Hospital's Drug Formulary (2nd Edition)

Damanhour Chest Hospital
Drug Information Unit
Drug
Formulary
damanhour chest hospital's
second edition
january 2024
Keep in touch:
Clinical Pharmacy Unit & DIC

in Damanhour Chest Hospital
druginfodch @gmail.com
Submit a drug information request

(DIR)
Drug Information Unit’s Library

We are delighted to present to you the drug
formulary, curated for Damanhour Chest Hospital in
its second edition.
This formulary provides reference-based
information compiled from multiple references, and
has been developed to help fellow healthcare
providers easily find the information they are
looking for, on the medications they use frequently
to treat their patients.
It includes information on the mechanism of action,
indications, dosing, dose adjustments,
contraindications, precautions, disease-related
concerns, adverse effects, drug-drug interactions,
preparation and administration directions, tags on
medication safety plus important clinical practice
notes.
All medications are organized in alphabetical order.
Feel free to reach out if you have any inquiries,
notes, corrections and any suggestions for our
future updates.
Mahmoud Bakr, BCPS, RPh

Drug Information Unit Coordinator
ICU clinical pharmacist
mahmoudbakr94@gmail.com
Contributors
Dr. Alaa Ahmed
Dr. Basant Elberkawy
Dr. Bothina Saleh
Dr. Eman Rahal
Dr. Eman Sallam
Dr. Fatma Omar
Dr. Maha Atef
Dr. Mahmoud Bakr
Dr. Mai Ashraf
Dr. Menna Beshara
Dr. Mennatullah Osama
Dr. Nada Ashraf
Dr. Rania Eltarras
Dr. Sara Elhalfawy
and the Inpatients’ Pharmacy team
Editing & Design

Dr. Mahmoud Bakr
Tags
& color codes
High-alert
‫عالي الخطورة‬
Sound-alike
‫متشابه في النطق‬
Look-alike
‫متشابه في الشكل‬
High concentration
‫عالي التركيز‬
Photo-sensitive
‫يتأثر بالضوء‬
CIs: Contra-indication(s)
AEs: Adverse effect(s)
DDIs: Drug-drug interaction(s)
Note
The supplied medications and preparations in
the hospital are chosen based on the lowest
product price available on the Unified
Procurement Authority (UPA) website.
All product prices provided in this formulary are

subject to change.
Copying, reproducing, or distributing any part

of this publication without authorization is
prohibited.
Please respect intellectual property rights and

refrain from unauthorized duplication.
Index
Drug Page Drug Page Drug Page

Acetylsalicylic acid 7 Famotidine 36 Piperacillin-tazobactam 69
Acetylcysteine 7 Fentanyl 37 Pirfenidone 70
Alteplase 7 Fluconazole 38 Potassium chloride 71
Ambroxol 8 Fluticasone + salmeterol 38 Prednisolone 73
Amikacin 8 Fondaparinux 39 Propofol 73
Aminoleban 9 Formoterol 40 Propranolol 74
Aminophylline 9 Fucidic Acid 40 Pyrazinamide 75
Amiodarone 10 Furosemide 41 Ramipril 75
Amlodipine 11 Gentamicin 41 Remdesivir 76
Amoxicillin 11 Glucose solution 42 Rifampin 77
Amoxicillin-clavulinate 12 Glyceryl trinitrate/nitroglycerin 42 Rifaximin 78
Ampicillin-sulbactam 12 Haloperidol 43 Ringer’s solution 78
Apixaban 13 Human Albumin 43 Salbutamol 79
Atorvastatin 14 Hydrocortisone 44 Sodium bicarbonate 80
Atracurium 14 Imipenem-cilastatin 46 Sodium chloride solution 80
Atropine 15 Insulin glargine 46 Spironolactone 81
Azithromycin 15 Insulin NPH 47 Tiemonium Methyl Sulfate 82
Beclomethasone 16 Insulin regular 47 Tigecycline 82
Bromhexine 16 Ipratropium 48 Torsemide 83
Bisoprolol 16 Isoniazid 49 Tranexamic acid 83
Budesonide 17 Ivabradine 49 TMP-SMX 84
Bupropion 17 Ketoprofen 50 Unfractionated heparin 85
Calcium gluconate 18 Kidmin 51 Ursodeoxycholic acid 86
Captopril 19 Lactulose 52 Vancomycin 87
Cefadroxil 20 Levetiracetam 52 Verapamil 88
Cefalexin 20 Levofloxacin 53 Vitamin B Complex 89
Cefepime 21 Lidocaine 54 Vitamin K 89
Cefotaxime 21 Linezolid 55 Warfarin 90
Ceftazidime 22 L-Ornithine L-Aspartate 56
Ceftriaxone 22 Magnesium sulfate 56
Chlorpheniramine maleate 23 Mannitol 57
Cisatracurium 24 Meropenem 58
Clarithromycin 24 Methylprednisolone 58
Clindamycin 25 Metoclopramide 59
Clopidogrel 25 Metronidazole 60
Colistin 26 Miconazole 61
Dexamethasone 27 Midazolam 61
Diclofenac sodium 28 Molnupiravir 62
Digoxin 28 Moxifloxacin 62
Dobutamine 30 Nalbuphine 63
Dopamine 30 Neomycin + Bacitracin 64
Doxycycline 31 Norepinephrine 64
Enoxaparin sodium 32 Ondansetron 65
Epinephrine 33 Oseltamivir 65
Epinephrine + Articaine 34 Pan-Amin G 66
Esomeprazole 34 Pantoprazole 66
Ethambutol 35 Paracetamol 67
Etamsylate 36 Phenytoin 68
6|Page
Acetylsalicylic acid - 75mg tablets (Aspirin, aspocid)
Mechanism of action Disrupts the production of prostaglandins throughout the body by targeting cyclooxygenase-1
(COX-1) and cyclooxygenase-2 (COX-2)
Indication and doses Acute coronary syndrome (STEMI and NSTEMI): Loading dose 162-325mg administered once
diagnosis is established (with clopidogrel), and maintenance dose: 75-100mg once daily
Ischemic heart disease (secondary prophylaxis): 75-100mg once daily
Acute ischemic stroke:
-Eligible for rTPA: 75-100mg once daily (delay for at least 24hr after IV alteplase use)
-Ineligible for rTPA: LD 160-325mg administered once then 50-100mg once daily started within
48hrs
-Aspirin + clopidogrel in patients within 24hr of minor stroke/ high-risk TIA: 160-325mg
administered once, followed by 50-100 mg once daily for 21 days
Dose adjustment Severe liver disease: avoid use
Renal dose adjustment: Intermittent HD: administer once daily after HD session. CrCl <10: Avoid
Important Considerations -CI: Hypersensitivity to NSAIDs
-Assess use in case of gastric ulceration
-AE: Bleeding disorders (risk factors include: concurrent steroid use, anti-thrombotic use, elderly)
Preparation/administration Administer with food or a full glass of water
and stability/sensitivity
Notes -Avoid dual antiplatelet therapy (DAPT) in stroke patients with hemorrhagic transformation
-Avoid use unless if lower doses are used for pregnancy-related conditions
- Cost/tab: 0.16592 LE
Monitoring parameters Signs and symptoms of drug reaction
Acetylcysteine – 200mg and 600mg sachets (Windy, acetylcystein, fluimucil)
Mechanism of action Exerts mucolytic action through its free sulfhydryl group, which opens up the disulfide bonds in the
mucoproteins thus lowering mucous viscosity
Indication and dose Mucolytic (adjunctive therapy) Oral: 200mg oral /8hr or 600mg /24hr
Nebulized inhalation: 1 ampoule of 300mg/3ml concentration given undiluted /6-8hr
Dose adjustment No adjustment necessary
Important considerations AEs: Hypersensitivity. Use caution in patients with asthma or history of bronchospasm.
Preparation/administration Oral: Effervescent Dissolve the effervescent tablets in the volume of water.
and stability/sensitivity Nebulized inhalation: Do not mix with any other nebulized drug
ً
‫ ال يتم إعطاؤه مخلوطا مع أدوية االستنشاق األخرى‬-
Notes -Safe to use in pregnancy
-Cost/sachet: 1.386 LE
Alteplase – 50mg vials (Actilyse) ☀
Mechanism of action Initiates local fibrinolysis by binding to fibrin in a thrombus (clot) and converts entrapped
plasminogen to plasmin
Indication and doses Acute ischemic stroke (within 4.5 hours of symptoms onset): IV 0.9 mg/kg (max total dose is 90mg
for patients weighing ≥100kg). Administer 10% of 0.9 mg/kg dose as an IV bolus over 1min, followed
by 90% of 0.9 mg/kg dose as a continuous infusion over 60 mins.
Pulmonary embolism (hemodynamically stable or unstable, intermediate to high risk)
IV: 100 mg infused over 2 hours.
STEMI: weight >67 kg: Infuse 15mg IV bolus over 1-2mins, followed by 50mg IV infusion over
30mins, then 35mg over 1hr; max total dose: 100mg
weight ≤67 kg: Infuse 15mg IV bolus over 1 to 2 minutes, followed by infusions of 0.75mg/kg over
30mins, then 0.5mg/kg over 1hr
Dose adjustment No adjustments are provided. Hepatic or renal impairment may increase the risk for bleeding.
7|Page
Important Considerations CIs:
STEMI/PE: Active internal bleeding; history of recent stroke (within 3months),
intracranial/intraspinal surgery, serious head trauma, presence of intracranial conditions that may
increase the risk of bleeding, known bleeding diathesis, severe uncontrolled hypertension
(unresponsive to emergency therapy)
Acute CVS: intracranial/subarachnoid hemorrhage, active internal bleeding, recent
intracranial/intraspinal surgery (within 3 months), severe head trauma, presence of intracranial
conditions that may increase the risk of bleeding, known bleeding diathesis; severe uncontrolled
hypertension (unless safely lowered to <185/110 mmHg)
AEs: Intracranial, GI and genitourinary hemorrhage. Extravasation.
Preparation/administration -50 mg vial: Use accompanying diluent (50ml vial of sterile water for injection). Mix by gentle
and stability/sensitivity swirling and/or slow inversion; do not shake. Vacuum is present in 50mg vial. Final concentration:
1 mg/ml.
-Store below 30°C. Protect from light
-Reconstituted vials are stable for 24hrs (store at 2-8°C)
‫حت ى ز‬
‫ ال يتم رج‬، ‫يمتج‬ ‫ يقلب الفيال برفق ى‬، ‫ مل من الماء المذيب المرفق بالعلبة‬50 ‫ يذاب الفيال الواحد باستخدام‬-
‫الفيال‬
ً ‫ز‬
‫ مئوية بعيدا عن الضوء‬30 ‫ يحفظ ف درجة حرارة تحت‬-
‫ز‬
)‫ مئوية‬8-2 ‫التحضت (يحفظ ف درجة حرارة الثالجة‬ ‫ ساعة بعد‬24 ‫ يستخدم الفيال خالل‬-
‫ر‬
Notes -PE: Institute/resume parenteral anticoagulation near the end of or immediately following alteplase
infusion when aPTT returns to twice normal or less
-Not recommended for routine use during cardiopulmonary arrest. May consider on a case-by-case
basis (e.g: PE-induced cardiac arrest)
Cost/vial: 5988.576 LE
Ambroxol – 15mg/5ml oral syrup (Ambroxol)
Mechanism of action Stimulates bronchial cells to release surfactant and increase ciliary activity
Indication and doses Mucolytic: 60-120 mg/day in 2-3 divided doses
Dose adjustment No dose adjustment necessary
Important Considerations CI: Hypersensitivity to ambroxol or any component of the formulation
AEs: hypersensitivity, rash, GI upset
Preparation/administration -Store below 30°C. Keep away from light in a dry place
and stability/sensitivity -Use within shelf-life
ً
‫ مئوية بعيدا عن الضوء والرطوبة‬30 ‫ يحفظ زف درجة حرارة تحت‬-
Notes Pregnancy: Avoid in first trimester
Cost/bottle: 5.039994 LE
Amikacin – 500mg/2ml vial (Amikin)
Mechanism of action Interferes with bacterial protein synthesis. Binds with 30s ribosomal subunit.
Indication and doses Bloodstream infection, sepsis and septic shock – adjunctive for resistant gram-negative bacteria:
15-30 mg/kg IV /24hr
Hospital-acquired or ventilator-associated pneumonia (in combination): 15-20mg/kg IV /24hr for
7days
Dose adjustment Renal dose adjustment:
CrCl 40-59: administer /36hr + adjust based on serum amikacin level
20-39: administer /48hr + adjust based on serum amikacin level
CrCl <20: administer usual first dose + subsequent doses based on serum amikacin level
BMI ≥30 kg/m2: Use adjusted body weight for dosing
Important Considerations Black Box Warning: Nephrotoxicity (dose-dependent), neurotoxicity such as ototoxicity (duration-
dependent)
DDIs: +colistin, +mannitol IV (avoid combination)
+vancomycin (avoid unless clinically indicated), +furosemide (avoid - may augment ototoxicity)
8|Page
Preparation/administration -Dilute 500mg in 100ml NS or D5W. administer over 30min
and stability/sensitivity -Store below 25°C
-Use within 24hrs after reconstitution. Store below 25°C
‫ دقيقة‬30 ‫ ويعىط عىل مدار‬%5 ‫ مل محلول ملح أو جلوكوز‬100 ‫مجم زف‬500 ‫ يحل الفيال‬-
‫ درجة مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬، ‫التحضت‬
‫ر‬ ‫ ساعة بعد‬24 ‫ يستخدم خالل‬-
Notes serum amikacin level: Peak: 40-60mg/L and trough <2mg/L. Draw peak 30 min after infusion start
and trough 30 min before next dose.
Cost/ampoule: 9.83367LE
Monitoring parameters Monitor renal function closely
Aminoleban IV solution ☀
Mechanism of action Promote protein synthesis, wound healing, and reduce the rate of endogenous protein catabolism.
Part of parenteral nutrition.
Indication and doses Amino acid supplementation in hepatic encephalopathy (chronic liver disease): IV: 500-1000ml
/24hr
Component of parenteral nutrition (PN started if patient anticipated to be unable to be fed
enterally for ≥7days): total amino acids
Stable: IV: 0.8-1.5 g/kg/day.
Critically ill, trauma, or sepsis: IV: 1.2-2.5 g/kg/day.
Dose adjustment Hepatic impairment: No adjustment necessary. Safe to use.
Renal impairment: The volume of urea removed and accumulated in patients on dialysis or
hemofiltration with serious renal disorder varies depending on the dialysis method and patients'
conditions. Use with caution and monitor response closely.
Important Considerations CIs: Hypersensitivity. Abnormal amino acid metabolism. Patients with renal disorder (unless on
dialysis)
Disease-related considerations: Patients with severe acidosis, congestive heart failure, fluid
overload, generalized edema, elevated serum urea (use with caution)
AEs: Extravasation, hepatobiliary effects, hyperammonemia, hyperglycemia or HHS
Preparation/administration -A dose of 500ml can be administered via a peripheral line but must be infused over 3-5hrs
and stability/sensitivity -Parenteral nutrition (combined with dextrose, other nutritive solutions) or osmolarity ≥900
mOsm/L must be infused via central venous catheter.
-Avoid use if indicator tablet has changed.
- Store below 25°C. Protect from light.
‫ ساعات‬5-3 ‫مل زف قسطرية وريدية طرفية عىل مدار‬500 ‫ يمكن إعطاء جرعة‬-
‫ تعىط التغذية الوريدية المركزية (مخلوطة مع المحاليل المغذية األخرى) عن طريق قسطرة وريدية مركزية‬-
‫تغت لون القرص المرفق معه‬
‫ تجنب استخدام العبوة إذا ر‬-
ً
‫ مئوية بعيدا عن الضوء‬25 ‫ يحفظ زف درجة حرارة تحت‬-
Notes -Extravasation management: If extravasation occurs, stop infusion immediately and disconnect
(leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line);
remove needle/cannula; apply dry cold compresses.
-Store in a temperature not exceeding 30oC
-Preservation/recovery of the lean body mass is related to improved outcomes in parenteral
nutrition patients
Cost/infusion bottle: 66.15 LE
Monitoring parameters Fluid balance, ABG, electrolytes status, blood glucose, renal and hepatic function, ammonia and
urea levels
Aminophylline – 2.5mg/ml ampoules (Minophylline)
Mechanism of action Smooth muscle relaxation (bronchodilation) and suppression of response of the airway to stimuli
9|Page
Indication and doses Treatment of acute exacerbations symptoms (not received aminophylline/theophylline in previous
24hrs)
IV LD: 5.7 mg/kg. IV MD: Age ≤60yrs: Continuous infusion 0.5 mg/kg/hour (max 1,125 mg/day)
Age >60yrs: Continuous infusion 0.38 mg/kg/hour (max 500 mg/day)
Dose adjustment Hepatic Impairment: Use with caution. Initial: 0.25 mg/kg/hour; max dose: 500 mg/day. Monitor
serum theophylline concentrations frequently.
Renal impairment: No dosage adjustment necessary.
Important considerations CIs: Hypersensitivity. Coronary artery disease where cardiac stimulation might prove harmful,
peptic ulcer disease.
-Use with caution in the elderly population, patients who have arrhythmias, hyperthyroidism, peptic
ulcers and seizure disorders.
-AEs: severe/potentially fatal toxicity may occur with reduced clearance (e.g: acute pulmonary
edema, heart failure, cor-pulmonale, fever for ≥24hrs, hepatic disease, acute hepatitis, cirrhosis,
hypothyroidism, sepsis with multiorgan failure, shock)
DDIs: +linezolid (BP may rise, closely monitor – decrease initial aminophylline dose)
+phenytoin (avoid and consider alternatives, decreased aminophylline concentration/effect)
Preparation/ 250 mg in 250 mL (final concentration 1 mg/mL) of D5W or NS.
administration Loading doses should be administered IV over 30min.
%5 ‫ مل محلول ملح أو جلوكوز‬50 ‫ امبول زف‬4 ‫ يحل‬-
‫ عىل مدار نصف ساعة‬loading dose ‫ يتم إعطاء الجرعة المبدئية‬-
Notes -Routine use of aminophylline is not recommended for the treatment of acute asthma
exacerbations or COPD exacerbations
- Dose used can be increased only if serum concentrations indicate need for larger dose
-Maternal use of aminophylline or theophylline is not associated with an increased risk of fetal
malformations
Cost/ampoule: 2.4253845 LE
Monitoring parameters Monitor heart rate, CNS activity and ABG.
Measure serum concentrations 30 min after the end of LD in patients who have not received
theophylline in the previous 24hrs if needing additional loading (serum conc <10 mcg/ml), or to
delay starting the MD infusion (serum conc >20 mcg/ml)
Amiodarone – 150mg/3ml ampoules and 200mg tablets (Amiron, cordarone)
Mechanism of action Class III antiarrhythmic agent. Inhibits adrenergic stimulation (alpha- and beta-blocking properties),
affects sodium, potassium, and calcium channels. Prolongs the action potential and refractory
period in myocardial tissue. Decreases AV conduction and sinus node function
Indication and doses Supraventricular arrhythmias: IV: 150 mg over 10 minutes, then 1mg/minute for 6 hours, then 0.5
mg/minute for 18 hours. Continue for a total loading dose of up to 10gm. Change to oral
maintenance dose when clinically indicated
Maintenance of sinus rhythm: Oral: 100-200mg once daily
Rate control: IV: 300 mg over 1hr followed by 10-50 mg/hr over 24hrs
or 150mg over 10-30 mins then 60mg/hr for 6hr, then 30mg/hr for 18hrs. Administer repeat boluses
of 150mg over 10-30mins as needed (no more than 9 boluses in any 24hr period)
Dose adjustment Hepatic Impairment:
If hepatic enzymes exceed 3 times normal or double in a patient with an elevated baseline,
consider decreasing the dose or discontinuing amiodarone.
Renal impairment: No dosage adjustment necessary
-Use the lower maintenance dose for elderly patients or patients with low body mass
Important Considerations CIs: Hypersensitivity to amiodarone, iodine, or any component of the formulation
10 | P a g e
AEs: Amiodarone can cause long-term hepatotoxicity, pulmonary toxicity, hypothyroidism,
hyperthyroidism and ocular effects
-Obtain baseline chest x-ray, pulmonary function tests, thyroid function tests and LFTs.
-Correct hypokalemia, hypomagnesemia and hypocalcemia before initiating therapy.
DDIs: +quinolones or macrolides: avoid combination and consider alternatives (increased risk of
QTc prolongation, monitor ECG continuously if combination is absolutely necessary)
+ondansetron, fluconazole, haloperidol or propofol (increased risk of QTc prolongation - monitor
ECG)
Preparation/administration -Injection must be diluted in D5W before continuous IV infusion use. Dilute to final concentration
and stability/sensitivity of 1-6mg/ml
%5 ‫ مل جلوكوز‬50 ‫ أمبول زف‬2 ‫ يتم حل‬-
Notes -Pregnancy: should be used only to treat refractory arrhythmias, or when other treatments are
contraindicated.
Cost/tablet: 1.265 LE
Monitoring parameters BP, heart rate, ECG, chest x-ray, pulmonary function, LFTs
AmLODIPine – 5mg and 10mg tablets (Alkapress, vasonorm)

Mechanism of action Non-dihydropyridine calcium channel blocker. Inhibits calcium ion from entering select voltage-
sensitive areas of vascular smooth muscle and myocardium during depolarization, producing a
relaxation of coronary vascular smooth muscle and coronary vasodilation.
Indication and doses Hypertension: 2.5-5 mg once daily, titrate dose as needed (max 10mg once daily)
Dose adjustment Hepatic impairment: Initial: 2.5 mg once daily; titrate slowly in patients with severe hepatic
impairment.
Renal impairment: no dose adjustment necessary
Important Considerations CIs: shock, unstable HF,
AEs: Peripheral edema 2-11% (dose-related, variable onset, more common in females)
- Use with caution in patients with hypertrophic cardiomyopathy
Notes -Females with preexisting hypertension may continue their medication during pregnancy unless
contraindications exist.
Cost amlodipine 5mg/tablet: 0.1936935 LE
Cost amlodipine 10mg/tablet: 0.208593 LE
Monitoring parameters Heart rate, BP, peripheral edema
Amoxicillin – 500mg and 1000mg tablets (biomox)
Mechanism of action Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins
(PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial
cell walls
Indication and doses Bronchiectasis exacerbations without beta-lactamase-positive H. influenzae or Pseudomonas
aeruginosa: Oral: 500 mg 3 times daily or 1 g 3 times daily for up to 14 days
CAP (outpatients without comorbidities or risk factors): Oral: 1gm 3 times daily for 5 days
Acute bacterial sinusitis: Oral: 500mg /8hr for 5 days
Streptococcal pharyngitis (group A): 500mg twice daily for 10 days
Dose adjustment Renal impairment: adjust according to usual dose
If usual dose is 500mg /8hr: CrCl <30: use 500mg /12hr
If usual dose is 1gm /8hr: CrCl 10-30: use 1gm /12hr, CrCl <10 or on HD: use 500mg /12hr
Important Considerations CIs: hypersensitivity to amoxicillin or beta-lactams
AEs: hypersensitivity, rash, DRESS, antibiotic-associated (non–Clostridioides difficile) diarrhea,
nausea, vomiting, C. difficile infection
11 | P a g e
Notes -In pregnancy: compatible for use
Cost/capsule: 0.59598 LE
Monitoring parameters Educate/monitor for signs of anaphylaxis during first dose
Amoxicillin-clavulinate – 1gm tablets (Megamox) ☀
Mechanism of action Amoxicillin: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding
proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in
bacterial cell walls. Clavulinic acid: Inhibits beta-lactamases that inactivate amoxicillin resulting in
an expanded spectrum of activity
Indication and doses Aspiration pneumonia (mild): Oral: 1gm /12hr for 5 days
CAP – outpatient + high-risk (combined with a macrolide or a quinolone): Oral: 1gm /12hr for
minimum 5 days
Acute bacterial sinusitis: Oral: 1gm /12hr for 5-7 days
Otitis media: Oral: 1gm /12hr. Duration: Mild: 5-7 days. Severe: 10 days
Dose adjustment Hepatic impairment: no dose adjustment necessary
Renal impairment:
Initial (can be considered): 1gm single dose
+ Maintenance dose:
CrCl 10-29: 250-500mg /12hr
CrCl <10: 250-500mg /12-24hr
On intermittent hemodialysis: 250-500mg /12-24hr, after HD session on dialysis days
Important Considerations CIs: Hypersensitivity to amoxicillin, clavulanic acid, other beta-lactams, history of cholestatic
jaundice/hepatic dysfunction with amoxicillin/clavulanate
Precautions:
-superinfection with prolonged use (possibly fungal and c. difficile)
AEs: Hypersensitivity (ranging from anaphylaxis to mild rash), diarrhea, nausea, vomiting,
cholestatic hepatitis (rare)
DDIs:
+warfarin (increased risk of bleeding/INR elevation – monitor closely)
Preparation/administration -Administer with food
and stability/sensitivity -Store below 25°C. Protect from light and humidity in aluminum foil
‫وف التغليف الخاص ر‬
‫بالشيط‬ ‫ مئوية من الضوء والرطوبة ز‬25 ‫يحفظ زف درجة حرارة تحت‬-
Notes -In pregnancy: Widely used in pregnant women and generally compatible. Necrotizing enterocolitis
in neonates or bowel disorders in children may be associated with amoxicillin/clavulanate when
exposure occurs near delivery
Monitoring parameters Assess patient at beginning/throughout therapy for infection, renal, hepatic, and hematologic
function periodically (prolonged use), LFTs at regular intervals (patients with hepatic impairment),
signs of anaphylaxis during first dose
Ampicillin-sulbactam – 1.5gm vials (Ultracillin, unictam)
Mechanism of action Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins -
inhibits the final transpeptidation of peptidoglycan synthesis in bacterial cell walls, thus inhibiting
cell wall biosynthesis. Sulbactam: a beta-lactamase inhibitor, to ampicillin extends the spectrum
of ampicillin to include some beta-lactamase-producing organisms and anerobes.
Indication and doses Aspiration pneumonia (community acquired): IV: 1.5-3gm /6hr for ≥5days
MDR Acinetobacter baumannii infection: IV: 9gm IV /8hr or 27gm continuous infusion over 24hrs.
Duration guided by clinical response
CAP (no pseudomonas risk – part of an appropriate combination): IV: 3gm /6hr for ≥5days
Dose adjustment Renal impairment:
12 | P a g e
CrCl 15-29: 1.5-3 gm /12hr
CrCl 5-14: 1.5-3gm /24hr
Intermittent HD: 1.5-3gm /12-24hr. administer after HD session on dialysis days
Important Considerations CIs: Hypersensitivity, history of cholestatic jaundice/hepatic dysfunction associated with ampicillin
sulbactam
AEs: Anaphylactoid/hypersensitivity reactions, hepatitis/cholestatic jaundice, rash, superinfection
(fungal or C. difficile) with prolonged use
DDIs: +aminoglycosides (decreased AG concentration – monitor AG level)
Preparation/administration -IV use: Dilute using WFI, then further dilute 1.5gm with 50ml (3gm with 100ml) NS. Administer
and stability/sensitivity and over 30mins
stability/sensitivity -Concurrent Y-site administration with aminoglycosides should be avoided
-Use immediately after reconstitution. Store below 25 C
‫مل محلول ملح ويعىط عىل مدار نصف ساعة‬50 ‫ ثم يحل الفيال الواحد زف‬، ‫ يحل باستخدام الماء المذيب المرفق‬-
‫ر ز‬
‫جنتاميسي‬ ‫ر ز‬
‫أميكاسي أو‬ ‫ يمنع إعطاؤه زف نفس الوقت زف القسطرة الوريدية الطرفية مع‬-
‫ درجة مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬،‫لتحضت‬‫ر‬ ‫يستخدم ر‬-
‫مباشة بعد ا‬
Notes -In pregnancy: generally considered compatible for use
Monitoring parameters CBC, renal, and hepatic function, signs of anaphylaxis during first dose
Apixaban – 2.5mg and 5mg tablets (Eliquis, pixcolt)
Mechanism of action Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of
free and clot-bound factor Xa.
Indication and doses AF (nonvalvular) Oral: 5 mg twice daily
Heparin-induced thrombocytopenia (HIT) Oral: 10 mg twice daily for 7days or until platelet count
recovery, followed by 5 mg twice daily.
VTE treatment: Oral: 10 mg twice daily for 7 days followed by 5 mg twice daily (if provoked: 3mo
duration. If unprovoked + persistent risk factors: ≥3 months
VTE prophylaxis: 2.5mg twice daily. Optimal duration is unknown.
Dose adjustment Hepatic impairment, according to Child-Pugh class:
Class A: no adjustment. Class B: use with caution. Class C: avoid
Renal dose adjustment:
AF (non-valvular): If two of: Age ≥80yrs, body weight ≤60 kg, or serum Cr ≥1.5 mg/dl: reduce dose
to 2.5mg twice daily
AF (non-valvular), on hemodialysis (3times/wk): 5mg twice daily, unless Age ≥80yrs or body weight
≤60kg: 2.5mg twice daily
Important Considerations CIs: presence of clinically significant bleeding, valvular AF patients, severe hypersensitivity
AEs: increased risk of bleeding
DDIs: +other anticoagulants (avoid combination)
+phenytoin, +rifampin - CYP3A4 inducers (avoid combination)
+aspirin (monitor/assess risk of bleeding)
+fluconazole - CYP3A5 inhibitor (monitor for any signs of bleeding)
Preparation/administration Administer without regard to meals
and stability/sensitivity Nasogastric/orogastric tube: may crush 5mg or 2.5mg tablets and suspend in 60ml of water, D5W,
or apple juice. Administer immediately. In applesauce for up to 4 hours.
‫عصت تفاح ويعىط ر‬
‫مباشة بعد‬ ‫ر‬ ‫ أو‬%5 ‫ مل ماء أو جلوكوز‬60 ‫ يطحن القرص ويحل زف‬:‫ تعليمات لألنبوبة المعدية‬-
‫التحضت‬
‫ر‬
Notes -In pregnancy: Avoid - potential risk for fetal bleeding or subclinical placental bleeding which may
increase the risk of miscarriage, preterm delivery, fetal compromise, or stillbirth.
-Transitioning from warfarin to apixaban: Discontinue warfarin, initiate apixaban if INR falls to <2
13 | P a g e
-Transitioning from parenteral anticoagulant to apixaban: Initiate apixaban at time of the next
scheduled dose of the parenteral anticoagulant
Monitoring parameters CBC, PTT, PT, serum creatinine and liver function tests.
Duration for unprovoked VTE treatment: assess depending on risk of VTE recurrence and bleeding
Atorvastatin – 40mg tablets (Ator, lipona)
Mechanism of action Competitively inhibit the enzyme hydroxymethylglutaryl-coenzyme A (HMG-CoA)
reductase, which catalyzes the conversion of HMG-CoA to mevalonic acid
Indication and doses Prevention of atherosclerotic cardiovascular disease (ASCVD): Patients with diabetes: Age 40-
75yrs + no additional ASCVD risk factors: Oral: 10-20 mg once daily
Secondary prevention (e.g: coronary heart disease, cerebrovascular disease, peripheral arterial
disease): Oral: 40-80 mg once daily
Dose adjustment Hepatic impairment: avoid in patients with acute liver failure/decompensated cirrhosis.
Important Considerations CIs: hypersensitivity
AEs: muscle-related effects (myalgia, myopathy, rhabdomyolysis), increased serum transaminases,
hepatotoxicity (Onset: Varied; occurs within 3 months of initiation/dose escalation)
Recent stroke/TIA, receiving long-term therapy with high-dose (i.e: 80 mg/day): increased risk for
hemorrhagic stroke
DDIs: +clarithromycin, +verapamil - CYP3A4 inhibitor (risk of statin AE/toxicity – limit to max
20mg/day)
Preparation/administration Administer with or without food; may take without regard to time of day.
Notes In pregnancy: potential for fetal harm. Should be discontinued once pregnancy is recognized.
Individualize based on the therapeutic needs of the patient.
Cost of atorvastatin10:0 .3653838 LE
Monitoring parameters Lipid panel, LFTs, myopathy/rhabdomyolysis
Atracurium – 50mg ampoules (Atrabesylate)
Mechanism of action Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites
Indication and doses ICU paralysis (e.g: severe ARDS, to increase chest wall compliance, etc) + adequate analgesia and
sedation: Loading dose: 0.4-0.6mg/kg IV bolus.
Followed by: continuous infusion dose: undiluted, or diluted: 0.3-0.6mg/kg/hr. Titrate according to
clinical response or peripheral nerve stimulation
Dose adjustment Hepatic dose adjustment: none necessary
Renal dose adjustment: none necessary
Obesity: Use ideal body weight or an adjusted body weight for morbidly obese patients
Important Considerations CIs: Hypersensitivity, use without adequate respiratory support/ventilation
AEs: bradycardia, prolonged paralysis
Disease-related considerations:
-Respiratory alkalosis, hypercalcemia and peripheral neuropathies may result in antagonism of
neuromuscular blockade
-Severe hypocalcemia, severe hypokalemia, hypermagnesemia, neuromuscular diseases, metabolic
acidosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in
potentiation of neuromuscular blockade
DDIs: +colistin (monitor for deeper, prolonged NBM effects, respiratory paralysis)
+systemic steroids (increased muscle weakness, use lowest possible dose of both drugs)
Preparation/administration -For IV use only
and stability/sensitivity -Do not administer with alkaline solutions in the same syringe/in the same IV line
-Dilute typically as 100mg in 50ml NS or G5% (2mg/ml)
14 | P a g e
‫ لالستخدام الوريدي فقط‬-
‫ ال يتم مزجه مع المحاليل الوريدية القلوية زف نفس الشنجة أو القسطرة الوريدية الطرفية‬-
%5 ‫ مل محلول ملح أو جلوكوز‬50 ‫مجم) زف‬100( ‫ أمبول‬2 ‫ يتم حل‬-
Notes -Limit the duration of paralysis as possible, and provide a physiotherapy regimen for patients
requiring continuous paralysis.
-Maintain adequate airway/respiratory support. Resistance may develop with chronic treatment.
-All patients should receive eye care including liberal use of lubricating drops. Eyelids should
remain closed.
-Acidosis and electrolyte disturbances alter NMBAs effect
-Reversal: Neostigmine: 0.5-2mg slow IV injection + atropine sulfate 0.6-1.2mg IV in a separate
syringe. Repeat as needed. Total dose of neostigmine should not exceed 5 mg.
Monitoring parameters Vital signs (heart rate, blood pressure, respiratory rate), degree of muscle paralysis (presence of
spontaneous movement, ventilator asynchrony, shivering, and consider use of a peripheral nerve
stimulator along with clinical assessments)
Atropine – 1mg ampoules (atropine sulfate)
Mechanism of action Blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and
the CNS; increases cardiac output, dries secretions.
Indication and doses Bradycardia during NMB reversal: IV: 15-20mcg/kg when administered with neostigmine
Bradycardia (symptomatic): IV/IM: 0.5-1 mg every 3-5 mins (max total dose: 3 mg) or
endotracheal: 1-2 mg every 3-5 mins.
Dose adjustment There are no dosage adjustments
Important Considerations AEs: Hypersensitivity. Hyperthermia: may inhibit sweating, possibly lead to heat-related injury in
patients exposed to warm environment
Use with caution in patients with myocardial ischemia, heart failure, tachyarrhythmias (including
sinus tachycardia), treatment-related BP increases and tachycardia may lead to
ischemia/precipitate MI/increase arrhythmogenic risk.
Preparation/administration -Administer undiluted by rapid IV injection. Slow injection may result in paradoxical bradycardia.
and stability/sensitivity -In bradycardia, atropine administration should not delay treatment with external pacing.
-Store below 25°C. Use immediately after opening.
ً
‫ يتم إعطاؤه وريديا بصورة شيعة دون تخفيفه‬-
‫ يستخدم ر‬، ‫ مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬-
‫مباشة بعد الفتح‬
Notes -IV doses <0.5 mg have been associated with paradoxical bradycardia. Restrict total dose to 0.03 to
0.04 mg/kg in patients with ischemic heart disease.
Monitoring parameters Heart rate, blood pressure, pulse, mental status
Azithromycin – 500mg capsules (Xiroximair)
Mechanism of action Binds to 50S ribosomal subunit
Indication and doses Acute exacerbation of COPD:
Oral: 500 mg on day 1, followed by 250 mg daily on days 2-5. Alternative: 500 mg daily for 3 days.
CAP (in combination with a beta-lactam antibiotic):
Outpatient: Oral: 500 mg on day 1, followed by 250 mg once daily on days 2-5. Alternative: 500
mg daily for 3 days.
Inpatient: Oral/IV: 500 mg once daily for min of 3 days
Dose adjustment No adjustment necessary
Important Considerations CIs: History of cholestatic jaundice. Hepatic dysfunction due to prior azithromycin use
15 | P a g e
AEs: Diarrhea (high single-dose may increase incidence), nausea (≤7%; high single-dose regimens:
5% to 18%), GI upset, cardiac conduction abnormalities
DDIs: Increased risk of QTc-interval prolongation (+amiodarone, +haloperidol)
Notes Avoid use in AECOPD patients with risk factors for Pseudomonas infection or poor outcomes (age
≥65 years + major comorbidities, FEV1 <50% predicted, frequent exacerbations).
In pregnancy: no fetal risk is documented
Monitoring parameters LFTs, symptoms of hepatitis
Beclomethasone – 50mcg/dose inhaler (Beclosone)
Mechanism of action Depresses the activity of endogenous chemical mediators of inflammation (e.g: kinins,
prostaglandins). Reverses capillary permeability and lysosomal stabilization at the cellular level to
prevent or control inflammation
Indication and doses Asthma: Adults: Inhalation: Low-dose 100-200 mcg/day, medium-dose: >200-400 mcg/day, High-
dose: >400 mcg/day. Administer in 2 divided doses.
Pediatrics: 5-11yr: 50mcg /12hr (max 100mcg/day)
≥12yr: 50-100mcg /12hr (max 400mcg/day)
COPD (in combination with LABA): Inhalation: 100-200mcg /12hr (max 400-1000mcg/day)
Rhinitis: Nasal spray: 1-2 puffs in each nostril /12hr
Dose adjustment No dosage adjustments are provided
Important Considerations CIs: Untreated fungal, bacterial, or tubercular infections of the respiratory tract
AEs: headache, pharyngitis, oral candidiasis, upper respiratory tract infections
Preparation/administration -Prime inhaler by spraying test sprays prior to initial use or if not in use for >14 days
and stability/sensitivity -Rinse mouth with water (without swallowing) after each use
-Higher doses in children <12yr may be associated with a higher risk of adverse effects
-Store below 30 C. protect from heat, light, humdity and physical damage
Notes Inhaled corticosteroids are recommended for the treatment of asthma during pregnancy. Due to
the risk of exacerbations, stepping down or stopping ICS should not be done during pregnancy.
Cost/inhaler: 16.141125 LE
Monitoring parameters Bone mineral density and growth (adolescents and children – long-term use), signs of oral
candidiasis
Bromhexine – 8mg tablets (Bromhexine)
Mechanism of action Disrupts the structure of acid mucopolysaccharide fibers in mucoid sputum and produces a less
viscous mucus, which is easier to expectorate
Indication and doses Mucolytic: 8 to 16 mg 3 times daily (maximum: 48 mg/day)
Dose adjustment No dose adjustments are provided
Important Considerations -Use with caution in patients with a history of gastric ulceration
AEs: GI upset, allergic reactions
Notes -Pregnancy: safe for use
-Cost/tablet: 0.1847538 LE
Bisoprolol – 5mg tablets (Egypro)
Mechanism of action Selective inhibitor of beta1-adrenergic receptors, with little or no effect on beta2-receptors at doses
≤20 mg
Indication and doses AF (rate control): 2.5-5 mg once daily (max dose 20mg once daily)
HFrEF: initial 1.25 mg once daily. Up-titrate gradually to a target dose of 10mg once daily
Hypertension (reserve for patients that have comorbidities requiring beta blocker use): 2.5-10 mg
once daily (max dose: 20 mg/day)
Ventricular arrhythmias: initial 2.5 mg once daily. Up-titrate gradually (max dose 10mg once daily)
Dose adjustment Hepatitis or cirrhosis: Initial: 2.5 mg once daily; increase cautiously
Renal dose adjustment:
16 | P a g e
CrCl <20mL/minute/1.73 m2: Start with 1.25-2.5 mg daily (depending on indication). Consider a
reduced maximum dose of 10 mg daily.
Important Considerations CIs: Cardiogenic shock; overt cardiac failure; marked sinus bradycardia or heart block greater than
first-degree (unless a pacemaker is installed)
AEs: Bradyarrhythmias: may cause first degree AV block, second degree AV block, or complete
heart block
-Bronchospasm: low risk (compared to non-selective beta-blockers)
-Potentiation/masking of hypoglycemia
Notes -Should not be withdrawn abruptly, but gradually tapered
- Females with preexisting hypertension may continue their medication during pregnancy unless
contraindications exist
Monitoring parameters Blood pressure, heart rate, ECG, serum glucose (in patients with diabetes), signs and symptoms of
bronchospasm, mental alertness
Budesonide – 0.25mg and 0.5mg nebules, 400mg capsules for inhalation (Pulmicort ☀ , budelizer)
Mechanism of action Depresses the activity of endogenous chemical mediators of inflammation (eg, kinins,
prostaglandins). Reverses capillary permeability and lysosomal stabilization at the cellular level to
prevent or control inflammation
Indication and doses Asthma (in combination with a bronchodilator): Oral inhalation: Low-dose 200-400 mcg/day,
Medium-dose: >400-800 mcg/day, High-dose >800 mcg/day
COPD: Nebulized inhalation: 0.25-1mg twice daily. Oral inhalation: 400mcg /12hr
Dose adjustment No dosage adjustments are provided
Important Considerations CIs: Untreated fungal, bacterial, or tubercular infections of the respiratory tract
AEs: headache, pharyngitis, oral candidiasis, upper respiratory tract infections
Preparation/administration -Budelizer: Rinse mouth with water (without swallowing) after each use
and stability/sensitivity -Store below 30°C. Protect from light (in aluminum foil)
-Opened foil: use within 3 months
-Opened units: use with 12hrs
‫ بي ر ز‬-
‫ ينصح المريض بالمضمضة (دون بلع الماء) بعد االستخدام‬:‫وديلتر‬
ً
‫ مئوية بعيدا عن الضوء زف التغليف الخاص به‬30 ‫ يحفظ زف درجة حرارة تحت‬-
‫ أشهر من فتح التغليف‬3 ‫ تستخدم األمبوالت المعرضة للضوء خالل‬-
‫ ساعة من فتحها‬12 ‫ تستخدم األمبوالت المفتوحة خالل‬-
Notes Inhaled corticosteroids are recommended for the treatment of asthma during pregnancy. Due to
the risk of exacerbations, stepping down or stopping ICS should not be done during pregnancy.
Cost/nebule: 10.593 LE
Monitoring parameters Bone mineral density and growth (adolescents and children – long-term use), signs of oral
candidiasis
Bupropion – 150mg SR tablets (Wellinta)
Mechanism of action Aminoketone antidepressant - a relatively weak inhibitor of the neuronal uptake of norepinephrine
and dopamine. Its metabolite inhibits the reuptake of norepinephrine. The primary mechanism of
action is thought to be dopaminergic and/or noradrenergic.
Indication and doses Smoking cessation: Initial: 150 mg SR tablet once daily for 3 days. Increase to 150mg twice daily
(max 300mg/day). Patients who do not tolerate titration to the full dose, consider continuing 150mg
once daily; the lower dose has shown efficacy. Treat for at least 12 weeks and up to 6-12months.
Individualize on a case-by-case basis
Dose adjustment Hepatic impairment:
Prior to treatment initiation:
Child-Turcotte-Pugh class A and B: initially 150mg /48hr + maintenance dose increased after 2weeks
17 | P a g e
Child-Turcotte-Pugh class C: Not recommended for use in smoking cessation
Declining hepatic function during treatment:
Progression to Child-Turcotte-Pugh class C: No dosage adjustment necessary - use with caution
Renal impairment:
CrCl 15-60: Use with caution. Max daily dose 150mg/day
CrCl <15 or on intermittent HD: Use with caution. Initial: 150 mg every 72 hours. Max daily dose
150mg/day
Important Considerations BLACK BOX WARNING: Increased the risk of suicidal thoughts and behavior in short-term trials.
Monitor closely for worsening/emergence of suicidal thoughts and behaviors
CIs: hypersensitivity, use of mono-amine oxidase inhibitors (MAOIs) concurrently/within 14 days,
combination with linezolid
Precautions:
-Can impair mental/physical abilities – caution when performing tasks requiring mental alertness
-May cause BP elevation
-Caution if weight loss not desirable
-Use with caution in patients with cardiovascular disease, history of hypertension, or coronary
artery disease
-Use with caution in the elderly patients (risk of drug accumulation)
-Abuse/misuse: Using doses higher than prescribed may result in increased motor activity,
agitation/excitement and euphoria
-Strong CYP2D6 Inhibitor
DDIs: +Monoamine Oxidase Inhibitors (linezolid) - monitor BP for 14 days after bupropion
discontinuation or until 24hrs after linezolid last dose
Preparation/administration May be taken without regard to meals. Do not crush, chew, or divide (sustained-release tablets)
Notes -Can be used as monotherapy or with nicotine replacement therapy
-Begin bupropion at least one week before quitting smoking
Monitoring parameters BP (baseline and periodically, especially when used in conjunction with nicotine transdermal
replacement), body weight, suicidality (during the initial 1-2 months of therapy or during periods of
dosage adjustments), renal and hepatic function (baseline and as clinically indicated)
Calcium gluconate – 1 gm ampoules (Calcionate)
Mechanism of action Moderates nerve and muscle performance via action potential threshold regulation
Indication and doses Hypocalcemia: IV bolus: Add 1-2gm diluted to 50ml D5W or NS. Infuse over 10-20min. repeat after
10-60mins if symptoms persist
Continuous infusion (use in patients with hypoparathyroidism or chronic hypocalcemia): dilute 5gm
in 450ml D5W or NS. Administer at 50-100ml/hr. Adjust dose to maintain albumin-corrected serum
Ca2+ levels at the lower end of normal.
Parenteral nutrition (maintenance req.): IV: Expressed in terms of elemental calcium: 10-15mEq
(~2-3gm Ca gluconate) /24hr. Adjust based on serum total or ionized calcium.
Cardiac arrest/cardiotoxicity or hyperkalemia: IV: 1.5-3 g over 2-5mins (avoid if on digoxin)
Dose adjustment No need for hepatic dose adjustment
Renal Impairment:
-Do not use IV calcium as initial therapy in patients with CKD who are asymptomatic/have stable
hypocalcemia/mild symptoms (e.g: paresthesias)
-Initiate with the lower limit of dosage range (accumulation may occur. Subsequent doses may
require adjustment based on serum calcium conc)
Important Considerations CIs: Hypersensitivity
18 | P a g e
AEs: Arrhythmia, bradycardia, cardiac arrest, decreased blood pressure, syncope, vasodilation,
Anxiety, tingling sensation.
Preparation/administration -Observe the vial for the presence of particulates. If particulates are observed, place vial in a warm
and stability/sensitivity water bath + occasional shaking until solution is clear.
-Shake vigorously. Cool to room temperature before use. Do not use vial if particulates do not
dissolve. Dilute in D5W or NS and use immediately.
-Bolus IV use: Dilute to 10-50mg/ml. Continuous infusion: Dilute to 5.8-10mg/ml
-Avoid extravasation. Monitor IV administration site closely.
‫ وإن وجدت يتم وضع األمبول زف حمام ماء ز ئ‬، ‫ يفحص األمبول لضمان عدم وجود ترسبات أو تكتالت‬-
‫داف ويرج برفق ى‬
‫حت‬
‫ ىيتك األمبول ى‬، ‫التسبات يمنع استخدام األمبول‬
‫حت يصل لدرجة حرارة الغرفة قبل االستخدام‬ ‫ إذا لم تذب ى‬، ‫تذوب‬
%5 ‫ مل محلول ملح أو جلوكوز‬100-20 ‫ يحل زف‬:‫ لالستخدام الوريدي‬-
%5 ‫مل محلول ملح أو جلوكوز‬100-50 ‫ يحل زف‬:‫للمحلول الوريدي المستمر‬-
Notes - 1gm Ca gluconate = 90mg elemental calcium.
Cost/ampoule:8.085 LE
-Asymptomatic hypocalcemia: give oral calcium. Taper IV Ca2+slowly while oral therapy is adjusted.
-Repeat ionized calcium measurement 6-10hours after completion of administration.
-Check for hypomagnesemia/correct if present.
-Consider continuous infusion if hypocalcemia is likely to recur due to ongoing losses
-Hypoalbuminemia: Must calculate CORRECTED Ca2+= serum Ca2+ + [0.8 * (4 – s. albumin level)]
-Hyperkalemia: Do not administer Ca2+ if patient is on digoxin (can precipitate digoxin toxicity)
Monitoring parameters For IV: Serum calcium, monitor every 1-4hrs during continuous infusion, albumin, phosphate,
magnesium, vitals, ECG, infusion site.
Captopril – 25mg tablets (Capoten, capotril)
Mechanism of action Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents conversion of angiotensin
I to angiotensin II, a potent vasoconstrictor. Results in lower levels of angiotensin II which causes an
increase in plasma renin activity and a reduction in aldosterone secretion.
Indication and doses Acute coronary syndrome:
Myocardial infarction with left ventricular dysfunction: Oral: Initial: 6.25 mg; increase to 12.5mg
/8hr if tolerated. Increase to 25mg /8hr during next several days. Target dose: 50mg /8hr as
tolerated.
HFrEF: Oral: Initial dose: 6.25mg /8hr; as tolerated, increase over 1-2 days intervals in hospitalized
patients. Target dose: 50 mg /8hr as tolerated
Hypertension: Oral: Initial dose: 12.5-25 mg /8-12hr. May increase at 1-2wk intervals based on
response up to 50 mg /8hr
Dose adjustment Renal Impairment
CrCl 10-50 mL/min: 75% of normal dose /12-18hrs
CrCl <10 mL/minute: 50% of normal dose /24hrs
Intermittent hemodialysis: After hemodialysis on dialysis days
Important Considerations CIs: hypersensitivity, pregnancy
AEs: Hypotension (1% to 3%), chest pain (1%), palpitations (1%), tachycardia (1%), skin rash,
hyperkalemia (1% to 11%), proteinuria (1%), hypersensitivity reactions, cough (<1% to 2%)
Preparation/administration -Administer at least 1hr before meals.
Notes -Discontinue as soon as possible once pregnancy is detected.
-Cost/tablet: 0.2604163 LE
Monitoring parameters Renal function, electrolytes, BP
19 | P a g e
Cefadroxil – 500mg capsules and 250mg/4ml oral suspension (Curisafe)
Mechanism of action 1st generation cephalosporin. Inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis
Indication and doses Group-A Streptococcal pharyngitis: Adult: Oral: 1gm once daily for 10 days or 500mg twice daily
Children and adolescents: 30mg/kg/days given once daily or divided /12hr for 10 days. Max dose
1gm/day
Dose adjustment No hepatic adjustment
Renal Impairment:
Initial: 1gm single dose
+ Maintenance dose:
CrCl 25-50: 500mg /12hr
CrCl 10-25: 500mg /24hr
CrCl <10: 500mg /36hr
Precautions:
-Hypersensitivity (including anaphylaxis) may occur
-Superinfection with prolonged use
-Use with caution in patients with history of colitis
-Use with caution in patients with history of penicillin allergy
AEs: Diarrhea, vomiting, pruritus, rash, hypersensitivity reactions, thrombocytopenia
DDIs:
+furosemide (increased furosemide nephrotoxicity risk – monitor closely)
Preparation/administration Administration with food may diminish GI complaints
Notes -In pregnancy: generally considered compatible for use during pregnancy
Monitoring parameters Renal function, signs/symptoms of anaphylaxis, clinical response to therapy
Cefalexin – 500mg tablets and 250mg/5ml oral suspension (cephalexin)
Mechanism of action 1st generation cephalosporin. Inhibits bacterial cell wall synthesis, leading to breakdown and
eventually cell death
Indication and doses Upper/lower respiratory tract infections (pharyngitis, tonsillitis, etc): Adult: Oral: 500mg /12hr for
7days
Children: Oral: 25-50mg/kg/day in 2-4 divided doses
CAP (mild due to MSSA or as step-down): Children: Oral: 75-100mg/kg in 3-4 divided doses for 10
days
Dose adjustment Renal Impairment:

CrCl 30-59: dose not to exceed 1gm/day
CrCl 15-29: 250 mg /8-12hrs
CrCl 5-14 not on dialysis: 250mg /24hrs
CrCl <5 not on dialysis: 250mg /48hrs
AEs: hypersensitivity (ranging from mild rash to anaphylaxis), C. difficile infection, GI distress,
diarrhea, superinfection, elevated LFTs, pancytopenia
DDIs: +warfarin (may cause INR elevation – monitor INR and signs of bleeding)
Preparation/administration Absorption is delayed when taken with food
Notes -Avoid prescribing if bacterial infection is absent
20 | P a g e
-In pregnancy: generally safe for use
Monitoring parameters Renal function, signs/symptoms of hypersensitivity, clinical response to therapy
Cefepime – 1gm vials (Pimfast, maxipime, wincef)
th
Mechanism of action 4 generation cephalosporin. Inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins.
Indication and doses Acute exacerbated COPD (if indicated) - risk of p. aeruginosa infection: 2gm IV /8hr
CAP (only for patients with risk of p. aeruginosa infection): 2gm IV /8hr for 5 days
Hospital-acquired or ventilator-associated pneumonia: 2gm IV /8hr for 7 days
Sepsis and septic shock (empiric coverage for p. aeruginosa): 2gm IV /8hr for 7-10 days, or longer
(based on response)
CrCl 30-60: 2gm IV /12hr
CrCl 11-29: 2gm IV /24hr
CrCl < 11: 1gm IV /24hr
Important Considerations AEs: Hypersensitivity: Immediate (anaphylaxis, angioedema, urticaria), and up to 6hr after
administration. Delayed: maculopapular reactions occur 7-10 days. Other reactions may occur up
to 3 months later
-Neurotoxicity (2-4 days from initiation): encephalopathy, aphasia, myoclonus, opsoclonus, seizure,
and nonconvulsive status epilepticus. Use with caution in case of history of seizures.
Preparation/administration -Administer as prolonged infusion over 4hrs, preferably. Usual diluent: D5W, NS
-After reconstitution: stable for 3 days at 2-8 °C
%5 ‫ ساعات بعد حله زف محلول ملح أو جلوكوز‬4 ‫ يعىط كمحلول وريدي عىل مدار‬-
‫يحفظ زف درجة حرارة الغرفة‬-
‫ درجة مئوية‬8-2 ‫ أيام زف درجة حرارة‬3 ‫ ثابت لمدة‬:‫التحضت‬
‫ر‬ ‫بعد‬-
Notes Can be used in pregnancy (no adverse effects were observed)
-High risk of Clostridiodes infection
Monitoring parameters CBC (WBCs), renal function, monitor for any signs of anaphylaxis during administration
Cefotaxime – 1gm vials (Cefotax)
(PBPs). A 3rd generation cephalosporin.
Indication and doses CAP (in combination with a macrolide/quinolone) - without risk factors for Pseudomonas
aeruginosa: IV: 1-2 gm IV /8hrs for 5 days
No adjustment necessary
Renal Impairment:
CrCl 11-50: 1-2gm IV /12hrs
CrCl ≤10: 1-2gm IV /24hrs
Important Considerations CIs: hypersensitivity to cefotaxime/other cephalosporins
AEs: Hypersensitivity reactions (immediate and delayed) ranging from maculopapular skin rash to
rare cases of anaphylaxis and anaphylactic shock. Clostridioides difficile colitis, nausea, vomiting,
diarrhea.
DDIs: +Calcium-containing solutions: forms an insoluble precipitate
Preparation/administration IV: Reconstitute vials with ≥10 mL WFI. May be further diluted up to 1000 mL with NS or D5W.
and stability/sensitivity Administer over 30 min.
ً
‫ بكمية تصل ى‬%5 ‫مجددا زف محلول ملح أو جلوكوز‬
‫مل‬1000 ‫حت‬ ‫ وقد يتم حله‬، ‫مل ماء مذيب‬10 ‫ يحل زف‬:‫لالستخدام الوريدي‬-
‫ يعىط عىل مدار نصف ساعة‬،
21 | P a g e
Notes -Prolonged use may cause fungal or bacterial superinfection
-In pregnancy: safe to use
Monitoring parameters Observe for signs and symptoms of anaphylaxis during first dose; CBC with differential (especially
with long courses [>10 days]); renal function
CefTAZidime – 1gm vials (Cefzim)
rd
Mechanism of action 3 generation cephalosporin. Inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins (PBPs), which in turn inhibits the final transpeptidation step in bacterial
cell walls, thus inhibiting cell wall biosynthesis
Indication and doses CAP (empiric with appropriate combination – risk of resistant gram-negative pathogen(s)): IV: 2gm
/8hr for ≥5days. Longer course may be required for P. aeruginosa infection
HAP/VAP (empiric with appropriate combination – risk of resistant gram-negative pathogen(s)):
IV: 2gm /8hr typically for 7days. Longer course may be required for severe/complicated infection,
or for P. aeruginosa infection
Bloodstream infection (empiric, suspected gram-negative bacteria including P. aeruginosa or
pathogen-directed therapy): IV: 2gm /8hrs. Duration 7-14days depending on source, pathogen,
extent of infection and clinical response
Cystic fibrosis (acute pulmonary exacerbation): IV: 2gm /6-8hrs or extended infusion method: IV:
2gm /8hrs over 3-4hrs
CrCl Usual dose 2gm /8 hours
31-50 2gm /12hours
16-30 2gm /24hours
≤15 1 gm /24hours
Intermittent hemodialysis (thrice weekly): IV: 500mg to 1gm /24hrs. Administer after hemodialysis
on dialysis days
Important Considerations CIs: Hypersensitivity to ceftazidime, other cephalosporins, penicillins and other beta-lactams
Precautions:
-May cause INR elevation (caution with predisposed, at higher-risk and malnourished patients)
-Hemolytic anemia (with all cephalosporins) – discontinue use if anemia develops pending cause
determination
-Neurotoxicity (seizure, encephalopathy, non-convulsive status epilepticus) especially with use of
high dose. Adjust dose based on renal function
-superinfection with prolonged use
-Use with caution in patients with history of colitis
AEs: Pruritus. rash, diarrhea, increased ALT and AST, alkaline phosphatase, hypersensitivity
reactions
DDIs:
+aminoglycosides (increased aminoglycoside nephrotoxicity risk – monitor closely)
+furosemide (increased furosemide nephrotoxicity risk – monitor closely)
Preparation/administration -IV: Reconstitute with SWFI. Furtherly dilute with 100ml G5% or NS to administer via IV infusion
and stability/sensitivity -Stored below 25°C. Protect from light
-Use within 3 days after reconstitution (stored at refrigerator) and within 12hrs (stored below
25°C)
%5 ‫ مل محلول ملح أو جلوكوز‬100 ‫ يحل زف الماء المذيب المرفق ثم يحل زف‬:‫لالستخدام الوريدي‬-
)‫ مئوية‬25 ‫ ساعة (عند الحفظ زف درجة حرارة تحت‬12 ‫ وخالل‬، )‫ أيام (عند الحفظ زف درجة حرارة الثالجة‬3 ‫يسىتخدم خالل‬-
Notes -In pregnancy: considered safe for use
Monitoring parameters Renal function, signs/symptoms of anaphylaxis, CBC, INR, clinical response to therapy
22 | P a g e
CefTRIAXone – 1gm vials (Cefaxone, rameceftrax)
(PBPs). A 3rd generation cephalosporin.
Indication and doses Acute exacerbation of COPD (without risk for Pseudomonas aeruginosa)
IV: 1gm once daily for 5-7 days (may switch to oral therapy based on clinical improvement)
CAP (in combination with a macrolide/quinolone):
IV: 1-2gm once daily for 5 days
Bacterial meningitis - community-acquired (a component of empiric therapy):
IV: 2gm /12hours for 7 to 21 days (based on causative pathogen(s) and clinical response)
Dose adjustment No hepatic or renal dose adjustments necessary
Important Considerations CIs: hypersensitivity to ceftriaxone/other cephalosporins
AEs: Hypersensitivity reactions (immediate and delayed) ranging from maculopapular skin rash to
rare cases of anaphylaxis and anaphylactic shock. Clostridioides difficile colitis, nausea, vomiting,
diarrhea. Increased LFTs
IV incompatibility: +Calcium-containing solutions: forms an insoluble precipitate
Preparation/administration -IV infusion: Reconstitute with WFI. Further with 50-100 mL of D5W or NS. Administer over 30 min.
and stability/sensitivity and -Store below 30 °C
stability/sensitivity ‫ يعىط عىل مدار نصف ساعة‬،%5 ‫مل محلول ملح أو جلوكوز‬100-50 ‫يحل باستخدام الماء المذيب المرفق ثم يحل باستخدام‬-
‫ درجة مئوية‬30 ‫يحفظ زف درجة حرارة تحت‬-
Notes -May increase INR level (caution in malnourished patients)
-Prolonged use may cause fungal or bacterial superinfection
-In pregnancy: safe to use
Monitoring parameters Prothrombin time/INR. Observe patient for signs and symptoms of anaphylaxis.
Chlorpheniramine maleate – 4mg tablets, 2mg/5ml syrup and 5mg/ml ampoules (Avil, Anallerge, pirafene)
Mechanism of action Competes with histamine for H1-receptor sites on effector cells in the gastrointestinal tract, blood
vessels, and respiratory tract
Indication and doses Allergic symptoms: Adult: Oral: 4 mg /4-6hrs. Max daily dose: 24 mg/day. IM/SQ: 10-20mg (may
repeat injection). IV slowly: 10-20mg /24hr
Children: Oral: 2 to <6 yrs: 1mg every /4-6hrs. Max daily dose: 6 mg/day
6 to <12 yrs: 2mg every /4-6hrs. Max daily dose: 12mg/day
≥12yrs and Adolescents: 4mg /4-6hrs. Max daily dose: 12mg/day
Important Considerations AEs: CNS depression (may impair physical or mental abilities - caution about performing tasks
which require mental alertness like operating machinery or driving).
DDIs:
+ipratropium (risk for anti-cholinergic effect – monitor patient closely if absolutely necessary)
+fentanyl, +nalbuphine (enhanced CNS depression – limit dose/duration for both)
Preparation/administration -Administered with food
and stability/sensitivity -store ampoules below 30°C
‫ مئوية‬30 ‫تحفظ األمبوالت زف درجة حرارة تحت‬-
Notes -In pregnancy: 2nd generation antihistamines are more preferred. If chlorpheniramine use is
necessary, limit to the lowest effective dose
-Avoid use in the elderly if possible (Beers' criteria)
-Overdose manifestations (CNS depression or stimulation)
Monitoring parameters Anti-cholinergic adverse effects (urinary retention, constipation, etc), enhanced CNS depression
23 | P a g e
Cisatracurium 10mg/5ml ampoules (Cis-atracure) ☀
Mechanism of action Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites
Indication and doses ICU paralysis (e.g: severe ARDS, to increase chest wall compliance, etc) + adequate analgesia and
sedation: Loading dose: 0.1-0.2 mg/kg IV bolus over 5-10sec
Followed by: continuous infusion dose: undiluted, or diluted: 0.06-0.18 IV mg/kg/hr, adjust rate
according to patient's response
Dose adjustment Hepatic dose adjustment: none necessary
Renal dose adjustment: none necessary
Obesity:
BMI 30-49.9: Use ideal body weight for dosing
BMI ≥50: Use adjusted body weight for dosing
Important Considerations CIs: Hypersensitivity, use without adequate respiratory support/ventilation
AEs: bradycardia, prolonged paralysis
-Respiratory alkalosis, hypercalcemia and peripheral neuropathies may result in antagonism of
neuromuscular blockade
-Severe hypocalcemia, severe hypokalemia, hypermagnesemia, neuromuscular diseases, metabolic
acidosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in
potentiation of neuromuscular blockade
DDIs: +colistin (monitor for deeper, prolonged NBM effects, respiratory paralysis)
+systemic steroids (increased muscle weakness, use lowest possible dose of both drugs)
Preparation/administration -Dilute as 20mg in 50ml NS or G5%
and stability/sensitivity -Use immediately after dilution. Store in between 2-8°C. Avoid freezing
%5 ‫مل محلول ملح أو جلوكوز‬50 ‫مجم) زف‬20( ‫ أمبول‬2 ‫ يحل‬-
‫ يمنع تجميده‬،‫ درجة مئوية‬8-2 ‫ يخزن زف درجة حرارة‬،‫تحضته‬
‫ر‬ ‫يستخدم ر‬-
‫مباشة بعد‬
Notes -Limit the duration of paralysis as possible, and provide a physiotherapy regimen for patients
requiring continuous paralysis.
-Maintain adequate airway/respiratory support. Resistance may develop with chronic treatment.
-All patients should receive eye care including liberal use of lubricating drops. Eyelids should
remain closed.
-Acidosis and electrolyte disturbances alter NMBAs effect
-Reversal: Neostigmine: 0.5-2mg slow IV injection + atropine sulfate 0.6-1.2mg IV in a separate
syringe. Repeat as needed. Total dose of neostigmine should not exceed 5 mg.
Monitoring parameters Vital signs (heart rate, blood pressure, respiratory rate), degree of muscle paralysis (presence of
spontaneous movement, ventilator asynchrony, shivering, and consider use of a peripheral nerve
stimulator along with clinical assessments)
Clarithromycin – 500mg tablets and vials (Clarithro, Klacid ☀)
Mechanism of action Binds to 50S ribosomal subunit. The 14-OH metabolite is twice as active against certain organisms.
Indication and doses Acute exacerbation of COPD: Oral: Immediate release: 500 mg /12hrs for 3-7 days
CAP (in combination with a beta-lactam antibiotic):
Inpatient: 500 mg IV/IR tablet twice daily for 5 days
Outpatient: 500 mg IV/IR tablet twice daily or 1gm once daily for 5 days
Dose adjustment No hepatic dose adjustment necessary
Renal Impairment:
CrCl <30 mL/minute: Decrease clarithromycin dose by 50%
Hemodialysis: Administer after HD session
Important Considerations CIs: severe hepatic+renal impairment. History of cholestatic jaundice. Hepatic dysfunction due to
prior azithromycin use. History of QTc-interval prolongation.
24 | P a g e
AEs: GI upset (nausea, vomiting, diarrhea, …)
DDIs: strong CYP3A4 inhibitor: +midazolam, +fentanyl their reduce doses
Increased risk of QTc-interval prolongation, monitor ECG (+amiodarone, +haloperidol)
Preparation/administration -Klacid: Dilute in 10ml Water for injection. Further diluted in at least 250ml NS. Administer over
and stability/sensitivity 1hr.
-The reconstituted and diluted solutions can be stored for 24 hours at 2-8°C, and for 6hrs below
25°C
‫مل محلول ملح ويعىط عىل مدار ساعة‬250 ‫مل ماء مذيب ثم يحل زف‬10 ‫ يحل زف‬:‫ كالسيد فيال‬-
‫ درجة مئوية‬25 ‫ ساعات زف درجة تحت‬6 ‫ ولمدة‬، ‫ ساعة بعد الحل‬24 ‫المحلول ثابت زف درجة حرارة الثالجة لمدة‬-
Notes -Avoid use in AECOPD patients with risk factors for Pseudomonas infection or poor outcomes (age
≥65 years + major comorbidities, FEV1 <50% predicted, frequent exacerbations)
-In pregnancy: Consider alternatives. Use only if absolutely necessary
Clindamycin – 600mg ampoules (Alfaclindamycin) ☀
Mechanism of action Reversibly binds to 50S ribosomal subunits preventing peptide bond formation thus inhibiting
bacterial protein synthesis; bacteriostatic/bactericidal depending on drug concentration, infection
site, and organism
Indication and doses Pneumonia (MRSA risk): Oral/IV: 600mg /8hr for at least 7days (based on severity/response)
Aspiration pneumonia: Oral/IV: 600mg /8hr for 7days
Dose adjustment No hepatic or Renal adjustment
Important Considerations BLACK BOX WARNING: has been associated with severe colitis, which may end fatally. Reserve it
for serious infections for which less toxic antimicrobial agents are inappropriate. Clostridioides
difficile-associated diarrhea must be considered in all patients who present with diarrhea
following antibiotic use
CIs: hypersensitivity to clindamycin or lincomycin
Precaution: use with caution in patients with history of colitis
AEs: Hypotension, thrombophlebitis, maculopapular rash, pruritus, skin rash, Stevens-Johnson
syndrome (rare), toxic epidermal necrolysis (TEN), abdominal pain, antibiotic-associated colitis, C.
difficile-associated diarrhea, diarrhea, thrombocytopenia, abnormal LFTs, jaundice
DDIs:
+phenytoin (decreased clindamycin conc – monitor clinical clindamycin efficacy)
+atracurium, +cisatracurium (enhanced neuromuscular blockade – monitor)
Preparation/administration -IV infusion: dilute with 50-100ml D5W or NS. concentration should not exceed 18mg/ml
and stability/sensitivity -Stable for 24hrs after reconstitution, if stored at 2-8°C
‫ئ‬
‫مل‬/‫مجم‬18 ‫النهائ‬ ‫ ى‬، %5 ‫مل محلول ملح أو جلوكوز‬100-50 ‫ يحل األمبول زف‬-
‫الت ر ز‬
‫كت‬
‫ ويحفظ زف درجة الثالجة‬، ‫تحضته‬
‫ر‬ ‫ ساعة بعد‬24 ‫ يمكن استخدامه خالل‬-
Notes -Aspiration pneumonia: typically reserved for patients with penicillins/beta-lactam allergy
-In pregnancy: can be used safely
Monitoring parameters Observe for changes in bowel frequency, colitis, resolution of symptoms. Monitor LFTs periodically
(in severe hepatic disease), CBC (in prolonged therapy), renal function tests periodically
Clopidogrel – 75mg tablets (Clopex, clatex)
Mechanism of action Prodrug - requires in vivo biotransformation to an active thiol metabolite. Irreversibly blocks the
P2Y12 component of ADP receptors on the platelet surface, which prevents activation of the
GPIIb/IIIa receptor complex, thereby reducing platelet aggregation. Platelets affected for the
remainder of their lifespan ~7-10 days.
Indication and doses STEMI (combined with a parenteral anticoagulant + aspirin) using FIBRINOLYTIC for reperfusion:
Age ≤75 years: Oral: LD: 300mg once, followed by 75mg once daily.
Age >75 years: Oral: 75 mg once daily.
25 | P a g e
Non-STEMI (ischemia-guided/conservative approach: combined with a parenteral anticoagulant +
aspirin: Oral: Initial: LD 300 or 600mg once, followed by 75mg once daily (some prefer an initial
dose 600mg unless high risk for bleeding, in which case, 300 mg is also appropriate)
Stroke/TIA secondary prevention: 75mg once daily (alternative to aspirin)
Minor stroke/high-risk TIA (50-69% stenosis of an intracranial large artery): 75 mg once daily for
21 days – combined with aspirin 75mg once daily
Peripheral atherosclerotic disease: Oral: 75 mg once daily.
Stable ischemic heart disease: Oral: 75 mg once daily (alternative to aspirin)
Dose adjustment Renal impairment: ESKD: associated with higher residual platelet reactivity with maintenance
dosing. Monitor for thrombotic complications/high risk for thrombotic events
Important considerations CIs: hypersensitivity
AEs: Minor hemorrhage (4% to 5%), major hemorrhage (4%), bruises, hematoma, epistaxis
DDIs:
+apixaban (increased bleeding risk – use with caution)
+enoxaparin/heparin (monitor for signs of bleeding)
+fluconazole (diminished clopidogrel effect – consider alternative)
Preparation/administration Administer without regard to meals
Notes -Duration of therapy: DAPT should be continued for 12 months unless bleeding is a concern.
-Reevaluate the need for DAPT at regular intervals (bleeding v thrombotic risks).
-Lower GI bleeding + CV disease (assess risks/benefits - continue DAPT for at least 90 days after
MI, if high bleeding risk, do not discontinue aspirin)
Pregnancy: only when strictly needed, for the shortest duration possible
Monitoring parameters Signs of bleeding; hemoglobin and hematocrit periodically
Colistin – 1million IU vials (Colomycin)
Mechanism of action Colistimethate (colistimethate sodium) is the inactive prodrug - hydrolyzed to colistin, which acts
as a cationic detergent and damages the bacterial cytoplasmic membrane causing leaking of
intracellular substances and cell death
Indication and doses HAP/VAP or bacteremia - susceptible MDR gram-ve bacilli (use in combination + meropenem):
IV: LD: 300mg (9million units) followed by MD 150mg (4.5million units) /12hr, started 12hrs after
the loading dose. Duration 7-10 days. Adjunctive inhaled colistin is recommended.
Bronchiectasis, colonization/infection with susceptible organisms in cystic fibrosis/noncystic
fibrosis patients: Inhalation: 30-150mg via nebulizer /12-24hr (max dose: 150mg /12hr). Use in
addition to systemic antibiotics.
Dose adjustment Renal impairment (no LD adjustment necessary. Adjust maintenance dose):
CrCl 60 to <70 mL/minute: 4mil units /12hr
CrCl 50 to <60 mL/minute: 3.5mil units /12hr
CrCl 10 to <30 mL/minute: 2.5mil units /12hr
CrCl <5 mL/minute: 2mil units /12hr
Intermittent HD: adjust MD: 2.5mil units /12hr, administer after HD session on dialysis days
AEs: Nephrotoxic (dose-related), CNS toxicity, bronchospasm (inhaled colistin), respiratory arrest,
superinfection (prolonged use)
DDIs: +aminoglycosides (nephrotoxic and neurotoxic combination – avoid)
+vancomycin (nephrotoxic combination – avoid if possible)
Preparation/administration IV: Reconstitute each vial containing 300mg (1mil units) with 4 ml of WFI. Swirl gently to avoid
and stability/sensitivity frothing. May further dilute using 500ml D5W or NS for IV infusion. Infuse over 30mins to 1hr.
26 | P a g e
-Inhaled colistin: prepare using 3-4ml NS. Must be used within 24hr of preparation. Administer
nebulized salbutamol 15mins prior nebulized colistin use.
-30 ‫ يعىط عىل مدار‬، %5 ‫مل محلول ملح أو جلوكوز‬500 ‫ ثم يحل زف‬، ‫ مل ماء مذيب‬4 ‫ يحل الفيال زف‬:‫ لالستخدام الوريدي‬-
‫ دقيقة‬60
Notes -In pregnancy: use for life-threatening infections (benefits outweigh risks)
-IV use is culture-based only. Administer in combination with meropenem 2gm /8hr as prolonged
infusion (adjust meropenem dose according in case of renal impairment)
Monitoring parameters Serum creatinine, BUN, urine output, signs of neurotoxicity
Dexamethasone Sodium Phosphate – 8mg/2ml ampoules (dexamethasone)
Mechanism of action Long-acting corticosteroid with minimal sodium-retaining potential. It decreases inflammation by
suppression of neutrophil migration, decreased production of inflammatory mediators, and reversal
of increased capillary permeability
Indication and doses Asthma, acute exacerbation (within 1hr of presentation to ER): IV: 8mg /24hr for 1 to 2 days only.
Longer treatment at this dose may be associated with metabolic adverse effects.
Moderate to severe ARDS (patients who are relatively early in the disease course - within 14 days):
IV: 20 mg once daily days 1-5, then 10 mg once daily from days 6-10
COVID-19, hospitalized patients (combined with antiviral): IV/Oral: 6mg once daily for up to 10
days (or until discharge if sooner)
Dose adjustment No dosage adjustment necessary
Important Considerations CIs: hypersensitivity, systemic fungal infections, active tuberculosis (unless meningeal)
AEs:
-Use with caution in patients with HF, associated with fluid retention, electrolyte disturbances,
hypertension, following acute MI
-Use with caution in patients with DM and GI diseases that are associated with perforation (ulcers,
diverticulitis, abscess, etc)
-Endocrine & metabolic: Adrenocortical insufficiency, Cushing syndrome, decreased serum K+,
drug-induced Cushing’s syndrome, glycosuria, growth retardation.
-Immunosuppression, increased susceptibility to infections, pulmonary edema, wound healing
impairment
-psychiatric disturbances (euphoria, insomnia, mood swings, personality changes, psychotic
manifestations): Resolve with dose reduction/discontinuation
-Myopathy (high dose corticosteroids): monitor CK; recovery may be delayed.
Precautions:
Concerns related to adverse effects:
▪ Adrenal suppression: in patients receiving high doses for prolonged periods.
▪ Anaphylactoid reactions: Rare.
▪ Immunosuppression: Prolonged use may increase the incidence of secondary infection, mask
acute infection (including fungal infections), prolong or exacerbate viral infections, or limit
response to killed or inactivated vaccines.
▪ Disease-related concerns:
▪ Hepatic, renal impairment: fluid retention may occur.
▪ Ocular disease (cataracts and/or glaucoma)
▪ Osteoporosis (if high doses and/or long-term use)
▪ Pheochromocytoma: has been reported with corticosteroids (may be fatal)
▪ Seizure disorders (reported with adrenal crisis).
▪ Treatment of sepsis in the absence of shock.
▪ Thyroid disease: (may necessitate dosage adjustments)
27 | P a g e
DDIs:
+phenytoin (assess efficacy of both medications, decrease in phenytoin levels reported more
frequently)
Preparation/administration -Deep IM injection or IV
and stability/sensitivity -Avoid scheduling steroid doses late at night, if possible, particularly higher doses (associated with
increased risk of insomnia, nightmares, neuropsychiatric adverse effects)
‫ لالستخدام الوريدي أو الحقن العضىل‬-
Notes -Withdrawal: Taper dose of corticosteroids gradually when used for more than 14 days
-Pregnancy Considerations: some studies have shown an association between first trimester
systemic corticosteroid use and oral clefts or decreased birth weight. They should only be used
when benefit outweighs risks
Monitoring parameters Serum glucose, electrolytes, BP, weight, presence of infection, behavioral or mood changes
Diclofenac sodium – 75mg ampoules (Declophen, epifenac)
Mechanism of action Reversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in decreased
formation of prostaglandin precursors. Has antipyretic, analgesic, and anti-inflammatory properties
Indication and doses Pain (acute, mild-moderate), fever: IM/IV: 75mg (1 ampoule). Can repeat few hrs later, if needed.
Do not exceed 150mg/day
*Refer to the hospital-based analgo-sedation protocol for more details
CrCl >60: No dosage adjustment necessary
CrCl 31-59: Give lowest dose possible, or preferably use analgesics other than NSAIDs
CrCl ≤30: Avoid (high risk of AKI)
Hepatic impairment:
Use with caution. Discontinue if hepatic function worsens
Older patients: use with caution – higher risk of adverse effects
Important Considerations BLACK BOX WARNING: increased risk of serious cardiovascular thrombotic and serious
gastrointestinal (GI) adverse events
-Avoid in patients with bronchospasm, asthma, aspirin-sensitive asthma, rhinitis, or urticaria with
NSAIDs use
-Avoid in patients with active GI bleeding or history of acute lower GI bleeding
DDIs:
+aspirin, +apixaban, +enoxaparin, +heparin (increased risk of bleeding – monitor closely)
+furosemide (increased risk of nephrotoxicity – monitor closely)
Preparation/administration -For IV use: dilute with NS. Administer as IV infusion over 30-120mins. Do not give as bolus IV
and stability/sensitivity injection
‫ر ز‬
‫ يمنع الحقن الوريدي الشي ع‬، ‫ساعتي‬ ‫ يحل زف محلول ملح ويعىط عىل مدار نصف ساعة إىل‬:‫ لالستخدام الوريدي‬-
Notes -Not to be used routinely for the critically ill patients
-In pregnancy: Maternal use of NSAIDs should be avoided beginning at 20 weeks' gestation
Consider ultrasound monitoring of amniotic fluid if treatment extends beyond 48hrs. Use should
be completely avoided starting at 30 weeks' gestation (premature closure of ductus arteriosus)
Monitoring parameters CBC, renal function, weight, edema, BP, observe for bleeding, bruising or GI effects
Digoxin – 0.5mg/2ml ampoules and 0.25mg tablets (Cardixin, lanoxin)
Mechanism of action Inhibition of the sodium/potassium ATPase pump in myocardial cells results in a transient increase
of intracellular sodium, which in turn promotes calcium influx via the sodium-calcium exchange
pump leading to increased contractility. May improve baroreflex sensitivity
28 | P a g e
Indication and doses AF or atrial flutter (rate control): Initial: IV: 0.25-0.5mg over several mins + repeat doses of 0.25mg
/6hrs (max: 1.5mg over 24hrs). Maintenance: Oral: 0.125-0.25 mg /24hr
HFrEF (loading dose not recommended): Oral: 0.125-0.25 mg /24hr
Supraventricular tachycardia (rate control): Initial: IV: 0.25-0.5mg + repeat doses of 0.125-0.25 mg
/6-8hr until evidence of adequate effect (max total dose over 24hrs: 8-12 mcg/kg [use lean body
weight], not exceeding 0.75-1.5 mg). Maintenance: Oral: 0.125-0.25 mg /24hr
Atrial fibrillation/flutter, supraventricular tachycardia:
Loading dose: Use with caution (only when rapid ventricular rate control is necessary).
CrCl >15: No dosage adjustment necessary.
CrCl ≤15: use 50% of usual dose
Maintenance dose: Patients with low lean body weight may require lower doses.
CrCl 45-59: 0.0625 to 0.125 mg once daily.
CrCl 30-44: 0.0625mg once daily.
CrCl <30: 0.0625 mg /48hr (or consider alternative)
Heart failure: Oral
Ideal body weight (kg) CrCl Digoxin dose
>60 to 70 >110 0.25 mg once daily
>35 to 110 0.125 mg once daily
15 to 35 0.0625 mg once daily
>70 to 80 >80 to 110 0.25 mg once daily
>20 to 80 0.125 mg once daily
>80 >70 0.25 mg once daily
Hemodialysis, intermittent (thrice weekly): Not dialyzable. Avoid use if possible; use in end-stage
kidney disease is associated with increased mortality
Important Considerations Medication Safety Issues:
Beers Criteria: to be avoided in patients 65yrs and older as first-line therapy for atrial fibrillation
(due to safer and more effective alternatives for rate control) or as first-line therapy for heart
failure
AEs:
-Digoxin toxicity (serum levels >2 ng/ml, however it is even possible at therapeutic levels due to
narrow therapeutic index): Symptoms of toxicity may include nausea, vomiting, visual
disturbances (“halos,” yellow or blurred vision), lethargy, and/or life-threatening arrhythmias.
-Warnings/Precautions: Use with caution in patients with an acute MI (may increase myocardial
oxygen demand and lead to ischemia)
-Correct electrolyte disturbances (hypokalemia or hypomagnesemia) prior to use and throughout
therapy. Maintain normo-calcemia.
DDIs:
+Amiodarone (Reduce the dose of digoxin by 30-50% or reduce frequency of administration)
Preparation/administration -IV route preferred. If IM injection necessary, administer by deep injection followed by massage at
and stability/sensitivity the injection site. Inject no more than 2mL per injection site.
-IV May be administered undiluted or diluted (NS or D5W). Inject slowly over ≥5mins
‫ يعىط ببطء عىل مدار ر‬، %5 ‫ أو يحل زف محلول ملح أو جلوكوز‬، ‫ يمكن استخدامه دون حله‬:‫ الحقن الوريدي‬-
‫ دقائق‬5 ‫أكت من‬
Notes -In pregnancy: Due to pregnancy-induced physiologic changes, some pharmacokinetic properties
may be altered. Closely monitor maternal serum digoxin.
-Recommended as a first-line agent for the chronic treatment of highly symptomatic
supraventricular tachycardia (SVT) in pregnancy at the lowest effective dose is recommended.
29 | P a g e
Monitoring parameters -Periodic ECG, HR, baseline/periodic serum creatinine, serum potassium, magnesium, and calcium
(if on diuretics, other medications that can cause electrolyte disturbance/history of hypokalemia
or hypomagnesemia. Observe patients for noncardiac signs of toxicity, confusion, and depression.
-digoxin serum level should be drawn at least 6-8hrs after last dose (optimally 12-24hrs after a
dose)
-HFrEF: target s. digoxin conc 0.5 to <0.9 ng/mL
DOBUTamine – 250mg vials (Dobutrex)
Mechanism of action Stimulates myocardial beta1-adrenergic receptors and some alpha1 receptors, resulting in
increased contractility and heart rate. Stimulates both beta2- and alpha1-receptors in the
vasculature
Indication and doses -Inotropic support – ADHF or septic shock: Continuous infusion: IV: Initial: 2-5mcg/kg/min; titrate
based on clinical end point (e.g: BP, end-organ perfusion). Usual dosage range: 2-10 mcg/kg/min.
Max dose: 20 mcg/kg/min
In ADHF: May consider for short-term use in patients with low cardiac index and hypotension or
end-organ hypoperfusion
Dose adjustment No dose adjustment needed
Important Considerations CIs: hypersensitivity, hypertrophic cardiomyopathy with outflow tract obstruction
AEs: increased HR, increased SBP, arrhythmias (ventricular and supraventricular arrhythmias)
-Use with caution following recent MI/active MI
-Correct electrolyte disturbances (e.g: hypokalemia or hypomagnesemia) and hypovolemia prior to
use and throughout.
DDIs:
+beta-Blockers (may diminish the therapeutic effect of dobutamine – Monitor/avoid if possible)
+linezolid/MAOIs (reduce initial doses of sympathomimetic agents, closely monitor for enhanced
pressor response)
+sympathomimetics (may enhance adverse/toxic effect of other sympathomimetics – monitor)
Preparation/administration -Dilute 20 mL vial in ≥50mL in D5W, ringer or NS. Max concentration 5mg/ml
and stability/sensitivity -Administer via infusion device and into a large vein.
‫مل ويعىط زف وريد قوي‬/‫مجم‬5 ‫النهائ ال يقل عن‬
‫ئ‬ ‫يحل الفيال زف ر‬-
‫ ى‬، ‫ أو رينجر‬%5 ‫مل محلول ملح أو جلوكوز‬50 ‫أكت من‬
‫الت ر ز‬
‫كت‬
Notes -Used in septic shock for inotropic support adjunctive to fluid resuscitation and vasopressors
-low dose as 0.5 mcg/kg/min is used in less severe cardiac decompensation
-In pregnancy: use should not be withheld due to concerns of fetal teratogenicity
Monitoring parameters BP, heart rate, ECG, hemodynamic parameters (e.g: CVP, RAP, MAP, CI, PCWP, SVR, ScvO2 or
SvO2), intravascular volume status, kidney function, urine output.
DOPamine – 200mg/5ml ampoules (Dopasunny)
Mechanism of action Stimulates both adrenergic (cardiac stimulation) and dopaminergic (renal and mesenteric
vasodilation receptors). In lower doses, it is predominately dopaminergic agonist, while higher
doses are both dopaminergic and B-adrenergic. Highest doses stimulate alpha-adrenergic receptors
(vasoconstrictive effect).
Indication and doses Bradycardia or atrioventricular block symptomatic (unresponsive to atropine): Continuous infusion:
Initial: 5 mcg/kg/min. Increase by 5 mcg/kg/min every 2 mins until desired effect. Max dose: 20
mcg/kg/min
Cardiogenic shock (not the preferred initial agent in cardiogenic shock; consider other inotropic
and/or vasopressor): Continuous infusion: 0.5-20 mcg/kg/min. Titrate based on clinical end point.
Septic shock and other vasodilatory shock states or hypoperfusion during or after fluid resuscitation
(only as an alternative/add-on to norepinephrine in patients with bradycardia who have a low risk
of tachyarrhythmias): Continuous infusion Initial: 2-5mcg/kg/min. Titrate to goal MAP (65 mmHg)
30 | P a g e
Post–cardiac arrest shock (not the preferred initial agent in post–cardiac arrest shock): Continuous
infusion: 5-20 mcg/kg/min. Titrate based on clinical end points (MAP preferred >80 mmHg)
Inotropic support (considered in patients with severe systolic dysfunction with decreased end-
organ perfusion): Continuous infusion: 5-15 mcg/kg/min
Dose adjustment Class 1, 2, and 3 obesity (BMI ≥30 kg/m2): Continuous infusion: Use ideal body weight
Important Considerations BLACK BOX WARNING:
Antidote for peripheral ischemia (due to dopamine extravasation): infiltrated as soon as possible
with 10-15ml NS + 5-10mg phentolamine (causes immediate and conspicuous local hyperemic
changes if the area is infiltrated within 12hrs)
CIs: pheochromocytoma, uncorrected tachyarrhythmias, ventricular fibrillation
AEs: atrial fibrillation, bradycardia, cardiac conduction disorder, hypertension, hypotension,
palpitations, tachycardia, ventricular arrhythmia, widened QRS complex on ECG
DDIs:
+spironolactone (may diminish the vasoconstricting effect of dopamine – monitor)
+sympathomimetics (may enhance adverse/toxic effect of other sympathomimetics – monitor)
+linezolid (may enhance hypertensive effect of dopamine - reduce initial doses of dopamine/closely
monitor BP)
Preparation/administration -Dilute 400mg in either 250ml D5W or NS (or 80mg in 50ml). Do not add additional medications to
and stability/sensitivity premixed solution.
-Administer as a continuous infusion in a central line
-If central line is not available, may administer for a short duration (<72hrs) through a peripheral IV
line placed in a large vein at a proximal site
-Store below 30°C. Use immediately after opening
، ‫ يعىط عن طريق قسطرة وريدية مركزية‬، %5 ‫مل محلول ملح أو جلوكوز‬50 ‫مل من األمبول) زف‬4( ‫مجم‬80 ‫ يحل‬-
‫ ساعة‬72 ‫يمكن استخدامه عن طريق األوردة الطرفية كمحلول مستمر لمدة ال تتجاوز‬
‫ مئوية ويستخدم ر‬30 ‫ يحفظ زف درجة حرارة تحت‬-
Notes -Correct electrolyte disturbances especially hypokalemia or hypomagnesemia prior to use and
throughout therapy to minimize the risk of arrhythmias
-Medications required for the treatment of critically ill pregnant patients should not be withheld
due to concerns of fetal teratogenicity
-If extravasation occurs, administer phentolamine (alternative: topical nitroglycerin ointment 2%)
+ dry warm compressions
Monitoring parameters BP, heart rate, ECG, hemodynamic parameters (e.g: CVP, RAP, CI, PCWP, SVR, ScvO2 or SvO2),
end-organ perfusion (e.g: urine output, mental status), infusion site for extravasation,
intravascular volume status
Doxycycline – 100mg tablets (Doxycost)
Mechanism of action Inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit. Bacteriostatic activity
against a broad range of G+ve and G-ve bacteria.
Indication and doses COPD exacerbation: Oral: 100mg once or twice daily for 5-7 days. May reserve for patients with
uncomplicated COPD (eg, <65 years of age without major comorbidities, FEV1 >50% predicted,
infrequent exacerbations)
Community-acquired pneumonia (empiric therapy + beta-lactam antibiotic): Oral: 100mg twice
daily for 5 days.
Dose adjustment No dose adjustment needed
Important Considerations CIs: Hypersensitivity to doxycycline/other tetracyclines.
Warnings/Precautions
▪ Intracranial hypertension: (pseudotumor cerebri) has been reported; headache, blurred
vision, diplopia, vision loss, and/or papilledema may occur. Women of childbearing age who
31 | P a g e
are overweight or have a history of intracranial hypertension are at greater risk. Intracranial
hypertension typically resolves after discontinuation of treatment; however, permanent visual
loss is possible.
▪ Superinfection: Prolonged use may result in fungal or bacterial superinfection.
▪ Oral candidiasis: use with caution in patients with history/predisposition to oral candidiasis.
AEs: Hypersensitivity, phototoxicity, GI irritation, genitourinary (vulvovaginal candidiasis),
hepatotoxicity, increased blood urea nitrogen.
Preparation/administration Administer on an empty stomach (immediate-release form)
Notes -Contraindicated during pregnancy if other agents are available and appropriate for use
-Use if there are no risk factors for antibiotic-resistant pathogens
-Duration: Min 5 days (assess clinical stability, vital signs, etc)
Monitoring parameters Cultures and sensitivities, clinical signs/symptoms of infection, white blood cell count, LFTs with
prolonged use
Enoxaparin sodium – 40mg and 60mg pre-filled syringes (Clexane, enoxacin)
Mechanism of action Low molecular weight heparin - anti-factor Xa and anti-thrombin (anti-factor IIa) activities.
Indication and doses Non-STEMI: SUBQ: 1mg/kg /12hrs (with an appropriate antiplatelet regimen). Continue for
duration of hospitalization or until PCI is performed.
STEMI:
<75yrs: Single IV bolus of 30mg + 1mg/kg SubQ /12hr (max 100mg for the first 2 doses only). The
first SUBQ dose should be administered with the IV bolus.
≥75yrs: 0.75 mg/kg SubQ /12hr (max 75mg for the first 2 doses only). No IV bolus.
VTE treatment: SUBQ: 1mg/kg /12hrs (preferred) or 1.5mg/kg /24hrs.
VTE prophylaxis: SUBQ: 40mg once daily. Continue for length of hospital stay or until patient is
fully ambulatory (low VTE risk)
There are no dosage adjustments provided. Use with caution.
Renal Impairment:
CrCl ≥30: No adjustment necessary
CrCl 20-30: Prophylactic dose: 20-30 mg subQ once daily. Therapeutic dose: 1mg/kg subQ /24hr
CrCl <20: Avoid. Use unfractionated heparin.
In Obese Patients thromboprophylaxis:
BMI ≥40 kg/m2: 40 mg subQ /12hr
BMI ≥50 kg/m2: 60 mg subQ /12hr
Alternative: 0.5mg/kg subQ twice daily (actual body weight for BMI 30 kg/m2 or greater can be used)
Important Considerations CIs: Active major bleeding, history of immune-mediated heparin-induced thrombocytopenia (HIT)
within the past 100 days/presence of circulating antibodies
Use caution in patients with active ulcerative and angio-dysplastic gastrointestinal disease
AEs: Bleeding, Thrombocytopenia: Discontinue therapy/consider alternative treatment if platelets
are <100,000/mm3 and/or thrombosis develops
Preparation/administration -Do not administer by IM injection
and stability/sensitivity -SubQ: Do not expel air bubble from the syringe prior to the injection
-Do not inject into skin that has bruises or scars
-Store below 25°C in the original package
‫ يعىط تحت الجلد دون تفري غ الشنجة من الهواء الموجود بها‬، ‫ يمنع الحقن العضىل‬-
‫ مئوية زف العلبة األصلية‬25 ‫تحفظ زف درجة حرارة تحت‬-
Notes -Safe for use in pregnancy
32 | P a g e
-STEMI receiving thrombolytics: give enoxaparin 15mins before or 30mins after fibrinolytic
therapy
-Overlap with warfarin for at least 3 days to accelerate reaching INR target + daily monitoring
Cost/enoxaparin 60mg: 49.56 LE
Cost/enoxaparin 40mg: 70.92816 LE
Monitoring parameters -Platelet count, hemoglobin, hematocrit, signs/symptoms of bleeding
-HIT: Assess for risk if thrombocytopenia occurs using 4Ts score
Epinephrine – 1mg/ml ampoules (Adrenaline)
Mechanism of action Stimulates alpha-, beta1-, and beta2- receptors resulting in relaxation of smooth muscle of the
bronchial tree, cardiac stimulation (increased myocardial oxygen consumption) and dilation of
skeletal muscle vasculature. Small doses can cause vasodilation via beta2-vascular receptors. Large
doses may produce constriction of skeletal and vascular smooth muscle
Indication and doses Anaphylaxis/other severe immediate hypersensitivity reactions: IM: 0.5mg in the anterolateral
aspect of the middle third of the thigh, may repeat every 5-15mins (or sooner if clinically indicated).
Give IV fluids and continuous IV epinephrine infusion if inadequate response. Reserve IV
administration for patients who are unresponsive (profoundly hypotensive) after several
epinephrine IM injections
Acute severe asthma (refractory to standard therapy - impending respiratory arrest): IM/SQ: 0.5mg,
may repeat 20min later up to 3 doses
Symptomatic bradycardia or AV block (refractory to atropine): continuous IV infusion: 40mcg/min
for 80kg patient + titrate to clinical effect
Inotropic support: 1-40mcg/min + titrate to desired BP or MAP
Sudden cardiac arrest: IV: 1mg every 3-5mins until return of spontaneous circulation, or
endotracheal: 2-2.5mg every 3-5mins until IV/intraosseous route is established or return of
spontaneous circulation
Dose adjustment Obesity (BMI ≥30 kg/m2): for weight-based dosing, use ideal body weight for initial calculations then
titrate to hemodynamic effect and clinical response
Important Considerations CIs: There are no absolute contraindications
Disease-related:
-May precipitate/aggravate angina pectoris or induce cardiac arrhythmias
-Due to peripheral constriction and cardiac stimulation, pulmonary edema may occur
-Due to renal blood vessel constriction, decreased urine output may occur
-Correct blood volume depletion before administering any vasopressor
-May transiently increase blood glucose levels
-Extravasation may cause severe ischemic necrosis
AEs: arrhythmias, increased cardiac output, hypertension, peripheral vasoconstriction, ventricular
fibrillation, hyperglycemia, hypokalemia, tremors
DDIs:
+haloperidol (may diminish the vasoconstricting effect of Epinephrine – consider alternatives)
+linezolid (reduce epinephrine dose – monitor BP)
Preparation/administration -Can be administered IM, intraosseous, endotracheally, IV, or SUBQ
and stability/sensitivity -IV infusions require an infusion pump. Administer via a central line (preferred)
‫ يتم استخدام قسطرة وريدية مركزية‬:‫ للحقن عن طريق المحلول الوريدي المستمر‬-
Notes -Extravasation management: stop infusion immediately and disconnect (leave cannula/needle in
place). Gently aspirate extravasated solution (do NOT flush the line). Remove needle/cannula and
elevate extremity. Initiate phentolamine or nitroglycerin 2% ointment. Apply dry warm compresses
33 | P a g e
Monitoring parameters Heart rate, blood pressure (invasive BP monitoring recommended with continuous infusion),
monitor site of infusion, continuous cardiac monitoring required during continuous infusion, assess
intravascular volume prior to + during therapy (if used for hypotension), blood glucose level
Epinephrine + Articaine (Alexandricaine)
Mechanism of action Articaine: Blocks both the initiation and conduction of nerve impulses by increasing the threshold
for electrical excitation in the nerve, slowing the propagation of the nerve impulse, and reducing
the rate of rise of the action potential.
Epinephrine: Increases the duration of action of articaine by causing vasoconstriction (via alpha
effects) which slows the vascular absorption of articaine.
Indication and doses Dental anesthesia: Submucosal infiltration and/or nerve block: Articaine 4%/epinephrine
Infiltration: 0.5-2.5 mL; total dose of articaine 20-100 mg; max dose of articaine: 7 mg/kg (0.175
mL/kg).
Nerve block: 0.5-3.4 mL; total dose of articaine 20-136 mg; max dose of articaine: 7 mg/kg (0.175
mL/kg).
Dose adjustment There are no dosage adjustments provided
Important Considerations Local toxicity: Epinephrine may cause local toxicity, including ischemic injury or necrosis.
Methemoglobinemia: Has been reported with local anesthetics; clinically significant closely
monitored for signs and symptoms of methemoglobinemia (e.g: cyanosis, headache, rapid pulse,
shortness of breath, lightheadedness, fatigue).
Systemic toxicity: Systemic absorption of local anesthetics may produce cardiovascular and/or CNS
effects. Toxic blood concentrations of local anesthetics depress cardiac conduction and
excitability, which may lead to AV block, ventricular arrhythmias, and cardiac arrest (sometimes
resulting in death). In addition, myocardial contractility
Cardiovascular disease: Use with caution in patients with impaired cardiovascular function
-May decrease the levels/effects of antidiabetic Agents.
DDIs: +alpha1-Blockers, +beta-Blockers (Beta1 Selective): levels/effects of articaine+epinephrine
may be decreased
Preparation/administration Aspirate the syringe after tissue penetration and before injection to minimize chance of direct
and stability/sensitivity vascular injection.
Notes -In pregnancy: Use in week 13 to 21 of pregnancy is likely to be safe (American Dental Association).
2nd trimester is the best time for dental procedures if necessary
-Lidocaine is preferred for use during pregnancy (FDA)
-During breastfeeding: In general, women administered single dose local anesthesia for dental
procedures may resume breastfeeding
Cost/ampoule:4.7042LE
Monitoring parameters Cardiovascular and respiratory vital signs, state of consciousness after each injection, CNS toxicity.
Esomeprazole – 40mg vials (Zomegipral)
Mechanism of action Proton pump inhibitor suppresses gastric acid secretion by inhibition of the H +/K+-ATPase in the
gastric parietal cell. S-isomer of omeprazole.
Indication and doses Acute upper GI bleeding: IV: 80mg bolus, followed by 8 mg/hour for 3-5days
Stress ulcer prophylaxis (high-risk patients): IV: 40mg /24hr until risk factors are no longer present
Acute upper GI bleed:
Child-Pugh class A or B: No change in IV bolus dose. Maintenance max dose 6mg/hr (~4ml/hr)
Child-Pugh class C: No change in IV bolus dose. Maintenance max dose 4mg/hr (2ml/hr)
Disease-related:
-May increase risk of C. difficile infections particularly in hospitalized patients
-May cause dermatologic reactions (DRESS, TEN, SJS, etc)
34 | P a g e
-May cause hypomagnesemia (prolonged use >3months)
AEs: flatulence, diarrhea, xerostomia, drug-induced fever
DDIs:
+rifampin (decreased esomeprazole conc/efficacy – avoid combination, use H2-blocker instead)
Preparation/administration -IV infusion instructions: dilute 2 vials (80mg) in NS to a total of 50ml, and administer by rate 5ml/hr
and stability/sensitivity using a syringe pump
-Flush line prior to and after administration with NS
-Administer intermittent IV infusion dose over 30mins
-Use within 24hrs after dilution. Store below 25°C
‫ساعة‬/‫مل‬5 ‫مل محلول ملح ويعىط بمعدل‬50 ‫ فيال زف‬2 ‫ يحل‬:‫ للمحلول الوريدي المستمر‬-
ً
‫ يتم حقن محلول ملح وريديا قبل وبعد االستخدام‬-
‫ يعىط عىل مدار نصف ساعة‬:‫ للجرعات الوريدية‬-
‫ مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬، ‫التحضت‬
‫ر‬ ‫ ساعة من‬24 ‫يستخدم خالل‬-
Notes High-risk conditions requiring SUP include:
▪ Bleeding diathesis (plt <50, INR >1.5 or PTT >2times control value)
▪ Mechanical ventilation for >48hrs especially if not enterally fed
▪ Chronic liver disease
▪ History of GI ulcer/GI bleed within 1yr
▪ Traumatic brain injury, traumatic spinal cord injury, or burn injury
▪ >2 of: sepsis, ICU stay >1week, occult GI bleed >5 days, or glucocorticoid use (>250mg
hydrocortisone or equivalent)
▪ On NSAIDs or antiplatelet
-For stress ulcer prophylaxis, consider using oral formulations (H2-blocker or oral PPO) if patient
tolerates oral feeding – no additional benefit of using IV form
Cost/vial:16.632 LE
Monitoring parameters Monitor for rebleeding in patients with upper GI bleeding, Mg2+ (baseline and periodically especially
if taking digoxin, diuretics, other drugs known to cause hypomagnesemia), Ca2+ (baseline and
periodically in patients at risk [e.g: hypoparathyroidism]), Clostridioides difficile-associated diarrhea
(CDAD)
Ethambutol – 500mg tablets
Mechanism of action Inhibits arabinosyl transferase resulting in impaired mycobacterial cell wall synthesis
Indication and doses Drug-susceptible TB (intensive phase): Adults: Oral: Daily dosage
40-55 kg: Oral: 800 mg (14.5 to 20 mg/kg)
56-75 kg: Oral: 1.2 g (16 to 21.4 mg/kg)
76-90 kg: Oral: 1.6 g (17.8 to 21.1 mg/kg)
Pediatrics (weight <40 kg): Oral: 20 mg/kg/dose once daily.
≥40kg: same is in adult dose.
*Refer to tuberculosis management protocol for further details.
Dose adjustment Hepatic impairment: no dose adjustment provided. Use with caution.
Renal impairment: no adjustment necessary if regimen is once daily dosing.
If on hemodialysis (intermittent, 3times /wk): Use with caution, close monitoring. May develop optic
adverse effects.
Doses should be based on lean body weight for patients within a normal weight range for their
height.
Important Considerations CIs: Hypersensitivity. optic neuritis (risk vs benefit decision).
(Use only in children whose visual acuity can accurately be determined and monitored (not
recommended for use in children <13yrs unless the benefit outweighs the risk).
AEs: Hepatic toxicity, optic neuritis
Preparation/administration -Administer with or without food; if GI upset occurs, administer with food.
and stability/sensitivity -Tablet may be crash and mixed with apple juice or apple sauce.
35 | P a g e
-Do not mix with other juices or syrups since they do not mask ethambutol's bitter taste or are not
stable.
-Administer ethambutol at least 4hrs before aluminum hydroxide.
Notes -In pregnancy: Due to the risks of untreated tuberculosis, ethambutol is recommended as part of
the initial treatment regimen of drug-susceptible active tuberculosis when the probability of
maternal disease is moderate to high
Monitoring parameters Baseline and periodic (monthly) visual testing and color discrimination tests (each eye individually
+ both eyes tested together) in patients receiving >15 mg/kg/day; baseline and periodic renal,
hepatic, and hematopoietic tests
Etamsylate – 250mg/2ml ampoules (Dicynone)
Mechanism of action Hemostatic and synthesis angio-protector. Improves platelet adhesion and restores capillary
resistance to reduce bleeding time and blood loss
Indication and doses Pre-surgical hemorrhage prophylaxis: IV/IM: 250-500mg (1-2 amp) given 1hr before surgery
Urgent treatment of hemorrhagic conditions or post-operative bleeding: IV: 250-500mg (1-2 amp)
/4-6hr until risk of bleeding subsides
Local management of bleeding (e.g: epistaxis): soak a cotton swab with 1 ampoule and apply to the
area. May combine with systemic administration
Dose adjustment No dose adjustment provided
Important Considerations CIs: hypersensitivity, acute porphyria, bronchial asthma (contains sulfite)
AEs: most commonly rash and asthenia
Preparation/administration -Can be used IM (pre-operative), IV or by local application
ً
‫موضعيا (عىل موضع ز ز‬
and stability/sensitivity )‫التيف‬ ‫ يمكن استخدامه للحقن العضىل أو الوريدي أو‬-
Notes -Take blood samples first before first daily dose of etamsylate to minimize interaction/interference
with result
-Etamsylate has no vasoconstrictive effect and does not modify coagulation factors
Monitoring parameters Resolution of bleeding, decrease in bleeding risk, CBC
Famotidine – 40mg tablets and ampoules (Famotak, antodine)
Mechanism of action Competitive inhibition of histamine at H2 receptors of the gastric parietal cells, which inhibits gastric
acid secretion
Indication and doses SUP in selected critically-ill patients (coagulopathy, on mechanical ventilator, on systemic CS, etc):
Oral/NG tube: 20mg twice daily. IV: 20 mg twice daily. Discontinue once risk factors resolved
Aspiration prophylaxis (patients undergoing anesthesia, at risk for aspiration): IV: 20mg single
dose ~40-90mins prior to induction of anesthesia. May be given with a rapid-acting antacid and/or
metoclopramide
IV: CrCl <50: 50% of usual dose
Oral:
CrCl Original dose 20mg /12hr
30-59 20 mg /24hr or 40 mg /48hr
<30 or on intermittent HD 10 mg /24hr or 20 mg /48hr
Intermittent HD: IV/oral: administer after HD session on dialysis days.
Precautions:
-Famotidine reduce absorption of vit B12
AEs: agitation, confusion and delirium (especially in the elderly, kidney impairment), risk of QTc-
prolongation
DDIs: +cefuroxime (decreased cefuroxime absorption - separate oral doses by at least 2hrs)
36 | P a g e
Preparation/administration -Store solution for injection at 2°C to 8°C
and stability/sensitivity -IV: push bolus over at least 2mins or as IV infusion over 15-30min.
-Dilute 2 mL (20 mg) with 5-8ml NS. Solution should be used immediately, or may be stored in
refrigerator and used within 48hrs
Oral: administer without regard to meals. May administer with antacids.
‫تخزن األمبوالت زف الثالجة قبل االستخدام‬-
‫ز‬ ‫ر ز‬
‫مل‬8-5 ‫مجم ف‬20 ‫ دقيقة بعد الحل (يحل األمبول‬30-15 ‫ يو عىل مدار‬، ‫دقيقتي‬ ‫ يعىط عىل مدار‬:‫لالستخدام الوريدي‬-
)‫محلول ملح‬
‫ ساعة‬48 ‫تحضته زف الثالجة لمدة‬
‫ر‬ ‫بعد‬ ‫المحلول‬ ‫تخزين‬ ‫يمكن‬-
Notes Compatible for use during pregnancy
Monitoring parameters CBC, Cr, gastric pH, occult blood with GI bleeding
FentaNYL – 100mg/2ml ampoules
Mechanism of action Potent opioid. Binds with stereospecific receptors at many sites within the CNS, increases pain
threshold, alters pain reception, inhibits ascending pain pathways.
Indication and doses Rapid sequence intubation: IV: 50-200mcg (or 1-3mcg/kg) over 30-60sec administered ~3mins
prior to induction.
If hemodynamically unstable: 1mcg/kg (or 50mcg) or avoid use.
If elevated ICH: 3mcg/kg (or 200mcg).
ICU pain and sedation management:
Loading dose: IV: 25-100mcg or 1-2mcg/kg, then use either intermittent or continuous dosing
Intermittent dosing: IV: 25-50mcg every 30-60mins as needed. Weight-based dose: 0.35-
0.5mcg/kg every 30-60mins as needed
Continuous infusion dosing: IV: 25-50 mcg/hr; titrate every 30-60mins to clinical effect
Usual dosing range: 50-200mcg/hr. Weight-based dose: 0.7-10mcg/kg/hr
Use with caution. Possible drug accumulation and increased serum concentration
Renal impairment:
Give lower initial doses and carefully monitor for drug accumulation
GFR 10-50: Administer 75% of normal dose. GFR <10: Administer 50% of normal dose
Obesity (BMI ≥30kg/m2): Use adjusted BW for initial weight-based dose calculations, titrate to
clinical effect. Do not change calculation method from actual to adjusted body weight during
therapy
Important Considerations BLACK BOX WARNING:
Life-threatening respiratory depression. Risk of addiction, abuse, and misuse
CIs: Avoid in patients with bradycardia, circulatory shock, known/suspected mechanical GI
obstruction.
AEs: Use with caution in patients with biliary tract dysfunction/acute pancreatitis, convulsive
disorders, patients susceptible to intracranial effects of CO2 retention
DDIs: +diltiazem, +fluconazole, +verapamil (CYP3A4 inhibitors): decrease fentanyl dose
+linezolid (monitor for signs of serotonin syndrome/serotonin toxicity)
+propofol (limit dose of both drugs, monitor for bradycardia, apnea or excessive CNS depression)
+midazolam (limit dose of both drugs)
+haloperidol (avoid when possible, limit the dosages/duration)
+chlorpheniramine (drugs with anti-cholinergic effects): monitor for evidence of constipation,
urinary retention, etc)
Preparation/administration -Administer IM/IV slowly over 1-2mins.
and stability/sensitivity -Dilute as 10mcg/ml in NS for continuous infusion preparations
37 | P a g e
-May repeat loading dose if severe pain persists and adverse effects are minimal at the time of
expected peak effect (~5 mins after administration)
‫ر ز‬
‫دقيقتي‬ ‫ أو الوريدي ببطء دون تخفيف عىل مدار دقيقة إىل‬، ‫ للحقن العضىل‬-
‫ئ‬
‫مل) محلول ملح‬/‫ميكروجم‬10 ‫كت النهائ‬ ‫مل ى‬10 ‫ يمكن حل األمبول زف‬:‫ للمحلول الوريدي المستمر‬-
‫(الت ر ز‬
Notes -In pregnancy: use may be associated with birth defects especially with prolonged use
Monitoring parameters Assess pain relief (with a validated scale). Monitor patient closely for respiratory depression
(initiation/dose escalation), BP, HR and GI symptoms (nausea, vomiting and diarrhea)
Fluconazole – 200mg vials (Sunnyfungal)
Mechanism of action Interferes with fungal cytochrome P450 activity (lanosterol 14-α-demethylase), decreasing
ergosterol synthesis (principal sterol in fungal cell membrane) and inhibiting cell membrane
formation
Indication and doses Oropharyngeal candidiasis: IV/Oral: 200 mg on day 1, then 100-200 mg once daily for 7-14 days. If
no response, use 400mg dose daily.
Cystitis (symptomatic): IV/Oral: 200 mg (or 3 mg/kg) once daily for 14days
Pyelonephritis or UTI fungal balls: 200-400 mg (or 3 to 6 mg/kg) once daily for 14days
Pulmonary aspergillosis or candidemia: 800mg (or 12 mg/kg) on day 1, then 400 mg (or 6mg/kg)
once daily. Continue for ≥14 days after first negative blood culture and resolution of
signs/symptoms.
Dose adjustment Renal impairment: CrCl ≤50: 50% dose
Hemodialysis, intermittent (thrice weekly): No dosage adjustment necessary for indication-specific
loading/initial or maintenance dose recommended. Only administer maintenance doses 3
times/week (on dialysis days) after the dialysis session
Obesity: BMI ≥30 kg/m2: use actual body weight (max LD 1600mg, MD 800mg)
Important Considerations CIs: Hypersensitivity
AEs: Cardiovascular effects (QTc prolongation), Dermatologic reactions, Hepatotoxicity
DDIs: +Ivabradine (high risk of QTc prolongation - avoid combination)
+amiodarone (high risk of QTc prolongation - monitor ECG continuously)
+clopidogrel (risk of diminished clopidogrel effect – consider alternative)
+fentanyl, +midazolam (consider fentanyl and midazolam dose reduction)
+warfarin (reduce warfarin dose by 10-20%, monitor INR/signs of bleeding)
+fluconazole, +haloperidol, ondansetron (monitor ECG for QTc prolongation)
Preparation/administration - Dilute to a final concentration of 2mg/ml. Infuse over ~1-2 hr. Do not exceed 200mg/hr rate
-Use immediately after reconstitution
‫ر ز‬
‫ساعتي‬ ‫مل محلول ملح ويعىط عىل مدار ساعة إىل‬100 ‫مجم زف‬200 ‫ يحل الفيال‬-
‫ يستخدم ر‬-
‫مباشة بعد التحض رت‬
Notes In pregnancy: high doses (≥400 mg/day) may cause fetal harm
Monitoring parameters LFTs (especially in patients with pre-existing liver disease), renal function tests, K level, rash signs
and symptoms of hepatic injury
Fluticasone + salmeterol – 125/25mcg inhaler (Seretide EvoHaler)
Mechanism of action Fluticasone: Anti-inflammatory activity, immunosuppressive properties, and antiproliferative
actions. Has extremely potent vasoconstrictive + anti-inflammatory activity.
Salmeterol: Relaxes bronchial smooth muscle by selective action on beta2-receptors with little
effect on heart rate. It is a LABA.
Indication and doses Asthma, maintenance/controller: Seretide Diskus: (fluticasone propionate 100mcg or 250mcg or
500mcg/salmeterol 50mcg per actuation): Oral inhalation: 1 inhalation twice daily. Max dose:
fluticasone 1,000 mcg/day, salmeterol 100 mcg/day.
38 | P a g e
Individualized based on severity: mild persistent asthma: 100-250mcg/day; moderate persistent
asthma >250-500 mcg/day; severe persistent asthma >500 mcg/day
COPD: Seretide Diskus: Oral inhalation: 1 inhalation twice daily; in patients with persistent
symptoms/exacerbations, may change to fluticasone propionate 500 mcg/salmeterol 50 mcg 1
inhalation twice daily
Important considerations CIs: Hypersensitivity to fluticasone/salmeterol, status asthmaticus, acute episodes of
asthma/COPD
AEs: Upper respiratory tract infection (16% to 27%), pneumonia (4% to 18%), pharyngitis (≤13%).
GI: Oral candidiasis (1% to 10%; mouth/throat infections).
Precautions: The use of LABAs as monotherapy has been associated with an increased risk of
severe exacerbations and asthma-related deaths.
-paradoxical bronchospasm, immunosuppression (prolonged use), patients with major risk factors
for decreased bone mineral density, patients with cardiovascular disease (arrhythmia, coronary
insufficiency, hypertension, or heart failure), diabetes mellitus, hypokalemia, cataracts and/or
glaucoma
DDIs:
+Beta2-Agonists (Long-Acting): May enhance the adverse/toxic effect of other Beta2-Agonists
(Long-Acting). Avoid combination
+Beta-Blockers (Nonselective): May diminish the bronchodilatory effect of Beta2-Agonists. Avoid
combination
+Linezolid: May enhance the hypertensive effect of Sympathomimetics. Reduce initial doses of
sympathomimetic agents/closely monitor for enhanced pressor response
+ QT-prolonging Agents: use with caution
Preparation/administration -Rinse mouth with water (without swallowing) after each use
Notes -ICS are recommended for the treatment of asthma during pregnancy and salmeterol is the
preferred LABA for the management of asthma in pregnant patients. Monitor asthma symptoms
monthly.
Cost/inhaler: 145.92446 LE
Monitoring parameters Pulmonary function tests; blood pressure, heart rate, CNS stimulation, bone mineral density
(baseline and periodically thereafter), serum potassium (hypokalemic patients), glucose (diabetic
patients), glaucoma/cataracts, signs/symptoms of oral candidiasis, growth (adolescents and
children via stadiometry).
Fondaparinux – 2.5mg and 7.5mg pre-filled syringes (Arixtra)
Mechanism of action Synthetic pentasaccharide that causes an antithrombin III-mediated selective inhibition of factor
Xa. Neutralization of factor Xa interrupts the blood coagulation cascade and inhibits thrombin
formation and thrombus development.
Indication and doses Acute coronary syndrome (STEMI and Non-STEMI): subQ: 2.5mg /24hr during hospitalization.
VTE treatment and Heparin-induced thrombocytopenia (HIT): subQ: acc. to patient wt <50kg: 2.5mg
/24hr, 50-100kg: 7.5mg /24hr, >100kg: 10mg /24hr
VTE prophylaxis: subQ: 2.5mg /24hr until fully ambulatory (avoid if patient weight <50kg)
Child-Pugh class A and B: No dosage adjustment necessary. Monitor for signs of bleeding.
Child-Pugh class C: No dosage adjustment. Use with caution
Renal impairment:
CrCl <30: Contraindicated
Important Considerations CIs: hypersensitivity, active major bleeding, bacterial endocarditis, body weight <50 kg (VTE
prophylaxis)
39 | P a g e
-Monitor patients platelet count closely. Discontinue therapy if platelets fall to <100,000/mm 3
AEs: Bleeding, thrombocytopenia, hypokalemia, increased LFTs
DDIs: +apixaban (avoid combination)
+aspirin, +clopidogrel, NSAIDs (monitor for signs of bleeding)
Preparation/administration -Do not expel air bubble from syringe before injection
and stability/sensitivity -Store below 25°C. Avoid freezing
‫ ال يتم تفري غ الشنجة من الهواء الموجود بها‬، ‫ للحقن تحت الجلد‬-
‫ يمنع تجميدها‬،‫ مئوية‬25 ‫تحفظ زف درجة حرارة تحت‬-
Notes -Fondaparinux can be used as monotherapy in case of STEMI patients that are re-perfused with a
thrombolytic only (not PCI)
-In pregnancy: should be limited to those women who have severe allergic reactions to heparin
-Not to be used for AF patients of high risk to thromboembolism
-Overlap fondaparinux + warfarin until therapeutic INR has been established. INR should be ≥2 for
≥24hrs and continue fondaparinux for at least 5 days
-From warfarin to fondaparinux: Discontinue warfarin and initiate fondaparinux as soon as INR
becomes subtherapeutic
Cost/fondaparinux 2.5mg: 48.048 LE
Cost/fondaparinux 7.5 mg: 54.142 LE
Monitoring parameters CBC, plt count, serum creatinine, signs/symptoms of bleeding
Formoterol – 12mcg capsules for inhalation (Metrohaler)
Mechanism of action Relaxes bronchial smooth muscle by selective action on beta2 receptors with little effect on heart
rate. Formoterol has a long-acting effect.
Indication and doses COPD: Contents of 1-2 capsules inhaled /12 hrs (max dose: 4 capsules/day).
Asthma (combined with ICS): Contents of 1 capsule inhaled /12 hrs (max dose: 2 capsules/day)
Exercise-induced bronchospasm: Contents of 1 capsule inhaled at least 15 mins before exercise
Dose adjustment No dose adjustment
Important considerations CIs: Hypersensitivity, presence of tachyarrhythmias
Precautions: patients with cardiovascular disease (arrhythmia, coronary insufficiency, or
hypertension), diabetes, hyperthyroidism, hypokalemia
AEs: ECG changes (flattening of the T-wave, QTc interval prolongation, ST-depression)
DDIs: +beta blockers (monitor for diminished bronchodilatory effect)
+linezolid (possible BP elevation - monitor closely)
Preparation/administration -Administer at the same time each day
and stability/sensitivity -If combined with ICS: Mouth rinse is recommended
Monitoring parameters Pulmonary function tests; shortness of breath; blood pressure, heart rate; CNS stimulation; serum
glucose, serum potassium.
Fucidic acid 2% cream (Fucidin)
Mechanism of action Inhibits protein synthesis by blocking aminoacyl-tRNA transfer to protein in susceptible bacteria.
Indication and doses Skin infections: Topical: Apply small amount to affected area 2-3 times daily for 7-14 days.
Important considerations -Superinfection: Prolonged use may result in superinfection (including fungal infections).
Discontinue use if superinfection occurs; evaluate and treat appropriately.
Preparation/administration -If a gauze dressing is used, frequency of application may be reduced to once or twice daily
Notes In pregnancy: systemic absorption is minimal
Cost/tube: 8.8725 LE
40 | P a g e
Furosemide – 40mg tablets and 20mg ampoules (Lasix, lasiphar)
Mechanism of action Primarily inhibits reabsorption of sodium and chloride in the ascending loop of Henle and proximal
and distal renal tubules, interfering with the chloride-binding cotransport system, thus causing its
natriuretic effect.
Indication and doses Bioequivalence: 20mg IV = 40mg PO furosemide
Edema/volume overload:
Naive to loop diuretics: Oral/IV: Initial: 20 to 40 mg once then titrate as needed (by 20 mg/dose
every 2-hr).
Refractory edema/acute decompensation in patients taking oral loop diuretics:
-Bolus/intermittent IV: 80-200 mg IV as an initial bolus once then titrate as needed (max single
dose 80-200 mg, max recommended total daily dose: 600 mg/day)
-Continuous IV infusion (if responded to bolus): 5 mg/hour initially (up to 40 mg/hr)
Ascites (+spironolactone): 40mg once daily titrate every 3-5 days (max 160mg/day)
GFR <30: single doses >160-200 mg IV (or oral equivalent) unlikely to result in additional effect
Continuous IV infusion: Initial: 20 mg/hr (up to 40 mg/hr)
Important considerations Black box warning: Fluid/electrolyte loss.
CIs: anuria, hepatic encephalopathy
AEs: Acute kidney injury (dose related), ototoxicity (mostly reversible), hypersensitivity reaction,
diminished natriuretic effect with increased sensitivity to hypokalemia/volume depletion in
cirrhosis, sulfa drug allergy (cross sensitivity may occur)
DDIs: +NSAIDs (nephrotoxic – high risk of AKI, particularly with concurrent ACEI use)
+aminoglycosides (nephrotoxic/ototoxic – monitor for symptoms)
Preparation/administration Oral: May administer with/without food.
and stability/sensitivity Parenteral: Undiluted direct IV injections at a rate of 20-40mg/min.
for high doses infusion (≥160 mg): max rate of 4mg/min
‫ر ز‬
‫دقيقتي‬ ‫ يعىط األمبول عىل مدار دقيقة إىل‬:‫لالستخدام الوريدي‬-
‫دقيقة‬/‫مجم‬4 ‫ يمكن إعطاؤه بمعدل أقىص‬:‫للمحاليل الوريدية المستمرة‬-
Monitoring parameters BP; serum electrolytes; kidney function, fluid intake and output.
Gentamicin – 80mg ampoules (Garamycin, epigent)
Mechanism of action Interferes with bacterial protein synthesis. Binds with 30s ribosomal subunit.
Indication and doses Reserve for immunocompromised patients or risk for resistant Gram –ve pathogens (p.
aeruginosa, in particular)
Sepsis and septic shock (empiric regimen): 5-7 mg/kg IV /24hr
CrCl 40-59: administer /36hr + adjust based on serum gentamicin level
20-39: administer /48hr + adjust based on serum gentamicin level
CrCl <20: administer usual first dose + subsequent doses based on serum gentamicin level
BMI ≥30 kg/m2: Use adjusted body weight for dosing
Important Considerations Black Box Warning: Nephrotoxicity (dose-dependent), neurotoxicity such as ototoxicity (duration-
dependent)
AEs: May cause neuromuscular blockade and respiratory paralysis, prolonged use may result in
fungal/bacterial superinfection (e.g: c. difficile).
Use with caution in patients with hypocalcemia, hypokalemia, hypomagnesemia, preexisting
vertigo, tinnitus, hearing loss and neuromuscular disorders (e.g: myasthenia gravis)
DDIs: +colistin, +mannitol IV (avoid combination)

