Approved Hospital Formulary
QR Code
Approved Hospital Formulary

CHI Memorial Hospital

Formulary Interchanges, Restrictions, & Usage Criteria

Updated: October 2021

 

Table of Contents:

(Use links here or press Ctrl+F to search for a specific drug or word within the page)

·        Analgesics

o   Analgesic Restrictions

o   Miscellaneous Analgesics

o   NSAIDs

o   Salicylates

o   Opiate Agonists

o   Long-acting Opiate Agonists

o   Combination Agents with Hydrocodone/Oxycodone

o   Serotonin Receptor Agonists (Triptans)

o   Skeletal Muscle Relaxants

·        Anticoagulants

o   Low-Molecular Weight Heparins

o   Thrombin Inhibitors

·        Anticonvulsants

·        Antidiabetics

o   Biguanides

o   DPP-IV Inhibitors

o   Incretin Mimetics and Amylin Analogs

o   Incretin Mimetic/Insulin Combination Products

o   Insulins – Long-acting

o   Insulins – Short-acting

o   Meglitinides

o   SGLT2 Inhibitors

·        Antidotes

·        Anti-Infectives

o   Anti-Infective Restrictions

o   Anti-Infective Automatic Stops

o   Anti-Retrovirals (HIV meds)

o   Antifungals

o   Carbapenems

o   Cephalosporins (1st gen, 2nd gen, 3rd gen, 4th gen)

o   Fluoroquinolones

o   Macrolides

o   Miscellaneous Antibiotics

o   Oxazolidinones

o   Penicillins

o   Tetracyclines

·        Antihistamines, Decongestants, Antitussives, Expectorants

·        Blood Factor Products

·        Biologic Response Modifiers

o   Colony Stimulating Factors

o   Long Acting ESA

·        Cardiovascular Agents

o   Antilipemics

o   Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)

o   Angiotensin II Receptor Blockers (ARBs)

o   Beta-Blockers

o   Bile Acid Sequestrants

o   Calcium Channel Blockers (CCBs)

o   Combination Agents

o   Diuretics

o   HMG-CoA Reductase Inhibitors (Statins)

o   Phosphodiesterase Inhibitors

·        Dermatological Agents

o   Topical Antifungals

o   Antifungal/Steroid Combinations

o   Topical Corticosteroids (Very High, High, Medium, Low Potencies)

o   Topical Antivirals

o   Topical Estrogens

·        Gastrointestinal Agents

o   Antiemetics

o   Antacids

o   Antidiarrheals

o   Antimuscarinics

o   Antispasmodics

o   Gastrointestinal Enzymes

o   Histamine H2-Antagonists

o   Laxatives

o   Mesalamine Products

o   Peripheral-acting Opioid Antagonists

o   Probiotics

o   Proton Pump Inhibitors (PPIs)

o   Suppositories

·        Genitourinary Agents

o   Bladder Antiseptics

o   Bladder Antispasmodics

o   BPH Agents

o   Urinary Analgesics

·        Hormones and Hormone Modifiers

o   Estradiol Transdermal Systems

o   Megace

o   Synthetic Glucocorticoids

·        Miscellaneous

o   Bisphosphonates

o   Calcium Modifiers

o   Immunoglobulin Restrictions

o   Miscellaneous Restrictions

o   Medications Not Approved for Outpatient Formulary

o   Therapeutic Restrictions to Outpatient Locations

·        Ophthalmics/Otics

o   Antihistamines

o   Anti-infective Ophthalmic Agents

o   Glaucoma Agents

o   Miscellaneous Ophthalmics

o   Miscellaneous Otics

o   Prostaglandins

o   NSAIDs

·        Psychotropic Agents

o   Alzheimer’s Agents

o   Antidepressants (SNRIs, SSRIs, TCAs)

o   Combination Products

o   Antipsychotics

o   CNS Stimulants

·        Respiratory Agents

o   Beta-Agonists (SABA & LABA)

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   Leukotriene Antagonists

o   Long-acting Beta-agonist/Long-acting Antimuscarinic/Inhaled Corticosteroid (LABA/LAMA/ICS)

o   Methylxanthines

o   Nasal Corticosteroids

·        Sedatives/Hypnotics for Sleep

·        Vitamins/Supplements

o   Injectable Iron Products

 

 

 

ANALGESICS

Analgesic Restrictions

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
(10 mg/kg – max 800 mg, Q 6 hrs x 8 doses)

Meperidine (Demerol®)

1. Only to be used for the following indications:

  1. Rigors in PACU
  2. Rigors with medication administration
  3. Conscious sedation
  4. Patients with multiple allergies and/or intolerant of other opiate

Liposomal bupivacaine (Exparel®)

1. Non-formulary per P&T April 2016.

 

 

Miscellaneous Analgesics

ORDERED

SUBSTITUTION

Aspirin/butalbital/caffeine (Fiorinal®)

Acetaminophen/butalbital/caffeine (Esgic/Fioricet®)

Aspirin/butalbital/caffeine/codeine
(Fiorinal w/ Codeine #3)

Acetaminophen/butalbital/caffeine (Esgic®)
+ Codeine 30 mg
(PHA set available)

Lidocaine 5% patch

Lidocaine 4% patch

 

 

Non-steroidal Anti-inflammatories (NSAIDs)

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

 

 

Salicylates

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:

Opiate Agonists

ORDERED

SUBSTITUTION

Sufentanil (Sufenta®)

Fentanyl

Morphine (Roxanol® 20 mg/ml)

Morphine standard concentration (10 mg/5 ml UDL)

 

 

Long- Acting Opiate Agonists

Zohydro®

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)

 

 

Kadian® Q 24 Hour Doses

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.

 

 

Kadian® Q 12 Hour Doses

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.

 

 

Avinza®

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.

 

 

Embeda® Q 24 Hour Doses

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

 

 

Embeda® Q 12 Hour Doses

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

 

 

Oramorph SR®

ORDERED

SUBSTITUTION

Oramorph SR®

MS Contin® 1:1 conversion,
same dosing interval

 

 

Opana® IR/ER

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

 

 

 

MorphaBond ER®
 (morphine sulfate extended release)

ORDERED

SUBSTITUTION

MorphaBond ER® 15 mg
(morphine sulfate extended-release)

MS Contin® 15 mg
(morphine sulfate extended release)

MorphaBond ER® 30 mg
(morphine sulfate extended-release)

MS Contin® 30 mg
(morphine sulfate extended release)

MorphaBond ER® 60 mg
(morphine sulfate extended-release)

MS Contin® 60 mg
(morphine sulfate extended release)

MorphaBond ER® 100 mg
(morphine sulfate extended-release)

MS Contin® 100 mg
(morphine sulfate extended release)

 

 

 

Tapentadol (Nucynta®)

ORDERED

SUBSTITUTION

Tapentadol ER (Nucynta ER®) 50 mg BID

Tapentadol IR (Nucynta IR®) 25 mg Q 6 hours
(requires splitting 50 mg tab)

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
(requires splitting 50 mg tab)

 

 

 

Xtampza ER®
(oxycodone extended release)

ORDERED

SUBSTITUTION

Xtampza ER® 9 mg
(oxycodone extended release)

OxyContin® 10 mg
(oxycodone extended release)

Xtampza ER® 13.5 mg
(oxycodone extended release)

OxyContin® 10 mg
(oxycodone extended release)

Xtampza ER® 18 mg
(oxycodone extended release)

OxyContin® 20 mg
(oxycodone extended release)

Xtampza ER® 27 mg
(oxycodone extended release)

OxyContin® 30 mg
(oxycodone extended release)

Xtampza ER® 36 mg
(oxycodone extended release)

OxyContin® 40 mg
(oxycodone extended release)

 

 

 

Combination Products with Hydrocodone or Oxycodone

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
(Vicodin®, Lortab®, Norco®, Lorcet®)

