FORMULARY: THERAPEUTIC CATEGORY...

34

N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx

FORMULARY: THERAPEUTIC CATEGORY LISTING* *Most current Formulary List of Drugs can be found:

1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf

2. LCHC website (http://www.lincolnchc.org/secondary/drug-formulary.html) 3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary. 4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs

Use Ctrl-F to quickly search the listing for a specific item.

Rx Pathways Plan Pfizer drugs are available to uninsured patients who are at or below 400% of the federal poverty

level. Only a dispensing fee is charged. NOTE: These medications are labeled as “RxP”. Patient Assistance Program Patients who meet specific eligibility requirements may receive formualry medications through

manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP” are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.

HIV Patient Assistance Program EI Clinic may access medications through for qualified patients. For patients that do not qualify for

ADAP, HIV medications may be obtained from manufacturer programs. http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf

Project Access Durham County Project Access Durham County (PADC) serves eligible low-income, uninsured Durham

residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.

Lab Monitoring Some formulary drugs require laboratory monitoring and are labeled as “LAB” (See Section VII.4.

Drugs Requiring Lab Monitoring pg 80)

Safety in Lactation Lactation safety data from American Academy of Pediatrics (www.aap.org) Medicaid Preferred Drug List http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf Medicaid Prior Authorizations https://www.nctracks.nc.gov/content/public/providers.html Hazardous Drugs Drugs identified by National Institute of Occupational Safety and Health as hazardous are labeled

as “HD”. Use caution when handling. (http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf)

https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf

http://www.projectaccessdurham.org/

http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf

http://www.aap.org/

http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf

https://www.nctracks.nc.gov/content/public/providers.html

http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf

http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf

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Therapeutic Category

Pharmacologic Category

Medication Brand Name Package Size (if applicable)

Preg Cat Safety in Lactation

Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ALZHEIMER DISEASE

Acetylcholinesterase Inhibitor (Central)

Donepezil Tablet 10mg Aricept C ? +

N-Methyl-D-Aspartate Receptor Antagonist

Memantine extended release tablet 7mg, 14mg, 21mg, 28mg Patient Assistance Program

Namenda XR 90 day supply PAP

B ? - K

ANALGESIC AND ANTIPYRETICS

Anticonvulsant, Analgesic Pregabalin Capsule 75mg, 150mg RxP

Lyrica C ? - K

Anticonvulsant, Neuropathic pain (unlabeled)

Gabapentin Capsule 100mg, 300mg

Neurontin C ? - K

Miscellaneous Acetaminophen Suspension 160mg/5mL

Tylenol Susp 120 mL B + L

Acetaminophen Tablet 325mg

Tylenol #100 tabs B + + L

Miscellaneous, Topical Capsaicin 0.025% Cream Capzasin 60 gm B +

NSAID Ibuprofen Suspension 100mg/5mL

Motrin B (D in 3rd trimester)

+ + K

Ibuprofen Tablet 400mg Motrin B (D in 3rd trimester)

+ + (taste may be

unacceptable)

+

K

Indomethacin Capsule 25mg, 50mg

Indocin B (D in 3rd trimester)

+ - + K

Naproxen Sodium Tablet 500mg

Naprosyn B (D in 3rd trimester)

+ + + K

NSAID, COX-2 Inhibitor Celecoxib Capsule 200mg RxP

Celebrex C (D in 3rd trimester)

? - +HF K/L

Opioid Acetaminophen/Codeine Tab 300mg/30mg

Tylenol With Codeine #3

C ? + L

Buprenorphine/Naloxone SL Tab 2mg/0.5mg, 8mg/ 2mg

Zubsolv C ? + K/L

Hydrocodone/ Acetaminophen Tab 5mg/325mg

Norco C ? + L

Tramadol Tablet 50mg Ultram C - + + K/L

ANTIANEMIA

AGENTS

Iron Preparations Ferrous Sulfate Drops

75mg/mL (15mg/mL elemental)

50mL + +

Iron Preparations Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)

480mL + +

36






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTIANEMIA AGENTS

Ferrous Sulfate Tablet 325mg (65mg elemental)

#100 tabs + + +

ANTICONVULSANT AGENTS

Anticonvulsant, Analgesic Pregabalin Capsule 150mg RxP

Lyrica C ? - K

Pregabalin Capsule 75mg RxP

Lyrica C ? - K

Anticonvulsant, Neuropathic pain (unlabeled)

