My Formulary 2

My Formulary
This is your (P)ersonal Formulary of (P)referred drugs for the management of the conditions
included in this curriculum series. This is where you record the default dose form, strength,
directions and other information for your P-drugs. You can access information about drugs from
the AMH, Therapeutic Guidelines or your own favourite web-sites (URLs). You can include your
own Prescribing notes and mark drugs as first choice agents for a particular condition. My
Formulary is always available by clicking the Rx icon at the top right of the screen. You will need it
when writing prescriptions and for reference during other parts of each module.
Indication 1. COPD
Drug Name amoxycillin
Dose Form oral (caps)
Strength 250 & 500 mg - use 500mg; in children dose <20kg 20-40mg/kg/day
Directions Take ONE 8 hourly for 5 days
Quantity 20
No. of Repeats 0
Drug of choice
Issues
Efficacy Some evidence of benefit in severe exacerbations
Safety Profile Wide safety margin for commonly used agents
Cost $8.12 (250mg), $10.22(500mg) for quantity of 20
Other Issues Resistance rates from 40 to as high as 80% to amoxycillin in some

parts of Australia.
My Prescribing Notes
First choice in acute exacerbations with increasing cough, sputum, purulence and dyspnea. Exclude
pneumonia. Aim of treatment: reduce the volume and purulence of sputum.
Although most are viral infections, antibiotics are helpful. Treatment monitored by effect and affected by
resistance. Sputum culture is not routine, colonisation with Haemophilus influenzae, Streptococcus
pneumoniae or Moraxella catarrhalis common. Treatment of H influenza better with amoxicillin (or
doxycycline) cf macrolides, cephalosporins, amox+clav; associated with side effects. Consider atypicals
(mycoplasma pneumoniae and Chlamydia pneumoniae) and in those patients with baseline FEV1 less
than 35% predicted normal, Gram-negative organisms.
CI: hypersensitivity, use doxycycline, fluoroquinolone
Adverse effects: erythematous maculopapular rash (pseudoallergic) often occurs after >7 days
treatment and resolves 1–7 days after treatment is stopped; more frequent in those with infectious
mononucleosis, acute lymphoblastic leukaemia, chronic lymphocytic leukaemia and HIV infection.
Although not immune-mediated, consider skin testing to check for hypersensitivity before using a
penicillin again. Hypersensitivity incl severe skin reactions, angioedema, anaphylaxis (rare);
superinfection; pseudomembranous colitis; GI upset; raised LFTs; blood dyscrasia; CNS effects (rare);
superficial tooth discolouration in children (very rare)
Caution: Phenylketonuria (some contain aspartame); Renal impairment; prolonged use (monitor renal,
hepatic, haemopoietic function); high dose (ensure adequate hydration, urinary output); chronic UTI
(monitor bacteriology); syphilis (monitor serology mthly >4m); pregnancy (incl labour, delivery), lactation,
neonates
Action: Penicillin; Bactericidal; interfere with bacterial cell wall peptidoglycan synthesis by binding to
penicillin-binding proteins leading to cell lysis and death
Indication 1. COPD
Drug Name amoxycillin + clavulanic acid
Dose Form tablet
Strength 875/125 mg
Directions 875/125 mg 12 hrly for 5 days
Quantity 10 (PBS)
No. of Repeats 0
Drug of choice
Issues
Cost Approx $14.17 for dispensed max.quantity of 10
Other Issues More adverse reactions than amoxycillin
Use only in severe acute exacerbations where there is evidence of b-lactamase inhibiting Haemophilus
influenzae. Associated with adverse reactions eg thrush, GI adverse effects, cholestasis, greater cost.
CI: history of cholestatic jaundice or hepatic dysfunction associated with amoxycillin with clavulanic acid,
or ticarcillin with clavulanic acid. Not associated with hepatic impairment.
Caution: Phenylketonuria—oral liquids contain aspartame
AE: transient increases in liver enzymes and bilirubin, amoxycillin/ampicillin rash; pustular drug eruption,
cholestatic hepatitis (due to clav, usu reversible, may persist, increased risk with age (>55 years), male
sex and length of treatment
Mechanism of action: Clavulanic acid inhibits beta-lactamase, which extends spectrum to cover beta-
lactamase-producing organisms
Indication 1. COPD
Drug Name beclomethasone
Dose Form Metered Dose Inhaler (MDI)
Strength 50,100 micrograms /dose
Directions 50-200 micrograms twice daily
Quantity 1 x 200 doses (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Glucocorticoids should be considered in patients with a documented
response or those who have severe COPD with frequent
exacerbations.
Safety Profile Some adverse reactions associated with long-term dosing.
Cost Approx. $26(50), $36(100) each
Other Issues General Pharm. Benefit.Autohaler available for pats. with co-
ordinating difficulties.
Aim: reduce exacerbation rates and slow the decline in health status, not to improve lung function per
se. NOT FIRST ILNE. For maintenance of stable COPD. Indicated: an FEV1 less than or equal to 50%
predicted, and two or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a
12-month period.
Potency of beclomethasone is similar to fluticasone, and approximately twice that of budesonide,
because of CFC-free formulation used. There is no evidence that any single inhaled corticosteroid is
safer than others. However, beclomethasone may be preferred during pregnancy because of greater
human experience. Some adverse reactions associated with long-term dosing.
To minimise oropharyngeal candidiasis and systemic absorption of inhaled corticosteroids, patients
should be advised to rinse their mouth with water and spit out directly after inhalation. Patients using a
pressurised metered dose inhaler should also be advised to use a spacer, which decreases the
oropharyngeal deposition of the inhaled corticosteroid, thereby reducing systemic absorption,
oropharyngeal candidiasis and dysphonia. Recent studies have suggested an increased risk of
pneumonia associated with inhaled corticosteroid use in COPD patients.
Indication 1. COPD
Drug Name budesonide
Dose Form Nebuliser (Single Dose Unit)
Strength 500 micrograms & 1 mg/ 2 mL
Directions 0.25 to 0.5 mg twice daily - suggested 400mcg bd
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
exacerbations.
Cost Approx. $35 (500mcg) & $47( 1 mg) / 30
Other Issues PBS Authority
FIRST LINE STEROID IN STABLE COPD
Aim: reduce exacerbation rates and slow the decline in health status, not to improve lung function per
se. For maintenance of stable COPD. Indicated: an FEV1 less than or equal to 50% predicted, and two
or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12-month period.
The potency of budesonide is approximately half that of fluticasone when given through comparable
devices. There is no evidence that any single inhaled corticosteroid is safer. Budesonide is one of two
corticosteroid available for nebulisation. Because of cost, increased systemic exposure, and topical
adverse effects, it is only PBS subsidised in patients who cannot have an inhaler with spacer.
Oral hygiene.
Indication 1. COPD
Drug Name doxycycline
Dose Form tablet /capsule
Strength 50 & 100 mg
Directions 200mg to start, then 100mg daily for 5 days - max is 100mg bd; in
children 2-4mg daily starting with 2mg bd on first day
Quantity 7
No. of Repeats 0
Drug of choice
Issues
Cost $8.50
Other Issues tetracycline
Indications: severe infective exacerbation of COPD, alternative to penicillin; also once daily.
Precautions: SLE can rarely be worsened by tetracyclines. Treatment with oral retinoids (eg isotretinoin,
acitretin)—may increase risk of benign intracranial hypertension; avoid combination (contraindicated by
some manufacturers).
RENAL: Tetracycline not recommended in renal impairment; doxycycline and minocycline can be used
without dose adjustment.
HEPATIC: Hepatotoxicity more likely in hepatic impairment; avoid high doses.
CHILDREN: Contraindicated in children <8 years as tetracyclines discolour teeth and cause enamel
dysplasia, which increases the risk of dental caries. They are also deposited in bone, causing
deformities and inhibiting bone growth.
PREGNANCY: Safe if used during the first 18 weeks of pregnancy (16 weeks post-conception); after
this they are contraindicated as they may discolour the baby’s teeth; Australian category D.
Breastfeeding: Courses of 7–10 days are considered safe.
ADVERSE EFFECTS
Common: nausea, vomiting, diarrhoea, epigastric burning; tooth discolouration, enamel dysplasia,
reduced bone growth (in children <8 years); photosensitivity (depends on tetracycline, dose and degree
of sun exposure)
Infrequent: rash, stomatitis, bone deformity, fungal overgrowth
Rare: photo-onycholysis and nail discolouration, oesophageal ulcers (due to partly swallowed tablets or
capsules), Clostridium difficile-associated disease, hepatitis, fatty liver degeneration (with high doses,
especially in pregnancy), benign intracranial hypertension, allergic reactions, toxic epidermal necrolysis,
worsening of systemic lupus erythematosus, serum sickness-like reactions
Directions: Take a single daily dose in the morning rather than at night
Mechanism of action: Tetracycline Bacteriostatic; inhibit bacterial protein synthesis by reversibly binding
to 30S subunit of the ribosome.
Indication 1. COPD
Drug Name eformoterol
Dose Form Dose Powder Inhaler (DPI)
Strength 6 & 12 micrograms/dose
Directions 6 to 12 micrograms twice daily, maximum daily dose 48 micrograms.

Use every day even when well.
Quantity 60 caps./ doses
No. of Repeats 5
Drug of choice
Issues
Efficacy Little evidence for use in acute exacerbations
Safety Profile Generally well tolerated, some safety concerns in asthma
Cost Approx. $24/ 60(6micrograms) & $34/60 (12micrograms)
Other Issues Not PBS approved for COPD
Used for maintenance and not acute exacerbations but not PBS approved for COPD. 2 available LABA
in Australia: eformoterol and salmeterol. Eformoterol has faster onset (1 to 3 minutes) cf salmeterol (10
to 20 minutes). Both have long duration of action (over 12 hours), twice as long as SABA. “Symptom
controllers” in asthma not already well controlled on inhaled CCS. Similar efficacy between eformoterol
and salmeterol. Together with SABA, improve QOL and reduce use of rescue medications compared to
use of short-acting bronchodilators alone. They also reduce the frequency of exacerbations.
There is individual variability in response to LABA: benefit from either anticholinergic or BA should be
determined on patient's perception of relief or prevention of breathlessness. Consider combining LABA
and anticholinergic to improve lung function and quality of life. Acute changes in FEV1 are not a guide
to long-term symptomatic benefit.
ADVERSE EFFECTS: Incidence and severity depend on dosage and route. Common: tremor,
palpitations, headache. Infrequent: hyperglycaemia (high dose), tachycardia, muscle cramps, agitation,
hyperactivity in children, insomnia. Rare: paradoxical bronchospasm, allergic reactions including
urticaria, angioedema and anaphylaxis, lactic acidosis (below). Serious hypokalaemia may occur,
worsened by theophyllines, corticosteroids, diuretics and hypoxia. Lactic acidosis uncommonly.
Mechanism: Relax bronchial smooth muscle by stimulating beta2 adrenoceptors.
Indication 1. COPD
Drug Name fluticasone
Strength 100, 250 & 500 micrograms dose
Directions 100 to 200 micrograms twice daily - 500mcg by inhalation twice daily
Quantity 60 doses (PBS)
No. of Repeats
Drug of choice
Issues
exacerbations.
Cost Approx.$16(100), $29(250) & $49(500 micrograms)/ 60
Other Issues General Pharm. Benefit
FIRST LINE IF ORAL CCS INDICATED. For maintenance of stable COPD. Indicated: an FEV1 less
than or equal to 50% predicted, and two or more exacerbations requiring treatment with antibiotics or
oral corticosteroids in a 12-month period.
Fluticasone has a potency approximately twice that of budesonide, and similar to beclomethasone.
There is no evidence that any single inhaled corticosteroid is safer. Data about systemic bioactivity of
fluticasone assessed by measures of adrenal suppression are conflicting and cannot be extrapolated to
clinical safety. ORAL CARE.
Indication 1. COPD
Drug Name hydrocortisone
Dose Form Intravenous solution
Strength 100 mg/ 2 mL, 250 mg/ 2 mL
Directions 100 mg 6 hourly
Quantity 2
No. of Repeats
Drug of choice
Issues
Efficacy Systemic steroids of benefit in acute management
Safety Profile Well tolerated in short term. Long term use associated with
significant systemic effects.
Cost $20-30
Other Issues Requires IV line and regular dosing
Use if oral medication cannot be tolerated - convert to ORAL ASAP.
More expensive than prednisolone and has greater risks (intravenous cannula, etc). No evidence
suggests parenteral steroids act more quickly or have more efficacy than oral.
Indication 1. COPD
Drug Name ipratropium
Strength 20 microgram/dose
Directions 40 micrograms as required. Repeat 40 to 80 micrograms 3 - 4 times

a day. Use even when well.
Quantity 2 (20 microgram)
No. of Repeats 5
Drug of choice
Issues
Efficacy Most studies suggest that ipratropium bromide and the beta2
agonists work equally well.
Safety Profile Side effects are rare as there is little systemic absorption
Cost Approx.$36/ 2
Other Issues General Pharm. Benefit. Autohaler available for pats. with co-
ordinating difficulties.
Ipratropium bromide (anticholinergic) produces bronchodilation by blocking vagal tone and reflexes
which mediate bronchoconstriction. Indicated for acute severe asthma, maintenance of severe asthma
and COPD. Used alone, not powerful bronchodilator. Duration of action: 6h (augments duration of
bronchodilation achieved with BA).
Equal efficacy with BA.
AE: related to anticholinergic action are rare as low systemic absorption. May have dry mouth, throat
irritation. Rare: urinary retention, constipation, acute closed-angle glaucoma, dizziness, palpitations,
allergy (eg itch, rash, angioedema, anaphylaxis)
PRECAUTIONS: Closed-angle glaucoma, prostatic hypertrophy—risk of aggravation; Pregnancy B1,
safe in breast feeding
Alternate doses: MDI, 2 puffs (40 micrograms) 3 or 4 times daily as necessary; up to 4 puffs (80
micrograms) 3 or 4 times daily prn
Nebulised: 250–500 micrograms up to 3 or 4 times daily. Dilute solution for nebulisation to 2–3 mL with
sodium chloride 0.9%. Avoid eye contact with nebulised mist. Inform Dr if eye pain or discomfort, blurred
vision or visual halos. Only if cannot tolerate MDI. RPBS.
Indication 1. COPD
Drug Name Nicotine
Dose Form Patch
Strength 7 - 21 mg/16 -24hrs
Directions Apply one patch to a different site each each day.on a non-hairy,
clean, dry site on the upper body or outer part of the upper arm
Quantity 7
No. of Repeats
Drug of choice
Issues
Efficacy Currently insufficient evidence to recommend one treatment over
another because of greater efficacy.
Safety Profile Few adverse effects in patients with moderate or severe nicotine
dependence.
Cost $5 to customer
Other Issues .
Nicotine replacement reduces the severity of tobacco withdrawal symptoms and increases the likelihood
of smoking cessation.
Precautions in Recent MI or stroke, unstable angina, severe arrhythmias—consider non-drug treatment
first. Dentures—avoid use of gum. Oral, oesophageal, pharyngeal or gastric inflammation—may be
worsened by use of gum, lozenge or sublingual tablets. Asthma or chronic throat conditions—avoid use
of nicotine inhaler. Generalised skin disease—avoid use of patches. Phenylketonuria—avoid use of
lozenge or lemon sublingual tablet as they contain aspartame (metabolised to phenylalanine).
Pregnancy: short-acting products are preferable. However, if patches are chosen, advise that they be
removed at night
AE: short-acting products are preferable. However, if patches are chosen, advise that they be removed
at night. Common: dizziness, headache, nausea, vomiting, hiccups, indigestion, abdominal pain,
myalgia, cough (inhaler), vivid dreams (especially 24-hour patch) Infrequent: tachycardia, palpitations,
chest pain, BP changes
FORMS: gum, inhaler, lozenge, patch, SL tablet
Indication 1. COPD
Drug Name prednisolone
Dose Form Oral tablet
Strength 1, 5, 25 mg
Directions 30 - 50 mg per day for 7 - 14 days
Quantity 100, 60, 30
No. of Repeats
Drug of choice
Issues
Efficacy Systemic steroids of benefit in acute management
Safety Profile Well tolerated in short term. Long term use associated with
significant systemic effects.
Cost $12-14
Other Issues n/a

Alternative is IV hydrocortisone. Use for acute exacerbations: A short course of systemic corticosteroids
has been shown to shorten the duration of hospital admission and hasten return to previous lung
function and stable symptom control. They should be used routinely for severe exacerbations. Longer
courses add no further benefit and have a higher risk of adverse effects. If the course of therapy has
been shorter than 14 days, the prednis(ol)one may be ceased abruptly without tapering.
Indication 1. COPD
Drug Name roxithromycin
Dose Form tablet
Directions 300mg daily Child, 2.5–4 mg/kg twice daily.
Quantity 5 or 10 (PBS)
No. of Repeats 0
Drug of choice
Issues
Cost $14/ 5
Other Issues General Pharm. benefit
Alternative to penicillin/doxycycline. Macrolides are less likely to suppress H. influenzae and are more
likely to result in early relapse.
Precautions: Treatment with ergot alkaloids—contraindicated by manufacturer. Associated with
prolonged QT interval. Use with caution in hepatic impairment; reduce dose.
AE: GI, ototoxicity, tend to be dose-related. Common: nausea, vomiting, diarrhoea, abdominal pain and
cramps, candidal infections. Infrequent: rash, headache. Rare: hypersensitivity (eg anaphylaxis, fixed
drug eruptions, Stevens-Johnson syndrome, interstitial nephritis), psychiatric disturbances, ototoxicity
(eg tinnitus, dizziness, hearing loss), Clostridium difficile-associated disease, cholestatic hepatitis,
pancreatitis, prolonged QT interval, blood dyscrasias, eg thrombocytopenia
Mechanism of action: Macrolide Bacteriostatic; inhibit bacterial protein synthesis by binding to the 50S
ribosomal subunit. They also have immunomodulatory and anti-inflammatory effects.
Have 15mins before a meal or with food.
Indication 1. COPD
Drug Name salbutamol
Strength 200 micrograms/dose
Directions 200 to 1000 micrograms ( 2-5 inhalations) as required
Quantity 200 (PBS)
No. of Repeats 5
Drug of choice
Issues
Efficacy Evidence supports use of beta2 agonists in acute exacerbations
Safety Profile Generally well tolerated
Cost Approx. $21/ 200 doses
Short-acting beta2 agonists (SABAs) available in Australia include salbutamol, and terbutaline. They are
fast-acting bronchodilators used to relieve bronchospasm and are often referred to as reliever
medications.
They have a rapid onset (5–15 minutes) and short duration (3–6 hours) of action . They are useful for
symptom relief in asthma and chronic obstructive pulmonary disease, and protection against exercise-
induced asthma. They have similar efficacy.
Indication 1. COPD
Drug Name salbutamol
Directions 200 to 1000 micrograms (2-10 inhalations ) as required
Quantity 2 (PBS)
No. of Repeats
Drug of choice
Issues
Cost Approx. $17/ 2 MDIs
Other Issues Autohaler available for pats. with co-ordinating difficulties.
Symptom relief during maintenance and in exacerbations. SABA available: salbutamol, terbutaline.
“Relievers” bronchospasm, rapid onset (5–15 minutes) and short duration (3–6 hours) of action. Similar
efficacy of neb and spacer.
Use nebuliser (most expensive) only if cannot be administered using an inhaler and spacer. Generally
well tolerated.
Precautions: Pregnancy A, safe in breastfeeding.
AE: Incidence and severity depend on dosage and route. Common: tremor, palpitations, headache.
Infrequent: hyperglycaemia (high dose), tachycardia, muscle cramps, agitation, hyperactivity in children,
insomnia. Rare: paradoxical bronchospasm, allergic reactions including urticaria, angioedema and
anaphylaxis, lactic acidosis (below). Hypokalaemia may be worsened by theophyllines, corticosteroids,
diuretics and hypoxia. Lactic acidosis.
Nebs cost: $25/60; MDI $12/2
Mechanism of action: Relax bronchial smooth muscle by stimulating beta2 adrenoceptors.
Dosing: Multidose solution for nebulisation may need dilution with sodium chloride
Indication 1. COPD
Drug Name salmeterol
Directions 50 micrograms twice daily; up to 100 micrograms twice daily in
more severe airways obstruction
Quantity 1
No. of Repeats 5
Drug of choice
Issues
Efficacy Little evidence for use in acute exacerbations
Safety Profile Generally well tolerated, some safety concerns in asthma
Cost $34 each
Other Issues Not PBS approved for COPD
Little evidence in acute exacerbations, maintenance therapy for COPD, PBS approved. LABA are
eformoterol and salmeterol. Salmeterol has slower onset (10 to 20 minutes) cf eformoterol (1 to 3
minutes). Long duration of action (over 12 hours). In asthma, useful for people already receiving inhaled
or oral corticosteroids but with uncontrolled symptoms (particularly nocturnal and exercise-induced
asthma). “Symptom controllers.” Can be used in combination with fluticasone in severe COPD with
repeated exacerbations inadequately controlled with regular BA therapy. Generally well tolerated.
AE: Incidence and severity depend on dosage and route of administration. Common: tremor,
palpitations, headache. Infrequent: hyperglycaemia (high dose), tachycardia, muscle cramps, agitation,
hyperactivity in children, insomnia. Rare: paradoxical bronchospasm, allergic reactions including
urticaria, angioedema and anaphylaxis, lactic acidosis. Serious hypokalaemia; may be worsened by
theophyllines, corticosteroids, diuretics and hypoxia. Lactic acidosis; Cost: $34 each. NOT PBS
APPROVED FOR COPD
Indication 1. COPD
Drug Name terbutaline
Directions 500 to 1000 micrgrams as required
Quantity 1(PBS)
No. of Repeats
Drug of choice
Issues
Cost Approx. $14 each
SABA (salbutamol, terbutaline, orciprenaline, fenoterol). Fast-acting bronchodilators used to relieve
asthma attacks “Relievers” Terbutaline, salbutamol have rapid onset of action (5–15 minutes) and short
duration of action (3–6 hours). Symptom relief in COPD. Similar efficacy. Same effect as neb, may have
greater adverse reactions.
Indication 1. COPD
Drug Name theophylline
Dose Form tablet & SR tablet
Strength 125, (Instant release) 200, 250 & 300 mg(SR)
Directions SR tablets 12 hourly, instant release 6 hrly. Max. 900mg daily.
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy No evidence of benefit in general (? of benefit in severe cases)
Safety Profile High incidence of nausea/vomiting. Risk of more serious toxicity due
to narrow therapeutic index
Cost $15-20
Other Issues Used in the maintenance treatment in severe COPD and asthma.
Narrow therapeutic index
Dosing information from the Australian Medicines Handbook: Dose to be initiated at 10 mg/kg daily;
maximum 300 mg daily. If initial dose is tolerated, increase dose after 3 days. First increment, 13 mg/kg
daily; maximum 450 mg daily. If the first increase is tolerated, increase dose after 3 days. Second
increment, 16 mg/kg daily; maximum 600 mg daily. Measure plasma concentration after 3 days at the
highest tolerated dose. Drug concentration should be monitored at initiation of treatment, if regimen is
altered or if adverse effects suspected and when stopping or starting smoking.
Indication 1. COPD
Drug Name tiotropium
Dose Form Dry powder inhaler
Strength 18 micrograms
Directions 1 capsule inhaled daily
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
Efficacy Most studies suggest that ipratropium bromide and the beta2
agonists work equally well.
Safety Profile Side effects are rare as there is little systemic absorption
Cost $75
Other Issues Not indicated in acute management
Maintenance therapy of COPD characterised by dyspnea. Binds more to the m3 subgroup of muscarinic
receptors, inhibiting cholinergic bronchomotor tone and has a much longer half life than ipratropium.
Only indicated for long-term maintenance treatment of bronchospasm and dyspnoea - reduces
dyspnoea, exacerbation rates and improves health status. Although more expensive than ipratropium
inhalers, because of its once daily dosing it would be more suitable for many patients. Long-acting
bronchodilators are indicated in patients who remain symptomatic despite treatment with short-acting
bronchodilators at adequate doses and optimal use of inhalers. They are usually used in conjunction
with short-acting 'rescue' bronchodilators. Long-acting anticholinergic therapy has been shown to
improve quality of life and reduce the frequency of exacerbations cf placebo and short-acting
anticholinergic drugs. Precautions: Closed-angle glaucoma, prostatic hypertrophy—risk of aggravation.
Pregnancy: Limited experience; Australian category B1, safe in breastfeeding.
AE: Common: dry mouth, throat irritation. Rare: urinary retention, constipation, acute closed-angle
glaucoma, dizziness, palpitations, allergy (eg itch, rash, angioedema, anaphylaxis).
Not indicated in acute management or immediate relief of symptoms.
Inform Dr if eye pain or discomfort, blurred vision or visual halos. Choice should take into account
patient preference, potential adverse effects, cost and response to a trial. Acute changes in FEV1 are
not a guide to long-term symptomatic benefit.
Indication 10. UTI
Drug Name amoxycillin
Dose Form oral (caps)
Directions 250-500 mg 8-hourly for 5 days
Quantity 20
No. of Repeats
Drug of choice
Issues
Efficacy Efficacy of antibiotics will depend on the resistance/sensitivity
patterns in the hospital/community in which you are working. Local
microbiology laboratories can give you current information about this
if they do not post it on a website.
Safety Profile Varies with the antibiotic chosen. Remember that safety to the
foetus must also be considered if prescribing for a pregnant patient.
Cost $8.12 (250mg), $10.22(500mg) for quantity of 20
Other Issues Resistance rates from 40 to as high as 80% to amoxycillin in some

parts of Australia.
Cost: $8.12-$10.22 for 20
Use if proven sensitivity - resistance rates as high as 40-80% in some parts
Drug class A in pregnancy
Bactericidal; interfere with bacterial cell wall peptidoglycan synthesis by binding to penicillin-binding
proteins, eventually leading to cell lysis and death.
Indicated in: Epididymo-orchitis, acute prostatitis, acute pyelonephritis, UTI
PRECAUTIONS: sodium restriction, heart failure (Na component); infectious mononucleosis, ALL, CLL,
HIV (rash), phenylketonuria; reduce dose if CrCl<30
RARE AE: pustular drug eruption, crystalluria (high IV doses); Amox/Amp Rash - widespread,
erythematous maculopapular rash (pseudoallergic) is common; it often occurs after >7 days treatment
and resolves 1–7 days after treatment is stopped, or after 6–14 days if it continues (consider skin
testing)
Practice points (Penicillins)
# use frequent doses of penicillins for maximal antibacterial effect
# monitor complete blood picture and renal and hepatic function during prolonged high-dose treatment
(>10 days)
# avoid penicillins and cephalosporins when the presence of ESCAPPM organisms is suspected or
proven, see Antibacterial resistance in Australia
Indication 10. UTI
Drug Name amoxycillin + clavulanic acid
Dose Form tablet
Strength 875/125 mg
Directions 500 /125 mg twice daily
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Cost Approx $14.17 for dispensed max.quantity of 10
Other Issues More adverse reactions than amoxycillin
Safety: Varies with Abx chosen. Remember safety to foetus must be considered.
Cost $14.17
Potassium clavulanate, the second component, inhibits the inactivation of amoxycillin by organisms
producing beta-lactamase (extended spectrum). E. coli with high resistance to amoxycillin alone may
have sensitivity as high as 90% to the combination with clavulanic acid. Normal dose 875/125mg twice
daily. Gastrointestinal side-effects may be mitigated by taking with meals.
More AE cf amoxycillin.
Indication: Epididymo-orchitis (urinary tract source); UTI
Precautions: infectious mononucleosis, ALL, CLL, HIV (rash), phenylketonuria
HEPATIC: CI hx of cholestatic jaundice or hepatic dysfunction with amox+clav/ticar+clav; can cause
cholestatic hepatitis (if >55y increased risk). Pre-existing hepatic impairment not a RF.
Avoid in pregnancy (PPROM) - risk of neonatal necrotising enterocolitis
AE: transient increased in liver enzymes, bilirubin, rash
Rare: pustular drug eruption; cholestatic hepatitis (due to clav acid, less severe cf fluclox, usu reversible
may appear during or weeks after and persist 5-6wks. Risk: male, >55y, length of Rx
Dose based on amoxy component.
Practice points:
* addition of metronidazole is not needed for Gram-negative anaerobic infections (eg Bacteroides
spp.)
* monitor hepatic function if treatment lasts for >14 days, especially if there are other risk factors
Indication 10. UTI
Drug Name ceftriaxone
Dose Form injection
Strength 1 gm, 2gm
Directions 1 gm, twice daily
Quantity maximum dispensed 5
No. of Repeats
Drug of choice
Issues
Cost $37.79 /1 gm
Other Issues Inject IV over 3-5 minutes to avoid rare arrhythmias. IM injection is
painful and not recommended.
If hypersensitive to penicillin.
Inject IV over 3-5 minutes to avoid rare arrhythmias. IM injection is painful and not recommended.
Ceftriaxone is expensive and has a broad spectrum of activity which includes use in Gram-negative
infections, severe pneumonia, and bacterial meningitis. Only available for intravenous use. Normally
given 12 or 24 hourly. Minor side effects include: diarrhoea, nausea and abdominal discomfort. More
major side effects include: antibiotic associated colitis, convulsions, anaphylaxis and aplastic anaemia.
Interfere with bacterial cell wall peptidoglycan synthesis by binding to penicillin-binding proteins,
eventually leading to cell lysis and death; bactericidal.
PRECAUTIONS: Na restriction, heart failure
Risk of bleeding due to impaired vitK synthesis (incl Rx w warfarin), low K stores (chronic disease and
malnutrition), ceftr may increase risk of bleeding due to effect on clotting factors, monitor INR
Renal: Patients with renal failure may be more at risk of bleeding due to ceftriaxone.
Cefotaxime is preferred to ceftriaxone for Gram-negative septicaemia in neonates as ceftriaxone
displaces bilirubin from albumin and may increase risk of bilirubin encephalopathy. However, single
dose ceftriaxone is used to treat neonatal gonococcal conjunctivitis.
Calcium and ceftriaxone are incompatible; calcium-ceftriaxone precipitates in the lungs and kidneys of
neonates have caused death.
AE: pancreatitis, cholecystitis
Pseudolithiasis: dose-dependent, asymptomatic and reversible biliary sludge formation due to calcium-
ceftriaxone complex; has been mistaken for gallstones on ultrasound scans and usually resolves after
stopping treatment.
Nephrolithiasis: formation of calcium-ceftriaxone renal stones, sometimes requiring treatment; usually
reversible.
Indication 10. UTI
Drug Name cephalexin
Dose Form Oral
Strength 250/500 mg
Directions 500 mg 12-hourly
Quantity 20
No. of Repeats
Drug of choice
Issues
Cost $8.42 for 20 x 250 mg/ $10.34 for 20x500mg.
Other Issues n/a
Cephalexin, a cephalosporin, commonly has a high efficacy against urinary E.coli. It seldom produces
adverse effects in short courses but can, like all penicillins/cephalosporins, produce occasional
hypersensitivity reactions. These are usually transient skin lesions but more severe hypersensitivity
occurs rarely.
Interfere with bacterial cell wall peptidoglycan synthesis by binding to penicillin-binding proteins,
eventually leading to cell lysis and death; bactericidal.
Indications: UTIs due to susceptible Gram-negative bacteria; Staphylococcal and streptococcal
infections in people with mild-to-moderate penicillin allergy; Epididymo-orchitis (urinary tract source)
PRECAUTIONS: Reduce dose if CrCl <20 mL/minute.
AE: cholestatic hepatitis
Dose: 500 mg every 12 hours for 5 days.
Admin: Rapid IV administration of large doses may result in seizures, especially if inappropriately high
doses are used in renal impairment.
IV products are physically incompatible with many substances; avoid mixing with other drugs.
Practice points:
give twice daily for uncomplicated UTIs, streptococcal pharyngitis and tonsillitis, skin and soft tissue
infections; twice daily dosing is not recommended if >500 mg per dose is required
Indication 10. UTI
Drug Name co-trimoxazole
Dose Form tablet
Strength trimethorprim 160mg/ sulphamethoxazole 800 mg
Directions one tablet of the combined preparation (160mg trimethoprim/800 mg

