Lexi Comps Drug Information Handbook 17th Edition

Brough to you by
NOTICE
Lexi-Drugs Online
This data is intended to serve the user as a handy reference and not as a complete drug information resource. It does not include information on every
therapeutic agent available. The publication covers over 1700 commonly used drugs and is specifically designed to present important aspects of drug data
in a more concise format than is typically found in medical literature or product material supplied by manufacturers.
The nature of drug information is that it is constantly evolving because of ongoing research and clinical experience and is often subject to
interpretation. While great care has been taken to ensure the accuracy of the information and recommendations presented, the reader is advised that
the authors, editors, reviewers, contributors, and publishers cannot be responsible for the continued currency of the information or for any errors,
omissions, or the application of this information, or for any consequences arising therefrom. Therefore, the author(s) and/or the publisher shall have
no liability to any person or entity with regard to claims, loss, or damage caused, or alleged to be caused, directly or indirectly, by the use of
information contained herein. Because of the dynamic nature of drug information, readers are advised that decisions regarding drug therapy must be
based on the independent judgment of the clinician, changing information about a drug (eg, as reflected in the literature and manufacturer's most
current product information), and changing medical practices. Therefore, this data is designed to be used in conjunction with other necessary
information and is not designed to be solely relied upon by any user. The user of this data hereby and forever releases the authors and publishers of
this data from any and all liability of any kind that might arise out of the use of this data. The editors are not responsible for any inaccuracy of
quotation or for any false or misleading implication that may arise due to the text or formulas as used or due to the quotation of revisions no longer
official.
Certain of the authors, editors, and contributors have written this book in their private capacities. No official support or endorsement by any federal or
state agency or pharmaceutical company is intended or inferred.
The publishers have made every effort to trace any third party copyright holders, if any, for borrowed material. If they have inadvertently
overlooked any, they will be pleased to make the necessary arrangements at the first opportunity.
If you have any suggestions or questions regarding any information presented in this data, please contact our drug information
pharmacists at
1-877-837-LEXI (5394)
Copyright © 2007 by Lexi-Comp Inc. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, used as a source of information for transcription into a hospital information
system or electronic health or medical record, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the publisher. Should you or your institution have a need for this information in a format we protect,
we have solutions for you. Please contact our office at the number below.
This information was produced using Lexi-Comp's Information Management System™ (LIMS) — Acomplete publishing service of Lexi Comp Inc.
Copyright (c) Lexi-Comp, Inc. 1978-2009 All Rights Reserved.

EDITORIAL ADVISORY PANEL
Lexi-Drugs Online
Judith A. Aberg, MD
Principal Investigator, AIDS Clinical Trials Unit
Director of HIV
Bellevue Hospital Center
Associate Professor of Medicine
New York University
New York, New York
William Alvarez Jr., BS, PharmD, RPh
Pharmacotherapy Specialist
Lexi-Comp, Inc
Hudson, Ohio
Lora Armstrong, RPh, PharmD, BCPS

Vice President, Clinical Affairs
Pharmacy & Therapeutics Committee Formulary Process
Clinical Program Oversight
CaremarkRx
Northbrook, Illinois
Kenneth A. Bachmann, PhD, FCP
Distinguished University Professor of Pharmacology
Codirector, Center for Applied Pharmacology
University of Toledo
Toledo, Ohio
Verna L. Baughman, MD
Professor
Anesthesiology and Neurosurgery
University of Illinois
Chicago, Illinois
Judith L. Beizer, PharmD, CGP, FASCP
Clinical Professor
Department of Clinical PharmacyPractice
St John's University College of Pharmacy and Allied Health Professions
Jamaica, New York
Mark F. Bonfiglio, BS, PharmD, RPh
Chief Content Officer
Lexi-Comp, Inc
Hudson, Ohio
Diedra L. Bragalone, BSPharm, BCOP

Lexi-Comp, Inc
Hudson, Ohio
Larisa H. Cavallari, PharmD, BCPS
Assistant Professor
Department of PharmacyPractice
Chicago, Illinois
Irene H. Chenowith, MD, FACP
Medical Director of Professional Affairs
Akron General Medical Center
Akron, Ohio
Associate Professor of Internal Medicine
Northeastern Ohio Universities
College of Medicine
Rootstown, Ohio
Matthew M. Cooney, MD
Hematology/Oncology
University Hospitals of Cleveland
Cleveland, Ohio
Harold L. Crossley, DDS, PhD
Associate Professor of Pharmacology
Baltimore College of Dental Surgery
Dental School
University of Maryland Baltimore
Baltimore, Maryland
Melanie Cucchi, PharmD
Lexi-Comp, Inc
Hudson, Ohio
Laura Cummings, PharmD, BCPS
Clinical Pharmacy Specialist, Pediatrics
The Children's Hospital at MetroHealth
Cleveland, Ohio
Julie A. Dopheide, PharmD, BCPP
Associate Professor of Clinical Pharmacy, Psychiatry and the Behavioral Sciences
University of Southern California
Schools of Pharmacy and Medicine
Los Angeles, California

Michael S. Edwards, PharmD, MBA
Chief, Oncology Pharmacy
Director, Oncology Pharmacy Residency Program
Walter Reed Army Medical Center
Washington, D.C.
Vicki L. Ellingrod, PharmD, BCPP
Associate Professor
University of Iowa
Iowa City, Iowa
Kelley K. Engle, BSPharm
Lexi-Comp, Inc
Hudson, Ohio
Erin Fabian, PharmD, RPh
Lexi-Comp, Inc
Hudson, Ohio
Margaret A. Fitzgerald, MS, APRN, BC, NP-C, FAANP
President
Fitzgerald Health Education Associates, Inc.
North Andover, Massachusetts
Family Nurse Practitioner
Greater Lawrence Family Health Center
Lawrence, Massachusetts
Lawrence A. Frazee, PharmD
Pharmacotherapy Specialist in Internal Medicine
Akron General Medical Center
Akron, Ohio
Matthew A. Fuller, PharmD, BCPS, BCPP, FASHP
Clinical Pharmacy Specialist, Psychiatry
Cleveland Department of Veterans Affairs Medical Center
Brecksville, Ohio
Associate Clinical Professor of Psychiatry
Clinical Instructor of Psychology
Case Western Reserve University
Cleveland, Ohio
Adjunct Associate Professor of Clinical Pharmacy
University of Toledo
Toledo, Ohio
Morton P. Goldman, RPh, PharmD, BCPS, FCCP

Director of Pharmacotherapy Services
The Cleveland Clinic Foundation
Cleveland, Ohio
Julie A. Golembiewski, PharmD
Clinical Associate Professor
Colleges of Pharmacy and Medicine
Clinical Pharmacist, Anesthesia/Pain
Chicago, Illinois
Jeffrey P. Gonzales, PharmD, BCPS
Critical Care Clinical Pharmacy Specialist
University of Maryland Medical Center
Baltimore, Maryland
Roland Grad, MDCM, MSc, CCFP, FCFP
Department of Family Medicine
McGill University
Montreal, Quebec, Canada
Larry D. Gray, PhD, ABMM
Director of Clinical Microbiology
TriHealth
Bethesda and Good Samaritan Hospitals
Cincinnati, Ohio
Tracy Hagemann, PharmD
Associate Professor
College of Pharmacy
The University of Oklahoma
Oklahoma City, Oklahoma
Martin D. Higbee, PharmD
Associate Professor
Department of PharmacyPractice and Science The
University of Arizona
Tucson, Arizona
Jane Hurlburt Hodding, PharmD
Director, Pharmacy
Miller Children's Hospital
Long Beach, California
Mark T. Holdsworth, PharmD, BCOP Associate
Professor of Pharmacy & Pediatrics Pharmacy
Practice Area Head
College of Pharmacy
The University of New Mexico
Albuquerque, New Mexico
Collin A. Hovinga, PharmD
Assistant Professor of Pharmacy and Pediatrics
College of Pharmacy
University of Tennessee Health Science Center
Memphis, Tennessee
Darrell T. Hulisz, PharmD
Department of Family Medicine
Cleveland, Ohio
Michael A. Kahn, DDS
Professor and Chairman
Department of Oral and Maxillofacial Pathology
Tufts UniversitySchool of Dental Medicine
Boston, Massachusetts
Polly E. Kintzel, PharmD, BCPS, BCOP
Clinical Pharmacy Specialist-Oncology
Spectrum Health
Grand Rapids, Michigan
Daren Knoell, PharmD

Associate Professor of Pharmacy Practice and Internal Medicine
Davis Heart and Lung Research Institute
The Ohio State University
Columbus, Ohio
Sandra Knowles, RPh, BScPhm
Drug Safety Pharmacist
Sunnybrook and Women's College HSC
Toronto, Ontario
Jill M. Kolesar, PharmD, FCCP, BCPS
Associate Professor
School of Pharmacy
Associate Professor
University of Wisconsin Paul P. Carbone Comprehensive Cancer Center
University of Wisconsin
Madison, Wisconsin
Donna M. Kraus, PharmD, FAPhA
Associate Professor of Pharmacy Practice

Departments of PharmacyPractice and Pediatrics Pediatric Clinical Pharmacist
Chicago, Illinois
Daniel L. Krinsky RPh, MS
Manager, MTM Services
Giant Eagle Pharmacy
Ravenna, Ohio
Assistant Professor
Department of PharmacyPractice
College of Pharmacy NEOUCOM
Rootstown, Ohio
Kay Kyllonen, PharmD
Clinical Specialist
The Cleveland Clinic Children's Hospital Cleveland, Ohio
Charles Lacy, MS, PharmD, FCSHP
Vice President for Executive Affairs
Professor, Pharmacy Practice
Professor, Business Leadership
University of Southern Nevada
Las Vegas, Nevada
Brenda R. Lance, RN, MSN
Program Development Director
Northcoast HealthCare Management Company Northcoast Infusion Network
Beachwood, Ohio
Leonard L. Lance, RPh, BSPharm
Clinical Pharmacist
Lexi-Comp, Inc
Hudson, Ohio
Jeffrey D. Lewis, PharmD
Giant Eagle
Canal Fulton, Ohio
Laurie S. Mauro, BS, PharmD
Professor of Clinical Pharmacy
College of Pharmacy
Adjunct Associate Professor of Medicine College of Medicine
The University of Toledo
Toledo, Ohio
Vincent F. Mauro, BS, PharmD, FCCP
Professor of Clinical Pharmacy College
of Pharmacy
Adjunct Professor of Medicine
College of Medicine
The University of Toledo
Toledo, Ohio
Barrie McCombs, MD, FCFP
Medical Information Service Coordinator
The Alberta Rural Physician Action Plan
Calgary, Alberta, Canada
Timothy F. Meiller, DDS, PhD
Professor
Diagnostic Sciences and Pathology
Professor of Oncology
Greenebaum Cancer Center
Baltimore, Maryland
Michael A. Militello, PharmD, BCPS
Clinical Cardiology Specialist
Department of Pharmacy
Cleveland, Ohio
Julie Miller, PharmD
Pharmacy Clinical Specialist, Cardiology
Columbus Children's Hospital
Columbus, Ohio
Tom Palma, MS, RPh
Lexi-Comp, Inc
Hudson, Ohio
Susie H. Park, PharmD, BCPP Assistan
Professor of Clinical Pharmacy University
of Southern Califormia Los Angeles,
California
Alpa Patel, PharmD

Antimicrobial Clinical Pharmacist
University of Louisville Hospital
Louisville, Kentucky
Deidre Payne, PharmD
Assistant Professor, Department of Pharmacy Practice
Hampton UniversitySchool of Pharmacy
Hampton, Virginia
Luis F. Ramirez, MD
Adjunct Associate Professor of Psychiatry
Cleveland, Ohio
A.J. (Fred) Remillard, PharmD
Assistant Dean, Research and Graduate Affairs
College of Pharmacy and Nutrition
University of Saskatchewan
Saskatoon, Saskatchewan
Martha Sajatovic, MD
Professor of Psychiatry
Cleveland, Ohio
Department of Psychiatry
University Hospitals of Cleveland
Cleveland, Ohio
Jennifer K. Sekeres, PharmD, BCPS
Infectious Diseases Clinical Specialist
Cleveland, Ohio
Todd P. Semla, PharmD, BCPS, FCCP, AGSF
Clinical Pharmacy Specialist
Department of Veterans Affairs
PharmacyBenefits Management Services
Associate Professor, Clinical
Department of Medicine and Psychiatry and Behavioral Health
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Joe Snoke, RPh, BCPS
Manager
Core Pharmacology Group
Lexi-Comp, Inc
Hudson, Ohio
Dominic A. Solimando, Jr, MA, FAPhA, FASHP, BCOP
Oncology Pharmacist
President, OncologyPharmacyServices, Inc
Arlington, Virginia
Joni Lombardi Stahura, BS, PharmD, RPh
Lexi-Comp, Inc
Hudson, Ohio
Dan Streetman, PharmD, RPh
Lexi-Comp, Inc
Hudson, Ohio
Darcie-Ann Streetman, PharmD, RPh
Lexi-Comp, Inc
Hudson, Ohio
Carol K. Taketomo, PharmD
Director of Pharmacy and Nutrition Services
Children's Hospital Los Angeles
Los Angeles, California
Mary Temple, PharmD
Pediatric Clinical Research Specialist
Hillcrest Hospital
Mayfield Heights, Ohio
Elizabeth A. Tomsik, PharmD, BCPS
Manager
Adverse Drug Reactions Group
Lexi-Comp, Inc
Hudson, Ohio
Dana Travis, RPh
Lexi-Comp, Inc
Hudson, Ohio
Jennifer Trofe, PharmD
Clinical Transplant Pharmacist
Hospital of The University of Pennsylvania

Philadelphia, Pennsylvania
Beatrice B. Turkoski, RN, PhD

Associate Professor, Graduate Faculty,
Pharmacology for Advanced Practice Nurses
College of Nursing
Kent State University
Kent, Ohio
Amy Van Orman, PharmD
Lexi-Comp, Inc
Hudson, Ohio
Christine Weinstein, BS, RPh
Lexi-Comp, Inc
Hudson, Ohio
David M. Weinstein, PhD, RPh
Manager
Metabolism, Interactions, and Genomics Group
Lexi-Comp, Inc
Hudson, Ohio
Anne Marie Whelan, PharmD
College of Pharmacy
Dalhouise University
Halifax, Nova Scotia
Nathan Wirick, PharmD
Infectious Disease and Antibiotic Management Clinical Specialist
Hillcrest Hospital
Cleveland, Ohio
Richard L. Wynn, BSPharm, PhD
Professor of Pharmacology
Dental School
Baltimore, Maryland

PREFACE
Lexi-Drugs Online
We are fortunate to live in an age where medications are readily available to prevent, treat, and cure a wide variety of conditions. Drugs can also
improve the quality of life and prolonging independence. Pharmaceutical innovation continues, and new medications will continue to play an important
role in improving the health.
However, new discoveries continue to increase the complexity of medical treatment, as well as monitoring of response. This complexity of therapy
often increases the potential for interactions, adverse reactions, and medication errors. Healthcare providers must continually assess the potential
risks and benefits of individual medications, as well as the complete therapeutic regimen as it relates to an individual patient.
New molecular entities, new warnings, new interactions and additional drug experience continue to expand, presenting a challenge to maintain a
current knowledge base concerning medications. It remains the goal of the authors of Lexi-Comp, Inc to provide you, the user, with the critical
information regarding pharmacology and the therapeutic use of drugs in a concise compendium, designed for ease of use by a variety of healthcare
professionals. We trust you find the information useful and balanced, and further hope it will assist you in your therapeutic decision-making and drug-
therapy monitoring.

DESCRIPTION OF FIELDS
Lexi-Drugs Online
Generic Name U.S. or Canadian adopted name.
The FDA-approved labeling includes a boxed warning.

See Warnings/Precautions section for a concise
ALERT: U.S. Boxed Warning Special Alerts Important information (new warnings, adverse reactions, etc) to be conveyed
to clinicians expeditiously.
In an effort to promote the safe use of medications, this field is intended to

highlight possible sources of medication errors such as sound-alike/look-alike
drugs or highly concentrated formulations which require vigilance on the part
of healthcare professionals. In addition, medications which have been
associated with severe consequences in the event of a medication error are
Medication Safety Issue also identified in this field.
summary of this information. For verbatim wording of the boxed warning,
consult the product labeling or www.fda.gov.
Pronunciation Phonetic pronunciation guide.
Brand Names
U.S. Brand NamesTrade names found in the United States (manufacturer-

specific).
Canadian Brand Names Trade names found in Canada.
Pharmacologic Category Unique systematic classification of medications. Uses
Information pertaining to approved FDA- or Canadian

Use: Labeled Indications approved indications for the drug.
Use: Unlabeled/InvestigationalInformation pertaining to unlabeled or investigational

indications of the drug.
Use: DentalInformation pertaining to appropriate dentistry-specific indications of the drug.
Dosages
Dosing:
• Adults
• Elderly • Combination Regimens
• Pediatric • Calculations
• Renal Impairment • Hepatic Impairment

Oncology: Bone Marrow - High Dose
The amount of the drug to be typically given or taken during therapy for
children and adults; also includes any dosing adjustment/comments for renal
impairment or hepatic impairment and other suggested dosing adjustments
Administration and Storage Issues Administration:
(eg, hematological toxicity). Combination regimens identify how the drug may
be used in combination with other agents for the treatment of neoplastic
disease. Calculations relevant
• I.M.
• Adjustment for Toxicity
• I.V. Chemotherapy doses 1.5- to 30-fold greater than standard dosages.
Nonhematologic adverse reactions are dose-limiting.
• I.V. Detail
• Oral
• Inhalation
• Topical
• Other
to dosing are also provided.
Information regarding the recommended final concentrations, rates of

administration for parenteral drugs, or other guidelines when giving the
medication.
Dietary Considerations Specific dietary modifications and/or restrictions. Information
regarding storage and stability of product
Storage
Reconstitution
Compatibility
ExtemporaneouslyPrepared Warnings & Precautions
Restrictions
and reconstitution guidance (where necessary). Provides the time and
conditions for which a solution or mixture will maintain full potency. For
example, some solutions may require refrigeration after reconstitution while
stored at room temperature prior to preparation. Also includes compatibility
information, when available, for admixtures, Y-site administration, and syringe
storage.
Directions for preparing liquid formulations from solid drug products. May
include stability information and references.
The controlled substance classification from the Drug Enforcement Agency

(DEA). U.S. schedules are I-V. Schedules vary by country and sometimes
state (eg, Massachusetts uses I-VI). May also include restricted availability
information.
ContraindicationsInformation pertaining to inappropriate use of the drug as dictated by
approved labeling.
Information relating to spectrum of reactions noted

Allergy Considerations Warnings/Precautions
with a true drug allergy; also describes timing of reactions, potential for cross-hypersensitivity, and patient management considerations.
Precautionary considerations, hazardous conditions related to use of the drug, and disease states or patient populations in which the drug should be
cautiously used. Boxed warnings, when present, are clearly identified and are adapted from the FDA approved labeling. Consult the product labeling for the
exact black box warning through the manufacturer's or
the FDA website.
Geriatric Considerations Pertinent information specific to older adults. Pregnancy&
Lactation
Five categories established by the FDAto indicate the

Pregnancy Risk Factor potential of a systemically absorbed drug for causing risk to fetus.
Asummary of human and/or animal information pertinent to or associated with

the use of the drug as it relates to clinical effects on the fetus, newborn, or
pregnant women.
Pregnancy Considerations
Indicates if the drug listed in the monograph is present in breast milk and the
manufacturers recommendation for use while breast-feeding (where
recommendation of American Academy of Pediatrics differs, notation is
made).
Lactation
Information pertinent to or associated with the human use of the drug as it
relates to clinical effects on the nursing infant or postpartum woman.
Detailed information on the effects of the medication on the fetus, newborn,

Breast-feeding Considerations and/or breast-feeding infant, as well as use of the drug in pregnant and
postpartum women.
Pregnancy& Lactation, In
Depth
Side effects are grouped by percentage of incidence (if known) and/or body
system, <1% effects are grouped only by percentage (Note: Includes
postmarketing and/or case report information if available).
Adverse Reactions
Adverse Reactions Indicates whether the drug is considered to be a vesicant and likely to cause
significant morbidity if the infusion infiltrates soft tissues.
Oncology-related Reactions Oncology: Vesicant
Oncology: Emetic Potential Likelihood that the drug will cause nausea or vomiting.
Oncology: Bone Marrow - Metabolism/Transport Effects

Unique Toxicity Nonhematologic adverse reactions that occur commonly with, or are unique
to, high-dose chemotherapy administration.
Interactions
If a drug has demonstrated involvement with cytochrome P450 enzymes, or Ethanol/Nutrition/Herb Interactions
other metabolism or transport proteins, this field will identify the drug as an between the drug listed in the monograph and other drugs or drug classes.
inhibitor, inducer, or substrate of the specific enzyme(s) (eg, CYP1A2 or Following a description of the interaction for a drug class, any drugs from that
UGT1A1). CYP450 isoenzymes are identified as substrates (minor or major), class which are NOT likely to cause a similar interaction with the monograph
inhibitors (weak, moderate, or strong), and inducers (weak or strong). drug are listed as exceptions. Lastly, the significance of the interaction is
identified in the form of a risk rating. Abrief description of the rating system is
as follows (please note that the risk levels of A and B exist, reflecting no
This field presents a description of the interaction known interactions or clinically-insignificant interactions, respectively;
however, for brevity, these interactions are not displayed in printed form: Risk
C: Monitor therapy – data demonstrate that the specified agents may interact
with each other in a clinically-significant manner, but the benefits of
concomitant use usually outweigh any risks. An appropriate monitoring plan
should be implemented to identify potential negative effects and dosage
adjustments may be needed in a minority of patients. Risk D: Consider
therapy modification - data demonstrate that the specified agents may
interact with each other in a clinically significant manner and patient-specific
assessment must be conducted to determine whether the benefits of
concomitant therapy outweigh the risks. Specific actions must be taken in
order to realize the benefits and/or minimize toxicity of concomitant use. Risk
X: Avoid combination - data demonstrate that the specified agents may
interact with each other in a clinically-significant manner and the risk
generally outweighs any potential benefit. Concurrent use of these agents is
generally considered contraindicated.
Drug Interactions
Presents a description of the interaction between the drug listed in the
monograph and ethanol, food, or herb/nutraceuticals.
Test Interactions Listing of assay interferences when relevant. Patient & Therapy
Management
Laboratory tests and patient physical parameters that

Monitoring Parameters should be monitored for safety and efficacy of drug therapy.
Reference RangeTherapeutic and toxic serum concentrations listed including peak and
trough levels.
Nursing Considerations
Monitoring guidelines for laboratory tests and patient

Nursing: Physical physical parameters; includes caregiver guidance relating to administration
Assessment/Monitoring issues and patient teachings that facilitate safe and efficacious therapy.
Monitoring: Lab TestsSuggested laboratory tests to monitor for safety and efficacy of
the drug.
Patient Education Specific information pertinent for the patient. Preparations
Provides availability information on products that have

been approved by the FDA, but not yet available for
Product Availability Dosage Forms
use. Estimates for when a product may be available are included, when this also provide any unique or critical drug availability issues (eg, drug shortage
information is known. May of a critical drug).
Information with regard to form, strength, and availability of the drug. Note:
Additional formulation information (eg, excipients, preservatives) is included
when available. Please consult product labeling for further information.
Generic Available Indicates availability of generic product(s).
ManufacturerIdentifies product manufacturer only if there is a sole supplier.
Pricing: U.S. Pharmacology& Pharmacokinetics