Gabapentin Capsule 100mg, 300mg

Neurontin C ? - K

Barbiturate Phenobarbital Tablet 30mg

D - + + K/L

Hydantoin Phenytoin Sodium Capsule 100mg LAB, HD

Dilantin D + - L

Phenytoin Sodium Chewable tablet 50g LAB,

HD

Dilantin Infatabs D + + L

Miscellaneous Carbamazepine Tablet 200mg LAB, HD

Tegretol D + + K/L

Divalproex Sodium Tablet 250mg LAB, HD

Depakote X ? - L

Miscellaneous Lamotrigine Tablet 25mg, 100mg

Lamictal C - + L

Lamotrigine Tablet 50mg, 200mg Patient Assistance Program

Lamictal 90 day supply PAP

C - L

Topiramate Tablet 25mg, 200mg LAB, HD

Topamax D ? - (taste may be

unacceptable)

K/L

ANTIDEPPRESSANT AGENTS

Alpha2 Antagonist Mirtazapine Tablet 30mg Remeron C ? + K/L

Dopamine Reuptake Inhibitor

Bupropion Tablet 100mg Wellbutrin C - + + K/L

Selective Serotonin Reuptake Inhibitor

Fluoxetine Capsule 20mg Prozac C (- in 3rd trimester)

- - + L

Sertraline Tablet 50mg, 100mg

Zoloft C (- in 3rd trimester)

+ + + L

Serotonin Reuptake Inhibitor/Antagonist

Trazadone Tablet 50mg Desyrel C - + + K/L

Serotonin/Norepinephrine Reuptake Inhibitor

Duloxetine Capsule 20mg, 30mg, 60mg Patient Assistance Program

Cymbalta 120 day supply PAP

C ? - (may open & mix w/

applesauce, NOT choclate)

K/L

37






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTIDEPPRESSANT AGENTS

Tricyclic Amitriptyline Tablet 25mg, 50mg

Elavil D - + +

Doxepin Capsule 25mg, 50mg

Sinequan C - - +

Imipramine Tablet 10mg, 25mg

Tofranil D - + +

Nortriptyline Tablet 25mg

Pamelor D + + + K/L

ANTIDOTE Aldehyde Dehydrogenase Inhibitor

Disulfiram Tablet 250mg Antabuse C ? +

Alpha/Beta Adrenergic Agonist

Epinephrine IM Injection 0.15mg/0.15mL, 0.3mg/0.3mL

EpiPen 2 Auto-Injectors

C -

Antihistamine Diphenhydramine Capsule 25mg, 50mg

Benadryl B - - +

Diphenhydramine Elixer 12.5ml/5mL

Benadryl B - +

Opioid Antagonist Naloxone Nasal Spray 4 mg/0.1mL

Narcan 2 devices C ?

Naltrexone Tablet 50mg Revia; Vivitrol C ? +

ANTIEMETIC/ANTI-VERTIGO AGENTS

5-HT3 Receptor Antagonist

Ondansetron Tablet 4mg Zofran B ? + L

Anticholinergic, Antihistamine

Meclizine Tablet 12.5mg Antivert B ? + +

Antidopaminergic, Phenothiazine

Promethazine Suppository 25mg

Phenergan C - + L

Promethazine Tablet 25mg

Phenergan C - + L

ANTI-INFECTIVES Antifungal Nystatin Cream 100,000 units/gm

Mycostatin 15 gm C ?

Nystatin Suspension 100,000 units/mL

Nilstat 60 mL bottle C ?

Fluconazole Tablet 200mg HD

Diflucan C (single dose vag

candida), D all other

indications

+ + K

Antifungal Griseofulvin Susp 125mg/5mL

Grifulvin C ?

Terbinafine Cream 1% LAB

Lamisil AT 15 gm B ?

Terbinafine Tablet 250mg LAB

Lamisil B - + K/L

38






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTI-INFECTIVES Antihelmintic Albendazole Tablet 200mg

Albenza C ? + K

Antimalarial Hydroxychloroquine Tablet 200mg

Plaquenil C + + K/L

Antiviral Acyclovir Capsule 200mg Zovirax B + - K/L

Acyclovir Suspension 200mg/5mL

Zovirax B + K/L

Antiviral (Antihepaciviral) Ledaspasvir/sofosbuvir Tablet 90 mg/ 400mg Patient Assistance Program

Harvoni 90 day supply PAP

B ? -

(taste) L

Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg Patient Assistance Program

