CHI Memorial Hospital
Formulary Interchanges, Restrictions, & Usage Criteria
Updated: March 2024
Table of Contents:
(Use links here or press Ctrl+F to search for a specific drug or word within the page)
o NSAIDs
o Combination Agents with Hydrocodone/Oxycodone
o Serotonin Receptor Agonists (Triptans)
o Low-Molecular Weight Heparins
o Incretin Mimetics and Amylin Analogs
o Incretin Mimetic/Insulin Combination Products
o Anti-Infective Automatic Stops
o Cephalosporins (1st gen, 2nd gen, 3rd gen, 4th gen)
· Antihistamines, Decongestants, Antitussives, Expectorants
o Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)
o Angiotensin II Receptor Blockers (ARBs)
o Calcium Channel Blockers (CCBs)
o HMG-CoA Reductase Inhibitors (Statins)
o Phosphodiesterase Inhibitors
o Antifungal/Steroid Combinations
o Topical Corticosteroids (Very High, High, Medium, Low Potencies)
o Antacids
o Peripheral-acting Opioid Antagonists
o Proton Pump Inhibitors (PPIs)
· Hormones and Hormone Modifiers
o Estradiol Transdermal Systems
o Megace
o Medications Not Approved for Outpatient Formulary
o Therapeutic Restrictions to Outpatient Locations
o Anti-infective Ophthalmic Agents
o NSAIDs
o Antidepressants (SNRIs, SSRIs, TCAs)
o Long-acting Antimuscarinics (LAMA)
o Short-acting Antimuscarinics (SAMA)
o Long-acting Beta-Agonists/Short-acting Antimuscarinics (LABA/LAMA)
o Short-acting Beta-Agonists/Short-acting Antimuscarinics (SABA/SAMA)
o Inhaled Corticosteroids (ICS)
o Inhaled Corticosteroid/Long-acting Beta-Agonist Combination (ICS/LABA)
o Long-acting Beta-agonist/Long-acting Antimuscarinic/Inhaled Corticosteroid (LABA/LAMA/ICS)
· Sedatives/Hypnotics for Sleep
DRUG |
RESTRICTION(S) |
Fentanyl IV push |
1. Restricted to ER, OR, PACU, CSSU, and ICUs. |
Fentanyl PCA |
1. Restricted to Hospice, ICUs and PACU |
Ibuprofen IV (Caldolor®) |
1. Restricted to Critical Care physicians only for a duration of 48 hrs |
Meperidine (Demerol®) |
1. Only to be used for the following indications:
|
Liposomal bupivacaine (Exparel®) |
1. Non-formulary per P&T April 2016. |
Remifentanil (Ultiva®) |
Ordering restricted to anesthesia providers for: - Craniotomies with very low associated post-op pain, or - Awake fiberoptic intubations |
ORDERED |
SUBSTITUTION |
Aspirin/butalbital/caffeine (Fiorinal®) |
Acetaminophen/butalbital/caffeine (Esgic/Fioricet®) |
Aspirin/butalbital/caffeine/codeine |
Acetaminophen/butalbital/caffeine (Esgic®) |
Lidocaine 5% patch |
Lidocaine 4% patch |
ORDERED |
SUBSTITUTION |
Diclofenac (Dyloject®) 37.5 mg IV q 6 hrs |
Ketorolac (Toradol®) 30 mg IV q 6 hrs |
Etodolac (Lodine®) 200 mg |
Ibuprofen 400 mg* |
Etodolac (Lodine®) 300 mg |
Ibuprofen 600 mg* |
Etodolac (Lodine®) 400 mg |
Ibuprofen 800 mg* |
Fenoprofen (Nalfon®) 600 mg |
Ibuprofen 600 mg* |
Flurbiprofen (Ansaid®) 50 mg |
Ibuprofen 400 mg q 6 hrs |
Flurbiprofen (Ansaid®) 100 mg |
Ibuprofen 600 mg q 6 hrs |
Ketoprofen (Orudis®) 50 mg |
Ibuprofen 400 mg* |
Ketoprofen (Orudis®) 75 mg |
Ibuprofen 600 mg* |
Ketoprofen CR (Oruvail CR®) 200 mg |
Ibuprofen 400 mg q 6 hours |
Naproxen 550 mg |
Naproxen 500 mg (2 x 250 mg tabs) |
Meclofenamate 50 mg |
Ibuprofen 400 mg* |
Meclofenamate 100 mg |
Ibuprofen 600 mg* |
Oxaprozin (Daypro®) 600 mg |
Nabumetone (Relafen®) 500 mg* |
Tolmetin (Tolectin®) 200 mg |
Ibuprofen 200 mg* |
Tolmetin (Tolectin®) 400 mg |
Ibuprofen 600 mg* |
Tolmetin (Tolectin®) 600 mg |
Ibuprofen 800 mg* |
* At same interval
ORDERED |
SUBSTITUTION |
Aspirin buffered (Ascriptin®) 325 mg |
Aspirin – enteric coated (Ecotrin®) 325 mg* |
Diflunisal (Dolobid®) 250 mg |
Ibuprofen 400 mg q 6 hours |
Diflunisal (Dolobid®) 500 mg |
Ibuprofen 600 mg q 6 hours |
* At same interval
Opiate Agonists:
ORDERED |
SUBSTITUTION |
Sufentanil (Sufenta®) |
Fentanyl |
Morphine (Roxanol® 20 mg/ml) |
Morphine standard concentration (10 mg/5 ml UDL) |
ORDERED |
SUBSTITUTION |
Buprenorphine 1.4 mg / naloxone 0.36 mg |
Buprenorphine 2 mg / naloxone 0.5 mg tab |
Buprenorphine 2 mg / naloxone 0.5 mg |
|
Buprenorphine 2.1 mg / naloxone 0.3 mg |
Two Buprenorphine 2 mg / naloxone 0.5 mg tabs |
Buprenorphine 2.9 mg / naloxone 0.71 mg |
|
Buprenorphine 4 mg / naloxone 1 mg |
|
Buprenorphine 4.2 mg / naloxone 0.7 mg |
Buprenorphine 8 mg / naloxone 2 mg tab |
Buprenorphine 5.7 mg / naloxone 1.4 mg |
|
Buprenorphine 8 mg / naloxone 2 mg |
|
Buprenorphine 6.3 mg / naloxone 1 mg |
Buprenorphine 8 mg / naloxone 2 mg tab + |
Buprenorphine 8.6 mg / naloxone 2.1 mg |
|
Buprenorphine 12 mg / naloxone 3 mg |
|
Buprenorphine 11.4 mg / naloxone 2.9 mg |
Two Buprenorphine 8 mg / naloxone 2 mg |
ORDERED |
SUBSTITUTION |
Hydrocodone ER (Zohydro®) 10 mg |
No equivalent dose. Must use patient’s home supply. |
Hydrocodone ER (Zohydro®) 15 mg |
Oxycodone ER (OxyContin®) 10 mg |
Hydrocodone ER (Zohydro®) 20 mg |
Oxycodone ER (OxyContin®) 10 mg |
Hydrocodone ER (Zohydro®) 30 mg |
Oxycodone ER (OxyContin®) 20 mg |
Hydrocodone ER (Zohydro®) 40 mg |
Oxycodone ER (OxyContin®) 25 mg (10 mg + 15 mg tabs) |
Hydrocodone ER (Zohydro®) 50 mg |
Oxycodone ER (OxyContin®) 30 mg (three x 10 mg tabs) |
ORDERED |
SUBSTITUTION |
Kadian® 10 mg Q 24 |
* |
Kadian® 20 mg Q 24 |
MS Contin® 15 mg Q12 |
Kadian® 30 mg Q 24 |
MS Contin® 15 mg Q12 |
Kadian® 40 mg Q 24 |
MS Contin® 15 mg Q12 |
Kadian® 50 mg Q 24 |
MS Contin® 15 mg Q8 |
Kadian® 60 mg Q 24 |
MS Contin® 30 mg Q12 |
Kadian® 70 mg Q 24 |
MS Contin® 30 mg Q12 |
Kadian® 80 mg Q 24 |
MS Contin® 30 mg Q8 |
Kadian® 100 mg Q 24 |
MS Contin® 30 mg Q8 |
Kadian® 130 mg Q 24 |
MS Contin® 45 mg Q8 |
Kadian® 150 mg Q 24 |
* |
Kadian® 200 mg Q 24 |
MS Contin® 100 mg Q12 |
* A comparable MS Contin® dose (within 10 mg of total 24 hour morphine dose) is not possible. Prescriber to be contacted for alternative orders or patient to utilize home supply dispensed by pharmacy. |
ORDERED |
SUBSTITUTION |
Kadian® 10 mg Q 12 |
MS Contin® 15 mg Q 12 |
Kadian® 20 mg Q 12 |
MS Contin® 15 mg Q 12 |
Kadian® 30 mg Q 12 |
MS Contin® 30 mg Q 12 |
Kadian® 40 mg Q 12 |
MS Contin® 30 mg Q 8 |
Kadian® 50 mg Q 12 |
MS Contin® 30 mg Q 8 |
Kadian® 60 mg Q 12 |
MS Contin® 60 mg Q 12 |
Kadian® 70 mg Q 12 |
MS Contin® 45 mg Q 8 |
Kadian® 80 mg Q 12 |
MS Contin® 75 mg Q 12 |
Kadian® 100 mg Q 12 |
MS Contin® 100 mg Q 12 |
Kadian® 130 mg Q 12 |
* |
Kadian® 150 mg Q 12 |
* |
Kadian® 200 mg Q 12 |
* |
* A comparable MS Contin® dose (within 10 mg of total 24 hour morphine dose) is not possible. Prescriber to be contacted for alternative orders or patient to utilize home supply dispensed by pharmacy. |
ORDERED |
SUBSTITUTION |
Avinza® 30 Q 24 |
MS Contin® 15 mg Q12 |
Avinza® 45 Q 24 |
MS Contin® 15 mg Q8 |
Avinza® 60 Q 24 |
MS Contin® 30 mg Q12 |
Avinza® 75 Q 24 |
* |
Avinza® 90 Q 24 |
MS Contin® 30 mg Q8 |
Avinza® 120 Q 24 |
MS Contin® 60 mg Q12 |
* A comparable MS Contin® dose (within 10 mg of total 24 hour morphine dose) is not possible. Prescriber to be contacted for alternative orders or patient to utilize home supply dispensed by pharmacy. |
ORDERED |
SUBSTITUTION |
Embeda® (morphine/naltrexone) 20/0.8 mg Q 24 |
MS Contin® 15 mg Q 12 |
Embeda® (morphine/naltrexone) 30/1.2 mg Q 24 |
