Dosing Flashcards
Unfractionated Heparin (UFH): VTE prophylaxis
5,000 units SC Q8-12H
Unfractionated Heparin (UFH): VTE TX
Bolus: 80 units/kg IV
Infusion: 18 units/kg/hr CIV
**Dose using total body weight
Unfractionated Heparin (UFH): ACS/STEMI TX
Bolus: 60 units/kg IV
Infusion: 12 units/kg/hr CIV
**Dose using total body weight
Enoxaparin: VTE prophylaxis
30mg SC Q12H or 40mg SC QD
CrCl <30mL/min: 30mg SC QD
Enoxaparin: VTE and unstable angina/NSTEMI TX
1mg/kg SC Q12H
Inpatient only: 1.5mg/kg SC QD
CrCl <30mL/min: 1 mg/kg SC QD
**Dose using total body weight
Enoxaparin: STEMI TX
<75 yo: 30mg IV bolus then 1mg/kg SC Q12H (max: 100mg for first two SC doses only)
-CrCl <30mL/min: 1mg/kg SC QD
75 yo or older: 0.75mg/kg SC Q12H (NO bolus)
-CrCl <30mL/min: 1mg/kg SC QD
**Dose using total body weight
Apixiban: Stroke prophylaxis in non-valvular Afib
5mg PO BID
**Adjust to 2.5mg PO BID if pt has two risk factors of bleeding or more
-Age 80 yo or older
-Body weight 60kg or less
-SCr 1.5mg/dL or higher
Apixiban: VTE TX
10mg PO BID x7D then 5mg PO BID
-Can use starter pack to help with dosing
Extended phase (6 months or more): 2.5mg PO BID
Rivaroxaban: Stroke prophylaxis in non-valvular Afib
CrCl >50mL/min: 20mg PO w/ evening meal
CrCl 15-50mL/min: 15mg PO w/ evening meal
CrCl <15mL/min: AVOID use
**Doses 15mg or greater must be taken with food (in evening was how trial was studied)
Rivaroxaban: VTE TX
15mg PO BID x21D then 20mg PO with food
-CrCl <30mL/min: AVOID use
**Doses 15mg or greater must be taken with food (in evening was how trial was studied)
Warfarin: what are the colors associated with the different strengths?
“Please Let Greg Brown Bring Peaches To Your Wedding”
P: Pink = 1mg
L: Lavender = 2mg
G: Green = 2.5mg
B: Brown/Tan = 3mg
B: Blue = 4mg
P: Peach = 5mg
T: Teal = 6mg
Y: Yellow = 7.5mg
W: White = 10mg
Warfarin: Initial dose and how to adjust for maintenance dose
Initial: 10mg or less for 2 days then adjust per INR (if for TX of active DVT/PE, start WHILE on pareneteral anticoagulant for at least 5 days until INR is 2 or higher for 24 hours)
Lower initial dose: 5mg or less
-Elderly, liver disease pt
-Malnourished
-Heart failure
-CYP inhibitor use
-Take select ABXs: pencillins, cephalosporins, quinolones, tetracyclines
Maintenance: take weekly dose and divide by 7 to see average daily dose
-Consider: INR, DDIs, dietary intake, risk factors
-Follow institutional protocol for adjustment
Protamine sulfate: heparin reversal
1mg IV for 100 units of heparin reversal in last 2-2.5 hours (max: 50mg)
Protamine sulfate: low molecular weight heparin reversal
1mg IV per 1mg of enoxaparin
**Less effective than reversal of heparin and reverses what was given in last 8 hours by about 60%
Digoxin: therapeutic ranges and dosing
Therapeutic range: 0.8-2ng/mL (lower range used for HF)
Dose: typically 0.125-0.25mg PO QD
-CrCl <60mL/min: decrease dose or frequency (hold in acute renal failure)
-Decrease dose by 20-25% when converting from PO to IV
-With amiodarone or dronedarone, decrease dose by 50%
Statins: high intensity
Atorvastatin: 40-80mg
Rosuvastatin: 20-40mg
Statins: moderate intensity
Atorvastatin: 10-20mg
Rosuvastatin: 5-10mg
Simvastatin: 20-40mg
Pravastatin: 40-80mg
Lovastastin: 40mg
Fluvastatin: 40mg BID or 80mg XL
Pitavstatin: 1-4mg
Statins: low intensity
Simvastatin: 10mg
Pravastatin: 10-20mg
Lovastatin: 20mg
Fluvastatin: 20-40mg
Statins: equivalent dosing and dose adjustments
Pitavastatin 2mg = Rosuvastatin 5mg = Atorvastatin = 10mg = Simvastatin 20mg = Lovastatin 40mg = Pravastatin 40mg = Fluvastatin 80mg
**Pitavastatin most potent on mg basis
**Rosuvastatin most potent to lower LDL (less dose than atorvastatin)
Dose adjustments:
-Reduce dose when CrCl <30mL/min except atorvastatin
-CrCl <60mL/min: reduce pitavastatin dose
Statins: maximum daily dose with DDIs (G-PACMAN)?
