COMPLETED - All of first half

Cell-Cycle Specific Chemotherapy Agents

• Which two major classes of chemotherapy agents are cell-cycle independent?

• Which specific drug class targets the S-phase (DNA synthesis and replication)?

• Which specific drug class targets the G2 phase?

• Which two specific drug classes target the M-phase (mitosis)?

Anzemet

• What is the generic name?

• What is the class?

• Indication

• What toxic effect makes the IV formulation contraindicated?

Dolasetron

• 5-HT3 receptor antagonist

• For chemo induced N/V, only PO

• QTc prolongation (contraindicated for CINV)

Sancuso

• Generic, class

• Dosage form (generic also comes…)

• Duration of action, Use how long before chemo

• Avoid…

Granisetron (5-HT3 receptor antagonist)

• Transdermal patch (granisetron also comes IV, SQ, PO)

• 7 days, 24-48 hrs before chemo

• Avoid sun exposure to the patch site

Zofran

Zuplenz → formulation

-

Generic, class

Indicated for …

Also comes (formulation)

Single IV dose max …due to …

Zuplenz: Oral soluble film (thin strip)

-

Ondansetron, 5ht3 receptor antagonist

Indicated for Chemotherapy-Induced Nausea and Vomiting (CINV)

Also comes oral, ODT, IV

Single IV dose max 16 mg due to QT prolongation

Aloxi

Generic, class, indication

Unique (2)

Palonosetron; 5HT3 receptor antagonist; Chemotherapy-Induced Nausea and Vomiting (CINV)

• It does not carry the high risk of QTc prolongation seen with other class agents

• A remarkably long half-life (36-48 hrs)

Akynzeo (→ generic)

Netupitant + palonosetron

(NK1 antagonist + 5HT3 antagonist)

Decadron

Medrol

in chemo

Steroids used alone or without 5HT3 antagonist for CINV

Dexamethasone (Decadron)

Methylprednisolone (Medrol)

PO Emend

• What is the generic name, pharmacologic class, and primary clinical indication?

• What is the unique mechanism of action of this class?

• What major CYP enzyme does this drug inhibit, requiring a dose reduction of what other med indicated for CINV?

Aprepitant; Neurokinin-1 (NK1) receptor antagonist; Chemotherapy-Induced Nausea and Vomiting (CINV)

• Blocks substance P from binding to NK1 receptors in the central nervous system

• CYP3A4 inhibitor, dose reduction of co-administered dexamethasone

Emend IV

• What is the generic name, pharmacologic class, and primary clinical indication?

• What is the structural relationship between this drug and aprepitant?

Fosaprepitant; Neurokinin-1 (NK1) receptor antagonist; Chemotherapy-Induced Nausea and Vomiting (CINV)

• It is an IV prodrug of aprepitant

Varubi

• What is the generic name, pharmacologic class, and primary clinical indication?

• Unlike aprepitant, this med does not inhibit CYP3A4, but it is a strong inhibitor of which different CYP enzyme?

• What is the unique

Rolapitant; Neurokinin-1 (NK1) receptor antagonist; Chemotherapy-Induced Nausea and Vomiting (CINV)

• CYP2D6 → caution with Tamoxifen (prodrug requires activation through CYP2D6)

• long t1/2

Marinol, Syndros

• What is the generic name, pharmacologic class, and primary clinical indication (2)?

• What is the federal controlled substance schedule and formulation?

• What are the specific storage requirements

Dronabinol; Cannabinoid; Chemotherapy-Induced Nausea and Vomiting (CINV) (and anorexia/weight loss in AIDS)

• Marinol is Schedule III; Syndros is Schedule II

• Marinol capsules versus Syndros oral solution

• Must be refrigerated

Cesamet

• What is the generic name, pharmacologic class, and primary clinical indication?

• What is the federal controlled substance schedule for this specific agent?

• What is the primary storage requirement for this medication?

Nabilone; Cannabinoid; Chemotherapy-Induced Nausea and Vomiting (CINV)

• Schedule II

• Store at room temperature (does not require refrigeration)

Reglan

• What is the generic name, pharmacologic class, and primary clinical indication?