(www.drugstore.com) Third party supplier of drug pricing based on estimated average retail prices.
Mechanism of Action How the drug works in the body to elicit a response.
The magnitude of a drug's effect depends on the drug

concentration at the site of action. The
pharmacodynamics are expressed in terms of onset
of action and duration of action. Pharmacokinetics are
Pharmacodynamics/Kinetics Pearls and Related Information expressed in terms of absorption, distribution (including appearance in breast
milk and crossing of the placenta), protein binding, metabolism,
bioavailability, half-life, time to peak serum concentration, and elimination.
Related InformationCross-reference links to other pertinent, related drug information.
PharmacotherapyPearlsInformation about sodium content and/or pertinent information

about specific brands.
Dental Info
Dental Health Professional Considerations Specific information for the mental health professional relative to the impact
on psychiatric treatment.
Mental Health:
Child/Adolescent
Dental Health: Effects on Dental Treatment
Considerations
Dental Health:
Vasoconstrictor/Local
Anesthetic Precautions Cardiovascular Considerations
Mental Health Info
Anesthesia and Critical Care Concerns/Other

Mental Health: Effect on Considerations
Mental Status
Oncology: Bone Marrow Comments

Mental Health: Effect on Specific information for the mental health professional relative to clinical trials
Psychiatric Treatment for children and adolescent patients.
Pharmacology-related comments and considerations relevant to the dental
professional.
This field provides a focused summary of some of the important issues
Specific information for the dental professional on how drug therapy affects concerning cardiovascular applications, outcomes, side effects, interactions,
the dental treatment/diagnosis with suggested management approaches. and recent developments relevant to the drug.
Specific information for the dental health professional to prevent potential This field provides a focused summary of some of the important issues
drug interactions related to anesthesia. concerning anesthesia and critical care applications relevant to the drug;
other additional information may be included.
Additional information relating to myelosuppressive toxicities anticipated with

the drug.
Specific information for the mental health professional indicating pertinent
drug effects which may affect or alter a patient's mental status.
Index TermsOther names or accepted abbreviations of the generic drug.
References Literature or source used in preparing the monograph.
International Brand NamesTrade names found throughout various international markets.
The following countries are included in the International Brand Names field and are abbreviated as follows:
Argentina (AR)
Australia (AU)
Austria (AT)
Belgium (BE)
Brazil (BR)
Bulgaria (BG)
Canada (CA)
Chile (CL)
China (CN)
Colombia (CO)
Costa Rica (CR)
Croatia / Hrvatska (HR)
Czech Republic (CZ)
Denmark (DK)
Egypt (EG)
Finland (FI)
France (FR)
Germany (DE)
Great Britain [UK] (GB)
Greece (GR)
Hong Kong (HK)
Hungary (HU)
Iceland (IS)
India (IN)
Ireland (IE)
Israel (IL)
Italy (IT)
Japan (JP)
Jordan (JO)
Korea [South] (KR)
Kuwait (KW)
Lebanon (LB)
Malaysia (MY)
Mexico (MX)
Monaco (MC)
Netherlands (NL)
New Zealand [Aotearoa] (NZ)
Norway (NO)
Poland (PL)
Portugal (PT)
Puerto Rico (PR)
Romania (RO)
Russian Federation (RU)
Singapore (SG)
Slovak Republic (SK)
Slovenia (SI)
South Africa (ZA)
Spain (ES)
Sweden (SE)
Switzerland (ST)
Syria (SY)
Taiwan (TW)
Thailand (TH)
Turkey (TR)
Ukraine (UA)
United States (US)
Venezuela (VE)
Yugoslavia (YU)

FDA PREGNANCY CATEGORIES
Lexi-Drugs Online
Throughout this book there is a field labeled Pregnancy Risk Factor and the letter A, B, C, D, or Ximmediately following which signifies a
category. The FDAhas established these five categories to indicate the potential of a systemically absorbed drug for causing birth defects. The key
differentiation among the categories rests upon the reliability of documentation and the risk:benefit ratio. Pregnancy CategoryXis particularly notable in that
if any data exists that may implicate a drug as a teratogen and the risk:benefit ratio is clearly negative, the drug is contraindicated during pregnancy.
These categories are summarized as follows:
Controlled
studies in
pregnant
women fail to
demonstrate a
risk to the fetus
in the first
AB C
trimester with no evidence of risk in later
trimesters. The possibility of fetal harm
appears
remote.
Either animal reproduction studies have not

demonstrated a fetal risk but there are no controlled
studies in
pregnant
women, or
animal
reproduction studies have shown an
adverse effect (other than a decrease in fertility) that
was not
confirmed in controlled
studies in
women in the first trimester and there is no evidence of a risk in later
trimesters.
Either studies in animals

have revealed adverse effects on the fetus (teratogenic or embryocidal
effects or
other) and
there are no controlled
studies in
women, or
studies in
women and
animals are
not available.
Drugs should
be given only if
the potential
benefits justify
the potential
risk to the
fetus.
There is
positive
evidence of
human fetal
risk, but the
benefits from
use in
pregnant
women may be
acceptable
D
despite the risk
(eg, if the drug
is needed in a
life-threatening
situation or for
a serious
disease for
which safer
drugs cannot
be used or are
ineffective).
Studies in
animals or
human beings
have
demonstrated
fetal
abnormalities
or there is
evidence of
fetal risk based
on human
experience, or
both, and the
X
risk of the use
of the drug in
pregnant
women clearly
outweighs any
possible
benefit. The
drug is
contraindicated
in women who
are or may
become
pregnant.

SAFE WRITING
Lexi-Drugs Online
Health professionals and their support personnel frequently produce handwritten copies of information they see in print; therefore, such
information is subjected to even greater possibilities for error or misinterpretation on the part of others. Thus, particular care must be given to how drug
names and strengths are expressed when creating written healthcare documents.
1
The following are a few examples of safe writing rules suggested by the Institute for Safe Medication Practices, Inc.
1. There should be a space between a number and its units as it is easier to read. There should be no periods after the abbreviations mg or mL.
Correct Incorrect
10 mg 10mg
100 mg 100mg
2. Never place a decimal and a zero after a whole number (2 mg is correct and 2.0 mg is incorrect). If the decimal point is not seen because it
falls on a line or because individuals are working from copies where the decimal point is not seen, this causes a tenfold overdose.
3. Just the opposite is true for numbers less than one. Always place a zero before a naked decimal (0.5 mL is correct, .5 mL is incorrect). 4. Never
abbreviate the word unit. The handwritten U or u, looks like a 0 (zero), and may cause a tenfold overdose error to be made. 5. IU is not a safe
abbreviation for international units. The handwritten IU looks like IV. Write out international units or use int. units. 6. Q.D. is not a safe abbreviation for
once daily, as when the Q is followed by a sloppy dot, it looks like QID which means four times daily.
7. O.D. is not a safe abbreviation for once daily, as it is properly interpreted as meaning “right eye” and has caused liquid medications such as
saturated solution of potassium iodide and Lugol's solution to be administered incorrectly. There is no safe abbreviation for once daily. It must
be written out in full.
8. Do not use chemical names such as 6-mercaptopurine or 6-thioguanine, as sixfold overdoses have been given when these were not recognized
as chemical names. The proper names of these drugs are mercaptopurine or thioguanine.
9. Do not abbreviate drug names (5FC, 6MP, 5-ASA, MTX, HCTZ, CPZ, PBZ, etc) as they are misinterpreted and cause error. 10. Do
not use the apothecary system or symbols.
11. Do not abbreviate microgram as μg; instead use mcg as there is less likelihood of misinterpretation.
12. When writing an outpatient prescription, write a complete prescription. Acomplete prescription can prevent the prescriber, the pharmacist,
and/or the patient from making a mistake and can eliminate the need for further clarification. The legible prescriptions should contain:
a. patient's full name
b. for pediatric or geriatric patients: their age (or weight where applicable)
c. drug name, dosage form and strength; if a drug is new or rarely prescribed, print this information
d. number or amount to be dispensed
e. complete instructions for the patient, including the purpose of the medication
f. when there are recognized contraindications for a prescribed drug, indicate to the pharmacist that you are aware of this fact (ie, when
prescribing a potassium salt for a patient receiving an ACE inhibitor, write “K serum level being monitored”)
1
From “Safe Writing” by Davis NM, PharmD and Cohen MR, MS, Lecturers and Consultants for Safe Medication Practices, 1143 Wright Drive,
Huntington Valley, PA19006. Phone: (215) 947-7566.

FDA NAME DIFFERENTIATION PROJECT: THE USE OF TALL-MAN LETTERS
Lexi-Drugs Online
Confusion between similar drug names is an important cause of medication errors. For years, The Institute For Safe Medication Practices (ISMP),
has urged generic manufacturers to use a combination of large and small letters as well as bolding (ie, chlorproMAZINEand chlorproPAMIDE) to help
distinguish drugs with look-alike names, especially when they share similar strengths. Recently the FDA's Division of Generic Drugs began to issue
recommendation letters to manufacturers suggesting this novel way to label their products to help reduce this drug name confusion. Although this
project has had marginal success, the method has successfully eliminated problems with products such as diphenhydrAMINEand dimenhyDRINATE.
Hospitals should also follow suit by making similar changes in their own labels, preprinted order forms, computer screens and printouts, and drug
storage location labels.
Lexi-Comp Medical Publishing will use “Tall-Man” letters for the drugs suggested by the FDAor recommended by ISMP. The
following is a list of generic product names and recommended revisions.
Drug Product Recommended Revision
acetazolamide acetaZOLAMIDE
acetohexamide acetoHEXAMIDE
alprazolam ALPRAZolam
amiloride aMILoride
amlodipine amLODIPine
azacitidine azaCITIDine
azathioprine azaTHIOprine
bupropion buPROPion
buspirone busPIRone
carbamazepine carBAMazepine
carboplatin CARBOplatin
cefazolin ceFAZolin
ceftriaxone cefTRIAXone
chlordiazepoxide chlordiazePOXIDE
chlorpromazine chlorproMAZINE
chlorpropamide chlorproPAMIDE
cisplatin CISplatin
clomiphene clomiPHENE
clomipramine clomiPRAMINE
clonazepam clonazePAM
clonidine cloNIDine
cycloserine cycloSERINE
cyclosporine cycloSPORINE
dactinomycin DACTINomycin
daptomycin DAPTOmycin
daunorubicin DAUNOrubicin
dimenhydrinate dimenhyDRINATE
diphenhydramine diphenhydrAMINE
dobutamine DOBUTamine
dopamine DOPamine
doxorubicin DOXOrubicin
duloxetine DULoxetine
ephedrine ePHEDrine
epinephrine EPINEPHrine
fentanyl fentaNYL
fluoxetine FLUoxetine
glipizide glipiZIDE
glyburide glyBURIDE
guaifenesin guaiFENesin
guanfacine guanFACINE
hydralazine hydrALAZINE
hydrocodone HYDROcodone
hydromorphone HYDROmorphone
hydroxyzine hydrOXYzine
idarubicin IDArubicin
infliximab inFLIXimab
lamivudine lamiVUDine
lamotrigine lamoTRIgine
lorazepam LORazepam
medroxyprogesterone medroxyPROGESTERone
metformin metFORMIN
methylprednisolone methylPREDNISolone
methyltestosterone methylTESTOSTERone
metronidazole metroNIDAZOLE
nicardipine niCARdipine
nifedipine NIFEdipine
nimodipine niMODipine
olanzapine OLANZapine
oxcarbazepine OXcarbazepine
oxycodone oxyCODONE
paroxetine PARoxetine
pentobarbital PENTobarbital
phenobarbital PHENobarbital
prednisolone prednisoLONE
prednisone predniSONE
quetiapine QUEtiapine
quinidine quiNIDine
quinine quiNINE
rituximab riTUXimab
sitagliptin sitaGLIPtin
sufentanil SUFentanil
sulfadiazine sulfADIAZINE
sulfisoxazole sulfiSOXAZOLE
sumatriptan SUMAtriptan
tiagabine tiaGABine
tizanidine tiZANidine
tolazamide TOLAZamide
tolbutamide TOLBUTamide
tramadol traMADol
trazodone traZODone
vinblastine vinBLAStine
vincristine vinCRIStine
Institute for Safe Medication Practices. “New Tall-Man Lettering Will Reduce Mix-Ups Due to Generic Drug Name Confusion,” ISMP Medication Safety
Alert, September 19, 2001. Available at: http://www.ismp.org.
Institute for Safe Medication Practices. “Prescription Mapping, Can Improve Efficiency While Minimizing Errors With Look-Alike Products,” ISMP
Medication Safety Alert, October 6, 1999. Available at: http://www.ismp.org.
Institute for Safe Medication Practices. "Use of Tall Man Letters Is Gaining Wide Acceptance," ISMP Medication Safety Alert, July 31, 2008.
Available at: http://www.ismp.org.
U.S. Pharmacopeia, “USP Quality Review: Use Caution-Avoid Confusion,” March 2001, No. 76. Available at: http://www.usp.org.

5+2
Lexi-Drugs Online
Jump To Field (Select Field Name)
Pharmacologic CategoryChemotherapy Regimen, Leukemia, Acute Myeloid

Regimen UseLeukemia, acute myeloid (induction)
Index TermsCytarabine-Daunorubicin (5 + 2); Daunorubicin-Cytarabine (5 + 2)
Regimen
2
Cytarabine: I.V.: 100-200 mg/m /day continuous infusion days 1 to 5
2
[total dose/cycle = 500-1000 mg/m ]
with
2
Daunorubicin: I.V.: 45 mg/m /day days 1 and 2
2
[total dose/cycle = 90 mg/m ]
References
Rai KR, Holland JF, Glidewell OJ, et al, âTreatment of Acute Myelocytic Leukemia: A Study by Cancer and Leukemia Group B,â Blood, 1981, 58(6):1203-12.
[PubMed 6946847 ]

7 + 3 (Daunorubicin)
Lexi-Drugs Online

Index TermsCytarabine-Daunorubicin (7 + 3)
Regimen
2
Cytarabine: I.V.: 100 mg/m /day continuous infusion days 1 to 7
2
2
Daunorubicin: I.V.: 45 mg/m /day days 1, 2, and 3
2
Administer one cycle only
References
Dilman RO, Davis RB, Green MR, et al, “A Comparative Study of Two Different Doses of Cytarabine for Acute Myeloid Leukemia: A Phase III Trial of Cancer and
Leukemia Group B,” Blood, 1991, 78(10):2520-6. [PubMed 1824249 ]
Preisler H, Davis RB, Kirs chner J, et al, “Comparison of Three Remission Induction Regimens and Two Postinduction Strategies for the Treatment of Acute
Nonlymphocytic Leukemia: A Cancer and Leukemia Group B Study,” Blood, 1987, 69(5):1441-9. [PubMed 3552076 ]
Rai KR, Holland JF, Glidewell OJ, et al, “Treatment of Acute Myelocytic Leukemia: A Study by Cancer and Leukemia Group B,” Blood, 1981, 58(6):1203-12.
[PubMed 6946847 ]
Vogler WR, Velez-Garcia E, Weiner RS, et al, “A Phase III Trial Comparing Idarubicin and Daunorubicin in Combination With Cytarabine in Acute Myelogenous Leukemia:
A Southeastern Cancer Study Group Study,” J Clin Oncol, 1992, 10(7):1103-11. [PubMed 1607916 ]
Yates J, Glidewell O, Wiernik P, et al, “Cytosine Arabinoside With Daunorubicin or Adriamycin® for Therapy of Acute Myelocytic Leukemia: A CALGB Study,” Blood,
1982, 60(2):454-62. [PubMed 6953986 ]
Yates JW, Wallace HJ Jr, Ellison RR, et al, “Cytosine Arabinoside (NSC-63878) and Daunorubicin (NSC-83142) Therapy in Acute Nonlymphocytic Leukemia,” Cancer
Chemother Rep, 1973, 57(4):485-8.[PubMed 4586956 ]

7 + 3 (Idarubicin)
Lexi-Drugs Online

Index TermsCytarabine-Idarubicin (7 + 3)
Regimen
2
2
[total dose/cycle = 700 - 1400 mg/m ]
2
Idarubicin: I.V.: 12 mg/m /day days 1, 2, and 3
2
References
Vogler WR, Velez-Garcia E, Weiner RS, et al, âA Phase III Trial Comparing Idarubicin and Daunorubicin in Combination With Cytarabine in Acute Myelogenous Leukemia:
A Southeastern Cancer Study Group Study,â J Clin Oncol, 1992, 10(7):1103-11.[PubMed 1607916 ]

7 + 3 (Mitoxantrone)
Lexi-Drugs Online

Index TermsCytarabine-Mitoxantrone (7 + 3)
Regimen
2
2
[total dose/cycle = 700-1400 mg/m ]
2
Mitoxantrone: I.V.: 12 mg/m /day days 1, 2, and 3
2
References
Arlin Z, Case DC Jr, Moore J, et al, âRandomized Multicenter Trial of Cytosine Arabinoside With Mitoxantrone or Daunorubicin in Previously Untreated Adult Patients
With Acute Nonlymphocytic Leukemia (ANLL),â Lederle Cooperative Group, Leukemia, 1990, 4(3):177-83.[PubMed 2179638 ]

7+3+7
Lexi-Drugs Online

Regimen UseLeukemia, acute myeloid
Index TermsCytarabine-Daunorubicin-Etoposide (7 + 3 + 7)
Regimen
2
Cytarabine: I.V.: 100 mg/m /day continuous infusion days 1 to 7
2
2
Daunorubicin: I.V.: 50 mg/m /day days 1, 2, and 3
2
2
Etoposide: I.V.: 75 mg/m /day days 1 to 7
2
Repeat cycle every 21 days; up to 3 cycles may be given based on individual response
References
Bishop JF, Lowenthal RM, Joshua D, et al, âEtoposide in Acute Nonlymphocytic Leukemia, Australian Leukemia Study Group,â Blood, 1990, 75(1):27-32.[PubMed
2403818 ]

8 in 1 (Brain Tumors)
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Brain Tumors

Regimen UseBrain tumors
RegimenNOTE: Multiple variations are listed below.
Variation 1:
2
Methylprednisolone: I.V.: 300 mg/m every 6 hours day 1 (3 doses)
2
2
Vincristine: I.V.: 1.5 mg/m (maximum 2 mg) day 1
2
Lomustine: Oral: 75 mg/m day 1
2
Procarbazine: Oral: 75 mg/m day 1; 1 hour after methylprednisolone and vincristine
2
Hydroxyurea: Oral: 3000 mg/m day 1; 2 hours after methylprednisolone and vincristine
2
Cisplatin: I.V.: 90 mg/m day 1; 3 hours after methylprednisolone and vincristine
2
Cytarabine: I.V.: 300 mg/m day 1; 9 hours after methylprednisolone and vincristine
2
Dacarbazine: I.V.: 150 mg/m day 1; 12 hours after methylprednisolone and vincristine
Repeat cycle every 14 days
Variation 2:
2
Methylprednisolone: I.V.: 300 mg/m every 6 hours day 1 (3 doses)
2
2
Vincristine: I.V.: 1.5 mg/m (maximum 2 mg) day 1
2
2
Procarbazine: Oral: 75 mg/m day 1; 1 hour after methylprednisolone and vincristine
2
Hydroxyurea: Oral: 3000 mg/m day 1; 2 hours after methylprednisolone and vincristine
2
Cisplatin: I.V.: 60 mg/m day 1; 3 hours after methylprednisolone and vincristine
2
Cytarabine: I.V.: 300 mg/m day 1; 9 hours after methylprednisolone and vincristine
2
Cyclophosphamide: I.V.: 300 mg/m day 1; 12 hours after methylprednisolone and vincristine
References
Pendergrass TW, Milstein JM, Geyer JR, et al, âEight Drugs in One Day Chemotherapy for Brain Tumors: Experience in 107 Children and Rationale for Preradiation
Chemotherapy,â J Clin Oncol, 1987, 5(8):1221-31.[PubMed 3040919 ]

8 in 1 (Retinoblastoma)
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Retinoblastoma

Regimen UseRetinoblastoma
Regimen
2
Vincristine: I.V.: 1.5 mg/m day 1
2
Methylprednisolone: I.V.: 300 mg/m day 1
2
2
Procarbazine: Oral: 75 mg/m day 1
2
Hydroxyurea: Oral: 1500 mg/m day 1
2
Cisplatin: I.V.: 60 mg/m day 1
2
Cytarabine: I.V.: 300 mg/m day 1
References
Doz F, Khelfaoui F, Mosseri V, et al, âThe Role of Chemotherapy in Orbital Involvement of Retinoblastoma. The Experience of a Single Institution With 33
Patients,â Cancer, 1994, 74(2):722-32.[PubMed 8033054 ]

AAV (DD)
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Wilms' Tumor

Regimen UseWilms' tumor
Regimen
Dactinomycin: I.V.: 15 mcg/kg/day days 1 to 5 of weeks 0, 13, 26, 39, 52, and 65
[total dose/cycle = 450 mcg/kg]
2
Doxorubicin: I.V.: 20 mg/m /day days 1, 2, and 3 of weeks 6, 19, 32, 45, and 58
2
2
Vincristine: I.V.: 1.5 mg/m day 1 of weeks 0-10, 13, 14, 26, 27, 39, 40, 52, 53, 65, and 66
2
[total dose/cycle = 31.5 mg/m ]
References
D'Angio GJ, Breslow N, Beckwith JB, et al, “Treatment of Wilms' Tumor. Results of the Third National Wilms' Tumor Study,” Cancer, 1989, 64(2):349-60.
[PubMed 2544249 ]

Abacavir, Lamivudine, and Zidovudine
Lexi-Drugs Online
English
ALERT: U.S. Boxed WarningThe FDA-approved labeling includes a boxed warning. See Warnings/Precautions section for a concise summary of this information. For
verbatim wording of the boxed warning, consult the product labeling or www.fda.gov. Special Alerts
Abacavir and Abacavir-Containing Products: Boxed Warning Update Concerning Increased Risk of Hypersensitivity Reactions in Patients with HLA-B*5701 Allele -
July 2008
The Food and Drug Administration (FDA) is requesting the manufacturer of abacavir and abacavir-containing products to update the boxed warning concerning serious
hypersensitivity reactions. The update includes a recommendation to test all patients for the presence of the HLA B*5701 allele prior to initiating therapy or resuming
therapy in patients of unknown HLA-B*5701 status, including patients previously tolerating therapy. Patients testing positive for the presence of this genotype are at an
increased risk for serious hypersensitivity reactions. If a patient tests positive for the presence of the HLA-B*5701 allele, abacavir is not recommended and an alternative
agent should be selected. If a suspected abacavir hypersensitivity reaction occurs during therapy, regardless of HLA-B*5701 status, abacavir should be dis continued
immediately and permanently.
Additional information may be found at http://www.fda.gov/medwatch.safety/2008/safety08.htm#Abacavir
Abacavir-Containing Products: Increased Risk of Myocardial Infarction Observed; Health Canada Issues Alert to Canadian Healthcare Professionals - June 2008
The Canadian Dear Healthcare Provider letter can be found at http://www.hc-s c.gc.ca/dhp-mps/medeff/advisories
avis/prof/_2008/abacavir_hpc-cps-eng.php
FDA Early Communication: Increased Risk of Myocardial Infarction Observed - March 2008
The Food and Drug Administration (FDA) has issued an Early Communication to patients, caregivers, and healthcare professionals informing them of new evidence
regarding the use of abacavir (Ziagen®) and didanosine (Videx®) and the risk of myocardial infarction (MI). Analysis from the Data Collection on Adverse Events of Anti-
HIV Drugs (D:A:D) Study, an observational study aimed at investigating the adverse effects of certain nucleoside reverse trans criptase inhibitors (NRTI) involving over
33,000 patients, suggests that patients taking Ziagen® or Videx® appear to be at an increased risk for MI in comparison to other NRTIs. The risk of MI appears to be
greatest with recent use (within 6 months) and in patients with existing risk factors for heart disease (eg, hypercholesterolemia, hypertension, diabetes, smoking, and
age). In addition, the risk of MI appears to be reversible upon dis continuation of the offending agents. Patients taking abacavir (Ziagen®) may have up to a 90%
increase in their risk of MI according to study results.
The FDA emphasizes that these are preliminary results of the D:A:D study and urges healthcare providers to weigh the potential risks and benefits of every
treatment option until further results become available.
Additional information is available at http://www.fda.gov/cder/drug/early_comm/abacavir.htm
Pronunciation(a BAK a veer, la MI vyoo deen, & zye DOE vyoo deen)
U.S. Brand NamesTrizivir®
Pharmacologic CategoryAntiretroviral Agent, Reverse Trans criptase Inhibitor (Nucleoside)
Use: Labeled IndicationsTreatment of HIV infection (either alone or in combination with other antiretroviral agents) in patients whose regimen would otherwise
contain the components of Trizivir®
Dosing: AdultsHIV treatment: Oral: 1 tablet twice daily. Note: Not recommended for patients <40 kg.
Dosing: ElderlyUse with caution.
Dosing: PediatricHIV treatment: Adoles cents: Refer to adult dosing (not recommended for patients <40 kg). Dosing: Renal
ImpairmentCl cr ≤50 mL/minute: Avoid use.
Dosing: Hepatic ImpairmentUse contraindicated.
Calculations
Creatinine Clearance: Adults
Administration: OralAdminister without regard to food or water.

