Medication Use Guidelines - Hospice Pharmacia

HOSP ICE P H ARM A C I A 

MUGs 

® 

Medication Use Guidelines 

- 1 0 T H E D I T I O N - 

[ UPDATED JULY 2012 ] 

INFORMATION REGARDING THE JULY 2012 UPDATE: 

Duoneb and Miralax are now included in the Medication Use Guidelines (MUGs). 

For your reference, these additions resulted in updates to pages: 

54.1, 55.1, 73.2, 75.1, 76.1, 149.1, 155.2, 159.2, 161.2.

Dear Colleague, 

Hospice Pharmacia is pleased to present you with the leading resource for hospice pharmaceutical 

care, the Hospice Pharmacia Medication Use Guidelines (MUGs®). The MUGs, now in its 10th 

edition, provide information to help you select clinically appropriate, cost-effective medications 

for your hospice patients. 

These guidelines were developed with input from administrators, medical directors, physicians, 

nurse practitioners, directors of nursing, staff nurses and consultant pharmacists practicing 

hospice and palliative care across the country. This edition is thoroughly updated to include new 

medications for depression and herpes zoster, expanded indications for existing medications, the 

latest dosing information, and revised algorithms. In addition, it has been reorganized to include 

tables of medications and cost information for pharmacologic therapy outside the per diem. 

The MUGs are an ever-changing clinical and cost reference source that is modified and reviewed 

continuously through a Pharmacy and Therapeutics Committee. With this edition, going 

forward, the MUGs are bound in a format that allows sections to be updated without the need 

to replace the MUGs in its entirety. This will help to ensure that you always have the most up-todate 

information. 

Hospice Pharmacia is proud to provide the 10th anniversary edition of the MUGs. We hope 

the information in the MUGs will help further improve the quality of life for hospice patients 

in your care settings. As always, your comments and suggestions for future improvements are 

welcomed and valued. Thank you for the opportunity to work together to positively impact the 

care of your hospice patients. 

Professionally, 

Kevin T. Bain, PharmD, MPH, BCPS, CGP, FASCP 

Vice President, Clinical Support 

Hospice Pharmacia, Philadelphia, PA 

The Hospice Pharmacia Medication Use Guidelines | i |

Mission & Corporate Values 

MISSION 

To advance public health and well-being through a passionate commitment to the appropriate use 

of medication. 

CORPORATE VALUES: 

Value 1: Passion 

Ensuring the appropriate use of medication 

Value 2: Dedication 

Taking responsibility to improve patient care 

Value 3: Leadership 

Strategizing continually to provide efficient, effective, and quality services 

Value 4: Professionalism 

Creating measurable value with our patients, partners, and team members 

Value 5: Innovation 

Fostering an environment of success through evidence-based science, continual discovery, knowledge, 

and experience 

| ii | The Hospice Pharmacia Medication Use Guidelines

Table of Contents 

WELCOME TO HOSPICE PHARMACIA 1 

ESSENTIAL USER GUIDE TO HP SERVICES 1 

HP IMPORTANT CONTACT INFORMATION 4 

HOW TO USE THE MUGs 5 

IMPORTANT INSTRUCTIONS FOR USE 5 

EXAMPLE SECTION OF THE MUGs 6 

MEDICATION OVERVIEW 7 

SUGGESTED DOSING 7 

ROUTE OF ADMINISTRATION 7 

COMPOUNDS 7 

HP MEDICATION PAKS 8 

PER DIEM INCLUSIONS 12 

MEDICATIONS with CRITERIA 13 

MEDICATIONS with POLICIES 16 

LONG-ACTING OPIOIDS 16 

MORPHINE INFUSIONS 16 

MEDICATIONS USED FOR INFECTIONS 17 

PER DIEM EXCLUSIONS 19 

ACKNOWLEDGMENTS 20 

AUTHORS 20 

REVIEWERS 20 

FOCUS GROUP PARTICIPANTS 22 

HP EDITORIAL STAFF 23 

ADDITIONAL HP CONTRIBUTORS 23 

QUESTIONS and ANSWERS 25 

SYMPTOMS 27 

AGITATION 27 

ANXIETY 30 

ASCITES 33 

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS 35 

BOWEL OBSTRUCTION 38 

CACHEXIA 41 

CARDIAC-RELATED DISORDERS 44 

CONSTIPATION 54 

COUGH 57 

DELIRIUM 61 

The Hospice Pharmacia Medication Use Guidelines | iii |

Table of Contents 

DEPRESSION 63 

DIARRHEA 67 

DYSPEPSIA 70 

DYSPNEA 73 

EDEMA 78 

FEVER 80 

GENITOURINARY SYMPTOMS 81 

HEPATIC ENCEPHALOPATHY 83 

HICCUPS 84 

HYPERGLYCEMIA 87 

INFECTIONS 89 

INSOMNIA 96 

MALABSORPTION DUE TO PANCREATIC INSUFFICIENCY 99 

MOVEMENT-RELATED DISORDERS 100 

MUSCLE SPASMS 103 

NAUSEA/VOMITING 107 

OPHTHALMIC & ORAL SYMPTOMS 111 

PAIN, NEUROPATHIC 113 

PAIN, NOCICEPTIVE 118 

PRURITUS 126 

SECRETIONS 131 

SEIZURES 134 

THROMBOEMBOLIC-RELATED DISORDERS 137 

THYROID-RELATED DISORDERS 141 

UPPER GASTRIC DISORDERS 142 

URINARY INCONTINENCE 145 

MEDICATION INDEX by GENERIC (BRAND) NAME 149 

MEDICATION INDEX by BRAND (GENERIC) NAME 157 

INJECTABLE INDEX 166 

COMPOUND INDEX 167 

| iv | The Hospice Pharmacia Medication Use Guidelines

Welcome to Hospice Pharmacia 

Hospice Pharmacia (HP), a service of excelleRx, Inc., an Omnicare Company, is proud to be your 

hospice pharmacy provider. We provide pharmaceutical care services, including clinical consultations, 

medication profile reviews, drug information, and medication dispensing for hospices and 

their patients throughout the United States and its territories. Our state-of-the-art support center 

is an essential component of these comprehensive services. Below is an easy-to-follow user guide to 

our services. 

ESSENTIAL USER GUIDE TO HP SERVICES 

New Admissions 

• Admit a hospice patient into the HP system by using www.hospicepharmacia.com or by calling 

toll-free at 1-877-882-7820. 

• Review the patient’s entire medication profile (including over-the-counter medications and 

supplements, as well as medications determined by the hospice to be unrelated to the patient’s 

hospice-qualifying terminal diagnosis), discuss the patient’s clinical presentation, and determine 

the patient’s medication care plan with our staff. 

• Seek prior approval from your hospice-designated authorizer(s) for medications that are outside 

the HP per diem and determined by your hospice interdisciplinary team to be related to the 

patient’s hospice-qualifying terminal diagnosis. 

Current Patients Residing at Home 

• Contact our staff for clinical consultations and/or to request medications. 

• When medications are requested, HP typically dispenses a 15-day supply of medication via 

national courier directly to the patient’s residence or to an alternate address as designated by the 

patient and/or your hospice. 

• HP serves as the pharmacy provider for patients residing in an Assisted Living Facility (ALF) 

without a contracted pharmacy, whereby services are provided and medications are dispensed in 

the manner described above. When appropriate, please provide HP staff with the patient’s unit 

or apartment number. 

Current Patients Residing in a Long-term Care (LTC) Facility or ALF with a Contracted Pharmacy 

• To ensure accurate medication profiles, patient safety and proper billing, contact our staff with 

all new prescriptions or changes in medications, including over-the-counter medications and 

supplements, as well as medications determined by the hospice to be unrelated to the patient’s 

hospice-qualifying terminal diagnosis. 

• The facility pharmacy serves as the dispensing pharmacy for patients residing in a LTC facility or 

ALF with a contracted pharmacy. 

• Medication access is coordinated with the facility’s contracted pharmacy. 

• HP communicates billing information to the pharmacy via fax on admission and every time HP 

is informed of a medication profile change. 

• For admissions or updates to a patient’s medication profile, fax information to HP at 

1-877-265-6852. 

The Hospice Pharmacia Medication Use Guidelines | 1 |


• When faxing, please include the following information: 

- Cover sheet; 

- Demographic information; 

- Medication profile with an indication and specification of related (“covered by the hospice”) 

or unrelated (“not covered by the hospice”) for each medication; 

- Start/stop dates for each medication; and, 

- Your call-back number for any clarifications. 

New Prescriptions 

• HP dispenses medication(s) for a hospice patient pursuant to a written prescription from a 

licensed prescriber or telephone verbal order from a licensed prescriber or agent of the prescriber 

in accordance with applicable state and federal laws. 

- For medications classified as Schedule II Controlled Substances, please see the CII process 

below. 

• For new prescriptions, please contact our staff to profile the medication(s) and/or to have the 

medication(s) dispensed. 

• Non-urgent medication requests: 

- At the discretion of the hospice nurse, HP dispenses medication(s) for either Next Business 

Day or Second Business Day delivery. 

• Same day medication requests: 

- Call HP and provide our staff with the prescription(s) and name of the local pharmacy. 

- HP staff is available to assist with locating contracted local pharmacies in your area. 

- If the patient will need more than a 7-day supply of the medication(s), request that the 

medication(s) also be dispensed by HP for Second Business Day delivery. 

- Call the local pharmacy, provide the pharmacy with the prescription(s), request that the 

pharmacy bill HP using the PBM Plus card, and provide the pharmacy with our phone 

number. 

- There should be no co-payment (“charge”) for the patient. 

- HP staff is available 24 hours per day, 7 days per week to assist local pharmacies with 

billing issues related to the PBM Plus card. For billing issues, ask the local pharmacy to 

contact HP. 

- The PBM Plus card information is as follows: 

- Member ID No: Patient’s SSN 

| 2 | The Hospice Pharmacia Medication Use Guidelines


CII Process 

• The process for requesting medications classified as Schedule II Controlled Substances is similar 

to the process for requesting new prescriptions with a few exceptions noted below. 

• According to federal regulations, in order to dispense a medication classified as a Schedule II 

Controlled Substance, HP must receive a signed prescription from a licensed prescriber who has 

CII-prescribing privileges. This can be achieved in one of two ways. 

- The prescriber or agent of the prescriber can fax a valid hard-copy prescription to HP at 1- 

800-530-1565; or 

- If a hard-copy prescription is not available, HP sends a faxed-copy of the medication request 

to the prescriber. The prescriber must sign and return the faxed-copy of the medication 

request to HP prior to the medication being dispensed by HP. 

• When HP sends a faxed-copy of the medication request to a prescriber for signature, we request 

a 30-day supply of the medication on the patient’s behalf. 

- The prescriber can alter the quantity, including up to a 60-day supply of the medication. 

- HP dispenses the medication in 15-day supply increments. 

- As the quantity of the signed CII medication request becomes depleted, HP automatically 

sends a new faxed-copy of the medication request to the prescriber for signature. 

- If the prescriber signs the CII medication request, it is placed on the patient’s profile for 

future dispensing. 

- This is done to streamline the CII process, requiring less effort for the prescriber and your 

hospice. 

• If the request for a medication classified as a Schedule II Controlled Substance is urgent, the 

prescriber must contact the local pharmacy and follow the appropriate state and federal laws 

regarding CII prescriptions. 

Refills 

• For your convenience, refills can be requested via our Automated Refill & Discharge System, via 

www.hospicepharmacia.com, or by calling our support center. 

• The following policies apply to refills: 

- Only medications previously dispensed by HP and without a change in the prescription are 

eligible for refill. 

- Refills must be requested by a licensed healthcare professional affiliated with your hospice or 

prescriber caring for the patient; they cannot be requested by a patient, caregiver, or other 

person not otherwise indicated. 

- Medications may be refilled within seven days of the refill due date marked on the label. 

- There is a delivery surcharge for refills requested for Saturday delivery. 

Delivery of Medications 

• HP offers the following convenient delivery options for your patients: 

- Next Business Day; 

- Second Business Day; and, 

- Saturday delivery in selected locations. 

• You can check the status of a delivery for your patient by tracking the package at 

www.hospicepharmacia.com or by calling Customer Service (CS) at HP. 

• Signature is not required for delivery unless specifically requested by your hospice. 

• Medication requests received by the following times will depart our facility for Next Business 

Day or Second Business Day delivery: 

- Weekdays (Monday through Friday): 8:30 p.m. Eastern Time 

- Saturday: 3:00 p.m. Eastern Time 



Trouble Shooting 

• Report all customer service and quality assurance (QA) issues and variances to HP immediately 

either through the CS icon at www.hospicepharmacia.com or by calling HP. 

HP IMPORTANT CONTACT INFORMATION 

To access all of Hospice Pharmacia’s services, 24 hours per day – 7 days per week, call 

1-877-882-7820. 

Toll-Free Direct Telephone Numbers 

• HP Pharmacy: 1-877-882-7820 

• HP Administration: 1-877-882-7822 

• Physician Line: 1-877-288-4633 

• Customer Service: 1-866-670-8162 

• Inpatient Unit (IPU) Services: 1-866-703-1726 

• HP Wound Care Services: 1-800-790-4138 

Toll-Free Fax Numbers 

• CII Prescription Fax: 1-800-530-1565 

• LTC Fax: 1-877-265-6852 

• IPU Fax: 1-866-923-5791 

e-Mail and Web Site Addresses 

• Customer Service: customerservice@hospicepharmacia.com 

• General Information: info@hospicepharmacia.com 

• MUGs: MUGs@hospicepharmacia.com 

• HP Online Support: support@hospicepharmacia.com 

• Web Site: www.hospicepharmacia.com 

Hours of Service – Support Center 

• Weekdays (Monday through Friday): 8:30 a.m. – 11:00 p.m. Eastern Time 

• Weekends (Saturday and Sunday) and Holidays: 9:00 a.m. – 8:00 p.m. Eastern Time 

After Hours Assistance and Support 

• Service: 1-877-882-7820 

- A message may be left for the pharmacy to retrieve the next business day; or, 

- Access to our Automated Refills & Discharges system; or, 

- Transfer to our Messaging Center for contact with an HP Pharmacist. 

• On-call Pharmacist Direct: 1-866-763-2543 

- Please limit use to emergent patient care-related issues 

• On-call Administrator: 1-800-395-2371 

- Please limit use to emergent operational and/or administrative issues 


How to Use the MUGs 

IMPORTANT INSTRUCTIONS FOR USE 

The MUGs is both informative and easy to use. It is organized alphabetically into sections 

according to specific indications. Each section includes the name of the indication, diagnosisrelated 

inclusion code(s), acronyms used in that section, pharmacologic therapy included in the 

per diem, non-pharmacologic therapy, and notes. Some sections may include an algorithm and 

some also include information on pharmacologic therapy outside the per diem. An excerpt is 

shown below for reference. 

Pharmacologic therapy is summarized in tabular format and in alphabetical order according to 

medication class. The Pharmacologic Therapy Included in the Per Diem (A) section includes the 

name and suggested dosing of the medication(s). Medications typically dispensed by their generic 

name are listed generically in the tables; medications typically dispensed by their brand name also 

have a brand name listed. The suggested dosing refers to the usual adult dosage for the specific 

indication. 

The Pharmacologic Therapy Outside the Per Diem (B) section includes the name of the 

medication(s) and the average cost of therapy. The average cost of therapy refers to the combined 

average cost of all strengths of a given medication. The dollar amount shown does not reflect the 

actual price of any single unit of the medication nor is it representative of what a hospice would be 

charged for the medication; rather, it is intended to provide an approximation for the relative cost 

of therapy. The actual cost of therapy is determined by the current contracted average wholesale 

price (AWP) and will vary based on the medication strength and dosage and the quantity of 

medication requested. Please inquire with HP staff to determine the actual cost of pharmacologic 

therapy outside the per diem. When combined with clinical information, including a patient assessment, 

the average cost of therapy is information that may be helpful with medication selection. 

The Non-pharmacologic Therapy (C) section includes strategies for managing the indication that 

do not fall within the realm of pharmacologic therapy. The Notes (D) section includes additional 

information related to the indication and/or one or more of the medication classes. 

*Please refer to the MUGs section example on the next page. 


How to Use the MUGs 

EXAMPLE SECTION OF THE MUGs 

A 

B 

C 

D 


Medication Overview 

SUGGESTED DOSING 

The suggested dosing provided in the MUGs refers to usual adult dosages. A guiding principle in 

patient care is that therapy must be tailored to the unique medical needs of the individual patient. 

This principle may be even more important in the hospice population, particularly among frail older 

adults, in which the propensity for (and cost of) iatrogenic harm is heightened. Unless otherwise 

noted, the suggested dosing provided throughout the MUGs is not intended to imply restrictions 

on dosages included in the HP per diem; rather, it is intended to guide the practicing clinician in 

choosing a safe and effective dosage for the individual patient. Dosages may need to be adjusted based 

on age, hepatic and/or renal function, concurrent medications, and clinical response, among other 

considerations. Please consult with your HP pharmacist for assistance with dosage adjustments. 

ROUTE OF ADMINISTRATION 

The oral route of administration is the preferred route of administration for most medications, primarily 

because it is the least invasive and the most extensively studied method of medication delivery. 

When the oral route becomes less reliable or unsuitable for administering medications, please consult 

with your HP pharmacist to discuss alternative routes of administration, including medication dosage 

formulations and dosing. 

COMPOUNDS 

At the end of life, routes of medication administration may be compromised. Although HP includes 

a multitude of commercially available dosage formulations in the per diem, for some patients there is 

no good alternative formulation available. As part of its comprehensive services, HP will compound a 

medication approved by the U.S. Food and Drug Administration (FDA) into a formulation requested 

by a licensed prescriber for use in an individual hospice patient. The compound index at the end of 

the MUGs is your resource for compounded formulations that are included in the HP per diem. 

Please consult with your HP pharmacist to discuss formulations for your patient. 

HP MEDICATION PAKS 

Hospice medication paks are frequently provided in the hospice patient’s home to prevent delays 

in treating symptoms that occur suddenly or when the route of administration needs to be altered. 

Medication paks often avert emergency department visits and hospital admissions, allowing patients 

and their families to receive care at home and reducing health care expenditures. Hospice Pharmacia 

was the first in the industry to provide medication paks for hospices and their patients. We are pleased 

to provide your hospice with four types of medication paks: ComfortPak, Cardiac ComfortPak, 

Pediatric ComfortPak, and Seizure ComfortPak. 


HP Medication Paks 

1. ComfortPak 

Indication Contents Quantity Directions for Use 

Pain, Fever 

Agitation 

Secretions 

Anxiety 

Pain, 

Shortness of 

breath 

Nausea, 

Vomiting 

Nausea, 

Vomiting 

2. Cardiac ComfortPak 

Acetaminophen 650 mg 

suppository 

Haloperidol 2 mg/mL oral 

concentrate 

Atropine 1% ophthalmic 

drops 

Lorazepam 1 mg tablet 

CIV 

Morphine sulfate 

20 mg/mL oral 

concentrate 

CII prescription for a 

terminally ill hospice 

patient 

Prochlorperazine 10 mg 

tablet 


suppository 

6 (six) 

suppositories 

15 (fifteen) 

mL 

2 (two) mL 

10 (ten) 

tablets 

15 (fifteen) 

mL 

6 (six) tablets 

6 (six) 

suppositories 

Insert 1 suppository rectally every 

6 hours as needed for mild pain or 

fever. 

Take 0.5 mL (1 mg) by mouth or 

under the tongue every 6 hours as 

needed for agitation. 

Place 2 drops under the tongue every 

4 hours as needed for secretions. 

Take 1 tablet by mouth every 6 hours 

as needed for anxiety. 



needed for moderate to severe pain 

or shortness of breath. 


as needed for nausea and vomiting. 


12 hours as needed for nausea and 

vomiting. 


Take as directed by mouth as needed 

for edema. 

Edema Furosemide 40 mg tablet 10 tablets 

Edema 

Furosemide 10 mg/mL 

solution for injection 

2 x 2 mL 

(vials) 

Contact the prescriber to obtain 

appropriate dose and instructions. 

Contact the HP pharmacist to 

communicate the patient-specific dose 

and instructions for this medication. 

Inject intravenously or intramuscularly 

as directed as needed for edema. Do 

not exceed a rate of 10 mg/min if 

given intravenously and the dose is < 

120 mg. 

Contact the prescriber to obtain 

appropriate dose and instructions. 

Contact the HP pharmacist to 

communicate the patient-specific dose 

and instructions for this medication. 



Chest pain 

Nitroglycerin sublingual 

0.4 mg tablet 

25 tablets 

Chest pain Aspirin 325 mg tablet 5 tablets 

Pain, 

Shortness of 

breath 

Morphine sulfate 10 mg/ 

mL solution for injection 



patient 

2 x 1 mL 

(vials) 

Take 1 tablet under the tongue every 

5 minutes for up to 3 doses as needed 

for chest pain. If 3 doses have been 

administered and chest pain is still 

present, contact the prescriber and 

notify the hospice nurse for further 

instructions. 

Chew 1 tablet by mouth for 1 dose 

with onset of chest pain. 

Contact the prescriber and notify the 

hospice nurse for further instructions. 

Inject 0.5 mL (5 mg) intravenously 

or subcutaneously every 2 hours as 

needed for severe pain or shortness 

of breath. 

3. Pediatric ComfortPak 

Indication 

Contents 

Dosage Calculation & Assessment 

Notes 

(Dose/weight (kg) x Weight (kg) 

= Dose) 

Qty 

Directions for 

Use 

Nausea, 

Vomiting 

Anxiety, 

Agitation 

Prochlorperazine 

syrup 5 mg/mL 

Lorazepam oral 

concentrate 

2 mg/mL 

CIV 

0.1 mg/kg x kg = mg 

Remove prochlorperazine if the patient 

is less than 2 years old OR less than 

10 kg (22 lbs). (Place a line through the 

item and initial next to the line.) 


OR 


Consult with an HP pharmacist 

to select the most appropriate 

dose between the dosage ranges 

calculated above. 

3 mcg/kg x kg = mcg 

15 

(fifteen) 

mL 

15 

(fifteen) 

mL 

Take mg 

by mouth 

divided 4 times 

daily as needed 

for nausea and 

vomiting. 

Take mg 

by mouth 

divided 4 times 

daily as needed 

for anxiety or 

agitation. 

Secretions 

Hyoscyamine oral 

solution 

0.125 mg/mL 

For patients less than 5kg, the dose 

for hyoscyamine (as seen to the right) 

cannot be accurately measured. Use 

the following alternate dosing regimen 

according to patient weight. 

5 kg = 20.8 mcg/dose; 3.4 kg = 16.7 

mcg/dose; 2.3 kg = 12.5 mcg/dose 

15 

(fifteen) 

mL 

Take mcg 

by mouth 

every 4 hours 

as needed 

for excess 

secretions. 

The Hospice Pharmacia Medication Use Guidelines | 9.1 |


Agitation 

Insomnia, 

Itching 

Nausea, 

Vomiting 

Haloperidol 

(pediatric) oral 

solution 1 mg/mL 

Diphenhydramine 

syrup 2.5 mg/mL 

Metoclopramide 

syrup 5 mg/mL 


OR 






Remove haloperidol if the patient is less 

than 3 years old. (Place a line through the 

item and initial next to the line.) 

1 mg/kg x kg = mg 


OR 






15 

(fifteen) 

mL 

30 

(thirty) 

mL 

15 

(fifteen) 

mL 

Take mg 

by mouth or 

under the 

tongue divided 

3 times daily 

as needed for 

agitation. 

Take mg 

by mouth every 

6 hours as need 

for sleep or 

itching. 

Take mg 

by mouth 

every 6 hours 

as needed for 

nausea and/or 

vomiting. 

4. Seizure ComfortPak 


Pain, Fever 

Agitation 

Secretions 

Anxiety 

Pain, 

Shortness of 

breath 

Nausea, 

Vomiting 

Nausea, 

Vomiting 

Seizure 

Acetaminophen 650 mg 

suppository 

Haloperidol 2 mg/ mL 

oral concentrate 

Atropine 1% ophthalmic 

drops 

Lorazepam 1 mg tablet 

CIV 

Morphine sulfate 20 

mg/mL oral concentrate 



patient 


tablet 


suppository 

Lorazepam 2 mg 

suppository 

CIV 

6 (six) 

suppositories 

15 (fifteen) 

mL 

2 (two) mL 

10 (ten) 

tablets 

15 (fifteen) 

mL 

6 (six) tablets 

6 (six) 

suppositories 

3 (three) 

suppositories 

Insert 1 suppository rectally every 6 

hours as needed for mild pain or fever. 



needed for agitation. 

Place 2 drops under the tongue every 

4 hours as needed for secretions. 


as needed for anxiety. 



needed for moderate to severe pain 

or shortness of breath. 


as needed for nausea and vomiting. 


12 hours as needed for nausea and 

vomiting. 

Insert 1 suppository rectally every 10 

minutes until seizure activity stops, up 

to a maximum of 2 doses. 

| 10.1 | The Hospice Pharmacia Medication Use Guidelines


HP MEDICATION PAK DISPENSING 

Prior to HP dispensing a medication pak, your hospice team should determine the safety and 

feasibility of having a pak in the residence. This is especially important for assisted-living and longterm 

care facilities where paks are sometimes not permitted due to local policies and procedures. 

When requesting medication paks for assisted-living and long-term care facilities, your hospice 

staff should: (i) inform HP staff that the facility will accept a medication pak, (ii) request that HP 

designate “signature required” on the delivery, and (iii) communicate specific delivery instructions 

(e.g., “deliver to nurse station”) to HP staff. 

Although medications cannot be added to a pak, your hospice may choose to have certain medications 

removed from a pak prior to dispensing. Please let your HP pharmacist know if a medication 

should be removed from a pak. 

ADDITIONAL COMFORTPAK INFORMATION 

HP Medication 

Pak 

ComfortPak 

Pediatric 

ComfortPak 

Inclusion Code 

(refer to the 

next section 

for definitions) 

A 

A 

Pak Storage 

Temperature 

controlled 

environment or 

refrigerated 

Temperature 

controlled 


refrigerated 

Additional Information 

Please refer to the Hospice 

Pharmacia Pediatric Medication Use 

Guidelines for additional information. 

The Cardiac ComfortPak is dispensed 

as a separate medication pak. 

Cardiac 

ComfortPak 

Seizure ComfortPak 

H 

A 

Specifically for 

patients at risk 

for an acute 

seizure related 

to the hospicequalifying 

terminal 

diagnosis 

Room 

temperature 

(do not 

refrigerate) 

Temperature 

controlled 


refrigerated 

The Cardiac ComfortPak does not 

contain parenteral supplies such as 

syringes, filter needles, or flushes; with 

the exception of flushes, parenteral 

supplies are outside the HP per diem 

(refer to the injectable index for 

flushes). 

Contains the same contents as the 

ComfortPak plus three lorazepam 

suppositories. 

When appropriate, for patients at 

risk for an acute seizure who have 

a ComfortPak in the residence, the 

hospice should request lorazepam 

suppositories as a separate 

prescription. 


Per Diem Inclusions 

Medications are included in the HP per diem based on the patient’s primary diagnosis. The patient’s 

primary diagnosis refers to the hospice-qualifying terminal diagnosis, determined by the hospice 

at admission and based on the International Classification of Diseases, Ninth Revision, Clinical 

Modification (ICD-9-CM) codes. Confirmation of the primary diagnosis and determination of 

which medications are related to the diagnosis are the responsibilities of the hospice. Determination 

of which medications are included in the HP per diem for an individual patient is the responsibility 

of HP. Hospice Pharmacia determines which medications are included in the HP per diem based 

on the following diagnosis-related inclusion codes: 

A: All symptoms related to the patient’s hospice-qualifying terminal diagnosis as determined by 

the hospice. 

C: Cancer and HIV/AIDS diagnoses, defined as ICD-9-CM codes 042 or 140-239. 

H: Heart (cardiac) diagnoses, defined as ICD-9-CM codes 391-429 or 440-459. 

L: Lung diagnoses, defined as ICD-9-CM codes 460-519. 

O: Other diagnoses that do not fall into one of the other diagnosis-related inclusion codes (e.g., 

cerebrovascular disease, defined as ICD-9-CM codes 430-438; cystic fibrosis, defined as ICD- 

9-CM code 277). 

Medications may fall into one of three categories: 

1. Related to the patient’s terminal diagnosis and medication is included in the HP per diem; or, 

2. Related to the patient’s terminal diagnosis but medication is outside the HP per diem; or, 

3. Not related to the patient’s terminal diagnosis and, therefore, medication is outside the HP per diem. 

Each hospice provider is responsible for carefully reviewing the patient’s medication regimen and 

determining which medications are needed or not needed to care for the patient. Medications that 

are not needed should be considered for discontinuation. The hospice is responsible for covering 

all medications that are needed to care for the patient’s terminal diagnosis and related conditions, 

regardless of HP per diem inclusion status. Determining whether a particular medication or a 

particular condition is related or unrelated to a patient’s terminal diagnosis requires thorough evaluation 

by the hospice medical director, patient’s attending physician, and interdisciplinary team. 


Medications with Criteria 

Some medications in the MUGs have criteria that must be met to be included in the HP per diem. 

These criteria, which are specified in the table below, apply to medications with Inclusion Code: A. In 

addition, some medications that are listed in sections designated with Inclusion Code: C, H, L, and O 

also have criteria. The term “primary diagnosis” used below refers to the hospice-qualifying terminal 

diagnosis as determined by the hospice. 

Your hospice may choose to prescribe a medication for a patient in a manner that does not follow the 

specified criteria and therefore is outside the HP per diem. This does not infer that a medication is 

unrelated to the patient’s primary diagnosis. To the contrary, according to federal regulations, if 

a hospice determines that a medication is related to the patient’s primary diagnosis, the hospice 

is responsible for covering the medication, regardless of HP per diem inclusion status. Hospice 

Pharmacia dispenses medications outside the per diem but requires prior authorization. Determination 

of personnel with prior authorization accountability is the responsibility of the hospice. The 

name(s) of personnel granting prior authorization should be communicated to HP through your 

hospice’s Client Relations Liaison (CRL) and updated as necessary. 

Hospice Pharmacia pharmacists will assist your hospice in selecting alternative medications that are 

included in the HP per diem. If there are no alternative medications included in the HP per diem for 

a particular symptom or condition that the hospice has determined is related to the patient’s primary 

diagnosis, HP pharmacists will assist your hospice in selecting the most cost-effective and clinically 

appropriate medication available. Please consult with your HP pharmacist for medication selection. 

Medication Criteria Page(s) 

Acyclovir (ZOVIRAX ® ) 

For the short-term (< 10 days) treatment of herpes 

zoster related to the primary diagnosis. AND 

Therapy is started within 72 hours of the first sign 

89 

or symptom of herpes zoster. 

Glipizide 

(GLUCOTROL ® ) 

Glyburide (DIABETA ® , 

MICRONASE ® ) 

Insulin (HUMULIN ® or 

NOVOLIN ® NPH, REG, 

and 70/30) 

For the management of hyperglycemia induced by 

a medication used for a symptom related to the 

primary diagnosis. AND 87 

Hyperglycemia affects the patient’s quality of life. 











Misoprostol 

(CYTOTEC ® ) 

Omeprazole 

(PRILOSEC ® ) 

Oxybutynin 

transdermal patch 

(OXYTROL ® ) 

Oxycodone and 

acetaminophen 

(ENDOCET ® , 

PERCOCET ® ) 

Ranitidine (ZANTAC ® ) 

Salmeterol 

(SEREVENT ® DISKUS ® ) 

Salmeterol and 

fluticasone (ADVAIR ® 

DISKUS ® ) 

For gastrointestinal (GI) prophylaxis in patients 

who are at high risk for experiencing an upper GI 

adverse event AND prescribed a nonsteroidal antiinflammatory 

drug (NSAID) or salicylate related to 121 

the primary diagnosis. AND 

Total daily dosage is < 800mcg/day. 

