CENTER FOR DRUG INFORMATION AND RESEARCH School of Pharmacy – LECOM, Erie, PA Drug Information Letter Independent best evidence analyses and commentary Date: August 2009 Volume 3 Issue 3 New Drug Evaluation Multaq (dronedarone) Tablets Editor’s Note: This review is based on the professional product label, or package insert, for dronedarone using the framework developed by the LECOM Center for Drug Information and Research for evaluating the therapeutic value of newly marketed drugs. ASSESSMENT OF MULTAQ (DRONEDARONE) DECREASE HOSPITALIZATIONS FOR ATRIAL FIBRILLATION AND INCREASED RISK OF DEATH Dronedarone is a new molecule that is indicated for a select subset of patients to reduce the risk of cardiovascular hospitalization in patients with paroxysmal or persistent atrial fibrillation (AF) or atrial flutter (AFL), with a recent episode of AF/AFL and associated cardiovascular risk factors who are in sinus rhythm or who will be cardioverted. Dronedarone carries a black box warning concerning deaths in patients with severe heat failure requiring hospitalizations or referral to specialized heart failure clinics for worsening symptoms. It is important to know which patient populations have benefited or been harmed from dronedarone use in the following trials; ATHENA1, EURIDIS2, ADONIS2, ERATO3, DAFNE4, and ANDROMEDA5. 1 Hohnloser SH, Crijns HJ, van Eickels M, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med. 2009. 360(7):668-78. 2 Singh BN, Connolly SJ, Crijns HJ, et al. Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter. N Engl J Med. 2007. 357(10):987-99. 3 Davy JM, Herold M, Hoglund C, et al. Dronedarone for the control of ventricular rate in permanent atrial fibrillation: the efficacy and safety of dronedarone for the control of ventricular rate during atrial fibrillation (ERATO) study. AM Heart J. 2008. 156(3):527.e1-9. 4 Touboul P, Brugada J, Capucci A, et al. Dronedarone for prevention of atrial fibrillation: a doseranging study. Eur Heart J. 2003. 24(16):1481-7. 5 Kober L, Torp-Pedersen C, McMurray JJ, et al. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med. 2008. 358(25):2678-87. Dronedarone is required to be dispensed with a Medication Guide. CAUTION DO NOT SUBSTITUTE LEXICOMP OR OTHER COMMERCIAL THIRD-PARTY DRUG INFORMATION SOURCES FOR FDA-APPROVED PROFESSIONAL PRODUCT LABELS. Food and Drug Administration (FDA) Approval6 Dronedarone, an antiarrhythmic benzofuran derivative, was approved by the FDA on July 1, 2009, to reduce the risk of cardiovascular hospitalization in patients with paroxysmal or persistent AF/AFL with a recent episode of AF/AFL, and associated cardiovascular risk factors (i.e., age > 70, hypertension, diabetes, prior cerebrovascular accident, left atrial diameter ≥ IN THIS ISSUE 50 mm or left ventricular ejection fraction < • New Drug Evaluation 40%), who are in sinus rhythm or who will be Multaq (dronedarone) cardioverted. • The FDA has required dronedarone’s professional product label to display a Black Box Warning concerning heart failure. Black Box Warnings are the strongest type of warnings that the FDA can require. The following Black Box Warning is verbatim from the package insert: Drug Topics – Top 200 Drugs WARNING: HEART FAILURE Multaq is contraindicated in patients with NYHA Class IV heart failure, or NYHA Class II-III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heat failure clinic. In a placebo-controlled study in patients with severe heat failure requiring recent hospitalization or referral to a specialized heart failure clinic for worsening symptoms (the ANDROMEDA5 Study), patients given dronedarone had a greater than two-fold increase in mortality. Such patients should not be given dronedarone. 6 Multaq (dronedarone) Professional Product Label. At: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022425lbl.pdf. Accessed: July 28, 2009. The above ANDROMEDA5 Study mentioned in the Black Box Warning and the following studies ATHENA1, EURIDIS2, ADONIS2, ERATO3, and DAFNE4 have been reviewed in the FDA’s product labeling for dronedarone. All of these studies were placebo controlled. Note that there is no regulatory requirement for new drugs to be therapeutically superior to drugs already marketed before approval. In the clinical trials submitted by manufacturers to support the new drug’s approval, the new drug, in many cases, is compared only to a placebo. Description of Dronedarone Dronedarone has antiarrhythmic properties belonging to all four VaughanWilliams classes, but the true clinical effect to each of these is unknown. There is a dose related effect increasing PR and QTc intervals. Unlike amiodarone, another benzofuran derivative, dronedarone possesses no iodine molecules, but does possess a potentially clinically relevant sulfonamide group (see below). O (CH2 )3CH3 (CH2)3 CH3 H3 CO 2SHN O N (CH2)3 CH3 O HCl Multaq (dronedarone) O (CH2)3CH3 I OCH2CH2 N(C2H5)2 O I HCl 7 Pacerone (amiodarone) There is no indication in the professional product label of patients having sulfonamide related allergic reactions but there could be a potential for cross allergenicity with other sulfonamide medications based on dronedarone’s chemical structure. 7 Figure adapted from: Pacerone (amiodarone) Professional Product Label. At: http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=10301. Accessed: July 28, 2009. Therapeutic Efficacy of Dronedarone The Clinical Studies section of the professional product label lists four placebo controlled studies. Study 1 – ATHENA1 ATHENA was a randomized, double blind, multicenter, multinational study. The study included AF/AFL patients who were ≥ 75 years of age, or ≥ 70 years old with at least one cardiovascular risk factor. If patients were not in sinus rhythm, they were expected to be electrically or chemically converted. Patients were randomized to either dronedarone 400 mg twice daily (2301 patients) or placebo (2327 patients) while patients were actively in AF/AFL or in sinus rhythm. Patients were also on conventional therapy for cardiovascular diseases. The primary endpoint of the study was time to first hospitalization for cardiovascular reasons or death from any cause. Table 1 – ATHENA Primary Endpoint Analysis Placebo Dronedarone Absolute Reduction Number Needed to Treat (NNT) (n = 2327) (n = 2301) 913 (39.2%) 727 (31.6%) 7.6% ≈ 13 - Cardiovascular hospitalization 856 (36.8%) 669 (29.1%) 7.7% ≈ 13 - Death from any cause 57 (2.4%) 58 (2.5%) ----- ---- Primary Endpoint Cardiovascular hospitalization or death from any cause Primary Endpoint Components (as first event) Table 1 reflects the primary endpoint analysis of the ATHENA Study. Overall, 13 patients must be treated with dronedarone to prevent one hospitalization for 22 months, but mortality was slightly higher in the dronedarone group. Study 2 and 3 – EURIDIS2 and ADONIS2 Patients in sinus rhythm with a prior history of AF/AFL were randomized to dronedarone 400 mg twice daily (n = 828) or placebo (n = 409) for a total of 1237 patients in EURIDIS and ADONIS in an outpatient setting. Patients ranged in age from 20 to 88 years of age, with the majority being Caucasian (97%). Patients were also taking conventional therapies for cardiovascular diseases. Patients were followed for 12 months. The primary endpoint was time to first recurrence of AF/AFL. In the pooled analysis from both EURIDIS2 and ADONIS2 dronedarone lowered the recurrence of AF/AFL during the 12 month study period. The absolute difference in recurrence rate was about 11% at 12 months. This reflects a number needed to treat of around 9 patients for 12 months. Study 4 – ANDROMEDA5 In ANDROMEDA