Secretions
Anti-secretory drugs help to dry up the bronchial or salivary secretions. However, they
do not affect any existing secretions. It is recommended that these drugs are started at
the first sign of secretions as they do not dry up secretions that are already present.
They are more effective on salivary than bronchial secretions and have limited impact
on secretions due to respiratory pathology such as pneumonia or pulmonary edema.
Because the anticholinergics dry up the bronchial secretions, they may contribute or
cause mucus plugs.
All of the anticholinergic agents have side effects such as blurred vision, constipation, dry
mouth, urinary retention, cardiac side effects (bradycardia or tachycardia, arrythymias).
There is no evidence to support a first choice anticholinergic for the treatment
of terminal secretions and congestion. Occasionally, patients with severe/abundant
secretions will require a combination of different medications. If patient is actively dying
and atropine alone not effective – consider alternating atropine with hyoscyamine hourly.
Atropine and scopolamine – readily cross the blood-brain barrier – which may lead
to increased CNS side effects such as confusion, delirium, hallucinations, sedation and
agitation.
Hyoscyamine and glycopyrrolate – are quaternary amines and do not cross BBB
and therefore less likely to cause CNS side effects.
Glycopyrrolate has 5x the antisecretory potency compared to atropine but has poor
and erratic oral absorption.
Scopolamine - typically this is not recommended in end of life care due to issues with
unpredictable absorption as well as difficulties with titration. It takes up to 12 hours for
effect – which makes it of limited benefit in actively dying patients. Up to 3 patches can
be used – however, this is based on case reports and anecdotal reports only.
Drug Name Drug Name
Atropine Hyoscyamine (Levsin®)
Commercially Solution: 1% Solution, oral drops: 0.125mg/mL
Available Solution: 0.125mg/5mL
Formulations 1-4 gtts po/SL Q1-4h Tablet: 0.15mg, 0.125mg, 0.375mg
4 applications daily Tablet, orally disintegrating: 0.125mg
Usual Dose -May cause anticholinergic Injection: 0.5mg/mL
Max Total Daily induced delirium if used for an
Dose (TDD) extended length of time 0.125-0.25mg po/SL Q4-6h PRN
Comments -May contribute or cause secretions
mucous plugs
Relative Cost/Day 1.5mg
Tier 1
-Patients may experience
anticholinergic side effects such as
blurred vision, urinary retention,
dry mouth and dry eyes
-Confusion is less common than
with atropine
-May contribute or cause mucous
plugs
Tier 1
190
Secretions (continued)
Commercially Drug Name Drug Name
Available Glycopyrrolate (Robinul®)
Formulations Scopolamine hydrobromide
Tablet: 1mg, 2mg (TransDerm Scop® Patch,
Injection, solution: 0.2mg/mL Scopace™)
Injectable solution: 0.4mg/mL
Patch: 1.5mg topically Q72h
Tablet, soluble: 0.4mg
Usual Dose 1-2mg po Q4-12h, Inj: 0.4-1mg 3-4 x/day
0.2mg SubQ Q4-12h Patch: 1.5mg Q72h topically
Tablet: 0.4-0.8 po Q8-12h
Max Total Daily po 8mg prn secretions
Dose (TDD) SubQ 0.8mg
4.5mg topically Q72h (3
patches)
Comments -Generally should be reserved -Injection may be given IM,
for patients who develop IV or SubQ. For IV injection
intolerable side effects dilute solution with an equal
or confusion with other volume of sterile water and
anticholinergic medications administer by direct IV; inject
-May contribute or cause over 2-3 minutes
mucous plugs -Patches are not preferred (as
compared with oral solutions)
due to difficulty in titration
- Patients may experience
anticholinergic side effects
such as blurred vision, urinary
retention, dry mouth, dry eyes,
and confusion
-May contribute or cause
mucous plugs
Relative Cost/Day Tier 3 Tier 3
References:
• http://www.fraserhealth.ca/media/18FHSymptomGuidelinesTerminalSecretions.pdf
• Bickel K, Arnold R. Death Rattle and Oral Secretions, 2nd Edition. Fast Facts and Concepts.
April 2008; 109. Available at: http://www.eperc.mcw.edu/fastfact/ff_109.htm
• Wilders H, Menten J. Death Rattle; prevalence, prevention and treatment. J Pain and
Symptom Manage 2002; 23:310-317
• Back IN, Jenkins K, Blower A, Beckhelling J. A study comparing hyoscine hydrobromide and
glycopyrrolate in the treatment of death rattle. Palliat Med 2001; 15: 329-336
• Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of
death rattle; evidence based guidelines for palliative care. Palliat Med 2002; 16:369-374
• Owens DA. Management of upper airway secretions at the end of life. J Hosp Palliat Nurs.
2006;8(1):12-14
• Hughes A,Wilcock A, Corcoran R, Lucas V et all. Audit of three antimuscarinic drugs for
managing retained secretions. Palliat Med. 2000;14(3):221-222
• Sorenson HM. Managing secetions in dying patients. Respir Care. 2000;45(11):1355-1363.
191
Seizures
Is patient Yes
actively seizing?
Initiate lorazepam 4mg
No po/SL OR diazepam
10mg po/SL. Assess
efficacy after 15 minutes.
Is patient able Effective?
to swallow?
No Yes
Initiate phenobarbital No
50-100mg PR Qday-BID.
Initiate lorazepam 2mg
Effective? Initiate levetiracetam po/SL Q15 min (max 8mg/
No 500-1500mg po BID.
episode) OR diazepam
10mg po/SL Q15 min
(max 30mg/episode).
Effective?
Initiate lorazepam No
1-2mg IV/SubQ
Initiate diazepam rectal gel*
Q6-8h. 10-20mg PR, repeat hourly
until seizures stop. +/- 20mg
Effective? PR QHS for prophylaxis.
No
Initiate lorazepam
1-2mg po/SL Q6-8h
OR clonazepam
1-4mg po BID.
*Requires CM approval.
192
Seizures
- Focal or generalized seizures are the presenting symptom in 15-20% of patients with
brain metastases. Metastases from melanoma have a 50% incident of seizures, possibly
because of their hemorrhagic nature.
- Prophylactic anticonvulsant therapy in patients with brain tumors/metastases is
controversial and has not been shown to provide a benefit in seizure control.Thus
antiepileptic medications should not be given routinely to patients with brain metastases
as they have not been found to prevent seizures and can be discontinued in patients
who have never had a seizure.
- Seizure prophylaxis should be instituted only after the first seizure or for patients with a
seizure history, and should be continued as long as possible.
- Antiepileptic medications with cytochrome P450 enzyme inducing properties should
be avoided due to the potential for multiple drug interactions. Most of the new
antiepileptic medications, such as gabapentin and levetiracetam, have no enzyme-inducing
activity and are good candidates in the treatment of partial seizures secondary to brain
metastases.
• Gabapentin 300mg po TID to QID with maintenance dose of 900 to 3600mg
per day.
• Rectal drug administration:
o There are reports of diazepam solution for injection being given rectally.
This is an alternative for patients who are actively seizing and do not have
access to diazepam rectal gel.
o Phenytoin should NOT be given rectally due to poor absorption and the
potential for severe rectal irritation due to its alkaline pH.
o Phenobarbital solution for injection may be given rectally.The oral solution
should not be given rectally due to its high volume and high sucrose content.