Dietary ConsiderationsMay be taken without regard to food or water.
StorageStore at room temperature 15°C to 30°C (59°F to 86°F).
RestrictionsAn FDA-approved medication guide and warning card (summarizing symptoms of hypersensitivity) must be distributed when
dispensing an outpatient pres cription (new or refill) where this medication is to be used without direct supervision of a healthcare provider. Medication guides are
available at http://www.fda.gov/cder/Offices/ODS/medication_guides.htm.
ContraindicationsHypersensitivity to abacavir, lamivudine, zidovudine, or any component of the formulation; hepatic impairment. Do not rechallenge patients
who have experienced hypersensitivity to abacavir.
Allergy Considerations
Abacavir Allergy
LamiVUDine Allergy
Zidovudine Allergy
Warnings/Precautions
Boxed warnings:
• Chronic hepatitis B: See “Disease-related concerns ” below.
• Hematologic toxicity: See “Concerns related to adverse effects ” below.
• HIV: Appropriate use: See “Disease-related concerns ” below.
• Hypersensitivity reactions: See “Concerns related to adverse effects ” below.
• Lactic acidosis/hepatomegaly: See “Concerns related to adverse effects ” below.
• Myopathy: See “Concerns related to adverse effects ” below.
Concerns related to adverse effects:
• Fat redistribution: May cause redistribution of fat (eg, buffalo hump, peripheral wasting with increased abdominal girth, cushingoid appearance).
• Hematologic toxicity: [U.S. Boxed Warning]: Zidovudine has been associated with hematologic toxicities (eg, neutropenia, anemia); use with caution in
patients with bone marrow compromise.
• Hypersensitivity reactions: [U.S. Boxed Warning]: Fatal hypersensitivity reactions have occurred in patients taking abacavir (in Trizivir®). Patients testing
positive for the presence of the HLA-B*5701 allele are at an increased risk for hypersensitivity reactions. Screening for HLA B*5701 allele status is
recommended prior to initiating abacavir-containing therapy or reinitiating therapy in patients of unknown status, including patients who previously
tolerated abacavir therapy. Trizivir® is not recommended in patients testing positive for the HLA-B*5701 allele. Patients exhibiting symptoms of fever, skin
rash, fatigue, respiratory symptoms (eg, pharyngitis, dyspnea, cough) and/or GI symptoms (eg, abdominal pain, nausea, vomiting, diarrhea) should dis
continue therapy immediately and call for medical attention. Trizivir® should be permanently dis continued if hypersensitivity cannot be ruled out, even when
other diagnoses are possible and regardless of HLA-B*5701 status. Trizivir® SHOULD NOT be restarted because more severe symptoms may occur within
hours, including LIFE-THREATENING HYPOTENSION AND DEATH. Fatal hypersensitivity reactions have occurred following the reintroduction of abacavir in
patients whose therapy was interrupted (eg, interruption in drug supply, temporary dis continuation while treating other conditions). Reactions occurred
within hours. In some cases, signs of hypersensitivity may have been previously present, but attributed to other medical conditions (eg, acute onset
respiratory diseases, gastroenteritis, reactions to other medications). If Trizivir® is to be restarted following an interruption in therapy, first evaluate the
patient for previously unsuspected symptoms of hypersensitivity. Do not restart if hypersensitivity is suspected or cannot be ruled out. To report these events
on Trizivir® hypersensitivity, a registry has been established (1-800-270-0425).
• Immune reconstitution syndrome: Patients may develop immune reconstitution syndrome resulting in the occurrence of an inflammatory response to an
indolent or residual opportunistic infection; further evaluation and treatment may be required.
• Lactic acidosis/hepatomegaly: [U.S Boxed Warning]: Lactic acidosis and severe hepatomegaly with steatosis have been reported with nucleoside analogues,
including fatal cases; use with caution in patients with risk factors for liver disease (risk may be increased with female gender, obesity, pregnancy or prolonged
exposure) and suspend treatment in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or hepatotoxicity (transaminase elevation
may/may not accompany hepatomegaly and steatosis).
• Myopathy: [U.S. Boxed Warning]: Prolonged use of zidovudine has been associated with symptomatic myopathy and myositis.
Disease-related concerns:
• Chronic hepatitis B: [U.S. Boxed Warning]: Exacerbation of hepatitis B has been reported with discontinuation of lamivudine in coinfected HIV/HBV patients;
monitor hepatic function closely for several months after dis continuing Trizivir® in coinfected patients.
• Coronary heart disease: Use caution in patients with risks for coronary heart disease; modifiable risk factors (eg, hypertension, hyperlipidemia,
diabetes mellitus, and smoking) should be minimized prior to use.
• HIV: Appropriate use: [U.S. Boxed Warning]: This combination should only be used as part of a multidrug regimen for which the individual
components are indicated.
• Renal impairment: Trizivir®, as a fixed-dose combination tablet, should not be used in patients with Cl cr ≤50 mL/minute. Concurrent drug
therapy issues:
• Interferon alfa: Use with caution in combination with interferon alfa with or without ribavirin in HIV/HBV coinfected patients; monitor closely for hepatic
decompensation, anemia, or neutropenia; dose reduction or dis continuation of interferon and/or ribavirin may be required if toxicity evident.
Special populations:
• Adults <40 kg: Trizivir®, as a fixed-dose combination tablet, should not be used in patients <40 kg or those requiring dosage adjustment.
• Pediatrics: Trizivir®, as a fixed-dose combination tablet, should not be used in children.
Pregnancy Risk FactorC

Pregnancy ConsiderationsSee individual agents.
LactationSee individual agents.
Breast-Feeding ConsiderationsSee individual agents.
Adverse ReactionsFatal hypersensitivity reactions have occurred in patients taking abacavir (in Trizivir®). If Trizivir® is to be restarted following an interruption
in therapy, first evaluate the patient for previously unsuspected symptoms of hypersensitivity. Do not restart if hypersensitivity is suspected or if hypersensitivity
cannot be ruled out.
The following information is based on CNA3005 study data concerning effects noted in patients receiving abacavir, lamivudine, and zidovudine. See
individual agents for additional information.
>10%:
Central nervous system: Headache (13%), malaise (12%), fatigue (12%)
Gastrointestinal: Nausea (19%)
1% to 10%:
Central nervous system: Fever/chills (6%), depression (6%), anxiety (5%)
Dermatologic: Rash (5%)
Endocrine & metabolic: Triglycerides increased (2% grade 3-4)
Gastrointestinal: Nausea and vomiting (10%), diarrhea (7%), amylase increased (2%)
Hematologic: Neutropenia (5%)
Hepatic: ALT increased (6%)
Neuromus cular & skeletal: CPK increased (7%)
Mis cellaneous: Hypersensitivity (2% to 9% based on abacavir component), ear/nose/throat infection (5), viral infection (5%) Other (frequency
unknown): Pancreatitis, GGT increased, fat redistribution, immune reconstitution syndrome Drug Interactions
Acyclovir-Valacyclovir: May enhance the CNS depressant effect of Zidovudine. Risk C: Monitor therapy
DOXOrubicin: May enhance the adverse/toxic effect of Zidovudine. DOXOrubicin may diminish the therapeutic effect of Zidovudine. Risk D: Consider therapy
modification
DOXOrubicin (Liposomal): May enhance the adverse/toxic effect of Zidovudine. DOXOrubicin (Liposomal) may diminish the therapeutic effect of Zidovudine. Risk D:
Consider therapy modification
Emtricitabine: LamiVUDine may enhance the adverse/toxic effect of Emtricitabine. Risk X: Avoid combination
Fluconazole: May decrease the metabolism of Zidovudine. Risk C: Monitor therapy
Ganciclovir-Valganciclovir: May enhance the adverse/toxic effect of Reverse Trans criptase Inhibitors (Nucleoside). Hematologic toxicity is of specific concern. Risk D:
Interferons: May enhance the adverse/toxic effect of Zidovudine. Interferons may decrease the metabolism of Zidovudine. Risk C: Monitor therapy
Methadone: May increase the serum concentration of Zidovudine. Risk C: Monitor therapy
Probenecid: May decrease the metabolism of Zidovudine. Risk C: Monitor therapy
Protease Inhibitors: May decrease the serum concentration of Zidovudine. Risk C: Monitor therapy
Protease Inhibitors: May decrease the serum concentration of Abacavir. Risk C: Monitor therapy
Ribavirin: May enhance the hepatotoxic effect of Reverse Trans criptase Inhibitors (Nucleoside). Lactic acidosis may occur. Risk D: Consider therapy modification
Rifamycin Derivatives: May increase the metabolism of Zidovudine. Exceptions: Rifabutin. Risk D: Consider therapy modification Stavudine:
Zidovudine may diminish the therapeutic effect of Stavudine. Risk D: Consider therapy modification
Trimethoprim: May decrease the excretion of LamiVUDine. Risk C: Monitor therapy
Valproic Acid: May decrease the metabolism of Zidovudine. Risk C: Monitor therapy
Zalcitabine: LamiVUDine may diminish the therapeutic effect of Zalcitabine. Risk D: Consider therapy modification Monitoring ParametersCBC with differential,
serum creatine kinase, CD4 count, HIV RNA plasma levels, bilirubin, serum transaminases,
triglycerides, serum amylase; HLA-B*5701 genotype status prior to initiation of therapy and prior to reinitiation of therapy in patients of unknown HLA-B*5701
status; signs and symptoms of hypersensitivity, particularly in patients untested for the HLA-B*5701 allele; signs and symptoms of pancreatitis; observe for
appearance of opportunistic infections
Nursing: Physical Assessment/MonitoringSee individual agents.
Monitoring: Lab TestsCBC with differential, serum creatine kinase, CD4 count, HIV RNA plasma levels, bilirubin, serum transaminases, triglycerides, serum
amylase; HLA-B*5701 genotype status prior to initiation of therapy and prior to reinitiation of therapy in patients of unknown HLA-B*5701 status
Patient EducationSee individual agents.
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. Tablet:
Trizivir®: Abacavir 300 mg, lamivudine 150 mg, and zidovudine 300 mg
Generic AvailableNo
Pricing: U.S. (www.drugstore.com)
Tablets (Trizivir)
300-150-300 mg (60): $1271.45
Mechanism of ActionThe combination of abacavir, lamivudine, and zidovudine is believed to act synergistically to inhibit reverse trans criptase via DNA chain
termination after incorporation of the nucleoside analogue as well as to delay the emergence of mutations conferring resistance.
Pharmacodynamics/KineticsBioavailability studies of Trizivir® show no difference in AUC or C max when compared to abacavir, lamivudine, and zidovudine given
together as individual agents. See individual agents.
Related Information
Abacavir
Antiretroviral Agents
Antiretroviral Therapy for HIV Infection: Adults and Adoles cents
LamiVUDine
Management of Healthcare Worker Exposures to HBV, HCV, and HIV
Zidovudine
Pharmacotherapy PearlsHypersensitivity testing (HLA-B*5701): Prevalence of hypersensitivity reactions has been estimated at 5% to 8% in Caucasians and 2% to 3%
in African-Americans. Pretherapy identification of HLA-B*5701-positive patients, and subsequent avoidance of abacavir therapy in these patients has been shown to
reduce the occurrence of abacavir-mediated hypersensitivity reactions. A skin patch test is in development for clinical s creening purposes; however, only PCR-mediated
genotyping methods are currently in clinical practice use for documentation of this sus ceptibility marker.
Dental Health: Effects on Dental TreatmentNo significant effects or complications reported
Dental Health: Vasoconstrictor/Local Anesthetic PrecautionsNo information available to require special precautions Mental Health:
Effects on Mental StatusMay cause insomnia
Mental Health: Effects on Psychiatric TreatmentGastrointestinal side effects are common; these effects may be additive with concurrent use of SSRIs, lithium, or
valproate. The hypnotic effect of the benzodiazepines may be diminished. Valproic acid may decrease the clearance of zidovudine. Increase in triglycerides is common
and may be additive with clozapine, olanzapine, or quetiapine. May cause pancreatitis; use caution with valproic acid and atypical antipsychotics. May increase GGT; use
caution with olanzapine and valproic acid. May cause aplastic anemia; use caution with clozapine and carbamazepine. Suspected Stevens-Johnson syndrome (SJS) has
been reported in patients receiving abacavir in combination with medications known to be associated with SJS (lamotrigine).
Index Terms3TC, Abacavir, and Zidovudine; Azidothymidine, Abacavir, and Lamivudine; AZT, Abacavir, and Lamivudine; Compound S, Abacavir, and Lamivudine;
Lamivudine, Abacavir, and Zidovudine; ZDV, Abacavir, and Lamivudine; Zidovudine, Abacavir, and Lamivudine References
“Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adoles cents. Panel on Clinical Practices for Treatment of HIV Infection,” January 29,
2008. Available at http://www.aidsinfo.nih.gov
Lucas A, Nolan D, and Mallal S, “HLA-B*5701 Screening for Sus ceptibility to Abacavir Hypersensitivity,” J Antimicrob Chemother, 2007, 59(4):591- 3.[PubMed
17317695]
“Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce
Perinatal HIV-1 Transmission in the United States,” October 12, 2006. Available at: http://www.aidsinfo.nih.gov.
Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children, “Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection,”
February 28, 2008. Available at: http://www.aidsinfo.nih.gov.
International Brand NamesTricivir (AR, CN); Trivudin (AR); Trizivir (AT, AU, BE, BG, CH, CL, CO, CR, CZ, DE, DK, FI, FR, GB, GR, HK, HN, IE, IL, IT, MX, NL, NO, PE, PT, RU,
SE, TR, TW, UY, VE)

Abacavir and Lamivudine
Lexi-Drugs Online
English
July 2008
Additional information may be found at http://www.fda.gov/medwatch.safety/2008/safety08.htm#Abacavir

Pronunciation(a BAK a veer & la MI vyoo deen)
U.S. Brand NamesEpzicom®
Canadian Brand NamesKivexa™
Use: Labeled IndicationsTreatment of HIV infections in combination with other antiretroviral agents
Dosing: AdultsHIV: Oral: One tablet (abacavir 600 mg and lamivudine 300 mg) once daily
Dosing: Renal ImpairmentCl cr <50 mL/minute: Use not recommended
Dosing: Hepatic ImpairmentUse contraindicated.
Calculations
Administration: OralMay be administered with or without food.

Dietary ConsiderationsMay be taken with or without food.
StorageStore at controlled room temperature of 15°C to 30°C (59°F to 86°F).
RestrictionsAn FDA-approved medication guide and warning card (summarizing symptoms of hypersensitivity) must be distributed when dispensing an outpatient
pres cription (new or refill) where this medication is to be used without direct supervision of a healthcare provider. Medication guides are available at
http://www.fda.gov/cder/Offices/ODS/medication_guides.htm.
ContraindicationsHypersensitivity to abacavir, lamivudine, or any component of the formulation; hepatic impairment. Do not rechallenge patients who have
experienced hypersensitivity to abacavir.
Abacavir Allergy
LamiVUDine Allergy
Boxed warnings:
• Chronic hepatitis B: See “Disease-related concerns ” below.
• HIV: Appropriate use: See “Disease-related concerns ” below.
• Hypersensitivity reactions: [U.S. Boxed Warning]: Fatal hypersensitivity reactions have occurred in patients taking abacavir (in Epzicom®). Patients testing
positive for the presence of the HLA-B*5701 allele are at an increased risk for hypersensitivity reactions. Screening for HLA B*5701 allele status is
recommended prior to initiating abacavir-containing therapy or reinitiating therapy in patients of unknown status, including patients who previously tolerated
abacavir therapy. Epzicom® is not recommended in patients testing positive for the HLA-B*5701 allele. Patients exhibiting symptoms of fever, skin rash,
fatigue, respiratory symptoms (eg, pharyngitis, dyspnea, cough) and/or GI symptoms (eg, abdominal pain, nausea, vomiting, diarrhea) should dis continue
therapy immediately and call for medical attention. Epzicom® should be permanently dis continued if hypersensitivity cannot be ruled out, even when other
diagnoses are possible and regardless of HLA-B*5701 status. Epzicom® SHOULD NOT be restarted because more severe symptoms may occur within hours,
including LIFE-THREATENING HYPOTENSION AND DEATH. Fatal hypersensitivity reactions have occurred following the reintroduction of abacavir in patients
whose therapy was interrupted (eg, interruption in drug supply, temporary dis continuation while treating other conditions). Reactions occurred within hours.
In some cases, signs of hypersensitivity may have been previously present, but attributed to other medical conditions (eg, acute onset respiratory diseases,
gastroenteritis, reactions to other medications). If Epzicom® is to be restarted following an interruption in therapy, first evaluate the patient for previously
unsuspected symptoms of hypersensitivity. Do not restart if hypersensitivity is suspected or cannot be ruled out. To report these events on Epzicom®
hypersensitivity, a registry has been established (1-800-270-0425).
• Chronic hepatitis B: [U.S. Boxed Warning]: Following discontinuation of lamivudine, severe acute exacerbations of hepatitis B in patients coinfected with HBV
and HIV have been reported. Monitor patients closely for several months following dis continuation of therapy for chronic hepatitis B; clinical exacerbations
may occur.
• HIV: Appropriate use: [U.S. Boxed Warning]: This combination should only be used as part of a multidrug regimen for which the individual
components are indicated.
• Renal impairment: Due to fixed dose of combination product, use is not recommended with renal impairment (Cl cr <50 mL/minute). Concurrent drug
therapy issues:
• Interferon alfa: Use with caution in combination with interferon alfa with or without ribavirin in HIV/HBV coinfected patients; monitor closely for hepatic
decompensation, anemia, or neutropenia; dose reduction or dis continuation of interferon and/or ribavirin may be required if toxicity evident.
• Pediatrics: Due to fixed dose of combination product, use is not recommended in children.

Pregnancy ConsiderationsSee individual agents.
LactationSee individual agents.
Breast-Feeding ConsiderationsHIV-infected mothers are dis couraged from breast-feeding to decrease potential transmission of HIV. See individual agents.
Adverse ReactionsSee individual agents.
Postmarketing and/or case reports: Alopecia, anaphylaxis, anemia, aplastic anemia, breath sounds abnormal, CPK increased, erythema
multiforme, fat redistribution, hepatic steatosis, hepatitis B exacerbation, hyperglycemia, hypersensitivity reaction, lactic acidosis, lymphadenopathy, mus cle
weakness, pancreatitis, paresthesia, peripheral neuropathy, rhabdomyolysis, seizure, splenomegaly, Stevens Johnson syndrome, stomatitis, urticaria, weakness,
wheezing
Drug Interactions
Emtricitabine: LamiVUDine may enhance the adverse/toxic effect of Emtricitabine. Risk X: Avoid combination
Trimethoprim: May decrease the excretion of LamiVUDine. Risk C: Monitor therapy
Zalcitabine: LamiVUDine may diminish the therapeutic effect of Zalcitabine. Risk D: Consider therapy modification
Monitoring ParametersAmylase, bilirubin, liver enzymes, hematologic parameters, viral load, and CD4 count; HLA-B*5701 genotype status prior to initiation of
therapy and prior to reinitiation of therapy in patients of unknown HLA-B*5701 status; signs and symptoms of hypersensitivity, particularly in patients untested for
the HLA-B*5701 allele
Nursing: Physical Assessment/MonitoringSee individual agents.
Monitoring: Lab TestsAmylase, bilirubin, liver enzymes, hematologic parameters, viral load, and CD4 count,HLA-B*5701 genotype status prior to initiation of therapy
and prior to reinitiation of therapy in patients of unknown HLA-B*5701 status
Patient EducationSee individual agents.
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. Tablet:
Epzicom®: Abacavir 600 mg and lamivudine 300 mg
Generic AvailableNo
ManufacturerGlaxoSmithKline
Tablets (Epzicom)
600-300 mg (30): $870.93
Mechanism of ActionNucleoside reverse trans criptase inhibitor combination.
Abacavir is a guanosine analogue which is phosphorylated to carbovir triphosphate which interferes with HIV viral RNA-dependent DNA polymerase resulting in
inhibition of viral replication.
Lamivudine is a cytosine analog. After lamivudine is triphosphorylated, the principle mode of action is inhibition of HIV reverse trans cription via viral DNA chain
termination; inhibits RNA-dependent DNA polymerase activities of reverse trans criptase.
Pharmacodynamics/KineticsSee individual agents.

Related Information
Abacavir
LamiVUDine
Pharmacotherapy PearlsA high rate of early virologic nonresponse was observed when abacavir, lamivudine, and tenofovir were used as the initial regimen in
treatment-naive patients. Use of this combination is not recommended; patients currently on this regimen should be closely monitored for modification of therapy.
Hypersensitivity testing (HLA-B*5701): Prevalence of hypersensitivity reactions has been estimated at 5% to 8% in Caucasians and 2% to 3% in African-Americans.
Pretherapy identification of HLA-B*5701-positive patients, and subsequent avoidance of abacavir therapy in these patients has been shown to reduce the occurrence of
abacavir-mediated hypersensitivity reactions. A skin patch test is in development for clinical s creening purposes; however, only PCR-mediated genotyping methods are
currently in clinical practice use for documentation of this sus ceptibility marker.
Dental Health: Vasoconstrictor/Local Anesthetic PrecautionsNo information available to require special precautions Mental Health: Effects on Mental StatusMay
cause anxiety, abnormal dreams, dizziness, depression, fatigue, lethargy, malaise, insomnia, and headache
Mental Health: Effects on Psychiatric TreatmentSide effects mimic depressive symptoms; use caution with benzodiazepines, CNS depressants, or
antidepressants. May rarely cause neutropenia; use caution with clozapine and carbamazepine. Index TermsAbacavir Sulfate and Lamivudine;
Lamivudine and Abacavir
References
17317695]
February 28, 2008. Available at: http://www.aidsinfo.nih.gov.
International Brand NamesKivexa (AR, AT, AU, BE, BG, CH, CN, CZ, DE, DK, ES, FI, FR, GB, GR, HK, HN, IE, IL, IT, MX, NL, NO, PT, RU, SE, TH, TR, TW, UY)

Abacavir
Lexi-Drugs Online
English
English Jump To Field (Select Field

Name)
July 2008
Additional information may be found at http://www.fda.gov/medwatch/safety/2008/safety08.htm#Abacavir

Pronunciation(a BAK a veer)
U.S. Brand NamesZiagen®
Canadian Brand NamesZiagen®
Use: Labeled IndicationsTreatment of HIV infections in combination with other antiretroviral agents
Dosing: AdultsHIV treatment: Oral: 300 mg twice daily or 600 mg once daily in combination with other antiretroviral agents Dosing:
ElderlyRefer to adult dosing.
Dosing: PediatricHIV treatment: Oral: 3 months to 16 years: 8 mg/kg body weight twice daily (maximum: 300 mg twice daily) in combination with other
antiretroviral agents
Dosing: Hepatic Impairment
Mild dysfunction (Child-Pugh s core 5-6): 200 mg twice daily (oral solution is recommended)
Moderate-to-severe dysfunction: Use is contraindicated by the manufacturer
Administration: OralMay be administered with or without food.

