*** ANTICHOLINERGIC :

Uses: to reduce secretions, Death Rattle, colic, bladder spasms, sleep, to produce urinary retention, to prevent EPS (extra pyramidal SE) ** Atropine ** Scopolamine ** Benadryl ** Cogentin • SE: dry mouth, confusion, agitation, ataxia, dizziness, delirium, bradycardia, photophobia, constipation, urinary retention


*** CONTICOSTEROID

:

USE: • Superior vena caval syndrome (Decadrone 8mg/d) • Upper Airway obstruction • With radiation or chemo-therapy • Bowel obstruction • Carcinomatous lymphangitis • lymphadema • Malignant effusion • Hemoptysis • Discharge from a rectal tumor • Raised intra cranial pressure secondary to tumor (high dose Decadrone 16mg/d) • Painful compressive Neuropathy • Bony metastases • Spinal cord compression • Hepatomegaly • vomiting due to Pyloric stenosis resistance to other meds • to improve appetite • Hypercalcemia • Excessive sweating: Prednisone up to 20mg/day in divided doses • Prednisone 7:1 ratio to Decadron (prednisone 30mg = Decadrone 4mg) • If no benefit after 7-10 days, then discontinue • after prolong use decrease steroids slowly (Decadron 2mg/week) • Dysphagia (esophageal cancer) • Dyspnea SE: • Peptic ulcer disease and hemorrhage rare • Infections • Tuberculosis: no difference in incidence • Oral candidiasis *Rx: ** nystatin, ** Mycelex ** ketoconazole: • Hyper-glycaemia • Euphoria and restlessness • manic depression • increased appetite • insomnia • psychosis: *Rx symptomatically • Avascular necrosis (femoral or humeral head) in 6 months • Adrenocortical atrophy in 16 months • gastric irritation • facial swelling • easy bruising • edema • weakness (potassium depletion, proximal sympathy) • hair growth • acne


***Morphine

About 100 trade names, opioid analgesic,

Uses:

Moderate to severe pain, most effective in Nociceptive pain, severe breathlessness, acute pulmonary edema, cough, diarrhea

Pointers:

*Contraindications: Proven allergic to morphine & codeine. Nausea / vomiting / hallucinations are not a contraindication.

*Lower dosage in hepatic / renal failure.  Parenteral use avoid first pass metabolism. No ceiling dose but typical Morphine dose is < 200 mg /d. Oral to parenteral ratio is 3:1.  The SC dose is 1/3 of oral dose. Oral to rectal the dose is same 1:1. Kadian /Avinza long acting Opioids are bioequilanat (mg to mg same), open capsule sprinkle / tube but do not chew or crush or dissolve.

*Rifampin Ô morphine; additive with CNS depressants; prokinetic effects of Metoclopramide antagonized by opioids.

*Stimulate mu receptors, descending inhibitory & medulary center of the brain.

*oral onset 30 minutes; Peak: oral 1 hr; IM 30 minutes; SC 6 minutes; Duration oral / SC 4-5 hours

Side effects:

Constipation 90%. Nausea / vomiting: first few days up to 5, responds to Haloperidol, Metoclopramide. Dose / duration dependent sedation, drowsiness, dry mouth, dizziness visual accommodation problems. Rotating to another opioid if needed. Respiratory depression: rare, happens only with inappropriately large doses. Side effects occur in sequential manner: drowsiness, confusion, loss of consciousness before respiratory depression.  Keep sedation score of less than 2: 0=wide awake, 1=easily wakes up, 2=unable to stay awake, 3=difficult to arouse.  Opioid naïve: start low, go slow, start short acting opioid in smaller dosage 2.5 mg Morphine IR q 4 hrs titrated to effect. Sublingual morphine is most likely absorbed through GI rather than oral mucosa. Not a very good buccal nor sublingual medication. If use buccal use soluble tab or concentrated oral sol.

