A-Z

DUTASTERIDE: Avodart, Various

Class: 5α-Reductase Inhibitor Dosage Forms. Oral Capsule: 0.5 mg Common FDA Label Indication, Dosing, and Titration. Benign prostatic hyperplasia: 0.5 mg po daily Off-Label Uses. Male pattern alopecia: 0.5 mg po daily MOA. Dutasteride inhibits the conversion of testosterone to 5α-dihydrotestosterone (DHT) by 5α-reductase, isoform 1 and 2. Drug Characteristics: Dutasteride Dose Adjustment Hepatic Not required Absorption F = 60%, minimal food effect Dose Adjustment Renal Not required Distribution Vd = 300-500 L Dialyzable Not known Metabolism Extensive hepatic; substrate of CYP3A4/5 Pregnancy Category X Elimination Renal <1% with a half-life of 5 wk Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to dutasteride, pregnancy, children Black Box Warnings None Medication Safety Issues: Dutasteride Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No Oral capsule No No No

FINASTERIDE: Proscar, Propecia, Various

Class: 5α-Reductase Inhibitor Dosage Forms. Oral Tablet: 1 mg, 5 mg Common FDA Label Indication, Dosing, and Titration. Benign prostatic hyperplasia: 5 mg po daily Male pattern alopecia: 1 mg po daily Off-Label Uses. Prostate cancer prevention: 5 mg po daily MOA. Finasteride inhibits the conversion of testosterone to 5α-dihydrotestosterone (DHT) by 5α-reductase, isoform 2. Drug Characteristics: Finasteride Dose Adjustment Hepatic Not required Absorption F = 63%, minimal food effect Dose Adjustment Renal Not required Distribution Vd = 76 L; 90% protein bound Dialyzable Unknown Metabolism <20% hepatic, CYP3A4/5 substrate Pregnancy Category X Elimination Renal 40% with a half-life of 6 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to finasteride, pregnancy, children Black Box Warnings None Medication Safety Issues: Finasteride Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No ProSom, Provera, PROzac No Drug Interactions: Finasteride. None Known Adverse Reactions: Finasteride Common (>10%) Less Common (1-10%) Rare but Serious (<1%) Impotence, reduced libido Gynecomastia, dizziness Heart failure, angioedema, allergic skin reactions, male breast cancer, prostate cancer (high grade)

ENALAPRIL: Vasotec, Various

Class: ACE-I, Antihypertensive Dosage Forms. Oral Tablet: 2.5 mg, 5 mg, 10 mg, 20 mg; Oral Solution: 1 mg/mL Common FDA Label Indication, Dosing, and Titration. Heart failure: Infants ≥4 d of age and Adolescents, 0.1-0.5 mg/kg po daily, max 0.94 mg/kg po daily; Adults, 2.5 mg po daily, titrate to 20-40 mg po daily in divided doses Hypertension: Infants ≥1 mo of age and Adolescents, 0.08 mg/kg up to 5 mg po daily, max 0.58 mg/kg or 40 mg po daily; Adults, 5 mg po daily, max 40 mg po daily in divided doses Kidney disease, nondiabetic: Children 7-18 y of age, 0.1-0.5 mg/kg po daily, max 20 mg po daily; Adults, 5 mg po daily, max 20 mg po daily Off-Label Uses. Diabetic nephropathy: 5-20 mg po daily MI: 2.5 mg po daily, may titrate to 20 mg po daily MOA. Enalapril is a prodrug that is rapidly converted to its active metabolite, enalaprilat, a competitive ACE-I. It reduces serum aldosterone, leading to decreased sodium retention, potentiates the vasodilator kallikrein-kinin system, inhibits the sympathetic nervous system, and inhibits the tissue renin-angiotensin system. The net effect is reduction in total peripheral resistance and blood pressure in hypertensive patients, and reduction of elevated afterload in patients with heart failure. Drug Characteristics: Enalapril Dose Adjustment Hepatic Not required Absorption F = 60%, no effect of food on absorption Dose Adjustment Renal CrCl <30 mL/min, initial dose 2.5 mg po daily, max 40 mg po daily Distribution 50-60% protein bound Dialyzable Yes Metabolism Extensive hepatic to 1 active metabolite Pregnancy Category D Elimination Renal 61% with a half-life of 1.3 h (parent drug), 11 h (metabolite) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to enalapril, history of angioedema, pregnancy, concurrent sacubitril Black Box Warnings Pregnancy

BENAZEPRIL: Lotensin, Various

Class: ACE-I, Antihypertensive Dosage Forms. Oral Tablet: 5 mg, 10 mg, 20 mg, 40 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: Adults, 10 mg po daily, may titrate to 20-40 mg po daily (max 80 mg/d); Children ≥6 y of age, 0.2 mg/kg po daily (max 0.6 mg/kg/d or 40 mg/d) Off-Label Uses. Diabetic nephropathy: 10 mg po daily Heart failure: 5-40 mg po daily in 2 divided doses Kidney disease: 10 mg po daily MOA. Benazepril is a competitive ACE-I. It also reduces serum aldosterone, leading to decreased sodium retention, potentiates the vasodilator kallikrein-kinin system, and can alter prostanoid metabolism, inhibit the sympathetic nervous system, and inhibit the tissue renin-angiotensin system. Drug Characteristics: Benazepril Dose Adjustment Hepatic Not required Absorption F = 37%, no effect of food on absorption Dose Adjustment Renal CrCl <30 mL/min, initial dose is 5 mg po daily, titrate to effect (max 40 mg/d) Distribution Vd = 8.7 L; 97% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic metabolism to 1 active metabolite (benazeprilat) Pregnancy Category D Elimination Renal 33%, bile 12% with a half-life of 0.6 h (parent drug), 22 h (benazeprilat) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity; history of angioedema; anuria; concomitant use with aliskiren in patients with diabetes mellitus; concurrent sacubitril Black Box Warnings

DEXAMETHASONE: Decadron, Various

Class: Adrenal Corticosteroid Dosage Forms. Oral Tablet: 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg; Oral Solution: 0.5 mg/5 mL, 1 mg/mL; Oral Elixir: 0.5 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Dosing for indications listed below: Adults, 0.75-9 mg/d po; Children, 0.02-0.3 mg/kg/d in 3-4 divided doses; for all patients, adjust dose according to patient response Allergic states (eg, asthma, etc) Dermatologic diseases (eg, exfoliative erythroderma, etc) Endocrine disorders (eg, adrenocortical insufficiency, etc) GI diseases (eg, regional enteritis, ulcerative colitis, etc) Hematologic disorders (eg, acquired hemolytic anemia, etc) Neoplastic diseases (eg, palliative management of leukemias and lymphomas, etc) Nervous system (eg, multiple sclerosis, cerebral edema, etc) Renal diseases (eg, idiopathic nephrotic syndrome, systemic lupus erythematosus, etc) Respiratory diseases (eg, idiopathic eosinophilic pneumonia, etc) Rheumatic disorders (eg, rheumatoid arthritis, etc) Off-Label Uses. Chemotherapy-induced nausea and vomiting: 20 mg IV before chemotherapy, 8 mg IV or po bid × 3 d after chemotherapy MOA. Glucocorticosteroids are naturally occurring and synthetic adrenocortical steroids that cause varied metabolic effects. They modify the body's immune responses to diverse stimuli and are used primarily for their anti-inflammatory effects in disorders of many organ systems. Drug Characteristics: Dexamethasone Dose Adjustment Hepatic Adjust dose to response Absorption F = 85% Dose Adjustment Renal Adjust dose to response Distribution Vd = 2 L/kg Dialyzable Not dialyzable Metabolism Hepatic; substrate of CYP3A4/5; inhibitor of P-glycoprotein; inducer of CYP3A4/5 and P-glycoprotein Pregnancy Category C Elimination Primarily renal with a half-life of 2-2.5 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to glucocorticosteroids; concurrent use of live vaccines; fungal infections Black Box Warnings None

BRIMONIDINE: Alphagan P, Lumify, Various

Class: Adrenergic Agonist; Antiglaucoma Agent Dosage Forms. Ophthalmic Solution: 0.025%, 0.1%, 0.15%, 0.2% Common FDA Label Indication, Dosing, and Titration. Ocular hypertension: 1 drop in affected eye(s) q8h, strength chosen based on therapeutic effect Open-angle glaucoma: 1 drop in affected eye(s) q8h, strength chosen based on therapeutic effect Ocular redness (OTC indication): 1 drop in affected eye(s) q6-8h prn (max 4 doses/d) Off-Label Uses. Capsulotomy of posterior lens capsule: 1 drop of 0.2% solution in operative eye 1 h prior to surgery, then 1 drop in operative eye immediately following procedure MOA.Brimonidine, a relatively selective α-adrenergic agonist, reduces aqueous humor production and increases uveoscleral outflow. It is used to lower IOP in open-angle glaucoma or ocular hypertension. Drug Characteristics: Brimonidine Dose Adjustment Hepatic Not required Absorption Minor systemic absorption following ocular instillation Dose Adjustment Renal Not required Distribution Effective penetration of brimonidine into aqueous humor Dialyzable Not dialyzable Metabolism 24% and occurs by unknown enzymes Pregnancy Category B Elimination Renal 74% with a half-life of 3 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to brimonidine, concurrent MAOIs, age <2 y Black Box Warnings None

EPINEPHRINE AUTO-INJECTOR: Adrenaclick, Auvi-Q, EpiPen, EpiPen Jr., Various

Class: Anaphylaxis Agent Dosage Forms. Solution for Auto-injection: 0.1 mg/0.1 mL, 0.15 mg/0.15 mL, 0.15 mg/0.3 mL, 0.3 mg/0.3 mL Common FDA Label Indication, Dosing, and Titration. Emergency treatment of acute anaphylaxis due to allergic reactions: Using auto-injector, Children 7.5-14 kg, 0.1 mg IM or sq; Children 15-30 kg, 0.15 mg IM or sq; Children >30 kg and Adults, 0.3 mg IM or sq; may be repeated if severe anaphylaxis persists Off-Label Uses. None MOA. Epinephrine treats severe allergic reactions to insect stings or bites, foods, drugs, and other allergens. It acts on both α- and β-adrenergic receptors. Through its action on α-adrenergic receptors, epinephrine lessens the vasodilation and increased vascular permeability that occurs during anaphylaxis, which can lead to loss of intravascular fluid volume and hypotension. Through its action on β-adrenergic receptors, epinephrine causes bronchial smooth muscle relaxation that helps alleviate bronchospasm, wheezing, and dyspnea that may occur during anaphylaxis. Epinephrine also alleviates pruritus, urticaria, and angioedema. Drug Characteristics: Epinephrine Dose Adjustment Hepatic Not required Absorption 20% of dose rapidly absorbed after sq dose; remaining 80% absorbed over 6-8 h Dose Adjustment Renal Not required Distribution N/A Dialyzable Not dialyzable Metabolism Rapid and complete hepatic Pregnancy Category C Elimination Renal as inactivated metabolites Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications None in emergency situations Black Box Warnings None

CANDESARTAN: Atacand, Various

Class: Angiotensin II Receptor Antagonist Dosage Forms. Oral Tablet: 4 mg, 8 mg, 16 mg, 32 mg Common FDA Label Indication, Dosing, and Titration. Heart failure: 4 mg po daily, may titrate to 32 mg po daily Hypertension: Adults, 16 mg po daily or in 2 divided doses, may titrate to 32 mg po daily; Children 1-5 y of age, 0.2 mg/kg po daily, may titrate to 0.4 mg/kg daily; Children 6-16 y of age and <50 kg, 4-8 mg po daily, may titrate to 32 mg daily; Children 6-16 y of age and ≥50 kg, 8-16 mg po daily, may titrate to 32 mg daily Off-Label Uses. None MOA. Candesartan is a selective, reversible, competitive antagonist of the angiotensin II receptor type 1 (AT1). Drug Characteristics: Candesartan Dose Adjustment Hepatic Decrease dose in patients with moderate hepatic impairment Absorption F = 15%, food does not affect absorption Dose Adjustment Renal CrCl 15-60 mL/min, 8 mg po daily Distribution Vd = 0.13 L; >99% protein bound Dialyzable Not dialyzable Metabolism Parent compound bioactivated during absorption via ester hydrolysis within intestinal wall to candesartan Pregnancy Category D Elimination Renal 33%, fecal 67% with a half-life of 5-10 h (metabolite) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to candesartan or other ARB, pregnancy Black Box Warnings Pregnancy Medication Safety Issues: Candesartan Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Antacid No

ALBENDAZOLE: Albenza, Various

Class: Anthelmintic Dosage Forms. Tablet: 200 mg Common FDA Label Indication, Dosing, and Titration. Parenchymal neurocysticercosis caused by Taenia solium, cystic hydatid disease of the liver, lung, and peritoneum caused by Echinococcus granulosus: Adults ≥60 kg, 400 mg po bid with meals × 8-30 d; Adults and Children <60 kg, 15 mg/kg/d (max 800 mg/d) in 2 divided doses × 8-30 d Off-Label Uses. Ancylostoma caninum, Ascaris lumbricoides (roundworm),Ancylostoma duodenale (hookworm), and Necator americanus (hookworm): 400 mg po as a single dose Enterobius vermicularis (pinworm): 400 mg po as a single dose, repeat in 2 wk Giardia duodenalis (giardiasis): 400 mg po once daily × 5 d MOA.Selective degeneration of cytoplasmic microtubules in intestinal and tegmental cells of intestinal helminths and larvae. This leads to impaired glucose uptake in parasites and ATP production decreases leading to energy depletion and death. Drug Characteristics: Albendazole Dose Adjustment Hepatic Use with caution in hepatic dysfunction Absorption F <5%, food enhances absorption up to 5 times Dose Adjustment Renal Not required Distribution Cyst, CSF Dialyzable Not dialyzable Metabolism Hepatic to 1 active metabolite; minor substrate of CYP3A4/5, 1A2 Pregnancy Category C Elimination Renal <1% with half-life of 8-15 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to albendazole Black Box Warnings None Medication Safety Issues: Albendazole Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Aplenzin, Relenza No

BUSPIRONE: BuSpar, Various

Class: Antianxiety Dosage Forms. Oral Tablet: 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg Common FDA Label Indication, Dosing, and Titration. Anxiety: Adults, 5 mg po bid-tid or 7.5 mg po bid, may titrate to 20-30 mg/d in 2-3 divided doses (max 60 mg/d) Off-Label Uses. Anxiety: Children, 5 mg/d po, may titrate to 15 mg po bid (max 50 mg/d) Depression: Adults, 5 mg po tid, may titrate to 40-55 mg/d in 2-3 divided doses (max 90 mg/d) MOA. Buspirone is the first of a class of selective serotonin-5-HT1A receptor partial agonists. It also has some effect on dopamine-D2 auto-receptors and, like antidepressants, can down-regulate β-adrenergic receptors. Unlike benzodiazepines, it lacks amnestic, anticonvulsant, muscle relaxant, and hypnotic effects. Its exact anxiolytic mechanism of action is complex and not clearly defined. Drug Characteristics: Buspirone Dose Adjustment Hepatic Use lower initial doses and increase gradually as needed and tolerated Absorption F = 90%; food increases AUC and Cmax Dose Adjustment Renal Use lower initial doses and increase gradually as needed and tolerated Distribution Vd = 5.3 L/kg; 86% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP3A4/5 Pregnancy Category B Elimination Renal 29-63% (primarily as metabolites) with a half-life of 2-3 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None

AMIODARONE: Cordarone, Pacerone, Various

Class: Antiarrhythmic Dosage Forms. Tablet: 100 mg, 200 mg, 400 mg Common FDA Label Indication, Dosing, and Titration. Ventricular arrhythmia, treatment and prophylaxis: 800-1600 mg po daily in divided doses × 1-3 wk, titrate down to 600-800 mg po daily × 1 mo, then to maintenance dose of 400-600 mg po daily given as single dose or divided bid Off-Label Uses. Atrial fibrillation, prophylaxis after open heart surgery: 600-1200 mg po daily in divided doses, started post-op and continued until hospital discharge Supraventricular arrhythmia: 600-1200 mg po daily for 1-2 wk, tapered to 400-600 mg po daily × 1-3 wk then to maintenance dose of 200 mg po daily MOA. Type III antiarrhythmic that prolongs the effective refractory period of atrial and ventricular tissue by blocking potassium conductance. Drug Characteristics: Amiodarone Dose Adjustment Hepatic Should be considered Absorption F = 50%, food enhances rate and extent of absorption Dose Adjustment Renal Not required Distribution Vd = 66 L/kg; 96% protein bound Dialyzable Not dialyzable Metabolism Hepatic via CYP2C8 and 3A4/5 to active metabolite; inhibitor of CYP2A6, 2C9, 2D6, 3A4/5 and P-glycoprotein Pregnancy Category D Elimination Renal with a half-life of 40-55 d Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity, severe bradycardia, severe sinus node dysfunction, 2nd or 3rd degree AV block, and cardiogenic shock Black Box Warnings Arrhythmias, hepatotoxicity, proarrhythmic effects, pulmonary toxicity Medication Safety Issues: Amiodarone Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoNoYesAmantadine, amiloride, Cardura, CordranAvoid as first line for atrial fibrillation unless patient has HF

CHLORHEXIDINE: Peridex, Paroex, Hibiclens, Various

Class: Antibacterial Cleansing Agent Dosage Forms. Liquid Oral Rinse: 0.12%; Topical Solution: 2%, 4% Common FDA Label Indication, Dosing, and Titration. Gingivitis: 15 mL oral rinse (undiluted, 0.12%), swish 30 s and spit bid (morning and evening) after tooth brushing Skin or wound cleansing: Rinse area to be cleansed, apply minimum amount of solution necessary to cover skin or wound area, and wash gently; then rinse Off-Label Uses. Burn, prevention of nosocomial infectious disease: Rinse area to be cleansed, apply minimum amount of 4% solution necessary to cover skin or wound area, and wash gently; then rinse Oropharyngeal decontamination, to reduce risk of ventilator-associated pneumonia in critically ill patients: 15 mL oral rinse (undiluted, 0.12%), swab oral area q8h MOA. Chlorhexidine, a polybiguanide, is an antiseptic and antimicrobial drug with bactericidal activity. The bactericidal effect of chlorhexidine is a result of the binding of this cationic molecule to negatively charged bacterial cell walls and extramicrobial complexes. Chlorhexidine has activity against gram-positive and gram-negative organisms, facultative anaerobes, aerobes, and yeast; it is both bacteriostatic and bactericidal, depending on its concentration. Drug Characteristics: Chlorhexidine Dose Adjustment Hepatic Not required Absorption Not absorbed Dose Adjustment Renal Not required Distribution Not absorbed Dialyzable Unknown Metabolism Not absorbed Pregnancy Category C Elimination Not absorbed Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to chlorhexidine Black Box Warnings None Medication Safety Issues: Chlorhexidine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Precedex No

ENOXAPARIN: Lovenox, Various

Class: Anticoagulant, Low-Molecular-Weight Heparin Dosage Forms. Prefilled Syringes: 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/1 mL, 120 mg/0.8 mL, 150 mg/1 mL; Multiple-Dose Vial: 300 mg/3 mL Common FDA Label Indication, Dosing, and Titration. Deep vein thrombosis prophylaxis, abdominal surgery: 40 mg sq once 2 h prior to surgery, then daily × 7-10 d Deep vein thrombosis prophylaxis, hip or knee replacement surgery: 30 mg sq q12h starting 12-24 h postoperatively × 7-14 d Deep vein thrombosis prophylaxis, acute medical illness: 40 mg sq daily × 6-11 d Deep vein thrombosis treatment: 1 mg/kg sq q12h or 1.5 mg/kg q24h; initiate warfarin therapy as soon as possible and continue enoxaparin for at least 5 d and until target INR is reached Acute ST segment elevation myocardial infarction: Adults <75 y of age, 30 mg IV together with 1 mg/kg sq once, then 1 mg/kg sq q12h (max 100 mg for the first 2 doses only); Adults ≥75 y of age, 0.75 mg/kg sq q12h (no initial bolus) Unstable angina and non-Q-wave myocardial infarction: 1 mg/kg sq q12h × 2-8 d with aspirin 100-325 mg po daily Off-Label Uses. None MOA. Enoxaparin is a low-molecular-weight heparin which has antifactor Xa and IIa properties. Drug Characteristics: Enoxaparin Dose Adjustment Hepatic Not required Absorption F = 100% following sq dose Dose Adjustment Renal CrCl <30 mL/min: avoid use or reduce dose by 50% Distribution Vd = 4.3 L Dialyzable Not dialyzable Metabolism Hepatic Pregnancy Category B Elimination Renal 40% with a half-life of 7 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to enoxaparin, heparin, or pork products; active major bleeding; concurrent neuraxial analgesia Black Box Warnings Neuraxial anesthesia may cause hematomas