patients were either randomized to dronedarone (n = 310) or placebo (n = 317) who were recently hospitalized with symptomatic heart failure and severe left ventricular systolic dysfunction. The primary composite end point was all-cause mortality or hospitalization for heart failure. The study was terminated early because of excess mortality in the dronedarone group. Twenty-five patients in the dronedarone group (8.1%) versus 12 patients in the placebo group (3.8%) had died. This is more than double the amount of deaths versus placebo. The main reason for death was worsening heart failure. Contrasting ANDROMEDA5 and ATHENA1 The ANDROMEDA and ATHENA populations differed markedly. In ANDROMEDA, the majority of patients had either NYHA Class II (40%) or III (50%). In ATHENA, only 25% of patients had NYHA Class I or II heart failure, and only 4% where in class III. All patients in ATHENA had AF/AFL but only 38% of the patients had AF/AFL in ANDROMEDA. It is important to note that those patients in ATHENA who had a LVEF < 35% (n = 179) did not benefit from dronedarone treatment. There was no difference in first cardiovascular hospitalization or death from any cause in this population. Based on these trials it is reasonable to recommend not giving dronedarone to any patient with heart failure. Risks highly outweigh the benefits. Safety of Dronedarone Beyond the important safety data in ANDROMEDA5 which resulted in the FDA to give dronedarone a Black Box Warning, and the unpublished safety data of the DIONYSOS8 trial, five additional placebo controlled trials totaling 6285 patients where evaluated for safety, ATHENA1, EURIDIS2, ADONIS2, ERATO3, and DAFNE4. Throughout the five trials, 3282 patients were treated with dronedarone, and 2875 patients were given placebo. The average exposure was 12 months. The most common adverse reactions included diarrhea, nausea, abdominal pain, vomiting, and asthenia. Clinically important laboratory data and ECG data not necessarily reported in the trials as adverse reactions is reported below. Table 2 – Laboratory data and ECG parameters Serum creatinine increased ≥ 10% five days after treatment initiation QTc Bazett prolongation (> 450 ms in males and > 470 ms in females) Placebo Dronedarone (n = 2875) (n = 3282) 21% 51% (n = 2237) (n = 2701) 19% 28% The elevation in serum creatinine has a rapid onset, reaches a plateau after 7 days and is reversible after discontinuation. The change in serum creatinine is the result of dronedarone’s inhibition of creatinine’s tubular secretion. If the QTc Bazett interval is ≥ 500 ms, dronedarone should be discontinued. Dronedarone is contraindicated in the following situations: • NYHA Class IV heart failure or NYHA Class II - III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic. • Second- or third-degree atrioventricular (AV) block or sick sinus syndrome (except when used in conjunction with a functioning pacemaker) • Bradycardia <50 bpm. • Concomitant use of strong CYP 3A inhibitors, such as ketoconazole, itraconazole, voriconazole, cyclosporine, telithromycin, clarithromycin, nefazodone and ritonavir. • Concomitant use of drugs or herbal products that prolong the QT interval and might increase the risk of Torsade de Pointes, such as phenothiazine anti-psychotics, tricyclic antidepressants, certain oral macrolide antibiotics, and Class I and III antiarrhythmics. • QTc Bazett interval ≥500 ms or PR interval >280 ms. • Severe hepatic impairment. • Pregnancy (Category X): dronedarone is contraindicated in women who are or may become pregnant. • Nursing Mothers. Beyond avoiding CYP 3A inhibitors, dronedarone has additional clinically important drug interactions. Patients should also avoid grapefruit juice, and rifampin and other CYP 3A inducers. If a patient is also taking digoxin, the digoxin dose should be halved. Various statin product labeling should also be followed closely because dronedarone has CYP 3A and P-gP inhibitor qualities. Dose adjustments to statins will need to be made depending on statin product. Patients’ potassium levels should be within normal ranges prior to the initiation of dronedarone. Concurrent therapy with potassium deleting diuretics may induce hypokalemia or hypomagnesemia. Conclusion There has been one trial, ATHENA1, indicating that dronedarone has decreased hospitalizations in patients with AF/AFL. To date dronedarone has not been shown to decrease mortality, and has shown to increase mortality in patients with heart failure (ANDROMEDA Study5). More patients in the dronedarone group also died in the ATHENA Study1. The question is, should a medication studied in such a select population showing a decrease in hospitalizations, but no mortality benefit be prescribed? Prescribing practices from medications such as Accutane (isotretinoin) teach us that this medication may be misused and patients may be placed in harms way. The large number of contraindications, drug interactions and potential for death outweigh the drug’s potential benefit. The FDA has instituted a Risk Evaluation and Mitigation Strategy (REMS) for dronedarone. The goal of the REMS is to prevent improper prescribing and inform patients about the risks of the drug. Elements of the REMS include a Medication Guide required by regulation to be given to patients, and a communication plan to inform healthcare professionals about the risks of the drug. The communication plan includes an informational sheet, and print advertisements in professional society journals. It is clear from the Black Box Warning and the REMS that the FDA is warning physicians on prescribing this medication and after this review it looks as if the risks highly outweigh the benefits for dronedarone use. Information Not Available in the Professional Product Label DIONYSOS trial8 – Unpublished data of the safety and efficacy of dronedarone versus amiodarone 1. DIONYSOS efficacy data DIONYSOS is an unpublished multicenter, randomized, double-blind, parallel-arm study to compare the safety and efficacy of dronedarone (400 mg BID) versus amiodarone (600 mg daily for 28 days, then 200 mg daily thereafter) to maintain sinus rhythm in patients with AF. It is important to note that there is no mention of the DIONYSOS trial in the product labeling. To date the trial data listed below has not been reviewed or commented on by the FDA. Results were first released by Sanofi-Aventis as a press release on December 23, 2008.9 Then a further review of the trial and a more complete analysis appears in Sanofi-Aventis’s Briefing Material for the March 18, 2009 Meeting of the Cardiovascular and Renal Drugs Advisory Committee.8 A total of 504 patients were randomized into the trial, 249 patients randomized to dronedarone and 255 patients to amiodarone. The primary composite endpoint was time to first AF recurrence or premature study drug discontinuation for intolerance or lack of efficacy. More patients randomized to dronedarone (75.1%) had a first recurrence of AF or premature study drug discontinuation at 12 months than the patients randomized to amiodarone (58.8%) (HR = 1.589, CI [1.275; 1.980] log- 8 Sanofi-Aventis. Multaq (Dronedarone) – Briefing Document – Advisory Committee Meeting of the Cardiovascular and Renal Drugs Division of the US Food and Drug Administration. March 18, 2009. At http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/Cardiova scularandRenalDrugsAdvisoryCommittee/UCM134981.pdf. Accessed 8/10/09. 