Body
| Drug | Preparations | Major Toxicitiesa | Special Instructions | |
|---|---|---|---|---|
| Indicating Need for Medical Attention | Indicating Need for Medical Attention if Persistent or Bothersome | |||
| Acyclovir (Zovirax) |
Oral Suspension:
|
More Frequent:
Parenteral Form Only:
|
More Frequent:
|
Requires dose adjustment in patients with renal impairment. Avoid other nephrotoxic drugs. Administer IV preparation by slow IV infusion over at least 1 hour at a final concentration not to exceed 7 mg/mL. This is to avoid renal tubular damage related to crystalluria; must be accompanied by adequate hydration. |
| Albendazole (Albenza) |
Tablets:
|
More Frequent:
|
Less frequent:
|
Should be given with food. May crush or chew tablets and give with water. Monitor CBC and LFTs prior to each cycle. |
| Amikacin | IV | More Frequent:
|
N/A | Must be infused over 30 to 60 minutes to avoid neuromuscular blockade. Requires dose adjustment in patients with impaired renal function. Should monitor renal function and hearing periodically (e.g., monthly) in children on prolonged therapy. Therapeutic drug monitoring (TDM). indicated |
| Amphotericin B Deoxycholate (Fungizone) | IV | More Frequent:
|
|
Monitor BUN, Cr, CBC, electrolytes, LFTs. Infuse over 1 to 2 hours; in patients with azotemia, hyperkalemia, or getting doses >1 mg/kg, infuse over 3 to 6 hours. Requires dose reduction in patients with impaired renal function. Avoid other nephrotoxic drugs, when possible,because nephrotoxicity is exacerbated with concomitant use of other nephrotoxic drugs; permanent nephrotoxicity is related to cumulative dose. Nephrotoxicity may be ameliorated by hydration with 0.9% saline IV over 30 minutes prior to the amphotericin B infusion. Infusion-related reactions less frequent in children than adults; the onset is usually 1 to 3 hours after infusion, duration <1 hour; frequency decreases over time. Pre-treatment with acetaminophen and/or diphenhydramine may alleviate febrile reactions. |
| Amphotericin B Lipid Complex (Abelcet) |
IV | More Frequent:
|
|
Monitor BUN, Cr, CBC, electrolytes, and LFTs. Infuse diluted solution at rate of 2.5 mg/kg/hour. In-line filters should not be used. Use with caution with other drugs that are bone marrow suppressants or that are nephrotoxic; renal toxicity is dose-dependent, but less renal toxicity than seen with conventional amphotericin B. Consider dose reduction in patients with impaired renal function. |
| Amphotericin B Liposome (AmBisome) |
IV | More Frequent:
|
|
Monitor BUN, Cr, CBC, electrolytes, and LFTs. Infuse over 2 hours. Consider dose reduction in patients with impaired renal function. |
| Artesunate | IV:
|
Rare:
|
|
Monitor CBC, LFTs, and electrolytes. ~40% less mortality than with quinidine use in severe malaria 50% lower incidence of hypoglycemia than quinidine |
| Atovaquone (Mepron) |
Oral Suspension:
|
Frequent:
|
Frequent:
|
Should be administered with a meal to enhance absorption; bioavailability increases 3-fold when administered with high-fat meal. |
| Atovaquone/ Proguanil (Malarone) |
Tablets:
|
Less frequent:
|
N/A | Pediatric tablets are available to make dosing easier. Side effects requiring discontinuation in ~1%–2% of patients Not recommended for prophylaxis in patients with CrCl <30 mL/min. |
| Azithromycin (Zithromax) |
Oral Suspension:
|
More Frequent:
|
|
Administer 1 hour before or 2 hours after a meal; do not administer with aluminum- and magnesium-containing antacids. IV should be infused at concentration of 1 mg/mL over a 3-hour period, or 2 mg/mL over a 1-hour period; should not be administered as a bolus. Use with caution in patients with hepatic function impairment; biliary excretion is the main route of elimination. Potential drug interactions. |
| Capreomycin (Capastat) |
IM | More Frequent:
|
