Cervidil® vaginal insert is indicated for the initiation and/or continuation of cervical ripening in patients near term in whom there is a medical or obstetrical indication for the induction of labor.
Dinoprostone vaginal pessary is well tolerated. The most frequently noted side effects (<1%) include fever, nausea, and abdominal pain. In cases of fetal distress when product removal was thought advisable, there was a return to normal rhythm and no neonatal sequelae.
The dosage of dinoprostone in the vaginal insert is 10 mg designed to be released at approximately 0.3 mg/hr over a 12 hour period. The product should be removed upon onset of active labor or 12 hours after insertion. A dinoprostone vaginal insert is placed transversely in the posterior fornix of the vagina immediately after removal from the foil package. The insert must be used with the removal system intact. A minimal amount of K-Y jelly may be used to assist in the insertion of the product. Patients should remain in the supine position for 2 hours following insertion, but thereafter may be ambulatory. Cervidil® is a class J agent on the KUMC Cost Code Index and replaces the dinoprostone cervical gel product (Prepidil®).
Carteolol ophthalmic solution is indicated in patients with chronic open-angle glaucoma and intraocular hypertension, either alone or in combination with other intraocular pressure lowering medications. Carteolol is a noncardioselective beta-blocker with intrinsic sympathomimetic activity and very weak membrane stabilizing activity. Blocking beta receptors reduces intraocular pressure through inhibition of aqueous humor production in the ciliary body. The mechanism by which aqueous humor production is reduced is not known.
Adverse effects are similar to those observed with other beta-blocker ophthalmic solutions. Local effects are eye pain and discomfort, burning, tearing, conjunctival hyperemia and edema. Systemic effects may include bradycardia, decreased blood pressure, headache, cardiac arrhythmias, dyspnea, and dizziness.
Studies suggest carteolol is associated with fewer side effects (less eye discomfort, effect on heart rate, fatigue, and headache) than timolol ophthalmic. In addition, carteolol induces less bradycardia than timolol and metipranolol, although all three agents were noted to produce some degree of bradycardia and bronchoconstriction. Other studies have shown carteolol to be similar to timolol in regard to systemic beta-blocking activity.
Differences in the incidence and severity of adverse effects between carteolol ophthalmic and other ophthalmic beta-blockers have not been well demonstrated. As with other agents in this class, carteolol should be administered with caution in patients predisposed to the adverse effects of systemic beta-blocking agents.
Due to potential for additive effects, carteolol ophthalmic should be used with caution in patients receiving a systemic beta-blocker. Caution should also be exercised when carteolol is administered to patients receiving catecholamine depleting agents, such as reserpine, due to the potential for additive effects.
The usual dose of carteolol 1% ophthalmic solution is one drop in the affected eye(s) twice daily. If the patient's intraocular pressure is not adequately controlled on this regimen, the use of additional agents should be considered. Carteolol carries a KUMC Cost Code Index of F.
Mycophenolate mofetil, a morpholinoethyl ester of mycophenolic acid antibiotic with immunosuppressant properties, is indicated for the prophylaxis of organ rejection in patients receiving allogenic renal transplants. This product should be used concomitantly with cyclosporine and corticosteroids.
The administration of mycophenolate mofetil with food lowered the peak concentration of the active metabolite by 40% and antacids lowered peak concentrations by 33%.
Adverse effects of mycophenolate mofetil occurring in greater then 20% of patients included pain, abdominal pain, fever, headache, anemia, leukopenia, urinary tract infections, hypertension, peripheral edema, diarrhea, constipation, and opportunistic infections relating to immunosuppression. Notably absent was nephrotoxicity.
The initial dose of mycophenolate mofetil should be given within 72 hours post- transplantation as 1 gram twice daily in combination with corticosteroids and cyclosporine in renal transplant patients. Doses of 1.5 gm BID are safe but no increase in efficacy was demonstrated in clinical trials. Cell Cept® should be taken on an empty stomach. The KUMC Cost Code Index for mycophenolate mofetil is Class J.
Cyclosporine, a potent immunosuppressive agent derived from its specific and reversible inhibition of immunocompetent lymphocytes in the G[0] and G[1] phase of the cell cycles, indicated for the prophylaxis of organ rejection in kidney, liver and heart allogenic transplants. Neoral® is a microencapsulated formulation and the Sandimmune® product is not a microemulsion.