suphamethoxazole) 12 hourly for 5 days
Quantity 10
No. of Repeats
Drug of choice
Issues
Cost $8.96 for 10 tablets
Other Issues Adverse effects can be serious e.g.Stevens-Johnson syndrome,

hepatitis.
Practice points
•use trimethoprim alone for common infections in adults (particularly UTI); trimethoprim with
sulfamethoxazole offers no advantage and there is a higher incidence of adverse effects
•to prevent crystalluria maintain adequate urine output; recommended adult fluid intake is at least 2–3 L
in 24 hours
•stop if rash or other symptom of hypersensitivity develops
•people allergic to, or unable to tolerate, trimethoprim with sulfamethoxazole may benefit from
desensitisation (see specialist literature) if use of this agent is considered necessary
Monitor
•complete blood picture and folate status during prolonged or high-dose treatment
•renal function and obtain urinalysis each month during prolonged treatment, particularly in people with
pre-existing renal impairment
•serum potassium, beginning on day 3, if the patient has renal impairment, is taking drugs that can
cause hyperkalaemia, or is taking a high dose, eg to treat PCP
Counselling: Take this medicine with food to reduce stomach upset. Drink a lot of fluid (at least 2–3 L
daily) during prolonged or high-dose treatment. To reduce risk of rash from the sun avoid sun exposure,
wear protective clothing and use sunscreen. Tell your doctor straight away if you get a sore throat,
fever, troublesome rash, cough, difficulty in breathing, joint pain, dark urine or pale stools.
AE can be serious e.g.Stevens-Johnson syndrome, hepatitis.
Contains trimethoprim + sulphamethoxazole. Both act on microbial folic acid metabolism. The
combination has a high efficacy against urinary E.coli. Minor side effects include sore mouth and
photosensitivity. Can cause hepatic damage - mainly after prolonged use in the elderly.
Sulfamethoxazole and trimethoprim are bacteriostatic; they competitively inhibit bacterial folate
production essential for bacterial growth.
Prec: Serious allergic reaction to sulfonamides—CI. HIV infection—increases allergic reactions to drugs;
often intolerable and may require use of alternative. Desensitisation may allow reintroduction of
trimethoprim with sulfamethoxazole (see Practice points).SLE—may worsen due to sulfonamide. Slow
acetylator phenotype—greater risk of adverse effects with sulfonamides. Treatment with oral typhoid
vaccine—trimethoprim with sulfamethoxazole is active against S. typhi and may inactivate the vaccine.
Drugs that cause potassium retention, eg ACE inhibitors—may contribute to hyperkalaemia caused by
trimethoprim.
Blood: CI megaloblastic anaemia due to folate deficiency. Folate deficiency may worsen, increasing risk
of blood dyscrasias; consider using calcium folinate supplement. Blood dyscrasias may worsen.
Sulfonamides increase risk of haemolysis in G6PD deficiency.
Indication 10. UTI
Drug Name nitrofurantoin
Dose Form 50, 100mg
Strength 50, 100 mg
Directions 50 to 100 mg 4 times daily for 3 to 5 days
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $16.01 for 30 x50mg/$23.75 for 30x 100mg.
Other Issues n/a
Nitrofurantoin is an older drug which has a general inhibitory action on both bacterial nucleoprotein and
cell wall synthesis. It is commonly reserved for the treatment of urinary tract infections. Can cause
nausea, vomiting, diarrhoea and very rarely hypersensitivity hepatitis, infiltrative pulmonary lesions,
polyneuritis - usually only in prolonged use and/or in presence of renal impairment. Because of the
emerging resistance of E.coli to several alternative antibiotics, nitrofurantoin is enjoying a revival of
popularity. The toxicity is low when used for a short course only.
Inhibits bacterial protein, DNA, RNA and cell wall synthesis.
Indications: Acute LUTI; Prophylaxis or long-term suppressive treatment in recurrent UTIs
Indication 10. UTI
Drug Name norfloxacin
Dose Form tablet
Strength 400 mg
Directions 400mg 12 hourly for 3 days.
Quantity 14
No. of Repeats
Drug of choice
Issues
Cost $17.29
Other Issues Norfloxacin is one of the group of quinolone antibiotics. It has been
used extensively for the treatment of UTI in many countries and
resistance is beginning to emerge. However, E.coli in Australia are
still largely sensititive
Norfloxacin is one of the group of quinolone antibiotics. It has been used extensively for Rx of UTI in
many countries and resistance is beginning to emerge. However, E.coli in Australia are still largely
sensititive
Norfloxacin is a quinolone antibiotic which is effective in the eradication of most urinary pathogens.
E.coli sensitivity >80%. Can cause headache, dizziness, nausea and vomiting. Photosensitivity is a risk
with this medication and patients should be advised to avoid sun exposure while taking it. Rarely
quinolone antibiotics may produce weakening and even rupture of cartilaginous structures such as
tendons but this is associated with courses of longer duration.
Bactericidal; inhibit bacterial DNA synthesis by blocking DNA gyrase and topoisomerase IV.
Indication 10. UTI
Drug Name trimethoprim
Dose Form tablet
Strength 300 mg
Directions daily for 3 days (at night to maximise urinary concentration for UTI)
Quantity 7
No. of Repeats
Drug of choice
Issues
Cost $8.05 for 7 tablets
Other Issues Trimethoprim has a high safety profile when used over a few days
for treatment of a UTI. Given long-term it may cause folate
deficiency but this is not a risk in short-course treatment.
Trimethoprim has a high safety profile when used over a few days for treatment of a UTI. Given long-
term it may cause folate deficiency but this is not a risk in short-course treatment.
Trimethoprim is not available in all countries as a single agent but often only in its combination with
sulphamethoxazole. In Australia it can be given as a single agent. It has high (80% or above) efficacy
against urinary E.coli.
Bacteriostatic; competitively inhibits bacterial folate production essential for bacterial growth.
Indication 11. Acute coronary syndrome (CP1)
Drug Name aspirin
Dose Form tablet
Strength 75 - 300 mg
Directions 300mg daily
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Dramatic reduction in progression to myocardial infarction
Safety Profile Small risk of bleeding when used in acute setting.
Cost $1.80 p/month
Other Issues Small risk of bleeding
Drug Name clopidogrel
Dose Form tablet
Strength 75 mg
Directions 300mg loading dose then 75mg daily
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
Safety Profile Small risk of bleeding when used in acute setting.
Cost Approx $90 p/month
Other Issues Efficacy in combination with aspirin. Similar bleeding to aspirin
Drug Name enoxaparin
Dose Form Subcutaneous injection
Strength Between 20 and 120 mg
Directions 1mg/kg bd (0.5mg/kg for renal impairment)
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Reduces the risk of progression to myocardial infarction
Safety Profile Small increased risk of major bleeding
Cost $33
Other Issues prevention of DVT
Reduces risk of progression to MI
Small increased risk of major bleeding
$33
Prevention of DVT
Drug Name glyceryl trinitrate
Dose Form sublingual spray
Strength 400 microgram/ dose
Directions 300-600 micrograms stat
Quantity 1 (200 doses) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Useful for symptomatic improvement
Safety Profile Poorly tolerated at high doses due to hypotension and headache
Cost $18/bottle
Other Issues For immediate relief of symptoms. Longer shelf life than tablets,
more expensive
Sublingual glyceryl trinitrate is the initial treatment of choice for patients presenting with unstable
angina. It can easily be administered sublingually, and has a rapid onset of effect. If hypotension occurs,
the sublingual tablet can be spat out, and the effects of the drug wears off very rapidly over minutes.
Unfortunately, because of the short half life of only a few minutes, the drug has to be readministered,
hence is not ideal for patients with continuing symptoms.
The choice between tablet or spray is purely a practical one: the spray is more expensive but has a
longer shelf life. It is also useful in patients who are acutely unwell and have a dry mouth. The tablet is
cheaper, but has to be kept in special containers.
Useful for symptomatic improvement
Poorly tolerated at high doses due to hypotension and headache
$18/bottle
For immediate relief of symptoms, longer shelf life than tablets more expensive
Dose Form tablet
Strength 600 microgram
Directions 300-600 micrograms, repeated every 3-4 minutes until pain is

resolved.
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Useful for symptomatic improvement
Safety Profile Poorly tolerated at high doses due to hypotension and headache
Cost $9 per bottle
Other Issues For immediate relief of symptoms.
Place half to one tablet under the tongue, don’t let the patient swallow. After the pain has been relieved,
they may spit it out or swallow it.
Drug Name morphine sulfate
Dose Form injection
Strength 10, 15 & 30 mg
Directions 2.5-5 mg stat
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective analgesics
Safety Profile Hypotension, sedation, respiratory depression
Cost ~$2.00 per vial
Other Issues Parenteral opiate with rapid onset of effect.
morphine sulfate injection 10, 15 & 30 mg 2.5-5 mg stat 5 (PBS) Nil (PBS) ~$2.00 per vial Parenteral
opiate with rapid onset
Morphine given via the parenteral route is the analgesic of choice for patients with severe unstable
angina pain. It provides pain relief within minutes when given intravenously, and within 15-20 minutes
when administered subcutaneously. Because of the rapid onset of effect, it is much easier to titrate the
dose to efficacy and toxicity.
Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and peripheral
nervous systems to produce analgesia, respiratory depression, sedation and constipation. They prevent
transmission of the pain impulse by acting pre- and post-synaptically in the spinal cord, and by
modulating the descending inhibitory pathways from the brain. Cough suppression occurs in the
medullary centre of the brain.
The affinity of individual opioid analgesics for receptors varies and opioids may act as pure agonists or
partial agonists, see Opioid comparative information (Table 3-2). Partial agonists demonstrate a 'ceiling
response' above which an increase in dose does not produce an additional increase in effect.
Effective analgesics
Hypotension, sedation, respiratory depression
~$2.00 per vial
Parenteral opiate with rapid onset of effect
Drug Name tirofiban
Dose Form IV
Strength 12.5 mg/50 ml
Directions 0.4 microgram/kg/minute for 30 min, then 0.1 microgram/kg/min
Quantity 1 (PBS)
No. of Repeats
Drug of choice
Issues
Safety Profile Small risk of bleeding when used in acute setting
Cost $360/12.5 mg vial
Other Issues Incremental efficacy in high risk patients
Dramatic reduction in progression to MI
Small risk of bleeding when used in acute setting
$360/12.5mg vial
Incremental efficacy in high risk

Drug Name unfractionated heparin
Dose Form IV injection
Strength 35,000 units in 35 ml
Directions 5000 units IV bolus, then 1000units/hour IV infusion
Quantity 12 PBS
No. of Repeats
Drug of choice
Issues
Efficacy Reduces the risk of progression to myocardial infarction
Safety Profile Small increased risk of major bleeding
Cost approx. $12/35,000 unit amp
Other Issues Intravenous infusion and dose has to be titrated to achieve target
APTT
Unfractionated heparin has additional benefits to antiplatelet therapy alone in preventing progression to
myocardial infarction. It appears to be as effective as dalteparin, and not as effective as enoxaparin.
In terms of safety, the incidence of bleeding in NSTEACS trials appears to be the same, but is lower
with low molecular weight heparins in other indications. Although, unfractionated heparin is likely to be
associated with more bleeding than LMWHs, it is probably just that it has not been studied enough in
this setting to demonstrate this. Quite apart from these issues, it has the disadvantage of needing
regular APTT monitoring.
The main reason for using unfractionated heparin is the ability to more fully reverse its effects (because
of its shorter half life and the ability to reverse it with protamine). Hence it is used in situations of greater
bleeding risk eg patient with active peptic ulcer, and in some centres where a procedure is planned.
Indication 12. Chronic angina after MI (CP 2)
Drug Name amlodipine
Dose Form tablet
Strength 5 & 10 mg
Directions 2.5-10mg daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Similar efficacy to beta-blockers and nitrates for symptoms of
angina.
Safety Profile Contraindicated in bradycardia, and congestive cardiac failure.
Cost $0.40 - 1.30 / day
Other Issues .
Similar in efficacy to B-blockers and nitrates for Sx of angina
CI in bradycardia, CCF
0.40-1.30 per day
Dose Form tablet
Strength 5 & 10 mg
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
angina.
Cost $0.40 - 1.30 / day
Other Issues .
Amlodipine is a dihydropyridine with an inherently long half life and slow onset and offset of action. For
this reason it is not associated with reflex tachycardia or worsening of heart failure in the same way as
other dihydropyridines are. It is more expensive than other agents and the patient has to pay an extra
premium for its use.
Drug Name aspirin
Dose Form enteric-coated tablets
Strength 100 mg
Quantity 84
No. of Repeats
Drug of choice
Issues
Efficacy 25% Reduction in incidence of vascular events
Safety Profile Risk of gastrointestinal and other bleeding
Cost $3 p/month
Other Issues enteric-coating has no effect on bleeding
25% reduction in incidence of vascular events
Risk of GIB
$3/month
Enteric coating has no effect on bleeding
Drug Name aspirin
Dose Form tablet
Directions 150mg (half 300 mg tablet) daily.
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $1.80 p/month
Drug Name aspirin
Dose Form enteric-coated tablets
Strength 100 mg
Quantity 84
No. of Repeats
Drug of choice
Issues
Cost $3 p/month
Other Issues enteric-coating has no effect on bleeding
All guidelines suggest that aspirin should be used in all patients with coronary artery disease unless
there is a contraindication. Aspirin causes approximately a 25% relative reduction in the risk of cardiac
events. The main risk is the development of gastrointestinal bleeding which occurs in approximately
0.5% of patients per year (even with low doses), and there is no advantage with the enteric coated
formulation.
Contraindications to aspirin include the development of aspirin/NSAID induced gastrointestinal

ulceration, pre-existing bleeding tendancy, and aspirin hypersensitivity ie anaphylaxis, urticaria or
asthma within 4 hours of ingestion of aspirin or NSAID’s.
The only advantage of the enteric coated formulation is that it is a low 100mg dose, and patients do not
have to cut the tablet in half.
Drug Name aspirin
Dose Form tablet
Directions 150mg (half 300 mg tablet) daily.
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $1.80 p/month
All guidelines suggest that aspirin should be used in all patients with coronary artery disease unless
there is a contraindication. Aspirin causes approximately a 25% relative reduction in the risk of cardiac
events. The main risk is the development of gastrointestinal bleeding which occurs in approximately
0.5% of patients per year (even with low doses)
Contraindications to aspirin include the development of aspirin/NSAID induced gastrointestinal

ulceration, pre-existing bleeding tendancy, and aspirin hypersensitivity ie anaphylaxis, urticaria or
asthma within 4 hours of ingestion of aspirin or NSAID’s.
Most patients are managed with taking half a 300mg aspirin tablet a day, or a 100mg (non-enterically
coated) tablet.
Drug Name atenolol
Dose Form tablet
Strength 50 mg
Directions 25-100mg oral daily
Quantity 50 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective for exertional angina, and mortality benefit post myocardial
infarction
Safety Profile Contraindicated in asthma, hypotension, bradycardia, heart block
Cost 32 cents - $ 1.28 / day
Effective for exertional angina, and mortality benefit post MI
CI in asthma, hypotension, bradycardia, heart block
32c - $1.28 per day
Gen Pharm Benefit
Drug Name atenolol
Dose Form tablet
Strength 50 mg
Quantity 50 (PBS)
No. of Repeats
Drug of choice
Issues
infarction
» Display Drug Commentary
Atenolol is a commonly used beta blocker in the management of chronic angina. It is a beta-1 selective
agent (hence less likely to exacerbate airways disease) which is hydrophilic, hence does not distribute
as much into the brain, and is associated with a smaller risk of CNS adverse reactions. It can be given
once daily.
Drug Name atorvastatin
Dose Form tablet
Strength 10, 20 & 40, 80 mg
Directions 10-80mg orally daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Improve dyslipidemia, limited evidence of CV event prevention
Safety Profile Not as well tolerated as statins.
Cost $1.40-3.70 per day
Other Issues Proven prevention of ischaemic events.
Atorvastatin is a potent statin, and its main advantage is that at its highest approved dose, it results in
greater LDL reduction, than the highest approved doses of most other statins. This is important as the
majority of the benefit of the statins appears to come from LDL cholesterol reduction.
As with many statins, however, most of the benefit is achieved with less than 50% of the maximum
dose.
There have been 2 studies that have shown that intensive cholesterol reduction with atorvastatin 80 mg
(compared to 10mg atorvastatin in one study, and pravastatin in another) prevents more cardiovascular
events. It is not clear, however, for whom this approach is most effective, and it is certainly not routine
practice in all patients.
Drug Name candesartan
Dose Form tablet
Strength 4, 8, 16, 32 mg
Directions Start with 4mg and titrate up to maximum tolerated
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy In limited trials similar efficacy to ACE inhibitors
Safety Profile Less cough than ACE, but otherwise similar
Cost $32
Other Issues proven CHF efficacy
In trials similiar to ACEi
Less cough
$32
Proven CHF efficacy
Dose Form tablet

Directions Start with 4mg and titrate up to maximum tolerated
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy In limited trials similar efficacy to ACE inhibitors
Cost $32
Candesartan is a long acting angiotensin II receptor blocker which has some proven efficacy in cardiac
failure in patients who cannot tolerate ACE inhibitors. It is a reasonable choice for patients who have
ACE intolerance, but should not be used first line
Drug Name captopril
Dose Form tablet,oral liquid
Strength 12.5, 25, 50 mg (tablet), 5 mg/ mL (liquid)
Directions 6.25-50mg three times per day
Quantity 90 (tab) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Prevention of cardiac events and mortality
Safety Profile Generally very well tolerated.
Cost $21- $32
Other Issues Short half life
Captopril is an ACE-I with a short half life and hence has to be given 2-3 times per day. Its use is hence
limited to situations where the patient may be at high risk of hypotension or renal impairment, eg elderly,
low BP, low Na, dhydrated patients on high dose diuretics. It is no less likely than other ACE-I to cause
these reactions, but if they were to occur, then the duration would be expected to be shorter with
captopril.
Drug Name captopril

Directions 6.25-50mg three times per day
No. of Repeats
Drug of choice
Issues
Cost $21- $32
Captopril is an ACE-I with a short half life and hence has to be given 2-3 times per day. Its use is hence
limited to situations where the patient may be at high risk of hypotension or renal impairment, eg elderly,
low BP, low Na, dhydrated patients on high dose diuretics. It is no less likely than other ACE-I to cause
these reactions, but if they were to occur, then the duration would be expected to be shorter with
captopril.
Drug Name carvedilol
Dose Form tablet
Strength 3.125, 6.25, 12.5 & 25 mg
Directions Gradually increase to 50mg in 1-2 daily doses
Quantity 60 (PBS)
No. of Repeats
Drug of choice
Issues
infarction
Cost $23 - $32
Other Issues Streamlined authority for CHF only
Dose Form tablet
Strength 3.125, 6.25, 12.5 & 25 mg
Directions Gradually increase to 50mg in 1-2 daily doses
Quantity 60 (PBS)
No. of Repeats
Drug of choice
Issues
infarction
Cost $23 - $32
Carvedilol is only PBS reimbursed for heart failure in Australia. It is a non-selective beta blocker, which
also has -blockade (and an anti-oxidant moiety if you must be finicky). It is very expensive compared to
other beta blockers and only really indicated where the patient has a combination of heart failure
benefiting from a beta blocker, as well as angina.
Drug Name cholestyramine
Dose Form sachets
Strength 4 & 8 mg
Directions 12-16gram 2-3 times daily
Quantity 50 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Improve dyslipidemia, limited evidence of CV event prevention.
Cost Appeox $2 p/day
Other Issues Poor tolerability discourages its use
Cholestyramine is presented as a powder which has to be taken 2-3 times per day in high doses.
Patients complain that it tastes similar to eating sand so it’s not a glowing endorsement really. It is
useful for reducing the LDL cholesterol by 15-25% and may be particularly useful in combination with
statins. It’s use is reserved for patients with hypercholesterolaemia who have a contraindication to
statins, and in those whose cholesterol is poorly controlled despite adequate doses of statins. It also
binds other weak acids that are not bile e.g. warfarin
Dose Form tablet
Strength 75 mg
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
Dose Form tablet
Strength 75 mg
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
Clopidogrel as monotherapy:
Clopidogrel has been shown to be very marginally (and we are talking very marginally) more effective
than aspirin in patients with ischaemic conditions, however its high cost does not justify its use in all
patients. It is indicated for patients who have a contraindication to aspirin such as gastric ulceration
caused by aspirin, or hypersensitivity ie anaphylaxis, urticaria or asthma within 4 hours of ingestion of
aspirin or NSAID’s. It can also be prescribed for the prevention of cerebrovascular or cardiovascular
events in patients who have had ischaemic events whilst on aspirin therapy. In terms of safety, although
it is less likely to cause gastric ulceration, the overall risk of bleeding is similar with clopidogrel as with
aspirin.
Clopidogrel in combination with aspirin:

In patients with high risk acute coronary syndrome ie ST elevation MI as well as NSTEACS with
troponin positivity or ECG changes, clopidogrel has been shown to have benefit in addition to aspirin.
Combination with aspirin has also been shown to be beneficial in patients having stents. A number of
trials have assessed the benefit of the combination in other settings, and have been proven to be of no
benefit and only associated with an increased risk of bleeding. These include:
* patients with a recent stroke or TIA,

* in patients with a history of documented vascular (but no recent acute coronary syndrome)
* patients with atrial fibrillation (compared to warfarin)
When used in combination with aspirin, the risk of major hemorrhage is increased by approximately 1-
2% per year.
Drug Name diltiazem
Dose Form Sustained release caps
Strength 180, 240, 360 mg SR caps
Directions 180-360mg daily.
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
angina.
Cost $30 p/month
Other Issues Central and peripherally acting. Once daily formulation.
Use sustained release.
Drug Name diltiazem
Dose Form Sustained release caps
Strength 180, 240, 360 mg SR caps
Directions 180-360mg daily.
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
angina.
Cost $30 p/month
Other Issues Central and peripherally acting. Once daily formulation.
Diltiazem can be used in patients who cannot tolerate beta blockers and/or verapamil, or in combination
with a beta blocker (with caution) in patients with angina. It is less likely to be associated with
bradycardia and heart failure than verapamil, and is less likely to cause reflex tachycardia than
dihydropyridines hence can be used as monotherapy.
The sustained release preparation is preferred due to its once daily dosing, and associated better
compliance.
Drug Name Ezetimibe
Dose Form Tablet
Strength 10 mg
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $2.30 per day
Other Issues Limited efficacy data. <a

href="http://www.pbs.gov.au/html/healthpro/product/restrictions?cod
e=8757X&publication=GE" target="_blank">Authority
prescription</a>
Ezetimibe is a new drug which appears to limit cholesterol absorption in a different way to bile acid
resins. It has been shown to reduce LDL cholesterol either alone or in combination with statins, but
there is no other efficacy data available, and limited safety data.
Hence, it has similar level of data as bile acid resins but is a more convenient tablet. It is an authority
prescription with fairly stringent criteria.
Drug Name felodipine
Dose Form extended release tablet

Strength 2.5, 5 & 10 mg
Directions 5-10 mg daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
angina.
Felodipine is a dihydropyridine calcium antagonist, hence causes much more vasodilatation of the
arterioles, than it has effects on the cardiac tissues. In clinical trials it has been shown to be useful as an
anti-anginal, but is not indicated for this reason in Australia, hence should only be used for patients with
concurrent angina and hypertension.
Drug Name fenofibrate
Dose Form tablet and capsule
Strength 48mg tab, 145 mg cap
Directions 48mg tablet up to 3 per day, 145mg capsule once daily.
Quantity 60 (48 mg), 30 (145mg) PBS
No. of Repeats
Drug of choice
Issues
Cost $1.30 p/day
Other Issues limited endpoint benefit
Fenofibrate has similar effect to other fibrates on lipids. In terms of preventing cardiovascular events,
most of the data comes from a trial in diabetics (FIELD study . In this study although did not significantly
reduce the risk of the primary outcome of coronary events, it did reduce the incidence of non-fatal
myocardial infarction. Unfortunately, there was also a statistically significant increase in the incidence of
thromboembolic events and pancreatitis.
Hence, fenofibrate can be considered in combination with a statin in patients who are at high risk of
cardiovascular events, and who have elevated triglyceride levels or low HDL levels. However, the
risk:benefit of each case should be carefully considered.
The dosing with fenofibrate is also complicated: 3 of the 48mg tablets are bioequivalent to a 145mg
capsule. In patients with estimated creatinine clearance >60ml/min the 145mg capsule can be given, but
in those with more renal impairment, the 48mg tablet can be given once or twice daily
The formulation has also changed recently so that in some of the literature they will refer to a 67mg
tablet and 160mg capsule. They are not making it easy are they??
Drug Name gemfibrozil
Dose Form tablet
Strength 600 mg
Directions 600mg twice daily
Quantity 60 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $1.30 p/day
Other Issues Efficacy proven in specific patients
Gemfibrozil has limited data to support the reduction in the incidence of cardiovascular events in both
primary and secondary prevention in patients with low HDL levels.
It is useful in patients with who cannot tolerate statins, or who are at high risk and have a low HDL on
statin therapy. There is, however, a higher incidence of rhabdomyolysis when the two drugs are
combined.
Directions 300-600 microgram sublingually as required.
No. of Repeats
Drug of choice
Issues
Efficacy Effective in relief of anginal symptoms
Safety Profile Tolerance, headache and postural hypotension.
Cost $18/bottle
more expensive
Sublingual glyceryl trinitrate is one of the short acting nitrates and one of these agents should be
prescribed to all patients with angina. It has a rapid onset of effect and is useful for the short term
management of symptoms when they occur. It can also be used prophylactically when a particular
activity is likely to bring on angina eg getting dressed first thing in the morning, but the effects only last a
few minutes. The tablet formulation unfortunately has a limited shelf life (has to be discarded 3 months
after opening), and has to be protected from moisture light and heat. It also loses its efficacy if it is
placed in other types of containers.
Dose Form tablet
Directions 300-600 microgram sublingually as required.
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $9 per bottle
Sublingual glyceryl trinitrate is one of the short acting nitrates and one of these agents should be
prescribed to all patients with angina. It has a rapid onset of effect and is useful for the short term
management of symptoms when they occur. It can also be used prophylactically when a particular
activity is likely to bring on angina eg getting dressed first thing in the morning, but the effects only last a
few minutes. The tablet formulation unfortunately has a limited shelf life (has to be discarded 3 months
after opening), and has to be protected from moisture light and heat. It also loses its efficacy if it is
placed in other types of containers.
Dose Form transdermal patch
Strength 5, 10 & 15 mg/ 24 hours
Directions 5-15mg patch for up to 16 hours
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost ~$1.00 per patch
Other Issues Prophylactic nitrate patch.
Transdermal patches administer glyceryl trinitrate whilst they are worn, and the effect wears off quickly
once taken off. They are popular for patients who get nocturnal angina, as well as for those who do not
like taking tablets. They are usually administered either during the day or at night, in order to allow a
patch free period to prevent tolerance developing. Patches do take 40-60 minutes for the onset of their
effect, however, hence may not be that useful where immediate anti-anginal efficacy is required eg first
thing upon rising in the morning. Also there is some evidence that they are associated with rebound ie
increasing angina during the patch off period. This same phenomenon is not associated with long acting
oral anti-anginals. In other ways patches are equivalent in efficacy to oral nitrate therapy.
Drug Name Isosorbide dinitrate
Dose Form tablet
Strength 10 mg
Directions 10-20mg up to 3/day
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $0.06 per dose
Other Issues Prophylactic short acting nitrate tablet.
Isosorbide dinitrate is essentially the same in terms of safety and efficacy as other long acting nitrates,
but just differs in its pharmacokinetics. Its onset of effect is only 15-30 minutes and its duration of effect
is approximately 4-6 hours. It is useful therapy when the patient has angina only during part of the day
eg first thing in the morning when dressing, showering etc…, when playing bowls etc…. It acts quickly,
lasts many hours, and does not subject the patient to unnecessary drug exposure for the entire day.
When used judiciously according to the patient’s symptoms it is also less likely to result in tolerance,
and as you can see it is also considerably cheaper than the patch or the sustained-release mononitrate.
Drug Name Isosorbide dinitrate
Dose Form sublingual tablet
Strength 5 mg
Directions 5mg sublingual as needed
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $0.06 per dose
Other Issues Relieving nitrate with longer duration of action than glyceryl trinitrate.
Isosorbide dinitrate sublingually is very much the underrated nitrate, and most clinicians do not even
know it exists!!! Its use is similar to the sublingual glyceryl trinitrate except that although the onset of
effect is only 2-5 minutes, the duration is much longer being generally about 1-2 hours. This makes it
the ideal prophylactic agent where certain activity, which usually takes a while to perform, is likely to
precipitate angina eg getting ready in the morning, walking when shopping, cleaning around the house
etc…
Drug Name Isosorbide mononitrate
Dose Form sutained release tablet
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Other Issues Prophylactic long acting nitrate.
Isosorbide mononitrate is available in Australia as a sustained release preparation. It is usually given in
the morning or at night, and because of its release characteristics it provides a nitrate-poor period so
that acute tolerance does not develop. Long term, however, attenuation of its effects may be seen, such
that the dose may need to be increased, without this necessarily implying that the patient’s angina is
worsening. Because of the sustained release preparation, the peak anti-anginal efficacy may not be
seen for 1-4 hours, so it may not be useful for where rapid anti-anginal efficacy is required eg first thing
upon rising in the morning.
Drug Name metoprolol
Dose Form tablet

