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Drug Cards Daily#72: hyoscyamine (Levsin) | GI or Bladder Spasms, Adjunct for IBS, PUD, Colic, and RhinitisHyoscyamine is also known by the brand name Levsin. It is most commonly used to treat GI or bladder spasms or as adjunct treatment for IBS, PUD, and colic. It is also used in the treatment of rhinitis. It comes in a wide variety of dosage forms with the most common strengths being 0.125 mg and 0.375 mg. A common dosing regimen is between 0.125 mg - 0.25 mg every 4 hours as needed. The 0.375 mg dose is most commonly used with extended release formulations and dosed every 8-12 hours. Common side effects are xerostomia, dry eyes, dizziness, fever, blurred vision, and insomnia. There...2022-02-2812 minDrug Cards Daily#71: haloperidol (Haldol) | Psychosis, Tourette Syndrome, and Acute Agitation TreatmentHaloperidol also known by the brand name Haldol is a first generation antipsychotic. Haldol is commonly used in the treatment of Psychosis and Tourette Syndrome. There is also an off label use for acute agitation. When using Haldol it is important to use the lowest effective dose. A common dosing range is between 0.5-2 mg which is taken by mouth and divided two to three times daily. In severe treatment cases the treatment range can be as high as 3-5 mg PO 2-3x daily. The mechanism of action is proposed to be from selective antagonism of dopamine D2...2022-02-2114 minDrug Cards Daily#70: paroxetine (Paxil) | Treating Various Mood Disorders Such as DepressionParoxetine, also known as Paxil, is a Selective Serotonin-Reuptake Inhibitor (SSRI) used in the treatment of various mood disorders. Mood disorders such as major depressive disorder, OCD, panic disorder, social anxiety disorder, generalized anxiety disorder, PTSD, premenstrual dysphoric disorder, and mild-moderate menopausal vasomotor symptoms. Dosing varies by indication but commonly between 20-50 mg PO qam for immediate release dosage forms and around 12.5-75 mg PO qam for the extended release dosage forms. The absorption of paroxetine is not affected by food and is completely bioavailable after oral administration. The half-life elimination is around 21-24 hours. There is a black...2022-02-1414 minDrug Cards Daily#69: triamterene+HCTZ (Diazide, Maxide) | Treating Hypertension and Peripheral EdemaTriamterene and hydrochlorothiazide (HCTZ) is a combination product that is known by the brand name DIazide or Maxide. It is a combination of two diuretics. Triamterene is a potassium-sparing diuretic while HCTZ is a thiazide diuretic. This combination product is used in the treatment of hypertension and peripheral edema. It comes as a capsule and as a tablet. Both work in the distal convoluted tubule but triamterene increases potassium retention while HCTZ does not. Common side effects are muscle cramps, electrolyte disorders, constipation, and orthostatic hypotension. There is a black box warning for hyperkalemia that can be potentially fatal...2022-02-0708 minDrug Cards Daily#68: glyburide (Diabeta, Glynase, Micronase) | Lowers Blood Glucose in Patients with DiabetesGlyburide also goes by the brand names of Diabeta, Glynase, and Micronase. It is most commonly used in the treatment of patients with type 2 diabetes. The dosing range varies and is based on the patients blood glucose and the level of control needed. The treatment range is between 1.25-20 mg PO divided 1-2 times daily. Glyburide is given with meals. The mechanism of action lowers blood glucose through the stimulation of pancreatic beta cells. It is very important to note that the conventional and micronized tablets are not interchangeable. The comparison is approximately 1.25 mg to 0.75 mg. Common side effects...2022-01-3107 minDrug Cards Daily#67: tamsulosin (Flomax) | Treating Benign Prostatic Hyperplasia and NephrolithiasisTamsulosin is a selective alpha-1-adrenergic blocking agent also known as the brand name Flomax. Tamsulosin comes as a 0.4 mg capsule that is typically dosed 0.4 mg PO qd for 30 minutes after the same meal. The most common side effects are dizziness, cough and various infections. Some of the more serious side effects are priapism, arrhythmia, and syncope. Tamsulosin is most commonly used in males for the treatment of enlarged prostatic hyperplasia. It is commonly used to relieve symptoms such as difficulty in the beginning of urination and for weak streams as well as the need to urinate often in...2022-01-2406 minDrug Cards Daily#66: alendronate (Fosamax) | Treating of Various forms of OsteoporosisAlendronate is a bone resorption inhibiting bisphosphonate. The most common brand name is Fosamax. There is a dosage form specific Binosto which is a tablet that dissolves in a solution. The main indication is in the treatment of osteoporosis. Some considerations to make for patients is the supplementation of Ca and Vitamin-D if there is inadequate dietary intake. When taking the tablet it should be administered with water and taken 30 minutes before the first meal or medication of the day. It’s also very important to avoid lying down for 30 minutes after taking it. The common dosing is 70 mg PO...2022-01-1708 minDrug Cards Daily#65: prednisone (Deltasone) | Treatment of Corticosteroid-Responsive Conditions Such as Asthma, COPD, & MSPrednisone is a glucocorticoid or corticosteroid with minimal mineralocorticoid activity. It is most often used in treating conditions that are corticosteroid-responsive such as in acute exacerbation of Multiple Sclerosis, or in the treatment of Acute Asthma. Common dosing ranges between 5-60 mg PO 1-2 times daily. If the patient has been on high dose therapy or has undergone longer term therapy it is highly recommended to taper the patient gradually off the medications. The most common side effects are weight gain, loss of appetite, mood changes, muscle & joint pain, and headache. One of the more serious considerations is to...2022-01-1015 minDrug Cards Daily#64: losartan+hydrochlorothiazide (Hyzaar) | Treatment of Hypertension and Prevention of StrokeHyzaar is the brand name for the combination of losartan and hydrochlorothiazide (HCTZ). It comes as a tablet in several strengths (losartan/HCTZ): 100 mg/25 mg, 100 mg/12.5 mg, and 50 mg/12.5 mg. The indications are for hypertension and for the prevention of stroke. Dosing is generally initiated at 50 mg/12.5 mg PO qd but if the patient has severe hypertension it is initiated at higher strengths. There is a Black Box Warning for fetal toxicity and the medication should not be used or discontinued immediately if pregnancy is detected or suspected. The most common side effects are