Medication Tables

Box App-1-1

Important

1

The list of dosage forms may not be complete and may change over time.
2

Not all drugs and dosage forms are available in each country.
3

Only the common adverse effects (AE) and drug interactions are listed.
4

The listed trade names either represent the only product available, or one that is commonly known.
5

Dosages may need adjustment for intercurrent conditions such as hepatic or renal failure.
6

Always refer to the PDR in the United States or the CPS in Canada or other online drug resources for a complete, up-to-date list of the products available, adverse effects, and drug interactions.

Adverse Effects

Adverse effects may be allergic, idiosyncratic, or dose–related extensions of known effects. They may increase with the number of different medications and the dosage. In the presence of liver or renal failure, adverse effects may emerge if dosage/frequency is not adjusted downward. If adverse effects occur, reduce or stop offending medications and provide appropriate antidotes.

As medications may have many effects, they may also produce many different adverse effects. In some instances, they occur frequently enough to be grouped as below:

Table App-1-1

Adverse Effect Group	Possible Adverse Effects
Anticholinergic (AC)	Dry mouth, decreased GI motility, constipation, tachycardia, urinary retention, mydriasis (pupil dilation), cycloplegia (paralysis of ciliary muscles of accommodation → blurred vision) May lead to restlessness, confusion, hallucinations, memory impairment and delirium May precipitate acute glaucoma
CNS excitation (CNS)	Euphoria, restlessness, agitation, vivid dreams, nightmares, hallucination, myoclonus (jerks/twitches), focal motor or grand mal seizures
Extrapyramidal (EPS)	Early effects (usually dose related): Acute dystonic reactions: torticollis (cervical muscle spasm → unnatural twisting of head), opisthotonos (a tetanic spasm with head and heels bent backward, body bowed forward), tics, grimacing, dysarthria, oculogyric crisis; Rx diphenhydramine 25–50 mg PO, IM, IV q 4 h PRN Parkinsonian reactions: tremor, bradykinesia, rigidity, abnormalities of gait and posture; Rx benztropine (Cogentin) 1–2 mg IV, IM acutely, then 1–2 mg PO daily–bid Akathisia: sense of constant motor restlessness; Rx benztropine 1–2 mg PO daily–bid Late effects: Tardive dyskinesia—involuntary movements of lips, tongue, jaws, extremities. May persist indefinitely after medication is stopped. Antidopaminergic drugs may suppress these movements
Hypersensitivity	Rash, urticaria, bronchospasm, laryngeal or angioneurotic edema; in extreme cases, anaphylactic shock
Signs of electrolyte imbalance, dehydration	Dry mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain/cramps, muscle fatigue, hypotension (may be orthostatic), oliguria, tachycardia, nausea/vomiting
Upper gastrointestinal (GI)	Nausea, vomiting, dyspepsia May include erosions, ulceration, bleeding; Rx misoprostol 200 mcg PO q 6 h or histamine H ₂receptor antagonists (see Antacids)

Table App-1-2

Abbreviations, Symbols

Routes of Administration
PO	By mouth ( per os )
PR	By the rectum ( per rectum )
IM	Intramuscular
IV	Intravenous
SC	Subcutaneous
SL	Sublingual
TD	Transdermal
IT	Intrathecal
Others
CPS	Compendium of Pharmaceuticals and Specialties (Canada)
COX-2	Cyclo-oxygenase–2 selective inhibitor; may have fewer gastrointestinal, renal, and antiplatelet adverse effects
ER/SR/CR	Extended/sustained/controlled release (extended/sustained release tablets must be taken intact, never broken or crushed)
Inj	Injectable
IR	Immediate release (tabs are IR unless noted)
ODT	Orally dissolving tabs
MAOI	Monoamine oxidase inhibitor
NA	Not available
NS	Normal saline
NSAID	Nonsteroidal anti-inflammatory drug
PDR	Physicians’ Desk Reference, Medical Economics Company, Inc., 1999 (USA)
SSRI	Selective serotonin reuptake inhibitor
TCA	Tricyclic antidepressant
↑	Upper dose limited only by need and adverse effects
†	Fixed-dose combinations not recommended in young children
††	Dose varies depending on condition being treated
CAUTION—CONSULT REQUIRED

