Subjective Counseling Points

macrolide antibiotics

warning: QT prolongation, hepatotoxicity, taste perversion

clindamycin

may cause C.diff (lowk rare though)

penicillin antibiotics

may cause diarrhea, seizures

do not use in pt with renal impairment

avoid in patients with beta lactam allergy

Pen-Vee K

take on an empty stomach

Bactrim

do not use in patients with sulfa allergy,

may cause skin reactions

Minocin

can cause DILE (drug induced lupus erythematous

Plaquenil

may cause irreversible retinopathy, myopathy, neuropathy, cardiomyopathy, vision changes, hepatotoxicity

Peridex

may cause teeth discoloration, altered taste, or irritation

NRTIs

may exacerbate acute Hep B

emtricitabine

may cause hyperpigmentation of hands or feet

bictegravir

avoid use with polyvalent cations

thiazide diuretics

do not use in pt with sulfa allergy,

caution with lithium (increases risk of toxicity) and NSAIDs

take in morning to avoid nocturia

Dyazide/Maxzide

BBW: hyperkalemia, severe renal disease (don’t forget about caution with lithium and NSAIDs)

spironolactone

effects: hyperkalemia,

caution with lithium (despite not being a thiazide)

loop diuretics

diuretics specifically that will cause fluid/electrolyte depletion (diuresis)

sulfa allergy cross-sensitivity

caution with NSAIDs and lithium

ACEi

BBW: fetal harm and death

sulfa allergy cross-sensitivity,

do not use within 36 hours of entresto,

may cause angioedema, hyperkalemia, renal impairment, dry cough

caution with ARBs, ARNI, and lithium

PDE-5 inhibitors

can cause/contribute to hypotension

Cardura

can cause ghost tablet in stool

ARNI

BBW: fetal harm or death

do not use within 36 hours of ACEi, with ARBs, with lithium

may cause angioedema, hyperkalemia, dry cough

Cordarone

BBW: pulmonary toxicity, hepatotoxicity

do not use in pt with iodine sensitivity,

may cause skin reaction

avoid grapefruit and therapy when pregnant

anti arrhythmics

may cause pro arrhythmia

Tambocor

BBW: pro arrhythmia effects,

do not use in 2nd/3rd deg heart block or cardiogenic shock

clonidine

do not D/C abruptly, taper over 2-4 days or risk rebound HTN

may cause dry mouth, constipation, dizziness, skin rash, impotenence

fibric acid derivatives, antihyperlipidemics

do not use in pt with severe liver disease

warning: increased risk of myopathy when used with a statin

BAS

do not use in pt with bowel obstruction

may cause constipation, GI upset, cramping, bloating, flatulence

HMG-CoA reductase inhibitors, antihyperlipidemics

do not use in pt with liver disease, pregnant, or lactating

may cause muscle damage, myopathy, rhabdomyolysis

avoid grapefruit

ARBs

very similar to ACEs

BBW: fetal harm and death

warning: hyperkalemia, angioedema, dry cough

caution with lithium, ACEi, and ARNI

(less cough and angioedema risk vs ACE)

ARNI

no washout period required (no need to stop taking meds prior taking this one to “washout” the effects of other drugs)

beta blockers

do not D/C abruptly, taper over 1-2 weeks

caution in diabetics and pt with bronchospastic diseases therefore caution with drugs that may cause hypoglycemia or hypotension

may cause depression or impotence

metoprolols

take with or immediately following food

dihydro calcium channel blocker

warning: hypotension risk

(Procardia: ER drug of choice for pregnant women,

Norvasc: safest calcium channel blocker to use in HFrEF)

non-dihydro calcium channel blocker

do not use in pt with HFrEF, pt with 2nd/3rd deg heart block

may cause edema, constipation

guanfacine (alpha-2 adrenergic agonist; antihypertensive)

do not D/C abruptly or risk rebound hypertension

may cause dry mouth, somnolence, constipation, decreased heart rate

warfarin

BBW: fatal bleeding

do not use in pregnant women

may cause necrosis/gangrene, purple toe syndrome

aspirin

do not use in pt with NSAID or salicylate allergy

do not use in children/teens at risk of Reyes Syndrome

Plavix

caution with omeprazole (Prilosec) and esomeprazole (Nexium) due to their decreasing of plavix’ effects

