bariatric consult pharmacy drug info handbook

Bariatric Consult Pharmacy

Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013

Bariatric Surgery: 8/12/2009, 6/2011, 6/2013

P and T: 9/2009, 3/2012, 9/2013

This is NOT a Do NOT Crush List

1

Generic Name Brand Name Drug Class Pharmacy Recommendations

Abacavir Ziagen NRTI Available as an oral solution (20 mg/ml)

Abacavir/Lamivudine Epzicom NRTI Please change abacavir/lamivudine combination tablet to abacavir oral solution (20mg/ml) and lamivudine oral solution

(10mg/ml)

Abacavir/Lamivudine/Zidovudine Trizivir NRTI Please change abacavir/lamivudine combination tablet to abacavir oral solution (20mg/ml), lamivudine oral solution

(10mg/ml) and zidivudine oral syrup (50mg/5ml)

Acarbose

Precose

Antidiabetic

May crush tablet prior to administration.

Tablet is small enough to swallow whole as it is smaller than the tip of a pencil eraser

Acetaminophen Tylenol Analgesic Change to oral solution (acetaminophen 160 mg/5 ml)

Acetaminophen/Codeine Tylenol # 3 Analgesic Change to oral solution Acetaminophen 120mg/Codeine 12mg, 5 mL

Acyclovir Zovirax Antiviral Change to oral suspension (acyclovir 200 mg/ 5 ml)

Alendronate Fosamax Bisphosphonate Change to oral solution (Fosamax(R) alendronate 70 mg/75 mL)

Alendronate

Fosamax

Osteoporosis

Please inform prescriber about the risks posed by conventional oral biphosphonate therapy following bariatric surgery (pill

esophagitis, erosions, ulceration, perforation, etc). Alternatives include (please refer to Alka V. document):

1) Effervescent alendronate (Binosto). Much more expensive than generic plain alendronate tablets

2) Injectable biphosphonates -- CAUTION regarding hypocalcemia with injectable biphosphonates. Regular monitoring of

serum calcium, PTH, vitamin D, and AlkPhos.

a) Zoledronic acid (yearly, IV)

b) Ibandronate (quarterly, IV)

c) Pamidronate (monthly, IV)

Aliskiren Tekturna Antihypertensive Do not crush or chew. Take tablet at exact same time everyday as high fat foods decrease absorption

Allopurinol Zyloprim Antigout Split or crush tablets prior to administration. Avoid alcohol, caffeine and large doses of Vitamin C

Alprazolam Xanax Antianxiety Split or crush medication prior to administration

Ambrisentan

Letairis Antihypertensive

Do not chew, break or crush if of child-bearing age. Women who are, or may become, pregnant, should not handle crushed

or broken tablets

Amitriptyline Elavil Antidepressant Split or crush tablet prior to administration

Amlodipine Norvasc Calcium Channel Blocker Split or crush tablet prior to administration

Amoxapine Moxadil Antidepressant Split or crush tablet prior to administration and mix with pureed food to minimize gastric irritation

Amoxicillin Amoxil Antibiotic Change to oral suspension (Amoxicillin 125 mg/5 mL, 200 mg/5 mL, 250 mg/5 mL, 400 mg/5 mL)

Amphetamine Salt IR Adderall CNS Stimulant Split tablet prior to administration

Amphetamine Salt XR

Adderall XR

CNS Stimulant

Do not chew, break or crush. Capsule contents can be sprinkled on pureed food, water or sugar free applesauce

APAP/Butalbital/Caffeine Esgic, Fioricet Analgesic Split or crush tablets prior to administration. Avoid additional acetaminophen

Aripiprazole

Abilify

Antipsychotic

Change to oral disintegrating tablet as there is no documentation regarding crushing the tablets. Do not push tablet through

foil when opening. Use dry hands to remove from foil. Place on tongue and let dissolve. Water is not needed. Do not

swallow whole, chew, break, or crush.


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


2

Ascorbic Acid

Vitamin C

Vitamin

Capsule: Open capsule and mix contents with 1-2 tbsp

pureed food, water, or sugar free

applesauce

Tablets: crush tablet prior to administration

Aspirin

Ecotrin

Analgesic

Continue aspirin unless surgeon documents in LMR to discontinue or hold it. Change to chewable aspirin post-procedure.

Atazanavir Reyataz PI If patient is not able to swallow the whole 200-mg capsule, patient can open and add two 200-mg capsules in 4oz of

applesauce just prior to administration (manufacturer recommends increasing the dose due to the risk of loss of capsule

content)

Atenolol Tenormin Beta-Blocker Split or crush tablet prior to administration and mix with pureed food, water, or sugar free applesauce

Atomoxetine

Strettera

Psych

Contact prescribing MD to review post-bariatric med rec's. Lilly has stability data to show that the contents of one 60-mg

atomoxetine capsule dissolved in approximately 2 ounces (60 mL) of grape juice (Welch’s®, 100% juice), apple juice

(Tropicana®, 100% juice), cranberry juice cocktail (Tropicana®, sweetened cranberry juice), and fruit punch (Gatorade®)

will be stable at room temperature for up to 6 hours and will quantitatively allow delivery of the full capsule dose (Data on

file). A 5-minute standing time was allowed after the initial mixing to allow for complete dissolution. The atomoxetine

capsule mixed with spring water was found to have a bitter perception. When you touch an open capsule wash your hands

thoroughly to prevent iiritation; do not touch face or eyes.

Atorvastatin Lipitor Antihyperlipidemic Split or crush tablet prior to administration

Azathioprine

Imuran

Antirheumatic


or broken tablets

Baclofen Lioresal Muscle Relaxant Split or crush tablet prior to administration

Benazepril Lotensin Antihypertensive Split or crush tablet prior to administration

Benztropine May crush prior to administration

Betaxolol Kerlone Beta-Blocker Split or crush tablet prior to administration

Bisacodyl

Dulcolax Stool softener

Unable to be split or crushed due to enteric coated. Change to dulcolax 10 mg suppositories daily or senna syrup daily

Bisoprolol Zebeta Beta-Blocker Split or crush tablet prior to administration

Bosentan

Bozentan Antihypertensive


or broken tablets

Bumetanide

Bumex Diuretic

Decrease to half the dose or discontinue the medication per surgeon approval [due to complication from diuresis s/p procedure]. Split or crush tablet prior to administration

Bupropion Wellbutrin Antidepressant Change to immediate release tablets and crush prior to administration

Buspirone Buspar Antianxiety Split or crush tablet prior to adminsitration

Butabarbital Butisol Sedative/Hypnotic Change to oral solution 30 mg/5 mL

Cabergoline Dostinex Ergot derivative Split or crush tablet prior to swallowing. Take at bedtime to prevent upset stomach

Caffeine Vivatian CNS Stimulant D/C until tolerating regular diet or per surgeon recommendation

Calcitriol Vitamin D Vitamin Change to oral solution (Rocaltrol®)1 mcg/ml

Calcium Carbonate Calcium Supplement Change to Calcium Citrate - Crush tablet prior to administration


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


3

Calcium/Mag/Zinc Electrolyte Supplement Change to Ovaltine (once to twice a day) or an alternate, crushable or liquid, formulation

Candesartan Atacand ARB Split or crush tablet prior to administration. May sprinkle over applesauce

Captopril Capoten Antihypertensive Split or crush tablet prior to administration

Carbamazepine

Tegretol

Anticonvulsant

Change to oral suspension 100mg/5ml, chewable tablet or may sprinkle extended release capsules in sugar free applesauce

Carisoprodol Soma Muscle Relaxant Split tablet prior to administration.

Carvedilol

Coreg

Beta-Blocker

Tablet: Split prior to administration.

Capsule: Open and sprinkle contents on sugar free applesauce and ingest immediately with water. Do not chew.

Cefadroxil Duricef Antibiotic Please change to oral suspension 250mg/5ml or 500mg/5ml

Celecoxib

Celebrex

Analgesic

Discontinue NSAIDs peri-operatively (5 days prior to procedure). Change to acetaminophen 160 mg/5 ml liquid formulation.

If NSAID is required and approved by surgeon, ibuprofen (Motrin®)) elixir 100mg/5mL is available, or celebrex capsules

may be opened and sprinkled on sugar free applesauce and ingest immediately with water. Do not chew.

Cetirizine Zyrtec Antihistamine Change to over-the-counter oral solution 5mg/5mL or chewable tablet

Chloral Hydrate Noctec Sedative/Hypnotic Change to oral syrup 500 mg/5 mL or rectal suppository

Chlordiazepoxide Librium Antianxiety Open capsule and mix contents with 1-2 tbsp pureed food, water or sugar free applesauce

Chlorothiazide

Diuril Diuretic

Decrease to half the dose or discontinue the medication per surgeon approval [due to complication from diuresis s/p

procedure]. Change to oral solution 250 mg/5 ml

Chlorpheniramine/ Pseudoephedrine

Deconamine

Antihistamine/

Decongestant Change to individual components: Chlorpheniramine liquid 2mg/5mL and pseudoephedrine liquid 30mg/5mL. To be taken

separately.

