Drug Explorer

Indication

Adjunct to PCI for selected high-risk lesio…

Dose

Bolus **0.25 mg/kg** + infusion per cath lab protocol (verify vial)

Warning

- **Thrombocytopenia** - **Access site and systemic bleeding** with heparin - Hypersensitivity (chimeric protein)

Indication

Altitude sickness · Glaucoma · …

Dose

STANDARD: Indication-specific dosing (see product labeling and pathway) Onset: hours (context-dependent)

Warning

- Causes metabolic acidosis (mechanism-based) - Hypokalemia risk - Sulfonamide-related reactions - Renal stones - Avoid in severe hepatic disease (risk of encephalopathy)

Indication

Otitis externa · Topical antimicrobial use · …

Dose

STANDARD: Use appropriate concentration depending on indication Onset: local effect

Warning

- Concentration-dependent toxicity - Can cause irritation or chemical injury if misused - Not for systemic infection - Avoid in perforated tympanic membrane

Indication

Paracetamol/acetaminophen overdose · Mucolytic therapy · …

Dose

Paracetamol overdose: protocol-based IV or oral regimen (weight-based, staged) Onset: most effective when started early; may still be indicated late in high-risk or toxic cases per guidance

Warning

- Start early in paracetamol overdose — do not delay while waiting if high-risk - Late presentation may still benefit → toxicology / poison center guidance - IV reactions can mimic allergy but are often anaphylactoid - Dosing is protocol-based and weight-dependent

Indication

Chronic gout (urate lowering) · Recurrent gout flares · …

Dose

Start low (e.g., 100 mg PO daily) Lower starting dose in CKD Titrate gradually on serum uric acid

Warning

- Allopurinol hypersensitivity syndrome (AHS) → life-threatening (rash, systemic involvement) - Start low and titrate slowly (especially renal impairment) - NOT an acute gout pain treatment - Initiation can trigger gout flare → prophylaxis often required - Stop immediately if rash develops

Indication

MDR gram-negative infection as part of spec… · MDR-TB regimen component under public healt… · …

Dose

15–20 mg/kg IV daily (MDR GNR) — **highly protocol-specific**; TB doses lower and less frequent

Warning

- Nephrotoxicity + ototoxicity — higher doses in MDR regimens → aggressive monitoring - Do not confuse **TB intermittent dosing** with **sepsis daily dosing** - Synergy nephrotoxicity with vancomycin / colistin / contrast - Pregnancy: fetal ototoxicity systemic use

Indication

Ventricular arrhythmias (VT, VF) · Atrial fibrillation · …

Dose

IV (acute/ICU): e.g., 150 mg IV over 10 min (protocol) → infusion per protocol PO (chronic): loading phase (high-dose) → maintenance (lower daily dose) — institution-specific

Warning

- Multi-organ toxicity (thyroid, liver, lung) - Very long half-life → effects persist for weeks–months - QT prolongation (torsades risk lower than other agents but still relevant) - Major drug interactions (warfarin, digoxin, many others) - IV use → hypotension / bradycardia risk - Pulmonary toxicity can be fatal

Indication

Hypertension · Chronic stable angina · …

Dose

PO START 2.5–5 mg daily; titrate gradually.

Warning

- Edema is common and dose-limiting - Not a rate-control drug

Indication

Acute otitis media · Streptococcal pharyngitis · …

Dose

Mild–moderate: 500 mg TID • Severe: 875 mg BID or 1 g TID

Warning

• Anaphylaxis → immediate IM epinephrine (life-threatening) • EBV infection → high risk of rash (misdiagnosis trap) • β-lactamase organisms → treatment failure unless inhibitor used • Avoid empiric use in high-resistance settings

Indication

Primary: ABRS, AOM, CAP (mild–moderate), bi… · Secondary: COPD exacerbation, UTI, diabetic… · …

Dose

875/125 mg PO q12h or 500/125 mg PO q8h — Severe infection: 875/125 mg q8h or 2000/125 mg ER q12h (monitor total clavulanate exposure)

Warning

Penicillin hypersensitivity / anaphylaxis risk • Clavulanate-associated cholestatic hepatitis (delayed onset up to 6 weeks) • Avoid excessive clavulanate dosing (hepatotoxicity risk) • Warfarin interaction — monitor INR

Indication

Primary: Listeria meningitis ; neonatal sep… · Secondary: Endocarditis → combination thera… · …

Dose

Meningitis / severe CNS: 2 g IV q4h (≈12 g/day — REQUIRED for CNS penetration) Standard IV: 1–2 g q4–6h PO (mild / step-down): 250–500 mg q6h — empty stomach PO NOT appropriate for meningitis, bacteremia, endocarditis, or neonatal sepsis

Warning

- Penicillin hypersensitivity (anaphylaxis risk) - Listeria meningitis / enterococcal endocarditis / selected serious enterococcal infection: MUST combine with gentamicin (synergy) — monotherapy → treatment failure risk - Meningitis, bacteremia, neonatal sepsis, endocarditis: IV only (PO inadequate) - Not reliable empirically for β-lactamase producers (e.g., many E. coli, H. influenzae, S. aureus) - Seizures: renal failure or high dose (β-lactam neurotoxicity) - Crystalluria → renal injury - EBV-associated rash (high likelihood)

Indication

Primary: Aspiration pneumonia; community-ac… · Secondary: Diabetic foot infection; hepatic… · …

Dose

IV 1.5–3 g q6h (combined product; severe infections: 3 g q6h)

Warning

- Penicillin hypersensitivity (anaphylaxis risk) - Hepatotoxicity (cholestatic pattern) - CDAD risk - No Pseudomonas coverage (avoid misuse) - Do NOT mix with aminoglycosides (IV inactivation)

Indication

Non-valvular atrial fibrillation — stroke p… · Treatment of DVT/PE and reduction in risk o… · …

Dose

5 mg BID vs **2.5 mg BID** if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5; **CrCl 15–29** often 2.5 mg BID for AF

Warning

- **Bleeding** — no routine monitoring; rely on renal function, age, weight, interactions - Strong **CYP3A4 + P-gp** dual inhibitors/inducers → major exposure changes — dose adjust or avoid - Neuraxial anesthesia → ASRA timing windows

Indication

Prophylaxis/treatment of thrombosis in HIT · PCI with HIT (specialized centers)

Dose

IV infusion **mcg/kg/min** — titrate **aPTT** 1.5–3× baseline per protocol

Warning

- **Bleeding** — especially with other anticoagulants - **Hepatic impairment** → major dose reduction - Transition overlap to warfarin — argatroban prolongs INR (interpretation nuance)

Indication

**Secondary prevention** — **standard of ca… · **Primary prevention** — **NOT routine**; o… · …

Dose

Secondary prevention often **75–100 mg daily**; ACS loading **160–325 mg** chewable (then maintenance per pathway)

Warning

- **GI bleed** and **ICH** — dose-dependent and interaction-dependent - **Reye syndrome** — children/teenagers with viral illness - Allergy / asthma / nasal polyps — **salicylate sensitivity**

Indication

Hypertension · Atrial fibrillation — **rate control** · …

Dose

**PO:** **25–50 mg daily** start → titrate to **HR/BP**; **↓ dose** if **CrCl reduced** per label

Warning

- Bradycardia / AV block - Renal failure → accumulation — adjust interval/dose - Abrupt withdrawal

Indication

Atypical pneumonia coverage component · Chlamydia / uncomplicated cervicitis / uret… · …

Dose

500 mg PO daily × 3d or 5d packs (indication-specific); CAP 500 mg day1 then 250 mg daily

Warning

- QT prolongation / torsades — check ECG if risk factors + other QT drugs - Hepatotoxicity - Sensory hearing loss with prolonged high exposure - Resistance: pneumococcus/macrolide — don’t rely monotherapy severe pneumococcal pneumonia in high-resistance regions

Indication

Susceptible gram-negative bacteremia / pneu… · Cystic fibrosis chronic Pseudomonas suppres… · …

Dose

1–2 g IV q6–8h; severe 2 g q6h; inhaled for chronic pseudomonas in CF

Warning

- β-lactam class — **rare cross-reactivity** with ceftazidime (side chain) in severe cephalosporin allergy - **No staph/strep/anaerobe** — catastrophic monotherapy for typical cellulitis/endocarditis - Renal adjustment - Resistance — inducible chromosomal beta-lactamases in some organisms