N/A | Requires dose adjustment in patients with impaired renal function. Administer only by deep IM injection into large muscle mass (superficial injections may result in sterile abscess). Should monitor renal function and hearing periodically (e.g., monthly) in children on prolonged therapy. Monitor LFTs and electrolytes. |
| Caspofungin (Cancidas) |
IV | More Frequent:
|
|
Requires dose adjustment in moderate-to-severe hepatic insufficiency. IV infusion over 1 hour in normal saline (do not use diluents containing dextrose) |
| Chloroquine Phosphate (Aralen) |
Tablets:
|
More Frequent:
|
|
Store in child-proof containers and protect from light. Can be toxic in overdose. Bitter tasting, so consider administering with foods that can mask the taste. Solution available worldwide, but not in United States. Caution in patients with G6PD deficiency or seizure disorder. Monitor CBC; periodic neurologic and ophthalmologic exams in patients on prolonged therapy. |
| Cidofovir (Vistide) |
IV | More Frequent:
|
|
Infuse over 1 hour. Should not be used in patients with severe renal impairment. Nephrotoxicity risk is decreased with pre-hydration with IV normal saline and probenecid with each infusion. Probenecid is administered prior to each dose and repeated for two additional doses after infusion. Additional hydration after infusion is recommended if tolerated. Concurrent use of other nephrotoxic drugs should be avoided. Monitor renal function, urinalysis, electrolytes, and CBC and perform ophthalmologic exams. |
| Ciprofloxacin (Cipro) |
Oral Suspension:
Cipro XR:
|
Less Frequent:
|
More Frequent:
|
Administer oral formulations at least 2 hours before, or 6 hours after, sucralfate or antacids or other products containing calcium, zinc, or iron (including daily products or calcium-fortified juices). Take with full glass of water to avoid crystalluria. Possible phototoxicity reactions with sun exposure. IV infusions should be over 1 hour. Do not split, crush, or chew extended-release tablets. |
| Clarithromycin (Biaxin) |
Oral Suspension:
|
Rare:
|
More Frequent:
|
Requires dose adjustment in patients with impaired renal function. Can be administered without regard to meals. Reconstituted suspension should not be refrigerated. Potential drug interactions |
| Clindamycin (Cleocin) |
Oral Solution:
|
More Frequent:
|
More Frequent:
|
IV preparation contains benzyl alcohol, not recommended for use in neonates. IV preparation must be diluted prior to administration. Capsule formulation should be taken with food or a full glass of water to avoid esophageal irritation. Reconstituted oral solution should not be refrigerated. |
| Cycloserine (Seromycin) |
Capsules:
|
More Frequent:
|
|
Take with food to minimize gastric irritation. Neurotoxicity is related to excessive serum concentrations; serum concentrations should be maintained at 25–30 mcg/mL. Requires dose adjustment in patients with impaired renal function. Do not administer to patients with severe renal impairment (because of increased risk of neurotoxicity). Should monitor serum levels, if possible. Should administer pyridoxine at the same time. Monitor renal function, LFTs, and CBC. |
| Dapsone | Syrup (available under Compassionate Use IND):
|
More Frequent:
|
|
Protect from light; dispense syrup in amber glass bottles. Monitor CBC and LFTs. |
| Doxycycline (Vibramycin) |
Tablets and Capsules:
|
More Frequent:
|
|
Swallow with adequate amounts of fluids Avoid antacids, milk, dairy products, and iron for 1 hour before or 2 hours after administration of doxycycline. Use with caution in hepatic and renal disease. IV doses should be infused over 1 to 4 hours. Patient should avoid prolonged exposure to direct sunlight (skin sensitivity). Generally not recommended for use in children aged <8 years because of risk of tooth enamel hypoplasia and discoloration, unless benefit outweighs risk. Monitor renal function, CBC, and LFTs if prolonged therapy. |
| Erythromycin | Erythromycin-Base Tablet:
Suspension:
Suspension:
Tablet:
|
Less Frequent:
|
|
