Carolinas Medical Center-Union
Therapeutic Interchange Guidelines
Updated May 2006

After clicking on a link below, click the BACK button to return to top of this page.

Accolate	Automatic Dosage Interchanges for Selected Antibiotics
Accupril	Automatic Dose Adjustment in Patients with Renal Impairment
Aceon	Automatic Dose Adjustment in Patients with Renal Impairment-Augmentin
Aciphex	Automatic Dose Adjustment in Patients with Renal Impairment-Neurontin
Aclovate	Avandamet
Actonel	Avandia
Actoplusmet	Avapro
Advair®	Avelox
AeroBid	Axid
Alavert	Azmacort
Albuterol	Beclovent®
Allegra	Beconase-AQ
Alomide	Benicar
Alphatrex	Biaxin
Altace	BiDil
Altocor/Altoprev	Buprenex
Alupent®	Byetta
Amaryl	Caduet
Ambien	Campral
Ambisome	Carisoprodol
Ampicillin	Ceclor
Anaprox	Cedax
Ansaid	Cefipime
Antara	Ceftazadime
Argatroban	Ceftin
Arthrotec	Celestone
Atacand	Celexa
Atuss-DM	Centrax
Atuss-HD	Chlorzoxazone
Atuss-MS	Chromagen
Chromagen-FA	Daypro
Ciloxan	Decadron
Cipro	Decaspray
Claforan	Default Indications-Commonly Used Legend PRN Medication Orders
Clarinex	Demadex
Claritin	DesOwen
Claritin-D	Detrol
Clinoril	Dialose
Cloderm	Diovan
Codeine-containing Cough Syrups	Diprolene
ComBgen	Diprosone
Combunex 5/400	Disalcid
Cordran	Ditropan
Cozaar	Dolasetron
Crestor	Dolobid
Cutivate	Cyclobenzaprine
Cyclocort	Dosage Regimens for Lovenox (enoxaparin) Prophylaxis in Patients with Severe Renal Impairment
Cymbalta	Dyazide
Darvon Cpd-65	E.E.S
Endal-HD	Flunisolide
Enduron	FML
Flomax	FML Forte
Flonase	Folbee
Florane	Folbee Plus
Flovent	Folbic
Floxin	Folcaps
Folgard	Glucovance
Folgard Rx	Granisetron
Folgard-OS	Guidelines for Oral Sodium Phosphates Solution (Fleet Phospho-Soda)
Folplex	Halcion
Foltx	Halog
Foradil®	Hemocyte
Forteo	Hemocyte-F
Gemfibrozil	Histussin-HC
Geodon Hydrocodone-containing Cough Syrups	Humalog, insulin lispro LacHydrin
Hytrin	Lacticare Lotion
Indocin SR	Lescol
Inflamase	Libritabs
Inflamase Forte	Lidoderm Transdermal
Intal MDI	Lipitor
Ketek	Lisinopril
Livostin	Maxair®
Lodine	Maxiflor
Lofibra	Maxivate
Lotensin	Metaglip
Lunesta	Metaxalone (Skelaxin®)
Lyrica	Methicillin Sodium
Magnesium Oxide 500mg	Methocarbamol
Mavik	Mevacor
Micardis	Optivar (azelastine)
Miconazole 2% Topical Powder	Orphenadrine
Monopril	Orudis
MultiHance	Oruvail
Mycelex Nalfon	Oxytrol Palladone
Naphcon-A	Panlor SS
Naprelan	Patanol
Naprosyn	Paxil-CR
Nasacort®	Phazyme
Nasonex	Phazyme-125
Nexium	Plan B
Nizoral	Pravachol
Noroxin	Precedex
Nystatin Topical Powder	Pred Forte
Ocuflox	Pred Mild
Omacor	Prenatal Vitamins
Omnicef	Prevacid
Ondansetron	Prilosec
Opcon-A	Prinivil
Optivar	Profenal
Prosom	Relafen
Pulmicort DPI	Remeron
PV-Tussin	Restoril
Pyridium Plus	Rhinocort Aqua
Quixin QVAR®	Rythmol Sonata
Serevent®	Spectracef
Serax	Spiriva
Skelaxin	Stadol
Suprax	Tarka
Symbyax	Temovate
Synalar	Tequin
Tagamet	Terazol
Terramycin	Topicort
Tevetan	Topicort-LP
Therapeutic Interchange of Selected Intravenous Pharmaceuticals to Oral Administration (IV to PO Switch)	Toradol
Ticlid	TriCor
Timentin	Tridesilon
Triglide	Ultravate
Tygacil	Univasc
Ultracet	Uticort
Vantin	VFEND
Vasotec	Vigamox
Visine	Wellbutrin
Voltaren	Westcort
Xenaderm	Zantac
Xopenex	Zestril
Zaditor	Zymar
Zyrtec