9 Sanofi-Aventis. DIONYSOS Study Results Showed the Respective Profiles of Dronedarone and Amiodarone. Press Release. December 23, 2008. At http://en.sanofiaventis.com/binaries/20081223_dionysos_fe_en_en_tcm28-23624.pdf. Accessed 8/10/09. rank p-value < 0.0001). The Kaplan-Meier curve below reflects the time to first recurrence of AF or premature study drug discontinuation. Table 3 - Components of the primary endpoint. Number of patients with the combined primary endpoint Atrial fibrillation recurrence Documented atrial fibrillation after conversion Unsuccessful electrical cardioversion No spontaneous conversion and no electrical cardioversion on day 10 to day 28 Premature study drug discontinuation Lack of efficacy Intolerance Dronedarone (n = 249) 184 (73.9%) 158 (63.5%) 91 (36.5%) 29 (11.6%) 38 (15.3%) Amiodarone (n = 255) 141 (55.3%) 107 (42.0%) 62 (24.3%) 16 (6.3%) 29 (11.4%) 26 (10.4%) 1 (0.4%) 25 (10.0%) 24 (13.3%) 0 34 (13.3%) Efficacy Conclusion: It is clear that dronedarone is not as effective as amiodarone in reducing AF recurrence. 2. DIONYSOS safety data The main safety endpoint in DIONYSOS was the time to first occurrence of thyroid, hepatic, pulmonary, neurological, skin, eye or gastrointestinal specific events or premature study drug discontinuation following any adverse effect. The main safety endpoint occurred in 39.3% of dronedarone treated patients and 44.5% of amiodarone treated patients after 12 months (HR = 0.80, 95% CI = 0.60; 1.07, log-rank p value = 0.13). The Kaplan-Meier curve below represents time to first study drug intake to main safety endpoint. The main safety endpoint was driven by lower thyroid, neurological, skin and ocular effects in the dronedarone group. The main gastrointestinal adverse effects were driven by a higher non-serious diarrheal occurrence in the dronedarone group (9.2%) versus the amiodarone group (3.1%). Table 4 - Analysis of time from first study drug intake to first specific event – All randomized and treated patients (DIONYSOS) Thyroid event Dronedarone (n = 249) Amiodarone (n = 255) Absolute Difference 3 (1.2%) 20 (7.8%) 6.6% Neurological Event(sleep disorders and tremor) 3 (1.2%) 24 (9.4%) 8.2% Skin Event (Photosensitivity reaction) 3 (1.2%) 5 (2.0%) 0.8% Dronedarone (n = 249) Amiodarone (n = 255) Absolute Difference Overall incidence of treatment emergent adverse effects (TEAEs) 60.6% 67.5% 6.9% Incidence of serious TEAEs 13.7% 14.5% 0.8% Serious TEAEs of Hepatobiliary Disorders 2 (0.8%) 2 (0.8%) --- Incidence of AEs leading to premature study drug discontinuation 12.9% 17.6% 4.7% 2 (0.8%) 5 (2.0%) 1.2% Deaths (on study period) 4 (1.6%) 7 (2.7%) 1.1% QTcB interval above 500 msec 10.9% 20.5% 9.6% Low hemoglobin values 1.3% 4.7% 3.4% Table 5 – Additional adverse events (DIONYSOS) Deaths (on treatment period) # # Last drug intake plus 10 days It is important to note there were no cases of torsades de pointes, or pulmonary events in either group. There were a higher proportion of patients with bradycardia and conduction disorders in the amiodarone group compared to dronedarone (number of patients not reported). In those patients taking oral anticoagulation the risk of hemorrhage was decreased by 50% in the dronedarone group compared to the amiodarone group (numbers of patients not reported). Along with thyroid events, thyroid abnormalities were also higher in the dronedarone group compared to the amiodarone group. Safety Conclusion: Other than non-serious gastrointestinal adverse effects it appears from the sponsor that dronedarone is safer than amiodarone in this 12 month analysis. Overall DIONYSOS Conclusion In an unpublished multicenter, randomized, double-blind, parallel-arm study to compare the safety and efficacy of dronedarone versus amiodarone to maintain sinus rhythm in patients with AF it appears that dronedarone is safer than amiodarone, but not as effective. The only available statement from the FDA, found in a FDA briefing document, was “…the effectiveness of dronedarone in preventing atrial fibrillation is substantially less than that of amiodarone.”10 Amiodarone is not FDA approved for the treatment of AF, and has not been proven safe or effective for the conversion or maintenance treatment of AF/AFL. TOP 200 Drugs In May, Drug Topics has published the top 200 branded and generic drugs by retail dollars and total prescriptions in 2008. Each of the top 200 drug lists can be found from the table below. 2008 Top 200 Drugs 10 Source US Food and Drug Administration. Multaq (Dronedarone) – Briefing Document – Advisory Committee Meeting of the Cardiovascular and Renal Drugs Division of the US Food and Drug Administration. March 18, 2009. At http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/Cardiova scularandRenalDrugsAdvisoryCommittee/UCM176354.pdf. Accessed 8/10/09. Branded drugs by total prescriptions http://drugtopics.modernmedicine.com/dr ugtopics/data/articlestandard//drugtopics/ 222009/599845/article.pdf Branded drugs by retail dollars http://drugtopics.modernmedicine.com/dr ugtopics/data/articlestandard//drugtopics/ 192009/597083/article.pdf Generic drugs by total prescriptions http://drugtopics.modernmedicine.com/dr ugtopics/data/articlestandard//drugtopics/ 222009/599844/article.pdf Generic drugs by retail dollars http://drugtopics.modernmedicine.com/dr ugtopics/data/articlestandard//drugtopics/ 192009/597086/article.pdf The top 200 drugs can be useful to give guidance on prescribing patterns throughout the United States and provide an avenue to teach students. Below is a table that can be converted into a poster for the “Top 100 Branded Drugs By Total Prescriptions” with brand/generic names, chemical structure, indications and usages, black box warnings, and total prescriptions. Feel free to use the poster as an educational tool. See attached PDF Table The Drug Information Letter is a publication of the Center for Drug Information and Research, LECOM School of Pharmacy, Erie, PA 16509 Editors: Sana R. Sukkari, B.Sc.Pharm., M.Phil LECOM School of Pharmacy G. Elliott Cook, Pharm.D., BCPS LECOM School of Pharmacy Erin Brown, Pharm.D. LECOM School of Pharmacy Larry D. Sasich, Pharm.D., MPH, FASHP LECOM School of Pharmacy Steven Levy, MD, FACP LECOM College of Medicine Matt Madurski Communications Assistant / Media Relations LECOM College of Medicine Ashok Philip, Ph.D. LECOM School of Pharmacy © Lake Erie College of Osteopathic Medicine. All material subject to this copyright may be photocopied or digitally reproduced only for noncommercial educational and scientific uses. Please contact the editor in writing for permission to reprint articles or portions of articles. Proper credit and copyright must accompany all reprinted material. Opinions expressed by individuals in this publication do not necessarily represent the official position of the School of Pharmacy Lake Erie College of Osteopathic Medicine unless otherwise noted. 