Hydrocodone/Acetaminophen
(Norco®) 5/325 mg
(Lortab®) 7.5/325 mg
(Lortab®) 10/325 mg
Closest available strength will be used

Oxycodone/Acetaminophen
(Percocet®, Endocet®, Roxicet®)

Oxycodone/Acetaminophen
(Percocet®) 5/325 mg
(Percocet®) 7.5/325 mg
(Percocet®) 10/325 mg

Closest available strength will be used

 

 

Serotonin Receptor Agonists (Triptans)

Imitrex® is the formulary triptan of choice

**Maximum Dose Imitrex® = 100 mg per dose or 200 mg per day**

ORDERED

SUBSTITUTION

Naratriptan (Amerge®)

2.5 mg may repeat x 1 in 4 hours

Sumatriptan (Imitrex®)

50 mg may repeat x 1 in 2 hours

Almotriptan (Axert®)

6.25-12.5 mg repeat x 1 in 2 hours

Frovatriptan (Frova®)

2.5 mg repeat x 1 in 2 hours

Rizatriptan (Maxalt®)

5-10 mg repeat x 1 in 2 hours

Zolmitriptan (Zomig®)

2.5-5 mg repeat x 1 in 2 hours

Eletriptan (Relpax®)

20-40 mg repeat x 1 in 2 hours

 

 

Skeletal Muscle Relaxants

ORDERED

SUBSTITUTION

Carisoprodol (Soma®)
250 mg PO TID/4XD
350 mg PO TID/4XD

Cyclobenzaprine (Flexeril®) 10 mg PO TID
(Use 5 mg for patients 65 and older)

 

Chlorzoxazone (Parafon/Lorzone®)
375 mg PO TID/4XD
500 mg PO TID/4XD
750 mg PO TID/4XD

Metaxalone (Skelaxin®)
800 mg PO TID/4XD

Orphenadrine (Norflex®)

Methocarbamol (Robaxin®) 4XD

Orphenadrine/aspirin/caffeine (Norgesic®)

Methocarbamol (Robaxin®) 4XD

 

 

ANTICOAGULANTS

Low-Molecular Weight Heparins

ORDERED

SUBSTITUTION

Dalteparin (Fragmin®)

Enoxaparin (Lovenox®)
Dose to be determined based on indication and renal function as outlined in the dosing protocol.

 

 

 

Thrombin Inhibitors

ORDERED

SUBSTITUTION

Lepirudin (Refludan®)
(Non-formulary – manufacturer discontinued product June 2013)

Argatroban or bivalirudin per protocol
(Must obtain new order from physician)

 

 

 

ANTICONVULSANTS

Levetiracetam XR (Keppra XR®)
Substitute with equivalent total daily dose of immediate-release levetiracetam divided into 2 doses. See example below.

ORDERED

SUBSTITUTION

Levetiracetam XR (Keppra XR®) 1000 mg daily

Levitiracetam (Keppra®) 500 mg BID

 

 

Gabapentin (Neurontin®)

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

 

 

Lamotrigine (Lamictal®)

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)
All IV phenytoin orders will be converted to IV fosphentoin.

ORDERED

SUBSTITUTION

Phenytoin (Dilantin®) 1 mg IV

Fosphenytoin (Cerebyx®) 1 mg PE IV

 

 

 

 

Antidotes

ORDERED

SUBSTITUTION

Acetylcysteine (CETYLEV®)
140 mg/kg x 1 dose (loading dose)
70 mg/kg every 4 hours x 17 doses

Acetylcysteine oral liquid (nebulizer solution)
140 mg/kg x 1 dose (loading dose)
70 mg/kg every 4 hours x 17 doses

 

 

ANTIDIABETICS

Biguanides

ORDERED

SUBSTITUTION

Metformin XR (Glucophage XR®)

Metformin (standard formulation)
Split into equivalent dosing BID
(e.g. 1000 mg XR daily à 500 mg standard BID)

 

 

DPP-4 Inhibitors

ORDERED

SUBSTITUTION

Linagliptin (Tradjenta®) 5 mg daily

Alogliptin (Nesina®) 25 mg daily
or adjusted for renal function*

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
or adjusted for renal function*

Sitagliptin (Januvia®) 25 mg daily

Alogliptin (Nesina®) 6.25 mg daily
or adjusted for renal function*

Combination DPP-4 + metformin agents

Alogliptin with dosing per above,
plus metformin

*See alogliptin renal adjustment below

 

Alogliptin (Nesina®) Renal Adjustment
(For use in above interchange table)

CrCl (ml/min)

Renal Adjustment

≥ 60

No dose adjustment

≥ 30 to ≤ 60

12.5 mg daily

< 30
or ESRD requiring dialysis

6.25 mg daily without regard to time of dialysis

 

 

 

Incretin Mimetics & Amylin Analogs

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.

 

 

 

Incretin Mimetic/Insulin Combination Products

ORDERED

SUBSTITUTION

Insulin glargine/lixisenatide (Soliqua®)
Once daily injection

Convert Soliqua® unit per unit to Lantus units at same dosing schedule.
Start 24 hours after patient received last home dose of Soliqua®.

Insulin degludec/liraglutide (Xultophy®)
Once daily injection

Convert Xultophy® unit per unit to Lantus units at same dosing schedule.
Start 24 hours after patient received last home dose of Xultophy®.

 

 

 

Insulins: Long-Acting

ORDERED

SUBSTITUTION

Insulin detemir (Levemir®)

Insulin glargine (Lantus®)
Same dosing frequency
(1:1 dose conversion)

Insulin glargine (Toujeo®) 300 units/ml

Insulin glargine (Lantus®)
Same dosing frequency
(1:1 dose conversion)

Insulin degludec (Tresiba®)
100 units/ml or 200 units/ml

Insulin glargine (Lantus®)
Same dosing frequency
(1:1 dose conversion)

Insulin degludec/insulin aspart
(Ryzodeg® 70/30)
(dose based on degludec component;
10 units = 10 units of degludec)

Insulin glargine (Lantus®)
Same dosing frequency
(1:1 dose conversion)
* short-acting component should be ordered separately *

 

 

Insulins: Short-Acting

ORDERED

SUBSTITUTION

Insulin aspart (Novolog®)

Insulin lispro (Humalog®)
Same dosing frequency
(1:1 dose conversion)

Insulin glulisine (Apidra®)

Insulin lispro (Humalog®)
Same dosing frequency
(1:1 dose conversion)

Insulin aspart/insulin aspart protamine
(Novolog® 70/30)

Insulin lispro/insulin lispro protamine
(Humalog® 75/25)
Same dosing frequency
(1:1 dose conversion)

Regular insulin/isophane insulin
(Novolin® 70/30)

Regular insulin/isophane insulin (Humulin® 70/30)
Same dosing frequency
(1:1 dose conversion)

Regular insulin (Novolin R®)

Regular insulin (Humulin R®)
Same dosing frequency
(1:1 dose conversion)

Isophane insulin (Novolin N®)

Isophane insulin (Humulin N®)
Same dosing frequency
(1:1 dose conversion)

Insulin, inhaled (Afrezza®)

Insulin lispro (Humalog®)
Same dosing frequency
(1:1 dose conversion)

*Novolog® may only be used for refilling implantable pumps

**All insulin pens are non-formulary; equivalent dose will be given via vial.

 

Meglitinides

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

 

 

SGLT2 Inhibitors*

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.

 

ANTI-INFECTIVES

Anti-infective Restrictions

DRUG

RESTRICTION(S)

Amphotericin
(Ambisome®)

  1. Infectious Diseases Service.
  2. Treatment of invasive fungal infections where treatment with amphotericin is indicated.

Ceftazidime (Fortaz®)

  1. Infectious Diseases Service
  2. Treatment of infections due to susceptible MDR gram-negative rod for which other preferred treatment options are unavailable.

 

All other orders should be substituted to cefepime.