+vancomycin (avoid unless clinically indicated)
41 | P a g e
Preparation/administration Dilute in (Ns or D5W) in 50 to 200 ml. Infuse over 30-120 min.
and stability/sensitivity ‫ر ز‬
‫ساعتي‬ ‫ ويعىط عىل مدار نصف ساعة إىل‬%5 ‫مل محلول ملح أو جلوكوز‬200-50 ‫يحل األمبول زف‬-
Notes -In pregnancy: may cause fetal harm. Use alternative.
Monitoring parameter -Monitor renal function closely, urinalysis, urine output
-Target gentamicin level (sepsis, pneumonia, serious infections): Peak: 7-10 mcg/ml and trough
<2mcg/ml
Draw peak 30 min after infusion start and trough immediately before next dose
Glucose – 5%, 10% and G25% IV solution (Dextrose)
Mechanism of action The principal source of energy in cellular metabolism. Given as a source of carbohydrate in
parenteral nutrition.
Indication and doses Carbohydrate supplementation (nutritional or rehydration with high carbohydrate needs): IV 500-
3,000ml glucose 5% per 24hrs (max dose range 5mg/kg/min)
Correcting hypoglycemia (patient with disturbed consciousness): IV 100ml of glucose 25% or
250ml of glucose 10%.
Important Considerations CIs: uncontrolled diabetes, other known glucose intolerances (such as metabolic stress situations),
hyperosmolar coma, hyperglycemia, hyperlactatemia and ascites. Avoid use during first 24hr of
brain trauma.
AEs: Acute hyponatremia (can lead to acute brain edema), hyperglycemia, precipitating refeeding
syndrome (in severe malnutrition), overhydration/hypervolemia, congested states (pulmonary
congestion/edema).
Preparation/administration -Administered via a central or a peripheral line
‫عت قسطرة وريدية مركزية‬ ‫ز‬
and stability/sensitivity ‫لالستخدام الوريدي الطرف أو ر‬-
Notes -Glucose 5% solution provides a caloric intake of 200 kcal/L (multiply for other glucose
concentrations 10%, 25%)
-Each 500ml glucose 5% will provide 50ml intravascular volume expansion
-For symptomatic hypoglycemia or blood glucose level >70mg/dl: administer glucose and re-check
random blood glucose level after 15 min. Repeat glucose administration and blood glucose level
check until level >70mg/dl
Cost/glucose 5% bottle: 8.465625 LE
Monitoring parameters Fluid balance, serum glucose, serum sodium/other electrolytes before and during administration
Glyceryl trinitrate/nitroglycerin – 50mg/50ml IV infusion solution and 5mg patches (Nitronal IV ☀, nitroderm patch)
Mechanism of action Forms free radical nitric oxide that activates guanylate cyclase which increases cGMP, leading to
dephosphorylation of myosin light chains and smooth muscle relaxation. Vasodilatory effect on
the peripheral veins and arteries - more prominent effects on the veins. Reduces cardiac oxygen
demand by decreasing preload and dilates coronary arteries.
Indication and doses Acute decompensated heart failure (congestion without symptomatic hypotension), adjunctive to
IV diuretics: IV infusion 5-10mcg/min, double the dose every 5min based on response/tolerability,
up to 200mcg/min (12mg/hr). Higher doses produce arterial VD.
Hypertensive emergency, or pulmonary edema: IV infusion 5 mcg/min, double the dose every
5min based on response/tolerability, up to 20 mcg/min (1.2mg/hr)
Prevention of angina: Transdermal patch: 0.2-0.4mg/hr, max 0.8mg/hr. Use a patch-on period 12-
14hrs/day. Ensure 10-12hrs/day nitrate-free to reduce tolerance.
Dose adjustment No dose adjustments necessary
Important Considerations CIs: Patients with severe hypotension (SBP <90 mmHg or >30 mmHg below baseline), marked
bradycardia or tachycardia, right ventricular MI, constrictive pericarditis, increased intracranial
pressure, severe anemia, acute circulatory failure/shock, hypertrophic cardiomyopathy with left
ventricular outflow tract obstruction (precipitate syncope/aggravate HF)
AEs: Tachyphylaxis: develops within 24-48hrs of continuous nitrate administration. If vasodilator
42 | P a g e
requirements continue for longer, transition to an alternative IV/oral vasodilator.
Hypotension, paradoxical bradycardia.
Precipitate/aggravate increased intracranial pressure (may worsen clinical outcomes in patients
with neurologic injury)
DDIs: +sildenafil (avoid combination),
Preparation/administration -IV infusion: 50mg/50ml concentration. Administer via infusion pump.
and stability/sensitivity -Transdermal patch: Application site should be clean, dry, and hair free. Rotate patch sites.
-Used immediately after dilution
-Store below 25°C. Protect from light.
‫ يعىط باستخدام مضخة محاليل وريدية حسب المعدل المحدد من قبل الطبيب‬:‫المحلول الوريدي‬-
ً
‫ يتم تبديل مكان وضع الالصقة بشكل دوري‬، ‫ المكان المستخدم يجب أن يكون نظيفا‬:‫الالصقة عىل الجلد‬-
ً
‫ مئوية بعيدا عن الضوء‬25 ‫يحفظ المحلول زف درجة حرارة تحت‬-
Notes -Hypertensive emergency: goal of therapy is to reduce MAP by ~10-20% over the first hr then by
an additional 5-15% over the next 23hrs
-In pregnancy: recommended for use in preeclampsia, when severe hypertension is associated
with pulmonary edema
Cost/patch: 4.053 LE
Monitoring parameters BP and HR
Haloperidol – 5mg ampoules (haloperidol)
Mechanism of action Haloperidol is a butyrophenone antipsychotic that non-selectively blocks postsynaptic
dopaminergic D2 receptors in the brain
Indication and doses Delirium, hyperactive (Nonpharmacologic interventions are preferred/recommended to prevent
and manage delirium): IM (ICU) initial 0.5-20 mg depending on degree of agitation. Repeat 15-
30min until calmness achieved (as total loading dose). Maintenance dose: ~25% of total loading
dose needed to achieve calm /6-12hrs if needed
IM (Non-ICU): 0.5-1mg. repeat in 30min intervals if needed (max 5mg /day)
Protein binding may decrease. Haloperidol serum concentration may increase.
Renal impairment:
No dose adjustment necessary.
Important Considerations Disease-related considerations: Avoid in thyrotoxicosis, transient hypotension, can cause
precipitation of angina pain
AEs: CNS depression, risk of falls, QTc-interval prolongation
DDIs: +ipratropium (monitor for signs of anticholinergic effects)
+amiodarone, +fluconazole, +levofloxacin, +ondansetron (increased risk of QTc prolongation -
monitor ECG)
Preparation/administration -Administer IM
and stability/sensitivity -IV: Dilute 50mg using 10ml NS (off-label route)
‫ مخصص للحقن العضىل‬-
‫مل محلول ملح‬10 ‫مجم زف‬50 ‫ يتم حل األمبول‬:‫لالستخدام الوريدي‬-
Notes -In pregnancy: use during the third trimester of pregnancy has a risk for abnormal muscle
movements (extrapyramidal symptoms). Min effective maternal dose should be used.
-Greater risk of QTc prolongation if IV route is used.
Monitoring parameters Mental status, vital signs, ECG
Human Albumin solution 20% (Albumin 20%)
Mechanism of action Provides increase in intravascular oncotic pressure and causes mobilization of fluids from
interstitial into intravascular space.
Indication and doses Adult respiratory distress syndrome (ARDS): IV: 25gm over 30mins (combined with furosemide).
May repeat /8hrs (if necessary) for 3 days. Titrate to fluid loss and normalization of serum total
protein.
Hypovolemia (5% albumin preferred): IV: Initial: 12.5-25gm; repeat after 15-30 mins as needed (if
hemodynamic stability is not achieved).
Cirrhotic ascites (large volume paracentesis): 50gm total for paracentesis >5L
Dose adjustment No dose adjustment
43 | P a g e
Important considerations CIs: Hypersensitivity to albumin/component of the formulation; severe anemia, heart failure;
patients at risk of volume overload,
Precautions:
-Coagulation abnormality: Monitor/replete with blood constituents if indicated.
-Electrolyte imbalance: due to large replacement volumes. Monitor electrolytes and replace or
maintain as indicated.
-Avoid rapid infusions in patients with a history of cardiovascular disease (may cause volume
overload/pulmonary edema).
-Hemodynamic effects: Cardiac or respiratory failure, kidney failure, or increasing intracranial
pressure can occur; closely monitor hemodynamic parameters in all patients.
-Hypervolemia/hemodilution: Use with caution in conditions where hypervolemia and its
consequences or hemodilution may increase the risk of adverse effects (eg, heart failure,
pulmonary edema, hypertension, hemorrhagic diathesis, cirrhosis, esophageal varices). Avoid
rapid infusions in patients with history of CVDs.
-Sodium restricted patients: Use with caution.
AEs: hypersensitivity reactions, hypotension, flushing, heart failure, hyperchloremic metabolic
acidosis
Preparation/administration -Rate of infusion is dependent upon use and clinical condition. Too rapid infusion may result in
and stability/sensitivity volume overload. In emergencies, may administer as rapidly as necessary to improve clinical
condition. Not recommended to exceed 1-2mL/min in patients without shock.
-albumin 20% may be given undiluted or diluted in normal saline. May give in combination or
through the same administration set as saline or carbohydrates.
-Warm to room temperature before use
-5% solutions may be prepared by diluting 20% human albumin with NS or glucose 5%. Do not use
sterile water to dilute albumin solutions (hypotonic-associated hemolysis)
‫دقيقة‬/‫مل‬2-1 ‫ بحد أقىص‬، ‫ يجب تجنب معدالت الحقن الوريدي الشي ع‬، ‫ لالستخدام الوريدي‬-
‫ر ز‬
‫ بعد حله بمحلول ملح أو دون حله‬%20 ‫ألبومي‬ ‫ يمكن استخدام‬-
‫حت يصل لدرجة حرارة الغرفة قبل االستخدام‬‫ ىيتك ى‬-
‫ر ز‬
‫ يمنع حله بالماء المذيب‬، %5‫ بعد حله بمحلول ملح أو جلوكوز‬%5 ‫ألبومي‬ ‫ يمكن استخدام‬-
Notes -Patients with chronic kidney insufficiency receiving albumin solution may be at risk for
accumulation of aluminum/potential toxicities (e.g: hypercalcemia, vitamin D refractory
osteodystrophy, anemia, severe progressive encephalopathy)
-In pregnancy: may be considered when contraindications to nonprotein colloids exist.
-In patients with sepsis or septic shock: Maybe considered after inadequate response to large
volumes of crystalloid therapy. The volume administered and the rate of infusion should be
adapted to individual response.
-Reserve for patients with existing kidney/severe hepatic impairment in case of spontaneous
bacterial peritonitis (e.g: creatinine >1 mg/dL, BUN >30 mg/dL, or bilirubin >4 mg/dL)
Monitoring parameters Monitor electrolytes, hemoglobin/hematocrit, and urine output regularly; monitor hemodynamic
parameters, BP, heart rate, volume status, and signs and symptoms of pulmonary edema, central
venous pressure, pulmonary artery occlusion pressure.
Hydrocortisone sodium succinate – 200mg vials (Hydrocortisone, solu-cortef)
Mechanism of action Short-acting corticosteroid with minimal sodium-retaining potential; decreases inflammation by
suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary
permeability.
Indication and doses Anti-inflammatory: IM, IV: Initial: 100-500 mg/dose at intervals of 2, 4, or 6 hrs.
Asthma, acute exacerbation (alternative agent): IV/oral: 200mg in divided doses for 5-7 days
COVID-19 (hospitalized, with anti-viral agent): IV: 50mg /8hrs up to 10days or discharge
(whichever is sooner)
44 | P a g e
Septic shock (refractory to vasopressors): IV: 50mg IV bolus /6hrs OR 200mg IV infusion /24hr for
5-7 days). Consider a slow taper over several days
Important considerations CIs: hypersensitivity, systemic fungal infections, active tuberculosis (unless meningeal)
AEs: -Use with caution in patients with HF, associated with fluid retention, electrolyte
disturbances, hypertension, following acute MI
diverticulitis, abscess, …)
-Endocrine & metabolic: Adrenocortical insufficiency, Cushing syndrome, decreased serum
potassium, drug-induced Cushing’s syndrome, glycosuria, growth retardation.
impairment
-Myopathy (high dose corticosteroids): monitor CK; recovery may be delayed.
Precautions:
Concerns related to adverse effects
▪ Adrenal suppression: in patients receiving high doses for prolonged periods.
▪ Anaphylactoid reactions: Rare.
▪ Immunosuppression: Prolonged use may increase the incidence of secondary infection, mask
acute infection (including fungal infections), prolong or exacerbate viral infections, or limit
response to killed or inactivated vaccines. Exposure to chickenpox or measles should be
avoided.
Disease-related concerns:
▪ Head injury: high-dose corticosteroids should not be used for the management of head injury.
▪ Hepatic, renal impairment: fluid retention may occur.
▪ Myasthenia gravis
▪ Ocular disease (cataracts and/or glaucoma)
▪ Osteoporosis (if high doses and/or long-term use)
▪ Pheochromocytoma: has been reported with corticosteroids (may be fatal).
▪ Seizure disorders (reported with adrenal crisis).
▪ Corticosteroids should not be administered for the treatment of sepsis in the absence of
shock.
▪ Thyroid disease: (may necessitate dosage adjustments).
Preparation/administration -IV bolus: Administer undiluted over ≥30sec; for large doses (≥500 mg) administer over 10mins.
and stability/sensitivity -Intermittent infusion: Further dilute in NS or G5% and administer over 20-30 mins
- Avoid rapid infusions in patients with a history of cardiovascular disease (may cause
overload/pulmonary edema)
-Store below 25°C. Avoid freezing. Protect from heat
‫ للجرعات العالية ر‬، ‫ ثانية‬30 ‫أكت من‬ ً
‫يديا عىل مدار ر‬
‫ دقائق‬10 ‫مجم) يعىط عىل مدار‬500 ‫(أكت من‬ ‫ يتم حقنه ور‬-
‫ز‬
‫لمرض القلب‬ ‫ يجب تجنب الحقن الوريدي الشي ع‬-
ً
‫ يمنع تجميده ويحفظ بعيدا عن الحرارة العالية‬، ‫ مئوية‬25 ‫يحفظ زف درجة حرارة تحت‬-
Notes -Use in COVID-19 hospitalized patients when dexamethasone is not available or there are other
indications
Withdrawal: Taper dose of corticosteroids gradually when used for more than 14 days
45 | P a g e
Imipenem-cilastatin – 500mg vials (Tienam)
Mechanism of action Inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins (PBPs) thus inhibiting
cell wall biosynthesis. Cilastatin prevents renal metabolism of imipenem.
Indication and doses Bloodstream infection (G-ve bacteremia): IV: 500mg /6hrs for 7-14 days, administer over 3hrs
Acute pulmonary exacerbation of cystic fibrosis: IV: 0.5-1gm /6hrs for 10-14 days, administer over
3hrs
CAP (empiric – if at risk of MDR G-ve infection including P. aeruginosa): IV: 500mg /6hrs for ≥5
days, administer over 3hrs
HAP and VAP (empiric – if at risk of MDR G-ve infection including P. aeruginosa, Acinetobacter
sp.): IV: 500mg /6hrs for ≥7 days, administer over 3hrs
Sepsis and septic shock (in combination): IV: 500mg /6hrs or 1gm /8hrs
Dose adjustment Hepatic impairment: no dosage adjustments provided
Renal impairment:
CrCl Usual dose 500mg /6hr Usual dose 1gm /8hr Usual dose 1gm /6hr
≥30 to <60 500mg /8hrs 500mg /8hrs 500mg /6hrs
≥15 to <30 500mg /12hrs 500mg /12hrs 250mg /6hrs
<15 Avoid unless on hemodialysis within 48hr, dose: 500mg /12hrs
Important considerations CIs: Hypersensitivity, allergenic cross-reactivity may occur
AEs: CNS (carbapenems have been associated with CNS adverse effects, confusional states and
seizures - use caution with CNS disorders)
Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated
diarrhea (CDAD) and pseudomembranous colitis
Preparation/administration -Dilute 500mg in 100ml NS, and 1gm in 250ml NS
and stability/sensitivity -Do not administer as an IV push.
-Extended-infusion administration (preferred): Administer over 3 hours, and intermittent infusion:
500mg over 30mins
-If reconstituted, stable at room temperature for 4hrs and in the refrigerator for 24hrs
‫مل محلول ملح‬250 ‫مجم زف‬1000 ‫ والفيال‬، ‫مل محلول ملح‬100 ‫مجم زف‬500 ‫ يحل الفيال‬-
‫ يعىط عىل مدار نصف ساعة‬:‫ للحقن الوريدي المعتاد‬، ‫ ساعات‬3 ‫ يعىط عىل مدار‬:‫ للمحلول الوريدي الممتد‬-
Notes In pregnancy: not preferred for management of cystic fibrosis. Considered as an alternative.
Cost/vial: 90.3 LE
Monitoring parameters CBC, periodic renal function, hepatic function, signs of anaphylaxis during first dose
Insulin glargine – 100 IU/ml cartridges (Lantus SoloStar) ☀
Mechanism of action Insulin glargine is a long-acting insulin analog. Differs from human insulin by adding two arginines
to the C-terminus of the B-chain in addition to containing glycine at position A21 in comparison to
the asparagine found in human insulin
Indication and doses Type-2 Diabetes Mellitus and hyperglycemia in hospitalized patients: SQ:
Not on insulin glargine prior to hospitalization: 0.1-0.3 units/kg once daily or 50% of the total
calculated daily insulin requirement (TDI) given once daily. Do not exceed 20u /day for the initial
dose
Patients on insulin glargine prior to hospitalization: continue home dose. May consider 20-50%
dose reduction in select cases
*Refer to the hospital-based insulin protocol for more details
Dose adjustment Hepatic impairment: no dose adjustment is provided
Renal impairment: initially, use 0.3u/kg/day total daily insulin regimen (administer 50% of the
calculated dose as basal insulin). Monitor random glucose level closely
Obesity: higher initial doses maybe required
Important considerations CIs: hypersensitivity, use during unresolved DKA
AEs: hypoglycemia, weight gain, hypokalemia
DDIs:
+carvedilol, +propranolol (may mask hypoglycemia symptoms and diminish insulin effect –
monitor closely)
46 | P a g e
+glucocorticoids especially if high-dose (increased hyperglycemia risk – monitor BGL closely)
+quinolones (risk of hypoglycemia/hyperglycemia – monitor BGL closely)
Preparation/administration -Intended for subcutaneous use only
and stability/sensitivity -Use within 28 days after opening and store at room temperature below 25°C. Avoid freezing.
‫ مخصص للحقن تحت الجلد فقط‬-
ً
‫ يمنع تجميده‬،‫ درجة مئوية‬25 ‫ يوما بعد الفتح ويخزن زف درجة حرارة الغرفة تحت‬28 ‫يستخدم خالل‬-
Notes -basal-bolus regimen is recommended over a sliding-scale regimen
-Continue insulin glargine use in patients who are NPO
-Review the insulin regimen used in case of symptomatic hypoglycemia or documented BG
<70mg/dl. Refer to the hospital-based hypoglycemia management protocol for more details
-Ensure a suitable diet is being offered to the patient throughout hospitalization with insulin use
Cost/cartridge: 96.3 LE
Monitoring parameters Blood glucose level /4-6hrs, signs/symptoms of hypersensitivity, signs/symptoms of hyperglycemia
or hypoglycemia
Insulin NPH 100 IU/ml vials (Insulatard HM, insulinagypt N) ☀
Mechanism of action Intermediate-acting insulin - an isophane suspension of human insulin
Indication and doses Type-2 Diabetes Mellitus and hyperglycemia in hospitalized patients: SQ:
Not on insulin prior to hospitalization: 0.1-0.3 units/kg once daily or 50% of the total calculated
daily insulin requirement (TDI) given at /12hr interval
Patients on insulin prior to hospitalization: continue home dose. May consider 20-50% dose
reduction in select cases
*Refer to the hospital-based insulin protocol for more details
Renal impairment: initially, use 0.3u/kg/day total daily insulin regimen (administer 50% of the
calculated dose as basal insulin). Monitor random glucose level closely
Important considerations CIs: hypersensitivity, use during unresolved DKA
AEs: hypoglycemia, hyperglycemia, weight gain, hypokalemia
DDIs:
monitor closely)
Preparation/administration -Intended for subcutaneous use only. Given on a /12hr interval.
and stability/sensitivity and -Use within 28 days of opening (stored in refrigerator). Store at 2-8°C. Avoid freezing.
sensitivity/stability ‫ مخصص للحقن تحت الجلد فقط‬-
‫ يمنع تجميده‬،‫ درجة مئوية‬8-2 ‫ يحفظ زف درجة حرارة‬،‫ يوم من تاري خ الفتح‬28 ‫يستخدم خالل‬-
Notes -All diabetic patients should be switched to insulin therapy once admitted to the hospital. Avoid
oral hypoglycemic medications use.
-Critically-ill patients: targeted BGL 140-180mg/dl
-Continue insulin NPH use if patient is NPO
Monitoring parameters Blood glucose level /4-6hrs, signs/symptoms of hypersensitivity, signs/symptoms of hyperglycemia
or hypoglycemia
Insulin regular – 100 IU/ml vials (Insulinagypt R) ☀
Mechanism of action Short-acting insulin analog. Regulates metabolism of carbohydrate, protein and fats. Stimulates
cellular uptake of amino acids, and cellular permeability to potassium, magnesium and phosphate
Indication and doses Ca-channel blockers or beta blockers overdose (refractory to atropine, calcium or vasopressors):
IV: 1u/kg bolus then continuous infusion of 0.5-1u/kg/hr. Titrate to clinical response. Higher doses
up to 10u/kg + continuous infusions of >10u/kg/hr have been used. Once hemodynamically stable,
gradually decrease insulin infusion rate
Type-2 Diabetes Mellitus and hyperglycemia in hospitalized patients:
47 | P a g e
Part of basal-bolus regimen: SQ: calculate total daily insulin (0.3-0.5u/kg/day) and administer 50%
of the dose as insulin regular, split three-ways before meals +/- correctional doses
*Refer to hospital-based insulin protocol for more details
Sliding-scale insulin: SQ (not recommended for routine use to control hyperglycemia): refer to
hospital-based insulin schedule
IV (preferred over SQ route in the critically-ill patients): refer to the hospital-based IV insulin
protocol/algorithms
DKA or HHS IV (correct fluid deficit and/or K+ disturbance): Initial: 0.1u/kg IV bolus, followed by
0.1u/kg/hr via IV infusion, or 0.14 units/kg/hr via IV infusion (no bolus). Hold insulin use if K+
<3.3mEq/l. Refer to hospital-based DKA and HHS protocols for more details
Hyperkalemia: IV: 10u bolus (5u if high-risk for hypoglycemia) + 100ml G25% over 5mins (given
separately). May give subsequent 500ml G10% over 5hrs. Repeat /2-4hrs and monitor BG and K+
levels every hour throughout. Consider omitting glucose use if BG ≥250 mg/dl
Renal impairment: initially, use 0.3u/kg/day total daily insulin regimen. Monitor random glucose
level closely
AEs: hypoglycemia, hyperglycemia, weight gain, hypokalemia
DDIs:
monitor closely)
Preparation/administration -IV route: for the treatment of uncontrolled hyperglycemia, dilute 50 units in 50ml NS
and stability/sensitivity and --Use within 28 days of opening (stored in refrigerator). Store at 2-8°C. Avoid freezing. ً
sensitivity/stability ‫مل محلول ملح‬50 ‫ وحدة دولية زف‬50 ‫ يحل‬:‫لمرض السكر المرتفع‬ ‫يديا ز‬ ‫عند استخدامه ور‬-
‫ز‬
‫ يمنع تجميده‬،‫ درجة مئوية‬8-2 ‫ يحفظ ف درجة حرارة‬،‫ يوم من تاري خ الفتح‬28 ‫يستخدم خالل‬-
Notes -All diabetic patients should be switched to insulin therapy once admitted to the hospital. Avoid
oral hypoglycemic medications use.
-Critically-ill patients: targeted BGL 140-180mg/dl
-Omit insulin regular use if patient is NPO
Monitoring parameters Blood glucose level typically /4-6hrs, signs/symptoms of hypersensitivity, signs/symptoms of
hyperglycemia or hypoglycemia, serum K+ level
Ipratropium – 250mcg and 500mcg nebules (Atrovent) ☀
Mechanism of action Blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing
bronchodilation
Indication and doses Asthma, acute exacerbation, moderate to severe (combine with salbutamol): nebulized: 500mcg
every 20mins for 3 doses, then x 1hr as needed for up to 3hrs
COPD exacerbation: nebulized: 500mcg /6-8hrs. Can increase frequency to /2-4hrs as needed
AEs: Paradoxical bronchospasm, dizziness/blurred vision, increase intraocular pressure (caution
with a glaucoma patient), urinary retention (caution with BPH/urinary obstruction)
DDIs: +atropine, +chlorpheniramine, +haloperidol (high risk of anticholinergic effect – monitor)
Preparation/administration -Compatibility with other medications (e.g: salbutamol, budesonide) in nebulizer has been
and stability/sensitivity reported
-Store below 30°C. Protect from light in aluminum foil
‫ يعىط عن طريق االستنشاق فقط‬-
ً
‫ يحفظ ف التغليف الخاص به بعيدا عن الضوء‬،‫ مئوية‬30 ‫ يحفظ زف درجة حرارة تحت‬-
‫ز‬
Notes -In pregnancy: Systemic exposure following inhalation is negligible
48 | P a g e
Cost/Atrovent 500mcg :3.937065 LE
Cost/Atrovent 250mcg: 3.705785 LE
Monitoring parameters pulmonary function tests, signs/symptoms hypersensitivity reactions, urinary retention
Isoniazid – 300mg tablets
Mechanism of action Inhibits synthesis of mycoloic acids, an essential component of bacterial cell wall. Bactericidal
against actively growing intracellular and extracellular Mycobacterium tuberculosis organisms.
Indication and doses Tuberculosis: adults: 5mg/kg (typically 300 mg) once daily,
Or 15 mg/kg/dose (typically 900 mg) administered once weekly or twice weekly or thrice weekly
Infants, Children, and Adolescents <15yr: Weighing <40Kg: 10-20 mg/kg/dose (max 600 mg) once
Daily, or 5 days per week by directly observed therapy (DOT)
or 20 to 30 mg/kg/dose (max 900mg) three times weekly by DOT
Children and Adolescents <15yr weighing >40 kg or Adolescents ≥15yr: 5 mg/kg/dose (typically
300mg) once daily or 5 days per week by directly observed therapy (DOT)
*Refer to tuberculosis management protocol for further details.
Dose adjustment Hepatic impairment: no dose adjustment provided
Renal impairment: no dose adjustment provided.
If on HD: administer after HD session on dialysis days
Important considerations BLACK BOX WARNING: Hepatitis: Severe and sometimes fatal hepatitis associated with isoniazid
therapy has been reported and may occur or may develop even after many months of treatment.
Risk is age related.
CIs: Hypersensitivity, drug-induced hepatitis, acute liver disease, previous history of hepatic injury
during isoniazid therapy, previous severe adverse reaction (drug fever, chills, arthritis) to isoniazid
Disease-related: Hepatitis: Patients must report any prodromal symptoms of hepatitis (fatigue,
paresthesia of hands and feet, weakness, dark urine, rash, anorexia, nausea, fever >3 days’
duration, and/or abdominal pain, especially right upper quadrant discomfort, icterus, or vomiting).
Immediately hold therapy if any of these symptoms occur.
Preparation/administration -Do not administer with food (bioavailability is decreased).
and stability/sensitivity -Administer on an empty stomach (1hr before or 2hrs after meals with water)
-Avoid tyramine and/or histamine containing foods. Increase dietary intake of folate, niacin,
magnesium.
Notes -In pregnancy: recommended as part of treatment regimen of drug-susceptible active TB when
the probability of maternal disease is moderate to high. May have an increased risk of severe
maternal hepatotoxicity, can temporarily require drug withdrawal in pregnant/postpartum
patients. Treatment of Latent TB can be delayed until after delivery in some cases
-Concomitant pyridoxine is recommended in any patient at risk for neuropathy
Cost/tablet:0.23 LE
Monitoring parameters Baseline and periodic liver function tests (ALT and AST), sputum cultures monthly (until 2
consecutive negative cultures reported), monitoring for prodromal signs of hepatitis
Ivabradine – 5mg tablets (Angiobradine)
Mechanism of action Selective and specific inhibition of the (HCN) channels within the sinoatrial (SA) node of cardiac
tissue, prolonging diastolic depolarization, slowing firing in the SA node, and ultimately reducing
heart rate. Has not demonstrated effects on myocardial contractility, relaxation, ventricular
repolarization, or conduction apart from the sinus node effects.
Indication and doses Heart failure with reduced ejection fraction (HFrEF) – adjunctive (patients who are persistently
symptomatic despite an optimal medical regimen): Initial 2.5-5mg twice daily. Adjust dose every
≥2 weeks as needed. Adults ≥75yr: Initial 2.5mg twice daily.
Inappropriate sinus tachycardia: Initial 5mg twice daily. Maintenance 7.5 mg twice daily. May be
combined with a beta-blocker if refractory to monotherapy.
Stable angina: Adults <75yr: Initial 2.5-5 mg twice daily. ≥75yr: Initial 2.5 mg twice daily.
Titrate up in increments of 2.5 mg after 3-4 weeks if symptoms persist and heart rate is >60bpm.
Max dose: 7.5 mg twice daily. Discontinue if symptoms do not improve within 3months of
initiation
Dose adjustment Hepatic impairment: Child-Pugh class C - Use is contraindicated
49 | P a g e
Renal impairment:
CrCl ≥15: No dosage adjustment necessary.
CrCl <15: No dosage adjustments provided
Adjust dose based on resting heart rate:
If HR >60 bpm: Increase dose by 2.5 mg twice daily; (max: 7.5 mg twice daily).
If HR 50 to 60 bpm: Maintain dose.
If HR <50 bpm or signs and symptoms of bradycardia: Decrease dose by 2.5 mg twice daily; if
current dose is 2.5 mg twice daily, discontinue therapy.
Important considerations CIs: Acute decompensated heart failure, clinically significant hypotension, sick sinus syndrome,
sinoatrial block, or third-degree AV block (unless a functioning pacemaker is present), clinically
significant bradycardia, severe hepatic impairment, pacemaker dependence (heart rate
maintained exclusively by the pacemaker), hypersensitivity, resting heart rate <70 bpm prior to
treatment, prolonged QTc interval, cardiogenic shock, acute myocardial infarction, pregnancy,
breastfeeding, or women of child-bearing potential not using appropriate contraception.
Precautions:
-Use increases the risk of atrial fibrillation
-Bradycardia and conduction disturbances
-Visual function: Phosphenes (transient enhanced brightness in a limited area of the visual field,
halos) may occur with use. Onset is within the first 2 months of therapy. Mild to moderate
intensity. mostly resolves during/after treatment discontinuation.
AEs: Bradycardia (4% to 10%), hypertension (9%), atrial fibrillation (8%)
DDIs:
+phenytoin, rifampin: May decrease ivabradine serum concentration - avoid combination
+diltiazem, +fluconazole, +verapamil: May increase ivabradine serum concentration - avoid
combination
Preparation/administration Administer with food - absorption delayed by 1hr
Notes -HFrEF: consider use in stable, euvolemic patients who are in sinus rhythm with resting heart rate
≥70 bpm despite being on a target or maximally tolerated dose of beta blocker, or if there is a
contraindication to beta-blocker use.
-Consider an initial 2.5mg dose in patients with a history of conduction defects or who may
experience hemodynamic compromise due to bradycardia.
-Stable angina: consider if symptoms are not controlled on beta-blocker/CCB monotherapy (if
combined with a calcium channel blocker, use a dihydropyridine CCB)
Effective contraception is recommended in women of reproductive potential.
-In Pregnancy: fetal harm may occur if administered to pregnant women. If treatment is needed
during pregnancy, closely monitor for destabilization of heart failure that could potentially result
from heart rate slowing caused by ivabradine, especially during the first trimester. Pregnant
women with chronic heart failure should also be monitored for preterm birth.
Monitoring parameters Heart rate, blood pressure, cardiac rhythm (assessing for atrial fibrillation)
Ketoprofen – 100mg ampoules (Ketofan)
Mechanism of action Reversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in decreased
formation of prostaglandin precursors. Has antipyretic, analgesic, and anti-inflammatory
properties
Indication and doses Pain (acute, mild-moderate), fever: IM: 100mg, up to max daily dose of 300mg/day
Dose adjustment Hepatic impairment: use with caution
Hepatic impairment + serum albumin <3.5 g/dL: max 100mg/day
Discontinue if signs/symptoms of hepatic disease develop, or if systemic manifestations occur
50 | P a g e
Renal impairment: eGFR calculation
eGFR 30-59: Avoid in presence of a condition that increases risk of acute kidney injury (KDIGO
2012 NSAIDs guidelines)
eGFR <30: avoid use (KDIGO 2012 NSAIDs guidelines), or consider max 100mg/day dose
Older patients: use with caution – higher risk of adverse effects
Important considerations BLACK BOX WARNING: increased risk of serious cardiovascular thrombotic and serious
gastrointestinal (GI) adverse events
-Avoid in patients with bronchospasm, asthma, aspirin-sensitive asthma, rhinitis, or urticaria with
NSAIDs use
-Avoid in patients with active GI bleeding or history of acute lower GI bleeding
AEs: hypersensitivity reactions, hypertension, GI bleeding, increased tendency for bleeding,
injection-site reaction
DDIs:
+aspirin, +apixaban, +enoxaparin, +heparin (increased risk of bleeding – monitor closely)
+furosemide (increased risk of nephrotoxicity – monitor closely)
Preparation/administration IM injection
and stability/sensitivity ‫ مخصص للحقن العضىل فقط‬-
Notes -Not to be used routinely for the critically ill patients
-In pregnancy: Maternal use of NSAIDs should be avoided beginning at 20 weeks' gestation
Consider ultrasound monitoring of amniotic fluid if treatment extends beyond 48hrs. Use should
be completely avoided starting at 30 weeks' gestation (premature closure of the ductus arteriosus
Monitoring parameters CBC, renal function, weight, edema, BP, observe for bleeding, bruising or GI effects
Kidmin 7.2% IV solution ☀
Mechanism of action Total parenteral nutrition (TPN). Favorable effect on serum total protein, albumin and rapid-
turnover protein with smaller changes in serum aminograms and increase in blood urea nitrogen.
Indication and doses Chronic Renal Failure: peripheral IV: Usual adult dosage: 200ml per day. Central vein infusion:
Usual adult dosage: 400 ml per day
Acute Renal Failure: Usual adult dosage is 600 ml per day, infused via a central vein
Dose adjustment Can be adjusted according to the patient's condition, body weight and age.
Important considerations CIs: hepatic coma/risk of hepatic coma, hyperammonemia, inherited abnormal amino acid
metabolism, hypersensitivity
AEs: Gastrointestinal (nausea, vomiting), cardiovascular (chest discomfort, palpitations), hepatic
(increased LFTs, ammonia), renal (increased BUN, creatinine), acidosis (with large dose and rapid
administration), chills, fever, feeling of warmth, headache, vascular pain, lower extremity edema,
hyperkalemia or dry mouth.
Use with caution:
▪ In patients with cardiovascular dysfunction (increase in circulating blood volume)
▪ In patients with hepatic disorder or GI bleeding. (Excess accumulation of amino acids or
hyperammonemia).
▪ Patients with severe electrolyte imbalance or abnormal acid-base balance. (The patient's
clinical condition may be worsened).
Preparation/administration -The usual infusion rate in adults is 100 ml/hr and should be slowly infused in the elderly and
and stability/sensitivity seriously ill patients)
-When vascular pain occurs, use an alternate site/discontinue the administration.
-Use after warming to near body temperature. Discard all unused solution.
-A crystalline precipitate may form due to temperature changes during storage. Shake the solution
at temperature of 15-25°C to dissolve precipitate before use.
51 | P a g e
-Do not use if the indicator tablet’s color has changed.
-Store below 25°C, protect from light.
ً ‫ز‬
‫األكت سنا‬
‫للمرض ر‬ ‫ يمكن استخدام معدل أبطأ‬، ‫ساعة‬/‫مل‬100 ‫ يعىط بمعدل‬:‫ لالستخدام الوريدي‬-
‫ يرج إلذابة أي تكتالت أو ترسبات‬، ‫ يفحص المحلول قبل استخدامه لضمان سالمته لالستخدام‬-
‫تغت لون قرص األمان المرفق‬
‫ تجنب استخدام العبوة إذا ر‬-
ً
‫ درجة مئوية بعيدا عن الضوء‬25 ‫ يحفظ زف درجة حرارة أقل من‬-
Notes - This product should be used in patients who need parenteral nutrition because oral or enteral
nutrition is inadequate or not possible
-Administer >300kCal non-protein calories for every 100 mL of this product, for more efficient
amino acid's utilization
Cost/Kidmen 250ml: 55.44 LE
Cost/Kidmen 500ml: 80.85LE
Monitoring parameters ABG, electrolyte balance, ammonia level rise, s. albumin, urea, creatinine, assess nutritional status
(if oral intake can be established/increased), signs of hypersensitivity
Lactulose 67% syrup (Laxolac, duphalac)
Mechanism of action The bacterial degradation of lactulose resulting in an acidic pH, that inhibits the diffusion of NH3
into the blood by causing the conversion of NH3 to NH4+; also enhances the diffusion of NH3 from
the blood into the gut where conversion to NH4+ occurs; produces an osmotic effect in the colon
with distention promoting peristalsis; reduces blood ammonia concentration to reduce the degree
of portal systemic encephalopathy
Indication and doses Constipation: Oral: 15-30 ml (1-2 packets) daily. May increase to 60 ml daily if necessary
Hepatic encephalopathy: Prevention (for recurrent hepatic encephalopathy): Oral: 30-45 ml 2-4
times daily. May adjust dose every 1-2 days to achieve 2-3 soft stools/day
Treatment (monotherapy or combination): Oral: Initial: 30-45 ml every 1-2hrs to induce ~2 soft
stools/day, then reduce to 30-45ml 2-4 times daily. May adjust dose every 1-2 days to achieve 2-3
soft stools/day
Enema: 300ml lactulose + 700ml water. Retain for 30-60min. Repeat /4-8hrs based on response
Dose adjustment No Dose adjustment necessary
Important considerations CIs: Patients requiring a low galactose diet.
Precautions:
-Caution for electrolyte imbalance when lactulose is used >6months or in patients predisposed to
electrolyte abnormalities (e.g: elderly, debilitated patients)
AEs: flatulence, abdominal spasms, diarrhea
Preparation/administration Oral solution: May mix with fruit juice, water or milk.
Notes -In pregnancy: can be used when an osmotic laxative is needed.
-Not recommended for routine treatment of minimal hepatic encephalopathy
-Elevated serum ammonia is not required to make diagnosis, nor it is specific for hepatic
encephalopathy
Monitoring parameters BP, serum electrolytes, bowel movement frequency, fluid status, serum ammonia.
LevETIRAcetam – 500mg ampoules (Kepilepsy)
Mechanism of action Inhibition of voltage-dependent N-type calcium channels. Facilitation of GABA-ergic inhibitory
transmission through displacement of negative modulators. Reduction of delayed rectifier
potassium current. Binding to synaptic proteins which modulate neurotransmitter release.
Indication and doses Focal (partial) and generalized onset seizures: IV: Initial: 500mg twice daily; increase every 2wks
by 500mg/dose based on response/tolerability. Max 1.5gm twice daily. Use >4 days has not been
studied.
Note: Additional benefit of oral or IV doses >3 g/day has not been established.
52 | P a g e
Status epilepticus (combination with midazolam): IV: 1-3gm administered at a rate of 2-
5mg/kg/min or 40-60mg/kg over 5-15 mins. Max dose: 4.5gm
Subarachnoid hemorrhage (short-term seizure prophylaxis): IV: LD: 20mg/kg over 5-15mins
MD: 1gm over 15mins /12hrs for 7 days. Max dose 1.5gm /12hrs
Dose adjustment Hepatic impairment: no dose adjustment.
Renal impairment: IV: CrCl using the Cockcroft-Gault adjusted for BSA:
CrCl 50-79mL/min/1.73m2: 500 mg-1gm /12hrs
CrCl 30-49mL/min/1.73m2: 250-750mg /12hrs
CrCl 15-29mL/min/1.73m2: 250-500mg /12hrs
CrCl <15mL/min/1.73m2: 250-500mg /24hrs
Important considerations CIs: Hypersensitivity (e.g: anaphylaxis, angioedema)
AEs: CNS depression (Dose-related), hypersensitivity reactions (delayed, non-dose-related),
psychiatric/behavioral abnormalities, paranoid ideation, hallucinations, suicidal ideation have also
been reported, respiratory (nasopharyngitis)
DDIs:
+fentanyl, +nalbuphine, +haloperidol (limit dose/duration - monitor patient for excessive CNS
depression)
Preparation/administration -IV: dilute using 100ml LR, NS or G5% and administer over 15mins
and stability/sensitivity -Store below 30°C. Use immediately after dilution
‫ دقيقة‬15 ‫ أو رينجر ويعىط عىل مدار‬%5 ‫مل محلول ملح أو جلوكوز‬100 ‫ يحل الفيال زف‬-
‫التحضت‬
‫ر‬ ‫ يستخدم م ر‬، ‫ مئوية‬30 ‫ يحفظ زف درجة حرارة تحت‬-
‫باشة بعد‬
Notes -Discontinuation of therapy: In chronic therapy, withdraw gradually to minimize the potential of
increased/breakthrough seizure unless safety concerns require a more rapid withdrawal
-In pregnancy: seizure monotherapy with the lowest effective dose is recommended
IV to oral and oral to IV switch: use same dose/frequency (interchangeable)
Monitoring parameters Monitor CNS depression (impaired coordination, ataxia, weakness, fatigue, dizziness, and
somnolence), psychiatric/behavioral symptoms (aggression, agitation, etc), CBC, signs/symptoms
of hypersensitivity or rash
LevoFLOXacin (Levoflotanet☀, respiflox☀, lee-flox)
Mechanism of action Inhibits DNA gyrase in susceptible organisms
Indication and doses Acute exacerbated COPD (if indicated): Oral or IV: 500 mg /24hr for 5-7 days. Use 750mg if p.
aeruginosa is suspected
CAP: Oral or IV: 750mg once daily for 5 days
Hospital-acquired or ventilator-associated pneumonia: Oral or IV: 750mg once daily for 7-10 days
Bacteremia (part of empiric combination): 500-750mg once daily for 14 days
Dose adjustment Renal impairment (based on 750mg /24hr dose):
CrCl 20-50 → 750mg /48hr
CrCl <20 →750mg initial dose, then 500mg /48hr
Hemodialysis (3 times /week) → 750mg initial dose, then 500mg /48hr after HD session on dialysis
days
Important considerations BLACK BOX WARNING:
-Tendinitis/tendon rupture, peripheral neuropathy, CNS effects
-May exacerbate muscle weakness (myasthenia gravis)
CIs:
-hypersensitivity
-avoid if known, or history of aortic aneurysm
AEs:
-phototoxicity, drug-induced liver injury, Clostridioides difficile associated diarrhea, hyperglycemia
and hypoglycemia
53 | P a g e
-QTc prolongation (avoid use in case of uncorrected hypokalemia, hypomagnesemia)
DDIs:
+amiodarone (QTc-interval prolongation – avoid combination)
+ondansetron, +haloperidol, +fluconazole (may prolong QTc interval - monitor ECG)
Preparation/administration -Infuse 750mg IV solution over 90min
and stability/sensitivity -Infuse 500mg IV solution over 60min
-Usual diluents: D5W and NS
-Levofloxacin 500mg: Use without dilution
-Levofloxacin 750mg: After dilution, stable for 72hrs below 25°C
-Protect from light
‫مجم‬500 ‫ وجرعة‬، ‫ دقيقة‬90 ‫مجم عىل مدار‬750 ‫ تعىط جرعة‬، ‫ يحل باستخدام محلول ملح أو جلوكوز‬: ‫لالستخدام الوريدي‬-
‫ دقيقة‬60 ‫عىل مدار‬
‫ر ز‬
‫مجم دون تخفيف‬500 ‫ساسي‬ ‫يستخدم ليفوفلوك‬-
‫تحضته‬
‫ر‬ ‫بعد‬ ‫ساعة‬ 72 ‫خالل‬ ‫مجم‬ 750 ‫ز‬
‫فلوكساسي‬
‫ر‬ ‫ليفو‬ ‫يمكن استخدام‬-
ً
‫يحفظ بعيدا عن الضوء‬-
Notes -Prolonged use may cause fungal or bacterial superinfection
-In pregnancy: use only if benefits outweigh risks
Cost/750mg vial: 32.18292 LE
Cost/500mgvial: 14.109375 LE
Monitoring parameters Signs of hypersensitivity, CBC (WBC), random blood glucose, hepatic and renal function
Lidocaine – 2% (20mg/ml) ampoules ☀
Mechanism of action Class Ib antiarrhythmic. Suppresses automaticity of conduction tissue, by increasing electrical
stimulation threshold of ventricle, His-Purkinje system, and spontaneous depolarization of the
ventricles during diastole. Blocks both initiation and conduction of nerve impulses
Indication and doses Local/regional anesthesia: Cutaneous infiltration: Maximum: 4.5mg/kg/dose – max dose 300mg.
Do not repeat within 2hrs
Sudden cardiac arrest (VFib, Pulseless VTach) - unresponsive to CPR, or for hemodynamically
stable patients: IV: 1-1.5mg/kg. Repeat dose 0.5-0.75mg/kg every 5-10mins as necessary (typical
dose 50-100mg. Max cumulative dose 3mg/kg, or up to 300mg within 1hr)
Preventing recurrent arrhythmias (after return of spontaneous circulation): continuous IV
infusion: 1-4mg/min (60-240mg/hr). Reduce dose if continuous infusion is used beyond 24hrs
Use with caution. Administer lower continuous infusion rate. Monitor for signs of toxicity
Renal impairment:
Administer lower continuous infusion rate. Monitor for signs of toxicity
Important considerations CIs: Hypersensitivity, Adam-Stokes syndrome, Wolff-Parkinson-White syndrome, severe SA, AV or
intraventricular heart block (except in patients with a functioning artificial pacemaker),
supraventricular arrhythmias, severe myocardial depression
AEs:
-CNS (confusion, anxiety, lethargy, seizures, headache, shivers, radiculopathy)
-Respiratory (Bronchospasm, dyspnea, respiratory depression)
-CVS (Bradycardia, cardiac arrhythmia, circulatory shock, coronary artery vasospasm, edema,
flushing, heart block)
-Hypersensitivity, anaphylactic/anaphylactoid reactions
Precautions:
-Use with caution in heart failure patients, marked hypoxia, severe respiratory depression,
hypovolemia, history of malignant hyperthermia, or shock
-Increased ventricular rate may be seen when administered to patients with atrial fibrillation
-Correct electrolyte disturbances (especially hypokalemia or hypomagnesemia) prior to use and
throughout therapy
-Correct underlying causes of ventricular arrhythmias
-Monitor closely for signs/symptoms of CNS toxicity
DDI:
+amiodarone (may increase lidocaine serum conc – monitor for signs of lidocaine toxicity/serum
54 | P a g e
lidocaine conc)
+propranolol (may increase lidocaine serum conc – monitor for signs of lidocaine toxicity/serum
lidocaine conc)
Preparation/administration -IV bolus: 25-50mg/min into a peripheral vein
and stability/sensitivity -IV infusion: dilute 1 ampoule (100mg/5ml) in 50ml NS or D5W. administer via infusion pump
‫ دقائق‬4-2 ‫ يعىط األمبول عىل مدار‬:‫ للحقن الوريدي الشي ع‬-
‫ ويعىط باستخدام مضخة محاليل وريدية حسب‬%5 ‫مل محلول ملح أو جلوكوز‬50 ‫ أمبول زف‬1 ‫ يحل‬:‫للحقن الوريدي المستمر‬-
‫المعدل المحدد‬
ً
‫ مئوية بعيدا عن الضوء‬25 ‫تحفظ زف درجة حرارة تحت‬-
Notes -In pregnancy: Medications used for treatment of cardiac arrest in pregnancy are the same as in
the non-pregnant woman
-Breastfeeding: considered to be compatible with breastfeeding when used as an antiarrhythmic
or as a local anesthetic
-cost/amp: 5.625 LE
Monitoring parameters LFTs, lidocaine serum conc especially in patients on continuous infusion for >24hr, ECG )during IV
administration(
Serum conc reference ranges:
Therapeutic level: 1.5-5mcg/ml, Potentially toxic: >6 mcg/ml, Toxic: >9mcg/ml
Linezolid – 600mg tablets and IV solution ☀
Mechanism of action Inhibits bacterial protein synthesis by binding to bacterial 23S ribosomal RNA of the 50S subunit.
Bacteriostatic against enterococci and staphylococci. Bactericidal against most strains of
streptococci
Indication and doses Bloodstream infection (empiric MRSA coverage or culture-based): Oral/IV: 600mg /12hr.
Duration: MRSA: ≥14 days from day of first -ve blood culture
Duration: VRE: 7-14 days from day of first -ve blood culture (can be shorter in select cases)
Cystic fibrosis exacerbation (empiric/directed MRSA coverage): Oral/IV: 600mg /12hr for 10-14
days
Pneumonia (empiric MRSA coverage or culture-based): Oral/IV: 600mg /12hr typically for 7 days
Dose adjustment Hepatic impairment: Child-Pugh class C: increased risk of thrombocytopenia in patients with
cirrhosis. Monitor closely
Important considerations CIs: hypersensitivity, concurrent/within 2 weeks MAOIs use
Disease-related:
-superinfection (prolonged use)
-hyperthyroidism
-history of seizures (use with caution)
-lactic acidosis (reversible - low risk but can be fatal)
AEs: thrombocytopenia, anemia, peripheral neuropathy, hypertension, C. difficile infection,
serotonin syndrome
DDIs:
+dextromethorphan, +pholcodine cough syrup (avoid – risk of serotonin syndrome)
+dopamine (enhanced risk of hypertension – initiate dopamine at 1/10 dose + monitor)
+fentanyl (enhanced risk of serotonin syndrome – monitor for signs/symptoms)
DFIs: +tyramine or caffeine -rich food (avoid – can cause hypertensive crisis or serotonin
syndrome)
Preparation/administration Oral: without regard to meals
and stability/sensitivity IV: flush line before administration. Infuse over 30-120mins
- Store below 25°C
‫ر ز‬
‫ساعتي‬ ‫ يعىط المحلول عىل مدار نصف ساعة إىل‬:‫ لالستخدام الوريدي‬-
Notes -Duration for MRSA or VRE treatment can be even longer than the usual provided, in case of
infective endocarditis or in multiple sites/sources of infection
-Review risk factors warranting MRSA coverage in the hospital-based antibiotics policy before
prescribing linezolid
-Should not be used in the empiric treatment of catheter-related bloodstream infections but may
be appropriate for targeted therapy
55 | P a g e
Cost/IV infusion bottle: 42.32812 LE
Monitoring parameters CBC (plt count and Hb level), signs/symptoms of lactic acidosis, signs/symptoms of serotonin
syndrome or neuroleptic malignant syndrome
L-Ornithine L-Aspartate - 5gm/10ml ampoules (Lolawest, hepa-merz)
Mechanism of action Lowers plasma ammonia concentrations by enhancing the metabolism of ammonia to glutamine.
Ammonia is removed from the body by formation of urea in periportal hepatocytes and/or by
synthesis of glutamine from glutamate in perivenous hepatocytes
Indication and doses Portal systemic encephalopathy (adjunctive to/in place of lactulose): IV infusion: 20-30gm (4-5
ampoules) /day. Max dose 40gm/day
Cr >3mg/dl: Avoid use
Disease-related: May exacerbate asthma (products containing sulfite)
AEs: hypersensitivity, nausea, vomiting, flatulence, GI distress
Preparation/administration -Dilute 4 ampoules in 250ml or 6 ampoules in 500ml NS or G5% (diluent chosen can be product-
and stability/sensitivity specific) and administer as IV infusion. Max infusion rate 5gm/hr
-The prepared solution is stable for 24hrs
-Store ampoules below 30°C
‫مل محلول ملح أو‬500 ‫ أمبول زف‬6 ‫ أو‬، %5 ‫مل محلول ملح أو جلوكوز‬250 ‫ أمبول زف‬4 ‫ يحل‬:‫ للحقن الوريدي المستمر‬-
‫ساعة‬/‫جم‬5 ‫ (حسب التعليمات المرفقة) ويعىط بمعدل‬%5 ‫جلوكوز‬
‫تحضته‬
‫ر‬ ‫ ساعة بعد‬24 ‫حت‬ ‫ز‬
‫المحض ثابت ى‬ ‫ المحلول‬-
‫ز‬
‫ مئوية‬30 ‫تحفظ األمبوالت ف درجة حرارة تحت‬-
Notes -Does not appear to be effective for patients with hepatic encephalopathy in the setting of acute
liver failure
-In pregnancy: Assess benefits and risks before use
Monitoring parameters Serum ammonia, serum and urine urea levels (with higher doses), assess hepatic encephalopathy
signs/symptoms resolution, signs of hypersensitivity
Magnesium sulfate 500mg/5ml ampoules (Magnisol)
Mechanism of action IV infusion: Causes relaxation of bronchial smooth muscle independent of serum magnesium
concentration. Improves pulmonary function. Also use for correction of hypomagnesemia and
resistant hypokalemia
IV push/push bolus: Decreases acetylcholine in motor nerve terminals. Acts on myocardium by
slowing rate of S-A node impulse formation and prolonging conduction time. Necessary for the
movement of calcium, sodium, and potassium in and out of cells, as well as stabilizing excitable
membranes
Indication and doses 1 Magnisol ampoule = 500mg that converts into 4mEq elemental Mg2+
Asthma (severe acute exacerbations): IV: 2 gm as a single dose over 20 mins
COPD (severe acute exacerbation) – refractory to initial therapy: IV: 2 gm as a single dose over 20
mins
Hypomagnesemia (asymptomatic): start oral Mg2+ supplementation if tolerated. Subsequent
supplementation can be as follows. IV:
Serum Mg2+ level (mg/dl) Mg sulfate dose
1.6-1.9 1-2gm over 1-2hr
1-1.5 2-4gm over 2-12hr
<1 4-8gm over 4-24hr
Symptomatic hypomagnesemia (tetany, arrhythmias, seizures, torsades de pointes and
eclampsia/preeclampsia): IV: If hemodynamically unstable: 1-2gm over 2-15mins. If
hemodynamically stable: 1-2gm over 5-60mins. Continuous ECG monitoring is recommended.
Parenteral nutrition (nutrient and other metabolic requirements needed before use): IV daily
requirement: Elemental magnesium 8-20mEq (2-5 ampoules). Adjust based on serum level +
clinical considerations
Hypomagnesemia: Reduce dose by 50%. Monitor serum Mg2+
56 | P a g e
Important considerations CIs: hypersensitivity, heart block, myocardial damage
Disease-related:
-Myasthenia gravis (use with caution)
AEs: IV use: Flushing (dose related), hypotension (rate related), vasodilation (rate related),
hypermagnesemia
DDIs:
+ aminoglycosides (monitor for -ve respiratory effect in case of elevated s. Mg+2)
+amlodipine (monitor for hypotension or muscle weakness)
Preparation/administration -IV push/push-bolus: Dilute in 25ml NS.
and stability/sensitivity IV infusion: Dilute every 1gm in 50ml NS and administer over at least 30mins
‫ مل محلول ملح‬25 ‫ يحل األمبول زف‬:‫ لالستخدام الوريدي‬-
‫مل محلول ملح ويعىط عىل مدار نصف ساعة عىل األقل‬50 ‫ أمبول زف‬2 ‫ يحل‬:‫ للمحلول الوريدي المستمر‬-
Notes -Not recommended for routine use for COPD exacerbation management
-Unlikely to effectively terminate irregular/polymorphic VT (with normal baseline QT interval)
-Hypomagnesemia associated with hypokalemia. Correct in order to normalize potassium.
Monitoring parameters Rapid administration: ECG, vital signs, deep tendon reflexes
IV infusion: serum Mg2+, Ca2+, K+ levels, renal function
Mannitol – 10% and 20% IV solution
Mechanism of action Thought to be reducing ICP by reducing blood viscosity, which transiently increases cerebral blood
flow and oxygen transport and constricts pial arterioles and reduces cerebral blood volume and
ICP. withdraws water from brain parenchyma and excretes water in the urine
Indication and doses Intracranial pressure reduction (ICP) - mainly for ICH and cerebral edema: IV: 0.5-2gm/kg once.
May repeat 0.25-1 g/kg /dose every 4-6hrs based on response and clinical status
Use caution in patients with underlying kidney disease. Contraindicated in severe impairment
Geriatric population: Consider initiation at lower end of dosing range
Important considerations CIs: hypersensitivity, severe hypovolemia, active intracranial bleeding, preexisting severe
pulmonary vascular congestion/pulmonary edema, anuria
Disease-related:
-May initially worsen pulmonary edema or heart failure – avoid large volumes of mannitol
-May accumulate in brain (rebound increase intracranial pressure) – give as intermittent boluses
-CNS toxicity (coma, confusion, lethargy) may occur. Risk increased in patients with impaired
kidney function/ concomitant neurotoxic drugs. Discontinue if CNS toxicity develops
-Nephrotoxicity (especially with high doses) – use caution if taking other nephrotoxic agents,
sepsis or preexisting kidney disease
AEs: hypersensitivity, worsening or new-onset cardiac/pulmonary congestion, fluid/electrolyte
imbalances, profound diuresis, nephrotoxicity (discontinue if AKI develops)
DDIs:
+aminoglycosides (avoid combination – nephrotoxic)
Preparation/administration -Administer over 10-30mins
and stability/sensitivity -Avoid extravasation (may cause compartment syndrome). Administration into a large central vein
-If crystals are present, redissolve by warming solution.
-Store below 30°C
‫عت قسطرة وريدية مركزية‬
‫ دقيقة ر‬30-10 ‫ تعىط الجرعة عىل مدار‬-
‫ يتم وضع المحلول زف حمام ماء ز ئ‬-
‫داف إلذابة أي ترسبات قبل االستخدام‬
‫ مئوية‬30 ‫يحفظ زف درجة حرارة تحت‬-
Notes -Correct electrolyte disturbances and adjust dose to avoid dehydration
-Do not administer simultaneously with blood due to the possibility of pseudo-agglutination or
hemolysis
-Extravasation management: Stop infusion immediately and disconnect IV set. Gently aspirate
extravasated solution (do NOT flush the line). Apply dry cold compresses and elevate extremity
Monitoring parameters -Renal, cardiac and pulmonary functions, urine output, intravascular volume status, electrolytes,
serum osmolality, ABG, serum glucose, intracranial pressure, monitor infusion site and for
signs/symptoms of hypersensitivity
57 | P a g e
-Osmolar gap (surrogate marker for mannitol accumulation) to evaluate for the risk of acute
kidney injury
Meropenem – 0.5gm and 1gm vials (mirage, merostarkyl)
Mechanism of action Inhibits bacterial cell wall synthesis by binding to several of the penicillin-binding proteins, which
in turn inhibit the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus
inhibiting cell wall biosynthesis – a carpabenem
Indication and doses Cystic fibrosis, acute pulmonary exacerbation (G-ve bacilli or p. aeruginosa): IV: 2gm /8hr over
3hrs for 10-14 days
Health-associated bacterial meningitis (empiric or culture-based): IV: 2gm /8hr over 3hrs for 7-
21days, min 14 days for G-ve bacilli
CAP (empiric if high-risk of MDR G-ve): IV: 1gm /8hr for minimum 5 days (longer duration in select
cases – refer to hospital-based antibiotics policy for details)
HAP or VAP (empiric if high-risk of MDR G-ve or culture-based): IV: 1gm /8hr over 3hrs for 7 days
Sepsis and septic shock (broad-spectrum combination empiric therapy): IV: 1-2gm /8hr. Duration
based on source of infection. Discontinuation once non-infectious etiology is identified
Renal impairment: Use Cockcroft-Gault equation with adjusted body weight
CrCl (ml/min) Usual dose 1gm /8hr Usual dose 2gm /8hr
>25 to ≤50 1gm /12hrs 2gm /12hrs
10 to ≤25 500mg /12hrs 1gm /12hrs
<10 500mg /24hrs 1gm /24hrs
Intermittent dialysis (3/week)* 500mg /24hrs 1 g /24hrs
*Administer after hemodialysis session on dialysis days
Important considerations CIs: hypersensitivity, previous anaphylaxis with beta-lactams use
Disease-related:
-superinfection (prolonged use)
-CNS toxicity (possible seizures, but lower risk than imipenem-cilastatin)
-In patients with renal dysfunction, thrombocytopenia has been observed
AEs: hypersensitivity, C. difficile infection, nephrotoxicity
Preparation/administration -Reconstitute using WFI, and further dilute with 100ml NS for prolonged IV infusion
and stability/sensitivity ‫مل محلول ملح زف حالة الحقن الوريدي الممتد‬100 ‫ ثم يحل زف‬، ‫ يحل باستخدام ماء مذيب‬-
Notes -Recommending 2gm /8hrs prolonged infusion over 3hrs for treatment of infections caused by
certain resistant organisms (carbapenem-resistant Acinetobacter baumannii, carbapenem-
resistant Enterobacterales)
-In pregnancy: no sufficient data available. No teratogenic effects were observed in animals
Cost/1gm vial: 61.23464 LE
Monitoring parameters CBC, renal function, hepatic function, signs/symptoms of anaphylaxis with first dose, cultures and
sensitivities before initiation
Methylprednisolone – 500mg and 1gm vials (Solu-medrol)
Mechanism of action Intermediate-acting glucocorticoid (duration 12-36hrs) with half mineralocorticoid activity of that
of hydrocortisone. It decreases inflammation by suppression of neutrophil migration, decreased
production of inflammatory mediators, and reversal of increased capillary permeability
Indication and doses ARDS (moderate-severe): IV (succinate): LD: 1mg/kg over 30mins, followed by a gradual taper
(divided doses): Days 1 to 14: 1mg/kg/day. Days 15 to 21: 0.5 mg/kg/day. Days 22 to 25: 0.25
mg/kg/day. Days 26 to 28: 0.125 mg/kg/day
Asthma exacerbation (moderate-severe, not responding to SABA): IV: 40-60mg divided into 1-2
doses for 5-7days. If critically-ill: IV: 60-80mg /6-12hrs for 5-7 days (longer duration considered if
symptoms do not resolve)
COPD exacerbation: IV: 40-60mg divided into 1-2 doses for 5-14 days. If critically-ill: IV: may use
60mg /6hrs. If patient improves with therapy, may discontinue without taper. May use longer
duration if no improvement
COVID-19 (hospitalized and requiring oxygen therapy): IV: 32 mg /24hr or 16mg /12hr for up to 10
days (or until discharge, if sooner)
58 | P a g e
Pneumocystis pneumonia (adjunctive in moderate-severe disease - if PaO2 <70 mm Hg on room air
or PAO2-PaO2 ≥35 mm Hg on room air): IV: 30mg /12hr on days 1-5 begin as early as possible, then
30mg /12hr on days 6-10, then 15mg /24hr on days 11-21
Acute severe sarcoidosis (rapidly progressive disease/extrapulmonary symptoms): IV: 0.5-
1gm/day for 3-5days then continue with prednisolone
Dose adjustment Obesity: Use ideal body weight to avoid overdosing
Important considerations CIs: hypersensitivity, systemic fungal infections
Disease-related precautions and AEs:
-Use with caution in patients with HF, fluid retention, electrolyte disturbances, hypertension,
following acute MI
diverticulitis, abscess, etc)
-Endocrine & metabolic: Adrenocortical insufficiency, Cushing syndrome, decreased serum K+,
drug-induced Cushing’s syndrome, glycosuria
impairment
-Myopathy (high dose corticosteroids): monitor CK; recovery may be delayed
DDIs:
+phenytoin (assess efficacy of both medications, decrease in phenytoin levels reported more
frequently)
Preparation/administration -Dilute 1gm vial in 20ml NS and 500mg vial in 10ml NS and administer over 5mins
and stability/sensitivity -Pulse steroid: Dilute 500mg or 1gm vials in 250ml NS and administer over 30-60mins
-IV administration: use succinate form only
-Rapid administration (faster than 30mins) of doses >250mg may cause hypotension, cardiac
arrhythmia and sudden death
-Avoid scheduling steroid doses late at night, if possible, particularly higher doses (associated with
increased risk of insomnia, nightmares, neuropsychiatric adverse effects)
-Store below 25°C. Protect from light and humidity. Use immediately after dilution
‫ تعىط الجرعة‬، ‫مل محلول ملح قبل االستخدام‬10 ‫مجم زف‬500 ‫ والفيال‬، ‫مل محلول ملح‬20 ‫جم زف‬1 ‫ يتم حل الفيال‬-
‫ دقائق‬5 ‫المحددة عىل مدار‬
‫ دقيقة‬60-30 ‫مل محلول ملح ويعىط عىل مدار‬250 ‫ يتم حل الفيال زف‬:‫مجم‬1000-500 ‫ للجرعات‬-
ً
‫التحضت‬
‫ر‬ ‫ تستخدم ر‬، ‫بعيدا عن الشمس والرطوبة‬
‫مباشة بعد‬ ‫ مئوية‬25 ‫تحفظ زف درجة حرارة تحت‬-
Notes -Use IV steroids in patients who cannot tolerate oral therapy (e.g: shock, mechanically ventilated)
-Withdrawal: Taper dose of corticosteroids gradually when used for more than 14 days
Cost/1gm vial: 163.71 LE
Metoclopramide – 10mg/2ml ampoules (Meclopram)
Mechanism of action Prokinetic - blocks dopamine receptors, also blocks serotonin receptors in chemoreceptor trigger
zone of the CNS. Enhances response to acetylcholine of tissue in upper GI tract causing enhanced
motility and accelerated gastric emptying. Increases lower esophageal sphincter tone
Indication and doses Gastroparesis: IV: 5-10mg /8-12hr (titrate to lowest effective dose)
Dose adjustment Hepatic impairment: can be used safely with advanced hepatic impairment but normal renal
function
Renal impairment:
CrCl 11-60: Administer ~50% of usual total daily dose
CrCl ≤10 or on intermittent dialysis: Administer ~33% (or less) of usual total daily dose
Geriatric population: May require only 5 mg/dose. Use lowest effective dose
can cause tardive dyskinesia, a serious movement disorder that is often irreversible. Risk increases
59 | P a g e
with duration of treatment and total cumulative dose (long-term use)
CIs: hypersensitivity, Mechanical GI obstruction/peroration/hemorrhage, pheochromocytoma,
seizure disorder, history of tardive dyskinesia, dystonia to metoclopramide, concurrent
medications that can cause extrapyramidal symptoms (EPS)
-May elevate BP – hypertensive crises in patients with undiagnosed pheochromocytoma
-Use with caution in patients who are at risk of fluid overload (HF, cirrhosis)
-Symptoms of Parkinson disease may be exacerbated
Preparation/administration -IV: can be given IV push undiluted over 1-2mins
and stability/sensitivity -Rapid IV administration may be associated with a transient (but intense) feeling of anxiety and
restlessness, followed by drowsiness
‫ر ز‬
‫دقيقتي‬ ‫ يعىط األمبول عىل مدار دقيقة إىل‬:‫للحقن الوريدي‬-
Notes -In pregnancy: Extrapyramidal symptoms or methemoglobinemia may potentially occur in the
neonate. Drug-induced acute dystonic reactions have been reported following use of
metoclopramide in nonpregnant and pregnant patients. Considered for adjunctive treatment of
nausea and vomiting in pregnant patients when symptoms persist
Monitoring parameters Signs of tardive dyskinesias, extrapyramidal symptoms, signs/symptoms of neuroleptic malignant
syndrome, mental alertness
MetroNIDAZOLE – 500mg tablets and IV solution (Metroflag, flagyl, amrizole)
Mechanism of action Interacts with pathogen's DNA to cause a loss of helical DNA structure and strand breakage
resulting in inhibition of protein synthesis and cell death in susceptible organisms
Indication and doses Treatment of C. difficile infection: Oral/IV: 500mg /8hrs for 10-14 days
Fulminant C. difficile infection (ileus, megacolon and/or hypotension/shock): IV: 500mg /8hrs
combined with oral and/or rectal vancomycin for 10 days (may extend to 14 days)
Aspiration pneumonia (combined with beta-lactam): Oral/IV: 500mg /8hr for 7days

