PRAC 142 Top Drugs (Key Counseling Points for the Drug)

Zocor (simvastatin)

Take in the evening; increased risk of myopathy including rhabdomyolysis w/ use of 80 mg dose

Lipitor (atorvastatin); Crestor (rosuvastatin); Zetia (ezetimibe); Tricor, Trilipix (fenofibrate); Prinivil, Zestril (lisinopril); Lotensin (benazepril); Lotrel (amlodipine/benazepril); Cozaar (losartan); Benicar (olmesartan); Avapro (irbesartan); Hyzaar (losartan/HCTZ); Diovan HCT (valsartan/HCTZ); Bystolic (nebivolol); Normodyne, Trandate (labetalol); Jardiance (empagliflozin); Januvia (sitagliptin); Novolog (insulin aspart); Humalog (insulin lispro); Lantus (insulin glargine); Levemir (insulin detemir); Duramorph, MS Contin (morphine); Voltaren XR (diclofenac sodium ER); Celebrex (celecoxib); Risperidal (risperidone); Aricept (donepezil); Zovirax (acyclovir); Lumigan (binatoprost); Xalatan (latanoprost)

none

Mevacor, Altoprev (lovastatin)

IR (Mevacor): Take w/ evening meal b/c fat facilitates absorption; ER (Altoprev): Take at bedtime

Vascepa (icosapent ethyl)

Take w/ food

Vasotec (enalapril)

May contain lactose

Zestoretic (lisinopril/HCTZ); Microzide (HCTZ)

May interfere w/ parathyroid function tests - alert MD of use

Diovan (valsartan)

Dizziness should decrease over time; susp and tabs cannot be subbed

Micardis (telmisartan)

Careful w/ concurrent use w/ digoxin

Lopressor (metoprolol tartrate)

Take w/ or after meals to enhance absorption

Toprol XL (metoprolol succinate)

Tabs are scored and can split in half; do not crush or chew tabs; caps can be opened and sprinkled over soft food; preferably w/ or after meals

Tenormin (atenolol)

Take at the same time each day; accumulation of drug may occur when CrCl

Coreg (carvedilol)

IR and ER cannot be subbed; orthostasis; take w/ food to slow absorption and reduce incidence of orthostasis; ER = very careful w/ concomitant alcohol containing meds/products - separate by at least 2 hours; caps may be opened and sprinkled on soft food; contact lens wearers may experience decreased lacrimation

Inderal (propranolol)

IR and ER cannot be subbed; tabs IR = take w/o food, caps er = with or w/o food but be consistent

Betapace, Sorine, Sotylize (sotalol)

Avoid use w/in 2 hrs of antacids containing Al or Mg; do not use while breastfeeding

Catapres, Catapres-TTS (clonidine)

Patch: apply 1 to clean dry skin every 7 days; remove patch before MRI; ER: swallow whole, take at night before bedtime

Apresoline (hydralazine)

Take w/ or w/o food but be consistent

Norvasc (amlodipine)

Monitor for S/Sx of peripheral and pulmonary edemas

Procardia, Procardia XL (nifedipine)

ER tabs: swallow whole, may be seen in poop; avoid grapefruit juice; take w/ food if nausea occurs

Cardizem LA, Tiazac (diltiazem)

May cause dizziness and fatigue - should decrease over time; do not crush/chew ER forms - swallow whole; avoid grapefruit juice

Thalitone (chlorthalidone)

Take in the morning w/ food

Maxzide, Dyazide (triamterene/HCTZ)

Increased risk of hyperkalemia when used w/ ACEi or K+ supplements

Lasix (furosemide)

IV to PO ratio 1:2

Demadex (torsemide)

IV to PO ratio 1:1

Bumex (bumetanide)

IV to PO ratio 1:1; cross-sensitivity w/ furosemide rarely observed so bumetanide may be used in pts allergic to furosemide

Entresto (sacubitril/valsartan)

Allow a 36 hr washout period when switching to or from ACEi

Glucophage, Glucophage XR (metformin)

Avoid alcohol due to lactic acidosis; contact PCP ASAP if any S/Sx of lactic acidosis; contact PCP if having a procedure requiring use of a contrast dye; take IR w/ food to reduce upset stomach; take ER forms w/ evening meal (may appear in stool)

Trulicity (dulaglutide)

Inject once a week; store unused, unopened pens in the fridge at 36 to 46 degrees F; do not freeze

Ozempic, Wegovy, Rybelsus (semaglutide)

Ozempic/Wegovy - inject once a week, SC inj, rotate inj sites, pen is for one-time use only; Rybelsus - tab form, take 30 min AC w/ no more than 4 oz of plain water, swallow whole, initial 3 mg is for Tx initiations and is not effective for glycemic control

Amaryl (glimepiride)

