Alphabetical Listing list alpha.pdf · Ambien CR 12.5mg Ambien 10mg Ambisome Abelcet (can use...

Therapeutic Interchange List

Alphabetical Listing

Revised 02-2019 See related Restricted Medications, 7300-VII-10, Attachment B

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No order needed to change to elixir as long as bioequivalence is the same. (P&T, 11/04)

No order needed to change route to via tube as long as drug is non-sustained release. (P&T, 11/04)

No order needed to change dilute or concentration on standard drips (7300-VIII-106)

NONFORMULARY FORMULARY P&T

approve

d

Accolate bid Singulair 10 mg daily (adults) 5mg daily (peds)

Accupril 2.5mg or 5 mg Altace 1.25mg

Accupril 10, 20, 40, 80 mg Altace 2.5mg, 5 mg, 10 mg, 20 mg (max)

Accuzyme ointment Santyl

Aceon 2, 4, 8, 16 Altace 2.5 mg, 5 mg, 10 mg, 20 mg (max)

Aciphex 20 mg daily Prilosec 20 mg daily (except if drug interaction, use Protonix) 11/15/1

0

Aclovate 0.05% crm or oint Tridesilon or Desowen 0.05%

Actonel 5 mg/day Fosamax 35 mg/week

Actonel 35 mg/week Fosamax 70 mg/week

Adderall XR 20 mg q day Adderall 10 mg bid 11/2016

Advair Diskus 100/50 1 inhalation bid Advair HFA 45/21, 2 puffs bid, Except for Isolation pt 5/11/10



Advair in Isolation patients Advair Diskus (administered per Resp Care) 5/11/10

Aerozin spray Benzoin swab

AlitraQ Perative

Allegra 60 mg bid or 180 mg q day Claritin 10 mg daily 5/10/11

Allegra-D bid Claritin-D bid 5/10/11

Alternagel (600 mg/5 ml) Aluminum hydroxide (320mg/5ml), use ½ ordered dose 7/2012

Ambien CR 12.5mg Ambien 10mg

Ambisome Abelcet (can use whichever is least expensive), ID only 11/14/1

1

Aminophylline 100 mg qid Theo-Dur 100 mg tid

Aminophylline ordered as 1000mg in 500ml,

pharmacy may change to 500mg in 250ml

Same concentration, not a therapeutic interchange

Anaprox (naproxen) 275 mg , 500 mg Naprosyn 375 mg, 500 mg

Ancef 1gm pre-op for pt ≤ 120 kg Ancef 2gm pre-op

Ancef 1gm or 2gm pre-op for Pt > 120 kg Ancef 3 gm pre-op 7/2015

Ancef IV 500 mg q8h Ancef IV 1g q8h

Ancef IV q 6 h Ancef IV q 8 h (same # of days/hrs as original order)

Ansaid 50 mg q6h or 100 mh bid Naprosyn 375 mg bid

Ansaid 100 mg tid Naprosyn 500 mg bid

Antacid Al, Mg, Simethicone XS

Antara 43 mg, 130 mg See Fenofibrate 9/4/12

Antifungals (oral and topical) DC- when Diflucan ordered

Anusol Ointment Tucks Ointment

Anzemet 100mg or 1.8mg/kg IV or PO daily Zofran 24mg po first, then 32mg IV if PO not effective DAILY

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Anzemet 12.5 mg (any interval, prn) Zofran 4mg q 8hr (prn)

Anzemet 25 mg (any interval, prn) Zofran 8mg q 8hr (prn)

Apidra (short acting insulin) No TI, recommend Humalog. 9/8/09

Aricept (donepezil) 23 mg Dispensing 2 x 10 mg tabs 5/2016

Arixtra CrCl < 30, contraindicated. Cardiac exception for CrCl 20-30, ok x 1 dose, then Clinical Pharmacist to TI

to Heparin Infusion (implement seq # 693 or # 24683 and sign “per TI”)

5/11/10

Artificial Tears See chart at the end of this document 2/2018

Asacol (mesalamine) Delzicol (mesalamine), same dose and frequency 10/2013

Ascriptin Ecotrin

Atacand (candesartan) 4, 8, 16 & 32mg Cozaar (losartan) 25 mg, 25mg, 50 mg, 100 mg 11/1/10

Augmentin 250 mg tid Augmentin 500 mg bid

Augmentin chewables Use Augmentin susp

Avapro (irbesartan) 75 mg, 150mg, 300 mg Cozaar (losartan) 25mg, 50 mg, 100 mg 11/1/10

Aveenobar Aveenobath

Avelox IV (during shortage situations)

Levaquin IV:

CrCl ≥ 50, Levaquin 750 mg IV q 24 hrs

CrCl 20-50 Levaquin 750 mg IV q 48 hrs

CrCl 10-19, Levaquin 500 mg IV q 48 hrs

CrCl < 10 or HD: Levaquin 500 mg IV q 36 hrs

01/06/1

5

09/2017

Avinza 120, 150, 180 & 210 mg daily MS Contin 60, 75, 90, 100 mg bid

Avinza 30, 60, 90 mg daily MS Contin 15, 30, 45 mg bid

Axid 150 mg bid Pepcid 20 mg bid

Axid 150mg, 300 mh q hs Pepcid 20 mg, 40 mg q hs

Banana Bag diluent LR Banana bags diluent is NS

Beclovent Azmacort (same puffs and intervals)

Beconase AQ regular strength Flonase (same # sprays) daily 5/1/12

Benicar (olmesartan) 5, 10, 20 & 40 mg Cozaar (losartan) 25 mg , 25mg, 50 mg, 100 mg 11/1/10

Betapace AF Sotalol (same drug, different indication) 5/2017

Biaxin XL 1000mg DAILY Biaxin 500 mg bid

Breast cream (Lanolin) Lansinoh Breast Cream

Bufferin (Buffered ASA) Ecotrin

Bumex IV 1mg (exception: neonates, no TI) No TI to Demadex IV, call physician 10/2014

Bumex PO 0.5 mg, 1mg, 2mg Demadex PO 5 mg, 10mg, 20 mg

BUTT cream (adults) Vasolex 11/14/1

1

Byetta (exenatide) No TI, must call MD. 9/8/09

Caduet (combo, use individual products) Amlodipine and atorvastatin 9/4/12

Calan Verapamil IR same dose and schedule 8/14

Calan SR

120 mg po daily

180 mg po daily

240 mg po daily

360 mg po daily

120 mg po BID

(same total daily dose given qAM)

Verapamil ER capsules 120 mg po qAM



Verapamil ER capsules 360 mg (2 x 180 mg) po qAM


8/14





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180 mg po BID

240 mg po BID



Calcitonin injection

(approx. $2,100 per 400 unit vial) - 24 hrs automatic stop after 2 doses and/or DC if serum Ca is

< 14. Providers can follow up on calcium or ionized calcium

daily as needed.

- Round to 200 units or 400 units.

7/3/18

Calcium Carbonate Products:

ORAL Calcium Formulary Products Elemental Calcium

Calcium Carbonate Chewable 500 mg (Tums) 200 mg

Calcium Carbonate tabs 1,250 mg (Oscal-500) 500 mg

Calcium Carbonate tabs 600 mg (Caltrate-D) 600 mg

Calcium Carbonate 1,250 mg/5ml Suspension 500 mg/5ml

Calcium Gluconate (shortage)

1 gm IV

The TI is for all Ca gluc excluding

NICU and ca drips (PTH) patients.