dizziness, cough, and dyspepsia. The...2022-01-0308 minDrug Cards Daily#63: folic acid (FaLessa) | Treatment of Megaloblastic Anemia and SupplementationFolic acid goes by many different names such as folate, Vitamin B9 or even by the brand name of FaLessa. It is a water-soluble vitamin and used in the treatment of Megaloblastic Anemia as well as in supplementation. When treating Anemia dosing is initiated at 1 mg PO qd up to a mas of 5 mg per day until hematologic correction occurs. When it comes to supplementation, dosing varies based on age. Folic acid is an important component in DNA synthesis as well as in erythropoiesis. Common side effects are rash, irritability, flatulence, and abdominal pain. Folic acid is found in...2021-12-2707 minDrug Cards Daily#62: risedronate (Actonel) | Treatment and Prevention of OsteoporosisRisedronate also is known by the brand names Actonel and Atelvia. It is a bisphosphonate derivative and used in the treatment of osteoporosis. A typical dosing regimen is 35 mg PO every week. Alternative dosing regimens are 5 mg PO qd and 150 mg PO every month. Risedronate works by inhibiting resorption of bone which indirectly leads to an increase of bone mineral density (BMD). Unlike other drugs, risedronate is not metabolized. This medication has an extremely long half-life at around 480-561 hours. When taking risedronate it is important to consider adequate Calcium and Vitamin-D intake. Common side effects are abdominal pain...2021-12-2009 minDrug Cards Daily#61: oxycodone (Roxicodone) | Treatment of Moderate to Severe PainOxycodone also is known as Roxicodone or as the extended release abuse deterrent formulations Oxycontin and Xtampza. The most common use for oxycodone is in the treatment of moderate to severe pain. When treating patients it is important to determine if the patient is opioid-naïve or opioid experienced. Opioid-naïve patients are doses at the lowest effective dose for the shortest effective duration. Initiating dosing is around 5-15 mg PO q4-6h prn. Opioid-experienced patients are dosed based on their current opioid intake and converted using the most current nomograms. There are multiple black box warnings and ex...2021-12-1311 minDrug Cards Daily#60: diazepam (Valium) | Treating Anxiety, Acute Alcohol Withdrawal, Seizures, & MoreDiazepam is also known as Valium and Diastat. It comes as a tablet, solution, nasal liquid, rectal gel, and concentrated solution. There are a wide variety of uses for diazepam such as for the treatment of anxiety, pre-op sedation, procedural sedation, alcohol withdrawal, muscle spasms, and seizures. A common dosing range when treating anxiety is 2-10 mg PO bid-qid. There are also approved uses in pediatrics such as for anxiety, muscle spasms, and status epilepticus. The benefits from diazepam are often linked to the enhancement of the GABA-A, not the GABA-B, receptors. The most common side effects are drowsiness...2021-12-0613 minDrug Cards Daily#59: atenolol (Tenormin) | Angina, HTN, Post-MI Heart Attack Prevention, & Migraine ProphylaxisAtenolol is a Beta-1 Selective Beta Blocker Antihypertensive Agent that is also known by the brand name Tenormin. The common indications are for Hypertension (HTN), Angina, and Post-MI Cardiovascular Event Prevention. It also has an off label use for Migraine Prophylaxis. Dosing range is between 25-200 mg PO qd depending on the indication. Should the patient ever need to discontinue the medication they should be tapered off gradually due to risks of exacerbation of treated indication. Common monitoring parameters include but are not limited to Cr and BP at baseline and periodically thereafter, ECG, and 10-year ASCVD risk assessment...2021-11-2908 minDrug Cards Daily#58: memantine (Namenda) ...AGAIN?! | Dementia Associated to Alzheimer’s Disease)Well it was bound to happen eventually. After recording & editing episode 58 it was brought to my attention that memantine was already covered back in episode 19! I guess here is the new version? Sorry everybody. EPISODE #19 Summary: Memantine is a NMDA antagonist that goes by the brand name Namenda. There are also titration packs available in the name brand. Memantine treats but does not cure confusion and dementia associated with Alzheimer's disease. There are multiple dosage forms being a capsule, solution, and tablet. Special considerations are for patients with renal and hepatic impairment. Memantine does appear to have hi...2021-11-2206 minDrug Cards Daily#57: methylprednisolone (Medrol Dose Pack) | Treating Corticosteroid-Responsive Conditions such as Asthma, Gout, and MSMethylprednisolone is a widely used corticosteroid used in the treatment of various corticosteroid-responsive conditions. The most commonly used dosing regimen comes in a pre-packaged punch card in order to help patients on the medication. The dosing begins at 24 mg (or six 4mg tablets) on day 1. Then decrease by 4 mg (or one tablet) each day until done. Since steroids can easily upset the stomach it is recommended to take it with food or milk. Since methylprednisolone is a steroid common concerns are either elevated blood pressure and glucose intolerance. If long term usage the concern grows to weight gain or...2021-11-1510 minDrug Cards Daily#56: cephalexin (Keflex) | A Beta-Lactam Cephalosporin Antibiotic That Treats Strep, UTI, & Other Bacterial InfectionsCephalexin is a widely used antibiotic. It is often used when treating various bacterial infections in both Adults and Pediatrics. Bacterial infections such as Streptococcal Pharyngitis, Uncomplicated Urinary Tract Infections (UTIs), and Bacterial Skin and Skin Structure Infections (SSSIs). There is also an off label indication for Dental Endocarditis Prophylaxis. Cephalexin works by causing bacteria cells to lyse by binding to penicillin-binding proteins (PBPs) thus inhibiting bacterial cell wall synthesis. Caution is to be used in renally impaired patients. Cephalexin appears to be safe for use during pregnancy and when breast-feeding. Common side effects are abdominal pain, nausea, vomiting...2021-11-0809 minDrug Cards Daily#55: digoxin (Digox) | An Antiarrhythmic Agent for HFrEF, AFib, and PSVT conversionDigoxin also goes by the brand names Digox, Digitalis, and Lanoxicaps. Digoxin comes as tablets, a solution, and an injection. In both Adults and Pediatrics, when calculating doses it is important to use the patient’s lean body weight (LBW) with dose adjustments based on levels. It is important to also remember that concentrations of >2 ng/mL lead to digoxin toxicity and can also be identified with signs and symptoms such as anorexia, nausea, vomiting, and visual changes. The