chapter 8: auxillary labels

Federal law requires what medications to have the following auxiliary label?

Schedule II, III and IV

Which government requires the following auxiliary label?

Federal or State?

State

What is the following auxiliary label required for?

Any single or a combination opioid

Opioid prescriptions require what labels?

“Federal Law Prohibits” and “Caution: Opioid”

Which government requires the following auxiliary label?

Federal or State?

State

The following auxiliary label must be included on which five drug classes?

1. Disulfiram and other drugs that may cause a disulfiram-like reaction

2. MAO Inhibitors

3. Nitrates

4. Cycloserine

5. Antidiabetic agents

What drugs cause a disulfiram-like reaction when combined with alcohol and require the following auxiliary sticker?

Chlorpropamide, metronidazole, tinidazole

Which antidiabetic agents should include have the following auxiliary sticker?

Insulin, metformin, and sulfonylureas (risk of hypoglycemia)

Alcohol should be avoided for ___ hours after the last dose of _________ medications.

48 hours; Disulfiram

Which government requires the following auxiliary label?

Federal or State?

State

List 12 drug classes or situations in which this auxiliary label is required per state law.

1. Muscle relaxants and analgesics

2. Antipsychotics

3. Antidepressants

4. Antihistamines

5. Motion sickness drugs

6. Antipruritics

7. Antiemetics

8. Anticonvulsants

9. Antihypertensives

10. All narcotics and controlled substances (schedules II-IV)

11. Anticholinergic drugs that may impair vision

12. Any other drugs based on the pharmacist’s professional judgement

List two antidepressants that may require the following auxiliary label.

Mirtazapine, Trazodone

List 20 drug classes that should receive the following auxiliary sticker.

1. ACEs

2. ARBs

3. Renin-inhibitors

4. Warfarin

5. Hormones (most, including estradiol, progesterone, raloxifene, testosterone, contraceptives)

6. Isotretinoin

7. Topical retinoids

8. Paroxetine

9. NSAIDS

10. Valproic acid

11. Carbamazepine

12. Phenytoin

13. Phenobarbital

14. Lithium

15. Topiramate

16. Ribavirin

17. Quinolones

18. Misoprostol, methotrexate

19. Thalidomide

20. Dutasteride, finasteride

Which medications would require this auxiliary label sticker?

Progesterone, clevidipine, and propfol

Which formulation of progesterone requires the following auxiliary label?

Prometrium only

Which high-alert medications should receive this auxiliary sticker?

1. Adrenergic agonists (ex: epinephrine)

2. Adrenergic antagonists (ex: beta-blockers)

3. Sedatives (ex: Versed, Diprivan)

4. Antiarrhythmics (ex: amiodarone, sotalol)

5. Anticoagulants (ex: heparin, rivaroxaban, warfarin)

6. Insulin

7. Positive inotropes (ex: dobutamine, milrinone)

8. Opioids (ex: hydromorphone, fentanyl)

9. Electrolytes (ex: hypertonic saline, potassium)

Adrenergic agonists such as epinephrine must have their drug dose specified in milligrams. 1:1000 is ____ mg/mL and 1:10,000 is ____ mg/mL

1:1000 is 1 mg/mL and 1:10,000 is 0.1 mg/mL

Adrenergic antagonists such as beta-blockers should receive caution when …

converting from PO to IV

Patients on sedatives such as Versed or Diprivan should have what closely monitored?

Respiratory rate and mental status

Antiarrhythmics such as amiodarone and sotalol should be administered by…

Protocol that defines dose or infusion rate and requirement for cardiac (ECG) monitoring.

Anticoagulants such as heparin, rivaroxaban, and warfarin should include a protocol that includes:

• Baseline labs (INR, aPTT and CBC)

• Verified lab goals (indication based)

• Frequency of monitoring labs

• Dose/ rate adjustments based on lab values.

• Monitoring for symptoms of bleeding

• Reversal strategy

Insulin to be administered by protocol that includes:

• Initial infusion rate (for IV administration),

• Blood glucose (BG)

• Potassium monitoring frequency

• Rate adjustment based on BG

• When to notity physician.

Prior to and frequently during the administration of positive inotropes such as dobutamine and milrinone, what should you do?

Monitor BP, HR, hemodynamic parameters (if available), and urine output

Administration and management of opioids such as hydromorphone and fentanyl should include:

• Screening and monitoring patients at risk for oversedation and respiratory depression.

