DABIGATRAN (PRADAXA)
WARNING: Pradaxa D/C w/o adequate anticoagulation may ↑ stroke risk; epidural or spinal hematomas may occur.
USES: *↓ Risk stroke/systemic embolism w/ nonvalvular afib; treat DVT and PE in patients who have been treated with a parenteral anticoagulant for 5–10 days.*
ACTIONS: Thrombin inhibitor.
DOSE: CrCl > 30 mL/min: 150 mg PO BID; CrCl 15–30 mL/min: 75 mg PO BID; do not chew/break/open caps.
W/P: [C, ?/−] Avoid w/ P-glycoprotein inducers (ie, rifampin); bleed risk ↑ w/ age.
CI: Active bleeding, prosthetic valve, hypersensitivity to dabigatran.
DISP: Caps 75, 150 mg.
SE: Bleeding, gastritis, dyspepsia.
NOTES: See label to convert between anticoagulants; caps sensitive to humidity (30-day life after opening bottle); routine coags not needed; ↑ PTT/INR/TT; w/ nl TT, no drug activity; half-life 12–17 hr.
DACLIZUMAB (ZENAPAX)
WARNING: Administer under skilled supervision in properly equipped facility.
USES: *Prevent acute organ rejection.*
ACTIONS: IL-2 receptor antagonist.
DOSE: 1 mg/kg/dose IV; 1st dose pretransplant, then 1 mg/kg q14d × 4 doses.
W/P: [C, ?].
CI: Component sensitivity.
DISP: Inj 5 mg/mL.
SE: Hyperglycemia, edema, HTN, ↓ BP, constipation, headache, dizziness, anxiety, nephrotox, pulm edema, pain, anaphylaxis/hypersens.
NOTES: Administer w/in 4 hr of prep.
DACTINOMYCIN (COSMEGEN)
WARNING: Administer under skilled supervision in properly equipped facility; powder and soln toxic, corrosive, mutagenic, carcinogenic, and teratogenic; avoid exposure and use precautions.
USES: *Choriocarcinoma, Wilms’ tumor, Kaposi and Ewing sarcomas, rhabdomyosarcoma, uterine and testicular cancer.*
ACTIONS: DNA-intercalating agent.
DOSE:
Adults: 15 μg/kg/d for 5 d q3–6 wk or 400–600 μg/m2 for 5d q3–6 wk
Peds: Sarcoma (per protocols); ↓ in renal impairment
W/P: [D, ?]
CI: Concurrent/recent chickenpox or herpes zoster; infants < 6 mo
DISP: Inj 0.5 mg
SE: Myelo/immunosuppression, severe N/V/diarrhea, alopecia, acne, hyperpigmentation, radiation recall phenomenon, tissue damage w/ extrav, hepatotox.
NOTES: Classified as antibiotic but not used as antimicrobial.
DALBAVANCIN (DALVANCE)
USES: *Acute bacterial SSSI.*
ACTIONS: Glycopeptide antibacterial (blocks cell wall synth). Spectrum: Includes methicillin-susceptible/resistant strains and Streptococcus pyogenes, enterococcus.
DOSE: 2-dose regimen: 1,000 mg then 500 mg 1 wk later.
W/P: [C, ?/−] Anaphylaxis reported; avoid rapid inf; ↑ALT, C. difficile-associated diarrhea reported.
CI: Component hypersensitivity.
DISP: 500 mg powder to reconstitute.
SE: N, D, HA.
NOTES: Not approved in peds.
DALTEPARIN (FRAGMIN)
WARNING: ↑ Risk of spinal/epidural hematoma w/ LP.
USES: *Unstable angina, non–Q-wave MI, prevent & Treat DVT following surgery (hip, abdominal), pt w/ restricted mobility, extended therapy Treat for PE/DVT in cancer pt.*
ACTIONS: LMW heparin.
DOSE: DVT prophylaxis: 2,500–5,000 U SQ 1–2 hr preop, then daily for 5–10 days. Systemic anticoagulation: 200 U/kg/d SQ or 100 U/kg BID SQ. Cancer: 200 IU/kg (max. 18,000 IU) SQ q24h × 30 days, mo 2–6 150 IU/kg SQ q24h (max, 18,000 IU).