New Patients
The initial oral dose of Neoral® can be given 4-12 hours prior to transplantation.
Suggested initial dosages are the same as initial doses of Sandimmune® with mean doses as
9±3 mg/kg/day for renal transplant patients, 8±4 mg/kg/day for liver transplant patients
and 7±3 mg/kg/day for heart transplant patients. Total daily doses were divided in two
equal daily doses. If cyclosporine trough blood concentrations are used, the target range
is the same for Neoral® and Sandimmune®. Using the same trough concentration range for
Neoral® as for Sandimmune® results in greater cyclosporine exposure when Neoral® is
administered. Dosing should be titrated based on clinical assessment of rejection and
tolerability. Lower Neoral® doses may be sufficient as maintenance therapy.
Sandimmune Patients
In transplant patients who will be converted from Sandimmune® to Neoral®, there is a 1:1
conversion. The Neoral® dose should be subsequently adjusted to attain the pre-conversion
blood trough concentrations.
Neoral® and Sandimmune® are priced exactly the same and carry a KUMC Cost Code Index of J.
Climara® is indicated for the treatment of moderate to severe vasomotor symptoms associated with menopause, the treatment of vulval and vaginal atrophy, hypoestrogenism, and abnormal uterine bleeding due to hormonal imbalance (in the absence of organic atrophy).
A commonly reported side effect in clinical trials was skin irritation at application site, resulting in a discontinuation rate of 6.8 %. Limited comparative data suggests that there is no significant differences in irritation rates between Climara® and the Estraderm® products at the end of three weeks [31% vs 25%]. Other adverse events noted include breast pain, leukorrhea, and uterine bleeding.
Initial treatment should begin with the 0.05 mg/day patch applied to the skin once weekly. Dosage adjustment may be necessary to control symptoms but clinical response should be managed with the lowest effective dose. The estradiol patch is usually administered on a cyclic schedule [3 weeks of therapy followed by 1 week without therapy]. In women who are currently taking oral estrogen, treatment with transdermal patches may begin one week after the withdrawal of oral therapy or sooner if symptoms reappear in less than one week.
The patch should be placed on a clean, dry area of the abdomen. Application sites should be rotated with an interval of at least one week between applications to a specific site. The area selected should not be oily, damaged or irritated. The waistline should be avoided as tight clothing may remove the product via rubbing. After application, press firmly with fingers for about 10 seconds. In the event that a patch falls off, a new system should be applied for the remainder of the 7 day dosing interval. Only one patch should be worn during the 7 day period.
The weekly costs of Climara® and Estraderm® are approximately equal. Therefore, Climara® will replace Estraderm® as the sole formulary estradiol transdermal system. Climara® carries a KUMC Cost Code Index of C.
| NOTE: There has been a formulation change in the product of Mylanta Double Strength yet the name has remained the same. The old product contained 400 mg of aluminum and magnesium and 40 mg of simethicone. The new product contains 700 mg of calcium and 300 mg of aluminum and it also contains confectioners sugar. Please note that all prescriptions written for Mylanta Double Strength will be filled with the new formulation. |
Changes in the KUMC Formulary since the 1995-1996 Publication
dinoprostone Vaginal Insert (Cervidil®)
carteolol ophthalmic solution (Ocupress®)
mycophenolate mofetil (Cell Cept®)
microemulsion cyclosporine (Neoral®)
estradiol transdermal system (Climara®)
varicella vaccine (Varivax®)
dorzolamide 2% (Trusopt®)
sevoflurane (Ultrane®)
fenfluramine (Pondimin®)
-restricted to cardiac catheterization lab
sonicated albumin 5% (Albunex®)
-restricted to Obesity Clinic Protocol
levomethadyl acetate (Orlaam®)
-restricted to cardiac catheterization lab
phentermine (Adipex-P®, Fastin®)
-restricted to Methadone Clinic
tobramycin and dexamethasone 0.1%, 0.3% (Tobradex®)
desflurane (Suprane®)
dinoprostone cervical gel (Prepidil®)
dexamethasone, neomycin and polymixin B (Maxitrol®)
estradiol transdermal system (Estraderm®)