Epclusa 84 day supply PAP

B ? -

(taste)

Cephalosporin, 1st gen Cephalexin Capsule 250mg

Keflex B ? - K

Cephalosporin, 1st gen Cephalexin Suspension 250mg/5ml

Keflex B ? K

Cephalosporin, 2nd gen Cefuroxime Tablets 250mg

Ceftin B ? - (taste)

Cephalosporin, 3rd gen Cefdinir Suspension 250mg/5mL

Omnicef B ? K

Macrolide Azithromycin Suspension 200mg/5mL

Zithromax B ? K/L

Azithromycin Tablet 250mg

Zithromax B ? + K/L

Clarithromycin Tablet 500mg

Biaxin C ? + K

Miscellaneous Clindamycin Capsule 150mg

Cleocin B ? + K

Clindamycin Oral Solution 75mg/5mL

Cleocin 100 mL B ? K

Clindamycin Topical Solution 1%

Cleocin-T 60 mL B ?

Metronidazole Tablet 500mg

Flagyl B ? + K/L

Penicillin Amoxicillin Capsule 250mg

Amoxil B + - K

Penicillin Amoxicillin Suspension 250mg/5mL

Amoxil B + K

Amoxicillin/Clavulanic Acid Tablet 875mg/125mg

Augmentin B ? + K/L

Penicillin VK Suspension 250mg/5mL

Pen-Vee K B ? K

39






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTI-INFECTIVES Penicillin VK Tablet 500mg

Veetids B ? + K

Quinolone Ciprofloxacin Ophth Soln 0.3%

Cipro 5 mL bottle C (but teratogenicity unlikely)

?

Ciprofloxacin Tablets 500mg

Cipro C (but teratogenicity unlikely)