Chlorpromazine Thorazine Antipsychotic Change to rectal suppository as no information found regarding splitting or crushing tablets

Chlorpropamide

Diabinese

Antidiabetic

Split or crush tablet prior to administration. Take with breakfast. Follow up with endocrinologist post surgery as requirement

may change

Chlorthalidone

Thalitone Diuretic


procedure]. Split or crush tablet prior to administration. Take medication in the morning with food

Chlorzoxazone Paraflex, Parafon Forte Muscle Relaxant Split or crush tablet and mix with food or liquid

Cholecalciferol

Vitamin D3

Vitamin

1000 IU tablet can be crushed. Also available as 400 IU tablet and multiple doses/strengths of the oral solution drops

Cholestyramine Questran Antihyperlipidemic Dissolve powder in liquid and take with meals

Ciprofloxacin Cipro Antibiotic Crush tablet(s) prior to administration or change to oral suspension 250mg/ml or 500mg/ml.

Citalopram Celexa Antidepressant Available as tablet and liquid formulation (10 mg/ 5 ml) - Tablet: may split or crush prior to adminsitration

Clarithromycin Biaxin Antibiotic Change to oral suspension: clarithromycin 125mg/5ml or 250 mg/5 ml

Clevidipine Cleviprex Antihypertensive ONLY AVAILABLE IV

Clomipramine

Anafranil

Antidepressant

Open the capsule and mix medicine beads with soft food (ex:unsweetened applesauce). Don't crush or chew the capsule

Clonazepam Klonopin Antianxiety Split or crush tablet prior to administration

Clonidine Catapres Antihypertensive Tablet: May crush tablet prior to administration Patch: No change


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


4

Clopidogrel

Plavix Platelet Inhibitor

Discontinue clopidogrel 5 days prior to procedure. Restart clopidogrel post-procedure. Crush one tablet and take by mouth

daily.

Clorazepate Tranxene Antianxiety Split or crush medication prior to administration

Closelvelam

Welchol

Antihyperlipidemic

Split or crush prior to administration and take with some form of liquid (water or unsweetened juice). May change to Oral

Powder for Suspension: 3.75 GM/Packet

Clotrimazole Mycelex Antifungal Troches are slowly dissolved in the mouth

Clozapine Clozaril Antipsychotic Split or crush tablet prior to administration or switch to Oral Disintegrating Tablet (ODT)

Colchicine Colcrys Antigout Split or crush tablet prior to administration

Coumadin Warfarin Anticoagulant Hold prior to surgery as directed by the surgeon. Post surgery, split or crush tablet prior to administration

Cyanocobalamin

Vitamin B12

Vitamin

Split or crush prior to administration if needed. Change to Sublingual Tablet, Disintegrating: 1000 MCG

Cyclobenzaprine Flexeril Muscle Relaxant Split or crush tablet prior to administration

Cyproheptadine Change to oral syrup 2mg/5ml (Up-To-Date)

Dabigatran

Pradaxa

Direct Thrombin Inhibitor

Do not break, chew, or open capsules as this may result in increased drug exposure. Notify surgeon to contact patient's

cardiologist/PCP to discuss peri-operative management. Refer to dabigatran guideline. Per package insert,

damaging/opening the capsule in any way increases drug bioavailability by 75%.

Dantrolene Dantrium Muscle Relaxant Open capsule and mix with (unsweetened-if available) orange juice (to maintain acidity)

Darunavir Prezista PI No data available; however powder is water-soluble and tablet is not enteric-coated or extended-release. May crush tablet

and mix in a glass with 4 oz of water and consume immediately. Rinse the glass with more water and swallow the entire

mixture to make sure you have taken all of the medication.

Delavirdine Rescriptor NNRTI If you have trouble swallowing the tablets, they may be dispersed in water. To prepare, add four tablets to at least 3 ounces

(88 milliliters) of water, allow to stand for a few minutes, and then stir until a uniform dispersion occurs. Drink the delavirdine-

water mixture right away. Rinse the glass and swallow the rinse to ensure that you have gotten the entire dose.When

delavirdine is administered in this manner, the oral bioavailability may be enhanced 20 percent

Desipramine Norpramin Antidepressant Split or crush tablet prior to administration

Desloratadine

Clarinex

Antihistamine

Change to Oral Syrup: 0.5 mg/mL or

Clarinex Reditabs Oral Disintegrating tablets: 2.5 MG, 5 MG

Desvenlafaxine Pristiq Antidepressant Do not crush or split. Consider switching to venlafaxine with approval from prescribing MD

Dexlansoprazole

Dexilant

Antiulcer

For patients with difficulty swallowing, the capsules may be opened and the contents sprinkled onto 1 tablespoonful of

applesauce. Swallow immediately. Do not chew the granules. Do not prepare doses before the time of administration

Dexmethylphenidate

Focalin

CNS Stimulant

Change Extended Release formulation to Immediate Release tablet. May crush immediate release tablet prior to

administration

Dextroamphetamine Dextrostat CNS Stimulant Change Extended Release formulation to Immediate Relase. May split before administration

Diazepam Valium Antianxiety Split tablet prior to administration. May change to Oral Solution: 5 mg/5 mL


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


5

Diazoxide

Hyperstat Antihypertensive

Change to Oral Suspension: 50 mg/mL. Shake well before administration

Diclofenac Potassium

Cataflam

Analgesic


If NSAID is required and approved by surgeon, ibuprofen (Motrin®)) elixir 100mg/5mL is available.

Diclofenac Sodium

Voltaren

Analgesic



Dicyclomine Bentyl Antimuscarinic Open capsule prior to administration. May change to Oral Syrup: 10 mg/5 mL

Didanosine Videx NRTI Available as an oral solution (10 mg/ml)

Didanosine Videx EC NRTI Available as chewable formulation (100mg tablets) and as a powder for suspension (10 mg/ml)

Diflunisal Dolobid Analgesic Avoid NSAIDS. Do not crush or chew

Digoxin Lanoxin Cardiac Glycoside Change to Digoxin oral elixir 0.05 mg/ml

Diltiazem

Tiazac, Dilacor Calcium Channel Blocker

Open capsule and sprinkle over unsweetened applesauce, do not chew pellets, consume whole. May change to tablet and crush tablet prior to administration

Diphenhydramine Benadryl Antihistamine Change to liquid formulation - 12.5 mg/ 5ml

Diphenoxylate Lomotil Antidiarrheal Split or crush tablet prior to administration. May change to Oral Solution: 0.025 mg/5 mL- 2.5 mg/5 mL

Divalproex Sodium

Depakote

Anticonvulsant

Change to Depakote XR sprinkles, may sprinkle capsule contents on a teaspoonful of soft food; swallow the drug/food

mixture immediately (avoid chewing) and do not store for future use

Docusate Sodium

Colace

Laxative

Change to Docusate liquid (100 mg/10 ml) as needed. Mix in small amount of water or sugar free apple sauce prior to

administration

Donepezil Aricept Cholinergics Change to oral disintegrating tablet: 5 mg, 10 mg. Allow to dissolve on tongue and follow with a glass of water

Doxazosin Cardura Beta-Blocker Crush tablet prior to administration

Doxepin Sinequan Antidepressant Change to doxepin oral solution (10mg/ml)

Doxycycline Vibramycin Antibiotic Change to doxycycline oral suspension (50 mg/5 ml)

Doxycycline

Tetracycline Antibiotic

Doxycycline may cause esophageal ulceration. Whether opening delayed-release capsules, crushing tablets, or using

doxycycline solution, they all require to be followed by about 8oz of cool water and sitting in an upright position for as long

as possible after administration. Volume of 8oz is much more than is allowed for post-op bariatric patients during the first

couple of weeks. Please consider switching to an alternative antibiotic post-operatively.

Duloxetine Cymbalta Antidepressant Open capsule and sprinkle on 100% (sugarfree) applesauce ONLY

Efavirenz Sustiva NNRTI May open capsules and sprinkle contents on soft food (ex. Apple sauce or grape jelly). Mix well and swallow. Rinse bowl

with water and drink mixture to ensure entire dose was administered.


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


6

Efavirenz/Emtricitabine/Tenofovir

Atripla

Antiretroviral

Contact prescribing MD to review post-bariatric med rec's. Combination tablet Atripla cannot be crushed or split. Please

change to Efavirenz and Emtricitabine/Tenofovir (Truvada) components. Efavirenz capsules may be open and contents

sprinkled onto soft food (ex. apple sauce or grape jelly). Mix well and swallow. Rinse bowl with water and drink mixture to

ensure entire dose was administered. Truvada tablet has NO enteric coating or sustained-release mechanism and will

disintegrate in water, grape juice, or orange juice. Truvada tablet is moisture sensitive and, thus, must be consumed

immediately after mixing. Rinse container and consume rinse.

