P Drug Supplied as Dose and route Special considerations Dimenhydrinate Tab: 50 mg Children: mg/kg/24 h divided q6 h PO/IV SE: drowsiness, H/A paradoxical excitement, bl vision, tinnitus, dry mouth, dizziness, hypotens anorexia, urinary frequency (Dramamine) Injection: 50 mg/mL (1 mL) Compazine (see prochlorperazine maleate, p 320) Max dose: 300 mg/d Class: antihistamine, antivertigo Adults: 50 mg divided q6 h PO 50–100 mg divided q6 h IV Max dose: 400 mg/d Diphenhydramine hydrochloride Caps: 25, 50 mg Children: mg/kg/d divided q6–8 h PO/IV Generally not effective alone as antiemetic, but potentiate phenothiazines; may also prevent extrapyramidal symptoms (EPS) when used in combination with phenothiazines Elixir: 2.5 mg/mL (5, 10, 120 mL) (Benadryl) Max dose: 300 mg/d Injection: 50 mg/mL (1, 10 mL) Class: antihistamine Adults: 25–50 mg q2–6 h PO/IV Max dose: 400 mg/d SE: sedation, dizziness, hypotension, paradoxic excitement, N/V, dry mucous membranes, urina retention, blurred vision, palpitations, insomnia P Drug Supplied as Dose and route Special considerations Droperidol Injection: 2.5 mg/mL (2 mL) Children: 0.088–0.165 mg/kg per dose IV q6 h Neuroleptic malignant syndrome can occur with of administration and can be life-threatening SE hypotension, tachycardia, dystonic reaction, aka oculogyric crisis, anxiety, hyperactivity, drowsi dizziness, hallucinations, chills, laryngospasm, bronchospasm (Inapsine) Adults: As premedication: 2.5–10 mg 30 Class: anesthetic adjunct, antiemetic prn: 0.088–0.165 mg/kg per dose IV q6 h Max dose: 10 mg/d Hydroxyzine Injection: 5, 10, 20, 25, 30, 40, Children: 50, 75, 100 mg (Vistaril) 2–4 mg/kg/d divided q6–8 h PO Tab: 25, 50, 100 mg Class: antihistamine, sedative/hypnotic Metoclopramide hydrochloride mg/kg per dose divided q4–6 h IV Adult: 25–100 mg per dose q6 h PO/IV Injection: mg/mL (2, 10 mL) Children: GI, hypomotility: PO/IV: Syrup: mg/mL (Reglan) Class: parasymphatomimetics; antiemetic Should only be administered IV via central ven because of risk of thrombosis and digital gangre 0.1 mg/kg per dose up to times per d, Tab: 10 mg Max dose: 0.5 mg/kg/d SE: Drowsiness, dry mouth, dizziness, ataxia, weakness, H/A, hypotension SE: diarrhea, weakness, restlesness, drowsiness rash, insomnia, dry mouth, extrapyramidal reac depression, hypotension, tachycardia, urticaria P Drug Supplied as Dose and route Special considerations Antiemetic: 1–2 mg/kg 30 before chemo and then q2–4 h IV Adults: GI hypomotility: PO/IV: 10 mg 30 before meals (ac) & at bedtime Antiemetic: 1–2 mg/kg 30 before & q2–4 h IV Ondansetron hydrochloride Injection: mg/mL (20 mL); 32 mg (single dose vial) Children: 10–20 kg: mg PO/IV (Zofran) Tab: 4, mg 20–40 kg: mg PO/IV > 40 kg: mg PO/IV Class: antiemetic Adults: < 70 kg: mg PO/IV Single dose: 24 or 32 mg may be given 30 prior to chemotheraphy Multiple dose: and h after first dose; no more than subsequent doses within 24 h period Phenergan (see promethazine hydrochloride, p 320) Small number of patients may experience tachyphylaxis with multiple doses SE: constipa diarrhea, abdominal cramping, dizziness, dry m rash, weakness P Drug Supplied as Dose and route Special considerations Prochlorperazine maleate Caps (sustained release): 10, 15, 30, 75 mg Children: (10 kg) 0.4 mg/kg/24 h PO/per rectum (PR) SE: akathisia, dystonia, hypotension, pigmentar retinopathy, tardive dyskinesia, constipation, in sweating, orthotastic hypotension, nasal conges extrapyramidal symptoms, tachycardia, metallic (Compazine) Tab: 5, 10, 25 mg 0.1–mg/kg per dose q6–8 h Syrup: mg/mL (120 mL) Adults: 5–10 mg q6–8 h POPR Suppository (supp): 2.5, 5, 