Indication

Spasticity from neurologic conditions · Intrathecal baclofen for severe refractory…

Dose

Start low (e.g., 5 mg TID) Titrate gradually based on response and tolerance

Warning

- Abrupt discontinuation -> withdrawal (agitation, hallucinations, seizures) - Intrathecal baclofen withdrawal -> LIFE-THREATENING (delirium, hyperthermia, seizures) - Renal impairment -> accumulation -> coma / severe CNS depression (dose reduce or avoid) - Sedation and respiratory depression (especially with CNS depressants)

Indication

Hypertension · HFrEF with **bisoprolol** (evidence-based G… · …

Dose

**PO:** **start low** (e.g. **1.25–2.5 mg daily**) → **slow up-titration** especially **HF** q **~2 weeks** to target per cardiology

Warning

- Bradycardia / hypotension on titration - Acute decompensated HF — **DO NOT start** / **hold** if hypotension, shock, pulmonary edema needing IV support, or escalating inotropes - Bronchospasm — not asthma-safe

Indication

Anticoagulation during PCI with aspirin · HIT patients needing PCI (experienced cente…

Dose

Bolus + infusion **mg/kg/h** — reduce if CrCl <30 per PCI label

Warning

- **Renal failure** prolongs effect — reduce infusion - **Bleeding** at access site and systemic - Stent thrombosis risk if anticoagulation inadequate — protocol-driven

Indication

Spinal anesthesia · Epidural anesthesia (labor, surgery) · …

Dose

2-2.5 mg/kg (no epi); 2.5-3 mg/kg (with epi)

Warning

Highest local anesthetic cardiotoxicity; strict LAST prevention required

Indication

OUD induction · Stabilization · …

Dose

OUD induction: 2–4 mg SL, titrate to 8–16 mg by day 1–2

Warning

Precipitated withdrawal, CNS depression with benzos/alcohol, delayed naloxone reversal

Indication

Hyperkalemia with ECG changes · Hypocalcemia · …

Dose

IV bolus dosing per protocol May repeat if ECG changes persist

Warning

- Does NOT lower potassium - Stabilizes myocardium only - Give early in hyperkalemia with ECG changes - Effect is temporary and repeat dosing may be required

Indication

Hypertension · HFrEF

Dose

PO START 4–8 mg daily; titrate to BP/HF targets with labs.

Warning

- Pregnancy contraindicated → DO NOT use

Indication

Hypertension · HFrEF · …

Dose

PO START low (e.g. 6.25–12.5 mg BID/TID), titrate with BP + labs.

Warning

- Angioedema can be delayed and fatal → DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated → DO NOT use

Indication

Hypertension · HFrEF with **carvedilol** (evidence-based G… · …

Dose

**PO:** **3.125 mg BID** HF start → **double q ~2 weeks** if tolerated toward target **HTN** may start/titrate faster per label — still watch **standing BP**

Warning

- Orthostatic hypotension → very common early (α1 effect) — start low, slow titration - Bradycardia - Acute decompensated HF → **DO NOT start** (stabilize first); **hold** if hypotension, shock, pulmonary edema needing IV support, or escalating inotropes

Indication

Primary: Surgical prophylaxis; MSSA celluli… · Secondary: Complicated UTI due to susceptib… · …

Dose

Mild–moderate infections: 1 g IV q8h Severe infections (e.g., bacteremia): 2 g IV q8h

Warning

- Hypersensitivity (anaphylaxis risk); cross-reactivity possible with severe penicillin allergy - Not for MRSA or ESBL/high-risk resistant gram-negatives — treatment failure risk - Inoculum effect — risk of failure in high-burden MSSA infections (e.g., endocarditis, deep abscess) - Mandatory renal dose/interval adjustment — high dose without adjustment → encephalopathy/seizures - Surgical prophylaxis must be within 60 min pre-incision; re-dose intra-op if prolonged surgery or blood loss ≥1500 mL - No oral formulation — IV/IM only

Indication

Hospital-acquired / ventilator-associated p… · Febrile neutropenia with regimen per IDSA · …

Dose

1–2 g IV q8–12h; febrile neutropenia often 2 g q8h

Warning

- β-lactam anaphylaxis - **Neurotoxicity (encephalopathy, seizures)** with under-dosed renal failure / accumulation - ESBL: variable institutional policy — carbapenem often preferred for definitive ESBL bacteremia - AmpC inducers — watch Enterobacter/Citrobacter treatment failures

Indication

Uncomplicated urinary tract infection · Otitis media / pharyngitis alternatives whe… · …

Dose

400 mg PO daily or 200 mg PO q12h (indication-specific)

Warning

- **Misuse boundary:** NOT appropriate as sole therapy for **pyelonephritis**, **bacteremia**, or **unstable systemic infection** — escalate route/spectrum when indicated - **MRSA:** **no reliable MRSA coverage** — do not use as monotherapy when MRSA in differential - β-lactam anaphylaxis - **Gonorrhea resistance** — ceftriaxone-based regimens often first-line; oral cefixime only where guideline-endorsed - Poor staph reliability — not first-line cellulitis if MRSA in differential - Renal adjustment

Indication

Severe sepsis / bacteremia due to susceptib… · Meningitis · …

Dose

1–2 g IV q6–8h (severe); moderate infections lower end

Warning

- β-lactam anaphylaxis - Renal adjustment required in CKD - ESBL / AmpC inducible organisms — treatment failure risk in wrong syndrome - Not anti-MRSA / not anti-enterococcus

Indication

Complicated intra-abdominal infection as co… · Mixed aerobic/anaerobic pelvic infections · …

Dose

1–2 g IV q6–8h; severe 2 g q6h

Warning

- β-lactam anaphylaxis - Not MRSA coverage — failure if staph is pathogen - Bacteroides resistance varies geographically — verify local Bacteroides susceptibility - Renal adjustment

Indication

Pseudomonas aeruginosa infection (susceptib… · Complicated UTI/pyelonephritis due to susce… · …

Dose

1–2 g IV q8h; extended/continuous infusion in some protocols; severe 2 g q8h

Warning

- β-lactam anaphylaxis - **Poor strep/MSSA reliability** — do not substitute for anti-staph beta-lactam when staph is concern - Renal dose adjustment - ESBL / carbapenem-resistant organisms — treatment failure if mis-selected

Indication

Community-acquired pneumonia · Pyelonephritis / complicated UTI · …

Dose

1–2 g IV/IM q24h (many indications); meningitis higher per protocol; some q12h severe

Warning

- β-lactam anaphylaxis - **Neonatal kernicterus / bilirubin displacement** — avoid in hyperbilirubinemic neonates per labeling - **Ca precipitation** — do not reconstitute/mix with Ringer’s lactate or Ca-containing solutions in same line - ESBL producers → treatment failure despite in vitro labels — know local epidemiology - Gallbladder sludge/pseudolithiasis with prolonged use

Indication

Community-acquired pneumonia (non-ICU) when… · Acute bacterial sinusitis / otitis media · …

Dose

IV: 750 mg–1.5 g q8h (infection severity); PO axetil 250–500 mg q12h

Warning

- β-lactam anaphylaxis risk - Not anti-pseudomonal — gram-negative treatment failure if Pseudomonas / resistant Enterobacterales - Axetil PO bioavailability food-dependent — give with food - Renal adjustment for IV formulation

Indication

OA · RA · …

Dose

100–200 mg BID

Warning

CV thrombotic risk + GI bleed + AKI + hepatic injury

Indication

Uncomplicated SSTI due to susceptible MSSA… · Uncomplicated cystitis / selected UTI · …

Dose

250–500 mg PO q6–12h (infection-dependent); UTI often 500 mg PO q12h

Warning

- **Misuse boundary:** NOT appropriate as sole therapy for **pyelonephritis**, **bacteremia**, or **unstable systemic infection** — escalate route/spectrum when indicated - **MRSA:** **no reliable MRSA coverage** — do not use as monotherapy when MRSA in differential - β-lactam → anaphylaxis risk; severe penicillin allergy → caution / alternative per protocol - Poor MRSA / enterococcus / anaerobe / many gram-neg coverage → treatment failure if wrong bug - Do not use for viral infections — drives resistance + C. diff risk - Renal impairment → reduce dose / extend interval