Emtricitabine Emtriva NRTI Available as an oral solution (10 mg/ml)

Emtricitabine/Tenofovir Truvada NRTI Crush the tablet and mix with small amout of water, grape juice or orange juice just prior to administration

Emtricitabine/Tenofovir/Rilpivarine

Complera

Antiretroviral

Contact patient's HIV specialist regarding the following information. Please see Rilpivarine information above and consider

alternative agent if possible. For the other two components, Emtricitabine/Tenofovir there is a combination tablet Truvada.

There is no data available on the pharmacokinetic differences between the crushed versus whole tablet. Tablet has NO

enteric coating or sustained-release mechanism and will disintegrate in water, grape juice, or orange juice. Truvada tablet is

moisture sensitive and, thus, must be consumed immediately after mixing. Rinse container and consume rinse.

Enalapril Vasotec Antihypertensive Split or crush tablet prior to administration

Enalapril/Felodipine Lexxel Antihypertensive Split or crush tablet prior to administration

Enalapril/HCTZ Vaseretic Antihypertensive Split or crush tablet prior to administration

Enbrel

Etanercep

Antirheumatic

Contact patient's rheumatologist or other applicable specialist for a specific plan regarding perioperative use of etanercept.

From previous experience with etanercept patients/communications with rheumatologists: The general approach is to skip

the dose prior to surgery and not restart it until the abdominal wound heals (about 2-3 weeks). Patient is most likely to flare

on cessation of Enbrel as it is active only for about a week.

Eplerenone

Inspra Diuretic


procedure]. Split or crush tablet prior to administration

Eprosartan Teveten ARB Split or crush tablet prior to administration

Ergocalciferol Vitamin D2 Vitamin Crush tablet prior to swallowing, or change to liquid ergocalciferol (8000 units/ml) for the 50,000 unit capsules

Escitalopram Lexapro Antidepressant Split or crush tablet prior to administration

Esomeprazole

Nexium

Antiulcer

Open capsule and sprinkle in 1-2 tablespoons of water for at least 2 weeks post surgery, may sprinkle over sugarfree

applesauce starting 3 weeks post surgery


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


7

Esomeprazole (capsules)

Nexium

PPI

sauce starting 3 weeks after surgery.

May also switch to esomeprazole delayed-release oral suspension. Empty the contents of a 10 mg, 20 mg, or 40 mg packet

into a container with 1 tablespoon (15 ml) of water. Stir and leave 2—3 minutes to thicken. Re-stir the mixture before

administration; administer within 30 minutes of preparation. Any residual drug left in container should be flushed with more

water and administered immediately.

For patients who have a nasogastric or gastric tube in place, add 15 ml of water to a catheter tipped syringe and then add

the contents of a 10 mg, 20 mg, or 40 mg packet. It is important to only use a catheter-tipped syringe when administering

through a nasogastric or gastric tube. Immediately shake the syringe and leave 2—3 minutes to thicken. Upon

administration, shake the syringe and inject through the nasogastric or gastric tube, French size 6 or larger, into the

stomach; administer within 30 minutes of preparation. Refill the syringe with 15 ml of water, shake and flush any remaining

contents from the nasogastric or gastric tube into the stomach.

Please verify with the surgeon that volume used to reconstitute the powder for suspension and flush the tube is not

excessive.

Estazolam Prosom Sedative/Hypnotic Split or crush prior to administration

Estradiol Climara Estrogen May need to stop 1 week prior to surgery based on thromboembolism complications

Eszopiclone Lunesta Sedative/Hypnotic Do not crush or chew. Swallow tablet whole as it is smaller than the tip of a pencil eraser

Etidronate

Didronel

Osteoporosis









Etodolac

Lodine

Analgesic


If NSAID is required and approved by surgeon, ibuprofen (Motrin®)) elixir 100mg/5mL is available. Etodolac 300 mg IR may

be crushed prior to administration if approved

Etravirine Intelence NNRTI If you have trouble swallowing the tablets, they may be dissolved in water. To prepare, add the tablets to a glass of water,

allow to stand for a few minutes, and then stir until a milky mixture occurs. Drink the etravirine-water mixture right away.

Rinse the glass with water and swallow the entire contents. Repeat process of rinsing and swallowing the rinse mixture

several times to make sure that the entire dose is taken.

Ezetimibe Zetia Antihyperlipidemic Split tablet prior to administration

Ezetimibe/Simvastatin Vytorin Antihyperlipidemic Change to individual components

Famotidine Pepcid Antiulcer Change to oral solution [Pepcid 40mg/5mL]

Felbamate Felbatol Anticonvulsant Change to oral solution [600mg/5mL]

Felodipine

Plendil Calcium Channel Blocker

Do not crush or chew extended release tablets. Swallow extended release tablet whole as it is smaller than the tip of a

pencil eraser

Fenofibrate Tricor Antihyperlipidemic Split tablet prior to administration

Fenofibrate 134mg capsules Antilipid Open and sprinkle contents on soft food or applesauce. Swallow without chewing.


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


8

Fenofibrate Capsules Anticholesterol Open and sprinkle contents on soft food or applesauce and ingest immediately with water. Do not chew

Fenofibric Tripilix Antihyperlipidemic Do not crush or chew, Alternative treatment must be used

Fenoldopam Corlopam Antihypertensive Only available as injection

Fenoprofen

Nalfon

Analgesic



Fentanyl Actiq Analgesic Change to lozenge or transdermal patch

Ferrous Gluconate

Iron

Supplement

Swallow tablet as it is smaller than the tip of a pencil eraser. Do not crush or chew enteric coated ferrous gluconate tablets.

Ferrous Sulfate Iron Supplement Change to either ferrous sulfate elixir (220 mg/5 ml)/Liquid 300mg/5 mL or Liquid Drops 75mg/0.6mL

Fexofenadine Allegra Antihistamine Change to Allegra suspension (30 mg/5mL)

Finasteride

Propecia, Proscar

Prostate/Alopecia Agent

Swallow tablet whole as it is smaller than the tip of a pencil eraser. Women of childbearing age should not touch or handle

broken tabs

Fingolimod

Gylenia

Multiple Sclerosis

Contact prescribing MD to review post-bariatric med rec's. Open the capsule and mix the content in 1 oz. (30ml) water, stir

and swallow. rinse the container with additional 1oz. (30ml) of water, to ensure that no drug is stuck to the side of container

for complete dose administration.

Flecainide Tambocor Antiarrhythmic Split tablet prior to administration

Fluconazole Diflucan Antifungal Crush tablet(s) prior to administration

Fluoxetine Prozac Antidepressant Change to Prozac 20 mg/5 mL liquid

Fluoxetine/Olanzapine Symbyax Antidepressant Change to individual components

Fluphenazine Prolixin Antipsychotic Change to oral solution: 5 mg/mL or oral elixir 2.5mg/5mL

Flurazepam Dalmane Sedative/Hypnotic Open capsule and mix contents with 1-2 tbsp pureed food, water, or sugar free applesauce, Do Not Chew

Flurbiprofen

Ansaid

Analgesic



Fluvasatatin XL Lescol XL Antihyperlipidemic Do not crush or chew. Swallow XL tablet whole as it is smaller than the tip of a pencil eraser

Fluvastatin Lescol Antihyperlipidemic Do not open capsules/Alternative treatment must be used

Fluvoxamine

Luvox

Antidepressant

Do not open Fluvoxamine XR Capsules/Change to immediate release tablets, and split tablet prior to administration

Folic Acid Vitamin B9, Folacin Vitamin Swallow tablet as it is smaller than the tip of a pencil eraser

Fosamprenavir Lexiva PI Available as an oral suspension (50 mg/ml)

Fosinopril Monopril Antihypertensive Split tablet prior to administration

Fosinopril/HCTZ Monopril HCT Antihypertensive Swallow tablet whole as it is smaller than the tip of a pencil eraser or change to individual components

Furosemide

Lasix

Diuretic


procedure]. Change to Furosemide 10 mg/ml solution or 40mg/5mL solution. Crush tablet prior to administration

Gabapentin Neurontin Anticonvulsant Change to gabapentin oral solution 250 mg/5 ml - Refrigerate solution

Galantamine Razadyne, Razadyne ER Cholinergics ER formulation cannot be opened. Change to oral solution 4 mg/mL

Gemfibrozil Lopid Antihyperlipidemic Split tablet prior to administration


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


9

Glimepiride Amaryl Antidiabetic Swallow tablet whole as it is smaller than the tip of a pencil eraser or split tablet prior to administration

Glimepiride/Pioglitazone Duetact Antidiabetic Change to individual components

Glimepiride/Rosiglitazone Avandryl Antidiabetic Change to individual components

Glipizide Glucotrol Antidiabetic Swallow tablet whole as it is smaller than the tip of a pencil eraser

Glipizide XL Glucotrol XL Antidiabetic Do not crush or chew. Swallow tablet whole as it is smaller than the tip of a pencil eraser

Glucosamine/Chondroitin

Glucosamine/Chondroitin

Supplement

Discontinue 14 days prior to surgery - may prolong bleeding time and cause mild stomach upset.

