Rx
Include here : common protocols, side-effects, how to take rx, c/i

#. PO DM rx.

SGLT inhibitors
> Jardiance: empagliflozin : start w/ 10mg daily --> can go up 25mg daily. Don’t start if GFR <45.
> Farxiga: dapagliflozin: start 5mg daily, can go up to 10mg daily. Don’t start if GFR <45.

GLP1-agonist
> Trulicity : dulaglutide : single dose pre-filled pen x1 injection weekly, no renal dosing. --> inject 0.75 mcg SC weekly --> can go up to 1.5mg weekly.
> Victoza : liraglutide : SC multi dose pens inject SC daily. Initial 0.6 mg dose for 1 week is to control GI side-effects : start 0.6mg SC qday for 1 week, then inc to 1.2 mg SC daily. Max at 1.8mg SC daily.
> Bydureon : exenatide : once weekly

> Saxenda is for OBESITY = liraglutide version
NOT indicated for DM2 itself --> is indicated for wt loss! do not use w/ insulin. Initiate at 0.5 mg sc daily for 1 week, then inc by 0.6 mcg daily week by week until reach 3mg/d.

Pioglitazone: start 15mg or 30mg daily, max 45 mg daily. contra-indicated in LFTs >2.5x ULN, CHF (can exacerbate), dose-related fluid retention (particularly if used w/ insulin).

Metformin:
- use Glucophage 500mg ER 2 tabs BID. ER version has more 24hr coverage and less side-effects.
- vs Glumetza XR or Fortamet ER? these other options are expensive. Glumetza is in >300$ range (!!!)


#: Hordeolum / Style / Chalazion
Px: acute red nodule TTP, foreign object sensation , tearing, photophobia. MC in teens.
Most resolve within 1-2 wk.
PP: obstructed meibomian glands, w/ staph infection.
Tx: Warm compress 4x/d  x1-2wk; erythromycin 0.5% ointment BID x7d.
RTC 2-4 weeks if not resolving. Can I&D if refractory.
Most self-limited & auto-resolve within 1-2 wk.
If not resolve within 4wk, I&D it.
If large or refractory, I&D it.
Complications: high risk recurrence; can progressive into pre-septal cellulitis (tx w/ PO abx w/ staph coverage).



#. Common Abx dosages:

Permethrin --> Scabies : 5% cream
Permethrin --> Head lice : 1% lotion; sig: wash once w/o conditioner, & towel dry, then lotion for 10 min, then wash out. repeat in 9-10d. typically 1 applications is 60 ml --> rx 120ml to cover 2 applications.
Permethrin directions:
https://www.mayoclinic.org/drugs-supplements/permethrin-topical-route/proper-use/drg-20065448

Genital warts : CareOregon pays for podofilox, not imiquimod. !!!
  • Podofilox 0.5% gel (apply BID for 3 days, then wait 4 days. If still present, repeat cycle. Can repeat up to 4 cycles). (~40$)
  • Imiquimod (apply every other night, wash off in the morning for 4 weeks). (28$)
  • Efficacy between the 2 rx are same. 50-75% clearance rate, recurrence is 4-33%.

Bacterial Sinusitis: 1st line: amoxicillin 1000mg BID x5d ; peds = 90mg/kg/d divided BID
2nd line: augmentin 875mg PO BID; peds = 45mg/kg/d divided BID; also omnicef / others
Pen-allergy: clindamycin 30-40mg /kg/d divided TID
***add peds table
 
Strep pharyngitis:
1st line : adult and children >27kg  =  penicillin 500mg BID  x10d.
Pen allergy: adult & children >40kg = azithromycin as zpack.
Recurrent : keflex 500mg PO BID
***add peds course
 
Acute Otitis Media:
1st line: amoxicillin 80 mg/kg/d divided BID x7-10d.
2nd line:  omnicef 14 mg/kg/day divided one to two times daily fo 10 days
Pen-allergy : clindamycin 30-40mg/ kg/d divided 4x/d x10d.
 