25 mg Sustained release: 10 mg q 12 h (12 to box) Max dose: 40 mg/d 5–10 mg q3–4 h IV Class: phenothiazine, antiemetic Injection: mg/mL (2, 10 mL) Max dose: 40 mg/24 h Promethazine hydrochloride Injection: 25, 50 mg/mL (1 mL) Children: 0.25–1.0 mg/kg Drowsiness, thickening of bronchial secretions, per dose q4–6 h prn fatigue, increased appetite, weight gain, nervou PO/IV dizziness, diarrhea, dry mouth Supp: 12.5, 25, 50 mg (Phenergan, Provigan) Syryp: 6.25 mg/5 mL Adults: 12.5–25 mg q4–6 h prn PO/IV 25 mg/5 mL with 7% alcohol Class: antihistamine, Phenothiazine, antiemetic Tab: 12.5, 25, 50 mg Scopolamine hydrobromide Patch: 1.5 mg delivers 0.5 mg over d Children: mg/kg per dose q6–8 h IV prn (Transdermal Scop) Injection: 0.43 mg/0.5 mL Max dose: 0.3 mg per dose > 12 y: patch q3 d Class: parasympatholytic, antivertigo agent Adults: 0.3–0.65 mg per dose q4–6 h IN prn Patch: patch q3 d SE: constipation; decreased sweating; sweating mouth, nose, and throat; local irritation; difficul swallowing; increased sensitivity to light P Drug Supplied as Dose and route Special considerations Caps: 100, 250 mg Children: IV/IM: not recommended Not approved for IV administration Supp: 100, 200 mg Oral: 13–40 kg: 100–200 SE: sedation extrapyramidal symptoms, mg 3–4 times per d hypersensitivity skin reactions, hypotension, blu vision, dizziness, seizures, blood dyscrasias, dia mood changes, hepatotoxity Injection: 100 mg/mL Rectal: < 13 kg: 100 mg 3–4 times per d or 15–20 mg/kg/day divided q6–8 h 14–40 kg: 100–200 mg 3–4 times per d Tigan (see trimethobenzamide hydrochloride, this page) Trimethobenzamide hydrochloride Class: antiemetic Adults: Oral: 250 mg 3–4 times per d IM/IV: 200 mg 3–5 times per d Thorazine (see chlorpromazine hydrochloride, p 316) Zofran (see ondansetron, hydrochloride, p 319) P D Antifungal agents Drug Supplied as Dose and route Special considerations Amphotericin B Injection: 50-mg vial Prophylaxis: 0.1–0.25 mg/kg/d SE: fevers, rigors; premedication with acetamin and diphenhydramine is required; extremely nephrotoxic: other nephrotoxins should be a avo possible; other SE: H/A, anemia, hypokalemia, hypomagnesemia, anorexia, malaise, generalize bone marrow depression, flushing (Fungizone) Class: antifungal Emperic dose: Initial: 0.25 mg/kg/d until desired dose of 1–1.5 mg/kg/d is achieved Critically ill patient: may initiate with 1–1.5 mg/kg/d with close observation Cumulative dose: 1.5–2 g over 6–10 wk Injection: mg (20 mL) Children and adults: mg/kg/d SE: similar to that of amphotericin B; is less nephrotoxic; increased risk of hypotension, card arrest, respiratory failure Clotrimazole Cream: Children > y & adults: SE: abnormal LFT levels N/V, local burning, ir bad taste (Gyne-Lotrimin, Lotrimin, Mycelex) Topical: 1% (30 g) Oral: 10 mg troche disolved times per d Amphotericin B lipid complex (Abelcet, ABCD) Class: antifungal Vaginal 1% (45 g) Solution, topical: 1% (30 mL) Topical: apply times per d Class: antifungal Tab, vaginal: 100 mg (7 s) Adults: Troche: 10 mg Vaginal cream: g (1 applicator)/24 h Vaginal tablet: (100 mg)/24 h for d P Drug Supplied as Dose and route Special considerations Fluconazole Tab: 50, 100, 200 mg Children: 3–8 mg/kg/d q24 h PO/IV SE: Use with caution in patients with known he renal dysfunction (Diflucan) Injection: mg/mL (100, 200 mL) Doses up to 12 mg/kg/d have been used in immunocompromised children For creatinine clearance (mL/min) Adults: 50, give 100% of dose Prophylaxis: 200 mg/d PO/IV 21–50, give 50% of dose Class: antifungal Coccidioidal/cryptococcal 11–20, give 25% of dose infection: 400 mg load, then 200 mg/d IV Acute systemic