FORMULARY ADDITIONS / DELETIONS
Date	Generic Name	Brand Name	Action
May 2006	Balsam Peru, Castor Oil USP/NF, Trypsin USP	Xenaderm	Added w/WOC consult required
May 2006	Carisoprodol	Soma	Deleted
May 2006	Chlorzoxazone	Parafon	Deleted
May 2006	Metaxalone	Skelaxin	Deleted
May 2006	Methocarbamol	Robaxin	Deleted
May 2006	Orphenadrine	Norflex	Deleted
January 2006	Acetaminophen, caffeine, dihydrocodeine	Panlor SS	Deleted
January 2006	Omacor	Omega-3-acid ethyl esters 90	Added w/automatic interchange for all Omega-3 orders
January 2006	Argatroban	Acova	Added
January 2006	Fenofibrate micronized	Antara	Deleted w/automatic interchange to gemfibrozil
November 2005	Pregabalin	Lyrica	Deleted
November 2005	Exenatide Injection	Byetta	Added
October 2005	Eszopiclone	Lunesta	Deleted w/automatic interchange to Ambien
October 2005	Gadobenate dimeglumine	MultiHance	Added
October 2005	Acamprosate calcium	Campral	Added
October 2005	Tigecycline	Tygacil	Added-ID consult recommended
August 2005	Hydromorphone, extended-release	Palladone	Deleted (Removed from market by FDA)
August 2005	Duloxetine	Cymbalta	Added
August 2005	Voriconazole	VFEND	Deleted
June 2005	Hydromorphone, extended-release	Palladone	Added
May 2005	Azelastine Ophthalmic	Optivar	Added
May 2005	Teriparatide	Forteo	Added for Long-Term Care Only
April 2005	Lidocaine 5% Transdermal	Lidoderm Transdermal	Added
FORMULARY ADDITIONS / DELETIONS
March 2005	Olanzapine I.M.	Zyprexa I.M.	Added
February 2005	Telithromycin	Ketek	Deleted
February 2005	Ziprasidone	Geodon	Deleted
January 2005	Dexmedetomidine	Precedex	Added
January 2005	Levonorgestrel 0.75mg	Plan B	Added

ACE Inhibitors & Combinations

(All Mavik orders to be dosed once daily*—maximum dose 4mg)

Accupril 5mg use Lisinopril 5mg

Accupril 10mg use Lisinopril 10mg

Accupril 20mg use Lisinopril 20mg

Accupril 40mg use Lisinopril 40mg

Accupril 80mg use Lisinopril 80mg

Aceon 2mg use Mavik 1mg

Aceon 4mg use Mavik 2mg

Aceon 8mg use Mavik 4mg

Altace 1.25mg use Mavik 0.5mg

Altace 2.5mg use Mavik 1mg

Altace 5mg use Mavik 2mg

Altace 10mg use Mavik 4mg

Lotensin 5mg use Lisinopril 5mg

Lotensin 10mg use Lisinopril 10mg

Lotensin 20mg use Lisinopril 20mg

Lotensin 40mg use Lisinopril 40mg

Monopril 10mg use Lisinopril 10mg

Monopril 20mg use Lisinopril 20mg

Prinivil/Zestril, all strengths use Formulary—do not substitute

Tarka (Mavik/Verapamil)

Tarka-1/240 use Mavik 1mg/Verapamil SR 240mg

Tarka-2/180 use Mavik 2mg/Verapamil SR 180mg

Tarka-2/240 use Mavik 2mg/Verapamil SR 240mg

Tarka 4/240 use Mavik 4mg/Verapamil SR 240mg

Univasc 7.5mg use Mavik 1mg

Univasc 15mg use Mavik 2mg

Univasc 30mg use Mavik 4mg

ACE Inhibitors & Combinations, continued

Vasotec 2.5mg use Mavik 0.5mg

Vasotec 5mg use Mavik 1mg

Vasotec 10mg use Mavik 2mg

Vasotec 20mg use Mavik 4mg

Vasotec 20mg BID* use Mavik 4mg BID* (exception to once daily Mavik dosing)

