Box App-1-1
Important
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The list of dosage forms may not be complete and may change over time.
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Not all drugs and dosage forms are available in each country.
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Only the common adverse effects (AE) and drug interactions are listed.
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The listed trade names either represent the only product available, or one that is commonly known.
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Dosages may need adjustment for intercurrent conditions such as hepatic or renal failure.
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Always refer to the PDR in the United States or the CPS in Canada or other online drug resources for a complete, up-to-date list of the products available, adverse effects, and drug interactions.
Adverse Effects
Adverse effects may be allergic, idiosyncratic, or dose–related extensions of known effects. They may increase with the number of different medications and the dosage. In the presence of liver or renal failure, adverse effects may emerge if dosage/frequency is not adjusted downward. If adverse effects occur, reduce or stop offending medications and provide appropriate antidotes.
As medications may have many effects, they may also produce many different adverse effects. In some instances, they occur frequently enough to be grouped as below:
Table App-1-1
| Adverse Effect Group | Possible Adverse Effects |
|---|---|
| Anticholinergic (AC) | Dry mouth, decreased GI motility, constipation, tachycardia, urinary retention, mydriasis (pupil dilation), cycloplegia (paralysis of ciliary muscles of accommodation → blurred vision) May lead to restlessness, confusion, hallucinations, memory impairment and delirium May precipitate acute glaucoma |
| CNS excitation (CNS) | Euphoria, restlessness, agitation, vivid dreams, nightmares, hallucination, myoclonus (jerks/twitches), focal motor or grand mal seizures |
| Extrapyramidal (EPS) | Early effects (usually dose related): Acute dystonic reactions: torticollis (cervical muscle spasm → unnatural twisting of head), opisthotonos (a tetanic spasm with head and heels bent backward, body bowed forward), tics, grimacing, dysarthria, oculogyric crisis; Rx diphenhydramine 25–50 mg PO, IM, IV q 4 h PRN Parkinsonian reactions: tremor, bradykinesia, rigidity, abnormalities of gait and posture; Rx benztropine (Cogentin) 1–2 mg IV, IM acutely, then 1–2 mg PO daily–bid Akathisia: sense of constant motor restlessness; Rx benztropine 1–2 mg PO daily–bid Late effects: Tardive dyskinesia—involuntary movements of lips, tongue, jaws, extremities. May persist indefinitely after medication is stopped. Antidopaminergic drugs may suppress these movements |
| Hypersensitivity | Rash, urticaria, bronchospasm, laryngeal or angioneurotic edema; in extreme cases, anaphylactic shock |
| Signs of electrolyte imbalance, dehydration | Dry mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain/cramps, muscle fatigue, hypotension (may be orthostatic), oliguria, tachycardia, nausea/vomiting |
| Upper gastrointestinal (GI) | Nausea, vomiting, dyspepsia May include erosions, ulceration, bleeding; Rx misoprostol 200 mcg PO q 6 h or histamine H 2 receptor antagonists (see Antacids) |
Table App-1-2
Abbreviations, Symbols
| Routes of Administration | |
| PO | By mouth ( per os ) |
| PR | By the rectum ( per rectum ) |
| IM | Intramuscular |
| IV | Intravenous |
| SC | Subcutaneous |
| SL | Sublingual |
| TD | Transdermal |
| IT | Intrathecal |
| Others | |
| CPS | Compendium of Pharmaceuticals and Specialties (Canada) |
| COX-2 | Cyclo-oxygenase–2 selective inhibitor; may have fewer gastrointestinal, renal, and antiplatelet adverse effects |
| ER/SR/CR | Extended/sustained/controlled release (extended/sustained release tablets must be taken intact, never broken or crushed) |
| Inj | Injectable |
| IR | Immediate release (tabs are IR unless noted) |
| ODT | Orally dissolving tabs |
| MAOI | Monoamine oxidase inhibitor |
| NA | Not available |
| NS | Normal saline |
| NSAID | Nonsteroidal anti-inflammatory drug |
| PDR | Physicians’ Desk Reference, Medical Economics Company, Inc., 1999 (USA) |