Calcium Chloride

333 mg IV

3/9/18

Caphosol (sodium phosphate) Biotene (polyglycitol) 11/12

Cardura XL 4 and 8mg Cardura 4 and 8mg daily at bed time respectively. 10/6/09

Cataflam 50 mg tid Naprosyn 500 mg bid

Ceclor 250mg & 500mg caps Ceftin 250mg & 500mg caps

Ceclor susp Ceftin susp

Cecon (ascorbic acid) 90 mg/ml Vit C (ascorbic acid)100 mg/ml syrup 3/3/10

Cefizox q 12hr Mefoxin q 8 hrs

Cefotan (q 12 hrs) Mefoxin (q 8 hrs)

Cefizox (q 8 or 12 hrs) Mefoxin (q 8 hrs)

Cefzil susp Ceftin susp

Celexa 10mg daily Lexapro 5mg daily

Celexa 20mg, 40mg daily Lexapro 10mg, 20mg daily

Cephalothin (Keflin) q4h or q6h Ancef q8h

Cerebyx loading doses (1 gm), during

shortage

Phenytoin 1 gm 5/11/10

Cerebyx Maintenance Doses, during

shortages

May change maintenance doses (ie. 100mg q 8hr) to generic

phenytoin (exception: patient with poor IV access)

Cetacaine spray used at bedside Cepacol or Chloraseptic spray at bedside

Chapstick Blistex

Chromogen FA Niferex 15- Forte

Cipro XR 500mg, 1000mg daily Cipro 250 mg , 500 mg bid

Claforan 500mg Rocephin 500 mg q 24 hrs

Claforan (ADULT indications) 1 gm –2 gm Rocephin 1 gm q 24 hrs

Clarinex 5mg daily Claritin 10 mg daily 5/10/11

Claritin D, all strengths Claritin D 10 mg/240 mg

Clotrimazole (Gyne-Lotrimin) Miconazole





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Combivent 2 puffs q6h

Used on ventilator patients only in ICU.

Combivent Respimat 1 puff q6 hr

Used on ventilator patients only in ICU.

3/2014

Copaxone (glatiramer) No TI, pt to bring own, do not order 9/8/09

Cordran 0.05% crm, oint, lotion Kenalog 0.025% oint,crm,lotion

Coreg CR 10, 20, 40, 80 mg daily Coreg 3.125 mg, 6.25 mg, 12.5 mg, 25 mg bid

Cortone Solu-cortef

Covera-HS

180 mg po qHS

240 mg po qHS

360 mg po qHS

480 mg po qHS





8/14

Cyclocort 0.1% crm or lotion Diprosone 0.05% oint

Cyclocort 0.1% ointment Lidex 0.05% crm, oint, soln

D51/4NS (adults only not peds) D51/2NS (adults only- not peds)

D50 Shortage, give D10 Hypoglycemia orders (#2513) :

▪ If patient can swallow, use juice, milk or peanut butter

crackers

▪ Or, Glucagon 1 mg SQ or IM (peak action is 10-15

minutes). Located in Accudose/Omnicell machines

▪ IV D50W indicated interchange to D10W:

▪ BG 60-69, give D10W 75 ml* (instead of D50W 15 ml)



▪ BG < 30, give D10W 150 ml* (instead of D50W 30 ml)

▪ *Infuse over 10-15 minutes

▪ D10W 250 ml is located in unit machines.

Hyperkalemia orders (#42874):

- if D50W is indicated, use D10W 250ml over 15 minutes prior

to administration of IV insulin per physician’s orders.

Endotool Userss

Substitution chart for Dextrose using D10W

Grams Dextrose D50W vol (mL) D10W vol (mL)

10 gm 20 ml 100 ml

15 gm 30 ml 150 ml

20 gm 40 ml 200 ml

3/5/13

09/2017





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25 gm 50 ml 250 ml

30 gm 60 ml 300 ml

35 gm 70 ml 350 ml

40 gm 80 ml 400 ml

45 gm 90 ml 450 ml

50 gm 100 ml 500 ml

Dakins

Full Strength = 0.5%

Half-Strength = 0.25%

Quarter Strength = 0.125%

Dalmane Restoril (same dose, but if pt > 65yo, use 15 mg)

Daypro 1200 mg Naprosyn 500 mg tid

Daypro 600 mg Naprosyn 375 mg bid

Decaspray 0.04% Kenalog aerosol

Demadex IV

5 mg

10 mg

20-60 mg

60-80 mg

100 mg

No TI to Bumex IV, call physician

0.5 mg

1 mg

2 mg

3 mg

4 mg

10/2014

Demerol 3 day stop

Denavir ointment Zovirax ointment

Detrol Detrol LA

Dexilant 30, 60 mg daily Prilosec 20mg, 40 mg daily ( if drug interaction, use Protonix) 11/15/1

0

Diflucan IV or PO q12h Diflucan q24h (Same DAILY dose)

Dilacor XR Cardizem CD

Dilantin 300 mg (IV or susp) daily Dilantin 100 mg q8h (IV or susp)

Dilaudid PCAs: when PCA vials on

backorder (can’t make)

Call MD, use Morphine or Demerol PCA or bolus with Dilaudid

Diltiazem Extended Release Tablet (Q day)

Cardiazem LA

Matzim LA tab(120mg, 180mg, 240mg, 300mg, 360 mg, 420mg)

Diltiazem Extended Release Capsule (Q day)





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Cardiazem CD

Dilacor XR

Dilt-XR

Dilt-CD

Taztia XT

Tiazac

Cartia XT (180 mg, 240 mg, 300 mg, 360 mg, 420 mg)

Diltiazem Sustained Release Caps (Q 12 hr)

Diltiazem SR

Diltiazem ER (q 12 hrs) generic 60 mg, 90 mg, 120 mg

Diltiazem Immediate Release Tab (tid, qid)

Cardiazem

Diltiazem generic 30 mg, 60 mg, 90 mg, 120 mg

Diprolene 0.05% ointment Temovate 0.05% ointment

Diprolene AF 0.05% cream Temovate 0.05% cream

Ditropan XL 5 mg daily Ditropan 2.5 mg bid

Ditropan XL 10 mg daily Ditropan 5 mg bid

Ditropan XL 15 mg daily Ditropan 5 mg tid

Ditropan XL 20 mg daily Ditropan 7.5 mg tid

Ditropan XL 30 mg daily Ditropan 10 mg tid

Dobutrex IV in any soln other than D5W D5W for diluent (even diabetic pt)

Doral Restoril (same dose- but if pt > 65yo use 15 mg)

Doribax 500mg q 8hr Merrem 1 gm q 8 hr

See CrCl chart for renal adjustments

7/2013

Doxidan = Biscodyl Dulcolax

Duricef Keflex (same dose-double interval )

Dyazide Maxzide 25 mg

EES 400 mg E-mycin or erythromycin base

Effexor bid or tid

Exception: TF (need immediate release)

Effexor XR daily (same total daily dose)

Exception: TF (need immediate release)