most common indications are for treating Heart Failure with reduced Ejection Fraction (HFrEF) and Atrial Fibrillation (AFib). Digoxin is poorly pr...2021-11-0114 minDrug Cards Daily#54: methylphenidate (Ritalin) | Controlling Attention Deficit Hyperactivity Disorder (ADHD)Methylphenidate comes in many dosage forms with a variety of brand names but this drug is most commonly known as Ritalin. Some of the dosage forms are as immediate release (IR) tablets, extended release (ER) capsules, patches, orally disintegrating tablets (ODT), and solutions. When treating ADHD, dosing is highly variable and based on dosage form but a common between most all of the oral dosage forms is to not take a dose after 6 pm and to take 30-45 minutes before a meal. Methylphenidate can be used in treating both children and adults with ADHD but there is one other...2021-10-2515 minDrug Cards Daily#53: carvedilol (Coreg) | Treats Hypertension, Heart Failure, and Ventricular DysfunctionCarvedilol comes in both an extended release capsule and an immediate release tablet. The brand name is Coreg. It is classified as an antihypertensive and beta-blocker with alpha blocking activity. Coreg works through selective alpha-1 adrenergic receptor antagonism. It has non-selective beta-1 and beta-2 adrenergic receptor antagonism. It is a racemic mixture with no intrinsic sympathomimetic activity. When discontinuing therapy taper the patient off the medication over 1-2 weeks. Some common side effects are dizziness, fatigue, and weight gain. Some serious side effects are severe bradycardia, SJS, and severe anemia. The medication should be taken with food in order...2021-10-1812 minDrug Cards Daily#52: tiotropium (Spiriva) | Treating COPD and Asthma with a LAMATiotropium is a long acting muscarinic antagonist (LAMA) that is also known by the brand name Spiriva. It comes as an inhaled aerosol solution as well as an inhaled capsule. The main indications are for the treatment of COPD and Asthma. Tiotropium works through reversible competitive inhibition of acetylcholine at type 3 muscarinic receptors in bronchial smooth muscle which leads to bronchodilation. The medication is poorly absorbed in the GI and hepatically metabolized via the CYP2D6 and CYP3A4 pathways. The time to peak is between 5-7 minutes with the half-life elimination between 25-44 hours. Although the data in...2021-10-1107 minDrug Cards Daily#51: citalopram (Celexa) | Treats Major Depressive & Obsessive Compulsive DisorderCitalopram is also known by the brand name Celexa. It is an antidepressant and a selective serotonin reuptake inhibitor (SSRI). The tablet come in a 10 mg, 20 mg, and 40 mg strength and is also available as a 10 mg/5 ml solution. In adults and pediatrics it can be used to treat both major depressive and obsessive compulsive disorder. There are other off-label indications in children but the only approved use is in adults for major depressive disorder. The treatment range for treating major depressive disorder in adults is 20-40 mg PO qd with a max of 40 mg/day. There is literature...2021-10-0410 minDrug Cards Daily#50: alprazolam (Xanax) | Treating Generalized Anxiety & Panic Disorder and VertigoAlprazolam, or brand name Xanax, comes as an immediate release, orally disintegrating, or extended release tablet; as well as coming as a concentrated solution. This hypnotic benzodiazepine is commonly used to treat generalized anxiety and panic disorders. There is also an off label indication for treating vertigo. Alprazolam’s proposed effects comes from an increased inhibitory effect of GABA on neurons resulting in a less excitable state of hyperpolarization creating stabilization. Alprazolam is rapidly absorbed with a time to peak b/t 1-2 hours if an immediate release formulation is used or around 9 hours if an extended release formulation is...2021-09-2710 min
Drug Cards Daily#49: benazepril (Lotensin) | Hypertension Treatment With Benefits in Heart FailureBenazepril, also known as Lotensin, is an antihypertensive agent. It works by competitively inhibiting the conversion of angiotensin I to angiotensin II. The onset of action is between 1-2 hours. When treating hypertension the treatment range is between 10-40 mg PO qd-bid. When first initiating, start at 10 mg PO qd with a max of 80 mg per day. There is black box warning for fetal toxicity. Common side effects are cough, fatigue, dizziness, hypotension, and hyperuricemia. Benazepril should be stopped ASAP if the patient is pregnant due to risks of fetal injury and fetal death. Sone monitoring parameters are blood...2021-09-2008 minDrug Cards Daily#48: clonazepam (Klonopin) | Treats Seizure & Panic Disorders, Off-Label for Anxiety, RLS, Sleep Terrors, & More!Clonazepam is an anticonvulsant benzodiazepine also known as Klonopin. The main indications are for seizure disorder and panic disorder. There are many off label indications such as for anxiety, sleep terrors, sleepwalking, Tourette's syndrome, and RLS. The treatment range for seizure or panic disorders is between 0.5-5 mg PO bid-tid respectively. The mechanism of action is unknown but believed to be a result of GABA activity enhancement. The onset of action is between 20-40 minutes. The time to peak is between 1-4 hours. There are several black box warnings. The first is for the risk of concomitant opioid use...2021-09-1311 minDrug Cards Daily#47: meloxicam (Mobic) | Osteoarthritis, Rheumatoid Arthritis, and Acute Gout FlaresMeloxicam is a nonsteroidal anti-inflammatory non-opioid analgesic medication used to treat osteoarthritis and rheumatoid arthritis. A treatment range is often between 5-15 mg PO qd with a max of 15 mg/day. Meloxicam works through reversible COX1/COX2 enzyme inhibition decreasing thromboxane and prostaglandins leading to antipyretic, anti-inflammatory, and analgesic effects. It is metabolized via the CYP2C9 and CYP3A4 pathways. The time to peak for tablets is around 4-5 hours with a half-life elimination of 13-22 hours. It should not be used during pregnancy and close to conception. Black Box Warning for cardiovascular thrombotic events and GI bleed...2021-09-0608 minDrug Cards Daily#46: promethazine (Phenergan) | Motion Sickness, Allergic Conditions, and SedationPromethazine, also known as Phenergan and Promethegan, is a first generation H1 histamine antagonist. It comes as a solution, suppositories, syrup, and tablets. There are a wide variety of indications for adults and children 2 years of age and older such as for allergic conditions, motion sickness, and sedation. A typical dosing range is between 25-50 mg tid-qid if PO and 6.25-25 mg IM/IV tid-qid. The max dose is 