Please talk to your surgeon about resuming this supplement after your surgery.

-Available over-the-counter as liquid: Joint Juice Glucosamine 1500 mg Orange Tangerine or tropical fruit – 1500 milligrams

of glucosamine HCl and 60 milligrams of vitamin -- Glucosamine alone

-Wellesse Glucosamine Joint Movement Powder Packets; Natural Citrus 2000 mg glucosamine; 1200 mg chondroitin; 500

mg MSM. Powder packet should be poured into bottled water and shaken.

-Wellesse Joint Movement Glucosamine Liquid With Chondroitin And MSM 2000 mg of Glucosamine; contains

glucosamine, chondroitin and includes also MSM, and Vitamins C & D.

Glyburide Micronase Antidiabetic Swallow tablet whole as it is smaller than the tip of a pencil eraser or split tablet prior to administration

Glyburide/Metformin Glucovance Antidiabetic Change to individual components

Guanabenz Wytensin Antihypertensive Swallow tablet whole as it is smaller than the tip of a pencil eraser or split tablet prior to administration

Guanfacine

Tenex

Antihypertensive

Change from Extended Release to Immediate Release as you can not crush extended release tablet; or swallow whole as it

is smaller than the tip of a pencil eraser.

Split immediate release tablet prior to administration

Haloperidol Haldol Antipsychotic Change to Haloperidol Lactate 2mg/ml Solution/ Crush tablet prior to administration

HCTZ/Irbesartan Avalide Antihypertensive Change to individual components

HCTZ/Lisinopril

Zestoretic Antihypertensive

Change to individual components Swallow tablet whole as it is smaller than the tip of a pencil eraser

HCTZ/Losartan Hyzaar Antihypertensive Change to individual components

HCTZ/Metoprolol Lopressor HCT Antihypertensive Change to individual components

HCTZ/Moexipril Uniretic Antihypertensive Change to individual components

HCTZ/Olmesartan Benicar HCT Antihypertensive Change to individual components

HCTZ/Quinapril Accuretic Antihypertensive Change to individual components

HCTZ/Telmisartan Micardis Antihypertensive Change to individual components

HCTZ/Valsartan Diovan Antihypertensive Change to individual components

Hormone Replacement Therapy

(Estrogen supplements)

Hormone Replacement

therapy

Contact prescribing MD to review post-bariatric med rec's. STOP hormone replacement therapy (HRT) 7 days prior to

surgery, because it may increase the risk of venous thromboembolism. Since, estradiol is mostly absorbed in the

duodenum/small intestine, its absorption may be especially decreased in patients undergoing RYGB. Transdermal and

topical methods may be considered, especially since these dosage forms carry a lower risk of venous thromboembolism

than oral forms.

Hydralazine Apresoline Antianginal Split or crush medication prior to administration

Hydralazine/HCTZ Apresazide Antihypertensive Change to individual components


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


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10

Hydrochlorothiazide

HCTZ

Diuretic


procedure]. May swallow whole if smaller than the the tip of a pencil eraser or change from capsule to tablet and split tablet

prior to administration

Hydrocodone/APAP Vicodin Analgesic Change to oxycodone oral solution 1 mg/ml following surgery

Hydromorphone Dilaudid Analgesic Change to liquid formulation - 4mg/4ml

Hydroxychloroquine

Plaquenil

Antirheumatic

Tablet may be crushed prior to administration. Due to bitter taste, it is recommended to mix with applesauce or pureed

food.

Hydroxyzine Pamoate Vistaril PO – available as oral syrup 10mg/5mL

Hyoscyamine

Levsin

Antimuscarinic

Continue therapy with oral disintegrating tablet (ODT) formulation. Also available as 0.125mg/5ml elixir and solution.

SL formulation - Levsin®/SL, Symax® may also be chewed

Hyoscyamine Levbid Antimuscarinic Discontinue prior to surgery, or change to oral disintegrating tablet (ODT) formulation

Ibuprofen

Motrin

Analgesic



Ibuprofen, Naproxen, Diclophenac,

etc

NSAID

Discontinue NSAIDs peri-operatively (5 days prior to procedure). Change to acetaminophen 160 mg/5 ml liquid

formulation. If NSAID is required and approved by surgeon, ibuprofen (Motrin®)) elixir 100mg/5mL is available, or celebrex

capsules may be opened and sprinkled on sugar free applesauce and ingest immediately with water. Do not chew.

Diclofenac Gel: some of diclofenac gel may get absorbed into the bloodstream (6% of equivalent of the oral dose) and

therefore there is still the risk of GI bleed, ulceration and perforation. It would be safer to use gel over oral NSAIDs but at the

same time the risk of complications is still there. The patient needs to discuss the therapy with his surgeon and PCP and if

they do decide to go forward with the gel, a concomitant PPI might be a good option.

May also use a lidocaine patch.

Iloperidone Fanapt Antipsychotic Company does not recommended crushing or splitting the unscored tablet due to limited information

Imipramine

Tofranil

Antidepressant

Switch to Imipramine HCl tablet formulation, to be crushed prior to administration. Do not crush or chew the capsules. You

may open the capsules and mix the medicine beads with soft food (sugarfree pudding or applesauce). Swallow the mixture

without chewing medicine beads

Indinavir Crixivan PI Open capsule and sprinkle capsule content over fruit purees such as banana, pear, and apple due to bitter taste of capsule

content.

Indomethacin

Indocin

Analgesic



Insulin

Diabetes

CAUTION: Your insulin requirements and dose may change following surgery. Please follow up with the doctor taking care

of your diabetic needs as soon as possible after surgery and monitor your blood sugars very closely and frequently.

Irbesartan Avapro ARB Crush prior to administration

Isocarboxazid Marplan Antidepressant Crush tablet prior to administration

Isosorbide Dinitrate Isordil Antianginal Smaller scored tablet, may be split prior to administration


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


11

Isosorbide Mononitrate

Ismo

Antianginal

Tablet slightly bigger than diameter of pencil eraser - extended release tablet should not be chewed or crushed - may be

split as it is scored or

Change to immediate release formulation isosorbide dinitrate

Isradipine

Dynacirc

Calcium Channel Blocker

Do not crush or chew tablets, available as DynaCirc CR (controlled release tablets) and Dynacirc capsules - change from

CR tablets to IR capsules and open capsule prior to administration mixing with 1-2 tbsp pureed food, water, or sugarfree

applesauce

Ketoprofen

Orudis

Analgesic



Ketorolac

Toradol

Analgesic



Labetolol Trandate Antihypertensive Split or crush tablet prior to administration

Lactase Enzyme Lactaid Enzyme Take Lactaid chewables (3 Lactaid original strength = 1 Lactaid chewable)

Lactobacillus Acidophilus

Probiotic Please purchase Enzymatic® Acidophilus Peals since they are about the size of the pencil eraser (about 6mm). Please

swallow pearls whole.

Lamivudine Epivir NRTI Available as an oral solution (10 mg/ml)

Lamivudine/Zidovudine Combivir NRTI Please change lamivudine/zidovudine combination tablet to lamivudine oral solution (10mg/ml) and zidovudine oral syrup

(50mg/5ml)

Lamotrigine Lamictal Anticonvulsant Change to Lamictal oral disintegrating tablet (ODT) or chewable tablets, or split tablet prior to administration

Lansaprozole (capsules)

Prevacid

PPI

orally disintegrating tablets.

Switch to lansoprazole delayed-release oral suspension or disintegrating tablets.

Lansoprazole delayed-release oral suspension: Packets containing the enteric-coated granules (15 or 30 mg doses) are

mixed with 2 tablespoonfuls (30 ml) of water to form a strawberry-flavored suspension intended for immediate administration

after mixing. Do not use with other liquids or foods. Stir well and drink immediately. Do not crush or chew the granules. If

any material remains after drinking, add more water, stir, and drink immediately.

Lansoprazole delayed-release disintegrating tablets: Place on the tongue and allow to disintegrate until the particles can be

swallowed. The tablet will disintegrate rapidly (< 1 minute). Do not cut, chew, or crush the tablets. For administration via an

oral syringe, the tablet can be dissolved in water (4 ml for 15 mg tablet, 10 ml for 30 mg tablet) and should be administered

within 15 minutes.

Patients with a nasogastric tube: Prevacid capsules or disintegrating tablets can be administered via a nasogastric tube.