W/P: [B, ?] w/ renal/hepatic impairment, active hemorrhage, cerebrovascular disease, cerebral aneurysm, severe HTN.
CI: Heparin-induced thrombocytopenia; pork product allergy; w/ mifepristone.
DISP: Inj multiple ranging from 2,500 U (16 mg/0.2 mL) to 25,000 U/mL (3.8 mL) prefilled vials.
SE: Bleeding, pain at site, ↓ plt.
NOTES: Predictable effects eliminates lab monitoring; not for IM/IV use.
DANTROLENE (DANTRIUM, REVONTO)
WARNING: Hepatotox reported; D/C after 45 days if no benefit observed.
USES: *Treat spasticity d/t upper motor neuron disorders (eg, spinal cord injuries, stroke, CP, MS); malignant hyperthermia.*
ACTIONS: Skelet al muscle relaxant.
DOSE:
Adults: Spasticity: 25 mg PO daily; ↑ 25 mg to effect to 100 mg PO q8h (400 mg/d max.).
Peds: 0.5 mg/kg/dose/d; ↑ by 0.5 mg/kg dose TID to 2 mg/kg/ dose TID (max. 400 mg/d).
Adults & Peds: Malignant hyperthermia: Treat: Cont rapid IV, start 1 mg/kg until Sxs subside or 10 mg/kg is reached. Postcrisis follow-up: 4–8 mg/kg/d in 3–4 ÷ doses for 1–3 days to prevent recurrence.
W/P: [C, ?] Impaired cardiac/pulm/hepatic function.
CI: Active hepatic disease; where spasticity needed to maintain posture or balance.
DISP: Caps 25, 50, 100 mg; powder for Inj 20 mg/vial.
SE: Hepatotoxic, ↑ LFTs, drowsiness, dizziness, rash, muscle weakness, diarrhea/N/V, pleural effusion w/ pericarditis, blurred vision, hep, photosensitivity.
NOTES: Monitor LFTs; avoid sunlight/EtOH/CNS depressants.
DARBEPOETIN ALFA (ARANESP)
WARNING: Associated w/ ↑ CV, thromboembolic events and/or mortality; D/C if Hgb > 12 g/dL; may increase tumor progression and death in cancer pts.
USES: *Anemia associated w/ CRF*, anemia in nonmyeloid malignancy w/ concurrent chemotherapy.
ACTIONS: ↑ Erythropoiesis, recombinant erythropoietin variant.
DOSE: 0.45 μg/kg single IV or SQ qwk; titrate, do not exceed target Hgb of 12 g/dL; use lowest doses possible, see PI to convert from Epogen.
W/P: [C, ?] May ↑ risk of CV &/or neurologic SE in renal failure; HTN; w/ Hx seizures.
CI: Uncontrolled HTN, component allergy.
DISP: 25, 40, 60, 100, 200, 300 μg/mL, 150 μg/0.75 mL in polysorbate or albumin excipient.
SE: May ↑ cardiac risk, CP, hypo/hypertension, N/V/diarrhea, myalgia, arthralgia, dizziness, edema, fatigue, fever, ↑ risk infection.
NOTES: Longer half-life than Epogen; check weekly CBC until stable.
DARIFENACIN (ENABLEX)
USES: *Overactive bladder with symptoms of urge urinary incontinence, urgency and frequency. *
ACTIONS: Muscarinic receptor antagonist.
DOSE: 7.5 mg/d PO; 15 mg/d max. (7.5 mg/d w/ mod hepatic impairment or w/ CYP3A4 inhibitor); w/ drugs metabolized by CYP2D6; swallow whole.
W/P: [C, ?/−] w/ hepatic impairment.
CI: Urinary/gastric retention, uncontrolled narrow-angle glaucoma, paralytic ileus.
DISP: Tabs ER 7.5, 15 mg.
SE: Xerostomia/ eyes, constipation, dyspepsia, abdominal pain, retention, abnormal vision, dizziness, asthenia.
DEGARELIX (FIRMAGON)
USES: *Advanced PCa.*
ACTIONS: Reversible LHRH antagonist, ↓ LH and testosterone w/o flare seen w/ LHRH agonists (transient ↑ in testosterone).
