Key Counseling Point + Clinical Pearls

Atomoxetine

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Growth rate and weight may need to be monitored more frequently in children.

Report new or worsened psychiatric problems, chest pain, palpitations, dyspnea, or signs/symptoms of cardiac dysrhythmias, MI, or cerebrovascular accident.

Do not open capsules as atomoxetine is an ocular irritant.

Safety and effectiveness not established in children <6 y of age.

Increased risk of suicidal ideation in short-term studies in children or adolescents with ADHD.

Monitor patients closely for suicidality (suicidal thinking and behavior), clinical worsening, or unusual changes in behavior.

Close observation and communication with the prescriber by families and caregivers is recommended.

Benztropine

Drug may impair heat regulation.

Advise patient to use caution with activities leading to an increased core temperature, such as strenuous exercise, exposure to extreme heat, or dehydration.

Patient should avoid activities requiring mental alertness or coordination until drug effects are realized.

Instruct patient to report sudden muscle weakness or stiffness, and signs/symptoms of tardive dyskinesia (tongue thrusting, facial grimacing/tics, random movements of extremities).

Patient should not drink alcohol while taking this drug.

Injectable formulation also available but must be administered at hospital or physician’s office.

Buprenorphine/Naloxone

Use a stool softener and/or laxative for preventing constipation.

May cause drowsiness; avoid driving or other tasks requiring motor coordination.

Avoid alcohol and other CNS depressants.

Do not crush or swallow the sublingual tablet.

Place the tablet under the tongue until it is dissolved.

If you take ≥2 tablets at a time, place all of the tablets under the tongue together.

If this is uncomfortable, place 2 tablets at a time under the tongue and repeat the process until all tablets have been taken.

If you are using the sublingual film, place the film under the tongue until it is dissolved.

If you need to take an additional film, place the new film on the opposite side from the first film.

Do not chew, swallow, or move the film after placing it under the tongue.

If using the buccal film, press and hold film to moistened cheek for 5 s with finger.

If you need an additional film, place on the inside of the other cheek.

Do not use >2 buccal films simultaneously.

Monitor for signs of diversion; case reports exist of users crushing or dissolving various formulations of buprenorphine/naloxone.

Taking opioids will result in precipitation of withdrawal symptoms.

The opioid agonist properties of buprenorphine are limited by a ceiling effect which occurs at higher doses.

The strengths of sublingual films and tablets are not interchangeable. For example, one 8 mg film is not equivalent to 4 films of 2 mg each.

Do not substitute multiple smaller dose films to equal a larger dose.

Recommended as a component of therapy including counseling and psychosocial support.

Not recommended for treatment of dependence on long-acting opiates or methadone; useful for withdrawal of short-acting opiates and heroin.

Both naloxone and buprenorphine are available as separate agents in a wide range of formulations.

Under REMS program requirements.

Carbamazepine

May decrease effectiveness of oral contraceptives; use an alternative form of birth control.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Take with food, but not alcohol, grapefruit, or grapefruit juice.

Avoid abrupt discontinuation.

Suspension is dosed 3-4 times per day.

Injectable formulation is available for adults when oral dosing is temporarily not feasible.

Not effective for absence seizures.

Testing for HLA-B*15:02 and HLA-A*31:01 should be performed in patients of Hong Kong, Thailand, Malaysia, the Philippines, Taiwan, and China ancestry.

Carbidopa/Levodopa

If you are using the oral disintegrating tablets, place on top of the tongue; does not require water or swallowing.

Since levodopa competes with certain amino acids for transport across the gut wall, the absorption of levodopa may be impaired in some patients on a high protein diet.

"Parkinsonism" refers to symptoms similar to Parkinson disease but are due to other causes.

Treat with levodopa/carbidopa at the same doses as used for Parkinson disease.

Most patients require carbidopa 75 mg/d to block decarboxylase.

When changing from regular release to extended release, doses may need to be increased by ≥20%.

A combination product of carbidopa, levodopa, and entacapone (Stalevo) is also available.

Suspension formulation (Duopa) available for continuous delivery via pump directly into jejunal tube.

Carisoprodol

Patients should avoid consuming alcohol.

Patients should avoid activities requiring mental alertness or coordination until drug effects are known, as drug may cause dizziness or sedative effects.

Patients withdrawing from prolonged therapy should be monitored carefully for withdrawal symptoms, including seizures.