Acute otitis externa: ciprodex 0.3% (otic or ophthalmic) 3 drops each ear x7d (or 3 days after sx resolved). If severe, add keflex PO.
---> ciprodex very expensive ==> use opthalmic cipro 0.3% and dexamethasone ophthalmic combo, much cheaper separate.
AOE fungal: acidify the ear alcohol : white vinegar 1:1 drops to acidify the ear. Debride it.
TM intact : clotrimiazole 1% drops TM perf: tinactin (tolnaftate) 1% drops

Otitis externa fungal : 10%  fungal (white = candida, black = aspergillus; tx = 1st line is 1:1 vinegar & etoh warm rinse, 2nd line is antifungal drops)

Dental caries / cavities / toothache: amoxicillin 500mg PO BID x7d.
 
Bronchitis/PNA - low risk: 
azithromycin take 2 tabs on day 1, then 1 tab daily for 4 more days.
If QT prolongation risk : doxycycline 200mg  BID x3d, then 100mg BID x4d.
 
Bronchitis/PNA - high risk:
Levofloxacin 500mg PO qday for 7-10d;
Levofloxacin if GFR 20-49: PO 500mg initial x1d, then 250mg daily.
 
UTI uncomplicated: macrobid 100mg BID x5d.
Bactrim DS BID x3d.
Keflex 250-500mg 4x/d x7d.
 
UTI complicated / pyelonephritis:
ciprofloxacin 250mg PO BID x3d.
 
Prostatitis: ciprofloxacin 500mg BID x10-14d.
 
Diverticulitis: requires 2 agents
Flagyl 500mg 4x/d PLUS ciprofloxacin 500mg BID
 
H.pylori infection: *** see the residency guide book
 
Skin infection: 
Topical mupirocin 2%  (bactroban) TID x5d.
keflex 500mg BID x7d
 
Skin MRSA:
Topical mupirocin 2%  (bactroban) TID x5d. (very expensive!)
bactrim DS 1-2 tab BID x7-10 days Clindamycin 300-450mg 4x/d x7-10 days
Doxy also;
 
Tinea cruris: diflucan 150mg q week x4 weeks.
Tinea corporis: Terbinafine 250mg daily x2-4 weeks, may extend after.

Onychomycosis: Terbinafine 250mg daily  -- toenails: 12 weeks, fingernails: 6 weeks

#. Eliquis rx; DVT tx dosage is 5mg 2 tabs BID x7d, then 1 tab BID from then on.
- write 2 rx to get it covered!
rx1 : 5mg tabs, take 2 tabs BID x7d, #14 tab to last 7 days (w/ copay card)
THEN rx2: 1 tab BID PO, #60. (needs PA)

#. Anal fissure / hemorrhoids :
careoregon --> generic proctosol HC cream 2.5% ; apply to cleaned affected area 3-4x per day.
lidocaine cream --> ***

#. Erectile dysfunction
Stendra : Avenafil : onset 15 min.
Cialis : tadalafil ---> 10mg 30-60 min before intercourse. Take no more than 2x per day. Can go up to 20mg or down to 5mg. goodrx; $30 for #30 10mg tabs
viagra : sildenafil --> start 50 mg tab PO 1hr before intercourse. can crush and place sub-lingual to get onset within 15 min. If >65 yo, renal / hepatic issues --> start w/ 25mg/d. goodrx; $20 for #30 50mg tabs.

AVS: “Possible side-effects include headache, upset stomach. WARNING: Do not take if also taking nitroglycerin or nitrates due to risk of dangerously low blood pressures.”

#. STI :

>> gonorrhea: azithromycin 1g + (ceftriaxone 500mg IM x1 OR cefiximine (suprax) 400mg PO x1).
* ceftriaxone is preferred overall. * cefixime NOT for pharyngeal gonorrhea.
* if severe cephalosporin allergy --> ( azithromycin 2g PO x1) + (gentamicin 240mg IM x1 or gemifloxacin 320mg PO x1) --> ToC at +2 weeks.
>> chlamydia: azithromycin 1g x1
- if tx gonorrhea, tx presumptively chlamydia as well.
- repeat for TC @ +2 weeks.

>> Genital warts:
Home tx: imiquimod (3.75% nightly)


#. GI Cocktail:

> 1:1:1 viscous lidocaine 2% : mylanta : diphenhydramine - fill at 120ml or 250ml ---> send order to PDX
> (Viscous lidocaine 2% 10ml) + (donnatal 10ml) + (mylanta 30ml)

#. Magic Mouthwash:
(diphenhydramine oral soln 20ml) + (Viscous lidocaine 2% 20ml) + (mylanta 20ml)

#. BCM Rx:
- Nexplanon:
- IUD

#. OCPs:
Sprintec is monophasic x28 day tabs.
ethinyl estradiol/ norgestimate (0.035MG/ 0.25MG)
To skip menses, just skip the week of inactive rx. Document: nonsmoker, no migraine w/ aura, no hx blood clots. UPT neg. Review w/ pt: the longer the interval, more likely the spotting. First few cycles may have more spotting in between. OCPs do not prevent STDs, c/w condom use for safety if any risk of exposure.


