Pharmacology

ANTIFUNGALS (TOPICAL)

Trade Name is a more correct term for the branded drug name.

Group	Generic Name	Trade Name	Formulation	Size	Dosing	Dermatophytes	Candida	OTC
Imidazole	Clotrimazole	Lotrimin	Cream, 1%	15, 30, 45, 90 g	bid	x	x
			Lotion, 1%	30 mL	bid	x	x
			Solution, 1%	10, 30 mL	bid	x	x
		Lotrimin-AF	Cream, 1%	12, 24 g	bid	x	x	x
			Lotion, 1%	20 mL	bid	x	x	x
			Solution, 1%	10 mL	bid	x	x	x
			Powder, 1%	90 g	bid	x	x	x
			Spray powder, 1%	3.5 oz	bid	x	x	x
			Spray liquid, 1%	4.0 oz	bid	x	x	x
			Deodorant powder, 1%	3.5 oz	bid	x	x	x
		Mycelex	Cream, 1%	15 g	bid	x	x	x
		Cruex Prescription Strength	Cream, 1%	0.5%	bid	x	x	x
		Desenex Prescription Strength	Cream, 1%	0.5%	bid	x	x	x
		Lotrisone (contains 0.05% Betamethasone)	Cream, 1%	15, 45 g	bid	x	x
		Fungoid	Solution, 1%	1.0 oz	bid	x	x	x
		Tineacide^a	Cream, 1%	1.25 oz	bid	x	x	x
	Econazole	Spectazole	Cream, 1%	15, 30, 85 g	bid	x	x
	Ketoconazole	Nizoral	Cream, 1%	15, 30, 60 g	Daily	x	x
	Luliconazole	Luzu	Cream, 1%	15, 30 g	Daily	x	x
	Miconazole	Monistat-Derm	Cream, 1%	15 g, 1, 3 oz	bid	x	x
		Micatin	Spray liquid, 1%	3 oz	bid	x	x	x
		Fungoid Tincture^a	Solution, 2%	1 oz, 1 pt	bid	x	x
		Cruex Prescription Strength	Spray powder, 2%	3 oz	bid	x	x	x
		Desenex Prescription Strength	Spray powder, 2%	3 oz	bid	x	x	x
			Spray liquid, 2%	3.5 oz	bid	x	x	x
		Lotrimin-AF	Powder, 2%	3 oz	bid	x	x	x
			Spray powder, 2%	3.5 oz	bid	x	x	x
			Spray deodorant powder, 2%	3.5 oz	bid	x	x	x
		Micro-Guard	Cream, 2%	2 oz	bid	x	x	x
			Powder, 2%	3 oz	bid	x	x	x
		Zeasorb-AF	Powder, 2%	2.5 oz	bid	x	x	x
	Oxiconazole	Oxistat	Cream, 1%	15, 30, 60 g	bid	x	x	x
			Lotion, 1%	30 mL	bid	x	x
	Sulconazole	Exelderm	Cream, 1%	15, 30, 60 g	bid	x	x
	Haloprogin	Halotex	Cream, 1%	15, 30 g	bid	x	x	x
			Solution, 1%	10 mL	bid	x	x	x
Antibiotics	Amphotericin B	Fungizone	Cream, 1%	20 g	bid		x
			Lotion, 1%	30 mL	bid	x
			Ointment, 1%	20 g	bid		x
	Nystatin	Mycostatin	Cream	30 g	bid		x
			Powder	15 g	bid	x
		Nilstat	Ointment	15 g	bid		x	x
			Cream	15 g	bid		x	x
		Pedi-Dri	Powder	2 oz	bid		x
		Nystop	Powder	15 g	bid	x
		Mycolog	Cream	15, 30, 60 g	bid		x	x
		Myco-Triacet II (contains Triamcinolone)	Cream	15, 30, 60 g	bid		x
Allylamine	Terbinafine	Lamisil-AT	Cream, 1%	15, 30 g	bid	x
	Naftifine	Naftin	Cream, 1%	15, 30, 60 g	bid	x
			Gel, 1%		bid	x
	Butenafine	Mentax	Cream, 1%	15, 30 g	qd	x
Miscellaneous	Undecylenic acid	Cruex	Spray powder	1.8, 3.5, 5.5 oz	bid	x		x
		Desenex	Spray powder	2.7 oz	bid	x		x
			Shake powder	1.5, 3 oz	bid	x		x
			Ointment	0.5, 1 oz	bid	x		x
		Gordochom^a	Solution	1 oz, 1 pt	bid	x		x
		FungiCure	Solution	1 oz	bid	x		x
			Gel	0.6 oz	bid	x		x
		FungiNaila	Solution, 25%	30 mL	bid	x		x
	Tolnaftate	Tinactin	Cream, 1%	15, 30 g	bid	x		x
			Powder, 1%	45, 90 g	bid	x		x
			Liquid spray, 1%	4 oz	bid	x		x
			Deodorant powder, 1%	3.5 oz	bid	x		x
		Aftate	Spray liquid, 1%	3.5, 4.0 oz	bid	x	x
			Spray powder, 1%	3.5, 4.0 oz	bid	x	x
		Pro Clearz	Solution	1 oz	bid	x	x	x
	Ciclopirox Olamine	Loprox	Cream, 1%	15, 30, 90 g	bid	x	x
		Penlac^a	Solution, 8%	3.3 mL	qd	x	x
			Lotion, 1%	30, 60 mL	bid	x	x
	Phenol 1.5%	Castellani’s Paintb	Solution, colored	1oz, 1 pt	bid
			Solution, colorless	1oz, 1 pt	bid
^aIndicated for fungal nails. ^bCastellani’s Paint is not technically an antifungal but an antiseptic astringent that is often used on macerated interdigital fungal infections. Its active ingredient, phenol, has been shown to have antifungal properties. The color, in the colored solution, is fuchsine and has no medicinal value.

