increase toxicity of lithium and methotrexate.
Increased
NSAIDs, ANALGESICS, MUSCLE
RELAXANTS
CELECOXIB (NSAIDs) (Celcoxx, Celebrex, Cofidec)
Adult : PO Osteoarthritis 200 mg/day in 1 or 2 divided doses.
May increase to 200 mg bid. Rheumatoid arthritis 100-200
mg bid. Ankylosing spondylitis Initial: 200 mg/day in 1 or 2
divided doses. May increase to 400 mg/day after 6 wk.
Dysmenorrhoea; Pain relief Initial: 400 mg followed by 200
mg on the 1st day. Maintenance: 200 mg bid.
Osteoarthritis Adult: 200 mg/day as a single dose or in 2
divided doses. May increase to 200 mg bid if necessary.
Dysmenorrhoea, Pain relief Adult: Initially, 400 mg followed
by 200 mg if necessary on the 1st day. Maintenance: 200 mg
bid.
Rheumatoid arthritis Adult: 100-200 mg bid.
Juvenile idiopathic arthritis Child: ≥2 yr ≥10 kg to ≤25 kg: 50
mg bid; >25 kg: 100 mg bid.
Ankylosing spondylitis Adult: Initially, 200 mg/day as a single
dose or in 2 divided doses. May increase to 400 mg/day after
6 wk.
Administration: may be taken with or without food.Px
counsel: This drug may cause dizziness, if affected do not
drive or operate machinery.
MOA: Celecoxib is a selective cyclooxygenase-2 (COX-2)
inhibitor primarily responsible to reduce mediators of pain
and inflammation. Its action is due to inhibition of
prostaglandin synthesis via inhibition of COX-2.
Pharmacokinetics:
Absorption: Absorbed from the GI tract. May delay
absorption with high fat meal. Time to peak plasma
concentration: Approx 3 hr.
MEFENAMIC ACID (NSAIDs) (Ponstan, Gardan,
Dolfenal, Revalan)
Adult : PO 500 mg tid.
Mild to moderate pain, Rheumatoid arthritis, Dental pain,
Postoperative pain, Dysmenorrhoea, Osteoarthritis,
Menorrhagia
Adult: 500 mg tid.
Child: >6 mth 25 mg/kg daily in divided doses for up to 7
days.
Should be taken with food.
Special Precaution: Patient w/ known CV disease or risk
factors for CV disease, history of GI bleeding or peptic
ulceration, fluid retention or heart failure. Renal and hepatic
impairment. Pregnancy and lactation.
Description: Mefenamic acid, an anthranilic acid derivative, is
a prototypical NSAID. It reversibly inhibits the
cyclooxygenase-1 and -2 (COX-1 and -2) enzymes, thus
resulting in reduced synthesis of prostaglandin precursors. It
has analgesic and antipyretic properties w/ minor anti-
inflammatory activity.
Duration: ≤6 hr.
IBUPROFEN (NSAIDs) (Advil, Dolan FP, Medicol)
Adult : PO Rheumatoid arthritis; Osteoarthritis 400-800 mg
3-4 times/day. Max: 3.2 g/day. Mild to moderate pain;
Dysmenorrhoea; Fever 200-400 mg 4-6 hrly. Max: 2.4 g/day.
IV Pain relief 400-800 mg 6 hrly, as needed. Max: 3.2 g/day.
Fever Initially, 400 mg followed by 400 mg 4-6 hrly, or 100-
200 mg 4 hrly. Max: 3.2 g/day. Topical/Cutaneous Pain and
inflammation associated w/ musculoskeletal and joint
disorders As 5% cream, foam, gel, spray soln or 10% gel:
Apply as directed.
Special Precautions: Bleeding disorders, CV disease. Infants
w/ increased total bilirubin. Premature neonates w/ existing
or at risk of infection. Hepatic and renal impairment. Elderly
(avoid chronic use).
Drug Interactions: Increased risk of GI bleeding w/ warfarin,
corticosteroids, SSRIs and aspirin. May reduce the natriuretic
effects of diuretics. Reduced antihypertensive effect of ACE
inhibitors and angiotensin II receptor antagonists. May
1
nephrotoxicity w/ ciclosporin and tacrolimus.
MOA: Ibuprofen inhibits synthesis of prostaglandins in body
tissues by inhibiting cyclooxygenase-1 and 2. It has anti-
inflammatory, analgesic and antipyretic properties.
Onset: Analgesic: 30-60 min. Anti-inflammatory: ≤7 days
(oral).
MELOXICAM (NSAIDs) (Mobic)
Acute exacerbations of osteoarthritis
Adult: 7.5 mg daily up to max 15 mg daily as a single dose.
Rheumatoid arthritis, Ankylosing spondylitis
Adult: 15 mg daily as a single dose. Patients w/ increased risk
of adverse effects: Initially 7.5 mg daily.
Elderly: 7.5 mg daily for long-term treatment.
Juvenile rheumatoid arthritis
Child: ≥2 yr 0.125 mg/kg once daily. Max: 7.5 mg daily.
Administration: May be taken with or without food. May be
taken w/ meals if GI discomfort occurs.
Drug Interactions: Increased risk of severe GI effects w/
aspirin or warfarin. May antagonise antihypertensive effects
of ACE inhibitors and angiotensin II receptor antagonists. May
reduce natriuretic effects of furosemide and thiazides.
Enhanced toxicity of methotrexate. May increase plasma
lithium concentration.
MOA: Meloxicam is an oxicam derivative which exhibits
analgesic, antipyretic and anti-inflammatory actions. It
reversibly inhibits the cyclooxygenase-1 and -2 (COX-1 and -2)
enzymes, thus resulting in reduced synthesis of prostaglandin
precursors.
ETORICOXIB (NSAIDs) (Arcoxia)
Ankylosing spondylitis, Rheumatoid arthritis
Adult: 90 mg once daily.
Child: <16 yr Contraindicated.
Osteoarthritis
Adult: 30 mg once daily, increased to 60 mg once
daily if needed.
Child: <16 yr Contraindicated.
Acute gout
Adult: 120 mg once daily. Max duration: 8 days.
Child: <16 yr Contraindicated.