Elocon 0.1% crm, oint, lotion Lidex 0.05% crm, oint, soln

Emend 5 day course: 150mg IV on Day 1 & Day 4 (we do not stock po) 8/16/11

Emla cream L.M.X.4

Empirin # 3 Tylenol #3

Enablex (darifenacin) 7.5 and 15mg q day Vesicare (solifenacin) 5 and 10mg once daily 10/6/09

Enlon (endrophonium) Enlon Plus (endrophonium & atropine)

Ensure Clinical Strength or Complete Ensure Enlive bid 2/2016

Enterals See chart at end of this document

Entex LA Entex PSE

Erthromycin (any brand) E-mycin or erthromycin base)

Erythormycin on backorder Call MD, use Zitromax or Biaxin for tx and Reglan for motility

Erythormycin ophthalmic 0.5% for neonates

on backorder

Use azithromycin ophthalmic 9/8/09

Estraderm patch (q 3 days) Climara patch (q 7 days)

Ethyl Chloride spray Fluori-Methan Spray

Famvir (famicyclovir)

125-250 mg bid (suppressive)

Valtrex

500mg bid

10/6/09,

12/2013





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500 mg q 8 hr (treatment herpes zoster)

250 mg q 8 hr (treatment genital herpes)

1 gm tid (usually for 7 days)

1 gm bid (usually for 7-10 days)

Feldene 10 mg, 20 mg daily Naprosyn 375 mg, 500 mg tid

Fenofibrate, may be given without regard to

meals

43mg or 67 mg (or any dose < 100)

130 mg, 134 mg, 200 mg (or any dose > 100)

If capsules are ordered, dispense tablets

Capsules: 43 mg, 67 mg, 130 mg, 134 mg,

200 mg

Fenofibrate generic 54 mg TABLET , 1:1 interchange (example:

Fenoglide 2 tabs of 43 mg will be switched to 2 tabs of 54 mg)

Fenofibrate generic 160 mg TABLET (max dose)

Tablets: 54 mg, 160 mg

Fenofibric acid 35 mg, 105 mg See Fenofibrate 9/4/12

Fenoglide 40mg, 120mg See Fenofibrate 9/4/12

Ferraheme NO TI, call MD (can use Ferrlicet), do not order 10/6/09

Fibricor 35mg, 105 mg See Fenofibrate 9/4/12

Flagyl Q6h Flagyl q8h

Flagyl IV (shortage) 500 mg q 8 hrs Cleocin IV 900 mg q 8 hrs 6/2014

Fleet Prep Kit 3 (discontinued) LoSo Prep Kit 02/10

Fleet enema Mineral Oil enema: Exception: bowel prep or specific order for

“saline” or ”sodium phosphate”

11/12

Florastor Culturelle 07/11

Flovent (fluticasone) inhaler

44 mcg 1-2 puffs bid

110 mcg 1 puff bid

110 mcg 2 puffs bid (max dose)

Pulmicort (budesonide) nebulizer

0.25 mg neb bid

0.25 mg neb bid

0.5 mg neb bid

11/2016

Floxin Otic Ciloxin Opth

Folic Acid 0.4 mg Folic Acid 1 mg 9/8/09

Forteo (teriparatide) pen call MD…We will NOT order this outpatient drug

Fosamax 10 mg/day Fosamax 70 mg/week

Fosamax 5 mg/day Fosamax 35 mg/week

Fragmin Lovenox, see 500-56 Attachment F:

Low Molecular Weight Heparin Dosing Guidelines 12/10

Gaviscon liquid Maalox XS 10/12

Gelusil or Gelusil M Maalox XS

Gentamicin /Ampicillin combo for pre-op

hysterectomy

Ancef 2 gm IV x 1 dose or 3 gm x 1 if pt > 120 kg 7/15

Glynase 1.5 mg, 3 mg, 6 mg Diabeta/micronase 2.5 mg, 5 mg, 10 mg

Golytely 3 tbsp Miralax, 1 packet

Granix (TBO- filgastrim) Neupogen (or Neupogen to Granix, whichever in stock) 12/2013

Gyne-Lotrimin Miconazole

H2 antagonist SUSPENSION Pepcid 20 mg tabs crushed

Halcion 0.125 mg, 0.25 mg Restoril 15 mg, 30 mg ( unless pt > 65yo then 15mg)


http://gwinnettwork/policies_active/PATIENT_CARE/500-56F.DOC




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Halog 0.1% crm, oint, or soln Lidex 0.05% crm, oint, soln

Heparin IV infusions in any soln other than

what we have pre-mixed

Pre-mixed Heparin will be at a concentration of 50 units/ml:

25,000 units in 500 ml of fluid (either D5W or 0.45NS,

depending on supply). Note that D5W can be used in diabetic

patients due to the very low volume.

Heparin 5,000 units SQ q 8-12 hrs for

prophylaxis

During shortage situations, TI to:

Lovenon 30-40 mg SQ q 24 hrs (dose based on CrCl)

9/2/14

Heparin SQ for CrCl > 30 AND BMI > 40

AND weight > 100 mg

Heparin 7,500 units SQ q 8 hrs (Clinical Pharmacist only TI) 3/2018

Humabid DM , one or two tabs a day

(600 mg Guaif– 30mg Methorphan)

Tussibid (1200 mg Guaif – 60mg Methorphan), one tab a day

Hurricaine spray Cetacaine spray…Do not use PRN or at bedside!

Hycomine PV Tuss or QV tussin

Indocin 25 mg (1 tsp) q6h Ibuprofen 600 mg (2 Tbsp) tid

Indocin SR 75mg q12h Naprosyn 500 mg bid

Insulin Novolog mix 70/30 Humalog 75/25

Insulin, Novolin 70/30 Humulin 70/30

Insulin, Novolin N Humulin N

Insulin, Novolin R Humulin R

Insulin, NovoLog Humalog

Insulin Sliding Scale (Regular) Humalog 8/6/13

Integrelin Aggrastat 12/2013

Iron Products See chart at end of this document

Iron products (oral) Ferrous Sulfate 325 mg (65 mg elemental iron) or

Fergon 27 mg elemental irom

Isoptin Verapamil IR same dose and schedule 8/14

Isoptin SR

120 mg po daily

180 mg po daily

240 mg po daily

360 mg po daily

120 mg po BID

180 mg po BID

240 mg po BID





Verapamil ER capsules 360 mg (2 x180 mg) po qAM




8/14

Isopto Tears (5% hydromellose) Naure Tears (4% hydromellose) 1/4/201

1

IV fluids/diluent Change to standard diluent (see policy 7300-VIII-106)

Juvisync (combo, use individual products) Januvia plus simvastatin 9/4/12

Kadian 20 or 30 mg q 12 hrs MS Contin 15 mg q 8 hrs


Kadian 50 mg q 12 hrs MS Contin 30 mg q 8 hrs








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Kaolin and pectin Pepto Bismol

Kaopectate Pepto Bismol

KCL bolus in fluid other than SWFI KCL bolus in SWFI

KCL supplement 10 mEq, 20 mEq K-dur 10 mEq

KCL supplement 8mEq Micro-K 8 mEq

Keftab Keflex

Kovia Accuzyme

Kytril 1-2mg Po or IV (any interval) Zofran 8 mg PO first, then 16 mg IV if PO not effective DAILY

