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HOSPICE PHARMACIA
MUGs
®
Medication Use Guidelines
- 1 0 TH E D I T I O N [ UP DATED J ULY 2 01 2 ]
INFORMATION REGARDING THE JULY 2012 UPDATE:
Duoneb and Miralax are now included in the Medication Use Guidelines (MUGs).
For your reference, these additions resulted in updates to pages:
54.1, 55.1, 73.2, 75.1, 76.1, 149.1, 155.2, 159.2, 161.2.
Dear Colleague,
Hospice Pharmacia is pleased to present you with the leading resource for hospice pharmaceutical
care, the Hospice Pharmacia Medication Use Guidelines (MUGs®). The MUGs, now in its 10th
edition, provide information to help you select clinically appropriate, cost-effective medications
for your hospice patients.
These guidelines were developed with input from administrators, medical directors, physicians,
nurse practitioners, directors of nursing, staff nurses and consultant pharmacists practicing
hospice and palliative care across the country. This edition is thoroughly updated to include new
medications for depression and herpes zoster, expanded indications for existing medications, the
latest dosing information, and revised algorithms. In addition, it has been reorganized to include
tables of medications and cost information for pharmacologic therapy outside the per diem.
The MUGs are an ever-changing clinical and cost reference source that is modified and reviewed
continuously through a Pharmacy and Therapeutics Committee. With this edition, going
forward, the MUGs are bound in a format that allows sections to be updated without the need
to replace the MUGs in its entirety. This will help to ensure that you always have the most up-todate information.
Hospice Pharmacia is proud to provide the 10th anniversary edition of the MUGs. We hope
the information in the MUGs will help further improve the quality of life for hospice patients
in your care settings. As always, your comments and suggestions for future improvements are
welcomed and valued. Thank you for the opportunity to work together to positively impact the
care of your hospice patients.
Professionally,
Kevin T. Bain, PharmD, MPH, BCPS, CGP, FASCP
Vice President, Clinical Support
Hospice Pharmacia, Philadelphia, PA
The Hospice Pharmacia Medication Use Guidelines
| i |
Mission & Corporate Values
MISSION
To advance public health and well-being through a passionate commitment to the appropriate use
of medication.
CORPORATE VALUES:
Value 1: Passion
Ensuring the appropriate use of medication
Value 2: Dedication
Taking responsibility to improve patient care
Value 3: Leadership
Strategizing continually to provide efficient, effective, and quality services
Value 4: Professionalism
Creating measurable value with our patients, partners, and team members
Value 5: Innovation
Fostering an environment of success through evidence-based science, continual discovery, knowledge, and experience
| ii | The Hospice Pharmacia Medication Use Guidelines
Table of Contents
WELCOME TO HOSPICE PHARMACIA
1
ESSENTIAL USER GUIDE TO HP SERVICES
1
HP IMPORTANT CONTACT INFORMATION
4
HOW TO USE THE MUGs
5
IMPORTANT INSTRUCTIONS FOR USE
5
EXAMPLE SECTION OF THE MUGs
6
MEDICATION OVERVIEW
7
SUGGESTED DOSING
7
ROUTE OF ADMINISTRATION
7
COMPOUNDS7
HP MEDICATION PAKS
8
PER DIEM INCLUSIONS
12
MEDICATIONS with CRITERIA
13
MEDICATIONS with POLICIES
16
LONG-ACTING OPIOIDS
16
MORPHINE INFUSIONS
16
MEDICATIONS USED FOR INFECTIONS
17
PER DIEM EXCLUSIONS
19
ACKNOWLEDGMENTS20
AUTHORS20
REVIEWERS20
FOCUS GROUP PARTICIPANTS
22
HP EDITORIAL STAFF
23
ADDITIONAL HP CONTRIBUTORS
23
QUESTIONS and ANSWERS
25
SYMPTOMS27
AGITATION27
ANXIETY30
ASCITES33
BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS
35
BOWEL OBSTRUCTION
38
CACHEXIA41
CARDIAC-RELATED DISORDERS
44
CONSTIPATION54
COUGH57
DELIRIUM61
The Hospice Pharmacia Medication Use Guidelines
| iii |
Table of Contents
DEPRESSION63
DIARRHEA67
DYSPEPSIA70
DYSPNEA73
EDEMA78
FEVER80
GENITOURINARY SYMPTOMS
81
HEPATIC ENCEPHALOPATHY
83
HICCUPS84
HYPERGLYCEMIA87
INFECTIONS89
INSOMNIA96
MALABSORPTION DUE TO PANCREATIC INSUFFICIENCY
99
MOVEMENT-RELATED DISORDERS
100
MUSCLE SPASMS
103
NAUSEA/VOMITING107
OPHTHALMIC & ORAL SYMPTOMS
111
PAIN, NEUROPATHIC
113
PAIN, NOCICEPTIVE
118
PRURITUS126
SECRETIONS131
SEIZURES134
THROMBOEMBOLIC-RELATED DISORDERS
137
THYROID-RELATED DISORDERS
141
UPPER GASTRIC DISORDERS
142
URINARY INCONTINENCE
145
MEDICATION INDEX by GENERIC (BRAND) NAME
149
MEDICATION INDEX by BRAND (GENERIC) NAME
157
INJECTABLE INDEX
166
COMPOUND INDEX
167
| iv | The Hospice Pharmacia Medication Use Guidelines
Welcome to Hospice Pharmacia
Hospice Pharmacia (HP), a service of excelleRx, Inc., an Omnicare Company, is proud to be your
hospice pharmacy provider. We provide pharmaceutical care services, including clinical consultations, medication profile reviews, drug information, and medication dispensing for hospices and
their patients throughout the United States and its territories. Our state-of-the-art support center
is an essential component of these comprehensive services. Below is an easy-to-follow user guide to
our services.
ESSENTIAL USER GUIDE TO HP SERVICES
New Admissions
• Admit a hospice patient into the HP system by using www.hospicepharmacia.com or by calling
toll-free at 1-877-882-7820.
• Review the patient’s entire medication profile (including over-the-counter medications and
supplements, as well as medications determined by the hospice to be unrelated to the patient’s
hospice-qualifying terminal diagnosis), discuss the patient’s clinical presentation, and determine
the patient’s medication care plan with our staff.
• Seek prior approval from your hospice-designated authorizer(s) for medications that are outside
the HP per diem and determined by your hospice interdisciplinary team to be related to the
patient’s hospice-qualifying terminal diagnosis.
Current Patients Residing at Home
• Contact our staff for clinical consultations and/or to request medications.
• When medications are requested, HP typically dispenses a 15-day supply of medication via
national courier directly to the patient’s residence or to an alternate address as designated by the
patient and/or your hospice.
• HP serves as the pharmacy provider for patients residing in an Assisted Living Facility (ALF)
without a contracted pharmacy, whereby services are provided and medications are dispensed in
the manner described above. When appropriate, please provide HP staff with the patient’s unit
or apartment number.
Current Patients Residing in a Long-term Care (LTC) Facility or ALF with a Contracted Pharmacy
• To ensure accurate medication profiles, patient safety and proper billing, contact our staff with
all new prescriptions or changes in medications, including over-the-counter medications and
supplements, as well as medications determined by the hospice to be unrelated to the patient’s
hospice-qualifying terminal diagnosis.
• The facility pharmacy serves as the dispensing pharmacy for patients residing in a LTC facility or
ALF with a contracted pharmacy.
• Medication access is coordinated with the facility’s contracted pharmacy.
• HP communicates billing information to the pharmacy via fax on admission and every time HP
is informed of a medication profile change.
• For admissions or updates to a patient’s medication profile, fax information to HP at
1-877-265-6852.
The Hospice Pharmacia Medication Use Guidelines
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Welcome to Hospice Pharmacia
• When faxing, please include the following information:
- Cover sheet;
- Demographic information;
- Medication profile with an indication and specification of related (“covered by the hospice”)
or unrelated (“not covered by the hospice”) for each medication;
- Start/stop dates for each medication; and,
- Your call-back number for any clarifications.
New Prescriptions
• HP dispenses medication(s) for a hospice patient pursuant to a written prescription from a
licensed prescriber or telephone verbal order from a licensed prescriber or agent of the prescriber
in accordance with applicable state and federal laws.
- For medications classified as Schedule II Controlled Substances, please see the CII process
below.
• For new prescriptions, please contact our staff to profile the medication(s) and/or to have the
medication(s) dispensed.
• Non-urgent medication requests:
- At the discretion of the hospice nurse, HP dispenses medication(s) for either Next Business
Day or Second Business Day delivery.
• Same day medication requests:
- Call HP and provide our staff with the prescription(s) and name of the local pharmacy.
- HP staff is available to assist with locating contracted local pharmacies in your area.
- If the patient will need more than a 7-day supply of the medication(s), request that the
medication(s) also be dispensed by HP for Second Business Day delivery.
- Call the local pharmacy, provide the pharmacy with the prescription(s), request that the
pharmacy bill HP using the PBM Plus card, and provide the pharmacy with our phone
number.
- There should be no co-payment (“charge”) for the patient.
- HP staff is available 24 hours per day, 7 days per week to assist local pharmacies with
billing issues related to the PBM Plus card. For billing issues, ask the local pharmacy to
contact HP.
- The PBM Plus card information is as follows:
- Member ID No: Patient’s SSN
| 2 | The Hospice Pharmacia Medication Use Guidelines
Welcome to Hospice Pharmacia
CII Process
• The process for requesting medications classified as Schedule II Controlled Substances is similar
to the process for requesting new prescriptions with a few exceptions noted below.
• According to federal regulations, in order to dispense a medication classified as a Schedule II
Controlled Substance, HP must receive a signed prescription from a licensed prescriber who has
CII-prescribing privileges. This can be achieved in one of two ways.
- The prescriber or agent of the prescriber can fax a valid hard-copy prescription to HP at 1800-530-1565; or
- If a hard-copy prescription is not available, HP sends a faxed-copy of the medication request
to the prescriber. The prescriber must sign and return the faxed-copy of the medication
request to HP prior to the medication being dispensed by HP.
• When HP sends a faxed-copy of the medication request to a prescriber for signature, we request
a 30-day supply of the medication on the patient’s behalf.
- The prescriber can alter the quantity, including up to a 60-day supply of the medication.
- HP dispenses the medication in 15-day supply increments.
- As the quantity of the signed CII medication request becomes depleted, HP automatically
sends a new faxed-copy of the medication request to the prescriber for signature.
- If the prescriber signs the CII medication request, it is placed on the patient’s profile for
future dispensing.
- This is done to streamline the CII process, requiring less effort for the prescriber and your
hospice.
• If the request for a medication classified as a Schedule II Controlled Substance is urgent, the
prescriber must contact the local pharmacy and follow the appropriate state and federal laws
regarding CII prescriptions.
Refills
• For your convenience, refills can be requested via our Automated Refill & Discharge System, via
www.hospicepharmacia.com, or by calling our support center.
• The following policies apply to refills:
- Only medications previously dispensed by HP and without a change in the prescription are
eligible for refill.
- Refills must be requested by a licensed healthcare professional affiliated with your hospice or
prescriber caring for the patient; they cannot be requested by a patient, caregiver, or other
person not otherwise indicated.
- Medications may be refilled within seven days of the refill due date marked on the label.
- There is a delivery surcharge for refills requested for Saturday delivery.
Delivery of Medications
• HP offers the following convenient delivery options for your patients:
- Next Business Day;
- Second Business Day; and,
- Saturday delivery in selected locations.
• You can check the status of a delivery for your patient by tracking the package at
www.hospicepharmacia.com or by calling Customer Service (CS) at HP.
• Signature is not required for delivery unless specifically requested by your hospice.
• Medication requests received by the following times will depart our facility for Next Business
Day or Second Business Day delivery:
- Weekdays (Monday through Friday): 8:30 p.m. Eastern Time
- Saturday: 3:00 p.m. Eastern Time
The Hospice Pharmacia Medication Use Guidelines
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Welcome to Hospice Pharmacia
Trouble Shooting
• Report all customer service and quality assurance (QA) issues and variances to HP immediately
either through the CS icon at www.hospicepharmacia.com or by calling HP.
HP IMPORTANT CONTACT INFORMATION
To access all of Hospice Pharmacia’s services, 24 hours per day – 7 days per week, call
1-877-882-7820.
Toll-Free Direct Telephone Numbers
• HP Pharmacy: 1-877-882-7820
• HP Administration: 1-877-882-7822
• Physician Line: 1-877-288-4633
• Customer Service: 1-866-670-8162
• Inpatient Unit (IPU) Services: 1-866-703-1726
• HP Wound Care Services: 1-800-790-4138
Toll-Free Fax Numbers
• CII Prescription Fax: 1-800-530-1565
• LTC Fax: 1-877-265-6852
• IPU Fax: 1-866-923-5791
e-Mail and Web Site Addresses
• Customer Service: [email protected]
• General Information: [email protected]
• MUGs: [email protected]
• HP Online Support: [email protected]
• Web Site: www.hospicepharmacia.com
Hours of Service – Support Center
• Weekdays (Monday through Friday): 8:30 a.m. – 11:00 p.m. Eastern Time
• Weekends (Saturday and Sunday) and Holidays: 9:00 a.m. – 8:00 p.m. Eastern Time
After Hours Assistance and Support
• Service: 1-877-882-7820
- A message may be left for the pharmacy to retrieve the next business day; or,
- Access to our Automated Refills & Discharges system; or,
- Transfer to our Messaging Center for contact with an HP Pharmacist.
• On-call Pharmacist Direct: 1-866-763-2543
- Please limit use to emergent patient care-related issues
• On-call Administrator: 1-800-395-2371
- Please limit use to emergent operational and/or administrative issues
| 4 | The Hospice Pharmacia Medication Use Guidelines
How to Use the MUGs
IMPORTANT INSTRUCTIONS FOR USE
The MUGs is both informative and easy to use. It is organized alphabetically into sections
according to specific indications. Each section includes the name of the indication, diagnosisrelated inclusion code(s), acronyms used in that section, pharmacologic therapy included in the
per diem, non-pharmacologic therapy, and notes. Some sections may include an algorithm and
some also include information on pharmacologic therapy outside the per diem. An excerpt is
shown below for reference.
Pharmacologic therapy is summarized in tabular format and in alphabetical order according to
medication class. The Pharmacologic Therapy Included in the Per Diem (A) section includes the
name and suggested dosing of the medication(s). Medications typically dispensed by their generic
name are listed generically in the tables; medications typically dispensed by their brand name also
have a brand name listed. The suggested dosing refers to the usual adult dosage for the specific
indication.
The Pharmacologic Therapy Outside the Per Diem (B) section includes the name of the
medication(s) and the average cost of therapy. The average cost of therapy refers to the combined
average cost of all strengths of a given medication. The dollar amount shown does not reflect the
actual price of any single unit of the medication nor is it representative of what a hospice would be
charged for the medication; rather, it is intended to provide an approximation for the relative cost
of therapy. The actual cost of therapy is determined by the current contracted average wholesale price (AWP) and will vary based on the medication strength and dosage and the quantity of
medication requested. Please inquire with HP staff to determine the actual cost of pharmacologic
therapy outside the per diem. When combined with clinical information, including a patient assessment, the average cost of therapy is information that may be helpful with medication selection.
The Non-pharmacologic Therapy (C) section includes strategies for managing the indication that
do not fall within the realm of pharmacologic therapy. The Notes (D) section includes additional
information related to the indication and/or one or more of the medication classes.
*Please refer to the MUGs section example on the next page.
The Hospice Pharmacia Medication Use Guidelines
| 5 |
How to Use the MUGs
EXAMPLE SECTION OF THE MUGs
A
B
C
D
| 6 | The Hospice Pharmacia Medication Use Guidelines
Medication Overview
SUGGESTED DOSING
The suggested dosing provided in the MUGs refers to usual adult dosages. A guiding principle in
patient care is that therapy must be tailored to the unique medical needs of the individual patient.
This principle may be even more important in the hospice population, particularly among frail older
adults, in which the propensity for (and cost of ) iatrogenic harm is heightened. Unless otherwise
noted, the suggested dosing provided throughout the MUGs is not intended to imply restrictions
on dosages included in the HP per diem; rather, it is intended to guide the practicing clinician in
choosing a safe and effective dosage for the individual patient. Dosages may need to be adjusted based
on age, hepatic and/or renal function, concurrent medications, and clinical response, among other
considerations. Please consult with your HP pharmacist for assistance with dosage adjustments.
ROUTE OF ADMINISTRATION
The oral route of administration is the preferred route of administration for most medications, primarily because it is the least invasive and the most extensively studied method of medication delivery.
When the oral route becomes less reliable or unsuitable for administering medications, please consult
with your HP pharmacist to discuss alternative routes of administration, including medication dosage
formulations and dosing.
COMPOUNDS
At the end of life, routes of medication administration may be compromised. Although HP includes
a multitude of commercially available dosage formulations in the per diem, for some patients there is
no good alternative formulation available. As part of its comprehensive services, HP will compound a
medication approved by the U.S. Food and Drug Administration (FDA) into a formulation requested
by a licensed prescriber for use in an individual hospice patient. The compound index at the end of
the MUGs is your resource for compounded formulations that are included in the HP per diem.
Please consult with your HP pharmacist to discuss formulations for your patient.
HP MEDICATION PAKS
Hospice medication paks are frequently provided in the hospice patient’s home to prevent delays
in treating symptoms that occur suddenly or when the route of administration needs to be altered.
Medication paks often avert emergency department visits and hospital admissions, allowing patients
and their families to receive care at home and reducing health care expenditures. Hospice Pharmacia
was the first in the industry to provide medication paks for hospices and their patients. We are pleased
to provide your hospice with four types of medication paks: ComfortPak™, Cardiac ComfortPak,
Pediatric ComfortPak, and Seizure ComfortPak.
The Hospice Pharmacia Medication Use Guidelines
| 7 |
HP Medication Paks
1. ComfortPak
Indication
Contents
Quantity
Directions for Use
Pain, Fever
Acetaminophen 650 mg
suppository
Agitation
Haloperidol 2 mg/mL oral
concentrate
15 (fifteen)
mL
Take 0.5 mL (1 mg) by mouth or
under the tongue every 6 hours as
needed for agitation.
Secretions
Atropine 1% ophthalmic
drops
2 (two) mL
Place 2 drops under the tongue every
4 hours as needed for secretions.
Anxiety
Lorazepam 1 mg tablet
CIV
10 (ten)
tablets
Take 1 tablet by mouth every 6 hours
as needed for anxiety.
Pain,
Shortness of
breath
Morphine sulfate
20 mg/mL oral
concentrate
CII prescription for a
terminally ill hospice
patient
15 (fifteen)
mL
Take 0.25 mL (5 mg) by mouth or
under the tongue every 4 hours as
needed for moderate to severe pain
or shortness of breath.
Nausea,
Vomiting
Prochlorperazine 10 mg
tablet
1 tablet by mouth every 6 hours
6 (six) tablets Take
as needed for nausea and vomiting.
Nausea,
Vomiting
Prochlorperazine 25 mg
suppository
Insert 1 suppository rectally every
6 (six)
hours as needed for nausea and
suppositories 12
vomiting.
Insert 1 suppository rectally every
6 (six)
hours as needed for mild pain or
suppositories 6fever.
2. Cardiac ComfortPak
Indication
Contents
Quantity
Directions for Use
Take as directed by mouth as needed
for edema.
Edema
Edema
Furosemide 40 mg tablet
Furosemide 10 mg/mL
solution for injection
10 tablets
2 x 2 mL
(vials)
| 8 | The Hospice Pharmacia Medication Use Guidelines
Contact the prescriber to obtain
appropriate dose and instructions.
Contact the HP pharmacist to
communicate the patient-specific dose
and instructions for this medication.
Inject intravenously or intramuscularly
as directed as needed for edema. Do
not exceed a rate of 10 mg/min if
given intravenously and the dose is <
120 mg.
Contact the prescriber to obtain
appropriate dose and instructions.
Contact the HP pharmacist to
communicate the patient-specific dose
and instructions for this medication.
HP Medication Paks
Chest pain
Nitroglycerin sublingual
0.4 mg tablet
25 tablets
Take 1 tablet under the tongue every
5 minutes for up to 3 doses as needed
for chest pain. If 3 doses have been
administered and chest pain is still
present, contact the prescriber and
notify the hospice nurse for further
instructions.
Chest pain
Aspirin 325 mg tablet
5 tablets
Chew 1 tablet by mouth for 1 dose
with onset of chest pain.
Contact the prescriber and notify the
hospice nurse for further instructions.
Pain,
Shortness of
breath
Morphine sulfate 10 mg/
mL solution for injection
CII prescription for a
terminally ill hospice
patient
2 x 1 mL
(vials)
Inject 0.5 mL (5 mg) intravenously
or subcutaneously every 2 hours as
needed for severe pain or shortness
of breath.
3. Pediatric ComfortPak
Indication Contents
Dosage Calculation & Assessment
Notes
(Dose/weight (kg) x Weight (kg)
= Dose)
0.1 mg/kg x
Nausea,
Vomiting
Prochlorperazine
syrup 5 mg/mL
Anxiety,
Agitation
0.1 mg/kg x
Hyoscyamine oral
solution
0.125 mg/mL
OR
kg =
mg
kg =
mg
Consult with an HP pharmacist
to select the most appropriate
dose between the dosage ranges
calculated above.
3 mcg/kg x
Secretions
mg
15
Remove prochlorperazine if the patient (fifteen)
is less than 2 years old OR less than
mL
10 kg (22 lbs). (Place a line through the
item and initial next to the line.)
0.05 mg/kg x
Lorazepam oral
concentrate
2 mg/mL
CIV
kg =
Qty
kg =
15
(fifteen)
mL
Directions for
Use
Take
mg
by mouth
divided 4 times
daily as needed
for nausea and
vomiting.
Take
mg
by mouth
divided 4 times
daily as needed
for anxiety or
agitation.
mcg
For patients less than 5kg, the dose
for hyoscyamine (as seen to the right)
cannot be accurately measured. Use
the following alternate dosing regimen
according to patient weight.
5 kg = 20.8 mcg/dose; 3.4 kg = 16.7
mcg/dose; 2.3 kg = 12.5 mcg/dose
Take
mcg
by
mouth
15
4 hours
(fifteen) every
as needed
mL
for excess
secretions.
The Hospice Pharmacia Medication Use Guidelines
| 9.1 |
HP Medication Paks
0.025 mg/kg x
0.05 mg/kg x
Agitation
OR
kg =
mg
kg =
mg
Consult with an HP pharmacist
to select the most appropriate
dose between the dosage ranges
calculated above.
Haloperidol
(pediatric) oral
solution 1 mg/mL
Remove haloperidol if the patient is less
than 3 years old. (Place a line through the
item and initial next to the line.)
Insomnia,
Itching
Diphenhydramine
syrup 2.5 mg/mL
1 mg/kg x
kg =
0.1 mg/kg x
Nausea,
Vomiting
Metoclopramide
syrup 5 mg/mL
0.2 mg/kg x
OR
mg
kg =
mg
kg =
mg
Consult with an HP pharmacist
to select the most appropriate
dose between the dosage ranges
calculated above.
Take
mg
by mouth or
under the
15
divided
(fifteen) tongue
3 times daily
mL
as needed for
agitation.
30
(thirty)
mL
Take
mg
by mouth every
6 hours as need
for sleep or
itching.
15
(fifteen)
mL
Take
mg
by mouth
every 6 hours
as needed for
nausea and/or
vomiting.
4. Seizure ComfortPak
Indication
Contents
Quantity
Directions for Use
Pain, Fever
Acetaminophen 650 mg
suppository
Agitation
Haloperidol 2 mg/ mL
oral concentrate
15 (fifteen)
mL
Take 0.5 mL (1 mg) by mouth or
under the tongue every 6 hours as
needed for agitation.
Secretions
Atropine 1% ophthalmic
drops
2 (two) mL
Place 2 drops under the tongue every
4 hours as needed for secretions.
Anxiety
Lorazepam 1 mg tablet
CIV
10 (ten)
tablets
Take 1 tablet by mouth every 6 hours
as needed for anxiety.
Pain,
Shortness of
breath
Morphine sulfate 20
mg/mL oral concentrate
CII prescription for a
terminally ill hospice
patient
15 (fifteen)
mL
Take 0.25 mL (5 mg) by mouth or
under the tongue every 4 hours as
needed for moderate to severe pain
or shortness of breath.
Nausea,
Vomiting
Prochlorperazine 10 mg
tablet
1 tablet by mouth every 6 hours
6 (six) tablets Take
as needed for nausea and vomiting.
Nausea,
Vomiting
Prochlorperazine 25 mg
suppository
Insert 1 suppository rectally every
6 (six)
hours as needed for nausea and
suppositories 12
vomiting.
Seizure
Lorazepam 2 mg
suppository
CIV
Insert 1 suppository rectally every 10
3 (three)
until seizure activity stops, up
suppositories minutes
to a maximum of 2 doses.
6 (six)
Insert 1 suppository rectally every 6
suppositories hours as needed for mild pain or fever.
| 10.1 | The Hospice Pharmacia Medication Use Guidelines
HP Medication Paks
HP MEDICATION PAK DISPENSING
Prior to HP dispensing a medication pak, your hospice team should determine the safety and
feasibility of having a pak in the residence. This is especially important for assisted-living and longterm care facilities where paks are sometimes not permitted due to local policies and procedures.
When requesting medication paks for assisted-living and long-term care facilities, your hospice
staff should: (i) inform HP staff that the facility will accept a medication pak, (ii) request that HP
designate “signature required” on the delivery, and (iii) communicate specific delivery instructions
(e.g., “deliver to nurse station”) to HP staff.
Although medications cannot be added to a pak, your hospice may choose to have certain medications removed from a pak prior to dispensing. Please let your HP pharmacist know if a medication
should be removed from a pak.
ADDITIONAL COMFORTPAK INFORMATION
HP Medication
Pak
ComfortPak
Pediatric
ComfortPak
Inclusion Code
(refer to the
next section
for definitions)
Pak Storage
A
Temperature
controlled
environment or
refrigerated
A
Temperature
controlled
environment or
refrigerated
Additional Information
Please refer to the Hospice
Pharmacia Pediatric Medication Use
Guidelines for additional information.
The Cardiac ComfortPak is dispensed
as a separate medication pak.
Cardiac
ComfortPak
Seizure ComfortPak
H
A
Specifically for
patients at risk
for an acute
seizure related
to the hospicequalifying
terminal
diagnosis
Room
temperature
(do not
refrigerate)
Temperature
controlled
environment or
refrigerated
The Cardiac ComfortPak does not
contain parenteral supplies such as
syringes, filter needles, or flushes; with
the exception of flushes, parenteral
supplies are outside the HP per diem
(refer to the injectable index for
flushes).
Contains the same contents as the
ComfortPak plus three lorazepam
suppositories.
When appropriate, for patients at
risk for an acute seizure who have
a ComfortPak in the residence, the
hospice should request lorazepam
suppositories as a separate
prescription.
The Hospice Pharmacia Medication Use Guidelines
| 11 |
Per Diem Inclusions
Medications are included in the HP per diem based on the patient’s primary diagnosis. The patient’s
primary diagnosis refers to the hospice-qualifying terminal diagnosis, determined by the hospice
at admission and based on the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) codes. Confirmation of the primary diagnosis and determination of
which medications are related to the diagnosis are the responsibilities of the hospice. Determination
of which medications are included in the HP per diem for an individual patient is the responsibility
of HP. Hospice Pharmacia determines which medications are included in the HP per diem based
on the following diagnosis-related inclusion codes:
A: All symptoms related to the patient’s hospice-qualifying terminal diagnosis as determined by
the hospice.
C: Cancer and HIV/AIDS diagnoses, defined as ICD-9-CM codes 042 or 140-239.
H: Heart (cardiac) diagnoses, defined as ICD-9-CM codes 391-429 or 440-459.
L: Lung diagnoses, defined as ICD-9-CM codes 460-519.
O: Other diagnoses that do not fall into one of the other diagnosis-related inclusion codes (e.g.,
cerebrovascular disease, defined as ICD-9-CM codes 430-438; cystic fibrosis, defined as ICD9-CM code 277).
Medications may fall into one of three categories:
1. Related to the patient’s terminal diagnosis and medication is included in the HP per diem; or,
2. Related to the patient’s terminal diagnosis but medication is outside the HP per diem; or,
3. Not related to the patient’s terminal diagnosis and, therefore, medication is outside the HP per diem.
Each hospice provider is responsible for carefully reviewing the patient’s medication regimen and
determining which medications are needed or not needed to care for the patient. Medications that
are not needed should be considered for discontinuation. The hospice is responsible for covering
all medications that are needed to care for the patient’s terminal diagnosis and related conditions,
regardless of HP per diem inclusion status. Determining whether a particular medication or a
particular condition is related or unrelated to a patient’s terminal diagnosis requires thorough evaluation by the hospice medical director, patient’s attending physician, and interdisciplinary team.
| 12 | The Hospice Pharmacia Medication Use Guidelines
Medications with Criteria
Some medications in the MUGs have criteria that must be met to be included in the HP per diem.
These criteria, which are specified in the table below, apply to medications with Inclusion Code: A. In
addition, some medications that are listed in sections designated with Inclusion Code: C, H, L, and O
also have criteria. The term “primary diagnosis” used below refers to the hospice-qualifying terminal
diagnosis as determined by the hospice.
Your hospice may choose to prescribe a medication for a patient in a manner that does not follow the
specified criteria and therefore is outside the HP per diem. This does not infer that a medication is
unrelated to the patient’s primary diagnosis. To the contrary, according to federal regulations, if
a hospice determines that a medication is related to the patient’s primary diagnosis, the hospice
is responsible for covering the medication, regardless of HP per diem inclusion status. Hospice
Pharmacia dispenses medications outside the per diem but requires prior authorization. Determination of personnel with prior authorization accountability is the responsibility of the hospice. The
name(s) of personnel granting prior authorization should be communicated to HP through your
hospice’s Client Relations Liaison (CRL) and updated as necessary.
Hospice Pharmacia pharmacists will assist your hospice in selecting alternative medications that are
included in the HP per diem. If there are no alternative medications included in the HP per diem for
a particular symptom or condition that the hospice has determined is related to the patient’s primary
diagnosis, HP pharmacists will assist your hospice in selecting the most cost-effective and clinically
appropriate medication available. Please consult with your HP pharmacist for medication selection.
Medication
Criteria
Acyclovir (ZOVIRAX )
®
Glipizide
(GLUCOTROL®)
Page(s)
For the short-term (< 10 days) treatment of herpes
zoster related to the primary diagnosis. AND
Therapy is started within 72 hours of the first sign
or symptom of herpes zoster.
For the management of hyperglycemia induced by
a medication used for a symptom related to the
primary diagnosis. AND
89
87
Hyperglycemia affects the patient’s quality of life.
Glyburide (DIABETA®,
MICRONASE®)
For the management of hyperglycemia induced by
a medication used for a symptom related to the
primary diagnosis. AND
87
Hyperglycemia affects the patient’s quality of life.
For the management of hyperglycemia induced by
Insulin (HUMULIN® or a medication used for a symptom related to the
®
NOVOLIN NPH, REG, primary diagnosis. AND
and 70/30)
Hyperglycemia affects the patient’s quality of life.
87
The Hospice Pharmacia Medication Use Guidelines
| 13.1 |
Medications with Criteria
Misoprostol
(CYTOTEC®)
For gastrointestinal (GI) prophylaxis in patients
who are at high risk for experiencing an upper GI
adverse event AND prescribed a nonsteroidal antiinflammatory drug (NSAID) or salicylate related to
the primary diagnosis. AND
121
Total daily dosage is < 800mcg/day.
For the management of dyspepsia. OR
Omeprazole
(PRILOSEC®)
For GI prophylaxis in patients who are at high risk
for experiencing an upper GI adverse event AND
prescribed a NSAID or salicylate related to the
primary diagnosis. AND
71, 121, 142
Total daily dosage is < 20mg/day.
For the management of urinary incontinence
related to the primary diagnosis. AND
Oxybutynin
transdermal patch
(OXYTROL®)
Oxycodone and
acetaminophen
(ENDOCET®,
PERCOCET®)
Ranitidine (ZANTAC®)
The patient is unable to tolerate oxybutynin
immediate-release tablets. OR
145
The patient is unresponsive to a treatment trial of
at least 4 to 8 weeks with oxybutynin immediaterelease tablets.
For the management of pain related to the primary
diagnosis. AND
One of the following commercially available
formulations: 5/500mg capsule, 5/325mg tablet, or
5/325mg/5mL oral solution.
For the management of dyspepsia related to the
primary diagnosis. AND
120
70
Total daily dosage is < 300mg/day.
For the management of dyspnea related to the
primary diagnosis. AND
Salmeterol
(SEREVENT® DISKUS®) The patient has a primary diagnosis of chronic
obstructive pulmonary disease or pulmonary
malignancy.
Salmeterol and
fluticasone (ADVAIR®
DISKUS®)
75
For the management of dyspnea related to the
primary diagnosis. AND
The patient has a primary diagnosis of chronic
obstructive pulmonary disease or pulmonary
malignancy.
| 14.1 | The Hospice Pharmacia Medication Use Guidelines
75
Medications with Criteria
Sucralfate
(CARAFATE®)
For GI prophylaxis in patients who are at high risk
for experiencing an upper GI adverse event AND
prescribed a NSAID or salicylate related to the
primary diagnosis. AND
121, 142
Total daily dosage is < 4gm/day.
Theophylline (THEODUR®)
For the management of dyspnea related to the
primary diagnosis. AND
The patient has a primary diagnosis of chronic
obstructive pulmonary disease or pulmonary
malignancy.
74, 75
For the management of urinary incontinence
related to the primary diagnosis. AND
Tolterodine extendedrelease (DETROL® LA)
Valacyclovir
(VALTREX®)
The patient is unable to tolerate oxybutynin
immediate-release tablets. OR
145
The patient is unresponsive to a treatment trial of
at least 4 to 8 weeks with oxybutynin immediaterelease tablets.
For the short-term (< 7 days) treatment of herpes
zoster related to the primary diagnosis. AND
Therapy is started within 72 hours of the first sign
or symptom of herpes zoster.
89
The Hospice Pharmacia Medication Use Guidelines
| 15 |
Medications with Policies
LONG-ACTING OPIOIDS
The purpose of this policy is to protect patients from undue harm and provide hospices with the
most cost-effective long-acting (LA) opioids.
Hospice Pharmacia has the following policy regarding the use of LA opioids:
• If a patient is prescribed two different LA opioids concurrently (e.g., morphine LA and fentanyl
transdermal patch), regardless of whether both opioids are procured through HP, one of the LA
opioids is outside the HP per diem.
- Hospice Pharmacia determines which opioid is outside the per diem.
• If a patient is prescribed a continuous opioid infusion and a LA opioid concurrently, regardless
of whether the infusion has been procured through HP, the LA opioid is outside the HP per
diem.
• If a patient is prescribed one of the following regimens, the LA opioid is outside the HP per
diem.
- A fentanyl transdermal patch (DURAGESIC®) dosed more frequently than every 48 hours.
- Morphine LA tablet (MS CONTIN®) dosed more frequently than every 8 hours.
- Morphine extended-release (ER) capsule (KADIAN®) dosed more frequently than every 12
hours.
- Morphine LA tablet, morphine ER capsule, or a fentanyl transdermal patch prescribed “as
needed.”
• This policy does not apply to methadone.
• Hospice Pharmacia dispenses opioids outside the per diem but requires prior authorization.
MORPHINE INFUSIONS
Hospice Pharmacia provides morphine infusions in the per diem for patients who require rapid
control of their pain and/or require pain management but cannot easily be administered medications orally or through other routes.
Hospice Pharmacia has the following policy regarding morphine infusions:
• Morphine infusions are included in the per diem for intravenous and subcutaneous administration; morphine infusions administered via other routes (e.g., epidural, intrathecal) are outside
the per diem and cannot be dispensed by HP.
• In order for a morphine infusion to be included in the HP per diem, it must be dispensed by
HP; morphine infusions cannot be adjudicated through the PBM Plus card.
