Drug Effects/Pearls

QT prolongation meds

Antiarrhythmics: Class Ia, Ic, III

Anti-infectives:

• Antimalarials (ie. hydroxychloroquine)

• Azole antifungals (Except: isavuconazonium; QT shortening)

• FQs

• Macrolides

• Others: Lefamulin

Antidepressants:

• SSRIs (citalopram & escitalopram >>)*

• TCAs

• Others: mirtazapine, trazodone, venlafaxine

Antiemetics:

• 5-HT3 receptor antagonists (ie. ondansetron)

• Others: droperidol, metoclopramide, promethazine

Antipsychotics:

• 1st gen: (ie. haloperidol, chlorpromazine, thioridazine)

• 2nd gen: (ziprasidone >>)

Oncology:

• Androgen deprivation therapy (ie. leuprolide)

• TKIs (ie. nilotinib)

• Oxaliplatin

Others:

• cilostazol, donepezil, fingolimod, hydroxyzine, loperamide, methadone, ranolazine, solifenacin, tacrolimus

*limit doses:

• citalopram 40 mg/day

  • 20 mg/day in elderly > 60 yo

• escitalopram 20 mg/day

  • 10 mg/day in elderly

CYP3A4 Inducers (7)

• Carbamazepine (also an auto-inducer)

• Oxcarbazepine

• Phenytoin

• Phenobarbital

• Rifampin (+ rifabutin, rifapentine)

• St. John’s Wort

• Smoking (CYP1A2)

CYP3A4 Inhibitors (8)

G - PACMAN

Grapefruit

Protease Inhibitors (ritonavir»)

Azole antifungals

Cobicistat & Cyclosporine

Macrolides (clarithro/erythro; not azithro)

Amiodarone (+ dronedarone)

Non-DHP CCBs (diltiazem, verapamil)

Statin DDI

G-PACMAN

Grapefruit juice

Protease Inhibitors

Azoles

Cyclosporine & Cobicistat

Macrolides (except azithro)

Amiodarone

• Simvastatin 20 mg/day max*

• Lovastatin 40 mg/day max*

Non-DHP CCBs

• Simvastatin 10 mg/day max*

• Lovastatin 20 mg/day max*

*concurrent amiodarone: capped at 20 mg/day

Protect from Light (7)

• Vitamin K (phytonidione)

• Epoprostenol

• Micafungin

• Nitroprusside

• Doxycycline

• Others:

  • GCSF: filgastrim/pegfilgastrim (store in refrigerator)

  • Tiriparatide (PTH analogs)

Drug-induced Photosensitivity

Amiodarone

Diuretics (THZ & Loops)

Methotrexate (MTX)

Retinoids (oral/topical)

Quinolones

St. John’s wort

Sulfa drugs

Tacrolimus

Tetracyclines

Voriconazole

Do NOT refrigerate (7)

Dexmedetomidine

SMX/TMP

Phenytoin (crystallizes)

Furosemide (crystallizes)

Metronidazole

Moxifloxacin

Enoxaparin

Requires an acidic gut (6)

Pseudomonas Coverage

FQ: ciprofloxacin & levofloxacin

PCN: pip/tazo

Cephs: ceftazidime & cefepime

Chelation with polyvalent cations (5)

• Bisphosphonates

• FQs

• INSTIs

• Levothyroxine

• Tetracyclines

Gastric Acid Suppression (PPIs, H2RAs, antacids)

• Antiretrovirals: rilpivirine, atazanavir

• Direct-acting antivirals: ledipasvir, velpatasvir

• Azoles: ketoconazole, itraconazole capsules

• Cephalosporins: cefpodoxime, cefuroxime

• Risendronate (DR)

Drug-induced lupus erythematosus (DILE)

• Antihypertensives: methyldopa & hydralazine

• Thionamides: PTU & methimazole

• Antiarrhythmics: procainamide, quinidine

• Anti-infectives: minocycline, terbinafine, isoniazid

• All TNF inhibitors (etanercept, infliximab, adalimumab, certolizumab pegol & golimumab)

Insulin Types & Properties (onset/peak/duration)

Basal Insulin: (ie. glargine, degludec)

• Onset: 3-4 hours

• “Peakless”

• Duration: ≥ 24 hours

Intermediate-Acting:

• Insulin NPH & Protamine:

  • Onset: 1-2 hours

  • Peaks: 4-12 hours

  • Duration: 14 - 24 hours

Rapid-Acting: (aspart, lispro, glulisine)

