HOSPICE CARE TEAM, INC PREFERRED DRUG LIST (Updated 6-10-05) 1. Drugs listed as ( 1 ) should be tried first, these are drugs under formulary; generic should always be ordered first. 2. Drugs listed as ( 2 ) should be tried when primary drugs fail, these are in the formulary but are more costly. 3. Drugs listed as (3) should be tried last; these are most expensive. Drugs not listed are not on formulary and require PCC ok. 4. All doses listed are ADULT doses.
CLASSIFICATION Steroids
Appetite Stimulant Antihistamines
Anxiety/ Agitation
Agitation
Benzodiazepines
Antihistamines
Formulary
SYMPTOM
NOTE: Drugs given for dx other than Primary hospice DX are not paid for by Hospice
GENERIC NAME
TRADE NAME Decadron
2-4 mg. q day (max 4mg/d)
1 Prednisone
Deltasone
5-10 mg. ( max 10 mg/day)
1 Cyproheptadine
Periactin
4 mg po tid
1 Lorazepam
Ativan
0.5-2mg po/SL/PR/SQ q4-6hr (max 10 mg/d)
2 Diazepam
Valium
Caution in NH pt
2
Xanax
Oral Conc 2mg/ml Caution in NH pt 0.25-1mg po/SL q4-6hr (max 20 mg/d)
Benadryl
Caution in NH pt
Alprazolam
1 Diphenhydramine 2 (Butyopenones)
Antipsychotics
Haldol
Chlorpromazine Severe agitation g
2 ((Phenothiazine))
Thorazine
Belching
Antiflatulants
1 Simethicone
Mylicon
Bleeding
Benzodiazepines
1 Diazepam
Valium
1
Senna + Docusate
Senokot S
1
Sorbitol 70%
Cathartics
Osmotic Cathartics
Magnesium Citrate
Citroma, Citro-Mag, Citro-Nesia
1
Bisacodyl
Dulcolax
1
Sodium Phosphate Biphosphate Enema
Fleets
1
Glycerin Supp
Stool Softeners
Stool Softeners
1
Docusate
Stool Softeners
Stool Softeners
1
Mineral Oil Enema Only
Mild diarrhea
Anti-diarrheal Agents
Loperamide
1
25-100mg q4-6h (max 400 mg/d)
Extra-pyramidal 0.5-5mg po/SL/IM/PR reactions common. q6-12hr (max 20 mg/d) Have Benadryl or Cogentin on hand (start w/ 1 mg. po bid)
10-50mg g po/SL/PR p q4-6hr q (max ( 200 mg/d) g )
40-125mg QID (max 500 mg./d)
1-4tabs QD-TID (max 4 tabs)
15-30ml QD-BID (max 150 ml)
Enulose
1
2-10mg po/SL/PR/SQ q4-6hr (max 40 mg/d)
10mg prn(q30min)
Lactulose
3
Contact Cathartics
RECOMMENDED DOSE
1 Dexamethasone
Haloperidol Hallucinations
COMMENTS
Limited Use for Diabetic pts Liver Disease Cirrhosis
15-30ml QD-BID (max 150 ml)
240 ml in a single dose or divided doses
5-10mg po HS/10mg PR HS (max 30 mg/d)
135ml (4.5oz.) PR PRN
Limited to PEDI Pt 1 supp PR PRN (OTC)
Colace
50-200mg QD-QID (OTC)
(OTC)
Imodium
2 caps x 1, then 1 after ea. Loose stool (max 8 tabs/d) Page 3
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CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
COMMENTS
RECOMMENDED DOSE
Diphenoxyl/Atropine
Lomotil
Metronidazole
Flagyl
Lorazepam
Ativan
Haloperidol
Haldol
Dexamethasone
Decadron
2-16mg QD
Benzonatate
Tessalon Perles
100mg po TID (max 600 mg/d)
Guaifenesin/codeine
Robitussin AC
1-2tsp q4-6h prn cough ( max 60 ml , 10 tsp.)