Ceftolozane/Tazobactam (Zerbaxa®)

  1. Infectious Diseases Service
  2. Treatment of infections due to susceptible MDR gram-negative rod for which other preferred treatment options are unavailable.

Ceftaroline (Teflaro®)

  1. Infectious Diseases Service

Ciprofloxacin (Cipro®)

  1. Infectious Diseases, Intensivists, Pulmonology Services
  2. Treatment of confirmed infection with Psuedomonas aeruginosa susceptible to ciprofloxacin.

Daptomycin (Cubicin®)

*Should not be used for treatment of pneumonia

  1. Infectious Diseases Service
  2. Treatment of bacteremia and/or endocarditis due to documented or suspected multi-drug resistant gram positive organisms (MRSA, MRSE, and VRE) when vancomycin cannot be used.
    1. Vancomycin allergy
    2. Vancomycin failure

                                                              i.      Clinical decompensation after 72 hours

                                                            ii.      Failure to clear blood cultures after 48 hours for bacteremia/endocarditis

    1. Vancomycin Staphylococcus aureus MIC > 2 mcg/ml
    2. Recent vancomycin therapy
  1. Treatment of complicated skin and skin structure infections due to multi-drug resistant gram positive organisms (MRSA, MRSE, and VRE) when both vancomycin and linezolid cannot be used. 

Ertapenem (Invanz®)

  1. Infectious Diseases Service
  2. One-time dose within 24 hours of expected discharge to support transition to outpatient IV antibiotic therapy.

Fidaxomicin (Dificid®)

  1. Infectious Diseases Service

Isavuconazonium
(Cresemba®)

  1. Infectious Diseases Service

Linezolid (Zyvox®)

* Not recommended for treatment of bacteremia or endocarditis.

  1. Infectious Diseases, Intensivists, Pulmonology Services
  2. Treatment of HCAP/HAP/VAP infections due to documented or suspected multi-drug resistant gram positive organisms (MRSA, MRSE, and VRE) when vancomycin cannot be used.
  3. Treatment of complicated skin and skin structure infection due to documented or suspected multi-drug resistant gram-positive organisms (MRSA, MRSE, and VRE) when vancomycin cannot be used.
  4. Treatment of VRE urinary tract infections.

Meropenem (Merrem®)

  1. Infectious Diseases, Intensivists, Pulmonology Services
  2. Treatment of confirmed, suspected, or past infection with multi-drug resistant organisms including extended-spectrum β-lactamase (ESBL) producing organisms and as deemed appropriate per the Antimicrobial Stewardship Team.
  3. Treatment of meningitis or febrile neutropenia where a carbapenem is needed.

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
(Mycamine®)

  1. Infectious Diseases, Intensivists, Pulmonology Services
  2. Empiric treatment of candidemia in ICU patients with shock or new organ dysfunction.
  3. Empiric treatment of febrile neutropenia.
  4. Treatment of azole-resistant fungal infections.

Minocycline – IV only
(Minocin®)

  1. Infectious Diseases Service

Nitazoxanide (Alinia®)

  1. Infectious Diseases Service

Nitrofurantoin macrocrystals (Macrodantin)

  1. Restricted to patients requiring medication administration via feeding tube.
  2. Other order to be interchanged to Macrobid at the same dose with BID interval.

Oritavancin (Orbactiv®)

  1. Infectious Diseases Service

Pentamidine (Pentam®)

(IV formulation only)

  1. Infectious Diseases Service
  2. Use as an alternative agent to oral TMP-SMX for PJP prophylaxis in hematology/oncology patients

Peramivir (Rapivab®)

  1. Infectious Diseases, Intensivists Services
  2. Patient must be in an ICU level of care
  3. Cannot or suspect unable to absorb oral/enteral Tamiflu
  4. If initiated, therapy to be re-evaluated after 5 days

Quinupristin/dalfopristin
(Synercid®)

  1. Infectious Diseases Service
  2. Treatment of multi-drug resistant gram positive organisms where vancomycin, linezolid, daptomycin, and tigecycline cannot be used based on susceptibility and indication.

Tigecycline (Tygacil®)

*Should not be used to treat bacteremia, urinary tract, or Pseudomonas infections.

  1. Infectious Diseases, Intensivists Services
  2. Treatment of documented multi-drug resistant gram-negative infections sensitive to tigecycline.
  3. Treatment as a second- or third-line agent for skin and skin structure infections when first-line agents cannot be used.
  4. Treatment of intra-abdominal infections in a patient who cannot tolerate β-lactams and fluoroquinolones.

Voriconazole (VFend®)

  1. Infectious Diseases, Intensivists, Hematology/Oncology Services
  2. Treatment of fluconazole resistant candidiasis

 

 

Anti-infective Automatic Stops

DRUG

STOP PARAMETER

Azithromycin (Zithromax®)

5 days when used for treatment of acute respiratory infection

Oseltamivir (Tamiflu®)

5 days for non-critically ill patients
10 days for critically ill ICU patients

 

 

Anti-Retrovirals (HIV medications)

ORDERED

SUBSTITUTION

Stribild® - 1 tab*
(Cobicistat/elvitegravir/emtricitabine/
tenofovir disoproxil fumarate)

cobicistat/elvitegravir/emtricitabine/tenofovir alafenamide (Genvoya®) – 1 tab daily

Prezcobix® - 1 tab*
(Cobicistat/darunavir)

darunavir 800 mg + ritonavir 100 mg daily

Descovy (emtricitabine/tenofovir alfenamide)*

Emtricitabine:

CrCl  50 mL/min or greater 200mg q24h

          30-49 mL/min: 200mg q48h

          15-29 mL/min: 200mg q72h

        <15 mL/min or HD: 200mg q96h

-PLUS-

Tenofovir:

CrCl  50mL/min or greater 300mg q24h

          30-49 mL/min: 300mg q48h

          10-29 mL/min: 300mg twice weekly (every 72-96 hours)

           HD: 300mg q 7 days

Atripla®

efavirenz 600mg + emtricitabine 200mg

+ tenofovir 300mg daily

Truvada®

emtricitabine 200mg + tenofovir 300mg

Combivir®

lamivudine 150mg + zidovudine 300mg

Epzicom®

abacavir 600mg + lamivudine 300mg

Triumeq®

abacavir 600mg + lamivudine 300mg

+ dolutegravir 50mg

* Treat as Non-formulary, Specialty and only execute substitution if home med cannot be obtained.

 

Antifungals

Restricted 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

                              

 

Other Antifungals

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

 

 

 

Carbapenems

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.

 

 

 

Cephalosporins:

Oral Cephalosporins (First Generation)

Formulary: Cefadroxil (Duricef®)

ORDERED

SUBSTITUTION

Cephalexin (Keflex®) 250 mg q 6 hrs

Cefadroxil (Duricef®) 500 mg BID

Cephalexin (Keflex®) 500 mg q 6 hrs

Cefadroxil (Duricef®) 1000 mg BID

 

Injectable Cephalosporins (First Generation)

Cefazolin (Ancef®) is the only Injectable First Generation Cephalosporin currently on the market.

 

 

 

Oral Cephalosporins (Second Generation)

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

 

 

Oral Cephalosporins (Third Generation)

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
(ID may order Fortaz®)

Ceftazidime (Fortaz®) 2 gm Q 8 hrs

Cefepime (Maxipime®) 2 gm Q 12 hrs
(ID may order Fortaz®)

Ceftriaxone (Rocephin®) 1 gm Q 12 hrs

Ceftriaxone (Rocephin®) 2 gm Q 24 hrs
(Unless suspected meningitis/CNS infection,
or ordered by ID)

 

 

Cephalosporins (Fourth Generation)

Cefepime (Maxipime®) is the only Fourth Generation Cephalosporin on the market.
Cefepime dose will be adjusted according to renal function & indication as outlined in the table below.

