: not recommended.

OTITIS MEDIA: ACUTE

OTIC ANALGESIC

antipyrine/benzocaine/zinc acetate dihydrate otic (C) fi ll ear canal with solution; then insert cotton plug into meatus; may repeat every 1-2 hours prn
Pediatric: same as adult
Otozin Otic soln: antipyr 5.4%/benz 1%/zinc1% per ml (10 ml w. dropper)

SYSTEMIC ANTI-INFECTIVES

• amoxicillin (B)(G) 500-875 mg bid or 250-500 mg tid x 10 days
  Pediatric: <40 kg (88 lb): 20-40 mg/kg/day in 3 divided doses x 10 days or 25-45 mg/kg/day in 2 divided doses x 10 days; see page 554 for dose by weight
  Amoxil Cap: 250, 500 mg; Tab: 875*mg; Chew tab: 125, 200, 250, 400 mg (cherry-banana-peppermint) (phenylalanine); Oral susp: 125, 250 mg/5 ml (80, 100, 150 ml) (strawberry); 200, 400 mg/5 ml (50, 75, 100 ml) (bubble gum); Oral drops: 50 mg/ml (30 ml) (bubble gum)
  Moxatag Tab: 775 mg ext-rel
  Trimox Tab: 125, 250 mg; Cap: 250, 500 mg; Oral susp: 125, 250 mg/5 ml (80, 100, 150 ml) (raspberry-strawberry)
  Comment: Consider 80-90 mg/kg/day in 3 divided doses for resistant for cases
• amoxicillin/clavulanate (B)(G) 500 mg tid or 875 mg bid x 10 days
  Augmentin Tab: 250, 500, 875 mg; Chew tab: 125, 250 mg (lemon-lime); 200, 400 mg (cherry-banana) (phenylalanine); Oral susp: 125 mg/5 ml (banana), 250 mg/5 ml (75, 100, 150 ml) (orange); 200, 400 mg/5 ml (50, 75, 100 ml) (orange) (phenylalanine)
  Pediatric: 40-45 mg/kg/day divided tid x 10 days or 90 mg/kg/day divided bid x 10 days see pages 556-557 for dose by weight
  Augmentin ES-600 Oral susp: 600 mg/5 ml (50, 75, 100, 125, 150, 200 ml) (strawberry cream) (phenylalanine) every 12 hours
  Pediatric: <3 months: not recommended; =3 months, <40 kg: 90 mg/kg/day in 2 divided doses; =40 kg: not recommended
  Augmentin XR 2 tabs q 12 hours x 7-10 days
  Pediatric: <16 years: use other forms; =16 years: same as adult
  Tab: 1000*mg ext-rel
• ampicillin (B) 250-500 mg qid x 10 days
  Pediatric: 50-100 mg/kg/day in 4 divided doses x 10 days; see page 558 for dose by weight
  Omnipen, Principen Cap: 250, 500 mg; Oral susp: 125, 250 mg/5 ml (100, 150, 200 ml) (fruit)
• azithromycin (B)(G) 500 mg x 1 dose on day 1, then 250 mg daily on days 2-5 or 500 mg daily x 3 days or Zmax 2 g in a single dose
  Pediatric: 12 mg/kg/day x 5 days; max 500 mg/day; see page 559 for dose by weight
  Zithromax Tab: 250, 500, 600 mg; Oral susp: 100 mg/5 ml (15 ml); 200 mg/5 ml (15, 22.5, 30 ml) (cherry); Pkt: 1 g for reconstitution (cherry-banana)
  Zithromax Tri-pak Tab: 3 x 500 mg tabs/pck
  Zithromax Z-pak Tab: 6 x 250 mg tabs/pck
  Zmax Oral susp: 2 g ext-rel for reconstitution (cherry-banana) (148 mg Na+)
• cefaclor (B)(G) 250-500 mg q 8 hours x 7-10 days
  Pediatric: <1 month: not recommended; 20-40 mg/kg bid or q 12 hours x 10 days; max 1 g/day; see page 560 for dose by weight
  Tab: 500 mg; Cap: 250, 500 mg; Susp: 125 mg/5 ml (75, 150 ml) (strawberry); 187 mg/5 ml (50, 100 ml) (strawberry); 250 mg/5 ml (75, 150 ml) (strawberry); 375 mg/5 ml (50, 100 ml) (strawberry)
  Cefaclor Extended Release
  Pediatric: <16 years: ext-rel not recommended
  Tab: 375, 500 mg ext-rel
• cefdinir (B) 300 mg bid or 600 mg daily x 5-10 days
  Pediatric: <6 months: not recommended; 6 months-12 years: 14 mg/kg/day in 1-2 divided doses x 10 days; >12 years: same as adult; see page 562 for dose by weight
  Omnicef Cap: 300 mg; Oral susp: 125 mg/5 ml (60, 100 ml) (strawberry)
• cefixime (B)
  Pediatric: <6 months: not recommended; 6 months-12 years, <50 kg: 8 mg/kg/day in 1-2 divided doses x 10 days; >12 years, =50 kg: same as adult; see page 563 for dose by weight
  Suprax Tab: 400 mg; Cap: 400 mg; Oral susp: 100, 200 mg/5 ml (50, 75, 100 ml) (strawberry)
• cefpodoxime proxetil (B) 100 mg bid x 5 days
  Pediatric: <2 months: not recommended; 2 months-12 years: 10 mg/kg/day (max 400 mg/dose) or 5 mg/kg/day bid (max 200 mg/dose) x 5 days; >12 years: same as adult; see page 564 for dose by weight
  Vantin Tab: 100, 200 mg; Oral susp: 50, 100 mg/5 ml (50, 75, 100 ml) (lemon creme)
• cefprozil (B) 250-500 mg bid or 500 mg daily x 10 days
  Pediatric: <2 years: same as adult; 2-12 years: 7.5 mg/kg bid x 10 days; >12 years: same as adult see page 565 for dose by weight
  Cefzil Tab: 250, 500 mg; Oral susp: 125, 250 mg/5 ml (50, 75, 100 ml) (bubble gum) (phenylalanine)
• ceftibuten (B) 400 mg daily x 10 days
  Pediatric: 9 mg/kg daily x 10 days; max 400 mg/day; see page 566 for dose by weight
  Cedax Cap: 400 mg; Oral susp: 90 mg/5 ml (30, 60, 90, 120 ml); 180 mg/5 ml (30, 60, 120 ml) (cherry)
• ceftriaxone (B)(G) 1-2 g IM x 1 dose; max 4 g
  Pediatric: 50 mg/kg IM x 1 dose
  Rocephin Vial: 250, 500 mg; 1, 2 g
• cefuroxime axetil (B)(G) 250-500 mg bid x 10 days
  Pediatric: 15 mg/kg bid x 10 days; see page 567 for dose by weight
  Ceftin Tab: 250, 500 mg; Oral susp: 125, 250 mg/5 ml (50, 100 ml) (tutti-frutti)
• cephalexin (B)(G) 250 mg qid x 10 days
  Pediatric: 25-50 mg/kg/day in 4 doses x 10 days; see page 568 for dose by weight
  Kefl ex Cap: 250, 333, 500, 750 mg; Oral susp: 125, 250 mg/5 ml (100, 200 ml) (strawberry)
• clarithromycin (C)(G) 500 mg bid or 500 mg ext-rel daily
  Pediatric: <6 months: not recommended; =6 months: 7.5 mg/kg divided bid x 7 days; see page 569 for dose by weight
  Biaxin Tab: 250, 500 mg
  Biaxin Oral Suspension Oral susp: 125, 250 mg/5 ml (50, 100 ml) (fruit-punch)
  Biaxin XL Tab: 500 mg ext-rel
• erythromycin/sulfi soxazole (C)(G)
  Pediatric: <2 months: not recommended; =2 months: 50 mg/kg/day in 3 divided doses x 10 days
  Eryzole Oral susp: eryth 200 mg/sulf 600 mg per 5 ml (100, 150, 200, 250 ml)
  Pediazole Oral susp: eryth 200 mg/sulf 600 mg per 5 ml (100, 150, 200 ml) (strawberry-banana)
  Comment: erythromycin may increase INR with concomitant warfarin, as well as increase serum level of digoxin, benzodiazepines and statins. sulfamethoxazole is not recommended in pregnancy or lactation. CrCl 15-30 mL/min: reduce dose by 1/2; CrCl <15 mL/min: not recommended.
• loracarbef (B) 400 mg bid x 10 days
  Pediatric: 30 mg/kg/day in divided bid x 7 days; see page 581 for dose by weight
  Lorabid Pulvule: 200, 400 mg; Oral susp: 100 mg/5 ml (50, 100 ml); 200 mg/5 ml (50, 75, 100 ml) (strawberry bubble gum)
• trimethoprim/sulfamethoxazole (C)(G)
  Pediatric: <2 months: not recommended; >2 months: 40 mg/kg/day of sulfamethoxazole in divided doses bid x 10 days; see page 587 for dose by weight
  Bactrim, Septra 2 tabs bid x 10 days
  Tab: trim 80 mg/sulfa 400 mg*
  Bactrim DS, Septra DS 1 tab bid x 10 days
  Tab: trim 160 mg/sulfa 800 mg*
  Bactrim Pediatric Suspension, Septra Pediatric Suspension
  Oral susp: trim 40 mg/sulfa 200 mg per 5 ml (100 ml) (cherry) (alcohol 0.3%)
  Comment: trimethoprim/sulfamethoxazole is not recommended in pregnancy or lactation. CrCl 15-30 mL/min: reduce dose by 1/2; CrCl <15 mL/min: not recommended.