Capsules: Open the capsule and mix the intact granules in 40 ml of apple juice and inject through the nasogastric tube into

the stomach. After administration, flush the nasogastric tube with additional apple juice to clear the tube. Disintegrating

Lansoprazole

Prevacid

Antiulcer

Open capsule and sprinkle over sugarfree applesauce. Also available as Prevacid Solutab - orally disintegrating tablets

Leflunomide

Arava

Antirheumatic

Tablet smaller than diameter of pencil eraser - can be swollowed whole, also tablet can not be crushed per Teva

pharmaceutical due to limited information on bioavailability


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


12

Leflunomide

Arava

Chemotherapy

Contact prescribing MD to review post-bariatric med rec's. Increased risk of infection post procedure. It also has a side

effect of diarrhea (17-27%), however the patient would probably be tolerant of this side effect if it is a regular medication for

them. If the decision is to discontinue prior to procedure it's important to note the elimination half-life of 2 weeks -- please

follow up with prescriber about the plan. A washout period would be needed or cholestyramine might be used to eliminate

drug (cholestyramine usually used just for toxicity or in women of childbearing age - category X).

Levetiracetam Keppra Anticonvulsant Tablets can be crushed, or switch to Keppra Oral Solution (500mg/5ml)

Levothyroxine

Levoxyl, Synthroid,

Unithroid Thyroid Supplement

May crush tablets and suspend in 5-10 ml of water prior to administration. Capsules cannot be crushed, cut, or suspended

in water - must be swallowed whole if smaller than the tip of a pencil eraser

Liothyronine

Cytomel

Thyroid Supplement

Tablet is smaller than diameter of pencil eraser - can be swollowed whole. Per company does not recommend crushing or

splitting the tablet due to limited information on bioavailability

Lisdexamfetamine

Vynase

CNS Stimulant

Open capsule and dissolve in a glass of water and consume the resulting solution immediately - do not store the solution

Lisinopril Zestril Antihypertensive Split or crush tablet prior to administration

Lithium

Eskalith

Antipsychotic

Change lithium carbonate IR to lithium citrate solution 300mg/5ml (equivalent to amount of lithium in lithium carbonate)

Loperamide

Imodium

Antidiarrheal

Split or crush tablet prior to administration, or change to solution 1 mg/5 ml. Also available as Imodium A-D - chewable

tablets

Lopinavir/Ritonavir Kaletra PI Available as an oral solution (80 mg/ml - 20 mg/ml)

Loratadine Claritin Antihistamine Change to 5 mg/5 ml liquid formulation if needed. Also available as orally disintegrating tablets (ODT)

Lorazepam Ativan Antianxiety Small, scored tablet. May swallow whole if smaller than the tip of a pencil eraser

Losartan Cozaar ARB Crush tablets prior to administration

Lovastatin

Mevacor Antihyperlipidemic

Swallow whole as tablet is smaller than diameter of pencil eraser. Also available as extended release tablets which cannot

be crushed.

Lovastatin/Niacin Advicor Antihyperlipidemic Avoid Niacin. May keep lovastatin with no change

Loxapine Loxapac Antipsychotic Company does not recommended opening the capsules due to limited information on bioavailability

Lubiprosone

Amitiza

Constipation

Capsule is 9mm long, but cannot be split, crushed, or tampered with. Tablet cannot be swallowed whole after any of the

procedures, including RYGB, band, or sleeve gastrectomy. Stop taking this medication and contact prescriber for

alternative therapy.

Lurasidone Hcl Latuda Crush tablet following surgery. Must be taken with meals.

Magnesium Gluconate

Magnesium

Supplement

Split or crush tablet prior to administration, available as Magonate (OTC) 1000mg/5ml liquid (equivalent to 54mg of

elemental magnesium) 500mg of magnesium gluconate tablet has 27mg of elemental magnesium

Maprotiline

Ludiomil

Antidepressant

Tablet smaller than diameter of pencil eraser - can be swollowed whole. Company does not recommend crushing the tablet

due to limited information on bioavailability

Maraviroc Selzentry Fusion Inhibitor No data available; however powder is water-soluble and tablet is not enteric-coated or extended-release. May crush tablet

and mix in a glass with 4 oz of water and consume immediately. Rinse the glass with more water and swallow the entire

mixture to make sure you have taken all of the medication.

Meclizine Antivert, Bonine Antiemetic Available as chewable tablets


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


13

Medroxyprogesterone

Provera

Progestin

Discuss with surgeon to continue peri-operatively. Tablet smaller than diameter of pencil eraser - can be swollowed whole,

also tablet can not be crushed Per Pfizer due to limited information on bioavailability

Mefenamic Acid

Ponstel

Analgesic



Megestrol Megace Progestin Tablets slightly bigger than diameter of pencil eraser. Oral solution available: 40mg/ml and 125mg/ml

Meloxicam

Mobic

Analgesic



Meprobamate Equanil Antianxiety Split or crush medication prior to administration

Mesalamine Asacol Anti-inflammatory Consider changing to other IBD meds. Tablet burden is too high and medication cannot be crushed

Mesalamine Rowasa Anti-inflammatory May continue suppository as directed

Mesalamine Pentasa Gastrointestinal Agent Open capsule and sprinkle contents on yogurt or peanut butter

Mesoridazine Serentil Antipsychotic Company has stopped manufacturing this product

Metaxalone Skelaxin Muscle Relaxant Crush medication or split into 1/4 tablets prior to administration

Metformin

Glucophage

Antidiabetic

Change to Riomet® 500 mg/5 ml. If Riomet® is unavailable crush tablet prior to administration. If bitter taste is intolerable,

split tablet into quarters small enough to be the size of a pencil eraser.

Metformin/Actos Actomet Antidiabetic Change to individual components; Actos 15 mg and Riomet 500 mg/ 5 ml.

Metformin/Pioglitazone Actoplus Met Antidiabetic Change to individual components; Actos 15 mg and Riomet 500 mg/ 5 ml.

Metformin/Rosiglitazone Avandamet Antidiabetic Change to individual components; Avandia and Riomet 500 mg/ 5 ml.

Metformin/Sitagliptin Janumet Antidiabetic May separate formulations (Riomet 500 mg/5 ml) but Januvia cannot be crushed

Methimazole

Tapazole

Antithyroid Do not crush or chew. Swallow tablet whole

as it is smaller than the tip of a pencil eraser

Methocarbamol Robaxin Muscle Relaxant Crush tablet prior to administration

Methotrexate

Trexall

Antirheumatic Swallow tablet whole as it is smaller than the tip of a pencil eraser.

Be sure to take on an empty stomach 1 hr prior to a meal or 2 hours after a meal

Methotrexate

Trexall

Antirheumatic

Contact patient's rheumatologist or other applicable specialist for a specific plan regarding perioperative use of

methotrexate. Please consider the following facts when dealing with oral MTX:

1. GI toxicity from MTX is a known concern, might be increased in pts w/ a pouch-sized stomach (stomatitis, N/V,

ulcerations)

2. Increased MTX concentrations in pt on PPI (usually with higher doses, but still a possibility)

3. Decreased folic acid absorption in pts post R-n-Y which might put pt at risk for MTX side effects (assuming folic acid is

used as an antidote to MTX)

4. If a patient takes 10 tablets of 2.5mg (total dose 25mg) once a week,(usualy dosing for RA). Tablets are small enough to

swallow whole. Tablets cannot be crushed due to environmental hazard.

5. MTX is usually stopped a week prior to surgery. MTX is usually not to be restarted until a week after the wound heals.

Methotrexate works slowly with several weeks needed to become active and several weeks without to lose activity. When

patient restarts methotrexate dose may be reduced. Methotrexate is equipotent as a liquid injectable taken orally or IM. IM

methotrexate may be used as an alternative to PO. May consider switching to IM injections.