#. Influenza:
Tamiflu: Dosage teens/adults 75mg BID x5d. within 48 hours sx onset, reduces sx by 1d.

Bisphosphonates
#. Alendronate :
- indicated for prevention AND tx of osteoporosis (prevent hip fx NNT x3 years = 91, vertebral fx = 15)
- counseling for directions : take pill by itself w/ full glass of water, not to be supine for at least 30 minutes after, wait 1-2 hours before eating. duration of tx should be 5 years (or 10!)
- side-effects / risks: osteonecrosis jaw, esophageal erosion / ulcer, bone / muscle / joint pain (may stop rx)
- c/i: if there is delayed gastric emptying.
- ppx dose : 5mg PO daily or 35mg PO weekly
- tx dose : 10mg PO daily or 70mg PO weekly

Patient AVS directions: ***


#. PRN Seizure
- clonazepam 20mg PO between teeth & cheeks as needed for convulsion >5 min. may repeat 1x if not resolve after 5min

#. COPD / Asthma Rx:
CareOregon formulary 3/18 for asthma/COPD rx.
Inhaled steroid:
> QVAR redihaler 40 mcg; QL 2 puffs per day; 60d supply per fill.
> Flovent 110, 220; QL 60d supply per fill. > Flovent disk 50mcg. If Flovent disk 100, 2050; is QL 60d.
 
anti-cholingergics
> atrovent HFA AER 17mcg ok.
> spiriva cap handihaler  (QL 1/d) or respimat (QL 2puffs/d)
 
B-agonist: > ventolin QL 90d fill.
Steroid/b-agonist combos: > Airduo (fluticasone + salmeterol) generic ok all strengths.
Inhaled AC / b-agonist combo: > combivent aer/ aer respimat brand ok all.


#. Fe Supplement ***


#. Smoking cessation
Chantix starter pack sig : Days 1-3: take 0.5 mg PO qDay, days 4-7: 0.5 mg PO BID, days 8 to end of treatment: 1 mg PO BID

#. Wt Management

Qysmia = phentermine/topiramate:
- name-brand :
7.5/46 mg per day to 15/92 mg per day.
- qysmia generic :
Generics: $20 lasts 2 month regimen
Phentermine 37.5mg tab, take 1/2 tab daily. #30 = $10. 
Topiramate 100mg tab, take 1/2 tab daily. #30 = $10
*can go 12 wk phentermine @ 37.5/d, then transition to qysmia long-term.

Contrave = naltrexone / bupropion
- name brand : BID dosing 16/90

Naltrexone 50mg tab, 1/2 tab/d. #30 = $31
Bupropion SR 100mg tab, 1 tab/daily. #30 = $18..  


#. Anti-depressants
- general class side-effects: decreased libido, fatigue.
- Sertraline
- Paroxetine
- Fluoxetine
- Citalopram
- Escitalopram

- Venlafaxine
- Duloxetine

- Bupropion: c/i if hx seizures.

#. Anti-depressant augmentation

Trazodone: ***
Bupropion: activating. Use if sexual side-effects. Target to 300-400mg/d.
Trazodone: good w/ sleep as well.
Aripripazole: 2nd gen anti-psych w/ least side-effects. Target 5-15mg/d.
Buspirone: ***


AVS for all anti-depressants: “
Regarding anti-depressant medications - side-effects are possible in 
all medications and we only use it when benefits outweigh the risks. 

For any anti-depressant medications, there is a warning that if you 
develop any thoughts of hurting yourself or others, it MAY be from the 
medication. So, if this happens, PLEASE immediately stop the medication, 
notify us, and/or go to the ER for care.”


#. Muscle Relaxants: indicated as adjunctive to NSAID for acute low back pain x 2 weeks.
• Flexeril / cyclobenzaprine: 5-10mg TID
• Robaxin / methocarbamol : 1500mg TID for 4 days, then 750mg 4x/day.
• Avoid: soma / carisopradol, baclofen, tizanidine.

