Note – The following doses are for adults. Contraindications always include hypersensitivity to the drug itself. “Warn/Prec” are some warnings that should be made and conditions where the medication may impose additional risk of adverse reaction. “Most common” side effects may be marked with an asterisk. The information presented here is abridged; please refer to the PDR or product inserts for more information, including pediatric dosing guidelines. (Drugs are listed in alphabetical order.)

Acetaminophen – oxycodone hydrochloride (Percocet, Endo; Roxicet, Roxane) – [tabs 325/2.5, 325/5, 325/7.5, 325/10, 500/7.5, 650/10 mg]

Indic/dosage: pain, moderate to moderate-severe: acetaminophen 325 to 650 mg/oxycodone 2.5 to 10 mg orally q6h prn; max 4,000 mg acetaminophen/day

Action: acetaminophen is a nonopiate and nonsalicylate analgesic and antipyretic drug; oxycodone hydrochloride, a semisynthetic pure opioid agonist, has actions similar in quality with those of morphine and acts predominantly on the CNS and organs composed of smooth muscle

Contra: bronchial asthma, known or suspected paralytic ileus, and respiratory depression

Warn/prec: chronic administration may result in psychic and physical dependence and tolerance, concomitant use of other CNS depressants (including alcohol), elderly or debilitated patients, and in pregnancy C (acetaminophen) and B (oxycodone)

Adverse reactions: constipation, nausea/vomiting, dizziness, light-headedness, and somnolence

Alendronate (Fosamax, Merck) – [tabs 5, 10, 35, 40, 70 mg]

Indic/dosage: osteoporosis prevention: 5 mg qd or 35 mg qwk; osteoporosis treatment: 10 mg qd or 70 mg qwk; Paget’s disease: 40 mg qd × 6 months; all tablets should be taken ≥30 minutes before first food or beverage of the day, with a full glass of water; avoid lying down for at least 30 minutes

Action: bisphosphonates act to inhibit normal and abnormal bone resorption; as a result, an asymptomatic reduction in serum Ca and PO₄ is noted

Contra: hypocalcemia, severe renal dysfunction, and dysphagia

Warn/prec: upper GI disease and pregnancy C

Adverse reactions: esophagitis, GI distress, headache, myalgias, arthralgias, back pain, dysphagia, abdominal distension, chest pain, peripheral edema, flulike symptoms, and esophageal ulcer

Amantadine (Symmetrel, Endo) – [caps 100 mg, syrup 50 mg/5 mL]

Indic/dosage: Parkinson’s disease/syndrome: 100 mg bid, can increase to 400 mg/day after one to several weeks, start at 100 mg qd for those
on other anti-Parkinson’s medications or medically ill patients; treatment or prophylaxis for influenza A: 200 mg initially, then 100 mg qd; off-label for poor arousal or inattention in TBI: 100 mg bid; off-label for postpolio syndrome pain, fatigue in MS as well as TBI, and hyperthermia of central origin in TBI

Action: blocks ion channels (nicotinic ACh, M2 ionic channel in influenza A); also believed to release dopamine from intact dopaminergic terminals

Warn/prec: seizure disorder, CHF, renal disease, and pregnancy C; withdrawal from amantadine should be gradual

Adverse reactions: (usually well-tolerated) dizziness, nausea, nervousness, ataxia, insomnia, dry mouth, GI hypomotility, urinary retention, changes in mood, confusion, hallucinations, CHF, edema, orthostatic hypotension, and livedo reticularis (particularly women)

Amitriptyline (Elavil, Merck) – [tabs 10, 25, 50, 75, 100, 150 mg]

Indic/dosage: depression: 50 to 150 mg qhs (for elderly 10 mg tid and 20 mg qhs may be sufficient; reduce dose for hepatic impairment); off-label for neuropathic pain (start at lower doses than for depression)

