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Kaiser Permanente: Promoting Evidence-Based Prescribing, , DRUGS, CHOICE, of, , Georgia Drug Information Services, PHARMACY SERVICES, January 2014

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Page 1, , Recommended adult immunization schedule by vaccine and age group — United States, 2013, VACCINEq AGE GROUPu, , 19-21 yrs, , 19–26 yrs, , 27–49 yrs, , 60–64 yrs, , ≥65 yrs, , 1 dose annually, , Influenza*, Tetanus, diptheria, pertussis, (Td/Tdap)*, , Substitute 1-time dose of Tdap for Td booster, then boost with Td every 10 yr, 2 doses, , Varicella*, Human papillomavirus (HPV)*, (females), HPV (males), , 50–59 yrs, , 3 doses, 3 doses, , 3 doses, 1 dose, , Zoster, Measles, mumps, rubella, (MMR)*, Pneumococcal, (polysaccharide), , 1 or 2 doses, 1 or 2 doses, , 1 dose, , 1 or more doses, , Meningococcal*, Hepatitis A*, , 2 doses, , Hepatitis B*, , 3 doses, , *Covered by the Vaccine Injury Compensation Program, For all persons in this category who meet the, age requirements and who lack evidence of immunity (e.g., lack documentation of vaccination, or have no evidence of prior infection), , Recommended if some other risk, factor is present (e.g., on the basis, of medical, occupational, lifestyle,, or other indications), , Tdap recommended for >65 if, contact with ≤12 month old child., Either Td or Tdap can be used if, no contact., , No recommendation, , Please refer to the CDC web site (www.cdc.gov/vaccines) for more information on the 2013 vaccine recommendations.

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Condition, , Treatment of Choice, , Second-line Treatment, , Page 2, , Cardiology, , Atrial Fib/Flutter, Antithrombotic therapy1 High risk factor or >1 moderate risk factor:, Warfarin (INR 2.0-3.0, target 2.5), One moderate risk factor: Aspirin 81-325 mg daily, or Warfarin (INR 2.0-3.0, target 2.5), No risk factors: Aspirin 81-325 mg daily, Rate control, Atenolol 25-100 mg daily, Diltiazem ER 180-360 mg daily, Metoprolol 25-100 mg bid, Verapamil ER 240-320 mg daily, Digoxin 125-250 mcg daily2, Heart Failure, Systolic dysfunction, (LVEF <35-40%), , Diastolic dysfunction, , Hypertension, , Lisinopril 5-40 mg daily, Furosemide 20-200 mg daily-bid, Carvedilol 3.125-25 mg bid or 50 mg bid in, patients >85 kg, Bisoprolol 2.5-20 mg daily, Spironolactone 25 mg daily, (class III and IV after ACEI titration), Furosemide 20-200 mg daily-bid, Lisinopril 5-40 mg daily, Treat fluid retention, hypertension, rhythm, abnormalities and ischemia., , Digoxin 125-250 mcg daily2, Metoprolol Succinate 12.5-200 mg daily (titrate slowly), If ACEI intolerance due to cough, rash, or, angioedema3 use Losartan 25-100 mg daily, In African Americans, or if ACEI intolerance due to, rising SCr, use Hydralazine 25 mg tid PLUS, Isosorbide Dinitrate 20-40 mg tid4 OR, Isosorbide Mononitrate 30-60 mg qam4., If ACEI intolerance due to cough, rash, or, angioedema3 use Losartan 25-100 mg daily, , Initial therapy: Lisinopril/HCTZ 20/25 mg5, (Advance as needed) Start with ½ tablet  1 tablet  2 tablets daily, If ACEI intolerant, replace w/ARB: Losartan 25 mg daily  25 mg bid  50 mg bid, If BP still above goal: add Amlodipine 2.5 mg  5 mg  10 mg daily, If BP still above goal: replace HCTZ with Chlorthalidone 25 mg daily