Precautions: ”Muscle relaxant medications can include side effects such as drowsiness / sleepiness, respiratory depression. Do NOT mix with alcohol or other sedative-hypnotic medications (such as benzodiazepines, barbituates, or opiates). Do not drive or operate heavy equipment while on this medication. Do not use if you have recent heart issues or have diagnosed cardiac arrhythmias or glaucoma. Muscle relaxants are typiclaly not for long-term use. Call or return to clinic if any concerns or questions."


#. ADHD

- Focalin 10mg BID; start qAM only.  Counseled on side-effects (HR, CP, dry mouth, insomnia, poor appetite)


#. Ca & Vit D
- Ca slows bone thinning, Vit D increases bone density.
- Vit D & hyperCa toxicity: HA, metallic taste, pancreatitis, n/v.

- Osteoporosis / osteoporosis : Vit D (800-2000 IU/d) + Ca (1200-1500mg/d)
- >>
Rx as: "calcium carbonate-Vit d3 1500mg, 800 IU tablet" 1 tab daily.

- Vit D deficiency: if mild = Vit D3 1000 IU/d (1000 maintenance + 1000 for each 10 shortfall) x8wk, then go to maintenance. Give along w/ Ca 1200-1500mg/d.
- Vit D deficiency : if severe = Vit D3 50,000 IU/d PO x1-3 wk.


#. Smoking Cessation Rx:
- Chantix : side-effects: nausea (MC; take w/ foods), c/i in seizures.
- Bupropion: c/i in seizure.
- Nicotine replacement:
- Nicotine patch: 3 step wean of nicotine dosage.

#. Statins
- Costs / efficacy:
- Atorvastatin mod intensity 10-20mg/d; high intensity 40-80 mg/d. side: myalgias
- Simvastatin
- Livalo ***
- Rosuvastatin

#. Constipation
- Protocol:
Peds:
> miralax 1cup w/ 1 glass water BID, plus senna BID until BM / sx resolve over the next 2 days.
> pt to stay home from school until 2/19/18 or longer UNTIL SX RESOLVED.
Start Miralax 17 gram/dose oral powder mix 17g with with gatorade, drink as instructed.
Start senna 8.6 mg tablet 1 tablet 2 times a day as needed

#. Herpes:
- acyclovir tx dose 400mg TID for 5d or until resolution of sx.
- acyclovir ppx dose : 400mg BID.
- abreva : apply 5x/d until healed.
- topical acyclovir very expensive, minor benefit.


#. Migraine Rx
- Sumatriptan: 100mg / 50mg / 25mg PO - can repeat 25mg tablet every 2 hours; max 200mg per day. Take no more than twice weekly.
- Adjunct tx w/ zofran (PO 4-8mg q6-q8), naproxen, caffeine, toradol x1 (IM 30 or 60mg) in clinic
- Excedrin : ASA / apap / caffeine
- see PCH HA protocol

#. Scabies
- Permethrin: shampoo ( ), cream ( )
- Permethrin can be expensive (if need tx whole family!); 2nd line is ivermectin and actually much cheaper.
-

#. Alcohol Dependence
- If abstaining : use Acamprosate: Take 1 tab (333mg) TID, can go up to 2 tab (666mg) TID.; c/i adv cirrhosis, GFR <30. reduces anxiety of abstinence. NNT 9-12. Titrate for GI side-effects (diarrhea, upset). generic $55/mo.
- Non-abstaining : Naltrexone 50mg qday; decreased pleasure of etoh. effective short-erm but not long-term.
- 2nd line agents: SSRI, topiramate (reduces severity & binge drinking)
- Adjunct : start taking thiamine (B1), ( ), folate ( ), MV (typically low Mg, K as well)
- *** cobalamin (B12):

#. Post-menopause vaginal atrophy Rx
- c/i in hx breast CA.
- best priced option is to use compounded estrogen cream!
- Vaginal ring: placed in vagina, replace q90d. 2mg rings.
- Estradiol tablet: 1 tablet qd x2 weeks, then 1tablet twice a week. 10 or 25mcg applicators.
- Estrogen cream (premarin): 0.5-2g /d applied topical daily.

#. Pediatric Tylenol / APAP & Ibuprofen
- can alternate APAP & ibuprofen q4 hr intervals.
- Ibuprofen is q6hr. APAP is q4hr.

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