Pradaxa

capsules must be swallowed whole and kept in the original container

Lovenox (enoxaparin)

comes as a prefilled syringe for subQ injections;

do not expel the air bubble from the syringe prior injection

antiplatelets, DOACs, others that allow for bleeding

monitor with NSAIDs

BBW: pt getting neuraxial anesthesia or spinal puncture at risk of hematoma or paralysis

hydralazine

can cause DILE (drug induced lupus erythematous)

used as antihypertensive in pt who cannot tolerate ACEi or ARB

nitroglycerin antianginal, vasodilator

do not use adjunct with PDE-5 inhibitor

Nitrostat

keep in original amber container

place under tongue and let tab dissolve

ranolazine

not for acute angina,

can cause QT prolongation

Fioricet

BBW: hepatotoxicity

take with food to decrease GI upset

Antivert

has anticholinergic side effects

can cause CNS depression or increased IOP

-triptans

can increase BP therefore do not use in pt with HTN

may cause tingling or numbness

rizatriptan, sumatriptan

do not use with MAOIs (adjunct or within 14 days)

GLP-1 agonists

BBW: risk of thyroid C-cell carcinoma,

do not use with DPP-4 inhibitor

rotate inj sites

Actos

BBW: do not use in NYHA class III-IV heart failure - can exacerbate heart failure

insulins

warnings: hypokalemia, hypoglycemia

may cause weight gain

avoid use with sulfonylurea

insulin short acting

inject 30 min prior meal

insulin rapid acting

inject 5-15 min prior meal

insulin intermediate acting

typically dosed twice dailt

roll slowly between hands to mix contents of vial

insulin long acting

usually injected once daily

do not mix with other insulins (because its effect lasts so long)

Novolin 70/30, Humulin 70/30 (insulin NPH 70%/regular 30%)

inject 30 min prior meal

usually dosed twice daily

Novolog Mix 70/30, Humalog Mix 75/25 (insulin protamine 70%/rapid acting 30%)

inject 15 min prior meal

usually dosed 2-3 times daily

Colcrys

warnings: myelosuppression, neuromuscular toxicity

at first sign of attack, take two tabs; one hour later take one more tab

do not exceed > 4 tabs in 24 hours

xanthine oxidase inhibitors

may cause severe skin reactions

when beginning therapy, use with colchicine or NSAID for 3-6 months due to high rate of gout attacks when initiating

Uloric

BBW: increased CV death

therefore typically limited to those intolerant of allopurinol

bisphosphonates, osteoporosis agents

warnings: osteonecrosis of the jaw

do not use in pt with hypocalcemia or pt unable to stand for at least 30 min

separate from polyvalent cations

dental work should be completed before therapy

take in the morning with water

Boniva

must be sitting upright or standing for at least 60 min after taking

raloxifene

do not use in pregnant women, pt with history of VTE

may cause hot flashes

birth controls:

not for immobile pt (on train, plane, etc) due to increased risk of VTE development

can cause hot flashes,

medroxyprogesterone and progestin contraceptives

may cause menstrual cycle irregularities

do not use in pregnant or breast cancer pt

if > 3 hr late, then backup contraceptive is needed for 48 hr

Combipatch, Premarin, Estrogens

BBW: increased risk of endometrial cancer, CVD, breast cancer, dementia

do not use in pt with DVT or breast cancer

caution use with anastrozole

Depo-Provera

BBW: loss of bone mineral density therefore do not use for long term (> 2 years)