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Page 3, If BP still above goal: add beta-blocker or Spironolactone., Atenolol 25 mg daily  50 mg daily (keep HR 55-70 bpm) OR, Spironolactone 12.5 mg daily  25 mg daily (if on thiazide therapy & eGFR ≥60 mL/min & K+<4.5), w/ CAD, , w/ Heart Failure, Systolic dysfunction, , Diastolic dysfunction, , Initial therapy: Atenolol 25 mg + Lisinopril 10 mg daily4, If BP still above goal: replace Lisinopril with Lisinopril/HCTZ 20/25 mg;, Start with ½ tablet  1 tablet  2 tablets daily, If ACEI intolerant, replace w/ ARB: Losartan 25 mg daily  25 mg bid  50 mg bid, If BP still above goal: optimize beta-blocker dose, increase Atenolol to 50 mg daily, If BP still above goal: add Amlodipine 2.5 mg  5 mg  10 mg daily, If BP still above goal: replace HCTZ with Chlorthalidone 25 mg daily, If BP still above goal: advance beta-blocker or use Spironolactone, Spironolactone 12.5 mg daily  25 mg daily (if on thiazide therapy & eGFR ≥60 mL/min & K+<4.5), Lisinopril 5-40 mg daily, Bumetanide 0.5-2 mg daily, Furosemide 20-200 mg daily-bid, In African Americans, or if ACEI intolerance due to, HCTZ 12.5-25 mg daily or, rising SCr, use Hydralazine 25 mg tid PLUS, Chlorthalidone 12.5-25 mg daily, Isosorbide Dinitrate 20-40 mg tid4 OR Isosorbide, Lisinopril/HCTZ 10/12.5 mg or 20/25 mg daily, Mononitrate 30-60 mg qam4., Carvedilol 3.125-25 mg bid or 50 mg bid in patients >85 kg, Atenolol 25-100 mg daily, Lisinopril 5-40 mg daily, Lisinopril/HCTZ 10/12.5 mg or 20/25 mg daily, Atenolol/Chlorthalidone 50/25 mg or 100/25 mg daily, , 1. High risk factors: prior CVA, TIA, or embolism; prosthetic heart valve. Moderate risk factors: Age ≥75, HTN, CHF, diabetes, ejection fraction <30%., Weaker risk factors: female, age 65-74, CAD, thyrotoxicosis. ACC/AHA/ESC 2006 Atrial Fibrillation Guidelines., 2. Avoid doses >125 mcg/day in those ≥65 years old., 3. If ACEI-induced angioedema is severe, use caution with ARBs., 4. A daily nitrate-free interval of at least 14 hours is advisable to minimize tolerance., 5. Verify effective contraception in women of child-bearing potential: use chlorthalidone or HCTZ. Use caution with ACEI if eGFR <30 ml/min or, K+>5.5. Use ARBs if ACEI intolerant and HTN not controlled on thiazide alone., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Condition, , Treatment of Choice, , Second-line Treatment, , Page 4, , Dermatology, , Acne, Mild inflammatory and/or Benzoyl peroxide/Erythromycin 5-3% gel, comedonal acne, daily-bid PLUS Tretinoin 0.025% cream qhs, Moderate-severe acne, or truncal involvement, , OTC Benzoyl peroxide 5% daily-bid +/Clindamycin 1% topical soln daily-bid PLUS, Tretinoin 0.025% cream qhs, Change from topical to oral antibiotic continue other treatments listed above:, EES 400 mg bid, Doxycycline 100 mg bid1, , Dermatitis, , Low potency (face and folds):, Hydrocortisone 1%, 2.5%, Medium potency:, Triamcinolone 0.1%, , Medium to High potency:, Fluocinonide 0.05%, High Potency:, Augmented betamethasone dip 0.05%, , Fungal Infection, , OTC Terbinafine cream, , OTC Clotrimazole cream, OTC Miconazole cream, , Pediculosis (lice), , OTC Permethrin 1% rinse (Nix)2—, leave on for 10 min, rinse well, , Permethrin 5% cream (Elimite)2 — apply to hair, cover, w/ shower cap, leave on overnight, rinse well, , Warts, , OTC salicylic acid 40% plasters—change daily, and scrape off dead skin before reapplying, , 1. Use of tetracyclines should be avoided during tooth development (i.e., last half of pregnancy and children <8 years old) because it may cause, permanent tooth discoloration., 2. Repeat in 7 days if nits are still present., , Endocrinology, , Diabetes (DM) Type 2, , Metformin IR 500-1000 mg bid, (max recommended is 2000 mg/day), Metformin ER 500-2000 mg once daily, (max recommended 2000 mg/day), Glipizide 2.5-10 mg bid, (max recommended is 20 mg/day), , Insulin glargine (Lantus B, NF) daily, (NF Long acting insulins: Equivalent to NPH in, blood sugar control. Consider if nocturnal, hypoglycemia or new onset Type I DM)

