Drug Counseling Points

Direct Acting Antivirals

• Many drug interactions

Mavyret

• Take with food

Ribavirin

• Avoid in pregnancy (teratogenic), including in male partners of pregnant women

• Can cause hemolytic anemia

NRTIs

• lactic acidosis

• Epivir HBV tablets and oral solution are not interchangeable with the Epivir tablets and solution used in HIV (which have higher doses)

• Take entecavir an empty stomach

All Antibiotics

• Proper storage (refrigeration or room temperature) and administration (with or without food) is essential

• Shake suspensions (except linezolid) well

• Antibiotics treat bacterial infections. They do not treat viral infections

• Complete the full course of therapy even if symptoms improve

• Measure liquid doses carefully using the measuring device/syringe that comes with the medication. Do not use household spoons

• Some oral liquid and chewable dosage forms contain phenylalanine. Do not use if you have phenylketonuria (PKU)

• Can cause:

  • rash

  • nausea

  • diarrhea, including C. difficle-associated diarrhea (abdominal pain, cramps, watery or bloody stool)

Quinolones

• CNS effects including seizures

• Hypo/hyperglycemia

• Peripheral neuropathy

• Photosensitivity

• QT prolongation

• Tendon inflammation (tendinitis) or tendon rupture. Can present with a “pop” or pain/swelling in the back of the ankle (Achilles), should or hand

• Avoid in pregnancy, breastfeeding and children

• Drug interactions due to binding

Macrolides

• GI upset

• QT prolongation

Azithromycin

• Z-pak: take two tablets on day 1, followed by one tablet daily on days 2-5

Tetracyclines

• Avoid in pregnancy, breastfeeding, and children <8 years

• Drug interactions due to binding

• Photosensitivity

Doxycycline (oral)

• Take with a full glass of water and remain upright for 30min after the dose to avoid GI irritation

Sulfamethoxazole/Trimethoprim

• Avoid in

  • pregnancy or breastfeeding

  • sulfa allergy

• Photosensitivity

• Crystals in the urine. Take with full glass of water

Metronidazole

• Do not consume products containing alcohol while using this medication, and for at least three days afterward

• Nausea

• Metallic taste

Nitrofurantoin

• Take with food to decrease nausea

• Nausea

• Brown discoloration of urine (temporary and harmless)

Mupirocin nasal ointment

• place an amount sufficient to cover the top of a cotton swab into each nostril. Press the nostrils at the same time and let go; do this many times (for about 1min) to spread the ointment into the nose

• Wash hand after use

• Can cause burning and itching in the nose

Azole antifungals

• Liver damage

• QT prolongation (except isavuconazonium)

• Many drug interactions

Ketconazole and Intraconazole

Itraconazole

• Tablets and capsules: take with food

• Solution: take on an empty stomach

• Can cause heart failure

• Possible drug interactions due to high gastric pH

Posaconazole

• tablets: take with food

• suspensions: take with a full meal or oral liquid nutritional supplement

Voriconazole

• Take on an empty stomach, at least one hour before or one hour after meals

• Photosensitivity

• Vision changes

• Store reconstituted oral suspension at room temp

Nystatin

• Oral suspension: shake well before using

Terbinafine

• oral can cause liver damage

• can take several months after finishing treatment to see the full benefit of this drug (it takes time for new healthy nails to grow and replace and the infected ones)

Oseltamivir

• treatment should begin within 2 days onset of influenza symptoms

• can cause delirium

Acyclovir and Valacyclovir

• this medication does not cure herpes infection (cold sores, chickenpox, shingles or genital herpes). Use safe sex practices to lower transmission risk

• Start treatment within 24 hours of the onset of symptoms

  Acyclovir

• drink plenty of fluids

• the topical cream can cause temporary burning or stinging

All HIV Medications

• Do not skip doses or stop taking HIV medications unless instructed to do so by your provider

• This medication is not a cure for HIV.

