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Class: Platelet GP IIb/IIIa inhibitor
Dosing: 0.25 mg/kg IV bolus over 5 min given 10-60 min prior to PCI, then 0.125 mcg/kg/min (max 10 mcg/min) infusion for 12 hr after PCI.
Mixing: Dilute total amount needed for infusion in 250 ml of NS or D5W, or use a standard concentration of 7.2 mg in 250 ml of NS or D5W.
Administration notes: Administer through a filter.
Class: Anti-arrhythmic agent
Dosing: Initially, give 6 mg IV over 1-2 seconds; if response to initial dose is inadequate, give 12 mg IV over 1-2 seconds. Repeat if needed.
Mixing: Do not dilute.
Administration notes: Quickly flush the line after each dose.
Half-life: <10 seconds
Elimination: Cellular uptake and degradation.
Class: Thrombolytic (tPA)
Dosing for MI (weight >67 kg): 15 mg IV bolus, followed by 50 mg IV infusion over 30 min, followed by 35 mg IV infusion over 1 hr.
Dosing for MI (weight < or =67 kg): 15 mg IV bolus, followed by 0.75 mg/kg IV infusion over 30 min, followed by 0.5 mg/kg IV infusion over 1 hr.
Mixing: Reconstitute with supplied sterile water.
Half-life: 25 min
Elimination: Hepatic
Class: Anti-arrhythmic agent
Oral dosing: Give loading dose of 400 mg q6h or q8h po for total of 10 grams, then 200 mg po q8h for 30 days. (One half of this total amount is usually given for treatment of supraventricular arrhythmias.) Doses should be individualized based upon response and adverse effects.
Maintenance dosing: 200-400 mg po qd.
IV dosing: Give 150-300 mg IV over 10-30 min, followed by 1 mg/min IV as infusion for 6 hr, followed by 0.5 mg/min thereafter. Additional 150 mg doses can be given for recurrent arrhythmias.
Mixing: For initial dose dilute 150 mg in 100 cc D5W (minibag). For infusion dilute 900 mg in 500 cc D5W (glass bottle).
Half-life: Approximately 50 days
Elimination: Hepatic (P4503A4)
ECG changes: Prolongation of QT, QRS, and PR intervals, bradyarrhythmias, heart block.
Class: Direct thrombin inhibitor
Dosing for HIT/HITTS: Give infusion at 2 mcg/kg/min (0.5 mcg/kg/min for hepatic impairment).
Monitoring: Measure aPTT 2 hr after initiation of infusion for a target aPTT of 1.5-3 times baseline (not to exceed 100 seconds, or dose of 10 mcg/kg/min). Platelet recovery occurs in approximately 3 days.
Mixing: 250 mg in 250 ml NS or D5W (1 mg/ml)
Half-life: 30-51 min
Elimination: Hepatic
Class: Beta-adrenergic blocking agent
Dosing post MI: Initially give 5 mg IV q5 min x 2, then 50-100 mg po qd.
Note: If CrCl is good, 100 mg po qd of atenolol is approximately equivalent to 100 mg po q12h of metoprolol.
Elimination: Renal
Class: Anticholinergic agent
Dosing: For bradyarrhythmias give 0.5-1 mg IV. This may be repeated in 3-5 min to total dose of 3 mg.
Mixing: Do not dilute.
Half-life: 2-3 hr
Elimination: Hepatic and renal
Class: Direct thrombin inhibitor
Dosing for PCI, without GP IIb-IIIa inhibitor: Give bolus of 1 mg/kg IV prior to PCI, followed by 2.5 mg/kg/h infusion for up to 4 hr, followed by 0.2 mg/kg/h for up to 20 hr if needed.
Dosing for PCI, with GP IIb-IIIa inhibitor: Give bolus of 0.75 mg/kg IV prior to PCI, followed by 1.75 mg/kg/h infusion for up to 4 hr (dosing not FDA-approved).
Dosing in renal insufficiency:
|
CrCl |
Infusion
dose |
|
>60
ml/min |
no change |
|
30-59 ml/min |
20%
reduction |
|
10-29 ml/min |
60%
reduction |
|
on
dialysis |
90%
reduction |
Mixing: Mix 500 mg in 100 ml or 1250 mg in
250 ml D5W or NS for final concentration of 5 mg/ml. For delivery at 0.2
mg/kg/h, the drug should be further diluted to 0.5 mg/ml.