OTIC ANTI-INFECTIVE

• ofloxacin (C)(G) 10 drops bid x 14 days
  Pediatric: <6 months: not recommended; 6 months-12 years: 5 drops bid x 14 days; >12 years: same as adult
  Floxin Otic Otic soln: 0.3% (5, 10 ml w. dropper)
  Comment: ofl oxacin may be used with patients with perforated tympanic membrane or tympanostomy tubes.
  Otic Anti-infective/Corticosteroid Combinations
  Comment: neomycin may cause ototoxicity. Do not use with known or suspected tympanic membrane rupture.
• chloroxylenol/pramoxine/hydrocortisone (C) 4 drops tid-qid x 5-10 days
  Pediatric: 3 drops tid-qid x 5-10 days
  Cortane Ear Drops, Otic drops: 10 ml
• ciprofl oxacin/hydrocortisone (C) otic susp 3 drops bid x 7 days
  Pediatric: <1 year: not recommended; =1 year: same as adult
  Cipro HC Otic susp: cipro 0.3%/dexa 0.1% (10 ml)
• ciprofl oxacin/dexamethasone (C) otic susp 4 drops bid x 7 days
  Pediatric: <6 months: not recommended; =6 months: same as adult
  Ciprodex Otic susp: cipro 0.3%/dexa 1% (7.5 ml)
  Comment: Ciprodex is indicated for the treatment of otitis media in pediatric patients with tympanostomy tubes (PE tubes).
• colistin/neomycin/hydrocortisone/thonzonium (C) 5 drops tid-qid x 5-10 days
  Pediatric: 4 drops tid-qid x 5-10 days
  Coly-Mycin S Otic susp: 5, 10 ml
• polymyxin b/neomycin/hydrocortisone (C)(G) 4 drops tid-qid; max 10 days
  Pediatric: 3 drops tid-qid; max 10 days
  Cortisporin Otic susp: 10 ml w. dropper; Otic soln: 10 ml w. dropper
  PediOtic Otic susp: 7.5 ml w. dropper
• polymyxin B/neomycin/hydrocortisone/surfactant (C) 4 drops tid-qid
  Pediatric: 3 drops tid-qid; max 10 days
  Cortisporin-TC Otic susp: 10 ml w. dropper

OTIC ANESTHETIC/ANALGESIC COMBINATIONS

• antipyrine/benzocaine/glycerine (C) fill ear canal and insert cotton plug; may repeat q 1-2 hours as needed
  Pediatric: same as adult
  A/B Otic Otic soln: antipy 5.4%/benzo 1.4% 15 ml w. dropper
• benzocaine (C)(OTC) 4-5 drops q 1-2 hours
  Pediatric: <1 year: not recommended; =1 year: same as adult
  Otic drops: 20% (15 ml dropper-top bottle)
  Americaine Otic Otic soln: 15 ml w. dropper
  Benzotic Otic soln: 20% (15 ml w. dropper)

OTITIS MEDIA: SEROUS
Anti-infectives see Otitis Media: Acute page 301
Oral Drugs for Allergy, Cough, and Cold see page 535
Oral Corticosteroids see page 509

PAGET’S DISEASE: BONE
Comment: Calcium decreases tetracycline absorption. calcium absorption is decreased by corticosteroids. calcium absorption is decreased by foods such as rhubarb, spinach, and bran.