Indication

Serious infections due to susceptible organ… · Rickettsial disease when doxycycline contra… · …

Dose

50–100 mg/kg/day IV divided q6h — max 4 g/day; **levels**

Warning

- **Irreversible aplastic anemia** idiosyncratic (rare, catastrophic) - **Gray baby syndrome** in neonates — circulatory collapse - **Bone marrow suppression** reversible dose-related - Inhibits mitochondrial protein synthesis — human toxicity

Indication

Intermittent claudication

Dose

**100 mg BID** (50 mg BID if on strong CYP3A4 inhibitors per label)

Warning

- **Contraindicated** HF reduced EF - **Tachycardia** - Bleed with aspirin

Indication

Complicated urinary tract infection / pyelo… · Pseudomonas infection oral step-down when s… · …

Dose

250–750 mg PO BID or 400 mg IV q8–12h — indication-specific

Warning

- **Tendon rupture** (Achilles) — risk ↑ steroids, elderly, renal failure - **QT prolongation** + seizures threshold - **Aortic dissection/aneurysm** risk discussion in high-risk patients - Resistance rising — verify local UTI antibiogram

Indication

Helicobacter pylori eradication regimens · Community-acquired pneumonia atypical cover… · …

Dose

500 mg PO BID; XL 1 g daily (formulation dependent); H. pylori regimens 500 mg BID

Warning

- QT prolongation - **CYP3A interactions** — colchicine contraindicated with clarithromycin in many renal scenarios; simvastatin contraindicated - Hepatotoxicity - Macrolide resistance S. pneumoniae in some regions

Indication

Skin/soft tissue infection when CA-MRSA sus… · Odontogenic / head-neck anaerobic infections · …

Dose

300–450 mg PO TID or 600 mg IV q6–8h severe

Warning

- **C. difficile colitis** — among highest-risk antibiotics - **Rapid IV bolus** → hypotension / cardiac arrest — infuse per policy - Not empiric for polymicrobial intra-abd without beta-lactam backbone (Bacteroides resistance varies) - Neuromuscular blockade potentiation

Indication

Seizure disorders (maintenance therapy) · Panic disorder · …

Dose

Start low (e.g., 0.25–0.5 mg BID); titrate gradually by response and tolerance

Warning

- CNS and respiratory depression (especially with opioids / alcohol) - Dependence and tolerance with chronic use - Abrupt discontinuation → withdrawal (anxiety, agitation, seizures) - Sedation → falls, impaired cognition

Indication

Hypertension · Resistant hypertension · …

Dose

HTN PO: start 0.1 mg BID → titrate cautiously; typical 0.1–0.3 mg BID (individualize) Patch: weekly transdermal — dose per product; slow onset / steady-state Titrate slowly to limit hypotension and sedation; adjust in renal impairment

Warning

- Rebound hypertension if abruptly stopped (can be severe) - CNS depression / sedation (additive with other sedatives) - Bradycardia / hypotension risk - Overdose → CNS depression, bradycardia, hypotension - Do NOT stop suddenly — taper required

Indication

DAPT after coronary stent (with aspirin) · ACS management pathways · …

Dose

Loading **300–600 mg** (ACS/PCI context) then **75 mg daily** maintenance

Warning

- **Bleeding** — DAPT and triple therapy - **Premature discontinuation** → stent thrombosis - TTP (rare)

Indication

Primary: MSSA cellulitis; MSSA abscess afte… · Secondary: Surgical site infection with MSS… · …

Dose

Oral: 500 mg PO q6h IV: 1–2 g IV q4–6h

Warning

- Hypersensitivity (anaphylaxis risk) - No MRSA coverage — DO NOT use if MRSA suspected or confirmed - Not active against MRSA — confirm MSSA before use in severe infection - Delayed cholestatic hepatitis may occur weeks after stopping therapy — monitor LFTs if symptoms - High sodium load (IV) — caution in heart failure, CKD, and ICU patients - Risk increases with prolonged use (>2 weeks) and older age - High-dose IV: electrolyte disturbance, AKI, neurotoxicity risk - PO absorption reduced by food — empty stomach preferred - Gram-negative/polymicrobial infection requires added coverage — not reliable monotherapy

Indication

Mild–moderate pain · Cough suppression · …

Dose

30–60 mg q4–6h

Warning

CYP2D6 variability, respiratory depression, hidden paracetamol toxicity

Indication

Carbapenem-resistant Enterobacterales infec… · Carbapenem-resistant Pseudomonas aeruginosa… · …

Dose

IV: million IU / mg CMS — **never guess** — pharmacy nomogram

Warning

- **Nephrotoxicity** near-universal vigilance - **Neurotoxicity** apnea with NMB/sedation stacks - **Dosing errors** between products/units — fatal - Inhaled vs IV indications different

Indication

Vitamin B12 deficiency · Megaloblastic anemia · …

Dose

IM loading regimen followed by maintenance; oral therapy possible in selected patients

Warning

- Untreated B12 deficiency can cause irreversible neurologic damage - Folate may correct anemia but does NOT correct neurologic deficits from B12 deficiency - Always evaluate the cause of deficiency (malabsorption, diet, and related factors)

Indication

NVAF stroke prevention · Treatment and reduction in recurrence of VTE

Dose

150 mg BID vs **110 mg BID** (some regions); CrCl ≤30 → **75 mg BID** (US) / avoid or reduce per EU label

Warning

- **Dyspepsia** common — PPI may help; adherence suffers if not addressed - **P-gp inhibitors** (dronedarone, ketoconazole) → contraindicated or dose-capped per label - Do not chew pellets outside approved administration methods

Indication

Thromboprophylaxis · Acute VTE treatment · …

Dose

Prophylaxis 2500–5000 IU SC daily/BID by risk; cancer thrombosis **~200 IU/kg daily ×1 month** then ~150 IU/kg — label-specific

Warning

- **Cancer dosing ≠ standard VTE dosing** — wrong schema → under-treatment - HIT risk as with all heparins - Renal failure → accumulation — dose reduction or alternative

Indication

MRSA complicated SSTI / bacteremia · Vancomycin-intolerant MRSA infection when d… · …

Dose

4–6 mg/kg IV q24h SSTI; 6–10 mg/kg q24h bacteremia/endocarditis — **indication-specific**

Warning

- **Contraindicated for pneumonia** — surfactant inactivation → clinical failure - **CPK elevation / rhabdomyolysis** — weekly CPK; hold statins - Eosinophilic pneumonia rare — hypoxia + fever → stop drug - Muscle pain — evaluate CPK

Indication

Status epilepticus · Acute seizures · …

Dose

IV / IM / PR per emergency protocol; repeat as directed with monitoring Oral for withdrawal and selected maintenance contexts (protocol-based)

Warning

- Respiratory depression → airway and ventilatory risk (especially with opioids, alcohol, and repeat dosing) - Profound CNS depression with co-sedation - Long half-life and active metabolites → accumulation and delayed oversedation with repeated or oral/chronic use - Paradoxical agitation (rare) — reassess if behavior worsens - Physical dependence with repeated use — withdrawal if stopped abruptly after sustained exposure

Indication

Acute pain · Renal colic (diclofenac K/IM) · …

Dose

50 mg PO TID (diclofenac K); 75 mg IM stat

Warning

Highest CV risk + GI bleed + hepatotoxicity

Indication

Atrial fibrillation · HFrEF · …

Dose

Maintenance: ~0.125–0.25 mg daily PO (lower in elderly / CKD / low body weight) Loading (if used): IV or PO in divided doses — protocol-based only

Warning

- Narrow therapeutic index → small dose changes can cause toxicity - Toxicity risk ↑ with renal impairment - Hypokalemia ↑ digoxin toxicity (major trap) - Arrhythmias (bradycardia, AV block, ventricular arrhythmias) - Toxicity can present with GI + visual + cardiac symptoms - Drug interactions are common and clinically significant

Indication

AF rate control pathways · Angina · …

Dose

Oral chronic and IV monitored-setting regimens are distinct; follow protocolized dosing.