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Condition, , Page 6, , Treatment of Choice, , Second-line Treatment, , Diverticulitis, , Ciprofloxacin 500 mg bid +, Metronidazole 500 mg tid x 10-14 days, TMP-SMX DS bid +, Metronidazole 500 mg tid x 10-14 days, , Amoxicillin/clavulante 875/125 mg BID x 10-14 days, , GERD, , Famotidine 20-40 mg bid EXCLUDED2, Ranitidine 150-300 mg bid EXCLUDED2, , Pantoprazole 20-40 mg daily1 EXCLUDED2, Omeprazole 20-60 mg daily1 EXCLUDED2, (Use if fails double dose H2RA, or if esophageal, ulcer/stricture), , Gastroenterology, , PUD or Barrett’s Esophagus Pantoprazole 20-40 mg daily1 EXCLUDED2, , Omeprazole 20-60 mg daily1 EXCLUDED2, , H.Pylori Eradication, , Omeprazole 20 mg bid1 +, Amoxicillin 1 gm bid +, Clarithromycin 500 mg bid for 14 days, Metronidazole 500 mg bid may be substituted, for Amoxicillin in patients with PCN allergies., , IBS, , Dicyclomine 20 mg qid prn§, Nortriptyline§ 10-50 mg qhs2,§, Hyoscyamine 0.125-0.25 mg SL tid-qid prn, For constipation, options include:, OTC psyllium (Konsyl or Metamucil) 1 tsp or, 1 Tbsp (depending on product) up to tid, (goal of stool large and soft), OTC Polyethylene glycol 17 g dissolved in, 4-8 oz beverage daily, For diarrhea: OTC Loperamide 4-8 mg/day, , 1. Very low cost Rx and OTC Omperazole 20 mg capsules and Pantoprazole 20-40 mg tablets are available for purchase at KP internal pharmacies., 2. Proton-pump inhibitors (i.e., Omeprazole) and H2-antagonists (i.e., Famotidine) are excluded from coverage under the Commercial prescription, drug benefit and are only available to members for the cash price., § Avoid in adults ≥65 years old.

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Condition, , Treatment of Choice, , Second-line Treatment, , Page 8, , Infectious Diseases, cont., , Community-Acquired Pneumonia, Risk Class II-III, Cefuroxime 500 mg bid x 7-10 days +, Azithromycin 500 mg daily x 5-7 days OR, Doxycycline 100 mg bid x 7-10 days, , Levofloxacin 750 mg daily x 5 days, , Herpes Zoster, , Acyclovir 800 mg 5 times daily x 7-10 days, , Valacyclovir NF 1 gm tid x 7 days, Famciclovir NF 500 mg tid x 7 days, , Otitis Media, , Amoxicillin 500 mg tid or 875 mg bid x 5 days, , Cefuroxime 500 mg bid x 7 days, Azithromycin 500 mg x 1 day, then 250 mg daily x 4, more days, , Pertussis, , Azithromycin 500 mg x 1 day then,, 250 mg daily x 4 more days, , Clarithromycin 500 mg bid x 7 days, Erythromycin 500 mg qid x 14 days, If macrolide-intolerant: TMP-SMX DS bid x 14 days, , Pharyngitis, Streptococcal, , Viral, , Patient to fill prescription only after positive Strep. probe confirmed., PCN VK 500 mg bid x 10 days, If PCN-allergic:, PCN G Benzathine 1.2 million units IM x 1 dose Cephalexin 500 mg bid x 10 days, Clindamycin 300 mg tid x 10 days, Azithromycin 500 mg x 1 day, then 250 mg daily x 4, more days, OTC throat spray or lozenge, , Sexually Transmitted Diseases, The Centers for Disease Control (CDC) recommends presumptive therapy for both gonococcal and Chlamydia infection when, making one of these diagnoses., Gonorrhea and, Ceftriaxone 250 mg IM x 1 dose PLUS, If patient has severe penicillin or cephalosporin, Chlamydia, Azithromycin 1 gm x 1 dose (DOT), allergy: Azithromycin 2 gm x 1 dose (DOT)