 

 

 

Fluoroquinolones

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

 

 

 

Macrolides

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

 

Miscellaneous Antibiotics

Rifaximin (Xifaxin®)

ORDERED

SUBSTITUTION

Rifaximin (Xifaxin®)
(any dose ordered for hepatic encephalopathy)

Rifaximin (Xifaxin®) 550 mg BID
(when ordered for hepatic encephalopathy)

 

Metronidzole (Flagyl®)

ORDERED

SUBSTITUTION

Metronidazole (Flagyl®)
(any dose)

Metronidazole (Flagyl®) 500 mg IV/PO Q 8 hrs
(standard dose)

 

 

Oxazolidinones

ORDERED

SUBSTITUTION

Tedizolid (Sivextro®) 200 mg daily

Linezolid (Zyvox®) 600 mg BID

 

 

Vancomycin (Oral)

ORDERED

SUBSTITUTION

Vancomycin PO 250 mg

Vancomycin PO 125 mg

 

 

Penicillins

Oral 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® XR) 1000 mg/62.5 mg – 2 tabs BID
(total = 2000 mg amoxicillin + 125 mg clavulanate)

Augmentin® 875 mg/125 mg BID
+ amoxicillin 500 mg (2 caps) BID
(total = 1875 mg amoxicillin + 125 mg clavulanate)

 

 

Injectable Penicillins

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
(continuous infusion over 24 hrs)

Oxacillin 10-12 gm daily
(continuous infusion over 24 hrs)

*Piperacillin/tazobactam dose will be determined as outlined here

 

 

 

Tetracyclines

ORDERED

SUBSTITUTION

Tetracycline

Doxycycline 100 mg BID

 

 

ANTIHISTAMINES, DECONGESTANTS, ANTITUSSIVES, EXPECTORANTS

Cough/Cold Products

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
UDL = 25 mg/10ml

Antihistamine (non-sedating) + Decongestant

Loratadine 10 mg
(no decongestant provided)

Claritin 10 mg daily
(no decongestant provided)

Antihistamine (sedating) + Decongestant

Chlorpheniramine 4 mg + Pseudoephedrine 60 mg

Chlor-Trimeton 4 mg
+ Sudafed 60 mg Q 4-6 hours

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

Blood Factor Products for Inherited Bleeding Disorders

Hemophilia A (Factor VIII)

See preferred products & determination of
appropriate products to use and/or order.

Hemophilia B (Factor IX)

Von Willebrand Disease (vWF)

 

 

BIOLOGIC RESPONSE MODIFIERS

Colony Stimulating Factors

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®)
1:1 dose conversion

 

Long Acting ESA Interchange*

ORDERED

DISPENSE

Darbepoetin alfa (Aranesp®)
10 mcg/week or less

Epoetin alfa-epbx (Retacrit®)
2,000 units SC once a week

Darbepoetin alfa (Aranesp®)
10.5 to 24.5 mcg/week

Epoetin alfa-epbx (Retacrit®)
4,000 units SC once a week

Darbepoetin alfa (Aranesp®)
25 to 39.5 mcg/week

Epoetin alfa-epbx (Retacrit®)
4,000 units SC twice a week

Darbepoetin alfa (Aranesp®)
25 to 39.5 mcg/week

Epoetin alfa-epbx (Retacrit®)
8,000 units SC once a week

Darbepoetin alfa (Aranesp®)
40 to 59.5 mcg/week

Epoetin alfa-epbx (Retacrit®)
10,000 units SC once a week

Darbepoetin alfa (Aranesp®)
60 to 99.5 mcg/week

Epoetin alfa-epbx (Retacrit®)
20,000 units SC once a week

Darbepoetin alfa (Aranesp®)
100 mcg/week or more

Epoetin alfa-epbx (Retacrit®)
20,000 units SC three times a week

* Pharmacist to confirm with provider if a dose is required during hospital stay; if so, interchange per the above.

 

CARDIOVASCULAR AGENTS

Antilipemics

ORDERED

SUBSTITUTION

Colestipol (Colestid®)
2-6 gm daily or in divided doses

Cholestyramine for oral suspension
4 gm PO daily

Colestipol (Colestid®)
7-12 gm daily or in divided doses

Cholestyramine for oral suspension
4 gm PO BID

Colestipol (Colestid®)
13-16 gm daily or in divided doses

Cholestyramine for oral suspension
4 gm PO TID

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
(Lovaza®, Epanova®)

Omega-3-Acid Ethyl Esters (Promega®)

 

 

 

ACE Inhibitors

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

 

 

Angiotensin II Receptor Blockers (ARBs)

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*

 

 

Beta-Blockers

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

 

 

Bile Acid Sequestrants*

ORDERED

DISPENSE

Colesevelam (Welchol®)* Tab
Total daily dose

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.

 

Calcium Channel Blockers

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

 

 

Combination Cardiovascular Agents

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

 

 

Diuretics

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
(Maxzide-25®) 1 tab BID

Triamterene (Dyrenium®) tablet 100 mg

Triamterene/HCTZ 75/50 mg
(Maxzide-50®) 1 tab BID

 

 

 

HMG-CoA Reductase Inhibitors (Statins)

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

 

 

 

Phosphodiesterase Inhibitors

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).

 

 

 

 

DERMATOLOGICAL AGENTS

(Orders per dermatology will be dispensed as written or below substitution approved by dermatology prior to dispensing)

Topical Antifungals

ORDERED

SUBSTITUTION

Creams, aerosols, gels, lotions:
Miconazole (except Baza), ciclopirox, econazole, ketoconazole, naftifine, oxiconazole, sertaconazole, sulconazole, tioconazole, terconazolem, terbinafine, tolnaftate

Clotrimazole 1% cream

Vaginal creams, suppositories:
Miconazole, terconazole, tioconazole,
nystatin (vaginal tablet)

Miconazole 3 day (Monistat-3)
(suppository + cream combination)

Shampoos:
Ciclopirox

Ketoconazole 2% shampoo (Nizoral®)

The following items are also stocked, but are not substituted for other products:
Miconazole cream (Baza®), Clotrimazole troche, Nystatin powder, Nystatin cream

 

 

Topical Antifungal/Steroid Combinations

ORDERED

SUBSTITUTION

Betamethasone/clotrimazole (Lotrisone®)

(0.05/1% cream, lotion)

Nystatin/triamcinolone (Mycolog®)

(100,000 units/gm – 0.1% cream)

 

 

Topical Steroids

Topical Corticosteroids – Very High Potency

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)

 

 

Topical Corticosteroids – High Potency

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.

 

 

Topical Corticosteroids – Medium Potency

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.

 

 

Topical Corticosteroids – Low Potency

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®)
+
Hydrocortisone 2.5% ointment

*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.

 

Topical Antivirals

ORDERED

SUBSTITUTION

Acyclovir (Zovirax®)

Docosanol (Abreva®)

Penciclovir (Denavir®)

Docosanol (Abreva®)

 

 

Topical Estrogens

ORDERED

SUBSTITUTION

Estrogen conjugated (Premarin®) vaginal cream

Estradiol (Estrace®) 0.01% vaginal cream

 

 

GASTROINTESTINAL AGENTS

Chemotherapy Induced Nausea & Vomiting: Substitutions & Restrictions

ORDERED

SUBSTITUTION

Aprepitant (Cinvanti®) 130 mg IV

Fosaprepitant (Emend®) 150 mg IV x1

Aprepitant (Emend®) 125 mg,
80 mg x 2 PO

Fosaprepitant (Emend®) 150 mg IV x1

Netupitant/Palonosetron (Akynzeo®)
 300-0.5 mg PO

Inpatient: Fosaprepitant (Emend®) 150 mg IV x1
+ ondansetron 8 mg IV
Outpatient: Fosaprepitant (Emend®) 150 mg IV x1
+ palonosetron 0.25 mg IV

Rolapitant (VARUBI®) 180 mg PO

Fosaprepitant (Emend®) 150 mg IV x1

Rolapitant (VARUBI®) 166.5 mg IV

Fosaprepitant (Emend®) 150 mg IV x1

Palonosetron (Aloxi®) 0.25 mg IV
(inpatient only)

Ondansetron 8 mg IV Q24 hours x 3 days

Granisetron (Kytril®)

Restricted to use in oncology patients for the prevention/treatment of chemotherapy induced nausea/vomiting

Ondansetron (Zofran®)

No single IV dose shall exceed 16 mg.