ANTIFUNGALS FOR NAILS (TOPICALS)

Efinaconazole (Jublia) 10% solution

Apply to nails daily.

Tavaborole (Kerydin) 5% solution

Apply to nails daily.

Kills only T. rubrum and T. mentagrophytes

Ciclopirox (Penlac)

Apply to nails daily.

Every 7 days remove film that develops with alcohol.

Tolnaftate (Formula 3) 1% solution

Apply to nails daily.

Undecylenic Acid (Tineacide)

Apply to nails daily.

ANTIFUNGALS (ORAL/IV)

Itraconazole (Sporanox, Onmel) 100 mg PO bid ×12 weeks for fungal toenails or ×6 weeks for fungal finger nails. “Pulse dosing” 200 mg PO bid ×1 week then 3 weeks off, 3 pulses for toenails and 2 pulses for fingernails. Onmel taken 200 mg qd ×12 weeks. [100mg, 200mg].

Imidazole derivative

Active against dermatophytes and Candida

Contraindicated with astemizole, terfenadine, cisapride

Possible hepatotoxicity; monitor hepatic function before treatment and at 1 month

Ketoconazole (Nizoral) 200 to 400 mg PO daily [200mg]

Imidazole derivative

Active against dermatophytes, Candida, and some G+, and has also shown to have some antiviral properties

Can cause hepatotoxicity

Contraindicated with cisapride, terfenadine

Amphotericin B (Abelcet, Amphotec, Fungizone) Test dose of 1 to 5 mg IV over 15 to 30 minutes, then wait 30 minutes. If there are no adverse reactions such as fever, chills, or muscle spasms, begin IV infusion. Dosage varies based on suspension.

Antibiotic antifungal

Used mostly for life-threatening fungal infections after other antifungals have failed

Active against fungus and Candida; does not affect bacteria or dermatophytes

Not effective orally

Can cause renal toxicity

Terbinafine HCL (Lamisil) 250 mg PO daily for 6 weeks for fingernails and for 12 weeks for toenails

Allylamine derivative

Fluconazole (Diflucan) Oropharyngeal candidiasis: 200 mg IV/PO first day, then 100 to 200 mg daily for at least 2 weeks. Cryptococcal meningitis: 400 mg IV first day, then 200 to 800 mg daily. Vaginal candidiasis: 150 mg PO single dose [tabs 50, 100, 150, 200 mg, susp 10 and 40 mg per mL].

