Pharmacy and Therapeutics Committee-approved Therapeutic Interchange

Transcription

1 Therapeutic Interchanges Therapeutic Interchange Revision Date Alpha Blockers 08/11 Alpha Reductase Inhibitors 05/16 ACE Inhibitors 08/11 Angiotensin Receptor Blockers 08/11 Buprenorphine 09/11 Calcium Channel Blockers (DHP) 08/11 Carbapenems 07/11 Cardioselective Beta Blockers 08/11 Cephalosporins 09/11 Corticosteroids, Inhaled 05/16 Corticosteroids, Intranasal 08/11 Fluoroquinolones 01/13 Glitazones 08/11 Histamine Receptor Antagonists (H2RAs) 08/11 Inhaled Anticholinergics 05/16 Insulin Analogs 05/16 IV to PO conversions 05/16 Leukotriene Receptor Antagonists 08/11 Levalbuterol 12/13 Miscellaneous Antidepressants 05/16 Miscellaneous CNS Stimulants 05/16 Nitroglycerin Sublingual 05/16 Non-benzodiazepine Hypnotics 08/11 Non-sedating Antihistamines 08/11 Ophthalmic Preparations 08/11 Phosphate Binders 01/13 Proton Pump Inhbitors 08/11 Statins 08/11 All conversions unless noted otherwise are for adult patients with normal renal and/or hepatic function. Please consult additional references when these clinical situations do not apply.

2 Therapeutic Interchange: Alpha Blockers Brand Name Dose Equivalents (mg/day) Terazosin Hytrin Doxazosin Cardura Tamsulosin Flomax N/A N/A N/A Alfuzosin UroXatral N/A N/A N/A *Formulary agents in bold. Prazosin is not included in this therapeutic interchange. Doxazosin and terazosin are therapeutically equivalent for the treatment of hypertension and benign prostatic hypertrophy (BPH). Alfuzosin and tamsulosin are therapeutically equivalent for the treatment of BPH and are the preferred agents in patients who are unable to tolerate the cardiovascular adverse effects from other alpha blockers. Document created: 08/11. Revised: None

3 Therapeutic Interchange: Alpha Reductase Inhibitors Finasteride Dutasteride *Formulary agents in bold. Brand Name Proscar Avodart Dose Equivalents (mg/day) 5 mg once daily 0.5 mg once daily Document created: 05/16. Revised: None

4 Therapeutic Interchange: ACE Inhibitors Brand Name Dose Equivalents (mg/day) Short-acting Captopril Capoten Intermediate-acting Benazepril Lotensin Enalapril Vasotec Moexipril Univasc Quinapril Accupril Ramipril Altace Long-acting Lisinopril Prinivil Fosinopril Monopril Perindopril Aceon Trandolapril Mavik *Formulary agents in bold. Captopril is short-acting and should be dosed 2-3 times daily. Enalapril and benazepril are intermediate-acting and should be dosed 1-2 times daily. Enalapril is the preferred intermediate-acting ACE inhibitor. Benazepril is available for continuation of outpatient therapy. Lisinopril is long-acting and should be dosed once daily. Document created: 12/03. Revised: 08/11.

5 Therapeutic Interchange: Angiotensin Receptor Blockers Brand Name Dose Equivalents (mg/day) Losartan Cozaar Candesartan Atacand Eprosartan Teveten Irbesartan Avapro Olmesartan Benicar Telmisartan Micardis Valsartan Diovan Document created: 08/11. Revised: None

6 Therapeutic Interchange: Buprenorphine Sublingual Brand Name Dose Equivalents (mg/day) Buprenorphine Subutex Buprenorphine/naloxone Suboxone 8/2 16/4 24/6 Suboxone strength expressed as buprenorphine/naloxone which are available as 2 mg/0.5 mg and 8 mg/2 mg sublingual tablets and film. Document created: 09/11. Revised: None

7 Therapeutic Interchange: Calcium Channel Blockers (Dihydropyridines) Brand Name Dose Equivalents (mg/day) Amlodipine Norvasc Nifedipine, extended release Procardia XL Felodipine, extended release Plendil Isradipine, immediate release DynaCirc Isradipine, controlled release DynaCirc CR Nicardipine, immediate release Cardene Nicardipine, controlled release Cardene CR Nisoldipine, extended release Sular *Formulary agents in bold. Nimodipine (Nimotop ) is not subject to therapeutic interchange. Amlodipine is the preferred dihydropyridine CCB. Nifedipine, extended release is available for continuation of outpatient therapy. Document created: 08/11. Revised: None