• What black box warning is associated with chronic or high-dose use of this medication?

• What neurological side effects can occur due to its mechanism

Metoclopramide; Dopamine receptor antagonist; Chemotherapy-Induced Nausea and Vomiting (CINV) (and gastroparesis)

• Tardive dyskinesia (often irreversible involuntary movements)

• Dystonic reactions and parkinsonism; manage with diphenhydramine

Benadryl

Vistaril

in CINV

Ativan in CINV

Zyprexa in CINV

Olanzapine

Atypical antipsychotic used off-label for CINV

Summary of CINV tx medications

PO vs IV timing with chemo

First line

First line: 5-HT3 blockers and/or steroids

Then NK1 receptor blocker

Epogen, Procrit, Retacrit → generic

Aranesp → generic

Indicated for…

• can only be used if cancer doesn’t…

Also causes…

5 lab values:

Storage →

Epogen, Procrit, Retacrit → Erythropoietin

Aranesp → Darbepoetin alfa

Indicated for ESRD with HD, and zidouvidine/chemo induced anemia

• can only be used if cancer doesnt have cure → increase tumor progression

Also causes clots

5 lab values: BP, ferritin, B12, folate, Hgb (btwn 10-11)

Storage →

• Refrigerate. Dont use if cloudy or frozen

• Room temp 21 days (erythropoietin)

Neumega

Generic, indication

Oprlvekin, chemo induced thrombocytopenia (low platelets)

Remember

• Pegfilgrastim (Neulasta) → chemo induced thrombocytopenia

• Filgrastin (Neupogen) → chemo induced leukopenia

• Erythropoietin (Epogen) → chemo induced anemia

Neupogen, Granix, Zarxio

• What is the generic name and primary clinical indication?

• What is the critical regulatory distinction between Zarxio and Granix relative to Neupogen?

• What is the primary, classic adverse effect that patients must be counseled on?

• Storage at room temp for how long

Chemo induced leukopenia/neutropenia (low segments/WBC)

just know formulation

Zarxio is an approved biosimilar to Neupogen; Granix is not a biosimilar (approved via a different biological pathway before the framework existed)

Neulasta

• What is the generic name

• primary clinical indication?

• What structural modification differentiates this drug from filgrastim, and what is the resulting dosing frequency per chemotherapy cycle?

• Storage

Pegfilgrastim

Chemo induced leukopenia/neutropenia (low segments/WBC)

NeuLASTa → LASTS longer than Filgrastim (Pegylated filgrastim)

• SQ given once per cycle

• Fridge or RT for 48 hrs (vs Filgrastim 24 hrs)

Remember

• Oprelvekin (Neumega) → chemo induced thrombocytopenia

• Filgrastim (Neupogen) → chemo induced leukopenia

• Erythropoietin (Epogen) → chemo induced anemia

Tumor lysis syndrome treatment

Allopurinol

PhosLo

Renvela

Amophjel

Kayexalate

Veltassa

Lokelma

-

Hydration + 4 electrolytes

IV hydration → NS

Hyperuricemia → Allopurinol (avoid with 6-mercaptopurine, azathioprine)

Hyperphosphatemia

• Calcium acetate (PhosLo)

• Sevelemer (Renvela) → take with food

• Aluminum hydroxide (Amophjel) → avoid in CKD

Hypocalcemia → IV clacium (chloride or gluconate, chloride more potent and irritating upon injection)

• Also used for cardioprotection in severe hyperkalemia regardless of calcium levels

Hyperkalemia

• shifts K+ into cells

  • Sodium bicarb (esp if metabolic acidosis)

  • Insulin (IV) and glucose

  • Beta 2 agonist

• Removes K+ from the body

  • Sodium polystyrene sulfonate (Kayexalate)

  • Patiromer (Veltassa)

  • Zirconium (Lokelma)

  • thiazides and loops

Compounding chemo agents

• Hood certified every…

• Color sharps container

• What are the explicit gloving requirements relative to the gown cuff when handling these agents?

• What type of outer packaging and what exact cautionary statement must be on the label when dispensing these drugs?

• What specific type of hood/cabinet must be used for compounding chemotherapy, and what is its specific airflow pattern?