Guaifenesin LA
Mucinex
Prior auth req
600mg po BID (max 2,400 mg.)
Diphenhydramine
Benadryl
Caution in NH pt
25-100mg HS (max. 400 mg)
Lorazepam
Ativan
Diazepam
Valium
Alprazolam
Xanax
0.25-1mg po/SL q4-6hr (max 4 mg./d)
1
Morphine
MS IR, Roxanol MS Soluble tabs
5-10 mg. po/sl q 2hrs. prn
3
Albuterol
Proventil/ Ventolin
Prior auth req
1-2puffs q4-6h 1 amp neb q4-6h prn (max 12 puffs/d)
3
Ipratropium
Atrovent
Prior auth req
2puffs QID 1 amp neb q6h prn ( max 12 puffs/d)
3
Theophylline
TheoDur
3
Albuterol/Ipratopium
Combivent Inhaler
Moderate diarrhea
2tabs now & 1tab q4h prn (max 8 tabs/day)
Anti-diarrheal Agents 2 Severe diarrhea
3
Use for unresolved diarrhea after 48 hrs
0.5-2mg po/SL/PR/SQ q4-6hr (max 10 mg/d)
Benzodiazepines
1
Confusion
Antipsychotics
1 Confusion-Brain mets
Steroids
1 1
Dry Cough/ Antitussives
Antitussive/ Expectorants
250 mg. po tid x 7 days
Oral Conc 2mg/ml Caution in NH pt
0.5-5mg po/SL/IM/PR q6-12hr (max 20 mg/d)
1 Antitussives/ Expectorants Wet Cough /Expectorants
3 Wet Cough
1 0.5-2mg po/SL/PR/SQ q4-6hr (max 10 mg./d)
1 Dyspnea / SOB due to agitation or anxiety
Benzodiazepines
Caution in NH pt
2-10mg po/SL/PR/SQ q4-6hr (max 40 mg./d)
1
2
Narcotics
Dyspnea / SOB
Bronchodilators Prior auth req
100-300mg BID monitor levels (max 900 mg)
Prior auth req
2 puffs QID (max 12 puffs/day) Page 4
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Dyspnea/SOB
Edema
Fever
CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
COMMENTS
RECOMMENDED DOSE
Bronchodilators
3
Albuterol/Ipratopium
Combivent Inhaler
Loop Diuretic
1
Furosemide
Lasix
10-160mg QD-BID
Potassium Sparing Diuretics
1
Spironolactone
Aldactone
25-100mg QD-QID (max 200 mg)
Thiazide Diuretic
2
HCTZ Hydrochlorothiazide
Oretic
Limited Use wRenal Impairment
25-50mg PO QD
Loop Diuretic
3
Bumetanide
Bumex
Prior auth req
0.5-2mg QD (max 5 mg)
Thiazide Diuretic
3
Metolazone
Zaroxolyn
Prior auth req
2.5-20mg po QD (max (20mg)
Potassium Supplement
1
Potassium Chloride
K-Dur
10-20mEq QD-BID (max 80 mEq)
1 1
Acetaminophen
Tylenol
650mg po/PR q4h (max 4000 mg)
Antipyretics
Naproxen
Aleve
200 mg. po tid
1
Ibuprofen
Motrin
200mg 1-2 qid prn
2
Dicyclomine
Bentyl
10-20mg PO TID-QID (max 160 mg)
Hyoscyamine
Levsin
Ranitidine
Zantac
150mg qHS or BID (max 300 mg.)