-PACMAN: Grapefruit, PIs, Azole Antifungals, Cyclosporine/Cobicistat, Macrolides (except azithromycin), Amiodarone, Non-DHP CCBs
G-M:
-Do NOT use with simvastatin or lovastatin
-Cyclosporine only: rosuvastatin 5mg/day
-Cobicistat only: atorvastatin 20mg/day
Amiodarone: simvastatin 20mg/day, lovastatin 40mg/day
Non-DHP CCBs: simvastatin 10mg/day, lovastatin 20mg/day
**In general: lovastatin and simvastatin are major CYP3A4 substrates followed then by atorvastatin
Chlorthalidone: HTN
12.5-25mg QD
**In practice, may see higher doses for other indications, but these are maximum doses with benefit for HTN
Hydrochlorothiazide: HTN
12.5mg-50mg QD
**In practice, may see higher doses for other indications, but these are maximum doses with benefit for HTN
Metoprolol tartrate: IV:PO ratio
1: 2.5
Aspirin: stable angina
75-100mg PO QD
Clopidogrel: stable angina
75mg PO QD
Entresto: HFrEF target dose
97/103 mg PO BID
Enalapril: HFrEF target dose
10-20mg PO BID
**Most ACEI targets = 40mg/day
Lisinopril: HFrEF target dose
20-40mg PO QD
**Most ACEI targets = 40mg/day
Quinapril: HFrEF target dose
20mg PO BID
**Most ACEI targets = 40mg/day
Ramipril: HFrEF target dose
10mg PO QD
Losartan: HFrEF target dose
50-150mg PO QD
Valsartan: HFrEF target dose
160mg PO BID
Metoprolol succinate: HFrEF target dose
200mg PO QD
Carvedilol: HFrEF target dose
IR: 25mg PO BID (if 85kg or less) or 50mg BID (>85kg)
CR: 80mg PO QD
Spironolactone: HFrEF target dose
25-50mg PO QD
Furosemide: IV:PO ratio
1:2
Bumetanide, ethacrynic acid: IV:PO ratio
1:1
Loop diuretics: equivalent dosing
Furosemide 40mg = Torsemide 20mg = Bumetanide 1mg = Ethacrynic acid 50mg
Epinephrine: IV push rate
0.1mg/mL
Epinephrine: IM injection or compounded IV product rate
1mg/mL
Corticosteroids: equivalent dosing
Least potent, short-acting:
-Cortisone: 25mg
-Hydrocortisone: 20mg
Intermediate-acting:
-Prednisone, prednisolone: 5mg
-Methylprednisolone, triamcinolone: 4mg
Most potent, long-acting:
-Dexamethasone: 0.75mg
-Betamethasone: 0.6mg
Methotrexate: Rheumatoid Arthritis
PO, SC, or IM: 7.5mg-20mg every WEEK
**Do NOT daily dose
Levothyroxine: hypothyroidism dose
Full replacement dose: 1.6mcg/kg/day
**Dose using IDEAL body weight
**If known CAD, start w/ 12.5-25mcg QD
Levothyroxine: IV:PO ratio
0.75:1
Levothyroxine: color tablets associated with strengths
“Orangutans Will Vomit on You Right Before They Become Larger Proud Giants”
O: Orange = 25mcg
W: White (no dye) = 50mcg
V: Violet = 75mcg
Y: Yellow = 100mcg
R: Rose = 112 mcg
B: Brown = 125mcg
T: Turquoise = 137mcg
B: Blue = 150mcg
L: Lilac = 175mcg
P: Pink = 200mcg
G: Green = 300mcg
Metformin: Type 2 Diabetes (Initial, Maintenance, and Maximum dose)
Initial (IR): 500mg QD or BID
Maintenance: 1000mg BID (titrate weekly)
Maximum: 2000-2550mg/day (2000mg is usually max benefit)
**Do NOT start in CrCl </=45 mL/min, CI in CrCl <30mL/min
Insulin: initial dose in Type 2 Diabetes
Basal insulin (added first): 10 units SC QD or 0.1-0.2 units/kg/day
-Titrate based on fasting plasma glucose (FPG)
