pharmacy and therapeutics committee-approved …ww4.mgh.org/physicians/formulary...

Pharmacy and Therapeutics Committee-approvedTherapeutic Interchanges

Therapeutic Interchange Revision Date

Alpha Blockers 08/11

Alpha Reductase Inhibitors 05/16

ACE Inhibitors 08/11

Angiotensin Receptor Blockers 08/11

Buprenorphine 09/11

Calcium Channel Blockers (DHP) 08/11

Carbapenems 07/11

Cardioselective Beta Blockers 08/11

Cephalosporins 09/11

Corticosteroids, Inhaled 06/16

Corticosteroids, Intranasal 08/11

Fluoroquinolones 01/13

Glitazones 08/11

Histamine Receptor Antagonists (H2RAs) 08/11

Inhaled Anticholinergics 05/16

Insulin Analogs 05/16

IV to PO conversions 05/16

Leukotriene Receptor Antagonists 08/11

Levalbuterol 12/13

Miscellaneous Antidepressants 05/16

Miscellaneous CNS Stimulants 05/16

Nitroglycerin Sublingual 05/16

Non-benzodiazepine Hypnotics 08/11

Non-sedating Antihistamines 08/11

Ophthalmic Preparations 08/11

Phosphate Binders 01/13

Proton Pump Inhbitors 08/11

Statins 08/11

All conversions unless noted otherwise are for adult patients with normal renal and/or hepatic

function. Please consult additional references when these clinical situations do not apply.

Upper Peninsula Health System - Marquette

Pharmacy and Therapeutics Committee-approved

Therapeutic Interchange: Alpha Blockers

Generic Name Brand Name

Terazosin Hytrin® 1 2 5 10 20

Doxazosin Cardura® 1 2 4 8 16

Tamsulosin Flomax® 0.4 0.8 N/A N/A N/A

Alfuzosin UroXatral® 10 10 N/A N/A N/A

*Formulary agents in bold.

Notes:

Prazosin is not included in this therapeutic interchange.

Dose Equivalents (mg/day)

Doxazosin and terazosin are therapeutically equivalent for the treatment of hypertension and benign

prostatic hypertrophy (BPH).

Alfuzosin and tamsulosin are therapeutically equivalent for the treatment of BPH and are the preferred

agents in patients who are unable to tolerate the cardiovascular adverse effects from other alpha blockers.

Document created: 08/11.

Revised: None



Therapeutic Interchange: Alpha Reductase Inhibitors


Finasteride Proscar®

Dutasteride Avodart®



5 mg once daily

0.5 mg once daily


Revised: None



Therapeutic Interchange: ACE Inhibitors


Short-acting

Captopril Capoten® 75 150 300 450

Intermediate-acting

Benazepril Lotensin® 5 10 20 40

Enalapril Vasotec® 5 10 20 40

Moexipril Univasc® 7.5 15 22.5 30

Quinapril Accupril® 5 10 20 40

Ramipril Altace® 2.5 5 10 20

Long-acting

Lisinopril Prinivil® 5 10 20 40

Fosinopril Monopril® 5 10 20 40

Perindopril Aceon® 4 8 12 16

Trandolapril Mavik® 1 2 4 8


Notes:

Captopril is short-acting and should be dosed 2-3 times daily.

Lisinopril is long-acting and should be dosed once daily.


Enalapril and benazepril are intermediate-acting and should be dosed 1-2 times daily. Enalapril is the

preferred intermediate-acting ACE inhibitor. Benazepril is available for continuation of outpatient therapy.


Revised: 08/11.



Therapeutic Interchange: Angiotensin Receptor Blockers


Losartan Cozaar® 25 50 100 100

Candesartan Atacand® 4 8 16 32

Eprosartan Teveten® 200 400 600 800

Irbesartan Avapro® 75 150 300 300

Olmesartan Benicar® 5 10 20 40

Telmisartan Micardis® 20 40 80 80

Valsartan Diovan® 40 80 160 320

*Formulary agent in bold.



Revised: None



Therapeutic Interchange: Buprenorphine Sublingual


Buprenorphine Subutex® 8 16 24

Buprenorphine/naloxone Suboxone® 8/2 16/4 24/6


Notes:


Suboxone® strength expressed as buprenorphine/naloxone which are available as 2 mg/0.5 mg and 8 mg/2

mg sublingual tablets and film.