Supply:   IR tab 15, 30 mg;   liq 20 mg/ml ;

MS contin 15, 30, 60, 100mg

Rx :

  1. Cough / breathlessness : start low 2.5-10 mg q 4 hrs
  2. Pain :  start low, go slow in opioid naïf patients
  3. opioids have no ceiling

Xanax (Alprazolam)


Phenobarbitol (Phenobarb)

Uses :Control terminal seizures; Sedation; Agitation refractory to other meds in end of life; Adjuvant in pain due to CNS origin; Epilepsy

Pointers

tablet may be crushed dilute inj in 10 times in water

HL 2-6 days so can be given as single dose as HS, anticonvulsant therapeutic level 15-40 mcg/L bioavailability 70-90%,

IV onset 5 min, duration 4-6 hrs, peak 8-12 hrs

inactive metabolized by liver, excreted major in urine

Side effects

resp depression (IV), ataxia, dizziness, drowsiness, confusion,

Available

Tab 15, 30, 60, 100 mg. Elixer 20 mg/5 ml. Inj 30,60,65,130 mg/ml

Rx

Loading : 20 mg/kg/dose oral, IV, IM, SQ at 25-60 mg/min max 1200 mg/24 hrs maintenance for seizures 1-3 mg/kg/d PO/IV div bid or tid sedation: 30-120 mg/d divided BID / TID max 400 mg/d Hypnotic / insomnia : 100-200 mg/ HS  (max 400 mg/d)


Adrenaline
Epinephrine
Uses
minimal external bleed
skin
cardiac arrest
anaphylaxis
bronchospasm
Rx:
Soak gauze in 1:1000, apply directly to bleeding points with little pressure
Anaphylaxis : 0.3 – 0.5 mg SC or IM 1:1000 (Epipen)
use in Asthma, COPD (half dose in CAD patients)


Arthrotec (diclofenac 50 mg + Misoprostrol 200 mcg)

musculoskeletal & bony pain
whenever you need NSAIDs

supply 50 mg 1tab bid / tid; 75 mg 1 tab bid
less GI side effects due GI protectio due to Misoprostrol (Cytotec)


Amitriptyline (Elavil)

Uses: :
Neuropathic pain
Depression
Insomnia
Postherpetic Neuralgia
Migraine prophylaxis
Eating disorder
Pointers:
effective in 3 weeks
sleep / appetite precedes analgesic effects
half life 9-27 hrs; metabolized by hepatic, renally excr 18%, small amounts excreted in feces
avoid in elderly due to side effects
Side effects:
constipation, drowsiness, dry mouth, confusion, inc sleep, inc appetite. QT prolongation, hypotension,
Available:
available:Tab 10, 25, 50, 75, 100, 150 mg. Oral Sol 25 mg/5 ml; 50 mg /5 ml
Rx
10-25 mg hs; 100-300 mg po / d as hs


Baclofen (Lioresol)

Uses: Chronic intense muscle spasm, spasticity, Neuropathic pain (3 rd line), Trigeminal neuralgia, Dystonia
Pointers:
avoid abrupt withdrawal
duration 4-8 hrs, onset 3-4 days; peak 2-3 hrs; peak effect 5-10 days; HL 2.5 -4 hrs; 70-80% excreted in urine; 30% protein bound
no sig benefits in stroke
dose reduction in renal failure
Side effects:
drowsiness, dizziness, nausea, headache, confusion
Supply:
tab 10, 20 mg
Rx
start 5 mg tid increase slowly to 60 mg/d in divided dosage (max 100 mg/d)


Carbamazepine (Tegretol)

Anticonvulsant
Uses: Epilepsy, Trigeminal neuralgia, bipolar, neuropathic pain, RLS
Caution: bone marrow supression, reduce doses in renal / hepatic impairment
Pointers:
CYP 450 enzyme:
inc Carbamazepine level by inhibitors: Cimetidine, Conazoles, Fluoxetine, Haloperidol, Octeriotide, Risperidone
decrease effects of Alprazolam, Amitriptyline, Clonazepam, Dexamethasone, Flecanide, Haloperidol, Methadone, Warfarin,
Serotonin crises with SSRIs
hepatotoxic with Acetaaminophine
monitor plasma concentration
Supply:
Chewable 100 mg
Tab 200 mg
Oral susp 100 mg / 5ml
Rx:
800-1200 mg / d in divided dosage, follow the level