2008 Top 100 Branded Drugs By Total Prescriptions Ashok Philip, Ph.D., G. Elliott Cook, Pharm.D., BCPS 1 LIPITOR (atorvastatin calcium) 2 NEXIUM (esomeprazole magnesium) 3 LEXAPRO (escitalopram oxalate) 4 SINGULAIR (montelukast sodium) 5 PLAVIX (clopidogrel bisulfate) 6 SYNTHROID (levothyroxine sodium) 7 PREVACID (lansoprazole) 8 9 ADVAIR DISKUS (fluticasone propionate & salmeterol) EFFEXOR XR (venlafaxine hydrochloride) 10 HOOC N MOA * Selective competitive inhibitor of HMGCoA reductase ZETIA (ezetimibe) Rxs: 26,267,000 Rxs:25,787,000 Rxs: 25,148,000 Rxs: 23,113,000 Rxs: 18,632,000 Rxs: 16,910,000 Indications and Usage * Treatment of GERD * Risk reduction of NSAID- associated Gastric Ulcer * H. pylori eradication to reduce the risk of Duodenal Ulcer Recurrence * Pathological hypersecretory conditions Including Zollinger-Ellison (Z-E) Syndrome Indications and Usage * Major Depressive Disorder * Generalized Anxiety Disorder Indications and Usage * Prophylaxis and chronic treatment of asthma * Prevention of exercise-induced bronchoconstriction * Relief of symptoms of allergic rhinitis, and perennial allergic rhinitis Indications and Usage * Reduction of atherothrombotic events: Recent MI, Recent Stroke or Established Peripheral Arterial Disease and Acute Coronary Syndromes Indications and Usage * Hypothyroidism * Pituitary TSH Suppression Indications and Usage * Short-Term Treatment of Active Duodenal Ulcer (DU) * H. pylori Eradication to Reduce Risk of DU Recurrence * Maintenance of Healed DU * Short-Term Treatment of Active Benign Gastric Ulcer(GU) * Healing of NSAID-Associated GU * Risk Reduction of NSAID-Associated GU * GERD * Maintenance of Healing of Erosive Esophagitis (EE) * Pathological Hypersecretory Conditions Including Z-E Syndrome Indications and Usage * Major Depressive Disorder * Generalized Anxiety Disorder * Social Anxiety Disorder * Panic Disorder MOA * Proton pump inhibitor that suppresses gastric acid secretion by inhibiting the + + gastric H /K ATPase at the secretory surface of gastric parietal cells 22 MOA * Escitalopram (S-enantiomer of racemic citalopram) inhibits CNS reuptake of serotonin (5-HT) BLACK BOX WARNING * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults TRICOR (fenofibrate) 23 CELEBREX (celecoxib) MOA * Inhibits physiologic actions of LTD4 at CysLT1 receptor MOA * A synthetic T4 that binds to thyroid receptor attached to DNA MOA * The active metabolite irreversibly inhibits binding of ADP to its platelet P2Y12 BLACK BOX WARNING receptor thereby inhibiting platelet * Do not use for the treatment of obesity aggregation or for weight loss 24 NASONEX (mometasone furoate monohydrate) 25 PREMARIN (conjugated estrogens) 26 LANTUS (insulin glargine) 27 VIAGRA (sildenafil citrate) Rxs: 17,820,000 Indications and Usage * Maintenance Treatment of Asthma * Maintenance Treatment of Chronic Obstructive Pulmonary Disease MOA * Fluticasone propionate is a synthetic trifluorinated corticosteroid with potent anti-inflammatory activity * Salmeterol is a selective, long-acting beta2-adrenergic agonist BLACK BOX WARNING * Increase risk of asthma-related death 28 YAZ (Drospirenone and ethinyl estradiol) Rxs: 10,997,000 MOA * Ezetimibe reduces blood cholesterol by inhibiting absorption of cholesterol by small intestine Rxs: 10,259,000 Rxs: 10,463,000 Rxs: 10,759,000 Indications and Usage * Osteoarthritis (OA) * Rheumatoid Arthritis (RA) * Juvenile Rheumatoid Arthritis (JRA) * Ankylosing Spondylitis (AS) * Acute Pain (AP) * Primary Dysmenorrhea (PD) * Familial Adenomatous Polyposis (FAP) Indications and Usage * Seasonal allergic and perennial allergic rhinitis * Prophylaxis of nasal symptoms of seasonal allergic rhinitis * Treatment of nasal polyps MOA * A corticosteroid demonstrating antiinflammatory properties MOA * An NSAID that selectively inhibits cyclooxygenase-2 (COX-2) Rxs: 10,442,000 Indications and Usage * Treatment: Moderate to severe vasomotor symptoms and vulvar and vaginal atrophy due to menopause, hypoestrogenism due to hypoganidism, castration or primary ovarian failure, breast cancer (palliation only), advanced androgen-dependent carcinoma of prostate (palliation only) * Prevention of postmenopausal osteoporosis Indications and Usage Rxs: 10,112,000 * Treatment of adult and pediatric patients with type 1 diabetes mellitus or adult Indications and Usage patients with type 2 diabetes mellitus * Treatment of erectile dysfunction (ED) MOA * Long-acting recombinant human insulin analog * Lowers blood glucose levels by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production * Inhibits lipolysis in adipocyte, inhibits proteolysis, and enhances protein synthesis MOA * Reduce elevated levels of gonadotropins (LH and FSH) in postmenopausal women BLACK BOX WARNING * Cardiovascular risk * Gastrointestinal risk MOA * Enhances effect of nitric oxide (NO) by inhibiting phosphodiesterase type 5 (PDE5) * NO activates guanylate cyclase, resulting in increased cGMP levels * cGMP causes smooth muscle relaxation and increased blood flow into corpus cavernosum * PDE5 degrades cGMP BLACK BOX WARNING * Endometrial cancer * Increased risk of MI, stroke, invasive breast cancer, pulmonary emboli, and DVT * Increased risk of dementia BENICAR HCT (olmesartan medoxomil and hydrochlorothiazide) 42 CYMBALTA (duloxetine hydrochloride) 14 PROAIR HFA (albuterol sulfate) 15 KLOR-CON (potassium chloride) S LYRICA (pregabalin) O N Rxs: 13,929,000 N N HN Rxs: 15,684,000 Indications and Usage * Hypertension * Heart Failure * Post-Myocardial Infarction 30 ADDERALL XR (Dextroamphetamine Sulfate, Dextroamphetamine saccharate, Amphetamine sulfate and Amphetamine aspartate) 31 VALTREX (valacyclovir hydrochloride) CH3 Rxs: 14,422,000 Rxs: 15,125,000 Indications and Usage * Hyperlipidemia and Mixed Dyslipidemia * Hypertriglyceridemia MOA * Homozygous Familial Rxs: 14,559,000 * Venlafaxine and its active metabolite, OHypercholesterolemia desmethylvenlafaxine are potent inhibitors MOA * Slowing of the Progression of Indications and Usage of neuronal serotonin and norepinephrine * Blocks vasoconstrictor and aldosterone- Atherosclerosis * Primary Hyperlipidemia reuptake and weak inhibitors of dopamine secreting effects of angiotensin II by * Homozygous Familial reuptake selectively blocking binding of angiotensin MOA Hypercholesterolemia (HoFH) * Selective and competitive inhibitor of II to the AT1 receptor in tissues, such as BLACK BOX WARNING vascular smooth muscle and the adrenal HMG-CoA reductase MOA * Increase risk of suicidal thinking and gland * Ezetimibe reduces blood cholesterol by suicidality in children, adolescents, and inhibiting absorption of cholesterol by young adults BLACK BOX WARNING small intestine * Use in pregnancy can cause injury and * Simvastatin (a prodrug) is hydrolyzed to its active β-hydroxyacid form (simvastatin even death to the developing fetus acid) Simvastatin is a specific inhibitor of HMG-CoA reductase 29 ARICEPT (donepezil hydrochloride) 43 ORTHO TRI-CYCLEN LO (norgestimate and ethinyl estradiol) 44 HYZAAR (losartan potassium and hydrochlorothiazide) 45 TRI-SPRINTEC (norgestimate and ethinyl estradiol) 46 CIALIS (tadalafil) 47 OXYCONTIN (oxycodone hydrochloride) Rxs: 9,962,000 Indications and Usage * Management of neuropathic pain associated with diabetic peripheral neuropathy * Management of postherpetic neuralgia * Adjunctive therapy for adult patients with Rxs: 8,799,000 partial onset seizures Indications and Usage * Management of fibromyalgia * Treatment of Attention Deficit Hyperactivity Disorder (ADHD) MOA Indications and Usage * Prevention of pregnancy (Oral contraception) * Treatment of symptoms of premenstrual * Binds with high affinity to alpha2-delta dysphoric disorder (PMDD) subunit of voltage-gated calcium channels and inhibits release of excitatory MOA neurotransmitter ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium drospirenone: * Spiranolactone analog with antimineralocorticoid activity * Exhibits antiandrogenic activity BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects 48 ACIPHEX (rabeprazole sodium) 49 LUNESTA (eszopiclone) MOA * Non-catecholamine sympathomimetic amines with CNS stimulant activity * Amphetamines block reuptake of norepinephrine and dopamine into presynaptic neuron and increase release of these monoamines into extraneuronal space 32 COZAAR (losartan potassium) Rxs: 8,521,000 Indications and Usage * Herpes Zoster * Genital Herpes * Cold Sores (Herpes Labialis) MOA * Rapidly converted to acyclovir * Competitive inhibition