MS Contin® 15 mg Q 12 |
Embeda® (morphine/naltrexone) 50/2 mg Q 24 |
MS Contin® 15 mg Q 8 |
Embeda® (morphine/naltrexone) 60/2.4 mg Q 24 |
MS Contin® 30 mg Q 12 |
Embeda® (morphine/naltrexone) 80/3.2 mg Q 24 |
MS Contin® 30 mg Q 8 |
Embeda® (morphine/naltrexone) 100/4 mg Q 24 |
MS Contin® 30 mg Q 8 |
ORDERED |
SUBSTITUTION |
Embeda® (morphine/naltrexone) 20/0.8 mg Q 12 |
MS Contin® 15 mg Q 12 |
Embeda® (morphine/naltrexone) 30/1.2 mg Q 12 |
MS Contin® 30 mg Q 12 |
Embeda® (morphine/naltrexone) 50/2 mg Q 12 |
MS Contin® 30 mg Q 8 |
Embeda® (morphine/naltrexone) 60/2.4 mg Q 12 |
MS Contin® 60 mg Q 12 |
Embeda® (morphine/naltrexone) 80/3.2 mg Q 12 |
MS Contin® 75 mg Q 12 |
Embeda® (morphine/naltrexone) 100/4 mg Q 12 |
MS Contin® 100 mg Q 12 |
ORDERED |
SUBSTITUTION |
Oramorph SR® |
MS Contin® 1:1 conversion, |
If IR, use oxycodone IR. If ER, use oxycodone CR (Oxycontin®). In both cases, double the dose of Opana® to make equianalgesic dose of oxycodone. See examples below. |
|
ORDERED |
SUBSTITUTION |
Oxymorphone ER (Opana® ER) 5 mg q 12 hrs |
Oxycodone CR (Oxycontin®) 10 mg q 12 hrs |
Oxymorphone IR (Opana®) 5 mg q 4 hrs PRN |
Oxycodone IR 10 mg q 4 hrs PRN |
ORDERED |
SUBSTITUTION |
MorphaBond ER® 15 mg |
MS Contin® 15 mg |
MorphaBond ER® 30 mg |
MS Contin® 30 mg |
MorphaBond ER® 60 mg |
MS Contin® 60 mg |
MorphaBond ER® 100 mg |
MS Contin® 100 mg |
ORDERED |
SUBSTITUTION |
Tapentadol ER (Nucynta ER®) 50 mg BID |
Tapentadol IR (Nucynta IR®) 25 mg Q 6 hours |
Tapentadol ER (Nucynta ER®) 100 mg BID |
Tapentadol IR (Nucynta IR®) 50 mg Q 6 hours |
Tapentadol ER (Nucynta ER®) 150 mg BID |
Tapentadol IR (Nucynta IR®) 50 mg Q 4 hours |
Tapentadol ER (Nucynta ER®) 200 mg BID |
Tapentadol IR (Nucynta IR®) 100 mg Q 6 hours |
Tapentadol ER (Nucynta ER®) 250 mg BID |
Tapentadol IR (Nucynta IR®) 125 mg Q 6 hours |
ORDERED |
SUBSTITUTION |
Xtampza ER® 9 mg |
OxyContin® 10 mg |
Xtampza ER® 13.5 mg |
OxyContin® 10 mg |
Xtampza ER® 18 mg |
OxyContin® 20 mg |
Xtampza ER® 27 mg |
OxyContin® 30 mg |
Xtampza ER® 36 mg |
OxyContin® 40 mg |
ORDERED |
SUBSTITUTION |
Aspirin/oxycodone (Percodan®) |
APAP/Oxycodone (Percocet®) If APAP allergy, uses plan oxycodone + ASA |
Hydrocodone/ibuprofen 7.5/200 mg (Vicoprofen®) |
Lortab® 7.5/325 mg + Ibuprofen (Advil®) 200 mg |
Hydrocodone/Acetaminophen |
Hydrocodone/Acetaminophen |
Oxycodone/Acetaminophen |
Oxycodone/Acetaminophen Closest available strength will be used |
ORDERED |
SUBSTITUTION |
Carisoprodol (Soma®) |
Cyclobenzaprine (Flexeril®) 10 mg PO TID
|
Chlorzoxazone (Parafon/Lorzone®) |
|
Metaxalone (Skelaxin®) |
|
Orphenadrine (Norflex®) |
Methocarbamol (Robaxin®) 4XD |
Orphenadrine/aspirin/caffeine (Norgesic®) |
Methocarbamol (Robaxin®) 4XD |
ORDERED |
SUBSTITUTION |
Dalteparin (Fragmin®) |
Enoxaparin (Lovenox®) |
ORDERED |
SUBSTITUTION |
Lepirudin (Refludan®) |
Argatroban or bivalirudin per protocol |
ORDERED |
SUBSTITUTION |
Gabapentin ER (Gralise®) 300 mg daily |
Gabapentin (Neurontin®) 100 mg TID |
Gabapentin ER (Gralise®) 600 mg daily |
Gabapentin (Neurontin®) 200 mg TID |
Gabapentin ER (Gralise®) 900 mg daily |
Gabapentin (Neurontin®) 300 mg TID |
Gabapentin ER (Gralise®) 1200 mg daily |
Gabapentin (Neurontin®) 400 mg TID |
Gabapentin ER (Gralise®) 1500 mg daily |
Gabapentin (Neurontin®) 500 mg TID |
Gabapentin ER (Gralise®) 1800 mg daily |
Gabapentin (Neurontin®) 600 mg TID |
Except for 25 mg dose, give regular release as the total daily dose divided BID |
|
ORDERED |
SUBSTITUTION |
Lamotrigine (Lamictal XR®) 25 mg daily |
Lamotrigine (Lamictal®) 25 mg daily |
Lamotrigine (Lamictal XR®) 200 mg daily |
Lamotrigine (Lamictal®) 100 mg BID |
Lamotrigine (Lamictal XR®) 350 mg daily |
Lamotrigine (Lamictal®) 175 mg BID |
Phenytoin (Dilantin®) to Fosphenytoin (Cerebyx) |
|
ORDERED |
SUBSTITUTION |
Phenytoin (Dilantin®) 1 mg IV |
Fosphenytoin (Cerebyx®) 1 mg PE IV |
ORDERED |
SUBSTITUTION |
Acetylcysteine (CETYLEV®) |
Acetylcysteine oral liquid (nebulizer solution) |
ORDERED |
SUBSTITUTION |
Metformin XR (Glucophage XR®) |
Metformin (standard formulation) |
ORDERED |
SUBSTITUTION |
Linagliptin (Tradjenta®) 5 mg daily |
Alogliptin (Nesina®) 25 mg daily |
Saxagliptin (Onglyza®) 2.5 mg daily |
|
Saxagliptin (Onglyza®) 5 mg daily |
|
Sitagliptin (Januvia®) 100 mg daily |
|
Sitagliptin (Januvia®) 50 mg daily |
Alogliptin (Nesina®) 12.5 mg daily |
Sitagliptin (Januvia®) 25 mg daily |
Alogliptin (Nesina®) 6.25 mg daily |
Combination DPP-4 + metformin agents |
Alogliptin with dosing per above, |
*See alogliptin renal adjustment below
Alogliptin (Nesina®) Renal Adjustment |
|
CrCl (ml/min) |
Renal Adjustment |
≥ 60 |
No dose adjustment |
≥ 30 to ≤ 60 |
12.5 mg daily |
< 30 |
6.25 mg daily without regard to time of dialysis |
ORDERED |
SUBSTITUTION |
Albiglutide (Tanzeum®) |
Non-formulary. Patient may use home supply. |
Exenatide (Byetta® & Bydureon®) |
Non-formulary. Patient may use home supply. |
Liraglutide (Victoza®) |
Non-formulary. Patient may use home supply. |
Pramlintide (Symlin®) |
Non-formulary. Patient may use home supply. |
ORDERED |
SUBSTITUTION |
Insulin glargine/lixisenatide (Soliqua®) |
Convert Soliqua® unit per unit to Semglee units at same dosing schedule. |
Insulin degludec/liraglutide (Xultophy®) |
Convert Xultophy® unit per unit to Semglee units at same dosing schedule. |
ORDERED |
SUBSTITUTION |
Insulin detemir (Levemir®) |
Insulin glargine-yfgn (Semglee®) |
Insulin glargine (Toujeo®) 300 units/ml |
Insulin glargine-yfgn (Semglee®) |
Insulin degludec (Tresiba®) |
Insulin glargine-yfgn (Semglee®) |
Insulin degludec/insulin aspart |
Insulin glargine-yfgn (Semglee®) |
ORDERED |
SUBSTITUTION |
Insulin aspart (Novolog®) |
Insulin lispro (Humalog®) |
Insulin glulisine (Apidra®) |
Insulin lispro (Humalog®) |
Insulin aspart/insulin aspart protamine |
Insulin lispro/insulin lispro protamine |
Regular insulin/isophane insulin |
Regular insulin/isophane insulin (Humulin® 70/30) |
Regular insulin (Novolin R®) |
Regular insulin (Humulin R®) |
Isophane insulin (Novolin N®) |
Isophane insulin (Humulin N®) |
Insulin, inhaled (Afrezza®) |
Insulin lispro (Humalog®) |
*Novolog® may only be used for refilling implantable pumps
**All insulin pens are non-formulary; equivalent dose will be given via vial.
ORDERED |
SUBSTITUTION |
Repaglinide (Prandin®) 0.5 mg PO TID |
Nateglinide (Starlix) 30 mg PO TID |
Repaglinide (Prandin®) 1 mg PO TID |
Nateglinide (Starlix) 60 mg PO TID |
Repaglinide (Prandin®) 2 mg PO TID |
Nateglinide (Starlix) 120 mg PO TID |
ORDERED |
SUBSTITUTION |
Canagliflozin (Invokana®) 100 mg daily |
Empagliflozin (Jardiance®) 10 mg daily |
Canagliflozin (Invokana®) 300 mg daily |
Empagliflozin (Jardiance®) 25 mg daily |
Dapagliflozin (Farxiga®) 5 mg daily |
Empagliflozin (Jardiance®) 10 mg daily |
Dapagliflozin (Farxiga®) 10 mg daily |
Empagliflozin (Jardiance®) 25 mg daily |
Ertugliflozin (Steglatro®) 5 mg daily |
Empagliflozin (Jardiance®) 10 mg daily |
Ertugliflozin (Steglatro®) 15 mg daily |
Empagliflozin (Jardiance®) 25 mg daily |
* See empagliflozin restriction criteria.