Action: tertiary amine tricyclic, norepinephrine (NE)/serotonin reuptake inhibitor; also has anti-α1-adrenergic and potent antimuscarinic properties; may potentiate analgesic effect of opioids

Contra: acute post-MI and concomitant monoamine oxidase inhibitor (MAOI) use

Warn/prec: cardiovascular (CV) disorders (can cause HTN), hyperthyroidism, schizophrenia/paranoia, pregnancy D, and discharge before elective surgery; withdraw gradually after long-term use to avoid insomnia and abdominal discomfort

Adverse reactions: dry mouth, blurred vision, constipation, urinary retention, CV effects (tachycardia and prolongation of AV conduction), weight gain, somnolence, seizures, photosensitivity, GI distress, leukopenia, gynecomastia, testicular swelling, sexual dysfunction, and menstrual irregularity

Monitoring: baseline and periodic leukocyte and differential counts, LFTs, and ECG. Patients with CV issues require surveillance

Baclofen (Lioresal, Novartis) – [tabs 10, 20 mg, intrathecal (IT)]

Indic/dosage: spasticity: titrate to a maximum dose of 20 mg qid as follows: 5 mg tid × 3 days, then 10 mg tid × 3 days, then 15 mg tid × 3 days, then 20 mg tid × 3 days, increase as needed; consider IT if oral in effective but titration limited by side effects; no indication of oral form for spasticity due to stroke, Parkinson’s disease, or CP

Action: analog of γ-aminobutyric acid (GABA) thought to bind to GABA-B receptors, inhibiting Ca influx into presynaptic terminals and suppressing spinal cord excitatory neurotransmitters

Warn/prec: impaired renal function, risk of seizure if withdrawn too quickly (therefore, should taper off over ≈1 week), and pregnancy C

Adverse reactions: Oral baclofen: drowsiness, dizziness, headache, nausea/vomiting, lassitude, GI upset, urinary frequency, CNS depression, confusion, slurred speech, nasal congestion, seizures, blurred vision,
weakness, hypotonia, HTN, CV collapse, respiratory failure, rash, pruritus, and increased LFTs; IT baclofen: fatigue and drowsiness

Overdosage: IV physostigmine 1 to 2 mg. Also see p. 213 for details on IT baclofen

Bisacodyl (Dulcolax, Boehringer Ingelheim) – [oral tab 5 mg, rectal suppository 10 mg]

Indic/dosage: constipation: 5 to 15 mg po qd up to 30 mg/day- or 10 mg suppository rectally qd

Action: stimulates enteric nerves to cause colonic mass movements, a contact laxative; increases fluid and NaCl secretion and increases peristalsis

Contra: appendicitis, intestinal obstruction, and gastroenteritis

Warn/prec: abdominal pain, nausea, vomiting, rectal bleeding, inflammatory bowel disease, use for more than 7 days is not recommended, and pregnancy A

Adverse reactions: abdominal colic, abdominal discomfort, diarrhea, and proctitis

Capsaicin (Zostrix, Medicis) – [cream 0.025%, 0.075%, both OTC]

Indic/dosage: FDA-approved for postherpetic neuralgia; commonly used for OA and neuropathic pain: apply a thin film to affected areas tid to qid; may require ongoing use for effect; experimental intravesical instillation inhibits contractions in neurogenic bladders

Action: evidence suggests that capsaicin depletes the pain neurotransmitter substance P from unmyelinated peripheral neurons

Warn/prec: wash hands after application, avoid contact with eyes, and avoid heating pads in treated areas

Adverse reactions: local burning sensation, which typically improves with repeated use, but may not be tolerated by some

Carbamazepine (Tegretol, Novartis) – [tabs 100, 200 mg, oral suspension 100 mg/5 mL]

Indic/dosage: epilepsy: start at 200 mg bid; trigeminal neuralgia: start at 100 mg qd; off-label for neuropathic pain: start at 100 mg bid; maximum dose for all indications is 1,200 mg/day, usually divided in tid doses, increase doses each week by ≤200 mg/day