DIVALPROEX: Depakote, Various

Class: Anticonvulsant Dosage Forms. Oral Tablet, Extended Release, 24 h: 250 mg, 500 mg; Oral Tablet, Delayed Release: 125 mg, 250 mg, 500 mg; Oral Capsule, Delayed-Release Sprinkles: 125 mg; Oral Solution: 250 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Absence seizure, simple and complex: 15 mg/kg/d po, may titrate to 60 mg/kg/d; delayed-release products are dosed bid, extended-release 24 h products are dosed daily Complex partial epileptic seizure: 10-15 mg/kg/d po, may titrate to 60 mg/kg/d; delayed-release products are dosed bid, extended-release 24 h products are dosed daily Manic bipolar disorder: 25 mg/kg/d po, may titrate to 60 mg/kg/d; delayed-release products are dosed bid, extended-release 24 h products are dosed daily Migraine prophylaxis: Extended release 24 h, 500 mg po daily for 1 wk, then 1 g po daily; delayed release 250 mg po bid, increasing to 500 mg po bid Off-Label Uses. None MOA. Divalproex is composed of sodium valproate and valproic acid. Valproic acid is a carboxylic acid compound whose anticonvulsant activity might be mediated by an inhibitory neurotransmitter, GABA. Valproic acid might increase GABA levels by inhibiting GABA metabolism or enhancing postsynaptic GABA activity. Valproic acid also limits repetitive neuronal firing through voltage- and usage-dependent sodium channels. Drug Characteristics: Divalproex Dose Adjustment Hepatic Avoid use in severe hepatic dysfunction Absorption F = 89%, food has no effect on absorption Dose Adjustment Renal Not required Distribution Vd = 11 L; 88-90% protein bound Dialyzable Yes, but no dosage supplementation required Metabolism Extensive hepatic metabolism; minor substrate of multiple CYP pathways Pregnancy Category X for migraine prophylaxis; D for all other indications Elimination Renal 30-50% with a half-life of 9-16 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to divalproex, hepatic disease, urea cycle disorders Black Box Warnings Hepatotoxicity, teratogenicity, pancreatitis Medication Safety Issues: Divalproex Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria ER No Extended release No Depakene, Senokot, vecuronium Avoid in certain circumstances

CARBAMAZEPINE: Tegretol, Various

Class: Anticonvulsant Dosage Forms. Oral Tablet: 200 mg; Oral Tablet, Chewable: 100 mg; Oral Tablet, Extended Release: 100 mg, 200 mg, 400 mg; Oral Suspension: 100 mg/5 mL; Oral Capsule, Extended Release: 100 mg, 200 mg, 300 mg Common FDA Label Indication, Dosing, and Titration. Epilepsy, partial, generalized, and mixed types: Adults, 200 mg po bid, may titrate to 1200 mg po daily; Children <6 y of age, 10-20 mg/kg/d po in 2-4 divided doses, may titrate to 250-350 mg/d po (or 35 mg/kg/d); Children 6-12 y of age, 100 mg po bid, may titrate to 800 mg po daily Trigeminal neuralgia: 100 mg po q12h, may titrate to 1200 mg po daily for pain control Off-Label Uses. Neuropathic pain: 50-100 mg po bid in combination with opioids, may titrate to 1200 mg/d po Bipolar disease, acute manic and mixed episodes: 200 mg po bid, may titrate to 1600 mg/d po MOA. Carbamazepine acts presynaptically to block firing of action potentials, which decreases the release of excitatory neurotransmitters, and postsynaptically by blocking high-frequency repetitive discharge initiated at cell bodies. Drug Characteristics: Carbamazepine Dose Adjustment Hepatic Avoid Absorption F = 89%; no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd = 0.59-2 L/kg; 75-90% protein bound Dialyzable Yes Metabolism Hepatic; major substrate of CYP3A4/5; strong inducer of CYP1A2, 2B6, 2C19, 2C8, 2C9, 3A4/5 and P-glycoprotein Pregnancy Category D Elimination Renal 72% with an initial half-life of 25-65 h, then 12-17 h after 3-5 wk of treatment due to autoinduction Lactation Compatible Pharmacogenetics Use alternative anticonvulsant in HLA-A*31:01 positive or HLA-B*15:02 positive patients, increased risk of Stevens-Johnson syndrome Contraindications Hypersensitivity to carbamazepine, history of bone marrow depression, MAOIs, nefazodone Black Box Warnings Agranulocytosis; aplastic anemia; dermatological reactions (especially in Asians); screen for HLA-B*15:02 Medication Safety Issues: Carbamazepine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XR CarBAMazepine, TEGretol Do not crush or chew ER tablets or capsules No OXcarbazepine, Toradol, TRENtal Avoid in certain circumstances

DULAGLUTIDE: Trulicity

Class: Antidiabetic Agent, Glucagon-Like Peptide-1 Receptor Agonist Dosage Forms. Pen Injector, Subcutaneous: 0.5 mg/mL, 1.5 mg/mL Common FDA Label Indication, Dosing, and Titration. Diabetes mellitus, type 2: Adults, 0.75-1.5 mg every wk sq Off-Label Uses. None MOA. Dulaglutide is an agonist of human glucagon-like peptide-1 (GLP-1) receptor and augments glucose-dependent insulin secretion and slows gastric emptying. Drug Characteristics: Dulaglutide Dose Adjustment Hepatic Not required Absorption F = 47-65% Dose Adjustment Renal Not required Distribution Vd = 17-19 L Dialyzable Unknown Metabolism Protein catabolism to component amino acids Pregnancy Category Consider alternative therapy Elimination Half-life of 5 d Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Family history of medullary thyroid carcinoma, MEN2 Black Box Warnings Risk of thyroid cancers

CANAGLIFLOZIN: Invokana

Class: Antidiabetic Agent, Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Dosage Forms. Oral Tablet: 100 mg, 300 mg Common FDA Label Indication, Dosing, and Titration. Diabetes mellitus, type 2: Adults, 100-300 mg po daily, before first meal Off-Label Uses. None MOA. Canagliflozin inhibits SGLT2 in the proximal renal tubules, which reduces reabsorption of filtered glucose from the tubular lumen. Drug Characteristics: Canagliflozin Dose Adjustment Hepatic Not required Absorption F = 65% Dose Adjustment Renal eGFR 45 to <60 mL/min/1.73 m2, max dose 100 mg daily; eGFR ≥30 to <45 mL/min/1.73 m2, avoid; eGFR <30 mL/min/1.73 m2, contraindicated Distribution Protein binding approximately 99% Dialyzable Contraindicated Metabolism Hepatic via UGT1A9 and 2B4 to inactive metabolites Pregnancy Category Consider alternative therapy Elimination Renal and fecal (unchanged drug and metabolites) with a half-life of 10 h Lactation Not recommended Pharmacogenetics None known Contraindications Severe renal impairment Black Box Warnings Lower limb amputation Medication Safety Issues: Canagliflozin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No Yes No No

DIPHENOXYLATE/ATROPINE: Lomotil, Various

Class: Antidiarrheal. C-V Dosage Forms. Oral Tablet: (Diphenoxylate/Atropine) 2.5 mg/0.025 mg; Oral Solution: (Diphenoxylate/Atropine) 2.5 mg/0.025 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Diarrhea: Children ≥2 y of age, 0.3 mg-0.4 mg/kg/d (diphenoxylate) po in 4 divided doses to max 20 mg/d (diphenoxylate); Adults, 2 tablets po qid until diarrhea resolves, then reduce dose to maintain efficacy, to max 20 mg/d (diphenoxylate) Off-Label Uses. None MOA. Diphenoxylate is a synthetic meperidine congener without analgesic activity that slows GI motility. Because high doses of diphenoxylate (40-60 mg) cause systemic opioid activity, atropine is added in subtherapeutic amounts to decrease abuse potential. Drug Characteristics: Diphenoxylate/Atropine Dose Adjustment Hepatic Not required Absorption F = 90% Dose Adjustment Renal Not required Distribution Vd = 324 L Dialyzable Not dialyzable Metabolism Rapidly and extensively hepatically metabolized to an active metabolite Pregnancy Category C Elimination Renal 14% with half-life of 2.5 h (parent), 12-14 h (active metabolite) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to diphenoxylate or atropine products; diarrhea associated with enterotoxin-producing bacteria or pseudomembranous enterocolitis; obstructive jaundice Black Box Warnings None Medication Safety Issues: Diphenoxylate/Atropine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No LaMICtal, LamISIL, loperamide No

CETIRIZINE: Zyrtec, Various

Class: Antihistamine Dosage Forms. Oral Tablet: 5 mg, 10 mg; Oral Tablet, Chewable: 5 mg, 10 mg; Oral Tablet, Disintegrating: 10 mg; Oral Capsule: 10 mg; Oral Solution: 1 mg/mL Common FDA Label Indication, Dosing, and Titration. Perennial or seasonal allergic rhinitis: Children 6-23 mo of age, 2.5 mg po daily; Children 2-5 y of age, 2.5-5 mg po daily; Children ≥6 y of age and Adults, 5-10 mg po daily Urticaria, chronic: Children 6-23 mo of age, 2.5 mg po daily; Children 2-5 y of age, 2.5-5 mg po daily; Children ≥6 y of age and Adults, 5-10 mg po daily Off-Label Uses. Atopic dermatitis: Children 6-23 mo of age, 2.5 mg po daily; Children 2-5 y of age, 2.5-5 mg po daily; Children ≥6 y of age and Adults, 5-10 mg po daily MOA. Cetirizine is a low-sedating, long-acting H1-receptor antagonist that is a metabolite of hydroxyzine. Cetirizine competitively inhibits the interaction of histamine with H1 receptors, thereby preventing the allergic response. Drug Characteristics: Cetirizine Dose Adjustment Hepatic Chronic liver failure, 5 mg po daily Absorption F = 70%, limited effect of food on absorption Dose Adjustment Renal CrCl <50 mL/min, max dose 5 mg po daily Distribution Vd = 0.5-0.8 L/kg with 90% protein binding Dialyzable Yes Metabolism Limited hepatic; substrate of P-glycoprotein Pregnancy Category B Elimination Renal 70% with a half-life of 8.3 h Lactation Weigh risks and benefits Pharmacogenetics None known ContraindicationsHypersensitivity to cetirizine or hydroxyzineBlack Box Warnings None

FEXOFENADINE: Allegra, Various

Class: Antihistamine Dosage Forms. Oral Tablet: 60 mg, 180 mg; Oral Disintegrating Tablet: 30 mg; Oral Suspension: 30 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Seasonal allergic rhinitis (OTC): Children 2-11 y of age, 30 mg po bid; Children ≥12 y of age and Adults, 60 mg po bid or 180 mg po daily Idiopathic urticaria: Children 6 mo-2 y of age, 15 mg po bid; Children 2-11 y of age, 30 mg po bid; Children ≥12 y of age and Adults, 60 mg po bid or 180 mg po daily Off-Label Uses. Perennial allergic rhinitis: Children 2-11 y of age, 30 mg po bid; Children ≥12 y of age and Adults, 60 mg po bid or 180 mg po daily MOA. Fexofenadine, the major active metabolite of terfenadine, is an antihistamine with selective peripheral H1-receptor antagonist activity. Both enantiomers of fexofenadine displayed approximately equipotent antihistaminic effects. Drug Characteristics: Fexofenadine Dose Adjustment Hepatic Not required Absorption Rapidly absorbed, bioavailability not established Dose Adjustment Renal Use with caution Distribution Vd = 5.4-5.8 L/kg Dialyzable Not dialyzable Metabolism Little hepatic or extrahepatic metabolism Pregnancy Category C Elimination Fecal 80% with a half-life of 14-18 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to fexofenadine Black Box Warnings None Medication Safety Issues: Fexofenadine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria Allergy, 24-HR No Do not split or chew disintegrating tablet No Viagra No

FENOFIBRATE: Antara, Fenoglide, Lipofen, Lofibra, Tricor, Trilipix, Various

Class: Antihyperlipidemic Dosage Forms. Oral Tablet: 35 mg, 40 mg, 48 mg, 54 mg, 105 mg, 120 mg, 145 mg, 160 mg; Oral Capsule: 30 mg, 43 mg, 50 mg, 67 mg, 90 mg, 130 mg, 134 mg, 150 mg, 200 mg; Oral Capsule, Delayed Release: 45 mg, 135 mg Common FDA Label Indication, Dosing, and Titration. Hypercholesterolemia, primary hypercholesterolemia, or mixed dyslipidemia (Frederickson type 2a, 2b): 160 mg po daily Hypertriglyceridemia, Frederickson types 4 and 5 hyperlipidemia: 54-160 mg po daily Off-Label Uses. None MOA. Fibric acid derivatives activate peroxisome proliferator-activated receptor α (PPARα), which increases lipolysis and elimination of triglyceride-rich particles from plasma by activating lipoprotein lipase and reducing production of apoprotein C-III (an inhibitor of lipoprotein lipase activity). The resulting fall in triglycerides produces an alteration in the size and composition of LDL from small, dense particles to large buoyant particles. These larger particles have a greater affinity for cholesterol receptors and are catabolized rapidly. Drug Characteristics: Fenofibrate Dose Adjustment Hepatic Avoid use in severe hepatic impairment Absorption F = 60%, absorption increased when taken with food Dose Adjustment Renal Avoid use in severe renal impairment Distribution Vd = 60 L; >99% protein bound Dialyzable Not dialyzable Metabolism Prodrug that undergoes rapid hydrolysis at the ester bond to fenofibric acid; fenofibric acid is glucuronidated in the liver Pregnancy Category C Elimination Renal 60-93% with a half-life of 24 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity, gallbladder disease, severe renal or hepatic dysfunction, nursing mothers Black Box Warnings

EZETIMIBE: Zetia, Various

Class: Antihyperlipidemic, Cholesterol Absorption Inhibitor Dosage Forms. Oral Tablet: 10 mg Common FDA Label Indication, Dosing, and Titration. Familial hypercholesterolemia-homozygous, with atorvastatin or simvastatin: Adults and Children >10 y of age, 10 mg po daily Mixed hyperlipidemia: 10 mg po daily in combination with fenofibrate Primary hypercholesterolemia: 10 mg po daily, alone or in combination with an HMG-CoA reductase inhibitor (statin) Off-Label Uses. None MOA. Ezetimibe localizes at the brush border of the small intestine and inhibits the absorption of cholesterol, leading to a decrease in the delivery of intestinal cholesterol to the liver. This causes a reduction of hepatic cholesterol stores and an increase in clearance of cholesterol from the blood; this distinct mechanism is complementary to that of statins and of fenofibrate. Drug Characteristics: Ezetimibe Dose Adjustment Hepatic Avoid if moderate or severe hepatic dysfunction Absorption F variable, food has no effect on absorption Dose Adjustment Renal Not required Distribution Vd = 105 L; 90% protein bound Dialyzable Unknown Metabolism In intestine and liver, not via CYP450 Pregnancy Category C Elimination Renal 11% with a half-life of 9-30 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to ezetimibe, gallbladder disease, severe hepatic dysfunction, concurrent use with a statin in a pregnant or nursing mother Black Box Warnings None Medication Safety Issues: Ezetimibe Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoNoNoZestrilNo

ELETRIPTAN: Relpax, Various

Class: Antimigraine Serotonin Receptor Agonist Dosage Forms. Oral Tablet: 20 mg, 40 mg Common FDA Label Indication, Dosing, and Titration. Migraine: 20-40 mg po at onset of migraine, may repeat after 2 h prn; max single dose 40 mg, max daily dose 80 mg/d Off-Label Uses. None MOA. Eletriptan binds with high affinity to serotonin (5-HT) subtypes 1B, 1D, and 1F receptors. It has no significant affinity or pharmacological activity at adrenergic α1, α2, or β; dopaminergic D1 or D2; muscarinic; or opioid receptors. Serotonin receptor agonists are believed to be effective in migraine, either through vasoconstriction (via activation of 5-HT1 receptors located on intracranial blood vessels) or through activation of 5-HT1 receptors on sensory nerve endings in the trigeminal system, resulting in the inhibition of pro-inflammatory neuropeptide release. Drug Characteristics: Eletriptan Dose Adjustment Hepatic Avoid in severe hepatic dysfunction Absorption F = 50%, high-fat food increases bioavailability 20-30% Dose Adjustment Renal Not required Distribution Vd = 138 L Dialyzable Unknown Metabolism Hepatic; substrate of CYP3A4/5 Pregnancy Category C Elimination Nonrenal 90% with a half-life of 4 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to eletriptan, cerebrovascular syndromes, hemiplegic or basilar migraine, ischemic bowel disease, ischemic heart disease, peripheral vascular disease, severe hepatic impairment, uncontrolled hypertension Black Box Warnings None Medication Safety Issues: Eletriptan Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Sumatriptan No

DICYCLOMINE: Bentyl, Various

Class: Antimuscarinic Dosage Forms. Oral Capsule: 10 mg; Oral Tablet: 20 mg; Oral Solution: 10 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Irritable bowel syndrome: Children 6 mo-2 y of age, 5 mg po tid-qid; Children 2-12 y of age, 10 mg po tid; Adults, 20 mg po qid, may titrate to 40 mg po qid Off-Label Uses. None MOA. Dicyclomine relieves smooth muscle spasm of the GI tract via a specific anticholinergic effect (antimuscarinic) at the acetylcholine-receptor sites and a direct effect on smooth muscle (musculotropic). Drug Characteristics: Dicyclomine Dose Adjustment Hepatic Not required Absorption Well absorbed, minimal food effect Dose Adjustment Renal Not required Distribution Vd = 3.65 L/kg Dialyzable Unknown Metabolism Minimal Pregnancy Category B Elimination Renal 80% with a half-life of 2 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to dicyclomine, age <6 mo, breastfeeding, GI obstruction, glaucoma, myasthenia gravis, obstructive uropathy, reflux esophagitis, severe ulcerative colitis, toxic megacolon, unstable cardiovascular state in acute hemorrhage Black Box Warnings None Medication Safety Issues: Dicyclomine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No DiphenhydrAMINE, doxycycline Highly anticholinergic; avoid

CARBIDOPA/LEVODOPA: Rytary, Duopa, Sinemet, Various

Class: Antiparkinsonian Dosage Forms. Oral Tablet, Immediate Release: (Carbidopa/Levodopa) 10 mg/100 mg, 25 mg/100 mg, 25 mg/250 mg; Oral Tablet, Extended Release: (Carbidopa/Levodopa) 25 mg/100 mg, 50 mg/200 mg; Oral Capsule, Extended Release: (Carbidopa/Levodopa) 23.75 mg/95 mg, 36.25 mg/145 mg, 48.75 mg/195 mg, 61.25 mg/245 mg; Orally Disintegrating Tablet: (Carbidopa/Levodopa) 10 mg/100 mg, 25 mg/100 mg, 25 mg/250 mg; Oral Suspension: (Carbidopa/Levodopa) 4.63 mg/20 mg/mL Common FDA Label Indication, Dosing, and Titration. Parkinson disease: Immediate release, 25 mg/100 mg po tid, increasing dose to therapeutic response; extended release, 50 mg/200 mg po bid, separate doses by at least 6 h; extended-release capsules, 23.75 mg/95 mg po tid × 3 d, then may increase to 36.25 mg/145 mg po tid; patients generally treated with 400-1600 mg of levodopa per d; max 200 mg of carbidopa and 2000 mg of levodopa Off-Label Uses. Restless legs syndrome: 25 mg/100 mg po qhs, may repeat dose if awakening within 2 h MOA. When levodopa is administered orally, it is rapidly decarboxylated to dopamine in extracerebral tissues so that only a small portion of a given dose is transported unchanged to the CNS. For this reason, when given alone, large doses of levodopa are required for adequate therapeutic effect. However, these doses often result in nausea and other adverse reactions. Carbidopa inhibits decarboxylation of circulating levodopa, preventing nausea and allowing more levodopa to reach the CNS. Carbidopa does not cross the blood-brain barrier and does not affect the metabolism of levodopa within the CNS. Drug Characteristics: Carbidopa/Levodopa Dose Adjustment Hepatic Not required Absorption Carbidopa F = 60%; levodopa F = 70-75% Dose Adjustment Renal Not required Distribution CSF concentrations of levodopa are 10-20% of plasma levels Dialyzable Not dialyzable Metabolism Levodopa undergoes extensive decarboxylation to dopamine in the gut wall, liver, and kidney; when given with carbidopa, peripheral decarboxylation of levodopa is blocked, increasing availability of levodopa for brain transport Pregnancy Category C Elimination Carbidopa, renal 30% with a half-life of 1-2 h; levodopa, renal 70-80% with a half-life of 45-90 min Lactation Avoid; may inhibit lactation Pharmacogenetics None known ContraindicationsHypersensitivity to carbidopa or levodopa, narrow-angle glaucoma, non-selective MAOIBlack Box Warnings

BENZTROPINE: Cogentin, Various

Class: Antiparkinsonian, Anticholinergic Dosage Forms. Oral Tablet: 0.5 mg, 1 mg, 2 mg Common FDA Label Indication, Dosing, and Titration. Extrapyramidal disease, medication-induced movement disorder: Adults, 1-4 mg po daily or bid; Children ≥3 y of age, 0.02-0.05 mg/kg/dose once or twice daily Parkinsonism: 1-2 mg/d po, may titrate to range 0.5-6 mg/d po Off-Label Uses. None MOA. Benztropine possesses anticholinergic and antihistamine effects. May inhibit reuptake and storage of dopamine. Drug Characteristics: Benztropine Dose Adjustment Hepatic Not required Absorption F = 29% Dose Adjustment Renal Not required Distribution Unknown Dialyzable Not dialyzable Metabolism Unknown Pregnancy Category B Elimination Unknown Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to benztropine, patients <3 y of age Black Box Warnings None Medication Safety Issues: Benztropine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Bromocriptine Avoid Drug Interactions: Benztropine Typical Agents Mechanism Clinical Management Amantadine Increased CNS toxicity (confusion, hallucinations) Monitor for signs of toxicity Phenothiazines Decreased phenothiazine concentrations, enhanced anticholinergic effects Monitor for efficacy and toxicity HaloperidolExcessive anticholinergic effectsMonitor for signs of toxicity