Latisse Xalatan (latanoprost) 8/6/13

Lescol 20mg, 40, and 80 mg (per day) Lipitor 10 mg (total daily dose administered q am) 9/4/12

Levemir (long acting insulin) Lantus (1:1 conversion)

Exception: Allowed for use in GWP only (Catagoty B)

1/2016

Lidex E 0.05% cream Lidex 0.05% crm, oint, soln

Lipofen 50 mg, 150 mg See Fenofibrate 9/4/12

Livalo (pitavastatin) 1, 2, 4 mg Pravachol (pracastatin) 20, 40, 80 mg 9/4/12

LOC (Laxative of Choice) No TI. RN to check w/ patient, then call MD to obtain an order. 9/8/09

Locold 1% soln Tridesilon or Desowen 0.05%

Lodine 200 mg bid, tid, qid Naprosyn 375 mg bid

Lodine 300 mg bid Naprosyn 375 mg bid

Lodine 300 mg tid or qid Naprosyn 500 mg bid

Lodine 400 mg bid or tid Naprosyn 500 mg bid

Lofibra 134 mg, 200 mg, 160 mg See Fenofibrate 9/4/12

Lortab Elixir Hycet Elixir (ml for ml). Both contain 7.5mg Hydrocodone, but

Hycet has APAP 325mg and Lortab has APAP 500mg

Lortab (HYDROcodone with 500 mg

acetaminophen)

Norco ((HYDROcodone with 325 mg acetaminophen) Approve

03/201,

effective

6/4/13

Lotensin 2.5 mg & 5 mg Altace 1.25mg

Lotensin 10 mg, 20 mg, 40mg, 80 mg Altace 2.5mg, 5 mg, 10mg, 30 mg (max)

Lovenox for CrCl > 30 AND BMI > 40

AND weight > 100 mg

For VTE Prophylaxis

Lovenox 40 mg SQ q 12 hrs (Clinical Pharmacist TI only) 3/2018

Lovenox for CrCl < 30 and weight > 100 kg

for VTE Prophylaxis

DC Lovenox

Give Heparin 7,500 units SQ q 12 hrs

02/2019

Lovenox (or Heparin, Arixtra or Coumadin)

ordered with “newer” oral anticoagulants that

work immediately (Pradaxa, Eliquis or

Xarelto)

DC Lovenox 6/2013

Lovenox rounding , see 500-56, Attachment F: Dose Rounding, if patient weighs….. Give

Lovenox 1 mg/kg q 12 hrs (< 50 kg) 40 mg q 12 hrs

Lovenox 1 mg/kg q 12hrs (50-69 kg) 60 mg q 12 hrs

Lovenox 1 mg/kg q 12hrs (70-89 kg) 80 mg q 12 hrs

01/2012


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Lovenox 1 mg/kg q 12 hrs (90-109 kg) 100 mg q 12 hrs





Lovenox 1 mg/kg q 12 hrs (170 kg and up) 180 mg q 12 hrs (maximum dose)

Lumigan (any strength) Xalatan (latanoprost) 8/6/13

Lunesta 1, 2 mg Ambien 5 mg

Lunesta 3mg Ambien 10 mg

Maalox and Maalox XS May interchange both in shortage situation 10/12

Maalox XS, Plus or TC Al, Mg, Simethicone XS

Macrodantin 100 mg qid Macrobid 100 mg bid

Magic Mouth Wash (shortage of Nystatin

suspension)

Modified Magic Mouth Wash (mixed without Nustatin) Plus

Mycelex trouche tid

2/2019

Mag Oxide 250 mg and Magtrate 500 mg Mag Ox 400 mg

Mannitol 25% 500 cc Mannitol 20 % 500 cc

Mavik 0.5 mg, 1mg, 2mg, 4mg, 8mg Altace 1.25 mg, 2.5mg, 5mg, 10mg, 20 mg (max)

Maxalt 5 mg Imitrex 50 mg

Maxalt 10 mg Imitrex 100 mg

Maxiflor 0.05% crm Diprosone 0.05% oint

Maxiflor 0.05% ointment Lidex 0.05% crm, oint, soln

Maxipime No TI to Fortaz, call MD

Meclomen 100 mg tid or qid Naprosyn 500 mg tid

Meclomen 50 mg qid Naprosyn 500 mg tid

Menthol 0.25% compounded Sarna 5%

Merrem (Merrem is FORMULARY and

administered over 4 hrs)-TI IS ONLY FOR

SHORTAGES

1-2 gm IV q 8 hrs (over 4 hrs)

Doribax 500 mg IV q 8 hrs

7/2010

Mevacor 10 mg, 20 mg and 40mg Lipitor 10 mg (total daily dose administered q am) 9/4/12

Mevacor 80 mg Lipitor 20 mg (total daily dose administered q am) 9/4/12

Micardis (telmisartan) 20mg, 40mg, 80 mg, Cozaar (losartan) 25mg, 50 mg, 100 mg 11/1/10

Minocin IV Doxycycline 100 mg IV q 12 hrs

Mobic (meloxicam) 7.5mg, 15 mg Naprosyn 375 mg, 500 mg bid

MOM/MO MOM + MO

Monopril 5 mg, 10 mg, 20 mg Lisinopril 5 mg, 10 mg, 20 mg

Monopril 40mg-80mg Lisinopril 40 mg

Morphine IV (during shortage),

1-2 mg IV q 3 hrs prn severe pain

Dilaudid IV for non-ICU surgical patients (during shortage)

0.25-0.5 mg IV q 3 hrs prn severe pain

12/11/1

2

Morphine prn with CrCl < 30 DC Morphine, order Dilaudid 0.25 mg IV q 3 hrs prn severe

pain

01/06/1

5

Mucofen and Mucofen LA Humibid LA

MVI (Multi dose vitamins)

MVI q day in hyperal during shortage

See Vitamin Chart at the end of this document

MVI in hyperal q M, W, F during shortage

10/2013

Mylanta or Mylanta II Maalox XS

Nafcillin shortage Oxacillin





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Nalfon 200 mg qid or 300 mg tid Naprosyn 375 mg bid

Nalfon 300 mg qid or 600 mg tid or qid Naprosyn 500 mg bid

Namenda (memantine)

5 mg po q day

5 mg po bid

5 mg po q am, 10 mg po q pm

10 mg po bid

Namenda XR (memantine)

7 mg po q day

14 mg po q day

21 mg po q day

28 mg po q day

03/2014

Naprosyn 250 mg bid Naprosyn 375 mg bid

Nasacort (triamcinolone) Flonase (fluticasone) 2 sprays in each nostril daily 5/1/12

Nasarel (flunisolide) Flonase (fluticasone) 2 sprays in each nostril daily 5/1/12

Nasonex (mometasone) Flonase (fluticasone) 2 sprays in each nostril daily 5/1/12

Nature’s Tears (hypromellous) 0.4% Refresh (carboxymethylcellulose) 1% 8/7/12

NeoCortef 1% ointment Cortisporin 1% ointment

Neodecadron crm Neo-Synalar crm

Nephrocap Renovite

Neupogen (filgastrim) Granix (or Granix to Neupogen, whichever in stock) 12/2013

Nexium

PO: 20mg, 40 mg

IV: 20mg, 40 mg (daily or bid)

Tube: 20mg, 40 mg

PO: Protonix 40 mg po q day

IV: Protonix 20mg, 40 mg (daily or bid)