DOSE: Initial 240 mg SQ abdomen in two 120 mg doses (40 mg/mL); maint 80 mg SQ (20 mg/mL) q28d.
W/P: [Not for women] ↑ QT interval; anaphylaxis, urticaria and angioedema reported.
CI: Women.
SUPPLIED: Inj vial 120 mg (3 mL) (initial); 80 mg (4 mL) (maint).
SE: Inj site reactions, hot flashes, ↑ Wt, ↑ serum GGT.
NOTES: Requires 2 Inj initially (volume); 44% testosterone castrate (<50 ng/dL) at day 1, 96% day 3.
DENOSUMAB (PROLIA, XGEVA)
USES: *Tx osteoporosis postmenopausal women; ↑ BMD in men on ADT (Prolia); prevent skelet al events w/ bone mets from solid tumors (Xgeva).*
ACTIONS: RANK ligand (RANKL) inhibitor (human IgG2 MoAb); inhibits osteoclasts.
DOSE: Prolia: 60 mg SQ q6mo; Xgeva: 120 mg SQ q4wk; in upper arm, thigh, abdominal.
W/P: [X (Xgeva), D (Prolia), ?/−].
CI: Hypocalcemia.
DISP: Inj Prolia 60 mg/mL; Xgeva 70 mg/mL.
SE: ↓ Ca2+, hypophosphatemia, serious infections, dermatitis, rashes, eczema, jaw osteonecrosis, pancreatitis, pain (musculoskelet al, back), fatigue, asthenia, dyspnea, N, abdominal pain, flatulence, hypercholesterolemia, anemia, cystitis.
NOTES: Give w/ calcium 1.000 mg & vit D 400 IU/d.
DESMOPRESSIN (ddAVP, DDAVP NASAL SPRAY, STIMATE)
WARNING: (Parenteral form) Not for hemophilia B or w/ factor VIII antibody; not for hemophilia A w/ factor VIII levels <5%.
USES: *Oral: Central diabetes insipidus; primary nocturnal enuresis, bleeding d/t uremia; Nasal spray: Central diabetes insipidus; Stimate Nasal spray: Hemophilia A, & type I von Willebrand disease; Parenteral: Central diabetes insipidus; hemophilia A, & type I von Willebrand disease.*
ACTIONS: Synthetic analog of vasopressin (human ADH) (1-deamino-8-D-arginine vasopressin, ddAVP; ddAVP is a neuropeptide that differs from endogenous vasopressin by a 2-amino acid substitute which gives the compound potent antidiuretic effect but no vasopressor activity); ↑ factor VIII.
DOSE: DI: Intranasal: Adults: 0.1–0.4 mL (10–40 μg/d in 1–3 ÷ doses). Peds: 3 mo–12 yr: 0.05–0.3 mL/d (5 μg/d) in 1 or 2 doses. Parenteral:
Adults: 0.5–1 mL (2–4 μg/d in 2 ÷ doses); converting from nasal to parenteral, use 1/10 nasal dose. PO: .05 mg BID; ↑ to max. of 1.2 mg. Hemophilia A & von Willebrand disease (type I):
Adults & Peds: >10 kg: 0.3 μg/kg in 50 mL NS, Inf over –30 min. Peds: <10 kg: As above w/ dilution to 10 mL w/ NS. Nocturnal enuresis: >6 yr: 20 μg intranasally hs or 0.2–0.6 mg hs PO.
W/P: [B, M] Avoid overhydration.
CI: (Varies by manufacturer) Hemophilia B; CrCl <50 mL/min, severe classic von Willebrand disease; pts w/ factor VIII antibodies; hyponatremia.
DISP: Tabs 0.1, 0.2, 0.4 mg; Inj 4 μg/mL; nasal spray 0.1 mg/mL (10 μg/spray) 1.5 mg/mL (150 μg/spray)
SE: Facial flushing, headache, dizziness, vulval pain, nasal congestion, pain at Inj site, ↓ Na+, H2O intoxication.