DRUG |
RESTRICTION(S) |
Amphotericin |
|
Ceftazidime (Fortaz®) |
All other orders should be substituted to cefepime. |
Ceftazidime/Avibactam (Avycaz®) |
|
Ceftolozane/Tazobactam (Zerbaxa®) |
|
Ceftaroline (Teflaro®) |
|
Ciprofloxacin (Cipro®) |
|
Cobicistat (Tybost®) |
1. Ordering or approval by Infectious Diseases Service for new therapy initiation 2. Any provider may order to continue a patient’s established home medication |
Daptomycin (Cubicin®) |
*Should not be used for treatment of pneumonia
i. Clinical decompensation after 72 hours ii. Failure to clear blood cultures after 48 hours for bacteremia/endocarditis
|
Ertapenem (Invanz®) |
|
Fidaxomicin (Dificid®) |
|
Isavuconazonium |
|
Linezolid (Zyvox®) |
* Not recommended for treatment of bacteremia or endocarditis.
|
Meropenem (Merrem®) |
|
Meropenem/vaborbactam (Vabomere®) |
Use is restricted to Infectious Diseases physicians and cases that meet the following criteria: 1. Preferred therapy for documented infection due to a carbapenemase producing gram-negative bacteria OR 2. Empiric therapy for critically ill patients with a history of a carbapenemase producing (carbapenem resistant) gram-negative bacteria with resistance to other non-restricted agents based on culture data and review by the antibiotic stewardship team. 3. Do not use for monobacterial infections caused by Pseudomonas when alternative agent available |
Micafungin |
|
Minocycline – IV only |
|
Nitazoxanide (Alinia®) |
|
Nitrofurantoin macrocrystals (Macrodantin) |
|
Oritavancin (Orbactiv®) |
|
Pentamidine (Pentam®) (IV formulation only) |
|
Peramivir (Rapivab®) |
|
Posaconazole (Noxafil®) |
|
Quinupristin/dalfopristin |
|
Sulbactam/durlobactam (Xacduro®) |
|
Tigecycline (Tygacil®) |
*Should not be used to treat bacteremia, urinary tract, or Pseudomonas infections.
|
Voriconazole (VFend®) |
|
DRUG |
STOP PARAMETER |
Azithromycin (Zithromax®) |
5 days when used for treatment of acute respiratory infection |
Oseltamivir (Tamiflu®) |
5 days for non-critically ill patients |
ORDERED |
SUBSTITUTION |
Stribild® - 1 tab* |
cobicistat/elvitegravir/emtricitabine/tenofovir alafenamide (Genvoya®) – 1 tab daily |
Prezcobix® |
darunavir 800 mg + cobicistat 150 mg daily |
Atripla® |
efavirenz 600mg + emtricitabine 200mg + tenofovir 300mg daily |
Truvada® |
emtricitabine 200mg + tenofovir disoproxil 300mg |
Combivir® |
lamivudine 150mg + zidovudine 300mg |
Epzicom® |
abacavir 600mg + lamivudine 300mg |
Triumeq® |
abacavir 600mg + lamivudine 300mg + dolutegravir 50mg |
Dovato® |
lamivudine 300mg + dolutegravir 50mg |
Symtuza® |
darunavir 800mg + cobicistat 150mg daily + descovy® 1 tablet |
Symfi & Symfi Lo® |
Efavirenz 600mg or 400mg (Symfi Lo uses 400mg) + lamivudine 300mg + tenofovir disoproxil 300mg |
Cimduo® & Temixys® |
lamivudine 300mg + tenofovir disoproxil 300mg |
* Treat as Non-formulary, Specialty and only execute substitution if home med cannot be obtained.
Antifungals
Restricted: May only be ordered by ID or intensivists. |
|||
Diagnosis |
ORDERED |
ORDERED |
Subsitution |
|
Caspofungin (Cancidas®) |
Anidulafungin (Eraxis®) |
Micafungin (Mycamine®) |
Candidemia, invasive |
70 mg IV infusion on day 1, then 50 mg IV daily thereafter; duration of therapy depends upon clinical response and microbiological response; continue for a minimum of 14 days beyond last positive culture |
200 mg IV on day 1, then 100 mg IV once daily; continue for at least 14 days after the last positive culture |
No loading dose required 100 mg/day IV over 1 hour |
Candidiasis, Hematopoietic Stem Cell Transplantation; Prophylaxis |
|
|
No loading dose required 50 mg/day IV over 1 hour; mean duration for prophylaxis, 19 days (range 6 to 51 days) |
Candidiasis of the esophagus |
50 mg IV daily |
100 mg IV on day 1, then 50 mg IV every day for a minimum of 14 days and for at least 7 days following resolution of symptoms . |
No loading dose required 150 mg/day IV over 1 hour; mean duration of therapy, 15 days (range 10 to 30 days) |
Disseminated candidiasis |
70 mg IV infusion on day 1, then 50 mg IV daily thereafter |
200 mg IV on day 1, then 100 mg IV once daily; |
No loading dose required 100 mg/day IV over 1 hour |
Aspergillosis
|
Aspergillosis, invasive, refractory: 70 mg IV infusion on day 1, then 50 mg IV daily thereafter; dose may be increased to 70 mg IV daily if there is inadequate response |
|
No loading dose required Aspergillosis, invasive, refractory: 100 mg/day IV infused over 1 hour; dose escalations allowed for disease progression or positive cultures. |
Febrile Neutropenia
|
Empiric antifungal therapy: 70 mg IV infusion on day 1, then 50 mg IV daily thereafter; if there is inadequate response and if 50 mg dose is well tolerated, dose may be increased to 70 mg IV daily |
|
No loading dose required Doses of 100 mg/day infused over 1 hour have been shown to be effective |
ORDERED |
SUBSTITUTION |
Griseofulvin 250 mg |
Fluconazole (Diflucan®) 100 mg daily |
Griseofulvin 330 mg |
Fluconazole (Diflucan®) 200 mg daily |
Griseofulvin 500 mg |
Fluconazole (Diflucan®) 200 mg daily |
Restricted: ID, Pulmonology, & Intensivists may order. Confirmed, suspected, or past ESBL infection; treatment of other MDR gram negative infections as deemed appropriate by the Antimicrobial Stewardship Team. |
|
ORDERED |
SUBSTITUTION |
Imipenem-cilastatin (Primaxin®) |
Meropenem (Merrem®)* |
Doripenem (Doribax®) |
Meropenem (Merrem®)* |
Ertapenem (INVanz®) |
Restricted to ID |
*Meropenem dose to be determined according to the Renal Dose Adjustment protocol.
Injectable Cephalosporins (First Generation) |
Cefazolin (Ancef®) is the only Injectable First Generation Cephalosporin currently on the market. |
ORDERED |
SUBSTITUTION |
Cefaclor (Ceclor®) |
Cefuroxime (Ceftin®) 500 mg BID |
Cefprozil (Cefzil®) |
Cefuroxime (Ceftin®) 500 mg BID |
Injectable Cephalosporins (Second Generation) Cefuroxime (Zinacef®) also on formulary, but there are no automatic substitutions to Zinacef®. |
|
ORDERED |
SUBSTITUTION |
Cefotetan (Cefotan®) 1 gm Q 12 hrs |
Cefoxitin (Mefoxin®) 1 gm Q 8 hrs |
Cefotetan (Cefotan®) 2 gm Q 12 hrs |
Cefoxitin (Mefoxin®) 2 gm Q 8 hrs |
ORDERED |
SUBSTITUTION |
Cefpodoxime (Vantin®) 100-400 mg BID |
Cefdinir (Omnicef®) 300 mg BID |
Cefixime (Suprax®) 400 mg daily |
Cefdinir (Omnicef®) 300 mg BID |
Ceftibuten (Cedax®) 400 mg daily |
Cefdinir (Omnicef®) 300 mg BID |
Cefditoren (Spectracef®) 400 mg BID |
Cefdinir (Omnicef®) 300 mg BID |
Injectable Cephalosporins (Third Generation) |
|
ORDERED |
SUBSTITUTION |
Cefotaxime (Claforan®) 1 gm q 8-12 hrs |
Ceftriaxone (Rocephin®) 1 gm daily |
Cefotaxime (Claforan®) 2 gm q 8-12 hrs |
Ceftriaxone (Rocephin®) 2 gm daily |
Ceftazidime (Fortaz®) 1 gm Q 8 hrs |
Cefepime (Maxipime®) 1 gm Q 12 hrs |
Ceftazidime (Fortaz®) 2 gm Q 8 hrs |
Cefepime (Maxipime®) 2 gm Q 12 hrs |
Ceftriaxone (Rocephin®) 1 gm Q 12 hrs |
Ceftriaxone (Rocephin®) 2 gm Q 24 hrs |
Cefepime (Maxipime®) is the only Fourth Generation Cephalosporin on the market. |
ORDERED |
SUBSTITUTION |
Ciprofloxacin (Cipro®) |
Levofloxacin (Levaquin®)* (unless ordered by ID or for documented Pseudomonas infection) |
Moxifloxacin (Avelox®) |
Levofloxacin (Levaquin®)* |
* Levofloxacin dose based on renal status as outlined here
ORDERED |
SUBSTITUTION |
Erythromycin 250-500 mg IV* q 6-8 hours |
Azithromycin 500 mg IV daily |
* Note: this interchange only applies to the IV route
Rifaximin (Xifaxin®) |
|
ORDERED |
SUBSTITUTION |
Rifaximin (Xifaxin®) |
Rifaximin (Xifaxin®) 550 mg BID |
ORDERED |
SUBSTITUTION |
Metronidazole (Flagyl®) |
Metronidazole (Flagyl®) 500 mg IV/PO Q 8 hrs |
ORDERED |
SUBSTITUTION |
Tedizolid (Sivextro®) 200 mg daily |
Linezolid (Zyvox®) 600 mg BID |
ORDERED |
SUBSTITUTION |
Vancomycin PO 250 mg |
Vancomycin PO 125 mg |
Penicillins
ORDERED |
SUBSTITUTION |
Ampicillin 250 mg q 6 hrs |
Amoxicillin 250 mg TID |
Ampicillin 500 mg q6 hrs |
Amoxicillin 500 mg TID |
Amoxicllin/clavulanate XR |
Augmentin® 875 mg/125 mg BID |
ORDERED |
SUBSTITUTION |
Ticarcillin/clavulanate (Timentin®) |
Piperacillin/tazobactam (Zosyn®)* |
Nafcillin 1-2 gm q 4-6 hrs |
Oxacillin 1-2 gm q 4-6 hrs |
Nafcillin 10-12 gm daily |
Oxacillin 10-12 gm daily |
*Piperacillin/tazobactam dose will be determined as outlined here
ORDERED |
SUBSTITUTION |
Tetracycline |
Doxycycline 100 mg BID |
ANTIHISTAMINES, DECONGESTANTS, ANTITUSSIVES, EXPECTORANTS
CLASS |
FORMULARY GENERIC NAME |
COMMON BRAND NAMES & ADULT DOSE |
Antihistamine (non-sedating) |
Loratadine 10 mg |
Claritin 10 mg daily |
Antihistamine (sedating) |
Diphenhydramine 25-50 mg |
Benadryl 25 mg Q 6-8 hours |
Antihistamine (non-sedating) + Decongestant |
Loratadine 10 mg |
Claritin 10 mg daily |
Antihistamine (sedating) + Decongestant |
Chlorpheniramine 4 mg + Pseudoephedrine 60 mg |
Chlor-Trimeton 4 mg |
Antitussive (e.g. Hycodan, Delsym) |
Benzonatate 100mg |
Tessalon Perles 100mg TID PRN Cough |
Antitussive + Decongestant |
Benzonatate 100 mg + Decongestant# |
Tessalon Perles 100mg TID PRN Cough + Decongestant# |
Antitussive + Expectorant |
(Guaifenesin + Dextromethorphan 200mg/20mg/10ml)
OR
(Guaifenesin ER + Dextromethorphan 600mg/30mg) |
Robitussin DM (10 ml UDL) Q4hrs PRN
Humibid DM 600mg Q 12hrs PRN/SCH |
Antitussive + Expectorant + Decongestant (opioid containing) |
(Guaifenesin + Codeine 200mg/20mg/10ml + Decongestant#) |
Robitussin AC (10 ml UDL) Q4hrs PRN + Decongestant# |
Antitussive + Expectorant + Decongestant (non-opioid containing) |
(Guaifenesin + Dextromethorphan 200mg/20mg/10ml + Decongestant#)
OR
(Guaifenesin ER + Dextromethorphan 600mg/30mg + Decongestant#) |
Robitussin DM (10 ml UDL) Q4hrs PRN + Decongestant#
Humibid DM 600mg Q12hr + Decongestant# |
Antitussive + Antihistamine (e.g. Tussionex) |
Benzonatate 100 mg + antihistamine*
OR
(Guaifenesin + Dextromethorphan 200mg/20mg/10ml + Antihistamine*) |
Tessalon Perles 100mg TID PRN Cough + Antihistamine*
Humibid DM 600 mg Q12 hrs + Antihistamine*
|
Antitussive + Antihistamine + Decongestant |
No triple agent available. Consider alternative combination product +/- individual formulary agents (example: Benzonatate + Decongestant# + Antihistamine*) |