Administration: May be taken with or without
food.
ADR: Potentially Fatal: Stevens-Johnson syndrome,
exfoliative dermatitis and toxic epidermal necrolysis; upper GI
ulceration, perforation and bleeding.
Drug Interaction: May increase INR w/ oral anticoagulants.
May decrease effects of ACE inhibitors, angiotensin II
antagonist and diuretics. May increase lithium plasma
concentrations. May reduce plasma levels w/ rifampicin.
Increased serum concentrations of ethinylestradiol.
MOA: Etoricoxib is a selective cyclooxygenase-2 (COX-2)
inhibitor primarily responsible to reduce mediators of pain
and inflammation. Its action is due to inhibition of
prostaglandin synthesis via inhibition of COX-2.
EPERISONE (Muscle Relaxant) (Myonal, Perispa)
Muscle spasms
Adult: 50 mg tid.
Administration: Should be taken with food. Take after meals.
Drug Interaction: Avoid concomitant use with tolperisone HCl
and methocarbamol.
MOA: Eperisone is centrally-acting skeletal muscle relaxant
used to improve myotonic symptoms.
NAPROXEN (NSAIDs) (Flanax, Skelan)
Dysmenorrhoea, Acute musculoskeletal disorders
Adult: Initially, 500 mg followed by 250 mg 6-8 hrly. Max:
1,250 mg on the 1st day and 1,000 mg thereafter.
Elderly: Dose reduction may be needed.
Rheumatic disorders
Adult: 0.5-1 g daily as a single or in 2 divided doses.
Elderly: Dose reduction may be needed.
Juvenile idiopathic arthritis
Child: >5 yr 10 mg/kg/day in 2 divided doses 12 hrly.
Acute gout
Adult: Initially, 750 mg followed by 250 mg 8 hrly.
Elderly: Dose reduction may be needed.
Renal Impairment: Severe: Contraindicated.
Administration: Should be taken with food.
Drug Interaction: May enhance methotrexate toxicity.
Reduced BP response to ACE inhibitors or angiotensin II
receptor antagonists. Increased risk of serious GI events (e.g.
ulcer) w/ aspirin. Increased risk of GI bleeding w/ warfarin.
May reduce the natriuretic effects of furosemide or thiazide
diuretics. May increase serum lithium concentrations and
reduce renal lithium clearance. Delayed absorption w/
antacids, colestyramine or sucralfate. May interfere w/ the
antihypertensive effects of β-blockers (e.g. propranolol). May
increase serum levels w/ probenecid.
Food Interaction: Rate of absorption may be reduced w/
food.
MOA: Naproxen, a propionic acid derivative, is a prototypical
NSAID. It reversibly inhibits the cyclooxygenase-1 and -2
(COX-1 and -2) enzymes, thus resulting in reduced synthesis
of prostaglandin precursors. It can inhibit platelet
aggregation, has anti-inflammatory, analgesic and antipyretic
actions.
Onset: Analgesic: 30-60 min.
Duration: Analgesic: <12 hr.
KETOPROFEN (NSAIDs)
Adult: PO Rheumatic disorders 100-200 mg/day in 2-4
divided doses. Max: 300 mg/day in divided doses. Pain and
inflammation 25-50 mg 6-8 hrly. Max: 300 mg/day. IM Pain
and inflammation associated w/ musculoskeletal and joint
disorders; Pain following orthopaedic surgery 50-100 mg by
deep inj into the gluteal muscle 4 hrly. Max: 200 mg/24 hr for
up to 3 days. Rectal Rheumatic disorders 100 mg at night.
Recommended total dose (combined oral and rectal): Not to
exceed 200 mg/day. Topical Local pain relief As 2.5% gel:
Apply 2-4 times/day for up to 10 days. As 30 mg plaster:
Apply 1 plaster bid.
Administration: Should be taken with food. Preferably taken
w/ or after meals.
Drug Interaction: Increases plasma concentrations of lithium
and methotrexate. Reduces effects of antihypertensives (e.g.
ACE inhibitors, angiotensin II receptor antagonists). Increased
risk of GI bleeding w/ warfarin. Decreased protein binding of
ketoprofen and increased risk for serious GI events w/ aspirin
and other NSAIDs. Increased risk of developing renal failure
w/ diuretics. Increased risk of GI bleeding and ulceration w/
corticosteroids. Increased plasma levels w/ probenecid.
Salicylate reduces conjugation and renal elimination of
ketoprofen.
Food Administration: Avoid alcohol due to increased GI
irritation.
MOA: Ketoprofen exhibits anti-inflammatory, analgesic and
antipyretic properties. It potently inhibits the enzyme
cyclooxygenase resulting in prostaglandin synthesis
inhibition.
DEXKETOPROFEN (NSAIDs) (Ketesse)
Mild to moderate pain
Adult: 12.5 mg every 4-6 hr or 25 mg every 8 hr. Max: 75
mg/day.
Elderly: Initial total daily dose should not exceed 50 mg/day.
May increase to the doses recommended for general
population only if well tolerated.
2
Drug Interaction: Concomitant use of salicylates, other
NSAIDs, anticoagulant (e.g. warfarin, heparin) or
corticosteroids may increase risk of bleeding and combination
use is not recommended. Caution if used with thrombolytics,
anti-platelets, selective serotonin reuptake inhibitors,
pentoxyfylline due to elevated bleeding risk. May increase
toxic effects of hydantoines and sulphonamides. May reduce
effects of antihypertensives. Increased risk of red cell line
toxicity with zidovudine, monitor complete blood count and
reticulocyte count. Renal function may be worsened when
used with ciclosporin or tacrolimus. May increase
hypoglycaemic effect of sulfonylureas. Probenacid may
increase plasma concentration of Dexketoprofen.
Potentially Fatal: NSAIDS may increase blood lithium levels;
and increase haematological toxicity of methotrexate.
Food Interaction: Reduced absorption rate when
administered with food.
MOA: Dexketoprofen is an isomer of ketoprofen. It is a
propionic acid derivative with analgesic, anti-inflammatory
and antipyretic properties. It is a non-steroidal anti-
inflammatory drug (NSAID) that reduces prostaglandin
synthesis via inhibition of cyclooxygenase pathway (both
COX-1 and COX-2) activity.