• Do not share needles or other drug mixing equipment. Use safe sex practices

• IRIS: do not stop taking ART; notify your provider of a new or worsening condition

All NRTIs

• if you have hepatitis B, do not stop taking this medication without discussing with your healthcare provider, as a severe worsening of liver disease can occur

• Can cause lactic acidosis

Abacavir

• before suing this medication, your blood should be tested to see if you are at high risk for a severe reaction

Emtricitabine

• This medication can cause darkened spots on the palms of the hands and on the soles of the feet

Tenofovir Disoproxil Fumarate and Tenofovir Alafenamide

• can cause (less with alafenamide):

  • kidney impairement

  • low bone density/fracture risk

All INSTIs

• This medication can interact with antacids. Take 2 hours before or 6 hours after this medication

All NNRTIs

• can cause:

  • rash/severe rash

  • hepatotoxicity

Efavirenz

• Take at bedtime on an empty stomach to reduce side effects

• Can cause (at the start, improve in 2-4 weeks):

  • depression/psychosis

  • confusion and abnormal dreams

Rilpivirine

• Take with a full meal (not a protein drink) and water

• Do not use proton pump inhibitors; H2RAs 12 hours before or 4 hours after, and antacids 2 hours before 4 hours after rilpvirine

• Can cause depression

All PIs

• can cause high blood glucose, high triglycerides or body fat redistribution

Azatanavir or Darunavir

• If taking ritonavir or cobicistat, make sure to take both at the same time

• Take with food to decrease GI upset

Atazanavir

• do not acid-suppressing medications with atazanavir

• Take with food to decrease GI upset

Azatanavir

• do not take acid-suppressing medications with atazanavir

• can cause hyperbilirubinemia

Darunavir, Fosamprenavir, Tipranavir

• Caution with sulfa allergy

All hypertension products

• can cause orthostasis

• check your blood pressure regularly

• take this medication as directed, even if you feel well.

  • lowering blood pressure decrease the risk of complications such as heart disease, kidney disease and stroke

Thiazide diuretics

• take this medication early in the day (no later than 4pm) to avoid getting up at night to go to the bathroom

• can cause:

  • hyperglycemia

  • photosensitivity

  • sexual dysfunction

Calcium Channel Blocker

• can cause:

  • peripheral edema

  • gingival hyperplasia

• ghost tablet in stool (Procardia XL)

ACE Inhibitors, ARBs, Aliskiren

• Avoid in pregnancy (tetratogenic)

• can cause:

  • angioedema

  • dry, hacking, cough

Beta-Blockers

• Do not abruptly discontinue without consulting your heatlhcare provider

• This medication can mask symptoms of low blood sugar. If you have diabetes, check blood sugar if you notice symptoms of sweating or hunger

• Take Coreg/Coreg CR with food

• Take Lopressor/Toprol XL with or immediately after

Clonidine

• Do not abruptly discontinue without consulting your healthcare provider

• Patch: apply weekly to upper outer arm or chest. The white adhesive cover can be applied over the patch to keep it in place. Remove before an MRI. Do not cut the patch.

• Can cause sexual dysfunction

Aspirin

• bleeding/bruising

• dyspepia

• allergic reaction

• tinnitus or loss of hearing with overdose

Clopidogrel

• bleeding/bruising

• thrombotic thrombocytopenia purpura (TTP)

All nitrate products

• orthostatis

• flushing and headache. often a sign the medication is working. usually go away with time

• nitrate-free interval required with long-acting products

• drug interactions with phosphodiesterase inhibitors

Short-acting Nitrates

• take 1 dose at first sign of chest pain

• call 911 immediately if chest pain persists after the 1st dose. continue to take 2 additional doses at 5 minute intervals while waiting for ambulance to arrive

• do not take more than 3 doses within 5min

Nitroglycerin SL tablets

• place the tablet under the tongue or between the inside of the cheek and the gums/teeth, and let it dissolve. Do not chew, crush or swallow

• slight burning or tingling sensation in the original amber glass bottle

• keep tightly capped in the original amber glass bottle and store at room temperature. Remove 1 tablet only; do not let other tablets get wet

Nitroglycerin TL Spray

• Prime before first use and if not used within 6 weeks

• Do not shake

• Spray onto or under the tongue

• Do not inhale the spray

Nitroglycerin patch

• chest is preferred application site

• any area can be selected except the extremities below the knees or elbows

Nitroglycerin oinment

• measure the dose of the ointment with the dose-measuring applicator

• spread the ointment, using the dose-measuring applicator lightly onto the skin. Do not rub into the skin. Tape the applicator into place