Angiotensin II Receptor Antagonists

Atacand 8mg bid or 16mg daily use Cozaar 25mg bid or 50mg daily

Atacand 16mg bid or 32mg daily use Cozaar 50mg bid or 100mg daily

Avapro, all strengths use Formulary—do not substitute

Benicar 10mg daily use Cozaar 25mg daily

Benicar 20mg daily use Cozaar 50mg daily

Benicar 40mg daily use Cozaar 100mg daily

Cozaar 25mg, 50, 100mg use Formulary—do not substitute

Diovan 80mg, 160mg, 320mg use Formulary—do not substitute

Micardis 20mg daily use Cozaar 25mg daily

Micardis 40mg daily use Cozaar 50mg daily

Micardis 80mg daily (max daily dose) use Cozaar 100mg daily

Tevetan 400mg daily use Cozaar 25mg daily

Tevetan 400mg bid use Cozaar 50mg daily or 100mg daily

Tevetan 600mg daily use Cozaar 50mg daily

Tevetan 800mg daily (max daily dose) use Cozaar 100mg daily

Cephalosporins

Ceftazidime 500mg IV Q12hr use Cefepime 500mg IV Q12hr

Ceftazidime 500mg IV Q24hr use Cefipime 500mg IV Q24hr

Ceftazidime 1G IV Q8-12hr use Cefipime 1G IV Q8-12hr

Ceftazidime 1G IV Q24hr use Cefipime 1G IV Q24hr

Ceftazidime 2G IV Q8-12hr use Cefipime 2G IV Q8-12hr

Ceftazidime 2G IV Q24hr use Cefipime 2G IV Q24hr

Ceftin 125mg po bid use Cefzil 125mg po bid

Ceftin 250mg po bid use Cefzil 250mg po bid

Ceftin 500mg po bid use Cefzil 500mg po bid

Claforan 1G Q6,8,12hr use Rocephin 1G Q 24hr

Claforan 2G Q6,8,12hr use Rocephin 2G Q 24hr

Ceclor 125mg po tid use Cefzil 125mg po bid (oral suspension)

Ceclor 250mg po tid use Cefzil 250mg po bid

Ceclor 500mg po tid use Cefzil 500mg po bid

Cedax 400mg Q 24hr use Vantin 200mg Q 12 hr

Omnicef 300mg Q 12hr use Vantin 200mg Q 12 hr

Spectracef 400mg Q 12hr use Vantin 200mg Q 12 hr

Suprax 400mg Q 24hr use Vantin 200mg Q 12 hr

Vantin 50mg po bid (PEDS) use Cefzil 125mg po bid (oral suspension)

Vantin 100mg po bid (PEDS) use Cefzil 250mg po bid (oral suspension)

Codeine-containing Cough Syrups

**The only codeine-containing cough syrups remaining on formulary will be:

1. Robitussin-AC

2. Phenergan w/Codeine

Therapeutic substitutions will be initiated by the pharmacist for codeine-containing syrups with different but similar formulations.

Hydrocodone-containing Cough Syrups

PV-Tussin, 5ml use Endal-HD 10ml

Histussin-HC, 5ml use Endal-HD 10ml

Atuss-HD, 5ml use Endal-HD, 5ml

Atuss-HD, 10ml use Endal-HD, 10ml

Atuss-MS, 5ml use Endal-HD, 10ml

**The only other hydrocodone-containing cough syrups on formulary will be Vicodin-Tuss and Tussionex.

Nasal Corticosteroid Inhaler Interchange

Pharmacist to perform auto-interchange for all nasal corticosteroid inhalers to flunisolide 0.025% nasal spray (25mcg/spray) per following table:

Flunisolide 0.025% (25mcg/spray)--Formulary Nasal Corticosteroid Inhaler.