• Hood ceritified every 6 months

• Yellow sharps container from chemotherapy

• Eye protection and two pairs of gloves; one pair under the gown cuff and the outer glove pulled over the gown cuff

• Dispensed in a Ziploc-type bag; labeled with "Contains Cytotoxic Agent! After use, dispose of properly."

• Vertical flow hood (Class II BSC); vertical unidirectional airflow with no recirculation within the work area to prevent inhalation exposure

Platinol

Generic, class

Causes…(ADE)

Protect…→ (method)

IV sets containing…shouldnt be used

Do not exceed…

Cisplatin; Alkylating agent (platinum analog)

All platins have peripheral neuropathy

Carboplatin

Class

vs Cisplatin

Alkylating agents

Busulfex

Myleran

-

Generic, Class

ADE

Pretreatment for what ADE

DDI for what ADE

Alkylating agent

Cytoxen

Ifex

Generic, class

ADE

Protect what organ with what med

Alkylating agents

BiCNU (→ generic)

Gleostine (→ generic)

Class

ADE → (4)

Can be used for…(indication) bc … (property)

Prepare in…

BiCNU → Carmustine

Gelostine → Lomustine

Alkylating agents

-

ADE → pulmonary fibrosis, hepatic and renal toxicity, bone marrow suppresion

Can be used for CNS tumors bc lipid soluble

Prepare in glass only

Bendamustine

Class

IV diluted in …stable …refrigerated OR …at room temp

Causes …→ can give…

Alkylating agent

IV diluted in NS, stable for 24 hrs refrigerated OR 3 hrs at room temp

Causes tumor lysis syndrome → can give allpurinol

Methotrexate

Class

Indications →

Side effects (acronym)

Administer with… (2)

Voraxaze

Anti-metabolites, chemo agent

Indication → RA, psoriasis, breast cancer

METHOTREXATE Side Effects

• M: Mucositis

• H: Hepatotoxicity

• O: phOtosensitivity

• R: Renal → keep urine alkaline (use sodium bicarb) and well hydrated to avoid toxicity

• X: Chest-X ray → pulmonary fibrosis, Pregnancy Category X

Administer with…

• Leucovorin (folinic acid) to prevent extensive damage to healthy cells

  • Also used to boost 5-FU efficacy

• Glucarpidase (Voraxaze) to breakdown MXT in ESRD

5-FU

Adrucil: formulation

Efudex 5%: formulation and indication

-

Generic, class

ADE

Coadminister with what to increase efficacy

Anti-metabolite

Adrucil: IV

Efudex 5%: cream for actinic or solar keratosis, superficial basal cell carcinoma

Xeloda

-

Generic, class

ADE

Formulation, Regards to food/frequency

BBW

Anti-metabolite

PO twice daily within 30 min after meals

BBW: don’t use with warfarin

Mercaptopurine

-

Class

2 drug interactions

• Decrease dose with…

• Caution with…for increased effect of…

Anti-metabolite

Imuran

Generic, class

Prodrug of..,

DDI

Azathioprine, anti-metabolite

Prodrug of mercaptopurine

DDI w/ xanthine oxidase inhibitors (allopurinol and febuxostat

Cytosar

Generic, class

Formulation

Administration

Cytarabine, antimetabolite

Fludarabine

-

Class

FOrmulation

ADE

Antimetabolite

Bleomycin

-

class

ADE

Max lifetime dose

Anti-tumor antibiotics

Adriamycin

-

Generic, class

ADE → Zenicard, Totect

Dont use in

Max lifetime dose

Anti-tumor antibiotics

dont use in preg

Has the most cardiotoxicity (including Mitoxantrone) of the chemo agents

rub → red urine/tears

Valrubicin

ADE

Indication, Formulation

Anti-tumor antibiotic

Dactinomycin

-

Class

Formulation

ADE

CI

Antitumor antibiotic

Avoid inhalation of vapors → toxic

CI with active chicken pox or herpes zoster

Novantrone

-

Generic, class

ADE

Color of urine/tears

Also indicated for

Max lifetime dose

Antitumor antibiotics

Has the most cardiotoxicity (including Doxa/Daunrubicin) of the chemo agents

Chemo agents have peripheral neuropathy

Vinca, Taxels and platins

Taxotere

Generic, class

ADE

Premedicate

Docetaxel, Plant alkaloids

ADE

• Peripheral neuropathy

• Hypersensitivity → premedicate with dexamethasone 8 mg BID for 3-5 days; start 1 day prior to chemo