• Can stain clothes

All patients with heart failure

• monitor and record body weight daily, in the morning after using the restroom and before eating

• limit salt intake. choose foods with “no sodium added” or “low sodium” such as:

• do not use NSAIDs: they can worsen sodium and water retention and reduce the effectiveness of HF medication

ARNI, ACE inhibitors and ARBs

• avoid in pregnancy (teratogenic)

• can cause angioedema

• ACE inhibitors and ARNI: tell your provider if you develop a dry, hacking cough

Beta blockers

• do not suddenly stop taking this medication without consulting your provider

• This medication can mask your symptoms of low blood sugar. If you have diabetes, check your blood sugar if you notice symptoms of sweating or hunger

• Can cause sexual dysfunction

• Take Coreg/Coreg CR with food

• Take Toprol XL with or immediately after meals

• The Coreg CR capsule can be opened and the contents sprinkled on a small amount applesauce

• The Kapspargo Sprinkle capsule can be opened and the contents sprinkled on a teaspoonful of applesauce, yogurt, or pudding

Loop diuretics

• take this medication early in the day (no later than 4pm) to avoid getting up at night to use the bathroom

• can use orthostasis

Digoxin

• Digoxin levels and kidney function will be monitored regularly

• Avoid dehydration; an overdose can occur more easily if you are dehyrated

• Symptoms of overdose including nausea, vomiting, decreased appetite, vision changes (blurred or yellow/green vision), confusion and delirium

• many drug interactions

Amiodarone

• lung damage

• liver damage

• eye damage (nerve damage and corneal disposition)

• hypo-/hyper- thyroidism

• photosensitivity

• skin discoloration to a blue-gray color. Not harmful effect; usually goes away months after the medication is stopped

• avoid grapefruit

• my drug interactions (enzyme inhibitor)

digoxin

• early symptoms of overdose include loss of appetite and nausea. If this occurs, check heart rate. If bradycardia, a digoxin level should be checked

• symptoms of severe overdose include vision changes

  • blurred

  • yellow/green vision

  • confusion

  • hallucinations

  • feeling of passing out

• Avoid dehydration; an overdose can occur more easily if you are dehydrated

• many drug interactions

For all anticoagulants

• can cause serious and life-thretening bleeding/bruising

• tell physicians/dentists that you are using this medication before any surgery is performed

• call you provider if you fall or injure yourself, especially if you hit your head

• avoid alcohol

• many drug interactions

• missed dose: take as soon as possible on the same day. do not double the dose the next day to make up for the missed dose

Dabigatran

• take with a full glass of water; swallow capsules whole

• dyspepsia

• only open one bottle of dabigatran a t a time. After opening a bottle of dabigatran, use within 4 months

• keeps dabigatran in the original bottle or blister package. do not put dabigatran in pill boxes or pill organizers

• missed dose: if your next dose is less than 6 hours away, skipp the missed dose

Rivaroxaban

• atrial fibrillation: take one daily with the evening meal

• blood clots in the veins of your legs or in the lungs: take once or twice daily, as prescribed with food at the same time each day

• missed dose: if taken twice daily, can take 2 doses at the same time to make up for missed dose

Enoxaparin

• SC injection; choose right or left side of your abdomen, at least 2 inches from the belly button

• do not expel the air bubble in the syringe prior to injection unless your health care provider has advised you to do so

• do not rub site of the injection

Warfarin

• take at the same time every day

• ask your pharmacist if your tablet looks different

• can rarely cause:

  • purple toe syndrome (painful toes and purple discoloration)

  • death of skin tissue

• frequent blood monitoring required (INR)

• consistent intake of vitamin K required (leafy green vegetables)

Oral Iron

• take on an empty stomach

• can cause:

  • constipation

  • dark stools

• drug interactions due to:

  • high gastric pH

  • Binding

ESA

• can cause:

  • blood clots

  • hypertension

• do not shake the vial or syringe; this will ruin the medication and it will not work

• Injection sites: arms, abdomen, hip, thigh

Hydroxyurea

• anyone handling the medication should wear disposable gloves to reduce risk of exposure