100 mg/day. Promethazine works through strong alpha adrenergic inhibition from blockade of postsynaptic mesolimbic dopaminergic receptors in the brain. It is metabolized via the CYP2D6 and CYP2B6 pathways. T...2021-08-3011 minDrug Cards Daily#45: quetiapine (Seroquel) | Schizophrenia, Bipolar Disorder, and Major Depressive DisorderQuetiapine is also known by the brand name Seroquel. It comes as both an immediate release and extended release formulation. There are several indications such as for schizophrenia and various classifications of Bipolar disorder. It can also be used as adjunct treatment in major depressive disorder. The max dose for quetiapine is 800 mg/day. Doses are generally divided bid-tid. Quetiapine’s antipsychotic activity is proposed to be a result of both dopamine type 2 (D2) and serotonin type 2 (5HT2) antagonism. There are many other antagonist effects on neurotransmitter receptors in the brain such as 5HT1A, 5HT2, D1, D2, H1, an...2021-08-2315 minDrug Cards Daily#44: rosuvastatin (Crestor) | Management of Dyslipidemia and Cardiovascular Event PreventionRosuvastatin is an antilipemic agent that works through the inhibition of the rate limiting enzyme in cholesterol synthesis (HMG CoA reductase). It is used in the management of dyslipidemia as well as having benefits in cardiovascular event prevention. The typical dosing range when treating dyslipidemia is between 5-40 mg PO qd. The max dose is 40 mg/day. Dose adjustments are made every 2-4 weeks after initiating between 10-20 mg PO qd. Some concerns are to avoid red yeast rice due to the similarity to the medication lovastatin, avoid use during pregnancy and breastfeeding, and dose at the lower end...2021-08-1610 minDrug Cards Daily#43: oxycodone+acetaminophen (Percocet) | Treating Moderate to Severe PainOxycodone+acetaminophen (APAP) is an analgesic combination product also known as Percocet. When dosing for Percocet one should consider also prescribing naloxone if there is a possible risk of opioid overdose or accidental ingestion. It is also very important to note that the lowest effective dose at the shortest effect duration should be used. Dosing for Percocet is based on the oxycodone component but limited by the APAP component. A general dosing range is 2.5-10 mg oxycodone PO q6h prn. Do not exceed 1 gram of APAP in 4 hours and 4 grams of APAP in 24 hours. There are a large...2021-08-0909 minDrug Cards Daily#42: furosemide (Lasix) | Edema, Hypertension, and Hypercalcemia TreatmentFurosemide is an antihypertensive loop diuretic drug. The main indications are for edema and hypertension with an off-label use for hypercalcemia. The general dosing range is between 40-120 mg per day with a max of 600 mg per day. The mechanism of action is it interferes with the chloride-binding co-transport system causing a natriuretic effect. It inhibits sodium and chloride resorption in the ascending Loop of Henle and the proximal and distal renal tubules. The onset of action for diuresis is around 30-60 minutes with symptomatic improvement of acute pulmonary edema occurs within 15-20 minutes. Caution should be observed in...2021-08-0210 minDrug Cards Daily#41: amlodipine (Norvasc) | Treating High Blood Pressure and Chest PainAmlodipine is an antianginal antihypertensive agent also known as Norvasc. It is indicated for hypertension and various types of angina. In adults when treating hypertension the general dosing range is between 5-10 mg PO qd. When treating angina the general dosing range is also between 5-10 mg PO qd. Amlodipine is also indicated in pediatrics when treating hypertension. In patients between 1-5 years of age, dosing is initiated at 0.1-0.6 mg/kg/dose PO qd with a max of 5 mg/day. Between the ages of 6-17 years of age dosing is initiated at 2.5-5 mg PO qd with a...2021-07-2608 minDrug Cards Daily#40: duloxetine (Cymbalta) | Beneficial As An Antidepressant and Pain MedicationDuloxetine is used in a wide variety of indications. It can be used in treating fibromyalgia, chronic musculoskeletal pain, and neuropathic pain due to diabetes mellitus. It is also used in treating mood disorders such as generalized anxiety disorder and major unipolar depressive disorder. The general dosing range for duloxetine is 30-60 mg PO qd. Although the max dose is 120 mg per day, therapeutic benefits do not appear evident past 60 mg per day. Duloxetine works through strong inhibition of neuronal serotonin and norepinephrine reuptake along with weak inhibition of dopamine reuptake. There is reduced bioavailability in patients who smoke...2021-07-1910 minDrug Cards Daily#39: simvastatin (Zocor) | Slow Progress of Heart Disease and Lower CholesterolSimvastatin is used to slow the progress of heart disease as well as lowering cholesterol in patients. It is also known by the brand name of Zocor. Simvastatin works by affecting the rate-limiting step in cholesterol synthesis. It is a competitive inhibitor of the HMG-CoA reductase enzyme. There are also other benefits such as reducing inflammation and coronary plaque sites, inhibiting platelet aggregation, as well as having an anticoagulant effect. Simvastatin is contraindicated in pregnancy and should be stopped immediately if pregnancy is suspected. Some serious side effects to be aware of are rhabdomyolysis; muscle pain, tenderness, and weakness...2021-07-1209 minDrug Cards Daily#38: esomeprazole (Nexium) | Get Stomach Acid and H. pylori Infection Under ControlEsomeprazole is available over the counter and by prescription. The commonly known brand name is Nexium. Esomeprazole is a substituted benzimidazole proton pump inhibitor (PPI). It comes in a delayed release capsule and as delayed release granule packets. When treating GERD and other hypersecretory conditions a typical dosing range is between 20-40 mg po qd-bid. Esomeprazole is also used as part of a multi-drug regimen for treating H. pylori infection. The mechanism of action behind esomeprazole is through the suppression of acid secretion by inhibiting hydrogen-potassium ATPase. Esomeprazole is the S-enantiomer of omeprazole (Prilosec). Since esomeprazole affects stomach acid i...2021-07-0513 minDrug Cards Daily#37: gabapentin (Neurontin) | For Seizures and Neuropathic PainGabapentin has a wide variety of uses but the main indications are for focal seizures in adults and children and for postherpatic neuralgia in adults. There are many commonly used off label indications such as for neuropathic pain, fibromyalgia, and alcohol dependence. Max dosing for gabapentin is around 3600 mg/day. Although the exact mechanism of action is unknown, it is clear that it is similar in chemical structure