Prometrium

do not use in pt with peanut/peanut oil allergy

caution with vaginal antifungals

estrogen/progestin contraceptives

BBW: do not use in women > 35 yrs who smoke

do not use in pt who have migraines with aura, are pregnant, have breast or liver cancer, or uncontrolled HTN

caution with anastrozole, some anticonvulsants, some antibiotics

-if one pill is missed/late, take most recent missed pill ASAP and return to schedule

-if two or more pills are missed/late, take the most recent missed pill ASAP and return to schedule with 7 days of backup contraceptive

-if missed pills are in third week of menstrual cycle, omit the hormone free week and start the next pack without skipping days

aromatase inhibitor

do not use in pregnant women

warning: risk of osteoporosis and CVD

may cause hot flashes

methotrexate

do not use in pregnant women

BBW: hepatotoxicty, myelosuppression, renal damage, teratogenic effects

can cause N/D, hand-foot syndrome

folic acid can reduce side effects

sulfasalazine

do not use in pt with sulfa or salicylate allergy

may cause severe skin reaction or folate deficiency

can cause yellow-orange discoloration of urine and skin

tacrolimus

avoid alcohol

BBW: increased susceptibility to infections and lymphoma

immunosuppressant agents

BBW: increased susceptibility to infections, lymphoma, skin conditions;

BBW: teratogenic effects, spontaneous abortion

caution with contraceptives

do not take at same time as multivitamins/antacids

myfortic and cellcept are not interchangeable

vitamin b-12

caution with colcrys (colcrys can decrease absorption of this drug)

folic acid

caution with phenytoin and phenobarbital

can decrease risk of neural tube defects if 600 mcg/day are taken in

omega 3 fatty acid supplement, antilipidemic agent

caution in pt with hypersensitivity to fish/shellfish

caution in pt taking warfarin

klor-con

do not use in pt with severe renal impairment

iron

caution with antacids, PPIs, H2RAs - decrease absorption of this drug

may cause constipation, dark tarry stools

vitamin c can increase absorption of this drug

timolol

may cause burning or stinging

timolol

may cause dry mouth, dry nose, sedation, fatigue

prostaglandin analogs, used for glaucoma

warning: may cause darkening of the iris, increased lash length/thickness

dorzolamide/timolol

warning: sulfonamide allergy

Tobradex

may cause eye irritation, vision changes, eyelid swelling

Pataday

may cause dry eyes, blurred vision, taste perversion

SABA

prime and shake before use

may cause cough, hyperglycemia, hypokalemia

SAMA

is an metered dosed inhaler

prime before use

do not shake before use

Duoneb

is a nebulizer

may cause cough, hyperglycemia, hypokalemia, nervousness

ICS

caution in pt with immunosuppression, increased risk of growth retardation

may cause dysphonia (trouble speaking), cough, hoarseness, oral candidiasis

rinse mouth after to prevent oral thrush

LAMA

may cause dry mouth, cough, bitter taste

LABA

monotherapy associated with increased risk of asthma-related deaths

Trelegy Ellipta

may cause HA, joint pain, flu-like symptoms, change in taste

rinse mouth after to prevent oral thrush

use at same time everyday

Flonase and Nasonex

warning: avoid use if recent nasal ulcers/surgery

may cause nose bleeds, dry nose, unpleasant taste

may take up to 1 week for full effect

montelukast

BBW: neuropsychiatric events

do not use more than 1 dose in 24 hours

epinephrine

may case tachycardia, hyperglycemia, arrhythmias

codeine/guaifenesin

BBW: may cause respiratory depression and death in children < 12 yrs

do not use in children under 12 or under 18 after tonsillectomy/adenoidectomy

Zyrtec

avoid concurrent use with alcohol/CNS depressants

Allegra

do not use at same time as aluminum and magnesium containing antacids

may cause back pain, dizziness, HA, GI discomfort

Astepro

bitter taste, nasal irritation, somnolence

benzonatate

do not use children under 10 years

varenicline

may cause serious neuropsychiatric events or seizures

start 1 week prior quit date

decrease nausea by taking with food and water