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Apixaban

Seek medical attention if any unexpected bleeding or trouble breathing. Take with or without food. Do not stop taking apixaban without talking with your HCP; stopping early may increase the risk of stroke, especially in patients with atrial fibrillation. Apixaban should be interrupted 24-48 h prior to dental and surgical procedures and re-started after hemostasis. Avoid OTC NSAIDs and high-dose aspirin; they increase the risk of bleeding.

Factor Xa inhibitors do not require routine monitoring of the INR and have a lower risk of bleeding when compared to warfarin as well as being orally administered and more convenient than heparin and low-molecular-weight heparin. Specific recommendations exist for converting from other anticoagulants to apixaban. FDA labeling does not require dose adjustment for patients with renal dysfunction taking for indications other than atrial fibrillation, but patients with CrCl <25 mL/min or SCr >2.5 mg/dL have been excluded from the trials. Dose adjustment for all patients with that degree of renal dysfunction may be warranted. If reversal is required for life-threatening or uncontrolled bleeding, recombinant coagulation factor Xa has been used.

Alendronate

Swallow the non-effervescent tablet whole with a large glass (240 mL) of plain water only.

Dissolve 1 effervescent tablet in 120 mL of room temperature plain water only (not mineral water or flavored water); once effervescence stops, wait ≥5 min and stir the solution for ∼10 s and then drink.

Remain upright at least 30 min after you swallow the tablet before you eat or drink anything or take any other medicines.

This will help your body absorb the medicine and do not lie down until after you have eaten some food.

Concurrent chemotherapy, radiation therapy, and poor oral hygiene increase the risk of osteonecrosis of the jaw.

Atypical fractures of the thigh have been reported in patients taking bisphosphonates for osteoporosis; discontinue therapy in patients who develop evidence of a femoral shaft fracture

For patients at lower risk for fracture, consider drug discontinuation after 3-5 y of use.

Adequate calcium and vitamin intake required for efficacy

Men >70 y of age and women >50 y of age should consume 1200 mg of elemental calcium from all sources (dietary + supplements), and all adults >50 y of age should consume 800-1000 units of vitamin D daily with a target serum level of >30 ng/mL.

Also available in combination with vitamin D, with 70 mg alendronate and either 2800 or 5600 units cholecalciferol per tablet (Fosamax Plus D).

Anastrozole

Seek medical attention if shortness of breath, swelling, chest pain, vaginal bleeding, blistering rash, rapid weight gain, severe nausea and vomiting, yellowing of the eyes or skin.

Take with or without food.

Because anastrozole lowers level of estrogen, can lead to loss of BMD and increased fracture risk.

As effective as tamoxifen in treating metastatic breast cancer, but decreased incidence of adverse effects (thromboembolic events and endometrial cancer)

Not indicated in premenopausal women.

Conjugated estrogens

Discuss potential long-term adverse effects of hormone therapy including MI, stroke, DVT, PE, and breast cancer.

Take at bedtime to minimize side effects.

Take with or without meals.

Injectable and vaginal cream is also available for other indications requiring estrogen replacement therapy.

Combination of estrogens and progestins should not be used for the prevention of cardiovascular disease

Increased risk (over placebo) of MI, stroke, invasive breast cancer, pulmonary emboli, and DVT has been shown in postmenopausal women

Because of these risks, estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.

In postmenopausal women with a uterus, a progestin (eg, medroxyprogesterone) should be added to estrogen to reduce the risk of endometrial cancer.

Increased incidence of dementia was observed in women ≥65 y of age taking estrogens

Also available in combination with bazedoxifene (Duavee) for osteoporosis prevention and vasomotor symptoms.

Cyanocobalamin

May require several weeks for maximum effect.

Take extended-release products with food.

Avoid alcohol as it inhibits the absorption of B12.

Drugs that interfere with folate metabolism (methotrexate, hydroxyurea, pemetrexed) will cause an elevated MCV in the absence of vitamin B deficiency.

Patients on pemetrexed receive B12 to prevent toxicity

Metformin decreases B12 concentrations.

Darifenacin

This drug may cause anticholinergic effects, including constipation, urinary retention, blurred vision, dyspepsia, or xerostomia

Heat prostration (due to decreased sweating) can occur when used in a hot environment.

Can be taken with or without food.

Seek medical attention for signs and symptoms of angioedema (swelling of tongue or laryngopharynx, difficulty breathing, etc).

May note decline in cognitive function, especially in elderly patients.

Dicyclomine

May cause drowsiness; avoid driving and operating heavy equipment

Heat prostration (due to decreased sweating) can occur when used in a hot environment.