? + K/L

Levofloxacin Tablet 500mg

Levaquin C ? + K

Sulfonamide Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL

Septra Suspension

C + K/L

Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg

Septra DS C + K/L

Sulfasalazine Tablet 500mg

Sulfazine, Azulfadine

D - + K/L

Tetracycline Doxycycline Tablet 100mg

Vibramycin D ? +

Urinary Nitrofurantoin Capsule 100mg

Macrobid B +? - + K/L

ANTINEOPLASTIC AGENTS

Anti-estrogen Tamoxifen Tablet 10mg LAB HD

Nolvadex D - -

Aromatase Inhibitor Anastrozole Tablet 1mg Patient Assistance ProgramLAB, HD

Arimidex 90 day supply PAP

X -

ANTIPARKINSON AGENTS

Anticholinergic Trihexphenidyl Tablet 2mg

Artane C - + + K/L

Dopamine Agonist Carbidopa/Levodopa Tablet 25mg/100mg

Sinemet C - + K/L

ANTIPSYCHOTIC AGENTS

Atypical, mixed serotonin-dopamine antagonist

Lurasidone Tablet 20mg, 40mg, 60mg, 80mg, 120mg Patient Assistance Program

Latuda 90 day supply PAP

B ? + + K/L

Atypical, Serotonin/Dopamine Receptor Antagonist

Quetiapine tablet 25mg, 50mg, 100mg, 200mg, 300mg LAB

Seroquel C - + + K

Atypical Risperidone 0.5mg, 1mg,

2mg HD

Risperdal C - + + K/L

Bipolar Disorder Lithium Carbonate Capsule 300mg LAB

Eskalith D - - + K

40






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTIPSYCHOTIC AGENTS

Typical, D2 Antagonist Haloperidol Tablet 1mg, 2mg

Haldol C - + +

Trifluoperazine Tablet 2mg

Stelazine C - + + K/L

ANXIOLYTICS, SEDATIVES, HYPNOTICS

Antianxiety Agent Buspirone Tablet 15mg Buspar B - + K/L

Antihistamine Diphenhydramine Capsule 25mg, 50mg

Benadryl B - - +

Diphenhydramine Elixer 12.5ml/5mL

Benadryl B - +

Hydroxyzine HCL Syrup 10mg/5mL

Atarax C - + K/L

Hydroxyzine HCL Tablet 25mg, 50mg

Atarax C - + + K/L

Benzodiazepine Diazepam Tablets 5mg Valium D - + + L

Oxazepam Capsule 15mg

Serax D - - +

Neurohormone, indole Melatonin Tablet 3mg #120 - -

CARDIOVASCULAR DRUGS

ACE-Inhibitor Lisinopril Tablet 5mg, 10mg, 20mg, 40mg LAB

Zestril D ? + K

ACE-Inhibitor/ Diuretic, Thiazide

Lisinopril/HCTZ Tablet 20/12.5mg, 20/25mg LAB

Zestoretic D ? + K

Alpha Adrenergic Inhibitor, Alpha2 Adrenergic Agonist

Methyldopa Tablet 250mg

Aldomet B + + + K/L

Alpha1 Blocker Doxazosin Tablet 2mg, 8mg

Cardura C ? + + L

Prazosin Capsule 1mg, 2mg, 5mg

Minipress C ? - + L


Alpha2 Adrenergic Agonist

Clonidine Tablet 0.1mg, 0.2mg, 0.3mg

Catapres C ? + + K

Angiotensin Receptor Blocker

Losartan Tablet 25mg, 50mg, 100mg

Cozaar D ? + L

Antiarrhythmic Amiodarone Tablet 200mg LAB

Cordarone D - + + L

Digoxin Tablets 0.125mg, 0.25mg LAB

Lanoxin C + + + K

41






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Anticoagulant (Direct Oral Anticoagulant)

Apixaban Tablets 2.5 mg, 5mg, 10mg Patient Assistance Program

Eliquis 90 day supply PAP

B - + K

Rivaroxaban Tablet 15mg, 20mg Patient Assistance Program

Xarelto 30-day supply prescription card PAP

C - + K/L

Anticoagulant Enoxaparin SQ Injection 30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg Patient Assistance Program LAB

Lovenox B + K

Warfarin Tablet 5mg LAB Coumadin - (1st trimester),

C

Use caution

+ K/L

Antihyperlipidemic, 2-Azetidinone

Ezetimibe tablet 10mg Patient Assistance Program

Zetia 90 day supply PAP

C ? + L

Antihyperlipidemic, Fibric Acid

Gemfibrozil Tablet 600mg

Lopid C ? + K

Antihyperlipidemic, HMG-CoA Reductase Inhibitor

Atorvastatin Tablet 10mg, 20mg, 40mg, 80mg

Lipitor X - + L

Antiplatelet Aspirin Tablet 81mg, 325mg (enteric coated)

Ecotrin #120 tablets

D ? - K/L

Clopidogrel Tablet 75mg Plavix B ? + L

Beta Blocker, cardioselective

Atenolol Tablet 50mg, 100mg

Tenormin D - - K

Metoprolol Tartrate Tablet 25mg, 50mg

Lopressor C ? + L

Beta Blocker, non-selective

Propranolol Tablet 10mg, 40mg

Inderal C + + K/L

Beta Blocker w/ alpha blocking ability

Carvedilol Tablet 3.125mg, 12.5mg, 25mg

Coreg C ? + L

Calcium Channel Blocker Amlodipine Tablets 5mg, 10mg

Norvasc C ? + L


Diltiazem HCl XR 180mg, 240mg Capsule

Cardizem CD C + - +

Nifedipine XL Tablet 30mg, 60mg, 90mg

Procardia XL C - - L

Verapamil SR Tablet 180mg, 240mg

Calan SR C - + split/- crush

+ K/L

Carbonic Anhydrase Inhibitor

Acetazolamide Tablet 500mg ER 12 hr

Diamox Sequels C - + K/L

42






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Diuretic, Loop Furosemide Tablet 40mg Lasix C ? + K/L

Diuretic, Potassium Sparing

Spironolactone Tablet 25mg HD

Aldactone D + + K

Spironolactone/HCTZ Tablet 25mg/25mg HD

Aldactazide D + + K

Diuretic, Thiazide Hydrochlorothiazide Tablet 25mg, 50mg

Hydrodiuril B (D is used in

pregnancy-induced HTN)

+ + K

Vasodilator Hydralazine Tablet 25mg, 50mg

Apresoline C + + K

Isosorbide Dinitrate Tablet 10mg, 20mg, 40mg

Isordil C ? +

Nitroglycerin SL Tablet 0.4mg

Nitrostat #100 tabs C ?

Nitroglycerin Transdermal Patch 0.2mg/hr, 0.4mg/hr, 0.6mg/hr

Transderm Nitro #30 patches C ? -

DEVICE Nasal Aspirator + +

Nasal Irrigation Kit Neti Pot + +

Peak Flow Meter + +

Pill Box + +

Spacer Aerochamber + +

Spacer, with mask Aerochamber + +

Syringes 31G 5/16" 0.5mL, 1mL

Monoject + +

Tablet Cutter + +

ELECTROLYTE SUPPLEMENT

Treatment of Dehydration Electrolyte Solution Pedialyte/ Infalyte

1,000 mL ? ?