For the management of dyspepsia. OR 

For GI prophylaxis in patients who are at high risk 

for experiencing an upper GI adverse event AND 

prescribed a NSAID or salicylate related to the 

71, 121, 142 

primary diagnosis. AND 

Total daily dosage is < 20mg/day. 

For the management of urinary incontinence 

related to the primary diagnosis. AND 

The patient is unable to tolerate oxybutynin 

immediate-release tablets. OR 

145 

The patient is unresponsive to a treatment trial of 

at least 4 to 8 weeks with oxybutynin immediaterelease 

tablets. 

For the management of pain related to the primary 

diagnosis. AND 

One of the following commercially available 

120 

formulations: 5/500mg capsule, 5/325mg tablet, or 

5/325mg/5mL oral solution. 

For the management of dyspepsia related to the 


Total daily dosage is < 300mg/day. 

For the management of dyspnea related to the 


The patient has a primary diagnosis of chronic 

75 

obstructive pulmonary disease or pulmonary 

malignancy. 




75 


malignancy. 



Sucralfate 

(CARAFATE ® ) 

Theophylline (THEO- 

DUR ® ) 

Tolterodine extendedrelease 

(DETROL ® LA) 

Valacyclovir 

(VALTREX ® ) 

For GI prophylaxis in patients who are at high risk 

for experiencing an upper GI adverse event AND 

prescribed a NSAID or salicylate related to the 


Total daily dosage is < 4gm/day. 





malignancy. 

For the management of urinary incontinence 

related to the primary diagnosis. AND 

The patient is unable to tolerate oxybutynin 

immediate-release tablets. OR 

The patient is unresponsive to a treatment trial of 

at least 4 to 8 weeks with oxybutynin immediaterelease 

tablets. 

For the short-term (< 7 days) treatment of herpes 

zoster related to the primary diagnosis. AND 

Therapy is started within 72 hours of the first sign 

or symptom of herpes zoster. 

121, 142 

74, 75 

145 

89 


Medications with Policies 

LONG-ACTING OPIOIDS 

The purpose of this policy is to protect patients from undue harm and provide hospices with the 

most cost-effective long-acting (LA) opioids. 

Hospice Pharmacia has the following policy regarding the use of LA opioids: 

• If a patient is prescribed two different LA opioids concurrently (e.g., morphine LA and fentanyl 

transdermal patch), regardless of whether both opioids are procured through HP, one of the LA 

opioids is outside the HP per diem. 

- Hospice Pharmacia determines which opioid is outside the per diem. 

• If a patient is prescribed a continuous opioid infusion and a LA opioid concurrently, regardless 

of whether the infusion has been procured through HP, the LA opioid is outside the HP per 

diem. 

• If a patient is prescribed one of the following regimens, the LA opioid is outside the HP per 

diem. 

- A fentanyl transdermal patch (DURAGESIC®) dosed more frequently than every 48 hours. 

- Morphine LA tablet (MS CONTIN®) dosed more frequently than every 8 hours. 

- Morphine extended-release (ER) capsule (KADIAN®) dosed more frequently than every 12 

hours. 

- Morphine LA tablet, morphine ER capsule, or a fentanyl transdermal patch prescribed “as 

needed.” 

• This policy does not apply to methadone. 

• Hospice Pharmacia dispenses opioids outside the per diem but requires prior authorization. 

MORPHINE INFUSIONS 

Hospice Pharmacia provides morphine infusions in the per diem for patients who require rapid 

control of their pain and/or require pain management but cannot easily be administered medications 

orally or through other routes. 

Hospice Pharmacia has the following policy regarding morphine infusions: 

• Morphine infusions are included in the per diem for intravenous and subcutaneous administration; 

morphine infusions administered via other routes (e.g., epidural, intrathecal) are outside 

the per diem and cannot be dispensed by HP. 

• In order for a morphine infusion to be included in the HP per diem, it must be dispensed by 

HP; morphine infusions cannot be adjudicated through the PBM Plus card. 

• In order for a morphine infusion to be dispensed for an individual patient, it must be delivered 

on the next business day. Therefore, HP must receive a signed CII prescription for the morphine 

infusion no later than 6:30 p.m. Eastern (3:30 p.m. Pacific) time Monday through Thursday. 

- If Saturday delivery is available to the patient’s residence then HP must receive a signed CII 

prescription for the morphine infusion no later than 6:30 p.m. Eastern (3:30 p.m. Pacific) 

time Friday. 

• Morphine infusions (bags or cassettes) can be prepared in concentrations up to 50mg/mL. 

• For CADD bags, a CADD Administration Set must be requested simultaneously. For this type 

of request, HP will attach and prime the tubing. The extension set is built into the CADD 

Administration Set and is included in the HP per diem. 



• For CADD cassettes, HP does not provide the extension tubing unless specifically requested. 

The extension tubing for CADD cassettes is outside the HP per diem. 

• With the exception of the extension set noted above and flushes, parenteral supplies are outside 

the HP per diem (refer to the injectable index for flushes). 

MEDICATIONS USED FOR INFECTIONS 

Inappropriate use of anti-infectives will promote development of resistance to anti-infectives, which 

not only affects the individual consuming the medication but also affects the surrounding environment 

and the individuals living within that environment, resulting in high human and economic 

costs. The purpose of this policy is to guide the appropriate use of anti-infectives in the hospice 

population by encouraging appropriate selection of anti-infectives, appropriate dosing, and appropriate 

duration of therapy. 

Hospice Pharmacia has the following policy regarding the use of anti-infectives: 

• Orally administered anti-infectives are included in the HP per diem for the short-term treatment 

of community acquired pneumonia, herpes zoster, oropharyngeal candidiasis, skin and skin 

structure infections, urinary tract infections, and vulvovaginal candidiasis related to the patient’s 

terminal diagnosis. 

• The specific indications included in the HP per diem are provided in the tables in the Infections 

section; orally administered anti-infectives used for indications other than those 

provided in the tables are outside the HP per diem. 

• The maximum duration of therapy included in the HP per diem for a single course of an 

orally administered anti-infective is 14 days. A second course with the same anti-infective 

for the same indication started within 7 days of the stop date of the first course is included in 

the per diem provided the second course of therapy does not exceed 14 days. A third course 

with the same anti-infective for the same indication started within 7 days of the stop date of 

the second course is outside the per diem. 

• Certain orally administered anti-infectives listed in the Infections section are available 

as powder for oral suspension. These powders need to be reconstituted at the time the 

medication is administered and, therefore, must be procured from a local pharmacy and 

billed through the PBM Plus card. 

• This policy also applies to anti-infectives administered via a feeding tube. 

• Topically administered anti-infectives are included in the HP per diem for the treatment of 

cutaneous candidiasis, ophthalmic infections, and skin and skin structure infections related to 

the patient’s terminal diagnosis; vaginally administered clotrimazole is included in the per diem 

for vulvovaginal candidiasis. 

• The specific indications included in the HP per diem are provided in the tables in the Infections 

section; topically and vaginally administered anti-infectives used for indications 

other than those provided in the tables are outside the HP per diem. 

• The duration of therapy of topically and vaginally administered anti-infectives vary. However, 

unless otherwise noted in the tables in the Infection section, treatment > 14 days is 

outside the per diem. 

• Rectally administered anti-infectives are outside the HP per diem. 

• Parenterally administered anti-infectives are outside the HP per diem; further, HP cannot dispense 

anti-infectives for parenteral administration. 



• Provided the anti-infective is used for the specific indication and duration, dosages other than 

those provided in the tables in the Infection section are included in the HP per diem. 

• Prophylactic therapy is defined as an anti-infective prescribed without a specific stop date. 

Prophylactic therapy is outside the HP per diem. 

• Topically administered clotrimazole, nystatin and silver sulfadiazine typically do not have a 

specific stop date because they are continued until healing occurs. These specific anti-infectives 

are not considered prophylactic therapy. 

• This policy also applies to metronidazole used for the treatment of infectious diarrhea 

(Clostridium difficile). 


Per Diem Exclusions 

Thousands of medications are marketed in the United States. Many medications are available in 

multiple dosage strengths and/or formulations. Each year, HP strives to include the most essential 

and cost-effective medications for end-of-life care in the per diem. The indices at the end of the 

MUGs are your guide to the medications included in the HP per diem. Please consult with your 

HP pharmacist to determine specific dosage strengths and/or formulations included in and outside 

of the HP per diem. The exclusion of a specific medication, dosage strength, or dosage formulation 

does not infer that the medication is unrelated to the patient’s primary diagnosis. To the 

contrary, according to federal regulations, if a hospice determines that a medication is related 

to the patient’s primary diagnosis, the hospice is responsible for covering the medication, 

regardless of HP per diem inclusion status. Hospice Pharmacia dispenses medications outside the 

per diem but requires prior authorization. An HP pharmacist will assist your hospice in selecting 

alternative medications that are included in the HP per diem, as well as assist in selecting the most 

cost-effective and clinically appropriate alternative medications that are outside the HP per diem 

when appropriate. 

MARKET CHANGES 

In an effort to ensure ongoing patient safety, the U.S. Food and Drug Administration (FDA) requires 

evidence that medications are both safe and effective prior to marketing in the United States. 

The FDA states that medications marketed without the required FDA approval may not meet modern 

standards for safety, effectiveness, quality, and labeling. To assist in this effort, in June 2006, the 

FDA issued a compliance policy guide, “Marketed Unapproved Drugs--Compliance Policy Guide,” 

that describes how the FDA intends to remove medications marketed in the United States that do 

not have the required FDA approval for marketing. As a result, a large number of medications have 

been removed from the market and more may be removed in the future. 

Hospice Pharmacia is aware of the impact the removal of certain medications has on the hospice 

and palliative care community. When a medication is removed from the market, HP will remove 

the medication from distribution and the HP per diem, and HP will notify your hospice of these 

changes. Hospice Pharmacia will continue to work with your hospice to provide alternative medications, 

and HP will continue to work with the FDA and key stakeholders to ensure that regulatory 

agencies understand the role of certain medications in hospice and palliative care. 


Acknowledgments 

We extend our thanks to everyone who participated in the development of the 10th edition of 

the MUGs. 

AUTHORS 

Jillian Baer, PharmD, CGP, BCPS 

Sr. Manager, Client/Patient Education 

Hospice Pharmacia 

Natalee Felten, PharmD, BCPS 

Pharmacist Trainer 


Carmen Jacobs, PharmD, CGP 

Clinical Pharmacist 


Jennifer Johansen, PharmD, BCPS 

Director, Drug Information 


Elisa Macklin, PharmD 



Thomas McCool, PharmD 

Pharmacist Leader 


Laura Scarpaci, PharmD, BCPS 

Manager, Clinical Performance Improvement 


Michelle Smith, PharmD, BCPS, CGP, CPE 



REVIEWERS 

Sanjay J. Amin, MD 

Medical Director 

Seasons Hospice & Palliative Care 

Renee Baird, RN, BSN, CHPN, CLCP 

Hospice Case Manager 

Mercy Medical Center Hospice 

Patty Boone, AND 


OSF Hospice 

JeriLu Breneman, RN, CHPN 

Hospice Per Diem Nurse 

Heartland Hospice 

Molly Brooks, RN, CHPN 

Hospice Administrator 

Heartland Hospice of Fairfax 

Patrick Carey, MD, ABIM, CAQ 

Hospice Medical Director 

Open Arms Hospice and McCall Hospice 

House 

Charlotte H. Creel 

Hospice Director 

Pointe Coupee Hospice 

Lucy W. Ertenberg, MD, FAAFP 

VP, Chief Medical Director 

Cornerstone Hospice 

Marie Etling, RN, BA, CHPN 


Hospice of Care Corporation 

Anne Finger RN, BSN 

Hospice Administrator 

Advocate Hospice 

Jacqueline P. Fournier, ACNS, NP, APN 

Health Reach Homecare and Hospice 

Christopher Frazer, RN, CHPN 

Hospice Manager 

Hospice of Moorestown VNA 



Shirley R. Hayes, MSN, CNS, AOCN 

Clinical Nurse Specialist 

Hospice of the Visiting Nurse Services 

Kathleen Heilich, RN, CHPN 

Case Manager, Field Program 

St. Anthony’s Hospice 

Patricia Hollis, RN, BSN, CHPN 

Triage Coordinator 

Hospice of Southern Indiana 

Nancy Hopkins, BSN 

Hospice Coordinator 

Rowan Regional Hospice 

Pamela L. Ingram, RN, BSN, MSN(c) 

Hospice Case Nurse 

DuBois Regional Medical Center Hospice 

Sandra Jackson, RN 


Rice Hospice 

Lauren Jaffke, ASN 


OSF Hospice-Rockford 

Suzanne Kelley, BSPharm 

Consultant Clinical Pharmacist 

Covenant Hospice 

Linda Kisby, RN, BSN, CHPN 

Director of Clinical Services 

AtlantiCare Hospice and Palliative Care 

Connie Leon, PharmD 


Hospice of the Comforter 

Rebecca Maxwell, LPN 

Resource CHPLN 

Vitas Innovative Hospice Care 

Sue McCausland, RN, BSN, CHPN 


AseraCare Hospice-Akron 

Debbie McGowan, RN, CHPN 


Celtic Hospice 

Mary Lynn McPherson, PharmD, BCPS, CPE 

Professor and Vice Chair 

University of Maryland School of Pharmacy 

Hospice Clinical Pharmacist 

JoAnne Nowak, MD 


Partners Hospice 

Charles L. Pankratz, MD, ABHPM 


Assisted Home Hospice 

Susan Penl, ADN, CHPN 

Clinical Supervisor 

McLaren Visiting Nurse and Hospice-Lansing 

Eileen Quigley, BSN, CHPN 

Hospice Supervisor 

Swedish Home Services 

Rachel Rebain, RN, BSN 


Hospice of Michigan 

Charlene Romani, RN 

Senior Case Manager 

AseraCare Hospice 

Shelly Rowlett, BSN, CHPNA 

Patient Care Coordinator 

Hospice of West Tennessee 

Mary A. Shockey, RN, BSN 

Clinical Service Director 

Pioneer Memorial Hospice 

Rebecca Slusser, RN, CHPN 

Columbia Montour Home Hospice 

Lorraine Smith, ASN 

Clinical Coordinator 

Florida Hospital Hospice Care 



Joseph B. Straton, MD, MSCE 

Chief Medical Officer 

Penn-Wissahickon Hospice 

Laurel R. Thomas, RN, CHPN 

Director of Professional Services 


David B. Tribble, MD, ABHPM, FAAFP 

Chief Medical Officer 

Alive Hospice 

Linda L. Twyeffort, BSN, RN, CHPN 


Baystate VNA & Hospice 

FOCUS GROUP PARTICIPANTS 

Therese Ahrens, RN, MS, CHPN 

Clinical Educator 

Hospice of Central New York 

Ann Bernesderfer, RN, CHPN 

Patient Care Administrator 

Vitas Inland Empire 

Carol Couper, RN, BS 

Clinical Care Director 

Northern Illinois Hospice 

Marie Glasgow, RN, BSN 

Director of Clinical Care 

Alive Hospice 

Donna Jolly, PharmD, BCPS, CPh 

Director Pharmacy Services 

Tidewell Hospice 

Sue Kelly, RN, CHPN 


Hospice of Volusia Flagler 

Marsha Lambert, RN, MSN, PHN, CHPN 



Terri Liberatoni 

Administrator 

Heartland Hospice Beltsville 

William Welsh, DO 


Hospice Care of the West 

Valerie Wheeler, BA, BSN, RN, CHPN 


Mercy Hospice 

Lauren Woode, RN, CHPN 


Mary Washington Hospice 

Philip Yule, MD 

Chief Medical Director 

Hospice of Santa Cruz County 

Ellen McCabe-Hemberger, RN, CHPN 

Organizational Staff Educator 

Hospice & Palliative Care of Cape Cod 

Joel Policzer, MD, FACP, FAAHPM 

Senior Vice-President, National Medical Director 

Vitas Hospice 

Glenn Ross, RN, NHA, MA 

Senor Director of Pharmacy Services 

Vitas Hospice 

Connie Shannon, RN 


SolAmor Hospice-Oklahoma City 

Kelly Squyres, RN, CHPN 

Admissions Director 


Teri Turner, RN, BSN, MS 


Arbor Hospice 

Stacey Vincent, RN, BSN, CHPN 

Staff Nurse 

Gaston County 

Jane Yates, RN, MBA, CHPN 

Clinical Operations Coordinator 

Hospice of NE Georgia Medical Center 



HP EDITORIAL STAFF 

Marcella R. Brown, BSPharm, MS, PharmD, 

MPH 

Editor-in-Chief 

Kevin T. Bain, PharmD, MPH, BCPS, CGP, 

FASCP 

Associate Editor & Vice President, Clinical 

Support 

Rebecca A. Lewis, PharmD, MBA 

Vice President, Marketing & Corporate 

Accounts 

Melissa Morris Ivone 

Director, Creative Services 

Jillian Baer, PharmD, CGP, BCPS 

Reviewer & Member, MUGs Development 

Committee 

Jennifer Johansen, PharmD, BCPS 


Committee 

Terri L. Maxwell, PhD, ACHPN 


Committee 

Jill Astolfi, PharmD 

Client Relations Liaison – Northeast 

Reviewer 

Breann K. Bruton, PharmD 

Vice President, Client Relations 

Reviewer 

Deanna Douglass, PharmD 

Client Relations Liaison – Midwest 

Reviewer 

David Kupperman, PharmD 

Client Relations Liaison – Atlantic 

Reviewer 

Thomas McCool, PharmD 

Pharmacist Leader 

Reviewer 

Iriny Salib, PharmD 

Client Relations Liaison – Upper Midwest 

Reviewer 

Ealia Washington, PharmD 


Reviewer 

Laura Scarpaci, PharmD, BCPS 


Committee 

ADDITIONAL HP CONTRIBUTORS 

Calvin J. Alt, RPh 

Vice President, Data Services 

Michael P. Cinque, PharmD, FAPhA 

Chief Pharmaceutical Care Officer 

Robert DeVito, MBA 

Vice President, Finance 

Ryan Emfinger, RPh, BSPharm 

Manager, Compounding/Specialty Services 

Tyler Ferguson, BS, CPhT 

Inventory Control Manager 

Dean Forman, MBA 

Senior Vice President, Sales, Marketing & 

Client Relations 

Linda M. Hoplamazian, RN, BSN, MHA, 

WCC 

Vice President, Sales & Partnering 



Kimberly A. Hunter, PharmD 

Vice President, Operations 

Gary W. Kadlec, RPh, MBA, ScD 

Chief Executive Officer, President 

Ronald Kralle 

Vice President, Purchasing 

Dennis Wilson, RPh, JD 

Senior Vice President, Operations & Corporate 

Compliance 

Catherine J. Woods, JD 

Senior Director, Corporate Compliance 

Laura Lutz, MBA 

Client Relations Program Manager 


Questions and Answers 

What is the Hospice Pharmacia Medication Use Guidelines (MUGs)? 

The MUGs is the leading resource for hospice pharmaceutical care in the United States. It provides 

information to help you select clinically appropriate, cost-effective medications for your hospice 

patients. 

Who is responsible for developing the MUGs? 

Hospice Pharmacia (HP), the nation’s leading hospice pharmaceutical care provider. Each year, HP 

undertakes a rigorous, peer-review process to develop the MUGs. Input received from administrators, 

medical directors, physicians, nurse practitioners, directors of nursing, staff nurses and consultant 

pharmacists practicing in hospice and palliative care is used in the development of the MUGs. 

Why did you create the MUGs? 

We developed this resource with your needs in mind. It is designed to assist hospice care practitioners 

to select clinically appropriate, cost-effective medications based upon the patient’s symptoms 

and/or underlying condition. 

Is the MUGs really just a formulary? 

No. The MUGs is first and foremost a robust clinical resource for hospice-focused medication 

information. It does not restrict the ability of hospices to cover certain medications. Hospices 

determine which medications are related to the patient’s hospice-qualifying terminal diagnosis and 

which medications they are responsible for covering. By utilizing the information in the MUGs 

in conjunction with our clinical consultative services, hospices can be confident that their patients 

receive clinically appropriate, cost-effective medications. 

If a medication is listed in the MUGs, does that mean that it is automatically included in the 

HP per diem? 

No. Hospices must first determine which medications are related or unrelated to the patient’s 

hospice-qualifying terminal diagnosis and which medications they will or will not cover. Medications 

that are unrelated to the patient’s diagnosis are outside the HP per diem, even if the 

medication is listed in the MUGs. For medications that are related to the patient’s diagnosis, HP 

decides which medications are included in the HP per diem based on diagnosis-related inclusion 

codes (refer to page 12). Certain medications in the MUGs have criteria (refer to page 13) 

and policies (refer to page 16) that further determine whether the medication is included in or 

outside of the HP per diem. 

Will the pharmacy dispense a medication that is outside the HP per diem? 

Yes. Hospices are responsible for covering all medications that are needed to care for the patient’s 

terminal diagnosis and related conditions. Hospice Pharmacia dispenses medications outside the 

HP per diem but requires prior authorization from the hospice. Please refer to your hospice’s policies 

and procedures for medications outside the HP per diem. 

Why don’t the MUGs include all medications? 

This edition of the MUGs contains numerous medications, strengths and formulations, including 

various compounded formulations, from more than 85 therapeutic drug classes. We selected these 

drug classes because of their clinical significance in hospice care and their impact on cost. 


Questions and Answers 

Why don’t all medications have brand names listed next to the generic name? 

Medications that are typically dispensed by brand name have a brand name listed, and those medications 

that are dispensed by their generic name are listed generically. 

What is the purpose of an algorithm? 

An algorithm is a systematic set of rules for solving a particular problem. In the MUGs, an algorithm 

provides an additional level of guidance for the pharmacological management of a symptom 

or condition. 

Why don’t the MUGs include an algorithm for every symptom or condition? 

An algorithmic approach to managing a symptom or condition is not always feasible. The decision 

to include an algorithm is determined by synthesizing the evidence base and by input received from 

administrators, medical directors, physicians, nurse practitioners, directors of nursing, staff nurses 

and consultant pharmacists practicing in hospice and palliative care. 

Where can I find more information? 

Our support center is staffed with doctorate-level and board-certified clinical pharmacists who 

specialize in hospice and palliative care and who have firsthand access to a wide array of drug 

information resources. Our Client Relations Liaisons (CRLs) have a wealth of experience working 

successfully with hospices through challenging or complex situations, overcoming obstacles, and 

keeping hospices appropriately informed. Additionally, the clinical information in the MUGs is 

well referenced, and reference citations can be furnished upon request. 


Agitation Title 

INCLUSION CODE: A 

ACRONYMS USED IN THIS MONOGRAPH: 

BID = twice a day 

IM = intramuscularly 

PO = by mouth 

PRN = as needed 

SC = subcutaneously 

SL = sublingually 

PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM: 

Neuroleptics 

Medication 

Chlorpromazine 

Haloperidol 

Risperidone 

Suggested Dosing 

12.5mg to 50mg PO every 4 to 6 hours PRN or 10mg to 

25mg IM every 4 to 6 hours PRN 

0.5mg to 10mg PO/SL/IM/SC every 2 to 4 hours PRN 

0.5mg to 1mg PO BID 

• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it should generally be 

used in patients who might benefit from these effects. It is best avoided in patients who might be 

harmed by these effects, such as patients with Parkinson’s disease. 

• Due to the increased risk of adverse events, the use of more than one neuroleptic (e.g., haloperidol 

and risperidone) in a patient is strongly discouraged. 

• Sometimes it is necessary to administer medications parenterally. Administer parenteral doses 

slowly to minimize hypotension. 

• Quetiapine (SEROQUEL®) is outside of the HP per diem for the management of agitation unless 

it meets the inclusion criteria found in the Behavioral and Psychological section on page 35.1. 

Benzodiazepines 


Lorazepam 


1mg to 2mg PO BID or every 1 to 2 hours PRN 

• Older adults (> 65 years) may be especially sensitive to the effects of benzodiazepines; lower doses 

(e.g., lorazepam < 3 mg/day) are generally considered to be equally effective and safer to use. 

• Paradoxical reactions to benzodiazepines may occur in older adults, severely ill patients, or those 

with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions 

are commonly manifested as excessive movement, excitement, and increased talkativeness. 


Agitation 


PHARMACOLOGIC THERAPY OUTSIDE THE PER DIEM*: 

• The cost represented in the table below is based on the average cost of a 15-day supply for all 

strengths of the medications. 

Neuroleptics 


Average Cost of Therapy 

Aripiprazole tablet (ABILIFY ® ) $290.00 

Fluphenazine tablet $18.83 

Olanzapine orally disintegrating tablet (ZYPREXA ® ZYDIS ® ) $211.05 

Olanzapine tablet (ZYPREXA ® ) $196.55 

Perphenazine tablet $21.80 

Quetiapine (SEROQUEL ® ) tablet $117.01 

Risperidone orally disintegrating tablet (RISPERDAL ® M-TAB ® ) $152.30 

Thioridazine tablet $14.97 

Ziprasidone capsule (GEODON ® ) $151.91 

*The average cost of therapy refers to the combined average cost of all strengths of a given medication. The dollar amount shown is 

intended to provide an approximation for the relative cost of therapy. The actual cost of therapy will vary based on the medication 

strength and dosage and the quantity of medication requested. 

NON-PHARMACOLOGIC THERAPY: 

• Verbal requests to cease disruptive behavior should be delivered in a calm, nonjudgmental, and 

reassuring manner. 

• The agitated patient should be separated from others, if possible. 

• A ‘show of force’ may be necessary, using an organized team of clinicians or security personnel to 

help prompt the patient to regain self-control. 

• Temporary physical restraint by caregivers may be necessary if the patient is at risk for harming 

him/herself or others. 

NOTES: 

• Before therapy is initiated, a thorough assessment of the underlying cause of agitation should be 

performed. 

• As needed dosing of any drug to control behavior should be reserved for infrequent, non-sustained 

agitation that cannot be linked to an eliciting event. 

• Dosing parameters for neuroleptics and benzodiazepines should include definitive, detailed 

directions specifying target behaviors, maximum daily doses, and monitoring parameters for the 

assessment of safety and effectiveness. 


Agitation 



Anxiety 



ATC = around the clock 

ER = extended-release 

HCl = hydrochloride 


PO = by mouth 


QID = four times a day 


TCAs = tricyclic antidepressants 




Alprazolam 

Clonazepam 

Diazepam 

Lorazepam 

Oxazepam 


0.25mg to 0.5mg PO/SL every 4 to 6 hours ATC or PRN 

0.5mg to 1mg PO every 8 to 12 hours ATC or PRN 

2mg to 10mg PO every 6 to 8 hours ATC or PRN 

0.5mg to 1mg PO/SL every 4 to 6 hours ATC or PRN 

10mg to 15mg PO 3 to 4 times daily or PRN 

• Among the benzodiazepines, lorazepam and oxazepam are the safest to use in patients with 

hepatic disease or impairment. 

• Older adults (> 65 years) may be especially sensitive to the effects of benzodiazepines; lower 

doses (e.g., alprazolam < 2 mg/day, lorazepam < 3 mg/day, oxazepam < 30 mg/day) are generally 

considered to be equally effective and safer to use. 

• Benzodiazepines with long half lives (e.g., clonazepam, diazepam) should be avoided or used 

cautiously in older adults, as they may accumulate and result in subsequent adverse drug events 

such as falls. 


with low frontal reserve (e.g., previous head trauma, neurodegenerative disease). These reactions are 

commonly manifested as excessive movement, excitement, and increased talkativeness. 

Antihistamines 


Hydroxyzine HCl 

(ATARAX ® ) 

Hydroxyzine pamoate 

(VISTARIL ® ) 


10mg to 25mg PO every 4 to 6 hours ATC or PRN or 50mg 

to 100mg PO QID 

25mg PO every 4 to 6 hours ATC or PRN 


• The cost represented in the tables below is based on the average cost of a 15-day supply for all 


Anticonvulsants 



Pregabalin (LYRICA ® ) $83.40 


Anxiety 


Anxiolytics 



Buspirone (BUSPAR ® ) $55.23 




Alprazolam ER tablet (XANAX ® XR) $56.66 

Alprazolam orally disintegrating tablet (NIRAVAM ® ) $76.26 

Chlordiazepoxide (LIBRIUM ® ) $12.05 

Clonazepam orally disintegrating tablet (KLONOPIN ® WAFER) $61.04 

Clorazepate dipotassium (TRANXENE ® ) $38.87 

Tricyclic Antidepressants (TCAs) 



Doxepin $10.77 





• Provide positive reassurance, cognitive-behavioral therapy and/or relaxation techniques. 

NOTES: 

• Dosing parameters for benzodiazepines should include definitive, detailed directions specifying 

target behaviors, maximum daily doses, and monitoring parameters for the assessment of safety 

and effectiveness. 


Anxiety 



Ascites 



ACE = angiotensin-converting enzyme 

IV = intravenously 

NSAID = non-steroidal anti-inflammatory drug 

PO = by mouth 

QD = daily 

TIPS = transjugular intrahepatic portocaval shunt 


Aldosterone Antagonists 


Spironolactone 


25mg to 100mg PO QD, up to 400mg/day 

Loop Diuretics 


Bumetanide 

Furosemide 

Thiazide Diuretics 


Hydrochlorothiazide 


0.5mg to 1mg PO QD, up to 10mg/day 

20mg to 40mg PO/IV daily, up to 600mg/day 


25mg to 100mg PO, given in single or divided doses 

• Hydrochlorothiazide should not be used as monotherapy; rather it is best used as adjuvant 

therapy. 




Aldosterone Antagonist-Thiazide Diuretic Combinations 



Spironolactone and hydrochlorothiazide (ALDACTAZIDE ® ) $21.97 




Bumetanide solution for injection $27.33 

Torsemide (DEMADEX ® ) $34.37 

Selective Aldosterone Receptor Antagonists 



Eplerenone (INSPRA ® ) $45.27 


Ascites 





Chlorothiazide tablet $7.22 





• Institute sodium restriction and/or water restriction (if persistent hyponatremia is present). 

• Sometimes a TIPS may be placed. 

NOTES: 

• Combination therapy with an aldosterone antagonist and a loop diuretic is often required to 

treat ascites: a dose ratio of 100mg spironolactone to 1mg bumetanide or 40mg furosemide has 

been shown to be beneficial. Dosing should be determined by patient response and tolerability. 

• Monitor potassium and renal function, as well as for signs and symptoms of hypotension. 

• Potassium supplementation may not be necessary for patients taking spironolactone, a potassium-sparing 

diuretic (e.g., triamterene), or an ACE inhibitor (e.g., enalapril). However, 

potassium supplementation is included in the HP per diem for patients who need potassium 

replacement as a result of pharmacologic therapy used to manage ascites. Please consult with your 

HP pharmacist to determine specific potassium products available in the per diem. 

• Assess the patient’s medication regimen and, if possible, avoid medications that inhibit prostaglandins 

(e.g., NSAIDs) because they can worsen ascites by decreasing renal perfusion. 


Behavioral and Psychological Symptoms 

INCLUSION CODE: O 



CR = controlled-release 

DR = delayed-release 


HS = at bedtime 

PO = by mouth 

QD = daily 

SSRIs = selective serotonin reuptake inhibitors 


TID = three times a day 


• The pharmacologic therapies listed below are for the management of behavioral and psychological 

symptoms related to Alzheimer’s disease and other dementias (defined as ICD-9-CM 

codes 290.0-290.9 or 331.0-331.9), Amyotrophic lateral sclerosis (defined as ICD-9-CM 

code 335.20), Huntington’s disease (Huntington’s chorea, defined as ICD-9-CM code 

333.4), and Parkinson’s disease (defined as ICD-9-CM codes 332., 332.0, or 332.1) as the 

patient’s hospice-qualifying terminal diagnosis. 

• Quetiapine (SEROQUEL®) is also included in the HP per diem for the management of 

behavioral and psychological symptoms in a patient with a co-morbidity of one of the 

aforementioned diagnosis. 