to GABA. This is important because GABA is responsible for modulating excitatory neurotransmitter release. Gabapentin is poorly protein bound at less than 3% and not metabolized. When discontinuing longer term therapies, doses...2021-06-2808 minDrug Cards Daily#36: azithromycin (Zithromax) | A Macrolide For CAP SSTI, Strep, COPD, STDs, and OthersAzithromycin is a macrolide antibiotic used to treat many bacterial infections. Some common uses are for Community Acquired Pneumonia (CAP), Group A Strep, Acute Exacerbations of COPD, STDs, among other bacterial infections. One of the most commonly known dosing regimens is 500 mg on day one, then 250 mg on days 2-5. When using the reconstituted suspension it must be refrigerated once reconstituted it must be discarded after 10 days. Azithromycin works through the inhibition of RNA-dependent protein synthesis by binding to the 50S ribosomal subunit. By blocking transpeptidation this inhibits the chain elongation step of protein synthesis. Azithromycin distributes well into...2021-06-2114 minDrug Cards Daily#35: potassium citrate (Urocit-K) | An Alkalinizing Agent for Managing Kidney StonesThere are two commonly used forms of potassium. Potassium chloride (to treat hypokalemia) and potassium citrate (as an alkalinizing agent). Unlike potassium chloride, potassium citrate is also measured in “mg” in addition to “mEq”. It comes in a 5 mEq (540 mg), 10 mEq (1080 mg), and 15 mEq (1620 mg) strength ER tablet. The main indication for potassium citrate in in the management of kidney stones. In mild-moderate treatment you initiate 15 mEq PO bid or 10 mEq PO tid with a max dose of 100 mEq per day. Since potassium citrate is an alkalinizing agent the way it works is it makes urine less acidic. It raises t...2021-06-1404 minDrug Cards Daily#34: potassium chloride (K-Tab) | Treatment and Management of HypokalemiaThere are two most commonly used versions of potassium. Potassium chloride (supplementation) or potassium citrate (alkalinizing agent). Potassium chloride, also known as K-Tab or Klor-Con, is an electrolyte supplementation used in treating and preventing Hypokalemia (low potassium). Potassium is an essential cation that is needed for the conduction of nerve impulses in the heart, brain, and muscle. Unlike most drugs, potassium is not measured in “mg'' and is measured in “mEq” or milliequivalents. Potassium chloride comes in multiple dosage forms such as an ER capsule and tablet, a powdered packet, oral solution, and also as an intravenous solution. When the IV...2021-06-0709 minDrug Cards Daily#33: valsartan (Diovan) | Treating NSTEMI, STEMI, Heart Failure and HypertensionValsartan, also known as Diovan, is an angiotensin II receptor blocker (ARB). It is used for treating NYHA class II to IV heart failure along with both treating and managing hypertension. Another common indication is for both STEMI and NSTEMI patients. Typical initiation dosing for heart failure, STEMI and NSTEMI is 20 mg twice daily with titrations up to 160 mg twice daily. When initiating treatment for hypertension the range begins at 80-160 mg po every day up to a max dose of 320 mg per day. Valsartan works by blocking AT2 from the AT1 receptor and is considered to be more...2021-05-3109 minDrug Cards Daily#32: tramadol (Ultram) | Pain Management when Alternatives are Not Tolerated or IneffectiveTramadol can be used to treat and manage moderate to severe acute and chronic pain. It is also known as Ultram. An off label use is for Restless Leg Syndrome (RLS). When treating acute or chronic pain initiate 25-50 mg every 4-6 hours as needed with a max dosing range of 50-100 mg every 4-6 hours. The max dose per day is 400 mg. Tramadol acts on the mu-opioid receptor by blocking the ascending pain pathway. It alters the pain response and perception along with blocking reuptake of both serotonin and norepinephrine. Tramadol is extensively metabolized hepatically via the CYP3A...2021-05-2410 minDrug Cards Daily#31: sertraline (Zoloft) | A Medication for Depression, OCD, PTSD, Panic Disorder, Anxiety, and PMDDSertraline, also known by the brand game Zoloft, is a selective serotonin reuptake inhibitor (SSRI) that is commonly associated with being an antidepressant. There are many indications for sertraline being for depression, OCD, panic disorder, PTSD, PMDD, and anxiety. Although the manufacturer established a max daily dose of 200 mg/day higher doses from 250-400 mg/day have proven beneficial in clinical practice. Sertraline is not to be used during or within 14 days of a MAOI. Common side effects are nausea, dizziness, dry mouth, sweating, diarrhea, upset stomach, and trouble sleeping. There is a black box warning for Suicidality and...2021-05-1711 minDrug Cards Daily#30: tamoxifen (Soltamox) | Reducing the Risk and Treating Breast CancerTamoxifen is a selective estrogen receptor modulator that comes in both a tablet and solution. The tablet comes in a 10 mg and 20 mg strength and the solution comes in a 10 mg/5 mL concentration. Tamoxifen, also known as the brand name Femara, when used in reducing the risk of Breast Cancer in high risk females the dosing is 20 mg once daily for 5 years. When used in treating Breast Cancer the dosing does vary at 20-40 mg once daily. When 40 mg is needed per day the daily dose is divided into separate doses. When tamoxifen is metabolized via the CYP2D6...2021-05-1008 minDrug Cards Daily#29: letrozole (Femara) | Treating and Preventing Breast Cancer, Ovarian Cancer, and Infertility in PCOS PatientsLetrozole is an aromatase inhibitor that acts as an antineoplastic agent. The brand name for letrozole is Femara. The main indication is for hormone receptor positive breast cancer in women after menopause. If treating early breast cancer letrozole is used after a 5 year course of tamoxifen. If treating advanced breast cancer letrozole follows antiestrogen therapy. There are many off label uses of letrozole such as the many variations of breast cancer along with treating infertility due to polycystic ovary syndrome (PCOS) through ovulation stimulation. Dosing is straight forward at 2.5 mg po qd with for 5 years (in early breast cancer...2021-05-0307 minDrug Cards Daily#28: loratadine (Claritin) | Treating Allergic Rhinitis, Conjunctivitis, and UrticariaLoratadine is available over the counter and by prescription. Over the counter the most commonly known brand name is Claritin. Loratadine is a second generation antihistamine that works by antagonizing the H1 receptor. The main indications are for allergic rhinitis, conjunctivitis, and urticaria. There are many different dosage forms available from