Warning

- Bradycardia / AV block risk - HFrEF caution where clinically inappropriate

Indication

Secondary stroke prevention · Pharmacologic stress testing (IV)

Dose

ER capsule **200 mg BID** (aspirin 25 mg fixed combo) OR IV stress per nuclear protocol

Warning

- **Hypotension** vasodilation - **Bleed** with aspirin component or anticoagulants - Headache common — adherence

Indication

Community-acquired pneumonia with atypical… · Skin/soft tissue infection due to CA-MRSA w… · …

Dose

100 mg PO q12h or 200 mg load then 100 mg daily (indication-specific)

Warning

- **Pill esophagitis** — take upright + full glass water; avoid pre-sleep dosing - Photosensitivity rash - Intracranial hypertension rare - Not first-line for severe bacterial meningitis

Indication

NVAF stroke prevention · VTE treatment after 5–10 days of parenteral…

Dose

AF: 60 mg daily vs **30 mg** if CrCl 15–50 or weight ≤60 kg or interacting P-gp inducers; CrCl >95 → **30 mg** or not recommended AF

Warning

- **CrCl >95** in NVAF → reduced efficacy signal — label mandates dose cap or avoidance - Must follow **parenteral lead-in** for VTE per label (5–10 days) - Strong inducers (rifampin etc.) → reduced edoxaban exposure

Indication

Hypertension · HFrEF · …

Dose

PO START at 2.5–5 mg daily (or BID in HF) and titrate with BP/renal labs.

Warning

- Angioedema can be delayed and fatal → DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated → DO NOT use

Indication

Thromboprophylaxis in surgical and medical… · Acute DVT/PE treatment · …

Dose

Prophylaxis 40 mg SC daily (often 30 mg BID post-op US); treatment 1 mg/kg BID or 1.5 mg/kg daily

Warning

- **HIT** — platelet fall or thrombosis while on heparin → stop enoxaparin; non-heparin anticoagulant - **Spinal/epidural hematoma** with neuraxial anesthesia + LMWH — timing rules - CrCl <30 → **dose reduction** or consider UFH — accumulation

Indication

Non-ST elevation ACS · PCI when GPI indicated

Dose

Double bolus + infusion per label; **CrCl <50** dose reduction

Warning

- Bleeding with heparin - thrombocytopenia - hypotension with bolus

Indication

Complicated intra-abdominal infection (with… · Complicated UTI including pyelonephritis · …

Dose

1 g IV/IM q24h

Warning

- β-lactam anaphylaxis - **No Pseudomonas / Acinetobacter** — wrong empiric choice in HAP/VAP with those risks - Seizure risk class effect — renal/hepatic combined adjustment per label - Valproate interaction (carbapenem class)

Indication

Streptococcal pharyngitis penicillin allerg… · Chlamydia / uncomplicated infections when o… · …

Dose

250–500 mg PO q6–12h base vs ethylsuccinate formulations differ

Warning

- QT prolongation — worse than azithro in many drug interaction scenarios - CYP3A inhibition — statins, colchicine, calcineurin inhibitors - Infantile hypertrophic pyloric stenosis with neonatal/postnatal exposure - Phlebitis IV

Indication

Acute atrial fibrillation / flutter with **… · Perioperative **tachycardia** · …

Dose

**IV infusion:** **load** optional per protocol → **titrate** every few minutes to **HR/BP** endpoint **Offset minutes** after stop — plan reassessment

Warning

- Hypotension / bradycardia during titration - Bronchospasm — not asthma-safe despite β1 selectivity - High potassium / AV conduction disease — synergy with other blockers

Indication

Active tuberculosis combination therapy · Mycobacterium avium complex treatment — spe…

Dose

15–25 mg/kg PO daily; max 1.6 g/day some references

Warning

- **Optic neuritis** — baseline visual acuity/color; stop if symptoms - Renal failure accumulation → ↑ ocular risk — dose reduce - Not monotherapy

Indication

RSI induction in hemodynamic instability · General anesthesia induction · …

Dose

RSI: 0.2-0.3 mg/kg IV

Warning

Adrenal suppression risk; no analgesia; avoid repeated/continuous dosing

Indication

GERD / dyspepsia · Peptic ulcer disease (selected contexts) · …

Dose

Typical PO: 20 mg BID or 40 mg daily (indication-dependent) IV: protocol-based for inpatient use Adjust for renal function

Warning

- Renal impairment → accumulation risk; dose reduction required - CNS effects can occur in elderly / renal dysfunction (confusion, agitation) - H2 blockers are weaker than PPIs for severe acid-related disease / GI bleed protocols - Long-term casual continuation without indication should still be reassessed - Do not let symptomatic relief delay evaluation of serious GI pathology

Indication

Procedural analgesia · ICU sedation · …

Dose

25–50 mcg IV bolus

Warning

Respiratory depression, chest wall rigidity, CYP3A4 interactions

Indication

Iron deficiency anemia · Iron deficiency states (without anemia)

Dose

Typically 100-200 mg elemental iron daily Use divided or alternate-day dosing depending on tolerance

Warning

- Do NOT treat anemia without confirming iron deficiency - Poor absorption reduces effectiveness (food, PPIs, calcium) - GI side effects are a major cause of non-adherence - Continue treatment after hemoglobin normalizes to replenish iron stores

Indication

Clostridioides difficile infection · Recurrent CDI prevention protocols — ID/gas…

Dose

200 mg PO BID × 10 days standard

Warning

- Does not treat systemic infection — CDI only - Hypersensitivity rare - Cost/access — formulary restrictions common

Indication

Primary: MSSA cellulitis; MSSA abscess afte… · Secondary: MSSA bacteremia (definitive ther… · …

Dose

Oral: 500 mg PO q6h IV: 1–2 g IV q4–6h

Warning

- Hypersensitivity (anaphylaxis risk) - No MRSA coverage — DO NOT use if MRSA suspected or confirmed - Not active against MRSA — confirm MSSA before use in severe infection - Delayed cholestatic hepatitis may occur weeks after stopping therapy — monitor LFTs if symptoms - High sodium load (IV) — caution in heart failure, CKD, and ICU patients - Flucloxacillin + paracetamol can cause high anion gap metabolic acidosis (5-oxoproline), especially with sepsis, malnutrition, renal impairment, or prolonged use - Risk increases with prolonged use (>2 weeks) and older age - High-dose IV: hypokalemia, AKI, neurotoxicity risk - PO absorption reduced by food — empty stomach preferred - Gram-negative/polymicrobial infection requires added coverage — not reliable monotherapy

Indication

Candidiasis · Cryptococcal infection · …

Dose

**Highly indication-dependent** — single-dose, daily, and prolonged courses are all in play; use institutional / ID and obstetric (if pregnancy) guidance.

Warning

- QT prolongation → arrhythmia risk (Torsades risk with co-QT agents / electrolyte disturbance) - CYP2C9 / CYP3A4 and other CYP effects → **major** drug–drug interactions and concentration shifts - Hepatotoxicity; monitor in prolonged therapy, baseline liver disease, or concerning symptoms - **Renal impairment: dose reduction required**; accumulation without adjustment

Indication

Folate deficiency · Megaloblastic anemia · …

Dose

Deficiency: typically ~1 mg daily Pregnancy supplementation: lower prophylactic dosing per guideline Onset / duration: gradual hematologic response

Warning

- Can mask vitamin B12 deficiency → neurologic damage may progress - Do NOT treat anemia without evaluating cause - Over-supplementation without indication is unnecessary

Indication

Major orthopedic surgery thromboprophylaxis · Acute superficial vein thrombosis (some reg… · …

Dose

2.5 mg SC daily prophylaxis; treatment **5–10 mg daily** weight-based — verify label

Warning

- **No reversal agent** — major bleed = supportive + PCC only in desperate protocols + hematology - Renal elimination — **avoid CrCl <30** for prophylaxis - HIT history: may use fondaparinux when heparins contraindicated (context — specialist)

Indication

Acute uncomplicated cystitis in women (sing… · ESBL E. coli cystitis salvage oral option —… · …

Dose

3 g PO single dose cystitis; IV grams multi-dose MDR — **separate pathways**

Warning

- **Misuse boundary:** NOT appropriate as sole therapy for **pyelonephritis**, **bacteremia**, or **unstable systemic infection** — escalate route/spectrum when indicated - **MRSA:** **no reliable MRSA coverage** — do not use as monotherapy when MRSA in differential - Oral fosfomycin ≠ IV fosfomycin indication/dose - Resistance emerging — verify local guidance - Do not use oral for pyelonephritis standard

Indication

Acute decompensated HF (IV) · Chronic edema (HF, CKD, cirrhosis) · …

Dose

PO: 20–40 mg start → titrate to urine output and congestion. IV: 20–40 mg → repeat/escalate; acute pulmonary edema: IV bolus ± infusion per protocol.