Dietary ConsiderationsMay be taken with or without food.
StorageStore oral solution and tablets at controlled room temperature of 20°C to 25°C (68°F to 77°F). Oral solution may be refrigerated; do not freeze.
RestrictionsAn FDA-approved medication guide and warning card (summarizing symptoms of hypersensitivity) must be distributed when dispensing an outpatient
pres cription (new or refill) where this medication is to be used without direct supervision of a healthcare provider. Medication guides are available at
http://www.fda.gov/cder/Offices/ODS/medication_guides.htm.
ContraindicationsHypersensitivity to abacavir or any component of the formulation (do not rechallenge patients who have experienced hypersensitivity to
abacavir); moderate-to-severe hepatic impairment
Abacavir Allergy
Boxed warnings:
• Hypersensitivity reactions: [U.S. Boxed Warning]: Serious and sometimes fatal hypersensitivity reactions have occurred. Patients testing positive for the
presence of the HLA-B*5701 allele are at an increased risk for hypersensitivity reactions. Screening for HLA-B*5701 allele status is recommended prior to
initiating therapy or reinitiating therapy in patients of unknown status, including patients who previously tolerated therapy. Therapy is not recommended in
patients testing positive for the HLA-B*5701 allele. Patients exhibiting symptoms from two or more of the following: Fever, skin rash, constitutional symptoms
(malaise, fatigue, aches), respiratory symptoms (eg, pharyngitis, dyspnea, cough), and GI symptoms (eg, abdominal pain, diarrhea, nausea, vomiting) should
dis continue therapy immediately and call for medical attention. Abacavir should be permanently dis continued if hypersensitivity cannot be ruled out, even
when other diagnoses are possible and regardless of HLA-B*5701 status. Abacavir SHOULD NOT be restarted because more severe symptoms may occur
within hours, including LIFE-THREATENING HYPOTENSION AND DEATH. Fatal hypersensitivity reactions have occurred following the reintroduction of abacavir
in patients whose therapy was interrupted (ie, interruption in drug supply, temporary dis continuation while treating other conditions). Reactions occurred
within hours. In some cases, signs of hypersensitivity may have been previously present, but attributed to other medical conditions (eg, acute onset
respiratory diseases, gastroenteritis, reactions to other medications). If abacavir is restarted following an interruption in therapy, evaluate the patient for
previously unsuspected symptoms of hypersensitivity. Do not restart if hypersensitivity is suspected or if hypersensitivity cannot be ruled out. To report these
events on abacavir hypersensitivity, a registry has been established (1-800-270-0425).
• Hepatic impairment: Use with caution in patients with mild hepatic dysfunction (contraindicated in moderate-to-severe dysfunction). • HIV: Appropriate use:
Abacavir should always be used as a component of a multidrug regimen.
• Pediatrics: Safety and efficacy have not been established in children <3 months of age.

Pregnancy ConsiderationsIt is not known if abacavir crosses the human placenta. No increased risk of overall birth defects has been observed following 1st trimester
exposure according to data collected by the antiretroviral pregnancy registry. Cases of lactic acidosis/hepatic steatosis syndrome have been reported in pregnant women
receiving nucleoside analogues. It is not known if pregnancy itself potentiates this known side effect; however, pregnant women may be at increased risk of lactic
acidosis and liver damage. Hepatic enzymes and electrolytes should be monitored frequently during the 3rd trimester of pregnancy in women receiving nucleoside
analogues. Dose adjustment is not needed for pregnancy. The Perinatal HIV Guidelines Working Group considers abacavir to be an alternative NRTI in dual nucleoside
combination regimens. Health professionals are encouraged to contact the antiretroviral pregnancy registry to monitor outcomes of pregnant women exposed to
antiretroviral medications (1-800-258-4263 or www.APRegistry.com).
LactationExcretion in breast milk unknown/contraindicated
Breast-Feeding ConsiderationsHIV-infected mothers are dis couraged from breast-feeding to decrease potential transmission of HIV. Adverse
ReactionsHypersensitivity reactions (which may be fatal) occur in ∼5% of patients (see Warnings/Precautions). Symptoms may include anaphylaxis, fever, rash
(including erythema multiforme), fatigue, diarrhea, abdominal pain; respiratory symptoms (eg, pharyngitis, dyspnea, cough, adult respiratory distress syndrome, or
respiratory failure); headache, malaise, lethargy, myalgia, myolysis, arthralgia, edema, paresthesia, nausea and vomiting, mouth ulcerations, conjunctivitis,
lymphadenopathy, hepatic failure, and renal failure.
Note: Rates of adverse reactions were defined during combination therapy with other antiretrovirals (lamivudine and efavirenz or lamivudine and zidovudine). Only
reactions which occurred at a higher frequency in adults (except where noted) than in the comparator group are noted.
Adverse reaction rates attributable to abacavir alone are not available.
>10%:
Central nervous system: Headache (7% to 13%)
Gastrointestinal: Nausea (7% to 19%, children 9%)
1% to 10%:
Central nervous system: Depression (6%), fever/chills (6%, children 9%), anxiety (5%)
Dermatologic: Rash (5% to 6%, children 7%)
Endocrine & metabolic: Triglycerides increased (2% to 6%)
Gastrointestinal: Diarrhea (7%), vomiting (children 9%), amylase increased (2%)
Hematologic: Thrombocytopenia (1%)
Hepatic: AST increased (6%)
Neuromus cular & skeletal: Mus culoskeletal pain (5% to 6%)
Mis cellaneous: Hypersensitivity reactions (2% to 9%; may include reactions to other components of antiretroviral regimen), infection (EENT 5%)
<1%, postmarketing, and/or case reports (limited to important or life-threatening): Erythema multiforme, fat redistribution, GGT increased, hepatic steatosis,
hepatomegaly, hepatotoxicity, lactic acidosis, MI, pancreatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis
Drug Interactions
Ethanol/Nutrition/Herb InteractionsEthanol: Ethanol may increase the risk of toxicity.

Monitoring ParametersCBC with differential, serum creatine kinase, CD4 count, HIV RNA plasma levels, serum transaminases, triglycerides, serum amylase; HLA-
B*5701 genotype status prior to initiation of therapy and prior to reinitiation of therapy in patients of unknown HLA B*5701 status; signs and symptoms of
hypersensitivity, particularly in patients untested for the HLA-B*5701 allele Nursing: Physical Assessment/MonitoringAssess closely for any previous
exposure/allergy to abacavir and evaluate risk factors for heart disease prior to beginning treatment. Assess other pharmacological or herbal products patient may be
taking for potential interactions or toxicity; dosing adjustments may be necessary. A list of medications that should not be used is available in each bottle and patients
should be provided with this information. Note: Patient must be closely monitored for any sign of hypersensitivity reaction which can occur within hours or at any time
and may be fatal (can occur also at reintroduction with patients who have no history of previous reaction) (See Warnings/Precautions). Assess results of laboratory
tests and effectiveness of therapy (decrease in infections and progress of disease; viral load and CD4 count) periodically during therapy. Teach patient proper use (eg,
timing of multiple medications and drugs that should not be used concurrently), possible side effects/appropriate interventions, and importance of immediately
reporting any sign of hypersensitivity or myocardial infarction.
Monitoring: Lab TestsCBC with differential, serum creatine kinase, CD4 count, HIV RNA plasma levels, serum transaminases, triglycerides, serum amylase; HLA-
B*5701 genotype status prior to initiation of therapy and prior to reinitiation of therapy in patients of unknown HLA B*5701 status
Patient EducationYou will be provided with a medication guide (identifying medications that should not be used during therapy) and a warning card (summarizing
symptoms of hypersensitivity). Do not take any new pres criptions, over-the-counter medications, or herbal products (even if they are not on the list) without consulting
pres criber. This drug will not cure HIV, nor has it been found to reduce transmission of HIV; use appropriate precautions to prevent spread to other persons. This drug is
pres cribed as one part of a multidrug combination; take exactly as directed for full course of therapy. Maintain adequate hydration (2-3 L/day of fluids) unless advised
by pres criber to restrict fluids. Avoid alcohol to decrease risk of hypersensitivity reaction. You may be sus ceptible to infection; avoid crowds and exposure to known
infections and do not have any vaccinations without consulting pres criber. Frequent blood tests may be required with prolonged therapy. May cause dizziness or
weakness (use caution when driving or engaging in tasks requiring alertness until response to drug is known); nausea and vomiting (small frequent meals, frequent
mouth care, chewing gum, or sucking lozenges may help). Note: Seek immediate emergency care if you experience unusual chest pain, palpitations, erratic heart beat or
if you suspect you are having a heart attack. Stop drug and report immediately symptoms of hypersensitivity (eg, fever; rash; fatigue, malaise, lethargy; persistent
nausea, vomiting, diarrhea, abdominal pain; mouth sores; sore throat, cough, difficulty breathing; headache; swelling of face, mouth or throat; numbness or loss of
sensation; pain, tingling, or numbness in toes, feet, mus cles or joints; swollen glands; alterations in urinary pattern; swelling of extremities or weight gain). Do not
restart without specific instruction by your pres criber. If you are instructed to stop the medication, do not restart in the future. Pregnancy/breast-feeding precautions:
Inform pres criber if you are or intend to become pregnant. Do not breast-feed. Dosage FormsExcipient information presented when available (limited, particularly
for generics); consult specific product labeling.
Solution, oral:
Ziagen®: 20 mg/mL (240 mL) [strawberry-banana flavor]
Tablet:
Ziagen®: 300 mg
Generic AvailableNo
ManufacturerGlaxoSmithKline
Solution (Ziagen)
20 mg/mL (240): $125.04
Tablets (Ziagen)
300 mg (60): $514.18
Mechanism of ActionNucleoside reverse trans criptase inhibitor. Abacavir is a guanosine analogue which is phosphorylated to carbovir triphosphate which
interferes with HIV viral RNA-dependent DNA polymerase resulting in inhibition of viral replication. Pharmacodynamics/Kinetics
Absorption: Rapid and extensive absorption
Distribution: Vd: 0.86 L/kg
Protein binding: 50%
Metabolism: Hepatic via alcohol dehydrogenase and glucuronyl transferase to inactive carboxylate and glucuronide metabolites Bioavailability: 83%
Half-life elimination: 1.5 hours
Time to peak: 0.7-1.7 hours
Excretion: Primarily urine (as metabolites, 1.2% as unchanged drug); feces (16% total dose)
Related Information
Pharmacotherapy PearlsA high rate of early virologic nonresponse was observed when abacavir, lamivudine, and tenofovir were used as the initial regimen in
treatment-naive patients. Use of this combination is not recommended; patients currently on this regimen should be closely monitored for modification of therapy.
Hypersensitivity testing (HLA-B*5701): Prevalence of hypersensitivity reactions has been estimated at 5% to 8% in Caucasians and 2% to 3% in African-Americans.
Pretherapy identification of HLA-B*5701-positive patients, and subsequent avoidance of abacavir therapy in these patients has been shown to reduce the occurrence of
abacavir-mediated hypersensitivity reactions. A skin patch test is in development for clinical s creening purposes; however, only PCR-mediated genotyping methods are
currently in clinical practice use for documentation of this sus ceptibility marker.

Effects on Mental StatusMay cause fatigue, lethargy, malaise, insomnia, and headache
Mental Health: Effects on Psychiatric TreatmentSide effects mimic depressive symptoms; caution with benzodiazepines or other CNS depressants and
antidepressants
Index TermsAbacavir Sulfate; ABC
References
Foster RH and Faulds D, “Abacavir,” Drugs, 1998, 55(5):729-36. [PubMed 9585869]
Havlir DV and Lange JM, “New Antiretrovirals and New Combinations,” AIDS, 1998, 12(Suppl A):165-74.
Kline MW, Blanchard S, Fletcher CV, et al, “A Phase I Study of Abacavir (1592U89) Alone and in Combination With Other Antiretroviral Agents in Infants and Children
With Human Immunodeficiency Virus Infection,” Pediatrics, 1999, 103(4):e47. Available at: http://www.pediatrics.org/cgi/content/full/103/4/e47. [PubMed
10103339]
17317695]
Mallal S, Nolan D, Witt C, et al, “Association Between Presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and Hypersensitivity to HIV-1 Reverse Trans criptase
Inhibitor Abacavir,” Lancet, 2002, 359:727-32. [PubMed 11888582]
“Perinatal HIV Guidelines Working Group. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States,” July 8, 2008. Available at
http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf.
Schmit JC and Weber B, “Recent Advances in Antiretroviral Therapy and HIV Infection Monitoring,” Intervirology, 1997, 40(5-6):304-21. [PubMed 9675636]
“Three New Drugs for HIV Infection,” Med Lett Drugs Ther, 1998, 40(1041):114-6. [PubMed 9854567]
Weverling GJ, Lange JM, Jurriaans S, et al, “Alternative Multidrug Regimen Provides Improved Suppression of HIV-1 Replication Over Triple Therapy,” AIDS, 1998,
12(11):F117-22. [PubMed 9708401]
July 29, 2008. Available at: http://www.aidsinfo.nih.gov.
International Brand NamesAbamune (IN); Ampi-quim (MX); Filabac (AR); Zepril (AR); Ziagen (AT, AU, BB, BE, BG, BM, BS, BZ, CH, CL, CN, CO, CR, CZ, DE, DK, DO, ES, FI,
FR, GB, GR, GT, GY, HK, HN, IE, IL, IT, JM, KP, NI, NL, NO, PA, PE, PL, PT, RU, SE, SG, SR, SV, TR, TT, TW, VE); Ziagenavir (AR, BR, MX, TH, UY)

Abatacept
Lexi-Drugs Online
English
English Jump To Field (Select Field

Name)
Medication Safety Issues
Sound-alike/look-alike issues:
Orencia® may be confused with Oracea™
Pronunciation(ab a TA sept)
U.S. Brand NamesOrencia®
Canadian Brand NamesOrencia®
Pharmacologic CategoryAntirheumatic, Disease Modifying
Use: Labeled Indications
Treatment of moderately- to severely-active adult rheumatoid arthritis (RA); may be used as monotherapy or in combination with other DMARDs
Treatment of moderately- to severely-active juvenile idiopathic arthritis (JIA); may be used as monotherapy or in combination with methotrexate
Note: Abatacept should not be used in combination with anakinra or TNF-blocking agents
Dosing: AdultsRheumatoid arthritis: I.V.: Dosing is according to body weight. Repeat dose at 2 weeks and 4 weeks after initial dose, and every 4 weeks thereafter:
<60 kg: 500 mg
60-100 kg: 750 mg
>100 kg: 1000 mg
Dosing: ElderlyRefer to adult dosing. Due to potential for higher rates of infections and malignancies, use caution. Dosing:
PediatricJIA: I.V.:
Children ≥6 years and <75 kg: 10 mg/kg, repeat dose at 2 and 4 weeks after initial infusion, and every 4 weeks thereafter; Maximum dose: 1000 mg
Children ≥6 years and >75 kg: Note: Dosage is according to body weight. Repeat dose at 2 weeks and 4 weeks after initial dose and every 4 weeks thereafter:
75-100 kg: 750 mg
>100 kg: 1000 mg
Dosing: Adjustment for ToxicityWithhold therapy for patients with serious infections.
Administration: I.V.Infuse over 30 minutes. Administer through a 0.2-1.2 micron low protein-binding filter Administration:
I.V. DetailpH: 7-8
StoragePrior to reconstitution, store at 2°C to 8°C (36°F to 46°F); protect from light. After dilution, may be stored for up to 24 hours at room temperature or
refrigerated at 2°C to 8°C (36°F to 46°F). Must be used within 24 hours of reconstitution.
ReconstitutionReconstitute each vial with 10 mL SWFI using the provided silicone-free disposable syringe (dis card solutions accidentally reconstituted with
siliconized syringe as they may develop translucent particles). Inject SWFI down the side of the vial to avoid foaming. The reconstituted solution contains 25 mg/mL
abatacept. Further dilute (using a silicone-free syringe) in 100 mL NS to a final concentration of ≤10
mg/mL. Prior to adding abatacept to the 100 mL bag, the manufacturer recommends withdrawing a volume of NS equal to the abatacept volume required, resulting in a
final volume of 100 mL. Mix gently; do not shake.
CompatibilityStable in NS.
ContraindicationsThere are no contraindications listed within the FDA-approved labeling.

• Anaphylaxis/hypersensitivity reactions: Rare cases of hypersensitivity, anaphylaxis, or anaphylactoid reactions have been reported; medication for the
treatment of hypersensitivity reactions should be available for immediate use.
• Infections: Caution should be exercised when considering the use in patients with a history of new/recurrent infections, with conditions that predispose them to
infections, or with chronic, latent, or localized infections. Patients who develop a new infection while undergoing treatment should be monitored closely. If a
patient develops a serious infection, therapy should be dis continued.
• Malignancy: Use may affect defenses against malignancies (via T cell inhibition); impact on the development and course of malignancies is not fully defined. As
compared to the general population, an increased risk of lymphoma and lung cancer has been
noted in clinical trials; however, rheumatoid arthritis has been previously associated with an increased rate of lymphoma. Disease-related
concerns:
• COPD: Use caution with chronic obstructive pulmonary disease (COPD), higher incidences of adverse effects (COPD exacerbation, cough, rhonchi, dyspnea)
have been observed; monitor closely.
Concurrent drug therapy issues:
• Anakinra: The manufacturer does not recommend concurrent use with anakinra.
• TNF-blocking agents: Adult patients receiving therapy in combination with TNF-blocking agents had higher rates of infections (including serious infections) than
patients on TNF-blocking agents alone. Concurrent use with TNF-blocking agents is not recommended. Monitor for signs and symptoms of infection when
transitioning from TNF-blocking agents to abatacept.
• Elderly: Use with caution, higher incidences of infection and malignancy were observed in the elderly.
• Pediatrics: Not FDA approved for use in children <6 years of age.
• Tuberculosis-positive patients: Safety has not been established in tuberculosis-positive patients; s creen patients for latent tuberculosis infection prior to
initiating therapy. Treat patients testing positive according to standard therapy prior to initiating abatacept.
Dosage form specific issues:
• Maltose: May contain maltose, which may result in falsely-elevated serum glucose readings on the day of infusion. Other
warnings/precautions:
• Hepatitis s creening: Patients should be s creened for viral hepatitis prior to use; antirheumatic therapy may cause reactivation of hepatitis B.
• Immunizations: Patients should be brought up to date with all immunizations before initiating therapy. Live vaccines should not be given concurrently or within
3 months of dis continuation of therapy; there is no data available concerning secondary transmission of live vaccines in patients receiving therapy.
Geriatric ConsiderationsThe number of elderly (≥65 years of age) were insufficient to draw significant clinical conclusions. The studies to date have not demonstrated
any differences in safety and efficacy between young adults and elderly. However, the frequency of infections and malignancy was higher in those >65 years of age than
those <65 years. Since elderly experience a higher incidence of infections and malignancies, use abatacept with caution in this population.
Pregnancy ConsiderationsTeratogenic effects were not observed in animal studies. There are no adequate and well-controlled studies in pregnant women. Due to
the potential risk for development of autoimmune disease in the fetus, use during pregnancy only if clearly needed. A pregnancy registry has been established to
monitor outcomes of women exposed to abatacept during pregnancy (1-877-311-8972). LactationExcretion in breast milk unknown/not recommended
Breast-Feeding ConsiderationsDue to the potential for adverse reactions and possible effects on the developing immune system, breast feeding is not
recommended.
Adverse ReactionsNote: Percentages not always reported; COPD patients experienced a higher frequency of COPD-related adverse reactions (COPD exacerbation,
cough, dyspnea, pneumonia, rhonchi)
>10%:
Central nervous system: Headache (≤18%)
Gastrointestinal: Nausea
Respiratory: Nasopharyngitis (12%), upper respiratory tract infection
Mis cellaneous: Infection (adults 54%; children 36%), antibody formation (2% to 41%)
1% to 10%:
Cardiovas cular: Hypertension (7%)
Central nervous system: Dizziness (9%), fever
Dermatologic: Rash (4%)
Gastrointestinal: Dyspepsia (6%), abdominal pain, diarrhea
Genitourinary: Urinary tract infection (6%)
Neuromus cular & skeletal: Back pain (7%), limb pain (3%)
Respiratory: Cough (8%), bronchitis, pneumonia, rhinitis, sinusitis
Mis cellaneous: Infusion-related reactions (2% to 9%), herpes simplex, influenza

<1%, postmarketing, and/or case reports: Acute lymphocytic leukemia, anaphylaxis, anaphylactoid reactions, cellulitis, COPD exacerbation,
disease flare, diverticulitis, dyspnea, flushing, hypersensitivity, hypotension, joint wear, lung cancer, lymphoma; malignancies (including bile duct, bladder, breast,
cervical, melanoma, myelodysplastic syndrome, prostate, renal, skin, thyroid and uterine); ovarian cyst, pruritus, pyelonephritis, rhonchi, urticaria, varicella
infection, wheezing
Drug Interactions
Anti-TNF Agents: May enhance the adverse/toxic effect of Abatacept. An increased risk of serious infection during concomitant use has been reported. Risk D:
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy modification
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Risk X: Avoid
combination
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Risk C: Monitor therapy
Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Vaccinal infections may develop. Immunosuppressants
may also decrease therapeutic response to vaccines. Risk X: Avoid combination
Ethanol/Nutrition/Herb InteractionsHerb/Nutraceutical: Avoid echinacea (has immunostimulant properties; consider therapy modifications).
Test InteractionsContains maltose; may result in falsely elevated blood glucose levels with dehydrogenase pyrroloquinolinequinone or glucose-dye-
oxidoreductase testing methods on the day of infusion. Glucose monitoring methods which utilize glucose dehydrogenase nicotine adenine dinucleotide (GDH-
NAD), glucose oxidase, or glucose hexokinase are recommended.
Monitoring ParametersSigns and symptoms of infection, signs and symptoms of infusion reaction; hepatitis and TB s creening prior to therapy initiation
Nursing: Physical Assessment/MonitoringMonitor therapeutic response and adverse reactions. Perform testing for tuberculosis prior to initiating therapy. Assess for
infection prior to initiating infusion. Teach patient appropriate interventions to reduce side effects and adverse symptoms to report.
Monitoring: Lab TestsHepatitis and TB s creening prior to therapy initiation
Patient EducationThis drug can only be administered by infusion. You may be more sus ceptible to infections. Report signs of infection. Avoid immunizations unless
approved by pres criber. May cause falsely elevated blood glucose readings on day of infusion. You may experience headache, sore throat, and nausea. Report
immediately respiratory difficulty, hives, dizziness, nausea, flushing, cough, or wheezing. Pregnancy/breast-feeding precautions: Inform pres criber if you are or intend
to become pregnant. Breast-feeding is not recommended. Dosage FormsExcipient information presented when available (limited, particularly for generics); consult
specific product labeling.
Injection, powder for reconstitution [preservative free]:
Orencia®: 250 mg [contains maltose]
Generic AvailableNo
ManufacturerBristol-Myers Squibb Company
Solution (reconstituted) (Orencia)
250 mg (1): $511.47
Mechanism of ActionSelective costimulation modulator; inhibits T-cell (T-lymphocyte) activation by binding to CD80 and CD86 on antigen presenting cells (APC),
thus blocking the required CD28 interaction between APCs and T cells. Activated T lymphocytes are found in the synovium of rheumatoid arthritis patients.
Pharmacodynamics/Kinetics
Distribution: Vss: 0.02-0.13 L/kg
Half-life elimination: 8-25 days