| SSRI | Selective serotonin reuptake inhibitor |
| TCA | Tricyclic antidepressant |
| ↑ | Upper dose limited only by need and adverse effects |
| † | Fixed-dose combinations not recommended in young children |
| †† | Dose varies depending on condition being treated |
| CAUTION—CONSULT REQUIRED | |
Websites/Online Drug Resources
Table App-1-3
Analgesics
| Generic Name | Dosage Forms Available | Route of Elimination | Usual Dosing | Recommended Maximum Dosing | Special Issues |
|---|---|---|---|---|---|
| Acetaminophen (paracetamol) | Tab: 325, 500, 650 mg Elixir: 80 mg/0.8 ml, 160 mg/5 ml Supp: 120, 325, 650 mg, 81 mg chew | Liver metabolism: 25% on first pass through liver Renal excretion: 1%–4% unchanged | 325–650 mg PO PR q 4 h routinely or PRN | 650 mg PO PR q 4 h (4 g/24 h) | Caution in liver disease |
| Acetylsalicylic acid (ASA) (salicylic acid derivative) | Caplets, Tab: 325, 500, 650 mg Children’s tab: 80 mg EC Tab: 81, 325, 500 mg Supp: 300, 600 mg | Liver metabolism Renal excretion: 5.6%–35.6% | 325–650 mg PO, PR q 4 h routinely or PRN | 650 mg PO PR q 4 h (5 g/24 h) | GI distress, may prolong bleeding |
| Celecoxib (COX-2 selective) | Cap: 100, 200, 400 mg | Liver metabolism: extensive Renal excretion: 27% Less than 3% of a dose is eliminated as unchanged drug Feces: 57% | 100–200 mg PO bid | 200 mg PO bid | |
| Diclofenac (acetic acid derivative) | IR Tab: 25,50 mg ER Tab: 50, 75, 100 mg Supp 50 mg (with 200 mcg misoprostol: Arthrotec ® 50, 75 mg) | Liver metabolism: extensive first-pass Renal excretion: 65% Bile: 35% | IR: 50–75 mg PO PR q 6–8 h or ER 75–100 mg PO q 8–12 h | 50 mg IR PO q 6 h or 75 mg ER PO q 8 h (225 mg/24 h) | GI adverse effects for all NSAIDs |
| Ibuprofen (propionic acid derivative) | Tab: 200, 400, 600, 800 mg Elixir: 40 mg/1 ml, 100 mg/5 ml | Liver metabolism: extensive Renal excretion: major route | 200–800 mg PO q 6–8 h | 800 mg PO q 6 h (3.2 g/24 h) | |
| Indomethacin (indole) | IR Tab: 25, 50 mg Supp: 50 mg Liquid 25 mg/5 ml | Liver metabolism: extensive Renal excretion: 60%; ≈ 26% eliminated as unchanged drug Feces: 33% | 25–75 mg PO q 8–12 h or 75 mg ER PO q 12–24 h | 50 mg PO q 6 h (200 mg/24 h) | |
| Ketoprofen (propionic acid derivative) | Cap: 50, 75 mg ER Tab: 100, 150, 200 mg Supp: 100 mg (CAN) | Liver metabolism Renal excretion: 80% Bile: up to 40% | 150–200 mg PO/24h IR: q 6–8 h ER: q 12–24 h | 75 mg PO q 6 h (300 mg/24 h) | |
| Ketorolac (acetic acid derivative) | Tab: 10 mg Inj: 15, 30 mg/ml | Liver metabolism Renal excretion: 92% excreted in the urine; 60.6% as unchanged drug Feces: 5.9%–6.3% | 10 mg PO qid or 60 mg IM, IV loading dose, then 10–30 mg IM, IV q 6 h | 40 mg PO/24 h or 120 mg IM, IV/24 h | Only recommended for very short term use |
| Naproxen (propionic acid derivative) | IR Tab: 250, 250, 375, 500, 550 mg ER tab: 750 mg Ent coated: 500 mg Liquid 125/5 ml | Liver metabolism: extensive Renal excretion: 95% | 250–500 mg PO q 8–12 h | 500 mg PO q 8 h (1.5 g/24 h) | |
| Codeine (alone) (methylmorphine, naturally occurring opioid metabolized into morphine) | IR Tab: 15, 30, 60 mg Elixir: 5 mg/ml Inj: 15, 30 mg/ml ER 50,100,150, 200 mg (CAN) | Liver metabolism: 24–89% (metabolized to morphine) Renal excretion: 90% (3%–16% of unchanged drug) Feces: about 5% | 15–60 mg PO, SC, IM q 4 h routinely or q 1 h PRN | 600 mg/24 h, then consider potent opioid | Ceiling dose of about 400 mg/day Patients (about 10%) may lack the enzyme that converts codeine to morphine |
| Codeine + acetaminophen combinations | Tabs: 15, 30, 60 mg codeine + 325 mg acetaminophen | Codeine and Acetaminophen: see Acetaminophen | 1–2 tabs PO q 4 h routinely or PRN | Limited to 12 tabs/24 h by acetaminophen | |
| Fentanyl | Patch: 12, 25, 50, 75, 100 mcg/hr Lozenge: 200, 400, 600, 800, 1200, 1600 mcg Soluble buccal film (new) Inj: 50 mcg/ml | Liver metabolism: to inactive metabolites Renal excretion: 75% (metabolites); 10% (unchanged drug) Feces: 9% | patch: 25–↑ mcg/h q 72 h lozenge: 200 mcg q 1 h titrate PRN | Limited only by need and adverse effects | Several new transmucosal formulations for breakthrough pain |