Half-life: 25 min (prolonged with renal impairment, up to 3.5 hr on dialysis).
Elimination: Renal
Class: Alpha and beta-adrenergic blocking agent
Dosing: 3.125 mg bid; may titrate up to 50 mg bid as tolerated.
Note: The ratio of alpha to beta blockade is 1:10.
Caution: May be more sensitive to the effects of carvedilol if >65 yrs or with NYHA Class IV HF.
Half-life: 7-10 hr, but may be prolonged in pts with liver impairment and NYHA Class IV HF.
Elimination: Hepatic (P4502D6)
Class: Low molecular weight heparin
Dosing for ACS: 120 IU/kg (max 10,000 IU) SQ every 12 hr for 5-8 days within 72 hr of onset of symptoms.
Note: The aPTT is not followed for dose adjustment; activity is measured by anti-Xa activity. Peak anti-Xa activity at 4 hr. Prolonged anti-Xa activity occurs in renal failure.
Caution: Avoid use prior to epidural/spinal anesthesia.
Elimination: Renal, dose-independent
Class: Cardiac glycoside
Dosing: Maintenance dose/day = ([(CrCl/5) + 14]/100) x 10 mcg/kg LBW (use 7 mcg/kg LBW for severe renal insufficiency).
Half-life for CrCl:
|
CrCl |
Half-life |
|
>60 ml/min |
1.5 days |
|
30
ml/min |
2 days |
|
15
ml/min |
3 days |
|
<10 ml/min |
>4
days |
Elimination: Renal (primary route), hepatic,
and intestinal degradation
Therapeutic drug conc.: 0.5-1.2 ng/ml in HF
Class: Calcium channel blocking agent
Dosing: Load (only if immediate effect needed) 0.25 mg/kg IV over 2 min; if no response, may be repeated in 15 min with 0.35 mg/kg IV.
Maintenance: 5-15 mg/hr IV
Conversion to p.o. dosing: Give same total daily dose as IV infusion in 3 or 4 divided doses of immediate release diltiazem. Give first po dose at the time that the infusion is stopped. Titrate dosage as needed. Then convert to sustained release preparation (dose = total daily dose of immediate release preparation).
Mixing: 125 mg in 100 ml D5W or NS, for a total volume of 125 ml (final concentration of 1 mg/ml)
Half-life: 3-7 hr
Elimination: Hepatic (P4503A4)
Class: Anti-arrhythmic agent
Dosing: Initially give 150 mg po q6h.
Dosing in renal insufficiency:
|
RI |
Dose |
|
moderate |
150mg
q12hr |
|
severe |
150mg
q24hr |
Note: Increase to 200-300 mg po q6h (150-300
mg q12-24h in RI) according to patient’s tolerance and serum concentration.
Conversion to sustained release: Divide total daily dose of non-sustained release by 2 and give q12h.
Half-life: 4-8 hr; 12-43 hr in RI
Elimination: Renal (primary route) and hepatic
ECG changes: QT prolongation
Therapeutic drug conc.: 3-6 mcg/ml
Class: Adrenergic agonist
Dosing: Give 2.5-30 mcg/kg/min (0.5 mcg/kg/min may be effective), then titrate to cardiac output/clinical effect.
Note: Predominantly beta agonist throughout dosing range (no alpha vasoconstriction).