Carisoprodol is used for the relief of discomfort associated with acute, painful musculoskeletal conditions in adults and should be used for only short periods (up to 2 or 3 wk).

May require tapering at discontinuation after chronic use.

The drug was approved by the FDA in 1959 and limited pharmacologic and pharmacokinetic data are available.

Avoid concomitant use with opioids.

Carvedilol

Take with food or milk. Report signs/symptoms of heart failure, bradyarrhythmias, bronchospasm, hypotension, syncope, or exacerbation of angina with initial dosing and dose changes. Avoid abrupt discontinuation, may cause rebound HTN. Avoid driving, using machinery, or doing anything else that could be dangerous if not alert. Diabetic patients should carefully follow blood sugar levels as beta-blockers may mask symptoms of hypoglycemia.

Safety and efficacy not established in pediatric patients. Reduce dose with bradycardia. Not recommended for the treatment of hypertension in the absence of comorbidities.

Desvenlafaxine

Take with or without food.

Avoid alcohol.

Symptomatic improvement may not be evident for a few weeks.

Do not discontinue drug abruptly, as this may precipitate withdrawal symptoms such as dysphoric mood, irritability, and agitation.

Avoid activities requiring mental alertness or coordination until drug effects are realized, as this medicine may cause dizziness or somnolence.

Safety and efficacy not established in children.

Medication guide required at dispensing.

Dexmethylphenidate

Avoid late evening doses due to resulting insomnia.

If you cannot swallow the extended-release capsule, you may open it and pour the medicine into a small amount of soft food such as applesauce.

Stir this mixture well and swallow it without chewing.

Dexmethylphenidate is the d-enantiomer of methylphenidate.

Amphetamines have a high potential for abuse, and administration for prolonged periods of time may lead to drug dependence and should be avoided.

Misuse of amphetamines may cause sudden death and serious cardiovascular adverse effects.

Eszopiclone

Take immediately before bedtime and to not take with heavy/high-fat meal.

Severe anaphylactic/anaphylactoid reactions, some fatal, have been reported.

Be aware of the risk of “sleep-driving” and other complex behaviors (eg, preparing and eating food, making phone calls) when the patient is not fully awake.

Risk is increased when drug is combined with alcohol or other CNS depressants.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Report insomnia that worsens or persists longer than 7-10 d.

Report abnormal thoughts or behavior (confusion, agitation, hallucinations, suicidal thoughts, new or worsening depression), memory loss, or anxiety.

Take drug only when experiencing insomnia.

This drug should not be taken on a regular schedule when insomnia is not present.

Do not drink alcohol while taking this drug.

Safety and efficacy not established in children.

Elderly may be more susceptible to adverse effects; use a lower starting dose and a max daily dose of 2 mg.

Medication guide must be provided at dispensing.

Fentanyl Transdermal

Use a laxative for preventing constipation.

May cause drowsiness; avoid driving or other tasks requiring motor coordination.

Avoid alcohol and other CNS depressants.

Apply to clean, dry skin.

Skin breaks may increase absorption.

Remove old patch when new patch applied.

Febrile patients may have increased absorption.

Monitor carefully.

Not appropriate for treatment of acute pain.

Use caution in elderly; appear more sensitive to the effects.

Tolerance and physical dependence may occur with chronic use; avoid abrupt discontinuation.

Significant addiction potential, care with storage and disposal.

Under REMS program requirements.

Also available as injectable, nasal spray, oral liquid, buccal film, buccal tablet, and sublingual tablet.

Substantial differences exist in the pharmacokinetic profile of fentanyl products.

Do not convert patients on a mcg-per-mcg basis from one fentanyl product to another fentanyl product; the substitution of one fentanyl product for another fentanyl product may result in a fatal overdose.

Do not cut patch.

Contraindicated in opioid-naïve patients; use limited to opioid tolerant patients.

Avoid concomitant use with benzodiazepines, alcohol or other CNS depressants. Absorption from patch is delayed 12-24 h after patch placement due to depot effect in the outer layer of skin.

Skin depot also results in lingering presence of drug in serum after patch removal.

Guanfacine

Avoid alcohol, CNS depressants.

Caution with driving and other tasks requiring alertness.

Swallow extended-release tablet whole, may be taken with or without food.

Report signs/symptoms of hypotension, exacerbation of angina peripheral edema, fatigue, hypotension, or hepatic dysfunction with initial dosing and dose changes.