Tube: Prevacid 30mg, 60 mg ODT

11/15/1

0

Niacor, Nicotinic acid short acting Niacin (same dose)

Niaspan, Nicotinic acid ER Slo-Niacin (same dose)

Niferex- 150 Ferrous Sulfate 300 mg tid (60mg Fe

Norflex 100 mg bid Flexeril 10 mg tid

Norflex 50 mg tid Flexeril 10 mg bid

Noroxin 400 mg bid Cipro 250 mg bid

Novolin 70/30 Humulin 70/30

Novolin N Humulin N

Novolin R Humulin R

NovoLog Humalog

Novolog mix 70/30 Humalog 75/25

Nystatin Suspension (shortage) Mycelex (clotrimazole) trouche tid 2/2019

Ocuflox eye drops Ciloxan eye drops

Ofirmev (acetaminophen IV) any dose 1 gm IV q 6 hrs x 2 doses in Post-op patients only (not prn)

If < 50 kg, or 2-12 y/o, use 15 mg/kg IV q 6 hrs x 2 doses

7/2014

Optison (perflutren) Definity (perflutren), use orders # 27027 10/2014

Orudis 50 mg q6h or 75 mg tid or Naprosyn 500 mg tid

Oruvail 200 mg daily Naprosyn 500 mg tid

Oxacillin IV Nafcillin IV

Oyster Shell Calcium Oyster Shell Calcium with Vit D

Pancreatic Enzymes New starts will be with Creon

(Will not stock Pancreaze, Zenpep- use patient’s own supply)

11/2017

Parafon Forte DSC 500 mg tid/qid Flexeril 10 mg tid

Parafon Forte DSC 750 mg tid Flexeril 10 mg tid





of 22 2/7/2019

Parafon Forte DSC 750 mg qid Flexeril 10 mg qid

Paxil CR 12.5 mg , 25 mg, 37.5 mg q day Paxil 10 mg, 20 mg, 40 mg q day

PBs (premixed) q12h or q24h in dextrose Keep in dextrose (even diabetic pts)

PD (Peritoneal Dialysis) fluids:

Low magnesium

PD (Peritoneal Dialysis) fluids:

High magnesium

Pepcid IV (during shortage) 20 mg IV bid Protonix IV 40 mg IV q 24 hrs

5/2014

Pepcid IVPB or continuous infusion Pepcid IV push over 2 minutes

Pepcid and PPI together DC PPI unless it is patient’s home med, policy 7300-IV-50 11/1/10

Percocet 20mg (10mg x 2 tabs) Must call MD (obtain new order for oxycodone plus APAP)

Percocet- No strength indicated Percocet 5 mg (the 5mg is the default strength)

Percodan Percocet

Peri-colace Senekot-S

Phazyme 95 and 125 Phazyme 180

Phenylephrine eye drops During shortage situations: Cyclomydril eye drops 9/2/14

Phosphate Must follow P&T guidelines

Plamanate Albumin 5%

Plendil (felodinpine) Norvasc (amlodipine) same dose and interval 8/2016

Post-op Prophylactic antibiotics “x 3 doses” Change to “x 2 doses” to not exceed 24 hrs

Potassium Must follow P&T guidelines

PPF (plasmanate) Albumin 5%

Pramosone 1% crm, oint, lotion Hydrocortisone 1% cream, oint

Pramosone 2.5% crm, oint, lotion Hydrocortisone 2% crm or lotion

Prevacid

PO: 15-30mg, 60 mg

IV: none, use Protonix

Tube: use Prevacid ODT

PO: Protonix 20mg, 40 mg

IV: Protonix

Tube: Prevacid ODT

11/15/1

0

Prilosec po Protonix po 9/2/14

Primaxin

500 mg, 750 mg, 1gm IV any interval

250 mg IV any interval

Merrem, usual dose 1-2 gm q 8 hrs, Adjust for CrCl per 7300-VII-40A

2013

Pristiq 50 mg, 100 mg Effexor XR 37.5mg, 75 mg

Probiotic Culturelle

Procardia 10 mg (short-acting, immediate

release)

CALL MD due to increased risk of arrythmias, MI & stroke.

ALTERNATIVES:

Capoten 12.5mg-25mg po q8h prn (onset 5-25min)

Catapres 0.1-0.2mg po X 1, then 0.1 mg q1h to max 0.8mg

(onset 30-60 min)

Vasotec 1.25mg IV over 5 min then q6h prn (onset 15 min)

Normodyne 20 mg IVP over 2 min, then 40-80mg q 10 min

(onset 5-15 min)

Lopressor 2.5-5mg iv q6h

Procrit dose in ESRD Max of 30,000 units per week 3/2014

Profilnine (3 F-PCC), but will use up current

stock

Kcentra (4-F- PCC) 10/2013

Prosom Restoril 15mg-30mg (if pt >65yo then 15mg)


http://gwinnettwork/policies_active/PHARMACY/7300-VII-40A.DOC




of 22 2/7/2019

Protonix

PO: no TI

IV: no TI

Tube: 20mg, 40mg, use Prevacid ODT

PO: dispense as ordered

IV: use Protonix

Tube: Prevacid ODT 30mg, 60 mg

11/15/1

0

Protonix 40 mg “bid” Change to “Q Day”. Exceptions: GI Bleed or “bid

is patient’s home dose regimen

11/2015

Protonix IV …during shortage 40 mg IV q day

Or

40 mg IV bid

– NON-GI BLEED and IV PPI ordered:

– Pantoprazole 40 mg PO q day (BID dosing is

reserved for GI bleed and H.Pylori patients) or

– Famotidine (Pepcid®) IV or PO 20 mg BID (if CrCl

< 50 ml/min, use q day)

– GI BLEED and IV PPI Ordered

– Pantoprazole 80 mg PO BID x 2 doses, then 40 mg

PO BID or

– Lansoprazole 60 mg via NGT BID x 2 doses, then

30 mg via NGT BID

07/2017

Provigil 100mg, 200mg Nuvigil 150 mg, 250 mg 10/5/10

Psorcon 0.05% cream Temovate 0.05% cream

PV Tussin (hydrocodone) Hycodan (hydrocodone & homatropine) 9-3-13

Qvar Inhaler

40 mcg 1-2 puffs bid

80 mcg 1 puff bid

160-320 mcg 1-2 puffs bid

Pulmicort (budesonide) nebulizer

0.25 mg neb bid

0.25 mg neb bid

0.5 mg neb bid

8/13/13

11/2016

Rapaflo (silodosin) 8 mg q day Flomax (tamsulosin) 0.4 mg q day 09/2015

Relafen 1000 mg daily Naprosyn 375 mg bid

Relafen 750 mg or 1000 mg bid Naprosyn 500 mg tid

Relafen 1500 mg or 2000 mg daily Naprosyn 500 mg tid

Remeron (mirtazapine) Solutabs Use generic mirtazapine (7.5mg is no longer manufacturered) 9/8/09

Renagel (sevelamer hydrochloride) Renvela (sevelamer carbonate)

Restoril 30 mg in pt > 65yo Restoril 15mg

Rhinocort (budesonide) Flonase (fluticasone) 2 sprays in each nostril daily 5/1/12

Risperdal 0.5mg, 1mg, 2mg Risperdal-M 0.5mg, 1mg, 2mg (Orally disintegrating tablets)

Robitussin CF Call MD- recommend (psuedoephedrine + Cardec DM) +

Robitussin

Robitussin PE Call MD- recommend pseudoephedrine + robitussin

Rocephin < 1g in PEDS (any interval) Rocephin 250mg,500mg,750mg q24h (if dosing 50mg/kg round

up; if dosing 100mg/kg round down)

Rocephin (Adults and Peds) q 12 hrs

If not documented as meningitis, call physician. If not

meningitis, change to q 24 hrs.