NOTES: In very young & old pts, ↓ fluid intake to avoid H2O intoxication & ↓ Na+;↓ urine output, ↑ urine osm, ↓ plasma osm; GI tract absorption limited (5%), the oral form is 1/10–1/20th the potency of the nasal form. Use of ddAVP for nocturia treatment is off-label (non-FDA approved) in the US. ddAVP has potentially severe side effects and should not be used over the age of 65.
DEXAMETHASONE (DECADRON)
See Steroids, Systemic and Steroids, Topical Pages 968, 969
DEXPANTHENOL (ILOPAN-CHOLINE [ORAL], ILOPAN)
USES: *Minimize paralytic ileus, Treat postop distention.*
ACTIONS: Cholinergic agent.
DOSE:
Adults: Relief of gas: 2–3 tabs PO TID. Prevent postop ileus: 250–500 mg IM stat, repeat in 2 hr, then q6h PRN. Ileus: 500 mg IM stat, repeat in 2 hr, then q6h, PRN.
W/P: [C, ?].
CI: Hemophilia, mechanical bowel obst.
DISP: Inj 250 mg/mL; cream 2% (Panthoderm cream [OTC]).
SE: GI cramps.
DIAZEPAM (VALIUM, DIASTAT, GENERIC) [C-IV]
USES: *Anxiety, EtOH withdrawal, muscle spasm, status epilepticus, panic disorders, amnesia, preop sedation.*
ACTIONS: Benzodiazepine.
DOSE:
Adults: Anxiety, muscle spasm: 2–10 mg PO BID–QID or IM/IV q3–4h PRN. Preop: 5–10 mg PO or IM 20–30 min or IV just prior to procedure.
Peds: Sedation, muscle relaxation: 0.04–0.3 mg/kg/dose q2–4h IM or IV to max. of 0.6 mg/kg in 8 hr, or 0.12–0.8 mg/kg/24 h PO ÷ TID–QID; ↓ w/ hepatic impairment.
W/P: [D, ?/−].
CI: Coma, CNS depression, resp depression, narrow-angle glaucoma, severe uncontrolled pain, pregnancy.
DISP: Tabs 2, 5, 10 mg; soln 5 mg/mL; Inj 5 mg/mL; rectal gel 2.5, 5, 10, 20 mg/mL.
SE: Sedation, amnesia, ↓ HR, ↓ BP, rash, ↓ resp rate.
NOTES: 5 mg/min IV max in adults or 1–2 mg/min in peds (resp arrest possible); IM absorption erratic; avoid abrupt D/C.
DIBUCAINE (NUPERCAINAL) [OTC]
USES: *Hemorrhoids & minor skin conditions.*
ACTIONS: Topical anesthetic.
DOSE: Insert PR w/ applicator BID & after each bowel movement; apply sparingly to skin.
W/P: [C, ?] Topical use only.
CI: Component sensitivity.
DISP: 1% oint w/ rectal applicator.
SE: Local irritation, rash.
DICLOFENAC, ORAL (CATAFLAM, VOLTAREN, VOLTAREN-XR, ZORVOLEX)
WARNING: May ↑ risk of CV events & GI bleeding; CI in postop CABG.
USES: *Arthritis (RA/OA) & pain, oral and topical, actinic keratosis.*
ACTIONS: NSAID.
DOSE: RA/OA: 150–200 mg/d ÷ 2–4 doses DR; 100 mg/d XR; Zorvolex: 18 or 35 mg PO TID; w/ food or milk.
W/P: [C (avoid after 30 wk), ?] CHF, HTN, renal/hepatic dysfunction, & Hx PUD, asthma; different forms not interchangeable.
CI: NSAID/aspirin ASA allergy; porphyria; following CABG.
DISP: Tabs 50 mg; tabs DR 25, 50, 75, 100 mg; XR tabs 100 mg; Zorvolex: 18, 35 mg caps.
SE: Oral: Abd cramps, heartburn, GI ulceration, rash, interstitial nephritis.
NOTES: Do not crush tabs; watch for GI bleed; check CBC, LFTs.
DICLOXACILLIN (GENERIC)
USES: *Treat of pneumonia, skin, & soft-tissue infections, & osteomyelitis caused by penicillinase-producing staphylococci.*
ACTIONS: Bactericidal; ↓ cell wall synth. Spectrum: S. aureus & Streptococcus.