BISPHOSPHONATES (CALCIUM MODIFIERS)
Comment: Biphosphonates should be swallowed whole in the AM with 6-8 oz of plain water 30 minutes before fi rst meal, beverage, or other medications of the day.
Monitor serum alkaline phosphatase. Contraindications include abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia, inability to stand or sit upright for at least 30 minutes post-dose, patients at risk of aspiration, and hypocalcemia. Coadministration of biphosphonates and calcium, antacids, or oral medications containing multivalent cations will interfere with absorption of the bophosphonate. Therefore, instruct patients to wait at least half hour aft er taking the biphosphonate before taking any other oral medications.

• alendronate (as sodium) (C) take once weekly, in the AM, 30 minutes before the first food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and after the first food of the day; not recommended with CrCl <35 mL/min.
  Pediatric: not recommended
  Binosto dissolve the eff ervescent tab in 4 oz (120 ml) of plain, room temperature, water (not mineral or fl avored); wait 5 minutes aft er the eff ervescence has subsided, then stir for 10 seconds, then drink
  Tab: 70 mg effervescent for buff ered solution (4, 12/carton) (strawberry)
  Fosamax (G) swallow tab whole; dosing regimens are the same for men and post-menopausal women; Prevention: 5 mg once daily or 35 mg once weekly; Treatment: 10 mg once daily or 70 mg once weekly
  Tab: 5, 10, 35, 40, 70 mg
• alendronate/cholecalciferol (vit d3) (C)(G) take 1 tab once weekly, in the AM, with plain water (not mineral) 30 minutes before the fi rst food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and aft er the fi rst food of the day
  Pediatric: not recommended
  Fosamax Plus D
  Tab: Fosamax Plus D 70/2800 alen 70 mg/chole 2800 IU
  Fosamax Plus D 70/5600 alen 70 mg/chole 5600 IU
• ibandronate (as monosodium monohydrate) (C)(G)
  Pediatric: not recommended
  Boniva take 2.5 mg once daily or 150 mg once monthly on the same day; take in the AM, with plain water (not mineral) 60 minutes before the first food, beverage, or medication of the day; do not lie down (remain upright) for at least 30 minutes and aft er the fi rst food of the day
  Tab: 2.5, 150 mg
  Boniva Injection administer 3 mg every 3 months by IV bolus over 15-30 seconds; if dose is missed, administer as soon as possible, then every 3 months from the date of the last dose
  Prefi lled syringe: 3 mg/3 ml (5 ml)
  Comment: Boniva Injection must be administered by a qualifi ed health care professional.
• risedronate (as sodium) (C)(G) take in the AM; swallow whole with a full glass of plain water (not mineral) do not lie down (remain upright) for 30 minutes aft erward
  Pediatric: not recommended
  Actonel take at least 30 minutes before any food or drink; Women: 5 mg once daily or 35 mg once weekly or 75 mg on two consecutive days monthly or 150 mg once monthly; Men: 35 mg once weekly; Tab: 5, 30, 35, 75, 150 mg
  Atelvia 35 mg once weekly immediately aft er breakfast
  Tab: 35 mg del-rel
• risedronate/calcium (C) 1 x 5 mg risedronate tab weekly and 1 x 500 mg calcium tab on days 2-7 weekly
  Actonel with Calcium Tab: risedronate 5 mg and Tab: calcium 500 mg (4 risedronate tabs + 30 calcium tabs/pck)
• zoledronic acid (D)(G)
  Pediatric: not recommended
  Reclast administer 5 mg via IV infusion over at least 15 minutes mg once a year (for osteoporosis) or once every 2 years (for osteopenia or prophylaxis)
  Bottle: 5 mg/100 ml (single-dose)
  Comment: Reclast is indicated for the treatment of postmenopausal osteoporosis in women who are at high risk for fracture and to increase bone mass in men with primary or hypogonadal osteoporosis who are at high risk for fracture. Administered by a qualifi ed health care professional. Contraindicated in hypocalcemia.
  Zometa administer 4 mg via IV infusion over at least 15 minutes every 3-4 weeks; optimal duration of treatment not known
  Bottle: 4 mg/5 ml; Vial: 4 mg/5 ml (single-dose)
  Comment: Zometa is indicated for the treatment of hypercalcemia of malignancy.
  The safety and effi cacy of Zometa in the treatment of hypercalcemia associated with hyperparathyroidism or with other nontumor-related conditions has not been established.

PAIN
Antidepressants see Depression page 105
Skeletal Muscle Relaxants see Muscle Strain page 273

ACETAMINOPHEN FOR IV INFUSION

• acetaminophen injectable (B) administer by IV infusion over 15 minutes; 1,000 mg q6 hours prn or 650 mg q 4 hours prn; max 4,000 mg/day
  Pediatric: <2 years: not recommended; 2-13 years <50 kg: 15 mg/kg q 6 hours prn or 2.5 mg/kg q 4 hours prn; max 750 mg single-dose; max 75 mg/kg per day; >13 years: same as adult
  Ofirmev Vial: 10 mg/ml (100 ml) (preservative-free)
  Comment: Th e Ofi rmev vial is intended for single-use. If any portion is withdrawn from the vial, use within 6 hours. Discard the unused portion. For pediatric patients, withdraw the intended dose and administer via syringe pump. Do not admix Ofi rmev with any other drugs. Ofi rmev is physically incompatible with diazepam and chlorpromazine hydrochloride.

IBUPROFEN FOR IV INFUSION

• ibuprofen (B) dilute dose in 0.9% NS, D5W, or Lactated Ringers (LR) solution; administer by IV infusion over at least 10 minutes; do not administer via IV bolus or IM; 400-800 mg q 6 hours prn; maximum 3,200 mg/day
  Pediatric: <6 months; not recommended; 6 months-<12 years: 10 mg/kg q 4-6 hours prn; max 400 mg/dose; max 40 mg/kg or 2,400 mg/24 hours, whichever is less; 12-17 years: 400 mg q 4-6 hours prn; max 2,400 mg/24 hours
  Caldolor Vial: 800 mg/8 ml single-dose
  Comment: Prepare Caldolor dolutiion for IV administration as follows: 100 mg dose: dilute 1 ml of Caldolor in at least 100 ml of diluent (IVF); 200 mg dose: dilute 2 ml of Caldolor in at least 100 ml of diluent; 400 mg dose: dilute 4 ml of Caldolor in at least 100 ml of diluent; 800 mg dose: dilute 8 ml of Caldolor in at least 200 ml of diluent. Caldolor is also indicated for management of fever. For adults with fever, 400 mg via IV infusion, followed by 400 mg q 4-6 hours or 100-200 mg q 4 hours prn.