|
Expectorant |
Guaifenesin 200mg/10ml
OR
Guaifenesin 600mg extended release tablet |
Robitussin 200 mg Q4hrs PRN
Humibid 600mg Q12hrs PRN |
Expectorant + Decongestant |
Guaifenesin 200 mg/10ml + Decongestant#
OR
Guaifenesin 600 mg extended release tablet + Decongestant# |
Robitussin 200 mg Q4hrs PRN + Decongestant#
Humibid 600mg Q12hrs PRN |
Decongestant |
Pseudoephedrine 60 mg |
Sudafed 60 mg Q 4-6 hours |
* Antihistamine – formulary non-sedating antihistamine
# Decongestant – formulary short acting decongestant (phenylephrine, pseudoephedrine, etc.)
Blood Factor Products for Inherited Bleeding Disorders |
|
Hemophilia A (Factor VIII) |
See preferred products & determination of |
Hemophilia B (Factor IX) |
|
Von Willebrand Disease (vWF) |
BIOLOGIC RESPONSE MODIFIERS
ORDERED |
DISPENSE |
Filgrastim (Neupogen®) 300 mcg |
Filgrastim-aafi (Nivestym®) 300 mcg |
Filgrastim (Neupogen®) 480 mcg |
Filgrastim-aafi (Nivestym®) 480 mcg |
Tbo-Filgrastim (Granix®) 300 mcg |
Filgrastim-aafi (Nivestym®) 300 mcg |
Tbo-Filgrastim (Granix®) 480 mcg |
Filgrastim-aafi (Nivestym®) 480 mcg |
Epoetin alfa (Procrit®) |
Epoetin alfa-epbx (Retacrit®) |
ORDERED |
DISPENSE |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa-epbx (Retacrit®) |
* Pharmacist to confirm with provider if a dose is required during hospital stay; if so, interchange per the above.
CARDIOVASCULAR AGENTS
ORDERED |
SUBSTITUTION |
Colestipol (Colestid®) |
Cholestyramine for oral suspension |
Colestipol (Colestid®) |
Cholestyramine for oral suspension |
Colestipol (Colestid®) |
Cholestyramine for oral suspension |
Fibric acid derivatives |
Formulary agent is Fenofibrate (Lofibra®) - available in 67 mg cap and 160 mg tab. Closest available strength will be substituted for other antilipemics. |
Gemfibrozil (Lopid®) 600 mg BID |
Fenofibrate (Lofibra®) 67 mg daily |
Icosapent Ethyl (Vascepa®) |
Omega-3-Acid Ethyl Esters (Promega®) |
Omega-3-Acid Ethyl Esters |
Omega-3-Acid Ethyl Esters (Promega®) |
ORDERED |
DISPENSE |
Benazepril (Lotensin®) 5 mg |
Lisinopril (Prinivil®) 5 mg |
Fosinopril (Monopril®) 5 mg |
|
Moexipril (Univasc®) 3.75 mg |
|
Perindopril (Aceon®) 2 mg |
|
Quinapril (Accupril®) 5 mg |
|
Trandolapril (Mavik®) 0.5 mg |
|
Benazepril (Lotensin®) 10 mg |
Lisinopril (Prinivil®) 10 mg |
Fosinopril (Monopril®) 10 mg |
|
Moexipril (Univasc®) 7.5 mg |
|
Perindopril (Aceon®) 4 mg |
|
Quinapril (Accupril®) 10 mg |
|
Trandolapril (Mavik®) 1 mg |
|
Benazepril (Lotensin®) 20 mg |
Lisinopril (Prinivil®) 20 mg |
Fosinopril (Monopril®) 20mg |
|
Moexipril (Univasc®) 15 mg |
|
Perindopril (Aceon®) 8 mg |
|
Quinapril (Accupril®) 20 mg |
|
Trandolapril (Mavik®) 2 mg |
|
Benazepril (Lotensin®) 40 mg |
Lisinopril (Prinivil®) 40 mg |
Fosinopril (Monopril®) 40 mg |
|
Moexipril (Univasc®) 30 mg |
|
Perindopril (Aceon®) 16 mg |
|
Quinapril (Accupril®) 40 mg |
|
Trandolapril (Mavik®) 4 mg |
ORDERED |
DISPENSE |
Olmesartan (Benicar®) 5 mg |
Valsartan (Diovan®) 40 mg |
Candesartan (Atacand®) 4 mg |
|
Eprosartan (Teveten®) 400 mg |
|
Irbesartan (Avapro®) 75 mg |
|
Telmisartan (Micardis®) 10 mg |
|
Losartan (Cozaar®) 25 mg* |
|
Olmesartan (Benicar®) 10 mg |
Valsartan (Diovan®) 80 mg |
Candesartan (Atacand®) 8 mg |
|
Eprosartan (Teveten®) 600 mg |
|
Irbesartan (Avapro®) 150 mg |
|
Telmisartan (Micardis®) 20 mg |
|
Losartan (Cozaar®) 50 mg* |
|
Olmesartan (Benicar®) 20 mg |
Valsartan (Diovan®) 160 mg |
Azilsartan (Edarbi®) 40 mg |
|
Candesartan (Atacand®) 16 mg |
|
Eprosartan (Teveten®) 800 mg |
|
Irbesartan (Avapro®) 300 mg |
|
Telmisartan (Micardis®) 40 mg |
|
Losartan (Cozaar®) 100 mg* |
|
Olmesartan (Benicar®) 40 mg |
Valsartan (Diovan®) 320 mg |
Azilsartan (Edarbi®) 80 mg |
|
Candesartan (Atacand®) 32 mg |
|
Telmisartan (Micardis®) 80 mg |
|
Losartan (Cozaar®) 150 mg* |
ORDERED |
DISPENSE |
Coreg CR® 10 mg PO once daily |
Carvedilol (Coreg®) 3.125 mg PO twice daily |
Coreg CR® 20 mg PO once daily |
Carvedilol (Coreg®) 6.25 mg PO twice daily |
Coreg CR® 40 mg PO once daily |
Carvedilol (Coreg®) 12.5 mg PO twice daily |
Coreg CR® 80 mg PO once daily |
Carvedilol (Coreg®) 25 mg PO twice daily |
Betaxolol (Kerlone®) |
Atenolol (Tenormin®) 50 mg daily |
Penbutolol (Levatol®) 20 mg |
Atenolol (Tenormin®) 50 mg |
ORDERED |
DISPENSE |
Colesevelam (Welchol®)* Tab |
Cholestyramine susp (Questran®) |
< 1875 mg |
4 gm daily |
> 1875 mg - 3750 mg |
4 gm BID |
> 3750 mg - 4400 mg |
4 gm TID |
* Colesevelam (Welchol) being phased off formulary (September 2018). Once supply is depleted, begin substitution to cholestyramine per chart.
ORDERED |
DISPENSE |
Felodipine ER (Plendil®) 2.5 mg Daily |
Amlodipine (Norvasc®) 2.5 mg Daily |
Nisoldipine (Sular®) 8.5 mg Daily |
|
Felodipine ER (Plendil®) 5 mg Daily |
Amlodipine (Norvasc®) 5 mg Daily |
Isradipine (Dynacirc®) 2.5 mg BID |
|
Isradipine (Dynacirc®) 5 mg Daily |
|
Nisoldipine (Sular®) 17 mg Daily |
|
Nisoldipine (Sular®) 20 mg Daily |
|
Felodipine ER (Plendil®) 10 mg Daily |
Amlodipine (Norvasc®) 10 mg Daily |
Nisoldipine (Sular®) 25.5 mg Daily |
|
Nisoldipine (Sular®) 30 mg Daily |
|
Nisoldipine (Sular®) 34 mg Daily |
|
Nisoldipine (Sular®) 40 mg Daily |
ORDERED |
SUBSTITUTION |
Nadolol/bendroflumethiazide (Corzide®) 40 mg/5 mg |
Nadolol 40 mg + Hydrochlorothiazide 50 mg |
Nadolol/bendroflumethiazide (Corzide®) 80 mg/5 mg |
Nadolol 80 mg + Hydrochlorothiazide 50 mg |
ORDERED |
SUBSTITUTION |
Chlorothiazide (Diuril®) tablet 250 mg |
Hydrochlorothiazide tablet 25 mg |
Chlorothiazide (Diuril®) tablet 500 mg |
Hydrochlorothiazide tablet 50 mg |
Triamterene (Dyrenium®) tablet 50 mg |
Triamterene/HCTZ 37.5/25 mg |
Triamterene (Dyrenium®) tablet 100 mg |
Triamterene/HCTZ 75/50 mg |
ORDERED |
SUBSTITUTION |
Fluvastatin (Lescol®) 20 mg Daily |
Atorvastatin (Lipitor®) 5 mg Daily |
Fluvastatin (Lescol®) 40 mg Daily |
Atorvastatin (Lipitor®) 5 mg Daily |
Fluvastatin (Lescol®) 80 mg Daily |
Atorvastatin (Lipitor®) 10 mg Daily |
Lovastatin (Mevacor®) 10 mg Daily |
Pravastatin (Pravachol®) 10 mg Daily |
Lovastatin (Mevacor®) 20 mg Daily |
Pravastatin (Pravachol®) 20 mg Daily |
Lovastatin (Mevacor®) 40 mg Daily |
Pravastatin (Pravachol®) 40 mg Daily |
Lovastatin (Mevacor®) 80 mg Daily or 40 mg BID |
Pravastatin (Pravachol®) 80 mg Daily |
Lovastatin ER (Altoprev®) 20 mg Daily |
Pravastatin (Pravachol®) 20 mg Daily |
Lovastatin ER (Altoprev®) 40 mg Daily |
Pravastatin (Pravachol®) 40 mg Daily |
Lovastatin ER (Altoprev®) 60 mg Daily |
Pravastatin (Pravachol®) 60 mg Daily |
Pitavastatin (Livalo®) 1 mg Daily |
Atorvastatin (Lipitor®) 5 mg Daily |
Pitavastatin (Livalo®) 2 mg Daily |
Atorvastatin (Lipitor®) 10 mg Daily |
Pitavastatin (Livalo®) 4 mg Daily |
Atorvastatin (Lipitor®) 20 mg Daily |
Simvastatin (Zocor®) 10 mg Daily |
Pravastatin (Pravachol®) 20 mg Daily |
Simvastatin (Zocor®) 20 mg Daily |
Atorvastatin (Lipitor®) 10 mg Daily |
Simvastatin (Zocor®) 40 mg Daily |
Atorvastatin (Lipitor®) 20 mg Daily |
Simvastatin (Zocor®) 80 mg Daily |
Atorvastatin (Lipitor®) 40 mg Daily |
ORDERED |
SUBSTITUTION |
Sildenafil (Viagra®) 25 mg |
Sildenafil (Revatio®) 20 mg |
Tadalafil (Adcirca®, Cialis®) 40 mg daily* |
Sildenafil (Revatio®) 20 mg TID |
*Doses intended for treatment of BPH (example: Cialis 5 mg daily) are non-formulary and patient will need to take their own supply (no feasible way to give comparable dose of sildenafil). |
(Orders per dermatology will be dispensed as written or below substitution approved by dermatology prior to dispensing)
ORDERED |
SUBSTITUTION |
Creams, aerosols, gels, lotions: |
Clotrimazole 1% cream |
Vaginal creams, suppositories: |
Miconazole 3 day (Monistat-3) |
Shampoos: |
Ketoconazole 2% shampoo (Nizoral®) |
The following items are also stocked, but are not substituted for other products: |
ORDERED |
SUBSTITUTION |
Betamethasone/clotrimazole (Lotrisone®) (0.05/1% cream, lotion) |
Nystatin/triamcinolone (Mycolog®) (100,000 units/gm – 0.1% cream) |
Topical Steroids
ORDERED |
SUBSTITUTION |
Augmented betamethasone dipropionate (Diprolene®) (0.05% cream, ointment, gel) |
Clobetasol propionate (Temovate®) (0.05% cream, gel, ointment) |
Diflorasone diacetate (Psorcon®) (0.05% ointment) |
Clobetasol propionate (Temovate®) (0.05% cream, gel, ointment) |
Halobetasol propionate (Ultravate®) (0.05% cream, ointment) |
Clobetasol propionate (Temovate®) (0.05% cream, gel, ointment) |
ORDERED |
SUBSTITUTION |
Amcinonide (Cyclocort®) (0.1% cream, lotion, ointment) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Augmented betamethasone dipropionate (Diprolene AF®) (0.05% cream) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Augmented betamethasone dipropionate (Diprolene®) (0.05% lotion) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Betamethasone valerate (Valisone®) (0.1% ointment) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Desoximetasone (Topicort®) (0.25% cream, ointment; 0.05% gel) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Diflorasone diacetate (Florone®, Florone E®, Maxiflor®, Psorcon®) (0.05% cream) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Diflorasone diacetate (Florone®, Maxiflor®) (0.05% cream) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Fluocinonide, Fluocinonide E (Lidex®, Lidex E®) (0.05% cream, gel, ointment) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Fluocinonide acetate (Synalar-HP®) (0.2% cream) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Halcinonide (Halog®) (0.1% cream, ointment) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
Triamcinolone (Kenalog®)* (0.5% cream, ointment) |
Betamethasone dipropionate (Diprosone®) (0.05% cream, lotion, ointment) |
*Note: Kenalog® 0.025% and 0.5% are non-formulary, but the 0.1% strength is on formulary.