*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.

 

 

Antacids

ORDERED

SUBSTITUTION

Maalox

Mylanta

Mint-O-Mag

MOM

Calcium Carbonate, Rolaids, etc.

Tums

 

 

Antidiarrheals

Loperamide (Imodium®) will be automatically held in
patients with pending or positive Clostridium difficile test.

 

 

Antimuscarinics

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

 

 

Antispasmodics

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
at same dose/interval

* Physician may order Levsin (hyoscyamine) and/or viscous lidocaine in addition to Mylanta if they wish for something more than plain antacid.

 

 

Gastrointestinal Enzymes

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
+
Zenpep® 5000 – 3 capsules

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
+
Zenpep® 5000 – 2 capsules

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

 

 

 

Histamine H2-Antagonists

ORDERED

SUBSTITUTION

Cimetidine (Tagamet®)
300 mg IV/PO daily
300 mg IV/ PO BID – 4XD
400 mg IV/PO BID

Famotidine (Pepcid®)
20 mg IV/PO daily
20 mg IV/PO BID*
20 mg IV/PO BID*

Ranitidine (Zantac®)
150 mg PO daily
150 mg PO BID
300 mg PO daily
50 mg IV daily
50 mg IV BID – TID

Famotidine (Pepcid®)
20 mg PO daily
20 mg PO BID*
40 mg PO daily
20 mg IV daily
20 mg IV BID*

Nizatidine (Axid®)
150 mg PO daily
150 mg PO BID
300 mg PO daily

Famotidine (Pepcid®)
20 mg PO daily
20 mg PO BID*
40 mg PO daily

* 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

 

 

Laxatives

MEDICATION

STATUS

Docusate (Surfak®) 240 mg

Docusate (Colace®) 200 mg

 

 

Mesalamine Products
(Delzicol®, Lialda® and Pentasa® are formulary products)

ORDERED

SUBSTITUTION

Mesalamine (Asacol®) 400 mg
(discontinued by manufacturer)

Mesalamine (Delzicol®) 400 mg

Mesalamine (Apriso®) 375 mg

(usual dose = 1500 mg once daily)

Mesalamine (Delzicol®) 400 mg
(For once daily Apriso® doses, divide total daily dose into 4XD dosing:
Apriso 1500 mg daily = Delzicol 400 mg 4XD)

 

 

Restriction: Peripheral-acting Opioid Antagonists

MEDICATION

STATUS

Alvimopan (Entereg®)

Only for open partial large or small bowel resections OR hand assisted laparoscopic colon resections. (See PSO #2211)
12 mg PO BID only until FIRST FLATUS or a maximum of 14 doses, then discontinue.

Methylnatrexone (Relistor®)

No longer restricted per P&T April 2016.
Pharmacy will automatically discontinue upon first sign of flatus or bowel movement.
See substitution to Movantik outlined below.

Naloxegol (Movantik®)

Use generally recommended in the following populations:
- Patients taking Movantik prior to admission for OIC.
- Patients receiving chronic (> 4 weeks) opioid therapy with failure to respond to oral and rectal laxative therapy.
- Candidates for SQ Relistor for OIC but who can tolerate oral therapy.

 

 

Substitutions: Peripheral-acting Opioid Antagonists

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®)
weight-based dosing (0.15 mg/kg SC)*
Weight-based dose < 12 mg SC
Weight-based dose ≥ 12 mg SC

Naloxegol (Movantik®) 12.5 mg PO same frequency**
Naloxegol (Movantik®) 25 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.

 

 

Probiotics

ORDERED

SUBSTITUTION

All probiotics (Lactinex, Culturelle, Bacid, etc.)

Saccharomyces Boulardii (Florastor®)
1 capsule PO BID

 

 

Proton Pump Inhibitors (PPIs)

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:
Protonix 40 mg IV at same interval
(if no IV access, pharmacy will compound omeprazole suspension for tube/oral administration;
key using non-formulary entry)

Pantoprazole (Protonix® Suspension)

If unable to take oral Protonix:
Protonix 40 mg IV at same interval
(if no IV access, pharmacy will compound omeprazole suspension for tube/oral administration;
key using non-formulary entry)

Esomeprazole (Nexium® Suspension)

If unable to take oral Protonix:
Protonix 40 mg IV at same interval
(if no IV access, pharmacy will compound omeprazole suspension for tube/oral administration;
key using non-formulary entry)

* Lansoprazole may be used for any patient intolerant of pantoprazole.
**Duplication of acid suppression therapy to be avoided as outlined below

 

 

Acid suppression therapy – therapeutic duplications

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).

Note: This does not apply to the single dose of famotidine from the pre-anesthesia orders or to patients receiving both H2RA and PPI as home medications.

 

 

 

Suppositories

ORDERED

SUBSTITUTION

Starch topical
(Tucks® or plain Anusol® suppositories)

Hydrocortisone suppository (Anusol HC®)

 

 

GENITOURINARY AGENTS

Bladder Antiseptics

ORDERED

SUBSTITUTION

Methenamine mandelate (Mandelamine®) 1 gm 4 times daily

Methenamine hippurate (Hiprex®) 1 gm BID

 

 

Bladder Antispasmodics

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
(if CrCl < 30 ml/min, 20 mg daily)

Fesoterodine (Toviaz®) 4-8 mg daily

Trospium IR (Sanctura®) 20 mg BID
(if CrCl < 30 ml/min, 20 mg daily)

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
(if CrCl < 30 ml/min, 20 mg daily)

Tolterodine (Detrol®) 1-2 mg BID

Trospium IR (Sanctura®) 20 mg BID
(if CrCl < 30 ml/min, 20 mg daily)

Tolterodine ER (Detrol LA®) 2-4 mg daily

Trospium IR (Sanctura®) 20 mg BID
(if CrCl < 30 ml/min, 20 mg daily)

Trospium ER (Sanctura XR®) 60 mg daily

Trospium IR (Sanctura®) 20 mg BID
(if CrCl < 30 ml/min, 20 mg daily)

Trospium IR (Sanctura®) 20 mg BID

** FORMULARY **

 

 

BPH Agents

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

 

 

Urinary Analgesics

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

Estradiol Transdermal Systems

ORDERED

SUBSTITUTION

Estradiol (Climara®)
0.025 mg apply once weekly
0.0375 mg apply once weekly
0.05 mg apply once weekly
0.06 mg apply once weekly
0.075 mg apply once weekly
0.1 mg apply once weekly

Estradiol (Vivelle Dot®, Alora®)
0.025 mg apply twice weekly
0.0375 mg apply twice weekly
0.05 mg apply twice weekly
0.05 mg apply twice weekly
0.075 mg apply twice weekly
0.1 mg apply twice weekly

Estradiol (Menostar®)
14 mcg apply once weekly

Estradiol (Vivelle Dot®)
0.025 mg apply twice weekly

 

 

 

Megestrol (Megace®)

ORDERED

SUBSTITUTION

Megestrol (Megace ES®) 625 mg/5ml

Megestrol (Megace®) 800 mg/20 ml

 

 

Synthetic Glucocorticoids

ORDERED

SUBSTITUTION

Prednisolone tablet or liquid*

Methylprednisolone tablet at 20% dose reduction

* Prednisolone liquid stock will only be kept for pediatric patient use.