OCULAR PAIN

• difluprednate (C) apply 1 drop to aff ected eye qid; for postop ocular pain, begin treatment 24 hours postop and continue x 2 weeks; then bid daily x 1 week; then taper
  Pediatric: not recommended
  Durezol Ophth emul: 0.05% (5 ml)
  Comment: Durezol is an ophthalmic steroid.
• nepafenac (C) apply 1 drop to aff ected eye tid; for postop ocular pain, begin treatment 24 hours before surgery and continue day of surgery and for two weeks post-op
  Pediatric: <10 years: not recommended; =10 years: same as adult
  Nevanac Ophth susp: 0.1% (3 ml) (benzalkonium chloride)
  Comment: Nevanac is an ophthalmic NSAID.

TOPICAL/TRANSDERMAL NSAIDs

• capsaicin (B)(G) apply tid-qid prn to intact skin
  Pediatric: <2 years: not recommended; =2 years: apply sparingly tid-qid prn
  Axsain Crm: 0.075% (1, 2 oz)
  Capsin Lotn: 0.025, 0.075% (59 ml)
  Capzasin-P (OTC) Crm: 0.025% (1.5 oz); Lotn: 0.025% (2 oz)
  Dolorac Crm: 0.025% (28 g)
  Double Cap (OTC) Crm: 0.05% (2 oz)
  R-Gel Gel: 0.025% (15, 30 g)
  Zostrix (OTC) Crm: 0.025% (0.7, 1.5, 3 oz)
  Zostrix HP (OTC) Emol crm: 0.075% (1, 2 oz)
  capsaicin 8% patch (B) apply up to 4 patches for one 60-minute application to clean dry skin; may prep area with topical anesthetic; wear nonlatex gloves; patches may be cut to size/shape; treatment may be repeated every 3 months; remove with cleansing gel after treatment
  Pediatric: <18 years: not recommended
  Qutenza Patch: 8% 1640 mcg/cm (179 mg) (1 or 2 patches, each w. 1-50 g tube cleansing gel/carton)
• diclofenac epolamine transdermal patch (C; D =30 wks) apply one patch to affected area bid; remove during bathing; avoid non-intact skin
  Pediatric: not recommended
  Flector Patch Patch: 180 mg/patch (30/carton)
• diclofenac sodium (C; D =30 wks)(G)
  Pediatric: not established
  Pennsaid 1.5% in 10 drop increments, dispense and rub into front, side, and back of knee: usually; 40 drops (40 mg) qid
  Topical soln: 1.5% (150 ml)
  Pennsaid 2% apply 2 pump actuations (40 mg) and rub into front, side, and back of knee bid
  Topical soln: 2% (20 mg/pump actuation, 112 g)
  Comment: Pennsaid is indicated for the treatment of pain associated with osteoarthritis of the knee.
  Pediatric: not recommended
  Voltaren Gel apply qid; avoid nonintact skin
  Gel: 1% (100 g)
  Comment: diclofenac is contraindicated with aspirin allergy. As with other NSAIDs, Voltaren Gel should be avoided in late pregnancy (=30 weeks) because it may cause premature closure of the ductus arteriosus.
  Other Prescription NSAIDs see page 501

TOPICAL/TRANSDERMAL LIDOCAINE

• lidocaine transdermal patch (C)(G) apply one patch to aff ected area for 12 hours (then off for 12 hours); remove during bathing; avoid non-intact skin; do not re-use
  Pediatric: not recommended
  Lidoderm Patch: 5% (10 cm x14 cm, 30/carton)