Take w/ first meal of the day

Glucotrol, Glucotrol XR (glipizide)

IR: take 30 min AC; ER: take w/ first meal of the day

Tradjenta (linagliptin)

Take w/ or w/o food

Tylenol #2, 3, 4 (APAP/codeine); Norco, Vicodin (APAP/hydrocodone); Percocet (APAP/oxycodone HCl)

Do not exceed 4g of APAP in 24 hrs

Oxycontin (oxycodone CR)

Swallow tabs whole and one at a time to avoid potentially fatal dose; not intended for “as needed” or short-term use

Ultram, Ultram ER (tramadol, tramadol ER)

Max dose of 400 mg/day; do not exceed 300 mg/day in pts > 75 yo; may increase risk of seizures (w/ combined use of serotonergic drugs); er only: do not crush/chew; be consistent in regards to food; er forms are not interchangeable - caution

Mobic (meloxicam)

Not interchangeable w/ other formulations of oral meloxicam

Motrin, Advil (ibuprofen)

Max dose of 3200 mg/day

Aleve, Naprosyn (naproxen)

Drug name caution; dosage strength varies based on brand and use - always check ingredients for strength

Toradol (ketorolac)

Do not exceed a total of >5 days of tx from all sources due to increased risk of bleeding

Flexeril (cyclobenzaprine)

Limit use to max of 2-3 weeks (meant for acute treatment); rise slowly from laying down/sitting to avoid falling as this drug can make you dizzy; if needed, peppermint candles, lozenges, or other oral aids can help combat dry mouth

Lioresal (baclofen)

May cause hypotonia (decreased muscle tone), HA; rise slowly from a seated or laying position as this can make you feel dizzy or weak; slowly taper (decrease) down when D/C therapy

Robaxin (methocarbamol)

Take w/ or w/o food; nasogastric (NG) tube administration; tabs may be crushed and suspended in water or saline solution to allow for NG administration

Xanax (alprazolam); Ativan (lorazepam); Valium (diazepam);

Not intended for use >4 months

Klonopin (clonazepam)

Not intended for use >9 weeks; take one dose at bedtime to decrease incidence of somnolence

Restoril (temazepam)

Not intended for use >10 days; may cause physiologic and/or psychologic dependence - limit use; take at bedtime 30-60 mins before intended sleep

Ambien, Ambien CR, Intermezzo (zolpidem)

Ambien, Ambien CR: Use only for sleep initiation and maintenance - take immediately before retiring; Intermezzo: Use only for awakening in the middle-of-the-night - use SL - take only if there are at least 4 hrs of bedtime remaining before planned waking

Plavix (clopidogrel)

Don’t stop taking w/o discussing w/ PCP first - may increase risk of VTE, heart attack, or stroke; Avoid/minimize grapefruit juice; Avoid taking this medication w/ omeprazole (Prilosec) or esomeprazole (Nexium) - may diminish anti-platelet effect

Coumadin, Jantoven (warfarin)

Have your blood work INR checked as told by the doctor; maintain consistent intake of vitamin K (e.g. green, leafy vegetables, broccoli, liver, and certain vegetable oils) and any other meds (prescription, OTC, alternative, etc.); avoid alcohol - may alter medication levels

Xarelto (rivaroxaban)

Take w/ food; may be crushed and mixed w/ applesauce; for missed doses of the 15 mg BID regimen; take as soon as it is remembered, no matter how close it is to the next dose to ensure intake of 30 mg of Xarelto per day - w/ resumption of normal schedule at the next dose

Eliquis (apixaban)

Do not stop taking apixaban w/o discussing w/ PCP first - may increase risk of VTE, heart attack, or stroke; avoid grapefruit juice; may be crushed and mixed w/ applesauce

Digox, Lanoxin (digoxin)

Maintain enough potassium in diet to decrease risk of hypokalemia (hypokalemia may increase risk of digoxin toxicity); S/Sx of toxicity: N/V/D, loss of appetite, confusion, uneven heartbeats, vision changes (blurred vision, green-yellow color disturbances, halo effect); inform PCP about any OTC meds, including herbal, or before starting

Pacerone (amiodarone)

Avoid grapefruit juice; some side effects to be aware of are numbness or “pins and needles” in extremities, thyroid gland changes, vision changes, and sun sensitivity - discuss any of these w/ your PCP if they occur; administer consistently w/ regard to meals; may cause N/V - if experience take w/ food and/or split dose if large dose

Tambocor (flecainide acetate)

Don’t increase dose more frequently than once every 4 days

Nitrostat (nitroglycerin SL)