Serax 10mg, 15mg, 30mg Ativan 0.5mg, 1mg, 2mg

Serevent MDI 2 puffs bid Serevent Discus 1 puff bid

Simcor (combo, use individual ingredients) Niacin ER plus simvastatin

Singulair 4mg Singulair 5mg

Slo-bid 100 mg, 200 mg, 300 mg bid Theo-Dur 100 mg, 200 mg , 300 mg bid

Slo-Niacin (any dose) Niaspan 500 mg qhs





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Slo-Phyllin 125 mg bid Slo-bid 125 mg bid

Slo-Phyllin 250 mg bid Theo-Dur 200 mg bid

Sodium Bicarbonate IV Shortage See Flyer Restricted Indications:

• Perfusion/Open Heart

• NICU – restrictions and conservation measures per Medical Director

• Alkalization of urine ONLY when ORAL Sodium bicarb CANNOT BE USED:

o Drug overdose: Tricyclic, salicylates, methyl alcohol, and barbiturate

o Hemolytic reactions (blood transfusion reactions/crush injuries) requiring alkalization of urine to decrease nephrotoxicity of blood pigments.

o Chemotherapy: alkalization of urine required to reduce toxicity.

• Other indications require approval from Dr J Clements, Dr M Austin, Dr B Yusuf, Dr P Kaplan, Dr D Chatoth, or Dr A Bier. Must enter the approving physician and indication in the CPOE med order comment.

Other Ordering Restrictions:

• No more partial Sodium bicarb vials. Increments of 50 mEq are only allowed (ex: 50, 100, 150 mEq/L) to avoid waste.

• Only one liter of sodium bicarb IVFs will be dispensed at a time. Nursing/pharmacy communication prior to the next bag needed. We avoid significant waste with this process.

• Pharmacists have been asked to call for clarification of any order that there may be questions about – even if an appropriate indication is documented

Alternatives to Na Bicarb IV:

• Oral Sodium Bicarbonate 650 mg tablets o Sodium Bicarb: 7 tablets (650 mg each) = 50 mEq NaHCO3 IV.

• Sodium Acetate IV can be used to replace Sodium Bicarb in IVF. o Sodium acetate 40 mEq = approximately 35 mEq of sodium

bicarb.

o Sodium acetate is on national shortage and we recommend using full 40 mEq vial (ex: 40 mEq, 80 mEq increments) to avoid waste

• Do NOT use if there is significant impairment of liver function

• Lactated Ringers, confirm the K+ level is normal, for mild acidosis.

5/2017

Sodium Phosphate IV (during shortage) If patients unable to replace via enteral route, give NaPO4 for

PO4 < 2 and K > 4.

If K < 4, use KPhosp IV

8/6/13

For patients on Electrolyte Replacement Protocol when IV

Phos replacement is necessary

• PO4 = 1.6-2.4 and K+ < 4.5: Potassium Phosphate

15 mM IVPB over 4 hours may be substituted.

• PO4 < 1.5 and K+ < 4.2: Potassium Phosphate 30

mM IVPB over 6 hours may be substituted.

12/13

(ASAP

approval

from

P&T

Chairs)





of 22 2/7/2019

• If KCl run is ordered concurrently, omit 20 mEq

KCl IV/po for every 15 mM of KPhos.

Check to see how much KCl has already been

administered.

• If K+ parameters are outside limits, call MD for

alternative instructions.

• Write order to clarify and coordinate changes

between nursing and pharmacy. Solu-Medrol IV ≤ 60 mg /day Predinsone 60 mg po q day 01/06/1

5

Sonata (zaleplon) Ambien (zolpidem)

Surfak Colace

Synalar 0.01% crm or soln Tridesilon or Desowen 0.05%

Synalar 0.025% oint Kenalog 0.025% oint,crm,lotion

Tablets Orally disintegrating tablets if same strength is available

Tagamet 200mg-400mg bid, tid or qid Pepcid 20 mg bid

Tagamet 800 mg Pepcid 40 mg qhs

Tagamet IV any dose any interval Pepcid IV 20 mg q12h

Terazol 7 Miconozole (monistat) 7

Terbutaline (Brethine) Only allowed in GWP, call MD & suggest albuterol

Tetevan (eprosartan) 200mg, 200-400mg,

600mg, 800mg

Cozaar (losartan) 25 mg , 25mg, 50 mg, 100 mg 11/1/10

Theophylline ORAL (any brand) Uniphyl (theophylline), same mg to mg, q day. Max dose is 600

mg

Comes as 400 mg and 600 mg (can be halved, but not crushed)

3/2017

Theophylline elixir Use only if clinically necessary (i.e. tube) or if you can’t get

dose close enough with tabs (rare…..renal patient on low dose)

Theophylline extended release (during

shortage situations), 600 mg max daily dose

Theophylline elixir, same total daily dose, but divided q 8 hrs.

Max daily dose is 600 mg

3/2/16

Theophylline** IV drip in any soln other than

D5W

D5W for diluent (even diabetic pt)

**exception for Drs Weinberg, McGann, Sineway and Kaplan

Theravac Plus mini-enemas Enimeez mini-enemas (this has no benzocaine) Must be unit

dosed.

Thiamine IV 100 mg daily (during shortage

situations)

Thiamine IV 500 mg IV q8h x 3 days, then

100 mg po daily (during shortage situations)

Thiamine 100 mg po daily

Thiamine 200 mg po BID x 3 days, then 100 mg po daily for

“Alcohol Withdrawal Orders”.

2/2018

Throat sprays and lozenges Cepacol spray and lozenges

Tiazac Cardizem CD

Titralac Tums

Tobi (tobramycin) for inhalation (nebulizer) Use Tobramycin vials, same dose

Topicort 0.05% gel Lidex 0.05% oint

Topicort 0.25% cr or oint Lidex 0.05% crm, oint





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Topicort LP 0.05% crm Lidex 0.05% crm

Toradol 5 day stop and must follow guidelines

Toradol 30 mg (>65yo, crcl<50,wt<50kg) Toradol 15 mg (max 60mg/day)

Toradol 60 mg IM (followed by IM doses) Toradol 30 mg (followed by IM doses)

Toviaz Detrol LA, not to exceed 2mg in patients taking strong CYP3A4

inhibitors or if CrCl < 30.

12/11/1

2

Trace element package in TPN during

shortage Addamel N (European product, approved by FDA) 10/2013

Tracleer (bosentan)

Patient to use their own home med if possible. No new starts

allowed.