 

 

MISCELLANEOUS

Restriction: Bisphosphonates

All bisphosonates (e.g. Fosamax®, Boniva®, etc.) are
non-formulary and will not be continued during hospitalization.
(safety issue – risk of erosive esophagitis if patient reclines after taking tablet)

 

 

Calcium Modifiers

ORDERED

SUBSTITUTION

Doxercalciferol (Hectorol®) 0.5 mg

Paricalcitol (Zemplar®) 1 mg

IV Zemplar, IV Hectorol are both non-formulary;
call MD and suggest calcitriol injection as alternative

Calcitonin injection – see Calcitonin Guidance Summary
for information regarding appropriate use & treatment alternatives

 

 

Immunoglobulin Restrictions

DRUG

RESTRICTION(S)

IVIG (Octagam®)

Chief of Neurology (Dr. Kodsi) to perform an independent physician review of all inpatient orders for IVIG from neurology.

 

 

Miscellaneous Restrictions

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.

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:

·         The patient is currently on and compliant with GDMT appropriate to his/her disease state(s) and has indications for additional therapy

·         eGFR is >/= 45 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).

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 mIU/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.

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.

 

 

Medications Not Approved for Outpatient Formulary
The below drugs have been reviewed by P&T and specifically designated as non-formulary.

Certolizumab pegol (Cimzia®)

Inotuzumab ozogamicin (Besponsa®)

IV Immunoglobulin (Privigen®)

Netupitant/Palonosetron (Akynzeo®)

Reslizumab (Cinqair®)

Rituximab and Hyaluronidase (Rituxan Hycela®)

Rolapitant (Varubi®)

Trastuzumab and Hyaluronidase (Herceptin Hylecta®)

 

 

Therapeutic Restrictions to Outpatient Locations
The below drugs will require supervisor approval for any and all inpatient uses not specifically outlined below.

MEDICATION

STATUS

Abatacept (Orencia®)

Approved for outpatient use only

Adalimumab (Humira®)

Approved for outpatient use only

Ado-trastuzumab (Kadcyla®)

Approved for outpatient use only

Atezolizumab (Tecentriq®)

Approved for outpatient use only

Avelumab (Bavencio®)

Approved for outpatient use only

Belimumab (Benlysta®)

Approved for outpatient use only

Benralizumab (Fasenra®)

Approved for outpatient use only

Bevacizumab (Avastin®)

Restricted to outpatient use only if bevacizumab biosimilar not available or payor-approved

Bevacizumab-awwb (Mvasi®)

Approved for outpatient use only

Blinatumomab (Blincyto®)

Approved for outpatient use and restricted to inpatient use for Cycles 1 and 2 according to package insert

Brentuximab vedotin (Adcetris®)

Approved for outpatient use only

C1 Inhibitor, Human (Cinryze®)

Approved for outpatient use only (Inpatient orders should be approved by management on a case-by-case basis)

Carfilzomib (Kyprolis®)

Approved for outpatient use only

Cemiplimab-rwlc (Libtayo®)

Approved for outpatient use only

Cetuximab (Erbitux®)

Approved for outpatient use only

Daratumumab (Darzalex®)

Approved for outpatient use only

Darbepoetin alfa (Aranesp®)

Restricted to outpatient use for patients with non-myeloid malignancy and chemo induced anemia whose treatment is not curative.

For inpatients, see interchange to Retacrit.

Denosumab (Prolia®)

Only used for outpatient if CrCl less than 35 mL/min

Denosumab (Xgeva®)

Only used for outpatient if CrCl less than 30 mL/min

Durvalumab (Imfinzi®)

Approved for outpatient use only

Eculizumab (Soliris®)

Approved for outpatient use and restricted to inpatient use for atypical HUS when outpatient treatment is not clinically appropriate  (Inpatient orders should be approved by management on a case-by-case basis)

Epoetin Alfa (Procrit®)

Formulary restricted to outpatient use only if epoetin alfa biosimilar is not available or payor-approved

Epoetin Alfa (Retacrit®)

Formulary agent for all inpatient use. Preferred agent for all outpatient use.

Eptinezumab (Vyepti®)

Approved for the outpatient setting for FDA-approved indications or payor-approved off-label indications subsequent to insurance approval or prior authorization.

Eribulin (Halaven®)

Approved for outpatient use only

Fexofenadine (Allegra®)

Restricted to outpatient use only as pre-medication for infusions

Fulvestrant (Faslodex®)

Approved for outpatient use only

Gemtuzumab ozogamicin (Mylotarg®)

Approved for outpatient use and restricted to inpatient use for induction therapy

Golimumab (Simponi ARIA®)

Approved for outpatient use only

Goserelin (Zoladex®)

Approved for outpatient use only

Ibandronate (Boniva®)

Approved for outpatient use only

Infliximab (Remicade®)

Restricted to outpatient use only if infliximab biosimilar not available or payor-approved

Infliximab-dyyb (Inflectra®)

Approved for outpatient use only (Inpatient orders should be approved by management on a case-by-case basis)

Ipilimumab (Yervoy®)

Approved for outpatient use only

IV Immunoglobulin (Gamunex C®)

Formulary restricted to patients who do not tolerate Octagam

IV Immunoglobulin (Octagam®)

Formulary preferred agent for all inpatient and outpatient IVIG

IV Iron Products (INFeD®, Feraheme®)

See injectable iron products

Ixabepilone (Ixempra®)

Approved for outpatient use only

Leuprolide (Eligard®)

Formulary preferred agent. Approved for outpatient use only (Inpatient orders should be approved by mangement on a case-by-case basis)

Leuprolide (Lupron®)

Non-formulary product. Request change to Eligard from provider

Liposomal daunorubicin-cytarabine (Vyxeos®)

Approved for outpatient use and restricted to inpatient use for induction therapy

Lurbinectedin (Zepzelca®)

Approved for outpatient use only for FDA-approved indications or payer-approved off-label subsequent to insurance approval or prior authorization.

Mepolizumab (Nucala®)

Approved for outpatient use only

Natalizumab (Tysabri®)

Approved for outpatient use only

Necitumumab (Portrazza®)

Approved for outpatient use only

Nivolumab (Opdivo®)

Approved for outpatient use only

Obinutuzumab (Gazyva®)

Approved for outpatient use only

Ocrelizumab (Ocrevus®)

Approved for outpatient use only

Octreotide (Sandostatin LAR®)

Approved for outpatient use only

Ofatumumab (Arzerra®)

Approved for outpatient use only

Omalizumab (Xolair®)

Approved for outpatient use only

Paclitaxel, Albumin-bound (Abraxane®)

Approved for outpatient use only

Palonosetron (Aloxi®)

Restricted to outpatient use for patients who are refractory to formulary preferred 5-HT3 antagonists for chemo induced N/V. Not approved for use in bariatric surgery

Panitumumab (Vectibix®)

Approved for outpatient use only

Pegfilgrastim (Neulasta®)

Restricted to outpatient use only if pegfilgrastim biosimilar not available or payor-approved

Pegfilgrastim-jmdb (Fulphila®)

Approved for outpatient use only (Inpatient orders should be approved by management on a case-by-case basis)

Pembrolizumab (Keytruda®)

Approved for outpatient use only

Pertuzumab (Perjeta®)

Approved for outpatient use only

Ramucirumab (Cyramza®)

Approved for outpatient use only

Rituximab (Rituxan®)

Restricted to outpatient use only if rituximab biosimilar not available or payor-approved

Rituximab-abbs (Truxima®)
Rituximab-pvvr (Ruxience®)
Rituximab-arrx (Riabni®)

Approved for outpatient use only

Temsirolimus (Torisel®)

Approved for outpatient use only

Tocilizumab (Actemra®)

Approved for outpatient use only

Trastuzumab (Herceptin®)

Restricted to outpatient use only if trastuzumab biosimilar not available or payor-approved

Trastuzumab (Kanjinti®)

Approved for outpatient use only

Varicella-zoster (Shingrix®) vaccine

Approved for outpatient use only

Vedolizumab (Entyvio®)