Warning

- Hypokalemia / electrolyte depletion → arrhythmia risk - Over-diuresis → AKI / hypotension - Ototoxicity with high dose / rapid IV administration - Diuretic resistance → repeated ineffective low dosing is unsafe

Indication

Neuropathic pain · Seizure adjunct · …

Dose

Start low (e.g., 100-300 mg) and titrate gradually Typically TID dosing

Warning

- Renal impairment -> accumulation -> sedation, confusion, or coma - CNS depression (increased risk with opioids and benzodiazepines) - Misuse/abuse potential (especially with opioids) - Withdrawal symptoms can occur if stopped abruptly (taper recommended)

Indication

Serious gram-negative infection in combinat… · Enterococcal / streptococcal endocarditis s… · …

Dose

5–7 mg/kg IV q24h extended interval OR traditional divided — **pharmacy-driven**

Warning

- **Nephrotoxicity + ototoxicity** — cumulative with vancomycin, diuretics, contrast - Levels mandatory for extended-interval and many traditional regimens - Neuromuscular blockade potentiation with NMB / myasthenia - Pregnancy — fetal ototoxicity risk

Indication

Acute VTE · ACS with anticoagulation pathway · …

Dose

IV bolus + infusion per weight-based protocol (e.g. 80 U/kg bolus + 18 U/kg/h) — **institutional nomogram**

Warning

- **HIT** — any falling platelets or thrombosis on UFH → stop and alternative anticoagulant - Bleeding with supratherapeutic aPTT — hold infusion + protamine if severe - Hyperkalemia, osteoporosis with prolonged use

Indication

Hypertension · Hypertensive urgency/emergency · …

Dose

IV (acute): intermittent IV for BP control — protocol-based PO (chronic): start low (e.g. 10–25 mg multiple times daily); titrate cautiously

Warning

- Reflex tachycardia (can worsen ischemia) - Hypotension (especially IV use) - Drug-induced lupus (chronic use) - Not first-line for routine hypertension - Use cautiously in CAD (↑ myocardial oxygen demand)

Indication

Hypertension · Mild edema states · …

Dose

HTN: 12.5–25 mg PO daily Edema: higher doses may be used in outpatient care — review electrolytes and renal function before titrating

Warning

- Hyponatremia / hypokalemia risk - Volume depletion / hypotension - Gout / hyperuricemia flare risk - Thiazide less effective in significant renal impairment - Not for acute pulmonary edema / emergency decongestion

Indication

Moderate-severe acute pain · Dental pain · …

Dose

5–10 mg hydrocodone PO q4–6h (IR combination)

Warning

Respiratory depression, paracetamol hepatotoxicity, ER misuse, CYP3A4 interactions

Indication

Inflammatory pain · Fever · …

Dose

200–400 mg q4–6h (OTC)

Warning

CV/GI/renal risk — lowest dose, shortest course

Indication

Severe intra-abdominal infection combinatio… · Hospital-acquired infections when carbapene… · …

Dose

500 mg–1 g IV q6h (imipenem component); dose by imipenem mg

Warning

- β-lactam anaphylaxis - **Seizure threshold** — higher risk than meropenem; worse with renal failure if not adjusted - **Valproate — avoid** (same class interaction) - Not first-line meningitis choice in many guidelines (meropenem preferred)

Indication

Diabetes mellitus · DKA · …

Dose

Highly protocol-based and insulin-type specific IV infusion in acute pathways; SC for maintenance regimens

Warning

- Hypoglycemia can be life-threatening - Requires frequent glucose monitoring - Intracellular potassium shift can cause hypokalemia - In hyperkalemia, pair insulin with glucose unless already markedly hyperglycemic

Indication

Hypertension · Diabetic kidney disease / albuminuria conte… · …

Dose

PO START 75–150 mg daily, titrate with BP/labs.

Warning

- Pregnancy contraindicated → DO NOT use - Monitor creatinine + potassium after start/dose changes

Indication

Latent tuberculosis infection treatment · Active tuberculosis combination therapy · …

Dose

5 mg/kg PO daily TB (max 300 mg); latent 300 mg daily or 900 mg biweekly high-dose regimens

Warning

- **Hepatitis** — baseline LFTs risk factors; monthly symptoms education - **Acute overdose** seizures → **pyridoxine** + benzos toxicology - Peripheral neuropathy — alcoholism, diabetes, pregnancy → B6 - Drug-induced lupus rare

Indication

Procedural sedation · Acute severe pain (opioid-sparing) · …

Dose

Analgesia 0.1-0.3 mg/kg IV; sedation 1-1.5 mg/kg IV; IM 4-5 mg/kg

Warning

Laryngospasm risk, sympathetic surge, emergence reactions

Indication

Postoperative pain · Trauma pain · …

Dose

15–30 mg IV q6h depending on patient type

Warning

GI bleed risk, renal injury, strict 5-day total duration limit

Indication

Hypertension · Acute severe hypertension in **monitored**…

Dose

**PO:** **start low** (e.g. **100 mg BID**) → titrate — **orthostasis** **IV:** **bolus** or **infusion** per protocol — **frequent BP** checks

Warning

- Hypotension — especially IV push - Bronchospasm (β2 blockade component) - Hepatic injury — rare idiosyncratic — LFTs if unwell

Indication

Focal seizures · Generalized tonic-clonic seizures · …

Dose

Loading (acute IV): ~1–3 g total — protocol-based only Maintenance: 500–1500 mg BID (individualize) IV and PO IR: 1:1 mg conversion for total daily dose Adjust for renal function (mandatory)

Warning

- Behavioral / neuropsychiatric effects (agitation, irritability, mood changes) — not behavior-neutral - Renal impairment → dose adjustment required - Rapid IV loading common in acute care — protocol-based only - Abrupt discontinuation may increase seizure risk - Additive sedation with CNS depressants

Indication

Community-acquired pneumonia (oral/IV) when… · Complicated urinary tract infections · …

Dose

500–750 mg PO/IV daily (indication-specific); CAP often 750 mg daily

Warning

- Tendon rupture - QT prolongation - CNS effects - Aortic aneurysm / dissection class warning

Indication

Hypothyroidism · Post-thyroidectomy replacement · …

Dose

Healthy adult replacement often ~1.6 mcg/kg/day PO (individualize) Elderly / CAD / frail: start 12.5–25 mcg daily → titrate slowly Mild / subclinical / partial replacement: lower starts when indicated

Warning

- Severe hypothyroidism / myxedema coma → emergency escalation; oral outpatient logic does not apply - Overtreatment → tachyarrhythmia / angina / bone loss risk - Undertreatment → persistent hypothyroid symptoms; pregnancy and cardiac patients are high-risk contexts - Absorption is highly interaction-sensitive (iron, calcium, PPIs, feeds, food) - Dose changes should be TSH / free T4 guided, not symptom-only

Indication

Local/regional anesthesia · Ventricular arrhythmias (VT/VF) · …

Dose

Local 4.5 mg/kg (no epi) or 7 mg/kg (with epi); IV bolus 1-1.5 mg/kg over 2-4 min

Warning

LAST, cardiac/CNS toxicity, unsafe rapid IV push

Indication

MRSA pneumonia · Complicated SSTI due to MRSA · …

Dose

600 mg IV/PO q12h (most serious); 400 mg q12h some indications — verify label

Warning

- **Serotonin syndrome** with SSRIs, SNRIs, triptans, MAOIs — avoid or hold serotonergics - **Myelosuppression** — CBC weekly if >2 weeks therapy - **Lactic acidosis** — rare but reported; hold if unexplained acidosis - Not first-line for catheter-related bacteremia without source control

Indication

Hypertension · HFrEF · …

Dose

PO START at 2.5–10 mg daily and titrate with BP + labs.

Warning

- Angioedema can be delayed and fatal → DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated → DO NOT use

Indication

Status epilepticus · Acute seizures · …

Dose

IV dosing per protocol (repeat dosing may be required) IM/PO in selected contexts

Warning

- Respiratory depression with airway compromise risk - Additive CNS depression (especially with opioids) - Oversedation risk with repeat dosing - Accumulation and prolonged sedation with repeated dosing

Indication

Hypertension · CKD with albuminuria/proteinuria · …

Dose

PO START 25–50 mg daily; titrate to BP/lab response.