Onset: About 30 min.
Duration: About 4-6 hr.
PARACETAMOL (Analgesics (Non-Opioid) &
Antipyretics)
Adult : PO 0.5-1 g 4-6 hrly. Max: 4 g/day. Rectal As supp: 0.5-
1 g 4-6 hrly. Max: 4 g/day. IV 33-50 kg: 15 mg/kg as a single
dose, at least 4 hrly. Max: 60 mg/kg/day up to 3 g/day; >50
kg: 1 g as a single dose, at least 4 hrly. Max: 4 g/day. Admin
by infusion over 15 min.
Administration: May be taken with or without food.
Food Interaction: Alcohol may increase risk of hepatotoxicity.
MOA: Paracetamol exhibits analgesic action by peripheral
blockage of pain impulse generation. It produces antipyresis
by inhibiting the hypothalamic heat-regulating centre. Its
weak anti-inflammatory activity is related to inhibition of
prostaglandin synthesis in the CNS.
Synonym: acetaminophen.
Onset: Oral: <1 hr. IV: 5-10 min (analgesia); w/in 30 min
(antipyretic).
Duration: 4-6 hr (analgesia). IV: ≥6 hr (antipyretic).
PARACETAMOL + ORPHENADRINE (Analgesics
(Non-Opioid) & Antipyretics / Analgesics (Opioid)
(Norgesic)
Pain and muscular spasms in musculoskeletal disorders
Adult: Each tablet containing paracetamol 450 mg and
orphenadrine citrate 35 mg: 2 tablets tid.
Srug Interaction: Increased paracetamol absorption with
metoclopramide and domperidone. Decreased paracetamol
absorption with cholestyramine. May increase risk of
bleeding with warfarin and coumarins. Increased
anticholinergic side effects with other anticholinergic drugs.
Additive CNS effects with propoxyphene. Increased
bupropion levels with concurrent use. May antagonise
actions of centrally acting anticholinesterases e.g. donepezil,
galantamine, rivastigmine, tacrine. May decrease levodopa
absorption with concurrent use.
Potentially Fatal: Increased risk of liver damage with alcohol.
MOA: Paracetamol, a para-aminophenol derivative, is a
peripherally acting analgesic with antipyretic and weak anti-
inflammatory activity. Orphenadrine, an analog of
diphenhydramine, is a skeletal muscle relaxant and is
postulated to act on cerebral motor center or on the medulla
through an atropine-like central action. It has anticholinergic,
local anaesthetic effects and some antihistaminic effects.
Orphenadrine is used either as the hydrochloride or the
citrate and doses are expressed in terms of the relevant salt.
PARACETAMOL + TRAMADOL (Analgesics (Non-
Opioid) & Antipyretics / Analgesics - Opioid)
(Algesia, Dolcet, TDL Plus)
Moderate to severe pain
Adult: Each tab contains tramadol HCl 37.5 mg and
paracetamol 325 mg: 2 tab 6 hrly. Max: 8 tab/day. Max
duration: 5 days.
Administration: May be taken with or without food. Swallow
whole, do not divide/chew/crush.
Drug Interaction: Increased risk of seizures and serotonin
syndrome w/ SSRIs, SNRIs, TCAs, and 5-HT agonists (e.g.
sumatriptan). Increased CNS depression w/ barbiturates,
benzodiazepines, other anxiolytics, hypnotics, sedative
antidepressants, sedative antihistamines, neuroleptics,
centrally-acting antihypertensive drugs, thalidomide and
baclofen. Decreased analgesic efficacy w/ ondansetron.
Increased INR w/ warfarin.
Potentially Fatal: May enhance serotonergic, neuroexcitatory
and/or seizure-potentiating effect of MAOIs.
Food Interaction: Increased sedative effect w/ alcohol. Food
may delay time to peak plasma levels.
MOA: Tramadol is a centrally acting opioid analgesic which
binds to mu-opioid receptors and weakly inhibits the
reuptake of norepinephrine and serotonin. Paracetamol, a
para-aminophenol derivative, has analgesic, antipyretic and
weak anti-inflammatory activity. Together, tramadol and
paracetamol has faster onset of action compared to tramadol
alone and longer duration of action compared to paracetamol
alone.
Duration: 5 hr.
TRAMADOL (Analgesics - Opioid) (Tramal,
Tramacet)
Adult : PO Moderate to severe pain 50-100 mg 4-6 hrly.
Extended-release tab: 50-100 mg 1-2 times/day. Max: 400
mg/day. IV/IM Moderate to severe pain 50-100 mg 4-6 hrly.
Post-op pain Initial: 100 mg, then 50 mg every 10-20 min if
needed, up to 250 mg for the 1st hr. Maintenance: 50-100 mg
4-6 hrly. Max: 600 mg/day.
Administration: May be taken with or without food.
Incompatibility: Diazepam, diclofenac Na, flunitrazepam,
glyceryl trinitrate, indometacin, midazolam, piroxicam,
phenylbutazone, aciclovir, clindamycin.
Drug Interaction: Increased risk of convulsions or serotonin
syndrome w/ SSRI, serotonin-norepinephrine reuptake
inhibitors (SNRI), TCA and other seizure threshold lowering
drugs (e.g. bupropion, mirtazapine, tetrahydrocannabinol).
Decreased serum concentrations w/ carbamazepine. May
potentiate the anti-depressant effect of norepinephrine, 5-HT
agonists or lithium. Increased INR and ecchymoses w/
coumarin derivatives (e.g. warfarin).
Potentially Fatal: Increased risk of seizures w/ MAOIs.
Food Interaction: Enhanced CNS depressant effect w/ alcohol.
MOA: Tramadol inhibits reuptake of norepinephrine,
serotonin and enhances serotonin release. It alters
perception and response to pain by binding to mu-opiate
receptors in the CNS.
Onset: Approx 1 hr.
Duration: 9 hr.
PIROXICAM (NSAIDs) (Feldene, Kapirox, Picaxor)
Oral
Ankylosing spondylitis, Osteoarthritis, Rheumatoid arthritis
Adult: 20 mg daily as a single dose, divided doses may be
used if necessary. Treatment should be reviewed w/in 14
days of starting.
