Top 200 Drug Podcasts - Set 9 - Black Box Warnings & Precautions

Front 1

Hydrocodone/APAP

Back 1

Use caution in patients who have a HX of drug or alcohol abuse. Both physical and psychological dependency may develop w/ prolonged use.

Front 2

Atorvastatin

Back 2

1) Dose-related risk of myopathy, increased w/ concurrent use of 3A4 inhibitors, fibric acid derivatives, such as gimfibrozil, or niacin at doses > 1 g/day. Elderly are at increased risk of myopathy. Recheck CPK upon report of unexplained muscle soreness and discontinue if CPK levels are greater than 10 times the upper limit of normal. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Check LFTs at baseline, 3 wks later, then semiannually. Discontinue if LFTs increase to > 3 times upper limit of normal.

Front 3

Levothyroxine

Back 3

Levothyroxine can cause rapid increase in metabolic rate and cardiac output, which can lead to angina, MI, CHF, arrhythmias, and even sudden cardiac death.

Front 4

Lisinopril

Back 4

1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ACE inhibitors can cause angioedema at any time during therapy. African Americans are at increased risk of developing angioedema. 3) Due to the buildup of bradykinin, ACE inhibitors can cause chronic cough. It is a dry, unproductive cough, usually seen within the first months of therapy, and it should resolve within a month of discontinuation. If cough becomes intolerable to the patient, try switching to an angiotensin receptor blocker, as ARBs are much less likely to cause cough. 4) ACE inhibitors can cause hyperkalemia. Risk of hyperkalemia increases w/ renal dysfunction, diabetes mellitus, and use of potassium-sparing diuretics or potassium supplements. DC if serum creatinine increases to > 35% over baseline. 5) Hypotension may occur, especially w/ initial therapy. The risk is higher in volume depleted patients. If hypotension is an issue, decrease the dose. 6) Use w/ caution in patients who have pre-existing renal impairment.

Front 5

Amoxicillin

Back 5

Renal impairment requires dosage adjustment.

Front 6

Esomeprazole

Back 6

Do not exceed 20 mg/day in severe hepatic impairment.

Front 7

Clopidogrel

Back 7

1) Use w/ caution in patients who have bleeding disorders or who are at increased risk of bleeding. 2) Use w/ caution in patients who have severe renal or hepatic impairment.

Front 8

Metoprolol Tartrate

Back 8

1) BBs can cause hypotension. Can potentially worsen bronchospastic conditions, such as asthma. 2) BBs can mask the symptoms of hypoglycemia. Note: Sweating is the only sign of hypoglycemia NOT masked by BBs.

Front 9

Montelukast

Back 9

1) Montelukast cannot be used to treat bronchoconstriction due to Aspirin/NSAID hypersensitivity. 2) Montelukast is not indicated to treat or reverse current asthmatic attacks or bronchospasms. It is only efficacious as a maintenancetherapy.

Front 10

Escitalopram

Back 10

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It is not approved for bipolar disorder and can cause a shift towards mania in patients who have bipolar disorder. 3) It can inhibit platelet aggregation, which can lead to an increased bleeding risk, which is especially important in patients taking NSAIDs or other anticoagulants. 4) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 5) Use w/ caution in patients who have a history or an increased risk of seizures, such as alcoholics and those who have had brain damage. 6) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 11

Albuterol Inhaler

Back 11

1) Although rare, paradoxical bronchospasm can occur (noted if the patient seems to get worse w/ use of the inhaler). 2) Immediate hypersensitivity reactions can occur and should be monitored w/ initial use of albuterol. 3) Use caution in patients who have a history of seizures or cardiovascular conditions (HTN or HF). 4) Beta agonists can increase serum glucose, something for diabetes to keep in mind. 5) Beta agonists can decrease serum potassium, so use w/ caution in patients who have hypokalemia. 6) Use caution in elderly patients. Tremors are seem more in the elderly as a result of beta agonist use.

Front 12

Simvastatin

Back 12

1) Dose-related risk of myopathy, increased w/ concurrent use of 3A4 inhibitors, fibric acid derivatives, such as gimfibrozil, or niacin at doses > 1 g/day. Elderly are at increased risk of myopathy. Recheck CPK upon report of unexplained muscle soreness and discontinue if CPK levels are greater than 10 times the upper limit of normal. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Check LFTs at baseline, 3 wks later, then semiannually. Discontinue if LFTs increase to > 3 times upper limit of normal.

Front 13

Amlodipine

Back 13

1) Can actually cause angina or MI upon initiation or dosage increase. 2) Use caution in patients who have aortic stenosis or hepatic impairment. 3) Initiate at lower doses in elderly (w/ 2.5 mg).

Front 14

Azithromycin

Back 14

1) Although rare, macrolides can cause prolongation of the QT interval, which can result in arrhythmias. 2) Use w/ caution in patients who have Myastenia Gravis (can cause exacerbations). 3) Can cause hepatotoxicity, so discontinue if symptoms occur such as nausea, vomiting, malaise, and fever. 4) Prolonged use can result in superinfections, such as CDAD.

Front 15

Metformin

Back 15

Black Box Warning (Lactic Acidosis): It is rare, but highly fatal, due to the buildup of metformin. Patients are at increased risk w/ sepsis, dehydration, excess alcohol intake, renal impairment, elderly greater than 80 years old, unstable conjective heart failure, and hepatic disease. Symptoms include a feeling of general discomfort or unease, muscle soreness, respiratory distress, and drowsiness. Lab findings for lactic acidosis include decreased pH, increased anion gap, and increased blood lactate. Use w/ caution in patients who have heart failure, elderly patients, patients who consume excess alcohol, and patients at risk of hypoglycemia.

Front 16

Metoprolol Succinate

Back 16

1) BBs can cause hypotension. Can potentially worsen bronchospastic conditions, such as asthma. 2) BBs can mask the symptoms of hypoglycemia. Note: Sweating is the only sign of hypoglycemia NOT masked by BBs.

Front 17

Hydrochlorothiazide

Back 17

1) Use caution in patients who have a HX of diabetes, as HCTZ can alter glucose control. 2) Use caution in patients who have a history of gout. HCTZ can precipitate a gouty attack. 3) Use caution in patients who have hepatic or renal impairment. HCTZ is not effective in patients who have severe renal impairment (CrCL < 30 mL/min). 4) Use caution in patients who have hypokalemia (can cause hypokalemia).

Front 18

Rosuvastatin

Back 18

1) Dose-related risk of myopathy. Elderly are at increased risk of myopathy. Recheck CPK upon report of unexplained muscle soreness and discontinue if CPK levels are greater than 10 times the upper limit of normal. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Use caution in patients who have hepatic impairment or who consume large amounts of alcohol. Patients should avoid excess alcohol. 3) Use caution in patients of asian descent, they are at increased risk of myopathy.

Front 19

Furosemide

Back 19

1) If the dosage is too high, excessive diuresis can occur, resulting in fluid and electrolyte depletion. Hence doses should be individualized based on patient presentation. 2) Use caution in patients who have electrolyte imbalances or who are prone to such imbalances, such as patients who have cirrhosis. 3) Use caution in diabetic patients: furosemide may alter glucose control. 4) Use caution in patients who have a HX of gout (can cause exacerbations). 5) Furosemide can cause exacerbation or activation of Lupus in patients who have Systemic Lupus Erythematosus (SLE).

Front 20

Warfarin

Back 20

Major or fatal bleeding can occur. Risk factors for bleeding include an INR > 4, age > 65, any bleeding disorders, drug interactions that could increase bleeding, changes in smoking habits, and changes in diet. Use w/ caution in elderly patients, severe renal or hepatic impairment, HTN or CV disease, indwelling catheters, severe diabetes, or changes in smoking or diet habits.

Front 21

Fluticasone & Salmeterol

Back 21

1) Black Box Warning: Long acting Beta-2 agonist may increase asthma related deaths. Hence for asthma, long acting Beta-2 agonists, such as salmeterol or formoterol, should only be added if the patient is not controlled on an inhaled corticosteroid alone and more maintenance therapy is needed. 2) Long term use of corticosteroids can lead to increased risk of infections. Patients should wash their mouth out after every use of advair to prevent oral candidiasis, i.e. thrush (a yeast infection causing painful white lesions on the mucous membranes of the mouth). 3) Use caution in diabetic patients. Beta-2 agonists can increase serum glucose. 4) Beta-2 agonists can cause CNS excitation, so use caution in patients who have cardiovascular disease or a seizure disorder. 5) Advair can cause hypokalemia.

Front 22

Ibuprofen

Back 22

1) Black Box Warning: NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, such as MI and stroke. This risk increases w/ prolonged use or w/ cardiovascular disease or cardiovascular risk factors. Reduce these risks by using the lowest effective dose for the shortest duration possible. 2) Black Box Warning: NSAIDs increase the risk of GI irritation, ulceration, and GI bleeding, so use w/ caution in the following situations: concurrent aspirin therapy, concurrent corticosteroids or anticoagulents, patients who have GI complications, patients who smoke or drink excess alcohol, and elderly patients. In these situations, consider also giving a proton pump inhibitor (PPI) to decrease the risk of GI complications. 3) Recommended maximum dose for self-treatment is 1,200 mg per day or for Rx is 3,200 mg per day. 4) Hold the dose in the case of anurea. 5) Avoid using in severe hepatic impairment. 6) Use caution in severe renal impairment. NSAIDs cause constriction of the afferent arterioles, which decreases renal perfusion. Because of this, exercise caution using NSAIDs in cases of heart failure or dehydration, in elderly patients, and w/ patients on diuretics or ACE inhibitors.