Treatment of Hypokalemia

Potassium Chloride Tablet 8mEq

Klor-Con C ? - K

ENDOCRINE AND METABOLIC AGENTS

Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor

Finasteride Tablet 5mg HD Proscar X - - HD

L


Antidiabetic, Biguanide Metformin Tablet 1000mg LAB

Glucophage B ? + K/L

Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib

Sitagliptin Tablet 25mg, 50mg, 100mg

Januvia B ? - K/L

Antidiabetic, GLP-1 Agonist

Liraglutide 18mg/3mL Pen Injector Patient Assistance Program

Victoza 120 day supply PAP

C -

43






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Antidiabetic, Insulin Rapid-Acting

Insulin Aspart 100units/mL

Novolog B/C + - + Sliding Scale

Insulin Lispro 100units/mL

Humalog B/C + + Sliding Scale

Insulin Glulisine 100units/mL Patient Assistance Program

Apidra 90 day supply PAP

B/C + + Sliding Scale

Antidiabetic, Insulin Short-Acting

Insulin Regular 100units/mL

Novolin R B/C + + Sliding Scale

Antidiabetic, Insulin Combination

Insulin Aspart Protamine and Insulin Aspart 100units/mL

NovoLog Mix 70/30

B/C +

Insulin Lispro Protamine and Insulin Lispro 100units/mL

Humalog Mix 75/25

B/C +

Insulin NPH and Insulin Regular 100units/mL

Novolin 70/30 B/C +

Antidiabetic, Insulin Intermediate-Acting

Insulin NPH 100units/mL Novolin NPH B/C +

Antidiabetic, Insulin Long-Acting

Insulin Detemir 100units/mL

Levemir B/C +

Insulin Glargine 100units/mL

Lantus 90 day supply PAP

B/C +

Antidiabetic, SGLT-2 Inhibitor

Empagliflozin Tablet 10mg, 25mg

Jardiance 90 day supply PAP

C - + K

Antidiabetic, Sulfonylurea Glipizide ER Tablet 5mg, 10mg

Glucotrol XL C ? - L

Antidiabetic, Thiazolidinedione

Pioglitazone Tablet 15mg, 30mg LAB

Actos C ? + L

Biphosphonates, Osteoporosis

Alendronate Tablet 4mg Fosamax #4 tabs C - + K

Contraceptive Hormone, Combination

Norethindrone/ E. Estradiol (triphasic) Tablet 0.5-0.75-1mg/0.035mg HD

Ortho-Novum 7/7/7

#28 tabs X/D - + + L

Norgestrel/ E. Estradiol Tablet 0.3mg/0.03mg HD

Lo-Ovral #28 tabs X - + + L


Contraceptive Hormone, Progestin

Medroxyprogesterone Acetate Tablet 10mg HD

Provera X + + + L

Norethindrone Tablet 0.35mg HD

Nor-Q-D #28 tabs X - (may start 6

wks after

preg)

+ + L

Contraceptive, Postcoital Levonorgestrel Plan B One-Step #1 X - + + L

Estrogen Estrogens, conjugated Tablet 0.625mg HD

Premarin X - + +

44






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Glucocorticoids Prednisolone Syrup 15mg/mL

Prelone C + + K/L

Prednisone Tablet 5mg, 20mg

Deltasone C + + + K/L

Gonadotropin Releasing Hormone Agonist

Leuprolide IM Injection 11.25mg, 22mg, 30mg Patient Assistance ProgramLAB, HD

Lupron 90 day supply PAP

X -

Gout Colchicine Tablet 0.6mg

HD Colcrys C ? + K/L

Gout, Xanthine Oxidase Inhibitors

Allopurinol Tablet 100mg, 300mg

Zyloprim C + + K

Progestin Megestrol Acetate Susp 40mg/mL HD

Megace D ? + K

Thyroid Levothyroxine 0.088mg, 0.1mg, 0.112mg, 0.125mg, 0.15mg, 0.175mg, 0.2mg Tablet LAB

Levoxyl A + +

Methimazole Tablet 10mg

Tapazole D + +

EYE, EAR, NOSE, AND THROAT

Analgesic Lidocaine (Viscous) Oral Solution 2%

Xylocaine 100 mL B +

Antiglaucoma, Alpha2 Agonist

Brimonidine Tartrate Ophthalmic 0.2%

Alphagan 5 mL B ?