Effects on Mental StatusMay cause dizziness
Mental Health: Effects on Psychiatric TreatmentMay cause nausea; concomitant use with SSRIs, lithium, valproic acid, and carbamazepine may produce additive
effects
Index TermsCTLA-4Ig
References
Doan T and Massarotti E, “Rheumatoid Arthritis: An Overview of New and Emerging Therapies,” J Clin Pharmacol, 2005, 45(7):751-62.[PubMed 15951465]
Furst DE, Breedveld FC, Kalden JR, et al, “Updated Consensus Statement on Biological Agents for the Treatment of Rheumatic Diseases, 2007,” Ann Rheum Dis, 2007,
66(Suppl 3):2-22.[PubMed 17934088]
Genovese MC, Becker JC, Schiff M, et al, “Abatacept for Rheumatoid Arthritis Refractory to Tumor Necrosis Factor Alpha Inhibition,” N Engl J Med, 2005, 353(11):1114-
23.[PubMed 16162882]
Kremer JM, Dougados M, Emery P, et al, “Treatment of Rheumatoid Arthritis With the Selective Costimulation Modulator Abatacept: Twelve Month Results of a
Phase IIb, Double-Blind, Randomized, Placebo-Controlled Trial,” Arthritis Rheum, 2005, 52(8):2263-71. [PubMed 16052582]
Kremer JM, Genant HK, Moreland LW, et al, “Effects of Abatacept in Patients With Methotrexate-Resistant Active Rheumatoid Arthritis: A Randomized Trial,”
Ann Intern Med, 2006, 144(12):865-76.[PubMed 16785475]
Kremer JM, Westhovens R, Leon M, et al, “Treatment of Rheumatoid Arthritis by Selective Inhibition of T-Cell Activation With Fusion Protein CTLA4Ig,” N Engl J
Med, 2003, 349(20):1907-15.[PubMed 14614165]
Tay L, Leon F, Vratsanos G, et al, “Vaccination Response to Tetanus Toxoid and 23-Valent Pneumococcal Vaccines Following Administration of a Single Dose of
Abatacept: A Randomized, Open-Label, Parrallel Group Study in Healthy Subjects,” Arthritis Res Ther, 2007, 9(2): R38.[PubMed 17425783]
Weinblatt M, Combe B, Covucci A, et al, “Safety of the Selective Costimulation Modulator Abatacept in Rheumatoid Arthritis Patients Receiving Background Biologic
and Nonbiologic Disease-Modifying Antirheumatic Drugs: A One-Year Randomized, Placebo-Controlled Study,” Arthritis Rheum, 2006, 54(9):2807-16.[PubMed
16947384]
International Brand NamesOrencia (AR, CH, CZ, DE, DK, EE, GB, IE, NO, SE)

Abciximab
Lexi-Drugs Online
English
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of
causing significant patient harm when used in error.
Pronunciation(ab SIK si mab)

U.S. Brand NamesReoPro®
Canadian Brand NamesReopro®
Pharmacologic CategoryAntiplatelet Agent, Glycoprotein IIb/IIIa Inhibitor
Use: Labeled IndicationsPrevention of acute cardiac is chemic complications in patients at high risk for abrupt closure of the treated coronary vessel and patients at
risk of restenosis; an adjunct with heparin to prevent cardiac is chemic complications in patients with unstable angina not responding to conventional therapy when a
percutaneous coronary intervention (PCI) is s cheduled within 24 hours Use: Unlabeled/InvestigationalAcute MI - combination regimen of abciximab (full dose),
tenecteplase (half dose), and heparin (unlabeled dose)
Dosing: Adults
Prevention of restenosis (patients at high risk for abrupt closure): I.V.: 0.25 mg/kg bolus administered 10-60 minutes before the start of intervention followed by an
infusion of 0.125 mcg/kg/minute (maximum: 10 mcg/minute) for 12 hours
Patients with unstable angina not responding to conventional medical therapy and with planned percutaneous coronary intervention within 24 hours: I.V.: 0.25
mg/kg intravenous bolus followed by an 18- to 24-hour intravenous infusion of 10 mcg/minute, concluding 1 hour after the percutaneous coronary
intervention.
Acute MI combination regimen (unlabeled): Half-dose tenecteplase (15-25 mg based on weight), abciximab 0.25 mg/kg bolus then 0.125 mcg/kg/minute
(maximum: 10 mcg/minute) for 12 hours and heparin dosing as follows: Concurrent bolus of 40 units/kg (maximum: 3000 units), then 7 units/kg/hour
(maximum: 800 units/hour) as continuous infusion. Adjust to aPTT target of 50-70 seconds.
Dosing: ElderlyRefer to adult dosing.

Calculations
Abciximab
Administration: I.V.Abciximab is intended for coadministration with aspirin postangioplasty and heparin infused and weight adjusted to maintain a therapeutic
bleeding time (eg, ACT 300-500 seconds). Solution must be filtered prior to administration. Do not shake the vial. Administration: I.V. Detail
Bolus dose: Aseptically withdraw the necessary amount of abciximab for the bolus dose into a syringe using a 0.2 or 5 micron low protein binding syringe filter (or
equivalent); the bolus should be administered 10-60 minutes before the procedure
Continuous infusion: Aseptically withdraw amount required of abciximab for the infusion through a 0.2 or 5 micron low protein-binding syringe filter into a syringe;
inject this into 250 mL of NS or D5W to make solution. If a syringe filter was not used when preparing the infusion, administer using an in-line 0.2 or 0.22 micron low
protein-binding filter. Note: Alternatively, a standard concentration of 7.2 mg in 250 mL of NS or D 5W may also be prepared for all patients and administered at the
standard dose (0.125 mcg/kg/minute; maximum: 10 mcg/minute) with a variable rate in mL/hour. Infuse for 12-24 hours via pump after bolus dose; length of therapy
dependent on indication.
StorageVials should be stored at 2°C to 8°C. Do not freeze or shake. After admixture, the prepared solution is stable for 12 hours. CompatibilityAbciximab
should be administered in a separate intravenous line. No incompatibilities have been observed with glass bottles or PVC bags.
ContraindicationsHypersensitivity to abciximab, to murine proteins, or any component of the formulation; active internal hemorrhage or recent (within 6 weeks)
clinically-significant GI or GU bleeding; history of cerebrovas cular accident within 2 years or cerebrovas cular accident with significant neurological deficit; clotting
abnormalities or administration of oral anticoagulants within 7 days unless prothrombin time (PT) is ≤1.2 times control PT value; thrombocytopenia (<100,000
cells/μL); recent (within 6 weeks) major surgery or trauma; intracranial tumor, arteriovenous malformation, or aneurysm; severe uncontrolled hypertension; history of
vas culitis; use of dextran before PTCA or intent to use dextran during PTCA; concomitant use of another parenteral GP IIb/IIIa inhibitor
Glycoprotein (GP) IIb/IIIa Inhibitor Allergy

• Anaphylaxis/hypersensitivity reactions: Administration may result in human antichimeric antibody formation that can cause hypersensitivity
reactions (including anaphylaxis).
• Bleeding: The most common complication is bleeding, including retroperitoneal, pulmonary, and spontaneous GI and/or GU bleeding; watch closely for bleeding,
3
especially the arterial access site for the cardiac catheterization. Use with extreme caution in patients with platelet counts <150,000/mm , patients with
hemorrhagic retinopathy, previous history of GI disease, recent thrombolytic therapy and in chronic dialysis patients. Use caution with administration of other
drugs affecting hemostasis. Minimize other procedures including arterial and venous punctures, I.M. injections, nasogastric tubes, etc. Increased risk of
hemorrhage during or following angioplasty is associated with unsuccessful PTCA, PTCA procedure >70 minutes duration, or PTCA performed within 12 hours
of symptom onset for acute myocardial infarction.
• Thrombocytopenia: Administration may result in human antichimeric antibody formation that can cause thrombocytopenia; readministration within 30 days
or in patients with human antichimeric antibodies (HACA) increases the incidence and severity of thrombocytopenia.
• Elderly: Use with caution in patients >65 years of age; increased risk of bleeding.
• Low weight patients: Use with caution in patients weighing <75 kg; increased risk of bleeding.
• Pediatrics: Safety and efficacy have not been established in children.
Other warnings/precautions:
• Diminished efficacy: Administration may result in human antichimeric antibody formation that can cause diminished efficacy.
• Sheath removal: Prior to pulling the sheath, heparin should be dis continued for 3-4 hours and ACT ≤175 seconds or aPTT ≤50 seconds. Use standard
compression techniques after sheath removal. Watch the site closely afterwards for further bleeding.

Pregnancy ConsiderationsAnimal reproduction studies have not been conducted. In vitro studies have shown only small amounts of abciximab to cross the
placenta. It is not known whether abciximab can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity.
LactationExcretion in breast milk unknown/use caution
Adverse ReactionsAs with all drugs which may affect hemostasis, bleeding is associated with abciximab. Hemorrhage may occur at virtually any site. Risk is dependent
on multiple variables, including the concurrent use of multiple agents which alter hemostasis and patient sus ceptibility.
>10%:
Cardiovas cular: Hypotension (14%), chest pain (11%)
Gastrointestinal: Nausea (14%)
Hematologic: Minor bleeding (4% to 17%)
Neuromus cular & skeletal: Back pain (18%)
1% to 10%:
Cardiovas cular: Bradycardia (5%), peripheral edema (2%)
Central nervous system: Headache (7%)
Gastrointestinal: Vomiting (7%), abdominal pain (3%)
3 3
Hematologic: Major bleeding (1% to 14%), thrombocytopenia: <100,000 cells/mm (3% to 6%); <50,000 cells/mm (0.4% to 2%) Local: Injection
site pain (4%)
<1% (Limited to important or life-threatening): Abnormal thinking, abnormal vision, agitation, allergic reactions/anaphylaxis (possible), anemia, anxiety, arteriovenous
fistula, bronchitis, bronchospasm, bullous eruption, cellulitis, coma, complete AV block, confusion, cystalgia, diabetes mellitus, diaphoresis increased, diarrhea,
diplopia, dizziness, dyspepsia, dysuria, embolism, gastroesophageal reflux, hyperkalemia, hypertonia, hypoesthesia, ileus, incomplete AV block, inflammation,
intracranial hemorrhage, leukocytosis, mus cle contractions, myalgia, nodal arrhythmia, pain, palpitation, peripheral coldness, petechiae, pleural effusion,
pneumonia, prostatitis, pruritus, pseudoaneurysm, pulmonary embolism, stroke, thrombophlebitis, urinary incontinence, urinary retention, ventricular
tachycardia, weakness, xerostomia
Drug Interactions
Anticoagulants: Antiplatelet Agents may enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy Antiplatelet
Agents: May enhance the anticoagulant effect of other Antiplatelet Agents. Risk C: Monitor therapy Dasatinib: May enhance the
anticoagulant effect of Antiplatelet Agents. Risk C: Monitor therapy
Dextran: May enhance the anticoagulant effect of Abciximab. Risk X: Avoid combination
Drotrecogin Alfa: Antiplatelet Agents may enhance the adverse/toxic effect of Drotrecogin Alfa. Bleeding may occur. Risk D: Consider therapy modification
Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Antiplatelet Agents. Bleeding may occur.
Risk D: Consider therapy modification
Ibritumomab: Antiplatelet Agents may enhance the adverse/toxic effect of Ibritumomab. Both agents may contribute to impaired platelet function and an
increased risk of bleeding. Risk C: Monitor therapy
Monoclonal Antibodies: Abciximab may enhance the potential for allergic or hypersensitivity reactions to Monoclonal Antibodies. Also may cause thrombocytopenia
or diminished therapeutic effects. Exceptions: Alefacept. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May enhance the adverse/toxic effect of Antiplatelet Agents. An increased risk of bleeding may occur. Nonsteroidal Anti-
Inflammatory Agents may diminish the cardioprotective effect of Antiplatelet Agents. This interaction is likely specific to aspirin, and not to other antiplatelet
agents. Risk C: Monitor therapy
Omega-3-Acid Ethyl Esters: May enhance the antiplatelet effect of Antiplatelet Agents. Risk C: Monitor therapy
Pentosan Polysulfate Sodium: May enhance the adverse/toxic effect of Antiplatelet Agents. Specifically, the risk of bleeding may be increased by concurrent use of
these agents. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the antiplatelet effect of Antiplatelet Agents. Risk C: Monitor therapy
Salicylates: Antiplatelet Agents may enhance the adverse/toxic effect of Salicylates. Increased risk of bleeding may result. Risk C: Monitor therapy
Thrombolytic Agents: Antiplatelet Agents may enhance the anticoagulant effect of Thrombolytic Agents. Risk C: Monitor therapy
Tositumomab and Iodine I 131 Tositumomab: Antiplatelet Agents may enhance the adverse/toxic effect of Tositumomab and Iodine I 131 Tositumomab.
Specifically, the risk of bleeding-related adverse events may be increased. Risk C: Monitor therapy
Monitoring ParametersProthrombin time, activated partial thromboplastin time (aPTT), hemoglobin, hematocrit, platelet count, fibrinogen, fibrin split products,
transfusion requirements, signs of hypersensitivity reactions, guaiac stools, Hemastix® urine. Platelet count should be monitored at baseline, 2-4 hours following bolus
infusion, and at 24 hours (or prior to dis charge, if before 24 hours). To minimize risk of bleeding:
Abciximab initiated 18-24 hours prior to PCI: Maintain aPTT between 60-85 seconds during the heparin/abciximab infusion period During PCI: Maintain
ACT between 200-300 seconds
Following PCI (if anticoagulation is maintained): Maintain aPTT between 50-75 seconds
Sheath removal should not occur until aPTT is ≤50 seconds or ACT ≤175 seconds.
Maintain bleeding precautions, avoid unnecessary arterial and venous punctures, use saline or heparin lock for blood drawing, assess sheath insertion site and distal
pulses of affected leg every 15 minutes for the first hour and then every 1 hour for the next 6 hours. Arterial access site care is important to prevent bleeding. Care
should be taken when attempting vas cular access that only the anterior wall of the femoral artery is punctured, avoiding a Seldinger (through and through)
technique for obtaining sheath access. Femoral vein sheath placement should be avoided unless needed. While the vas cular sheath is in place, patients should be
maintained on complete bedrest with the head of the bed at a 30° angle and the affected limb restrained in a straight position.
Observe patient for mental status changes, hemorrhage; assess nose and mouth mucous membranes, puncture sites for oozing, ecchymosis, and hematoma
formation; and examine urine, stool, and emesis for presence of occult or frank blood; gentle care should be provided when removing dressings.
Nursing: Physical Assessment/MonitoringMonitor vital signs and laboratory results prior to, during, and after therapy. Assess infusion insertion site and peripheral
pulses during and after therapy. Observe and teach patient bleeding precautions (avoid invasive procedures and activities that could result in injury). Monitor closely for
signs of excessive bleeding. Pregnancy risk factor C. Note breast-feeding caution. Monitoring: Lab TestsProthrombin time, activated partial thromboplastin time
(aPTT), hemoglobin, hematocrit, platelet count, fibrinogen, fibrin split products, transfusion requirements, signs of hypersensitivity reactions, guaiac stools, Hemastix®
urine. Platelet count should be monitored at baseline, 2-4 hours following bolus infusion, and at 24 hours (or prior to dis charge, if before 24 hours). To minimize risk of
bleeding:
Abciximab initiated 18-24 hours prior to PCI: Maintain aPTT between 60-85 seconds during the heparin/abciximab infusion period During PCI: Maintain
ACT between 200-300 seconds
Following PCI (if anticoagulation is maintained): Maintain aPTT between 50-75 seconds
Sheath removal should not occur until aPTT is ≤50 seconds or ACT ≤175 seconds.
Patient EducationThis medication can only be administered I.V. You will have a tendency to bleed easily following this medication; use caution to prevent injury (use
electric razor, soft toothbrush, and use caution with knives, needles, or anything sharp). If bleeding occurs, apply pressure to bleeding spot until bleeding stops
completely. Report unusual bruising or bleeding; blood in urine, stool, or vomitus; bleeding gums; or vision changes. Pregnancy/breast-feeding precautions: Inform pres
criber if you are or intend to become pregnant. Consult pres criber if breast-feeding.
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. Injection, solution:
ReoPro®: 2 mg/mL (5 mL)
Generic AvailableNo
Mechanism of ActionFab antibody fragment of the chimeric human-murine monoclonal antibody 7E3; this agent binds to platelet IIb/IIIa receptors, resulting in
steric hindrance, thus inhibiting platelet aggregation
Pharmacodynamics/KineticsHalf-life elimination: ∼30 minutes
Related Information
Glycoprotein Antagonists
Dental Health: Effects on Dental TreatmentKey adverse event(s) related to dental treatment: As with all anticoagulants, bleeding is a potential adverse effect
of abciximab during dental surgery; risk is dependent on multiple variables, including the intensity of anticoagulation and patient sus ceptibility. Medical consult
is suggested. It is unlikely that ambulatory patients presenting for dental treatment will be taking intravenous anticoagulant therapy.
Effects on Mental StatusNone reported
Mental Health: Effects on Psychiatric TreatmentNone reported
Cardiovas cular Considerations
Acute Coronary Syndrome (ACS): The 2002 ACC/AHA guidelines for unstable angina/non-ST-segment elevation myocardial infarctions (UA/NSTEMI) recommend
administration of intravenous glycoprotein llb/llla inhibitors (along with ASA and heparin) in patients with non-ST-segment elevation ACS who are expected to undergo
catheterization and PCI. In such patients in which PCI in not expected, eptifibatide or tirofiban should be administered (along with ASA and either heparin or LMWH) if
high-risk features (eg, positive biochemical markers of infarction, ST segment depression, sustained VT, >75 years of age, or signs of LV dysfunction) or refractory is
chemia are present.
Percutaneous Coronary Intervention (PCI): A glycoprotein llb/llla inhibitor is recommended for patients who will undergo PCI, especially those with unstable angina or
other high risks for postprocedure is chemic complications. In the TARGET trial, abciximab (FDA-approved dose) and tirofiban (10 mcg/kg bolus; infusion of 0.15
mcg/kg/minute for 18-24 hours) were compared to each other in patients undergoing coronary stenting. The primary endpoint was death, nonfatal MI, or urgent
target vessel revas cularization at 30 days. Abciximab improved outcome to a greater extent than tirofiban did primarily by reducing nonfatal MI. Follow-up at 6
months revealed no significant difference in primary outcomes between treatments, but a trend existed in favor of abciximab reducing the occurrence of MIs.
STEMI: Adjunct to Thrombolysis: In the GUSTO V trial, patients with acute MI were randomized to standard-dose reteplase or half-dose reteplase (two boluses of 5
units each, 30 minutes apart) and full-dose abciximab. Mortality at 30 days (primary endpoint) was similar in both groups. The combination treatment group had
significantly fewer reinfarctions or recurrent episodes of is chemia. Combination treatment was also associated with less need for urgent revas cularization. More
bleeding occurred in the combination treatment group, but the incidence of nonfatal disabling stroke and stroke of any type were similar in both groups. Overall, no
difference in intracranial hemorrhages was observed between the two treatments, but a trend towards an increased incidence occurred in patients >75 years of age
who received combination treatment. Patients with acute MI were randomized in an open-label study to full-dose tenecteplase and enoxaparin, half-dose tenecteplase
with low-dose, weight-based heparin and a 12-hour infusion of abciximab or full-dose tenecteplase with weight-based heparin (ASSENT-3 Investigators, 2001). The
primary endpoint (30 days) was mortality, in-house reinfarction, and in-house refractory is chemia. The abciximab arm and the enoxaparin arm had significantly less
mortality, reinfarction, and refractory is chemia than in the unfractionated heparin/full-dose tenecteplase. One year mortality (secondary endpoint) was similar in all
three treatment arms (Sinnaeve PR, 2004). However, the 1-year outcome tended to be worse with abciximab in patients with diabetes. The 2004 ACC/AHA guidelines for
STEMI recommend that pharmacologic reperfusion with abciximab and half-dose reteplase or tenecteplase may be considered in patients <75 years of age with anterior
wall infarctions and no risk factors for bleeding.
Platelet Effects: Abciximab has a long duration of action and platelet effects reverse slowly. It can take 24-48 hours for platelet function to return to normal after dis
continuation of infusion making it difficult to use in patients likely to need CABG. Antiplatelet effects can be reversed with platelet transfusions. Platelet count
monitoring is recommended 2-4 hours after initiation, and at 24 hours or prior to dis charge, whichever is first. Acute profound thrombocytopenia with abciximab
occurs within 24 hours of administration and may be treated by dis continuing the infusion (if still running) and administering platelets. Platelet counts should recover
rapidly after dis continuation.
Anesthesia and Critical Care Concerns/Other ConsiderationsPlatelet Effects: Abciximab has a long duration of action and platelet effects reverse slowly. It can take
24-48 hours for platelet function to return to normal after dis continuation of infusion making it difficult to use in patients likely to need CABG. Antiplatelet effects can
be reversed with platelet transfusions. Platelet count monitoring is recommended 2-4 hours after initiation, and at 24 hours or prior to dis charge, whichever is first.
Acute profound thrombocytopenia with abciximab occurs within 24 hours of administration and may be treated by dis continuing the infusion (if still running) and
administering platelets. Platelet counts should recover rapidly after dis continuation.
Index Terms7E3; C7E3
References
Antman EM, Anbe SC, Alpert JS, et al, “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - Executive Summary: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the
Management of Patients With Acute Myocardial Infarction),” Circulation, 2004, 110(5):588-636. Available at:
http://www.circulationaha.org/cgi/content/full/110/5/588. Last accessed October 26, 2004. [PubMed 15289388]
Aguirre FV, Topol EJ, and Ferguson JJ, “Bleeding Complications With the Chimeric Antibody to Platelet Glycoprotein IIb/IIIa Intergrin in Patients Undergoing
Percutaneous Coronary Intervention. EPIC Investigators,” Circulation, 1995, 91(12):2882-90. [PubMed 7796496]
Antman EM, Giugliano RP, Gibson CM, et al, “Abciximab Facilitates the Rate and Extent of Thrombolysis: Results of the Thrombolysis in Myocardial Infarction
(TIMI) 14 Trial. The TIMI 14 Investigators,” Circulation, 1999, 99(21):2720-32. [PubMed 10351964]
“ASSENT-3 Investigators. Efficacy and Safety of Tenecteplase in Combination With Enoxaparin, Abciximab, or Unfractionated Heparin: The ASSENT-3 Randomised
Trial in Acute Myocardial Infarction,” Lancet, 2001, 358 (9282):605-13. [PubMed 11530146]
Berkowitz SD, Harrington RA, Rund MM, et al, “Acute Profound Thrombocytopenia After C7E3 Fab (Abciximab) Therapy,” Circulation, 1997, 95(4):809- 13. [PubMed
9054735]
Braunwald E, Antman EM, Beasley JW, et al, “ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non ST-Segment Elevation
Myocardial Infarction - Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
the Management of Patients With Unstable Angina),” J Am Coll Cardiol, 2002, 40(7):1366-74. Available at:
http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm. Accessed May 20, 2003. [PubMed 12383588]
Brener SJ, Barr LA, Burchenal JE, et al, “Randomized, Placebo-Controlled Trial of Platelet Glycoprotein IIb/IIIa Blockade With Primary
Angioplasty for Acute Myocardial Infarction,” ReoPro and Primary PTCA Organization and Randomized Trial (RAPPORT) Investigators, Circulation, 1998, 98(8):734-41.
Hamm CW, Hees chen C, Goldmann B, et al, “Benefit of Abciximab in Patients With Refractory Unstable Angina in Relation to Serum Troponin T Levels. c7E3 Fab
Antiplatelet Therapy in Unstable Refractory Angina (CAPTURE) Study Investigators,” N Engl J Med, 1999, 340(21):1623-9. [PubMed 10341274]
Lincoff AM, Califf RM, Anderson KM, et al, “Evidence for Prevention of Death and Myocardial Infarction With Platelet Membrane Glycoprotein IIb/IIIa Receptor
Blockade by Abciximab (c7E3 Fab) Among Patients With Unstable Angina Undergoing Percutaneous Coronary Revas cularization. EPIC Investigators. Evaluation of
7E3 in Preventing Is chemic Complications,” J Am Coll Cardiol, 1997, 30(1):149-56. [PubMed 9207636]
Lincoff AM, Califf RM, Moliterno DJ, et al, “Complementary Clinical Benefits of Coronary-Artery Stenting and Blockade of Platelet Glycoprotein IIb/IIIa Receptors.
Evaluation of Platelet IIb/IIIa Inhibition in Stenting Investigators,” N Engl J Med, 1999, 341(5):319-27. [PubMed 10423466]
Lincoff AM, Califf RM, Van de Werf F, et al, “Mortality at 1 Year With Combination Platelet Glycoprotein IIb/IIIa Inhibition and Reduced-Dose Fibrinolytic Therapy vs
Conventional Fibrinolytic Therapy for Acute Myocardial Infarction: GUSTO V Randomized Trial,” JAMA, 2002, 288(17):2130- 5. [PubMed 12413372]
Lincoff AM, Tcheng JE, Califf RM, et al, “Sustained Suppression of Is chemic Complications of Coronary Intervention by Platelet GP IIb/IIIa Blockade With Abciximab:
One-Year Outcome in the EPILOG Trial. Evaluation in PTCA to Improve Long-Term Outcome With Abciximab GP IIb/IIIa Blockade,” Circulation, 1999, 99(15):1951-8.
[PubMed 10208997]
Moliterno DJ, Yakubov SJ, DiBattiste PM, et al, “Outcomes at 6 months for the Direct Comparison of Tirofiban and Abciximab During Percutaneous Coronary Revas
cularization With Stent Placement: The TARGET Follow-up Study.” Lancet, 2002, 360(9330):355-60. [PubMed 12241774]
“Platelet Glycoprotein IIb/IIIa Receptor Blockade and Low-Dose Heparin During Percutaneous Coronary Revas cularization. The EPILOG Investigators,” N Engl
J Med, 1997, 336(24):1689-96. [PubMed 9182212]
“Randomised Placebo-Controlled Trial of Abciximab Before and During Coronary Intervention in Refractory Unstable Angina: The CAPTURE Study,” Lancet, 1997,
349(9063):1429-35. [PubMed 9164316]
Sinnaeve PR, Alexander JH, Bogaerts K, et al, "Efficacy of Tenecteplase in Combination With Enoxaparin, Abciximab, or Unfractionated Heparin: One-Year Follow-Up
Results of the Assessment of the Safety of a New Thrombolytic-3 (ASSENT-3) Randomized Trial in Acute Myocardial Infarction," Am Heart J, 2004, 147:993-8.[PubMed
15199346]
Smith SC Jr, Dove JT, Jacobs AK, et al, “ACC/AHA Guidelines of Percutaneous Coronary Interventions (Revision of the 1993 PTCA Guidelines) - Executive Summary. A
Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for
Percutaneous Transluminal Coronary Angioplasty),” J Am Coll Cardiol, 2001, 37(8):2215-39. [PubMed 11419905]
Topol EJ, Ferguson JJ, Weisman HF, et al, “Long-Term Protection From Myocardial Is chemic Events in a Randomized Trial of Brief Integrin Beta 3 Blockade With
Percutaneous Coronary Intervention. EPIC Investigator Group. Evaluation of Platelet IIb/IIIa Inhibition for Prevention of Is chemic Complication,” JAMA, 1997,
278(6):479-84. [PubMed 9256222]
Topol EJ, GUSTO V Investigators, “Reperfusion Therapy for Acute Myocardial Infarction With Fibrinolytic Therapy or Combination Reduced Fibrinolytic Therapy and
Platelet Glycoprotein IIb/IIIa Inhibition: The GUSTO V Randomized Trial,” Lancet, 2001, 357:1905-14. [PubMed 11425410]
Topol E, Moliterno DJ, Herrmann HC, et al, “Comparison of Two Platelet Glycoprotein IIb/IIIa Inhibitors, Tirofiban and Abciximab, for the Prevention of Is chemic
Events With Percutaneous Coronary Revas cularization,” N Engl J Med, 2001, 244:1888-94.
“Use of a Monoclonal Antibody Directed Against the Platelet Glycoprotein IIb/IIIa Receptor in High-Risk Coronary Angioplasty. The EPIC Investigation,” N Engl J
Med, 1994, 330(14):956-61. [PubMed 8121459]
van den Merkhof LF, Zijlstra F, Olsson H, et al, “Abciximab in the Treatment of Acute Myocardial Infarction Eligible for Primary Percutaneous Transluminal Coronary
Angioplasty. Results of the Glycoprotein Receptor Antagonist Patency Evaluation (GRAPE) Pilot Study,” J Am Coll Cardiol, 1999, 33(6):1528-32.[PubMed 10334418]
International Brand NamesReoPro (AR, AT, AU, BE, BR, CH, CN, CZ, DE, DK, ES, FI, FR, GB, GR, IE, IN, IT, KP, LU, MX, MY, NL, NO, PE, PK, PL, PT, SE, SG, TH, TW, ZA)