ORDERED |
SUBSTITUTION |
Betamethasone benzoate (Unicort®) (0.025% cream, gel, lotion) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Betamethasone valerate (Valisone®) (0.1% cream) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Clocortolone pivalate (Cloderm®) (0.1% cream) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Desoximetasone (Topicort®) (0.05% cream) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Fluocinolone acetonide (Synalar®) (0.025% cream, ointment) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Flurandrenolide (Cordran®) (0.025% cream, ointment; 0.05% cream, lotion, otmt) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Fluticasone propionate (Cutivate®) (0.05% cream; 0.005% ointment) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Hydrocortisone valerate (Westcort®) (0.2% cream, ointment) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Hydrocortisone butyrate (Locoid®) (0.1% ointment, solution) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Mometasone furoate (Elocin®) (0.1% cream, lotion, ointment) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
Triamcinolone (Kenalog®)* (0.025% cream, lotion, ointment) |
Triamcinolone acetonide (Kenalog®)* (0.1% cream, lotion, ointment) |
*Note: Kenalog® 0.025% and 0.5% are non-formulary, but the 0.1% strength is on formulary.
ORDERED |
SUBSTITUTION |
Aclometasone dipropionate (Aclovate®) (0.05% cream, ointment) |
Hydrocortisone (1% cream, ointment, lotion, aerosol) |
Desonide (Tridesilon®, DesOwen®) (0.05% cream, ointment) |
Hydrocortisone (1% cream, ointment, lotion, aerosol) |
Dexamethasone (Aeroseb-Dex®, Decaspray®) (0.01% aerosol, 0.04% aerosol) |
Hydrocortisone (1% cream, ointment, lotion, aerosol) |
Dexamethasone sodium phosphate (Decadron®) (0.1% cream) |
Hydrocortisone (1% cream, ointment, lotion, aerosol) |
Fluocinolone acetonide (Synalar) (0.01% cream, solution) |
Hydrocortisone (1% cream, ointment, lotion, aerosol) |
Hydrocortisone* (0.5% cream, ointment; 2.5% cream) |
Hydrocortisone* (1% cream, lotion, aerosol) |
Neomycin, polymyxin B, bacitracin, hydrocortisone (Cortisporin®) |
Triple antibiotic (Neosporin®) |
*Note: Only the Hydrocortisone 1% cream on formulary for topical use. Other strengths will be substituted. A 2.5% cream is stocked for rectal use only.
ORDERED |
SUBSTITUTION |
Acyclovir (Zovirax®) |
Docosanol (Abreva®) |
Penciclovir (Denavir®) |
Docosanol (Abreva®) |
ORDERED |
SUBSTITUTION |
Estrogen conjugated (Premarin®) vaginal cream |
Estradiol (Estrace®) 0.01% vaginal cream |
*Fosaprepitant is rarely given more than one time per cycle of chemotherapy, even for multi-day regimens. If there is an order for more than one dose of fosaprepitant, please contact the prescriber to clarify. There is rarely a reason to give this drug more than once in a 7 day period.
ORDERED |
SUBSTITUTION |
Maalox |
Mylanta |
Mint-O-Mag |
MOM |
Calcium Carbonate, Rolaids, etc. |
Tums |
Loperamide (Imodium®) will be automatically held in |
ORDERED |
SUBSTITUTION |
Mepenzolate (Cantil®) |
Dicyclomine (Bentyl®) 10 mg 4XD |
Propantheline (Pro-Banthine®) 7.5 mg |
Dicyclomine (Bentyl®) 10 mg 4XD |
Propantheline (Pro-Banthine®) 15 mg |
Dicyclomine (Bentyl®) 20 mg 4XD |
ORDERED |
SUBSTITUTION |
Chlordiazepoxide/clidinium (Librax®) 5/2.5 mg |
Chlordiazepoxide (Librium®) 5 mg |
Donnatal/Antacid (GI Cocktail) |
Antacid monotherapy (Mylanta UDL)* |
Hyoscyamine (Levsin®) IV |
Hyoscyamine (Levsin®) sublingual |
* Physician may order Levsin (hyoscyamine) and/or viscous lidocaine in addition to Mylanta if they wish for something more than plain antacid.
ORDERED |
SUBSTITUTION |
Lipase (Zenpep®) 3,000 units |
Zenpep® 5000 – 1 capsule |
Lipase (Zenpep®) 5,000 units |
Zenpep® 5000 – 1 capsule |
Lipase (Zenpep®) 10,000 units |
Zenpep® 5000 – 2 capsules |
Lipase (Zenpep®) 15,000 units |
Zenpep® 5000 – 3 capsules |
Lipase (Zenpep®) 20,000 units |
Zenpep® 5000 – 4 capsules |
Lipase (Zenpep®) 25,000 units |
Creon® 24,000 – 1 capsule |
Lipase (Zenpep®) 40,000 units |
Creon® 24,000 – 1 capsule |
Lipase (Creon®) 3,000 units |
Zenpep® 5000 – 1 capsule |
Lipase (Creon®) 6,000 units |
Zenpep® 5000 – 1 capsule |
Lipase (Creon®) 12,000 units |
Zenpep® 5000 – 2 capsules |
Lipase (Creon®) 36,000 units |
Creon® 24,000 – 1 capsule |
Lipase (Pancreaze®) 4,200 units |
Zenpep® 5000 – 1 capsule |
Lipase (Pancreaze®) 10,500 units |
Zenpep® 5000 – 2 capsules |
Lipase (Pancreaze®) 16,800 units |
Zenpep® 5000 – 3 capsules |
Lipase (Pancreaze®) 21,000 units |
Creon® 24,000 – 1 capsule |
Lipase (Viokace-10®) 10,440 units |
Zenpep® 5000 – 2 capsules |
Lipase (Viokace-20®) 20,880 units |
Creon® 24,000 – 1 capsule |
Lipase (Ultresa®) 13,800 units |
Zenpep® 5000 – 3 capsules |
Lipase (Ultresa®) 20,700 units |
Creon® 24,000 – 1 capsule |
Lipase (Ultresa®) 23,000 units |
Creon® 24,000 – 1 capsule |
Lipase (Pertyze®) 8,000 units |
Zenpep® 5000 – 2 capsules |
Lipase (Pertyze®) 16,000 units |
Zenpep® 5000 – 3 capsules |
ORDERED |
SUBSTITUTION |
Cimetidine (Tagamet®) |
Famotidine (Pepcid®) |
Ranitidine (Zantac®) |
Famotidine (Pepcid®) |
Nizatidine (Axid®) |
Famotidine (Pepcid®) |
* Twice daily Pepcid will be automatically reduced to once daily in patients with CrCl < 50 ml/min.
**Duplication of acid suppression therapy to be avoided as outlined below
MEDICATION |
STATUS |
Docusate (Surfak®) 240 mg |
Docusate (Colace®) 200 mg |
MEDICATION |
STATUS |
Alvimopan (Entereg®) |
Only for open partial large or small bowel resections OR hand assisted laparoscopic colon resections. (See PSO #2211) |
Methylnatrexone (Relistor®) |
No longer restricted per P&T April 2016. |
Naloxegol (Movantik®) |
Use generally recommended in the following populations: |
ORDERED |
SUBSTITUTION |
Methylnaltrexone (Relistor®) 150 mg PO daily |
Naloxegol (Movantik®) 12.5 mg daily |
Methylnaltrexone (Relistor®) 450 mg PO daily |
Naloxegol (Movantik®) 25 mg daily |
Methylnaltrexone (Relistor®) 8 mg SC* |
Naloxegol (Movantik®) 12.5 mg PO same frequency** |
Methylnaltrexone (Relistor®) 12 mg SC* |
Naloxegol (Movantik®) 25 mg PO same frequency** |
Methylnaltrexone (Relistor®) |
Naloxegol (Movantik®) 12.5 mg PO same frequency** |
* Methylnaltrexone ordered subcutaneously by GI physicians will be given as ordered, not substituted to naloxegol.
** Adjust initial naloxegol dose for CrCl ≤ 60 ml/min to 12.5 mg daily, may increase to 25 mg if ineffective.
For use with concomitant moderate CYP3A4 inhibitors, reduce dose to 12.5 mg daily (use with strong CYP3A4 inhibitors is contraindicated).