• In order for a morphine infusion to be dispensed for an individual patient, it must be delivered
on the next business day. Therefore, HP must receive a signed CII prescription for the morphine
infusion no later than 6:30 p.m. Eastern (3:30 p.m. Pacific) time Monday through Thursday.
- If Saturday delivery is available to the patient’s residence then HP must receive a signed CII
prescription for the morphine infusion no later than 6:30 p.m. Eastern (3:30 p.m. Pacific)
time Friday.
• Morphine infusions (bags or cassettes) can be prepared in concentrations up to 50mg/mL.
• For CADD bags, a CADD Administration Set must be requested simultaneously. For this type
of request, HP will attach and prime the tubing. The extension set is built into the CADD
Administration Set and is included in the HP per diem.
| 16 | The Hospice Pharmacia Medication Use Guidelines
Medications with Policies
• For CADD cassettes, HP does not provide the extension tubing unless specifically requested.
The extension tubing for CADD cassettes is outside the HP per diem.
• With the exception of the extension set noted above and flushes, parenteral supplies are outside
the HP per diem (refer to the injectable index for flushes).
MEDICATIONS USED FOR INFECTIONS
Inappropriate use of anti-infectives will promote development of resistance to anti-infectives, which
not only affects the individual consuming the medication but also affects the surrounding environment and the individuals living within that environment, resulting in high human and economic
costs. The purpose of this policy is to guide the appropriate use of anti-infectives in the hospice
population by encouraging appropriate selection of anti-infectives, appropriate dosing, and appropriate duration of therapy.
Hospice Pharmacia has the following policy regarding the use of anti-infectives:
• Orally administered anti-infectives are included in the HP per diem for the short-term treatment
of community acquired pneumonia, herpes zoster, oropharyngeal candidiasis, skin and skin
structure infections, urinary tract infections, and vulvovaginal candidiasis related to the patient’s
terminal diagnosis.
• The specific indications included in the HP per diem are provided in the tables in the Infections section; orally administered anti-infectives used for indications other than those
provided in the tables are outside the HP per diem.
• The maximum duration of therapy included in the HP per diem for a single course of an
orally administered anti-infective is 14 days. A second course with the same anti-infective
for the same indication started within 7 days of the stop date of the first course is included in
the per diem provided the second course of therapy does not exceed 14 days. A third course
with the same anti-infective for the same indication started within 7 days of the stop date of
the second course is outside the per diem.
• Certain orally administered anti-infectives listed in the Infections section are available
as powder for oral suspension. These powders need to be reconstituted at the time the
medication is administered and, therefore, must be procured from a local pharmacy and
billed through the PBM Plus card.
• This policy also applies to anti-infectives administered via a feeding tube.
• Topically administered anti-infectives are included in the HP per diem for the treatment of
cutaneous candidiasis, ophthalmic infections, and skin and skin structure infections related to
the patient’s terminal diagnosis; vaginally administered clotrimazole is included in the per diem
for vulvovaginal candidiasis.
• The specific indications included in the HP per diem are provided in the tables in the Infections section; topically and vaginally administered anti-infectives used for indications
other than those provided in the tables are outside the HP per diem.
• The duration of therapy of topically and vaginally administered anti-infectives vary. However,
unless otherwise noted in the tables in the Infection section, treatment > 14 days is
outside the per diem.
• Rectally administered anti-infectives are outside the HP per diem.
• Parenterally administered anti-infectives are outside the HP per diem; further, HP cannot dispense anti-infectives for parenteral administration.
The Hospice Pharmacia Medication Use Guidelines
| 17 |
Medications with Policies
• Provided the anti-infective is used for the specific indication and duration, dosages other than
those provided in the tables in the Infection section are included in the HP per diem.
• Prophylactic therapy is defined as an anti-infective prescribed without a specific stop date.
Prophylactic therapy is outside the HP per diem.
• Topically administered clotrimazole, nystatin and silver sulfadiazine typically do not have a
specific stop date because they are continued until healing occurs. These specific anti-infectives are not considered prophylactic therapy.
• This policy also applies to metronidazole used for the treatment of infectious diarrhea
(Clostridium difficile).
| 18 | The Hospice Pharmacia Medication Use Guidelines
Per Diem Exclusions
Thousands of medications are marketed in the United States. Many medications are available in
multiple dosage strengths and/or formulations. Each year, HP strives to include the most essential
and cost-effective medications for end-of-life care in the per diem. The indices at the end of the
MUGs are your guide to the medications included in the HP per diem. Please consult with your
HP pharmacist to determine specific dosage strengths and/or formulations included in and outside
of the HP per diem. The exclusion of a specific medication, dosage strength, or dosage formulation does not infer that the medication is unrelated to the patient’s primary diagnosis. To the
contrary, according to federal regulations, if a hospice determines that a medication is related
to the patient’s primary diagnosis, the hospice is responsible for covering the medication,
regardless of HP per diem inclusion status. Hospice Pharmacia dispenses medications outside the
per diem but requires prior authorization. An HP pharmacist will assist your hospice in selecting
alternative medications that are included in the HP per diem, as well as assist in selecting the most
cost-effective and clinically appropriate alternative medications that are outside the HP per diem
when appropriate.
MARKET CHANGES
In an effort to ensure ongoing patient safety, the U.S. Food and Drug Administration (FDA) requires evidence that medications are both safe and effective prior to marketing in the United States.
The FDA states that medications marketed without the required FDA approval may not meet modern standards for safety, effectiveness, quality, and labeling. To assist in this effort, in June 2006, the
FDA issued a compliance policy guide, “Marketed Unapproved Drugs--Compliance Policy Guide,”
that describes how the FDA intends to remove medications marketed in the United States that do
not have the required FDA approval for marketing. As a result, a large number of medications have
been removed from the market and more may be removed in the future.
Hospice Pharmacia is aware of the impact the removal of certain medications has on the hospice
and palliative care community. When a medication is removed from the market, HP will remove
the medication from distribution and the HP per diem, and HP will notify your hospice of these
changes. Hospice Pharmacia will continue to work with your hospice to provide alternative medications, and HP will continue to work with the FDA and key stakeholders to ensure that regulatory
agencies understand the role of certain medications in hospice and palliative care.
The Hospice Pharmacia Medication Use Guidelines
| 19 |
Acknowledgments
We extend our thanks to everyone who participated in the development of the 10th edition of
the MUGs.
AUTHORS
Jillian Baer, PharmD, CGP, BCPS
Sr. Manager, Client/Patient Education
Hospice Pharmacia
Elisa Macklin, PharmD
Clinical Pharmacist
Hospice Pharmacia
Natalee Felten, PharmD, BCPS
Pharmacist Trainer
Hospice Pharmacia
Thomas McCool, PharmD
Pharmacist Leader
Hospice Pharmacia
Carmen Jacobs, PharmD, CGP
Clinical Pharmacist
Hospice Pharmacia
Laura Scarpaci, PharmD, BCPS
Manager, Clinical Performance Improvement
Hospice Pharmacia
Jennifer Johansen, PharmD, BCPS
Director, Drug Information
Hospice Pharmacia
Michelle Smith, PharmD, BCPS, CGP, CPE
Clinical Pharmacist
Hospice Pharmacia
REVIEWERS
Sanjay J. Amin, MD
Medical Director
Seasons Hospice & Palliative Care
Charlotte H. Creel
Hospice Director
Pointe Coupee Hospice
Renee Baird, RN, BSN, CHPN, CLCP
Hospice Case Manager
Mercy Medical Center Hospice
Lucy W. Ertenberg, MD, FAAFP
VP, Chief Medical Director
Cornerstone Hospice
Patty Boone, AND
Hospice Case Manager
OSF Hospice
Marie Etling, RN, BA, CHPN
Hospice Case Manager
Hospice of Care Corporation
JeriLu Breneman, RN, CHPN
Hospice Per Diem Nurse
Heartland Hospice
Anne Finger RN, BSN
Hospice Administrator
Advocate Hospice
Molly Brooks, RN, CHPN
Hospice Administrator
Heartland Hospice of Fairfax
Jacqueline P. Fournier, ACNS, NP, APN
Health Reach Homecare and Hospice
Patrick Carey, MD, ABIM, CAQ
Hospice Medical Director
Open Arms Hospice and McCall Hospice
House
Christopher Frazer, RN, CHPN
Hospice Manager
Hospice of Moorestown VNA
| 20 | The Hospice Pharmacia Medication Use Guidelines
Acknowledgments
Shirley R. Hayes, MSN, CNS, AOCN
Clinical Nurse Specialist
Hospice of the Visiting Nurse Services
Debbie McGowan, RN, CHPN
Hospice Case Manager
Celtic Hospice
Kathleen Heilich, RN, CHPN
Case Manager, Field Program
St. Anthony’s Hospice
Mary Lynn McPherson, PharmD, BCPS, CPE
Professor and Vice Chair
University of Maryland School of Pharmacy
Hospice Clinical Pharmacist
Patricia Hollis, RN, BSN, CHPN
Triage Coordinator
Hospice of Southern Indiana
Nancy Hopkins, BSN
Hospice Coordinator
Rowan Regional Hospice
Pamela L. Ingram, RN, BSN, MSN(c)
Hospice Case Nurse
DuBois Regional Medical Center Hospice
Sandra Jackson, RN
Hospice Case Manager
Rice Hospice
Lauren Jaffke, ASN
Hospice Case Manager
OSF Hospice-Rockford
Suzanne Kelley, BSPharm
Consultant Clinical Pharmacist
Covenant Hospice
Linda Kisby, RN, BSN, CHPN
Director of Clinical Services
AtlantiCare Hospice and Palliative Care
Connie Leon, PharmD
Clinical Pharmacist
Hospice of the Comforter
Rebecca Maxwell, LPN
Resource CHPLN
Vitas Innovative Hospice Care
Sue McCausland, RN, BSN, CHPN
Director of Clinical Services
AseraCare Hospice-Akron
JoAnne Nowak, MD
Medical Director
Partners Hospice
Charles L. Pankratz, MD, ABHPM
Medical Director
Assisted Home Hospice
Susan Penl, ADN, CHPN
Clinical Supervisor
McLaren Visiting Nurse and Hospice-Lansing
Eileen Quigley, BSN, CHPN
Hospice Supervisor
Swedish Home Services
Rachel Rebain, RN, BSN
Hospice Case Manager
Hospice of Michigan
Charlene Romani, RN
Senior Case Manager
AseraCare Hospice
Shelly Rowlett, BSN, CHPNA
Patient Care Coordinator
Hospice of West Tennessee
Mary A. Shockey, RN, BSN
Clinical Service Director
Pioneer Memorial Hospice
Rebecca Slusser, RN, CHPN
Columbia Montour Home Hospice
Lorraine Smith, ASN
Clinical Coordinator
Florida Hospital Hospice Care
The Hospice Pharmacia Medication Use Guidelines
| 21 |
Acknowledgments
Joseph B. Straton, MD, MSCE
Chief Medical Officer
Penn-Wissahickon Hospice
William Welsh, DO
Medical Director
Hospice Care of the West
Laurel R. Thomas, RN, CHPN
Director of Professional Services
Heartland Hospice
Valerie Wheeler, BA, BSN, RN, CHPN
Hospice Case Manager
Mercy Hospice
David B. Tribble, MD, ABHPM, FAAFP
Chief Medical Officer
Alive Hospice
Lauren Woode, RN, CHPN
Patient Care Coordinator
Mary Washington Hospice
Linda L. Twyeffort, BSN, RN, CHPN
Hospice Case Manager
Baystate VNA & Hospice
Philip Yule, MD
Chief Medical Director
Hospice of Santa Cruz County
FOCUS GROUP PARTICIPANTS
Therese Ahrens, RN, MS, CHPN
Clinical Educator
Hospice of Central New York
Ellen McCabe-Hemberger, RN, CHPN
Organizational Staff Educator
Hospice & Palliative Care of Cape Cod
Ann Bernesderfer, RN, CHPN
Patient Care Administrator
Vitas Inland Empire
Joel Policzer, MD, FACP, FAAHPM
Senior Vice-President, National Medical Director
Vitas Hospice
Carol Couper, RN, BS
Clinical Care Director
Northern Illinois Hospice
Glenn Ross, RN, NHA, MA
Senor Director of Pharmacy Services
Vitas Hospice
Marie Glasgow, RN, BSN
Director of Clinical Care
Alive Hospice
Connie Shannon, RN
Director of Clinical Services
SolAmor Hospice-Oklahoma City
Donna Jolly, PharmD, BCPS, CPh
Director Pharmacy Services
Tidewell Hospice
Kelly Squyres, RN, CHPN
Admissions Director
Heartland Hospice
Sue Kelly, RN, CHPN
Patient Care Coordinator
Hospice of Volusia Flagler
Teri Turner, RN, BSN, MS
Director of Clinical Services
Arbor Hospice
Marsha Lambert, RN, MSN, PHN, CHPN
Director of Clinical Services
Heartland Hospice
Stacey Vincent, RN, BSN, CHPN
Staff Nurse
Gaston County
Terri Liberatoni
Administrator
Heartland Hospice Beltsville
Jane Yates, RN, MBA, CHPN
Clinical Operations Coordinator
Hospice of NE Georgia Medical Center
| 22 | The Hospice Pharmacia Medication Use Guidelines
Acknowledgments
HP EDITORIAL STAFF
Marcella R. Brown, BSPharm, MS, PharmD,
MPH
Editor-in-Chief
Jill Astolfi, PharmD
Client Relations Liaison – Northeast
Reviewer
Kevin T. Bain, PharmD, MPH, BCPS, CGP,
FASCP
Associate Editor & Vice President, Clinical
Support
Breann K. Bruton, PharmD
Vice President, Client Relations
Reviewer
Rebecca A. Lewis, PharmD, MBA
Vice President, Marketing & Corporate
Accounts
Deanna Douglass, PharmD
Client Relations Liaison – Midwest
Reviewer
Melissa Morris Ivone
Director, Creative Services
David Kupperman, PharmD
Client Relations Liaison – Atlantic
Reviewer
Jillian Baer, PharmD, CGP, BCPS
Reviewer & Member, MUGs Development
Committee
Thomas McCool, PharmD
Pharmacist Leader
Reviewer
Jennifer Johansen, PharmD, BCPS
Reviewer & Member, MUGs Development
Committee
Iriny Salib, PharmD
Client Relations Liaison – Upper Midwest
Reviewer
Terri L. Maxwell, PhD, ACHPN
Reviewer & Member, MUGs Development
Committee
Ealia Washington, PharmD
Clinical Pharmacist
Reviewer
Laura Scarpaci, PharmD, BCPS
Reviewer & Member, MUGs Development
Committee
ADDITIONAL HP CONTRIBUTORS
Calvin J. Alt, RPh
Vice President, Data Services
Tyler Ferguson, BS, CPhT
Inventory Control Manager
Michael P. Cinque, PharmD, FAPhA
Chief Pharmaceutical Care Officer
Dean Forman, MBA
Senior Vice President, Sales, Marketing &
Client Relations
Robert DeVito, MBA
Vice President, Finance
Ryan Emfinger, RPh, BSPharm
Manager, Compounding/Specialty Services
Linda M. Hoplamazian, RN, BSN, MHA,
WCC
Vice President, Sales & Partnering
The Hospice Pharmacia Medication Use Guidelines
| 23 |
Acknowledgments
Kimberly A. Hunter, PharmD
Vice President, Operations
Gary W. Kadlec, RPh, MBA, ScD
Chief Executive Officer, President
Ronald Kralle
Vice President, Purchasing
Dennis Wilson, RPh, JD
Senior Vice President, Operations & Corporate
Compliance
Catherine J. Woods, JD
Senior Director, Corporate Compliance
Laura Lutz, MBA
Client Relations Program Manager
| 24 | The Hospice Pharmacia Medication Use Guidelines
Questions and Answers
What is the Hospice Pharmacia Medication Use Guidelines (MUGs)?
The MUGs is the leading resource for hospice pharmaceutical care in the United States. It provides
information to help you select clinically appropriate, cost-effective medications for your hospice
patients.
Who is responsible for developing the MUGs?
Hospice Pharmacia (HP), the nation’s leading hospice pharmaceutical care provider. Each year, HP
undertakes a rigorous, peer-review process to develop the MUGs. Input received from administrators, medical directors, physicians, nurse practitioners, directors of nursing, staff nurses and consultant pharmacists practicing in hospice and palliative care is used in the development of the MUGs.
Why did you create the MUGs?
We developed this resource with your needs in mind. It is designed to assist hospice care practitioners to select clinically appropriate, cost-effective medications based upon the patient’s symptoms
and/or underlying condition.
Is the MUGs really just a formulary?
No. The MUGs is first and foremost a robust clinical resource for hospice-focused medication
information. It does not restrict the ability of hospices to cover certain medications. Hospices
determine which medications are related to the patient’s hospice-qualifying terminal diagnosis and
which medications they are responsible for covering. By utilizing the information in the MUGs
in conjunction with our clinical consultative services, hospices can be confident that their patients
receive clinically appropriate, cost-effective medications.
If a medication is listed in the MUGs, does that mean that it is automatically included in the
HP per diem?
No. Hospices must first determine which medications are related or unrelated to the patient’s
hospice-qualifying terminal diagnosis and which medications they will or will not cover. Medications that are unrelated to the patient’s diagnosis are outside the HP per diem, even if the
medication is listed in the MUGs. For medications that are related to the patient’s diagnosis, HP
decides which medications are included in the HP per diem based on diagnosis-related inclusion codes (refer to page 12). Certain medications in the MUGs have criteria (refer to page 13)
and policies (refer to page 16) that further determine whether the medication is included in or
outside of the HP per diem.
Will the pharmacy dispense a medication that is outside the HP per diem?
Yes. Hospices are responsible for covering all medications that are needed to care for the patient’s
terminal diagnosis and related conditions. Hospice Pharmacia dispenses medications outside the
HP per diem but requires prior authorization from the hospice. Please refer to your hospice’s policies and procedures for medications outside the HP per diem.
Why don’t the MUGs include all medications?
This edition of the MUGs contains numerous medications, strengths and formulations, including
various compounded formulations, from more than 85 therapeutic drug classes. We selected these
drug classes because of their clinical significance in hospice care and their impact on cost.
The Hospice Pharmacia Medication Use Guidelines
| 25 |
Questions and Answers
Why don’t all medications have brand names listed next to the generic name?
Medications that are typically dispensed by brand name have a brand name listed, and those medications that are dispensed by their generic name are listed generically.
What is the purpose of an algorithm?
An algorithm is a systematic set of rules for solving a particular problem. In the MUGs, an algorithm provides an additional level of guidance for the pharmacological management of a symptom
or condition.
Why don’t the MUGs include an algorithm for every symptom or condition?
An algorithmic approach to managing a symptom or condition is not always feasible. The decision
to include an algorithm is determined by synthesizing the evidence base and by input received from
administrators, medical directors, physicians, nurse practitioners, directors of nursing, staff nurses
and consultant pharmacists practicing in hospice and palliative care.
Where can I find more information?
Our support center is staffed with doctorate-level and board-certified clinical pharmacists who
specialize in hospice and palliative care and who have firsthand access to a wide array of drug
information resources. Our Client Relations Liaisons (CRLs) have a wealth of experience working
successfully with hospices through challenging or complex situations, overcoming obstacles, and
keeping hospices appropriately informed. Additionally, the clinical information in the MUGs is
well referenced, and reference citations can be furnished upon request.
| 26 | The Hospice Pharmacia Medication Use Guidelines
Agitation
Title
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
IM = intramuscularly
PO = by mouth
PRN = as needed
SC = subcutaneously
SL = sublingually
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Neuroleptics
Medication
Suggested Dosing
Chlorpromazine
12.5mg to 50mg PO every 4 to 6 hours PRN or 10mg to
25mg IM every 4 to 6 hours PRN
Haloperidol
0.5mg to 10mg PO/SL/IM/SC every 2 to 4 hours PRN
Risperidone
0.5mg to 1mg PO BID
• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it should generally be
used in patients who might benefit from these effects. It is best avoided in patients who might be
harmed by these effects, such as patients with Parkinson’s disease.
• Due to the increased risk of adverse events, the use of more than one neuroleptic (e.g., haloperidol
and risperidone) in a patient is strongly discouraged.
• Sometimes it is necessary to administer medications parenterally. Administer parenteral doses
slowly to minimize hypotension.
• Quetiapine (SEROQUEL®) is outside of the HP per diem for the management of agitation unless
it meets the inclusion criteria found in the Behavioral and Psychological section on page 35.1.
Benzodiazepines
Medication
Lorazepam
Suggested Dosing
1mg to 2mg PO BID or every 1 to 2 hours PRN
• Older adults (> 65 years) may be especially sensitive to the effects of benzodiazepines; lower doses
(e.g., lorazepam < 3 mg/day) are generally considered to be equally effective and safer to use.
• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those
with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions
are commonly manifested as excessive movement, excitement, and increased talkativeness.
The Hospice Pharmacia Medication Use Guidelines
| 27.1 |
Agitation
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medications.
Neuroleptics
Medication
Average Cost of Therapy
Aripiprazole tablet (ABILIFY )
$290.00
®
Fluphenazine tablet
$18.83
Olanzapine orally disintegrating tablet (ZYPREXA ZYDIS )
$211.05
Olanzapine tablet (ZYPREXA®)
$196.55
Perphenazine tablet
$21.80
®
®
Quetiapine (SEROQUEL ) tablet
$117.01
Risperidone orally disintegrating tablet (RISPERDAL® M-TAB®)
$152.30
®
Thioridazine tablet
$14.97
Ziprasidone capsule (GEODON®)
$151.91
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Verbal requests to cease disruptive behavior should be delivered in a calm, nonjudgmental, and
reassuring manner.
• The agitated patient should be separated from others, if possible.
• A ‘show of force’ may be necessary, using an organized team of clinicians or security personnel to
help prompt the patient to regain self-control.
• Temporary physical restraint by caregivers may be necessary if the patient is at risk for harming
him/herself or others.
NOTES:
• Before therapy is initiated, a thorough assessment of the underlying cause of agitation should be
performed.
• As needed dosing of any drug to control behavior should be reserved for infrequent, non-sustained agitation that cannot be linked to an eliciting event.
• Dosing parameters for neuroleptics and benzodiazepines should include definitive, detailed
directions specifying target behaviors, maximum daily doses, and monitoring parameters for the
assessment of safety and effectiveness.
| 28.1 | The Hospice Pharmacia Medication Use Guidelines
Agitation
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 29 |
Anxiety
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
ER = extended-release
HCl = hydrochloride
IM = intramuscularly
PO = by mouth
PRN = as needed
QID = four times a day
SL = sublingually
TCAs = tricyclic antidepressants
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Benzodiazepines
Medication
Alprazolam
Clonazepam
Diazepam
Lorazepam
Oxazepam
Suggested Dosing
0.25mg to 0.5mg PO/SL every 4 to 6 hours ATC or PRN
0.5mg to 1mg PO every 8 to 12 hours ATC or PRN
2mg to 10mg PO every 6 to 8 hours ATC or PRN
0.5mg to 1mg PO/SL every 4 to 6 hours ATC or PRN
10mg to 15mg PO 3 to 4 times daily or PRN
• Among the benzodiazepines, lorazepam and oxazepam are the safest to use in patients with
hepatic disease or impairment.
• Older adults (> 65 years) may be especially sensitive to the effects of benzodiazepines; lower
doses (e.g., alprazolam < 2 mg/day, lorazepam < 3 mg/day, oxazepam < 30 mg/day) are generally
considered to be equally effective and safer to use.
• Benzodiazepines with long half lives (e.g., clonazepam, diazepam) should be avoided or used
cautiously in older adults, as they may accumulate and result in subsequent adverse drug events
such as falls.
• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those
with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions are
commonly manifested as excessive movement, excitement, and increased talkativeness.
Antihistamines
Medication
Hydroxyzine HCl
(ATARAX®)
Hydroxyzine pamoate
(VISTARIL®)
Suggested Dosing
10mg to 25mg PO every 4 to 6 hours ATC or PRN or 50mg
to 100mg PO QID
25mg PO every 4 to 6 hours ATC or PRN
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticonvulsants
Medication
Pregabalin (LYRICA®)
| 30 | The Hospice Pharmacia Medication Use Guidelines
Average Cost of Therapy
$83.40
Anxiety
INCLUSION CODE: A
Anxiolytics
Medication
Average Cost of Therapy
Buspirone (BUSPAR®)
$55.23
Benzodiazepines
Medication
Average Cost of Therapy
Alprazolam ER tablet (XANAX® XR)
$56.66
Alprazolam orally disintegrating tablet (NIRAVAM )
$76.26
Chlordiazepoxide (LIBRIUM®)
$12.05
®
Clonazepam orally disintegrating tablet (KLONOPIN WAFER)
$61.04
Clorazepate dipotassium (TRANXENE®)
$38.87
®
Tricyclic Antidepressants (TCAs)
Medication
Doxepin
Average Cost of Therapy
$10.77
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Provide positive reassurance, cognitive-behavioral therapy and/or relaxation techniques.
NOTES:
• Dosing parameters for benzodiazepines should include definitive, detailed directions specifying
target behaviors, maximum daily doses, and monitoring parameters for the assessment of safety
and effectiveness.
The Hospice Pharmacia Medication Use Guidelines
| 31 |
Anxiety
INCLUSION CODE: A
| 32 | The Hospice Pharmacia Medication Use Guidelines
Ascites
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ACE = angiotensin-converting enzyme
IV = intravenously
NSAID = non-steroidal anti-inflammatory drug
PO = by mouth
QD = daily
TIPS = transjugular intrahepatic portocaval shunt
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Aldosterone Antagonists
Medication
Suggested Dosing
Spironolactone
25mg to 100mg PO QD, up to 400mg/day
Loop Diuretics
Medication
Suggested Dosing
Bumetanide
0.5mg to 1mg PO QD, up to 10mg/day
Furosemide
20mg to 40mg PO/IV daily, up to 600mg/day
Thiazide Diuretics
Medication
Suggested Dosing
Hydrochlorothiazide
25mg to 100mg PO, given in single or divided doses
• Hydrochlorothiazide should not be used as monotherapy; rather it is best used as adjuvant
therapy.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Aldosterone Antagonist-Thiazide Diuretic Combinations
Medication
Average Cost of Therapy
Spironolactone and hydrochlorothiazide (ALDACTAZIDE )
®
$21.97
Loop Diuretics
Medication
Average Cost of Therapy
Bumetanide solution for injection
$27.33
Torsemide (DEMADEX )
$34.37
®
Selective Aldosterone Receptor Antagonists
Medication
Eplerenone (INSPRA®)
Average Cost of Therapy
$45.27
The Hospice Pharmacia Medication Use Guidelines
| 33 |
Ascites
INCLUSION CODE: A
Thiazide Diuretics
Medication
Chlorothiazide tablet
Average Cost of Therapy
$7.22
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Institute sodium restriction and/or water restriction (if persistent hyponatremia is present).
• Sometimes a TIPS may be placed.
NOTES:
• Combination therapy with an aldosterone antagonist and a loop diuretic is often required to
treat ascites: a dose ratio of 100mg spironolactone to 1mg bumetanide or 40mg furosemide has
been shown to be beneficial. Dosing should be determined by patient response and tolerability.
• Monitor potassium and renal function, as well as for signs and symptoms of hypotension.
• Potassium supplementation may not be necessary for patients taking spironolactone, a potassium-sparing diuretic (e.g., triamterene), or an ACE inhibitor (e.g., enalapril). However,
potassium supplementation is included in the HP per diem for patients who need potassium
replacement as a result of pharmacologic therapy used to manage ascites. Please consult with your
HP pharmacist to determine specific potassium products available in the per diem.
• Assess the patient’s medication regimen and, if possible, avoid medications that inhibit prostaglandins (e.g., NSAIDs) because they can worsen ascites by decreasing renal perfusion.
| 34 | The Hospice Pharmacia Medication Use Guidelines
Behavioral and Psychological Symptoms
INCLUSION CODE: O
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
CR = controlled-release
DR = delayed-release
ER = extended-release
HS = at bedtime
PO = by mouth
QD = daily
SSRIs = selective serotonin reuptake inhibitors
TCAs = tricyclic antidepressants
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of behavioral and psychological symptoms related to Alzheimer’s disease and other dementias (defined as ICD-9-CM
codes 290.0-290.9 or 331.0-331.9), Amyotrophic lateral sclerosis (defined as ICD-9-CM
code 335.20), Huntington’s disease (Huntington’s chorea, defined as ICD-9-CM code
333.4), and Parkinson’s disease (defined as ICD-9-CM codes 332., 332.0, or 332.1) as the
patient’s hospice-qualifying terminal diagnosis.
• Quetiapine (SEROQUEL®) is also included in the HP per diem for the management of
behavioral and psychological symptoms in a patient with a co-morbidity of one of the
aforementioned diagnosis.
• Low-dose haloperidol or risperidone are often the treatment of choice for severe agitation due to
delirium.
• For the management of agitation and delirium, please refer to the Agitation and Delirium sections, respectively.
Anticonvulsants
Medication
Carbamazepine regular-release
Divalproex sodium (DEPAKOTE®)
Valproic acid (DEPAKENE®)
Suggested Dosing
50mg to 100mg PO BID
125mg to 250mg PO BID
125mg to 250mg PO BID
• Anticonvulsants are generally used to manage aggression and mania.
Antidepressants
Medication
Amitriptyline
Fluoxetine
Nortriptyline
Sertraline
Suggested Dosing
10mg to 25mg PO HS
10mg to 20mg PO QD
10mg to 25mg PO HS
25mg to 50mg PO QD
• Antidepressants are generally used to manage pathological crying and/or laughing.
• Other antidepressants from the Depression section also may be effective and are included in the
HP per diem.
• TCAs, especially amitriptyline, have anticholinergic properties and may be poorly tolerated by
older adults.
• Among the SSRIs, sertraline has a lower potential for drug-drug interactions than fluoxetine.
• Abrupt discontinuation of antidepressant therapy should be avoided if possible, as it may precipitate withdrawal symptoms. A taper of the dose over one to two weeks is recommended when
discontinuing therapy.
The Hospice Pharmacia Medication Use Guidelines
| 35.1 |
Behavioral and Psychological Symptoms
INCLUSION CODE: O
Neuroleptics
Medication
Chlorpromazine
Haloperidol
Quetiapine (SEROQUEL®)
Risperidone
Suggested Dosing
10mg PO TID
0.25mg to 0.5mg PO BID
25mg PO BID
0.25mg PO BID
• Neuroleptics are generally used to manage psychosis, which is usually accompanied by hallucinations and delusions.
• Due to the increased risk of adverse events, the use of more than one neuroleptic (e.g., haloperidol and risperidone) in a patient is strongly discouraged.
• Doses of Quetiapine (Seroquel®) less than 50mg/day or greater than 200mg/day are generally not appropriate for managing behavioral and psychological symptoms.
• Although psychosis is more common in Lewy body dementia than in Alzheimer’s disease, neuroleptics should be avoided in patients with Lewy body dementia because these medications often
make symptoms worse or have other severe, sometimes life-threatening adverse effects.
• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it is best used in patients
who might benefit from these effects. It should generally be avoided in patients who might be
harmed by these effects, such as patients with Parkinson’s disease.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticonvulsants
Medication
Average Cost of Therapy
Depakote sodium ER (DEPAKOTE ER)
®
$80.19
Antidepressants
Medication
Duloxetine DR capsule (CYMBALTA®)
Paroxetine suspension (PAXIL®)
Paroxetine tablet (PAXIL®)
Paroxetine CR tablet (PAXIL® CR)
Venlafaxine ER capsule (EFFEXOR® XR)
Venlafaxine tablet (EFFEXOR®)
| 36.1 | The Hospice Pharmacia Medication Use Guidelines
Average Cost of Therapy
$88.95
$106.59
$35.95
$40.75
$81.84
$48.04
Behavioral and Psychological Symptoms
INCLUSION CODE: O
Neuroleptics
Medication
Average Cost of Therapy
Aripiprazole tablet (ABILIFY )
$290.00
®
Fluphenazine tablet
$18.83
Olanzapine orally disintegrating tablet (ZYPREXA® ZYDIS®)
$211.05
Olanzapine tablet (ZYPREXA®)
$196.55
Perphenazine tablet
$21.80
Risperidone orally disintegrating tablet (RISPERDAL M-TAB )
$152.30
Thioridazine tablet
$14.97
®
Ziprasidone capsule (GEODON )
®
®
$151.91
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Behavioral interventions such as redirection and psychotherapy.
• Environmental interventions such as reduction in disruptive stimuli and placing familiar and
comforting objects (e.g., pictures, books) in the patient’s room.
• Family support and education, including referring families and caregivers to local support
groups and providing written materials.
• Sensory interventions such as music therapy, light therapy, and physical touch.
NOTES:
• Suggested dosing noted above refers to initial dosages. Therapies may need to be adjusted based
on clinical response as well as patient and medication characteristics. Please consult with your HP
pharmacist for dosage adjustments.
• Dosing parameters for neuroleptics should include definitive, detailed directions specifying
target behaviors, maximum daily doses, and monitoring parameters for the assessment of safety
and effectiveness.
The Hospice Pharmacia Medication Use Guidelines
| 37 |
Bowel Obstruction
INCLUSION CODE: C
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
BID = twice a day
CNS = central nervous system
FDA = Food and Drug Administration
GI = gastrointestinal
IM = intramuscularly
IV = intravenously
PEG = percutaneous endoscopic gastrostomy
PO = by mouth
PR = rectally
PRN = as needed
QD = daily
SC = subcutaneously
SL = sublingually
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of bowel obstruction due to
cancer (defined as ICD-9-CM codes 140-239).
Therapies for Constipation
Medication
Suggested Dosing
Docusate calcium
240mg/day to 480mg/day PO, given in single or divided doses
Docusate sodium
50mg/day to 300mg/day PO, given in single or divided doses
Lactulose
15mL to 60mL PO QD
• Because of their potential to exacerbate colic, oral stimulant laxatives (e.g., bisacodyl, senna)
generally should be avoided, especially in patients with a complete obstruction.
Therapies for Nausea & Vomiting
Medication
Suggested Dosing
Dopamine Antagonists
Chlorpromazine
10mg to 25mg PO/IV/IM every 4 to 6 hours ATC or PRN
Haloperidol
0.5mg to 2mg PO/IM/SC every 4 to 6 hours ATC or PRN
Prochlorperazine
5mg to 10mg PO every 6 hours ATC or PRN or 25mg PR
every 8 to 12 hours ATC or PRN or 5mg to 10mg IV/IM
every 3 to 4 hours ATC or PRN
Promethazine
12.5mg to 25mg PO/IM/PR every 4 to 6 hours ATC or PRN
Prokinetic Agents
Metoclopramide
10mg to 20mg PO/IM/IV 3 to 4 times a day, up to 240mg/day
• Sometimes it is necessary to administer medications parenterally. Parenteral doses of neuroleptics are
generally twice as potent as oral doses. Administer parenteral doses slowly to minimize hypotension.
• Although chlorpromazine is an effective antiemetic, it is sedating and has anticholinergic
properties. Therefore, it is best used in patients who might benefit from these effects. It is best
avoided in patients who might be harmed by these effects, such as patients with Parkinson’s disease.
• If parenteral use of promethazine is necessary, the preferred route of administration is by deep IM
injection; however, the IV route can be used. When administered IV, promethazine should be given
in a concentration no greater than 25mg/mL at a rate not to exceed 25mg/min; it is preferable to
inject through the tubing of an IV infusion set that is known to be functioning satisfactorily.
| 38 | The Hospice Pharmacia Medication Use Guidelines
Bowel Obstruction
INCLUSION CODE: C
• Prokinetic agents are contraindicated in patients with complete bowel obstruction. However,
they may be helpful in patients with partial bowel obstruction because of their positive effect on
gastric emptying.
• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include
involuntary and repetitive movements of the face and body, even after metoclopramide is
stopped. These symptoms are rarely reversible and there is no known treatment. The U.S. FDA
recommends against use of metoclopramide for durations longer than 3 months.
• Older adults, especially females, are more likely to develop tardive dyskinesia and thus
metoclopramide should be used cautiously, if at all, in older adults. Consider starting with a
lower (5mg) dose of metoclopramide in older adults.