Front 23

Sertraline

Back 23

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It is not approved for bipolar disorder and can cause a shift towards mania in patients who have bipolar disorder. 3) It can inhibit platelet aggregation, which can lead to an increased bleeding risk, which is especially important in patients taking NSAIDs or other anticoagulants. 4) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 5) Use w/ caution in patients who have a history or an increased risk of seizures, such as alcoholics and those who have had brain damage. 6) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 24

Valsartan

Back 24

1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) Valsartan can cause hypotension. So use w/ caution at initiation of therapy, especially in patients who are volume depleted or have heart failure. 4) Use of ARBs can lead to renal dysfunction, especially in patients who have prior renal dysfunction or decreased renal blood flow. Use caution in patients who have hepatic impairment, renal impairment, or bilateral renal artery stenosis. Monitoring renal function: check serum creatinine at baseline and again in 4 wks. If serum creatinine increases > 35% over baseline, then discontinuevalsartan at least until renal function is back to normal.

Front 25

Zolpidem

Back 25

1) Zolpidem can cause CNS depression, behavioral changes, as well as increased risk of sleep walking or sleep driving. Hence it should only be taken right before bed when one can get a full night's sleep. 2) Use caution in patients who have depression, drug abuse potential, hepatic impairment, or any respiratory issues. 3) Abrupt withdraw can lead to withdrawal symptoms, though, in general, nonbenzodiazepine are associated with less withdrawal than traditional benzodiazepines.

Front 26

Oxycodone/APAP

Back 26

1) Use caution in patients who have a HX of drug or alcohol abuse. Both physical and psychological dependency may develop w/ prolonged use. 2) Overdose can cause hepatotoxicity. 3) Can cause CNS depression or hypotension. Patients should use caution when performing tasks that require mental alertness.

Front 27

Duloxetine

Back 27

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. The risk of suicide is not increased in patients greater than 24 years of age and is actually decreased in patients greater than 65 years of age. 2) It can inhibit platelet aggregation, which can lead to an increased bleeding risk, which is especially important in patients taking NSAIDs or other anticoagulants. 3) Use caution in patients w/ alcoholism due to possible hepatotoxicity. 4) Use caution in patients who have diabetes. Duloxetine can cause an increase in serum glucose and A1C. 5) Duloxetine can cause sexual dysfunction. 6) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 7) Use w/ caution in patients who have a history or an increased risk of seizures, such as alcoholics and those who have had brain damage. 8) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 28

Quetiapine

Back 28

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) Black Box Warning: Antipsychotics increase the risk of death, due to cardiovascular complications or infections, in elderly patients who have dementia-related psychosis. Hence quetiapine is not approved for dementia-related psychosis. 3) Quetiapine can cause a shift towards mainia in some patients who have bipolar disorder. 4) Quetiapine can alter cardiac conduction, which can lead to life threatening arrhythmias. 5) Quetiapine can cause anticholinergic effects (dry mouth, dry eyes, blurred vision, constipation, urinary retention, cognitive impairments). 6) Antipsychotics can cause hyperglycemia, increased cholesterol, and weight gain. 7) Extrapyramidal symptoms (EPS) may occur, including pseudoparkinsonism, dystonic reactions, akathisia, and tardive dyskinesia. EPS is less of an issue w/ atypical antiphychotics compared to typical antipsychotics, though the risk is increased w/ higher doses. 8) Abrupt withdraw can cause withdraw syndrome, so taper the withdraw slowly.

Front 29

Venlafaxine

Back 29

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) Venlafaxine can inhibit platelet aggregation, which can increase the risk of bleeding, especially in patients on aspirin or NSAIDs. 3) Venlafaxine can cause an increase in cholesterol and blood pressure. 4) Venlafaxine can cause CNS depression. 5) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 6) Sexual dysfunction can occur. 7) Dose-related weight loss can occur. 8) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 30

Tamsulosin

Back 30

1) Before starting therapy w/ tamsulosin, make sure the patient does not have prostate cancer. 2) Angina, priapism, and syncopy can occur. Discontinue if any of these are an issue. 3) Use caution in patients who have a sulfa allergy. [May want to avoid if the patient has a severe sulfa allergy.]

Front 31

Alprazolam

Back 31

1) CNS depression is a major concern. It can impair both physical and mental abilities. Use caution in patients who have major depressive disorder or respiratory disease (respiratory depression can occur). 2) Use caution in patients who have a history or potential for drug or alcohol abuse. 3) Use caution in renal or hepatic impairment.

Front 32

Valsartan / Hydrochlorothiazide

Back 32

1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) Valsartan can cause hypotension. So use w/ caution at initiation of therapy, especially in patients who are volume depleted or have heart failure. 4) Use of ARBs can lead to renal dysfunction, especially in patients who have prior renal dysfunction or decreased renal blood flow. Use caution in patients who have hepatic impairment, renal impairment, or bilateral renal artery stenosis. Monitoring renal function: check serum creatinine at baseline and again in 4 wks. If serum creatinine increases > 35% over baseline, then discontinuevalsartan at least until renal function is back to normal.

Front 33

Trazodone

Back 33

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It is not approved for bipolar disorder and can cause a shift towards mania in patients who have bipolar disorder. 3) The risk of orthostatic hypotension is higher w/ trazodone than w/ other antidepressants. So use caution in patients at increase risk of hypotension, such as elderly patients, patients who are volume depleted or who have cardiovascular issues or who are on other medications that cause hypotension. 4) Priapism can occur and has caused permanent damage in some cases. So discontinue immediately if prolonged erection occurs. 5) Use w/ caution in patients who have a history of or increased risk of seizures. 6) Avoid abrupt discontinuation in patients on high doses or long term therapy. 7) Use caution in renal or hepatic dysfunction.

Front 34

Pioglitazone

Back 34

1) Black Box Warning: Thiazolidinediones can exacerbate or cause heart failure, so monitor for signs and symptoms of heart failure closely upon initiation of therapy and dosage increases (edema, rapid weight gain, shortness of breath). If heart failure is suspected, then discontinue or, at least, reduce the dose. 2) Pioglitazone is not recommended for Type I Diabetes or Diabetic Ketoacidosis. [The MOA is insulin dependent.] 3) Pioglitazone can cause weight gain (dose related). 4) Pioglitazone can increase risk of fractures, so use caution in patients who have increased fracture risk, such as elderly women. 5) Use caution in patients who have hepatic impairment. 6) Initiation in patients who have an ALT > 2.5 times the upper limit of normal is not recommended. Discontinuation is recommended if ALT becomes > 3 times the upper limit of normal or if jaundice (yellowing of the skin or eyes) occurs.

Front 35

Alendronate

Back 35

1) Bisphosphanates can cause bone or muscle pain. 2) It can cause irritation of the upper GI mucosa, which is why patients should take it w/ a full glass of water and remain upright for at least 30 minutes following administration. 3) Bisphosphanates can cause hypocalcemia, so ensure patients have adequate calcium and vitamin D intake. 4) Bisphosphanates can cause osteonecrosis of the jaw.

Front 36

Sulfamethoxazole/Trimethoprim

Back 36

1) SMX/TMP can cause blood dyscrasias, hepatic necrosis, as well as dermatologic reactions. discontinueuse if rash or severe adverse reactions develop. 2) SMX/TMP can also cause hyperkalemia and hypoglycemia. 3) Prolonged use can result in super-infections, such as C. difficile-associated diarrhea (CDAD).

Front 37

Lansoprazole

Back 37

1) Prolonged use can lead to increased fracture risk. 2) Use caution in patients who have severe hepatic impairment. The dose may need to be decreased in such cases.

Front 38

Clonazepam

Back 38

1) CNS depression is a major concern. It can impair both physical and mental abilities. Use caution in patients who have major depressive disorder or respiratory disease (respiratory depression can occur). 2) Because CNS depression can occur, use caution w/ elderly patients and patients who are at increased risk of falling. 3) Use caution in patients who have a history or potential for drug or alcohol abuse. 4) Use caution in renal or hepatic impairment.

Front 39

Tramadol

Back 39

1) Tramadol causes CNS depression, which can impair both physical and mental abilities. 2) Use w/ caution in patients having respiratory depression or major depressive disorder. 3) Avoid use in patients at increase risk of suicide. 4) Use caution in patients who have a history of seizures. 5) Use caution in patients who have a Hx of drug or alcohol abuse. 6) Tolerance and dependence can occur and abrupt discontinuation should be avoided due to the possibility of withdraw syndrome. 7) Crushing or chewing the extended release tablets can lead to overdose.