• Onset: 15 min

• Peak: 1-2 hours

• Duration: 3-5 hours

Short-Acting: (regular)

• Onset: 30 min

• Peak: ~ 2 hours

• Duration: 6-10 hours

Drugs associated with severe cutaneous ADRs

Allopurinol

Amoxicillin

Ampicillin

Carbamazepine

Ethosuximide

Lamotrigine

Nevirapine

Phenytoin

SMX

Sulfasalazine

Vancomycin

PGx Testing (drug-genotype)

Human Leukocyte Antigen (HLA) Testing

• Do not use if (+):

  • Abacavir (HLA-B*5701)

    • hypersensitivity rxns

  • Allopurinol (HLA-B*5801)

    • SJS; discontinue

  • Carbamazepine (HLA-B*1502)

    • SJS/TEN

    • more common in asians

    • testing suggested for: oxcarbazepine/phenytoin/fosphenytoin

CYP450 Polymorphisms:

• Citalopram (CYP2C19)

• Clopidogrel (CYP2C19)

  • prodrug

    • PM = less metabolism = poor efficacy & more CV events

      • Consider alternative tx

• Codeine (CYP2D6)

  • prodrug ( —> morphine)

    • UM = risk of opioid overdose/toxicity; do not use

    • ie. infant deaths if UM nursing mothers on codeine

• Warfarin (CYP2C9*2/3, VKORC1)

  • increased bleeding risk

  • Use a lower dose

Other:

• Trastuzumab: HER2 (-) = not effective

• Cetuximab: KRAS (+) mutation - do not use

  • only use in wild-type KRAS (-)

• Azathioprine: TPMT deficiency —> myelosuppression risk

  • use low dose or alternative med

• Capecitabine/Flurouracil: dihydropyrimidine dehydrogenase (DPD) deficiency = toxicity risk (diarrhea/neutropenia/neurotoxicity); do not use

Patch Pearls

Frequency	Patch
BID	Diclofenac (Flector)
QD	Diclofenac (Licart) Methylphenidate (Daytrana) Nicotine (Nicoderm CQ) Rivastigmine (Exelon) Remove before MRI Rotigotine (Neupro) Selegiline (Emsam) Testosterone
Daily with special instructions	Lidocaine (Lidoderm): on for ≤ 12 hours, off for 12 hours Nitroglycerin: on for 12-14 hours, off for 10-12 hours
Every 72 hours	Fentanyl Fold & flush Do not cover with heating pad; apply to hairless skin Scopolamine (Transderm Scop) Remove before MRI; avoid alcohol
Twice Weekly	Estradiol (Vivelle-Dot) Oxybutynin (Oxytrol)
Weekly	Buprenorphine (Butrans) Clonidine (Catapres-TTS) Remove before MRI; fold & trash Estradiol (Climara) Ethinyl estradiol/norelgestromin (Xulane, Zafemy) Ethinyl estradiol/levonorgestrel (Twirla) Donepezil (Adlarity) Store in refrigerator

Sterile BUD

Immediate use: 4 hours

Category 1 (ISO 5 PEC in SCA)

• Room temp: 12 hours

• Refrigerator: 24 hours

• Freezer: n/a

Category 2 (ISO 5 PEC in cleanroom)

• Room temp: 1 - 45 days

• Refrigerator: 4 - 60 days

• Freezer: 45 - 90 days

Category 3 (ISO 5 PEC in cleanroom + additional reqs)

• Room temp: 60 - 90 days

• Refrigerator: 90 - 120 days

• Freezer: 120 - 180 days

Refrigerate

Dronabinol

Do not shake/agitate

• Protein/blood products:

  • albumin

  • immune globulins

  • mAbs

  • insulin

• Foaming products:

  • Alteplase

  • etanercept

  • rasburicase

• Reconstituted vaccines: VZV

IV drugs = colored solutions

Anthracyclines

• doxorubicin - red

• mitoxanthrone - blue

Rifampin - red

Common drugs with Filter requirements

Most = 0.22 micron filter

Golimumab

AmphoB (lipid formulations) - requires a 5 micron filter

Lipids - 1.2 micron

Isavuconazonium

Phenytoin (during continuous infusion; not IV push)

Amiodarone

Taxanes (cabazitaxel, paclitaxel)

Mannitol ≥ 20%

Parenteral nutrition - 1.2 micron

Non-PVC container required

Leach Absorbs To Take In Nutrients

Lorazepam

Amiodarone

Tacrolimus

Taxanes (except paclitaxel-albumin combo; Abraxane)