• Metoclopramide should be used cautiously, if at all, in patients with a seizure disorder (or acute
seizures) or Parkinson’s disease.
Therapies for Peritumoral Edema
Medication
Suggested Dosing
Dexamethasone
4mg to 8mg PO//IM/IV, given in single or divided doses, up to
60mg/day
• While data are inconclusive, the use of dexamethasone in patients with a bowel obstruction is
associated with a trend towards symptom relief.
• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone may also be
effective and are included in the HP per diem.
• When dexamethasone (or any corticosteroid) is administered in divided doses, it is suggested
that the last dose be given in the afternoon to avoid insomnia.
Therapies for Secretions
Medication
Suggested Dosing
Glycopyrrolate
1mg to 2mg PO every 8 hours
Hyoscyamine regular-release
0.125mg to 0.25mg PO/SL every 4 to 6 hours ATC or PRN
Scopolamine, transdermal patch
(TRANSDERM SCOP®)
Apply 1 patch behind the ear every 3 days
Anticholinergics
Somatostatin Analogue
Octreotide
0.1mg IV/SC TID, up to 0.8mg/day
• Anticholinergics may decrease GI secretions and relieve smooth muscle spasms/colic. They may
also reduce nausea/vomiting and can be used in combination with other antiemetics.
• Major side effects of anticholinergics are blurred vision, constipation, dry mouth, and urinary
retention. Older adults are especially sensitive to these side effects. Of the anticholinergics, glycopyrrolate does not cross the blood-brain barrier and, therefore, is less likely to cause CNS side
effects.
• Octreotide has multiple mechanisms of action that are beneficial for treating a bowel obstruction, including a decrease in GI secretions and motility, inhibition of hormonal mediators that
contribute to obstruction and its symptoms, and facilitation of water and electrolyte absorption
by the gut wall.
The Hospice Pharmacia Medication Use Guidelines
| 39 |
Bowel Obstruction
INCLUSION CODE: C
• Octreotide may be administered as intermittent injections or as a continuous infusion. Continuous infusions are outside the HP per diem.
• When using octreotide solution for injection supplied in a glass ampule, a filter needle must
be used to remove glass particles from the solution. Once drawn up into the syringe via a filter
needle, a standard needle can be used to administer the medication. Filter needles are outside
the HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medications.
Therapies for Secretions
Medication
Average Cost of Therapy
Glycopyrrolate solution for injection (ROBINUL )
$26.37
Scopolamine solution for injection
$79.70
Scopolamine tablet (SCOPACE )
$11.62
®
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• PEG – this is generally the treatment of choice for symptom palliation; it may be particularly
beneficial for gastric venting and relief of nausea/vomiting.
• Surgery – patients with advanced disease often are not candidates for this intervention.
• Stents – contraindicated if obstruction is multifocal or in patients with peritoneal carcinomatosis; may be an option for some patients who have limited surgical options.
• Nasogastric suction – because suction is intrusive and distressing to the patient, this should only
be considered as a temporary measure when pharmacologic therapy fails.
• Hydration – this may result in increased bowel secretions and may be uncomfortable for patients; therefore, the risks vs. benefits of hydration must be carefully weighed.
- Dry mouth/thirst can usually be addressed with local interventions such as sips of water, ice
chips, and mouth care.
- Parenteral hydration may be particularly beneficial when dehydration is causing agitated
confusion, or when dehydration-associated renal failure results in the accumulation of drug
metabolites and leads to drug toxicity (e.g., opioid-induced neurotoxicity).
NOTES:
• To date, no clinical trials have compared the efficacy of different antiemetics for the management of malignant bowel obstruction.
| 40 | The Hospice Pharmacia Medication Use Guidelines
Cachexia
INCLUSION CODE: C, O
ACRONYMS USED IN THIS MONOGRAPH:
ACE = angiotensin-converting enzyme
CNS = central nervous system
PO = by mouth
QD = daily
SSRIs = selective serotonin reuptake inhibitors
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of cachexia due to cancer
(defined as ICD-9-CM codes 140-239; INCLUSION CODE: C), failure to thrive-adult
(defined as ICD-9-CM code 783.7; INCLUSION CODE: O), or HIV/AIDS (defined as
ICD-9-CM code 042; INCLUSION CODE: C).
Miscellaneuous Therapies
Medication
Suggested Dosing
Cyproheptadine
2mg PO 2 to 3 times daily with meals, up to 12mg/day in 2 to
3 divided doses
Dexamethasone
4mg PO QD, given in single or divided doses, up to 32mg/day
Megestrol acetate suspension
400mg to 800mg PO QD
• The usual initial dose of cyproheptadine is 4mg/day to 6mg/day. Weight gain is usually noted
during the first few weeks of therapy. Doses are typically increased over a three-week period to
the usual maintenance dose of 8mg/day to 12mg/day.
• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone also may be
effective and are included in the HP per diem.
• Megestrol is not recommended if life expectancy is less than 30 days, and its benefits for more
than 12 weeks has not been established.
• Use megestrol cautiously in patients with a history of thromboembolic disease.
• Megestrol suspension is included in the HP per diem if treatment with a corticosteroid is
contraindicated or has failed to improve cachexia. Doses of megestrol suspension < 400mg/
day and megestrol tablets are outside the HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Cannabinoids
Medication
Dronabinol (MARINOL®)
Average Cost of Therapy
$188.17
Miscellaneuous Therapies
Medication
Megestrol acetate tablet
Average Cost of Therapy
$30.98
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
The Hospice Pharmacia Medication Use Guidelines
| 41 |
Cachexia
INCLUSION CODE: C, O
NON-PHARMACOLOGIC THERAPY:
•
•
•
•
Explore and address the emotional and spiritual issues related to the patient’s weight loss.
Determine the goals of therapy (e.g., improved appetite and well-being, weight gain).
Remove dietary restrictions.
Reduce portion size and eliminate foods with odors that are offensive to the patient.
NOTES:
• Evaluate the patient’s medication profile for anorexigenics (e.g., SSRIs [e.g., sertraline], CNS
stimulants [e.g., methylphenidate]) or drugs that cause taste perversions (e.g., clarithromycin,
ACE inhibitors [e.g., enalapril]).
| 42 | The Hospice Pharmacia Medication Use Guidelines
Cachexia
INCLUSION CODE: C, O
The Hospice Pharmacia Medication Use Guidelines
| 43 |
Cardiac-Related Disorders
INCLUSION CODE: H
ACRONYMS USED IN THIS MONOGRAPH:
ACE = angiotensin-converting enzyme
ARBs = angiotensin II receptor blockers
AV = atrioventricular
BID = twice a day
CHD = coronary heart disease
CNS = central nervous system
CR = controlled-release
CSA = chronic stable angina
ER = extended-release
FDA = Food and Drug Administration
GI = gastrointestinal
IR = immediate-release
MI = myocardial infarction
NSAIDs = non-steroidal anti-inflammatory drugs
PO = by mouth
PRN = as needed
QD = daily
QID = four times daily
SL = sublingual
SR = sustained-release
TCAs = tricyclic antidepressants
ARRHYTHMIAS
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of arrhythmias associated with
cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459).
Beta-blockers
Medication
Suggested Dosing
Metoprolol tartrate
25mg to 100mg PO BID
Propranolol
80mg to 320mg PO daily, given in 2 to 4 divided doses
• Contraindications to metoprolol include AV block, bradycardia, cardiogenic shock, acute
decompensated heart failure, hypotension, pheochromocytoma, and sick sinus syndrome.
• Contraindications to propranolol include asthma, AV block, bradycardia, and cardiogenic shock.
• Other beta-blockers such as atenolol may also be effective for rate control.
• Atenolol also may be effective for rate control and is included in the HP per diem for the
management of arrhythmias.
• Avoid abruptly discontinuing beta-blockers. If discontinuation is necessary, taper the dose over
at least 1 to 2 weeks.
Calcium Channel Blockers
Medication
Suggested Dosing
Diltiazem
120mg to 360mg PO daily, given in a single dose (ER or SR)
or in 3 to 4 divided doses (regular-release)
Verapamil
120mg to 480mg PO daily, given in a single dose (SR) or in 3
to 4 divided doses (regular-release)
• Contraindications to diltiazem and verapamil include acute myocardial infarction (diltiazem),
AV block, cardiogenic shock, heart failure (verapamil), hypotension, Lown-Ganong-Levine
syndrome, sick sinus syndrome, ventricular dysfunction (verapamil), ventricular tachycardia, and
Wolff-Parkinson-White syndrome.
• Grapefruit juice may increase diltiazem and verapamil levels, resulting in toxicity. Patients prescribed diltiazem or verapamil should avoid drinking grapefruit juice.
| 44 | The Hospice Pharmacia Medication Use Guidelines
Cardiac-Related Disorders
INCLUSION CODE: H
Class 1A Antiarrythmics
Medication
Suggested Dosing
Disopyramide
400mg to 800mg PO daily, given in equally divided doses
every 12 hours (ER) or every 4 to 6 hours (IR)
Quinidine gluconate ER
324mg to 648mg PO every 8 to 12 hours
Quinidine sulfate IR
200mg to 300mg PO every 6 to 8 hours
• Contraindications to disopyramide include AV block, cardiogenic shock, and QT prolongation.
• Contraindications to quinidine include AV block, bundle-branch block, myasthenia gravis, and
quinidine hypersensitivity.
• Class 1A antiarrythmics are strongly anticholinergic. Major side effects are blurred vision, constipation, dry mouth, and urinary retention. Older adults are especially sensitive to these side effects.
Class 1C Antiarrythmics
Medication
Suggested Dosing
Propafenone IR and Propafenone
SR (RYTHMOL® SR)
150mg to 300mg PO every 8 hours (IR) or 225mg to 425mg
PO every 12 hours (SR)
• Contraindications to propafenone include acute bronchospasm, asthma, AV block, bradycardia,
cardiogenic shock, electrolyte imbalance, heart failure, hypotension, and sick sinus syndrome.
Class III Antiarrythmics
Medication
Suggested Dosing
Amiodarone
100mg to 400mg PO QD
• Contraindications to amiodarone include AV block, benzyl alcohol hypersensitivity, bradycardia,
cardiogenic shock, iodine hypersensitivity, and sick sinus syndrome.
• Grapefruit juice may increase amiodarone levels, resulting in toxicity. Patients prescribed
amiodarone should avoid drinking grapefruit juice.
• Pulmonary toxicity, a serious side effect of amiodarone, generally presents as non-specific
respiratory symptoms such as exertional dyspnea, nonproductive cough, and rales or decreased
breath sounds on exam. Advanced age, high maintenance doses (above 300 mg/day), longer
duration of therapy, and pre-existing, restrictive lung disease all seem to predispose to
amiodarone pulmonary toxicity.
Cardiac Glycosides
Medication
Suggested Dosing
Digoxin
0.125mg to 0.375mg PO QD
• Ventricular fibrillation is a contraindication to digoxin.
• Maintenance doses should be based on lean body weight, clinical response, and renal function.
• Higher doses (i.e., concentrations) of digoxin may be required for treating arrhythmias than for
treating heart failure.
• Serum digoxin concentrations can be used to help guide dosage adjustments. Concentrations
should be drawn at least 6 to 8 hours after a dose (a trough concentration is preferable). Most
The Hospice Pharmacia Medication Use Guidelines
| 45 |
Cardiac-Related Disorders
INCLUSION CODE: H
patients achieve effectiveness (without evidence of toxicity) at a serum digoxin concentration
ranging from 0.8ng/mL to 2ng/mL.
• Signs and symptoms of digoxin toxicity, which may be precursors to development of proarrhythmias, include the following: GI effects (nausea, vomiting, anorexia), CNS effects (headache,
generalized weakness, drowsiness, confusion), and ocular effects (visual disturbances).
• Avoid abruptly discontinuing digoxin. If discontinuation is necessary, taper the dose over at least
1 to 2 weeks.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Beta-blockers
Medication
Average Cost of Therapy
Nadolol (CORGARD®)
$15.92
Sotalol (BETAPACE )
$60.46
®
Class 1C Antiarrythmics
Medication
Average Cost of Therapy
Flecainide (TAMBOCOR )
®
$59.62
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Non-pharmacologic therapies are highly individualized and may include implantable cardioverter-defibrillator devices, pacemakers, electrocardioversion, radiofrequency ablation, and valsalva
movements, among others.
• Patients with arrhythmias or those at risk should avoid inciting factors such as caffeine, tobacco, alcohol, illicit drugs (e.g., cocaine), and certain over-the-counter (e.g., pseudoephedrine) and prescription
medications (e.g., methylphenidate, TCAs), especially medications that prolong the QT interval.
NOTES:
• In general, antiarrhythmics are associated with a multitude of drug interactions and potentially
serious side effects. Additionally, these medications typically require monitoring and dosage
adjustments based on patient and medication characteristics. Consult with your HP pharmacist
about potential drug interactions, side effects, monitoring, and dosage adjustments associated with
antiarrhythmics therapies.
| 46 | The Hospice Pharmacia Medication Use Guidelines
Cardiac-Related Disorders
INCLUSION CODE: H
CHRONIC STABLE ANGINA
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of chronic stable angina associated with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459).
ACE Inhibitors
Medication
Suggested Dosing
Captopril
12.5mg to 25mg PO 2 to 3 times a day, up to 150mg 2 to 3
times a day
Enalapril
2.5mg PO BID, up to 10mg BID
Fosinopril
5mg PO QD, up to 20mg/day given in a single or divided dose
Lisinopril
5mg PO QD, up to 10mg QD
• ACE inhibitors decrease the risk of mortality in patients with CHD.
• However, ACE inhibitors have not been shown to control anginal symptoms as well as betablockers, calcium channel blockers, or nitrates; therefore, their role in the management of CSA
at the end of life has yet to be defined.
Beta-blockers
Medication
Suggested Dosing
Atenolol
50mg/day to 200mg/day PO, given in a single or divided dose
Carvedilol
25mg to 50mg PO BID
Metoprolol succinate
100mg to 400mg PO QD
Metoprolol tartrate
100mg/day to 400mg/day, given in a single or divided dose
Propranolol
160mg/day to 320mg/day, given in 2 to 4 divided doses
• Beta-blockers are indicated as first-line therapy for angina prevention for all patients with CHD,
regardless of history of MI.
Calcium Channel Blockers
Medication
Suggested Dosing
Amlodipine
5mg to10mg PO QD
Diltiazem ER or SR
240mg to 480mg PO QD
Verapamil SR
240mg to 360mg PO QD
• Calcium channel blockers are indicated as second-line therapy for angina prevention. They
are indicated as first-line therapy if beta-blockers are contraindicated or for vasospastic or
Prinzmetal’s angina.
The Hospice Pharmacia Medication Use Guidelines
| 47 |
Cardiac-Related Disorders
INCLUSION CODE: H
Chronic Nitrate Therapy
Medication
Suggested Dosing
Isosorbide dinitrate IR
5mg to 20mg PO 2 to 3 times a day
Isosorbide dinitrate SR
40mg to 160mg PO QD
Isosorbide mononitrate (IMDUR®) 30mg to 60mg PO QD, up to 120mg/day
Isosorbide mononitrate (ISMO®)
5mg to 10mg PO BID, up to 20mg BID, with doses separated
by 7 hours
Nitroglycerin transdermal patch
0.4mg/hr to 0.8mg/hr applied topically to intact skin every 24
hours
Nitroglycerin ER
2.5mg to 9mg PO every 8 to 12 hours
Nitroglycerin ointment 2%
15mg to 30mg (2.5cm to 5cm as squeezed from the tube;
approximately 1 to 2 inches) applied topically to the skin
every 8 hours during waking hours and at bedtime, up to
75mg/day (12.5cm as squeezed from the tube)
• Chronic nitrate therapy is indicated as third-line therapy for angina prevention. It is indicated as
second-line therapy for vasospastic or Prinzmetal’s angina.
• To prevent tolerance, in general, a 10- to 12-hour nitrate-free interval is recommended. For
example, the nitroglycerin transdermal patch should be applied and left on for 12 to 14 hours
then removed for 10 to 12 hours prior to applying the next patch.
• Nitroglycerin ointment should be applied in a thin layer covering approximately 2 to 3 inches of
skin, but should not be massaged into the skin.
Short-acting Nitrate Therapy
Medication
Suggested Dosing
Nitroglycerin SL tablets
Place 1 tablet under the tongue every 5 minutes for up to 3
doses PRN
• Unless contraindicated, all patients with CHD should be prescribed short-acting nitrate therapy
for relief of acute chest pain.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
ACE Inhibitors
Medication
Average Cost of Therapy
Benazepril (LOTENSIN®)
$16.40
Quinapril (ACCUPRIL )
$21.39
®
Ramipril (ALTACE )
$28.94
Trandolapril (MAVIK®)
$19.21
®
| 48 | The Hospice Pharmacia Medication Use Guidelines
Cardiac-Related Disorders
INCLUSION CODE: H
ACE Inhibitor-Calcium Channel Blocker Combinations
Medication
Average Cost of Therapy
Benazepril and amlodipine (LOTREL )
$42.53
®
Antianginals
Medication
Average Cost of Therapy
Ranolazine (RANEXA )
$131.98
®
Beta-blockers
Medication
Average Cost of Therapy
Bisoprolol (ZEBETA )
$18.38
Nadolol (CORGARD®)
$15.92
®
Calcium Channel Blockers
Medication
Average Cost of Therapy
Felodipine ER tablet
$28.67
Nifedipine capsule (PROCARDIA )
$23.99
Nifedipine ER tablet (NIFEDIAC® CC, NIFEDICAL XL®)
$40.47
Nisoldipine ER tablet (SULAR )
$43.49
®
®
Short-acting Nitrate Therapy
Medication
Average Cost of Therapy
Nitroglycerin sublingual spray (NITROLINGUAL
PUMPSPRAY)
®
$175.45
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Risk factor reduction with therapeutic lifestyle changes, such as weight loss and smoking cessation, should be employed whenever possible.
NOTES:
• When used in combination with beta-blockers, a long-acting dihydropyridine calcium channel
blocker (e.g., amlodipine) is preferred to a nondihydropyridine calcium channel blocker (e.g.,
diltiazem).
• Avoid short-acting, immediate-release calcium channel blockers (e.g., diltiazem IR, verapamil
IR) if possible, as they may enhance the risk of cardiac-related adverse events.
• The terms “first-line,” “second-line,” “third-line,” and “preferred” do not refer to HP per diem
status; rather, these terms refer to the recommended place in therapy of certain medications according to evidence-based guidelines.
The Hospice Pharmacia Medication Use Guidelines
| 49 |
Cardiac-Related Disorders
INCLUSION CODE: H
HEART FAILURE
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of heart failure associated with
cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459).
ACE Inhibitors
Medication
Suggested Dosing
Captopril
50mg to 450mg PO daily, given in 2 to 3 divided doses
Enalapril
5mg to 40mg PO daily, given in 2 divided doses
Fosinopril
5mg to 40mg PO daily, given as a single dose
Lisinopril
5mg to 40mg PO daily, given as a single dose
• Contraindications to ACE inhibitors include angioedema and ACE inhibitor hypersensitivity.
• Enalapril and fosinopril are prodrugs and, therefore, should be avoided in patients with clinically
significant hepatic dysfunction.
Angiotensin II Receptor Blockers (ARBs)
Medication
Suggested Dosing
Valsartan (DIOVAN )
®
80mg to 320mg PO daily, given in 2 divided doses
• ARBs are typically used as alternative therapy to ACE inhibitors for patients who cannot tolerate
the latter.
Aldosterone Antagonists
Medication
Suggested Dosing
Spironolactone
25mg to 50mg PO daily, given as a single or divided dose
• Contraindications to spironolactone include anuria, hyperkalemia, and renal failure.
Beta-blockers
Medication
Suggested Dosing
Carvedilol
6.25mg to 100mg PO daily, given in 2 divided doses
Carvedilol CR (COREG CR™)
10mg to 80mg PO daily, given as a single dose
Metoprolol succinate
12.5mg to 200mg PO daily, given as a single dose
Metoprolol tartrate
12.5mg to 150mg PO daily, given in 2 to 3 divided doses
• Contraindications to carvedilol include asthma, AV block, bradycardia, cardiogenic shock,
hepatic disease, and sick sinus syndrome.
• Carvedilol should be administered with food. This reduces the rate of absorption and minimizes
the risk of orthostatic hypotension.
• Carvedilol CR (COREG CR™) capsules may be carefully opened and the beads sprinkled over a
spoonful of (cold) applesauce. The mixture should be consumed immediately in its entirety.
| 50 | The Hospice Pharmacia Medication Use Guidelines
Cardiac-Related Disorders
INCLUSION CODE: H
• Please consult with your HP pharmacist for assistance when converting from regular-release
carvedilol to COREG CR™.
• Metoprolol tartrate has been studied, but has not been approved by the U.S. FDA for heart
failure.
Cardiac Glycosides
Medication
Suggested Dosing
Digoxin
0.125mg to 0.25mg PO daily, given as a single dose
• Digoxin may need to be dosed every other day in some patients.
Vasodilators
Medication
Suggested Dosing
Hydralazine in combination with
isosorbide dinitrate
75mg hydralazine with 40mg isosorbide dinitrate PO QID
• Contraindications to hydralazine include coronary artery disease and rheumatic heart disease.
• The suggested dosing above is based on historical data from clinical trials using hydralazine in
combination with isosorbide dinitrate as adjunctive treatment of heart failure in patients taking
standard heart failure therapy.
• The combination of hydralazine and isosorbide dinitrate has been shown to be particularly effective
in self-identified African Americans with heart failure who remain symptomatic despite optimal
medical therapy. The commercially available formulation of hydralazine hydrochloride and
isosorbide dinitrate for this indication (BIDIL®, 37.5-20mg) is outside the HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
ACE Inhibitors
Medication
Average Cost of Therapy
®
Benazepril (LOTENSIN )
$16.40
Quinapril (ACCUPRIL®)
$21.39
Ramipril (ALTACE )
$28.94
Trandolapril (MAVIK®)
$19.21
®
ACE Inhibitor-Thiazide Diuretic Combinations
Medication
Average Cost of Therapy
Benazepril and hydrochlorothiazide (LOTENSIN® HCT)
$20.48
Lisinopril and hydrochlorothiazide (PRINZIDE , ZESTORETIC )
®
®
$16.33
The Hospice Pharmacia Medication Use Guidelines
| 51 |
Cardiac-Related Disorders
INCLUSION CODE: H
ARBs
Medication
Average Cost of Therapy
Candesartan (ATACAND )
$46.20
®
®
Irbesartan (AVAPRO )
$52.76
Losartan (COZAAR®)
$31.15
Olmesartan (BENICAR®)
$38.03
ARB-Thiazide Diuretic Combinations
Medication
Average Cost of Therapy
Candesartan and hydrochlorothiazide (ATACAND HCT)
$87.44
Losartan and hydrochlorothiazide (HYZAAR®)
$36.88
®
Olmesartan and hydrochlorothiazide (BENICAR HCT)
$59.12
Telmisartan and hydrochlorothiazide (MICARDIS® HCT)
$62.26
Valsartan and hydrochlorothiazide (DIOVAN HCT)
$76.40
®
®
Beta-blockers
Medication
Average Cost of Therapy
Bisoprolol (ZEBETA )
$18.38
Nebivolol (BYSTOLIC™)
$45.76
®
Beta-blocker-Thiazide Diuretic Combinations
Medication
Average Cost of Therapy
Atenolol and chlorthalidone (TENORETIC®)
$18.31
Bisoprolol and hydrochlorothiazide (ZIAC )
$21.33
®
Vasodilators
Medication
Average Cost of Therapy
Hydralazine in combination with isosorbide dinitrate (BIDIL )
®
$53.93
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Assess the patient’s medication regimen and, if possible, discontinue medications known to adversely affect the clinical status of patients with heart failure and reduced left ventricular ejection
fraction (e.g., NSAIDs, most antiarrhythmics, and most calcium channel blockers).
• Avoidance of alcohol and nicotine should be encouraged.
• Sodium restriction and supervised fluid intake is often necessary to prevent exacerbations.
| 52 | The Hospice Pharmacia Medication Use Guidelines
Cardiac-Related Disorders
INCLUSION CODE: H
NOTES:
• The suggested dosing provided above is the usual dosage range for the treatment of heart failure.
Dosages should be adjusted based on the patient’s clinical response and tolerability.
• Patients with heart failure often are prescribed a loop diuretic for fluid retention, particularly
for transient worsening heart failure. Although loop diuretics deplete potassium, supplemental
potassium may not be necessary for patients taking spironolactone, an ACE inhibitor (e.g.,
enalapril), or an ARB (e.g., valsartan). However, potassium supplementation is included in
the HP per diem for patients who need potassium replacement as a result of pharmacologic
therapy used to manage heart failure. Please consult with your HP pharmacist to determine specific
potassium products available in the per diem.
• Monitor weight, electrolytes (especially potassium) and renal function, as well as for signs and
symptoms of worsening heart failure.
The Hospice Pharmacia Medication Use Guidelines
| 53 |
Constipation
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
PO = by mouth
PR = rectally
PRN = as needed
QD = daily
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM :
Evacuants
Medication
Suggested Dosing
Sodium phosphate dibasic and
monobasic rectal enema
1 enema PR as directed
Lubricant Laxatives
Medication
Suggested Dosing
Mineral oil rectal enema
1 enema PR as directed
Osmotic Laxatives
Medication
Suggested Dosing
Glycerin suppository
1 suppository PR QD PRN
Lactulose
15mL to 60mL PO QD PRN
Magnesium citrate solution
½ to 1 bottle (150mL to 300mL) as a single or divided dose
PO PRN
Polyethylene glycol 3350 power
(MIRALAX®)
17g of powder mixed into 120mL to 240mL of fluid and
given PO QD
Sorbitol 70%
15mL to 60mL PO QD PRN
• Avoid osmotic laxatives in a patient who is dehydrated.
• Magnesium citrate is contraindicated in patients with hypermagnesemia, severe renal impairment, renal failure, or renal disease leading to renal failure.
Saline Laxatives
Medication
Suggested Dosing
Milk of magnesia
30mL PO QD PRN
Mineral oil oral solution
15mL to 45mL PO QD PRN
• Milk of magnesia should not be used in patients with renal failure unless their serum magnesium
levels are being closely monitored.
• Use of mineral oil should be avoided in older adults due to risk of aspiration.
Stimulant Laxatives
Medication
Suggested Dosing
Bisacodyl tablet
5mg to 15mg PO 1 to 3 times a day PRN, up to 30mg/day
Bisacodyl suppository
1 suppository PR QD PRN
Senna concentrate tablet
1 to 2 tablets PO QD PRN
Senna solution or syrup
1 to 2 teaspoonfuls PO QD PRN
Senna-docusate sodium
1 to 2 tablets PO QD PRN
54.1| |The
TheHospice
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PharmaciaMedication
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UseGuidelines
Guidelines
| | 54
Constipation
INCLUSION CODE: A
• Senna-docusate sodium is not available as a liquid formulation. Patients who lose the ability to
swallow senna-docusate sodium tablets can be switched to senna and docusate sodium liquids,
which are separate products.
Stool Softeners
Medication
Docusate calcium
Docusate sodium
Docusate sodium enema
(ENEMEEZ® MINI ENEMA)
Suggested Dosing
240mg/day to 480mg/day PO, given in single or divided doses
50mg/day to 300mg/day PO, given in single or divided doses
1 enema PR as directed
• Directions for usage of docusate sodium solution: Shake well and administer using a calibrated
measuring device. May be mixed with 120mL of milk, fruit juice, or infant formula to mask the
bitter taste.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Chloride Channel Activators
Medication
Lubiprostone (AMITIZA®)
Average Cost of Therapy
$108.11
Peripherally-Acting Mu-Opioid Receptor Antagonists
Medication
Methylnaltrexone bromide vial (RELISTOR™)
Methylnaltrexone bromide kit (RELISTOR™)
Average Cost of Therapy
$81.59
$520.18
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
•
•
•
•
Increase dietary fiber if feasible.
Increase fluid intake if not contraindicated by renal or heart disease.
Use natural laxatives (e.g., raisins, prunes).
Frozen Vaseline® balls: for high impaction, consider rolling Vaseline® into pea-sized sugar-coated
balls, freezing the balls, and administering them PO 1 to 3 times a day PRN. Note that this
intervention is anecdotal.
• Manual fecal disimpaction is a painful and distressing procedure. The patient should be premedicated with analgesics prior to manual fecal disimpaction.
NOTES:
• All patients who are prescribed opioid therapy should have a bowel regimen in place.
The Hospice
Hospice Pharmacia
Pharmacia Medication
Medication Use
Use Guidelines
Guidelines | | 55.1
55 |
The
Constipation
INCLUSION CODE: A
| 56 | The Hospice Pharmacia Medication Use Guidelines
Cough
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
CHPA = Committee and Consumer Healthcare
Products Association
ER = extended-release
FDA = Food and Drug Administration
OTC = over the counter
PHA = Public Health Advisory
PO = by mouth
PRN = as needed
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Antihistamine-Antitussive Combinations
Medication
Suggested Dosing
Promethazine with codeine syrup
5mL PO every 4 to 6 hours PRN, up to a maximum of
30mL/day
Promethazine with
dextromethorphan syrup
5mL PO every 4 to 6 hours PRN, up to a maximum of
30mL/day
Antihistamine-Antitussive-Decongestant Combinations
Medication
Suggested Dosing
Promethazine with codeine and
phenylephrine syrup
5mL PO every 4 to 6 hours PRN, up to a maximum of
30mL/day
Antihistamine-Decongestant Combinations
Medication
Suggested Dosing
Promethazine with phenylephrine
syrup
5mL PO every 4 to 6 hours PRN, up to a maximum of
30mL/day
Antitussives
Medication
Suggested Dosing
Benzonatate liquid filled capsule
100mg to 200mg PO TID or 100mg PO every 4 hours;
maximum recommended dose is 600mg/day
Dextromethorphan ER
suspension (DELSYM®)
10mL PO every 12 hours
Homatropine and hydrocodone
syrup
5mL to 10mL PO every 4 hours ATC or PRN
Homatropine and hydrocodone
tablet
1 to 2 tablets PO every 4 hours ATC or PRN
Antitussive-Expectorant Combinations
Medication
Suggested Dosing
Guaifenesin with codeine solution
or syrup
5mL to 10mL PO every 4 hours ATC or PRN
Guaifenesin with
dextromethorphan solution or
syrup
5mL to 10mL PO every 4 hours ATC or PRN
The Hospice Pharmacia Medication Use Guidelines
| 57.1 |
Cough
INCLUSION CODE: A
Antitussive-Decongestant-Expectorant Combinations
Medication
Suggested Dosing
Guaifenesin with codeine and
pseudoephedrine solution or syrup 5mL to 10mL PO every 4 hours PRN
Guaifenesin with
dextromethorphan and
phenylephrine HCl solution
10mL PO every 4 hours PRN
Expectorants
Medication
Suggested Dosing
Guaifenesin tablet
100mg to 400mg PO every 4 hours ATC or PRN; maximum
recommended dose is 2400mg/day
Guaifenesin solution or syrup
Miscellaneous
5mL to 10mL PO every 4 hours ATC or PRN
Medication
Suggested Dosing
Sodium chloride nebulizer
solution 0.9%
1 ampule via nebulizer every 2 to 4 hours PRN
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Antihistamine-Antitussive Combinations
Medication
Average Cost of Therapy
Chlorpheniramine with hydrocodone ER suspension
(TUSSIONEX®)
$100.96
Antitussives
Medication
Average Cost of Therapy
Codeine sulfate tablet
$22.62
Antitussive-Expectorant Combinations
Medication
Average Cost of Therapy
Guaifenesin with dextromethorphan ER tablet
(MUCINEX® DM)
$18.70
Expectorants
Medication
Average Cost of Therapy
Guaifenesin ER tablet (MUCINEX )
®
| 58.1 | The Hospice Pharmacia Medication Use Guidelines
$18.91
Cough
INCLUSION CODE: A
Mucolytics
Medication
Average Cost of Therapy
Acetylcysteine (MUCOMYST )
$41.79
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
•
•
•
•
•
•
Provide adequate hydration.
Reposition the patient to promote drainage.
Use demulcents (e.g., sugar cough drops).
Use a humidifier.
When appropriate, encourage smoking cessation.
When appropriate, use suction.
NOTES:
• Some drugs contained in cough/cold products have been sold for many years without undergoing FDA approval. In June 2006, the FDA issued a guidance called “Marketed Unapproved
Drugs--Compliance Policy Guide,” which outlines a plan for taking action against unapproved
drugs. A number of manufacturers have removed unapproved drugs from the market. As a result, many cough/cold products are no longer available for dispensing. Please check with your HP
pharmacist for product availability.
• Additionally, in October 2007, the Pediatric Advisory CHPA recommended that all OTC
cough/cold products be updated to advise against using them in children younger than 4 years
of age. In January 2008, a PHA was issued by the FDA that recommended against using cough/
cold products in infants and children younger than 2 years of age. More detailed information on
this topic is available at: http://www.fda.gov/fdac/features/2007/107_drug.html.
The Hospice Pharmacia Medication Use Guidelines
| 59 |
Cough
INCLUSION CODE: A
| 60 | The Hospice Pharmacia Medication Use Guidelines
Delirium
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
EPS = extrapyramidal symptoms
IM = intramuscularly
PO = by mouth
PRN = as needed
SC = subcutaneously
SL = sublingually
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Neuroleptics
Medication
Chlorpromazine
Haloperidol
Risperidone
Suggested Dosing
12.5mg to 50mg PO every 4 to 12 hours ATC or PRN or
10mg to 25mg IM every 4 to 6 hours PRN
0.5mg to 2mg PO/SL/IM/SC every 2 to 8 hours ATC or PRN
0.25mg to 1mg PO 1 to 2 times a day
• Low-dose haloperidol or risperidone are often the treatment of choice for severe agitation due to
delirium.
• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it should generally be
used in patients who might benefit from these effects. It is best avoided in patients who might be
harmed by these effects, such as patients with Parkinson’s disease.
• Doses of risperidone needed to treat delirium are generally well below effective doses for schizophrenia. The usual effective dose of risperidone is 1mg/day; doses greater than 2mg/day increase
the risk of adverse effects yet generally do not provide additional benefit.
• Due to the increased risk of adverse events, the use of more than one neuroleptic (e.g., haloperidol and risperidone) in a patient is strongly discouraged.
• Sometimes it is necessary to administer medications parenterally. Administer parenteral doses
slowly to minimize hypotension.
• Quetiapine (SEROQUEL®) is outside of the HP per diem for the management of delirium
unless it meets the inclusion criteria found in the Behavioral and Psychological section on
page 35.1.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medications.
Neuroleptics
Medication
Aripiprazole tablet (ABILIFY®)
Fluphenazine tablet
Olanzapine orally disintegrating tablet (ZYPREXA® ZYDIS®)
Olanzapine tablet (ZYPREXA®)
Perphenazine tablet
Average Cost of Therapy
$290.00
$18.83
$211.05
$196.55
$21.80
Quetiapine (SEROQUEL®) tablet
Risperidone orally disintegrating tablet (RISPERDAL® M-TAB®)
Thioridazine tablet
Ziprasidone capsule (GEODON®)
$117.01
$152.30
$14.97
$151.91
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
The Hospice Pharmacia Medication Use Guidelines
| 61.1 |
Delirium
INCLUSION CODE: A
NON-PHARMACOLOGIC THERAPY:
• Many medications can cause cognitive impairment, particularly in older adults. To minimize
this risk the clinician should:
- Avoid polypharmacy: use the minimum number of medications necessary to manage the
patient’s symptoms.
- Achieve multiple benefits from one medication (e.g., nortriptyline for neuropathic pain and
depression).
- Adjust dosages based on age, renal function, hepatic function, and other patient and medication characteristics. Please consult with your HP pharmacist for dosage adjustments.
- Use the lowest effective dose of a medication for the shortest duration possible.
- Discontinue medications causing or contributing to cognitive impairment.
• Maintain fluid and electrolyte balance, if possible.
• Reduce anxiety and disorientation.