Elderly: Use the lowest effective dose for the shortest
duration.
Topical/Cutaneous
Pain and inflammation
Adult: As 0.5% gel: Apply to the affected area 3-4 times daily.
Treatment should be reviewed after 4 wk.
Administration: Should be taken with food.
3
Drug Interaction: Increased risk of GI bleeding w/ anti-
platelets and SSRIs. May exacerbate cardiac failure, reduce
GFR and increase plasma glycoside levels. Increased risk of
nephrotoxicity w/ ciclosporin and tacrolimus. Increased
absorption w/ cimetidine. Increased risk of GI ulceration w/
corticosteroids. May interfere w/ the natriuretic action of
diuretics. May displace other highly protein-bound drugs.
May increase steady state plasma lithium levels. May
antagonise the effect of antihypertensives. May reduce the
excretion of methotrexate, leading to acute toxicity.
Increased risk of convulsions w/ quinolones. May interfere w/
mifepristone-mediated termination of pregnancy.
Potentially Fatal: May enhance the effect of anticoagulants
(e.g. warfarin). Increased risk of serious GI events w/ aspirin
and other NSAIDs.
Food Interaction: Food decreases the rate of absorption.
MOA: Piroxicam is an NSAID, belonging to the oxicam group.
It reversibly inhibits cyclooxygenase-1 and -2 (COX-1 and -2)
enzymes, which results in decreased formation of
prostaglandin precursors.
SARIDON
Paracetamol 250 mg, Propyphenazone 150 mg,
Caffeine 50 mg
(Analgesics (Non-Opioid) & Antipyretics)
Indication: Relief of pain eg mild to severe headache,
toothache, menstrual discomfort, post-op & rheumatic pain,
pain & fever associated w/ colds & flu.
Adult 1-2 tab. Adolescent 12-16 yr 1 tab. May be taken up to
3 single doses w/in 24 hr. Do not take for >1 wk or at doses
higher than recommended.
ANTIVERTIGO DRUGS
BETAHISTINE (Serc, Betavert, Exigo, Ergo, Verist)
Indication: Meniere's disease.
Adult : PO As betahistine HCl: Initial: 8-16 mg tid.
Maintenance: 24-48 mg/day. As betahistine mesilate: 6-12
mg tid.
Administration: Should be taken with food.
Contraindication: Pheochromocytoma
Drug Interaction: Diminished therapeutic effect w/
antihistamines. May decrease bronchodilator effects of β2
agonists. Increased serum concentrations w/ MAOIs
Food Interaction: Food intake slows down absorption of
betahistine.
MOA: Betahistine acts as both partial histamine H1-receptor
agonist and histamine H3-receptor antagonist in neuronal
tissue. It improves the microcirculation in the labyrinth, thus
reducing endolymphatic pressure.
CINNARIZINE (Peripheral Vasodilators & Cerebral
Activators / Antivertigo Drugs) (Cinnabloc)
Adult : PO Vertigo and vestibular disorders 30 mg tid or 75
mg 1-2 times/day. Motion sickness 30 mg 2 hr before travel
then 15 mg 8 hrly during the journey if necessary.
Cerebrovascular disorders 75 mg once daily. Peripheral
vascular disease 75 mg bid or tid.
Administration: Should be taken with food.
Drug Interaction: Increased sedative effect w/ CNS
depressants or TCAs.
Food Interaction: Increased sedative effect w/ alcohol.
Description: Cinnarizine is a non-competitive antagonist of
smooth muscle contractions caused by various vasoactive
agents (e.g. histamine). It selectively inhibits Ca influx into
depolarised cells, thereby reducing free Ca ions available for
the induction and maintenance of contraction.

ANTIEMETIC DRUGS
MECLIZINE (Bonamine)
Motion sickness 25-50 mg. Adult & childn ≥11 yr 25-50 mg.
Childn 5-10 yr 12.5 mg. All doses to be taken 1 hr before
travel for 24-hr protection. Nausea & vomiting of pregnancy
25-50 mg/day. Labyrinthine & vestibular disturbances 25-
100 mg/day. Radiation sickness 50 mg 2-12 hr prior to
radiation therapy.
Administration : May be taken with or without food.
Drug Interaction: CNS depressants including barbiturates,
alcohol, tranquilizers & sedatives. Pain relievers, cold &
allergy medication.
METOCLOPRAMIDE
Adult : PO GERD 10-15 mg 4 times/day. If symptoms are
intermittent, may give single doses of 20 mg prior to
provoking situation. Max duration: 12 wk.
Diabetic gastric stasis 10 mg 4 times/day for 2-8 wk. Nausea
and vomiting associated w/ cancer chemotherapy or
radiotherapy 10 mg, up to tid. Max duration: 5 days
Prophylaxis of post-op nausea and vomiting 10 mg as a
single dose by IM or slow IV inj over at least 3 min. IV
Prophylaxis of chemotherapy-induced nausea and vomiting
For highly emetogenic drugs/regimens: Initial: 2 mg/kg by
slow inj over at least 15 min, 30 min before chemotherapy.
Repeat 2 hrly for 2 doses, then 3 hrly for 3 doses. For less
emetogenic drugs/regimens: 1 mg/kg may be used. Max
duration: 5 days
Drug Interaction: Antagonistic effect w/ anticholinergics and
morphine derivatives. Potentiation of sedative effects w/ CNS
depressants. Additive effect w/ other neuroleptics on the
occurrence of extrapyramydal disorders. May increase the
risk of serotonin syndrome w/ serotonergic drugs (e.g. SSRIs).
May decrease digoxin bioavailability. May increase ciclosporin
bioavailability. May prolong the neuromuscular blocking
effect of mivacurium and suxamethonium. Increased
exposure levels w/ strong CYP2D6 inhibitors (e.g. fluoxetine).
May reduce plasma concentration of atovaquone.
Potentially Fatal: Mutual antagonistic effect w/ levodopa or
dopaminergic agonists.
Food Interaction: May potentiate sedative effect w/ alcohol.