ARIPIPRAZOLE: Abilify, Various

Class: Antipsychotic Dosage Forms. Tablet: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg; Tablet, Disintegrating: 10 mg, 15 mg; Solution: 1 mg/mL Common FDA Label Indication, Dosing, and Titration. Bipolar disorder, manic or mixed episodes, acute treatment: Adults, 10-15 mg po daily, may titrate to 15-30 mg po daily; Children >10 y, 2 mg po daily, may titrate to 10 mg po daily Schizophrenia: Adults, 10-15 mg po daily, may titrate to max 30 mg/d; Children >13 y, 2 mg po daily, may titrate to 10 mg po daily Depression, adjunctive with antidepressant: 2-4 mg po daily, may titrate to 15 mg po daily Tourette syndrome: Children ≥6 y of age and <50 kg, 2 mg po daily, may titrate to 5-10 mg po daily; Children ≥6 y of age and ≥50 kg, 2 mg po daily, may titrate to 10-20 mg po daily Irritability with autistic disorder: Children ≥6 y of age, 2 mg po daily × 7 d, then 5 mg po daily, may titrate to 15 mg/d Off-Label Uses. None MOA. Aripiprazole is an atypical antipsychotic agent (quinolinone derivative). It exhibits partial agonist activity at dopamine D2 and D3 receptors and serotonin 5-HT1A receptors and antagonist activity at 5-HT2A receptors. Drug Characteristics: Aripiprazole Dose Adjustment Hepatic Not required Absorption F = 87%, no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd = 4.9 L/kg; >99% protein bound Dialyzable Not dialyzable Metabolism Hepatic, 80%; major substrate of CYP2D6 and 3A4/5 Pregnancy Category C Elimination Renal 10-20% with a half-life of 75-94 h Lactation Weigh risks and benefits Pharmacogenetics CYP2D6 poor metabolizers should receive 50% lower dose Contraindications Hypersensitivity Black Box Warnings Dementia, suicidality Medication Safety Issues: Aripiprazole Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoARIPiprazoleDisintegrating tabletNoAmbien, lansoprazole, omeprazole, pantoprazole, rabeprazoleStroke risk; avoid except in schizophrenia or bipolar disorder

ATAZANAVIR: Reyataz, Various

Class: Antiretroviral Agent, Protease Inhibitor Dosage Forms. Capsule: 150 mg, 200 mg, 300 mg; Oral Powder: 50 mg Common FDA Label Indication, Dosing, and Titration. Treatment of HIV-1 infection, antiretroviral-naïve: Adults and Children ≥13 y of age and ≥40 kg, 300 mg po daily with ritonavir 100 mg or cobicistat 150 mg; Adults unable to tolerate ritonavir, atazanavir 400 mg daily (ritonavir unboosted regimen not recommended in Children) Treatment of HIV-1 infection, patients with prior virologic failure: Adults and Children ≥13 y of age and ≥40 kg, 300 mg po daily with ritonavir 100 mg or cobicistat (monotherapy with atazanavir not recommended); Children <13 y of age, weight based and used in combination with ritonavir Treatment of HIV-1 infection in pregnant patients, antiretroviral-naïve or experienced: 300 mg po daily with ritonavir 100 mg po daily Off-Label Uses. None MOA. Binds to the site of HIV-1 protease activity and inhibits cleavage of viral Gag-Pol polyprotein precursors into individual functional proteins required for infectious HIV. This results in the formation of immature, noninfectious viral particles. Drug Characteristics: Atazanavir Dose Adjustment Hepatic Use with caution if moderate hepatic impairment Absorption F approaches 100%, food increases absorption by 50% Dose Adjustment Renal Not required Distribution CSF and semen Dialyzable Yes Metabolism Hepatic; substrate of CYP3A4/5, strong inhibitor of CYP3A4/5 and UGT1A1 Pregnancy Category B Elimination Hepatic 80% with half-life of 7 h Lactation Weigh risks and benefits Pharmacogenetics Resistance is associated with HIV mutations Contraindications Hypersensitivity or concurrent therapy with alfuzosin, cisapride, ergot derivatives indinavir, irinotecan, lovastatin, midazolam (oral), pimozide, rifampin, sildenafil, simvastatin, or triazolam Black Box Warnings None Medication Safety Issues: Atazanavir Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No Do not open capsule Yes No No

EFAVIRENZ: Sustiva, Various

Class: Antiretroviral Agent, Reverse Transcriptase Inhibitor Dosage Forms. Oral Capsule: 50 mg, 200 mg; Oral Tablet: 600 mg Common FDA Label Indication, Dosing, and Titration. Treatment of HIV-1 infections: Adults and Children ≥40 kg, 600 mg po daily hs; Children <40 kg, weight based; if coadministering with rifampin, increase efavirenz to 800 mg po daily; if coadministering with voriconazole, decrease efavirenz to 300 mg po daily and increase voriconazole to 400 mg po q12h Off-Label Uses. None MOA. Binds to HIV reverse transcriptase, blocking the RNA-dependent and DNA-dependent DNA polymerase activities including HIV-1 replication. Drug Characteristics: Efavirenz Dose Adjustment Hepatic Avoid if moderate or severe hepatic impairment Absorption F = 42%, food increases absorption by 20-30% Dose Adjustment Renal Not required Distribution CSF concentration exceeds serum concentration Dialyzable No Metabolism Hepatic; substrate of via CYP3A/5, 2B6; inhibits CY2C9 and 2C19; induces CYP3A4/5 Pregnancy Category D Elimination Renal 14-34% (metabolites), fecal 16-60% (unchanged) with half-life of 52-76 h Lactation Avoid Pharmacogenetics Resistance is associated with HIV mutations, CYP2B6 poor metabolizers have increased risk of QTc prolongation Contraindications Hypersensitivity or concurrent use of bepridil, cisapride, midazolam, pimozide, triazolam, St. John's wort, or ergot alkaloids Black Box Warnings None Medication Safety Issues: Efavirenz Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No Do not open, crush, or chew capsule Yes No No

EMTRICITABINE/TENOFOVIR DISOPROXIL: Truvada

Class: Antiretroviral Agent, Reverse Transcriptase Inhibitor Dosage Forms. Oral Tablet: (Emtricitabine/Tenofovir) 100 mg/150 mg, 133 mg/200 mg, 167 mg/250 mg, 200 mg/300 mg Common FDA Label Indication, Dosing, and Titration. Treatment of HIV-1 infection in combination with other antiretroviral agents: Adults and Children ≥35 kg, Emtricitabine/Tenofovir 200 mg/300 mg po daily; Children <35 kg, weight-based dosing Preexposure prophylaxis (PrEP) for prevention of HIV-1 infection in adults who are at high risk for acquiring HIV: Emtricitabine/Tenofovir 200 mg/300 mg po daily (high risk is defined as inconsistent condom use, incarcerated, drug, and alcohol dependence) Off-Label Uses. Treatment of hepatitis B in patients with antiviral-resistant HBV or coinfection with HIV: Emtricitabine/Tenofovir 200 mg/300 mg po daily MOA. Emtricitabine is a cytidine analogue while tenofovir is an analogue of adenosine 5'-monophosphate. Each drug interferes with HIV viral RNA-dependent DNA polymerase resulting in inhibition of viral replication. Drug Characteristics: Emtricitabine/Tenofovir Disoproxil Dose Adjustment Hepatic Not required Absorption Emtricitabine F = 92%; tenofovir F = 25%, no food effect Dose Adjustment Renal CrCl = 30-49 mL/min, increase dose interval to 48 h; CrCl <30 mL/min, avoid Distribution Emtricitabine, saliva, semen; tenofovir, lymphocytes Dialyzable No Metabolism Minimal; tenofovir induces P-glycoprotein Pregnancy Category B Elimination Emtricitabine, renal 86% (unchanged) with half-life of 10 h; tenofovir, renal 70-80% with half-life of 17 h Lactation Weigh risks and benefits Pharmacogenetics Resistance is associated with HIV mutations Contraindications Do not use for preexposure prophylaxis in patients with unknown or HIV-1 positive status. Only for use in combination with other antiretrovirals Black Box Warnings Hepatitis B, lactic acidosis, drug resistance with preexposure prophylaxis

ENTECAVIR: Baraclude, Various

Class: Antiretroviral Agent, Reverse Transcriptase Inhibitor Dosage Forms. Oral Tablet: 0.5 mg, 1 mg; Oral Solution: 0.05 mg/1 mL Common FDA Label Indication, Dosing, and Titration. Treatment of chronic HBV infection: Adults, 0.5-1 mg po daily; Children, weight-based dosing for patients ≤30 kg Off-Label Uses. HBV reinfection prophylaxis, HIV/HBV coinfection: Adults, 0.5-1 mg po daily MOA. Intracellularly phosphorylated to guanosine triphosphate which competes with natural substrates to effectively inhibit HBV polymerase; enzyme inhibition blocks reverse transcriptase activity thereby reducing viral DNA synthesis. Drug Characteristics: Entecavir Dose Adjustment Hepatic Not required Absorption F approaches 100%, food decreases absorption by 50% Dose Adjustment Renal CrCl <50 mL/min, increase dosing interval Distribution Extensive tissue Dialyzable Yes, administer after dialysis Metabolism Not metabolized Pregnancy Category C Elimination Renal 60-70% with half-life of 140 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications None Black Box Warnings HIV resistance in chronic hepatitis B patients with unrecognized or untreated HIV infection; discontinuation of therapy may result in disease exacerbation; lactic acidosis Medication Safety Issues: Entecavir Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

ETANERCEPT: Enbrel, Erelzi

Class: Antirheumatic, Disease Modifying Dosage Forms. Solution Auto-injector: 50 mg/1 mL; Solution Prefilled Syringe: 25 mg/0.5 mL, 50 mg/1 mL; Powder for Reconstitution: 25 mg Common FDA Label Indication, Dosing, and Titration. Ankylosing spondylitis: Adults, 50 mg sq once per wk or 25 mg sq twice per wk Polyarticular juvenile idiopathic arthritis: Children ≥2 y of age and <63 kg, 0.8 mg/kg (max 50 mg) sq once per wk; ≥63 kg, 50 mg once per wk Plaque psoriasis: Adults, 50 mg twice per wk × 3 mo, then 50 mg sq once per wk Psoriatic arthritis: Adults, 50 mg sq once per wk or 25 mg sq twice per wk Rheumatoid arthritis: Adults, 50 mg sq once per wk or 25 mg sq twice per wk Off-Label Uses. Acute graft-versus-host disease: Adults, 0.4 mg/kg sq (max 25 mg/dose) twice per wk × 8 wk MOA. Etanercept is a recombinant DNA-derived protein composed of tumor necrosis factor receptor (TNFR) linked to the Fc portion of human IgG1. Etanercept binds to soluble human tumor necrosis factor alpha (TNF-alpha) with the p55 and p75 cell surface TNF receptors. Drug Characteristics: Etanercept Dose Adjustment Hepatic Not required Absorption F = 60% Dose Adjustment Renal Not required Distribution Vd = 1.78-3.39 L/m2 Dialyzable Unknown Metabolism Not metabolized Pregnancy Category B Elimination Half-life of 102 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity, sepsis Black Box Warnings Serious infections, malignancies Medication Safety Issues: Etanercept Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Levbid No

BENZONATATE: Tessalon Perles, Various

Class: Antitussive Dosage Forms. Oral Capsule, Liquid Filled: 100 mg, 150 mg, 200 mg Common FDA Label Indication, Dosing, and Titration. Cough: Adults and Children >10 y of age, 100-200 mg po tid prn, max 600 mg/d Off-Label Uses. Endotracheal intubation hiccups: 100 mg po × 1 dose, may repeat in 4 h MOA. Benzonatate acts peripherally by anesthetizing the stretch receptors located in the respiratory passages, lungs, and pleura by dampening their activity and thereby reducing the cough reflex at its source. Drug Characteristics: Benzonatate Dose Adjustment Hepatic Not required Absorption Clinical onset of action, 15-20 min Dose Adjustment Renal Not required Distribution Unknown Dialyzable Not dialyzable Metabolism Unknown Pregnancy Category C Elimination Unknown Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None Medication Safety Issues: Benzonatate Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No Do not bite, chew, or open; swallow capsule whole No No No

ANASTROZOLE: Arimidex, Various

Class: Aromatase Inhibitor Dosage Forms. Tablet: 1 mg Common FDA Label Indication, Dosing, and Titration. Breast cancer, adjuvant, postmenopausal, hormone receptor-positive: 1 mg po daily × 5 y (or × 10 y when used in combination with tamoxifen) Breast cancer, advanced or metastatic, postmenopausal, following tamoxifen therapy: 1 mg po daily, until tumor progression Off-Label Uses. Breast cancer, neoadjuvant, postmenopausal, hormone receptor-positive: 1 mg po daily for 3-6 mo Breast cancer, prophylaxis, postmenopausal women at high risk: 1 mg po daily × 5 y MOA. Adrenally generated androstenedione is the primary source of estrogen in postmenopausal women and is converted to estrone by aromatase. Anastrozole is a nonsteroidal aromatase inhibitor. Drug Characteristics: Anastrozole Dose Adjustment Hepatic Severe, use with caution Absorption F = 80%, minimal food effect Dose Adjustment Renal Not required Distribution Vd = 300-500 L; 40% protein bound Dialyzable Unknown Metabolism 85% metabolism but not by CYP Pregnancy Category X Elimination Renal 10% with a half-life of 50 h Lactation Avoid Pharmacogenetics For use in patients with estrogen receptor-positive tumors Contraindications Hypersensitivity and pregnancy Black Box Warnings None Medication Safety Issues: Anastrozole Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No Yes Aromasin, letrozole No

ALPRAZOLAM: Xanax, Various

Class: Benzodiazepine, Short or Intermediate. C-IV Dosage Forms. Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg; Tablet, Disintegrating: 0.25 mg, 0.5 mg, 1 mg, 2 mg; Tablet, Extended Release: 0.5 mg, 1 mg, 2 mg, 3 mg; Solution: 1 mg/mL Common FDA Label Indication, Dosing, and Titration. Anxiety: immediate-release, orally disintegrating tablet or solution, 0.25-0.5 mg po tid; max daily dose, 4 mg in divided doses Panic disorder, with or without agoraphobia: immediate-release or orally disintegrating tablets, 0.5 mg po tid, extended-release 3-6 mg po daily; dose may be increased every 3-4 d by <1 mg/d Off-Label Uses. Alcohol withdrawal syndrome: 0.5-1 mg po bid × 7-10 d MOA. Enhances the postsynaptic effect of the inhibitory neurotransmitter, γ-aminobutyric acid (GABA). Drug Characteristics: Alprazolam Dose Adjustment Hepatic Reduce initial dose to 0.25 mg in advanced liver disease Absorption F = 80%, no effect of food on absorption of immediate release, food increases absorption of ER formulation by 25% Dose Adjustment Renal Not required Distribution Vd = 0.9-1.2 L/kg; 80% protein bound Dialyzable Not dialyzable Metabolism Hepatic 20-30%; major substrate of CYP3A4/5 Pregnancy Category D Elimination Renal 80% with a half-life of 10-12 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to benzodiazepines, narrow-angle glaucoma, concurrent ketoconazole, or itraconazole Black Box Warnings Concurrent use with opioids Medication Safety Issues: Alprazolam Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XRALPRAZolamALPRAZolam XRNoZantac, LORazepam, XopenexAvoid

DIAZEPAM: Valium, Various

Class: Benzodiazepine. C-IV Dosage Forms. Oral Tablet: 2 mg, 5 mg, 10 mg; Oral Solution: 1 mg/mL, 5 mg/mL; Gel, Rectal Syringe: 2.5 mg, 10 mg, 20 mg Common FDA Label Indication, Dosing, and Titration. Alcohol withdrawal syndrome: 10 mg po tid-qid in first 24 h, then 5 mg po tid-qid prn Anxiety: Adults, 2-10 mg po bid-qid; Children, 1-2.5 mg po tid-qid Seizure, adjunct: Adults, 2-10 mg po bid-qid; Children, 1-2.5 mg po tid-qid Off-Label Uses. Benzodiazepine withdrawal syndrome: 10 mg po tid-qid in first 24 h, then 5 mg po tid-qid prn MOA. Enhanced postsynaptic effect of the inhibitory neurotransmitter, γ-aminobutyric acid (GABA) Drug Characteristics: Diazepam Dose Adjustment Hepatic Use with caution Absorption F = 98%, high-fat meal may delay and decrease total absorption Dose Adjustment Renal Not required Distribution Vd = 1 L/kg; 99% protein bound Dialyzable Not dialyzable Metabolism Hepatic; substrate of CYP2C19 and CYP3A4/5 Pregnancy Category D Elimination Renal 75% with a half-life of 24-48 h Lactation Avoid Pharmacogenetics Use with caution in CYP2C19 poor metabolizers Contraindications Hypersensitivity to benzodiazepines, narrow-angle glaucoma, severe liver disease, myasthenia gravis, sleep apnea, respiratory insufficiency, children <6 mo Black Box Warnings Concurrent use with opioids Medication Safety Issues: Diazepam Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoDiazePAMNoNoLORazepam, diltiazemAvoid

ALENDRONATE: Fosamax, Binosto, Various

Class: Bisphosphonate Dosage Forms. Tablet: 5 mg, 10 mg, 35 mg, 40 mg, 70 mg; Solution: 70 mg/75 mL; Effervescent Tablet: 70 mg Common FDA Label Indication, Dosing, and Titration. Postmenopausal osteoporosis, prophylaxis: 5 mg po daily or 35 mg po once weekly Postmenopausal osteoporosis, treatment: 10 mg po daily or 70 mg po once weekly Osteoporosis, treatment, male: 10 mg once daily or 70 mg po once weekly Glucocorticoid-induced osteoporosis in those with daily dosage ≥7.5 mg of prednisone (or equivalent): 5 mg po once daily; a dose of 10 mg po once daily should be used in postmenopausal females who are not receiving estrogen Paget disease: 40 mg po daily for 6 mo Off-Label Uses. Postoperative knee arthroplasty: 10 mg po once daily beginning after knee arthroplasty for up to 1 y Osteogenesis imperfecta: 10 mg po once daily or 70 mg po once weekly MOA. Alendronate binds to bone hydroxyapatite, and at the cellular level, inhibits osteoclast activity, thereby inhibiting bone resorption and modulating bone metabolism. Drug Characteristics: Alendronate Dose Adjustment Hepatic Not required Absorption F <1%, food impairs absorption, take 30-60 min prior to meal Dose Adjustment Renal CrCl <35 mL/min, avoid use Distribution Vd = 2576 L; 78% protein bound Dialyzable Not dialyzable Metabolism Not metabolized Pregnancy Category C Elimination Renal 50% with a half-life in bone of >10 y Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Esophageal abnormalities, hypersensitivity, hypocalcemia, inability to sit or stand upright for at least 30 min; increased risk for adverse esophageal effects Black Box Warnings None

ESZOPICLONE: Lunesta, Various

Class: Nonbarbiturate Hypnotic. C-IV Dosage Forms. Oral Tablet: 1 mg, 2 mg, 3 mg Common FDA Label Indication, Dosing, and Titration. Insomnia: 1 mg po immediately before bedtime; dosing may be initiated at or titrated to 2-3 mg Off-Label Uses. None MOA. The exact mechanism of action of eszopiclone, a non-benzodiazepine hypnotic, is unknown. It is believed that eszopiclone binds to or interacts allosterically at the GABA-receptor complex domain. Drug Characteristics: Eszopiclone Dose Adjustment Hepatic Severe impairment, 1 mg po qhs, max 2 mg/d Absorption F = 75%, high-fat meal delays absorption Dose Adjustment Renal Not required Distribution 52-59% protein bound Dialyzable Unknown Metabolism Extensive hepatic; substrate of CYP3A4/5 Pregnancy Category C Elimination Renal 75% with a half-life of 5-6 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to eszopiclone, history of complex sleep behavior Black Box Warnings Risk of complex sleep behaviors (sleepwalking, sleep driving, etc) Medication Safety Issues: Eszopiclone Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Neulasta Avoid

DEXMETHYLPHENIDATE: Focalin, Various

Class: CNS Stimulant. C-II Dosage Forms. Oral Tablet: 2.5 mg, 5 mg, 10 mg; Oral Capsule, Extended Release: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg Common FDA Label Indication, Dosing, and Titration. Attention-deficit hyperactivity disorder, methylphenidate-naive patients: Adults, immediate release 2.5 mg po bid (max 20 mg po daily) or extended release 10 mg po daily (max 40 mg/d); Children ≥6 y of age, immediate release 2.5 mg po bid (max 20 mg po daily) or extended release 5 mg po daily (max 30 mg/d) Attention-deficit hyperactivity disorder, currently using methylphenidate: Adults and Children ≥6 y of age, one-half the total daily dose of extended-release racemic methylphenidate; patients currently using dexmethylphenidate immediate release may be switched to the same daily dose of dexmethylphenidate extended release Off-Label Uses. None MOA. Amphetamines are noncatecholamine sympathomimetic amines with CNS stimulant activity. Amphetamines are thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. Drug Characteristics: Dexmethylphenidate Dose Adjustment Hepatic Not required Absorption F = 22-25%, minimal food effect Dose Adjustment Renal Not required Distribution Vd = 2.6 L/kg Dialyzable Unknown Metabolism Extensive via de-esterification Pregnancy Category C Elimination Minimal renal with a half-life of 3 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to amphetamines, MAOI use, drug dependence, glaucoma, tics, or history of Tourette syndrome Black Box Warnings Tolerance and dependence Medication Safety Issues: Dexmethylphenidate Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XL No Extended-release capsule, but may open No Methadone, Folotyn No