There are reports that administration of dicyclomine to infants has been followed by serious respiratory symptoms (dyspnea, shortness of breath, breathlessness, respiratory collapse, apnea, asphyxia), seizures, syncope, pulse rate fluctuations, muscular hypotonia, and coma. Death has been reported.

Injectable formulation also available for IM use only (not to be used IV).

Dutasteride

Symptoms may not improve for up to 6 mo after starting treatment.

Do not donate blood while taking or for 6 mo after stopping dutasteride, as it may be transfused to a pregnant woman

Women who are pregnant or may become pregnant should avoid touching or handling this medicine

This medicine can get into the body through the skin and may prevent development of genitalia in an unborn male baby.

May be combined with the alpha-blocker tamsulosin for the treatment of BPH; combination product (Jalyn), containing dutasteride 0.5 mg and tamsulosin 0.4 mg, also available.

Draw baseline PSA before initiating therapy

Note that PSA will decrease by 50% with treatment; double PSA values when assessing for prostate cancer.

Estradiol oral

Report abnormal vaginal bleeding or signs/symptoms of a thromboembolic disorder

Do not smoke during therapy, as this increases the risk of thromboembolic events.

Estrogens increase the risk of endometrial cancer; monitor for abnormal vaginal bleeding.

Increased risks of MI, stroke, invasive breast cancer, pulmonary emboli, and DVT in postmenopausal women have been reported.

An increased risk of developing dementia in women ≥65 y of age has also been reported.

Estrogens, with or without progestins, should be prescribed at the lowest effective doses and for the shortest duration possible.

Also available as injectable, in a variety of topical formulations (gel, cream, aerosol spray, patch, etc) and as a vaginal ring.

Estradiol transdermal patch

Report abnormal vaginal bleeding or signs/symptoms of a thromboembolic disorder

Do not smoke during therapy, as this increases the risk of thromboembolic event

Place patch on clean, dry skin, preferably on the lower abdomen, upper quadrant of the buttock, or outer aspect of the hip; do not apply to the breasts or waistline; rotate sites of application with 1 wk allowed between applications to a particular site.

Estrogens increase the risk of endometrial cancer; monitor for abnormal vaginal bleeding

Increased risks of MI, stroke, invasive breast cancer, pulmonary emboli, and DVT in postmenopausal women have been reported

An increased risk of developing dementia in women ≥65 y of age has also been reported.

Estrogens, with or without progestins, should be prescribed at the lowest effective doses and for the shortest duration possible

Also available in injectable, oral, and vaginal formulations, as well as a number of other topical formulations

Patch contains metal; remove prior to MRI

Do not cut patch.

Ethinyl Estradiol

If the vaginal ring is inadvertently expelled or removed, it may be rinsed in cool to lukewarm water and reinserted as soon as possible, at the latest within 3 h.

If the ring-free interval has been extended beyond 7 d or if the vaginal ring has been left in place for >4 wk, an additional form of contraception must be used until the vaginal ring has been used continuously for 7 d.

Patients should not smoke during therapy, as this increases the risk of serious cardiovascular side effects.

Finasteride

For hair loss, you may need to take this medicine for 3 mo or longer before you see an effect

For an enlarged prostate, you may need to take this medicine for up to 6 mo to see the full effect

Women who are pregnant or may become pregnant should avoid touching or handling this medicine

This medicine can get into the body through the skin and may prevent development of genitalia in an unborn male baby.

They should also avoid semen of a man taking finasteride

Report shortness of breath, breast swelling or breast mass to HCP.

Not effective for the treatment of prostate cancer.

Is effective in reducing the overall incidence of prostate cancer, although an increase in the incidence of high-grade prostate cancers has been observed.

Draw baseline PSA before initiating therapy. Note that PSA will decrease by 50% with treatment, double PSA values when assessing for prostate cancer. Does not affect free PSA level

For BPH, often used in combination with alpha-blocker (eg, tamsulosin) which provides more rapid symptom relief but does not impact gland size.

Hazardous agent:

Use appropriate precautions for handling and disposal

Case reports exist associating suicidal ideation with finasteride administration.

Ibandronate

Take this medicine as soon as you get out of bed in the morning, before you eat or have anything to drink.

Swallow the tablet whole with a large glass (240 mL) of plain water only (not mineral water, coffee, juice, or any other liquid).

Do not take the medicine while you are still in bed, and do not take it at bedtime.

Wait for at least 60 min after you swallow the tablet before you eat or drink anything or take any other medicines. This will help your body absorb the medicine.