Directions 25-100mg oral twice daily
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
infarction
Cost $15 - $33
Dose Form tablet
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
infarction
Cost $15 - $33
Metoprolol is a beta-1 selective agent hence it is less likely to cause problems in patients with airways
disease. Because of its lipophilicity it is more likely to cause CNS effects such as nightmares than
atenolol. It has a short half life, hence has the advantage that it may be more suitable for patients who
may be more sensitive to its adverse effects eg low heart rate, or blood pressure.
It also has demonstrated efficacy in heart failure, hence is ideal for the patient with angina and heart
failure.
Drug Name nicorandil
Dose Form tablet
Strength 10 & 20 mg
Quantity 60 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Additive efficacy to other anti-anginals for symptom relief.
Safety Profile Nicorandil can cause headache and flushing; perhexiline has
serious long term toxicity.
Other Issues Useful additional anti-anginal
Nicorandil is a potassium channel opener that also has a nitrate moiety. Because of its nitrate moiety
some tolerance may develop to its effects. The main adverse effects are headache, which can be
severe, and flushing.
At that dose of 20mg twice daily it has been shown to reduce unplanned hospital admission in addition
to standard anti-anginal therapy.
Drug Name nifedipine
Dose Form Sustained release caps and tablets
Strength 10. 20 mg (tablets), 20, 30, 60 mg (Caps)
Directions Tablet: 10-40mg twice daily, Capsule 20-60mg once daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
angina.
Cost $30 p/month
Other Issues peripherally acting CCB
Nifedipine is a dihydropyridine and may be associated with reflex tachycardia and a worsening of
angina symptoms. For this reason, it is beneficial to combine it with a beta-blocker. Because of its
inherently short half life, it is usually administered in a sustained release preparation. This is available in
a twice daily tablet, or a once daily capsule which has a premium for the patient to pay associated with
it.
Drug Name perhexiline
Dose Form tablet

Strength 100 mg
Directions 50mg per week to 400mg per day
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Additive efficacy to other anti-anginals for symptom relief.
Safety Profile Nicorandil can cause headache and flushing; perhexiline has
serious long term toxicity.
Cost $0.03 to $2.00 not including cost of monitoring
Other Issues Difficult to manage. Needs plasma monitoring
Perhexiline is a very difficult drug to prescribe and management should be in the hands of specialists: it
has genetic polymorphism in its metabolism (8% of the population do not have the enzyme that clears it
and only need 50-100mg per week compared to 200-400mg per day for the rest of the population); it
has non-linear pharmacokinetics so small doses can result in large concentration changes; it has
concentration-dependent hepato- and neurotoxicity; it has a number of important drug interactions;
patients need to have regular drug levels. Having said that, it is an effective anti-anginal but only when
other treatments have failed and only in the hands of experts.
Drug Name perindopril
Dose Form tablet
Strength 2, 4, and 8mg of erbumine salt; 2.5, 5, and 10mg of arginine salt
Directions 2-8mg of erbumine salt, or 2.5-10mg of arginine salt
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $17 - $30
Other Issues Confusing formulations
Perindopril is very similar to other ACE inhibitors. It’s main disadvantage is that it comes in 2 different
formulations with 2 different sets of doses, which are bioequivalent. To make matters worse you can get
the arginine formulation as brand name Coversyl in doses of 2.5, 5 and 10mg, but if you want to
combine it with a thiazide diuretic, (Coversyl Plus) it is only available as the erbumine salt (perindopril 4
mg/indapamide 1.25mg). Prescribing other ACE inhibitors is less likely to confuse patients.

Drug Name pravastatin
Dose Form tablet
Strength 5, 10, 20 & 40 mg
Directions 20-80 orally nightly
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Other Issues Proven prevention of ischemic events.
Pravastatin is one of the most studied statin in outcome trials demonstrating benefit in reduction of
mortality as well as other cardiovascular outcomes. These include both primary and secondary
prevention studies. At the maximum dose it results in less cholesterol reduction than simvastatin or
atorvastatin.
Drug Name ramipril
Dose Form tablet
Strength 1.25, 2.5, 5 and 10 mg
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $15-30
Other Issues Once daily ACE inhibitor
Drug Name ramipril
Dose Form tablet

Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $15-30
Ramipril is a once daily ACE inhibitor which was used in the HOPE trial, which demonstrated that 10mg
of ramipril produced mortality benefits in patients with a past history of ischemic heart disease
compared to placebo. As a result, some guidelines advocate only prescribing 10mg of ramipril for this
indication, whereas others see it as a class effect of all ACE inhibitors.
The main advantage of ramipril is that it comes in a range of doses including a low dose of 1.25mg,
which can be halved further in patients with low blood pressure or renal impairment.
There is currently a patient premium to be paid with ramipri
Drug Name rosuvastatin
Dose Form tablet
Strength 5, 10, 20 & 40mg
Directions 5-20mg orally daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Other Issues Potent statin.
Rosuvastatin is the most recent statin on the market. Although it has been shown to be very potent (ie
lower dose required to achieve the same LDL reduction) there is no outcome data available for it yet.
Think about the following examples of drugs which did indeed achieve their desired efficacy but were
associated with other adverse outcomes with long term use:
* Rofecoxib : fewer gastric ulcers but more heart attacks

* Fenofibrate: fewer non-fatal MIs but more thromboembolic events and even pancreatitis
* Some forms of hormone replacement therapy : fewer menopausal symptoms and protection against
osteoporotic fractures, but more cardiovascular events
* Atypical antipsychotics: fewer short term extrapyramidal adverse effects but greater incidence of
diabetes, weight gain, and cardiovascular events
I could go on!!
Where there are similar drugs available with long term safety and efficacy clinical data, a new drug in
the same class should not be prescribed in preference, simply because it has an advantage in its
pharmacology or in a surrogate endpoint.
Drug Name simvastatin
Dose Form tablets
Strength 5, 10 ,20, 40 & 80 mg
Directions 10-80mg orally nightly
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Other Issues Proven prevention of ischaemic events.
Simvastatin has been shown to reduce cardiac events in both primary and secondary prevention. It’s
maximum dose achieves greater cholesterol reduction than pravastatin and nearly as much as
atorvastatin. In a trial of patients on 80mg of simvastatin (equivalent to ~40mg of atorvastatin) there
were more adverse effects than seen with similar doses of atorvastatin in other trials. It does have the
advantage of also being available as a combination product with ezetimibe.
Drug Name trandolapril
Dose Form capsule
Strength 2, 4 and 8 mg
Directions 500microgram -4mg per day
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $20-30
Other Issues Long half life ACE-I
Prevention of cardiac events and mortality
Generally well tolerated
$20-$30
Long half-life ACEi
Dose Form capsule
Directions 500microgram -4mg per day
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $20-30
Trandolapril has a long half life and is a suitable ACE-I for long term dosing. Otherwise it is very similar
to many other once daily ACE-I.
Indication 13. Hypertension
Drug Name amiloride
Dose Form tablet
Strength 5 mg
Quantity 100
No. of Repeats 1
Drug of choice
Issues
Efficacy Mainly used to avoid hypokalemia with diuretics
Safety Profile Risk of hyperkalemia
Cost $15 - $18
Other Issues Not usually needed if ACE inhibitor used
Amiloride is a potassium sparing diuretic, which is a weak diuretic and antihypertensive. As a result it is
rarely used on its own in hypertension. It may be given with a diuretic either in a combination product, or
on its own. It can also be prescribed in primary hyperaldosteronism.
Dose Form tablet
Strength 5 & 10 mg
Directions 2.5-10mg mane
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
Efficacy Effectively lower BP and reduce stroke similarly to other agents, but
associated with increased coronary events and heart failure.
Safety Profile Generally well tolerated. Varies with type of agent.
Cost $0.40 - 1.30 / day
Other Issues .
Amlodipine has a long half life and may be dosed once daily up to a maximum of 10 mg. Like all
dihydropyridine CCBs it acts predominantly by relaxing arterial and arteriolar wall smooth muscle with
little myocardial depressant effect. It should be avoided as sole therapy in coronary disease which it can
worsen. Interactions with other drugs metabolized by the cytochrome P450 system may occur, e.g.
cimetidine and erythromycin. Dosage reduction is advised in the elderly and those with liver impairment.
Because of its cost an additional patient premium payment is required.
Drug Name atenolol
Dose Form tablet
Strength 50 mg
Directions 25 - 100mg daily
Quantity 50 (PBS)
No. of Repeats 5
Drug of choice
Issues
Efficacy Not as effective in prevention of strokes especially elderly
Only metoprolol and atenolol are beta 1 selective, a property which usually reduces side effects such as
exacerbation of airways disease. Atenolol is preferred by many clinicians, for its once daily convenience
(though it is mostly renally excreted and the dose should be reduced in renal failure). It is also less
lipophilic and less likely to cause CNS adverse reactions.
Drug Name bumetanide
Dose Form tablet
Strength 1 mg
Directions 0.5-4mg once or twice daily
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Only limited efficacy in hypertension. Might be considered if severe
heart failure also present.
Safety Profile Most adverse effects are dose related and include electrolyte
disturbances, diziness, gout and rarely tinnitus.
Cost $10 approx.
Other Issues Not on PBS
Loop diuretics at larger doses achieve larger naturesis than thiazides and are employed when
hypertension proves resistant, or for comorbid cardiac failure or oedematous states eg liver disease,
nephrotic syndrome. Loop diuretics have half-lives < 6 hours and should usually be taken twice a day to
maintain naturesis
Dose Form tablet
Directions 8-16mg daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy AIIRB's effectively lower BP but limited outcome data so far
Cost $32
The AII-receptor blockers (AIIRB’s) currently available in Australia appear to have similar clinical
efficacy and long half-lives, enabling once-daily dosing. AIIRB’s are predominantly hepatobiliary (as
opposed to renally) excreted - eprosartan 60/40, respectively, candesartan 70/30, irbesartan 75/25,
telmisartan 100/0, enabling their use usually without dose reduction in renal failure. AIIRB’s should be
avoided or reduced in dose in liver failure.
Candesartan has the advantage of having proven efficacy in cardiac failure.
Drug Name captopril
Directions 12.5-5mg bd
No. of Repeats 5
Drug of choice
Issues
Efficacy Effectively lower blood pressure, similar to thiazides in reducing
endpoints
Safety Profile Cough in ~10%
Cost $21- $32
ACE-Is all appear to have similar clinical efficacy, and the decision for what to prescribe is usually
based on whether it can be dosed once daily or not, cost, and for some clinicians, proven efficacy in
particular clinical situations eg post-myocardial infarction, post-stroke.
Captopril is rarely used in the long term management of hypertension because of its short half life and
the need for multiple daily dosing. It may be used to commence patients on an ACE-I if the patient is
particularly susceptible to the adverse effects of an ACE-I eg underlying renal impairment, on high dose
diuretic, aortic stenosis. In these circumstances, they are no less likely to develop these adverse
reactions with captopril, but should they occur, it is not going to last as long as with an ACE-I with a
longer half life.
This makes it a useful addition to a P drug list.
Dose Form tablet
Strength 3.125, 6.25, 12.5 & 25 mg

Quantity 60 (PBS)
No. of Repeats 5
Drug of choice
Issues
Cost $23 - $32
The use of carvedilol is reserved for heart failure. It is more expensive, and is also non-selective and
more likely to result in adverse reactions.
Drug Name chlorthalidone
Dose Form tablet
Strength 25 mg
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Extensive evidence of efficacy in lowering BP and reducing
cardiovascular events
Safety Profile At recommended low doses low incidence of metabolic adverse

effects
Cost $18
Other Issues Thiazide (low ceiling) diuretic
Chlorthalidone has a duration of action of 48-72 hours, longer in renal failure, compared to 6-12 hours
with hydrochlorothiazide, and 24-36 hours with indapamide, with the result that chlorthalidone often
accumulates and more often causes metabolic side effects. You should choose one thiazide and
generally use a lower dose to avoid the metabolic side effects.
Meta-analyses have shown that lower doses are associated with similar blood pressure reduction as
higher doses, but surprisingly have greater efficacy in preventing cardiac events. Higher doses have a
greater diuretic effect, and as a result may cause more symptomatic as well as metabolic adverse
reactions.
Drug Name clonidine
Dose Form tablet

Strength 100 & 150 microgam
Directions 150–300 micrograms twice daily
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy As effective as other agents
Safety Profile Postural hypotension, sedation, depression, insomnia quite

common.
Cost $26-$34 for 100
Other Issues General Pharm. Benefit.
Clonidine is approved for hypertension and treatment of menopausal flushing. Withdraw clonidine
gradually over at least 7 days; stopping abruptly may precipitate a severe withdrawal syndrome;
maintain treatment through perioperative period using parenteral dosing if necessary. While it has been
used for treating migraine prophylaxis efficacy is not well documented.
Drug Name diltiazem
Dose Form controlled release capsule
Strength 180, 240 & 360 mg
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $0.50-1.10/day
Other Issues .
Diltiazem is available in modified release formulations for the treatment of hypertension, allowing once
daily dosing up to 360 mg. Diltiazem, like verapamil, significantly depresses cardiac conduction and
myocardial contractility (less so than verapamil) and is a less potent arterial vasodilator than the
dihydropyridine CCBs. It can be useful for comorbid atrial tachycarrhythmias. Like verapamil, diltiazem
is contra-indicated in patients with heart failure. It may interact with a range of drugs. Combination of
diltiazem with a beta-blocking drug is generally not recommended because of the risk of undue
bradycardia. The initial starting dose is 180 or 240 mg once a day.
Drug Name enalapril

Dose Form tablet
Strength 2.5, 5,10 & 20 mg
Directions 5-40mg bd
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
endpoints
Cost $21-25
Other Issues Once daily ACE inhibitor.
The ACE-inhibitors all appear to have similar clinical efficacy, and the decision for what to prescribe is
usually based on whether it can be dosed once daily or not, cost, and for some clinicians, proven
efficacy in particular clinical situations eg post-myocardial infarction, post-stroke.
Enalapril has extensive evidence particularly in heart failure, but is not favoured in hypertension as it
really should be given twice daily. It is renally cleared.
Drug Name eprosartan
Dose Form tablet
Quantity 56 for 400 mg, 28 for 600 mg
No. of Repeats
Drug of choice
Issues
Other Issues General PBS benefit

Drug Name felodipine
Dose Form extended release tablet
Strength 2.5, 5 & 10 mg
Directions 5-20 mg
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
Felodipine is a dihydropyridine CCB which is available as a modified release tablet allowing once daily
dosing up to a maximum of 10 mg. Its predominant mode of action is relaxation of the arterial and
arteriolar wall smooth muscle with little myocardial depressant effect. It is only approved for treating
hypertension. It should be avoided as sole therapy in coronary disease which it can worsen. Interactions
with other drugs metabolized by the cytochrome P450 system may occur, e.g. cimetidine and
erythromycin and with enzyme-inducing anti-epileptic agents which may reduce its efficacy. Initial
dosage reduction is recommended in the elderly and those with liver impairment.
Drug Name frusemide
Dose Form tablet
Directions 10-40mg up to twice daily
Quantity 100
No. of Repeats 1
Drug of choice
Issues
Efficacy Only limited efficacy in hypertension. Might be considered if severe
heart failure also present.
Safety Profile Most adverse effects are dose related and include electrolyte
disturbances, diziness, gout and rarely tinnitus.
Cost $13- $23
Other Issues Oral loop diuretic
hypertension proves resistant, or for comorbid cardiac failure or oedematous states eg liver disease,
maintain naturesis
Drug Name hydrochlorothiazide
Dose Form tablet
Strength 25 mg
Quantity 100
No. of Repeats
Drug of choice
Issues

effects
Cost $26
Hydrochlorothiazide is a convenient choice because it is the most commonly used thiazide in ACE-
inhibitor or AII receptor blocker & diuretic combination formulations. At doses of up to 25mg it has little
effect on electrolytes or metabolic profile.
You should choose one thiazide and generally use a lower dose to avoid the metabolic side effects.
Meta-analyses have shown that lower doses are associated with similar blood pressure reduction as
higher doses, but surprisingly have greater efficacy in preventing cardiac events. Higher doses have a
greater diuretic effect, and as a result may cause more symptomatic as well as metabolic adverse
reactions.
Drug Name indapamide
Dose Form tablet
Strength 1.5 mg(sustained release)& 2.5 mg
Directions 1 tablet daily
Quantity 90 (PBS)
No. of Repeats
Drug of choice
Issues

effects
Cost $22 - $25
Indapamide is really a thiazide diuretic. It is no better than other thiazides, but at recommended doses is
a little more expensive. The sustained release preparation means that instead of having to dose it once
per day, you can dose it, well, only once per day! (it has a half life of 24-36 hours)
It has been reported to have a higher frequency of significant hyponatraemia and hypokalaemia than
other thiazides.
Drug Name irbesartan
Dose Form tablet
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
Cost $26- $32
Other Issues Commonly prescribed angiotensin receptor blocker
opposed to renally) excreted - eprosartan 60/40, respectively, candesartan 70/30, irbesartan 75/25%,
Irbesartan has been the most studied in the prevention of diabetic renal disease.
Drug Name lercanidipine
Dose Form tablet
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues

Cost $0.85-1.30/ day
Other Issues Patient has to pay premium
Lercanidipine is a newer dihydropyridine CCB with a long half life and may be dosed once daily up to a
maximum of 20 mg. It has a slower onset of effect which may take to longer to fully establish. It acts
predominantly by relaxing arterial and arteriolar wall smooth muscle with little myocardial depressant
effect. It is currently only approved for treating hypertension. It should be avoided as sole therapy in
coronary disease which it can worsen. Interactions with other drugs metabolized by the cytochrome
P450 system may increase blood concentrations and effect. Monitor clinically and reduce the dose if
necessary. The beta-blockers metoprolol and propranolol may decrease the concentrations and
therefore a dose increase of lercanidipine may be needed
Drug Name methyldopa
Dose Form tablet
Strength 250 mg
Directions Complex! See AMH
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues

common.
Cost $12.97/100
Little-used antihypertensive. Can be used safely during pregnancy (ADEC category A). The sedating
effect of methyldopa is exacerbated by dose increases; increase dosage at night to minimise
inconvenience of increased sedation.
Monitor blood count and liver function during first 6–12 weeks of treatment
Dose Form tablet
Directions 50 - 100 mg bd
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $15 - $33
Only metoprolol and atenolol are beta1 selective, a property which usually reduces side effects such as
exacerbation of airways disease. The half-life of metoprolol requires that it be administered at least
twice daily, and it is also more lipophilic, and more likely to give rise to CNS adverse reactions.
Drug Name moxonidine
Dose Form tablet
Strength 200 microgram, 400 microgram
Directions 200 micrograms daily
Quantity 30
No. of Repeats 5
Drug of choice
Issues

common.
Cost $20- $30
Other Issues Restricted Benefit
Moxonidine is a centrally acting antihypertensive that decreases activation of the sympathetic nervous
system. It is similar to clonidine but is selective for imidazoline I 1 receptors over alpha 2 -adrenergic
receptors. This selectivity may explain why rebound hypertension appears less common with
moxonidine than with clonidine.
Moxonidine is contraindicated for patients with bradycardia or bradyarrhythmia, malignant arrhythmia,

heart failure or severe renal impairment. Oh and it can potentiate the action of benzodiazepines and
alcohol.
Apart from that it is pretty much what you would use if the patient cannot tolerate, or has a
contraindication to the traditional 5 classes of antihypertensives.
Drug Name nifedipine
Dose Form tablet and controlled release tablet
Strength 10,20 mg tablet & 20,30 & 60 mg (CR tablet)
Directions 20-40 mg bd
Quantity 60 (tablet) & 30 (CR tablet) (PBS)
No. of Repeats
Drug of choice
Issues
Cost $0.60-1.90 / day
Other Issues General Pharm Benefit
Nifedipine is a dihydropyridine CCB available as a conventional tablet (dosed twice daily) and a
modified release tablet (which may be dosed once daily). It acts predominantly by relaxing arterial and
arteriolar wall smooth muscle with little myocardial depressant effect. It should be avoided as sole
therapy in coronary disease which it can worsen. Conventional tablets may cause reflex tachycardia
which can worsen ischaemic heart disease. Interactions with other drugs metabolized by the
cytochrome P450 system may increase blood concentrations and effect. Monitor clinically and reduce
the dose if necessary. The 60 mg controlled release tablet given once daily is approximately equivalent
to one 20 mg conventional tablet given twice daily.
Drug Name olmesartan
Dose Form Tablet
Strength 20 mg, 40 mg
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost Approx $24- $29
Other Issues Restricted Schedule
This is a new drug; unreported adverse effects may occur. Expect little additional reduction in BP from
increasing dosage from 20mg daily to 40mg daily. Consider adding a thiazide or related diuretic (or
increasing diuretic dosage) instead.
Dose Form tablet
Directions 2-8mg of erbumine salt, or 2.5-10mg of arginine salt daily
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
endpoints
Cost $17 - $30
The main disadvantage of perindopril is that it comes in 2 different formulations with 2 different sets of
doses, which are bioequivalent. To make matters worse you can get the arginine formulation as brand
name Coversyl in doses of 2.5, 5 and 10mg, but if you want to combine it with a thiazide diuretic,
(Coversyl Plus) it is only available as the erbumine salt (perindopril 4 mg/indapamide 1.25mg).
Prescribing other ACE inhibitors is less likely to confuse patients.
Drug Name prazosin
Dose Form tablet
Strength 1, 2 &5 mg
Directions 1-20mg daily (tds regimen)
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Less effective than other agents
Safety Profile Postural hypotension, particularly with early and larger doses, and in
elderly
Cost 13 - 96 cents / day
Prazosin is usually employed if diuretics, beta-blockers, Ca channel-blockers, ACE-inhiitors and/or
AIIRB’s have first proven unsatisfactory. Comorbid prostatism may prompt introducing prazosin sooner.
Postural hypotension is common and particularly a problem in the elderly.
Drug Name propranolol
Dose Form tablet

Directions 20-40 mg in 2 divided doses
Quantity 100 (PBS)
No. of Repeats 5
Drug of choice
Issues
Cost 16-34 cents / day
Propranolol may be more effective than the other beta-blockers for comorbid migraine, essential tremor
and anxiety, probably because of concomitant beta 2 receptor blockade. However, it is a non-selective
beta blocker and is lipophilic hence is more likely to give rise to adverse reactions. It also has to be
taken twice daily which is not desirable for the treatment of hypertension.
Drug Name ramipril
Dose Form tablet
Directions 2.5-10mg as one or two doses
Quantity 30
No. of Repeats
Drug of choice
Issues
endpoints
Cost $15-30
Ramipril is preferred by some clinicians as it has a long half life, and has been proven in a number of
different clinical trials. Unfortunately, currently there is a patient premium associated with its use
because of its higher price.
It is one of the few ACE-I that also has a component of hepatic excretion.

Drug Name telmisartan
Dose Form tablet
Strength 40 & 80 mg
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
Cost 70c - 94c / day
Other Issues General PBS benefit
Dose Form capsule
Quantity 30
No. of Repeats 5
Drug of choice
Issues
endpoints
Cost $20-30
Trandolapril has the longest half life of the ACE-I and is preferred by some clinicians for this reason.
The only other comment to make about trandolapril are the unusual brand names: Odrik, Gopten and
now Tarka (as a combination with Verapamil). Sound like the sort of medications you would buy over
the internet from a bloke called Borat in Kazhakstan.
Drug Name verapamil
Dose Form controlled release tablet
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $0.50-1.10/day
Verapamil is a phenylalkylamine CCB which is available as a modified release tablet allowing once daily
dosing. It has greater cardiac effects, reducing contractility, heart rate and conduction with less effect on
arterial and arteriolar wall smooth muscle than the dihydropyridine class. It is extensively metabolised in
the liver, with significant first pass clearance, and most metabolites are inactive and excreted in the
urine. Use should be avoided or the dose reduced in liver failure. Verapamil can be useful for co-morbid
atrial tachyarrthmias. Combination of verapamil with a beta-blocking drug is generally not recommended
because of the risk of undue bradycardia. One disadvantage of verapamil is that it may cause significant
constipation.
Indication 14. Respiratory tract infection in a child
Drug Name ibuprofen
Dose Form oral liquid
Strength 20 mg/mL, 40 mg/mL
Directions Child > 3 months: 5-10 mg/kg/dose given 3-4 times daily
Quantity 100 or 200 mL (20 mg/mL), 30 or 40 mL (40 mg/mL)
No. of Repeats
Drug of choice
Issues
Efficacy Effective for pain and fever
Safety Profile Renal dysfunction, gastrointestinal bleeding
Cost about $6–20
Other Issues Non PBS, Available OTC
Ibuprofen has at least equivalent antipyretic efficacy to paracetamol, but it’s unclear whether ibuprofen
is equally effective in relieving clinical symptoms and discomfort associated with fever. Some studies
suggest that it may be a more potent antipyretic than oral paracetamol, with earlier onset of action and
larger magnitude of temperature reduction. However, any difference appears to be small and the
antipyretic effects of the two agents follow a similar course, with both drugs exhibiting maximal activity
3-4 hours after oral administration. The main difference between ibuprofen and paracetamol is in the
toxicity profile of the two agents. Since ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID), its
use can potentially be associated with any of the adverse effects attributed to this class of drugs, the
most important of which being renal dysfunction and gastrointestinal bleeding. In one large study, the
risk of hospitalisation for acute gastrointestinal bleeding in children receiving ibuprofen for treatment of
fever was 7.2 per 100,000. There has also been a number of case reports of reversible acute renal
failure associated with short term use of ibuprofen, particularly in the setting of concurrent dehydration.
Although short term use (e.g. single dose) for fever control appears to be relatively safe, the safety of
longer term and more widespread use of ibuprofen in the setting of febrile illnesses in children has not
been well studied.
Indication 14. Respiratory tract infection in a child
Drug Name paracetamol
Strength 24, 48, 50 or 100 mg/mL
Directions Child > 1 month: 15 mg/kg every 4–6 hours maximum 60 mg/kg
daily for up to 48 hours (without medical supervision)
Quantity 20 or 50 mL (50 or 100 mg/mL), 100 or 200 mL (24 or 48 mg/mL)
No. of Repeats
Drug of choice
Issues
Efficacy Effective for pain and fever
Safety Profile Generally safe when dosed appropriately. Multiple formulation

strengths and compound preparations containing paracetamol may
lead to parent/carer confusion and accidental overdose.
Cost about $6-18
Other Issues General Pharm. Benefit (some products); Available OTC
Paracetamol is efficacious as both an analgesic and antipyretic agent and is the pharmacological agent
of choice for the management of pain and symptomatic high fever in children with acute infections.
There appears to be little difference in antipyretic efficacy between paracetamol and the alternative
agent, ibuprofen (a nonsteroidal anti-inflammatory drug) but these two commonly used agents have
different toxicities (also see commentary for ibuprofen).
Children may be at increased risk of experiencing liver toxicity under the following circumstances and so
prescribers should take these into consideration when evaluating the specific risk:benefit ratio of
paracetamol therapy for an individual child:
•Co-existing conditions which may be associated with impaired liver function (e.g. dehydration; poor oral
intake; concomitant viral infection; metabolic problems)
•Lack of parental or carer awareness about the different dose strengths of the currently available
paediatric formulations of paracetamol poses a major risk. Every effort should be made to educate
carers appropriately so that the risk of dosing errors and inadvertent overdosing is minimised.
•Co-administration of other products containing paracetamol (e.g. cough and cold remedies). These are
not recommended in young children. Parents should be advised accordingly, and also made aware that
they may contain paracetamol and co-administration with paracetamol poses additional risks of
paracetamol toxicity due to overdosing.
•Co-administration of drugs which induce liver enzymes (e.g. anticonvulsants, anti-TB agents)
Indication 15. Seizure
Drug Name carbamazepine
Dose Form tablet
Directions 100-200mg twice daily
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy varies depending on the individual agent
Safety Profile varies depending on the individual agent
Cost $20-$70 per month
Other Issues Enzyme inducer
FIRST LINE
Carbamazepine is a first line agent for the treatment of generalized tonic-clonic seizures, and is the
preferred agent for partial seizures. When carbamazepine is first commenced, it can cause sedation or
nausea, but tolerance to these adverse effects can develop within a few days. It also induces its own
metabolism (by CYP3A4); this becomes apparent within 3-5 days of therapy and is usually maximal
within 3-4 weeks. This results in a decrease in its half-life from 25-65 hours to 12-17 hours with
repeated dosing and requires a 3-fold increase in dose to maintain the same concentrations.
Consequently, the initial dose is usually low (50-100mg BD) and gradually increased over a month. This
tablet preparation has the advantage that very small doses can be administered eg 50mg twice daily as
an initial dose to the elderly who may be sensitive to its sedative and other CNS effects.
Directions 200-400mg. Increase slowly every 2 weeks if required
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Carbamazepine is one of the first line agents for the treatment of generalized tonic-clonic seizures, and
is the preferred agent for partial seizures. The only advantage of the controlled release preparation is
that it results in lower peak concentrations (it still has to be given twice daily). Thus if patients are
reporting transient symptoms of toxicity (e.g. dizziness), a few hours after a dose, it may reduce these
symptoms. The disadvantage of this preparation is that very small doses cannot be given because the
smallest dose is 200mg and the controlled release preparation cannot be broken.
For this reason it is generally used for maintenance therapy rather than initiation. If changing a patient
from the standard to the controlled release tablets, you may need to use a higher dose to achieve the
same anti-convulsant effect due to reduced bioavailability of the controlled release form. If increasing
the dose, do so at 2 week intervals to allow for the drug's auto-induction.
Drug Name clonazepam
Dose Form tablet
Strength 500 microgram & 2 mg
Directions 0.5 to 8mg in divided doses
Quantity 200 (PBS)
No. of Repeats 2
Drug of choice
Issues
Efficacy Initial agents of choice in status epilepticus, and in drug intoxication
(e.g. cocaine, amphetamines) or alcohol withdrawal seizures.
Safety Profile Can cause sedation and respiratory depression
Cost $20-40/month
Other Issues Long term tolerance
Oral clonazepam is not used in treating generalised tonic-clonic seizures. It is sometimes used as a
second line agent in other epileptic syndromes, e.g. absence seizures. It is associated with sedation,
and there is a risk of tolerance and dependence such that if the drug is suddenly withdrawn, seizures
may be precipitated.
Drug Name clonazepam
Dose Form injection
Strength 1 mg/ 2 mL
Directions 1mg-2mg by slow IV injection
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues

Cost $15 / 5 (PBS)
Other Issues Diazepam alternative for status epilepticus
Clonazepam is an alternative to diazepam in the treatment of status epilepticus. It is more expensive
and there may be a greater risk of accidental overdose, hence it is not frequently used first line for
status epilepticus.
Drug Name diazepam
Dose Form injection
Strength 10 mg/ 2mL
Directions 10 mg/ 2mL
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $10 for 5 amps
Other Issues Used in status epilepticus
FIRST LINE
Diazepam (intravenously or rectally) is first line treatment for the management of status epilepticus.
There is no commercial rectal preparation, but it may be made up by individual hospital pharmacy
departments eg in a children’s hospital. The intravenous formulation can also be given rectally (either
undiluted or diluted with 50% propylene glycol).
Drug Name lamotrigine
Dose Form tablet
Strength 2, 5, 25, 50, 100, 200 mg
Directions Depends on co-medication:
Quantity 56 (PBS)
No. of Repeats 5
Drug of choice
Issues
Cost $60-120 p/month

Other Issues Needs careful dose incrementation
Lamotrigine is an effective agent for the management of a variety of seizure types and can be used as
monotherapy. It is not used first line because its dose needs to be slowly escalated in order to minimise
the risk of rashes. It is also not as effective as carbamazepine, and is much more expensive.
Drug Name midazolam
Dose Form injection
Strength 5 mg/5 mL
Directions Up to 10mg
Quantity .
No. of Repeats
Drug of choice
Issues
Cost Approx. $8 / 5 amps. (hospital)
Other Issues Non Pharm. Benefit.
Midazolam is a benzodiazepine with a relatively short half life. It has the advantage that it can be given
via a number of different routes if intravenous access is not available, such as intranasal, and buccal. It
is not marketed for this indication, but this is a widely accepted use for midazolam. The main
disadvantage of midazolam is its short duration of action and further doses are often required.
Drug Name oxcarbazepine
Dose Form tablet
Directions 300mg twice daily, increasing according to response
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $100-150 per month
Other Issues Simpler dosing than carbamazepine

Oxcarbazepine is a keto-analogue of carbamazepine that itself undergoes metabolism to the active
drug. It is indicated for use as monotherapy or adjunctive therapy for the treatment of partial seizures
and generalised tonic-clonic seizures, in adults and children. It was hoped initially that it would have a
similar efficacy to carbamazepine with easier dosing and fewer adverse reactions. Although the
incidence of adverse reactions may be apparently less than with carbamazepine there is also less data
known on its long-term efficacy and safety. Patients who have had a rash with carbamazepine still have
a 15-30% risk of cross-reactivity with oxcarbazepine. Oxcarbazepine can induce cytochrome P450 3A4
and is an inhibitor of 2C19. One advantage of oxcarbazepine is its easier dosing as it does not induce
its own metabolism and does not require therapeutic drug monitoring. However, given its very high cost
and the minimal advantages that apply to only a few patients, it is largely used as a second-line option
for patients inadequately controlled on first line therapy.
Drug Name phenobarbitone
Dose Form tablet
Strength 30 mg
Directions 60-240 mg/day
Quantity 200 (PBS)
No. of Repeats 4
Drug of choice
Issues
Efficacy Tolerance to the anti-convulsant effect may develop
Safety Profile Sedation and impaired cognition are dose limiting
Cost $5-10/month
henobarbitone is as effective as phenytoin and carbamazepine in partial and generalised tonic-clonic
seizures, but its use is limited by initial sedative effects and possible tolerance to its anticonvulsant
effects. It also induces the metabolism of a number of other drugs. Because of these efficacy, safety
and suitability issues, it is relegated to being 3rd or 4th line.
Drug Name phenytoin
Dose Form injection
Strength 100 mg/2 mL & 250 mg/5mL
Directions 15-20mg/Kg in normal saline infused at less than 50mg/min
Quantity 1
No. of Repeats
Drug of choice
Issues

Cost $10-12
Other Issues Irritant to veins, cardiotoxic with rapid infusion
Intravenous phenytoin is frequently administered to patients presenting with seizures, as their post-ictal
state can preclude ready administration of oral medications, and it allows an effective preventative
therapy to be initiated early. Unfortunately, phenytoin is not very stable in an intravenous formulation,
and has to be dissolved in propylene glycol in a pH of about 12!! Hence it needs to be given fairly
slowly, and can lead to thrombophlebitis.
NOTE: Phenytoin should be loaded on a mg per kilogram basis. The unfortunately widespread practice
of giving every patient a dose of 1000mg IV will often lead to both under and overdosing.
Intravenous phenytoin is frequently administered to patients presenting with seizures, as their post-ictal
state can preclude ready administration of oral medications, and it allows an effective preventative
therapy to be initiated early. Unfortunately, phenytoin is not very stable in an intravenous formulation,
and has to be dissolved in propylene glycol in a pH of about 12!! Hence it needs to be given fairly
slowly, and can lead to thrombophlebitis.
Drug Name phenytoin
Dose Form capsule/tablet
Strength 30, 100 mg (caps), 50 mg (tab)
Directions 4-5mg/kg daily initially
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $20-40 p/month
Other Issues Enzyme inhibitor
Phenytoin is frequently commenced in the acute management of generalized tonic-clonic seizures.
However, (as discussed previously) its long term toxicity, non-linear kinetics and multiple drug
interactions mean it is usually relegated to second or third line for maintenance therapy.
Low dosage products such as 30mg capsules and 50mg tablets are available for the careful adjustment
that is required due to its non-linear kinetics.
Drug Name primidone
Dose Form tablet
Strength 250 mg
Directions 125mg bedtime up to 750mg twice daily
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Tolerance to the anti-convulsant effect may develop
Safety Profile Sedation and impaired cognition are dose limiting
Cost $20/month
Other Issues Enzyme inducer.
Primidone is partly metabolised to phenobarbitone in the body and is also considered to have
antiepileptic activity in its own right. Appears to have more frequent adverse effects than
phenobarbitone.
Drug Name valproate
Strength 200 mg/5 mL
Directions 15mg/kg/day in 2-3 divided doses
Quantity 2 X 300ml (PBS)
No. of Repeats
Drug of choice
Issues
Cost $30-50 p/month
FIRST LINE
Valproate is a first line agent for the treatment of generalized tonic-clonic seizures. It is more simple to
dose than carbamazepine and phenytoin, and is generally well tolerated. It is an enzyme inhibitor that
sets it apart from the other first line agents, but generally the effect of this is mild and is not as
problematic as with carbamazepine or phenytoin. The syrup preparation is useful for patients who
cannot swallow the tablets, but may result in more gastric irritation.
If used in early pregnancy, it is associated with a higher rate of neural tube and other birth defects.
Hence special consideration needs to be given when used to woman of reproductive age.
Drug Name valproate
Dose Form tablet, plain & enteric-coated
Strength 100 mg crushable, 200, 500 mg enteric-coated
Directions 15mg/kg/day in 2-3 divided doses
Quantity 200 (PBS)

No. of Repeats
Drug of choice
Issues
Cost $30-50 p/month
Valproate is a first line agent for the treatment of generalized tonic-clonic seizures. It is more simple to
dose than carbamazepine and phenytoin, and is generally well tolerated. It is an enzyme inhibitor that
sets it apart from the other first line agents, but generally the effect of this is mild and is not as
problematic as with carbamazepine or phenytoin. It is generally administered as an enterically coated
tablet which reduces gastric irritation.
If used in early pregnancy, it is associated with a higher rate of neural tube and other birth defects.
Hence special consideration needs to be given when used to woman of reproductive age.
Indication 16. Polypharmacy in multiple system failure
Dose Form tablet
Strength 1 mg
Directions 0.5-4 mg 1-2 times daily
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Most potent and are the diuretics of choice in heart failure.
Safety Profile Electrolyte disturbances.
Cost $10 approx.
An alternative loop diuretic to frusemide. However, it still has a sulphonamide moiety, hence patients
who are allergic to frusemide for this reason, may still not tolerate bumetanide and ethacrynic acid
should be considered.
Drug Name captopril

Directions 12.5-50mg bd
No. of Repeats 5
Drug of choice
Issues
Efficacy Extensive evidence of benefits in prolonging survival and reducing
morbidity in left ventricular dysfunction
Cost $21- $32
particular clinical situations e.g. post-myocardial infarction, post-stroke.
Captopril is rarely used in the long term management of hypertension because of its short half life and
the need for multiple daily dosing. It may be used to commence patients on an ACE-I if the patient is
particularly susceptible to the adverse effects of an ACE-I e.g. underlying renal impairment, on high
dose diuretic, aortic stenosis. In these circumstances, they are no less likely to develop these adverse
reactions with captopril, but should they occur, it is not going to last as long as with an ACE-I with a
longer half life.
This makes it a useful addition to a P drug list.
Drug Name diazepam
Dose Form tablet, oral liquid, supp, rectal solution, injection
Strength 2 mg & 5 mg tablets; 1 mg/mL, 100 mL oral liquid; 10 mg supp; 1

mg/mL; 5 & 10 mL rectal solution; 5 mg/mL, 2 mL injection
Directions 1-2 tablets up to 3 times per day
Quantity 50 tablets, 100 mL oral liquid, 20 supp, 5 mL & 10 mL rectal

solution, 5 & 50 injections
No. of Repeats
Drug of choice
Issues
Efficacy Hypnotic and anxiolytic properties.
Safety Profile Long term use likely to result in tolerance and dependence.
Cost $7.42 - $7.64 tablets, $11.05 injections (5 mL)
Diazepam is a long acting (half life >24 hours) benzodiazepine. In the elderly it carries an increased risk
of over-sedation, falls and memory impairment. Use low doses of a short or medium acting preparation
to avoid hangover effect.

Drug Name digoxin
Dose Form tablet
Strength 62.5 & 250 micrograms
Directions 62.5-250mcg/day
Quantity 200 (62.5 micrograms), 100 (250 micrograms) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Second line in heart failure (useful if atrial fibrillation also present).
Safety Profile Narrow therapeutic index.
Cost $17 - $33
Maintenance dose needs to be at the lower end of the range in the elderly and those with renal
impairment. Therapeutic drug monitoring is helpful in avoiding toxicity. When commencing treatment or
changing dose it is necessary to wait for 4-5 half lives (5-7 days) for steady state to be reached. Blood
should be taken at least 6 hours after the last dose to allow for redistribution.
Drug Name enalapril
Dose Form tablet
Strength 2.5, 5,10 & 20 mg
Directions 5-20mg bd
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $21-25
The ACE-inhibitors all appear to have similar clinical efficacy, and the decision for what to prescribe is
usually based on whether it can be dosed once daily or not, cost, and for some clinicians, proven
efficacy in particular clinical situations e.g. post-myocardial infarction, post-stroke.
Enalapril has extensive evidence particularly in heart failure, but is not favoured in hypertension as it
really should be given twice daily. It is renally cleared.

Drug Name frusemide
Dose Form tablet
Directions 10-40mg up to twice daily
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Most potent and are the diuretics of choice in heart failure.
Safety Profile Electrolyte disturbances.
Cost $13- $23
hypertension proves resistant, or for comorbid cardiac failure or oedematous states e.g. liver disease,
maintain naturesis
Drug Name glibenclamide
Dose Form tablet
Strength 5 mg
Directions 2.5 mg daily up to 10 mg bd
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Stimulate pancreatic insulin release. Work best when food is
ingested. All of them are equally efficacious in equivalent doses.
Those with longer half-lives and renally excreted active metabolites
(glibenclamide and glimepiride) have longer lasting actions and can
be given once a day.
Safety Profile Hypoglycaemia if too high a dose is given or removal by metabolism

or renal excretion is slowed. Weight gain. Other side effects are
minor but sulphonylureas can cause allergic rashes. These are rare
and do not appear to cross react with sulphonamide allergies.
Cost $12.70
Other Issues General Pharm. Benefit (5mg)
Glibenclamide is the most likely to cause hypoglycaemia possibly because it is the most potent; tablets
are 5 mg and starting dose should be 2.5 mg. Also it has very active metabolites which are excreted by
the kidney and accumulate in renal impairment. It has been shown to have a greater risk for
hypoglycaemia then glipizide (or the recently discontinued short acting tolbutamide) (Ferner & Neil). ALL
sulphonylureas should be given with or before food to increase efficacy and potentially reduce risk of
hypoglycaemia.
References
Ferner RE, Neil HA. Sulphonylureas and hypoglycaemia. Br Med J - Clinical Research 1988; 296: 949-
50
Salas M, Caro JJ. Hypoglycaemia and other adverse effects similar among sulfonylureas? Drug React
Toxicol Rev 2002; 21: 205-217
Drug Name gliclazide
Dose Form tablet, CR tablet
Strength 80 mg, Controlled release 30 mg
Directions 40 mg daily up to 160 mg bd; 30 mg daily up to 120 mg/day (MR)
Quantity 100
No. of Repeats
Drug of choice
Issues

Cost $14.73
Studies have shown that gliclazide which is metabolised by the liver and has no demonstrated active
metabolites, is less likely than glibenclamide to cause hypoglycaemia. It has a new Modified Release
formulation (30 mg compared with 80 mg) that is intended to last for 24 hours. Unpublished experience
suggests that its hypoglycaemic action might not last for this long in many patients.
Drug Name glimepiride
Dose Form tablet
Strength 1 mg,2 mg, 3mg & 4 mg
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues

Cost $10.13 (1 mg) to $15.49 (4 mg).
Glimepiride is long acting, has renally excreted active metabolites, is given once a day. One study has
shown it less likely than glibenclamide to cause hypoglycaemia but no comparative data are available
with other agents.
References
Holstein A et al. Lower incidence of severe hypoglycaemia in patients with type 2 diabetes treated with
glimepiride versus glibenclamide. Diabetes Metab Res Rev 2001; 17: 467-473
Drug Name glipizide
Dose Form tablet
Strength 5 mg
Directions 2.5 mg daily up to 20 mg bd
Quantity 100
No. of Repeats
Drug of choice
Issues

Cost $12.70
Glipizide is short acting, may be given 2 or 3 times a day, is completely metabolised by the liver and has
no active metabolites. It is therefore the available drug most equivalent to the recently discontinued
tolbutamide. This latter agent was generally considered the least likely to cause hypoglycaemia.

Drug Name lorazepam
Dose Form tablet
Strength 1 mg, 2.5 mg
Directions 1-2 mg at night
Quantity 50
No. of Repeats
Drug of choice
Issues
Cost Approx. $8.50 (2 & 5 mg)
* indicated for insomnia associated with anxiety.
* long term use of benzodiazepines may result in tolerance and dependence
* suddenly stopping treatment in dependent people may produce withdrawal symptoms, including
anxiety and insomnia
* withdrawal symptoms may not occur until several days after stopping, and can last for several
weeks
Drug Name metformin
Dose Form tablet
Strength 500 mg
Directions 1g three times daily.
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective oral hypoglycaemic.
Safety Profile Do not use in renal impairment.
Cost Approx. $16/100
Reduces hepatic glucose production and increases peripheral glucose utilisation. Lactic acidosis is a
rare complication which is usually predictable and caused by metformin accumulation when
contraindications overlooked (e.g. renal or hepatic impairment, moderate-severe cardiac failure, major
illness, surgery, IV radiographic contrast given in renal impairment).
Renally cleared. Do not use if creatinine clearance is less than 30ml/min, and adjust maximum dose if
there is any renal impairment. (See AMH dosing guide.)
Dose Form tablet
Strength 500 mg
Directions 500-1000 mg every 4-6 hours500-1000 mg every 4-6 hours
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Moderate
Safety Profile Exceeding maximum recommended daily dose of 4g carries risk of

acute liver damage
Cost Approx. $10/ pack (liquid) & $9/ 100 (tabs.)
Other Issues Paracetamol is a p-aminophenol derivative that exhibits analgesic

and antipyretic activity.
Paracetamol is an effective analgesic for acute pain, and provided that it is not excessively dosed has
similar adverse reactions to placebo! Oral form not helpful to a patient who is vomiting, under these
circumstances use an intravenous formulation.
Drug Name potassium chloride
Dose Form sustained release tablet.
Strength 600 mg
Directions 600 to 3600mg orally, daily in divided doses depending on the

plasma level.
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Used to treat hypokalaemia associated with potassium losing
diuretics.
Safety Profile Beware hyperkalaemia if used with ACE inhibitors or potassium

sparing diuretics.
Cost Approx. $12/ 200
Potassium supplements should hardly be needed these days. That is because if a loop diuretic is being
prescribed, then almost always an angiotensin converting enzyme inhibitor (or similar) will also be
needed, which will help balance the potassium concentration.
Drug Name ramipril
Dose Form tablet
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $15-30
Ramipril is preferred by some clinicians as it has a long half life, and has been proven in a number of
different clinical trials. Unfortunately, currently there is a patient premium associated with its use
because of its higher price.
It is one of the few ACE-I that also has a component of hepatic excretion.
Drug Name temazepam
Dose Form tablets
Strength 10 & 20 mg
Quantity 25
No. of Repeats
Drug of choice
Issues
Cost $10 - 20 per packet
Other Issues General PBS
* marketed for short term treatment of insomnia
* short acting
* IV abuse of gelatin capsules has been a concern
weeks
Dose Form capsule
Directions 1-4mg mane
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $20-30
Trandolapril has the longest half life of the ACE-I and is preferred by some clinicians for this reason.
The only other comment to make about trandolapril are the unusual brand names: Odrik, Gopten and
now Tarka (as a combination with Verapamil). Sound like the sort of medications you would buy over
the internet from a bloke called Borat in Khazhakstan.
Drug Name verapamil
Directions 80 to 160mg two or three times daily.
Quantity 30 (PBS)
No. of Repeats 5
Drug of choice
Issues
Cost $0.50-1.10/day
Verapamil is indicated for the relief of ongoing ischemic symptoms where beta-blockers are
contraindicated e.g. asthmatic patients. (Its use is contraindicated, however, in patients who are already
on beta-blockers due to the combined negative chronotropic and inotropic effects of these agents).
Indication 17. Anaemia
Drug Name cyanocobalamin
Dose Form tablet
Directions 100 micrograms BD (prevention)
Quantity 75
No. of Repeats
Drug of choice
Issues
Efficacy Essential nutrient required for red blood cell production – a good
response is expected in all deficiency states.
Safety Profile There are no important safety issues with oral or IM preparations.
Cost $25-50/75
Other Issues n/a
Used only occasionally for long-term prevention in diets devoid of vitamin B12 (vegans).
Essential for haematopoeisis
Vitamin B12 is an essential element required for erythropoeisis and neuronal function. It is required for
DNA synthesis and other essential metabolic functions. For most causes of vitamin B12 deficiency
lifelong replacement is required.
There are 2 forms of vitamin B12 available, hydroxocobalamin and cyanocobalamin.
Mode of action
Essential for nerve development, nucleic acid synthesis and normal erythropoiesis.
Indications
Prevention and treatment of vitamin B12 deficiency
Treatment of optic neuropathies, eg tobacco amblyopia and Leber's optic neuropathy
(hydroxocobalamin only)
Coexisting conditions
Malabsorption—do not use oral vitamin B12.
Pregnancy
Safe to use if indicated. Megaloblastic anaemia in pregnancy is usually due to folate deficiency.
Breastfeeding
Safe to use; should be given to breastfeeding women who are strictly vegetarian (vegan).
Adverse effects
Rare
hypokalaemia and cardiac arrest (with high doses), allergy (including itch and anaphylaxis)
Dosage
The following doses apply to both adults and children.
Initial treatment of vitamin B12 deficiency
IM 1000 micrograms on alternate days for 1–2 weeks or until improvement occurs.
Prevention and maintenance treatment of vitamin B12 deficiency
Cyanocobalamin, IM 1000 micrograms once a month.
$25-50/75
Drug Name ferrous fumarate/ folic acid combination
Dose Form tablet
Strength 310 mg ferrous fumarate/ 350 microgram folic acid
Directions 1 - 2 tablets daily
Quantity 60
No. of Repeats
Drug of choice
Issues
response is expected in all simple deficiency states.
Safety Profile There are no important safety issues with oral preparations in iron
deficient individuals but there are occasional severe infusion
reactions.
Cost up to $17.63
Other Issues 310 mg ferrous fumarate contains 100 mg elemental iron
Essential for RBC production
Safety: occ severe infusion reactions
Cost: up to $17.63
310mg ferrous furamate contains 100mg elemental iron
Indication: Where haematopoiesis is rapid, folate stores may occasionally be rate limiting
Drug Name ferrous sulfate

Dose Form MR tablet
Strength 325 mg
Directions 1-2 tablets daily
Quantity 30
No. of Repeats
Drug of choice
Issues
reactions.
Cost $5-10/30-60
Other Issues 325 mg dried ferrous sulfate contains 105 mg of elemental iron
Essential for haematopoeisis, expect good response
Nil important safety data
$5-10/30-60
Iron is an essential element required for the formation of haemoglobin and myoglobin. Acute overdose
or long-term excessive use in non-iron deficient people may lead to very serious adverse events and the
diagnosis of iron deficiency should always be confirmed with laboratory iron studies. However, it is safe
and extremely effective when used to reverse iron deficiency.
Mode of action
Essential element required for the formation of haemoglobin and myoglobin.
Indications
Prevention and treatment of iron deficiency
Treatment of iron deficiency anaemia in people on haemodialysis receiving epoetin
Combination with folic acid
Prevention and treatment of iron and folate deficiency, eg during pregnancy
CI: Haemochromatosis
Anaemia not due to iron deficiency
Allergy to parenteral
Specific considerations
Coexisting conditions
Transfusion-dependent anaemias—risk of iron overload; avoid iron supplementation.
GI disease—may be exacerbated by oral iron.
Safe to use in pregnancy (not parenteral in first trimester)
Adverse effects
Common
Oral, abdominal pain, nausea, vomiting, constipation, diarrhoea (all dose-related), black discolouration
of faeces
Infrequent
IM, pain, inflammation and discolouration at injection site
IV, taste change, nausea, vomiting, headache, arthralgia, myalgia, tachycardia, sweating,
bronchospasm, hypotension, chest pain, rash, angioedema
Oral liquid, black discolouration of teeth
Rare
IV/IM, anaphylaxis
Oral, GI erosion and perforation with high doses
Overdose
Excessive iron intake (>20 mg/kg elemental iron) may result in toxicity (vomiting, diarrhoea,
hypotension, tachycardia, acidosis, CNS depression). Treat with whole bowel irrigation; desferrioxamine
may be necessary
Adult, 100–200 mg daily.
Accidental overdose can be very serious, even fatal, in children. Store out of reach and sight, tightly
closed.
Absorbed best if taken on an empty stomach 1 hour before, or 2 hours after, food. If it upsets your
stomach, it can be taken with or shortly after food. Avoid taking oral iron supplements with tea or coffee.
Dilute oral liquid with water and drink through a straw to prevent discolouration of teeth.
GI adverse effects may be reduced by starting at a low dose and gradually increasing, or by taking
smaller doses more frequently
controlled release preparations are claimed to have fewer GI adverse effects, but may also have lower
bioavailability
oral and parenteral iron should not be used together
105 mg iron
Drug Name folic acid
Dose Form tablet
Strength 5 mg
Directions 5 mg daily
Quantity 200 (PBS)
No. of Repeats 1
Drug of choice
Issues
Safety Profile There are no important safety issues with oral preparations in folate
deficient individuals, except co-existent B12 deficiency (if present)
must also be treated.
Cost $7.66/200 (PBS)
Other Issues
Efficacy: Essential nutrient required for RBC production - expect good response
Safety profile: no important safety issues with oral preparations, except treat co-existent B12 deficiency
if present.
Folate is an essential element required for erythropoeisis. It is required for DNA synthesis and other
essential metabolic functions. It is necessary to exclude vitamin B12 deficiency before using folic acid
alone to treat megaloblastic anaemia; high doses of folic acid can correct the anaemia of vitamin B12
deficiency without preventing the associated neurological damage.
Mode of action: Required for synthesis of purine and pyrimidine bases (DNA) and for amino acid
metabolism and normal erythropoiesis. Involved in the maturation of all rapidly proliferating tissues.
Important for embryonic organogenesis, particularly neural tube closure.
Indications: Treatment of folate-deficiency anaemia. Prevention of folate deficiency during pregnancy,
thereby preventing fetal neural tube defect
Combination: Prevention and treatment of iron and folate deficiency, particularly during pregnancy
Accepted indications: Prevention of folate deficiency during chronic haemolysis and renal dialysis.
Prevention of methotrexate adverse effects in treatment of rheumatoid arthritis and psoriasis.
$7.66/200
Directions for use: Take one table daily, represent to doctor