FELODIPINE: Plendil, Various

Class: Calcium Channel Blocker Dosage Forms. Oral Tablet, Extended Release: 2.5 mg, 5 mg, 10 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: 2.5-5 mg po once daily, may increase to 10 mg po once daily Off-Label Uses. Chronic stable angina: 2.5-5 mg po once daily, may increase to 10 mg po once daily MOA. Felodipine is a dihydropyridine calcium-channel-blocking drug with potent arterial and coronary vasodilating properties. A reflex increase in sympathetic tone (in response to vasodilation) counteracts the direct depressant effects on SA and AV nodal conduction. This renders felodipine ineffective in the treatment of supraventricular tachycardias. Drug Characteristics: Felodipine Dose Adjustment Hepatic Liver failure, reduce dose to 2.5 mg po daily Absorption F = 13-20%, no food effect Dose Adjustment Renal Not required Distribution Vd = 10 L/kg, protein binding 99% Dialyzable Not dialyzable Metabolism Extensive hepatic metabolism, CYP3A4/5 substrate; moderate CYP2C8 inhibitor Pregnancy Category C Elimination Renal 70% with a half-life of 26-33 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to felodipine Black Box Warnings None Medication Safety Issues: Felodipine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoDo not chew or crush ER tabletNoIsordil, pindolol, Pletal, PriLOSEC, Prinivil

DILTIAZEM: Cardizem, Cartia XT, Dilacor XR, Dilt-XR, Taztia XT, Tiazac, Various

Class: Calcium Channel Blocker Dosage Forms. Oral Tablet: 30 mg, 60 mg, 90 mg, 120 mg; Oral Capsule, Extended Release, 12 h: 60 mg, 90 mg, 120 mg; Oral Capsule, Extended Release, 24 h: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg; Oral Tablet, Extended Release, 24 h: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: Extended release, 12 h, 60-120 mg po bid, may titrate to 360 mg/d po; extended release, 24 h, 120-240 mg po daily, may titrate to 540 mg po daily Stable, chronic angina: Immediate release, 30 mg po qid, may titrate to 360 mg/d po; extended release, 24 h, 120 mg po daily, may titrate to 540 mg/d po Atrial arrhythmia and paroxysmal supraventricular tachycardia: 180-360 mg po daily (frequency of dosing based on formulation) Off-Label Uses. Hypertension: Children, 1.5-2 mg/kg/d po in 3-4 divided doses, may titrate to 3.5 mg/kg/d po MOA. Diltiazem is a calcium-channel-blocking drug that decreases heart rate, prolongs AV nodal conduction, and decreases arteriolar and coronary vascular tone. It also has negative inotropic properties. Drug Characteristics: Diltiazem Dose Adjustment Hepatic Dosage reduction may be needed Absorption F = 35-40% immediate release, F = 93-95% extended release; food decreases absorption Dose Adjustment Renal Not required Distribution Vd = 305-391 L; 77-93% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; substrate of CYP3A4/5, P-glycoprotein; moderate inhibitor of CYP3A4/5 Pregnancy Category C Elimination Renal 35% with a half-life of 3-6.6 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to diltiazem; hypotension; 2nd- or 3rd-degree AV block, sick sinus syndrome Black Box Warnings None

AMLODIPINE: Norvasc, Various

Class: Calcium Channel Blocker Dosage Forms. Tablet: 2.5 mg, 5 mg, 10 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: Children 6-17 y of age, 2.5-5 mg po daily; Adults, 5-10 mg po daily Stable angina: 5-10 mg po daily Variant angina: 5-10 mg po daily Off-Label Uses. Diabetic nephropathy: 5-15 mg po daily Raynaud phenomenon: 10 mg po daily MOA. Amlodipine is a long-acting dihydropyridine calcium-channel-blocking drug with potent arterial and coronary vasodilating properties. Drug Characteristics: Amlodipine Dose Adjustment Hepatic Reduce initial dose to 2.5 mg po daily in hepatic impairment Absorption F = 64-90%, no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd = 21 L/kg; 93% protein bound Dialyzable Not dialyzable Metabolism Hepatic, 90%; major substrate of CYP3A4/5 Pregnancy Category C Elimination Renal 10% with a half-life of 30-50 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to amlodipine Black Box Warnings None Medication Safety Issues: Amlodipine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoAmLODIPineNoNoaMILoride Navane, Norvir, VascorNo

BISOPROLOL: Zebeta, Various

Class: Cardioselective β-Adrenergic Blocker Dosage Forms. Oral Tablet: 5 mg, 10 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: 2.5-5 mg po daily, may titrate to max of 20 mg po daily Off-Label Uses. Angina: 5-20 mg po daily Atrial fibrillation: 2.5-10 mg po daily Heart failure: 1.25-10 mg po daily MOA. Bisoprolol is a cardioselective β-adrenergic blocker that decreases AV nodal conduction in supraventricular tachycardia and blockade of catecholamine-induced dysrhythmias. The antihypertensive mechanism is unknown, but contributing factors are renin blockade and decreases in myocardial contractility and cardiac output. Drug Characteristics: Bisoprolol Dose Adjustment Hepatic Initiate with 2.5 mg po daily, may titrate to max of 10 mg po daily Absorption F = 80%; food has no effect on absorption Dose Adjustment Renal Initiate with 2.5 mg po daily, may titrate to max of 10 mg po daily Distribution Protein binding 30%; distribution limited to extracellular fluid space and kidneys Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP3A4/5 Pregnancy Category C Elimination Renal 50% with a half-life of 9-12 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to bisoprolol, severe sinus bradycardia, 2nd- or 3rd-degree AV block, overt heart failure, cardiogenic shock Black Box Warnings None Medication Safety Issues: Bisoprolol Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoNoNoDiaBeta, ZetiaNo

DONEPEZIL: Aricept, Various

Class: Central Cholinesterase Inhibitor Dosage Forms. Oral Tablet: 5 mg, 10 mg, 23 mg; Oral Disintegrating Tablet: 5 mg, 10 mg Common FDA Label Indication, Dosing, and Titration. Alzheimer disease, dementia (mild-moderate): 5 mg po daily hs, may titrate to max 10 mg/d Alzheimer disease, dementia (moderate-severe): 5 mg po daily qhs, may titrate to 10 mg/d at 4-6 wk to max 23 mg/d (immediate-release tablet) or 10 mg/d (disintegrating tablet) Off-Label Uses. Multi-infarct dementia: 5-10 mg po daily hs MOA. Donepezil enhances the action of acetylcholine by reversibly inhibiting acetylcholinesterase (AChE), the enzyme responsible for its hydrolysis. It has a high degree of selectivity for AChE in the CNS, which might explain the relative lack of peripheral side effects. Drug Characteristics: Donepezil Dose Adjustment Hepatic Not required Absorption F = 100%; no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd = 12 L/kg; 96% protein bound Dialyzable Unknown Metabolism Extensive hepatic; minor substrate of CYP3A4/5 and CYP2D6 Pregnancy Category C Elimination Renal 57% with a half-life of 70 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to donepezil or piperidine derivatives Black Box Warnings None Medication Safety Issues: Donepezil Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria ODT No Disintegrating tablet, 23-mg tablet No AcipHex No

BACLOFEN: Lioresal, Various

Class: Centrally Acting Skeletal Muscle Relaxant Dosage Forms. Oral Tablet: 5 mg, 10 mg, 20 mg Common FDA Label Indication, Dosing, and Titration. Spasticity: 5 mg po tid; may increase dose in 5-15 mg/d increments; max dose in Adults and Children ≥12 y of age, 80 mg/d po; max dose in Children 8-12 y of age, 60 mg/d; max dose in Children <8 y of age, 40 mg/d po Off-Label Uses. Intractable hiccoughs: 5 mg po bid, increasing to 15-45 mg/d in 3 divided doses; or 10-20 mg 2-3 times daily MOA. Baclofen inhibits both monosynaptic and polysynaptic reflexes at the spinal level, possibly by hyperpolarization of afferent terminals, although actions at supraspinal sites may also occur and contribute to its clinical effect. Baclofen is an analogue of γ-aminobutyric acid (GABA), but there is no conclusive evidence that actions on GABA systems are involved in the production of its clinical effects. Drug Characteristics: Baclofen Dose Adjustment Hepatic Not required Absorption F = 100%, no effect of food on absorption Dose Adjustment Renal In patients with renal dysfunction, monitor carefully for toxicity and reduce dose as necessary Distribution Vd = 59.1 L; 30% protein bound Dialyzable Yes Metabolism Limited hepatic metabolism Pregnancy Category C Elimination Renal 60-80% with a half-life of 3-7 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings Avoid abrupt discontinuation of oral or intrathecal product Medication Safety Issues: Baclofen Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No Yes, intrathecal Bactroban

CARISOPRODOL: Soma, Various

Class: Centrally Acting Skeletal Muscle Relaxant. C-IV Dosage Forms. Oral Tablet: 250 mg, 350 mg Common FDA Label Indication, Dosing, and Titration. Disorder of musculoskeletal system: 250-350 mg po tid and hs Off-Label Uses. None MOA. Carisoprodol blocks interneuronal activity in descending reticular formation and spinal cord, resulting in muscle relaxation. Drug Characteristics: Carisoprodol Dose Adjustment Hepatic Use lower doses initially and increase dose carefully in patients with hepatic failure Absorption Unknown Dose Adjustment Renal Not required Distribution Unknown Dialyzable Yes Metabolism Hepatic; major substrate of CYP2C19 Pregnancy Category C Elimination Renal with a half-life of 8 h Lactation Avoid Pharmacogenetics CYP2C19 poor metabolizers at increased risk of toxicity Contraindications Hypersensitivity to carisoprodol or meprobamate, acute intermittent porphyria Black Box Warnings None Medication Safety Issues: Carisoprodol Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No Avoid

ETHINYL ESTRADIOL AND ETONOGESTREL RING: NuvaRing

Class: Contraceptive Dosage Forms. Vaginal Ring: Releases ethinyl estradiol 15 mcg/d and etonogestrel 0.12 mg/d Common FDA Label Indication, Dosing, and Titration. Contraception: 1 ring inserted vaginally by patient and remaining continuously for 3 wk, then removed for 1 wk; a new ring is then inserted, regardless whether bleeding has or has not finished Off-Label Uses. Treatment of menorrhagia (dose same as for contraception) Dysfunctional uterine bleeding (dose same as for contraception) MOA. See Preface C Card: General Content Related to All Oral Contraceptives Drug Characteristics: Ethinyl Estradiol and Etonogestrel Ring Dose Adjustment Hepatic Not required Absorption F = 40% for ethinyl estradiol; F = 100% for etonogestrel Dose Adjustment Renal Not required Distribution Vd = 45 L/kg for ethinyl estradiol; Vd = 201-245 L for etonogestrel; highly protein bound Dialyzable Not dialyzable Metabolism Hepatic via CYP3A4/5 for both components Pregnancy Category X Elimination Ethinyl estradiol, renal with a half-life of 24 h; etonogestrel, renal with half-life of 23-28 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to ethinyl estradiol or progestin component; history of thromboembolic disorders, endometrial cancer, uncontrolled hypertension, pregnancy; smoking 15 or more cigarettes per day Black Box Warnings

CELECOXIB: Celebrex, Various

Class: Cyclooxygenase-2 Inhibitor Dosage Forms. Oral Capsule: 50 mg, 100 mg, 200 mg, 400 mg Common FDA Label Indication, Dosing, and Titration. Osteoarthritis: 100 mg po bid or 200 mg po daily Rheumatoid arthritis: Adults, 100-200 mg po bid; Children >2 y of age, 10-25 kg, 50 mg po bid, >25 kg, 100 mg po bid Ankylosing spondylitis: 100 mg po bid or 200 mg po daily; may increase to 400 mg po daily if not improved within 6 wk Acute pain, primary dysmenorrhea: 200 mg po bid prn Off-Label Uses. Acute gout: 200 mg po bid × 5-7 d MOA. Inhibition of the COX-2 enzyme isoform is thought to be responsible for the anti-inflammatory effects of NSAIDs. Drug Characteristics: Celecoxib Dose Adjustment Hepatic Moderate: reduce dose by 50%; severe: avoid use Absorption Well absorbed, food enhances absorption Dose Adjustment Renal CrCl <30 mL/min: avoid use Distribution Vd = 400 L; 97% protein bound Dialyzable Unknown Metabolism Hepatic 97%; major substrate of CYP2C9; moderate inhibitor of CYP2C8 and 2D6 Pregnancy Category C prior to 30 wk gestation; D from 30 wk gestation Elimination Renal 27% with a half-life of 11 h Lactation Weigh risks and benefits Pharmacogenetics Consider dose reduction of 50% in CYP2C9 poor metabolizers Contraindications Asthma, urticaria, or allergic-type reaction following aspirin or other NSAID administration; CABG surgery, treatment of perioperative pain, hypersensitivity to sulfonamides Black Box Warnings GI toxicity, cardiotoxicity, CABG Medication Safety Issues: Celecoxib Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No CeleBREX No No CeleXA, Cerebyx, Cervarix, Clarinex Avoid in certain circumsta

DIGOXIN: Lanoxin, Various

Class: Digitalis Glycoside Dosage Forms. Oral Tablet: 62.5 mcg, 125 mcg, 250 mcg; Oral Solution: 0.05 mg/mL Common FDA Label Indication, Dosing, and Titration. Atrial fibrillation: Loading dose of 0.25 mg po q2h to a total dose of 1.5 mg, then 0.125-0.375 mg po daily Heart failure: Premature Infant, loading dose of 20 mcg/kg, then 5 mcg/kg/d; Full-term Infant to Children 2 mo of age, loading dose of 30 mcg/kg, then 8-10 mcg/kg/d; Children 2-23 mo of age, loading dose of 40-50 mcg/kg, then 10-12 mcg/kg/d; Children 2-10 y of age, loading dose of 30-40 mcg/kg (solution), then 8-10 mcg/kg/d; Children >10 y of age, loading dose of 0.75-1.5 mg/kg, then 0.125-0.5 mg/kg po; Adults, loading dose of 0.5-0.75 mg po once, followed by 0.125-0.375 mg po q6-8h to achieve response, followed by 0.125-0.5 mg po daily Supraventricular tachyarrhythmia: Loading dose of 0.75-1.5 mg po (divided into 3 doses, 50% of total dose initially, followed by 25% of total dose at 6-8 h intervals later), then 0.125-0.5 mg po daily Off-Label Uses. Fetal tachycardia, supraventricular tachycardia: 0.125-0.375 mg po daily (administered to mother) MOA. Digitalis glycosides exert positive inotropic effects through improved availability of calcium to myocardial contractile elements, thereby increasing cardiac output in heart failure. Antiarrhythmic actions are caused primarily by an increase in AV nodal refractory period via increased vagal tone, sympathetic withdrawal, and direct mechanisms. Drug Characteristics: Digoxin Dose Adjustment Hepatic Not required Absorption F = 60-80% (tablet); food reduces absorption rate Dose Adjustment Renal Mild-to-moderate renal impairment, 125 mcg po daily; severe renal impairment, 62.5 mcg po daily; titrate q2wk Distribution Vd = 4-7 L/kg; 25% protein bound Dialyzable Not dialyzable Metabolism Modest hepatic; substrate of P-glycoprotein Pregnancy Category C Elimination Renal 57-50% (unchanged) with a half-life of 1.3-2.2 d Lactation Compatible Pharmacogenetics None known Contraindications Hypersensitivity to digoxin, ventricular fibrillation Black Box Warnings None

EPOETIN: Epogen, Procrit, Retacrit

Class: Erythropoietic Stimulating Agent Dosage Forms. Injection Solution: 2000 units/mL, 3000 units/mL, 4000 units/mL, 10 000 units/mL, 20 000 units/mL, 40 000 units/mL Common FDA Label Indication, Dosing, and Titration. Anemia of cancer chemotherapy: Children, 600 units/kg (max 40 000 units) IV once weekly; Adults, 40 000 units sq weekly; dose adjusted based on changes in Hgb levels Anemia of chronic renal failure: Children, 50 units/kg IV or sq 3 times per week; Adults not on dialysis, 10 000 units sq weekly, 20 000 units sq every other week, 30 000 units every 3rd wk, or 40 000 units sq every 4 wk; Adults on dialysis, 50-100 units/kg IV or sq 3 times per week; dose adjusted based on changes in Hgb levels Perioperative collection of blood for allogeneic infusion: 300 units/kg/d sq for 10 d before surgery, on the day of surgery, and for 4 d postoperatively Off-Label Uses. Anemia due to myelodysplastic syndrome: 40 000-60 000 units sq 1-3 times/wk MOA. Epoetin alfa is recombinant human erythropoietin. It binds to the erythropoietin receptor on erythroid progenitor cells, stimulating production/differentiation of mature red cells. Drug Characteristics: Epoetin Dose Adjustment Hepatic Not required Absorption Subcutaneously, F = 22-33% Dose Adjustment Renal Not required Distribution Vd = 52 mL/kg Dialyzable Not dialyzable Metabolism Hepatic via galactose receptors Pregnancy Category C Elimination Renal (minimal) with a half-life of 4-13 h (in CKD patients), 16-67 h (in anemic cancer patients) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to epoetin, albumin, uncontrolled hypertension Black Box Warnings Increased CV, stroke, DVT, mortality risk; cancer recurrence Medication Safety Issues: Epoetin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Neupogen, darbepoetin No

ESTRADIOL ORAL: Estrace, Various

Class: Estrogen Dosage Forms. Oral Tablet: 0.5 mg, 1 mg, 2 mg Common FDA Label Indication, Dosing, and Titration. Abnormal vasomotor function (moderate to severe), menopause: 1-2 mg po daily for 21 d followed by 7 d off Atrophic vulva or vagina (moderate to severe), menopause: Oral tablet, 1-2 mg po daily in a cyclical pattern (3 wk on, 1 wk off) Breast cancer, metastatic, for palliation only: 10 mg po tid × 3 mo Carcinoma of prostate, advanced, androgen-dependent, for palliation only: 1-2 mg po tid Decreased estrogen level, secondary to hypogonadism, castration, or primary ovarian failure: 1-2 mg po daily Postmenopausal osteoporosis, prophylaxis: 0.5 mg po daily for 23 d followed by 5 d off Off-Label Uses. None MOA. Estradiol (17β-estradiol; E2) is the most potent of the naturally occurring estrogens and the major estrogen secreted during the reproductive years. Estradiol and other estrogens produce characteristic effects on specific tissues (such as breast), cause proliferation of vaginal and uterine mucosa, increase calcium deposition in bone, and accelerate epiphyseal closure after initial growth stimulation. Drug Characteristics: Estradiol Oral Dose Adjustment Hepatic Not required Absorption F = 40%, food has no effect on absorption Dose Adjustment Renal Not required Distribution Widely distributed; 98% protein bound Dialyzable Yes Metabolism Extensive hepatic; substrate of many CYP pathways, major substrate of CYP3A4/5, 1A2, P-glycoprotein Pregnancy Category X Elimination Renal with a half-life of 21 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to estradiol; history of thromboembolic disorders, breast cancer, any estrogen-dependent neoplasm, known or suspected pregnancy Black Box Warnings Endometrial and breast cancer risk, dementia risk; should not be used to reduce CV risk; secondary exposure risk (transdermal solution)

ESTRADIOL TRANSDERMAL PATCH: Alora, Climara, Minivelle, Menostar, Vivelle-DOT, Various

Class: Estrogen Dosage Forms. Transdermal Patch, Once Weekly or Twice Weekly: 0.014 mg/d, 0.025 mg/d, 0.0375 mg/d, 0.05 mg/d, 0.06 mg/d, 0.075 mg/d, 0.1 mg/d Common FDA Label Indication, Dosing, and Titration. Abnormal vasomotor function or atrophic vagina or vulva (moderate-severe), menopause: 0.025-0.0375 mg/d patch applied to the skin twice weekly (dose and frequency of patch change dependent on specific product selected); adjust dose as necessary based on response and attempt taper and discontinuation at 3-6 mo intervals Postmenopausal osteoporosis, prophylaxis: 0.014-0.025 mg/d patch applied to the skin once or twice weekly (dose and frequency of patch change dependent on specific product selected); adjust dose as necessary based on response Off-Label Uses. None MOA. Estradiol (17β-estradiol; E2) is the most potent of the naturally occurring estrogens and the major estrogen secreted during the reproductive years. Estradiol and other estrogens produce characteristic effects on specific tissues (such as breast), cause proliferation of vaginal and uterine mucosa, increase calcium deposition in bone, and accelerate epiphyseal closure after initial growth stimulation. Drug Characteristics: Estradiol Transdermal Patch Dose Adjustment Hepatic Not required Absorption F improved by bypassing first-pass metabolism via topical administration Dose Adjustment Renal Not required Distribution Widely distributed; 98% protein bound Dialyzable Yes Metabolism Extensive hepatic; substrate of many CYP pathways, major substrate of CYP3A4/5, 1A2, P-glycoprotein Pregnancy Category X Elimination Renal with a half-life of 21 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to estradiol; history of thromboembolic disorders, breast cancer, any estrogen-dependent neoplasm, pregnancy Black Box Warnings Endometrial and breast cancer risk, dementia risk; should not be used to reduce CV risk; secondary exposure risk (transdermal solution)