• wash hands before and after handling

• the capsules should not be opened

• can cause infections

• avoid in pregnancy (teratogenic). effective contraception required for sexually active males and females of reproductive potential both during and after treatment (6months after for females)

• avoid live vaccines

Antihistamines

• some formulations contain phenylalanine. do not use if you have phenylketonuria (PKU)

All eye drops

• can cause stinging/burning (except for preservative-free)

• wait 5min in betwen 2 drops of the same medication

• wait 5-10min in between drops of 2 different medications

• apply gels last. wait 10min after the last eye drop before use

• remove contact lenses prior to using eye drops. wait 15 minutes to reinsert

Prostaglandin analogs

• darkening of the iris

• increase in eyelash growth

• do not use with bimatoprost (Latisse), can reduce the effectiveness of other prostaglandins

All patients with asthma

• always have your rescue inhaler with you for asthma attacks

• if asthma symptoms get worse, or if you increase use of your rescue inhaler, contact your provider

montelukast

• take in the evening

• can cause suicidal ideation, behavior and mood changes

• do not use more than one dose within 24hr. if using daily for another indication, do not take another do to prevent exercise-induced asthma

• oral granules:

  • administer within 15min of opening the packet

  • can be mixed with teaspoonful of baby formula, breast milk, applesauce, mashed carrots, rice or ice cream or given directly

budesonide (pulmicort respules)

• store upright, protected from light at room temp

• ampules should be used within 2 weeks of opening the aluminum package

• gently swirl the ampule in a circular motion before use

• rinse the mouth with water and spit out after each dose. if a face mask was used, wash face after each treatment

nicotine lozenge

• do not eat/drink for 15min before or during use

• do not chew or swallow. allow it to dissolve slowly. move the lozenge from one side of the mouth to the other until it has completely dissolved

• may cause a warm or tingling sensation

• do not use more than 1 lozenge at a time or continuously use one lozenge after another

nicotine inhaler

• inhale deeply into the back of the throat or puff in short breaths

• each cartridge provides about 20 minutes of active puffing and is only good for 1 day after opening

• clean the mouthpiece with soap and water regularly

• keep at room temp; cold temperatures reduce the amount of nicotine inhaled

nicotine nasal spray

• tilt the head back slightly and spray once in each nostril while breathing through the mouth. do not sniff, swallow or inhale through the nose

• can cause sneezing, coughing, watery eyes, runny nose and a hot peppery feeling in the back of the throat

bupropion

• start taking 1 week before desired quit date

• can cause:

  • suicidal ideation

  • insomnia (avoid near bedtime)

• do not use if you have a seizure disorder, anorexia or bulimia

varenicline

• start taking 1 week before desired quit date

• can cause:

  • suicidal ideation or depression

  • insomnia

  • nausea

  • impairment of ability to drive or properly operate heavy machinery

• can increase the effects of alcohol. reduce amount of alcohol consumed

methotrexate

• dosed once weekly for rheumatoid arthritis and psoriasis. do not use daily or double-up doses. choose a day of the week to take your medications that you can remember

• can cause:

  • liver damage

  • infection

  • mouth sores

  • stomach bleeding, when used with aspirin/NSAIDs

  • avoid in pregnancy (teratogenic). use an effective form of birth control, whether you are male or female

  • avoid alcohol

  • take folic acid to decrease side effects

Rasuvo and Otrexup single-use autoinjectors

• administer SC into the abdomen or upper thigh only

• pinch the skin and inject at 90 degree angle. press firmly until you hear a click. hold 3 seconds for Oxtrexup and 5 seconds for Rasuvo

• needles are included

Adalimumab, Enterecept and Golimumab

• administer SC (1 weekly for enteracept, q1-2 week for adalimumab, monthly for golimumab)

• can cause:

  • injection site reaction

  • infection

  • liver damage

  • heart failure

• store the medication at room temp for. max 14 days

• adalimumab: inject SC into abdomen or thigh

• etanercept syringe or auto-injector: inject SC into abdomen, thigh or upper arm

• golimumab: inject SC into abdomen, thigh, or upper arm

• needles are included