Avoid abrupt discontinuation to avoid rebound HTN.

Guanfacine and other α-adrenergic agents are rarely used for HTN.

Also not a first-line treatment of ADHD, and are usually reserved for children that do not respond to first-line agents or have unacceptable side effects.

Can be used in children with coexisting behavioral condition or tic disorder.

When discontinuing extended-release formulation, taper slowly, reducing dose by ≤1 mg every 3-7 d.

Ibuprofen

Take with food or milk to decrease GI upset.

Counsel heart failure patients post discharge on NSAIDs avoidance due to fluid retention, edema leading to exacerbations.

Elderly patients are at increased risk of GI ulceration.

NSAIDs are associated with an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke. Use the lowest effective dose for the shortest possible duration; after observing initial response, adjust dose and frequency to meet individual patient’s needs.

NSAIDs are also associated with renal adverse events, especially in patients with preexisting CKD, nephrotic syndrome, liver disease, and patients who are volume depleted.

Various OTC ibuprofen products are available; caution patients not to duplicate dosing with multiple ibuprofen products.

Lidocaine

Instruct patients on the appropriate application process.

Leave patches on skin for no >12 h within a 24-h period.

Caution patients to administer only as directed, to intact skin, without covering with occlusive dressing or tight clothes.

Patches may be cut into smaller sizes prior to removal of release liner to refine dose to meet patients’ needs.

Patients should be instructed to fold used patches after removal so that the adhesive side sticks to itself and safely discard used patches or pieces of cut patches where children and pets cannot get to them.

Accidental ingestion of used patches can lead to serious adverse effects.

Lidocaine also available in a wide range of other dosage forms, including topical ointments, lotions, gels and creams, injectables, and oral sprays and gels.

Lithium

An FDA-approved patient medication guide must be dispensed with this medication.

Swallow extended-release tablets whole; do not crush or chew.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Report signs/symptoms of toxicity, which may vary depending on the degree of toxicity.

These may include diarrhea, vomiting, tremor, ataxia, drowsiness, muscle weakness, lack of coordination, giddiness, blurred vision, tinnitus, or large volumes of dilute urine.

Maintain adequate fluid intake and normal salt intake

Safety and effectiveness in patients <12 y of age have not been established.

Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels.

Ability to tolerate lithium is greater during the acute manic phase and decreases when manic symptoms subside.

Do not confuse dosing in mEq versus mg. Doses should be in mg (300 mg = 8 mEq).

Methadone

Use a motility-promoting laxative for preventing constipation.

May cause drowsiness; avoid driving or other tasks requiring motor coordination.

Avoid alcohol and other CNS depressants.

Seek medical attention if short of breath or extremely drowsy.

Breast-feeding women should monitor child for signs of sedation and respiratory depression.

Tolerance and physical dependence may occur with chronic use; avoid abrupt discontinuation.

High interpatient variability in absorption, metabolism, and relative analgesic potency of methadone requires careful dose initiation and titration.

Fatal respiratory depression has occurred; the highest risk is at initiation and with dosage increases.

For oral administration only; excipients to deter use by injection are contained in tablets.

Do not chew or swallow tablet for suspension—dissolve in liquid and drink.

Keep away from children and pets. Should avoid concomitant use with benzodiazepines.

Injectable formulation also available.

Medication guide required at dispensing.

Under REMS program requirements.

Modafinil

This drug may decrease effectiveness of hormonal or IUD contraception.

Recommend additional form of birth control during therapy and 1 mo after last dose.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

If using drug for daytime wakefulness, take in the morning; if using to maintain wakefulness during shift work, take drug 1 h prior to working.

Do not drink alcohol while taking this drug.

Practice good sleep hygiene.

Does not replace need for CPAP machines in patients with obstructive sleep apnea.

Safety and effectiveness in children <16 y of age have not been established.

HR and BP should be evaluated at baseline, during routine follow-up within 1-3 mo, and at follow-up visits every 6-12 mo.

Increases in BP and HR have been reported with the use of certain ADHD drugs.

Medication guide required at dispensing.

Several fatigue-related off-label uses exist.

Naproxen

Take with food or milk to decrease GI upset.

Elderly patients are at increased risk of GI ulceration.

Patients with underlying cardiac dysfunction are at increased risk of cardiovascular effects.

Use lowest dose for shortest duration to minimize toxicity.