Decadron (Dexamethasone)

Anti-inflammatory
Uses: tumors: compression / swelling / obstruction; Headaches due inc intracranial pressure; brain mets; Analgesic : nerve / spinal cord compression; Antiemetic: N/V due to chemo; other tumors; improve appetite : anorexia, cachexia,
Pointers:
use in spinal cord compression, Superior Venacaval obs, bony pain, some causes dyspnea
Dexamethasone 1 mg = 7 mg of Prednisone
side effects : weight gain, Cushingoid, diabetes, osteoporosis, muscle wasting, peptic ulcer, agitation, avoid in delirium
Available:
tab: 1, 2, 4, mg; elixir 0.5 mg/5 ml; oral concentrate 1 mg/1ml; inj 4 mg / ml or 10 mg /ml
Rx:
Inflammation : oral / inj 0.75 mg – 9 mg /d
Brain mets: 10 mg IV then 4 mg IM q 6hrs reduce in 2-4 days to d/c
Allergic reaction: 4-8 mg reduce 1-2 mg every 2 days to d/c
Chemo induce N/V : 8-12 mg PO/IV with / without antiemetic before chemotherapy 8 mg /d for 1-3 days
acute mountain sickness: 2-4 mg q 6hrs then reduce 50 % for 2-3 days on the same elevation
spinal cord compression: 10-100 mgIV then 4-24 mg IV q 6 hrs then tapered
Anorexia: 1-2 mg po q 8 hrs


Fluconazole

Diflucan)

Antifuncal, impairs Ergosterol
Uses:
Fungal infection, Candidiasis,
Caution:
normal initial dose but adjust according to creatinin
no dose adjustment needed in hepatic failure
Pointers:
metabolized by CYP 450 system, clinical sig is generally low, so use this in appropriate patient
Disulfiram-like effect with alcohol
inc effect/concentration of : Alprazolam,Amitriptyline, Carbamazepine, Diazepam, Fentanyl, Methadone, Nortriptyline, Oxybutynin, Oxycodone, Phenytoin, prednisone, Venlafaxine, Warfarin
less severe interaction than Ketoconazole
peak 0.5-2 hrs, HL (half life) around 30 hrs,
Side effects:
GI upset, headache, rash (stop med), arrythmias, vlood disorder, convulsions, hypokalemia, dizziness
Available: 50, 100, 150, 200 mg
Rx:
Vaginal candidiasis: 150 mg single dose
oropharyngeal candidiasis : 200 mg first day then 100 mg /d for 14 days
Esophageal Candidiasis: ame as above but need for 3 weeks


Haldol

(Haloperidol)

uses: Agitation; hallucination; psychosis; nausea; vomiting (due to metabolic or unknown; difficult to manage); Restless; confusion; intractable hiccups
Pointers:
D1 & D2 receptor antagonist (dopamine antagonist)
typical antipsychotic
metabolized by hepatic P 450, CYP3A4, multiple interactions
Metabolites: HYDROXYHALOPERIDOL
inhibits CYP2D6, 92% protein bound
HL 10-20 hrs, excretion 30% in urine, 15% in feces
long acting inj Deconoate 3 weeks
Side effects:
Akathesia, Parkinsonism, Tardive dyskinesia, Anticholinergic
Availabe:
tab: 0.5,1,2,5,10,20 mg. oral concentrate: 5 mg/ml
inj : 50 mg/ml, 100 mg/ml
Rx : start low: 0.5 – 2 mg q 1-4 hrs prn. later 3-5 mg q 8hrs max 30 mg/d (max ever used 100 mg/d)

 

*** HALDOL

 

: non-sedating anti-emetic or anxiolytic • calm a severely agitated person •use it in terminal delirium as early as possible ** Haldol: Uses: psychosis, agitation, combativeness, pain, nausea, intractable vomiting, pelvic-abdominal radiation induced pain & discomfort • Haldol: available in tabs / concentrated liquid/IM, absorbed sublingually, less sedative, less anticholinergic, minimal cardiac/CNS side effects, long acting.