In practice:
exclude vitamin B12 deficiency before using folic acid to treat megaloblastic anaemia
causes of folic acid deficiency include inadequate diet, malabsorption (gluten enteropathy, tropical
sprue), increased utilisation (pregnancy, prematurity, malignancy, chronic haemolysis, myelofibrosis),
increased loss (renal dialysis)
Drug Name hydroxocobalamin
Dose Form injection
Directions 1000 micrograms IM second alternate days x 7 doses then 2-3

monthly
Quantity 2 (PBS)
No. of Repeats
Drug of choice
Issues
response is expected in all deficiency states.
Safety Profile There are no important safety issues with oral or IM preparations.
Cost $11.26 (PBS)
Other Issues n/a
Lifelong treatment usually required.
$11.26 (PBS)
•confirm diagnosis and cause of vitamin B12 deficiency before use; vitamin B12 use may mask clinical
and haematological features of folate deficiency
•causes of vitamin B12 deficiency include pernicious anaemia, total or partial gastrectomy, ileal disease
or resection, drugs, inadequate diet (vegan)
•pernicious anaemia or bowel resection requires lifelong treatment with vitamin B12 injection
•IM hydroxocobalamin produces a greater and more sustained increase in serum vitamin B12 than does
the same dose of cyanocobalamin
•monitor potassium concentration during initiation of vitamin B12 treatment, and correct hypokalaemia
as needed
•monitor vitamin B12 and blood count every year
•hydroxocobalamin combines with cyanide to form cyanocobalamin; a high-strength hydroxocobalamin
product is available via the SAS for the treatment of cyanide toxicity; administer according to local
protocols
Treatment of Leber's optic atrophy and tobacco amblyopia
Use in malabsorption states
Drug Name IRON Sucrose
Dose Form inj
Strength 20mg/mL, 5mL
Directions 100 mg IM/IV every 2 days until total dose administered
Quantity 5
No. of Repeats
Drug of choice
Issues
reactions.
Cost $33
Other Issues PBS Authority
Use only where oral administration is not possible or contraindicated. Less adverse effects than iron-
polymaltose complex but far more expensive PBS authority is very restricted –“ iron deficiency anaemia,
with either epoetin alfa or darbepoetin alfa, in patients undergoing chronic haemodialysis with a
documented hypersensitivity reaction to iron polymaltose and in whom continued IV iron therapy is
appropriate.”
PBS authority
$33
Drug Name Iron-polymaltose complex
Dose Form injection
Strength 50mg/mL, 2mL
Directions 100 mg IM/IV every 2 days until total dose administered
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
reactions.
Cost $52.29 / 5 (PBS)
Other Issues Reserved for use where oral iron is ineffective
Use only where oral administration is not possible or contraindicated. May be given IM or IV, but IM is
safer (even if painful).
$52.29 /5
Reserved for use where oral iron is ineffective
Indication 18. Anticoagulation in Atrial Fibrillation
Drug Name aspirin
Dose Form tablet
Directions 75-300 mg per day
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Less effective than anticoagulants
Safety Profile Less bleeding than anticoagulants
Cost $1.80 p/month
Less effective than anti-coagulants
Less bleeding cf anti-coagulants
$1.80 per month
Small risk of bleeding
Aspirin is the most commonly used antiplatelet agent because it is readily available and inexpensive. In
randomised trials it reduces the risk of stroke with AF by about 20%. It is associated with an
approximate 0.5% per year risk of serious adverse effects even at the lowest doses.
Dose Form tablet
Strength 75 mg
Directions 75 mg daily
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Less effective than anticoagulants
Safety Profile Less bleeding than anticoagulants
Less effective than anticoagulants, but use in hypersensitivity
Less bleeding
Approx $90/month
Efficacy and bleeding risk similar to aspirin.
Because of its cost, clopidogrel is usually indicated in situations where there is aspirin hypersensitivity
or if there is evidence of gastrointestinal toxicity, e.g. gastric ulcers due to aspirin. In patients with other
vascular conditions, it is only marginally more effective than aspirin, but certainly not enough to justify its
cost. It is important to note that the overall bleeding risk is the same with clopidogrel as with aspirin, and
that it only has the advantage of being less likely to cause gastrointestinal ulceration. There are certain
circumstances in which it is beneficial to combine aspirin and clopidogrel together. Currently AF is not
one of them. The evidence is that the combination is not as good as warfarin and we have evidence that
adding clopidogrel to aspirin increases the risk of bleeding by about 1% per year, but there is currently
no evidence for how much it might reduce the risk of stroke (until the ACTIVE study is completed).
Directions 1 mg/kg twice daily
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective anticoagulants but untested in AF
Safety Profile Uncertain long term risk but thought to be similar to warfarin
Cost $33
Effective anticoagulant but untested in AF
Uncertain long term risk but thought similar to warfarin
$33
Prevention of DVT
Enoxaparin is a commonly prescribed low molecular weight heparin for parenteral anticoagulation. It
has fairly simple dosing, does not require APTT monitoring, and is an effective anticoagulant. However,
because it is given subcutaneously, and it does not bind well to protamine, it can be difficult to reverse
in cases of bleeding.
Enoxaparin is frequently used in the management of recent onset AF, until decisions regarding
cardioversion, etc are determined.
It can also be used for long term anticoagulation in patients in whom warfarin would be difficult to
manage (e.g. those who cannot manage warfarin dosage alterations, who have wildly variable INRs and
warfarin doses, etc). In these cases twice daily enoxaparin administration at a fixed dose may be easier
to manage. Note, however, that the evidence base for enoxaparin in this setting is very poor and that
the risk of bleeding due to the anticoagulant itself would be the same as warfarin.
Drug Name warfarin
Dose Form tablet
Strength 1, 2, 3 & 5 mg
Directions Variable dosing
Quantity 50 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Very effective in preventing strokes
Safety Profile Bleeding risk
Cost $0.15-0.30 per day (monitoring not included)
Other Issues Oral agent that takes many days to achieve anti-coagulation effect.
Effective in preventing strokes
Bleeding risk
$0.15-$0.30 per day (not including monitoring)
May take many days to achieve anti-coagulant effect.
Warfarin is the only drug to consider in this class (another called phenindione is also available but only
used in specialist cases). Warfarin has a number of properties which makes its dosing very variable
between patients and also within the same patient at different times: it acts indirectly via a mechanism
which is influenced by Vitamin K intake in the diet, it is hepatically metabolised by enzymes which
exhibit a large degree of variability in the community, it has a number of drug-drug, -food, and disease
interactions, and many others. It also requires monitoring with INRs, and regular dosage adjustments,
which requires a high level of concordance and cooperation from the patient. For this reason, long term
anticoagulation for the patient represents quite a social and behavioural undertaking. There are now a
number of tools for predicting the risk of bleeding with warfarin. These tools are only appropriate for
patients who do not have a contraindication to warfarin! The most validated is the Outpatient Bleeding
Risk Index: score 1 point for each of age 65, history of gastrointestinal bleeding, history of stroke, and
one or more of either myocardial infarction, hematocrit <30%, creatinine >130 µmol/L, or diabetes. At 1
year the risks of major bleeding are : 3% for a score of 0, 12% for a score of 1-2, and >20% for a score
of 3-4.
Indication 19. Prophylaxis in deep venous thrombosis

Drug Name dalteparin
Strength 7,500/0.75 mL & 10,000 units/ mL
Directions 2500 or 5000 units daily
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective for VTE prophylaxis
Safety Profile Acceptable increase in bleeding risk
Cost approx. $11/10,000 units
Other Issues Twice daily subcutaneous injection
Subcutaneous injection
7,500/0.75 mL & 10,000 units/ mL
2500 or 5000 units daily
10 (PBS) (repeat 1 (PBS))
approx. $11/10,000 units
Twice daily subcutaneous injection
LMWH: for prevention of VTE, no advantage over enoxaparin; given OD; recommended for all but low
risk pts. DOSE: 2500 units OD for moderate risk, and 5000 units OD for high risk. Similarly associated
with lower risk of HITS cf UFH.
Inactivate clotting factors IIa (thrombin) and Xa by binding to antithrombin III; LMWHs and danaparoid
have a much greater effect on factor Xa than on thrombin. Danaparoid is a more selective inhibitor of
factor Xa than LMWHs.
Indications:
Marketed: Prevention VTE in surgical patients; Rx venous thrombosis; Prevention extracorporeal
thrombosis during haemodialysis; Rx unstable angina and non–Q-wave MI
Accepted: Pregnancy when full anticoagulation required (seek specialist advice); Treatment of
pulmonary embolism
Contraindications: Severe thrombocytopenia with heparin or LMWH (danaparoid may be used);

Bleeding disorders, including haemophilia; Thrombocytopenia; Peptic ulcer; Cerebral haemorrhage;
Severe uncontrolled hypertension; Severe hepatic disease, including oesophageal varices; Bacterial
endocarditis; Major trauma or recent surgery (particularly at sites where bleeding would pose a serious
risk, eg eye or CNS)
Use LMWHs (dalteparin, enoxaparin) with caution, monitor clinical condition and antifactor Xa levels;
consider dosage reduction when creatinine clearance is <30 mL/minute
Directions 20 or 40mg daily
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $33
S/C injection Between 20-120mg 20-40mg 10(PBS) 1 $33 Prevention of DVT
Enoxaparin is a commonly used low molecular weight heparin. It has been extensively evaluated for the
prevention of venous thrombombolism, and is recommended for all levels of risk apart from low risk
patients. The recommended dosing is 20mg for moderate risk surgical patients and 40mg for high risk
medical and surgical patients. In patients with a calculated creatinine clearance of <30ml/minute, the
recommended dose is 20mg once daily. As it can be given once daily, it is more convenient for both the
patient and nursing staff. Enoxaparin is associated with a lower risk of HITS than unfractionated
heparin.
Inactivate clotting factors IIa (thrombin) and Xa by binding to antithrombin III; LMWHs and danaparoid
have a much greater effect on factor Xa than on thrombin. Danaparoid is a more selective inhibitor of
factor Xa than LMWHs.
Drug Name Fondaparinu
Dose Form Injection
Strength 2.5 mg/0.5 mL
Directions 2.5mg daily
Quantity 1
No. of Repeats
Drug of choice
Issues
Efficacy Less proven efficacy in VTE prophylaxis
Safety Profile Appear to have similar safety to heparins
Cost $17 per day
Other Issues PBS authority for major hip and knee replacement surgery
Injection 2.5 mg/0.5 mL 2.5mg daily 1 n/a $17 per day PBS authority for major hip and knee
replacement surgery Fondaparinux is a recently approved agent for the prevention of venous
thromboembolism. It has been shown in a number of clinical trials to be more effective in preventing
VTE than low molecular weight heparins, however it is substantially more expensive, and the trials have
not shown a difference in clinical (rather than asymptomatic radiographic) events. It also has to be
strictly given at least 6 hours after surgical closure, as in the trials there was a substantially higher risk
of bleeding in patients in whom it was given prior to this time.
It is renally cleared and the risk of bleeding is increased in patients aged >75, body weight <50kg, or
moderate renal impairment (creatinine clearance 30-50ml/min). It should not be used in patients with
creatinine clearance <30ml/min.
Due to its cost it is only PBS subsidised for high risk patients such as hip or knee surgery.
Drug Name unfractionated heparin
Dose Form IV injection

Strength 35,000 units in 35 ml
Directions 5000 units subcutaneously 2-3/day
Quantity 12 PBS
No. of Repeats
Drug of choice
Issues
Cost approx. $12/35,000 unit amp
Other Issues Intravenous infusion and dose has to be titrated to achieve target
APTT
IV injection 35,000 units in 35 ml 5000 units subcutaneously 2-3/day 12 PBS 5 approx. $12/35,000 unit
amp
Acceptable increase in bleeding risk
IV infusion and dose titrated to achieve target APTT
Indication 2. Peptic ulceration with H. pylori
Drug Name esomeprazole
Dose Form tablet
Strength 20, 40 mg
Directions 20mg twice daily (for H. Pylori eradication); Initially, oral/IV 20 mg

once daily for 4–8 weeks; change from IV to oral treatment as soon
as possible. In severe oesophagitis, increase oral dose to 40 mg
once daily for a further 4 weeks if response inadequate.
Maintenance, oral, reduce to minimum required. Child 10–20 mg
once daily for up to 8 weeks.
Quantity 30
No. of Repeats
Drug of choice
Issues
Efficacy Effective for ulcer healing, reflux oesophagitis and NSAID ulcer
prevention.
Safety Profile May mask symptoms and delay diagnosis of gastric carcinoma.
Drug interactions can occur.
Cost $32.90
Other Issues S-isomer of omeprazole
Esomeprazole (the S-stereoisomer of omeprazole) At high doses, is better at controlling symptoms of
reflux disease than other agents. However, no advantage demonstrated in terms of safety or efficacy.
Irreversibly inactivate the hydrogen/potassium ATPase enzyme system (proton pump), suppressing
both stimulated and basal acid secretion. When PPIs are stopped, acid secretion is restored by
synthesis of new hydrogen/potassium ATPase.
AE: alopecia, confusion, paraesthesia
PPIs are generally well-tolerated. Recent evidence suggests an association between PPIs and
increased risk of C.difficile infection, commonly-acquired pneumonia and fracture (long term use).
These adverse effects may be rare and difficult to predict.
Drug Name famotidine
Dose Form tablet
Strength 20 & 40 mg
Directions Initial - oral 40 mg in the evening night for 4-8 weeks
Quantity 60 (20 mg), 30 (40 mg) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Moderately effective. 80-90% ulcer healing at 4-6 weeks.
Safety Profile Dosage reduction is rarely required except for severe renal
impairment
Cost $20
Cimetidine, famotidine, nizatidine and ranitidine are the histamine H2-receptor antagonists presently
available in Australia. All four agents are well absorbed orally, although their absorption is reduced by
concurrent administration of antacids. The approximate plasma half-life of famotidine is 3 hours. All four
agents are principally renally excreted, so dose reductions may be required in patients with significant
renal impairment. Adverse effects are uncommon with these agents, but all of them can occasionally
cause blood dyscrasias and skin rashes.
Drug Name lansoprazole
Dose Form capsule
Strength 15 and 30 mg
Directions 30 mg daily for 4 weeks (duodenal ulcer) or 8 weeks (gastric ulcer)
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention.
Cost Approx.$21 (15 mg) & $31 (30 mg)
Other Issues Restricted Pharm. Benefit.
Omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole are the proton pump inhibitors
presently available in Australia. They inhibit the enzyme hydrogen potassium adenosine triphosphatase,
thus suppressing acid secretion irrespective of the stimulus to acid production. They have no significant
direct effect on acetylcholine or histamine receptors. They have also been shown to heal ulcers more
rapidly than other antiulcerants.
Lansoprazole is well absorbed and exhibits high bioavailability. It is extensively metabolised in the liver,
and the metabolites are excreted by the renal and biliary routes. Despite its short plasma half-life (1 to 2
hours),lansoprazole produces prolonged acid suppression for up to 24 hours.
Lansoprazole is a weak inducer of cytochrome P450, but while there is a possibility of interactions with
other drugs metabolised by this system, no clinical effects have been observed with diazepam,
phenytoin or warfarin.
Drug Name nizatidine
Dose Form Capsule
Directions Initial - 300 mg daily as a single evening dose or 2 divided doses for
4-8 weeks
Quantity 60 (150 mg) , 30 (300 mg ) (PBS)
No. of Repeats
Drug of choice
Issues
impairment
Cost $23
concurrent administration of antacids. The approximate plasma half-life of nizatidine is 1.5 hours.
Nizatidine is principally renally excreted, so dose reductions may be required in patients with significant
renal impairment.
Adverse effects are uncommon with these agents, but all of them can occasionally cause blood
dyscrasias and skin rashes.

Drug Name omeprazole
Directions 20 mg once daily for 4 weeks (duodenal ulcer) or 4-8 weeks (gastric
ulcer)
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention.
Cost Approx $30
Other Issues Restricted Pharm.Benefit
Omeprazole has rather poor and variable bioavailability, which increases as gastric acid secretion is
inhibited. Despite its short plasma half-life (40 minutes), omeprazole produces prolonged acid
suppression for up to 24 hours. It is almost entirely metabolised in the liver to inactive metabolites which
are renally excreted. Omeprazole has slight, but significant, inhibitory effects on hepatic oxidative
enzymes, and has been shown to significantly reduce the metabolism of phenytoin and warfarin.
Drug Name pantoprazole
Dose Form tablet
Directions 40 mg once daily for 4 weeks (duodenal ulcer) or 4-8 weeks (gastric
ulcer)
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention.
Cost Approx. $20 (20 mg) & $33 (40 mg)

Other Issues Restricted Pharm. Benefit
Despite its short plasma half-life (1 hour), pantoprazole produces prolonged acid suppression for up to
24 hours.
Drug Name Proton Pump Inhibitor (PPI), amoxycillin and metronidazole
Dose Form oral
Strength mixed
Directions PPI standard dose(bd), amoxycillin 500 mg (tds) and metronidazole

400 mg (tds) for 14 days
Quantity 14-day supply
No. of Repeats
Drug of choice
Issues
Efficacy >80-90% eradication rates.
Safety Profile Side effects vary with combination used.
Cost ~$40 for 7 days
Other Issues Second line therapy. Each drug has to be individually prescribed.
Currently second line therapy when clarithromycin is not suitable. Metronidazole has relatively high
rates of pretreatment resistance and combinations containing it have a greater risk of treatment failures.
Adverse effects may also be more common with metronidazole compared to other antibiotics.
Drug Name Proton Pump Inhibitor (PPI), clarithromycin and amoxycillin
Dose Form tablets/capsules
Strength mixed
Directions PPI standard dose, amoxycillin 1000 mg, clarithromycin 500 mg all
twice daily for 7 days
Quantity 7 day pack (PBS)
No. of Repeats
Drug of choice
Issues
Cost Approx.$32/ pack
Other Issues First line therapy. Can be prescribed as a single product (Klacid Hp
7, Nexium Hp7)
Clarithromycin-containing regimens are rated as first line therapy and offer the most convenient dosing
regimens. H. pylori resistance to clarithromyin in Australia is presently ~20%. Most studies from which
eradication rates are quoted employed omeprazole, although other PPIs are likely to be equally
effective. Eradication rates are >90%, however, this is currently the most expensive regimen.
Drug Name Proton Pump Inhibitor (PPI), clarithromycin and metronidazole
Strength mixed
Directions PPI standard dose, clarithromycin 500 mg, metronidazole 400 mg,
all twice daily for 7 days.
Quantity 7 days treatment
No. of Repeats
Drug of choice
Issues
Cost ~$70
Other Issues Not PBS subsidised. Use in cases of penicillin intolerance or allergy.
Metronidazole is used in combination with another antimicrobial (amoxycillin, clarithromycin or
tetracycline), and an acid suppressant (proton pump inhibitor or H2 antagonist) for second line therapy
and for treatment failures in the eradication of Helicobacter pylori. It may be used in cases of penicillin
allergy or intolerance. It has relatively high rates of pre-treatment resistance and combinations
containing it have a greater risk of treatment failures (eradication rates >80%).
Drug Name rabeprazole
Dose Form tablet
Directions 20 mg once daily for 4-8 weeks
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention.
Cost $33.30
Other Issues Restricted Pharm Benefit
Despite its short plasma half-life (1 hour), rabeprazole produces prolonged acid suppression for up to 24
hours.
Drug Name ranitidine
Dose Form tablet
Directions Initial - 300 mg daily as a single evening dose or 2 divided doses, for
4-8 weeks
Quantity 60 (150 mg ), 30 (300 mg) (PBS)
No. of Repeats
Drug of choice
Issues
impairment
Cost $20
concurrent administration of antacids. The approximate plasma half-life of ranitidine is 2 hours.
Ranitidine is principally renally excreted, so dose reductions may be required in patients with significant
renal impairment.
Adverse effects are uncommon with these agents. but all of them can occasionally cause blood
Effervescent tablets (150 mg) or syrup (150 mg/10 mL) are available for those with swallowing
difficulties but there is an additional therapeutic premium associated with it which the patient is required
to pay, or requires an authority prescription.
Drug Name sucralfate
Dose Form tablets
Strength 1g
Directions 1 g 4 times daily for 4-8 weeks; Maintenance, 1 g twice daily
Quantity 120 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Similar efficacy in ulcer healing to H2 antagonists.
Safety Profile Well tolerated. Contraindicated in severe renal impairment. Risk of

encephalopathy associated with aluminium accumulation.
Cost Approx. $25
Sucralfate is an aluminium salt of a sulfated disaccharide, similar to sucrose. It produces an adherent
cytoprotective barrier over ulcers by complexing with proteins, pepsin and bile. Its effect is entirely local
on the peptic ulcer and only extremely small amounts of aluminium are absorbed systemically.
Because of its lack of systemic absorption, very few systemic adverse effects occur. However,
constipation may sometimes be an adverse effect. Even though systemic absorption is extremely
limited, long-term sucralfate therapy should not be used in patients with renal impairment as even the
small amounts of aluminium absorbed may then accumulate and cause adverse effects, particularly on
bone.
For sucralfate to be effective, it must be ingested at least 1 hour before meals because an acid
environment is required for it to have its effect. Concomitant administration of antacids or inhibitors of
gastric acid secretion also reduce its efficacy The main problem with sucralfate is its dosing frequency: it
needs to be given 4 times a day, and this can be quite a problem compared to some of the other options
available.
Indication 20. Adolescent Mental Health
Drug Name Citalopram
Dose Form Tablets
Strength 10 mg, 20 mg and 40 mg Tabs
Directions Initially 0.25mg/kg/day (max 10mg) for 4 to 7 days, increasing if

necessary to 0.5mg/kg/day (max 20mg)
Quantity 28
No. of Repeats 5
Drug of choice
Issues
Efficacy If a medication is required current evidence indicates that this is the
preferred choice of prescribed antidepressant medication.
Safety Profile There needs to be a comprehensive management plan that includes

monitoring for suicide ideation emergence. This is more likely to
occur early in therapy or where therapy is irregular or interrupted.
Cost 10 mg - $19.32 per pack of 28, 20 mg- $26.52 to $30.97 per pack of
28, 40 mg- $41.10 per pack of 28
Other Issues Restricted benefit
Considered potential second choice antidepressant in those 12 years or older by the Therapeutic
Guidelines-Psychotropic.
May be taken with food to reduce stomach upsets. Usually taken in the morning. Monitor during the
initial few months for the emergence of suicidality. Be aware for switching to hypomania or manic states
because approx 20% will eventually develop bipolar disorder. Low potential for drug interactions caused
through cytochrome P450 isoenzymes. Coadministration with serotonergic substances may result in
serotonin syndrome (including complementary eg St John’s Wort and illicit drugs eg ecstasy, cocaine).
Drug Name Escitalopram
Dose Form Tablets & liquid
Strength 10 mg & 20 mg Tabs Oral liquid 10 mg/ mL
Directions No dosage schedule for depression in those under 18 years of age
Quantity 28 (tabs), 1 (liquid)
No. of Repeats
Drug of choice
Issues

Cost 10 mg- $27.88 to $32.64 per pack of 28,

20 mg - $28.01 to $35.01 per pack of 28
10 mg/mL Oral solution - $40.06 per pack of 28 mL
This is the active isomer of citalopram, but has no greater efficacy and is more expensive to the
government PBS scheme.
May be taken with food to reduce stomach upsets. Oral liquid can be mixed with water, apple or orange
juice for administration, usually taken in the morning. Monitor during the initial few months for the
emergence of suicidality. Be aware for switching to hypomania or manic states because approx 20% will
eventually develop bipolar disorder.
Low potential for drug interactions caused through cytochrome P450 isoenzymes. Coadministration with
serotonergic substances may result in serotonin syndrome (including complementary eg St John’s Wort
and illicit drugs eg ecstasy, cocaine).
Drug Name Fluoxetine
Dose Form Tabs or Caps
Strength 20 mg
necessary to 0.5mg/kg/day (max 20mg)
Quantity 28
No. of Repeats
Drug of choice
Issues

Cost $24.00
Other Issues PBS listed as Restricted benefit.
When non drug treatment on its own seems to be ineffective it may be appropriate to consider
fluoxetine. Currently this is the first line drug treatment choice for young people with depression.
Although not approved for those under 18 years for treating depression in Australia at present, it is the
only antidepressant approved in other countries eg USA, European Union and has the most evidence
for efficacy and safety of any antidepressant in this age group.
May be taken with food to reduce stomach upsets. Usually taken in the morning. Doses above 20
mg/day may be administered on a b.i.d. schedule (i.e. morning and noon) to minimise adverse effects.
Very long elimination half-life. The extensive half life means it takes longer to reach steady state than
other SSRI’s and therefore takes potentially longer to be efficacious. Also drug interactions may occur
for a week or so after ceasing the medication because of the long half life. Gradually stopping fluoxetine
is usually not required and withdrawal reactions are less likely than with other SSRI’s.
Coadministration with serotonergic substances may result in serotonin syndrome (including

complementary eg St John’s Wort and illicit drugs eg ecstasy, cocaine).
Drug Name Sertraline
Dose Form tablets
Strength 50 mg & 100 mg Tabs

necessary to 1.5mg/kg/day (max 50 mg).
Quantity 30
No. of Repeats
Drug of choice
Issues

Cost 50 mg- $28.69 to $29.23 per pack of 30, 100 mg- $28.69 to $29.23
per pack of 30
Other Issues resticted benefit

Considered potential second choice antidepressant in those 12 years or older by the Therapeutic
Guidelines-Psychotropic.
May be taken with food to reduce stomach upsets. Usually taken in the morning. Monitor during the
initial few months for the emergence of suicidality. Be aware for switching to hypomania or manic states
because approx 20% will eventually develop bipolar disorder. Low potential for drug interactions caused
through cytochrome P450 isoenzymes. Coadministration with serotonergic substances may result in
serotonin syndrome (including complementary eg St John’s Wort and illicit drugs eg ecstasy, cocaine).
Indication 21. Analgesics in persistent pain
Drug Name amitriptyline
Dose Form tablet
Directions 10-25 mg at night, titrate up to a maximum night time dose of 150

mg in pain management.
Quantity 50
No. of Repeats 2
Drug of choice
Issues
Efficacy Have been shown to be useful in a number of chronic pain states,
including neuropathic pain
Safety Profile There is an increased risk of cardiovascular adverse effects
Cost 10 mg - $7.38 per 50, 25 mg - $7.49 per 50, 50 mg - $7.81 per 50
Other Issues General pharm. benefit
Tricyclic antidepressants have been shown to be useful in a number of chronic pain states, including
neuropathic pain. Their use is limited by their adverse effect profile. They are also associated with an
increased risk of cardiovascular adverse effects. They appear to relieve pain independently of their
mood-altering effects. Amitriptyline is the most commonly used.2
Drug Name aspirin
Dose Form tablet
Strength 300 mg
Directions 300-900 mg every 4-6 hours
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Drug and indication specific
Safety Profile Drug and indication specific

Cost Approx $8/100
Aspirin has both analgesic, antipyretic and anti-inflammatory effects. It s a non-selective NSAID. It can
be used alone or in combination with codeine in the treatment of mild-to-moderate pain. Aspirin also has
antiplatelet actions which need to be considered before use.
Drug Name celecoxib
Dose Form capsule
Strength 100, 200 mg
Directions Up to 200 mg daily, in 1 or 2 doses (maximum 200 mg daily)
Quantity 60 (100 mg, 30 (200 mg)
No. of Repeats 3
Drug of choice
Issues
Efficacy COX-2 selective NSAIDs are no more effective than conventianal
NSAIDs but there is inter patient variability between all drugs
Safety Profile Serious adverse effects, including renal impairment, GI bleeding and
heart failure are associated with all NSAIDs.
Cost $30
Risk of cardiovascular adverse events is dose-related; during long-term treatment do not use > 200 mg
daily
NSAIDs are modestly more effective than paracetamol but with an increased risk of adverse events.
NSAIDs are a suitable addition for people who experience inadequate analgesia from regular
paracetamol. However they can cause serious adverse effects and are unsuitable for some people. Any
patient being considered for treatment with an NSAID should have their risk of cardiovascular disease,
gastrointestinal and renal adverse effects assessed. As NSAIDs have similar efficacy, the choice of
NSAID should be based on the risk profile of the drug, its efficacy in the individual patient and practicle
considerations such as available formulations and the required dosing schedule.
Weigh up a patient's risk of cardiovascular, gastrointestinal and renal adverse effects agonists the
potential benefits of the NSAID. When possible, those at high risk of adverse effects should not be
started on an NSAID.
Drug Name codeine
Dose Form tablet
Strength 30 mg
Directions 30-60 mg every 4 hour (maximum 240 mg/24 hours)
Quantity 20 (PBS)
No. of Repeats
Drug of choice
Issues
Safety Profile Types and severity of adverse effects is dependant upon the dose
and indication for use.
Cost $11-20
Other Issues General pharm. benefit, schedule 8
Codeine is used in the management of mild-moderate pain, in combination with paracetamol or an
NSAID. Its short duration of action may make it more suitable for control of incident pain or other short-
lasting mild-to moderate pain than control of persistent pain.
When considering treatment options for patients, use a stepwise approach to the management of her
persistent pain. Whilst codeine is the weak opioid of first choice, patients may have an allergy to
codeine making it an inappropriate choice.
Drug Name Codeine phosphate with paracetamol
Dose Form tablet
Strength 30 mg codeine phosphate + 500 mg paracetamol
Directions 1-2 tablets every 4-6 hours (maximum 8 tablets daily)
Quantity 20
No. of Repeats nil
Drug of choice
Issues
Cost $12
Other Issues n/a
This combination is a step up in analgesic potency from paracetamol alone, but its use brings the
adverse effects attributable to codeine.
Drug Name dextropropoxyphene
Dose Form capsules
Strength 100 mg
Directions 100 mg every 4 hours (maximum 600 mg daily)
Quantity 50 (RPBS)
No. of Repeats Nil

Drug of choice
Issues
Cost Approx $15/50
Other Issues Repatriation pharm. benefit, Schedule 4 item
Dextropoxyphene is a weak opioid. It is not recommended for use in persistent pain due to its limited
efficacy and unfavourable safety profile. The efficacy of dextropoxyphene in combination with
paracetamol is no greater than paracetamol alone, and the combination is usually dosed at a frequency
that makes accumulation likely.
The major metabolite dextropoxyphene is cardiotoxic. It has a longer half-life than the parent drug, so
may accumulate with repeated dosing, particularly in people with renal impairment leading to adverse
effects such as coma or cardiotoxicity.
Drug Name diclofenac
Dose Form tablet
Strength 25 & 50 mg
Directions 75-150 mg daily in 2-3 doses (maximum 200 mg daily)
Quantity 20 (PBS)
No. of Repeats 1
Drug of choice
Issues
Cost Approx. $8/20
Other Issues General Pharm. Benefit and Schedule 4 item
Nonsteroidal anti-inflammatory drugs have anti-inflamatory, analgesic and antipyretic effects. Diclofenac
is a conventional NSAID that acts on both COX-1 and COX-2.
paracetamol. However they can casuse serious adverse effects and are unsuitable for some people.
Any patient being considered for treatment with an NSAID should have their risk of cardiovascular
disease, gastrointestinal and renal adverse effects assessed. As NSAIDs have similar efficacy, the
choice of NSAID should be based on the risk profile of the drug, its efficacy in the individual patient and
practicle considerations such as available formulations and the required dosing schedule.
Recent evidence suggests an increase risk of cardiovascular disease associated with dicolfenac. Until
the evidence is available to refute the findings, diclofenac should be avoided in those at increased
cardiovascular risk.
Drug Name ibuprofen
Dose Form tablet
Strength 200 & 400* mg
Directions 200-400 mg 3 or 4 times daily (maximum 2400 mg daily)
Quantity 20* & 100 (PBS)
No. of Repeats 1&3
Drug of choice
Issues
Cost Approx. $8/20* , $10(200mg) & $13(400mg)/ 100
Other Issues *General (20 x 400mg, Restricted Pharm. Benefit, Schedule 2 item.)
Nonsteroidal anti-inflammatory drugs have anti-inflamatory, analgesic and antipyretic effects.
paracetamol. However they can cause serious adverse effects and are unsuitable for some people. Any
patient being considered for treatment with an NSAID should have their risk of cardiovascular disease,
gastrointestinal and renal adverse effects assessed. As NSAIDs have similar efficacy, the choice of
NSAID should be based on the risk profile of the drug, its efficacy in the individual patient and practical
considerations such as available formulations and the required dosing schedule.
Dose Form tablet
Strength 5, 10, 15, 20, 30, 50, 60, 90, 100, 120 mg
Directions 5-30 mg (modified-release twice daily) and adjust dose according to

response after 1 week or less.
Quantity 20 (PBS)
No. of Repeats Nil
Drug of choice
Issues
Cost <$0.75 per tablet
Use a stepwise approach to the management of persistent pain. At this stage Maria has other drug
choices available before considering morphine. The decision to start a patient on a strong opioid needs
careful consideration of the risk and benefits. Strong opioids can be used when other analgesics do not
provide sufficient pain relief or are unsuitable because of adverse effects.
Morphine is usually the strong opioid of first choice in severe persistent non-cancer pain. Ideally patients
should be referred to a multidisplinary pain clinic or pain specialist. However, it can be difficult to get an
appointment in a timely manner. Consider whether it is appropriate to initiate strong opioid therapy
before a visit to a pain clinic, or seek advice from a specialist.
Drug Name oxycodone
Dose Form tablet
Directions 5-15 mg every 4-6 hours
Quantity 20 (PBS)
No. of Repeats Nil
Drug of choice
Issues
Cost ~$1.00 per tablet
Other Issues Strong oral opiate as alternative to morphine. Restricted Pharm.

