Drug Midterm Counseling Points

Strattera (atomoxetine)

BBW: Risk of suicidal ideation

Contraindications: Do not use within 14 days of MAOIs.

Warnings/Side Effects: Severe hepatoxicity (rare), decreased appetite, insomnia, somnolence, dry mouth, hypertension, tachycardia

*Do not open capsules

dexmethylphenidate & methylphenidate

BBW: High potential for abuse

Contraindications: Do not use within 14 days of MAOIs.

Warnings/Side Effects: Increase heart rate and BP (can cause serious CV events), priapism, psychosis, lowers the seizure threshold, insomnia, decreased appetite, weight loss, headache, irritability

Adderall (amphetamine/dextroamphetamine)

See counseling points for dexmethylphenidate. **Boxed Warning: Misuse can cause sudden death and CV events

Vyvanse (lisdexamphetamine)

See counseling points for dexmethylphenidate. *Low abuse potential

Provigil (modafinil)

Side Effects: Severe rash (SJS), headache, insomnia

Adipex-P (phentermine)

Contraindications: Cardiovascular disease (e.g. uncontrolled hypertension), hyperthyroidism, glaucoma, pregnancy, history of drug abuse

Side Effects: Tachycardia, agitation, increased blood pressure

Soma (carisoprodol)

Side Effects: Drowsiness, dizziness, confusion, asthenia (muscle weakness)

Drug Interactions: Increased carisoprodol concentrations in poor CYP2C19 metabolizers

Flexeril (cyclobenzaprine)

Side Effects: Dry mouth, drowsiness, dizziness, confusion, muscle weakness

Drug Interactions: Risk of serotonin syndrome (rare) when used with other serotonergic drugs

*Use caution with alcohol (CNS depressants)

Zanaflex (tizanidine)

Side Effects: Hypotension, dry mouth, drowsiness, dizziness, confusion, muscle weakness

*Use caution with alcohol (CNS depressants)

Lioresal (baclofen)

Side Effects: Sedation, dizziness, confusion, muscle weakness, nausea, constipation, headache, hypotension

*Use caution with alcohol (CNS depressants)

Robaxin (methocarbamol)

Side Effects: Sedation, dizziness, confusion, muscle weakness

Methadose (methadone)

BBW: QT prolongation, abuse and misuse can lead to overdose and death, respiratory depression (can be fatal)

Side Effects: Constipation, N/V, somnolence, dizziness/lightheadedness, risk of respiratory depression

Drug Interactions: Caution with other CNS depressants (e.g. benzodiazepines)

Counseling points: Avoid alcohol

Suboxone (buprenorphine/naloxone) & MS Contin (morphine sulfate) & Oxycontin (oxycodone)

BBW: Abuse and misuse can lead to overdose and death, respiratory depression (can be fatal)

Side Effects: Constipation, N/V, somnolence, dizziness/lightheadedness, risk of respiratory depression

Drug Interactions: Caution with other CNS depressants (e.g. benzodiazepines)

Counseling points: Avoid alcohol

Duragesic (fentanyl)

BBW: Abuse and misuse can lead to overdose and death, respiratory depression (can be fatal)

Side Effects: Constipation, N/V, somnolence, dizziness/lightheadedness, risk of respiratory depression, application site erythema (patch)

Drug Interactions: Caution with other CNS depressants (e.g. benzodiazepines)

Counseling points: Avoid alcohol. Patch - apply to hairless skin, do NOT cover with a heating pad, fold patch in half and dispose in the toilet. Do not discard in trash.

Dilaudid (hydromorphone)

BBW: Abuse and misuse can lead to overdose and death, respiratory depression (can be fatal)

Side Effects: Constipation, N/V, somnolence, dizziness/light-headedness, risk of respiratory depression

Drug Interactions: Caution with other CNS depressants (e.g. benzodiazepines)

Notes: Potent, high risk for overdose

Counseling points: Avoid alcohol.

Tylenol with Codeine (codeine/acetaminophen)

BBW: Abuse and misuse with codeine can lead to overdose and death, respiratory depression (can be fatal), CYP450 2D6 ultra-rapid metabolizers have increased risk of respiratory depression and death

Contraindications: Do not use in children under 12 years of age. Do not use in children under 18 years of age following a tonsillectomy or adenoidectomy surgery.

Side Effects: Constipation, N/V, somnolence, dizziness/lightheadedness, risk of respiratory depression

Drug Interactions: Caution with other CNS depressants (e.g. benzodiazepines)

Notes: Codeine has a high degree of GI side effects.

Counseling points: Avoid alcohol.

Tussionex (hydrocodone/chlorpheniramine polistirex)

See counseling points for oxycodone. *Do not use in patients under 18 years of age.