Revised: None



Therapeutic Interchange: Calcium Channel Blockers (Dihydropyridines)


Amlodipine Norvasc® 2.5 5 10

Nifedipine, extended release Procardia XL® 30 60 90

Felodipine, extended release Plendil® 2.5 5 10

Isradipine, immediate release DynaCirc® 5 10 20

Isradipine, controlled release DynaCirc CR® 5 10 20

Nicardipine, immediate release Cardene® 60 90 120

Nicardipine, controlled release Cardene CR® 60 90 120

Nisoldipine, extended release Sular® 17 25.5 34


Notes:

Nimodipine (Nimotop®) is not subject to therapeutic interchange.


Amlodipine is the preferred dihydropyridine CCB. Nifedipine, extended release is available for continuation

of outpatient therapy.


Revised: None



Therapeutic Interchange: Carbapenems


Meropenem Merrem® 2000 3000

Doripenem Doribax® 1500 3000

Imipenem/cilastatin Primaxin® 2000 3000


Notes:


The preferred dosing for the treatment of infections caused by multi-resistant gram negative bacilli or

empiric therapy is meropenem 500 mg every 6 hours. Please refer to the Carbapenem Guidelines for Use

for further details.


Revised: None



Therapeutic Interchange: Cardioselective Beta Blockers


Atenolol Tenormin® 25 50 100 N/A

Metoprolol Toprol® 50 100 200 400

Betaxolol Kerlone® 10 20 N/A N/A

Bisoprolol Zebeta® 5 10 20 N/A

Nebivolol Bystolic® 5 10 20 40


Notes:


Metoprolol is the preferred cardioselective beta blocker. Atenolol is available for continuation of outpatient

therapy.


Revised: None



Therapeutic Interchange: Cephalosporins


Ceftriaxone Rocephin® 1000 2000 3000 4000

Cefotaxime Claforan® 3000 6000 9000 12000


Notes:


Ceftriaxone is the preferred third generation cephalosporin in adult patients. Cefotaxime is available for use

in neonates and for orders written by Infectious Diseases faculty.

Usual adult dosing for ceftriaxone is 1-2 gm every 12-24 hours (max: 4 gm/day), usual adult dosing for

cefotaxime is 1-2 gm every 6-8 hours (max: 12 gm/day).


Revised: None



Therapeutic Interchange: Corticosteroids, Inhaled


Beclomethasone

dipropionate QVAR® 80 mcg 1 2 4 6 8

Budesonide Pulmicort® 180 mcg 1 2 to 3 4 to 5 6 7+

Fluticasone Arnuity® Ellipta 100 mcg

Fluticasone Arnuity® Ellipta 200 mcg

Fluticasone Flovent® HFA 44 mcg 1 to 3 4 to 6 7 to 8 9 to 10 11+

Fluticasone Flovent® HFA 110 mcg 1 2 3 4 5+

Fluticasone Flovent® HFA 220 mcg N/A 1 N/A 2 3+

Fluticasone Flovent® Diskus 50 mcg 1 to 3 4 to 6 7 to 8 9 to 10 11+

Fluticasone Flovent® Diskus 100 mcg 1 2 to 3 4 5 6+

Fluticasone Flovent® Diskus 250 mcg N/A 1 N/A 2 3+

Mometasone Asmanex® 220 mcg N/A 1 2 3 4+



Budesonide/formoterol Symbicort® 80/4.5

Budesonide/formoterol Symbicort® 160/4.5

Mometasone/formoterol Dulera® 100/5

Mometasone/formoterol Dulera® 200/5

Fluticasone/vilanterol Breo® Ellipta 100/25

Fluticasone/vilanterol Breo® Ellipta 200/25

Fluticasone/salmeterol Advair® HFA 45/21



Fluticasone/salmeterol Advair® Diskus 100/50




Notes:

Breo® Ellipta (fluticasone/vilanterol) is indicated for asthma at one inhalation (100 mcg/25 mcg) once daily with

maximum dosing of one inhalation (200 mcg/25 mcg) once daily and for COPD at one inhalation (100 mcg/25 mcg) once

daily.

N/A

N/A 1 inhalation twice daily

1 inhalation twice daily

N/A

1 inhalation twice daily N/A

N/A

N/A

N/A

N/A 1 inhalation once daily

1 inhalation once daily N/A

2 puffs twice daily

N/A

2 puffs twice daily

2 puffs twice daily

2 puffs twice daily

2 puffs twice daily

N/A

2 puffs twice daily

N/A

2 puffs twice daily

Dose Equivalents (puffs per day)

Dose Equivalents (puffs per day)

1 inhalation once daily

N/A

2 inhalations once daily

N/A


Revised: 01/17.