Use with caution in liver disease. Oral therapy should replace IV therapy as soon as possible. Give oral doses after meals. Parenteral administration should consist of a continuous drip or slow infusion over 1 hour or longer. Adjust dose in renal failure. Erythromycin should be used with caution in neonates; hypertrophic pyloric stenosis and life-threatening episodes of ventricular tachycardia associated with prolonged QTc interval have been reported. High potential for interaction with many ARVs and other drugs. |
| Ethambutol (Myambutol) |
Tablets:
|
Less Frequent:
|
|
Requires dose adjustment in patients with impaired renal function. Take with food to minimize gastric irritation. Monitor visual acuity and red-green color discrimination regularly. Monitor renal function, LFTs, and CBC. Avoid concomitant use of drugs with neurotoxicity. |
| Ethionamide (Trecator-SC) |
Tablets:
|
Less Frequent:
|
More Frequent:
|
Avoid use of other neurotoxic drugs that could increase potential for peripheral neuropathy and optic neuritis. Administration of pyridoxine may alleviate peripheral neuritis. Take with food to minimize gastric irritation. Monitor LFTs, glucose, and thyroid function. Perform periodic ophthalmologic exams. |
| Fluconazole (Diflucan) |
Oral Suspension:
|
Less Frequent:
|
More Frequent:
|
Can be given orally without regard to meals. Shake suspension well before dosing. Requires dose adjustment in patients with impaired renal function. IV administration should be administered over 1–2 hours at a rate ≤200 mg/hour. Daily dose is the same for oral and IV administration. Multiple potential drug interactions Monitor periodic LFTs, renal function, and CBC. |
| Flucytosine (Ancobon) |
Capsules:
|
More Frequent:
|
|
Monitor serum concentrations and adjust dose to maintain therapeutic levels and minimize risk of bone marrow suppression. Requires dose adjustment in patients with impaired renal function; use with extreme caution. Fatal aplastic anemia and agranulocytosis have been rarely reported. Oral preparations should be administered with food over a 15-minute period to minimize GI side effects Monitor CBC, LFTs, renal function, and electrolytes. |
| Foscarnet (Foscavir) |
IV | More Frequent:
|
Frequent:
|
Requires dose adjustment in patients with impaired renal function. Use adequate hydration to decrease nephrotoxicity. Avoid concomitant use of other drugs with nephrotoxicity. Monitor serum electrolytes, renal function, and CBC. Consider monitoring serum concentrations (TDM) IV solution of 24 mg/mL can be administered via central line but must be diluted to a final concentration not to exceed 12 mg/mL if given via peripheral line. Must be administered at a constant rate by infusion pump over ≥2 hours (or no faster than 1 mg/kg/minute). |
| Ganciclovir (Cytovene) |
Capsules:
|
More Frequent:
|
|
Requires dose adjustment in patients with renal impairment. Avoid other nephrotoxic drugs. IV infusion over at least 1 hour. In-line filter required. Maintain good hydration. Undiluted IV solution is alkaline (pH 11); use caution in handling and preparing solutions and avoid contact with skin and mucus membranes. Administer oral doses with food to increase absorption. Do not open or crush capsules. Monitor CBC, LFTs, renal function; conduct ophthalmologic examinations. |
| Interferon-alfa-2B (IFN-α-2B; Intron) |
Parenteral (SQ or IV use) | More Frequent:
|
More Frequent:
|
Severe adverse effects less common in children than adults. Toxicity dose-related, with significant reduction over the first 4 months of therapy. For non-life-threatening reactions, reduce dose or temporarily discontinue drug and restart at low doses with stepwise increases. If patients have visual complaints, an ophthalmologic exam should be performed to detect possible retinal hemorrhage or retinal artery or vein obstruction. Should not be used in children with decompensated hepatic disease, significant cytopenia, autoimmune disease, or significant pre-existing renal or cardiac disease. If symptoms of hepatic decompensation occur (ascites, coagulopathy, jaundice), IFN-α-2B should be discontinued. Reconstituted solution stable for 24 hours when refrigerated. Monitor CBC, renal function, LFTs, thyroid function, and glucose. |