Famitodine
Pepcid
20mg bid or 40mg hs
Sucralfate
Carafate
Omeprazole
Prilosec (OTC)
Pantoprazole
Protonix
Prior auth req
Belladonna w/Phenobarb tabs
Donnatol (similar not exact generic)
TABS ONLY
1
Diphenhydramine
Benadryl
Caution in NH pt
1
Trazadone
Desyrel
1
Amitriptyline
Elavil
GI Irritation/Colic/ spasms
Prior auth req
2 puffs QID (max 12 puffs/day)
Anticholinergics GI Irritation/ Colic w/ GI secretions
Caution in NH pt
0.125-0.25mg PO/SL q4-6h (max 1.5 mg)
1
GI Irritation/ Colic
H2- Antagonist
1 1
GI irritation/ GI Bleed
Coating Agent
Prior auth req
1gm QID ( max 4 grams)
1
GI Irritation
Proton-Pump Inhibitors
20mg qd
1 40mg HS x8wks (max 80 mg)
3 GI Spasms
Antispasmodic
3 Antihistamine Insomnia
Antidepressants
25-100mg po HS (max 100 mg.)
25-100mg po HS (max 200 mg) Caution in NH pt
10-150mg po HS (max 150 mg.) Page 5
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Insomnia
CTZ- Area Postrema Constant N/V
CTZ- Area Postrema Constant N/V , Opioidinduced , radiotherapy, chemotherapy, hypercalcemia, renal failure, non-specified & inderterminate
CLASSIFICATION Benzodiazepines
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
COMMENTS
RECOMMENDED DOSE
1
Temazepam
Restoril
3
Zolpidem
Ambien
Promethazine
Phenergan
Haloperidol
Haldol
Caution in NH pt
0.5-5mg q4-12hr (max 20 mg.)
Prochlorperazine
Compazine
NO Spansules
5-10mg po/25mg PR q4-8h (max po 40 mg; pr 50 mg)
Chlorpromazine
Thorazine
Metoclopramide
Reglan
Caution in NH pt
5-20mg QID ( max 60 mg.)
Hyoscyamine
Levsin
Caution in NH pt
0.125-0.25mg PO/SL q4-6h ( max 1.5 mg)
Lorazepam Diphenhydramine Haloperidol
ABH Compound
Prior auth req
1 cap/supp q4-6h prn N/V
Acetaminophen
Tylenol
only cover supp & liq for pedi pt
650mg po/PR q4h (max 4000 mg.)
Desipramine
Norpramin
less sedating
10-25 mg po q day
Antihistamines
15-60mg po HS (max 30 mg.) Prior auth req
5-10mg po HS (max 10 mg.) 25-50mg po/pr q4h prn
1
Antipsychotics
1
CTZ- Area Postrema, constant N/V, Moderate chemical emetogenic stimuli
2 CTZ- Area Postrema, Constant N/V Broad Spectrum approach
Antipsychotics
10-100mg q4-6h ( max 200 mg.)
1
Nausea/Vomiting - Gastric Statis/Prokinetic Nausea +/- vomiting 12hrs after eating
Prokinetic
1 Movement induces nausea +/-Vomiting Anticholingergic/Antimuscar inics
Anticholinergic
1
N&V
Combination Agents
3
Pain - Mild - Non-Opioid
Analgesic
1 Neuropathic Pain, "Tingling", "Shooting", "Stabbing", "Searing", "Burning", "Electric"
Tricyclic Antidepressants
2 Page 6
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Neuropathic Pain, "Tingling", "Shooting", "Stabbing", "Searing", "Burning", "Electric"
CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
RECOMMENDED DOSE
Amitriptyline
Elavil
Titrate by 25mg 23 days
25-50mg. Stat; then q hs ( max 150 mg.q hs)
Nortriptyline
Pamelor
less sedating
25mg q hs Ç 75 over 72-96 hrs. ( max 75 mg.
Carbamazepine
Tegretol
100-200 mg po BID ( max 1200 mg/d)
Ibuprofen
Motrin/Advil
400-800mg TID-q4h ( max 3200 mg)
1
Tricyclic Antidepressants
COMMENTS
1 Anticonvulsants
1 Visceral & Somatic NSAIDS - Cox 1 & 2 mixed
Visceral & Somatic
1 NSAIDS
Choline Magnesium Trisalicylate
Trilisate
naproxen
Naprosyn
250-750mg BID ( max 1500 mg)
Dexamethasone
Decadron
2-16mg po qd
Prednisone
Deltasone
10-80mg po qd dose all in AM taper off if on long term or high dose
Hydrocodone/APAP
Lortab/Vicodin 5/500mg;7.5/500mg;10 /500mg 500mg APAP only
2 Visceral & Somatic NSAIDS Cox 1 & 2 mixed
Does not affect platelets; avoid use in renal pts. 750 mg. tid or qid ( max 3000 mg/d) Due to magnesium content.