• Conversion support systems to help convert between agents

• Tall man lettering and separate look-alike/sound-alike

Electrolytes such as hypertonic saline or potassium due to be administered should go by protocol that includes:

• A maximum infusion rate

• Monitoring requirements.

• No preparation on the patient unit

Neuromuscular blocking agents such as those ending in curonium and succinylcholine should receive this auxillary label.

Neuromuscular blocking agents can only be given to a patient who is already on BOTH…

1. An analgesic (such as fentanyl)

2. and under deep sedation with pain and sedation assessed continuously.

These medications can have serious clinical implications if discontinued before the course has been completed, such as…

• Antimicrobial resistance

• Not fully treating an infection with antibiotics, antifungals or antivirals

Medications that are well known to cause blurry vision include:

• Anticholinergics (such as scopolamine)

• Voriconazole (Vfend)

• Telithromycin

• PDE-5 inhibitors (such as sildenafil).

What drugs can cause blurry or double vision (diplopia) if toxic?

Alcohol and CNS depressants

Digoxin can manifest as ____________ if there’s toxicity.

yellow/green halos

Other drugs that can affect vision include:

• Hydroxychloroquine

• Tamoxifen

• Amiodarone

• Ethambutol

• Isotretinoin

• Isoniazid

• Ivabradine.

Avoid prolonged exposure to direct and/or artificial sunlight while using the following medications due to increased skin sensitivity:

1. Sulfa antibiotics

2. Quinolones

3. Tetracyclines

4. Metronidazole

5. Isoniazid

6. Topical retinoids (newer ones less risk)

7. Ritonavir and a few other HIV drugs

8. NSAIDs (piroxicam, diclofenac, ibuprofen, naproxen)

9. Diuretics

10. Isotretinoin (oral)

While on the following medications, patients should be counseled to use an alternative contraceptive to prevent pregnancy since some of these medications may decrease the efficacy of birth control pills:

• Barbiturates (ex: phenobarbital)

• Ampicillin

• Tetracycline

• Rifampin, rifapentine

• Griseofulvin

• Bosentan

• Anticonvulsants (such as topiramate, lamotrigine, carbamazepine, primidone, phenytoin, oxcarbazepine)

• Some HIV drugs (some protease inhibitors, NNRTls)

Persistent diarrhea due to colitis may occur weeks after using the medication. This should be reported to your doctor immediately as it can be a dangerous side effect. What medications can cause this?

• Clindamycin

• Quinolones

• Broad-spectrum antibiotics.

May cause discoloration of the urine, skin and sweat and could stain contact lenses and clothing. List the medications that can do this.

• Entacapone

• Carbidopa/ levodopa

• Metronidazole

• Rifampin

• Nitrofurantoin

• Phenazopyridine

• Sulfasalazine

• Doxorubicin

• Mitoxantrone

Which medications should be taken on an empty stomach?

• Ampicillin

• Voriconazole (Vfend)

• Efavirenz (Sustiva/Atripla)

• Didanosine

• Bisphosphonates

• Captopril

• Iron (if tolerated)

• PPIs

• Levothyroxine

• Oxymorphone

• Mycophenolate (CellCept)

• Tacrolimus EX (Astagraf XL, Envarsus XR)

• Zafirlukast

What is the standard time frame for an individual should eat food while taking a medication that should be taken on an empty stomach?

1 hour before or 2-3 hours after a meal

Which medications should be taken with food?

• Carvedilol (Coreg)

• Metoprolol Tartrate (Lopressor)

• Lovastatin (with dinner)

• Fenofibrate and derivatives (Lipofen, Fenoglide)

• Niacin

• Gemfibrozil (Lopid)

• Metformin (IR with breakfast and dinner, XR with dinner)

• Itraconazole capsules

• Phosphate binders (when eating)

• NSAIDs

• Steroids

• Opioids (except oxymorphone)

Drugs can get "stuck" going down, especially if dysphagia is present. What drugs are preferred to be taken with a full glass of water.

• Bactrim

• Bisphosphonates

• Sulfasalazine (Azulfidine - take with water & food)

• Pancrelipase

Do not eat grapefruit or drink grapefruit juice at any time while taking the following medications to avoid drug interactions:

• Statins: lovastatin, simvastatin, atorvastatin

• Amiodarone

• Dofetilide

• Buspirone

• Carbamazepine

• Cyclosporine \

• Tacrolimus

• Diazepam, Triazolam

• HTN Meds: Verapamil, Nicardipine, Felodipine, Nisoldipine and Nifedipine

Which medications should be separated from dairy products, calcium, magnesium, iron and antacids because it can make the medication less effective?