Front 40

Levofloxacin

Back 40

1) Black Box Warning (Tendon Rupture): Fluoroquinolones can cause tendon inflammation or tendon rupture. Concurrent use w/ corticosteroids, older patients usually over 60 years of age, patients taking corticosteroids, and in patients w/ kidney, heart, or lung transplants Use caution in patients who have rheumatoid arthritis because of the risk fo tendon rupture. The most common site of tendon rupture is the achilles tendon. And levofloxacin should be discontinued at first sign of tendon inflammation. 2) Levofloxacin can cause altered cardiac conduction and prolonged QT interval. 3) Levofloxacin can cause CNS stimulation (restlessness, confusion, &/or tremors). Use w/ caution in patients who have seizure disorders. 4) Fluoroquinolones can increase the risk of hypoglycemia, especially in patients who have diabetes. 5) Severe hepatotoxicity has been reported w/ levofloxacin. 6) Levofloxacin may increase sensitivity to light, so caution patients to wear sunscreen and avoid prolonged direct exposure to sunlight. 6) As w/ most antibiotics, prolonged use can result in superinfections, such as CDAD.

Front 41

Fluoxetine

Back 41

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It can inhibit platelet aggregation, which can lead to an increased bleeding risk, which is especially important in patients taking NSAIDs or anticoagulants. 3) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 4) Use w/ caution in patients who have a history or an increased risk of seizures, such as alcoholics and those who have had brain damage. 5) Sexual dysfunction can occur, but it is reversible upon discontinuation. 6) Fluoxetine may cause hypoglycemia, so use caution in patients who have diabetes. 7 Fluoxetine may cause anorexia and/or weight loss. 8) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 42

Prednisone

Back 42

1) Adrenal suppression or suppression of the hypothalmic-pituitary (HPA) axis can occur. This is dose- and duration-dependent. Corticosteroids should be tapered slowly when discontinuing if they were given for an extended period of time. In general, corticosteroids do not been to be tapered if used for less than 2 to 3 wks, unless abrupt discontinuation may cause a flare (as in poison ivy) or if the patient is very ill. A good rule of thumb: Predsisone should be tapered if 20 mg or more is used for greater than 3 wks and the taper should be 5 to 20% every 1 to 2 wks. 2) Prolonged use may cause immunosuppression, which can increase the risk of infection. 3) Corticosteroids can cause hyperglycemia, especially in patients who have diabetes. 4) Use w/ caution in patients who have heart failure, due to possible fluid retention and hypertension associated w/ corticosteroids. 5) Use caution in patients who have increased risk of osteoporosis, especially w/ prolonged use. Corticosteroids interfere w/ calcium absorption. 6) Use caution in hepatic impairment. The dose may need to be adjusted.

Front 43

Omeprazole

Back 43

1) Long term use can lead to increased fracture risk. 2) Use caution in patients who have severe hepatic impairment. The dose may need to be decreased.

Front 44

Atenolol

Back 44

1) Black Box Warning: Abrupt withdrawal can result in angina, MI, ischemia, and HTN. Taper gradually over 1 to 2 wks. Restart treatment (at least temporarily) if any of the aforementioned effects occur. 2) BBs can cause hypotension. 3) BBs can potentially worsen bronchospastic conditions, such as asthma. 4) Use caution in patients who have diabetes. 5) BBs can mask the signs and symptoms of hypoglycemia. Note: sweating is the only sign of hypoglycemia not masked by BBs.

Front 45

Insulin Glargine

Back 45

1) Hypoglycemia is the main concern. There are many aspects that can increase the risk of hypoglycemia, such as not eating, taking too much insulin, and increased physical activity. Patients should check their blood glucose often, especially during initial therapy or during times of increased stress, such as illness or emotional disturbances. Make sure patients know the s/s of hypoglycemia and what to do if it occurs. 2) Hypokalemia is another concern. Insulin can cause hypokalemia, which, if left untreated, can lead to serious cardiac and respiratory conditions. Because of this, electrolites (especially potassium) should be monitored. 3) Use caution if switching insulin formulations. The dose may need to be adjusted. 4) Dose may need to be altered in hepatic or renal impairment.

Front 46

Amoxicillin / Clavulanate

Back 46

1) Hypersensitivity is a major concern, 2) Use w/ caution in patients who have hepatic impairment, 3) Prolonged use can result in super infections, such as Clostridium difficile associated diarrhea (CDAD)

Front 47

Fenofibrate

Back 47

1) Can cause cholelithiasis, so discontinue if gall stones occur. 2) Can cause a dose-related increase in liver function tests, so get LFTs periodically (baseline, 6 & 12 wks). Discontinue if LFTs increase and stay elevated greater than 3 times the upper limit of normal. 3) Although rare, it can cause myopathy/rhabdomyolysis. Tell patients to report any unexplained muscle weakness or pain or brown urine. The risk of developing myopathy is increased in elderly patients, and patients who have diabetes, kidney failure, or hypothyroidism as well as patients taking statins. 4) Can cause an increase in serum creatinine, and b/c of this the dose should be decreased and the patient monitered more carefully in cases of mild-to-moderate renal impairment. 5) Can cause increased risk of venous thromboembolism (VTE).

Front 48

Celecoxib

Back 48

1) Black Box Warning: Celecoxib may increase the risk of cardiovascular thrombotic events, such as MI or stoke. Risk may be increased in patients who have cardiovascular issues and it is recommended to avoid use in patients who have heart failure. 2) NSAIDs may increase the risk of gastrointestinal irritation, ulceration, and bleeding. Note: Since celecoxib is selective for COX-2, it is more likely to cause the cardiovascular complications and less likely to cause the GI issues. When only COX-2 is inhibited, it can increase the proliferation of COX-1, which is GI protective to some extent, but can also increase platelet aggregation, increasing the risk of thrombus or MI. 3) Poor CYP 2C9 metabolizers will most likely need the dose to be decreased by 50%. 4) Use is not recommended in patients who have severe hepatic or renal impairment.

Front 49

Donepezil

Back 49

1) Can cause bradycardia, heart block, and cardiac conduction abnormalities. Use caution in patients who have cardiovascular issues. 2) Use w/ caution in patients who have COPD or asthma as well as those who have a Hx of seizures. 3) Can exacerbate urinary tract infections. 4) Use caution in patients who have benign prostatic hyperplasia (BPH).

Front 50

Ezetimibe & Simvastatin

Back 50

1) Dose-related risk of myopathy, increased w/ concurrent use of 3A4 inhibitors, fibric acid derivatives, such as gimfibrozil, or niacin at doses > 1 g/day. Elderly are at increased risk of myopathy. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Use w/ caution in patients who have a Hx of liver impairment or who consume large amounts of alcohol. Use is contraindicated in acute liver disease. Patients should avoid excess alcohol.

Front 51

Cephalexin

Back 51

1) Use caution in patients who have penicillin allergy, 2) Use w/ caution in renal impairment (adjust dose if CrCL < 50 mL/min), 3) Prolonged use can lead to superinfections, such as CDAD.

Front 52

Mometasone

Back 52

Avoid use if any nasal ulcers or wounds are present. Wait until the issue is healed to use use mometasone.

Front 53

Drospirenone & Ethinyl Estradiol

Back 53

1) Black Box Warning: Smoking cigarettes while taking oral contraceptives increases the risk of serious cardiovascular events. The risk is increased w/ increased age > 35 years old and increased number of cigarettes > 15 cig/day. 2) Oral contraceptives can increase the risk of thromboembolism. Use w/ caution in patients who are at increased risk of VTE. Note: The risk of thrombosis w/ any oral contraceptive is less than the risk of thrombosis during pregnancy. 3) Use of oral contraceptives slightly increases the risk of breast cancer. 4) Use w/ caution in women who are at increased risk of cardiovascular complications. All oral contraceptives can increase blood pressure to some extent. 5) Use w/ caution in patients who have a Hx of migraines as well as patients w/ depression.

Front 54

Vitamin D3

Back 54

Use caution in patients who have renal impairment or kidney stones.

Front 55

Ezetimibe

Back 55

Use w/ caution in patients who have hepatic impairment or renal impairment (being a CrCL < 30 mL/min). Avoid use in severe hepatic impairment.

Front 56

Gabapentin

Back 56

1) Can cause CNS depression, which may impair physical and mental abilities. 2) Use w/ caution in patients w/ depression or suicidal ideation. 3) Use w/ caution in renal impairment.

Front 57

Pregabalin

Back 57

1) Angioedema can occur and the risk may be increased if given with other drugs known to cause angioedema, such as ACE inhibitors, or if the patient has a Hx of angioedema. 2) Pregabalin can also cause rhabdomyolysis w/ increased CPK levels. 3) Use caution and adjust the dose in renal impairment w/ a CrCL of < 30 mL/min. 4) Pregabalin can cause CNS depression and alter physical and mental abilities. 5) Use w/ caution in patients w/ mental depression or suicidal ideation. 6) Use w/ caution in patients who have cardiovascular disease.

Front 58

Sildenafil

Back 58

1) Hypotension can occur due to the vasodilatory effects. Because of this, use w/ caution in patients who have cardiovascular disease. 2) Priapism can occur and patients should seek medical attention if erection lasts longer than 4 hrs. 3) Lower the dose if the patient has hepatic impairment or renal impairment w/ a CrCL < 30 mL/min. 4) Note: Vision loss and hearing loss have been reported in rare cases.