Do not lie down for at least 60 min after taking this medicine, and do not lie down until after you have eaten some food.

Concurrent chemotherapy and poor oral hygiene increase the risk for osteonecrosis of the jaw.

Atypical fractures of the thigh (subtrochanteric and diaphyseal femur fractures) have been reported in patients taking bisphosphonates for osteoporosis; discontinue therapy in patients who develop evidence of a femoral shaft fracture.

Given the toxicities, the FDA recommends consideration of discontinuation of ibandronate in patients at lower risk of osteoporosis after 3-5 y of therapy.

Medication guide required at dispensing.

Recommend adjunct calcium and vitamin D if dietary intake is inadequate.

Injectable formulation also available.

Medroxyprogesterone

Menstrual bleeding should occur 3-7 d after last dose.

Patients should report if menstruation does not occur within 7 d after last dose

Do not use if you become pregnant.

Injectable formulation of medroxyprogesterone is administered IM or sq every 3 mo for contraception and for pain associated with endometriosis.

Combination of estrogens and progestins should not be used for the prevention of cardiovascular disease

Increased risk of AMI, stroke, invasive breast cancer, PE, and DVT has been shown in postmenopausal women.

Methylprednisolone

For short-term treatment, inform patients to take doses with meals to prevent GI upset.

For high-dose or longer-term treatment, inform patients to monitor for signs of hyperglycemia, osteoporosis, adrenocortical insufficiency, and infection.

Available in a variety of dosage forms for various indications, including ophthalmic and injectable preparations

Use the lowest effective dose and discontinue as soon as possible to avoid serious long-term adverse effects.

Consider tapering after long-term therapy

Injectable formulations sold by compounding pharmacies have been associated with outbreak of fatal fungal infections

Steroids can elicit psychiatric disturbances, including mood swings, insomnia, or severe depression in individuals without diagnosed depression.

Mirabegron

Monitor BP and HR and contact HCP for fast heartbeat or elevations in BP, bladder irritation or difficulty with urination.

Life-style changes, including avoiding fluids at bedtime and reducing consumption of mild diuretics like caffeine and alcohol is first line therapy for managing bladder symptoms

Many patients also benefit from pelvic floor training

Initial pharmacologic therapy includes alpha adrenergic agents and 5 alpha-reductase inhibitors in men.

Anticholinergics (tolterodine, oxybutynin, darifenacin, solifenacin, fesoterodine, and trospium) are also commonly used, effective, and inexpensive options.

Mirabegron is more effective than placebo and as effective as anticholinergics, with less dry mouth.

Oxybutynin

This drug may cause anticholinergic effects, including constipation, urinary retention, blurred vision, dyspepsia, or xerostomia

Heat prostration (due to decreased sweating) can occur when used in a hot environment.

Patients should be advised to exercise caution in decisions to engage in potentially dangerous activities until the drug’s effects have been determined.

May note decline in cognitive function, especially in elderly

The transdermal patch is available OTC.

Progesterone

Menstrual bleeding should occur 3-7 d after last dose. Report if menstruation does not occur within 7 d after last dose

For vaginal formulation, avoid using other vaginal drugs within 6 h before or 6 h after using progesterone.

Injectable depot formulation of progesterone (medroxyprogesterone) is used for contraception (150 mg IM q3mo).

Combination of estrogens and progestins should not be used for the prevention of cardiovascular disease

Increased risk of AMI, stroke, invasive breast cancer, PE, and DVT has been shown in postmenopausal women

Evidence regarding teratogenicity is conflicting; some studies show birth defects, and other studies show no effect.

Raloxifene

Raloxifene increases the risk of blood clots, especially during the first 4 mo of therapy

Avoid sitting for long periods and be aware of the symptoms of DVT

If taking for osteoporosis, consider calcium and vitamin D supplementation.

Tamoxifen and raloxifene are equivalent in efficacy for preventing breast cancer; however, raloxifene causes less endometrial hyperplasia, thromboembolic events, and cataracts.

Medication guide required at dispensing.

Risedronate

Take as soon as you get out of bed in the morning, before you eat or have anything to drink

Swallow tablet whole with 240 mL of plain water only (not mineral water, coffee, juice, or any other liquid)

Do not chew tablet.

Do not take the medicine while you are still in bed, and do not take it at bedtime.

Wait at least 30 min after you swallow the tablet before you eat or drink anything or take any other medicines.

Do not lie down for at least 30 min after taking this medicine, and do not lie down until after you have eaten some food.