Insulin

Nitroglycerin

Mix in Dextrose Only

Only Sugar Always

Oxaliplatin

SMX/TMP

Amphotericin B (all)

Mix in Saline (NS) Only

A DIAbetic Can’t Eat Pie:

Ampicillin*

Daptomycin

Infliximab

Ampicillin/Sulbactam*

Caspofungin

Ertapenem

Phenytoin

*shorter stability in dextrose

Michaelis-Menten Kinetic Drugs (3)

Phenytoin

Theophylline

Voriconazole

Broad-spectrum ASMs (4) vs. Narrow-spectrum (6)

Broad-spectrum: focal & generalized

• Lamotrigine

• Levetiracetam

• Topiramate

• Valproate/Divalproex

Narrow-spectrum: focal

• Lacosamide

• Carbamazepine

• Oxcarbazepine

• Phenytoin

• Fosphenytoin

• Phenobarbital

Select Drugs that can discolor skin & secretions (13)

Brown:

• Entacapone

• Levodopa

• Methyldopa

Red: Anthracyclines

Red-Orange:

• Phenazopyridine

• Rifampin

Orange/Yellow:

• Sulfasalazine

Brown/Yellow: Nitrofurantoin

Green: Propofol

Blue:

• Methylene blue

• Mitoxantrone

Blue-Gray: Amiodarone

Black/Green: Iron (stool)

Insulin Stability at Room Temperature

1-2 weeks (10 days) - H mix pens

• Humaog Mix 50/50 & 75/25 pens

• Humulin 70/30 pen

2 weeks (14 days) - HN, Nmix pens

• Humulin N pen

• Novolog Mix 70/30 pen

~ 4 weeks:

• *28 days - RA, mix vials, humulin vial, novolin pen, U-500 pen

  • Apidra, Humalog, Novolog, Ademelog, Lyumjev, Fiasp (vials & pens)

  • Humalog Mix 75/25 vial

  • Novolog Mix 70/30 vial

  • Novolin R U-100, N, and 70/30 pens

  • Humulin R U-500 pen

  • Lantus, Basaglar, Semglee vials & pens

• 31 days

  • Humulin R U-100, N, and 70/30 vials

~ 6 weeks:

• 40 days: Humulin R U-500 vial

• 42 days: Novolin R U-100, N, and 70/30 vials

8 weeks (56 days): Tresiba & Toujeo pens

Concentrated Insulins:

• RA (2)

• SA (1)

• LA (2)

Rapid-Acting Insulin: lispro kwikpens - 200 units/mL

• Humalog Kwikpen

• Lyumjev Kwikpen

Short-Acting Insulin:

• Humulin R U-500 Kwikpen & vial: 500 units/mL

Long-Acting Insulin:

• Tresiba Flextouch pen (Degludec): 200 units/mL

• Toujeo Solostar/Max Solostar pens (glargine): 300 units/mL

*most insulin products = 100 units/mL

• vials - usually 10 mL

  • except: Humulin R U-500 (20 mL)

• pens - usually 3 mL

  • except: Toujeo (1.5 mL, 3 mL)

Hypoglycemia Tx

CONSCIOUS:

1. 15-20 grams of glucose (or simple carbs)

2. Recheck BG after 15 min

3. if still hypoBG —> repeat steps 1 & 2

4. once BG = normal —> eat small meal/snack

UNCONSCIOUS:

1. IV access? —> dextrose

2. OR - glucagon IM: 1 mg SC or nasal spray

   • place patient in a lateral recumbent position (on side)

Hypoglycemia: 15 grams of carbs

• 4 oz (1/2 cup) of Juice

• 8 oz (1 cup) of Milk

• 4 oz (1/2 cup) of regular soda (not diet)

• 1 tablespoon of sugar/honey/corn syrup

• 3-4 glucose tablets or 1 serving glucose gel

Dietary Supplement: St. John’s Wort

• indications (2)

• drug interactions (3)

Indications:

• anxiety

• depression

Drug interactions:

• Inducer (CYP/P-gp)

• Serotonergic —> risk of serotonin syndrome

  • do not use with MAO inhibitors

  • concurrent use with other serotonergics: SSRIs, SNRIs, etc.