Dissolve 1 tab under tongue at the first sign of an acute anginal attack, after 5 mins if 2nd tab is needed call 911 FIRST, then take the 2nd tab; may take 3rd tab after an additional 5 mins if needed while waiting for EMS; NITROSTAT may be used prophylactically 5-10 mins prior to engaging in activities that might precipitate an acute attack; store in original glass container, sealed tightly at room temp to prevent loss of tablet potency

Monoket, Imdur (isosorbide mononitrate)

Take w/ at least 4 oz of fluid; for IR products, take the 2 doses 7 hrs apart to avoid development of tolerance; don’t take this med around the clock - adhere strictly to the timing schedule; for ER product take in the morning

Ranexa (ranolazine)

ER - take w/ or w/o meals, swallow tab whole, do not crush, break, or chew; if dose is missed, skip dose and take the next dose at scheduled time; don’t double dose; drug may cause QT prolongation, dizziness, and lightheadedness; limit grapefruit juice intake

Calan, Verelan (verapamil)

Don’t take alcohol (increased ethanol levels); avoid grapefruit juice; capsules may be opened and mixed w/ applesauce

Amantine (midodrine)

Dosing should take place during daytime hours when pt needs to be upright, pursuing ADL; don’t give last dose of the day after last meal of the day or

Prilosec (omeprazole)

Take on empty stomach, 1 hr before meals; if given QD, take before 1st meal of the day; delayed release caps: don’t crush/chew, but may be opened and sprinkled on applesauce, yogurt, fruit juice, or water; OTC tabs and Rx caps are not interchangeable

Nexium (esomeprazole magnesium)

Take on empty stomach, 1 hr before meals; if given QD, take before 1st meal of the day

Dexilant (dexlansoprazole)

Take w/o regards to meals; can be opened and sprinkled on applesauce

Protonix (pantoprazole)

Delayed release: preferable to take on empty stomach, 30-60 min before meals

Pepcid (famotidine)

Take w/o regards to meals; if nausea/upset stomach occurs, take w/ food or milk

Celexa (citalopram)

ADR: dry mouth, (use peppermint candies and/or gum), nausea (take w/ food), somnolence (take at night/bedtime)

Lexapro (escitalopram)

ADR: nausea (take w/ food), somnolence (take at night/bedtime), HA (APAP)

Prozac (fluoxetine)

Take dose preferably in the morning; don’t drink alcohol while using; if you find the drug sedating, may take at night; ADR: nausea (take w/ food)

Zoloft (sertraline)

ADR: nausea (take w/ food but remain consistent)

Paxil (paroxetine)

More dangerous than other SSRIs in pregnancy (Category D); ADR: nausea (take w/ food); take in the morning

Cymbalta (duloxetine)

Don’t open caps

Effexor, Effexor XR (venlafaxine)

Take w/ food to minimize GI side effects in the morning/evening at the same time each day; XR: can be opened and sprinkled on spoonful of applesauce, and then swallowed immediately w/o chewing, followed by a glass of water

Elavil (amitriptyline)

For single daily dosage: preferably take at bedtime; alert PCP if any changes in sight are experienced; ADR: drowsiness/sedation (take at bedtime), dry mouth (eat peppermint candies/gum), constipation (increase fluid and fiber intake), HA (APAP PRN)

Pamelor (nortriptyline)

Take w/ or w/o food; ADRs: anticholinergic effects (constipation, dry mouth, blurred vision, tachycardia, urinary retention)

Silenor (doxepin)

Take w/in 30 mins of bedtime; IR: do not take w/in 3 hrs after a meal (increases next day effects)

Wellbutrin, Wellbutrin SR, Wellbutrin XL (bupropion)

IR: at least 6 hrs between successive doses; SR: at least 8 hrs between successive doses; ER: at least 24 hrs between successive doses; patients may experience dream abnormalities

Remeron (mirtazapine)

Take once daily dosing regimens at bedtime

Buspar (buspirone)

Not intended for “as needed” (prn) use or for brief, situational anxiety; take w/ or w/o food but remain consistent

Abilify (aripriprazole)

Possible ADR: EPS (shaking hands, unsteady gait, coordination difficulty); administered w/o regard to meals

Zyprexa (olanzapine)

Administered w/o regard to meals

Seroquel, Seroquel XR (quetiapine)

If medication is D/C for >7 days, then initial titration schedule will need to be used; administer XR tabs w/o food or w/ light meal (\~300 cals)

Depakote, Depakote ER, Depakote Sprinkles (divalproex sodium/valproic acid)

Effective contraception should be used in women w/ childbearing potential; formulations aren’t bioequivalent - remain consistent on type used (ER, DR, IR); take in divided doses if total daily dose >250 mg; sprinkle capsules may be sprinkled on a soft food and swallowed w/o chewing

Neurontin, Gralise, Horizant (gabapentin)

IR: Use split tablets w/in 28 days of splitting; brand names are not interchangeable - remain consistent; take once daily ER formulations w/ food, preferably w/ evening meal (5 pm) and do not chew/crush/or split