• Low-dose haloperidol or risperidone are often the treatment of choice for severe agitation due to 

delirium. 

• For the management of agitation and delirium, please refer to the Agitation and Delirium sections, 

respectively. 




Carbamazepine regular-release 50mg to 100mg PO BID 

Divalproex sodium (DEPAKOTE ® ) 125mg to 250mg PO BID 

Valproic acid (DEPAKENE ® ) 125mg to 250mg PO BID 

• Anticonvulsants are generally used to manage aggression and mania. 

Antidepressants 


Amitriptyline 

Fluoxetine 

Nortriptyline 

Sertraline 


10mg to 25mg PO HS 

10mg to 20mg PO QD 



• Antidepressants are generally used to manage pathological crying and/or laughing. 

• Other antidepressants from the Depression section also may be effective and are included in the 

HP per diem. 

• TCAs, especially amitriptyline, have anticholinergic properties and may be poorly tolerated by 

older adults. 

• Among the SSRIs, sertraline has a lower potential for drug-drug interactions than fluoxetine. 

• Abrupt discontinuation of antidepressant therapy should be avoided if possible, as it may precipitate 

withdrawal symptoms. A taper of the dose over one to two weeks is recommended when 

discontinuing therapy. 




Neuroleptics 



Haloperidol 

Quetiapine (SEROQUEL ® ) 

Risperidone 


10mg PO TID 

0.25mg to 0.5mg PO BID 

25mg PO BID 

0.25mg PO BID 

• Neuroleptics are generally used to manage psychosis, which is usually accompanied by hallucinations 

and delusions. 



• Doses of Quetiapine (Seroquel®) less than 50mg/day or greater than 200mg/day are generally 

not appropriate for managing behavioral and psychological symptoms. 

• Although psychosis is more common in Lewy body dementia than in Alzheimer’s disease, neuroleptics 

should be avoided in patients with Lewy body dementia because these medications often 

make symptoms worse or have other severe, sometimes life-threatening adverse effects. 

• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it is best used in patients 

who might benefit from these effects. It should generally be avoided in patients who might be 








Depakote sodium ER (DEPAKOTE ® ER) $80.19 




Duloxetine DR capsule (CYMBALTA ® ) $88.95 

Paroxetine suspension (PAXIL ® ) $106.59 

Paroxetine tablet (PAXIL ® ) $35.95 

Paroxetine CR tablet (PAXIL ® CR) $40.75 

Venlafaxine ER capsule (EFFEXOR ® XR) $81.84 

Venlafaxine tablet (EFFEXOR ® ) $48.04 




Neuroleptics 















• Behavioral interventions such as redirection and psychotherapy. 

• Environmental interventions such as reduction in disruptive stimuli and placing familiar and 

comforting objects (e.g., pictures, books) in the patient’s room. 

• Family support and education, including referring families and caregivers to local support 

groups and providing written materials. 

• Sensory interventions such as music therapy, light therapy, and physical touch. 

NOTES: 

• Suggested dosing noted above refers to initial dosages. Therapies may need to be adjusted based 

on clinical response as well as patient and medication characteristics. Please consult with your HP 

pharmacist for dosage adjustments. 

• Dosing parameters for neuroleptics should include definitive, detailed directions specifying 

target behaviors, maximum daily doses, and monitoring parameters for the assessment of safety 

and effectiveness. 


Bowel Obstruction 

INCLUSION CODE: C 




CNS = central nervous system 

FDA = Food and Drug Administration 

GI = gastrointestinal 



PEG = percutaneous endoscopic gastrostomy 

PO = by mouth 

PR = rectally 


QD = daily 





• The pharmacologic therapies listed below are for the management of bowel obstruction due to 

cancer (defined as ICD-9-CM codes 140-239). 

Therapies for Constipation 


Docusate calcium 

Docusate sodium 

Lactulose 


240mg/day to 480mg/day PO, given in single or divided doses 


15mL to 60mL PO QD 

• Because of their potential to exacerbate colic, oral stimulant laxatives (e.g., bisacodyl, senna) 

generally should be avoided, especially in patients with a complete obstruction. 

Therapies for Nausea & Vomiting 



Haloperidol 


Promethazine 



Dopamine Antagonists 

10mg to 25mg PO/IV/IM every 4 to 6 hours ATC or PRN 

0.5mg to 2mg PO/IM/SC every 4 to 6 hours ATC or PRN 

5mg to 10mg PO every 6 hours ATC or PRN or 25mg PR 

every 8 to 12 hours ATC or PRN or 5mg to 10mg IV/IM 

every 3 to 4 hours ATC or PRN 

12.5mg to 25mg PO/IM/PR every 4 to 6 hours ATC or PRN 

Prokinetic Agents 

10mg to 20mg PO/IM/IV 3 to 4 times a day, up to 240mg/day 

• Sometimes it is necessary to administer medications parenterally. Parenteral doses of neuroleptics are 

generally twice as potent as oral doses. Administer parenteral doses slowly to minimize hypotension. 

• Although chlorpromazine is an effective antiemetic, it is sedating and has anticholinergic 

properties. Therefore, it is best used in patients who might benefit from these effects. It is best 

avoided in patients who might be harmed by these effects, such as patients with Parkinson’s disease. 

• If parenteral use of promethazine is necessary, the preferred route of administration is by deep IM 

injection; however, the IV route can be used. When administered IV, promethazine should be given 

in a concentration no greater than 25mg/mL at a rate not to exceed 25mg/min; it is preferable to 

inject through the tubing of an IV infusion set that is known to be functioning satisfactorily. 




• Prokinetic agents are contraindicated in patients with complete bowel obstruction. However, 

they may be helpful in patients with partial bowel obstruction because of their positive effect on 

gastric emptying. 

• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include 

involuntary and repetitive movements of the face and body, even after metoclopramide is 

stopped. These symptoms are rarely reversible and there is no known treatment. The U.S. FDA 

recommends against use of metoclopramide for durations longer than 3 months. 

• Older adults, especially females, are more likely to develop tardive dyskinesia and thus 

metoclopramide should be used cautiously, if at all, in older adults. Consider starting with a 

lower (5mg) dose of metoclopramide in older adults. 

• Metoclopramide should be used cautiously, if at all, in patients with a seizure disorder (or acute 

seizures) or Parkinson’s disease. 

Therapies for Peritumoral Edema 


Dexamethasone 


4mg to 8mg PO//IM/IV, given in single or divided doses, up to 

60mg/day 

• While data are inconclusive, the use of dexamethasone in patients with a bowel obstruction is 

associated with a trend towards symptom relief. 

• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone may also be 

effective and are included in the HP per diem. 

• When dexamethasone (or any corticosteroid) is administered in divided doses, it is suggested 

that the last dose be given in the afternoon to avoid insomnia. 

Therapies for Secretions 


Glycopyrrolate 

Hyoscyamine regular-release 

Scopolamine, transdermal patch 

(TRANSDERM SCOP ® ) 

Octreotide 


Anticholinergics 

1mg to 2mg PO every 8 hours 


Apply 1 patch behind the ear every 3 days 

Somatostatin Analogue 

0.1mg IV/SC TID, up to 0.8mg/day 

• Anticholinergics may decrease GI secretions and relieve smooth muscle spasms/colic. They may 

also reduce nausea/vomiting and can be used in combination with other antiemetics. 

• Major side effects of anticholinergics are blurred vision, constipation, dry mouth, and urinary 

retention. Older adults are especially sensitive to these side effects. Of the anticholinergics, glycopyrrolate 

does not cross the blood-brain barrier and, therefore, is less likely to cause CNS side 

effects. 

• Octreotide has multiple mechanisms of action that are beneficial for treating a bowel obstruction, 

including a decrease in GI secretions and motility, inhibition of hormonal mediators that 

contribute to obstruction and its symptoms, and facilitation of water and electrolyte absorption 

by the gut wall. 




• Octreotide may be administered as intermittent injections or as a continuous infusion. Continuous 

infusions are outside the HP per diem. 

• When using octreotide solution for injection supplied in a glass ampule, a filter needle must 

be used to remove glass particles from the solution. Once drawn up into the syringe via a filter 

needle, a standard needle can be used to administer the medication. Filter needles are outside 

the HP per diem. 




Therapies for Secretions 



Glycopyrrolate solution for injection (ROBINUL ® ) $26.37 

Scopolamine solution for injection $79.70 

Scopolamine tablet (SCOPACE ® ) $11.62 





• PEG – this is generally the treatment of choice for symptom palliation; it may be particularly 

beneficial for gastric venting and relief of nausea/vomiting. 

• Surgery – patients with advanced disease often are not candidates for this intervention. 

• Stents – contraindicated if obstruction is multifocal or in patients with peritoneal carcinomatosis; 

may be an option for some patients who have limited surgical options. 

• Nasogastric suction – because suction is intrusive and distressing to the patient, this should only 

be considered as a temporary measure when pharmacologic therapy fails. 

• Hydration – this may result in increased bowel secretions and may be uncomfortable for patients; 

therefore, the risks vs. benefits of hydration must be carefully weighed. 

- Dry mouth/thirst can usually be addressed with local interventions such as sips of water, ice 

chips, and mouth care. 

- Parenteral hydration may be particularly beneficial when dehydration is causing agitated 

confusion, or when dehydration-associated renal failure results in the accumulation of drug 

metabolites and leads to drug toxicity (e.g., opioid-induced neurotoxicity). 

NOTES: 

• To date, no clinical trials have compared the efficacy of different antiemetics for the management 

of malignant bowel obstruction. 


Cachexia 

INCLUSION CODE: C, O 




PO = by mouth 

QD = daily 



• The pharmacologic therapies listed below are for the management of cachexia due to cancer 

(defined as ICD-9-CM codes 140-239; INCLUSION CODE: C), failure to thrive-adult 

(defined as ICD-9-CM code 783.7; INCLUSION CODE: O), or HIV/AIDS (defined as 

ICD-9-CM code 042; INCLUSION CODE: C). 

Miscellaneuous Therapies 


Cyproheptadine 

Dexamethasone 

Megestrol acetate suspension 


2mg PO 2 to 3 times daily with meals, up to 12mg/day in 2 to 

3 divided doses 

4mg PO QD, given in single or divided doses, up to 32mg/day 


• The usual initial dose of cyproheptadine is 4mg/day to 6mg/day. Weight gain is usually noted 

during the first few weeks of therapy. Doses are typically increased over a three-week period to 

the usual maintenance dose of 8mg/day to 12mg/day. 

• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone also may be 


• Megestrol is not recommended if life expectancy is less than 30 days, and its benefits for more 

than 12 weeks has not been established. 

• Use megestrol cautiously in patients with a history of thromboembolic disease. 

• Megestrol suspension is included in the HP per diem if treatment with a corticosteroid is 

contraindicated or has failed to improve cachexia. Doses of megestrol suspension < 400mg/ 

day and megestrol tablets are outside the HP per diem. 




Cannabinoids 



Dronabinol (MARINOL ® ) $188.17 

Miscellaneuous Therapies 



Megestrol acetate tablet $30.98 





Cachexia 



• Explore and address the emotional and spiritual issues related to the patient’s weight loss. 

• Determine the goals of therapy (e.g., improved appetite and well-being, weight gain). 

• Remove dietary restrictions. 

• Reduce portion size and eliminate foods with odors that are offensive to the patient. 

NOTES: 

• Evaluate the patient’s medication profile for anorexigenics (e.g., SSRIs [e.g., sertraline], CNS 

stimulants [e.g., methylphenidate]) or drugs that cause taste perversions (e.g., clarithromycin, 

ACE inhibitors [e.g., enalapril]). 


Cachexia 



Cardiac-Related Disorders 

INCLUSION CODE: H 



ARBs = angiotensin II receptor blockers 

AV = atrioventricular 


CHD = coronary heart disease 



CSA = chronic stable angina 




IR = immediate-release 

MI = myocardial infarction 

NSAIDs = non-steroidal anti-inflammatory drugs 

PO = by mouth 


QD = daily 

QID = four times daily 

SL = sublingual 

SR = sustained-release 


ARRHYTHMIAS 


• The pharmacologic therapies listed below are for the management of arrhythmias associated with 

cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459). 

Beta-blockers 


Metoprolol tartrate 

Propranolol 


25mg to 100mg PO BID 

80mg to 320mg PO daily, given in 2 to 4 divided doses 

• Contraindications to metoprolol include AV block, bradycardia, cardiogenic shock, acute 

decompensated heart failure, hypotension, pheochromocytoma, and sick sinus syndrome. 

• Contraindications to propranolol include asthma, AV block, bradycardia, and cardiogenic shock. 

• Other beta-blockers such as atenolol may also be effective for rate control. 

• Atenolol also may be effective for rate control and is included in the HP per diem for the 

management of arrhythmias. 

• Avoid abruptly discontinuing beta-blockers. If discontinuation is necessary, taper the dose over 

at least 1 to 2 weeks. 

Calcium Channel Blockers 


Diltiazem 

Verapamil 


120mg to 360mg PO daily, given in a single dose (ER or SR) 

or in 3 to 4 divided doses (regular-release) 

120mg to 480mg PO daily, given in a single dose (SR) or in 3 

to 4 divided doses (regular-release) 

• Contraindications to diltiazem and verapamil include acute myocardial infarction (diltiazem), 

AV block, cardiogenic shock, heart failure (verapamil), hypotension, Lown-Ganong-Levine 

syndrome, sick sinus syndrome, ventricular dysfunction (verapamil), ventricular tachycardia, and 

Wolff-Parkinson-White syndrome. 

• Grapefruit juice may increase diltiazem and verapamil levels, resulting in toxicity. Patients prescribed 

diltiazem or verapamil should avoid drinking grapefruit juice. 




Class 1A Antiarrythmics 


Disopyramide 

Quinidine gluconate ER 

Quinidine sulfate IR 


400mg to 800mg PO daily, given in equally divided doses 

every 12 hours (ER) or every 4 to 6 hours (IR) 

324mg to 648mg PO every 8 to 12 hours 


• Contraindications to disopyramide include AV block, cardiogenic shock, and QT prolongation. 

• Contraindications to quinidine include AV block, bundle-branch block, myasthenia gravis, and 

quinidine hypersensitivity. 

• Class 1A antiarrythmics are strongly anticholinergic. Major side effects are blurred vision, constipation, 

dry mouth, and urinary retention. Older adults are especially sensitive to these side effects. 

Class 1C Antiarrythmics 


Propafenone IR and Propafenone 

SR (RYTHMOL ® SR) 


150mg to 300mg PO every 8 hours (IR) or 225mg to 425mg 

PO every 12 hours (SR) 

• Contraindications to propafenone include acute bronchospasm, asthma, AV block, bradycardia, 

cardiogenic shock, electrolyte imbalance, heart failure, hypotension, and sick sinus syndrome. 

Class III Antiarrythmics 


Amiodarone 



• Contraindications to amiodarone include AV block, benzyl alcohol hypersensitivity, bradycardia, 

cardiogenic shock, iodine hypersensitivity, and sick sinus syndrome. 

• Grapefruit juice may increase amiodarone levels, resulting in toxicity. Patients prescribed 

amiodarone should avoid drinking grapefruit juice. 

• Pulmonary toxicity, a serious side effect of amiodarone, generally presents as non-specific 

respiratory symptoms such as exertional dyspnea, nonproductive cough, and rales or decreased 

breath sounds on exam. Advanced age, high maintenance doses (above 300 mg/day), longer 

duration of therapy, and pre-existing, restrictive lung disease all seem to predispose to 

amiodarone pulmonary toxicity. 

Cardiac Glycosides 


Digoxin 


0.125mg to 0.375mg PO QD 

• Ventricular fibrillation is a contraindication to digoxin. 

• Maintenance doses should be based on lean body weight, clinical response, and renal function. 

• Higher doses (i.e., concentrations) of digoxin may be required for treating arrhythmias than for 

treating heart failure. 

• Serum digoxin concentrations can be used to help guide dosage adjustments. Concentrations 

should be drawn at least 6 to 8 hours after a dose (a trough concentration is preferable). Most 




patients achieve effectiveness (without evidence of toxicity) at a serum digoxin concentration 

ranging from 0.8ng/mL to 2ng/mL. 

• Signs and symptoms of digoxin toxicity, which may be precursors to development of proarrhythmias, 

include the following: GI effects (nausea, vomiting, anorexia), CNS effects (headache, 

generalized weakness, drowsiness, confusion), and ocular effects (visual disturbances). 

• Avoid abruptly discontinuing digoxin. If discontinuation is necessary, taper the dose over at least 

1 to 2 weeks. 




Beta-blockers 



Nadolol (CORGARD ® ) $15.92 

Sotalol (BETAPACE ® ) $60.46 

Class 1C Antiarrythmics 



Flecainide (TAMBOCOR ® ) $59.62 





• Non-pharmacologic therapies are highly individualized and may include implantable cardioverter-defibrillator 

devices, pacemakers, electrocardioversion, radiofrequency ablation, and valsalva 

movements, among others. 

• Patients with arrhythmias or those at risk should avoid inciting factors such as caffeine, tobacco, alcohol, 

illicit drugs (e.g., cocaine), and certain over-the-counter (e.g., pseudoephedrine) and prescription 

medications (e.g., methylphenidate, TCAs), especially medications that prolong the QT interval. 

NOTES: 

• In general, antiarrhythmics are associated with a multitude of drug interactions and potentially 

serious side effects. Additionally, these medications typically require monitoring and dosage 

adjustments based on patient and medication characteristics. Consult with your HP pharmacist 

about potential drug interactions, side effects, monitoring, and dosage adjustments associated with 

antiarrhythmics therapies. 




CHRONIC STABLE ANGINA 


• The pharmacologic therapies listed below are for the management of chronic stable angina associated 

with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459). 

ACE Inhibitors 


Captopril 

Enalapril 

Fosinopril 

Lisinopril 


12.5mg to 25mg PO 2 to 3 times a day, up to 150mg 2 to 3 

times a day 

2.5mg PO BID, up to 10mg BID 

5mg PO QD, up to 20mg/day given in a single or divided dose 

5mg PO QD, up to 10mg QD 

• ACE inhibitors decrease the risk of mortality in patients with CHD. 

• However, ACE inhibitors have not been shown to control anginal symptoms as well as betablockers, 

calcium channel blockers, or nitrates; therefore, their role in the management of CSA 

at the end of life has yet to be defined. 

Beta-blockers 


Atenolol 

Carvedilol 

Metoprolol succinate 


Propranolol 


50mg/day to 200mg/day PO, given in a single or divided dose 



100mg/day to 400mg/day, given in a single or divided dose 

160mg/day to 320mg/day, given in 2 to 4 divided doses 

• Beta-blockers are indicated as first-line therapy for angina prevention for all patients with CHD, 

regardless of history of MI. 



Amlodipine 

Diltiazem ER or SR 

Verapamil SR 


5mg to10mg PO QD 



• Calcium channel blockers are indicated as second-line therapy for angina prevention. They 

are indicated as first-line therapy if beta-blockers are contraindicated or for vasospastic or 

Prinzmetal’s angina. 




Chronic Nitrate Therapy 


Isosorbide dinitrate IR 

Isosorbide dinitrate SR 

Isosorbide mononitrate (IMDUR ® ) 

Isosorbide mononitrate (ISMO ® ) 

Nitroglycerin transdermal patch 

Nitroglycerin ER 

Nitroglycerin ointment 2% 


5mg to 20mg PO 2 to 3 times a day 



5mg to 10mg PO BID, up to 20mg BID, with doses separated 

by 7 hours 

0.4mg/hr to 0.8mg/hr applied topically to intact skin every 24 

hours 

2.5mg to 9mg PO every 8 to 12 hours 

15mg to 30mg (2.5cm to 5cm as squeezed from the tube; 

approximately 1 to 2 inches) applied topically to the skin 

every 8 hours during waking hours and at bedtime, up to 

75mg/day (12.5cm as squeezed from the tube) 

• Chronic nitrate therapy is indicated as third-line therapy for angina prevention. It is indicated as 

second-line therapy for vasospastic or Prinzmetal’s angina. 

• To prevent tolerance, in general, a 10- to 12-hour nitrate-free interval is recommended. For 

example, the nitroglycerin transdermal patch should be applied and left on for 12 to 14 hours 

then removed for 10 to 12 hours prior to applying the next patch. 

• Nitroglycerin ointment should be applied in a thin layer covering approximately 2 to 3 inches of 

skin, but should not be massaged into the skin. 

Short-acting Nitrate Therapy 


Nitroglycerin SL tablets 


Place 1 tablet under the tongue every 5 minutes for up to 3 

doses PRN 

• Unless contraindicated, all patients with CHD should be prescribed short-acting nitrate therapy 

for relief of acute chest pain. 







Benazepril (LOTENSIN ® ) $16.40 

Quinapril (ACCUPRIL ® ) $21.39 

Ramipril (ALTACE ® ) $28.94 

Trandolapril (MAVIK ® ) $19.21 




ACE Inhibitor-Calcium Channel Blocker Combinations 



Benazepril and amlodipine (LOTREL ® ) $42.53 

Antianginals 



Ranolazine (RANEXA ® ) $131.98 

Beta-blockers 



Bisoprolol (ZEBETA ® ) $18.38 





Felodipine ER tablet $28.67 

Nifedipine capsule (PROCARDIA ® ) $23.99 

Nifedipine ER tablet (NIFEDIAC ® CC, NIFEDICAL XL ® ) $40.47 

Nisoldipine ER tablet (SULAR ® ) $43.49 

Short-acting Nitrate Therapy 


Nitroglycerin sublingual spray (NITROLINGUAL ® 

PUMPSPRAY) 


$175.45 





• Risk factor reduction with therapeutic lifestyle changes, such as weight loss and smoking cessation, 

should be employed whenever possible. 

NOTES: 

• When used in combination with beta-blockers, a long-acting dihydropyridine calcium channel 

blocker (e.g., amlodipine) is preferred to a nondihydropyridine calcium channel blocker (e.g., 

diltiazem). 

• Avoid short-acting, immediate-release calcium channel blockers (e.g., diltiazem IR, verapamil 

IR) if possible, as they may enhance the risk of cardiac-related adverse events. 

• The terms “first-line,” “second-line,” “third-line,” and “preferred” do not refer to HP per diem 

status; rather, these terms refer to the recommended place in therapy of certain medications according 

to evidence-based guidelines. 




HEART FAILURE 


• The pharmacologic therapies listed below are for the management of heart failure associated with 

cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459). 



Captopril 

Enalapril 

Fosinopril 

Lisinopril 



5mg to 40mg PO daily, given in 2 divided doses 

5mg to 40mg PO daily, given as a single dose 


• Contraindications to ACE inhibitors include angioedema and ACE inhibitor hypersensitivity. 

• Enalapril and fosinopril are prodrugs and, therefore, should be avoided in patients with clinically 

significant hepatic dysfunction. 

Angiotensin II Receptor Blockers (ARBs) 


Valsartan (DIOVAN ® ) 


80mg to 320mg PO daily, given in 2 divided doses 

• ARBs are typically used as alternative therapy to ACE inhibitors for patients who cannot tolerate 

the latter. 

Aldosterone Antagonists 




25mg to 50mg PO daily, given as a single or divided dose 

• Contraindications to spironolactone include anuria, hyperkalemia, and renal failure. 

Beta-blockers 


Carvedilol 

Carvedilol CR (COREG CR ) 

Metoprolol succinate 



6.25mg to 100mg PO daily, given in 2 divided doses 


12.5mg to 200mg PO daily, given as a single dose 

12.5mg to 150mg PO daily, given in 2 to 3 divided doses 

• Contraindications to carvedilol include asthma, AV block, bradycardia, cardiogenic shock, 

hepatic disease, and sick sinus syndrome. 

• Carvedilol should be administered with food. This reduces the rate of absorption and minimizes 

the risk of orthostatic hypotension. 

• Carvedilol CR (COREG CR) capsules may be carefully opened and the beads sprinkled over a 

spoonful of (cold) applesauce. The mixture should be consumed immediately in its entirety. 




• Please consult with your HP pharmacist for assistance when converting from regular-release 

carvedilol to COREG CR. 

• Metoprolol tartrate has been studied, but has not been approved by the U.S. FDA for heart 

failure. 

Cardiac Glycosides 


Digoxin 


0.125mg to 0.25mg PO daily, given as a single dose 

• Digoxin may need to be dosed every other day in some patients. 

Vasodilators 


Hydralazine in combination with 

isosorbide dinitrate 


75mg hydralazine with 40mg isosorbide dinitrate PO QID 

• Contraindications to hydralazine include coronary artery disease and rheumatic heart disease. 

• The suggested dosing above is based on historical data from clinical trials using hydralazine in 

combination with isosorbide dinitrate as adjunctive treatment of heart failure in patients taking 

standard heart failure therapy. 

• The combination of hydralazine and isosorbide dinitrate has been shown to be particularly effective 

in self-identified African Americans with heart failure who remain symptomatic despite optimal 

medical therapy. The commercially available formulation of hydralazine hydrochloride and 

isosorbide dinitrate for this indication (BIDIL®, 37.5-20mg) is outside the HP per diem. 







Benazepril (LOTENSIN ® ) $16.40 

Quinapril (ACCUPRIL ® ) $21.39 

Ramipril (ALTACE ® ) $28.94 

Trandolapril (MAVIK ® ) $19.21 

ACE Inhibitor-Thiazide Diuretic Combinations 



Benazepril and hydrochlorothiazide (LOTENSIN ® HCT) $20.48 

Lisinopril and hydrochlorothiazide (PRINZIDE ® , ZESTORETIC ® ) $16.33 




ARBs 



Candesartan (ATACAND ® ) $46.20 

Irbesartan (AVAPRO ® ) $52.76 

Losartan (COZAAR ® ) $31.15 

Olmesartan (BENICAR ® ) $38.03 

ARB-Thiazide Diuretic Combinations 



Candesartan and hydrochlorothiazide (ATACAND ® HCT) $87.44 

Losartan and hydrochlorothiazide (HYZAAR ® ) $36.88 

Olmesartan and hydrochlorothiazide (BENICAR ® HCT) $59.12 

Telmisartan and hydrochlorothiazide (MICARDIS ® HCT) $62.26 

Valsartan and hydrochlorothiazide (DIOVAN ® HCT) $76.40 

Beta-blockers 



Bisoprolol (ZEBETA ® ) $18.38 

Nebivolol (BYSTOLIC ) $45.76 

Beta-blocker-Thiazide Diuretic Combinations 



Atenolol and chlorthalidone (TENORETIC ® ) $18.31 

Bisoprolol and hydrochlorothiazide (ZIAC ® ) $21.33 

Vasodilators 



Hydralazine in combination with isosorbide dinitrate (BIDIL ® ) $53.93 





• Assess the patient’s medication regimen and, if possible, discontinue medications known to adversely 

affect the clinical status of patients with heart failure and reduced left ventricular ejection 

fraction (e.g., NSAIDs, most antiarrhythmics, and most calcium channel blockers). 

• Avoidance of alcohol and nicotine should be encouraged. 

• Sodium restriction and supervised fluid intake is often necessary to prevent exacerbations. 




NOTES: 

• The suggested dosing provided above is the usual dosage range for the treatment of heart failure. 

Dosages should be adjusted based on the patient’s clinical response and tolerability. 

• Patients with heart failure often are prescribed a loop diuretic for fluid retention, particularly 

for transient worsening heart failure. Although loop diuretics deplete potassium, supplemental 

potassium may not be necessary for patients taking spironolactone, an ACE inhibitor (e.g., 

enalapril), or an ARB (e.g., valsartan). However, potassium supplementation is included in 

the HP per diem for patients who need potassium replacement as a result of pharmacologic 

therapy used to manage heart failure. Please consult with your HP pharmacist to determine specific 

potassium products available in the per diem. 

• Monitor weight, electrolytes (especially potassium) and renal function, as well as for signs and 

symptoms of worsening heart failure. 


Constipation 



PO = by mouth 

PR = rectally 


QD = daily 

PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM : 

Evacuants 


Sodium phosphate dibasic and 

monobasic rectal enema 


1 enema PR as directed 

Lubricant Laxatives 


Mineral oil rectal enema 

Osmotic Laxatives 


Glycerin suppository 

Lactulose 

Magnesium citrate solution 

Polyethylene glycol 3350 power 

(MIRALAX ® ) 

Sorbitol 70% 




1 suppository PR QD PRN 

15mL to 60mL PO QD PRN 

½ to 1 bottle (150mL to 300mL) as a single or divided dose 

PO PRN 

17g of powder mixed into 120mL to 240mL of fluid and 

given PO QD 


• Avoid osmotic laxatives in a patient who is dehydrated. 

• Magnesium citrate is contraindicated in patients with hypermagnesemia, severe renal impairment, 

renal failure, or renal disease leading to renal failure. 

Saline Laxatives 


Milk of magnesia 

Mineral oil oral solution 


30mL PO QD PRN 


• Milk of magnesia should not be used in patients with renal failure unless their serum magnesium 

levels are being closely monitored. 

• Use of mineral oil should be avoided in older adults due to risk of aspiration. 

Stimulant Laxatives 


Bisacodyl tablet 

Bisacodyl suppository 

Senna concentrate tablet 

Senna solution or syrup 

Senna-docusate sodium 


5mg to 15mg PO 1 to 3 times a day PRN, up to 30mg/day 

1 suppository PR QD PRN 

1 to 2 tablets PO QD PRN 

1 to 2 teaspoonfuls PO QD PRN 

1 to 2 tablets PO QD PRN 

| | 54.1 | | The The Hospice Pharmacia Medication Use Use Guidelines

Constipation 


• Senna-docusate sodium is not available as a liquid formulation. Patients who lose the ability to 

swallow senna-docusate sodium tablets can be switched to senna and docusate sodium liquids, 

which are separate products. 

Stool Softeners 


Docusate calcium 

Docusate sodium 

Docusate sodium enema 

(ENEMEEZ ® MINI ENEMA) 





• Directions for usage of docusate sodium solution: Shake well and administer using a calibrated 

measuring device. May be mixed with 120mL of milk, fruit juice, or infant formula to mask the 

bitter taste. 




Chloride Channel Activators 



Lubiprostone (AMITIZA ® ) $108.11 

Peripherally-Acting Mu-Opioid Receptor Antagonists 



Methylnaltrexone bromide vial (RELISTOR ) $81.59 

Methylnaltrexone bromide kit (RELISTOR ) $520.18 





• Increase dietary fiber if feasible. 

• Increase fluid intake if not contraindicated by renal or heart disease. 

• Use natural laxatives (e.g., raisins, prunes). 

• Frozen Vaseline® balls: for high impaction, consider rolling Vaseline® into pea-sized sugar-coated 

balls, freezing the balls, and administering them PO 1 to 3 times a day PRN. Note that this 

intervention is anecdotal. 

• Manual fecal disimpaction is a painful and distressing procedure. The patient should be premedicated 

with analgesics prior to manual fecal disimpaction. 

NOTES: 

• All patients who are prescribed opioid therapy should have a bowel regimen in place. 