EDOXABAN: Savaysa

Class: Factor Xa Inhibitor Dosage Forms. Tablet: 15 mg, 30 mg, 60 mg Common FDA Label Indication, Dosing, and Titration. Atrial fibrillation (prophylaxis, to reduce the risk of stroke): 60 mg po once daily Deep vein thrombosis or pulmonary embolism (treatment, following 5-10 d of parenteral anticoagulant): Adults, weight >60 kg, 60 mg po once daily, weight ≤60 kg, 30 mg po once daily Off-Label Uses. Prophylaxis of thrombosis post arthroplasty of knee: 30 mg po daily, beginning 6-24 h postoperatively and continuing for 11-14 d MOA. Edoxaban is a selective inhibitor of FXa. By inhibiting FXa, edoxaban decreases thrombin generation and thrombus development. Drug Characteristics: Edoxaban Dose Adjustment Hepatic Moderate to severe, not recommended Absorption F = 62%, no food effect Dose Adjustment Renal For nonvalvular atrial fibrillation and CrCl >95 mL/min, do not use; for CrCl 15-50 mL/min, 30 mg once daily; for CrCl <15 mL/min, avoid Distribution Vd = 107 L; 55% protein bound Dialyzable Minimal Metabolism Minimal, substrate of PgP Pregnancy Category C Elimination Renal 50% with a half-life of 10-14 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity, active bleeding Black Box Warnings Premature discontinuation increases risk of thrombotic events; increased risk of spinal hematoma with spinal puncture or neuraxial anesthesia; reduced efficacy in nonvalvular atrial fibrillation patients with CrCl >95 mL/min

APIXABAN: Eliquis

Class: Factor Xa Inhibitor Dosage Forms. Tablet: 2.5 mg, 5 mg Common FDA Label Indication, Dosing, and Titration. Atrial fibrillation, nonvalvular (prophylaxis, to reduce the risk of stroke): 5 mg po bid Hip or knee replacement surgery (prophylaxis, to reduce the risk of deep vein thrombosis and pulmonary embolism): 2.5 mg po bid × 12 d (knee replacement) or 35 d (hip replacement); start 12-24 h postoperatively Deep vein thrombosis or pulmonary embolism (treatment and to reduce the future risk): 10 mg po bid × 7 d, then 5 mg po bid Off-Label Uses. Heparin-induced thrombocytopenia with thrombosis, hemodynamically stable patients or after initial therapy with parenteral non-heparin anticoagulant: with thrombosis, 10 mg po bid × 7 d, then 5 mg po bid; without thrombosis, 5 mg po bid MOA. Apixaban is a selective inhibitor of FXa. By inhibiting FXa, apixaban decreases thrombin generation and thrombus development. Drug Characteristics: Apixaban Dose Adjustment Hepatic Severe, not recommended Absorption F = 50%, no food effect Dose Adjustment Renal In atrial fibrillation patients, if 2 or more of following characteristics, reduce dose to 2.5 mg bid: age ≥80 y, body weight ≤60 kg, or SCr ≥1.5 mg/dL Distribution Vd = 21 L; 87% protein bound Dialyzable Use same dose in patients undergoing hemodialysis Metabolism Hepatic, primarily via CYP3A4/5 Pregnancy B Elimination Renal 27% with a half-life of 12 h Lactation Weigh risks and benefits Pharmacogenetics None known ContraindicationsHypersensitivity, active bleedingBlack Box WarningsPremature discontinuation increases risk of thrombotic events; increased risk of spinal hematoma with spinal puncture or neuraxial anesthesiav

CEPHALEXIN: Keflex, Various

Class: First-Generation Cephalosporin Dosage Forms. Powder for Oral Suspension: 125 mg/5 mL, 250 mg/5 mL; Oral Tablet: 250 mg, 500 mg; Oral Capsule: 250 mg, 500 mg, 750 mg Common FDA Label Indication, Dosing, and Titration. Infection of skin and/or subcutaneous tissue: Adults, 500 mg po q12h; Children, 25-50 mg/kg/d po divided q6h to q12h Osteomyelitis: Adults, 250 mg-1 g po q6h; Children, 25-100 mg/kg/d po divided q6h, max 4 g/d Otitis media, respiratory tract infection, urinary tract infection: Adults, 250 mg-1 g po q6h; Children, 25-100 mg/kg/d po divided q6h, max 4 g/d Streptococcal pharyngitis: Adults, 500 mg po q12h × 10 d; Children, 25-50 mg/kg/d po divided q6h × 10 d, max 4 g/d Off-Label Uses. Bacterial endocarditis; prophylaxis for high-risk patients; dental, respiratory, or infected skin/skin structure or musculoskeletal tissue procedures: Adults, 2 g po 30-60 min prior to procedure; Children, 50 mg/kg 30-60 min prior to procedure MOA. Cephalexin is a 1st-generation cephalosporin that inhibits bacterial wall synthesis of actively dividing cells by binding to ≥1 penicillin-binding proteins (PBPs). Most gram-positive bacteria, including non-penicillinase and penicillinase-producing staphylococci, and streptococci. Activity against gram-negative bacteria is less than that observed with the 2nd-and 3rd-generation cephalosporins and is primarily restricted to Escherichia coli, Klebsiella, and Proteus mirabilis. Drug Characteristics: Cephalexin Dose Adjustment Hepatic Not required Absorption F = 90%, food has little effect on absorption Dose Adjustment Renal CrCl <50 mL/min, max dose 500 mg q12h Distribution Widely into body tissues and fluids Dialyzable Dialyzable by both hemodialysis and peritoneal dialysis Metabolism Not metabolized Pregnancy Category B Elimination Renal 80-100% with a half-life of 1 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to cephalosporins Black Box Warnings None

CIPROFLOXACIN ORAL: Cipro, Cipro XR, Various

Class: Fluoroquinolone Antibiotic Dosage Forms. Microcapsules for Oral Suspension: 250 mg/5 mL, 500 mg/5 mL; Oral Tablet: 100 mg, 250 mg, 500 mg, 750 mg; Oral Tablet, Extended Release: 500 mg, 1000 mg Common FDA Label Indication, Dosing, and Titration. Anthrax, postexposure prophylaxis: Adults, 500 mg po q12h × at least 60 d, Children, 15 mg/kg po bid × at least 60 d, max 500 mg/dose Bacterial prostatitis, chronic: 500 mg po q12h × 28 d Bronchitis, lower respiratory tract infection, infection of bone, skin, or soft tissue, sinusitis: 500-750 mg po q12h × 7-14 d Urinary tract infectious disease: Immediate release, 250-500 mg po q12h × 3 d, or extended release, 500 mg q24h × 3 d Off-Label Uses. Traveler's diarrhea: 750 mg po as a single dose (mild); 500 mg po bid × 3 d (severe) MOA. Ciprofloxacin is a fluoroquinolone that inhibits bacterial DNA gyrase. It is highly active against aerobic, gram-negative bacilli. Drug Characteristics: Ciprofloxacin Oral Dose Adjustment Hepatic Not required Absorption F = 50-85%, minor food effect Dose Adjustment Renal CrCl 30-50 mL/min, 250-500 mg q12h; CrCl 5-29 mL/min, 250-500 mg q18h Distribution Widespread (bile, CSF, gynecologic tissues, liver, lung, prostate, peritoneum, synovial fluid, sputum, etc) Dialyzable Dialyzable by both hemodialysis and peritoneal dialysis. Give 250-500 mg q24h after dialysis Metabolism Not metabolized; substrate of P-glycoprotein; strong inhibitor of CYP1A2 Pregnancy Category C Elimination Renal 30-57% with a half-life of 3-6 h Lactation Weigh risks and benefits Pharmacogenetics Serious and sometimes fatal hemolytic reactions may occur in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Contraindications Hypersensitivity to ciprofloxacin or other quinolones, concomitant tizanidine Black Box Warnings Myasthenia gravis, tendon inflammation and rupture, peripheral neuropathy, CNS effects, cardiac, dermatologic and hypersensitivity reactions, aortic dissection and rupture, hypoglycemia, mental health adverse effects Medication Safety Issues: Ciprofloxacin Oral Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XR No XR formulation No Ceftin,

BIMATOPROST: Lumigan, Latisse, Various

Class: Prostaglandin, Antiglaucoma Agent, Cosmetic Agent for Eyelash Growth Dosage Forms. Ophthalmic Solution: 0.01%, 0.03% Common FDA Label Indication, Dosing, and Titration. Ocular hypertension and open-angle glaucoma: Adults and Adolescents ≥16 y of age, 1 drop in affected eye(s) daily in the evening Hypotrichosis of the eyelashes: Adults and Children ≥5 y of age, 1 drop nightly to clean, upper eyelid margin at base of eyelashes, blot excess, repeat with new sterile applicator to opposite eyelid, do not apply to lower eyelids Off-Label Uses. None MOA. Bimatoprost is a synthetic prostaglandin analogue. Bimatoprost lowers intraocular pressure (IOP) by increasing the outflow of aqueous humor through both the trabecular meshwork and uveoscleral drainage systems. The exact mechanism of action for bimatoprost in stimulating eyelash growth is unknown. Drug Characteristics: Bimatoprost Dose Adjustment Hepatic Not required Absorption Systemic absorption following ocular instillation is very low Dose Adjustment Renal Not required Distribution 88% protein binding after systemic absorption Dialyzable Not dialyzable Metabolism Hepatic metabolism, extent unknown Pregnancy Category C Elimination Renal 67% with a half-life of 45 min Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None

CIPROFLOXACIN OTIC: Cetraxal, Otiprio, Various

Class: Fluoroquinolone Antibiotic Dosage Forms. Otic Solution: 0.2%; Suspension, Intratympanic: 6% Common FDA Label Indication, Dosing, and Titration. Otitis externa, acute: Adults and Children >1 y of age, 0.25 mL (entire single-use container) into affected ear(s) bid (approximately q12h) × 7 d Otitis media with effusion: 0.1 mL (6 mg) once intratympanically to each affected ear following suctioning of middle ear effusion during tympanostomy tube placement Off-Label Uses. None MOA. Ciprofloxacin is a fluoroquinolone that inhibits bacterial DNA gyrase, an enzyme responsible for the unwinding of DNA for transcription and subsequent supercoiling of DNA for packaging into chromosomal subunits. It is highly active against aerobic, gram-negative bacilli, especially Enterobacteriaceae, with MICs often <8.1 mg/L. It is also active against some strains of Pseudomonas aeruginosa and Staphylococcus sp., with an MIC of 0.5-1 mg/L. However, recent reports indicate increasing resistance to this agent in Staphylococcus aureus. It has poor activity against streptococci and anaerobes. Drug Characteristics: Ciprofloxacin Otic Dose Adjustment Hepatic Not required Absorption Not systemically absorbed Dose Adjustment Renal Not required Distribution Not systemically absorbed Dialyzable Not absorbed Metabolism Not systemically absorbed Pregnancy Category C Elimination Not systemically absorbed Lactation Unknown if ciprofloxacin otic solution is excreted into breast milk. Weigh risks and benefits Pharmacogenetics None known that affect otic solution administration Contraindications Hypersensitivity to ciprofloxacin or other quinolones Black Box Warnings None Medication Safety Issues: Ciprofloxacin Otic Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No CefTRIAXone, cephalexin No

EXENATIDE: Byetta, Bydureon

Class: Glucagon-Like Peptide-1 Receptor Agonist Dosage Forms. Subcutaneous Solution for Injection, Immediate Release: 5 mcg/0.02 mL, 10 mcg/0.04 mL; Subcutaneous Suspension for Injection, Extended Release: 2 mg Common FDA Label Indication, Dosing, and Titration. Diabetes mellitus, Type 2: Immediate release, 5-10 mcg sq bid before meals; extended release, 2 mg sq weekly Off-Label Uses. None MOA. Exenatide is an agonist of human glucagon-like peptide-1 (GLP-1) receptor and augments glucose dependent insulin secretion and slows gastric emptying. Drug Characteristics: Exenatide Dose Adjustment Hepatic Not required Absorption F = 65-76% after sq dose Dose Adjustment Renal CrCl 30-50 mL/min, initial dose 5 mcg and increase with caution; avoid if CrCl <30 mL/min Distribution Vd = 28.3 L after sq dose Dialyzable Unknown Metabolism Minimal Pregnancy Category C Elimination Renal with a half-life of 2.4 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to exenatide Black Box Warnings Thyroid C-cell tumors (Bydureon) Medication Safety Issues: Exenatide Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria BCise No No No No No

ATORVASTATIN: Lipitor, Various

Class: HMG-CoA Reductase Inhibitor Dosage Forms. Tablet: 10 mg, 20 mg, 40 mg, 80 mg Common FDA Label Indication, Dosing, and Titration. Hyperlipidemia: 10-20 mg po daily, may increase to 80 mg po daily Primary and secondary prevention of atherosclerotic cardiovascular disease: 10-20 mg po daily, may increase to 80 mg po daily for those patients requiring high-intensity therapy (eg, LDL >190 mg/dL or high ASCVD risk) Secondary prevention of cardiovascular events in patients with or at high risk for CAD: 80 mg daily, may reduce dose to 40 mg po daily if high dose not tolerated Familial hypercholesterolemia (homozygous): Children (boys and postmenarchal girls 10-17 y of age), 10 mg po daily, may titrate to 40 mg po daily; Adults, 10-80 mg po daily Off-Label Uses. None MOA.HMG-CoA reductase inhibitors competitively inhibit conversion of HMG-CoA to mevalonate, an early rate-limiting step in cholesterol synthesis. A compensatory increase in LDL receptors, which bind and remove circulating LDL-cholesterol, results. Production of LDL-cholesterol also can decrease because of decreased production of VLDL-cholesterol or increased VLDL; removal by LDL receptors. Drug Characteristics: Atorvastatin Dose Adjustment Hepatic Avoid use in patients with active liver disease or unexplained persistent elevated LFTs Absorption F = 14%, food slows rate of absorption Dose Adjustment Renal Not required Distribution Vd = 381 L; 98% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP3A4/5 and P-glycoprotein; inhibits P-glycoprotein Pregnancy Category X Elimination Biliary and renal with a half-life of 7-14 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to atorvastatin, pregnancy or lactation Black Box Warnings None Medication Safety Issues: Atorvastatin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No AtorvaSTATin No No AtoMOXetine, lovastatin, nystatin, pravastatin, rosuvastatin, simvastatin No

FAMOTIDINE: Pepcid, Various

Class: Histamine H2 Antagonist Dosage Forms. Oral Tablet: 10 mg, 20 mg, 40 mg; Powder for Oral Suspension: 40 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Duodenal ulcer, acute: Children >1 y of age, 0.5 mg/kg/d po hs, max 40 mg/d; Adults, 20 mg po bid or 40 mg po daily hs Duodenal ulcer, maintenance: Adults, 20 mg po daily hs Gastroesophageal reflux disease: Children >1 y of age, 1 mg/kg/d po hs, max 80 mg/d, duration based on response; Adults, 20-40 mg po bid × up to 12 wk Gastric ulcer, acute: Children >1 y of age, 0.5 mg/kg/d po hs, max 40 mg/d; Adults, 40 mg po daily hs Indigestion (OTC): 10-20 mg po bid Off-Label Uses. None MOA. Famotidine is a competitive inhibitor of histamine H2 receptors. The primary clinically important pharmacologic activity of famotidine is inhibition of gastric secretion. Both the acid concentration and the volume of gastric secretion are suppressed by famotidine, while changes in pepsin secretion are proportional to volume output. Drug Characteristics: Famotidine Dose Adjustment Hepatic Not required Absorption F = 40-45%, no effect of food on absorption Dose Adjustment Renal Adults, CrCl <50 mL/min, reduce dose 50% or increase dosing interval to 36-48 h; Children, CrCl 30-60 mL/min/1.73 m2, administer 50% of dose; Children, CrCl <30 mL/min/1.73 m2, administer 25% of dose Distribution Vd = 1.3 L/kg; 10-20% protein bound Dialyzable Not dialyzable Metabolism Minimal Pregnancy Category B Elimination Renal 60% with a half-life of 2.5-3.5 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to famotidine or other H2 antagonists Black Box Warnings None

DOXYCYCLINE: Vibramycin, Various

Class: Tetracycline Antibiotic Dosage Forms. Powder for Oral Suspension: 25 mg/5 mL; Oral Tablet: 20 mg, 50 mg, 75 mg, 100 mg, 150 mg; Oral Capsule, Delayed Release: 40 mg; Oral Tablet, Delayed Release: 50 mg, 75 mg, 100 mg, 150 mg, 200 mg; Oral Capsule: 50 mg, 75 mg, 100 mg, 150 mg; Oral Syrup: 50 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Acinetobacter infection: Children <8 y of age and <45 kg, 2.2-4.4 mg/kg po in 1-2 divided doses; Children >8 y of age and >45 kg and Adults, 100 mg po q12h on d 1, then 100 mg po daily Acne vulgaris: Children <8 y of age and <45 kg, 2.2-4.4 mg/kg po in 1-2 divided doses; Children >8 y of age and >45 kg and Adults, 100 mg po q12h on d 1, then 100 mg po daily or bid Gonorrhea, uncomplicated: 100 mg po bid × 7 d or 300-mg po single dose followed in 1 h by another 300-mg dose Staphylococcal infection of skin: Children <8 y of age and <45 kg, 2.2-4.4 mg/kg po in 1-2 divided doses; Children >8 y of age and >45 kg and Adults, 100 mg po q12h on d 1, then 100 mg po daily Off-Label Uses. Lyme disease, prophylaxis: 200 mg po as a single dose MOA. Doxycycline is a broad-spectrum bacteriostatic compound that inhibits protein synthesis at the 30S ribosomal subunit. Activity includes gram-positive, gram-negative, aerobic, and anaerobic bacteria, as well as spirochetes, mycoplasmas, rickettsiae, chlamydiae, and some protozoa. Many bacteria have developed plasmid-mediated resistance. Drug Characteristics: Doxycycline Dose Adjustment Hepatic Not required Absorption F = 100%, food has no effect on absorption Dose Adjustment Renal Not required Distribution Vd = 0.75 L/kg, 80% protein bound Dialyzable Not dialyzable Metabolism Hepatic, 50% Pregnancy Category C Elimination Renal 35-45% with a half-life of 15-24 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to doxycycline or concurrent retinoic acid derivatives Black Box Warnings None

FLUCONAZOLE: Diflucan, Various

Class: Imidazole Antifungal Dosage Forms. Oral Suspension: 10 mg/mL, 40 mg/mL; Oral Tablet: 50 mg, 100 mg, 150 mg, 200 mg Common FDA Label Indication, Dosing, and Titration. Candidal vulvovaginitis, uncomplicated: 150 mg po × 1 Candidal vulvovaginitis, complicated: 150 mg po q72h × 3 doses Candidiasis, systemic: Adults, 400 mg po daily; Children ≥6 mo of age, 6-12 mg/kg/d po Cryptococcal meningitis: Adults, 400-800 mg po daily × 8 wk, then 200 mg po daily × 6-12 mo; Children ≥6 mo of age, 12 mg/kg po on day 1, then 6 mg/kg/d (max 12 mg/kg/d) for 10-12 wk Oropharyngeal candidiasis: Adults, 100-200 mg po daily × 7-14 d; Children ≥6 mo of age, 6 mg/kg po on day 1, then 3 mg/kg once daily for at least 2 wk Off-Label Uses. Onychomycosis due to dermatophyte: 200 mg po qwk × 3 mo (fingernails) or × 6 mo (toenails) Tinea: 200 mg po qwk × 3 doses MOA. Fluconazole inhibits biosynthesis of ergosterol or other sterols, damaging the fungal cell wall membrane and altering its permeability. Drug Characteristics: Fluconazole Dose Adjustment Hepatic Not required Absorption F = 90% with no food effect Dose Adjustment Renal Not required for single-dose therapy; for repeated dose therapy, CrCl 21-50 mL/min, increase dosing interval to 48 h or decrease dose by 50%; CrCl <10 mL/min, extend dosing interval to 48 h and decrease dose by 50% Distribution Blister, CSF, nails, skin, saliva, sputum, vaginal tissue, urine Dialyzable 100% of dose is removed by hemodialysis Metabolism Minimal metabolism, but moderate inhibitor of CYP2C19, 3A4/5 and strong inhibitor of CYP2C9 Pregnancy Category C Elimination Renal 80% (unchanged) with a half-life of 30 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to fluconazole, concurrent ergot alkaloids, CYP3A4/5 substrates that prolong QTc Black Box Warnings None