8 Therapeutic Interchange: Carbapenems Brand Name Dose Equivalents (mg/day) Meropenem Merrem Doripenem Doribax Imipenem/cilastatin Primaxin *Formulary agents in bold. The preferred dosing for the treatment of infections caused by multi-resistant gram negative bacilli or empiric therapy is meropenem 500 mg every 6 hours. Please refer to the Carbapenem Guidelines for Use for further details. Document created: 07/11. Revised: None

9 Therapeutic Interchange: Cardioselective Beta Blockers Brand Name Dose Equivalents (mg/day) Atenolol Tenormin N/A Metoprolol Toprol Betaxolol Kerlone N/A N/A Bisoprolol Zebeta N/A Nebivolol Bystolic *Formulary agents in bold. Metoprolol is the preferred cardioselective beta blocker. Atenolol is available for continuation of outpatient therapy. Document created: 08/11. Revised: None

10 Therapeutic Interchange: Cephalosporins Brand Name Dose Equivalents (mg/day) Ceftriaxone Rocephin Cefotaxime Claforan Ceftriaxone is the preferred third generation cephalosporin in adult patients. Cefotaxime is available for use in neonates and for orders written by Infectious Diseases faculty. Usual adult dosing for ceftriaxone is 1-2 gm every hours (max: 4 gm/day), usual adult dosing for cefotaxime is 1-2 gm every 6-8 hours (max: 12 gm/day). Document created: 09/11. Revised: None

11 Therapeutic Interchange: Corticosteroids, Inhaled Brand Name Dose Equivalents (puffs per day) Beclomethasone dipropionate QVAR 80 mcg Budesonide Pulmicort 180 mcg 1 2 to 3 4 to Ciclesonide Alesco 80 mcg Comparative data not available. Flunisolide AeroBID 250 mcg No longer available. Fluticasone Flovent HFA 44 mcg 1 to 3 4 to 6 7 to 8 9 to Fluticasone Flovent HFA 110 mcg Fluticasone Flovent HFA 220 mcg N/A 1 N/A 2 3+ Fluticasone Flovent Diskus 50 mcg 1 to 3 4 to 6 7 to 8 9 to Fluticasone Flovent Diskus 100 mcg 1 2 to Fluticasone Flovent Diskus 250 mcg N/A 1 N/A 2 3+ Mometasone Asmanex 220 mcg N/A Triamcinolone Azmacort 100 mcg No longer available. Brand Name Budesonide/formoterol Symbicort 80/4.5 Budesonide/formoterol Symbicort 160/4.5 Mometasone/formoterol Dulera 100/5 Mometasone/formoterol Dulera 200/5 Fluticasone/vilanterol Breo 100/25 Fluticasone/vilanterol Breo 200/25 Fluticasone/salmeterol Advair HFA 45/21 Fluticasone/salmeterol Advair HFA 115/21 Fluticasone/salmeterol Advair HFA 230/21 Fluticasone/salmeterol Advair Diskus 100/50 Fluticasone/salmeterol Advair Diskus 250/50 Fluticasone/salmeterol Advair Diskus 500/50 Dose Equivalents (puffs per day) 2 puffs twice daily N/A N/A 2 puffs twice daily 2 puffs twice daily N/A N/A 2 puffs twice daily 1 inhalation once daily N/A N/A 1 inhalation once daily 2 puffs twice daily N/A N/A 2 puffs twice daily N/A 2 puffs twice daily 1 inhalation twice daily N/A N/A 1 inhalation twice daily N/A 1 inhalation twice daily Flovent and Advair Diskus are the preferred delivery devices unless specified HFA. The following Flovent HFA will be maintained in inventory: 220 mcg. The following Flovent Diskus will be maintained in inventory: 50 mcg, 100 mcg, 250 mcg. The following Advair HFA will be maintained in inventory: 230 mcg. The following Advair Diskus will be maintained in inventory: 100 mcg, 250 mcg, 500 mcg. Breo Ellipta (fluticasone/vilanterol) is indicated for asthma at one inhalation (100 mcg/25 mcg) once daily with maximum dosing of one inhalation (200 mcg/25 mcg) once daily and for COPD at one inhalation (100 mcg/25 mcg) once daily. Document created: 01/08. Revised: 05/16.

12 Therapeutic Interchange: Corticosteroids, Intranasal Brand Name Dose Equivalents Fluticasone propionate Flonase 2 sprays in each nostril daily Beclomethasone Beconase AQ 1 to 2 sprays in each nostril twice daily Budesonide Rhinocort Aqua 1 spray in each nostril daily Ciclesonide Omnaris 2 sprays in each nostril daily Flunisolide Nasarel 2 sprays in each nostril 2 to 3 times daily Fluticasone furoate Veramyst 2 sprays in each nostril daily Mometasone Nasonex 2 sprays in each nostril daily Triamcinolone Nasacort AQ 1 to 2 sprays in each nostril daily Document created: 01/08. Revised: 08/11.

