IV Medications Flashcards
Precycle Oral medications - Antibiotics:
Doxycycline Hyclate-> Patient scheduling a tubal evaluation (HSG/HyCoSy/SIS w/tubal flush) that meet one of the following:
History of PID
100mg BID x 5days starting morning of procedure
Spring patient completing HSG outside of a Spring facility:
100mg BID, on day of procedure—take AM of procedure or at least one hour prior with food, second dose ~8 hours later (evening)
If history of PID or diagnosed with hydrosalpinx- to follow above directions of 5-day regimen
Z-pack (Azithromycin)- Patient and partner usually advised at start of treatment (within 6mths of attempting conception) depending on MD order.
500mg first day, 250mg daily the following 4 days (5 days total) = 6 tabs total
Precycle Oral medications - Thyroid regulation: TSH levels
Hypothyroidism:
TSH 2.5 - 4.0, TPO (antibodies) + > Subclinical Hypothyroidism
TSH > 4.0mIU/L, regardless of TPO –> Hypothyroidism
If abnormal results, inquire if patient on biotin supplement. If so, d/c x 2days and repeat test as biotin supplementation can cause false results. See CO2. Management of thyroid function abnormalities.
Priming medication - Estrace (E2)/Estradiol - luteal phase
Indication:
Used in the luteal phase as a priming medication prior to IVF stimulation to suppress follicular growth that can occur prior to period start.
Used for development and/or stabilization of endometrial lining for embryo transfer.
Priming medication - when is it used? and what does it do?
Indication:
this is to decrease possible follicle growth, makes luteal phase longer
Contraceptive; Progestin
Used in the luteal phase as a priming medication prior to IVF stimulation to suppress follicular growth. More suppressive than estrace.
May also be used to help manage Endometriosis
Dosage/Frequency:
For IVF priming:
Per standard protocol: 5 mg (1 tablet) daily for total of 10 days, starting 5 days after +OPK (LH surge)
Can be manipulated to taking 8-10 days
Can be manipulated to start 3-6 days post +OPK
Priming medication cont. - Birth control pill (Monophasic - the same amount of meds in every pill): this is the most suppressive one
Ethinyl estradiol 0.03 mg and desogestrel 0.15 mg
Contraceptive: Monophasic pill containing Estrogen & Progesterone
Used as a priming medication prior to IVF stimulation or FET cycle
Most commonly started in the follicular ( CD (day)1-3) or luteal phase (LH+5)
NOTE: if patient taking over 21days, ensure purchases and uses 2nd pack of pills, advise patient to discard the placebo pills- don’t take the last day of rows, this is a placebo pill
Priming medication cont. -Testosterone*
Label indications include delayed puberty and male hypogonadism
it suppresses follicles, and once you take it away you may get a stronger response
Off label indications include transgender hormone therapy (female-to-male)
At Spring, utilized in priming along with Aygestin or Estrace, to help in increasing FSH receptors on follicles to help improve stimulation outcomes
ATP IVF protocol : Aygestin/Testosterone Priming
Options/Dosing: (goal if for patient to receive 2-3mg per 12 hour exposure)
usually used for 10 days
Androderm Patch: 2mg/24 hour patch (Not currently available)
1 patch to outer thigh at 9PM and remove at 9AM each day
T-Gel: 1% transdermal gel pump – OR-
T- Cream: Transdermal solution metered pump. 30 mg/actuation (1.5 mL) (CHEAPEST OPTION)
1 pump once daily applied at 9pm and washed off at 9 am
*can be difficult to obtain, Alto has:
C-Testosterone cream 12.5mg/gm (1.25%)–1 click applied at 9pm—washed off at 9am –OR-
C-Testosterone cream 5mg/gm (0.5%) –2 clicks applied at 9pm, washed off at 9am
IVF Stimulation Medications—PO (oral - Clomiphene Citrate (Clomid)- CC - what is the dose?
Dosage (50mg tablets)
Common dose—100mg/day
Min/Max dosage: 25mg/day/ Max is 250mg/day (rare)
Duration—5 days
Start cycle day 2-5, depending on baseline US or when patient calls with period start..
Indications:
Non PCOS pts, first line in Superovulation for IUI
DOR
Concerning side effects:
Blurred/Double vision
Thin Endometrium
IVF Stimulation Medications—PO (oral) - Letrozole/Femara- LTZ - what is the common dose?