MOA: Metoclopramide blocks dopamine receptors and in
higher doses, it also blocks serotonin receptors in
chemoreceptor trigger zone of the CNS. It enhances the
response to acetylcholine of tissue in upper GI tract causing
enhanced motility and accelerated gastric emptying w/o
stimulating gastric, biliary, or pancreatic secretions. It also
increases lower esophageal sphincter tone.
Onset: Oral: 30-60 min; IV: 1-3 min; IM: 10-15 min.
Duration: Therapeutic: 1-2 hr.
DOMPERIDONE
Dosage Administration: Nausea and vomiting
Adult: 10 mg tid. Max: 30 mg daily.
Child: ≤12 yr <35 kg: 250 mcg/kg up to tid. Max: 750 mcg/kg
daily; >12 yr ≥35 kg: Same as adult dose.
Gastrointestinal motility disorders
Adult: 10 mg tid. Max: 30 mg daily.
Rectal
Nausea and vomiting
Adult: 30 mg bid.
Child: ≤12 yr >15 kg: 750 mcg/kg bid; >12 yr ≥35 kg: Same as
adult dose.
Elderly: No dosage adjustment needed.
Administration: Should be taken on an empty stomach. Take
15-30 min before meals.
Drug Interaction: May antagonise the hypoprolactinaemic
effect of bromocriptine. May antagonise the prokinetic effect
w/ opioid analgesics and antimuscarinics.
Potentially Fatal: Additive effect w/ other drugs which
prolong QT interval. Potent CYP3A4 inhibitors (e.g.
ketoconazole, erythromycin or ritonavir) may increase serum
4
domperidone levels and subsequently increasing the risk of
QT prolongation.
MOA: Domperidone is a peripheral dopamine-receptor
blocker. It increases oesophageal peristalsis, enhances
gastroduodenal coordination and lower oesophageal
sphincter pressure, gastric motility, and peristalsis, thus
facilitating gastric emptying and decreasing small bowel
transit time.
LAXATIVES, PURGATIVES
BISACODYL (Dulcolax)
Bowel evacuation
Adult: Initially, 10-20 mg the night before the procedure
followed by 10 mg rectal supp the next morning.
Alternatively, 10 mg on each of the 2 nights before the
procedure.
Child: 4-10 yr 5 mg the night before the procedure and 5 mg
rectal supp the following morning; >10 yr Same as adult dose.
Constipation
Adult: 5-10 mg at night, up to 20 mg may be given as
necessary.
Child: 4-10 yr 5 mg at night; >10 yr Same as adult dose.
Rectal
Constipation
Adult: As supp or enema: 10 mg in the morning.
Child: ≤10 yr 5 mg in the morning; >10 yr Same as adult dose.
Should be taken on an empty stomach. Do not take w/in 1 hr
of antacids, milk or other dairy products.
Risk of dyspepsia and gastric irritation w/ antacids. Increased
risk of electrolyte imbalance w/ diuretics or adreno-
corticosteroids.
Increased risk of dyspepsia and gastric irritation w/ milk
products.
Description: Bisacodyl stimulates peristalsis by directly
irritating the smooth muscle of the large intestine. It alters
water and electrolyte secretion, producing net interstitial
fluid accumulation and laxation.
Onset: 6-12 hr (oral); 15-60 min (supp); 5-20 min(enema).
LACTULOSE (Lilac, Movelax)
Dosage Admnistration: Constipation Adult: As powd or 3.335
g/5 mL soln: Initially, 10-20 g (15-30 mL) daily as a single dose
or in 2 divided doses, may increase up to 45 mL of the soln (or
up to 40 g of the reconstituted powd) daily. Adjust gradually
according to patient's response. Child: As 3.335 g/5 mL soln:
1 mth to 1 yr 2.5 mL; >1-5 yr 5 mL; >5-10 yr 10 mL; >10-18 yr
15 mL. All doses to be given bid. Hepatic encephalopathy
Adult: As powd or 3.335 g/5 mL soln: 60-100 g (90-150 mL)
daily in 3 divided doses, adjust as necessary to produce 2-3
soft stools daily.
Administration: May be taken with or without food. May be
taken w/ meals to reduce GI discomfort. Dilute w/ water,
milk, or fruit juice to improve taste.
Drug Interaction: Reduced effect w/ non-absorbable
antacids, neomycin and other oral anti-infectives.
Concomitant use w/ other laxatives may falsely suggest that
adequate lactulose dosage has been achieved.
MOA: Lactulose promotes peristalsis by producing an osmotic
effect in the colon w/ resultant distention. In hepatic
encephalopathy, it reduces absorption of ammonium ions
and toxic nitrogenous compounds, resulting in reduced blood
ammonia concentrations.
Onset: Constipation: Up to 24-48 hr. Hepatic encephalopathy:
At least 24-48 hr.
STANDARDIZED SENNA CONCENTRATE
(Senokot/(Forte))
Senokot: Each tablet contains 187 mg Standardized Senna
Concentrate equivalent to 8.6 mg Sennosides A and B.
Senokot Forte: Each tablet contains 374 mg Standardized
Senna Concentrate equivalent to 17.2 mg Sennosides A and
B.Dosage Admnistration: Senokot Adult 2 tab. Max: 4 tab bid.
Childn >60 lb 1 tab. Max: 2 tab bid. Senokot Forte Adult 1-2
tab. Max: 2 tab bid.
Administration: May be taken with or without food:
Preferably taken at bedtime.
MOA: STANDARDIZED SENNA CONCENTRATE
(SENOKOT/SENOKOT FORTE) tablet are natural vegetable
laxatives derived from the senna plant that has been
standardized for predictable results. The active components
responsible for its laxative effect in STANDARDIZED SENNA
CONCENTRATE (SENOKOT/SENOKOT FORTE) are senna
glycosides or sennosides. Glycosides are converted into
aglycones through the enzymatic action of colonic bacteria,
which induce colonic peristalsis and bowel evacuation. This
action is virtually colon-specific, since these compounds have
little or no action in the stomach and small intestine.
ANTACIDS, ANTIREFLUX AGENTS &
ANTIULCERANTS
SODIUM BICARBONATE
Relief of symptoms of hyperacidity (eg, belching, heartburn,
acid indigestion, gas pains), gastritis & peptic ulcer. Urine
alkalinizer.