Child-Pugh class A or B: No dosage adjustment necessary. Use with caution. Monitor for adverse
events
Child-Pugh class C: Reduce dose by 50%
Renal impairment:
-Monitor closely for adverse effects due to accumulation of metabolites (CrCl <30)
-CrCl <10, non-Clostridioides difficile infections: 500mg /12hrs may be adequate to achieve
therapeutic plasma levels for mild-moderate infections
Intermittent hemodialysis: On dialysis days, administer after dialysis. If administration cannot be
separated from hemodialysis, consider supplemental dose following hemodialysis.
Important considerations Black box warning:
Carcinogenic in mice and rats. Unnecessary use of the drug should be avoided
CIs: hypersensitivity, propylene glycol-containing products during therapy or within 3 days of
therapy discontinuation (e.g: IV phenytoin), Cockayne syndrome, active neurological disorders;
history of blood dyscrasias, hypothyroidism, hypoadrenalism
-Use with caution in patients with a history of seizure disorder
-Use injection with caution in patients with HF, edema, or other sodium-retaining states, including
corticosteroid treatment (high sodium content)
-Associated with a range of CNS effects (peripheral neuropathy, aseptic meningitis, ataxia, neuro
cerebellar toxicity, confusion or disorientation, dysarthria, encephalopathy, seizures, optic
neuropathy and vertigo)
DDIs:
+propylene glycol-containing product (enhanced adverse/toxic effect of products containing
propylene glycol)
+warfarin (may cause INR elevation – Monitor INR/reduce warfarin dose)
Preparation/administration -Oral: Take with food to minimize stomach upset
and stability/sensitivity -IV: Infuse over 30-60 mins
-Use vial immediately after opening
60 | P a g e
‫ دقيقة‬60-30 ‫ يعىط عىل مدار‬:‫ للحقن الوريدي‬-
‫يستخدم الفيال ر‬-
Notes -C. difficile initial episode: use as alternative agent if oral vancomycin unavailable/contraindicated
-Criteria for disease severity is based on expert opinion and should not replace clinical judgment.
Non-severe C. difficile (WBC ≤15,000 cells/mm3 and Cr <1.5 mg/dL)
-In pregnancy: being carcinogenic in some animal species, concern has been raised if it should be
used during pregnancy. Use of other agents is preferred for treatment of C. difficile
Monitoring parameters CBC with differential at baseline (in prolonged/repeated courses of therapy), monitor elderly
patients, patients with severe hepatic impairment or ESRD for adverse reactions, neurologic
symptoms
Miconazole – 2% oral gel (Miconaz, micoban)
Mechanism of action Broad spectrum anti-fungal – Inhibits biosynthesis of ergosterol, damaging the fungal cell wall
membrane, which increases permeability causing leaking of nutrients
Indication and doses Oral candida treatment and prophylaxis: Oral gel: apply 4 times daily
Important considerations Generally, well tolerated. If local irritation/sensitivity reaction occurs, discontinue use
Cost/tube: 9.273695 LE
Preparation/administration Should be kept in mouth for as long as possible
Midazolam – 5mg/ml and 15mg/3ml ampoules (Medathetic)
Mechanism of action Short-acting benzodiazepine - binds to stereospecific benzodiazepine receptors on the
postsynaptic GABA neuron at several sites. Enhancement of inhibitory effect of GABA on neuronal
excitability results by increased neuronal membrane permeability to Cl- ions (hyperpolarization, a
less excitable state, and stabilization)
Indication and doses Sedation of mechanically-ventilated patients: IV: LD 0.5-5mg, continuous infusion MD: 1-8mg/hr
or 0.01-0.1mg/kg/hr. Titrate to clinical effect
Procedural sedation (outside the OR): IV: 0.5-2.5mg over ≥2mins. Repeat in 2-5 mins if needed.
Max total dose 5mg
Status epilepticus (convulsive and nonconvulsive): IM: 10 mg once
Refractory status epilepticus: LD: 0.2mg/kg slowly. Repeat LD every 3-5mins as needed (max total
dose: 2mg/kg). followed by Continuous infusion MD: 0.05-2mg/kg/hr, titrated to cessation of
electrographic seizures/burst suppression
Dose adjustment Hepatic impairment: Expect longer duration of action/accumulation with multiple dosing and
continuous infusion. Dose reduction likely to be necessary
Renal impairment: Use with caution
Half-life of midazolam + active metabolites are prolonged, especially in acutely-ill patients with
AKI. Consider additional boluses instead of higher basal continuous infusion rate
Obesity (BMI ≥30 kg/m2):
Use adjusted body weight for initial weight-based dosing calculations, then titrate to clinical
effect. May show prolonged effect after discontinuation
Geriatric population:
Consider reducing dose by 20-50% in elderly, chronically ill, or debilitated patients and those
receiving opioids/CNS depressants. Also, apply slower titration of doses
-Associated with profound sedation, respiratory depression, and respiratory arrest, especially
when used for sedation in non-critical care settings
-Concomitant use with opioids may result in profound sedation, respiratory depression, coma, and
death. Reserve treatment to when alternative options are inadequate. Limit dosages and
durations. Monitor for respiratory depression and sedation
-Risks of abuse, misuse, and addiction - can lead to overdose or death
CIs: Hypersensitivity
Disease-related concerns and AEs:
-Benzodiazepines have been associated with anterograde amnesia
61 | P a g e
-Cardiorespiratory effects (cardiac arrest, hypotension, permanent neurologic injury and death)
-CNS depression
-Paradoxical reactions, including hyperactive or aggressive behavior
-Severe fluid or electrolyte disturbances – use with caution
-Avoid rapid IV administration in heart failure patients
-Glaucoma - use with caution
-Tolerance develops to the sedative and antiseizure effects of midazolam
DDIs:
+fentanyl, +nalbuphine (enhanced CNS depression – monitor/limit dose duration)
Preparation/administration -Can be administered IV, IM or buccally according to indication
and stability/sensitivity -Administer undiluted by slow IV injection over at least 2mins (5mg/ml ampoules)
-IV infusion: typically diluted as 50mg in 50ml NS and administered via a syringe pump according
to a set-rate
-Store below 30°C
‫ر ز‬
‫دقيقتي عىل األقل‬ ‫مجم) دون حله عىل مدار‬5( ‫ يمكن اعطاء األمبول‬:‫للحقن الوريدي‬-
‫ز‬
‫مل محلول ملح ويعىط ر‬50 ‫مجم) ف‬5( ‫ أمبول‬10 ‫ يحل‬:‫للحقن الوريدي المستمر‬-
‫عت مضخة محاليل وريدية‬
‫ مئوية‬30 ‫يحفظ زف درجة حرارة تحت‬-
Notes -Does not have analgesic, antidepressant, or antipsychotic properties
-Used as part of multimodal strategy. Non-benzodiazepine sedation is preferred due to risk of
prolonged sedation and delirium with continuous benzodiazepine use >48hrs
-Titrate to a light level of sedation (e.g: Richmond Agitation Sedation Scale 0 to −2) or clinical
effect
-Does not protect against increases in intracranial pressure, HR and/or BP during intubation
-Status epilepticus: IM midazolam is the preferred benzodiazepine in patients without IV access.
Intranasal and buccal administration are effective alternatives in patients without IV access
Monitoring parameters Vital signs, level of sedation (assess/adjust dose in ventilated patients according to validated
scoring systems such as SAS, RASS)
Molnupiravir – 200mg tablets
Mechanism of action Metabolized to cytidine nucleoside analog (NHC), furtherly phosphorylated to active
ribonucleoside triphosphate (NHC-TP). NHC-TP is incorporated into SARS-CoV-2 RNA by viral RNA
polymerase, resulting in errors in viral genome and subsequently inhibition of replication
Indication and doses COVID-19 (outpatients, mild-moderate with high-risk of progression): Oral: 800mg /12hr for 5
days
Important considerations CIs: hypersensitivity, use in patients <18 years
AEs: Dermatologic (erythema of skin, skin rash, urticaria), hypersensitivity
Preparation/administration -If a dose is missed within 10hrs of usual time, administer missed dose as soon as possible and
and stability/sensitivity resume normal dosing schedule. Do not double the dose to make up for a missed dose
Notes -After initiating treatment, if hospitalization is required, completion of 5-day course is at the
health care provider's discretion
-In pregnancy: use of molnupiravir in pregnancy is not recommended unless no other options are
available, and therapy is clearly indicated
-Breastfeeding is not recommended by the manufacturer during therapy and for 4 days after the
last molnupiravir dose
Moxifloxacin – 400mg IV infusion ☀
Mechanism of action DNA gyrase inhibitor (bactericidal effect). Also inhibits topoisomerase-4. DNA gyrase
(topoisomerase-2) is an essential bacterial enzyme that maintains the super-helical structure of
DNA
Indication and doses COPD exacerbation: 400mg /24hr for 5-7 days
CAP: 400mg /24hr for min 5 days
*Refer to hospital-based antibiotics policy for further details
Use with caution (higher risk of QTc-interval prolongation)
Renal impairment:
62 | P a g e
No dosage adjustment necessary
-Tendinitis/tendon rupture, peripheral neuropathy, CNS effects
-May exacerbate muscle weakness (myasthenia gravis)
CIs: hypersensitivity, known/history of aortic aneurysm
-Use with caution in patients with significant bradycardia or acute myocardial ischemia
-QTc prolongation (avoid use in case of uncorrected hypokalemia, hypomagnesemia)
-Psychiatric reactions (agitiation, nervousness, delirium, insomnia, etc)
-Superinfection (prolonged use)
AEs: phototoxicity, drug-induced liver injury, Clostridioides difficile associated diarrhea,
hyperglycemia and hypoglycemia
DDIs:
+amiodarone (Qtc-interval prolongation – avoid combination)
+ondansetron, +haloperidol, +fluconazole (may prolong QTc interval - monitor ECG)
Preparation/administration -IV: Infuse over 60mins
and stability/sensitivity -Store below 30°C. Protect from light
-Use immediately after opening
‫ يعىط عىل مدار ساعة‬:‫للحقن الوريدي‬-
ً
‫يستخدم ر‬-
Notes -COPD exacerbation: may reserve for patients who have risk factors for poor outcomes but low
pseudomonas risk (e.g: ≥65yrs, FEV1 <50% predicted, frequent exacerbations, major
comorbidities)
-In pregnancy: use only if benefits outweigh risks
Cost/IV bottle: 45.15 LE
Monitoring parameters WBC, signs of infection, signs/symptoms of disordered glucose regulation, ECG in patients with
liver cirrhosis or Qt-c interval prolonging medications
Nalbuphine – 10mg/ml ampoules (Nalufin)
Mechanism of action Agonist of kappa opiate receptors and partial antagonist of mu opiate receptors in the CNS,
causing inhibition of ascending pain pathways, altering the perception of and response to pain,
produces generalized CNS depression
Indication and doses Pain management: IM, IV, SubQ: 10mg every 3-6hrs as needed (70kg patient). Max: 20mg/dose;
160mg/day. Titrate dose to appropriate effect.
Dose adjustment Hepatic impairment: None provided. Use lowest dose possible.
Renal impairment: None provided. Use lowest dose possible.
Life-threatening respiratory depression: Monitor for respiratory depression, especially during
initiation of nalbuphine or following a dose increase.
Risks from concomitant use with benzodiazepines/CNS depressants: Reserve for use in patients
for whom alternative treatment options are inadequate. Limit dosages/durations to minimum
required.
CIs: Avoid use in patients with pre-existing opioid dependence (mixed agonist-antagonist effect),
Disease-related precautions and AEs: patients with severe hypotension or hypovolemia (use with
caution), patients with elevated intracranial pressure (use with extreme caution)
DDIs:
+fentanyl: diminish fentanyl effect – avoid combination
+midazolam: enhanced CNS depression – limit combined dose/duration as much as possible
Preparation/administration -IM and subQ: administer undiluted
and stability/sensitivity -IV: Commonly diluted as 10mg in 10ml NS preparation and is stable for 48hrs
-Store below 25°C.
‫ يمكن استخدامه للحقن العضىل دون حله‬-
‫تحضته‬
‫ر‬ ‫من‬ ‫ساعة‬ 48 ‫خالل‬ ‫استخدامه‬ ‫مكن‬ ‫وي‬ ‫ملح‬ ‫محلول‬ ‫مل‬ 10 ‫مجم زف‬10 ‫ يحل أمبول‬:‫ للحقن الوريدي‬-
‫ مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬-
63 | P a g e
Notes -In pregnancy: The minimum effective dose should be used if opioids are needed
Monitoring parameters Monitor closely for respiratory depression (especially during initiation or dose escalation), BP,
mental status.
Neomycin + Bacitracin aerosolized powder (Bivatracin)
Mechanism of action Broad-spectrum topical antibacterial combination. Neomycin: Interferes with bacterial protein
synthesis by binding to 30S ribosomal subunits. Bacitracin: Inhibits bacterial cell wall synthesis by
preventing transfer of mucopeptides into the growing cell wall
Indication and doses Superinfection of bedsores, ulcers and wounds: Spray: apply onto the affected area several times
per day
Important considerations CIs: hypersensitivity, pre-existing nerve damage
-Systemic absorption may occur (if applied on large areas or >20% of body surface)
-Toxicity is rare, occurs only with prolonged use/large area application
-Use should be limited, up to 7 days
Preparation/administration Shake well before use. Apply from 20-25cm distance on areas affected
Notes -Assess bedsores severity before use. Address any modifiable causes
-Cost: 31.28895 LE
Monitoring parameters Progression of bedsores and ulceration, signs/symptoms of hypersensitivity
Norepinephrine – 4mg/4ml ampoules (Levophrine) ☀
Mechanism of action Affects alpha receptors (vasoconstriction) greater than beta receptors (inotropic and chronotropic
effects). Increases systemic BP and coronary blood flow
Indication and doses Cardiogenic shock: IV: dose range 0.003-0.024 mg/kg/hr. Titrate to target BP and end-organ
perfusion
Post-cardiac arrest, vasodilatory or septic shock states: IV: dose range 0.003-0.009mg/kg/hr. If
refractory: 0.06-0.2mg/kg/hr
Dose adjustment Obesity BMI ≥30 kg/m2: Use ideal body weight for initial calculations then titrate to target
hemodynamic parameters/clinical effect
Important considerations CIs: Hypotension from hypovolemia (except as an emergency measure to maintain
coronary/cerebral perfusion until volume could be replaced)
-Address hypovolemia before initiating therapy
-Use in patients with profound hypoxia or hypercarbia may produce ventricular
tachycardia/fibrillation
-Gradually reduce infusion rate while expanding blood volume with IV fluids to avoid hypotension
-Assure adequate circulatory volume to minimize need for vasopressors
-Extravasation may cause severe ischemic necrosis. Administer using a central line
-Formulation contains sodium metabisulfite – monitor asthma patients for bronchospasm
DDIs:
+linezolid (enhanced BP elevation – reduce initial NE rate)
Preparation/administration -Typically diluted as 4mg in 50ml or 8mg in 50ml G5% and administered using a syringe pump
and stability/sensitivity -Avoid infusion into leg veins. Monitor IV site closely
-If central line is not available, may administer for a short duration (<72hrs) through a peripheral
IV catheter placed in a large vein at a proximal site (in/proximal to antecubital fossa)
-Levophrine: store at 20-25°C. Protect from light. Avoid freezing.
‫ز‬
‫ ويعىط باستخدام مضخة محاليل وريدية ر‬، %5 ‫مل جلوكوز‬50 ‫مجم) ف‬8( ‫ أمبول‬2 ‫ يحل‬:‫ للحقن الوريدي المستمر‬-
‫عت‬
‫قسطرة وريدية مركزية‬
‫ ساعة‬72 ‫ يمكن حقنه زف األوردة الطرفية لمدة ال تتعدى‬-
ً
‫ يمنع تجميده‬، ‫ درجة مئوية بعيدا عن الضوء‬25-20 ‫ يخزن زف درجة حرارة‬:‫ليفوفرين‬-
Notes -Post-cardiac arrest shock: titrate to MAP >65mmHg, preferably systolic BP 80-100mmHg to
optimize cerebral and end-organ perfusion
-Septic shock: maintain goal MAP ~65mmHg. Consider use if patient is in shock or has
hypoperfusion during/after fluid resuscitation
-Extravasation: infiltrate the area with diluted phentolamine or nitroglycerin ointment (apply a 1-
64 | P a g e
inch strip to site of ischemia, may repeat /8hrs as necessary)
Monitoring parameters BP (or MAP), HR, cardiac output (as appropriate), intravascular volume status, pulmonary capillary
wedge pressure (as appropriate), urine output, peripheral perfusion, infusion site
Ondansetron – 4mg ampoules (Danset, emerest) ☀