• Reduce the level of evening activity such as bathing, visits from family members, and noise from
television or radios.
• Provide structure, routine, and familiarity in the patient’s life.
• Provide adequate lighting (including access to natural light), familiar objects, alarm clocks,
and/or a calendar in the patient’s residence.
• Make sure the caregiver gets adequate rest.
NOTES:
• Although benzodiazepines are ineffective as monotherapy and may worsen cognitive impairment, the addition of a benzodiazepine may be beneficial in patients whose symptoms are not
adequately controlled using a neuroleptic. This strategy may also minimize EPS associated with
neuroleptics and allow for lower neuroleptic doses to be used. Benzodiazepines are included in
the HP per diem for the management of delirium. Please consult with your HP pharmacist for
recommendations regarding their use, including specific dosing recommendations.
| 62.1 | The Hospice Pharmacia Medication Use Guidelines
Depression
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
CNS = central nervous system
CR = controlled-release
DR = delayed-release
ER = extended-release
GI = gastrointestinal
HS = at bedtime
NG = nasogastric
PEG = percutaneous endoscopic gastrostomy
PO = by mouth
QD = daily
SNRIs = serotonin-norepinephrine reuptake
inhibitors
SR = sustained-release
SSRIs = selective serotonin reuptake inhibitors
TCAs = tricyclic antidepressants
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Selective Serotonin Reuptake Inhibitors (SSRIs)
Medication
Suggested Dosing
Citalopram
20mg PO QD, up to 60mg/day
Fluoxetine
20mg PO QD, up to 80mg/day
Sertraline
50mg PO QD, up to 200mg/day
• If necessary, the daily dose of citalopram may be increased by 20mg after one week of therapy,
up to a maximum recommended dose of 60mg/day. However, doses above 40mg/day are not
ordinarily recommended.
• If necessary, the daily dose of fluoxetine may be increased by 10mg or 20mg every month, up to
a maximum recommended dose of 80mg/day.
• If necessary, the daily dose of sertraline may be increased by 25mg or 50mg every week, up to a
maximum recommended dose of 200mg/day.
• Citalopram and sertraline have a lower potential for drug-drug interactions than most other
SSRIs, including fluoxetine.
• A note about sertraline (ZOLOFT®) oral solution:
- The oral solution should be further diluted in an acceptable liquid immediately before administering the dose.
- Measure the dose using the supplied calibrated dropper. Place the dose in at least 4 oz.
(120mL) of water, ginger-ale, lemon-lime soda, lemonade, or orange juice and mix.
- Drink the entire dose of the mixed liquid immediately; do not prepare doses in advance.
- The solution does not need to be diluted if administering the dose via NG or PEG tube.
- Sertraline oral solution should be used cautiously in patients with a latex allergy because the
dropper contains dry natural rubber.
Tricyclic Antidepressants (TCAs)
Medication
Suggested Dosing
Amitriptyline
25mg to 75mg PO HS or in divided doses, up to 200mg/day
Desipramine
50mg to 75mg PO in 1 to 4 divided doses, up to 200mg/day
Nortriptyline
25mg to 50mg PO HS or in divided doses, up to 150mg/day
The Hospice Pharmacia Medication Use Guidelines
| 63.1 |
Depression
INCLUSION CODE: A
• If necessary, the daily dose of amitriptyline may be increased by 25mg or 50mg every week, up
to a maximum recommended dose of 200mg/day.
• If necessary, the daily dose of desipramine may be increased by 25mg or 50mg every week, up to
a maximum recommended dose of 200mg/day.
• If necessary, the daily dose of nortriptyline may be increased by 25mg or 50mg every week, up
to a maximum recommended dose of 150mg/day.
• TCAs, especially amitriptyline, have anticholinergic properties and may be poorly tolerated by
older adults.
Tetracyclic Antidepressants
Medication
Suggested Dosing
Mirtazapine
15mg PO HS, up to 45mg/day
• Dosage adjustments should not be made more frequently than every 1 to 2 weeks.
Miscellaneous Antidepressants
Medication
Suggested Dosing
Trazodone
150mg/day PO in divided doses, up to 400mg/day
• If necessary, the daily dose of trazodone may be increased by 50mg every 3 to 4 days, up to a
maximum recommended dose of 400mg/day.
CNS Stimulants
Medication
Suggested Dosing
Methylphenidate
2.5mg PO BID, given in the morning and at noon
• If necessary, the daily dose of methylphenidate may be increased by 2.5mg or 5mg every 2 to 3
days until the desired response is achieved.
• CNS stimulants may aggravate co-existing anxiety or agitation in depressed patients. Therefore,
their use is usually reserved for treatment-refractory cases or when standard therapies are not
tolerated.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Medication
Average Cost of Therapy
Duloxetine DR capsule (CYMBALTA )
$88.95
Venlafaxine ER capsule (EFFEXOR® XR)
$81.84
Venlafaxine tablet (EFFEXOR®)
$48.04
®
| 64.1 | The Hospice Pharmacia Medication Use Guidelines
Depression
INCLUSION CODE: A
SSRIs
Medication
Average Cost of Therapy
Escitalopram (LEXAPRO )
$73.60
®
Paroxetine suspension (PAXIL )
$106.59
Paroxetine tablet (PAXIL®)
$35.95
®
Paroxetine CR tablet (PAXIL CR)
$40.75
®
TCAs
Medication
Average Cost of Therapy
Doxepin
$10.77
Imipramine (TOFRANIL®)
$28.01
Miscellaneous Antidepressants
Medication
Average Cost of Therapy
Bupropion (WELLBUTRIN®)
$35.16
Bupropion extended-release, 12 hour (BUDEPRION SR)
$40.29
Bupropion extended-release, 24 hour (BUDEPRION® XL)
$56.55
®
CNS Stimulants
Medication
Average Cost of Therapy
Methylphenidate SR (RITALIN® SR)
$49.34
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Psychotherapy in combination with pharmacologic therapy often is more effective than either
therapy alone.
• Relaxation techniques may help reduce anxiety often accompanying depression.
• Social worker and chaplain visits may be comforting to the patient.
NOTES:
• Maximum benefit of antidepressants may not be achieved for 4 to 6 weeks.
• Abrupt discontinuation of antidepressant therapy should be avoided if possible, as it may precipitate withdrawal symptoms. A taper of the dose over one to two weeks is recommended when
discontinuing therapy.
• The use of more than one antidepressant concurrently should be avoided whenever possible
because it could lead to toxicity.
• Some antidepressants are more sedating than others (e.g., mirtazapine, trazodone). These antidepressants may be particularly useful in depressed patients with sleep disturbances.
• When initiating SSRIs or TCAs in older adults, the dose is usually half the suggested dose provided in the tables above.
The Hospice Pharmacia Medication Use Guidelines
| 65.1 |
Depression
INCLUSION CODE: A
| 66.1 | The Hospice Pharmacia Medication Use Guidelines
Diarrhea
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
GI = gastrointestinal
PO = by mouth
PRN = as needed
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Adsorbents
Medication
Suggested Dosing
Bismuth subsalicylate suspension
30mL PO every 30 to 60 minutes PRN, up to 240mL (4.2gm)
(262mg/15mL)
(BISMATROL®, PEPTO-BISMOL®) per day
• Bismuth subsalicylate is contraindicated in patients with salicylate hypersensitivity.
• Due to an increased risk of bleeding, use of bismuth subsalicylate is contraindicated in patients
with hematological disease (i.e., conditions that increase the risk of bleeding), such as severe
hepatic impairment due to hepatic disease or in patients receiving warfarin.
• Bismuth subsalicylate is contraindicated in the presence of GI bleeding and in peptic ulcer disease.
• Avoid concurrent treatment with bismuth subsalicylate and other salicylates, including aspirin.
Bile Acid Sequestrants
Medication
Suggested Dosing
Cholestyramine powder (plain
and light)
Mix 2gm to 4gm in 60mL to 180mL of fluid (e.g., water, milk,
fruit juice, or other non-carbonated beverage) PO 2 to 4
times a day
• Administer other medications at least 1 hour before or 4 to 6 hours after each dose of cholestyramine,
as this medication may impede the absorption of other medications.
• The powder may also be mixed with a highly fluid soup or a pulpy fruit with high moisture (e.g.,
applesauce, crushed pineapple).
• The palatability of and compliance with cholestyramine may be improved if the dose is mixed and
refrigerated overnight.
• The difference between cholestyramine plain and cholestyramine light is the amount of dried resin
that is present in the powder. Cholestyramine plain has 4gm of active ingredient per 9gm of powder;
cholestyramine light has 4gm of active ingredient per 5gm of powder.
Hypomotility Agents
Medication
Suggested Dosing
Camphorated opium tincture
2mg/5mL solution (PAREGORIC®) 2mg to 4mg (5mL to 10mL) PO 1 to 4 times a day PRN
Diphenoxylate with atropine
2 tablets (5mg) or 10mL PO 3 to 4 times a day PRN, up to 8
tablets or 40mL per day
Loperamide
4mg PO initially followed by 2mg after each loose stool PRN,
up to 16mg/day
The Hospice Pharmacia Medication Use Guidelines
| 67 |
Diarrhea
INCLUSION CODE: A
• PAREGORIC® is 25-times less potent than opium tincture. Unlike opium tincture, the dose of
PAREGORIC® is given as 5mL to 10mL or as 1 to 2 teaspoonsfuls and not as drops.
• Diarrhea usually improves within 48 hours of initiating treatment with a hypomotility agent.
After clinical improvement is observed, the dose should be reduced or the medication should
be discontinued. If clinical improvement is not observed within 10 days of treatment with the
maximum daily dose, symptoms are unlikely to be controlled by further administration.
Antibiotics for Infectious Diarrhea
Medication
Suggested Dosing
Metronidazole
250mg to 500mg PO 3 to 4 times a day for 7 to 14 days
• Metronidazole can inhibit alcohol dehydrogenase and other alcohol-metabolizing enzymes.
This inhibition can lead to the development of side effects such as abdominal cramps, flushing,
headache, nausea, and vomiting.
• Alcohol and alcohol-containing medications should be avoided during therapy with metronidazole and for 3 days after therapy is discontinued. Please consult with your HP pharmacist for help
determining whether medications or medication formulations contain alcohol content.
• Prophylactic or suppressive antibiotic therapy is outside the HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost for a single course of the
anti-infective.
Antibiotics for Infectious Diarrhea
Medication
Vancomycin hydrochloride capsule (VANCOCIN® HCl)
Average Cost of Therapy
$636.12
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Modify diet: clear liquids for a day, avoidance of dairy products, BRAT diet (bananas, rice,
apples, and toast).
• Avoid stimulants such as caffeine and nicotine.
• Provide perianal skin care.
NOTES:
• If Clostridium difficile (C. diff) is documented as the etiology of infectious diarrhea, hypomotility
agents (e.g., loperamide) should not be used because they may increase the severity of the infection and/or lead to pseudomembranous colitis.
| 68 | The Hospice Pharmacia Medication Use Guidelines
Diarrhea
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 69.1 |
Dyspepsia
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
AC = before meals
CrCl = creatinine clearance
DR = delayed-release
FDA = Food and Drug Administration
H2RA = histamine2-receptor antagonists
HS = at bedtime
PC = after meals
PO = by mouth
PPIs = proton pump inhibitors
QD = daily
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Antacids
Medication
Suggested Dosing
Aluminum hydroxide suspension
10mL PO 5 to 6 times a day, PC and HS
Aluminum hydroxide/magnesium
hydroxide with simethicone
suspension (ALAMAG PLUS™)
10mL to 20mL PO between meals and HS
• Aluminum hydroxide causes constipation and should be used with extreme caution in patients who
are predisposed to constipation or complications associated with constipation, including older adults,
patients taking antidiarrheals or anticholinergics, and patients with gastric outlet obstruction.
• Aluminum hydroxide and magnesium hydroxide should be avoided in patients with renal
insufficiency.
Antiflatulent Agents
Medication
Suggested Dosing
Simethicone
80mg to 125mg PO TID
Histamine2-Receptor Antagonists (H2RAs)
Medication
Suggested Dosing
Ranitidine
75mg to 150mg PO 1 to 2 times a day
• Total daily dosages of ranitidine > 300mg/day are outside the HP per diem.
Prokinetic Agents
Medication
Suggested Dosing
Erythromycin
125mg to 250mg PO 3 to 4 times a day, 30 minutes AC and HS
Metoclopramide
10mg to 15mg PO up to 4 times a day, 30 minutes AC and HS
• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary and repetitive movements of the face and body, even after metoclopramide is stopped.
These symptoms are rarely reversible and there is no known treatment. The U.S. FDA recommends against use of metoclopramide for durations longer than 3 months.
• Older adults, especially females, are more likely to develop tardive dyskinesia and thus metoclopramide should be used cautiously, if at all, in older adults. Consider starting with a lower (5mg)
dose of metoclopramide in older adults.
| 70.1 | The Hospice Pharmacia Medication Use Guidelines
Dyspepsia
INCLUSION CODE: A
• Metoclopramide should be used cautiously, if at all, in patients with a seizure disorder (or acute
seizures) or Parkinson’s disease.
Proton Pump Inhibitors (PPIs)
Medication
Omeprazole
Suggested Dosing
20mg PO QD
• PPIs should be administered with a full glass of water 30 minutes before breakfast.
• Total daily dosages of omeprazole > 20mg/day are outside the HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Antacids
Medication
Aluminum hydroxide/magnesium carbonate chewable tablet
(GAVISCON®)
Average Cost of Therapy
$9.36
H2RAs
Medication
Cimetidine tablet (TAGAMET® HB)
Famotidine solution for injection (PEPCID®)
Famotidine tablet and suspension (PEPCID®)
Average Cost of Therapy
$31.68
$15.29
$8.98
PPIs
Medication
Esomeprazole DR capsule (NEXIUM®)
Esomeprazole DR powder for suspension (NEXIUM®)
Lansoprazole DR capsule (PREVACID®)
Lansoprazole DR orally disintegrating tablet (PREVACID® SOLUTAB™)
Pantoprazole DR tablet (PROTONIX®)
Average Cost of Therapy
$108.75
$136.33
$99.00
$124.32
$59.52
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
•
•
•
•
•
•
Avoid activities that worsen indigestion, such as eating too quickly and eating large or greasy meals.
Avoid consuming alcohol.
Avoid foods that trigger dyspepsia, such as spicy foods.
Encourage regular exercise when feasible.
Maintain a healthy weight.
When appropriate, encourage smoking cessation.
NOTES:
• Adjust dosages based on age, renal function, and other patient and medication characteristics.
For example, the daily dosage of H2RAs should be decreased by 50% for patients with estimated
CrCl < 50 mL/min. Please consult with your HP pharmacist for dosage adjustments.
The Hospice Pharmacia Medication Use Guidelines
| 71.1 |
Dyspepsia
INCLUSION CODE: A
| 72.1 | The Hospice Pharmacia Medication Use Guidelines
Dyspnea
INCLUSION CODE: A, C, L
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
ER = extended-release
IR = immediate-release
MDI = metered dose inhaler
PO = by mouth
PRN = as needed
QD = daily
SR = sustained-release
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of dyspnea related to the
patient’s hospice-qualifying terminal diagnosis (INCLUSION CODE: A).
Anticholinergics
Medication
Suggested Dosing
Ipratropium bromide inhalation
aerosol (17mcg/actuation)
(ATROVENT® HFA)
2 sprays PO 3 to 4 times a day at least 4 hours apart, up to
12 sprays (204mcg) in a 24-hour period
Ipratropium bromide nebulizer
solution (0.02%, 0.5mg/2.5mL)
1 unit dose vial via oral nebulizer every 6 to 8 hours
Anticholinegic Bronchodilator - Short-acting Combination
Medication
Suggested Dosing
Albuterol sulfate and ipratropium
bromide nebulizer solution
(DUONEB®)
1 unit dose vial via oral nebulizer every 6 to 8 hours
Bronchodilators – Short-acting Sympathomimetics
Medication
Suggested Dosing
Albuterol sulfate HFA inhalation
aerosol (90mcg/actuation)
(PROAIR® HFA, PROVENTIL®
HFA, VENTOLIN® HFA)
2 inhalations PO every 4 to 6 hours PRN
Albuterol sulfate nebulizer
solution (0.083%, 2.5mg/3mL)
1 unit dose vial via oral nebulizer every 6 to 8 hours PRN
Albuterol sulfate nebulizer
solution (0.5%, 5mg/1mL)
0.5mL (2.5mg) via oral nebulizer every 6 to 8 hours PRN
Albuterol sulfate syrup (2mg/5mL)
2mg to 4mg PO every 6 to 8 hours PRN
Albuterol sulfate tablet
2mg to 4mg PO every 6 to 8 hours PRN
• The maximum recommended daily dose of albuterol is 32mg/day.
• Because of the adverse effect profile and delayed onset, it is recommended that albuterol syrup or
tablets be reserved for patients who are unable to use a MDI and/or nebulizer.
The Hospice Pharmacia Medication Use Guidelines
| 73.2 |
Dyspnea
INCLUSION CODE: A, C, L
Corticosteroids – Inhaled
Medication
Suggested Dosing
Beclomethasone dipropionate
inhalation aerosol (40mcg or
80mcg per actuation)
(QVAR®)
1 to 2 inhalations PO BID
Triamcinolone acetonide inhalation 2 inhalations PO 3 to 4 times a day, or 4 inhalations PO BID,
aerosol (75mcg/actuation)
not to exceed 16 inhalations/day
(AZMACORT®)
• Patients prescribed both an inhaled corticosteroid and bronchodilator should be instructed to
administer the bronchodilator first then wait five minutes before administering the inhaled corticosteroid. This opens up the airways to ensure maximum delivery of the inhaled corticosteroid.
• To reduce the risk of oral candidiasis, patients should be instructed to rinse their mouth (gargling with water) after each dose of the inhaled corticosteroid.
Corticosteroids – Oral
Medication
Suggested Dosing
Dexamethasone
4mg PO 1 to 2 times a day
Methylprednisolone
4mg PO 1 to 2 times a day, or as directed per dosepak
Prednisone
20mg to 40mg PO QD
• The minimum effective dose of an oral corticosteroid should be used for the shortest duration
possible. Whenever possible, a dose reduction should be attempted in order to reduce the risk of
long-term systemic adverse effects.
• When a corticosteroid is administered in divided doses, it is suggested that the last dose be given
in the afternoon to avoid insomnia.
Opioids
Medication
Suggested Dosing
Morphine IR
Opioid naïve patients: 5mg PO for 1 dose then repeat
5mg/dose every 30 minutes until dose that provides relief is
achieved; give effective dose every 2 to 4 hours PRN
Opioid tolerant patients: Increase dose of current regimen by
25% to 50% and give every 2 to 4 hours PRN
• Opioids reduce the feeling of breathlessness and should be considered for use in all patients unless otherwise contraindicated.
• The preferred route of administration of opioids for the management of dyspnea is oral or parenteral;
there is a paucity of data to support the use of opioids administered via the nebulization route.
• Other opioids also may be effective for managing dyspnea. Hydromorphone IR and oxycodone IR are included in the HP per diem for managing dyspnea.
• If the IR opioid is effective, consider adding a long-acting opioid to the patient’s regimen for
consistent relief of dyspnea.
| 74.1 | The Hospice Pharmacia Medication Use Guidelines
Dyspnea
INCLUSION CODE: A, C, L
DISEASE-SPECIFIC PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The additional pharmacologic therapies listed below are for the management of dyspnea specifically associated with chronic obstructive pulmonary disease (COPD, defined as ICD-9-CM
code 496; INCLUSION CODE: L) or pulmonary malignancy (defined as ICD-9-CM code
162.9; INCLUSION CODE: C).
Anticholinergic-Bronchodilator (short-acting) Combinations
Medication
Suggested Dosing
Albuterol sulfate and ipratropium
bromide inhalation aerosol
(103mcg-18mcg/actuation)
(COMBIVENT®)
2 inhalations PO every 4 to 6 hours PRN
Bronchodilators – Long-acting Sympathomimetics
Medication
Suggested Dosing
Salmeterol (50mcg/actuation)
(SEREVENT® DISKUS®)
1 inhalation PO every 12 hours
• Salmeterol has a relatively slow onset of action; it should not be used to treat acute dyspnea.
Rather, the patient should have on hand a quick-onset, short-acting beta-adenergic bronchodilator (e.g., albuterol) for management of acute dyspnea.
• Salmeterol prescribed more frequently than 1 inhalation PO every 12 hours is outside the
per diem.
Bronchodilator (long-acting)-Corticosteroid (inhaled) Combinations
Medication
Suggested Dosing
Salmeterol and fluticasone
propionate inhalation powder
(100-50mcg/actuation, 25050mcg/actuation, 500-50mcg/
actuation) (ADVAIR® DISKUS®)
1 inhalation PO every 12 hours
• Salmeterol and fluticasone prescribed more frequently than 1 inhalation PO every 12 hours
is outside the per diem.
Bronchodilators – Xanthines
Medication
Suggested Dosing
Theophylline SR tablets
10mg/kg/day PO in divided doses every 8 to 12 hours
Theophylline elixir or solution
(80mg/15mL)
10mg/kg/day PO in divided doses every 6 to 8 hours
• The dose of theophylline should be adjusted to achieve and maintain a serum theophylline
concentration of 10mcg/mL (range, 8mcg/mL to 12mcg/mL) at steady-state.
The Hospice Pharmacia Medication Use Guidelines | | 75.1
75 |
Dyspnea
INCLUSION CODE: A, C, L
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticholinergics
Medication
Average Cost of Therapy
Tiotropium bromide inhalation powder (SPIRIVA
HANDIHALER®)
®
$172.69
Bronchodilators – Long-acting Sympathomimetics
Medication
Average Cost of Therapy
Arformoterol tartrate nebulizer solution (BROVANA®)
$169.87
Formoterol fumarate inhalation powder (FORADIL
AEROLIZER®)
$140.59
®
Formoterol fumarate nebulizer solution (PERFOROMIST™)
$183.90
Bronchodilators – Short-acting Sympathomimetics
Medication
Average Cost of Therapy
Albuterol sulfate nebulizer solution (0.63mg/3mL) (ACCUNEB )
$48.19
Albuterol sulfate ER tablet (VOSPIRE )
$39.93
®
®
Levalbuterol tartrate inhalation aerosol (XOPENEX HFA®)
$52.63
Levalbuterol hydrochloride nebulizer solution (XOPENEX )
$168.69
Terbutaline sulfate tablet
$20.66
®
Bronchodilator (long-acting)-Corticosteroid (inhaled) Combinations
Medication
Average Cost of Therapy
Formoterol fumarate and budesonide pressurized inhalation
powder (SYMBICORT®)
$183.60
Salmeterol and fluticasone propionate inhalation aerosol
(ADVAIR® HFA)
$241.07
Corticosteroids – Inhaled
Medication
Average Cost of Therapy
Budesonide inhalation powder (PULMICORT FLEXHALER™)
$122.49
Budesonide nebulizer suspension (PULMICORT RESPULES )
$225.68
Fluticasone propionate inhalation aerosol (FLOVENT® HFA)
$170.97
Mometasone furoate inhalation powder (ASMANEX
TWISTHALER®)
$182.43
™
®
Corticosteroids – Oral
Medication
Average Cost of Therapy
Hydrocortisone (CORTEF®)
$15.98
Prednisone dosepack (STERAPRED UNI-PAK)
®
76 | | The Hospice Pharmacia Medication Use Guidelines
| 76.1
$10.30
Dyspnea
INCLUSION CODE: A, C, L
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Allow the patient to assume a comfortable position (usually sitting or reclined).
• Determine the patient’s perception of dyspnea and assist the patient to find a less frightening
significance for the symptom (e.g., dyspnea = death versus dyspnea = manageable symptom).
• For patients who are receptive, teach relaxation techniques to control and avert respiratory panic
attacks.
• Make sure the patient’s room is well ventilated. If necessary, use a fan to create a breeze over the
patient’s face.
• In some cases, oxygen may be effective.
NOTES:
• Spacers (e.g., ACE Aerosol Cloud Enhancer) are tube-like devices that are used in combination
with MDIs to aid in the delivery of aerosolized medication to the lungs. Please consult with your
HP pharmacist to determine whether your patient would benefit from having a spacer.
• Anxiolytics, particularly benzodiazepines (e.g., lorazepam), also may be useful for the management of dyspnea at the end of life, especially for patients with severe anxiety or when the
dyspnea is a somatic manifestation of a panic disorder. Anxiolytics often are used in combination
with opioids.
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| 77 |
Edema
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
CrCl = creatinine clearance
IM = intramuscularly
IV = intravenously
PO = by mouth
PRN = as needed
QD = daily
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Loop Diuretics
Medication
Suggested Dosing
Bumetanide
0.5mg to 2mg PO QD, up to 10mg/day
Furosemide
40mg to 120mg PO QD, up to 600mg/day.
• The estimated relative potency of loop diuretics is as follows: bumetanide 1mg = furosemide
40mg = torsemide 20mg. Torsemide is outside the HP per diem.
• The initial dose of furosemide is typically 20mg to 80mg PO as a single dose, repeated in 6 to 8
hours if necessary. Doses are usually increased in 20mg to 40mg increments to the usual dose of
40mg to 120mg per day.
• Patients exhibiting signs of furosemide-resistant edema may benefit from a switch to parenteral
furosemide, a switch to another loop diuretic such as bumetanide, or the addition of a thiazide
diuretic such as metolazone. When using furosemide parenterally, administer IV doses slowly. A
maximum infusion rate of 4mg/min is recommended when administering doses > 120mg and
for patients with cardiac or renal failure.
Potassium-Sparing Diuretics
Medication
Suggested Dosing
Spironolactone
25mg to 200mg PO daily, given in 1 to 2 divided doses
Triamterene-hydrochlorothiazide
37.5/25mg to 75/50mg PO QD
Thiazide Diuretics
Medication
Suggested Dosing
Hydrochlorothiazide
25mg to 100mg PO daily, given in 1 to 2 divided doses
Metolazone
5mg to 10mg PO QD, up to 20mg/day
• When using metolazone concurrently with a loop diuretic, the initial dose should be 2.5mg
PO QD.
• Thiazides are typically less effective than loop diuretics for the management of edema, especially in patients with renal impairment (CrCl < 30mL/min).
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Loop Diuretics
Medication
Average Cost of Therapy
Torsemide (DEMADEX )
®
| 78 | The Hospice Pharmacia Medication Use Guidelines
$34.37
Edema
INCLUSION CODE: A
Potassium-Sparing Diuretics
Medication
Average Cost of Therapy
Amiloride (MIDAMOR )
$19.31
Triamterene (DYRENIUM®)
$20.05
®
Potassium-Sparing Diuretic-Thiazide Diuretic Combinations
Medication
Amiloride and hydrochlorothiazide
Average Cost of Therapy
$14.02
Thiazide Diuretics
Medication
Chlorothiazide tablet
Average Cost of Therapy
$7.22
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Assess the patient’s medication regimen and, if possible, discontinue medications causing or
worsening edema.
• Elevate the patient’s legs above the heart while lying down.
• Exercising the legs helps fluid to work back into the veins and lymphatic channels. This may
improve swelling.
• Provide pressure with elastic bandages or support stockings to help reduce ankle swelling.
• Recommend a low-salt diet to help reduce fluid retention and ankle swelling.
• Recommend that the patient avoids sitting or standing without moving for prolonged periods
of time.
• Recommend that the patient avoids wearing constricting clothing.
NOTES:
• Monitor weight change or input-output to assist in gauging efficacy of diuretics.
• Monitor potassium and renal function, as well as for signs and symptoms of hypotension or
dehydration.
• Potassium supplementation may not be necessary for patients taking spironolactone, a potassium-sparing diuretic (e.g., triamterene), or an ACE inhibitor (e.g., enalapril). However,
potassium supplementation is included in the HP per diem for patients who need potassium
replacement as a result of pharmacologic therapy used to manage edema. Please consult with your
HP pharmacist to determine specific potassium products available in the per diem.
The Hospice Pharmacia Medication Use Guidelines
| 79 |
Fever
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
NSAIDs = non-steroidal anti-inflammatory drugs PR = rectally
PO = by mouth
PRN = as needed
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Antipyretics
Medication
Suggested Dosing
Acetaminophen
325mg to 650mg PO/PR every 4 to 6 hours PRN, up to
4000mg/day
Aspirin
325mg to 650mg PO or 300mg to 600mg PR every 4 hours
PRN
Choline magnesium trisalicylate
750mg to 1000mg PO 2 to 3 times a day
Ibuprofen
200mg to 400mg PO every 4 to 6 hours PRN, up to
1200mg/day
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medication.
Antipyretics
Medication
Ketoprofen capsule
Average Cost of Therapy
$37.29
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Cool the patient by sponging with tepid water; however, this therapy should only be used
when the external environment is warm or humid because extremes of temperature may be
uncomfortable to the patient.
• Encourage oral fluid intake, if appropriate.
NOTES:
• Other NSAIDs such as diclofenac sodium, nabumetone, and naproxen may also be effective and
are included in the HP per diem.
• Corticosteroids are sometimes used to treat fever of unknown origin when other pharmacologic
therapy is ineffective. Dexamethasone, methylprednisolone, prednisolone, and prednisone
are included in the HP per diem to treat fever.
• The use of antibiotics in patients who are approaching the end of life is controversial. If antibiotics are used, the goals and duration of antibiotic therapy should be clear.
| 80 | The Hospice Pharmacia Medication Use Guidelines
Genitourinary Symptoms
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
ER = extended-release
HS = at bedtime
IR = immediate-release
PC = after meals
PO = by mouth
PR = rectally
PRN = as needed
SL = sublingual or sublingually
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Anorectal Drugs
Medication
Suggested Dosing
Benzocaine rectal ointment (20%) Apply to perianal area up to 6 times per day
Dibucaine topical ointment (1%)
Apply to perianal area every 3 to 4 hours PRN
Hydrocortisone rectal cream
(2.5%)
Apply to perianal area 3 to 4 times a day
Hydrocortisone acetate
suppository (25mg)
(ANUCORT-HC™, ANUSOLHC®, HEMORRHOIDAL HC)
1 suppository PR BID for 14 days
Lidocaine topical gel/jelly (2%) or
ointment (5%)
Apply to perianal area every 3 to 4 hours PRN
• Anorectal drugs are useful for temporarily relieving rectal pain and discomfort, especially soreness and/or pruritus associated with hemorrhoids and anorectal inflammation.
Local Analgesics/Anesthetics
Medication
Suggested Dosing
Phenazopyridine
200mg PO TID PC
• Phenazopyridine is useful for the symptomatic relief of pain, burning, urgency, frequency, and
other discomforts resulting from irritation of the lower urinary tract mucosa.
• Phenazopyridine has no antimicrobial properties. Therapy with phenazopyridine generally
should not exceed three days; however, some patients may benefit from a longer duration of
therapy. Therapy beyond three days is included in the HP per diem.
Smooth Muscle Relaxants
Medication
Suggested Dosing
Belladonna-opium (B&O)
suppository
1 suppository PR 1 to 2 times a day PRN
Hyoscyamine regular-release
0.125mg to 0.25mg PO/SL every 4 hours PRN
Hyoscyamine ER
0.375mg to 0.75mg PO every 12 hours
Oxybutynin IR
5mg PO 2 to 4 times a day
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| 81 |
Genitourinary Symptoms
INCLUSION CODE: A
• Smooth muscle relaxants are useful for managing bladder spasms.
• Smooth muscle relaxants are strongly anticholinergic. Major side effects are blurred vision,
constipation, dry mouth, and urinary retention. Older adults are especially sensitive to these side
effects.
• B&O suppositories are available in the following strengths: 15A (belladonna 15mg and opium
30mg) and 16A (belladonna 15mg and opium 60mg).
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anorectal Drugs
Medication
Average Cost of Therapy
Hydrocortisone and pramoxine rectal foam
(PROCTOFOAM-HC®)
$64.88
Smooth Muscle Relaxants
Medication
Average Cost of Therapy
Oxybutynin ER (DITROPAN XL)
®
$79.25
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Inspect the patient’s skin routinely and look for any reddened areas.
• Cleanse the affected area with mild soap and warm water.
• Use an astringent (e.g., TUCKS® medicated pads) to help relieve burning and irritation due to
hemorrhoids.
NOTES:
• Additional management strategies are provided in the Urinary Incontinence section.
| 82 | The Hospice Pharmacia Medication Use Guidelines
Hepatic Encephalopathy
INCLUSION CODE: C, O
ACRONYMS USED IN THIS MONOGRAPH:
PO = by mouth
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of hepatic encephalopathy
due to liver disease (defined as ICD-9-CM codes 570, 571.0-571.9, 572.0, 573.0-573.9; INCLUSION CODE: O), malignant neoplasm of the liver and intrahepatic bile ducts (defined
as ICD-9-CM codes 155.-155.2 or 197.7; INCLUSION CODE: C), or malignant neoplasm
of the gallbladder and extrahepatic bile ducts (defined as ICD-9-CM codes 156.-156.9;
INCLUSION CODE: C).
Aminoglycosides
Medication
Suggested Dosing
Neomycin
1gm PO every 6 hours for 5 to 6 days
• The usual dosage of neomycin for the adjunctive treatment of hepatic encephalopathy is 1gm to
3gm PO every 6 hours for 5 to 6 days.
• The maximum dosage of neomycin is 2gm PO every 4 hours.
Osmotic Laxatives
Medication
Suggested Dosing
Lactulose
30mL to 45mL PO 3 to 4 times daily
• If necessary, hourly doses of lactulose (30mL to 45mL) may be given until a laxative effect is
induced. Once a laxative effect has been established, the dosage should be reduced to produce 2
to 3 loose stools daily.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medication.
Rifamycins
Medication
Average Cost of Therapy
Rifaximin (XIFAXAN™)
$212.02
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Avoid medications that further impair mental status.
• Discontinue or reduce doses of medications metabolized by the liver.
• Restrict or eliminate protein from the diet.
NOTES:
• Seizures have been described as a rare manifestation of hepatic encephalopathy. Seizures are usually controlled by oral lactulose or neomycin.
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| 83 |
Hiccups
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
FDA = Food and Drug Administration
PO = by mouth
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Anticonvulsants
Medication
Suggested Dosing
Valproic acid (DEPAKENE®)
5mg/kg/dose PO TID
• Although a dose of 15mg/kg/day has been the effective dose reported in the literature, the final
therapeutic dose should be based on tolerability and clinical response.
• In general, the dose of valproic acid should be reduced and titrated more slowly in older adults.
Skeletal Muscle Relaxants
Medication
Suggested Dosing
Baclofen
5mg to 10mg PO TID
• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with
hallucinations, spasticity, and seizures. Baclofen therapy should be discontinued slowly.
Neuroleptics
Medication
Suggested Dosing
Chlorpromazine
25mg to 50mg PO 3 to 4 times a day
Haloperidol
0.5mg to 1mg PO TID
• Although chlorpromazine is an effective neuroleptic for the management of hiccups, it is sedating and has anticholinergic properties. Therefore, it is best used in patients who might benefit
from these effects. It is best avoided in patients who might be harmed by these effects, such as
patients with Parkinson’s disease.
Prokinetic Agents
Medication
Suggested Dosing
Metoclopramide
5mg to 10mg PO TID
• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary and repetitive movements of the face and body, even after metoclopramide is stopped.
These symptoms are rarely reversible and there is no known treatment. The U.S. FDA recommends against use of metoclopramide for durations longer than 3 months.
• Older adults, especially females, are more likely to develop tardive dyskinesia and thus metoclopramide should be used cautiously, if at all, in older adults. Consider starting with a lower (5mg)
dose of metoclopramide in older adults.
• Metoclopramide should be used cautiously, if at all, in patients with a seizure disorder (or acute
seizures) or Parkinson’s disease.
| 84 | The Hospice Pharmacia Medication Use Guidelines
Hiccups
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Calcium Channel Blockers
Medication
Average Cost of Therapy
Nifedipine capsule (PROCARDIA )
®
$23.99
Neuroleptics
Medication
Average Cost of Therapy
Perphenazine
$21.80
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Gargling with water or drinking water rapidly (“hard”) or from the “wrong side” of the glass;
holding breath or gasping with sudden fright; hyperventilation or rebreathing into a paper bag;
and lemon wedges with bitters, sugar, honey, or vinegar are some non-pharmacologic therapies
that anecdotally have been reported to be effective for relieving hiccups.