There is no significant difference between oral and rectal absorption.
o Injectable form of lorazepam may be administered rectally. Bioavailability is
approximately 80%.
o Carbamazepine 200mg BID-QID, valproic acid 15mg/kg/day, and lamotrigine
can all be given rectally: Carbamazepine should be divided into small doses
administered 6-8 times a day. Lamotrigone is administered rectally by
crushing and suspending the chewable tablets in 10mL of water. When
clinically indicated, drug levels of lamotrigine should be monitored as rectal
absorption is erratic.
Antiepileptic Medication Dosing and Routes.
Drug Status loading dose Maintenance dose
Diazepam 0.2mg/kg or 10-20mg PR 20mg PR QHS
Lorazepam 0.1mg/kg IV or IM 1-2mg po Q8h
Clonazepam 1mg IV or SubQ 0.5-5mg po TID
Phenytoin 20mg/kg IV 200-400mg po per day
Phenobarbital 10-15mg/kg 60-100mg po/PR Qday-BID
193
Seizures (continued)
Commercially Drug Name Drug Name
Available Levetiracetam (Keppra®)
Formulations Tablet: 250mg, 500mg, 750mg, Phenobarbital (Luminal®)
1,000mg
Usual Dose Solution: 100mg/mL Tablet: 15mg, 30mg, 32mg,
Max Total Daily Tablet, ER: 500, 750mg 60mg, 65mg, 100mg
Dose (TDD) Elixir: 20mg/5mL
500-1,500mg po BID Injection, solution, as sodium:
3000mg 60mg/mL, 65mg/mL;
130mg/mL
60-100mg po Qday-BID
Based on therapeutic value
Adults: 20-40mcg/mL
Comments -Immediate release tablets can -May be given PO, PR, IM
be crushed -Long half-life allows for less
frequent dosing
Relative Cost/Day Tier 2 Tier 1
Drug Name Drug Name
Lorazepam (Ativan®) Diazepam (Valium®, Diastat®)
Commercially Solution, oral [concentrate]: Injection, solution: 5mg/mL
Available 2mg/mL Solution, oral: 5mg/5mL, 5mg/
Formulations Tablet: 0.5mg, 1mg, 2mg mL
Injection, solution: 2mg/mL, Tablet: 2mg, 5mg, 10mg
4mg/mL Rectal gel (Diastat®): 2.5mg
Rectal gel (Diastat® AcuDial):
Usual Dose 0.5-2mg po/sl Q4-6h PRN 5mg, 7.5mg, 10mg, 12.5mg,
Max Total Daily seizures or scheduled 15mg, 17.5mg, 20mg
Dose (TDD) 5-10mg SL/PR Q10 min up to
Comments Based on individual patient 60mg per episode
tolerance 60mg
Relative Cost/Day
-Can be given PO, SL, PR, -Tablet may be given PO, SL
SubQ or PR
-Reduce initial dose if liver
disease present Tablet:Tier 1
-May cause a paradoxical Diastat rectal:Tier 3
reaction, contributing to
(instead of relieving) anxiety
Tier 1
References:
• Taillibert, Sophie, and Jean-Yves Delattre.“Palliative care in patients with brain metastases.”
Current opinion in oncology 17.6 (2005): 588-592.
• Dreifuss, Fritz E., et al.“A comparison of rectal diazepam gel and placebo for acute repetitive
seizures.” New England Journal of Medicine 338.26 (1998): 1869-1875.
• Connelly J,Weissman DE. Seizure Management in the Dying Patient. Fast Facts and Concepts.
April 2010; 229. Available at: http://www.eperc.mcw.edu/fastfact/ff_229.htm.
• http://www.fraserhealth.ca/media/19FHSymptomGuidelinesMyoclonus.pdf
194
Thrush
No Patient on Yes
methadone?
GFR � 30? No Initiate nystatin suspension
100,000 units/mL,
Yes
5mL po swish & swallow
Initiate clotrimazole QID x 7-14 days.
troches* 10mg po 5x/day
x 14 days OR fluconazole Initiate fluconazole 200mg
po x 1 dose, then 100mg
50-100mg po Qday
x 7-14 days. po Qday x 13 days.
Recurrent
episodes of
thrush?
Yes
Initiate fluconazole
100mg po 3 times per
week as ongoing
suppressive therapy.
*Requires CM approval.
195
Thrush
- Candidiasis usually presents as adherent white plaques but can also present as
erythema
- The decision to treat should be based on goals of care.Treatments include either
systemic or topical anti-fungal drugs and should be continued for 10-14 days. Denture
cleaning, if applicable, is important to prevent recurrence.
- If esophageal candidiasis is suspected, systemic therapy is necessary as topical treatment
is ineffective.
Topical Agents:
• Nystatin suspension is the usual treatment, especially in patients taking methadone due
to the lack of interaction between these two agents. Note that it is less effective in
immunocompromised patients
• Clotrimazole is nearly as effective as the systemic azole anti-fungals; however, it is
associated with a higher recurrence rate of thrush.
• Clotrimazole troches are a reasonable therapy for patients in the palliative care setting
if the troches are tolerable and 5 times a day dosing is acceptable. If not, and/or if the
patient has problems with recurrent thrush, fluconazole should be used. (Clinical
Manager approval is necessary)
Systemic drugs are more effective than the topicals. However they are more expensive
and have significant drug-drug interactions.
• Fluconazole is the systemic treatment of choice; it is more effective with fewer drug
interactions than ketoconazole.
o Fluconazole should NOT be used in patients taking methadone for pain
management due to the significant drug-drug interaction between these
agents (prolonged QT Interval).
o Itraconazole suspension (200mg po daily) is an alternative to fluconazole. It is
better absorbed and more effective than itraconazole capsules.
Commercially Drug Name
Available Clotrimazole (Mycelex®)
Formulations Troche, oral: 10 mg
Usual Dose
Treatment: 10mg po 5x/day
Max Total Daily Prophylaxis: 10mg po 3x/day
Dose (TDD) 50mg
Comments
-Duration of treatment is 14 consecutive days.
-Troches should be dissolved slowly in the mouth over 15-30
minutes.
-May be used as prophylaxis in patients receiving
chemotherapy or systemic corticosteroids.
Relative Cost/Day Tier 3
196
Thrush (continued)
Commercially Drug Name Drug Name
Available
Formulations Nystatin (Mycostatin®) Fluconazole (Diflucan®)
Usual Dose Suspension, oral: 100,000 Tablet: 50mg, 100mg, 150mg,
units/mL 200mg
Max Total Daily Powder for oral suspension:
Dose (TDD) 10mg/mL, 40mg/mL
Comments 500,000-1,000,000 units 100mg po Qday x 7 days
swish and swallow QID *Renal dose adjustment required
x 10-14 days
200-800mg; duration and
2.4 million units dose dependent on severity of
infection
-Poorly absorbed through
mucous membranes -Requires renal dose adjustment
therefore minimal to no if estimated CrCl less than
systemic absorption or 50mL/min: Fluconazole 100mg
drug interactions po every other day x 3 doses
-Shake suspension prior to -Shake suspension prior to
administration administration, discard unused
-May be kept at room portion after 2 weeks
temperature -May be kept at room
temperature
Relative Cost/Day Tier 2 Tier 1
References:
• Regnard, Claud, Sarah Allport, and Lydia Stephenson.“ABC of palliative care: Mouth care,
skin care, and lymphoedema.” BMJ 315.7114 (1997): 1002-1005.