Mixing: 1g in 250 ml
Half-life: Approximately 2 min
Elimination: Hepatic and tissue
Class: Anti-arrhythmic agent
Dosing: Prior to starting, verify that QTc is less than 440 msec (500 msec if patient has ventricular conduction abnormalities). Starting dose is based upon CrCl:
|
CrCl |
Starting
dose |
|
>60 ml/min |
500 mcg
bid |
|
40-60 ml/min |
250 mcg
bid |
|
20-39 ml/min |
125 mcg
bid |
|
<20 ml/min |
contraindicated |
Half-life: 10 hr (longer with RI)
Elimination: Renal and hepatic (CYP3A4)
ECG changes: QT prolongation
Notes: 1) An educational module on dofetilide must be completed before being allowed to prescribe this medication. 2) Hospitalization required for the first 3 days of therapy. 3) Medication is NOT available in retail pharmacies. It can only be obtained through mail order. 4) QTc should be measured 2-3 hr after the first 5 doses. If QTc is >500 msec (550 msec for pts with ventricular conduction abnormalities) or >15% over baseline after 1st dose, the dose needs to be reduced. If QTc after subsequent doses is >500 msec (550 msec for pts with ventricular conduction abnormalities), the medication should be discontinued. 5) Do not administer dofetilide with cimetidine, ketoconazole, prochlorperazine, megestrol, verapamil, or trimethoprim.
Class: Adrenergic agonist
Dosing: 2-5 mcg/kg/min to start, titrate to desired BP; usually effective below rates of ~20 mcg/kg/min
|
~1-2
mcg/kg/min |
“renal
dose” |
|
~2-5
mcg/kg/min |
mostly
beta |
|
>~5
mcg/kg/min |
alpha
& beta |
|
>~10
mcg/kg/min |
mostly
alpha |
Note: There is considerable
patient-to-patient variation between dose and response. Partial to complete
ineffectiveness may be found in pts with systemic acidosis.
Mixing: 800 mg in 250 ml
Half-life: Approximately 2 min
Elimination: Hepatic, renal, and tissue
Class: ACE inhibitor
Dosing: Starting dose is 0.625 mg to 1.25 mg IV q6h, depending upon renal function and fluid status. Dosage is increased based upon response.
Mixing: Give undiluted or mix with 50 ml of D5W or NS.
Administration: Give IV dose over 5 min.
Half-life: Approximately 11 hr (increases in RI)
Elimination: Renal
Class: Low molecular weight heparin
Dosing for ACS: 1 mg/kg SQ q12h. Decrease dose 25-50% when significant renal impairment is present.
Dosing for DVT prophylaxis: 30mg SQ q12h or 40 mg SQ QD.
Note: aPTT is not followed for dosing adjustments.
Caution: Avoid use prior to epidural/spinal anesthesia.
Half-life: 5 hr
Elimination: Renal and hepatic
Dosing: 0.01-1.2 mcg/kg/min, individualize therapy.
Mixing: 5 mg in 250 ml
Elimination: Hepatic and tissue
Class: Platelet glycoprotein IIb-IIIa inhibitor
Dosing for ACS:
Bolus: 180 mcg/kg (to a max of 22.6 mg) over 1-2 min
Infusion (SCr <2): 2 mcg/kg/min (to a max of 15 mg/h) for 24-72 hr
Infusion (SCr 2-4): 1 mcg/kg/min (to a max of 7.5 mg/h) for 24-72 hr
Dosing for PCI:
Double-bolus: 180 mcg/kg (to a max of 22.6 mg) over 1-2 min, separated by 10 minutes
Infusion (SCr <2): 2 mcg/kg/min (to a max of 15 mg/h) for 18-24 hr
Infusion (SCr 2-4): 1 mcg/kg/min (to a max of 7.5 mg/h) for 18-24 hr
Mixing: Premixed as 75 mg in 100 ml
Half-life: 2.5 hr
Elimination: Renal
Class: Beta-adrenergic blocking agent
Dosing: Start with infusion of 0.05-0.1 mg/kg/min and titrate up by 0.05 mg/kg/min q 15-20 min to desired HR (max. dose 0.25 mg/kg/min).
Mixing: 2.5 grams in 250 ml
Half-life: 2-5 min
Elimination: RBC esterases
Class: Anti-arrhythmic agent
Dosing: Start with 50-100 mg po q12h (50-100 mg po q24h in elderly, HF, hepatic disease, severe RI) and increase dose by 50-100 mg/day q3-7 days depending on ECG changes. Usual maximum dose is 400 mg/day.