2
Visceral & Somatic bone/nerve compression pain
1
Steroids Visceral & Somatic bone/nerve compression pain
1
1
Mild-Moderate Pain
1-2tabs q4-6h ( max 8 tabs/day or 4,000mg of Acetaminophen/24 hrs.))
Combination Opioid/NonOpioid Drugs
1Tbsp q6h prn pain ( max 8 tabs/ day)
1
Hydrocodone/APAP
7.5/500 per 15ml Elixir
Tramadol
Ultram 50mg
1tab q4h prn pain ( max 300 mg/day)
Propoxyphene N/APAP 100/650mg
Darvocet N 100
1tab q4h prn pain (max 6 tabs/ day)
Aceta/Codeine 300/30
Tylenol #3
2
1 Moderate -Severe Pain
Pure Opioid
Prior auth req
1tab q4h prn pain ( max 12 tabs/ day)
1 Page 7
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CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
Morphine
MS IR, Roxanol MS Soluble tabs
Methadone
Dolophine
COMMENTS
RECOMMENDED DOSE
1 2.5 mg - up (Refer to table) Titrate dose every 3-4 days due to long drug half-life and high risk of toxicity
1
5 mg. - up
Oxycodone Roxicodone OxyIR, OxyFast
3
Moderate -Severe Pain
Hydromorphone
Dilaudid
2mg. - up
Methadone
Dolophine
Refer to table. Titrate dose every 3-4 days due to long drug half-life and high risk of toxicity
Morphine SR
MS Contin
15mg.-up
Fentanyl transdermal
Duragesic
Prior auth req
25 mcg.-up
Oxycodone SR
OxyContin
Prior auth req
10 mg.-up
Diphenhydramine
Benadryl
Caution in NH pt
25-100mg HS Sedating ( max 400 mg)
Hydroxyzine
Atarax
Caution in NH pt
25-100mg q4-6h ( max 400 mg.)
Cholestyramine
Questran
Prior auth req
4gm QD-QID ( max 24 grams)
Listerine/witch hazel
1 bottle of Listerine with3 capfuls of witch hazel
Paroxetine
Paxil
Ranitidine
Zantac
Diazepam
Valium
3
Pure Opioid
1
2
3
3
Pruritus
1
Antihistamine
2 Renal- Induced Pruritus
Cholesterol Lowering Agent Combination Agent
Pruritus- SSRI Renal, Hepatic, Opioid Induced
Antidepressant
Pruritus
H2- Antagonist
2 1 3
do not use CR tab 20-50mg qAM ( max 50 mg.) prior auth req.
150mg HS-BID ( max 300 mg)
1 Active Seizure Control
Benzodiazepines
1
DON'T USE DIASTAT!!!
5-10mg (5mg/ml Oral Conc) SL/PR q10min up to 60mg per seizure episode Page 8
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CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
TRADE NAME
COMMENTS
RECOMMENDED DOSE
Lorazepam
Ativan
Use 2mg/ml Oral conc
1-2mg SL/PR q15min up to 6mg per seizure episode
Diazepam
Valium
Caution in NH pt
2-10mg PO/SL q6-8h ( max 40 mg.)
Caution in NH pt
60-100mg BID or 15-20mg/kg/day ( max 300 mg.)
1
Benzodiazepines
1 Phenobarbital
1
Seizures - Maintenance Therapy
3 Anticonvulsants
Clonazepam
Klonopin
Prior auth req
0.5-5mg po TID ( max 20 mg.)
Phenytoin
Dilantin
Not Absorbed Rectally
300mg PO QD ( max 1,200 mg.)
Carbamazepine
Tegretol
100-200mg PO BID-QID ( max 1,200 mg.)