AZATHIOPRINE: Azamun, Imuran, Various

Class: Immunosuppressant Agent Dosage Forms. Oral Tablet: 50 mg, 75 mg, 100 mg Common FDA Label Indication, Dosing, and Titration. Renal transplantation: Adults, 3-5 mg/kg/d po immediately after the transplant, then 1-3 mg/kg po daily Rheumatoid arthritis: Adults, 1-2.5 mg/kg/d po either once daily or divided bid Off-Label Uses. Crohn disease, ulcerative colitis: Adults, 1.5-2.5 mg/kg/d po MOA.Incorporated into replicating DNA, also inhibits purine synthesis, both actions halt DNA synthesis. Drug Characteristics: Azathioprine Dose Adjustment Hepatic Not required Absorption Well absorbed Dose Adjustment Renal Reduce dose to 75% of dose if CrCl 10-50 mL/min; Reduce dose to 50% of dose if CrCl <10 mL/min Distribution Protein binding approximately 30% Dialyzable No Metabolism Hepatic, to inactive metabolite by TPMT Pregnancy Category D Elimination Primarily renal, as metabolites, with a half-life of 2 h Lactation Avoid, present in breast milk Pharmacogenetics TPMT poor metabolizers require dose reductions Contraindications Pregnancy (for rheumatoid arthritis), prior alkylating therapy Black Box Warnings Malignancy Medication Safety Issues: Azathioprine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No AzaTHIOprine Oral tablet No azaCITIDine, azidothymidine, azithromycin, Azulfidine No

BUDESONIDE: Pulmicort Respules, Pulmicort Flexhaler, Various

Class: Inhaled Corticosteroid Dosage Forms. Inhalation Suspension: 0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/2 mL; Metered-Dose Inhaler (MDI): 90 mcg/actuation, 180 mcg/actuation Common FDA Label Indication, Dosing, and Titration. Asthma: Children 1-8 y of age with no previous inhaled corticosteroid therapy, 0.5 mg inhaled via nebulization in 1 or 2 divided doses; Children 1-8 y of age previously treated with corticosteroids, 0.5 mg inhaled via nebulization daily or bid, may titrate to 1 mg/d; Children >8 y of age and Adults, 180-360 mcg bid via MDI, max 720 mcg bid via MDI Off-Label Uses. COPD, stable: 100-400 mcg daily via MDI in combination with long-acting bronchodilator MOA. Budesonide is an anti-inflammatory with potent glucocorticoid and weak mineralocorticoid activity. It exhibits a broad range of active inhibition against multiple cell types and mediators involving allergic and nonallergic/irritant-mediated inflammation. Drug Characteristics: Budesonide Dose Adjustment Hepatic Not required Absorption F = 6% Dose Adjustment Renal Not required Distribution Vd = 3 L/kg; protein binding 85-90% Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP3A4/5 Pregnancy Category B Elimination Renal 60%, fecal 15-29% with a half-life of 2-3 h Lactation Weigh risks and benefits Pharmacogenetics None known ContraindicationsHypersensitivity to budesonide; hypersensitivity to milk proteins (Flexhaler); primary treatment of status asthmaticus or other acute episodes of asthmaBlack Box Warnings

BUDESONIDE/FORMOTEROL: Symbicort

Class: Inhaled Corticosteroid/Bronchodilator Combination Dosage Forms. Metered-Dose Inhaler (MDI): (Budesonide/Formoterol) 80 mcg/4.5 mcg/inhalation, 160 mcg/4.5 mcg/inhalation Common FDA Label Indication, Dosing, and Titration. Asthma: Children ≥12 y of age and Adults, 80 mcg/4.5 mcg, 2 inhalations bid, may titrate to 160 mcg/4.5 mcg, 2 inhalations bid COPD: 160 mcg/4.5 mcg 2 inhalations bid Off-Label Uses. Asthma: Children 5-11 y of age, 80 mcg/4.5 mcg, 2 inhalations bid MOA. Budesonide is an anti-inflammatory with potent glucocorticoid and weak mineralocorticoid activity. It exhibits a broad range of active inhibition against multiple cell types and mediators involving allergic and nonallergic/irritant-mediated inflammation. Formoterol is a long-acting selective β2-adrenergic agonist that produces bronchodilation. Drug Characteristics: Budesonide/Formoterol Dose Adjustment Hepatic Not required Absorption F = 39% for budesonide; unknown for formoterol inhalation Dose Adjustment Renal Not required Distribution Protein binding 85-90% (budesonide); 31-64% for formoterol Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP3A4/5 (budesonide) Pregnancy Category C Elimination Renal 60% with a half-life of 2-3 h (budesonide); renal 1-28% with a half-life of 10 h (formoterol) Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to budesonide or formoterol; primary treatment of status asthmaticus or acute episodes of asthma or COPD Black Box Warnings Asthma deaths; pediatrics, increased risk of hospitalization Medication Safety Issues: Budesonide/Formoterol Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoNoNoNoNo

FIDAXOMICIN: Dificid

Class: Macrolide Antibiotic Dosage Forms. Oral Tablet: 200 mg Common FDA Label Indication, Dosing, and Titration. Clostridium difficile infection: 200 mg po bid × 10 d Off-Label Uses. None MOA. Fidaxomicin is an antibacterial agent that acts locally in the GI tract on C. difficile via inhibition of RNA polymerases. Drug Characteristics: Fidaxomicin Dose Adjustment Hepatic Not required Absorption Minimal oral bioavailability, no effect of food on absorption Dose Adjustment Renal Not required Distribution Not absorbed systemically Dialyzable Unknown Metabolism Not absorbed Pregnancy Category B Elimination Fecal >92% unchanged with half-life of 11.7 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications None Black Box Warnings None Medication Safety Issues: Fidaxomicin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

AZITHROMYCIN: Zithromax, Z-Pak, Various

Class: Macrolide Antibiotic Dosage Forms. Oral Tablet: 250 mg, 500 mg, 600 mg; Microspheres for Suspension: 2 g/bottle; Powder for Oral Suspension: 100 mg/5 mL, 200 mg/5 mL, 1 g packet Common FDA Label Indication, Dosing, and Titration. Acute infective exacerbation of COPD, skin or tissue infection: 500 mg po daily × 3 d or 500 mg po × 1 dose, then 250 mg po daily × 2-5 d Bacterial sinusitis: Adults, 500 mg po daily × 3 d; Children, 10 mg/kg po daily × 3 d, or 2 g po × 1 dose Chancroid, nongonococcal cervicitis, nongonococcal urethritis: 1 g po × 1 dose Community-acquired pneumonia: 500 mg po daily × 3 d or 500 mg po × 1 dose, then 250 mg po daily × 2-5 d; Infants ≥6 mo of age, tablets and immediate-release suspension, 10 mg/kg po on day 1, then 5 mg/kg po daily × 2-5 d or extended-release suspension, <34 kg, 60 mg/kg po × 1 dose; >34 kg, 2 g po × 1 dose Gonorrhea, urethritis, or cervicitis: 2 g po × 1 dose Streptococcal pharyngitis: 500 mg po × 1 dose, then 250 mg po daily × 2-5 d; Children, 12 mg/kg po daily × 5 d Off-Label Uses. Traveler's diarrhea: Adults, 1000 mg po × 1 dose, or 500 mg po daily × 3 d; Children, 10 mg/kg po daily × 3 d Bacterial endocarditis, prophylaxis: Adults, 500 mg po 30-60 min prior to procedure; Children, 15 mg/kg po 30-60 min prior to procedure MOA. Azithromycin is a macrolide antibiotic that is slightly less active than erythromycin against gram-positive bacteria but substantially more active against Moraxella (Branhamella)catarrhalis, Haemophilus sp., Legionella sp., Neisseria sp., Bordetella sp., Mycoplasma sp., and Chlamydia trachomatis. Azithromycin binds to the 50S ribosomal subunit, thus interfering with microbial protein synthesis. Drug Characteristics: Azithromycin Dose Adjustment Hepatic Not required Absorption F = 38%, no effect of food on absorption Dose Adjustment Renal Not required Distribution Blister fluid, bronchial secretions, cervix, ear fluid, ovaries, sputum, soft tissue Dialyzable Not dialyzable Metabolism Hepatic Pregnancy Category B Elimination Renal 6% with a half-life of 68 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity to azithromycin, erythromycin, or any macrolide or ketolide antibiotic Black Box Warnings None Medication Safety Issues: Azithromycin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Azathioprine, erythromycin, Fosamax No

CLARITHROMYCIN: Biaxin, Various

Class: Macrolide Antibiotic Dosage Forms. Oral Tablet: 250 mg, 500 mg; Oral Suspension: 125 mg/5 mL; 250 mg/5 mL; Oral Tablet, Extended Release: 500 mg Common FDA Label Indication, Dosing, and Titration. Acute infective exacerbation of bronchitis: 250-500 mg po bid × 7-14 d or extended-release tablets, 1000 mg po daily for 7 d Community-acquired pneumonia, skin infection, sinusitis, pharyngitis: Adults, 250 mg po bid × 7-14 d or extended-release tablets, 1000 mg po daily for 7 d; Children ≥6 mo of age, 15 mg/kg/d divided q12h × 10 d Disseminated infection due to M. avium-intracellulare group, prophylaxis-HIV infection, primary prevention and treatment: 500 mg po bid H. pyloriGI tract infection: 500 mg, bid × 10-14 d in combination with various other antibiotics and PPIs Off-Label Uses. Bacterial endocarditis prophylaxis for high-risk patients; dental, respiratory, or infected skin/skin structure or musculoskeletal tissue procedures: Adults, 500 mg po 30-60 min prior to procedure; Children, 15 mg/kg po 30-60 min prior to procedure MOA. Clarithromycin binds to the 50S ribosomal subunit of the 70S ribosome of susceptible organisms, thereby inhibiting bacterial RNA-dependent protein synthesis. Drug Characteristics: Clarithromycin Dose Adjustment Hepatic Not required Absorption F = 50%, extended release should be taken with food, immediate release can be taken without regard to food Dose Adjustment Renal CrCl <30 mL/min, reduce dose by 50% or increase interval to q24h Distribution Gastric tissue, lung, ear fluid, prostate, sputum, soft tissue Dialyzable Unknown Metabolism Hepatic; substrate of CYP3A4/5 to active metabolites, inhibitor of CYP3A4/5, P-glycoprotein Pregnancy Category C Elimination Renal 20-40% with a half-life of 5-7 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to any macrolide or ketolide antibiotic; concomitant colchicine, cisapride, pimozide, astemizole, terfenadine, ergotamine, dihydroergotamine, or HMG-CoA reductase inhibitors metabolized by CYP3A4/5 Black Box Warnings None Medication Safety Issues: Clarithromycin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XL No XL formulation No Claritin No

BUPROPION: Aplenzin, Forfivo, Wellbutrin, Zyban, Various

Class: Monocyclic Antidepressant Dosage Forms. Oral Tablet (Immediate Release): 75 mg, 100 mg; Oral Tablet (Extended Release 12 h): 100 mg, 150 mg, 200 mg; Oral Tablet (Extended Release 24 h): 150 mg, 174 mg, 300 mg, 348 mg, 450 mg, 522 mg Common FDA Label Indication, Dosing, and Titration. Depression: Immediate release, 100 mg po bid × 3 d, increase to 100 mg po tid (max 450 mg/d); Extended release 12 h, 150 mg po daily in the morning × 3 d, then increase to 150 mg po bid (max 200 mg bid); Extended-release hydrochloride 24 h, 150 mg po daily × 3 d, then increase to 300 mg po daily (max 450 mg/d); Extended-release hydrobromide 24 h, 174 mg po daily × 3 d, then increase to 348 mg po daily (max 522 mg/d) Seasonal affective disorder (SAD): Extended-release hydrochloride 24 h, 150 mg po daily, may titrate to 300 mg po daily; Extended-release hydrobromide 24 h, 174 mg po daily, may titrate to 348 mg po daily Smoking cessation assistance: Extended release 12 h, 150 mg po daily in the morning × 3 d, then 150 mg po bid (max 300 mg/d) for 7-12 wk; begin treatment 1 wk prior to smoking quit date Off-Label Uses. None MOA. Bupropion is a monocyclic antidepressant, unique as a mild dopamine and norepinephrine uptake inhibitor with no direct effect on serotonin receptors or MAO. Drug Characteristics: Bupropion Dose Adjustment Hepatic Mild to moderate: reduce frequency and/or dose. Severe liver disease: max dose 150 mg qod Absorption Food has minimal effect on absorption Dose Adjustment Renal Reduce frequency and/or dose Distribution Vd = 19-21 L/kg; 84% protein bound Dialyzable Not dialyzable Metabolism Hepatic, 10-15%; major substrate of CYP2B6; inhibitor of CYP2D6 Pregnancy Category C Elimination Renal 87%, fecal 10% with a half-life of 14-37 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Seizure disorder; history of anorexia/bulimia; use of MAOI within 14 d; patients undergoing abrupt discontinuation of ethanol, benzodiazepines, barbiturates, or antiepileptics Black Box WarningsSuicidality; neuropsychiatric reactions

DICLOFENAC: Cambia, Voltaren, Zipsor, Zorvolex, Various

Class: NSAID Dosage Forms. Oral Tablet: 50 mg; Oral Tablet, Extended Release: 25 mg, 50 mg, 75 mg, 100 mg; Oral Capsule: 18 mg, 25 mg, 35 mg; Powder for Oral Solution: 50 mg Common FDA Label Indication, Dosing, and Titration. Pain: Immediate-release tablet or capsule only, 18-50 mg po tid Dysmenorrhea: Immediate-release tablets only, 50 mg po tid Migraine: Powder for solution only, 50 mg po once Osteoarthritis: 100 mg extended release po daily or bid Rheumatoid arthritis: 100 mg extended release po daily or bid Off-Label Uses. None MOA. Nonselective inhibitor of cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) Drug Characteristics: Diclofenac Dose Adjustment Hepatic Not required Absorption F = 50%, minimal food effect Dose Adjustment Renal CrCl <30 mL/min, avoid use Distribution Vd = 1.3 L/kg Dialyzable Unknown Metabolism Hepatic; minor substrate of multiple CYP pathways Pregnancy Category C, <30 wk gestation; D, ≥30 wk gestation Elimination Renal 65% with a half-life of 2 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to diclofenac, concurrent ketorolac use, asthma, allergic-type reaction following other NSAID use, CABG Black Box Warnings Cardiovascular, GI risk, CABG Medication Safety Issues: Diclofenac Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria XR No XR No Diflucan Avoid chronic use

ETODOLAC: Lodine, Various

Class: NSAID Dosage Forms. Tablet, Immediate Release: 400 mg, 500 mg; Tablet, Extended Release: 400 mg, 500 mg, 600 mg; Capsule, Immediate Release: 200 mg, 300 mg Common FDA Label Indication, Dosing, and Titration. General pain: Immediate release, 200-400 mg po q6h; max 1000 mg/d Osteoarthritis and rheumatoid arthritis: Immediate release, 300 mg po bid-tid or 400-500 mg po bid; extended release, 400-1000 mg po daily; max 1000 mg/d Juvenile rheumatoid arthritis: Extended release, Children 6-16 y of age and 20-30 kg, 400 mg po daily; 31-45 kg, 600 mg po daily; 46-60 kg, 800 mg po daily; >60 kg, 1000 mg po daily Off-Label Uses. None MOA. Nonselective inhibitor of cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) and reversibly alters platelet function and prolongs bleeding time. Drug Characteristics: Etodolac Dose Adjustment Hepatic Not required Absorption F = 80%, food has minimal effect on absorption Dose Adjustment Renal Avoid in severe renal failure Distribution Vd = 393 mL/kg (immediate release); Vd = 570 mL/kg (extended release); 99% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic not via CYP450 Pregnancy Category C Elimination Renal 72% with a half-life of 6-7 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to etodolac; concurrent use of ketorolac or pentoxifylline; allergic-type reaction following aspirin or other NSAID; CABG surgery, treatment of perioperative pain Black Box Warnings Cardiovascular and GI risk Medication Safety Issues: Etodolac Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria CR No Extended-release product No Lopid Avoid chronic use

AZELASTINE: Astelin, Astepro, Various

Class: Nasal Antihistamine Dosage Forms. Nasal Spray: 0.1%, 0.15%, 137 mcg/actuation Common FDA Label Indication, Dosing, and Titration. Perennial allergic rhinitis: Adults and Children ≥12 y of age, 2 sprays per nostril bid; Children 6-12 y of age, 1 spray per nostril bid Seasonal allergic rhinitis: Adults and Children ≥12 y of age, 1-2 sprays per nostril bid; Children 6-12 y of age, 1 spray per nostril bid Vasomotor rhinitis: Adults and Children ≥12 y of age, 2 sprays per nostril bid Off-Label Uses. None MOA. Azelastine is a selective H1-receptor antagonist that blocks release of histamine from cells involved in the allergic response. It also inhibits other mediators of allergic reactions (eg, leukotrienes, etc), and reduces chemotaxis and eosinophil activation. Drug Characteristics: Azelastine Dose Adjustment Hepatic Not required Absorption F = 40% when administered nasally Dose Adjustment Renal Not required Distribution Vd = 14.5 L/kg; 78-95% protein bound Dialyzable Unknown Metabolism Hepatic, 90% Pregnancy Category C Elimination Fecal 75% with a half-life of 22-25 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None

ATOMOXETINE: Strattera, Various

Class: Norepinephrine Reuptake Inhibitor, CNS Stimulant Dosage Forms. Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg Common FDA Label Indication, Dosing, and Titration. ADHD: Children >6 y of age and weighing ≤70 kg, 0.5 mg/kg/d po, may titrate to lower of 1.4 mg/kg/d or 100 mg/d; Children >6 y of age and weighing >70 kg, 40 mg/d po, may titrate to 100 mg/d; Adults, 40 mg po daily, may titrate to 100 mg/d Off-Label Uses. None MOA.Atomoxetine is a selective norepinephrine reuptake inhibitor that produces therapeutic effects in patients with ADHD. The exact mechanism of how selective inhibition of presynaptic norepinephrine exerts effects in ADHD has not been determined. Drug Characteristics: Atomoxetine Dose Adjustment Hepatic Child-Pugh Class B: initial and target doses should be reduced to 50% of normal dose; Child-Pugh Class C: initial and target doses should be reduced to 25% of normal dose Absorption F = 63% (normal metabolizers); 94% (poor metabolizers); food does not affect absorption Dose Adjustment Renal Not required Distribution Vd = 0.85 L/kg; 98% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic to 1 active metabolite; major substrate of CYP2D6 Pregnancy Category C Elimination Renal 80%, fecal 17% with a half-life of 5.2-21.6 h Lactation Weigh risks and benefits Pharmacogenetics CYP2D6 poor metabolizers, decrease dose as with drug interaction with CYP2D6 inhibitor Contraindications Hypersensitivity to atomoxetine; concomitant use of MAOIs or use within 2 wk; narrow-angle glaucoma, pheochromocytoma Black Box Warnings Suicidality in children and adolescents

FENTANYL TRANSDERMAL: Duragesic, Ionsys, Various

Class: Opioid Analgesic. C-II Dosage Forms. Transdermal Patch: 12.5 mcg/h, 25 mcg/h, 50 mcg/h, 75 mcg/h, 87.5 mcg/h, 100 mcg/h; Transdermal Iontophoretic System: 40 mcg/actuation Common FDA Label Indication, Dosing, and Titration. Pain, chronic (moderate to severe): Adults and Children >2 y of age, opioid tolerant, with pain that cannot be managed by other means, transdermal fentanyl dosage based on the patient's current 24-h oral morphine requirement; replace patch q72h; may replace patch q48h in patients not achieving adequate analgesia Off-Label Uses. None MOA. Fentanyl is a phenylpiperidine opioid agonist with predominant effects on the mu opioid receptor and is about 50-100 times more potent as an analgesic than morphine. Drug Characteristics: Fentanyl Transdermal Dose Adjustment Hepatic Not required Absorption F = 92% with transdermal Dose Adjustment Renal CrCl <10 mL/min, reduce dose by 50% Distribution Vd = 6 L/kg; 80-85% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic metabolism, CYP3A4/5 substrate Pregnancy Category C Elimination Renal 75% with a half-life of 20-24 h Lactation Usually compatible Pharmacogenetics None known Contraindications Acute or postoperative pain, bronchial asthma, hypersensitivity to fentanyl, mild or intermittent pain management, opioid nontolerant patients, paralytic ileus Black Box Warnings CYP3A4/5 inhibitors; respiratory depression; transdermal not for use postoperatively; fatalities in children; formulations not interchangeable; fever; care with disposal; REMS program; concurrent use with benzodiazepines or other CNS depressants Medication Safety Issues: Fentanyl Transdermal Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria Suffix describes mcg/h of fentanyl delivered. Transdermal fentanyl patches should always be prescribed in mcg/h, not size FentaNYL Do not cut patch

BUPRENORPHINE/NALOXONE: Bunavail, Suboxone, Zubsolv, Various

Class: Opioid Partial Agonist and Antagonist Combination. C-III Dosage Forms. Sublingual Film: (Buprenorphine/Naloxone) 2 mg/0.5 mg, 4 mg/1 mg, 8 mg/2 mg, 12 mg/3 mg; Sublingual Tablet: (Buprenorphine/Naloxone) 0.7 mg/0.18 mg, 1.4 mg/0.36 mg, 2 mg/0.5 mg, 2.9 mg/0.71 mg, 5.7 mg/1.4 mg, 8.6 mg/2.1 mg, 11.4 mg/2.9 mg; Buccal Film: (Buprenorphine/Naloxone) 2.1 mg/0.3 mg, 4.2 mg/0.7 mg, 6.3 mg/1 mg Common FDA Label Indication, Dosing, and Titration. Opioid dependence: Adults and Children >16 y of age, 12-16 mg (buprenorphine component) once daily sublingually, titrate to response; typical dose range from 4 to 24 mg/d Off-Label Uses. None MOA. Buprenorphine is a µ-opioid receptor partial agonist and a -opioid receptor antagonist. Naloxone is a µ-opioid receptor antagonist that causes opioid withdrawal when injected parenterally and is included in the formulation to reduce the risk of abuse. Drug Characteristics: Buprenorphine/Naloxone Dose Adjustment Hepatic Use with caution Absorption F = 15% (buprenorphine); F = 3% (naloxone) Dose Adjustment Renal Not required Distribution Vd = 97-187 L (buprenorphine) Dialyzable Unknown Metabolism Buprenorphine, hepatic, major substrate of CYP3A4/5; naloxone, hepatic via glucuronidation Pregnancy Category C Elimination Renal 30% with half-life of 33 h (buprenorphine), 6 h (naloxone) Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None Medication Safety Issues: Buprenorphine/Naloxone Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria NoNoNoYesNoNo