Dosage Admnistration: Adult 325-mg tab 3-6 tab qid. 650-mg
tab 2-4 tab tid.
Administration: Should be taken with food.
CIMETIDINE
Adult : PO Benign gastric and duodenal ulceration 800 mg
daily at bedtime or 400 mg bid for at least 4 wk (duodenal
ulcer), 6 wk (gastric ulcer) and 8 wk (NSAID-associated ulcer).
Maintenance: 400 mg daily at bedtime or bid. GERD 400 mg 4
times/day or 800 mg bid for 4-12 wk. Zollinger-Ellison
syndrome 300 or 400 mg 4 times/day. Prophylaxis of GI
haemorrhage from stress ulceration 200-400 mg 4-6 hrly.
Prophylaxis of acid aspiration during general anaesth 400
mg 90-120 min before induction of anaesth up to 400 mg 4
hrly if needed. Non-ulcer dyspepsia Max: 800 mg/day in
divided doses. Prophylaxis of nocturnal heartburn 100 mg at
bedtime. Short bowel syndrome Initial: 400 mg bid, adjusted
according to response. Pancreatic insufficiency 800-1600
mg/day in 4 divided doses. IV Benign gastric and duodenal
ulceration; Zollinger-Ellison syndrome Intermittent infusion:
300 mg 6-8 hrly infused over 15-20 min. Max: 2400 mg/day.
Continuous infusion: 37.5 mg/hr (900 mg/day). A 150 mg IV
loading dose may be given in patients requiring rapid
elevation of gastric pH.
Administration: Should be taken with food.
Drug Interaction: Reduces absorption of dasatinib,
ketoconazole, itraconazole and posaconazole. May increase
serum levels of phenytoin, theophylline, lidocaine,
hydroxyzine and oral anticoagulants. Absorption may be
reduced by antacids. Decreased bioavailability w/
metoclopramide, sucralfate or propantheline. May potentiate
the myelosuppressive effects (e.g. agranulocytosis,
neutropenia) of myelosuppressive drugs (e.g.
antimetabolites, alkylating agents) or therapies (e.g.
radiation).
Food Interaction: Food delays the rate and slightly decreases
extent of absorption. May enhance gastric mucosal irritation
w/ alcohol.
MOA: Cimetidine competitively inhibits histamine at H2-
receptors of the gastric parietal cells resulting in decreased
gastric acid secretion, gastric volume and hydrogen ion
concentration. It is also used in patients w/ pancreatic
insufficiency to reduce the breakdown of pancreatic enzyme
supplements.
Onset: 1 hr.
Duration: 4-5 hr.
OMEPRAZOLE (Acifre, Losec, Prosec, Risek)
Dosage Administration: Adult : PO Peptic ulcer 20 or 40
mg/day in severe cases for 4 wk (duodenal ulcer) or 8 wk
(gastric ulcer). Maintenance: 10-20 mg/day. NSAID-
5
associated ulceration 20 mg/day. GERD 20 mg once daily for
4 wk, may continue for another 4-8 wk if needed. Refractory
oesophagitis: 40 mg/day. Maintenance: 20 mg/day (after
healing of oesophagitis); 10 mg/day (acid reflux). Erosive
oesophagitis 20 mg daily for 4-8 wk. Maintenance: 20
mg/day. Acid-related dyspepsia 10 or 20 mg/day 2-4 wk.
Zollinger-Ellison syndrome Initial: 60 mg once daily. Dose
Range: 20-120 mg/day. All doses to be given once in the
morning but doses >80 mg in 2 divided doses. Prophylaxis of
acid aspiration during general anaesth 40 mg in the evening
and another 40 mg 2-6 hr pre-op. H.pylori infection 20 mg
bid or 40 mg once daily w/ clarithromycin and either
amoxicillin or metronidazole. IV Gastric and duodenal ulcers;
NSAID-associated ulceration; GERD 40 mg once daily infused
over 20-30 min or slow inj over 5 min until PO can be
resumed. Zollinger-Ellison syndrome Initial: 60 mg/day,
adjust if needed. Daily doses >60 mg/day should be given in 2
divided doses.
Administration: Cap: Should be taken with food. Take
immediately before a meal.
Mups Tab: May be taken with or without food.
Powd For Oral Susp: Should be taken on an empty stomach.
Take at least 1 hr before a meal.
Delayed-Release Cap: Should be taken on an empty stomach.
Take at least 1 hr before meals. Swallow whole, do not
chew/crush. For patients w/ difficulty swallowing, cap may be
carefully opened & entire contents sprinkled in a spoonful of
applesauce. Swallow drug/food mixt w/o chewing
immediately after prep. Drug/food mixt should not be stored
for future use.
Drug Interaction: Increased risk of hypomagnesaemia w/
diuretics. May increase INR and prothrombin time w/
warfarin. Increased risk of digoxin-induced cardiotoxic
effects. May increase plasma concentration benzodiazepines
(e.g. diazepam), clarithromycin and methotrexate. Decreased
absorption of itraconazole, ketoconazole, posaconazole,
dasatinib, iron salts. May prolong elimination of diazepam,
cilostazol, phenytoin and ciclosporin. May reduce the
antiplatelet effect of clopidogrel.
Potentially Fatal: May decrease plasma concentrations and
pharmacological effects of rilpivirine, nelfinavir and
atazanavir.
Food Interaction: Avoid concomitant St John's wort as it may
decrease omeprazole levels.
MOA: Omeprazole is a substituted benzimidazole gastric
antisecretory agent and is also known as PPI. It blocks the
final step in gastric acid secretion by specific inhibition of
H+/K+ ATPase enzyme system present on the secretory
surface of the gastric parietal cell. Both basal and stimulated
acid are inhibited.
Onset: Approx 1 hr.
Duration: Up to 72 hr.
ALUMINUM HYDROXIDE + MAGNESIUM
HYDROXIDE (Antacid)
Dosage Administration: Gastrointestinal hyperacidity
(Adult):
Chew 2-4 tab 4 times a day or as required. Max: 16 tab per 24
hours.
Child: ≥12 years Same as adult dose.