Divalproex
Depakote
250-500mg PO BID-TID ( max 60 mg./kg/day)
lidocaine viscous
Xylocaine Viscous
Prior auth req
5cc swish/swallow qid prn
Oncology Mouth wash #1
Benadryl/tetracycline/ny Prior auth req statin/synalar
5cc swish/swallow qid prn
Mouth Rinse
1tsp NaCl, 1tsp baking soda, 1 qt of H2O
1 1 3 3 Sore Mouth
Combination Agents
3 1
Atropine 1% Oph Soln
6-10 gtts. SL q4-6h prn ( max 18 gtts)
1
Terminal Secretions
Anti-Cholinergics/AntiMuscurinics
Scopolamine
Trans-scop
Hyoscyamine
Levsin
1
Lorazepam
Ativan
1
Haloperidol
Haldol
2
Chlorpromazine
Thorazine
2
Phenobarbital
1
Nystatin
Mycostatin
3
Ketoconizole
Nizoral 200mg tab
1patch q72h
2 Caution in NH pt
0.125-0.25mg q4-6h (max 1.5 mg/d)
1 Terminal restlessness
Benzodiazepines
Terminal agitation w/ hallucination
0.5-2mg po/SL/PR/SQ q4-6hr ( max 10 mg./day)
Oral Conc 2mg/ml 0.5-5mg po/SL/IM/PR Caution in NH pt q6-12hr ( max 20 mg./day)
Antipsychotics Severe terminal agitation
Terminal sedation
Anticonvulsants
Thrush
Antifungals
10-50mg po/SL/PR q4-6hr ( max 200 mg./day)
if actively dying
100-200mg q6h prn ( max 800 mg/day) 5-10ml QID x14days ( max 2.4 mil units)
prior auth req
1t qd for 10 days Page 9
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CLASSIFICATION
Formulary
SYMPTOM
GENERIC NAME
3
Clotrimazole troche
Upper Respiratory Infectionantibiotic-Penicillin
3 2
Antibiotics - Cephalosporins
TRADE NAME
COMMENTS
RECOMMENDED DOSE
Mycelex troche
prior auth req
1t 5x/d for 14d
Fluconazole
Diflucan
Prior auth req
100-200mg QOD x3days ( max 200 mg)
Amoxicillin
Trimox
250-500mg TID ( max 3,000 mg/d)
3
Cephalexin
Keflex
250-1000mg po q6h ( max 4,000 mg/d)
Antibiotics - Sulfonamides
1
Sulfamethoxazole/ Trimethaprim
Bactrim
1 DS tab BID x10-14days ( max 2 tabs)
Antibiotics - Macrolides
3
Azithromycin
Zithromycin
Prior auth req
500mg on day 1, then 250mg qd on days 2-5 ( max 1,000 mg/d)
3
Ciprofloxacin
Cipro
Prior auth req
250-750mg q12h x5-10days ( max 1,500/d)
Antibiotics - Quinolones
3
Levofloxacin
Levaquin
Prior auth req
250-500mg q12hx5-12days ( max 750/day)
UTI--antibiotic
1
Sulfamethoxazole/ Trimethaprim
Bactrim
UTI--symptom relief
2
Phenazopyridine 95mg
Azo Standard
prior auth req
2t tid prn
Keflex
prior auth req (women)
250-1000mg po q6h ( max 4,000 mg/day)
Vibramycin
prior auth req (men-if can't tolerate Bactrim)
100mg BID x10days ( max 300 mg/d)
Antifungals
Thrush
Antibiotics - Quinolones
Antibiotics
3
UTI--antibiotic
3
UTI--antibiotic
Cephalexin Doxycycline
1 DS tab BID x10-14days ( max 2 tabs/day)
Drugs BOLDED are controlled substances and need to be destroyed at death or non-use
Suzanne McClure MD Medical Director
Date
Titus Venyah, MD Medical Director
Date
Lee Grumbles, MD Medical Director
Date
Deborah Perryman, LMSW Field Staff Administrator
Date
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