• Rosielle D. Oropharyngeal Candidiasis. Fast Facts and Concepts. December 2005; 147.
Available at: http://www.eperc.mcw.edu/fastfact/ff_147.htm
197
Algorithm Key to Flow Chart Symbols
Title
Box
A Step in the Process
Arrows lead from
one step to the next
Decision Step: No
Usually a yes
or no question
Yes
Beginning and
Ending Steps
fourMM EE TT HH AA DD OO NN EE II NN FF OO RR MM AATT II OO NN Methadone Info
Methadone Information includes detailed recommendations
for administration of methadone with specific protocol
outlined for the five days following initiation of the medication
to a patient.
Methadone Equianalgesic Dosing Chart
Morphine Methadone
Source: Story P, Primer of Palliative Care, 3rd ed. AANPM 2004
Calculate total daily methadone dose and schedule every 8 to 12 hours.
24 Hour Oral Morphine Morphine: Methadone
Equivalent Ratio per 24 Hours
<30 mg/24 hrs 2:1
30-99 mg/24 hrs 4:1
100-299 mg/24 hrs 8:1
300-499 mg/24 hrs 10:1
500-999 mg/24 hrs 15:1
1000-1999 mg/24 hrs 20:1
2000-2999 mg/24 hrs** 30:1
>3000 mg/24 hrs** 40:1
**Theoretical addition to original chart, not evidence-based
Methadone Morphine
Ratio: 1:3-4*
PO Methadone to IV Methadone IV Methadone to
PO:IV 2:1 PO Methadone***
IV:PO 0.7:1
*Many clinicians use a 1:3 ratio (ME:M). Walker et al. found a ratio of 1:4.7 (ME:M)
based on data from 29 patients evaluated; however, due to study limitations, the authors
recommend a more conservative ratio than what was found in the study and suggest
relying on rescue medications to maintain pain consults.
***Going from PO:IV is not the same as going from IV:PO. The bioavailability of oral
methadone is 70-80%, so if the IV dose is doubled and the bioavailability is higher
than 50%, the patient may be at risk for neurotoxicity. A more accurate conversion
ratio of 0.7:1 was discovered by Gonzalez-Barboteo and colleagues during a study of 8
cancer patients who were switched from parenteral to oral methadone (with good pain
control. Thus, the TDD parenteral methadone must be multiplied by 1.3 to determine
TDD oral methadone using the "stop and go" approach (first oral dose given when IV
ME stopped).
Guiding Principle: All published opioid equianalgesic/conversion ratios should be
thought of as a general reference guide to help avoid gross under or over dosing.
Once a conversion is chosen, the calculated dose is just a starting point for upward
or downward dose titration based on specific patient information and history.
Selected References:
1. Breitbart W. An alternative algorithm for dosing transdermal fentanyl for
cancer-related pain. Oncology. 2000; 14:695-702.
2. Divvela S,Williams A, Meives C, Gozun E. Opioid Analgesics: Comparison of
Pharmacokinetics and Equianalgesic Doses. Hospital Pharmacy, 2006;Vol 42, 11: 1130-1135.
3. Eastern Metropolitan Palliative Care Consortium (Victoria). Opioid Conversion Ratios –
Guide To Practice. October 2008 with amendments 1/12/2009.
4. EPERC Fast Fact and Concept #2: Converting To-From Transdermal Fentanyl
5. McPherson ML. Demystifying Opioid Conversion Calculations: A Guide for Effective
Dosing. Bethesda, MD: American Society of Health-System Pharmacists; 2010:2–7.
6. Pharmacist’s Letter. Equianalgesic Dosing of Opioids for Pain Management. July 2010; 26:260712
7. The Clinical Journal of Pain. Clinical Application of Opioid Equianalgesic Data. 2003:19:286-297
8. Walker PW et al. J Palliative Med 2008;11:1103 1108.
9. Gonzalez Barboteo J et al. J Pain Palliative Care Pharmacotherapy 2008;22:200 205.
198
Methadone Safe Use Protocol
By: Mary G. Mihalyo, PharmD
Methadone Safe Use Protocol − EXAMPLE ONLY
All Hospice patients receiving methadone will do so within the structure of “Any”
Hospice Methadone Safe-Use Protocol.
When methadone is initiated for a Hospice patient, the patient will be monitored on
a daily basis for five days following initiation of methadone or a dosage adjustment.
Monitoring a patient on methadone will consist of daily RN contact, using the specific
visit/phone contact protocol below:
Day One An RN visit on the day of methadone initiation.
Day Two RN contact is made the following day, about 16-24 hours after
methadone initiation, which can be RN phone contact.
Day Three An RN visit is made to assess methadone effectiveness and
monitor for side effects.
Day Four An RN contact by phone is made to assess methadone
effectiveness and monitor for side effects.
Day Five An RN contact by phone is made to assess methadone
effectiveness.
On each of the above visits or phone contacts, the following assessment questions
should be asked:
1. How does the patient rate and describe his/ her pain level today? (high and
low rating).
2. How many break through doses of pain medication have been taken/
administered in the past 24 hours? (both the number of doses and
the amount of each dose in mg).
If it is methadone Day 1, and the patient is taking more than 2.5mg of
methadone per day with no requirement for breakthrough pain medication,
consider contacting the prescriber to reduce the methadone dose by 25%
per day.
3. Is the patient sleeping more than normal and if so is he/she easily aroused?
4. Has the patient fallen?
After each of the nurse’s five assessment contacts, a call will be made to the “Methadone
champion” which may be the ProCare HospiceCare clinical pharmacist, the Hospice
Medical Director or the physician who prescribed the methadone to report the
assessment findings. The prescriber may order an adjustment in the dose of methadone
depending on the information obtained by the nursing assessment.
The nurse will document his /her methadone assessment in the patient’s medical
record including the answers to the four (4) questions above. In addition, the nurse will
document which day of methadone treatment it is for the patient and what the current
dose of methadone is.
199
A Clinical Approach to Drug-Induced
QT Prolongation
When using drugs known to prolong QT interval, a clinician needs to:
• Understand the pharmacology of the drug, in particular factors which may
lead to accumulation, e.g. drug-drug interaction, impaired elimination
• Whenever possible, avoid the concurrent use of more than one drug which
prolongs the QT interval
• Evaluate and balance the potential benefit against the potential risk, taking
into account the presence of risk factors and specific circumstances,
o Avoid the use of all QT-prolonging drugs in patients with a known
(or pre-existing) prolonged QT interval, unless under specialist
guidance
o In patients with cardiac disease, drugs which prolong QT interval
should generally be avoided unless no suitable alternatives exists
o In patients with cardiac disease, if a cardiac, if a cardiac anti-
arrhythmic known to prolong the QT interval is prescribed, consider
undertaking an ECG before and after starting the drug, and
monitoring the plasma potassium and magnesium concentrations
o The benefit of certain drugs used in the terminal phase, e.g.,
haloperidol, is likely to far outweigh any risk, and an ECG is not
required
Methadone and Prolonged QT
The association between methadone, prolonged QT and torsade de pointes was first
described in 17 patients receiving a median dose of methadone 330mg/day PO; all had
QT >500msec and most had additional risk factors.