ABVD
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Lymphoma, Hodgkin's Disease

Regimen UseLymphoma, Hodgkin's disease
Regimen
2
Doxorubicin: I.V.: 25 mg/m /day days 1 and 15
2
2
Bleomycin: I.V.: 10 units/m /day days 1 and 15
2
[total dose/cycle = 20 units/m ]
2
Vinblastine: I.V.: 6 mg/m /day days 1 and 15
2
2
Dacarbazine: I.V.: 375 mg/m /day days 1 and 15
2
References
Bonadonna G, Zucali R, DeLena M, et al, “Combined Chemotherapy (MOPP or ABVD) - Radiotherapy Approach in Advanced Hodgkin's Disease,” Cancer Treat Rep,
1977, 61(5):769-77.[PubMed 70270]
Canellos GP, Anderson JR, Propert KJ, et al, “Chemotherapy of Advanced Hodgkin's Disease With MOPP, ABVD, or MOPP Alternating With ABVD,” N Engl J Med, 1992,
327(21):1478-84.[PubMed 1383821]
AC/Paclitaxel (Sequential)
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Breast Cancer

Regimen UseBreast cancer
Regimen
Variation 1: AC + Paclitaxel (conventional):
2
Doxorubicin: I.V.: 60 mg/m day 1
2
2
Cyclophosphamide: I.V.: 600 mg/m day 1
2
Repeat cycle every 21 days for 4 cycles
followed by
2
Paclitaxel: I.V.: 175 mg/m day 1
2
Variation 2: AC + Paclitaxel (dose dense):
2
2
2
2
Filgrastim: SubQ: 5 mcg/kg/day days 3 to 10
followed by
2
2
Filgrastim: SubQ: 5 mcg/kg/day days 3 to 10
References
Variation 1:
Henderson IC, Berry DA, Demetri GD, et al, “Improved Outcomes From Adding Sequential Paclitaxel but not From Es calating Doxorubicin Dose in an Adjuvant
Chemotherapy Regimen for Patients With Node-Positive Primary Breast Cancer,” J Clin Oncol, 2003, 21(6):976-83.[PubMed 12637460 ]
Variation 2:
Citron ML, Berry DA, Cirrincione C, et al, “Randomized Trial of Dose-Dense Versus Conventionally Scheduled and Sequential Versus Concurrent Combination
Chemotherapy as Postoperative Adjuvant Treatment of Node-Positive Primary Breast Cancer: First Report of Intergroup Trial C9741/Cancer Leukemia Group B Trial
9741,” J Clin Oncol, 2003, 21(8):1431-9.[PubMed 12668651 ]
AC-Paclitaxel-Trastuzumab
Lexi-Drugs Online

Variation 1:
2
2
2
2
followed by
2
2
Trastuzumab: I.V.: 4 mg/kg (loading dose) day 1 (cycle 1 only) [total
dose/cycle = 4 mg/kg]
followed by I.V.: 2 mg/kg/day days 8 and 15 (cycle 1)
[total dose/cycle = 4 mg/kg]
then I.V.: 2 mg/kg/day days 1, 8, and 15 (cycles 2, 3, and 4)
followed by
Trastuzumab: I.V.: 2 mg/kg weekly for 40 weeks
Variation 2:
2
2
2
2
followed by
2
Paclitaxel: I.V.: 80 mg/m day 1 week 13
2
Trastuzumab: I.V.: 4 mg/kg (loading dose) day 1 week 13 only [total
dose/cycle = 4 mg/kg]
followed by
2
Paclitaxel: I.V.: 80 mg/m weekly
2
Trastuzumab: I.V.: 2 mg/kg /weekly

Repeat cycle every week for 11 cycles
followed by
Trastuzumab: I.V.: 2 mg/kg /weekly for 40 weeks
References
Romond EH, Perez EA, Bryant J, et al, âTrastuzumab Plus Adjuvant Chemotherapy for Operable HER2-Positive Breast Cancer,â N Engl J Med, 2005, 353(16):1673-84.
[PubMed 16236738]

AC
Lexi-Drugs Online

Variation 1: AC (conventional):
2
2
2
2
Variation 2:
2
Cyclophosphamide: Oral: 200 mg/m /day days 3 to 6
2
2
2
Repeat cycle every 3 weeks for 3 cycles, then every 4 weeks
References
Variation 1:
Fisher B, Brown AM, Dimitrov NV, et al, “Two Months of Doxorubicin-Cyclophosphamide With and Without Interval Reinduction Therapy Compared With 6 Months
of Cyclophosphamide, Methotrexate, and Fluorouracil in Positive-Node Breast Cancer Patients With Tamoxifen Nonresponsive Tumors: Results From the National
Surgical Adjuvant Breast and Bowel Project B-15,” J Clin Oncol, 1990, 8(9):1483-96. [PubMed 2202791 ]
Variation 2:
Jones SE, Durie BG, and Salmon SE, “Combination Chemotherapy With Adriamycin and Cyclophosphamide for Advanced Breast Cancer,” Cancer, 1975, 36(1):90-7.
[PubMed 1203853 ]

Acamprosate
Lexi-Drugs Online
English
Pronunciation(a kam PROE sate)

U.S. Brand NamesCampral®
Canadian Brand NamesCampral®
Pharmacologic CategoryGABA Agonist/Glutamate Antagonist
Use: Labeled IndicationsMaintenance of alcohol abstinence
Dosing: AdultsAlcohol abstinence: Oral: 666 mg 3 times/day (a lower dose may be effective in some patients).
Adjustment in patients with low body weight (unlabeled): A lower dose (4 tablets/day) may be considered in patients with low body weight (eg, <60 kg).
Note: Treatment should be initiated as soon as possible following the period of alcohol withdrawal, when the patient has achieved abstinence.

Dosing: Renal Impairment
Cl cr 30-50 mL/minute: Initial dose should be reduced to 333 mg 3 times/day.
Cl cr <30 mL/minute: Contraindicated in severe renal impairment.
Calculations
Administration: OralMay be administered without regard to meals. Tablet should be swallowed whole; do not crush or chew. Dietary
ConsiderationsMay be taken without regard to meals. Each 333 mg tablet contains 33 mg of elemental calcium. StorageStore at 25°C (77°F);
excursions permitted to 15°C to 30°C (59°F to 86°F).
ContraindicationsHypersensitivity to acamprosate or any component of the formulation; severe renal impairment (Cl cr <30 mL/minute)
• Suicidal ideation/attempt: Attempted and completed suicides have occurred in acamprosate-treated patients; use with caution in suicidal ideation.
Monitor for depression and/or suicidal thinking.
• Alcohol dependence: Appropriate use: Should be used as part of a comprehensive program to treat alcohol dependence. Treatment should be initiated as
soon as possible following the period of alcohol withdrawal, when the patient has achieved abstinence. Acamprosate does not eliminate or diminish the
symptoms of alcohol withdrawal.
• Renal impairment: Use with caution in patients with moderate renal impairment (Cl cr 30-50 mL/minute).
Dosage form specific issues:
• Sulfites: Traces of sulfites may be present in the formulation.
Geriatric ConsiderationsInitial studies did not include sufficient geriatric patients to be able to derive sufficient data to compare elderly to younger adults. Only 41 out
of 4234 patients in clinical trials were ≥65 years of age with none ≥75 years. However, since this medication is cleared renally exclusively, caution should be used since
many elderly have Cl cr 30-50 mL/minute where dosage reduction is required (see Dosage).
Pregnancy ConsiderationsTeratogenic in animal studies. No adequate or well-controlled studies in pregnant women; use only if potential benefit outweighs
possible risk to the fetus.
LactationExcretion in breast milk unknown/use caution
Adverse Reactions
Note: Many adverse effects associated with treatment may be related to alcohol abstinence; reported frequency range may overlap with placebo.
>10%: Gastrointestinal: Diarrhea (10% to 17%)

1% to 10%:
Cardiovas cular: Syncope, palpitation, edema (peripheral)
Central nervous system: Insomnia (6% to 9%), anxiety (5% to 8%), depression (4% to 8%), dizziness (3% to 4%), pain (2% to 4%), paresthesia (2% to 3%), headache,
somnolence, amnesia, tremor, chills
Dermatologic: Pruritus (3% to 4%), rash

Endocrine & metabolic: Weight gain, libido decreased
Gastrointestinal: Anorexia (2% to 5%), flatulence (1% to 3%), nausea (3% to 4%), abdominal pain, dry mouth (1% to 3%), vomiting, dyspepsia,
constipation, appetite increased, taste perversion
Genitourinary: Impotence
Neuromus cular & skeletal: Weakness (5% to 7%), back pain, myalgia, arthralgia
Ocular: Abnormal vision
Respiratory: Rhinitis, dyspnea, pharyngitis, bronchitis
Mis cellaneous: Diaphoresis (2% to 3%), suicide attempt
<1%, postmarketing, and/or case reports (limited to important or life-threatening): Angina, asthma, exfoliative dermatitis, gastrointestinal hemorrhage,
hallucinations, hypothyroidism, MI, ophthalmitis, pancreatitis, photosensitivity, psychosis, pulmonary embolus, renal calculus, renal failure, seizure, suicidal
ideation, suicide attempts, suicide completion
Drug InteractionsThere are no known significant interactions.

Ethanol/Nutrition/Herb Interactions
Ethanol: Abstinence is required during treatment. Ethanol does not affect the pharmacokinetics of acamprosate; however, the continued use of ethanol will decrease
desired efficacy of acamprosate.
Food: Food decreases absorption of acamprosate (not clinically significant).
Nursing: Physical Assessment/MonitoringAssess other medications patient may be taking for effectiveness and potential interactions. May cause depression. Monitor
for suicide ideation.
Patient EducationTaking this medication helps maintain abstinence only when used as part of a treatment program that includes counseling and support. Swallow
tablet whole. Do not chew or crush. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake by pres criber. Can cause drowsiness (use
caution when driving or engaging in activities requiring alertness until response to drug is known). You may experience diarrhea (buttermilk, boiled milk, or yogurt may
help), peripheral edema, insomnia, anxiety, depression, and generalized weakness. Report persistent diarrhea, excessive or sudden weight gain, swelling of extremities,
respiratory difficulties, fainting, or thoughts of suicide. Pregnancy/breast-feeding precautions: Inform pres criber if you are or intend to become pregnant. Consult pres
criber before breast-feeding.
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. Tablet, enteric coated,
delayed release, as calcium:
Campral®: 333 mg [contains calcium 33 mg and sulfites]
Generic AvailableNo
ManufacturerForest Pharmaceuticals
Tablet, EC (Campral)
333 mg (180): $136.08
Tablet, EC (Campral Dose Pak)
333 mg (180): $150.10
Mechanism of ActionMechanism not fully defined. Structurally similar to gamma-amino butyric acid (GABA), acamprosate appears to increase the activity of the
GABA-ergic system, and decreases activity of glutamate within the CNS, including a decrease in activity at N-methyl D-aspartate (NMDA) receptors; may also affect
CNS calcium channels. Restores balance to GABA and glutamate activities which appear to be disrupted in alcohol dependence. During therapeutic use, reduces
alcohol intake, but does not cause a disulfiram-like reaction following alcohol ingestion.
Distribution: Vd: 1 L/kg
Protein binding: Negligible
Metabolism: Not metabolized
Bioavailability: 11%
Half-life elimination: 20-33 hours
Excretion: Urine (as unchanged drug)

Related Information
Addiction Treatments
Dental Health: Effects on Dental TreatmentKey adverse event(s) related to dental treatment: Xerostomia and changes in salivation (normal salivary flow resumes
upon dis continuation) and taste perversion.
Dental Health: Vasoconstrictor/Local Anesthetic PrecautionsNo information available to require special precautions Index
TermsAcamprosate Calcium; Calcium Acetylhomotaurinate
References
Brasser SM, McCaul ME, and Houtsmuller EJ, “Alcohol Effects During Acamprosate Treatment: A Dose-Response Study in Humans,” Alcohol Clin Exp Res, 2004,
28(7):1074-83. [PubMed 15252294]
Graham R, Wodak AD, and Whelan G, “New Pharmacotherapies for Alcohol Dependence,” Med J Aust, 2002, 177(2):103-7. [PubMed 12098353]
Overman GP, Teter CJ, and Guthrie SK, “Acamprosate for the Adjunctive Treatment of Alcohol Dependence,” Ann Pharmacother, 2003, 37(7-8):1090- 9.[PubMed
12841823]
International Brand NamesAcampral (KP); Aotal (FR); Campral (AR, AT, AU, BE, BG, BR, CH, CN, CZ, DE, DK, ES, FI, FR, GB, GR, HN, IE, IT, MX, NL, NO, PL, PT, RU, SE,
TR)

Acarbose
Lexi-Drugs Online
English
Precose® may be confused with PreCare®
International issues:
Precose® may be confused with Precosa® which is a brand name for Saccharomyces boulardii in Denmark, Finland, Norway, and Sweden
Pronunciation(AY car bose)

U.S. Brand NamesPrecose®
Canadian Brand NamesGlucobay™
Pharmacologic CategoryAntidiabetic Agent, Alpha-Glucosidase Inhibitor
Use: Labeled IndicationsAdjunct to diet and exercise to lower blood glucose in patients with type 2 diabetes mellitus (noninsulin dependent, NIDDM)
Dosing: AdultsType 2 diabetes: Oral:
Initial: 25 mg 3 times/day with the first bite of each main meal; to reduce GI effects, some patients may benefit from initiating at 25 mg once daily with gradual
titration to 25 mg 3 times/day as tolerated
Maintenance dose: Should be adjusted at 4- to 8-week intervals based on 1-hour postprandial glucose levels and tolerance until maintenance dose is reached;
maintenance dose: 50-100 mg 3 times/day. Dosage must be individualized on the basis of effectiveness and tolerance while not exceeding the maximum
recommended dose.
Maximum:
≤60 kg: 50 mg 3 times/day
>60 kg: 100 mg 3 times/day
Patients receiving sulfonylureas or insulin: Acarbose given in combination with a sulfonylurea or insulin will cause a further lowering of blood glucose and may
increase the hypoglycemic potential of the sulfonylurea or insulin. If hypoglycemia occurs, appropriate adjustments in the dosage of these agents should be
made.

Dosing: Renal Impairment
Cl cr <25 mL/minute: Peak plasma concentrations were 5 times higher and AUCs were 6 times larger than in volunteers with normal renal function.
Significant renal dysfunction (Scr >2 mg/dL): Use is not recommended.
Administration: OralShould be administered with the first bite of each main meal.
Dietary ConsiderationsTake with food (first bite of meal).
StorageStore at <25°C (77°F). Protect from moisture.
ContraindicationsHypersensitivity to acarbose or any component of the formulation; patients with diabetic ketoacidosis or cirrhosis; patients with inflammatory
bowel disease, colonic ulceration, partial intestinal obstruction, or in patients predisposed to intestinal obstruction; patients who have chronic intestinal diseases
associated with marked disorders of digestion or absorption, and in patients who have conditions that may deteriorate as a result of increased gas formation in the
intestine

• Elevated serum transaminases: Treatment-emergent elevations of serum transaminases (AST and/or ALT) occurred in up to 14% of acarbose-treated patients in
long-term studies. These serum transaminase elevations appear to be dose related. At doses >100 mg 3 times/day, the incidence of serum transaminase
elevations greater than 3 times the upper limit of normal was 2-3 times higher in the acarbose group than in the placebo group. These elevations were
asymptomatic, reversible, more common in females, and, in general, were not associated with other evidence of liver dysfunction. Fulminant hepatitis has
been reported rarely.
• Renal impairment: Use not recommended in patients with significant impairment (S cr >2 mg/dL); use with caution in other patients with renal impairment.
• Stress-related states: It may be necessary to dis continue acarbose and administer insulin if the patient is exposed to stress (ie, fever,
trauma, infection, surgery).
Concurrent drug therapy issues:
• Sulfonylureas/insulin: In combination with a sulfonylurea or insulin will cause a further lowering of blood glucose and may increase the hypoglycemic
potential of the sulfonylurea or insulin.
Geriatric ConsiderationsNo specific trials in older adults have been conducted; mean age in clinical trials has been <60 years; monitor change in preprandial blood
glucose concentrations to account for potential age-related changes in postprandial glucose. In clinical trials, elderly had serum concentrations 1.5 times those of
younger adults. Patients with Cl cr <25 mL/minute had serum concentrations 5 times those with normal renal clearance. No clinical significance can be attributed to this
at this time. No adjustments in dose are recommended. Intensive glucose control (Hb A 1c <6.5) has been linked to increased all cause and cardiovas cular mortality,
hypoglycemia requiring assistance, and weight gain in adult type 2 diabetes. For elderly patients with diabetes who are relatively healthy, attaining target goals for
aspirin use, blood pressure, lipids, smoking cessation, and diet and exercise may be more important than normalized glycemic control. Pregnancy Risk FactorB
Pregnancy ConsiderationsAdverse events have not been reported in animal reproduction studies; therefore, acarbose is classified as pregnancy category B. Low
amounts of acarbose are absorbed systemically which should limit fetal exposure. Maternal hyperglycemia can be associated with adverse effects in the fetus, including
macrosomia, neonatal hyperglycemia, and hyperbilirubinemia; the risk of congenital malformations is increased when the Hb A 1cis above the normal range. Diabetes
can also be associated with adverse effects in the mother. Poorly-treated diabetes may cause end-organ damage that may in turn negatively affect obstetric outcomes.
Physiologic glucose levels should be maintained prior to and during pregnancy to decrease the risk of adverse events in the mother and the fetus. Acarbose has been
studied for its potential role in treating GDM; however, only limited information is available des cribing pregnancy outcomes. Until additional safety and efficacy data
are obtained, the use of oral agents is generally not recommended as routine management of GDM or type 2 diabetes mellitus during pregnancy. Insulin is the drug of
choice for the control of diabetes mellitus during pregnancy. LactationExcretion in breast milk unknown/not recommended
Breast-Feeding ConsiderationsIt is not known if acarbose is found in breast milk; however, low amounts of acarbose are absorbed systemically in adults,
which may limit the amount that could distribute into breast milk. Breast-feeding is not recommended by the manufacturer.
Pregnancy & Lactation, In-Depth
Acarbose in Pregnancy & Lactation
Adverse Reactions
>10%:
Gastrointestinal: Diarrhea (31%) and abdominal pain (19%) tend to return to pretreatment levels over time; frequency and intensity of flatulence (74%) tend
to abate with time
Hepatic: Transaminases increased (≤4%)
Postmarketing and/or case reports: Edema, erythema, exanthema, hepatitis, ileus/subileus, jaundice, liver damage, rash, urticaria Drug Interactions
Corticosteroids (Orally Inhaled): May diminish the hypoglycemic effect of Antidiabetic Agents. In some instances, corticosteroid-mediated HPA axis suppression has led
to episodes of acute adrenal crisis, which may manifest as enhanced hypoglycemia, particularly in the setting of insulin or other antidiabetic agent use. Risk C:
Monitor therapy
Corticosteroids (Systemic): May diminish the hypoglycemic effect of Antidiabetic Agents. In some instances, corticosteroid-mediated HPA axis suppression has led to
episodes of acute adrenal crisis, which may manifest as enhanced hypoglycemia, particularly in the setting of insulin or other antidiabetic agent use. Risk C:
Monitor therapy
Digoxin: Acarbose may decrease the serum concentration of Digoxin. Risk C: Monitor therapy
Herbs (Hypoglycemic Properties): May enhance the hypoglycemic effect of Hypoglycemic Agents. Risk C: Monitor therapy Luteinizing Hormone-Releasing
Hormone Analogs: May diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy Pegvisomant: May enhance the hypoglycemic effect
of Antidiabetic Agents. Risk C: Monitor therapy
Somatropin: May diminish the hypoglycemic effect of Antidiabetic Agents. Risk D: Consider therapy modification
Ethanol/Nutrition/Herb InteractionsEthanol: Limit ethanol.