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Herpes Simplex (Genital Herpes), First clinical episode, Acyclovir 400 mg tid x 7-10 days or until clinical resolution, Recurrent episodes, Acyclovir 400 mg tid x 5 days, Acyclovir 800 mg tid x 2 days, Suppressive therapy, Acyclovir 400 mg bid, Sinusitis, NO ANTIBIOTIC INDICATED, If antibiotic indicated:, OTC saline nasal spray, Doxycycline 100 mg bid x 7 days, OTC decongestant, TMP/SMX DS bid x 7 days, If antibiotic indicated:, Azithromycin 500 mg daily x 3 days, Amoxicillin 1000 mg bid x 7 days, , Insomnia, , Identify and treat the etiology of insomnia, Non-pharmacological practices, Overcoming™ Insomnia CBT program, Sleep hygine (.piinsomnia), , 1. Avoid chronic use (>90 days per year) in adults ≥65 years old., § Avoid in adults ≥65 years old., , Neurology, , Fibromyalgia, Migraine, , Migraine prevention, , NF = Non-Formulary, , Amitriptyline 25-150 mg qhs§, Tramadol 50-100 mg q4-6h prn, Cyclobenzaprine 5-10 mg tid§, Sumatriptan 25-100 mg; may repeat after, 2 hrs, max 200 mg/day, , Page 9, , If medication indicated, use short-term (<30 days), Trazodone 25-100 mg qhs prn, Zolpidem 5 mg qhs prn1, Zaleplon 5-20 mg qhs prn1, Temazepam 15 mg qhs prn§, Mirtazapine 7.5 mg -15 mg qhs prn, Melatonin 3 mg -5 mg qhs prn, Nortriptyline 10-75 mg qhs§, , Naratriptan 2.5 mg; may repeat after 4 hrs,, max 5 mg/day, Rizatriptan 5 mg; may repeat after 2 hrs,, max 30 mg/day, Propranolol 20 mg bid, h up to 240 mg/day Topiramate 25-100 mg daily, Valproic Acid 250 mg bid, h to max 500 mg bid, Divalproex delayed release (Depakote DR), 250 mg bid, h to max 500 mg bid, Nortriptyline 25-75 mg qhs§, § Avoid in adults ≥65 years old., B = Brand name drug – higher copay for tiered plans

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Condition, , Page 10, , Treatment of Choice, , Second-line treatment, , Neuropathic Pain, , Amitriptyline 25-150 mg qhs§, Tramadol 50-100 mg q4-6h prn, Cyclobenzaprine 5-10 mg tid§, , Nortriptyline 10-75 mg qhs§, Venlafaxine ER 37.5 mg daily x 7 d, h to 75 mg/ d, x 7 days, then h by 37.5 mg/d up to 150 mg/d2, , Restless Legs Syndrome, , Ropinorole 0.25 mg once daily 1-3 hours before bedtime, If needed, after 2 days, can h dose to 0.5 mg; h to 1 mg, after first week; then h by 0.5 mg weekly (up to 4 mg), Pramipexole 0.125 mg [½ of 0.25 mg], once daily 2-3 hours before bedtime, If needed, double the dose every 4-7 days (up to 0.5 mg), , 1, , Neurology, cont., , 1. Successful pain relief is defined as a 30-50% reduction in frequency and intensity from baseline on scale of 0-10, 2. If pain is not relieved after 1 month of therapy at 150 mg/day, increase Venlafaxine dose to 225 mg/day. Venlafaxine should be taken with food., Daily doses can be divided bid or tid (if using Venlafaxine IR tablets) or one time daily (if using Venlafaxine ER capsules), § Avoid in adults ≥65 years old., , OB/GYN – Women’s Health, Dysmenorrhea, , Ibuprofen 600 mg q6h or 800 mg q8h, Naproxen 500 mg initially, then 250 mg q6-8h, (max 1250 mg/day), , Menopausal Symptoms1, Non-Hormonal Therapy for Hot Flashes2:, , For Hot Flashes With or Without Vaginal Dryness:, Uterus absent, Estradiol 0.5-1 mg daily§, , Oral contraceptive (i.e., Levora, Microgestin 1/20), , Venlafaxine 37.5-150 mg/day, Sertraline 25-50 mg daily3,§, Citalopram 10-20 mg daily4, Gabapentin up to 300 mg tid x 4 weeks, Estradiol (Climara) transdermal patch 0.025-0.1 mg/24, hrs; Apply topically weekly§