Mechanism of action Serotonin 5-HT3 receptor antagonists. Blocks the action of serotonin that may cause nausea and
vomiting.
Indication and doses Nausea and/or vomiting, acute, severe: IV, IM: 4-8mg as a single dose. May repeat /4-8hrs as
needed.
Dose adjustment Hepatic Impairment:
Severe impairment (Child-Pugh class C): IV Max daily dose 8 mg
Renal impairment: No dose adjustments necessary
Precautions and AEs:
-Immediate hypersensitivity reactions may occur
-Increases in ECG intervals (eg, PR, QRS duration, JT); prolonged QT interval on ECG; and
bradycardia have been observed.
-Serotonin syndrome, predominantly when used in combination with other serotonergic agents
DDIs:
+amiodarone (enhanced QTc-prolonging effect risk. Consider alternatives. Monitor ECG closely if
necessary)
+linezolid (Serotonin syndrome: Serotonin syndrome (SS) , predominantly when used in
combination with other serotonergic agents .
Preparation/administration -IM given undiluted.
and stability/sensitivity and -IV bolus undiluted over 2-5mins, or infusion: diluted in 50ml NS or G5% given over 15mins
sensitivity/stability -Protect from light. Store below 25°C
‫ للحقن العضىل‬-
‫ز‬ :
‫ دقيقة‬15 ‫ عىل مدار‬%5 ‫مل محلول ملح أو جلوكوز‬50 ‫ أو بعد حله ف‬، ‫ دقيقة‬5-2 ‫ للحقن الوريدي يعىط دول حله عىل مدار‬-
ً
Notes -IV administration is preferred over IM when possible
-In pregnancy: the risk of developing a major congenital malformation following first trimester
exposure is under study. Considered for the treatment of severe/refractory nausea and vomiting
of pregnancy when preferred agents have failed.
Cost/4mg ampoule: 4.158 LE
Monitoring parameters Monitor ECG, serum K+, Mg2+, signs/symptoms of serotonin syndrome and decreased bowel
activity.
Oseltamivir – 75mg capsules and 12mg/ml oral suspension (Tamiflu)
Mechanism of action Reversible competitive inhibitor of influenza neuraminidase. Virion release from infected cells and
spread with the respiratory tract are inhibited due to blockade of this enzyme.
Indication and doses Influenza (seasonal) treatment: Oral: 75 mg twice daily for 5 days; a longer duration can be
considered in severely ill/immunocompromised patients
Dose adjustment Hepatic impairment: Use with caution in severe hepatic impairment
Renal impairment:
CrCl 30-60: 75 mg × 1 dose, then 30mg twice daily
CrCl 10-30: 30mg once daily
CrCl <10: 30mg /48hr
Hemodialysis, intermittent (thrice weekly): 30mg immediately then 30mg after every hemodialysis
session for at least 5 days.
AEs: Nausea, vomiting, headache, general body pain
65 | P a g e
Preparation/administration -Administered without regard to meals. Take with food to improve tolerance
and stability/sensitivity -Ventilated patients: via naso- or orogastric tube. Dissolve powder from capsules in 20ml of sterile
water and inject down the NG/OG tube. Follow with 10ml sterile water flush.
-Taminil-N syrup: Store below 25°C. Use within 17 days after opening.
‫ مل من الماء‬10 ‫ يعىط‬، ‫مل ماء معقم قبل استخدامه‬20 ‫ يتم حل محتوى الكبسولة زف‬:‫عت األنبوبة المعدية‬
‫لالستخدام ر‬-
‫المعقم بعد ذلك لتنظيف األنبوبة‬
ً
‫ يوما من الفتح‬17 ‫ يستخدم خالل‬،‫ مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬:‫تامينيل رشاب‬-
Notes -In pregnancy: maternal use has not been shown to increase the risk of adverse pregnancy
outcomes
-In patients with severe, complicated, or progressive illness; hospitalized patients; or those at
increased risk for complications, initiate treatment as soon as possible even if >48hrs have elapsed
since illness onset. Do not delay for laboratory confirmation
-Oseltamivir is not a substitute for the influenza virus vaccine
Cost/oral susp. bottle: 173.25 LE
Monitoring parameters Signs/symptoms of unusual behavior (attempts at self-injury, confusion, and/or delirium)
Pan-Amin G IV infusion ☀
Mechanism of action Promote protein synthesis, wound healing, and reduce the rate of endogenous protein
catabolism. Part of parenteral nutrition.
Indication and doses Parenteral nutrition (in moderate catabolic states, requiring nitrogen-saving): IV: 500ml over 50-
100mins (80-130 drops/min) /24hr
Dose adjustment Hepatic impairment: aminoleban is more suitable for use
Renal impairment: no dose adjustment provided. Use with caution. Monitor for elevated urea
Important considerations Disease-related concerns:
-Should not be administered to patients with severe hepatic disorder - resulting in induction of
hepatic coma
AEs: Hypersensitivity, extravasation, hepatobiliary effects, hyper-azotemia
Preparation/administration - Administer IV. Infusion rate should be slow in the elderly and severely ill patients
and stability/sensitivity - Store below 25°C. Protect from light
-Avoid use if the indicator tablet’s color has changed
‫ر ز‬
‫ساعتي عىل األقل‬ ‫ يعىط ببطء عىل مدار ساعة إىل‬:‫لالستخدام الوريدي‬-
ً
‫ مئوية بعيدا عن الضوء‬25 ‫ يحفظ زف درجة حرارة تحت‬-
‫غت لون قرص األمان المرفق‬
‫ تجنب استخدام العبوة إذا ت ر‬-
Notes -Transition into oral protein intake once patient tolerates oral/enteral feeding
Cost: 40.95 LE
Monitoring parameters Sign/symptoms of hypersensitivity, LFTs, serum urea
Pantoprazole – 40mg vials
Mechanism of action Proton pump inhibitor - suppresses gastric acid secretion by inhibition of the H+/K+-ATPase in the
gastric parietal cell
Indication and doses Acute upper GI bleeding: IV: 80mg bolus, followed by 8 mg/hour for 3-5 days
Stress ulcer prophylaxis (high-risk patients): IV: 40mg /24hr until risk factors are no longer present
-Immediate hypersensitivity reactions secondary to PPIs range from urticaria to rare cases of
anaphylaxis
-May increase risk of C. difficile infections, gastroenteritis and diarrhea particularly in hospitalized
patients
-May cause dermatologic reactions (DRESS, TEN, SJS, etc)
-May cause hypomagnesemia (prolonged use >3months)
Preparation/administration -Flush IV line before and after administration with NS or G5%
and stability/sensitivity -Bolus IV: Reconstitute with WFI and further dilute with 100ml NS. Infuse over 15mins at rate
66 | P a g e
7ml/min
-Continuous infusion: dilute 80mg in 50ml NS. Administer using a syringe pump. Rate 5ml/hr
‫ساعة‬/‫مل‬5 ‫مل محلول ملح ويعىط بمعدل‬50 ‫ فيال زف‬2 ‫ يحل‬:‫ للمحلول الوريدي المستمر‬-
ً
‫ يتم حقن محلول ملح أو جلوكوز وريديا قبل وبعد االستخدام‬-
‫ دقيقة‬15 ‫ يعىط عىل مدار‬:‫ للجرعات الوريدية‬-
Notes High-risk conditions requiring SUP include:
▪ Bleeding diathesis (plt <50, INR >1.5 or PTT >2times control value)
▪ Mechanical ventilation for >48hrs especially if not enterally fed
▪ Chronic liver disease
▪ History of GI ulcer/GI bleed within 1yr
▪ Traumatic brain injury, traumatic spinal cord injury, or burn injury
▪ >2 of: sepsis, ICU stay >1week, occult GI bleed >5 days, or glucocorticoid use (>250mg
hydrocortisone or equivalent)
▪ On NSAIDs or antiplatelet
-For stress ulcer prophylaxis, consider using oral formulations (H2-blocker or oral PPO) if patient
tolerates oral feeding – no additional benefit of using IV form
Monitoring parameters Monitor for rebleeding in patients with upper GI bleeding, Mg2+ (baseline and periodically
especially if taking digoxin, diuretics, other drugs known to cause hypomagnesemia), Ca2+
(baseline and periodically in patients at risk [e.g: hypoparathyroidism]), Clostridioides difficile-
associated diarrhea (CDAD)
Paracetamol – 500mg tablets and 1gm IV bottles (Paramol, medalgesic, injectmol)
Mechanism of action Analgesic effect: activation of descending serotonergic inhibitory pathways in the CNS.
Interactions with other nociceptive systems may be involved
Anti-pyretic effect: inhibition of the hypothalamic heat-regulating center
Indication and doses Pain (mild-moderate, monotherapy or adjunctive), fever: IV/Oral: 1gm /6hrs. Max single dose:
1gm. Max daily dose: 4gm/day.
Dose adjustment Hepatic impairment: Use with caution. Max ≤2-3 gm/day) is usually well tolerated in patients with
chronic liver disease or cirrhosis. Assess for presence of other factors/use of medications that
increase the risk of paracetamol-induced hepatoxicity
Renal impairment: No dose adjustment necessary
Weight-based (patients <50kg): 15mg/kg every 6hrs; max daily dose: 75mg/kg/day
Important considerations CIs: Hypersensitivity, severe hepatic impairment.
Disease-related precautions: known G6PD deficiency (use with caution), hypovolemia (IV
formulation - use with caution with severe hypovolemia)
DDIs:
+isoniazid (monitor for signs of hepatoxicity)
+rifampin (monitor for signs of hepatoxicity and decreased paracetamol effect)
+warfarin (enhanced anticoagulant effect of Vit K antagonists, monitor INR, signs of bleeding)
Preparation/administration IV: Administer undiluted over 15mins
and stability/sensitivity -Store vials below 30°C. Use immediately after opening
‫ دقيقة‬15 ‫ يعىط عىل مدار‬:‫ لالستخدام الوريدي‬-
‫ تستخدم مباشة بعد الفتح‬، ‫ مئوية‬30 ‫ تحفظ الفياالت زف درجة حرارة تحت‬-
‫ر‬
Notes -In pregnancy: possible association between prenatal constriction of the ductus arteriosus
following maternal use during the third trimester has been investigated. An increased risk is not
likely associated with short-term use of acetaminophen at recommended doses based on data
Monitoring parameters liver enzymes (patients with prolonged use/reduced hepatic function), relief of pain/fever
67 | P a g e
Phenytoin – 250mg/5ml ampoules (Epilog, phenytin) ☀
Mechanism of action Stabilizes neuronal membranes, decreases seizure activity by increasing efflux or decreasing influx
of Na+ ions across cell membranes in the motor cortex during generation of nerve impulses.
Prolongs refractory period and suppresses ventricular pacemaker automaticity, shortens action
potential in the heart
Indication and doses Seizure prevention (select patients at elevated risk with concerns for secondary complications): IV:
LD: 17-20mg/kg (max dose 2gm) given at max rate 50mg/min, and MD: 100mg /8hr oral or IV
given 8-12hrs after loading dose. Duration varies but generally 7 days
Focal (partial) onset or generalized onset seizures: IV/Oral: for phenytoin-naïve patients, LD:
15mg/kg (total dose 1-1.5gm) and MD: 4-7mg/kg/day given /8hrs given 8-12hrs after LD (total
maintenance dose 300-400mg)
Status epilepticus (with or directly after IV midazolam): LD (phenytoin naive): IV: 20 mg/kg at rate
of 25-50mg/min with continuous cardiac and blood pressure monitoring. Decrease rate if adverse
effects occur. Additional 5-10mg/kg dose can be given if necessary (total max dose 30mg/kg). LD:
IV: 4-7mg/kg/day given /8hrs given 8-12hrs after LD (total maintenance dose 300-400mg)
Dose adjustment Hepatic impairment: Decreased metabolism/clearance. Monitor serum phenytoin level closely.
Discontinue use if hepatoxicity occurs
Renal impairment: Free (not total) serum conc should be monitored in patients with severe kidney
dysfunction (CrCl <25ml/min) or those receiving renal replacement
Obesity: BMI ≥40kg/m2: LD: 15 mg/kg (using actual body weight) and MD: initially 4-7mg/kg/day
(using ideal body weight) given in 2-4 doses
Geriatric population: clearance is decreased. Lower doses/less frequent dosing may be required
Important considerations BLACK BOX WARNING: Cardiovascular risk associated with rapid infusion (should not exceed 50
mg/min). Careful cardiac monitoring is needed when IV phenytoin is being used.
CIs: hypersensitivity, history of phenytoin-related hepatotoxicity, sinus bradycardia, sinoatrial
block, 2nd and 3rd degree heart block, Adams-Stokes syndrome, sick sinus syndrome, QTc-interval
prolongation
Disease-related:
-Use with caution in patients with underlying cardiac disease
-May inhibit insulin release and increase serum glucose in patients with diabetes
-Hepatic impairment: Use with caution
-Hypoalbuminemia: Use with caution. Monitor s. phenytoin level + calculate adjusted level
-Hypothyroidism: may alter thyroid hormone serum concentrations (with chronic administration)
-Myasthenia gravis: Use with caution – may cause exacerbation
-May cause exacerbation of porphyria
-Use with caution in patients who are debilitated
AEs: Blood dyscrasias (agranulocytosis, granulocytopenia, leukopenia, macrocytosis, megaloblastic
anemia, pancytopenia, pure red cell aplasia, and thrombocytopenia with or without bone marrow
depression). Cardiovascular effects with rapid IV infusion (hypotension, severe cardiac arrhythmia,
bradycardia, heart block, ventricular tachycardia and ventricular fibrillation). Dose-dependent CNS
effects (drowsiness, fatigue, and nystagmus disorder to ataxia, incoordination, and slurred speech
and even drug-induced seizure). Delayed-onset gingival hyperplasia. Hepatotoxicity (reversible,
occurs within 2-8 weeks of use). Hypersensitivity with variable onset (SJS, DRESS, TEN, etc)
Propylene glycol: Epilog (contain propylene glycol): large amounts are potentially toxic and have
been associated hyperosmolality, lactic acidosis, seizures and respiratory depression - use caution
DDIs: phenytoin is a strong CYP3A4 inducer
+apixaban, +rivaroxaban (decreased NOAC effect – avoid combination)
+diltiazem, +verapamil (monitor phenytoin serum conc/toxicity and for decreased CCB effect)
+clarithromycin (decreased clarithromycin efficacy – consider alternatives)
+dexamethasone (decreased dexamethasone and/or fluctuating phenytoin serum conc)
+methylprednisolone (decreased methylprednisolone serum conc – consider dose increase)
+metronidazole (enhanced phenytoin toxicity risk, decreased metronidazole effect - monitor, IV
phenytoin only)
+aminophylline (risk of sub-therapeutic serum conc or toxicity – consider alternatives)
68 | P a g e
Preparation/administration -Dilute in NS only. Dilute every 1gm of loading dose (4 ampoules) in 180ml, and every 100mg of
and stability/sensitivity maintenance dose in 18ml. Final conc 5mg/ml
-Administer at max rate of 50mg/min. In the elderly administer at a slower rate (20mg/min)
-Avoid IV administration into small veins
-inject phenytoin slowly and directly into a large vein through a large gauge needle or IV catheter.
Follow with NS flushes through the same needle or IV catheter to reduce risk of purple glove
syndrome
-Enteral nutrition (NG/OG tube): Administration of phenytoin with enteral nutrition and/or related
nutritional supplements may decrease phenytoin absorption. Hold feedings for 1-2hrs prior to and
1-2hrs after phenytoin administration
-After dilution: Use within 1hr. Store below 25°C
‫ يحل باستخدام محلول ملح فقط‬-
‫ز‬
‫مل محلول ملح‬180 ‫ جم) ف‬1( ‫ أمبول‬4 ‫ يحل‬: loading dose ‫ الجرعة المبدئية‬-
‫مل محلول ملح‬18 ‫مجم زف‬100 ‫ يحل كل‬:maintenance doses ‫ الجرعات االستكمالية‬-
‫ يتم اعطاء محلول ملح بعد انتهاء‬، ‫ يجب تجنب الحقن زف أوردة ضعيفة‬، ‫دقيقة‬/‫مجم‬50 ‫يعىط بمعدل أقىص للحقن الوريدي‬-
‫حقن الجرعة‬
‫ مئوية‬25 ‫ يحفظ زف درجة حرارة تحت‬، ‫يستخدم خالل ساعة بعد الحل‬-
Notes -Purple glove syndrome (i.e: discoloration with edema and pain of distal limb) may occur following
peripheral IV administration of phenytoin. Symptoms may resolve spontaneously.
However, skin necrosis and limb ischemia may occur
-Not indicated for the treatment of absence seizures, myoclonic seizures, or seizures due to
hypoglycemia or other metabolic causes
-Plasma conc sustained above the optimal range may produce confusional states (delirium,
psychosis, or encephalopathy, irreversible cerebellar dysfunction and/or cerebellar atrophy).
Measure plasma phenytoin conc at first sign of acute toxicity
-Antiseizure should not be discontinued abruptly (possible increase in seizure frequency). Should
be withdrawn gradually
-In pregnancy: An increased risk of congenital malformations/adverse outcomes may occur.
Maternal use of phenytoin should be avoided when possible. Maternal use of folic acid
throughout pregnancy is recommended to reduce congenital malformation risk if phenytoin use is
necessary
Monitoring parameters CBC, ECG with IV infusion use, comprehensive metabolic profile, liver function, signs/symptoms of
hematological change (fever, sore throat, mouth ulcers, infections, easy bruising, petechial or
purpuric hemorrhage), plasma phenytoin conc - trough conc are generally recommended for
routine monitoring
-Phenytoin level monitoring:
First concentration: Consider obtaining within 2-3 days of therapy initiation. Draw 2hrs after
completion of IV loading dose or 6-12hrs after oral loading dose
Second concentration: Draw within 5-8 days of therapy initiation. Subsequent doses of phenytoin
adjusted accordingly
-Therapeutic level: total phenytoin level: 10-20 mg/L and free phenytoin: 1-2 mg/L
-Adjusted phenytoin level (if low s. albumin) = total phenytoin level / [ (0.2 x albumin) + 0.1]
-Predicted free phenytoin (if ESRD) = (total phenytoin level / [(0.1 × albumin) + 0.1]) × 0.1
Piperacillin-tazobactam – 4.5gm vials (Tazocin)
Mechanism of action Piperacillin inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding
proteins and inhibits the final transpeptidation in bacterial cell walls. Bacteria eventually lyse due
to ongoing activity of cell wall autolytic. Piperacillin exhibits time-dependent killing. Tazobactam
inhibits many beta-lactamases
Indication and doses Sepsis (empiric combination or culture-based therapy): IV: 4.5gm IV /6hr for. Duration: source-
dependent
Cystic fibrosis exacerbation (combined + quinolone or AG): IV: 4.5gm IV /6hr for 10-14 days
CAP (patients with risk of resistant G-ve pathogens infection): IV: 4.5gm /6hr for ≥5 days (maybe
extended in case of severe/resistant infection)
HAP (empiric or culture-based therapy): IV: 4.5gm IV /6hr for 7 days
Dose adjustment Renal impairment (adjustments based on 4.5gm dosage):
69 | P a g e
CrCl 20-40: 4.5gm /8hr
CrCl <20: 4.5gm /12hr
Intermittent HD: 4.5gm /12hr (preferred to schedule dose after HD session)
Important considerations CIs: Hypersensitivity to penicillins/beta-lactams
AEs: electrolytes abnormalities (Na+, K+), superinfection, C. difficile infection, drug-induced
immune thrombocytopenia (DITP), bone-marrow suppression, neurotoxicity (encephalopathy or
tonic-clonic seizures)
DDIs:
+aminoglycosides especially gentamicin (decreased aminoglycoside level -monitor AG level)
+vancomycin (monitor renal function - risk of AKI)
Preparation/administration -IV intermittent bolus: dilute in 100ml NS and administer over 30min.
and stability/sensitivity -IV extended-infusion (preferred): dilute using 50ml NS and administer using a syringe pump over
4hrs
-store below 25°C
-stable after dilution for 12hrs (in refrigerator)
‫مل محلول ملح ويعىط عىل مدار نصف ساعة‬100 ‫ يحل الفيال باستخدام‬:‫للحقن الوريدي المعتاد‬-
‫ ساعات‬4 ‫مل محلول مل ويعىط بمضخة محاليل وريدية عىل مدار‬50 ‫ يحل الفيال باستخدام‬:‫للحن الوريدي الممتد‬-
ً
)‫التحضت (محفوظا زف الثالجة‬
‫ر‬ ‫ ساعة بعد‬12 ‫يمكن استخدامه خالل‬-
Notes -In pregnancy: compatible for use
-Prolonged infusion (over 4hrs) method is preferred due to pharmacokinetics properties (time-
dependent killing) and reduced renal toxicity
Cost/vial: 60.22 LE
Monitoring parameters Cr, urea, CBC with differential, PT, PTT, serum electrolytes, LFTs, urinalysis, signs of bleeding,
monitor for signs of anaphylaxis during first dose (if a skin rash develops monitor closely), CNS
effects.
Pirfenidone – 267mg tablets (Pirfenex, Perdofenex)
Mechanism of action Antifibrotic properties: decreases fibroblast proliferation and production of fibrosis-associated
proteins and cytokines. May decrease the formation and accumulation of extracellular collagen.
Anti-inflammatory properties: decreases the accumulation of inflammatory cells resulting from a
variety of stimuli.
Indication and doses Idiopathic pulmonary fibrosis:
Days 1-7: Oral: 267 mg 3 times daily; total daily dose: 801 mg/day
Days 8-14: Oral: 534 mg 3 times daily; total daily dose: 1,602 mg/day
Day 15 and thereafter: Oral: 801 mg 3 times daily; maximum daily dose: 2,403 mg/day
Hepatic disease present before use:
Child-Pugh class A and B: No dose adjustment provided. Use with caution. Consider dose
modification and interruptions, as needed.
Child-Pugh class C: Use is not recommended.
Hepatotoxicity during treatment:
ALT/AST >3 to ≤5 ×ULN without hyperbilirubinemia or symptoms: Rule out other causes +
discontinue confounding medications. May hold use, reduce dose or discontinue therapy until
ALT/AST normalize. Once resolved, may restart + re-titrate to the recommended daily dose.
ALT/AST >3 to ≤5 × ULN + hyperbilirubinemia or symptoms: Discontinue therapy and do not
reinitiate.
ALT/AST >5 × ULN (regardless of bilirubin level): Discontinue therapy and do not reinitiate.
Renal impairment:
CrCl ≥30ml/min: There are no dosage adjustments provided. Use with caution. Consider dose
modification and interruptions, as needed.
CrCl <30ml/min and ESRD patients on hemodialysis: use is not recommended.
Gastrointestinal symptoms (eg, nausea, diarrhea, dyspepsia, vomiting): No dose adjustments