OPIOIDS AND OTHER ORAL ANALGESICS

• butalbital/acetaminophen (C)(G) 1 tab q 4 hours prn; max 6 tabs/day
  Pediatric: <12 years: not recommended; =12 years: same as adult
  Tab: but 50 mg/acet 325 mg
  Phrenilin 1-2 tabs q 4 hours prn; max 6 tabs/day
  Tab: but 50 mg/acet 325 mg
  Phrenilin Forte 1 tab or cap q 4 hours prn; max 6 caps/day
  Cap: but 50 mg/acet 325 mg; Tab: but 50 mg/acet 325 mg
• butalbital/acetaminophen/caff eine (C)(G)
  Pediatric: not recommended
  Fioricet 1-2 tabs q 4 hours prn; max 6/day
  Tab: but 50 mg/acet 325 mg/caf 40 mg
  Zebutal 1 cap q 4 hours prn; max 5/day
  Cap: but 50 mg/acet 325 mg/caf 40 mg
• butalbital/aspirin/caff eine (C)(III)(G)
  Pediatric: <12 years: not recommended; =12 year: same as adult
  Fiorinal 1-2 tabs or caps q 4 hours prn; max 6 caps/day
  Tab/Cap: but 50 mg/asa 325 mg/caf 40 mg
• butalbital/aspirin/codeine/caff eine (C)(III)(G)
  Pediatric: <12 years: not recommended; =12 year: same as adult
  Fiorinal with Codeine 1-2 caps q 4 hours prn; max 6 caps/day
  Cap: but 50 mg/asp 325 mg/cod 30 mg/caf 40 mg
• codeine sulfate (C)(III)(G) 15-60 q 4-6 hours prn; max 60 mg/day
  Tab: 15, 30, 60 mg
• codeine/acetaminophen (C)(III)(G) 15-60 mg of codeine q 4 hours prn; max 360 mg of codeine/day
  Pediatric: not recommended
  Tab: Tylenol #1 cod 7.5 mg/acet 300 mg (sulfi tes)
  Tylenol #2 cod 15 mg/acet 300 mg (sulfi tes)
  Tylenol #3 cod 30 mg/acet 300 mg (sulfi tes)
  Tylenol #4 cod 60 mg/acet 300 mg (sulfi tes)
  Tylenol with Codeine Elixir (C)(III)
  Pediatric: 1 mg of codeine/kg/dose q 4-6 hours prn; max 60 mg of codeine/dose; <3 years: not recommended; 3-6 years: 5 ml tid-qid; 7-12 years: 10 ml tid-qid; >12 years: same as adult
  Elix: cod 12 mg/acet 120 mg per 5 ml (cherry) (alcohol)
• dihydrocodeine/acetaminophen/caff eine (C)(III)(G)
  Pediatric: not recommended
  Panlor DC 1-2 caps q 4-6 hours prn; max 10 caps/day
  Cap: dihydro 16 mg/acet 325 mg/caf 30 mg
  Panlor SS 1 tab q 4 hours prn; max 5 tabs/day
  Tab: dihydro 32 mg/acet 325 mg/caf 60*mg
• dihydrocodeine/aspirin/caff eine (D)(III)(G) 1-2 caps q 4 hours prn
  Pediatric: not recommended
  Synalgos-DC
  Cap: dihydro 16 mg/asa 356.4 mg/caf 30 mg
• hydrocodone bitartrate (C)(II)
  Pediatric: <18 years: not recommended
  Hysingla ER swallow whole; 1 tab once daily at the same time each day
  Tab: 20, 30, 40, 60, 80, 100, 120 mg ext-rel
  Vantrela ER swallow whole; 1 tab once daily at the same time each day
  Tab: 15, 30, 45, 60, 90 mg ext-rel
  Zohydro ER swallow whole; Opioid naïve: 10 mg q 12 hours; may increase by 10 mg q 12 hours every 3-7 days; when discontinuing, titrate downward every 2-4 days
  Cap: 10, 15, 20, 30, 40, 50 mg ext-rel
• hydrocodone bitartrate/acetaminophen (C)(II)(G)
  Pediatric: not recommended
  Hycet 3 tsp (15 ml) q 4-6 hours prn; max 18 tsp/day
  Liq: hydro 7.5 mg/acet 325 mg per 15 ml
  Lorcet 1-2 caps q 4-6 hours prn; max 8 caps/day
  Cap: hydro 5 mg/acet 325 mg
  Lorcet 10/650 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 10 mg/acet 325 mg
  Lorcet-HD 1 cap q 4-6 hours prn; max 6 tabs/day
  Cap: hydro 5 mg/acet 325 mg
  Lorcet Plus 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 7.5 mg/acet 325 mg
  Lortab 2.5/500 1-2 tabs q 4-6 hours prn; max 8 tabs/day
  Tab: hydro 2.5 mg/acet 325*mg
  Lortab 5/500 1-2 tabs q 4-6 hours prn; max 8 tabs/day
  Tab: hydro 5 mg/acet 325*mg
  Lortab 7.5/500 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 7.5 mg/acet 325*mg
  Lortab 10/500 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 10 mg/acet 325*mg
  Lortab Elixir 3 tsp q 4-6 hours prn; max 18 tsp/day
  Liq: hydro 7.5 mg/acet 300 mg per 15 ml (tropical fruit punch) (alcohol)
  Maxidone 1 tab q 4-6 hours prn; max 5 tabs/day
  Tab: hydro 10 mg/acet 325*mg
  Norco 5/325 1 tab q 4-6 hours prn; max 8 tabs/day
  Tab: hydro 5 mg/acet 325*mg
  Norco 7.5/325 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 7.5 mg/acet 325*mg
  Norco 10/325 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 10 mg/acet 325*mg
  Vicodin 1-2 tabs q 4-6 hours prn; max 8 tabs/day
  Tab: hydro 5 mg/acet 300*mg
  Vicodin ES 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 7.5 mg/acet 300*mg
  Vicodin HP 1 tab q 4-6 hours prn; max 6 tabs/day
  Tab: hydro 10 mg/acet 300*mg
  Xodol 5/300 1-2 tabs q 4-6 hours prn; max 8 caps/day
  Tab: hydro 5 mg/acet 300*mg
  Xodol 7.5/300 1 tab q 4-6 hours prn; max 6 caps/day
  Tab: hydro 7.5 mg/acet 300*mg
  Xodol 10/300 1 tab q 4-6 hours prn; max 6 caps/day
  Tab: hydro 10 mg/acet 300*mg
  Zamicet 10/325 1-2 tabs q 4-6 hours prn; max 8 caps/day
  Liq: hydro 10 mg/acet 325 mg per 15 ml
  Zydone 5/400 1-2 tabs q 4-6 hours prn; max 8 caps/day
  Tab: hydro 5 mg/acet 400 mg
  Zydone 7.5/400 1 tab q 4-6 hours prn; max 6 caps/day
  Tab: hydro 7.5 mg/acet 400 mg
  Zydone 10/400 1 tab q 4-6 hours prn; max 6 caps/day
• hydrocodone/ibuprofen (C; not for use in 3rd)(II)(G)
  Pediatric: not recommended
  Ibudone 5/200 1 tab q 4-6 hours prn; max 5 tabs/day
  Tab: hydro 5 mg/ibup 200 mg
  Ibudone 10/200 1 tab q 4-6 hours prn; max 5 tabs/day
  Tab: hydro 10 mg/ibup 200 mg
  Reprexain 1 tab q 4-6 hours prn; max 5 tabs/day
  Tab: hydro 5 mg/ibup 200 mg
  Vicoprofen 1 tab q 4-6 hours prn; max 5 tabs/day
  Tab: hydro 7.5 mg/ibup 200 mg