Drug Interaction: Interferes with the absorption of
ciprofloxacin, chloroquine, hydroxychloroquine,
chlorpromazine, cefdinir, cefpodoxime, ketoconazole,
levothyroxine, rifampicin, rosuvastatin, tetracyclines,
vitamins. May reduce the effect of polystyrene sulphonate.
Decreased serum concentration of velpatasvir. Increased
absorption with citrate-containing preparations. May
decrease absorption of Fe salts.
Magnesium hydroxide: Increases the excretion of salicylates.
MOA: Aluminium hydroxide is a slow-acting antacid that
binds phosphate in the gastrointestinal tract to form
insoluble complexes and reduces phosphate absorption. It
also acts as an astringent and may cause diarrhoea.
Magnesium hydroxide is a fast-acting antacid which
counteracts the constipating effect of aluminium hydroxide.
CALCIUM CARBONATE (CaCO3)
Dosage Administration: Hyperphosphataemia in patients
with chronic renal failure
Adult: Initially, 2.5 g daily, given in divided doses, may
increase up to 17 g daily in divided doses if needed.
Hyperacidity
Adult: Per tablet contains 500 mg calcium carbonate: Take 1-
2 tablets as needed, up to a max of 16 tablets/day. May suck
or chew tablets. Pregnant women: 1-2 tablets as needed, up
to a max of 7 tablets in 24 hr.
Administration: May be taken with or without food. Take w/
meals for better absorption. Avoid taking w/ large amount of
fibre-rich food.
Drug Interaction: Co-administration with thiazide diuretics or
vit D may lead to milk-alkali syndrome and hypercalcaemia.
Decreased absorption with corticosteroids. Decreases
absorption of tetracyclines, atenolol, iron, quinolones,
alendronate, Na fluoride, Zn and calcium-channel blockers.
Enhances cardiac effects of digitalis glycosides and may
precipitate digitalis intoxication.
Food Interaction: Absorption may be increased with food.
Decreased absorption with bran, foods high in oxalates and
whole grain cereals. Calcium may reduce iron absorption.
MOA: Calcium carbonate can neutralise gastric acid rapidly
and effectively. However, it may adversely activate Ca
dependent processes, leading to secretion of gastric and
hydrochloric acid. It can induce rebound acid secretion and,
prolonged high doses may cause hypercalcemia, alkalosis and
milk-alkali syndrome.
ESOMEPRAZOLE
Dosage Administration: Adult : PO Erosive oesophagitis 40
mg once daily for 4 wk, up to another 4 wk if needed.
Maintenance: 20 mg once daily. GERD 40 mg once daily for 4
wk, up to another 4 wk if needed. Maintenance or GERD w/o
erosive oesophagitis: 20 mg once daily. Peptic ulcer 20 mg
bid for 7 days or 40 mg once daily for 10 days as triple
therapy w/ amoxicillin and clarithromycin. Prophylaxis of
NSAID-induced ulcers 20 or 40 mg/day. NSAID-associated
ulceration 20 mg once daily for 4-8 wk. Zollinger-Ellison
syndrome Initial: 40 mg bid. Usual range: 80-160 mg/day.
Daily doses >80 mg should be given in 2 divided doses. IV
GERD 20 or 40 mg by inj over at least 3 min or infusion over
10-30 min once daily for ≤10 days until PO can be resumed.
NSAID-associated ulceration 20 mg/day by inj over at least 3
min or infusion over 10-30 min until PO can be resumed.
Gastric and duodenal ulcers 80 mg infusion over 30 min
followed by continuous infusion 8 mg/hr over 72 hr, until PO
can be resumed given as 40 mg once daily for 4 wk.
Administration: Delayed-Release Cap: Should be taken on an
empty stomach. Take 1 hr before meals.
Tab: May be taken with or without food.
Drug Interaction: Increased risk of digoxin-induced
cardiotoxic effects. Increased risk of hypomagnesaemia w/
diuretics. May increase INR and prothrombin time w/
warfarin. May increase serum concentration of tacrolimus,
saquinavir, methotrexate. May interfere the elimination of
drugs metabolised by CYP2C19 (e.g. diazepam). May decrease
the bioavailability of ketoconazole, erlotinib and Fe salts.
Potentially Fatal: May decrease serum concentration and
pharmacological effects of rilpivirine, atazanavir and
nelfinavir. May decrease the antiplatelet effects of
clopidogrel.
Food Interaction: Avoid St John's wort as it may decrease the
serum levels of esomeprazole.
MOA: Esomeprazole is a PPI that suppresses gastric acid
secretion by inhibiting H+/K+ ATPase in the gastric parietal
cell. It is the S-isomer of omeprazole.
Onset: W/in 1 hr.
LANSOPRAZOLE
Dosage Administration: Adult : PO Acid-related dyspepsia
15-30 mg once in the morning for 2-4 wk. GERD 15-30 mg
once in the morning for 4-8 wk. Maintenance: 15-30 mg once
daily. Erosive oesophagitis 30 mg once in the morning for up
to 8 wk. Maintenance: 15 mg once daily. Peptic ulcer 30 mg
6
once in the morning for up to 4 wk (duodenal ulcer) or up to
8 wk (gastric ulcer). H.pylori infection 30 mg bid, usually w/
clarithromycin and amoxicillin or metronidazole. NSAID-
associated ulceration 30 mg once in the morning for 4-8 wk.
Prophylaxis of NSAID-induced ulcers 15-30 mg once in the
morning. Zollinger-Ellison syndrome Initial: 60 mg once in the
morning. Daily doses >120 mg should be given in 2 divided
doses. IV Erosive oesophagitis 30 mg over 30 min for up to 7
days.
Administration: Should be taken on an empty stomach. Take
before meals.
Drug Interaction: Increased risk of hypomagnesaemia w/
diuretics and digoxin. May decrease plasma concentration of
erlotinib, dasatinib and lapatinib. May decrease the
bioavailability of itraconazole and ketoconazole. May increase
plasma concentration of cilostazol and methotrexate.
Reduced bioavailability w/ antacids and sucralfate.
Potentially Fatal: May decrease serum levels and
pharmacological effects of rilpivirine and atazanavir.
Food Interaction: Avoid St John's wort as it may decrease the
serum levels of lansoprazole.