Half-life: 7-23 hr (may be prolonged to 60 hr in elderly, HF, hepatic disease, severe RI)
Elimination: Hepatic (P4502D6) and renal
ECG changes: PR and QRS prolongation
Therapeutic drug conc.: 0.2-1 mcg/ml
Dosing for ACS: Bolus 60 units/kg, not to exceed 6000 units (not to exceed 4000 units if fibrinolytic therapy given within 12 hr), followed by infusion:
|
Age |
Female |
Male |
|
<60 |
12
U/kg/hr |
14
U/kg/hr |
|
60-79 |
11
U/kg/hr |
12
U/kg/hr |
|
>80 |
10
U/kg/hr |
11
U/kg/hr |
Mixing: premixed bag available as 25,000
units in 250 ml 0.45 NS.
Elimination: Possible transfer and storage in reticuloendoethelial cells.
Class: Anti-arrhythmic agent
Note: For administration in ICU or monitored environment only.
Dosing: 1 mg IV over 10 min (or 0.01 mg/kg for pts <60 kg) in monitored setting. If no response within 10 min, may repeat 50%-100% of initial dose. Consider dose reduction in those >65 yr.
Monitoring caution: Patient should be monitored closely for proarrhythmias for at least 4 hr after dose is given.
Mixing: 1 mg in 50 ml of D5W or NS, or give undiluted.
Half-life: 6 hr
Elimination: Hepatic (isoenzyme unknown)
EKG changes: QT prolongation
Class: Beta-adrenergic agonist
Dosing: 2-20 mcg/min (usual range), titrate to heart rate and/or rhythm.
Mixing: 2 mg in 250 ml
Elimination: Hepatic and renal
Class: Direct thrombin inhibitor
Dosing for HIT: Initial bolus of 0.2-0.4 mg/kg (not to exceed 44 mg) injected over 15-20 seconds, followed by infusion of 0.1-0.15 mg/kg/hr (not to exceed 16.5 mg/hr).
Dosing with thrombolytics: Initial bolus of 0.2 mg/kg, followed by infusion of 0.1 mg/kg/hr.
Dosing in renal insufficiency: bolus dose of 0.2 mg/kg, followed by infusion:
|
CrCl |
Cr |
Infusion |
|
45-60 |
1.6-2 |
0.075
mg/kg/hr |
|
30-44 |
2.1-3 |
0.045
mg/kg/hr |
|
15-29 |
3.1-6 |
0.0225
mg/kg/hr |
|
<15 |
>6 |
none* |
*give 0.1 mg/kg bolus QOD or redose when aPTT <1.5x baseline.
Monitoring:
Measure aPTT 4hr after start of infusion and adjust dose to reach an aPTT of 1.5-2.5 times baseline.
For aPTT >target, stop infusion for 2hr, restart at 50% previous rate without bolus. Recheck aPTT in 4hr.
For aPTT <target, increase rate of infusion by 20% and recheck aPTT in 4hr.
Mixing: Initial bolus 50 mg in 10 ml of NS or D5W (5 mg/ml); infusion mixed as 100 mg in 250 ml of NS or D5W.
Half-life: 1.3 hr (up to 2 days with renal failure: CrCl <15 ml/min or hemodialysis).
Class: Anti-arrhythmic agent
Dosing (normal LV & hepatic function):
Boluses: 75 mg IV, then 50 mg IV q5 min x3 (total dose 225 mg)
Infusion: 2 mg/min
Dosing (moderate LV dysfunction):
Boluses: 75 mg IV, then 50 mg IV in 5 min x1 (total dose 125 mg)
Infusion: 1 mg/min
Dosing (severe LV dysfunction or hepatic impairment):
Bolus: 50-75 mg IV x1
Infusion: 0.5 mg/min
Mixing: 2 grams in 500 ml
Half-life: 1.5-2 hr; (4-12 hr with HF or cirrhosis)
Elimination: Hepatic (P4503A4)
ECG changes: None
Therapeutic drug conc.: 2-5 mcg/ml
Class: Beta-adrenergic blocking agent
Dosing post MI: 5 mg IV q3-5 min x3 doses, then 50-100 mg po q12h.
Note: If CrCl is good, 100 mg po qd of atenolol is approximately equivalent to 100 mg po q12h of metoprolol. Daily doses of metoprolol and metoprolol XL/CR are equivalent.
Elimination: Hepatic (P4502D6)
Class: Anti-arrhythmic agent
Dosing: Start with 150 mg po q8 hr and increase dose q1-3 days by 50 mg q8 hr depending on side effects. Usual maximum dose is 900-1200 mg/day.