Transderm Nitro patch Nitro-Dur patch

Travatan 0.004% (travoprost + benzalkonium)

Or

Travatan Z 0.004% (travoprost)

Xalatan (latanoprost) 8/6/13

Tricor 54 mg, 160 mg See Fenofibrate 9/4/12

Tridesilon 0.05% oint Kenalog 0.025% oint,crm,lotion

Triglide 50 mg, 160 mg See Fenofibrate 9/4/12

Trilipix 45mg, 135 mg See Fenofibrate 9/4/12

Tube feedings See chart at end of this document

Tussinex (hydrocodone & phenytoloxamine) Hycodan (hydrocodone & homatropine) 9-3-13

Tussi-organidin DM Robitussin DM (generic interchange)

Tuss-Organidin Robitussin AC (generic interchange)

Tylox Percocet

Ultracet Ultram 50mg plus Acetaminophen 325mg

Ultravate 0.05% cr or oint Temovate 0.05% cr or oint

Unasyn (ampicillin/sulbactam) IV shortage

During the shortage, call physician. No TI

Only during a shortage of Unasyn, call MD and recommend:

- Gynecological, use Mefoxin or Rocephin + Flagyl

- Intra-abdominal, use Mefoxin or Rocephin + Flagyl (or

Invanz alone if Cephalosporin allergy)

- Skin and Soft Tissue, use Ancef (or Invanz alone if

Cephalosporin allergy)

- Head and Neck, use Cleocin

09/2015

Univasc 15 mg and 22.5 mg Altace 5 mg

Univasc 3.75 mg, 7.5 mg, 30 mg, 60mg Altace 1.25 mg, 2.5 mg, 10 mg, 20mg (max)

Urised, 2 tabs (atropine, methenamine,

hyoscyamine, methylene blue, benzoic acid)

Uribel (methenamine, phosphate , hyoscyamine, methylene

blue)

Uroxatrol (alfuzosin) 10 mg po q day Flomax (tamsulosin) 0.4 mg po q day 12015

Urso 250mg Actigall 300mg

Utira-C Uribel (methenamine, phosphate , hyoscyamine, methylene

blue)

Valsartan (Diovan)- shortage

Diovan 40 mg

Diovan 80 mg

Diovan 160 mg

Diovan 320 mg

To Cozaar (Losartan)

Cozaar 25 mg

Cozaar 25 mg

Cozaar 50 mg

Cozaar 100 mg

7/2018


http://www.thomsonhc.com/hcs/librarian/ND_T/HCS/ND_PR/Main/CS/FF40D6/DUPLICATIONSHIELDSYNC/D99BC3/ND_PG/PRIH/ND_B/HCS/SBK/4/ND_P/Main/PFPUI/7M129692mBIus7/PFActionId/hcs.common.RetrieveDocumentCommon/DocId/0036/ContentSetId/31/SearchOption/BeginWith





http://www.thomsonhc.com/hcs/librarian/ND_T/HCS/ND_PR/Main/CS/FF40D6/DUPLICATIONSHIELDSYNC/D99BC3/ND_PG/PRIH/ND_B/HCS/SBK/2/ND_P/Main/PFPUI/7M129692mBHYW0/PFActionId/hcs.common.RetrieveDocumentCommon/DocId/0119/ContentSetId/31/SearchOption/BeginWith













of 22 2/7/2019

Valisone 0.1% crm or lotion Kenalog 0.025% oint,crm,lotion

Valisone 0.1% oint Diprosone 0.05% oint

Vancomycin post op orders “x 2 doses” Vancomycin post op doses “x 1 dose” 02/11

Vancomycin 250 mg po Vancomycin 125 mg po q 6 hrs

Vancomycin 500 mg po NEW STARTS are restricted to Critical

Care areas, but can continue upon transfer. Consider de-

escalation after 3 days.

7/3/18

Vasolex ointment (DC by manufacturer) Venelex (trypsin free) ointment 9/2015

Vasotec Lisinopril – same dose

Vasotec IV Formulary- dispense

Venofer 100mg Ferrlicet 125 mg in 100ml NS over 1 hr 10/09

Venofer 200mg Ferrlicet 250mg in 150-200 ml NS over 2 hrs 10/09

Veramyst (fluticasone) Flonase (fluticasone) 2 sprays in each nostril daily 5/1/12

Verelan

120 mg po qAM

180 mg po qAM

240 mg po qAM

360 mg po qAM

480 mg po qAM






8/14

Verelan PM

100 mg po qHS

200 mg po qHS

300 mg po qHS

400 mg po qHS



Verapamil ER capsules 300 mg (1 x 120 + 1 x 180 mg) po qAM


8/14

Vigamox eye drops 3% Ciprofloxacin eye drops 3%

Vitamins See chart at end of this document

Vitamin K route: IM or Sub Q

(EXCEPTION: Neonates may receive IM)

If ordered IM and patient is npo, give SQ.

If ordered IM and patient can take orals, give po

10/12

Voltaren 25mg-50mg q6-8h Naprosyn 500 mg bid

Voltaren XR 75 mg bid Naprosyn 500 mg bid

Vytorin (combo, use individual agents) Zetia plus simvastatin 9/4/12

Wellbutrin SR Wellbutrin XL (same total dose, administered q day)

(maximum of 400mg/day)

Westcort 0.2% crm or lotion Kenalog 0.025% oint,crm,lotion

Xanax XR –Daily (same total daily dose) Xanax tid (same total daily dose)

Xifaxan (rifaximin) 400 mg tid Xifaxan 550 mg bid 5/10/11

Xopenex q 2hrs, q 4 hrs Q 6 hrs

Xyzal (levocetirizine) 5 mg daily Allergra 180 mg daily. 9/8/09

Zantac IV 150mg/day (ie 50mg q8h or LV) Pepcid IV 20 mg q12h

Zantac PO 75mg any interval Pepcid 10mg bid

Zantac PO 150, 300 mg Pepcid 20 mg bid, 40 mh q hs

Zinacef (750mg-1.5mg q 8hr) Rocephin 1gm q 24hr

Zofran po Using ODT exlusively 12/09

Zomig 2.5 mg, 5 mg Imitrex 50 mg, 100 mg





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Zosyn any dose for CrCl > 20 Zosyn 3.375 gm q 8 hr over 4 hrs if CrCl is > 20

Zyban Wellbutrin SR

Zyrtec 5 or 10 mg daily Claritin 10 mg

Zytrec D Claritin D

Verapamil products: do not stock SR tablets Calan Verapamil IR same dose and schedule 8/14

Isoptin Verapamil IR same dose and schedule 8/14

Calan SR

120 mg po daily

180 mg po daily

240 mg po daily

360 mg po daily

120 mg po BID

180 mg po BID

240 mg po BID









8/14

Isoptin SR

120 mg po daily

180 mg po daily

240 mg po daily

360 mg po daily

120 mg po BID

180 mg po BID

240 mg po BID





Verapamil ER capsules 360 mg (2 x180 mg) po qAM




8/14

Covera-HS

180 mg po qHS

240 mg po qHS

360 mg po qHS

480 mg po qHS





8/14

Verelan

120 mg po qAM

180 mg po qAM

240 mg po qAM

360 mg po qAM

480 mg po qAM






8/14

Verelan PM

100 mg po qHS

200 mg po qHS

300 mg po qHS



Verapamil ER capsules 300 mg (1 x 120 + 1 x 180 mg) po qAM

8/14





of 22 2/7/2019

400 mg po qHS Verapamil ER capsules 360 mg (2 x 180 mg) po qAM

If “Per tube”