of viral DNA polymerase * Incorporation and termination of the growing viral DNA chain * Inactivation of viral DNA polymerase Indications and Usage * Major Depressive Disorder * Generalized Anxiety Disorder * Diabetic Peripheral Neuropathic Pain * Fibromyalgia MOA * Potent inhibitor of neuronal serotonin and norepinephrine reuptake BLACK BOX WARNING * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults 33 TOPAMAX (topiramate) LAMICTAL (lamotrigine) Rxs: 8,389,000 Indications and Usage * Bronchospasm * Exercise-Induced Bronchospasm MOA * A beta2-adrenergic agonist * Activation of beta2-adrenergic receptors leads to activation of adenylcyclase and to an increase in intracellular concentration of cAMP. This increase of cAMP is associated with activation of protein kinase A, which in turn inhibits phosphorylation of myosin and lowers intracellular ionic calcium concentrations, resulting in muscle relaxation 34 CONCERTA (Methylphenidate hydrochloride) Indications and Usage * Hypertension * Hypertensive patients with left ventricular hypertrophy * Nephropathy in type 2 diabetic patients MOA * Blocks vasoconstrictor and aldosteronesecreting effects of angiotensin II by selectively blocking binding of angiotensin II to the AT1 receptor in tissues, such as vascular smooth muscle and the adrenal gland Rxs: 7,888,000 Rxs: 7,863,000 Indications and Usage * Monotherapy - Epilepsy * Adjunctive Therapy - Epilepsy * Migraine prophylaxis Indications and Usage * Attention Deficit Hyperactivity Disorder (ADHD) MOA * Blocks voltage-dependent sodium channels * Augments activity of GABA at some subtypes of GABA-A receptor * Antagonizes AMPA/kainate subtype of the glutamate receptor * Inhibits carbonic anhydrase enzyme, particularly isozymes II and IV 17 LEVAQUIN (levofloxacin) 18 ACTOS (pioglitazone hydrochloride) Indications and Usage * Hypokalemia with or without metabolic acidosis * Digitalis intoxication * Hypokalemic periodic familial periodic paralysis * Prevention of Hypokalemia MOA + * K the principal intracellular cation participates in a number of essential physiological processes that include maintenance of intracellular tonicity, transmission of nerve impulses, contraction of cardiac, skeletal and smooth muscle maintenance of normal renal function 35 LEVOXYL (levothyroxine sodium) 51 DETROL LA (tolterodine tartrate) 52 CHANTIX (varenicline tartrate) MOA * A racemic mixture comprised of the Dand L-isomers * D-isomer is more pharmacologically active than L-isomer * Block reuptake of norepinephrine and dopamine into presynaptic neuron and increase release of these monoamines into extraneuronal space Rxs: 7,745,000 Indications and Usage * Hypothyroidism * Pituitary TSH Suppression MOA * A synthetic T4 that binds to thyroid receptor attached to DNA BLACK BOX WARNING * Do not use for the treatment of obesity or for weight loss Rxs:12,898,000 Rxs:13,196,000 Indications and Usage * Hypertension Indications and Usage * Nosocomial Pneumonia * Community-Acquired Pneumonia * Acute Bacterial Sinusitis * Acute Bacterial Exacerbation of Chronic Bronchitis * Complicated & Uncomplicated Skin and Skin Structure Infections * Chronic Bacterial Prostatitis * Complicated & Uncomplicated Urinary Tract Infections * Acute Pyelonephritis * Inhalational Anthrax (Post-Exposure) 19 FLOMAX (tamsulosin hydrochloride) MOA * Valsartan blocks vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in tissues, such as vascular smooth muscle and the adrenal gland * Hydrochlorothiazide affects renal MOA tubular mechanisms of electrolyte * Inhibition of bacterial topoisomerase IV reabsorption, directly increasing excretion and DNA gyrase of Na and Cl in approximately equivalent amounts BLACK BOX WARNING Increased risk of tendinitis and tendon BLACK BOX WARNING rupture * Use in pregnancy can cause injury and even death to the developing fetus 37 AMBIEN CR 36 ACTONEL (zolpidem tartrate) (risedronate sodium) Rxs: 7,261,000 Indications and Usage * Postmenopausal Osteoporosis * Osteoporosis in Men * Glucocorticoid-Induced Osteoporosis * Paget's Disease MOA * Exhibits affinity for hydroxyapatite crystals in bone and acts as an antiresorptive agent * At cellular level inhibits osteoclasts Rxs:12,518,000 Rxs:11,576,000 Indications and Usage * Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Indications and Usage * Treatment of signs and symptoms of benign prostatic hyperplasia (BPH) MOA * Potent agonist for peroxisome proliferator-activated receptor-gamma (PPARγ) 53 AVAPRO (irbesartan) 54 PROVENTIL HFA (albuterol sulfate) 55 ABILIFY (aripiprazole) 56 YASMIN 28 (drospirenone and ethinyl estradiol) MOA * A selective alpha1A adrenoceptor blocking agent in the human prostate. Approximately 70% of the alpha1receptors in human prostate are of the alpha1A subtype BLACK BOX WARNING * May cause or exacerbate congestive heart failure * Not recommended in patient with symptomatic heart failure 20 SEROQUEL (quetiapine fumarate) 38 SPIRIVA (tiotropium bromide monohydrate) 39 BENICAR (olmesartan medoxomil) 40 XALATAN (latanoprost) Rxs: 6,251,000 Indications and Usage Rxs: 7,121,000 * Treatment of insomnia, characterized by difficulties with sleep onset and/or sleep Indications and Usage maintenance * Maintenance treatment of bronchospasm associated with chronic MOA obstructive pulmonary disease (COPD), * Binds the BZ1 receptor preferentially including chronic bronchitis and with a high affinity ratio of the emphysema alpha1/alpha5 subunits MOA * Long-acting, antimuscarinic agent * In the airways inhibits M3-receptors at the smooth muscle leading to bronchodilation BUDEPRION XL (bupropion) Indications and Usage * Depressive episodes associated with bipolar disorder * acute manic episodes associated with bipolar I disorder as either monotherapy or adjunct therapy to lithium or divalproex * Schizophrenia MOA * Atypical antipsychotic with D2 and 5HT2A antagonism Also antagonizes H1, alpha 1 and alpha 2 receptors Rxs: 7,214,000 57 Rxs:11,509,000 BLACK BOX WARNING * Increased mortality in elderly patients with dementia-related psychosis * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults BLACK BOX WARNING * Drug dependence, use with caution in patients with a history of drug dependence or alcoholism BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus BLACK BOX WARNING * High potential for abuse * Misuse may cause sudden death and serious cardiovascular adverse effects 50 16 DIOVAN HCT (valsartan and hydrochlorothiazide) KCl Rxs: 13,549,000 Rxs: 9,845,000 Indications and Usage * Treatment of Hypercholesterolemia * Treatment of Hypertriglyceridemia Indications and Usage * Primary Hyperlipidemia – Monotherapy, MOA combination w/ statins, combination w/ * Activates peroxisome proliferator fenofibrate activated receptor α (PPARα) * Homozygous Familial Fenofibric acid is the active metabolite of hypercholesterolemia (HoFH) fenofibrate * Homozygous Sitosterolemia Rxs: 11,046,000 41 13 O OCH3 Rxs: 26,856,000 MOA + + * Specific inhibition of H /K -ATPase pump in gastric parietal cell 21 VYTORIN (ezetimibe and simvastatin) CH3 HN Indications and Usage * Prevention of cardiovascular disease * Hypercholesterolemia 12 CH3 N H3C Rxs: 49,043,000 CRESTOR (rosuvastatin calcium) CH3 H N S N 11 DIOVAN (valsartan) O H3C H3CO 58 NIASPAN (niacin) Rxs: 6,821,000 Indications and Usage * Hypertension Indications and Usage * Reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension. MOA MOA * Reduces intraocular pressure (IOP) by * Blocks vasoconstrictor and aldosteroneincreasing the outflow of aqueous humor secreting effects of angiotensin II by selectively blocking binding of angiotensin