• Massage or relaxation techniques might be a useful therapeutic option.
NOTES:
• Suggested dosing noted above refers to initial dosages. Therapies may need to be adjusted based
on clinical response as well as patient and medication characteristics. Please consult with your HP
pharmacist for dosage adjustments.
• In collaboration with your HP pharmacist, thoroughly review the patient’s medication profile for
drugs that may cause or worsen hiccups. These may include, but are not limited to, barbiturates
(short-acting), chlordiazepoxide, dexamethasone, diazepam, methyldopa, and sulfonamides.
The Hospice Pharmacia Medication Use Guidelines
| 85 |
Hiccups
INCLUSION CODE: A
| 86 | The Hospice Pharmacia Medication Use Guidelines
Hyperglycemia
INCLUSION CODE: A, C, O
ACRONYMS USED IN THIS MONOGRAPH:
ER = extended-release
PO = by mouth
QD = daily
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of hyperglycemia due
to diabetes as the hospice-qualifying terminal diagnosis (defined as ICD-9-CM codes
250.0-250.9; INCLUSION CODE: O), hyperglycemia due to pancreatic cancer (defined
as ICD-9-CM codes 157.0-157.9 or 197.8; INCLUSION CODE: C), or hyperglycemia
induced by a medication used for a symptom related to the patient’s hospice-qualifying terminal diagnosis (INCLUSION CODE: A), whereby the hyperglycemia affects the
patient’s quality of life.
Insulins
Medication
Insulin human NPH, REG, and
70/30 (HUMULIN®)
Insulin human NPH, REG, and
70/30 (NOVOLIN®)
Suggested Dosing
Dosing based upon patient-specific factors
Dosing based upon patient-specific factors
Sulfonylureas
Medication
Suggested Dosing
Glipizide regular-release
5mg to 10mg PO QD
Glyburide
2.5mg to 5mg PO QD
• Although the maximum recommended dosage of regular-release glipizide is 40mg/day, it has
been suggested that doses > 10mg/day may produce little or no additional benefit and may
reduce beta-cell function. In general, when daily doses exceed 30mg/day, glipizide should be
divided into two doses.
• The usual dosage range for glyburide is 1.25mg/day to 20mg/day. For some patients, particularly
those taking doses > 10mg/day, better glucose control may be achieved with twice daily dosing.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Biguanides
Medication
Metformin (GLUCOPHAGE®)
Metformin ER (GLUCOPHAGE® XR)
Average Cost of Therapy
$20.91
$19.12
Biguanide-Sulfonylurea Combinations
Medication
Average Cost of Therapy
Metformin and glyburide (GLUCOVANCE )
®
$37.71
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| 87 |
Hyperglycemia
INCLUSION CODE: A, C, O
Dipeptidyl Peptidase-4 Inhibitors
Medication
Average Cost of Therapy
Sitagliptin (JANUVIA )
$76.13
™
Fibric Acid Derivatives
Medication
Average Cost of Therapy
Gemfibrozil (LOPID®)
$29.08
Insulins
Medication
Insulin aspart vial (NOVOLOG®)
Insulin detemir vial (LEVEMIR®)
Insulin glargine vial (LANTUS®)
Insulin lispro vial (HUMALOG®)
Insulin lispro protamine suspension-insulin lispro vial
(HUMALOG® MIX)
Average Cost of Therapy
$103.71
$100.02
$99.31
$103.17
$153.71
Meglitinides
Medication
Average Cost of Therapy
Repaglinide (PRANDIN )
$32.47
®
Sulfonylureas
Medication
Average Cost of Therapy
Glimepiride (AMARYL®)
$10.14
Glipizide ER (GLUCOTROL XL)
Thiazolidinediones
®
Medication
$13.80
Average Cost of Therapy
Pioglitazone (ACTOS®)
$112.93
Rosiglitazone (AVANDIA )
®
$58.91
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Encourage lifestyle modifications, particularly diet and exercise.
NOTES:
• Insulin syringes are included in the HP per diem; however, pre-filled insulin syringes and insulin pens are outside the HP per diem. In order for insulin syringes to be included in the per diem,
they must be dispensed by HP; insulin syringes cannot be adjudicated through the PBM Plus card.
• Conventional formulations of glyburide (DIABETA® and MICRONASE®) are included in
the HP per diem, whereas micronized formulations (GLYNASE™) are not. These two formulations are not bioequivalent. Consult with your HP pharmacist for dosage adjustments.
| 88 | The Hospice Pharmacia Medication Use Guidelines
Infections
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
CAP = community-acquired pneumonia
PHN = post-herpetic neuralgia
PO = by mouth
QD = daily
UTI = urinary tract infection
WA = while awake
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The following is a list of pharmacologic therapies that are included in the HP per diem for the
treatment of infections related to the patient’s hospice-qualifying terminal diagnosis. This list is
organized by route of administration and medication class.
• The specific indications included in the HP per diem are provided in the tables; indications
other than those provided in the tables are outside the HP per diem.
• Refer to the Medications with Policies section (page 17) for additional information regarding
the policy for medications used for infections.
ORAL THERAPIES
Antifungals
Medication
Clotrimazole troche
Fluconazole
Nystatin suspension
Antivirals
Medication
Acyclovir
Valacyclovir (VALTREX®)
Suggested Dosing
Oropharyngeal candidiasis:
1 troche buccally 5 times a day, given every 4 hours WA, for 7
to 14 days
Oropharyngeal candidiasis:
200mg PO on day 1, then 100mg PO QD for 7 to 14 days
UTI:
50mg to 200mg PO QD for 7 to 14 days
Vulvovaginal candidiasis:
150mg PO for 1 dose
Oropharyngeal candidiasis:
Swish and swallow with 5mL PO every 6 hours for 7 to
14 days, continuing treatment for at least 48 hours after
symptoms are resolved
Suggested Dosing
Herpes zoster:
800mg PO 5 times a day, given every 4 hours WA, for 7 to
10 days
Herpes zoster:
1gm PO every 8 hours for 7 days
• Antivirals do not eradicate the infection, rather they can help relieve and shorten the duration of
symptoms.
• Antivirals should be started at the first sign or symptom of herpes zoster (shingles), preferably
within 48 hours of onset. Efficacy of treatment started after 72 hours has not been established;
therefore, antiviral treatment started after 72 hours of the first sign or symptom of herpes
zoster is outside the HP per diem.
• Dosages of antivirals should be adjusted in patients with renal impairment. Please consult with
your HP pharmacist for dosage adjustments of antivirals.
The Hospice Pharmacia Medication Use Guidelines
| 89.1 |
Infections
INCLUSION CODE: A
Cephalosporins
Medication
Cefpodoxime proxetil
(VANTIN®)
Cefuroxime axetil
Cephalexin
Suggested Dosing
CAP:
200mg PO every 12 hours for 10 to 14 days
Skin and skin structure infections:
400mg PO every 12 hours for 7 to 14 days
CAP or skin and skin structure infections:
250mg to 500mg PO every 12 hours for 5 to 10 days
Skin and skin structure infections:
500mg PO every 6 to 12 hours for 7 to 14 days
UTI:
500mg PO every 12 hours or 250mg PO every 8 hours for
7 to 14 days
Fluoroquinolones
Medication
Ciprofloxacin
Levofloxacin (LEVAQUIN®)
Suggested Dosing
Skin and skin structure infections:
500mg to 750mg PO every 12 hours for 7 to 14 days
UTI:
250mg to 500mg PO every 12 hours for 7 to 14 days
CAP:
750mg PO QD for 5 days or 500mg PO QD for 7 to 14 days
Skin and skin structure infections:
500mg to 750mg PO QD for 7 to 10 days
UTI:
750mg PO QD for 5 days or 250mg PO QD for 10 days
Macrolides
Medication
Azithromycin
Erythromycin regular-release
Erythromycin delayed-release
Suggested Dosing
CAP or skin and skin structure infections:
500mg PO on day 1, then 250mg PO QD for 4 more days
CAP:
250mg to 500mg PO every 6 hours for 7 to 10 days
Skin and skin structure infections:
250mg to 500mg PO every 6 hours for 7 to 10 days
Skin and skin structure infections:
333mg PO every 8 hours or 500mg PO every 12 hours for
7 to 10 days
Miscellaneous Anti-infectives
Medication
Clindamycin
Metronidazole
Suggested Dosing
CAP:
150mg to 450mg PO every 6 hours for 10 days
Skin and skin structure infections:
150mg to 450mg PO every 6 hours for 10 days
Skin and skin structure infections:
500mg PO every 8 to 12 hours for 7 to 14 days
| 90.1 | The Hospice Pharmacia Medication Use Guidelines
Infections
INCLUSION CODE: A
• Metronidazole can inhibit alcohol dehydrogenase and other alcohol-metabolizing enzymes.
This inhibition can lead to the development of side effects such as abdominal cramps, flushing,
headache, nausea, and vomiting.
• Alcohol and alcohol-containing medications should be avoided during therapy with metronidazole and for 3 days after therapy is discontinued. Please consult with your HP pharmacist for help
determining whether medications or medication formulations contain alcohol content.
• Metronidazole tablets crushed and sprinkled onto the skin (wound bed) are outside the HP
per diem. Metronidazole topical cream and gel and compounded topical paste, powder, and
spray also are outside the HP per diem. Please consult with your HP wound care specialist for
help with the management of wounds.
Penicillins
Medication
Amoxicillin
Amoxicillin-clavulanate regularrelease
Amoxicillin-clavulanate extendedrelease (AUGMENTIN® XR)
Dicloxacillin
Penicillin VK
Suggested Dosing
CAP:
500mg to 1000mg PO every 8 hours for 10 to 14 days
Skin and skin structure infections:
250mg to 500mg PO every 8 hours or 875mg PO every 12
hours for 10 to 14 days
UTI:
250mg to 500mg PO every 8 hours or 875mg PO every 12
hours for 10 days
CAP:
250mg (of amoxicillin) PO every 8 hours or 500mg PO every
8 to 12 hours or 875mg PO every 12 hours for 7 to 10 days
Skin and skin structure infections:
250mg (of amoxicillin) PO every 8 hours or 500mg PO every
8 to 12 hours or 875mg PO every 12 hours for 10 to 14 days
UTI:
250mg (of amoxicillin) PO every 8 hours or 500mg PO
every 12 hours for 3 to 10 days
CAP:
2000mg (of amoxicillin) PO every 12 hours for 7 to 10 days
CAP:
250mg to 500mg PO every 6 hours for 14 days
Skin and skin structure infections:
250mg to 500mg PO every 6 hours for 14 days
Skin and skin structure infections:
250mg to 500mg PO every 6 hours for 10 to 14 days
Sulfonamides
Medication
Sulfamethoxazole-trimethoprim
(BACTRIM®)
Suggested Dosing
CAP:
6mg/kg/day to 20mg/kg/day (of trimethoprim) PO every 6 to
12 hours for 14 days
Skin and skin structure infection:
400/80mg or 800/160mg PO every 12 hours for 7 to 14 days
UTI:
400/80mg or 800/160mg PO every 12 hours for 3 to 14 days
The Hospice Pharmacia Medication Use Guidelines
| 91.1 |
Infections
INCLUSION CODE: A
Tetracyclines
Medication
Suggested Dosing
Doxycycline
CAP or skin and skin structure infections or UTI:
100mg PO every 12 hours for 7 to 14 days
TOPICAL THERAPIES
Antibacterials
Medication
Bacitracin topical ointment
Bacitracin-polymyxin topical
powder (POLYSPORIN®
POWDER)
Bacitracin-neomycin-polymyxin
topical ointment (TRIPLE
ANTIBIOTIC® OINTMENT)
Bacitracin-neomycin-polymyxin
ophthalmic ointment
Bacitracin-neomycin-polymyxinhydrocortisone ophthalmic
ointment
Erythromycin ophthalmic
ointment
Gentamicin sulfate ophthalmic
solution (GENTAK®)
Neomycin-polymyxindexamethasone ophthalmic
suspension (MAXITROL®)
Silver sulfadiazine topical cream
Suggested Dosing
Skin and skin structure infections:
Apply to affected area(s) every 8 to 12 hours for 7 days
Skin and skin structure infections:
Apply to affected area(s) every 3 to 4 hours for 7 to 10 days
Skin and skin structure infections:
Apply sparingly to affected area(s) 2 to 5 times a day for 7 to
10 days
Ophthalmic infections:
Apply 1⁄4 to 1⁄2 inch to affected eye(s) every 3 to 4 hours
WA for 7 to 10 days
Ophthalmic infections:
Apply 1⁄4 to 1⁄2 inch to affected eye(s) every 3 to 4 hours
WA for 7 to 10 days
Ophthalmic infections:
Apply 1⁄2 inch to affected eye(s) every 4 to 6 hours WA for
7 to 10 days
Ophthalmic infections:
Instill 1 to 2 drops into affected eye(s) every 4 hours WA for
7 to 10 days
Ophthalmic infections:
Instill 1 to 2 drops into affected eye(s) 4 to 6 times per day
for 7 to 10 days
Skin and skin structure infections:
Apply to affected area(s) BID until healed
Antifungals
Medication
Suggested Dosing
Cutaneous candidiasis:
Clotrimazole topical cream
Apply to affected skin and surrounding areas BID until
complete healing
Vulvovaginal candidiasis:
Clotrimazole vaginal cream
Insert 1 applicatorful vaginally HS for 7 to 14 days
candidiasis:
Nystatin topical cream, ointment, Cutaneous
Apply to affected area(s) BID (cream, ointment) or 2 to 3
or powder
times a day (powder) until complete healing
Inflammatory cutaneous candidiasis:
Nystatin and triamcinolone
acetonide topical cream, ointment Apply sparingly to affected area(s) BID for < 14 days
| 92.1 | The Hospice Pharmacia Medication Use Guidelines
Infections
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost for a single course of the
anti-infectives.
ORAL THERAPIES
Antifungals
Medication
Ketoconazole
Voriconazole (VFEND®)
Average Cost of Therapy
$88.77
$522.86
Cephalosporins
Medication
Average Cost of Therapy
Cefdinir (OMNICEF®)
$61.44
Fluoroquinolones
Medication
Average Cost of Therapy
Moxifloxacin tablet (AVELOX )
$95.39
®
Macrolides
Medication
Average Cost of Therapy
Clarithromycin regular-release tablet (BIAXIN®)
$79.97
Miscellaneous Anti-infectives
Medication
Average Cost of Therapy
Trimethoprim
$12.94
Nitrofurans
Medication
Nitrofurantoin macrocrystalline capsule (MACRODANTIN®)
Nitrofurantoin mono/macrocrystals capsule (MACROBID®)
Nitrofurantoin suspension (FURADANTIN®)
Average Cost of Therapy
$21.46
$29.39
$344.24
Oxazolidinones
Medication
Average Cost of Therapy
Linezolid tablet (ZYVOX )
®
$915.07
Penicillins
Medication
Ampicillin
Average Cost of Therapy
$11.51
The Hospice Pharmacia Medication Use Guidelines
| 93.1 |
Infections
INCLUSION CODE: A
Tetracyclines
Medication
Average Cost of Therapy
Minocycline (MINOCIN )
$39.65
Tetracycline
$12.68
®
TOPICAL THERAPIES
Antibacterials
Medication
Average Cost of Therapy
Bacitracin-polymyxin topical ointment (POLYSPORIN®
OINTMENT)
$9.90
Ciprofloxacin ophthalmic solution (CILOXAN®)
$42.15
Gentamicin topical ointment
$12.22
Gramicidin-neomycin-polymyxin ophthalmic solution
(NEOSPORIN®)
$28.78
Metronidazole topical cream (METROCREAM®)
$76.61
Metronidazole topical gel (METROGEL®)
$151.35
Mupirocin calcium nasal ointment (BACTROBAN NASAL®)
$95.13
®
Mupirocin calcium topical cream (BACTROBAN CREAM )
$71.41
Mupirocin topical ointment (BACTROBAN® OINTMENT)
$43.93
Neomycin-polymyxin-dexamethasone ophthalmic ointment
(MAXITROL®)
$11.78
Sulfacetamide ophthalmic solution (BLEPH®-10)
$8.13
®
Tobramycin ophthalmic ointment (TOBREX )
$69.45
Tobramycin ophthalmic solution (TOBREX )
$16.05
Tobramycin-dexamethasone ophthalmic suspension
(TOBRADEX®)
$86.46
Trimethoprim-polymyxin ophthalmic solution (POLYTRIM®)
$17.12
®
Antifungals
Medication
Average Cost of Therapy
Clotrimazole and betamethasone dipropionate topical cream
(LOTRISONE®)
$49.25
Econazole nitrate topical cream
$48.80
Ketoconazole topical cream (KURIC CREAM)
$31.22
Miconazole nitrate topical cream (BAZA® ANTIFUNGAL)
$12.47
Miconazole nitrate topical powder (ZEASORB®-AF)
$16.41
™
| 94.1 | The Hospice Pharmacia Medication Use Guidelines
Infections
INCLUSION CODE: A
Antivirals
Medication
Average Cost of Therapy
Acyclovir topical cream (ZOVIRAX CREAM)
$137.01
Acyclovir topical ointment (ZOVIRAX OINTMENT)
$165.59
®
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Cognitive coping strategies such as distraction methods (e.g., imagery), meditation and/or relaxation to divert attention from PHN.
• Wet compresses often are soothing for PHN.
• To prevent bacterial infections from developing, patients with shingles should keep the affected
skin clean and dry and should not scratch the blisters.
• In general, follow applicable infection control policies and procedures (e.g., hand washing).
NOTES:
• The herpes zoster vaccine helps reduce the risk of shingles and the residual pain it can cause (i.e.,
PHN).
• Adjuvants (e.g., gabapentin) and topical pain relievers (e.g., lidocaine patch) often are used for
the management of PHN; opioids are sometimes needed.
• Sometimes combination anti-infective therapy is necessary to treat an infection. Combination
anti-infective therapy is included in the HP per diem provided the anti-infectives are used for
an indication provided in the tables and the duration of therapy does not exceed 14 days.
• Certain anti-infectives should be administered with regard to food and before or after specific
medications.
• Adjust dosages of anti-infectives based on age, renal function, and other patient and medication
characteristics.
• Certain anti-infectives are available as powder for oral suspension. These powders need to be
reconstituted at the time the medication is dispensed and, therefore, must be procured from
a local pharmacy and billed through the PBM Plus card.
• Please consult with your HP pharmacist for administration instructions, dosage adjustments, and
procurement of an anti-infective formulated as a powder for oral suspension.
• The duration of topical therapy should be regularly reevaluated, as some skin infections may
progress despite topical therapy.
The Hospice Pharmacia Medication Use Guidelines
| 95 |
Insomnia
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
CNS = central nervous system
GI = gastrointestinal
HCl = hydrochloride
HS = at bedtime
IM = intramuscularly
IV = intravenously
OTC = over-the-counter
PO = by mouth
SC = subcutaneously
SL = sublingually
SSRIs = selective serotonin reuptake inhibitors
TCAs = tricyclic antidepressants
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Antihistamines
Medication
Suggested Dosing
Diphenhydramine
25mg to 50mg PO/IV/IM HS
Hydroxyzine HCl (ATARAX )
25mg to 50mg PO HS
Hydroxyzine pamoate (VISTARIL®)
25mg to 50mg PO HS
®
• Antihistamines should be used cautiously, if at all, in older adults because their anticholinergic
properties may result in mental confusion, falls, constipation, and urinary retention.
• Tolerance to antihistamines may develop after 1 to 2 weeks of continuous use.
Antidepressants
Medication
Suggested Dosing
Trazodone
25mg to 50mg PO HS
• Antidepressants are recommended for patients with depression and insomnia; therapy with
antidepressants solely for the indication of insomnia is generally not warranted. Further, some
antidepressants may be effective for managing insomnia (e.g., TCAs), whereas others may cause
or worsen insomnia (e.g., SSRIs).
• The dosage of trazodone for the management of insomnia is typically much lower than the dosage used for the management of depression.
Benzodiazepines
Medication
Suggested Dosing
Alprazolam
0.25mg to 0.5mg PO HS
Clonazepam
0.125mg to 1mg PO HS
Diazepam
2mg to 5mg PO/IV/IM HS
Lorazepam
0.5mg to 1mg PO/SL/IV/IM/SC HS
Oxazepam
10mg to 15mg PO HS
Temazepam
7.5mg to 15mg PO HS
• Among the benzodiazepines, lorazepam, oxazepam, and temazepam are the safest to use in
patients with hepatic disease or impairment.
• Benzodiazepines with long half lives (e.g., clonazepam, diazepam) should be avoided or used
cautiously in older adults, as they may accumulate and result in subsequent adverse drug events
such as falls.
| 96 | The Hospice Pharmacia Medication Use Guidelines
Insomnia
INCLUSION CODE: A
• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those
with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions
are commonly manifested as excessive movement, excitement, and increased talkativeness.
Non-benzodiazepine Hypnotics
Medication
Suggested Dosing
Zolpidem
5mg to 10mg PO HS
Sedative Hypnotics
Medication
Suggested Dosing
Chloral hydrate
250mg to 500mg PO HS
• Chloral hydrate can cause significant GI distress and CNS adverse reactions, such as delirium,
dizziness, hallucinations, nightmares and paranoia. It should generally be reserved as a “last-line”
therapy for the management of insomnia.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Analgesic-Antihistamine Combinations
Medication
Average Cost of Therapy
Acetaminophen and diphenhydramine (TYLENOL PM)
®
$5.30
Antidepressants
Medication
Average Cost of Therapy
Doxepin
$10.77
Benzodiazepines
Medication
Average Cost of Therapy
Alprazolam orally disintegrating tablet (NIRAVAM )
$76.26
Clonazepam orally disintegrating tablet (KLONOPIN®
WAFER)
$61.04
Flurazepam (DALMANE®)
$7.28
Triazolam (HALCION )
$13.20
®
®
Melatonin & Melatonin Receptor Agonists
Medication
Average Cost of Therapy
Melatonin
$6.05
Ramelteon (ROZEREM )
®
$61.88
The Hospice Pharmacia Medication Use Guidelines
| 97 |
Insomnia
INCLUSION CODE: A
Non-benzodiazepine Hypnotics
Medication
Average Cost of Therapy
Eszopiclone (LUNESTA )
$86.13
®
Zolpidem extended-release (AMBIEN CR)
®
$87.45
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Non-pharmacologic therapies, which are primarily designed to correct maladaptive behaviors
that are not conducive to healthy sleep, should be considered first-line therapy for all chronic
types of insomnia.
• Treatment generally combines several approaches, which are more effective than individual
techniques alone.
• The most common cognitive behavioral therapy approaches include stimulus control therapy,
sleep restriction, relaxation therapy, paradoxical intention, and sleep hygiene education.
• It usually takes 1 to 3 months for successful implementation of non-pharmacologic therapies.
Thus, supplemental pharmacotherapy may be required for a brief period of time.
NOTES:
• Patients often self-medicate with OTC medications that may affect sleep patterns. A thorough
medication history, including evaluation of OTC medications, is an important component to
the assessment and management of insomnia.
• The selection of pharmacotherapy is primarily based on the patient’s chief complaint (e.g., difficulty
falling asleep or maintaining sleep) and the pharmacokinetic properties of the medication.
• In general, medications for the management of insomnia should be started at a low dose and
titrated slowly. Consider short-term, intermittent doses (i.e., PRN) whenever feasible.
• The continual need for pharmacotherapy should be routinely reassessed; dose reduction and/or
therapy cessation should be tried periodically.
| 98 | The Hospice Pharmacia Medication Use Guidelines
Malabsorption Due to Pancreatic Insufficiency
INCLUSION CODE: C, O
ACRONYMS USED IN THIS MONOGRAPH:
PO = by mouth
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of malabsorption due to pancreatic insufficiency, including steatorrhea, associated with either pancreatic cancer (defined as
ICD-9-CM codes 157.0-157.9 or 197.8) or cystic fibrosis (defined as ICD-9-CM code 277).
Pancreatic Enzymes
Medication
Suggested Dosing
Pancreatic enzyme supplements
(general)
1 to 2 capsules or tablets PO with each meal and/or snack
• A full listing of the available pancreatic enzyme products is provided in the table below.
Contents
Pancreatic Enzyme Product
Capsules, enteric-coated
minimicrospheres
Creon® DR 6,000
Creon® DR 12,000
Creon® DR 24,000
Lipase
(Units)
Amylase
(Units)
Protease
(Units)
6,000
12,000
24,000
19,000
60,000
120,000
30,000
38,000
76,000
NON-PHARMACOLOGIC THERAPY:
• Make adjustments in the patient’s diet as necessary.
NOTES:
• Pancreatic enzyme products are not interchangeable. In some cases, the substitution of one
product for another has resulted in therapeutic failures and adverse events.
• Therapy must be tailored to meet the individual patient’s needs.
• Consult with you HP pharmacist for assistance with dosing and product availability.
The Hospice Pharmacia Medication Use Guidelines
| 99.1 |
Movement-Related Disorders
INCLUSION CODE: O
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
EPS = extrapyramidal symptoms
ER = extended-release
HS = at bedtime
IM = intramuscularly
IV = intravenously
MAOIs = monoamine oxidase inhibitors
PO = by mouth
QD = daily
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of movement-related disorders
related to Amyotrophic lateral sclerosis (defined as ICD-9-CM code 335.20), Huntington’s
disease (Huntington’s chorea, defined as ICD-9-CM code 333.4), Lewy body dementia (defined as ICD-9-CM code 331.82), Parkinson’s disease (defined as ICD-9-CM codes 332.,
332.0, or 332.1), and other degenerative diseases of the basal ganglia such as Shy-Drager
syndrome and progressive supranuclear palsy (defined as ICD-9 code 333.0) as the patient’s
hospice-qualifying terminal diagnosis.
• Movement-related disorders include (but are not limited to) chorea, cramps, fasciculations,
rigidity, spasticity, and tremors.
Anticholinergics
Medication
Suggested Dosing
Benztropine
0.5mg PO HS
Diphenhydramine
25mg to 50mg PO 1 to 2 times a day
Trihexyphenidyl
1mg to 2mg PO TID
• Anticholinergics are generally used to manage rigidity and tremors.
• Anticholinergics should be avoided in patients with Lewy body dementia because they may
worsen cognition and cause hallucinations.
• Anticholinergics also are included in the HP per diem for treating drug-induced EPS
related to the patient’s hospice-qualifying terminal diagnosis (INCLUSION CODE: A).
Benzodiazepines
Medication
Suggested Dosing
Clonazepam
0.5mg PO 1 to 3 times a day
Diazepam
2mg to 10mg PO/IV/IM 3 to 4 times a day for spasticity or
2.5mg PO/IV/IM QD for chorea
• Clonazepam is generally used to manage chorea (involuntary jerky movements, especially of the
arms, legs and face), cramps, and fasciculations (“muscle twitch”).
• Diazepam is generally used to manage chorea and spasticity.
• Based on their mechanism of action, other benzodiazepines may be effective for the management of chorea, cramps, fasciculations, and spasticity. Alprazolam, lorazepam, oxazepam, and
temazepam also are included in the HP per diem for these indications.
• Clonazepam and diazepam should be used cautiously in older adults, as they may accumulate
and result in subsequent adverse drug events such as falls.
• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those
with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions
are commonly manifested as excessive movement, excitement, and increased talkativeness.
| 100.1 | The Hospice Pharmacia Medication Use Guidelines
Movement-Related Disorders
INCLUSION CODE: O
Dopamine Precursors/Potentiators
Medication
Suggested Dosing
Carbidopa-levodopa
10/100mg or 25/100mg PO 2 to 3 times a day
Entacapone (COMTAN )
200mg PO with each dose of carbidopa-levodopa
Entacapone-carbidopa-levodopa
(STALEVO®)
Dosing based on patient’s current carbidopa-levodopa dose
®
• Dopamine precursors/potentiators are generally used to manage Parkinsonian-like symptoms
such as rigidity.
• The effectiveness of carbidopa-levodopa decreases with time, resulting in “on and off” phenomenon, “wearing off” phenomenon, and dyskinesias in patients with Parkinson’s disease. Effectiveness can be improved by adding entacapone to the patient’s regimen.
• Entacapone should not be used as monotherapy.
• Neuroleptic malignant syndrome has been reported with abrupt discontinuation or reduction
of levodopa-containing medications (e.g., STALEVO®). Thus, if necessary, therapy should be
discontinued or reduced slowly.
Dopamine Receptor Agonists
Medication
Suggested Dosing
Bromocriptine
1.25mg PO BID
Pramipexole (MIRAPEX®)
0.125mg PO TID
• Dopamine receptor agonists are generally used to manage Parkinsonian-like symptoms such as
dyskinesias and rigidity.
Miscellaneous
Medication
Suggested Dosing
Amantadine
50mg to 100mg po QD
• Amantadine is generally used to manage bradykinesia and rigidity.
Skeletal Muscle Relaxants
Medication
Suggested Dosing
Baclofen
5mg to 10mg PO TID
Carisoprodol
350mg PO 3 to 4 times a day
Cyclobenzaprine
5mg to 10mg PO TID
• Baclofen is generally used to manage chorea and spasticity.
• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with hallucinations, spasticity, and seizures. Baclofen therapy should be discontinued slowly.
• If spasticity does not respond well to baclofen or if the patient cannot tolerate baclofen, other
skeletal muscle relaxants should be tried.
The Hospice Pharmacia Medication Use Guidelines
| 101.1 |
Movement-Related Disorders
INCLUSION CODE: O
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Benzodiazepines
Medication
Clonazepam orally disintegrating tablet (KLONOPIN® WAFER)
Average Cost of Therapy
$61.04
Dopamine Precursors/Potentiators
Medication
Carbidopa-levodopa orally disintegrating tablet (PARCOPA®)
Average Cost of Therapy
$104.88
Dopamine Receptor Agonists
Medication
Cabergoline
Ropinirole (REQUIP®)
Ropinirole ER (REQUIP® XL)
Average Cost of Therapy
$81.28
$90.33
$134.92
Monoamine Oxidase Inhibitors (MAOIs)
Medication
Rasagiline (AZILECT®)
Selegiline capsule, tablet
Average Cost of Therapy
$143.83
$47.31
Skeletal Muscle Relaxants
Medication
Chlorzoxazone (PARAFON FORTE® DSC)
Dantrolene (DANTRIUM®)
Metaxalone (SKELAXIN®)
Methocarbamol (ROBAXIN®)
Orphenadrine ER (NORFLEX)
Tizanidine (ZANAFLEX®)
Average Cost of Therapy
$21.99
$62.76
$64.49
$26.38
$29.14
$59.63
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Physiotherapy: exercises to promote strength, range of motion, and endurance.
• Occupational therapy: environmental adaptations and special equipment to provide maximal
functioning capabilities.
• Speech therapy (for dysarthria): techniques taught to maximize communication with non-verbal
modalities.
• Swallowing therapy (for dysphagia): therapy to assist with eating and drinking.
NOTES:
• Suggested dosing noted above refers to initial dosages. Therapies may need to be adjusted based
on clinical response as well as patient and medication characteristics. Please consult with your HP
pharmacist for dosage adjustments.
| 102.1 | The Hospice Pharmacia Medication Use Guidelines
Muscle Spasms
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
IM = intramuscularly
IV = intravenously
PO = by mouth
PRN = as needed
QD = daily
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Benzodiazepines
Medication
Suggested Dosing
Clonazepam
0.5mg PO TID PRN
Diazepam
2mg PO/IV/IM 3 to 4 times a day PRN
• Based on their mechanism of action, all benzodiazepines may be effective for muscle spasms.
However, only diazepam has been studied specifically for spasticity disorders. Clonazepam has
been shown to be effective for myoclonus. Alprazolam, lorazepam, oxazepam, and temazepam
also are included in the HP per diem for muscle spasms.
• Clonazepam and diazepam should be used cautiously in older adults, as they may accumulate
and result in subsequent adverse drug events such as falls.
• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those
with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions
are commonly manifested as excessive movement, excitement, and increased talkativeness.
Skeletal Muscle Relaxants
Medication
Suggested Dosing
Baclofen
5mg PO TID PRN
Carisoprodol
350mg PO 3 to 4 times a day PRN
Cyclobenzaprine
5mg PO TID PRN
• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with hallucinations, spasticity, and seizures. Baclofen therapy should be discontinued slowly.
Miscellaneous Therapies
Medication
Suggested Dosing
Potassium chloride
10mEq to 20mEq PO QD
Spironolactone
25mg to 50mg PO QD
• Miscellaneous therapies should only be used for muscle spasms related to confirmed hypokalemia.
• Potassium levels should be monitored when using these therapies and doses should be adjusted
based on potassium levels and patient response.
• There are numerous potassium products available on the market. Please consult with your HP
pharmacist to determine specific potassium products available in the per diem.
The Hospice Pharmacia Medication Use Guidelines
| 103 |
Muscle Spasms
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Benzodiazepines
Medication
Average Cost of Therapy
Clonazepam orally disintegrating tablet (KLONOPIN WAFER)
®
$61.04
Skeletal Muscle Relaxants
Medication
Average Cost of Therapy
Chlorzoxazone (PARAFON FORTE DSC)
$21.99
Dantrolene (DANTRIUM®)
$62.76
Metaxalone (SKELAXIN®)
$64.49
Methocarbamol (ROBAXIN®)
$26.38
Orphenadrine ER (NORFLEX)
$29.14
Tizanidine (ZANAFLEX )
$59.63
®
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
•
•
•
•
Applying moist heat to the muscle may help relieve symptoms.
Encourage the patient to avoid or minimize alcohol consumption.
If the patient is bed-bound or inactive, move the patient around at regular intervals.
Other techniques such as muscle massages and stretching exercises may help relieve symptoms.
NOTES:
• Opioids and other analgesics may help manage pain or discomfort associated with muscle
spasms.
• Suggested dosing noted above refers to initial dosages. Therapies may need to be adjusted based
on clinical response as well as patient and medication characteristics. Please consult with your HP
pharmacist for dosage adjustments.
| 104 | The Hospice Pharmacia Medication Use Guidelines
Muscle Spasms
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 105 |
| 106 | The Hospice Pharmacia Medication Use Guidelines
Nausea/Vomiting
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
BID = twice a day
ER = extended-release
FDA = Food and Drug Administration
HCl = hydrochloride
IM = intramuscularly
IV = intravenously
PO = by mouth
PR = rectally
PRN = as needed
SC = subcutaneously
SL = sublingually
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Anticholinergics
Medication
Suggested Dosing
Dicyclomine
10mg to 20mg PO every 6 hours
Hyoscyamine regular-release
0.125mg to 0.25mg PO/SL every 4 to 6 hours ATC or PRN
Hyoscyamine ER
0.375mg to 0.75mg PO every 12 hours
Scopolamine, transdermal patch
(TRANSDERM SCOP®)
Apply 1 to 3 patches behind the ear every 3 days
• Scopolamine transdermal patch may take up to 12 hours to reach maximum effect. For acute
control, an anticholinergic with a shorter duration of action (e.g., hyoscyamine) should be used.
• Other anticholinergics such as atropine and glycopyrrolate also may be effective and are
included in the HP per diem.
Antihistamines
Medication
Suggested Dosing
Hydroxyzine HCl (ATARAX®)
10mg to 25mg PO every 6 hours PRN
Hydroxyzine pamoate (VISTARIL®) 25mg PO every 6 hours PRN
Meclizine
12.5mg to 25mg PO every 6 hours PRN
Benzodiazepines
Medication
Suggested Dosing
Lorazepam
0.5mg to 1mg PO/SL/IV/IM/SC every 4 to 6 hours PRN
• Older adults may be especially sensitive to the effects of benzodiazepines; lower doses (e.g.,
lorazepam < 3 mg/day) are generally considered to be equally effective and safer to use.
Corticosteroids
Medication
Suggested Dosing
Dexamethasone
4mg PO/IV/IM/SC BID
• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone also may be
effective and are included in the HP per diem.