Websites/Online Drug Resources

www.palliativedrugs.com

Table App-1-3

Analgesics

Generic Name	Dosage Forms Available	Route of Elimination	Usual Dosing	Recommended Maximum Dosing	Special Issues
Acetaminophen (paracetamol)	Tab: 325, 500, 650 mg Elixir: 80 mg/0.8 ml, 160 mg/5 ml Supp: 120, 325, 650 mg, 81 mg chew	Liver metabolism: 25% on first pass through liver Renal excretion: 1%–4% unchanged	325–650 mg PO PR q 4 h routinely or PRN	650 mg PO PR q 4 h (4 g/24 h)	Caution in liver disease
Acetylsalicylic acid (ASA) (salicylic acid derivative)	Caplets, Tab: 325, 500, 650 mg Children’s tab: 80 mg EC Tab: 81, 325, 500 mg Supp: 300, 600 mg	Liver metabolism Renal excretion: 5.6%–35.6%	325–650 mg PO, PR q 4 h routinely or PRN	650 mg PO PR q 4 h (5 g/24 h)	GI distress, may prolong bleeding
Celecoxib (COX-2 selective)	Cap: 100, 200, 400 mg	Liver metabolism: extensive Renal excretion: 27% Less than 3% of a dose is eliminated as unchanged drug Feces: 57%	100–200 mg PO bid	200 mg PO bid
Diclofenac (acetic acid derivative)	IR Tab: 25,50 mg ER Tab: 50, 75, 100 mg Supp 50 mg (with 200 mcg misoprostol: Arthrotec ^®50, 75 mg)	Liver metabolism: extensive first-pass Renal excretion: 65% Bile: 35%	IR: 50–75 mg PO PR q 6–8 h or ER 75–100 mg PO q 8–12 h	50 mg IR PO q 6 h or 75 mg ER PO q 8 h (225 mg/24 h)	GI adverse effects for all NSAIDs
Ibuprofen (propionic acid derivative)	Tab: 200, 400, 600, 800 mg Elixir: 40 mg/1 ml, 100 mg/5 ml	Liver metabolism: extensive Renal excretion: major route	200–800 mg PO q 6–8 h	800 mg PO q 6 h (3.2 g/24 h)
Indomethacin (indole)	IR Tab: 25, 50 mg Supp: 50 mg Liquid 25 mg/5 ml	Liver metabolism: extensive Renal excretion: 60%; ≈ 26% eliminated as unchanged drug Feces: 33%	25–75 mg PO q 8–12 h or 75 mg ER PO q 12–24 h	50 mg PO q 6 h (200 mg/24 h)
Ketoprofen (propionic acid derivative)	Cap: 50, 75 mg ER Tab: 100, 150, 200 mg Supp: 100 mg (CAN)	Liver metabolism Renal excretion: 80% Bile: up to 40%	150–200 mg PO/24h IR: q 6–8 h ER: q 12–24 h	75 mg PO q 6 h (300 mg/24 h)
Ketorolac (acetic acid derivative)	Tab: 10 mg Inj: 15, 30 mg/ml	Liver metabolism Renal excretion: 92% excreted in the urine; 60.6% as unchanged drug Feces: 5.9%–6.3%	10 mg PO qid or 60 mg IM, IV loading dose, then 10–30 mg IM, IV q 6 h	40 mg PO/24 h or 120 mg IM, IV/24 h	Only recommended for very short term use
Naproxen (propionic acid derivative)	IR Tab: 250, 250, 375, 500, 550 mg ER tab: 750 mg Ent coated: 500 mg Liquid 125/5 ml	Liver metabolism: extensive Renal excretion: 95%	250–500 mg PO q 8–12 h	500 mg PO q 8 h (1.5 g/24 h)
Codeine (alone) (methylmorphine, naturally occurring opioid metabolized into morphine)	IR Tab: 15, 30, 60 mg Elixir: 5 mg/ml Inj: 15, 30 mg/ml ER 50,100,150, 200 mg (CAN)	Liver metabolism: 24–89% (metabolized to morphine) Renal excretion: 90% (3%–16% of unchanged drug) Feces: about 5%	15–60 mg PO, SC, IM q 4 h routinely or q 1 h PRN	600 mg/24 h, then consider potent opioid	Ceiling dose of about 400 mg/day Patients (about 10%) may lack the enzyme that converts codeine to morphine
Codeine + acetaminophen combinations	Tabs: 15, 30, 60 mg codeine + 325 mg acetaminophen	Codeine and Acetaminophen: see Acetaminophen	1–2 tabs PO q 4 h routinely or PRN	Limited to 12 tabs/24 h by acetaminophen
Fentanyl	Patch: 12, 25, 50, 75, 100 mcg/hr Lozenge: 200, 400, 600, 800, 1200, 1600 mcg Soluble buccal film (new) Inj: 50 mcg/ml	Liver metabolism: to inactive metabolites Renal excretion: 75% (metabolites); 10% (unchanged drug) Feces: 9%	patch: 25–↑ mcg/h q 72 h lozenge: 200 mcg q 1 h titrate PRN	Limited only by need and adverse effects	Several new transmucosal formulations for breakthrough pain
Hydrocodone + acetaminophen (USA only)	Tab: 5/500, 5/325, 7.5/325, 7.5/500, 7.5/750, 10/325, 10/500, 10/660 Elixir: 7.5/500 in 15 ml	Liver metabolism: Acetaminophen: see above Hydrocodone: extensive active metabolites Renal excretion: 26%	1–2 tabs PO q 4–6 h routinely or PRN	Limited to 4 g acetaminophen in 24 h	One of the drugs often abused