13 Therapeutic Interchange: Fluoroquinolones Brand Name Dose Equivalents (mg/day) Intravenous Oral Mild to moderate infections: 200 to 400 mg every 12 hours Mild to moderate infections: 250 to 500 mg every 12 hours Severe infections: 400 mg every Severe infections: 500 to 750 mg Ciprofloxacin Cipro 8 to 12 hours every 8 to 12 hours Moxifloxacin Avelox 400 mg every 24 hours 400 mg every 24 hours Mild to moderate infections: 250 Mild to moderate infections: 250 to 500 mg every 24 hours to 500 mg every 24 hours Severe infections: 500 to 750 mg Severe infections: 500 to 750 mg Levofloxacin Levaquin every 24 hours every 24 hours Ofloxacin Floxin N/A 200 to 400 mg every 12 hours Norfloxacin Noroxin N/A 400 mg every 12 hours Gemifloxacin Factive N/A 320 mg every 24 hours *Formulary agents in bold. Note: Moxifloxacin should not be used for genitourinary infections and gram-negative bacteremias. Document created: 05/06. Revised: 01/13.

14 Therapeutic Interchange: Thiazolidinediones (Glitazones) Brand Name Dose Equivalents (mg/day) Pioglitazone Actos Rosiglitazone Avandia Document created: 06/07. Revised: 08/11.

15 Therapeutic Interchange: Histamine Receptor Blockers Brand Name Dose Equivalents (mg/day) Famotidine, oral Pepcid Cimetidine Tagamet N/A 600 to 1200 Nizatidine Axid Ranitidine Zantac Famotidine, injection Pepcid IV Cimetidine Tagamet IV N/A 900 to 1200 Ranitidine Zantac IV 50 to to 200 By declaration of the P&T Committee, the H2RAs are subject to automatic IV to PO interchange. Please refer to the Intravenous to Oral Medication Conversion Program for further details. Document created: 02/08. Revised: 08/11.

16 Therapeutic Interchange: Inhaled Anticholinergics Brand Name Dose Equivalents Albuterol MDI Proventil 1-2 inhalations every 4-6 hours Albuterol nebulization solution Proventil 1 vial three to four times per day Ipratropium nebulization solution Atrovent 1 vial three to four times per day Ipratropium/albuterol nebulization solution DuoNeb 1 vial four times per day Tiotropium inhalation Spiriva 1 capsule once daily Aclidinium inhalation Tudorza 1 inhalation twice daily Ipratropium/albuterol MDI Combivent 2 inhalations four to six times per day Ipratropium MDI Atrovent 2 inhalations four to six times per day *Formulary agents in bold. Combivent Respimat inhalers are not available for inpatient use at UPHSM. Non-ventilated patients may be switched to tiotropium inhalation with or without an albuterol MDI (albuterol must be ordered separately) or to ipratropium/albuterol (DuoNeb ) nebulization solution. Ventilated patients may be switched to ipratropium/albuterol (DuoNeb ) nebulization solution. Atrovent metered dose inhalers (MDIs) are not available for inpatient use at UPHSM. Non-ventilated patients may be switched to tiotropium inhalation or ipratropium (Atrovent ) nebulization solution. Ventilated patients may be switched to ipratropium (Atrovent ) nebulization solution. Combivent Respimat inhaler contains ipratropium 20 mcg and albuterol 100 mcg in each inhalation (120 inhalations per cartridge). DuoNeb contains ipratropium 0.5 mg and albuterol 3 mg in each 3 ml unit-dose vial. Spiriva HandiHaler is to be used for administration of tiotropium which is dosed at 2 inhalations of a single 18 mcg capsule once daily. Tudorza Pressair inhaler contains aclidinium 400 mcg in each inhalation and may be switched to tiotropium (Spiriva ). Document created: 08/11. Revised: 05/16.

17 Therapeutic Interchange: Insulin Analogs Brand Name Dose Equivalents Insulin lispro 75/25 mix Humalog 75/ to 1 units/kg/day in divided doses Insulin aspart 70/30 mix Novolog 70/ to 1 units/kg/day in divided doses Insulin glargine Lantus Initial dose of 0.2 units/kg (10 units) once daily Insulin detemir Levemir Initial dose of 0.2 units/kg (10 units) once daily *Formulary agent in bold (detemir preferred). When changing therapy in patients receiving basal insulin with insulin detemir once-daily to insulin glargine, a 1:1 conversion is recommended. However, for patients receiving basal dosing two or more times per day, a 20% reduction in the total daily basal dose is recommended for conversion to the insulin glargine dose. Document created: 02/08. Revised: 04/13.