| Isoniazid (Nydrazid) |
Oral Syrup:
|
More Frequent:
|
|
Take with food to minimize gastric irritation. Take ≥1 hour before aluminum-containing antacids. Hepatitis less common in children. Use with caution in patients with hepatic function impairment, severe renal failure, or history of seizures. Pyridoxine supplementation should be provided for all HIV-infected children. Monitor LFTs and periodic ophthalmologic examinations. |
| Itraconazole (Sporanox) |
Oral Solution:
|
Less frequent:
|
More Frequent:
|
Oral Solution:
IV infusion over 1 hour. Multiple potential drug interactions Monitor LFTs and potassium levels. Monitor serum concentrations (TDM) in severe infections. |
| Kanamycin | IV IM |
More Frequent:
|
N/A | Must be infused over 30 to 60 minutes to avoid neuromuscular blockade. Requires dose adjustment in patients with impaired renal function. Should monitor renal function and hearing periodically (e.g., monthly) in children on prolonged therapy. Monitor serum concentrations (TDM). Monitor renal function; conduct, hearing exams for patients receiving prolonged therapy. |
| Ketoconazole (Nizoral) |
Tablets:
|
Less Frequent:
|
Frequent:
|
Adverse GI effects occur less often when administered with food. Drugs that decrease gastric acidity or sucralfate should be administered ≥2 hours after ketoconazole. Disulfiram-like reactions have occurred in patients ingesting alcohol. Hepatotoxicity is an idiosyncratic reaction, usually reversible when stopping the drug, but rare fatalities can occur any time during therapy; more common in females and adults >40 years, but cases reported in children. High-dose ketoconazole suppresses corticosteroid secretion, lowers serum testosterone concentration (reversible). Multiple potential drug interactions. Monitor LFTs. |
| Mefloquine (Lariam) |
Tablets:
|
More Frequent:
|
|
Side effects less prominent in children. Administer with food and plenty of water. Tablets can be crushed and added to food; bitter tasting so administer with foods that can mask the taste Monitor LFTs. |
| Nitazoxanide (Alinia) |
Oral Suspension:
|
N/A | More Frequent:
|
Should be given with food. Shake suspension well prior to dosing. |
| P-Aminosalicyclic Acid (Paser) |
Delayed Release Granules:
|
Rare:
|
|
Should not be administered to patients with severe renal disease. Drug should be discontinued at first sign of hypersensitivity reaction (rash, fever, and GI symptoms typically precede jaundice). Vitamin B12 therapy should be considered in patients receiving for >1 month. Administer granules by sprinkling on acidic foods such as applesauce or yogurt or a fruit drink like tomato or orange juice. Maintain urine at neutral or alkaline pH to avoid crystalluria. The granule soft “skeleton” may be seen in the stool. Monitor CBC and LFTs. |
| Pegylated Interferon Alfa-2A (Pegasys) |
Injection:
|
More Frequent:
|
More Frequent:
|
Toxicity dose-related. Dose modifications based on type and degree of toxicity. For non-life threatening reactions, reduce dose or temporarily discontinue drug and restart at low doses with stepwise increases. If patients have visual complaints, an ophthalmologic exam should be performed to detect possible retinal hemorrhage or retinal artery or vein obstruction. Should not be used in children with decompensated hepatic disease, significant cytopenia, autoimmune disease, or significant pre-existing renal or cardiac disease. If symptoms of hepatic decompensation occur (ascites, coagulopathy, jaundice), Peg- IFN-α-2A should be discontinued. Monitor CBC, renal function, LFTs, thyroid function, and glucose. Store vials and syringes in refrigerator. Protect from light. Administer SQ in abdomen or thigh. Rotate injection sites. |