• When dexamethasone (or any corticosteroid) is administered in divided doses, it is suggested
that the last dose be given in the afternoon to avoid insomnia.
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| 107 |
Nausea/Vomiting
INCLUSION CODE: A
Dopamine Antagonists
Medication
Suggested Dosing
Chlorpromazine
10mg PO/IV/IM every 4 to 6 hours PRN
Haloperidol
0.5mg to 1mg PO/IM/SC every 4 to 6 hours PRN
Prochlorperazine
5mg PO/IV/IM every 4 to 6 hours PRN or 25mg PR every 8
to 12 hours PRN
Promethazine
12.5mg to 25mg PO/PR/IM every 4 to 6 hours PRN
• Sometimes it is necessary to administer medications parenterally. Parenteral doses of neuroleptics are generally twice as potent as oral doses. Administer parenteral doses slowly to minimize
hypotension.
• Although chlorpromazine is an effective antiemetic, it is sedating and has anticholinergic properties. Therefore, it is best used in patients who might benefit from these effects. It is best avoided
in patients who might be harmed by these effects, such as patients with Parkinson’s disease.
• If parenteral use of promethazine is necessary, the preferred route of administration is by deep
IM injection; however, the IV route can be used. When administered IV, promethazine should
be given in a concentration no greater than 25mg/mL at a rate not to exceed 25mg/min; it is
preferable to inject through the tubing of an IV infusion set that is known to be functioning
satisfactorily.
Prokinetic Agents
Medication
Suggested Dosing
Erythromycin
125mg to 250mg PO every 8 to 12 hours
Metoclopramide
5mg to 10mg PO/IV/IM/SC every 6 to 8 hours PRN
• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary and repetitive movements of the face and body, even after metoclopramide is stopped.
These symptoms are rarely reversible and there is no known treatment. The U.S. FDA recommends against use of metoclopramide for durations longer than 3 months.
• Older adults, especially females, are more likely to develop tardive dyskinesia and thus metoclopramide should be used cautiously, if at all, in older adults. Consider starting with a lower (5mg)
dose of metoclopramide in older adults.
• Metoclopramide should be used cautiously, if at all, in patients with a seizure disorder (or acute
seizures) or Parkinson’s disease.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticholinergics
Medication
Glycopyrrolate solution for injection (ROBINUL®)
Average Cost of Therapy
$26.37
Scopolamine solution for injection
$79.70
Scopolamine tablet (SCOPACE®)
$11.62
| 108 | The Hospice Pharmacia Medication Use Guidelines
Nausea/Vomiting
INCLUSION CODE: A
Antihistamines
Medication
Average Cost of Therapy
Meclizine chewable tablet (BONINE )
$7.00
®
Benzamides
Medication
Average Cost of Therapy
Trimethobenzamide (TIGAN®)
$54.10
Cannabinoids
Medication
Average Cost of Therapy
Dronabinol (MARINOL®)
$188.17
Dopamine Antagonists
Medication
Average Cost of Therapy
Perphenazine
$21.80
Neurokinin 1 (NK1) Receptor Antagonists
Medication
Average Cost of Therapy
Aprepitant (EMEND COMBO PACK)
$389.48
®
Serotonin Receptor Antagonists
Medication
Average Cost of Therapy
Granisetron tablet (KYTRIL®)
$747.26
Granisetron transdermal patch (SANCUSO )
$575.73
Ondansetron oral solution (ZOFRAN®)
$373.67
®
Ondansetron orally disintegrating tablet (ZOFRAN ODT®)
$49.19
Ondansetron solution for injection (ZOFRAN®)
$143.75
Ondansetron tablet (ZOFRAN®)
$56.76
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Avoid strong and offensive odors.
• Eliminate medications that may contribute to nausea/vomiting, if possible.
• Relaxation techniques may help reduce the anxiousness and/or anticipation often preceding
nausea/vomiting.
NOTES:
• Many of the pharmacologic therapies listed above have anticholinergic properties. Major side effects of medications with anticholinergic properties are blurred vision, constipation, dry mouth,
and urinary retention. Older adults and patients with Parkinson’s disease are especially sensitive
to these side effects.
The Hospice Pharmacia Medication Use Guidelines
| 109 |
Nausea/Vomiting
INCLUSION CODE: A
| 110 | The Hospice Pharmacia Medication Use Guidelines
Ophthalmic & Oral Symptoms
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
PRN = as needed
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
THERAPIES FOR OPHTHALMIC SYMPTOMS
Lubricants
Medication
Suggested Dosing
Artificial tears ophthalmic
ointment
Apply a small amount of ointment, roughly ¼ inch, to the
inside of the lower eyelid 1 to 4 times a day PRN
Artificial tears ophthalmic drops,
solution
Instill 1 to 2 drops into the affected eye(s) 2 to 4 times a day
PRN
• Adjust the frequency of application of both the ointment and solution as needed.
• If necessary, the ointment may be applied every 4 hours or may instill the drops every hour.
• Discontinue use of the specific product if ocular pain, ocular pruritus or other ocular irritation
symptoms occur or worsen, or if the condition has not improved within 72 hours of use of the
product.
• There are numerous artificial tears products on the market. Please check with your HP pharmacist
to determine whether a particular product is included in the per diem prior to the product being
dispensed by the pharmacy.
THERAPIES FOR ORAL SYMPTOMS
Dental and Periodontal Agents
Medication
Suggested Dosing
Chlorhexidine gluconate rinse
(0.12%)
Rinse mouth with 15mL for 30 seconds BID following
toothbrushing.
• Expectorate (or spit) after rinsing; do not swallow.
• Do not dilute chlorhexidine.
Oral Anesthetics
Medication
Suggested Dosing
Lidocaine oromucosal (viscous)
solution (2%)
Apply 5mL to oral or mucosal membranes every 3 to 4
hours PRN
Phenol oromucosal spray (1.4%)
Spray affected area(s) of the mouth or throat, allow to remain
in place for at least 15 seconds then spit out; may repeat
every 2 hours
• For use of lidocaine viscous in the mouth, swish around in the mouth and spit out.
• For use of lidocaine viscous in the pharynx, gargle with the undiluted solution and either swallow or spit out the solution. Do not administer more frequently than every 3 hours and do not
give more than 8 doses in any 24-hour period.
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| 111 |
Ophthalmic & Oral Symptoms
INCLUSION CODE: A
Oromucosal Moisturizers
Medication
Suggested Dosing
Saliva substitute (BIOTENE®)
Shake twice before use. Spray directly into mouth whenever
relief is needed. Can swallow to keep throat moist.
Saliva substitute
(MOUTHKOTE®)
Shake well before using. Spray in the mouth 3 to 5 times,
swirl for eight to ten seconds, then swallow or spit out. Use as
often as needed to maintain moistness.
• Directions for use may differ among saliva substitute products. Please consult with your HP pharmacist to determine the suggested dosing of the specific product for your patient.
NON-PHARMACOLOGIC THERAPY:
• Stomatitis
- Dietary interventions
- Limit diet to foods that do not require much chewing; acidic, dry, or salty foods should
be avoided.
- Serve food at room temperature, not hot.
- Chilled or frozen yogurt may soothe the mucosa and is a high protein snack.
- Avoid alcohol and tobacco.
- Mouth care
- Mouth care including removal and cleaning of dentures, gentile cleansing of the oral
cavity, and oral rinses with a weak basic solution (e.g., salt and baking soda) should be
performed routinely.
• Xerostomia
- Stimulate salivary flow by using crushed ice, sugar-free chewing gum, pineapple chunks,
and/or foods that require chewing. Additionaly, rehydrate the oral mucosa periodically by
using sips of water, spraying the mouth with water, and swabbing the mouth with moistened
gauze.
- Avoid substances that dry or irritate the oral mucosa such as alcohol-containing mouth
washes, caffeine, and citrus fruits.
- Good oral hygiene including brushing teeth with a soft toothbrush and fluoride gel toothpaste, dental flossing, rinsing with fluorinated (non-alcoholic) mouth washes, and avoiding
dietary sugar should be practiced routinely.
NOTES:
• Saliva substitute products contain sorbitol, which may induce bloating and/or diarrhea.
• For the treatment of oral candidiasis (thrush), please refer to the antifungals in the Infections
section.
• Please note that sodium chloride nose spray/drops (0.65%) also is included in the HP per
diem for the treatment of nasal congestion or dryness.
| 112 | The Hospice Pharmacia Medication Use Guidelines
Pain, Neuropathic
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
DR = delayed-release
ER = extended-release
HS = at bedtime
IM = intramuscularly
IV = intravenously
PO = by mouth
PRN = as needed
QD = daily
QID = four times a day
SC = subcutaneously
SSRIs = selective serotonin reuptake inhibitors
TCAs = tricyclic antidepressants
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Anticonvulsants
Medication
Suggested Dosing
Carbamazepine regular-release
tablets or suspension
200mg PO 2 to 4 times a day
Gabapentin
300mg PO TID
Valproic acid (DEPAKENE®)
250mg PO TID
• Carbamazepine is usually initiated at a dosage of 100mg PO BID for the tablets or 50mg PO
QID for the suspension. The dosage is usually titrated to 600mg/day to 800mg/day or until side
effects are intolerable.
• Gabapentin is usually initiated at a dosage of 300mg PO QD on day 1, then 300mg PO BID
on day 2, and 300mg PO TID on day 3. The dosage is usually titrated up PRN for pain relief,
typically to an effective dosage range of 1800mg/day to 3600mg/day.
• Valproic acid is usually initiated at a dosage of 125mg PO TID. The dosage is then titrated to
750mg/day to 1500mg/day or until side effects are intolerable. Divalproex sodium (DEPAKOTE®) also may be effective for neuropathic pain. The total daily dose is usually the same as
valproic acid; however, divalproex sodium is administered BID.
Antidepressants
Medication
Suggested Dosing
Amitriptyline
25mg to 75mg PO HS
Desipramine
25mg to 75mg PO HS
Nortriptyline
25mg to 75mg PO HS
• The TCAs are usually initiated at a dosage of 10mg to 25mg PO HS. The dosage is then titrated
up by 10mg to 25mg every 2 to 3 days to 100mg/day to 150mg/day or until side effects are
intolerable.
• Amitriptyline tends to be more sedating and has greater anticholinergic effects than desipramine
or nortriptyline. Thus, the latter two medications are generally better tolerated, particularly in
older adults.
• Among the TCAs listed above, desipramine may be the least sedating.
The Hospice Pharmacia Medication Use Guidelines
| 113 |
Pain, Neuropathic
INCLUSION CODE: A
Corticosteroids
Medication
Suggested Dosing
Dexamethasone
4mg PO/IM/IV/SC 1 to 2 times a day
Methylprednisolone
4mg PO 1 to 2 times a day
Prednisolone
20mg PO 1 to 2 times a day
Prednisone
20mg PO 1 to 2 times a day
• The minimum effective dose of an oral corticosteroid should be used for the shortest duration
possible. Whenever possible, a dose reduction should be attempted in order to reduce the risk of
long-term systemic adverse effects.
• When a corticosteroid is administered in divided doses, it is suggested that the last dose be given
in the afternoon to avoid insomnia.
Local Anesthetics
Medication
Suggested Dosing
Dibucaine topical ointment (1%)
Apply to painful area(s) PRN, not to exceed 30gm of the
ointment per day
Lidocaine topical gel/jelly (2%) or
ointment (5%)
Apply to painful area(s) every 3 to 4 hours PRN, not to
exceed 20gm of the ointment (or approximately 1000mg of
lidocaine base) per day
Lidocaine transdermal patch (5%)
(LIDODERM®)
Apply up to 3 patches to intact skin to cover the most painful
area for up to 12 hours in a 24-hour period
• For the treatment of neuropathic pain, lidocaine transdermal patches are typically left on for
12 hours and then removed. The patches may be cut into smaller sizes prior to removal of the
release liner.
NMDA-receptor Antagonists
Medication
Suggested Dosing
Capsaicin (0.025%, 0.075%)
Apply to painful area(s) 2 to 4 times a day
Miscellaneous
Medication
Suggested Dosing
Clonazepam
0.25mg to 0.5mg PO TID
Clonidine
0.1mg to 0.3mg PO TID
Mexiletine
150mg to 200mg PO TID
• Clonazepam should be avoided or used cautiously in older adults, as it may accumulate and
result in subsequent adverse drug events such as falls.
• Clonidine may be useful if an autonomic/sympathetic component is believed to be present (e.g.,
diaphoresis, mottling of extremities).
| 114 | The Hospice Pharmacia Medication Use Guidelines
Pain, Neuropathic
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticonvulsants
Medication
Average Cost of Therapy
Carbamazepine ER capsule (CARBATROL )
$137.33
Carbamazepine ER tablet (TEGRETOL XR®)
$40.34
Oxcarbazepine suspension (TRILEPTAL )
$106.17
Oxcarbazepine tablet (TRILEPTAL®)
$69.40
®
®
Pregabalin (LYRICA )
$83.40
Topiramate (TOPAMAX®)
$157.08
®
Antidepressants
Medication
Average Cost of Therapy
Duloxetine DR capsule (CYMBALTA )
$88.95
Imipramine (TOFRANIL®)
$28.01
®
Venlafaxine ER capsule (EFFEXOR XR)
$81.84
Venlafaxine tablet (EFFEXOR®)
$48.04
®
Miscellaneous
Medication
Average Cost of Therapy
Clonazepam orally disintegrating tablet (KLONOPIN® WAFER)
$61.04
Local Anesthetics
Medication
Average Cost of Therapy
Lidocaine cream (LIDAMANTLE )
®
$41.42
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Acupuncture may have some benefits for managing pain.
• Cognitive coping strategies such as imagery, meditation, and/or relaxation are sometimes used to
divert attention from pain.
• Surgery is sometimes employed for the management of refractory neuropathic pain.
NOTES:
• Although TCAs are frequently used for the treatment of neuropathic pain, patients often are
prescribed another type of antidepressant (e.g., SSRI) for depression. The use of more than one
antidepressant concurrently should be avoided whenever possible.
The Hospice Pharmacia Medication Use Guidelines
| 115 |
Pain, Neuropathic
INCLUSION CODE: A
| 116 | The Hospice Pharmacia Medication Use Guidelines
Pain, Neuropathic
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 117 |
Pain, Nociceptive
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
ER = extended-release
DR = delayed-release
GI = gastrointestinal
IM = intramuscularly
INR = international normalized ratio
IR = immediate-release
IV = intravenously
LA = long-acting
NSAIDs = non-steroidal anti-inflammatory drugs
PO = by mouth
PR = rectally
PRN = as needed
PUD = peptic ulcer disease
QD = daily
QID = four times a day
SC = subcutaneously
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of nociceptive pain, including somatic, visceral, and bone pain. Not all therapies are indicated for every type of pain.
Please consult with your HP pharmacist to aid in product selection, dosing, and monitoring for your
individual patient.
Corticosteroids
Medication
Suggested Dosing
Dexamethasone
4mg PO/IM/IV/SC 1 to 2 times a day
Methylprednisolone
4mg PO 1 to 2 times a day
Prednisolone
20mg PO 1 to 2 times a day
Prednisone
20mg PO 1 to 2 times a day
• The optimal dosing and duration for corticosteroids for treating pain has not been established.
The minimum effective dose should be used for the shortest duration possible. Whenever possible, a dose reduction should be attempted in order to reduce the risk of long-term systemic
adverse effects.
• When a corticosteroid is administered in divided doses, it is suggested that the last dose be given
in the afternoon to avoid insomnia.
• Dexamethasone often is considered the corticosteroid of choice because of its mineralocorticoid
potency.
Non-opioid Analgesics
Medication
Suggested Dosing
Acetaminophen
325mg to 650mg PO/PR every 4 to 6 hours, up to 4000mg/day
• Acetaminophen can cause hepatotoxicity and can increase the risk of bleeding in patients
prescribed warfarin, especially if administered in large doses (> 2000mg/day) for prolonged
periods of time (> 10 to 14 days). The patient’s medication regimen should be reviewed for other
potentially hepatotoxic medications (e.g., amiodarone, statins) and the patient’s INR may need
to be monitored more closely when prescribed acetaminophen.
| 118 | The Hospice Pharmacia Medication Use Guidelines
Pain, Nociceptive
INCLUSION CODE: A
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Medication
Suggested Dosing
Diclofenac sodium
50mg PO 2 to 3 times a day
Ibuprofen
400mg to 600mg PO every 6 hours
Nabumetone
500mg PO BID
Naproxen
250mg to 500mg PO BID
Naproxen sodium
220mg PO 2 to 3 times a day
Opioids — Long-acting
Medication
Suggested Dosing
Fentanyl transdermal patch
Dosing based on short-acting opioid requirements. Apply
patch transdermally to the upper torso every 72 hours
Methadone
Dosing based on patient-specific factors
Morphine LA
Dosing based on short-acting opioid requirements. Take PO
every 12 hours
• The dosing of long-acting opioids varies substantially depending on the patient’s opioid tolerance and response. Please consult with your HP pharmacist for dosing recommendations and conversion strategies for long-acting opioids.
• Most patients can be maintained adequately with fentanyl transdermal patch applied every 72
hours. However, some patients may require application of the patch at 48-hour intervals to
maintain adequate analgesia.
• Lower initial doses of fentanyl transdermal patches are recommended when older adults or
debilitated patients are converted from another opioid because they are more likely to experience
respiratory depression due to altered pharmacokinetics.
• Cachectic patients may have impaired fentanyl absorption due to poor fat stores and muscle
wasting, but how this affects the dosing of fentanyl transdermal patch is uncertain.
• Refer to the Medications with Policies section (page 16) for information regarding the
long-acting opioids policy.
Opioids — Short-acting
Medication
Suggested Dosing
Codeine and acetaminophen
30/300mg PO every 4 to 6 hours PRN
Hydrocodone and
acetaminophen
5/325mg to 10/650mg PO every 4 to 6 hours PRN
Hydromorphone
2mg to 4mg PO/PR every 3 to 4 hours PRN
Morphine IR
5mg to 10mg PO/PR every 3 to 4 hours PRN
Oxycodone IR
5mg to 10mg PO every 3 to 4 hours PRN
Oxycodone and acetaminophen
5/325mg to 10/650mg PO every 4 to 6 hours PRN
Oxycodone and aspirin
4.5-0.38/325mg tablet PO every 6 hours PRN
Propoxyphene and
acetaminophen
50/325mg to 100/650mg PO every 4 to 6 hours PRN,
up to 600mg/day (propoxyphene) and 4000mg/day
(acetaminophen)
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| 119 |
Pain, Nociceptive
INCLUSION CODE: A
• Commercially available formulations of oxycodone and acetaminophen other than the 5/500mg
capsule, 5/325mg tablet, and 5/325mg/5mL oral solution are outside the HP per diem.
• Propoxyphene and acetaminophen is not recommended for use in older adults due to the increased risk of side effects.
• Refer to the Medications with Policies section for information regarding the morphine
infusions policy.
Salicylates
Medication
Aspirin
Choline magnesium trisalicylate
Suggested Dosing
325mg to 650mg PO or 300mg to 600mg PR every 4 to 6 hours
500mg to 1000mg PO 2 to 3 times a day
• Unlike aspirin, choline magnesium trisalicylate does not affect platelet aggregation.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Miscellaneous Analgesics
Medication
Tramadol (ULTRAM®)
Tramadol ER (ULTRAM® ER)
Tramadol and acetaminophen (ULTRACET®)
Average Cost of Therapy
$34.11
$82.47
$46.49
NSAIDs
Medication
Celecoxib (CELEBREX®)
Diclofenac epolamine topical patch (FLECTOR® PATCH)
Diclofenac potassium tablet (CATAFLAM®)
Diclofenac sodium ER tablet (VOLTAREN® XR)
Diclofenac sodium and misoprostol DR tablet (ARTHROTEC®)
Indomethacin capsule
Ketoprofen capsule
Ketoprofen ER capsule
Ketorolac tromethamine tablet
Ketorolac tromethamine solution for injection
Meloxicam (MOBIC®)
Naproxen enteric coated tablet (EC-NAPROSYN®)
Piroxicam (FELDENE®)
Average Cost of Therapy
$82.32
$156.03
$43.60
$51.67
$53.18
$14.39
$37.29
$60.71
$25.86
$12.88
$59.17
$48.97
$22.84
Opioids – Long-acting
Medication
Morphine ER capsule (AVINZA®)
Oxycodone ER (OXYCONTIN®)
| 120 | The Hospice Pharmacia Medication Use Guidelines
Average Cost of Therapy
$293.53
$180.25
Pain, Nociceptive
INCLUSION CODE: A
Opioids – Short-acting
Medication
Codeine sulfate tablet
Fentanyl citrate lozenge (ACTIQ®)
Hydrocodone and ibuprofen (VICOPROFEN®)
Hydromorphone solution for injection (DILAUDID®)
Levorphanol tablet
Meperidine solution for injection (DEMEROL®)
Meperidine tablet (DEMEROL®)
Oxycodone and acetaminophen (PERCOCET®), strengths
other than 5/325mg or 5/500mg
Propoxyphene capsule (DARVON®)
Average Cost of Therapy
$22.62
$424.17
$44.72
$36.48
$39.88
$16.29
$29.21
$75.37
$14.13
Salicylates
Medication
Average Cost of Therapy
Salsalate (ARGESIC -SA)
®
$9.09
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Acupuncture may have some benefits for managing pain.
• Cognitive coping strategies such as imagery, meditation, and/or relaxation are sometimes used to
divert attention from pain.
• Massage therapy, range of motion and/or flexibility exercises, and warm soaks may help to
diminish stiffness.
NOTES:
• Many analgesic combinations contain acetaminophen. In general, the total (i.e., additive) daily
dose of acetaminophen should not exceed 4000mg/day. The recommended maximum total daily
dose in patients with hepatic disease, those who consume alcohol chronically, and patients who
use acetaminophen continuously for more than 10 days is 2000mg/day.
• Patients prescribed an NSAID or salicylate related to the hospice-qualifying terminal diagnosis
who are at high risk for experiencing an upper GI adverse event should be prescribed a gastroprotective medication. These patients include those who are 65 years of age or older, have a past
history of PUD or upper GI bleeding, or are concurrently prescribed a systemic corticosteroid or
anticoagulant. For these patients, consider using one of the following regimens:
- Misoprostol 200mcg PO QID, or
- Omeprazole 20mg PO QD, or
- Sucralfate 1gm PO QID.
• Gastroprotective medication is outside the HP per diem for patients prescribed systemic
corticosteroid monotherapy.
• NSAIDs and salicylates should be used cautiously in patients with congestive heart failure,
hypertension, and/or renal insufficiency.
• All patients who are prescribed an opioid should have a bowel regimen prescribed.
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| 121 |
Pain, Nociceptive
INCLUSION CODE: A
| 122 | The Hospice Pharmacia Medication Use Guidelines
Pain, Nociceptive
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 123 |
Pain, Nociceptive
INCLUSION CODE: A
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Pain, Nociceptive
INCLUSION CODE: A
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| 125 |
Pruritus
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
HCl = hydrochloride
IM = intramuscularly
IV = intravenously
PO = by mouth
PRN = as needed
QD = daily
SC = subcutaneously
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Bile Acid Sequestrants
Medication
Cholestyramine powder (plain
and light)
Suggested Dosing
Mix 4gm in 60mL to 180mL of fluid (e.g., water, milk, fruit
juice, or other non-carbonated beverage) PO QD.
If necessary, increase by 4gm every 2 to 3 days, up to 16gm/
day in a single or divided dose
• Administer other medications at least 1 hour before or 4 to 6 hours after each dose of cholestyramine, as this medication may impede the absorption of other medications.
• The powder may also be mixed with a highly fluid soup or a pulpy fruit with high moisture (e.g.,
applesauce, crushed pineapple).
• The palatability of and compliance with cholestyramine may be improved if the dose is mixed
and refrigerated overnight.
• The difference between cholestyramine plain and cholestyramine light is the amount of dried
resin that is present in the powder. Cholestyramine plain has 4gm of active ingredient per 9gm
of powder; cholestyramine light has 4gm of active ingredient per 5gm of powder.
Systemic Antihistamines
Medication
Suggested Dosing
Chlorpheniramine
4mg PO every 4 to 6 hours PRN
Cyproheptadine
4mg PO 3 to 4 times a day PRN
Diphenhydramine
25mg to 50mg PO/IM/IV every 4 to 6 hours PRN
Hydroxyzine HCl (ATARAX®)
25mg PO 3 to 4 times a day PRN
Hydroxyzine pamoate
(VISTARIL®)
25mg PO 3 to 4 times a day PRN
Systemic Corticosteroids
Medication
Suggested Dosing
Dexamethasone
4mg PO 1 to 2 times a day
Methylprednisolone dosepak
4mg PO 1 to 2 times a day
Prednisolone
10mg to 20mg PO QD
Prednisone
10mg to 20mg PO QD
• The minimum effective dose of an oral corticosteroid should be used for the shortest duration
possible. Whenever possible, a dose reduction should be attempted in order to reduce the risk of
long-term systemic adverse effects.
| 126 | The Hospice Pharmacia Medication Use Guidelines
Pruritus
INCLUSION CODE: A
• When a corticosteroid is administered in divided doses, it is suggested that the last dose be given
in the afternoon to avoid insomnia.
Topical Anesthetics
Medication
Suggested Dosing
Lidocaine topical gel/jelly (2%) or
ointment (5%)
Apply to affected area(s) every 3 to 4 hours PRN
• Topical anesthetics may provide relief of itching that is refractory to other topical pharmacologic
therapies.
Topical Antihistamines
Medication
Suggested Dosing
Diphenhydramine cream (1%, 2%)
Apply to itchy area(s) 3 to 4 times a day
Topical Corticosteroids – Low-potency
Medication
Suggested Dosing
Hydrocortisone cream, ointment
(0.5%, 1%, 2.5%)
Apply to itchy area(s) 2 to 4 times a day
Topical Corticosteroids – Medium-potency
Medication
Suggested Dosing
Fluocinolone acetonide cream,
ointment (0.025%)
Apply sparingly to itchy area(s) 2 to 4 times a day
Triamcinolone acetonide cream,
ointment (0.025%, 0.1%)
Apply sparingly to itchy area(s) 2 to 4 times a day
Topical Corticosteroids – High-potency
Medication
Suggested Dosing
Betamethasone dipropionate
cream, lotion ointment (0.05%)
Apply sparingly to itchy area(s) 2 to 4 times a day
Fluocinonide cream, ointment
(0.05%)
Apply sparingly to itchy area(s) 1 to 4 times a day
Fluocinonide cream (0.05%,
emulsified base)
Apply sparingly to itchy area(s) 1 to 4 times a day
Triamcinolone acetonide cream,
ointment (0.5%)
Apply sparingly to itchy area(s) 2 to 4 times a day
• Topical corticosteroids should be used sparingly and for the shortest duration possible in order
to reduce the risk of long-term adverse effects (e.g., thinning skin).
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| 127 |
Pruritus
INCLUSION CODE: A
Topical Emollients / Protectants
Medication
Suggested Dosing
Bag balm
Apply to affected area(s) as directed; massage into skin
thoroughly and allow ointment to remain for full softening
effect
Zinc oxide
Apply to affected area(s) as directed
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Miscellaneous Dermatologic Agents
Medication
Average Cost of Therapy
Ammonium lactate cream (AMLACTIN®)
$17.55
Ammonium lactate lotion (AMLACTIN )
$27.64
®
Systemic Antihistamines
Medication
Average Cost of Therapy
Cetirizine (ZYRTEC )
$31.76
Desloratadine (CLARINEX®)
$20.27
®
Fexofenadine (ALLEGRA®)
$30.35
Levocetirizine (XYZAL®)
$37.12
Loratadine (CLARITIN®)
$16.98
Systemic Corticosteroids
Medication
Average Cost of Therapy
Hydrocortisone (CORTEF )
®
$15.98
Topical Anesthetics
Medication
Lidocaine cream (LIDAMANTLE®)
Average Cost of Therapy
$41.42
Topical Corticosteroids – Low-potency
Medication
Average Cost of Therapy
Desonide cream (DESOWEN®)
$57.06
Hydrocortisone lotion
$20.54
Topical Corticosteroids – Medium-potency
Medication
Triamcinolone acetonide lotion
| 128 | The Hospice Pharmacia Medication Use Guidelines
Average Cost of Therapy
$30.34
Pruritus
INCLUSION CODE: A
Topical Corticosteroids – High-potency
Medication
Average Cost of Therapy
Fluocinonide solution
$18.70
Topical Corticosteroids – Very High-potency
Medication
Average Cost of Therapy
Clobetasol propionate cream (TEMOVATE )
$34.61
®
Topical Emollients / Protectants
Medication
Average Cost of Therapy
Zinc acetate ointment (PELEVERUS GOLD )
$34.23
Zinc oxide and dimethicone (BAZA® PROTECT CREAM)
$18.50
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Provide proper skin care.
NOTES:
• Some medications may cause or worsen pruritus. Consult with your HP pharmacist to identify
medications that may cause or worsen pruritus.
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| 129 |
Pruritus
INCLUSION CODE: A
| 130 | The Hospice Pharmacia Medication Use Guidelines
Secretions
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
ATC = around the clock
ER = extended-release
IM = intramuscularly
IV = intravenously
PO = by mouth
PRN = as needed
SC = subcutaneously
SL = sublingually
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Anticholinergics
Medication
Suggested Dosing
Atropine ophthalmic (1%)
1 to 2 drops PO/SL every 4 to 6 hours ATC or PRN
Atropine solution for injection
0.4mg to 0.6mg IV/IM/SC every 4 to 6 hours ATC or PRN
Glycopyrrolate
1mg to 2mg PO every 8 hours ATC or PRN
Hyoscyamine regular-release
0.125mg to 0.25mg PO/SL every 4 to 6 hours ATC or PRN
Hyoscyamine ER
0.375mg PO every 12 hours
Scopolamine, transdermal patch
(TRANSDERM SCOP®)
Apply 1 to 3 patches behind the ear every 3 days
• Major side effects of anticholinergics are blurred vision, constipation, dry mouth, and urinary
retention. Older adults are especially sensitive to these side effects. Of the anticholinergics, glycopyrrolate does not cross the blood-brain barrier and, therefore, is less likely to cause CNS side
effects. Conversely, atropine is more likely to cause CNS side effects.
• Atropine ophthalmic (eye) drops are safe to administer via the oral or sublingual route for management of excess secretions. To minimize the risk of side effects from atropine ophthalmic, the
lowest effective dose should be used for the shortest duration possible, and the total daily dose
should not exceed 36 drops.
• Scopolamine transdermal patch may take up to 12 hours to reach maximum effect. For acute
control, an anticholinergic with a shorter duration of action (e.g., hyoscyamine) should be used.
Expectorants
Medication
Suggested Dosing
Guaifenesin tablet
100mg to 400mg PO every 4 hours ATC or PRN; maximum
recommended dose is 2400mg/day
Guaifenesin solution or syrup
5mL to 10mL PO every 4 hours ATC or PRN
Miscellaneous
Medication
Suggested Dosing
Sodium chloride 0.9% nebulizer
solution
1 ampule via nebulizer every 2 to 4 hours ATC or PRN
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| 131 |
Secretions
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medications.
Anticholinergics
Medication
Average Cost of Therapy
Glycopyrrolate solution for injection (ROBINUL )
$26.37
Scopolamine solution for injection
$79.70
Scopolamine tablet (SCOPACE )
$11.62
®
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Discontinue IV hydration or tube feedings if still being administered, as they will worsen secretions.
• Reassure family and friends that secretions usually do not bother or harm the patient.
• Reposition the patient into an upward, supine position to facilitate drainage from the oropharynx and tracheal regions.
NOTES:
• There is no conclusive evidence that one anticholinergic medication is more effective than
another; therefore, the choice should be based on the medication’s side effect profile, onset of
action, duration of action, and route of administration.
| 132 | The Hospice Pharmacia Medication Use Guidelines
Secretions
INCLUSION CODE: A
The Hospice Pharmacia Medication Use Guidelines
| 133 |
Seizures
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
ER = extended-release
IV = intravenously
PO = by mouth
QID = four times a day
TID = three times a day
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Barbiturates
Medication
Phenobarbital
Suggested Dosing
Status epilepticus:
10mg/kg IV initially, followed by an additional 5mg/kg IV
approximately 30 to 60 minutes after the first dose
Maintenance:
1mg/kg/day to 3mg/kg/day PO or IV, given in 1 to 2 divided
doses
• Phenobarbital is indicated for the treatment of status epilepticus and all types of seizure
disorders, including partial seizures, clonic seizures, myoclonic seizures, tonic seizures, or tonicclonic seizures not responding to other anticonvulsants.
• Because the full antiepileptic effect of phenobarbital is not immediate, IV benzodiazepines (e.g.,
diazepam, lorazepam) should be given initially.
• For the treatment of status epilepticus, an additional 5mg/kg may be given for refractory
seizures. The usual maximum total loading dose for phenobarbital is 25mg/kg to 30mg/kg.
• The maintenance dose should be initiated 12 to 24 hours after the loading dose.
• Because phenobarbital is sedating and has a long half-life, it is recommended that phenobarbital
be administered as a single daily dose at bedtime.
Benzodiazepines
Medication
Suggested Dosing
Clonazepam
0.5mg PO TID
Diazepam
Status epilepticus:
5mg to 10mg IV initially, repeated at 10 to 15 minute intervals
to a maximum dosage of 30mg
Adjunctive treatment:
2mg PO 2 to 4 times a day
Lorazepam
Status epilepticus:
4mg IV initially, repeated in 10 to 15 minutes if needed to a
maximum dosage of 8mg
• Clonazepam is indicated for the alternative treatment of absence seizures, petit mal variant
(Lennox-Gastaut syndrome), and akinetic and myoclonic seizures. The dosage provided above
is initial dosing. This dosage may be increased by 0.5mg to 1mg every 3 days until seizures are
controlled, up to a maximum dosage of 20mg/day. The typical maintenance dose of clonazepam
ranges between 2mg/day and 8mg/day. Older adults and debilitated patients may require lower
initial dosages and/or slower dosage titration.
• For the treatment of status epilepticus or drug-induced seizures, the dosage of diazepam may
be repeated in 2 to 4 hours if needed. The maintenance dose should be initiated 12 to 24 hours
after the loading dose.
| 134 | The Hospice Pharmacia Medication Use Guidelines
Seizures
INCLUSION CODE: A
• Diazepam is indicated for adjunctive treatment in refractory patients with partial seizures or
generalized tonic-clonic seizures who require intermittent use of the medication to control bouts
of increased seizure activity. It is not indicated as monotherapy and the manufacturer notes that
diazepam may not be effective as adjunctive treatment for > 4 months. The dosage provided
above is initial dosing. This dosage may be increased by 2mg to 5mg every 3 days until seizures
are controlled, up to a maximum dosage of 40mg/day. Older adults and debilitated patients may
require lower initial dosages and/or slower dosage titration.
• For the treatment of status epilepticus, lorazepam should be administered slowly over 2 to 5
minutes.
Hydantoins
Medication
Suggested Dosing
Phenytoin
4mg/kg/day to 7mg/kg/day PO, given as a single daily dose (ER
capsules) or in 2 to 3 divided doses (suspension, tablets)
• Phenytoin is indicated for the treatment of tonic-clonic and complex partial seizures.
• Different phenytoin dosage formulations are not directly interchangeable. For example,
phenytoin capsules contain phenytoin sodium, which is 92% phenytoin; chewable tablets and
suspensions contain 100% phenytoin.
• Phenytoin serum concentrations should be monitored during chronic therapy.
Miscellaneous Anticonvulsants
Medication
Suggested Dosing
Carbamazepine regular-release
tablets or suspension
200mg PO BID (tablets) or 100mg PO QID (suspension)
10mg/kg/day to 15mg/kg/day PO initially, given in 2 to 3
Divalproex sodium (DEPAKOTE®) divided doses
Gabapentin
300mg PO TID
Valproic acid (DEPAKENE®)
10mg/kg/day to 15mg/kg/day PO initially, given in 2 to 3
divided doses
• Carbamazepine is indicated for the treatment of generalized tonic-clonic seizures and partial
seizures, either simple or complex.