capsule, solution, syrup, tablet, chewable tablet, and disintegrating tablet. When dosing for adults the most common dosing is 10 mg po qd or 5 mg po bid with a max of 10 mg per day. For children 2-6 the chewable tablet or liquid is generally the preferred dosage form and dosed...2021-04-2606 minDrug Cards Daily#27: dicyclomine (Bentyl) | Treating Abdominal Pain Associated with IBSDicyclomine is an antispasmodic anticholinergic agent that is used to treat stomach and intestinal cramping that is often associated with irritable bowel syndrome (IBS). The brand name is Bentyl. There are various dosage forms such as oral and intramuscular solutions but the most commonly used are capsules. The capsules come in a 10 and 20 mg strength. When dosing to treat the abdominal pain associated with IBS, initiate 20 mg po qid for 2 weeks or less. Longer durations of treatment have not proven any additional benefits to the patient. Dicylomine works by blocking acetylcholine at parasympathetic sites such as the smooth muscle...2021-04-1905 minDrug Cards Daily#26: ibuprofen (Motrin) | Rx and OTC Use for Analgesic and Antipyretic EffectsIbuprofen is a very well known medication available over the counter (OTC) and by prescription (Rx). The most common brand names are Advil and Motrin. Ibuprofen is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that is often used for it’s non-opioid analgesic effect as well as it’s antipyretic effect. The OTC product comes in a wide variety of dosage forms but generally limited to a 200 mg strength. Strengths higher than that are Rx only. When treating pain in adults a common dosing regimen is 200-800 mg po 3-4 times daily (q6-8h) with the max daily dose at 3200 mg p...2021-04-1210 minDrug Cards Daily#25: carisoprodol (Soma) | Short Term Benefit For Discomfort of Musculoskeletal ConditionsCarisoprodol is a skeletal muscle relaxant that is most commonly known as the brand name Soma. The lesser known brand name is Vanadom. This drug has benefits in treating discomfort experienced from acute painful skeletal muscle conditions over a 2-3 week duration of therapy. The benefits beyond a short term duration (2-3 weeks) has not been proven. There are two strengths in a tablet form being 250 mg and 350 mg. The medication is dose qid with tid in addition to at bedtime. Carisoprodol forms the metabolite meprobamate which has anxiolytic and sedative effects. Since CYP2C19 function is crucial to...2021-04-0505 minDrug Cards Daily#24: erenumab (Aimovig) | 3 Months of Migraine Days Per Year May Get EliminatedAimovig is currently the brand-only drug for erenumab. Erenumab is used in the prevention of migraines in adults. The drug comes as a 70 mg/mL or 140 mg/mL subcutaneous autoinjector that is used for one dose every month. Aimovig is considered various things being called a calcitonin gene-related (CGRP) receptor antagonist or CGRP inhibitor, a monoclonal antibody, and an antimigraine agent. Erenuman blocks the CGRP receptor which decreases the CGRP protein which is known as the cause for intense inflammation in the meninges and nerve endings in the brain. Although there are not any direct drug interactions of note...2021-03-2904 minDrug Cards Daily#23: trazodone (Desyrel) | Treating Unipolar Major Depressive Disorder and InsomniaTrazodone is an antidepressant that also is commonly used for insomnia (off-label). When treating MDD in adults the immediate release tablet is initiated at 50 mg twice daily and incrementally increased every 3-7 days to a typical dose range between 200-400 mg/day. If used for treating MDD and if the sedative effect is not desired it is recommended to have a smaller daytime dose and a larger bedtime dose. When treating insomnia dosing is initiated at 50-100 mg at bedtime. Most common side effects are sedation, dizziness, and low blood pressure. Serotonin syndrome is a concern so watch for...2021-03-2208 minDrug Cards Daily#22: esketamine (Spravato) | A REMS Drug Used for Major & Treatment-Resistant DepressionEsketamine is a REMS program drug that is currently brand only known as Spravato. It is a Non-Selective Non-Competitive NMDA Receptor Antagonist and typically administered in a healthcare setting that is enrolled in the REMS program. Spravato is used along with an antidepressant when treating patients with treatment-resistant depression or a major depressive disorder with acute suicidal ideation and behavior. It is not recommended for pediatric use and the efficacy in reducing and preventing suicide or suicidal behavior has not been proven. Spravato comes in a nasal spray in a 56 mg and 84 mg strength. In addition to the more...2021-03-1507 minDrug Cards Daily#21: warfarin (Coumadin) | Anticoagulant for Treatment of Myocardial Infarction and Thromboembolic ComplicationsWarfarin is an anticoagulant that is also known by the brand name Coumadin. It is used in the treatment of myocardial infarction and thromboembolic complications. There is a wide variety of tablet strengths from 1 mg to as high as 10 mg. When dosing warfarin it is very patient-specific. The therapeutic goal is based on various factors and treatment nomograms may vary from institution to institution. Prior to initiation it is wise to establish the patient’s genetic variant for CYP2C9 since this will play a large role in predicting their drug sensitivity. When attempting to reach a therapeutic target th...2021-03-0817 minDrug Cards Daily#20: zolpidem (Ambien) | A Short-Term Treatment for Sleep-Onset and Sleep-Maintenance InsomniaZolpidem is a hypnotic drug that selectively agonizes the benzodiazepine-1 receptor. It comes in multiple tablet forms as well as in a spray. The most common brand name zolpidem is identified with is Ambien. The most recognizable orally disintegrating tablet brand is Intermezzo. Zolpidem is used for short term treatment of sleep-onset and sleep-maintenance insomnia. It is important to transition patients off zolpidem to avoid symptoms of withdrawal. A commonly prescribed regimen for the immediate release tablet is 5 mg po immediately before bedtime allowing for 7-8 hours of uninterrupted sleep. Some factors to consider are females appear to have...2021-03-0111 minDrug Cards Daily#19: memantine (Namenda) | Dementia Associated to Alzheimer’s DiseaseMemantine is a NMDA antagonist that goes by the brand name Namenda. There are also titration packs available in the name brand. Memantine treats but does not cure confusion and dementia associated to Alzheimer’s disease. There are multiple dosage forms being a capsule, solution, and tablet. Special considerations are for patients with renal and hepatic impairment. Memantine does appear to have