Action: unknown, but related to the tricyclic antidepressants (TCAs); may be a result of Na channel blockade in rapidly firing neurons and reduced excitatory synaptic transmission in the trigeminal nucleus

Contra: TCA hypersensitivity, history of bone marrow depression, and concomitant use of MAOIs (or within 14 days of discharge)

Warn/prec: impaired liver/renal function, hyponatremia, pregnancy C, and numerous drug interactions

Adverse reactions: initially dizziness, ataxia, drowsiness, nausea/vomiting, but usually subside spontaneously within a week, bone marrow suppression, hepato/nephrotoxicity, nystagmus, rash, Stevens-Johnson syndrome (SJS), and arrhythmias

Monitoring: pretreatment CBC, BUN, LFTs, and Fe, with periodic follow-up (frequency guidelines not established)

Celecoxib (Celebrex, Pfizer/Searle/Pharmacia) – [caps 100, 200 mg]

Indic/dosage: OA: 200 mg qd or 100 mg bid; rheumatoid arthritis (RA): 100 to 200 mg bid; acute pain/dysmenorrhea: 400 mg initially, followed by 200 mg if needed on first day, then 200 mg bid prn

Action: COX-2 selective NSAIDs

Contra: hypersensitivity to sulfonamides, ASA, and NSAIDs

Warn/prec: HTN, CHF, history of GI bleed, and renal insufficiency; monitor INRs closely with concomitant warfarin treatment, pregnancy C, and nasal polyps

Adverse reactions: edema, GI distress/bleed, thrombocytopenia, nephro/hepatotoxicity, bronchospasm, and agranulocytosis. Note: In the CLASS study,¹ annual incidence of upper GI ulcer complications (bleeding, perforation, and obstruction) for celecoxib 200 mg bid versus NSAIDs (ibuprofen 800 mg tid or diclofenac 75 mg bid) was 0.76% versus 1.45%; when combined with symptomatic ulcers, annual incidence was 2.08% versus 3.54% (p = 0.02)

Clonidine (Catapres, Boehringer Ingelheim) – [tabs 0.1, 0.2, 0.3 mg, transdermal therapeutic system (TTS) qwk patch 0.1/24, 0.2/24, 0.3 mg/24 h]

Indic/dosage: HTN: start orally at 0.1 to 0.3 mg bid or TTS 0.1 mg/24 h qwk, maximum dose is 2.4 mg/day orally or TTS 0.3 mg/24 h qwk; off-label for spasticity: dosing similar to HTN; IT clonidine used investigationally for spasticity and neuropathic pain

Action: central α-adrenergic agonist that ↓ sympathetic discharge

Warn/prec: CV disease, impaired liver/renal function, withdraw gradually to avoid rebound HTN, and pregnancy C

Adverse reactions: dry mouth/eyes, headache, dizziness, nausea, constipation, sedation, weakness, fatigue, orthostatic hypotension, edema, anorexia, erectile dysfunction, joint pain, and leg cramps

Cyclobenzaprine (Flexeril, Merck) – [tab 10 mg]

Indic/dosage: muscle spasm due to acute painful musculoskeletal conditions: 10 mg tid, maximum 60 mg/day, not to exceed 2 to 3 weeks

Action: structurally related to the TCAs; thought to act on the brain stem to reduce skeletal muscle hyperactivity, but not effective for spasticity of central origin

Contra: TCA hypersensitivity, concomitant MAOIs (or within 14 days of discharge), and recovery from acute MI, CHF, arrhythmias, conduction disturbances, and hyperthyroidism

Warn/prec: glaucoma, prostatic hypertrophy, and pregnancy B

Adverse reactions: drowsiness, dizziness, dry mouth, weakness, taste changes, fatigue, paresthesias, nausea, insomnia, blurred vision, seizures, hepatitis, and tachycardia