Product ordered à ¯	Adult Dose     à ¯	Pediatric dose   à ¯	Nasalide®, Nasarel® (flunisolide 25 mcg/spray) (Formulary) ADULT/CHILDREN > 6 DOSE
Beconase-AQ® , Vancenase-AQ® Vancenase®	Adults & children >=6 years: 1-2 Sprays each nostril BID	Not indicated for children <6 years	Adults & children >=6 years: 2 Sprays each nostril BID
Nasacort®, Nasacort AQ® (triamcinolone 55 mcg/spray)	Adults & children >=11 years: 2 Sprays each nostril daily	Children 6-11 years: 1 Spray each nostril daily	Same as above
Flonase® (fluticasone 50 mcg/spray)	Adults & children >=11 years: 2 Sprays each nostril daily	Children 4-11 years (DO NOT SUBSTITUTE IN CHILDREN < 4 YEARS): 1 Spray each nostril daily	Same as above
Rhinocort Aqua® (budesonide 32 mcg/spray)	Adults & children >=6 years: 1 Spray each nostril daily	Not indicated for children <6 years	Same as above
Nasonex® (mometasone) 50mcg/spray	Adults & children >=6 years 2 Sprays each nostril daily	Children 2-11 years (DO NOT SUBSTITUTE IN CHILDREN 2-6 YEARS 1 Spray each nostril daily	Same as above

Note: Please Check to determine the

“Pharmacy Preferred Intranasal Steroid”

It may change based on acquisition cost.

1. If MD prescribes “Nasal Steroid per pharmacy.” The pharmacy will profile and dispense the pharmacy preferred nasal steroid at starting dosages listed above.
2. Any nasal steroid order for patients 6 years or older will be therapeutically interchanged to the pharmacy preferred nasal steroid at the starting dosage listed above – please note pediatric dosage. (NOTE: Nasonex® is indicated for Children 2 years and above)

Oral Inhaled Corticosteroid Interchanges & Dosing

Find current product, find current dose per day (based on total daily puffs), convert to FORMULARY item-- FLOVENT® (Fluticasone)
Product		CURRENT TOTAL Dose	FORMULARY ITEM
AeroBid® (Flunisolide)		2-4 total puffs per day	FLOVENT® 44mcg 2 puffs BID
		4-8 total puffs per day	FLOVENT 110mcg 2 puffs BID
		>8 total puffs per day	FLOVENT 220mcg 2 puffs BID
Azmacort® (Triamcinolone)		< 10 total puffs per day	FLOVENT 44mcg 2 puffs BID
		10-20 total puffs per day	FLOVENT 110mcg 2 puffs BID
		> 20 puffs per day	FLOVENT 220mcg 2 puffs BID
Pulmicort DPI® (Budesonide)		< 3 total puffs per day	FLOVENT 44mcg 2 puffs BID
		3-6 total puffs per day	FLOVENT 110mcg 2 puffs BID
		> 6 puffs per day	FLOVENT 220mcg 2 puffs BID
Beclovent® (Beclomethasone) (not available)	42 mcg inhaler	-	FLOVENT 44 mcg- same dosing regimen
QVAR® (Beclomethasone Dip.)	40 mcg inhaler 80 mcg inhaler	2-6 puffs per day 1-3 puffs per day	FLOVENT 44mcg 2 puffs BID
	40 mcg inhaler 80 mcg inhaler	6-16 puffs per day 3-8 puffs per day	FLOVENT 110mcg 2 puffs BID
	40 mcg inhaler 80 mcg inhaler	>16 puffs per day >8 puffs per day	FLOVENT 220mcg 2 puffs BID

MDI/DPI Interchanges Short & Long-Acting Beta Agonists
Non-Formulary Product	Dose/Frequency	USE à	Formulary Product	Dose/Frequency
Alupent® (metaproterenol)MDI	1-2 inhalations Q 4-6 hours		Albuterol MDI	2 inhalations every 4 hours
Maxair® (pirbuterol) MDI	1-2 inhalations Q 4-6 hours		Albuterol MDI	2 inhalations every 4 hours
Serevent® (salmeterol) Diskus	1 inhalation BID		Foradil®(fomoterol fumarate) capsules	1 inhalation BID
Advair® 100/50 (salmeterol/fluticasone)	1 inhalation BID		Foradil® (fomoterol) + Flovent (fluticasone 110mcg	1 inhalation BID 1 inhalation BID
Advair® 250/50 (salmeterol/fluticasone)	1 inhalation BID		Foradil® (fomoterol) + Flovent® (fluticasone 220mcg	1 inhalation BID 1 inhalation BID
Advair® 500/50 (salmeterol/fluticasone)	1 inhalation BID		Foradil® (fomoterol) + Flovent® (fluticasone 220mcg	1 inhalation BID 2 inhalations BID