Ultram (tramadol)

BBW: Abuse and misuse can lead to overdose and death, respiratory depression (can be fatal). CYP450 2D6 ultra-rapid metabolizers have increased risk of respiratory depression and death

Contraindications: Do not use in children under 12 years of age. Do not use in children under 18 years of age following a tonsillectomy or adenoidectomy. Do not use within 14 days of MAOIs.

Warnings/Precautions: Seizure risk, hypoglycemia, risk of serotonin syndrome when used with other serotonergic drugs

Side Effects: Constipation, N/V, somnolence, dizziness/lightheadedness, risk of respiratory depression

Drug Interactions: Caution with other agents that lower seizure threshold.

Counseling point: Avoid alcohol.

Tylenol (acetaminophen)

BBW: Severe hepatoxicity with doses >4 grams/day

Side Effects: Generally well-tolerated

Drug Interactions: Doses >2g/day can increase INR when used with warfarin.

Notes: OTC, no anti-inflammatory effect

Counseling point: Limit/avoid alcohol use due to hepatoxicity. Recommend a lower max dose of 3g/day to avoid hepatotoxicity.

Voltaren (diclofenac sodium) & Cataflam (diclofenac potassium) & Mobic (meloxicam) & Relafen (nabumetone)

BBW: GI bleed risk, CV risk (myocardial infarction and stroke)

Contraindications: Avoid use after CABG surgery.

Side Effects: Decreases renal clearance, increases blood pressure, nausea, photosensitivity, edema

Drug Interactions: Caution with medications with bleeding risk. Avoid use with other NSAIDs. Can increase lithium levels.

Notes: Avoid in pregnancy (teratogenic).

Counseling Points: Take with food to limit nausea.

***Gel formulation is available OTC. Use the dosing card provided in package to correctly measure the dose.***

Indocin (indomethacin)

See counseling points for diclofenac sodium/potassium. *Causes CNS side effects

Toradol (ketorolac)

See counseling points for diclofenac sodium/potassium.

***BBW: Maximum duration of 5 days. Warnings: Acute renal failure, liver failure

Naprosyn (naproxen) & Aleve (naproxen sodium)

See counseling points for diclofenac sodium/potassium.

*****Can be dosed BID. Available OTC.

Motrin, Advil (ibuprofen)

See counseling points for diclofenac sodium/potassium. ****Available OTC. Max Adult Dose: 3.2g/day (Rx) or 1.2g/day (OTC)

Celebrex (celecoxib)

See counseling points for diclofenac sodium/potassium. ****Contraindicated in sulfonamide allergy

Lunesta (eszopiclone) & Ambien (zolpidem tartrate)

BBW: Complex sleep behaviors can cause serious injury or death.

Contraindications: History of complex sleep behavior

Warnings/Precautions: Potential for abuse. Risk of CNS depression

Side Effects: Somnolence, dizziness, ataxia, headache, parasomnias (unusual actions while sleeping)

Drug Interactions: Additive effects with other sedating drugs.

Counseling Point: Avoid alcohol.

Desyrel (trazodone)

BBW: Increased risk of suicidal thoughts in children, teenagers, and young adults in the first few months of treatment.

Contraindications: Do not use with MAOIs, linezolid, or IV methylene blue

Side Effects: Sedation, orthostasis, priapism

Drug Interactions: Increased risk with other QT prolonging drugs. Avoid use with other serotonergic drugs.

Counseling Points: Take at bedtime. Can take 1-2 weeks to feel a benefit. May take 6-8 weeks for full effect.

Remeron (mirtazapine)

**Indicated for depression, appetite stimulant, and sleep

BBW: Increased risk of suicidal thoughts in children, teenagers, and young adults in the first few months of treatment

Contraindications: Do not use with MAOIs, linezolid, or IV methylene blue

Side Effects: Sedation, increased appetite, weight gain

Drug Interactions: Increased risk with other QT prolonging drugs. Avoid use with other serotonergic drugs.

Counseling Points: Take at bedtime. Can take 1-2 weeks to feel a benefit. May take 6-8 weeks for full effect.

Wellbutrin (bupropion)

BBW: Increased risk of suicidal thoughts in children, teenagers, and young adults in the first few months of treatment.

Contraindications: Seizure disorder, history of eating disorders. Do not use within 14 days of MAOIs. Do not use with linezolid or IV methylene blue.

Side Effects: Dry mouth, insomnia, tremors/seizures, weight loss

Notes: Lower risk of sexual dysfunction compared with other antidepressants.

Counseling Points: Can take 1-2 weeks to feel a benefit. May take 6-8 weeks for full effect.