candidal infections: 400 mg load, then 200 mg/d IV Other SE: H/A, nausea, rash, abdominal pain, e levels of ALT, alanine Transaminase (ALT), an alkaline phosphatase Don not administer to pat cisapride or terfenadine Oral/esophageal candidiasis (in immunocompromised patients): 200 mg/d Itraconazole Caps: 100 mg SE: N/V, diarrhea, edema, fatigue, fever, H/A, r pruritis Adults: (Sporanox) Children: No data available Instruct patient to take with carbonated beverag not administer to patients on cisapride or terfena Prophylaxis: 200 mg/d PO Class: antifungal Treatment: 200–400 mg/d Max dose: 600 mg/d Ketoconazole (Nizoral) Tab: 200 mg Children: 3.3–6.6 mg/kg/d Adults: 200–400 mg/d Dose reduction should be considered in patients liver disease P Drug Supplied as Dose and route Special considerations Do not administer to patients on cisapride or terfenadine SE: N/V, pruitus, abdominal pain Class: antifungal Miconazole nitrate Cream: Children: IV: 20–40 mg/kg/d divided q8 h (Monistat) Topical: 2% (30 g) Topical: Apply 1–2 times IV form not commonly used in bone marrow per d transplantation (BMT) setting Vaginal, as nitrate: 2% Adults: IV: initial 200 mg, then 1.2–3.6 g/d Lotion: 2% (30 mL) Topical: apply 1–2 times per d Vaginal supp: 100, 200 mg Vaginal: applicator of cream (100 mg) qhs for d OR 200-mg suppository qhs for d Class: antifungal Use with caution in patients with hepatic dysfun SE: Fever, chills, rash, itching, N/V, anemia, thrombocytopenia Injection: 10 mg/mL divided q8 h Nystatin Cream, topical: 100,000 U/g (15 g) Oral candidiasis: treatment & prophylaxis (Mycostatin, Nilstat) Ointment: 100,000U/g (15 g) Infants: 200,000 U times per d Class: topical antifungal Powder: 100,000 U/g (15 g) Children and adults: 4000,000–600,000 U times per d OR Susp: 100,000 U/mL (60 mL) Troche: 200,000–400,000 U 4–5 times per d Tab/pastille: 500,000 U Mucocutaneous infections: Vaginal tablet: 100,000 U (15s, 30s) Children and adults: Topical cream Have patient swish and swallow oral form SE: abdominal cramping, diarrhea P Drug Supplied as Dose and route Troche: 200,000 U Special considerations or ointment to effected areas, moist areas are best treated with powder Vaginal infections: Adults: vaginal tablets: insert tablet/d at hs for wk E Antihypertensive agents/diuretics Drug Supplied as Dose and route Special considerations Bumetanide Tab: 0.5, 1.2 mg Children: 0.015 mg/kg every day (qd) to 0.1 mg/kg qd PO Safety and efficacy in children < 18 y has not be established Half-life is times longer in infants mo (Bumex) Injection: 0.25 mg/mL (1% benzy alcohol) Adults: 0.5–2 mg/24 h PO as single dose PO; may give second and third doses at 4–5 h intervals to max dose of 10 mg/24 h SE: muscle cramps, dizziness, hypotension, H/A encephalopathy, hypokalemia, hypochloremia, hyponatremia, hypophosphatemia, hypocalcemia metabolic alkalosis Class: loop diuretics IV: 0.5–1 mg over 1–2 may give second and third doses at 2–3 h intervals, not to exceed max 10 mg IV Captopril Caps: 0.5, mg Infants > mo & children: (Capoten) Tab: 12.5, 25, 50, 100 mg Initial dose: 0.5 mg/kg; SE: neutropenia, agranulocytosis, proteinuria, titrate dose in twofold of taste increments to max dose of mg/kg/d in 1–4 divided doses or 75 mg/d Class: antihypertensive angiatensin converting enzyme (ACE) inhibitor Use with caution in patients with underlying ren dysfunction or those on other nephrotoxins P Drug Supplied as Dose and route Special considerations Enalapril maleate Tab: 2.5, 5, 10, 20 mg Children: Safety in children not yet established; consult renal service before using Use with extreme caution in patients with renal