| Pegylated Interferon Alfa-2B (Pegintron) |
Injection:
|
More Frequent:
|
More Frequent:
|
Toxicity dose-related. Dose modifications should be based on type and degree of toxicity. For non-life-threatening reactions, reduce dose or temporarily discontinue drug and restart at low doses with stepwise increases. If patients have visual complaints, ophthalmologic exam should be performed to detect possible retinal hemorrhage or retinal artery or vein obstruction. Should not be used in children with decompensated hepatic disease, significant cytopenia, autoimmune disease, or significant pre-existing renal or cardiac disease. If symptoms of hepatic decompensation occur (ascites, coagulopathy, jaundice), Peg-IFN-α-2B should be discontinued. Monitor CBC, renal function, LFTs, thyroid function, glucose. Store vials and syringes in refrigerator. Protect from light. Administer SQ in abdomen or thigh. Rotate injection sites. |
| Pentamidine (Pentam) |
IV Aerosol |
IV More Frequent:
More Frequent:
|
IV More Frequent:
More Frequent:
|
Rapid infusion may result in precipitous hypotension; IV infusion should be administered over ≥1 hour (preferably 2 hours). Cytolytic effect on pancreatic beta islet cells, leading to insulin release, can result in prolonged severe hypoglycemia (usually occurs after 5–7 days of therapy, but can also occur after the drug is discontinued); risk increased with higher dose, longer duration of therapy, and re-treatment within 3 months of prior treatment. Hyperglycemia and diabetes mellitus can occur up to several months after drug discontinued. Monitor LFTs, renal function, glucose, electrolytes, BP. Inhalation:
|
| Posaconazole (Noxafil) |
Oral Solution:
|
Less Frequent:
|
|
Must be given with meals. Adequate absorption is dependent on food for efficacy. Monitor LFTs, renal function and electrolytes. Monitor serum drug concentrations (TDM). Shake suspension prior to dosing. |
| Primaquine | Tablets:
|
More Frequent:
|
|
Take with meals or antacids to minimize gastric irritation. Store in a light-resistant container. Bitter taste. Monitor CBC. |
| Pyrazinamide | Tablets:
|
More Frequent:
|
|
Avoid in patients with severe hepatic impairment. Reduce dose in patients with renal or hepatic impairment. Monitor LFTs and uric acid. |
| Pyrimethamine (Daraprim) |
Tablet:
|
Less Frequent:
|
|
To prevent hematologic toxicity, administer with leucovorin. Monitor CBC. |
| Quinidine | IV | Serious:
|
Very Frequent:
|
EKG monitoring is standard of care. Do not give by bolus infusion. If EKG changes observed, slow infusion rate. Monitor CBC and LFTs. |
| Ribavirin Virazole Powder for solution for nebulization Rebetol Oral capsules and oral solution Copegus, Ribasphere, Ribapak Oral tablets and capsules |
Powder for Solution for Nebulization:
|
|
|
Should not be used in patients with severe renal impairment. Should not be used as monotherapy for treatment of hepatitis C, but used in combination with IFN-α. Intracellular phosphorylation of pyrimidine nucleoside analogues (zidovudine, stavudine, zalcitabine) decreased by ribavirin, may have antagonism; use with caution. Enhances phosphorylation of didanosine; use with caution because of increased risk of pancreatitis/mitochondrial toxicity. Oral solution contains propylene glycol. Teratogenic/embryocidal. Contraindicated in pregnant women and their male partners. Avoid pregnancy for additional 6 months after treatment. Monitor CBC, renal function, LFTs, and thyroid function. Perform pregnancy tests regularly while on therapy. |
| Rifabutin (Mycobutin) |
Capsules:
|
More Frequent:
|
|
Preferably take on empty stomach, but may be administered with food in patients with GI intolerance. The contents of capsules may be mixed with applesauce if patient is unable to swallow capsule. May cause reddish to brown-orange color urine, feces, saliva, sweat, skin, or tears (can discolor soft contact lenses). Uveitis seen with high-dose rifabutin (i.e., adults >300 mg/day), especially when combined with clarithromycin. Multiple potential drug interactions Use with caution in patients with renal or hepatic impairment. Monitor CBC, LFTs; conduct ophthalmologic examinations. Reduce dose in patients with renal impairment. |