Hydrocodone + ibuprofen (USA only)	Tab: 7.5/200	Liver metabolism: see above Renal excretion: see above	1–2 tabs PO q 4–6 h routinely or PRN	Limited–2,400 mg ibuprofen in 24 h
Hydromorphone	IR tab:1, 2, 4, 8 mg CR cap: 3,6, 12, 18, 24, 30 mg (CAN) Once daily ER cap: 8, 12, 16 mg Elixir: 1 mg/ml Inj: 1, 2, 4, 10 mg/ml Powder: 250 mg/vial Supp: 3 mg	Liver metabolism: extensive Renal excretion: As hydromorphone 1.3%–13.2% Conjugates: 22%–51%	1–↑ mg: PO q 4 h routinely or q 1 h PRN, SC, IM q 3 h routinely or q 30 min PRN, SC, IV q 1 h via infusion + breakthrough q 30 min PRN	Limited only by need and adverse effects	May accumulate with decreased renal clearance
Levorphanol (USA only)	Tab: 2 mg	Liver metabolism: extensive Renal excretion: extensive as conjugate	2–↑ mg PO q 6–8 h	Limited only by need and adverse effects
Meperidine (pethidine)	Tab: 50, 100 mg Inj: 50, 75, 100 mg/ml Syrup: 50 mg/5 ml	Liver metabolism: 50% first pass through the liver Renal excretion: 0.5%–5.2% (average 2.2%) unchanged Active metabolite, normeperidine, excreted 0.6%–21% (average 6.2%) unchanged in urine	50–150 mg PO IM, SC, IV q 4 h PRN	150 mg q 3–4 h, 900–1200 mg/24 h	NOT RECOMMENDED FOR CHRONIC DOSING— active metabolite, normeperidine, may produce adverse effects Very poorly absorbed orally
Methadone	Tab: 1, 5, 10, 25, 40 mg Elixir: 1, 2, 10 mg/ml Powder for injectable forms	Liver metabolism: 4 times greater after PO administration than after IM administration	5 mg PO q 8 h Titrate dose q 3–5 days due to delayed clearance	Limited only by need and adverse effects	Interactive with drugs using cytochrome P450 metabolism Do drug interaction survey when adding to other drugs or when other drugs added Do not use where QT interval prolongation exists
Morphine, IR	IR tab: 5,10, 15, 25, 30 50 mg Elixir: 1, 2, 10, 20 mg/ml Supp: 5, 10, 20, 30 mg Inj: 1, 2, 10, 15, 25, 50 mg/ml	Liver metabolism: ≈ 90% of a given dose is conjugated morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G-active) Renal excretion: 90% (metabolites and free drug) within 24 hr; altered in renal failureClearance is decreased M3G and M6G accumulate several fold with associated risk of toxicity Feces: 7–10%	1–↑ mg: PO PR q 4 h routinely or q 1 h PRN, SC, IM q 3h routinely or q 30 min PRN, or SC, IV q 1 h via infusion + breakthrough q 30 min PRN	Limited only by need and adverse effects	May accumulate with decreased renal clearance
Morphine, ER	CR 24 h cap: 20, 50, 100 mg (q 12–24 h) ER tab (USA) 30, 45, 60, 75 mg, 90 mg, 120 mg CR tab: 15, 30, 60, 100, 200 mg (q 8–12 h) CR cap: 10,30,60 mg (CAN)		10–↑ mg: PO/PR q 8–24 h routinely only (depending on product) Provide breakthrough doses using IR morphine q 1 h PRN	Limited only by need and adverse effects
Oxycodone (alone)	IR tab: 5, 10, 15, 30 mg CR tab: 10, 20, 40, 80 mg Elixir: 1 mg/ml (USA)	Liver metabolism: extensive Renal excretion: extensive with approximately 20% unchanged	5–↑ mg IR PO PR q 4 h routinely, or q 1 h PRN or 10–↑ mg ER PO q 12 h	Limited only by need and adverse effects
Oxycodone + acetaminophen combinations	5 mg oxycodone + 325 mg acetaminophen tab: 5/500,7.5/325, 7.5/500, 10/325, 10/650 (may include caffeine)	See above acetaminophen and oxycodone	1–2 tabs PO q 4 h routinely or PRN	Limited to 12 tabs/24h by acetaminophen	Caution in liver disease
Oxycodone + aspirin combinations	5 mg oxycodone + 325 mg ASA tab: (may include caffeine)	Renal excretion: approximately 20% unchanged See above for ASA and oxycodone	1–2 tabs PO q 4 h routinely or PRN	Limited to 12 tabs/24h by ASA
Tramadol	Tab: 50 mgER tab: 100, 200, 300 mgTab: 37.5 mg with acetaminophen 325 mg	Liver metabolism: extensive Renal excretion: 30% excreted in the urine as unchanged drug, 60% of dose excreted as metabolites	1–2 tabs PO q 6 h	2 tabs PO q 6 h	Dose ceiling 400 mg/day Caution with antidepressant drugs because of interaction & possible serotonin syndrome