II to the AT1 receptor in tissues, such as vascular smooth muscle and the adrenal gland BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus 59 COMBIVENT (ipratropium bromide and albuterol sulfate) 60 JANUVIA (sitagliptin) F F N H H3C H3C O Rxs: 5,381,000 O Rxs: 6,,214,000 Rxs: 6,235,000 Indications and Usage * Mild, moderate and severe Alzheimer's disease Indications and Usage * Hypertension MOA * Postulated to exert its therapeutic effect MOA by enhancing cholinergic function. This is * Olemesartan: accomplished by increasing the Blocks vasoconstrictor and aldosterone- concentration of acetylcholine through secreting effects of angiotensin II by reversible inhibition of its hydrolysis by selectively blocking binding of angiotensin acetylcholinesterase II to the AT1 receptor in tissues, such as vascular smooth muscle and the adrenal gland * Hydrochlorothiazide: Affects renal tubular mechanisms of electrolyte reabsorption, directly increasing excretion of Na and Cl in approximately equivalent amounts BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus 61 BONIVA (ibandronate sodium) NH2 O N N Rxs: 5,221,000 O 62 TRINESSA (norgestimate and ethinyl estradiol) Rxs: 5,780,000 Rxs: 6,069,000 Rxs: 6,,021,000 Indications and Usage * Prevention of pregnancy (Oral contraception) MOA ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium * norgestimate: and 17-deacetyl norgestimate (major serum metabolite) combine high progestational activity with minimal intrinsic androgenicity BLACK BOX WARNING * Does not protect against HIV infection (AIDS) and other STDs 63 NUVARING (etonogestrel and ethinyl estradiol) Indications and Usage * Hypertension * Hypertensive patients with left ventricular hypertrophy Indications and Usage * Prevention of pregnancy (Oral contraception) * Treatment of moderate acne vulgaris in females MOA losaratan: * Blocks vasoconstrictor and aldosteronesecreting effects of angiotensin II by selectively blocking binding of angiotensin II to the AT1 receptor in tissues Hydrochlorothiazide: * Affects renal tubular mechanisms of electrolyte reabsorption, directly increasing excretion of Na and Cl in approximately equivalent amounts MOA ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium * norgestimate: and 17-deacetyl norgestimate (major serum metabolite) combine high progestational activity with minimal intrinsic androgenicity BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects 64 65 RISPERDAL (risperidone) POLYMAGMA PLAIN Rxs: 5,689,000 Rxs: 5,601,000 Rxs: 5,677,000 Indications and Usage Indications and Usage * Management of moderate to severe pain Rxs: 5,675,000 * Treatment of erectile dysfunction when a continuous, around-the-clock analgesic is needed for extended period Indications and Usage * Healing of Erosive or Ulcerative GERD MOA of time * Maintenance of healing of erosive of * Inhibition of phosphodiesterase type 5 Ulcerative GERD (PDE5) enhances erectile function by MOA * Treatment of Symptomatic GERD increasing the amount of cGMP. * Oxycodone is a pure opioid agonist * Healing of Duodenal Ulcers * cGMP causes smooth muscle relaxation whose principal therapeutic action is * Helicobacter pylori eradication to reduce and increased blood flow into corpus analgesia risk of Duodenal Ulcer recurrence cavernosum * Treatment of pathological BLACK BOX WARNING hypersecretory conditions, including Z-E * Schedule II, with an abuse liability syndrome similar to morphine * 80 and 160 mg for use in opioid-tolerant MOA patients only * Not intended for use as a PRN analgesic * Proton pump inhibitor that suppresses gastric acid secretion by inhibiting the * Swallow whole, not to be broken, + + gastric H /K -ATPase at the secretory chewed or crushed surface of gastric parietal cells Rxs: 5,423,000 Rxs: 5,622,000 Indications and Usage Indications and Usage * Epilepsy: * Treatment of overactive bladder with Indications and Usage Adjunctive Therapy: Partial seizures, * Treatment of insomnia, decreased sleep Primary generalized tonic-clonic seizures, symptoms of urge urinary incontinence, latency and improved sleep maintenance Generalized seizures of Lennox-Gastaut urgency, and frequency syndrome MOA Monotherapy: Conversion to monotherapy MOA * Tolterodine and its active metabolite 5* Nonbenzodiazepine hypnotic of the in adults with partial seizures hydroxymethyl are competitive muscarinic cyclopyrrolone class receptor antagonists * Effect is believed to result from MOA interaction with GABA-receptor complexes * Inhibits voltage-sensitive sodium at binding domains located closely to or channels and thereby stabilizing neuronal allosterically coupled to benzodiazepine membranes and consequently modulating receptors release of presynaptic excitatory amino Rxs: 5,243,000 Indications and Usage * Aid to smoking cessation treatment MOA * Binds with high affinity and selectivity at α4β2 neuronal nicotinic acetylcholine receptors * The efficacy of CHANTIX in smoking cessation is believed to be the result of its agonistic effects at the nicotinic receptor, while simultaneously preventing nicotine binding to α4β2 receptors acids (Glutamate and Aspartate) BLACK BOX WARNING * Serious skin rashes Indications and Usage * Bronchospasm * Exercise-Induced Bronchospasm Rxs: 5,330,000 MOA * A beta2-adrenergic agonist Indications and Usage * Activation of beta2-adrenergic receptors * Hypertension leads to activation of adenylcyclase and to * Nephropathy in Type 2 Diabetic Patients an increase in intracellular concentration of cAMP. This increase of cAMP is MOA associated with activation of protein * Blocks vasoconstrictor and aldosteronekinase A, which in turn inhibits secreting effects of angiotensin II by phosphorylation of myosin and lowers selectively blocking binding of angiotensin intracellular ionic calcium concentrations, II to the AT1 receptor in tissues, such as resulting in muscle relaxation vascular smooth muscle and the adrenal gland BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus Indications and Usage * Schizophrenia * Bipolar Disorder * Adjunctive Treatment of Major Depressive Disorder * As an injection for agitation Associated with Schizophrenia or Bipolar Mania MOA * Mediated through a combination of partial agonist activity at D2 and 5-HT1A receptors and antagonist activity at 5HT2A receptors F N Rxs: 5,083,000 Rxs: 5,146,000 Indications and Usage * Major depressive disorder Rxs: 5,157,000 Indications and Usage * Prevention of pregnancy (Oral contraception) BLACK BOX WARNING * Increased mortality in elderly patients with dementia-related psychosis * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults MOA ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium drospirenone: * Spiranolactone analog with antimineralocorticoid activity * Exhibits antiandrogenic activity 75 76 MOA * Weak inhibitor of neuronal uptake of norepinephrine and dopamine BLACK BOX WARNING * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults MOA * Partial inhibition of release of free fatty acids from adipose tissue * Increases lipoprotein lipase activity, which may increase the rate of chylomicron triglyceride removal from plasma 77 78 N CF3 Indications and Usage * Primary hyperlipidemia * Mixed dyslipidemia * Reduce risk of recurrent non-fatal myocardial infarction Rxs: 4,878,000 * Slow progression or promote regression of atherosclerotic disease Indications and Usage * Severe hypertriglyceridemia * COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator Rxs: 4,868,000 Indications and Usage * Monotherapy and Combination Therapy to improve glycemic control in type 2 diabetes mellitus MOA: * DPP 4 