Therapeutic Interchange: Corticosteroids, Intranasal

Generic Name Brand Name Dose Equivalents

Fluticasone propionate Flonase® 2 sprays in each nostril daily

Beclomethasone Beconase AQ® 1 to 2 sprays in each nostril twice daily

Budesonide Rhinocort Aqua® 1 spray in each nostril daily

Ciclesonide Omnaris® 2 sprays in each nostril daily

Flunisolide Nasarel® 2 sprays in each nostril 2 to 3 times daily

Fluticasone furoate Veramyst® 2 sprays in each nostril daily

Mometasone Nasonex® 2 sprays in each nostril daily

Triamcinolone Nasacort AQ® 1 to 2 sprays in each nostril daily



Revised: 08/11.



Therapeutic Interchange: Fluoroquinolones


Intravenous Oral

Ciprofloxacin Cipro®

Mild to moderate infections: 200

to 400 mg every 12 hours

Severe infections: 400 mg every

8 to 12 hours



Severe infections: 500 to 750 mg

every 8 to 12 hours

Moxifloxacin Avelox® 400 mg every 24 hours 400 mg every 24 hours

Levofloxacin Levaquin®




every 24 hours




every 24 hours

Ofloxacin Floxin® N/A 200 to 400 mg every 12 hours

Norfloxacin Noroxin® N/A 400 mg every 12 hours

Gemifloxacin Factive® N/A 320 mg every 24 hours


Note:

Moxifloxacin should not be used for genitourinary infections and gram-negative bacteremias.



Revised: 01/13.



Therapeutic Interchange: Thiazolidinediones (Glitazones)


Pioglitazone Actos® 15 30 45

Rosiglitazone Avandia® 2 4 8




Revised: 08/11.



Therapeutic Interchange: Histamine Receptor Blockers


Famotidine, oral Pepcid® 20 40

Cimetidine Tagamet® N/A 600 to 1200

Nizatidine Axid® 150 300

Ranitidine Zantac® 150 300

Famotidine, injection Pepcid IV® 20 40

Cimetidine Tagamet IV® N/A 900 to 1200

Ranitidine Zantac IV® 50 to 100 150 to 200



By declaration of the P&T Committee, the H2RAs are subject to automatic IV to PO interchange.

Please refer to the Intravenous to Oral Medication Conversion Program for further details.


Revised: 08/11.



Therapeutic Interchange: Inhaled Anticholinergics


Albuterol MDI Ventolin® 1-2 inhalations every 4-6 hours

Albuterol nebulization solution Ventolin® 1 vial three to four times per day

Ipratropium nebulization solution Atrovent® 1 vial three to four times per day

Ipratropium/albuterol nebulization solution DuoNeb® 1 vial four times per day

Ipratropium/albuterol MDI Combivent® 2 inhalations four to six times per day

Ipratropium MDI Atrovent® 2 inhalations four to six times per day

Tiotropium inhalation Spiriva® Respimat 2 inhalations (2.5 mcg each) once daily

Tiotropium inhalation Spiriva® Handihaler 1 capsule once daily

Aclidinium inhalation Tudorza® 1 inhalation twice daily

Umeclidinium inhalation Incruse® 1 inhalation once daily


Notes:

DuoNeb® contains ipratropium 0.5 mg and albuterol 3 mg in each 3 mL unit-dose vial.

Spiriva® HandiHaler is to be used for administration of tiotropium which is dosed at 2 inhalations of a single 18

mcg capsule once daily.

Combivent® Respimat inhaler contains ipratropium 20 mcg and albuterol 100 mcg in each inhalation (120

inhalations per cartridge).

Combivent® Respimat inhalers are not available for inpatient use at UPHSM. Non-ventilated patients may be

switched to umeclidinium inhalation with or without an albuterol MDI (albuterol must be ordered separately) or

to ipratropium/albuterol (DuoNeb®) nebulization solution. Ventilated patients may be switched to

ipratropium/albuterol (DuoNeb®) nebulization solution.

Atrovent® metered dose inhalers (MDIs) are not available for inpatient use at UPHSM. Non-ventilated patients

may be switched to umeclidinium inhalation or ipratropium (Atrovent®) nebulization solution. Ventilated

patients may be switched to ipratropium (Atrovent®) nebulization solution.

Tudorza® and Spiriva® inhalers may be switched to umeclidinium (Incruse®).


Revised: 01/17.



Therapeutic Interchange: Insulin Analogs


Insulin lispro 75/25 mix Humalog 75/25® 0.5 to 1 units/kg/day in divided doses

Insulin aspart 70/30 mix Novolog 70/30® 0.5 to 1 units/kg/day in divided doses

Insulin glargine Lantus® Initial dose of 0.2 units/kg (10 units) once daily

Insulin detemir Levemir® Initial dose of 0.2 units/kg (10 units) once daily

*Formulary agent in bold (detemir preferred).