Approved for outpatient use only

Zoledronic Acid (Reclast®)

Approved for outpatient use only

Zoledronic Acid (Zometa®)

Approved for outpatient use only. For inpatient doses, request MD change to pamidronate (Aredia®)

 

 

 

 

OPHTHALMICS & OTICS

 

Antihistamines

ORDERED

SUBSTITUTION

Azelastine (Optivar®)
1 drop in each eye twice daily

Ketotifen (Zaditor®)
1 drop in each eye twice daily

Epinastine (Elestat®)
1 drop in each eye twice daily

Ketotifen (Zaditor®)
1 drop in each eye twice daily

Lodoxamide (Alomide®)
1-2 drops in each eye 4XD

Ketotifen (Zaditor®)
1 drop in each eye twice daily

Olopatadine (Patanol®) 0.1%
1 drop in each eye twice daily

Ketotifen (Zaditor®)
1 drop in each eye twice daily

Olopatadine (Patanol®, Pataday®) 0.2%
1 drop in each eye once daily

Ketotifen (Zaditor®)
2 drops in each eye twice daily

Emedastine (Emadine®)
1 drop in each eye four times daily

Ketotifen (Zaditor®)
1 drop in each eye twice daily

 

 

Anti-infective Ophthalmic Agents

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®)
ophthalmic suspension

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

 

 

 

Glaucoma Agents

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

 

 

Miscellaneous Ophthalmics

ORDERED

SUBSTITUTION

Cyclosporine 0.05% ophthalmic emulsion (Restasis)

Instill 1 drop into affected eye(s) BID

Artificial tears 1.4% ophthalmic drops

1-2 drops into affected eye(s) TID and as needed

 

 

Miscellaneous Otics

ORDERED

SUBSTITUTION

Neomycin/polymyxin B/hydrocortisone
Otic Suspension
(Cortisporin Otic®)

Neomycin/polymyxin B/dexamethasone
Ophthalmic solution for OTIC use
(Maxitrol Ophthalmic®)

Ofloxacin 0.3% Otic
(Floxin Otic®)

Ciprofloxacin ophthalmic 0.3%
ophthalmic solution for OTIC use
(Cipro Ophthalmic®)

 

 

Prostaglandin Analogs

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

 

 

 

Non-Steroidal Anti-Inflammatories (NSAIDs)

ORDERED

SUBSTITUTION

Bromfenac (Xibrom®) ophthalmic

Ketorolac (Acular®) 0.5% ophthalmic
1 drop 4 times daily

Diclofenac (Voltaren®) ophthalmic

Ketorolac (Acular®) 0.5% ophthalmic
1 drop 4 times daily

Flurbiprofen (Ocufen®) ophthalmic

Ketorolac (Acular®) 0.5% ophthalmic
1 drop 4 times daily

Nepafenac (Nevanac®) ophthalmic

Ketorolac (Acular®) 0.5% ophthalmic
1 drop 4 times daily

 

 

PSYCHOTROPIC AGENTS

Alzheimer’s Agents

ORDERED

SUBSTITUTION

Donepezil (Aricept®) 23 mg daily

Donepezil (Aricept®) 20 mg daily

Memantine (Namenda XR®) 7 mg daily

Memantine (Namenda®) 5 mg daily
(standard formulation)

Memantine (Namenda XR®) 14 mg daily

Memantine (Namenda®) 5 mg BID
(standard formulation)

Memantine (Namenda XR®) 21 mg daily

Memantine (Namenda®) 10 mg BID
(standard formulation)

Memantine (Namenda XR®) 28 mg daily

Memantine (Namenda®) 10 mg BID
(standard formulation)

 

Antidepressants

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

ORDERED

SUBSTITUTION

Desvenlafaxine (Pristiq®) 50 mg daily

Venlafaxine (Effexor XR®) 75 mg daily

Desvenlafaxine (Pristiq®) 100 mg daily

Venlafaxine (Effexor XR®) 150 mg daily

 

 

Selective Serotonin Reuptake Inhibitors (SSRIs)

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

 

 

Tricyclic Antidepressants

ORDERED

SUBSTITUTION

Imipramine pamoate (Tofranil-PM®)

(capsule)

Imipramine (Tofranil®)

(tablet) – give in divided doses

 

 

Combination Products

ORDERED

SUBSTITUTION

Olanzapine/fluoxetine 3/25 mg
(Symbyax® 3/25 mg)

Olanzapine 2.5 mg + fluoxetine 20 mg

Olanzapine/fluoxetine 6/25 mg
(Symbyax® 6/25 mg)

Olanzapine 5 mg + fluoxetine 20 mg

Olanzapine/fluoxetine 12/25 mg
(Symbyax® 12/25 mg)

Olanzapine 12.5 mg + fluoxetine 20 mg

Olanzapine/fluoxetine 6/50 mg
(Symbyax® 6/50 mg)

Olanzapine 5 mg + fluoxetine 50 mg

Olanzapine/fluoxetine 12/50 mg
(Symbyax® 12/50 mg)

Olanzapine 12.5 mg + fluoxetine 50 mg

 

 

Antipsychotics

ORDERED

SUBSTITUTION

Quetiapine (Seroquel XR®)

Quetiapine (Seroquel®)
Substitute on a 1:1 mg basis – give as single daily dose

Paliperidone (Invega®)

Non-formulary. Patient may use own med.
Recommend change to Risperidone for new starts.

Brexpiprazole (Rexulti®) 1 mg
Brexpiprazole (Rexulti®) 2 mg
Brexpiprazole (Rexulti®) 3 mg
Brexpiprazole (Rexulti®) 4 mg

Aripiprazole (Abilify®) 5 mg
Aripiprazole (Abilify®) 10 mg
Aripiprazole (Abilify®) 15 mg
Aripiprazole (Abilify®) 20 mg

 

 

CNS Stimulants

ORDERED

SUBSTITUTION

Armodafinil (Nuvigil®) 50 mg daily

Modafinil (Provigil®) 100 mg daily

 

 

 

RESPIRATORY AGENTS

Beta-agonists (SABA & LABA)

ORDERED

SUBSTITUTION

Formoterol (Foradil®)
1 inhalation (12 mcg) twice daily

Arformoterol (Brovana®)
15 mcg via neb twice daily

Formoterol (Perforomist®)

Arformoterol (Brovana®)
15 mcg via neb twice daily

Indacaterol (Arcapta® Neohaler)
1 inhalation (75 mcg) once daily

Arformoterol (Brovana®)
15 mcg via neb twice daily

Levalbuterol (Xopenex®)

Albuterol

Olodaterol (Striverdi Respimat®)
2 inhalations (5 mcg) once daily

Arformoterol (Brovana®)
15 mcg via neb twice daily

Salmeterol (Serevent Diskus®)
1 inhalation (50 mcg) twice daily

Arformoterol (Brovana®)
15 mcg via neb twice daily

 

 

 

Short-acting Antimuscarinics (SAMA)

ORDERED

SUBSTITUTION

Ipratropium (Atrovent MDI®)
2 sprays inhaled 2-4 times daily

Ipratropium nebulizer solution
0.5 mg via neb at same frequency

 

 

 

Long-acting Antimuscarinics (LAMA)

ORDERED

SUBSTITUTION

Tiotropium (Spiriva Handihaler®)
18 mcg (1 cap) once daily via oral inhalation

Tiotropium (Spiriva Respimat®)
5 mcg (2 puffs) via oral inhalation once daily

Aclidinium (Tudorza®)
400 mcg twice daily via oral inhalation

Tiotropium (Spiriva Respimat®)
5 mcg (2 puffs) via oral inhalation once daily

Glycopyrrolate (Seebri Neohaler®)
15.6 mcg (1 cap) via oral inhalation twice daily

Tiotropium (Spiriva Respimat®)
5 mcg (2 puffs) via oral inhalation once daily

Umeclidinium (Incruse Ellipta®)
62.5 mcg (1 puff) via oral inhalation once daily

Tiotropium (Spiriva Respimat®)
5 mcg (2 puffs) via oral inhalation once daily

Revefenacin (Yupelri®)175mcg via
175mcg via nebulization once daily

Tiotropium (Spiriva Respimat®)
5 mcg (2 puffs) via oral inhalation once daily

Note: When tiotropium (Spiriva Respimat®) is ordered for a patient currently on ipratropium (Atrovent®), the Atrovent® will automatically be discontinued per protocol.