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


14

Methsuximide Celontin Anticonvulsant Extemporaneous formulation can be compounded if needed

Methyldopa Aldomet Antihypertensive Can swallow tablet whole as it is smaller than the tip of a pencil eraser

Methylphenidate Ritalin CNS Stimulant Can swallow tablet whole as it is smaller than the tip of a pencil eraser

Metoclopramide Reglan Antiemetic Can swallow tablet whole as it is smaller than the tip of a pencil eraser

Metolazone

Zaroxolyn

Diuretic Decrease to half the dose or discontinue the medication per surgeon approval [due to complication from diuresis s/p

procedure]. Can swallow tablet whole as it is smaller than the tip of a pencil eraser

Metoprolol Lopressor Beta-Blocker May split or crush tablets prior to administration

Metoprolol XL Toprol XL Beta-Blocker Change to metoprolol IR and split tablets if necessary

Mexelitine Mexitil Antiarrhythmic Capsules can be opened and mixed with water prior to administration

Miglitol

Glyset

Antidiabetic Do not crush or chew. Swallow tablet whole

as it is smaller than the tip of a pencil eraser

Minoxidil Loniten Antihypertensive Tablets can be crushed and mixed with water prior to administration

Mirtazapine

Remeron

Antidepressant Option 1: Tablets are scored and may be split prior to administration. Option 2: Change to ODT (available 15mg, 30mg, and 45mg)

Modafinil Provigil CNS Stimulant May split prior to administration

Molindone Moban Antipsychotic Split or crush tablet prior to administration

Montelukast Singulair Antiasthma Change to Singulair chewable tablets

Moricizine Ethmozine Antiarrhythmic Crush prior to administration

Multivitamin Centrum Supplement Change to Centrum chewables

Nabumetone

Relafen

Analgesic



Nadolol Corgard Beta-Blocker Crush tablet prior to administration

Naproxen

Aleve

Analgesic



Nateglinide Starlix Antidiabetic Crush tablet prior to administration

Nebivolol Bystolic Antihypertensive Split or crush tablet prior to administration

Nefazodone Serzone Antidepressant Crush tablet prior to administration. Dosing after meals may decrease absorption

Nelfinavir Viracept PI 1. If you are unable to swallow the tablet, you may put it in a glass and dissolve it in a small amount of water. Mix the liquid

well, and drink it immediately. Rinse the glass with more water and swallow the entire mixture to make sure you have taken

all of the medication.

2. Nelfinavir oral powder may be added to water, milk, formula, soy milk, or dietary supplements. Mix well, and drink all of

the liquid right away in order to take the full dose. Your prescription label tells you how many scoops of nelfinavir powder to

add to the liquid. If the mixture is not taken immediately it must be stored in the refrigerator and taken within 6 hours. Do not

mix nelfinavir oral powder with acidic food or juice (orange juice, apple juice, or apple sauce). Do not mix nelfinavir with

water in the original container. (oral powder for suspension - 50 mg/gm)

Nevirapine Viramaune NNRTI Available as an oral suspension (50 mg/5 ml)


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


15

Niacin

Nicotinic Acid/Vitamin B3

Antihyperlipidemic Discontinue

Niacin

Nicotinic Acid/Vitamin B3

Antihyperlipidemic Discontinue

Niacin/Simvastatin Simcor Antihyperlipidemic Discontinue Niacin. Simvastatin may be split or crushed

Niacinamide Vitamin B3 Antihyperlipidemic Crush prior to administration

Nicardipine

Cardene

Antihypertensive

If on SR, convert to IR. The total daily dose of IR product may not be equivalent to the daily SR dose; use caution in

converting. Do not chew or crush the SR formulation, do not open or cut capsules. IR can be split or crushed.

Nifedipine XR Procardia Calcium Channel Blocker Change to amlodipine

Nimodipine

Nimotop

Calcium Channel Blocker

Can puncture capsule and take contents by mouth

Nisoldipine

Sular

Calcium Channel Blocker Do not crush or chew tablets

Nitroglycerin Nitrostat, Nitrobid Antianginal Available as sublingual tablets (SL) or spray

Nizatidine Axid Antiulcer Change to oral solution 15mg/ml

Norethindrone Aygestin Progestin Oral tablet may be crushed or chewed

Nortriptyline Pamelor Antidepressant Change to liquid formulation - 10 mg/5 ml

Nystatin Mycostatin Antifungal Liquid formulation available. 100,000 units/gram

Olanzapine Zyprexa Antipsychotic Switch to Zydis® oral disintegrating tablet (ODT)

Olmesartan Benicar ARB Crush tablet prior to adminsitration

Omega-3-Acid Ethyl Esters

Lovaza

Antihyperlipidemic Discuss with surgeon continuation peri-operatively. If approved, capsules must be swallowed whole, however larger than

the diameter of a pencil eraser. Do not puncture gelatin capsules

Omeprazole

Prilosec

Antiulcer Open capsule and sprinkle in 1-2 tablespoonfuls of water for at least 2 weeks post-surgery, may sprinkle over sugarfree

applesauce starting 3 weeks post-surgery

Omeprazole (delayed release

capsules and tablets)

Prilosec

PPI

Omeprazole tablets should be switched to omeprazole capsules. Capsules can be opened and sprinkled in 1-2 tablespoons

of water for at least 1-2 weeks post surgery, and then in sugar free apple sauce starting 3 weeks post surgery. If a patient

has a NG or gastric tube, omeprazole powder for suspension can be considered. When administering via an NG or gastric

tube (French size 6 or larger), add 15 ml of water to a catheter tipped syringe; then, add the contents of omeprazole powder

for suspension packet to the syringe. Shake immediately, allowing 2—3 minutes for the suspension to thicken. Shake once

more and give through the NG or gastric tube. Refill the syringe with an equal amount of water. Shake and flush any

remaining contents from the tube. In all cases, administer the suspension within 30 minutes of preparation. Please verify

with the surgeon that volume used to reconstitute the powder for suspension and flush the tube is not excessive.

Ondansetron

Zofran

Antiemetic Do not crush or chew. Swallow tablet whole as it is smaller than the tip of a pencil eraser, or split tablet prior to

administration


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


16

Oral Contraceptives

N/A

Oral contraceptives

Contact prescribing MD to review post-bariatric med rec's. STOP oral contraceptives (OCP's) 7 days prior to surgery,

because they may increase the risk of venous thromboembolism, and use alternative method of contraception. Due to

increased fertility following bariatric surgery/weight loss and decreased absorption of oral contraceptive tablets (especially

with malabsorptive procedures [RYGB]), please inform prescriber to switch to a birth control method which bypasses the GI

tract, such as an IUD, injectable depot, vaginal ring, or a patch.

Orphenadrine

Norflex

Muscle Relaxant Discuss with surgeon. Do not crush, chew, or break the ER tablet. Swallow the pill whole. Breaking or crushing the pill may

cause too much of the drug to be released at one time

Oxaprozin

Daypro

Analgesic Discontinue NSAIDs peri-operatively (5 days prior to procedure). Change to acetaminophen 160 mg/5 ml liquid formulation.


Oxazepam Serax Antianxiety Split or crush medication prior to administration

Oxcarbazepine Trileptal Anticonvulsant Switch to Trileptal oral solution (300mg/5ml)

Oxybutynin Urinary Change to immediate release oral syrup 5mg/5ml (Up-To-Date)

Oxycodone Oxycontin Analgesic Do not crush, consider changing to oxycodone liquid 5mg/ 5ml

Oxycodone/APAP Percocet Analgesic Change to Roxicet 5 mg oxycodone-325 mg acetaminophen/5 ml

Oxymorphone

Opana

Analgesic Change to oxycodone 1 mg/ml solution or split or crush the IR tablets prior to administration. ER formulation can't be split or

crushed, change to IR

Paliperidone Invega Antipsychotic Swallow whole. Do not chew, crush, or split tablets

Pantoprazole Protonix Antiulcer Change to omeprazole 20 mg capsules; open capsules and sprinkle in applesauce or pureed food

Pantoprazole (tablets)

Protonix

PPI

sauce starting 3 weeks after surgery.

If patient has a nasogastric tube, pantoprazole tablets may be switched to pantoprazole delayed release oral suspension.

Granules may be sprinkled on 5 ml (one teaspoonful) of applesauce; administer within 10 minutes. Alternatively, granules

may be mixed in a small cup with 5 ml (one teaspoonful) of apple juice; stir for 5 seconds and administer, then rinse the

container with additional apple juice and administer, to assure delivery of the full dose. Do not prepare using any other

liquids or foods, including water. Patients should be advised to not chew or crush the granules.

Patients with a nasogastric tube: Use the oral suspension granules. Empty the contents of one packet into the barrel of a 60

ml (2 ounce) catheter tip syringe (with the plunger removed) that is connected to a 16 French (or larger) nasogastric tube.

Add 10 ml of apple juice and gently tap and/or shake the barrel of the syringe to help empty the syringe into the tube. Add

an additional 10 ml of apple juice and gently tap and/or shake the barrel of the syringe to rinse the syringe and the

nasogastric tube. Rinse with additional apple juice at least twice or until the syringe is clear of granules.