inhibitor * DPP 4 is the primary protease responsible for degrading incretin hormones (GLP-1 and GIP) MOA: * ipratropium bromide: Anticholinerigic agent * albuterol: β2 adrenergic agonist BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects 66 FLOVENT HFA (fluticasone propionate) 67 IMITREX (sumatriptan succinate) 68 EVISTA (raloxifene hydrochloride) 69 AVELOX (moxifloxacin hydrochloride) 70 DEPAKOTE ER (divalproex sodium) 71 PROTONIX (pantoprazole sodium) 72 AVALIDE (irbesartan and hydrochlorothiazide) 73 LIDODERM (Lidocaine) 74 ZYPREXA (olanzapine) NAMENDA (memantine hydrochloride) A hydrated silicate of aluminum and magnesium TUSSIONEX (hydrocodone polistirex and chlorpheniramine polistirex) ARMOUR THYROID (thyroid tablets) HUMALOG (insulin lispro) 79 VIGAMOX (moxifloxacin hydrochloride) 80 TAMIFLU (oseltamivir phosphate) Rxs: 4,476,000 Indications and Usage * Management of diarrhea Rxs: 4,789,000 Indications and Usage * Treatment and Prevention of Postmenopausal Osteoporosis MOA * Exhibits affinity for hydroxyapatite crystals in bone and acts as an antiresorptive agent * At cellular level inhibits osteoclasts Rxs: 4,633,000 Rxs: 4,783,000 Rxs: 4,733,000 Indications and Usage * Prevention of pregnancy (Oral contraception) * Treatment of moderate acne vulgaris in females Indications and Usage * Prevention of pregnancy (Oral contraception) MOA ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium norgestimate: * norgestimate and 17-deacetyl norgestimate (major serum metabolite) combine high progestational activity with minimal intrinsic androgenicity Indications and Usage * Schizophrenia * Bipolar Mania * Irritability Associated with Autistic Disorder MOA * Works by adsorbing (binding) large numbers of bacteria and toxins and reducing the loss of water MOA * Mediated through a combination of dopamine Type 2 (D2) and serotonin Type 2 (5HT2) receptor antagonism MOA * Combination hormonal contraceptives act by suppression of gonadotropins * Primary effect of this action is inhibition of ovulation BLACK BOX WARNING * Other alterations include changes in the * Increased mortality in elderly patients cervical mucus (which increase the with dementia-related psychosis difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation) Rxs: 4,313,000 Rxs: 4,400,000 Indications and Usage * Treatment and rrevention of Indications and Usage * Acute treatment of migraine attacks with osteoporosis in postmenopausal women * Reduction in risk of invasive breast or without aura in adults cancer in postmenopausal women with osteoporosis MOA * Reduction in risk of invasive breast * A selective agonist of vascular 5cancer in postmenopausal women at high hydroxytryptamine 1 (5-HT1D & 5-HT1B) risk of invasive breast cancer receptor family * Activation of these receptors causes MOA MOA vasoconstriction (an action in humans * Anti-inflammatory actions of correlating with the relief of migraine and * A selective estrogen receptor modulator (SERM) corticosteroids contribute to their efficacy cluster headache) * As an estrogen agonist in bone, in asthma decreases bone resorption and bone turnover, increases bone mineral density (BMD) and decreases fracture incidence Rxs: 4,403,000 Indications and Usage * Maintenance treatment of asthma as prophylactic therapy in patients 4 years of age and older * Also indicated for patients requiring oral corticosteroid therapy for asthma BLACK BOX WARNING * Increased risk of venous thromboembolism and death from stroke BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects 81 BUDEPRION SR (bupropion) 82 SUBOXONE (buprenorphine hydrochloride and naloxone hydrochloride) Rxs: 4,086,000 Indications and Usage * Acute bacterial sinusitis * Acute bacterial exacerbation of chronic bronchitis * Community acquired pneumonia * Complicated and uncomplicated skin and skin structure infections * Complicated intra-abdominal infections MOA * Inhibits topoisomerase II (DNA gyrase) and topoisomerase IV required for bacterial DNA replication, transcription, repair, and recombination * C8-methoxy moiety contributes to enhanced activity and lower selection of resistant mutants of gram-positive bacteria * Bulky bicycloamine substituent at C-7 prevents active efflux Rxs: 3,860,000 Rxs: 4,059,000 Indications and Usage * Mania * Epilepsy * Migraine Rxs: 4,023,000 Rxs: 4,044,000 Indications and Usage MOA * Short-term treatment of erosive * Divalproex sodium dissociates to the esophagitis associated with GERD valproate ion in gastrointestinal tract * Maintenance of healing of erosive * Suggested activity in epilepsy is related esophagitis to increased brain concentrations of * Pathological hypersecretory conditions gamma-aminobutyric acid (GABA) including Z-E syndrome BLACK BOX WARNING * Hepatotoxicity * Teratogenicity * Pancreatitis MOA * Proton pump inhibitor that suppresses gastric acid secretion by inhibiting the + + gastric H /K ATPase at the secretory surface of gastric parietal cells Indications and Usage * Hypertension Indications and Usage * Relief of pain associated with postherpetic neuralgia MOA * Lidocaine is an amide-type local MOA anesthetic agent and is suggested to * Irbesartan: Blocks vasoconstrictor and aldosterone- stabilize neuronal membranes by inhibiting the ionic fluxes required for the secreting effects of angiotensin II by selectively blocking binding of angiotensin initiation and conduction of impulses II to the AT1 receptor in tissues, such as vascular smooth muscle and the adrenal gland * hydrochlorthiazide: Affects renal tubular mechanisms of electrolyte reabsorption, directly increasing excretion of Na and Cl in approximately equivalent amounts BLACK BOX WARNING * Use in pregnancy can cause injury and even death to the developing fetus LANOXIN (digoxin) 84 LOESTRIN 24 Fe (norethindrone acetate and ethinyl estradiol) 85 AVODART (dutasteride) 86 COUMADIN (warfarin sodium) 87 WELLBUTRIN XL (bupropion) 88 ENDOCET (acetaminophen and oxycodone) * Increased risk of tendinitis and tendon rupture 89 SKELAXIN (metaxalone) 90 NASACORT AQ (triamcinolone acetonide) 91 KEPPRA (levetiracetam) Rxs: 3,806,000 Indications and Usage * Schizophrenia * Bipolar I Disorder (Manic or Mixed Episodes) * ZYPREXA IntraMuscular: Agitation Associated with Schizophrenia and Bipolar I Mania * ZYPREXA and Fluoxetine in Combination: Depressive Episodes Associated with Bipolar I Disorder * ZYPREXA and Fluoxetine in Combination: Treatment Resistant Depression Indications and Usage * Treatment of moderate to severe dementia of the Alzheimer's type Rxs: 3,722,000 Rxs: 3,738,000 Rxs: 3,789,000 MOA * A low to moderate affinity uncompetitive Indications and Usage (open-channel) NMDA receptor antagonist * Relief of cough and upper respiratory which binds preferentially to the NMDA symptoms associated with allergy or a receptor-operated cation channels cold in adults and children 6 years of age and older Indications and Usage * Replacement or supplemental therapy in patients with hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis * In the treatment or prevention of various types of euthyroid goiters MOA * As diagnostic agents in suppression * A semisynthetic narcotic antitussive and tests to differentiate suspected mild analgesic and is believed to act directly on hyperthyroidism or thyroid gland the cough center autonomy * Chlorpheniramine is an H1 receptor antagonist that also possesses MOA anticholinergic and sedative activity * A natural T3 and T4 that binds to thyroid receptor attached to DNA MOA * Efficacy in Schizophrenia is mediated through a combination of dopamine and serotonin type 2 (5HT2) antagonism * MOA of