Lyrica (pregabalin)

ER formulation should be given after evening meal; when D/C, should taper over at least 1 week

Lamictal (lamotrigine)

If rash develops, report healthcare provider immediately; oral contraceptives may change concentration of lamotrigine - remain consistent - alert PCP if planned to start/stop; strict dose titration schedule must be followed to decrease risk of serious rash; if >=5 days of therapy missed, alert PCP immediately - must restart titration

Keppra, Keppra XR (levetiracetam)

XR: May see tablet in stool - this is normal - the active ingredient has been absorbed

Topamax (Topiramate)

Caution if you have an allergy to amphetamines; effective contraception should be used in women w/ childbearing potential - consider alternatives to estrogen-containing regimens; be careful to remain well hydrated - particularly in hot weather; sprinkle capsules: swallow whole; alternatively, the contents of the capsules may be sprinkled on a small amount of soft food (e.g. applesauce, custard, ice cream, oatmeal, pudding, or yogurt) for administration; tablets: b/c of the bitter taste, the tablets shouldn’t be broken; seek medical attention if blurred vision, visual disturbances, or periorbital pain

Mysoline (primidone)

Total daily dose shouldn’t exceed 2 g; this drug may cause suicidal thinking and behavior; TDD shouldn’t exceed 2 g

Namenda (memantine)

Follow the initial titration schedule carefully - if missed several days of dose, re-titration will likely be required - contact PCP; ER capsule can be opened and sprinkled on applesauce and immediately swallowed w/o chewing

Valtrex (valacyclovir)

Be sure to remain hydrated while on this medication

Keflex (cephalexin)

Take w/ food if GI upset occurs; store reconstituted suspension in fridge - shake well before using - discard after 14 days

Omnicef (cefdinir)

Take at least 2 hrs before or after antacids or iron supplements; store suspension at room temp - discard after 10 days

Penicillin VK (penicillin VK)

Store suspension in fridge - discard after 14 days; take on empty stomach 1 hr before or 2 hrs after meals (preferred); take w/ food if GI upset occurs

Amoxil (amoxicillin)

ER: take w/in 1 hr of finishing meal; store reconstituted suspension in fridge (preferred) or at room temp - shake well before using - discard after 14 days

Augmentin (amoxicillin/clavulanic acid)

Take dose at the start of the meal for best results; store reconstituted suspension in fridge (preferred) - shake well before using - discard after 10 days; avoid high fat meals; caution - formulations are not interchangeable

Z-Pak, Zithromax (azithromycin)

Don’t take w/ aluminum- or magnesium-containing antacids w/in 2 hrs of taking med - stagger; tablet: take w/ food if nausea occurs; store reconstituted suspension at room temp - shake well before using - discard after 10 days

E.E.S., EryPed (erythromycin)

Avoid concomitant use w/ lovastatin or simvastatin due to increased risk of myopathy, including rhabdomyolysis; take on empty stomach, 30 mins before or 2 hrs after meals (preferred); take w/ food if GI upset occurs; suspension: store granules at room temp; after mixing, refrigerate and discard after 10 days

Cipro (ciprofloxacin)

Take at least 2 hrs before or 6 hrs after supplements or juices that contain multiple vitamins, antacids, calcium (including dairy products), iron, zinc, magnesium, or aluminum; careful w/ concomitant use of tizanidine, caffeine, theophylline, and excessive exposure to sun; maintain adequate hydration

Levaquin (levofloxacin)

Take at least 2 hrs before or after supplements or juices that contain multiple vitamins, antacids, calcium (including dairy products), iron, zinc, magnesium, or aluminum; maintain adequate hydration

Cleocin (clindamycin HCl)

Take w/ full glass of water to avoid esophageal irritation; store reconstituted suspension at room temp - shake well before using - discard after 14 days; take w/ food if GI upset occurs

Flagyl (metronidazole)

Avoid alcohol (including some cough syrups) during use and for at least 72 hrs after the last dose; IR: may be take w/ food to minimize stomach upset; ER: take on an empty stomach 1 hr before or 2 hrs after meals

Oracea, Vibramycin, Doryx (doxycycline hyclate)

Take w/ full glass of water to avoid esophageal irritation; don’t take w/ multiple vitamins, antacids, iron, zinc, magnesium, or aluminum; take w/ food if nausea occurs; avoid excessive sunlight - use sunblock; delayed-release pellets may be sprinkled on spoonful of applesauce and swallowed immediately w/o chewing; store suspension at room temp - discard after 14 days

Bactroban (mupirocin)

Ointment and cream formulations are not interchangeable - use only as directed; wash hands before and after applying; avoid contact w/ eyes - if it gets into eyes, rinse thoroughly w/ water