• hydromorphone (C)(II)(G)
  Pediatric: not recommended
  Dilaudid initially 2-4 mg q 4-6 hours prn
  Tab: 2, 4, 8 mg (sulfi tes)
  Dilaudid Oral Liquid 2.5-10 mg q 3-6 hours prn
  Liq: 5 mg/5 ml (sulfi tes)
  Dilaudid Rectal Suppository 2.5-10 mg q 6-8 hours prn
  Rectal supp: 3 mg
  Dilaudid Injection initially 1-2 mg SC or IM q 4-6 hours prn
  Amp: 1, 2, 4 mg/ml (1 ml)
  Dilaudid-HP Injection initially 1-2 mg SC or IM q 4-6 hours prn
  Amp: 10 mg/ml (1 ml)
  Exalgo initially 8-64 mg once daily
  Tab: 8, 12, 16, 32 mg ext-rel (sulfi tes)
• meperidine (C; D in 2nd, 3rd)(II)(G) 50-150 mg q 3-4 hours prn
  Pediatric: 0.5-0.8 mg/lb q 3-4 hours prn; max adult dose
  Demerol Tab: 50, 100 mg; Syr: 50 mg/5 ml (banana) (alcohol-free)
• meperidine/promethazine (C; D in 2nd, 3rd)(II)(G)
  Pediatric: not recommended
  Mepergan 1-2 tsp q 3-4 hours prn
  Syr: mep 25 mg/prom 25 mg per ml
  Mepergan Fortis 1-2 tsp q 4-6 hours prn
  Tab: mep 50 mg/prom 25 mg
• methadone (C)(II) 2.5-10 mg PO, SC, or IM q 3-4 hours prn
  Pediatric: not recommended
  Dolophine Tab: 5, 10 mg; Dispersible tab: 40 mg (dissolve in 120 ml orange juice or other citrus drink); Oral conc: 5, 10 mg/5 ml; 10 mg/10 ml; Inj: 10 mg/ml
  Comment: methadone maintenance is allowed only by approved treatment programs with strict state and federal regulations.
• morphine sulfate (C)(II)(G) tabs, usually 15-30 mg q 4 hours prn; solution, usually 10-20 mg q 4 hours prn
  Pediatric: <18 years: not recommended
  Tab: 15*, 30*mg; Oral soln: 10 mg/5 ml, 20 mg/5 ml (100, 500 ml), 100 mg/5 ml (30, 120 ml)
• morphine sulfate (immed- and sust-rel) (C)(II)
  Comment: Dosage dependent upon previous opioid dosage; see mfr pkg insert for conversion guidelines; not for prn use; swallow whole or sprinkle contents of caps on applesauce (do not crush, chew, or dissolve). Generic morphine sulfate is available in the following forms: Tab: 15*, 30*mg; Oral soln: 10, 20 mg/5 ml (100 ml); 100 mg/5 ml (30, 120 ml w. oral syringe)
  Pediatric: <18 years: not recommended
  Arymo ER swallow whole; 1 tab once daily at the same time each day
  Tab: 15, 30, 60 mg ext-rel
  Duramorph administer per anesthesia
  IV/Intrathecal/Epidural: 0.5, 1 mg/ml
  Infumorph administer per anesthesia
  Intrathecal/Epidural: 10, 20 mg/ml
  Kadian (G) 1 cap every 12-24 hours
  Cap: 10, 20, 30, 50, 60, 80, 100, 200 mg sust-rel
  MS Contin (G) 1 tab every 24 hours
  Tab: 15, 30, 60, 100, 200 mg sust-rel
  MSIR 5-30 mg q 4 hours prn
  Tab: 15*, 30*mg; Cap: 15, 30 mg
  MSIR Oral Solution 5-30 mg q 4 hours prn
  Oral soln: 10, 20 mg/5 ml (120 ml)
  MSIR Oral Solution Concentrate 5-30 mg q 4 hours prn
  Oral conc: 20 mg/ml (30, 120 ml w. dropper)
  Oramorph SR 1 cap every 12-24 hours
  Tab: 15, 30, 60, 100 mg sust-rel
  Roxanol Oral Solution 10-30 mg q 4 hours prn
  Oral soln: 20 mg/ml (1, 4, 8 oz)
  Roxanol Rescudose
  Oral soln: 10 mg/2.5 ml (25 single-dose)
• morphine sulfate/naltrexone (C)(II)
  Pediatric: <18 years: not recommended
  Embeda 1 cap q 12-24 hours
  Cap: Embeda 20/0.8 morph 20 mg/nal 0.8 mg ext-rel
  Embeda 30/1.2 morph 30 mg/nal 1.2 mg ext-rel
  Embeda 50/2 morph 50 mg/nal 2 mg ext-rel
  Embeda 60/2.4 morph 60 mg/nal 2.4 mg ext-rel
  Embeda 80/3.2 morph 80 mg/nal 3.2 mg ext-rel
  Embeda 100/4 morph 100 mg/nal 4 mg ext-rel
  Comment: Embeda is not for prn use; for use in opioid-tolerant patients only; swallow whole or sprinkle contents of caps on applesauce (do not crush, chew, or dissolve); do not administer via NG or gastric tube (PEG tube).
• oxycodone (B)(II)(G) 5-15 mg q 4-6 hours prn
  Comment: Concomitant use os CYP3A4 inhibitors may increase opioid eff ects and CYP3A4 inducers may decrease eff ects or possibly cause development of an abstinence syndrome (withdrawal symtoms) in patients who are physically oxycodone dependent/addicted.
  Pediatric: <18 years: not recommended
  Oxaydo Tab: 5, 7.5 mg
  Comment: Oxaydo is the fi rst and only immediate-release oral oxycodone that discourages intranasal abuse. Oxaydo is formulated with sodium lauryl sulfate, an inactive ingredient that may cause nasal burning and throat irritation when snorted and, thus potentially reducing abuse liability. Th ere is no generic equivalent.
  Oxecta Tab: 5, 7.5 mg
  Oxycodone Oral Solution (G) Oral soln: 5 mg/5 ml (15, 30 ml)
  OxyIR (G) Cap: 5 mg
  Roxycodone Tab: 5, 15*, 30*mg; Oral soln: 5 mg/ml
  Roxycodone Intensol Oral soln: 20 mg/ml
• oxycodone cont-rel (B)(II)(G) dosage dependent upon previous opioid dosages; see mfr pkg insert: <11 years: not recommended; 11-16 years: must already tolerate minimum opium dose equal to oxycodone 20 mg/day x 5 days; >16 year: same as adult
  OxyContin dose q 12 hours
  Tab: 10, 15, 20, 30, 40, 60, 80 mg cont-rel
  OxyFast dose q 6 hours
  Oral conc: 20 mg/ml (30 ml w. dropper)
  Xtampza ER dose q 12 hours
  Pediatric: not recommended
  Cap: 10, 15, 20, 30, 40 mg ext-rel
  Comment: May open the Xtampza ER capsule and sprinkle in water or on soft food.
• oxycodone/acetaminophen (C)(II)(G)
  Comment: Maximum 4 grams acetaminophen per day.
  Pediatric: not recommended
  Magnacet 2.5/400 1 tab q 6 hours prn; max 10 tabs/day
  Tab: oxy 2.5 mg/acet 325 mg
  Magnacet 5/400 1 tab q 6 hours prn; max 10 tabs/day