Hyocyamine  sulphate (Levsin)

Parasympatholytic (Atropine like), Anticholinergic
Uses: hypermotility of lower urinary or GI tract; irritable bowel synd; PUD; GI spasm/ colic; bladder spasm; antisecretory; death rattle
Caution :
closed angle glaucoma, MG, paralytic ileus, obstructive uropathy / BPH, GI obs, renal/hepatic impairment, CHF, COPD, tachyarrythmia, Hyperthyroidism
Pointers:
oral action 20-30 min, SL 5-20 min; duration 4 hrs; peak 2.5 hrs, HL 3.5 hrs
Hepatic metabolism
may antagonise prokinetic effects of Metoclopramide
Side effects: dry mouth / skin, blurred vision, dysphagia, constipation, photosensitivity, orthostatic hypotension, tachycardia, urinary retension, lethargy
Supply:
Tab 0.125 mg; Cap 0.375 mg ER; Elixir 0.125 mg/5ml
Rx
0.125 – 0.25 mg PO/SL Q 4 hrs prn use (max 1.5 mg/d)


Ketoconazole (Nizoral)

Antifungal
Uses: fungal infection, oral candidiasis, reapeated vaginal candidiasis, mucocutaneous candidiasis in immunocompromised,
Caution:
hepatic disease, no dose ajustment in renal failure, C.I. with Domperidone
Pointers:
GI upset, pruritus, hepatitis, liver damage (if used more than 14 days)
metabolized by CYP 450 system, clinical sig is generally low, so use this in appropriate patient
Disulfiram-like effect with alcohol
inc effect/concentration of : Alprazolam, Bupropion, Carbamazepine, Dexamethasone, Diazepam, Fentanyl, Methadone, Nortriptyline, Oxybutynin, Oxycodone, Phenytoin, prednisone, Venlafaxine, Warfarin
Peak 1-2 hrs, HL biphasical 2 hrs initially 8 hrs terminally
Side effects: nausea, vomiting, pruritis, headache, dizziness, hepatotoxicity
Supply: Tab 200 mg
Rx: 200 mg /d for up to 7 days
not a first line


Lorazepam (Ativan)

Bezodiazepine

Uses: Anxiety; GAD; agitation; distress; seizures; muscle spasms
Pointers:
well tolerated sublingual,
injectable form can be use sublingual
potency : 10 times diazepam per mg as sedative / anxiolytic
causes drowsiness, sedation, respiratory depression (high dosage)
90% bioavailable; inactive metabolites; 85% protein bound
Caution:
precaution: Renal
no dose adjustment in hepatic failure
Side effects:
adverse effects : sedation, unsteadiness, dizziness,
Available:
tab 0.5, 1, 2 mg; Oral conc 2 mg/ml. inj 2 mg/ml
skin paste 1, 2 mg
Rx
Anxiety: 2-3 mg PO q 8-12 hrs (max 10 mg/d)
Insomnia: short term 2-4 mg PO hs
Seizures: 4 mg slow IV at 2 mg/min
N/V due to chemotherapy: 1- 2.5 mg PO / IV 1/2 hr before then q 4 hrs prn


Methylphenidate (Ritalin)

