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Dosing Flashcards

1
Q

Unfractionated Heparin (UFH): VTE prophylaxis

A

5,000 units SC Q8-12H

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2
Q

Unfractionated Heparin (UFH): VTE TX

A

Bolus: 80 units/kg IV
Infusion: 18 units/kg/hr CIV

**Dose using total body weight

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3
Q

Unfractionated Heparin (UFH): ACS/STEMI TX

A

Bolus: 60 units/kg IV
Infusion: 12 units/kg/hr CIV

**Dose using total body weight

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4
Q

Enoxaparin: VTE prophylaxis

A

30mg SC Q12H or 40mg SC QD

CrCl <30mL/min: 30mg SC QD

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5
Q

Enoxaparin: VTE and unstable angina/NSTEMI TX

A

1mg/kg SC Q12H

Inpatient only: 1.5mg/kg SC QD

CrCl <30mL/min: 1 mg/kg SC QD

**Dose using total body weight

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6
Q

Enoxaparin: STEMI TX

A

<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

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7
Q

Apixiban: Stroke prophylaxis in non-valvular Afib

A

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

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8
Q

Apixiban: VTE TX

A

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

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9
Q

Rivaroxaban: Stroke prophylaxis in non-valvular Afib

A

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)

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10
Q

Rivaroxaban: VTE TX

A

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)

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11
Q

Warfarin: what are the colors associated with the different strengths?

A

“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

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12
Q

Warfarin: Initial dose and how to adjust for maintenance dose

A

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

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13
Q

Protamine sulfate: heparin reversal

A

1mg IV for 100 units of heparin reversal in last 2-2.5 hours (max: 50mg)

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14
Q

Protamine sulfate: low molecular weight heparin reversal

A

1mg IV per 1mg of enoxaparin

**Less effective than reversal of heparin and reverses what was given in last 8 hours by about 60%

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15
Q

Digoxin: therapeutic ranges and dosing

A

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%

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16
Q

Statins: high intensity

A

Atorvastatin: 40-80mg
Rosuvastatin: 20-40mg

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17
Q

Statins: moderate intensity

A

Atorvastatin: 10-20mg
Rosuvastatin: 5-10mg
Simvastatin: 20-40mg
Pravastatin: 40-80mg
Lovastastin: 40mg
Fluvastatin: 40mg BID or 80mg XL
Pitavstatin: 1-4mg

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18
Q

Statins: low intensity

A

Simvastatin: 10mg
Pravastatin: 10-20mg
Lovastatin: 20mg
Fluvastatin: 20-40mg

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19
Q

Statins: equivalent dosing and dose adjustments

A

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

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20
Q

Statins: maximum daily dose with DDIs (G-PACMAN)?