The Hospice Pharmacia Medication Use Guidelines | | 55.1 |

Constipation 



Cough 




CHPA = Committee and Consumer Healthcare 

Products Association 



OTC = over the counter 

PHA = Public Health Advisory 

PO = by mouth 




Antihistamine-Antitussive Combinations 


Promethazine with codeine syrup 

Promethazine with 

dextromethorphan syrup 

Antihistamine-Antitussive-Decongestant Combinations 


Promethazine with codeine and 

phenylephrine syrup 

Antihistamine-Decongestant Combinations 


Promethazine with phenylephrine 

syrup 


5mL PO every 4 to 6 hours PRN, up to a maximum of 

30mL/day 


30mL/day 



30mL/day 



30mL/day 

Antitussives 


Benzonatate liquid filled capsule 

Dextromethorphan ER 

suspension (DELSYM ® ) 

Homatropine and hydrocodone 

syrup 

Homatropine and hydrocodone 

tablet 


100mg to 200mg PO TID or 100mg PO every 4 hours; 

maximum recommended dose is 600mg/day 

10mL PO every 12 hours 

5mL to 10mL PO every 4 hours ATC or PRN 

1 to 2 tablets PO every 4 hours ATC or PRN 

Antitussive-Expectorant Combinations 


Guaifenesin with codeine solution 

or syrup 

Guaifenesin with 

dextromethorphan solution or 

syrup 





Cough 


Antitussive-Decongestant-Expectorant Combinations 


Guaifenesin with codeine and 

pseudoephedrine solution or syrup 

Guaifenesin with 

dextromethorphan and 

phenylephrine HCl solution 


5mL to 10mL PO every 4 hours PRN 

10mL PO every 4 hours PRN 

Expectorants 


Guaifenesin tablet 

Guaifenesin solution or syrup 

Miscellaneous 


Sodium chloride nebulizer 

solution 0.9% 


100mg to 400mg PO every 4 hours ATC or PRN; maximum 

recommended dose is 2400mg/day 



1 ampule via nebulizer every 2 to 4 hours PRN 




Antihistamine-Antitussive Combinations 


Chlorpheniramine with hydrocodone ER suspension 

(TUSSIONEX ® ) 


$100.96 

Antitussives 



Codeine sulfate tablet $22.62 

Antitussive-Expectorant Combinations 


Guaifenesin with dextromethorphan ER tablet 

(MUCINEX ® DM) 


$18.70 

Expectorants 



Guaifenesin ER tablet (MUCINEX ® ) $18.91 


Cough 


Mucolytics 



Acetylcysteine (MUCOMYST ® ) $41.79 





• Provide adequate hydration. 

• Reposition the patient to promote drainage. 

• Use demulcents (e.g., sugar cough drops). 

• Use a humidifier. 

• When appropriate, encourage smoking cessation. 

• When appropriate, use suction. 

NOTES: 

• Some drugs contained in cough/cold products have been sold for many years without undergoing 

FDA approval. In June 2006, the FDA issued a guidance called “Marketed Unapproved 

Drugs--Compliance Policy Guide,” which outlines a plan for taking action against unapproved 

drugs. A number of manufacturers have removed unapproved drugs from the market. As a result, 

many cough/cold products are no longer available for dispensing. Please check with your HP 

pharmacist for product availability. 

• Additionally, in October 2007, the Pediatric Advisory CHPA recommended that all OTC 

cough/cold products be updated to advise against using them in children younger than 4 years 

of age. In January 2008, a PHA was issued by the FDA that recommended against using cough/ 

cold products in infants and children younger than 2 years of age. More detailed information on 

this topic is available at: http://www.fda.gov/fdac/features/2007/107_drug.html. 


Cough 



Delirium 




EPS = extrapyramidal symptoms 


PO = by mouth 





Neuroleptics 



Haloperidol 

Risperidone 


12.5mg to 50mg PO every 4 to 12 hours ATC or PRN or 

10mg to 25mg IM every 4 to 6 hours PRN 

0.5mg to 2mg PO/SL/IM/SC every 2 to 8 hours ATC or PRN 

0.25mg to 1mg PO 1 to 2 times a day 

• Low-dose haloperidol or risperidone are often the treatment of choice for severe agitation due to 

delirium. 

• Chlorpromazine is sedating and has anticholinergic properties. Therefore, it should generally be 

used in patients who might benefit from these effects. It is best avoided in patients who might be 


• Doses of risperidone needed to treat delirium are generally well below effective doses for schizophrenia. 

The usual effective dose of risperidone is 1mg/day; doses greater than 2mg/day increase 

the risk of adverse effects yet generally do not provide additional benefit. 



• Sometimes it is necessary to administer medications parenterally. Administer parenteral doses 

slowly to minimize hypotension. 

• Quetiapine (SEROQUEL®) is outside of the HP per diem for the management of delirium 

unless it meets the inclusion criteria found in the Behavioral and Psychological section on 

page 35.1. 




Neuroleptics 








Quetiapine (SEROQUEL ® ) tablet $117.01 








Delirium 



• Many medications can cause cognitive impairment, particularly in older adults. To minimize 

this risk the clinician should: 

- Avoid polypharmacy: use the minimum number of medications necessary to manage the 

patient’s symptoms. 

- Achieve multiple benefits from one medication (e.g., nortriptyline for neuropathic pain and 

depression). 

- Adjust dosages based on age, renal function, hepatic function, and other patient and medication 

characteristics. Please consult with your HP pharmacist for dosage adjustments. 

- Use the lowest effective dose of a medication for the shortest duration possible. 

- Discontinue medications causing or contributing to cognitive impairment. 

• Maintain fluid and electrolyte balance, if possible. 

• Reduce anxiety and disorientation. 

• Reduce the level of evening activity such as bathing, visits from family members, and noise from 

television or radios. 

• Provide structure, routine, and familiarity in the patient’s life. 

• Provide adequate lighting (including access to natural light), familiar objects, alarm clocks, 

and/or a calendar in the patient’s residence. 

• Make sure the caregiver gets adequate rest. 

NOTES: 

• Although benzodiazepines are ineffective as monotherapy and may worsen cognitive impairment, 

the addition of a benzodiazepine may be beneficial in patients whose symptoms are not 

adequately controlled using a neuroleptic. This strategy may also minimize EPS associated with 

neuroleptics and allow for lower neuroleptic doses to be used. Benzodiazepines are included in 

the HP per diem for the management of delirium. Please consult with your HP pharmacist for 

recommendations regarding their use, including specific dosing recommendations. 


Depression 










NG = nasogastric 

PEG = percutaneous endoscopic gastrostomy 

PO = by mouth 

QD = daily 

SNRIs = serotonin-norepinephrine reuptake 

inhibitors 





Selective Serotonin Reuptake Inhibitors (SSRIs) 


Citalopram 

Fluoxetine 

Sertraline 


20mg PO QD, up to 60mg/day 



• If necessary, the daily dose of citalopram may be increased by 20mg after one week of therapy, 

up to a maximum recommended dose of 60mg/day. However, doses above 40mg/day are not 

ordinarily recommended. 

• If necessary, the daily dose of fluoxetine may be increased by 10mg or 20mg every month, up to 

a maximum recommended dose of 80mg/day. 

• If necessary, the daily dose of sertraline may be increased by 25mg or 50mg every week, up to a 

maximum recommended dose of 200mg/day. 

• Citalopram and sertraline have a lower potential for drug-drug interactions than most other 

SSRIs, including fluoxetine. 

• A note about sertraline (ZOLOFT®) oral solution: 

- The oral solution should be further diluted in an acceptable liquid immediately before administering 

the dose. 

- Measure the dose using the supplied calibrated dropper. Place the dose in at least 4 oz. 

(120mL) of water, ginger-ale, lemon-lime soda, lemonade, or orange juice and mix. 

- Drink the entire dose of the mixed liquid immediately; do not prepare doses in advance. 

- The solution does not need to be diluted if administering the dose via NG or PEG tube. 

- Sertraline oral solution should be used cautiously in patients with a latex allergy because the 

dropper contains dry natural rubber. 



Amitriptyline 

Desipramine 

Nortriptyline 


25mg to 75mg PO HS or in divided doses, up to 200mg/day 

50mg to 75mg PO in 1 to 4 divided doses, up to 200mg/day 

25mg to 50mg PO HS or in divided doses, up to 150mg/day 


Depression 


• If necessary, the daily dose of amitriptyline may be increased by 25mg or 50mg every week, up 

to a maximum recommended dose of 200mg/day. 

• If necessary, the daily dose of desipramine may be increased by 25mg or 50mg every week, up to 

a maximum recommended dose of 200mg/day. 

• If necessary, the daily dose of nortriptyline may be increased by 25mg or 50mg every week, up 

to a maximum recommended dose of 150mg/day. 

• TCAs, especially amitriptyline, have anticholinergic properties and may be poorly tolerated by 

older adults. 

Tetracyclic Antidepressants 


Mirtazapine 


15mg PO HS, up to 45mg/day 

• Dosage adjustments should not be made more frequently than every 1 to 2 weeks. 

Miscellaneous Antidepressants 


Trazodone 


150mg/day PO in divided doses, up to 400mg/day 

• If necessary, the daily dose of trazodone may be increased by 50mg every 3 to 4 days, up to a 

maximum recommended dose of 400mg/day. 

CNS Stimulants 


Methylphenidate 


2.5mg PO BID, given in the morning and at noon 

• If necessary, the daily dose of methylphenidate may be increased by 2.5mg or 5mg every 2 to 3 

days until the desired response is achieved. 

• CNS stimulants may aggravate co-existing anxiety or agitation in depressed patients. Therefore, 

their use is usually reserved for treatment-refractory cases or when standard therapies are not 

tolerated. 




Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 







Depression 


SSRIs 



Escitalopram (LEXAPRO ® ) $73.60 

Paroxetine suspension (PAXIL ® ) $106.59 

Paroxetine tablet (PAXIL ® ) $35.95 

Paroxetine CR tablet (PAXIL ® CR) $40.75 

TCAs 




Imipramine (TOFRANIL ® ) $28.01 

Miscellaneous Antidepressants 



Bupropion (WELLBUTRIN ® ) $35.16 

Bupropion extended-release, 12 hour (BUDEPRION ® SR) $40.29 

Bupropion extended-release, 24 hour (BUDEPRION ® XL) $56.55 

CNS Stimulants 



Methylphenidate SR (RITALIN ® SR) $49.34 





• Psychotherapy in combination with pharmacologic therapy often is more effective than either 

therapy alone. 

• Relaxation techniques may help reduce anxiety often accompanying depression. 

• Social worker and chaplain visits may be comforting to the patient. 

NOTES: 

• Maximum benefit of antidepressants may not be achieved for 4 to 6 weeks. 

• Abrupt discontinuation of antidepressant therapy should be avoided if possible, as it may precipitate 

withdrawal symptoms. A taper of the dose over one to two weeks is recommended when 

discontinuing therapy. 

• The use of more than one antidepressant concurrently should be avoided whenever possible 

because it could lead to toxicity. 

• Some antidepressants are more sedating than others (e.g., mirtazapine, trazodone). These antidepressants 

may be particularly useful in depressed patients with sleep disturbances. 

• When initiating SSRIs or TCAs in older adults, the dose is usually half the suggested dose provided 

in the tables above. 


Depression 



Diarrhea 




PO = by mouth 



Adsorbents 



Bismuth subsalicylate suspension 

(262mg/15mL) 

30mL PO every 30 to 60 minutes PRN, up to 240mL (4.2gm) 

(BISMATROL ® , PEPTO-BISMOL ® ) 

per day 

• Bismuth subsalicylate is contraindicated in patients with salicylate hypersensitivity. 

• Due to an increased risk of bleeding, use of bismuth subsalicylate is contraindicated in patients 

with hematological disease (i.e., conditions that increase the risk of bleeding), such as severe 

hepatic impairment due to hepatic disease or in patients receiving warfarin. 

• Bismuth subsalicylate is contraindicated in the presence of GI bleeding and in peptic ulcer disease. 

• Avoid concurrent treatment with bismuth subsalicylate and other salicylates, including aspirin. 

Bile Acid Sequestrants 


Cholestyramine powder (plain 

and light) 


Mix 2gm to 4gm in 60mL to 180mL of fluid (e.g., water, milk, 

fruit juice, or other non-carbonated beverage) PO 2 to 4 

times a day 

• Administer other medications at least 1 hour before or 4 to 6 hours after each dose of cholestyramine, 

as this medication may impede the absorption of other medications. 

• The powder may also be mixed with a highly fluid soup or a pulpy fruit with high moisture (e.g., 

applesauce, crushed pineapple). 

• The palatability of and compliance with cholestyramine may be improved if the dose is mixed and 

refrigerated overnight. 

• The difference between cholestyramine plain and cholestyramine light is the amount of dried resin 

that is present in the powder. Cholestyramine plain has 4gm of active ingredient per 9gm of powder; 

cholestyramine light has 4gm of active ingredient per 5gm of powder. 

Hypomotility Agents 


Camphorated opium tincture 

2mg/5mL solution (PAREGORIC ® ) 

Diphenoxylate with atropine 

Loperamide 


2mg to 4mg (5mL to 10mL) PO 1 to 4 times a day PRN 

2 tablets (5mg) or 10mL PO 3 to 4 times a day PRN, up to 8 

tablets or 40mL per day 

4mg PO initially followed by 2mg after each loose stool PRN, 

up to 16mg/day 


Diarrhea 


• PAREGORIC® is 25-times less potent than opium tincture. Unlike opium tincture, the dose of 

PAREGORIC® is given as 5mL to 10mL or as 1 to 2 teaspoonsfuls and not as drops. 

• Diarrhea usually improves within 48 hours of initiating treatment with a hypomotility agent. 

After clinical improvement is observed, the dose should be reduced or the medication should 

be discontinued. If clinical improvement is not observed within 10 days of treatment with the 

maximum daily dose, symptoms are unlikely to be controlled by further administration. 

Antibiotics for Infectious Diarrhea 



Metronidazole 

250mg to 500mg PO 3 to 4 times a day for 7 to 14 days 

• Metronidazole can inhibit alcohol dehydrogenase and other alcohol-metabolizing enzymes. 

This inhibition can lead to the development of side effects such as abdominal cramps, flushing, 

headache, nausea, and vomiting. 

• Alcohol and alcohol-containing medications should be avoided during therapy with metronidazole 

and for 3 days after therapy is discontinued. Please consult with your HP pharmacist for help 

determining whether medications or medication formulations contain alcohol content. 

• Prophylactic or suppressive antibiotic therapy is outside the HP per diem. 


• The cost represented in the table below is based on the average cost for a single course of the 

anti-infective. 

Antibiotics for Infectious Diarrhea 



Vancomycin hydrochloride capsule (VANCOCIN ® HCl) $636.12 





• Modify diet: clear liquids for a day, avoidance of dairy products, BRAT diet (bananas, rice, 

apples, and toast). 

• Avoid stimulants such as caffeine and nicotine. 

• Provide perianal skin care. 

NOTES: 

• If Clostridium difficile (C. diff) is documented as the etiology of infectious diarrhea, hypomotility 

agents (e.g., loperamide) should not be used because they may increase the severity of the infection 

and/or lead to pseudomembranous colitis. 


Diarrhea 



Dyspepsia 



AC = before meals 

CrCl = creatinine clearance 



H 2 

RA = histamine 2 

-receptor antagonists 


PC = after meals 

PO = by mouth 

PPIs = proton pump inhibitors 

QD = daily 



Antacids 


Aluminum hydroxide suspension 

Aluminum hydroxide/magnesium 

hydroxide with simethicone 

suspension (ALAMAG PLUS ) 


10mL PO 5 to 6 times a day, PC and HS 

10mL to 20mL PO between meals and HS 

• Aluminum hydroxide causes constipation and should be used with extreme caution in patients who 

are predisposed to constipation or complications associated with constipation, including older adults, 

patients taking antidiarrheals or anticholinergics, and patients with gastric outlet obstruction. 

• Aluminum hydroxide and magnesium hydroxide should be avoided in patients with renal 

insufficiency. 

Antiflatulent Agents 


Simethicone 


80mg to 125mg PO TID 

Histamine 2 

-Receptor Antagonists (H 2 

RAs) 



Ranitidine 


• Total daily dosages of ranitidine > 300mg/day are outside the HP per diem. 



Erythromycin 



125mg to 250mg PO 3 to 4 times a day, 30 minutes AC and HS 

10mg to 15mg PO up to 4 times a day, 30 minutes AC and HS 

• Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary 

and repetitive movements of the face and body, even after metoclopramide is stopped. 

These symptoms are rarely reversible and there is no known treatment. The U.S. FDA recommends 

against use of metoclopramide for durations longer than 3 months. 

• Older adults, especially females, are more likely to develop tardive dyskinesia and thus metoclopramide 

should be used cautiously, if at all, in older adults. Consider starting with a lower (5mg) 

dose of metoclopramide in older adults. 


Dyspepsia 




Proton Pump Inhibitors (PPIs) 


Omeprazole 


20mg PO QD 

• PPIs should be administered with a full glass of water 30 minutes before breakfast. 

• Total daily dosages of omeprazole > 20mg/day are outside the HP per diem. 




Antacids 


Aluminum hydroxide/magnesium carbonate chewable tablet 

(GAVISCON ® ) 


$9.36 

H 2 

RAs 



Cimetidine tablet (TAGAMET ® HB) $31.68 

Famotidine solution for injection (PEPCID ® ) $15.29 

Famotidine tablet and suspension (PEPCID ® ) $8.98 

PPIs 



Esomeprazole DR capsule (NEXIUM ® ) $108.75 

Esomeprazole DR powder for suspension (NEXIUM ® ) $136.33 

Lansoprazole DR capsule (PREVACID ® ) $99.00 

Lansoprazole DR orally disintegrating tablet (PREVACID ® SOLUTAB) $124.32 

Pantoprazole DR tablet (PROTONIX ® ) $59.52 





• Avoid activities that worsen indigestion, such as eating too quickly and eating large or greasy meals. 

• Avoid consuming alcohol. 

• Avoid foods that trigger dyspepsia, such as spicy foods. 

• Encourage regular exercise when feasible. 

• Maintain a healthy weight. 


NOTES: 

• Adjust dosages based on age, renal function, and other patient and medication characteristics. 

For example, the daily dosage of H 2 

RAs should be decreased by 50% for patients with estimated 

CrCl < 50 mL/min. Please consult with your HP pharmacist for dosage adjustments. 


Dyspepsia 



Dyspnea 

INCLUSION CODE: A, C, L 





MDI = metered dose inhaler 

PO = by mouth 


QD = daily 



• The pharmacologic therapies listed below are for the management of dyspnea related to the 

patient’s hospice-qualifying terminal diagnosis (INCLUSION CODE: A). 



Ipratropium bromide inhalation 

aerosol (17mcg/actuation) 

(ATROVENT ® HFA) 

Ipratropium bromide nebulizer 

solution (0.02%, 0.5mg/2.5mL) 


2 sprays PO 3 to 4 times a day at least 4 hours apart, up to 

12 sprays (204mcg) in a 24-hour period 

1 unit dose vial via oral nebulizer every 6 to 8 hours 

Anticholinegic Bronchodilator - Short-acting Combination 


Albuterol sulfate and ipratropium 

bromide nebulizer solution 

(DUONEB ® ) 


Bronchodilators – Short-acting Sympathomimetics 


Albuterol sulfate HFA inhalation 


(PROAIR ® HFA, PROVENTIL ® 

HFA, VENTOLIN ® HFA) 

Albuterol sulfate nebulizer 

solution (0.083%, 2.5mg/3mL) 

Albuterol sulfate nebulizer 

solution (0.5%, 5mg/1mL) 

Albuterol sulfate syrup (2mg/5mL) 

Albuterol sulfate tablet 

1 unit dose vial via oral nebulizer every 6 to 8 hours 


2 inhalations PO every 4 to 6 hours PRN 

1 unit dose vial via oral nebulizer every 6 to 8 hours PRN 

0.5mL (2.5mg) via oral nebulizer every 6 to 8 hours PRN 

2mg to 4mg PO every 6 to 8 hours PRN 


• The maximum recommended daily dose of albuterol is 32mg/day. 

• Because of the adverse effect profile and delayed onset, it is recommended that albuterol syrup or 

tablets be reserved for patients who are unable to use a MDI and/or nebulizer. 


Dyspnea 


Corticosteroids – Inhaled 


Beclomethasone dipropionate 

inhalation aerosol (40mcg or 

80mcg per actuation) 

(QVAR ® ) 

Triamcinolone acetonide inhalation 


(AZMACORT ® ) 


1 to 2 inhalations PO BID 

2 inhalations PO 3 to 4 times a day, or 4 inhalations PO BID, 

not to exceed 16 inhalations/day 

• Patients prescribed both an inhaled corticosteroid and bronchodilator should be instructed to 

administer the bronchodilator first then wait five minutes before administering the inhaled corticosteroid. 

This opens up the airways to ensure maximum delivery of the inhaled corticosteroid. 

• To reduce the risk of oral candidiasis, patients should be instructed to rinse their mouth (gargling 

with water) after each dose of the inhaled corticosteroid. 

Corticosteroids – Oral 


Dexamethasone 

Methylprednisolone 

Prednisone 


4mg PO 1 to 2 times a day 

4mg PO 1 to 2 times a day, or as directed per dosepak 


• The minimum effective dose of an oral corticosteroid should be used for the shortest duration 

possible. Whenever possible, a dose reduction should be attempted in order to reduce the risk of 

long-term systemic adverse effects. 

• When a corticosteroid is administered in divided doses, it is suggested that the last dose be given 

in the afternoon to avoid insomnia. 

Opioids 


Morphine IR 


Opioid naïve patients: 5mg PO for 1 dose then repeat 

5mg/dose every 30 minutes until dose that provides relief is 

achieved; give effective dose every 2 to 4 hours PRN 

Opioid tolerant patients: Increase dose of current regimen by 

25% to 50% and give every 2 to 4 hours PRN 

• Opioids reduce the feeling of breathlessness and should be considered for use in all patients unless 

otherwise contraindicated. 

• The preferred route of administration of opioids for the management of dyspnea is oral or parenteral; 

there is a paucity of data to support the use of opioids administered via the nebulization route. 

• Other opioids also may be effective for managing dyspnea. Hydromorphone IR and oxycodone 

IR are included in the HP per diem for managing dyspnea. 

• If the IR opioid is effective, consider adding a long-acting opioid to the patient’s regimen for 

consistent relief of dyspnea. 


Dyspnea 


DISEASE-SPECIFIC PHARMACOLOGIC THERAPY INCLUDED IN THE PER DIEM: 

• The additional pharmacologic therapies listed below are for the management of dyspnea specifically 

associated with chronic obstructive pulmonary disease (COPD, defined as ICD-9-CM 

code 496; INCLUSION CODE: L) or pulmonary malignancy (defined as ICD-9-CM code 

162.9; INCLUSION CODE: C). 

Anticholinergic-Bronchodilator (short-acting) Combinations 



Albuterol sulfate and ipratropium 

bromide inhalation aerosol 

(103mcg-18mcg/actuation) 

2 inhalations PO every 4 to 6 hours PRN 

(COMBIVENT ® ) 

Bronchodilators – Long-acting Sympathomimetics 


Salmeterol (50mcg/actuation) 

(SEREVENT ® DISKUS ® ) 


1 inhalation PO every 12 hours 

• Salmeterol has a relatively slow onset of action; it should not be used to treat acute dyspnea. 

Rather, the patient should have on hand a quick-onset, short-acting beta-adenergic bronchodilator 

(e.g., albuterol) for management of acute dyspnea. 

• Salmeterol prescribed more frequently than 1 inhalation PO every 12 hours is outside the 

per diem. 

Bronchodilator (long-acting)-Corticosteroid (inhaled) Combinations 


Salmeterol and fluticasone 

propionate inhalation powder 

(100-50mcg/actuation, 250- 

50mcg/actuation, 500-50mcg/ 

actuation) (ADVAIR ® DISKUS ® ) 


1 inhalation PO every 12 hours 

• Salmeterol and fluticasone prescribed more frequently than 1 inhalation PO every 12 hours 

is outside the per diem. 

Bronchodilators – Xanthines 


Theophylline SR tablets 

Theophylline elixir or solution 

(80mg/15mL) 


10mg/kg/day PO in divided doses every 8 to 12 hours 

10mg/kg/day PO in divided doses every 6 to 8 hours 

• The dose of theophylline should be adjusted to achieve and maintain a serum theophylline 

concentration of 10mcg/mL (range, 8mcg/mL to 12mcg/mL) at steady-state. 


Dyspnea 







Tiotropium bromide inhalation powder (SPIRIVA ® 

HANDIHALER ® ) 


$172.69 

Bronchodilators – Long-acting Sympathomimetics 


| 76.1 | | The Hospice Pharmacia Medication Use Guidelines 


Arformoterol tartrate nebulizer solution (BROVANA ® ) $169.87 

Formoterol fumarate inhalation powder (FORADIL ® 

AEROLIZER ® ) 

$140.59 

Formoterol fumarate nebulizer solution (PERFOROMIST ) $183.90 

Bronchodilators – Short-acting Sympathomimetics 



Albuterol sulfate nebulizer solution (0.63mg/3mL) (ACCUNEB ® ) $48.19 

Albuterol sulfate ER tablet (VOSPIRE ® ) $39.93 

Levalbuterol tartrate inhalation aerosol (XOPENEX HFA ® ) $52.63 

Levalbuterol hydrochloride nebulizer solution (XOPENEX ® ) $168.69 

Terbutaline sulfate tablet $20.66 

Bronchodilator (long-acting)-Corticosteroid (inhaled) Combinations 


Formoterol fumarate and budesonide pressurized inhalation 

powder (SYMBICORT ® ) 

Salmeterol and fluticasone propionate inhalation aerosol 

(ADVAIR ® HFA) 

Corticosteroids – Inhaled 


$183.60 

$241.07 



Budesonide inhalation powder (PULMICORT FLEXHALER ) $122.49 

Budesonide nebulizer suspension (PULMICORT RESPULES ) $225.68 

Fluticasone propionate inhalation aerosol (FLOVENT ® HFA) $170.97 

Mometasone furoate inhalation powder (ASMANEX ® 

TWISTHALER ® ) 

$182.43 

Corticosteroids – Oral 



Hydrocortisone (CORTEF ® ) $15.98 

Prednisone dosepack (STERAPRED ® UNI-PAK) $10.30

Dyspnea 






• Allow the patient to assume a comfortable position (usually sitting or reclined). 

• Determine the patient’s perception of dyspnea and assist the patient to find a less frightening 

significance for the symptom (e.g., dyspnea = death versus dyspnea = manageable symptom). 

• For patients who are receptive, teach relaxation techniques to control and avert respiratory panic 

attacks. 

• Make sure the patient’s room is well ventilated. If necessary, use a fan to create a breeze over the 

patient’s face. 

• In some cases, oxygen may be effective. 

NOTES: 

• Spacers (e.g., ACE Aerosol Cloud Enhancer) are tube-like devices that are used in combination 

with MDIs to aid in the delivery of aerosolized medication to the lungs. Please consult with your 

HP pharmacist to determine whether your patient would benefit from having a spacer. 

• Anxiolytics, particularly benzodiazepines (e.g., lorazepam), also may be useful for the management 

of dyspnea at the end of life, especially for patients with severe anxiety or when the 

dyspnea is a somatic manifestation of a panic disorder. Anxiolytics often are used in combination 

with opioids. 


Edema 






PO = by mouth 


QD = daily 




Bumetanide 

Furosemide 


0.5mg to 2mg PO QD, up to 10mg/day 

40mg to 120mg PO QD, up to 600mg/day. 

• The estimated relative potency of loop diuretics is as follows: bumetanide 1mg = furosemide 

40mg = torsemide 20mg. Torsemide is outside the HP per diem. 

• The initial dose of furosemide is typically 20mg to 80mg PO as a single dose, repeated in 6 to 8 

hours if necessary. Doses are usually increased in 20mg to 40mg increments to the usual dose of 

40mg to 120mg per day. 

• Patients exhibiting signs of furosemide-resistant edema may benefit from a switch to parenteral 

furosemide, a switch to another loop diuretic such as bumetanide, or the addition of a thiazide 

diuretic such as metolazone. When using furosemide parenterally, administer IV doses slowly. A 

maximum infusion rate of 4mg/min is recommended when administering doses > 120mg and 

for patients with cardiac or renal failure. 

Potassium-Sparing Diuretics 



Triamterene-hydrochlorothiazide 



Hydrochlorothiazide 

Metolazone 



37.5/25mg to 75/50mg PO QD 




• When using metolazone concurrently with a loop diuretic, the initial dose should be 2.5mg 

PO QD. 

• Thiazides are typically less effective than loop diuretics for the management of edema, especially 

in patients with renal impairment (CrCl < 30mL/min). 







Torsemide (DEMADEX ® ) $34.37 


Edema 


Potassium-Sparing Diuretics 



Amiloride (MIDAMOR ® ) $19.31 

Triamterene (DYRENIUM ® ) $20.05 

Potassium-Sparing Diuretic-Thiazide Diuretic Combinations 



Amiloride and hydrochlorothiazide $14.02 




Chlorothiazide tablet $7.22 





• Assess the patient’s medication regimen and, if possible, discontinue medications causing or 

worsening edema. 

• Elevate the patient’s legs above the heart while lying down. 

• Exercising the legs helps fluid to work back into the veins and lymphatic channels. This may 

improve swelling. 

• Provide pressure with elastic bandages or support stockings to help reduce ankle swelling. 

• Recommend a low-salt diet to help reduce fluid retention and ankle swelling. 

• Recommend that the patient avoids sitting or standing without moving for prolonged periods 

of time. 

• Recommend that the patient avoids wearing constricting clothing. 

NOTES: 

• Monitor weight change or input-output to assist in gauging efficacy of diuretics. 

• Monitor potassium and renal function, as well as for signs and symptoms of hypotension or 

dehydration. 

• Potassium supplementation may not be necessary for patients taking spironolactone, a potassium-sparing 

diuretic (e.g., triamterene), or an ACE inhibitor (e.g., enalapril). However, 

potassium supplementation is included in the HP per diem for patients who need potassium 

replacement as a result of pharmacologic therapy used to manage edema. Please consult with your 

HP pharmacist to determine specific potassium products available in the per diem. 


Fever 




PO = by mouth 

PR = rectally 



Antipyretics 


Acetaminophen 

Aspirin 

Choline magnesium trisalicylate 

Ibuprofen 


325mg to 650mg PO/PR every 4 to 6 hours PRN, up to 

4000mg/day 

325mg to 650mg PO or 300mg to 600mg PR every 4 hours 

PRN 


200mg to 400mg PO every 4 to 6 hours PRN, up to 

1200mg/day 



strengths of the medication. 

Antipyretics 



Ketoprofen capsule $37.29 





• Cool the patient by sponging with tepid water; however, this therapy should only be used 

when the external environment is warm or humid because extremes of temperature may be 

uncomfortable to the patient. 

• Encourage oral fluid intake, if appropriate. 

NOTES: 

• Other NSAIDs such as diclofenac sodium, nabumetone, and naproxen may also be effective and 

are included in the HP per diem. 

• Corticosteroids are sometimes used to treat fever of unknown origin when other pharmacologic 

therapy is ineffective. Dexamethasone, methylprednisolone, prednisolone, and prednisone 

are included in the HP per diem to treat fever. 

• The use of antibiotics in patients who are approaching the end of life is controversial. If antibiotics 

are used, the goals and duration of antibiotic therapy should be clear. 


Genitourinary Symptoms 







PC = after meals 

PO = by mouth 

PR = rectally 


SL = sublingual or sublingually 



Anorectal Drugs 


Benzocaine rectal ointment (20%) 

Dibucaine topical ointment (1%) 

Hydrocortisone rectal cream 

(2.5%) 

Hydrocortisone acetate 

suppository (25mg) 

(ANUCORT-HC , ANUSOL- 

HC ® , HEMORRHOIDAL HC) 

Lidocaine topical gel/jelly (2%) or 

ointment (5%) 


Apply to perianal area up to 6 times per day 

Apply to perianal area every 3 to 4 hours PRN 

Apply to perianal area 3 to 4 times a day 

1 suppository PR BID for 14 days 

Apply to perianal area every 3 to 4 hours PRN 

• Anorectal drugs are useful for temporarily relieving rectal pain and discomfort, especially soreness 

and/or pruritus associated with hemorrhoids and anorectal inflammation. 

Local Analgesics/Anesthetics 


Phenazopyridine 


200mg PO TID PC 

• Phenazopyridine is useful for the symptomatic relief of pain, burning, urgency, frequency, and 

other discomforts resulting from irritation of the lower urinary tract mucosa. 

• Phenazopyridine has no antimicrobial properties. Therapy with phenazopyridine generally 

should not exceed three days; however, some patients may benefit from a longer duration of 

therapy. Therapy beyond three days is included in the HP per diem. 