Paricalcitol Zemplar Antithyroid Do not crush or chew. Swallow tablet whole as it is smaller than the tip of a pencil eraser

Paroxetine Paxil Antidepressant Switch to Paxil oral suspension (10mg/5ml)

Perindopril Aceon Antihypertensive Split or crush tablet prior to administration

Perphenazine Trilafon Antipsychotic Split or crush tablet prior to administration

Phenelzine Nardil Antidepressant Split or crush tablets prior to administration

Phenobarbital Phenobarbital Anticonvulsant Change to Phenobarbital elixir (20mg/5ml); or Phenobarbital solution (20mg/5ml)

Phenylephrine tannate Nasop Antihistamine Split or crush tablets prior to administration

Phenytoin Dilantin Anticonvulsant Change to 50mg chewable tablet; or Phenytoin oral suspension(100mg/4ml or 125mg/5ml)

Pimozide Orap Antipsychotic Split or crush tablet prior to administration


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Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


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17

Pindolol Visken Beta-Blocker Split or crush tablet prior to administration

Pioglitazone Actos Antidiabetic Split or crush tablets prior to administration

Piroxicam

Feldene

Analgesic



Potassium Chloride

Potassium

Electrolyte

Change to Potassium Chloride powder for solution. (20meq/pk, Dissolve 1 packet in cold water or fruit juice); or switch to

oral solution 20meq/15ml or 40meq/15ml (dilute 15 mL with 4 to 6 ounces of cold water or fruit juice)

Potassium Chloride

K-DUR

Electrolyte

May place whole tablet in approximately 4 ounces of water and allow to disintegrate, then swirl and stir; consume

immediately; be sure to consume all of the residue by adding more water and swirling

Potassium Chloride oral tablets (ER

or IR)

Supplement Switch to potassium chloride oral powder for suspension, NOT the oral solution (requires 6oz of fluid instead of 4oz for

powder formulation).

Potassium Citrate

Potassium

Electrolyte

Change to oral powder for suspension (citric acid-potassium citrate) 1002 mg/packet - 3300 mg/packet (mix with at least 6

ounces cool water or juice); or change to oral solution (citric acid-potassium citrate) 334 mg/5ml - 1100 mg/5ml (dilute

solution with 1 glass of water to minimize gastrointestinal injury )

Pramipexole Mirapex Antiparkinsonian Split or crush tablets prior to administration

Pravastatin Pravachol Antihyperlipidemic Split or crush tablet prior to administration

Prazosin Minipress Beta-Blocker No Change, small capsule (bad taste) may be swallowed whole if smaller than the tip of a pencil eraser

Pregabalin Lyrica GABA Open capsules and sprinkle in 4 oz. of water (20mg/ml liquid is not available)

Primidone Mysoline Anticonvulsant May crush prior to administration

Probenecid Benemid Antigout Tablets are scored, may split tablet prior to administration

Procainamide Pronestyl Antiarrhythmic Open capsule and mix with 1 teaspoonful of soft solids (sugarfree yogurt, applesauce)

Prochlorperazine Compazine Antiemetic Split or crush tablets prior to administration, may also consider using suppository

Progesterone Prometrium/Endometrin Progestin Capsule may not be opened or altered in anyway, consider switching to other dosage forms (vaginal tab/gel)

Promazine Sparine Antipsychotic No Change. Swallow tablet whole if smaller than the tip of a pencil eraser

Promethazine Phenergan Antihistamine Tablets are scored, may split tablet prior to administration

Propafenone Rythmol Antiarrhythmic Tablets are scored, may split tablet prior to administration

Propoxyphene Darvon Analgesic Do Not crush tablet (Bad taste), switch to other pain meds such as oxycodone 1mg/mL

Propranolol Inderal LA Beta-Blocker Change to IR propranolol

Propranolol

Inderal Beta-Blocker

Oral solution available: 20 mg/5 mLL, 40 mg/5 mL. Split tablet prior to administration.

Consistently take at same time of day with or without food.

Propylthiouracil Propylthiouracil Antithyroid Tablets are scored, may split tablet prior to administration

Protriptyline Vivactil Antidepressant Crush tablets prior to administation

Pseudophedrine

Sudafed

Decongestant

Change to oral solution 30 mg/5 mL. Long-acting formulation must be swallowed whole, cannot be chewed, broken or

crushed

Psyllium Metamucil Fiber supplement Continue therapy, split dose into quarters if not able to drink full glas of water at once

Pyridoxine Vitamin B6 Vitamin Change to oral solution 200 mg/5 ml

Quazepam Doral Sedative/Hypnotic Split or crush prior to administration

Quetiapine Seroquel Antipsychotic Switch to immediate release (IR) and crush tablet prior to administration

Quinapril Accupril Antihypertensive Split or crush tablet prior to administration


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


18

Quinidine Gluconate

Antiarrhythmic

Contact prescribing MD to review post-bariatric med rec's. 1) The usual dosage range of QUINIDINE GLUCONATE is 324

to 648 milligrams (1 to 2 tablets) every 8 to 12 hours. It is only available as extended-release tablets. However, dosage

may vary considerably depending upon patient response. For titration purposes, tablets may be broken in half; however, if

tablets are crushed or chewed, their sustained-release properties will be lost [52]. SALT CONVERSIONS b) Quinidine

sulfate contains 83% anhydrous quinidine alkaloid. Quinidine gluconate contains 62% anhydrous quinidine, whereas

quinidine polygalacturonate contains 60% anhydrous quinidine [26]. IMPORTANT: SINCE ABSORPTION OF ANTI-

ARRHYTHMIC AGENTS MAY DECREASE AFTER SURGERY, PLEASE CHECK TO SEE IF PATIENT HAS AN AICD

AND CONTACT THEIR CARDIOLOGIST TO CHECK IF THE DEVICE SETTINGS NEED TO BE CHANGED.

Quinidine sulfate Quinidex Extentabs Antiarrhythmic Split or crush immediate release tablets prior to administration. Extended release tablets cannot be crushed

Rabeprazole Aciphex Antiulcer Do not crush or chew. Swallow whole

Raloxifene Evista SERM Do not crush or chew, swallow whole (bad taste, teratogenic potential upon skin contact)

Raltegravir Isentress Integrase Inhibitor No data available; however powder is water-soluble and tablet is not enteric-coated or extended-release. May crush tablet

and mix in a glass with 4 oz of water and consume immediately. Rinse with more water and swallow the entire mixture to

make sure you have taken all of the medication.

Ramelteon Rozerem Sedative/Hypnotic Do not break tablets; swallow whole

Ramipril Altace Antihypertensive Open capsule & mix contents with 1 teaspoonful of soft food prior to administration

Ranitidine Zantac Antiulcer Change to Zantac oral syrup 15 mg/ml

Repaglinide Prandin Antidiabetic Swallow whole as tablet is smaller than diameter of pencil eraser.

Reserpine Harmonyl Antihypertensive Split or crush tablet prior to administration

Retinol Vitamin A Vitamin Oral capsule. Do not crush or chew

Rifampin

Antibiotic

1) Open capsule and sprinkle onto or mix with no more than 1 ounce of applesauce. Please take at least 1 hour before or

2 hours after meals. Rifampin will cause a reddish discoloration of bodily fluids (tears, urine, sweat, etc). May permanently

stain soft contact lenses.

Rilpivarine

Edurant

Antiretroviral

Contact patient's HIV specialist regarding the following precautions. Rilpivarine 25mg tablets are smaller than the pencil

eraser, BUT caution must be exercised s/p bariatric procedures which lead to significantly decreased aciditiy of stomach

pouch (sleeve gastrectomy and Roux-en-Y); this also applies to patients getting acid-suppressive therapy. Bioavailability

and, thus, effectiveness of rilpivarine is greatly reduced when pH of the stomach is increased; it is also reduced if

administered during fasting state or with high-protein food (as opposed to high-calorie [fatty], low-protein food) -- this is

especially important in the first 3-4 weeks when patients have minimal food intake.

Risedronate

Actonel

Osteoporosis









Risperidone Risperidol Antipsychotic Switch to Oral Solution: 1 mg/mL


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


19

Ritonavir Norvir PI Available as an oral solution (80 mg/ml) - mix with Ensure or Chocolate milk

Rosiglitazone Avandia Antidiabetic Split or crush tablet prior to administration

Rosuvastatin Crestor Antihyperlipidemic Crush tablet prior to administration

Salicylic acid

Trilisate

Analgesic



Saquinavir Invirase PI Manufacturer does not provide any additional information not included in the package insert. However powder is water-

soluble and not enteric-coated or extended-release; no stability data available.

Saw palmetto Saw palmetto Herbal supplement Discontinue and discuss with surgeon

Saxagliptin

Onglyza

Antidiabetic

Recommmend not to crush/split/chew due to the lack of stability/bioavailability data (both strenghs have tablet size slightly

bigger than pencil eraser)

Selegiline Eldepryl Antidepressant Swallow whole as tablet is smaller than diameter of pencil eraser.

Sertraline

Zoloft

Antidepressant

Change to Sertraline liquid 20 mg/ml. Pour 4 oz. (1/2 cup) of any of the following liquids into a drinking glass: water, ginger

ale, lemon/lime soda, lemonade or orange juice. Do not use any other liquids besides these.

• Draw up the proper amount of ZOLOFT Oral Concentrate into the special dropper that comes

with the medicine.

• Squeeze the ZOLOFT Oral Concentrate out of the dropper into the drinking glass. Stir well. It

is normal if a slight haze appears after mixing.

• Drink all the liquid as soon as you have mixed it. Do not mix it in advance.