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Uterus present, , Estradiol (oral or transdermal) +, Medroxyprogesterone 2.5 mg daily, or, 5 mg for 12 consecutive days monthly, For Isolated Vaginal Dryness:, Conjugated Estrogen (Premarin B) vaginal, cream 0.5 g 2x/week, Oral Contraceptive5, , Estradiol (oral or transdermal) +, Norethindrone 0.35 mg daily, or, 0.7 mg for 12 consecutive days monthly, , Page 11, , Estradiol (Estring B) vaginal ring 2 mg;, one ring vaginally every 90 days, , Monophasic, Biphasic, Aviane, Necon1/11, Levora6, Triphasic, Microgestin Fe 1/20, Leena, Microgestin Fe 1.5/30, Nortrel 7/7/7, Necon 0.5/35, Tri-Sprintec, Necon 1/35, Trivora, Reclipsen, Sprintec (35 mcg EE + 0.25 mg Norgestimate), Kelnor 1/35, Cryselle 28, , Osteoporosis7,8, , Alendronate 70 mg once weekly, , Ibandronate (generic Boniva, NF) 150 mg monthly, , Yeast Infection, , OTC vaginal antifungal, , Fluconazole 150 mg x 1 dose, , 1. HRT should be discontinued while patient is hospitalized or at extended bed rest and restarted based on noncardiac benefits/risks. Do not start, HRT in patients who have a recent history of CVD., 2. Off label use. There are no FDA-approved non-hormonal therapies for treatment of hot flashes. Data for the agents listed are some what limited., 3. Avoid if patient on concomitant tamoxifen. Drug interaction may reduce the effects of tamoxifen., 4. The maximum recommended dose of Citalopram is 20 mg per day for patients with hepatic impairment, >60 years of age, CYP2C19 poor metabolizers or taking concomitant CYP2C19 inhibitors., 5. Not listed as first and second line therapy, but listed alphabetically by phases., 6. Preferred formulary alternative for extended cycle regimen., 7. For osteopenia, refer to Fracture Risk Assessment (FRAX) tool to estimate individual fracture risk (www.shef.ac.uk/FRAX)., 8. Total daily intake (from diet and supplements) of calcium 1,200 mg/day and vitamin D3 1,000 units/day is recommended for postmenopausal, women and for men 50 years and older., § Avoid in adults ≥65 years old., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Page 13, , Hydrocodone to Morphine SR, 1 to 1.5 mg Hydrocodone = 1 mg morphine sulfate, Total Daily dose of HYDROCODONE, , Approximate Daily Dose of Morphine, , Equianalgesic dose of MORPHINE SR, , 20-30 mg, , 15-30 mg, , 15 mg daily-BID, , 40-60 mg, , 30-60 mg, , 15-30 mg BID, , 80-120 mg, , 60-120 mg, , 30-60 mg, , 1. Limit APAP dose to ≤3 gm/day; ≤2 gm/day for adults with liver dysfunction or history of alcohol use., 2. Use with caution. Avoid in opioid-naive patients & in those where long-term use may be required for non-cancer and non-post surgical conditions., 3. Other long-acting opioid options include transdermal Fentanyl (reserved for patients with chronic pain who are opioid-tolerant and/or unable to, take oral medications) and methadone (associated with cardiac complications i.e., QTc prolongation and one must be familiar with the appropriate, monitoring guidelines before initiating its use)., 4. Start with short-acting opioid to determine appropriate dose and can substitute with equivalent dose of long-acting formulation (i.e., Morphine SR), if opioid is effective & well-tolerated., § Avoid in adults ≥65 years old., , Psychiatry, Anxiety, Acute, Chronic, , Depression, , Lorazepam 0.5-1 mg bid prn§, Fluoxetine 10-40 mg daily§, Citalopram 10-40 mg daily1, Paroxetine10-20 mg daily, Fluoxetine 10-60 mg daily (max 80 mg/day)§, Citalopram 10-40 mg daily (max 40 mg/day)1, Sertraline 50-100 mg daily (max 200 mg/day), Escitalopram 5-20 mg daily (max 20 mg/day)1, Paroxetine 20-40 mg daily (max 50mg/day), , Alprazolam 0.5 mg tid prn§, Buspirone 5-10 mg bid-tid (max 60 mg/day), Sertraline 25-100 mg daily, Venlafaxine 37.5-75 mg