• Tetracyclines

• Quinolones

• Levothyroxine

Which dosage forms should receive this label?

• All suspensions

• Most asthma aerosol inhalers

• Nasal steroid spray

• Lidocaine viscous topical liquid

Enteric-coated formulations (ex: bisacodyl or aspirin), any long-acting formulations, timecaps, and sprinkles should receive this sticker. Which long-acting formulations can you cut at the score line but cannot be crushed or chewed?

• Metoprolol XR

• Carbidopa/Levodopa SR

Chemotherapeutic agents require special packaging and labeling for proper handling of the medication and proper disposal of the bag and tubing. Alternative wording for an auxiliary label includes:

Chemotherapy: Dispose of Properly

Any type of irrigation should be labeled so that it is NOT administered intravenously. This includes:

1. Peritoneal dialysis irrigation solution

2. Saline

3. Sterile water irrigation solution

Epidural or ___________ solutions should be labeled to decrease risk of administration via an incorrect route.

Intrathecal

Which oral suspensions should not be refrigerated.

Azithromycin, Cefdinir, Clindamycin

Which IV medications should not be refrigerated.

• Dexmedetomidine

• Bactrim

• Phenytoin

• Furosemide

• Metronidazole

• Moxifloxacin

• Enoxaparin

Acronym to remember IV medications that should not be refrigerated:

Dear Boring Pharmacist, Freezing Makes Me Edgy (DBPFMME)

What does DBPFMME stand for?

• Dexmedetomidine

• Bactrim

• Phenytoin

• Furosemide

• Metronidazole

• Moxifloxacin

• Enoxaparin

Medications that require refrigeration should be kept between…

36-46°F

Antibiotic suspensions that require refrigerate after reconstitution:

• Augmentin

• Amoxicillin (not required, but improves taste

• Cefpodoxime

• Cefprozil

• Cefuroxime

• Ceftibuten

• Cephalexin

• Benzamycin

• Penicillin V

Eyedrops that require refrigeration until they’re opened”

• Latanoprost (Xalatan)

• Tafluprost (Zioptan)

Medications that should be protected from light:

• Phytonadione

• Epoprostenol

• Nitroprusside

• Micafungin

• Doxycycline

Acronym to remember medications that should be protected from light

PENMD

This auxiliary label is indicated for which specific dosage type? Other dosage types might need additional labels with specifics…

Topical medication

Intramuscular (IM) injections should be labeled to decrease the risk of administration via an incorrect route.

For example, the preferred route of promethazine injection is IM due to risk of…

Tissue irritation and damage

Intramuscular (IM) injections should be labeled to decrease the risk of administration via an incorrect route.

Why is promethazine contraindicated in patients < 2 years old?

Increased risk of fatal respiratory depression

It is contraindicated or not recommended to give promethazine via what other routes of administration?

Subcutaneous injection, not recommended for IV

This auxillary label is for drugs that must be administered via central (not peripheral) IV access only. Due primarily to the risk of phlebitis (vein irritation) and for vesicant medications (risk of severe tissue damage if line extravasates).

Which medications have a risk of phlebitis if given peripherally?

• Parenteral nutrition, most chemotherapeutics

• Calcium chloride

• Hypertonic saline

• Mannitol

• Digoxin

• Foscarnet

• Nafcillin

• Mitomycin

• Quinupristin/dalfopristin (Synercid)

• KCI

• Amiodarone (concentrated)

This auxillary label is for drugs that must be administered via central (not peripheral) IV access only. Due primarily to the risk of phlebitis (vein irritation) and for vesicant medications (risk of severe tissue damage if line extravasates).

Which vesicant medications should be given via a central line

• Vesicant

• Vasopressors (ex: norepinephrine, dopamine)

• Anthracyclines (ex: doxorubicin)

• Vinca alkaloids (ex: vincristine)

  • Do not administer vincristine by intrathecal administration.

Which medications should receive this auxillary label?

• Golimumab

• Amiodarone

• Phenytoin

• Parenteral nutrition

• Lipids

• Amphotericin B

• Carbazitaxel

• Paclitaxel