Monitoring ParametersPostprandial glucose, glycosylated hemoglobin levels, serum transaminase levels should be checked every 3 months during the first year of
treatment and periodically thereafter, renal function (serum creatinine); blood pressure Reference RangeRecommendations for glycemic control in adults with
diabetes:
Hb A1c: <7%
Preprandial capillary plasma glucose: 70-130 mg/dL
Peak postprandial capillary blood glucose: <180 mg/dL

Nursing: Physical Assessment/MonitoringAssess potential for interactions with other pres criptions, OTC medications, or herbal products patient may be taking.
Assess results of laboratory tests, therapeutic effectiveness, and adverse response on a regular basis throughout
therapy. Teach patient proper use (or refer patient to diabetic educator), possible side effects/appropriate interventions (eg, importance of adequate hydration), and
adverse symptoms to report.
Monitoring: Lab TestsPostprandial glucose, glycosylated hemoglobin levels, and serum transaminase levels should be checked every 3 months during the first
year of treatment and periodically thereafter, renal function (serum creatinine)
Patient EducationDo not take any new medication during therapy unless approved by pres criber. Take this medication exactly as directed, with the first bite of each
main meal. Do not change dosage or dis continue this medicine without first consulting pres criber. Do not take other medications with or within 2 hours of this
medication unless advised by pres criber. Avoid alcohol. It is important to follow dietary and lifestyle recommendations of pres criber. You will be instructed in signs of
hypo- or hyperglycemia by pres criber or diabetic educator. If combining acarbose with other diabetic medication (eg, sulfonylureas, insulin), keep source of glucose in
the form of dextrose (NOT table sugar, candy, or cookies) on hand in case hypoglycemia occurs. May cause mild side effects during first weeks of acarbose therapy (eg,
bloating, flatulence, diarrhea, abdominal dis comfort); these should diminish over time. Report severe or persistent side effects, fever, extended vomiting or flu, or
change in color of urine or stool. Breast-feeding precaution: Consult pres criber if breast-feeding. Dosage FormsExcipient information presented when available
(limited, particularly for generics); consult specific product labeling.
Tablet: 25 mg, 50 mg, 100 mg
Precose®: 25 mg, 50 mg, 100 mg
Generic AvailableYes
ManufacturerBayer Corp (Biological and Pharmaceutical Division)
Tablets (Acarbose)
25 mg (100): $81.99
50 mg (100): $87.99
100 mg (100): $89.99
Tablets (Precose)
25 mg (90): $85.52
50 mg (90): $88.49
100 mg (90): $102.58
Mechanism of ActionCompetitive inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases, resulting in delayed hydrolysis of ingested complex
carbohydrates and disaccharides and absorption of glucose; dose-dependent reduction in postprandial serum insulin and glucose peaks; inhibits the metabolism of
sucrose to glucose and fructose
Absorption: <2% as active drug; ~35% as metabolites
Metabolism: Exclusively via GI tract, principally by intestinal bacteria and digestive enzymes; 13 metabolites identified (major metabolites are sulfate, methyl, and
glucuronide conjugates)
Bioavailability: Low systemic bioavailability of parent compound; acts locally in GI tract
Half-life elimination: ~2 hours
Time to peak: Active drug: ~1 hour
Excretion: Urine (~34% as inactive metabolites, <2% parent drug and active metabolite); feces (~51% as unabsorbed drug) Related
Information
Diabetes Mellitus Management, Adults
Dental Health: Effects on Dental TreatmentAlthough acarbose does not cause hypoglycemia, it is frequently used in combination and may complicate the
management of hypoglecemic episodes caused by other medications. As part of its therapeutic effect, acarbose slows the absorption of complex sugars or
disaccharides such as sucrose. This would delay effective treatment of hypoglycemia. Simple sugars, including glucose (dextrose), are not affected. If a patient
experiences hypoglycemia, use of food items such as table sugar, candy, or cookies will NOT effectively increase blood glucose. Administration of oral glucose is
required in mild-moderate hypoglycemia, and parenteral glucose is required for severe hypoglycemia.
Effects on Mental StatusMay cause drowsiness
Mental Health: Effects on Psychiatric TreatmentAntipsychotics and tricyclic antidepressants may decrease the effects of acarbose. Monoamine oxidase
inhibitors, SSRIs, and nefazodone may increase the effects of acarbose.
Cardiovas cular ConsiderationsAcarbose produces a slight but statistically significant reduction in Hb A 1c(~1%) and fasting plasma glucose (~25 mg/dL). In general,
acarbose may be used in combination with other agents (eg, sulfonylurea, metformin) or as monotherapy for patients with Type 2 diabetes. Therapy should be titrated
slowly to minimize gastrointestinal side effects.
References
American Diabetes Association, “Standards of Medical Care in Diabetes -- 2008,” Diabetes Care, 2008, 31(Suppl 1):12-54. [PubMed 18165335] Balfour JA and
McTavish D, “Acarbose: A Reappraisal,” Drugs, 1993, 46(6):1025-54. [PubMed 7510610]
Bis choff H, “Pharmacology of α-Glucosidase Inhibition,” Eur J Clin Invest, 1994, 24(Suppl 3):3-10.
Scheen AJ, de Magalhaes AC, Salvatore T, et al, “Reduction of the Acute Bioavailability of Metformin by the α-Glucosidase Inhibitor Acarbose in Normal Man,” Eur J Clin
Invest, 1994, 24(Suppl 3):50-4.
International Brand NamesDecarbay (TW); Deglu (TW); Dibose (MY); Glibose (TW); Glicobase (IT); Glucar (MY); Glucobay (AE, AR, AT, AU, BB, BD, BE, BF, BG, BH, BJ,
BM, BR, BS, BZ, CH, CI, CL, CN, CO, CR, CY, CZ, DE, DK, DO, EG, ES, ET, FI, GB, GH, GM, GN, GT, GY, HK, HN, HR, HU, ID, IE, IL, IN, IQ, IR, IT, JM, JO, JP, KE, KP, KW, LB, LR,
LU, LY, MA, ML, MR, MU, MW, MX, MY, NE, NG, NI, NL, NO, OM, PA, PE, PH, PK, PL, PT, PY, QA, SA, SC, SD, SE, SG, SL, SN, SR, SV, SY, TH, TN, TT, TW, TZ, UG, UY, VE, YE,
ZA, ZM, ZW); Gluconase (PH); Glucor (FR); Glumida (ES); Incardel (MX); Prandase (IL); Precose (MY); Rebose (IN); Sincrosa (MX)

ACAV (J)
Lexi-Drugs Online
Pharmacologic CategoryChemotherapy Regimen, Wilms' Tumor

Regimen UseWilms' tumor
Regimen
Dactinomycin: I.V.: 15 mcg/kg/day days 1 to 5 of weeks 0, 13, 26, 39, 52, and 65
Cyclophosphamide: I.V.: 10 mg/kg/day days 1, 2, and 3 of weeks 0, 6, 13, 19, 26, 32, 39, 45, 52, 58, and 65
2
Doxorubicin: I.V.: 20 mg/m /day days 1, 2, and 3 of weeks 6, 19, 32, 45, and 58
2
2
Vincristine: I.V.: 1.5 mg/m day 1 of weeks 0-10, 13, 14, 19, 20, 26, 27, 32, 33, 39, 40, 45, 52, 53, 56, 57, 65, and 66 [total
2
dose/cycle = 42 mg/m ]
References
D'Angio GJ, Breslow N, Beckwith JB, et al, âTreatment of Wilms' Tumor. Results of the Third National Wilms' Tumor Study,â Cancer, 1989, 64(2):349-60.
[PubMed 2544249 ]

Acebutolol
Lexi-Drugs Online
English
Sectral® may be confused with Factrel®, Seconal®, Septra®
Pronunciation(a se BYOO toe lole)

U.S. Brand NamesSectral®
Canadian Brand NamesApo-Acebutolol®; Gen-Acebutolol; Monitan®; Novo-Acebutolol; Nu-Acebutolol; Rhotral; Rhoxal-acebutolol; Sandoz Acebutolol; Sectral®
Pharmacologic CategoryAntiarrhythmic Agent, Class II; Beta Blocker With Intrinsic Sympathomimetic Activity Use: Labeled
IndicationsTreatment of hypertension; management of ventricular arrhythmias
Use: Unlabeled/InvestigationalTreatment of chronic stable angina
Dosing: Adults
Angina, ventricular arrhythmia: Oral: 400 mg/day in divided doses; maintenance: 600-1200 mg/day in divided doses; maximum: 1200 mg/day
Hypertension: Oral: 400-800 mg/day (larger doses may be divided); maximum: 1200 mg/day; usual dose range (JNC 7): 200-800 mg/day in 2 divided doses
Dosing: ElderlyOral: Initial: 200-400 mg/day; dose reduction due to age-related decrease in Cl cr will be necessary; do not exceed 800 mg/day. Dosing: Renal
Impairment
Cl cr 25-49 mL/minute: Reduce dose by 50%.
Cl cr <25 mL/minute: Reduce dose by 75%.
Dosing: Hepatic ImpairmentUse with caution.

Calculations
Administration: OralTo dis continue therapy, taper dose gradually over a period of 2 weeks. May be administered without regard to meals. Dietary
ConsiderationsMay be taken without regard to meals.
StorageStore at controlled room temperature of 20°C to 25°C (68°F to 77°F). Protect from light and dispense in a light-resistant, tight container.
ContraindicationsOvert cardiac failure; cardiogenic shock; persistently-severe bradycardia or second- and third-degree heart block (except in patients with a
functioning artificial pacemaker)
Beta-Blocker Allergy
Concerns related to adverse events:
• Anaphylactic reactions: Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated
challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects.
• Bronchospastic disease: In general, patients with bronchospastic disease should not receive beta-blockers; for patients with bronchospastic disease who do not
respond to or cannot tolerate other therapies, initial low doses of acebutolol may be employed and used cautiously with close monitoring. Ensure patient
has an inhaled beta 2-agonist immediately available.
• Conduction abnormality: Consider pre-existing conditions such as sick sinus syndrome before initiating.
• Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.
• Heart failure (HF): Beta-blockers with intrinsic sympathomimetic activity (eg, acebutolol) are likely to worsen survival in patients with HF and should be avoided.
Beta-blockers shown to improve survival in clinical trials should be used in these patients.
• Hepatic impairment: Use with caution in patients with hepatic impairment.
• Mesenteric vas cular disease: Can precipitate or aggravate symptoms of arterial insufficiency in patients with mesenteric vas cular disease. Use with
caution in these patients. Observe closely for progression of arterial obstruction.
• Myasthenia gravis: Use with caution in patients with myasthenia gravis.
• Peripheral vas cular disease (PVD): Can precipitate or aggravate symptoms of arterial insufficiency in patients with PVD. Use with caution in these patients.
Observe closely for progression of arterial obstruction.
• Pheochromocytoma (untreated): Adequate alpha 1-receptor blockade is required prior to use of any beta-blocker. • Psychiatric disease: Use with
caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression. • Raynaud's disease: Use with caution in these
patients with Raynaud's disease; may precipitate symptoms of Raynaud's.
• Renal impairment: Use with caution in patients with renal impairment, especially the elderly. Elimination of the metabolite, diacetolol, is reduced resulting in a
two- to threefold increase in its half-life.
• Thyrotoxicosis: Beta-blockade may mask signs of hyperthyroidism (eg, tachycardia). Abrupt dis continuation may also induce a thyroid storm.
• Elderly: Use reduced doses in elderly patients; concentrations of acebutolol and diacetolol are significantly higher in the elderly. Dose should not exceed 800
mg/day.
• Abrupt withdrawal: Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered to avoid acute
tachycardia, hypertension, and/or is chemia.
Geriatric ConsiderationsSince bioavailability increased in elderly about twofold, geriatric patients may require lower maintenance doses, therefore, as serum and
tissue concentrations increase beta 1 selectivity diminishes; due to alterations in the beta-adrenergic autonomic nervous system, beta-adrenergic blockade may result in
less hemodynamic response than seen in younger adults. Studies indicate that despite decreased sensitivity to the chronotropic effects of beta-blockade with age, there
appears to be an increased myocardial sensitivity to the negative inotropic effect during stress (ie, exercise). Controlled trials have shown the overall response rate for
propranolol to be only 20% to 50% in elderly populations. Therefore, all beta-adrenergic blocking drugs may result in a decreased response as compared to younger
adults. Adjust dose for renal function.
Pregnancy Risk FactorB (manufacturer); D (2nd and 3rd trimesters - expert analysis)
Pregnancy ConsiderationsTeratogenic effects were not observed in animal studies. Acebutolol and its metabolite cross the human placenta. The neonatal half-life of
acebutolol is 6-14 hours and diacetolol is 24-30 hours. Decreased birth weight, blood pressure, and heart rate have been observed in neonates following maternal use
of acebutolol during pregnancy. Neonatal hypoglycemia has also been reported. Available evidence suggests beta-blockers are generally safe during pregnancy (JNC 7).
Monitoring of the newborn is recommended. LactationEnters breast milk/not recommended (AAP recommends “use with caution”)
Breast-Feeding ConsiderationsAcebutolol and its metabolites are found in human breast milk; the milk/plasma ratio is 7.1 for acebutolol and 12.2 for diacetolol.
Hypotension, bradycardia, and tachypnea have been reported in nursing infants.
Adverse Reactions
>10%: Central nervous system: Fatigue (11%)
1% to 10%:
Cardiovas cular: Chest pain (2%), edema (2%), bradycardia, hypotension, CHF
Central nervous system: Headache (6%), dizziness (6%), insomnia (3%), depression (2%), abnormal dreams (2%), anxiety, hyper- /hypoesthesia
Dermatologic: Rash (2%), pruritus
Gastrointestinal: Constipation (4%), diarrhea (4%), dyspepsia (4%), nausea (4%), flatulence (3%), abdominal pain, vomiting Genitourinary:
Micturition frequency (3%), dysuria, impotence, nocturia
Neuromus cular & skeletal: Myalgia (2%), back pain, joint pain
Ocular: Abnormal vision (2%), conjunctivitis, dry eyes, eye pain
Respiratory: Dyspnea (4%), rhinitis (2%), cough (1%), pharyngitis, wheezing
Postmarketing and/or case reports: Alkaline phosphatase increased, anorexia, AV block, bilirubin increased, cold extremities, drug-induced lupus-like syndrome,
exacerbate pre-existing renal insufficiency, facial edema, hepatotoxic reaction, lichen planus, palpitation, pleurisy, pneumonitis, pulmonary granulomas, systemic
lupus erythematosus, transaminases increased, urinary retention, ventricular arrhythmia, xerostomia
Potential adverse effects (based on experience with other beta-blocking agents) include agranulocytosis, allergic reactions, alopecia, catatonia, claudication,
depression (reversible), disorientation, emotional lability, erythematous rash, is chemic colitis, laryngospasm, mesenteric artery thrombosis, Peyronie's disease,
purpura, respiratory distress, short-term memory loss, slightly clouded sensorium, thrombocytopenia
Metabolism/Transport EffectsInhibits CYP2D6 (weak)

Drug Interactions
Acetylcholinesterase Inhibitors: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy
Alpha-/Beta-Agonists (Direct-Acting): Beta-Blockers may enhance the vasopressor effect of Alpha-/Beta-Agonists (Direct-Acting). Epinephrine used as a local
anesthetic for dental procedures will not likely cause clinically relevant problems. Exceptions: Dipivefrin. Risk D: Consider therapy modification
Alpha1-Blockers: Beta-Blockers may enhance the orthostatic effect of Alpha1-Blockers. The risk associated with ophthalmic products is probably less than
systemic products. Risk D: Consider therapy modification
Alpha2-Agonists: Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the alpha 2- agonist is abruptly
withdrawn. Exceptions: Apraclonidine; Brimonidine. Risk D: Consider therapy modification
Amifostine: Antihypertensives may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, antihypertensive
medications should be withheld for 24 hours prior to amifostine administration. If antihypertensive therapy can not be withheld, amifostine should not be
administered. Risk D: Consider therapy modification
Aminoquinolines (Antimalarial): May decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy
Amiodarone: May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-
Blockers. Risk C: Monitor therapy
Anilidopiperidine Opioids: May enhance the bradycardic effect of Beta-Blockers. Anilidopiperidine Opioids may enhance the hypotensive effect of Beta-Blockers.
Risk C: Monitor therapy
Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents
(Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy
Barbiturates: May decrease the serum concentration of Beta-Blockers. Risk C: Monitor therapy
Beta2-Agonists: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-
blockers or higher doses of the beta1 selective beta-blockers. Risk C: Monitor therapy
Calcium Channel Blockers (Nondihydropyridine): May enhance the hypotensive effect of Beta-Blockers. Bradycardia and signs of heart failure have also been
reported. Calcium Channel Blockers (Nondihydropyridine) may increase the serum concentration of Beta-Blockers. Risk C: Monitor therapy
Cardiac Glycosides: Beta-Blockers may enhance the bradycardic effect of Cardiac Glycosides. Risk C: Monitor therapy Diazoxide: May
enhance the hypotensive effect of Antihypertensives. Risk C: Monitor therapy
Dipyridamole: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy
Disopyramide: May enhance the bradycardic effect of Beta-Blockers. Risk C: Monitor therapy
Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensives. Risk C: Monitor therapy Herbs
(Hypotensive Properties): May enhance the hypotensive effect of Antihypertensives. Risk C: Monitor therapy Insulin: Beta-Blockers may
enhance the hypoglycemic effect of Insulin. Risk C: Monitor therapy
Lidocaine: Beta-Blockers may decrease the metabolism of Lidocaine. Risk C: Monitor therapy
Methacholine: Beta-Blockers may enhance the adverse/toxic effect of Methacholine. Risk X: Avoid combination
Methylphenidate: May diminish the antihypertensive effect of Antihypertensives. Risk C: Monitor therapy
Midodrine: Beta-Blockers may enhance the bradycardic effect of Midodrine. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May diminish the antihypertensive effect of Beta-Blockers. Risk C: Monitor therapy
Propafenone: May decrease the metabolism of Beta-Blockers. Propafenone possesses some independent beta blocking activity. Risk C: Monitor therapy
Propoxyphene: May decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the hypotensive effect of Antihypertensives. Risk C: Monitor therapy
QuiNIDine: May decrease the metabolism of Beta-Blockers. Risk C: Monitor therapy
Reserpine: May enhance the hypotensive effect of Beta-Blockers. Risk C: Monitor therapy
Rifamycin Derivatives: May decrease the serum concentration of Beta-Blockers. Exceptions: Rifabutin. Risk C: Monitor therapy RiTUXimab:
Antihypertensives may enhance the hypotensive effect of RiTUXimab. Risk D: Consider therapy modification
Theophylline Derivatives: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Theophylline Derivatives. This is true at higher beta-blockers
doses where cardioselectivity is lost. Risk C: Monitor therapy
Food: Peak serum acebutolol levels may be slightly decreased if taken with food.
Herb/Nutraceutical: Avoid dong quai if using for hypertension (has estrogenic activity). Avoid yohimbe, ginseng (may worsen hypertension).
Test InteractionsIncreased AST, ALT, alkaline phosphatase, bilirubin, cholesterol, glucose, LDH, potassium, thyroxine, triglycerides, uric acid; decreased HDL
Monitoring ParametersBlood glucose; blood pressure, orthostatic hypotension, heart rate, CNS effects, ECG Nursing: Physical Assessment/MonitoringAssess
effectiveness and interactions of other medications patient may be taking. Assess results of laboratory tests, therapeutic effectiveness, and adverse response on a
regular basis during therapy. When dis continuing therapy, taper dosage over 2 weeks. Assess knowledge/teach patient appropriate use, possible side effects (including
altered glucose tolerance for patients with diabetes)/appropriate interventions, and adverse symptoms to report.
Monitoring: Lab TestsBlood glucose
Patient EducationTake exactly as directed; do not increase, decrease, or adjust dosage without consulting pres criber. May be taken without regard to meals. Take
pulse daily, prior to medication, and follow pres criber's instruction about holding medication. Do not take with antacids. Do not use OTC medications such as cold
remedies without consulting pres criber. If you have diabetes, monitor serum sugar closely (drug may alter glucose tolerance or mask signs of hypoglycemia). May cause
fatigue, dizziness (use caution when driving or engaging in tasks that require alertness until response to drug is known); postural hypotension (use caution when
changing position from lying or sitting to standing or when climbing stairs); or alteration in sexual performance (reversible). Report chest pain or palpitations,
unresolved swelling of extremities or unusual weight gain, respiratory difficulty or new cough, skin rash, unresolved fatigue, unresolved constipation or diarrhea,
unusual mus cle weakness, or CNS disturbances. Pregnancy/breast-feeding precautions: Inform pres criber if you are pregnant. Consult pres criber if breast-feeding.
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. Capsule, as
hydrochloride: 200 mg, 400 mg
Sectral®: 200 mg, 400 mg
Generic AvailableYes
Capsules (Acebutolol HCl)
200 mg (100): $54.98
400 mg (30): $21.99
Capsules (Sectral)
200 mg (60): $169.99
400 mg (30): $124.99
Mechanism of ActionCompetitively blocks beta 1-adrenergic receptors with little or no effect on beta 2-receptors except at high doses; exhibits membrane
stabilizing and intrinsic sympathomimetic activity
Onset of action: 1-2 hours
Duration: 12-24 hours
Absorption: Oral: 40%
Protein binding: ∼26%