• The dose of carbamazepine should be increased by no more than 200mg/day at weekly intervals.
The minimum effective range is typically 800mg/day to 1200mg/day, but determined by serum
concentrations. The usually accepted serum concentration range is 4mcg/mL to 12mcg/mL.
• Periodic monitoring of serum carbamazepine concentrations is recommended.
• Divalproex sodium/valproic acid is indicated for the treatment of absence seizures (either simple
or complex), complex partial seizures, myoclonic seizures, and tonic-clonic seizures.
• The dose of divalproex sodium/valproic acid can be increased by 5mg/kg/day to 10mg/kg/day
at weekly intervals, as tolerated and necessary, up to 60mg/kg/day. For patients who do not
respond, measure plasma concentrations to determine whether they are within the usually
accepted range (50mcg/mL to 100mcg/mL).
• Gabapentin is indicated for the adjunctive treatment of partial seizures with or without
secondary generalized tonic-clonic seizures.
• The effective dose of gabapentin is usually 900mg/day to 1800mg/day, but up to 2400mg/day
has been used long-term.
The Hospice Pharmacia Medication Use Guidelines
| 135 |
Seizures
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Barbiturates
Medication
Average Cost of Therapy
Primidone (MYSOLINE®)
$13.52
Benzodiazepines
Medication
Average Cost of Therapy
Clonazepam orally disintegrating tablet (KLONOPIN® WAFER)
$61.04
Diazepam rectal gel (DIASTAT ACUDIAL )
$435.32
®
™
Miscellaneous Anticonvulsants
Medication
Average Cost of Therapy
Carbamazepine ER capsule (CARBATROL®)
$137.33
Carbamazepine ER tablet (TEGRETOL XR )
$40.34
Divalproex sodium ER (DEPAKOTE® ER)
$80.19
®
Lamotrigine (LAMICTAL )
$95.13
Levetiracetam solution (KEPPRA®)
$120.99
®
Levetiracetam tablet (KEPPRA®)
$117.94
Oxcarbazepine suspension (TRILEPTAL®)
$106.17
Oxcarbazepine (TRILEPTAL®)
$69.40
Pregabalin (LYRICA®)
$83.40
Tiagabine (GABITRIL )
$145.67
®
Topiramate (TOPAMAX )
$157.08
Zonisamide (ZONEGRAN®)
$71.87
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NOTES:
• Some medications used for the management of seizures can interact with other medications
and dosages for some medications should be adjusted in patients with hepatic and/or renal
impairment. Please consult with your HP pharmacist for assistance with dosing and monitoring.
• Some medications used for the management of seizures can effectively be administered by the
rectal route (e.g., carbamazepine, valproic acid), whereas others are not recommended to be
administered via this route (e.g., phenytoin, gabapentin). Please consult with your HP pharmacist
for assistance with alternative routes of administration.
• Corticosteroids often are given as adjuvant therapy, particularly for patients with brain
malignancy. For example, dexamethasone has been used, up to 96mg/day, to decrease pain and
swelling associated with cerebral edema. Dexamethasone, methylprednisolone, prednisolone,
and prednisone are included in the HP per diem as adjuvant therapy for seizures.
| 136 | The Hospice Pharmacia Medication Use Guidelines
Thromboembolic-Related Disorders
INCLUSION CODE: C, H, O
ACRONYMS USED IN THIS MONOGRAPH:
ACCP = American College of Chest Physicians
AF = atrial fibrillation
BID = twice a day
CHD = coronary heart disease
ER = extended-release
INR = international normalized ratio
IVC = inferior vena cava
LMWHs = low-molecular-weight heparins
MI = myocardial infarction
NSAIDs = non-steroidal anti-inflammatory
drugs
PO = by mouth
QD = daily
TIA = transient ischemic attack
ARRHYTHMIAS
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of arrhythmias associated
with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459; INCLUSION
CODE: H).
Anticoagulation & Antiplatelet Therapy
Medication
Suggested Dosing
Aspirin
325mg PO QD
Warfarin
Titrate dose to achieve therapeutic INR
• Warfarin is recommended for most patients with AF, particularly those with major risk factors
for stroke (e.g., previous TIA, ischemic stroke, or systemic embolism; poor left ventricular function; diabetes mellitus; hypertension).
• Aspirin is indicated for patients < 75 years with no major risk factors for stroke.
• Warfarin has a narrow therapeutic index, meaning that there is small range within which warfarin is considered safe and effective. This range is monitored using the INR. A safe and effective
INR for warfarin is typically between 2.0 and 3.5, depending on the indication for use.
• The ACCP recommends that patients prescribed warfarin have an INR measured every 4 weeks
at minimum. Some patients may require more frequent monitoring; for example, an INR
should be drawn within 7 days of starting or changing the dose of warfarin.
• As a patient safety standard, HP requests hospices to provide an INR at least every 4 weeks
for patients prescribed warfarin. Further, in order for warfarin to be included in the HP per
diem, an INR must be reported to HP at least every 4 weeks.
NON-PHARMACOLOGIC THERAPY:
• Patients prescribed warfarin should avoid profound changes in their dietary habits.
• Patients prescribed anticoagulation and/or antiplatelet therapy should avoid certain over-thecounter and prescription medications, herbals, and dietary supplements that may increase the
risk of bleeding (e.g., NSAIDs, garlic, green tea).
• Smoking cessation – smoking is a risk factor for blood clotting; thus, smoking cessation should
be encouraged.
The Hospice Pharmacia Medication Use Guidelines
| 137 |
Thromboembolic-Related Disorders
INCLUSION CODE: C, H, O
CEREBROVASCULAR DISEASE
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapy listed below is for ischemic stroke prophylaxis in patients with a
hospice-qualifying, primary diagnosis of cerebrovascular disease (defined as ICD-9-CM codes
430-438; INCLUSION CODE: O).
Anticoagulation & Antiplatelet Therapy
Medication
Suggested Dosing
Aspirin
75mg to 325mg PO QD
Dipyridamole
200mg PO BID
Warfarin
Titrate dose to achieve therapeutic INR
• Dipyridamole often is used in combination with aspirin.
• If the ischemic stroke is due to blood clots originating in the heart, warfarin is generally the
treatment of choice.
• Warfarin has a narrow therapeutic index, meaning that there is small range within which warfarin is considered safe and effective. This range is monitored using the INR. A safe and effective
INR for warfarin is typically between 2.0 and 3.5, depending on the indication for use.
• The ACCP recommends that patients prescribed warfarin have an INR measured every 4 weeks
at minimum. Some patients may require more frequent monitoring; for example, an INR
should be drawn within 7 days of starting or changing the dose of warfarin.
• As a patient safety standard, HP requests hospices to provide an INR at least every 4 weeks
for patients prescribed warfarin. Further, in order for warfarin to be included in the HP per
diem, an INR must be reported to HP at least every 4 weeks.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medications.
Antiplatelet Therapy
Medication
Average Cost of Therapy
Aspirin and dipyridamole ER (AGGRENOX )
$71.26
Clopidogrel (PLAVIX®)
$76.38
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Patients prescribed warfarin should avoid profound changes in their dietary habits.
• Patients prescribed anticoagulation and/or antiplatelet therapy should avoid certain over-thecounter and prescription medications, herbals, and dietary supplements that may increase the
risk of bleeding (e.g., NSAIDs, garlic, green tea).
• Smoking cessation – smoking is a risk factor for blood clotting; thus, smoking cessation should
be encouraged.
| 138 | The Hospice Pharmacia Medication Use Guidelines
Thromboembolic-Related Disorders
INCLUSION CODE: C, H, O
CHRONIC STABLE ANGINA
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapy listed below is for the management of chronic stable angina associated with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459; INCLUSION CODE: H).
Antiplatelet Therapy
Medication
Suggested Dosing
Aspirin
75mg to 325mg PO QD
• Antiplatelet therapy is indicated in all patients with CHD as first-line therapy for prevention of
unstable angina, acute MI, and death.
• In general, low-dose aspirin (i.e., 75mg/day to 150mg/day) is recommended for most patients
with CHD as it provides the same benefits as high-dose aspirin (i.e., 325mg/day) and is associated with fewer side effects.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the table below is based on the average cost of a 15-day supply for all
strengths of the medication.
Antiplatelet Therapy
Medication
Average Cost of Therapy
Clopidogrel (PLAVIX®)
$76.38
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Patients prescribed antiplatelet therapy should avoid certain over-the-counter and prescription medications, herbals, and dietary supplements that may increase the risk of bleeding (e.g.,
NSAIDs, garlic, green tea).
• Smoking cessation – smoking is a risk factor for blood clotting; thus, smoking cessation should
be encouraged.
VENOUS THROMBOEMBOLISM RESULTING FROM MALIGNANCY
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapy listed below is for the management of venous thromboembolism
associated with cancer (defined as ICD-9-CM codes 140-239; INCLUSION CODE: C).
Anticoagulation Therapy
Medication
Suggested Dosing
Warfarin
Titrate dose to achieve therapeutic INR
The Hospice Pharmacia Medication Use Guidelines
| 139 |
Thromboembolic-Related Disorders
INCLUSION CODE: C, H, O
• Warfarin has a narrow therapeutic index, meaning that there is small range within which warfarin is considered safe and effective. This range is monitored using the INR. A safe and effective
INR for warfarin is typically between 2.0 and 3.5, depending on the indication for use.
• The ACCP recommends that patients prescribed warfarin have an INR measured every 4 weeks
at minimum. Some patients may require more frequent monitoring; for example, an INR
should be drawn within 7 days of starting or changing the dose of warfarin.
• As a patient safety standard, HP requests hospices to provide an INR at least every 4 weeks
for patients prescribed warfarin. Further, in order for warfarin to be included in the HP per
diem, an INR must be reported to HP at least every 4 weeks.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Indirect Factor Xa Inhibitors (Anticoagulants)
Medication
Average Cost of Therapy
Fondaparinux (ARIXTRA )
$783.54
®
Low-Molecular-Weight Heparins (LMWHs)
Medication
Average Cost of Therapy
Dalteparin sodium solution for injection (FRAGMIN )
$438.78
Enoxaparin sodium solution for injection (LOVENOX®)
$735.22
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Bed rest is unnecessary except to help relieve symptoms.
• If painful skin ulcers develop, properly applied compression bandages can help.
• Inferior vena cava (IVC) filter – very rarely, a tiny metal filter device resembling an umbrella is
placed, usually inside the inferior vena cava, to prevent emboli from reaching the lungs.
• Patients prescribed warfarin should avoid profound changes in their dietary habits.
• Patients prescribed anticoagulation and/or antiplatelet therapy should avoid certain over-thecounter and prescription medications, herbals, and dietary supplements that may increase the
risk of bleeding (e.g., NSAIDs, garlic, green tea).
• Smoking cessation – although not a direct therapy for venous thromboembolism, smoking is a
risk factor for blood clotting and can therefore contribute to deep vein thrombosis. Thus, smoking cessation should be encouraged.
NOTES:
• In general, how long patients continue treatment with anticoagulation and/or antiplatelet
therapy varies according to the degree of risk. In the hospice population, these therapies might
be continued indefinitely.
• Analgesics, usually opioids, may be used to relieve pain.
| 140 | The Hospice Pharmacia Medication Use Guidelines
Thyroid-Related Disorders
INCLUSION CODE: C
ACRONYMS USED IN THIS MONOGRAPH:
PO = by mouth
QD = daily
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapy listed below is for the management of thyroid-related disorders,
namely hypothyroidism due to thyroid cancer (defined as ICD-9-CM code 193) or from the
effects of surgery or radiation related to the patient’s hospice-qualifying terminal diagnosis.
Medication
Suggested Dosing
Levothyroxine
Usual maintenance dose:
100mcg to 200mcg PO QD
• The dose of levothyroxine must be individualized based on clinical response and laboratory
parameters.
NON-PHARMACOLOGIC THERAPY:
• The mainstay of therapy for thyroid-related disorders is pharmacologic therapy. Nevertheless, medication compliance is an important issue in the management of thyroid-related disorders. Non-pharmacologic interventions such as pill boxes can be used to improve medication compliance.
NOTES:
• Thyroid function tests aid in assessing response to thyroid hormone therapy. These tests should
be performed periodically to ensure the patient is clinically euthyroid.
• Testing should be performed and/or repeated 6 to 8 weeks after levothyroxine dose changes.
The Hospice Pharmacia Medication Use Guidelines
| 141.1 |
Upper Gastric Disorders
INCLUSION CODE: C, O
ACRONYMS USED IN THIS MONOGRAPH:
BID = twice a day
CrCl = creatinine clearance
GERD = gastroesophageal reflux disease
GI = gastrointestinal
H2RAs = histamine2-receptor antagonists
PO = by mouth
PPIs = proton pump inhibitors
QD = daily
QID = four times a day
ACTIVE GI BLEED OR GERD
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of active GI bleed or
gastroesophageal reflux disease (GERD) due to esophageal cancer (defined as ICD-9-CM
codes 150.0-150.9), gastric cancer (defined as ICD-9-CM codes 151.0-151.9), or pancreatic
cancer (defined as ICD-9-CM codes 157.0-157.9 or 197.8).
Gastric Mucosal Agents
Medication
Suggested Dosing
Sucralfate
1gm PO QID
• Sucralfate should be taken on an empty stomach, at least one hour prior to a meal and at bedtime.
• Do not administer H2RAs or PPIs within 30 minutes before or one hour after sucralfate.
Histamine2 Receptor Antagonists (H2RAs)
Medication
Suggested Dosing
Ranitidine
150mg to 300mg PO BID
• Total daily dosages of ranitidine > 600mg/day are outside the HP per diem.
Proton Pump Inhibitors (PPIs)
Medication
Suggested Dosing
Omeprazole
20mg to 40mg PO QD
Rabeprazole (ACIPHEX )
®
20mg to 40mg PO QD
• PPIs should be administered with a full glass of water 30 minutes before breakfast.
• Total daily dosages of omeprazole > 40mg/day and rabeprazole > 40mg/day are outside the
HP per diem.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
| 142.1 | The Hospice Pharmacia Medication Use Guidelines
Upper Gastric Disorders
INCLUSION CODE: C, O
H2RAs
Medication
Average Cost of Therapy
Cimetidine tablet (TAGAMET HB)
$31.68
®
Famotidine solution for injection (PEPCID®)
$15.29
Famotidine tablet and suspension (PEPCID )
$8.98
®
PPIs
Medication
Average Cost of Therapy
Esomeprazole DR capsule (NEXIUM )
$108.75
Esomeprazole DR powder for suspension (NEXIUM®)
$136.33
®
Lansoprazole DR capsule (PREVACID )
$99.00
Lansoprazole DR orally disintegrating tablet (PREVACID®
SOLUTAB™)
$124.32
Pantoprazole DR tablet (PROTONIX®)
$59.52
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Avoid triggering substances such as alcohol and fatty foods.
• Raising the head of the bed about 6 inches can prevent acid from flowing into the esophagus as
the patient sleeps.
• When appropriate, encourage smoking cessation.
• Surgery is sometimes needed to treat GI bleeding.
ESOPHAGEAL OR GASTRIC VARICES
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
• The pharmacologic therapies listed below are for the management of esophageal or gastric varices
due to liver disease (defined as ICD-9-CM codes 570, 571.0-571.9, 572.0, 573.0-573.9; INCLUSION CODE: O), malignant neoplasm of the liver and intrahepatic bile ducts (defined
as ICD-9-CM codes 155.-155.2 or 197.7; INCLUSION CODE: C), or malignant neoplasm
of the gallbladder and extrahepatic bile ducts (defined as ICD-9-CM codes 156.-156.9;
INCLUSION CODE: C).
Beta-blockers
Medication
Suggested Dosing
Propranolol
40mg PO BID
• For the treatment of portal hypertension and/or variceal bleeding prophylaxis in patients with
esophageal varices, doses of propranolol are titrated to achieve heart rate reduction of 25%.
Proton Pump Inhibitors (PPIs)
Medication
Suggested Dosing
Omeprazole
20mg to 40mg PO QD
The Hospice Pharmacia Medication Use Guidelines
| 143.1 |
Upper Gastric Disorders
INCLUSION CODE: C, O
• PPIs should be administered with a full glass of water 30 minutes before breakfast.
• The duration of therapy for omeprazole is typically 4 to 8 weeks.
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Beta-blockers
Medication
Average Cost of Therapy
Nadolol (CORGARD®)
$15.92
PPIs
Medication
Average Cost of Therapy
Esomeprazole DR capsule (NEXIUM®)
$108.75
Esomeprazole DR powder for suspension (NEXIUM )
$136.33
®
Lansoprazole DR capsule (PREVACID®)
Lansoprazole DR orally disintegrating tablet (PREVACID
SOLUTAB™)
$99.00
®
Pantoprazole DR tablet (PROTONIX®)
$124.32
$59.52
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Avoid or reduce alcohol intake.
• Blood transfusions are sometimes given to replace lost blood.
• Surgery is sometimes needed to treat varices.
NOTES:
• Dosages of the medications listed above may need to be adjusted based on age, renal function,
hepatic function, and other patient and medication characteristics. For example, the daily dosage
of H2RAs should be decreased by 50% for patients with estimated CrCl < 50 mL/min. Please
consult with your HP pharmacist for dosage adjustments.
| 144.1 | The Hospice Pharmacia Medication Use Guidelines
Urinary Incontinence
INCLUSION CODE: A
ACRONYMS USED IN THIS MONOGRAPH:
BPH = benign prostatic hyperplasia
ER = extended-release
HS = at bedtime
IR = immediate-release
PO = by mouth
QD = daily
TCAs = tricyclic antidepressants
PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM:
Alpha-adrenergic Blockers
Medication
Suggested Dosing
Doxazosin
1mg PO HS
• Doxazosin is indicated for the treatment of BPH.
• The dosage provided above is initial dosing. The dosage should be adjusted based on clinical
response. The maximum recommended dosage of doxazosin is 8mg/day.
• Older adults may be more sensitive to the hypotensive effects of doxazosin.
Smooth Muscle Relaxants
Medication
Suggested Dosing
Oxybutynin IR
5mg PO 2 to 4 times a day
Oxybutynin transdermal patch
(3.9mg/day)
(OXYTROL®)
1 patch applied to the abdomen, hip, or buttock twice weekly
(every 3 to 4 days)
Tolterodine ER (DETROL® LA)
4mg PO QD
• Smooth muscle relaxants are indicated for the treatment of an overactive bladder with symptoms
of urinary frequency, urinary urgency, or urge-related urinary incontinence.
• Smooth muscle relaxants are strongly anticholinergic. Major side effects are blurred vision,
constipation, dry mouth, and urinary retention. Older adults are especially sensitive to these side
effects.
• Oxybutynin transdermal patch (OXYTROL®) and tolterodine ER (DETROL® LA) are included in the HP per diem if the patient is unable to tolerate oxybutynin IR or the patient
is unresponsive to a treatment trial of at least 4 to 8 weeks with oxybutynin IR.
• The dose of tolterodine should be reduced to 2mg/day in patients with renal or hepatic impairment or those taking medications that inhibit the CYP3A4 isoenzyme.
Tricyclic Antidepressants (TCAs)
Medication
Suggested Dosing
Desipramine
25mg PO HS
Nortriptyline
25mg PO HS
• The dosage provided above is initial dosing. The dosage should be adjusted based on clinical
response.
• TCAs have anticholinergic properties and may be poorly tolerated by older adults.
• Desipramine tends to be less sedating than nortriptyline.
The Hospice Pharmacia Medication Use Guidelines
| 145 |
Urinary Incontinence
INCLUSION CODE: A
PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*:
• The cost represented in the tables below is based on the average cost of a 15-day supply for all
strengths of the medications.
Alpha-adrenergic Blockers
Medication
Average Cost of Therapy
Prazosin (MINIPRESS )
$8.01
Tamsulosin (FLOMAX®)
$51.48
Terazosin
$26.34
®
Muscarinic Antagonists
Medication
Average Cost of Therapy
Darifenacin (ENABLEX )
$105.40
Flavoxate
$48.01
®
Solifenacin (VESICARE )
$113.28
®
Smooth Muscle Relaxants
Medication
Average Cost of Therapy
Oxybutynin ER (DITROPAN XL)
$79.25
Tolterodine (DETROL®)
$61.39
®
TCAs
Medication
Average Cost of Therapy
Imipramine (TOFRANIL®)
$28.01
5-Alpha Reductase Inhibitors
Medication
Average Cost of Therapy
Dutasteride (AVODART )
$54.72
Finasteride (PROSCAR®)
$45.33
®
*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is
intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication
strength and dosage and the quantity of medication requested.
NON-PHARMACOLOGIC THERAPY:
• Behavioral management techniques (e.g., timed voiding), exercise programs (e.g., Kegel
exercises), and lifestyle modification (e.g., decreased amount and type of fluid intake) are
the cornerstones of non-pharmacologic therapy for urinary incontinence. One or more of
these therapies should be continuously employed whenever possible, including along with
pharmacologic therapy. The use of non-pharmacologic therapy sometimes is limited, though,
due to moderate effectiveness, delayed response, diminished efficacy over time, and cognitive
impairment in the frail elderly.
• Invasive devices/procedures (e.g., catheter, urethral stenting) and/or surgery are sometimes
needed.
| 146 | The Hospice Pharmacia Medication Use Guidelines
Urinary Incontinence
INCLUSION CODE: A
NOTES:
• Pharmacologic therapy should be started at a low dose and titrated slowly. The maximum benefit
of pharmacologic therapy may not be apparent for several weeks to months.
• Pharmacologic therapy should be continually evaluated for clinical effectiveness and tolerability.
• Periodically, attempts should be made to reduce the dosage or discontinue the medication to
determine if the incontinence can be managed with non-pharmacologic therapy.
The Hospice Pharmacia Medication Use Guidelines
| 147 |
| 148 | The Hospice Pharmacia Medication Use Guidelines
Medication Index by Generic (Brand) Name
MEDICATION INDEX BY GENERIC (BRAND) NAME
Medications typically dispensed by their generic names are listed generically; medications typically
dispensed by their brand name also have a brand name listed.
A
Page(s)
Acetaminophen
Acetaminophen/codeine
Acyclovir
Albuterol sulfate
Albuterol sulfate HFA inhalation aerosol (PROAIR® HFA, PROVENTIL®
HFA, VENTOLIN® HFA)
Albuterol sulfate nebulizer solution
Albuterol sulfate/ipratropium bromide inhalation aerosol
(COMBIVENT®)
Albuterol sulfate/ipratropium bromide nebulizer solution (DUONEB®)
Alprazolam
Aluminum hydroxide suspension
Aluminum hydroxide/magnesium hydroxide/simethicone suspension
(ALAMAG PLUS™)
Amantadine
Amiodarone
Amitriptyline
Amlodipine
Amoxicillin
Amoxicillin/clavulanate potassium
Amoxicillin/clavulanate potassium extended-release (AUGMENTIN® XR)
Aspirin
Aspirin Buffered
Atenolol
Atropine ophthalmic drops 1%
Azithromycin
B
8, 10, 80, 97, 118, 119,
120, 121, 122
119, 123
89, 95
73, 75, 76
73, 75, 76
73, 75, 76
75
73.2
30, 31, 32, 96, 97, 103
70, 72
70, 72
101
45, 118
35, 63, 64, 66, 113, 116
47, 49
91
91
91
67, 80, 119, 120, 122,
125, 137, 138, 139
67, 80, 120, 137, 138,
139
44, 47, 52
8, 10, 131, 133
90
Page(s)
Bacitracin ophthalmic ointment
Bacitracin zinc topical ointment
Bacitracin zinc/polymyxin B sulfate topical powder (POLYSPORIN®
POWDER)
Bacitracin zinc/neomycin sulfate/polymyxin B sulfate topical ointment
(TRIPLE ANTIBIOTIC OINTMENT)
Baclofen
Bag Balm
Beclomethasone dipropionate inhalation aerosol (QVAR®)
Belladonna/opium suppository
92
92
92
92
84, 86, 101, 103, 105
128, 130
73
81, 82
The Hospice Pharmacia Medication Use Guidelines | | 149.1
149 |
Medication Index by Generic (Brand) Name
Benzocaine rectal ointment 20% (AMERICAINE® HEMORRHOIDAL)
Benzonatate
Benztropine
Betamethasone dipropionate cream, lotion, ointment 0.05%
Bisacodyl
Bismuth subsalicylate suspension (BISMATROL®, PEPTO-BISMOL®)
Bromocriptine
Bumetanide
81
57, 60
100
127, 130
38, 54, 56
67, 69
101
33, 34, 78
C
Page(s)
Camphorated opium tincture (PAREGORIC®)
Capsaicin
Captopril
Carbamazepine
Carbidopa/levodopa
Carbidopa/levodopa/entacapone (STALEVO®)
Carboxymethylcellulose sodium ophthalmic drops 0.5% (REFRESH
TEARS®, REFRESH PLUS®)
Carisoprodol
Carvedilol
Carvedilol extended-release (COREG CR®)
Cefpodoxime proxetil
Cefuroxime axetil
Cephalexin
Chloral hydrate
Chlorhexidine gluconate 0.12% rinse
Chlorpheniramine
Chlorpromazine
Choline magnesium trisalicylate
Cholestyramine powder
Cholestyramine light powder
Ciprofloxacin
Citalopram
Clindamycin
Clonazepam
Clonidine
Clotrimazole cream 1%
Clotrimazole troche
Clotrimazole vaginal cream 1%
Cyclobenzaprine
Cyproheptadine
| 150 | The Hospice Pharmacia Medication Use Guidelines
67, 69
114, 116
47, 50
35, 113, 115, 116, 135,
136
101, 102
101
111
101, 105
47, 50, 51
50, 51
90
90
90
97
111
126, 130
27, 36, 38, 61, 84, 86,
108, 110
80, 120, 122, 125
67, 69, 126, 130
67, 69, 126, 130
90, 94
63, 66
90
30, 31, 32, 96, 97, 100,
102, 103, 104, 105, 114,
115, 117, 134, 136
114, 117
92
89
92
101, 103, 105
41, 43, 126, 130
Medication Index by Generic (Brand) Name
D
Page(s)
Dextromethorphan extended-release suspension (DELSYM®)
Desipramine
Dexamethasone
Dextran 70/hypromellose 0.3% ophthalmic drops, solution (TEARS
NATURALE II®, TEARS RENEWED®)
Diazepam
Dibucaine topical ointment 1%
Diclofenac sodium
Dicloxacillin
Dicyclomine
Digoxin
Diltiazem
Diltiazem extended-release
Diphenhydramine
Diphenhydramine hydrochloride 1% / zinc acetate 0.1% topical cream
Diphenhydramine hydrochloride 2% / zinc acetate 0.1% topical cream
Diphenoxylate/atropine
Dipyridamole
Disopyramide
Disopyramide extended-release
Divalproex sodium (DEPAKOTE®)
Docusate calcium
Docusate sodium
Docusate sodium enema (ENEMEEZ® MINI ENEMA)
Doxazosin
Doxycycline
E
57
63, 64, 66, 113, 116,
145
39, 41, 43, 74, 80, 85,
107, 110, 114, 116, 117,
118, 125, 126, 130, 136
111
30, 32, 85, 96, 100, 103,
105, 134, 135, 136
81, 114, 116
80, 119, 120, 122, 125
91
107, 110
45, 46, 51
44, 49
47
10, 96, 97, 100, 126,
130
127, 130
127, 130
67, 69
138
45
45
35, 113, 135
38, 55, 56
38, 55, 56
55, 56
145
92
Page(s)
Enalapril
Entacapone (COMTAN®)
Erythromycin
Erythromycin base
Erythromycin delayed-release, gastro-resistant
Erythromycin ethylsuccinate
Erythromycin ophthalmic ointment 0.5%
Erythromycin stearate
34, 42, 47, 50, 53, 79
101
70, 90, 108, 110
72, 90, 108, 110
72, 90, 108, 110
72, 90, 108, 110
92
90, 108
The Hospice Pharmacia Medication Use Guidelines
| 151.1 |
Medication Index by Generic (Brand) Name
F
Fentanyl transdermal system
Fluconazole
Fluocinolone acetonide cream, ointment 0.025%
Fluocinonide cream, ointment 0.05%
Fluocinonide emulsified cream 0.05%
Fluoxetine
Fluticasone propionate/salmeterol inhalation powder (ADVAIR® DISKUS®)
Fosinopril
Furosemide
G
Page(s)
119, 124
89
127, 130
127, 130
127, 130
35, 63, 66
75, 76
47, 50
8, 33, 34, 78
Page(s)
Gabapentin
Gentamicin sulfate 0.3% ophthalmic solution
Glipizide
Glyburide
Glycerin adult suppository
Glycerin pediatric suppository
Glycerin 0.2% / hypromellose 0.2% / polyethylene glycol 400 1%
ophthalmic drops (VISINE® TEARS®)
95, 113, 116, 135, 136
92
87
87, 88
54, 56
54, 56
Glycopyrrolate
39, 40, 107, 108, 131,
132, 133
58, 60, 131, 133
57, 60
58, 60
57, 58, 60
58
Guaifenesin
Guaifenesin/codeine
Guaifenesin/codeine/pseudoephedrine
Guaifenesin/dextromethorphan
Guaifenesin/dextromethorphan/phenylephrine
H
Haloperidol
Hydralazine
Hydrochlorothiazide
Hydrocodone/acetaminophen
Hydrocodone bitartrate/homatropine methylbromide
Hydrocortisone cream (0.5%, 1%, 2.5%), ointment (0.5%, 1%, 2.5%)
Hydrocortisone rectal cream 2.5% (PROCTOZONE-HC™)
Hydrocortisone acetate suppositories (ANUCORT-HC™, ANUSOLHC®, HEMORRHOIDAL HC)
Hydromorphone
Hydroxyzine hydrochloride (ATARAX®)
Hydroxyzine pamoate (VISTARIL®)
| 152.1 | The Hospice Pharmacia Medication Use Guidelines
111
Page(s)
8, 10, 27, 36, 38, 61, 84,
86, 108, 110
51, 52
33, 51, 52, 78, 79
119, 123
57, 60
127, 130
81
81
74, 119, 121, 123, 124
30, 32, 96, 107, 126,
130
30, 32, 96, 107, 110,
126, 130
Medication Index by Generic (Brand) Name
Hyoscyamine
Hypromellose 0.5% ophthalmic drops (ISOPTO® TEARS)
I
Page(s)
Ibuprofen
Ipratropium bromide inhalation aerosol (ATROVENT® HFA)
Ipratropium bromide nebulizer solution
Isosorbide dinitrate
Isosorbide mononitrate (IMDUR®, ISMO®)
L
M
Magnesium citrate solution
Meclizine
Megestrol acetate suspension
Methadone
Methylphenidate
Methylprednisolone
Metoclopramide
Metolazone
Metoprolol succinate
Metoprolol tartrate
Metronidazole
Mexiletine
Milk of magnesia
80, 119, 121, 122, 125
73
73, 76
48, 51, 53
48
Page(s)
Lactulose
Lanolin 2% / mineral oil 15% / white petrolatum base 83% ophthalmic
ointment (AKWA TEARS®)
Levofloxacin (LEVAQUIN®)
Levothyroxine sodium
Lidocaine hydrochloride oromucosal solution 2%
Lidocaine hydrochloride topical gel/jelly 2%
Lidocaine ointment 5%
Lidocaine topical solution 4%
Lidocaine 5% transdermal patch (LIDODERM®)
Lisinopril
Loperamide
Lorazepam
9, 39, 81, 107, 110, 131,
133
111
38, 54, 56, 83
111
90
141
111
81, 114, 116, 127, 130
81, 114, 116, 127, 130
114, 127
95, 114, 116
47, 50, 51
67, 68, 69
8, 9, 10, 27, 30, 32, 77,
96, 103, 107, 110, 134,
135
Page(s)
54
107, 109, 110
41, 43
117, 119, 124
42, 46, 64, 65, 66
39, 41, 74, 80, 107, 114,
116, 117, 118, 125, 126,
130, 136
38, 39, 70, 71, 72, 84,
86, 108, 110
78
47, 50
44, 47, 50, 51
68, 69, 91
114, 117
54
The Hospice Pharmacia Medication Use Guidelines
| 153.1 |
Medication Index by Generic (Brand) Name
Mineral oil rectal enema
Mineral oil oral solution
Mineral oil 3% / white petrolatum base 94% ophthalmic ointment
(TEARS NATURALE P.M.®)
Mirtazapine
Misoprostol
Morphine sulfate
N
Nabumetone
Naproxen
Naproxen sodium
Neomycin
Neomycin sulfate/polymyxin B sulfate/bacitracin zinc ophthalmic
ointment
Neomycin sulfate/polymixin B sulfate/dexamethasone ophthalmic
suspension
Neomycin sulfate/polymyxin B sulfate/bacitracin zinc/hydrocortisone
acetate ophthalmic ointment
Nitroglycerin
Nitroglycerin ointment 2%
Nitroglycerin transdermal patch
Nortriptyline
Nystatin
Nystatin 100,000 units/gm topical cream, ointment
Nystatin 100,000 units/gm topical powder
Nystatin 100,000 units/gm / triamcinolone acetonide 0.1% topical cream,
ointment
O
Omeprazole
Oxazepam
Oxybutynin
Oxybutynin transdermal patch (OXYTROL®)
Oxycodone
Oxycodone/acetaminophen
Oxycodone/aspirin
P
Pancreatic enzymes (various)
Penicillin VK
Phenazopyridine
Phenobarbital
Phenol 1.4% oromucosal spray
| 154.1 | The Hospice Pharmacia Medication Use Guidelines
54, 56
54
111
64, 65, 66
121, 125
8, 10, 74, 119, 120, 123, 124
Page(s)
81, 119, 122, 125
80, 119, 120, 122, 125
119, 122, 125
83
92
92
92
9, 48, 49
48
48
35, 62, 63, 64, 66, 113,
116, 145
89
93
93
93
Page(s)
71, 72, 121, 125, 142, 143
30, 32, 96, 103
81, 82, 145, 146
145
74, 119, 120, 123, 124
119, 120, 121, 123
119, 123
Page(s)
99
91
81
134
111
Medication Index by Generic (Brand) Name
Phenytoin sodium extended-release
Phenytoin chewable tablet (DILANTIN® INFATABS®)
Phenytoin oral suspension
Polyethylene glycol 3350 powder (MIRALAX®)
Polyethylene glycol 400 1% / polyvinyl alcohol 1% ophthalmic drops,
solution (ARTIFICIAL TEARS, HYPO TEARS®)
Polyvinyl alcohol 1.4% / benzalkonium chloride 0.005% (AKWA TEARS®)
Potassium bicarbonate (KLOR-CON® EF)
Potassium bicarbonate/chloride
Potassium chloride
Pramipexole (MIRAPEX®)
Prednisolone
Prednisone
Prochlorperazine
Promethazine
Promethazine/codeine
Promethazine/dextromethorphan
Promethazine/phenylephrine
Promethazine/phenylephrine/codeine
Propafenone immediate-release
Propafenone extended-release (RYTHMOL® SR)
Propoxyphene/acetaminophen
Propranolol hydrochloride
Propranolol extended-release
Q
135, 136
135, 136
135, 136
54.1
111
111
34, 53, 78, 79, 103, 105
34, 53, 78, 79, 103, 105
34, 53, 78, 79, 103, 105
101
39, 41, 80, 107, 114,
116, 117, 118, 125, 126,
130, 136
39, 41, 74, 76, 80, 107,
114, 116, 117, 118, 125,
126, 130, 136
8, 10, 38, 108
38, 108
57, 60
57, 60
57, 60
57, 60
45
45
119, 120, 121
44, 47, 143
44, 47
Page(s)
Quetiapine (SEROQUEL®)
Quinidine gluconate extended-release
Quinidine sulfate immediate-release
36
45
45
R
Page(s)
Rabeprazole sodium (ACIPHEX®)
Ranitidine
Risperidone
142
70, 72, 142
27, 28, 36, 37, 61
S
Page(s)
Saliva substitute (BIOTENE®, MOUTHKOTE®)
Salmeterol (SEREVENT® DISKUS®)
Scopolamine transdermal patch (TRANSDERM SCOP®)
Senna
112
75
39, 107, 110, 131, 133
38, 54, 56
The Hospice Pharmacia Medication Use Guidelines
| 155.2 |
Medication Index by Generic (Brand) Name
Senna/docusate sodium
Sertraline
Silver sulfadiazine cream 1%
Simethicone
Sodium chloride nasal spray 0.65%
Sodium chloride nebulizer solution 0.9%
Sodium phosphate dibasic and monobasic rectal enema
Sorbitol 70% solution
Spironolactone
Sucralfate
Sulfamethoxazole/trimethoprim
T
54, 55, 56
35, 42, 63, 66
92
70
112
58, 131, 133
54
54, 56, 112
33, 34, 50, 53, 78, 79,
103, 105
121, 125, 142
91
Page(s)
Temazepam
Theophylline
Tolterodine extended-release (DETROL® LA)
Trazodone
Triamcinolone acetonide cream, ointment 0.025%, 0.1%, 0.5%
Triamcinolone acetonide inhalation aerosol (AZMACORT®)
Triamterene/hydrochlorothiazide
Trihexyphenidyl
96, 103
75
145
64, 65, 66, 96
127, 130
73
78
100
U
Page(s)
V
Page(s)
Valacyclovir (VALTREX®)
Valproic acid (DEPAKENE )
®
Valsartan (DIOVAN®)
Verapamil regular-release
Verapamil sustained-release
W
Warfarin
89
35, 84, 86, 113, 116,
135, 136
50, 53
44, 49
44, 47
Page(s)
67, 118, 137, 138, 139,
140
Z
Page(s)
Zinc oxide 10% / Dimethicone 1% (A & D® ointment)
Zinc oxide topical ointment 11.3% (BALMEX® Diaper Rash Ointment)
Zinc oxide topical ointment 40%
Zolpidem
128, 130
128, 130
128, 130
97, 98
| 156.1 | The Hospice Pharmacia Medication Use Guidelines
Medication Index by Brand (Generic) Name
MEDICATION INDEX by BRAND (GENERIC) NAME
This index includes a list of medications from the MUGs by common brand names. It is not
intended to imply inclusion in the HP per diem. Please consult with your HP pharmacist to
determine specific medications included in and outside of the per diem.