• Hepatotoxicity

• Visual impairment

• Fluid retention

All taxels are premedicated

Paclitaxel (Taxol)

Taxol

-

Generic, Class

ADE

Plant alkaloids

PAClitaxel

• P =

  • PVC leeches → use non-PVC

  • Peripheral neuropathy

  • Premedicate (dexamethasone, IV diphenhydramine, IV ranitidine or famotidine)

• A= Alcohol containing → disulfiram like reaction with Flagyl

• Castor oil allergy → dont use

All taxels are premedicated

Class
Etoposide → VP 16 formulation, storage

Teniposide

Infuse over…

Plant alkaloids

VP-16 → capsules, stored in fridge

Infused over 30-60 min to prevent hypotension

Camptosar

(Topotecan)

-

Class

ADE and treatment

Plant alkaloids

I ran to the can → diarrhea

Loperamide usually has Rx max dose of 16 mg/d → but not max dose here bc life threatening diarrhea

Remember plant alkaloids → -taxel, -poside, -tecan

VinCristine

VinBlastine

VinOrelbine

-

Med specific ADE

All have…ADE

Formulation

Oncovin (→ generic)

Vincristine

Alkylating Agents Names Summary

Cisplatin, Carboplatin, Oxaplatin

Busulfan

Cyclophosphamide, Ifosphamide

Carmustine, Lomustine, Bendamustine

Anti-metabolite Names Summary

Methotrexate, Mercaptopurine

5-FU

Capecitabine, Cytarabine, Fludarabine

Anti-tumor Antibiotics Names Summary

Doxorubicin, Daunorubicin, Valrubicin

Bleomycin, Dactinomycin

Mitoxantrone

Plant Alkaloids Names Summary

Docetaxel, Paclitaxel

Etoposide, Teniposide

Irinotecan, Topotecan

Tyrosine Kinase Inhibitors Name Summary

Imatinib (Gleevec)

Erlotinib (Tarceva)

Lapatinib (Tykerb)

Nilotinib (Tasigna)

Gleevec

Generic, class

Imatinib, tyrosine kinase inhibitor (all PO)

Remember

• Erlotinib (Tarceva)

• Lapatinib (Tykerb)

• Nilotinib (Tasigna)

Tarceva

Generic, class

Other MOA

Erlotinib, tyrosine kinase inhibitor (all PO)

Also targets EGFR

Remember

• Imatinib (Gleevec)

• Lapatinib (Tykerb) → also EGFR, HER2

• Nilotinib (Tasigna)

Tykerb

Generic, class

Other MOA

Lapatinib, tyrosine kinase inhibitor (all PO)

Mixed EGFR and HER2 inhibitor

Remember

• Imatinib (Gleevec)

• Erlotinib (Tarceva) → also EGFR

• Nilotinib (Tasigna)

Nilotinib

Generic, class

Tasigna, tyrosine kinase inhibitor (all PO)

Remember

• Imatinib (Gleevec)

• Erlotinib (Tarceva) → also EGFR

• Lapatinib (Tykerb) → also EGFR, HER2

Erbitux

Generic, class

ADE

Cetuximab

EGFR inhibitor (all IV)

Can cause skin rash

Avastin

Generic, class

Formulation

ADE

Bevacizumab

VEGF inhibitor (chemo)

IV with NS

Surgery and wound healing complication

Hydrea, Droxia

Generic

Also indicated for outside of chemo

Recommend what supplement

Thalomid

Generic

ADE

Pomalyst

ADE

Pomalidomide

Misc chemo agent

Pregnancy Category X → strict REMS program due to severe teratogenicity

Alkylating agents

ADE

Causes the most impaired fertility out of chemo agents

Soltamox

• What is the generic name, pharmacologic class

• Unique clinical indication/place in therapy?

• What three severe toxicities/risks are associated with this medication?