DOSE:
Adults: 150–500 mg QID (2 g/d max.)
Peds: <40 kg: 12.5–100 mg/kg/d ÷ QID; take on empty stomach.
W/P: [B, ?].
CI: Component or PCN sensitivity.
DISP: Caps 125, 250, 500 mg.
SE: N/diarrhea, abdominal pain.
NOTES: Monitor PTT if pt on warfarin.
DILTIAZEM (CARDIZEM, CARDIZEM CD, CARDIZEM LA, CARDIZEM SR, CARTIA XT, DILACOR XR, DILTIA XT, TAZTIA XT, TIAZAC)
USES: *Angina, prevention of reinfarction, HTN, AF or A flutter, & PAT.*
ACTIONS: Calcium channel blocker.
DOSE: HTN: SR: 60–120 mg PO BID; ↑ to 360 mg/d max. CD or XR: 120–360 mg/d (max. 540 mg/d) or LA 180–360 mg/d.
W/P: [C, +] ↑ Effect w/ amiodarone, cimetidine, fentanyl, Li, cyclosporine, digoxin, β-blockers, theophylline.
CI: SSS, AV block, ↓ BP, AMI, pulm congestion.
DISP: Cardizem CD: Caps 120, 180, 240, 300, 360 mg; Cardizem LA: Tabs 120, 180, 240, 300, 360, 420 mg; Cardizem SR: Caps 60, 90, 120 mg; Cardizem: Tabs 30, 60, 90, 120 mg; Cartia XT: Caps 120, 180, 240, 300 mg; Dilacor XR: Caps 120, 180, 240 mg; Diltia XT: Caps 120, 180, 240 mg; Tiazac: Caps 120, 180, 240, 300, 360, 420 mg; Inj 5 mg/mL; Taztia XT: 120, 180, 240, 300, 360 mg.
SE: Gingival hyperplasia, ↓ HR, AV block, ECG abnormalities, peripheral edema, dizziness, headache.
NOTES: Cardizem CD, Dilacor XR, & Tiazac not interchangeable.
DIMETHYL SULFOXIDE [DMSO] (RIMSO-50)
USES: *Interstitial cystitis.*
ACTIONS: Unknown.
DOSE: Intravesical, 50 mL, retain for 15 min; repeat q2wk until relief.
W/P: [C, ?].
CI: Component sensitivity.
DISP: 50% soln.
SE: Cystitis, eosinophilia, GI, & taste disturbance.
DIPHENHYDRAMINE (BENADRYL, GENERIC) [OTC]
USES: *Treat & prevent allergic reactions, motion sickness, potentiate narcotics, sedation, cough suppression, & Treat of extrapyramidal reactions.*
ACTIONS: Antihistamine, antiemetic.
DOSE:
Adults: 25–50 mg PO, IV, or IM TID–QID.
Peds: >2 yr: 5 mg/kg/24 h PO or IM ÷ q6h (max. 300 mg/d); ↑ dosing interval w/ mod–severe renal insufficiency.
W/P: [B, −] Elderly, narrow-angle glaucoma, BPH, w/ MAOI.
CI: Acute asthma.
DISP: Tabs & caps 25, 50 mg; chew tabs 12.5 mg; elixir 12.5 mg/ 5 mL; syrup 12.5 mg/5 mL; liq 12.5 mg/5 mL; Inj 50 mg/mL, cream, gel, liq 2%.
SE: Anticholinergic (eg, xerostomia, urinary retention, sedation).
DIPHENOXYLATE/ATROPINE (LOMOTIL, LONOX, GENERIC) [C-V]
USES: *Diarrhea.*
ACTIONS: Constipating meperidine congener, ↓ GI motility.
DOSE:
Adults: Initial, 5 mg PO TID–QID until controlled, then 2.5–5 mg PO BID; 20 mg/d max.
Peds: >2 yr: 0.3–0.4 mg/kg/24 h (of diphenoxylate) BID–QID, 10 mg/d max.
W/P: [C, ?/−] Elderly, w/ renal impairment.