Benefit.
Use a stepwise approach to the management of persistent pain. Patients have other drug choices
available before considering oxycodone. The decision to start a patient on a strong opioid needs careful
consideration of the risk and benefits. Strong opioids should be used only if all other available
therapeutic treatments for pain relief have failed.
Oxycodone is an alternative for patients intolerant to morphine.
Drug Name Oxycodone (Controlled Release)
Dose Form tablet
Strength 5, 10, 20, 40, 80 mg
Directions Total daily dose as determined by the conventional product. Give

half total daily dose every 12 hours.
Quantity 20
No. of Repeats Nil
Drug of choice
Issues
Cost up to $32
Other Issues Restricted benefit. Do not use for initial stabilisation. Titrate
depending on response
Use a stepwise approach to the management of persistent pain. Patients have other drug choices
available before considering oxycodone. The decision to start a patient on a strong opioid needs careful
consideration of the risks and benefits. Strong opioids should be used only if all other available
therapeutic treatments for pain relief have failed.
Oxycodone is an alternative for patients intolerant to morphine. Do not use modified release
preparations for initial stabilization. Titrate dose depending on response.
Dose Form tablet
Strength 500 mg
Directions 500-1000 mg every 4-6 hours (maximum 4000 mg daily)
Quantity 100
No. of Repeats
Drug of choice
Issues

Paracetamol (acetaminophen) has analgesic and antipyretic actions. Paracetamol is rapidly absorbed
after oral administration, with a peak concentration in 10-60 minutes. Dosing in persistant pain should
be time contingent, rather than pain contingent.
Paracetamol’s efficacy, in combination with its excellent tolerability and safety profile and low propensity
for drug interactions, makes it the drug of first choice in persistent pain. Advise patients not to exceed
the maximum daily dose and to avoid other paracetamol containing preparations (such as cold and flu
tablets).
If adherence is a problem for patients, a three times daily dosing of modified release paracetamol may
allow a more steady state of the drug to be achieved. Modified-release paracetamol has similar efficacy
to immediate-release paracetamol. Modified-release paracetamol maybe considered for patients who
are taking regular paracetamol doses, this may aid adherence and pain control.
Drug Name paracetamol (modified release)
Dose Form tablet
Strength 665 mg
Directions 1330 mg every 6-8 hours (maximum 3990 mg daily)
Quantity 192
No. of Repeats
Drug of choice
Issues
Cost Up to $21
Paracetamol (acetaminophen) has analgesic and antipyretic actions. Paracetamol is rapidly absorbed
after oral administration, with a peak concentration in 10-60 minutes.
Paracetamol’s efficacy, in combination with its excellent tolerability and safety profile and low propensity
for drug interactions, makes it the drug of first choice in persistent pain. Modified-release paracetamol
maybe considered for patients who are taking regular paracetamol doses, this may aid adherence and
pain control. Modified-release paracetamol has similar efficacy to immediate-release paracetamol.
Advise patients not to exceed the maximum daily dose and to avoid other paracetamol containing
preparations (such as cold and flu tablets).
For some people, the need to take 4 daily doses to maintain around-the-clock pain relief is a barrier to
using paracetamol. The controlled release formulation of paracetamol may help by reducing the number
daily doses.
Drug Name tramadol
Dose Form capsules
Strength 50 mg
Directions 50-100 mg every 4-6 hours (maximum 400 mg daily, or 300 mg if >
75 years of age)
Quantity 20
No. of Repeats Nil
Drug of choice
Issues
Cost $13- $23
Other Issues Significant interactions with SSRIs, MAOIs, TCAs and St Johns Wort
and pethidine.
Tramadol is a weak opioid which may be considered an alternative to an NSAID when paracetamol
alone is inadequate, particularly for people at high risk of NSAID-induced adverse effects. It may also be
an alternative to low doses of strong opioids in patients who cannot tolerate these due to respiratory
depression or sedation.
Tramadol may be useful in selected patients, but consider the possibility of drug interactions and
adverse effect. Always start at a low dose and slowly titrate dosage to minamise the risk of adverse
effects. Do not use modified release preparations for acute pain management as slow onset and offset
make rapid, safe titration impossible.
Codeine is the weak opioid of first choice, but if a patient has an allergy to codeine, it becomes an
inappropriate choice. Adding tramadol to the treatment regimen is the next most appropriate choice
based on a stepwise approach. Introducing tramadol as an immediate release tablet allows the opioid
dose to be titrated to effect and tolerability. Opioids should be used as part of a multimodal treatment
program incorporating non-drug measures and non-opioid analgesics.
Other limitations include its short duration of action (3-4 hours) and the fact that 10% of Caucasians and
1-2% Asians cannot metabolise codeine to morphine (which is its active metabolite producing the
therapeutic effect). Ensure adequate dosing, doses below 30 mg are unlikely to be effective.
Drug Name tramadol (sustained release)
Dose Form tablet
Strength 50 mg, 100 mg, 150 mg, 200 mg
Directions 50-200 mg every 12 hours (maximum 400 mg daily, or 300 mg if >

75 years of age)
Quantity 20
No. of Repeats
Drug of choice
Issues
Cost up to $23
Other Issues Do not use for initial stabilisation
Tramadol is a weak opioid which may be considered an alternative to an NSAID when paracetamol
alone is inadequate, particularly for people at high risk of NSAID-induced adverse effects. It may also be
an alternative to low doses of strong opioids in patients who cannot tolerate these due to respiratory
depression or sedation.
Tramadol may be useful in selected patients, but consider the possibility of drug interactions and
adverse effect. Always start at a low dose and slowly titrate dosage to minamise the risk of adverse
effects. Do not use modified release preparations for acute pain management as slow onset and offset
make rapid, safe titration impossible.
When considering treatment options for the patient, use a stepwise approach to the management of her
persistent pain. Whilst codeine is the weak opioid of first choice, if the patient has an allergy to codeine,
it becomes an inappropriate choice. Adding tramadol to the treatment regimen is the next most
appropriate choice based on a stepwise approach. Introducing tramadol as an immediate release tablet
allows the opioid dose to be titrated to effect and tolerability. Opioids should be used as part of a
multimodal treatment program incorporating non-drug measures and non-opioid analgesics.
Indication 22, 23 & 24.Management of type 2 diabetes

Drug Name acarbose
Dose Form tablet
Directions 50 mg daily - 100 mg tds (max dose 600 mg day)
Quantity 90
No. of Repeats
Drug of choice
Issues
Efficacy Smaller reduction (~0.5%) in blood glucose and HbA1c than
metformin and sulphonylureas.
Safety Profile Not well tolerated due to gastrointestinal side effects.
Cost $30 - $41
Other Issues Gen Pharm benefit
Should be given with food. Dose usually limited by adverse effects.
Drug Name exenatide
Dose Form Preloaded injector
Strength 5 mcg/0.02 ml and 10 mcg/0.04 ml
Directions Initially 5 micrograms twice daily. If initial dose tolerated, after 1

month increase to 10 micrograms twice daily.
Quantity 1
No. of Repeats
Drug of choice
Issues
Efficacy Short term studies demonstrate reduction in blood glucose and
HbA1c similar to metformin and sulphonylureas (~1.5%).
Safety Profile Gastrointestinal side effects are common. May rarely cause
hypoglycaemia. Necrotizing pancreatitis is very rare but potentially
fatal.
Cost $190 / month
Other Issues No government subsidy
Exenatide is administered parenterally (injection). Longer acting preparations are in development. Long-
term outcomes with exenatide are currently unknown.
Drug Name glibenclamide

Dose Form tablet
Strength 5 mg
Directions 2.5 – 20 mg daily in 1-2 doses (max 10 mg per dose)
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Increase insulin secretion and reduce glycaemia over the whole 24-
hour period. Considered as second line agents as they reduce
microvascular outcomes, but not macrovascular and diabetes
related deaths. First line therapy where metformin cannot be used or
in lean young patients with hypoinsulinaemia rather than insulin
resistance.
Safety Profile Common adverse effects: hypoglycaemia, weight gain (~3 kg

average). The risk of hypoglycaemia appears greatest with
gibenclamide. Infrequent: nausea, diarrhoea, metallic taste,
headache, rash. Rare: blood disorders, allergic reaction,
photosensitivity, hepatotoxicity.
Cost $12.70
Other Issues General Pharm. Benefit (5mg)
The available sulfonylureas have very similar safety and efficacy but glibebclamide is more likely to
cause hypoglycaemia compared to some other sulfonylureas. Glibenclamide has an active metabolite
which is renally cleared. It also comes in a combination tablet with metformin.
Drug Name gliclazide
Dose Form tablet, CR tablet
Strength 80 mg, Controlled release 30 mg
Directions Controlled release tablet: 30 – 120 mg daily, Conventional tablet: 40

– 320 mg daily in 1-2 divided doses (max 160 mg per dose)
Quantity 100
No. of Repeats
Drug of choice
Issues
resistance.

Cost $14.73
The available sulfonylureas have very similar safety and efficacy. Gliclazide is one of the short acting
sulfonylureas. Gliclazide 80mg conventional tablet is equivalent to 30 mg controlled release tablet.
Drug Name glimepiride
Dose Form tablet
Strength 1 mg,2 mg, 3mg & 4 mg
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
resistance.

Cost $10.13 (1 mg) to $15.49 (4 mg).
The available sulfonylureas have very similar safety and efficacy. Glimepiride is long acting due to an
active metabolite which is renally cleared.
Drug Name glipizide
Dose Form tablet
Strength 5 mg
Directions 2.5 - 40 mg in 1-2 doses (max 15 mg per dose)
Quantity 100
No. of Repeats
Drug of choice
Issues
resistance.

Cost $12.70
The available sulfonylureas have very similar safety and efficacy. Glipizide has the shortest half life (3
hours) and is therefore less likely to cause hypoglycaemia.
Drug Name Insulin aspart (Novorapid)
Dose Form Injection: Cartridge 3 mLs, disposable pen 3mLs, or Vial 10mLs
Strength 100 units/mL
Directions Administer with meals
Quantity 5 x 5 cartridges or disposable pens or 5 vials
No. of Repeats
Drug of choice
Issues
Efficacy Rapidly reduces blood glucose and an essential component type 1
diabetes treatment. Provides bolus insulin and correction factors.
Safety Profile Risk of hypoglycaemia. Capillary glucose monitoring is essential.

Before and after meal glucose concentrations guide changes in
bolus insulin doses. If used, correction factors should be
established for an individual. Associated with weight gain.
Cost Cartridge or disposable pen: $264.22 or Vial: $159.22 maximum

cost to patient is $33.30
Other Issues Duration of action - about 4 hours.
Insulin aspart is used as a bolus (mealtime) insulin. It has a duration of action of 4-5 hours. It is used
together with a long-acting insulin in a basal bolus regime. It is an insulin analogue with rapid onset of
action and hence administered at meal times. The amount required varies depending on carbohydrate
intake, planned exercise and current capillary glucose.
Drug Name Insulin aspart / aspart protamine (NovoMix 30)
Dose Form Injection: cartridge 3 mLs, disposable pen 3 mLs

Directions Administer twice daily, in mornings and evenings
Quantity 5 x 5 cartridges or disposable pens
No. of Repeats
Drug of choice
Issues
Efficacy Effectively reduces blood glucose and HbA1c. These insulins are
used in situations when long and rapid acting insulins may be less
suitable.
Safety Profile Risk of hypoglycaemia (capillary glucose monitoring essential).

Associated with weight gain.
Cost Cartridge: $264.22 maximum cost to patient is $33.30
Other Issues Combination product.
This is a biphasic insulin which contains 30% insulin aspart and 70% insulin aspart protomine (the latter
has a similar profile to isophane insulin). It is usually given twice daily with the morning and evening
meals. It provides the convenience of 2 injections per day, but as the insulin is pre-mixed it does not
allow for individual dose adjustment. Look up the component drugs for more information.
Drug Name Insulin detemir (Levemir)
Dose Form Cartridge 3mLs, disposable pen 3mLs
Directions Administer once or twice daily
No. of Repeats
Drug of choice
Issues
Efficacy Effectively reduces blood glucose and HbA1c in type 1 and type 2
diabetes. Provides basal insulin.

Fasting glucose concentrations guide changes in basal insulin
doses. Associated with weight gain.
Cost $432.72 maximum cost to patient is $33.30
Other Issues Duration of action - about 16 hours. Only subsidised for type 1
diabetes.
Insulin detemir is used as a basal insulin and has duration of action of 12-24 hours. It may be used
together with a rapid acting insulin in a basal bolus regime or alone as basal insulin. It is not PBS-listed
for use in type 2 diabetes. It is an insulin analogue with low dose to dose variability.
Drug Name Insulin glargine (Lantus)

Dose Form Injection: cartridge 3mLs, disposable pen 3mLs, vial 10 mLs
Directions Administer once daily
Quantity 5 x 5 cartridges, disposable pens or vials
No. of Repeats
Drug of choice
Issues

Cost $432.72 maximum cost to patient is $33.30
Other Issues Duration of action >24 hours. Vials not PBS listed
Insulin glargine is used as a basal insulin and has a duration of action >24 hours. It may used together
with a rapid acting insulin in a basal bolus regime or alone as basal insulin. It is an insulin analogue with
a long duration of action.
One of the advantages of insuline glargine is that it can be given at any time of the day because of its
prolonged and flat profile. NICE recommended use of insulin glargine for patients who require
assistance with administration of insulin injections, whose lifestyle is significantly restricted by recurrent
symptomatic hypoglycaemic episodes and who would otherwise need twice-daily basal insulin injections
in combination with oral antidiabetic medications.
Drug Name Insulin glulisine (Apidra)
Dose Form Injection: disposable pen 3 mLs or Vial 10 mLs
Quantity 5 x 5 disposable pens or 5 vials
No. of Repeats
Drug of choice
Issues

Cost disposable pen: $264.22 or Vial: $159.27 maximum cost to patient is

$33.40
Insulin glulisine is used as a bolus (mealtime) insulin. It has a duration of action of 4-5 hours. It is used
together with a long acting insulin in a basal bolus regime. It is an insulin analogue with rapid onset of
Drug Name Insulin isophane (Humulin NPH™, Protaphane™ & Hypurin

Isophane™)
Dose Form Injection: Cartridge 3mLs. disposable pen 3mL or vial 10mLs
Quantity 5 x 5 cartridges or 5 vials
No. of Repeats
Drug of choice
Issues

Cost Cartridge: $224.32 or Vial: $133.82 maximum cost to patient is

$33.30.
Insulin isophane is used as a basal insulin and has a duration of action of 12-24 hours. It may used
together with a rapid acting insulin in a basal bolus regime or alone as basal insulin. It is also known as
insulin neutral protamine hagedorn (NPH). It requires a gentle rotate to ensure uniform distribution of
the drug before injection.
Drug Name Insulin lispro (Humalog)
Dose Form Injection: Cartridge 3 mLs, disposable pen 3 mLs, or Vial 10 mLs
Strength 100 units/ml
Quantity 5 x 5 cartridges or disposable pens or 5 vials
No. of Repeats
Drug of choice
Issues

Cost Cartridge or disposable pen: $264.22 or Vial: $159.27 maximum
cost to patient is $32.90
Insulin lispro is used as a bolus (mealtime) insulin. It has a duration of action of 4-5 hours. It is used
together with a long acting insulin in a basal bolus regime. It is an insulin analogue with rapid onset of
Drug Name Insulin lispro / lispro protamine (Humalog Mix 25, Humalog Mix 50)
Dose Form Injection: cartridge 3 mLs, disposable pen 3 mLs
No. of Repeats
Drug of choice
Issues
suitable.

Cost Cartridge: $264.22 maximum cost to patient is $33.30. Vial: $159.27
Other Issues Combination product
This is a mixture of rapid and long acting insulins. 25 or 50% (respectively) of each dose is rapid acting
insulin and 75 or 50% (respectively) is long acting insulin. It is usually given twice daily with the morning
and evening meals. It provides the convenience of 2 injections per day, but as the insulin is pre mixed it
does not allow for individual dose adjustment. Look up the component drugs for more information.
Drug Name Insulin neutral (Actrapid, Humulin R, Hypurin Neutral)
Dose Form Injection: Cartridge 3mLs or Vial 10mLs
Directions Administer according to use
No. of Repeats
Drug of choice
Issues
suitable.


$33.30
Other Issues Duration of action – about 8 hours
Neutral insulin (human insulin) is predominantly used in intravenous infusions and occasionally as a sc
bolus insulin. It has a duration of action of 6-8 hours and a slower onset of action than the rapid acting
insulin analogues; this makes it unsuitable for use as a mealtime insulin. Intravenous insulin infusion
rates are adjusted based on current capillary glucose and rate of change of capillary glucose.
Drug Name Insulin neutral / insulin isophane (Humulin 30/70, Mixtard 30/70,
Mixtard 50/50)
Dose Form Injection: Cartridge 3 mLs or Vial 10 mLs
Directions Administer twice daily, in mornings and evenings
No. of Repeats
Drug of choice
Issues
suitable.


$33.30.
Other Issues Combination product
This is a mixture of neutral and long acting insulins. 30 or 50% of each dose is neutral insulin and 70 or
50% is long acting insulin. It is usually given twice daily with the morning and evening meals. It provides
the convenience of 2 injections per day, but as the insulin is pre mixed it does not allow for individual
dose adjustment. Look up the component drugs for more information.
Drug Name metformin
Dose Form tablet
Strength Conventional Tablet: 500 mg & 1000 mg Controlled Release Tablet:

500 mg
Directions Conventional tablet: 250 mg daily – 1000 mg tds, controlled release

tablet: 500 mg - 2000 mg nocte
Quantity CR 500 mg 90 tabs, 500 and 1000 mg 90 tabs
No. of Repeats
Drug of choice
Issues
Efficacy Reduce blood glucose concentration and HbA1c by similar a
magnitude to sulphoylureas (~1.5% decrease in HbA1c)
Safety Profile Gastrointestinal side effects are common. Lactic acidosis is very
rare.
Cost $14.12 - $19.07
Other Issues On general pharmaceutical benefit
DRUG OF CHOICE
Start slowly, 250-500 mg daily or bd as approximately 1/3 people will get some GI adverse effects (eg.
nausea and diarrhoea), The dose can be titrated up as GI effects settle, although approximately 1/50
will not tolerate metformin at all. If GI effects permit maximise the dose (2-3g/day for patients with
normal renal function). Metformin is renally cleared (renal clearance 100%) and the dose should be
adjusted to GFR. Metformin has a slow onset of effect and it may take up to 2 weeks to establish
control.
Lactic acidosis is rare (and controversial). Metformin should be avoided in patients with severe renal,
hepatic or cardiac impairment,. Metformin should be withheld during, major illness (ie surgery, trauma,
sepsis, myocardial infarction etc). and with contrast radiology. It may cause malabsorption of vitamin
B12.
Blood glucose should be monitored when switching from standard tablets to a fixed-dose combination.
When changing from conventional to controlled-release tablets, start with the patient's usual daily dose.
Reduces hepatic glucose production; increases peripheral utilisation of glucose.
Indications
Type 2 diabetes in adults, including combinations with:
* glibenclamide
* rosiglitazone
* sitagliptin
Type 2 diabetes in children >10 years

Accepted
With clomiphene for anovulatory infertility due to polycystic ovary syndrome (unresponsive to
clomiphene alone) and BMI >25, under specialist supervision
Precautions
Type 1 diabetes—contraindicated.
Ketoacidosis—contraindicated.
Respiratory failure—contraindicated.
Severe infection or trauma—contraindicated.
Dehydration—contraindicated.
Alcohol misuse—contraindicated.
Moderate-to-severe heart failure—may increase risk of lactic acidosis.
Intravascular iodinated contrast media—may cause renal failure and therefore increase risk of lactic
acidosis, especially in those with pre-existing renal impairment. Stop metformin before, or at the time of,
contrast media administration; restart metformin after 48 hours if renal function is normal.
Renal
Renal impairment increases risk of lactic acidosis; reduce maximum dose in mild impairment, do not use
when CrCl is <30 mL/minute. Replace with insulin if possible.
Drug Name pioglitazone
Dose Form tablet
Strength 15 mg, 30 mg, 45 mg
Directions 15 - 45 mg daily
Quantity 28
No. of Repeats
Drug of choice
Issues
magnitude to metformin and sulphoylureas (~1.5% decrease in
HbA1c). There is a lack of evidence that they improve diabetes-
related clinical complications.
Safety Profile Commonly cause fluid retention and hence increase the risk of heart
failure. Long term use is associated with osteoporotic fractures in
distal limbs. Thiazolidediones are contraindicated in moderate to
severe heart failure. They may increase the risk of myocardial
infarction.
Cost max cost to patient $32.90
Other Issues PBS Authority. Strict conditions on authorised use. (See PBS
Schedule)
The available thiazolidinediones have similar safety and efficacy. Pioglitazone has a “more favourable”
effect on lipid profile than rosiglitazone but long-term outcome improvements have not yet been shown.
Marketed to use as monotherapy, but with limited long term data and uncertainty regarding
cardiovascular safety. PBS listed as dual therapy with either metformin or a sulfonylurea, triple therapy
with metformin and a sulfonylurea or in combination with insulin. It can be prescribed when there is a
contraindication to prescribing either metformin or a sulfonylurea, an intolerance has developed to either
of them or if blood glucose is still uncontrolled on metformin and a sulfonylurea. Doses should not be
increased until after 8 weeks of treatment as full effect of the drug may not be seen before this time.
Approximately 30% of patients do not have a significant response.
Drug Name repaglinide
Dose Form tablet
Strength 1 & 2 mg
Directions Initially 0.5 mg 3 times daily, increase every 1-2 weeks up to 4 mg 3

times daily. Maximum dose 16 mg daily.
Quantity 90
No. of Repeats
Drug of choice
Issues
Efficacy Reduce blood glucose concentration and HbA1c by smaller amount
than sulphonylureas
Safety Profile Can cause hypoglycaemia (monitoring required) and is associated

with weight gain.
Cost 1mg $39.15/ 90 ; 2mg $43.20/90
Other Issues Non-PBS item.
Caution for people with renal and hepatic impairment, contraindicated in children under 12 years. No
data for people older than 75 years.
Drug Name rosiglitazone
Dose Form tablet
Strength 4mg, 8mg
Directions 4 – 8 mg daily
Quantity 28 (PBS)
No. of Repeats
Drug of choice
Issues
magnitude to metformin and sulphoylureas (~1.5% decrease in
HbA1c). There is a lack of evidence that they improve diabetes-
related clinical complications.
Safety Profile Commonly cause fluid retention and hence increase the risk of heart
failure. Long term use is associated with osteoporotic fractures in
distal limbs. Thiazolidediones are contraindicated in moderate to
severe heart failure. They may increase the risk of myocardial
infarction.
Cost 4 mg $61.61/ 28 ; 8 mg $92.25/28
Other Issues PBS Authority. Strict conditions on authorised use. (See PBS
Schedule)
The available thiazolidinediones have similar safety and efficacy . Rosiglitazone also comes in a
combination tablet with metformin.
Marketed to use as monotherapy, but with limited long term data and uncertainty regarding
cardiovascular safety. PBS listed as dual therapy with either metformin or a sulfonylurea. It can be
prescribed when there is a contraindication to prescribing either metformin or a sulfonylurea or
intolerance has developed to either of them. Doses should not be increased until after 8 weeks of
treatment as full effect of the drug may not be seen before this time. Approximately 30% of patients do
not have a significant response. Combination with insulin is contraindicated.
Drug Name sitagliptin
Dose Form tablet
Strength 25 mg, 50 mg & 100 mg
Directions 100 mg daily adjusted for GFR
Quantity 28
No. of Repeats
Drug of choice
Issues
Efficacy Smaller reduction (~0.5%) in blood glucose and HbA1c than
metformin and sulphonylureas.
Safety Profile Minimal adverse effects reported (but this is a new drug and
unreported adverse effects or interactions may occur).
Cost $91.19 maximum cost to patient is $32.90.
Other Issues On restricted pharmaceutical benefits: for combination use with

either metformin or a sulfonylurea where a combination of metformin
and sulphonylurea is not tolerated or contraindicated.
Sitagliptin does not increase the risk of hypoglycaemia and has a generally neutral effect on
bodyweight. Renal clearance 100%. Other drugs in this class are likely to be available soon.
Inhibits dipeptidyl peptidase-4 (DPP-4) thereby increasing the concentration of the incretin hormones
glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide; glucose-dependent insulin
secretion is increased and glucagon production reduced.
Indications: Type 2 diabetes, dual therapy with metformin, a sulfonylurea or a thiazolidinedione
Combination with metformin
Type 2 diabetes
AE: Treatment with a sulfonylurea—increases risk of hypoglycaemia; may need to reduce sulfonylurea
dose.
Renal
The manufacturer suggests reducing the dose if CrCl <50 mL/minute, however, safety in these patients
has not been adequately studied.
Do not use the combination product in renal impairment.
Indication 25. Management options to maximise sleep
Drug Name lorazepam
Dose Form tablet
Directions For insomnia - 1–2 mg at night
Quantity 50
No. of Repeats
Drug of choice
Issues
Efficacy Enhance effects of all 3 omega subtypes of neurotransmitter
gamma-aminobutyric acid (GABA) resulting in anxiolytic, sedative,
hypnotic, muscle relaxant and antiepileptic effects.
Safety Profile Can cause drowsiness, oversedation, light-headedness, memory

loss, hypersalivation, ataxia, slurred speech. See commentary below
for more information.
Medium-acting benzodiazepine, with approximate half-life of 12 hours. Indicated for anxiety, short term
treatment of insomnia associated with anxiety, premedication for surgery. May be taken with or without
food.
Benzodiazepines potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic,
sedative, hypnotic, muscle relaxant and antiepileptic effects.
Indications: Anxiety; Short-term treatment of insomnia associated with anxiety;
Premedication for surgery or procedure
You may feel drowsy while taking this medication; drowsiness may persist the following day; avoid
driving or operating heavy equipment until you know how you react.
Avoid alcohol and other medications that may cause drowsiness while taking this drug.
If you take this medicine regularly for more than 2–4 weeks your body may become used to it and in
time, you may need a higher dose for it to continue to work. If you stop the medicine suddenly, you may
have unpleasant effects (eg feeling anxious, difficulty sleeping). Discuss how to stop the medicine with
your doctor first.
* reserve for short-term use only (eg 2–4 weeks); they should be part of a broader treatment plan, not
a first or sole treatment
* there is no convincing evidence for the use of benzodiazepines to treat depression, but they are
appropriately used short term to treat severe anxiety or agitation in depressed people waiting for
response to antidepressants
* benzodiazepines are sometimes misused for their euphoric and sedative effects, both alone and
with other drugs
* long-term use of benzodiazepines may result in tolerance and dependence; signs of dependence
include drug-seeking behaviour, craving, and disturbed work and personal function
Withdrawal symptoms
anxiety, dysphoria, irritability, insomnia, nightmares, sweating, memory impairment, hallucinations,
hypertension, tachycardia, psychosis, tremors and seizures
* these may not occur until several days after stopping, and can last for several weeks or longer after
prolonged use
* prevent or alleviate by gradual dose reduction
Drug Name oxazepam
Dose Form tablet
Directions 7.5–30 mg at night
Quantity 25 (PBS)
No. of Repeats
Drug of choice
Issues

