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Therapeutics

Note

11/03: This page hasn't been maintained for a few years, so it's quite dated. Also, the links from med names to entries in the Nursing PDR no longer work; that service went to a subscriber only model.

Links

• local: Anticoagulation, Antidepressants, Osteoporosis, Osteomalacia and Paget's, Skin Therapeutics, Therapies (eye), Trauma and Procedures (Foreign Bodies)
• 2008 review of newer medications

Main Outpatient Meds

not on Health Partners Formulary, monitored drugs (failed, contraindicated, insists, other)

allergies

• chlor-trimeton (chlorpheniramine) 8mg (6-12y) or 12 mg (adult) SR BID
• Allegra (fexofenadine) 1 capsule qAM, chlorpheniramine 1 tab hs
• Claritin (loratidine) 5 mg/5ml 5mg qD (age 2-12, wt < 30 kg) 10 mg tab qD on formulary
• Zyrtec (cetirizine) syrup: 1 mg/mL; tab: 5 mg, 10 mg. 6y-adult: 5 or 10 mg qD (renal/hepatic limits) 2-5y: 2.5 - 5.0 mg qD (most effective?)
• Afrin 2-3 spray q12h if nose too congested to get Vancenase in, max 3-4 days.
• Vancenase DS AQ 1 puff, 1-2 times day
• Flonase (fluticasone): most effective, low systemic absorption. 1 spray qD, max 2 spray qD age > 4y.
• Ocular meds
  • vasoconstrictors: Visine L.R., Albalon 1-2 gtt q 3-4 hrs (naphazoline)
  • mast cell stab: Alomide (lodoxamide .1%) 1-2 gtt qid for up to 3 mo, 2y+
  • antihistamine: Patanol (olopatadine) .1%: (> 3 yo) 1-2 gtt BID (6-8 h interval)

antibacterial

• Augmentin (500mg BID or 875mg BID, 200mg or 400mg chew, 200/400/5ml, 45mg/kg/d for OM, sinusitis, else 25mg/kg/d)
• Azithromycin (Zithromax) 250mg tab.  Suspension 100/200 mg/5ml; use 1h before or 2h after meals.
  • adult: Start 2, then 1 PO qD x 4.
  • child > 6 mo pneu/OM: 10mg/kg (max 500) qD x 1, then 5mg/kg (max 250) qD x 4
  • child > 2 y pharyn/tons: 12 mg/kg qD x 5 days
• Bactrim DS, Bactrim Susp (40mg/5ml, 8mg/kg/day), cephalexin (keflex)
• Ceftin (cefuroxime) 125mg/5ml, 125, 250, 500. 3mo-12y: 15mg/kg BID, >12y:250-500 mg PO BID.
• Cipro 500 mg BID, 250mg BID for UTI. Caffeine, theo, coumadin and cyclosporine increases.
• EES 400 mg tab TID, 200mg/5ml or 400mg/5ml
• Macrobid 100 mg BID. Less Candida, GI Sx than other UTI meds
• Pen G Benzathine (<27 kg 600,000U, >27 kg 1.2 millionU for strep)
• PenVK 250mg/5ml, 250 or 500 mg tab (500 BIDx10d)
• Vantin (cefpodoxime) 3rd gen oral ceph, 50 or 100 mg/5ml, 100 or 200 mg tab. 5 mg/kg q12h for OM, 200 mg q12h for 14d for adult pneumonia. Bitter taste, resistant OM.

antiemetic

These are mild to moderately effective fairly inexpensive agents. For a discussion of powerful antiemetics see Antiemetic Inpatient.

antihistamine-like: safer, less effective. Tigan best?

• Benadryl (dimenhyrdramine) 25-50 mg caps, 12.5mg/5ml. age 2-6: 6.25 mg; age 6-12: 12.5-25 mg; 12+: 25-50 mg. All q4-6h. (safest, weakest)
• Dramamine (dimenhydrinate, contains diphenhydramine and chlorotheophylline) 50 mg, 12.5 mg/5ml. 50-100 mg q6h. prec: glauc, PKU.
• Tigan (trimethobenzamide - weak antihistamine): 100, 250 mg caps; 100, 200 mg supp with benzocaine. Adult caps 250 mg TID-QID. Supp TID-QID: <30 lb, 100 mg. 30-90 lb 100-200 mg, > 90 lb 200 mg.

phenothiazide: more effective. Compazine more s/e.