A
Page(s)
ACIPHEX® (rabeprazole)
ADVAIR® DISKUS® (fluticasone propionate/salmeterol inhalation powder)
ADVIL® (ibuprofen)
AKWA TEARS® LUBRICANT EYE DROPS (polyvinyl alcohol 1.4%/
benzalkonium chloride 0.005%)
AKWA TEARS® LUBRICANT OPHTHALMIC OINTMENT (lanolin 2% /
mineral oil 15% / white petrolatum base 83% ophthalmic ointment)
ALAMAG PLUS™ (aluminum hydroxide/magnesium hydroxide/
simethicone suspension)
142
75, 76
80, 119, 121, 122, 125
ALDACTONE® (spironolactone)
33, 34, 50, 53, 78, 79,
103, 105
119, 122, 125
97, 98
81
91
70, 72
107, 109, 110
81
51, 52
100
ALEVE® (naproxen sodium)
AMBIEN® (zolpidem)
AMERICAINE® HEMORRHOIDAL (benzocaine rectal ointment 20%)
AMOXICILLIN (generic only)
AMPHOGEL® (aluminum hydroxide suspension)
ANTIVERT® (meclizine)
ANUCORT-HC™, ANUSOL®-HC (hydrocortisone acetate suppositories)
APRESOLINE® (hydralazine)
ARTANE® (trihexyphenidyl)
ARTIFICIAL TEARS (polyethylene glycol 400 1% / polyvinyl alcohol 1%
ophthalmic drops, solution)
111
111
70, 72
111
30, 32, 96, 107, 110,
126, 130
8,
10,
27,
30, 32, 77, 96,
®
ATIVAN (lorazepam)
103, 107, 110, 134, 135
73
ATROVENT® HFA (ipratropium bromide inhalation aerosol)
73, 76
ATROVENT® nebulizer solution (ipratropium bromide nebulizer solution)
AUGMENTIN® (amoxicillin/clavulanate potassium)
91
91
AUGMENTIN® XR (amoxicillin/clavulanate potassium extended-release)
73
AZMACORT® (triamcinolone acetonide inhalation aerosol)
ATARAX® (hydroxyzine hydrochloride)
B
Page(s)
B & O® SUPPRETTES (belladonna/opium suppository)
BACITRACIN zinc topical ointment (generic only)
BACTRIM® (sulfamethoxazole/ trimethoprim)
BAG BALM®
81, 82
92
91
128, 130
The Hospice Pharmacia Medication Use Guidelines
| 157.1 |
Medication Index by Brand (Generic) Name
BALMEX® (zinc oxide topical ointment 11.3%)
BAYER® (aspirin)
BENADRYL® KAPSEAL® (diphenhydramine oral capsule)
BENADRYL® TOPICAL CREAM (diphenhydramine hydrochloride 1% /
zinc acetate 0.1% topical cream)
BENADRYL® EXTRA STRENGTH TOPICAL CREAM (diphenhydramine
hydrochloride 2% / zinc acetate 0.1% topical cream)
BENTYL® (dicyclomine)
BIOTENE® (saliva substitute)
BISMATROL® (bismuth subsalicylate suspension)
BUFFERIN® (aspirin buffered)
BUMEX® (bumetanide)
C
CALAN® (verapamil regular-release)
CALAN® SR (verapamil sustained-release)
CAPOTEN® (captopril)
CARAFATE® (sucralfate)
CARDIZEM® (diltiazem)
CARDIZEM® SR, CARDIZEM® CD (diltiazem extended-release)
CARDURA® (doxazosin)
CATAPRES® (clonidine)
CEFTIN® (cefuroxime axetil)
CELEXA® (citalopram)
CHLORAL HYDRATE (syrup, generic only)
CHLORASEPTIC® (phenol 1.4% oromucosal spray)
CHLOR-TRIMETON® (chlorpheniramine)
CIPRO® (ciprofloxacin)
CLEOCIN® (clindamycin)
COGENTIN® (benztropine)
COLACE® (docusate sodium)
COMBIVENT® (albuterol sulfate/ipratropium bromide inhalation aerosol)
COMPAZINE® (prochlorperazine)
COMTAN® (entacapone)
CORDARONE® (amiodarone)
COREG® (carvedilol)
COREG CR® (carvedilol extended-release)
COUMADIN® (warfarin)
CREON® (pancreatic enzymes)
CYTOTEC® (misoprostol)
| 158.1 | The Hospice Pharmacia Medication Use Guidelines
128, 130
67, 80, 119, 120, 122,
125, 137, 138, 139
96, 97, 100, 126, 130
127, 130
127, 130
107, 110
112
67, 69
67, 80, 120, 137, 138,
139
33, 34, 78
Page(s)
44, 49
44, 47
47, 50
121, 125, 142
44, 49
47
145
114, 117
90
63, 66
97
111
126, 130
90, 94
91
100
38, 55, 56
75
8, 10, 38, 108
101
45, 118
47, 50, 51
50, 51
67, 118, 137, 138, 139,
140
99
121, 125
Medication Index by Brand (Generic) Name
D
Page(s)
DARVOCET®-N 50 (propoxyphene/acetaminophen)
DARVOCET®-N 100 (propoxyphene/acetaminophen)
DECADRON® (dexamethasone)
DEEP SEA® (sodium chloride nasal spray 0.65%)
DELSYM® (dextromethorphan extended-release suspension)
DEPAKENE® (valproic acid)
DEPAKOTE® (divalproex sodium)
DESITIN® (zinc oxide topical ointment 40%)
DESYREL® (trazodone)
DETROL® LA (tolterodine extended-release)
DIABETA® (glyburide)
DIFLUCAN® (fluconazole)
DILANTIN-125® (phenytoin oral suspension)
DILANTIN® INFATABS® (phenytoin chewable tablet)
DILANTIN® KAPSEALS® (phenytoin sodium extended-release)
DILAUDID® (hydromorphone)
DIOVAN® (valsartan)
DIPROLENE® (betamethasone dipropionate cream, lotion, ointment 0.05%)
DITROPAN® (oxybutynin immediate-release)
DOC-Q-LAX (senna/docusate sodium)
DOLOPHINE® (methadone tablet)
DULCOLAX® (bisacodyl)
DUONEB® (albuterol sulfate/ipratropium sulfate nebulizer solution)
DURAGESIC® (fentanyl transdermal system)
DYAZIDE® (triamterene/hydrochlorothiazide)
DYNAPEN® (dicloxacillin)
E
119, 120, 122
119, 120, 122
39, 41, 43, 74, 80, 85,
107, 110, 114, 116, 117,
118, 125, 126, 130, 136
112
57
35, 84, 86, 113, 116,
135, 136
35, 113, 135
128, 130
64, 65, 66, 96
145
87, 88
89
135, 136
135, 136
135, 136
74, 119, 121, 123, 124
50, 53
127, 130
81, 82, 145, 146
54, 55, 56
117, 119, 124
38, 54, 56
73.2
119, 124
78
91
Page(s)
EFFERVESCENT POTASSIUM/CHLORIDE (potassium bicarbonate/
potassium chloride)
ELAVIL® (amitriptyline)
ENDOCET® (oxycodone/acetaminophen tablet)
ENDODAN® (oxycodone/aspirin)
ENEMEEZ® MINI ENEMA (docusate sodium enema)
ENULOSE® (lactulose)
ERY®-TAB (erythromycin base)
ERYTHROMYCIN CAPSULE (generic only)
E-MYCIN® (erythromycin delayed-release, gastro-resistant)
E.E.S.® 400 (erythromycin ethylsuccinate)
ERYTHROCIN® Filmtab (erythromycin stearate)
ETH-OXYDOSE™ (oxycodone concentrate solution)
34, 53, 78, 79, 103, 105
33, 63, 64, 66, 113, 116
119, 120, 121, 123
119, 123
55, 56
38, 54, 56, 83
72, 90, 108, 110
70, 90, 108, 110
72, 90, 108, 110
72, 90, 108, 110
72, 90, 108, 110
74, 119, 120, 123, 124
The Hospice Pharmacia Medication Use Guidelines
| 159.2 |
Medication Index by Brand (Generic) Name
F
FLAGYL® (metronidazole)
FLEET® MINERAL OIL ENEMA (mineral oil rectal enema)
FLEXERIL® (cyclobenzaprine)
G
GAS-X® (simethicone)
GENTAK® 0.3% (gentamicin sulfate ophthalmic solution)
GLUCOTROL® (glipizide)
GLYCERIN ADULT suppository (generic only)
GLYCERIN PEDIATRIC suppository (generic only)
GYNE-LOTRIMIN® (clotrimazole vaginal cream 1%)
H
HALDOL® (haloperidol)
HEMMORHOIDAL HC (hydrocortisone acetate suppositories)
HYCODAN® (hydrocodone bitartrate/homatropine methylbromide)
HYDRAMINE® (diphenhydramine oral solution)
HYDRODIURIL® (hydrochlorothiazide)
HYPO TEARS® (polyethylene glycol 400 1% / polyvinyl alcohol 1%
ophthalmic drops, solution)
HYTONE® (hydrocortisone cream [0.5%, 1%, 2.5%], ointment [0.5%, 1%,
2.5%])
I
IMDUR® (isosorbide mononitrate)
IMODIUM® (loperamide)
INDERAL® LA (propranolol extended-release capsule)
ISMO® (isosorbide mononitrate)
ISOPTO® ATROPINE (atropine ophthalmic drops 1%)
ISOPTO® TEARS (hypromellose 0.5% ophthalmic drops)
ISORDIL® (isosorbide dinitrate)
K
KADIAN® (morphine sulfate extended-release capsule)
K-TAB® (potassium chloride extended-release tablet)
K-LYTE® (potassium bicarbonate)
KEFLEX® (cephalexin)
KLONOPIN® (clonazepam)
KLOR-CON® (potassium chloride extended-release tablet)
KLOR-CON® EF (potassium bicarbonate)
| 160.1 | The Hospice Pharmacia Medication Use Guidelines
Page(s)
68, 69, 91
54, 56
101, 103, 105
Page(s)
70
92
87
54, 56
54, 56
93
Page(s)
8, 10, 27, 36, 38, 61, 84,
86, 108, 110
81
57, 60
96, 97, 100, 126, 130
33, 51, 52, 78, 79
111
127, 130
Page(s)
48
67, 68, 69
44, 47
48
8, 10, 131, 133
111
48, 51, 53
Page(s)
119, 120
34, 53, 78, 79, 103, 105
34, 53, 78, 79, 103, 105
90
30, 31, 32, 96, 97, 100,
102, 103, 104, 105, 114,
115, 117, 134, 136
34, 53, 78, 79, 103, 105
34, 53, 78, 79, 103, 105
Medication Index by Brand (Generic) Name
L
Page(s)
LANOXIN® (digoxin)
LASIX® (furosemide)
LEVAQUIN® (levofloxacin)
LEVBID® (hyoscyamine extended-release)
LEVSIN® (hyoscyamine regular-release)
LIDEX® (fluocinonide cream, ointment 0.05%)
LIDEX-E® (fluocinonide emulsified cream 0.05%)
LIDODERM® (lidocaine 5% transdermal patch)
LIORESAL® (baclofen)
LOMOTIL® (diphenoxylate/atropine)
LOPRESSOR® (metoprolol tartrate)
LORTAB® (hydrocodone/acetaminophen)
LOTRIMIN® (clotrimazole cream 1%)
M
Page(s)
MAG-CITRATE® (magnesium citrate solution)
MAXITROL (neomycin-polymixin-dexamethasone ophthalmic suspension)
MAXZIDE® (triamterene/hydrochlorothiazide)
MEDROL® (methylprednisolone)
MEGACE® (megestrol acetate suspension)
METHADOSE® (methadone solution)
MEXITIL® (mexiletine)
MICRO-K® (potassium chloride extended-release capsule)
MICRONASE® (glyburide)
MILK OF MAGNESIA®
MINERAL OIL-HEAVY (mineral oil oral solution)
MIRALAX® (polyethylene glycol 3350 powder)
MIRAPEX® (pramipexole)
MOM® (milk of magnesia)
MONOPRIL® (fosinopril)
MOTRIN® (ibuprofen)
MOUTHKOTE® (saliva substitute)
MS CONTIN® (morphine sulfate extended-release tablet)
MYCELEX® troche (clotrimazole troche)
MYCOSTATIN® (nystatin 100,000 units/gm topical powder)
MYLICON® (simethicone)
N
NAPROSYN® (naproxen)
NEOMYCIN (generic only)
45, 46, 51
8, 33, 34, 78
90
81, 107, 131, 133
9, 39, 81, 107, 131, 133
127, 130
127, 130
95, 114, 116
84, 86, 101, 103, 105
67, 69
44, 47, 50, 51
119, 123
93
54
92
78
39, 41, 74, 80, 107, 114,
116, 117, 118, 125, 126,
130, 136
41, 43
117, 119, 124
114, 117
34, 53, 78, 79, 103, 105
87, 88
54
54
54.1
101
54
47, 50
80, 119, 121, 122, 125
112
119, 120
89
93
70
Page(s)
80, 119, 120, 122, 125
83
The Hospice Pharmacia Medication Use Guidelines
| 161.2 |
Medication Index by Brand (Generic) Name
NEOMYCIN sulfate/polymyxin B sulfate/bacitracin zinc ophthalmic
ointment (generic only)
NEOMYCIN sulfate/polymyxin B sulfate/bacitracin zinc/hydrocortisone
acetate ophthalmic ointment (generic only)
NEURONTIN® (gabapentin)
NITRO-BID® (nitroglycerin ointment 2%)
NITRO-DUR® (nitroglycerin transdermal patch)
NITROGLYCERIN SLOCAPS (nitroglycerin extended-release capsule)
NITROSTAT® (nitroglycerin sublingual tablet)
NORPACE® (disopyramide)
NORPACE® CR (disopyramide extended-release)
NORPRAMIN® (desipramine)
NORVASC® (amlodipine)
NUPERCAINAL® (dibucaine topical ointment 1%)
NYSTATIN 100,000 units/mL suspension (generic only)
NYSTATIN 100,000 units/gm topical cream, ointment (generic only)
NYSTATIN 100,000 units/gm / triamcinolone acetonide 0.1% topical
cream, ointment (generic only)
NYSTOP® (nystatin 100,000 units/gm topical powder)
O
OCEAN® (sodium chloride nasal spray 0.65%)
ORGANIDIN® NR (guaifenesin)
OXYFAST® (oxycodone concentrate solution)
OXY IR® (oxycodone capsule)
OXYTROL® (oxybutynin transdermal patch)
P
PAMELOR® (nortriptyline)
PARLODEL® (bromocriptine)
PAREGORIC® (camphorated opium tincture)
PCE® (erythromycin base)
PENICILLIN VK (generic only)
PEPTO-BISMOL® (bismuth subsalicylate suspension)
PERCOCET® (oxycodone/acetaminophen tablet)
PERCODAN® (oxycodone/aspirin)
PERIACTIN® (cyproheptadine)
PERIDEX®, PERIOGARD®, PERIORX®, PERISOL® (chlorhexidine
gluconate 0.12% rinse)
PERSANTINE® (dipyridamole)
PHAZYME® (simethicone)
PHENERGAN® (promethazine)
| 162.1 | The Hospice Pharmacia Medication Use Guidelines
92
92
95, 113, 116, 135, 136
48
48
48, 49
8, 48, 49
45
45
63, 64, 66, 113, 116,
145
47, 49
81, 114, 116
89
93
93
93
Page(s)
112
58, 60, 131, 133
74, 119, 123, 124
74, 119, 123, 124
145
Page(s)
145
101
67, 79
72, 90, 108, 110
91
67, 69
119, 120, 121, 123
119, 123
41, 43, 126, 130
111
138
70
38, 108
Medication Index by Brand (Generic) Name
PHENOBARBITAL (generic only)
POLYSPORIN® POWDER (bacitracin zinc/polymixin B sulfate topical
powder)
POTASSIUM CHLORIDE solution (generic only)
PREDNISONE (generic only)
PRELONE® (prednisolone solution)
PRILOSEC® (omeprazole)
PRINIVIL® (lisinopril)
PROCTOZONE-HC™ (hydrocortisone rectal cream 2.5%)
PROMETH with CODEINE (promethazine/codeine)
PROMETHAZINE DM (promethazine/dextromethorphan)
PROMETH VC with CODEINE (promethazine/phenylephrine/codeine)
PROMETH VC PLAIN (promethazine/phenylephrine)
PROPRANOLOL hydrochloride (generic only)
PROZAC® (fluoxetine)
PYRIDIUM® (phenazopyridine)
Q
134
92
34, 53, 78, 79, 103, 105
39, 41, 74, 76, 80, 107,
114, 116, 117, 118, 125,
126, 130, 136
39, 41, 80, 107, 114,
116, 117, 118, 125, 126,
130, 136
71, 72, 121, 125, 142, 143
47, 50, 51
81
57, 60
57, 60
57, 60
57, 60
44, 47, 143
35, 63, 66
81
Page(s)
QUESTRAN® (cholestyramine)
QUINIDINE GLUCONATE extended-release tablet (generic only)
QUINIDINE SULFATE immediate-release tablet (generic only)
QVAR® (beclomethasone dipropionate inhalation aerosol)
R
67, 69, 126, 130
45
45
73
Page(s)
REFRESH PLUS® (carboxymethylcellulose sodium ophthalmic drops 0.5%)
REFRESH TEARS® (carboxymethylcellulose sodium ophthalmic drops 0.5%)
REGLAN® (metoclopramide)
RELAFEN® (nabumetone)
REMERON® (mirtazapine)
RESTORIL® (temazepam)
RISPERDAL® (risperidone)
RITALIN® (methylphenidate)
ROBINUL® (glycopyrrolate)
ROBITUSSIN® AC (guaifenesin/codeine)
ROBITUSSIN® CF (guaifenesin/detromethorphan/phenylephrine)
ROBITUSSIN® DAC (guaifenesin/codeine/pseudoephedrine)
ROBITUSSIN® DM (guaifenesin/dextromethorphan)
ROMYCIN (erythromycin ophthalmic ointment 0.5%)
ROXANOL™ (morphine sulfate concentrated solution)
ROXICET® (oxycodone/acetaminophen solution, tablet)
111
111
38, 39, 70, 71, 72, 84,
86, 108, 110
80, 119, 122, 125
64, 65, 66
96, 103
27, 28, 36, 37, 61
42, 46, 64, 65, 66
39, 40, 107, 108, 131,
132, 133
57, 60
58
58, 60
57, 58, 60
92
8, 10, 74, 119, 123, 124
119, 120, 121, 123
The Hospice Pharmacia Medication Use Guidelines
| 163.1 |
Medication Index by Brand (Generic) Name
ROXICODONE® (oxycodone solution, tablet)
RYTHMOL® (propafenone immediate-release)
RYTHMOL® SR (propafenone extended-release)
S
SENOKOT® (senna)
SENOKOT-S® (senna/docusate sodium)
SEPTRA® (sulfamethoxazole/ trimethoprim)
SERAX® (oxazepam)
SEREVENT® DISKUS® (salmeterol)
SEROQUEL® (quetiapine)
SINEMET® (carbidopa/levodopa)
SODIUM PHOSPHATE DIBASIC and MONOBASIC RECTAL ENEMA
(generic only)
SODIUM CHLORIDE NEBULIZER SOLUTION 0.9% (generic only)
SOMA® (carisoprodol)
SOMNATE® (chloral hydrate capsule)
SORBITOL 70% SOLUTION (generic only)
SORE THROAT SPRAY (phenol 1.4% oromucosal spray)
SSD® (silver sulfadiazine cream 1%)
STALEVO® (carbidopa/levodopa/entacapone)
SUR-Q-LAX® (docusate calcium)
SYMMETREL® (amantadine)
SYNALAR® (fluocinolone acetonide cream, ointment 0.025%)
SYNTHROID® (levothyroxine sodium)
T
TEARS NATURALE® P.M. (mineral oil 3% / white petrolatum base 94%
ophthalmic ointment)
TEGRETOL® (carbamazepine)
TENORMIN® (atenolol)
TEARS NATURALE II®, TEARS RENEWED® (dextran 70/hypromellose
0.3% ophthalmic drops, solution)
TESSALON® (benzonatate)
THEO-DUR® (theophylline)
THORAZINE® (chlorpromazine)
TOPROL® XL (metoprolol succinate)
TRANSDERM SCOP® (scopolamine transdermal patch)
TRIAMCINOLONE ACETONIDE cream, ointment 0.025%, 0.1%, 0.5%
(generic only)
TRILISATE® (choline magnesium trisalicylate)
TRIPLE ANTIBIOTIC OINTMENT (bacitracin zinc/neomycin sulfate/
polymyxin B sulfate topical ointment)
| 164.1 | The Hospice Pharmacia Medication Use Guidelines
74, 119, 123, 124
45
45
Page(s)
38, 54, 56
54, 55, 56
91
30, 32, 96, 103
75
36
101, 102
54
58, 131, 133
101, 105
97
54, 56, 112
111
92
101
38, 55, 56
101
127, 130
141
Page(s)
111
33, 113, 115, 116, 135,
136
44, 47, 52
111
57, 60
75
27, 36, 38, 61, 84, 86,
108, 110
47, 50
37, 107, 110, 131, 133
127, 130
80, 120, 122, 125
92
Medication Index by Brand (Generic) Name
TRIXAICIN® (capsaicin)
TYLENOL® (acetaminophen)
TYLENOL® with Codeine (acetaminophen/codeine)
TYLOX® (oxycodone/acetaminophen capsule)
TUSSIGON® (hydrocodone bitartrate/homatropine methylbromide)
V
114, 116
8, 10, 80, 97, 118, 119,
120, 121, 122
119, 123
119, 120, 121, 123
57, 60
Page(s)
VALIUM (diazepam)
®
VALTREX® (valacyclovir)
VANTIN® (cefpodoxime proxetil)
VASOTEC® (enalapril)
VENTOLIN® HFA (albuterol sulfate inhalation aerosol)
VENTOLIN® nebulizer solution (albuterol sulfate nebulizer solution)
VENTOLIN® (albuterol sulfate)
VIBRAMYCIN® (doxycycline)
VICODIN® (hydrocodone/acetaminophen)
VISINE® TEARS (glycerin 0.2% / hypromellose 0.2% / polyethylene glycol
400 1% ophthalmic drops)
VISTARIL® (hydroxyzine pamoate)
Vitamin A & D OINTMENT (zinc oxide 10%/ dimethicone 1%)
VOLTAREN® (diclofenac sodium)
X
ZANTAC® (ranitidine)
ZAROXOLYN® (metolazone)
ZESTRIL® (lisinopril)
ZITHROMAX® (azithromycin)
ZOLOFT® (sertraline)
ZOSTRIX® (capsaicin)
ZOVIRAX® (acyclovir)
111
30, 32, 96, 107, 110,
126, 130
128, 130
91
Page(s)
XANAX® (alprazolam)
XYLOCAINE® VISCOUS (lidocaine hydrochloride oromucosal solution 2%)
XYLOCAINE® TOPICAL JELLY (lidocaine hydrochloride topical gel/jelly 2%)
XYLOCAINE®TOPICAL SOLUTION (lidocaine topical solution 4%)
XYLOCAINE® OINTMENT (lidocaine ointment 5%)
Z
30, 32, 85, 96, 100, 103,
105, 134, 135, 136
89
90
34, 42, 47, 50, 53, 79
73, 75, 76
73, 75, 76
73, 75, 76
92
119, 123
30, 31, 32, 96, 97, 103
111
81, 114, 116, 127, 130
114, 127
81, 114, 116, 127, 130
Page(s)
70, 72, 142
78
47, 50, 51
90
35, 42, 63, 66
114, 116
89, 95
The Hospice Pharmacia Medication Use Guidelines
| 165.1 |
Injectable Medication Index
As a service to your patient, Hospice Pharmacia (HP) provides a variety of medications in injectable
formulation. This index includes a listing of injectable medications included in the HP per diem.
This does not infer that every injectable medication is related to the patient’s hospice-qualifying terminal diagnosis and, therefore, that every injectable medication is included in the HP
per diem for an individual patient. Hospice Pharmacia determines which injectable medications
are included in the HP per diem based on diagnosis-related inclusion codes (refer to Inclusions
section for additional information regarding diagnosis-related inclusion codes). Please consult with
your HP pharmacist to determine specific injectable formulations included in the per diem and the
most appropriate dose for the individual patient.
Atropine
Chlorpromazine
Dexamethasone
Diazepam
Diphenhydramine
Furosemide
Haloperidol
Heparin flush
Insulin human NPH, REG, 70/30*
Lorazepam
Metoclopramide
Morphine
Octreotide
Phenobarbital
Prochlorperazine
Promethazine
Sodium chloride bacteriostatic 0.9%
Sodium chloride flush 0.9%
Insulin syringes are included in the HP per diem for patients prescribed insulin for the management of hyperglycemia due to diabetes as the hospice-qualifying terminal diagnosis (defined as
ICD-9-CM codes 250.0-250.9; INCLUSION CODE: O), hyperglycemia due to pancreatic cancer
(defined as ICD-9-CM codes 157.0-157.9 or 197.8; INCLUSION CODE: C), or hyperglycemia
induced by a medication used for a symptom related to the patient’s hospice-qualifying terminal
diagnosis (INCLUSION CODE: A), whereby the hyperglycemia affects the patient’s quality of
life. In order for insulin syringes to be included in the per diem, they must be dispensed by HP;
insulin syringes cannot be adjudicated through the PBM Plus card. Pre-filled insulin syringes and
insulin pens are outside the HP per diem.
*
Hospice Pharmacia does not provide any other types of injectable supplies.
| 166.1 | The Hospice Pharmacia Medication Use Guidelines
Compound Index
Hospice Pharmacia (HP) will compound a medication approved by the U.S. Food and Drug Administration into a formulation requested by a licensed prescriber for use in an individual hospice
patient. This index includes a listing of compounds included in the HP per diem. This does not
infer that every compound is related to the patient’s hospice-qualifying terminal diagnosis
and, therefore, that every compound is included in the HP per diem for an individual patient.
Hospice Pharmacia determines which compounds are included in the HP per diem based on
diagnosis-related inclusion codes (refer to Inclusions section for additional information regarding
diagnosis-related inclusion codes).
To make this index an easy-to-use, workable tool, compounds have been organized by dosage formulation and listed in alphabetical order. Please consult with your HP pharmacist to determine the
most appropriate formulation for your patient.
ACRONMYMS USED IN THIS INDEX:
A = lorazepam (ATIVAN®)
B = diphenhydramine (BENADRYL®)
C = prochlorperazine (COMPAZINE®)
D = dexamethasone (DECADRON®)
H = haloperidol (HALDOL®)
P = promethazine (PHENERGAN®)
R = metoclopramide (REGLAN®)
SF = sugar free
Capsules
ABH 0.5/12.5/0.5mg
ABHR 0.5/12.5/0.5/10mg
ABR 0.5/12.5/10mg
BDR 20/4/4mg
Dextromethorphan 30mg
Dextromethorphan 100mg
Gels
A 0.5mg per 1mL
A 1mg per 1mL
AB 1/50mg per 1mL
ABH 0.5/25/0.25mg per 1mL
ABH 1/12.5/1mg per 1mL
ABH 1/25/1mg per 1mL
ABH 2/50/4mg per 1mL
ABHR 0.5/12.5/0.5/5mg per 1mL
ABHR 1/25/1/10mg per 1mL
ABR 1/12.5/20mg per 1mL
AHR 1/1/10mg per 1mL
BHR 25/1/10mg per 1mL
Chlorpromazine 100mg per 1mL
D 2mg per 1mL
D 4mg per 1mL
H 0.5mg per 1mL
H 1mg per 1mL
H 5mg per 1mL
The Hospice Pharmacia Medication Use Guidelines
| 167.1 |
Compound Index
HA 1/1mg per 1mL
Ketamine 10mg per 1mL
Ketamine 20mg per 1mL
Ketamine 50mg per 1mL
Ketamine 100mg per 1mL
Ketamine/bupivacaine 10% / 4% per 1mL
Ketoprofen 50mg per 1mL
Ketoprofen 150mg per 1mL
Morphine 5mg per 1mL
Morphine 10mg per 1mL
Morphine 20mg per 1mL
PR 25/10mg per 1mL
PRA 25/10/1mg per 1mL
Promethazine 25mg per 1mL
Promethazine 50mg per 1mL
R 10mg per 1mL
Scopolamine 0.025% per 1mL
Pastes
“MAGIC BUTT PASTE” (hydrophilic ointment/lidocaine 5% ointment/A & D® ointment/zinc oxide
ointment in a 1/1/2/2 proportion)
Solutions
A 0.25mg per 1mL
A 1mg per 1mL
A 2mg per 1mL
Chlorpromazine 50mg per 1mL
Chlorpromazine 100mg per 1mL
D 4mg per 1mL
Enalapril 5mg per 5mL
Glycopyrrolate 0.2mg per 1mL
H 2mg per 1mL
Hydromorphone 1mg per 1mL
Hydromorphone 4mg per 1mL
Hydromorphone 10mg per 1mL
Hydromorphone 50mg per 1mL
Hydroxyzine 50mg per 1mL
Methadone 50mg per 1mL
Morphine 1mg per 1mL
Morphine 20mg per 1mL SF for nebulization
Morphine 40mg per 1mL
Morphine 50mg per 1mL
Oxycodone 40mg per 1mL
Pilocarpine 5mg per 5mL
| 168.1 | The Hospice Pharmacia Medication Use Guidelines
Compound Index
Suppositories
A 0.5mg
A 1mg
A 2mg
ABH 0.5/12.5/0.5mg
ABHR 0.25/6.25/0.25/5mg
ABHR 0.5/12.5/0.5/10mg
ABHR 1/25/1/10mg
ABHR 1/25/1/20mg
ABR 0.5/12.5/10mg
B 25mg
BDR 20/4/4mg
Baclofen 5mg
Baclofen 20mg
Carbamazepine 200mg
Carbamazepine 300mg
Carbamazepine 400mg
Chlorpromazine 25mg
Chlorpromazine 50mg
Chlorpromazine 100mg
Choline magnesium trisalicylate 500mg
Clonazepam 2mg
D 2mg
D 4mg
D 6mg
D 8mg
D 10mg
D 12mg
D 20mg
DRA 4/10/1mg
DRH 4/10/1mg
Diazepam 2mg
Diazepam 5mg
Diazepam 10mg
Diazepam 20mg
H 1mg
H 2mg
H 5mg
Hydrocodone/acetaminophen 5/500mg
Hydrocodone/acetaminophen 7.5/500mg
Hydrocodone/acetaminophen 7.5/750mg
Hydromorphone 4mg
Ibuprofen 400mg
Ibuprofen 600mg
The Hospice Pharmacia Medication Use Guidelines
| 169.1 |
Compound Index
Ibuprofen 800mg
Methadone 40mg
Methadone 50mg
Methadone 100mg
Methadone 200mg
Morphine 5mg
Morphine 10mg
Morphine 15mg
Morphine 20mg
Morphine 30mg
Morphine 100mg
Morphine 200mg
Naproxen 500mg
Phenobarbital 30mg
Phenobarbital 60mg
Phenobarbital 100mg
Phenobarbital 200mg
Prednisone 5mg
Prednisone 20mg
Promethazine 50mg
R 10mg
Valproic acid 250mg
Valproic acid 375mg
Valproic acid 500mg
Suspensions
ABH 0.5/12.5/0.5mg per 5mL
ABHD 0.5/16/0.25/3mg per 5mL
ABHR 0.5/12.5/0.5/10mg per 5mL
ABR 0.5/12.5/10mg per 5mL
Alprazolam 1mg per 1mL
Amitriptyline 25mg per 5mL
Amitriptyline 50mg per 5mL
Amitriptyline 100mg per 1mL
Amlodipine 1mg per 1mL
BDR 20/4/4/mg per 5mL
BHR 12.5/0.5/10mg per 5mL
“BANHURT” (B/nystatin/prednisone/tetracycline 12.5mg/250,000 units/2.5mg/125mg per 15mL)
Baclofen 1mg per 1mL
Baclofen 10mg per 5mL
Baclofen 20mg per 5mL
Bumetanide 0.5mg per 1mL
C 2mg per 1mL
| 170.1 | The Hospice Pharmacia Medication Use Guidelines
Compound Index
C 5mg per 1mL
C 10mg per 1mL
Captopril 1mg per 1mL
Captopril 12.5mg per 5mL
Carbidopa/levodopa 25/100mg per 5mL
Carbidopa/levodopa 25/250mg per 5mL
Clonazepam 1mg per 1mL
Clonazepam 1mg per 5mL
Cyclobenzaprine 10mg per 5mL
D 10mg per 1mL
Fluconazole 100mg per 5mL
Glycopyrrolate 2mg per 1mL
Hydrocodone/acetaminophen 5/500mg per 5mL
Ibuprofen 200mg per 5mL
Ibuprofen 400mg per 5mL
Ibuprofen 600mg per 5mL
Ibuprofen 800mg per 5mL
“MAGIC MOUTHWASH” New Formulation (B/aluminum hydroxide-magnesium hydroxidesimethicone/viscous lidocaine in equal volume proportions)
“MAGIC MOUTHWASH with NYSTATIN” New Formulation (B/aluminum hydroxide-magnesium
hydroxide-simethicone/viscous lidocaine/nystatin in equal volume proportions)
Metoprolol 12.5mg per 5mL
Metronidazole 250mg per 5mL
Naproxen 250mg per 5mL
Nortriptyline 10mg per 5mL
Nortriptyline 50mg per 5mL
Omeprazole 2mg per 1mL
Oxazepam 10mg per 1mL
Phenobarbital 30mg per 1mL
Prednisone 20mg per 1mL
Prednisone 20mg per 5mL
Promethazine 25mg per 1mL
Propoxyphene/acetaminophen 100/650mg per 5mL
R 5mg per 1mL
Spironolactone 100mg per 5mL
Trazodone 100mg per 5mL
Troches
ABHR 0.5/12.5/0.5/10mg
The Hospice Pharmacia Medication Use Guidelines
| 171.1 |