Front 59

APAP/Codeine

Back 59

1) CNS depression can occur, which can impair both physical and mental abilities. 2) Use w/ caution in patients who have respiratory depression, COPD, or other obstructive pulmonary diseases. 3) Hepatotoxicity can occur. This is mainly due to the APAP, which should be limited to no more than 3 g per day (down from the former guideline of 4 g/day). 4) Due to both risk of CNS depression and hepatotoxicity, use APAP/codeine w/ caution in patients who consume large amounts of alcohol. 5) Use w/ caution in patients who have a Hx of drug abuse or alcoholism, both physical and psychological dependence can develope w/ prolonged use. 5) Use w/ caution in patients who have renal or hepatic impairment as well as patients who have a seizure disorder or thyroid dysfunction.

Front 60

Fluconazole

Back 60

1) QT prolongation can occur. Use w/ caution in patients who have arrhythmias or who are on other medications that can prolong the QT interval. 2) Use w/ caution in patients who have renal or hepatic impairment. 3) Hepatotoxicity can occur and patients should report any yellowing of the skin or eyes.

Front 61

Intranasal Fluticasone

Back 61

None listed.

Front 62

Losartan

Back 62

1) Black Box Warning (Pregnancy): Drugs affecting the angiotensin system have been shown to cause injury or death to the fetus in the 2nd and 3rd trimesters, and should be discontinued as soon as pregnancy is detected. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) ARBs can cause hypotension. Use caution at the initiation of therapy, especially in patients who are volume depleted or have HF. 4) ARBs can lead to renal dysfunction, especially in patients with prior renal dysfunction or decreased renal blood flow. Monitor SrCr, and if it increases > 35% over baseline, then temporarily discontinue losartan at least until renal function is back to normal.

Front 63

Propoxyphene-N/APAP

Back 63

1) Black Box Warning (Accidental or Intentional Overdose): It is not uncommon for fatalities to occur within the first hour. Look for patients w/ depression or emotional disturbances. This risk is increased in patients who consume alcohol or who are taking CNS depressants. 2) Black Box Warning: Concurrent use w/ strong CYP 3A4 inhibitors can greatly increase Propoxyphene levels and the dose may need to be adjusted. This includes such as ritonavir, ketoconazole, itraconazole, fluconazole, erythromycin, clarithromycin, grapefruit juice, and verapamil. 3) CNS depression can occur, leading to impairment of both physical and mental abilities, especially w/ initial therapy. 4) Hepatotoxicity can occur, especially w/ acute overdose. 5) Be sure to keep the APAP dose lower than 3 g per day (down from previous guideline of 4 g/day). 6) Use caution in patients who have a Hx of drug or alcohol abuse. 5) Use caution in patients who have G6PD deficiency. 6) Use caution in patients w/ any head injury, prostatic hypertrophy, or renal impairment.

Front 64

Valacyclovir

Back 64

1) CNS effects, such as hallucinations, seizures, and confusion can occur. It is more likely in elderly patients. 2) Urinary precipitation can occur. Patients need to stay well hydrated. 3) Use w/ caution in renal impairment. Dose needs to be adjusted if CrCL < 30 mL/min.

Front 65

Lorazepam

Back 65

1) CNS depression is a big concern. It can impair both physical and mental abilities. Due to CNS depression, use caution in patients w/ major depressive disorder or respiratory disease (respiratory depression can occur). Also exercise caution w/ elderly patients and patients at increased risk of falling. 2) Use caution in patients w/ Hx or potential for drug or alcohol abuse. 3) Use caution in renal or hepatic impairment.

Front 66

Pantoprazole

Back 66

1) Long term use can lead to increased fracture risk. 2) Use caution in patients who have severe hepatic impairment. The dose may need to be decreased.

Front 67

Amlodipine/Benazepril

Back 67

1) Black Box Warning (Pregnancy): Drugs affecting the angiotensin system have been shown to cause injury or death to the fetus in the 2nd and 3rd trimesters, and should be discontinued as soon as pregnancy is detected. 2) Watch for angioedema, especially after the 1st dose. 3) Development of chronic cough should be remedied by switching from an ACE inhibitor to an ARB. 4) Watch for hyperkalemia, especially in patients who have renal dysfunction or diabetes mellitus. 5) Renal dysfunction: monitor SrCr and discontinue any ACE inhibitor or ARB if it increases > 35% over baseline. 6) Hypotension is a concern, especially w/ this combination of drugs, and is the main reason for initiating at a low dose and titrating slowly as needed.

Front 68

Conjugated Estrogens

Back 68

1) Black Box Warning (Dementia): Increased risk in females 65 years old or older. 2) Black Box Warning (Endometrial Carcinoma): Be sure to rule out malignancy in situations of abnormal vaginal bleeding. 3) Black Box Warning (CV Disease): Conjugated esters can increase the risks of MI, stroke, VTE, or HTN, especially in postmenopausal women. 4) Black Box Warning: Weight patient-specific risks and benefits before prescribing conjugated esters and continue to do so periodically while on therapy. Use the lowest effective dose for the shortest time possible. 5) Increased risk of breast cancer. Check family Hx. 6) Increased risk of venous thromboembolism (VTE).

Front 69

Oseltamivir

Back 69

1) Although rare, anaphylaxis and neuropsychiatric events, such as confusion and hallucinations, have been reported. 2) Use w/ caution in patients who have hepatic or renal impairment (dose should be reduced by half if CrCL is 10 to 30 mL/min).

Front 70

Tiotropium

Back 70

1) Although rare, paradoxical bronchospasm can occur. Discontinue if this is an issue. 2) Tiotropium can potentially worsen narrow angle glaucoma, myasthenia gravis, and prostatic hyperplasia. So use caution in these patient populations. 3) Capsules contain lactose, so use w/ caution in patients who have a severe milk protein allergy.

Front 71

Aripiprazole

Back 71

1) Black Box Warning: Aripiprazole is not approved for dementia related to psychosis and its use may increase mortality in elderly patients who have dementia. Most deaths are due to cardiac complications or infections. 2) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 3) Blood dyscrasias, such as lukopenia, neutropenia, and agranulocytosis have been reported. Discontinue if absolute neutrophil count drops below 1000 / mm^3. 4) Use w/ caution in patients who have CV disease or a Hx of seizures. 5) Extrapyramidal symptoms (EPS) may occur, including pseudoparkinsonism, dystonic reactions, akathisia, and tardive dyskinesia. 5) Rare cases of neuroleptic malignant syndrome (NMS) have been reported. Symptoms include muscle rigidity, altered mental status, and irregular pulse or blood pressure.

Front 72

Methylphenidate

Back 72

1) Black Box Warning (Drug Abuse or Dependency): Do not discontinue abruptly in patients who have been on this medication for prolonged periods of time. Exercise caution in recommending this drug for patients who have a Hx of alcohol or drug abuse. 2) Use w/ caution in the following patient populations a) psychosis or bipolar disorder, b) Hx or risk of seizures, c) Hx or risk of substance abuse, d) Hx of GI obstruction or stricture, e) hyperthyroidism.

Front 73

Digoxin

Back 73

Many Precautions! Here are a few. 1) Digoxin can have proarrhythmic effects. 2) Use in Wolff-Parkinson White syndrome or other accessory pathway or bypass tracts can lead to ventricular fibrillation and should be avoided. 3) Use can increase the risk of MI, especially within 6 months of a previous MI. 4) Hypothyroidism can lead to increased digoxin levels, while hyperthyroidism may lead to decreased digoxin levels.

Front 74

Fluticasone

Back 74

None listed.

Front 75

Fexofenadine

Back 75

1) Renal Impairment: Decrease the initial dose to 60 mg/day if CrCL is < 80 mL/min. 2) The orally disintegrating tablets contain phenylalanine.

Front 76

Olmesartan

Back 76

1) Black Box Warning (Pregnancy): Drugs affecting the angiotensin system have been shown to cause injury or death to the fetus in the 2nd and 3rd trimesters, and should be discontinued as soon as pregnancy is detected. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) ARBs can cause hypotension. Use caution at the initiation of therapy, especially in patients who are volume depleted or have HF. 4) ARBs can lead to renal dysfunction, especially in patients with prior renal dysfunction or decreased renal blood flow. Monitor SrCr, and if it increases > 35% over baseline, then temporarily discontinue losartan at least until renal function is back to normal. 5) Use w/ caution if any of the following are present: a) renal artery stenosis or any other renal impairment, b) hepatic impairment, c) volume depletion, and d) hyponatremia.

Front 77

Pravastatin

Back 77

1) Dose-related risk of myopathy, increased w/ concurrent of fibric acid derivatives, such as gimfibrozil, or niacin. Elderly are at increased risk of myopathy. Recheck CPK upon report of unexplained muscle soreness and discontinue if CPK levels are greater than 10 times the upper limit of normal. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Hepatic Impairment: Since statins can cause liver dysfunction, use w/ caution in patients who have a Hx of liver impairment or who consume large amounts of alcohol. Tell patients to avoid excess alcohol.