Warning

- Pregnancy contraindicated → DO NOT use - Check creatinine + potassium after start and dose changes

Indication

Osteoarthritis · Rheumatoid arthritis · …

Dose

60 mg TID (chronic) OR 60-120 mg PRN

Warning

GI bleeding, AKI, seizure risk with quinolones

Indication

Torsades de pointes · Eclampsia · …

Dose

Indication-specific IV dosing (bolus or infusion) per protocol

Warning

- Respiratory depression can occur at high magnesium levels - Loss of deep tendon reflexes is an early toxicity sign - Rapid infusion can cause hypotension - Antidote for toxicity is IV calcium

Indication

ESBL-producing Enterobacterales invasive in… · Severe polymicrobial intra-abdominal infect… · …

Dose

1 g IV q8h standard; extended infusion; meningitis higher per protocol

Warning

- β-lactam anaphylaxis (cross-reactivity concern with severe penicillin allergy — test dose / desensitization pathways institution-specific) - **Valproate: meropenem → rapid VPA loss → seizure breakthrough** — avoid combo or substitute AED - Renal adjustment mandatory - Carbapenem-resistant organisms (CRE) → treatment failure — infection control + adjuncts

Indication

Type 2 diabetes mellitus · Selected insulin resistance states

Dose

Start low (e.g., 500 mg once or twice daily) Titrate gradually based on tolerance and glycemic response

Warning

- Lactic acidosis is rare but serious - Renal function determines safety and dosing - HOLD during acute illness, hypoxia, hemodynamic instability, or contrast exposure - GI intolerance is common and can reduce adherence

Indication

Nausea / vomiting · Migraine-associated nausea (adjunct) · …

Dose

Common antiemetic: 10 mg PO / IV / IM Repeat / schedule per indication and protocol Adjust in renal impairment

Warning

- Extrapyramidal symptoms (dystonia, akathisia) can occur early - Tardive dyskinesia risk increases with prolonged use → avoid chronic casual prescribing - Sedation / CNS effects - Dose-reduce in renal impairment - Do not use when prokinetic effect is dangerous (e.g., mechanical obstruction)

Indication

Edema in heart failure · Edema in renal disease / nephrotic states · …

Dose

Typical start 2.5–5 mg PO daily; titrate cautiously on response + labs Often combined with a loop diuretic — some protocols time metolazone before the loop; monitor K, Na, Cr early

Warning

- Severe hypokalemia / hyponatremia → arrhythmia and neurologic risk - Over-diuresis → AKI, hypotension - With loop diuretics: powerful diuresis, highest K/Na/renal risk (sequential nephron blockade) - Do not repeat or escalate blindly without labs and volume reassessment - Not a stand-alone rescue for acute pulmonary edema

Indication

Hypertension · **ONLY metoprolol succinate ER** is guideli… · …

Dose

**PO:** start **low** (e.g. **25–50 mg** tartrate BID or succinate QD) → **titrate** to **HR/BP** and tolerance

Warning

- Bradycardia / AV block — hold if symptomatic - Acute decompensated HF — **DO NOT start** / **hold** if SBP <90–100, hypoperfusion, cardiogenic shock, or pulmonary edema requiring IV therapy - Abrupt stop after chronic use → rebound HR / ischemia

Indication

Intra-abdominal mixed infection anaerobic c… · Clostridioides difficile infection · …

Dose

500 mg IV/PO q8h many anaerobic infections; C. diff per guideline dosing

Warning

- **Alcohol / propylene glycol** — disulfiram reaction - **Peripheral neuropathy** with prolonged courses - **Encephalopathy** high-dose prolonged - Metallic taste common

Indication

Procedural sedation · Status epilepticus · …

Dose

Sedation 1 mg IV increments; seizure 0.1 mg/kg IV

Warning

Respiratory depression risk, especially with opioids or rapid IV push

Indication

Symptomatic orthostatic hypotension · Vasopressor weaning (ICU adjunct) · …

Dose

2.5–10 mg PO TID during daytime Last dose several hours before bedtime Titrate to standing symptoms and BP

Warning

- Supine hypertension (major risk) - Do NOT give near bedtime (avoid nighttime hypertension) - Monitor BP both standing and supine - Can cause bradycardia via reflex mechanisms - Not for hypertensive patients

Indication

Moderate–severe acne vulgaris · CA-MRSA SSTI oral alternative · …

Dose

100 mg PO q12h then 50–100 mg daily maintenance (acne lower)

Warning

- Vestibular toxicity — dizziness common - Drug-induced lupus / autoimmune hepatitis rare - Pigmentation with prolonged use - Same tetracycline pregnancy/teeth rules as doxy

Indication

Asthma · Allergic rhinitis · …

Dose

10 mg PO once daily (often evening) Not for acute relief

Warning

- Neuropsychiatric effects (mood changes, agitation, depression, suicidal ideation) - NOT for acute asthma attack (no bronchodilator effect) - Should not replace inhaled corticosteroids in moderate–severe asthma - Use only when benefit clearly outweighs risk (especially mild disease)

Indication

Severe acute pain · Cancer pain · …

Dose

1–2 mg slow IV (opioid-naive); 0.1 mg/kg weight-based; titrate q5–10 min

Warning

Respiratory depression, hypotension, misuse/dependence risk

Indication

Community-acquired pneumonia when regimen a… · Complicated intra-abdominal infection combi… · …

Dose

400 mg PO/IV daily

Warning

- **QT prolongation** — stronger than some FQ - **Hepatotoxicity** — LFTs if prolonged; EU restrictions historically - **Not for uncomplicated UTI** — fails urine levels - Same tendon / CNS / aneurysm class warnings

Indication

Acute pain · Gout · …

Dose

250–500 mg BID (Rx); 220 mg q8–12h OTC

Warning

GI/renal/CV risk — avoid in eGFR <30 and active GI bleed

Indication

Hypertension · Atrial fibrillation — **rate control** (adj… · …

Dose

**PO:** **2.5–5 mg daily** start → titrate to **BP/HR** per label (some patients **10 mg**)

Warning

- Bradycardia - HF decompensation — hold new start - Hepatic impairment dosing

Indication

Hypertension (ER formulations) · Angina (selected pathways) · …

Dose

PO ER start/titrate by indication; avoid casual IR use for rapid BP drops.

Warning

- Short-acting IR misuse for rapid BP reduction can be dangerous

Indication

Acute uncomplicated cystitis in women · Urinary tract infection prophylaxis selecte… · …

Dose

Macrocrystal 100 mg PO BID × 5–7d cystitis; prophylaxis 50–100 mg HS

Warning

- **Misuse boundary:** NOT appropriate as sole therapy for **pyelonephritis**, **bacteremia**, or **unstable systemic infection** — escalate route/spectrum when indicated - **MRSA:** **no reliable MRSA coverage** — do not use as monotherapy when MRSA in differential - **CrCl <30** → avoid (ineffective urine levels + toxicity) - **Pulmonary fibrosis** acute/chronic — stop if new dyspnea - **Hepatotoxicity** — LFTs if prolonged - Peripheral neuropathy renal impairment

Indication

Acute pain · Labor analgesia · …

Dose

30-70% N2O with oxygen (minimum 30% O2); commonly 50% N2O / 50% O2 (Entonox), self-administered

Warning

Critical trapped-gas expansion risk and B12-related neurotoxicity risk

Indication

Hypertension

Dose

PO START 20 mg daily; titrate as needed.

Warning

- Pregnancy contraindicated → DO NOT use

Indication

GERD · Peptic ulcer disease (PUD) · …

Dose

GERD / dyspepsia: 20 mg PO daily PUD: 20–40 mg PO daily H. pylori: component of combination regimen (per protocol) IV GI bleed: bolus ± infusion per institutional guideline

Warning

- Overuse / prolonged use without indication is common and harmful - Long-term use → hypomagnesemia, B12 deficiency, fracture risk, infections (C. difficile) - Drug interaction with clopidogrel (CYP2C19 inhibition → ↓ antiplatelet effect) - Masking serious pathology (e.g., malignancy) if used without evaluation - Rebound acid hypersecretion after abrupt discontinuation

Indication

Acute nausea/vomiting · Postoperative nausea/vomiting · …

Dose

PO/ODT/IV commonly 4–8 mg depending on indication. Post-op / acute ED: often **4 mg IV** when IV route is chosen. CINV/RINV: follow emetogenic-risk pathways (may allow higher scheduled/regimen doses per protocol).