provided. Consider temporary dose reduction and interruptions, as needed.
Photosensitivity reaction/rash: No dose adjustments provided. Consider temporary dose
70 | P a g e
reduction and interruptions, as needed.
CNS symptoms (dizziness, fatigue, etc): No dose adjustments provided. Consider temporary dose
reduction and interruptions, as needed.
Important considerations CIs: Hypersensitivity, angioedema with pirfenidone use, concurrent use of fluvoxamine, severe-
hepatic impairment, severe renal impairment
AEs:
Skin rash (30%), Abdominal pain (24%), anorexia (13%), decreased appetite (21%), diarrhea (26%),
dyspepsia (19%), gastroesophageal reflux disease (11%), nausea (36%), vomiting (13%), dizziness
(18%), fatigue (26%), headache (22%), sinusitis (11%), upper respiratory tract infection (27%)
Precautions:
-Photosenstivity/rash – especially during the first 6 months: avoid/minimize sun exposure. Wear
sunscreen (SPF +50)
-Weight loss/anorexia: monitor weight during therapy
-Cigarette smokers (tobacco): Clearance may be increased due to CYP1A2 induction. Instruct to
quit smoking prior to initiation
DDIs:
+fluvoxamine (CYP1A2 inhibitor) – increased pirfenidone serum conc leading to adv. effects. Use
267mg 3 times daily dose
Preparation/administration -Administer with food during the same time each day to avoid/minimize adverse effects.
ً
and stability/sensitivity ‫ينصح المريض بتناول القرص مع الطعام زف نفس الوقت يوميا لتقليل اآلثار الجانبية المحتملة‬-
Notes -If therapy interruption <14 consecutive days, may reinitiate therapy at previous daily dose.
-if therapy interruption ≥14 consecutive days, reinitiate the initial 2-week titration period up to
recommended daily dose.
-In pregnancy: animal data suggest moderate risk, but the absence of human pregnancy
experience prevents a better assessment of the embryo–fetal risk.
-During breastfeeding: No reports describing the use of pirfenidone during lactation. Medication
characteristics suggest its excretion into milk. Decision to continue/discontinue breastfeeding
should take into account the risk of infant exposure, benefits of breastfeeding to the infant, and
benefits of treatment to the mother.
-Cost/tablet: 19.6LE
Monitoring parameters LFTs (ALT, AST, bilirubin - prior to initiation, monthly for first 6 months, then every 3 months
thereafter and as clinically indicated), signs of photosensitivity, GI symptoms
Potassium chloride – 15% ampoules
Mechanism of action The major cation of intracellular fluid. Essential for the conduction of nerve impulses in heart,
brain, and skeletal muscle; contraction of cardiac, skeletal and smooth muscles, maintenance of
normal renal function and acid-base balance
Indication and doses 1 ampoule KCl is equivalent to 10mEq and provides roughly about 1mEq/L
165mg/5ml oral KCl syrup is equivalent to 2.2mEq. 600mg KCl tablet is equivalent to 8mEq
Diabetic ketoacidosis or hyperosmolar hyperglycemic state:
Serum K+ <3.3mEq/L: IV: Initial: 20-40mEq/hr, then supplement as needed. Monitor K+ level every
1-2hrs until serum K+ ≥3.3mEq/L. Delay insulin until serum potassium reaches ≥3.3mEq/L
Serum K+ 3.3-5.2mEq/L: IV: Add 20-30mEq to every liter of IV fluid. Target serum K 4-5 mEq/L
Hypokalemia and maintenance of normal level: IV:
Serum level Central administration Peripheral administration Monitoring/recheck
3.6-3.9mEq/l 20mEq over 2hr x 1 10mEq over 1hr x2 None
3.4-3.5mEq/l 20mEq over 2hr x1 10mEq over 1hr x 3 None
and 10mEq over 1hr x 1
3.1-3.3mEq/l 20mEq over 2hr x 2 10mEq over 1hr x 4 2hrs after last dose
2.6-3mEq /l 20mEq over 2hr x 2 10mEq over 1hr x 5 2hrs after last dose
and 10mEq over 1hr x 1
71 | P a g e
2.3-2.5mEq/l 20mEq over 2hr x 3 10mEq over 1hr x 6 2hrs after last dose
< 2.3 mEq /l 20mEq over 2hr x 3 10mEq over 1hr x 6 2hrs after last dose
Oral:
Serum level PO replacement dose Monitoring
3.7-3.9mEq/l 20mEq x1 None
3.5-3.6mEq/l 20mEq every 2 hr x 2 None
3.3-3.4mEq /l 20mEq every 2 hr x3 Recheck 4hrs after last dose
3.1-3.2mEq /l 20mEq every 2 hr x 4 Recheck 4hrs after last dose
<3.1mEq/l 20mEq every 2 hr x 4 Recheck 4hrs after last dose
Dose adjustment Hepatic impairment: Use oral formulations with caution in patients with cirrhosis and start at the
low end of dosage range.
Renal impairment:
IV: CrCl <30, or on intermittent HD (thrice weekly): Reduce initial dose by at least 50% - use with
caution and monitor closely
Oral: Initiate at the lower end of dosing range, particularly if on medications known to increase K+
levels. Use with caution and monitor closely
Elderly: May require less K+ than younger adults
Important considerations CIs: avoid combination of K++ K+-sparing diuretics – use only in select patients under close
supervision
Parenteral: Do not administer undiluted/IV Push
AEs:
-hyperchloremia, hyperkalemia, extensive burns or tissue injury (use with caution), heart failure,
acute dehydration, systemic acidosis, adrenal insufficiency, hyponatremia, bradycardia, burning
sensation at injection site, erythema, phlebitis, venous thrombosis
DDIs:
+spironolactone (enhanced hyperkalemic effect - avoid combination)
Preparation/administration -Parenteral: Recommended infusion rate:10mEq/hr. Max rate 20mEq/hr. 40mEq/hr can also be
and stability/sensitivity used in emergency situation with continuous ECG monitoring. Must be diluted prior to parenteral
administration.
-Peripheral infusion max conc: 10mEq/100ml (=1amp/100ml) and for central-line infusion 20-
40mEq/100ml (=2-4amp/100ml)
-Compatible with NS, ringer or D5W
-Extravasation: Vesicant/irritant at conc >0.1mEq/ml. Ensure proper catheter/needle position to
avoid extravasation
‫البد من حل األمبول بأحد المحاليل قبل استخدامه‬-
‫مل ملح أو رينجر أو‬250 ‫ أمبول ف‬2 ، ‫مل محلول ملح أو رينجر أو جلوكوز‬100 ‫ يتم حل األمبول زف‬:‫للحقن زف االوردة الطرفية‬-
‫ز‬
‫ ويعىط عىل مدار ساعة لكل أمبول‬، ‫مل ملح أو رينجر أو جلوكوز‬500 ‫ أمبول زف‬3 ، ‫جلوكوز‬
‫مل ملح أو رينجر أو جلوكوز‬100 ‫ أمبول زف‬4-2 ‫ يمكن حل‬:‫ للحقن زف القسطرة الوريدية المركزية‬-
Notes -Use with caution in pregnant women with underlying conditions (pre-eclampsia – maybe more
likely to develop hyperkalemia)
-Oral K+ administration is preferred in patients on dialysis unless more rapid K+ repletion is needed
-if no response to K+ replacement in hypokalemia, check serum Mg+2. Long-term diuretics and PPIs
may result in hypomagnesemia
-Concomitant use of a loop diuretic + KCl is common. Discontinue K+ once loop diuretic is
discontinued
-Cost/ampoule:2.59182 LE
Monitoring parameters Acid-base balance, serum Na+, K+, Mg+2, renal function, ECG (if intermittent infusion or >10mEq/hr
in adults), repeat serum K+ level 2-4hrs after dose, IV infusion site.
72 | P a g e
PrednisoLONE – 20mg tablets (Disprelone-D)
Mechanism of action Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and
reversal of increased capillary permeability. Suppresses the immune system by reducing activity
and volume of the lymphatic system
Indication and doses Asthma (acute exacerbation) moderate-severe exacerbations or in those who do not respond
completely to SABA administered within 1hr of presentation to ER: Oral: 40-60mg daily for 5-
7days. Administer in 1-2 divided doses.
COPD exacerbation (severe but not life-threatening exacerbations) Oral: 40-60mg once daily for 5-
14 days.
Pneumocystis pneumonia moderate-severe disease, patients with PaO2 <70mmHg or <92% on
room air. Oral: 40mg twice daily on days 1-5, followed by 40mg once daily on days 6-10, then
20mg once daily on days 11-21
COVID-19, hospitalized patients - requiring supplemental oxygen or ventilatory support. Oral:
40mg once daily or 20mg twice daily for up to 10 days (or until discharge, if sooner)
Non-specific interstitial pneumonia: Oral: 0.5-1mg/kg ideal body weight /24hr. Max 60mg/day for
1month, followed by 30-40mg/day for 2 months.
For patients who respond/stabilize with treatment, gradually taper dose. Goal 5-10 mg daily or
alternate days, by the end of 6-9 months, with attempted cessation after at least 1 year of therapy
Important considerations AEs: Infections, hyperglycemia, flushing, high Respiratory rate, Cushing syndrome, adrenal gland
suppression, myopathy, muscle pain or weakness, muscle cramps, tachycardia, abnormal HR, poor
sores healing
-Use with caution in patients with HF, HTN, DM, osteoporosis, thyroid disease and peptic ulcer
DDIs:
+NSAIDS, +salicylates (enhanced adverse/toxic effect of NSAIDs – monitor)
+quinolones: (high risk of tendonitis/tendon rupture – monitor)
+atracurium, +cisatracurium (enhanced muscle weakness, polyneuropathies and myopathies - use
lowest dose/shortest duration and monitor for new-onset/worsening muscle weakness)
Preparation/administration -Administer after meals/with food or milk to decrease GI upset.
and stability/sensitivity -Orodispersible tablet: Do not break, cut, split or use partial tablet. May swallow whole or allow to
dissolve on tongue.
Notes -In pregnancy: preferred oral steroid for controlling acute exacerbations or treating severe
persistent asthma, and suitable for patients with severe COVID-19
-Asthma exacerbation: If symptoms do not resolve and peak expiratory flow is not at >70% then
longer duration of treatment may be required
-AECOPD: Discontinue without taper if patient improves. If no improvement, a longer duration of
therapy may be indicated
Monitoring parameters BP, blood glucose level, electrolytes, presence of bacterial infection, Hb level, occult blood loss,
bedsores, Intra-ocular pressure with therapy >6 weeks
Propofol – 1% ampoules (Diprivan, Pofol) ☀
Mechanism of action Short-acting, lipophilic intravenous general anesthetic. Causes global CNS depression, presumably
through agonism of GABAA receptors. Perhaps reduced glutamatergic activity through NMDA
receptor blockade
Indication and doses MV patients in ICU: IV: initial 5mcg/kg/min (0.3mg/kg/hr). increase by 5-10mcg every 5-10mins
until sedation goal is achieved. Max dose 60-80mcg/kg/min. Usual dose 5-50mcg/kg/min (0.3-
3mg/kg/hr)
Obesity: BMI ≥30 kg/m2: use adjusted body weight. Do not change dosing weight from one weight
73 | P a g e
metric to another during therapy
AEs: injection-site reaction, elevated ICP (use with caution), infection risk (due to micro-organism
growth)
Precautions:
-Propofol-related infusion syndrome (PRIS): characterized by dysrhythmia
(bradycardia/tachycardia), widening of the QRS complex, heart failure, hypotension, asystole,
lipemia and hypertriglyceridemia, metabolic acidosis, and/or rhabdomyolysis or myoglobinuria
with acute kidney injury and hyperkalemia. Dose and duration related. Rapid onset (1-4 days)
-avoid abrupt discontinuation
-lacks analgesic effect – supplement with analgesic
DDIs:
+fentanyl, +nalbuphine (enhanced CNS depression – limit dose/duration for both)
+amiodarone (increased risk of QTc prolongation – monitor ECG closely)
+rifampin (enhanced propofol hypotensive effect – avoid combination)
Preparation/administration -Administered undiluted, used usually as 2 ampoules (400mg/40ml) installed in a syringe pump
and stability/sensitivity and -Do not use if contamination is suspected
sensitivity/stability -Do not administer through the same IV catheter with blood or plasma. Tubing and any unused
portions of propofol vials should be discarded after 12hrs
-Store in temperature less than 25°C.
ً
‫مل) وريديا دون تخفيف باستخدام مضخة المحاليل الوريدية‬40/‫مجم‬400( ‫ أمبول‬2 ‫ يعىط‬-
ً
‫ يتم التخلص من أي كمية متبقية من األمبوالت‬، ‫ يمنع استخدامها إذا كانت هناك شكوك زف تلوثها‬، ‫ يتم فحص األمبوالت جيدا‬-
‫ ساعة من فتحها‬12 ‫المفتوحة بعد‬
‫ يمنع اعطاؤه زف نفس الوريد بنفس وقت حقن وحدات البالزما أو وحدات كرات الدم الحمراء‬-
‫ درجة مئوية‬25 ‫يخزن زف درجة حرارة أقل من‬-
Notes -Used as part of combination of sedatives + analgesics for ICU sedation
-Preferred over a benzodiazepine due to less risk of prolonged sedation, improved time to
extubation. Awakening trial is recommending every day (titrate-down slowly to avoid rapid
awakening)
-Titrate to maintain a light level of sedation (e.g: RASS 0 to −2) or clinical effect (eg, ventilator
synchrony)
Monitoring parameters -Assess and adjust sedation according to scoring system (Richmond Agitation-Sedation Scale or
Sedation-Agitation Scale)
-Cardiac monitor, BP, oxygen saturation, ABG (with prolonged infusions). Signs/symptoms of
propofol-related infusion syndrome, metabolic acidosis, hyperkalemia, rhabdomyolysis/elevated
CPK, hepatomegaly, progression of cardiac/renal failure.
-Diprivan (product-specific): Monitor zinc levels in patients predisposed to deficiency (burns,
diarrhea, major sepsis) or after 5 days of treatment.
Propranolol – 1mg/ml ampoules (Mayestrotense)
Mechanism of action Nons-elective B-adrenergic blocker (class II antiarrhythmic). Competitively blocks response to
beta-adrenergic stimulation which results in decreases in heart rate, myocardial contractility,
blood pressure and myocardial oxygen demand
Indication and doses Atrial fibrillation/flutter (acute ventricular rate control) or SVT: IV: 1mg over 1min. Repeat every
2mins if needed. Max x3 doses
Ventricular tachycardia (combined +amiodarone, in hemodynamically stable patient): IV: 1-3mg
every 5mins, up to a total 5mg
Dose adjustment Hepatic impairment: increases systemic exposure - use with caution
Renal impairment: use with caution particularly in those with more advanced kidney impairment
Geriatric population: initiate at lower-end of dosing
Important considerations CIs: Hypersensitivity, uncompensated heart failure (unless failure is due to tachyarrhythmias),
severe sinus bradycardia, sick sinus syndrome, heart block >1st degree without pacemaker,
bronchial asthma, bronchospasm
-Myasthenia gravis: Use with caution
-Can precipitate/aggravate symptoms of arterial insufficiency in patients with peripheral vascular
74 | P a g e
disease and Raynaud disease
-Associated with induction or exacerbation of psoriasis
-May mask signs of hyperthyroidism
-Avoid use in vasospastic angina (B-blockade without alpha-1 receptor blocking activity)
-May worsen, prolong, or cause hypoglycemia
-May cause CNS effects (fatigue, insomnia, vivid dreams, memory impairment)
-May cause first-degree, second-degree or complete AV block
DDIs:
+salbutamol, +formoterol (decreased B2-agoinsts bronchodilatory effect – avoid combination)
Preparation/administration -Administer IV push (1mg/min)
ً
and stability/sensitivity ‫يتم حقن األمبول وريديا عىل مدار دقيقة دون تخفيف‬-
Notes -Beta-blockers should be gradually tapered to avoid acute tachycardia, hypertension and/or
ischemia in patients with underlying cardiovascular disease (dose-dependent. Onset varies)
-In pregnancy: Exposure to beta-blockers during the 3rd trimester may increase risk for
bradycardia, hypoglycemia, hypotension, and respiratory depression in the neonate. Can be used
for treatment of maternal ventricular arrhythmias, atrial fibrillation/atrial flutter, or
supraventricular tachycardia during pregnancy
Monitoring parameters ECG, heart rate, blood pressure, signs and symptoms of bronchospasm, random blood glucose
Pyrazinamide – 500mg tablets
Mechanism of action Converted to pyrazinoic acid in susceptible strains of Mycobacterium which lowers the pH of the
environment. The exact mechanism of action has not been elucidated
Indication and doses Drug-susceptible TB, intensive phase (based on lean BW): Adults: Duration: 2months
40-55 kg: Oral: 1gm once daily
56-75 kg: Oral: 1.5gm once daily
76-90 kg: Oral: 2gm once daily
Infants, Children, and Adolescents weighing <40 kg: Oral: 35mg/kg/dose once daily
Children and Adolescents weighing ≥40 kg: same as in adult dose
*Refer to hospital-based TB management protocol for details
Dose adjustment Hepatic impairment: no dose adjustment provided. Contraindicated in case of severe impairmen
Renal impairment: if CrCl <30 (based on lean BW): Administered 3 times weekly
Important considerations CIs: Hypersensitivity, acute gout, severe hepatic damage
AEs: Hepatotoxic (dose-related)
▪ Diabetes: use with caution – monitor closely
▪ Gout: may elicit acute attacks
DDIs:
+favipiravir (may increase serum uric acid conc – monitor)
Preparation/administration Taken without regard to food
Notes -Evaluate pregnancy status prior to treatment of multidrug-resistant tuberculosis in females of
reproductive potential. Females of reproductive potential should use effective contraception
during treatment for multidrug-resistant tuberculosis
-In pregnancy: May be used as part of the initial treatment regimen of drug-susceptible
tuberculosis when the probability of maternal disease is moderate to high. Risks/benefits of use
during pregnancy should be individualized.
Cost/talet:0.399LE
Monitoring parameters Periodic LFTs, serum uric acid, sputum culture, chest x-ray 2-3months into treatment + at
completion
Ramipril – 2.5mg tablets (Tritace)
Mechanism of action Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents conversion of angiotensin
I to angiotensin II, a potent vasoconstrictor. Results in lower levels of angiotensin II which causes
an increase in plasma renin activity and a reduction in aldosterone secretion
Indication and doses Non-STEMI: Oral: Initial: 2.5mg once daily. Titrate slowly based on tolerability/response, up to
20mg/day in 1-2 divided doses
75 | P a g e
STEMI Oral: Initial: 2.5mg once daily initiated within 24 hours of presentation; titrate slowly based
on tolerability and response up to 20 mg/day in 1 or 2 divided doses
HFrEF: Oral: Initial: 1.25-2.5mg once daily. Double as tolerated every 1-2weeks. Target dose 10mg
once daily. May titrate more rapidly as tolerated (hospitalized patients)
Hypertension, chronic: Oral: Initial: 2.5 mg once daily. Evaluate response after 2-4weeks, double
as needed up to 20 mg/day in 1-2 divided doses. if additional BP control is needed, consider
combination therapy (CCB or thiazide)
Dose adjustment Hepatic impairment: no dose adjustment. Generally, avoid use in patients with ascites due to
cirrhosis/refractory ascites. if use cannot be avoided, monitor BP and kidney function
Renal impairment:
-eGFR 15-29 ml/min/1.73m2: Initial: 1.25mg once daily. Max 5mg/day
-eGFR <15 ml/min/1.73m2: use alternative agents. If necessary, initiate at 1.25mg once daily. Max
5mg/day
Important considerations BLACK BOX WARNING: Fetal toxicity: When pregnancy is detected, discontinue ramipril as soon as
possible.
CIs: Hypersensitivity to ramipril/ACE inhibitors, hereditary/idiopathic angioedema, history of
angioedema related to previous ACE inhibitor use, concomitant use or within 36hrs of switching
to/from ARNIs, hypotensive/hemodynamically unstable states, pregnancy
-Small, transient increases in SCr are likely to occur within 4 weeks following initiation of
therapy/increase in dose. If SCr increases by >30%, review for possible etiologies (e.g: AKI, volume
depletion, concomitant medications, renal artery stenosis) before determining dose
reduction/discontinuation of ramipril.
-Aortic stenosis (use with caution)
-Hypertrophic cardiomyopathy with left ventricular outflow tract obstruction (use with caution)
- Anemia: more likely in presence of CKD
AEs: AKI, angioedema, dry cough, hyperkalemia
DDIs:
+ARBs (combination is not recommended)
Notes -NON-STEMI: Initiate in stable patients prior to hospital discharge. Continue indefinitely for
patients with concurrent diabetes, left ventricular ejection fraction ≤40%, hypertension, or stable
chronic kidney disease.
-STEMI: In hemodynamically stable patients with large anterior ST-elevation myocardial infarction,
consider starting within 24hrs of presentation. Continue therapy indefinitely.
-In pregnancy/females not using a contraceptive: avoid use
Cost/tablet:0.6615 LE
Monitoring parameters Blood pressure, BUN, SCr, electrolytes (e.g: K+), if patient has collagen vascular disease and/or
kidney impairment, periodic CBC with differential, if angioedema is suspected, assess risk of
airway obstruction
Remdesivir – 100mg vials
Mechanism of action Inhibitor of the SARS-CoV-2 RNA-dependent RNA polymerase (RdRp) - essential for viral
replication. An adenosine nucleotide prodrug that is metabolized to nucleoside triphosphate
metabolite after being distributed into cells that acts as an adenosine triphosphate analog and
competes for incorporation into RNA chains by the SARS-CoV-2 RdRp, resulting in delayed chain
termination during viral RNA replication. Remdesivir triphosphate can also inhibit viral RNA
synthesis due to incorporation into the viral RNA template.
Indication and doses COVID-19, treatment (hospitalized patients) + dexamethasone if requires oxygen
supplementation: IV: 200mg on day 1, followed by 100mg once daily for 5 days or until hospital
discharge, whichever is first. May extend to up to 10 days based on clinical response. Initiate as
soon as possible after the diagnosis of symptomatic COVID-19.
76 | P a g e
Dose adjustment Hepatic impairment prior to treatment initiation: Baseline LFTs should be, and periodically during
treatment
ALT >10 times ULN: Consider discontinuation. If therapy is continued, no dosage adjustment
necessary.
Signs/symptoms of liver inflammation: discontinue
Renal impairment: significant toxicity with short duration use (5-10 days) is unlikely. No dose
adjustment is recommended.
Important considerations CIs: Hypersensitivity
AEs: bradycardia, hepatic effects (including increased serum ALT, AST, bilirubin),
hypersensitivity/infusion related reactions
Preparation/administration -Dilute 200mg in 210ml NS, and 100mg in 230ml NS
and stability/sensitivity and -Administer as an IV infusion over 30 to 120 minutes. May be an irritant; avoid extravasation
sensitivity/stability -Storage after dilution: for 24hrs (in temperarure 2-8°C), and for 4hrs (in temperature less than
25°C). Avoid freezing or heating.
‫مل محلول ملح‬230 ‫ فيال زف‬1‫ و‬، ‫مل محلول ملح‬210 ‫ فيال زف‬2 ‫يتم حل‬-
ً ‫ر ز‬
‫ساعتي ويتم متابعة المريض جيدا لعدم حدوث أي أعراض تحسسية‬ ‫يعىط عىل مدار نصف ساعة إىل‬-
‫ز‬ ً ‫ز‬ ً
‫ ساعات (محفوظا ف درجة‬4 ‫ وخالل‬، )‫ درجة مئوية‬8-2 ‫تحضته (محفوظا ف درجة حرارة‬
‫ر‬ ‫ ساعة بعد‬24 ‫يستخدم خالل‬-
‫ يمنع تجميده أو تسخينه‬،‫ درجة مئوية‬25 ‫حرارة أقل من‬
Notes -In pregnancy: treat same as in nonpregnant patients
-Cost/vial: 399.5 LE
Monitoring parameters Heart rate, liver chemistries (ALT, AST, bilirubin, alkaline phosphatase, and PT at baseline, then
every 1-2 days, renal function (baseline and periodically during therapy), signs/symptoms of
infusion/hypersensitivity reaction (observe for at least 1hr after infusion is complete)
RifAMPin – 300mg tablets and 100mg/5ml oral suspension
Mechanism of action Inhibits bacterial RNA synthesis by binding to the beta subunit of DNA-dependent RNA
polymerase, blocking RNA transcription
Indication and doses Drug-susceptible TB: Intensive phase: Oral: 10mg/kg (max dose 600mg) once daily (or 5 days per
week by directly observed therapy [DOT]) as part of 4-drug regimen for 2months
Infants, Children, and Adolescents <15yrs weighing ≤40 kg: Oral: 10-20mg/kg/dose once daily
(max dose 600mg)
Continuation phase: Oral: 10 mg/kg (max dose 600mg) once daily (or 5 days per week by DOT)
with isoniazid for at least 4months or longer for cavitary disease with positive cultures (7 months),
bone and joint disease (6-9 months), CNS disease (≥12 months)
Latent TB: Oral: 10mg/kg (max dose 600mg) once daily for 4months or with isoniazid for 3months
Infants, Children, and Adolescents: Oral: 15-20 mg/kg once daily (max dose 600mg) for 4months
or with isoniazid for 3months
*Refer to hospital-based tuberculosis management protocol for further specific details