daily, Venlafaxine 37.5 mg/day x 7 days, h to 75 mg/day x 7, days, then h to 150 mg/day (max 375 mg/day), Bupropion SR 150 mg qam x 3 days, h to 150 mg bid, x several weeks (max 400 mg/day), Mirtazapine 15-45 mg qhs (max 45 mg/day), , 1. The maximum recommended dose of Citalopram is 20 mg per day and Escitalopram is 10 mg per day for patients with hepatic impairment, >60, years of age, CYP2C19 poor metabolizers or taking concomitant CYP2C19 inhibitors., § Avoid in adults ≥65 years old, short term only., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Page 15, 31-40 cigarettes/day: OTC Nicotine patch (high dose) 35 mg/day [21 mg + 14 mg] x 4 wks, 21 mg/d, 5, x 2 wks, 14 mg/d x 2 wks, 7 mg/d x 2 wks + OTC Nicotine gum or lozenge + Bupropion SR, >40 cigarettes/day: OTC Nicotine patch (high dose) 42 mg/day [2 x 21 mg] x 4 wks, 21 mg/d x 2 wks,, 14 mg/d x 2 wks, 7 mg/d x 2 wks + OTC Nicotine gum or lozenge + Bupropion SR5, 1. Antihistamines can be used for mild or breakthrough symptoms or in combination with an intranasal steroid., 2. Stepwise approach to therapy is recommended. The goal of therapy is to maintain long-term control with the least amount of medication, thereby, exposing the patient to the least risk for medication adverse effects. For more information on therapy options, please refer to the Adult Asthma, guidelines on cl.kp.org., 3. Use of albuterol more than 2 days per week for symptom relief (not prevention of exercise induced bronchospasm) generally indicates inadequate, control and the need to step-up treatment., 4. Final selection and dosage of medication may depend on patient preference, contraindications, potential for ADEs, and previous experience., 5. Bupropion therapy should begin one week prior to quit date., , Rheumatology, Gout (Acute), , Gout (Prevention)1, Urate-lowering therapy, Gout (Prophylaxis)4, , Indomethacin 50 mg tid x 3 days, then, 50 mg bid x 4-7 days (or until resolved)§, Ibuprofen 800 mg tid x 2 days, then, 400 mg tid for 4-7 days (or until resolved)§, , Prednisone 40 mg daily x 3 days, 30 mg daily x 3 days, 20 mg daily x 3 days, 10 mg x 3 days, then 5 mg, x 3 days (or until resolved), IM or intra-articular corticosteroid injection, (i.e., methylprednisolone, triamcinolone), Non-pharmacological practices (i.e., diet), Probenecid 250 mg bid x 1 week, h to 500 mg bid3, Allopurinol 100 mg, h by 100 mg/day every 2-4 (max 400 mg/day), weeks until serum uric acid level <6 mg/dl2, (max 800 mg/day), Indomethacin 50 mg daily-bid§, Naproxen 500 mg daily§, Colchicine (Colcrys B, NF) 0.6 mg daily-bid4, , 1. Urate lowering therapy is indicated for patients with recurrent gout attacks, chronic gouty arthropathy, tophi, and uric acid stones., 2. Start with allopurinol 50 mg daily in patients with CKD stage 4 or 5., 3. Probenecid is not an option for patients who are under-excretors of uric acid and in those resistant to, or intolerant of allopurinol. It should not be, used in patients with renal impairment or a history of nephrolithiasis., 4. Prophylaxis therapy should be initiated with urate lowering therapy and continued for 4-6 months after uric acid target (<6 mg/dL) is achieved., Colchicine dose should be adjusted in those with eGFR <50 mL/min and avoided in patients with eGFR <10 mL/min., § Avoid in adults ≥65 years old., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Page 16, , Condition, Urology, , Treatment of Choice, , Second-line Treatment, , BPH, , Terazosin 2 mg qhs; if ineffective may increase Tamsulosin 0.4 mg daily 30 min after the same meal1, by 2 mg every