A

-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

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21
Q

Chlorthalidone: HTN

A

12.5-25mg QD

**In practice, may see higher doses for other indications, but these are maximum doses with benefit for HTN

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22
Q

Hydrochlorothiazide: HTN

A

12.5mg-50mg QD

**In practice, may see higher doses for other indications, but these are maximum doses with benefit for HTN

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23
Q

Metoprolol tartrate: IV:PO ratio

A

1: 2.5

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24
Q

Aspirin: stable angina

A

75-100mg PO QD

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25
Clopidogrel: stable angina
75mg PO QD
26
Entresto: HFrEF target dose
97/103 mg PO BID
27
Enalapril: HFrEF target dose
10-20mg PO BID **Most ACEI targets = 40mg/day
28
Lisinopril: HFrEF target dose
20-40mg PO QD **Most ACEI targets = 40mg/day
29
Quinapril: HFrEF target dose
20mg PO BID **Most ACEI targets = 40mg/day
30
Ramipril: HFrEF target dose
10mg PO QD
31
Losartan: HFrEF target dose
50-150mg PO QD
32
Valsartan: HFrEF target dose
160mg PO BID
33
Metoprolol succinate: HFrEF target dose
200mg PO QD
34
Carvedilol: HFrEF target dose
IR: 25mg PO BID (if 85kg or less) or 50mg BID (>85kg) CR: 80mg PO QD
35
Spironolactone: HFrEF target dose
25-50mg PO QD
36
Furosemide: IV:PO ratio
1:2
37
Bumetanide, ethacrynic acid: IV:PO ratio
1:1
38
Loop diuretics: equivalent dosing
Furosemide 40mg = Torsemide 20mg = Bumetanide 1mg = Ethacrynic acid 50mg
39
Epinephrine: IV push rate
0.1mg/mL
40
Epinephrine: IM injection or compounded IV product rate
1mg/mL
41
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
42
Methotrexate: Rheumatoid Arthritis
PO, SC, or IM: 7.5mg-20mg every WEEK **Do NOT daily dose
43
Levothyroxine: hypothyroidism dose
Full replacement dose: 1.6mcg/kg/day **Dose using IDEAL body weight **If known CAD, start w/ 12.5-25mcg QD
44
Levothyroxine: IV:PO ratio
0.75:1
45
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
46
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
47
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
48
Insulin: initial dose in Type 1 Diabetes
1. Calculate total daily dose (TDD): 0.5 units/kg/day using total body weight 2. Divided TDD into 50% for basal and 50% for prandial insulin 3. Divide the prandial dose into thirds for each meal **NPH: given BID with 30% of TDD in AM and 20% in PM
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
Amoxicillin: acute otitis media
90mg/kg/day --> divide into BID dosing **If using Augmentin, use lowest clavulanate (diarrhea)
57
Amoxicillin: infective endocarditis prophylaxis prior to dental procedure
2 grams PO once 30-60 minutes before procedure
58
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
59
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
60
Azithromycin: Zpak and Tripak dosing
Zpak: two 250mg (500mg) tablets on day 1 then 250mg QD x4D Tripak: 500mg QD x3D
61
Doxycycline, minocycline: IV:PO ratio
1:1
62
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
63
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
64
Vancomycin: C. difficile
125mg PO QD x10D Severe, complicated disease in combo w/ IV metronidazole: 500mg QID
65
Linezolid: IV:PO ratio
1:1
66
Metronidazole: IV:PO ratio
1:1
67
Fosfomycin: uncomplicated UTI
3 grams (1 packet) mixed in 3-4 oz of water PO once
68
Nitrofurantoin: uncomplicated UTI
Macrobid: 100mg PO BID x5D **Macrodantin: QID **Do NOT use in CrCl <60mL/min
69
Ceftriaxone: gonorrhea
<150kg: 500mg IM once 150kg or greater: 1 gram IM once
70
Doxycycline: chlamydia
100mg PO BID x7D
71
Azithromycin: chlamydia
1 gram PO once
72
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)
73
Azole antifungals: IV:PO ratio
1:1
74
Fluconazole: vaginal candidiasis
150mg PO once
75
Oseltamivir: flu TX and prophylaxis
Age > 12 yo, TX: 75mg PO BID x5D Age 12 yo, prophylaxis: 75mg QD x10D
76
Levonorgestrel: emergency contraception
1.5mg once ASAP within 3 days of unprotected sex **Consider second dose if vomit within 2 hours of taking
77
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
78
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
79
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
80
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
81
Iron supplementation: breastfeeding infants at 4 months and older if needed
1mg/kg
82
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
83
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
84
Levetiracetam: IV:PO ratio
1:1
85
Phenytoin: IV:PO ratio
1:1
86
Converting between phenytoin to fosphenytoin
1mg PE (Phenytoin equivalent) = 1.5mg fosphenytoin
87
Pancrealipase: Cystic Fibrosis Maximum dose
Max dose based on lipase component (
88
Acetaminophen: maximum dose in adults
<4,000 mg/day
89
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
90
Naproxen: OTC dosing
220mg (200mg naproxen = 220mg naproxen sodium salt) Q8-12H **Avoid in CrCl <30mL/min
91
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)
92
Hydromorphone: pain (both PO and IV dosing)
PO: 2-4mg Q4-6H PRN IV: 0.2-1mg Q2-3H PRN
93
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
94
Citalopram: depression
20-40mg PO QD (max: 40mg/day) **Max dose in elderly (>60 yo): 20mg/day
95
Escitalopram: depression
10mg PO QD (max: 20mg/day) **Max dose in elderly (>60 yo): 10mg/day
96
Venlafaxine: depression max dose
IR max: 375mg/day
97
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
98
Montelukast: asthma in children
1-5 yo: 4mg PO Qpm 6-14 yo: 5mg PO Qpm
99
Combivent Respimat: COPD rescue
1 inhalation Q4-6H PRN
100
Atrovent: COPD rescue
2 inhalations Q4-6H PRN
101
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
102
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
103
Pepto-Bismol: Traveler's Diarrhea
524-1050mg PO QID with meals and at bedtime
104
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
105
Ticagrelor: maintenance dose post ACS
90mg PO BID x1 year then 60mg BID Do NOT exceed doses of 100mg/day (reduce efficacy)
106
Dapagliflozin: HFrEF target dose
10mg PO QD **Cutoff: eGFR <25 mL/min **If pt on med and then eGFR falls bellow cutoff, can continue
107
Empagliflozin: HFrEF target dose
10mg PO QD **Cutoff: eGFR <20mL/min **If pt on med and then eGFR falls bellow cutoff, can continue
108
Alteplase: Ischemic stroke
0.9mg/kg (max: 90mg)
109
Aspirin: Acute management in ischemic stroke
81-325mg PO ASAP within 28 hours after stroke onset **Do NOT give within 24 hours of fibrinolytic
110
Ferrous sulfate: iron deficiency anemia
325mg (65mg elemental iron) QD or QOD **QOD still shows same Hgb increases w/ less AVEs

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