Front 78

Triamterene/Hydrochlorothiazide

Back 78

1) Black Box Warning (Hyperkalemia): Can be fatal if uncontrolled. Risk is increased w/ renal impairment, diabetes, elderly patients, and patients who are severely ill. Serum potassium should be monitered at initiation of therapy, changes in doses, or in the case of severe illness or renal impairment. 2) Photosensitivity can develop (due to HCTZ). 3) HCTZ can potentially precipitate gout in susceptible patients (Hx/family Hx, chronic renal failure). 4) HCTZ can potentially cause or worsen hypercalcemia as well as hypercholesterolemia. 5) Use w/ caution in patients w/ hepatic impairment or kidney stones.

Front 79

Methylprednisolone

Back 79

1) Adrenal suppression or suppression of the hypothalmic-pituitary (HPA) axis can occur. This is dose- and duration-dependent. Corticosteroids should be tapered slowly when discontinuing if they were given for an extended period of time. In general, corticosteroids do not been to be tapered if used for less than 2 to 3 wks, unless abrupt discontinuation may cause a flare (as in poison ivy) or if the patient is very ill. 2) Prolonged use may cause immunosuppression, which can increase the risk of infection. 3) Corticosteroids can cause hyperglycemia, especially in patients who have diabetes. 4) Use w/ caution in patients who have heart failure, due to possible fluid retention and hypertension associated w/ corticosteroids. 5) Use caution in patients who have increased risk of osteoporosis, especially w/ prolonged use. Corticosteroids interfere w/ calcium absorption. 6) Use caution in hepatic impairment. The dose may need to be adjusted.

Front 80

Cyclobenzaprine

Back 80

1) Cyclobenzaprine can have anticholinergic effects, such as vision disturbances, dry mouth, urinary retention, and constipation. 2) Use caution in patients who have angle closure glaucoma or any other issues that could be exacerbated by anticholinergic effects. 3) CNS depression can occur w/ cyclobenzaprine therapy, leading to impairment of both physical and mental abilities. 4) Since it is related to TCAs, it has similar toxic potentials, such as conduction time prolongation, arrhythmias, and tachycardia. 5) Use w/ caution in patients w/ hepatic impairment. Avoid using the extended release capsules and decrease the initial dose of the immediate release tablets to 5 mg in mild impairment. Avoid use all-together in moderate-severe impairment. 6) Extended release capsules are not recommended for use in the elderly (due to poor tolerance).

Front 81

Clonidine

Back 81

1) Abrupt withdrawal of clonidine can cause rapid increase in blood pressure. Discontinuation should be done gradually over about 1 wk. If the patient is also on a beta blocker, the beta blocker should be discontinued gradually several days before discontinuation of clonidine. 2) Clonidine can cause CNS depression. Clonidine should be used w/ caution in patients w/ coronary insufficiency, recent MI, or cerebrovascular disease. Clonidine should also be used w/ caution in patients who have chronic renal impairment.

Front 82

Risedronate

Back 82

1) Bisphosphanates can cause bone or muscle pain. 2) It can cause irritation of the upper GI mucosa, which is why patients should take it w/ a full glass of water and remain upright for at least 30 minutes following administration. 3) Bisphosphanates can cause hypocalcemia, so ensure patients have adequate calcium and vitamin D intake. 4) Bisphosphanates can cause osteonecrosis of the jaw.

Front 83

Diazepam

Back 83

1) CNS depression is a big concern. It can impair both physical and mental abilities. Due to CNS depression, use caution in patients w/ major depressive disorder or respiratory disease (respiratory depression can occur). Also exercise caution w/ elderly patients and patients at increased risk of falling. 2) Use caution in patients w/ Hx or potential for drug or alcohol abuse. 3) Use caution in renal or hepatic impairment.

Front 84

Carisoprodol

Back 84

1) CNS depression can occur, which can impair both physical and mental abilities. 2) Drug abuse is of concern. Use w/ caution in patients w/ a Hx of drug or alcohol abuse. 3) Tolerance and dependence can occur w/ long term use. 4) Avoid abrupt discontinuation after prolonged use. 5) Use w/ caution in the elderly. They may have decreased tolerance to carisoprodol due to anticholinergic effects, such as sedation and weakness. Carsioprodol is considered "high severity risk" in the elderly on the Beers list. 6) Use w/ caution in patients who have either renal or hepatic impairment.

Front 85

Promethazine

Back 85

1) Black Box Warning: Promethazine is contraindicated in children less than 2 years old b/c it can cause respiratory depression, which can be fatal. Use the lowest effective dose in patients who are greater than 2 years old. 2) Black Box Warning: Promethazine injection can cause severe irritation and tissue damage regardless of the route of administration. 3) May alter cardiac conduction. 4) Extrapyramidal symptoms may occur (pseudoparkinsonism, dystonic reactions, akathisia, tardive dyskinesia). 5) May cause anticholinergic effects (constipation, dry mouth, blurred vision, urinary retention). 6) Photosensitivity may occur.

Front 86

Memantine

Back 86

1) Use w/ caution in patients who have severe hepatic or renal impairment. 2) Use w/ caution in patients who have a Hx of seizures.

Front 87

Potassium Chloride

Back 87

1) Hyperkalemia can occur. Symptoms include muscle weakness or paralysis; leg cramps; and cardiac conduction abnormalities, including heart block and arrhythmias. 2) Use w/ caution in patients who have CV disease due to the possibility of cardiac conduction abnormalities. 3) Use with caution in renal impairment (avoid use if the impairment is severe).

Front 88

Citalopram

Back 88

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It can inhibit platelet aggregation, which can lead to an increased bleeding risk, which is especially important in patients taking NSAIDs or other anticoagulants. 3) Serotonin syndrome can develop: symptoms include agitation or restlessness, diarrhea, fast heart beat, hallucinations, increased body temperature, loss of coordination, nausea, overactive reflexes, rapid changes in blood pressure, vomiting, and sexual dysfunction. 4) Use w/ caution in patients who have a history or an increased risk of seizures, such as alcoholics and those who have had brain damage. 5) Taper slowly to avoid withdraw syndrome: symptoms include anxiety, confusion, headache, lethargy, insomnia, and seizures.

Front 89

Meloxicam

Back 89

1) Black Box Warning (CV Events): Increased risk of CV events w/ prolonged use or in the presence of CV disease or CV risk factors. Due to CV risk, use is contraindicated for the treatment of perioperative pain due to coronary artery bypass graft (CABG). 2) Black Box Warning (GI Events): NSAIDs increase risk of GI irritation, ulceration, and GI bleeding. Use caution w/ the following: a) concurrent ASA therapy, b) corticosteroids or anticoagulants, c) patients who have GI complications, d) patients who smoke or drink excess alcohol, and e) elderly patients. If meloxicam is being used in any of these situations, consider also giving a PPI to decrease the risk of GI complications. 3) Use w/ caution in hepatic impairment. 4) Use w/ caution in renal impairment. NSAIDs cause constriction of the afferent arteriole of the kidneys, which can decrease renal function. Use is not recommended if CrCL < 15 mL/min. Use w/ caution in heart failure (HF), dehydration, elderly, and patients on diuretics or ACE inhibitors due to increased risk of renal dysfunction. 5) Use caution in HTN. Can cause HTN and decrease response to diuretics and ACE inhibitors (mainly due to NSAIDs effect on the kidneys). 6) The elderly are at increased risk of ADRs.

Front 90

Latanoprost

Back 90

1) Latanoprost, over time, can increase the brown pigmentation of the iris, eyelids, and eyelashes as well as increase the length or number of eyelashes. 2) Contacts should be removed prior to administration and wait at least 15 min after administration before reinserting.

Front 91

Carvedilol

Back 91

1) Hypotension can occur, especially upon initial treatment. 2) Use w/ caution in patients who have diabetes. Carvedilol can mask the signs and symptoms of hypoglycemia, except sweating (and hunger?). 3) Avoid abrupt withdrawal b/c it can cause reflex tachycardia, HTN, or ischemia.

Front 92

Oxycodone

Back 92

1) Black Box Warning(s): Oxycodone should not be used on an "as-needed" basis for analgesia or for postoperative pain management. Oxycodone should not be crushed, broken, or chewed. Abuse potential should be considered and healthcare providers should be alert to problems or signs of misuse, abuse, and diversion. Use w/ strong 3A4 inhibitors can prolong the effect of oxycodone, which may lead to severe or even fatal respiratory depression. 2) CNS depression is of concern, which may impair mental and physical abilities, especially w/ initial therapy. 3) Hypotension can occur, especially in patients who are hypovolemic or who have cardiovascular disease or who are on other drugs that can cause hypotension.

Front 93

Paroxetine

Back 93

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) Paroxetine can inhibit platelet aggregation, which can increase the risk of bleeding. Use w/ aspirin, NSAIDs, or Warfarin can increase bleeding risk. 3) Serotonin Syndrome can occur. Symptoms include tachycardia, rapid changes in blood pressure, hallucinations, increased body temperature, loss of coordination, overactive reflexes, and N/V/D.