 

 

 

Short-acting Beta-Agonists/Short-acting Antimuscarinics (SABA/SAMA)

ORDERED

SUBSTITUTION

Ipratropium/albuterol (Combivent MDI®)
2 inhalations four times daily

Ipratropium/albuterol (Duoneb®)
1 nebulization four times daily

Ipratropium/albuterol (Combivent Respimat®)
1 inhalation four times daily

COVID(+) patients who have underlying COPD or asthma
and do not require ventilation*:

Albuterol sulfate (Ventolin HFA®) 1 puff at same frequency
+
Ipratropium bromide (Atrovent HFA®) 1 puff at same frequency

 

COVID (+) patients who have underlying COPD or asthma
and are ventilated:

Ipratropium/albuterol (Duoneb®)
1 nebulization four times daily

 

COVID (-) patients:

Ipratropium/albuterol (Duoneb®)
1 nebulization four times daily

 

 

 

Long-acting Beta-Agonists/Long-acting Anticholinergics (LABA/LAMA)

ORDERED

SUBSTITUTION

Glycopyrrolate/indacaterol (Utibron Neohaler®)
15.6 mcg/27.5 mcg (1 cap) via oral inhalation twice daily

Tiotropium/olodaterol (Stiolto Respimat®)
5 mcg/5 mcg (2 puffs) via oral inhalation once daily

Umeclidinium/vilanterol (Anoro Ellipta®)
62.5 mcg/25 mcg (1 puff) via oral inhalation once daily

Tiotropium/olodaterol (Stiolto Respimat®)
5 mcg/5 mcg (2 puffs) via oral inhalation once daily

Glycopyrrolate/formoterol (Bevespi Aerosphere®)
18 mcg/9.6 mcg (2 inhalations)

Tiotropium/olodaterol (Stiolto Respimat®)
5 mcg/5 mcg (2 puffs) via oral inhalation once daily

Note: When tiotropium (component of Stiolto Respimat®) is ordered for a patient currently on ipratropium (Atrovent®), the Atrovent® will automatically be discontinued per protocol.

 

 

 

Inhaled Corticosteroids (ICS) - HFA

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®)
100 mcg/day

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

 

 

 

Inhaled Corticosteroid/Beta-agonist Combination (ICS/LABA)

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

 

 

Leukotriene Antagonists

ORDERED

SUBSTITUTION

Zafirlukast (Accolate®)

Montelukast (Singulair®) 10 mg daily

 

 

 

Long-acting Beta-agonist/Long-acting Antimuscarinic/Inhaled Corticosteroid (LABA/LAMA/ICS)

ORDERED

SUBSTITUTION

Vilanterol/umeclidinium/fluticasone (Trelegy Ellipta®)
25 mcg/62.5 mcg/ 100 mcg – 1 inhalation daily

Tiotropium/olodaterol (Stiolto Respimat®)
5 mcg/5 mcg (2 puffs) via oral inhalation once daily
PLUS
Mometasone HFA (Asmanex)

200mcg /inhalation - 2 inhalations BID

Budesonide/glycopyrrolate/formoterol (Breztri Aerosphere®)

160 mcg/9 mcg/4.8 mcg – 2 actuations twice daily

Tiotropium/olodaterol (Stiolto Respimat®)
5 mcg/5 mcg (2 puffs) via oral inhalation once daily
PLUS
Mometasone HFA (Asmanex)

200mcg /inhalation - 2 inhalations BID

Note: When tiotropium (component of Stiolto Respimat®) is ordered for a patient currently on ipratropium (Atrovent®), the Atrovent® will automatically be discontinued per protocol.

 

 

 

Methylxanthines

ORDERED

SUBSTITUTION

Theophylline ER BID (non-24 hour formulations)
Theophylline ER 200 mg BID
Theophylline ER 300 mg BID

Theo-24 (total daily dose or ER product ONCE Daily)
Theo-24 400 mg DAILY*
Theo-24 600 mg 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.

 

 

 

Nasal Corticosteroids

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

Sedative/Hypnotics for Sleep

ORDERED

SUBSTITUTION

Ramelteon (Rozerem®) 8 mg

Melatonin® 3 mg

Zaleplon (Sonata®) 5 mg

Zolpidem (Ambien®) 5 mg

Zaleplon (Sonata®) 10 mg

Zolpidem (Ambien®) 5 mg

Triazolam (Halcion®) 0.25 mg

Zolpidem (Ambien®) 5 mg

Eszopiclone (Lunesta®) 1 mg

Zolpidem (Ambien®) 2.5 mg

Eszopiclone (Lunesta®) 2 mg

Zolpidem (Ambien®) 5 mg

Eszopiclone (Lunesta®) 3 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

 

 

 

VITAMINS/SUPPLEMENTS

Vitamins/Supplements

ORDERED

SUBSTITUTION

Beta-carotene multivitamin (Ocuvite®, PreserVision®)

Multivitamin (MVI)
(no minerals)

Ferrous fumarate (Ferro-Sequels®)

Ferrous Sulfate 300/325 mg
(contains 65 mg elemental iron)

Ferrous sulfate (Slow FE®) 160 mg
(contains 50 mg elemental iron)

Ferrous Sulfate 300/325 mg (one-for-one)
(contains 65 mg elemental iron)

Ferrous gluconate

Ferrous sulfate 300/325 mg

Ferrous sulfate & ascorbic acic
(Ferro-Grad 500)

Ferrous sulfate 300/325 mg

Folic acid, cyanocobalamin, pyridoxine
(Foltx®)

Folic acid 1 mg

Levomefolate, mecobalamin, pyridoxal-5-phosphate
(Metanx®)

Folic acid 1 mg

Cerefolin

Folic acid 1 mg

Vitamin B complex, vitamin C, biotin, folic acid
(Diatx®)

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)
(no minerals)

Multivitamin with minerals, no iron (Eldertonic®)

Multivitamin liquid (MVI)
(no minerals)

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

 

 

 

INPATIENT Injectable Iron Products

ORDERED

SUBSTITUTION

Iron dextran (INFeD®)

Formulary product; drug of choice for single dose iron replenishment

Iron sucrose (Venofer®) 100 mg

Sodium ferric gluconate complex
(Ferrlecit®/Nulecit®) 125 mg

Iron sucrose (Venofer®) 200 mg

Sodium ferric gluconate complex
(Ferrlecit®/Nulecit®) 250 mg

Sodium ferric gluconate complex (Ferrlecit®/Nulecit®)

Inpatient use only

Ferumoxytol (Feraheme®)

Outpatient use only

 

 

 

OUTPATIENT Injectable Iron Products
No automatic therapeutic substitutions – call physician to obtain new orders if necessary

ORDERED

STATUS

Ferumoxytol (Feraheme®)

Approved for outpatient use

Iron dextran (INFeD®)

Approved for outpatient use

Sodium ferric gluconate complex (Ferrlecit®/Nulecit®)

Inpatient use only

 

Pharmacy Phone Numbers
Memorial Pharmacy (Glenwood) 423-495-8380
Memorial Hixson Pharmacy 423-495-7137
Stat 423-495-7470
Outpatient 423-495-8981
Chemo 423-495-7475
Surgery 423-495-8779

This site is intended for the staff of Memorial Health Care System.
While others may view accessible pages, Memorial Health Care System makes no warranty, express or implied,
as to the use of this information outside of Memorial Health Care System.