CNS stimulant, related to Amphetamine

Uses: ADHD; Attention deficit; Narcolepsy; Depression; Opioid induce somnolence; fatigue; Neurobehavioral changes due to: brain tumor or injuries; Dementia;
Caution: Anxiety, Glaucoma, Agitation, Hyperthyroidism, HTN, Cardiac issues, Epilepsy
Pointers:
reduce the dose by 50% in hepatic impairment
little effect due to renal
CYP 450 : effect increased by Valproate; dec by Carbamazepine
Side effects:
insomnia, nervousness, arrhythmia, hallucination, blurred vision,
Supply:
Tab 5, 10, 20 mg.
Rx:
2.5 to 5 mg before meals QAM, NOON. Avoid late afternoon & evening. titerate to effect. max 60 mg/d


Oxybutanin (Ditropan)

Anticholinergic

Uses: Urinary frequency, Urgency or incontinent, bladder spasm, catheter induced bladder spasm, overactive bladder
Caution: GI or urinary obstruction, Arrhythmias, CAD, CHF, Prostatic hypertrophy (BPH), GERD, Inflammatory bowel disease, close angle Glaucoma, elderly, exposure to high temperature, hepatic & renal failure
Pointers:
metabolized by CYP 450;
Ketoconazole: increases concentration / effect
delirium with other anticholinergic meds
antispasmodic / antimuscarinic
Side effects: dry mouth, confusion, constipation, urinary retention, somnolence, blurred vision, nausea, vomiting,
Supply: Tab 5 mg
Rx : 2.5 mg HS titerate to effect, max 20 mg/d


Phenobarbitol (Phenobarb)

Uses: Control terminal seizures; Sedation; Agitation refractory to other meds in end of life; Adjuvant in pain due to CNS origin; Epilepsy; Status epilepticus
Pointers
tablet may be crushed
dilute inj in 10 times in water
HL 2-6 days so can be given as single dose as HS,
anticonvulsant therapeutic level 15-40 mcg/L
bioavailability 70-90%,
IV onset 5 min, duration 4-6 hrs, peak 8-12 hrs
inactive metabolized by liver, excreted major in urine
Side effects
resp depression (IV), ataxia, dizziness, drowsiness, confusion,
Available
Tab 15, 30, 60, 100 mg. Elixer 20 mg/5 ml. Inj 30,60,65,130 mg/ml
Rx
Loading : 20 mg/kg/dose oral, IV, IM, SQ at 25-60 mg/min
max 1200 mg/24 hrs
maintenance for seizures 1-3 mg/kg/d PO/IV div bid or tid
sedation: 30-120 mg/d divided BID / TID max 400 mg/d
Hypnotic / insomnia : 100-200 mg/ HS (max 400 mg/d)


**

Risperidone (risoerdal)

Uses:
Agitation
Delirium
Psychosis
other: bipolar, post-traumatic stress, schizophrenia, tourette
Pointers:
Extrapyramidal s/s are less than older antipsychotics
caution: in epilepsy, cardiovascular disorders
avoid if history of falls / fractures / dementia / CVA ? hypovolumia
Available:
tab 0.25, 0.5, 1,2,3,4 mg (same for orally disintegrating);
oral sol 1 mg/ml
injectable powder 12.5, 25, 37.5,50 mg q 2 weeks
Rx
tab 0.25 mg -3 mg/d


Warfarin (Coumadin)

Oral anticoagulant
prevention / treatment of Thrombotic disorders
Caution: hemorrhagic conditions, sudden drastic dietary changes, renal / hepatic impairment
Pointers: Interfere with Vit K dependent factors : II, VII, IX, X, protein C, S
onset 36-48 hrs; peak:1.5-3 days; duration: 2-5 days; 99% protein bound to albumin; HL 20-60 hrs; INR range 2-3; high Vit K consumption decreases effectiveness; if needed check INR after 2 days; if stable q 4-6 weeks (12 week)
Side effects: bleeding, hair loss, fever, hematuria, rash, purple toe syndrome (rare), inc fracture risk with long term use
Supply:
Tab: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg
Rx:
initial dose 2-5 mg/d (10 mg/d for 2 days in healthy subjects.
maintenance dose 2-10 mg/d