Half-life: 8-15 hr
Elimination: Hepatic (P4502D6)
ECG changes: None
Therapeutic drug conc.: Not helpful
Class: Phosphodiesterase inhibitor
Dosing: No loading dose is needed. Initiate dose at 0.125-0.25 mcg/kg/min. Dose can be gradually titrated up to 0.5-0.75 mcg/kg/min.
Dosing for pts with renal insufficiency: Decrease above doses by 50%.
Mixing: 20 mg in 100 ml (0.2 mg/ml) of D5W (premixed solution in glass bottle)
Half-life: 1.5-2.5 hr in pts with HF (increases to 4+ hr in RI)
Elimination: Renal
Class: Anti-arrhythmic agent
Dosing: Start with 200 mg po q8h, increase dose in 3-5 day intervals to 250 mg po q8h, then 300 mg po q8h depending on ECG changes and side effects.
Half-life: 3-4 hr (May have active metabolite with activity up to 18-24 hr. In RI, t1/2 increases up to 40 hr.)
Elimination: Hepatic (isoenzyme unknown) and renal
ECG changes: PR and QRS prolongation
Therapeutic drug conc.: Not available
Class: Vasodilator
Dosing: 10-20 mcg/min IV to start; increase 10 mcg/min q5 min until relief of angina, fall in BP or PCWP. Individualize therapy. Maximum dose is approximately 400 mcg/min. Tolerance develops over time.
Mixing: 50 mg in 250 ml
Half-life: 1-4 min
Elimination: Hepatic and tissue
Class: Vasodilator
Dosing: 0.5-0.8 mcg/kg/min to start, increase by 0.5 mcg/kg/min to a maximum of 8-10 mcg/kg/min. Titrate dose to expected BP/CO. Individualize therapy.
Mixing: 100 mg in 250ml
Elimination: RBCs and tissue
Class: Adrenergic agonist
Dosing: 2-20 mcg/min usual range and titrate to BP. There is considerable variation between pts.
Mixing: 8 mg in 250 ml
Elimination: Hepatic and tissue
Class: Adrenergic agonist
Dosing: 0.1-10 mcg/kg/min, titrate
Mixing: 80 mg in 250 ml
Elimination: Hepatic and tissue
Class: Anti-arrhythmic agent
Dosing (normal renal function):
Loading: 17 mg/kg over 30-60 min
Infusion: 3 mg/kg/hr
Dosing (mild RI):
Loading: 15 mg/kg over 30-60 min
Infusion: 2 mg/kg/hr
Dosing (mod-severe RI: CrCl ~20 ml/min):
Loading: 13 mg/kg over 30-60 min
Infusion: 1 mg/kg/hr
Dosing (ESRD or CrCl <20 ml/min):
Avoid use
Note: Dosing is based upon total body weight. NAPA is an active metabolite.
Mixing: 2 gm in 250 ml
Conversion of IV to po: Total daily dose of IV procainamide is similar to total daily dose of oral procainamide. Stop IV 4 hr after 1st po dose.
Half-life with normal renal function: procainamide: 4 hr, NAPA: 8 hr
Half-life with renal insufficiency: procainamide: 8-24 hr, NAPA: 12-70 hr
Elimination: Renal and hepatic (NAPA is primarily renal)
ECG changes: QT prolongation
Therapeutic drug conc.: Procainamide: 4-10 mcg/ml; NAPA: <25-30 mcg/ml
Class: Anti-arrhythmic
Dosing: Start with 150 mg po q8h, increase dose in 3-5 day intervals to 225 mg po q8h, then 300mg po q8h depending on ECG changes.