in the treatment of acute manic or mixed episodes associated with Bipolar I Disorder is unknown 93 92 ALLEGRA-D 12 Hour (fexofenadine HCl and pseudophedrine HCl) STRATTERA (atomoxetine HCl) 94 LOVAZA (omega-3-acid ethyl esters) Indications and Usage * Treatment of patients with diabetes mellitus for the control of hyperglycemia Rxs: 3,545,000 Indications and Usage * Treatment of bacterial conjunctivitis MOA MOA * Inhibits topoisomerase II (DNA gyrase) * A rapid-acting agent and topoisomerase IV required for * Regulation of glucose metabolism * In muscle and other tissues (except the bacterial DNA replication, transcription, brain): Causes rapid transport of glucose repair, and recombination & amino acids intracellularly, promotes anabolism, and inhibits protein catabolism * In the liver: Promotes uptake and storage of glucose in form of glycogen, inhibits gluconeogenesis, and promotes conversion of excess glucose into fat Rxs: 3,468,000 Indications and Usage * Treatment of Influenza * Prophylaxis of Influenza MOA * An ethyl ester prodrug requiring ester hydrolysis for conversion to the active form, oseltamivir carboxylate * Oseltamivir carboxylate is an inhibitor of influenza virus neuraminidase BLACK BOX WARNING * Do not use for the treatment of obesity or for weight loss BLACK BOX WARNING * Increased mortality in elderly patients with dementia-related psychosis BLACK BOX WARNING 83 Rxs: 3,813,000 95 AVANDIA (rosiglitazone) 96 OCELLA (drospirenone and ethinyl estradiol) 97 VYVANSE (lisdexamfetamine dimesylate) 98 TOPROL XL (metoprolol succinate) 99 LEVITRA (vardenafil) 100 ASTELIN (azelastine HCl) Rxs: 3,088,000 Indications and Usage * Major depressive disorder MOA * Weak inhibitor of neuronal uptake of norepinephrine and dopamine BLACK BOX WARNING * Increase risk of suicidal thinking and suicidality in children, adolescents, and young adults Rxs: 3,439,000 Indications and Usage * Treatment of opioid dependence MOA * buprenorphine: Partial opioid agonist at μ and Κ receptors * naloxone: Non-specific opioid antagonist Indications and Usage * Mild to moderate heart failure * Control of ventricular response rate in patients with chronic atrial fibrillation MOA * Inhibits sodium-potassium ATPase, an enzyme that regulates the quantity of sodium and potassium inside cells Rxs: 3,218,000 Rxs: 3,303,000 Rxs: 3,385,000 Rxs: 3,462,000 Rxs: 3,315,000 Rxs: 3,379,000 Indications and Usage * Prevention of pregnancy (Oral contraception) MOA * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium BLACK BOX WARNING * Smoking increases the risk of serious cardiovascular side effects Indications and Usage * Monotherapy; Treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate * Combination: With alpha-blocker tamsulosin is indicated for treatment of symptomatic BPH in men with an enlarged prostate Indications and Usage * Prophylaxis and/or treatment of venous thrombosis and its extension, and pulmonary embolism * Prophylaxis and/or treatment of thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement * To reduce risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction Indications and Usage * Adjunct to rest, physical therapy, and other measures for relief of discomforts associated with acute, painful musculoskeletal conditions Rxs: 3,301,000 Rxs: 3,255,000 Indications and Usage * Major depressive disorder Indications and Usage * Moderate to severe pain MOA * Weak inhibitor of neuronal uptake of norepinephrine and dopamine MOA * oxycodone: A semisynthetic pure opioid MOA agonist whose principal therapeutic action * May be due to general central nervous system depression is analgesia * acetaminophen: A non-opiate, nonsalicylate analgesic and antipyretic * Site and mechanism for analgesic effect of acetaminophen has not been determined * Antipyretic effect of acetaminophen is accomplished through inhibition of endogenous pyrogen action on hypothalamic heat-r egulating centers BLACK BOX WARNING MOA * Increase risk of suicidal thinking and * A competitive and non-selective inhibitor suicidality in children, adolescents, and of type 1 and type 2 5α-reductase young adults MOA * Conversion of testosterone to * Inhibit synthesis of vitamin K dependent dihydrotestosterone (DHT) is inhibited clotting factors (Factors II, VII, IX and X) * DHT (androgen) primarily responsible for and anticoagulant proteins C and S initial development and subsequent enlargement of prostate gland BLACK BOX WARNING Bleeding risk Rxs: 3,126,000 Rxs: 3,195,000 Rxs: 3,206,000 Indications and Usage * Treatment of nasal symptoms of seasonal and perennial allergic rhinitis MOA * A corticosteroid demonstrating antiinflammatory properties Indications and Usage * Treatment of partial onset seizures * Treatment of myoclonic seizures * Treatment of primary generalized tonicclonic seizures MOA * Thought to interact with SV2A protein which may contribute to antiepileptic action Rxs: 3,138,000 Rxs: 3,130,000 Indications and Usage * Seasonal allergic rhinitis Indications and Usage * ADHD MOA * fexofenadine: Selective peripheral H1 receptor antagonist * pseudophedrine: Mixed acting sympathomimetic which exerts a nasal decongestant action MOA * Thought to be related to selective inhibition of pre-synaptic norepinephrine transporter BLACK BOX WARNING * Suicidal ideation in children and adolescents Indications and Usage * Adjunct to diet to reduce triglyceride levels Rxs: 3,103,000 Indications and Usage * ADHD Indications and Usage * To improve glycemic control in adults with type 2 diabetes MOA MOA * Highly selective and potent agonist for * Inhibition of acyl CoA: 1,2-diacylglycerol the peroxisome proliferator-activated acyl transferase, increased mitochondrial receptor-gamma (PPARγ) and peroxisomal β-oxidation in liver, decreased lipogenesis in liver and BLACK BOX WARNING increased plasma lipoprotein lipase * May cause or exacerbate congestive activity heart failure * Not recommended in patient with symptomatic heart failure * Increase risk of MI Rxs: 3,091,000 Indications and Usage * Prevention of pregnancy (Oral contraception) MOA ethinyl estradiol: * Act by suppression of gonadotropins * Primarily act by inhibition of ovulation * Changes in cervical mucus and endometrium drospirenone: * Spiranolactone analog with antimineralocorticoid activity * Exhibits antiandrogenic activity BLACK BOX WARNING *Smoking increases the risk of serious cardiovascular side effects References: Drug Topics. 2008 Top 200 branded drugs by total prescriptions. At: http://drugtopics.modernmedicine.com /drugtopics/data/articlestandard//drugt opics/222009/599845/article.pdf. Accessed: July, 21, 2009. DailyMed. Professional Product Labels accessed at: http://dailymed.nlm.nih.gov/dailymed/a bout.cfm. MOA * Prodrug of dextroamphetamine * Amphetamines block reuptake of norepinephrine and dopamine into presynaptic neuron and increase release of these monoamines into extraneuronal space BLACK BOX WARNING * High potential for abuse * Misuse may cause sudden death and serious cardiovascular adverse effects Rxs: 2,812,000 Rxs: 3,060,000 Indications and Usage * Hypertension * Angina pectoris * Heart failure MOA *Selective β1-blocker Rxs: 2,835,000 Indications and Usage * ED Indications and Usage * Seasonal allergic rhinitis * Vasomotor rhinitis MOA * H1 receptor antagonist * Major metabolite desmethyl azelastine also possess H1 receptor antagonism MOA * Inhibition of phosphodiesterase type 5 (PDE5) enhances erectile function by increasing the amount of cGMP. * cGMP causes smooth muscle relaxation and increased blood flow into corpus cavernosum
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