A review of reports to the FDA has confirmed that torsade de pointes is generally
seen with higher doses (median 345mg, range 30-1,680mg) and when other risk factors
are generally present, e.g. multiple QT-prolonging drugs, drug interaction, hypokalemia,
hypomagnesemia or cardiac disease.
Methadone increases the QT interval and risk of torsades de pointes in a dose-
dependent manner, such that, with a median PO dose of about 100mg/day (range
4-600mg), <= 1/3 have prolonged QT, 1/6 have a QTc >500msec and 4% develop
torsade de pointes.
Conversely, no prolonged QT intervals were seen in chronic pain patients receiving
up to 60mg/day PO, or persistant QTc >500msec in those receiving a median dose of
30mg/day. However, QTc >500msec has been seen with doses as little as 30mg/day and
torsade de pointes at 40mg/day PO.
In November of 2006, The Food and Drug Administration issued the following “Black
Box Warning” for methadone:
In January 2009 Katz et al. issued the following specific recommendations or guidelines
regarding the use of methadone in any patient population:
• Recommendation 1 (Disclosure): When clinicians prescribe methadone, they
should inform patients about arrhythmia risk.
• Recommendation 2 (Clinical History): Clinicians should ask patients about
any history of structural heart disease, arrhythmia, or syncope.
• Recommendation 3 (Screening): All patients should have a pretreatment
electrocardiogram (ECG) to measure QTc interval and a follow-up ECG
within 30 days and each year. If the methadone dosage is greater than
100mg/day, or if patients have unexplained syncope or seizures, additional
ECG is recommended. 200
• Screening with ECG May also be done as indicated for patients
receiving methadone with multiple risk factors for QTc interval
prolongation, such as a family history of long QT syndrome or early
sudden cardiac death or electrolyte depletion. Screening is also
recommended when a cytochrome P450 inhibitor or other QTc
interval–prolonging drug, including cocaine, is started.
• Recommendation 4 (Risk Stratification): For patients in whom the QTc
interval is between 450 and 500 milliseconds, the potential risks and benefits
should be discussed, and they should be monitored more frequently.
• If the QTc interval is greater than 500 milliseconds, discontinuing or
decreasing the methadone dose should be considered, as well as
eliminating other contributing factors such as drugs that cause
hypokalemia. Use of an alternative therapy may be indicated.
• Recommendation 5 (Drug Interactions): Clinicians should be knowledgeable
concerning interactions between methadone and other drugs that tend to
prolong the QT interval or to slow the elimination of methadone.
Since their publication in January 2009, the above guidelines have contributed to a
tremendous amount of disagreement among clinicians regarding their validity and
applicability.
Hospice and Palliative Care clinicians in particular are in disagreement regarding the
application of these guidelines to the end-of-life care patient population. Until the
debate subsides, it is most likely prudent to collect baseline ECG information on a
hospice patient especially if this information already exists in the medical record due
to a recent hospital stay. At a minimum, the patients medication profile should be
reviewed to identify pertinent issues with respect to QT prolongation and the potential
for exacerbation of such due to a combination of medications which prolong the QT
inter val.
Another important issue which must be considered when prescribing methadone is
drug interactions. Drug interactions via the CYP 450 pathways may result in increased
or decreased methadone serum concentrations depending on whether the interacting
medication is an inhibitor or an inducer of the CYP450 enzyme. The chart below list
medications that the clinician should readily recognize as a medication that interacts
with methadone.
Methadone Drug Interactions
CYP 3A4 INDUCERS: drugs that CYP 3A4 INHIBITORS: drugs that
REDUCE Methadone Levels INCREASE Methadone Levels
Carbamazepine (Tegretol®) Acute ethanol ingestion
Chronic Alcohol Ingestion® Cimetidine (Tagamet®)
Nicotine Ciprofloxacin (Cipro®)
Pentobarbital (Nembutal®) Citalopram (Celexa®)
Phenobarbital Escitalopram (Lexapro®)
Phenytoin (Dilantin®) Clarithromycin (Biaxin®)
Resperidone (Risperdal®) Erythromycin (Erytab®)
Rifampin Fluconazole (Diflucan®)
Ritnavir (Norvir®) Fluoxetine (Prozac®)
Secobarbital (Seconal®) Fluvoxamine (Luvox®)
Spironolactone (Aldactone®) Grapefruit Juice
Ketoconazole (Nizoral®)
Paroxetine (Paxil®)
Sertraline (Zoloft®)
Verapamil (Isoptin®)
References:
Twycross R and Wilcock A, editors. Hospice and Palliative Care Formulary USA, 2nd ed.
Nottingham, United Kingdom: palliativedrugs.com, Ltd; 2008. P. 534-535.
Used with permission
201
Drugs That Prolong the QT Interval or Induce
Torsades De Pointes
Generally Accepted to Have a Risk
Generic Name (Brand Name) Drug Class/Clinical Use
Amiodarone (Cordarone®, Pacerone®)* Antiarrhythmic
Chloroquine (Arelan®) Anti-malarial
Chlorpromazine (Thorazine®) Antipsychotic/antiemetic
Clarithromycin (Biaxin®) Antibiotic
Disopyramide (Norpace®)* Antiarrhythmic
Dromperidone (Inapsine®) Sedative/antiemetic
Erythromycin (Erythrocin®)* Antibiotic
Haloperidol (Haldol®) Antipsychotic/antiemetic
Methadone (Methadose®) Opiate analgesic
Pentamidine (Pentam®) Antibiotic-pneumocystis
Pimozide (Orap®) Antipsychotic
Procainamide (Procan®) Antiarrhythmic
Quinidine (Quinaglute®) Antiarrhythmic
Sotalol (Betapace®)* Antiarrhythmic
Sparfloxacin (Zagam®) Antibiotic
Thioridazine (Mellaril®) Antipsychotic
Generally Reported to Have a Risk
Generic Name (Brand Name) Drug Class/Clinical Use
Alfuzosin (Uroxatral®) Alpha1 blocker/ BPH
Amantadine (Symmetrel®) Antiviral/dopaminergic antiparkinson’s
Azithromycin (Zlthromax®) Antibiotic
Chloral Hydrate (Noctec®) Sedative
Dolasetron (Anzemet®) Antiemetic
Felbamate (Felbatrol®) Anticonvulsant
Flecainide (Tambocor®) Antiarrhythmic
Foscamet (Foscavir®) HIV Antiviral
Fosphenytoin (Cerebyx®) Anticonvulsant
Gatifloxacin (Tequin®) Antibiotic
Granisetron (Kytril®) Antiemetic
Indapamide (Lozol®) Diuretic
Isradipine (Dynacirc®) Antihyper tensive
Levofloxacin (Levoquin®) Antibiotic
Lithium (Eskolith®) Bipolar Disorder
Moxifloxacin (Avelox®) Antibiotic
Nicardipine (Cardene®) Antihyper tensive
Octreotide (Sandostatin®) Carcinoid syndrome
Ofloxacin (Floxin®) Antibiotic
Ondansetron (Zofran®) Antiemetic
Quetiapine (Seroquel®) Antipsychotic
202
Generally Reported to Have a Risk
Generic Name (Brand Name) Drug Class/Clinical Use
Ranolazine (Ranexa®) Anti-anginal
Tacrolimus (Prograf®) Immunosuppressant
Tamoxifen (Novadex®) Anti-cancer
Telithromycin (Ketek®) Antibiotic
Tizanidine (Zanaflex®) Muscle relaxant
Vardenafil (Levitra®) Vasodilator
Venlafaxine (Effexor®) Antidepressant
Voriconazole (VFend®) Antifungal
Ziprasidone (Geodon®) Antipsychotic
*In general, women are approximately twice as likely to develop Torsades de Pointes
than are men.