Front 94

Olmesartan/Hydrochlorothiazide

Back 94

Olmesartan: 1) Black Box Warning (Pregnancy): Drugs affecting the angiotensin system have been shown to cause injury or death to the fetus in the 2nd and 3rd trimesters, and should be discontinued as soon as pregnancy is detected. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) ARBs can cause hypotension. Use caution at the initiation of therapy, especially in patients who are volume depleted or have HF. 4) ARBs can lead to renal dysfunction, especially in patients with prior renal dysfunction or decreased renal blood flow. Monitor SrCr, and if it increases > 35% over baseline, then temporarily discontinue losartan at least until renal function is back to normal. 5) Use w/ caution if any of the following are present: a) renal artery stenosis or any other renal impairment, b) hepatic impairment, c) volume depletion, and d) hyponatremia. HCTZ: 1) Use caution in patients who have a HX of diabetes, as HCTZ can alter glucose control. 2) Use caution in patients who have a history of gout. HCTZ can precipitate a gouty attack. 3) Use caution in patients who have hepatic or renal impairment. HCTZ is not effective in patients who have severe renal impairment (CrCL < 30 mL/min). 4) Use caution in patients who have hypokalemia (can cause hypokalemia).

Front 95

Tadalafil

Back 95

1) Chest pain/angina can occur. Patients should seek immediate medical attention if this is an issue. Use w/ caution in patients who have cardiovascular disease. 2) Hypotension can occur due to the vasodilatory effects and this effect can be increased when used w/ other medication that cause hypotension as well as w/ alcohol. 3) Priapism can occur and patients should seek medical attention if erection lasts longer than 4 hrs. 4) Lower the dose if the patient has hepatic impairment or renal impairment w/ a CrCL < 50 mL/min. 5) Vision loss and hearing loss have been reported in rare cases.

Front 96

Sitagliptin

Back 96

1) Acute pancreatitis has been reported w/ use. 2) Sitagliptin is not to be used in patients w/ T1DM.

Front 97

Ciprofloxacin

Back 97

1) Black Box Warning (Tendon Rupture): Fluoroquinolones can cause tendon inflammation or tendon rupture. Concurrent use w/ corticosteroids, older patients usually over 60 years of age, patients taking corticosteroids, and in patients w/ kidney, heart, or lung transplants Use caution in patients who have rheumatoid arthritis because of the risk fo tendon rupture. The most common site of tendon rupture is the achilles tendon. And ciprofloxacin should be discontinued at first sign of tendon inflammation. 2) Ciprofloxacin can cause altered cardiac conduction and prolonged QT interval. 3) Ciprofloxacin can cause CNS stimulation (restlessness, confusion, &/or tremors). Use w/ caution in patients who have seizure disorders. 4) Fluoroquinolones can increase the risk of hypoglycemia, especially in patients who have diabetes. 5) As w/ most antibiotics, prolonged use can result in superinfections, such as CDAD. 6) Ciprofloxacin may increase sensitivity to light, so caution patients to wear sunscreen and avoid prolonged direct exposure to sunlight.

Front 98

Amitriptyline

Back 98

1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. The reason is that antidepressants, in general, increase energy/appetite before they affect mood, giving patients the energy needed for suicide. 2) It is not approved for bipolar disorder and can cause a shift towards mania in patients who have bipolar disorder. 3) The risk of arrhythmias is high w/ amitriptyline, compared to other antidepressants. Use w/ caution in patients who have cardiovascular disease. 4) Use w/ caution in patients who have diabetes due to the potential for altered glucose regulation. 5) Use w/ caution in patients who have seizure disorders as amitriptyline may lower the seizure threshold.

Front 99

Naproxen

Back 99

1) Black Box Warning (CV Events): Increased risk of CV events w/ prolonged use or in the presence of CV disease or CV risk factors. Due to CV risk, use is contraindicated for the treatment of perioperative pain due to coronary artery bypass graft (CABG). 2) Black Box Warning (GI Events): NSAIDs increase risk of GI irritation, ulceration, and GI bleeding. Use caution w/ the following: a) concurrent ASA therapy, b) corticosteroids or anticoagulants, c) patients who have GI complications, d) patients who smoke or drink excess alcohol, and e) elderly patients. If naproxen is being used in any of these situations, consider also giving a PPI to decrease the risk of GI complications. 3) Use w/ caution in hepatic impairment. 4) Use w/ caution in renal impairment. NSAIDs cause constriction of the afferent arteriole of the kidneys, which can decrease renal function. Use w/ caution in heart failure (HF), dehydration, elderly, and patients on diuretics or ACE inhibitors due to increased risk of renal dysfunction. 5) Use caution in HTN. Can cause HTN and decrease response to diuretics and ACE inhibitors (mainly due to NSAIDs effect on the kidneys). 6) The elderly are at increased risk of ADRs. 7) Naproxen should definitely not be used late in pregnancy (> 31 wks) due to premature closure of the ductus arteriosus, which connects the pulmonary artery to the aortic arch in the fetus (to bypass the fluid-filled, non-functioning lungs).

Front 100

Niacin ER

Back 100

1) Truncal or facial flushing can occur. The dose is titrated gradually to help reduce flushing. Taking aspirin 325 mg or an NSAID, approximately an hour before administration, may also help if flushing is an issue. 2) Use w/ caution in patients w/ unstable angina or MI. Niacin can cause arrhythmias. 3) Use caution in patients who have gout. Niacin has been associated w/ hyperuricemia. 4) Although it appears to be rare, niacin may increase the risk of hyperglycemia in patients who have diabetes.

Front 101

Allopurinol

Back 101

1) Bone marrow suppression and reversible hepatotoxicity have been reported as side effects in rare cases. 2) Adjust the dose in renal impairment.

Front 102

Losartan/Hydrochlorothiazide

Back 102

Losartan: 1) Black Box Warning (Pregnancy): Drugs affecting the angiotensin system have been shown to cause injury or death to the fetus in the 2nd and 3rd trimesters, and should be discontinued as soon as pregnancy is detected. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) ARBs can cause hypotension. Use caution at the initiation of therapy, especially in patients who are volume depleted or have HF. 4) ARBs can lead to renal dysfunction, especially in patients with prior renal dysfunction or decreased renal blood flow. Monitor SrCr, and if it increases > 35% over baseline, then temporarily discontinue losartan at least until renal function is back to normal. 5) Use w/ caution if any of the following are present: a) renal artery stenosis or any other renal impairment, b) hepatic impairment, c) volume depletion, and d) hyponatremia. HCTZ: 1) Use caution in patients who have a HX of diabetes, as HCTZ can alter glucose control. 2) Use caution in patients who have a history of gout. HCTZ can precipitate a gouty attack. 3) Use caution in patients who have hepatic or renal impairment. HCTZ is not effective in patients who have severe renal impairment (CrCL < 30 mL/min). 4) Use caution in patients who have hypokalemia (can cause hypokalemia).

Front 103

Tolterodine

Back 103

1) CNS effects may occur, including drowsiness, blurred vision, and impairment of physical and mental abilities. Use caution, especially w/ initiation of therapy. 2) Use w/ caution in patients who have bladder flow obstructions or gastrointestinal obstructive disorders. 3) Use w/ caution in patients who have myasthenia gravis.

Front 104

Lisinopril/Hydrochlorothiazide

Back 104

Lisinopril: 1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ACE inhibitors can cause angioedema at any time during therapy. African Americans are at increased risk of developing angioedema. 3) Due to the buildup of bradykinin, ACE inhibitors can cause chronic cough. It is a dry, unproductive cough, usually seen within the first months of therapy, and it should resolve within a month of discontinuation. If cough becomes intolerable to the patient, try switching to an angiotensin receptor blocker, as ARBs are much less likely to cause cough. 4) ACE inhibitors can cause hyperkalemia. Risk of hyperkalemia increases w/ renal dysfunction, diabetes mellitus, and use of potassium-sparing diuretics or potassium supplements. DC if serum creatinine increases to > 35% over baseline. 5) Hypotension may occur, especially w/ initial therapy. The risk is higher in volume depleted patients. If hypotension is an issue, decrease the dose. HCTZ: 1) Use caution in patients who have a HX of diabetes, as HCTZ can alter glucose control. 2) Use caution in patients who have a history of gout. HCTZ can precipitate a gouty attack. 3) Use caution in patients who have hepatic or renal impairment. HCTZ is not effective in patients who have severe renal impairment (CrCL < 30 mL/min). 4) Use caution in patients who have hypokalemia (can cause hypokalemia).

Front 105

Norgestimate & Ethinyl Estradiol

Back 105

1) Black Box Warning: Smoking cigarettes while taking oral contraceptives increases the risk of serious cardiovascular events. The risk is increased w/ increased age > 35 years old and increased number of cigarettes > 15 cig/day. 2) Oral contraceptives can increase the risk of thromboembolism. Use w/ caution in patients who are at increased risk of VTE. Note: The risk of thrombosis w/ any oral contraceptive is less than the risk of thrombosis during pregnancy. 3) Use of oral contraceptives slightly increases the risk of breast cancer. 4) Use w/ caution in women who are at increased risk of cardiovascular complications. All oral contraceptives can increase blood pressure to some extent. 5) Use w/ caution in patients who have a Hx of migraines as well as patients w/ depression.