higher exposure in women than men. Memantine is purposed to work on the glutamate receptor blocking the receptor much like magnesium does under “normal” conditions. This drug has a long elimination half-life between 60-80 hours. The main side e...2021-02-2206 minDrug Cards Daily#18: aripiprazole (Abilify) | Mood Disorders (Schizophrenia, Bipolar, Depression, Irritability)Aripiprazole is an atypical second generation antipsychotic agent. It commonly goes by the brand name Abilify. It is a quinolinone derivative which looks similar to but different from quinolones (antibiotic class). There are many indications for Abilify such as in the treatment of schizophrenia and bipolar disorder but can also be used to treat the irritability often seen in autistic disorder. Dosing initiation is often titrated. For example, when initiating dosing for adults with bipolar disorder initiation begins with 10-15mg po qd with 5-10mg dose increases weekly with the max dose of 30mg/day. Common side effects...2021-02-1513 minDrug Cards Daily#17: omeprazole (Prilosec) | GERD, Heartburn, PUD, and Zollinger-Ellison SyndromeOmeprazole is a proton pump inhibiting drug that helps regulate the secretion of stomach acid. The most common brand name is Prilosec. Omeprazole is available over the counter (OTC) as well as by prescription only (RX). The OTC indication is for heartburn and should be used no longer than 14 days in a 4 month period. Typical dosing ranges from 10 -40 mg po qid to bid unless treating Zollinger-Ellison Syndrome. When treating Zollinger-Ellison Syndrome doses can get as high as 180 mg daily. The average Zollinger-Ellison Syndrome dose is 60-70 mg qd. Omeprazole should be used cautiously (if at all) in the...2021-02-0809 minDrug Cards Daily#16: albuterol (Proair, Ventolin) | Treating BronchospasmsAlbuterol is a bronchodialating beta-2 adrenergic agonist. Common brand names are ProAir, Ventolin, and Proventil. The most common use is for treating and preventing bronchospasms in patients with obstructive airway diseases. There are several dosage forms with the most common being metered dose inhalers (MDI) and dry powdered inhalers (DPI). Albuterol is generally considered a quick relief or rescue inhaler with dosing being 2 puffs by mouth every 4-6 hours as needed. Since albuterol specifically targets the beta-2 adrenergic receptor in bronchial smooth muscle there is little to no effect on heart rate. Although the drug is targeted it is...2021-02-0115 minDrug Cards Daily#15: ubrogepant (Ubrelvy) | Treatment for Acute Migraines in AdultsUbrogepant is currently brand only and known as Ubrelvy. This drug is a Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist used to treat migraines. There are two tablet strengths being the 50 mg and 100 mg dose. Initiated begins between 50 - 100 mg po for one dose and may be repeated after 2 hours for one more dose. The max dose is 200 mg per day. Dose adjustments should be made in patients with renal and/or hepatic impairment. This drug is primarily metabolized hepatically through the CYP3A4 pathway. Strong inhibitors or inducers for CYP3A4 should be avoided or used with dose adjustments...2021-01-2504 minDrug Cards Daily#14: hydrochlorothiazide (Microzide) | Edema, Hypertension, Calcium Nephrolithiasis Prevention, and Nephrogenic Diabetes InsipidusHydrochlorothiazide is a thiazide diuretic that goes by the brand name Microzide. The way this drug works is through the inhibition of sodium reabsorption in the distal tubules of the kidneys. The drug is most commonly used in the treatment of Edema but has other pharmacological uses. Typical edema treatment dosing is initiated at 25-100 mg po qd divided into 1-2 doses. Thiazide diuretics are not the preferred diuretic for edema but does have its place in therapy. There is a concern in patients with sulfonamide-derived drug allergies but this is often challenged. The drug is excreted in the u...2021-01-1807 minDrug Cards Daily#13: cyclobenzaprine (Flexeril) | Muscle Spasms and Musculoskeletal PainCyclobenzaprine is a skeletal muscle relaxant that goes by brand names Flexeril and Amrix. The drug’s effects are achieved through acting centrally on the skeletal muscle and reducing the motor activity of both the alpha and gamma motor neurons. Typical dosing is initiated at 5 mg po tid with one of the doses being at bedtime. The duration of therapy is short term being 2-3 weeks max. Can be taken with or without food. Capsules can be opened and sprinkled but tablets are recommended to be taken whole. The main drug interaction concerns are with CNS depressants, serotonin increasing dr...2021-01-1108 minDrug Cards Daily#12: escitalopram (Lexapro) | Depression, Anxiety, and Other Mood DisordersEscitalopram is the S-enantiomer of citalopram. This drug works by selectively inhibiting serotonin. The brand name that escitalopram is most recognized as Lexapro. Dosing is typically initiated at 10 mg po qd with adjustments made incrementally with the max dose generally being around 20 mg per day. There are many off label uses for escitalopram so those should be utilized on a case by case basis. However, the main indications for this drug is to treat depression and anxiety. Escitalopram is not approved for use in patients under the age of 12. The black box warning for escitalopram is for suicidal thoughts...2021-01-0410 minDrug Cards Daily#11: metoprolol (Lopressor) | Angina, HF, MI, and HTNMetoprolol is an anti-anginal, anti-hypertensive agent that works by selectively inhibiting the beta1 adrenergic receptor. Some of the brand names are Lopressor, Toprol XL, and Kapspargo Sprinkle. Dosing may vary based on if the formulation is the IR or ER form and by indication. For Angina in adults the IR tartrate form starts at 50 mg po bid with weekly increases to a max of 400 mg/day. There is a black box warning for Ischemic Heart Disease warning that abrupt cessation of therapy may harm patients and if therapy is to be discontinued, the patient should be titrated down over 1...2020-12-2811 minDrug Cards Daily#10: fluticasone (Flovent) | Inhaled Corticosteroid Used for Asthma and COPDFluticasone is an inhaled corticosteroid (ICS). Some of the brand names are Flovent and Arnuity Ellipta. This drug is a potent local vasoconstrictor as well as an anti-inflammatory agent. The main indication is in the treatment of asthma with off label uses in COPD and EoE. Dosing is based on prior ICS treatment and/or level of severity. The furoate form is generally preferred over the propionate form due to a better binding affinity. The main side effect and counseling point is for oral candidiasis (Thrush). Go to