impairment Use only after other agents have fa achieve control SE: renal failure, nausea, diarrh H/A, hypotension, rash, neutropenia, anemia, lo taste, hyperkalemia, cough, muscle cramps, imp (Vasotec) Adults: mg qd initially PO up to 40 mg/24 h Class: ACE inhibitor Furosemide Tab: 20, 40, 80 mg Oral: (Lasix) Injection: 10 mg/mL Infants & children: mg/kg per dose 6–8 prn; may increase by 1–2 mg/kg per dose Liquid: 10 mg/mL (60 mL) mg/mL Adults: 20–80 mg/24 h qd or bid May increased 20–40 mg up to 600 mg/24 h Class: loop diuretic Parenteral: Infants & Children: mg/kg per dose q6–12 h IV prn; may increase by mg/kg per dose Adults: 20–80 mg per dose Max single dose: mg/kg SE: Ototoxicity may occur in presence of renal especially when used with aminoglycosides Us caution in hepatic disease Other SE: hypokalem alkalosis, dehydration, hyperuricemia, increased calcium excretion; prolonged use in premature i may result in nephrocalcinosis P Drug Supplied as Dose and route Special considerations with 0.5 mEq/kg in 10 prn; infusion rate should not exceed 10 mEq/min cerebral hemorrhage (especially with rapid inje intracranial acidosis (especially with inadequate ventilation), gastric distension, flatulence Children and adults: initial IVP: mEq/kg; may repeat with 0.5 mEq/kg in 10 once as indicated Metabolic acidosis: mEq bicarbonate needed = 0.4 times wt (kg) x base deficit (mEq/L); give one- half calculated dose, then reevaluate If acid-base status not available: Children and adults: 2–5 mEq/kg IV over 4–8 h Urine alkalinization: (Oral) Children: 1–10 mEq (84–840 mg)/kg/d in divided doses; dose should be titrated to desired urinary pH Adults: Initial: 48 mEq (4 g), then 12–24 mEq (1–2 g) q4 h; dose should be titrated to desired urinary pH; doses up to 16 g/d have been used P K Immune regulators Drug Supplied as Dose and route Special considerations Granulocyte colonyInjection: 300 µg/mL (1, 1.6 stimulating factor (filgrastim, mL) Neupogen) Children and adults: 5–10 SE: medullary bone pain, especially in lower ba µg/kg/d (~ 150–300 iliac crests, sternum, splenomegaly, fever, rash, µg/m-d) once daily until hypersensitivity absolute neutrophil count (ANC) is approximately 7000–10,000/mL Class: blood formation Dose escalations at µg/kg/d may be required in some individuals when response is inadequate (IV or SQ) (Refer to individuals protocols.) Granulocyte-macrophage colony-stimulating factor (Sargramostim, Leukine, Prokine) Class: blood formation Injection: 250, 500µg Children: (No dosing for children has been FDA approved.) 250 µg/m2/d IV over h to begin 2–4 h after marrow infusion, or not less than 24 h after chemotherapy; if toxicity is noted, then cut dose in half Adults: 250 µg/m 2/d IV over h to begin 2–4 h after marrow infusion, or not less than 24 h after chemotherapy (refer to individual protocols) SE: ''first-dose" reaction with fever hypotension tachycardia, rigors, N/V, flushing, dyspnea; als cause asthenia, H/A, bone pain, myalgia, rash, m diarrhea, elevated LFT levels, pericardial effusi fluid, retention, stomatitis, polydipsia, GI hemo P Drug Supplied as Dose and route Special considerations Cytomegalovirus immune globulin CMV prophylaxis: 100–150 mg/kg/wk IV until d 100 SE: hypersensitivity reaction may occur (preme with subsequent doses); fever, rash, hives, chill flushing Class: immune regulator Treatment of CMV disease: 100–150 mg/kg/d for 3–5 d; may repeat as indicated Intravenous immune globulin Prophylaxis: (generalized/CMV): 250–500 mg/kg IV qwk until day 100 (IVIG; various brands) Treatment of CMV disease: 500 mg/kg/d IV for 5–7 d; may repeat as indicated Class: immune regulator Platelet alloimmunization: 500–2000 mg/kg/d IV for 3–5 d administered just before transfusion; may repeat as indicated SE: hypersensitivity reaction may occur (pre-m with subsequent doses); fever, rash, hives, chill flushing P L Immunosuppressants Drug Supplied as Dose and route Special considerations Antithymocyte globulin Injection: 50 mg/5mL Conditioning agent: Have SQ epinephrine at bedside for test dose S allergic reaction, serum sickness (fever, chills, r arthralgias, myalgias), leukopenia, thrombocyto (ATG, ATGAM) 10–30 mg/kg/d for 1–3 doses pretransplant (refer to individual protocol) Class: immunosuppressant Treatment of steriodresistant graft-versus host disease (GVHD): 10–20 mg/kg/d for 5–7 d; may repeat once at 7–14 d Test dose: must give 1:1000 intradermal test dose prior to first dose Azathioprine Injection: mg/mL Chronic GVHD: (Imuran) Tab: 50 mg 1–3 mg/kg/d PO Cyclosporin A Caps: 25, 100 mg Children and adults: (Sandimmune, Neoral) Solution: 100 mg/mL (50 mL) IV: 1.5 mg/kg IV q12 h starting day -1; continue until conversion to PO Class: immunosuppressant Injection: 50 mg/mL SE: bone marrow depression, N/V, anorexia, di rash, fever, alopecia, hepatotoxicity, aphthous, stomatitis, retinopathy, arthralgias Class: immunosuppressant Oral: Conversion to oral is 1:3 or 1:4 Reduce dose with renal Dose adjustments based on biweekly levels (see specific protocol) SE: renal failure, neurologic toxicity (ataxia, se cortical blindness, H/A), burning in hands and f P Drug Supplied as 75% > 2.0 Dose adjustments based on biweekly levels; 10– ng/mL for 24 h CI; 0.5–2 ng/mL for oral dosing center-specific protocol) 25% > 1.75 hirsutism, gingival hyperplasia, hepatic dysfunc hemolytic uremic syndrome, hypertrichosis, hypertension lymphoproliferative disorder Cyclosporin A Reduction > 1.5 Special considerations impairment (adults) Creatine (mg/dL) Dose and route Hold until creatinine < 2.0 mg/dL, then resume at 20% to 25% of prior dose FK-506 Caps: 1, mg Children and adults: (tacrolimus Injection: 5mg/mL (1 mL) IV: 0.01–0.1 mg/kg/d by continuous IV infusion starting day 1; continue until conversion to PO Class: immunosuppressant Oral: Conversion to oral is 1:4 Adjust dose for renal and liver impairment based on therapeutic levels SE: nephrotoxicity with hyperkalemia, elevated creatinine level, hypertension, neurotoxicity (in tremors, H/A, photophobia, hyperesthesia, conf seizure, coma) dysarthria, N/V, abdominal pain diabetes, lymphoproliferative disorder P Drug Supplied as Dose and route Special considerations Methotrexate sodium Tab: 2.5 mg GVHD prophylaxis: Doses may be held due to severe mucositis or elevations in creatinine or bilirubin levels SE: Mucositis, N/V, hepatotoxicity, rash (Mexate) Injection: 25 mg/mL Day 1: 15 mg/m2 IV Days 3, 6, 11*: 10 mg/m2 IV Class: antimetabolite *Day 11 dose is eliminated in some regimens CNS prophylaxis: 10–12 mg given intrathecally before BMT and intermittently thereafter (see individual protocol) Methylprednisolone Injection: As acetate (Depo0.5–1 mg/kg/d divided Medrol): 40 mg/mL (1 mL) As q6–12 h (see individual sodium succinate protocol) (Depo-Medrol, Medrol, SoluMedrol) (Solu-Medrol): 40, 125, 500 mg Treatment of GVHD: Class: immunosuppressant Tab (Medrol): 4, 16 mg 2–10 mg/kg/d divided q6–12 h Tapered by 10% qwk once control is obtained SE: increased appetite, muscle weakness, osteop fractures, Cushing's syndrome, pituitary-adrena suppression, growth suppression, glucose intole acne, edema, hypertension, hypokalemia, alkalo cataracts, glaucoma, peptic ulcer, N/V, H/A, ve seizures, psychosis, pseudotumor cerebri, skin