Concurrent chemotherapy, IV administration, and poor oral hygiene increase the risk for osteonecrosis of the jaw

Atypical fractures of the thigh (subtrochanteric and diaphyseal femur fractures) have been reported in patients taking bisphosphonates for osteoporosis; discontinue therapy in patients who develop evidence of a femoral shaft fracture

Atelvia is the brand name of the delayed release product.

Medication guide required at dispensing.

Sildenafil

Take 30 min-4 h prior to anticipated sexual activity, but do not take more frequently than once q24h.

The choice between avanafil, tadalafil, sildenafil, or vardenafil is largely one of patient preferences

Sexual stimulation is required to initiate the local release of nitric oxide; the inhibition of PDE5 has no effect in the absence of sexual stimulation

Dose-dependent increase in mortality in children using for PAH; use alternative agent if possible

Many antidepressant and antihypertensive agents cause erectile dysfunction; assess and consider discontinuing.

Advise patients that lifestyle modifications (stopping smoking, weight loss) can also improve sexual functioning

Revatio is brand name for PAH indication.

Injectable formulation also available.

Tadalafil

If taking as needed, take 30 min prior to anticipated sexual activity. Do not take more frequently than once q24h

Avoid driving or other activities that require mental alertness until the drug’s effects have been determined.

Seek medical attention if severe skin rash, chest pain, erection lasting >4 h, tinnitus, dizziness, or shortness of breath.

The choice between avanafil, tadalafil, sildenafil, and vardenafil is largely one of patient preferences; tadalafil may be preferred in those desiring “full-day coverage.”

Sexual stimulation is required to initiate the local release of NO; the inhibition of PDE5 has no effect in the absence of sexual stimulation

Many antidepressant and antihypertensive agents cause erectile dysfunction, assess and consider discontinuing.

Advise patients that lifestyle modifications (stopping smoking, weight loss) can also improve sexual functioning

Adcirca is FDA approved for pulmonary artery HTN; Cialis is FDA approved for erectile dysfunction.

Tamsulosin

Administer 30 min after same meal daily as fasting increases bioavailability by 30%.

Avoid activities requiring coordination until drug effects are realized, as drug may cause vertigo or dizziness.

Rise slowly from a sitting/lying position, as this drug may cause orthostatic hypotension.

Syncope or loss of consciousness is possible with 1st dose or dose increases, especially if in an upright position.

Alpha-blockers commonly used for HTN.

Patients with both HTN and BPH should avoid taking other α-adrenergic blocking agents while taking this drug.

Tamsulosin is not indicated for HTN.

Testosterone

Gel to be applied to clean, dry, intact skin of the shoulders and upper arms and/or abdomen but should not be applied to genitals.

Gel should be allowed to dry well; swimming and showering should be avoided for 5-6 h after application.

Patients should keep application site covered, as direct skin contact can transfer drug to others.

Virilization has been reported in children who were secondarily exposed to testosterone gel (coming in contact with bare skin around gel application site).

Male patients should report too frequent or persistent erections.

Female sexual partners of patients using drug should report male-like changes

Do not use higher doses than you have been prescribed, or combine with other anabolic steroids, serious adverse effects can occur.

Seek medical attention if chest pain, shortness of breath, signs of stroke, or behavioral changes.

In addition to topical dosage forms (gel and patch), other dosage forms include subcutaneous implants and injectable, which are indicated for delayed puberty, breast cancer, female-to-male gender identity disorder, and others.

Avoid other medications containing testosterone, including those purchased without a prescription in health food stores or on the Internet.

The patch may contain metal; remove prior to MRIs.

Testosterone has been subject to abuse, typically at doses higher than recommended for the approved indication and in combination with other anabolic androgenic steroids.

If testosterone abuse is suspected, check serum testosterone concentrations to ensure they are within therapeutic range and consider testosterone abuse in men presenting with serious cardiovascular or psychiatric symptoms.

Under REMS program requirements.

Tolterodine

Avoid activities requiring mental alertness or coordination until drug effects are realized, as this drug may cause blurred vision, dizziness, and drowsiness.

Swallow extended-release capsule whole; do not crush, break, or chew.

In the presence of a high environmental temperature, heat prostration can occur with drug use (fever and heat stroke due to decreased sweating). If symptoms occur, the drug should be discontinued and supportive measures instituted

May note decline in cognitive function, particularly in elderly.

Lifestyle changes can also improve urinary symptoms.

Patients should lose weight and avoid beverages containing alcohol or caffeine.

Long-acting product is generally better tolerated.