18 Therapeutic Interchange: Intravenous to Oral IV Dosage Oral Dosage Azithromycin 500 mg every 24 hours 500 mg every 24 hours Cefazolin 1 gm every 8 hours Cephalexin 500 mg every 6 hours Ciprofloxacin 400 mg every 12 hours mg every 12 hours Famotidine 20 mg every 12 hours 20 mg every 12 hours Fluconazole 400 mg every 24 hours 400 mg every 24 hours Levofloxacin 500 mg every 24 hours 500 mg every 24 hours Levothyroxine 50 mcg every 24 hours 100 mcg every 24 hours Linezolid 600 mg every 12 hours 600 mg every 12 hours Metronidazole 500 mg every 6 hours 500 mg every 6 hours Ondansetron 4-8 mg 8-16 mg Pantoprazole 40 mg every 24 hours Omeprazole 20 mg every 24 hours Rifampin 300 mg every 12 hours 300 mg every 12 hours Valproic acid 500 mg every 6 hours 500 mg every 6 hours Voriconazole LD: 6 mg/kg every 12 hours x2; MD: 4 mg/kg every 12 hours Pt wt 40 kg: 200 mg every 12 hours Pt wt 40 kg: 100 mg every 12 hours Dosage for PO conversion of ciprofloxacin depends upon severity of infection. Recommendation for valproic acid conversion based on using immediate-release formulation of solution or capsules. Situations where IV to PO conversion is appropriate: q Patient is receiving/tolerating other oral medications; q Patient is receiving regular diet and has not been designated Nothing Per Os (NPO); q Patient s enteral route is functional [i.e., receiving enteral feedings without residuals or has evidence that gastrointestinal (GI) tract is functional (i.e., no evidence of ileus or profuse diarrhea)]; q Patient does not have active GI bleeding; q Patient has been afebrile for at least 24 hours (antibiotics only); q Patient is not hypotensive (i.e., SBP < 90 mmhg) or on vasopressor support to maintain blood pressure; q Patient does not have mucositis (for patients undergoing chemotherapy and who do not have a nasogastric tube). Document created: 07/11. Revised: 05/16.

19 Therapeutic Interchange: Leukotriene Receptor Antagonists Brand Name Dose Equivalents (mg/day) Montelukast Singulair 10 Zafirlukast Accolate 40 Document created: 06/07. Revised: 08/11.

20 Therapeutic Interchange: Levalbuterol Brand Name Dose Equivalents Albuterol nebulization solution Generic 2.5 mg every 4 hours Levalbuterol nebulization solution Xopenex 0.63 mg to 1.25 mg every 4-6 hours Brand Name Dose Equivalents Albuterol MDI Ventolin HFA 1-2 inhalations every 4 hours Levalbuterol MDI Xopenex HFA 1-2 inhalations every 4-6 hours The automatic therapeutic interchange for levalbuterol is approved for inpatients 12 years of age and older unless appropriate documentation is provided for levalbuterol use (see guidelines for use). Levalbuterol orders with a PRN frequency will be interchanged with albuterol orders with a PRN frequency. Albuterol nebulization solution contains albuterol 2.5 mg in each 3 ml unit-dose vial (0.083%). Levalbuterol HFA contains 45 mcg per actuation Albuterol HFA contains 90 mcg per actuation Document created: 03/08. Revised: 12/13.

21 Therapeutic Interchange: Miscellaneous Antidepressants Brand Name Dose Equivalents (mg/day) Venlafaxine, extended release Effexor XR N/A Desvenlafaxine Pristiq N/A *Formulary agents in bold. Desvenlafaxine is the major active metabolite of venlafaxine. In clinical studies, desvenlafaxine dosages of 50 to 400 mg/day were shown to be effective, although no additional benefit was demonstrated at dosages of more than 50 mg/day. Adverse reactions and discontinuations were more frequent at higher doses. Document created: 08/11. Revised: 05/16.