ER 480 mg = immediate release 120 mg (1 x 80 mg + 1 x 40 mg tab) QID

ER 360 mg = immediate release 120 mg (1 x 80 mg + 1 x 40 mg tab) TID

ER 240 mg = immediate release 80 mg tab TID

ER 180 mg = immediate release 60 mg (1 and ½ X 40 mg tab) TID

ER 120 mg = immediate release 40 mg tab TID

8/14

Enteral and Tube feeding TI Chart

Nonformulary Formulary

Boost Ensure Complete

Ensure Plus Ensure Complete

Ensure Ensure Complete

Ensure Pudding Ensure Pudding

Fibersource Jevity 1.2

Glytrol oral Glucerna Shakes

Glucerna oral Glucerna Shakes

Glytrol Glucerna 1.2

HepaticAid oral Osmolite 1.5

Hepatic Aid TF Osmolite 1.5

Impact Glutamine Vital High Protein

Impact Vital High Protein

Isosource 1.0 Osmolite 1.5

Isosource 1.2 Osmolite 1.5

Jevity oral Ensure Complete

Nutren 1.0 TF Osmolite 1.5

Nutren 1.0 oral Ensure Complete

Nutren 2.0 TwoCal HN

Nutren Jr. oral Pediasure

Nutren Jr. TF Pediasure

Nutren Pulmonary TF Osmolite 1.5

Nutren Pulmonary Oral Osmolite 1.5

Nutren Renal Nepro

Nutrihep oral Osmolite 1.5

Nutrivent Osmolite 1.5

Osmolite 1.0 Osmolite 1.5

Optimental Vital AF 1.2

Oxepa Pivot





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Peptamen Vital AF 1.2

Promod Beneprotein

Pulmocare oral Ensure Complete

Pulmocare TF Osmolite 1.5

Replete oral Ensure Complete

Suplena Nepro

TwoCal HN oral TwoCal HN cans

Vital HN oral Vital AF 1.2 cans

Vivonex Vital AF 1.2

Inhalation Medication TI (see policy 7300-VII-60) The exceptions to this policy include:

• Patients who receive inhalers at home and are admitted for non-respiratory issues.

Pharmacy will implement the initial interchange on all, however Respiratory

Care will evaluate for “non-respiratory issues and order MDI if needed.

• Locations: NICU, GWP, ED and CEC, Glancy Rehab, GECC

Ordered

Metered Dose Inhaler (MDI): Note: HFA = hydrofluoroalkane,

propellant in the inhaler

Pharmacy Will Dispense

Nebulized Medications: All nebulizer meds will be administered as unit dose

or diluted with saline with other medication to a

total volume of at least 2.5 ml

Albuterol

(Proventil, Ventolin, Proair) HFA

Albuterol 2.5 mg at the same scheduled frequency

PLUS

Albuterol 2.5 mg q 4 hrs PRN for SOB and wheezing.

Albuterol/ Ipratropium

(Combivent or Respimat)

Albuterol 2.5 mg & Ipratropruim 0 .5 mg at the same

scheduled frequency

PLUS

Albuterol 2.5 mg q 4 hrs PRN for SOB and wheezing .

Dulera (formoterol and mometasone)

100 mcg/5 mcg or 200 mcg/5 mcg

Pulmicort (budesonide )

0.25 mg or 0.5 mg BID

PLUS

Brovana (aformoterol) 15 mcg BID This should never

be PRN.

Budesonide & Formoterol HFA

(Symbicort 80/4.5)

Pulmicort (budesonide ) 0.25 mg BID

PLUS

Brovana (aformoterol) 15 mcg BID

This should never be PRN.

Budesonide & Formoterol HFA

(Symbicort 160/4.5)

Pulmicort (budesonide ) 0 .5 mg BID

PLUS



Fluticasone and Salmeterol HFA Pulmicort (budesonide ) 0.25 mg BID





of 22 2/7/2019

(Advair 45/21)

PLUS



Fluticasone and Salmeterol HFA

(Advair 115/21)

Pulmicort (budesonide ) 0.5 mg BID

PLUS



Fluticasone and Salmeterol HFA

(Advair 230/21)

Pulmicort (budesonide ) 0 .5 mg BID

PLUS



Fluticasone HFA

(Flovent 110 or 44 mcg)

Pulmocort (budesonide) 0.25 mg BID

Fluticasone HFA

(Flovent 220 mcg)

Pulmicort (budesonide) 0.5 mg BID

Ipratropium HFA (Atrovent)

Ipratropium 0.5 mg at the same frequency

Levalbuterol HFA (Xopenex) Xopenex 1.25 mg at the same frequency

PLUS

Xopenex 1.25 mg q 6 hrs PRN for SOB and wheezing.

Tiotropium (Spiriva)

Atrovent 0.5 mg qid

Other Interchanges:

Ordered:

Dispensed:

Mucomyst (acetylcysteine)

and

Neut (4% sodium bicarbonate )

or

Pulmozyme (dornase)

- DC Mucomyst, continue Neut or Pulmozyme

- Do not mix Pulmozyme with other nebulized medications.

Also administer separately in the nebulizer.

VITAMIN and IRON chart

Vitamins/Iron Product NON-FORMULARY

Examples of non-form products MD might order

(use TI to left of product)

T.I.

(Therapeutic Interchange)

VITAMINS

Multi Centrum, Ocuvite, Ocuvite with lutein any

standard Multivitamin

Thera-Tab

Geriatric or Minerals Centrum silver, Optivite, any multivitamin with

minerals

Thera-M

B-12 and/or intrinsic factor

Folic Acid and/or IRON

Chromagen** Hemocyte F, Chromagen FA**, Folbic, Folbee, Foltx,

Hemocyte Plus, Hemocyte F, Proferrin Forte, Ferocon,

Niferex 150 Forte

Ferrex Forte 150





of 22 2/7/2019

PRENATAL-Calcium and

IRON

Stuartnatal 1+1, any prenatal vitamin Prenatal Plus

RENAL Nephrocap, Metanx, Dialyvite, Diatx, Nephplex Nephro-vite

B complex w/ C vitamin

(stress/substance abuse)

Vicon C (discontinued), Allbee C Folbee CZ

Iron products

(no vitamin component)

Also see Vitamin with iron products above

Proferrin ES

Ferrous Sulfate 325 mg

(65 mg elemental iron) OR

Ferrous Gluconate (27 mg

elemental iron)

* Chewable form available for plain and prenatal MVI

** Trinsicon, Chromagen and Chromagen FA are no longer made by the manufacturer

Artificial Tears Generic Equivalent Brands GMC Stocks: Carboxymethylcellulose

1%

TheraTears Gel

Refresh Liquigel

Lubricant Eye Gel (does not indicate Pres Free)

Hypromellose eye drop

Nature Tears

Mineral Oil

White Petrolatum

AWKA Tears Opth Oint

LubriFresh P.M. Oint

(if ointment not available, TI to 1-2 drops in each eye)

Artificial Tears Oint

or

Refresh P.M. Oint

Lubricant eye oint, Preservative Free

Polyvinyl Alcohol 1.4% Liquifilm Tears Drops Artificial Tears Soln

Lubricant Eye Drops, (contains Preservative)


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