CI: Obstructive jaundice, diarrhea d/t bacterial infection; children <2 yr.
DISP: Tabs 2.5 mg diphenoxylate/0.025 mg atropine; liq 2.5 mg diphenoxylate/0.025 mg atropine/5 mL.
SE: Drowsiness, dizziness, xerostomia, blurred vision, urinary retention, constipation.
DOCETAXEL (TAXOTERE)
WARNING: Do not administer if neutrophil count <1,500 cells/mm3; severe reactions possible in hepatic dysfunction.
USES: *Breast, ovarian, non-small cell lung, gastric, head, neck, and prostate cancers.*
ACTIONS: Antimitotic agent; promotes microtubular aggregation; semisynthetic taxoid.
DOSE: Prostate cancer: 75 mg/m2 over 1 hr IV q3wk w/ prednisone 5 mg PO BID; ↓ dose w/ ↑ bili levels.
W/P: [D, −].
CI: Sensitivity to meds w/ polysorbate 80, component sensitivity.
DISP: Inj 20 mg/0.5 mL, 80 mg/2 mL.
SE: ↓ BM, neuropathy, N/V, alopecia, fluid retention syndrome; cumulative doses of 300–400 mg/m2 w/o steroid prep & post-Tx & 600–800 mg/m2 w/ steroid prep; allergy possible (rare w/ steroid prep).
NOTES: Check bili/SGOT/SGPT prior to each cycle; frequent CBC during Treat.
DOCUSATE CALCIUM (SURFAK)/DOCUSATE POTASSIUM (DIALOSE)/ DOCUSATE SODIUM (DOSS, COLACE) [OTC]
USES: *Constipation; adjunct to painful anorectal conditions (hemorrhoids).*
ACTIONS: Stool softener.
DOSE:
Adults: 50–500 mg PO ÷ daily–QID.
Peds: Infants–3 yr: 10–40 mg/24 h ÷ daily–QID. 3–6 yr: 20–60 mg/24 h ÷ daily–QID. 6–12 yr: 40–150 mg/24 h ÷ daily–QID.
W/P: [C, ?].
CI: Use w/ mineral oil; intestinal obst, acute abdominal pain, N/V.
DISP: Calcium: Caps 50, 240 mg. Potassium: Caps 100, 240 mg. Na: Caps 50, 100 mg; syrup 50, 60 mg/15 mL; liq 150 mg/15 mL; soln 50 mg/ mL; enema 283 mg/mL.
SE: Rare abdominal cramping, diarrhea.
NOTES: Take w/ full glass of water; no laxative action; do not use >1 wk.
DORIPENEM (DORIBAX)
USES: *Complicated intra-abdominal infection and UTI including pyelo.*
ACTIONS: Carbapenem, ↓ cell wall synth, a β-lactam. Spectrum: Excellent gram(+) (except MRSA and Enterococcus sp), excellent gram(−) coverage including β-lactamase producers, good anaerobic.
DOSE: 500 mg IV q8h, ↓ w/ renal impairment.
W/P: [B, ?].
CI: Carbapenem β-lactams hypersens.
DISP: 250, 500 mg vial.
SE: Headache, N/diarrhea, rash, phlebitis.
NOTES: May ↓ valproic acid levels; overuse may ↑ bacterial resistance; monitor for C. difficile-associated diarrhea 0.5%.
SE: Irritation, bitter taste, superficial keratitis, ocular allergic reaction.
DOXAZOSIN (CARDURA, CARDURA XL, GENERIC)
USES: *HTN & symptomatic BPH.*
ACTIONS: α1-Adrenergic blocker; relaxes bladder neck smooth muscle.
DOSE:
Adult: HTN: Initial 1 mg/d PO; may be ↑ to 16 mg/d PO. BPH: Initial 1 mg/d PO, may ↑ to 8 mg/d; XL 4–8 mg q a.m.
Peds: (not FDA) <6 yr 0.5 mg daily; >6 yr 1 mg daily.
W/P: [C, ?] w/ Liver impairment; use w/ PDE5 inhibitor (eg, sildenafil) can cause ↓ BP.
CI: Component sensitivity.