Antiglaucoma, Beta-Adrenergic Blocker

Timolol Maleate Ophth Soln 0.5%

Timoptic 5 mL C +

Antiglaucoma, Carbonic Anhydrase Inhibitor

Dorzolamide 2% Trusopt 10 mL C -

Antiglaucoma, Cholinergic Agent

Pilocarpine Ophth Soln 4%

Pilocar 15 mL C ?

Antiglaucoma, Prostaglandin Inhibitor

Latanoprost Ophth Sol 0.005%

Xalatan 2.5 mL C ?


Anti-infective Chlorhexidine Oral Rinse 0.12%

Peridex 480 mL B ?


Anti-infective Erythromycin 5mg/gm Ilotycin 3.5 gm B +

Polymyxin/Trimethoprim Ophth Soln 10,000 units-1mg/mL

Polytrim 10 mL C ?

Anti-infective, Corticosteroid

Neomycin/Polymyxin B/Hydrocortisone Otic Susp

Cortisporin Otic Otic 10mL ? ?

Cerumenolytic Carbamide Peroxide Otic Drops 6.5%

Debrox 15 mL ? ?

45






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Corticosteroid Fluticasone Propionate Nasal Spray 50mcg/spray

Flonase 16 gm C ?

Ketorolac 0.5% Ophth Soln

Acular 5 mL C ?

Prednisolone Acetate Ophth Soln 1%

Pred Forte 15 mL C ?

Corticosteroid, Antifungal, Antihistamine

Hydrocortisone, Nystatin, Diphenhydramine Susp

Duke's Mouthwash

120 mL per bottle

? -

Irrigation Saline Nose Spray Saline Spray 45 mL + +

Lubricant Artificial Tear Drops Artificial Tears 15 Ml + +

Artificial Tear Ointment Duratears 3.5 gm + +

Mydriatic Atropine Ophth Soln 1% Atropine 15 mL C +

Antihistamine, Mast Cell Stabilizer

Ketotifen Ophth Soln 0.025%

Zaditor

5 mL C ?

Vasoconstrictor/ Antihistamine

Naphazoline/Pheniramine Ophth Soln 0.025%/0.3%

Vasocon-A 15 mL C ?

GASTROINTESTINAL DRUGS

Antacid Magnesium/Aluminum/ Simethicone Suspension

Maalox Max Strength

480 mL C ? K

Anticholinergic Dicyclomine Capsules 10mg

Bentyl B - - +

Antidiarrheal Diphenoxylate/Atropine Sulf Tablets 2.5/0.025mg

Lomotil; Lonox C - - K/L

Bismuth Subsalicylate Tablet 262mg

Pepto-Bismol #30 tabs D ? +

Antidiarrheal Loperamide Tablet 2mg Imodium #12 tabs C + +

GASTROINTESTINAL DRUGS

Antiflatulent Simethicone Drops 40mg/0.6mL

Mylicon 30 mL C but + ?

Constipation, Chronic Lactulose Syrup 10gm/15mL

Duphalac Syrup B ?

Constipation, IBS Lubiprostone Capsule 24mcg Patient Assistance Program

Amitiza 90 day supply PAP

C ? -

Histamine H2 Antagonist Ranitidine Syrup 15mg/mL

Zantac B ? +

Ranitidine Tablet 150mg, 300mg

Zantac B ? + +

46






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Laxative, Diphenylmethane

Bisacodyl Tablet 5mg Dulcolax C ? -

Laxative, Osmotic Glycerin 1 gm suppository

Pedia-Lax Rectal A + +

Laxative, Osmotic Glycerin 2 gm suppository

Sani-Supp Adult Rectal

A + +

Polyethylene Glycol MiraLax 255 gm C ?

Laxative, Osmotic (for Bowel Prep)

Polyethylene Glycol with Electrolytes

GoLytely 4,000 mL C ?

Laxative, Bulk Psyllium Hydrophilic Powder

Metamucil 284 gm + ?