| Rifampin (Rifadin) |
Oral Suspension:
|
Less Frequent:
|
|
Preferably take on empty stomach, but can be administered with food in patients with GI intolerance; take with full glass of water. Suspension formulation stable for 30 days. Shake well prior to dosing. May cause reddish to brown-orange color urine, feces, saliva, sweat, skin, or tears (can discolor soft contact lenses). Multiple potential drug interactions Use with caution in patients with hepatic impairment. Administer IV by slow infusion. Extravasation may cause local irritation and inflammation. Monitor CBC and LFTs. |
| Streptomycin | IM | More Frequent:
|
|
Usual route of administration is deep IM injection into large muscle mass. For patients who cannot tolerate IM injections, dilute to 12–15 mg in 100 mL of 0.9% sodium chloride; must be infused over 30 to 60 minutes to avoid neuromuscular blockade. Requires dose adjustment in patients with impaired renal function. Monitor renal function and hearing periodically (e.g., monthly) in children on prolonged therapy. Monitor serum concentrations (TDM). |
| Sulfadiazine | Tablet:
|
Rare:
|
|
Ensure adequate fluid intake to avoid crystalluria. Monitor CBC, renal function, and urinalysis. Monitor serum concentrations (TDM) if serious infection. |
| Trimethoprim- Sulfamethoxazole (TMP-SMX) (Bactrim, Septra) |
Oral Suspension:
Single Strength:
|
More Frequent:
|
|
Requires dose adjustment in patients with impaired renal function. Maintain adequate fluid intake to prevent crystalluria and stone formation (take with full glass of water). Potential for photosensitivity skin reaction with sun exposure. IV infusion over 60 to 90 minutes Monitor CBC, renal function. |
| Valacyclovir (Valtrex) |
Tablets:
|
Rare:
|
More Frequent:
|
Thrombotic thrombocytopenia purpura/hemolytic uremic syndrome has been reported in HIV-infected adults with advanced disease receiving high (i.e., 8 g/day) but not low doses. Monitor CBC and renal function. |
| Valganciclovir (Valcyte) |
Tablets:
|
More Frequent:
|
|
Requires dose adjustment in patients with renal impairment. Avoid other nephrotoxic drugs. Tablets should not be broken or crushed. Monitor CBC and renal function. Potentially teratogenic and carcinogenic. |
| Voriconazole (VFEND) |
Tablet:
|
Less Frequent:
|
More Frequent:
|
Oral tablets should be taken 1 hour before or after a meal. Shake oral suspension well prior to dosing. Maximum IV infusion rate 3 mg/kg/hour over 1 to 2 hours. Oral administration to patients with impaired renal function if possible (accumulation of IV vehicle occurs in patients with renal insufficiency) Dose adjustment needed if hepatic insufficiency. Visual disturbances common (>30%) but transient and reversible when drug is discontinued. Multiple potential drug interactions Monitor renal function, electrolytes, and LFTs Consider monitoring serum concentrations (TDM). |
| a The toxicities listed in the table have been selected based on their potential clinical significance and are not inclusive of all side effects reported for a particular drug. Key to Acronyms: ARV = antiretroviral; BP = blood pressure; BUN = blood urea nitrogen; CBC = complete blood count; CDC = Centers for Disease Control and Prevention; CNS = central nervous system; Cr = creatinine; CrCl = creatinine clearance; EKG = electrocardiogram; G6PD = Glucose-6-phosphate dehydrogenase; GI = gastrointestinal; IFN-α = interferon alfa; IM = intramuscular; IND = investigational new drug; IV = intravenous; LFT = liver function test; SJS = Stevens-Johnson Syndrome; SMX = sulfamethoxazole; SQ = subcutaneous; TDM = therapeutic drug monitoring; TMP = trimethoprim |
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