Notes:

When changing therapy in patients receiving basal insulin with insulin detemir once-daily to insulin glargine, a

1:1 conversion is recommended. However, for patients receiving basal dosing two or more times per day, a

20% reduction in the total daily basal dose is recommended for conversion to the insulin glargine dose.


Revised: 04/13.



Therapeutic Interchange: Intravenous to Oral

Generic Name IV Dosage Oral Dosage

Azithromycin 500 mg every 24 hours 500 mg every 24 hours

Cefazolin 1 gm every 8 hours Cephalexin 500 mg every 6 hours

Ciprofloxacin 400 mg every 12 hours 500-750 mg every 12 hours

Famotidine 20 mg every 12 hours 20 mg every 12 hours

Fluconazole 400 mg every 24 hours 400 mg every 24 hours

Levofloxacin 500 mg every 24 hours 500 mg every 24 hours

Levothyroxine 50 mcg every 24 hours 100 mcg every 24 hours

Linezolid 600 mg every 12 hours 600 mg every 12 hours

Metronidazole 500 mg every 6 hours 500 mg every 6 hours

Ondansetron 4-8 mg 8-16 mg

Pantoprazole 40 mg every 24 hours Omeprazole 20 mg every 24 hours

Rifampin 300 mg every 12 hours 300 mg every 12 hours

Valproic acid 500 mg every 6 hours 500 mg every 6 hours

Voriconazole

LD: 6 mg/kg every 12 hours x2;

MD: 4 mg/kg every 12 hours

Pt wt ≥40 kg: 200 mg every 12 hours

Pt wt ≤40 kg: 100 mg every 12 hours

Notes:

Situations where IV to PO conversion is appropriate:

q Patient is receiving/tolerating other oral medications;

q Patient is receiving regular diet and has not been designated ‘Nothing Per Os’ (NPO);

q Patient’s enteral route is functional [i.e., receiving enteral feedings without residuals or has evidence that

gastrointestinal (GI) tract is functional (i.e., no evidence of ileus or profuse diarrhea)];

q Patient does not have active GI bleeding;

q Patient has been afebrile for at least 24 hours (antibiotics only);

q Patient is not hypotensive (i.e., SBP < 90 mmHg) or on vasopressor support to maintain blood pressure;

q Patient does not have mucositis (for patients undergoing chemotherapy and who do not have a nasogastric

tube).

Recommendation for valproic acid conversion based on using immediate-release formulation of solution or

capsules.

Dosage for PO conversion of ciprofloxacin depends upon severity of infection.


Revised: 05/16.



Therapeutic Interchange: Leukotriene Receptor Antagonists

Generic Name Brand Name Dose Equivalents (mg/day)

Montelukast Singulair® 10

Zafirlukast Accolate® 40



Revised: 08/11.



Therapeutic Interchange: Levalbuterol


Albuterol nebulization solution Generic 2.5 mg every 4 hours

Levalbuterol nebulization solution Xopenex® 0.63 mg to 1.25 mg every 4-6 hours



Albuterol MDI Ventolin HFA® 1-2 inhalations every 4 hours

Levalbuterol MDI Xopenex HFA® 1-2 inhalations every 4-6 hours


Notes:

Levalbuterol orders with a PRN frequency will be interchanged with albuterol orders with a PRN frequency.

Albuterol nebulization solution contains albuterol 2.5 mg in each 3 mL unit-dose vial (0.083%).

Levalbuterol HFA contains 45 mcg per actuation

Albuterol HFA contains 90 mcg per actuation

The automatic therapeutic interchange for levalbuterol is approved for inpatients 12 years of age and older

unless appropriate documentation is provided for levalbuterol use (see guidelines for use).


Revised: 12/13.



Therapeutic Interchange: Miscellaneous Antidepressants


Venlafaxine, extended release Effexor XR® 75 150 N/A

Desvenlafaxine Pristiq® 50 100 N/A


Notes:

Desvenlafaxine is the major active metabolite of venlafaxine.


In clinical studies, desvenlafaxine dosages of 50 to 400 mg/day were shown to be effective, although no

additional benefit was demonstrated at dosages of more than 50 mg/day. Adverse reactions and

discontinuations were more frequent at higher doses.


Revised: 05/16.