22 Therapeutic Interchange: Miscellaneous CNS Stimulants Brand Name Dose Equivalents Armodafinil Nuvigil 150 to 250 mg once daily in the morning Modafinil Provigil 200 to 400 mg once daily in the morning Document created: 05/16. Revised: None

23 Therapeutic Interchange: Nitroglycerin Sublingual Brand Name Dose Equivalents Nitroglycerin 0.4 mg/actuation spray Nitroglycerin 0.4 mg tablet Nitrolingual NitroStat 1 to 2 sprays every 5 minutes for a maximum of 3 sprays in 15 minutes 0.4 mg every 5 minutes for a maximum of 3 tablets in 15 minutes Nitroglycerin spray will be maintained on formulary as a uterine relaxant; however, for the management of angina, it will be interchanged with nitroglycerin sublingual tablets. Document created: 05/16. Revised: None

24 Therapeutic Interchange: Non-benzodiazepine Hypnotics Brand Name Dose Equivalents (mg/day) Zolpidem Ambien N/A 5 10 N/A Eszopiclone Lunesta 1 2 N/A 3 Zaleplon Sonata N/A Zolpidem, extended release Ambien CR N/A N/A Document created: 11/05. Revised: 08/11.

25 Therapeutic Interchange: Non-sedating Antihistamines Brand Name Dose Equivalents (mg/day) Loratadine Claritin Cetirizine Zyrtec Desloratadine Clarinex N/A 5 5 Fexofenadine Allegra Patients receiving decongestant/antihistamine combination products (i.e., Allegra-D 12 and 24 hour, Claritin- D, and Zyrtec-D) will be converted to loratadine and pseudoephedrine individually. Document created: 08/05. Revised: 08/11.

26 Therapeutic Interchange: Ophthalmic Preparations Brand Name Dose Equivalents Latanoprost Xalatan 1 drop into affected eye(s) once daily in the evening Bimatoprost Lumigan 1 drop into affected eye(s) once daily in the evening Travoprost Travatan 1 drop into affected eye(s) once daily in the evening Brand Name Dose Equivalents Dorzolamide Trusopt 1 drop into affected eye(s) three times daily Brinzolamide Azopt 1 drop into affected eye(s) three times daily Brand Name Dose Equivalents Timolol Timoptic 1 drop into affected eye(s) twice daily Betaxolol Betoptic-S 1 to 2 drops into affected eye(s) twice daily Carteolol Ocupress 1 drop into affected eye(s) twice daily Levobunolol Betagan 1 to 2 drops into affected eye(s) twice daily Metipranolol Optipranolol 1 drop into affected eye(s) twice daily Initial dose for timolol is 0.25%, 1 drop into affected eye(s). Timoptic is usually dosed twice daily; Timoptic- XE is usually dosed once daily. If clinical response is not adequate, the dosage may be changed to the 0.5% solution. Betaxolol is available in 0.25% and 0.5% solutions. Carteolol is available in a 1% solution. Levobunolol is available in 0.25% and 0.5% solutions. Metipranolol is available in a 0.3% solution. Document created: 08/11. Revised: None

27 Therapeutic Interchange: Phosphate Binders Brand Name Dose Equivalents (mg/meal) Calcium acetate PhosLo Sevelamer hydrochloride Renagel Sevelamer carbonate Renvela Lanthanum Fosrenol *Formulary agents in bold. Calcium acetate is available in 667 mg tablets. Document created: 05/06. Revised: 01/13.

28 Therapeutic Interchange: Proton Pump Inhibitors Brand Name Dose Equivalents (mg/day) Omeprazole, oral Prilosec Dexlansoprazole Kapidex Esomeprazole Nexium Lansoprazole Prevacid Pantoprazole Protonix Rabeprazole Aciphex Pantoprazole, injection Protonix IV Esomeprazole Nexium IV *Formulary agents in bold. By declaration of the P&T Committee, the Proton Pump Inhibitors are subject to automatic IV to PO interchange. Please refer to the Intravenous to Oral Medication Conversion Program for further details. Document created: 03/02. Revised: 08/11.

29 Therapeutic Interchange: HMG CoA Reductase Inhibitors (Statins) Brand Name Dose Equivalents (mg/day) Atorvastatin Lipitor Pravastatin Pravacol N/A N/A Rosuvastatin Crestor Simvastatin Zocor N/A Fluvastatin Lescol 80 N/A N/A N/A Lovastatin Mevacor N/A N/A Pitavastatin Livalo 2 4 N/A N/A *Formulary agents in bold. Due to the increased risk of myopathy, including rhabdomyolysis, use of simvastatin 80 mg daily should be restricted to patients who have been taking simvastatin 80 mg per day chronically (i.e., 12 months or longer) without evidence of muscle toxicity. Simvastatin is the preferred therapeutic substitution for lovastatin. Document created: 08/11. Revised: None