Sevelamer Renagel Renal failure (other) Do not Crush. Please switch to such alternatives as Lanthanum Carbonate (Fosrenol) or Calcium Acetate (Phos-Lo)

Sildenafil Viagra, Revatio Antihypertensive Split or crush tablet prior to administration

Simethicone Gas-X Antiflatulent Change to oral suspension 40mg/0.6ml

Simvastatin Zocor Antihyperlipidemic Crush tablet prior to administration. Avoid prolonged exposure to light.

Sitagliptin Januvia Antidiabetic DO NOT CRUSH; May Consider re-evaluating need for sitagliptin if pt undergoing Roux-en-Y gastric bypass.

Solifenacin ER

Enablex ER

Urinary Please consider changing to tolterodine IR. Solifenacin ER 5-10mg per day approximately equivalent to 2mg twice a day of

tolterodine.

Sotalol

Betapace Beta-Blocker

Do not crush or chew tablet, however, tablet is scored, may split if necessary; may consider ordering sotalol liquid from

local compounding pharmacy (recipes are available)

Spironolactone

Aldactone Diuretic


procedure]. Crush tablet prior to administration

Stavudine Zerit NRTI Available as an oral powder for solution (1 mg/ml)

Sucralafate Carafate Antiulcer Recommend change to PPI, liquid carafate dosing tends to require high volume

Sulfasalazine

Sulfazine

GI/antiinflammatory

DO NOT CRUSH (enteric-coated). Consider switching to mesalamine if therapeutically indicated -- it is available as rectal

enema or rectal suppository

Sulindac

Clinoril

Analgesic


If NSAID is required and approved by surgeon, ibuprofen (Motrin®)) elixir 100mg/5mL is available. Tablet is scored, may cut

in half

Sumatriptan Imitrex Antimigraine No Change since tablet is the size of pencil eraser or consider Imitrex nasal spray

Tacrolimus Prograf Transplant Open capsule and mix with small amount of liquid prior to administration


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


20

Tamoxifen

Nolvadex

Anticancer

Contact prescribing MD to review post-bariatric med rec's. Crush medication prior to administration. Not to be crushed by or

around pregnant women and children. Contact the tamoxifen prescriber in regards to continuing tamoxifen after a bariatric

surgery. Limited data in patients post Roux-en-Y suggest that tamoxifen serum levels might be below therapeutic levels and

monitoring of steady state tamoxifen serum levels and dose adjustment might be necessary. Until adequate data suggest

otherwise, parenteral anticancer should be considered when systemic therapy is needed in a patient with malabsorption.

Tamsulosin Flomax Urinary/BPH Open capsule and mix with 1-2 tablespoonfuls of water, swallow immediately, do not chew beads

Telmisartan Micardis Antihypertensive Split or crush tablet prior to administration

Temazepam Restoril Sedative/Hypnotic Open capsule and mix with small amount of liquid prior to administration

Tenofovir Disoproxil Fumarate (use

full name)

Viread NRTI Crush the tablet and mix with small amout of water, grape juice or orange juice just prior to administration - I also found this

It is water soluble, is not enteric coated and not sustained release. It will dissolve if crushed and added to 100 mL of water

Terazosin Hytrin Antihypertensive Consider changing to doxazosin IR and crushing tablet.

Terbinafine

Lamisil

Antifungal

Available as packets (125 mg/packet, 187.5 mg/packet) -- (oral granules) sprinkle content of each packet on a spoonful of

pudding or other soft, non-acidic food; swallow the entire spoonful without chewing; may sprinkle on more than 1 spoonful if

2 packets are required; do not put on applesauce or fruit-based foods

Theophylline ER Asthma Change to theophylline solution 80mg/15ml divided every 6 hours. Do not use elixir due to 20% ethanol content.

Thiamine Vitamin B1 Vitamin Crush tablet prior to administration

Thiothixene Navane Antipsychotic Switch to Thiothixene Hydrochloride Oral solution 5mg/ml

Tiagabine Gabitril Anticonvulsant Crush tablet prior to administration

Timolol

Blocarden

Beta-Blocker

May crush tablet prior to administration. Tablet is small enough to swallow whole as it is smaller than the tip of a pencil

eraser.

Tipranavir Aptivus PI Available as an oral solution (100 mg/ml)

Tizanidine

Zanaflex

Muscle Relaxant

May crush tablet prior to administration. Tablet is small enough to swallow whole as it is smaller than the tip of a pencil

eraser.

Topiramate

Topamax

Anticonvulsant

Do Not Crush. Please switch to Topiramate capsules. Hold the

capsule upright over the food. You should be able to read the word 'TOP' on the capsule.

Twist off the clear part of the capsule and pour the entire contents onto the spoonful of food.

Swallow the entire mixture immediately without chewing.

Drink fluids right after swallowing to wash down the mixture and to be sure that you swallow all of it.

Torsemide

Demadex

Diuretic


procedure]. All tablets are scored - please split tablets before administration (split tablets smaller than pencil eraser)

Tramadol Ultram Analgesic If capsule, change to tablet, and split prior to administration if larger than the diameter of a pencil eraser

Tramadol/APAP Ultracet Analgesic Change to oxycodone oral solution 1 mg/ml following surgery

Trandolapril Mavik Antihypertensive Crush tablets prior to administration

Tranylcypromine Parnate Antidepressant Crush tablet prior to administraion

Trazodone Desyrel Antidepressant Crush tablets prior to administration

Treprostinil Remodulin Antihypertensive Crush tablets prior to administration


Drug Info Handbook

Policy: 7/10/2009: 9/2010, 10/2011

Phamacy: 7/23/2009, 6/2011, 3/2012, 6/2013


P and T: 9/2009, 3/2012, 9/2013


21

Triamterene/HCTZ

Dyazide

Diuretic

Decrease to half the dose or discontinue the medication per surgeon approval [due to complication from diuresis s/p procedure]. Change to Maxzide and crush tablet prior to adminsitration

Triamterene/HCTZ

Maxzide

Diuretic


procedure]. Crush tablet prior to administration

Triazolam Halcion Sedative/Hypnotic Split or crush prior to administration

Trifluoperazine Stelazine Antipsychotic Split or crush tablet prior to administration

Triflupromazine Vesprin Antipsychotic Split or crush tablet prior to administration; caution with crushed material -- can cause contact dermatitis

Trimipramine Surmontil Antidepressant Change to oral solution - 40 mg/ml

Valdecoxib Bextra Analgesic Do not use -- Withdrawn from market in 2005

Valproate Depakote Anticonvulsant Change to oral solution 250mg/5ml

Valproic Depakene Anticonvulsant Change to oral solution 250mg/5ml

Valsartan Diovan Antihypertensive Crush tablet prior to administration

Valsartan/HCTZ Diovan HCT Antihypertensive Change to independent formulations. Diovan can be crushed prior to administration and HCTZ may swallow whole

Venlafaxine

Effexor

Antidepressant

Crush or split if immediate-release tablet. If extended-release, capsule may be open and poured into a small amount of soft

food such as sugarfree pudding, yogurt, or applesauce. Stir this mixture well and swallow it without chewing.

Venlafaxine XR

Effexor XR

Antidepressant

Contact prescribing MD to review post-bariatric med rec's. The beads in capsules are extended-release and cannot be crushed. Switch to an immediate-release tablets (crushable) and use BID or TID dosing.

Verapamil Calan, Verelan, Isoptin Calcium Channel Blocker Change to verapamil IR and crush tablet prior to adminsitration

Vitamin B-100 B-Complex Vitamin Crush tablet prior to adminsitration

Vitamin D gelcap Vitamin You can melt the gel cap in 15 mls (tablespoon) of warm water

Vitamin E Vitamin E Vitamin Change to oral solution 4600 IU/5ml

Voriconazole Vfend Antifungal Available as powder for suspension 40mg/ml. Note: pregnancy category D, caution in women of childbearing age

Zaleplon Sonata Sedative/Hypnotic Open capsule and mix with small amount of liquid prior to administration

Zidovudine Retrovir NRTI Available as an oral syrup (50 mg/5 ml)

Ziprasidone Geodon Antipsychotic Open capsule and mix with small amount of liquid prior to administration

Zolmitriptan Zomig Antimigraine May change to ZMT formulation (oral disintegrating tablet)

Zolpidem

Ambien

Sedative/Hypnotic

May crush tablet prior to administration. Tablet is small enough to swallow whole as

it is smaller than the tip of a pencil eraser.

Zolpidem

Ambien CR

Sedative/Hypnotic

Do not crush or chew. Swallow tablet whole as it is smaller than the tip of a pencil eraser or change to immediate release

formulation

Zonisamide Zonegran Anticonvulsant Do not crush

References: Micromedex, Lexicomp, drug manufacturers (detailed information on file)

bariatric consult pharmacy drug info handbook

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