DISP: Tabs 1, 2, 4, 8 mg; XL 4, 8 mg.
SE: Dizziness, headache, drowsiness, fatigue, malaise, sexual dysfunction, doses >4 mg ↑ postural ↓ BP risk; intraoperative floppy iris syndrome.
NOTES: 1st dose hs; syncope may occur w/in 90 min of initial dose.
DOXORUBICIN (ADRIAMYCIN, GENERIC)
USES: *Acute leukemias; Hodgkin disease & NHLs; soft tissue, osteo & Ewing sarcoma; Wilms’ tumor; neuroblastoma; bladder, breast, ovarian, gastric, thyroid, & lung cancers*; intravesical for bladder cancer.
ACTIONS: Intercalates DNA; ↓ DNA topoisomerase I & II.
DOSE: 60–75 mg/m2 q3wk; ↓ w/ hepatic impairment; IV use only ↓ cardiotox w/ weekly (20 mg/m2/wk) or cont Inf (60–90 mg/m2 over 96 hr); (per protocols).
W/P: [D, ?].
CI: Severe CHF, cardiomyopathy, pre-existing ↓ BM, previous Treat w/ total cumulative doses of doxorubicin, idarubicin, daunorubicin.
DISP: Inj 10, 20, 50, 150, 200 mg.
SE: ↓ BM, venous streaking & phlebitis, N/V/diarrhea, mucositis, radiation recall phenomenon, cardiomyopathy rare (dose related).
NOTES: Limit of 550 mg/m2 cumulative dose (400 mg/m2 w/ prior mediastinal irradiation); dexrazoxane may limit cardiac tox; tissue damage w/ extrav; red/orange urine; tissue vesicant w/ extrav, treat w/ dexrazoxane; liposomal formulations available; intravesical regimens include 30–50 mg in 25–50 mL saline, retain for 2 hr.
DOXYCYCLINE (ADOXA, ORACEA, VIBRAMYCIN, VIBRA-TABS)
USES: *Broad-spectrum antibiotic* acne vulgaris, uncomplicated GC, chlamydia, PID, Lyme disease, skin infections, anthrax, malaria prophylaxis.
ACTIONS: Tetracycline; bacteriostatic; ↓ protein synth. Spectrum: Limited gram(+) and (−), Rickettsia sp, Chlamydia, M. pneumoniae, B. anthracis
DOSE:
Adults: 100 mg PO q12h on 1st day, then 100 mg PO daily–BID or 100 mg IV q12h; acne q day, chlamydia × 7 days, Lyme × 21 days, PID × 14 days.
Peds: >8 yr: 5 mg/kg/24 h PO, 200 mg/d max ÷ daily–BID.
W/P: [D, −] hepatic impairment.
CI: Children <8 yr, severe hepatic dysfunction.
DISP: Tabs 20, 50, 75, 100, 150 mg; caps 50, 75, 100, 150 mg; Oracea 40 mg caps (30 mg timed release, 10 mg DR); syrup 50 mg/5 mL; susp 25 mg/5 mL; Inj 100/vial.
SE: Diarrhea, GI disturbance, photosensitivity.
NOTES: ↓ Effect w/ antacids; tetracycline of choice w/in renal impairment.
d-PENICILLAMINE (CUPRIMINE, DEPEN)
WARNING: Physicians planning to use penicillamine should thoroughly familiarize themselves with its toxicity, special dosage considerations, and therapeutic benefits. Penicillamine should never be used casually. Each patient should remain constantly under the close supervision of the physician. Patients should be warned to report promptly any symptoms suggesting toxicity.
USES: *Refractory rheumatoid arthritis, Wilson disease, cystinuria.*
ACTIONS: Chelating agent.
DOSE:
Adult: Cystinuria: Titrate to keep cystine excretion 100–200 mg/d (<100 mg/d with history of urolithiasis), 1–4 g/d PO in divided doses q6h, typical dose 2 g/d.
Peds: Titrate to keep cystine excretion 100–200 mg/d (<100 mg/d with history of urolithiasis), 30 mg/kg/d in 4 divided doses.
W/P: [D, −]; w/ other meds that act as hematopoietic depressants.