Automatic Adjustment of Dose and Frequency for Xopenex (levalbuterol)

1. Automatic adjustment of dose and frequency by the pharmacist for Xopenex® (levalbuterol) in patients 6 years of age and older according to the following parameters as approved by the FDA and per the manufacturer’s package insert.
• Children 6-11 years old: Recommended dosage of levalbuterol is 0.31mg administered by nebulization every 6 hours; routine dosing should not exceed 0.63mg three times a day. There are no current recommendations for adjustments in children less than 6 years old.
• Adults and Adolescents ≥ 12 years old: Recommended starting dosage of levalbuterol is 0.63mg administered by nebulization every 6 hours. Patients with more severe asthma or not responding to the starting dose may be adjusted to a maximum dosage of 1.25mg three times a day.

Management of Concurrent Orders for Spiriva® (tiotropium) and Atrovent® (ipratropium)

· Pharmacist to discontinue existing order(s) for tiotropium or ipratropium when an order for the other product is received

· Orders received concurrently for both agents will prompt the pharmacist to contact the prescribing physician for appropriate therapy selection

H₂ Antagonists

Axid 150mg po BID use Pepcid 40mg po qHS

Axid 300mg po qHS use Pepcid 40mg po qHS

Tagamet 300-1200 mg/24hr po use Pepcid 40mg po qHS (1^st dose STAT)

Tagamet 200-300mg IV q6-8h use Pepcid 20mg IV q12h

Tagamet 300-400mg IV q12-24h use Pepcid 20mg IV q24h

Zantac 150mg po Q DAY use Pepcid 20mg po qHS

Zantac 150mg po BID use Pepcid 40mg po qHS

Zantac 300mg po Q DAY use Pepcid 40mg po qHS

Zantac 50mg IV q8h use Pepcid 20mg IV q12h

Zantac 50mg IV q12h use Pepcid 20mg IV q12h

Zantac 50mg IV q24h use Pepcid 20mg IV q24h

HMG-CoA Reductase Inhibitors (“statins”)

Use same dosing frequency for all therapeutic conversions—Zocor to be given at 2100

Altocor/Altoprev 20mg use Zocor 10mg

Altocor/Altoprev 40mg use Zocor 20mg

Altocor/Altoprev 60mg use Zocor 40mg

Crestor (rosuvastatin) 5mg use Zocor 10mg

Crestor (rosuvastatin) 10mg use Zocor 20mg

Crestor (rosuvastatin) 20mg use Zocor 40mg

Crestor (rosuvastatin) 40mg use Zocor 80mg.

Lescol 20mg use Zocor 5mg

Lescol 40mg use Zocor 10mg

Lescol 80mg use Zocor 20mg

Lescol-XL 80mg use Zocor 20mg

Lipitor 10mg use Zocor 20mg

Lipitor 20mg use Zocor 40mg

Lipitor 40mg use Zocor 80mg

Lipitor 80mg DO NOT SUBSTITUTE

Mevacor 10mg use Zocor 5mg

Mevacor 20mg use Zocor 10mg

Mevacor 40mg use Zocor 20mg

Mevacor 80mg use Zocor 40mg

Pravachol 10mg use Zocor 5mg

Pravachol 20mg use Zocor 10mg

Pravachol 40mg use Zocor 20mg

Therapeutic Interchange of Fenofibrate Formulations

Current Autosubstitution *Do not substitute in patients receiving concomitant HMG CoA Reductase Inhibitor therapy (P&T approved 03/03):

Indication and Dose Range	Interchange with
Adjunct to diet for Hypertriglyceridemia TriCor® 67 – 201 mg/day à	Gemfibrozil 600 mg PO BID