• What is the standard treatment duration for this therapy?

• What specific hepatic enzyme pathway activates this drug, and what five medications will decrease its active levels?

Evista

Generic, class

Indication

Increases…but not…

DC

• At least … for prolonged immobilization

• … prior to surgery

Raloxifene, SERM

Indication → breast cancer PPX (not Tx), osteoporosis PPX/Tx

Increase clots but not endometrial cancer (like tamoxifen)

-

DC

• At least 72 hrs prior for prolonged immobilization

• 2-4 weeks prior to surgery

Remember Tamoxifen (Soltamax) for breast cancer tx and risk of endometrial cancer

Aromatase inhibitors

-

Frequency

DDI

ADE

Only for…

QD

Tamoxifen decrease levels

suppress estrogen levels by binding to and blocking the enzyme aromatase → ADE of low estrogen (hot flashes)

for postmenopausal women only

Arimidex (→ generic)

Anastrozole (Aromatase inhibitors)

Femara (→ generic)

Letrozole (Aromatase inhibitors)

Aromasin (→ generic)

Exemastane (Aromatase inhibitor)

Ibrance

-

Generic

Indication

Used in combo with..,.

Palbociclib (Ibrance)

-

ER+, HER2- breast cancer

Used with aromatase inhibitors (Anastrozole, Letrozole, Examestane)

Remember Ribociclib (Kisqali)

Kisqali

-

Generic, Class

Indication

Used in combo with..,.

Ribociclib (Kisqali)

-

ER+, HER2- breast cancer

Used with aromatase inhibitors (Anastrozole, Letrozole, Examestane)

Remember Palbociclib (Ibrance)

Afinitor

-

Generic, Class

Indication

Used in combo with..,.

Everolimus (Afinitor)

-

ER+, HER2- breast cancer

Used with aromatase inhibitors (Anastrozole, Letrozole, Examestane)

Faslodex

Generic, Class

Formulation, Dosing

ADE

Herceptin

Formulation, indication

In combo

Used for…weeks

BBW

Trastuzumab

IV infusion indicated for ER-, HER2+ breast cancer

Great in combination with chemo agents (paclitaxel, docetaxel)

Used for 52 weeks

BBW: cardiotox, pulm tox, anaphylaxis

Remember

• Trastuzumab (Herceptin) → cardio + pulm tox

• Ado-trastuzumab emtansine (Kadcyla) → cardio + hepato tox

• Pertuzumab (Perjeta) → cardio tox, infusion reaction

Perjeta

Formulation, indication

Works best in…patients with …

BBW

Pertuzumab

IV infusion indicated for ER-, HER2+ breast cancer

Works best in treatment naive patients with chemo agents (paclitaxel, docetaxel) and trastuzumab

BBW: cardiotox, infusion reactions

Remember

• Trastuzumab (Herceptin) → cardio + pulm tox

• Ado-trastuzumab emtansine (Kadcyla) → cardio + hepato tox

• Pertuzumab (Perjeta) → cardio tox, infusion reaction

Kadcyla

Generic

Formulation

Indication

BBW

Ado-trastuzumab emtansine (monoclonal antibody + chemo agent)

IV

Last line in ER-, HER2+ breast cancer

Remember

• Trastuzumab (Herceptin) → cardio + pulm tox

• Ado-trastuzumab emtansine (Kadcyla) → cardio + hepato tox (just like TNF alpha blocker

• Pertuzumab (Perjeta) → cardio tox, infusion reaction

Megace

MOA, indication

ADE

Megestrol

Progestin that for breast and endometrial cancer

Can increase appetite → anorexia/cachexia associated with AIDS

Also increase BP, glucose and causes clots

LH-RH agonist/GnRH analog

Names

Indication

Frequency

Initial med pairing and why

ADE

Lueprolide (Lupron)

Goserelin (Zoladex)

Triptorelin

-

Usually for prostate cancer

• Can also be used for endometriosis and pre-menopausal ER+ breast cancer

All given every few months

Will increase hormones first → tumor flare (prevent by pairing with anti androgens) → then decrease via neg feed back

ADE:

• Decrease testosterone → gynecomastia in males

• pulmonary embolism and MI

Lupron (→ generic)