Smooth Muscle Relaxants 


Belladonna-opium (B&O) 

suppository 


Hyoscyamine ER 

Oxybutynin IR 


1 suppository PR 1 to 2 times a day PRN 

0.125mg to 0.25mg PO/SL every 4 hours PRN 

0.375mg to 0.75mg PO every 12 hours 



Genitourinary Symptoms 


• Smooth muscle relaxants are useful for managing bladder spasms. 

• Smooth muscle relaxants are strongly anticholinergic. Major side effects are blurred vision, 

constipation, dry mouth, and urinary retention. Older adults are especially sensitive to these side 

effects. 

• B&O suppositories are available in the following strengths: 15A (belladonna 15mg and opium 

30mg) and 16A (belladonna 15mg and opium 60mg). 




Anorectal Drugs 


Hydrocortisone and pramoxine rectal foam 

(PROCTOFOAM-HC ® ) 


$64.88 




Oxybutynin ER (DITROPAN ® XL) $79.25 





• Inspect the patient’s skin routinely and look for any reddened areas. 

• Cleanse the affected area with mild soap and warm water. 

• Use an astringent (e.g., TUCKS® medicated pads) to help relieve burning and irritation due to 

hemorrhoids. 

NOTES: 

• Additional management strategies are provided in the Urinary Incontinence section. 


Hepatic Encephalopathy 



PO = by mouth 


• The pharmacologic therapies listed below are for the management of hepatic encephalopathy 

due to liver disease (defined as ICD-9-CM codes 570, 571.0-571.9, 572.0, 573.0-573.9; IN- 

CLUSION CODE: O), malignant neoplasm of the liver and intrahepatic bile ducts (defined 

as ICD-9-CM codes 155.-155.2 or 197.7; INCLUSION CODE: C), or malignant neoplasm 

of the gallbladder and extrahepatic bile ducts (defined as ICD-9-CM codes 156.-156.9; 

INCLUSION CODE: C). 

Aminoglycosides 


Neomycin 


1gm PO every 6 hours for 5 to 6 days 

• The usual dosage of neomycin for the adjunctive treatment of hepatic encephalopathy is 1gm to 

3gm PO every 6 hours for 5 to 6 days. 

• The maximum dosage of neomycin is 2gm PO every 4 hours. 

Osmotic Laxatives 


Lactulose 


30mL to 45mL PO 3 to 4 times daily 

• If necessary, hourly doses of lactulose (30mL to 45mL) may be given until a laxative effect is 

induced. Once a laxative effect has been established, the dosage should be reduced to produce 2 

to 3 loose stools daily. 




Rifamycins 



Rifaximin (XIFAXAN ) $212.02 





• Avoid medications that further impair mental status. 

• Discontinue or reduce doses of medications metabolized by the liver. 

• Restrict or eliminate protein from the diet. 

NOTES: 

• Seizures have been described as a rare manifestation of hepatic encephalopathy. Seizures are usually 

controlled by oral lactulose or neomycin. 


Hiccups 




PO = by mouth 





Valproic acid (DEPAKENE ® ) 


5mg/kg/dose PO TID 

• Although a dose of 15mg/kg/day has been the effective dose reported in the literature, the final 

therapeutic dose should be based on tolerability and clinical response. 

• In general, the dose of valproic acid should be reduced and titrated more slowly in older adults. 

Skeletal Muscle Relaxants 


Baclofen 



• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with 

hallucinations, spasticity, and seizures. Baclofen therapy should be discontinued slowly. 

Neuroleptics 



Haloperidol 



0.5mg to 1mg PO TID 

• Although chlorpromazine is an effective neuroleptic for the management of hiccups, it is sedating 

and has anticholinergic properties. Therefore, it is best used in patients who might benefit 

from these effects. It is best avoided in patients who might be harmed by these effects, such as 

patients with Parkinson’s disease. 
















Hiccups 








Nifedipine capsule (PROCARDIA ® ) $23.99 

Neuroleptics 



Perphenazine $21.80 





• Gargling with water or drinking water rapidly (“hard”) or from the “wrong side” of the glass; 

holding breath or gasping with sudden fright; hyperventilation or rebreathing into a paper bag; 

and lemon wedges with bitters, sugar, honey, or vinegar are some non-pharmacologic therapies 

that anecdotally have been reported to be effective for relieving hiccups. 

• Massage or relaxation techniques might be a useful therapeutic option. 

NOTES: 




• In collaboration with your HP pharmacist, thoroughly review the patient’s medication profile for 

drugs that may cause or worsen hiccups. These may include, but are not limited to, barbiturates 

(short-acting), chlordiazepoxide, dexamethasone, diazepam, methyldopa, and sulfonamides. 


Hiccups 



Hyperglycemia 

INCLUSION CODE: A, C, O 



PO = by mouth 

QD = daily 


• The pharmacologic therapies listed below are for the management of hyperglycemia due 

to diabetes as the hospice-qualifying terminal diagnosis (defined as ICD-9-CM codes 

250.0-250.9; INCLUSION CODE: O), hyperglycemia due to pancreatic cancer (defined 

as ICD-9-CM codes 157.0-157.9 or 197.8; INCLUSION CODE: C), or hyperglycemia 

induced by a medication used for a symptom related to the patient’s hospice-qualifying 

terminal diagnosis (INCLUSION CODE: A), whereby the hyperglycemia affects the 

patient’s quality of life. 

Insulins 


Insulin human NPH, REG, and 

70/30 (HUMULIN ® ) 

Insulin human NPH, REG, and 

70/30 (NOVOLIN ® ) 


Dosing based upon patient-specific factors 

Dosing based upon patient-specific factors 

Sulfonylureas 


Glipizide regular-release 

Glyburide 



2.5mg to 5mg PO QD 

• Although the maximum recommended dosage of regular-release glipizide is 40mg/day, it has 

been suggested that doses > 10mg/day may produce little or no additional benefit and may 

reduce beta-cell function. In general, when daily doses exceed 30mg/day, glipizide should be 

divided into two doses. 

• The usual dosage range for glyburide is 1.25mg/day to 20mg/day. For some patients, particularly 

those taking doses > 10mg/day, better glucose control may be achieved with twice daily dosing. 




Biguanides 



Metformin (GLUCOPHAGE ® ) $20.91 

Metformin ER (GLUCOPHAGE ® XR) $19.12 

Biguanide-Sulfonylurea Combinations 



Metformin and glyburide (GLUCOVANCE ® ) $37.71 


Hyperglycemia 

INCLUSION CODE: A, C, O 

Dipeptidyl Peptidase-4 Inhibitors 



Sitagliptin (JANUVIA ) $76.13 

Fibric Acid Derivatives 



Gemfibrozil (LOPID ® ) $29.08 

Insulins 



Insulin aspart vial (NOVOLOG ® ) $103.71 

Insulin detemir vial (LEVEMIR ® ) $100.02 

Insulin glargine vial (LANTUS ® ) $99.31 

Insulin lispro vial (HUMALOG ® ) $103.17 

Insulin lispro protamine suspension-insulin lispro vial 

$153.71 

(HUMALOG ® MIX) 

Meglitinides 



Repaglinide (PRANDIN ® ) $32.47 

Sulfonylureas 



Glimepiride (AMARYL ® ) $10.14 

Glipizide ER (GLUCOTROL ® XL) $13.80 

Thiazolidinediones 



Pioglitazone (ACTOS ® ) $112.93 

Rosiglitazone (AVANDIA ® ) $58.91 





• Encourage lifestyle modifications, particularly diet and exercise. 

NOTES: 

• Insulin syringes are included in the HP per diem; however, pre-filled insulin syringes and insulin 

pens are outside the HP per diem. In order for insulin syringes to be included in the per diem, 

they must be dispensed by HP; insulin syringes cannot be adjudicated through the PBM Plus card. 

• Conventional formulations of glyburide (DIABETA® and MICRONASE®) are included in 

the HP per diem, whereas micronized formulations (GLYNASE) are not. These two formulations 

are not bioequivalent. Consult with your HP pharmacist for dosage adjustments. 


Infections 




CAP = community-acquired pneumonia 

PHN = post-herpetic neuralgia 

PO = by mouth 

QD = daily 

UTI = urinary tract infection 

WA = while awake 


• The following is a list of pharmacologic therapies that are included in the HP per diem for the 

treatment of infections related to the patient’s hospice-qualifying terminal diagnosis. This list is 

organized by route of administration and medication class. 

• The specific indications included in the HP per diem are provided in the tables; indications 

other than those provided in the tables are outside the HP per diem. 

• Refer to the Medications with Policies section (page 17) for additional information regarding 

the policy for medications used for infections. 

ORAL THERAPIES 

Antifungals 


Clotrimazole troche 

Fluconazole 

Nystatin suspension 

Antivirals 


Acyclovir 

Valacyclovir (VALTREX ® ) 


Oropharyngeal candidiasis: 

1 troche buccally 5 times a day, given every 4 hours WA, for 7 

to 14 days 


200mg PO on day 1, then 100mg PO QD for 7 to 14 days 

UTI: 

50mg to 200mg PO QD for 7 to 14 days 

Vulvovaginal candidiasis: 

150mg PO for 1 dose 


Swish and swallow with 5mL PO every 6 hours for 7 to 

14 days, continuing treatment for at least 48 hours after 

symptoms are resolved 


Herpes zoster: 

800mg PO 5 times a day, given every 4 hours WA, for 7 to 

10 days 

Herpes zoster: 

1gm PO every 8 hours for 7 days 

• Antivirals do not eradicate the infection, rather they can help relieve and shorten the duration of 

symptoms. 

• Antivirals should be started at the first sign or symptom of herpes zoster (shingles), preferably 

within 48 hours of onset. Efficacy of treatment started after 72 hours has not been established; 

therefore, antiviral treatment started after 72 hours of the first sign or symptom of herpes 

zoster is outside the HP per diem. 

• Dosages of antivirals should be adjusted in patients with renal impairment. Please consult with 

your HP pharmacist for dosage adjustments of antivirals. 


Infections 


Cephalosporins 


Cefpodoxime proxetil 

(VANTIN ® ) 

Cefuroxime axetil 

Cephalexin 


CAP: 

200mg PO every 12 hours for 10 to 14 days 

Skin and skin structure infections: 


CAP or skin and skin structure infections: 

250mg to 500mg PO every 12 hours for 5 to 10 days 


500mg PO every 6 to 12 hours for 7 to 14 days 

UTI: 

500mg PO every 12 hours or 250mg PO every 8 hours for 

7 to 14 days 

Fluoroquinolones 


Ciprofloxacin 

Levofloxacin (LEVAQUIN ® ) 




UTI: 


CAP: 

750mg PO QD for 5 days or 500mg PO QD for 7 to 14 days 


500mg to 750mg PO QD for 7 to 10 days 

UTI: 

750mg PO QD for 5 days or 250mg PO QD for 10 days 

Macrolides 


Azithromycin 

Erythromycin regular-release 

Erythromycin delayed-release 


CAP or skin and skin structure infections: 

500mg PO on day 1, then 250mg PO QD for 4 more days 

CAP: 





333mg PO every 8 hours or 500mg PO every 12 hours for 

7 to 10 days 

Miscellaneous Anti-infectives 


Clindamycin 

Metronidazole 


CAP: 

150mg to 450mg PO every 6 hours for 10 days 




500mg PO every 8 to 12 hours for 7 to 14 days 


Infections 


• Metronidazole can inhibit alcohol dehydrogenase and other alcohol-metabolizing enzymes. 

This inhibition can lead to the development of side effects such as abdominal cramps, flushing, 

headache, nausea, and vomiting. 

• Alcohol and alcohol-containing medications should be avoided during therapy with metronidazole 

and for 3 days after therapy is discontinued. Please consult with your HP pharmacist for help 

determining whether medications or medication formulations contain alcohol content. 

• Metronidazole tablets crushed and sprinkled onto the skin (wound bed) are outside the HP 

per diem. Metronidazole topical cream and gel and compounded topical paste, powder, and 

spray also are outside the HP per diem. Please consult with your HP wound care specialist for 

help with the management of wounds. 

Penicillins 


Amoxicillin 

Amoxicillin-clavulanate regularrelease 

Amoxicillin-clavulanate extendedrelease 

(AUGMENTIN ® XR) 

Dicloxacillin 

Penicillin VK 


CAP: 



250mg to 500mg PO every 8 hours or 875mg PO every 12 

hours for 10 to 14 days 

UTI: 

250mg to 500mg PO every 8 hours or 875mg PO every 12 

hours for 10 days 

CAP: 

250mg (of amoxicillin) PO every 8 hours or 500mg PO every 

8 to 12 hours or 875mg PO every 12 hours for 7 to 10 days 


250mg (of amoxicillin) PO every 8 hours or 500mg PO every 

8 to 12 hours or 875mg PO every 12 hours for 10 to 14 days 

UTI: 

250mg (of amoxicillin) PO every 8 hours or 500mg PO 

every 12 hours for 3 to 10 days 

CAP: 

2000mg (of amoxicillin) PO every 12 hours for 7 to 10 days 

CAP: 






Sulfonamides 


Sulfamethoxazole-trimethoprim 

(BACTRIM ® ) 


CAP: 

6mg/kg/day to 20mg/kg/day (of trimethoprim) PO every 6 to 

12 hours for 14 days 

Skin and skin structure infection: 

400/80mg or 800/160mg PO every 12 hours for 7 to 14 days 

UTI: 

400/80mg or 800/160mg PO every 12 hours for 3 to 14 days 


Infections 


Tetracyclines 


Doxycycline 


CAP or skin and skin structure infections or UTI: 


TOPICAL THERAPIES 

Antibacterials 


Bacitracin topical ointment 

Bacitracin-polymyxin topical 

powder (POLYSPORIN ® 

POWDER) 

Bacitracin-neomycin-polymyxin 

topical ointment (TRIPLE 

ANTIBIOTIC ® OINTMENT) 

Bacitracin-neomycin-polymyxin 

ophthalmic ointment 

Bacitracin-neomycin-polymyxinhydrocortisone 

ophthalmic 

ointment 

Erythromycin ophthalmic 

ointment 

Gentamicin sulfate ophthalmic 

solution (GENTAK ® ) 

Neomycin-polymyxindexamethasone 

ophthalmic 

suspension (MAXITROL ® ) 

Silver sulfadiazine topical cream 



Apply to affected area(s) every 8 to 12 hours for 7 days 


Apply to affected area(s) every 3 to 4 hours for 7 to 10 days 


Apply sparingly to affected area(s) 2 to 5 times a day for 7 to 

10 days 

Ophthalmic infections: 

Apply 1⁄4 to 1⁄2 inch to affected eye(s) every 3 to 4 hours 

WA for 7 to 10 days 


Apply 1⁄4 to 1⁄2 inch to affected eye(s) every 3 to 4 hours 

WA for 7 to 10 days 


Apply 1⁄2 inch to affected eye(s) every 4 to 6 hours WA for 

7 to 10 days 


Instill 1 to 2 drops into affected eye(s) every 4 hours WA for 

7 to 10 days 


Instill 1 to 2 drops into affected eye(s) 4 to 6 times per day 

for 7 to 10 days 


Apply to affected area(s) BID until healed 

Antifungals 


Clotrimazole topical cream 

Clotrimazole vaginal cream 

Nystatin topical cream, ointment, 

or powder 

Nystatin and triamcinolone 

acetonide topical cream, ointment 


Cutaneous candidiasis: 

Apply to affected skin and surrounding areas BID until 

complete healing 

Vulvovaginal candidiasis: 

Insert 1 applicatorful vaginally HS for 7 to 14 days 

Cutaneous candidiasis: 

Apply to affected area(s) BID (cream, ointment) or 2 to 3 

times a day (powder) until complete healing 

Inflammatory cutaneous candidiasis: 

Apply sparingly to affected area(s) BID for < 14 days 


Infections 



• The cost represented in the tables below is based on the average cost for a single course of the 

anti-infectives. 

ORAL THERAPIES 

Antifungals 



Ketoconazole $88.77 

Voriconazole (VFEND ® ) $522.86 

Cephalosporins 



Cefdinir (OMNICEF ® ) $61.44 

Fluoroquinolones 



Moxifloxacin tablet (AVELOX ® ) $95.39 

Macrolides 



Clarithromycin regular-release tablet (BIAXIN ® ) $79.97 

Miscellaneous Anti-infectives 



Trimethoprim $12.94 

Nitrofurans 



Nitrofurantoin macrocrystalline capsule (MACRODANTIN ® ) $21.46 

Nitrofurantoin mono/macrocrystals capsule (MACROBID ® ) $29.39 

Nitrofurantoin suspension (FURADANTIN ® ) $344.24 

Oxazolidinones 



Linezolid tablet (ZYVOX ® ) $915.07 

Penicillins 



Ampicillin $11.51 


Infections 


Tetracyclines 



Minocycline (MINOCIN ® ) $39.65 

Tetracycline $12.68 

TOPICAL THERAPIES 

Antibacterials 


Bacitracin-polymyxin topical ointment (POLYSPORIN ® 

OINTMENT) 


$9.90 

Ciprofloxacin ophthalmic solution (CILOXAN ® ) $42.15 

Gentamicin topical ointment $12.22 

Gramicidin-neomycin-polymyxin ophthalmic solution 

$28.78 

(NEOSPORIN ® ) 

Metronidazole topical cream (METROCREAM ® ) $76.61 

Metronidazole topical gel (METROGEL ® ) $151.35 

Mupirocin calcium nasal ointment (BACTROBAN NASAL ® ) $95.13 

Mupirocin calcium topical cream (BACTROBAN CREAM ® ) $71.41 

Mupirocin topical ointment (BACTROBAN ® OINTMENT) $43.93 

Neomycin-polymyxin-dexamethasone ophthalmic ointment 

$11.78 

(MAXITROL ® ) 

Sulfacetamide ophthalmic solution (BLEPH ® -10) $8.13 

Tobramycin ophthalmic ointment (TOBREX ® ) $69.45 

Tobramycin ophthalmic solution (TOBREX ® ) $16.05 

Tobramycin-dexamethasone ophthalmic suspension 

$86.46 

(TOBRADEX ® ) 

Trimethoprim-polymyxin ophthalmic solution (POLYTRIM ® ) $17.12 

Antifungals 



Clotrimazole and betamethasone dipropionate topical cream 

$49.25 

(LOTRISONE ® ) 

Econazole nitrate topical cream $48.80 

Ketoconazole topical cream (KURIC CREAM) $31.22 

Miconazole nitrate topical cream (BAZA ® ANTIFUNGAL) $12.47 

Miconazole nitrate topical powder (ZEASORB ® -AF) $16.41 


Infections 


Antivirals 



Acyclovir topical cream (ZOVIRAX ® CREAM) $137.01 

Acyclovir topical ointment (ZOVIRAX ® OINTMENT) $165.59 





• Cognitive coping strategies such as distraction methods (e.g., imagery), meditation and/or relaxation 

to divert attention from PHN. 

• Wet compresses often are soothing for PHN. 

• To prevent bacterial infections from developing, patients with shingles should keep the affected 

skin clean and dry and should not scratch the blisters. 

• In general, follow applicable infection control policies and procedures (e.g., hand washing). 

NOTES: 

• The herpes zoster vaccine helps reduce the risk of shingles and the residual pain it can cause (i.e., 

PHN). 

• Adjuvants (e.g., gabapentin) and topical pain relievers (e.g., lidocaine patch) often are used for 

the management of PHN; opioids are sometimes needed. 

• Sometimes combination anti-infective therapy is necessary to treat an infection. Combination 

anti-infective therapy is included in the HP per diem provided the anti-infectives are used for 

an indication provided in the tables and the duration of therapy does not exceed 14 days. 

• Certain anti-infectives should be administered with regard to food and before or after specific 

medications. 

• Adjust dosages of anti-infectives based on age, renal function, and other patient and medication 

characteristics. 

• Certain anti-infectives are available as powder for oral suspension. These powders need to be 

reconstituted at the time the medication is dispensed and, therefore, must be procured from 

a local pharmacy and billed through the PBM Plus card. 

• Please consult with your HP pharmacist for administration instructions, dosage adjustments, and 

procurement of an anti-infective formulated as a powder for oral suspension. 

• The duration of topical therapy should be regularly reevaluated, as some skin infections may 

progress despite topical therapy. 


Insomnia 









OTC = over-the-counter 

PO = by mouth 









Hydroxyzine HCl (ATARAX ® ) 

Hydroxyzine pamoate (VISTARIL ® ) 


25mg to 50mg PO/IV/IM HS 



• Antihistamines should be used cautiously, if at all, in older adults because their anticholinergic 

properties may result in mental confusion, falls, constipation, and urinary retention. 

• Tolerance to antihistamines may develop after 1 to 2 weeks of continuous use. 



Trazodone 



• Antidepressants are recommended for patients with depression and insomnia; therapy with 

antidepressants solely for the indication of insomnia is generally not warranted. Further, some 

antidepressants may be effective for managing insomnia (e.g., TCAs), whereas others may cause 

or worsen insomnia (e.g., SSRIs). 

• The dosage of trazodone for the management of insomnia is typically much lower than the dosage 

used for the management of depression. 



Alprazolam 

Clonazepam 

Diazepam 

Lorazepam 

Oxazepam 

Temazepam 


0.25mg to 0.5mg PO HS 

0.125mg to 1mg PO HS 

2mg to 5mg PO/IV/IM HS 

0.5mg to 1mg PO/SL/IV/IM/SC HS 


7.5mg to 15mg PO HS 

• Among the benzodiazepines, lorazepam, oxazepam, and temazepam are the safest to use in 

patients with hepatic disease or impairment. 

• Benzodiazepines with long half lives (e.g., clonazepam, diazepam) should be avoided or used 

cautiously in older adults, as they may accumulate and result in subsequent adverse drug events 

such as falls. 


Insomnia 





Non-benzodiazepine Hypnotics 


Zolpidem 

Sedative Hypnotics 


Chloral hydrate 





• Chloral hydrate can cause significant GI distress and CNS adverse reactions, such as delirium, 

dizziness, hallucinations, nightmares and paranoia. It should generally be reserved as a “last-line” 

therapy for the management of insomnia. 




Analgesic-Antihistamine Combinations 



Acetaminophen and diphenhydramine (TYLENOL ® PM) $5.30 








Alprazolam orally disintegrating tablet (NIRAVAM ® ) $76.26 

Clonazepam orally disintegrating tablet (KLONOPIN ® 

WAFER) 

$61.04 

Flurazepam (DALMANE ® ) $7.28 

Triazolam (HALCION ® ) $13.20 

Melatonin & Melatonin Receptor Agonists 



Melatonin $6.05 

Ramelteon (ROZEREM ® ) $61.88 


Insomnia 


Non-benzodiazepine Hypnotics 



Eszopiclone (LUNESTA ® ) $86.13 

Zolpidem extended-release (AMBIEN ® CR) $87.45 





• Non-pharmacologic therapies, which are primarily designed to correct maladaptive behaviors 

that are not conducive to healthy sleep, should be considered first-line therapy for all chronic 

types of insomnia. 

• Treatment generally combines several approaches, which are more effective than individual 

techniques alone. 

• The most common cognitive behavioral therapy approaches include stimulus control therapy, 

sleep restriction, relaxation therapy, paradoxical intention, and sleep hygiene education. 

• It usually takes 1 to 3 months for successful implementation of non-pharmacologic therapies. 

Thus, supplemental pharmacotherapy may be required for a brief period of time. 

NOTES: 

• Patients often self-medicate with OTC medications that may affect sleep patterns. A thorough 

medication history, including evaluation of OTC medications, is an important component to 

the assessment and management of insomnia. 

• The selection of pharmacotherapy is primarily based on the patient’s chief complaint (e.g., difficulty 

falling asleep or maintaining sleep) and the pharmacokinetic properties of the medication. 

• In general, medications for the management of insomnia should be started at a low dose and 

titrated slowly. Consider short-term, intermittent doses (i.e., PRN) whenever feasible. 

• The continual need for pharmacotherapy should be routinely reassessed; dose reduction and/or 

therapy cessation should be tried periodically. 


Malabsorption Due to Pancreatic Insufficiency 



PO = by mouth 


• The pharmacologic therapies listed below are for the management of malabsorption due to pancreatic 

insufficiency, including steatorrhea, associated with either pancreatic cancer (defined as 

ICD-9-CM codes 157.0-157.9 or 197.8) or cystic fibrosis (defined as ICD-9-CM code 277). 

Pancreatic Enzymes 


Pancreatic enzyme supplements 

(general) 


1 to 2 capsules or tablets PO with each meal and/or snack 

• A full listing of the available pancreatic enzyme products is provided in the table below. 

Contents 

Pancreatic Enzyme Product 

Lipase Amylase Protease 

(Units) (Units) (Units) 

Creon ® DR 6,000 6,000 19,000 30,000 

Capsules, enteric-coated 

minimicrospheres 

Creon ® DR 12,000 12,000 60,000 38,000 

Creon ® DR 24,000 24,000 120,000 76,000 


• Make adjustments in the patient’s diet as necessary. 

NOTES: 

• Pancreatic enzyme products are not interchangeable. In some cases, the substitution of one 

product for another has resulted in therapeutic failures and adverse events. 

• Therapy must be tailored to meet the individual patient’s needs. 

• Consult with you HP pharmacist for assistance with dosing and product availability. 


Movement-Related Disorders 




EPS = extrapyramidal symptoms 





MAOIs = monoamine oxidase inhibitors 

PO = by mouth 

QD = daily 



• The pharmacologic therapies listed below are for the management of movement-related disorders 

related to Amyotrophic lateral sclerosis (defined as ICD-9-CM code 335.20), Huntington’s 

disease (Huntington’s chorea, defined as ICD-9-CM code 333.4), Lewy body dementia (defined 

as ICD-9-CM code 331.82), Parkinson’s disease (defined as ICD-9-CM codes 332., 

332.0, or 332.1), and other degenerative diseases of the basal ganglia such as Shy-Drager 

syndrome and progressive supranuclear palsy (defined as ICD-9 code 333.0) as the patient’s 

hospice-qualifying terminal diagnosis. 

• Movement-related disorders include (but are not limited to) chorea, cramps, fasciculations, 

rigidity, spasticity, and tremors. 



Benztropine 


Trihexyphenidyl 


0.5mg PO HS 



• Anticholinergics are generally used to manage rigidity and tremors. 

• Anticholinergics should be avoided in patients with Lewy body dementia because they may 

worsen cognition and cause hallucinations. 

• Anticholinergics also are included in the HP per diem for treating drug-induced EPS 

related to the patient’s hospice-qualifying terminal diagnosis (INCLUSION CODE: A). 



Clonazepam 

Diazepam 


0.5mg PO 1 to 3 times a day 

2mg to 10mg PO/IV/IM 3 to 4 times a day for spasticity or 

2.5mg PO/IV/IM QD for chorea 

• Clonazepam is generally used to manage chorea (involuntary jerky movements, especially of the 

arms, legs and face), cramps, and fasciculations (“muscle twitch”). 

• Diazepam is generally used to manage chorea and spasticity. 

• Based on their mechanism of action, other benzodiazepines may be effective for the management 

of chorea, cramps, fasciculations, and spasticity. Alprazolam, lorazepam, oxazepam, and 

temazepam also are included in the HP per diem for these indications. 

• Clonazepam and diazepam should be used cautiously in older adults, as they may accumulate 

and result in subsequent adverse drug events such as falls. 







Dopamine Precursors/Potentiators 


Carbidopa-levodopa 

Entacapone (COMTAN ® ) 

Entacapone-carbidopa-levodopa 

(STALEVO ® ) 


10/100mg or 25/100mg PO 2 to 3 times a day 

200mg PO with each dose of carbidopa-levodopa 

Dosing based on patient’s current carbidopa-levodopa dose 

• Dopamine precursors/potentiators are generally used to manage Parkinsonian-like symptoms 

such as rigidity. 

• The effectiveness of carbidopa-levodopa decreases with time, resulting in “on and off” phenomenon, 

“wearing off” phenomenon, and dyskinesias in patients with Parkinson’s disease. Effectiveness 

can be improved by adding entacapone to the patient’s regimen. 

• Entacapone should not be used as monotherapy. 

• Neuroleptic malignant syndrome has been reported with abrupt discontinuation or reduction 

of levodopa-containing medications (e.g., STALEVO®). Thus, if necessary, therapy should be 

discontinued or reduced slowly. 

Dopamine Receptor Agonists 


Bromocriptine 

Pramipexole (MIRAPEX ® ) 


1.25mg PO BID 

0.125mg PO TID 

• Dopamine receptor agonists are generally used to manage Parkinsonian-like symptoms such as 

dyskinesias and rigidity. 

Miscellaneous 


Amantadine 


50mg to 100mg po QD 

• Amantadine is generally used to manage bradykinesia and rigidity. 



Baclofen 

Carisoprodol 

Cyclobenzaprine 





• Baclofen is generally used to manage chorea and spasticity. 

• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with hallucinations, 

spasticity, and seizures. Baclofen therapy should be discontinued slowly. 

• If spasticity does not respond well to baclofen or if the patient cannot tolerate baclofen, other 

skeletal muscle relaxants should be tried. 











Dopamine Precursors/Potentiators 



Carbidopa-levodopa orally disintegrating tablet (PARCOPA ® ) $104.88 

Dopamine Receptor Agonists 



Cabergoline $81.28 

Ropinirole (REQUIP ® ) $90.33 

Ropinirole ER (REQUIP ® XL) $134.92 

Monoamine Oxidase Inhibitors (MAOIs) 



Rasagiline (AZILECT ® ) $143.83 

Selegiline capsule, tablet $47.31 




Chlorzoxazone (PARAFON FORTE ® DSC) $21.99 

Dantrolene (DANTRIUM ® ) $62.76 

Metaxalone (SKELAXIN ® ) $64.49 

Methocarbamol (ROBAXIN ® ) $26.38 

Orphenadrine ER (NORFLEX) $29.14 

Tizanidine (ZANAFLEX ® ) $59.63 





• Physiotherapy: exercises to promote strength, range of motion, and endurance. 

• Occupational therapy: environmental adaptations and special equipment to provide maximal 

functioning capabilities. 

• Speech therapy (for dysarthria): techniques taught to maximize communication with non-verbal 

modalities. 

• Swallowing therapy (for dysphagia): therapy to assist with eating and drinking. 

NOTES: 





Muscle Spasms 





PO = by mouth 


QD = daily 





Clonazepam 

Diazepam 


0.5mg PO TID PRN 

2mg PO/IV/IM 3 to 4 times a day PRN 

• Based on their mechanism of action, all benzodiazepines may be effective for muscle spasms. 

However, only diazepam has been studied specifically for spasticity disorders. Clonazepam has 

been shown to be effective for myoclonus. Alprazolam, lorazepam, oxazepam, and temazepam 

also are included in the HP per diem for muscle spasms. 

• Clonazepam and diazepam should be used cautiously in older adults, as they may accumulate 

and result in subsequent adverse drug events such as falls. 






Baclofen 

Carisoprodol 

Cyclobenzaprine 


5mg PO TID PRN 

350mg PO 3 to 4 times a day PRN 

5mg PO TID PRN 

• Abrupt discontinuation of baclofen may result in a withdrawal syndrome associated with hallucinations, 

spasticity, and seizures. Baclofen therapy should be discontinued slowly. 

Miscellaneous Therapies 


Potassium chloride 



10mEq to 20mEq PO QD 


• Miscellaneous therapies should only be used for muscle spasms related to confirmed hypokalemia. 

• Potassium levels should be monitored when using these therapies and doses should be adjusted 

based on potassium levels and patient response. 

• There are numerous potassium products available on the market. Please consult with your HP 

pharmacist to determine specific potassium products available in the per diem. 


Muscle Spasms 












Chlorzoxazone (PARAFON FORTE ® DSC) $21.99 

Dantrolene (DANTRIUM ® ) $62.76 

Metaxalone (SKELAXIN ® ) $64.49 

Methocarbamol (ROBAXIN ® ) $26.38 

Orphenadrine ER (NORFLEX) $29.14 

Tizanidine (ZANAFLEX ® ) $59.63 





• Applying moist heat to the muscle may help relieve symptoms. 