a straie H2 blocker is indicated P Drug Supplied as Dose and route Special considerations Muromonab-CD3 Injection: mg/mL Refractory GVHD: Premedication with methylprednisolone mg/k prior to dose, and hydrocortisone 100 mg 30 mi infusion are highly recommended SE: first-dos anaphylaxis, fever, chills, rash, severe pulmona edema; CPR may be required (Orthoclone OKT3) Children: Dose recommendation not available Class: immunosuppressant Adults: mg/d IV Prednisone Tab: 1, 2.5, 5, 10, 20, Treatment of GVHD: (Deltasone, Orasone) 50 mg Patients are generally converted from IV methylprednisolone to PO prednisone once GV under control and patient can tolerate PO SE: s methylprednisolone Ensure patient is on H2 blo 2–10 mg/kg/d divided q6–12 h Tapered by 10% qwk once control is obtained Solution: mg/mL Class: immunosuppressant Syrup: mg/mL M Premedications Drug Supplied as Dose and route Special considerations Acetaminophen Tab: 325, 500 mg/ Children: Contraindicated in patients with know G6PD deficiency; overdose (OD) can cause hepatotox (Tylenol, Tempra, Panodol, others) Chewable: 80 mg 10–15 mg/kg per dose q4 h OR Drops: 80 mg/0.8 mL 0–3 mo: 40 mg per dose Elixir: 160 mg/5 mL 4–11 mo: 80 mg per dose P N Urinary tract medications Drug Supplied as Dose and route Special considerations Allopurinol Tab: 100, 300 mg Children and adults: Decrease dose with renal impairment SE: rash, neuritis, GI disturbances, hepatotoxicity (Zyloprim) Susp: 10, 20 mg/mL 10 mg/kg/24 h divided tid-qid OR 300 mg/m2/24 h divided q6 h Max dose: 600 mg/24 h Oxybutynin chloride Tab: mg Children: (Ditropan) Syrup: mg/mL (473 mL) 1–5 y: 0/2 mg/kg per dose 2–4 times per day Class: urinary antispasmodic SE: Dry mouth, decreased sweating, urinary hesistancy, retention, hot flushes, fever, tachyca palpitations, blurred vision, drowsiness, weakne dizziness, insomnia, N/V, constipation, rash > y: mg times per d Max dose: mg times per d Adults: mg 2–3 times per d Max dose: mg times per d Phenazopyridine hydrochloride Tab: 100, 200 mg Children: (Pyridium) Caps: 50 mg 12 mg/kg/d in divided doses PO hemolytic anemia, acute Class: urinary analgesic Adults: 200 mg tid PO SE: methemoglobinemia, renal failure, H/A, ski pigmentation, vertigo, rash, hepatitis P Drug Supplied as Sodium 2-mercaptoethane sulfonate (mesna, Mesnex) Injection: 100 mg/mL (2, 4, 10 Children and adults: SE: diarrhea, N/V, H/A, (w/w) of malaise, rash mL) Ifosfamide: 20%–100% taste, limb pain, hypotension weight per weight dose at a time of administration and and h after each dose (refer to individual protocol) Class uroprotectant Dose and route Special considerations Cyclophosphamide: 20% to 100% w/w of dose prior to administration and 3, 6, 9, and 12 h after each dose (refer to individual protocol) O Miscellaneous medications Drug Supplied as Dose and route Albumin (human) (5%/25%) Injection: 5% (5 g/dL) 25% (25 g/dL) Hypoproteinemia: (normal serum albumin) Each contains 130–160 mEq of Na per L 0.5–1 g/kg per dose IV over 2–4 h OR by continuous IV infusion (in TPN solution); repeat q1–2 or as calculated to replace losses Class: protein/volume replacement Hypovolemia: 0.5–1 g/kg per dose IV; repeat prn as rapidly as necessary Max dose: g/kg/24 h Special considerations P Drug Supplied as Dose and route Digoxin Tab: 0.125, 0.25 mg Age (Lanoxin) Special considerations Daily maintenance dose (mg/kg) Therapeutic concentration: 0.8–2 Pediatric elixir: 50 mg/mL (60 mL) PO IV PO IV Decrease dose for renal insufficie Injection (pediatric): mo–2 y 0.1 mg/mL 2–5 y 5–10 y > 10 y Class: digitalis glycoside Total Digoxin dose (mg/kg) 35–60 30–40 20–25 10–15 30–50 