Therapeutic Interchange: Miscellaneous CNS Stimulants


Armodafinil Nuvigil® 150 to 250 mg once daily in the morning

Modafinil Provigil® 200 to 400 mg once daily in the morning



Revised: None



Therapeutic Interchange: Nitroglycerin Sublingual


Nitroglycerin 0.4 mg/actuation

spray Nitrolingual®

1 to 2 sprays every 5 minutes for a maximum of 3

sprays in 15 minutes

Nitroglycerin 0.4 mg tablet NitroStat®

0.4 mg every 5 minutes for a maximum of 3 tablets in

15 minutes


Notes:

Nitroglycerin spray will be maintained on formulary as a uterine relaxant; however, for the management of

angina, it will be interchanged with nitroglycerin sublingual tablets.


Revised: None



Therapeutic Interchange: Non-benzodiazepine Hypnotics


Zolpidem Ambien® N/A 5 10 N/A

Eszopiclone Lunesta® 1 2 N/A 3

Zaleplon Sonata® N/A 5 10 20

Zolpidem, extended release Ambien CR® N/A 6.25 12.5 N/A




Revised: 08/11.



Therapeutic Interchange: Non-sedating Antihistamines


Loratadine Claritin® 5 10 10

Cetirizine Zyrtec® 2.5 5 10

Desloratadine Clarinex® N/A 5 5

Fexofenadine Allegra® 60 120 180


Notes:


Patients receiving decongestant/antihistamine combination products (i.e., Allegra-D 12 and 24 hour, Claritin-

D, and Zyrtec-D) will be converted to loratadine and pseudoephedrine individually.


Revised: 08/11.



Therapeutic Interchange: Ophthalmic Preparations


Latanoprost Xalatan® 1 drop into affected eye(s) once daily in the evening

Bimatoprost Lumigan® 1 drop into affected eye(s) once daily in the evening

Travoprost Travatan® 1 drop into affected eye(s) once daily in the evening



Dorzolamide Trusopt® 1 drop into affected eye(s) three times daily

Brinzolamide Azopt® 1 drop into affected eye(s) three times daily



Timolol Timoptic® 1 drop into affected eye(s) twice daily

Betaxolol Betoptic-S® 1 to 2 drops into affected eye(s) twice daily

Carteolol Ocupress® 1 drop into affected eye(s) twice daily

Levobunolol Betagan® 1 to 2 drops into affected eye(s) twice daily

Metipranolol Optipranolol® 1 drop into affected eye(s) twice daily


Notes:

Betaxolol is available in 0.25% and 0.5% solutions.

Carteolol is available in a 1% solution.

Levobunolol is available in 0.25% and 0.5% solutions.

Metipranolol is available in a 0.3% solution.

Initial dose for timolol is 0.25%, 1 drop into affected eye(s). Timoptic® is usually dosed twice daily; Timoptic-

XE® is usually dosed once daily. If clinical response is not adequate, the dosage may be changed to the 0.5%

solution.


Revised: None



Therapeutic Interchange: Phosphate Binders


Calcium acetate PhosLo® 667 1334 2001 2668

Sevelamer hydrochloride Renagel® 800 1600 2400 3200

Sevelamer carbonate Renvela® 800 1600 2400 3200

Lanthanum Fosrenol® 250 500 750 1000


Notes:

Calcium acetate is available in 667 mg tablets.

Dose Equivalents (mg/meal)


Revised: 01/13.



Therapeutic Interchange: Proton Pump Inhibitors


Omeprazole, oral Prilosec® 20 40

Dexlansoprazole Kapidex® 30 60

Esomeprazole Nexium® 20 40

Lansoprazole Prevacid® 15 30

Pantoprazole Protonix® 20 40

Rabeprazole Aciphex® 20 20

Pantoprazole, injection Protonix IV® 40 80

Esomeprazole Nexium IV® 40 80



By declaration of the P&T Committee, the Proton Pump Inhibitors are subject to automatic IV to PO

interchange. Please refer to the Intravenous to Oral Medication Conversion Program for further details.


Revised: 08/11.



Therapeutic Interchange: HMG CoA Reductase Inhibitors (Statins)


Atorvastatin Lipitor® 10 20 40 80

Pravastatin Pravacol® 40 80 N/A N/A

Rosuvastatin Crestor® 5 10 20 40

Simvastatin Zocor® 20 40 80 N/A

Fluvastatin Lescol® 80 N/A N/A N/A

Lovastatin Mevacor® 40 80 N/A N/A

Pitavastatin Livalo® 2 4 N/A N/A


Notes:

Simvastatin is the preferred therapeutic substitution for lovastatin.


Due to the increased risk of myopathy, including rhabdomyolysis, use of simvastatin 80 mg daily should be

restricted to patients who have been taking simvastatin 80 mg per day chronically (i.e., 12 months or longer)

without evidence of muscle toxicity.


Revised: None

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