• Photosensitivity (use sun protection)

• may lower seizure threshold; caution

Dietary supplements that increase bleeding risk (9)

5 G’s: garlic, ginger, ginko, ginseng, glucosamine

Fish oils (at high doses)

Vitamin E
Dong quai

Willow bark (contains salicylate)

Dietary supplements - Hepatotoxicity risk (2)

Black cohosh (used for menopausal symptoms)

Kava (used for stress/anxiety; known hepatotoxin)

Dietary Supplements - Cardiotoxicity risk (4)

Ephedra (removed from market)

Bitter orange (contains synephrine)

• stimulant

Yohimbe (used for ED & increase libido)

Caffeine (high doses) —> increases BP & HR

Vitamins & their common names

Vitamin A - retinol

Vitamin B1 - thiamine

Vitamin B2 - riboflavin

Vitamin B3 - niacin

Vitamin B6 - pyridoxime

Vitamin B9 - folate

Vitamin B12 - cobalamin

Vitamin C - ascorbic acid

Vitamin D2 - ergocalciferol

Vitamin D3 - cholecalciferol

Vitamin E - alpha-tocopherol

“COLOR” Drug References (8)

Orange Book (FDA) - interchangeable drugs with generics based on therapeutic equivalence; AB rating

Pink Book (CDC) - epidemiology & vaccine-preventable diseases

Pink Sheet (Pharma Intelligence) - news reports on regulatory/legislative/legal/business developments

Purple Book (FDA) - biologics + biosimilars

Red Book, Pharmacy - Drug pricing information

Red Book, Pediatrics (AAP) - pediatrics ID, abx tx, and vaccinations

Yellow Book (CDC) - health risks of international travel; vaccines & ppx medications

Green Book (FDA) - approved animal drug products

Agranulocytosis Drug Causes (7)

• clozapine

• propylthiouracil (PTU)

• methimazole

• procainamide

• carbamazepine

• isoniazid

• SMX/TMP

Drug-induced hemolytic anemia (immune-mediated/G6PD deficiency)

Immune-mediated Hemolytic Anemia: (+) Coombs Test; dc offending drug

• penicillins & cephalosporins

• isoniazid

• levodopa

• methyldopa

• rifampin

• quinidine

• quinine

• sulfonamides

G6PD deficiency Hemolytic Anemia:

• stress

• foods (fava beans)

• dapsone

• methylene blue

• nitrofurantoin

• pegloticase

• rasburicase

• primaquine

• quinidine

• quinine

• sulfonamides

Common Live Vaccines (7)

MICRO-VY

Measles, mumps, rubella (MMR)

Intranasal influenza (flumist)

Cholera (Vaxchora)

Rotavirus (po; 1 - rotarix; 5 - rota teq)

Oral typhoid (Vivotif)

Varicella (Varivax)

Yellow fever (YF-VAX)

P-gp common substrates, inducers, inhibitors

P-gp Substrates:

Anticoagulants: apixaban, rivaroxaban

CV drugs: digoxin, diltiazem, verapamil

HCV drugs: sofosbuvir

Immunosuppressants: cyclosporine, tacrolimus

Others: colchicine

P-gp Inducers:

Carbamazepine, phenobarbital, phenytoin, rifampin, St. John’s wort

P-gp Inhibitors:

Anti-infectives: (clarithro, itraconazole, posaconazole)

CV drugs: amiodarone, diltiazem, verapamil

HCV drugs: ledipasvir

HIV drugs: cobicistat, ritonavir

Others: cyclosporine

Ototoxic drugs

Aminoglycosides

Cisplatin

Loop diuretics (rapid IV administration»)

Salicylates

Vancomycin

Common vesicants & their reversals

Vesicants —> reversals:

• Vasopressors (ie. DA, NE) —> phentolamine

• Anthracyclines —> cold compress + dexrazoxane

• Vinca alkaloids —> warm compress + hyaluronidase

Anti-arrhythmics: Vaughan Williams Classification

CLASS I: Na+ channel blockers

• Ia: disopyramide, quinidine, procainamide

• Ib: lidocaine, mexilitine

• Ic: flecainide, propafenone

CLASS II: Beta-blockers

CLASS III: K+ channel blockers

• amiodarone, dronedarone, dofetilide, ibutilide, sotalol

CLASS IV: Non-DHP CCBs

• diltiazem, verapamil

BUD for Nonsterile Compounded Products

Aqueous dosage forms (Aw ≥ 0.6)

Nonpreserved (aq): 14 days; store in refrigerator

Preserved (aq): 35 days

Nonaqueous dosage forms (Aw < 0.6)

Oral liquid: 90 days (~3 months)

Other non-(aq) dosage forms: 180 days (~ 6 months)