Cost Approx. $7/ $25 (15 & 30 mg)
Indications: anxiety, short-term treatment insomnia
Drug Name temazepam
Dose Form tablets
Strength 10 & 20 mg
Directions 5–10 mg at night
Quantity 25
No. of Repeats
Drug of choice
Issues

FIRST LINE: temazepam 10 mg orally, before bedtime
Short-acting benzodiazepine, with approximate half-life of 10 hours. Indicated for short term treatment of
insomnia, can be taken half an hour before retiring. Not recommended for children.
Indications: short-term for insomnia
Drug Name zopiclone
Dose Form tablet
Strength 7.5 mg
Directions 7.5 mg at night for up to 4 weeks. Reduce to 3.75 mg if possible
Quantity 10 & 30
No. of Repeats
Drug of choice
Issues
Efficacy Potentiation of inhibitory effects of selective omega-1 GABA
receptor. Marketed as hypnotics, they have a sedative effect. They
produce less rebound insomnia compared with the
benzodiazepines.
Safety Profile Can cause drowsiness, diarrhoea, taste disturbance, dry mouth.
Cost $20.11
Other Issues On repatriation pharmaceutical benefits, restricted benefit – for

short-term treatment of insomnia
Short-acting hypnotic, indicated for short term treatment of insomnia, prolongs stage 2 and 4 sleep with
no significant changes in REM sleep. Problems similar to Zolpidem have rarely been reported. The most
common adverse effects reported with zopiclone use were metallic taste and dry mouth. Should be
taken shortly before retiring.
Potentiates inhibitory effects of GABA.
Indications: Short-term treatment of insomnia
Concomitant alcohol intake—contraindicated.
Avoid use in pregnancy; Australian category C.
AE: taste disturbance (bitter), dry mouth, drowsiness
You may feel drowsy while taking this medication; drowsiness may persist the following day; avoid
driving or operating heavy equipment until you know how you react.
Avoid alcohol and other medications that may cause drowsiness while taking this drug.
use short term, as a withdrawal syndrome has been reported when zopiclone is stopped
Indication 3. Peptic ulceration with NSAID use
Drug Name aluminium hydroxide
Dose Form tablet
Strength 600 mg
Directions 1-2 tablets up to 4 times per day
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Have been shown to heal peptic ulcer. Unknown NSAID ulcer
prevention efficacy.
Safety Profile Cause constipation and electrolyte disturbances.
Cost $27.00
Other Issues Not PBS
Antacids have been used for symptomatic treatment of upper gastrointestinal discomfort for centuries,
for instance the use of baking soda (sodium bicarbonate). Many different antacid preparations are
available without prescription. This is a preparation which only contains aluminium and is likely to cause
constipation.
Drug Name cimetidine
Dose Form tablet
Directions Initial - 800 mg at night or 2 divided doses, for 4-8 weeks
Quantity 120 (200 mg), 60 (400 mg ), 30 ( 800 mg) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Moderate efficacy in NSAID ulcer prevention
impairment.
Cost $25
Other Issues PBS General Benefit, Less suitable than others
concurrent administration of antacids. The approximate plasma half-life of cimetidine is 2 hours.
Cimetidine is principally renally excreted, so dose reductions may be required in patients with significant
renal impairment.
Adverse effects are uncommon with these agents. In therapeutic doses, cimetidine causes
gynaecomastia and can occasionally cause confusion and acute psychosis, particularly in the elderly
and in patients with renal failure; it also inhibits liver oxidative enzymes, so it inhibits the metabolism of
such drugs as warfarin, phenytoin, carbamazepine, prednisolone and theophylline. An effervescent 800
mg tablet is also available for those with swallowing difficulties. An alternative H2 receptor antagonist
may be preferred to avoid these potential drug interactions.
Drug Name esomeprazole
Dose Form tablet
Strength 20, 40 mg
Directions 20 mg once daily (for peptic ulcer)
Quantity 30
No. of Repeats
Drug of choice
Issues
prevention
Cost $32.90
Other Issues S-isomer of omeprazole
Esomeprazole is just the S-stereoisomer of omeprazole (esomeprazole, esomeprazole, get it!). At
doses much higher than other agents, esomeprazole is better at controlling symptoms of reflux disease
than other agents. However, there has not been any advantage demonstrated with its use either in
terms of safety or efficacy at equivalent doses.
Drug Name famotidine
Dose Form tablet
Strength 20 & 40 mg
Directions Initial: oral 40 mg in the evening for 4-8 weeks
Quantity 60 (20 mg), 30 (40 mg) (PBS)
No. of Repeats
Drug of choice
Issues
impairment.
Cost $20
concurrent administration of antacids. The approximate plasma half-life of famotidine is 3 hours. All four
agents are principally renally excreted, so dose reductions may be required in patients with significant
renal impairment. Adverse effects are uncommon with these agents, but all of them can occasionally
Drug Name lansoprazole
Dose Form capsule
Directions 30 mg once daily
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention
Cost Approx.$21 (15 mg) & $31 (30 mg)
Lansoprazole is well absorbed and exhibits high bioavailability. It is extensively metabolised in the liver,
and the metabolites are excreted by the renal and biliary routes. Despite its short plasma half-life (1 to 2
hours), lansoprazole produces prolonged acid suppression for up to 24 hours.
Lansoprazole is a weak inducer of cytochrome P450, but while there is a possibility of interactions with
other drugs metabolised by this system, no clinical effects have been observed with diazepam,
phenytoin or warfarin.
Lansoprazole is the only PPI listed here which does not have a TGA indication for prevention against
adverse effects of NSAIDS.
Drug Name misoprostol
Dose Form tablet
Directions 800 micrograms daily in 2-4 divided doses, for 4-8 weeks.
Quantity 120 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Particularly effective in NSAID-induced ulcers
Safety Profile May induce premature labour. ADEC category X. GI adverse

reactions common
Cost $50
Other Issues Contraindicated in pregnancy. Authority Pharm Benefit
Misoprostol is a synthetic analogue of prostaglandin E1, which inhibits gastric acid secretion and also
produces cytoprotection. Its cytoprotective effect is particularly evident against mucosal damage
produced by NSAIDs, including aspirin. Misoprostol is rapidly absorbed, has a short plasma half-life of
approximately 30 minutes and is metabolised to a variety of fatty acid products, most of which are
excreted in the urine. The major adverse effects of misoprostol are diarrhoea, abdominal pain and loose
stools. These effects occur in 10 to 15 percent of patients treated with recommended therapeutic doses.
Women may also occasionally suffer menorrhagia or an accentuation of dysmenorrhoea. It is an
abortifacient so must not be used in pregnancy.
It is an authority benefit under the PBS for reduction of complications in ulcer patients who have
continuing need for NSAIDs.
Drug Name nizatidine
Dose Form Capsule

Directions Initial - 300 mg daily as a single evening dose or 2 divided doses for
4-8 weeks
Quantity 60 (150 mg) , 30 (300 mg ) (PBS)
No. of Repeats
Drug of choice
Issues
impairment.
Cost $23
concurrent administration of antacids. The approximate plasma half-life of nizatidine is 1.5 hours.
Nizatidine is principally renally excreted, so dose reductions may be required in patients with significant
renal impairment. Adverse effects are uncommon with these agents. but all of them can occasionally
Directions 20-40 mg once daily for 4-8 weeks for healing then 20mg per day for
prevention
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention
Cost Approx $30
(PPIs) presently available in Australia. They inhibit the enzyme hydrogen potassium adenosine
triphosphatase, thus suppressing acid secretion irrespective of the stimulus to acid production. They
have no significant direct effect on acetylcholine or histamine receptors. They have also been shown to
heal ulcers more rapidly than other antiulcerants. As with the H2-receptor antagonists, ulcer recurrence
commonly occurs on cessation of treatment.
Omeprazole has rather poor and variable bioavailability, which increases as gastric acid secretion is
inhibited. Despite its short plasma half-life (40 minutes), omeprazole produces prolonged acid
suppression for up to 24 hours. It is almost entirely metabolised in the liver to inactive metabolites which
are renally excreted. Omeprazole has slight, but significant, inhibitory effects on hepatic oxidative
enzymes, and has been shown to significantly reduce the metabolism of phenytoin and warfarin.
Drug Name pantoprazole
Dose Form tablet
Directions 40 mg once daily for 4-8 weeks then 20mg per day for long term
prevention
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention
Cost Approx. $20 (20 mg) & $33 (40 mg)
Other Issues Restricted Pharm. Benefit
Omeprazole, lansoprazole and pantoprazole, rabeprazole and esomeprazole are the proton pump
inhibitors (PPIs) presently available in Australia. They inhibit the enzyme hydrogen potassium
adenosine triphosphatase, thus suppressing acid secretion irrespective of the stimulus to acid
production. They have no significant direct effect on acetylcholine or histamine receptors. They have
also been shown to heal ulcers more rapidly than other antiulcerants. As with the H2-receptor
antagonists, ulcer recurrence commonly occurs on cessation of treatment.
Despite its short plasma half-life (1 hour), pantoprazole produces prolonged acid suppression for up to
24 hours.
Studies with pantoprazole have shown no interaction with the cytochrome P450 system. PPIs are
generally well-tolerated. Recent evidence suggests an association between PPIs and increased risk of
C. difficile infection, commonly-acquired pneumonia and fracture (long term use). These adverse effects
may be rare and difficult to predict.
Drug Name Proton Pump Inhibitor (PPI), amoxycillin and metronidazole
Dose Form oral

Strength mixed
Directions PPI standard dose (bd), amoxycillin 500 mg (tds) and metronidazole
400 mg (tds) for 14 days.
Quantity 14-day supply
No. of Repeats
Drug of choice
Issues
Efficacy No effect on NSAID-induced ulcers apart from effect of proton pump
inhibitor.
Cost ~$40 for 7 days
Other Issues Second line therapy. Each drug has to be individually prescribed.
Currently second line therapy when clarithromycin is not suitable. Metronidazole has relatively high
rates of pretreatment resistance and combinations containing it have a greater risk of treatment failures.
Adverse effects may also be more common with metronidazole compared to other antibiotics.
Drug Name Proton Pump Inhibitor (PPI), clarithromycin and amoxycillin
Strength mixed
Directions PPI standard dose, amoxycillin 1000 mg, clarithromycin 500 mg all
twice daily for 7 days
Quantity 7 day pack (PBS)
No. of Repeats
Drug of choice
Issues
inhibitor.
Cost Approx.$32/ pack
Other Issues First line therapy. Can be prescribed as a single product (Klacid Hp
7, Nexium Hp7)
Clarithromycin-containing regimens are rated as first line therapy and offer the most convenient dosing
regimens. H. pylori resistance to clarithromyin in Australia is presently ~20%. Most studies from which
eradication rates are quoted employed omeprazole, although other PPIs are likely to be equally
effective. Eradication rates are >90%, however, this is currently the most expensive regimen.
Drug Name Proton Pump Inhibitor (PPI), clarithromycin and metronidazole

Strength mixed
Directions PPI standard dose, clarithromycin 500 mg and metronidazole 400

mg all twice daily for 7 days.
Quantity 7 days treatment
No. of Repeats
Drug of choice
Issues
inhibitor.
Cost ~$70
Other Issues Not PBS subsidised. Use in cases of penicillin intolerance or allergy.
Metronidazole is used in combination with another antimicrobial (amoxycillin, clarithromycin or

tetracycline), and an acid suppressant (proton pump inhibitor or H2 antagonist) for second line therapy
and for treatment failures in the eradication of Helicobacter pylori. It may be used in cases of penicillin
allergy or intolerance. It has relatively high rates of pretreatment resistance and combinations containing
it have a greater risk of treatment failures (eradication rates >80%).
Drug Name rabeprazole
Dose Form tablet
Directions 20 mg once daily for 4-8 weeks
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
prevention
Cost $33.30
Other Issues Restricted Pharm Benefit
rapidly than other antiulcerants. As with the H2-receptor antagonists, ulcer recurrence commonly occurs
on cessation of treatment.
Despite its short plasma half-life (1 hour), rabeprazole produces prolonged acid suppression for up to 24
hours.
These adverse effects may be rare and difficult to predict
Drug Name ranitidine
Dose Form tablet
Directions Initial - 300 mg daily as a single evening dose or 2 divided doses, for
4-8 weeks or IV/IM 50 mg every 6-8 horus.
Quantity 60 (150 mg ), 30 (300 mg) (PBS)
No. of Repeats
Drug of choice
Issues
impairment.
Cost $20
concurrent administration of antacids. The approximate plasma half-life of ranitidine is 2 hours.
Ranitidine is principally renally excreted, so dose reductions may be required in patients with significant
renal impairment.
Adverse effects are uncommon with these agents. but all of them can occasionally cause blood
Effervescent tablets (150 mg) or syrup (150 mg/10 mL) are available for those with swallowing
difficulties but there is an additional therapeutic premium associated with it which the patient is required
to pay, or requires an authority prescription.
Drug Name sucralfate
Dose Form tablets
Strength 1g
Directions 1 g 4 times daily for 4-8 weeks; Maintenance, 1 g twice daily
Quantity 120 (PBS)

No. of Repeats
Drug of choice
Issues
Efficacy Less efficacy in NSAID ulcer prevention than misoprostol or proton
pump inhibitor.
Safety Profile Well tolerated. Contraindicated in severe renal impairment. Risk of

encephalopathy associated with aluminium accumulation.
Cost Approx. $25
Sucralfate is an aluminium salt of a sulfated disaccharide, similar to sucrose. It produces an adherent
cytoprotective barrier over ulcers by complexing with proteins, pepsin and bile. Its effect is entirely local
on the peptic ulcer and only extremely small amounts of aluminium are absorbed systemically.
Because of its lack of systemic absorption, very few systemic adverse effects occur. However,
constipation may sometimes be an adverse effect. Even though systemic absorption is extremely
limited, long-term sucralfate therapy should not be used in patients with renal impairment as even the
small amounts of aluminium absorbed may then accumulate and cause adverse effects, particularly on
bone.
For sucralfate to be effective, it must be ingested at least 1 hour before meals because an acid
environment is required for it to have its effect. Concomitant administration of antacids or inhibitors of
gastric acid secretion also reduce its efficacy. The main problem with sucralfate is its dosing frequency:
it needs to be given 4 times a day, and this can be quite a problem compared to some of the other
options available.
Indication 4. Post-operative pain
Drug Name celecoxib
Dose Form capsule
Strength 100, 200 mg
Directions 100mg bd
Quantity 60 (100 mg, 30 (200 mg)
No. of Repeats
Drug of choice
Issues
Efficacy Effective adjuncts to opioid analgesia in severe pain.
Safety Profile Significant renal, gastrointestinal and cardiovascular adverse

events.
Cost $30
COX-2 selective NSAIDs are associated with less gastrointestinal ulceration but are associated with
more cardiovascular events and may cause renal impairment, and are therefore not a good choice for
this lady with pre-existing renal impairment.

Drug Name dexamethasone
Dose Form injection
Strength 4mg/ 1 & 2 ml ampules
Directions 4 mg iv
Quantity 30
No. of Repeats
Drug of choice
Issues
Efficacy Effective in prophylaxis of post-operative nausea and vomiting
(PONV) and treatment of late PONV.
Safety Profile Adverse effects associated with corticosteroid administration have

not been reported with a single dose of dexamethasone.
Cost Up to $30
Other Issues Significant side effects are rare with a single dose of
dexamethasone
Give drugs from another class if there is continuing nausea and vomiting.
Drug Name droperidol
Dose Form injection
Strength 2.5 mg in 1ml
Directions 0.625mg iv
Quantity 10
No. of Repeats
Drug of choice
Issues
Efficacy Effective
Safety Profile Extrapyramidal side effects more pronounced in elderly and the
young.
Cost Relatively expensive
More effective if given to prevent rather than treat established PONV. Give drugs from another class if
there is continuing nausea and vomiting.
Drug Name fentanyl
Dose Form parenteral

Strength 50 micrograms – 3.5 mg
Directions 10 microgram bolus via PCA
Quantity n/a
No. of Repeats
Drug of choice
Issues
Efficacy Mainstay of treatment for moderate to severe acute pain
Safety Profile Sedation, itch, nausea, vomiting, gut motility reduction and urinary
retention. Adverse events are dose related.
Cost There are additional costs of PCA equipment and patient monitoring
when using fentanyl PCA.
Other Issues Usually only used parenterally as patient controlled analgesia

through acute pain services
Fentanyl is commonly used for acute pain management via PCA, but not other modalities. Some
institutions do have nasal delivery devices in the Emergency Department for paediatric use.
Drug Name hydromorphone
Dose Form injection
Strength 2 mg/1 mL
Directions 1-2mg every 4 hours subcutaneous
Quantity 5
No. of Repeats
Drug of choice
Issues
Cost Approx $15
Other Issues Severe disabling pain not responding to non-narcotic analgesics

Restricted pharm. benefit
Hydromorphone is generally only used by specialist pain services.
Drug Name metoclopramide
Dose Form injection
Strength 10 mg/ 2mL

Directions 10 mg/2 mL
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective
Safety Profile Extrapyramidal side effects more pronounced in elderly and the
young.
Cost Approx. $13 - 15/ 10 amps.
Doses of 10mg have minimal anti-emetic effect.
Dose Form injection
Directions 2.5-5 mg subcut every 3 hours. 1mg bolus via PCA
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
The drug of choice in this situation as it is easily available parenterally, effective and cheap. Side effect
profile is similar to other opioids. Dosage needs to be individualised. May be administered via PCA, but
in general this requires review by anaesthetists or Acute Pain Services.
Dose Form modified release capsules, sachets & tablets
Strength 5, 10, 20, 30, 50, 60 & 100 mg
Directions If opioid naive, start at lowest dose or titrate with IR morphine

initially. Tablets should not be crushed or chewed
Quantity 20 (PBS)
No. of Repeats
Drug of choice
Issues
Cost <$1.50 per capsule/ tablet
Other Issues Oral sustained release morphine with slow onset of effect (hours).
Slow release preparations are not an appropriate formulation for treatment of acute pain. This lady is
also vomiting and would not tolerate oral medications.
Drug Name ondansetron
Dose Form injection
Strength 2 mg/mL, 2 & 4 mL
Directions 4mg IV at induction of anaesthesia. 8 mg IV as single dose.
Quantity 1 ampoule
No. of Repeats
Drug of choice
Issues
Efficacy Effective
Safety Profile Consider reducing dose in liver impairment.
Cost Approx $30
Other Issues Not available on PBS for PONV
Identifying patients at risk of PONV and treating prophylactically at induction is advisable. Give drugs
from another class if there is continuing nausea and vomiting.
Drug Name oxycodone
Dose Form tablet
Directions 2.5-5mg subcut every 3 hours
Quantity 20 (PBS)
No. of Repeats
Drug of choice
Issues
Cost ~$1.00 per tablet
Other Issues Strong oral opiate as alternative to morphine. Restricted Pharm.

Benefit.
Oral oxycodone is inappropriate here because of vomiting.
Dose Form tablet
Strength 500 mg
Directions 0.5-1gm every 4-6 hours, maximum 4gm per day
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Effective as adjunct to opioid analgesia
Safety Profile Caution in hepatic impairment, malnutrition

Effective in reducing opioid requirements in severe pain and may reduce opioid related side effects.
Hepatotoxic in overdose.
Drug Name promethazine
Dose Form injection
Strength 12.5 mg/ mL
Directions 12.5mg iv
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective in treating motion sickness and prophylaxis of
postoperative nausea and vomiting.
Safety Profile Side effects include central nervous system (CNS)

depression/excitation and anticholinergic effects.
Cost Approx. $16/ 10amps.
Use promethazine in postoperative nausea and vomiting when other agents have failed. Sedation may
limit use.
Drug Name tramadol
Dose Form capsules
Strength 50 mg
Directions IR 50-100mg every 4-6 hours;SR 100-200mg bd; maximum 400mg

daily
Quantity 20
No. of Repeats
Drug of choice
Issues
Cost $13- $23
Other Issues Significant interactions with SSRIs, MAOIs, TCAs and St Johns Wort
and pethidine.
Active metabolites formed by CYP2D6, so 10% of the population will have limited efficacy. May
occasionally be used in PCA.
Drug Name tropisetron
Dose Form injection
Strength 2 mg/2 mL
Directions 2mg iv daily
Quantity 1 ampoule
No. of Repeats
Drug of choice
Issues
Efficacy Effective
Safety Profile Consider reducing dose in liver impairment.
Cost Cost 10x metoclopramide
Other Issues Not available on PBS for PONV
Identifying patients at risk of PONV and treating prophylactically at induction is advisable. Give drugs
from another class if there is continuing nausea and vomiting.
Indication 5. Opioid Dependence
Drug Name buprenorphine
Strength 0.4 mg, 2 mg, 8 mg
Directions Start with 4 mg and increase in increments of 2-4 mg every 1-3 days
to maximum 32 mg daily.
Quantity n/a
No. of Repeats
Drug of choice
Issues
Efficacy Proven efficacy in reducing illicit opioid use.
Safety Profile Adverse events are dose related with methadone. Buprenorphine
can precipitate withdrawal if used too soon after use of a full opioid
agonist.
Cost $10-30
Other Issues Section 100 drug; Must have daily supervised dosing from clinic or
pharmacy.
Take-home doses may be provided after a period of stabilisation and with appropriate monitoring. In
general, take-home doses are provided as buprenorphine/naloxone combination product. Appropriate
State or Territory legislation should be followed, and may vary between jurisdictions.
Drug Name buprenorphine/naloxone
Strength buprenorphine 2 mg with naloxone 0.5 mg, buprenorphine 8 mg with

naloxone 2 mg
Directions Start at buprenorphine dose of 4 mg and increase in increments of

2-4 mg every 1-3 days to maximum 32 mg daily.
Quantity n/a
No. of Repeats
Drug of choice
Issues
agonist.
Cost $42-120
pharmacy.
Take home doses may be provided after a period of stabilisation and with appropriate monitoring. In
general, take home doses are provided as buprenorphine/naloxone combination product. In general, the
buprenorphine/naloxone combination is only used when take-home doses are being considered.
However some facilities may offer only 1one of buprenorphine or buprenorphine/naloxone combination.
Appropriate State or Territory legislation should be followed, and may vary between jurisdictions.
Drug Name methadone
Dose Form liquid
Strength 5mg/mL
Directions Start at lowest dose of 20-30 mg and increase by 5 mg every 3 days

until maximum of 120 mg. The maintenance dose for most patients
is usually aorund 60-80 mg daily.
Quantity n/a
No. of Repeats
Drug of choice
Issues
agonist.
Cost $25-30
pharmacy.
Take-home doses may be provided after a period of stabilisation and with appropriate monitoring.
Appropriate State or Territory legislation should be followed, and may vary between jurisdictions.
Adverse events are dose-related. For example the risk of prolonging QT interval is greater with doses >
than 120 mg daily.
Drug Name naltrexone
Dose Form tablets
Strength 50 mg
Directions Initial dose of 25 mg daily, increasing to 50 mg daily if no withdrawal

symptoms occur.
Quantity 30
No. of Repeats
Drug of choice
Issues
Efficacy Limited efficacy in preventing relapse to opioid use.
Safety Profile Several safety issues – see commentary box below
Cost $33
Other Issues Only available on PBS for alcohol dependence. For opioid
dependence it must be dispensed on a private script.
This treatment is of very limited efficacy. Treatment retention is poor and relapse to illicit opioid use is
high. Patients should be warned of the risk of overdose if there is a relapse to opioid use after a period
of abstinence with naltrexone, as a result of loss of tolerance to opioids.
There is a risk of precipitated withdrawal with use of naltrexone. A naloxone challenge test may be
necessary to ensure that the patient has been opioid abstinent prior to the first dose of naltrexone.
Directions NSAID induced ulcers, 20mg-40mg daily for 4-8 weeks
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Inactivate the hydrogen/potassium ATPase enzyme system (proton
pump), suppressing acid secretion.
Cost Approx $30
Esomeprazole, the S-isomer of omeprazole is available in Australia. Efficacy of esomperazole is similar
to that of omeprazole.
Indication 6. Confusion in an elderly woman
Drug Name chlorpromazine
Dose Form tablet, oral liquid
Strength 10, 25,100 mg & 5 mg/mL
Directions 50-100mg every two hours as needed.
Quantity 100, 100 mL

No. of Repeats
Drug of choice
Issues
Efficacy Very effective in confusional states.
Safety Profile Short term problems uncommon. Medium and long term problems
such as dystonias and Parkinsonian tremor very common.
Cost Approx. $10(25 mg), $14(100 mg)/ 100 & $10 (liq) ea
Chlorpromazine is fairly sedative, causes a lot of postural hypotension and also is moderately
anticholinergic. These latter qualities make it a less desirable agent. Initial doses should always be
started low and if repeated the patient should be carefully monitored. If oral therapy is possible, small
(50mg) doses of chlorpromazine may be tried.
Interestingly the syrup is pink and some people think is the basis of the line "pink Champagne on ice" in
the Hotel California song. Google it and see!
Dose Form injection
Strength 50 mg /2 mL
Directions IV 25-50 mg up to 3 or 4 times daily.
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Cost Approx. $15/ 10 amps.
Chlorpromazine is fairly sedative, causes a lot of postural hypotension and also is moderately
anticholinergic. These latter qualities make it a less desirable agent.
If chlorpromazine is given, the IV route is preferred as the solution is irritant and IM injection may cause
site abscesses.
Dose Form tablet
Strength 25 mg
Quantity 100
No. of Repeats
Drug of choice
Issues
cardiovascular events.

effects
Cost $18
Chlorthalidone has a duration of action of 48-72 hours, longer in renal failure, compared to 6-12 hours
with hydrochlorothiazide, and 24-36 hours with indapamide, with the result that chlorthalidone often
accumulates and more often causes metabolic side effects. You should choose one thiazide and
generally use a lower dose to avoid the metabolic side effects. Meta-analyses have shown that lower
doses are associated with similar blood pressure reduction as higher doses, but surprisingly have
greater efficacy in preventing cardiac events. Higher doses have a greater diuretic effect, and as a
result may cause more symptomatic as well as metabolic adverse reactions.
Drug Name diazepam

Directions 2-10mg 2-6 hrly

No. of Repeats
Drug of choice
Issues
Efficacy Will produce sedation but used by some doctors in this context.
Safety Profile Generally safe in the absence of respiratory failure.
Benzodiazepines are a possible option in this context but elderly patients require lower doses and
repeated doses may result in cumulative effects that may prove dangerous.
Diazepam 5-10mg orally, reviewed and repeated if required 2-6 hourly, depending on response, is an
option.