• Encourage the patient to avoid or minimize alcohol consumption. 

• If the patient is bed-bound or inactive, move the patient around at regular intervals. 

• Other techniques such as muscle massages and stretching exercises may help relieve symptoms. 

NOTES: 

• Opioids and other analgesics may help manage pain or discomfort associated with muscle 

spasms. 





Muscle Spasms 




Nausea/Vomiting 










PO = by mouth 

PR = rectally 







Dicyclomine 








0.375mg to 0.75mg PO every 12 hours 

Apply 1 to 3 patches behind the ear every 3 days 

• Scopolamine transdermal patch may take up to 12 hours to reach maximum effect. For acute 

control, an anticholinergic with a shorter duration of action (e.g., hyoscyamine) should be used. 

• Other anticholinergics such as atropine and glycopyrrolate also may be effective and are 

included in the HP per diem. 





Meclizine 



Lorazepam 


10mg to 25mg PO every 6 hours PRN 

25mg PO every 6 hours PRN 

12.5mg to 25mg PO every 6 hours PRN 


0.5mg to 1mg PO/SL/IV/IM/SC every 4 to 6 hours PRN 

• Older adults may be especially sensitive to the effects of benzodiazepines; lower doses (e.g., 

lorazepam < 3 mg/day) are generally considered to be equally effective and safer to use. 

Corticosteroids 


Dexamethasone 


4mg PO/IV/IM/SC BID 

• Other corticosteroids such as methylprednisolone, prednisolone, and prednisone also may be 


• When dexamethasone (or any corticosteroid) is administered in divided doses, it is suggested 

that the last dose be given in the afternoon to avoid insomnia. 







Haloperidol 


Promethazine 


10mg PO/IV/IM every 4 to 6 hours PRN 

0.5mg to 1mg PO/IM/SC every 4 to 6 hours PRN 

5mg PO/IV/IM every 4 to 6 hours PRN or 25mg PR every 8 

to 12 hours PRN 

12.5mg to 25mg PO/PR/IM every 4 to 6 hours PRN 

• Sometimes it is necessary to administer medications parenterally. Parenteral doses of neuroleptics 

are generally twice as potent as oral doses. Administer parenteral doses slowly to minimize 

hypotension. 

• Although chlorpromazine is an effective antiemetic, it is sedating and has anticholinergic properties. 

Therefore, it is best used in patients who might benefit from these effects. It is best avoided 

in patients who might be harmed by these effects, such as patients with Parkinson’s disease. 

• If parenteral use of promethazine is necessary, the preferred route of administration is by deep 

IM injection; however, the IV route can be used. When administered IV, promethazine should 

be given in a concentration no greater than 25mg/mL at a rate not to exceed 25mg/min; it is 

preferable to inject through the tubing of an IV infusion set that is known to be functioning 

satisfactorily. 



Erythromycin 




5mg to 10mg PO/IV/IM/SC every 6 to 8 hours PRN 

























Meclizine chewable tablet (BONINE ® ) $7.00 

Benzamides 



Trimethobenzamide (TIGAN ® ) $54.10 

Cannabinoids 



Dronabinol (MARINOL ® ) $188.17 




Perphenazine $21.80 

Neurokinin 1 (NK1) Receptor Antagonists 



Aprepitant (EMEND ® COMBO PACK) $389.48 

Serotonin Receptor Antagonists 



Granisetron tablet (KYTRIL ® ) $747.26 

Granisetron transdermal patch (SANCUSO ® ) $575.73 

Ondansetron oral solution (ZOFRAN ® ) $373.67 

Ondansetron orally disintegrating tablet (ZOFRAN ODT ® ) $49.19 

Ondansetron solution for injection (ZOFRAN ® ) $143.75 

Ondansetron tablet (ZOFRAN ® ) $56.76 





• Avoid strong and offensive odors. 

• Eliminate medications that may contribute to nausea/vomiting, if possible. 

• Relaxation techniques may help reduce the anxiousness and/or anticipation often preceding 

nausea/vomiting. 

NOTES: 

• Many of the pharmacologic therapies listed above have anticholinergic properties. Major side effects 

of medications with anticholinergic properties are blurred vision, constipation, dry mouth, 

and urinary retention. Older adults and patients with Parkinson’s disease are especially sensitive 

to these side effects. 





Ophthalmic & Oral Symptoms 






THERAPIES FOR OPHTHALMIC SYMPTOMS 

Lubricants 



Artificial tears ophthalmic 

ointment 

Artificial tears ophthalmic drops, 

solution 

Apply a small amount of ointment, roughly ¼ inch, to the 

inside of the lower eyelid 1 to 4 times a day PRN 

Instill 1 to 2 drops into the affected eye(s) 2 to 4 times a day 

PRN 

• Adjust the frequency of application of both the ointment and solution as needed. 

• If necessary, the ointment may be applied every 4 hours or may instill the drops every hour. 

• Discontinue use of the specific product if ocular pain, ocular pruritus or other ocular irritation 

symptoms occur or worsen, or if the condition has not improved within 72 hours of use of the 

product. 

• There are numerous artificial tears products on the market. Please check with your HP pharmacist 

to determine whether a particular product is included in the per diem prior to the product being 

dispensed by the pharmacy. 

THERAPIES FOR ORAL SYMPTOMS 

Dental and Periodontal Agents 



Chlorhexidine gluconate rinse 

(0.12%) 

• Expectorate (or spit) after rinsing; do not swallow. 

• Do not dilute chlorhexidine. 

Rinse mouth with 15mL for 30 seconds BID following 

toothbrushing. 

Oral Anesthetics 


Lidocaine oromucosal (viscous) 

solution (2%) 

Phenol oromucosal spray (1.4%) 


Apply 5mL to oral or mucosal membranes every 3 to 4 

hours PRN 

Spray affected area(s) of the mouth or throat, allow to remain 

in place for at least 15 seconds then spit out; may repeat 

every 2 hours 

• For use of lidocaine viscous in the mouth, swish around in the mouth and spit out. 

• For use of lidocaine viscous in the pharynx, gargle with the undiluted solution and either swallow 

or spit out the solution. Do not administer more frequently than every 3 hours and do not 

give more than 8 doses in any 24-hour period. 


Ophthalmic & Oral Symptoms 


Oromucosal Moisturizers 


Saliva substitute (BIOTENE ® ) 

Saliva substitute 

(MOUTHKOTE ® ) 


Shake twice before use. Spray directly into mouth whenever 

relief is needed. Can swallow to keep throat moist. 

Shake well before using. Spray in the mouth 3 to 5 times, 

swirl for eight to ten seconds, then swallow or spit out. Use as 

often as needed to maintain moistness. 

• Directions for use may differ among saliva substitute products. Please consult with your HP pharmacist 

to determine the suggested dosing of the specific product for your patient. 


• Stomatitis 

- Dietary interventions 

- Limit diet to foods that do not require much chewing; acidic, dry, or salty foods should 

be avoided. 

- Serve food at room temperature, not hot. 

- Chilled or frozen yogurt may soothe the mucosa and is a high protein snack. 

- Avoid alcohol and tobacco. 

- Mouth care 

- Mouth care including removal and cleaning of dentures, gentile cleansing of the oral 

cavity, and oral rinses with a weak basic solution (e.g., salt and baking soda) should be 

performed routinely. 

• Xerostomia 

- Stimulate salivary flow by using crushed ice, sugar-free chewing gum, pineapple chunks, 

and/or foods that require chewing. Additionaly, rehydrate the oral mucosa periodically by 

using sips of water, spraying the mouth with water, and swabbing the mouth with moistened 

gauze. 

- Avoid substances that dry or irritate the oral mucosa such as alcohol-containing mouth 

washes, caffeine, and citrus fruits. 

- Good oral hygiene including brushing teeth with a soft toothbrush and fluoride gel toothpaste, 

dental flossing, rinsing with fluorinated (non-alcoholic) mouth washes, and avoiding 

dietary sugar should be practiced routinely. 

NOTES: 

• Saliva substitute products contain sorbitol, which may induce bloating and/or diarrhea. 

• For the treatment of oral candidiasis (thrush), please refer to the antifungals in the Infections 

section. 

• Please note that sodium chloride nose spray/drops (0.65%) also is included in the HP per 

diem for the treatment of nasal congestion or dryness. 


Pain, Neuropathic 









PO = by mouth 


QD = daily 









Carbamazepine regular-release 

tablets or suspension 

Gabapentin 




300mg PO TID 

250mg PO TID 

• Carbamazepine is usually initiated at a dosage of 100mg PO BID for the tablets or 50mg PO 

QID for the suspension. The dosage is usually titrated to 600mg/day to 800mg/day or until side 

effects are intolerable. 

• Gabapentin is usually initiated at a dosage of 300mg PO QD on day 1, then 300mg PO BID 

on day 2, and 300mg PO TID on day 3. The dosage is usually titrated up PRN for pain relief, 

typically to an effective dosage range of 1800mg/day to 3600mg/day. 

• Valproic acid is usually initiated at a dosage of 125mg PO TID. The dosage is then titrated to 

750mg/day to 1500mg/day or until side effects are intolerable. Divalproex sodium (DEPAK- 

OTE®) also may be effective for neuropathic pain. The total daily dose is usually the same as 

valproic acid; however, divalproex sodium is administered BID. 



Amitriptyline 

Desipramine 

Nortriptyline 





• The TCAs are usually initiated at a dosage of 10mg to 25mg PO HS. The dosage is then titrated 

up by 10mg to 25mg every 2 to 3 days to 100mg/day to 150mg/day or until side effects are 

intolerable. 

• Amitriptyline tends to be more sedating and has greater anticholinergic effects than desipramine 

or nortriptyline. Thus, the latter two medications are generally better tolerated, particularly in 

older adults. 

• Among the TCAs listed above, desipramine may be the least sedating. 






Dexamethasone 


Prednisolone 

Prednisone 


4mg PO/IM/IV/SC 1 to 2 times a day 









Local Anesthetics 


Dibucaine topical ointment (1%) 


ointment (5%) 

Lidocaine transdermal patch (5%) 

(LIDODERM ® ) 


Apply to painful area(s) PRN, not to exceed 30gm of the 

ointment per day 

Apply to painful area(s) every 3 to 4 hours PRN, not to 

exceed 20gm of the ointment (or approximately 1000mg of 

lidocaine base) per day 

Apply up to 3 patches to intact skin to cover the most painful 

area for up to 12 hours in a 24-hour period 

• For the treatment of neuropathic pain, lidocaine transdermal patches are typically left on for 

12 hours and then removed. The patches may be cut into smaller sizes prior to removal of the 

release liner. 

NMDA-receptor Antagonists 


Capsaicin (0.025%, 0.075%) 

Miscellaneous 


Clonazepam 

Clonidine 

Mexiletine 


Apply to painful area(s) 2 to 4 times a day 


0.25mg to 0.5mg PO TID 

0.1mg to 0.3mg PO TID 


• Clonazepam should be avoided or used cautiously in older adults, as it may accumulate and 

result in subsequent adverse drug events such as falls. 

• Clonidine may be useful if an autonomic/sympathetic component is believed to be present (e.g., 

diaphoresis, mottling of extremities). 










Carbamazepine ER capsule (CARBATROL ® ) $137.33 

Carbamazepine ER tablet (TEGRETOL XR ® ) $40.34 

Oxcarbazepine suspension (TRILEPTAL ® ) $106.17 

Oxcarbazepine tablet (TRILEPTAL ® ) $69.40 


Topiramate (TOPAMAX ® ) $157.08 








Miscellaneous 




Local Anesthetics 



Lidocaine cream (LIDAMANTLE ® ) $41.42 





• Acupuncture may have some benefits for managing pain. 

• Cognitive coping strategies such as imagery, meditation, and/or relaxation are sometimes used to 

divert attention from pain. 

• Surgery is sometimes employed for the management of refractory neuropathic pain. 

NOTES: 

• Although TCAs are frequently used for the treatment of neuropathic pain, patients often are 

prescribed another type of antidepressant (e.g., SSRI) for depression. The use of more than one 

antidepressant concurrently should be avoided whenever possible. 








Pain, Nociceptive 








INR = international normalized ratio 



LA = long-acting 


PO = by mouth 

PR = rectally 


PUD = peptic ulcer disease 

QD = daily 




• The pharmacologic therapies listed below are for the management of nociceptive pain, including 

somatic, visceral, and bone pain. Not all therapies are indicated for every type of pain. 

Please consult with your HP pharmacist to aid in product selection, dosing, and monitoring for your 

individual patient. 



Dexamethasone 


Prednisolone 

Prednisone 


4mg PO/IM/IV/SC 1 to 2 times a day 




• The optimal dosing and duration for corticosteroids for treating pain has not been established. 

The minimum effective dose should be used for the shortest duration possible. Whenever possible, 

a dose reduction should be attempted in order to reduce the risk of long-term systemic 

adverse effects. 



• Dexamethasone often is considered the corticosteroid of choice because of its mineralocorticoid 

potency. 

Non-opioid Analgesics 


Acetaminophen 


325mg to 650mg PO/PR every 4 to 6 hours, up to 4000mg/day 

• Acetaminophen can cause hepatotoxicity and can increase the risk of bleeding in patients 

prescribed warfarin, especially if administered in large doses (> 2000mg/day) for prolonged 

periods of time (> 10 to 14 days). The patient’s medication regimen should be reviewed for other 

potentially hepatotoxic medications (e.g., amiodarone, statins) and the patient’s INR may need 

to be monitored more closely when prescribed acetaminophen. 




Non-steroidal Anti-inflammatory Drugs (NSAIDs) 



Diclofenac sodium 


Ibuprofen 


Nabumetone 

500mg PO BID 

Naproxen 


Naproxen sodium 


Opioids — Long-acting 


Fentanyl transdermal patch 

Methadone 

Morphine LA 


Dosing based on short-acting opioid requirements. Apply 

patch transdermally to the upper torso every 72 hours 

Dosing based on patient-specific factors 

Dosing based on short-acting opioid requirements. Take PO 

every 12 hours 

• The dosing of long-acting opioids varies substantially depending on the patient’s opioid tolerance 

and response. Please consult with your HP pharmacist for dosing recommendations and conversion 

strategies for long-acting opioids. 

• Most patients can be maintained adequately with fentanyl transdermal patch applied every 72 

hours. However, some patients may require application of the patch at 48-hour intervals to 

maintain adequate analgesia. 

• Lower initial doses of fentanyl transdermal patches are recommended when older adults or 

debilitated patients are converted from another opioid because they are more likely to experience 

respiratory depression due to altered pharmacokinetics. 

• Cachectic patients may have impaired fentanyl absorption due to poor fat stores and muscle 

wasting, but how this affects the dosing of fentanyl transdermal patch is uncertain. 

• Refer to the Medications with Policies section (page 16) for information regarding the 

long-acting opioids policy. 

Opioids — Short-acting 


Codeine and acetaminophen 

Hydrocodone and 

acetaminophen 

Hydromorphone 

Morphine IR 

Oxycodone IR 

Oxycodone and acetaminophen 

Oxycodone and aspirin 

Propoxyphene and 

acetaminophen 


30/300mg PO every 4 to 6 hours PRN 

5/325mg to 10/650mg PO every 4 to 6 hours PRN 

2mg to 4mg PO/PR every 3 to 4 hours PRN 

5mg to 10mg PO/PR every 3 to 4 hours PRN 


5/325mg to 10/650mg PO every 4 to 6 hours PRN 

4.5-0.38/325mg tablet PO every 6 hours PRN 

50/325mg to 100/650mg PO every 4 to 6 hours PRN, 

up to 600mg/day (propoxyphene) and 4000mg/day 

(acetaminophen) 




• Commercially available formulations of oxycodone and acetaminophen other than the 5/500mg 

capsule, 5/325mg tablet, and 5/325mg/5mL oral solution are outside the HP per diem. 

• Propoxyphene and acetaminophen is not recommended for use in older adults due to the increased 

risk of side effects. 

• Refer to the Medications with Policies section for information regarding the morphine 

infusions policy. 

Salicylates 


Aspirin 

Choline magnesium trisalicylate 


325mg to 650mg PO or 300mg to 600mg PR every 4 to 6 hours 


• Unlike aspirin, choline magnesium trisalicylate does not affect platelet aggregation. 




Miscellaneous Analgesics 



Tramadol (ULTRAM ® ) $34.11 

Tramadol ER (ULTRAM ® ER) $82.47 

Tramadol and acetaminophen (ULTRACET ® ) $46.49 

NSAIDs 



Celecoxib (CELEBREX ® ) $82.32 

Diclofenac epolamine topical patch (FLECTOR ® PATCH) $156.03 

Diclofenac potassium tablet (CATAFLAM ® ) $43.60 

Diclofenac sodium ER tablet (VOLTAREN ® XR) $51.67 

Diclofenac sodium and misoprostol DR tablet (ARTHROTEC ® ) $53.18 

Indomethacin capsule $14.39 

Ketoprofen capsule $37.29 

Ketoprofen ER capsule $60.71 

Ketorolac tromethamine tablet $25.86 

Ketorolac tromethamine solution for injection $12.88 

Meloxicam (MOBIC ® ) $59.17 

Naproxen enteric coated tablet (EC-NAPROSYN ® ) $48.97 

Piroxicam (FELDENE ® ) $22.84 

Opioids – Long-acting 



Morphine ER capsule (AVINZA ® ) $293.53 

Oxycodone ER (OXYCONTIN ® ) $180.25 




Opioids – Short-acting 



Codeine sulfate tablet $22.62 

Fentanyl citrate lozenge (ACTIQ ® ) $424.17 

Hydrocodone and ibuprofen (VICOPROFEN ® ) $44.72 

Hydromorphone solution for injection (DILAUDID ® ) $36.48 

Levorphanol tablet $39.88 

Meperidine solution for injection (DEMEROL ® ) $16.29 

Meperidine tablet (DEMEROL ® ) $29.21 

Oxycodone and acetaminophen (PERCOCET ® ), strengths 

other than 5/325mg or 5/500mg 

$75.37 

Propoxyphene capsule (DARVON ® ) $14.13 

Salicylates 



Salsalate (ARGESIC ® -SA) $9.09 





• Acupuncture may have some benefits for managing pain. 

• Cognitive coping strategies such as imagery, meditation, and/or relaxation are sometimes used to 

divert attention from pain. 

• Massage therapy, range of motion and/or flexibility exercises, and warm soaks may help to 

diminish stiffness. 

NOTES: 

• Many analgesic combinations contain acetaminophen. In general, the total (i.e., additive) daily 

dose of acetaminophen should not exceed 4000mg/day. The recommended maximum total daily 

dose in patients with hepatic disease, those who consume alcohol chronically, and patients who 

use acetaminophen continuously for more than 10 days is 2000mg/day. 

• Patients prescribed an NSAID or salicylate related to the hospice-qualifying terminal diagnosis 

who are at high risk for experiencing an upper GI adverse event should be prescribed a gastroprotective 

medication. These patients include those who are 65 years of age or older, have a past 

history of PUD or upper GI bleeding, or are concurrently prescribed a systemic corticosteroid or 

anticoagulant. For these patients, consider using one of the following regimens: 

- Misoprostol 200mcg PO QID, or 

- Omeprazole 20mg PO QD, or 

- Sucralfate 1gm PO QID. 

• Gastroprotective medication is outside the HP per diem for patients prescribed systemic 

corticosteroid monotherapy. 

• NSAIDs and salicylates should be used cautiously in patients with congestive heart failure, 

hypertension, and/or renal insufficiency. 

• All patients who are prescribed an opioid should have a bowel regimen prescribed. 














Pruritus 







PO = by mouth 


QD = daily 



Bile Acid Sequestrants 


Cholestyramine powder (plain 

and light) 


Mix 4gm in 60mL to 180mL of fluid (e.g., water, milk, fruit 

juice, or other non-carbonated beverage) PO QD. 

If necessary, increase by 4gm every 2 to 3 days, up to 16gm/ 

day in a single or divided dose 

• Administer other medications at least 1 hour before or 4 to 6 hours after each dose of cholestyramine, 

as this medication may impede the absorption of other medications. 

• The powder may also be mixed with a highly fluid soup or a pulpy fruit with high moisture (e.g., 

applesauce, crushed pineapple). 

• The palatability of and compliance with cholestyramine may be improved if the dose is mixed 

and refrigerated overnight. 

• The difference between cholestyramine plain and cholestyramine light is the amount of dried 

resin that is present in the powder. Cholestyramine plain has 4gm of active ingredient per 9gm 

of powder; cholestyramine light has 4gm of active ingredient per 5gm of powder. 

Systemic Antihistamines 


Chlorpheniramine 

Cyproheptadine 



Hydroxyzine pamoate 

(VISTARIL ® ) 

Systemic Corticosteroids 


Dexamethasone 

Methylprednisolone dosepak 

Prednisolone 

Prednisone 


4mg PO every 4 to 6 hours PRN 


25mg to 50mg PO/IM/IV every 4 to 6 hours PRN 












Pruritus 




Topical Anesthetics 



ointment (5%) 


Apply to affected area(s) every 3 to 4 hours PRN 

• Topical anesthetics may provide relief of itching that is refractory to other topical pharmacologic 

therapies. 

Topical Antihistamines 


Diphenhydramine cream (1%, 2%) 


Apply to itchy area(s) 3 to 4 times a day 

Topical Corticosteroids – Low-potency 


Hydrocortisone cream, ointment 

(0.5%, 1%, 2.5%) 

Topical Corticosteroids – Medium-potency 


Fluocinolone acetonide cream, 

ointment (0.025%) 

Triamcinolone acetonide cream, 

ointment (0.025%, 0.1%) 

Topical Corticosteroids – High-potency 


Betamethasone dipropionate 

cream, lotion ointment (0.05%) 

Fluocinonide cream, ointment 

(0.05%) 

Fluocinonide cream (0.05%, 

emulsified base) 

Triamcinolone acetonide cream, 

ointment (0.5%) 


Apply to itchy area(s) 2 to 4 times a day 


Apply sparingly to itchy area(s) 2 to 4 times a day 







• Topical corticosteroids should be used sparingly and for the shortest duration possible in order 

to reduce the risk of long-term adverse effects (e.g., thinning skin). 


Pruritus 


Topical Emollients / Protectants 


Bag balm 

Zinc oxide 


Apply to affected area(s) as directed; massage into skin 

thoroughly and allow ointment to remain for full softening 

effect 

Apply to affected area(s) as directed 




Miscellaneous Dermatologic Agents 



Ammonium lactate cream (AMLACTIN ® ) $17.55 

Ammonium lactate lotion (AMLACTIN ® ) $27.64 

Systemic Antihistamines 



Cetirizine (ZYRTEC ® ) $31.76 

Desloratadine (CLARINEX ® ) $20.27 

Fexofenadine (ALLEGRA ® ) $30.35 

Levocetirizine (XYZAL ® ) $37.12 

Loratadine (CLARITIN ® ) $16.98 

Systemic Corticosteroids 



Hydrocortisone (CORTEF ® ) $15.98 

Topical Anesthetics 



Lidocaine cream (LIDAMANTLE ® ) $41.42 

Topical Corticosteroids – Low-potency 



Desonide cream (DESOWEN ® ) $57.06 

Hydrocortisone lotion $20.54 

Topical Corticosteroids – Medium-potency 



Triamcinolone acetonide lotion $30.34 


Pruritus 


Topical Corticosteroids – High-potency 



Fluocinonide solution $18.70 

Topical Corticosteroids – Very High-potency 



Clobetasol propionate cream (TEMOVATE ® ) $34.61 

Topical Emollients / Protectants 



Zinc acetate ointment (PELEVERUS GOLD ® ) $34.23 

Zinc oxide and dimethicone (BAZA ® PROTECT CREAM) $18.50 





• Provide proper skin care. 

NOTES: 

• Some medications may cause or worsen pruritus. Consult with your HP pharmacist to identify 

medications that may cause or worsen pruritus. 


Pruritus 



Secretions 







PO = by mouth 







Atropine ophthalmic (1%) 

Atropine solution for injection 







1 to 2 drops PO/SL every 4 to 6 hours ATC or PRN 

0.4mg to 0.6mg IV/IM/SC every 4 to 6 hours ATC or PRN 

1mg to 2mg PO every 8 hours ATC or PRN 


0.375mg PO every 12 hours 

Apply 1 to 3 patches behind the ear every 3 days 

• Major side effects of anticholinergics are blurred vision, constipation, dry mouth, and urinary 

retention. Older adults are especially sensitive to these side effects. Of the anticholinergics, glycopyrrolate 

does not cross the blood-brain barrier and, therefore, is less likely to cause CNS side 

effects. Conversely, atropine is more likely to cause CNS side effects. 

• Atropine ophthalmic (eye) drops are safe to administer via the oral or sublingual route for management 

of excess secretions. To minimize the risk of side effects from atropine ophthalmic, the 

lowest effective dose should be used for the shortest duration possible, and the total daily dose 

should not exceed 36 drops. 

• Scopolamine transdermal patch may take up to 12 hours to reach maximum effect. For acute 

control, an anticholinergic with a shorter duration of action (e.g., hyoscyamine) should be used. 

Expectorants 


Guaifenesin tablet 

Guaifenesin solution or syrup 

Miscellaneous 


Sodium chloride 0.9% nebulizer 

solution 


100mg to 400mg PO every 4 hours ATC or PRN; maximum 

recommended dose is 2400mg/day 



1 ampule via nebulizer every 2 to 4 hours ATC or PRN 


Secretions 















• Discontinue IV hydration or tube feedings if still being administered, as they will worsen secretions. 

• Reassure family and friends that secretions usually do not bother or harm the patient. 

• Reposition the patient into an upward, supine position to facilitate drainage from the oropharynx 

and tracheal regions. 

NOTES: 

• There is no conclusive evidence that one anticholinergic medication is more effective than 

another; therefore, the choice should be based on the medication’s side effect profile, onset of 

action, duration of action, and route of administration. 


Secretions 



Seizures 






PO = by mouth 




Barbiturates 


Phenobarbital 


Status epilepticus: 

10mg/kg IV initially, followed by an additional 5mg/kg IV 

approximately 30 to 60 minutes after the first dose 

Maintenance: 

1mg/kg/day to 3mg/kg/day PO or IV, given in 1 to 2 divided 

doses 

• Phenobarbital is indicated for the treatment of status epilepticus and all types of seizure 

disorders, including partial seizures, clonic seizures, myoclonic seizures, tonic seizures, or tonicclonic 

seizures not responding to other anticonvulsants. 

• Because the full antiepileptic effect of phenobarbital is not immediate, IV benzodiazepines (e.g., 

diazepam, lorazepam) should be given initially. 

• For the treatment of status epilepticus, an additional 5mg/kg may be given for refractory 

seizures. The usual maximum total loading dose for phenobarbital is 25mg/kg to 30mg/kg. 

• The maintenance dose should be initiated 12 to 24 hours after the loading dose. 

• Because phenobarbital is sedating and has a long half-life, it is recommended that phenobarbital 

be administered as a single daily dose at bedtime. 



Clonazepam 

Diazepam 

Lorazepam 


0.5mg PO TID 


5mg to 10mg IV initially, repeated at 10 to 15 minute intervals 

to a maximum dosage of 30mg 

Adjunctive treatment: 



4mg IV initially, repeated in 10 to 15 minutes if needed to a 

maximum dosage of 8mg 

• Clonazepam is indicated for the alternative treatment of absence seizures, petit mal variant 

(Lennox-Gastaut syndrome), and akinetic and myoclonic seizures. The dosage provided above 

is initial dosing. This dosage may be increased by 0.5mg to 1mg every 3 days until seizures are 

controlled, up to a maximum dosage of 20mg/day. The typical maintenance dose of clonazepam 

ranges between 2mg/day and 8mg/day. Older adults and debilitated patients may require lower 

initial dosages and/or slower dosage titration. 

• For the treatment of status epilepticus or drug-induced seizures, the dosage of diazepam may 

be repeated in 2 to 4 hours if needed. The maintenance dose should be initiated 12 to 24 hours 

after the loading dose. 


Seizures 


• Diazepam is indicated for adjunctive treatment in refractory patients with partial seizures or 

generalized tonic-clonic seizures who require intermittent use of the medication to control bouts 

of increased seizure activity. It is not indicated as monotherapy and the manufacturer notes that 

diazepam may not be effective as adjunctive treatment for > 4 months. The dosage provided 

above is initial dosing. This dosage may be increased by 2mg to 5mg every 3 days until seizures 

are controlled, up to a maximum dosage of 40mg/day. Older adults and debilitated patients may 

require lower initial dosages and/or slower dosage titration. 

• For the treatment of status epilepticus, lorazepam should be administered slowly over 2 to 5 

minutes. 

Hydantoins 


Phenytoin 


4mg/kg/day to 7mg/kg/day PO, given as a single daily dose (ER 

capsules) or in 2 to 3 divided doses (suspension, tablets) 

• Phenytoin is indicated for the treatment of tonic-clonic and complex partial seizures. 

• Different phenytoin dosage formulations are not directly interchangeable. For example, 

phenytoin capsules contain phenytoin sodium, which is 92% phenytoin; chewable tablets and 

suspensions contain 100% phenytoin. 

• Phenytoin serum concentrations should be monitored during chronic therapy. 

Miscellaneous Anticonvulsants 


Carbamazepine regular-release 

tablets or suspension 

Divalproex sodium (DEPAKOTE ® ) 

Gabapentin 



200mg PO BID (tablets) or 100mg PO QID (suspension) 

10mg/kg/day to 15mg/kg/day PO initially, given in 2 to 3 

divided doses 

300mg PO TID 

10mg/kg/day to 15mg/kg/day PO initially, given in 2 to 3 

divided doses 

• Carbamazepine is indicated for the treatment of generalized tonic-clonic seizures and partial 

seizures, either simple or complex. 

• The dose of carbamazepine should be increased by no more than 200mg/day at weekly intervals. 

The minimum effective range is typically 800mg/day to 1200mg/day, but determined by serum 

concentrations. The usually accepted serum concentration range is 4mcg/mL to 12mcg/mL. 

• Periodic monitoring of serum carbamazepine concentrations is recommended. 

• Divalproex sodium/valproic acid is indicated for the treatment of absence seizures (either simple 

or complex), complex partial seizures, myoclonic seizures, and tonic-clonic seizures. 

• The dose of divalproex sodium/valproic acid can be increased by 5mg/kg/day to 10mg/kg/day 

at weekly intervals, as tolerated and necessary, up to 60mg/kg/day. For patients who do not 

respond, measure plasma concentrations to determine whether they are within the usually 

accepted range (50mcg/mL to 100mcg/mL). 

• Gabapentin is indicated for the adjunctive treatment of partial seizures with or without 

secondary generalized tonic-clonic seizures. 

• The effective dose of gabapentin is usually 900mg/day to 1800mg/day, but up to 2400mg/day 

has been used long-term. 


Seizures 





Barbiturates 



Primidone (MYSOLINE ® ) $13.52 





Diazepam rectal gel (DIASTAT ® ACUDIAL ) $435.32 

Miscellaneous Anticonvulsants 



Carbamazepine ER capsule (CARBATROL ® ) $137.33 

Carbamazepine ER tablet (TEGRETOL XR ® ) $40.34 

Divalproex sodium ER (DEPAKOTE ® ER) $80.19 

Lamotrigine (LAMICTAL ® ) $95.13 

Levetiracetam solution (KEPPRA ® ) $120.99 

Levetiracetam tablet (KEPPRA ® ) $117.94 

Oxcarbazepine suspension (TRILEPTAL ® ) $106.17 

Oxcarbazepine (TRILEPTAL ® ) $69.40 


Tiagabine (GABITRIL ® ) $145.67 

Topiramate (TOPAMAX ® ) $157.08 

Zonisamide (ZONEGRAN ® ) $71.87 




NOTES: 

• Some medications used for the management of seizures can interact with other medications 

and dosages for some medications should be adjusted in patients with hepatic and/or renal 

impairment. Please consult with your HP pharmacist for assistance with dosing and monitoring. 