| Hydrocodone + acetaminophen (USA only) | Tab: 5/500, 5/325, 7.5/325, 7.5/500, 7.5/750, 10/325, 10/500, 10/660 Elixir: 7.5/500 in 15 ml | Liver metabolism: Acetaminophen: see above Hydrocodone: extensive active metabolites Renal excretion: 26% | 1–2 tabs PO q 4–6 h routinely or PRN | Limited to 4 g acetaminophen in 24 h | One of the drugs often abused |
| Hydrocodone + ibuprofen (USA only) | Tab: 7.5/200 | Liver metabolism: see above Renal excretion: see above | 1–2 tabs PO q 4–6 h routinely or PRN | Limited–2,400 mg ibuprofen in 24 h | |
| Hydromorphone | IR tab:1, 2, 4, 8 mg CR cap: 3,6, 12, 18, 24, 30 mg (CAN) Once daily ER cap: 8, 12, 16 mg Elixir: 1 mg/ml Inj: 1, 2, 4, 10 mg/ml Powder: 250 mg/vial Supp: 3 mg | Liver metabolism: extensive Renal excretion: As hydromorphone 1.3%–13.2% Conjugates: 22%–51% | 1–↑ mg: PO q 4 h routinely or q 1 h PRN, SC, IM q 3 h routinely or q 30 min PRN, SC, IV q 1 h via infusion + breakthrough q 30 min PRN | Limited only by need and adverse effects | May accumulate with decreased renal clearance |
| Levorphanol (USA only) | Tab: 2 mg | Liver metabolism: extensive Renal excretion: extensive as conjugate | 2–↑ mg PO q 6–8 h | Limited only by need and adverse effects | |
| Meperidine (pethidine) | Tab: 50, 100 mg Inj: 50, 75, 100 mg/ml Syrup: 50 mg/5 ml | Liver metabolism: 50% first pass through the liver Renal excretion: 0.5%–5.2% (average 2.2%) unchanged Active metabolite, normeperidine, excreted 0.6%–21% (average 6.2%) unchanged in urine | 50–150 mg PO IM, SC, IV q 4 h PRN | 150 mg q 3–4 h, 900–1200 mg/24 h | NOT RECOMMENDED FOR CHRONIC DOSING— active metabolite, normeperidine, may produce adverse effects Very poorly absorbed orally |
| Methadone | Tab: 1, 5, 10, 25, 40 mg Elixir: 1, 2, 10 mg/ml Powder for injectable forms | Liver metabolism: 4 times greater after PO administration than after IM administration | 5 mg PO q 8 h Titrate dose q 3–5 days due to delayed clearance | Limited only by need and adverse effects | Interactive with drugs using cytochrome P450 metabolism Do drug interaction survey when adding to other drugs or when other drugs added Do not use where QT interval prolongation exists |
| Morphine, IR | IR tab: 5,10, 15, 25, 30 50 mg Elixir: 1, 2, 10, 20 mg/ml Supp: 5, 10, 20, 30 mg Inj: 1, 2, 10, 15, 25, 50 mg/ml | Liver metabolism: ≈ 90% of a given dose is conjugated morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G-active) Renal excretion: 90% (metabolites and free drug) within 24 hr; altered in renal failureClearance is decreased M3G and M6G accumulate several fold with associated risk of toxicity Feces: 7–10% | 1–↑ mg: PO PR q 4 h routinely or q 1 h PRN, SC, IM q 3h routinely or q 30 min PRN, or SC, IV q 1 h via infusion + breakthrough q 30 min PRN | Limited only by need and adverse effects | May accumulate with decreased renal clearance |
| Morphine, ER | CR 24 h cap: 20, 50, 100 mg (q 12–24 h) ER tab (USA) 30, 45, 60, 75 mg, 90 mg, 120 mg CR tab: 15, 30, 60, 100, 200 mg (q 8–12 h) CR cap: 10,30,60 mg (CAN) | 10–↑ mg: PO/PR q 8–24 h routinely only (depending on product) Provide breakthrough doses using IR morphine q 1 h PRN | Limited only by need and adverse effects | ||
| Oxycodone (alone) | IR tab: 5, 10, 15, 30 mg CR tab: 10, 20, 40, 80 mg Elixir: 1 mg/ml (USA) | Liver metabolism: extensive Renal excretion: extensive with approximately 20% unchanged | 5–↑ mg IR PO PR q 4 h routinely, or q 1 h PRN or 10–↑ mg ER PO q 12 h | Limited only by need and adverse effects | |
| Oxycodone + acetaminophen combinations | 5 mg oxycodone + 325 mg acetaminophen tab: 5/500,7.5/325, 7.5/500, 10/325, 10/650 (may include caffeine) | See above acetaminophen and oxycodone | 1–2 tabs PO q 4 h routinely or PRN | Limited to 12 tabs/24h by acetaminophen | Caution in liver disease |
| Oxycodone + aspirin combinations | 5 mg oxycodone + 325 mg ASA tab: (may include caffeine) | Renal excretion: approximately 20% unchanged See above for ASA and oxycodone | 1–2 tabs PO q 4 h routinely or PRN | Limited to 12 tabs/24h by ASA | |
| Tramadol | Tab: 50 mgER tab: 100, 200, 300 mgTab: 37.5 mg with acetaminophen 325 mg | Liver metabolism: extensive Renal excretion: 30% excreted in the urine as unchanged drug, 60% of dose excreted as metabolites | 1–2 tabs PO q 6 h | 2 tabs PO q 6 h | Dose ceiling 400 mg/day Caution with antidepressant drugs because of interaction & possible serotonin syndrome |
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