*** Contact RN prior to converting methlynaltrexone SC to naloxegol PO to confirm patient is able to take PO.
ORDERED |
SUBSTITUTION |
All probiotics (Lactinex, Culturelle, Bacid, etc.) |
Saccharomyces Boulardii (Florastor®) |
ORDERED |
SUBSTITUTION |
Omeprazole (PrilosecÒ) |
Pantoprazole (Protonix®) 40 mg at same interval |
Rabeprazole (AcipHex®) |
Pantoprazole (Protonix®) 40 mg at same interval |
Lansoprazole (PrevacidÒ)* |
Pantoprazole (Protonix®) 40 mg at same interval |
Esomeprazole (Nexium®) |
Pantoprazole (Protonix®) 40 mg at same interval |
Dexlansoprazole (Dexilant®) |
Pantoprazole (Protonix®) 40 mg at same interval |
Lansoprazole (Prevacid® Solutab) |
If unable to take oral Protonix: |
Pantoprazole (Protonix® Suspension) |
If unable to take oral Protonix: |
Esomeprazole (Nexium® Suspension) |
If unable to take oral Protonix: |
* Lansoprazole may be used for any patient intolerant of pantoprazole.
**Duplication of acid suppression therapy to be avoided as outlined below
If a patient has active orders for both a PPI and a H2RA then the most potent agent will be continued (PPI) and the other medication will be automatically discontinued. If there is a question regarding the provider’s intent, then clarification should be requested (e.g. if ordered by a GI physician). |
ORDERED |
SUBSTITUTION |
Starch topical |
Hydrocortisone suppository (Anusol HC®) |
GENITOURINARY AGENTS
ORDERED |
SUBSTITUTION |
Methenamine mandelate (Mandelamine®) 1 gm 4 times daily |
Methenamine hippurate (Hiprex®) 1 gm BID |
ORDERED |
SUBSTITUTION |
Any of the below for feeding tube administration |
Oxybutynin (Ditropan®) 5 mg per feeding tube TID |
Darifenacin ER (Enablex®) 7.5-15 mg |
Trospium IR (Sanctura®) 20 mg BID |
Fesoterodine (Toviaz®) 4-8 mg daily |
Trospium IR (Sanctura®) 20 mg BID |
Mirabegron (Myrbetriq®) 25-50 mg daily |
** FORMULARY ** |
Oxybutynin ER (Ditropan XL) 5-15 mg daily |
** FORMULARY ** |
Oxybutynin IR 5 mg TID |
** FORMULARY ** |
Oxybutynin topical gel (Gelnique®) |
Oxybutynin ER (Ditropan XL®) 15 mg daily |
Oxybutynin transdermal patch (Oxytrol®) |
Oxybutynin ER (Ditropan XL®) 15 mg daily |
Sorifenacin (Vesicare®) 5-10 mg daily |
Trospium IR (Sanctura®) 20 mg BID |
Tolterodine (Detrol®) 1-2 mg BID |
Trospium IR (Sanctura®) 20 mg BID |
Tolterodine ER (Detrol LA®) 2-4 mg daily |
Trospium IR (Sanctura®) 20 mg BID |
Trospium ER (Sanctura XR®) 60 mg daily |
Trospium IR (Sanctura®) 20 mg BID |
Trospium IR (Sanctura®) 20 mg BID |
** FORMULARY ** |
Vibegron (Gemtasa®) 75 mg daily |
Mirabegron (Myrbetriq®) 25 mg daily |
ORDERED |
SUBSTITUTION |
Alfuzosin (Uroxatral®) 10 mg ONCE daily |
Tamsulosin (Flomax®) 0.4 mg ONCE daily |
Silodosin (Rapaflo®) 4 mg ONCE daily |
Tamsulosin (Flomax®) 0.4 mg ONCE daily |
Silodosin (Rapaflo®) 8 mg ONCE daily |
Tamsulosin (Flomax®) 0.4 mg ONCE daily |
ORDERED |
SUBSTITUTION |
Phenazopyridine (Pyridium®) 100 mg |
Phenazopyridine (Azo Urinary Pain Relief) 95 mg |
Phenazopyridine (Pyridium®) 200 mg |
Phenazopyridine (Azo Urinary Pain Relief) 190 mg |
HORMONES AND HORMONE MODIFIERS
ORDERED |
SUBSTITUTION |
Estradiol (Climara®) |
Estradiol (Vivelle Dot®, Alora®) |
Estradiol (Menostar®) |
Estradiol (Vivelle Dot®) |
ORDERED |
SUBSTITUTION |
Megestrol (Megace ES®) 625 mg/5ml |
Megestrol (Megace®) 800 mg/20 ml |
ORDERED |
SUBSTITUTION |
Prednisolone tablet or liquid* |
Methylprednisolone tablet at 20% dose reduction |
* Prednisolone liquid stock will only be kept for pediatric patient use.
All bisphosonates (e.g. Fosamax®, Boniva®, etc.) are |
DRUG |
RESTRICTION(S) |
Aminolevulinic acid (Gleolan®) |
May be used inpatient and outpatient for patients with high-grade glioma undergoing fluorescence-guided surgical resections. Restricted to hospitals that are confirmed to have the appropriate microscope and filters and to neurosurgeons who have completed the training program provided by the distributor. The dispensing pharmacist must confirm that the requesting neurosurgeon is an approved user prior to dispensing (Dr. Babu). |
Brivaracetam (Briviact®) |
New starts restricted to neurology. |
Cangrelor (Kengreal®) |
1. Restricted to Interventional Cardiologists and Cardiothoracic Surgeons. 2. STEMI or high-risk PCI patients when oral or enteral (eg, per NG tube) loading is not feasible or GI absorption of oral/enteral agents is questionable. 3. Selected cases where likelihood of urgent* CABG is high [*Urgent procedure: Defined as a procedure required within 24 hours in order to minimize chance of further clinical deterioration] 4. Use in perioperative bridging outside of urgent CABG is prohibited due to lack of indication and documented benefit. 5. Patients should be transitioned to oral/enteral therapy as soon as possible after initiation; at least 2 hours after start of infusion or for the duration of the procedure, whichever is longer) or as soon as the patient can tolerate oral or enteral intake. If maintenance infusions beyond the procedure are necessary, 0.75 mcg/kg/min should be considered and the necessity of such infusions should be re-evaluated regularly. |
Caplacizumab-yhdp (Cablivi®) |
Restricted to the following criteria: · Ordering restricted to hematology/oncology physicians · Patients with confirmed, high-risk acquired thrombotic thrombocytopenic purpura (neurologic or cardiac involvements) · Patient must receive one treatment of plasma exchange, in addition to immunosuppressive therapy, prior to initiation of caplacizumab. · Must be given in conjunction with plasma exchange and immunosuppression therapy. · Prior to ordering the first dose of caplacizumab, a case management consult to begin the prior authorization approval process and to determine cost to the patient for outpatient |
Cisatracurium (Nimbex®) |
Restricted to patients with multi-system organ failure who are not candidates for therapy with rocuronium or vecuronium. |
Collagenase (Santyl®) |
Restricted to the following criteria: · Necrotic tissue or severe burns in need of enzymatic therapy, OR · Not a candidate for other debridement therapy (if available); assess cost-effectiveness of Autolytic Debridement (e.g. Hydrocolloids, Hydrogels, Alginates, Iodosorb, Mesalt, Antiseptics, or Silver dressings) or Mechanical Debridement (e.g. Larval therapy, Pulsatile Lavage and Hydrotherapy, Ultrasound therapy, Ultrasonic Mist, Debrisoft, or Wet to dry gauze dressings) |
Conivaptan (Vaprisol®) |
Non-formulary. Tolvaptan may be utilized as oral alternative. |
Dehydrated alcohol |
Restricted to the following criteria: · Interventional radiology for use in celiac plexus neurolysis. · If doxycycline therapy is unsuccessful after use in sclerotherapy for seroma treatment. · Do not utilize for preventing and treating alcohol withdrawal. |
Digoxin immune fab (Digifab®) |
Restricted to use in patients with life-threatening or potentially life-threatening toxicity. See dosing recommendations. |
Droperidol (Inapsine®) |
Restricted to the following criteria: · Maximum single dose = 2.5 mg · Indications: · Prevention and/or treatment of nausea and vomiting associated with surgical and diagnostic procedures · Prior to using droperidol for off-label indcations (such as nausea and vomiting, migraine and agitation), other treatments should be utilized, as clinically appropriate · When used for agitation: · Utilize 2.5 mg IV or IM dose · Use limited to scenarios of urgent potential harm to the patient and/or staff and other medications for agitation were attempted first · Do not administer if K+ and Mg++ are abnormal (if labs available) · Baseline Monitoring: · Baseline SBP > 100 mmHg · Baseline electrocardiogram is recommended; use of droperidol is not recommended if there is evidence of QTc prolongation |
Empagliflozin (Jardiance®) |
Restricted to continuation of home therapy OR new inpatient orders in which the following patient conditions are met: · eGFR is >/= 25 and renal function is stable or improving · Patient does not have recurrent UTIs · Patient does not have history of, or at high risk for, DKA · Patient does not have hypovolemia · Patient does not have severe PAD, foot ulcerations, or at risk of amputation |
Ethacrynic acid (Edecrin®) |
Restricted to patients with true allergy to any loop diuretic or intolerance to all other loop diuretics. IV formulation should only be used when absolutely necessary (not stocked). |
Gauifenesin-codeine (Robitussin AC®) |
Restricted to use in adults. |
Hemin (Panhematin®) |
Restricted to the following criteria: · Treatment of mild, moderate, or severe attacks of AIP in patients with established AIP Repeat urinary PBG test is recommended for confirmation of an acute AIP attack · Treatment of suspected AIP with appropriate diagnostic lab tests collected at presentation of attack: 1. Elevated urinary PBG concentration 2. Elevated total urinary porphyrin level · Treatment with hemin should not be delayed while awaiting laboratory results |
Ivermectin |