CI: Hypersensitivity to components, renal insufficiency, previous aplastic anemia due to drug, pregnancy.
DISP: Caps 250 mg.
SE: Allergic reactions in up to 33%; agranulocytosis, aplastic anemia, diarrhea, anorexia, abdominal pain, dermatologic manifestations, nephrotic syndrome.
NOTES: Do not d/c therapy in cystinuria; interruptions of a few days can cause hypersensitivity with resumption of therapy; monitor CBC, UA (proteinuria, hematuria), urinary cysteine levels; use THIOLA if intolerant of d-penicillamine.
DULOXETINE (CYMBALTA)
WARNING: Antidepressants may ↑ risk of suicidality; consider risks/benefits of use. Closely monitor for clinical worsening, suicidality, or behavior changes; not for peds.
USES: *Depression, diabetic peripheral neuropathic pain, generalized anxiety disorder (GAD), fibromyalgia, chronic osteoarthritis & back pain.*
ACTIONS: Selective serotonin & norepinephrine reuptake inhibitor (SSNRI).
DOSE: Depression: 40–60 mg/d PO ÷ BID. DM neuropathy: 60 mg/d PO; GAD: 60 mg/d, max. 120 mg/d; Fibromyalgia, Osteoarthritis/back pain: 30–60 mg/d, 60 mg/d max.
W/P: [C, ?/−]; use in 3rd tri; avoid if CrCl <30 mL/min, narrow-angle glaucoma, w/ fluvoxamine, inhibitor of CYP2D6 TCAs, phenothiazines, type class 1C anti-arrhythmics.
CI: ↑ risk serotonin syndrome w/ MAOIs [linezolid or IV meth blue] MAOI use w/in 14 days, w/ thioridazine, narrow-angle glaucoma, hepatic insufficiency.
DISP: Caps delayed release 20, 30, 60 mg.
SE: N, dry mouth, somnolence, fatigue, constipation, ↓ appetite, hyperhidrosis.
NOTES: Swallow whole; monitor BP; avoid abrupt D/C; approved for stress incontinence in some countries (not US).
DUTASTERIDE (AVODART)
USES: *Symptomatic BPH to improve symptoms, ↓ risk of retention and BPH surgery alone or in combo w/ tamsulosin.*
ACTIONS: 5α-reductase inhibitor; ↓ intracellular dihydrotestosterone (DHT).
DOSE: Monotherapy: 0.5 mg PO/d. Combination: 0.5 mg PO q day w/ tamsulosin 0.4 mg q day.
W/P: [X, −] Hepatic impairment; pregnant women should not handle pills; R/O cancer before starting.
CI: Women, peds.
DISP: Caps 0.5 mg.
SE: ↑ Testosterone, ↑ TSH, impotence, ↓ libido, gynecomastia, ejaculatory disturbance, may ↑ risk of high-grade prostate cancer.
NOTES: No blood donation until 6 mo after D/C; ↓ PSA, check new baseline PSA at 6 mo (corrected PSA × 2); any PSA rise on dutasteride suspicious for cancer; now available in fixed dose combination w/ tamsulosin (see Jalyn); not approved to prevent prostate cancer.
DUTASTERIDE/TAMSULOSIN (JALYN)
USES: *Symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate.*
ACTIONS: 5α-Reductase inhibitor (↓ intracellular DHT) w/ α-blocker.
DOSE: 1 capsule daily after same meal.
W/P: [X, −] w/ CYP3A4 and CYP2D6 inhibitor may ↑ SEs; pregnant women should not handle pills; R/O cancer before starting; intraoperative floppy iris syndrome (tamsulosin related) discuss w/ ophthalmologist before cataract surgery; rare priapism; w/ warfarin; may ↑ risk of high-grade prostate cancer.
CI: Women, peds, component sens.
DISP: Caps 0.5 mg dutasteride w/ 0.4 mg tamsulosin.
SE: Impotence, decreased libido, ejaculation disorders, and breast disorders.
NOTES: No blood donation until 6 mo after D/C; ↓ PSA, check new baseline PSA at 6 mo (corrected PSA × 2); any PSA rise on dutasteride suspicious for cancer (see dutasteride and tamsulosin individual listings).