Pain, Hematology, and Oncology

Question 1

Transdermal: Duragesic, IV: Sublimaze

Fentanyl (transdermal, IV)

Answer 1

Pharmacologic category: opioid analgesic
Common indication: pain
Key side effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related) US Boxed Warning: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use of opioids with benzodiazepines or CNS depressants (including alcohol), may result in profound sedation, respiratory depression, coma, and death; concomitant use with CYP P450 3A4 inhibitors may increase serum concentrations; exposure of application site to direct external heating sources (e.g., heating pads, heating lamps, hot baths, saunas) may increase absorption and lead to overdose and/or death; Other Notes: ISMP-high alert medication

Question 2

PO: Exalgo; PO, IV: Dilaudid

Hydromorphone (PO, IV)

Answer 2

Pharmacologic category: opioid analgesic
Common indication: pain
Key side effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related); US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use of opioids with benzodiazepines or CNS depressants (including alcohol), may result in profound sedation, respiratory depression, coma, and death; several formulations available including concentrated solution, take care to avoid dosing errors among strengths and between mg and mL
Other Notes: ISMP-high alert medication

Question 3

MS Contin, MorphaBond, Kadian

Morphine (extended release) (PO)

Answer 3

Pharmacologic Category: opioid analgesic
Common indication: Pain
Key side effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related); US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use of opioids with benzodiazepines or CNS depressants (including alcohol), may result in profound sedation, respiratory depression, coma, and death; several formulations available including concentrated solution, take care to avoid dosing errors among strengths and between mg and mL; avoid alcohol consumption with ER capsules as alcohol may increase plasma morphine levels; Other Notes: ISMP-high alert medication

Question 4

PO: Roxanol; IV: Duramorph

morphine (immediate release) (PO, IV)

Answer 4

Pharmacologic category: opioid analgesic
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related) US Boxed Warnings: use exposes to risk of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use of opioids with benzodiazepines or CNS depressants (including alcohol), may result in profound sedation, respiratory depression, coma, and death; several formulations available including concentrated solution, take care to avoid dosing errors among strengths and between mg and mL; avoid alcohol consumption with ER capsules as alcohol may increase plasma morphine levels; Other Notes: ISMP-high alert medication

Question 5

Oxycontin, Roxicodone, Oxaydo, Xtampza ER

Oxycodone (PO)

Answer 5

Pharmacologic category: opioid analgesic
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related); US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use of opioids with benzodiazepines or CNS depressants (including alcohol), may result in profound sedation, respiratory depression, coma, and death; concomitant use with cytochrome P450 3A4 inhibitors may increase serum concentrations; several formulations available including concentrated solution, take care to avoid dosing errors among strengths and between mg and mL; Other Notes: ISMP-high alert medication

Question 6

Dolophine, Methadose

Methadone (PO, IV)

Answer 6

Pharmacologic category: opioid analgesic
Common indication: opioid use disorder, severe chronic pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related), QTc prolongation; US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; for detoxification and maintenance of opioid dependence, methadone should be administered in accordance with documented treatment standards, including limitations on unsupervised administration; QTc interval prolongation and serious arrhythmias (torsades de pointes) have occurred during treatment with methadone

Question 7

PO: Tylenol, IV: Ofirmev

Acetaminophen (PO, IV)

Answer 7

Pharmacologic category: analgesic (non-opioid), antipyretic
Common indication: pain, fever
Key side effects: nausea, vomiting, increased hepatic transaminases
US Boxed Warnings: dosing errors (confusion with mg and mL) can lead to accidental overdose and death; total daily dose from all sources should not exceed maximum daily limit; hepatotoxicity

Question 8

Ultram, Ultram ER

Tramadol (PO)

Answer 8

Pharmacologic category: central analgesic
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related)
US Boxed Warnings: serious, life-threatening, or fatal respiratory depression may occur
Other Notes: lowers seizure threshold (use caution in patients with a seizure history, those at risk of seizures, and those on other drugs that may lower seizure threshold)

Question 9

Ultracet

Tramadol and acetaminophen (PO)

Answer 9

Pharmacologic category: central analgesic and non opioid analgesic combination
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related)
US Boxed Warnings (all acetaminophen products): products containing acetaminophen have been associated with acute liver failure (maximum daily dose is 4000mg from all sources)
Other Notes: lowers seizure threshold (use caution in patients with a seizure history, those at risk of seizures, and those on other drugs that may lower seizure threshold)

Question 10

Lortab, Vicodin, Norco, Xodol

Hydrocodone and acetaminophen (PO)

Answer 10

Pharmacologic category: opioid and nonopioid analgesic combination
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related)
US Boxed Warnings (all opioid analgesics): use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use with CYP P450 3A4 inhibitors may increase serum concentrations; products containing acetaminophen have been associated with acute liver failure (maximum daily dose is 4000mg from all sources)

Question 11

Percocet, Endocet, Roxicet, Xartemis XR

Oxycodone and acetaminophen (PO)

Answer 11

Pharmacologic category: opioid and analgesic combination
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related)
US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; concomitant use CYP P450 3A4 inhibitors may increase serum concentrations; products containing acetaminophen have been associated with acute liver failure (maximum daily dose is 4000mg from all sources)

Question 12

Tylenol with Codeine #3, Tylenol with Codeine #4

Acetaminophen and codeine (PO)

Answer 12

Pharmacologic indication: opioid and nonopioid analgesic combination
Common indication: pain
Key Side Effects: dizziness, drowsiness, nausea, vomiting, constipation, respiratory depression (dose-related)
US Boxed Warnings: use exposes to risks of opioid addiction, abuse, and misuse which can lead to overdose and death; serious, life-threatening, or fatal respiratory depression may occur; accidental ingestion, especially in children, may result in fatal overdose; prolonged use in pregnancy may result in neonatal opioid withdrawal syndrome; products containing acetaminophen have been associated with acute liver failure (maximum daily dose is 4000mg from all sources)