week to a max of 10 mg/day, Doxazosin NF 1 mg qhs; if ineffective may increase, by 1 mg every week to a max of 4 mg/day, , Hyperactive Bladder, (Urge incontinence), , Behavioral modifications (i.e., kegels, timed, voiding, bladder training), Oxybutynin 2.5-5 mg bid-tid§, Oxybutynin ER 5-15 mg/day2,§, , Oxybutynin transdermal patch (Oxytrol, OTC) 3.9 mg/day, One patch twice weekly (every 3-4 days)§, Trospium IR 20 mg bid3, (20 mg daily in those >75 years), , Prostatitis, Acute4, Young sexually active men Ceftriaxone 250 mg IM x 1 dose PLUS, Azithromycin 1000 mg x 1 dose, Older patients, TMP-SMX DS bid up to 6 weeks, Ciprofloxacin 500 mg bid up to 6 weeks, Urinary Tract Infection5, Uncomplicated cystitis in No antibiotic indicated for asymptomatic bacteriuria in non-pregnant women, non-pregnant women TMP-SMX DS bid x 3 days, Ciprofloxacin 250 mg bid x 3 days6, Nitrofurantoin 100 mg bid x 7 days7, Cystitis in pregnancy, Cephalexin 500 mg bid x 3-7 days, Nitrofurantoin 100 mg bid x 5 days3, Pyelonephritis, , Ciprofloxacin 500 mg bid x 10 days, , TMP/SMX DS bid x 14 days8, (if organism is susceptible), , 1. Tamsulosin is associated with increased complications during cataract surgery (Intraoperative Floppy Iris Syndrome [IFIS]). Consider non-selective, alpha-blockers (i.e., Terazosin, Doxazosin) for patients diagnosed with cataracts and who have not undergone cataract surgery., 2. May be preferred in adults ≥65 years because of improved side effect profile. May be preferred for elderly patients with dementia., 3. If duration of symptoms >3 weeks, treat for 21-28 days., 4. Therapeutic options for UTI maybe limited and should be based on known or local patterns of susceptibility for the causative pathogen(s).

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Page 17, , 5. Consider Cephalexin therapy in areas with high rates (>20%) of E. coli resistant to TMP/SMX., 6. Caution should be used when using Ciprofloxacin in the elderly due to the risk of tendonitis and tendon rupture., 7. Nitrofurantoin is contraindicated in patients with significant renal impairment (eGFR <60 mL/min). Avoid chronic use in adults >65 years old., 8. Avoid use in 1st and 3rd trimester of pregnancy., § Avoid in adults >65 years old., , Pediatrics, , Allergic Rhinitis, , ≥4 yrs: Fluticasone 1-2 sprays each nostril daily OTC Loratadine 5 mg/5 mL liquid, ≥6 yrs: Flunisolide 2 sprays each nostril bid, OTC Cetirizine 5 mg/5 mL liquid, OTC Fexofenadine 30 mg/5 mL liquid, OTC Brompheniramine + PE (Dimetapp)1, Chlorpheniramine 2 mg/5 mL syrup1, , Asthma (persistent) 2, , Albuterol prn for acute symptoms3 + long acting controller, <5 yrs:, Fluticaonse HFA (Flovent B) 44 mcg only, If unable to use inhaler, consider budesonide, 44 mcg 1-2 puffs bid, max 2 puffs bid4, nebulizer suspension, 5-11 years:, 4-11 yrs:, Beclomethasone HFA (QVAR B), Mometasone (Asmanex B) 110 mcg 1 inh qpm, 40 mcg 1-2 puffs bid, max 2 puffs bid, ≥12 years:, Beclomethasone HFA (QVAR B), Mometasone (Asmanex B) 220 mcg 1 inh qpm 80 mcg 1-2 puffs bid, max 4 puffs bid, 2 inh bid, , 1. FDA cautions against the use of cough and cold medicines in children under 4 years of age., 2. For asthma not controlled on ICS therapy alone, addition of montelukast (generic Singulair) is a potential option. For asthma not controlled on, low-to-medium dose ICS in older kids, consider change to combination ICS/LABA therapy. For more information on therapy options, please refer, to the Asthma guidelines on cl.kp.org., 3. Use of albuterol more than 2 days per week for symptom relief (not