Dantrolene (Dantrium, Procter & Gamble) – [caps 25, 50, 100 mg, injection]

Indic/dosage: spasticity: start at 25 mg qd, increase by 25 mg q4-7d to a maximum of 400 mg/day divided into bid-qid (considered the oral agent of choice in TBI due to peripheral action and less CNS side effects); off-label for malignant hyperthermia: 2 mg/kg IV push until symptoms subside or cumulative dose of 10 mg/kg reached; also off-label for heat stroke and cocaine overdose rigidity

Action: reduces excitation-contraction coupling via reduction of sarcoplasmic reticulum Ca release

Contra: active liver disease and lactation

Warn/prec: risk of hepatic dysfunction higher in women or if >35 years, cardiomyopathy or pulmonary disease present, and pregnancy C

Adverse reactions: weakness, malaise, sedation, dizziness, nausea, diarrhea, acnelike rash, pruritus, headache, insomnia, photosensitivity, fatal/nonfatal hepatotoxicity (most commonly 3 to 12 months after initiation of treatment, most cases resolve with discharge), and seizures Monitoring: baseline/periodic LFTs

Diazepam (Valium, Roche) – [tabs 2, 5, 10 mg, oral solution 5 mg/5 mL, 5 g/1 mL, injection]

Indic/dosage: skeletal muscle spasticity due to local reflex spasm, UMN spasticity, athetosis, and stiff-man syndrome: 2 to 10 mg po/IM tid-qid (geriatric patient, 1 to 2.5 mg qd-bid); anxiety dosing similar to spasticity; EtOH withdrawal: initially 2 to 5 mg IV, repeat q3-4h prn; status epilepticus: 0.2 to 0.5 mg/kg/dose IV q15-30min to a maximum of 30 mg

Action: proposed mechanism for antispasticity effect is a postsynaptic facilitation of spinal cord GABA w/o a direct GABA-mimetic effect

Contra: CNS depression and acute angle glaucoma

Warn/prec: class IV, impaired liver/renal function, depression may worsen with use, and pregnancy D

Adverse reactions: sedation, “hangover,” dizziness, ataxia, diplopia, hypotension, confusion, constipation, urinary retention/incontinence, anterograde amnesia, dependency, withdrawal syndrome, bone marrow suppression, rash, fever, hepatotoxicity, blood dyscrasias, and injection site reaction (local pain and thrombophlebitis); apnea/cardiac arrest (rare, typically only after IV administration or in elderly or medically ill patients)

Docusate sodium (Colace, Purdue Products LP) – [tabs 50, 100 mg]

Indic/dosage: constipation: 50 to 200 mg po qd or in divided doses 2 to 4× daily; 50 to 100 mg rectally as an enema

Action: actively draws water into stool, thus softening stool and achieving ease in bowel movement

Contra: concomitant use of mineral oil, intestinal obstruction, acute abdominal pain, and nausea/vomiting

Warn/prec: sudden change in bowel habits > 2 weeks duration, use > 1 week, rectal bleeding, and pregnancy A

Adverse reactions: abnormal taste in mouth, diarrhea, nausea, cramping, and hepatotoxicity (rare)

Etanercept (Enbrel, Amgen) – [subcutaneous (SC) powder for solution 25 mg, SC: 50 mg/mL]

Indic/dosage: ankylosing spondylitis, psoriatic arthritis, RA (moderate to severe): in each case, 50 mg SC qwk given as one 50 mg injection or two 25 mg injections in one day or one 25 mg injection given twice weekly, 72 to 96 hours apart

Action: dimeric soluble form of the p75 TNF receptor that specifically binds TNF-α and TNF-β, binding of etanercept to TNF renders it
biologically inactive; also modulates biologic responses that are induced or regulated by TNF, including expression of adhesion molecules responsible for leukocyte migration, serum levels of cytokines, and serum levels of matrix metalloproteinase

Contra: sepsis