  Tab: oxy 5 mg/acet 325 mg
  Magnacet 7.5/400 1 tab q 6 hours prn; max 8 tabs/day
  Tab: oxy 7.5 mg/acet 325 mg
  Magnacet 10/400 1 tab q 6 hours prn; max 6 tabs/day
  Tab: oxy 10 mg/acet 325 mg
  Percocet 2.5/325 1 tab q 6 hours prn; max 4 g acet/day
  Tab: oxy 2.5 mg/acet 325 mg
  Percocet 5/325 1 tab q 6 hours prn; max 4 g acet/day
  Tab: oxy 5 mg/acet 325*mg
  Percocet 7.5/325 1 tab q 6 hours prn; max 4 g acet/day
  Tab: oxy 7.5 mg/acet 325 mg
  Percocet 7.5/500 1 tabs q 6 hours prn; max 4 g acet/day
  Tab: oxy 7.5 mg/acet 325 mg
  Percocet 10/325 1 tabs q 6 hours prn; max 4 g acet/day
  Tab: oxy 10 mg/acet 325 mg
  Percocet 10/650 1 tab q 6 hours prn; max 4 g acet/day
  Tab: oxy 10 mg/acet 325 mg
  Roxicet 5/325 1 tab/tsp q 6 hours prn
  Tab: oxy 5 mg/acet 325 mg; Oral soln: oxy 5 mg/acet 325 mg per 5 ml
  Roxicet 5/500 1 caplet q 6 hours prn
  Cplt: oxy 5 mg/acet 325 mg
  Roxicet Oral Solution 1 tsp q 6 hours prn
  Oral soln: oxy 5 mg/acet 325 mg per 5 ml (alcohol 0.4%)
  Tylox 1 cap q 6 hours prn
  Cap: oxy 5 mg/acet 325 mg
  Xartemis XR 2 tabs q 12 hours prn
  Tab: oxy 7.5 mg/acet 325 mg
• oxycodone/aspirin (D)(II)(G)
  Percodan 1 tab q 6 hours prn
  Pediatric: not recommended
  Tab: oxy 4.8355 mg/asa 325*mg
  Percodan-Demi 1-2 tabs q 6 hours prn
  Pediatric: 6-12 years: 1/4 tab q 6 hours prn; >12-18 years: 1/2 tab q 6 hours prn
  Tab: oxy 2.25 mg/oxy tere 0.19 mg/asa 325 mg
• oxycodone/ibuprofen (C)(II)(G)
  Pediatric: <14 years: not recommended; =14 years: same as adult
  Combunox 1 tab q 6 hours prn
  Tab: oxy 5 mg/ibu 400*mg
• oxycodone/naloxone (C)(II) 1 tab q 3-4 hours prn
  Pediatric: not recommended
  Targiniq
  Tab: Targiniq 10/5 oxy 10 mg/nal 5 mg
  Targiniq 20/10 oxy 20 mg/nal 10 mg
  Targiniq 40/20 oxy 40 mg/nal 20 mg
• oxymorphone (C)(II)(G)
  Pediatric: <18 years: not recommended
  Numorphan 1supp q 4-6 hours prn
  Rectal supp: 5 mg; Vial: 1 mg/ml (1 ml), Amp: 1.5 mg/ml (10 ml);
  Comment: Store in refrigerator in original package. 1 mg of Numorphan is approximately equivalent in analgesic activity to 10 mg of morphine sulfate.
  Opana 1-1 tab q 4-6 hours prn
  Tab: 5, 10 mg
  Opana ER 1 tab q 12 hours prn
  Tab: 5, 7.5, 10, 15, 20, 30, 40 mg ext-rel crush-resistant
  Opana Injection initially 0.5 mg IV or IM; 1 x 1 mg IM or IV q 4-6 hours prn
  Amp: 1 mg/ml (1 ml) (paraben/sodium dithionite-free)
• pentazocine/aspirin (D)(IV) 2 cplts tid or qid prn
  Pediatric: not recommended
  Talwin Compound Cplt: pent 12.5 mg/asa 325 mg
• pentazocine/naloxone (C)(IV) 1 tab q 3-4 hours prn
  Pediatric: not recommended
  Talwin NX Tab: pent 50 mg/nal 0.5*mg
• pentazocine lactate (C)(IV) 30 mg IM, SC, or IV q 3-4 hours; max 360 mg/day
  Pediatric: <1 year: not recommended; >1 year: 0.5 mg/kg IM
  Talwin Injectable Amp: pent 30 mg/ml (1, 1.5, 2 ml)
• propoxyphene napsylate/acetaminophen (C)(IV)(G)
  Comment: Max 4 g acetaminophen per day.
  Pediatric: not recommended
  Balacet 325 1 tab q 4 hours prn; max 6 tabs/day
  Tab: prop 100 mg/acet 325 mg
• tramadol (C)(IV)(G)
  Rybix ODT initially 100 mg once daily; may increase by 100 mg every 5 days; max 300 mg/day; CrCl <30 mL/min or severe hepatic impairment: not recommended;
  Cirrhosis: max 50 mg q 12 hours
  Pediatric: <17 years: not recommended
  ODT: 50 mg (mint) (phenylalanine)
  Ryzolt initially 100 mg once daily; may increase by 100 mg every 5 days; max 300 mg/day; CrCl <30 mL/min or severe hepatic impairment: not recommended
  Pediatric: <16 years: not recommended; =16 years: same as adult
  Tab: 100, 200, 300 mg ext-rel
  Ultram 50-100 mg q 4-6 hours prn; max 400 mg/day; CrCl <30 mL/min: max
  100 mg q 12 hours; Cirrhosis: max 50 mg q 12 hours
  Pediatric: <16 years: not recommended; =16 year: same as adult
  Tab: 50*mg
  Ultram ER initially 100 mg once daily; may increase by 100 mg every 5 days; max 300 mg/day; CrCl <30 mL/min or severe hepatic impairment: not recommended
  Pediatric: <18 years: not recommended
  Tab: 100, 200, 300 mg ext-rel
• tramadol/acetaminophen (C)(IV)(G) 2 tabs q 4-6 hours; max 8 tabs/day; 5 days;
  CrCl <30 mL/min: max 2 tabs q 12 hours; max 4 tabs/day x 5 days
  Pediatric: <16 years: not recommended; =16 year: same as adult
  Ultracet Tab: tram 37.5/acet 325 mg
• buprenorphine (C)(III) change patch every 7 days; do not increase the dose until previous dose has been worn for at least 72 hours; aft er removal, do not re-use the site for at least 3 weeks; do not expose the patch to heat
  Pediatric: <16 years: not recommended; =16 years: same as adult
  Butrans Transdermal System
  Transdermal patch: 5, 10, 20 mcg/hour (4/pck)
• fentanyl transdermal system (C)(II) apply to clean, dry, non-irritated, intact, skin; hold in place for 30 seconds; start at lowest dose and titrate upward; Opioid-naïve: change patch every 3 days (72 hours)
  Pediatric: <18 years or <110 lb: not recommended
  Duragesic Transdermal patch: 12, 25, 37.5, 50, 62.5, 75, 87.5, 100 mcg/hour (5/pck)
  fentanyl iontophoretic transdermal system
  Ionsys is a transdermal patient-controlled device that sticks to the arm or chest; it is activated when the patient pushes the button
  Comment: Ionsys is for in-hospital use only and should be discontinued prior to hospital discharge. It is indicated for post-op pain relief.

