Methadone HCl

Dolophine®, Methadose®

Schedule: C-II

BBW: Deaths reported during initiation and conversion of pain pts to methadone treatment from treatment w/ other opioids. Resp depression and QT prolongation, arrhythmias observed. Only dispensed by certified opioid treatment programs for addiction. Analgesic use must outweigh risks

Uses: Severe pain not responsive to non-narcotics; detox w/ maint of narcotic addiction

MOA: Narcotic analgesic

Dose: 2.5-10 mg IM/IV/SQ or 5-15 mg PO q8h; titrate as needed; ↓ in renal impair

Caution: C, -, Avoid w/ severe liver disease

CI: Resp depression, acute asthma, ileus

Disp: Tabs 5, 10 mg; tab dispersible 40 mg; PO soln 5, 10 mg/5 mL; PO conc 10 mg/mL; Inj 10 mg/mL

SE: Resp depression, sedation, constipation, urinary retention, ↑ QT interval, arrhythmias, ↓ HR, syncope, ↓ K+, ↓ Mg2+

Notes: Parenteral:oral 1:2; Equianalgesic w/ parenteral morphine; longer 1/2; resp depression occurs later and lasts longer than analgesic effect, use w/ caution to avoid iatrogenic OD 

Guaifenesin/Codeine

Cheratussin® AC, Robitussin® AC

Schedule: C-V

Uses: Relief of dry cough

MOA: Antitussive w/ expectorant

Dose: 5-10 mL or 1 tab PO q6-8h (max 60 mL/24 h)

Caution: C, +

Disp: Brontex tab 10 mg codeine/300 mg guaifenesin; liq 2.5 mg codeine/75 mg guaifenesin/5 mL; others 10 mg codeine/100 mg guaifenesin/5 mL

SE: Somnolence, constipation

Tizanidine HCl

Zanaflex®

Uses: Muscle relaxant

MOA: Exact mechanisn unknown; binds to central alpha-2 adrenergic receptors, increasing presynaptic motor neuron inhibition and reducing spasticity (centrally acting muscle relaxant)

Dose: 4 mg PO x 1, incr 2-4 mg increments q6-8h until desired effect, Max 3 doses/24 h; 12 mg/dose. Give w/ food or on empty stomach; taper dose gradually to DC

Caution: C, ?, elderly pts, renal/hepatic impair

CI: Hypersens, abrupt withdrawal

Disp: Tabs 2, 4 mg

SE: Dry mouth, somnolence, dizziness, ↓ BP, ↓ HR, constipation, vomiting, blurred vision

Quinapril

Accupril®

BBW: ACE inhib used during PRG can cause fetal injury & death

Uses: HTN, CHF, DN, post-MI

MOA: ACE inhib

Dose: 10-80 mg PO daily; ↓ in renal impair

Caution: D, +, w/ RAS, vol depletion

CI: ACE inhib sensitivity, angioedema, PRG

Disp: Tabs 5, 10, 20, 40 mg

SE: Dizziness, HA, ↓ BP, impaired renal fxn, angioedema, taste perversion, cough

Butalbital/Acetaminophen/Caffiene

Fioricet®

Schedule: C-III

Uses: *Tension HA*, mild pain

MOA: Nonnarcotic analgesic w/ barbiturate

Dose: 1-2 tabs or caps PO q4-6h PRN; ↓ in renal/hepatic impair; 4 g/24 h APAP max

Caution: C/D, +, alcoholic liver disease, G6PD deficiency

CI: Hypersens

Disp: Caps, Tabs 50 mg butalbital/40 mg caffeine/325 mg APAP; Caps 50 mg butalbital/40 mg caffeine/500 mg APAP; Liq 50 mg butalbital/40 mg caffeine/325 mg APAP/15 mL

SE: Drowsiness, dizziness, "hangover" effect, N/V

Notes: Butalbital habit forming; avoid EtOH

Metoclopramide

Reglan®

BBW: Chronic use may cause tardive dyskinesia; DC if symptoms develop; avoid prolonged use (>12 wks)

Uses: *Diabetic gastroparesis, symptomatic GERD; chemotherapy & post-op N/V, facilitate small-bowel intubation & upper GI radiologic evaluation,* stimulate gut in prolonged post-op ileus

MOA: ↑ upper GI motility; blocks dopamine in chemoreceptor trigger zone, sensitized tissues to ACH