prevention of exercise induced bronchospasm) generally indicates inadequate, control and the need to Step-Up therapy., 4. Reserve use for pediatric patients <5 years or patient >5 years who have failed, or who are intolerant to beclomethasone HFA (QVAR)., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Condition, , Treatment of Choice, , Second-line Treatment, , OTC Ketotifen (Zaditor) 0.025% soln 1 gtt bid, OTC Naphazoline/Pheniramine (Opcon-A), 1 gtt qid, Gentamicin soln 1 gtt tid, Polymyxin B/TMP (Polytrim) soln 1 gtt tid, Sulfacetamide soln 1 gtt tid, , Ketorolac 0.5% 1 gtt qid, , Page 18, , Pediatrics, cont., Conjunctivitis, Allergic, Infectious, , Ofloxacin ophthalmic drops 1 gtt qid, , Otitis Media2, , Antibiotics are not indicated for otitis media with effusion only (OME)., Amoxicillin 80-90 mg/kg/day ÷ bid x 10 days Failure of treatment after 48-72 hrs or recurrence:, Adolescents:, Amoxicillin/Clavulanate ES 90 mg/kg/d ÷, Amoxicillin 1000 mg bid x 5-7 days, bid x 10 days, Azithromycin 500 mg daily x 1 day, then, Cefdinir susp 14 mg/kg/day daily or ÷ bid x 10 days, 250 mg daily x 4 more days, Clindamycin 30-40 mg/kg/day ÷ tid x 10 days, If PCN Allergic:, Ceftriaxone 50 mg/kg/d IM daily x 1-3 days, Adolescents:, Non-Type 1 hypersensitivity: Cefdinir susp, 14 mg/kg/day daily or ÷ bid x 10 days, Cefuroxime 500 mg bid x 7 days, Type 1 hypersensitivity:, Amoxicillin/Clavulanate 875/125 mg bid x 7 days, Azithromycin 10 mg/kg/day daily (max 500 mg), x 1 day then, 5 mg/kg/day daily (max 250 mg), x 4 more days, Clarithromycin 15 mg/kg/day ÷ bid x 7-10 days, , Pertussis, , Azithromycin 10 mg/kg x 1 day, then 5 mg/kg, daily for 4 more days, , Clarithromycin 15 mg/kg/day ÷ bid x 7 days, Erythromycin 40-50 mg/kg/day ÷ qid x 14 days, If macrolide-intolerant:, TMP-SMX 8 mg/kg/day ÷ bid x 14 days

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Pharyngitis, Streptococcal, , Page 19, Patient to fill prescription only after positive strep. probe confirmed., PCN VK, PCN G benzathine, <27 kg 250 mg bid x 10 days, <27 kg 600,000 units IM x 1 dose, ≥27 kg 500 mg bid x 10 days, ≥27 kg 1.2 million units IM x 1 dose, If PCN-allergic:, Amoxicillin 45 mg/kg/day ÷ bid x 10 days, (max 10000 mg/day), Cephalexin, <27 kg 250 mg bid x 10 days, ≥27 kg 500 mg bid x 10 days, Clindamycin 15-30 mg/kg/day ÷ tid x 10 days, Azithromycin 12 mg/kg/day x 5 days, , Sinusitis, Acute bacterial, , Amoxicillin/Clavulanate 45 mg/kg/day ÷, bid x 10-14 days, Adolescents:, Amoxicillin/Clavulanate 1000 mg bid x 10-14 days, Doxycycline 100 mg bid x 10-14 days, If PCN allergic:, Non-Type 1 hypersensitivity (use combination therapy):, Cefdinir susp 14 mg/kg/day daily or ÷ bid -PLUSClindamycin 30-40 mg/kg/day ÷ tid x 10-14 days, Type 1 hypersensitivity:, Levofloxacin 10-20 mg/kg/day daily or ÷ bid x 10-14 days, , URI, , Treat symptoms, OTC PSE, APAP, or Chlorpheniramine1, , 1. FDA recommends that over-the-counter (OTC) cough and cold medicines not be used for children under 2 years of age., 2. A shorter treatment course of 5-7 days may be considered for children ≥ 2 years old., , NF = Non-Formulary, , B = Brand name drug – higher copay for tiered plans

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Kaiser Foundation Health Plan of Georgia, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA 30305, , This document is for clinician use only., Under no circumstances should any portion be, reproduced or distributed to others, including, members, vendors, brokers, etc., , 60198611 01/14, © 2014 Kaiser Foundation Health Plan of Georgia, Inc.