If FPG NOT at goal or signs prandial insulin needed: add 4 units or 10% of basal dose SC QD prior to largest meal
-Titrate based on prandial BG and add doses prior to other meals PRN
Insulin: initial dose in Type 1 Diabetes
- Calculate total daily dose (TDD): 0.5 units/kg/day using total body weight
- Divided TDD into 50% for basal and 50% for prandial insulin
- Divide the prandial dose into thirds for each meal
**NPH: given BID with 30% of TDD in AM and 20% in PM
Insulin: conversions between types
Majority are 1:1 ratio with exceptions of:
-NPH dose BID to insulin glargine: use 80% of NPH dose
-Toujeo to insulin glargine or determine: use 80% of Toujeo dose
Insulin: mealtime dose adjustments
Option 1: insulin-to-carbohydrate ratio (ICR) - amount of grams of carbohydrates covered by 1 unit of insulin
-Regular Insulin: 450/TDD = ICR
-Rapid-acting insulin: 500/TDD = ICR
Option 2: carbohydrate correction method - how much BG will be lowered by 1 unit of insulin
-Regular insulin: 1500/TDD
-Rapid-acting insulin: 1800/TDD
Once correction factor calculated for both options:
-Correction dose = [BG now - target BG] / correction factor
**TDD includes BOTH basal and bolus insulin dose
Diphenhydramine: adult dose for allergic rhinitis
25mg PO Q4-6H or 50mg PO Q6-8H
**Do NOT use OTC in children <6 yo unless directed by healthcare provider
Acetaminophen: children’s dose for cough and colds
10-15mg/kg Q4-6H
-Do NOT exceed 5 doses in 24 hours
**Infants drops, children’s liquid: comes as 160mg/5mL
Ibuprofen: children’s dose for cough and colds
5-10mg/kg Q6-8H
-Do NOT exceed 40mg/kg/day
**Infants drops: 50mg/1.25mL
**Children’s liquid: 100mg/5mL
Topical steroids: list ones with very high, high, high/medium, medium, and lowest potency
Very high:
-Clobetasol
-Fluocinonide 0.1% cream
High:
-Betamethasone dipropionate 0.05% cream
-Fluocinonide 0.05% ointment
-Mometasone furoate 0.1% ointment
High/medium: fluocinonide 0.05% cream
Medium:
-Mometasone furoate 0.1% lotion
-Triamcinolone
Lowest: hydrocortisone
Loperamide: Diarrhea
4mg PO after first loose stool then 2mg after each subsequent loose stool
Maximum dosing:
-OTC: 8mg/day, do NOT use >48 hours
-RX: 16mg/day
Amoxicillin: acute otitis media
90mg/kg/day –> divide into BID dosing
**If using Augmentin, use lowest clavulanate (diarrhea)
Amoxicillin: infective endocarditis prophylaxis prior to dental procedure
2 grams PO once 30-60 minutes before procedure
Gentamicin, Tobramycin: traditional dosing
Usually 1.25-5mg/kg IV (use Q8H if CrCl >/=60 mL/min)
Trough: draw before or 30 minutes before 4th dose (goal: <2 mcg/mL)
Peak: draw 30 minutes after end of infusion for 4th dose (goal: 5-10 mcg/mL)
**Selecting which weight for dose:
-Underweight < IBW: use total body weight
-Normal weight: IBW or TBW (depends on protocol)
-Obese: use adjusted body weight
Gentamicin, Tobramycin: extended interval dosing
4-7 mg/kg IV Q24H (usually 7 mg/kg)
Draw random level and use nomogram to determine frequency
**Selecting which weight for dose:
-Underweight < IBW: use total body weight
-Normal weight: IBW or TBW (depends on protocol)