Dose: Gastroparesis: 10 mg PO 30 min AC & HS for 2-8 wks PRN, or same dose IM/IV for 10 d, then PO. Reflux: 10-15 mg PO 30 min AC & HS. Chemotherapy Antiemetic: 1-3 mg/kg/dose IV 30 min before chemotherapy, then q2h x 2 doses, then q3h x 3 doses. Post-op: 10-20 mg IV/IM q4-6h PRN. Intestinal intubation: 10 mg IV x 1 over 1-2 min

Caution: B, -, drugs w/ extrapyramidal ADRs, MAOIs, TCAs, sympathomimetics

CI: EPS meds, GI bleeding, pheochromocytoma, seizure disorders, GI obst

Disp: Tabs 5, 10 mg; syrup 5 mg/5 mL; Inj 5 mg/mL

SE: Dystonic rxns common w/ high doses (treat w/ IV diphenhydramine), fluid retention, restlessness, D, drowsiness

Clotrimazole/Betamethasone

Lotrisone®

Uses: Fungal skin infxns

MOA: Imidazole antifungal & anti-inflammatory. Spectrum: Tinea pedis, cruris, & corporis

Dose: Apply & massage into area BID for 2-4 weeks

Caution: C, ?, varicella infxn

CI: Children < 12 yo

Disp: Cream, Lotion 1/0.05%

SE: Local irritation, rash

Notes: Not for diaper dermatitis or under occlusive dressings

Doxazosin

Cardura®

Uses: HTN & symptomatic BPH

MOA: Alpha-1 adrenergic blocker; relaxes bladder neck smooth muscle

Dose: HTN: Initial 1 mg/d PO, may be ↑ to 16 mg/d PO. BPH: Initial 1 mg/d PO, may ↑ to 8 mg/d; XL 2-8 mg qAM

Caution: B, ?, w/ liver impair

CI: Component sensitivity; use w/ PDE5 inhib (eg. sildenafil) can cause ↓ BP

Disp: Tabs 1, 2, 4, 8 mg; XL 4, 8 mg

SE: Dizziness, HA, drowsiness, fatigue, malaise, sexual dysfunction, doses >4 mg ↑ postural ↓ BP risk; intraoperative floppy iris synd

Notes: 1st dose HS; syncope may occur w/in 90 min of initial dose

Methocarbamol

Robaxin®

Uses: Relief of discomfort associated w/ painful musculoskeletal conditions

MOA: Centrally acting skeletal muscle relaxant

Dose: 1.5 g PO QID for 2-3 d, then 1 g PO QID maint. Tetanus: 1-2 g IV q6h x 3 d, then use PO

Caution: C, +, seizure disorders

CI: Myasthenia Gravis, renal impair, w/IV

Disp: Tabs 500, 750 mg; Inj 100 mg/mL

SE: Can discolor urine, lightheadedness, drowsiness, GI upset, ↓ HR, ↓ BP

Notes: Tabs can be crushed and added to NG, do not operate heavy machinery

Buproprion, extended release

Budeprion® XL, Wellbutrin® XL

BBW: All pts being treated w/ bupropion for smoking cessation treatment should be observed for neuropsychiatric signs and symptoms (hostility, agitation, depressed mood, and suicide-related events; most during/after Zyban; Symptoms may persist following DC; Closely monitor for worsening depression or emergence of suicidality, increased suicidal behavior in young adults

Uses: *Depression, smoking cessation adjunct,* ADHD

MOA: Weak inhib of neuronal uptake of serotonin & NE; ↓ neuronal dopamine reuptake

Dose: Depression: 150-450 mg daily. Smoking Cessation: 150 mg/d x 3 days, then 150 mg BID x 8-12 wks, last dose before 6 PM, ↓ dose w/ renal/hepatic impair

Caution: C, ?/-

CI: Seizure disorder, history of anorexia nervosa or bulimia, MAOI w/ or w/in 14 d, abrupt DC of EtOH or sedatives, inhibitors/inducers of CYP 2B6, w/ ritonavir and lopinavir/ritonavir

Disp: XL tabs 150, 300 mg

SE: Seizures, agitation, insomnia, HA, tachycardia, ↓ wgt

Notes: Avoid EtOH & other CNS depressants, SR & XR do not crush/chew/cut, may ↑ adverse events including seizures