Dosage (2.5mg tablets)
Common dose—5mg/day
Min/Max dosage: 2.5mg/day-7.5mg/day
Duration—5 days
Start cycle day 2-5, depending on baseline US or when patient calls with period start..
Indications:
Ovulation induction- First line for PCOS patients
Decrease estrogen levels
Utilized long term in breast cancer patients
Can be given during IVF stim to keep E2 low if patient at risk (extended course- ~10-15 days)
i.e.. Cancer pt., hormonally induced migraines
Gonadotropins – Injectable Fertility Meds - rFSH - what is the name? where does this come from?
(gonal gonad)
rFSH
Gonal-F®/Follistim®
Recombinant FSH
SQ injection
Well tolerated
Gonal-F Rediject Pens
offered in 300, 450, & 900 IU pens
Follistim AQ Cartridge,
offered in 300, 600, & 900 IU pens. Require a pen to administer.
Gonadotropins – Injectable Fertility Meds - LH - when are these used?
LH
single use vial (75 IU FSH & 75 IU of LH activity)
Referred to as 75iu of LH: lyophilized powder/pellet dispensed with diluent vials (2ml) and Q-Cap® vial adapters.
Consists of FSH + LH activity. It directly stimulates follicular growth at the ovaries. Often used in combination with rFSH (Gonal-F or Follistim).
SQ injection
Redness/pain at injection site common
Adjunct—Growth Hormone - (HGH/GH) how to store it?
Human Growth Hormone (HGH/GH)
Omnitrope 5.8 mg or Zomacton 5mg or 10mg vial depending on availability
Dose is 1.45 mg daily started with IVF stim
Omnitrope 5.8mg vial (25 units/0.25 mL)
Zomacton 5mg vial (30 units/0.30mL)
Zomacton 10mg vial (15units/.15 mL)
May allow for follicles to respond better to gonadotropins
Can lead to better egg/embryo quality
Keep Refrigerated at ALL times
GnRH Agonist
Lupron ®/Leuprolide Acetate 1mg/0.2ml: Two week kit
SQ injection
IVF or FET/Down regulation: (10 units/0.5mg daily for ~12days)
This prevents LH and FSH causing the follicle to grow bigger.
GnRH Antagonist (Cetrotide/Ganirelix/Fyremadel)
Ganirelix/Fyremadyl (prefilled syringe) /Cetrotide (requires mixing)
SQ injection
Binds to GnRH-receptors, blocking the release of LH-preventing ovulation - this makes the follicle grow bigger.
Can also be used in combination with estrogen in EAP priming to help suppress endogenous FSH secretion and lead to more synchronized starting follicle cohort than estrogen alone.
When used to suppress ovulation (most common use) begin when follicles ~12-14 mm.
Continue daily until day of trigger
Oral medication to suppress premature ovulation - what is it called?
(provent ovulation)
Provera 10mg Tablets
Could be used in place of injectable antagonist, for those NOT planning to transfer an embryo in the same cycle.
Helps to keep medication costs down.
TriggerMedications - HCG - what is it similar to?
HCG (Human Chorionic Gonadotropin) : HCG is similar to LH
chemically similar to LH – mimics the effects of LH causing final maturation and ovulation.
Dosage 1600iu to 5000iu, MD will advise based on risk of OHSS
Cabergoline
(OHSS is in the cab with dopamine)
Cabergoline 0.5 mg tablets
To help to decrease symptoms of OHSS following the retrieval the MD may order Cabergoline (Dopamine Agonist) for those at higher risk.
This medication inhibits VEGFR-2 phosphorylation and signaling.
one pill orally or vaginally starting on day of trigger for 8 days
Additional medication given at embryo transfer - what is the steroid?
(Mildred on steroids)
Valium/Diazepam
10mg tablet given ~1 hour prior to embryo transfer
Goal: relax the uterus/individual
Patient must have a ride
Medrol
16mg given for 5 days prior to embryo transfer
Low dose steroid used to suppress the immune system response and inflammation that may impact implantation
Luteal support-
Fresh or Frozen Embryo transfer
Estrogen (Estrace tablet/Vivelle patch)
Used for development and/or stabilization of endometrial lining for embryo transfer.
Progesterone (Tablet/IM injection or vaginal gel)
Luteal phase progesterone support
Medication costs
Costs for the oral medications are generally low
-can be sent to any local pharmacy (Rite Aid, Walgreens, etc..)