25–35 15–30 8–12 10–15 7.5–10 5–10 2.5–5 7.5–12 6–9 4–8 2–3 SE: anorexia, N/V, sinus bradyca AV block, sinoatrial block, atrial nodal arrhythmias, bigeminy, trig atrial tachycardia, H/A, fatigue, lethargy, neuralgia, vertigo, disorientation, hyperkalemia with toxicity, feeding intolerance, blu vision, halos, diplopia, photopho flashing lights Injection (adult): 0.25 mg/mL Loading doses are administered in divided doses with approximately 50% of total dose given as the first dose; additional fractions of the loading dose (generally 25% fractions) are administered at 4–8 h intervals IV or 6–8-h intervals PO, until a therapeutic response is attained, toxic effects occur, or the total digitalizing dose has been administered Adults: Total Digoxin dose: 0.75–1.5 mg PO 0.5–1 mg IV Daily maintenance dose: 0.125–0.5 mg PO 0.1–0.4 mg IV P Drug Supplied as Dose and route Special considerations Dopamine hydrochloride Injection: 40–80, 160 mg/mL Low dose: (renal dose) Correct hypovolemic states (Inotropin) Prediluted in D5W: 800, 1600 2–5 mg/kg/min IV mg/mL SE: Tachyarrhythmias, ectopic beats, hypertension, vasoconstriction, vomiting Intermediate dose: Class: sympathomimetic 5–15 mg/kg/min IV High dose: 20 mg/kg/min IV (decreases renal perfusion) Max recommended dose: 20–50 mg/kg/min IV Folic acid Tab: mg Children: 0.5–1.0 mg/24 h qd Normal levels: serum > ng/mL; (Folvite) Injection: mg/mL Adults: 1–3 mg/24 h divided qd-tid SE: allergic reaction with pruritus Class: blood formation Oral solution: mg/mL Leucovorin calcium Tab: mg Children and adults: SE: Rash, pruritus, erythema, urticaria, wh thrombocytosis (Folinic acid) Injection: 50 mg 10–15 mg/m2 IV on days of methotrexate dosing (refer to individual protocol) Tab: 10 mg (Provera) Adolescents and adults: Injection: 100 mg/mL (5 ml) (BMT settings) (Depo-Provera) Oral: 10 mg/d PO; may increase by 10 mg/d increments for breakthrough bleeding prn; continue until platelet recovery Class: blood formation Medroxyprogesterone acetate (Provera, Depo-Provera) Class: progestin Assure adequate platelet count before administering IM SE: Weight gain, mood breakthrough bleeding, cholestatic jaundice melasma, depression, urticaria, acne, thromboembolic disorders, dizziness, P Drug Supplied as Dose and route Special considerations Injection: (IM): 100 mg nervousness IM prior to BMT offers mo of protection Caps: 20 mg Adults: 20 mg PO qd SE: H/A, diarrhea, N/V, abdominal pain, dizzin rash, constipation, cough, asthenia, back pain Ranitidine hydrochloride Tab: 150 mg Children: SE: H/A, dizziness, sedation, malaise, mental confusion, constipation, N/V, rash, hepatitis, gynecomastia, bradycardia, tachycardia, arthral (Zantac) Oral solution: 15 mg/mL Oral: 2–3 per dose q12 h Injection: 25 mg/mL IV: mg/kg per dose q8 h Omeprazole (Prilosec) Class: proton pump inhibitor Class: histamine antagonist Adults: Oral: 150 mg per dose q12 h IV: 50 mg per dose q8 h Dosing interval with renal failure: (creatinine clearance < 50 mL/min) Oral: administer q24 h IV: administer q18–24 h Page 369 II Special Drug Monitoring A Cyclosporin A (Sandimmune, Neoral) Pharmacokinetics and metabolism are highly variable Neoral is a microemulsion formula of cyclosporin A developed to improve absorption and bioavailability in order to reduce variability Cyclosporin A is extensively metabolized in the liver and intestine by the cytohcrome P450 mechanism Numerous interactions with other drugs undergo the same route of metabolism The most common adverse effect is nephrotoxicity, which is dose and concentration dependent Trough levels of cyclosporin A should be measured frequently (i.e., twice weekly) A variety of methods exists for measurement of cyclosporin A levels: high-performance liquid chromatography (HPLC), radioimmunoassay (RIA), and fluorescent polarization immunoassay (FPIA) Each assay provides a different target concentration The polyclonal FPIA correlates with renal insufficiency See p 345 for dosing in renal insufficiency Each transplant center will determine a target concentration range based upon the type of assay used If the trough dose is elevated, the dose of cyclosporin A should be decreased by 20%–25% Low trough levels may be a risk for the development of GVHD Dose should be increased if the trough level is lower than the target concentration B FK-506/Tacrolimus (Prograf) FK-506 is a macrolide antibiotic with immunosuppressant efficiency comparable to cyclosporin A Pharmacokinetics and metabolism are highly variable Metabolism is via the cytochrome P-450 mechanism Page 370 Two assays are available for measurement of drug levels: enzyme-linked immunoabsorbent assay (ELISA) and microparticle enzyme immunoassay (MEIA) As with cyclosporin A, numerous drug interactions exist Trough levels should be monitored frequently Hepatic dysfunction will prolong drug half-life and slow clearance C Aminoglycoside antibiotics Specific immunoassays are available to measure drug levels Trough levels must be monitored at least every 48 hours Clearance of the drug is decreased in patients with impaired renal function The risk of ototoxicity and nephrotoxicity increases if the trough concentration > mg/L (5 mg/L with amikacin) Dehydration will increase the risk of toxicity The risk of toxicity increases with longer duration of treatment D Vancomycin Peak and trough concentrations should be monitored regularly Peak concentration samples are collected 30 to 60 minutes after the end of the infusion The exact time of the infusion and specimen collection should be noted Trough concentrations should not exceed to 10 mg/L The relationship of peak/trough levels to toxicity is not clear Page 371 Doses should be individualism based on creatinine clearance Red man syndrome, a histamine-like reaction with flushing and pruritus, can be avoided by slowing IV administration to 15 mg/min III Antiemetic Management A There are three categories of emesis related to chemotherapy: anticipatory nausea/vomiting, acute chemotherapy-induced emesis, and delayed nausea/vomiting B In the BMT setting, anticipatory nausea and vomiting may occur in patients previously treated with chemotherapy Medications having amnesic effect may be effective in combination with antiemetic drugs C Acute chemotherapy-induced emesis is multifactorial Patient-related factors include advancing age, poor general health, and metabolic disturbances.6 The variable related to chemotherapy is the emetic potential Each chemotherapeutic agent exhibits some potential for inducing emesis, ranging from very low to very high potential Table 7.3 summarizes the emetic potential of many chemotherapeutic agents in current use ... IV Acute systemic candidal infections: 400 mg load, then 200 mg/d IV Other SE: H /A, nausea, rash, abdominal pain, e levels of ALT, alanine Transaminase (ALT), an alkaline phosphatase Don not administer... mg/mL SE: bone marrow depression, N/V, anorexia, di rash, fever, alopecia, hepatotoxicity, aphthous, stomatitis, retinopathy, arthralgias Class: immunosuppressant Oral: Conversion to oral is 1:3... Tab/pastille: 500,000 U Mucocutaneous infections: Vaginal tablet: 100,000 U (15s, 30s) Children and adults: Topical cream Have patient swish and swallow oral form SE: abdominal cramping, diarrhea