DIPYRIDAMOLE: Persantine, Various

Class: Platelet Aggregation Inhibitor Dosage Forms. Oral Tablet: 25 mg, 50 mg, 75 mg Common FDA Label Indication, Dosing, and Titration. Thromboprophylaxis after heart valve replacement: 75-100 mg po qid as an adjunct to warfarin therapy Off-Label Uses. None MOA. Inhibits the uptake of adenosine into platelets, endothelial cells, and erythrocytes resulting in an increase in local concentrations of adenosine, which is a coronary vasodilator and a platelet aggregation inhibitor. Drug Characteristics: Dipyridamole Dose Adjustment Hepatic Not required Absorption F = 27-66% Dose Adjustment Renal Not required Distribution Vd = 2.43-3.38 L/kg; 99% protein bound Dialyzable Not dialyzable Metabolism Extensively metabolized but not by CYP; inhibits P-glycoprotein Pregnancy Category B Elimination Bile with a half-life of 10 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to dipyridamole Black Box Warnings None Medication Safety Issues: Dipyridamole Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Periactin, disopyramide Orthostatic hypotension; avoid (does not apply to IV formulation

ESOMEPRAZOLE: Nexium, Various

Class: Proton Pump Inhibitor Dosage Forms. Oral Capsule, Delayed Release: 20 mg, 40 mg, 49.3 mg; Oral Tablet, Delayed Release: 20 mg; Oral Granules: 2.5 mg, 5 mg, 10 mg, 20 mg, 40 mg Common FDA Label Indication, Dosing, and Titration. Helicobacter pylori GI infection: 40 mg po daily × 10-14 d in combination with amoxicillin 1000 mg and clarithromycin 500 mg po bid Erosive esophagitis, GERD treatment: Children 1-11 y of age and <20 kg, 10 mg po daily × 8 wk; Children ≥20 kg, 10-20 mg po daily × 8 wk; Adults, 20-40 mg po daily × 4-8 wk Erosive esophagitis, heartburn: Children 1-11 y of age, 10 mg po daily × 8 wk; Children ≥12 y of age and Adults, 20-40 mg po daily × up to 8 wk Prevention of NSAID-induced gastropathy: 20-40 mg po daily × up to 6 mo Zollinger-Ellison syndrome: 40 mg po bid up to 240 mg/d Off-Label Uses. None MOA. Esomeprazole is a proton pump inhibitor (PPI) that, when protonated in the secretory canaliculi of the parietal cells, covalently binds to H+/K+-ATPase (proton pump), which is the final pathway for acid secretion. Esomeprazole produces a profound and prolonged antisecretory effect, and inhibits basal, nocturnal, pentagastrin-stimulated, and food-stimulated gastric acid secretion. Drug Characteristics: Esomeprazole Dose Adjustment Hepatic Severe, max dose of 20 mg daily Absorption F = 90%, food reduces F by 50% Dose Adjustment Renal Not required Distribution Vd = 16 L; 97% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; substrate of CYP2C19; inducer of CYP2C19 Pregnancy Category B Elimination Renal 80% with a half-life of 60-90 min Lactation Weigh risks and benefits Pharmacogenetics For CYP2C19 poor metabolizers should consider 20 mg dose; moderate CYP2C19 inhibitor Contraindications Hypersensitivity to omeprazole or esomeprazole Black Box Warnings None

DEXLANSOPRAZOLE: Dexilant

Class: Proton Pump Inhibitor Dosage Forms. Oral Capsule, Delayed Release: 30 mg, 60 mg; Oral Disintegrating Tablets: 30 mg Common FDA Label Indication, Dosing, and Titration. Erosive esophagitis, treatment: Adults and Children ≥12 y of age, 60 mg po daily × 8 wk; thereafter may continue 30 mg po daily × 6 mo (16 wk for Children <18 y of age) Symptomatic gastroesophageal reflux disease: Adults and Children ≥12 y of age, 30 mg po daily × 4 wk Off-Label Uses. None MOA. Dexlansoprazole is a proton pump inhibitor (PPI) that, when protonated in the secretory canaliculi of the parietal cells, covalently binds to H+/K+-ATPase (proton pump), which is the final pathway for acid secretion. Drug Characteristics: Dexlansoprazole Dose Adjustment Hepatic Child-Pugh class B: max 30 mg po daily; Child-Pugh class C: avoid Absorption Well absorbed after oral administration Dose Adjustment Renal Not required Distribution Vd = 40.3 L; 96-99% protein bound Dialyzable Not dialyzable Metabolism Hepatic by multiple pathways including CYP2C19 and 3A4/5, but CYP inhibitors/inducers may not produce clinically relevant interactions Pregnancy Category B Elimination Renal 50.7%, fecal 47.6% with a half-life of 1-2 h Lactation Weigh risks and benefits Pharmacogenetics Circulating metabolites vary with CYP2C19 phenotype; unclear clinical significance ContraindicationsHypersensitivity to dexlansoprazole or other PPIBlack Box WarningsNone

ADAPALENE: Differin, Plixda, Various

Class: Retinoid, Antiacne Dosage Forms. Cream: 0.1%; Gel: 0.1%, 0.3%; Lotion: 0.1%; Solution: 0.1%; Pads: 0.1% Common FDA Label Indication, Dosing, and Titration. Acne vulgaris: Adults and Children >12 y of age, apply thin film topically to affected area(s) daily hs Off-Label Uses. Rosacea: Apply thin film topically to affected area(s) daily hs × 12 wk MOA. Adapalene exhibits retinoic acid-like activity, reducing important features of the pathology of acne vulgaris by normalizing the differentiation of follicular epithelial cells and keratinization to prevent microcomedone formation. Adapalene enhances keratinocyte differentiation without inducing epidermal hyperplasia and severe irritation, which is associated with retinoic acid. Adapalene decreases formation of comedones, and inflammatory and noninflammatory acne lesions. Drug Characteristics: Adapalene Dose Adjustment Hepatic Not required Absorption Not absorbed Dose Adjustment Renal Not required Distribution Not applicable Dialyzable Unknown Metabolism Not applicable Pregnancy Category C Elimination Not applicable Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None Medication Safety Issues: Adapalene Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

CITALOPRAM: Celexa, Various

Class: SSRI Antidepressant Dosage Forms. Oral Tablet: 10 mg, 20 mg, 40 mg; Oral Solution: 10 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Depression: 20 mg po daily, may titrate to 40 mg po daily Off-Label Uses. OCD, posttraumatic stress disorder, binge eating disorder: 20 mg po daily, may titrate to 40 mg po daily Panic disorder: 20-30 mg po daily, may titrate to 40 mg po daily MOA. Citalopram is a bicyclic antidepressant that is a selective and potent inhibitor of presynaptic reuptake of serotonin (an SSRI). It does not affect reuptake of norepinephrine or dopamine and has a relative lack of affinity for muscarinic, histamine, α1- and α2-adrenergic, and serotonin receptors. Drug Characteristics: Citalopram Dose Adjustment Hepatic Max dose 20 mg po daily in hepatic impairment Absorption F = 80%; no effect of food on absorption Dose Adjustment Renal Use with caution in severe renal impairment Distribution Vd = 12 L/kg; 80% protein bound Dialyzable Not dialyzed Metabolism Hepatic >90%; substrate of CYP2C19 (major), 3A4/5 (major) and 2D6 (minor) Pregnancy Category C Elimination Fecal 20%, renal 20% (12-13% unchanged) with a half-life of 33-37 h Lactation Avoid Pharmacogenetics CYP2C19 poor metabolizers, max dose 20 mg/d; no dose adjustment needed for CYP2D6 poor or extensive metabolizers

ESCITALOPRAM: Lexapro, Various

Class: SSRI Antidepressant Dosage Forms. Oral Tablet: 5 mg, 10 mg, 20 mg; Oral Solution: 5 mg/5 mL Common FDA Label Indication, Dosing, and Titration. Depression: Children ≥12 y of age and Adults, 10 mg po daily, may titrate to 20 mg po daily Generalized anxiety disorder: 10 mg po daily, may titrate to 20 mg po daily Off-Label Uses. OCD: 20-60 mg po daily Panic disorder: 20-30 mg po daily, may titrate to 60 mg po daily Hot flashes: 10 mg once po daily, may increase to 20 mg once daily after 4 wk MOA. Escitalopram is the s-enantiomer of racemic citalopram and is an antidepressant that is a selective and potent inhibitor of presynaptic reuptake of serotonin (an SSRI). It does not affect reuptake of norepinephrine or dopamine and has a relative lack of affinity for muscarinic, histamine, α1- and α2-adrenergic, and serotonin receptors. Drug Characteristics: Escitalopram Dose Adjustment Hepatic Dose at 10 mg po daily Absorption F = 80%, food has no effect on absorption Dose Adjustment Renal Use with caution in severe renal impairment Distribution Vd = 12 L/kg; 56% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; substrate of CYP3A4/5, CYP2C19 Pregnancy Category C Elimination Renal 10% with a half-life of 27-32 h Lactation Avoid Pharmacogenetics Increased risk of adverse reactions with CYP2C19 poor metabolizers Contraindications Hypersensitivity to citalopram or escitalopram; concurrent MAOI use Black Box Warnings Suicidality Medication Safety Issues: Escitalopram Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Loxitane Avoid in certain circumstances

CEFUROXIME: Ceftin, Various

Class: Second-Generation Cephalosporin Dosage Forms. Oral Tablet: 125 mg, 250 mg, 500 mg Common FDA Label Indication, Dosing, and Titration. Acute infective exacerbation of COPD, uncomplicated skin and/or subcutaneous tissue infection, acute bacterial maxillary sinusitis, uncomplicated urinary tract infection: Adults, 250-500 mg po bid × 10 d Acute otitis media: Children who are able to swallow tablets, 250 mg po bid × 10 d Bronchitis, acute, secondary bacterial infection: Adults and Children >12 y of age, 250-500 mg po bid × 5-10 d Gonorrhea, uncomplicated: 1 g po × 1 dose Lyme disease: 500 mg po bid × 14-21 d Pharyngitis, tonsillitis: Adults, 250 mg po bid × 10 d Off-Label Uses. None MOA. Cefuroxime is a 2nd-generation cephalosporin whose activity is better than cefazolin but less than cefotaxime, against Haemophilus influenzae, including β-lactamase-producing strains. The activity of cefuroxime against Staphylococcus aureus is slightly less than that of cefazolin. Its activity against anaerobes is poor, similar to the 1st-generation cephalosporins. Drug Characteristics: Cefuroxime Dose Adjustment Hepatic Not required Absorption F = 37%, food increases absorption to 52%, suspension must be taken with food; tablets can be taken without regard to food Dose Adjustment Renal CrCl = 10-30 mL/min, administer full dose every 24 h; CrCl ≤10 mL/min, administer full dose every 48 h Distribution Aqueous humor, bronchial secretions, ear fluid, placenta, sinus Dialyzable Dialyzable by both hemodialysis and peritoneal dialysis Metabolism Cefuroxime is rapidly hydrolyzed by plasma and GI esterases Pregnancy Category B Elimination Renal 50% with a half-life of 2 h Lactation Usually compatible Pharmacogenetics None known ContraindicationsHypersensitivity to cephalosporinsBlack Box WarningsNone

ALBUTEROL: ProAir HFA, Proventil HFA, Ventolin HFA, ProAir Respiclick, Various

Class: Selective β2-Adrenergic Agonist Dosage Forms. Metered-Dose Inhaler (MDI), Aerosol Solution for Inhalation, Aerosol Powder for Inhalation, Dry Powder Inhaler (DPI): 90 (base) mcg/actuation; Tablet: 2 mg, 4 mg; Extended-Release Tablet: 4 mg, 8 mg; Syrup: 2 mg/5 mL; Nebulization Solution for Inhalation: 0.63 mg/3 mL, 2.5 mg/3 mL, 2.5 mg/0.5 mL Common FDA Label Indication, Dosing, and Titration. Asthma (acute exacerbation): Adults, MDI, 4-8 inhalations every 20 min up to 4 h, then every 1-4 h prn; Children, 4-8 inhalations every 20 min for 3 doses, then every 1-4 h prn (use mask for children <4 y of age) Asthma (bronchospasm): Adults and Children, MDI/DPI, 2 inhalations every 4-6 h prn; Adults and Children ≥12 y of age, oral, 2-4 mg immediate-release tablet po tid or qid or 4-8 mg extended-release tablet po q12h (max 32 mg/d); Children 6-11 y of age, 2 mg immediate-release tablet po tid or qid or 4 mg extended-release tablet po q12h; Children 2-6 y of age, 0.1 mg/kg oral syrup po tid Exercise-induced asthma, prevention: Adults, MDI/DPI, 2 inhalations 15-30 min prior to exercise; Children ≥4 y of age, 2 inhalations 15-30 min prior to exercise Off-Label Uses. None MOA. Albuterol is a selective β2-adrenergic agonist that acts on β2-adrenergic receptors of intracellular adenylyl cyclase to increase cyclic AMP levels resulting in bronchial smooth muscle relaxation. Drug Characteristics: Albuterol Dose Adjustment Hepatic Not required Absorption F = 50-85% (oral tablet), 100% (extended-release tablet), food decreases rate (but not extent) of absorption of extended-release tablet Dose Adjustment Renal Not required Distribution Vd = 156 L; 10% protein bound Dialyzable Unknown Metabolism 20% via sulfotransferases Pregnancy Category C Elimination Renal 80% with a half-life of 3.8 h (inhalation), 3.7-5 h (oral) Lactation Compatible Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings None

DULOXETINE: Cymbalta, Various

Class: Serotonin/Norepinephrine Reuptake Inhibitor Dosage Forms. Oral Capsule, Delayed Release: 20 mg, 30 mg, 40 mg, 60 mg Common FDA Label Indication, Dosing, and Titration. Anxiety: 60 mg po daily, may titrate to 120 mg po daily Depression: 20-30 mg po bid or 60 mg po once daily, may titrate to 120 mg po daily Diabetic peripheral neuropathy pain, fibromyalgia, musculoskeletal pain: 60 mg po daily, may titrate to 120 mg po daily Off-Label Uses. Urinary incontinence: 40 mg po bid MOA. Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor that exerts its antidepressant and pain inhibitory actions by potentiating the serotonergic and noradrenergic activity in the CNS. It has no significant affinity for adrenergic, dopaminergic, cholinergic, opioid, glutamate, or histaminergic receptors in vitro and does not inhibit monoamine oxidase. Drug Characteristics: Duloxetine Dose Adjustment Hepatic Avoid Absorption F = 30-80%; food slows absorption Dose Adjustment Renal Initiate at low dose and titrate slowly; avoid if CrCl <30 mL/min Distribution Vd = 1640 L; 90% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; substrate of CYP1A2 and CYP2D6; inhibits CYP2D6 Pregnancy Category C Elimination Renal 70% with a half-life of 8-17 h Lactation Weigh risks and benefits Pharmacogenetics Use with caution when co-administered with CYP1A2 and 2D6 inhibitors, CYP1A2 inducers, or with agents metabolized by CYP2D6 Contraindications Hypersensitivity to duloxetine; MAOI, TCA, linezolid use, uncontrolled glaucoma Black Box Warnings Suicidality; not approved for children Medication Safety Issues: Duloxetine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No DULoxetine Delayed-release capsule No FLUoxetine, vortioxetine Avoid in certain circumstances

DESVENLAFAXINE: Pristiq, Khedezla, Various

Class: Serotonin/Norepinephrine Reuptake Inhibitor Dosage Forms. Oral Tablet, Extended Release: 25 mg, 50 mg, 100 mg Common FDA Label Indication, Dosing, and Titration. Depression: 50 mg po daily Off-Label Uses. Menopausal flushing: 100 mg po daily MOA. Desvenlafaxine is a potent reuptake inhibitor of serotonin and norepinephrine but lacks effects on muscarinic, α-adrenergic, or histamine receptors. Drug Characteristics: Desvenlafaxine Dose Adjustment Hepatic Moderate to severe impairment, max dose, 100 mg po daily Absorption F = 80%; no effect of food on absorption Dose Adjustment Renal CrCl = 30-50 mL/min, max 50 mg po daily; CrCl <30 mL/min, max 50 mg po qod Distribution Vd = 3.4 L/kg; 30% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic metabolism via UGT Pregnancy Category C Elimination Renal 45% (unchanged) with a half-life of 10-11 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to desvenlafaxine or venlafaxine; MAOI use Black Box Warnings Suicidality; not for use in children; not for bipolar disorder Medication Safety Issues: Desvenlafaxine Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No ER tablets No PriLOSEC Avoid in certain circumstances

CHLORTHALIDONE: Hygroton, Thalitone, Various

Class: Thiazide Diuretic Dosage Forms. Oral Tablet: 25 mg, 50 mg Common FDA Label Indication, Dosing, and Titration. Hypertension: Adults, 25 mg po daily, may titrate to max of 100 mg po daily Edema: 50 mg po daily, may titrate to max of 200 mg po daily; systolic heart failure-associated edema, 12.5-25 mg po daily, may titrate to max of 100 mg po daily Off-Label Uses. Hypertension: Children, 0.3 mg/kg po daily, may titrate to max of 2 mg/kg/d or 50 mg/d, whichever is less Calcium nephrolithiasis, prevention of recurrent kidney stones: 25 mg po daily MOA. Chlorthalidone increases sodium and chloride excretion by interfering with their reabsorption in the cortical-diluting segment of the nephron. Drug Characteristics: Chlorthalidone Dose Adjustment Hepatic Not required Absorption F = 65%, food has no effect on absorption Dose Adjustment Renal CrCl <10 mL/min: increase dosing interval to q48h Distribution Vd = 3-13 L/kg; protein binding 75% Dialyzable Not dialyzable Metabolism Hepatic Pregnancy Category B Elimination Renal 50-74% with a half-life of 40-60 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to chlorthalidone or sulfonamides; anuria Black Box Warnings None Medication Safety Issues: Chlorthalidone Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

CEFDINIR: Omnicef, Various

Class: Third-Generation Cephalosporin Dosage Forms. Powder for Oral Suspension: 125 mg/5 mL, 250 mg/5 mL; Oral Capsule: 300 mg Common FDA Label Indication, Dosing, and Titration. Acute otitis media, pharyngitis, tonsillitis: Children 6 mo through 12 y, 7 mg/kg po bid × 5-10 d or 14 mg/kg po daily × 10 d; max 600 mg/d; Adults, 300 mg po bid × 5-10 d Bronchitis, acute, secondary bacterial infection: Adults and Children >12 y of age, 300 mg po bid × 5-10 d Community-acquired pneumonia, uncomplicated skin, and/or subcutaneous tissue infection: 300 mg po bid × 10 d Off-Label Uses. Acute uncomplicated cystitis or acute simple cystitis: 300 mg po BID × 5-7 d Urinary tract infection, including pyelonephritis: 300 mg po BID × 10-14 d MOA. Cefdinir is a 3rd-generation cephalosporin with activity against a number of gram-positive and gram-negative bacteria including β-lactamase-producing strains. Drug Characteristics: Cefdinir Dose Adjustment Hepatic Not required Absorption F = 25%, food decreases absorption by 30% Dose Adjustment Renal CrCl <30 mL/min, decrease interval to daily Distribution Lung, maxillary sinus, middle ear fluid, skin, sputum Dialyzable Administer after hemodialysis and decrease interval to qod Metabolism Not metabolized Pregnancy Category B Elimination Renal 18% with a half-life of 2 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to cephalosporin Black Box Warnings None Medication Safety Issues: Cefdinir Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

DOXEPIN: Sinequan, Silenor, Various

Class: Tricyclic Antidepressant Dosage Forms. Oral Capsule: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg; Oral Tablet: 3 mg, 6 mg; Oral Solution: 10 mg/mL Common FDA Label Indication, Dosing, and Titration. Depression, anxiety, alcoholism: Very mild, 25-50 mg po daily, may titrate to 300 mg po daily; Mild-moderate, 75 mg po daily, may titrate to 300 mg po daily Insomnia: Adults <65 y of age, 6 mg po daily hs; Adults ≥65 y of age, 3 mg po daily hs, may titrate to 6 mg po daily hs Off-Label Uses. None MOA. Doxepin is a tricyclic antidepressant, which influences the adrenergic activity at the synapses where it prevents norepinephrine deactivation through reuptake into the nerve terminals. By binding to histamine receptor sites, it competitively inhibits the biological activation of histamine receptors. Antagonism of the H1 receptor is the most likely mechanism by which doxepin exerts its sleep maintenance effect. Drug Characteristics: Doxepin Dose Adjustment Hepatic Not required Absorption Food increases AUC and Cmax, delays Tmax Dose Adjustment Renal Not required Distribution Vd = 20.2 L/kg; 80% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; major substrate of CYP2D6 Pregnancy Category C Elimination Renal with a half-life of 15 h Lactation Avoid Pharmacogenetics Caution with CYP2D6 poor metabolizers Contraindications Hypersensitivity to doxepin; MAOI use, glaucoma, severe urinary retention Black Box Warnings Suicidality Medication Safety Issues: Doxepin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No SINEquan No No SEROquel, doxazosin, digoxin Highly anticholinergic, orthostatic hypotension; avoid dose >6 mg/d