Metabolism: Extensive first-pass effect to equipotent and cardioselective diacetolol metabolite
Half-life elimination: Parent drug: 3-4 hours; Metabolite: 8-13 hours
Time to peak: 2-4 hours
Excretion: Feces (50% to 60%); urine (30% to 40%); diacetolol eliminated primarily in the urine
Related Information
Beta-Blockers
Dental Health: Effects on Dental TreatmentAcebutolol is a cardioselective beta-blocker. Local anesthetic with vasoconstrictor can be safely used in patients
medicated with acebutolol. Nonselective beta-blockers (ie, propranolol, nadolol) enhance the pressor response to epinephrine, resulting in hypertension and
bradycardia; this has not been reported for acebutolol. Many nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can reduce the hypotensive
effect of beta-blockers after 3 or more weeks of therapy with the NSAID. Short-term NSAID use (ie, 3 days) requires no special precautions in patients taking beta-
blockers.
Dental Health: Vasoconstrictor/Local Anesthetic PrecautionsNo information available to require special precautions. Local anesthetic with vasoconstrictor can be
safely used in patients medicated with acebutolol.
Mental Health: Effects on Mental StatusDrowsiness/fatigue is common; may cause insomnia, depression, abnormal dreams, and polyuria Mental Health: Effects
on Psychiatric TreatmentAdditive hypotensive and/or sedative effects may be seen with concurrent use of antipsychotics, antidepressants, or benzodiazepines
Cardiovas cular ConsiderationsThis drug possesses intrinsic sympathomimetic activity (ISA). While beta-blockers with ISA induce fewer side effects, the cardiovas
cular benefits listed below are less clear than for beta-blockers without ISA.
Heart Failure: Beta-blockers with ISA (eg, acebutolol) are likely to worsen survival and should be avoided. Beta-blockers shown to improve survival in clinical trials
should be used in these patients.
Hypertension: Beta-blocker therapy in the treatment of hypertension has been associated with improved cardiovas cular outcomes. According to the 2003 JNC-VII
guidelines for the treatment of hypertension, most patients with hypertension will require treatment with at least 2 antihypertensives. First-line therapy for
hypertension is a diuretic (eg, hydrochlorothiazide or chlorthalidone). When a diuretic cannot be used or when a compelling indication exists for another drug, other
types of antihypertensives may be used (eg, ACEIs, ARBs, beta-blockers, CCBs). Beta-blockers are among the multiple choices of agents that have shown benefit in a
number of different patient subtypes. Compelling indications for a beta-blocker include patients with heart failure, postmyocardial infarction, high coronary disease risk,
or diabetes. In type 2 diabetic patients, a UK Prospective Diabetes Study Group (UKPDS) trial showed that beta-blocker therapy (atenolol) was as effective as an ACE
inhibitor in reducing cardiovas cular events and that the benefits of therapy were related more to the degree of antihypertensive efficacy rather than the class of drug
used.
Treatment should be targeted to a goal blood pressure of <140/90 mm Hg. If diabetes or renal disease coexists, the blood pressure goal should be <130/80 mm
Hg.
Withdrawal: Beta-blocker therapy should not be withdrawn abruptly, but gradually tapered to avoid acute tachycardia and hypertension.
Index TermsAcebutolol Hydrochloride

References
Adams KF, Lindenfeld J, Arnold JMO, et al, “HFSA 2006 Comprehensive Heart Failure Practice Guideline,” J Card Fail, 2006, 12(1):e1–122. Available at
http://www.heartfailureguideline.org[PubMed 16500560]
“American Academy of Pediatrics Committee on Drugs. The Transfer of Drugs and Other Chemicals Into Human Milk,” Pediatrics, 2001, 108(3):776- 89. [PubMed
11533352]
Anderson JL, Adams CD, Antman EM, et al, “ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction:
Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration With the American College
of Emergency Physicians, The Society of Cardiovas cular Angiography and Interventions, and the Society of Thoracic Surgeons,” J Am Coll Cardiol, 2007, 50(7):1-157.
Available at http://content.onlinejacc.org/cgi/reprint/50/7/e1[PubMed 17692738]
Antman EM, Anbe DT, Armstrong PW, et al. “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of
Patients With Acute Myocardial Infarction),” J Am Coll Cardiol, 2004, 44(3):671-719. Available at http://www.acc.org/qualityands
cience/clinical/guidelines/stemi/Guideline1/index.htm[PubMed 15358045]
Boutroy MJ, Bianchetti G, Dubruc C, et al, “To Nurse When Receiving Acebutolol: Is It Dangerous for the Neonate?” Eur J Clin Pharmacol, 1986, 30(6):737-9.
[PubMed 3770068]
Chobanian AV, Bakris GL, Black HR, et al, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure: The JNC 7 Report,” JAMA, 2003, 289(19):2560-71. [PubMed 12748199]
Dumez Y, Tchobroutsky C, Hornych H, et al, “Neonatal Effects of Maternal Administration of Acebutolol,” Br Med J (Clin Res Ed), 1981, 283(6299):1077-9.
[PubMed 6794766]
Gibbons RJ, Abrams J, Chatterjee K, et al, “ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina - Summary Article: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable
Angina),” J Am Coll Cardiol, 2003, 41(1):159-68. Available at
http://www.acc.org/qualityands cience/clinical/guidelines/stable/stable_clean.pdf[PubMed 12570960]
Gibbons RJ, Chatterjee K, Daley J, et al, “ACC/AHA/ACP-ASIM Guidelines for the Management of Patients With Chronic Stable Angina: A Report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines,” J Am Coll Cardiol, 1999, 33(7):2092-197. [PubMed 10362225]
Lang DM, “Anaphylactoid and Anaphylactic Reactions. Hazards of Beta-Blockers,” Drug Saf, 1995, 12(5):299-304.[PubMed 7669259]
Mokhlesi B, Leikin JB, Murray P, et al, “Adult Toxicology in Critical Care: Part II: Specific Poisonings,” Chest, 2003, 123(3):897-922. [PubMed 12628894]
Ryan TJ, Anderson JL, Antman EM, et al, “ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction. A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction),” J Am Coll Cardiol, 1996,
28(5):1328-428.[PubMed 8890834]
UK Prospective Diabetes Study Group, “Efficacy of Atenolol and Captopril in Reducing Risk of Macrovas cular and Microvas cular Complications in Type 2 Diabetes:
UKPDS 39,” BMJ, 1998, 317(7160):713-20.[PubMed 9732338]
International Brand NamesAbutol (PL); ACB (NZ); Acebutolol (PL); Acecor (PL); Acetanol (JP); Beloc (CN); Butobloc (ZA); Cetolol (PL); Diasectral (DK, FI); Flebutol
(VE); Grifobutol (CN); Prent (CH, DE, IT, PT); Rhodiasectral (AR); Sectral (AE, AT, BB, BE, BG, BH, BM, BR, BS, BZ, CH, CY, CZ, EG, ES, FR, GB, GY, HK, IE, IL, IN, IQ, IR, IT,
JM, JO, JP, KW, LB, LU, LY, NL, OM, PL, QA, SA, SR, SY, TT, TW, YE, ZA); Sectral LP (FR); Wesfalin (AR)

Acenocoumarol
Lexi-Drugs Online
English
Medication Safety IssuesInterferes with hepatic synthesis of vitamin K-dependent coagulation factors (II, VII, IX, X)
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes which have a heightened risk of
causing significant patient harm when used in error.
Pronunciation(a see no KOOM a rol)

Canadian Brand NamesSintrom®
Pharmacologic CategoryAnticoagulant, Coumarin Derivative
Use: Labeled IndicationsProphylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders; atrial fibrillation with risk of
embolism; adjunct in the prophylaxis of coronary occlusion and transient is chemic attacks Dosing: AdultsNote: Dosage must be individualized. The following
information is based on the manufacturer's labeling in Canada.
Oral: Initial: 8-12 mg on day 1, followed by 4-8 mg on day 2. Subsequent dosage should be based on PT/INR measurements. Usual range of maintenance doses: 1-
10 mg/day. Tapering of dosage is recommended prior to dis continuation.

Administration: OralAdminister at the same time each day.
Dietary ConsiderationsFoods high in vitamin K (eg, beef liver, pork liver, green tea, and leafy green vegetables) inhibit anticoagulant effect. Do not change dietary
habits once stabilized on acenocoumarol therapy. A balanced diet with a consistent intake of vitamin K is essential. Avoid large amounts of alfalfa, asparagus, broccoli,
Brussels sprouts, cabbage, cauliflower, green teas, kale, lettuce, spinach, turnip greens, watercress; these decrease efficacy of oral anticoagulants. It is recommended
that the diet contain a CONSISTENT vitamin K content of 70-140 mcg/day. Check with healthcare provider before changing diet. Avoid using multivitamins that contain
vitamin K. Storage Store at 20°C to 25°C (68°F to 77°F).
RestrictionsNot available in U.S.
ContraindicationsHypersensitivity to acenocoumarol or any component of the formulation; hemorrhagic tendencies; hemophilia; thrombocytopenia purpura;
leukemia; recent or potential surgery of the eye or CNS; major regional lumbar block anesthesia or surgery resulting in large, open surfaces; bleeding from the GI,
respiratory, or GU tract; threatened abortion; aneurysm; prolonged dietary insufficiencies (vitamin K deficiency); as corbic acid deficiency; history of bleeding
diathesis; prostatectomy; continuous tube drainage of the small intestine; polyarthritis; diverticulitis; emaciation; malnutrition; cerebrovas cular hemorrhage;
eclampsia/pre-eclampsia; blood dys crasias; severe uncontrolled or malignant hypertension; severe hepatic disease; pericarditis or pericardial effusion; subacute
bacterial endocarditis; vis ceral carcinoma; following spinal puncture and other diagnostic or therapeutic procedures with potential for significant bleeding; history of
warfarin-induced necrosis; an unreliable, noncompliant patient; alcoholism; patient who has a history of falls or is a significant fall risk; pregnancy
Coumarin-Type Anticoagulant Allergy
• Anaphylaxis/hypersensitivity: May cause hypersensitivity reactions, including anaphylaxis; use with caution in patients with anaphylactic disorders.
• Bleeding: May cause major or fatal bleeding. Risk factors for bleeding include high intensity anticoagulation (INR >4), age (>65 years), variable INRs, history of GI
bleeding, hypertension, cerebrovas cular disease, serious heart disease, anemia, severe diabetes, malignancy, trauma, renal insufficiency, polycythemia vera,
vas culitis, open wound, history of PUD, indwelling catheters, menstruating and postpartum women, drug-drug interactions and long duration of therapy.
Patient must be instructed to report bleeding, accidents, or falls as well as any new or dis continued medications, herbal or alternative products used,
significant changes in smoking or dietary habits.
• Skin necrosis/gangrene: Necrosis or gangrene of the skin and other tissues can occur (rarely) due to early hypercoagulability; risk is increased in patients with
protein C deficiency. "Purple toe” syndrome, due to cholesterol microembolization, has been des cribed with coumarin-type anticoagulants.
• Infection: Use with caution in patients with acute infection or active TB; antibiotics and fever may alter response to acenocoumarol. • Renal impairment:
Use with caution in patients with renal impairment.
• Thyroid disease: Use with caution in patients with thyroid disease.
• Elderly: The elderly may be more sensitive to anticoagulant therapy.

• Ovulating women: May be at risk of developing ovarian hemorrhage at the time of ovulation.
• Patient selection: Use care in the selection of patients appropriate for this treatment; ensure patient cooperation especially from the alcoholic, illicit drug
user, demented, or psychotic patient.
Pregnancy ConsiderationsOral anticoagulants cross the placenta and produce fetal abnormalities. Fatal hemorrhage in the fetus has been reported even when the
mother’s acenocoumarol levels were in the therapeutic range. Acenocoumarol should not be used during pregnancy because of significant risks. Adjusted-dose heparin
can be given safely throughout pregnancy in patients with venous thromboembolism. Women of childbearing potential are advised to use effective contraception
during treatment.
LactationEnters breast milk/not recommended (per manufacturer)
Adverse ReactionsAs with all anticoagulants, bleeding is the major adverse effect of acenocoumarol. Hemorrhage may occur at virtually any site. Risk is dependent on
multiple variables, including the intensity of anticoagulation and patient sus ceptibility.
Frequency not defined.
Cardiovas cular: Hemorrhagic shock
Central nervous system: Fever, headache, stroke (hemorrhagic)
Dermatologic: Rash, urticaria, skin necrosis
Skin necrosis/gangrene, due to paradoxical local thrombosis, is a known but rare risk of oral anticoagulant therapy. Its onset is usually within the first
few days of therapy and is frequently localized to the limbs, breast, or penis. The risk of this effect is increased in patients with protein C or S
deficiency.
Additional adverse reactions associated with warfarin, but likely to also occur with indanediones, include priapism and skin necrosis (“purple toe” syndrome or
cutaneous gangrene).
Gastrointestinal: Gastrointestinal bleeding, melena
Genitourinary: Hematuria
Hematologic: Hemorrhage, retroperitoneal hematoma, unrecognized bleeding sites (eg, colon cancer) may be uncovered by anticoagulation. Other hematologic
reactions reported with coumarin derivatives include agranulocytosis, red cell aplasia, anemia, thrombocytopenia, eosinophilia.
Hepatic: Hepatitis, hepatotoxicity, hematobilia
Ocular: Ocular hemorrhage
Respiratory: Epistaxis, hemoptysis, pulmonary hemorrhage
Mis cellaneous: Hypersensitivity/allergic reactions
Metabolism/Transport EffectsSubstrate of CYP1A2 (major), 2C9 (major), 2C19 (minor)

Drug Interactions
Acetaminophen: May enhance the anticoagulant effect of Vitamin K Antagonists. Most likely with daily acetaminophen doses >1.3 g for >1 week. Risk C: Monitor
therapy
Allopurinol: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification
Aminoglutethimide: May increase the metabolism of Vitamin K Antagonists. Risk D: Consider therapy modification Amiodarone:
May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification
Androgens: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Anticoagulants:
May enhance the anticoagulant effect of other Anticoagulants. Risk C: Monitor therapy
Antifungal Agents (Azole Derivatives, Systemic): May decrease the metabolism of Vitamin K Antagonists. Risk D: Consider therapy modification
Antineoplastic Agents: May enhance the anticoagulant effect of Vitamin K Antagonists. Antineoplastic Agents may diminish the anticoagulant effect of Vitamin K
Antagonists. Exceptions: Alitretinoin; Altretamine; Aminoglutethimide; Anastrozole; Asparaginase; AzaCITIDine; Bleomycin; Capecitabine; CARBOplatin;
Carmustine; Chlorambucil; CISplatin; Cladribine; Cytarabine; Cytarabine (Liposomal); Dacarbazine; DACTINomycin; DAUNOrubicin Citrate (Liposomal);
DAUNOrubicin Hydrochloride; Denileukin Diftitox; Docetaxel; DOXOrubicin (Liposomal); Epirubicin; Estramustine; Etoposide Phosphate; Exemestane; Fludarabine;
Goserelin; Hydroxyurea; IDArubicin; Irinotecan; Letrozole; Leuprolide; Lomustine; Mechlorethamine; Megestrol; Mitomycin; Mitoxantrone; Nilutamide; Paclitaxel;
Pegaspargase; Pentostatin; Polyestradiol; Porfimer; RiTUXimab; Streptozocin; Tamoxifen; Temozolomide; Teniposide; Thioguanine; Thiotepa; Topotecan;
Toremifene; Tretinoin (Oral); Valrubicin; VinBLAStine; Vinorelbine. Risk C: Monitor therapy
Antiplatelet Agents: May enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy
Antithyroid Agents: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification AzaTHIOprine:
May diminish the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Barbiturates: May increase the metabolism of Vitamin K Antagonists. Risk D: Consider therapy modification
Bile Acid Sequestrants: May decrease the absorption of Vitamin K Antagonists. Risk C: Monitor therapy
Bosentan: May increase the metabolism of Vitamin K Antagonists. Risk C: Monitor therapy
Capecitabine: May increase the serum concentration of Vitamin K Antagonists. Risk D: Consider therapy modification CarBAMazepine:
May decrease the serum concentration of Vitamin K Antagonists. Risk D: Consider therapy modification
Cephalosporins: May enhance the anticoagulant effect of Vitamin K Antagonists. Exceptions: Cefaclor; Cefadroxil; Cefdinir; Cefepime; Cefixime; Cefonicid; Cefotaxime;
Cefpodoxime; Cefprozil; Ceftazidime; Ceftibuten; Ceftizoxime; Ceftobiprole; Cefuroxime; Cephalexin; Cephradine [Off Market]. Risk C: Monitor therapy
Cimetidine: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Coenzyme Q-
10: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Contraceptive (Progestins): May diminish the anticoagulant effect of Vitamin K Antagonists. In contrast, enhanced anticoagulant effects have also been noted with
some products. Risk D: Consider therapy modification
CYP1A2 Inducers (Strong): May increase the metabolism of CYP1A2 Substrates. Risk C: Monitor therapy
CYP1A2 Inhibitors (Moderate): May decrease the metabolism of CYP1A2 Substrates. Risk C: Monitor therapy
CYP1A2 Inhibitors (Strong): May decrease the metabolism of CYP1A2 Substrates. Risk D: Consider therapy modification CYP2C9 Inducers (Highly
Effective): May increase the metabolism of CYP2C9 Substrates (High risk). Risk C: Monitor therapy CYP2C9 Inhibitors (Moderate): May decrease
the metabolism of CYP2C9 Substrates (High risk). Risk C: Monitor therapy CYP2C9 Inhibitors (Strong): May decrease the metabolism of CYP2C9
Substrates (High risk). Risk D: Consider therapy modification Dasatinib: May enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor
therapy
Dicloxacillin: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Disulfiram: May increase the serum concentration of Vitamin K Antagonists. Risk C: Monitor therapy
Drotrecogin Alfa: Vitamin K Antagonists may enhance the adverse/toxic effect of Drotrecogin Alfa. Bleeding may occur. Risk D: Consider therapy modification
Efavirenz: May increase the serum concentration of Vitamin K Antagonists. Risk C: Monitor therapy
Etoposide: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Fenugreek: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Fibric Acid Derivatives: May
enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Fluconazole: May decrease the metabolism of
Vitamin K Antagonists. Risk D: Consider therapy modification
Fluorouracil: May increase the serum concentration of Vitamin K Antagonists. Risk D: Consider therapy modification Gefitinib: May
enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Ginkgo Biloba: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Glucagon: May
Glutethimide: May increase the metabolism of Vitamin K Antagonists. Risk D: Consider therapy modification
Griseofulvin: May increase the metabolism of Vitamin K Antagonists. Risk C: Monitor therapy
Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Anticoagulants. Bleeding may occur. Risk D:
HMG-CoA Reductase Inhibitors: May enhance the anticoagulant effect of Vitamin K Antagonists. Exceptions: Atorvastatin. Risk C: Monitor therapy Ifosfamide: May
Ivermectin: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Leflunomide: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Macrolide Antibiotics: May decrease the metabolism of Vitamin K Antagonists. Exceptions: Dirithromycin [Off Market]; Spiramycin. Risk C: Monitor therapy
Mercaptopurine: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
MetroNIDAZOLE: May decrease the metabolism of Vitamin K Antagonists. Risk D: Consider therapy modification
Nafcillin: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification NSAID (COX-2
Inhibitor): May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
NSAID (Nonselective): May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification
Oral Contraceptive (Estrogens): May diminish the anticoagulant effect of Vitamin K Antagonists. In contrast, enhanced anticoagulant effects have also been noted
with some products. Risk D: Consider therapy modification
Pentosan Polysulfate Sodium: May enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy
Phenytoin: May enhance the anticoagulant effect of Vitamin K Antagonists. Vitamin K Antagonists may increase the serum concentration of Phenytoin. Risk D:
Phytonadione: May diminish the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Propafenone:
May increase the serum concentration of Vitamin K Antagonists. Risk C: Monitor therapy
Propoxyphene: May decrease the metabolism of Vitamin K Antagonists. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the adverse/toxic effect of Anticoagulants. Specifically, the antiplatelet effects of these agents may lead to an increased risk of
bleeding with the combination. Risk C: Monitor therapy
QuiNIDine: May enhance the anticoagulant effect of Vitamin K Antagonists. Note that the prothrombin time might be unchanged in the face of increased bleeding. Risk
C: Monitor therapy
Quinolone Antibiotics: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy Rifamycin
Derivatives: May increase the metabolism of Vitamin K Antagonists. Risk C: Monitor therapy
Salicylates: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Selective Serotonin Reuptake
Inhibitors: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy St Johns Wort: May increase the metabolism of
Vitamin K Antagonists. Risk D: Consider therapy modification
Sulfinpyrazone [Off Market]: May decrease the metabolism of Vitamin K Antagonists. Sulfinpyrazone [Off Market] may decrease the protein binding of Vitamin K
Antagonists. Risk D: Consider therapy modification
Sulfonamide Derivatives: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Tamoxifen: May
increase the serum concentration of Vitamin K Antagonists. Risk X: Avoid combination
Tetracycline Derivatives: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy Thrombolytic
Agents: May enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy
Thyroid Products: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification Tricyclic
Antidepressants: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy Vitamin A: May enhance the
anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Vitamin E: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Vorinostat: May enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Zafirlukast: May decrease the metabolism of Vitamin K Antagonists. Risk C: Monitor therapy
Ethanol: Avoid ethanol. Acute ethanol ingestion (binge drinking) decreases the metabolism of oral anticoagulants and increases PT/INR. Chronic daily ethanol use
increases the metabolism of oral anticoagulants and decreases PT/INR.
Food: The anticoagulant effects of acenocoumarol may be decreased if taken with foods rich in vitamin K. Vitamin E may increase anticoagulant effect.
Herb/Nutraceutical: St John's wort may decrease oral anticoagulant levels. Alfalfa contains large amounts of vitamin K as do many enteral products. Coenzyme Q 10 may
decrease response to oral anticoagulants. Avoid cat's claw, dong quai, evening primrose, feverfew, red clover, horse chestnut, garlic, green tea, ginseng, and
ginkgo (all have additional antiplatelet activity).
Monitoring ParametersPT/INR; hepatic function, CBC, urinalysis (for albuminuria/proteinuria)

Monitoring: Lab TestsPT/INR; hepatic function, CBC, urinalysis (for albuminuria/proteinuria)
Dosage FormsExcipient information presented when available (limited, particularly for generics); consult specific product labeling. [CAN] = Canadian brand name
Tablet:
Sintrom® [CAN]: 1 mg, 4 mg [not available in the U.S.]
Generic AvailableNo
ManufacturerPendopharm (Canada)
Mechanism of ActionInterferes with hepatic synthesis of vitamin K-dependent coagulation factors (II, VII, IX, X)
Onset of action: Peak anticoagulant effect: Oral: 36-48 hours

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Principal Investigator, AIDS Clinical Trials Unit

Bellevue Hospital Center

Associate Professor of Medicine

New York University

New York, New York

William Alvarez Jr., BS, PharmD, RPh

Lora Armstrong, RPh, PharmD, BCPS

Pharmacy & Therapeutics Committee Formulary Process

Clinical Program Oversight

Kenneth A. Bachmann, PhD, FCP

Distinguished University Professor of Pharmacology

Codirector, Center for Applied Pharmacology

Anesthesiology and Neurosurgery

Judith L. Beizer, PharmD, CGP, FASCP

Department of Clinical PharmacyPractice

St John's University College of Pharmacy and Allied Health Professions

Jamaica, New York

Mark F. Bonfiglio, BS, PharmD, RPh

Chief Content Officer

Diedra L. Bragalone, BSPharm, BCOP

Larisa H. Cavallari, PharmD, BCPS

Irene H. Chenowith, MD, FACP

Medical Director of Professional Affairs

Akron General Medical Center

Associate Professor of Internal Medicine

Northeastern Ohio Universities

University Hospitals of Cleveland

Harold L. Crossley, DDS, PhD

Associate Professor of Pharmacology

Baltimore College of Dental Surgery

University of Maryland Baltimore

Melanie Cucchi, PharmD

Laura Cummings, PharmD, BCPS

Clinical Pharmacy Specialist, Pediatrics

The Children's Hospital at MetroHealth

Julie A. Dopheide, PharmD, BCPP

Associate Professor of Clinical Pharmacy, Psychiatry and the Behavioral Sciences

University of Southern California

Schools of Pharmacy and Medicine

Los Angeles, California

Chief, Oncology Pharmacy

Director, Oncology Pharmacy Residency Program

Walter Reed Army Medical Center

Vicki L. Ellingrod, PharmD, BCPP

Iowa City, Iowa

Kelley K. Engle, BSPharm

Erin Fabian, PharmD, RPh

Margaret A. Fitzgerald, MS, APRN, BC, NP-C, FAANP

North Andover, Massachusetts

Family Nurse Practitioner

Greater Lawrence Family Health Center

Lawrence A. Frazee, PharmD

Pharmacotherapy Specialist in Internal Medicine

Akron General Medical Center

Matthew A. Fuller, PharmD, BCPS, BCPP, FASHP

Clinical Pharmacy Specialist, Psychiatry

Cleveland Department of Veterans Affairs Medical Center