• Some medications used for the management of seizures can effectively be administered by the 

rectal route (e.g., carbamazepine, valproic acid), whereas others are not recommended to be 

administered via this route (e.g., phenytoin, gabapentin). Please consult with your HP pharmacist 

for assistance with alternative routes of administration. 

• Corticosteroids often are given as adjuvant therapy, particularly for patients with brain 

malignancy. For example, dexamethasone has been used, up to 96mg/day, to decrease pain and 

swelling associated with cerebral edema. Dexamethasone, methylprednisolone, prednisolone, 

and prednisone are included in the HP per diem as adjuvant therapy for seizures. 


Thromboembolic-Related Disorders 

INCLUSION CODE: C, H, O 


ACCP = American College of Chest Physicians 

AF = atrial fibrillation 


CHD = coronary heart disease 


INR = international normalized ratio 

IVC = inferior vena cava 

LMWHs = low-molecular-weight heparins 

MI = myocardial infarction 

NSAIDs = non-steroidal anti-inflammatory 

drugs 

PO = by mouth 

QD = daily 

TIA = transient ischemic attack 

ARRHYTHMIAS 


• The pharmacologic therapies listed below are for the management of arrhythmias associated 

with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459; INCLUSION 

CODE: H). 

Anticoagulation & Antiplatelet Therapy 


Aspirin 

Warfarin 


325mg PO QD 

Titrate dose to achieve therapeutic INR 

• Warfarin is recommended for most patients with AF, particularly those with major risk factors 

for stroke (e.g., previous TIA, ischemic stroke, or systemic embolism; poor left ventricular function; 

diabetes mellitus; hypertension). 

• Aspirin is indicated for patients < 75 years with no major risk factors for stroke. 

• Warfarin has a narrow therapeutic index, meaning that there is small range within which warfarin 

is considered safe and effective. This range is monitored using the INR. A safe and effective 

INR for warfarin is typically between 2.0 and 3.5, depending on the indication for use. 

• The ACCP recommends that patients prescribed warfarin have an INR measured every 4 weeks 

at minimum. Some patients may require more frequent monitoring; for example, an INR 

should be drawn within 7 days of starting or changing the dose of warfarin. 

• As a patient safety standard, HP requests hospices to provide an INR at least every 4 weeks 

for patients prescribed warfarin. Further, in order for warfarin to be included in the HP per 

diem, an INR must be reported to HP at least every 4 weeks. 


• Patients prescribed warfarin should avoid profound changes in their dietary habits. 

• Patients prescribed anticoagulation and/or antiplatelet therapy should avoid certain over-thecounter 

and prescription medications, herbals, and dietary supplements that may increase the 

risk of bleeding (e.g., NSAIDs, garlic, green tea). 

• Smoking cessation – smoking is a risk factor for blood clotting; thus, smoking cessation should 

be encouraged. 




CEREBROVASCULAR DISEASE 


• The pharmacologic therapy listed below is for ischemic stroke prophylaxis in patients with a 

hospice-qualifying, primary diagnosis of cerebrovascular disease (defined as ICD-9-CM codes 

430-438; INCLUSION CODE: O). 

Anticoagulation & Antiplatelet Therapy 


Aspirin 

Dipyridamole 

Warfarin 



200mg PO BID 


• Dipyridamole often is used in combination with aspirin. 

• If the ischemic stroke is due to blood clots originating in the heart, warfarin is generally the 

treatment of choice. 













Antiplatelet Therapy 



Aspirin and dipyridamole ER (AGGRENOX ® ) $71.26 

Clopidogrel (PLAVIX ® ) $76.38 














CHRONIC STABLE ANGINA 


• The pharmacologic therapy listed below is for the management of chronic stable angina associated 

with cardiac diagnoses (defined as ICD-9-CM codes 391-429 or 440-459; INCLU- 

SION CODE: H). 



Aspirin 



• Antiplatelet therapy is indicated in all patients with CHD as first-line therapy for prevention of 

unstable angina, acute MI, and death. 

• In general, low-dose aspirin (i.e., 75mg/day to 150mg/day) is recommended for most patients 

with CHD as it provides the same benefits as high-dose aspirin (i.e., 325mg/day) and is associated 

with fewer side effects. 







Clopidogrel (PLAVIX ® ) $76.38 





• Patients prescribed antiplatelet therapy should avoid certain over-the-counter and prescription 

medications, herbals, and dietary supplements that may increase the risk of bleeding (e.g., 

NSAIDs, garlic, green tea). 



VENOUS THROMBOEMBOLISM RESULTING FROM MALIGNANCY 


• The pharmacologic therapy listed below is for the management of venous thromboembolism 

associated with cancer (defined as ICD-9-CM codes 140-239; INCLUSION CODE: C). 

Anticoagulation Therapy 


Warfarin 


















Indirect Factor Xa Inhibitors (Anticoagulants) 



Fondaparinux (ARIXTRA ® ) $783.54 

Low-Molecular-Weight Heparins (LMWHs) 



Dalteparin sodium solution for injection (FRAGMIN ® ) $438.78 

Enoxaparin sodium solution for injection (LOVENOX ® ) $735.22 





• Bed rest is unnecessary except to help relieve symptoms. 

• If painful skin ulcers develop, properly applied compression bandages can help. 

• Inferior vena cava (IVC) filter – very rarely, a tiny metal filter device resembling an umbrella is 

placed, usually inside the inferior vena cava, to prevent emboli from reaching the lungs. 





• Smoking cessation – although not a direct therapy for venous thromboembolism, smoking is a 

risk factor for blood clotting and can therefore contribute to deep vein thrombosis. Thus, smoking 

cessation should be encouraged. 

NOTES: 

• In general, how long patients continue treatment with anticoagulation and/or antiplatelet 

therapy varies according to the degree of risk. In the hospice population, these therapies might 

be continued indefinitely. 

• Analgesics, usually opioids, may be used to relieve pain. 


Thyroid-Related Disorders 



PO = by mouth 

QD = daily 


• The pharmacologic therapy listed below is for the management of thyroid-related disorders, 

namely hypothyroidism due to thyroid cancer (defined as ICD-9-CM code 193) or from the 

effects of surgery or radiation related to the patient’s hospice-qualifying terminal diagnosis. 


Levothyroxine 


Usual maintenance dose: 

100mcg to 200mcg PO QD 

• The dose of levothyroxine must be individualized based on clinical response and laboratory 

parameters. 


• The mainstay of therapy for thyroid-related disorders is pharmacologic therapy. Nevertheless, medication 

compliance is an important issue in the management of thyroid-related disorders. Non-pharmacologic 

interventions such as pill boxes can be used to improve medication compliance. 

NOTES: 

• Thyroid function tests aid in assessing response to thyroid hormone therapy. These tests should 

be performed periodically to ensure the patient is clinically euthyroid. 

• Testing should be performed and/or repeated 6 to 8 weeks after levothyroxine dose changes. 


Upper Gastric Disorders 





GERD = gastroesophageal reflux disease 


H 2 

RAs = histamine 2 

-receptor antagonists 

PO = by mouth 

PPIs = proton pump inhibitors 

QD = daily 


ACTIVE GI BLEED OR GERD 


• The pharmacologic therapies listed below are for the management of active GI bleed or 

gastroesophageal reflux disease (GERD) due to esophageal cancer (defined as ICD-9-CM 

codes 150.0-150.9), gastric cancer (defined as ICD-9-CM codes 151.0-151.9), or pancreatic 

cancer (defined as ICD-9-CM codes 157.0-157.9 or 197.8). 

Gastric Mucosal Agents 


Sucralfate 


1gm PO QID 

• Sucralfate should be taken on an empty stomach, at least one hour prior to a meal and at bedtime. 

• Do not administer H 2 

RAs or PPIs within 30 minutes before or one hour after sucralfate. 

Histamine 2 

Receptor Antagonists (H 2 

RAs) 


Ranitidine 



• Total daily dosages of ranitidine > 600mg/day are outside the HP per diem. 



Omeprazole 

Rabeprazole (ACIPHEX ® ) 





• Total daily dosages of omeprazole > 40mg/day and rabeprazole > 40mg/day are outside the 

HP per diem. 







H 2 

RAs 



Cimetidine tablet (TAGAMET ® HB) $31.68 

Famotidine solution for injection (PEPCID ® ) $15.29 

Famotidine tablet and suspension (PEPCID ® ) $8.98 

PPIs 






Lansoprazole DR orally disintegrating tablet (PREVACID ® 

SOLUTAB ) 

$124.32 






• Avoid triggering substances such as alcohol and fatty foods. 

• Raising the head of the bed about 6 inches can prevent acid from flowing into the esophagus as 

the patient sleeps. 


• Surgery is sometimes needed to treat GI bleeding. 

ESOPHAGEAL OR GASTRIC VARICES 


• The pharmacologic therapies listed below are for the management of esophageal or gastric varices 

due to liver disease (defined as ICD-9-CM codes 570, 571.0-571.9, 572.0, 573.0-573.9; IN- 

CLUSION CODE: O), malignant neoplasm of the liver and intrahepatic bile ducts (defined 

as ICD-9-CM codes 155.-155.2 or 197.7; INCLUSION CODE: C), or malignant neoplasm 

of the gallbladder and extrahepatic bile ducts (defined as ICD-9-CM codes 156.-156.9; 

INCLUSION CODE: C). 

Beta-blockers 


Propranolol 


40mg PO BID 

• For the treatment of portal hypertension and/or variceal bleeding prophylaxis in patients with 

esophageal varices, doses of propranolol are titrated to achieve heart rate reduction of 25%. 



Omeprazole 







• The duration of therapy for omeprazole is typically 4 to 8 weeks. 




Beta-blockers 




PPIs 






Lansoprazole DR orally disintegrating tablet (PREVACID ® 

SOLUTAB ) 

$124.32 






• Avoid or reduce alcohol intake. 

• Blood transfusions are sometimes given to replace lost blood. 

• Surgery is sometimes needed to treat varices. 

NOTES: 

• Dosages of the medications listed above may need to be adjusted based on age, renal function, 

hepatic function, and other patient and medication characteristics. For example, the daily dosage 

of H 2 

RAs should be decreased by 50% for patients with estimated CrCl < 50 mL/min. Please 

consult with your HP pharmacist for dosage adjustments. 


Urinary Incontinence 



BPH = benign prostatic hyperplasia 




PO = by mouth 

QD = daily 



Alpha-adrenergic Blockers 


Doxazosin 


1mg PO HS 

• Doxazosin is indicated for the treatment of BPH. 

• The dosage provided above is initial dosing. The dosage should be adjusted based on clinical 

response. The maximum recommended dosage of doxazosin is 8mg/day. 

• Older adults may be more sensitive to the hypotensive effects of doxazosin. 



Oxybutynin IR 

Oxybutynin transdermal patch 

(3.9mg/day) 

(OXYTROL ® ) 

Tolterodine ER (DETROL ® LA) 



1 patch applied to the abdomen, hip, or buttock twice weekly 

(every 3 to 4 days) 

4mg PO QD 

• Smooth muscle relaxants are indicated for the treatment of an overactive bladder with symptoms 

of urinary frequency, urinary urgency, or urge-related urinary incontinence. 

• Smooth muscle relaxants are strongly anticholinergic. Major side effects are blurred vision, 

constipation, dry mouth, and urinary retention. Older adults are especially sensitive to these side 

effects. 

• Oxybutynin transdermal patch (OXYTROL®) and tolterodine ER (DETROL® LA) are included 

in the HP per diem if the patient is unable to tolerate oxybutynin IR or the patient 

is unresponsive to a treatment trial of at least 4 to 8 weeks with oxybutynin IR. 

• The dose of tolterodine should be reduced to 2mg/day in patients with renal or hepatic impairment 

or those taking medications that inhibit the CYP3A4 isoenzyme. 



Desipramine 

Nortriptyline 


25mg PO HS 

25mg PO HS 

• The dosage provided above is initial dosing. The dosage should be adjusted based on clinical 

response. 

• TCAs have anticholinergic properties and may be poorly tolerated by older adults. 

• Desipramine tends to be less sedating than nortriptyline. 







Alpha-adrenergic Blockers 



Prazosin (MINIPRESS ® ) $8.01 

Tamsulosin (FLOMAX ® ) $51.48 

Terazosin $26.34 

Muscarinic Antagonists 



Darifenacin (ENABLEX ® ) $105.40 

Flavoxate $48.01 

Solifenacin (VESICARE ® ) $113.28 




Oxybutynin ER (DITROPAN ® XL) $79.25 

Tolterodine (DETROL ® ) $61.39 

TCAs 




5-Alpha Reductase Inhibitors 



Dutasteride (AVODART ® ) $54.72 

Finasteride (PROSCAR ® ) $45.33 





• Behavioral management techniques (e.g., timed voiding), exercise programs (e.g., Kegel 

exercises), and lifestyle modification (e.g., decreased amount and type of fluid intake) are 

the cornerstones of non-pharmacologic therapy for urinary incontinence. One or more of 

these therapies should be continuously employed whenever possible, including along with 

pharmacologic therapy. The use of non-pharmacologic therapy sometimes is limited, though, 

due to moderate effectiveness, delayed response, diminished efficacy over time, and cognitive 

impairment in the frail elderly. 

• Invasive devices/procedures (e.g., catheter, urethral stenting) and/or surgery are sometimes 

needed. 




NOTES: 

• Pharmacologic therapy should be started at a low dose and titrated slowly. The maximum benefit 

of pharmacologic therapy may not be apparent for several weeks to months. 

• Pharmacologic therapy should be continually evaluated for clinical effectiveness and tolerability. 

• Periodically, attempts should be made to reduce the dosage or discontinue the medication to 

determine if the incontinence can be managed with non-pharmacologic therapy. 



Medication Index by Generic (Brand) Name 

MEDICATION INDEX BY GENERIC (BRAND) NAME 

Medications typically dispensed by their generic names are listed generically; medications typically 

dispensed by their brand name also have a brand name listed. 

A 

Page(s) 

Acetaminophen 

8, 10, 80, 97, 118, 119, 

120, 121, 122 

Acetaminophen/codeine 119, 123 

Acyclovir 89, 95 

Albuterol sulfate 73, 75, 76 

Albuterol sulfate HFA inhalation aerosol (PROAIR ® HFA, PROVENTIL ® 

HFA, VENTOLIN ® HFA) 

73, 75, 76 

Albuterol sulfate nebulizer solution 73, 75, 76 

Albuterol sulfate/ipratropium bromide inhalation aerosol 

(COMBIVENT ® ) 

75 

Albuterol sulfate/ipratropium bromide nebulizer solution (DUONEB ® ) 73.2 

Alprazolam 30, 31, 32, 96, 97, 103 

Aluminum hydroxide suspension 70, 72 

Aluminum hydroxide/magnesium hydroxide/simethicone suspension 

(ALAMAG PLUS) 

70, 72 

Amantadine 101 

Amiodarone 45, 118 

Amitriptyline 35, 63, 64, 66, 113, 116 

Amlodipine 47, 49 

Amoxicillin 91 

Amoxicillin/clavulanate potassium 91 

Amoxicillin/clavulanate potassium extended-release (AUGMENTIN ® XR) 91 

Aspirin 

67, 80, 119, 120, 122, 

125, 137, 138, 139 

Aspirin Buffered 

67, 80, 120, 137, 138, 

139 

Atenolol 44, 47, 52 

Atropine ophthalmic drops 1% 8, 10, 131, 133 

Azithromycin 90 

B 

Page(s) 

Bacitracin ophthalmic ointment 92 

Bacitracin zinc topical ointment 92 

Bacitracin zinc/polymyxin B sulfate topical powder (POLYSPORIN ® 

POWDER) 

92 

Bacitracin zinc/neomycin sulfate/polymyxin B sulfate topical ointment 

(TRIPLE ANTIBIOTIC OINTMENT) 

92 

Baclofen 84, 86, 101, 103, 105 

Bag Balm 128, 130 

Beclomethasone dipropionate inhalation aerosol (QVAR ® ) 73 

Belladonna/opium suppository 81, 82 



Benzocaine rectal ointment 20% (AMERICAINE ® HEMORRHOIDAL) 81 

Benzonatate 57, 60 

Benztropine 100 

Betamethasone dipropionate cream, lotion, ointment 0.05% 127, 130 

Bisacodyl 38, 54, 56 

Bismuth subsalicylate suspension (BISMATROL ® , PEPTO-BISMOL ® ) 67, 69 

Bromocriptine 101 

Bumetanide 33, 34, 78 

C 

Page(s) 

Camphorated opium tincture (PAREGORIC ® ) 67, 69 

Capsaicin 114, 116 

Captopril 47, 50 

Carbamazepine 

35, 113, 115, 116, 135, 

136 

Carbidopa/levodopa 101, 102 

Carbidopa/levodopa/entacapone (STALEVO ® ) 101 

Carboxymethylcellulose sodium ophthalmic drops 0.5% (REFRESH 

TEARS ® , REFRESH PLUS ® ) 

111 

Carisoprodol 101, 105 

Carvedilol 47, 50, 51 

Carvedilol extended-release (COREG CR ® ) 50, 51 

Cefpodoxime proxetil 90 

Cefuroxime axetil 90 

Cephalexin 90 

Chloral hydrate 97 

Chlorhexidine gluconate 0.12% rinse 111 

Chlorpheniramine 126, 130 


27, 36, 38, 61, 84, 86, 

108, 110 

Choline magnesium trisalicylate 80, 120, 122, 125 

Cholestyramine powder 67, 69, 126, 130 

Cholestyramine light powder 67, 69, 126, 130 

Ciprofloxacin 90, 94 

Citalopram 63, 66 

Clindamycin 90 

30, 31, 32, 96, 97, 100, 

Clonazepam 

102, 103, 104, 105, 114, 

115, 117, 134, 136 

Clonidine 114, 117 

Clotrimazole cream 1% 92 

Clotrimazole troche 89 

Clotrimazole vaginal cream 1% 92 

Cyclobenzaprine 101, 103, 105 

Cyproheptadine 41, 43, 126, 130 



D 

Page(s) 

Dextromethorphan extended-release suspension (DELSYM ® ) 57 

Desipramine 

63, 64, 66, 113, 116, 

145 

39, 41, 43, 74, 80, 85, 

Dexamethasone 

107, 110, 114, 116, 117, 

118, 125, 126, 130, 136 

Dextran 70/hypromellose 0.3% ophthalmic drops, solution (TEARS 

NATURALE II®, TEARS RENEWED ® ) 

111 

Diazepam 

30, 32, 85, 96, 100, 103, 

105, 134, 135, 136 

Dibucaine topical ointment 1% 81, 114, 116 

Diclofenac sodium 80, 119, 120, 122, 125 

Dicloxacillin 91 

Dicyclomine 107, 110 

Digoxin 45, 46, 51 

Diltiazem 44, 49 

Diltiazem extended-release 47 


10, 96, 97, 100, 126, 

130 

Diphenhydramine hydrochloride 1% / zinc acetate 0.1% topical cream 127, 130 

Diphenhydramine hydrochloride 2% / zinc acetate 0.1% topical cream 127, 130 

Diphenoxylate/atropine 67, 69 

Dipyridamole 138 

Disopyramide 45 

Disopyramide extended-release 45 

Divalproex sodium (DEPAKOTE ® ) 35, 113, 135 

Docusate calcium 38, 55, 56 

Docusate sodium 38, 55, 56 

Docusate sodium enema (ENEMEEZ ® MINI ENEMA) 55, 56 

Doxazosin 145 

Doxycycline 92 

E 

Page(s) 

Enalapril 34, 42, 47, 50, 53, 79 

Entacapone (COMTAN ® ) 101 

Erythromycin 70, 90, 108, 110 

Erythromycin base 72, 90, 108, 110 

Erythromycin delayed-release, gastro-resistant 72, 90, 108, 110 

Erythromycin ethylsuccinate 72, 90, 108, 110 

Erythromycin ophthalmic ointment 0.5% 92 

Erythromycin stearate 90, 108 



F 

Page(s) 

Fentanyl transdermal system 119, 124 

Fluconazole 89 

Fluocinolone acetonide cream, ointment 0.025% 127, 130 

Fluocinonide cream, ointment 0.05% 127, 130 

Fluocinonide emulsified cream 0.05% 127, 130 

Fluoxetine 35, 63, 66 

Fluticasone propionate/salmeterol inhalation powder (ADVAIR ® DISKUS ® ) 75, 76 

Fosinopril 47, 50 

Furosemide 8, 33, 34, 78 

G 

Page(s) 

Gabapentin 95, 113, 116, 135, 136 

Gentamicin sulfate 0.3% ophthalmic solution 92 

Glipizide 87 

Glyburide 87, 88 

Glycerin adult suppository 54, 56 

Glycerin pediatric suppository 54, 56 

Glycerin 0.2% / hypromellose 0.2% / polyethylene glycol 400 1% 

ophthalmic drops (VISINE ® TEARS ® ) 

111 


39, 40, 107, 108, 131, 

132, 133 

Guaifenesin 58, 60, 131, 133 

Guaifenesin/codeine 57, 60 

Guaifenesin/codeine/pseudoephedrine 58, 60 

Guaifenesin/dextromethorphan 57, 58, 60 

Guaifenesin/dextromethorphan/phenylephrine 58 

H 

Page(s) 

Haloperidol 

8, 10, 27, 36, 38, 61, 84, 

86, 108, 110 

Hydralazine 51, 52 

Hydrochlorothiazide 33, 51, 52, 78, 79 

Hydrocodone/acetaminophen 119, 123 

Hydrocodone bitartrate/homatropine methylbromide 57, 60 

Hydrocortisone cream (0.5%, 1%, 2.5%), ointment (0.5%, 1%, 2.5%) 127, 130 

Hydrocortisone rectal cream 2.5% (PROCTOZONE-HC) 81 

Hydrocortisone acetate suppositories (ANUCORT-HC, ANUSOL- 

HC ® , HEMORRHOIDAL HC) 

81 

Hydromorphone 74, 119, 121, 123, 124 

Hydroxyzine hydrochloride (ATARAX ® ) 

30, 32, 96, 107, 126, 

130 


30, 32, 96, 107, 110, 

126, 130 



Hyoscyamine 

9, 39, 81, 107, 110, 131, 

133 

Hypromellose 0.5% ophthalmic drops (ISOPTO ® TEARS) 111 

I 

Page(s) 

Ibuprofen 80, 119, 121, 122, 125 

Ipratropium bromide inhalation aerosol (ATROVENT ® HFA) 73 

Ipratropium bromide nebulizer solution 73, 76 

Isosorbide dinitrate 48, 51, 53 

Isosorbide mononitrate (IMDUR ® , ISMO ® ) 48 

L 

Page(s) 

Lactulose 38, 54, 56, 83 

Lanolin 2% / mineral oil 15% / white petrolatum base 83% ophthalmic 

ointment (AKWA TEARS ® ) 

111 

Levofloxacin (LEVAQUIN ® ) 90 

Levothyroxine sodium 141 

Lidocaine hydrochloride oromucosal solution 2% 111 

Lidocaine hydrochloride topical gel/jelly 2% 81, 114, 116, 127, 130 

Lidocaine ointment 5% 81, 114, 116, 127, 130 

Lidocaine topical solution 4% 114, 127 

Lidocaine 5% transdermal patch (LIDODERM ® ) 95, 114, 116 

Lisinopril 47, 50, 51 

Loperamide 67, 68, 69 

8, 9, 10, 27, 30, 32, 77, 

Lorazepam 

96, 103, 107, 110, 134, 

135 

M 

Page(s) 

Magnesium citrate solution 54 

Meclizine 107, 109, 110 

Megestrol acetate suspension 41, 43 

Methadone 117, 119, 124 

Methylphenidate 42, 46, 64, 65, 66 

39, 41, 74, 80, 107, 114, 


116, 117, 118, 125, 126, 

130, 136 


38, 39, 70, 71, 72, 84, 

86, 108, 110 

Metolazone 78 

Metoprolol succinate 47, 50 

Metoprolol tartrate 44, 47, 50, 51 

Metronidazole 68, 69, 91 

Mexiletine 114, 117 

Milk of magnesia 54 



Mineral oil rectal enema 54, 56 

Mineral oil oral solution 54 

Mineral oil 3% / white petrolatum base 94% ophthalmic ointment 

(TEARS NATURALE P.M. ® ) 

111 

Mirtazapine 64, 65, 66 

Misoprostol 121, 125 

Morphine sulfate 8, 10, 74, 119, 120, 123, 124 

N 

Page(s) 

Nabumetone 81, 119, 122, 125 

Naproxen 80, 119, 120, 122, 125 

Naproxen sodium 119, 122, 125 

Neomycin 83 

Neomycin sulfate/polymyxin B sulfate/bacitracin zinc ophthalmic 

ointment 

92 

Neomycin sulfate/polymixin B sulfate/dexamethasone ophthalmic 

suspension 

92 

Neomycin sulfate/polymyxin B sulfate/bacitracin zinc/hydrocortisone 

acetate ophthalmic ointment 

92 

Nitroglycerin 9, 48, 49 

Nitroglycerin ointment 2% 48 

Nitroglycerin transdermal patch 48 

Nortriptyline 

35, 62, 63, 64, 66, 113, 

116, 145 

Nystatin 89 

Nystatin 100,000 units/gm topical cream, ointment 93 

Nystatin 100,000 units/gm topical powder 93 

Nystatin 100,000 units/gm / triamcinolone acetonide 0.1% topical cream, 

ointment 

93 

O 

Page(s) 

Omeprazole 71, 72, 121, 125, 142, 143 

Oxazepam 30, 32, 96, 103 

Oxybutynin 81, 82, 145, 146 

Oxybutynin transdermal patch (OXYTROL ® ) 145 

Oxycodone 74, 119, 120, 123, 124 

Oxycodone/acetaminophen 119, 120, 121, 123 

Oxycodone/aspirin 119, 123 

P 

Page(s) 

Pancreatic enzymes (various) 99 

Penicillin VK 91 

Phenazopyridine 81 

Phenobarbital 134 

Phenol 1.4% oromucosal spray 111 



Phenytoin sodium extended-release 135, 136 

Phenytoin chewable tablet (DILANTIN ® INFATABS ® ) 135, 136 

Phenytoin oral suspension 135, 136 

Polyethylene glycol 3350 powder (MIRALAX ® ) 54.1 

Polyethylene glycol 400 1% / polyvinyl alcohol 1% ophthalmic drops, 

solution (ARTIFICIAL TEARS, HYPO TEARS ® ) 

111 

Polyvinyl alcohol 1.4% / benzalkonium chloride 0.005% (AKWA TEARS ® ) 111 

Potassium bicarbonate (KLOR-CON ® EF) 34, 53, 78, 79, 103, 105 

Potassium bicarbonate/chloride 34, 53, 78, 79, 103, 105 

Potassium chloride 34, 53, 78, 79, 103, 105 

Pramipexole (MIRAPEX ® ) 101 

39, 41, 80, 107, 114, 

Prednisolone 

116, 117, 118, 125, 126, 

130, 136 

39, 41, 74, 76, 80, 107, 

Prednisone 

114, 116, 117, 118, 125, 

126, 130, 136 

Prochlorperazine 8, 10, 38, 108 

Promethazine 38, 108 

Promethazine/codeine 57, 60 

Promethazine/dextromethorphan 57, 60 

Promethazine/phenylephrine 57, 60 

Promethazine/phenylephrine/codeine 57, 60 

Propafenone immediate-release 45 

Propafenone extended-release (RYTHMOL ® SR) 45 

Propoxyphene/acetaminophen 119, 120, 121 

Propranolol hydrochloride 44, 47, 143 

Propranolol extended-release 44, 47 

Q 

Page(s) 

Quetiapine (SEROQUEL ® ) 36 

Quinidine gluconate extended-release 45 

Quinidine sulfate immediate-release 45 

R 

Page(s) 

Rabeprazole sodium (ACIPHEX ® ) 142 

Ranitidine 70, 72, 142 

Risperidone 27, 28, 36, 37, 61 

S 

Page(s) 

Saliva substitute (BIOTENE ® , MOUTHKOTE ® ) 112 

Salmeterol (SEREVENT ® DISKUS ® ) 75 

Scopolamine transdermal patch (TRANSDERM SCOP ® ) 39, 107, 110, 131, 133 

Senna 38, 54, 56 



Senna/docusate sodium 54, 55, 56 

Sertraline 35, 42, 63, 66 

Silver sulfadiazine cream 1% 92 

Simethicone 70 

Sodium chloride nasal spray 0.65% 112 

Sodium chloride nebulizer solution 0.9% 58, 131, 133 

Sodium phosphate dibasic and monobasic rectal enema 54 

Sorbitol 70% solution 54, 56, 112 


33, 34, 50, 53, 78, 79, 

103, 105 

Sucralfate 121, 125, 142 

Sulfamethoxazole/trimethoprim 91 

T 

Page(s) 

Temazepam 96, 103 

Theophylline 75 

Tolterodine extended-release (DETROL ® LA) 145 

Trazodone 64, 65, 66, 96 

Triamcinolone acetonide cream, ointment 0.025%, 0.1%, 0.5% 127, 130 

Triamcinolone acetonide inhalation aerosol (AZMACORT ® ) 73 

Triamterene/hydrochlorothiazide 78 

Trihexyphenidyl 100 

U 

Page(s) 

V 

Page(s) 

Valacyclovir (VALTREX ® ) 89 


35, 84, 86, 113, 116, 

135, 136 

Valsartan (DIOVAN ® ) 50, 53 

Verapamil regular-release 44, 49 

Verapamil sustained-release 44, 47 

W 

Warfarin 

Page(s) 

67, 118, 137, 138, 139, 

140 

Z 

Page(s) 

Zinc oxide 10% / Dimethicone 1% (A & D ® ointment) 128, 130 

Zinc oxide topical ointment 11.3% (BALMEX ® Diaper Rash Ointment) 128, 130 

Zinc oxide topical ointment 40% 128, 130 

Zolpidem 97, 98 


Medication Index by Brand (Generic) Name 

MEDICATION INDEX by BRAND (GENERIC) NAME 

This index includes a list of medications from the MUGs by common brand names. It is not 

intended to imply inclusion in the HP per diem. Please consult with your HP pharmacist to 

determine specific medications included in and outside of the per diem. 