Clomid 50mg #10—as low as 8.00 (up to ~20.00)
Letrozole 2.5mg #10—as low as 5.00 (up to 50.00)
Costs for injectable medications are much higher
~3-7K for full set of fertility medications needed for EF/IVF cycle
Need to utilize specialty pharmacy (Alto, MDR, Freedom fertility, or Cloud Rx if insurance)
Review Questions
- What is the name of the oral priming medication, often given in the luteal phase, and is a form of progesterone? What is the dose/typical duration for this medication? - Agestin - dose is 5 mg for 10 days
- Name the two rFSH injectable gonadotropins.
- What is the name of the GnRH agonist that can be used as a suppression medication or to trigger ovulation? What is the dosage for suppression vs. Trigger?
Lupron, supress 0.5 mg, trigger 4 mg - What type of medication is Ganirelix/Cetrotide/Fyremadel and why are they used?
antagonists- used to stop LH surge to prevent ovulation - What PO medication might be prescribed to help decrease OHSS symptoms? What is the dosage/duration?
Cabergoline - 0.5 mg for 8 days, start day of trigger
Trigger medications - Ovidrel
Ovidrel (prefilled syringe)- not the preferred medication for IVF triggers since you cannot control the dosage as well.
Trigger meds -LH - what is it called?
(lupe in the lh)
LH (Lupron):
Lupron (Leuprolide Acetate) when given as a single high dose (4 mg) will work as a pulse to the pituitary gland to surge production of LH for final maturation and ovulation
how much synthroid to take? and what time of day to take it? when to retest TSH?
Synthroid (Levothyroxine) Dosage varied based on need 25mcg-100mcg+ (usually order like 45 days worth)
Taken daily, first thing in AM 30min-1 hour prior to a meal
Recheck levels ~ 4-6 weeks after starting medication, once TSH within target range. Recheck lab in ~ 6mths or if pregnancy (at 2nd bhcg).
Increase of ~25-30% is generally needed in pregnancy.
estrace (estradiol) - why use post hysteroscopy?
Used post hysteroscopy to allow for proliferation of endometrium and allow for healing.
estradiol dosing
hysteroscopyDose/Frequency:
For IVF priming: 2 mg (1 tablet) BID until menses starts, starting 5 days after +OPK (LH surge)
For luteal support (fresh transfer): 2 mg (1 tablet) BID, starting 4 days post retrieval and continue until pregnancy test and if pregnant until approx. 9 wks. gestation - this is to get all of the follicles to grow equal sizes so we have more follicles to choose from. this is a low dose.
For controlled FET (embryo transfer) (sub for Vivelle): 1 patch q 72hrs = 1 pill (2mg)/day therefore 1 pill x 6 days, 2 pills x 3 days, 4 pills x 3 days, until P4 started, on P4 start decrease to 3 pills x 3 days, then 2 pills/daily until pregnancy test and if pregnant until approx. 9 wks. gestation - this is to help endomentral lining
For post HSC (hysteroscopy): 2 mg (1 tablet) BID typically for 4 weeks (pending MD order). Will often add Provera (progesterone) for 7-10 days overlap to induce period following procedure. This will help endometrium , less scar tissue
HCG med names
(HGC is PN)
Pregnyl
Novarel
Generic
what is the P4 med called?
(I’m gestin progest)
Aygestin (P4)
what time of day to take clomid?
Take recommended number of tablets together, in the evening, ~ same time each day.
what time of day to take letrozole?
Take recommended number of tablets together, in the evening, ~ same time each day.
what is E2 med called?
Estracew
what is gonadotropin med called?
Menopur ®
where does monopur come from?
Derived from urine of menopausal women, which has been purified.
what days to use provera?
(provent on day 6 until trigger)
Patient advised to begin ~ 6th day of IVF stimulation and continue until day of trigger.
antagonists
bind to receptors blocking them
agonists
bind and activate
name of GnRH agonist?
(lupe in the agonist)
(Lupron)
lupron - how does it work?
GnRH agonist binds to GnRH receptors, initially activating but with prolonged use will desensitize and therefore suppress gonadotropin secretion.
lupron as a trigger
Trigger (4mg)
Used instead of or in combination with HCG to trigger ovulation prior to egg retrieval.
NOTE: If given to down regulate, Lupron cannot be used to trigger ovulation.
can cause menopausal symptoms
how does lupron help with OHSS?
Decreases severity or occurrence of OHSS by not using HCG as the primary trigger medication.
OHSS
ovarian hyperstimulation syndrome