References:
Walker, Georgina;Wilcock, Andrew; Carey, Ann Marie; et al. Prolonation of QT Interval in Palliative
Care JPSM Vol 26 No 3 Sept 2003. Woosley, RI. Drugs That Prolong the QT Interval and/or Induce
Torsades de Pointes.
Arizona Center for Education and Research on Therapeutics.
http://www.arizonacert.org/medical-pros/drug-lists/printable-drug-list.cfm. Accessed 1/28/07
Used with permission
203
fivePPAATTIIEENNTT IINNFFOORRMMAATTIIOONN LLEEAAFFLLEETTSS
Patient Information Leaflets contain critical medical
information that can directly contribute to the health and
well-being of your patients. “Off label” use of medications
commonly prescribed in end-of-life care is provided in an
easy-to-read format. These leaflets are designed specifically
to improve medication compliance, which will result in
improved symptom control for your patients.
PIL
Generic Name: Alprazolam
Xanax®
What is alprazolam used for?2
Xanax (alprazolam) is used for the treatment of anxiety, particularly panic attacks. Alprazolam
can also be used for anxiety associated with shortness of breath.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. Do not take more of this medication than you are told to take. If you have been taking
this medicine regularly for some time, do not suddenly stop taking it. Instead, gradually reduce
the dose to avoid severe side effects. Use a specially marked spoon or dropper to measure
your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with alprazolam?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking alprazolam?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• confusion, forgetfulness
• depression
• difficulty sleeping
• difficulty speaking
• feeling faint or lightheaded, falls
• mood changes, excitability or aggressive behavior
• muscle cramps
• trouble passing urine or change in the amount of urine
• unusually weak or tired
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• change in sex drive or performance
• changes in appetite
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Benzodiazepines. In, Hospice and Palliative
Care Formulary USA (p. 90). Nottingham, UK: Palliativedrugs.co LTD.
204
Generic Name: Atropine Sulfate
Atropine®, Isopto®
What is atropine used for?2
Atropine is given sublingually to dry excessive oral secretions. It can also be administered for
ophthalmic use to dilate the pupils before an eye examination.
How should I take this medication?1
Follow the directions on the prescription label. Do not take more of this medication than you
are told to take. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with atropine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking atropine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• breathing problems
• decrease in blood pressure
• feeling faint or lightheaded, falls
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• eye irritation, swelling of the eyelids
• increased sensitivity of the eyes to sun or ultraviolet light
Reference:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
205
Generic Name: Choline Magnesium Trisalicylate
Trilisate®
What is Trilisate used for?1,2
Trilisate is an anti-inflammatory medication related to aspirin, used to treat mild to moderate
pain, osteo-arthritis, rheumatoid arthritis, and fever. This medication can also be used to treat
bone pain.
How should I take this medication?1
Trilisate comes in a tablet and liquid formulation. Do not use if you have a salicylate or aspirin
allergy. Take this medication with a full glass of water and with food if it upsets your stomach.
Follow the directions on the prescription label. Use a specially marked spoon or dropper to
measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with Trilisate?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking Trilisate?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips or tongue
• ringing in the ears or changes in hearing
• black or bloody stools
• breathing problems
• confusion
• dark urine
• unusual bleeding or bruising
• unusually weak or tired
• vomiting
• yellowing of eyes or skin
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation or diarrhea • headache
• dizziness • minor upset stomach
• gas or heartburn • nausea
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: Choline magnesium trisalicylate. In, Hospice and Palliative
Care Formulary USA (p. 200). Nottingham, UK: Palliativedrugs.co LTD.
206
Generic Name: Dexamethasone
Decadron®
What is dexamethasone used for?2
Decadron (dexamethasone) is used to treat inflammatory disorders, including inflammation
surrounding a tumor. This medication can also be used as an appetite stimulant, to elevate
mood, relieve shortness of breath, and to treat bone pain.
How should I take this medication?1
Take this medicine by mouth with a drink of water and take it with food or milk to avoid
stomach upset. Follow the directions on the prescription label. If you are taking this medicine
once a day, take it in the morning. Do not take more medicine than you are told to take.
Do not suddenly stop taking this medicine. If your doctor wants you to stop the medicine,
the dose may be slowly lowered over time to avoid any side effects. Use a specially marked
spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with dexamethasone?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking dexamethasone?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• fever, sore throat, sneezing, cough, or other signs of infection, wounds that will not
heal
• mental depression, mood swings, mistaken feelings of self importance or of being
mistreated
• pain in hips, back, ribs, arms, shoulders, or legs
• redness, blistering, peeling or loosening of the skin, including inside the mouth
• trouble passing urine or change in the amount of urine
• swelling of feet or lower legs • increased thirst
• changes in vision • unusual bleeding or bruising
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• headache • nausea, vomiting
• skin problems, acne, thin and shiny skin • weight gain
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Endocrine System and Immunomodulation: Corticosteroids. In,
Hospice and Palliative Care Formulary USA (p. 302). Nottingham, UK: Palliativedrugs.co LTD.
207
Generic Name: Diazepam
Valium®
What is diazepam used for?2
Valium (diazepam) is used to treat anxiety, panic disorder, and seizures. This medication may
also be used to treat restless leg syndrome, neuropathic pain, and terminal agitation.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. If this medicine upsets your stomach, take it with food or milk. Do not take more of
this medication than you are told to take. If you have been taking this medicine regularly for
some time, do not suddenly stop taking it. Instead, gradually reduce the dose to avoid severe
side effects. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with diazepam?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking diazepam?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• angry, confused, depressed, other mood changes
• trouble passing urine or change in the amount of urine
• problems with balance, talking, walking
• breathing problems • restlessness
• feeling faint or lightheaded, falls • tremors
• muscle cramps • unusually weak or tired
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• difficulty sleeping, nightmares
• dizziness, drowsiness, clumsiness, or unsteadiness, a hangover effect
• headache
• nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Diazepam. In, Hospice and Palliative Care
Formulary USA (p. 91). Nottingham, UK: Palliativedrugs.co LTD.
208
Generic Name: Fentanyl transdermal
Duragesic®
What is Fentanyl used for?2
Duragesic (fentanyl) is a medication used to treat moderate to severe pain, only in people
who have been taking an opioid pain medication for longer than one week.