Drug Name diazepam
Dose Form injection
Strength 10 mg/2 mL
Directions 5-20 mg 2-6 hourly
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
Benzodiazepines are a possible option in this context but elderly patients require lower doses and
repeated doses may result in cumulative effects that may prove dangerous.
Diazepam 2.5-5mg IV, given slowly and repeated 2-6 hourly, depending on response, is an option.
Drug Name haloperidol
Dose Form Oral Liquid
Strength 2 mg per mL, 100 mL
Directions 1-5mg 2-3 times daily
Quantity 1
No. of Repeats
Drug of choice
Issues
Cost $17- $20
Other Issues .
An oral dose should be given where possible as injections can be difficult and scare the patient. The
elderly will usually respond to lower doses (0.5mg in very elderly.)
Dose Form injection

Strength 5* and 10 mg/ml
Directions IM 0.5-1mg hourly as needed up to a specified maximum
Quantity * 10 (PBS)
No. of Repeats
Drug of choice
Issues
Cost * Approx. $20/ 10 amps.
Other Issues * General Pharm. Benefit
This type of agent is the treatment of choice in elderly confused patients but initial doses should always
be started low and if repeated the patient should be carefully monitored. Haloperidol should be
prescribed at a starting dose of 0.5-1mg IM in the elderly — repeated cautiously as required in relation
to symptoms. Following IM injection, the therapeutic effect is seen within 45-60 minutes.
There is a high risk of dystonias (e.g. laryngeal) and unpleasant extrapyramidal adverse effects with
haloperidol when either excessive initial or repeated doses are given without observation and
monitoring.When administered carefully in small doses with regular review and dose titration,
haloperidol is an ideal agent as it has a rapid onset of action, and has minimal effects on postural
hypotension or anticholinergic activity.
Drug Name olanzapine
Dose Form tablet
Strength 2.5, 5, 7.5, 10 mg
Quantity 30
No. of Repeats
Drug of choice
Issues
Efficacy Atypical agents generally have a lower incidence of EPSE than the
conventional agents and may also decrease relapse rates.
Safety Profile Incidence of serious adverse effects such as tardive dyskinesia and
neuroleptic malignant syndrome is lower than conventional agents.
Cost $100-400 for 30 tabs
Other Issues Associated with increased risk of vascular events and death.
Olanzapine is an atypical antipsychotic which is very popular with some clinicians for the management
of delirium. Because of its atypical nature, it has a much lower incidence of extrapyramidal adverse
reactions than typical antipsychotics, with prolonged dosing.
Compared to other atypical antipsychotics it is very sedative and is also anticholinergic hence may be
associated with dry mouth, impaired vision, and urinary retention.
Its main disadvantage is that it is has a slow onset of action with the peak concentration occurring 6
hours after oral administration, hence it can be very difficult to titrate the dose against the desired effect.
Its sedative and anticholinergic effects can also be troublesome, especially in the elderly. It is also very
expensive and is not available on the PBS, hence if the patient requires ongoing management for their
confusional state, the dosing cannot be continued in the community.
Drug Name risperidone
Dose Form tablet
Strength 0.5 & 1 mg
Directions 0.25mg twice daily
Quantity 60
No. of Repeats
Drug of choice
Issues
Cost $38 (0.5 mg) & $72 (1 mg)
Other Issues Maybe associated with increased risk of vascular events and death.
PBS authority.
Risperidone has recently been PBS authority approved for the treatment of behavioural disturbances in
dementia. It is the only atypical antipsychotic which has this approval.
Although an atypical antipsychotic, with prolonged dosing, risperidone has a higher incidence of
extrapyramidal effects compared to other agents such as olanzapine or quetiapine. In patients with
behavioural disturbances associated with dementia, however, it has the advantage of being PBS
subsidised, hence it can be prescribed on an ongoing basis in the community. In the short term and at
recommended doses, these extrapyramidal reactions tend not to be troublesome.
Drugs such as risperidone also appear to increase the risk of cerebrovascular events and death in
patients with dementia. (See NPS RADAR for further information.)
Drug Name temazepam
Dose Form tablets
Strength 10 & 20 mg
Quantity 25
No. of Repeats
Drug of choice
Issues
* marketed for short term treatment of insomnia
* short acting
* IV abuse of gelatin capsules has been a concern
weeks
Dose Form capsule
Directions 1-4mg mane
Quantity 30
No. of Repeats
Drug of choice
Issues
endpoints
Cost $20-30
particular clinical situations eg post-myocardial infarction, post-stroke. Trandolapril has the longest half
life of the ACE-I and is preferred by some clinicians for this reason. The only other comment to make
about trandolapril are the unusual brand names: Odrik, Gopten and now Tarka (as a combination with
Verapamil). Sound like the sort of medications you would buy over the internet from a bloke called Borat
in Khazhakstan.
Indication 7. Confusion associated with ETOH withdrawal
Dose Form tablet

Directions 400 mg twice daily
Quantity 200 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Effective in reducing seizures
Safety Profile Dizziness, nausea, vomiting.
Carbamazepine is a first line agent for the treatment of generalized tonic-clonic seizures. There is some
data to support the use of anti-epileptics for alcohol withdrawal and most of the trials have been
conducted with carbamazepine.
In the majority of cases, however, carbamazepine would be used in conjunction with a benzodiazepine
such as diazepam. Although it may be effective in preventing seizures, it does not address the
autonomic symptoms of alcohol withdrawal, and is associated with a high incidence of ataxia, nausea
and vomiting at recommended doses.
Dose Form tablet, oral liquid
Strength 10, 25,100 mg & 5 mg/mL
Directions 50-100 mg every two hours as needed.
Quantity 100, 100 mL
No. of Repeats
Drug of choice
Issues
Efficacy Very effective in confusional states but less so for ethanol
withdrawal.
Cost Approx. $10(25 mg), $14(100 mg)/ 100 & $10 (liq) ea
Psychotropic drugs are not treatment of first choice as they are less effective than benzodiazepines in
reducing delirium and seizures. However if agitation and hallucinations are severe then one or two
doses of a psychotropic may be added to diazepam.
Note: They should never be used alone because they are associated with a high rate of complications
such as seizures and delirium tremens.
Oral chlorpromazine (50 mg) is a possible choice but will have a slower onset of action and is likely to
be less effective than haloperidol.
Dose Form injection
Directions IV 25-50 mg up to 3 or 4 times daily
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
withdrawal.
Psychotropic drugs are not the treatment of first choice, as they are less effective than benzodiazepines
in reducing delirium and seizures. However if agitation and hallucinations are severe then one or two
doses of a psychotropic may be added to diazepam.
Note: They should never be used alone because they are associated with a high rate of complications
such as seizures and delirium tremens.
IV chlorpromazine carries a relatively lower risk of dystonias and extrapyramidal effects than other
antipsychotics. However, because it acts on many different types of receptors it can have a variety of
different adverse reactions.
Drug Name clonidine
Dose Form tablet
Strength 100 & 150 microgam
Directions 50-75 micrograms 8-12 hourly
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Only useful as adjunctive therapy.
Safety Profile High doses may result in withdrawal to the drug when it is stopped.
Cost $26-$34 for 100
Many of the symptoms of withdrawal e.g. tachycardia, sweating, tremor and agitation are due to
overactivity of the sympathetic nervous system. It therefore seems logical to use drugs to antagonise
adrenergic activity.
All drugs in this group should be considered as third line therapy. Clonidine, added to diazepam, has
been shown to reduce symptoms but no good data are available to indicate whether it reduces seizures
or hallucinations.
The same is true of beta-blockers. If a beta-blocker is used it should be non-selective (e.g. propranolol)
as beta-selective agents (e.g. metoprolol) will not affect beta-2 responses such as tremor.
Drug Name diazepam

Directions 5-20 mg if alcohol withdrawal scale >10

No. of Repeats
Drug of choice
Issues
Efficacy Ideal characteristics to produce sedation but may need high doses
Safety Profile Care needed with respiratory failure and elderly patients.
Diazepam, with its long half life, is the drug of choice for treating alcohol withdrawal and preventing
progression to delirium tremens. Doses required may range from 30mg-120mg in the first 24-48 hours.
An IV dose could be given initially, assuming a cannula is in place, but subsequent dosing is usually
oral. In general, individualising therapy results in lower total doses and shorter treatment times. Start
with lower doses in the elderly or those patients with respiratory failure.
Many of you may wonder why it is that diazepam has a really long half life (which is desirable) but then
only seems to help with agitation or anxiety for a few hours. The reason is that it is a very lipophilic drug,
and similar to other lipophilic drugs it is first distributed to areas of high blood flow. This includes the
brain, hence you get a rapid onset of effect, because the brain concentration is high (although the
peripheral blood concentration may be low). With time, however, the drug distributes out of the brain
(hence diminishing effect seen) and distributes into blood on its way to lower blood flow organs such as
adipose tissue. The half life of the drug which is quoted is this slower elimination half life, rather than the
distribution (out of the brain) half life, which is more reflective of the half life of the effect.
See! Pharmacokinetics can be cool, and actually useful!
Drug Name diazepam
Dose Form injection
Strength 10 mg/2 mL
Directions 5-20 mg if alcohol withdrawal scale >10
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
Diazepam, with its long half life, is the drug of choice for treating alcohol withdrawal and preventing
progression to delirium tremens. Doses required may range from 30mg-120mg in the first 24-48 hours.
An IV dose could be given initially, assuming a cannula is in place, but subsequent dosing is usually
oral. In general, individualising therapy results in lower total doses and shorter treatment times. Start
with lower doses in the elderly or those patients with respiratory failure.
Many of you may wonder why it is that diazepam has a really long half life (which is desirable) but then
only seems to help with agitation or anxiety for a few hours. The reason is that it is a very lipophilic drug,
and similar to other lipophilic drugs it is first distributed to areas of high blood flow. This includes the
brain, hence you get a rapid onset of effect, because the brain concentration is high (although the
peripheral blood concentration may be low). With time, however, the drug distributes out of the brain
(hence diminishing effect seen) and distributes into blood on its way to lower blood flow organs such as
adipose tissue. The half life of the drug which is quoted is this slower elimination half life, rather than the
distribution (out of the brain) half life, which is more reflective of the half life of the effect.
See! Pharmacokinetics can be cool, and actually useful!
Drug Name droperidol
Dose Form injection
Strength 10 mg/2 mL
Directions IM 5-25 mg repeated if necessary in 4 to 6 hours.
Quantity 10
No. of Repeats
Drug of choice
Issues
withdrawal.
Cost Relatively expensive
Droperidol should only be used by psychiatrists or drug and alcohol experts. It is very potent and has
been associated with QTc prolongation at these doses.
Dose Form injection
Strength 5* and 10 mg/ml
Directions IM 0.5-5 mg hourly as needed
Quantity * 10 (PBS)
No. of Repeats
Drug of choice
Issues
withdrawal.
Cost * Approx. $20/ 10 amps.
Other Issues * General Pharm. Benefit
The drug of choice amongst antipsychotics is haloperidol with dose being adjusted down to 1 or 1.5mg
for older patients. Repeated dosing of haloperidol carries a risk of dystonias and extrapyramidal effects.
Drug Name lorazepam
Dose Form tablet

Quantity 50
No. of Repeats
Drug of choice
Issues
Trials have shown that other benzodiazepines, such as lorazepam, will work, but short acting drugs
such as oxazepam and midozolam should be avoided. Longer acting drugs are more effective at
preventing seizures. The main reason for not using lorazepam is that most clinicians are not familiar
with it and there may be dosing errors associated with it as a result. For example, do you know off the
top of your head how many milligrams of diazepam is 10mg of lorazepam?
Reference:
AMH Drug Choice Companion: Emergency and Primary Care - Alcohol withdrawal p 32
Drug Name olanzapine
Dose Form tablet
Strength 2.5, 5, 7.5, 10 mg
Directions 2.5-10 mg daily
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $100-400 for 30 tabs
Other Issues Associated with increased risk of vascular events and death.
Olanzapine is an atypical antipsychotic which is very popular with some clinicians for the management
of delirium. Because of its atypical nature, it has a much lower incidence of extrapyramidal adverse
reactions than typical antipsychotics, when there is prolonged dosing.
Its main disadvantage is that it is has a slow onset of action with the peak concentration occurring 6
hours after oral administration, hence it can be very difficult to titrate the dose against the desired effect.
Its sedative and anticholinergic effects can also be troublesome, especially in the elderly. It also has a
long half life.
As a result it can be really difficult to titrate against effect in a patient acutely withdrawing from alcohol.
Drug Name propranolol
Dose Form tablet
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Only useful as adjunctive therapy.
Safety Profile Safe in normal therapeutic doses.
Cost 16-34 cents / day
Many of the symptoms of withdrawal, e.g. tachycardia, sweating, tremor and agitation are due to
overactivity of the sympathetic nervous system. It therefore seems logical to use drugs to antagonise
adrenergic activity.
All drugs in this group should be considered as third line therapy. If a beta-blocker is used it should be
non-selective (e.g. propranolol) as beta-1 selective agents (e.g. metoprolol) will not affect beta-2
responses such as tremor.
Drug Name thiamine
Dose Form injection
Strength 100 mg/mL
Directions 100 mg daily for 3-5 days
Quantity 5
No. of Repeats
Drug of choice
Issues
Efficacy Essential to prevent complications.
Safety Profile No side effects.
Cost Approx. $13/5 amps.
Daily thiamine injections are essential. Without them, there is a major risk of permanent frontal lobe
damage (Wernicke’s encephalopathy). Thiamine (vitamin B1) has been shown to prevent this damage.
The patient has a high MCV due to his alcohol intake. It is possible that he has folate or vitamin B12
deficiency but this should not be treated unless or until deficiency is established. If he is B12 deficient it
could be dangerous to give him folate alone as this might precipitate subacute combined degeneration
of the spinal cord.
Indication 8. Acute pulmonary oedema in CHF
Drug Name digoxin
Dose Form tablet
Strength 62.5 & 250 micrograms
Directions Loading dose 500 micrograms orally repeat at 4 and 8 hours if

necessary to a maximum of 1.5 mg then daily maintenance dose of
125 to 250 micrograms (reduce dose in elderly.
Quantity 200 (62.5 micrograms), 100 (250 micrograms) (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Only recommended in rapid atrial fibrillation
Safety Profile Increased risk of arrhythmias
Cost $17 - $33
Not indicated in the management of acute pulmonary oedema unless it is required for rate control of a
rapid ventricular response in a patient in atrial fibrillation.
Drug Name dobutamine
Dose Form injection
Strength 250 mg/ 20 mL
Directions initially 2.5-5mcg/kg/minute then according to response
Quantity 1
No. of Repeats
Drug of choice
Issues
Efficacy Short term hemodynamic efficacy
Safety Profile Increased arrhythmia risk
Cost
Other Issues More vasodilatory than other inotropes
Can be considered for short term support of the circulation if pulmonary oedema is severe with low
cardiac output and not responding to treatment with diuretics and nitrates. As it tends to cause more
vasodilatation than other inotropes, may not be associated with as great a rise in blood pressure as
other agents.
Drug Name dopamine
Dose Form injection
Strength 20 0mg/ 5 mL,
Directions initially 2.5-5microgram/kg/minute
Quantity .
No. of Repeats
Drug of choice
Issues
Efficacy Short term hemodynamic efficacy
Safety Profile Increased arrhythmia risk
Cost Variable as hospital only
Other Issues Inotropic agent
Can be considered for short term support of the circulation if pulmonary oedema is severe with low
cardiac output and not responding to treatment with diuretics and nitrates.
Quantity 10 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Prevention of VTE in bedridden patients
Safety Profile Bleeding incidence is similar for heparin and LMWHs
Cost $33
Low molecular with heparin such as enoxaparin are recommended treatments for DVT prophylaxis in
high risk medical patients.40mg is the standard dose which may need to reduced for patients with renal
impairment.
Drug Name frusemide
Dose Form injection
Directions 40-80 mg as required IV
Quantity 5
No. of Repeats
Drug of choice
Issues
Efficacy Effective in symptom control and reducing fluid overload
Safety Profile Risk of hypotension and dehydration
Cost $5-10
Other Issues Intravenous loop diuretic
This is a preferred diuretic for acute pulmonary oedema. It is a powerful loop diuretic and produces a
rapid diuresis. As it is a high ceiling diuretic if the initial dose is insufficient increasing doses are likely to
have increasing effect. The intravenous route may produce a transient venodilatation as well as rapid
onset of action.
Drug Name frusemide
Dose Form tablet
Directions 40-80 mg once or twice daily
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Effective in symptom control and reducing fluid overload
Safety Profile Risk of hypotension and dehydration
Cost $13- $23
A good choice for ongoing management but onset of action may not be fast enough for rapid symptom
relief in the acute situation.

Directions 1-2 sprays as required
No. of Repeats
Drug of choice
Issues
Efficacy Effective in reducing preload and myocardial oxygen requirements
Safety Profile Hypotension, headache
Cost $18/bottle
more expensive
Rapid onset of action but short duration of action . Useful in administering a nitrate loading dose to
patient whilst infusion is being organized.
Dose Form injection
Directions 10-80mcg/min
Quantity n/a
No. of Repeats
Drug of choice
Issues
Cost variable – hospital only
Other Issues ideal nitrate for titrating dose to effect
This is the preferred nitrate for severe pulmonary oedema especially if associated with ischaemia or
hypertension. It has a short half life hence the dose can be easily adjusted to titrate against the patient's
blood pressure and symptoms. As it can take a while to put up an infusion, usually follows
administration of sublingual nitrate.
Dose Form tablet

Directions 5-20mg prn
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $9 per bottle
Rapid onset but short duration of action . Useful in administering a nitrate loading dose to patient whilst
infusion is being organized. The only disadvantage is has is that in some patients who are tachypnoeic,
their dry mouth makes the tablets difficult to dissolve.
Dose Form tablet
Directions 5-20mg prn
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $9 per bottle
Rapid onset of action with with longer duration of action than GTN. May be repeated after 30 minutes if
necessary.
Drug Name milrinone
Dose Form injection
Directions Initially 50 micrograms/kg slowly over 10 minutes then 0.375-0.75

mcg/kg/min
Quantity .
No. of Repeats
Drug of choice
Issues
Efficacy Short term parenteral inotropic support
Safety Profile Increased risk of arrhythmias and other detrimental effects
Cost Variable as hospital only
Other Issues Hospital specialist use only
Phosphodiesterase inhibitors are indicated in severe refractory heart failure and low cardiac output
states eg post-cardiac surgery. A trial has shown that milrinone is no better than placebo and possibly
worse in the management of patients with acute pulmonary oedema. Hence its use is only really
indicated under special circumstances in the intensive/coronary care setting.
Dose Form injection
Directions 2.5 to 10 mg IV (lower doses in elderly)
Quantity 5 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Relief of symptoms and transient venodilatation
Safety Profile May produce adverse haemodynamic effects, sedation, nausea and
vomiting
Intravenous morphine has a rapid onset of action and may produce a transient venodilatation,
contributing to preload reduction, as well as relieving distress and reducing myocardial oxygen demand.
Although it can cause respiratory depression, this is rarely an issue in this setting as small doses (2.5-
5mg) are titrated to effect.
Indication 9. CHF
Dose Form tablet
Strength 1 mg
Directions 0.5-4 mg 1-2 times daily
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Effective for symptom control
Safety Profile Electrolyte abnormality, postural hypotension, neurohormonal

activation
Cost $10 approx.
bumetanide tablet 1 mg 0.5-4 mg 1-2 times daily 100 1 $10 approx. Not on PBS
An alternative loop diuretic to frusemide. However, it still has a sulphonamide moiety, hence patients
who are allergic to frusemide for this reason, may still not tolerate bumetanide and ethacrynic acid
should be considered.
Effective for symptom control

Electrolyte abn, postural hypotension, neurohormonal activation
$10 approx
Not on PBS
Indication 9. CHF
Dose Form tablet
Directions 4mg starting, 32mg target dose
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Efficacy in patients unable to tolerate ACE inhibitors
Safety Profile Similar to ACE inhibitors without the cough.
Cost $32
candesartan tablet 4, 8, 16, 32 mg 4mg starting, 32mg target dose 30 (PBS) 5 (PBS) $32 proven CHF
efficacy
Candesartan has been shown to be effective in patients who cannot tolerate ACE inhibitors, and
appears to have (less) additional benefit for patients who are already on an ACE inhibitor.
Indication 9. CHF
Drug Name captopril
Directions 6.25 mg twice daily starting, 50 mg three times per day target
No. of Repeats
Drug of choice
Issues
morbidity in left ventricular dysfunction.
Safety Profile Low incidence of adverse events if dosing initiated correctly.
Cost $21- $32
Extensive evidence of benefits in prolonging survival and reducing morbidity in LV dysfunction.
Low incidence of adverse events if dosing initiated correctly. $21-$32
Short half life.
ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of
bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and
aldosterone release. They also reduce the effect of angiotensin on sympathetic nervous activity and as
a growth factor.
Captopril is an ACE inhibitor with a short half life and hence has to be given 2-3 times per day. Its use is
hence limited to situations where the patient may be at high risk of hypotension or renal impairment, e.g.
elderly, low BP, low Na, or dehydrated patients on high dose diuretics. It is no less likely than other ACE
inhibitor to cause these reactions, but if they were to occur, then the duration would be expected to be
shorter with captopril.
Indication 9. CHF
Dose Form tablet
Strength 3.125, 6.25, 12.5 & 25 mg
Directions 3.125 mg twice daily starting, 25 mg twice daily target
Quantity 60 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Dramatic mortality benefit in addition to ACE inhibitors
Safety Profile Hypotension, dizziness, worsening of heart failure, heart block
Cost $23 - $32
Dramatic mortality benefit in addition to ACEi
Hypotension, dizziness, worsening of heart failure, heart block
$23-$32
Authority for CCF only
Indication 9. CHF

Dose Form tablet
Strength 25 mg
Quantity 100
No. of Repeats
Drug of choice
Issues
Efficacy Mild diuretic for symptomatic benefit in mild heart failure
Safety Profile Electolyte abnormality, postural hypotension, ? neurohormonal

activation
Cost $18
chlorthalidone tablet 25 mg 12.5-25mg daily 100 1 $18 Thiazide (low ceiling) diuretic
An appropriate choice if a low ceiling diuretic is required.
Mild diuretic for symptomatic benefit in mild heart failure
Electrolyte abn, postural hypotension ?neurohormonal activation
$18
Thiazide (low ceiling) diuretic
Indication 9. CHF
Drug Name enalapril
Dose Form tablet
Strength 2.5, 5,10 & 20 mg
Directions Initially 2.5 mg daily, increased up to 10–20 mg daily as 1 or 2 doses
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $21-25
This would be an appropriate drug and the lowest dose would be an appropriate starting dose which
should subsequently be increased to the maximum tolerated dose.
Extensive evidence of benefits in prolonging survival and reducing morbidity in LV dysfunction.
Low incidence of adverse events if dosing initiated correctly.
$21-25
Indication 9. CHF
Drug Name fosinopril
Dose Form tablet
Strength 10 & 20 mg
Directions 5mg daily starting , 20-40mg daily target
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $20 - $25
fosinopril tablet 10 & 20 mg 5mg daily starting , 20-40mg daily target 30 5 $20 - $25 Once daily ACE-I
This would be an appropriate drug and the lowest dose would be an appropriate starting dose which
should subsequently be increased to the maximum tolerated dose.
Indication 9. CHF
Drug Name frusemide
Dose Form injection
Directions 40-80 mg
Quantity 5
No. of Repeats
Drug of choice
Issues

activation
Cost $5-10
Other Issues Intravenous loop diuretic
frusemide injection 20 mg/ 2 mL 40-80 mg 5 Nil $5-10 Intravenous loop diuretic
This would be an inappropriate and inconvenient route of administration for chronic heart failure.
Indication 9. CHF
Drug Name frusemide
Dose Form tablet

Directions 40-80 mg 1-2 times daily
Quantity 100
No. of Repeats
Drug of choice
Issues

activation
Cost $13- $23
frusemide tablet 10, 40, 500 mg 40-80 mg 1-2 times daily 100 1 $13- $23 Oral loop diuretic
A good choice for ongoing management but if heart failure is well controlled consider reducing dose,
replacing with a thiazide diuretic or ceasing. Patients are usually commenced on 40-80mg daily, but as
the dose of ACE inhibitor is increased and other medications with other benefits such as beta-blockers
are introduced, the dose of frusemide should be reduced. The eventual aim is to use the lowest dose of
frusemide (which may be none) and let the patient adjust their frusemide dose according to their
symptoms and weight.
Indication 9. CHF
Drug Name hydrochlorothiazide
Dose Form tablet
Strength 25 mg
Quantity 100
No. of Repeats
Drug of choice
Issues

activation
Cost $26
hydrochlorothiazide tablet 25 mg 25-50mg daily 100 1 $26 Thiazide (low ceiling) diuretic
An appropriate choice if a low ceiling diuretic is required.
Indication 9. CHF
Drug Name indapamide

Dose Form tablet
Strength 1.5 mg(sustained release)& 2.5 mg
Directions 1.25–2.5 mg once daily in the morning
Quantity 90 (PBS)
No. of Repeats
Drug of choice
Issues

activation
Cost $22 - $25
indapamide tablet 1.5 mg(sustained release)& 2.5 mg 1.25–2.5 mg once daily in the morning 90 (PBS)
1 (PBS) $22 - $25 General Pharm. Benefit
Although still common, the risk of hypokalaemia is less with 1.5 mg controlled release tablet than with
2.5 mg conventional tablet; their antihypertensive effect is similar
Indication 9. CHF
Drug Name irbesartan
Dose Form tablet
Directions 75mg starting dose, aim for maximum tolerated
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Efficacy Efficacy in patients unable to tolerate ACE inhibitors
Safety Profile Similar to ACE inhibitors without the cough.
Cost $26- $32
Other Issues Commonly prescribed angiotensin receptor blocker
irbesartan tablet 75, 150 & 300 mg 75mg starting dose, aim for maximum tolerated 30 (PBS) 5 (PBS)
$26- $32 Commonly prescribed angiotensin receptor blocker
Irbesartan is a commonly prescribed angiotensin receptor blocker. Although it is indicated for
hypertension, and has efficacy data in prevention of renal disease progression, there is no efficacy data
in heart failure.
Indication 9. CHF

Dose Form tablet
Directions 12.5 mg twice daily starting, 100mg twice daily target
Quantity 100 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $15 - $33
metoprolol tablet 50 & 100 mg 12.5 mg twice daily starting, 100mg twice daily target 100 (PBS) 5 (PBS)
$15 - $33 General Pharm. Benefit
A long acting formulation of metoprolol has been shown be of benefit in the management of heart
failure, and this benefit is likely to be shared by the short acting formulation. Some would argue that
since the long acting formulation is the one that has been proven in a clinical trial, only this formulation
should be used. The main disadvantage of this formulation of metoprolol is the difficulty in dividing the
tablets accurately into small enough doses for safe initiation of treatment.
Indication 9. CHF
Strength 23.75 mg, 47.5 mg, 95 mg, 190 mg
Directions 23.75 mg daily starting, 190 mg daily target
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $33
Other Issues General Pharm. benefit
metoprolol controlled release tablet 23.75 mg, 47.5 mg, 95 mg, 190 mg 23.75 mg daily starting, 190 mg
daily target 30 (PBS) 5 (PBS) $33 General Pharm. Benefit
This sustained release formulation of metoprolol has been shown in a clinical trial to be effective in the
management of heart failure. Its main advantage over the normal metoprolol preparation is that smaller
initial doses can be readily given (without having to cut the tablet into 4 little pieces!) and that it is once
daily. Its main disadvantage is the cost. There are some who argue that given that it is the formulation
which was used in the clinical trial of metoprolol in heart failure, then it should be used rather than the
much cheaper non-sustained release preparation.
Its main other disadvantage is the confusing dosing: I don't know about you, but I was never very good
at my 23.75 times tables! Its main advantage over carvedilol is that it is beta1 selective, hence it is less
likely to give rise to adverse reactions in patients with reversible airways disease, however, it may not
be as effective.
Dramatic mortality benefit in addition to ACEI
Hypotension, dizziness, worsening of heart failure, heart block
$33
Gen Pharm Benefit
Indication 9. CHF
Dose Form tablet
Directions Initially 2.5mg-5 mg once daily. Maximum 10 mg daily.
Quantity 30 (PBS)
No. of Repeats
Drug of choice
Issues
Cost $17 - $30
perindopril tablet 2, 4, and 8mg of erbumine salt; 2.5, 5, and 10mg of arginine salt Initially 2.5mg-5 mg
once daily. Maximum 10 mg daily. 30 (PBS) 5 (PBS) $17 - $30 Confusing formulations
Perindopril erbumine 2,4 and 8 mg equals Perindopril arginine 2.5, 5, and 10 mg. This would be an
appropriate drug and the lowest dose would be an appropriate starting dose which should subsequently
be increased to the maximum tolerated dose.
Indication 9. CHF
Drug Name quinapril
Dose Form tablet
Strength 5,10 & 20 mg
Directions 2.5mg daily starting, target 20-40mg daily
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $18 - $22
quinapril tablet 5,10 & 20 mg 2.5mg daily starting, target 20-40mg daily 30 5 $18 - $22 Once daily ACE-I
The dose of quinapril should be increased from 2.5 mg daily to 20-40mg or as near to this as tolerated.
Indication 9. CHF
Drug Name ramipril
Dose Form tablet
Directions 1.25 daily starting, 5-10mg target
Quantity 30
No. of Repeats
Drug of choice
Issues
Cost $15-30
ramipril tablet 1.25, 2.5, 5 and 10 mg 1.25 daily starting, 5-10mg target 30 5 $15-30 .
This would be an appropriate drug and the lowest dose would be an appropriate starting dose wish
should subsequently be increased to the maximum tolerated dose. There is currently a small patient
premium for the patient to pay.

My Formulary 2

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

My Formulary 2

Hochgeladen von

Copyright:

Verfügbare Formate

My Formulary

Drug Name amoxycillin

Dose Form oral (caps)

Directions Take ONE 8 hourly for 5 days

Safety Profile Wide safety margin for commonly used agents

Cost $8.12 (250mg), $10.22(500mg) for quantity of 20

Other Issues Resistance rates from 40 to as high as 80% to amoxycillin in some

Drug Name amoxycillin + clavulanic acid

Dose Form tablet

Directions 875/125 mg 12 hrly for 5 days

Safety Profile Wide safety margin for commonly used agents

Cost Approx $14.17 for dispensed max.quantity of 10

Other Issues More adverse reactions than amoxycillin

Drug Name beclomethasone

Dose Form Metered Dose Inhaler (MDI)

Strength 50,100 micrograms /dose

Directions 50-200 micrograms twice daily

Quantity 1 x 200 doses (PBS)

Safety Profile Some adverse reactions associated with long-term dosing.

Cost Approx. $26(50), $36(100) each

Drug Name budesonide

Dose Form Nebuliser (Single Dose Unit)

Strength 500 micrograms & 1 mg/ 2 mL

Directions 0.25 to 0.5 mg twice daily - suggested 400mcg bd

Safety Profile Some adverse reactions associated with long-term dosing.

Cost Approx. $35 (500mcg) & $47( 1 mg) / 30

Other Issues PBS Authority

Drug Name doxycycline

Dose Form tablet /capsule

Strength 50 & 100 mg

Safety Profile Wide safety margin for commonly used agents

Other Issues tetracycline

Drug Name eformoterol

Dose Form Dose Powder Inhaler (DPI)

Strength 6 & 12 micrograms/dose

Directions 6 to 12 micrograms twice daily, maximum daily dose 48 micrograms.

Quantity 60 caps./ doses

Safety Profile Generally well tolerated, some safety concerns in asthma

Cost Approx. $24/ 60(6micrograms) & $34/60 (12micrograms)

Other Issues Not PBS approved for COPD

Drug Name fluticasone

Dose Form Dose Powder Inhaler (DPI)

Strength 100, 250 & 500 micrograms dose

Quantity 60 doses (PBS)

Safety Profile Some adverse reactions associated with long-term dosing.

Cost Approx.$16(100), $29(250) & $49(500 micrograms)/ 60

Other Issues General Pharm. Benefit

Drug Name hydrocortisone

Dose Form Intravenous solution

Strength 100 mg/ 2 mL, 250 mg/ 2 mL

Directions 100 mg 6 hourly

Other Issues Requires IV line and regular dosing

Drug Name ipratropium

Dose Form Metered Dose Inhaler (MDI)

Directions 40 micrograms as required. Repeat 40 to 80 micrograms 3 - 4 times

Quantity 2 (20 microgram)

Dose Form Patch

Strength 7 - 21 mg/16 -24hrs

Drug Name prednisolone

Dose Form Oral tablet

Directions 30 - 50 mg per day for 7 - 14 days

Quantity 100, 60, 30

Other Issues n/a