Front 106

Penicillin VK

Back 106

1) Hypersensitivity can be severe. Use w/ extreme caution in patients who have had a previous allergic reaction to a beta-lactam antibiotic, which includes the penicillins, cephalosporins, and carbapenems. 2) Prolonged use can lead to severe infections, such as CDAD. This is a caution w/ any antibiotic and is one of the reasons antibiotics should be used at the lowest effective dose for the shortest duration. 3) Use w/ caution in renal impairment. Adjust the dose if CrCL < 50 mL/min. 4) Use w/ caution in patients who have a seizure disorder. Increased levels of penicillin may increase the risk of seizures.

Front 107

Codeine & Guaifenesin

Back 107

1) CNS depression can occur, which can impair both physical and mental abilities. 2) Use w/ caution in patients who have respiratory depression, COPD, or other obstructive pulmonary diseases. 3) Use w/ caution in patients who have a Hx of drug abuse or alcoholism. 4) Use w/ caution in patients who have severe renal or hepatic impairment.

Front 108

Glyburide

Back 108

1) Hypoglycemia. Review signs and symptoms of hypoglycemia w/ the patient. 2) Use w/ caution in elderly patients. They are more sensitive to side effects, especially hypoglycemia. 3) Use w/ caution in patients w/ a sulfonamide allergy. This includes medications such as thiazide and loop diuretics as well as carbonic anhydrase inhibitors. Avoid use if the patient has had a previous severe reaction. 4) The micronized tablets are not interchangeable w/ the regular tablets.

Front 109

Fluticasone Inhaler

Back 109

1) Adrenal suppression can occur. It is seen more commonly in younger children or patients on high doses for long periods of time. Because of this, corticosteroids should be used at the lowest effective dose and should be tapered to discontinue after long term use. 2) Immunosuppression can occur w/ long term use. 3) Use w/ caution in heart failure. long term use may lead to fluid retention as well as HTN. 4) Use w/ caution in diabetes. 5) Patients should rinse their mouth out after each use to prevent oral candida infection, a.k.a. thrush.

Front 110

Rabeprazole

Back 110

Use of PPIs may increase the risk of pneumonia, GI infections, as well as osteoporosis risk fractures. The risk is greater in patients > 50 yo and w/ use of rabeprazole for long periods of time ( > 1 yr).

Front 111

Lisdexamfetamine

Back 111

1) Black Box Warning (CV Events): CNS stimulants have been associated w/ CV events, such as MI, stroke, or sudden death, in patients who have pre-existing structural cardiac abnormalities or serious heart problems. 2) Black Box Warning (Drug Abuse): There is a potential for dependency and prolonged use may lead to drug dependency. 3) Lisdexamfetamine should be used as part of a comprehensive treatment program for ADHD. 4) HTN is a potential side effect. Use w/ caution in patients who have HTN or other cardiovascular conditions. 5) Use w/ caution in patients who have psychiatric disorders. Lisdexamfetamine may exacerbate symptoms in such patients. 6) Use w/ caution in patients who have a seizure disorder. Lisdexamfetamine can lower the seizure threshold, which can increase seizure activity. Discontinue if seizures occur.

Front 112

Isosorbide Mononitrate

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1) Hypotension and bradycardia can occur. Ethanol increases the risk. Use w/ caution in patients who have low blood pressure. 2) Tolerance can occur. Tolerance can be overcome by short periods of nitrate absence or withdrawal. This is the reason the twice daily doses should be taken approximately 7 hrs apart (so there is a longer period w/o nitrates in the body). Tolerance cannot be overcome by increasing the dose.

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Lamotrigine

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1) Black Box Warning (Skin Rashes): Severe skin rashes have been reported. Risk may be increased by high starting doses, rapid titration, and use w/ valproic acid. The majority of cases occur within the 1st 8 wks of therapy. 2) Blood dyscrasias, such as neutropenia, leukopenia, thrombocytopenia, etc., have been reported. Early detection is important and patients w/ a Hx of adverse hematologic reactions w/ any drug may be at increased risk. 3) CNS depression can occur, which can impair both physical and mental abilities. 4) Use w/ caution in patients w/ cardiovascular disease, hepatic impairment, or renal impairment. 5) Increase in suicidal ideation can occur, especially during initial therapy. 6) Do not withdrawal abruptly due to potential increase in seizure frequency. To discontinue, taper over at least 2 wks when possible. 7) Drug induced aseptic meningitis can occur. It is very rare and is reversible upon discontinuation.

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Olanzapine

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1) Black Box Warning: Antipsychotics increase the risk of death, due to cardiovascular complications or infections, in elderly patients who have dementia-related psychosis. Hence olanzapine is not approved for dementia-related psychosis. 2) Olanzapine may alter cardiac conduction, which can lead to life threatening arrhythmias. However, olanzapine has a lower risk of cardiac problems compared to many other atypical antipsychotics. 3) Blood dyscrasias can occur, including leukopenia, neutropenia, and agranulocytosis. Monitor blood count periodically in patients w/ pre-existing risk factors, such as low WBC count or a Hx of drug-induced blood dyscrasia. Discontinue therapy if absolute neutrophil count drops below 1000/mm^3. 4) Extrapyramidal symptoms (EPS) may occur, including pseudoparkinsonism, dystonic reactions, akathisia, and tardive dyskinesia. The risk is increased w/ higher doses, use w/ younger patients or male patients, or use with typical antipsychotics. 5) Hyperglycemia can develop, so use caution in patients who have diabetes. This risk may be higher w/ olanzapine compared to other atypical antipsychotics. 6) Hyperlipidemia may occur, so use w/ caution in patients who have high cholesterol. 7) Weight gain can occur, so consider switching to another antipsychotic if weight gain is > 5% over baseline. Aripiprazole (Abilify), lurasidone (Latuda), asenapine (Saphris), and ziprasidone (Geodon) are good alternatives if weight gain is an issue. 8) Use caution in hepatic or renal impairment.

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Lovastatin

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1) Dose-related risk of myopathy, increased w/ concurrent use of 3A4 inhibitors, fibric acid derivatives, such as gimfibrozil, or niacin at doses > 1 g/day. Elderly are at increased risk of myopathy. Recheck CPK upon report of unexplained muscle soreness and discontinue if CPK levels are greater than 10 times the upper limit of normal. Rhabdomyolysis can result in acute renal failure if not controlled. 2) Hepatic Impairment: Since statins can cause liver dysfunction, use w/ caution in patients who have a Hx of liver impairment or who consume large amounts of alcohol. Check LFTs at baseline, 3 wks later, then semiannually. Discontinue if LFTs increase to > 3 times upper limit of normal.

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Ethinyl Estradiol & Etonogestrel Vaginal Ring

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1) Black Box Warning: Smoking cigarettes while taking oral contraceptives increases the risk of serious cardiovascular events. The risk is increased w/ increased age > 35 years old and increased number of cigarettes > 15 cig/day. 2) Hormonal contraceptives can increase the risk of thromboembolism. Use w/ caution in patients who are at increased risk of VTE. Note: The risk of thrombosis w/ any hormonal contraceptive is less than the risk of thrombosis during pregnancy. 3) Use of hormonal contraceptives slightly increases the risk of breast cancer. 4) Use w/ caution in women who are at increased risk of cardiovascular complications. All hormonal contraceptives can increase blood pressure to some extent. 5) Use w/ caution in patients who have a Hx of migraines as well as patients w/ a Hx of depression.

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Bupropion

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1) Black Box Warning (Suicidal Ideation): Antidepressants can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 - 24 yo) who have major depressive disorder or other psychiatric disorders. Bupropion is not approved for children or for bipolar depression. Observe patients for suicidal ideology, especially during the 1st few months of therapy. 2) Black Box Warning: Use of bupropion has been associated w/ serious neuropsychiatric events, including depression, suicidal thoughts, and suicide. 3) Risk of seizures is dose-dependent and is increased in patients w/ a Hx of seizures, anorexia/bulimia, head trauma, CNS tumor, hepatic cirrhosis, abrupt discontinuation of sedatives (including alcohol), use w/ other medications that lower the seizure threshold, stimulants, or anti-diabetic agents. 4) CNS stimulation can occur, which can lead to restlessness, anxiety, insomnia, or anorexia. 5) Bupropion can impair physical and mental abilities. Warn patients to use caution, especially w/ initial therapy. 6) Weight loss can occur. Use w/ caution in patients in which weight loss would not be favorable. 6) Use w/ caution in patients w/ cardiovascular disease, renal impairment, or hepatic impairment.

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Doxycycline

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1) Tissue hyperpigmentation can occur, including nails, skin, eyes, teeth, and many inner organs. 2) Can cause a dose-related increase in BUN. 3) Rarely, hepatotoxicity can occur.