-Obese: use adjusted body weight
Azithromycin: Zpak and Tripak dosing
Zpak: two 250mg (500mg) tablets on day 1 then 250mg QD x4D
Tripak: 500mg QD x3D
Doxycycline, minocycline: IV:PO ratio
1:1
Bactrim: uncomplicated UTI
How supplied:
-SS: 400mg SMX / 80mg TMP
-DS: 800mg SMX / 160mg TMP
**All product s formulated as SMX/TMP 5:1 ratio
Uncomplicated UTI: 1 DS tablet PO BID x3D
Vancomycin: systemic infections
15-20mg/kg IV Q8-12H (based on total body weight)
CrCl 20-49mL/min: Q24H
AMC/MIC ratio of 400-600 or ss trough of 15-20mcg/mL (drawn 30 minutes before 4th or 5th dose)
**Other infections (UTI, skin): goal trough less of 10-15 mcg/mL
**Do NOT infuse faster then 1 g/hour
Vancomycin: C. difficile
125mg PO QD x10D
Severe, complicated disease in combo w/ IV metronidazole: 500mg QID
Linezolid: IV:PO ratio
1:1
Metronidazole: IV:PO ratio
1:1
Fosfomycin: uncomplicated UTI
3 grams (1 packet) mixed in 3-4 oz of water PO once
Nitrofurantoin: uncomplicated UTI
Macrobid: 100mg PO BID x5D
**Macrodantin: QID
**Do NOT use in CrCl <60mL/min
Ceftriaxone: gonorrhea
<150kg: 500mg IM once
150kg or greater: 1 gram IM once
Doxycycline: chlamydia
100mg PO BID x7D
Azithromycin: chlamydia
1 gram PO once
Penicillin G Benzathine: syphilis
2.4 million units IM once for early intervention or Qweek x 3 weeks
**Never give IV (lipid emulsion can cause death)
Azole antifungals: IV:PO ratio
1:1
Fluconazole: vaginal candidiasis
150mg PO once
Oseltamivir: flu TX and prophylaxis
Age > 12 yo, TX: 75mg PO BID x5D
Age 12 yo, prophylaxis: 75mg QD x10D
Levonorgestrel: emergency contraception
1.5mg once ASAP within 3 days of unprotected sex
**Consider second dose if vomit within 2 hours of taking
Sildenafil: starting dose in erectile dysfunction
50mg PO one hour before sexual activity
**Reduce dose by 50% if 65 yo and older, using an alpha-blocker, using a CYP3A4 inhibitor, or in severe renal or liver disease
Vardenafil: starting dose in erectile dysfunction
10mg PO one hour before sexual activity
**Reduce dose by 50% if 65 yo and older, using an alpha-blocker, using a CYP3A4 inhibitor, or in severe renal or liver disease
Tadalafil: starting dose in erectile dysfunction
10mg PO at least 30 minutes before sexual activity
**Reduce dose by 50% if 65 yo and older, using an alpha-blocker, using a CYP3A4 inhibitor, or in severe renal or liver disease
Daily dosing: 2.5-5mg PO QD
Avanafil: starting dose in erectile dysfunction
100mg PO 15-30 minutes before sexual activity
**Reduce dose by 50% if 65 yo and older, using an alpha-blocker, using a CYP3A4 inhibitor, or in severe renal or liver disease
Iron supplementation: breastfeeding infants at 4 months and older if needed
1mg/kg
Sinemet: Parkinson Disease
Initial:
-IR: 25/100mg PO TID
-ER: 50/200mg PO BID
70-100mg of carbidopa may be required to inhibit dopa decarboxylate
Catechol-O-Methyltransferase (COMT) inhibitors: Parkinson Disease
200mg PO with each carbidopa/levodopa dose
**May need to decrease levodopa dose by 10-30% when adding
Levetiracetam: IV:PO ratio
1:1
Phenytoin: IV:PO ratio
1:1