Pancreatic Enzymes Pancreatic Enzymes Capsule Lipase/Protease/Amylase 6k/19k/30k, 12k/38k/60k, 24k/76k/120k Patient Assistance Program

Creon 90 day supply PAP

C ? - (OK to open

and give with

apple-sauce or pudding)

K

Prokinetic Metoclopramide Tablet 10mg

Reglan B ? + + K

Proton Pump Inhibitor Omeprazole Capsule 20mg

Prilosec C ? - + L

Stool Softener Docusate Sodium Capsule 100mg

Colace #100 caps C ? - (taste may be

unacceptable)

GENITOURINARY AGENTS

Alpha1 Blocker Tamsulosin 0.4mg Capsule

Flomax B + -

Analgesic, Urinary Phenazopyridine Tablet 100mg, 97.5mg or 95mg

Pyridium B ? + K

Anticholinergic, Urinary Tolterodine Tartrate extended release tablet 4mg RxP

Detrol LA C - - + K/L

GENITOURINARY AGENTS

Antispasmodic, Urinary Oxybutynin Chloride Tablet 5mg

Ditropan B ? + + K/L

MIGRAINE AGENTS Migraine Combinations Butalbital, Acetaminophen and Caffeine Tablet 50mg/325mg/40mg

Note: Fioricet changed strength April 2014 and no longer has a generic

C - + +

K/L

Serotonin 5-HT1 Receptor Agonist

Eletriptan Tablet 40mg RxP

Relpax 6 tabs per box

C ? + L

NEPHROLOGY Calcium, Phosphate Binder

Calcium Acetate Capsule 667mg

PhosLo C ? -

47






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Treatment of Hyperkalemia

Sodium Polystyrene Sulfonate Susp 15gm/60mL

Kayexalate 60 mL per bottle

C ?

Vitamin D Analog Calcitriol Capsule 0.5mcg Rocaltrol C ? -

Vitamin D Analog Paricalcitol Capsule 1mcg, 2mcg, 4mcg Patient Assistance Program

Zemplar 90 day supply PAP

C ? -

NUTRIENTS AND NUTRITIONAL AGENTS

Calcium Supplement Calcium (elemental) Tablet 500mg

Calcium #60 tabs per bottle

+ (? 1st trimester)

? + K

Hypomagnesemia Magnesium Oxide Tablet 400mg (240mg elemental)

MagOx #120 A + + L

Nutritional Supplement Thiamine Tablet 100mg Various #100 tabs A + +

Vitamin Cyanocobalamin Tablets 500mcg

Vitamin B12 #130 tabs C + +

Folic Acid Tablet 1mg A + +

Multivitamin Drops with Iron

Poly-vi-sol 50 mL + +

Multivitamin Tablet, Adult

Centrum #100 tabs + + +

Multivitamin tablet, Children

Flinstones #100 tabs + + +

NUTRIENTS AND NUTRITIONAL AGENTS

Omega-3 Fatty Acids (180 EPA / 120 DHA)

Fish Oil #100 caps C ? - L

Prenatal Vitamins Natalins RX #100 tablets + + +

Vitamin D3 Tablet 400 IU, 1000 IU

#100 tabs C Avoid high doses

Vitamin D3 Capsule 50000 IU

C Avoid high doses

RESPIRATORY AGENTS

Antihistamine Cetirizine Solution 1mg/mL

Zyrtec 120 mL B - K

Cetirizine Tablet 10mg Zyrtec #30 tablets B - + K

48






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Loratadine Tablet 10mg Claritin #30 tabs B + + K

Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist)

Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg

Actifed #24 tabs - (1st trimester),

C

? + +

Antitussive Benzonatate Capsule 100mg

Tessalon Perles #20 caps C ? -

Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant

Fluticasone Propionate/Salmeterol Diskus 100/50mcg, 250/50mcg, 500/50mcg

Advair Diskus C ?

Bronchodilator, Anticholinergic

Ipratropium Bromide MDI 17mcg/actuation Patient Assistance Program

Atrovent MDI: 90 day supply PAP

B ?

Ipratropium Bromide Nebulizer Soln 0.02%

Atrovent 25 vials per box

B ?

Tiotropium Bromide Cap for inhalation 18mcg

Spiriva C - -

Bronchodilator, Beta2-Adrenergic Agonist

Albuterol MDI Proventil, Ventolin, ProAir

6.7 gm C ?

Albuterol Nebulizer Solution 0.083%

Proventil, Ventolin

#25 C ?

Corticosteroids, Inhalant Beclomethasone 40mcg, 80mcg MDI

QVAR 8.7 gm C ?

Fluticasone Propionate MDI 44mcg/puff, 110mcg/puff, 220mcg/puff

Flovent C ?