Naproxen is also available OTC as a 220 mg tablet. If taken as OTC for fever, do not take longer than 10 d unless directed by physician.

Oxcarbazepine

Suspension should be shaken well and dose prepared immediately using oral dosing syringe.

Suspension can be mixed in a small glass of water just prior to administration or may be swallowed directly from the syringe.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Advise patient to report signs/symptoms of serious dermatologic reactions, myelosuppression, or hepatotoxicity.

Take with food, but not alcohol, grapefruit, or grapefruit juice.

Avoid abrupt discontinuation to avoid risk of seizure.

Safety and efficacy not established in pediatric patients <2 y of age.

With adjunctive therapy, children 2-4 y of age may require up to twice the oxcarbazepine dose per body weight compared to adults, and children 4-12 y of age may require a 50% higher oxcarbazepine dose per body weight compared to adults.

Medication guide required at dispensing.

Taper dose when discontinuing to reduce risk of increased seizures.

Consider monitoring sodium levels, particularly in the first 3 mo of treatment in patients at risk for hyponatremia.

Paroxetine

Do not chew or crush controlled-release tablet or film-coated tablet (Pexeva).

Shake suspension well before using.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Symptomatic improvement may not be seen for several weeks.

Avoid abrupt discontinuation.

Do not drink alcohol.

Use caution with NSAIDs or aspirin while taking this drug.

If intolerable withdrawal symptoms occur following a decrease in dose or therapy discontinuation, may need to resume the previous dose and taper at a more gradual rate.

Symptomatic improvement may not be seen for several wk; typically takes 6-8 wk of treatment on therapeutic dose for maximal efficacy.

Phenobarbital

Avoid activities requiring mental alertness or coordination until drug effects are realized, as drug may cause dizziness, light-headedness, or somnolence.

Advise patient against sudden discontinuation of drug.

Do not drink alcohol or use other CNS depressant drugs while taking phenobarbital.

Many drug interactions; check with HCP when starting new medications or OTC products.

Avoid use in children and elderly who are at higher risk of toxicity.

Avoid abrupt withdrawal to decrease risk of seizures.

Also available in an injectable dosage form.

Recent guidelines recommend against use as a hypnotic for sleep induction.

Phenytoin

Suspension requires extensive shaking before administration.

Do not crush extended-release capsules.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Report signs/symptoms of pancytopenia, hepatotoxicity, systemic lupus erythematosus, or severe skin reaction.

Do not drink alcohol while taking this drug.

Many drug interactions; check with health-care provider when starting new medications or OTC products.

Highly protein bound, so albumin levels should be taken into account when measuring phenytoin concentration; dose adjustment based on free phenytoin concentration.

Injectable formulation available but not for use IM (causes “purple glove syndrome” related to tissue necrosis).

Medication guide required at dispensing. Non–1st-order pharmacokinetics.

Pramipexole

Take with food if nausea occurs.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Rise slowly from a sitting/lying-down position.

Report new or increased gambling urges, sexual urges, compulsive eating or buying, as well as new-onset or worsening dyskinesia.

Do not discontinue abruptly, as this may cause emergent hyperpyrexia and confusion.

Do not drink alcohol, and avoid concomitant use of other CNS depressants.

Safety and efficacy in children not established.

May switch patient from immediate-release to extended-release tablets overnight at same daily dose.

Pregabalin

Solution must be used within 45 d of first opening the bottle.

Avoid activities requiring mental alertness or coordination until drug effects are realized.

Avoid sudden discontinuation of drug due to risk of withdrawal, including increased seizure frequency.

Avoid concurrent use of CNS depressants, such as alcohol.

Safety and efficacy have not been established in children.

Data suggest an increased risk of suicidal behavior or ideation may exist in patients receiving therapy with AEDs.

The dose of the solution should be written as milligrams.

Ropinirole

Take with food to reduce nausea.

Avoid driving and other activities requiring mental alertness or coordination until drug effects are realized.

Rise slowly from sitting/lying-down position.

Report new onset or exacerbation of dyskinesia, changes in BP, fainting, or unusual urges.

Avoid sudden discontinuation of drug; it increases risk of neuroleptic malignancy syndrome.

Do not drink alcohol or take other CNS depressants while using this drug.

May switch directly from immediate-release ropinirole to extended release; start an extended-release dose that matches most closely with the total daily immediate-release dose.