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Enalapril

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1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ACE inhibitors can cause angioedema at any time during therapy. African Americans are at increased risk of developing angioedema. 3) Due to the buildup of bradykinin, ACE inhibitors can cause chronic cough. It is a dry, unproductive cough, usually seen within the first months of therapy, and it should resolve within a month of discontinuation. If cough becomes intolerable to the patient, try switching to an angiotensin receptor blocker, as ARBs are much less likely to cause cough. 4) ACE inhibitors can cause hyperkalemia. Risk of hyperkalemia increases w/ renal dysfunction, diabetes mellitus, and use of potassium-sparing diuretics or potassium supplements. DC if serum creatinine increases to > 35% over baseline. 5) Hypotension may occur, especially w/ initial therapy. The risk is higher in volume depleted patients. If hypotension is an issue, decrease the dose. 6) Use w/ caution in patients who have pre-existing renal impairment.

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Irbesartan

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1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ARBs can cause hyperkalemia. Monitor serum potassium and use caution in patients who have diabetes or renal dysfunction or who use other drugs that also increase potassium, such as ACE-Is, potassium sparing diuretics, or potassium supplements. 3) Valsartan can cause hypotension. So use w/ caution at initiation of therapy, especially in patients who are volume depleted or have heart failure. 4) Use of ARBs can lead to renal dysfunction, especially in patients who have prior renal dysfunction or decreased renal blood flow. Use caution in patients who have hepatic impairment, renal impairment, or bilateral renal artery stenosis. Monitoring renal function: check serum creatinine at baseline and again in 4 wks. If serum creatinine increases > 35% over baseline, then discontinuevalsartan at least until renal function is back to normal.

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Amphetamine & Dextroamphetamine

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1) Black Box Warning (CV Events): CNS stimulants have been associated w/ CV events, such as MI, stroke, or sudden death, in patients who have pre-existing structural cardiac abnormalities or serious heart problems. 2) Black Box Warning (Drug Abuse): There is a potential for dependency and prolonged use may lead to drug dependency. 3) Lisdexamfetamine should be used as part of a comprehensive treatment program for ADHD. 4) HTN is a potential side effect. Use w/ caution in patients who have HTN or other cardiovascular conditions. 5) Use w/ caution in patients who have psychiatric disorders. Lisdexamfetamine may exacerbate symptoms in such patients. 6) Use w/ caution in patients who have a seizure disorder. Stimulants can lower the seizure threshold, which can increase seizure activity. Discontinue if seizures occur.

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Ibandronate

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1) Bisphosphanates can cause bone or muscle pain. 2) It can cause irritation of the upper GI mucosa, which is why patients should take it w/ a full glass of water and remain upright for at least 60 minutes following administration. 3) Bisphosphanates can cause hypocalcemia, so ensure patients have adequate calcium and vitamin D intake. 4) Bisphosphanates can cause osteonecrosis of the jaw.

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Eszopiclone

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1) Eszopiclone can cause CNS depression, behavioral changes, as well as increased risk of sleep walking or sleep driving. Hence it should only be taken right before bed when one can get a full night's sleep. 2) Rare cases of angioedema have been reported in patients after taking the frist or subsequent doses of sedative-hypnotics, including eszopiclone.

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Ipratropium & Albuterol Inhaler

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1) Although rare, paradoxical bronchospasm can occur w/ inhaled beta agonist. This is something to be aware of if the patient seems to get worse w/ use of their inhaler. 2) Immediate hypersensitivity reactions can occur and should be monitored for w/ initial therapy. 3) Beta agonists can cause CNS excitation. Use w/ caution in patients w/ a Hx of seizures or CV conditions, such as HTN or HF. 5) Beta agonists can increase serum glucose. 6) Use w/ caution in patients having benign prostatic hyperplasia (BPH) or bladder neck obstruction. Ipratropium can potentially exacerbate the condition.

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Folic Acid

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1) Folic acid should not be used as monotherapy for pernicious, aplastic, or normocytic anemias if there is a vitamin B12 deficiency. 2) The injection solution contains the preservative benzyl alcohol (1.5%), which has been associated w/ "gasping syndrome" in neonates.

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Meclizine

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1) CNS depression may occur, which can lead to impairment of physical and mental abilities. 2) Use caution in patients who have asthma, narrow angle glaucoma, BPH or urinary stricture, and pyloric or duodenal obstruction. All of these conditions may be exacerbated by meclizine. 3) Use w/ caution in elderly patients, who may be more sensitive to the adverse effects, and children < 12 yo, with whom safety and efficacy has not been established.

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Ethinyl Estradiol & Norethindrone

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1) Black Box Warning (Dementia): Risk of dementia is increased in postmenopausal women, especially women 65 years old or older. 2) Black Box Warning: Estrogens, w/ or w/o protestin, should not be used to treat or prevent coronary heart disease. 3) Black Box Warning: Smoking cigarettes while taking oral contraceptives increases the risk of serious cardiovascular events. The risk is increased w/ increased age > 35 years old and increased number of cigarettes > 15 cig/day. Oral contraceptives can increase the risk of thromboembolism. Use w/ caution in patients who are at increased risk of VTE. Note: The risk of thrombosis w/ any oral contraceptive is less than the risk of thrombosis during pregnancy. 5) Use of oral contraceptives slightly increases the risk of breast cancer. 6) Use w/ caution in women who are at increased risk of cardiovascular complications. All oral contraceptives can increase blood pressure to some extent. 7) Use w/ caution in patients who have a Hx of migraines as well as patients w/ depression.

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Buprenorphine & Naloxone

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1) May cause CNS depression, which can impair physical and mental abilities. 2) Hepatic events have been reported w/ buprenorphine use, including hepatitis and increased LFTs. Use w/ caution in patients w/ pre-existing liver dysfunction. Get baseline LFTs and test periodically throughout therapy. 3) Also use w/ caution in patients who have adrenal insufficiency, biliary tract dysfunction, bowel obstruction, alcoholism, benign prostatic hyperplasia, psychosis, thyroid dysfunction, as well as respiratory disease.

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Raloxifene

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1) Black Box Warning: Raloxifene may increase the risk of DVT or PE. Use is contraindicated in patients w/ current or Hx of venous thromboembolism. 2) Black Box Warning: Raloxifene may increase risk of death due to stroke in women w/ coronary heart disease or risk of such events. 3) Use w/ caution in patients who have hepatic and/or renal impairment. 4) Triglycerides may be increased, especially if patients had increased TGs in response to oral estrogens in the past.

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Omega-3-Acid Ethyl Esters

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The ethyl esters of omega-3 fatty acids may be obtained from the oil of several fish sources. It is not known whether patients w/ allergies to fish and/or shellfish are at increased risk of allergic reaction, so use w/ caution in patients w/ a known hypersensitivity to fish and/or shellfish.

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Lidocaine Patch 5%

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1) Use caution in patients having hepatic impairment. Decreased ability to metabolize lidocaine, due to hepatic impairment, increases the risk of toxic blood concentrations developing. 2) Do not apply the patch to broken or inflamed skin. 3) External heat sources, such as heading pads, should not be used over lidocaine patches as they may increase plasma lidocaine levels.

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Ramipril

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1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ACE inhibitors can cause angioedema at any time during therapy. African Americans are at increased risk of developing angioedema. 3) Due to the buildup of bradykinin, ACE inhibitors can cause chronic cough. It is a dry, unproductive cough, usually seen within the first months of therapy, and it should resolve within a month of discontinuation. If cough becomes intolerable to the patient, try switching to an angiotensin receptor blocker, as ARBs are much less likely to cause cough. 4) ACE inhibitors can cause hyperkalemia. Risk of hyperkalemia increases w/ renal dysfunction, diabetes mellitus, and use of potassium-sparing diuretics or potassium supplements. DC if serum creatinine increases to > 35% over baseline. 5) Hypotension may occur, especially w/ initial therapy. The risk is higher in volume depleted patients. If hypotension is an issue, decrease the dose. 6) Use w/ caution in patients who have pre-existing renal impairment.

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Benazepril

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1) Black Box Warning (Pregnancy): Drugs that affect the angeotension system have been shown to cause injury or death to the fetus in the 2nd or 3rd trimesters. 2) ACE inhibitors can cause angioedema at any time during therapy. African Americans are at increased risk of developing angioedema. 3) Due to the buildup of bradykinin, ACE inhibitors can cause chronic cough. It is a dry, unproductive cough, usually seen within the first months of therapy, and it should resolve within a month of discontinuation. If cough becomes intolerable to the patient, try switching to an angiotensin receptor blocker, as ARBs are much less likely to cause cough. 4) ACE inhibitors can cause hyperkalemia. Risk of hyperkalemia increases w/ renal dysfunction, diabetes mellitus, and use of potassium-sparing diuretics or potassium supplements. DC if serum creatinine increases to > 35% over baseline. 5) Hypotension may occur, especially w/ initial therapy. The risk is higher in volume depleted patients. If hypotension is an issue, decrease the dose. 6) Use w/ caution in patients who have pre-existing renal impairment.

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Verapamil

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1) Hypotension may occur. Caution patients to go slowly from lying or sitting to standing. 2) When heart failure is not severe or rate related, it should be controlled w/ digitalis glycosides and diuretics before verapamil is used. In patients w/ moderately severe to severe cardiac dysfunction, acute worsening of heart failure may be seen.

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Ranitidine

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1) Use w/ caution in renal or hepatic impairment. 2) Avoid use of ranitidine in patients who have a Hx of acute porphyria, as it may precipitate an acute porphyric attack.