Restricted to the treatment of parasitic infections, such as Strongyloides stercoralis, Onchocerca volvulus, Pediculus capitis, Pediculus corporis, Pediculosis pubis, Sarcoptes scabiei, Wuchereria bancrofti, larva currens, larva migrans, acne rosacea, ascariasis, enterobiasis, trichuriasis and scabies. |
Levalbuterol (Xopenex®) |
Restricted to continuation of home therapy due to albuterol intolerability or documented tachydysrhythmia with albuterol. |
Levothyroxine (Synthroid®) injection |
Restricted to use when at least one of the following criteria are met: · IV levothyroxine may be initiated after 5 days without PO therapy (due to long half-life). Once therapy is started, adjust dosing interval for IV route to 48 hours. · Presence of clinical hypothyroidism (TSH ≥ 10 uIU/mL, decreased T4 or signs and symptoms of hypothyroidism) who are strict NPO · Myxedema coma · Patients on hypothermia protocol · Potential organ donor status |
Linaclotide (Linzess®) |
Use is restricted to continuation of home medications only; no new starts during hospitalization. |
Lubiprostone (Amitiza®) |
Use is restricted to continuation of home medications only; no new starts during hospitalization. |
Lurasidone (Latuda®) |
Restricted to continuation of patient home maintenance therapy. |
Pneumococcal polysaccharide vaccine 23 valent (Pneumovax 23®) |
Restricted to post-splenectomy patients who have already received Prevnar 13. |
Polidocanol (Varithena®) |
Restricted to the following criteria: · Outpatient procedures with confirmed payer approval, and · Treatment of superficial symptomatic venous insufficiency, varicose veins, and incompetent tributaries and perforators in the legs |
Roflumilast (Daliresp®) |
Restricted to continuation of patient home maintenance therapy. |
Sacubitril/valsartan (Entresto®) |
Restricted to the following criteria: · Patient has not taken an ACE inhibitor in the last 36 hours · Patient has a blood pressure sufficiently high enough to support Entresto initiation · Patient has hemodynamically stable NYHA Class II to IV HF with reduced EF (≤ 40%) · Patient does not have a history of hereditary angioedema or history of angioedema related to previous ACE inhibitor or ARB therapy |
Sugammadex (Bridion®) |
· Neostigmine/glycopyrrolate should be used for the routine reversal of neuromuscular blockade · Sugammadex may be considered for use in the following scenarios: o Failed reversal after a neostigmine dose of at least 50 mcg/kg (maximum dose of 5 mg) for rocuronium and vecuronium reversal o Immediate reversal of neuromuscular blockade in a “cannot intubate/cannot ventilate” or another emergency situation o Procedures requiring fast onset-short duration, where succinylcholine is contraindicated o Reversal of intubation doses of rocuronium/vecuronium to shorten anesthesia time for abandoned or cancelled procedures o Patients with pulmonary hypertension, myasthenia gravis and muscular dystrophy o Patients with end stage pulmonary disease (FEV1 <30) or currently on home oxygen therapy o Patients who remain deeply paralyzed at the end of a case (0 twitches) o Contraindications to either neostigmine or glycopyrrolate |
Tolvaptan (Samsca®) |
May only be prescribed by nephrologists, cardiologists, and intensivists. Serum Sodium must be less than 130. |
Venetoclax (Venclexta®) |
Restricted to hematology/oncology service for CLL, SLL, or AML, for first cycle or for admitted patients and next cycle is needed (unable to defer to outpatient administration or obtain from specialty pharmacy). For continuation of therapy during hospitalization, the patient’s own medication supply must be utilized if on therapy prior to hospitalization. |
ORDERED |
SUBSTITUTION |
Azelastine (Optivar®) |
Ketotifen (Zaditor®) |
Epinastine (Elestat®) |
Ketotifen (Zaditor®) |
Lodoxamide (Alomide®) |
Ketotifen (Zaditor®) |
Olopatadine (Patanol®) 0.1% |
Ketotifen (Zaditor®) |
Olopatadine (Patanol®, Pataday®) 0.2% |
Ketotifen (Zaditor®) |
Emedastine (Emadine®) |
Ketotifen (Zaditor®) |
ORDERED |
SUBSTITUTION |
Gentamicin ophthalmic ointment |
Gentamicin ophthalmic solution |
Tobramycin (Tobrex®) ophthalmic ointment |
Tobramycin (Tobrex®) ophthalmic solution |
Gentamicin/prednisolone (Pred-G S.O.P.®) ophthalmic ointment Gentamicin/prednisolone (Pred-G Liquifilm®) ophthalmic suspension Tobramycin/dexamethasone (Tobradex®) ophthalmic ointment Tobramycin/loteprednol (Zylet®) ophthalmic suspension |
Tobramycin/dexamethasone (Tobradex®) |
Besifloxacin (Besivance®) ophthalmic solution Ciprofloxacin (Cipro®) ophthalmic ointment Gatifloxacin (Zymar) ophthalmic solution Levofloxacin (Quixin®) ophthalmic solution Norfloxacin (Chibroxin®) ophthalmic solution Ofloxacin (Ocuflox®) ophthalmic solution |
Ciprofloxacin (Ciloxan®) 0.3% ophthalmic 1-2 drops q 2-4 hours while awake |
Ciprofloxacin/dexamethasone (CiproDex®) otic |
Ciprofloxacin (Ciloxan®) 0.3% ophthalmic + Dexamethasone (Maxidex®) 0.1% ophthalmic |
Azithromycin (Azasite®) ophthalmic solution |
Erythromycin ophthalmic ointment |
Sulfacetamide/prednisolone (Blephamide®) ophthalmic ointment |
Sulfacetamide/prednisolone (Blephamide®) ophthalmic solution |
Bacitracin ophthalmic ointment Bacitracin/polymyxin (AK-Poly-Bac®) ophthalmic ointment |
Bacitracin/polymyxin (Polysporin®) ophthalmic ointment |
Neomycin/polymyxin/hydrocortisone (Cortisporin®) ophth. suspension |
Neomycin/polymyxin/dexamethasone (Maxitrol®) ophthalmic suspension |
ORDERED |
SUBSTITUTION |
Alpha Adrenergic Agonists |
|
Apraclonidine (Iopidine) 0.5% or 1% Up to 6 drops TID in affected eye(s) |
Brimonidine 0.2% 1 drop in affected eye(s) TID |
Brimonidine (AlphaganP) 0.1% or 0.15% Instill 1 drop in affected eye(s) TID |
Brimonidine 0.2% Instill 1 drop in affected eye(s) TID |
Alpha Adrenergic Agonists + Beta Adrenergic Blocking Agents (Combo Products) |
|
Brimonidine 0.2%/Timolol 0.5% (Combigan) 1 drop in affected eye(s) BID |
Brimonidine 0.2% 1 drop in affected eye(s) BID AND Timolol maleate 0.5% 1 drop in affected eye(s) BID |
Alpha Adrenergic Agonists + Carbonic Anhydrase Inhibitors (Combo Products) |
|
Brinzolamide 1%/ Brimonidine 0.2% (Simbrinza) 1 drop in affected eye(s) TID |
Brimonidine 0.2% 1 drop in affected eye(s) BID AND Dorzolamide 2% 1 drop in affected eye(s) TID |
Beta Adrenergic Blocking Agents |
|
Betaxolol HCL (Betoptic) 0.25% 1-2 drops in affected eye(s) BID |
Timolol maleate 0.25% 1 drop in affected eye(s) BID |
Carteolol HCL (Cartol) 1% 1 drop in affected eye(s) BID |
|
Levobunolol HCL (Betagan) 0.25% 1-2 drops in affected eye(s) BID |
|
Metipranolol HCL (Optipranolol) 0.3% 1 drop in affected eye(s) BID |
|
Timolol gel forming solution (GFS) 0.25% 1 drop in affected eye (s) daily |
|
Betaxolol HCL (Betoptic) 0.5% 1-2 drops in affected eye(s) BID |
Timolol maleate 0.5% 1 drop in affected eye(s) BID |
Levobunolol (Betagan) 0.5% 1-2 drops in affected eye(s) daily |
|
Timolol gel forming solution (GFS) 0.5% 1 drop in affected eye(s) daily |
|
Carbonic Anhydrase Inhibitors |
|
Brinzolamide (Azopt) 1% 1 drop in affected eye(s) TID |
Dorzolamide 2% 1 drop in affected eye(s) TID |
ORDERED |
SUBSTITUTION |
Cyclosporine 0.05% ophthalmic emulsion (Restasis) |
Artificial tears ophthalmic drops |
Fluorometholone (FML) |
Dexamethasone 0.1% suspension |
Loteprednol (Lotemax) |
|
Loteprednol etabonate 0.5% suspension |
ORDERED |
SUBSTITUTION |
Neomycin/polymyxin B/hydrocortisone |
Neomycin/polymyxin B/dexamethasone |
Ofloxacin 0.3% Otic |
Ciprofloxacin ophthalmic 0.3% |
ORDERED |
SUBSTITUTION |
Bimatoprost (Lumigan®) 0.03% |
Latanoprost (Xalatan®) 0.005% at same dose |
Latanoprostene bunod (Vyzulta®) 0.024% |
Latanoprost (Xalatan®) 0.005% at same dose |
Travoprost (Travatan®) 0.004% |
Latanoprost (Xalatan®) 0.005% at same dose |
Tafluprost (Zioptan®) 0.0015% |
Latanoprost (Xalatan®) 0.005% at same dose |
ORDERED |
SUBSTITUTION |
Bromfenac (Xibrom®) ophthalmic |
Ketorolac (Acular®) 0.5% ophthalmic |
Diclofenac (Voltaren®) ophthalmic |
Ketorolac (Acular®) 0.5% ophthalmic |
Flurbiprofen (Ocufen®) ophthalmic |
Ketorolac (Acular®) 0.5% ophthalmic |
Nepafenac (Nevanac®) ophthalmic |
Ketorolac (Acular®) 0.5% ophthalmic |
ORDERED |
SUBSTITUTION |
Donepezil (Aricept®) 23 mg daily |
Donepezil (Aricept®) 20 mg daily |
Memantine (Namenda XR®) 7 mg daily |
Memantine (Namenda®) 5 mg daily |
Memantine (Namenda XR®) 14 mg daily |
Memantine (Namenda®) 5 mg BID |
Memantine (Namenda XR®) 21 mg daily |
Memantine (Namenda®) 10 mg BID |
Memantine (Namenda XR®) 28 mg daily |
Memantine (Namenda®) 10 mg BID |
Antidepressants
ORDERED |
SUBSTITUTION |
Desvenlafaxine (Pristiq®) 50 mg daily |
Venlafaxine (Effexor XR®) 75 mg daily |
Desvenlafaxine (Pristiq®) 100 mg daily |
Venlafaxine (Effexor XR®) 150 mg daily |
ORDERED |
SUBSTITUTION |
Paroxetine (Paxil CR®) 12.5 mg |
Paroxetine (Paxil®) 10 mg |
Paroxetine (Paxil CR®) 25 mg |
Paroxetine (Paxil®) 20 mg |
Paroxetine (Paxil CR®) 37.5 mg |
Paroxetine (Paxil®) 40 mg |
ORDERED |
SUBSTITUTION |
Imipramine pamoate (Tofranil-PM®) (capsule) |
Imipramine (Tofranil®) (tablet) – give in divided doses |
Combination Products |
|
ORDERED |
SUBSTITUTION |
Olanzapine/fluoxetine 3/25 mg |