A 

Page(s) 

ACIPHEX ® (rabeprazole) 142 

ADVAIR ® DISKUS ® (fluticasone propionate/salmeterol inhalation powder) 75, 76 

ADVIL ® (ibuprofen) 80, 119, 121, 122, 125 

AKWA TEARS ® LUBRICANT EYE DROPS (polyvinyl alcohol 1.4%/ 

benzalkonium chloride 0.005%) 

111 

AKWA TEARS ® LUBRICANT OPHTHALMIC OINTMENT (lanolin 2% / 

mineral oil 15% / white petrolatum base 83% ophthalmic ointment) 

111 

ALAMAG PLUS (aluminum hydroxide/magnesium hydroxide/ 

simethicone suspension) 

70, 72 

ALDACTONE ® (spironolactone) 

33, 34, 50, 53, 78, 79, 

103, 105 

ALEVE ® (naproxen sodium) 119, 122, 125 

AMBIEN ® (zolpidem) 97, 98 

AMERICAINE ® HEMORRHOIDAL (benzocaine rectal ointment 20%) 81 

AMOXICILLIN (generic only) 91 

AMPHOGEL ® (aluminum hydroxide suspension) 70, 72 

ANTIVERT ® (meclizine) 107, 109, 110 

ANUCORT-HC, ANUSOL ® -HC (hydrocortisone acetate suppositories) 81 

APRESOLINE ® (hydralazine) 51, 52 

ARTANE ® (trihexyphenidyl) 100 

ARTIFICIAL TEARS (polyethylene glycol 400 1% / polyvinyl alcohol 1% 

ophthalmic drops, solution) 

111 

ATARAX ® (hydroxyzine hydrochloride) 

30, 32, 96, 107, 110, 

126, 130 

ATIVAN ® (lorazepam) 

8, 10, 27, 30, 32, 77, 96, 

103, 107, 110, 134, 135 

ATROVENT ® HFA (ipratropium bromide inhalation aerosol) 73 

ATROVENT ® nebulizer solution (ipratropium bromide nebulizer solution) 73, 76 

AUGMENTIN® (amoxicillin/clavulanate potassium) 91 

AUGMENTIN ® XR (amoxicillin/clavulanate potassium extended-release) 91 

AZMACORT ® (triamcinolone acetonide inhalation aerosol) 73 

B 

Page(s) 

B & O ® SUPPRETTES (belladonna/opium suppository) 81, 82 

BACITRACIN zinc topical ointment (generic only) 92 

BACTRIM ® (sulfamethoxazole/ trimethoprim) 91 

BAG BALM ® 128, 130 



BALMEX ® (zinc oxide topical ointment 11.3%) 128, 130 

BAYER ® (aspirin) 

67, 80, 119, 120, 122, 

125, 137, 138, 139 

BENADRYL ® KAPSEAL ® (diphenhydramine oral capsule) 96, 97, 100, 126, 130 

BENADRYL ® TOPICAL CREAM (diphenhydramine hydrochloride 1% / 

zinc acetate 0.1% topical cream) 

127, 130 

BENADRYL ® EXTRA STRENGTH TOPICAL CREAM (diphenhydramine 

hydrochloride 2% / zinc acetate 0.1% topical cream) 

127, 130 

BENTYL ® (dicyclomine) 107, 110 

BIOTENE ® (saliva substitute) 112 

BISMATROL ® (bismuth subsalicylate suspension) 67, 69 

BUFFERIN ® (aspirin buffered) 

67, 80, 120, 137, 138, 

139 

BUMEX ® (bumetanide) 33, 34, 78 

C 

Page(s) 

CALAN ® (verapamil regular-release) 44, 49 

CALAN ® SR (verapamil sustained-release) 44, 47 

CAPOTEN ® (captopril) 47, 50 

CARAFATE ® (sucralfate) 121, 125, 142 

CARDIZEM ® (diltiazem) 44, 49 

CARDIZEM ® SR, CARDIZEM® CD (diltiazem extended-release) 47 

CARDURA ® (doxazosin) 145 

CATAPRES ® (clonidine) 114, 117 

CEFTIN ® (cefuroxime axetil) 90 

CELEXA ® (citalopram) 63, 66 

CHLORAL HYDRATE (syrup, generic only) 97 

CHLORASEPTIC ® (phenol 1.4% oromucosal spray) 111 

CHLOR-TRIMETON ® (chlorpheniramine) 126, 130 

CIPRO ® (ciprofloxacin) 90, 94 

CLEOCIN ® (clindamycin) 91 

COGENTIN ® (benztropine) 100 

COLACE ® (docusate sodium) 38, 55, 56 

COMBIVENT ® (albuterol sulfate/ipratropium bromide inhalation aerosol) 75 

COMPAZINE ® (prochlorperazine) 8, 10, 38, 108 

COMTAN ® (entacapone) 101 

CORDARONE ® (amiodarone) 45, 118 

COREG ® (carvedilol) 47, 50, 51 

COREG CR ® (carvedilol extended-release) 50, 51 

COUMADIN ® (warfarin) 

67, 118, 137, 138, 139, 

140 

CREON ® (pancreatic enzymes) 99 

CYTOTEC ® (misoprostol) 121, 125 



D 

Page(s) 

DARVOCET ® -N 50 (propoxyphene/acetaminophen) 119, 120, 122 

DARVOCET ® -N 100 (propoxyphene/acetaminophen) 119, 120, 122 

39, 41, 43, 74, 80, 85, 

DECADRON ® (dexamethasone) 

107, 110, 114, 116, 117, 

118, 125, 126, 130, 136 

DEEP SEA ® (sodium chloride nasal spray 0.65%) 112 

DELSYM ® (dextromethorphan extended-release suspension) 57 

DEPAKENE ® (valproic acid) 

35, 84, 86, 113, 116, 

135, 136 

DEPAKOTE ® (divalproex sodium) 35, 113, 135 

DESITIN ® (zinc oxide topical ointment 40%) 128, 130 

DESYREL ® (trazodone) 64, 65, 66, 96 

DETROL ® LA (tolterodine extended-release) 145 

DIABETA ® (glyburide) 87, 88 

DIFLUCAN ® (fluconazole) 89 

DILANTIN-125 ® (phenytoin oral suspension) 135, 136 

DILANTIN ® INFATABS ® (phenytoin chewable tablet) 135, 136 

DILANTIN ® KAPSEALS ® (phenytoin sodium extended-release) 135, 136 

DILAUDID ® (hydromorphone) 74, 119, 121, 123, 124 

DIOVAN ® (valsartan) 50, 53 

DIPROLENE ® (betamethasone dipropionate cream, lotion, ointment 0.05%) 127, 130 

DITROPAN ® (oxybutynin immediate-release) 81, 82, 145, 146 

DOC-Q-LAX (senna/docusate sodium) 54, 55, 56 

DOLOPHINE ® (methadone tablet) 117, 119, 124 

DULCOLAX ® (bisacodyl) 38, 54, 56 

DUONEB® (albuterol sulfate/ipratropium sulfate nebulizer solution) 73.2 

DURAGESIC ® (fentanyl transdermal system) 119, 124 

DYAZIDE ® (triamterene/hydrochlorothiazide) 78 

DYNAPEN ® (dicloxacillin) 91 

E 

Page(s) 

EFFERVESCENT POTASSIUM/CHLORIDE (potassium bicarbonate/ 

potassium chloride) 

34, 53, 78, 79, 103, 105 

ELAVIL ® (amitriptyline) 33, 63, 64, 66, 113, 116 

ENDOCET ® (oxycodone/acetaminophen tablet) 119, 120, 121, 123 

ENDODAN ® (oxycodone/aspirin) 119, 123 

ENEMEEZ ® MINI ENEMA (docusate sodium enema) 55, 56 

ENULOSE ® (lactulose) 38, 54, 56, 83 

ERY ® -TAB (erythromycin base) 72, 90, 108, 110 

ERYTHROMYCIN CAPSULE (generic only) 70, 90, 108, 110 

E-MYCIN ® (erythromycin delayed-release, gastro-resistant) 72, 90, 108, 110 

E.E.S. ® 400 (erythromycin ethylsuccinate) 72, 90, 108, 110 

ERYTHROCIN ® Filmtab (erythromycin stearate) 72, 90, 108, 110 

ETH-OXYDOSE (oxycodone concentrate solution) 74, 119, 120, 123, 124 



F 

Page(s) 

FLAGYL ® (metronidazole) 68, 69, 91 

FLEET ® MINERAL OIL ENEMA (mineral oil rectal enema) 54, 56 

FLEXERIL ® (cyclobenzaprine) 101, 103, 105 

G 

Page(s) 

GAS-X ® (simethicone) 70 

GENTAK® 0.3% (gentamicin sulfate ophthalmic solution) 92 

GLUCOTROL ® (glipizide) 87 

GLYCERIN ADULT suppository (generic only) 54, 56 

GLYCERIN PEDIATRIC suppository (generic only) 54, 56 

GYNE-LOTRIMIN ® (clotrimazole vaginal cream 1%) 93 

H 

Page(s) 

HALDOL ® (haloperidol) 

8, 10, 27, 36, 38, 61, 84, 

86, 108, 110 

HEMMORHOIDAL HC (hydrocortisone acetate suppositories) 81 

HYCODAN ® (hydrocodone bitartrate/homatropine methylbromide) 57, 60 

HYDRAMINE ® (diphenhydramine oral solution) 96, 97, 100, 126, 130 

HYDRODIURIL ® (hydrochlorothiazide) 33, 51, 52, 78, 79 

HYPO TEARS ® (polyethylene glycol 400 1% / polyvinyl alcohol 1% 

ophthalmic drops, solution) 

111 

HYTONE ® (hydrocortisone cream [0.5%, 1%, 2.5%], ointment [0.5%, 1%, 

2.5%]) 

127, 130 

I 

Page(s) 

IMDUR ® (isosorbide mononitrate) 48 

IMODIUM ® (loperamide) 67, 68, 69 

INDERAL ® LA (propranolol extended-release capsule) 44, 47 

ISMO ® (isosorbide mononitrate) 48 

ISOPTO ® ATROPINE (atropine ophthalmic drops 1%) 8, 10, 131, 133 

ISOPTO ® TEARS (hypromellose 0.5% ophthalmic drops) 111 

ISORDIL ® (isosorbide dinitrate) 48, 51, 53 

K 

Page(s) 

KADIAN ® (morphine sulfate extended-release capsule) 119, 120 

K-TAB ® (potassium chloride extended-release tablet) 34, 53, 78, 79, 103, 105 

K-LYTE ® (potassium bicarbonate) 34, 53, 78, 79, 103, 105 

KEFLEX ® (cephalexin) 90 

30, 31, 32, 96, 97, 100, 

KLONOPIN ® (clonazepam) 

102, 103, 104, 105, 114, 

115, 117, 134, 136 

KLOR-CON ® (potassium chloride extended-release tablet) 34, 53, 78, 79, 103, 105 

KLOR-CON ® EF (potassium bicarbonate) 34, 53, 78, 79, 103, 105 



L 

Page(s) 

LANOXIN ® (digoxin) 45, 46, 51 

LASIX ® (furosemide) 8, 33, 34, 78 

LEVAQUIN ® (levofloxacin) 90 

LEVBID ® (hyoscyamine extended-release) 81, 107, 131, 133 

LEVSIN ® (hyoscyamine regular-release) 9, 39, 81, 107, 131, 133 

LIDEX ® (fluocinonide cream, ointment 0.05%) 127, 130 

LIDEX-E ® (fluocinonide emulsified cream 0.05%) 127, 130 

LIDODERM ® (lidocaine 5% transdermal patch) 95, 114, 116 

LIORESAL ® (baclofen) 84, 86, 101, 103, 105 

LOMOTIL ® (diphenoxylate/atropine) 67, 69 

LOPRESSOR ® (metoprolol tartrate) 44, 47, 50, 51 

LORTAB ® (hydrocodone/acetaminophen) 119, 123 

LOTRIMIN ® (clotrimazole cream 1%) 93 

M 

Page(s) 

MAG-CITRATE ® (magnesium citrate solution) 54 

MAXITROL (neomycin-polymixin-dexamethasone ophthalmic suspension) 92 

MAXZIDE ® (triamterene/hydrochlorothiazide) 78 

39, 41, 74, 80, 107, 114, 

MEDROL ® (methylprednisolone) 

116, 117, 118, 125, 126, 

130, 136 

MEGACE ® (megestrol acetate suspension) 41, 43 

METHADOSE ® (methadone solution) 117, 119, 124 

MEXITIL ® (mexiletine) 114, 117 

MICRO-K ® (potassium chloride extended-release capsule) 34, 53, 78, 79, 103, 105 

MICRONASE ® (glyburide) 87, 88 

MILK OF MAGNESIA ® 54 

MINERAL OIL-HEAVY (mineral oil oral solution) 54 

MIRALAX ® (polyethylene glycol 3350 powder) 54.1 

MIRAPEX ® (pramipexole) 101 

MOM ® (milk of magnesia) 54 

MONOPRIL ® (fosinopril) 47, 50 

MOTRIN ® (ibuprofen) 80, 119, 121, 122, 125 

MOUTHKOTE ® (saliva substitute) 112 

MS CONTIN ® (morphine sulfate extended-release tablet) 119, 120 

MYCELEX ® troche (clotrimazole troche) 89 

MYCOSTATIN ® (nystatin 100,000 units/gm topical powder) 93 

MYLICON ® (simethicone) 70 

N 

Page(s) 

NAPROSYN ® (naproxen) 80, 119, 120, 122, 125 

NEOMYCIN (generic only) 83 



NEOMYCIN sulfate/polymyxin B sulfate/bacitracin zinc ophthalmic 

ointment (generic only) 

92 

NEOMYCIN sulfate/polymyxin B sulfate/bacitracin zinc/hydrocortisone 

acetate ophthalmic ointment (generic only) 

92 

NEURONTIN ® (gabapentin) 95, 113, 116, 135, 136 

NITRO-BID ® (nitroglycerin ointment 2%) 48 

NITRO-DUR ® (nitroglycerin transdermal patch) 48 

NITROGLYCERIN SLOCAPS (nitroglycerin extended-release capsule) 48, 49 

NITROSTAT ® (nitroglycerin sublingual tablet) 8, 48, 49 

NORPACE ® (disopyramide) 45 

NORPACE ® CR (disopyramide extended-release) 45 

NORPRAMIN ® (desipramine) 

63, 64, 66, 113, 116, 

145 

NORVASC ® (amlodipine) 47, 49 

NUPERCAINAL ® (dibucaine topical ointment 1%) 81, 114, 116 

NYSTATIN 100,000 units/mL suspension (generic only) 89 

NYSTATIN 100,000 units/gm topical cream, ointment (generic only) 93 

NYSTATIN 100,000 units/gm / triamcinolone acetonide 0.1% topical 

cream, ointment (generic only) 

93 

NYSTOP ® (nystatin 100,000 units/gm topical powder) 93 

O 

Page(s) 

OCEAN ® (sodium chloride nasal spray 0.65%) 112 

ORGANIDIN ® NR (guaifenesin) 58, 60, 131, 133 

OXYFAST ® (oxycodone concentrate solution) 74, 119, 123, 124 

OXY IR ® (oxycodone capsule) 74, 119, 123, 124 

OXYTROL ® (oxybutynin transdermal patch) 145 

P 

Page(s) 

PAMELOR ® (nortriptyline) 145 

PARLODEL ® (bromocriptine) 101 

PAREGORIC ® (camphorated opium tincture) 67, 79 

PCE ® (erythromycin base) 72, 90, 108, 110 

PENICILLIN VK (generic only) 91 

PEPTO-BISMOL ® (bismuth subsalicylate suspension) 67, 69 

PERCOCET ® (oxycodone/acetaminophen tablet) 119, 120, 121, 123 

PERCODAN ® (oxycodone/aspirin) 119, 123 

PERIACTIN ® (cyproheptadine) 41, 43, 126, 130 

PERIDEX ® , PERIOGARD®, PERIORX®, PERISOL® (chlorhexidine 

gluconate 0.12% rinse) 

111 

PERSANTINE ® (dipyridamole) 138 

PHAZYME ® (simethicone) 70 

PHENERGAN ® (promethazine) 38, 108 



PHENOBARBITAL (generic only) 134 

POLYSPORIN ® POWDER (bacitracin zinc/polymixin B sulfate topical 

powder) 

92 

POTASSIUM CHLORIDE solution (generic only) 34, 53, 78, 79, 103, 105 

39, 41, 74, 76, 80, 107, 

PREDNISONE (generic only) 

114, 116, 117, 118, 125, 

126, 130, 136 

39, 41, 80, 107, 114, 

PRELONE ® (prednisolone solution) 

116, 117, 118, 125, 126, 

130, 136 

PRILOSEC ® (omeprazole) 71, 72, 121, 125, 142, 143 

PRINIVIL ® (lisinopril) 47, 50, 51 

PROCTOZONE-HC (hydrocortisone rectal cream 2.5%) 81 

PROMETH with CODEINE (promethazine/codeine) 57, 60 

PROMETHAZINE DM (promethazine/dextromethorphan) 57, 60 

PROMETH VC with CODEINE (promethazine/phenylephrine/codeine) 57, 60 

PROMETH VC PLAIN (promethazine/phenylephrine) 57, 60 

PROPRANOLOL hydrochloride (generic only) 44, 47, 143 

PROZAC ® (fluoxetine) 35, 63, 66 

PYRIDIUM ® (phenazopyridine) 81 

Q 

Page(s) 

QUESTRAN ® (cholestyramine) 67, 69, 126, 130 

QUINIDINE GLUCONATE extended-release tablet (generic only) 45 

QUINIDINE SULFATE immediate-release tablet (generic only) 45 

QVAR ® (beclomethasone dipropionate inhalation aerosol) 73 

R 

Page(s) 

REFRESH PLUS ® (carboxymethylcellulose sodium ophthalmic drops 0.5%) 111 

REFRESH TEARS ® (carboxymethylcellulose sodium ophthalmic drops 0.5%) 111 

REGLAN ® (metoclopramide) 

38, 39, 70, 71, 72, 84, 

86, 108, 110 

RELAFEN ® (nabumetone) 80, 119, 122, 125 

REMERON ® (mirtazapine) 64, 65, 66 

RESTORIL ® (temazepam) 96, 103 

RISPERDAL ® (risperidone) 27, 28, 36, 37, 61 

RITALIN ® (methylphenidate) 42, 46, 64, 65, 66 

39, 40, 107, 108, 131, 

ROBINUL ® (glycopyrrolate) 

132, 133 

ROBITUSSIN ® AC (guaifenesin/codeine) 57, 60 

ROBITUSSIN ® CF (guaifenesin/detromethorphan/phenylephrine) 58 

ROBITUSSIN ® DAC (guaifenesin/codeine/pseudoephedrine) 58, 60 

ROBITUSSIN ® DM (guaifenesin/dextromethorphan) 57, 58, 60 

ROMYCIN (erythromycin ophthalmic ointment 0.5%) 92 

ROXANOL (morphine sulfate concentrated solution) 8, 10, 74, 119, 123, 124 

ROXICET ® (oxycodone/acetaminophen solution, tablet) 119, 120, 121, 123 



ROXICODONE ® (oxycodone solution, tablet) 74, 119, 123, 124 

RYTHMOL ® (propafenone immediate-release) 45 

RYTHMOL ® SR (propafenone extended-release) 45 

S 

Page(s) 

SENOKOT ® (senna) 38, 54, 56 

SENOKOT-S ® (senna/docusate sodium) 54, 55, 56 

SEPTRA ® (sulfamethoxazole/ trimethoprim) 91 

SERAX ® (oxazepam) 30, 32, 96, 103 

SEREVENT ® DISKUS ® (salmeterol) 75 

SEROQUEL ® (quetiapine) 36 

SINEMET ® (carbidopa/levodopa) 101, 102 

SODIUM PHOSPHATE DIBASIC and MONOBASIC RECTAL ENEMA 

(generic only) 

54 

SODIUM CHLORIDE NEBULIZER SOLUTION 0.9% (generic only) 58, 131, 133 

SOMA ® (carisoprodol) 101, 105 

SOMNATE ® (chloral hydrate capsule) 97 

SORBITOL 70% SOLUTION (generic only) 54, 56, 112 

SORE THROAT SPRAY (phenol 1.4% oromucosal spray) 111 

SSD ® (silver sulfadiazine cream 1%) 92 

STALEVO ® (carbidopa/levodopa/entacapone) 101 

SUR-Q-LAX ® (docusate calcium) 38, 55, 56 

SYMMETREL ® (amantadine) 101 

SYNALAR ® (fluocinolone acetonide cream, ointment 0.025%) 127, 130 

SYNTHROID ® (levothyroxine sodium) 141 

T 

Page(s) 

TEARS NATURALE ® P.M. (mineral oil 3% / white petrolatum base 94% 

ophthalmic ointment) 

111 

TEGRETOL ® (carbamazepine) 

33, 113, 115, 116, 135, 

136 

TENORMIN ® (atenolol) 44, 47, 52 

TEARS NATURALE II ® , TEARS RENEWED ® (dextran 70/hypromellose 

0.3% ophthalmic drops, solution) 

111 

TESSALON ® (benzonatate) 57, 60 

THEO-DUR ® (theophylline) 75 

THORAZINE ® (chlorpromazine) 

27, 36, 38, 61, 84, 86, 

108, 110 

TOPROL ® XL (metoprolol succinate) 47, 50 

TRANSDERM SCOP ® (scopolamine transdermal patch) 37, 107, 110, 131, 133 

TRIAMCINOLONE ACETONIDE cream, ointment 0.025%, 0.1%, 0.5% 

(generic only) 

127, 130 

TRILISATE® (choline magnesium trisalicylate) 80, 120, 122, 125 

TRIPLE ANTIBIOTIC OINTMENT (bacitracin zinc/neomycin sulfate/ 

polymyxin B sulfate topical ointment) 

92 



TRIXAICIN ® (capsaicin) 114, 116 

TYLENOL ® (acetaminophen) 

8, 10, 80, 97, 118, 119, 

120, 121, 122 

TYLENOL ® with Codeine (acetaminophen/codeine) 119, 123 

TYLOX ® (oxycodone/acetaminophen capsule) 119, 120, 121, 123 

TUSSIGON ® (hydrocodone bitartrate/homatropine methylbromide) 57, 60 

V 

Page(s) 

VALIUM ® (diazepam) 

30, 32, 85, 96, 100, 103, 

105, 134, 135, 136 

VALTREX ® (valacyclovir) 89 

VANTIN ® (cefpodoxime proxetil) 90 

VASOTEC ® (enalapril) 34, 42, 47, 50, 53, 79 

VENTOLIN ® HFA (albuterol sulfate inhalation aerosol) 73, 75, 76 

VENTOLIN ® nebulizer solution (albuterol sulfate nebulizer solution) 73, 75, 76 

VENTOLIN ® (albuterol sulfate) 73, 75, 76 

VIBRAMYCIN ® (doxycycline) 92 

VICODIN ® (hydrocodone/acetaminophen) 119, 123 

VISINE ® TEARS (glycerin 0.2% / hypromellose 0.2% / polyethylene glycol 

400 1% ophthalmic drops) 

111 

VISTARIL ® (hydroxyzine pamoate) 

30, 32, 96, 107, 110, 

126, 130 

Vitamin A & D OINTMENT (zinc oxide 10%/ dimethicone 1%) 128, 130 

VOLTAREN ® (diclofenac sodium) 91 

X 

Page(s) 

XANAX ® (alprazolam) 30, 31, 32, 96, 97, 103 

XYLOCAINE ® VISCOUS (lidocaine hydrochloride oromucosal solution 2%) 111 

XYLOCAINE ® TOPICAL JELLY (lidocaine hydrochloride topical gel/jelly 2%) 81, 114, 116, 127, 130 

XYLOCAINE ® TOPICAL SOLUTION (lidocaine topical solution 4%) 114, 127 

XYLOCAINE ® OINTMENT (lidocaine ointment 5%) 81, 114, 116, 127, 130 

Z 

Page(s) 

ZANTAC ® (ranitidine) 70, 72, 142 

ZAROXOLYN ® (metolazone) 78 

ZESTRIL ® (lisinopril) 47, 50, 51 

ZITHROMAX ® (azithromycin) 90 

ZOLOFT ® (sertraline) 35, 42, 63, 66 

ZOSTRIX ® (capsaicin) 114, 116 

ZOVIRAX ® (acyclovir) 89, 95 


Injectable Medication Index 

As a service to your patient, Hospice Pharmacia (HP) provides a variety of medications in injectable 

formulation. This index includes a listing of injectable medications included in the HP per diem. 

This does not infer that every injectable medication is related to the patient’s hospice-qualifying 

terminal diagnosis and, therefore, that every injectable medication is included in the HP 

per diem for an individual patient. Hospice Pharmacia determines which injectable medications 

are included in the HP per diem based on diagnosis-related inclusion codes (refer to Inclusions 

section for additional information regarding diagnosis-related inclusion codes). Please consult with 

your HP pharmacist to determine specific injectable formulations included in the per diem and the 

most appropriate dose for the individual patient. 

Atropine 


Dexamethasone 

Diazepam 


Furosemide 

Haloperidol 

Heparin flush 

Insulin human NPH, REG, 70/30 * 

Lorazepam 


Morphine 

Octreotide 

Phenobarbital 


Promethazine 

Sodium chloride bacteriostatic 0.9% 

Sodium chloride flush 0.9% 

* 

Insulin syringes are included in the HP per diem for patients prescribed insulin for the management 

of hyperglycemia due to diabetes as the hospice-qualifying terminal diagnosis (defined as 

ICD-9-CM codes 250.0-250.9; INCLUSION CODE: O), hyperglycemia due to pancreatic cancer 

(defined as ICD-9-CM codes 157.0-157.9 or 197.8; INCLUSION CODE: C), or hyperglycemia 

induced by a medication used for a symptom related to the patient’s hospice-qualifying terminal 

diagnosis (INCLUSION CODE: A), whereby the hyperglycemia affects the patient’s quality of 

life. In order for insulin syringes to be included in the per diem, they must be dispensed by HP; 

insulin syringes cannot be adjudicated through the PBM Plus card. Pre-filled insulin syringes and 

insulin pens are outside the HP per diem. 

Hospice Pharmacia does not provide any other types of injectable supplies. 


Compound Index 

Hospice Pharmacia (HP) will compound a medication approved by the U.S. Food and Drug Administration 

into a formulation requested by a licensed prescriber for use in an individual hospice 

patient. This index includes a listing of compounds included in the HP per diem. This does not 

infer that every compound is related to the patient’s hospice-qualifying terminal diagnosis 

and, therefore, that every compound is included in the HP per diem for an individual patient. 

Hospice Pharmacia determines which compounds are included in the HP per diem based on 

diagnosis-related inclusion codes (refer to Inclusions section for additional information regarding 

diagnosis-related inclusion codes). 

To make this index an easy-to-use, workable tool, compounds have been organized by dosage formulation 

and listed in alphabetical order. Please consult with your HP pharmacist to determine the 

most appropriate formulation for your patient. 

ACRONMYMS USED IN THIS INDEX: 

A = lorazepam (ATIVAN ® ) 

B = diphenhydramine (BENADRYL ® ) 

C = prochlorperazine (COMPAZINE ® ) 

D = dexamethasone (DECADRON ® ) 

H = haloperidol (HALDOL ® ) 

P = promethazine (PHENERGAN ® ) 

R = metoclopramide (REGLAN ® ) 

SF = sugar free 

Capsules 

ABH 0.5/12.5/0.5mg 

ABHR 0.5/12.5/0.5/10mg 

ABR 0.5/12.5/10mg 

BDR 20/4/4mg 

Dextromethorphan 30mg 

Dextromethorphan 100mg 

Gels 

A 0.5mg per 1mL 

A 1mg per 1mL 

AB 1/50mg per 1mL 

ABH 0.5/25/0.25mg per 1mL 

ABH 1/12.5/1mg per 1mL 

ABH 1/25/1mg per 1mL 

ABH 2/50/4mg per 1mL 

ABHR 0.5/12.5/0.5/5mg per 1mL 

ABHR 1/25/1/10mg per 1mL 

ABR 1/12.5/20mg per 1mL 

AHR 1/1/10mg per 1mL 

BHR 25/1/10mg per 1mL 

Chlorpromazine 100mg per 1mL 

D 2mg per 1mL 

D 4mg per 1mL 

H 0.5mg per 1mL 

H 1mg per 1mL 

H 5mg per 1mL 



HA 1/1mg per 1mL 

Ketamine 10mg per 1mL 




Ketamine/bupivacaine 10% / 4% per 1mL 

Ketoprofen 50mg per 1mL 

Ketoprofen 150mg per 1mL 

Morphine 5mg per 1mL 



PR 25/10mg per 1mL 

PRA 25/10/1mg per 1mL 

Promethazine 25mg per 1mL 


R 10mg per 1mL 

Scopolamine 0.025% per 1mL 

Pastes 

“MAGIC BUTT PASTE” (hydrophilic ointment/lidocaine 5% ointment/A & D ® ointment/zinc oxide 

ointment in a 1/1/2/2 proportion) 

Solutions 

A 0.25mg per 1mL 

A 1mg per 1mL 

A 2mg per 1mL 



D 4mg per 1mL 

Enalapril 5mg per 5mL 

Glycopyrrolate 0.2mg per 1mL 

H 2mg per 1mL 

Hydromorphone 1mg per 1mL 




Hydroxyzine 50mg per 1mL 

Methadone 50mg per 1mL 


Morphine 20mg per 1mL SF for nebulization 



Oxycodone 40mg per 1mL 

Pilocarpine 5mg per 5mL 



Suppositories 

A 0.5mg 

A 1mg 

A 2mg 

ABH 0.5/12.5/0.5mg 

ABHR 0.25/6.25/0.25/5mg 

ABHR 0.5/12.5/0.5/10mg 

ABHR 1/25/1/10mg 

ABHR 1/25/1/20mg 

ABR 0.5/12.5/10mg 

B 25mg 

BDR 20/4/4mg 

Baclofen 5mg 

Baclofen 20mg 

Carbamazepine 200mg 



Chlorpromazine 25mg 



Choline magnesium trisalicylate 500mg 

Clonazepam 2mg 

D 2mg 

D 4mg 

D 6mg 

D 8mg 

D 10mg 

D 12mg 

D 20mg 

DRA 4/10/1mg 

DRH 4/10/1mg 

Diazepam 2mg 

Diazepam 5mg 

Diazepam 10mg 

Diazepam 20mg 

H 1mg 

H 2mg 

H 5mg 

Hydrocodone/acetaminophen 5/500mg 

Hydrocodone/acetaminophen 7.5/500mg 

Hydrocodone/acetaminophen 7.5/750mg 

Hydromorphone 4mg 

Ibuprofen 400mg 





Methadone 40mg 




Morphine 5mg 

Morphine 10mg 

Morphine 15mg 

Morphine 20mg 

Morphine 30mg 

Morphine 100mg 

Morphine 200mg 

Naproxen 500mg 

Phenobarbital 30mg 




Prednisone 5mg 

Prednisone 20mg 

Promethazine 50mg 

R 10mg 

Valproic acid 250mg 



Suspensions 

ABH 0.5/12.5/0.5mg per 5mL 

ABHD 0.5/16/0.25/3mg per 5mL 

ABHR 0.5/12.5/0.5/10mg per 5mL 

ABR 0.5/12.5/10mg per 5mL 

Alprazolam 1mg per 1mL 

Amitriptyline 25mg per 5mL 



Amlodipine 1mg per 1mL 

BDR 20/4/4/mg per 5mL 

BHR 12.5/0.5/10mg per 5mL 

“BANHURT” (B/nystatin/prednisone/tetracycline 12.5mg/250,000 units/2.5mg/125mg per 15mL) 

Baclofen 1mg per 1mL 



Bumetanide 0.5mg per 1mL 

C 2mg per 1mL 



C 5mg per 1mL 

C 10mg per 1mL 

Captopril 1mg per 1mL 

Captopril 12.5mg per 5mL 

Carbidopa/levodopa 25/100mg per 5mL 

Carbidopa/levodopa 25/250mg per 5mL 

Clonazepam 1mg per 1mL 

Clonazepam 1mg per 5mL 

Cyclobenzaprine 10mg per 5mL 

D 10mg per 1mL 

Fluconazole 100mg per 5mL 

Glycopyrrolate 2mg per 1mL 

Hydrocodone/acetaminophen 5/500mg per 5mL 

Ibuprofen 200mg per 5mL 




“MAGIC MOUTHWASH” New Formulation (B/aluminum hydroxide-magnesium hydroxidesimethicone/viscous 

lidocaine in equal volume proportions) 

“MAGIC MOUTHWASH with NYSTATIN” New Formulation (B/aluminum hydroxide-magnesium 

hydroxide-simethicone/viscous lidocaine/nystatin in equal volume proportions) 

Metoprolol 12.5mg per 5mL 

Metronidazole 250mg per 5mL 

Naproxen 250mg per 5mL 

Nortriptyline 10mg per 5mL 

Nortriptyline 50mg per 5mL 

Omeprazole 2mg per 1mL 

Oxazepam 10mg per 1mL 

Phenobarbital 30mg per 1mL 

Prednisone 20mg per 1mL 

Prednisone 20mg per 5mL 


Propoxyphene/acetaminophen 100/650mg per 5mL 

R 5mg per 1mL 

Spironolactone 100mg per 5mL 

Trazodone 100mg per 5mL 

Troches 

ABHR 0.5/12.5/0.5/10mg

Medication Use Guidelines - Hospice Pharmacia

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