Imidazole derivative

Active against dermatophytes and some Candida, but has no antibacterial properties

Can cause renal toxicity

Griseofulvin (Fulvicin, Grifulvin, Grisactin, Gris-PEG) For tinea corporis, tinea cruris, and tinea capitus 375 mg daily. For tinea pedis and tinea unguium 375 mg bid [tabs 125, 250, 500 mg, susp 125 mg per 5 mL].

Active against dermatophytes; does not kill Candida

Renal and hepatic function should be monitored.

Gentian Violet

Topically bid for 3 days

Active against dermatophytes, Candida, and G Pos (color is due to crystal violet, hence G Pos activity)

Not commonly used for dermatophyte infections due to low efficacy, and has local irritant and staining properties

Solution 0.5%, 1%, 2%

Drying properties; so use on macerated infections

PEDAL ANTIPERSPIRANTS

The following are aluminum-based antiperspirants. Aluminum-based antiperspirants work by blocking the sweat ducts.

Ostiderm roll-on

Daily [3 oz bottle]

Xerac AC

Daily at bedtime [35 cc, 60 cc Dab-O-Matic bottle]

Drysol

Daily at bedtime [37.5 cc bottle, 35 cc, 60 cc Dab-O-Matic bottle]

Bromi-Lotion

Daily [4 oz bottle]

Dr. Scholl’s Antiperspirant Spray

Bid [3.5 oz]

TOPICAL KERATOLYTICS

Salicylic Acid (Duofilm, Duoplant)

Topically daily

Used for scaling dermatosis and localized hyperkeratosis

Also used for seborrheic dermatitis, psoriasis, and dandruff

12% to 17.6%

Urea (Ureacin, Carmol, Vanamide, Keralac)

Topically daily tid

Cream/lotion 5% to 40%

Sulfur (Sulforcin, Sulfron)

Cream/lotion/ointment 2% to 5%

FIBROLYTICS

Hyaluronidase (Wydase)

Used as an adjuvant to increase the dispersion and absorption of parenteral fluids

Also used to break up scar tissue

Contraindicated in cases of infection and cancer because it could facilitate spreading

EMOLLIENTS (SOFTENING AGENTS)

Aquaphor (ointment) Apply bid [1.75 oz tube, 3.25, or 16 oz jar]

Calamine (lotion) Apply bid

Cetaphil (cream, lotion) Apply bid

Eucerin (cream, lotion) Apply bid [4, 8, 16 oz jars]

Lac-Hydrin 12% (cream, lotion)

Apply bid

Ammonium lactate

Lanolin (cream) Apply bid

Moisturel (cream, lotion) Apply bid

CONTROLLED SUBSTANCE ACT

Schedule I (CI)

Drugs with no accepted medical use and with high abuse potential

Examples include heroin, LSD, ecstasy, methaqualone.

Schedule II (CII)

High potential for abuse

Examples include fentanyl, oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Norco), methadone, hydromorphone (Dilaudid), meperidine (Demerol), amphetamine (Dexedrine, Adderall), methylphenidate (Ritalin).

Schedule III (CIII)

Moderate abuse potential

Schedule IV (CIV)

Low abuse potential

Examples include benzodiazepines (Valium, Xanax), d-propoxyphene, Ambien, tramadol (Ultram).

Schedule V (CV)

Rx not required when provided in low doses

OPIOID ANALGESICS

Side effects include hypotension, respiratory depression, nausea, urinary retention, and constipation.

Low-dose opioids suppress the cough reflex.

Contraindicated in cases of head trauma; opioids caused an increase in intracranial pressure

All opioids cause tolerance and dependence when used for chronic pain management in all patients and addiction in some patients.

Opioid Agonists

Fentanyl (Sublimaze) CII

IV fentanyl is often used for anesthesia due to its quick onset and short-acting properties.

A wide range of fentanyl preparations are available for analgesia, including buccal tablets, lollipops, nasal sprays, inhalers, and transdermal patches.