Lueprolide (LH-RH agonist/GnRH analog)

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin (Trelstar)

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Zoladex (→ generic)

Goserelin (LH-RH agonist/GnRH analog)

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin (Trelstar)

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Degarelix

Class

Formulation, frequency

LHRH antagonist for prostate cancer

SC every 28 days

Casodex

Class

ADE

DDI

Bicalutamide

Anti-androgen → all increase in LFT

Causes diarrhea (but less than flutamide)

Increase warfarin levels

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Flutamide

Class

ADE

Anti-androgen → all increase in LFT

Causes the most amount of diarrhea

Causes yellow-green urine (bicalutamide → increase INR w warfarin)

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Nilutamide

ADE

Anti-androgen → all increase in LFT

Causes constipation (Bicalutamide, Flutamide cause diarrhea)

Disulfiram reaction

Decrease reaction to darkness → Caution driving

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Xtandi

Generic, class

ADE

Enzaulutamide

Last line anti-androgen → all increase in LFT

May cause seizures

Remember

• LH-RH agonist: Leuprolide (Lupron), Goserelin (Zoladex), Triptorelin

• Anti-androgen: Bicalutamide (Casodex), Flutamide, Nilutamide → Enzalutamide (Xtandi)

Nizoral

Indication

ADE

DDI

Ketoconazole

Reduces levels of testosterone and cortisol → good for prostate cancer and cushings

ADE: gynemcomastia

DDI

• Needs acidic environment → take with food

• Inhibits CYP3A4

Proscar vs Propecia

Dosing

Class

Indication

Proscar (Finasteride 5 mg) vs Propecia (Finasteride 1 mg for alopecia)

Inhibits 5-alpha-reductase

Prostate cancer prevention

Avodart

Dosing

Class

Indication

Avodart (Dutasteride 0.5 mg)

Inhibits 5-alpha-reductase

Prostate cancer prevention

Remember Proscar (Finasteride 5 mg) as well

Provenge

Generic

Formulation

MOA

Spiulencel-T

“vaccine” that exposes patients’s WBC to recombinant immunogen so that the WBC would recognize prostate cancer and stimulate body’s immune response when returned to the patient

Keytruda

Generic, Class

Pembrolizumab

Keytruda, PD-1 inhibitor monoclonal antibody

Immunotherapy

AMES test

Compro

Generic

Class, Indication

Prochlorperazine

Dopamine antagonist for CINV

Amisulpride

Class, Indication

Formulation

Dopamine antagonist for CINV

IV

Chemo meds that cause pulmonary toxicity/fibrosis

Bleomycin, Busulfan, MTX

(amiodarone)

COPD (general)

Chronic, irreversible

Usually from lifestyle (smokers) not from genetic like family history

Not due to inflammation → ICS not used first line (increase risk of pneumonia instead)

SMI

Suffix

Counseling Tips

Dont…

Discard after

“Respimat”

-

P-TOP

Prime. Turn. Open. Press

Dont need to shake or require spacer

-

Discard after 3 months

Anticholinergic oral inhalers

Names and Frequency

CI in…

Dont use in what allergy

Ipratropium - QID

Tiotropium, Umeclidinium - QD

Aclidinium, Glycopyrrolate - BID

Caution: glaucoma, BPH, bladder neck obstruction

-

do NOT give 2 anticholinergics together

Dont use with allergy to atropine

Atorvent HFA

Generic, Class

Formulation

Frequency

Comment

Ipratropium, anticholinerigc

(Atorvent HFA) → MDI

QID

MDI that does NOT need shaking (other one is Ciclesonide (Alvesco))

Combivent Respimat

Generic, Frequency

Formulation → Discard after…

Not CI…

Ipratropium + Albuterol, QID

SMI → discard after 3 months

NOT contraindicated with soybean or peanut allergy

Albuterol (Ventolin, Proventil, ProAir), Ipratropium (Atrovent)

Duoneb

Generic, Formulation

Frequency

Ipratropium + Albuterol (neb) → anticholineric + saba

QID PRN

Ipratropium (Atrovent)

Ipratropium + Albuterol inhaler (Combivent Respimat)