DrugCardsDaily.com for episode show notes which consist of t...2020-12-2112 minDrug Cards Daily#9: montelukast (Singulair) | Not First-Line But Useful in Allergic Rhinitis, Asthma, and EIBMontelukast is best used as an adjunctive drug. It is best when used for the treatment of allergic rhinitis, asthma, and exercise induced bronchoconstriction (EIB). The brand name is Singulair. This drug works through selectively inhibiting the cysteinyl leukotrienes which leads to pulmonary and nasal mucosal benefits along with the alteration of the inflammation process. This comes in several dosage forms being 4 mg packets/granules, a 10 mg tablet, and in 4 mg and 5 mg chewable tablets. Common side effects include dizziness, fatigue, urticaria, and infection. There is a black box warning for serious neuropsychiatric events so it is very important...2020-11-3010 minDrug Cards Daily#8: clopidogrel (Plavix) | Treating STEMI, NSTEMI, MI and StrokeClopidogrel is an antiplatelet drug. When I was in school it was the “classic” example of a prodrug. The brand name is Plavix. This drug works by irreversibly blocking the P2Y12 component of ADP receptors which prevents GPIIb/IIIa activation causing a reduction in platelet aggregation. Based on indications and diagnosis there may be a loading dose of 300 mg to 600 mg with the general treatment dosing of 75 mg po qd. The active form of this drug relies on the Cytochrome P450 CYP2C10 oxidation to active thiol. Common side effects include bleeding, bruising, rash. There is a black box...2020-11-2318 minDrug Cards Daily#7: metformin (Glucophage) | Getting Blood Sugars Under ControlMetformin is a medication used in the treatment of patients with Type 2 Diabetes. One of the brand names is Glucophage. This drug works by decreasing glucose production, decreasing interstitial glucose absorption, and by increasing peripheral glucose uptake and insulin sensitivity. Metformin is commonly dosed using either immediate release or extended release tablets. Initial dosing begins with 500 mg 1-2 times daily or with 850 mg once daily then titrated to a goal of 850-1000 mg twice daily. This drug is not metabolized hepatically with around 90% being excreted in the urine. Side effects include diarrhea, flatulence, and infection. There is a black...2020-11-1611 minDrug Cards Daily#6: atorvastatin (Lipitor) | Treating Dyslipidemia and ASCVDThis episode of Drug Cards Daily is on the drug atorvastatin. The name brand is Lipitor. Atorvastatin is a HMG-CoA Reductase Inhibitor that is known for treatment of Dyslipidemia and ASCVD. The tablets come in a variety of doses. Initial dosing for dyslipidemia/hypercholesterolemia begins at 10-20 mg once daily and is evaluated every 1-3 months after initiation and then every 3-12 months thereafter. This dosing distinction is categorized as either moderate-intensity (10-20 mg/day, reducing LDL-C by 30-49%) and high-intensity (40-80 mg/day, reducing LDL-C by 50% or more). ASCVD (Atherosclerotic Cardiovascular Disease) treatment follows the moderate-intensity/high-intensity dosing...2020-11-0912 minDrug Cards Daily#5: amoxicillin (Amoxil) | Treating CAP, UTI, SSTI, & Other InfectionsThis episode of Drug Cards Daily is on the drug amoxicillin. The name brand is Amoxil. Amoxicillin is a penicillin antibiotic used in treating a wide variety of infections such as community acquired pneumonia (CAP), urinary tract infections (UTI), as well as others. This medication comes in a powder for reconstitutions and tablets. The general dosing in adults is around 500 mg-1000 mg po q8-12h for 5-7 days. Ranges, doses, duration is based on indication and severity of signs and symptoms. Sixty percent of this drug is excreted through the urine. Amoxicillin has a wide distribution and can...2020-11-0210 minDrug Cards Daily#4: lisinopril (Prinivil, Zestril) | Treating Hypertension and STEMIThis episode of Drug Cards Daily is on the drug lisinopril. The name brands are Zestril, Prinivil, Qbrelis (Solution). Lisinopril is an Angiotensin-Converting Enzyme (ACE) inhibitor that is most known for treatment of hypertension. Other indications are for heart failure and ST-elevation myocardial infarction. Tablets come in a variety of doses. Initial dosing for hypertension begins at 5-10 mg once daily and is evaluated every 4-5 weeks. The dose is then doubled with the goal of 40 mg/day is achieved or until the patient’s tolerance is reached. This drug is not metabolized with any unused unchanged drug being ex...2020-09-2806 minDrug Cards Daily#3: elexacaftor+ivacaftor+tezacaftor (Trikafta) | Cystic Fibrosis Treatment in F508del PatientsThis episode of Drug Cards Daily is on the drug Trikafta. As of 2020 it is Brand only. Trikafta consists of three drugs which are elexacaftor, ivacaftor, tezacaftor. It is twice a day dosing with 2 tablets in the morning and 1 tablet (12 hours later) in the evening. The morning tablet is orange in color and consists of elexacaftor 100 mg + tezacaftor 50mg + ivacaftor 75 mg while the evening dose (which is a light blue colored tablet) consists of ivacaftor 150 mg. Currently the drug is approved for use in ages 12 years and older. The main concerns are patients must have the F508del mutation...2020-09-2506 minDrug Cards Daily#2: hydrocodone/APAP (Norco, Vicodin) | Treating Acute and Chronic PainThis episode of Drug Cards Daily is on the drug hydrocodone/APAP. Hydrocodone/APAP has a variety of brand names but most commonly known as Norco or Vicodin. It is a combination product containing an opioid and analgesic. Hydrocodone/APAP is typically used in the management of both acute and chronic pain. It comes in a tablet, solution, and elixir form. The main concerns are the potential for abuse, the CNS depressing effects, and not exceeding >4000 mg/day of acetaminophen (APAP). Constipation is a very common concern due to the opioid component so recommending a stool softener is highly...2020-09-2405 minDrug Cards Daily#1: levothyroxine (Synthroid, Levoxyl) | Treating Hypothyroidism and Thyrotropin-Dependent CancersThis episode of Drug Cards Daily is on the drug levothyroxine. Levothyroxine has many brand names such as Synthroid, and Tirosint (to name a few) and is used as first-line in hypothyroidism. It is also used in the treatment of thyrotropin-stimulating hormone (TSH) dependent thyroid cancers. The main dosage form is tablets and it comes in a wide variety of strengths commonly dosed in micrograms (mcg). Dosing is individualized with a general standard of either approximately 1-1.6 mcg/kg/day or 50 mcg/day. From there adjustments are made in 12-25 mcg increments every 3-6 weeks until serum TSH and...2020-09-2303 min