prior to treatment: no dosage adjustments provided (use with caution)
during treatment - new or worsening hepatic damage: Discontinue
Renal impairment:
No dosage adjustment necessary for indication-specific doses that are ≤600 mg/day
Important considerations CIs: Hypersensitivity rifampin/rifamycins, concurrent use of atazanavir, darunavir, fosamprenavir,
praziquantel, ritonavir/saquinavir, saquinavir, or tipranavir
AEs: C. difficile infection, decreased hemoglobin, disorder of hemostatic components of blood
(vitamin K-dependent), disseminated intravascular coagulation, eosinophilia, hemolysis, hemolytic
anemia, hemorrhage, leukopenia, thrombocytopenia, hepatotoxicity, flu-like symptoms,
interstitial pulmonary disease, strong CYP3A4 inducer (numerous significant drug interactions)
▪ Diabetes mellitus: Use with caution – monitor closely
▪ Meningococcal disease: Do not use for treatment of meningococcal disease
▪ Porphyria: Use with caution
▪ Patients with Thrombotic microangiopathy, including thrombotic thrombocytopenic purpura
77 | P a g e
and hemolytic uremia syndrome: Discontinue therapy
DDIs:
+apixaban, +rivaroxaban (decreased DOAC conc – avoid combination)
+esomeprazole, +omeprazole (decreased esomeprazole conc – avoid combination)
+clarithromycin (decreased therapeutic efficacy of clarithromycin – consider alternative)
+clopidogrel (increased serum conc of active clopidogrel conc – monitor for bleeding)
+fluconazole (monitor fluconazole clinical effect and signs of rifampin toxicities)
+propofol (enhanced hypotensive effect of propofol + avoid combination when possible)
+verapamil, +deltiazem (decreased conc – monitor efficacy/avoid combination if possible)
+warfarin (decreased warfarin effect – monitor INR closely)
Preparation/administration Oral: Administer on an empty stomach
Notes -In pregnancy: recommended as part of the initial treatment regimen of drug-susceptible and
latent TB when the probability of maternal disease is moderate to high. There is an Increased risk
of maternal hepatotoxicity, which may require temporary drug withdrawal in pregnant and
postpartum patients
Monitoring parameters Baseline LFTs (AST, ALT, bilirubin), SCr, CBC (every 2-4wks during therapy), signs/symptoms of liver
injury (especially in prolonged therapy or with concurrent hepatotoxic drugs), mental status,
sputum culture, chest X-ray 2-3months into treatment, signs/symptoms of hypersensitivity,
coagulation tests during treatment (patients at risk of vitamin K deficiency), symptoms of
interstitial lung disease/pneumonitis
RifAXIMin –550mg tablets (Gastrobiotic, biorefamin)
Mechanism of action Inhibits bacterial RNA synthesis by binding to bacterial DNA-dependent RNA polymerase
Indication and doses C. difficile infection (second/subsequent recurrence): Oral: 400mg 3 times daily for 20 days after
a 10-day course of oral vancomycin
Hepatic encephalopathy, add-on treatment: Oral: 550mg twice daily or 400mg 3 times daily
Dose adjustment No renal or hepatic dosage adjustment
Important considerations CIs: Hypersensitivity to rifaximin/other rifamycins
AEs: Infection due to inappropriate use/unexpected failure of therapy, risk of resistant
infections/superinfections
Precautions:
-Diarrhea: Avoid use in diarrhea with fever and/or blood in the stool and in treatment of non-E.
coli diarrhea. Consider alternatives if symptoms persist/worsen 24-48hrs of treatment
- C. difficile: Rifaximin resistance may be a concern. Some experts avoid in patients who have
previously received rifamycins/not routinely recommend this regimen
Preparation/administration Administer with or without food.
Notes -In pregnancy: limited oral absorption of rifaximin. Exposure to the fetus is expected to be low
Monitoring parameters Hypersensitivity reactions, temperature, blood in stool, change in symptoms; serum ammonia as
clinically indicated
Ringer's IV solution
Mechanism of action Isotonic intravenous solution that contains electrolytes matching those in plasma
Indication and doses - Replace extracellular fluid losses,
- Restore the sodium, potassium, calcium and chloride balances, for treatment of isotonic
dehydration
Dosing: depends on the age, weight, clinical and biological conditions of the patient and
concomitant therapy.
The recommended dosage for adults, the elderly and adolescents: 500-3,000ml /24hr
78 | P a g e
Important considerations CIs: Extracellular hyperhydration/hypervolemia, hypertonic dehydration, hyperkalemia,
hypernatremia, hypercalcemia, hyperchloremia, severe renal insufficiency (with oliguria/anuria),
uncompensated cardiac failure, severe hypertension, general edema and ascitic cirrhosis
AEs: electrolytes disturbance, worsening of fluid overload and edema
DDIs:
+ceftriaxone (avoid mixing/simultaneous administration – can cause Ca2+-ceftriaxone precipitate)
+corticosteroids (retention of sodium and water – monitor for edema and hypertension).
+potassium-sparing diuretics, ACE inhibtors, ARBs (monitor serum K+ level
Preparation/administration The infusion rate is usually 40ml/kg/24hrs in adults, the elderly and adolescents
Notes -Pressurizing intravenous solutions contained in flexible plastic containers to increase flow rates
can result in air embolism if the residual air in the container is not fully evacuated prior to
administration
-Ringer Acetate contains sodium acetate (converted into sodium bicarbonate in a 1:1 MEq ratio)
and is most suitable for use in patients with hepatic impairment
Monitoring parameters Fluid balance, plasma electrolytes concentrations (sodium, potassium, calcium and chlorides)
Salbutamol – 5mg/ml nebulized solution (Farcolin, viasalmol, salbovent) ☀
Mechanism of action Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on heart rate
Indication and doses 1ml nebulized solution = 20dps that contain 5mg salbutamol
Oral syrup = 2mg/5ml
Asthma (acute exacerbation): Metered-dose inhaler: (90 mcg/actuation): 2-4 inhalations every
20min x3 doses. If good response, can lengthen interval to /3-4hrs as needed. If incomplete
response, can lengthen interval to /1-3hrs as needed
Nebulized solution: 2.5mg /20mins x3 doses. If good response, can lengthen interval to /3-4hrs as
needed. If incomplete response, can lengthen interval to /1-3hrs as needed
Moderate to severe exacerbations (combined with an inhaled SAMA): Metered-dose inhaler (90
mcg/actuation): 4-10 inhalations /20mins x3 doses, then taper as tolerated (to 2-4 inhalations /1-4
hrs as needed).
Nebulized solution: 2.5-5mg (10-20dps or 0.5-1ml) /20mins x3 doses, then taper as tolerated (to
2.5-5mg /1-4hrs as needed). For critically ill patients, 10-15mg (40-60dps or 2-3ml) by continuous
nebulization over 1hr
COPD (acute exacerbation): Nebulized solution: 2.5mg (10dps or 0.5ml) /1hr x2-3 doses, then /2-
4hrs as needed
Metered-dose inhaler: (90 mcg/actuation):
For patients requiring ER/hospital-based care: consider 4 inhalations /1hr x2-3 doses
For patients requiring mechanical ventilation, up to 8 inhalations /1hr x2-3 doses, if needed
Bronchospasm due to anaphylaxis (moderate to severe) + epinephrine:
Metered-dose inhaler (90 mcg/actuation): 2-3 inhalations as needed. Nebulized solution: 2.5-5mg.
Repeat as needed
Bronchodilation: Oral: Adults: 4mg /6-8hr. Max dose 8mg /6-8hr
Children: 2-6yrs: 1-2mg /6-8hr. 6-12yrs: 2mg /6-8hr. >12yrs: 2-4mg /6-8hr
Hyperkalemia (adjunctive therapy/alternative): Nebulized solution: 10-20mg over 10mins
Dose adjustment No adjustments provided
Disease-related: CV disease (arrhythmias, coronary insufficiency, hypertension, HF), hypokalemia,
diabetes, hyperthyroidism, seizures, glaucoma (use with caution)
AEs: tachycardia, QTc interval changes, cardiac ischemia, CNS effects (excitement, nervousness,
tremor, anxiety, hyperactive behavior, insomnia)
79 | P a g e
DDIs:
+haloperidol (risk of QTc-interval prolongation – monitor ECG)
+linezolid (enhanced hypertensive effect – reduce initial doses of salbutamol + monitor BP)
+furosemide, +torsemide (enhanced hypokalemia – monitor serum K+)
Preparation/administration -Metered-dose inhalers: Shake well before use. Spacer device could be used with metered-dose
and stability/sensitivity inhalers
-Nebulization solution: Adjust nebulizer flow to deliver dosage over 5-15mins
-Vental: store below 30 C. protect from heat, light, humdity and physical damage
-Salbovent syrup: Store below 30°C. Protect from light and humidity. Use within shelf-life
Notes -In pregnancy: preferred SABA for use during asthma exacerbations
Monitoring parameters ECG monitoring, serum glucose level, serum potassium level, FEV1, peak flow and/or other
pulmonary function tests
Sodium bicarbonate – 8.4% ampoules
Mechanism of action Dissociates to provide HCO3- ion which neutralizes hydrogen ion concentration and raises blood
and urinary pH
Indication and doses 25ml (1 ampoule sodium bicarbonate) 8.4% = ~25mEq/gm HCO3-
Hyperkalemia with cardiac arrest: IV: 50mEq over 5mins
Hyperkalemia with metabolic acidosis (persistent severe hyperkalemia and/or ECG changes
despite using Ca2+ and other therapies): IV: 150mEq in 1L G5% over 2-4hrs
Acute metabolic acidosis (pH <7.1 or AKI + pH of ≤7.2): IV: 100mEq once over 1-2mins and re-
assess ABG/clinical status every 2hrs. If pH remains <7.3: Administer additional 50-100mEq or
initiate continuous infusion: IV:
Dose = 0.5 × weight (kg) × [goal serum HCO3- – observed serum HCO3-]. Administer over 2-4hrs
Metabolic acidosis in patients with CKD: Oral: 500mg cap 2-3 times daily. Target HCO3-: 24 to 26
mEq/L
Prevention of contrast-induced nephropathy: IV: (150mEq/L sodium bicarbonate in G5% solution):
given 3ml/kg/hr for 1hr immediately before contrast injection, then 1ml/kg/hr during contrast
exposure and for 6hrs after procedure
Dose adjustment Hepatic impairment: Use with caution (especially in clinical states associated with edema and
sodium retention)
Renal impairment: no dose adjustment provided (can cause sodium retention)
Important considerations Precautions:
-Extravasation: ensure proper catheter or needle position prior to and during infusion
-Cirrhosis, edema, heart failure, pulmonary edema – use with caution
-May cause cardiac failure exacerbation, edema, hypernatremia, hypokalemia, metabolic alkalosis
Preparation/administration -For direct IV infusion in emergencies: administer slowly
and stability/sensitivity For IV infusion: dilute to a max conc 0.5 mEq/ml in G5% (e.g: 25ml (1 ampoule) in 50ml G5%)
-IV infusion: if diluted, use G5% - avoid using NS
‫ يعىط ببطء‬:)‫للحقن الوريدي دون تخفيف (حاالت الطوارئ‬-
‫ يمنع حله باستخدام محلول ملح‬، %5 ‫مل جلوكوز‬50 ‫مل) زف‬25( ‫ أمبول‬1 ‫ يحل‬:‫للحقن الوريدي بعد التخفيف‬-
Notes -KDIGO guidelines suggest oral replacement in CKD when plasma HCO3- conc are <22 mEq/L
-Extravasation management: If extravasation occurs, stop infusion immediately and disconnect
(leave needle/cannula in place). Gently aspirate extravasated solution (do NOT flush the line).
Remove needle/cannula. Apply dry cold compresses and elevate extremity
Monitoring parameters Serum electrolytes (including bicarbonate, potassium, sodium, calcium), urinary pH, ABG
Sodium chloride – 0.9% solution
Mechanism of action Principal extracellular cation. Functions in fluid and electrolyte balance, osmotic pressure control
and water distribution
Indication and doses Each 1L 0.9% NaCl = 154mEq Na+
Cystic fibrosis (hypertonic saline 3% inhalation): 4ml /12hr. Pre-treat with nebulized salbutamol
DKA or HHS (NaCl 0.9%): 15-20ml/kg/hr for 1-2hrs (total ~1-1.5L/hr)
Hyponatremia:
80 | P a g e
Acute hyponatremia <130mEq/L – asymptomatic (3% NaCl): IV: 50ml bolus over >5mins. Monitor
serum Na+ to assess need for additional treatment
Acute hyponatremia <130mEq/L – asymptomatic (3% NaCl): IV: 100ml over 10mins. Repeat up to
x3 doses if symptoms persist. Monitor serum Na+ to assess need for additional treatment
Chronic hyponatremia <120-129mEq/L – asymptomatic/mild symptoms: 3% saline not indicated.
Correct underlying cause
Chronic hyponatremia <120 mEq/L but asymptomatic/mild-moderate: (3% NaCl): IV: 1ml/kg bolus
(max bolus 100mL) over 10mins /6hrs as needed
Severe hyponatremia <120mEq/L or intracranial pathology: (3% NaCl): IV: 100ml over 10mins.
Repeat up to x3 doses over 30mins or 150ml over 20mins. Repeat up to x2 doses with serum Na+
level check between doses
Intracranial hypertension: (23.4% NaCl): Central IV: 15-60ml administered over 2-20mins
Na+ maintenance (parenteral nutrition): IV: 1-2 mEq/kg/24hrs. Customize individually.
Min 30ml/kg within the first 3hrs for shock or hypoperfusion. Additional IV fluid guided by
frequent reassessment of hemodynamic status
Subarachnoid hemorrhage with Na+ ≤133 mEq/L, or drop ≥6mEq/L over 24-48hrs): (3% NaCl): IV:
Initial: 20ml/hr. Increase by 10-20ml/hr to maintain serum Na+ between 136-140mEq/L
*Refer to hospital-based DKA and uncontrolled hyperglycemia protocols for details
Important considerations -CIs: Avoid Na+ toxicity: Rate of correction is dependent upon whether or not hyponatremia is
acute or chronic
AEs:
-Extravasation: Concentrated IV sodium chloride (>1%) is irritant
-Heart failure: Use with caution
-Hypertension: Use with caution
-Kidney impairment: Use with caution (causes Na+ retention)
Preparation/administration -Administer IV
and stability/sensitivity -~3% hypertonic saline: can be obtained by mixing 300ml NS with 200mEq (4 ampoules) sodium
bicarbonate
Notes -DKA and HHS: If shocked, use more aggressive replacement, and if mild(euvolemic), use clinical
assessment for less aggressive therapy
-Hyponatremia: max serum Na+ correction 8mEq/L /24hrs. Avoid overcorrection/too rapid
correction due to increased risk of iatrogenic osmotic demyelination syndrome
-If severe symptoms/other need for urgent correction: may increase serum Na+ by 4-6mEq/L
within the first 6hrs. Postpone further correction until next day
- Use 3% hypertonic saline for symptomatic hyponatremia patients only
-Septic shock: administer vasopressors during/after fluid resuscitation to maintain MAP ≥65mmHg
Monitoring parameters -Serum Na+, K+, Cl-, HCO3-, osmolarity, intake/output, weight, infusion site
-DKA and HHS: serum glucose, anion gap, venous pH, serum BUN, Cr, serum osmolality, fluid
status, signs/symptoms of dehydration or fluid overload, anion gap and mental status
Spironolactone – 25mg tablets (Spectone)
Mechanism of action Potassium-sparing diuretic – Competes with aldosterone for receptor sites in the distal renal
tubules. Increasing Na+, Cl- and water excretion, while conserving K+ and H+ ions. Blocks
aldosterone effect on arteriolar smooth muscle
Indication and doses Cirrhotic ascites (+furosemide) Oral: Initial: 100mg once daily (50mg if minimal ascites). Titrate
every 3-5 days based on response/tolerability. Max dose 400mg once daily
Heart failure:
HFpEF (symptomatic + elevated s. natriuretic peptide or hospitalized for heart failure in last 12
months): Oral: 12.5mg daily. Titrate every 2-4 weeks if renal function stable/tolerable to target
dose 50mg /12-24hr
HFrEF (NYHA class II-IV): Oral: 12.5-25mg daily. Titrate after 4 weeks if renal function
stable/tolerable to target dose 50mg /12-24hr
Hypertension (add-on if refractory/resistant): Oral: 25mg once daily. Titrate 2-4 weeks based on
response/tolerance up to 50-100mg once daily
Dose adjustment Hepatic impairment: initiate with low dose and titrate slowly (cirrhosis). May precipitate hepatic
coma if electrolytes imbalance present
81 | P a g e
Renal impairment: Monitor K+ prior to initiation + during therapy
-Cirrhotic ascites and hypertension: no specific dose adjustment provided
-Heart failure:
eGFR 30-50mL/min/1.73 m2: Initial: 12.5mg once daily or every other day. Max target 25mg daily
eGFR <30 mL/min/1.73 m2: Use not recommended
Important considerations CIs: Hyperkalemia, Addison disease, concomitant use with eplerenone, AKI, anuria, pregnancy
-Fluid/electrolyte imbalance (e.g: hypomagnesemia, hyponatremia, hypocalcemia, hyperglycemia,
hyperkalemia) may occur
-Heart failure: Discontinue therapy if serum K+ cannot be maintained <5.5 mEq/L or if kidney
function worsens
-May cause gynecomastia in patients of any age
DDIs:
+potassium chloride (enhanced hyperkalemic effect – avoid combination)
Preparation/administration -High-fat and high-calorie meal increase the bioavailability of spironolactone by ~90%.
Notes -Cirrhotic ascites: can be used as monotherapy if hypokalemia is present
-Heart failure: Ensure serum K+ <5.5mEq/L, serum Cr ≤2.5 mg/dL (men) and ≤2mg/dL (women) or
eGFR >30mL/min/1.73m2 before initiation. Assess renal function and serum K+ during therapy for
dose adjustment or discontinuation
-In pregnancy: use of mineralocorticoid receptor antagonists is not recommended
Monitoring parameters BP, serum electrolytes (potassium, sodium), uric acid, glucose, kidney function, volume status.
Tiemonium Methyl Sulfate – 5mg/2ml ampoules (Spasmofree)
Mechanism of action Strengthens calcium bonding with phospholipids and proteins, thus stabilizing the cell membrane
of the GI tract. Reduces muscle spasms of the intestine, biliary system, uterus & urinary bladder
Indication and doses Anti-spasmodic: IM/slow IV: 5mg (1 ampoule) PRN or /8hr
Important considerations CIs: patient with closed-angle glaucoma, urethra-prostatic disorder with risk of urine retention
coronary, hepatic, renal insufficiency and prostate disorders - use with caution
Preparation/administration Slow IV or IM
and stability/sensitivity ‫للحقن العضىل أو الوريدي ببطء‬-
Notes -In pregnancy: assess risks and benefits before use
Tigecycline – 50mg vials (Tygacil)
Mechanism of action Glycylcycline antibiotic - Binds to the 30S ribosomal subunit of susceptible bacteria thereby
inhibiting protein synthesis. Generally considered bacteriostatic; however, has bactericidal activity
against isolates of S. pneumoniae and L. pneumophila
Indication and doses Pneumonia (reserved, culture-based and in combination): IV: LD 200mg, followed by MD 100mg
/12hrs. Duration generally 3-7 days based on clinical response
Child-Pugh class A or B: no dose adjustment necessary
Child-Pugh class C: LD 200mg followed by MD 50mg /12hr
In a meta-analysis of Phase 3 and 4 clinical trials, an increase in all-cause mortality has been
observed in tigecycline-treated patients vs comparator-treated patients
CIs: hypersensitivity
-Anaphylactic/Hypersensitivity reactions: avoid use in patients with known hypersensitivity to
tetracycline-class antibiotics
-Antianabolic effects (increased BUN, azotemia, acidosis, and hyperphosphatemia)
-Coagulopathy (including prolongation of PT, aPTT and decreased fibrinogen)
-Abnormal LFTs (increased total bilirubin, prothrombin time, transaminases) have been reported
82 | P a g e
-Acute pancreatitis (including fatalities) has been reported
Preparation/administration -Dilute in NS (200mg dose in 200ml, and 100mg in 100ml)
and stability/sensitivity -IV: Infuse over 30-60 mins. flush line before and after administration
‫ دقيقة‬60-30 ‫ ويعىط عىل مدار‬، )‫ مجم‬100 ‫مل محلول ملح لكل‬100( ‫يحل باستخدام محلول ملح‬-
‫ز‬
‫الطرف قبل إعطاء وبعد انتهاء الجرعة‬ ‫يحقن محلول ملح زف الوريد‬-
Notes -Not to be used for bloodstream or urinary-tract infections
-Has no activity against pseudomonas aeruginosa
Cost/vial: 115.5 LE
Monitoring parameters Hepatic function, aPTT, PTT, fibrinogen (at baseline and regularly during therapy), signs and
symptoms of anaphylaxis during administration
Torsemide – 10mg ampoules (Torseretic, examide)
Mechanism of action Inhibits reabsorption of Na+ and Cl- in the ascending loop of Henle and distal renal tubule,
interfering with the chloride-binding cotransport system, thus causing increased excretion of
water, Na+, Cl-, Mg2+ and Ca2+. Does not alter GFR, renal plasma flow or acid-base balance
Indication and doses Edema/fluid overload (naïve to loop diuretics): IV: 10-20mg once daily. Double dose as needed.
Max effective single dose 50-100mg. Max daily recommended dose 200mg in 2 divided doses
Torsemide infusion: LD 20mg, then 5-20mg/hr
Renal impairment: single doses >50-100mg unlikely to result in additional diuresis
Important considerations CIs: hypersensitivity, hepatic coma patients, anuric patients
-Risk of AKI (dose-related – volume depletion and concurrent use of nephrotoxic drugs)
-May precipitate hyperuricemia
-Sulfa allergy (cross-reactivity between antibiotic and non-antibiotic sulfonamides is extremely low
but possible)
-Risk of skin photosensitivity, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis
-Avoid use of doses higher than max recommended dose (risk of ototoxicity)
Avoid use of diuretics for treatment of elevated BP in primary adrenal insufficiency (Addison
disease)
-Diabetic patients (monitor blood glucose periodically)
-Hepatic impairment (use with caution and maintain normo-kalemia)
-When multiple diuretics are used, serum electrolytes need to be monitored more closely
DDIs:
+diclofenac, +ketoprofen (enhanced nephrotoxicity, diminished diuretic effect – monitor for AKI)
Preparation/administration -Administer as IV bolus or infusion. Do not use as IM injection
and stability/sensitivity -Continuous IV infusion: Flush the line with 0.9% NaCl before and after administration to avoid IV
incompatibilities
)‫للحقن الوريدي فقط (يمنع الحقن العضىل‬-
Notes -Torsemide IV/PO 10mg = furosemide IV 20mg = furosemide PO 40mg
-Consider as replacement if initial therapy with furosemide is not effective (e.g: poor furosemide
absorption)
-Max effective dose varies by population. Higher-than-usual doses may be required for patients
with nephrotic syndrome or kidney failure
-In pregnancy: Adverse events have been observed in animal reproduction studies – avoid use
Monitoring parameters Kidney function, electrolytes, BP, blood glucose, fluid intake and output
Tranexamic acid – 500mg/5ml ampoule (Kapron)