Converting between phenytoin to fosphenytoin
1mg PE (Phenytoin equivalent) = 1.5mg fosphenytoin
Pancrealipase: Cystic Fibrosis Maximum dose
Max dose based on lipase component (</=10,000 units/kg/day)
Acetaminophen: maximum dose in adults
<4,000 mg/day
Ibuprofen: OTC adult dosing
200-400mg Q4-6H PO
-OTC max: 1.2 grams/day (limit use to <10D)
-Rx max: 3.2 grams/day
**Avoid in CrCl <30mL/min
Naproxen: OTC dosing
220mg (200mg naproxen = 220mg naproxen sodium salt) Q8-12H
**Avoid in CrCl <30mL/min
Diclofenac: maximum dose and OTC dosing
Maximum: 32 grams/day for total body
OTC dosing:
-Hands, wrists, or elbows: 2 grams QID (max: 8g/day)
-Feet, ankles, or knees: 4 grams QID (max: 16 g/day)
Hydromorphone: pain (both PO and IV dosing)
PO: 2-4mg Q4-6H PRN
IV: 0.2-1mg Q2-3H PRN
Colchicine: acute gout attack
1.2mg PO (two 0.6mg tablets) followed by 0.6mg in 1 hour starting within 36 hours of symptom onset
**Do NOT exceed 1.8mg in 1 hour or 2.4mg/day
**Wait 12 hours after TX dose before resuming prophylaxis dosing
Citalopram: depression
20-40mg PO QD (max: 40mg/day)
**Max dose in elderly (>60 yo): 20mg/day
Escitalopram: depression
10mg PO QD (max: 20mg/day)
**Max dose in elderly (>60 yo): 10mg/day
Venlafaxine: depression max dose
IR max: 375mg/day
Albuterol: asthma attacks and exercise-induced bronchospasms
Asthma attack: 1-2 inhalations Q4-6H PRN
Exercise-induced bronchospasms: 2 inhalations 5 minutes prior to exercise
Montelukast: asthma in children
1-5 yo: 4mg PO Qpm
6-14 yo: 5mg PO Qpm
Combivent Respimat: COPD rescue
1 inhalation Q4-6H PRN
Atrovent: COPD rescue
2 inhalations Q4-6H PRN
Nicotine patches: smoking cessation
> 10 cigarrettes/day: 21mg/day x6 weeks then 14mg/day x2 weeks then 7mg/day x2 weeks
10 cigarrettes or less/day: 14mg/day x6 weeks then 7mg/day x2 weeks
Nicotine gum/lozenges: smoking cessation
First cigarrette within 30 minutes of waking: 4mg Q1-2H x6 weeks (>/=9 pieces/day in 6 weeks) then 4mg Q2-4H x3 weeks then 4mg Q4-8H x3 weeks
First cigarrette post 30 minutes of waking: 2mg Q1-2H x6 weeks (>/=9 pices/day in 6 weeks) then 2mg Q2-4H x3 weeks then 2mg Q4-8H x3 weeks
Max lozenges/day: 20
Pepto-Bismol: Traveler’s Diarrhea
524-1050mg PO QID with meals and at bedtime
Nitroglycerin: short acting dose for chest pain
0.4mg SL tablet or TL spray
Can take additional doses at 5 minute intervals
Do NOT exceed 3 doses per 15 minutes
Ticagrelor: maintenance dose post ACS
90mg PO BID x1 year then 60mg BID
Do NOT exceed doses of 100mg/day (reduce efficacy)
Dapagliflozin: HFrEF target dose
10mg PO QD
**Cutoff: eGFR <25 mL/min
**If pt on med and then eGFR falls bellow cutoff, can continue
Empagliflozin: HFrEF target dose
10mg PO QD
**Cutoff: eGFR <20mL/min
**If pt on med and then eGFR falls bellow cutoff, can continue
Alteplase: Ischemic stroke
0.9mg/kg (max: 90mg)
Aspirin: Acute management in ischemic stroke
81-325mg PO ASAP within 28 hours after stroke onset
**Do NOT give within 24 hours of fibrinolytic
Ferrous sulfate: iron deficiency anemia
325mg (65mg elemental iron) QD or QOD
**QOD still shows same Hgb increases w/ less AVEs