RESPIRATORY AGENT

Decongestant (Alpha/Beta Adrenergic Agonist)

Pseudoephedrine Tablet 30mg, 60mg

Sudafed #24 tabs C + + + K

Decongestant (topical) Oxymetazoline Nasal Spray 0.05%

Afrin 15 mL C ?

Expectorant Guaifenesin Tablet 200mg

Humibid #100 tabs C + +

Leukotriene Inhibitor Montelukast Chewable Tablet 4mg, 5mg

Singulair B ? + L

Montelukast Tablet 10mg Singulair B ? + L

RHEUMATOLOGY Disease Modifying Antirheumatic Drug (DMARD)

Methotrexate Tablet 2.5mg LAB, HD

Rheumatrex X - + K/L

Tumor Necrosis Factor Blocking Agent

Adalimumab Injection 40mg Patient Assistance

Humira 90 day supply PAP

B - - ?

49






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ProgramLAB

SKELETAL MUSCLE RELAXANT

Centrally Acting Cyclobenzaprine Tablets 5mg

Flexeril B ? + + L

Methocarbamol Tablet 500mg

Robaxin C ? + + L

Baclofen Tablet 10mg Lioresal C + + K

SKIN AND MUCOUS MEMBRANE AGENTS

Acne Benzoyl Peroxide Gel 5% Panoxyl 42.5 gm C ?

Tretinoin Cream 0.05%

HD Retin-A 45 gm D -

Antibiotic, Topical Bacitracin Ointment 500 units/gm

15 gm B ?

Mupirocin 2% Ointment Bactroban 22 gm B ?

Antifungal Ketoconazole 2% Shampoo

Nizoral 120 mL C ?

Miconazole Cream 2% Micatin 30 gm + ?

Nystatin Cream 100,000 units/gm

Mycostatin 15 gm C ?

Terconazole Vaginal Cream 0.8%

Terazol-3 20 gm C -

Anti-infective Silver Sulfadiazine Silvadene 20 gm B -

Antiparasitic Agent, Pediculocide

Piperonyl Butoxide and Pyrethrum Extract Kit

Rid Shampoo 120 mL C ?

Permethrin Cream 5% Elimite 60 gm B ?


Anti-viral, topical immunomodulator

Imiquimod Cream 5% Aldara #12 single-use packets

C ?

Corticosteroid Clobetasol Ointment 0.05%

Temovate 15 gm C ?

Clobetasol Solution 0.05%

Temovate 50 mL C ?

Fluocinonide Cream 0.05%

Lidex 30 gm C -

Hydrocortisone Cream 1%, 2.5%

30gm (1%) 20gm(2.5%)

C ?

Hydrocortisone Ointment 1%

30 gm

Hydrocortisone Suppository 25mg

Anusol-HC #12 per box C ?

Triamcinolone Acetonide Cream 0.1%

Aristocort; Kenalog

15 gm, 80 gm

C ?

50






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Triamcinolone Acetonide Dental Paste 0.1%

Oralone 5 gm C ?

Dandruff Sulfur/Salicylic Acid Shampoo 2%/2%

Sebulex 120 mL C -

Estrogen Estrogens, conjugated Cream 0.625mg/gm HD

Premarin 30 gm X -

Miscellaneous Metronidazole Gel 0.05% (Topical)

Metrogel 45 gm B ?

Moisturizing Moisturizing Cream Eucerin 120 gm + +

Protectant Zinc Oxide Ointment 20%

Desitin 30 gm + +


Tinea Versicolor; Dandruff; Seborrheic Dermatitis

Selenium Sulfide Lotion 2.5%

Selsun 120 mL C ?

SMOKING CESSATION

Dopamine Reuptake Inhibitor

Bupropion Tablet 100mg Wellbutrin C - + + K/L

SMOKING CESSATION

Nicotine Product Nicotine Gum 2mg, 4mg Nicorette Gum 110 pieces C - K/L

Nicotine Transdermal Patch 7mg, 14mg, 21mg

Nicoderm CQ #14 patches D - K/L

Partial Nicotine Agonist Varenicline Tablet Starter Pack RxP

Chantix C - + K

VareniclineTablet Continuing Pack RxP

Chantix C - + K

STIMULANT ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tabs 10mg

Adderall C - + + K

Methylphenidate HCl Tablet 5mg

Ritalin C ? + +

Updated: February 28th, 2018

Date post:	27-Jul-2018
Category:	Documents
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