Half-life: 2-32 hr (extensive and poor metabolizers, active metabolites)
Elimination: Hepatic (P4501A2, P4502D6, and P4503A4)
ECG changes: Prolongation in PR and QRS
Therapeutic drug conc.: Not helpful
Class: Anti-arrhythmic
Dosing (age <65, no RI):
sulfate: 600 mg q6h
Quinidex®: 600 mg q8h
Quinaglute® : 648 mg q8h
Dosing (age > or =65, no RI):
sulfate: 300 mg q6h
Quinidex®: 300 mg q8h
Quinaglute® : 324 mg q8h
Dosing (severe RI):
sulfate: 200 mg q8h
Quinidex®: 300 mg q12h
Quinaglute® : 324 mg q12h
Half-life: 6 hr (increases up to 12 hr in elderly, hepatic disease)
Elimination: Hepatic (P4503A4) and renal
ECG changes: QT prolongation
Therapeutic drug conc.: 1.5-5 mcg/ml
Class: Thrombolytic (rPA)
Dosing for MI: 10 units IV over 2 min given twice at 30 minute intervals.
Class: Anti-arrhythmic
Dosing: Start with 80 mg po q12 (40-80 mg po qd if renal impairment), increase dose q 2-3 days (q4-6 days if renal impairment) if needed. Maximum dose about 480 mg per day.
Caution: Proarrhythmias increase with increasing dose.
Half-life: 8-20 hr (increases to 40 hr with RI)
Elimination: Renal
ECG changes: QT prolongation
Class: Thrombolytic (TNK-tPA)
Dosing for MI: IV bolus over 5 seconds.
|
Pt
weight |
Dose |
|
<60 kg |
30 mg |
|
60-69 kg |
35 mg |
|
70-79 kg |
40 mg |
|
80-89 kg |
45 mg |
|
>90
kg |
50 mg |
Class: Platelet glycoprotein IIb-IIIa inhibitor
Dosing for ACS: 0.4 mcg/kg/min (up to 60 mcg/min) for 30 min, then 0.1 mcg/kg/min (up to 0.9 mg/hr) for up to 48 hr.
Dosing for renal insufficiency: Reduce loading and infusion doses by 50% for CrCl <30 ml/minute.
Mixing: 12.5 mg in 250 ml NS
Half-life: 2 hr
Elimination: Renal
Class: Calcium channel blocking agent
Dosing for SVT: 5-10 mg IV given slowly over 3-10 min. May repeat in 30 min if needed.
Half-life: 3-7 hr
Elimination: Hepatic (P4501A2, P4503A4)
ACS = acute coronary syndrome
CO = cardiac output
CrCl = creatinine clearance
DVT = deep-vein thrombosis
ECG = electrocardiogram
ESRD = end-stage renal disease
HF = congestive heart failure
HIT = heparin-induced thrombocytopenia
HITTS = heparin-induced thrombocytopenia-thrombosis syndrome
LBW = lean body weight
LV = left ventricular
MI = myocardial infarction
PCI = percutaneous coronary intervention
PCWP = pulmonary capillary wedge pressure
RI = renal insufficiency
SCr = serum creatinine
The Duke Heart Center Dosing Guide 2001: Dosing of Selected Cardiovascular Medications for Adults.
Authors: Nancy M. Allen LaPointe, PharmD; Gary Dunham, PharmD; Tracy DeWald, PharmD
Edited for the Pocket PC by James E. Tcheng, MD
Supported by unrestricted grants from Wyeth-Ayerst, Pfizer, GlaxoSmithKline, and Merck. Developed in collaboration with the Centers for Education & Research on Therapeutics (CERTs) at Duke. Copyright © 2001 CERTs. All rights reserved. No part of this publication may be reproduced in any form or by any means without the expressed written permission of the authors.
1. These data represent general guidelines based on studies in adults. Dosages need to be adjusted for each individual patient based upon that individual’s pharmacokinetic properties and pharmacodynamic response. Numerous factors including age, gender, genetic phenotype, physiologic state, presence of concurrent disease, body weight, and presence of interacting drugs may require an adjustment in dosage.
2. Steady state serum concentrations are not reached until after 4-5 times the half-life of the drug. Drug concentration measurements made prior to steady state are difficult to interpret. Trough drug concentrations are preferred. Therapeutic drug conc. ranges reported are based upon the assay methodology used at Duke Hospital at the time of publication.
3. Total body weight should be used in calculations unless otherwise specified.
4. These general guidelines are for the exclusive use of practitioners employed by Duke University and/or Duke University Health System and members or employees of the Private Diagnostic Clinic, PLLC. Any other use is prohibited and unauthorized.