AMITRIPTYLINE: Elavil, Various

Class: Tricyclic Antidepressant Dosage Forms. Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg Common FDA Label Indication, Dosing, and Titration. Depression: Adults, 75 mg po divided into 1-3 daily doses, titrate to max 300 mg/d; Children ≥12 y of age, 10 mg po tid or 20 mg po daily hs Off-Label Uses. Migraine prophylaxis: 10-25 mg po daily hs; titrate to max 150 mg/d Chronic pain: 25-100 mg po daily hs; titrate to max 150 mg/d Polyneuropathy, postherpetic neuralgia, treatment and prophylaxis: 10-25 mg po daily hs; may titrate to max 200 mg/d Posttraumatic stress disorder (PTSD): 50 mg po daily; titrate to max 300 mg/d MOA. Amitriptyline is a tricyclic antidepressant that blocks presynaptic reuptake of serotonin and norepinephrine with subsequent down-regulation of adrenergic receptors. Drug Characteristics: Amitriptyline Dose Adjustment Hepatic Start with low initial doses and increase as needed and tolerated Absorption F = 100%, no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd is highly variable Dialyzable Not dialyzable Metabolism Extensive hepatic; minor substrate of CYP1A2, 2B6, 2C9, 2C19, and 3A4/5; major substrate of CYP2D6 Pregnancy Category C Elimination Minimal renal with a half-life of 9-27 h Lactation Weigh risks and benefits Pharmacogenetics Caution in CYP2D6 poor metabolizers, or concurrently with CYP2D6 inhibitors ContraindicationsHypersensitivity; concurrent MAOI or MAOI use in last 14 d; use during acute recovery period after MIBlack Box WarningsSuicidality; not approved for children <12 y of age

DARIFENACIN: Enablex, Various

Class: Urinary Antispasmodic Dosage Forms. Oral Tablet, Extended Release: 7.5 mg, 15 mg Common FDA Label Indication, Dosing, and Titration. Overactive bladder: 7.5 mg po daily, may titrate to 15 mg po daily Off-Label Uses. None MOA. Darifenacin is a competitive muscarinic receptor antagonist. Muscarinic receptors play an important role in several major cholinergically mediated functions, including contractions of the urinary bladder smooth muscle and stimulation of salivary secretion. Drug Characteristics: Darifenacin Dose Adjustment Hepatic Child-Pugh B, do not exceed 7.5 mg po daily; Child-Pugh C, not recommended Absorption F = 15-25%, no effect of food on absorption Dose Adjustment Renal Not required Distribution Vd = 163 L Dialyzable Unknown Metabolism Extensive hepatic; substrate of CYP3A4/5; inhibits CYP2D6 Pregnancy Category C Elimination Renal 60% with a half-life of 13-19 h Lactation Weigh risks and benefits Pharmacogenetics Variable pharmacokinetics in CYP2D6 poor metabolizers Contraindications Hypersensitivity to darifenacin, gastric retention, glaucoma, urinary retention Black Box Warnings None Medication Safety Issues: Darifenacin Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No Do not crush or chew No Solifenacin No

DIPHTHERIA TOXOID: Adacel, Boostrix, Daptacel, Infanrix, Tenivac

Class: Vaccine, Inactivated, Bacterial Dosage Forms. Suspension for Intramuscular Injection: Children, primary immunization formulation available in combination with tetanus and acellular pertussis (DTaP, indicated for patients ≤6 y of age), or with tetanus (DT) in combination with other pediatric vaccines; Adults, booster formulation available in combination with tetanus (Td), and tetanus and acellular pertussis (Tdap, indicated for patients ≥10 y of age, or 7-10 y of age if primary vaccination series not completed, has lower dose of diphtheria toxoid and acellular pertussis vaccine than DTaP) Common FDA Label Indication, Dosing, and Titration. Prevention of diphtheria: Children, as primary series of DTaP, all infants at 2, 4, 6 mo of age (may be given as early as 6 wk of age and repeated q4-8wk × 3 doses), 4th dose at 15-18 mo of age (≥6 mo since 3rd dose, as early as 12 mo of age), and a 5th dose at 4-6 y of age; booster of Tdap at 11-12 y of age; Adults and Children ≥7 y of age, Td every 10 y if primary series completed (Tdap should replace Td as single dose of 10 y booster in patient who has not completed primary series or if vaccination status unknown); if Child has a valid contraindication to pertussis vaccine, DT should be used to complete primary vaccine series Off-Label Uses. None Drug Characteristics: Diphtheria Toxoid Pregnancy Category C ADME Not known Lactation Caution advised; weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to diphtheria toxoid or a component of the vaccine (some formulations may contain: polysorbate 80) Black Box Warnings None Medication Safety Issues: Diphtheria Toxoid Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Adacel, Daptacel, Tdap, DTaP No

ACYCLOVIR: Zovirax, Various

Class: Viral DNA Polymerase Inhibitor Dosage Forms. Capsule: 200 mg; Suspension: 200 mg/5 mL; Tablet: 400 mg, 800 mg Common FDA Label Indication, Dosing, and Titration. Genital herpes simplex: Adults, initial episode, 400 mg po tid or 200 mg po 5 times a day × 7-10 d; Adults, recurrent episode, 400 mg po tid × 5 d or 800 mg bid × 5 d or 800 mg tid × 2 d; Children ≥12 y of age, 1000-1200 mg/d po in 3-5 divided doses × 7-10 d Genital herpes simplex, suppressive therapy: Adults and Children ≥12 y of age, 400 mg po bid for up to 12 mo Herpes zoster (shingles): Adults and Children ≥12 y of age, 800 mg po 5 times a day × 7-10 d Varicella (chickenpox): Adults and Children ≥2 y of age and ≥40 kg, 800 mg po qid × 5 d; Children ≥2 y of age and < 40 kg, 20 mg/kg po qid × 5 d Off-Label Uses. Genital herpes simplex in HIV-positive patients, initial or recurrent: 400 mg po tid × 5-10 d Genital herpes simplex in HIV-positive patients, chronic suppression: 400-800 mg po bid-tid Cold sores (orolabial herpes simplex virus [HSV]), treatment: 200-400 mg 5 times a day × 5 d MOA. Acyclovir is an acyclic nucleoside analogue of deoxyguanosine that is selectively phosphorylated by the virus-encoded thymidine kinase to its monophosphate form. Cellular enzymes then convert the monophosphate to the active antiviral acyclovir triphosphate, which competitively inhibits viral DNA synthesis by inactivation of viral DNA polymerase and incorporation into and termination of viral DNA replication. Acyclovir has potent activity against HSV I and II and herpes zoster virus (varicella-zoster virus [VZV]). Drug Characteristics: Acyclovir Dose Adjustment Hepatic Not required Absorption F = 10-20%, food has no effect on absorption Dose Adjustment Renal CrCl 10-25 mL/min, increase interval to q8h; CrCl <10 mL/min, increase interval to q12h Distribution Vd = 0.8 L/kg; 9-33% protein bound, placenta, CSF, kidney, brain, lung, heart Dialyzable Hemodialysis removes 60% of dose. No adjustment for peritoneal (<10% removed) Metabolism Not metabolized Pregnancy Category B Elimination Renal 62-90% with a half-life of 2.5-3.3 h Lactation Compatible Pharmacogenetics None known Contraindications Hypersensitivity to acyclovir or valacyclovir Black Box Warnings None

FEBUXOSTAT: Uloric

Class: Xanthine Oxidase Inhibitor Dosage Forms. Oral Tablet: 40 mg, 80 mg Common FDA Label Indication, Dosing, and Titration. Hyperuricemia in patients not adequately treated with, or having adverse effects from, allopurinol: 40 mg po daily, may titrate to 120 mg po daily Off-Label Uses. None MOA. Selectively inhibits xanthine oxidase, the enzyme responsible for converting xanthine to uric acid. Lowers uric acid and reduces gout. Drug Characteristics: Febuxostat Dose Adjustment Hepatic Use with caution if severe hepatic dysfunction Absorption F ≥49% Dose Adjustment Renal CrCl <30 mL/min, max dose 40 mg/d Distribution Vd = 50 L; 99% protein bound Dialyzable Unknown Metabolism Extensively metabolized by numerous enzymes; individual enzymes have little contribution to total metabolism Pregnancy Category C Elimination Renal 50% with a half-life of 5-8 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Concurrent azathioprine or mercaptopurine Black Box Warnings Increased risk of death (cardiac, all-cause) Medication Safety Issues: Febuxostat Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No No No

ALLOPURINOL: Zyloprim, Various

Class: Xanthine Oxidase Inhibitor; Antigout Dosage Forms. Tablet: 100 mg, 300 mg Common FDA Label Indication, Dosing, and Titration. Gout, mild: 100-300 mg po daily; max dose 800 mg/d Gout, moderate to severe: 400-600 mg po daily in 2-3 divided doses, max dose 800 mg/d Hyperuricemia, tumor lysis syndrome: Children <6 y, 50 mg po tid or 150 mg po daily for 2-3 d; Children 6-10 y, 100 mg po tid or 300 mg po daily for 2-3 d; Adults, 600-800 mg/d po daily in 2-3 divided doses for 2-3 d; starting 12 h-3 d prior to chemotherapy Off-Label Uses. Malaria: 12 mg/kg/d po in 3 divided doses × 5 d, with quinine MOA. Allopurinol decreases the production of uric acid by inhibiting the action of xanthine oxidase, the enzyme that converts hypoxanthine to xanthine and xanthine to uric acid. Drug Characteristics: Allopurinol Dose Adjustment Hepatic Not required Absorption F = 80-90%, no effect of food on absorption Dose Adjustment Renal CrCl 10-20 mL/min, 200 mg po daily; CrCl 3-9 mL/min, 100 mg po daily, CrCl <3 mL/min, 100 mg at extended intervals (>24 h) Distribution Vd = 1.6-2.43 L/kg; <1% protein bound Dialyzable Yes, supplementation may be needed after dialysis Metabolism Hepatic (78%) and red blood cells Pregnancy Category C Elimination Renal 80% with a half-life of 2 h (parent compound), 15-25 h (active metabolite, oxypurinol) Lactation Usually compatible Pharmacogenetics None known ContraindicationsHypersensitivity to allopurinol, concurrent use of didanosineBlack Box WarningsNone

CARVEDILOL: Coreg, Coreg CR, Various

Class: α/β-Adrenergic Blocker Dosage Forms. Oral Tablet: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg; Oral Capsule, Extended Release: 10 mg, 20 mg, 40 mg, 80 mg Common FDA Label Indication, Dosing, and Titration. Heart failure: Tablet, 3.125 mg po bid, may titrate to 25 mg po bid for patients weighing <85 kg, 50 mg po bid for patients weighing >85 kg; Hypertension: Tablet, 6.25 mg po bid; max 25 mg po bid; Extended-release capsule, 20 mg po daily in the morning, max 80 mg po daily Impaired left ventricular function post-myocardial infarction: Tablet, 3.125-6.25 mg po bid, may titrate to 25 mg po bid; extended-release capsule, 10-20 mg po daily in the morning, max 80 mg po daily Off-Label Uses. Angina pectoris: 25-50 mg po bid Cardiac dysrhythmia: 6.25 mg po bid, may titrate to 50 mg po bid Post-acute coronary syndrome: 3.215 mg po bid, may titrate to 25 mg po bid MOA. Carvedilol is a selective α1- and nonselective β-adrenergic blocker that decreases AV nodal conduction in supraventricular tachycardias and blockade of catecholamine-induced dysrhythmia. Drug Characteristics: Carvedilol Dose Adjustment Hepatic Avoid use in patients with hepatic impairment; contraindicated in severe liver dysfunction Absorption F = 25-35%; food significantly increases AUC and Cmax for extended-release product Dose Adjustment Renal Not required Distribution Vd = 115 L; >95% protein bound Dialyzable Not dialyzable Metabolism Hepatic 98%; major substrate of CYP2D6, P-glycoprotein; inhibitor of P-glycoprotein Pregnancy Category C Elimination Renal 16%, fecal 60% with a half-life of 6-10 h Lactation Weigh risks and benefits Pharmacogenetics CYP2D6 poor metabolizers with higher plasma levels, consider lower initial dose Contraindications Hypersensitivity, bronchial asthma, severe sinus bradycardia, 2nd- or 3rd-degree AV block, sick sinus syndrome, overt heart failure, cardiogenic shock, severe hepatic impairment Black Box Warnings

DOXAZOSIN: Cardura, Cardura XL, Various

Class: α1-Adrenergic Blocker Dosage Forms. Oral Tablet: 1 mg, 2 mg, 4 mg, 8 mg; Oral Tablet, Extended Release, 24 h: 4 mg, 8 mg Common FDA Label Indication, Dosing, and Titration. Benign prostatic hyperplasia: Immediate release, 1 mg po daily, may titrate to 1-8 mg po daily; extended release, 4 mg po daily, may titrate to 8 mg po daily Hypertension: Immediate release, 1 mg po daily, max 16 mg po daily Off-Label Uses. Expulsion of distal ureteral stone: Immediate release, 2-4 mg po daily in evening × 4 wk Pheochromocytoma: 1-8 mg po daily MOA. Doxazosin selectively blocks postsynaptic α1-adrenergic receptors, reducing peripheral resistance through arterial and venous dilations. Reflex tachycardia that occurs with other vasodilators is infrequent because there is no presynaptic α2-receptor blockade. Increase urine flow by relaxing smooth muscle tone in the bladder neck and prostate. Drug Characteristics: Doxazosin Dose Adjustment Hepatic Not required Absorption F = 65%, food increases AUC and Cmax of extended-release product Dose Adjustment Renal Not required Distribution 98% protein bound Dialyzable Not dialyzable Metabolism Extensive hepatic; substrate of CYP3A4/5 Pregnancy Category C Elimination Renal 9%, fecal 63% with a half-life of 22 h Lactation Weigh risks and benefits Pharmacogenetics None known Contraindications Hypersensitivity to doxazosin or other quinazolines Black Box Warnings None

ATENOLOL: Tenormin, Various

Class: β-Adrenergic Blocker, Cardioselective Dosage Forms. Tablet: 25 mg, 50 mg, 100 mg Common FDA Label Indication, Dosing, and Titration. Angina pectoris, chronic: 50 mg po daily; titrate to 100-200 mg po daily Hypertension: Adults, 50 mg po daily, titrate to 100 mg po daily; Children, 0.5-1 mg/kg/d po in 1-2 divided doses, titrate to 2 mg/kg/d po in 1-2 divided doses (max 100 mg/d) Off-Label Uses. Cardiac dysrhythmia: Adults, 50-100 mg po daily; Children, 0.3-1.4 mg/kg po daily, titrate to 2 mg/kg po daily Migraine prophylaxis: 50-100 mg po daily MOA. Atenolol is a cardioselective β-adrenergic that decreases AV nodal conduction in supraventricular tachycardias and blockade of catecholamine-induced dysrhythmias. Drug Characteristics: Atenolol Dose Adjustment Hepatic Not required Absorption F = 50%, food decreases AUC by 20% Dose Adjustment Renal CrCl 15-35 mL/min, max dose 50 mg po daily; CrCl <15 mL/min, max dose 25 mg po daily Distribution Vd = 50-75 L; <5% protein bound Dialyzable Yes, give 25-50 mg after each dialysis procedure Metabolism Not metabolized Pregnancy Category D Elimination Renal 40-50%, fecal 50% (unchanged) with a half-life of 6-7 h Lactation Avoid Pharmacogenetics None known Contraindications Hypersensitivity to atenolol, severe sinus bradycardia, 2nd- or 3rd-degree AV block, overt heart failure or cardiogenic shock Black Box Warnings Avoid abrupt withdrawal Medication Safety Issues: Atenolol Suffixes Tall Man Letters Do Not Crush High Alert Confused Names Beers Criteria No No No No Albuterol No

AMOXICILLIN: Amoxil, Moxatag, Various

Class: β-Lactam Antibiotic Dosage Forms. Capsule: 250 mg, 500 mg; Chewable Tablet: 125 mg, 250 mg; Suspension: 125 mg/5 mL, 200 mg/5 mL; 250 mg/5 mL, 400 mg/5 mL; Tablet: 500 mg, 875 mg; Tablet, Extended Release: 775 mg Common FDA Label Indication, Dosing, and Titration. Acute otitis media: Adults, 500-875 mg po q12h × 10 d; Children, 80-90 mg/kg/d po in 2-3 divided doses Lower respiratory tract infection: Adults, 1 g po tid × 10 d; Children, 45 mg/kg/d divided q12h Pharyngitis, tonsillitis: Adults and Children >12 y, 775 mg po daily × 10 d Streptococcal pharyngitis: Adults, 1 g po daily × 10 d; Children, 50 mg/kg po once daily for 10 d, max 1 g daily Ear, nose, and throat infection, infection of skin and/or subcutaneous tissue, infection of genitourinary system: Adults, 500-875 mg po q12h × 10 d; Children, 25-45 mg/kg/d po divided q12h Helicobacter pylori gastrointestinal tract infection: 1 g po bid with PPI Off-Label Uses. Bacterial endocarditis, prophylaxis: Adults, 2 g po 1 h before procedure; Children, 50 mg/kg po 1 h prior to procedure, max 2 g daily Lyme disease: 500 mg po tid × 21-30 d; Children: 50 mg/kg/d po in 3 divided doses × 21-30 d MOA. Semisynthetic penicillin derivative that inhibits the biosynthesis of bacterial cell wall mucopeptide. Typically active against Streptococcus, Enterococcus, Staphylococcus, and Enterobacteriaceae. Drug Characteristics: Amoxicillin Dose Adjustment Hepatic Not required Absorption F = 85%, no effect of food on absorption Dose Adjustment Renal Moderate, increase interval to 8-12 h; severe, increase interval to q24h Distribution 17-20% protein bound. Lung, pleural fluid, bile, liver, and inner ear Dialyzable Yes (hemodialysis only) Metabolism Partially hepatic Pregnancy Category B Elimination Renal 50-70% with a half-life of 1-2 h Lactation Usually compatible Pharmacogenetics None known Contraindications Hypersensitivity Black Box Warnings

AMOXICILLIN/CLAVULANATE: Augmentin, Various

Class: β-Lactam Antibiotic Dosage Forms. Tablet: 250 mg amoxicillin/125 mg clavulanate, 500 mg amoxicillin/125 mg clavulanate, 875 mg amoxicillin/125 mg clavulanate; Tablet, Extended Release: 1000 mg amoxicillin/62.5 mg clavulanate; Tablet, Chewable: 200 mg amoxicillin/28.5 mg clavulanate, 400 mg amoxicillin/57 mg clavulanate; Suspension: 125 mg amoxicillin/31.25 mg clavulanate/5 mL, 200 mg amoxicillin/28.5 mg clavulanate/5 mL, 250 mg amoxicillin/62.5 mg clavulanate/5 mL, 400 mg amoxicillin/57 mg clavulanate/5 mL, 600 mg amoxicillin/42.9 mg clavulanate/5 mL Common FDA Label Indication, Dosing, and Titration. Acute otitis media: Adults, 500-875 mg po q12h × 10 d; Children, 80-90 mg/kg/d po in 2-3 divided doses Community-acquired pneumonia: Adults, 2000 mg po bid × 7-10 d Lower respiratory tract infection: Adults, 1000 mg po tid × 10 d; Children, 45 mg/kg/d po divided q12h Sinusitis, infection of skin or subcutaneous tissue, infectious disease of genitourinary system: Adults, 500-875 mg po q12h × 10 d; Children, 25-45 mg/kg/d po divided q12h Off-Label Uses. Streptococcal pharyngitis: Adults, 875 mg po q12h or 500 mg po q8h; Children, 45 mg/kg/d divided q12h MOA. Amoxicillin is a semisynthetic penicillin derivative. Typically active against Streptococcus, Enterococcus, Staphylococcus, and Enterobacteriaceae. Amoxicillin is not effective against β-lactamase-producing bacteria. Clavulanate, a β-lactamase inhibitor, has weak antibacterial activity but is a potent inhibitor of plasmid-mediated β-lactamases and protects amoxicillin from degradation by β-lactamases. Drug Characteristics: Amoxicillin/Clavulanate Dose Adjustment Hepatic Consider dose adjustment in severe impairment Absorption F = 85%, no effect of food on absorption Dose Adjustment Renal CrCl 10-30 mL/min, increase interval to q12h; CrCl <10 mL/min, increase interval to q24h; avoid 875 mg tablet and extended-release tablet for those on hemodialysis or CrCl <30 mL/min Distribution 17-20% protein bound; lung, pleural fluid, bile, liver, and inner ear Dialyzable Yes (peritoneal and hemodialysis) Metabolism Amoxicillin not metabolized, extensive metabolism of clavulanic acid Pregnancy Category B Elimination Renal 50-70% (amoxicillin) with a half-life of 1-2 h Lactation Compatible Pharmacogenetics None known ContraindicationsHypersensitivity to penicillins; extended-release products are contraindicated in patients on dialysis or severe renal dysfunctionBlack Box Warnings