Indications and Dose Ranges	Interchange with
Adjunct to diet for Hypertriglyceridemia and Hypercholesterolemia or Mixed hyperlipidemia Ø TriCor® 48 mg- 145 mg/day à (with/without food) Ø Antara™ 43 – 130 mg/day (with meals) à Ø Lofibra™ 67 – 200 mg/day (with meals) à Ø Triglide™ 50 – 160 mg/day (with/without food) à	Gemfibrozil 600 mg PO BID (30 min. before breakfast and dinner)

Formulation	Acquisition Unit Cost
Antara™ 43 mg à (Capsule) 130 mg à	$ 0.91 2.73
Lofibra™ 67 mg à (Capsule) 134 mg à 200 mg à	$ 0.67 1.33 2.07
TriCor® 48 mg à (Tablet) 54 mg à 145 mg à 160 mg à	$ 0.95 0.91 2.84 2.73
Triglide™ 50 mg à (Tablet) 160 mg à	$ 0.73 2.73
Gemfibrozil (generic for Lopid®) 600 mg à	$ 0.16

Hypnotics

Use same dosing frequency for all therapeutic conversions

(Do not substitute Restoril for Ambien in patients: 1) who are pregnant; 2) with lung disease; 3) at risk for falls 4) over 65 years of age

Ambien 5, 10mg use Restoril 15mg

Halcion 0.125mg use Restoril 15mg

Halcion 0.25mg use Restoril 15mg

Lunesta (eszopiclone) 1mg use Ambien 5mg

Lunesta (eszopiclone) 2mg use Ambien 5mg

Lunesta (eszopiclone) 3mg use Ambien 5mg, may repeat in 30 minutes X 1 if

inadequate response

Prosom 1mg use Restoril 15mg

Prosom 2mg use Restoril 15mg

Sonata 5mg use Restoril 15mg

Sonata 10mg use Restoril 15mg

Macrolides

Biaxin use Zithromax equivalents Q DAY, mg-for-mg.

Physicians desiring Biaxin for treatment of Helicobacter pylori should write DO NOT

SUBSTITUTE.

Miscellaneous Substitutions

Use same dosing frequency for all therapeutic conversions

Accolate use Singulair (montelukast)

Adults/adolescents >15yrà10mg QHS

Pediatric Patients 6-14yrà5 mg QHS

Pediatric Patients 2-5yrà4mg chewable tablet QHS

Actonel 35mg once weekly use Fosamax 70mg once weekly

Actoplusmet 15/500 use Actos 15mg + metformin 500mg

Actoplusmet 15/850 use Actos 15mg + metformin 850mg

Amaryl 1mg Q DAY use Glyburide 2.5mg Q DAY

Amaryl 2mg Q DAY use Glyburide 5mg Q DAY

Amaryl 4mg Q DAY use Glyburide 5mg BID

Amaryl 8mg Q DAY use Glyburide 10mg BID

Ambisome 3-5mg/kg use Abelcet 5mg/kg

Ampicillin Oral, QID use Amoxicillin Oral (same strength), TID (q8h)

Atuss-DM, 5ml use Cardec-DM, 2.5ml

Atuss-DM, 10ml use Cardec-DM, 5ml

(For infants < 2 years of age use Cardec-DM drops w/age-based dosing per manufacturer’s recommendation)

Avandia 2mg BID use Actos 15mgQ DAY

Avandia 4mg Q DAY use Actos 15mg Q DAY

Avandia 8mg Q DAY use Actos 30mg Q DAY

Avandia 4mg BID use Actos 45mg Q DAY

Avandamet 1mg/500mg use Actos 7.5mg + Metformin 500mg

Avandamet 2mg/500mg use Actos 15mg + Metformin 500mg

Avandamet 4mg/500mg use Actos 15mg + Metformin 500mg

BiDil 20/37.5 (isosorbide dinitrate / hydralazine) use Isosorbide dinitrate 20mg +

hydralazine 25mg, 1-1/2 tablet

Buprenex 0.3mg use Nubain 10mg

Buprenex 0.6mg use Nubain 20mg

Caduet 5/10 use Norvasc 5mg + Zocor 20mg

Caduet 5/20 use Norvasc 5mg + Zocor 40mg

Caduet 5/40 use Norvasc 5mg + Zocor 80mg

Caduet 5/80 use Norvasc 5mg + Lipitor 80mg (Do not substitute Zocor)                  &