• Phenergan (promethazine - antihistamine/phenothiazine) 6.25 mg/5 mL, 25 mg/5 mL, 25 mg tab/suppository. 0.25-0.50 mg/kg q4-6, 25mg BID.
• Compazine (prochlorperazine) 5, 10 mg tab, 25 mg supp, 5mg/5ml. 5-10 mg tab PO TID-QID and 25 mg PR q12h. Risk NMS, akathisia, etc.

antifungal

• nystatin (Mycostatin) susp 100,000U/ml 1 ml on each side of mouth QID (infant)
• see vaginitis, antifungal

antiviral

• zoster: Valtrex (valcyclovir): 1 gm q8h x 7 days, adjust RENAL
• chicken pox: Acyclovir 200mg/5ml 20mg/kg QID x 5 days
• Herpes simplex, recurrent: Valtrex 2000 mg q12h x 1 day (2 doses), adjust RENAL
• HIV (way beyond these simple notes!)

influenza

• Rimantidine (Flumadine)
  • Influenza A only
  • child - prophylaxis only: 50mg/5ml. age 1-9: 5 mg/kg/day to max 150mg/day. age 10+: as adult
  • adult: 100mg PO BID. (if elderly, renal/hepatic -- then 100 mg qD)
• Zanamivir
  • Influenza A and (limited) B
  • treat within 30 hours of onset, may cause bronchospasm

apthous ulcers, mouth sores, severe pharyngitis

• see GI section on mucositis

asthma and COPD

See also: Asthma Therapeutics

oral

• ventolin (albuterol) syrup 2mg/5ml 0.1 mg/kg TID, incr to 0.2 mg/kg TID (max 2-4 mg TID)
• Accolate (zafirlukast: leukotriene antagonist): 20 mg BID. Cytochrome P450 inhibition. better without food. Age > 12 yo. Asthenia/generalized pain, headache, drug interactions.

aerosol

• Ventolin/albuterol
  • MDI 4-6 puffs q30-60 min
  • neb: 0.02 ml/kg in 2-3 ml NSS q 1-2 h. Max 0.5 ml/dose, max 3 ml/24h.
• Azmacort: 2 - 6 puff q 2-4 h, has a built in well-designed delivery system.
• Atrovent: 2-4 puff q2-4 h
• Combivent (ipatropium and albuterol) for COPD. 2 inh QID
• Flovent (fluticasone): 0.11 mg/inh, 0.22 mg/inh, 0.44 mg/inh. Start 100 mcg BID up to 1000 mcg BID. Preferrred med, HP has .22 only. $$$$

steroids - po/iv

• Pediapred (prednisolone NaPO4) 5mg/5ml: .5-2.0 mg/kg daily in 3-4 doses.
• solumedrol: 2.0 mg/kg bolus then 0.5-1.0 mg/kg q6h x 2-3d then PO prednisone 40-125mg q4-6h & taper.
• prednisone (bitter) 1-2 mg/kg/day tid x 2 days, then 1 mg/kg/day x 3 days then stop.
• dexamethasone (less bitter, longer half life, more supprn) 0.1-0.2 mg/kg/day.
• depo-medrol: 80 mg IM in adults, esp. if non-compliant. Good if d/c from ER. Last @1-2 weeks.

dysuria

• pyridium 200 mg tab TID after meals max 2 days

GI

• Imodium (loperamide): 2 mg capsule. 2 tabs, then 1 per unformed stool max 8/day
• tagament 800 mg (ulcer qhs, reflux bid)
• reglan 5mg, 10mg, 5mg/5ml
• prilosec 20 mg qAM x 4w for duodenal ulcer (plus Abs) and GERD. 40 mg qAM for gastric ulcer 4-8 wks.

migraine/headache

• Migranal is on formulary. See Migraine for most of the meds.

NSAID

• Ibuprofen
• Naprosyn 250-500 q12h.

ophthalmic antibacterial

• genoptic .3%
• sulfacetamide 10% (preferred)

otitis externa/cerumen

• auralgin (anesthesia)
• otic cortisporin
• sulfacetamide
• debrox 5-10 gtt BID-QID x 4 d

otitis media: tympanostomy tubes or perforated

• Vasocidin (sulfacetamide - prednisolone 10%, .25%) ophthalmic 3 gtt TID (5ml lasts 3 days)

steroids

• see steroid comparisons and asthma steroids

topical antibacterial

• bacitracin
• bactroban

topical steroids

• see also dermatology discussion
• tenovate .05% cream and ointment
• triamcinolone (Kenalog, generic)
  • .1% ointment
  • .1% cream (may not carry)
  • .1% lotion

URI

• Robitussin AC
• Phenergan AC: Adults: 5 mL q 4-6 hr, not to exceed 30 mL/day; pediatric, 6-12 years: 2.5-5 mL q 4-6 hr, not to exceed 30 mL/day; pediatric, 2-6 years: 1.25-2.5 mL q 4-6 hr.
• Tessalon Perle 100 mg PO TID

vaginitis

• Nizoral (ketoconazole) topical 2% (ketoconazole) cream
• Mycelex (clotrimazole) 10 mg troche 5x/day for 14 days
• Diflucan (fluconazole) 150 mg tab (x1 for vaginitis)
• Cleocin vaginal (clindamycin) 2% cream, 1 applicator intravag hs 3-7 days, pregnant (2-3 trim) 7 days
• Metrogel vaginal (metronidazole .75%):1 applicator intravag BID or hs for 7d (preg cat B)