How should I take this medication?1
Prepare: Choose a site to apply the patch on the chest, back, or any flat part of the body
where there is no hair. Try to avoid sensitive areas or areas of excessive movement. If there
is hair, do not shave (shaving irritates the skin). Do not apply to irritated or cut skin. Clean
the site with water only, not alcohol or soap. Do not cut the patch because you could receive
too much medication, which is dangerous.
Peel: Peel the liner from the back of the patch. Touch the sticky side as little as possible.
Apply: Press the patch onto the skin with the palm of your hand and hold it there for at
least 30 seconds, making sure it sticks well, particularly at the edges. Wash your hands when
you have finished applying fentanyl patch. After three days, or as directed by your doctor, the
fentanyl patch should be removed. Then a new patch should be applied to a different place
on the skin, repeating steps above. Do not apply the new patch to the same place as the last
one. Avoid applying adhesive tape over the patch. Do not apply heat to patch.
What if I miss a dose?
If you forget to change your patch, change it as soon as you remember. Do not wear more
than one patch unless directed by your doctor.
What drug(s) may interact with fentanyl?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Do not
store patches outside of their wrappers. Store at room temperature, away from excess
moisture (bathroom) and heat. This medicine can be abused so protect this medicine from
theft and do not share it with anyone.
What should I watch for while taking fentanyl?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions (skin rash, itching/hives, swelling of face, lips or tongue)
• trouble passing urine or change in the amount of urine
• problems with balance, talking, walking
• breathing problems
• changes in vision
• confusion/hallucination • high or low blood pressure
• feeling faint, lightheaded • irregular heartbeat
• fever, flu-like symptoms • unusual bleeding or bruising
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation • loss of appetite
• dry mouth • nausea, vomiting
• itching where the patch was applied • sweating
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: Fentanyl. In, Hospice and Palliative Care Formulary USA
(p. 247). Nottingham, UK: Palliativedrugs.co LTD.
209
Generic Name: Glycopyrrolate
Robinul®
What is glycopyrrolate used for?1,2
Robinul (glycopyrrolate) is used to treat peptic ulcer disease and excessive secretions.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. Do not take more of this medication than you are told to take.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with glycopyrrolate?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking glycopyrrolate?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• agitation, nervousness, confusion
• blurred vision and other eye problems
• decreased sweating
• dizziness, drowsiness
• irregular heartbeat
• pain or difficulty passing urine
• unusually weak or tired
• vomiting
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation • nausea
• difficulty sleeping • sexual difficulty
• headache
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Gastro-Intestinal System: Antimuscarinics. In, Hospice and Palliative
Care Formulary USA (p. 4). Nottingham, UK: Palliativedrugs.co LTD.
210
Generic Name: Haloperidol
Haldol®
What is haloperidol used for?2
Haldol (haloperidol) is used to treat agitation, behavioral disturbances and delirium. This
medication is also used to treat nausea, vomiting, and intractable hiccups.
How should I take this medication?1
Take this medicine by mouth with a glass of water, with or without food. Follow the directions
on the prescription label. Do not take more of this medication than you are told to take. If
you have been taking this medicine regularly for some time, do not suddenly stop taking it.
Instead, gradually reduce the dose to avoid severe side effects. Use a specially marked spoon
or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with haloperidol?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking haloperidol?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• breast pain or swelling or unusual production of breast milk
• uncontrollable tongue or chewing movements, smacking lips or puffing cheeks
• uncontrollable muscle spasms, in the face hands, arms, or legs, twisting body
movements
• difficulty passing urine, or sudden loss of bladder control
• difficulty breathing • skin rash
• difficulty in speaking or swallowing • stiffness, spasms, trembling
• dizziness or light headedness • unusually weak or tired
• fast or irregular heartbeat • confusion
• hot, dry skin or lack of sweating • seizures
• loss of balance or difficulty walking • fever, chills, or sore throat
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• anxiety or agitation • menstrual changes
• constipation or diarrhea • nausea or vomiting
• decreased sexual ability • weight gain
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http:/www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Haloperidol. In, Hospice and Palliative Care
Formulary USA (p. 101). Nottingham, UK: Palliativedrugs.co LTD.
211
Generic Name: Hydromorphone
Dilaudid®
What is hydromorphone used for?2
Dilaudid (hydromorphone) is used to treat moderate to severe pain.
How should I take this medication?1
Take this medication with a full glass of water and with food or milk if it upsets your stomach.
Follow the directions on the prescription label. Do not take more of this medication than you
are told to take. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with hydromorphone?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat. This medicine can be
abused so protect this medicine from theft and do not share it with anyone.
What should I watch for while taking hydromorphone?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• trouble passing urine or change in the amount of urine
• feeling faint or lightheaded, falls
• breathing problems
• changes in vision
• trouble with balance, talking, walking
• confusion
• seizures
• slow or fast heartbeat
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• difficulty sleeping • headache
• drowsiness • itching
• dry mouth • loss of appetite
• flushing • nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: Hydromorphone. In, Hospice and Palliative Care Formulary
USA (p. 257). Nottingham, UK: Palliativedrugs.co LTD.
212
Generic Name: Hyoscyamine
Levsin®,HyoMax®
What is hyoscyamine used for?1, 2
Hyoscyamine is used to treat peptic ulcer disease, excessive secretions, GI tract spasms,
neurogenic bladder/bowel, and irritable bowel.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. Do not take more of this medication than you are told to take.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with hyoscyamine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking hyoscyamine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• agitation, nervousness, confusion
• blurred vision and other eye problems
• decreased sweating
• dizziness, drowsiness
• irregular heartbeat
• pain or difficulty passing urine
• unusually weak or tired
• vomiting
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation
• difficulty sleeping
• headache
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009.
URL: http://www.clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Gastro-Intestinal System: Antimuscarinics. In,“Hospice and
Palliative Care Formulary USA” (p. 3). Nottingham, UK: Palliativedrugs.co LTD.
213
Generic Name: Ibuprofen
Motrin®,Advil®
What is Ibuprofen used for?1,2
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) used to treat mild to moderate
pain related to headaches, fever, dental pain, osteoarthritis, rheumatoid arthritis, and bone
pain.
How should I take this medication?1
You should take this medication with a full glass of water and with food if it upsets your
stomach. Try not to lie down for 10 minutes after taking this medication. Follow the
directions on the prescription label. Use a specially marked spoon or dropper to measure
your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with ibuprofen?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking ibuprofen?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• black or bloody stools, blood in the urine or in vomit
• redness, blistering, peeling or loosening of the skin, including inside the mouth
• slurred speech or weakness on one side of the body
• general ill feeling or flu-like symptoms
• unexplained weight gain or swelling
• breathing problems
• changes in vision • stomach pain
• chest pain • unusually weak or tired
• nausea or vomiting • yellowing of eyes or skin
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation or diarrhea • gas or heartburn
• dizziness • stomach upset
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: NSAIDs. In, Hospice and Palliative Care Formulary USA
(p. 184). Nottingham, UK: Palliativedrugs.co LTD
214
Generic Name: Lorazepam
Ativan®
What is lorazepam used for?2
Ativan (lorazepam) is used to treat anxiety, insomnia, seizures, nausea and vomiting. This
medication can also be used to treat anxiety associated with shortness of breath.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. If it upsets your stomach, take it with food or milk. Do not take more of this medication
than you are told to take. If you have been taking this medicine regularly for some time, do
not suddenly stop taking it. Instead, gradually reduce the dose to avoid severe side effects.
Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with lorazepam?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking lorazepam?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• mood changes, excitability or aggressive behavior
• movement difficulty, staggering or jerky movements
• changes in vision
• confusion
• depression
• muscle cramps
• restlessness
• weakness or tiredness
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation or diarrhea
• difficulty sleeping, nightmares
• dizziness, drowsiness
• headache
• nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Lorazepam. In, Hospice and Palliative Care
Formulary USA (p. 95). Nottingham, UK: Palliativedrugs.co LTD.
215
Generic Name: Methadone
Dolophine®
What is methadone used for?2
Dolophine (methadone) is medication used to treat severe pain, cough, as an alternative pain
medication in cases of tolerance to other strong opioids, and pain relief in severe renal failure.
This medication can also be used in treating patients that are addicted to pain medications or
illegal drugs (i.e.,“methadone clinics”).
How should I take this medication?1
Take this medication with a full glass of water and with food or milk if it upsets your stomach.
Follow the directions on the prescription label. Do not take more of this medication than you
are told to take. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with methadone?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat. This medicine can be
abused so protect this medicine from theft and do not share it with anyone.
What should I watch for while taking methadone?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• breathing problems
• chest pain
• confusion
• feeling faint or lightheaded, falls
• unusually fast or slow heartbeat
• unusually weak or tired
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• nausea, vomiting
• sweating
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: Methadone. In, Hospice and Palliative Care Formulary USA
(p. 259). Nottingham, UK: Palliativedrugs.co LTD.
216
Generic Name: Mirtazapine
Remeron®
What is mirtazapine used for?2
Remeron (mirtazapine) is used to treat depression. This medication can also be used to treat
neuropathic pain, as an appetite stimulant, and to help with insomnia.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. Do not take more of this medication than you are told to take.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with mirtazapine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking mirtazapine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• confusion
• fever, sore throat, or mouth ulcers or blisters
• flu like symptoms including fever, chills, cough, muscle or joint aches and pains
• stomach pain with nausea and/or vomiting
• suicidal thoughts or other mood changes
• swelling of the hands or feet
• unusual bleeding or bruising
• unusually weak or tired
• vomiting
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation
• increased appetite
• weight gain
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Mirtazapine. In, Hospice and Palliative Care
Formulary USA (p. 129). Nottingham, UK: Palliativedrugs.co LTD.
217
Generic Name: Morphine
MS Contin®, Roxanol®
What is morphine used for?2
Morphine is used to treat moderate to severe pain, and shortness of breath.
How should I take this medication?1
Take this medication with a full glass of water and with food or milk if it upsets your stomach.
Follow the directions on the prescription label. Do not take more of this medication than you
are told to take. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with morphine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat. This medicine can be
abused so protect this medicine from theft and do not share it with anyone.
What should I watch for while taking morphine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• breathing difficulties, wheezing
• confusion
• light headedness or fainting spells
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• itching
• nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009.
URL: http://www.clinicalpharmacology.com. Updated February, 2009.
218
Generic Name: Naproxen
Aleve®, Naprosyn®,Anaprox®
What is naproxen used for?1
Naproxen is a non-steroidal anti-inflammatory drug (NSAID), which is used to reduce
swelling and to treat pain related to musculoskeletal disorders, dysmenorrheal, acute gout,
bone pain from cancer metastases, and neoplastic fever.
How should I take this medication?1
Take this medicine by mouth with a glass of water or with food if it upsets your stomach.
Do not lie down for at least 10 minutes after taking this medication. Follow the directions
on the prescription label. Do not take more of this medication than you are told to take, as
continuous use of this medication may increase risk of stroke or heart attack.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for your next dose,
just take that scheduled dose. Do not double up or take extra doses.
What drug(s) may interact with naproxen?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:1
Store at room temperature, away from heat, moisture, pets and children.
What should I watch for while taking naproxen?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• black or bloody stools, blood in the urine or vomit
• skin rash, skin redness, blistering or peeling skin, hives, or itching
• slurred speech or weakness on one side of the body
• blurred vision
• chest pain
• difficulty breathing or wheezing
• nausea or vomiting • unexplained weight gain or swelling
• severe stomach pain • unusually weak or tired
• swelling of eyelids, throat, lips • yellowing of eyes or skin
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation
• headache
• heartburn
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
219
Generic Name: Ondansetron
Zofran®
What is ondansetron used for?1
Ondansetron (Zofran) is used to treat nausea and vomiting caused by chemotherapy,
radiotherapy and after surgery. It may also be used for intractable vomiting due to chemical,
abdominal and cerebral causes when usual approaches have failed. It has also been used
to treat opioid-induced itching and possibly itching due to kidney disease (uremia) and liver
disease (cholestasis).
How should I take this medication?1
Take this medicine by mouth with a glass of water, at regular intervals. Follow the directions
on the prescription label. Do not take more of this medication than you are told to take.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for your next dose,
just take that scheduled dose. Do not double up or take extra doses.
What drug(s) may interact with ondansetron?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:1
Store at room temperature, away from heat, moisture, pets and children.
What should I watch for while taking ondansetron?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• difficulty breathing, wheezing, shortness of breath
• fast or irregular heartbeat
• fever and chills
• tightness in the chest
• skin rash, itching
• swelling of the face, tongue, throat, hands and feet
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• constipation or diarrhea
• dizziness
• headache
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
220
clinicalpharmacology.com. Updated February, 2009.
Generic Name: Oxycodone
Oxycontin, OxyIR®, Oxyfast®, Oxydose®
What is oxycodone used for?2
Oxycodone is used to treat moderate to severe pain, and shortness of breath.
How should I take this medication?1
Take this medication with a full glass of water and with food or milk if it upsets your stomach.
Follow the directions on the prescription label. Do not take more of this medication than you
are told to take. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for your next dose,
just take that scheduled dose. Do not double up or take extra doses.
What drug(s) may interact with oxycodone?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat. This medicine can be
abused so protect this medicine from theft and do not share it with anyone.
What should I watch for while taking oxycodone?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• breathing difficulties, wheezing
• confusion
• light headedness or fainting spells
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• itching
• nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Analgesics: Oxycodone. In, Hospice and Palliative Care Formulary USA
(p. 266). Nottingham, UK: Palliativedrugs.co LTD.
221
Generic Name: Prednisone
Deltasone®
What is prednisone used for?
Deltasone (prednisone) is a corticosteroid commonly used to treat inflammation of the skin,
joints, lungs, and other organs. Prednisone can also be used for shortness of breath, appetite
and mood stimulation, and is the drug of choice for bone pain.