Warning

- QT prolongation / arrhythmia risk - Correct K / Mg abnormalities if clinically relevant - Avoid in congenital long QT or major QT-prolonging combinations when alternatives are suitable - Severe hepatic impairment lowers safe dose ceiling

Indication

Treatment of influenza · Post-exposure prophylaxis in selected patie… · …

Dose

Treatment (adult / adolescent): - 75 mg PO BID for 5 days Prophylaxis: - 75 mg PO once daily — duration per exposure / institutional protocol Renal impairment: adjust per CrCl / eGFR table (label / pharmacy) Do not interchange treatment and prophylaxis schedules

Warning

- Start early when indicated; severe / hospitalized / high-risk patients may still benefit when started later — do not withhold solely on time alone without clinical judgment - Treatment and prophylaxis are NOT the same regimen (dose, frequency, duration) - Renal impairment → mandatory dose / schedule adjustment per label or institutional table - Does NOT replace evaluation for bacterial coinfection, secondary pneumonia, or clinical deterioration - Pregnancy: oral oseltamivir preferred when antiviral treatment is indicated (per current guidance / OB)

Indication

Moderate-severe pain · Cancer pain · …

Dose

5–15 mg PO q4–6h (IR)

Warning

Respiratory depression, ER dose-dumping, CYP3A4 interactions

Indication

Headache · Musculoskeletal / soft-tissue pain · …

Dose

500–1000 mg PO q4–6h PRN · IV per product

Warning

Hepatotoxicity: cap total daily dose

Indication

Primary: Syphilis (all stages); streptococc… · Secondary: Endocarditis (streptococci); men… · …

Dose

Severe: 2–4 million units IV q4–6h High-dose: up to 24 million units/day (e.g., meningitis/endocarditis)

Warning

- Hypersensitivity (anaphylaxis risk) - Neurotoxicity (high dose or renal failure) - Electrolyte load (Na⁺ or K⁺ salts → hypernatremia or hyperkalemia) - Jarisch–Herxheimer reaction - Wrong formulation: NEVER use benzathine IM for systemic infection when aqueous IV therapy is required; NEVER benzathine IV - Resistance risk in prolonged therapy

Indication

Primary: Streptococcal pharyngitis/tonsilli… · Secondary: Rheumatic fever prophylaxis; asp… · …

Dose

250–500 mg PO q6–8h Pharyngitis: 250 mg PO BID–TID × 10 days (GAS)

Warning

- Hypersensitivity (anaphylaxis risk) - Not for severe/systemic infection (e.g., sepsis, meningitis, endocarditis) - Reduced absorption with food → take on empty stomach - Narrow spectrum → ineffective against resistant organisms - Adherence critical → rheumatic fever risk (GAS)

Indication

Hypertension · Cardiovascular risk-reduction contexts

Dose

PO START low (e.g. 2–4 mg daily) and titrate with BP + labs.

Warning

- Angioedema can be delayed and fatal → DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated → DO NOT use

Indication

Seizure disorders · Status epilepticus (adjunct/refractory) · …

Dose

Seizures: individualized; loading often required in acute settings Status epilepticus (adjunct): IV loading per protocol -> maintenance dosing Sedation: protocol-based only

Warning

- Respiratory depression -> airway risk - Profound sedation/coma at high doses - Hypotension (especially with IV loading) - Strong enzyme induction -> major drug interaction burden - Withdrawal can precipitate seizures (do not stop abruptly)

Indication

Seizure disorders · Status epilepticus (second-line)

Dose

IV loading dose followed by maintenance dosing Adjust using serum levels and clinical response

Warning

- IV infusion can cause hypotension and arrhythmias - Purple glove syndrome risk with extravasation - Narrow therapeutic window requires level-guided dosing - Nonlinear kinetics: small dose changes can cause large level shifts - Strong enzyme induction causes major interaction burden

Indication

Primary: Sepsis / septic shock; HAP/VAP; co… · Secondary: Neutropenic fever; post-surgical… · …

Dose

4.5 g IV q6–8h Severe/ICU: 4.5 g q6h (extended infusion preferred)

Warning

- Severe β-lactam hypersensitivity (anaphylaxis risk) - AKI risk (↑ with vancomycin) - Renal toxicity (dose-dependent accumulation) - Neurotoxicity (high exposure or renal failure) - Do NOT mix with aminoglycosides (IV inactivation) - Time-dependent killing → infusion strategy matters

Indication

Hypokalemia

Dose

Oral or IV depending on severity

Warning

- NEVER give IV push due to fatal arrhythmia risk - Rapid infusion can cause cardiac arrest - High-dose IV therapy requires close ECG monitoring - Renal function determines replacement safety

Indication

ACS managed with PCI — DAPT with aspirin (l…

Dose

Loading **60 mg** then **10 mg daily** (5 mg if <60 kg or age ≥75 per label)

Warning

- **Prior TIA/stroke — contraindicated** - **Bleeding** ↑ vs clopidogrel — age ≥75 and low weight cautions - Premature DAPT stop → stent thrombosis

Indication

Asthma / COPD exacerbation · Allergic reactions · …

Dose

Short course (e.g., asthma/COPD): 30–50 mg PO daily × 5–10 d (often no taper) Moderate inflammatory disease: ~10–40 mg PO daily (severity-dependent) Severe disease: higher PO or IV steroids (hydrocortisone / methylpred) per protocol

Warning

- Immunosuppression → infection risk (can mask sepsis) - Hyperglycemia (especially diabetics) - Adrenal suppression → DO NOT stop abruptly if prolonged use - Psychiatric effects (mood, agitation, psychosis) - GI risk (ulcer, bleeding esp. with NSAIDs) - Long-term: osteoporosis, weight gain, Cushingoid features

Indication

Induction of anesthesia · ICU sedation (adult ventilated) · …

Dose

Induction 1-2.5 mg/kg IV; ICU sedation 25-50 mcg/kg/min

Warning

PRIS risk with prolonged high-dose infusion; no intrinsic analgesia

Indication

Hypertension · Atrial fibrillation — **rate control** · …

Dose

**PO:** **start low** (e.g. **20–40 mg** divided) → titrate — **portal/migraine** targets differ from HTN **IV** (acute thyroid storm protocols only — institutional)

Warning

- DO NOT use in asthma / active bronchospasm - DO NOT use in stimulant (e.g. cocaine) chest pain due to unopposed alpha vasospasm risk - Bradycardia / AV block - Severe OD — seizures / CNS (lipophilic)

Indication

Active pulmonary/extrapulmonary tuberculosi… · Never monotherapy

Dose

25 mg/kg PO daily max 2 g; intermittent 50–70 mg/kg 2×/week max 4 g

Warning

- **Hepatitis** additive with INH/rifampin — LFTs - **Hyperuricemia** → gout flare — symptom check - Not used latent standard regimens

Indication

HFrEF · Post-MI LV dysfunction risk reduction · …

Dose

PO START low (e.g. 1.25–2.5 mg daily) and titrate with BP/labs.