TRANSMUCOSAL OPIOID
Comment: For chronic severe pain. For management of breakthrough pain in patients with cancer who are already receiving and who are tolerant to opioid therapy. Opioidtolerant patients are those taking oral morphine =60 mg/day, transdermal fentanyl =25 mcg/hr, oxycodone =30 mg/day, oral hydromorphone =8 mg/day, or an equianalgesic dose of another opioid, for =1 week

ORAL OPIOID PARTIAL AGONIST-ANTAGONIST

• buprenorphine (C)
  Pediatric: <16 years: not recommended; =16 year: same as adult
  Subutex 8 mg in a single dose on day 1; then 16 mg in a single dose on day 2; target dose is 16 mg/day in a single dose; dissolve under tongue; do not chew or swallow whole
  SL tab (lemon-lime) or SL film (lime): 2, 8 mg (30/pck)
• fentanyl buccal soluble film (C)(II) dissolve 1 fi lm on moistened area inside cheek; initially 200 mcg; no more than 4 doses/day at least 2 hours apart; max 1200 mcg/dose; do not cut film
  Pediatric: <18 years: not recommended
  Onsolis Buccal fi lm: 200, 400, 600, 800, 1200 mcg (30 films/pck)
• fentanyl citrate transmucosal unit (C)(II)(G) initially one 200 mcg unit placed between cheek and lower gum; move from side to side; suck (not chew); use 6 units before titrating; titrate dose as needed; max 4 units/day
  Pediatric: <18 years: not recommended
  Actiq Unit: 200, 400, 600, 800, 1200, 1600 mcg (24 units/pck)
  Fentora Unit: 100, 200, 400, 600, 800 mcg (24 units/pck)
• fentanyl sublingual tab (C)(II) initially one 100 mcg dose; if inadequate aft er 30 minutes, may repeat; titrate in increments of 100 mcg; max 2 doses per episode, up to 4 episodes per day; wait at least 2 hours before treating another episode; Maintenance: use only one tablet of appropriate strength; do not chew, suck, or swallow tablets; do not convert from other fentanyl products on a mcg-per-mcg basis or interchange with other fentanyl products
  Pediatric: <18 years: not recommended
  Abstral SL tab: 100, 200, 300, 400, 600, 800 mcg (32 tabs/pck)
• fentanyl sublingual spray (C)(II)
  Pediatric: <18 years: not recommended
  Subsys 100, 200, 400, 600, 800 mcg/S L spray
  Comment: Subsys is not bioequivalent with other fentanyl products. Do not convert patients from other fentanyl products to Subsys on a mcg-per-mcg basis. Th ere are no conversion directions available for patients on any other fentanyl products other than Actiq. (Note: Th is includes oral, transdermal, or parenteral formulations of fentanyl.)

PARENTERAL OPIOID AGONIST/ANTAGONIST

• nalbuphine (B)(G) 10 mg/70 kg IM, SC, or IV q 3-6 hours prn
  Pediatric: <18 years: not recommended
  Nubain Amp: 10, 20 mg/ml (1 ml) (sulfi te-free, parabens-free)
• pentazocine/naloxone (C)(IV) 1-2 tabs q 3-4 hours prn; max 12 tabs/day
  Pediatric: <12 years: not recommended; =12 year: same as adult
  Talwin-NX Tab: pent 50 mg/nal 0.5*mg

INTRANASAL TRANSMUCOSAL NARCOTIC ANALGESICS

• butorphanol tartrate nasal spray (C)(IV) initially 1 spray (1 mg) in one nostril and may repeat aft er 60-90 minutes (Elderly 90-120 minutes) in opposite nostril if needed or 1 spray in each nostril and may repeat q 3-4 hours prn
  Pediatric: <18 years: not recommended
  Butorphanol Nasal Spray Nasal spray: 1 mg/actuation (10 mg/ml, 2.5 ml)
  Stadol Nasal Spray Nasal spray: 1 mg/actuation (10 mg/ml, 2.5 ml)
• fentanyl nasal spray (C)(II) initially 1 spray (100 mcg) in one nostril and may repeat after 2 hours; when adequate analgesia is achieved, use that dose for subsequent breakthrough episodes
  Titration steps: 100 mcg using 1 x 100 mcg spray; 200 mcg using 2 x 100 mcg spray (1 in each nostril); 400 mcg using 1 x 400 mcg spray; 800 mcg using 2 x 400 mcg (1 in each nostril); max 800 mcg; limit to =4 doses per day
  Pediatric: <18 years: not recommended
  Lazanda Nasal Spray Nasal spray: 100, 400 mcg/100 mcl (8 sprays/bottle)
  Comment: Lazanda Nasal Spray is available by restricted distribution program.
  Call 855-841-4234 or visit www.LazandaREMS.com to enroll. Lazanda Nasal Spray is indicated for the management of breakthrough pain in cancer patients who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Patients considered opioid tolerant are those who are taking at least 60 mg of oral morphine/day, 25 mcg of transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic dose of another opioid for a week or longer. Patients must remain on around-the-clock opioids when using Lazanda Nasal Spray. As such, it is contraindicated in the management of acute or postop pain, including headache/migraine, or dental pain.

INTRATHECAL NARCOTIC ANALGESICS

• ziconotide intrathecal (IT) infusion (C) initially no more than 2.4 mcg/day (0.1 mcg/hour) and titrate to upward by up to 2.4 mcg/day (0.1 mcg/day at intervals of no more than 2-3 times per week, up to a recommended maximum of 19.2 mcg/day (0.8 mcg/hr) by Day 21; dose increases in increments of less than 2.4 mcg/day (0.1 mcg/hr) and increases in dose less frequently than 2-3 times per week may be used.
  Pediatric: not recommended
  Prialt Vial: 25 mcg/ml (20 ml), 100 mcg/ml (1, 2, 5 ml)
  Comment: Patients with a pre-existing history of psychosis should not be treated with ziconotide. Contraindications to the use of IT analgesia include conditions such as the presence of infection at the microinfusion injection site, uncontrolled bleeding diathesis, and spinal canal obstruction that impairs circulation of CSF.