Dosage:	IV analgesia/procedural sedation:	50 to 100 mcg slow IV over 1 to 2 minutes, titrate to effect
	IM analgesia:	50 to 100 mcg IM q1 to 2h prn
	Transdermal patch (Duragesic):	1 patch q72h [12, 25, 50, 75, 10 mcg per hour]

Alfentanil (Alfenta) CII

Used as anesthesia in surgery; quick onset, short acting

Dosage:

8 to 20 mcg per kg IV increments

Codeine CII

Used to treat mild to moderate pain

Dosage:	0.5 mg per kg up to 15 to 60 mg PO/IM q4 to 6h [15, 30, 60 mg. Oral soln: 15 mg per 5 mL]
	Low dose suppresses a cough (15 to 20 mg q4 to 6h, max 120 mg per day).

Codeine + Acetaminophen (Tylenol #3, Tylenol #4)

Tylenol #3 (acetaminophen 300 mg + codeine 30 mg) 1 to 2 tabs PO q4h

Tylenol #4 (acetaminophen 300 mg + codeine 60 mg) 1 to 2 tabs PO q4h

Hydrocodone CII

A semisynthetic opioid derived from codeine

Used to treat moderate to severe pain and as an antitussive to treat cough

Hydrocodone + Acetaminophen (Norco, Vicodin, Lortab)

Norco (5/325, 7.5/325, 10/325)

Vicodin (5/300)

Vicodin ES (7.5/300)

Vicodin HP (10/300)

Lortab (5/325, 7.5/325, 10/325)

Lorcet (5/325)

Lorcet Plus (7.5/325)

Lorcet HD (10/325)

Lortab Elixir (10 to 300 mg per 15 mL oral solution)

Hydrocodone + Ibuprofen (Reprexain, Ibudone, Vicoprofen)

Reprexain (2.5/200, 5/200, 10/200)

Ibudone 5 (5/200, 10/200)

Vicoprofen (7.5/200)

Oxycodone (Roxicodone, Oxaydo) CII

Management of moderate to severe pain

Dosage:	PO:	5 to 10 mg PO q4 to 6h [5, 10, 15, 20, 30 mg]
	Controlled release (OxyContin):	10 to 40 mg q12h [10, 15, 20, 30, 40, 60, 80 mg]

Oxycodone + Acetaminophen (Percocet)

Percocet (2.5/325, 5/325, 7.5/325, 10/325)

1 tab PO q4 to 6h prn

Xartemis XR (7.5/325)

Controlled release: 2 tabs PO bid prn

Oxycodone + Aspirin (Percodan)

Percodan (4.84/325)

1 tab PO q4 to 6h prn

Controlled release (OxyContin) 10 to 40 mg PO q12h [tab 5, syrup 5 mg per 5 mL, controlled release OxyContin 10, 20, 40, 80, 160 mg]

Hydromorphone (Dilaudid) CII

A derivative of morphine; used to management of moderate to severe pain

Dosage:	PO:	2 to 4 mg q4 to 6h prn
	IM/SC:	0.5 to 2 mg or slow IV q4 to 6h

Levorphanol (Levo-Dromoran) CII

Management of moderate to severe pain

Dosage:

PO: 2 mg q6 to 8h

Meperidine (Demerol) CII

Management of severe pain

Dosage:	PO/IM/SC:	1 to 1.8 mg per kg q3 to 4h up to 150 mg prn
	IV:	1 to 1.8 mg per kg slow infusion q3 to 4h up to 150 mg prn

Methadone (Dolophine) CII

Used as an oral replacement for IV heroin; it does not “detoxify”

Management of moderate to severe pain

Dosage:	PO/IM/SC:	2.5 to 10 mg q8 to 12h prn pain
	PO:	20 mg daily for treatment of opioid dependence

Morphine (MS Contin, Kadian) CII

Management of moderate to severe pain

Dosage:	PO:	(Controlled release tabs: MS Contin) 30 mg q8 to 12h
	PO:	(Controlled release caps: Kadian) 20 mg q12 to 24h
	IM/SC:	0.1 to 0.2 mg per kg up to 15 mg q4h prn
	IV:	0.1 to 0.2 mg per kg infused slow up to 15 mg q4h prn