Warning

- Angioedema can be delayed and fatal → DO NOT re-challenge any ACE inhibitor - Pregnancy is contraindicated → DO NOT use

Indication

Tuberculosis treatment and latent therapy (… · Prosthetic valve / hardware MRSA infection… · …

Dose

TB: 10 mg/kg PO daily max 600 mg; intermittent supervised therapy higher mg/kg — **program-specific**

Warning

- **Drug interactions** — induces CYP3A/2C9 etc. → loss of efficacy of many drugs - **Hepatotoxicity** — LFTs baseline and periodic - Orange discoloration body fluids — warn patient - Flu-like syndrome intermittent dosing errors

Indication

NVAF stroke prevention · DVT/PE treatment and reduction in recurrence · …

Dose

AF: 20 mg daily with **evening meal** if CrCl >50; **15 mg daily** if CrCl 15–49; VTE: 15 mg BID ×21d then 20 mg daily

Warning

- **GI bleeding** risk may be higher than some DOACs — patient and indication context - Food: **15/20 mg** with meal; absorption depends on dose - CrCl cutoffs change **AF vs VTE** tables — do not mix

Indication

Labor epidural analgesia · Surgical epidural anesthesia · …

Dose

Peripheral block up to 300 mg; epidural infusion 12-28 mg/hr

Warning

LAST can be delayed; avoid intravascular injection and ensure lipid rescue availability

Indication

Acute bronchospasm (asthma, COPD) · Hyperkalemia (adjunct therapy)

Dose

Inhaled PRN via MDI or nebulizer Nebulized dosing for moderate-severe exacerbations

Warning

- Tachycardia and arrhythmia risk - Hypokalemia risk, especially with repeated high-dose use - Overuse signals uncontrolled asthma and poor controller coverage - Hyperkalemia role is adjunctive only, not definitive therapy

Indication

Induction of anesthesia (mask/circuit) · Maintenance of general anesthesia · …

Dose

Induction 6-8% inhaled; maintenance about 0.5-1.5 MAC (about 1-3%)

Warning

Malignant hyperthermia trigger, QT risk, and high-concentration neuroexcitation

Indication

Erectile dysfunction · Pulmonary arterial hypertension

Dose

ED (PRN): - 25–100 mg PO ~30–60 min before activity - Start lower if elderly, hepatic impairment, renal impairment, or CYP3A4 inhibition PAH (scheduled): - 20 mg TID per protocol (follow approved product / institution) ED and PAH dosing are NOT interchangeable.

Warning

- Nitrates (any route): ABSOLUTE contraindication → severe / life-threatening hypotension - Riociguat: contraindicated → profound hypotension risk - Hypotension risk with alpha-blockers, volume depletion, other vasodilators / antihypertensives - Unstable cardiovascular status (e.g. recent MI, severe hypotension, decompensated HF) - Priapism → urgent evaluation if prolonged - Visual and hearing adverse effects: rare but can be serious

Indication

Severe metabolic acidosis with clear indica… · TCA/sodium-channel blocker toxicity · …

Dose

Emergency/protocol-based dosing Bolus dosing for toxicity or severe acidosis as indicated Infusion may be used in selected ICU/toxicology pathways

Warning

- NOT a universal treatment for acidosis - Hyperkalemia use is adjunctive and does NOT replace definitive stabilization/elimination strategy - Sodium load and volume load can worsen CHF or pulmonary edema - Overcorrection can cause alkalosis, hypokalemia, and reduced ionized calcium - TCA/sodium-channel blocker toxicity is a high-yield indication; treat ECG/QRS targets, not just numbers

Indication

HFrEF · Ascites · …

Dose

HFrEF: 12.5–25 mg daily → titrate 25–50 mg daily as tolerated Ascites: start 100 mg daily → titrate (often with furosemide) Cirrhosis pathway reference: spironolactone:furosemide ≈ 100:40 (protocol-guided; not universal) Resistant HTN: ~25–50 mg daily

Warning

- Hyperkalemia → life-threatening arrhythmia risk - Renal impairment → potassium accumulation risk - Do NOT combine with ACEi + ARB + K-sparing without clear plan (dual RAAS risk) - Cirrhotic ascites: spironolactone first-line; loop often added — ≈100:40 is a **protocol reference**, not mandatory universal pairing - Endocrine effects → gynecomastia (clinically relevant)

Indication

MRSA complicated SSTI / bacteremia (suscept… · Enterococcal infection when susceptible and… · …

Dose

Loading 6–12 mg/kg q12h × 3 doses then 6 mg/kg q24h — **product/regional variation**

Warning

- β-lactam–like hypersensitivity rare but reported - Nephrotoxicity lower than vancomycin historically — still monitor - Red man possible — slow infusion - Not oral CDI standard therapy

Indication

Hypertension · CV-risk protocol-driven contexts

Dose

PO START 20–40 mg daily, titrate to response.

Warning

- Pregnancy contraindicated → DO NOT use

Indication

ACS (with aspirin) per cardiology pathway · Post-MI extended therapy in some regions

Dose

Loading **180 mg** then **90 mg BID** × up to 12 mo ACS; then often **60 mg BID** continuation per label

Warning

- **Dyspnea** — common; HF vs drug - **Bradyarrhythmia** post-ACS - Bleeding on DAPT

Indication

Complicated intra-abdominal infection (comb… · Complicated skin/soft tissue infection · …

Dose

100 mg IV load then 50 mg IV q12h

Warning

- **Mortality signal** in some meta-analyses vs comparators — reserve for appropriate cases; combination therapy often preferred - **Bacteriostatic** — caution monotherapy in bacteremia (especially pneumonia) - Pancreatitis - Tooth/bone deposition pediatric — avoid young kids

Indication

Acute symptomatic VTE treatment · Thromboprophylaxis in surgical/medical pati… · …

Dose

Treatment **175 IU/kg SC daily**; prophylaxis **3500–4500 IU daily** — verify indication + label

Warning

- **HIT** — stop all heparin; **do not** switch to another LMWH for HIT treatment - **Renal failure** — accumulation; dose reduction or UFH alternative - Neuraxial hematoma with mistimed block

Indication

NSTE-ACS · selected PCI

Dose

Loading infusion then maintenance — **CrCl ≤60** halve maintenance per label

Warning

- Bleeding - thrombocytopenia - hypotension

Indication

Pseudomonas infection synergy with anti-pse… · Cystic fibrosis airway Pseudomonas · …

Dose

5–7 mg/kg IV q24h extended OR traditional divided — pharmacy

Warning

- Nephrotoxicity + ototoxicity - Levels + renal monitoring - Inhaled: bronchospasm risk — pre-bronchodilator per protocol - Pregnancy fetal ototoxicity

Indication

Post-op pain · MSK pain · …

Dose

50–100 mg q4–6h (IR)

Warning

Respiratory depression + seizures + serotonin syndrome risk

Indication

Uncomplicated UTI and some pyelonephritis o… · CA-MRSA skin infection oral/IV · …

Dose

DS tablet BID (many infections); PJP 15–20 mg/kg/day TMP component IV divided — **distinct**

Warning

- **Hyperkalemia** — TMP like amiloride; worse with ACEi/ARB/spironolactone/CKD - **Stevens-Johnson / TEN** — counsel rash/fever/mucosa - **Bone marrow suppression** high-dose / HIV - Folate antagonism — avoid in first trimester relative; G6PD hemolysis sulfonamide component

Indication

Seizure disorders · Bipolar disorder · …

Dose

Start low and titrate based on response and levels Loading may be used in acute settings (protocol-based)

Warning

- Hepatotoxicity can be severe or fatal - Pregnancy exposure carries major teratogenic risk - Hyperammonemia may present with confusion or encephalopathy - Thrombocytopenia and pancreatitis are important toxicity signals

Indication

Hypertension · HFrEF · …

Dose

PO START 40–80 mg daily or BID (indication-dependent), titrate with labs.

Warning

- Pregnancy contraindicated → DO NOT use - Avoid routine dual RAAS blockade

Indication

MRSA bacteremia with source control + ID fo… · MRSA pneumonia / SSTI / osteomyelitis when… · …

Dose

15–20 mg/kg IV q8–12h loading strategies; **AUC 400–600** target many serious infections — pharmacy

Warning

- **Nephrotoxicity** — worse with aminoglycosides, pip-tazo (debated), contrast, hypotension - **Red man** if rapid infusion — extend infusion time - **Ototoxicity** rare IV vs historic reports — still monitor risk factors - MRSA MIC creep / heteroresistance — consult ID for persistent bacteremia

Indication

Rate-control pathways · Angina · …

Dose

Oral dosing titrated by HR/BP and tolerability; route/formulation specific.

Warning

- Bradycardia / AV block risk - Constipation is common and clinically relevant

Indication

Treatment and secondary prevention of VTE · Non-valvular atrial fibrillation / flutter… · …

Dose

Initiation 2–5 mg daily (often 5 mg if healthy outpatient); titrate to **target INR** (2–2.5 vs 2.5–3.5)

Warning

- **Bleeding** — intracranial, GI, retroperitoneal; risk ↑ with supratherapeutic INR, falls, NSAIDs, uncontrolled HTN - Teratogenic — **pregnancy contraindicated** for warfarin (except rare mechanical valve scenarios — specialist) - Major drug–drug and drug–food interactions → unpredictable INR