Mechanism of action Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of
fibrinolysis. Also inhibits the proteolytic activity of plasmin
Indication and doses Epistaxis: local application using parenteral form: soak cotton swab with 1 ampoule. Place until
bleeding stops
Hemoptysis (non-massive): nebulized using parenteral form: 500mg /8hr for up to 5days
Intracranial hemorrhage associated with thrombolytic use within 24hrs: IV: 1gm (10-15mg/kg)
once. Administer at a rate <100mg/min (generally 10-20mins)
83 | P a g e
Trauma-associated hemorrhage (significant hemorrhage/at risk) IV: LD 1gm over 10mins started
within 3hrs of injury, followed by 1gm over 8hrs
Renal impairment:
Cr ≥1.4 to <2.8mg/dL: adjust to /12hr interval
Cr ≥2.8 to <5.7 mg/dL: adjust to /24hr interval
Serum creatinine ≥5.7 mg/dL: adjust to /48hr interval or administer 50% of dose
On intermittent hemodialysis: administer after hemodialysis when possible
Important considerations CIs: hypersensitivity, active intravascular clotting, subarachnoid hemorrhage, history/risk of
thrombosis
-Disseminated intravascular coagulation: Use with extreme caution
-Subarachnoid hemorrhage (cerebral edema and infarction may occur)
-Use with caution in patients with uncorrected cardiovascular/cerebrovascular disease
(complications of thrombosis)
-Immediate hypersensitivity reactions (anaphylaxis) have been reported. Ranging from mild
pruritus and/or urticaria to more severe reactions
-Visual defects (e.g: vision color changes, visual impairment, vision loss), retinal artery occlusion,
and retinal venous occlusion
-Seizures and myoclonus (dose-related, rapid onset – unknown etiology)
-Risk of thromboembolic events
DDIs:
+alteplase (discontinue tranexamic acid if alteplase is needed)
Preparation/administration -Nebulized: administer over 15mins
and stability/sensitivity -IV loading dose: can be administered undiluted over 10mins (100mg/min)
-Continuous infusion: dilute with 50-250ml G5% or NS and administer over 10-30mins (max rate
100mg/min)
‫ دقيقة‬15 ‫ يعىط عىل مدار‬:‫لالستنشاق‬-
‫ دقائق دون حله‬10 ‫ يعىط ببطء عىل مدار‬:‫للحقن الوريدي‬-
‫ دقيقة‬30-10 ‫ ويعىط عىل مدار‬%5 ‫مل محلول ملح أو جلوكوز‬250-50 ‫يمكن حل األمبول زف‬-
Notes -Excretion: Urine (>95% as unchanged drug)
Monitoring parameters Signs/symptoms of hypersensitivity reactions, seizures, bleeding resolution
Trimethoprim-sulfamethoxazole – S.S. 400/80mg and D.S. 800/160mg tablets (Sutrim, septrin DS)
Mechanism of action Sulfamethoxazole interferes with bacterial folic acid synthesis and growth via inhibition of
dihydrofolic acid formation from para-aminobenzoic acid. Trimethoprim inhibits dihydrofolic acid
reduction to tetrahydrofolate (sequential inhibition of enzymes of the folic acid pathway)
Indication and doses Double-strength (DS): TMP 160mg + SMX 800mg
Single-strength (SS): TMP 80mg + SMX 800mg
Weight-based dosing based on trimethoprim component
COPD exacerbation (not high-risk patient or risk for pseudomonas): Oral: 1 DS tablet /12hrs for 5-
7days
Pneumocystitis pneumonia (moderate-severe infection): Oral: 15-20mg/kg/8hrs or 2 DS tablets
/8hrs for 21days
Dose adjustment Hepatic impairment: Use with caution. Contraindicated in cases of marked hepatic damage
Renal impairment:
CrCl If recommended dose 1 DS tablet /12hrs If recommended dose 2 DS tablets /8hrs
>30 No dosage adjustment necessary No dosage adjustment necessary
Reduce dose to ~50% of usual dose
Reduce dose to ~50% of usual dose
15-30 (1 DS tablet once, followed by 1 SS tablet
(2 DS tablets /12hrs)
/12hrs)
Reduce to ~25-50% of usual dose. Use Reduce dose to ~25-50% of usual dose. Use
<15
with caution and appropriate monitoring with caution and appropriate monitoring
84 | P a g e
(1 DS tablet once, followed by 1 SS tablet (1 to 2 DS tablets /12hrs)
/12-24hrs or (2 DS tablets /24hrs)
Important considerations CIs: Hypersensitivity to any sulfa drug, history of drug induced-immune thrombocytopenia with
use of sulfonamides or trimethoprim, megaloblastic anemia due to folate deficiency, marked
hepatic damage or severe renal disease (if patient not monitored), blood dyscrasias, pregnancy
-Asthma/Allergies: Use with caution
-Thyroid dysfunction: Use with caution
-Patients with potential for folate deficiency: Use with caution (malnourished, chronic antiseizure
therapy, or elderly)
-C. difficile infection (CDI) has occurred with sulfamethoxazole/trimethoprim
-Drug-induced liver injury – hepatotoxicity: (mixed hepatocellular cholestasis)
-Various blood dyscrasias (agranulocytosis, hemolytic anemia, leukopenia, and thrombocytopenia)
-Hyperkalemia and hyponatremia (dose-related, reversible)
-Hypoglycemia
-Immediate hypersensitivity reactions (non dose-related, immunologic)
-Delayed hypersensitivity reactions – days/weeks after exposure (generalized exanthematous
pustulosis, DRESS, SJS, Sweet’s syndrome, and TEN)
DDIs:
+phenytoin (increased phenytoin/decreased TMP-SMX serum conc – consider alternatives)
+warfarin (reduce warfarin weekly dose by 10-20% + monitor INR/bleeding closely)
Preparation/administration Administer with ~240ml water with or without meals
and stability/sensitivity )‫مل‬240( ‫كبت‬
‫يعىط للمريض مع كوب ماء ر‬-
Notes -In pregnancy: Increased risk of congenital malformations following maternal use during
pregnancy has been observed. Adequate maternal folic acid supplementation may decrease the
risk of some birth defects, if use is absolutely necessary. Avoid use in 3 rd trimester
Cost/tablet:0.33495 LE
Monitoring parameters CBC, electrolytes, renal function, signs/symptoms of hypersensitivity
Unfractionated heparin – 5,000 IU ampoules (Heparin sodium) ☀
Mechanism of action Potentiates the action of antithrombin III and thereby inactivates thrombin (as well as other
coagulation factors IXa, Xa, XIa, XIIa and plasmin). Prevents the conversion of fibrinogen to fibrin
Indication and doses Atrial Fibrillation: IV: Initial bolus 60-80units/kg (max 5,000units), followed by continuous infusion
12-18units/kg/hr (max 1,000units/hr) for ≥48hrs. Target aPTT of 1.5 to 2 times control
STEMI: IV: Initial bolus 60units/kg (max bolus dose is 4,000units in case of fibrinolytic being used.
If no fibrinolytic, max dose can be 5,000units), followed by continuous infusion 12units/kg/hr (max
1,000units/hr) for ≥48hrs. Target aPTT of 1.5 to 2 times control
NSTEMI: IV: Initial bolus 60units/kg (max 4,000units) followed by
continuous infusion 12units/kg/hr (max 1,000units/hr) for ≥48hrs. Target aPTT of 1.5 to 2 times
control
VTE prophylaxis: SUBQ: 5,000units /8-12hrs during hospital stay/fully ambulatory
VTE treatment: IV: Initial bolus 80units/kg (or 5,000 unit) , followed by continuous infusion
18units/kg/hr (or 1,333units/hr). Target aPTT of 1.5 to 2 times control. SUBQ: 333units/kg
followed by 250units/kg /12hrs
*Refer to hospital-based VTE prophylaxis protocol for details
Dose adjustment Hepatic impairment: no dose adjustment required. Adjust therapeutic dose heparin according to
aPTT as usual
Renal impairment: No dose adjustment necessary
Intermittent hemodialysis: no supplemental doses required
Obesity:
Thromboprophylaxis: BMI ≥30 kg/m2: 5,000-5,700 units /8hr
VTE treatment (IV route): BMI 30-39 kg/m2: Use actual body weight. BMI ≥40 kg/m2: Use adjusted
body weight
Older population (>60yr): Use the lower-end of dosages (can be more sensitive to heparin)
85 | P a g e
Important considerations CIs: hypersensitivity, severe thrombocytopenia, history of HIT + thrombosis, uncontrolled active
bleeding,
-Use with caution in patients with an increased risk of bleeding
-Dose requirements >35,000 units/24hrs to maintain a therapeutic aPTT may occur in patients
with antithrombin deficiency (heparin resistance)
-Elevations in serum aminotransferases have been observed
-Hyperkalemia may occur (patients with risk factors or taking concomitant K+-sparing drugs)
-Hypersensitivity reactions (fever, chills, urticaria, asthma, rhinitis, lacrimation and anaphylaxis)
-Discontinue/consider alternatives if plt count falls <100,000/mm3, there is a >50% reduction in plt
count from baseline and/or thrombosis develops on heparin therapy
DDIs:
+apixaban, +rivaroxaban (avoid combination)
+streptokinase (avoid concomitant use)
+aspirin, +NSAIDs (enhanced anticoagulant effect – consider dose reductions + monitor for bleed)
Preparation/administration -Administer SUBQ. Rotate injection sites. Do not administer IM
and stability/sensitivity -IV push: give undiluted, or dilute in 50ml G5%
-IV infusion: administer using a syringe pump - 5,000units (1 ampoule) diluted in 50ml NS or G5%
-Store ampoules at 20-25°C. Avoid freezing. Keep away from light
-Heparin infusion solution is stable for 28 days at 4°C
‫ يتم تدوير أماكن الحقن‬:‫للحقن تحت الجلد‬-
%5 ‫مل محلول جلوكوز‬50 ‫ أو باستخدام‬، ‫ يمكن حقنه دون تخفيف‬:‫للحقن الوريدي الشي ع‬-
‫ ويعىط باستخدام مضخة محاليل وريدية‬%5 ‫مل محلول ملح أو جلوكوز‬50 ‫ أمبول زف‬1 ‫ يحل‬:‫للحقن الوريدي المستمر‬-
ً
‫ يحفظ بعيدا عن الضوء‬،‫ يمنع تجميده‬،‫ مئوية‬25-20 ‫يحفظ زف درجة حرارة‬-
‫ مئوية‬4 ‫ يوم عند حفظه زف درجة حرارة‬28 ‫المحض للحقن الوريدي يمكن استخدامه خالل‬
‫ز‬ ‫المحلول‬-
Notes -Doses and duration provided in acute MI management is based on conservative strategy (no PCI)
-Heparin infusion: adjust rate to maintain target laboratory values (1-1.5 times the control value)
-VTE prophylaxis: Low-weight patients (<50 kg) may be more sensitive to prophylactic doses.
Consider adhering to /12hr dosing interval
-VTE treatment: IV heparin may be preferred for initial therapy in patients who are
hemodynamically unstable
-Central venous catheters: Must be flushed with heparin solution when newly inserted, daily (at
the time of tubing change), after blood withdrawal or transfusion, and after an intermittent
infusion through an injectable cap
-In pregnancy: Heparin may be used but LMWH is preferred
Monitoring parameters -Platelet count, PT, aPTT, hemoglobin, hematocrit, signs/symptoms of bleeding, risk factors for
bleeding, fecal occult blood test (if clinically indicated), potassium
-HIT: Assess for risk if thrombocytopenia occurs using 4Ts score
Ursodeoxycholic acid, ursodiol – 450mg capsules (Livagoal)
Mechanism of action Decreases the cholesterol content of bile and bile stones by reducing the secretion of cholesterol
from liver and fractional reabsorption of cholesterol by the intestines. Reduces hydrophobic bile
acids
Indication and doses Non-alcoholic steatosis hepatitis: Oral: 13-15 mg/kg/day in 2-4 divided doses
Dose adjustment Renal impairment: No dosage adjustment necessary
Important considerations CIs: hypersensitivity, use in calcified cholesterol stones, radiopaque stones, or radiolucent bile
pigment stones, patients with unremitting acute cholecystitis, cholangitis, biliary obstruction,
gallstone pancreatitis, or biliary-gastrointestinal fistula, allergy to bile acids, complete biliary
obstruction of extrahepatic origin, widespread intrahepatic obstruction
-Maintain bile flow during therapy to prevent obstruction
-Use with caution in patients with chronic liver disease (monitor LFTs). Consider discontinuation in
patients with significant elevations in LFTs
Preparation/administration Taken with food
86 | P a g e
Notes -In pregnancy: considered first-line therapy for treatment of intrahepatic cholestasis of pregnancy
during the second and third trimesters of pregnancy by the American College of Gastroenterology
guideline for liver disease in pregnancy
Monitoring parameters ALT, AST, ultrasound on abdominal area
Vancomycin – 500mg vials (Vancolon)
Mechanism of action Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding
tightly to D-alanyl-D-alanine portion of cell wall precursor
Indication and doses Bloodstream infection (empiric/culture-based for MRSA): IV: LD 20-35mg/kg (max 3gm) then MD
15-20mg/kg /8-12hrs for ≥14 days from first -ve blood culture (longer courses warranted for
endocarditis/metastatic sites of infection)
C. difficile prophylaxis (high-risk patients): Oral: 125mg /6hrs for 5-7 days (after completion of
systemic antibiotics)
C. difficile treatment - Initial, non-fulminant infection: Oral: 125mg /6hrs for 10 days. If delayed
response consider duration up to 14 days
Recurrent, non-fulminant infection: 125mg /6hrs for 10 days. If delayed response consider
duration up to 14 days (may be reserved for patients who did not receive vancomycin in initial
episode)
Fulminant infection (ileus, megacolon, and/or hypotension/shock): Oral/via nasogastric tube: 500
mg 4 times daily + IV metronidazole for 10 days. If delayed response consider duration up to 14
days (if ileus is present, may consider vancomycin retention enema)
Cystic fibrosis moderate-severe exacerbation (empiric/culture-based for MRSA): IV: 15-20mg/kg
/8-12hrs for 10-14 days based on response
Bacterial meningitis (empiric/culture-based for MRSA and resistant S. pneumoniae): IV: LD 20-
35mg/kg (max 3gm) then MD 15-20mg/kg /8-12hrs. Duration for MRSA and pneumococcal
infections is 10-14 days
Pneumonia (empiric/culture-based for MRSA): IV: LD 20-35mg/kg (max 3gm) then MD 15-
20mg/kg /8-12hrs for 7 days
Sepsis/septic shock (empiric/culture-based for MRSA): IV: LD 20-35mg/kg (max 3gm) then MD 15-
20mg/kg /8-12hrs. Administer within 1hr of sepsis suspicion/identification. Duration is guided by
underlying source + clinical response
*Refer to the hospital-based antibiotics policy for details
Renal impairment:
CrCl Loading dose Maintenance dose Interval
>90 to <130 25-30 mg/kg 15-20 mg/kg /8-12 hours
50-90 20-25 mg/kg 15-20 mg/kg /12 hours
15-49 20-25 mg/kg 10-15 mg/kg /24 hours
<15 20-25 mg/kg 10-15 mg/kg /48-72 hours
Obesity: BMI ≥30 kg/m2: Loading dose: calculate dose based on actual body weight. Maintenance
dose: measure peak and trough serum levels for optimization
Avoid using the formulation that contains polyethylene glycol (PEG 400) and N-acetyl D-alanine
(NADA) during first/second trimester of pregnancy, due to risk of animal fetal malformations
CIs: hypersensitivity
-IV vancomycin is an irritant. Ensure proper needle/catheter placement prior to and during
infusion to avoid extravasation
-Use with caution in patients with renal impairment or receiving other nephrotoxic drugs
-Rarely cause rapid, life-threatening immune-mediated anaphylaxis (generalized, extensive
pruritus and/or erythema of skin, respiratory distress, bronchospasm, hypoxia, and hypotension)
87 | P a g e
similar to a nonimmune-mediated anaphylactoid infusion-related reaction formerly called “red
man syndrome “
-C. difficile colitis has been reported with IV vancomycin
-Risk of drug-induced immune thrombocytopenia (DITP)
-Delayed hypersensitivity (maculopapular rash, DRESS, SJS, TEN, etc)
-Hematologic (neutropenia, pancytopenia, agranulocytosis, drug fever)
-Ototoxicity (tinnitus, hearing loss, vertigo, etc – non-dose related)
DDIs:
+aminoglycosides (ototoxic/nephrotoxic – avoid combination unless clinically indicated)
+colistin (nephrotoxic – avoid combination whenever possible)
Preparation/administration -IV: dilute 500mg in 100ml NS or G5% (final conc 5mg/ml) and administer every 500mg over
and stability/sensitivity ≥30mins
-Oral: dilute 500mg using 120ml water and give 30ml (125mg per dose) orally for C. difficile. Stable
for 24hrs
‫ ويعىط عىل مدار نصف ساعة عىل األقل لكل‬%5 ‫مل محلول ملح أو جلوكوز‬100 ‫مجم زف‬500 ‫ يحل كل‬:‫لالستخدام الوريدي‬-
‫مجم‬500
‫مل) ويحفظ ى‬30( ‫ وتعىط جرعة‬، ‫مل ماء مقطر‬120 ‫مجم زف‬500 ‫ يحل‬:‫لالستخدام عن طريق الفم‬-
‫الباف – صالح لالستخدام‬
‫ ساعة‬24 ‫خالل‬
Notes -IV use: individualize vancomycin dose using early Bayesian model (2 serum concentrations within
first 24-48hrs) to achieve target AUC
-C. difficile prophylaxis: For patients with a recent history of C. difficile infection (CDI) who
subsequently require systemic antibiotics. May reserve for patients who are older (≥65yrs),
significantly immunocompromised who have been hospitalized with severe CDI in the past 3
months. Other experts consider use for any patients with CDI in prior 12 months.
-C. difficile treatment: preferred for use over metronidazole
-Bacterial meningitis: empiric antimicrobial combination used is dependent on source of infection
(community-acquired or nosocomial)
-If severe renal impairment (CrCl <15): Monitor vancomycin serum conc more frequently,
especially early on in therapy
-Extravasation management: stop infusion immediately and disconnect (leave cannula/needle in
place). Gently aspirate extravasated solution. Do NOT flush the line. Remove needle/cannula.
Elevate extremity
Monitoring parameters -Renal function tests, CBC, pregnancy test prior to use (formulation containing PEG 400 and NADA
excipients), serial auditory function testing helpful to minimize risk of ototoxicity.
-Serum trough vancomycin conc in select patients (aggressive dosing, life-threatening infection,
seriously ill, unstable renal function, concurrent nephrotoxins, prolonged courses)
-Bayesian model to estimate AUC: requires Peak conc (Cmax) drawn 1-2hrs after infusion + trough
conc (Cmin) drawn at the end of the dosing interval
-Draw trough conc just before the administration of a dose at steady-state conditions (usually
within 1hr before administration of 4th dose)
-Target AUC/MICBMD: 400-600
-Target trough: 10 to 20 mg/L (should be 15 mg/L to meet target AUC/MIC of ≥400)
Verapamil – 2.5mg/ml ampoules (Izoptomil)
2+
Mechanism of action Inhibits Ca from entering “slow channels” of vascular smooth muscle and myocardium during
depolarization. Produces relaxation of coronary vascular smooth muscle and coronary
vasodilation. Increases myocardial oxygen delivery in patients with vasospastic angina. Slows
automaticity and conduction of AV node
Indication and doses Atrial fibrillation/flutter (acute ventricular rate control), SVT, and ventricular arrhythmias:
IV: 5-10 mg over ≥2mins. If inadequate response, repeat after 15-30mins. Total doses: x2 doses
Refractory Atrial fibrillation/flutter: continuous infusion 5-20mg/hr (titrate to goal heart rate)
-Severe impairment: use with caution + monitor ECG
-In cirrhosis: reduce dose to 50% + monitor ECG
-In repeat doses: monitor BP and PR-interval closely. Use smaller doses
88 | P a g e
Important considerations CIs: hypersensitivity, severe LV dysfunc, cardiogenic shock, sick sinus syndrome, 2nd and 3rd degree
AV block (without pacemaker), concurrent IV beta blocker or ivabradine, Wolff-Parkinson-White
syndrome, Lown-Ganong-Levine syndrome, ventricular tachycardia
-Patients with wide complex tachycardias (unless supraventricular) – avoid
-Duchenne muscular dystrophy, myasthenia gravis – use with caution/reduce dose
-Heart failure – avoid
-Left ventricular systolic dysfunction (result in acute HF, pulmonary edema and/or hypotension)
-May cause first-, second-, third-degree AV block or bradycardia
-Hepatic effects (increased LFTs or self-limited jaundice)
DDIs:
+ivabradine (increased ivabradine conc – avoid arrhythmogenic combination)
+atorvastatin (risk of statin AEs – limit atorvastatin to max 20mg daily)
+fentanyl (increased fentanyl serum conc – reduce fentanyl dose/monitor for AEs)
+phenytoin (increased phenytoin conc – consider alternatives/monitor for phenytoin toxicity)
Preparation/administration -Administer IV push over ≥2mins
and stability/sensitivity -In older patients with SVT, administer over 3mins
‫ر ز‬
‫دقيقتي عىل األقل‬ ‫للحقن الوريدي عىل مدار‬-
‫ دقائق‬3 ‫ يعىط عىل مدار‬:‫لكبار السن‬-
Notes -In pregnancy: Calcium channel blockers may be used to treat hypertension. Hypertrophic
cardiomyopathy controlled with verapamil prior to pregnancy can continued
Monitoring parameters Blood pressure, heart rate, liver function
Vitamin B Complex ampoules (Neurovit, B-com) ☀
Mechanism of action Consists of vitamin B1, B6 and B12
Indication and doses Neurological/other disorders due to vitamin B complex deficiencies (prevention/treatment): IM:
ampoule once daily (in severe cases)
AEs: Sweating, tachycardia, injection-site/skin reactions
Notes Cost/ampoule: 2.714499 LE
Preparation/administration -Neurovit: Intended for IM use only
and stability/sensitivity -B-Com: Use immediately after dilution
‫ للحقن العضىل فقط‬:‫نيوروفيت‬-
‫ يستخدم ر‬:‫كوم‬-‫ئ‬-
‫مباشة بعد الحل‬
ً ‫ر‬
‫يحفظ زف درجة حرارة الغرفة بعيدا عن الضوء‬-
Vitamin K – 10mg/ml ampoules (Amri-K, Konakion)
Mechanism of action Synthetic preparation of vitamin K. The presence of vitamin K promotes liver synthesis of clotting
factors; prothrombin, factor VII, factor IX and factor X (anti-hemorrhagic activity)
Indication and doses Hypoprothrombinemia and hemorrhage caused by anticoagulant therapy: IM: 2.5-10mg. Repeat
/6-8hrs if necessary
Reversal of warfarin activity (supratherapeutic INR/bleeding incidence - urgent): IV: 2.5-10mg
single dose. Repeat INR 12-48hr later to decide if subsequent dose(s) needed
*Refer to hospital-based warfarin toxicity management algorithm for details
Hypersensitivity reactions with IV and IM use
-Dermatologic toxicity: Cutaneous reactions have occurred after parenteral administration
-Hypersensitivity/anaphylactoid reactions
-Anticoagulant-induced coagulopathy (high vit K doses (10 to 15 mg) may lead to warfarin
resistance for ≥1 week
-Liver disease/coagulopathy: If initial doses do not reverse coagulopathy, then higher doses are
unlikely to be effective
89 | P a g e
DDIs:
+warfarin (antagonizing effect – monitor for decreased PT/INR)
Preparation/administration -Amri-K: intended for IM route only
and stability/sensitivity -Konakion MM: for IV or oral use
-SUBQ administration is not recommended due to unpredictable absorption
-Low dose (1-2.5mg) of parenteral form of vitamin K can be given orally directly or dissolved (e.g:
in orange juice), in non-urgent situations
-IV administration: Dilution dose in 50ml NS or G5%. Administer using syringe pump over 30mins.
Faster rate not to exceed 1mg/min
‫ مخصص للحقن العضىل فقط‬:‫ك‬-‫أمري‬-
‫ مخصص للحقن الوريدي أو عن طريق الفم‬:‫كوناكيون‬-
‫ يعىط باستخدام مضخة محاليل وريدية عىل مدار نصف‬، %5 ‫مل محلول ملح أو جلوكوز‬50 ‫ يحل األمبول زف‬:‫للحقن الوريدي‬-
‫ساعة‬
Notes -Dose given should be governed by PT/INR monitoring
In pregnancy: antidotes should be administered if there is a clear indication for use and should not
be withheld because of fears of teratogenicity
-Cost/ampoule: 2.72474525 LE
Monitoring parameters PT/INR, resolution of vitamin K antagonist toxicity/bleeding
Warfarin – 3mg tablets (Marevan)
Mechanism of action Competitively inhibits the subunit 1 of multi-unit VKOR complex, thus depleting functional vitamin
K reserves and reducing synthesis of active clotting factors (factors II, VII, IX, and X), as well as
proteins C and S
Indication and doses Anticoagulation: Oral: Initial: 5mg once daily for most patients (lower/higher starting dose
depends upon patient-specific factors)
Dose adjustment Hepatic impairment: consider initiation with a lower dose as response may be markedly enhanced
in obstructive jaundice, hepatitis and cirrhosis. INR should be closely monitored
Renal impairment:
-Patients with eGFR <60mL/min/1.73 m2 tend to require ~10-20% lower warfarin doses and are at
higher risk of over-anticoagulation and bleeding (retrospective data). Consider starting with lower
initial doses + monitor INR closely
-End-stage kidney disease: tend to require ~20% lower doses. Use low initial dose + monitor INR
Older population:
Patients >60yrs tend to require lower dosages to produce a therapeutic level of anticoagulation
Warfarin can cause major or fatal bleeding. Monitor INR regularly and instruct patients on how to
minimize risk of bleeding/report any signs or symptoms of bleeding
CIs: Hypersensitivity, hemorrhagic tendencies (active GI ulceration or bleeding, respiratory or
urinary tract bleeding), cerebral aneurysm, CNS hemorrhage, dissecting aortic aneurysm, spinal
puncture, diagnostic/therapeutic procedures with potential for significant bleeding, major
regional lumbar block anesthesia, blood dyscrasias, malignant hypertension, pericarditis or
pericardial effusion, bacterial endocarditis, patients with high potential for noncompliance,
eclampsia/preeclampsia, threatened abortion, pregnancy (except with mechanical heart valves at
high risk for thromboembolism)
Precautions:
-Use with caution in patients with prolonged dietary insufficiencies (vit K deficiency)
-Use with caution in patients with heparin-induced thrombocytopenia (HIT)
-Use with caution in patients with acute infection, active TB or any disruption of normal GI flora
(antibiotics and fever may alter response)
-Use with caution in patients with thyroid disease (warfarin responsiveness may increase)
AEs: purple toe syndrome, skin rash, livedo reticularis, gangrene of skin and/or subcutaneous
tissues, abrupt and intense lower extremity pain, abdominal pain, flank pain, or back pain,
hematuria, calcium uremic arteriolopathy (rare)
DDIs:
+amoxicillin-clavulinate, +cefadroxil, +cefalexin, +ceftazidime, +metronidazole, +paracetamol
(increased risk of bleeding/INR elevation – monitor closely)
+fluconazole, +TMP-SMX (reduce warfarin dose by 10-20%, monitor INR/signs of bleeding)
90 | P a g e
+rifampin (decreased warfarin effect – monitor INR closely)
+vitamin K (antagonizing effect – monitor for decreased PT/INR)
Preparation/administration Administer with or without food. Outpatients: once a day at approximately the same time
Notes -Response to warfarin is influenced by numerous factors (e.g: age, organ function, concurrent
drugs, vitamin K-rich diet, supplements)
-Although an elevated INR can be seen as soon as 24-48hrs after 1st dose (depletion of factor VII),
this does not represent therapeutic anticoagulation because other vitamin K–dependent clotting
factors with longer half-lives must also be depleted (factors II, IX, and X)
-Overlap (bridging) with a parenteral anticoagulant may be necessary during initiation of warfarin
until a stable therapeutic INR is attained
-In pregnancy: Teratogenic effects have been reported following first trimester use.
-Use is contraindicated during pregnancy except in patients with mechanical heart valves who are
at high risk for thromboembolism (use during the first trimester may be considered if therapeutic
INR can be achieved with a dose ≤5mg/day or use LMWH until after the first trimester)
-Warfarin should be discontinued and changed to heparin at least 1 week prior to delivery
Monitoring parameters PT, INR, hemoglobin, hematocrit
91 | P a g e
References:
Drug monographs and drug-drug

interactions compiled from Lexicomp,
Micromedex, EMC, PDR and GlobalRPh
(latest access date Jan-2024)
Information from medications’ leaflets
FDA’s and ISMP’s 2016 Lists of Look-Alike

Drug Names with Recommended Tall-Man
Letters
2024 © ALL RIGHTS RESERVED

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Damanhour Chest Hospital

Drug Information Unit

Clinical Pharmacy Unit & DIC

Submit a drug information request

Drug Information Unit’s Library

Mahmoud Bakr, BCPS, RPh

Editing & Design

All product prices provided in this formulary are

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Please respect intellectual property rights and

Drug Page Drug Page Drug Page

AmLODIPine – 5mg and 10mg tablets (Alkapress, vasonorm)

Dose adjustment Renal Impairment:

DDIs: +colistin, +mannitol IV (avoid combination)

Dose adjustment Hepatic impairment:

Ondansetron – 4mg ampoules (Danset, emerest) ☀

Gastrointestinal symptoms (eg, nausea, diarrhea, dyspepsia, vomiting): No dose adjustments

Photosensitivity reaction/rash: No dose adjustments provided. Consider temporary dose

Dose adjustment Hepatic impairment:

Tranexamic acid – 500mg/5ml ampoule (Kapron)

Drug monographs and drug-drug

Information from medications’ leaflets

FDA’s and ISMP’s 2016 Lists of Look-Alike

You might also like

Hospital's Drug Formulary (2nd Edition)

Hospital's Drug Formulary (2nd Edition)

Hospital's Drug Formulary (2nd Edition)