Alerts, Newer Meds, Updates

Alerts

• Serzone (nefazodone): 2/99 - early case reports of subacute liver failure

Updates and Newer

1. Vitamin Therapies
   • folate 1 mg qD for NTD prophylaxis and ASHD
   • vitamin C: 1 gm/day for chronic recurrent furunculosis, but it doesn't help with iron absorption
   • vitamin D: 400 IU/day for osteoarthritis
   • vitamin E
     • 200-400 IU/day for atherosclerotic disease reduction (with Vitamin C?)
     • alzheimer's prophylaxis (dose?)
2. Fibrocystic Breast Disease: elemental Iodine??

Noteworthy interactions

1. hydrocholorothiazide, Celecoxib (celebrex) and related meds: cross-reactivity with sulfonamides - beware allergies, also have Stevens-Johnson risk.
2. some authorities suggest avoid bactrim and other folate antagonists in all potentially pregnant women because of theoretical increase in NTD risk.
3. decreased fluoroquinolone absorption from cations (calcium, ferrous sulfate, etc)
4. tylenol and coumadin
5. rezulin may reduce effectiveness of OCP
6. viagra: any nitrates (lethal)
7. problem drugs: erythromycin, azoles, tagamet, lipid agents, coumadin, antidepressants, triptans, second-generation antihistamines
8. CYP3A4 drugs
• Serzone, lovostatin, sporanox/itraconazole, erythromycin, ketoconazole, nefazodone
• itraconazole (Sporanox) and lovostatin causes 20 fold increse in lovostatin

Antiemetic Inpatient

• see NCI/PDQ statement (updated material)
• ativan: 1-2 mg sq q3-4h x 2: amnesia
• reglan: 2-3 mg/kg iv with cogentin
• decadron or solumedrol with reglan/cogentin
• zofran (serotonin agonist)
  • less severe: 16mg iv x 1
  • platinol: 32 mg iv x 1

Breast Feeding - Avoid Rx

• atenolol, bromocriptine, cyclosporine, diazepam, ergotamine, lithium, methotrexate

Helicobacter ulcer/gastritis

1. Indications: recurrent peptic ulcer

2. option 1: Two weeks, may need H2 blocker or Omeprazole also

• Pepto-Bismol regular strength: 2 tab with meals and hs
• flagyl 250 mg tid
• tetracycline 500 mg qid (empty stomach, between meals)

3. option 2: Two weeks, may need H2 blocker also

• bismuth subsalicylate (Pepto-Bismol) 2 tabs TID
• flagyl 250 mg TID
• amoxil 500 mg TID/QID

Herbal and Alt Med - Problems

NSAIDs

1. clinoril: safest for kidney
2. classes
   • proprionic acid: orudis, motrin, naprosyn, ansaid
   • acetic acid: indocin, clinoril, voltaren
   • enolic acid: feldene
   • pyrano: lodine
   • salicylic: dolobid, asa, disalcid, trilisate
   • fenamic: meclomen

Misc Remedies

• nocturnal leg cramps: Quinine Sulfate begin with 200mg at supper for 3-4 days then add 300 mg hs. if needed. Expect response within 1 week or so. Controversial!
• recurrent staph skin infections
  • nasal Bactroban (BID for 5 days each month)
  • vitamin C 1 gm/day for 4-6 weeks (only works in patients with some sort of neutrophil defect)
• severe acute pharyngitis: beta-methasone?
• aspirin 300 mg loading dose then 40 mg qD gives optimal inhibition with few s/e (Buerke, Am Heart J 1995 p.465)

Pain Control

Outpatient

bone pain: NSAIDs

visceral pain and bone pain

• tylenol
• hydrocodone (Anexsia 7.5/650)
• oxycodone (Percocet 5.0/325)
• Morphine
  • Plain MS: PO, SQ, IM. short acting, 1-2 hours
  • Roxanol SR (8 hours): 30 mg tab.
  • MS Contin (12 hours) sustained release tabs. 15, 30, 60, 100 mg.
• PCA
• epidural duramorph

neuralgic pain

• elavil
• tegretol

Therapeutic Equivalents

oral	drug	IM
100	codeine	60
15	MS	5
10	oxycodone	7.5

Pyelonephritis (not pregnant)

• 1. rocephin 1 gm IM, observe and hydrate
• 2. cephalexin 500mg QID for 10 days

Steroid Comparison

Tapering anti-hypertensives

• decrease over 7-10 days to equiv of 30mg propranolol then stable for 2 weeks.
• clonidine (Catapres) taper over two weeks.