Question 13

Subutex

Buprenorphine (PO, IV, IM, transdermal)

Answer 13

Pharmacologic category: partial opioid agonist
Common indication: opioid use disorder, pain
Key Side Effects: headache, opioid withdrawal syndrome in opioid-dependent populations, pain, diaphoresis
Other Notes: potentially life-threatening respiratory depression (particularly when combined with other CNS and respiratory depressants); prescribing the treatment of opioid use disorder limited to physicians meeting qualifying criteria and with a specific DEA number (begins with “X”); addition of naloxone to buprenorphine reduces possibility of parenteral misuse by producing opioid withdrawal symptoms when injected

Question 14

Narcan

Naloxone (IV, IM, subcutaneous, intranasal)

Answer 14

Pharmacologic category: opioid antagonist
Common indication: opioid overdose
Key Side Effects: headache, opioid withdrawal syndrome in opioid-dependent populations, pain, diaphoresis
Other Notes: potentially life-threatening respiratory depression (particularly when combined with other CNS and respiratory depressants); prescribing for treatment of opioid use disorder limited to physicians meeting qualifying criteria and with a specific DEA number (begins with “X”); addition of naloxone to buprenorphine reduces possibility of parenteral misuse by producing opioid withdrawal symptoms when injected

Question 15

Suboxone

Buprenorphine and naloxone (PO)

Answer 15

Pharmacologic category: partial opioid agonist and opioid antagonist
Common indication: opioid use disorder
Key Side Effects: headache, opioid withdrawal syndrome in opioid-dependent populations, pain, diaphoresis
Other Notes: potentially life-threatening respiratory depression (particularly when combined with other CNS and respiratory depressants); prescribing for treatment of opioid use disorder limited to physicians meeting qualifying criteria and with a specific DEA number (begins with “X”); addition of naloxone to buprenorphine reduces possibility of parenteral misuse by producing opioid withdrawal symptoms when injected

Question 16

Trexall, Rheumatrex

Methotrexate (PO, IV)

Answer 16

Pharmacologic category: antimetabolites (folic acid antagonist)
Common indication: rheumatoid arthritis, psoriasis, various hematologic and solid tumors
Key Side Effects: stomatitis, diarrhea, n/v, thrombocytopenia, leukopenia, increased hepatic transaminases, pulmonary fibrosis (rare), pneumonitis (rare); US Boxed Warnings: serious toxic reactions (only use in life-threatening neoplasticism disease, severe psoriasis, or severe rheumatoid arthritis); may cause fetal death and/or congenital abnormalities (avoid in pregnancy); severe (sometimes fatal) bone marrow suppression, aplastic anemia, and toxicity have been reported with concomitant administration of methotrexate and NSAIDs; elimination is reduced in impaired renal function, ascites, or in patients with pleural effusions (careful monitoring necessary); may cause hepatotoxicity, fibrosis, and cirrhosis (generally only after prolonged use); methotrexate-induced lung disease, including acute or chronic interstitial pneumonitis may occur; severe (sometimes fatal) gastrointestinal toxicity has been reported with concomitant administration of methotrexate and NSAIDs; secondary malignancy may occur; may induce tumor lysis syndrome in patients with rapidly growing tumors; severe (sometimes fatal) dermatologic toxicity has been reported; potentially fatal opportunistic infections (especially Pneumocystis jirovecii pneumonia) may occur; Other Notes: ISMP-high alert medication, folic acid supplementation may be taken during use to reduce hematologic, gastrointestinal, and hepatic side effects; harmful (sometimes fatal) errors have been associated with incorrect dosing (verify dosing frequency based on indication - for most indications, oral doses are often only given once weekly)

Question 17

Arimidex

Anastrozole (PO)

Answer 17

Pharmacologic category: aromatase inhibitor
Common indication: hormone receptor-positive breast cancer
Key side effects: rash, flushing, hot flashes, arthralgia, nausea, vomiting, hypertension, peripheral edema, osteoporosis
Other Notes: cardiovascular side effects (i.e,. Hypercholesterolemia, CAD); fetal toxicity (CI in pregnancy)

Question 18

Fioricet, Esgic, Zebutal

Butalbital, acetaminophen, and caffeine (PO)

Answer 18

Pharmacologic category: analgesic
Common indication: tension headaches
Key side effects: dizziness, drowsiness, lightheadedness
US Boxed Warnings: products containing acetaminophen have been associated with acute liver failure (maximum daily dose is 4000mg from all sources)

Question 19

Adipex-P, Lomaira

Phentermine (PO)

Answer 19

Pharmacologic category: CNS stimulant
Common indication: obesity
Key Side Effects: hypertension, nausea, dizziness, xerostomia, primary pulmonary hypertension (rare)
Other Notes: only approved for short-term use (a few weeks); CI in those with a history of cardiovascular disease or drug abuse, pregnancy, hyperthyroidism, or within 14 days of MAOI inhibitor therapy

Question 20

Cyanocobalamin (vitamin B12) (PO, IM)

Answer 20

Pharmacologic category: water-soluble vitamin
Common indication: vitamin B12 deficiency (manifests as macrocytic anemia)
Key Side Effects: No major side effects

Question 21

Folic acid (PO, IV)

Answer 21

Pharmacologic category: water-soluble vitamin
Common indications: folic acid deficiency (manifests as macrocytic anemia), prevention of neural tube defects in pregnancy
Key Side Effects: No major side effects