MOA: Lansoprazole is a substituted benzimidazole, and is also
known as PPI due to its property to block the final step of acid
secretion by inhibiting H+/K+ ATPase enzyme system in gastric
parietal cell. Both basal and stimulated acid are inhibited.
Onset: Oral: 1-3 hr.
Duration: Oral: >1 day.
REBAMIPIDE (Mucosta)
Dosage Administration: Gastritis, Peptic ulcer
Adult: 100 mg tid, in the morning, evening and before
bedtime.
Administration: May be taken with or without food.
MOA: Description: Rebamipide is a mucosal protective agent
and is postulated to increase gastric blood flow,
prostaglandin biosynthesis and decrease free oxygen radicals.
RANITIDINE (Zantac)
Dosage Administration: PO Benign gastric and duodenal
ulceration Initial: 300 mg at bedtime or 150 mg bid for 4-8
wk. Maintenance: 150 mg at bedtime. Max: 300 mg bid.
NSAID-associated ulceration 150 mg bid or 300 mg at
bedtime for 8-12 wk. Prophylaxis: 150 mg bid. H. Pylori
infection 300 mg at bedtime or 150 mg bid w/ amoxicillin and
metronidazole for 2 wk. Continue w/ ranitidine for a further 2
wk. GERD 150 mg bid or 300 mg at bedtime for up to 8 wk.
Severe: 150 mg 4 times/day for 12 wk. Erosive oesophagitis
150 mg 4 times/day. Maintenance: 150 mg bid.
Hypersecretory conditions Initial: 150 mg bid or tid. Max: 6
g/day. Prophylaxis of acid aspiration during general anaesth
150 mg 2 hr before induction of anaesth, and preferably a
dose of 150 mg on the previous evening. Chronic episodic
dyspepsia 150 mg bid for up to 6 wk. Short-term
symptomatic relief of dyspepsia 75 mg, up to 4 doses/day if
needed. Max: 2 wk of continuous use at one time. IV
Hypersecretory conditions Initial: 1 mg/kg/hr, may increase
by increments of 0.5 mg/kg/hr after 4 hr if needed.
Administration: May be taken with or without food.
Drug Interaction: Delayed absorption and increased peak
serum concentration w/ propantheline bromide. Ranitidine
minimally inhibits hepatic metabolism of coumarin
anticoagulants, theophylline, diazepam and propanolol. May
alter absorption of pH-dependent drugs (e.g. ketoconazole,
midazolam, glipizide). May reduce bioavailability w/ antacids.
Food Interaction: May cause gastric mucosal irritation w/
alcohol.
MOA: Ranitidine competitively blocks histamine at H2-
receptors of the gastric parietal cells which inhibits gastric
acid secretion. It does not affect pepsin secretion,
pentagastrin-stimulated intrinsic factor secretion or serum
gastrin.
RABEPRAZOLE

Dosage Administration: PO GERD 20 mg/day for 4 wk.

Maintenance: 10 or 20 mg/day. Erosive oesophagitis 20
mg/day for 4-8 wk. May continue for up to 8 wk if needed.
Maintenance: 10 or 20 mg/day. Peptic ulcer disease 20
mg/day for 4-8 wk (duodenal ulcer) or 6-12 wk (gastric ulcer).
Zollinger-Ellison syndrome Initial: 60 mg/day up to max 120
mg/day if needed. All doses to be taken once in the morning
but daily doses >100 mg should be given in 2 divided doses.
H. pylori infection 20 mg bid w/ clarithromycin and either
amoxicillin or metronidazole for 1 wk.
Administration: Delayed-Release: May be taken with or
without food.
Drug Interaction: May decrease serum concentration of
ketoconazole, itraconazole and clopidogrel. Increased risk of
hypomagnesaemia w/ diuretics and digoxin. May increase
prothrombin time and INR of warfarin. May increase plasma
concentration of saquinavir and methotrexate. Decreased
serum levels w/ sucralfate.
Potentially Fatal: May decrease plasma concentrations and
pharmacological effects of rilpivirine and atazanavir.
Food Interaction: Avoid St John's wort as it may decrease the
serum levels of rabeprazole.
MOA: Rabeprazole is a PPI that suppresses gastric acid
secretion by inhibiting H+/K+ ATPase at the secretory surface
of the gastric parietal cell.
Onset: W/in 1 hr.
Duration: 24 hr.

PANTOPRAZOLE

Dosage Administration: PO GERD 20-40 mg for 4 wk, up to 8

wk if needed. Maintenance: 20-40 mg/day. Erosive
oesophagitis 20-40 mg for up to 16 wk if needed. Peptic ulcer
40 mg for 2-4 wk (duodenal ulcer) or 4-8 wk for (benign
gastric ulceration). Prophylaxis of NSAID-induced ulcers 20
mg. Zollinger-Ellison syndrome Initial: 80 mg. Max: 240
mg/day. Daily doses >80 mg should be given in 2 divided
doses. All doses to be taken once daily in the morning.
H.pylori infection 40 mg bid w/ clarithromycin and either
amoxicillin or metronidazole. IV Zollinger-Ellison syndrome
80 mg once or twice daily until PO can be resumed. Max: 240
mg/day in divided doses. GERD; Peptic ulcer 40 mg/day until
PO can be resumed.
Administration: Normal Release: May be taken with or
without food.
Controlled-Release: Should be taken on an empty stomach.
Take 1 hr before meals. Swallow whole, do not chew/crush.
Drug Interaction: Increased risk of digoxin-induced
cardiotoxic effects. Increased risk of hypomagnesaemia w/
diuretics. May increase INR and prothrombin time of
warfarin. May increase serum concentration of methotrexate
and saquinavir. Delayed absorption and decreased
bioavailability w/ sucralfate. Decreased absorption of
ketoconazole, itraconazole.
Potentially Fatal: May decrease serum levels and
pharmacological effects of rilpivirine, atazanavir and
nelfinavir.
MOA: Pantoprazole is a substituted benzimidazole, and also
known as PPI due to its property to block the final step of acid
secretion by inhibiting H+/K+ ATPase enzyme system in gastric
parietal cell. Both basal and stimulated acid are inhibited.
Duration: >24 hr.