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

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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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