Olanzapine 2.5 mg + fluoxetine 20 mg |
Olanzapine/fluoxetine 6/25 mg |
Olanzapine 5 mg + fluoxetine 20 mg |
Olanzapine/fluoxetine 12/25 mg |
Olanzapine 12.5 mg + fluoxetine 20 mg |
Olanzapine/fluoxetine 6/50 mg |
Olanzapine 5 mg + fluoxetine 50 mg |
Olanzapine/fluoxetine 12/50 mg |
Olanzapine 12.5 mg + fluoxetine 50 mg |
ORDERED |
SUBSTITUTION |
Quetiapine (Seroquel XR®) |
Quetiapine (Seroquel®) |
Paliperidone (Invega®) |
Non-formulary. Patient may use own med. |
Brexpiprazole (Rexulti®) 1 mg |
Aripiprazole (Abilify®) 5 mg |
Olanzapine/samidorphan (Lybalvi®) 5mg/10mg Olanzapine/samidorphan (Lybalvi®) 10mg/10mg Olanzapine/samidorphan (Lybalvi®) 15mg/10mg Olanzapine/samidorphan (Lybalvi®) 20mg/10mg |
Olanzapine 5mg Olanzapine 10mg Olanzapine 15mg Olanzapine 20mg |
ORDERED |
SUBSTITUTION |
Armodafinil (Nuvigil®) 50 mg daily |
Modafinil (Provigil®) 100 mg daily |
ORDERED |
SUBSTITUTION |
Formoterol (Foradil®) |
Arformoterol (Brovana®) |
Formoterol (Perforomist®) |
Arformoterol (Brovana®) |
Indacaterol (Arcapta® Neohaler) |
Arformoterol (Brovana®) |
Levalbuterol (Xopenex®) |
Albuterol |
Olodaterol (Striverdi Respimat®) |
Arformoterol (Brovana®) |
Salmeterol (Serevent Diskus®) |
Arformoterol (Brovana®) |
ORDERED |
SUBSTITUTION |
Ipratropium (Atrovent MDI®) |
Ipratropium nebulizer solution |
ORDERED |
SUBSTITUTION |
Tiotropium (Spiriva Handihaler®) |
Tiotropium (Spiriva Respimat®) |
Aclidinium (Tudorza®) |
Tiotropium (Spiriva Respimat®) |
Glycopyrrolate (Seebri Neohaler®) |
Tiotropium (Spiriva Respimat®) |
Umeclidinium (Incruse Ellipta®) |
Tiotropium (Spiriva Respimat®) |
Revefenacin (Yupelri®)175mcg via |
Tiotropium (Spiriva Respimat®) |
Note: When tiotropium (Spiriva Respimat®) is ordered for a patient currently on ipratropium (Atrovent®), the Atrovent® will automatically be discontinued per protocol. |
ORDERED |
SUBSTITUTION |
LOW DOSE (HFA) |
|
Beclomethasone HFA (QVAR®) 40mcg/inhalation – 2-5 inhalations/day |
Mometasone HFA (Asmanex®)2 200 mcg /inhalation- 1 inhalation once daily |
Beclomethasone HFA (QVAR®) 80mcg/inhalation – 1-2 inhalations/day |
|
Fluticasone HFA (Flovent®) 44mcg/inhalation- 1-5 inhalations/day |
|
Fluticasone HFA (Flovent®) 110 mcg/inhalation- 1-2 inhalations/day |
|
Fluticasone HFA (Flovent®) 220 mcg/inhalation- 1 inhalations/day |
|
Ciclesonide MDI (Alvesco®) 80mcg/inhalation- 2-3 inhalations/day |
|
Ciclesonide MDI (Alvesco®) 160mcg/inhalation- 1 inhalations/day |
|
MEDIUM DOSE (HFA) |
|
Beclomethasone HFA (QVAR®) 40mcg/inhalation – 6-12 inhalations/day |
Mometasone HFA (Asmanex®) 200mcg /inhalation- 2 inhalations once daily |
Beclomethasone HFA (QVAR®) 80mcg/inhalation – 3-6 inhalations/day |
|
Fluticasone HFA (Flovent®) 44mcg/inhalation- 6-10 inhalations/day |
|
Fluticasone HFA (Flovent®) 110 mcg/inhalation- 3-4 inhalations/day |
|
Fluticasone HFA (Flovent®) 220 mcg/inhalation- 2 inhalations/day |
|
Fluticasone furoate (Arnuity Ellipta®) |
|
Ciclesonide MDI (Alvesco®) 80mcg/inhalation- 4-8 inhalations/day |
|
Ciclesonide MDI (Alvesco®) 160mcg/inhalation- 2-4 inhalations/day |
|
HIGH DOSE (HFA) |
|
Beclomethasone HFA (QVAR®) 40mcg/inhalation – >12 inhalations/day |
Mometasone HFA (Asmanex®) 200mcg /inhalation- 2 inhalations BID |
Beclomethasone HFA (QVAR®) 80mcg/inhalation – >6 inhalations/day |
|
Fluticasone HFA (Flovent®) 44mcg/inhalation- 11-15 inhalations/day |
|
Fluticasone HFA (Flovent®) 110 mcg/inhalation- 5-6 inhalations/day |
|
Fluticasone HFA (Flovent®) 220 mcg/inhalation- 3 or more inhalations/day |
|
Fluticasone furoate (Arnuity Ellipta) 200 mcg/day |
|
Ciclesonide MDI (Alvesco®) 80mcg/inhalation- >8 inhalations/day |
|
Ciclesonide MDI (Alvesco®) 160mcg/inhalation- >4 inhalations/day |
Inhaled Corticosteroids (ICS) – Dry Powder |
|
ORDERED |
SUBSTITUTION |
LOW DOSE (Dry Powder Inhaler) |
|
Budesonide DPI (Pulmicort®) 90mcg/inhalation – 1-3 inhalations BID |
Mometasone HFA (Asmanex) 200mcg /inhalation -1 inhalation once daily |
Fluticasone DPI (Flovent Diskus®) 50mcg/inhalation 1-2 inhalations BID |
|
MEDIUM DOSE (Dry Powder Inhaler) |
|
Budesonide DPI (Pulmicort®) 180mcg/inhalation – 2 inhalations BID |
Mometasone HFA (Asmanex) 200mcg /inhalation -2 inhalations once daily |
Fluticasone DPI (Flovent Diskus®) 50mcg/inhalation 3-5 inhalations BID |
|
Fluticasone furoate (Arnuity Ellipta) 100 mcg/day |
|
HIGH DOSE (Dry Powder Inhaler) |
|
Budesonide DPI (Pulmicort®) 180mcg/inhalation– >2 inhalations BID |
Mometasone HFA (Asmanex) 200mcg /inhalation - 2 inhalations BID |
Fluticasone furoate (Arnuity Ellipta) 200 mcg/day |
|
Fluticasone DPI (Flovent Diskus®) 50mcg/inhalation >5 inhalations BID |
ORDERED |
SUBSTITUTION |
Fluticasone-salmeterol (Advair Diskus®) 100 mcg-50 mcg, 1 puff BID |
Mometasone-formoterol (Dulera®) 200 mcg-5 mcg, 2 puffs BID |
Fluticasone-salmeterol (Advair Diskus®) 250 mcg-50 mcg, 1 puff BID |
|
Fluticasone-salmeterol (Advair Diskus®) 500 mcg-50 mcg, 1 puff BID |
|
Fluticasone-salmeterol (Advair HFA®) 45 mcg-21 mcg, 2 puff BID |
|
Fluticasone-salmeterol (Advair HFA®) 115 mcg-21 mcg, 2 puff BID |
|
Fluticasone-salmeterol (Advair HFA®) 230 mcg-21 mcg, 2 puff BID |
|
Budesonide-formoterol (Symbicort®) 80 mcg-4.5 mcg, 2 puffs BID |
|
Budesonide-formoterol (Symbicort®) 160 mcg-4.5 mcg, 2 puffs BID |
|
Fluticasone-vilanterol (Breo Ellipta®) 100 mcg-25 mcg, 1 puff DAILY |
ORDERED |
SUBSTITUTION |
Zafirlukast (Accolate®) |
Montelukast (Singulair®) 10 mg daily |
ORDERED |
SUBSTITUTION |
Theophylline ER BID (non-24 hour formulations) |
Theo-24 (total daily dose or ER product ONCE Daily) |
* Note: Orders for Theo-24 BID will be continued on a TWICE DAILY schedule if this is how they take this product at home per home med sheet.
ORDERED |
SUBSTITUTION |
Beclomethasone (Beconase AQ®, Vancenase AQ®) 1-2 sprays/nostril BID |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Triamcinolone (Nasacort®) 1-2 sprays/nostril daily |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Flunisolide (Nasarel®) 2 sprays/nostril BID to TID |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Mometasone (Nasonex®) 2 sprays/nostril daily |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Budesonide (Rhinocort Aqua®) 1-4 sprays/nostril daily |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Fluticasone furoate (Veramyst®) 2 sprays/nostril daily |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Ciclesonide (Omnaris®) Any dose |
Fluticasone propionate (Flonase®) 2 sprays/nostril daily |
Sedative/Hypnotics for Sleep No sedative/hypnotic will be administered for sleep to any patient 65 or greater unless receiving it at home. |
|
ORDERED |
SUBSTITUTION |
Ramelteon (Rozerem®) 8 mg |
Melatonin® 3 mg |
Zaleplon (Sonata®) 5 mg |
Eszopiclone (Lunesta®) 1 mg OR Zolpidem (Ambien®) 5 mg |
Zaleplon (Sonata®) 10 mg |
Eszopiclone (Lunesta®) 2 mg OR Zolpidem (Ambien®) 5 mg |
Triazolam (Halcion®) 0.25 mg |
Zolpidem (Ambien®) 5 mg |
Flurazepam (Dalmane®) 15 mg or 30 mg |
Zolpidem (Ambien®) 5 mg |
Estazolam (Prosom®) 1 mg or 2 mg |
Temazepam (Restoril®) 15 mg |
Temazepam (Restoril®) 7.5 mg |
Zolpidem (Ambien®) 5 mg |
Temazepam (Restoril®) 15 mg or 30 mg |
Temazepam (Restoril®) 15 mg |
Zolpidem CR (Ambien CR®) 6.25 mg or 12.5 mg |
Zolpidem (Ambien®) 5 mg |
Suvorexant (Belsomra®) 10 mg |
Eszopiclone (Lunesta®) 1 mg OR Zolpidem (Ambien®) 5 mg |
Suvorexant (Belsomra®) 20 mg |
Eszopiclone (Lunesta®) 2 mg OR Zolpidem (Ambien®) 5 mg |
VITAMINS/SUPPLEMENTS
Vitamins/Supplements |
|
ORDERED |
SUBSTITUTION |
Beta-carotene multivitamin (Ocuvite®, PreserVision®) |
Multivitamin (MVI) |
Ferrous fumarate (Ferro-Sequels®) |
Ferrous Sulfate 300/325 mg |
Ferrous sulfate (Slow FE®) 160 mg |
Ferrous Sulfate 300/325 mg (one-for-one) |
Ferrous gluconate |
Ferrous sulfate 300/325 mg |
Ferrous sulfate & ascorbic acic |
Ferrous sulfate 300/325 mg |
Folic acid, cyanocobalamin, pyridoxine |
Folic acid 1 mg |
Levomefolate, mecobalamin, pyridoxal-5-phosphate |
Folic acid 1 mg |
Cerefolin |
Folic acid 1 mg |
Vitamin B complex, vitamin C, biotin, folic acid |
Folic acid 1 mg |
Magnesium chloride 64 mg |
Mag-Ox 200 mg (1/2 of 400 mg tab) |
Multivitamin with minerals (Thera M®) |
Multivitamin (MVI) |
Multivitamin with minerals, no iron (Eldertonic®) |
Multivitamin liquid (MVI) |
Multivitamin with iron (Hemocyte Plus®) |
Multivitamin (MVI) + ferrous sulfate 325 mg |
Nephro Vitamin |
Rena-vite |
Prenatal RX |
MVI + folic acid 1 mg |
Stress Tab with Iron |
Stresstab + ferrous sulfate 325 mg |
ORDERED |
SUBSTITUTION |
Iron dextran (INFeD®) |
Formulary product; drug of choice for single dose iron replenishment |
Iron sucrose (Venofer®) 100 mg |
Sodium ferric gluconate complex |
Iron sucrose (Venofer®) 200 mg |
Sodium ferric gluconate complex |
Sodium ferric gluconate complex (Ferrlecit®/Nulecit®) |
Inpatient use only |
Ferumoxytol (Feraheme®) |
Outpatient use only |
OUTPATIENT Injectable Iron Products |
|
ORDERED |
STATUS |
Ferumoxytol (Feraheme®) |
Approved for outpatient use |
Iron dextran (INFeD®) |
Approved for outpatient use |
Sodium ferric gluconate complex (Ferrlecit®/Nulecit®) |
Inpatient use only |