How should I take this medication?1
Prednisone may be taken by mouth or rectally. Take this medication with plenty of water and
take with food or milk to avoid an upset stomach. If you are taking this medication once a
day, take it in the morning. Do not stop taking this medication suddenly. Instead, your doctor
may want to slowly decrease the dose to avoid side effects. Follow the directions on the
prescription label. Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with prednisone?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking prednisone?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• eye pain, decreased or blurred vision, or bulging eyes
• fever, sore throat, sneezing, cough, or other signs of infection, wounds that will not
heal
• frequent passing of urine, increased thirst
• hyperglycemia (high blood sugar)
• mental depression, mood swings, mistaken feelings of self-importance or of being
mistreated
• pain in hips, back, ribs, arms, shoulders or legs
• swelling of feet or lower legs
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• confusion, excitement, restlessness
• skin problems, acne, thin and shiny skin
• headache
• nausea, vomiting
• weight gain
Reference:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
222
clinicalpharmacology.com. Updated February, 2009.
Generic Name: Prochlorperazine
Compazine®
What is prochlorperazine used for?2
Compazine (prochlorperazine) is used to treat nausea and vomiting. This medication can also
be used to treat anxiety, itching, as a generalized sedative, and to prevent motion sickness.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. This medication is also available as a rectal suppository. Wash your hands before and
after use of suppository. Take off the foil wrapping. Wet the tip of the suppository with
cold tap water to make it easier to use. Lie on your side with your lower leg straightened
out and your upper leg bent forward toward your stomach. Lift upper buttock to expose
the rectal area. Apply gentle pressure to insert the suppository completely into the rectum,
pointed end first. Hold buttocks together for a few seconds. Remain lying down for about
15 minutes to avoid having the suppository come out. Do not take more of this medication
than you are told to take. If you have been taking this medicine regularly for some time, do
not suddenly stop taking it. Instead, gradually reduce the dose to avoid severe side effects.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with prochlorperazine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking prochlorperazine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• blurred vision
• breast enlargement in men or women
• breast milk in women who are not breast-feeding
• drooling, shaking, movement difficulty (shuffling walk) or rigidity
• involuntary or uncontrollable movements
• chest pain, fast or irregular heartbeat • stomach area pain
• confusion, restlessness • unusually weak or tired
• dark yellow or brown urine • unusual bleeding or bruising
• difficulty breathing or swallowing • yellowing of skin or eyes
• dizziness or fainting spells
• seizures
• fever, chills, sore throat
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• difficulty passing urine • sexual dysfunction
• difficulty sleeping • skin rash, or itching
• headache
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System:Antiemetics. In, Hospice and Palliative Care
Formulary USA (p. 152). Nottingham, UK: Palliativedrugs.co LTD.
223
Generic Name: Promethazine
Phenergan®
What is promethazine used for?2
Phenergan (promethazine) is used to treat nausea and vomiting. This medication can also be
used to treat anxiety, itching, as a general sedative, and to prevent motion sickness.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. This medication is also available as a rectal suppository. Wash your hands before and
after use of suppository. Take off the foil wrapping. Wet the tip of the suppository with
cold tap water to make it easier to use. Lie on your side with your lower leg straightened
out and your upper leg bent forward toward your stomach. Lift upper buttock to expose
the rectal area. Apply gentle pressure to insert the suppository completely into the rectum,
pointed end first. Hold buttocks together for a few seconds. Remain lying down for about
15 minutes to avoid having the suppository come out. Do not take more of this medication
than you are told to take. If you have been taking this medicine regularly for some time, do
not suddenly stop taking it. Instead, gradually reduce the dose to avoid severe side effects.
Use a specially marked spoon or dropper to measure your liquid medicine.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses.
What drug(s) may interact with promethazine?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking promethazine?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• irregular heartbeat, palpitations or chest pain
• blurred vision
• muscle or facial twitches
• pain or difficulty passing urine
• seizures
• skin rash
• slowed or shallow breathing
• unusual bleeding or bruising
• yellowing of the eyes or skin
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• nightmares, agitation, nervousness, excitability, not able to sleep (these are more
likely in children)
• headache
• stuffy nose
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Antiemetics. In, Hospice and Palliative Care
Formulary USA (p. 152). Nottingham, UK: Palliativedrugs.co LTD.
224
Generic Name: Temazepam
Restoril®
What is temazepam used for?2
Restoril (temazepam) is used to treat insomnia. This medication can also be used to treat
anxiety.
How should I take this medication?1
Take this medicine by mouth, only at bedtime. Follow the directions on the prescription label.
Swallow the tablets or capsules with a drink of water. If it upsets your stomach, take it with
food or milk. Do not take more of this medication than you are told to take.
What if I miss a dose?
If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, take
only that dose. Do not take double or extra doses. Only take this medication when you are
prepared to dedicate at least six hours to sleep.
What drug(s) may interact with temazepam?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:
Keep out of the reach of children, in a container that small children cannot open. Store at
room temperature, away from excess moisture (bathroom) and heat.
What should I watch for while taking temazepam?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• confusion
• depression • suicidal thoughts
• feeling faint or lightheaded • tremors
• hallucinations • unusually weak or tired
• memory loss
• mood changes, excitability or aggressive behavior
• muscle cramps
• problems with balance, speaking, walking
• unusual activities while asleep like driving, eating, making phone calls
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• dizziness, drowsiness • increased dreaming
• headache • nausea, vomiting
References:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
2) Twycross R,Wilcock A (2000). Central Nervous System: Antiemetics. In, Hospice and Palliative Care
Formulary USA (p. 152). Nottingham, UK: Palliativedrugs.co LTD.
225
Generic Name: Zolpidem
Ambien®
What is zolpidem used for?1
Zolpidem (Ambien) is used to treat insomnia. It will help you to fall asleep and sleep through
the night.
How should I take this medication?1
Take this medicine by mouth with a glass of water. Follow the directions on the prescription
label. It is best to take this medication on an empty stomach and only at bedtime. Do not
take more of this medication than you are told to take. If you have been taking this medicine
regularly for some time and suddenly stop taking it, you may experience some unpleasant
withdrawal effects.
What if I miss a dose?1
This does not apply. This medicine should only be taken immediately before going to sleep.
Do not take double or extra doses unless instructed to do so by your physician.
What drug(s) may interact with zolpidem?
Tell your doctor, hospice nurse, and pharmacist about all of the medications you are taking,
including non-prescription medicines, nutritional supplements, or herbal products.
Storage Information:1
Keep out of the reach of children.This medicine can be abused. Keep your medicine in a safe
place to protect it from theft. Do not share this medicine with anyone. Selling or giving away
this medicine is dangerous and against the law. Store at room temperature between 20 and
25 degrees C (68 and 77 degrees F).Throw away any unused medicine after the expiration
date.
What should I watch for while taking zolpidem?1
Side effects that you should report to your doctor and/or hospice/nurse as soon as possible:
• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• changes in vision
• confusion
• depressed mood
• feeling faint or lightheaded, falls
• hallucinations
• problems with balance, speaking, walking
• restlessness, excitability, or feelings of agitation
• unusual activities while asleep like driving, eating, making phone calls
Common side effects (Tell your doctor and/or hospice nurse if they continue or are
bothersome):
• diarrhea
• dizziness, or daytime drowsiness, sometimes called a hangover effect
• headache
Reference:
1) Clinical Pharmacology [database online].Tampa, FL: Gold Standard, Inc.; 2009. URL: http://www.
clinicalpharmacology.com. Updated February, 2009.
226
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